MedLine Research on the Borderline Personality Disorder - Biological Unhappiness

MEDLINE RESEARCH ON THE BORDERLINE PERSONALITY DISORDER

By Leland M. Heller, M.D.

Medline is run by the National Medical Library, and summarized (via abstracts) what are felt to be the most important articles on most medical subjects for the medical profession. These abstracts from Medline are about the BPD.

1980-1985
Am J Psychiatry 1982 Jun;139(6):741-6
"Aggression, suicide, and serotonin: relationships to CSF amine metabolites"
Low levels of the serotonin metabolite (5-HIAA) are associated with aggression and suicidal behavior. (metabolite means a breakdown product)

Arch Gen Psychiatry 1982 Jul;39(7):765-9
"Familial transmission of DSM-III borderline personality disorder"
No increased risk of schizophrenia in relatives with BPD. A relative of a BPD patient had ten times greater risk of developing the BPD compared to those whose relatives had bipolar or schizophrenia.

J Autism Dev Disord 1983 Mar;13(1):67-72
"'Borderline' children"
Sixteen children diagnosed with the BPD on comprehensive evaluation did not meet BPD criteria. The BPD diagnosis had a negative impact on some of the children.

J Clin Psychol 1983 Sep,39(5):722-6
"Screening for borderline personality disorders with the MMPI-168"
On this test the BPD pattern was clearly distinguishable from the majority of college students. (Note: severity of the BPD was not selected out for)

Psychiatry Res 1983 Jun;9(2):107-13
"The TRH test in patients with borderline personality disorder"
7/15 BPD patients had a blunted TSH response to TRH infusion (note: the thyroid stimulating hormone - TSH - should have gone up normally).

J Nerv Ment Dis 1984 Feb;172(2):98-104
"Multiple personality as a borderline disorder"
This study suggests the multiple personality should be viewed as a borderline disorder.

Psychiatr Clin North Am 1984 Mar;7(1):69-87
"Are multiple personalities borderline? An analysis of 33 cases."
BPD is very prevalent in patients with multiple personality disorder, but it is not universal and is a separate and distinct disorder.

J Clin Psychol 1984 Mar;40(2):410-3
"Borderline personality disorder and the MMPI"
14 patients showed considerable variability, but some categories were higher for BPD patients, offering partial support for it's validity. (Note: severity of the BPD was not selected out for)

Arch Gen Psychiatry 1984 Jun;41(6):565-8
"Structured interviews and borderline personality disorder"
The DIB - Diagnostic Interview for Borderlines - was only 70% sensitive for diagnosing the BPD, and 10% diagnosed with the BPD did not fit BPD criteria.

J Clin Psychiatry 1984 Oct;45(10):441-2
"Treatment of attention deficit and borderline personality disorders with psychostimulants: case report"
A young woman with attention deficit disorder and BPD was successfully treated with methylphenidate (Ritalin).

Psychoneuroendocrinology 1984;9(3):311-4
"A dramatic behavioral response to thyrotropin-releasing hormone following low-dose neuroleptics"
The administration of TRH (thyrotropin-releasing hormone - stimulates thyroid hormone production) dramatically improved mood and behavior after treatment with low dose neuroleptics. Neither high dose neuroleptics nor TRH alone had this effect. (Note: neuroleptics include medications like Haldol and Navane)

J Pers Assess 1985 Feb,49(1):47-55
"MMPI characteristics of borderline psychopathology in adolescent inpatients"
MMPI test was 82.1% successful in correctly classifying borderline patients and 78.0% accurate in identifying non-borderline patients. (Note: this means approximately 20% are misdiagnosed)

1986-1989
Arch Gen Psychiatry 1986 Jan;43(1):20-30
"The Chestnut Lodge follow up study. III. Long-term outcome of borderline personalities"
Outcome varied over time, BPD patients did best in the second decade after discharge.

Am J Psychiatry 1986 Feb;143(2):212-5
"Schizotypal symptoms in patients with borderline personality disorders"
Schizotypal disorder symptoms were very common in those with the BPD.

J Clin Psychiatry 1986 Apr;47(4):196-8
"The demographic profile of the borderline personality disorder"
A survey of 23 patients showed that most were young, white and female. The source of information was considered suspect by the authors, who recommended that their findings be confirmed by other studies.

Suicide Life Threat Behav 1986 Spring;16(1):28-39
"Selected behavioral features of patients with borderline personality traits"
Irregular hospital discharges, frequent suicide attempts, first suicide attempt before age 40, violence inside and outside the hospital, and gradual deterioration in social and occupational functioning were found more often in patients with "high levels of borderline personality traits."

J Nerv Men Dis 1986 Jun;174(6):328-31
"An empirical study of borderline personality disorder and psychiatric suicides"
In this study of 134 consecutive psychiatric suicides from 1961-1980 only 12% had the BPD.

Psychopathology 1986;19(1-2):68-79
"Prognosis of the borderline disorders"
Wide variability, but in general better than in individuals with schizophrenia.

Acta Psychiatr Scand 1986 Mar;73(3):307-14
"Characterizing somatization, hypochondriasis, and hysteria and the borderline personality disorder"
These symptoms are more common in individuals with dysthymia (low level depression) than in the BPD.

J Stud Alcohol 1986 May;47(3):196-200
"Borderline personality disorder and alcoholism treatment: a one year follow-up study"
This study documents that short term treatment of alcoholics with "severe character pathology" can help them. (I strongly disagree - the BPD is not a character disorder, it's a medical one.)

Am J Psychiatry 1986 Aug;143(8):998-1003
"An examination of the borderline diagnosis in children"
A study of 86 children aged 6-12 psychiatrically hospitalized showed some features of these symptoms when they went on to develop the BPD as an adult. Further research needed to draw any conclusions.

Psychopathology 1986;19(3):131-7
"Challenges of research with the borderline patient"
"Clinical research of the borderline personality disorder can be difficult and challenging for investigator" due to the "core psychopathology and characteristic defense mechanisms," difficulty of completing studies, and 'classical' and 'total' counter transference.

Am J Psychiatry 1986 Oct;143(10):1287-9
"Pseudologia fantastica in the borderline patient"
"An infrequently described clinical feature sometimes associated with borderline personality disorder is pseudologia fantastica" (pathological lying).

Am J Psychiatry 1986 Dec;143(12):1605-7
"Psychotic symptoms of borderline personality disorder"
A study of 13 BPD patients showed "derealization" and "depersonalization" were common symptoms, but drug free hallucinations were also observed.

Can J Psychiatry 1986 Dec;31(9):859-60
"Borderline personality disorder in the elderly: a case study"
"The case suggests that features of BPD persist throughout life and may worsen with the stresses associated with aging."

J Pers Assess 1986 Winter;50(4):540-53
"The MMPI, prototypal topology and borderline personality disorder"
Unstructured interviews were more reliable than the MMPI.

Percept Mot Skills 1986 Apr;62(2):579-85
"On the consistency of the MMPI in borderline personality disorder"
14 patients showed consistent results, but variability between patients. "A note of caution is advised for those investigators who assume that a prototypical borderline MMPI profile exists" (note: I had a patient who had a mildly abnormal MMPI when doing well, and the next day when dysphoric had one interpreted as 'strong antisocial features')"

J Clin Psychopharmacol 1986 Aug;6(4):236-9
"Development of melancholia during carbamazepine treatment in borderline personality disorder"
During carbamazepine (Tegretol) treatment 18% developed melancholia, which went away on discontinuation of carbamazepine. (Note: in my experience many of my patients with this pattern developed low thyroid - hypothyroidism - and the depression remitted with the addition of thyroid replacement hormone)

Acta Psychiatr Scand 1986 May;73(5):500-5
"Characterizing paranoia in the DSM-III borderline personality disorder"
"Paranoia was both more prevalent and severe in borderline patients."

J Clin Psychiatry 1987 May;48(5):181-4
"Is bulimia associated with borderline personality disorder? A controlled study"
Only 1.9% of bulimic patients in this study using the DIB instead of DSM criteria had the BPD. (The DIB in a previous study was felt to be relatively inaccurate in diagnosing the BPD)

Am J Psychiatry 1987 Jun;144(6);748-52
"Sexual practices among patients borderline personality disorder"
"Homosexuality was 10 times more common among the men and six times more common among the women and borderline personality disorder than in the general population or in a depressed control group." Bisexuality and paraphilias were also relatively common.

