Publications by authors named "John G Gunderson"

111 Publications

A Clinical Trial of a Psychoeducation Group Intervention for Patients With Borderline Personality Disorder.

J Clin Psychiatry 2019 12 31;81(1). Epub 2019 Dec 31.

McLean Hospital, Belmont, Massachusetts, USA.

Objective: The objective of this study was to assess the impact of a 6-session psychoeducational group (PEG) intervention for borderline personality disorder (BPD) in an underserved community-based outpatient setting.

Methods: The study was conducted between July 2015 and January 2017. Of 96 outpatients who met DSM-IV criteria for BPD, the first 48 received the experimental treatment, whereas the next 48 were assigned to a wait list. All received non-intensive treatment as usual. The primary outcome measure, the Zanarini Rating Scale for DSM-IV Borderline Personality Disorder (ZAN-BPD), was administered at baseline, at the end of treatment, and 2 months after the end of treatment.

Results: The PEG intervention was associated with a significant improvement on all sectors of BPD (P < .001). Improvements were greater for the PEG on all sectors except impulsivity. Benefits remained stable during 2-month follow-up. The PEG intervention had a large effect size (Cohen d = -1.16), whereas the wait list effect size was small (Cohen d = -0.18). The between-arms effect size was 0.80 after treatment and 0.90 at follow-up. With full response defined as a decrease of ≥ 50% from baseline in ZAN-BPD total score, 22 patients (46%) in the psychoeducation group and 3 (6%) in the wait list group were considered full responders.

Conclusions: This study shows that a PEG intervention can be an effective treatment for patients with BPD. The overall cost benefits of group interventions and the the applicability of a PEG intervention to underserved patients demonstrate its potential to address significant public health needs.
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http://dx.doi.org/10.4088/JCP.19m12753DOI Listing
December 2019

Working With Patients Who Self-injure.

JAMA Psychiatry 2019 09;76(9):976-977

McLean Hospital, Harvard Medical School, Belmont, Massachusetts.

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http://dx.doi.org/10.1001/jamapsychiatry.2019.1241DOI Listing
September 2019

Attitudes of Mental Health Staff Toward Patients With Borderline Personality Disorder: An Italian Cross-Sectional Multisite Study.

J Pers Disord 2019 02 20:1-16. Epub 2019 Feb 20.

Unit of Psychiatry, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy.

Negative attitudes toward borderline personality disorder (BPD) can present a barrier to those seeking care. We explored caring attitudes toward BPD among 860 mental health professionals, including psychiatrists, psychologists, social health educators, nurses, and social workers. The results showed that social workers and nurses scored significantly lower on caring attitudes than psychiatrists, social health educators, and psychologists. Our analysis showed that the more BPD patients treated in the past year, more years of experience in mental health, and having prior BPD training were positively associated with caring attitudes scores. For all professional subgroups, except for social health educators, the caring attitudes score is higher in those who have had prior BPD training, and for professionals with low and medium level of experience in mental health. This result shows that training on BPD should target less experienced clinicians and those professional groups who had less opportunity to receive such education.
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http://dx.doi.org/10.1521/pedi_2019_33_421DOI Listing
February 2019

Medication Management for Patients With Borderline Personality Disorder.

Am J Psychiatry 2018 08;175(8):709-711

From the Department of Psychiatry, Harvard Medical School, Boston; and the Department of Psychiatry, McLean Hospital, Belmont, Mass.

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http://dx.doi.org/10.1176/appi.ajp.2018.18050576DOI Listing
August 2018

Borderline personality disorder.

Nat Rev Dis Primers 2018 05 24;4:18029. Epub 2018 May 24.

Department of Psychiatry, Harvard Medical School, McLean Hospital, Belmont, MA, USA.

Caretakers are often intimidated or alienated by patients with borderline personality disorder (BPD), compounding the clinical challenges posed by the severe morbidity, high social costs and substantial prevalence of this disorder in many health-care settings. BPD is found in ∼1.7% of the general population but in 15-28% of patients in psychiatric clinics or hospitals and in a large proportion of individuals seeking help for psychological problems in general health facilities. BPD is characterized by extreme sensitivity to perceived interpersonal slights, an unstable sense of self, intense and volatile emotionality and impulsive behaviours that are often self-destructive. Most patients gradually enter symptomatic remission, and their rate of remission can be accelerated by evidence-based psychosocial treatments. Although self-harming behaviours and proneness to crisis can decrease over time, the natural course and otherwise effective treatments of BPD usually leave many patients with persistent and severe social disabilities related to depression or self-harming behaviours. Thus, clinicians need to actively enquire about the central issues of interpersonal relations and unstable identity. Failure to correctly diagnose patients with BPD leads to misleading pharmacological interventions that rarely succeed. Whether the definition of BPD should change is under debate that is linked to not fully knowing the nature of this disorder.
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http://dx.doi.org/10.1038/nrdp.2018.29DOI Listing
May 2018

Competing Theories of Borderline Personality Disorder.

