History of childhood sexual abuse and general psychopathology.

Reported history of childhood sexual abuse (CSA) was correlated with general measures of psychopathology on the SCL-90-R in a sample that included inpatients with borderline personality disorder (BPD), inpatients with major depression, and a nonpatient control group. When subjects who reported abuse were compared with those who did not, scores for the Global Severity Index (GSI) and all subscales of the SCL-90-R, except for the obsessive-compulsive and somatization subscales, were significantly-higher. When only those subjects who reported CSA were studied and when specific measures of CSA were the independent variables and SCL-90-R subscales were the dependent variables, scores on the hostility, interpersonal sensitivity, and paranoia subscales of the SCL-90-R were significantly higher. Because a large proportion of the sample consisted of borderline patients, and because both the specific measures of CSA and the borderline diagnosis could predict similar SCL-90-R subscale results, a series of stepwise regressions were performed. In the first regression, diagnosis, gender, and specific measures of CSA were the predictor variables and SCL-90-R subscale scores were the dependent variables; in the second regression, SCL-90-R subscales and specific measures of CSA were the predictor variables and diagnosis was the dependent variable. Interpersonal sensitivity was the only significant predictor of the borderline diagnosis. We suggest that, at least in some cases, interpersonal sensitivity may be the constitutional/environmental substrate on which traumatic experiences interact to arrive at the borderline diagnosis.

A preliminary report of short-term cognitive-behavioral group therapy for inpatients with personality disorders.

A randomized, controlled study evaluated the effectiveness of a cognitive-behavioral therapy group, based on Linehan's dialectical behavior therapy, for inpatients with personality disorders. The treatment, a problem-solving skills group focused on parasuicidality, was compared with a discussion control group. Change was assessed by self-report measures and behavioral observations on the unit. Subjects in both groups improved significantly on most change measures, although no significant between-group differences were found. However, the treatment group patients viewed the intervention as more beneficial to them in their lives outside the hospital. The usefulness of this type of group on a short-term unit is discussed.

Borderline personality disorder symptoms and severity of sexual abuse.

OBJECTIVE: This study explored the relationship of specific symptoms of borderline personality disorder to dimensions of severity of sexual abuse experiences in childhood. METHOD: A group of 41 patients with borderline personality disorder who retrospectively reported a childhood history of sexual abuse on the Familial Experiences Interview were studied. Six items from the Diagnostic Interview for Borderline Patients (DIB) were chosen on the basis of their univariate (chi-square) association with a sexual abuse severity scale that was developed by the authors and their research team. These six DIB items were each modeled in a logistic regression. Predictor variables were the most severe experience within each of three dimensions of sexual abuse: 1) perpetrator (sexual abuse by a parent), 2) duration (sexual abuse that was ongoing), and 3) type (sexual abuse that involved penetration). RESULTS: The severity dimension that was most frequently found to be a significant predictor of the sum of the six DIB items as well as the total scaled DIB score was the duration dimension. Ongoing sexual abuse predicted parasuicidal behavior as well. CONCLUSIONS: Ongoing sexual abuse may be a strong determinant of specific aspects of the disordered interpersonal behavior and functioning found in patients with borderline personality disorder. The expectation that the world is an empty, malevolent place may have some of its roots in the repetition of sexual abuse experiences in childhood. This expectation of malevolence among patients with borderline personality disorder may manifest itself in psychotherapy through regressive and distancing behavior.

Clinical assessment of object relations and social cognition using stories told to the picture arrangement subtest of the WAIS-R.

For many years clinicians have supplemented the Wechsler Adult Intelligence Scale-Revised (WAIS-R; Wechsler, 1981) Picture Arrangement (PA) subtest by asking subjects to "tell the story" made by the sequence of cards. Doing so allows assessment of the underlying reasoning behind the subject's response and adds a projective element to the task. This article describes a method for systematically assessing several dimensions of object relations and social cognition from the stories subjects tell to the PA subtest. Six scales, which have been validated in several studies, are described: Episode Integration, Accuracy of Causal Attributions, Affect-Tone of Relationship Paradigms, Capacity for Emotional Investment in Relationships and Moral Standards, Complexity of Representations, and Accuracy of Character Ascriptions. Evidence for convergent and discriminant validity is presented by comparing PA scale scores of reliably diagnosed borderline inpatients, depressed inpatients, and normal comparison subjects, with scores from self-report instruments measuring symptomatology and social adjustment. Clinical use of the scales is then illustrated by applying them to PA story texts of a borderline patient and a normal subject.