Arch Gen Psychiatry 1987 Jul;44(7):645-50
Auditory P300 in borderline personality disorder and schizophrenia
Those with BPD had different results on EEG, particularly in the P300 location, sharing a dysfunction of auditory neurointegration with schizophrenia.

Psychiatry Res 1987 Aug;21(4):307-11
"Lack of effect of dopamine receptor blockade on the TSH response to TRH in borderline personality disorder"
The reduction in TSH response to TRH is not due to dopamine function.

J Clin Psychiatry 1987 Aug;48 Suppl:15-25
"Psychopharmacology of borderline personality disorder: a review"
"The frequent presence of comorbid disorders and the occurrence of a wide array of possible target symptoms complicate clinical assessment. "Neuroleptics, MAO inhibitors and carbamazepine (Tegretol) were helpful.

Am J Psychiatry 1988 Jun;145(6):737-9
"Suicide attempts in patients with borderline personality disorder"
BPD patients with both depression and substance abuse are at a higher risk of suicide.

Am J Psychiatry 1988 Jul;145(7):809-14
"The amphetamine challenge test in patients with borderline disorder"
Amphetamine administration helped those with BPD unless they also had the schizotypal personality disorder. (How much of the effect was on borderlines who had attention deficit disorder wasn't addressed)

Can J Psychiatry 1988 Jun;33(5):336-40
"Characteristics of borderline personality disorder: A Canadian study"
Inpatients with the BPD have a chronic severe disorder, which begins in adolescence and probably were neglected or abused as children.

Am J Psychiatry 1988 Nov;145(11):1453-4
"A comparison of three measures for the diagnosis of borderline personality disorder"
Three testing systems showed were not good for making the diagnosis, and more than half those studied had at least three personality disorder diagnoses.

Arch Gen Psychiatry 1988 Feb;45(2):111-9
"Pharmacotherapy of borderline personality disorder. Alprazolam, carbamazepine, trifluoperazine, and tranylcypromine."
16 female BPD outpatients with severe behavior control problems but without major depression at the time of the study received the above medications. All but alprazolam improved the patient's condition. Alprazolam (Xanax) worsened behavioral dyscontrol (losing control of behavior). Patients taking carbamazepine (Tegretol) had a "marked decrease in the severity of behavioral dyscontrol." (Note: this landmark study by Dr. Cowdry and Dr. Gardner at NIMH has been invaluable to me for treating the BPD - it's one of the most important, informative and useful BPD studies ever performed)

Biol Psychiatry 1988 Sep;24(5):587-94
"Changes in EEG mean frequency associated with anxiety and with amphetamine challenge in BPD"
EEG is often abnormal in the BPD, further study with a stimulant showed minimal change, except in anxiety.
(Note: to me this reflects on attention deficit disorder and the generalized anxiety disorder in borderlines. The EEG is more often abnormal during dysphoric spells. The EEG measures surface readings, whereas deep brain structures are most likely involved in the BPD)

Can J Psychiatry 1988 Jun,33(5):350-4
"Biological markers in borderline personality disorders: an overview"
A summary of what is known, including REM latency (an indicator of sleep and brain function).

J Nerv Ment Dis 1988 Jan;176(1):40-4
"Factors associated with completed suicide in borderline personality disorder"
Highest risks included multiple hospitalizations, more suicide attempts, and severe suicidal behavior at admission. Expecting to go home frequently resulted in suicide.

Can J Psychiatry 1989 Feb;34(1):8-9
"Predictors of suicide in borderline personality disorder"
The most significant predictors of completed suicide were previous attempts and higher education.

Am J Psychiatry 1989 Apr;146(4):490-5
"Childhood trauma in borderline personality disorder"
81% had major childhood trauma. 71% had physical abuse. 68% had sexual abuse. 62% witnessed serious domestic violence. (Note: 1/5 statistically were NOT victims of childhood trauma)

Psychiatry Res 1989 Feb;27(2):111-5
"Cerebral structure in borderline personality disorder"
No evidence of structural brain pathology using CT scans.

1990-1992
Biol Psychiatry 1990 Aug 1;28(3):247-54
"CSF metabolites in borderline personality disorder compared with normal controls"
No different from non BPD. However, those with genuine suicide attempts had low levels.

Am J Psychiatry 1990 Apr;147(4):470-6
"The borderline diagnosis in adolescents: symptoms developmental history"
The following predict BPD in adolescents: disrupted attachments, maternal neglect, maternal rejection, grossly inappropriate parental behavior, number of mother and father surrogates, physical abuse, sexual abuse, and their families were chronically disrupted - particularly during early childhood.

Am Fam Physician 1990 May;41(5):1481-6
"Psychiatric implications of tattoos
Psychiatric disorders, such as antisocial personality disorder, drug or alcohol abuse and BPD, are frequently associated with tattoos. Finding a tatoo on physical examination should alert the physician to the possibility of an underlying psychiatric condition.

Am J Psychiatry 1990 Aug;147(8):1002-7
"Substance use in BPD"
67% of BPD inpatients also had substance use problems, particularly alcohol and hypnotics. When substance abuse was removed as a diagnostic criteria, 23% no longer met BPD criteria. The combination of BPD and substance use changes the severity and course of their illness. Substance use may play a role in BPD development.

Can J Psychiatry 1990 Oct;35(7):590-5
"A comparison of borderline and schizophrenic patients for childhood life events and parent-child relationships"
Borderlines had more childhood sexual and physical abuse, more early separation from their mothers, more paternal criminality, less maternal care, and were more overprotected.

Am J Psychiatry 1990 Aug;147(8):1014-7
"Altered platelet alpha 2-adrenergic receptor binding sites in BPD"
Fewer alpha 2-adrenergic receptor binding sites compared with borderlines on low doses of benzodiazepines. Non medicated BPD's were more anxious than medicated patients, raising the possibility that lower alpha 2-adrenergic receptor binding in BPD is related to anxiety.

Am J Psychiatry 1991 Jan;148(1):106-11 (from NIMH)
"Neuropsychological testing of patients with BPD"
"...significantly impaired with that of the normal group on memory tests requiring uncued recall of complex, recently learned material. Cues given on an auditory memory task partially corrected that deficit." "...Also significantly impaired on several visual perceptual tests." These abnormal findings did not appear to be due to attention problems, depression, alcohol use or "psychomotor impairment."

J Nerv Ment Dis 1991 Mar;179(3):157-61 (from NIMH)
"Self-ratings of anger and hostility in BPD"
Patients with BPD had significantly higher anger and hostility scores than volunteers, not related to gender, treatment or research setting, the degree of acute distress, or the presence of major depression. "...Anger and depression may represent independent clinical conditions with independent biological mechanisms regulating these two affective states."

Am J Psychiatry 1991 May;148(5):648-51
"Parents' emotional neglect and overprotection according to the recollections of patients with BPD"
"...patients with BPD remembered both their fathers and their mothers as having been significantly less caring and more controlling than did the nonborderline patients." (How much of it is a true phenomenon and how much was splitting is unclear and was not addressed in this study - L. Heller, M.D.)

J Nerv Ment Dis 1991 Jun;179(6):329-37
"A comparison of four measures to diagnose DSM-III-R BPD in outpatients"
Four tests were evaluated to determine how accurate they were at predicting the actual criteria. The DIB (diagnostic interview schedule for borderlines) was the best, and others better than chance levels. (Previous studies showed 70% accuracy for the best test, the DIB - L. Heller, M.D.)

J Clin Psychopharmacol 1991 Apr;11(2):116-20
"A preliminary trial of fluoxetine in refractory borderline patients"
5 BPD patients with severe symptoms resistant to phenelzine and neuroleptics were treated with fluoxetine 20mg to 40mg for 8 weeks. The findings suggested effectiveness for the depressive and impulsive symptoms of refractory BPD patients.

