Refining the Phenotype of Borderline Personality Disorder: Diagnostic Criteria and Beyond

Department of Psychiatry, University of Pittsburgh Medical Center, USA.
Personality Disorders: Theory, Research, and Treatment (Impact Factor: 3.54). 07/2012; 3(3):228-46. DOI: 10.1037/a0027953
Source: PubMed


Borderline personality disorder (BPD) is a heterogeneous disorder, and previous analyses have parsed its phenotype in terms of subtypes or underlying traits. We refined the BPD construct by testing a range of latent variable models to ascertain whether BPD is composed of traits, latent classes, or both. We also tested whether subtypes of BPD could be distinguished by anger, aggressiveness, antisocial behavior, and mis-trustfulness, additional putative indicators drawn from Kernberg's (1967, 1975) theory of BPD. In a mixed clinical and nonclinical sample (N = 362), a factor mixture model consisting of two latent classes (symptomatic and asymptomatic) and a single severity dimension fit the BPD criteria, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), data better than latent class or factor analytic approaches. In the second analytic phase, finite mixture modeling of the symptomatic latent class (n = 100) revealed four BPD subtypes: angry/aggressive, angry/mistrustful, poor identity/low anger, and prototypical. Our results support a hybrid categorical-dimensional model of the BPD DSM-IV criteria. The BPD subtypes emerging from this model have important implications for treatment and etiological research.

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    • "The methods and technology required for identification of biomarkers is emerging rapidly, and these approaches have the capability of identifying whole biological systems or networks that are involved in conferring risk for BPD (e.g., Neylan, Schadt, & Yehuda, 2014). To the extent that BPD consists of subtypes, including an aggression subtype (Hallquist & Pilkonis, 2012) as described in Mancke et al. (2015), these approaches are likely to assist in identifying such subtypes. "
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    ABSTRACT: Comments on the article by F. Mancke et al. (see record 2015-31349-001). The article presents a multidimensional model of aggression in the context of borderline personality disorder (BPD), with a selective review of the research literature. BPD is arguably the most widely researched personality disorder, and the review suggests that there has been extensive progress in characterizing behavioral and biological correlates of aggression. What is not clear from the review, and indeed, the broader literature, is whether the research cited in this review is specific to BPD or can generally be applied to reactive aggression in the context of other disorders (or by extension into the normative range of the behavior). The review by Mancke et al. also highlights the fact that there is a general lack of research establishing predictive validity of aggression in BPD, with most research comparing two groups sampled at one time point. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
    Personality Disorders: Theory, Research, and Treatment 07/2015; 6(3):294-295. DOI:10.1037/per0000134 · 3.54 Impact Factor
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    ABSTRACT: This review summarizes recent neurocognitive research to better delineate the nosology, prognostication and cause underlying borderline personality disorder (BPD). BPD had marked clinical heterogeneity with high comorbidity. Executive dysfunction in this disorder was linked to suicidality and treatment adherence, and may serve as an endophenotype. BPD was also characterized by cognitive distortions such as risky decision-making, deficient feedback processing, dichotomous thinking, jumping to conclusion, monocausal attribution and paranoid cognitive style. Social cognition deficits recently described in BPD include altered social inference and emotional empathy, hypermentalization, poorer facial emotional recognition and facial expressions. In electrophysiological studies, BPD was found to have predominantly right hemispheric deficit in high-order cortical inhibition. Reduced left orbitofrontal activity by visual evoked potential and magnetoencephalography correlated with depressive symptoms and functional deterioration. Brain structures implicated in BPD include the hippocampus, dorsolateral prefrontal cortex and anterior cingulate cortex. Abnormal anatomy and functioning of frontolimbic circuitry appear to correlate with cognitive deficits. Frontolimbic structural and functional abnormalities underlie the broad array of cognitive abnormalities in BPD. Further research should espouse broader considerations of effects of comorbidity and clinical heterogeneity, and include community samples and, possibly, longitudinal designs.
    Current opinion in psychiatry 01/2013; 26(1):90-6. DOI:10.1097/YCO.0b013e32835b57a9 · 3.94 Impact Factor
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    ABSTRACT: The definition of personality disorder has evolved from agrowing clinical consensus to official status in the DSM diagnosticsystem since DSM-III. The definition proposed for DSM-5 highlightsimpairments in self and interpersonal functioning and thepresence of pathological personality traits. There remains a cleartension in this definition. Researchers prefer traits that can be measureddimensionally, and clinicians prefer description of functionalprocesses. Furthermore, the definition implies that personality disorderfunctioning is relatively stable over time, but the issue of whatis stable and what is changing about personality and personalitydysfunction remains an important area of research investigation.This review of the evolution of our understanding of BPDsuggests significant advance since the 1970s. As we have seen, clinicalexperience with these patients in the 1970s lead to a phenomenologicalapproach that informed the criteria in DSM-III and aphenomenological/structural approach that posits an internal psychological organization that guides behavior. Ecological momentary assessment and social neurocognitive science are bringing advanced technology to how patients with BPD function in the present, progressing from attention to certain incoming stimuli, appraisal of these stimuli, and cognitive-affect and behavioral reactions. This sequence of functioning is disturbed in patients with BPD in particular ways. With greater precision in detecting the interpersonal behavior of patients with BPD through ecological momentary assessment and the use of fMRI to detect the operation of underlying neurocognitive structures, the field is approaching an integration of the phenomenological approach of Gunderson and the structural approach of Kernberg. This review suggests that methodological advances have helped take us beyond a purely phenomenological approach to an understanding that personality disorder is an emergent end product of interacting processes, with neurobehavioral systems underpinning the psychological organization and behavior at another level of the organism. From this point of view, BPD may be seen as a dysregulated, reflexive response to managing the rejection/trust dilemma in interpersonal situations. Patients with BPD are constantly faced with an approach/avoidance dilemma in which they desperately want to connect with others while being intensely threatened by the prospect of rejection. However, they may show different types of maladaptive solutions to deal with this dilemma, resulting in different phenomenological subtypes. With the approaching arrival of DSM-5, which will have no changes in the criteria for the personality disorders, and the contrasting RDoC approach of the NIMH, it remains to be seen how these two divergent approaches can clearly take us from the research laboratory to clinical practice. There is a real danger that the clinical world and the research world will proceed in somewhat different directions. With the growing understanding of the behavioral repertoire and the underlying neurobehavioral organization in borderline pathology, it may enable us to more carefully define the changing characteristics of patients with BPD and those elements that are more consistent and stable over time. With these advances, it is possible that future treatment development will be guided less by theory (i.e.,cognitive behavioral, schema, psychodynamic) but more by the empirical understanding of the sequence of cognitive-affective reactions that disturb interpersonal functioning in patients with BPD.
    The Journal of nervous and mental disease 02/2013; 201(2):88-93. DOI:10.1097/NMD.0b013e31827f61f6 · 1.69 Impact Factor
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