Biparental psychopathology and borderline personality disorder

The pathology of parents is thought to be associated with the emergence of Borderline Personality Disorder (BPD) among offspring by both genetic and environmental pathways (Links and Blum 1990). In an effort toward clearer delineation, not only reliable diagnoses of patients, but also direct study of families, are recommended (Gunderson 1990; Gunderson and Zanarini 1989; Links and Blum 1990; Ogata et al. 1990; Zanarini et al. 1990). With this in mind, we conducted a pilot, retrospective study of parental psychiatric status, developmental events, and family climate during the developmental years of 30 young women hospitalized for BPD, to be reported here. In studying these three dimensions of family life, we hoped to shed light on environmental underpinings (Gunderson 1990; Gunderson and Zanarini 1989; Links 1992; Rutter and Quinton 1984). Even though our cohort is small and select, and the data on a comparison group not yet available, our research approach holds promise of yielding fresh insights.

Disability in geriatric depression

OBJECTIVE

The authors' purpose was to identify the relationship of disability to clinical measures that are part of a comprehensive psychiatric examination of depressed elderly patients.

METHOD

The disability of 75 elderly inpatients and outpatients with major depression whose cognitive function ranged from normality to mild dementia was assessed with the Philadelphia Multilevel Assessment Instrument. Age at onset of depression, chronicity of depression, severity of depression, cognitive impairment, medical burden, social support and living environment were assessed with standardized instruments.

RESULTS

Impairment in instrumental activities of daily living was significantly associated with advanced age, severity of depression, and medical burden. The relationship of depressive symptoms to impairment in instrumental activities of daily living was not influenced by age or medical burden. Anxiety and depressive ideation as well as retardation and weight loss were significantly associated with impairment in instrumental activities of daily living. Interviewer-rated global disability was associated with advanced age at onset of depression, medical burden, and overall cognitive impairment. Specifically, a disturbance in initiation and perseveration was significantly related to global disability.

CONCLUSIONS

Impairment in instrumental activities of daily living appears to be a relatively independent dimension of health status that is related to depressive symptoms, particularly anxiety and depressive ideation as well as retardation and weight loss. Global disability may be associated with impairment in initiation and perseveration and with late onset of depression. These findings provide a basis for studies investigating whether psychotherapy aimed at depressive ideation and rehabilitation efforts focused on instrumental activities of daily living can improve the outcome of geriatric depression.

Factors associated with multiple hospitalizations of patients with borderline personality disorder

OBJECTIVE

The study sought to identify aspects of borderline personality disorder and comorbid axis I conditions associated with multiple hospitalizations in a sample of patients with borderline personality disorder.

METHODS

Data were collected as part of a larger study of treatment course of inpatients with this disorder. Predictors of multiple hospitalization from three domains were considered: demographic characteristics, criteria of borderline personality disorder, and comorbid axis I pathology. A sequential model-building strategy was used, with each domain considered separately and result combined into an overall regression model of factors related to multiple hospitalization.

RESULTS

Three factors were related to frequency of hospitalization: anorexia, psychotic symptoms, and suicidality. Other variables that are often assumed to be related to hospitalization, such as depression, did not emerge as significant predictors.

CONCLUSIONS

Clinicians should intervene early to address the emergence of certain axis I conditions among patients with borderline personality disorder. Increased expenditure of outpatient resources may prevent hospitalization when these conditions are present.

Studying the treatment contract in intensive psychotherapy with borderline patients

