Organization of co-occurring Axis II features in borderline personality disorder

Cluster analysis of personality traits in psychiatric patients with borderline personality disorder

BACKGROUND

Though the heterogeneous expression of symptoms of borderline personality disorder (BPD) is well-known, it is far from fully understood. Hybrid models combining dimensional and categorical ways of diagnosing BPD have been suggested to better handle this heterogeneity, but more research is needed. The aim of this study was to identify potential clusters in BPD, and evaluate if these clusters differed in diagnostic composition, severity, psychiatric symptoms, emotion regulation and control, or sociodemographic features.

METHODS

Clusters were based on personality traits measured with the Swedish universities Scales of Personality (SSP) in 141 psychiatric patients diagnosed with BPD. Hierarchical cluster analysis was performed using Ward's method. We used one-way analysis of variance to explore the different clusters' properties. Effect sizes were calculated using partial eta squared.

RESULTS

We found three distinct clusters: the lower psychopathology cluster (N = 67), the externalizing cluster (N = 28), and the internalizing cluster (N = 46). The clusters differed regarding trait composition, severity, and emotion regulation and control.

CONCLUSIONS

Our findings support hybrid models for diagnosing BPD by showing that clusters differed in terms of both severity (lower and higher psychopathology) and personality traits/style (internalizing and externalizing). Assessment of personality traits may be a feasible way to differentiate between clusters. In the future, this knowledge might be used to personalize treatment.

Borderline Personality Disorder “Discouraged Type”: A Case Report

Borderline Personality Disorder (BPD) is a mental illness associated with a significant degree of distress and impairment because of the difficulties in effectively regulating emotions. BPD is frequently associated with Depressive Disorders, most commonly Major Depressive Disorder and Dysthymia. Here, we present a case report of an 18-year-old female patient hospitalized with a severe depressive episode and psychotic symptoms. A few months after discharge, the interpersonal difficulties, unstable self-image, fear of chronic abandonment, feeling of emptiness, paranoid ideation, helplessness, obsessive-compulsive elements, perfectionism, and social retreat led to the patient’s impaired functionality. The spectrum of signs and symptoms presented were characteristic of BPD. The specific presentation of mixed dependent/avoidant pattern of personality, with persistent feelings of guilt and shame, social anxiety, emotional attachments, obsessions, and feelings of inadequacy have further narrowed the diagnosis to discouraged BPD, as described by Theodore Millon. In our case, this particular subtype of personality disorder can be understood as BPN associated with social perfectionism. Both BPD and perfectionism, as a trait personality, were thought to exacerbate issues with self-conception and identity formation in this patient.

In light of the DSM-5 dimensional model of personality: Borderline personality disorder at the crossroads with the bipolar spectrum

BACKGROUND

State-of-the-art research highlights that borderline personality disorder (PD) and bipolar spectrum disorders have clinical characteristics in common, which imply uncertainty in differential diagnoses. Although there is a growing body of literature on the DSM-5 dimensional model of personality disorder, its discriminative features between these clinical samples are still understudied. In this study, we seek to identify the best set of predictors that differentiate between borderline PD and bipolar spectrum, based on pathological and normative personality traits and symptoms.

METHODS

A cross-sectional study of three clinical samples: 1) Borderline PD group of 63 participants; 2) Major depressive disorder group of 89 participants; 3) Bipolar disorder group of 65 participants. Self-reported assessment: Personality Inventory for DSM-5; Brief Symptom Inventory; FFM Inventory. A series of one-way ANOVAs and logistic regression analyses were computed.

RESULTS

The major set of data emerging as common discriminants of borderline PD across the bipolar spectrum are unusual beliefs & experiences, paranoid ideation, obsession-compulsion and extraversion. Depressivity (OR: 34.95) and impulsivity (OR: 22.35) pathological traits displayed the greatest predictive values in the differential diagnosis.

LIMITATIONS

The small size of the samples; a lack of data from participants' previous clinical history.

