D. Bradford Reich

Severity of reported childhood sexual abuse and its relationship to severity of borderline psychopathology and psychosocial impairment among borderline inpatients.

This study has two purposes. The first purpose is to describe the severity of sexual abuse reported by a well-defined sample of borderline inpatients. The second purpose is to determine the relationship between the severity of reported childhood sexual abuse, other forms of childhood abuse, and childhood neglect and the severity of borderline symptoms and psychosocial impairment. Two semistructured interviews of demonstrated reliability were used to assess the severity of adverse childhood experiences reported by 290 borderline inpatients. It was found that more than 50% of sexually abused borderline patients reported being abused both in childhood and in adolescence, on at least a weekly basis, for a minimum of 1 year, by a parent or other person well known to the patient, and by two or more perpetrators. More than 50% also reported that their abuse involved at least one form of penetration and the use of force or violence. Using multiple regression modeling and controlling for age, gender, and race, it was found that the severity of reported childhood sexual abuse was significantly related to the severity of symptoms in all four core sectors of borderline psychopathology (affect, cognition, impulsivity, and disturbed interpersonal relationships), the overall severity of borderline personality disorder, and the overall severity of psychosocial impairment. It was also found that the severity of childhood neglect was significantly related to five of the 10 factors studied, including the overall severity of borderline personality disorder, and that the severity of other forms of childhood abuse was significantly related to two of these factors, including the severity of psychosocial impairment. Taken together, the results of this study suggest that the majority of sexually abused borderline inpatients may have been severely abused. They also suggest that the severity of childhood sexual abuse, other forms of childhood abuse, and childhood neglect may all play a role in the symptomatic severity and psychosocial impairment characteristic of borderline personality disorder.

Time to Attainment of Recovery From Borderline Personality Disorder and Stability of Recovery: A 10-year Prospective Follow-Up Study

OBJECTIVE The purposes of this study were to determine time to attainment of recovery from borderline personality disorder and to assess the stability of recovery. METHOD A total of 290 inpatients who met both DSM-III-R and Revised Diagnostic Interview for Borderlines criteria for borderline personality disorder were assessed during their index admission using a series of semistructured interviews and self-report measures. The same instruments were readministered every 2 years for 10 years. RESULTS Over the study period, 50% of participants achieved recovery from borderline personality disorder, which was defined as remission of symptoms and having good social and vocational functioning during the previous 2 years. Overall, 93% of participants attained a remission of symptoms lasting at least 2 years, and 86% attained a sustained remission lasting at least 4 years. Of those who achieved recovery, 34% lost their recovery. Of those who achieved a 2-year remission of symptoms, 30% had a symptomatic recurrence, and of those who achieved a sustained remission, only 15% experienced a recurrence. CONCLUSIONS Taken together, the results of this study suggest that recovery from borderline personality disorder, with both symptomatic remission and good psychosocial functioning, seems difficult for many patients to attain. The results also suggest that once attained, such a recovery is relatively stable over time.

The 10-year course of psychosocial functioning among patients with borderline personality disorder and axis II comparison subjects

Zanarini MC, Frankenburg FR, Bradford Reich D, Fitzmaurice G. The 10‐year course of psychosocial functioning among patients with borderline personality disorder and axis II comparison subjects.

Ten-year use of mental health services by patients with borderline personality disorder and with other axis II disorders.

OBJECTIVE The study determined the prevalence of use of three treatment modalities (individual therapy, medication, and hospitalization) reported over a ten-year period by patients with borderline personality disorder and by those in a comparison group with other axis II disorders. Time to cessation and time to resumption for each modality among patients with borderline personality disorder were also determined. METHODS Treatment history of inpatients with a reliable diagnosis of borderline personality disorder (N=290) and of other axis II disorders (N=72) was assessed with an interview of proven reliability during the index admission. Treatment history was reassessed at two-year intervals for ten years. RESULTS For all three treatment modalities, prevalence of use declined significantly among patients with borderline personality disorder and among those in the comparison group. Among patients with borderline personality disorder, 52% reported having stopped individual therapy and 44% reported having stopped medication at one or more of the follow-up interviews over ten years. However, 85% of those who had stopped psychotherapy and 67% of those who stopped taking medication resumed these treatments during a subsequent two-year period. In contrast, 88% had experienced at least one two-year period without a psychiatric hospitalization by the time of the ten-year follow-up; however, almost half of these patients were subsequently rehospitalized. CONCLUSIONS The results suggest that patients with borderline personality disorder tend to use outpatient treatments without interruption over prolonged periods. They also suggest that inpatient treatment is used far more intermittently by patients with borderline personality disorder.

