Anxiety Disorders: Gunderson JG

Gunderson JG. · McLean Hospital, Harvard Medical School, Belmont, MA 02478, USA. · Am J Psychiatry. · Pubmed #19411380 No free full text.

Abstract: OBJECTIVE: The purpose of this article is to describe the development of the borderline personality disorder diagnosis, highlighting both the obstacles encountered and the associated achievements. METHOD: On the basis of a review of the literature, the author provides a chronological account of the borderline construct in psychiatry, summarizing progress in decade-long intervals. RESULTS: Borderline personality disorder has moved from being a psychoanalytic colloquialism for untreatable neurotics to becoming a valid diagnosis with significant heritability and with specific and effective psychotherapeutic treatments. Nonetheless, patients with this disorder pose a major public health problem while they themselves remain highly stigmatized and largely neglected. CONCLUSIONS: Despite remarkable changes in our knowledge about borderline personality disorder, increased awareness involving much more education and research is still needed. Psychiatric institutions, professional organizations, public policies, and reimbursement agencies need to prioritize this need.

Skodol AE, Gunderson JG, Shea MT, McGlashan TH, Morey LC, Sanislow CA, Bender DS, Grilo CM, Zanarini MC, Yen S, Pagano ME, Stout RL. · New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons, NY 10032, USA. · J Pers Disord. · Pubmed #16274278 No free full text.

Abstract: The Collaborative Longitudinal Personality Disorders Study (CLPS; Gunderson et al., 2000) was developed to fill gaps in our understanding of the nature, course, and impact of personality disorders (PDs). Here, we review published findings to date, discuss their implications for current conceptualizations of PDs, and raise questions that warrant future consideration. We have found that PDs are more stable than major depressive disorder, but that meaningful improvements are possible and not uncommon. We have confirmed also that PDs constitute a significant public health problem, with respect to associated functional impairment, extensive treatment utilization, negative prognostic impact on major depressive disorder, and suicide risk. At the same time, we have demonstrated that dimensional models of PDs have clinical validity that categories do not, especially greater temporal stability. Furthermore, dimensional personality traits appear to be the foundation of behaviors described by many PD criteria. Taken together, our results lead us to hypothesize that PDs may be reconceptualized as hybrids of stable personality traits and intermittently expressed symptomatic behaviors.

Skodol AE, Siever LJ, Livesley WJ, Gunderson JG, Pfohl B, Widiger TA. · Department of Psychiatry, Columbia University College of Physicians and Surgeons, and the New York State Psychiatric Institute, New York, New York, USA. · Biol Psychiatry. · Pubmed #12062878 No free full text.

Abstract: In Part I of this three-part article, consideration of the core features of BPD psychopathology, of comorbidity with Axis I disorders, and of underlying personality trait structure suggested that the borderline diagnosis might be productively studied from the perspective of dimensions of trait expression, in addition to that of the category itself. In Part II, we review the biology, genetics, and clinical course of borderline personality disorder (BPD), continuing to attend to the utility of a focus on fundamental dimensions of psychopathology. Biological approaches to the study of personality can identify individual differences with both genetic and environmental influences. The aspects of personality disorder that are likely to have biologic correlates are those involving regulation of affects, impulse/action patterns, cognitive organization and anxiety/inhibition. For BPD, key psychobiological domains include impulsive aggression, associated with reduced serotonergic activity in the brain, and affective instability, associated with increased responsivity of cholinergic systems. There may be a strong genetic component for the development of BPD, but it seems clear, at least, that there are strong genetic influences on traits that underlie it, such as neuroticism, impulsivity, anxiousness, affective lability, and insecure attachment. The course of BPD suggests a heterogeneous disorder. Predictors of poor prognosis include history of childhood sexual abuse, early age at first psychiatric contact, chronicity of symptoms, affective instability, aggression, substance abuse, and increased comorbidity. For research purposes, at least, biological, genetic, and prognostic studies all continue to suggest the need to supplement categorical diagnoses of BPD with assessments of key underlying personality trait dimensions and with historical and clinical observations apart from those needed to make the borderline diagnosis itself.

