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PERSPECTIVES

Understanding Self-mutilation in Borderline Personality Disorder

Joel Paris, MD

Self-mutilation is common in borderline personality disorder, but this pattern of behavior does not usually carry suicidal intent. Instead, it serves other functions, including regulation of dysphoric affect, communication of distress, expression of emotions, and coping with dissociative states. Mul- tiple causal factors, including biological, psychological, and social risks, influence thresholds for self-mutilation. Management of this behavior can be informed by understanding its psychological functions. (HARV REV PSYCHIATRY 2005;13:179–185.)

Keywords: self-mutilation, borderline personality disorder

To examine the empirical and clinical literature on the origins of self-mutilation in borderline personality dis- order (BPD), this review made use of both MEDLINE and PsycINFO databases, identifying all English articles between 1980 and 2004 containing one or more of the fol- lowing keywords: self-mutilation, self-cutting, self-injury, or deliberate self-harm. Since the focus of the review was on pa- tients with personality disorders, the search was limited to combinations of these keywords with either “personality dis- order” or “borderline personality disorder.” This procedure identified 113 publications, from which the review selected all empirical studies and systematic reviews (eliminating most case reports). These articles were then supplemented by relevant publications prior to 1980.

From the Department of Psychiatry, McGill University; Institute of Community and Family Psychiatry, and Sir Mortimer B. Davis– Jewish General Hospital, Montreal.

Original manuscript submitted 9 August 2004; revised manuscript received 1 March 2005, accepted for publication 31 March 2005.

Correspondence: Joel Paris, MD, Sir Mortimer B. Davis–Jewish Memorial Hospital, 4333 Chemin de la Cote Ste. Catherine, Mon- treal, Québec, H3T1E4, Canada. Email: [email protected]

©c 2005 President and Fellows of Harvard College

DOI: 10.1080/10673220591003614

DEFINING THE CLINICAL PROBLEM

There are many difficult aspects of managing BPD, but self- mutilation is one of the most challenging. These patients can be a source of worry when they cut, burn, or hurt themselves. This review will focus on the pattern seen in BPD: repetitive, nonlethal self-injury without intent to die.1

The literature has used multiple and somewhat confusing descriptive terms to describe this pattern. “Self-mutilation” has been defined by Favazza2 as “the deliberate nonsui- cidal destruction of one’s body tissue.” Two other terms— “self-injury”3 and “self-injurious behavior”4—have similar meanings. “Deliberate self-harm,” defined as “the inten- tional injuring of one’s own body without apparent suici- dal intent,”5 while seemingly similar, has been used in re- search to describe both self-poisoning and self-injury, while excluding repetitive self-cutting.6 The term “parasuicide,” defined as “any nonfatal, self-injurious behavior with a clear intent to cause bodily harm or death,”7 has also been used in a broader way. To maximize clarity, this review will confine itself to the terms “self-mutilation” and “self- injury.”

Self-mutilation began to be discussed in the psychi- atric literature only several decades ago, in a series of clinical reports and reviews8–13 that described patients who repeatedly, but superficially, cut their wrists. Re- peated self-mutilation has been found to be associated with serious psychopathology, most particularly mental retarda- tion, schizophrenia, and personality disorders,14–16 and it is especially common in BPD.1

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Self-mutilation associated with major mental disorders needs to be distinguished from similar behaviors occurring in more normative or situational settings. Thus, self- mutilation has been documented in historical data, par- ticularly in relation to religious practices.17 It has also been described in community populations,6,18,19 although such reports do not distinguish between occasional self- mutilation and repetitive behavior. Finally, self-injury has been described as being common among prison inmates with personality disorders;20 it is not known whether this behav- ior continues after release from confinement.

