An object relations perspective on borderline personality.

One of the principal formulations of borderline personality disorder is based on object relations theory, a component of psychoanalytic theory. To remain relevant, psychoanalytic formulations must find support from empirical research. After summarizing the object relations understanding of borderline personality, the authors review studies in biological neuroscience, developmental psychology and cognitive science related to the fundamental concepts of object relations theory as it aplies to borderline pathology. This review suggests that these empirical studies support psychoanalytic formulations originally derived from clinical practice and observation.

Childhood antisocial behaviors as predictors of psychotic symptoms and DSM-III-R borderline criteria among inpatients with borderline personality disorder.

Structured clinical interviews of 107 female inpatients diagnosed with borderline personality disorder (BPD) were used to determine whether antisocial personality disorder (APD) diagnostic criteria evident prior to age 15 could be used to predict current Axis I and Axis II psychopathology. Diagnostic information was gathered using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) and the Structured Clinical Interview for DSM-III-R-Patient Version (SCID-P). Childhood APD criteria were subjected to principal-components analysis, and three factors--rule-breaking, assault, and sadism--emerged. The severity of the childhood APD criteria was related to psychotic symptoms, as well as to the unstable relationships and labile affect BPD criteria and the current overall severity of BPD criteria. Sadism predicted psychotic symptoms and BPD severity, while rule-breaking predicted unstable relationships and BPD severity. Childhood APD severity also had a larger effect on BPD severity than on psychotic symptoms. Possible explanations for these findings are explored and discussed.

Emergence of highly antibiotic-resistant Pseudomonas aeruginosa in relation to duration of empirical antipseudomonal antibiotic treatment.

OBJECTIVE: This study examines antibiotic resistance in Pseudomonas aeruginosa in hospitalized patients in relation to prior empirical antibiotic therapy. DESIGN: Two retrospective case analyses comparing patients who manifested P aeruginosa with differing patterns of antibiotic resistance. SETTING AND PARTICIPANTS: Patients acquiring P aeruginosa in a community hospital. MEASURES: Patients were compared on duration of hospitalization and days and doses of antibiotics prior to recovery of P aeruginosa. Patients were grouped, based on susceptibility patterns of their P aeruginosa isolates classified as follows: (1) fully susceptible (susceptible to all classes of antipseudomonal antibiotics [SPA]), (2) multidrug-resistant (resistant to two classes of antipseudomonal antibiotics [MDRPA]), or (3) highly drug-resistant (resistant to > or = 6 classes of antipseudomonal antibiotics [HRPA]). To control for duration of hospitalization, antibiotic treatments of HRPA and SPA patients were compared during the first 21 days of care. RESULTS: Prior to recovery of HRPA, six HRPA patients received greater amounts of antibiotics, both antipseudomonal and non-antipseudomonal, than did six SPA patients prior to recovery of SPA. For 14 patients with hospital-acquired SPA who later manifested MDRPA, duration and dosage of antipseudomonal antibiotics, but not all antibiotics, were significantly higher for the SPA-to-MDRPA interval than for the preceding admission-to-SPA interval. The median duration of antipseudomonal antibiotic treatment prior to the recovery of P aeruginosa was 0 days for SPA, 11 days for MDRPA, and 24 days for HRPA. CONCLUSION: Duration of empirical antipseudomonal antibiotic treatment influences selection of resistant strains of P aeruginosa; the longer the duration, the broader the pattern of resistance.

Comorbid mood disorders as modifiers of treatment response among inpatients with borderline personality disorder.

Structured clinical interviews of 63 female inpatients diagnosed with borderline personality disorder were used to study the relations of comorbid mood disorders to treatment response. Diagnostic information was gathered using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) and the Structured Clinical Interview for DSM-III-R-Patient Version (SCID-P). Information about psychotic symptoms was also based upon responses to the SCID-P. Treatment response was assessed through weekly ratings on the Symptom Checklist-90-Revised over 25 weeks of hospitalization. Initial depression but not initial or previous bipolar disorder was found to predict treatment course. Initial psychotic symptoms were also found to predict treatment course among patients with initial bipolar disorder and tended to modify the trajectory of symptoms over time among patients with initial depression. Possible explanations for these findings are explored and discussed.

Factors associated with multiple hospitalizations of patients with borderline personality disorder.

OBJECTIVE: The study sought to identify aspects of borderline personality disorder and comorbid axis I conditions associated with multiple hospitalizations in a sample of patients with borderline personality disorder. METHODS: Data were collected as part of a larger study of treatment course of inpatients with this disorder. Predictors of multiple hospitalization from three domains were considered: demographic characteristics, criteria of borderline personality disorder, and comorbid axis I pathology. A sequential model-building strategy was used, with each domain considered separately and result combined into an overall regression model of factors related to multiple hospitalization. RESULTS: Three factors were related to frequency of hospitalization: anorexia, psychotic symptoms, and suicidality. Other variables that are often assumed to be related to hospitalization, such as depression, did not emerge as significant predictors. CONCLUSIONS: Clinicians should intervene early to address the emergence of certain axis I conditions among patients with borderline personality disorder. Increased expenditure of outpatient resources may prevent hospitalization when these conditions are present.

Predictors of dropout in psychodynamic psychotherapy of borderline personality disorder.