J Pers Disord 2018 04;32(2):148-167

McLean Hospital, Belmont, Massachusetts.

The authors review four theories that propose different conceptualizations of borderline personality disorder's (BPD) core psychopathology: excess aggression, emotional dysregulation, failed mentalization, and interpersonal hypersensitivity. The theories are compared in their ability to explain BPD's coaggregation of four usually distinct sectors of psychopathology, their high overlap with other disorders, their ability to distinguish BPD from other disorders, their integration of heritability, and their clinical applicability. The aims of this review are to increase awareness of these theories, to stimulate improved theories, and to f ster testable hypotheses so that research can advance our knowledge about BPD's core.
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http://dx.doi.org/10.1521/pedi.2018.32.2.148DOI Listing
April 2018

Mechanisms of Change in Treatments of Personality Disorders: Commentary on the Special Section.

Authors:
John G Gunderson

J Pers Disord 2018 01;32(Suppl):129-133

McLean Hospital and Harvard Medical School, Belmont, Massachusetts.

Ueli Kramer has assembled an eclectic and original set of articles on mechanisms of change in the treatment of borderline personality disorder. They largely focus on patient variables. Several authors make the point that developmentally based variables may have more predictive power than symptom-based variables. Several other articles illustrate that changes occur early in treatments and studying their mechanisms is a promising approach that could have longer term significance. These articles document the variety of research methodologies that can be used to study mechanisms of change and the potential clinical significance of doing this. For showing the field the potential of such research, we owe Dr. Kramer our gratitude.
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http://dx.doi.org/10.1521/pedi.2018.32.supp.129DOI Listing
January 2018

Functional outcomes in community-based adults with borderline personality disorder.

J Psychiatr Res 2017 06 24;89:105-114. Epub 2017 Jan 24.

McLean Hospital, Belmont, MA 02478, USA; Department of Psychiatry, Harvard Medical School, Boston, MA 02115, USA.

Many individuals in clinical samples with borderline personality disorder (BPD) experience high levels of functional impairment. However, little is known about the levels of functional impairment experienced by individuals with BPD in the general community. To address this issue, we compared overall and domain-specific (educational/occupational; social; recreational) functioning in a sample of community-based individuals with BPD (n = 164); community-based individuals without BPD (n = 901); and clinically-ascertained individuals with BPD (n = 61). BPD diagnoses and functional outcomes were based on well-accepted, semi-structured interviews. Community-based individuals with BPD were significantly less likely to experience good overall functioning (steady, consistent employment and ≥1 good relationship) compared to community-based individuals without BPD (BPD: 47.4%; Non- BPD: 74.5%; risk difference -27.1%; p < 0.001), even when compared directly to their own non-BPD siblings (risk difference -35.5%; p < 0.001). Community-based individuals with BPD versus those without BPD did not differ significantly on most domain-specific outcomes, but the former group experienced poorer educational/occupational performance and lower quality relationships with parents, partners, and friends. However, community-based individuals with BPD were significantly more likely to experience good overall functioning than clinically-based individuals with BPD (risk difference -35.2%; p < 0.001), with the latter group more likely to experience reduced employment status, very poor quality relationships with partners, and social isolation. In conclusion, community-based individuals with BPD experienced marked functional impairment, especially in the social domain, but were less likely to experience the more extreme occupational and social impairments seen among patients with BPD.
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http://dx.doi.org/10.1016/j.jpsychires.2017.01.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5483330PMC
June 2017

Personality and life events in a personality disorder sample.

Personal Disord 2017 Oct 31;8(4):376-382. Epub 2016 Oct 31.

Department of Psychiatry, Harvard Medical School.

