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  • Borderline - An Adjective in Search of A Noum

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    Akiskal, 1982, JClinPsych

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    Akiskal, 1982, JClinPsych

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    Borderline - An Adjective in Search of A Noum

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    Akiskal, 1982, JClinPsych

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    ii Borderline: An Adjective in Search of a Noun HAGOP S. AKISKAL, M.D., SHEN E. CHEN, M.D., GLENN C. DAVIS, M.D., VAHE R. PUZANTIAN, M.D., MARK KASHGARIAN, M.D., and JOHN M. BOLINGER, M.D. nts diagnosed as borderline (N=100) were ly followed for 6-36 months and examined from phenomenologic, developmental, and family his- tory perspectives. At index evaluation, 66 met eriteria for recurrent depressive, dysthymic, eyelothymic, or bi- polar II disorders, and 16 for those of schizotypal per. sonality. Other subgroups included sociopathic, somatization, panic-agoraphobic, attention deficit, epic leptic, and identity disorders. Compared with nonbor_ derline personality controls, borderlines had a significantly elevated risk for major affective but not for schizophrenic breakdowns during follow-up. Prominent substance abuse history, tempestuous biographies, and unstable carly home environment were common 10 ll diagnostic subgroups. In family history, borderlines were most like bipolar controls, and differed signifi. cantly from schizophrenic, unipolar, and. personality controls. Its concluded that, despite considerable over lap with subaffective disorders, the current adjectival use of this rubric does not identify a specific psycho- pathologic syndrome, (J Clin Psychiatry 46:41-48, 1985) —————_$____ ‘The diagnosis of borderline conditions enjoys great clin- ical popularity in North American psychiatry. The most Prevalent opinion is that these are primitive disorders of developmental origin, characterized by an unstable sense of self and low-level defensive operations. It is also thought that borderline patients have an unusually high liability for transient breaks with reality.” Despite eriticism by phenom enologically oriented clinical investigators,” the borderline concept fas been introduced into DSM-IIl, DSM-I1 had Fecognized such conditions only as “dilute” or “latent” forms of schizophrenia, In restricting the operational terri tory of schizophrenia to “process” or Kraepelinian schizo- phrenia, DSM-III has now pushed the borderline concept into the domain of personality disorders, where itis listed under two overlapping rubrics: 1) bordertine personality disorder, manifested by such unstable characterologic at. tributes as impulsivity, drug-seeking, polymorphous sex ally, extreme affective lability, boredom, anhedonia, and From the Department of Peychiatry a the University of Tomessee Cen ‘cr fr the Health Sciences and Northeast Mental Health Cone, Memphea Dr: Pucantian i deceased Presented at the 136th Anmual Meeting ofthe American Psychiaric Association, New York, April 0-May 6, 1983, ‘eprint requests to: Hogop S, Akskal, M.D.. UTCHS Deparment of Poochiatr, Suite 633, 06.N. Pauline erect, Memphis, TM 3960, bizarre attempts at selfharm, and 2) schizorypal personality disorder, the hallmarks of which are oddities of communi, cation or perception and other soft signs of “micropsycho- sis.” typically, although not exclusively, associated with a schizoid existence. Despite efforts to identity a distinct schizotypal disor der, considerable overlap exists between schizotypal, schizoid, and avoidant types. Likewise, borderline patients are not easily diseriminable from antisocial and histrionie Personality disorders. One is reminded of Mack's sugges- ion that “borderline” refers to a personality disorder with- ut a characterologic specialty." Implicit in the DSM-III Position is that schizotypal disorders, believed to be on the border of schizophrenia, should be separated from the more nebulous mélange of unstable characterologie attributes Constituting borderline conditions. In line with these deve ‘epments, recent research, exemplified by Stone's work." hhas suggested a shift of the borderline