Adult Experiences of Abuse Reported by Borderline Patients and Axis Ii Comparison Subjects Over Six Years of Prospective Follow-up

The main objective of this study was to assess the rates of adult experiences of verbal, emotional, physical, and sexual abuse reported by borderline patients and Axis II comparison subjects during 6 years of prospective follow-up. A semistructured interview was administered to 290 borderline patients and 72 Axis II comparison subjects during their index admission. A follow-up analogue to this interview was administered at three contiguous 2-year follow-up periods. Over 94% of surviving patients were reinterviewed at all three follow-up waves. The rates of all four forms of reported abuse declined significantly over time for all subjects considered together. However, each of these types of abuse was reported by a significantly higher percentage of borderline patients than Axis II comparison subjects. When the presence of these forms of abuse was used to predict time to remission, all but sexual abuse were strongly associated with the failure to achieve symptomatic remission from borderline personality disorder. Taken together, the results of this study suggest that the rates of adult abuse reported by borderline patients decline significantly with time but remain relatively high. They also suggest that adult experiences of abuse are strongly associated with a failure to remit from borderline personality disorder.

Affective lability in bipolar disorder and borderline personality disorder

BACKGROUND The boundaries between the affective instability in bipolar disorder and borderline personality disorder have not been clearly defined. Using self-report measures, previous research has suggested that the affective lability of patients with bipolar disorder and borderline personality disorder may have different characteristics. METHODS We assessed the mood states of 29 subjects meeting Revised Diagnostic Interview for Borderlines and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for BPD and 25 subjects meeting DSM-IV criteria for bipolar II disorder or cyclothymia using the Affective Lability Scale (ALS), the Affect Intensity Measure (AIM), and a newly developed clinician-administered instrument, the Affective Lability Interview for Borderline Personality Disorder (ALI-BPD). The ALI-BPD measures frequency and intensity of shifts in 8 affective dimensions. Subjects in the borderline group could not meet criteria for bipolar disorder; subjects in the bipolar/cyclothymia group could not meet criteria for BPD. RESULTS Patients in the bipolar group had significantly higher scores on the euthymia-elation subscale of the ALS; patients in the BPD group had significantly higher scores on the anxiety-depression subscale of the ALS. Patients with bipolar disorder had significantly higher total AIM scores and significantly higher score on the AIM positive emotion subscale. In terms of frequency, patients in the borderline group reported the following: (1) significantly less frequent affective shifts between euthymia-elation and depression-elation on the ALI-BPD and (2) significantly more frequent shifts between euthymia-anger, anxiety-depression, and depression-anxiety. In terms of intensity, borderline patients reported the following: (1) significantly less intense shifts between euthymia-elation and depression-elation on the ALI-BPD and (2) significantly more intense shifts between euthymia-anxiety, euthymia-anger, anxiety-depression, and depression-anxiety. CONCLUSION The affective lability of patients with borderline and bipolar II/cyclothymic can be differentiated with respect to frequency and intensity using both self-report and clinician-administered measures.

A longitudinal study of the 10-year course of interpersonal features in borderline personality disorder.

The literature on borderline personality disorder (BPD) describes interpersonal disturbances as a core sector of psychopathology. The longitudinal course of these features remains poorly understood. Our aim is to describe the course of interpersonal features of BPD in a more detailed way than has been done previously. Twenty interpersonal aspects of borderline psychopathology were assessed using two reliable semi-structured diagnostic interviews at baseline and at five successive two-year follow-up waves in the ongoing McLean Study for Adult Development. Behaviorally-oriented features, such as recurrent breakups, sadism, demandingness, entitlement, regression in treatment, and boundary violations, remitted quickly and were rare at the end of follow-up. The interpersonal features slowest to remit were affective responses to being alone, active caretaking, discomfort with care, and dependency. The behavioral interpersonal features of BPD remit rapidly, while core affectively-oriented features related to intolerance of aloneness and conflicts over dependency are more persistent.