Individuals with a personality disorder (PD) tend to experience more negative life events (NLEs) than positive life events (PLEs). In community samples, the Five Factor Model of personality (FFM) predicts both positive and negative life events. The present research examined whether FFM normal personality traits were associated with positive and negative life events among individuals with 1 of 4 PDs: avoidant, borderline, schizotypal, and obsessive-compulsive, and tested whether associations between the FFM of personality and PLEs and NLEs were similar across the 4 PD groups and a control group. Among aggregated PDs, neuroticism was positively associated with NLEs, whereas extraversion, openness to experience, and conscientiousness were positively associated with PLEs. Comparisons of each PD group to a control group of individuals with a major depressive disorder indicated that the FFM traits operated similarly across clinical samples with and without PD. Our findings indicate that normal personality traits can be used to help understand the lives of individuals with PD. (PsycINFO Database Record
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http://dx.doi.org/10.1037/per0000214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5411350PMC
October 2017

"Good Enough" Psychiatric Residency Training in Borderline Personality Disorder: Challenges, Choice Points, and a Model Generalist Curriculum.

Harv Rev Psychiatry 2016 Sep-Oct;24(5):367-77

From Harvard Medical School and McLean Hospital, Belmont, MA.

While the public health burden posed by borderline personality disorder (BPD) rivals that associated with other major mental illnesses, the prevailing disposition of psychiatrists toward the disorder remains characterized by misinformation, stigma, aversive attitudes, and insufficient familiarity with effective generalist treatments that can be delivered in nonspecialized health care settings. Residency training programs are well positioned to better equip the next generation of psychiatrists to address these issues, but no consensus or guidelines currently exist for what and how residents should be taught about managing BPD. Instead, disproportionately limited curricular time, teaching of non-evidence-based approaches, and modeling of conceptually confused combinations of techniques drawn from specialty BPD treatments are offered. In this article, we (1) explain why training in a generalist model is sensible and why alternative approaches are not appropriate for residents, (2) propose a plan for giving residents adequate training via a generalist model, highlighting minimal didactic and clinical-training objectives (dubbed "core competencies" and "milestones") and a model curriculum developed at the Massachusetts General Hospital/McLean Hospital residency program, and (3) describe obstacles to implementation of effective generalist training posed by infrastructural, faculty-centered, and resident-centered variables.
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http://dx.doi.org/10.1097/HRP.0000000000000119DOI Listing
January 2018

Evidence-Based Treatments for Borderline Personality Disorder: Implementation, Integration, and Stepped Care.

Harv Rev Psychiatry 2016 Sep-Oct;24(5):342-56

From Harvard Medical School (Drs. Choi-Kain and Gunderson) and McLean Hospital, Belmont, MA (Drs. Choi-Kain and Gunderson, and Ms. Albert).

Learning Objective: After participating in this activity, learners should be better able to:• Evaluate evidence-based therapies for borderline personality disorder

Abstract: Several manualized psychotherapies for treating borderline personality disorder (BPD) have been validated in randomized, controlled trials. Most of these approaches are highly specialized, offering different formulation of BPD and different mechanisms by which recovery is made possible. Mental health clinicians are challenged by the degree of specialization and clinical resources that these approaches require in their empirically validated adherent forms. While these effective treatments have renewed optimism for the treatment of BPD, clinicians may feel limited in their ability to offer any of them or may integrate an eclectic assortment of features from the different treatments. This article will evaluate four major evidence-based treatments for BPD-dialectical behavioral therapy, mentalization-based treatment, transference-focused psychotherapy, and General Psychiatric Management-and possible modes of implementation in adherent and integrative forms. Models of implementing these diverse treatment approaches will be evaluated, and the potential advantages of combining evidence-based treatments will be discussed, along with some cautionary notes. A proposal for providing stepwise care through assessment of clinical severity will be presented as a means of achieving system-wide changes and greater access to care.
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http://dx.doi.org/10.1097/HRP.0000000000000113DOI Listing
January 2018

Introduction.

Harv Rev Psychiatry 2016 Sep-Oct;24(5):309-10

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http://dx.doi.org/10.1097/HRP.0000000000000130DOI Listing
March 2018

The Emergence of a Generalist Model to Meet Public Health Needs for Patients With Borderline Personality Disorder.

Authors:
John G Gunderson

Am J Psychiatry 2016 05;173(5):452-8

From the Department of Psychiatry, Harvard Medical School, Boston; and the BPD Center for Treatment, Research, and Training, McLean Hospital, Belmont, Mass.