Int Psychogeriatr 1991 Spring;3(1):39-52
"BPD in late life"
A record review of 8 elderly patients shows the individuals didn't fit criteria later in life. (Note: in my experience - and subsequent data - most crippling symptoms remain including the mood swings, emptiness, anger and social function problems - L. Heller, M.D.)

J Nerv Ment Dis 1991 Jul,179(7):428-31
"Post Traumatic Stress Disorder among children clinically diagnosed as BPD"
"These findings raise the possibility that a diagnosis of borderline personality in childhood can often represent posttraumatic stress disorder."

Clin Electroencephalogr 1991 Jul;22(3):188-92
"Auditory evoked potentials in BPD"
"Paroxysmal (without warning) changes in affect (mood) and behavior, high incidence of soft neurologic signs and frequent EEG alterations, and evidence of clinical response to antiepileptic drugs have suggested cerebral dysfunction, particularly involving the limbic system or reticular activating system." (After doing their research on brain waves they remarked...) "These findings may suggest differences from normals in attention maintenance and limbic system function."(Since many borderlines also have attention deficit disorder, their findings may represent limbic system malfunction in borderlines, and attention maintenance problems in those with ADD - L Heller, MD)

Am J Psychiatry 1991 Oct;148(10):1371-7
"The comorbidity of BPD and other DSM-III-R axis II personality disorders"
80% of those with BPD had at least one additional personality disorder. The authors wonder if there is a "general personality disorder concept" rather than a true BPD diagnosis.

Acta Psychiatr Scand 1991 Jul;84(1):72-7
"Personality disorders 2-5 years after treatment: a prospective follow-up study"
79 patients followed for 3 years had a "moderate symptom reduction," a "fair global outcome," and the "overall suicide are was low."

Am J Psychiatry 1991 Nov;148(11):1541-7
"A prospective follow-up study of so-called borderline children"
The childhood borderline diagnosis appears to be an antecedent of an array of adult personality disorders, but it is not associated with the adult BPD per se, nor with axis I diagnoses (such as depression).

Arch Gen Psychiatry 1991 Dec;48(12):1060-4
"Cognitive-behavioral treatment of chronically parasuicidal borderline patients: (by Marsha Linehan and her group at the U of Washington in Seattle)"
A trial of DBT (dialectical behavior therapy) for chronically parasuicidal women studied for one year showed fewer incidences of parasuicide and less medically severe parasuicides, they were more likely to stay in individual therapy, and had fewer inpatient psychiatric days. No change in measures of depression, hopelessness, suicide ideation, or reasons for living although they did diminish in both the DBT and control groups over the study year.

1993-1995
Am J Psychiatry 1993 Dec;150(12):1836-42
"The impact of mother-child interaction on the development of BPD"
Maternal over-involvement and mismanagement and inappropriateness of maternal guidance and support were shown to only be a problem when the coexisted.

Am J Psychiatry 1993 Dec;150(12):1843-8
"Continuation pharmacotherapy of BPD with haloperidol and phenelzine"
Continuous treatment with haloperidol (Haldol) was ineffective except for irritability. Phenelzine offered modest improvement in irritability. (Note: my experience is Haldol works best on an "as needed" basis only - L Heller, MD)

J Clin Psychol 1993 Mar;49(2):277-81
"Features of borderline personality and violence" (from U of Southern California)
"It is concluded that borderline personality may predispose towards extreme forms of violence"

Am J Psychiatry 1993 Aug;150(8):1233-6
"Comorbidity of conduct disorder and personality disorders in an incarcerated juvenile population"
Conduct disorder in children and adolescents leads to antisocial personality disorder, not the borderline disorder.

Arch Psychiatr Nurs 1993 Jun;7(3):163-73
"Long-term consequences of childhood physical and sexual abuse"
"Physical and sexual abuse is associated with acute psychiatric symptomatology in children and may progress to a spectrum of psychiatric and medical disorders in adults, ranging from the extreme adaptive reactions seen in multiple personality disorder and refractory psychosis to intermediate adaptive reactions present in BPD to more delimited reactions manifest in chronic headaches and unremitting pelvic pain."

Am J Psychiatry 1993 Dec;150(12):1835-5
"Psychopathology in the families of children and adolescents with BPD"
"...significant family psychopathology is associated with the disorder."

Arch Gen Psychiatry 1993 Dec;50(12):971-4 (from Marsha Linehan)
"Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients"
"In general, the superiority of DBT over treatment-as-usual, found in previous studies at the completion of 1 year of treatment, was retained during a 1-year follow-up."

Am J Drug Alcohol Abuse 1993;19(4):491-7
"Substance abuse in BPD"
"Substance abuse appears to be a devastating complication in the patient with BPD."

Int J Eat Disord 1993 Dec;14(4):403-16
"Comorbidity of DSM-III-R eating disorders and personality disorders"
Bulimia nervosa with BPD, anorexia nervosa with Avoidant PD. "Eating disorders with personality disorders are characterized by chronicity and low levels of functioning compared with eating disorders with personality disorders."

J Psychol 1993 Nov;127(6):657-76
"Relationship of childhood sexual abuse to BPD, posttraumatic stress disorder, and multiple personality disorder"
A convincing relationship exists between childhood sexual abuse and BPD, posttraumatic stress disorder and multiple personality disorder.

Comp Psychiatry 1993 Nov-Dec;34(6):402-5
"Clozapine treatment of borderline patients: a preliminary study."
Clozapine is effective for atypical psychotic symptoms in some BPD patients.

Compr Psychiatry 1993 Nov-Dec;34(6):418-23
"Diagnosis and clinical features of BPD in the east and west: a preliminary report"
BPD is present in Japan and is the same basic disorder. Differences include a low incidence of substance use disorders, and the maintenance of a "stormy one-to-one or masochistic relationships with their parents because they live at home."

J Behav Ther Exp Psychiatry 1993 Sep;24(3):261-7
"The behavioral treatment of self-starvation and severe self-injury in a patient with BPD"
Self-starvation can be a form of self-injury.

Jpn J Psychiatry Neurol 1993 Mar;47(1):37-46
"Relationship between clinical symptoms and EEG findings in BPD"
No specific diagnostic EEG findings, however abnormalities were found.

Eur Neuropsychopharmacol 1994 Dec;4(4):479-86
"A trial of carbamazepine (Tegretol) in BPD"
No significant positive results were found as a first choice pharmacological treatment. (Note: that has been my experience as well. It only works for those who need it when they've been on an SSRI for at least a week - Prozac has been the most consistently successful medication to combine with Tegretol. L Heller, MD)

Psychiatry Res
"Temporal glucose metabolism in BPD"
"Underlying organic factors such as epilepsy are suspected because clinical characteristics of the syndrome are similar to some manifestations of patients with complex partial seizures." No PET scan data to show temporal lobe epilepsy. (Note: This study does not preclude small areas in the limbic system that are having seizures that extend at times to the temporal lobes during severe dysphoria (anxiety, rage, depression and despair). L. Heller, MD)

Sante Ment Que 1994 Fall;19(2):117-29
"Suicide in patients with BPD"
Long term research shows about 10% will eventually complete suicide. The authors suggest that suicide prevention should not be the major priority of therapy.

Am J Psychiatry 1994 Feb;151(2):277-80
"Serotonergic sensitivity in BPD: preliminary findings"
Malfunction in the serotonin system is found in the BPD. (Note: low levels are not necessarily the same thing as a malfunction. L Heller, MD)

Child Abuse Negl 1994 Jan;18(1):97-101
"Childhood sexual abuse and BPD in eating disorders"
Childhood sexual abuse at less than 14 years old is associated with BPD patients with eating disorders.

Neuropsychopharmacology 1994 Feb;10(1):21-8
"Positron-emission tomography and personality disorders"
A significant decrease in frontal cortex metabolism was seen in the BPD. (Note: this finding is further evidence of physical abnormalities, although the significance of this particular finding is unclear. It may be related to the frequent complication of head injuries. L Heller, MD)

J Nerv Ment Dis 1994 Jul;182(7):375-80
"Risk factors for borderline personality in male outpatients"
Childhood sexual abuse, separation or loss, and problems with their fathers are important for BPD development in males.