FUNCTIONS OF SELF-MUTILATION IN BPD

Why do patients with BPD injure themselves? The crucial point is that the intent of self-mutilation is not necessar- ily “suicidal.” In a study comparing 30 suicide attempters with cluster B personality disorders and a history of self- mutilation to a matched group of 23 suicide attempters with cluster B personality disorders and no history of self-mutilation, Stanley and colleagues21 found that while self-mutilators were more chronically suicidal and more impulsive, most were aware that wrist cutting is not life threatening. Similarly, in a study of 75 BPD patients, Brown and colleagues22 found that self-cutting was described as a means to relieve dysphoria, while overdosing was described as motivated by a need to escape difficult life situations. The independence of self-mutilation and suicidal intent in BPD patients is further supported by a five-year prospec- tive follow-up of 37 borderline patients,23 which found that changes in self-harm and suicide attempts over time were not correlated. Although about 10% of patients with BPD eventually end their lives by suicide, most completions occur late in the course of the illness.24 Moreover, while “deliber- ate self-harm” (in general) is associated with higher rates of completion,25 suicide is not predicted by self-mutilating behavior.24 Thus, the term “suicidal” is not appropriate as a descriptor for self-mutilation.26

Although self-injury often lacks suicidal intent, it can per- form other psychological functions, several of which have been suggested in the BPD literature. The first (and most often discussed) is that self-injury can provide relief from negative mood states.27,28 Since self-mutilation tends to re- duce dysphoria resulting from stressful life events, it can become a habitual method of dealing with psychological dis- tress. In such cases the behavior comes to function like an addiction; Linehan28 has suggested that this effect derives from its very success in reducing dysphoria. These mech- anisms are not necessarily unique to patients with BPD and may not even be unique to humans; self-injury has been observed in other species as a response to stressful circumstances.29

Second, distraction is another mechanism by which self- mutilation can reduce distress in BPD. As described by Linehan,28 physical injury tends to refocus the patient’s attention away from mental pain to physical pain.

A third function of self-mutilation in BPD is that it can be used to communicate distress and obtain care from other people—significant others as well as therapists.30,31 While many patients are initially secretive about self-injury,32 the presence of visible scars or burn marks (particularly in the summer months) eventually tends to bring the behavior to the attention of other people.

A fourth potential function is that self-mutilation can be used to express emotions in a symbolic fashion.26,27 Some pa- tients describe cutting as a self-punishment related to guilty feelings or as a way of expressing anger that cannot be com- municated in another way.33

A fifth function of self-mutilation derives from its connec- tion with dissociative phenomena.34–37 BPD patients may experience dissociation as dysphoric or may be in a disso- ciated state when they cut.35 In this context, the sight of blood can remind patients that they are really alive. Scores on scales measuring dissociation are consistently higher in BPD patients who self-mutilate.36,37 In these states of mind, cutting may not even be painful. Several studies have found that self-mutilators are relatively insensitive to pain,38–42 a phenomenon that has been hypothesized to be related to the production of endogenous opioids.1,43

BPD PATIENTS WHO DO, AND DO NOT, SELF-MUTILATE

Self-mutilation is seen in about half of all patients with BPD.36,43 We need to explain why only some patients with BPD injure themselves. Unfortunately, there have been only a few studies comparing patients with and without this behavior.

A first level of explanation is that patients with lower levels of functioning are more likely to self-mutilate. Self- injury in BPD has been shown to have a strong association with multiple comorbidities and illness severity.44

A second level of explanation derives from the rela- tionship of self-mutilation to impulsive traits.45,46 Affec- tive instability and impulsivity have been seen as the primary traits underlying BPD.47 Affective instability de- scribes rapid shifts of moods in relation to environmental cues.48 Linehan28 applies a similar concept, emotion dysreg- ulation, in which emotions are more intense and take longer to return to baseline. Affective instability is also found, how- ever, in personality disordered patients who do not self- mutilate.49 To understand the role of self-injury in BPD, one has also to consider the influence of impulsive traits. Although self-mutilation can sometimes be planned, the

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tendency to use action to reduce inner distress is a key aspect of impulsivity50—a central characteristic of patients with BPD.51,52

In support of this mechanism, Simeon and colleagues43

reported that self-injury in personality disorders is associated with overall high levels of impulsivity. This trait is one that has been shown to be heritable,52 and impulsive behaviors, including self-mutilation, are associ- ated with variations in neurobiological functioning, most particularly central serotonergic dysfunction.53–55 For ex- ample, in a study comparing personality disordered patients who self-mutilated to those who did not, self-injury was as- sociated with abnormal paroxetine binding.43 Also, in a be- havioral genetics study of personality dimensions in com- munity and clinical populations,56 self-harm emerged from factor analysis as a distinct trait dimension having a heri- table component.

