When Your Loved One Has Borderline Personality Disorder

Escape Plan From a Borderline Woman

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Borderline personality disorder

The psychobiological model of personality proposed by Cloninger et al.(2Z> suggests a treatment strategy that combines medication and psychotherapy. Certain medications appear to improve target symptoms associated with temperament, such as impulsivity and affective lability, while psychotherapy may address the character problems such as self-directedness and co-operativeness. At least three studies using a double-blind placebo-controlled design have demonstrated that impulsivity and anger in patients with borderline personality disorder are significantly improved with the use of serotonin-selective reuptake inhibitors. (5 5 and 52> These agents do not cure borderline personality disorder, but they do facilitate the psychotherapy process. When the affect and the impulsivity is toned down by the use of medication, patients often find it easier to reflect on internal states and process what is happening between them and others.

Variations of the Borderline Personality

Argue that the DSM borderline pattern overlaps nearly every other personality disorder, with some exceptions. Because most subjects diagnosed as borderline are female by a ratio of 2 to 1 or even higher, subjects with dependent, histrionic, avoidant, depressive, and negativistic features are common, though for different reasons. In general, any personality pattern that makes others the center of life is at risk to develop a borderline personality. The desire to magically fuse with others who will support you emotionally and meet your every need is evidence of both ego weakness and identity disturbance, leading to instability in interpersonal relationships and feelings of emptiness and desperation when others seem to separate. In contrast, a DSM borderline diagnosis is probably less likely for male compulsive, sadistic, paranoid, and some narcissistic personalities, for whom dogmatism, righteous indignation, or grandiosity artificially boost the coherence of the self, giving it rigid...

Borderline Personality and Sexual Trauma Connections between Trauma and Safe Attachments

Although the conceptualization of the borderline personality and its causes remain unclear (Paris, 1994a, 1994b Zanarini & Frankenburg, 1997), most empirical research shows a marked relationship between childhood trauma and borderline symptoms. Risk factors that differentiate borderline patients usually include loss, histories of sexual and physical abuse, severe neglect or emotional abuse, being witness to domestic violence, and parental substance abuse or criminality (Guzder, Paris, Zelkowitz, & Marchessault, 1996 Laporte & Guttman, 1996 Zanarini et al., 1997). Of these, many studies suggest an especially significant relationship between childhood sexual abuse and the development of the borderline personality (see Paris, 1994b Sabo, 1997 Zanarini & Frankenburg, 1997). To unravel factors that might contribute to abuse, Silk, Lee, Hill, and Lohr (1995) constructed an index of the severity. Cases were coded in terms of who abused the subject, how long the subject was...

Borderline personality disorder DLT Definition

Many definitions and meanings have been proposed for borderline personality disorder. This most controversial of all personality disorders is best understood as a heterogeneous syndrome manifested by egosyntonic affective instability and impulsivity (behavioural dyscontrol) and propensity to cognitive-perceptual distortions in the context of a chronically unstable interpersonal relationships. Early psychoanalysis did not explicitly deal with borderline personality disorder, although a careful retrospective study of the literature shows that some of Freud's classical patients (e.g. the wolf-man) would have been diagnosed today as typical borderline cases. Stern (36> was the first to use the term 'borderline' in 1938, placing borderline patients on the border between neuroses and psychoses. The concepts of 'ambulatory schizophrenia', 'as-if' personality, 'pseudoneurotic schizophrenia', 'borderline states', and 'psychotic character' paved the way to the contemporary concept of...

The Case of Lenore Borderline Personality Disorder

The defense of splitting is central in the repertoire of those with a personality disorder in Cluster B, especially for those with Borderline Personality Disorder (BPD). The reality of the individual with BPD is notable for affective and cognitive experiences and distortions, which shift with remarkable alacrity to the extremes. There is no gray. People and events are experienced as all good or all bad. The splitting transcends multiple relationships and venues, typically wreaking havoc.

Application to Borderline Personality Disorder

The DSM-IV-TR states that people with Borderline Personality Disorder have a chronic pattern of instability in interpersonal relationships, impulsivity, intense anger, suicidal attempts, and stress-related dissociative episodes. Borderline Personality Disorder has an early adult onset, and may occur three times more in females than males. On the surface, it appears that individuals with these features would not have much reproductive success. However, according to the DSM-IV-TR, its prevalence rate is about 2 in general populations throughout the world, 10 of all patients in outpatient settings, 20 among psychiatric inpa-tients, and 30 to 60 of all patients with a suspected personality disorder. Thus, it is a relatively common personality disorder despite this array of seemingly negative elements. One reason for its persistence from an evolutionary perspective may be that, although Borderline Personality Disorder may be highly heritable, an adult onset in contemporary society might...

Borderline personality disorders

These anti-group potentialities can be managed to good effect in the containing setting of closed or specialized institutions, and there is an increasing literature on different approaches of this kind. (115) It is generally better to place one or two borderline patients in otherwise well-functioning groups where there is a good therapeutic stance and the capacity to understand and care. Other members will not always respond to borderline pathology at the same primitive level. They may, like the adult carers of children, respond with understanding, find ways of setting limits, and expect co-operation with the task in hand. After sometimes lengthy periods in which borderline patients maintain a frustrating presence on the margins of the group or make themselves felt in aggravating terms at its very centre, they can acquire resources to take part in the group's work in more mature terms. This combination of borderline and neurotic members in a carefully composed group can benefit both...

Chapter References

Borderline conditions and pathological narcissism. Jason Aronson, New York. 34. Kernberg, O.F., Selzer, M.A., Koenigsberg, H.W., Carr, A.C., and Appelbaum, A.H. (1989). Psychodynamic psychotherapy of borderline patients. Basic Books, New York. 36. Clarkin, J.F., Yeomans, F., and Kernberg, O.F. (1999). Psychotherapy for borderline personality. Wiley, New York.