Am J Psychiatry 1994 Sep;151(9):1305-11
"Clinical correlates of self-mutilation in BPD"
Self-mutilators are at a higher risk for suicidal behavior, major depression and eating disorders.

Ann Clin Psychiatry 1994 Mar;6(1):17-20
"Divalproex sodium in the treatment of aggressive behavior"
A.k.a. Depakote: effective to reduce agitation in many psychiatric conditions, especially with bipolar or BPD."

J Clin Psychopharmacol 1995 Feb;15(1):23-9
"Effect of fluoxetine on anger in symptomatic volunteers with BPD"
Fluoxetine (Prozac) reduced anger independent of changes in depression in mild to moderately severe BPD patients.

Am J Psychiatry 1995 May;152(5):789-91
"Psychological dimensions of depression in BPD"
Self-criticism is an underemphasized characteristic of depression in BPD.

1996
Am J Psychiatry 1996 Jun;153(6):752-8
"The borderline patient's intolerance of aloneness: insecure attachments and therapist availability"
"Intolerance of aloneness is a core deficit in BPD." (Note: while usually true, it's not an absolute. Many borderlines enjoy being alone when doing better. LHeller, M.D.)

Am J Psychiatry 1996 Oct;153(10):1329-33
"Structured interview data on 35 cases of dissociative identity disorder in Turkey"
DID (f.k.a. multiple personality disorder) is a world wide disorder, with a consistent set of features throughout North America, the Netherlands, and in Turkey.

Psychiatr Serv 1996 Apr;47(4):426-9
"Comorbidity of DSM-III-R axis I and II disorders among female inpatients with eating disorders"
Social phobia, substance use disorders, BPD, and Avoidant personality disorder were more frequently diagnosed in eating disorder patients.

J Am Acad Child Adolesc Psychiatry 1996 Oct;35(10):1338-43
"BPD in adolescents: affective and cognitive features"
Adolescents with BPD have significant impairments in self-concept, suggestive of pervasive emptiness and identity disturbances associated with the BPD."

Can J Psychiatry 1996 Jun;41(5):285-90
"Psychopathology in offspring of mothers with BPD: a pilot study"
The offspring of mothers with the BPD are at a higher risk for psychiatric problems, particularly impulse control problems.

Psychiatr Q 1996 Winter;67(4):287-95
"Relationship of borderline symptoms to histories of abuse and neglect: a pilot study"
Mood swings (affective instability), intense anger, and identity disturbances were not correlated with abuse or neglect. (Note: childhood abuse was correlated in an earlier study with derealization and chronic dysphoria (anxiety, rage, depression and despair). LHeller, MD)

Clin Electroencephalogr 1996 Jan;27(1):35-9
"A review of the usefulness of the standard EEG in psychiatry"
Positive spikes have again been associated with impulsivity and 6/sec spike and wave complexes with interpersonal problems.

J Affect Disord 1996 Apr 12;37(2-3):157-70 (from France)
"Comorbidity of personality disorders and unipolar major depression: a review"
20-50% of inpatients and 50-85% of outpatients have a personality disorder.

1997-1998
Am J Psychiatry 1997 Aug;154(8):1101-6
"Reported pathological childhood experiences associated with the development of BPD"
Sexual abuse is neither necessary nor sufficient for the development of BPD. Other childhood experiences, particularly neglect by caretakers of both genders, are also significant risk factors.

J Clin Psychiatry 1998 Mar;59(3):103-7
"Low-dose Clozapine in acute and continuation treatment of severe BPD"
"Psychotic-like symptoms in patients affected by BPD are usually treated with low-dose neuroleptics, which show controversial acute effects and lead to a worsening of affective-related symptoms and to severe neurologic side effects after prolonged administration. ...Low-dose Clozapine for acute and continuation treatment led to improvement in overall symptomatology in a small sample of severe BPD patients."

Compr Psychiatry 1998 Mar-Apr;39(2):72-4
"Comorbidity of personality disorders with bipolar mood disorders"
BPD was more prevalent in those with bipolar illness.

Gen Hosp Psychiatry 1997 May;19(3):209-15
"Serious overdosers admitted to a general hospital: comparison with nonoverdose self-injuries and medically ill patients with suicidal ideation"
Female borderline patients are particularly associated with an overdose method of attempting suicide.

Psychiatry Res 1997 May 30;70(3):175-83
"Pain assessment in a self-injurious patients with BPD using signal detection theory"
‘Analgesia' during self-injury in patients with BPD is related to both neurosensory and attitudinal/psychological abnormalities.

Psychiatry Res 1998 Feb 9;77(2):131-8
"Electroencephalographic abnormalities in BPD"
Including only definitely abnormal tracings, 40% of borderlines had an abnormality (diffuse slow activity) but no true epileptiform features. Carbamazepine did not change the EEG. (Note: this is consistent with deep brain structures having the seizure like activity. L Heller, MD)

Biol Psychiatry 1998 May 15;43(10):740-6
"Platelet serotonin, monoamine oxidase activity, and [3H] paroxetine binding related to impulsive suicide attempts and BPD"
The serotonin system affects impulsiveness, suicidal behavior, and chronic feelings of emptiness. When platelet serotonin measurements were low, chronic emptiness resulted.

Neuropsychopharmacology 1997 Oct;17(4):264-73
"Depressive response to physostigmine challenge in BPD patients"
The cholinergic system may be involved in mood regulation in patients with personality disorders.

J Clin Psychiatry 1997;58 Suppl 14():48-52;discussion 53
Pharmacotherapy of BPD
The MAOI's, SSRI's, and newer antidepressants such as venflaxine (Effexor) have the greatest effect on BPD symptoms.

1998-2000
Flashbacks and dissociative symptoms respond to naltrexone. J Clin Psychiatry 1999 Sep
The opiate blocker naltrexone (ReVia) taken 25-100mg four times daily for two weeks showed a "highly significant" reduction in dissociative symptoms and the number of flashbacks for 6 of the 9 patients studied.

Partial hospitalization treatment of BPD: Am J Psychiatry 1999 Oct
Psychoanalytically oriented partial hospitalization for BPD was more successful than "standard psychiatric care." The improvement began after 6 months, and were continued for 18 months. There was a decrease in suicidal and self-mutilatory acts, reduced inpatient hospitalization days, and better social and interpersonal function.

Childhood sexual abuse as a BPD risk factor: J Personal Disord 1999 Fall
This "meta-analysis" disputes some literature findings and the experience of clinicians treating individuals with BPD by stating that there was no increased risk of BPD with childhood sexual abuse.

Psychotherapy with BPD patients: Aust N Z J Psychiatry 1999 Aug
Psychotherapy can help patients with the BPD.

Clozapine in BPD: Clin Psychol Rev 1999 Aug
Clozapine helped with severe self-mutilation, aggression and violence. (unfortunately clozapine is a very dangerous medication that requires very close follow up)

Substance abuse in hospitalized BPD patients: Compr Psychiatry 1999 Jul-Aug
This study from Greece showed that 76% of hospitalized BPD patients had a substance abuse problem.

Lamotrigine for treating BPD: J Affect Disorder 1998 Dec
75% of those with BPD showed improvement with lamotrigine (Lamictil). The authors argue that depression in BPD dysphoria is a different phenomenon than "unipolar depression."

Abnormal frontal brain lobes in BPD: J Affect Disord 1998 Sept
This study from South Korea showed smaller frontal lobe volume on brain MRI's.

Spinal fluid chemicals in BPD: Neuropsychobiology 1998 Nov
This study from Sweden showed no difference from controls in some neurotransmitter metabolites.

2000-2002
Behav Res Ther 2000 Sep Dept of Psychiatry, University of Freiburg, Germany
"Evaluation of inpatient dialectical-behavioral therapy for borderline personality disorder - a prospective study."
Three month inpatient DBT treatment of 24 women with BPD were compared at admission and one month after discharge. Significant improvements in ratings of depression, dissociation, anxiety and overall stress. Significant reduction in parasuicidal acts (primarily cutting).