CONCLUSIONS

Findings support the DSM-5 pathological traits as differentiating borderline PD through bipolar spectrum, and reinforcing the joint use of symptom-related pathological functioning and normal-range personality traits. Alongside the bipolar spectrum, borderline pathology sheds light upon a hypothetical overlap along the depressive and schizoaffective/schizophrenia spectra, representing a borderland space at a crossroads with the psychopathology of a meta-spectrum.

Latent profiles of patients with borderline pathology based on the alternative DSM-5 model for personality disorders

BACKGROUND

There have been multiple attempts to try to parse out heterogeneity within borderline pathology by identifying patient subtypes; thus far, these works have yielded few consistent results. Recent developments in the operationalization of borderline pathology may provide new opportunities to identify clinically and conceptually meaningful subgroups of patients. The Alternative DSM-5 Model for Personality Disorders (AMPD) offers a categorical-dimensional operationalization of Borderline personality disorder (BPD) that has yet to be tested for identification of patient subgroups. The purpose of the present study is to test whether the combination of the Criterion A elements (pertaining to level of severity) and the seven pathological facets from Criterion B that define BPD in the AMPD can yield meaningful patient profiles.

METHODS

A total of 211 outpatients from a specialized PD treatment program (133 women, Mage = 33.66, SD = 10.97) were selected based on the presence of at least moderate borderline pathology according to cutoffs recently proposed for the Borderline Symptom List-23. Valid Criterion A (Self and Interpersonal Functioning Scale) and B (Personality Inventory for DSM-5 Faceted Brief Form) self-reports were administered to measure elements and facets that define BPD in the AMPD model; these variables were used as indicators in a latent profile analysis (LPA).

RESULTS

The optimal solution generated by LPA yielded four distinct profiles: (a) Borderline traits; (b) Moderate pathology with Impulsivity; (c) Moderate pathology with Identity problems and Depressivity; and (d) Severe pathology. Clinically meaningful distinctions emerged among profiles on AMPD indicators and external variables relevant to PD, especially aggression and impulsivity.

CONCLUSIONS

Profiles reflected both the "severity" and "style" components imbedded within Criterion A and B of the AMPD, as they were mainly distinguished by a continuum of severity but also by some meaningful qualitative differences that may have important clinical implications for treatment planning and contracting. Results also suggest that the four Criterion A elements have independent value to identify important differences in patients with borderline pathology. They also highlight that some Criterion B facets that define BPD in the AMPD may be especially important to identify subgroups of patients, mainly Impulsivity and Depressivity.

Uncovering general, shared, and unique temporal patterns in ambulatory assessment data

Intensive longitudinal data provide psychological researchers with the potential to better understand individual-level temporal processes. While the collection of such data has become increasingly common, there are a comparatively small number of methods well-suited for analyzing these data, and many methods assume homogeneity across individuals. A recent development rooted in structural equation and vector autoregressive modeling, Subgrouping Group Iterative Multiple Model Estimation (S-GIMME), provides one method for arriving at individual-level models composed of processes shared by the sample, a subset of the sample, and a given individual. As this algorithm was motivated and validated for use with neuroimaging data, its performance is less understood in the context of ambulatory assessment data. Here, we evaluate the performance of the S-GIMME algorithm across various conditions frequently encountered with daily diary (compared to neuroimaging) data; namely, a smaller number of variables, a lower number of time points, and smaller autoregressive effects. We demonstrate, for the first time, the importance of the autoregressive effects in recovering data-generating connections and directions, and the ability to use S-GIMME with lengths of data commonly seen in daily diary studies. We demonstrate the use of S-GIMME with an empirical example evaluating the general, shared, and unique temporal processes associated with a sample of individuals with borderline personality disorder (BPD). Finally, we underscore the need for methods such as S-GIMME moving forward given the increasing use of intensive longitudinal data in psychological research, and the potential for these data to provide novel insights into human behavior and mental health. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Subtypes of borderline personality disorder patients: a cluster-analytic approach

BACKGROUND

The borderline personality disorder (BPD) population is notably heterogeneous, and this has potentially important implications for intervention. Identifying distinct subtypes of patients may represent a first step in identifying which treatments work best for which individuals.