Predictors of suicide attempts in patients with borderline personality disorder over 16 years of prospective follow-up

BACKGROUND It is clinically important to understand the factors that increase the likelihood of the frequent and recurrent suicide attempts seen in those with borderline personality disorder (BPD). Although several studies have examined this subject in a cross-sectional manner, the aim of this study was to determine the most clinically relevant baseline and time-varying predictors of suicide attempts over 16 years of prospective follow-up among patients with BPD. METHOD Two-hundred and ninety in-patients meeting Revised Diagnostic Interview for Borderlines (DIB-R) and DSM-III-R criteria for BPD were assessed during their index admission using a series of semistructured interviews and self-report measures. These subjects were then reassessed using the same instruments every 2 years. The generalized estimating equations (GEE) approach was used to model the odds of suicide attempts in longitudinal analyses, controlling for assessment period, yielding an odds ratio (OR) and 95% confidence interval (CI) for each predictor. RESULTS Nineteen variables were found to be significant bivariate predictors of suicide attempts. Eight of these, seven of which were time-varying, remained significant in multivariate analyses: diagnosis of major depressive disorder (MDD), substance use disorder (SUD), post-traumatic stress disorder (PTSD), presence of self-harm, adult sexual assault, having a caretaker who has completed suicide, affective instability, and more severe dissociation. CONCLUSIONS The results of this study suggest that prediction of suicide attempts among borderline patients is complex, involving co-occurring disorders, co-occurring symptoms of BPD (self-harm, affective reactivity and dissociation), adult adversity, and a family history of completed suicide.

The course of substance use disorders in patients with borderline personality disorder and Axis II comparison subjects: a 10-year follow-up study

AIM The purpose of this study is to detail the course of substance use disorders (SUDs) over 10 years of prospective follow-up among patients with borderline personality disorder (BPD) and Axis II comparison subjects. DESIGN This study uses data from the McLean Study of Adult Development (MSAD), a multi-faceted study of the longitudinal course of BPD using reliable repeated measures administered every 2 years over a decade of prospective follow-up. SETTING All subjects were initially in-patients at McLean Hospital in Belmont Massachusetts. PARTICIPANTS; A total of 290 patients with BPD and 72 Axis II comparison subjects were assessed at baseline and five waves of follow-up. MEASUREMENTS The Structured Clinical Interview for DSM-III-R Axis I Disorders (SCID-I), the Revised Diagnostic Interview for Borderlines (DIB-R) and the Diagnostic Interview for DSM-III-R Personality Disorders (DIPD-R) were administered six times. Generalized estimating equations were used to assess longitudinal prevalence of SUDs. Kaplan-Meier analyses were used to assess time-to-remission, recurrence and new onsets of SUDs. RESULTS The prevalence of SUDs among borderline patients and Axis II comparison subjects declined significantly over time, while remaining significantly more common among those with BPD. More than 90% of borderline patients meeting criteria for a SUD at baseline experienced a remission by 10-year follow-up. Recurrences and new onsets of SUDs were less common (35-40% and 21-23%). CONCLUSIONS Remissions of alcohol and drug abuse/dependence among borderline patients are both common and relatively stable. Results also suggest that new onsets of these disorders are less common than might be expected.

Developmental aspects of borderline personality disorder.

This study examined whether patients with borderline personality disorder and controls with other personality disorders remember their childhoods differently with respect to separation difficulties, evocative memory, temperamental factors such as frustration tolerance and mood reactivity, and onset of symptoms. Two hundred and ninety patients with borderline personality disorder and 72 with other personality disorders were assessed using an instrument to rate memories of separation difficulties, temperamental problems, and onset of symptoms before age 18. Patients with borderline personality disorder remembered more difficulties with separation between ages 6 and 17 years, more mood reactivity and poorer frustration tolerance between ages 6 and 17, and the onset of more symptoms (most prominently sadness, depression, anxiety, and suicidality) before age 18 than did patients with other personality disorders. The groups did not differ in reports of evocative memory before age 18. These results indicate that many of the features of adult patients with borderline personality disorder may initially appear during childhood and adolescence and that these features may be used to differentiate borderline from other personality disorders.