This study aimed to identify patient factors that predict early dropout from psychodynamic psychotherapy for borderline personality disorder (BPD). Thirty-six BPD patients began an open-ended course of twice per week psychodynamic psychotherapy that was defined in a treatment manual and supervised. Dropout rates were 31% and 36% at 3 and 6 months of therapy, respectively. Survival analysis techniques demonstrated that age and hostility ratings predicted early dropout, with continuers more likely to be older and expressing lower levels of hostility than dropouts. Many variables hypothesized to predict dropout failed to do so. Both the positive and negative findings are discussed relative to the literature.

Factors Related to Drop-outs by Borderline Patients : Treatment Contract and Therapeutic Alliance.

High patient drop-out rates have traditionally interfered with both treatment and study of patients with borderline personality disorder (BPD). The authors tested hypotheses that an adequate treatment contract, a positive therapeutic alliance, and the severity of illness would all correlate with continuation of treatment versus drop-out in a BPD cohort receiving psychodynamic psychotherapy. Therapists' contributions to the contract and to the alliance correlated with the length of treatment. Patients' impulsivity was negatively related to length of treatment. This study supports the view that the therapist's technique plays a role in engaging the borderline patient to remain in treatment.

Antisocial traits as modifiers of treatment response in borderline inpatients.

The relationship of antisocial traits to treatment response in 35 female inpatients with borderline personality disorder was studied. Antisocial traits were measured with the Personality Assessment Inventory. Treatment response was measured by weekly ratings on the Symptom Checklist-90-Revised over 25 weeks of hospitalization. Treatment course was found to be significantly associated with the level of antisocial behavior reported at admission.

Studying the treatment contract in intensive psychotherapy with borderline patients.

A pilot study on the process of psychodynamic psychotherapy of borderline personality disorder at the Cornell University Medical College is designed to investigate the teaching and application of a specific model of treatment for borderline patients (Clarkin et al. 1992; Kernberg and Clarkin 1992). The project has involved teaching a group of self-selected trainees and faculty the manualized therapy (Kernberg et al. 1989); taping each of the twice-weekly therapy sessions over a period of 2 years; and rating (1) each therapist's adherence to the manual (Koenigsberg et al. 1985), (2) each therapist's skill, and (3) patient change. The patients are women with borderline personality disorder, between 20 and 40 years of age, diagnosed by DSM-III-R criteria (American Psychiatric Association 1987), SCID-II (Spitzer et al. 1987), and a self-report questionnaire for level of personality organization. At regular intervals, the patients are evaluated for symptom status, change in BPD criteria, and functioning. The therapists are evaluated for adherence to the manual and level of therapeutic skill. In teaching and carrying out the manualized therapy, it became clear that a critical moment in the treatment was the setting up of the treatment contract. A study was organized to look systematically at the adherence of the therapists to the model of treatment with regard to this initial phase of the therapy.

The role of figurative language in the induction phase of an expressive psychotherapy.

Figurative language has long been recognized as playing a role in psychotherapy, mostly in terms of interpreting "within the patient's metaphor." The therapist's use of metaphor has been less studied. The authors examine figurative language used by a therapist in psychodynamic psychotherapy with a borderline patient. Hypotheses that figures of speech are more frequent in interpretations than in other types of therapist interventions and that a high percentage of interpretations contain figurative language were supported. The discussion considers how figurative language may aid in gaining access to defended-against material and in communicating concepts in a personalized way to the patient.

Water molecule dynamics in hydrated lysozyme. A deuteron magnetic resonance study.

Proton nuclear magnetic resonance relaxation investigations of water dynamics in hydrated protein powders have the serious drawback that protein-water intermolecular dipolar interactions make the unambiguous interpretation of the results difficult. To circumvent this difficulty, deuteron spin-lattice and spin-spin relaxation times in lysozyme powder hydrated with deuterium oxide were measured as a function of temperature and at two frequencies. Although the deuteron relaxation results are compatible with a water molecule dynamics model based on either a bimodal distribution of correlation times or anisotropic motion, a comparison of the present results with proton data suggests than an anisotropic motion model is more likely to provide a reasonable description of the water molecule motion. An analysis based on an anisotropic motion model that uses two correlation times to characterize the motion shows that most of the water molecules rotate about their twofold axis of symmetry at a rate that is only approximately 100 times smaller than the rate of isotropic diffusion in the bulk liquid. The reorientation of the twofold axis of symmetry itself is characterized by a correlation time of approximately 10(-7) s.

Introduction of a Vickers M300 analyser into the routine service of a hospital laboratory. 1. Installation, staffing, logistics.

A Vickers M300 analyser has been successfully installed in a busy hospital laboratory. A permanent team of operators is used, but this introduces problems for staff rotation, particularly for educational purposes. The vials used for the collection of samples are an essential feature of the system, but they present many difficulties and are no longer used for collecting samples from outpatients, or at remote sites. Direct costs during 1974, excluding staff and depreciation, amounted to approximately pounds 0-45 per patient sample: this is assessed on the rising workload during implementation. An increased workload could still be handled with existing staff. The siting of such high-capacity analysers constitutes an important policy decision.

Introduction of a Vickers M300 analyser into the routine service of a hospital laboratory. 2. Tests, methods, evaluation.

A Vickers M300 analyser has been introduced into a busy hospital laboratory; a profile of 13 biochemical tests is currently provided. Analytical performance has been assessed over one year of routine service operation, and mechanical performance has been assessed over two separate three-month periods. At its best, the M300 achieves high standards of precision and accuracy and has the advantage of unrivalled speed. Enzyme assay methods are less satisfactory than the kinetic assays in current use. Random analytical errors occur and are difficult to detect. The restricted facilities of the integral process-control computer are inadequate for effective quality control.