Borderline Personality Disorder (Medical Psychiatry)

393 Pages·2005·2.82 MB·English

by  Mary C. Zanarini

DK3738_half-series-title.qxd 8/9/05 11:52 AM Page i
Borderline
Personality
Disorder
edited by
Mary C. Zanarini
Harvard Medical School
Boston, Massachusetts, U.S.A.
McLean Hospital
Belmont, Massachusetts, U.S.A.
New York London
DK3738_Discl.fm Page 1 Thursday, July 7, 2005 10:09 AM
Published in 2005 by
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
© 2005 by Taylor & Francis Group, LLC
No claim to original U.S. Government works
Printed in the United States of America on acid-free paper
10 9 8 7 6 5 4 3 2 1
International Standard Book Number-10: 0-8247-2928-5 (Hardcover)
International Standard Book Number-13: 978-0-8247-2928-8 (Hardcover)
This book contains information obtained from authentic and highly regarded sources. Reprinted material is
quoted with permission, and sources are indicated. A wide variety of references are listed. Reasonable efforts
have been made to publish reliable data and information, but the author and the publisher cannot assume
responsibility for the validity of all materials or for the consequences of their use.
No part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic,
mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and
recording, or in any information storage or retrieval system, without written permission from the publishers.
For permission to photocopy or use material electronically from this work, please access www.copyright.com
(http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC) 222 Rosewood Drive,
Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registration
for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate
system of payment has been arranged.
Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only
for identification and explanation without intent to infringe.
Library of Congress Cataloging-in-Publication Data
Catalog record is available from the Library of Congress
Visit the Taylor & Francis Web site at
http://www.taylorandfrancis.com
Taylor & Francis Group
is the Academic Division of T&F Informa plc.
Preface
Borderline personality disorder (BPD) is both a common and very serious
psychiatric disorder. Recent studies have found that about 2% of American
adults meet criteria for BPD. Perhaps more troubling is the fact that this
diagnosis is associated with high levels of mental health service utilization,
psychosocial impairment, and subjective distress.
The disorder was first described by Adolph Stern in 1938, but it did
not enter the official nomenclature of the American Psychiatric Association
until 1980. In the introductory chapter on History of the Concept, we will
review the many psychoanalytic concepts that were used during the 1950s
and 1960s to describe borderline patients (e.g., psychotic character, as-if
personality). The chapter will also review the efforts of descriptive psychia-
try to conceptualize BPD as a subsyndromal version of first schizophrenia,
then mood disorders, impulse spectrum disorders, and finally, traumatic
disorders.
Much of the recent research has focused on the etiology of BPD.
This research has investigated four pathways to the development of BPD.
The first of these areas of investigation is environmental factors. Kenneth Silk
reviews the existing literature, which first focused on relatively subtle failures in
early parenting, and more recently has focused on frank experiences of neglect
and abuse. This chapter addresses the controversy of whether sexual abuse is
either necessary or sufficient for the development of BPD.
iii
iv Preface
The second area of etiological research is the role of temperament.
Thomas Widiger reviews the vast literature on the etiological significance
of disordered personality to the development of BPD. Emil Coccaro
addresses the third area of etiological research—neurobiological factors that
may underlie the symptomatic expression of BPD and its attendant psycho-
social impairment. Svenn Torgersen addresses the fourth pathway to the
development of BPD—its genetic inheritance.
BPD is often comorbid with a number of other conditions—most com-
monly mood disorders, anxiety disorders, eating disorders, and substance
use disorders. This has led to the unfortunate practice of many borderline
patients being misdiagnosed as suffering from bipolar II disorder. It has also
led to the unfortunate tendency of some therapists to ignore a patient’s bor-
derline personality and instead treat their ‘‘chronic post-traumatic stress
disorder’’—often with serious negative consequences. Bruce Pfohl reviews
the literature on comorbidity and suggests useful ways to correctly identify
and treat comorbid conditions.