Gratz KL, Tull MT, Gunderson JG. · Center for Addictions, Personality, and Emotion Research and the Department of Psychology, University of Maryland, College Park, MD 20742, USA. · J Psychiatr Res. · Pubmed #17637464 No free full text.

Abstract: Although research on the temperamental vulnerabilities associated with borderline personality disorder (BPD) has focused primarily on the role of impulsive-aggression, affective instability, and emotional vulnerability, growing evidence suggests that anxiety sensitivity (AS) also may increase vulnerability for BPD. This study provides preliminary data on the relationship between AS and BPD, examining whether AS distinguishes outpatients with BPD from outpatients without a personality disorder (non-PD), and whether the relationship between AS and BPD is mediated by experiential avoidance (i.e., attempts to avoid unwanted internal experiences, such as anxiety). Findings indicate that BPD outpatients reported higher levels of AS than non-PD outpatients and AS reliably distinguished between these two groups. Furthermore, the relationship between AS and BPD was mediated by experiential avoidance. Finally, results indicate that AS (and experiential avoidance as a mediator) accounted for a significant amount of additional variance in BPD status above and beyond both negative affect and two well-established temperamental vulnerabilities for BPD (affect intensity/reactivity and impulsivity). Findings suggest the need to further explore the role of AS in the pathogenesis of BPD.

Gunderson JG, Daversa MT, Grilo CM, McGlashan TH, Zanarini MC, Shea MT, Skodol AE, Yen S, Sanislow CA, Bender DS, Dyck IR, Morey LC, Stout RL. · McLean Hospital, 155 Mill St., Belmont, MA 02478, USA. · Am J Psychiatry. · Pubmed #16648322 links to  free full text

Abstract: OBJECTIVE: The primary purpose of this report was to investigate whether characteristics of subjects with borderline personality disorder observed at baseline can predict variations in outcome at the 2-year follow-up. METHOD: Hypothesized predictor variables were selected from prior studies. The patients (N=160) were recruited from the four clinical sites of the Collaborative Longitudinal Personality Disorders Study. Patients were assessed at baseline and at 6, 12, and 24 months with the Structured Clinical Interview for DSM-IV Axis I Disorders; the Diagnostic Interview for DSM-IV Personality Disorders, a modified version of that instrument; the Longitudinal Interval Follow-Up Evaluation; and the Childhood Experiences Questionnaire-Revised. Univariate Pearson's correlation coefficients were calculated on the primary predictor variables, and with two forward stepwise regression models, outcome was assessed with global functioning and number of borderline personality disorder criteria. RESULTS: The authors' most significant results confirm prior findings that more severe baseline psychopathology (i.e., higher levels of borderline personality disorder criteria and functional disability) and a history of childhood trauma predict a poor outcome. A new finding suggests that the quality of current relationships of patients with borderline personality disorder have prognostic significance. CONCLUSIONS: Clinicians can estimate 2-year prognosis for patients with borderline personality disorder by evaluating level of severity of psychopathology, childhood trauma, and current relationships.

Skodol AE, Grilo CM, Pagano ME, Bender DS, Gunderson JG, Shea MT, Yen S, Zanarini MC, McGlashan TH. · Columbia University College of Physicians and Surgeons, New York, NY 10032, USA. · J Psychiatr Pract. · Pubmed #16304504 links to  free full text