METHODS

A cluster-analysis on dimensional personality disorder (PD) features, as assessed with the SCID-II, was performed on a sample of carefully screened BPD patients (N = 187) referred for mentalization-based treatment. The optimal cluster solution was determined using multiple indices of fit. The validity of the clusters was explored by investigating their relationship with borderline pathology, symptom severity, interpersonal problems, quality of life, personality functioning, attachment, and trauma history, in addition to demographic and clinical features.

RESULTS

A three-cluster solution was retained, which identified three clusters of BPD patients with distinct profiles. The largest cluster (n = 145) consisted of patients characterized by "core BPD" features, without marked elevations on other PD dimensions. A second "Extravert/externalizing" cluster of patients (n = 27) was characterized by high levels of histrionic, narcissistic, and antisocial features. A third, smaller "Schizotypal/paranoid" cluster (n = 15) consisted of patients with marked schizotypal and paranoid features. Patients in these clusters showed theoretically meaningful differences in terms of demographic and clinical features.

CONCLUSIONS

Three meaningful subtypes of BPD patients were identified with distinct profiles. Differences were small, even when controlling for severity of PD pathology, suggesting a strong common factor underlying BPD. These results may represent a stepping stone toward research with larger samples aimed at replicating the findings and investigating differential trajectories of change, treatment outcomes, and treatment approaches for these subtypes.

TRIAL REGISTRATION

The study was retrospectively registered 16 April 2010 in the Nederlands Trial Register, no. NTR2292.

Self-reported symptoms of schizotypal and borderline personality disorder in patients with mood disorders

BACKGROUND

Distinguishing between symptoms of schizotypal (SPD) and borderline personality disorders (BPD) is often difficult due to their partial overlap and frequent co-occurrence. We investigated correlations in self-reported symptoms of SPD and BPD in questionnaires at the levels of both total scores and individual items, examining overlapping dimensions.

METHODS

Two questionnaires, the McLean Screening Instrument (MSI) for BPD and the Schizotypal Personality Questionnaire Brief (SPQ-B) for SPD, were filled in by patients with mood disorders (n=282) from specialized psychiatric care in a study of the Helsinki University Psychiatric Consortium. Correlation coefficients between total scores and individual items of the MSI and SPQ-B were estimated. Multivariate regression analysis (MRA) was conducted to examine the relationships between SPQ-B and MSI.

RESULTS

The Spearman's correlation between total scores of the MSI and SPQ-B was strong (rho=0.616, P<0.005). Items of MSI reflecting disrupted relatedness and affective dysregulation correlated moderately (rφ varied between 0.2 and 0.4, P<0.005) with items of SPQ. Items of MSI reflecting behavioural dysregulation correlated only weakly with items of SPQ. In MRA, depressive symptoms, sex and MSI were significant predictors of SPQ-B score, whereas symptoms of anxiety, age and SPQ-B were significant predictors of MSI score.

CONCLUSIONS

Items reflecting cognitive-perceptual distortions and affective symptoms of BPD appear to overlap with disorganized and cognitive-perceptual symptoms of SPD. Symptoms of depression may aggravate self-reported features of SPQ-B, and symptoms of anxiety features of MSI. Symptoms of behavioural dysregulation of BPD and interpersonal deficits of SPQ appear to be non-overlapping.

