Parent-adolescent concordance on the Revised Diagnostic Interview for Borderlines (DIB-R) and the Childhood Interview for Borderline Personality Disorder (CI-BPD).

While the degree of concordance between parent and adolescent self-report of internalizing and externalizing pathology is well studied, virtually nothing is known about concordance in borderline pathology and the implication of parent-adolescent discrepancies for outcomes. The present study aimed to (1) examine discrepancies between parents and adolescents on two interview-based measures of borderline personality disorder (BPD)-the Revised Diagnostic Interview for Borderlines (DIB-R22 ) and the Childhood Interview for Borderline Personality Disorder (CI-BPD23 ); and (2) investigate the implications of discrepancies for clinical outcomes. Diagnostic concordance on the DIB-R and CI-BPD showed rates of 82% and 94% respectively, with lower concordance demonstrated for dimensionally scored variables. Standardized difference scores between adolescent and parent reports on both borderline measures were significantly correlated with few interview-based axis I diagnoses as reported by parents, but not adolescents themselves. Implications regarding the use of each measure for the assessment and diagnosis of borderline personality disorder are discussed. Copyright © 2017 John Wiley & Sons, Ltd.

Prediction of time-to-attainment of recovery for borderline patients followed prospectively for 16 years.

OBJECTIVE: The purpose of this study was to determine the most clinically relevant baseline predictors of time-to-recovery from borderline personality disorder. METHOD: Two hundred and ninety in-patients meeting rigorous criteria for borderline personality disorder were assessed during their index admission using a series of semistructured interviews and self-report measures. Recovery status, which was defined as concurrent symptomatic remission and good social and full-time vocational functioning, was reassessed at eight contiguous 2-year time periods. Survival analytic methods (Cox regression), which controlled for overall baseline severity, were used to estimate hazard ratios and their confidence intervals. RESULTS: All told, 60% of the borderline patients studied achieved a 2-year recovery. In bivariate analyses, seventeen variables were found to be significant predictors of earlier time-to-recovery. Six of these predictors remained significant in multivariate analyses: no prior psychiatric hospitalizations, higher IQ, good full-time vocational record in 2 years prior to index admission, absence of an anxious cluster personality disorder, high extraversion, and high agreeableness. CONCLUSION: Taken together, the results of this study suggest that prediction of time-to-recovery for borderline patients is multifactorial in nature, involving factors related to lack of chronicity, competence, and more adaptive aspects of temperament.

The contribution of familial internalizing and externalizing liability factors to borderline personality disorder.

BACKGROUND: Individuals with borderline personality disorder (BPD) frequently display co-morbid mental disorders. These disorders include 'internalizing' disorders (such as major depressive disorder and anxiety disorders) and 'externalizing' disorders (such as substance use disorders and antisocial personality disorder). It is hypothesized that these disorders may arise from latent 'internalizing' and 'externalizing' liability factors. Factor analytic studies suggest that internalizing and externalizing factors both contribute to BPD, but the extent to which such contributions are familial is unknown. METHOD: Participants were 368 probands (132 with BPD; 134 without BPD; and 102 with major depressive disorder) and 885 siblings and parents of probands. Participants were administered the Diagnostic Interview for DSM-IV Personality Disorders, the Revised Diagnostic Interview for Borderlines, and the Structured Clinical Interview for DSM-IV. RESULTS: On confirmatory factor analysis of within-person associations of disorders, BPD loaded moderately on internalizing (factor loading 0.53, S.E. = 0.10, p < 0.001) and externalizing latent variables (0.48, S.E. = 0.10, p < 0.001). Within-family associations were assessed using structural equation models of familial and non-familial factors for BPD, internalizing disorders, and externalizing disorders. In a Cholesky decomposition model, 84% (S.E. = 17%, p < 0.001) of the association of BPD with internalizing and externalizing factors was accounted for by familial contributions. CONCLUSIONS: Familial internalizing and externalizing liability factors are both associated with, and therefore may mutually contribute to, BPD. These familial contributions account largely for the pattern of co-morbidity between BPD and internalizing and externalizing disorders.