Information concerning the longitudinal course of BPD is important
in informing patients and their families about what they can reasonably
expect in the future. It is also important to inform clinicians about the nat-
ural history of the disorder so that they can be as supportive and patient as
needed. To date, 17 small-scale, short-term prospective studies of the course
of BPD have been conducted. Four large-scale, long-term follow-back stud-
ies of the course of BPD have also been conducted. It has been difficult,
however, to generalize from the results of these studies due to a series of
methodological difficulties (e.g., failure to use reliable diagnostic interviews
for BPD, high attrition rates, only one follow-up assessment per study).
More recently, two large-scale, long-term prospective studies of the course
of BPD have been funded by the National Institute of Mental Health. The first
of these studies—theMcLean Study of Adult Development—found that remis-
sions from BPD are far more common than previously recognized and that
recurrences of BPD are extremely rare. Additionally, two different types of bor-
derline symptoms, with different courses, have been identified. The second of
these studies—the Collaborative Longitudinal Personality Disorders Study—
found even higher rates of remission in an even shorter period of time. Taken
together, the results of these ongoing studies suggest that the prognosis formost,
but not all, borderline patients is better than previously recognized.
Andrew Skodol reviews what these different generations of studies
have found concerning the psychosocial functioning of borderline patients.
Mary Zanarini reviews the symptomatic course of BPD (and its treatment
over time). Joel Paris reviews the varying suicide rates found in these studies
(3–10%) and offers suggestions about the assessment of suicide risk and the
handling of crises related to suicidality.
Most borderline patients are in treatment for their disorder and its
attendant level of psychosocial disability. John Gunderson, the ‘‘father’’ of
Preface v
the borderline diagnosis, reviews the latest information concerning the psy-
chodynamic therapy of borderline patients. He also presents his approach to
handling many of the difficulties in treating these patients that lead to the
premature termination of treatment. Marsha Linehan, the developer of dia-
lectical behavioral therapy, presents the latest evidence for the effectiveness
of her widely used treatment approach.
Other treatment approaches are also widely used. Naturalistic studies
have found that a high percentage of borderline patients are taking psycho-
tropic medications and, in fact, many are being treated with aggressive poly-
pharmacy. Frances Frankenburg reviews this information as well as the
results of open-label and placebo-controlled trials of antidepressants, mood
stabilizers, and neuroleptics. She also presents new empirically informed
guidelines for the pharmacotherapy of BPD.
Both family therapy and day treatment are also common treatment
modalities for those with BPD. Perry Hoffman presents the most up-to-date
information concerning the family therapy of borderline patients, emphasiz-
ing the importance of empowering families to actively advocate for their
borderline children. Anthony Bateman reports on his highly regarded
psychodynamically informed day treatment approach for very seriously
impaired borderline patients.
In addition, brain imaging studies of borderline patients are beginning
to appear with regularity and are aiding in our understanding of the pathol-
ogy of BPD. In Kyoon Lyoo reviews the available literature on functional
MRI and positron-emission tomography studies of criteria-defined border-
line patients. Paul Soloff reports on his cutting-edge research concerning the
neurobiological bases of suicidality.
Finally, Michael First, who was deeply involved with the development
of the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV),
reports on possible changes to the borderline construct that will be contained
in DSM-V. One possible change is to move BPD from axis-II and put it onto
a spectrum with mood disorders. Another would be to adopt a dimensional
approach to diagnosing BPD. This could involve either noting the severity of
a particular patient’s borderline disorder or dropping all of the current cri-
teria for the disorder and using a complex system of rating various personal-
ity features derived from academic psychology. The first of these dimensional
approaches would be consistent with other branches of medicine where dis-
orders are viewed both categorically and dimensionally (e.g., hypertension,
hypercholesterolemia). The second dimensional approach would involve an
entirely new approach to identifying borderline psychopathology.
It is our hope that this volume will serve as a source for psychiatrist,
psychologist, and other mental health professionals seeking answers to the
many questions related to the understanding and treatment of BPD.