Diagnosis and differential diagnosis

The differential diagnosis includes a variety of other disorders. A key difference between schizotypal personality disorder and schizophrenia, a psychotic mood disorder, or another psychotic condition involves the transient nature of psychotic symptoms in schizotypal personality disorder. It may be distinguished from developmental communication disorders by a lack of compensatory means (e.g. gestures) of communicating, and it may be distinguished from autistic or Asperger's disorders by the relatively greater deficits in social awareness and frequent presence of stereotyped behaviours in those disorders. Schizotypal personality disorder may be confused with several other personality disorders, but it can be distinguished. In particular, it differs from schizoid personality disorder by its pattern of cognitive-perceptual distortions, and by the odd appearance or behaviour shown frequently by schizotypal patients. The pattern of schizotypal symptoms also differs from that manifested in...

Clinical features and diagnostic considerations

By definition, individuals with cyclothymia report short cycles of depression and hypomania that fail to meet the sustained duration criterion for major affective syndromes. At various times, they exhibit the entire range of manifestations required for the diagnosis of depression and hypomania, but only from a few days at a time up to 1 week, rarely longer. (79) These cycles follow each other in an irregular fashion, often changing abruptly from one mood to another, with only rare interposition of 'even' periods. The unpredictability of mood swings is a major source of distress for cyclothymes, as they do not know from moment to moment, how they will feel.(80) As one patient put it, 'my moods swing like a pendulum, from one extreme to another'. The rapid mood shifts, which undermine the patients' sense of self, may lead to the misleading diagnostic label of borderline personality. But unlike a personality disorder, the mood changes in cyclothymes have a circadian component. One...

Albert Ellis and Carl Rogers Finding Your Own Therapeutic Style

These movements, however, are only the latest in a long series of adaptations, not the final word. More appropriate to the symptom disorders of Axis I, they represent only an intermediate step toward a psychotherapy logically coordinated to the personality disorders. Personality pathologies are notoriously resistant to treatment. They not only make for fragile gains that are often suddenly and dramatically reversed, but also complicate transference and countertransference reactions with unanticipated issues and just naturally tend to generate Axis I symptoms. The borderline personality, infamous among therapists, provides an outstanding example. Borderlines often improve, only to suddenly become depressed and suicidal again as termination approaches. Moreover, contemporary therapies fail to recognize an intrinsic contradiction between the formal properties of therapy as it is currently practiced and the formal properties of psychotherapy that personality disorders logically require....

General psychopathology

A subgroup of patients with bulimia nervosa have 'impulse-control' problems, such as the overconsumption of alcohol or drugs, or repeated self-harm. Some of these patients also meet diagnostic criteria for borderline personality disorder. The prevalence of such features varies according to treatment setting they are unusual in community samples 20 whereas they are more frequent among patients seen in specialist treatment centres.

Personality disorders

It is hazardous making personality disorder diagnoses among those with eating disorders. This is because eating disorders have their onset in adolescence and they directly affect many of the characteristics upon which personality is judged. Thus there is a risk of overestimating the presence of personality disturbance. Nevertheless, some patients with bulimia nervosa do seem to have a coexisting personality disorder, the most common form being borderline personality disorder. (19 Little is known about the rate of personality disturbance among the relatives of these patients.

Developmental issues

Case histories of patients in psychodynamically oriented treatment revealed the presence of developmental conflicts in borderline personality disorder. Masterson (53) emphasized the abandonment fears which originate in traumatic childhood separation experiences. Gunderson (54) identified intolerance of aloneness as a serious psychological deficit which seems to develop from developmental attachment failures. Kernberg(41) and the object relation theorists believe that a lack of optimal emotional availability on the part of the mother during the rapprochement subphase of separation-individuation may be critical in the development of a future borderline personality. Splitting remains in the internal world of pre-borderline children, identity diffusion prevails, and object constancy is never reached. Superego pathology is evident, with sadistic superego forerunners being predominant. The role of childhood trauma in the development of borderline personality disorder has been identified as...

Interpersonal relationships

Interpersonal relationships are unstable, intense, demanding, clinging, and characterized by alternation between extremes of idealization and devaluation, deriving from splitting, which is a clinical marker of borderline personality disorder. Diagnostics can be improved by Kernberg's structural interview (58) and the Diagnostic Interview for Borderline Patients.(59) Borderline personality disorder is frequently comorbid with affective disorders (major depression, dysthymia, and 'double depression'), anxiety disorders, somatization disorder, post-traumatic stress disorder, and alcohol abuse. Comorbidity with affective disorders is particularly important. There is an ongoing debate about which condition begins first and may be primary. Borderline personality disorder has been shown to be associated with most personality disorders, especially with those from the dramatic cluster. A high prevalence of comorbid personality disorders may be a result of insufficient criteria, or of the...

Minimum requirements for establishment of efficacy

However, there has been considerable interest in the dynamic psychotherapy of borderline personality disorder in the last 20 years. As discussed in Chapter4,12.3, borderline personality disorder is not typical of other personality disorders and patients often seek treatment for it repeatedly. Because it is associated with intense anger and emotion, the normal processes of psychoanalysis, involving interpretation, transference, and countertransference, are not considered suitable for this group and more subtle approaches are needed. (616)

Summary of treatments claimed to be effective in personality disorder Psychological treatments

Although dynamic psychotherapy and psychoanalysis have used personality disorder (mainly the less serious variety) as their stock-in-trade for treatment over many years, there is little evidence to suggest clear gains for this approach in its treatment. Nevertheless, the absence of evidence is largely related to the absence of adequate research, and there are several approaches that may be of value for borderline personality disorder in particular, but the consensus is that the brief forms of psychotherapy are likely to be the most valuable in these conditions and that conventional psychotherapeutic approaches are not efficacious. (56>

Associated psychopathology and comorbidity

Intermittent explosive disorder often co-occurs with other psychiatric disorders. For example, of 46 impulsive violent offenders ( n 24) and fire-setters (n 22) in one study,(8) 33 (72 per cent) of whom met the DSM-III criteria for intermittent explosive disorder, 44 (96 per cent) had a lifetime diagnosis of alcohol abuse, 41 (89 per cent) had borderline personality disorder, 24 (52 per cent) had a mood disorder, and nine (20 per cent) had antisocial personality disorder. Of 27 subjects with DSM-IV intermittent explosive disorder evaluated with the Structured Clinical Interview for DSM-IV, (6) 25 (93 per cent) met lifetime criteria for a mood disorder (with 15 (55 per cent) meeting criteria for a bipolar disorder), 13 (48 per cent) for a substance use disorder, 13 (48 per cent) for an anxiety disorder (with six (22 per cent) meeting criteria for obsessive-compulsive disorder), six (22 per cent) for an eating disorder, and 12 (44 per cent) for an impulse control disorder other than...