concept from a sub- schizophrenic to a subaffective disorder. Gunderson, how. ever, who was among the first to attempt to bring oper tional clarity to this murky psychopathologic area, in recent collaborative work with Pope et al.," seems to espouse the view that the eharacterologic pathology of borderline pa tients is distinct from any concurrent affective episodes Monroe," who subscribes to the existence of a third (nei. ther schizophrenic nor affective) psychosis related to epi- Jepsy, has postulated that “episodic dyscontrol” manifested by unmodiulated affects is at the core of borderline psycho- pathology. Kernberg’s concept,’ probably the broadest of all, embraces a wide spectrum of subpsychotie tempera- mental and polysymptomatic neurotic disorders tied to- gether by identity diffusion and common, primitive defensive operations like spliting and projective identifica, tion, in the presence of grossly intact reality testing Despite 2 considerable amount of empirical work in the Past few years, several controversies regarding the noso. logic status of borderline conditions remain unresolved. 1. Is bordertine a personality disorder? 2. Does it refer to formes frusies or interepisodie mani- festations of affective, schizophrenic, or epileptic psycho 3. Is it an intermediate mode of functioning between neurosis and psychosis? Several interview schedules for a descriptive identifica: tion of borderline and schizotypal personality disorders hhave been developed. Khouri et al.,”in their attempt to fo. cus on subschizophrenic disorders, have excluded affective symptoms from their inventory. By contrast, the Gunderson et al." diagnostic interview for bordcrtines (DIB) casts Eee a 0 CLIN PSYCHIATRY 46:2 — FEBRUARY 1965 wider net which includes circumscribed psychotic, affec~ tive, acting out, interpersonal, and social areas. Pope et al.” attempted (0 validate DIB borderlines by using the Washington University approach to validating psyeitatric entities. Soloff and Millward" and Loranger ct al."* who used the same instrument, focused on the familial aspects of the disorder, Perry and Klerman,” using a related instru- ment, examined the phenomenologic features of the disor- der. The data from these studies indicate 1) lack of lationship of the disorder to schizophrenia, 2) failure 10 discriminate from antisocial and histrionie character disor- ders, and 3) at least some degree of overlap with primary affective disorder. Considering the general confusion in this area, the sub- stantive findings of these studies are quite impressive, Nev- ertheless, one must bear in mind the following limitations: First, they were not generally conducted in outpatient set- tings, where the largest number of borderlines are encoun tered clinically. Second, proband Axis I diagnosis and family history were often based on chart review. Third, a control group of bipolar affective disorder was not specific cally provided. Fourth, repeated evaluations at follow-up ‘vere not instituted, minimizing the chances of detecting hy~ pomanic episodes. Finally, the degree of overlap of borde lines with antisocial and histrionic personality disorders could not be estimated in the absence of a control group consisting of such personalities. We have elsewhere reported preliminary family history and follow-up data suggesting substantial overlap of bor- derline personality disorders with dysthymic and eyelothy- ‘ic temperaments and atypical bipolar II disorder." Our findings were tentative because data collection on control troup had not been completed when our report was pub- ished. In the present article, we attempt to address the methodologic issues raised above and provide comparisons with schizophrenic, bipolar, unipolar, and personality dis- order controls. Furthermore, we explore the possibility that childhood object loss and unstable home environment due to assortative parental psychopathology may form the de- velopmental background of borderline conditions. The ‘overall aim of this exercise is to prospectively delineate the range of psychopathologic conditions for which the adjec- ive “borderline” is currently applicable. (Our main hypothesis is that borderlines are heteroge- neous groups of patients who meet specitic criteria for more explicit Axis I psychiatric diagnoses, Based on prior work, wwe also hypothesized that borderlines would show high es of familial affective (but not of schizophrenic) disor~ ders, and would develop full-blown affective (rather than schizophrenic) breakdowns during prospective follow-up similar to affective but unlike nonaffective controls. Be- cause borderline patients are often considered to have com- plicated biographies, we wished to test the possibility that increased rates of early separations and broken homes— associated with assortative parental psychopathology— might underlie their character pathology. 