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http://dx.doi.org/10.1176/appi.ajp.2015.15070885DOI Listing
May 2016

Ambivalence About Recovery in a Case of Psychotic Illness: Diagnostic, Treatment, and Cultural Challenges.

Harv Rev Psychiatry 2016 Jan-Feb;24(1):61-8

From Harvard Medical School; Department of Psychiatry, Massachusetts General Hospital, Boston, MA (Drs. Lokko and Chen); McLean Hospital, Belmont, MA (Drs. Lokko, Öngür, and Gunderson).

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http://dx.doi.org/10.1097/HRP.0000000000000107DOI Listing
October 2016

Promoting Good Psychiatric Management for Patients With Borderline Personality Disorder.

J Clin Psychol 2015 Aug 20;71(8):753-63. Epub 2015 Jul 20.

Harvard Medical School.

General psychiatric management for patients with borderline personality disorder was devised to be an outpatient intervention that could be readily learned and easily delivered by independent community mental health professionals. To disseminate the approach, Drs. Gunderson and Links developed the Handbook of Good Psychiatric Management for Borderline Personality Disorder (Gunderson & Links, ) that presented the basics of the approach, videos to illustrate the appropriate clinical skills, and case examples to practice adherence to the approach. Unfortunately, the inclusion of "psychiatric" in the treatment's name may discourage psychologists and other mental health professionals from using this therapy. In this article, we review the basic principles and approaches related to general psychiatric management. With a case example, we illustrate how psychologists can use all the general psychiatric management principles for their patients with BPD, except medications and, as a result, provide and deliver this approach effectively.
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http://dx.doi.org/10.1002/jclp.22203DOI Listing
August 2015

Promoting Good Psychiatric Management for Patients With Borderline Personality Disorder.

J Clin Psychol 2015 Aug 20;71(8):753-63. Epub 2015 Jul 20.

Harvard Medical School.

General psychiatric management for patients with borderline personality disorder was devised to be an outpatient intervention that could be readily learned and easily delivered by independent community mental health professionals. To disseminate the approach, Drs. Gunderson and Links developed the Handbook of Good Psychiatric Management for Borderline Personality Disorder (Gunderson & Links, ) that presented the basics of the approach, videos to illustrate the appropriate clinical skills, and case examples to practice adherence to the approach. Unfortunately, the inclusion of "psychiatric" in the treatment's name may discourage psychologists and other mental health professionals from using this therapy. In this article, we review the basic principles and approaches related to general psychiatric management. With a case example, we illustrate how psychologists can use all the general psychiatric management principles for their patients with BPD, except medications and, as a result, provide and deliver this approach effectively.
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http://dx.doi.org/10.1002/jclp.22203DOI Listing
August 2015

Interactions of borderline personality disorder and anxiety disorders over 10 years.

J Clin Psychiatry 2015 Nov;76(11):1529-34

McLean Hospital, 115 Mill St, M/S 312, Belmont, MA, 02478

Objective: This report examines the relationship of DSM-IV borderline personality disorder (BPD) to anxiety disorders using data on the reciprocal effects of improvement or worsening of BPD and anxiety disorders over the course of 10 years.

Method: We reliably and prospectively assessed borderline patients (n = 164) with DSM-IV-defined co-occurring generalized anxiety disorder (GAD; n = 42), panic disorder with agoraphobia (n = 39), panic disorder without agoraphobia (n= 36), social phobia (n = 48), obsessive-compulsive disorder (OCD; n = 36), and posttraumatic stress disorder (PTSD; n = 88) annually over a period of 10 years between 1997 and 2009. We used proportional hazards regression analyses to assess the effects of monthly improvement or worsening of BPD and anxiety disorders on each other's remission and relapse the following month.

Results: BPD improvement significantly predicted remission of GAD (hazard ratio [HR] = 0.65, P <.05) and PTSD (HR = 0.57, P < .05), whereas BPD worsening significantly predicted social phobia relapse (HR = 1.87, P < .05). The course of anxiety disorders did not predict BPD remission or relapse, except that worsening PTSD significantly predicted BPD relapse (HR = 1.90, P < .05).