Personality Disorders and Mindreading: Specific Impairments in Patients With Borderline Personality Disorder Compared to Other PDs

The capacity of understanding mental states is a complex function which involves several components. Single components can be selectively impaired in specific clinical populations. It has been suggested that impairments in mindreading are central for borderline personality disorder (BPD). However, empirical findings are inconsistent, and it is debatable whether BPD presents a specific profile of mindreading impairments. The aim of this study is to compare BPD and other PDs in mindreading. Seventy-two patients with BPD and 125 patients with other PD diagnoses were assessed using the Metacognition Assessment Interview. BPD showed difficulties in two mindreading functions, differentiation and integration, even when the severity of psychopathology was controlled. These results suggest a specific mindreading impairment in BPD and a strong relationship between these impairments and the severity of psychopathology.

Borderline personality features and emotional reactivity: the mediating role of interpersonal vulnerabilities

BACKGROUND AND OBJECTIVES

The purpose of this study was to examine the mediating role of interpersonal vulnerabilities in the association of borderline personality (BP) features with emotional reactivity to an interpersonal stressor.

METHODS

For this study, female university students with high (N = 23), mid (N = 23), and low (N = 22) BP features completed the Inventory of Interpersonal Problems-Personality Disorders-25 (IIP-PD-25). Self-reported emotions, skin conductance responses (SCRs), interbeat intervals, and heart rate variability measured emotional reactivity to a social rejection stressor.

RESULTS

BP features were positively associated with interpersonal dysfunction and predicted greater SCR reactivity and self-reported emotional reactivity. Interpersonal dysfunction mediated the association between BP features and physiological (SCRs), but not self-reported, emotional reactivity. In particular, scores on the interpersonal ambivalence subscale of the IIP-PD-25 mediated the association of BP features with SCR reactivity.

LIMITATIONS

This study examined BP features in a non-clinical sample, and relied on a relatively small sample. Furthermore, the design of the present study does not capture the potential transaction between interpersonal vulnerabilities and emotional dysfunction.

CONCLUSIONS

The findings of this study illuminate one potential mechanism underlying the heightened reactivity of persons with BP features to rejection, suggesting that interpersonal ambivalence plays a particularly important role in physiological reactivity.

Clarifying interpersonal heterogeneity in borderline personality disorder using latent mixture modeling

Significant interpersonal impairment is a cardinal feature of borderline personality disorder (BPD). However, past research has demonstrated that the interpersonal profile associated with BPD varies across samples, which is evidence for considerable interpersonal heterogeneity. The current study used inventory of interpersonal problems-circumplex (IIP-C; Alden, Wiggins, & Pincus, 1990) scale scores to investigate interpersonal inhibitions and excesses in a large sample (N = 255) selected for significant borderline pathology. Results indicated that BPD symptom counts were unrelated to the primary dimensions of the IIPC, but were related to generalized interpersonal distress. A latent class analysis clarified this finding by revealing six homogeneous interpersonal classes with prototypical profiles associated with Intrusive, Vindictive, Avoidant, Nonassertive, and moderate and severe Exploitable interpersonal problems. These classes differed in clinically relevant features (e.g., antisocial behaviors, self-injury, past suicide attempts). Findings are discussed in terms of the incremental clinical utility of the interpersonal circumplex model and the implications for developmental and nosological models of BPD.

Relationship between Schizotypal and Borderline Traits in College Students

The main objective of the present investigation was to analyze the relationship between self-reported schizotypal and borderline personality traits in a sample of 759 college students (M = 19.63 years; SD = 2.03). For this purpose, the Schizotypal Personality Questionnaire-Brief (SPQB; Raine and Benishay, 1995) and Borderline Personality Questionnaire (BPQ; Poreh et al., 2006) were administered. The results showed that schizotypal and borderline features are partially related at subclinical level. The exploratory factor analysis conducted on the subscales revealed a three-factor solution comprised of the following factors: Identity/Interpersonal, Lack of Control and Schizotypal. The canonical correlation analysis showed that schizotypal features and borderline personality traits shared 34.8 % of the variance. The data highlight the overlap between schizotypal and borderline personality traits in nonclinical young adults. Future studies should continue to examine the relationship and the degree of overlap between these traits in community samples.