Repetitive selfmutilation Clinical description

Although recommendations that repetitive self-mutilation be included as a formal impulse control disorder not elsewhere classified in DSM-IV were rejected because of concerns that it was usually a symptom of borderline personality disorder, numerous clinical studies suggest that this syndrome does in fact meet the DSM-IV and ICD-10 concepts of impulse control disorders, and as such, may exist in the absence of borderline personality disorder. (2 29 and 30) Specifically, repetitive self-mutilation is characterized by intrusive, recurrent, and irresistible impulses to harm oneself without suicidal intent that are associated with increasing tension, anxiety, anger, or other dysphoric states, along with relief of the uncomfortable affect with or shortly after the act of self-harm. In addition, the act of self-harm is often not associated with pain and performed privately.

Epidemiology and course

Repetitive self-mutilation often co-occurs with other Axis I and II psychiatric disorders, especially mood, substance use, eating, psychotic, and borderline personality disorders. For example, in a 1983 review of 56 cases from the literature of patients with the 'deliberate self-harm syndrome', 45 per cent of patients were depressed, 41 per cent were psychotic, and 36 per cent were substance abusers.(28) In another evaluation of 54 psychiatric inpatients with 'self-injurious behaviour', eating disorders were the most common associated ICD-10 Axis I diagnosis, present in 54 per cent of patients, followed by substance use (33 per cent), affective disorders (20 per cent), and schizophrenic disorders (18 per cent). (29> Borderline and histrionic were the most frequent personality disorders, present in 52 and 23 per cent of the group, respectively. However, 22 per cent of patients did not fulfil criteria for any personality disorder.

Course and prognosis

Trichotillomania usually develops in childhood or adolescence with a mean age of onset around 13 years. (34) Claims that trichotillomania is usually self-limited in childhood are only partially substantiated.(3) Prognosis may be better if the duration of trichotillomania at intervention is 6 months or less. Otherwise, the disorder typically takes on a chronic waxing and waning course. Prognosis following treatment has been poorly studied. However, patients with comorbid borderline personality disorder or anxiety disorders appear to be more resistant to treatment.(9)

Psychosocial treatments

One trial has been conducted in which an intensive form of psychological treatment known as dialectical behaviour therapy was evaluated. ( 5) Female patients with borderline personality disorders who had a history of repeated self-harm were offered a year of individual and group cognitive-behavioural therapy aimed at

Emotional contributors to the patients physical symptoms

Although physicians often consider whether there is amplification of physical symptoms on an emotional basis, the intentional simulation of illness or fabrication of symptoms is usually not taken into account. Patients with factitious disorders may do so for no apparent reason other than to assume the patient role, in contrast with malingerers who seek some other secondary gain from medical or surgical treatment. Many of these patients with factitious disorders clearly manifest major psychopathology, most often features of borderline personality disorder.(4) However, others, most often young women working in health-related fields, present with apparent high levels of social and occupational functioning. (5) While relatively rare, factitious disorders pose particular challenges to the psychiatric and surgical teams in both their detection and treatment. Individuals with factitious disorders may produce symptoms that require surgical intervention, including self-inflicted wounds, or...

Neuroanatomical Studies

Deficits in impulse control and executive functions have been robustly linked to frontal lobe abnormalities. As above, the gambling task, a measure of impulsive decision making, is significantly impaired in patients with orbito-frontal lesions (Bechara et al, 1994). Impulsive patients, such as borderline personality disorder patients, have decreased frontal glucose metabolic rates, and those with greater aggression have lower frontal activity (Goyer et al, 1991). Further, electrophys-iological studies demonstrate a link between impulsivity and impaired frontal function (Kiehl, Hare et al, 1999 Barratt, Stanford et al. 1997).

Preliminary Findings Study design

A single large trial of IPSRT as a treatment for bipolar disorder (in combination with medication) is currently nearing completion at the University of Pittsburgh. This study, Maintenance Therapies in Bipolar Disorder (MTBD), is funded by a grant from the National Institute of Mental Health (R37 MH29618). In MTBD, acutely ill patients meeting criteria for bipolar I disorder are treated with medication and randomly assigned to either IPSRT or intensive clinical management (ICM). In order to enter the protocol, subjects must meet the Schedule for Affective Disorders and Schizophrenia criteria (Spitzer & Endicott, 1978) or the Research Diagnostic Criteria (Endicott et al., 1977) for bipolar I disorder with a score of 15 or greater on the 24-item HRSD (Hamilton, 1960 Thase et al., 1991) or the Bech-Rafaelson Mania Scale (Bech et al., 1979). Exclusion criteria include pregnancy, chronic alcohol and drug abuse, rapid cycling (defined as four or more affective episodes in 1 year), or an...

Psychological Treatments

Interpersonal psychotherapy (IPT) is a directive treatment model that uses dynamic, cognitive, and behavioral techniques to modify maladaptive relationship patterns. Interpersonal Psychotherapy was developed as a short-term treatment model for depression, and has been shown to be effective with this clinical population. The model has recently been adapted specifically for older adults (see Hin-richsen & Clougherty, 2006). However, it has not been studied as a treatment modality for older adults with a personality disorder, with or without comorbid depression. One study reported on an adaptation of IPT for use with young adults with Borderline Personality Disorder, which suggested some success (Weissman, Markowitz, & Klerman, 2000). The focus with IPT is on the interpersonal context, at the juncture at which most problems (and stress) occur this is especially problematic for the individual with a personality disorder. The adaptation for use with Borderline Personality Disorder...

Additional risk factors

Who had both borderline personality disorder and major depression with those who had only major depression or only borderline personality disorder. Depressed and borderline patients did not differ from each other in characteristics of suicide attempts (number of attempts, level of lethal intent, medical damage, objective planning, or degree of violence of method), but those with both disorders had higher levels of objective planning and a greater number of attempts. Comorbid depression and alcoholism are also associated with higher rates of suicidality than is depression alone (Cornelius et al., 1995).