42 AKISKAL ET AL. HOD Selection of Subjects We selected 100 borderline patients from a large pool of ‘general psychiatric outpatients by examining consecutive jdmissions in two urban mental health centers. ‘These sub- jects met at leust five of the six Gunderson-Singer eriteria.* (This study was conducted prior to the availability of the DIB.") Most probands had extensive psychiatric histories dating back 10 adolescence or early adulthood, and had been considered complex diagnostic problems by referring clinicians. They had often been presented at diagnostic staff conferences and had received such diagnoses as borderline and xed personality disorder, as well as “Intent” and schizophrenia. Although 40% had had ‘one or more psychiatric hospitalizations prior to the index outpatient interview, none had received the diagnosis of & definite affective or schizophrenic disorder, Four control groups were selected lrom consecutive ad- mission in the same outpatient settings: 57 schizophrenic subjects, 50 nonaffective personality disorders (definite or probable somatization and antisocial), 50 classical (bipolar 1) manic-depressives, and 40 episodic major (unipolar) de- pressives. Diagnostic Procedures ‘All probands and control subjects were evaluated in semistructured diagnostic interviews based on the Washing- ton University Criteria."” Since DSM-III is more widely known to practicing psychiatrists, we have translated diag- noses to the corresponding DSM-III terms. {All Gunderson-Singer borderline probands also met the DSMAIIl criteria for borderline personality, but only 16 fully met those for schizotypal personality. Borderline, schizotypal, and antisocial personalities were the only Axis I diagnoses used in this study; all other diagnoses were based on Axis I. Since DSM-III does not specifically distin- guish hypomania from mania, we found it useful to set the following threshold for hypomania: 1) symptomatic criteria for mania of atleast 2 days; 2) absence of querulous beliger ‘ence; 3) no psychotic symptoms; and 4) no hospitalization, Each proband received principal and, when applicable, concurrent diagnoses. “Principal diagnosis” refers to the chronologically primary or most incapacitating disorder which usually brought the patient to clinical attention “Concurrent diagnoses” include all additional diagnoses, which often followed the principal disorder chronologi- cally Substance (including ethanol) use disorders were so prevalent in our borderline probands (unsurprisingly, be ccause these arc among the Gunderson-Singer and DSM-III defining criteria) that it was more meaningful to consider them independently from descriptive diagnoses. They were classified as sedative-hypnotic abuse or dependence, aleo- hol abuse or dependence, or psychedelic (hallucinogen-can- -psychostimulant) abuse or dependence. JOLIN PSYCHIATRY 45:2 — FEBRUARY 1985 BORDERLINE DIAGNOSIS. TABLE 1. Family History for Major Depression and Bipolar Disorder in Borderine and Control Groups Borderiine Porsonality, Bipolar Unipolar ‘Group Controls, Controls Controls (N=97) (N= 50) (N=40) Family History W % ii % N % N % Major depression 7 175 3 10 1 22 8 20 Bipolar disordor 7 475" 1 2 13 26 1 3 “Significantly different trom personality controls, Patients were seen at 1-8 week intervals (as warranted Clinically), and followed over a 6-36 month prospective ob- servation period. Mean duration of follow-up was compara- ble for study and control groups. Pharmacologic, Psychotherapeutie, and sociotherapeutic interventions were Provided as deemed clinically appropriate. Schizophreni: form, hypomanic, manic, and major depressive episodes, as well