Abstract

The term “borderline” has been in clinical use for decades, reflecting an early notion of a group of patients on the border between the neuroses and the psychoses.  This view, that this multisymptomatic condition represented a schizophrenia-spectrum illness, was revised after criteria were developed for Axis II disorders for the DSM-III, and schizotypal PD was identified as the personality disorder on the schizophrenia spectrum.  Borderline PD was then proposed to be on the affective or mood disorders spectrum, but later described as a disorder of impulse control.  In fact, the polythetic system uniformly adopted for Axis II by DSM-III-R and DSM-IV guarantees significant heterogeneity within each diagnostic category.  Clarkin et al., in 1983, determined that using DSM-III criteria there were 56 different “official” ways to be diagnosed with BPD, and this number would now be greater since a ninth criterion was added in DSM-IV. It is important to recognize this inherent heterogeneity within the definition of BPD, since it crucially guides treatment planning, depending on the predominant symptomatology in a given patient.  Furthermore, extensive intra-Axis II comorbidity is common, and Axis I/II comorbidity is the rule rather than the exception, further accentuating the variability between one borderline patient and another.  A method to sub-type patients with BPD will be presented, based on theories of etiology of the disorder. Data will be presented from the Collaborative Longitudinal Personality Disorder Study (CLPS) exemplifying typical diagnostic heterogeneity in a large borderline cohort, and the recently published American Psychiatric Association Practice Guideline for the Treatment of Borderline Personality Disorders will be discussed.

Objectives:

•	understand how genetic and environmental effects may be estimated
•	describe genetic and environmental contributions to the development of borderline personality disorder
•	understand how genetic and environmental influences interact in the development of borderline personality disorder

Objectives:

•	know the structure and treatment targets of in-patient DBT
•	know the most recent data on evaluation of in-patient DBT
Abstract Dialectical Behavioral Therapy (DBT) was initially developed and evaluated as an outpatient treatment program for chronically suicidal individuals meeting criteria for borderline personality disorder (BPD). Within the last few years, several adaptations to specific settings have been developed. This study aims to evaluate a three-month DBT inpatient treatment program in Germany. Clinical outcomes, including changes on measures of psychopathology and frequency of self-mutilating acts, were assessed for 50 female patients meeting criteria for BPD. Thirty-one patients had participated in a DBT inpatient program, and 19 patients had been placed on a waiting list and received treatment as usual in the community. Post-testing was conducted four months after the initial assessment (i.e. four weeks after discharge for the DBT group). Pre-post-comparison showed significant changes for the DBT group on 10 of 11 psychopathological variables and significant reductions in self-injurious behavior. The waiting list group did not show any significant changes at the four-months point. The DBT group improved significantly more than participants on the waiting list on seven of the nine variables analyzed, including depression, anxiety, interpersonal functioning, social adjustment, global psychopathology and self-mutilation. Analyses based on Jacobson’s criteria for clinically relevant change indicated that 42% of those receiving DBT had clinically recovered on a general measure of psychopathology. The data suggest that three months of inpatient DBT treatment is significantly superior to non-specific outpatient treatment. Within a relatively short time frame, improvement was found across a broad range of psychopathological features.

Objectives

•	appreciate the role of temperament as a risk factor for suicidal behavior in BPD
•	understand the relationship between diminished central serotonergic function, impulsivity and aggression in BPD
•	review emerging evidence for prefrontal and medial temporal (hippocampal) dysregulation in borderline psychopathology

Learning Objective

•	Identify impulsive aggression as a specific factor in BPD
•	Identify aspects of the neuroscience of impulsive aggression
•	Identify potential brain region abnormalities in impulsive aggression

Learning Objectives

•	Understand the rationale for a family education program
•	Identify a set of coping skills that benefit family members
•	Know the specific impact a family education program has on the well being of family members

Learning Objectives

Abstract

Virtually all research and treatment development for individuals with Borderline Personality Disorder has been community or hospital based. Unfortunately, another domain exists that begs our focused attention. Given the impulsivity, emotional instability, and interpersonal difficulties that are characteristic of the diagnosis of BPD, it is reasonable to expect that such individuals may become involved with the criminal justice system and subsequently become incarcerated. Indeed, multiple studies report estimates of approximately 10% of incarcerated men and 25% of incarcerated women meet criteria for BPD.  Given that 2 million people are currently in our nation’s jails and prisons, this suggests that about 250,000 meet criteria for BPD. In this panel, we will discuss issues of diagnosis, presentation in a correctional environment, management and treatment issues, and the coordination of care following discharge into the community. The opportunities and challenges for improving recognition and treatment of offenders with borderline personality disorder will be discussed.

