Bruce Pfohl

The borderline diagnosis I: psychopathology, comorbidity, and personaltity structure

Borderline personality disorder (BPD) is a complex and serious mental disorder associated with severe functional impairment, substantial treatment utilization, and a high rate of mortality by suicide. Recently, BPD has become a focus of intensifying study. In Part I of this three-part article meant to provide a foundation to researchers on the current status of the borderline diagnosis and prospects for its future development, we examine the psychopathology, comorbidity, and personality structure of BPD. Although the descriptive characteristics of BPD are well-represented by DSM-IV diagnostic criteria, other important aspects of BPD psychopathology are not included. The descriptive criteria in conjunction with semistructured interviews have, however, increased the ability of investigators to diagnose BPD as reliably as many Axis I disorders. Frequent comorbidity of BPD with Axis I disorders necessitates a broad assessment of psychopathology to help account for clinical heterogeneity. Because of the absence of evidence of the validity of the diagnostic threshold for a categorical diagnosis of BPD, and because of the heterogeneity within the diagnosis, investigators should also supplement their DSM-IV diagnoses with assessments of underlying personality trait structures. Although there are a number of competing models of personality structure, they have remarkable convergence on a set of three to five basic personality dimensions.

The borderline diagnosis II: biology, genetics, and clinical course

In Part I of this three-part article, consideration of the core features of BPD psychopathology, of comorbidity with Axis I disorders, and of underlying personality trait structure suggested that the borderline diagnosis might be productively studied from the perspective of dimensions of trait expression, in addition to that of the category itself. In Part II, we review the biology, genetics, and clinical course of borderline personality disorder (BPD), continuing to attend to the utility of a focus on fundamental dimensions of psychopathology. Biological approaches to the study of personality can identify individual differences with both genetic and environmental influences. The aspects of personality disorder that are likely to have biologic correlates are those involving regulation of affects, impulse/action patterns, cognitive organization and anxiety/inhibition. For BPD, key psychobiological domains include impulsive aggression, associated with reduced serotonergic activity in the brain, and affective instability, associated with increased responsivity of cholinergic systems. There may be a strong genetic component for the development of BPD, but it seems clear, at least, that there are strong genetic influences on traits that underlie it, such as neuroticism, impulsivity, anxiousness, affective lability, and insecure attachment. The course of BPD suggests a heterogeneous disorder. Predictors of poor prognosis include history of childhood sexual abuse, early age at first psychiatric contact, chronicity of symptoms, affective instability, aggression, substance abuse, and increased comorbidity. For research purposes, at least, biological, genetic, and prognostic studies all continue to suggest the need to supplement categorical diagnoses of BPD with assessments of key underlying personality trait dimensions and with historical and clinical observations apart from those needed to make the borderline diagnosis itself.

The Implications of DSM-III Personality Disorders for Patients with Major Depression

We studied 78 inpatients with DSM-III major depression. Forty-one (53%) had a concurrent personality disorder (PD) according to a detailed structured interview for DSM-III personality disorders. The patients with depression plus PD differed from patients with depression alone on numerous measures. The PD patients had earlier onset; higher HRS scores; poorer social support; more life stressors; more frequent separation and divorce; more frequent nonserious suicide attempts, less frequent dexamethasone nonsuppression; poorer response to antidepressant medication; and higher risk for depression, alcoholism and antisocial personality among first-degree relatives. The PD subgroup shares many attributes with Winokurs subtype of depression spectrum disorder and Akiskals character spectrum disorder. An attempt to identify a subgroup of personality disorders which might be an atypical affective disorder was inconclusive. However, patients in DSM-III cluster III were similar to the patients with no-PD on the dexamethasone suppression test, response to treatment, and familial risk for depression and antisocial personality.

Systems Training for Emotional Predictability and Problem Solving (STEPPS) for Outpatients With Borderline Personality Disorder: A Randomized Controlled Trial and 1-Year Follow-Up

OBJECTIVE Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a 20-week manual-based group treatment program for outpatients with borderline personality disorder that combines cognitive behavioral elements and skills training with a systems component. The authors compared STEPPS plus treatment as usual with treatment as usual alone in a randomized controlled trial. METHOD Subjects with borderline personality disorder were randomly assigned to STEPPS plus treatment as usual or treatment as usual alone. Total score on the Zanarini Rating Scale for Borderline Personality Disorder was the primary outcome measure. Secondary outcomes included measures of global functioning, depression, impulsivity, and social functioning; suicide attempts and self-harm acts; and crisis utilization. Subjects were followed 1 year posttreatment. A linear mixed-effects model was used in the analysis. RESULTS Data pertaining to 124 subjects (STEPPS plus treatment as usual [N=65]; treatment as usual alone [N=59]) were analyzed. Subjects assigned to STEPPS plus treatment as usual experienced greater improvement in the Zanarini Rating Scale for Borderline Personality Disorder total score and subscales assessing affective, cognitive, interpersonal, and impulsive domains. STEPPS plus treatment as usual also led to greater improvements in impulsivity, negative affectivity, mood, and global functioning. These differences yielded moderate to large effect sizes. There were no differences between groups for suicide attempts, self-harm acts, or hospitalizations. Most gains attributed to STEPPS were maintained during follow-up. Fewer STEPPS plus treatment as usual subjects had emergency department visits during treatment and follow-up. The discontinuation rate was high in both groups. CONCLUSIONS STEPPS, an adjunctive group treatment, can deliver clinically meaningful improvements in borderline personality disorder-related symptoms and behaviors, enhance global functioning, and relieve depression.

