Psychiatry - August 2008 - (Page 19)

[the interface] others. Schmideberg7 described nine specific features of BPD, including the inability to tolerate routines, low motivation for treatment, chaotic lifestyle patterns, and difficulties in establishing emotional contact with others. Hoch and Polatin8 described the clinical triad of pan-anxiety, pansexuality, and pan-neurosis. Knight9 emphasized the presence of multiple neurotic symptoms, lack of achievement, and psychological vacillation between neurotic and psychotic states. Indeed, all of these varied descriptive features certainly capture many of the clinical facets of individuals with BPD. In more recent times, the diagnosis of BPD has continued to rely on the presence of particular symptoms or symptom clusters. For example, Kernberg10 developed a diagnostic approach to BPD entitled the “Presumptive Diagnostic Elements,” which highlights the symptoms of pervasive anxiety, multiple neuroses, impulsivity, and addictions. Kolb and Gunderson11 described five fundamental characteristics of patients with BPD, which are quasipsychotic phenomena (i.e., fleeting losses of reality), impulsivity (i.e., chronic selfregulation difficulties, longstanding selfdestructive behavior), a superficially intact social façade, chaotic interpersonal relationships, and chronic affective disturbance. These clinical characteristics subsequently became the cornerstones for the Diagnostic Interview for Borderlines (original version).11 The focus on diagnosis through specific symptom assessment has also culminated in the current criteria for BPD, which were initially described in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (published in 1980).12 (The two prior versions of the DSM did not contain the diagnosis of BPD at all.) The most recent criteria for the disorder, which are described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR),13 are (a) frantic efforts to avoid abandonment; (b) a history of unstable and intense relationships with others; (c) identity disturbance; (d) impulsivity in at least two functional areas, such as spending, sex, substance use, eating, or driving; (e) recurrent suicidal threats or behaviors as well as self-mutilation; (f) affective instability with marked reactivity of mood; (g) chronic feelings of emptiness; (h) inappropriate and intense anger or difficulty controlling anger; and (i) transient stress-induced paranoid ideation or severe dissociative symptoms. Five of the preceding nine criteria are required for diagnosis. We wish to underscore that the previous clinicians and investigators have accurately described a number of clinical features that may be attributed to BPD. Yet, with the exception of the DSM criteria, there appears to be only modest overlap among the historical criteria sets. Is this ongoing declaration of diverse symptoms due to mistaken clinical observations and/or conclusions? Or could it represent the fact that patients with BPD have proliferative symptoms? We suspect the latter explanation. In other words, in addition to the type of symptoms commonly encountered in BPD, which respected authorities might debate, it appears that the number of symptoms may be an essential diagnostic indicator, as well. MULTIPLE PSYCHIATRIC SYMPTOMS IN BPD Note that many of the preceding authorities in the field have alluded to the presence of a high number of diverse clinical symptoms in BPD, without actually highlighting this prominent and unusual psychiatric characteristic, itself. For example, Hoch and Polatin,8 Knight,9 and Kernberg10 all refer to multiple neurotic symptoms. The criteria in the Diagnostic Interview for Borderlines includes a section on impulsivity, which explores multiple self-regulation and self-harm behaviors.11 Finally, the contemporary DSM-IV-TR criteria refer to impulsivity “in at least two areas,” suggesting the presence of multiple diverse symptoms.13 However, are there any research data that support these impressions? Multiple Axis I disorders: The evidence. Several studies document the presence of multiple Axis I disorders in patients with BPD. The first was undertaken by Zanarini and colleagues,14 who examined the prevalence of Axis I comorbidity among 379 patients with BPD, compared with 125 patients with other personality disorders. These authors concluded that complex Axis I comorbidity is strongly predictive of the BPD diagnosis. Zimmerman and Mattia15 examined comorbidity patterns among 409 patients using semistructured diagnostic interviews. The BPD subsample was diagnosed with significantly more Axis I diagnoses than the non-BPD subsample. In this study, the authors found that the BPD subsample was twice as likely to receive diagnoses of three or more current Axis I disorders and nearly four times as likely to receive diagnoses of four or more Axis I disorders. In this cohort, a high level of Axis I comorbidity was observed for both current and lifetime diagnoses. In a sample of outpatients being seen in a university-based resident psychotherapy clinic, we retrospectively examined Axis I comorbidity among 61 patients with BPD, 128 patients with another personality disorder, and 91 patients without any personality disorder.16 The BPD subgroup had significantly more Axis I diagnoses than either of the comparison groups. Finally, in a study of patients from “everyday clinical practice,” Conklin [AUGUST] Psychiatry 2008 19

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Psychiatry - August 2008 Editor’s Message Editorial Advisory Board Contents Borderline Personality Disorder: Are Proliferative Symptoms Characteristic? Short-acting versus Long-acting Medications for the Treatment of ADHD Baby Stimuli and the Parent Brain: Functional Neuroimaging of the Neural Substrates of Parent-Infant Attachment These Boots Are Made for Stalking: Characteristics of Female Stalkers Managing Attention Deficit Hyperactivity Disorder in the Emergency Department Obstructive Sleep Apnea, Hypoxia, and Metabolic Syndrome in Psychiatric and Nonpsychiatric Settings Improving the Quality of Life in Patients with Alzheimer’s Disease The Process of Getting New Drugs to Market Journal Watch Classified Advertising Information for Authors

Psychiatry - August 2008

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