as mixed states, were carefully noted during follow- up. Hypomanic responses to antidepressants were consid- red pharmacologically occasioned if they occurred within 6 weeks after administration of tricyclic antidepressants or monoamine oxidase inhibitors. Criteria for familial and developmental factors. One- third of affected family members were patients in our men- tal health clinics, one-third were directly interviewed 10 ascertain their diagnoses, and, in the remaining third, dia nostic information was obtained from other family mem- bers, using the Research Diagnostic Criteria - Family History version.” Except for familial schizophrenia (which included both first- and second-degree relatives), all other family history items refer to first-degree biologic relatives, Assortative mating, i.¢., where both parents suffered from Psychiatrie disorders, was noted in particular. OF the 100 probands, 3 were adopted and were unable to provide fars- ily histories. Developmental object loss was assessed by the follow. ing criteria, modified from Amark:” 1) proband born out of wedlock and parents not subsequently married of living to- ether: 2) one or both parents lost by death before proband feached age 15; 3) parents separated or divorced before proband reached age of 15; 4) proband adopted or lived in Foster homes or orphanages. Statistical techniques. Except for age distribution, which was analyzed by ANOVA, comparisons between groups were made by chi-square analysis, with Yates cor- rection when appropriate. RESULTS Demographic and Family History Characteristics Borderline and control probands were preponderantly from Hollingshcad-Redlich classes MI and IV. The mean ‘age at index evaluation was 29 years for borderline pro- bands, 34 for schizophrenics, 30 for nonaffective personali- ties, 38 for the bipolar controls, and 47 for recurrent major depressive controls; these differences in age were not statis- tically significant. About two-thirds of the subjects in each group were women. 03, p <02; and from unipolar contras, 96, p<.05, Borderline probands, when compared with schizo- Phrenic controls, had a significantly higher rate of familial affective disorders (35% vs. 9%, x'=11.76, p<.001) and 4 significantly lower rate of schizophrenia G% vs. 21%, °=11.21, p< .001). Borderlines and control groups did not differ in family history for major depression (see Table 1), However, with respect to familial bipolar disorder, borderlines were simi: lar to bipolar controls but significantly different from per- sonality disorder and unipolar controls Diagnoses at Index Evaluation Table 2 provides diagnostic information on the 100 bor- derline probands at index evaluation. These probunds can be categorized into five groups based on principal diagno- sis. The largest group (N=45) consisted of affective disor- ders, primarily eyclothymic or dysthymic and atypical (bipolar 11) rather than “elassic" forms. The next largest 2T0UP, personality disorders (N=21), consisted of probable ‘or definite somatization disorder and antisocial personali- ties, An almost equal category was the polysymptomatic neurosis group (N= 18), consisting of panic, agoraphobic and obsessive-compulsive disorders. There were 9 patients with schizorypal personality and no concurrent disorders, The organic group is represented by 2 epileptic patients and 1 with adult (residual) attention deficit disorder The remaining 4 probands were considered undiagnosed at index evaluation; they had some alfinity to adolescent identity disorder as defined in DSM-lII, except that their condition had persisted beyond adolescence, was chronic, and had its basis in physical defects or abnormalities that could be expected to produce an irreconcilable identity con flict. For example, one subject was an albino girl born ta black parents, and another was a very intelligent college- educated woman with multiple congenital abnormalities and short stature. The profound identity disturban these patients was based on realistic anatomie factors. Also displayed in Table 2 are the concurrent diagnoses given to 37 cases, OF these, secondary or superimposed dysthymia with chronic Muctuating course was the most common (N=21), Of the remaining patients with multiple diagnoses, 7 