Abstract: BACKGROUND: Patients with depressive disorders have limitations in physical and emotional functioning comparable to patients with chronic medical conditions. Personality disorders (PDs) are also known to be associated with functional impairment. AIMS: To determine the effects of PDs on the functioning and well-being of patients with major depressive disorder (MDD). METHOD: In the Collaborative Longitudinal Personality Disorders Study, 668 patients who met criteria for schizotypal, borderline, avoidant, or obsessive-compulsive PDs or for MDD and no PD were assessed with semi-structured interviews at baseline, 6, 12, 24, and 36 months. In this study, 151 patients who met criteria for current MDD at the 36-month follow-up were compared on the basis of the presence (n = 118) or absence (n = 33) of persistent PD. Physical and social/emotional functioning and well-being were assessed using the Medical Outcomes Study (MOS) Short-Form Health Survey (SF-36). These results were compared with those of a sample of patients with MDD seen in the mental health specialty sector who were followed in the Medical Outcomes Study. RESULTS: Patients with MDD and co-occurring PD had significantly more impairment on scales measuring role limitations due to emotional problems, social functioning, and general health perceptions than patients with MDD and no PD. Although patients with MDD and no PD were found to have levels of functioning and well-being that were lower in several domains than those previously reported in depressed patients recruited from mental health settings, patients with MDD and co-occurring PD were found to have much lower levels of functioning in all areas than reported samples. CONCLUSIONS: Co-occurring PDs contribute significantly to impairment in social and emotional functioning and reduced well-being in patients with MDD.

Markowitz JC, Skodol AE, Petkova E, Xie H, Cheng J, Hellerstein DJ, Gunderson JG, Sanislow CA, Grilo CM, McGlashan TH. · New York State Psychiatric Institute and Columbia University, New York, NY 10032, USA. · Compr Psychiatry. · Pubmed #16175753 No free full text.

Abstract: BACKGROUND: Few studies have compared the related diagnostic constructs of depressive personality disorder (DPD) and dysthymic disorder (DD). The authors attempted to replicate findings of Klein and Shih in longitudinally followed patients with personality disorder or major depressive disorder (MDD) in the Collaborative Longitudinal Personality Disorders Study. METHODS: Subjects (N = 665) were evaluated at baseline and over 2 years (n = 546) by reliably trained clinical interviewers using semistructured interviews and self-report personality questionnaires. RESULTS: Only 44 subjects (24.6% of 179 DPD and 49.4% of 89 early-onset dysthymic subjects) met criteria for both disorders at baseline. Depressive personality disorder was associated with increased comorbidity of some axis I anxiety disorders and other axis II diagnoses, particularly avoidant (71.5%) and borderline (55.9%) personality disorders. Depressive personality disorder was associated with low positive and high negative affectivity on dimensional measures of temperament. Depressive personality disorder subjects had lower likelihood of remission of baseline MDD at 2-year follow-up, whereas DD subjects did not. The DPD diagnosis appeared unstable over 2 years of follow-up, as only 31% (n = 47) of 154 subjects who had DPD at baseline and also had follow-up assessment met criteria on blind retesting. LIMITATIONS: Results from this sample may not generalize to other populations. CONCLUSIONS: Depressive personality disorder and dysthymic disorder appear to be related but differ in diagnostic constructs. Its moderating effect on MDD and predicted relationship to measures of temperament support the validity of DPD, but its diagnostic instability raises questions about its course, utility, and measurement.

Ralevski E, Sanislow CA, Grilo CM, Skodol AE, Gunderson JG, Tracie Shea M, Yen S, Bender DS, Zanarini MC, McGlashan TH. · Yale University School of Medicine, New Haven, CT 06519, USA. · Acta Psychiatr Scand. · Pubmed #16095476 No free full text.

Abstract: OBJECTIVE: Existing evidence from anxiety disorder research indicates that social phobics (SP) with avoidant personality disorder (AVPD) experience more anxiety and show more impairment than patients with SP alone. The purpose of this study was to examine whether in patients diagnosed with AVPD, the co-occurrence of SP adds to its severity. We hypothesized that the addition of SP will not add to the severity of AVPD alone. METHOD: Two groups of patients (AVPD=224; AVPD/SP=101) were compared at baseline and 2 years later on multiple demographic and clinical variables. RESULTS: Patients with AVPD and an additional diagnosis of SP differed little from patients with AVPD alone. CONCLUSION: These findings suggest that AVPD and SP may be alternative conceptualizations of the same disorder.