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

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

The 10-year course of PTSD in borderline patients and axis II comparison subjects.

OBJECTIVE: The first objective is to detail the prevalence of post-traumatic stress disorder (PTSD) over a decade of follow-up for those in both study groups. The second is to determine time-to-remission, recurrence, and new onset of PTSD, and the third is to assess the relationship between sexual adversity and the likelihood of remission and recurrence of PTSD. METHOD: The SCID I was administered to 290 borderline in-patients and 72 axis II comparison subjects during their index admission and re-administered at five contiguous 2-year follow-up periods. RESULTS: The prevalence of PTSD declined significantly over time for patients with borderline personality (BPD) (61%). Over 85% of borderline patients meeting criteria for PTSD at baseline experienced a remission by the time of the 10-year follow-up. Recurrences (40%) and new onsets (27%) were less common. A childhood history of sexual abuse significantly decreased the likelihood of remission from PTSD, and an adult history of sexual assault significantly increased the likelihood of a recurrence of PTSD. CONCLUSION: Taken together, the results of this study suggest that PTSD is not a chronic disorder for the majority of borderline patients. They also suggest a strong relationship between sexual adversity and the course of PTSD among patients with BPD.

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

OBJECTIVE: The purpose of this study was to determine the 10-year course of the psychosocial functioning of patients with borderline personality disorder (BPD). METHOD: The social and vocational functioning of 290 inpatients meeting both the Revised Diagnostic Interview for Borderlines (DIB-R) and DSM-III-R criteria for BPD and 72 axis II comparison subjects were carefully assessed during their index admission. Psychosocial functioning was reassessed using similar methods at five contiguous 2-year time periods. RESULTS: Borderline patients without good psychosocial functioning at baseline reported difficulty attaining it for the first time. Those who had such functioning at baseline reported difficulty retaining and then regaining it. In addition, over 90% of their poor psychosocial functioning was due to poor vocational but not social performance. CONCLUSION: Good psychosocial functioning that involves both social and vocational competence is difficult for borderline patients to achieve and maintain over time. In addition, their vocational functioning is substantially more compromised than their social functioning.

Temperamental and acute symptoms of borderline personality disorder: associations with normal personality traits and dynamic relations over time.

BACKGROUND: Recent research suggests the utility of distinguishing temperamental and acute symptoms of borderline personality disorder (BPD). Temperamental symptoms, such as chronic anger and odd thinking, remit relatively slowly and have been hypothesized to reflect a hyperbolic predisposition to emotional pain and negativistic cognitions, whereas acute symptoms, such as substance abuse and chaotic relationships, remit relatively quickly and have been hypothesized to represent the consequences of maladaptations to triggering environmental events. METHOD: The relationships of temperamental and acute BPD symptoms with normal personality traits and stability and dynamic associations over time across these symptom sets were tested in a 10-year longitudinal study of 362 patients with personality disorders. RESULTS: Temperamental symptoms were associated with high neuroticism, whereas acute symptoms were associated with low agreeableness. These symptoms had similar rank-order stabilities and relative changes in symptom sets were reciprocally linked in a cross-lagged path model suggesting dynamic associations between temperamental and acute symptoms over time. CONCLUSIONS: The distinction between temperamental and acute BPD symptoms is supported by differential relations of these symptom sets to normal personality traits. Moreover, these symptoms appear to be linked in a mutually reinforcing dynamic over time. This distinction should be kept in mind in future studies of the aetiology of BPD and in diagnostic and treatment considerations.

Psychotherapy of borderline personality disorder.

OBJECTIVE: Psychotherapy is considered the primary treatment for borderline personality disorder (BPD). Currently, there are four comprehensive psychosocial treatments for BPD. Two of these treatments are considered psychodynamic in nature: mentalization-based treatment and transference-focused psychotherapy. The other two are considered to be cognitive-behavioral in nature: dialectical behavioral therapy and schema-focused therapy. METHOD: A review of the relevant literature was conducted. RESULTS: Each of these lengthy and complex psychotherapies significantly reduces the severity of borderline psychopathology or at least some aspects of it, particularly physically self-destructive acts. CONCLUSION: Comprehensive, long-term psychotherapy can be a useful form of treatment for those with BPD. However, less intensive and less costly forms of treatment need to be developed.

