Frances R. Frankenburg

Childhood experiences of borderline patients.

The childhood histories of 50 outpatients meeting both Diagnostic Interview for Borderlines (DIB) and DSM-III criteria for Borderline Personality Disorder, 29 outpatients meeting DSM-III criteria for Antisocial Personality Disorder, and 26 outpatients meeting DSM-III for Dysthymic Disorder as well as DSM-III criteria for some other type of Axis II disorder were assessed, blind to proband diagnosis, using a semistructured interview. Borderlines were significantly more likely than those in either control group to report a history of abuse, particularly verbal and sexual abuse. They were also significantly more likely than antisocial controls to report a history of neglect, particularly emotional withdrawal, and significantly more likely than dysthymic other personality disorder controls to report a history of early separation experiences. The authors conclude that the development of Borderline Personality Disorder is more strongly associated with (1) exposure to chronically disturbed caretakers than prolonged separations from these same adults and (2) a history of abuse than a history of neglect.

The diagnostic interview for personality disorders: Interrater and test-retest reliability

Abstract The Diagnostic Interview for Personality Disorders (DIPD) is a semistructured interview of 252 questions that encompasses all 11 Axis II disorders described in the DSM-III. Its interrater reliability was assessed using a sample of 43 patients and its test-retest reliability was assessed using a separate sample of 54 patients. Adequate kappas were obtained in both situations for all disorders except schizoid personality disorder, which was never diagnosed. Interrater coefficients ranged from .52 to 1.0, with nine in the excellent range (κ > .75). Test-retest coefficients ranged from .46 to .85, with four in the excellent range. These results compara very favorably to those achieved using the other two Axis II interviews that have appeared in the literature, the Structured Interview for the DSM-III Personality Disorders (SIDP) and the Personality Disorder Examination (PDE).

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.

Axis II Comorbidity of Borderline Personality Disorder

The purpose of this study was to assess the prevalence of a full range of DSM-III-R axis II disorders in a sample of criteria-defined borderline patients and axis II controls. The axis II comorbidity of 504 personality-disordered inpatients was assessed blind to clinical diagnosis using a semistructured research interview. Odd, anxious, and dramatic cluster disorders were each common among borderline patients. However, only odd and anxious cluster disorders were significantly more common among borderline patients (N = 379) than axis II controls (N = 125). Paranoid, avoidant, and dependent personality disorders were the most highly discriminating disorders between borderline patients and controls. In addition, male and female borderline patients exhibited somewhat different patterns of comorbidity. Although the rates of avoidant and dependent personality disorders were similar, male borderlines were significantly more likely than female borderlines to meet DSM-III-R criteria for paranoid, passive-aggressive, narcissistic, sadistic, and antisocial personality disorders. These results suggest that there is a particularly strong relationship between anxious cluster disorders and borderline personality disorder (BPD). They also suggest that gender plays an important role in the expression of axis II comorbidity, particularly with respect to dramatic cluster disorders.

The pain of being borderline: dysphoric states specific to borderline personality disorder.

&NA; The objective of this study was to identify the dysphoric states that best characterize patients meeting criteria for borderline personality disorder and distinguish them from those in patients with other forms of personality disorder. One hundred forty‐six patients with criteria‐defined borderline personality disorder and 34 Axis II controls filled out the Dysphoric Affect Scale, a 50‐item self‐report measure that was designed for this purpose and has good internal consistency and test‐retest reliability. Twenty‐five dysphoric states (mostly affects) were found to be significantly more common among borderline patients than controls but nonspecific to borderline personality disorder. Twenty‐five other dysphoric states (mostly cognitions) were found to be both significantly more common among borderline patients than controls and highly specific to borderline personality disorder. These states tended to fall into one of four clusters: (1) extreme feelings, (2) destructiveness or self‐destructiveness, (3) fragmentation or “identitylessness,” and (4) victimization. In addition, three of the 25 more‐specific states (feeling betrayed, like hurting myself, and completely out of control), when occurring together, were particularly strongly associated with the borderline diagnosis. Equally important, overall mean Dysphoric Affect Scale scores correctly distinguished borderline personality disorder from other personality disorders in 84% of the subjects. Taken together, the results of this study suggest that the subjective pain of borderline patients may be both more pervasive and more multifaceted than previously recognized, and that the overall “amplitude” of this pain may be a particularly good marker for the borderline diagnosis.