Br J Med Psychol 2000 Jun Kings College, London, UK
"Effectiveness of time-limited cognitive analytic therapy of borderline personality disorder: factors associated with outcome."
This study showed psychotherapy can help and could cease fitting DSM BPD criteria. Poorer outcome associated with stronger BPD symptoms, cutting, alcohol abuse and unemployment.

J Clin Psychiatry 2000 Jun Eating Disorders Clinic, Douglas Hospital, Verdun, Quebec, Canada
"Childhood abuse and platelet tritiated-paroxetine binding in bulimia nervosa - implications of borderline personality disorder."
Strong similar causes of bulimia and BPD, which frequently are comorbid. Serotonin function, including transporter malfunction, may be a part of both disorders.

Med Hypotheses 2000 Apr Argyll and Bute Hospital, Lochgilphead, UK
"The role of dysregulated amygdalic emotion in borderline personality disorder."
The authors propose that the disorder arises from impaired modulation of subcortical inputs to consciousness. "We hypothesize that the amygdaloid complex, and it’s connections with thalamus, cingulate cortex and insular cortex are critical in the development and maintenance of the disorder. If this is the case, peptides such as galanin, somatostatin and cholecystokinin will be the most important neurotransmitters..."

Am J Psychiatry 2000 Apr Western Psychiatric Institute, U of Pittsburgh, PA (Soloff PH, Lynch KG)
"Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: a comparative study."
"Hopelessness and impulsive aggression independently increase the risk of suicidal behavior in patients with borderline personality disorder and in patients with major depressive episode."

J Personal Disord 2000 Winter Western Psychiatric Institute and Clinic, U of Pittsburgh, Pittsburgh, PA
"Recent life events, social adjustment, and suicide attempts in patients with major depression and borderline personality disorder"
"Borderline disordered patients low on overall social adjustment were over 16 times more likely to have attempted suicide than patients diagnosed with major depression only. Recent life events may elevate suicide risk in groups already at high risk for suicide completion, whereas high levels of social adjustment may be protective against stress-related suicidal behavior."

Arch Gen Psychiatry 2000 Dec (from Germany).
"Magnetic resonance imaging volumes of the hippocampus and the amygdala in women with borderline personality disorder and early traumatization."
Individuals with BPD had approximately 16% smaller hippocampus volumes and 8% smaller amygdala volumes. The reason and significance are not clear.

Biol Psychiatry 2000 Mar (Soloff PH) Dept of Psychiatry, U of Pittsburgh, PA
"A fenfluramine activated FDG-PET study of borderline personality disorder"
"Patients with BPD have diminished response to serotonergic stimulation in areas of prefrontal cortex associated with regulation of impulsive behavior."

J Clin Psychol 2000 Dec Indiana State University Psychology Dept.
"Neuropsychological functioning in patients with borderline personality disorder."
"The BPD group performance did not differ from the normal group on most tasks of executive functioning or memory, and the introduction of emotional stimuli did not impair performance."

J Personal Disord 2000 Fall (Zanarini MC) Laboratory for the Study of Adult Development, McLean Hospital, Belmont, MA
"Biparental failure in the childhood experiences of borderline patients"
55% reported a childhood history of biparental abuse; 77% reported a childhood history of biparental neglect.

J Neuropsychiatry Clin Neurosci 2001 Fall Freiberg, Germany.
"Subtle prefrontal neuropathology in a pilot magnetic resonance spectroscopy study in patients with borderline personality disorder."
"The authors...found a significant 19% reduction of absolute N-acetylaspartate concentrations in the dorsolateral prefrontal cortex in BPD..."

Am J Psychiatry May 2001 McGill University, Montreal, Canada
"Brain regional alpha-[11C]methyl-L-tryptophan trapping in impulsive subjects with borderline personality disorder."
"Low 5-HT (serotonin) synthesis capacity in corticostriatal pathways may contribute to the development of impulsive behaviors in persons with BPD."

J Clin Psychiatry 2001 Mar Mount Sinai School of medicine, NY
"A preliminary double-blind, placebo-controlled trial of divalproex sodium in borderline personality disorder"
16 patients with BPD were treated with Depakote (divalproex sodium). "Treatment with divalproex sodium may be more effective than placebo for global symptomatology, level of functioning, aggression and depression. Controlled trials with larger sample sizes are warranted to confirm these preliminary findings."

Can J Psychiatry 2001 Nov Universite de Toulouse-Le Mirail, Toulouse France
"Frequency of borderline personality disorder in a sample of French high school students Based on a screening test."
"We estimated the overall frequency of BPD to be 10% for boys and 18% for girls."

J ECT 2001 Jun Stanford University
"Is electroconvulsive therapy (ECT) effective for the depressed patient with comorbid borderline personality disorder?"
"The depressed, borderline patient appears to have two distinct disorders, one which is responsive to ECT and the other which is not."

Compr Psychiatry 2001 Nov-Dec from McGill University Montreal Canada
"A 27 year follow-up of patients with borderline personality disorder."
64 BPD patients followed for an average of 27 years. Most showed improvement over time, with only a small percentage still meeting criteria. The total percentage of suicides was 10.3%. (Note: symptoms tend to change over time, but the underlying neurological symptoms rarely go away)

Biol Psychiatry 2001 Aug (from Germany)
"Evidence of abnormal amygdala functioning in borderline personality disorder: a functional MRI study."
"Our main finding was that dependent functional MRI signal in the amygdala on both sides." This was seen in BPD subjects but not the controls.

Gen Hosp Psychiatry 2001 Jul-Aug Wright State University School of Medicine, Dayton, OH
" The prevalence of borderline personality among primary care patients with chronic pain."
"In this sample, the prevalence of BPD was substantial. Chronic pain may be a manifestation of a self-regulatory disturbance among some patients with BPD."

Int J Eat Disord 2001 Jan Wright State University School of Medicine, Dayton, OH
"Obesity, borderline personality symptomatology, and body image among women in a psychiatric outpatient setting."
"In a psychiatric outpatient setting, borderline personality symptomatology is associated with higher body weight as well as body-image issues that are not necessarily due to larger body size."

J Forensic Sci West Virginia University
"An investigation of the psychological characteristics of stalkers: empathy, problem-solving, attachment and borderline personality features"
"Stalkers scored significantly higher than controls on measures of insecure attachment and borderline personality features, suggesting that the stalking group demonstrates a general pattern of inadequate interpersonal attachment, has limited abilities to form and maintain appropriate relationships, is emotionally labile and unstable, and experiences ambivalence regarding their interpersonal relationships."

Am J Psychiatry 2002 Dec
"SSRI treatment of borderline personality disorder: an randomized, placebo-controlled clinical trial for female patients with borderline personality disorder."
"In this study, Luvox (fluvoxamine) significantly improved rapid mood shifts in female borderline patients, but not impulsivity and aggression."
Harv Rev Psychiatry 2002 Nov
"Implications of long-term outcome research for the management of patients with borderline personality disorder."
"Fifteen and 27 year follow-up studies of patients with borderline personality disorder show that most of them no longer meet full criteria for the disorder by age 40, and that even more show improvement by age 50. The mechanisms behind remission could include maturation, social learning and the avoidance of conflictual intimacy. Affective instability (mood swings) is slower to change than impulsivity. Suicide rates in patients with this disorder are close to 10%, with most completions occurring late in the course of illness; early mortality from all causes exceeds 18%."
(Note: the symptoms change over time, but usually the biologically based symptoms remain: unprovoked mood swings, chronic anger - including self directed, emptiness, boredom and stress induced dysphoria (anxiety, rage, depression and despair). Instability in the brain’s limbic system during adolescence and early adulthood improves over time. Avoidance of intimate relationships, while understandable, keeps borderlines from fully enjoying the human experience. Having a successful love relationship is one of my goals for a BPD patient. - L. Heller, M.D.)

J Clin Psychiatry 2002 May
"Divalproex sodium treatment of women with borderline personality disorder and bipolar II disorder: a double-blind placebo-controlled pilot study."
30 women aged 18-40. "The results of this study suggest that divalproex sodium (Depakote) may be a safe and effective agent in the treatment of women with criteria defined borderline personality disorder and comorbid bipolar II disorder, significantly decreasing their irritability and anger, the tempestuousness of their relationships, and their impulsive aggressiveness."