Conclusion: BPD negatively affects the course of GAD, social phobia, and PTSD. In contrast, the anxiety disorders, aside from PTSD, had little effect on BPD course. For GAD and social phobia, whose course BPD unidirectionally influences, we suggest prioritizing treatment for BPD, whereas BPD should be treated concurrently with panic disorders, OCD, or PTSD. We discuss state/trait issues in the context of our findings.
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http://dx.doi.org/10.4088/JCP.14m09748DOI Listing
November 2015

The Effect of Attending Good Psychiatric Management (GPM) Workshops on Attitudes Toward Patients With Borderline Personality Disorder.

J Pers Disord 2016 08 25;30(4):567-76. Epub 2015 Jun 25.

Department of Psychiatry, McLean Hospital.

The effect that attending a 1-day workshop on Good Psychiatric Management (GPM) had on attitudes about borderline personality disorder (BPD) was assessed among 297 clinicians. Change was recorded by comparing before and after scores on a 9-item survey previously developed to assess the effects of workshops on Systems Training for Emotional Predictability and Problem Solving (STEPPS). Participants reported decreased inclination to avoid borderline patients, dislike of borderline patients, and belief that BPD's prognosis is hopeless, as well as increased feeling of competence, belief that borderline patients have low self-esteem, feeling of being able to make a positive difference, and belief that effective psychotherapies exist. Less clinical experience was related to an increased feeling of competence and belief that borderline patients have low self-esteem. These findings were compared to those from the STEPPS workshop. This assessment demonstrates GPM's potential for training clinicians to meet population-wide needs related to borderline personality disorder.
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http://dx.doi.org/10.1521/pedi_2015_29_206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4691210PMC
August 2016

Familial aggregation of candidate phenotypes for borderline personality disorder.

Personal Disord 2015 Jan 21;6(1):75-80. Epub 2014 Jul 21.

Department of Psychiatry, Harvard Medical School.

Borderline personality disorder (BPD) and its core Diagnostic and Statistical Manual of Mental Disorders (DSM) factor-analytically derived phenotypes aggregate in families. To potentially inform future conceptualizations of BPD, this study examined the familial aggregation and co-aggregation with BPD of 3 additional candidate phenotypes for BPD psychopathology: anxiousness, aggressiveness, and cognitive dysregulation. Participants included 347 probands (126 with BPD, 128 without BPD, and 93 with major depressive disorder) and 814 parents and siblings of probands. All participants completed diagnostic assessments and scales assessing the candidate phenotypes. The familial aggregation of phenotypes (correlation of level of phenotype between family members), the familial co-aggregation of phenotypes with BPD (correlation of phenotype with BPD between family members), and the within-individual correlation of phenotypes with BPD were assessed. All 3 candidate phenotypes showed high levels of familial aggregation (rs = .14 - .53, ps < .001), the magnitudes of which were comparable with DSM-based core sectors of psychopathology. Anxiousness and cognitive dysregulation showed strong within-individual associations with BPD (rs = .55 and .46, respectively; ps < .001) and substantial familial co-aggregation with BPD (rs = .12 and .13, respectively; ps ≤ .002). In contrast, aggressiveness showed a weak within-individual association with BPD (r = .11, p = .12) and little familial co-aggregation with BPD (r = .05, p = .21). These findings suggest that anxiousness and cognitive dysregulation are promising phenotypes for BPD psychopathology that move beyond factor-analytically based conceptualizations. In contrast, aggressiveness was only weakly related to BPD, suggesting that this phenotype may not represent an essential feature of this disorder.
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http://dx.doi.org/10.1037/per0000079DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4428552PMC
January 2015

Interactions of borderline personality disorder and mood disorders over 10 years.

J Clin Psychiatry 2014 Aug;75(8):829-34

McLean Hospital, 115 Mill St, Belmont, MA 02478

Objective: To examine the relationship of borderline personality disorder (BPD) to mood disorders by using data from the Collaborative Longitudinal Personality Disorders Study on the reciprocal interactions of BPD with both depressive and bipolar disorders over the course of 10 years.

Method: The study included 223 BPD patients with DSM-IV-defined co-occurring major depressive disorder (MDD) (n = 161), bipolar I disorder (n = 34), and bipolar II disorder (n = 28) who were reliably and prospectively assessed over a period of 10 years between 1997 and 2009. Proportional hazards regression analyses were used to assess the effects of improvement or worsening of BPD and mood disorders on each disorder's time to remission and time to relapse.