A pilot study on the process of psychodynamic psychotherapy of borderline personality disorder at the Cornell University Medical College is designed to investigate the teaching and application of a specific model of treatment for borderline patients (Clarkin et al. 1992; Kernberg and Clarkin 1992). The project has involved teaching a group of self-selected trainees and faculty the manualized therapy (Kernberg et al. 1989); taping each of the twice-weekly therapy sessions over a period of 2 years; and rating (1) each therapist's adherence to the manual (Koenigsberg et al. 1985), (2) each therapist's skill, and (3) patient change. The patients are women with borderline personality disorder, between 20 and 40 years of age, diagnosed by DSM-III-R criteria (American Psychiatric Association 1987), SCID-II (Spitzer et al. 1987), and a self-report questionnaire for level of personality organization. At regular intervals, the patients are evaluated for symptom status, change in BPD criteria, and functioning. The therapists are evaluated for adherence to the manual and level of therapeutic skill. In teaching and carrying out the manualized therapy, it became clear that a critical moment in the treatment was the setting up of the treatment contract. A study was organized to look systematically at the adherence of the therapists to the model of treatment with regard to this initial phase of the therapy.

Issues in research design in psychiatric hospitals

This paper is a review of the status of research pertaining to the hospital setting and a proposed design for a program of research for psychiatric hospitals. Assessment of patient status, treatment, hospital characteristics, and aftercare settings are reviewed in the first section. The second section presents some possible instruments to measure these factors. The third section deals with the various hypotheses that have been proposed in the literature. The hypotheses are categorized into an overall theory to be tested by a program of research. The final section proposes a research program to test those hypotheses.

Suicide attempts in patients with borderline personality disorder

Among 180 patients with DSM-III borderline personality disorder, patients with concurrent affective and substance use disorders had a higher rate of serious suicide attempts than other patients. Clinicians should be alert to axis I disorders in assessing suicide potential in borderline patients.

Comorbidity of borderline personality disorder

In a retrospective study of 180 inpatients with DSM-III borderline personality disorder (BPD), the degree and direction of psychiatric comorbidity were used to examine the extent to which BPD is a homogeneous entity with clearly defined boundaries. Ninety-one percent of patients with BPD had one additional diagnosis, and 42% had two or more additional diagnoses. Both patients with BPD and controls with other personality disorders had similar rates and directions of comorbidity. The two groups did not differ significantly in prevalence of affective disorder. The DSM-III BPD appears to constitute a very heterogeneous category with unclear boundaries, overlapping with many different disorders but without a specific association with any one Axis I disorder. Comorbidity in patients with BPD may reflect base rates of psychopathology rather than anything inherent to BPD. Future studies should control for comorbidity to ensure homogeneity of comparison groups.

A multidimensional scaling of the DSM-III personality disorders

The DSM-III employs a categorical model for the classification of personality disorders. A dimensional model provides certain advantages, but there has not yet been an empiric attempt to identify an optimal set of dimensions. We systematically assessed the presence of each of the symptoms for the personality disorders in 84 patients. The number of symptoms of each of the personality disorders possessed by each patient was correlated across patients, and the correlations were subjected to a multidimensional scaling program. A three-dimensional solution was compared with the placements of the personality disorders predicted by dimensions published previously.

Reliability of data taken from medical charts

While it is desirable to conduct clinical research across different institutions using the richness and complexity of daily clinical data from the hospital chart, it is possible only if reliable information can be obtained. This report represents the efforts made by eight collaborating private psychiatric hospitals to devise two instruments to provide reliable rating and notation of clinical information found in the medical record. Such information will spawn future studies of applied clinical research.

Patient and hospital treatment clusters

Patient admission data and treatment data collected for 536 cases from 11 collaborating private psychiatric hospitals were subjected to cluster analysis. From the patient admission data, four large clusters and three small clusters emerged. Two very large and general clusters and four very small clusters were obtained from the treatment data. Both sets of clusters were cross-classified against diagnosis, length of hospital stay, and attainment of therapeutic goals. There were several significant but small relationships between clusters and these criteria. There was little overlap between diagnosis and the patient data or treatment data clusters. Length of stay related only to the treatment clusters which included a number of variables measuring different treatment amounts. The method seems potentially useful because it groups individuals along dimensions of interest, but further effort must be spent on more specific treatment descriptions and better outcome variables.

Stability and distinctness of borderline personality disorder

In a 3-year follow-up study the authors examined the diagnostic stability of borderline personality disorder over time, its relation to affective disorder, and the severity of functional impairment. The data support the usefulness of borderline personality disorder as a diagnostic construct.