Am J Psychiatry 2002 May
"Characterizing affective instability in borderline personality disorder"
"Greater lability in terms of anger and anxiety and oscillation between depression and anxiety, but not in terms of oscillation between depression and elation, was associated with borderline personality disorder." (Note: this is an important distinction between bipolar and BPD)

Am J Psychiatry 2002 Feb
"Confirmatory factor analysis of DSM-IV criteria for borderline personality disorder: findings from the collaborative longitudinal personality disorders study"
"The diagnostic criteria for borderline personality disorder appear to reflect a statistically coherent construct."

Neuropsychobiology 2002
"Serum cholesterol and leptin levels in patients with borderline personality disorder"
"In conclusion, the present study demonstrates that the patients with borderline personality disorder have lower cholesterol and leptin levels than healthy controls. Low serum cholesterol and leptin levels are associated with all dimensions of the disorder - impulsivity, aggression and suicidality - but are not associated with the presence and the severity of comorbid depression."

Compr Psychiatry 2002 Sep-Oct (from Milano, Italy)
"History of childhood attention deficit/hyperactivity disorder symptoms and borderline personality disorder: a controlled study."
"The results of this study seem to support the hypothesis of an association between history of childhood ADHD symptoms and adult BPD diagnosis."

Biol Psychiatry 2002 Dec (Dept of Psychiatry, Free University Amsterdam, The Netherlands)
"Hyperresponsiveness of hypothalamic-pituitary-adrenal axis to combined dexamethasone/corticotropin-releasing hormone challenge in female borderline personality disorder subjects with a history of sustained childhood abuse."
"Chronically abused BPD patients had a significantly enhanced corticotropin (ACTH) and cortisol response to the DEX/CRH challenge compared with nonabused subjects. Cormorbid PTSD significantly attenuated the ACTH response."

Am J Psychiatry 2002 Dec
"Short-term diagnostic stability of schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders"
"Individual differences in personality disorder features appear to be highly stable, although the number of criteria present decreases over time."

Psychol Med 2002 Nov
"Neurocognitive deficits in decision-making and planning of patients with DSM-III-R borderline personality disorder"
"The performance of the BPD patients on the decision-making task was characterized by a pattern of delayed and maladaptive choices when choosing between competing actions, and by impulsive, disinhibited responding when gambling on the outcome of their decisions. BPD patients also showed impairments on the planning task. There was no evidence of impaired visual recognition memory."

Arch Intern Med 2002 Jan
"Borderline personality disorder in primary care."
"The prevalence of BPD in primary care is high, about 4-fold higher than that found in general community studies. Despite availability of various pharmacological and psychological interventions that are helpful in treating symptoms of BPD, and despite the association of this disorder with suicidal ideation, comorbid psychiatric disorders, and functional impairment, BPD is largely unrecognized and untreated. These findings are also important for the primary care physician, because unrecognized BPD may underlie difficult patient-physician relationships and complicate medical treatment." (See my 1991 article for primary care physicians at http://www.BiologicalUnhappiness.com/abstract.htm, along with the 1999 update at http://www.BiologicalUnhappiness.com/update.htm)

2003
Am J Psychiatry 2003 Jan;160(1):165-6 "Diminished impulsivity in older patients with borderline personality disorder"
"Older patients with borderline personality disorder showed less impulsivity than younger patients, but there was no difference in terms of affect (mood) disturbance, identity disturbance, and interpersonal problems."

Am J Psychiatry 2003 Jan;160(1):167-9 (Harvard University) "Omega-3 fatty acid treatment of women with borderline personality disorder: a double-blind, placebo-controlled pilot study"
For 8 weeks10 were given placebo (sugar pills), 20 were given 1 gm (1000mg) of E-EPA (ethyl-eicosapentaenoic acid). "E-EPA was superior to placebo in diminishing aggression as well as the severity of depressive symptoms." (Omega 3 oils have previously been shown to help bipolar disorder as well as many medical problems including heart disease).

Harv Rev Psychiatry 2003 Jan-Feb;11(1):8-19 "Family studies of borderline personality disorder: a review"
The most significant finding from this study shows no link between BPD and schizophrenia."

Am J Psychiatry 2003 Feb;160(2):274-83 (Harvard University) "The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder"
362 inpatients followed for 6 years. Only 290 met DSM-III-R BPD criteria initially. These individuals received "multiple treatments" both before the admission and during the study. There were "criteria for remission" that were followed. 34.5% met these criteria at 2 years, 49.4% at 4 years, 68.6% at 6 years, and 73.5% through the entire followup period. Impulsive symptoms improved the most. Mood symptoms were the most chronic. (This study shows improvement for most BPD patients with treatment over time, although mood symptoms remained a significant problem. Specific medication regimens such as Prozac (fluoxetine) with Tegretol (carbamazepine) deserve a similar study).

Aust N Z J Psychiatry 2003 Jun;37:270-6 "Moral Responsibility and borderline personality disorder"
"Impulsivity, acting out and the less severe forms of dissociation to not vitiate responsibility. Severe dissociative and psychotic symptoms may well render people with BPD less morally responsible for their actions. Comorbid conditions in BPD may also affect the ability to act responsibly."

Biol Psychiatry 2003 Jul 15;54(2):163-71 "Frontolimbic brain abnormalities in patients with borderline personality disorder: a volumetric magnetic resonance imaging study."
"We found a significant reduction of hippocampal and amydgala volumes in borderline personality disorder. There was a significant 24% reduction of the left orbitofrontal and a 26% reduction of the right anterior cingulate gyrus." This is an "unspecific finding in neuropsychiatry."

Am J Psychiatry 2003 Nov;160(11):2018-24 "The relationship of borderline personality disorder to posttraumatic stress disorder and traumatic events."
"The results do not appear (to single out the) borderline personality disorder from other personality disorders as a trauma-spectrum disorder or variant of PTSD."

Biol Psychiatry 2003 Dec 1;54(11):1284-93 (Yale University) "Amygdala hyperreactivity in borderline personality disorder: implications for emotional dysregulation"
"Borderline patients showed significantly greater left amygdala activation to the facial expressions of emotion compared with normal control subjects." (The amygdala is a part of the limbic system, particularly associated with anger and emotions)

J Personal Disord 2003 Dec;17(6):568-73 (Harvard University) "A screening measure for BPD: the McLean Screening Instrument for borderline personality disorder (MSI-BPD)"
The MSI-BPD can be useful as a screening test looking for the BPD.

J Personal Disord 2003 Dec;17(6):497-509 "Frontal Lobe dysfunctions in borderline personality disorder? Neuropsychological findings."
"Borderline personality patients show no indications of frontal cognitive dysfunction."

2004
J Clin Psychiatry 2004 Dec;65(12):1660-5
"The association between borderline personality disorder and chronic medical illnesses, poor health-related lifestyle choices, and costly forms of health care utilization."
If not successfully treated individuals with BPD have a significantly increased risk of health problems and higher health care costs. ‘

J Clin Psychiatry 2004 Nov;65(11):1515-9
"Topiramate treatment of aggression in female BPD patients: a double blind, placebo controlled study."
This study on 11 BPD patients showed an improvement in anger and mild weight loss. In my experience a high percentage of individuals on Topamax (topiramate) see their underlying BPD get worse.

Am J Psychiatry 2004 Nov;161(11):2108-14
"Axis I comorbidity in patients with BPD: 6 year follow-up and prediction of time to remission."
Some anxiety and depression problems that co-exist with the BPD improve over time, however those with substance use disorders failed to show significant improvement in the BPD and other symptoms over time.

Am J Psychiatry Nov,162(11):2073-80
"Clinical outcome of ECT in patient with major depression and comorbid BPD"
ECT (electro shock therapy) does not work well for the BPD.

J Clin Psychiatry 2004 Oct:65(10):1414-9
"Clonidine in acute aversive inner tension and self-injurious behavior in female patients with BPD"
There was some improvement in dissociation and urge to commit self-injurious behaviors in 14 females with BPD. (Clonidine is an anti-hypertension medication with many side effects. In my opinion there are better options, although this may help a few individuals).