Specific psychotherapies

Dialectical behavioural therapy (DBT) is the only form of psychotherapy that has been shown in a randomized control trial to reduce suicidality in adults with borderline personality disorder. (49 This treatment is based on a biosocial theory in which suicidal behaviours are considered to be maladaptive solutions to painful negative emotions that also have affect-regulating qualities and elicit help from others. (S

From Normality to Abnormality

Although its symptoms are obviously severe, the borderline personality can nevertheless be viewed as existing on a continuum with normality. The mercurial style (Oldham & Morris, 1995) is described as living a roller coaster life. Frequent ups and downs are the rule, and attachment is the central theme in all relationships. Echoing the borderline's frantic attempts to avoid abandonment is a desire always to be involved in a passionate romantic relationship. Such individuals, these authors state, process experience emotionally rather than logically, showing their feelings with spontaneity and creativity. Socially, they are lively and engaging, with an open mind toward experimenting with various roles and value systems. Exhibiting aspects of the dependent and histrionic personalities, they urgently seek closeness with their partners, like a merging of souls but even more intensely. They expect the same from others and quickly become hurt whenever the same desire is not forthcoming....

HIV and Personality Disorders High Risk Behavior and Disease Susceptibility

Personality disorders are more common among those infected with Human Immunodeficiency Virus (HIV), with borderline personality being one of the most frequent. For example, Perkins, Davidson, Leserman, Liao, and Evans (1993) found a higher prevalence of personality disorder among HIV-positive than HIV-negative subjects, with borderline the principal diagnosis. Later studies have supported this finding. In a longitudinal study, Jacobsberg, Frances, and Perry (1995) discovered that almost two-fifths of subjects who tested seropositive could be diagnosed with a personality disorder. Among subjects who did not know their HIV status, significantly more HIV-positive than HIVnegative subjects could be diagnosed as borderlines. Others have found that personality disorders and other serious mental conditions may impair self-assessment of risk and reduce the effectiveness of educational programs (Knox, Boaz, Friedrich, & Dow, 1994). Borderline Personality Disorder DSM-IV Criteria

The Interpersonal Perspective

Nevertheless, the stormy interpersonal life of the borderline personality, where action flows freely from mood, is legendary. Although everyone wants a special someone, many borderlines hunger for that one relationship to validate their very existence, a powerful or nurturing figure who can make them feel secure. At the beginning, they feel magically involved, idealizing their partner, putting him or her on a pedestal as the greatest thing the world has ever seen. Because their partner is so special, borderlines are special, too, for it is they who are the recipient of the love and affection of this perfect person. Distance is intolerable and separation unthinkable. At one time, Jenny probably felt exactly this way about her boyfriend.

Borderlines and Self Injury Is There a Rationale for Self Injury

Most researchers make a distinction between self-injurious behavior and self-mutilation (Herpertz, 1995). Self-injurious refers to moderate forms of self-inflicted bodily injury such as cutting, carving, and burning of the skin, as well as manipulative suicidal behavior. Such moderate forms of harm to self are characteristic of the borderline personality. Self-mutilation is generally considered to be a wider category that includes self-injurious behavior and other forms of more severe self-harm, such as enucleation, castration, and amputation of body parts. These more severe forms are generally associated with schizophrenic disorders and, on occasion, psychotic breakdowns of transsexual subjects. What developmental factors might increase the likelihood of self-injurious behaviors Parental sexual abuse and emotional neglect during childhood, also related to the genesis of the borderline personality, are significantly related to self-injurious behaviors (Dubo, Zanarini, Lewis, &...

Marsha Linehan and Dialectical Behavior Therapy Leading Models of Personality Disorder Treatment

Linehan, Dialectical Behavior Therapy (DBT 1993) is a therapeutic approach specifically designed for the treatment of Borderline Personality Disorder and suicidal behaviors and is currently the field's leading model in treating one of the most difficult of personality disorders. It uses both cognitive and behavioral techniques, such as problem solving, exposure techniques, skills training, contingency management, and cognitive modification, to effect a hierarchy of treatment goals. Potential outcomes of DBT intervention may include successfully teaching skills that will allow borderlines to regulate emotions, tolerate distress, and effectively interact with others. However, for such coveted abilities to be attained, the distinguishing aspects of DBT must be adhered to accept and validate current behaviors, acknowledge and treat the behaviors that pose disruption to the therapeutic process, perceive the therapeutic relationship as indispensable to treatment, and...

Sexual abuse and borderline processes

The example of the father's use of everyday language to signal the beginning and end of episodes of abuse, illustrates the way in which trust in what is said can be undermined, in abuse. If some sentences are uttered under one set of metarules and others under different rules, but the difference cannot be acknowledged, then the child is likely to feel uncertain about the meaning of apparently straightforward communications. This will have implications for the monitoring of the individual's state of mind, and for his her understanding of what is happening between people. In contrast to the infant who looks to the parent for help in deciding whether to cross the visual cliff (Section 6.4.4), the child who is being abused may not have adults with whom communications are sufficiently unambiguous that such checking could be possible. The importance of an undermining of metarepresentations in borderline disorders is supported by the studies referred to earlier. Specific factors included...

Development intentional and borderline processes

Let us summarize now the developmental processes that may be impaired when a child is abused sexually or in other ways, and underline the links with intentional processes in borderline personality disorder. Firstly children need to register the presence of perceptions, thoughts, and emotions, and their differences, and to move among them without fear, just as happens in their play. When certain states of mind are not allowed they may become disconnected, unintegrated, and disruptive. Secondly, the content of these representations needs to be tested for their applicability, truth, and possible modification. In the language of our earlier discussion, the underlying rules have specificity and generality so that they can mediate between events and actions. Where such mental representations cannot be tested, for instance through play with other children, or through being brought into relationships with adults, they are likely to become rigid, and inappropriate. The child, and then the...

Sadistic Personality Disorder Dsmiiir Appendix A

Davis hypothesize that explosive sadistic types are hypersensitive to any hint of betrayal by those with whom they have relationships, and they explode with rage when their feelings of humiliation reach intolerable levels. In this regard, they may also have features of borderline personality disorder.