A third factor in self-mutilation derives from its rela- tionship to life experiences, particularly childhood adver- sities. Self-mutilation in BPD is associated with a history of abuse in childhood,57,58 and it has been suggested that self-injury might even be a marker for such abuse.34 These associations can probably best be accounted for, however, by latent variables. Sexual abuse, physical abuse, and neglect are equally common in the childhood of patients with BPD who do not self-mutilate as in those who do.34,57 More- over, meta-analyses indicate that the relationship between childhood trauma and BPD is only of moderate strength.59

While there is some relationship between traumatic histo- ries and impulsivity,60 the other key trait behind BPD, af- fective instability, lacks a strong relationship to trauma.61

Finally, impulsive traits have been shown to be heritable.62

Thus, the real association is most likely between childhood trauma and BPD, rather than with any specific symptom of the disorder.

A fourth possible explanation as to why some patients with BPD self-mutilate and others do not derives from the social environment—in particular, from learning (through imitation) of behaviors observed in other patients or in the media. Thus, patients who have not previously cut them- selves may begin to do so after a hospital admission in which they have had the chance to observe such behavior.14,63

This process, termed “social contagion,”64 has been shown to influence the development of other impulsive disorders.65

CLINICAL IMPLICATIONS FOR MANAGING SELF-MUTILATION IN BPD

Self-mutilation is a troubling symptom, but understanding its functions for patients can help with management. Also, once therapists realize that self-injury does not usually carry

a great risk for completed suicide, they can feel more com- fortable treating patients in an outpatient setting.

This issue has not always been fully understood in the clinical community. Self-mutilation is one of the symptoms that often leads patients with BPD to be hospitalized.66 Yet it makes little sense to hospitalize such patients in order to prevent them from committing suicide, if that is not the real purpose of their actions; although hospitalization can provide short-term relief for distress, doing so has lit- tle to do with safety. There are also problems with admis- sions that become repetitive, since responding consistently to self-injury with hospitalization can be reinforcing for some patients.67 Instead, therapists might think of self-mutilation as an expectable part of the territory one traverses in treat- ing patients with BPD. Finally, there is no evidence that hos- pitalization prevents suicide in this population, even among patients who seriously want to die.67

If one of the primary functions of self-injury is to reduce dysphoria, then therapy needs to identify the causes of that dysphoria and to help patients find better ways of deal- ing with emotions. These goals are the underpinnings of Linehan’s28 dialectical behavior therapy (DBT), which is specifically designed to target parasuicidal behaviors by improving emotion regulation. Controlled trials in several settings68–70 have shown that self-mutilation in BPD can be reduced by DBT within a year of treatment, yielding results significantly better than treatment as usual. While other forms of cognitive-behavioral therapy (CBT) have been proposed for BPD,71,72 they have not yet been subjected to empirical testing. In a randomized controlled trial, Tyrer and colleagues73 found that manualized CBT was equiva- lent to treatment as usual for the treatment of recurrent “deliberate self-harm.”