J Clin Psychiatry 2004 Jul;65(7):903-7
"A preliminary, randomized trial of fluoxetine, olanzapine and the olanzapine-fluoxetine combination in women with BPD"
The combination of Zyprexa (olanzapine) with Prozac (fluoxetine) was more effective than either alone. (While this is true, olanzapine’s weight gain and diabetes limit it’s use. Many patients complain that they have no feelings on olanzapine as well. In my experience the combination of Tegretol (carbamazepine) with Prozac (fluoxetine) is far more effective.)

J Personal Disord 2004 Jun;18(3):240-7
"Is hospitalization useful for suicidal patients with BPD?"
10% of BPD patients eventually complete suicide. For chronic suicidal thoughts, hospitalization is not more effective than outpatient treatment.

Curr Psychiatry Rep 2004 Jun;6(3):225-31
"Psychopharmacology of BPD"
Omega 3 fatty acids can be helpful in the treatment of BPD.

Harv Rev Psychiatry 2004 May-Jun;12(3):140-5
"Borderline or bipolar? Distinguishing BPD from bipolar spectrum disorders"
"There are major differences in phenomenology, family history, longitudinal course, and treatment response between BPD and bipolar disorder, and the findings of comorbidity studies are equivocal. Thus, existing evidence is insufficient to support the concept that BPD falls in the bipolar spectrum." (Bipolar and BPD are clearly separate disorders, although it’s not uncommon to have both diagnoses).

J Affect Disord 2004 Apr;79(1-3):297-303
"BPD in patients with bipolar disorder and response to lamotrigine"
In some individuals with both disorders, Lamictil (lamotrigine) improved some BPD symptoms.

Psychiatry Res 2004 Mar 15;125(3):257-67
"BPD: impaired visual perception and working memory"
"It is concluded that perceptional speed and working memory are impaired in BPD, but that the deficits are not augmented by increasing cognitive load."

J Clin Psychiatry 2004 Mar;65(3):379-85
"Combined dialectical behavior therapy and fluoxetine in the treatment of BPD"
A small study (20 patients) showed no added benefit when Prozac (fluoxetine) was added to DBT. (The issue in this study is what do the findings actually mean. Fluoxetine has consistently been shown in studies to be effective with anger, although many patients require higher doses before any benefits are seen. Individuals with the BPD experiencing chronic dysphoria (anxiety, rage, depression and despair) rarely experience benefit from fluoxetine unless Tegretol (carbamazepine) is added a week later. Effective counseling (including DBT) with medication is the optimal treatment).

Curr Psychiatry Rep 2004 Feb;6(1):43-50 (from Germany)
"New developments in the neurobiology of BPD"
"Most of the neuropsychologic, physiologic, endocrinologic, and neuroimaging data support the theory that a dual brain pathology, affecting prefrontal and limbic circuits, may underlie this hyperarousal-dyscontrol syndrome."

J Clin Psychiatry 2004 Jan;65(1):104-9
"Olanzapine versus placebo in the treatment of BPD"
After 4 weeks there was a definite benefit for both men and women with BPD treated with Zyprexa (olanzapine). Most patients were on 5-10mg daily. Weight gain was a significant problem.

Acta Psychiatr Scand 2004 Jul;110(1):45-54 (from England)
"Impaired spatial working memory in adults with ADHD: comparisons with performance in adults with BPD and in control subjects."
"The results are consistent with the claim that aspects of working memory are particularly impaired in adult ADHD. Also, the BPD group had a longer deliberation time for one of the additional tasks, compared with the ADHD group, which indicated that the patient groups may have different patterns of neuropsychological impairments."

Int J Psychophysiol 2004 Jun;53(1):57-70
"Effects of BPD features and a family history of alcohol or drug dependence on P300 in adolescents."
The "P300 amplitude" (a measurement found on a brain wave test - EEG) is associated with BPD symptoms during adolescence.

Biol Psychiatry 2004 Mar 15;55(6):603-11
"Posttraumatic stress disorder and functional MRI activation patterns of traumatic memory in patients with BPD"
"Dependent on absence or presence of additional PTSD different neural networks seem to be involved in the traumatic memory of patients with BPD."

J Personal Disord 2004 Oct;18(5):439-47
"Borderline psychopathology in the first-degree relatives of borderline and axis II comparison probands"
Five of the criteria were more common among the relatives: inappropriate anger, mood swings, paranoia/dissociation, general impulsivity and intense, unstable relationships.

Pharmacopsychiatry 2004 Sep;37(5):196-9
"Naloxone in the treatment of acute dissociative states in female patients with BPD"
"..this study does not support the assumption that naloxone in a single dose of 0.4mg IV is superior to placebo in acute dissociative states in patients with BPD." (only 9 patients were studied)

J Clin Psychiatry 2004 Aug;65(8):1049-56
"Major depressive disorder and BPD revisited: longitudinal interactions"
"When BPD and major depressive disorder (MDD) co-occur, they can sometimes have independent courses, but more often improvements in MDD are predicted by prior improvements in BPD. Clinicians should not ignore BPD in hopes that treatment of MDD will be followed by improvement of BPD." (Three of the most important long term BPD researchers and clinicians were a part of this Harvard study - Drs. Gunderson, McGlashan and Zanarini. Their findings are consistent with what I’ve seen in a private primary care practice with a strong depression and BPD emphasis. The most severe borderlines get the most attention, but the majority of individuals with BPD are not that severe and are primarily treated for depression and/or anxiety problems.)

Psychiatry Res 2004 Jul 30;131(2):125-33
"Anatomical MRI study of BPD patients"
This study also found diminished hippocampal volumes. Putamen enlargement seems to be due to substance use disorders.

Behav Res Ther 2004 May;42(5):487-99
"Effectiveness of inpatient dialectical behavioral therapy for BPD: a controlled trial."
A 3 month inpatient DBT treatment was more effective than outpatient treatment. No follow up was done, however.

Prog Neuropsychopharmacol Biol Psychiatry 2004 Mar;28(2):329-41
"Neurocognitive function in BPD."
Neuropsychological testing implied a dysfunction in the right hemisphere frontotemporal region in BPD individuals.

Psychiatry Res 2004 Jan 1;121(3):239-52
"Neurobiological correlates of diagnosis and underlying traits in patients with BPD compared with normal controls."
Psychological and neurotransmitter testing suggest that serotonin system abnormalities are associated with impulsive traits.

Biol Psychiatry 2004 Apr 1;55(7):759-65 (from Germany)
"A positron emission tomography study of memories of childhood abuse in BPD"
"Dysfunction of dorsolateral and medial prefrontal cortex, including anterior cingulate, seems to be correlated with the recall of traumatic memories in women with BPD. These brain areas might mediate trauma-related symptoms, such as dissociation or affective instability, in patients with BPD."

Acta Psychiatr Scand 2004 Dec;110(6):416-20
"Axis II comorbidity of BPD: description of 6 year course and prediction to time-to-remission"
"The results of this study suggest that axis II disorders co-occur less commonly with BPD over time, particularly for remitted borderline patients. They also suggest that anxious cluster disorders are the axis II disorders which most impede symptomatic remission from BPD."

Prostaglandins Leikot Essent Fatty Acids 2004 Oct;71(4):211-6
"Essential fatty acids and their role in the treatment of impulsive disorders"
Both ADHD and the BPD can improve with the addition of essential fatty acids, which have also been shown to improve depression, schizophrenia and dementia.

J Child Adolesc Psychopharmacol 2004 Winter;14(4):531-8
"Psychosurgery for Self-injurious Behavior in Tourette’s Disorder"
An adolescent male with severe Tourette’s and self injurious behavior underwent two surgical procedures for cingulotomy and subsequent limbic leucotomy. "After the second surgery the severity and frequency of his self injurious behavior were reduced."

J Personal Disord 2004 APr;18(2):193-211
"Childhood maltreatment with adult personality disorders: findings from the Collaborative Longitudinal Personality Disorders Study."
"Results indicate that rates of childhood maltreatment among individuals with personality disorders are generally high {73% reporting abuse; 82% reporting neglect}. As expected, BPD was more consistently associated with childhood abuse and neglect than other personality disorder diagnoses."