met the eriteria for schizotypal personality dis- ‘order, 2 for epilepsy, 2 for adult (residual) attention deficit disorder, and 5 for somatization, sociopathic, and panic dis- orders. Patients with multiple concurrent diagnoses were ot uncommon (¢.g., an agoraphobic woman who suffered from preexisting somatization disorder and superimposed or secondary dysthymic disorder). J CLIN PSYCHIATRY 46:2 — FEBRUARY 1985 TABLE 2. Axis | Diagnoses in 100 Borderline Patient AKISKAL ET AL, Index Evaluation* Substance Use Principal Diagnosis Concurrent Diagnosis Disorderst Afectve group (N= 45) Fecurrent major depression (6) Sedativerhypnotics @ Dysthymi disorder (14) Schizotypal disorder (3) Sedativeshypnotios @ Alcohol a Paychedolics o Cyclothymic disorder (7) ‘Somatization disorder (1) Sedatverhyonoties @ Prychedolies @ Alcohol to} (Atypical bipolar 1 Sociopathy (1) Sedative hypnotics “ disorder (17), ‘Somatization disorder (1) Aleoho! iy Residual (adult) attention Paychedolics @ defct sisorder (1) Parsonality( Sociopathy (9) Residual (adult) attontion ict disorder (1) Sedatveshypnotics @ Schizotypal disorder (1) Paychedelics © “Temporal lobe epilepsy (1) Aleohol 6 Dyzthymia (3) ‘Somatization disorder (12) Panic disorder (2) Sociopathy (2) Sedatve-hypnotics (12) ‘Temporal lobe epilepsy (1) ‘Aleoho! @ Senizotypal disorder (1) Paychadelies @ Dysthymia (7) Polysymptomatic Neurosis group (N= 18) Panic and agoraphobe: Dysthymia (6) Sedative-nypnotics @ disorders (10) Sociopathy (1) Aicoho! iy Somalizaton disorder (1) Paychedelics a) Schizotypal disordor (1) Obsessive-compulsive disorder (8) Dystnymia (5) Schizotypal eisorder (1) Schizotypal group (N=9) ‘Schizotypal cisorder (9) Organi group (N=3) Grand mal epilepsy (1) “Temporal lobe epilepsy (1) Residual (adul) attention ‘ofict isorder (1) Undiagnosed group (N=4) “Chronic identity disorder" (4) Sedatwve-nypnotics 0 Sedative-hypnotics 2 Aleoho! wy Paychedolies @ ‘Alcon! 0 Sodative:hypnatics ia) Peychedalios 0 Alcohol wy ‘Alcoho! ° Peychedelics @ ‘Sedatwve-hypnotics @ *Hambors in parenthesss rofor to the numbers of patients with given disorder or condition. Substance abuse/dependence occurred in 55% of the probands and was equally distributed across all diagnostic groups (Table 2). Sedative-hypnotics were the most fre- quent drugs of abuse (46%), followed by alcohol (21%) and psychedclics (19%); many patients abused multiple rugs, Follow-Up Course As shown in Table 3, major depressive episodes with melancholic features developed in 29 borderline probands; 11 others had brief hypomanic excursions (6 on tricyclic challenge), 4 had manic episodes (1 of which was on tri- ic administration), and 8 evolved into mixed affective states (coexisting manic and depressive features). Four pro- 44 bands were known to have committed suicide after drop- ping out of treatment; their diagnoses ranged from obsessive-compulsive to somatization, schizotypal, and epi- leptic disorders, Schizophreniform episodes (nonaffective psychotic symptoms that cleared within weeks) occurred in 4 border- fines and 1 personality disorder control. One borderline proband developed full-fledged paranoid schizophrenia, ‘and 2 others (who at follow-up satisfied the Hoch and Po- latin” description of pseudoneurotic schizophrenia) were Classified as chronic undifferentiated type. Thus, 8% of the borderline group developed "‘schizophrenia-related” disor- ders (assuming schizopreniform illness is related to schizo- phrenia), compared with 2% of personality disorder eSO-OENea—a—n ESS J CLIN PSYCHIATRY 46:2 — FEBRUARY 1965 BORDERLINE DIAGNOSIS TABLE 3. Prospective Follow-up Outcome in Borderlines and Nonaffective Personality Disorder Controls Personally Borderline Group Controls (W100). Outcome N % wtat=1) p Affective episodes Major depression 29 29 2 1122 <.001 Hypomania or mania" 15 5 ° 075 <07 Mixed states 3 8 ° 275 Ns Sue 4 4 8 0.80 NS Schizophrenie-rolated outcome Schizophreniform psyenosis 5 5 -1 2 0.20 NS Fseudoneuroti schizophrenia 2 2 ° ° 0.08 NS Paranoid schizophrenia 1 1 ° ° 013 NS Includes ful episodes curing antidepressant drug administration which did not remit upon reduction of Grug dosage and required hsm administration, controls ("= 1.19, .05

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