Results: Borderline personality disorder and MDD had strong and statistically significant reciprocal effects, delaying each disorder's time to remission (BPD's effect on MDD, P = .0004; MDD's effect on BPD, P = .0002) and accelerating time to relapse (BPD's effect on MDD, P = .0410; MDD's effect on BPD, P = .0011), whereas BPD and the bipolar disorders were largely independent disorders except that bipolar II lengthened BPD's time to remission (P = .0085).

Conclusions: Borderline personality disorder and MDD interactions suggest overlap in their psychopathologies and argue for prioritizing the treatment of BPD. Borderline personality disorder and bipolar disorders appear to be independent disorders, underscoring the need to provide appropriate treatment for each.
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http://dx.doi.org/10.4088/JCP.13m08972DOI Listing
August 2014

Approaches to psychotherapy for borderline personality: demonstrations by four master clinicians.

Personal Disord 2014 Jan;5(1):108-16

McLean Hospital.

Several efficacious therapies for borderline personality disorder (BPD) now exist despite longstanding skepticism in the field regarding amenability to treatment. In this article, 4 master clinicians describe a brief interaction with an actress playing the part of a patient with BPD that occurred at the First Annual Meeting of the North American Society for the Study of Personality Disorders in Boston, April 2013. The approaches include dialectical behavior therapy, transference focused psychotherapy, mentalization based therapy, and good psychiatric management. The paper concludes with a discussion of what these approaches have in common, how they differ, and future directions for the treatment of BPD.
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http://dx.doi.org/10.1037/per0000055DOI Listing
January 2014

Seeking clarity for future revisions of the personality disorders in DSM-5.

Authors:
John G Gunderson

Personal Disord 2013 Oct;4(4):368-76

McLean Hospital.

This article reviews the process by which the DSM-5 Personality Disorder (PD) proposal for change was developed, challenged, and then ultimately rejected. The DSM-5 workgroup's mandate to introduce radical changes were inherently fraught by the limited time allowed, but their efforts were undermined by dissension within the committee, the lack of a clearly identified scientific rationale, and by the inconsistent dialogue with the existing community of PD experts. Nonetheless, valuable steps were taken to establish a better definition for PD's, introduce dimensions, and identify the steps needed for future revisions. The author only in retrospect has concluded that borderline personality disorder and antisocial personality disorder be treated differently than other PD's because of their clinical significance and empirical support. Specifically, these "major" PD's should remain on Axis I, while other PD's are secondary disorders that are more comfortably dimensionalized and belong on Axis II.
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http://dx.doi.org/10.1037/per0000026DOI Listing
October 2013

Seeking clarity for future revisions of the personality disorders in DSM-5.

Authors:
John G Gunderson

Personal Disord 2013 Oct;4(4):368-76

McLean Hospital.

This article reviews the process by which the DSM-5 Personality Disorder (PD) proposal for change was developed, challenged, and then ultimately rejected. The DSM-5 workgroup's mandate to introduce radical changes were inherently fraught by the limited time allowed, but their efforts were undermined by dissension within the committee, the lack of a clearly identified scientific rationale, and by the inconsistent dialogue with the existing community of PD experts. Nonetheless, valuable steps were taken to establish a better definition for PD's, introduce dimensions, and identify the steps needed for future revisions. The author only in retrospect has concluded that borderline personality disorder and antisocial personality disorder be treated differently than other PD's because of their clinical significance and empirical support. Specifically, these "major" PD's should remain on Axis I, while other PD's are secondary disorders that are more comfortably dimensionalized and belong on Axis II.
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http://dx.doi.org/10.1037/per0000026DOI Listing
October 2013

Socioeconomic-status and mental health in a personality disorder sample: the importance of neighborhood factors.

J Pers Disord 2013 Dec 17;27(6):820-31. Epub 2012 Sep 17.

This cross-sectional study examined the associations between neighborhood-level socioeconomic-status (NSES), and psychosocial functioning and personality pathology among 335 adults drawn from the Collaborative Longitudinal Personality Disorders Study. Participants belonged to four personality disorder (PD) diagnostic groups: Avoidant, Borderline, Schizotypal, and Obsessive Compulsive. Global functioning, social adjustment, and PD symptoms were assessed following a minimum two-year period of residential stability. Residence in higherrisk neighborhoods was associated with more PD symptoms and lower levels of functioning and social adjustment. These relationships were consistent after controlling for individual-level socioeconomic-status and ethnicity; however, the positive association between neighborhood-level socio-economic risk and PD symptoms was evident only at higher levels of individual-level socio-economic risk. Our findings identify NSES as a candidate for explaining some of the variability in symptoms and functioning among PD individuals.
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http://dx.doi.org/10.1521/pedi_2012_26_061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4628287PMC
December 2013

Ten-year rank-order stability of personality traits and disorders in a clinical sample.