Mary C. Zanarini
Contents
Preface . . . . iii
Contributors . . . . xv
1. Borderline Personality Disorder:
History of the Concept . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Michael H. Stone
1. Introduction . . . . 1
2. Late 19th Century Origins of the
Borderline Concept . . . . 2
3. The Early Years of the 20th Century . . . . 3
4. The Borderline Concept at Mid-Century . . . . 7
5. The Formulations of Kernberg and Gunderson, and the
Foundations of the Borderline Personality Disorder
Concept in Contemporary Psychiatry . . . . 9
6. Borderline Personality Disorder Becomes Official:
Its Inclusion in DSM-III . . . . 12
7. Recent Developments in BPD Research:
The Return of the ‘‘Splitters’’ . . . . 13
References . . . . 15
vii
viii Contents
2. The Subsyndromal Phenomenology of Borderline Personality
Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Mary C. Zanarini
1. Introduction . . . . 19
2. Affective Psychopathology . . . . 20
3. Cognitive Psychopathology . . . . 22
4. Behavioral or Impulsive Psychopathology . . . . 24
5. Interpersonal Psychopathology . . . . 27
6. Toward DSM-V . . . . 35
7. Conclusions . . . . 37
References . . . . 37
3. Environmental Factors in the Etiology of Borderline Personality
Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Kenneth R. Silk, Teri L. Wolf, Dorit A. Ben-Ami, and
Ernest W. Poortinga
1. Introduction . . . . 41
2. The PRE-DSM-III Descriptions of Borderline
Personality Disorder . . . . 42
3. A Psychoanalytic–Object Relations
Approach to the Development of BPD: The Internal
Environment . . . . 43
4. The Reinforcing Early Environment:
Attachment, Loss, and the Early Familial
Environment . . . . 47
5. The Environment of Experience: Childhood Maltreatment
and Abuse . . . . 50
6. Conclusion . . . . 56
References . . . . 57
4. A Temperament Model of Borderline
Personality Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Thomas A. Widiger
1. Fundamental Temperaments . . . . 64
2. The Temperament of Borderline
Personality Disorder . . . . 65
3. Empirical Support for Temperament
Model of BPD . . . . 68
4. Implications of Temperament Model of BPD . . . . 73
5. Conclusions . . . . 76
References . . . . 77
Contents ix
5. Neurobiology of Impulsive Aggression . . . . . . . . . . . . . . . 83
Yong Li and Emil F. Coccaro
1. Introduction . . . . 83
2. Neuropsychopharmacology of Aggression . . . . 84
3. Neuroanatomy and Functional Neuroimaging
of Aggression . . . . 88
4. Pharmacological Treatment of
Persistent Aggression . . . . 90
References . . . . 91
6. Biochemical Endophenotypes in Borderline Personality
Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Michael J. Minzenberg and Larry J. Siever
1. Genes and Environment . . . . 103
2. Two Issues: Nosology and the Complex Genetics of
Psychiatric Illness . . . . 104
3. Endophenotypes as an Emerging Strategy in
Psychiatric Genetics . . . . 105
4. Evolution of a Dimensional Perspective on
Personality Disorders . . . . 106
5. Impulsivity and Aggression . . . . 107
6. Affective Instability . . . . 113
7. Conclusion . . . . 115
References . . . . 116
7. Genetics of Borderline Personality Disorder . . . . . . . . . . 127
Svenn Torgersen
1. Study Designs . . . . 128
2. Personality Traits Related to BPD . . . . 129
3. Studies of BPD Itself . . . . 130
4. Conclusions . . . . 132
References . . . . 132
8. Comorbidity and Borderline Personality
Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Bruce Pfohl
1. Introduction . . . . 135
2. Comorbidity with Axis-I Disorders . . . . 137
3. Comorbidity with Other Axis-II Disorders . . . . 140
4. Implications of Axis-I Comorbidity . . . . 142