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Article

Behind Bars: Personality Disorders, Robert L. Trestman, Ph.D., M.D., reprinted from The Journal of the American Academy of Psychiatry and the Law, 28:2:232-235 (2000)

Learning Objectives

•	To understand the current state of knowledge regarding developmental aspects of borderline personality disorder
•	To appreciate the long term negative prognosis for this disorder despite periods of better function
•	To understand the potential integrative utility of a better biological understanding of borderline PD

Learning Objectives

•	Understand the components of DBT
•	Understand DBT outcomes for suicide attempts and self-injury
•	Understand DBT outcomes for quality of life measures

Objectives:

•	understand the concept of psychological structure
•	understand its relation to the symptoms of borderline personality
•	understand its relation to treatment for borderline personality

Abstract

TFP is based on psychodynamic concepts and designed specifically for borderline patients. This twice-per-week individual therapy is described in a treatment manual. TFP combines many of the elements in the Guidelines for the Treatment of Borderline Personality issued by the American Psychiatric Association. For example, TFP places special emphasis on the assessment and on the treatment contract and frame. This part of the treatment has a behavioral quality in that parameters are established to deal with the likely threats that may occur both to the patient’s well-being and to the treatment. The patient is engaged as a collaborator in setting up these parameters.

A feature of TFP is the belief in a deep psychological structure that underlies the specific symptoms of BPD. The focus of treatment is on a fundamental split in the patient’s mind that divides perceptions of self and others into extremes of bad and good. This internal split determines the patient’s way of experiencing self, others and the environment, and it leads to the specific symptoms of BPD, such as chaotic interpersonal relations and impulsive self-destructive behaviors. 

After the behaviors typical of borderline pathology are contained through structure and limit setting, this split psychological structure is observed and analyzed as it unfolds in the transference [the relation with the therapist as perceived by the patient].  This work leads to an integration of the split internal world that allows for more flexible, adaptive, and satisfying functioning.

Learning Objectives

•	Understand the difference between Axis I and Axis II
•	Understand why BPD and other personality disorders are on Axis I
•	Understand some of the pros and the cons of having BPD on Axis II

Borderline’s Location of Axis II

Borderline Personality Disorder’s location on Axis II, like other personality disorders and mental retardation is because:  “The listing of Personality Disorders and Mental Retardation on a separate axis ensures that consideration will be given to the possible presence of Personality Disorder and Mental Retardation that might otherwise be overlooked when attention is directed to the usually more florid Axis I disorders.  The coding of Personality Disorders on Axis II should not be taken to imply that their pathogenesis or range of appropriate treatment is fundamentally different from that for the disorders coded on Axis I.”

Does the segregation of Personality Disorders and Mental Retardation from other psychiatric disorders well serve people with Borderline Personality Disorder?  There is no evidence that it does.  On the other hand, there is a concern that being segregated:

More generally, the multiaxial system, including Axis II, separates the reporting of people with psychiatric illnesses different from the reporting of people with other illnesses.  Thus, in addition to the specific issue of segregation of Borderline Personality Disorder from Axis I disorders, the psychiatrically ill are probably poorly served by the multiaxial system generally.

A recent review of the issues around whether the multiaxial system is a diagnostic system or simple a reporting system has remained unanswered, raising the issue of whether there is an issue if it is only the latter.

References

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision, 2000, Arlington, VA; American Psychiatric Association, page 28.

Livesley WJ: Diagnostic dilemmas in classifying personality disorder, in Phillips KA, First MB, Pincus HA [eds]: Advancing DSM: Dilemmas in Psychiatric Diagnosis. 2003. Arlington, VA: American Psychiatric Association. Pages 153-190.   

Learning Objectives