Personality change due to a general medical condition JLC

The treatment of psychopathic and borderline patients. American Journal of Psychotherapy, 1, 45-71. 39. Gunderson, J.G. and Kolb, J.E. (1978). Discriminating features of borderline patients. American Journal of Psychiatry 135, 792-6. 41. Kernberg, O.F. (1975). Borderline conditions and pathological narcissism. Aronson, New York. 43. Gunderson, J.G. (1984). Borderline personality disorder. American Psychiatric Press, Washington, DC. 44. Berelowitz, M. and Tarnopolsky, A. (1993). The validity of borderline personality disorder an updated review of recent research. In Personality disorder reviewed (ed. P. Tyrer and G. Stein), pp. 90-112. Gaskell, London. 48. Widiger, T.A. and Frances, A. (1989). Epidemiology, diagnosis, and comorbidity of borderline personality disorder. In American Psychiatric Press review of psychiatry, Vol. 8 (ed. A. Tasman, R.E. Hales, and A.J. Frances), pp. 8-24. American Psychiatric Press, Washington, DC. 52. Andrulonis, P.A., Gluesch,...

The Debate about Stability versus Change for the Personality Disorders

B y definition, a Personality Disorder is an enduring pattern of thinking, feeling, and behaving that is relatively stable over time. Some types of Personality Disorders (notably Antisocial and Borderline Personality Disorders) tend to become less evident or to remit with age, whereas this appears to be less true for some other types (e.g., Obsessive-Compulsive and Schizotypal Personality Disorders). (p. 688) (76 ). For specific personality disorders, younger patients were more likely to receive a diagnosis of Borderline Personality Disorder than older patients, but older patients were more likely to receive a diagnosis of Narcissistic Personality Disorder than younger patients.

Passive Aggressive Personality Disorder Dsmivtr Appendix B

The first DSM noted that Passive-Aggressive Personality Disorder was characterized by three types passive-dependent, aggressive, and passive-aggressive. The passive-dependent type has seemingly evolved into the current Dependent Personality Disorder because the first version of the DSM listed feelings of helplessness, indecisiveness, and a tendency to cling childlike to a parentlike figure. The aggressive type appears to share many symptoms of the modern Borderline Personality Disorder such as temper tantrums, recurrent anger, irritability, and destructive behavior. It is the third, passive-aggressive type, that appears to have evolved into the modern Passive-Aggressive Personality Disorder with historical and current features of stubbornness, procrastination, inefficiency, and passive obstructivism.

Presence and subjective credibility of pathogenic beliefs

Irrational beliefs about the outside world are common in anxiety disorders. Especially interesting are people with monosymptomatic phobia who tend, in contrast to other anxiety patients, not to suffer from comorbid pathology and who present the clearest case of irrational emotions and behaviour in otherwise healthy people. While egodystony in specific phobias is even a diagnostic criterion of DSM-IV ('The person recognizes that the fear is excessive or unreasonable'), systematic questioning using a paper-and-pencil task, without the social pressure of an interviewer, reveals that spider phobics tend to endorse highly irrational beliefs about the dangerousness of spiders. The credibility of these frightening ideas is especially high in the presence of the phobic cue. (102) Social phobics appear to have negative beliefs about their own social performance and about others, whom they believe to be more critical and rejecting than they actually are. M0.4and 105) Furthermore, prominent...

The Fearful or Anxious Cluster C Personality Disorders and Aging

The similarities of the three personality disorders in Cluster C include underlying pervasive nervousness, anxiety, or fearfulness. Compared with the erratic and impulsive personality disorders in Cluster B with their characteristic interpersonal chaos, the Cluster C personality disorders often present with debilitating indecision, social inhibition, and avoidance. Based on the anxious nature of these personality disorders, it should not be surprising that when sufferers seek psychotherapy, they often do so to deal with their feelings of fear and apprehension. Like the personality disorders discussed in the preceding chapters, individuals with Cluster C personality disorders typically have little sense that their personality is maladaptive or part of the problem. Notably, there has been less systematic research conducted on the personality disorders in Cluster C compared with those in Cluster A (Schizotypal Personality Disorder in particular) and Cluster B (Antisocial and Borderline...

Psychoneuroendocrinological research in personality disorders

Coccaro et al. (36> found a blunted prolactin response to stimulation with fenfluramine in patients with personality disorders with physical aggression and motor impulsivity. Moreno et al.(3Z) obtained similar results in patients with a borderline personality disorder and impulsive suicidal behaviour, and a blunted response to prolactin after stimulation with clomipramine in pathological gamblers. Recent research has revealed the impact of social conditions on the neuroendocrine regulation of the individual, particularly with respect to the adaptation to stressful situations. In our sample of patients with a borderline personality disorder and impulsive suicidal behaviour we have found high basal concentrations of cortisol (suggesting a high level of stress) and a very blunted response to the stimulus (suggesting a reduced capacity to respond to external stimulus) compared with the control group. We have found the same pattern in heroin-dependent individuals receiving naltrexone...

Therapeutic Strategies and Techniques

Psychodynamic thinkers are agreed that modifications of the classical technique are necessary to prevent the borderline from regressing in the unstructured environment of the couch. However, they are divided on whether to advocate supportive or expressive therapy. Because the borderline suffers from ego weakness and the therapist acts as an auxiliary ego for the subject, supportive therapy seems logical. However, Kernberg (1985a) argues that supportive therapy may perpetuate pathology by allowing borderlines unlimited gratification of pathological needs, specifically, a need to express anger at early caretakers, now symbolized by the therapist. The borderline personality is not a pathology of ego weakness, but a pathology of object relations. Instead, Kernberg proposes that confrontation can be therapeutic when addressed to borderlines' tendency to alternate between idealization and devaluation. Confrontation does not connote hostility, but simply an effort by the therapist to draw...