Personality traits as prospective predictors of suicide attempts.

OBJECTIVE: To examine higher order personality factors of negative affectivity (NA) and disinhibition (DIS), as well as lower order facets of impulsivity, as prospective predictors of suicide attempts in a predominantly personality disordered sample. METHOD: Data were analyzed from 701 participants of the Collaborative Longitudinal Personality Disorders Study with available follow-up data for up to 7 years. Cox proportional hazards regression analyses was used to examine NA and DIS, and facets of impulsivity (e.g. urgency, lack of perseverance, lack of premeditation and sensation seeking), as prospective predictors of suicide attempts. RESULTS: NA, DIS and all facets of impulsivity except for sensation seeking were significant in univariate analyses. In multivariate models which included sex, childhood sexual abuse, course of major depressive disorder and substance use disorders, only NA and lack of premeditation remained significant in predicting suicide attempts. DIS and the remaining impulsivity facets were not significant. CONCLUSION: NA emerged as a stronger and more robust predictor of suicide attempts than DIS and impulsivity, and warrants greater attention in suicide risk assessment. Distinguishing between facets of impulsivity is important for clinical risk assessment.

Improvement in borderline personality disorder in relationship to age.

OBJECTIVE: It is commonly believed that some features of borderline personality disorder (BPD) improve as individuals reach their late 30s and 40s. This study examined age-related change in borderline criteria and functional impairment, testing the hypothesis that older age would be associated with relatively more improvement than younger age. METHOD: A total of 216 male and female participants with BPD were followed prospectively with yearly assessments over 6 years. RESULTS: Participants showed similar rates of improvement in borderline features regardless of age. A significant age by study year interaction showed functioning in older subjects to reverse direction and begin to decline in the latter part of the follow-up, in contrast to younger subjects who maintained or continued improvement over the 6 years. Despite the decline, functioning for the older subjects was comparable with or slightly better at year 6 than at year 1. CONCLUSION: Improvement in borderline features is not specific to the late 30s and 40s. There may be a reversal of improvement in functioning in some borderline patients in this older-age range.

The course of dissociation for patients with borderline personality disorder and axis II comparison subjects: a 10-year follow-up study.

OBJECTIVE: The purpose of this study was to assess the severity of dissociation reported by borderline patients and axis II comparison subjects over 10 years of prospective follow-up. METHOD: The Dissociative Experiences Scale (DES) - a 28-item self-report measure - was administered to 290 borderline in-patients and 72 axis II comparison subjects during their index admission. It was also re-administered at five contiguous 2-year follow-up periods. RESULTS: The overall severity of dissociative experiences of those in both study groups decreased significantly over time but was discernibly greater in borderline patients (61% vs. 43%). The same pattern emerged for the subtypes of dissociation that were studied: absorption, depersonalization and amnesia. CONCLUSION: The severity of dissociation declines significantly over time for even severely ill borderline patients. However, it remains as a recurring problem for over a third of those with DES scores that initially were in the range associated with trauma-spectrum disorders.

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

OBJECTIVE: The purpose of this paper was to determine the frequency and methods of two forms of physically self-destructive acts (i.e. self-mutilation and suicide attempts) reported by borderline patients and axis II comparison subjects over 10 years of prospective follow-up. METHOD: Two hundred and ninety borderline patients and 72 axis II comparison subjects were interviewed about their physically self-destructive acts during their index admission and at five contiguous 2-year follow-up periods. RESULTS: It was found that a high percentage of borderline patients reported multiple acts and methods of each of these two forms of physically self-destructive behavior prior to their index admission. It was also found that the percentage of borderline patients reporting multiple acts and methods declined significantly over time. However, these acts remained significantly more common among borderline patients than axis II comparison subjects. CONCLUSION: The course of self-mutilation and suicide attempts among borderline patients is initially more serious and ultimately more benign than previously recognized.

