ReviewThe borderline diagnosis I: psychopathology, comorbidity, and personaltity structure
Introduction
Borderline personality disorder (BPD) is a complex and serious mental disorder characterized by a pervasive pattern of instability in regulation of emotion, interpersonal relationships, self-image, and impulse control. It is estimated to occur in 1%–2% of the general population (Torgersen et al 2001) and is the most common personality disorder in clinical settings, affecting 10% of all psychiatric outpatients and 15%–20% of inpatients (Widiger and Frances 1989). BPD is characterized by severe functional impairment, substantial treatment utilization, and a mortality rate by suicide of almost 10%—50 times higher than the rate in the general population (Work Group on Borderline Personality Disorder 2001).
Recently, through the efforts of the National Institute of Mental Health, the Borderline Personality Disorder Research Foundation, and family advocacy groups, borderline personality disorder is becoming a focus of intensifying study. This three-part article is meant to provide a foundation and to offer guidance to researchers on important aspects of the borderline diagnosis. In Part I, we examine the psychopathology, comorbidity, and personality structure of BPD. In Part II, we review its biology, genetics, and clinical course. In part III, an endophenotypic approach to the genetics of BPD is described.
Section snippets
Origins and evolution of the borderline diagnosis
Following the seminal clinical accounts of “borderline” patients by Stern (1938) and Knight 1953, Kernberg 1967 made an effort to define their intrapsychic features. Kernberg described borderline personality organization (BPO) as an intermediary level of internal personality organization, framed on one side by more severe psychotic personality organization and on the other by less severe neurotic organization. The BPO construct encompassed all serious forms of personality disorder and was
Axis I comorbidity
The importance of comorbidity in the study of BPD is highlighted by the number of publications identified by literature searches. As of June 2000, a MedLine search of the literature for the last 35 years identified only 3 personality disorders for which there are more than 1000 published studies: schizotypal personality disorder (n = 1030), antisocial personality disorder (n = 3876), and BPD (n = 2182). One hundred nineteen studies on comorbidity were identified for borderline personality, a
Categorical versus dimensional models
The question of whether mental disorders are optimally classified categorically or dimensionally has been a long-standing issue and one of particular relevance for personality disorders Livesley 1985, Widiger and Frances 1985. Many arguments favoring a dimensional model have been presented thoroughly in a number of prior papers (e.g., Clark et al 1997, Gunderson et al 1991, Livesley 1985, Livesley 1998, Oldham and Skodol 2000, Widiger 1993, Widiger and Frances 1985). Critics of categorical
Conclusions
Modern diagnostic criteria to describe patients with BPD have evolved over the past 35 years. Although the descriptive characteristics of BPD are well-represented by the criteria, other important aspects of BPD psychopathology are not included. The descriptive criteria have the advantage, however, of having increased the ability of investigators to diagnose BPD reliably—as reliably, in fact, as many more widely studied Axis I disorders.
Semistructured interviews are needed for the reliable
Acknowledgements
Supported in part by the Borderline Personality Disorder Research Foundation and National Institute of Mental Health Grant MH 50839.
This paper was commissioned by and written with the support of the Board of Trustees of the Borderline Personality Disorder Research Foundation (BPDRF) and aspects of this work were presented and discussed at the First Annual Scientific Meeting of the Foundation, July 13–14, 2000. The authors are or were members of or consultants to the Scientific Advisory Board of
References (146)
Borderline personality disorder and bipolar II disorder in private practice depressed outpatients
Compr Psychiatry
(2000)- et al.
The effects of changing Axis II diagnostic criteria
Compr Psychiatry
(1992) - et al.
Latent structure analysis of DSM-IV borderline personality disorder criteria
Compr Psychiatry
(1999) - et al.
A systematic assessment of the comorbidity of DSM-III-R personality disorders in alcoholic out patients
Compr Psychiatry
(1993) - et al.
The implications of DSM-III personality disorders for patients with major depression
J Affective Disord
(1984) - et al.
The relationship of personality to affective disordersA critical review
Arch Gen Psychiatry
(1983) Diagnostic and Statistical Manual of Mental Disorders
(1980)Diagnostic and Statistical Manual of Mental Disorders
(1987)Diagnostic and Statistical Manual of Mental Disorders
(1994)The borderline personality and transitional relatedness
Am J Psychiatry
(1981)
Effect of Axis II diagnoses on treatment outcome with clomipramine in 55 patients with obsessive-compulsive disorder
Arch Gen Psychiatry
Personality, temperament, and character dimensions and the DSM-IV personality disorders in substance abusers
J Abnorm Psychol
Attachment
Cognitive Therapy of Personality Disorders
Personality disorder in obsessive-compulsive volunteers, well comparison subjects, and their first-degree relatives
Am J Psychiatry
Defense styles and borderline personality disorder
J Personal Disord
Transitional objects and borderline personality disorder
Am J Psychiatry
Psychotic symptoms in borderline personality disorder
Am J Psychiatry
Manual for the Schedule for Nonadaptive and Adaptive Personality (SNAP)
Two approaches to identifying the dimensions of personality disorderConvergence on the five-factor model
Personality disorder assessmentThe challenge of construct validity
J Personal Disord
Convergence of two systems for assessing personality disorder
Psychol Assess
Symptoms and traits of personality disorderTwo new methods for their assessment
Psychol Assess
Personality disorder symptomatology from the five-factor model perspective
Factor structure of borderline personality disorder criteria
J Personal Disord
Prototypic typology and the borderline personality disorder
J Abnorm Psychol
Integrative psychobiological approach to psychiatric assessment and treatment
Psychiatry
Measurement of psychopathology as variants of personality
A psychobiological model of temperament and character
Arch Gen Psychiatry
Revised NEO Personality Inventory (NEO-PI-R) and NEO Five-Factor Inventory (NEO-FFI) Professional Manual
Personality structureEmergence of the five-factor model
Annual Review of Psychology
Axis I and Axis II comorbidity in alcohol dependence and the two types of alcoholism
Alcohol Clin Exp Res
Pure personality disorders in an intake psychiatric setting
J Personal Disord
The Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II), Part IDescription
J Personal Disord
The Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II), Part IIMulti-site test-retest reliability study
J Personal Disord
Structured Clinical Interview for DSM-IV (SCID-I) (User’s Guide and Interview) Research Version
Playing with realityThe development of psychic reality and its malfunction in borderline personalities
Int J Psychoanal
Reliability of criteria for borderline personality disorderA comparison of DSM-III and the Diagnostic Interview for Borderline Personality Disorder
Am J Psychiatry
The DSM-III personality disorders sectionA commentary
Am J Psychiatry
DSM-III-R personality disorders in patients with eating disorders
Am J Psychiatry
Schizotypal symptoms in patients with borderline personality disorders
Am J Psychiatry
From ace to zombieSome explorations in the language of personality
The structure of phenotypic personality traits
Am Psychol
Controlled study of psychiatric comorbidity in psychiatrically hospitalized young adults with substance use disorders
Am J Psychiatry
The Borderline SyndromeA Behavioral Study of Ego Functions
Borderline Personality Disorder
The borderline patient’s intolerance of alonenessInsecure attachments and therapist availability
Am J Psychiatry
DSM-IV personality disordersFinal overview
Borderline and schizophrenic patientsA comparative study
Am J Psychiatry
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