Shea MT, Stout RL, Yen S, Pagano ME, Skodol AE, Morey LC, Gunderson JG, McGlashan TH, Grilo CM, Sanislow CA, Bender DS, Zanarini MC. · Department of Psychiatry and Human Behavior, Brown University Medical School, Duncan Building, 700 Butler Drive, Providence, RI 20906, USA. · J Abnorm Psychol. · Pubmed #15535783 No free full text.

Abstract: In this study, the authors examined time-varying associations between schizotypal (STPD), borderline (BPD), avoidant (AVPD), or obsessive-compulsive (OCPD) personality disorders and co-occurring Axis I disorders in 544 adult participants from the Collaborative Longitudinal Personality Disorders Study. The authors tested predictions of specific longitudinal associations derived from a model of crosscutting psychobiological dimensions (L. J. Siever & K. L. Davis, 1991) with participants with the relevant Axis I disorders. The authors assessed participants at baseline and at 6-, 12-, and 24-month follow-up evaluations. BPD showed significant longitudinal associations with major depressive disorder and posttraumatic stress disorder. AVPD was significantly associated with anxiety disorders (specifically social phobia and obsessive-compulsive disorder). Two of the four personality disorders under examination (STPD and OCPD) showed little or no association with Axis I disorders.

Grilo CM, Sanislow CA, Gunderson JG, Pagano ME, Yen S, Zanarini MC, Shea MT, Skodol AE, Stout RL, Morey LC, McGlashan TH. · Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06519, USA. · J Consult Clin Psychol. · Pubmed #15482035 No free full text.

Abstract: The authors examined the stability of schizotypal (STPD), borderline (BPD), avoidant (AVPD) and obsessive-compulsive (OCPD) personality disorders (PDs) over 2 years of prospective multiwave follow-up. Six hundred thirty-three participants recruited at 4 collaborating sites who met criteria for 1 or more of the 4 PDs or for major depressive disorder (MOD) without PD were assessed with semistructured interviews at baseline, 6, 12, and 24 months. Lifetable survival analyses revealed that the PD groups had slower time to remission than the MDD group. Categorically, PD remission rates range from 50% (AVPD) to 61% (STPD) for dropping below diagnostic threshold on a blind 24-month reassessment but range from 23% (STPD) to 38% (OCPD) for a more stringent definition of improvement. Dimensionally, these findings suggest that PDs may be characterized by maladaptive trait constellations that are stable in their structure (individual differences) but can change in severity or expression over time.

Morey LC, Skodol AE, Grilo CM, Sanislow CA, Zanarini MC, Shea MT, Gunderson JG, McGlashan TH. · Department of Psychology, Texas A&M University, College Station, TX 77843-4235, USA. · J Pers Disord. · Pubmed #15342325 No free full text.

Abstract: This study sought to investigate the coherence of changes observed in diagnostic criteria for borderline, schizotypal, obsessive-compulsive, and avoidant personality disorders. Five hundred, forty-nine patients were independently evaluated 2 years apart, and correlations of observed changes in each diagnostic criterion with changes in other criteria were examined to determine if there was within-syndrome consistency in these changes. The observed changes in criteria were consistent within syndrome (median alpha = 0.72 across 4 disorders), and reasonably specific to that syndrome relative to the other disorders. The results support the validity of these criterion sets as representing coherent syndromes.

Gunderson JG, Morey LC, Stout RL, Skodol AE, Shea MT, McGlashan TH, Zanarini MC, Grilo CM, Sanislow CA, Yen S, Daversa MT, Bender DS. · Harvard Medical School and McLean Hospital, Boston, Mass 02478, USA. · J Clin Psychiatry. · Pubmed #15323588 No free full text.