Do psychotherapies have specific effects?

The authors provide a critical review of the evidence from psychotherapy outcome research for and against the assumption that specific techniques produce specific effects. They describe the refinement in research and methodology that will be necessary to document specific effects.

Selection criteria for individual dynamic psychotherapies

The authors discuss the indications, contraindications, and enabling factors for four types of psychodynamically informed psychotherapy: supportive, focal, exploratory, and psychoanalysis. They outline the inherent and practical difficulties impeding psychotherapy outcome studies and summarize the limited research regarding psychodynamic treatments. The overall efficacy of psychotherapy has been documented, but to date studies have not demonstrated specific differential effectiveness and indications. The authors present the rationale for each of the four approaches and suggest ways of selecting among them.

Sexual histories and premenstrual affective syndrome in psychiatric inpatients

Of 45 female inpatients with schizophrenia, depression, borderline personality, or depression and borderline personality, 28 met criteria for probable or definite premenstrual affective syndrome. Of these 28, 16 had abnormal sexual histories, compared with only 1 of the 17 women who did not have premenstrual affective syndrome. Of the 12 patients with both depression and borderline personality disorder, 9 had both premenstrual affective syndrome and abnormal sexual histories. The 6 patients who had been raped all met the criteria for premenstrual affective syndrome. The authors suggest that premenstrual affective syndrome may signify unresolved sexual conflicts in subgroups of psychiatric patients.

Selection criteria for partial hospitalization

During the early 1960s partial hospitalization emerged as an important component of community-based psychiatric treatment. Initially partial hospitals offered all types of treatment to all types of patients. To help mental health professionals make informed decisions when matching specific treatments to specific patient characteristics, the authors define three kinds of partial hospitals--intensive care, chronic care, and rehabilitation partial hospitals--and propose selection criteria for referral to each model. Factors to be considered in making differential therapeutic decisions between a specific type of partial hospital program and alternative methods of treatment, such as inpatient treatment, are discussed.

Differential therapeutics: a guide to treatment selection

Practical and scientific developments have recently focused attention on treatment selection in psychiatry. Based on the research literature, the opinions of leading practitioners, and the authors' clinical experience, tentative guidelines for treatment selection are offered. The indications, patient enabling factors, and relative contraindications that influence the choice of treatment format, orientation, and duration are outlined, as are indications for combining psychotherapy with psychotropic medication and for a prescription of no treatment. Critics of differential therapeutics might argue that the outcome of psychotherapy is influenced primarily by its nonspecific aspects and by patient characteristics, and that it may be premature to form guidelines given the incompleteness of the research. However, as outcome studies are more carefully designed, specific effects of different treatments may well emerge. Furthermore, treatment selection is a practical necessity, and a careful analysis of the available data and opinion helps to inform these choices and to identify areas for continued research.

Focal therapy in the day hospital

The authors describe their adaptation of focal therapy to the day hospital setting. Its goal is circumscribed characterological change through the interpretive uncovering of only one area of conflict. It has previously been used mainly with patients seen in individual outpatient treatment who are more likely to meet the regorous selection criteria; however, the day hospital's more intense setting permits it to be used with patients who would be disqualified in outpatient treatment. The authors present a case report of a severely disturbed woman who benefited significantly from the treatment technique.

Organic factors in Gilles de la Tourette's syndrome

Gilles de la Tourette's syndrome had been considered an organic, often hereditary illness for many years after it was first described in 1885 (1, 2), but when medicine became psychologically oriented, the syndrome was more frequently classified as a psychological illness (3), and patients have been said to be schizophrenic, psychotic, obsessive-compulsive, hysteric, to have inhibited aggression, and eventually to deteriorate intellectually and psychologically. However, no support for common psychopathological and dynamic factors was found in our previous study of 34 patients or in a review of the literature (4). Recently, as medicine has shifted back from a psychological orientation, and as case histories have accumulated, an organic aetiology has been more frequently postulated.