Avoidant personality disorder and social phobia: distinct enough to be separate disorders?

OBJECTIVE: Existing evidence from anxiety disorder research indicates that social phobics (SP) with avoidant personality disorder (AVPD) experience more anxiety and show more impairment than patients with SP alone. The purpose of this study was to examine whether in patients diagnosed with AVPD, the co-occurrence of SP adds to its severity. We hypothesized that the addition of SP will not add to the severity of AVPD alone. METHOD: Two groups of patients (AVPD=224; AVPD/SP=101) were compared at baseline and 2 years later on multiple demographic and clinical variables. RESULTS: Patients with AVPD and an additional diagnosis of SP differed little from patients with AVPD alone. CONCLUSION: These findings suggest that AVPD and SP may be alternative conceptualizations of the same disorder.

[Validation of a Spanish version of the Diagnostic Interview for Bordelines-Revised (DIB-R)]. / Validación de la versión española de la Diagnostic Interview for Bordelines-Revised (DIB-R).

INTRODUCTION: Borderline Personality Disorder (BPD) is the most studied Axis II disorders. However, there are no Spanish versions of specific interviews. The Diagnostic Interview for Borderlines-Revised (DIB-R) is a semistructured interview used to determine the diagnosis and severity of BPD patients. The aim of this study was to validate the DIB-R for use in a Spanish-speaking sample. METHOD: The psychometric characteristics of the DIB-R Spanish version were assessed in a sample of 156 patients with the possible diagnosis of borderline personality disorder. There were 29 men and 127 women with a mean age of 27.6 years (SD: 6.5; range: 18-45). The Spanish adaptation of the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) was used as gold standard. RESULTS: The DIB-R showed good total internal consistency (Cronbach's alpha: 0.89) and high inter-rater reliability (within-class correlation: 0.94). Using logistic regression analyses the best cut-off was judged to be 6 or more, obtaining high sensitivity (0.81), specificity (0.94) and moderate convergent validity of the diagnosis with the SCID-II (kappa: 0.59). CONCLUSIONS: The Spanish version of the DIB-R showed psychometric characteristics similar to those in the original interview and may be useful to determine BPD presence and severity.

Axis II comorbidity of borderline personality disorder: description of 6-year course and prediction to time-to-remission.

OBJECTIVE: The purpose of this study was to compare the axis II comorbidity of 202 patients whose borderline personality disorder (BPD) remitted over 6 years of prospective follow-up to that of 88 whose BPD never remitted. METHOD: The axis II comorbidity of 290 patients meeting both DIB-R and DSM-III-R criteria for BPD was assessed at baseline using a semistructured interview of demonstrated reliability. Over 96% of surviving patients were reinterviewed about their co-occurring axis II disorders blind to all previously collected information at three distinct follow-up waves: 2-, 4-, and 6-year follow-up. RESULTS: Both remitted and non-remitted borderline patients experienced declining rates of most types of axis II disorders over time. However, the rates of avoidant, dependent, and self-defeating personality disorders remained high among non-remitted borderline patients. Additionally, the absence of these three disorders was found to be significantly correlated with a borderline patient's likelihood-of-remission and time-to-remission; self-defeating personality disorder by a factor of 4, dependent personality disorder by a factor of 3 1/2, and avoidant personality disorder by a factor of almost 2. CONCLUSION: The results of this study suggest that axis II disorders co-occur less commonly with BPD over time, particularly for remitted borderline patients. They also suggest that anxious cluster disorders are the axis II disorders which most impede symptomatic remission from BPD.

Stressful life events as predictors of functioning: findings from the collaborative longitudinal personality disorders study.