Abstract: BACKGROUND: This report investigates the longitudinal association of changes in major depressive disorder (MDD) and borderline personality disorder. METHOD: A DSM-IV-diagnosed sample of 161 patients with borderline personality disorder who have been followed with repeated measures at 6, 12, 24, and 36 months are investigated to see whether those with co-occurring MDD differ at baseline and in their course. Proportional hazard regression and cross-lagged panel analyses are used to demonstrate whether changes in the course of either disorder have predictable effects on the course of the other. RESULTS: The rate of remissions of borderline personality disorder was not affected by whether patients had co-occurring MDD. The rate of MDD remissions was significantly reduced by co-occurring borderline personality disorder. Both regression analyses and panel analyses indicated that improvements in borderline personality disorder were often followed by improvements in MDD but that improvements in MDD were not followed by improvements in borderline personality disorder. Five of the 9 borderline criteria, including those that most relate to affects, were particularly apt to remit prior to MDD remissions. CONCLUSIONS: When borderline personality disorder and MDD co-occur, they can sometimes have independent courses, but more often improvements in MDD are predicted by prior improvements in borderline personality disorder. Clinicians should not ignore borderline personality disorder in hopes that treatment of MDD will be followed by improvement of borderline personality disorder.

Grilo CM, Skodol AE, Gunderson JG, Sanislow CA, Stout RL, Shea MT, Morey LC, Zanarini MC, Bender DS, Yen S, McGlashan TH. · Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06520, USA. · Acta Psychiatr Scand. · Pubmed #15180781 No free full text.

Abstract: OBJECTIVE: To examine the longitudinal diagnostic efficiency of the DSM-IV criteria for obsessive-compulsive personality disorder (OCPD). METHOD: At baseline, criteria and diagnoses were determined using diagnostic interviews, and blinded assessments were performed 24 months later with 550 participants. Diagnostic efficiency indices (conditional probabilities, total predictive power, and kappa) were calculated for each criterion determined at baseline, using the independent OCPD diagnosis at follow-up as the standard. RESULTS: Longitudinal diagnostic efficiencies for the OCPD criteria varied; findings suggested the overall predictive utility of 'preoccupied with details', 'rigid and stubborn', and 'reluctant to delegate'. CONCLUSION: These findings suggest the predictive validity of three cognitive-interpersonal OCPD criteria.

Zlotnick C, Johnson DM, Yen S, Battle CL, Sanislow CA, Skodol AE, Grilo CM, McGlashan TH, Gunderson JG, Bender DS, Zanarini MC, Shea MT. · Brown University School of Medicine, Department of Psychiatry and Human Behavior, Butler Hospital, Providence, RI 02906, USA. · J Nerv Ment Dis. · Pubmed #14614337 No free full text.

Abstract: The aims of this study were to examine differences in clinical features, impairment, and types of childhood traumas among women with borderline personality disorder (BPD), women with BPD and posttraumatic stress disorder (PTSD), and those with other personality disorders and PTSD. Using baseline data from the Collaborative Longitudinal Study of Personality Disorders, 186 women were divided into 3 groups (BPD+PTSD, BPD, PTSD), based on structured diagnostic interviews for Axis I and Axis II disorders and compared on selected clinical variables. The additional diagnosis of PTSD in borderline women did not significantly increase the degree of borderline pathology and psychiatric morbidity but did significantly increase general dysfunction and the occurrence of hospitalization. The additional diagnosis of BPD in women with PTSD significantly increased the features of suicide proneness and impulsiveness. Both groups of women with PTSD reported significantly more types of childhood traumas relative to borderline women without PTSD. Consistent with other research, the findings suggest that PTSD does not appear to alter the central features of BPD. The clinical implications of our findings are considered.