Refining the phenotype of borderline personality disorder: Diagnostic criteria and beyond

Borderline personality disorder (BPD) is a heterogeneous disorder, and previous analyses have parsed its phenotype in terms of subtypes or underlying traits. We refined the BPD construct by testing a range of latent variable models to ascertain whether BPD is composed of traits, latent classes, or both. We also tested whether subtypes of BPD could be distinguished by anger, aggressiveness, antisocial behavior, and mis-trustfulness, additional putative indicators drawn from Kernberg's (1967, 1975) theory of BPD. In a mixed clinical and nonclinical sample (N = 362), a factor mixture model consisting of two latent classes (symptomatic and asymptomatic) and a single severity dimension fit the BPD criteria, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), data better than latent class or factor analytic approaches. In the second analytic phase, finite mixture modeling of the symptomatic latent class (n = 100) revealed four BPD subtypes: angry/aggressive, angry/mistrustful, poor identity/low anger, and prototypical. Our results support a hybrid categorical-dimensional model of the BPD DSM-IV criteria. The BPD subtypes emerging from this model have important implications for treatment and etiological research.

Comorbidity of borderline personality disorder with other personality disorders in psychiatric outpatients: how does it look at 2-year follow-up?

BACKGROUND

The rates of remission of comorbid personality disorders for patients with a primary borderline personality disorder (BPD) have previously only been addressed in samples of inpatients or former inpatients with BPD receiving treatment-as-usual.

AIMS

The aim of the current study was to assess the rates of remission of comorbid axis II personality disorders in a sample of 32 outpatients with a primary BPD receiving open-ended non-manualized psychotherapy.

METHODS

Structured psychiatric interviews for DSM-IV were conducted by independent assessors at intake, discharge and 2-year follow-up. Independent t-test, chi-square and McNemar analyses based on intent-to-treat were used.

RESULTS

The overall rate of comorbid axis II disorders was significantly reduced from intake to 2-year follow-up. Patients with non-remitted BPD had significantly more PD diagnoses and symptomatic distress on all outcome measures at follow-up.

CONCLUSION

Comorbid personality disorders among outpatients with BPD can be expected to remit with time and with remission of BPD. In the current sample of outpatients, comorbid paranoid, avoidant and obsessive-compulsive personality disorders at 2-year follow-up were associated with non-remitted BPD. The clinical implication of the results is that especially comorbid avoidant and obsessive-compulsive personality disorders may require specific attention in treatment of patients with BPD.

Tailoring common treatment principles to fit individual personalities

The American Psychological Association Task Force headed by Castonguay and Beutler (2006) distilled general treatment principles common to all therapies from the empirical literature. As part of this work, Critchifield and Benjamin (2006a, 2006b) summarized principles for treatment of personality disorder. The principles are pragmatic in the sense that they are based on evidence of what works, and clinicians are encouraged to apply them in ways that fit the unique presentation and needs of a given patient. An important element of the recommended approach is that it be coherent, well-coordinated, and agreed upon by the patient. Additional principles emphasize the importance of an individual's attachment and trauma history. A complex case example is presented to illustrate one way in which emphasis on an individual's relational learning history can be used to further refine and extend wisdom inherent in the cross-cutting principles and move in the direction of an integrative treatment that is closely tailored to specific case features. A research approach is also outlined for how to test the validity of principles that prescribe differential use of technique to address diverse patient presentations.

The neuroendocrinology of childhood trauma in personality disorder

BACKGROUND

Childhood trauma has been associated with elevated central corticotropin releasing hormone (CRH) drive in adults meeting general DSM-IV criteria for personality disorder. It is not clear how this may be related to pituitary or adrenal responsiveness in personality disorder. It was hypothesized that high levels of childhood trauma would be associated with blunted cortisol and adrenocorticotropin releasing hormone (ACTH) response to the combined dexamethasone(DEX)/CRH test in adults meeting general DSM-IV criteria for personality disorder.