Sadistic personality disorder DLT

Like the early psychoanalysts, Kernberg(4 > connects two dispositions (sadistic and masochistic) into a sadomasochistic character, which includes 'help-rejecting complainers' and often has underlying borderline personality organization. In tune with this, other authors consider sadistic personality disorder to be complementary to self-defeating personality disorder, because the person who is prone to abusing others is likely to be masochistic (or self-defeating) and the person who is repeatedly abused is likely to be sadistic. (U5)

The Psychodynamic Perspective

The most important contribution to contemporary psychodynamic conceptions, however, is Kernberg's (1967) idea of levels of organization in personality. Unlike the idea of borderline states or conditions, the idea of a borderline level of organization draws attention to a quality of integration of intrapsychic elements that is stable over time, yet falls midway on the continuum from neurosis to psychosis. All the personality disorders, as well as many psychodynamic character types, can be put on this continuum. Conceived as a level of personality organization, the borderline is thus much broader than the borderline personality described by the DSM. For example, Kernberg puts the schizoid personality at a lower level of borderline functioning. Yet, the socially removed style of schizoids is inconsistent with the intense interpersonal need of DSM borderlines, specifically, their frantic attempts to avoid abandonment, listed as the first diagnostic criterion. What then, does borderline...

The Evolutionary Neurodevelopmental Perspective

As a pathology of the total integration of personality, the borderline construct might be applied to almost any personality disorder. Clinical experience suggests, however, that dependent, histrionic, narcissistic, antisocial, and negativistic personalities are more frequently found in conjunction with a borderline diagnosis. Whatever the actual content, such individuals follow one of two developmental pathways. In the first, the personality develops a significant level of integration but breaks down under conditions of persistent environmental stress. In the second, no significant level of integration develops. Those following the first pathway are best referred to as borderline histrionics, for example, letting borderline modify histrionic and those following the second pathway might be referred to as dependent borderlines, indicating that the consequences of a lack of integration swamp the contribution of personality traits to organized behavior. Whatever the case, the common...

Neuroses Psychoses and Personality Disorders

As projection, denial, and omnipotence. In high affective states, there is a severe loss of reality testing often resulting in a lack of differentiation between self and object representations. A splitting often occurs under these conditions to protect psychotic persons from their perceived chaotic and aggressive conditions. According to Kernberg, the current cluster of symptoms of the Borderline Personality Disorder typifies the psychotic personality organization. Kernberg (1996) has attempted to classify modern personality disorders into psychoanalytic schema. He views the interrelationships among personality disorders as varying along several continua. First, personality disorders may vary from mild to extreme severity. He considered Obsessive-Compulsive and Depressive Personality Disorders in the mildest category and characteristic of the neurotic personality organization. The Dependent, Histrionic, and Narcissistic (some of the better functioning narcissists) Personality...

Recurrent brief depression

However, they do not meet the requirement that an episode should last for 2 weeks or more. The diagnosis of recurrent brief depression has not been adopted fully in DSM-IV, but it is included in ICD-10. It should be distinguished from recurrent suicidal behaviour, for example in patients with borderline personality disorder.

Alpf Medical Research Personality Disorders

One of the fundamental principles of therapy holds that interpersonal pathologies are recaptured in the therapeutic relationship itself. For the borderline personality, this means high expectations for nurturance from the therapist, inevitably followed by distorted perceptions of the therapeutic relationship and periods of intense anger and manipulation. Borderlines not only idealize and then devalue the therapist but also bring into therapy threats of suicide and, sometimes, frequent and repeated self-mutilation, dramatic physical evidence of psychopathology. Clinicians who treat borderlines should carefully monitor their own countertransference feelings to maintain a healthy level of detachment from the emotional lability and intensity to which every session is susceptible. In fact, many clinicians find it necessary to limit the number of borderline patients in their caseload. Otherwise, they risk therapeutic burnout, dreading sessions with their borderline patients and even finding...

Cyclothymia hypomania hyperthymia and personality disorder Axis II

One of the difficulties of this area of research is the separation on the continuum between personality disorder features and the point at which symptoms become disorder in terms of bipolar disorder rather than abnormalities of personality or temperament. An awareness of boundaries is important, as personality tests in common use have been known to misattribute subthreshold mood changes to borderline personality disorder (O'Connell et al., 1991).

Course and Prognosis for the Personality Disorders

A diagnosis of Borderline Personality Disorder also has a generally poor prognostic implication. There have been strong suggestions of a history of childhood trauma as a precipitating event for the development of this disorder (e.g., Millon & Davis, 1996). However, not all borderline patients have a history of trauma and not all individuals with trauma develop the disorder. Also, many personality disordered patients other than Borderline Personality Disorder do have trauma history as well as do adults without a personality disorder. Early traumatic brain injury as a precursor in Borderline Personality Disorder has also been proposed (e.g., van Reekum, 1993). Similar to the finding regarding childhood physical and sexual abuse, some borderline patients have a history of brain injury, but others do not (Coolidge, Segal, Stewart, & Ellett, 2000). Millon and Davis concluded that there are likely many paths to the development of the Borderline Personality Disorder, and for all the...

The Biological Perspective

More than anything else, the intense moodiness and rapidly shifting emotions of the borderline personality have caused observers to wonder whether some biological abnormality might underlie the disorder or at least create a predisposition that favors its development. Some biological basis seems necessary to fuel the intense emotional reactivity of the borderline, as seen in Jenny and Georgia. After all, anger is an intensely arousing emotion, as Jenny shows us consistently throughout her case study. Alternatively, we might suppose that reactivity itself has some biological basis. Perhaps some people simply react more intensely than others given any negative stimulus, and borderlines fall at the extreme upper end of such a distribution. changeable moods. Homer, Hippocrates, and Aretaeus vividly described impulsive anger, intense activity, irritability, and depression, noting both the vacillation among these spells and the personalities in which they are embodied. As with most medical...

Contemporary concepts

Modern concepts can be summarized in four groups borderline personality organization, borderline personality disorder, the DSM-III (IV) concept, and borderline as a severe personality dysfunction. 1. Otto Kernberg(41> is one of the most prominent authors in the field and his theory is the most coherent. He proposed the term 'borderline personality organization', a broad concept encompassing all severe personality disorders. Borderline personality organization is a stable permanent state based on three criteria diffuse identity, primitive defences centred around splitting and intact reality testing. Dahl's (42) concept of a core borderline syndrome is in agreement with Kernberg's theory. 2. Gunderson(43) focused attention on 'borderline personality disorder' as a distinct entity which could be distinguished from both other mental disorders and other personality disorders. Gunderson's descriptive phenomenological designation had a considerable influence on contemporary classifications...