DSM-III personality disorders: Diagnostic overlap and internal consistency of individual DSM-III criteria

Abstract We rated the presence or absence of every DSM-III personality criteria in a cohort of 131 non-psychotic subjects. Ratings were based on the Structured Interview for DSM-III Personality Disorders (SIDP) which was administered to each patient and a knowledgable informant. Diagnositc overlap of the personality disorders (PD) was examined. Sensitivity, specificity, predictive value—positive and negative, and interrater reliability was calculated for each criteria item of each personality disorder. Problems in reliability of DSM-III personality disorders can be traced to specific criteria within those disorders that are associated with low reliability and/or low predictive value positive when compared to the other criteria used to define the personality disorder. Improvements are suggested. We were unable to demonstrate a significantly greater enhancement of reliability among criteria structures using a polythetic classification over those using monothetic classification despite a trend favoring the former. This study agrees with others that find a great deal of overlap between borderline PD and histrionic PD as defined in DSM-III. Passive-aggressive PD is very rare in the absence of some other PD. Paranoid and schizoid personality disorders were also rare though this may reflect the fact that individuals with these disorders rarely seek treatment.

A Test of the Tridimensional Personality Theory: Association with Diagnosis and Platelet Imipramine Binding in Obsessive-Compulsive Disorder

We administered the Tridimensional Personality Questionnaire (TPQ) to a sample of 25 individuals with obsessive-compulsive disorder (OCD) and 35 normal controls. As predicted, OCD cases scored much higher on the harm avoidance dimension than normal controls. Findings for the novelty seeking and reward dependence dimensions were less dramatic, although compatible with the underlying theory. Despite a theoretical link between the harm avoidance dimension and serotonin-mediated neuropathways, we failed to find an association between this dimension and platelet imipramine binding in either OCD cases or controls.

The clinical and neuroendocrine features of psychotic depression.

The authors compared 65 patients with major depression and psychotic features to 192 patients with major depression and no psychotic features in terms of clinical features, family history, and hypothalamic-pituitary-adrenocortical axis function. In accord with other studies, patients with psychotic depression were more likely to have bipolar depression, psychomotor disturbance, a family history of schizophrenia, and a more severely disordered hypothalamic-pituitary-adrenocortical axis. Whether psychotic depression is best considered apart from nonpsychotic depression or as simply a more severe form of depression remains unsettled. Nevertheless, research to date does give the diagnosis of psychotic depression a practical significance which is enhanced by its simplicity.

Clinical correlates of self-mutilation among psychiatric inpatients

The charts of 660 consecutive admissions to a university psychiatric hospital were examined. After excluding those with mental retardation, 32 patients who had mutilated themselves and 88 patients admitted for unsuccessful suicide attempts were identified. Women were significantly overrepresented among the mutilators, but the groups did not differ with respect to age. Most analyses were restricted to women, of whom 27 were self-mutilators and 51 were nonmutilating suicide attempters. Mutilators were less likely to receive diagnoses of major depression or adjustment disorder but were more likely to have a history of substance abuse and receive Axis II diagnoses. The mutilative behavior was generally repetitive. The most common form was superficial cutting of the arms and wrists. Reports of lifetime sexual or physical abuse were more common among mutilators. Mutilators also had frequent histories of suicide attempts distinct from their mutilation behavior, multiple hospitalizations, and transfer to state hospitals for longer-term care. These findings suggest a chronic course with significant morbidity and associated features which may be of clinical significance.

Differences in plasma ACTH and cortisol between depressed patients and normal controls

Although studies have repeatedly demonstrated that depressed patients average higher baseline and postdexamethasone serum cortisol than normal controls, studies examining similar trends in adrenocorticotrophic hormone (ACTH) have produced conflicting results. The current study uniquely employs 48 hr of every 20-min serum sampling: the first 24 hr prior to dexamethasone administration and the second 24 hr subsequent. The depressed patients showed higher baseline cortisol levels than normal controls, with the greatest differences between 2 AM and 6 AM. After an 11 PM dose of dexamethasone, the difference was greatest between the hours of 8 AM and 4 PM. Among the depressed patients, those who reported recent weight loss had significantly higher plasma ACTH and cortisol levels than those without weight loss. Depressed patients without weight loss had higher baseline plasma ACTH than normal controls, and the differences reached significance during some time periods.

Influence of age on the cortisol response to dexamethasone.

Controversy exists regarding the association of age with postdexamethasone serum cortisol levels. We evaluated this relationship in 95 patients with major depressive disorder and 49 healthy controls. Age and 8 a.m. postdexamethasone cortisol levels were not correlated among the healthy controls, but were positively associated among the depressives. There was also a trend for age and 4 p.m. postdexamethasone cortisol levels to be positively associated in depressives. Multiple linear regression analyses revealed that these associations could not be explained by other variables such as sex, psychotic features, or familial subtype of depression. Several hypotheses that might account for these associations are examined.