Rettew DC, Zanarini MC, Yen S, Grilo CM, Skodol AE, Shea MT, McGlashan TH, Morey LC, Culhane MA, Gunderson JG. · Harvard Medical School and McLean Hospital, USA. · J Am Acad Child Adolesc Psychiatry. · Pubmed #12960713 No free full text.

Abstract: OBJECTIVE: To explore potential risk factors and early manifestations of avoidant personality disorder (AVPD) by examining retrospective reports of social functioning and adverse childhood experiences. METHOD: Early social functioning and pathological childhood experiences were assessed using the Childhood Experiences Questionnaire-Revised. The responses of 146 adults diagnosed with primary AVPD were compared with a group of 371 patients with other personality disorders as a primary diagnosis and a group of 83 patients with current major depression disorder and no personality disorders, using chi2 analyses. Diagnoses were based on semistructured interviews by trained reliable clinicians. RESULTS: Adults with AVPD reported poorer child and adolescent athletic performance, less involvement in hobbies during adolescence, and less adolescent popularity than the depressed comparison group and the other personality disorder group. Reported rates of physical and emotional abuse were higher than the depressed group, but this result was influenced by comorbid diagnoses. CONCLUSIONS: These results suggest that early manifestations of AVPD are present in childhood but that various forms of abuse are not specific to the disorder.

Yen S, Shea MT, Battle CL, Johnson DM, Zlotnick C, Dolan-Sewell R, Skodol AE, Grilo CM, Gunderson JG, Sanislow CA, Zanarini MC, Bender DS, Rettew JB, McGlashan TH. · Department of Psychiatry, Brown University Medical School, 700 Butler Drive, Providence, RI 02906, USA. · J Nerv Ment Dis. · Pubmed #12193835 No free full text.

Abstract: The association between trauma and personality disorders (PDs), while receiving much attention and debate, has not been comprehensively examined for multiple types of trauma and PDs. The authors examined data from a multisite study of four PD groups: schizotypal, borderline (BPD), avoidant, and obsessive-compulsive, and a major depression comparison group. Rates of traumatic exposure to specific types of trauma, age of first trauma onset, and rates of posttraumatic stress disorder are compared. Results indicate that BPD participants reported the highest rate of traumatic exposure (particularly to sexual traumas, including childhood sexual abuse), the highest rate of posttraumatic stress disorder, and youngest age of first traumatic event. Those with the more severe PDs (schizotypal, BPD) reported more types of traumatic exposure and higher rates of being physically attacked (childhood and adult) when compared to other groups. These results suggest a specific relationship between BPD and sexual trauma (childhood and adult) that does not exist among other PDs. In addition, they support an association between severity of PD and severity of traumatic exposure, as indicated by earlier trauma onset, trauma of an assaultive and personal nature, and more types of traumatic events.

Sanislow CA, Morey LC, Grilo CM, Gunderson JG, Shea MT, Skodol AE, Stout RL, Zanarini MC, McGlashan TH. · Yale University School of Medicine, New Haven, CT 06520-8098, USA. · Acta Psychiatr Scand. · Pubmed #12086222 No free full text.

Abstract: OBJECTIVE: To test the diagnostic constructs implied by DSM-IV Axis-II personality disorders by examining relationships between different combinations of DSM-IV criteria. METHOD: Confirmatory factor analysis was used to test the borderline, schizotypal, avoidant and obsessive-compulsive personality disorder constructs in a large treatment-seeking sample (N= 668) from a multisite study. A model based on the three DSM-IV Axis II clusters was also tested. Both models were tested against a unitary 'generic' model constructed from four criteria sets combined. RESULTS: Goodness-of-fit for both the three-cluster and four disorder models was significantly better than the unidimensional model, and the four-disorder model was significantly better than the three-cluster model. Results were replicated using data from 2-year follow-up obtained by interviewers blind to original Axis II diagnoses at baseline. CONCLUSION: Support is provided for the DSM-IV disorder-level classification for schizotypal, borderline, avoidant and obsessive-compulsive personality disorders in a treatment-seeking sample.