Other models, such as psychodynamically oriented outpa- tient therapy, might achieve many of the same results, as has been suggested by two meta-analyses.74,75 There have been few empirical tests of psychodynamic therapy for patients with BPD, but findings from a randomized controlled trial of “mentalization-based treatment” (MBT), designed to reduce impulsive behaviors in BPD by increasing self-observation, have been encouraging.76–78 MBT obtained a significant reduction in suicidal and parasuicidal behaviors within 18 months, as compared to treatment as usual. Although the main trial was conducted in the context of day treatment, preliminary evidence suggests that therapy is also effective in outpatient settings.79 Finally, a recent comparative study of DBT versus “treatment by [BPD] experts,” which showed some advantage for DBT in reducing overdoses, also showed that many forms of psychotherapy are effective in reducing self-mutilation.80

Self-mutilation has been a target not only for psychother- apy, but also for pharmacological interventions. A variety

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of agents has been studied, including low-dose neuro- leptics,81–84 selective serotonin reuptake inhibitors (SSRIs),85,86 mood stabilizers,87–90 and naltrexone.91 In a controlled study that focused specifically on the effects of SSRIs on self-mutilation, high doses were effective in many cases, but patients had difficulty tolerating side effects.85

It is likely that these drugs work through a common mechanism, in that they all reduce levels of impulsivity.92,93

Clinicians need to keep in mind, however, that while pharmacological agents can be helpful, one rarely sees remission in BPD.93

Above and beyond controlled clinical trials, practi- cal methods for addressing self-mutilation in BPD have been suggested by experts working with this group of patients.27,28,94 The general principles common to these approaches are consistent with existing research on self- injury in BPD.

First, one need be concerned, but not alarmed, when patients cut themselves. If patients who self-mutilate are distressed, therapists need to empathize with that distress. While being careful not to invalidate the patient’s inner experience, a clinician’s response to a patient’s report of self- injury can be calm and neutral, using comments such as “you must have been very upset to have done that.”

Second, therapy needs to focus on modifying the traits of affective instability and impulsivity that lie behind self- mutilation. Thus, to give up their addiction to cutting, patients need to stand outside their intense emotions and impulsive responses in order to modulate them. Therapists of all orientations27,28,94,95 have recommended that clinicians understand and address the life events and emotions that have led to self-mutilation. Here the response can be: “Let’s understand how this happened.” Linehan28 uses behavioral analysis to reconstruct the precipitants of episodes, and similar approaches have been described in other forms of therapy.27 In the cognitive tradition, “decentering” has been developed for the management of impulsive symptoms in related conditions, such as bulimia nervosa.96 Decentering involves teaching patients to observe their emotions rather than being taken over by them. This concept is similar to Bateman and Fonagy’s78 construct of “mentalization,” which describes the ability to observe self and others accurately, even when emotions and impulses are strong.

Third, therapy can deal with more distal causes of self- mutilation, including patterns of maladaptive functioning rooted in schemas derived from early experience.27,71 The evidence reviewed here does not support any simple cor- respondence between self-mutilation and specific childhood adversities. In line with the principles of developmental psychopathology,97 this behavioral pattern is most likely an endpoint of many adversities, reflecting interactions between temperament, adult life experiences, and social influences.

Finally, any theory of self-mutilation needs to explain why it tends to be more frequent in younger patients with BPD, and then decreases over time.93 Follow-up stud- ies of patients with BPD98–104 show that most recover, no longer meeting criteria for BPD; part of this process involves remission from self-injury. In some cases, the behavior stops at a much earlier stage.103 It is notable that both psychotherapeutic28 and psychopharmacological interventions92 reduce self-mutilation, even before other symptoms remit.

These findings support a treatment plan in which BPD patients are managed symptomatically while working actively to make the recovery process proceed more rapidly.93

Clinicians can also be reassured that however alarming the patterns of self-mutilation they treat, this behavior rarely continues over many years.

REFERENCES

1. Gerson J, Stanley B. Suicidal and self-injurious behavior in personality disorder: controversies and treatment directions. Curr Psychiatry Rep 2002;4:30–8.

2. Favazza AR. The coming of age of self-mutilation. J Nerv Ment Dis 1998;186:259–68.

3. Osuch EA, Noll JG, Putnam FW. The motivations for self- injury in psychiatric inpatients. Psychiatry 1999:62:334– 46.

4. Schroeder SR, Oster-Granite M-L, Thompson T, eds. Self- injurious behavior: gene-brain-behavior relationships. Wash- ington, DC: American Psychological Association, 2002.