Application of Semi Structured Interviews with Older Adults

Despite the potential concerns we have noted, semi-structured interviews can and should have an important place in the assessment process. For example, a semi-structured interview may be used with all patients at the beginning of treatment, or it may be administered after a more unstructured clinical interview or self-report objective personality inventory is completed. As noted previously, this requires a significant investment in time and expertise. Using sections of an interview to clarify specific diagnostic hypotheses generated from a clinical interview or a self-report inventory (e.g., only the Borderline Personality Disorder module of the SCID-II may be administered to enable a more comprehensive evaluation of the borderline pathology) is a less time-consuming option. With their premium on diagnostic reliability and comprehensive assessment of criteria, structured interviews can be valuable resources for the geropsychological clinician and researcher.

Psychological factors Personality

Community and clinical epidemiology findings point to the presence of other psychiatric disorders as one of the most significant psychological risk factors in alcoholism. The risk is particularly high in persons with schizophrenia, bipolar disorder, major depression, social phobia, panic disorder, post-traumatic stress, attention-deficit hyperactivity disorder, and antisocial and borderline personality disorders. (40)

Biological substrates of personality and personality disorders

According to the hypothesis of a spectrum of disorders, personality disorders can often be treated by the same method as those applied to the major psychiatric disorders to which they are related. Patients with anxious or avoidant personality disorder may respond to anxiolytic medication, patients with borderline personality disorder may respond to lithium and antidepressives, patients with schizotypal personality disorder may respond to antipsychotic agents, and patients with disorders characterized by poor impulse control may respond to antidepressives with a selective serotonergic action.

Alpf Medical Research Personality

While biologically, there does not appear to be a paranoid temperament, most likely the same irritable and aggressive temperament that may also lead to antisocial, sadistic, or borderline personality plays a role in the paranoid, with early environmental factors playing a great role in determining the ultimate path of development. Limited empirical research conducted on the heritability of a paranoid personality has been inconclusive as have been studies that try to link paranoid personality to schizophrenia and delusional disorder.


Designed to measure depression, anxiety, psychosis, tendency to exaggerate symptoms, anger, intelligence, and so forth. Our psychologist administers the Minnesota Multi-phasic Personality Inventory, Milton Clinical Multi-axial Inventory, Affect Adjective Stress Test, Beck's Depression Score, and the Beck's or Taylor Anxiety Scale. In addition, our psychiatrist interviews all patients, with all emotional and stress issues being addressed and treated and opiate detoxification carried out. Evidence of psychosis and borderline personality disorder are considered contraindications for surgery. Patients with obsessive-compulsive disorder are in general very difficult to treat with any pain treatment modality because they tend to obsess about their pain, controlled or not.

Mythology And Legend

This story has led to the name being used as the term 'narcissism' or 'narcissistic personality disorder', in which people described by this condition have a grandiose view of their own uniqueness and abilities they are preoccupied with fantasies of great success. To say they are self-centred is an understatement (Davison and Neale, 1998). These characteristics have been validated in empirical studies (Ronnington and Gunderson, 1990) and are often a factor with borderline personality disorders (Morey, 1988). Such people are constantly seeking attention and adulation, and are, underneath, extremely sensitive to criticism and have a deep fear of failure. Many of the contemporary studies have been carried out by Heinz Kohut (Kohut, 1971, 1977 Kohut and Wolf, 1978).

Biological issues

Research into the biological mechanism underlying borderline personality disorder is, although promising, still in its infancy. Most theories suggest that an interaction between an innate biological vulnerability to stress (anxiety, affect regulation) and an invalidating parental environment would cause future borderline psychopathology 3, dl) Family studies of borderline personality disorder support the constitutional psychobiological role. There is increasing evidence that parents of borderline patients have a high incidence of affective disorder and borderline-type behaviours, alcoholism, antisocial personality disorder, and other cluster B personality disorders. (50) A number of investigators have performed studies on well-diagnosed patients with borderline personality disorder, focusing on biological variables (abnormal dexamethasone suppression test results, shortened rapid eye movement latency, blunted thyrotrophin response, and an abnormal sensitivity to amphetamine). However,...


Psychotherapy of borderline patients is often approached with pessimism. Various psychotherapeutical modalities are used, including psychodynamic psychotherapy, supportive psychotherapy, and dialectical-cognitive psychotherapy. Classical psychoanalysis has been considered to be contraindicated. Long-term individual psychotherapy can be helpful to patients with borderline personality disorder. Kernberg(62) recommended a more structured form, expressive psychotherapy (a modified psychoanalytical procedure), involving an active technique focusing on confrontation of maladaptive defences and interpretation of transference, focusing on the 'here and now', without attempting the achievement of a full genetic reconstruction. Short-term psychotherapy is useful for managing crises or introducing long-term forms of therapy. Supportive psychotherapy is suggested for more fragile borderline patients, who are prone to serious regression in treatment. In practice, supportive therapy, with a...

Cognitive style

Comorbidity with many personality disorders (histrionic, borderline, obsessive-compulsive, dependent, narcissistic) is also frequently observed. People with these personality disorders may use passive aggression as a defence mechanism. Suicide attempts are not as frequent as in histrionic and borderline personality disorders, and features of passive-aggressive personality are less dramatic, affective, openly aggressive, and severe.

Drug treatment

Drugs are often used for treating personality disorders although it is important to note that none are licensed for the treatment of these conditions. As with other forms of treatment, borderline personality disorder constitutes the largestest group in which drug treatment is being used and is therefore worth examining separately. Again, it is important to note that borderline personality disorder is one of the most heterogeneous of all groups within the personality classification and includes extensive comorbidity with other personality disorders as well as with mental state disorders, particularly mood and stress-related disorders.


This is particularly clear with the more disturbed narcissistic or borderline patients who bring to the group more primitive psychic structures and processes that put strain on the resources of other group members. Such patients can create turmoil, in which the leader's task is to maintain the responses of the group from a more mature level of psychic organization. By responding to part-object relationships and processes on the level of whole-object relations, more benign containing responses can be established. Progressively, these help to build up for the disturbed patient a more benign world of inner object relationships and processes. (82> More disturbed patients desperately seek attention in ways that are inappropriate and disruptive. This search for attention arises because the patient cannot establish a sense of connection between him- or herself and the processes of the group. Mirroring and resonance can steadily come to replace these isolated and fragmentary responses,...