Progressive ventricular enlargement in schizophrenia: Comparison to bipolar affective disorder and correlation with clinical course

Previous studies of long-term serial changes in ventricular size in schizophrenia (SCZ) have yielded mixed, albeit predominantly negative results. The current study examined ventricular changes in CT scans over intervals of 1-to 4 1/2 years in chronic schizophrenic and bipolar patients. The results indicated significant progression of ventricular size from initial to final scan in the schizophrenia group but not in the bipolar or control groups; the percent increase in VBR over baseline was 25% (p less than 0.01) in the schizophrenia group as compared with 11% (n.s.) in the bipolar group. The increases in ventricular enlargement in the schizophrenic group did not correlate with duration of illness but did appear to show an irregular stepwise pattern in several patients. It is concluded that progressive ventricular enlargement after onset of illness does occur in a subgroup of schizophrenic patients characterized by a chronic or deteriorating clinical course. The etiological implications of this finding are discussed.

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.

A controlled family history study of bulimia.

Using the family history method, we assessed the morbid risk for psychiatric disorders in the first-degree relatives of 69 probands with bulimia, 24 probands with major depression, and 28 nonpsychiatric control probands. The morbid risk for major affective disorder among the first-degree relatives of the bulimic probands was 32%, significantly greater than that found in the nonpsychiatric control probands. The rate of familial major affective disorder was significantly greater in bulimic probands who had a history of major affective disorder themselves than in bulimic probands without such a history - but the latter group, in turn, displayed significantly higher rates than the nonpsychiatric control probands. Eating disorders were slightly, but not significantly, more prevalent in the families of bulimic probands than nonpsychiatric control probands. We present two alternative hypotheses which might explain these findings.

The 10‐year course of physically self‐destructive acts reported by borderline patients and axis II comparison subjects

Objective:  The purpose of this paper was to determine the frequency and methods of two forms of physically self‐destructive acts (i.e. self‐mutilation and suicide attempts) reported by borderline patients and axis II comparison subjects over 10 years of prospective follow‐up.

Clozapine and metabolites: concentrations in serum and clinical findings during treatment of chronically psychotic patients.

Clozapine (CLZ) and metabolites norclozapine and clozapine-N-oxide were assayed with a new, sensitive (2 pmol), and selective method in 68 serum samples from 44 psychotic subjects, 20 to 54 years old, ill 16 years, and treated with CLZ for 2.2 years (currently at 294 mg, 3.4 mg/kg daily). CLZ levels averaged 239 ng/ml (0.73 microM; 92 ng/ml per mg/kg dose) or 48% of total analytes (norclozapine = 41% [91% of CLZ] and clozapine-N-oxide = 11%); metabolite and CLZ levels were highly correlated (rs = 0.9), and CLZ levels varied with daily dose (rs = 0.7). Sampling twice yielded similar within-subject analyte levels (r = 0.8 to 0.9; difference = 24% to 33%). Range and variance narrowed when levels were expressed per weight-corrected dose (ng/ml per mg/kg). Levels per dose were 40% higher in nonsmoking women than men, despite a 60% lower milligram per kilogram dose in women, and did not vary by diagnosis or age in this limited sample. Fluoxetine increased serum CLZ analytes by 60%; valproate had less effect. Patients rated treatment very positively; observer-assessed benefits typically were more moderate. Common late side effects were sialorrhea (80%), excess sedation (58%), obesity (55% > 200 lb), mild tachycardia (51%), constipation (32%), and enuresis (27%); there were no seizures or leukopenia. There was little evident relationship of drug dose or serum level to current clinical measures or side effect risks.