J Pers 2013 Jun 5;81(3):335-44. Epub 2013 Feb 5.

Psychology Department, Michigan State University Psychological Clinic, Psychology Building, 316 Physics-Room 107A, East Lansing, MI 48824, USA.

Objective: This study compares the 10-year retest stability of normal traits, pathological traits, and personality disorder dimensions in a clinical sample.

Method: Ten-year rank-order stability estimates for the Revised NEO Personality Inventory, Schedule for Nonadaptive and Adaptive Personality, and Diagnostic Interview for DSM-IV Personality Disorders were evaluated before and after correcting for test-retest dependability and internal consistency in a clinical sample (N = 266).

Results: Dependability-corrected stability estimates were generally in the range of.60-.90 for traits and.25-.65 for personality disorders.

Conclusions: The relatively lower stability of personality disorder symptoms may indicate important differences between pathological behaviors and relatively more stable self-attributed traits and imply that a full understanding of personality and personality pathology needs to take both traits and symptoms into account. The five-factor theory distinction between basic tendencies and characteristic adaptations provides a theoretical framework for the separation of traits and disorders in terms of stability in which traits reflect basic tendencies that are stable and pervasive across situations, whereas personality disorder symptoms reflect characteristic maladaptations that are a function of both basic tendencies and environmental dynamics.
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http://dx.doi.org/10.1111/j.1467-6494.2012.00801.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3593979PMC
June 2013

Pathological personality traits among patients with absent, current, and remitted substance use disorders.

Addict Behav 2011 Nov 5;36(11):1087-90. Epub 2011 Jul 5.

Michigan State University, United States.

Personality traits may provide underlying risk factors for and/or sequelae to substance use disorders (SUDs). In this study Schedule for Nonadaptive and Adaptive Personality (SNAP) traits were compared in a clinical sample (N=704, age 18-45) with current, past, or no historical alcohol or non-alcohol substance use disorders (AUD and NASUD) as assessed by DSM-IV semi-structured interview. Results corroborated previous research in showing associations of negative temperament and disinhibition to SUD, highlighting the importance of these traits for indicating substance use proclivity or the chronic effects of substance use. Certain traits (manipulativeness, self-harm, disinhibition, and impulsivity for AUD, and disinhibition and exhibitionism for NASUD) were higher among individuals with current relative to past diagnoses, perhaps indicating concurrent effects of substance abuse on personality. The positive temperament characteristics detachment and entitlement distinguished AUDs and NASUDs, respectively, perhaps clarifying why this higher order trait tends to show limited relations to SUD generally. These findings suggest the importance of systematically integrating pathological and normative traits in reference to substance-related diagnosis.
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http://dx.doi.org/10.1016/j.addbeh.2011.06.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3412532PMC
November 2011

Family study of borderline personality disorder and its sectors of psychopathology.

Arch Gen Psychiatry 2011 Jul;68(7):753-62

The Borderline Center, McLean Hospital, Belmont, MA 02478.

Context: The familiality of borderline personality disorder (BPD) and its sectors of psychopathology are incompletely understood.

Objectives: To assess the familial aggregation of BPD and its 4 major sectors (affective, interpersonal, behavioral, and cognitive) and test whether the relationship of the familial and nonfamilial associations among these sectors can be accounted for by a latent BPD construct.

Design: Family study, with direct interviews of probands and relatives.

Setting: A psychiatric hospital (McLean Hospital) and the Boston-area community.

Participants: A total of 368 probands (132 with BPD, 134 without BPD, and 102 with major depressive disorder) and 885 siblings and parents of probands. MAIN ASSESSMENTS: The Diagnostic Interview for DSM-IV Personality Disorders and the Revised Diagnostic Interview for Borderlines (DIB-R) were used to assess borderline psychopathology, and the Structured Clinical Interview for DSM-IV was used to assess major depressive disorder.