5. Klonsky ED, Oltmanns TF, Turkheimer E. Deliberate self- harm in a nonclinical population: prevalence and psychological correlates. Am J Psychiatry 2003;160:1501–8.

6. Haw C, Hawton K, Houston K, Townsend E. Psychiatric and personality disorders in deliberate self-harm patients. Br J Psychiatry 2001;178:48–54.

7. Comtois KA. A review of interventions to reduce the preva- lence of parasuicide. Psychiatr Serv 2002;53:1138–44.

8. Asch SS. Wrist scratching as a symptom of anhedonia. Psy- choanal Q 1967;40:630–7.

9. Graff H, Mallin R. The syndrome of the wrist cutter. Am J Psychiatry 1967;124:36–42.

10. Gruenbaum H, Klerman GL. Wrist slashing. Am J Psychiatry 1967;124:527–34.

11. Pao NP. The syndrome of deliberate self-cutting. Brit J Med Psychol 1967;42:195–206.

12. Rosenthal RJ, Rinzler C, Walsh R, Klausner E. Wrist-cutting syndrome. Am J Psychiatry 1972;128:1363–8.

13. Pattison EM, Kahan J. The deliberate self-harm syndrome. Am J Psychiatry 1983;140:867–72.

14. Walsh BW, Rosen P. Self-mutilation: theory, research, and practice. New York: Guilford, 1988.

15. Winchel RM, Stanley M. Self-injurious behavior: a review of the behavior and biology of self-mutilation. Am J Psychiatry 1991;148:306–17.

Harv Rev Psychiatry

Volume 13, Number 3 Paris 183

16. Herpertz S. Self-injurious behaviour. Psychopathological and nosological characteristics in subtypes of self-injurers. Acta Psychiatr Scand 1995;91:57–68.

17. Favazza AR, Favazza B. Bodies under siege: self-mutilation in culture and psychiatry, Baltimore, MD: Johns Hopkins Uni- versity Press, 1988.

18. Favazza AR. Why patients mutilate themselves. Hosp Com- munity Psychiatry 1989;40:137–45.

19. Zoroglu SS, Tuzun U, Sar V, et al. Suicide attempt and self- mutilation among Turkish high school students in relation with abuse, neglect and dissociation. Psychiatry Clin Neurosci 2003;57:119–26.

20. Mohino JS, Ortega-Monasterio L, Planchat-Teruel LM, Cuquerella-Fuentes A, Talon-Navarro T, Macho-Vives LJ. Discriminating deliberate self-harm (DSH) in young prison inmates through personality disorder. J Forensic Sci 2004;49:137–40.

21. Stanley B, Gameroff MJ, Michalsen V, Mann JJ. Are suicide attempters who self-mutilate a unique population? Am J Psy- chiatry 2001;158:427–32.

22. Brown MZ, Comtois KA, Linehan MM. Reasons for suicide attempts and nonsuicidal self-injury in women with borderline personality disorder. J Abnorm Psychol 2002;111:198–202.

23. Sabo AN, Gunderson JG, Najavits LM, Chauncey D, Kisiel C. Changes in self-destructiveness of borderline patients in psychotherapy. A prospective follow-up. J Nerv Ment Dis 1995;183:370–6.

24. Paris J. Implications of long-term outcome research for the management of patients with borderline personality disorder. Harv Rev Psychiatry 2002;10:315–23.

25. Hawton K, Zahl D, Weatherall R. Suicide following deliberate self harm: long-term follow-up of patients who presented to a general hospital. Br J Psychiatry 2003;182:537–42.

26. Gunderson JG, Ridolfi ME. Borderline personality disorder: suicidality and self-mutilation. Ann N Y Acad Sci 2001;932:61– 73.

27. Gunderson JG. Borderline personality disorder: a clinical guide. Washington, DC: American Psychiatric Press, 2001.

28. Linehan MM. Dialectical behavioral therapy of borderline per- sonality disorder. New York: Guilford, 1993.

29. Crawley JN, Sutton ME, Pickar D. Animal models of self destructive behavior and suicide. Psychiatr Clin N Am 1985;8:299–310.