METHOD

24 healthy, medication free adults with personality disorder (N=16) and a group of healthy controls (N=8) underwent semi-structured diagnostic interviews and completed the Childhood Trauma Questionnaire (CTQ). Across two separate study sessions separated by at least a week, cerebrospinal fluid (CSF) was sampled by lumbar puncture for measurement of CRH concentration (N=17), and peripheral blood cortisol and ACTH levels were measured after challenge with DEX/CRH (N=24).

RESULTS

As hypothesized, high CTQ score was associated with a blunted cortisol and ACTH response to DEX/CRH challenge. Indices of cortisol and ACTH response (peak level and area under the curve (AUC)) to DEX/CRH were in turn significantly negatively correlated with CSF CRH concentration.

CONCLUSION

Childhood trauma in adults with personality disorder is associated with blunted cortisol and ACTH secretion following DEX/CRH challenge. These effects are independent of depression or posttraumatic stress disorder. Previous work would suggest that blunted pituitary-adrenal response is related to elevated central CRH drive. Corroborating this, CSF CRH levels were significantly and negatively correlated with peak level and AUC of both cortisol and ACTH.

Clinical phenomenology of childhood abuse-related complex PTSD in a population of female patients: patterns of personality disturbance

OBJECTIVE

Complex posttraumatic stress disorder (PTSD) involves a variety of personality disturbances presumed to result from repeated interpersonal trauma such as child abuse. As Complex PTSD patients are a heterogeneous population, we searched for clinically relevant personality-based subtypes.

METHOD

This study used a cluster analysis of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), Axis II features within a sample of 71 female outpatients with systematically assessed child abuse-related Complex PTSD.

RESULTS

Two main subtypes were found: adaptive and nonadaptive. The latter was further differentiated into withdrawn, alienated, suffering, and aggressive subtypes, characterized by different levels of introversion and disinhibition. Among the nonadaptive subtypes, the severity of Complex PTSD symptoms was lowest in the withdrawn (introverted only) subtype. The subtypes differed in their level of dissociation and depression but did not differ regarding PTSD symptoms, trauma history, or parental bonding characteristics.

CONCLUSION

Confirming earlier findings, our study found personality-based Complex PTSD subtypes, which could implicate differential treatment needs and results.

Psychotherapy for personality disorders

Personality disorders are widely prevalent among those seeking mental health services, resulting in substantial distress and a heavy burden on public assistance and health resources. We conducted a qualitative review of randomized controlled trials (RCTs) of psychosocial interventions for personality disorders. Articles were identified through searches of electronic databases and classified based on the focus of the psychological intervention. Data regarding treatment, participants and outcomes were identified. We identified 33 RCTs that evaluated the efficacy of various psychosocial treatments. Of these studies, 19 focused on treatment of borderline personality disorder, and suggested that there are several efficacious treatments and one well-established treatment for this disorder. In contrast, only five RCTs examined the efficacy of treatments for Cluster C personality disorders, and no RCTs tested the efficacy of treatments for Cluster A personality disorders. Although other personality disorders, especially Cluster A, place heavy demands on public assistance, and in spite of recommendations that psychosocial interventions should be the first line of treatment for these disorders, our review underscored the dearth of treatment research for many of these personality disorders. We highlight some obstacles to such research and suggest directions for future research.

[Personality structure and clinical severity of borderline personality disorder]

OBJECTIVES

To correlate personality structure and clinical severity of borderline personality disorder.

METHODS

Based on data from a sample of 104 female patients with borderline personality disorder, we computed bivariate correlations and group comparisons using the scales from the Structured Interview of Personality Organization (STIPO) as well as indicators of clinical severity of the disorder (axis-II comorbidity, suicide attempts, self-destructive behaviour, service utilization).

RESULTS

Patients with a clinically more severe disorder revealed a worse level of personality structure. Specific associations between dimensions of personality structure and phenomenology were found.

CONCLUSIONS

The diagnoses of personality structure and of phenomenology complement each other and should be combined in clinical settings as well as for research purposes.