2005
Curr Psychiatry Rep. 2005; 7(1):65-72
"Neuroimaging and personality disorders"
"Functional and structural studies provide support for dysfunction in fronto-limbic circuits in BPD and APD, whereas temporal lobe and basal striatal-thalamic compromise is evident in schizotypal personality disorder.

Neuroreport 2005; 16(3):289-93
"Distinct pattern of P3a event-related potential in BPD"
"...distinctive disturbances in P3a in (unmedicated) BPD patients were found: abnormally enhanced amplitude, failure to habituate and a loss of temporal locking with P3b."

Dev Psychopathol. 2005; 17(4):1197-206
"Defining the neurocircuitry of BPD: functional neuroimaging approaches"
"Functional neuroimaging...is beginning to identify abnormal frontolimbic circuitry..."

Clin Neurophysiol. 2005; 116(6):1424=32
"BPD features in adolescent girls: P300 evidence of altered brain maturation."
"The present findings suggest abnormal brain maturation among adolescent girls exhibiting features of BPD."

J Psychiatr Res. 2005; 39(5);489-98
"Increased delta power and discrepancies in objective and subjective sleep measurements in BPD"
"BPD patients showed a tendency for shortened REM latency and significantly decreased NonREM sleep (stage 2)...There was a marked discrepancy between objective and subjective sleep measurements, which indicates an altered perception of sleep in BPD."

Am J Psychiatry 2005; 162(12):2360-73
"BPD, impulsivity, and the orbitofrontal cortex"
"The patients with orbitofrontal cortex lesions and the patients with BPD performed similarly on several measures. Both groups were more impulsive and reported more inappropriate behaviors."
(Note: the orbitofrontal cortex is considered part of the limbic system)

Am J psychiatry. 2005; 162(3):621-4
"Impact of trait impulsivity and state aggression on divalproex versus placebo response in BPD"
Depakote (divalproex, valproic acid or valproate) was superior to placebo for impulsive aggressiveness.

Psychiatr Serv. 2005; 56 (2): 193-7
"Intensive dialectical behavior therapy for outpatients with BPD who are in crisis"
"The three-week, intensive version of dialectical behavior therapy was found to be an effective treatment. Treatment completion was high, and patients showed statistically significant improvements in depression and hopelessness measures."

J Clin Psychiatry 2005; 66(9):1111-5
"Oxcarbazepine in the treatment of BPD: a pilot study"
Trileptal (oxcarbazepine), a variation of the Tegretol (carbamazepine) molecule, is an option for treating the BPD. 25% of those with significant side effects from Tegretol (carbamazepine) can have the same side effects from Trileptal (oxcarbazepine). (low sodium, low magnesium and allergic reactions are concerns).

Am J Psychiatry. 2005; 162(5):883-9
"Two-year prevalence and stability of individual DSM-IV criteria for schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders: toward a hybrid model of axis II disorders."
"The most prevalent and least changeable criteria over 2 years were mood swings (affective instability) and anger for BPD. The least prevalent and most changeable criteria were self-injury and behaviors defending against abandonment for BPD."

Am J Psychiatry 2006; 163(5);827-32
"Prediction of the 10-year course of BPD"
88% of 290 inpatients studied achieved remission over 10 years. The best predictors of remission were younger age, absence of childhood sexual abuse, no family history of substance use disorder, good vocational record, absence of an anxious cluster personality disorder, low neuroticism, and high agreeableness.

("Remission" is a challenging concept in dealing with the BPD. Some authorities base it on prevalence of DSM criteria, some the absence of suicide attempts or self mutilation, others on interviews, sometimes it's based on the severity of symptoms. Mood swings, anger (which can be self directed) and episodes of dysphoria (anxiety, rage, depression and despair) generally persist. In my experience, the medical BPD symptoms persist for most patients throughout life unless medically treated, although they can be expressed differently. Stress can bring on symptoms that are under control without that stress. The 88% statistic may be based to a large degree on preadmission substance problems, especially alcohol. Alcohol alone can cause BPD symptoms, can markedly worsen the BPD, and frequently leads to hospital admission. In the 18 years I've been treating BPD patients, I've found psychiatric hospitalization to be a rare phenomenon. The patients studied in this group may represent a skewed population).

Am J Psychiatry 2005; 162(1):168-74
"Bone mineral density, markers of bone turnover, and cytokines in young women with BPD with and without comorbid major depressive disorder"
"The bone mineral density of 10 patients with BPD plus current major depressive episode was significantly lower than that of the healthy subjects and the patients with BPD without depression. Values of crosslaps, osteocalcin, serum cortisol, tumor necrosis factor-alpha (TNF-alpha), and interleukin-6 were significantly higher in the patients with BPD plus current major depressive episode than in the healthy subjects."

Am J Psychiatry 2005; 162(6):1221-4
"Double-blind, placebo-controlled study of dialectical behavior therapy plus olanzapine for BPD"
"A combined psychotherapeutic plus pharmacological approach appears to lower dropout rates and constitutes an effective treatment for BPD."
(The mean dose for Zyprexa (olanzapine) was 8.83mg/day. The problem with this medication is risk of massive weight gain and diabetes)

2006
Curr Opin Psychiatry. 2006; 19(4):428031
"Personality disorders and medical comorbidity"
Individuals with personality disorders don't feel as well medically and are more likely to have medical problems when their psychiatric problems are more symptomatic.

J Personal Disord 2006; 20(1):9-15 (Drs. Zanarini and Gunderson at Harvard)
"Reported childhood onset of self-mutilation among borderline patients"
32.8% of self mutilators started mutilating prior to age 13. These individuals problems with self mutilation were much worse. (Since the BPD appears to start at puberty when the brain's limbic system revs up, it would be significant to determine if these self mutilators had already started puberty or if the self mutilation considerably predated puberty - possibly as a symptom of childhood onset bipolar disorder).

Brain Inj 2006; 20(1):67-81
"Inhibition and object relations in borderline personality traits after traumatic brain injury (TBI)"
This study of 30 individuals with moderate to severe TBI compared to 30 normals showed post injury BPD traits to be rare and to be more significant regarding moods and pre-injury BPD trains rather than problems with inhibition control. (Note: in the 3.5 years of doing weekly BPD support groups I frequently asked about serious head injuries - approximately 50% had experienced at least one serious head injury.)

Int Clin Psychopharmacol 2006: 21(6):345-53
"Efficacy of pharmacotherapy against core traits of borderline personality disorder: meta-analysis of randomized controlled trials."
"Pharmacotherapy can exert a modest beneficial effect on some core traits of BPD." (Dose and combinations of medications are crucial, there is no "borderline drug.")

Psychol Med 2006; 36(8):1163-72
"The influence of emotions on inhibitory functioning in BPD"
"Our data suggest that individuals with BPD have difficulties in actively suppressing irrelevant information when it is of an aversive nature."

Emotion 2006; 6(4):647-55
"Heightened sensitivity to facial expressions of emotion in BPD"
"Overall, results appear to support the contention that heightened emotional sensitivity may be a core feature of BPD."

J Clin Psychiatry 2006; 67(7):1042-6
"Efficacy and tolerability of quetiapine in the treatment of BPD: A pilot study"
Seroquel (quetiapine) is effective and well tolerated for the BPD, particularly when impulsive / aggressive symptoms are prominent. (Note: I have found Seroquel (quetiapine) to be disappointing overall. Zyprexa (olanzapine), Risperdal, and Abilify (aripiprazole) have been more useful in my practice).

Am J Psychiatry 2006; 163(5):833-8
"Aripiprazole in the treatment of patients with BPD: a double-blind, placebo-controlled study."
"Abilify (aripiprazole) appears to be a safe and effective agent in the treatment of patients with BPD." (Note: while not as effective as Risperdal (risperidone) or Zyprexa (olanzapine), Abilify (aripiprazole) doesn't cause the weight gain and is my antipsychotic of choice for chronic use when long term antipsychotic medication is necessary.)

Permission by Leland M. Heller, M.D.