Results: Borderline personality disorder meeting both DSM-IV and DIB-R criteria showed substantial familial aggregation for BPD in individuals with a family member with BPD vs those without a family member with BPD, using proband-relative pairs (risk ratio, 2.9; 95% confidence interval, 1.5-5.5) as well as using all pairs of family members (3.9; 1.7-9.0). All 4 sectors of BPD psychopathology aggregated significantly in families, using both DSM-IV and DIB-R definitions (correlation of traits among all pairs of family members ranged from 0.07 to 0.27), with the affective and interpersonal sectors showing the highest levels; however, the level of familial aggregation of BPD was higher than that of the individual sectors. The relationship among the sectors was best explained by a common pathway model in which the sectors represent manifestations of a latent BPD construct.

Conclusions: Familial factors contribute to BPD and its sectors of psychopathology. Borderline personality disorder may arise from a unitary liability that finds expression in its sectors of psychopathology.
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http://dx.doi.org/10.1001/archgenpsychiatry.2011.65DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3150490PMC
July 2011

Personality assessment in DSM-5: empirical support for rating severity, style, and traits.

J Pers Disord 2011 Jun;25(3):305-20

Michigan State University, USA.

Despite a general consensus that dimensional models are superior to the categorical representations of personality disorders in DSM-IV, proposals for how to depict personality pathology dimensions vary substantially. One important question involves how to separate clinical severity from the style of expression through which personality pathology manifests. This study empirically distinguished stylistic elements of personality pathology symptoms from the overall severity of personality disorder in a large, longitudinally assessed clinical sample (N = 605). Data suggest that generalized severity is the most important single predictor of current and prospective dysfunction, but that stylistic elements also indicate specific areas of difficulty. Normative personality traits tend to relate to the general propensity for personality pathology, but not stylistic elements of personality disorders. Overall, findings support a three-stage diagnostic strategy involving a global rating of personality disorder severity, ratings of parsimonious and discriminant valid stylistic elements of personality disorder, and ratings of normative personality traits.
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http://dx.doi.org/10.1521/pedi.2011.25.3.305DOI Listing
June 2011

Clinical practice. Borderline personality disorder.

Authors:
John G Gunderson

N Engl J Med 2011 May;364(21):2037-42

Psychosocial and Personality Research Program, McLean Hospital, Belmont, MA 02478, USA.

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http://dx.doi.org/10.1056/NEJMcp1007358DOI Listing
May 2011

Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorders study.

Arch Gen Psychiatry 2011 Aug 4;68(8):827-37. Epub 2011 Apr 4.

McLean Hospital, 115 Mill St, Belmont, MA 02478, USA.

Context: Borderline personality disorder (BPD) is traditionally considered chronic and intractable.

Objective: To compare the course of BPD's psychopathology and social function with that of other personality disorders and with major depressive disorder (MDD) over 10 years.

Design: A collaborative study of treatment-seeking, 18- to 45-year-old patients followed up with standardized, reliable, and repeated measures of diagnostic remission and relapse and of both global social functioning and subtypes of social functioning.

Setting: Nineteen clinical settings (hospital and outpatient) in 4 northeastern US cities.

Participants: Three study groups, including 175 patients with BPD, 312 with cluster C personality disorders, and 95 with MDD but no personality disorder.

Main Outcome Measures: The Diagnostic Interview for DSM-IV Personality Disorders and its follow-along version (the Diagnostic Interview for DSM-IV Personality Disorders-Follow-Along Version) were used to diagnose personality disorders and assess changes in them. The Structured Clinical Interview for DSM-IV Axis I Disorders and the Longitudinal Interval Follow-up Evaluation were used to diagnose MDD and assess changes in MDD and in social function.

Results: Eighty-five percent of patients with BPD remitted. Remission of BPD was slower than for MDD (P < .001) and minimally slower than for other personality disorders (P < .03). Twelve percent of patients with BPD relapsed, a rate less frequent and slower than for patients with MDD (P < .001) and other personality disorders (P = .008). All BPD criteria declined at similar rates. Social function scores showed severe impairment with only modest albeit statistically significant improvement; patients with BPD remained persistently more dysfunctional than the other 2 groups (P < .001). Reductions in criteria predicted subsequent improvements in DSM-IV Axis V Global Assessment of Functioning scores (P < .001).

Conclusions: The 10-year course of BPD is characterized by high rates of remission, low rates of relapse, and severe and persistent impairment in social functioning. These results inform expectations of patients, families, and clinicians and document the severe public health burden of this disorder.
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http://dx.doi.org/10.1001/archgenpsychiatry.2011.37DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3158489PMC
August 2011
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