OBJECTIVE: Although much attention has been given to the effects of adverse childhood experiences on the development of personality disorders (PDs), we know far less about how recent life events influence the ongoing course of functioning. We examined the extent to which PD subjects differ in rates of life events and the extent to which life events impact psychosocial functioning. METHOD: A total of 633 subjects were drawn from the Collaborative Longitudinal Personality Disorders Study (CLPS), a multi-site study of four personality disorders--schizotypal (STPD), borderline (BPD), avoidant (AVPD), obsessive-compulsive (OCPD)--and a comparison group of major depressive disorders (MDD) without PD. RESULTS: Borderline personality disorder subjects reported significantly more total negative life events than other PDs or subjects with MDD. Negative events, especially interpersonal events, predicted decreased psychosocial functioning over time. CONCLUSION: Our findings indicate higher rates of negative events in subjects with more severe PDs and suggest that negative life events adversely impact multiple areas of psychosocial functioning.

Longitudinal diagnostic efficiency of DSM-IV criteria for obsessive-compulsive personality disorder: a 2-year prospective study.

OBJECTIVE: To examine the longitudinal diagnostic efficiency of the DSM-IV criteria for obsessive-compulsive personality disorder (OCPD). METHOD: At baseline, criteria and diagnoses were determined using diagnostic interviews, and blinded assessments were performed 24 months later with 550 participants. Diagnostic efficiency indices (conditional probabilities, total predictive power, and kappa) were calculated for each criterion determined at baseline, using the independent OCPD diagnosis at follow-up as the standard. RESULTS: Longitudinal diagnostic efficiencies for the OCPD criteria varied; findings suggested the overall predictive utility of 'preoccupied with details', 'rigid and stubborn', and 'reluctant to delegate'. CONCLUSION: These findings suggest the predictive validity of three cognitive-interpersonal OCPD criteria.

Internal consistency, intercriterion overlap and diagnostic efficiency of criteria sets for DSM-IV schizotypal, borderline, avoidant and obsessive-compulsive personality disorders.

OBJECTIVE: To evaluate performance characteristics of DSM-IV Personality Disorders (PDs) criteria. METHOD: Six hundred and sixty-eight adults recruited for the Collaborative Longitudinal Personality Disorders Study (CLPS) were assessed with diagnostic interviews. RESULTS: Within-category inter-relatedness was evaluated by Cronbach's alpha and median intercriterion correlations (MIC). Cronbach's alpha ranged from 0.47 to 0.87 (median=0.71); seven of the 10 PDs had alphas greater than 0.70. Between-category criterion overlap was evaluated by "inter-category" intercriterion correlations between all PD pairs (ICMIC). ICMIC values (median=0.08) were lower than MIC values (median=0.23). Diagnostic efficiency statistics (sensitivity, specificity, positive predictive power and negative predictive power were calculated for schizotypal, borderline, avoidant and obsessive-compulsive PDs. CONCLUSION: DSM-IV PD criteria sets have some convergent validity and discriminant validity: criteria for individual PDs correlate better with each other than with criteria for other PDs. Diagnostic efficiency statistics provide guidance regarding usefulness of criteria for inclusion or exclusion.

Developmental aspects of borderline personality disorder.

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

Attainment and maintenance of reliability of axis I and II disorders over the course of a longitudinal study.

The baseline interrater reliability, test-retest reliability, follow-up interrater reliability, and follow-up longitudinal reliability of axis I and axis II diagnoses were assessed using the Structured Clinical Interview for DSM-III-R Axis I Disorders (SCID-I) and the Diagnostic Interview for DSM-III-R Personality Disorders (DIPD-R). Excellent kappas (>.75) were found in each of these reliability substudies for the majority of axis II disorders diagnosed five times or more. Dimensional reliability figures for axis II diagnoses were generally somewhat higher than those for their categorical counterparts; most intraclass correlation coefficients (ICCs) were in the excellent range. Excellent kappas were also found in each of these four reliability substudies for over half of the axis I disorders diagnosed five times or more. Taken together, the results of this study suggest that the reliability of axis II disorders is both good to excellent and practically equivalent to that found for most axis I disorders. The results of this study also suggest that high levels of reliability, once achieved, can be maintained over time for both axis I and II disorders.