Recent history

The creation of the National Health Service in 1948 provided the stimulus to address the major problems of institutionalization revealed in a number of studies of large mental hospitals in the United Kingdom and United States.(8,,9.) In the 1950s and 1960s some of these hospitals developed what Clark (19 called the 'therapeutic community approach'. Their aim was to humanize the environment and resocialize the patient populations, bringing many long-term residents to the level of functioning where they could re-enter a society from which they had been excluded 20, 30, or more years ago. In the 1970s and 1980s concepts of collective responsibility fell from favour and individualism prevailed. There was a gradual decline in the therapeutic community movement as the large old mental hospitals closed and services were switched to the community, although specialized autonomous units remained active. The 1990s has seen a revival of interest in therapeutic communities within more specific...

Staff roles

Resident involvement is a key aspect of therapeutic community treatment. The type and level of responsibilities given to residents will vary according to their needs and capacities, and the constraints of the organization. Autonomous units for severe and borderline personality disorders and for ex-drug addicts will be able to make fullest use of the roles and responsibilities outlined below. Units for patients with chronic mental illness and prison-based units will have more restricted opportunities.

Acute schizophrenia

A small number of therapeutic communities have been established in the United Kingdom, the United States, and Switzerland to discover whether young people with first or second admissions suffering from acute schizophrenia or schizophreniform psychosis could be effectively treated in small family-like settings with the minimal use of neuroleptics. Two studies using controls treated in conventional settings demonstrated comparable or better outcome on a number of indices in the therapeutic community samples. Reliance on medication at follow-up was significantly lower, although there were no cost savings.(2 26) A 20-year study of an acute psychiatric ward in Finland found that acute psychotic and borderline patients seemed to benefit from the therapeutic community model with a high level of support, negotiation, order, and organization.(27)


In reviewing psychiatric syndromes, some themes recur. This does not lead to a general theory of disorder, but to an analysis that has some general features. Set against a developmental background, disorder is viewed in relation to the tasks that must be achieved where multiple sets of mental rules are possible. These include the monitoring of internal and interpersonal rules, the maintenance of the individual's experience of continuity in the presence of multiple states of mind, and the capacity to understand the mental states and actions of others. Many of the overarching, metarepresentational functions could also be characterized as functions of the self, and these appear to be disrupted in conditions that are as widely different as schizophrenia and borderline personality disorder. In schizophrenia the monitoring of the individual's own thoughts or actions may be impaired, whilst in borderline functioning the continuity of states of mind is undermined. If the sense of self is...


As Gray(25> and Zuckerman(23) have pointed out, there is no one-to-one relationship between basic traits and neurohormone systems. For example, the enzyme monoamine oxidase, which has an important function in dopamine breakdown, is negatively correlated with sensation-seeking. (26) This is in line with the observation that disinhibitory forms of psychopathology (e.g. borderline personality disorder, bipolar disorder, positive schizophrenic symptoms) are accompanied by low levels of monoamine oxidase. However, sensation-seeking also correlates strongly with testosterone. Likewise, the arousal component of neurotic anxiety is thought to be mediated by high levels of noradrenaline (norepinephrine), while the avoidance component has been related to low levels of g-aminobutyric acid. The important point to note is that personality dimensions can be decomposed in more basal behavioural tendencies which probably do correspond to discrete neurohormone systems. For example, the trait of...

Somatic Treatments

Cannot wait for drug therapy to become effective (e.g., with the catatonic or suicidal patient). There have been a number of studies of ECT with patients with Borderline Personality Disorder, but not specifically in older patients (DeBattista & Meuller, 2001). Electroconvulsive therapy is generally found to be a good, effective treatment that appears to treat the depression but which does not have a significant effect on the underlying personality disorder condition. Another study has suggested that those with comorbid personality disorder have a poorer outcome, especially those with a Cluster B personality disorder, and have a higher relapse rate of the depression (Sareen, Enns, & Guertin, 2000). Although there are some well-supported benefits of ECT, its use is especially problematic with older adults because some common side effects of the treatment with older adults include falls, confusion, and cardiovascular problems (Sackeim, 1994). Electroconvulsive therapy also can...


The countertransferential experience enables insight into the phenomenology of the individual. How the clinician feels when with this individual, often reflects (mirrors) what the patient feels. For example, it is not unusual to feel the incipient rage of a person with Borderline Personality Disorder when they are talking about a relationship that triggers their anger dyscontrol. Distance regulation refers to the clinician's ability to maintain an appropriate distance in the clinical relationship for the treatment to be effective. Personality disorders make maintaining this distance difficult. For example, the aloof and arelational stance of the Schizoid Personality Disorder interferes, and often precludes, the establishment of a therapeutic alliance. In another example, the affective lability of the Borderline Personality Disorder often is mirrored by a distance lability in relationship with the clinician, vacillating between becoming too close or too far apart.

Personality change

Changes in personality(34) include apathy and impairment of motivation and ambition. Patients are often described as childish this covers a range of traits including impulsivity, poor tolerance of frustration, being demanding and self-centred, and generally lacking the ability to take on the adult role in terms of independent decision-making. Patients may be fatuous and facetious. Antisocial behaviours (see below) and disinhibition are severe handicaps that make integration back into the community very difficult. Sexual disinhibition of any type is particularly worrisome. A spectrum of severity is seen, ranging from being inappropriately flirtatious through to indiscriminate sexual assaults. Head injury is a risk factor for borderline personality disorder. (,35>

Focus on Research

Because theory can only suggest possibilities, it must always be followed up by empirical research. Studies have shown that the antisocial is indeed the most common personality disorder among alcoholics (Hesselbrock, Meyer, & Keener, 1985). Other personality disorders, however, have also been observed. In addition to the antisocial, Morgenstern, Langenbucher, Labouvie, and Miller (1997) found high numbers of borderline and paranoid personalities. Although these disorders have no exact parallel in Cloninger's model, their vulnerability to alcoholism can nevertheless be understood in terms of their characteristic traits. As noted in DSM-IV, borderlines are disposed to indulge themselves impulsively in self-damaging ways, including excessive spending, reckless driving, binge eating, and substance abuse. Excessive alcohol consumption serves the same end. Moreover, as the borderline personality has frequently been associated with mood swings and chronic depression, it is likely that...

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