Malevolence, splitting, and parental ratings by borderlines.

Malevolent object relations as well as splitting have long been considered by psychodynamic theorists as central features of borderline personality disorder. We tested the hypotheses that borderlines would a) perceive their parents more negatively than both nonborderline major depressive patients and nonpatient normal controls, and b) split their representations of their parents into opposites more than the comparison subjects. Borderlines (N = 31), who were identified by the Diagnostic Interview for Borderlines, Research Diagnostic Criteria major depressives (N = 15), and nonpatient controls (N = 14) were asked to rate each parent on the Adjective Check List (ACL; Gough and Heilbrun, 1983). Seven ACL scales were studied: Favorable, Unfavorable, Critical Parent, Nurturing Parent, Nurturance, Aggression, and Dominance. Correlations were performed between scores for mother and father on the various scales for each of the three cohorts. Analysis of variance and one-way t-tests with Bonferroni correction were used to test group differences. Borderlines rated their parents, especially their fathers, not only as more unfavorable on negative scales than depressives or normals, but as less favorable on positive scales than the comparison groups. Analysis of covariance revealed that a significant portion of the variance in father scores, but not in mother scores, was related to age of respondent and history of sexual abuse. While borderlines did not appear to split their parents into one good and one bad parent, they did show significantly less correlation between parents on the Favorable scale when compared with either depressives or normal subjects. The results imply that borderlines have a greater tendency to view the world in negative, malevolent ways than to split their object representations.

Malevolent object representations in borderline personality disorder and major depression.

To study malevolent representations, earliest memories were reliably coded on scales of affect tone. Ss were diagnosed with borderline personality disorder: 31 without and 30 with concurrent major depression. Nonborderline comparison subjects had either major depressive disorder (n = 26) or no psychiatric diagnosis (n = 30). Borderline subjects were discriminated from comparison subjects by their more malevolent representations; they more frequently produced memories involving deliberate injury; and they portrayed potential helpers as less helpful. Results suggest the diagnostic significance of malevolent representations, which need to be explained by any theory of borderline personality disorder.

Object representations in the early memories of sexually abused borderline patients.

OBJECTIVE: This study analyzed psychological representations in 58 subjects in order to achieve a better understanding of the relation between adult borderline personality disorder and reported histories of childhood sexual and physical abuse. METHOD: The subjects were 29 inpatients with borderline personality disorder diagnosed according to the Diagnostic Interview for Borderlines, 14 nonborderline inpatients with major depressive disorder according to the Research Diagnostic Criteria, and 15 normal comparison subjects recruited from the community and screened for the absence of psychopathology. Earliest memories were used as the source of mental representations in all subjects. The memories were reliably coded for malevolent affect tone, presence of deliberate injury, and effectiveness of helpers. Family histories of childhood sexual and physical abuse were obtained with the Familial Experiences Interview, a structured interview. Abuse histories for a subset of the subjects were corroborated by interviews with family members. RESULTS: A reported history of sexual abuse, but not a reported history of physical abuse, predicted the presence of extremely malevolent representations in these earliest memories as well as representations involving deliberate injury. These two kinds of representations also discriminated borderline patients who reported histories of sexual abuse from borderline patients who did not report sexual abuse. Mean affect tone (from malevolent to benevolent) did not, however, discriminate sexually abused or physically abused subjects. CONCLUSION: The results suggest that malevolent representations associated with the borderline diagnosis in previous research may be partially related to a history of childhood sexual abuse. Implications for the object relations theory of borderline personality disorder are noted.

Childhood sexual and physical abuse in adult patients with borderline personality disorder.

Experiences of abuse and neglect were assessed in 24 adults diagnosed as having borderline personality disorder according to the Diagnostic Interview for Borderline Patients and in 18 depressed control subjects without borderline disorder. Significantly more of the borderline patients than depressed patients reported childhood sexual abuse, abuse by more than one person, and both sexual and physical abuse. There were no between-group differences for rates of neglect or physical abuse without sexual abuse. A stepwise logistic regression revealed that derealization, diagnostic group, and chronic dysphoria were the best predictors of childhood sexual abuse in this group of patients.

DSM-III and DSM-III-R schizotypal symptoms in borderline personality disorder.

