The borderline personality diagnosis in adolescents: gender differences and subtypes.

BACKGROUND: This study aimed to identify personality features characterizing adolescent girls and boys with borderline personality disorder (BPD) and to see whether meaningful patterns of heterogeneity exist among adolescents diagnosed with the disorder. METHODS: Two hundred and ninety-four randomly selected doctoral-level clinicians described adolescent patients using Axis II rating scales and the Shedler-Westen Assessment Procedure-200 for Adolescents (SWAP-200-A). We used the SWAP-200-A to provide empirically derived descriptions of female and male adolescents meeting DSM-IV criteria for BPD (who differed substantially in their profiles), and used Q-factor analysis to identify naturally occurring groupings of female patients based on shared personality features. RESULTS: The symptoms and phenomenology of adolescent girls with BPD are similar to those of adults. Adolescent boys meeting BPD criteria have a more aggressive, disruptive, antisocial presentation. Although Ns did not permit further analysis of the data on adolescent boys, Q-analysis isolated four clinically coherent subgroups of girls with BPD: high-functioning internalizing, histrionic, depressive internalizing, and angry externalizing. CONCLUSIONS: BPD in female adolescents resembles DSM-IV BPD as defined for adults. The operating characteristics of the DSM-IV criteria for adolescent boys require further investigation. Empirically derived subgroups are similar to those identified in recent research with adult females. Differences across subgroups on internalizing and externalizing Child Behavior Checklist (CBCL) scales provide preliminary data on the validity of subgroups and raise questions about the place of BPD among internalizing and externalizing spectrum disorders.

Borderline personality disorder in clinical practice.

OBJECTIVE: Most studies of borderline personality disorder have drawn patients from among hospital inpatients or outpatients. The aims of this study were to examine the nature of borderline personality disorder patients in everyday clinical practice and to use data from a sample of borderline personality disorder patients seen in the community to refine the borderline construct. METHOD: A random national sample of 117 experienced psychiatrists and psychologists from the membership registers of the American Psychiatric Association and American Psychological Association provided data on a randomly selected patient with borderline personality disorder (N=90) or dysthymic disorder (N=27) from their practice. The clinicians provided data on axis I comorbidity, axis II comorbidity, and adaptive functioning, as well as a personality description of the patient using the Shedler-Westen Assessment Procedure-200 (SWAP-200) Q-sort, an instrument designed for assessment and taxonomic purposes. Analyses compared borderline personality disorder and dysthymic disorder groups on variables of interest and aggregated SWAP-200 items across all borderline personality disorder patients to create a composite portrait of borderline personality disorder as seen in the community. RESULTS: The borderline personality disorder sample strongly resembled previously studied borderline personality disorder samples with regard to comorbidity and adaptive functioning. However, the SWAP-200 painted a portrait of borderline personality disorder patients as having more distress and emotion dysregulation, compared to the DSM-IV description. CONCLUSIONS: Borderline personality disorder patients in research samples are highly similar to those seen in a cross-section of clinical practice. However, several studies have now replicated a portrait of borderline personality disorder symptoms that places greater weight than the DSM-IV description on the intense psychological pain of these patients and suggests candidate diagnostic criteria for DSM-V.

Countertransference phenomena and personality pathology in clinical practice: an empirical investigation.

OBJECTIVE: This study provides initial data on the reliability and factor structure of a measure of countertransference processes in clinical practice and examines the relation between these processes and patients' personality pathology. METHOD: A national random sample of 181 psychiatrists and clinical psychologists in North America each completed a battery of instruments on a randomly selected patient in their care, including measures of axis II symptoms and the Countertransference Questionnaire, an instrument designed to assess clinicians' cognitive, affective, and behavioral responses in interacting with a particular patient. RESULTS: Factor analysis of the Countertransference Questionnaire yielded eight clinically and conceptually coherent factors that were independent of clinicians' theoretical orientation: 1) overwhelmed/disorganized, 2) helpless/inadequate, 3) positive, 4) special/overinvolved, 5) sexualized, 6) disengaged, 7) parental/protective, and 8) criticized/mistreated. The eight factors were associated in predictable ways with axis II pathology. An aggregated portrait of countertransference responses with narcissistic personality disorder patients provided a clinically rich, empirically based description that strongly resembled theoretical and clinical accounts. CONCLUSIONS: Countertransference phenomena can be measured in clinically sophisticated and psychometrically sound ways that tap the complexity of clinicians' reactions toward their patients. Countertransference patterns are systematically related to patients' personality pathology across therapeutic approaches, suggesting that clinicians, regardless of therapeutic orientation, can make diagnostic and therapeutic use of their own responses to the patient.