The frequency of DSM-III and DSM-III-R schizotypal personality disorder (SPD) symptoms and diagnosis was explored in 39 inpatients classified as borderline by the Diagnostic Interview for Borderlines (DIB) and 19 inpatient major depressive disorder (MDD) controls. Most SPD symptoms in all groups, except the nondepressed borderlines, derived from social-interpersonal items. By DSM-III, 24 borderlines (62%) but only six controls (32%) had cognitive-perceptual SPD symptoms (P = .03), whereas by DSM-III-R only 14 borderlines (36%) and seven controls (37%) had such symptoms. Of the 24 borderlines showing cognitive-perceptual symptoms, 16 also had MDD, a significant difference from the non-MDD borderlines (P = .04). This difference disappears in DSM-III-R. The results suggest that some SPD symptoms in borderlines may be related to a concurrent affective episode.

The relationship between borderline personality disorder and anxiety disorders.

Eleven "pure" borderlines, ten borderlines with depression, 16 "pure" depressives, and 31 normal subjects were compared on a number of standardized inventories of anxiety. While patient groups experienced more anxiety of all types than did normals, borderlines did not emerge as more anxious than other patient groups. Qualitative differences in the anxiety experienced by borderlines and nonborderlines are discussed.

Comparison of early and delayed inpatient dexamethasone suppression tests.

Ninety-five inpatients completed a dexamethasone suppression test (DST) within 72 hours after admission and again after at least 1 week of medication-free hospital care. The frequency of cortisol nonsuppression in patients with endogenous depression (ED) was high and not significantly different at both tests. In patients with diagnoses other than ED, the higher rate of cortisol nonsuppression at the first DST was associated with a significant decrease in test specificity. Change in postdexamethasone cortisol levels at repeat testing was associated with a decrease in depressive symptomatology, but was not related to weight change during hospitalization.

Prolactin response to TRH in depression.

We studied the prolactin response to TRH in 53 unmedicated psychiatric inpatients. The prolactin response of females was significantly greater than the response of male subjects. There was no significant difference in the prolactin response to TRH between depressed patients and those with other psychiatric diagnoses. There was no significant relationship between the prolactin response to TRH and the severity of depression, the TSH response to TRH or the resistance to suppression of cortisol secretion by dexamethasone.

Cortisol escape from morphine suppression.

Twenty-one unmedicated, sequentially admitted psychiatric patients of either sex and four male healthy volunteers were given an intravenous injection of 2.5 mg morphine. Blood samples were drawn immediately before and at 30-minute intervals for 3 hours after the injection and assayed for cortisol. Morphine suppressed cortisol secretion. Early resumption of cortisol secretion (escape) was more frequent in patients with a diagnosis of major depressive disorder and with abnormal dexamethasone suppression test results. The sensitivity of this infusion paradigm for the diagnosis of major depressive disorder was 40%, and the specificity was 82%. The implications of these findings for the pathophysiology of depression are discussed.

Opioid regulation of hypothalamic-pituitary-adrenal function in depression.

A morphine infusion paradigm was used to investigate opioid mechanisms in the regulation of the hypothalamic-pituitary-adrenal (HPA) axis in depression. The subjects were unmedicated psychiatric inpatients and healthy volunteers. Morphine suppressed cortisol secretion. Early resumption of cortisol secretion was associated with a diagnosis of major depression and abnormal dexamethasone suppression test results. Our data suggest that the hyperactivity of the HPA axis observed in depression is abnormally resistant to opioid inhibition as well as glucocorticoid feedback.

Prolactin response to morphine in depression.

Twenty-two unmedicated inpatients with major depression and 18 healthy volunteers of either sex were given an intravenous injection of 5 mg morphine. Blood samples were drawn immediately before and at intervals for 3 hrs after the injection and assayed for prolactin. Morphine stimulated prolactin secretion. The prolactin response of females was significantly greater than the response of male subjects. There were no significant differences in the prolactin response to morphine between depressed and healthy subjects. The implications of these findings for the hypothesized role of the opioid system in the pathophysiology of depression are discussed.

Test-retest reliability of the diagnostic interview for borderlines.

Gunderson's Diagnostic Interview for Borderlines (DIB) has gained increasing acceptance and use as a diagnostic research instrument. Although previous studies report interrater reliability for the DIB, no attention has been given to problems of test-retest reliability or variability among different clinicians conducting a semistructured clinical interview. This study demonstrated both interrater and test-retest reliability for the DIB when it is administered by trained clinicians. No effects of interviewer sex were found, but less experienced clinicians tended to give higher (more borderline) scores than more experienced clinicians.