30. Paris J. Half in love with easeful death: the meaning of chronic suicidality in borderline personality disorder. Harv Rev Psy- chiatry 2004;12:42–8.

31. Paris J. Chronic suicidality in borderline personality disorder. Psychiatr Serv 2002;53:738–42.

32. Dubo ED, Zanarini MC, Lewis RE, Williams AA. Childhood antecedents of self-destructiveness in borderline personality disorder. Can J Psychiatry 1997;42:63–9.

33. Shearer SL. Phenomenology of self-injury among inpatient women with borderline personality disorder. J Nerv Ment Dis 1994:182:524–6.

34. van der Kolk BA, Hostetler A, Herron N, Fisler RE. Trauma and the development of borderline personality disorder. Psy- chiatr Clin N Am 1994;17:715–30.

35. Leibenluft E, Gardner DL, Cowdry RW. The inner experience of the borderline self-mutilator. J Personal Disord 1987;1:317– 24.

36. Zweig-Frank H, Paris J, Guzder J. Psychological risk factors for disssociation and self-mutilation in female patients with personality disorders. Can J Psychiatry 1994;39:259–65.

37. Zlotnick C, Mattia JI, Zimmerman M. Clinical correlates of self-mutilation in a sample of general psychiatric patients. J Nerv Mental Dis 1999;187:296–301.

38. Russ MJ, Clark WC, Cross LW, Kemperman I, Kakuma T, Harrison K. Pain and self-injury in borderline patients: sen- sory decision theory, coping strategies, and locus of control. Psychiatry Res 1996;63:57–65.

39. Russ MJ, Campbell SS, Kakuma T, Harrison K. Zanine E. EEG theta activity and pain insensitivity in self-injurious border- line patients. Psychiatry Res 1999;89:201–14.

40. Kemperman I, Russ MJ, Clark WC, Kakuma T, Zanine E, Harrison K. Pain assessment in self-injurious patients with borderline personality disorder using signal detection theory. Psychiatry Res 1997;70:175–83.

41. Kemperman I, Russ MJ, Shearin E. Self-injurious behavior and mood regulation in borderline patients. J Personal Disord 1997;11:146–57.

42. Bohus M, Limberger M, Ebner U, et al. Pain perception during self-reported distress and calmness in patients with borderline personality disorder and self-mutilating behavior. Psychiatry Res 2000;95:251–60.

43. Simeon D, Stanley B, Frances A, Mann JJ, Winchel R, Stan- ley M. Self-mutilation in personality disorders: psychologi- cal and biological correlates. Am J Psychiatry 1992;149:221– 6.

44. Dulit RA, Fyer MR, Leon AC, Brodsky BS, Frances AJ. Clinical correlates of self-mutilation in borderline personality disorder. Am J Psychiatry 1994;151:1305–11.

45. Herpertz S, Sass H, Favazza A. Impulsivity in self-mutilative behavior: psychometric and biological findings. J Psychiatr Res 1997;31:451–65.

46. Goodman M, New A. Impulsive aggression in borderline per- sonality disorder. Curr Psychiatry Rep 2000;2:56–61.

47. Siever LJ, Davis KL. A psychobiological perspective on the personality disorders. Am J Psychiatry 1991;148:1647–58.

48. Koenisgberg HW, Harvey PD, Mitropolou V, et al. Characteriz- ing affective instability in borderline personality disorder. Am J Psychiatry 2002;159:784–8.

49. Bruce KR, Steiger H, Koerner NM, Israel M, Young SN. Bu- limia nervosa with co-morbid avoidant personality disorder: behavioural characteristics and serotonergic function. Psychol Med 2004;34:113–24.

50. Moeller FG, Barratt ES, Dougherty DM, Schmitz JM, Swann AC. Psychiatric aspects of impulsivity. Am J Psychiatry 2001;158:1783–93.

51. Links PS, Heslegrave R, van Reekum R. Impulsivity: core aspect of borderline personality disorder. J Personal Disord 1999;13:131–9.

52. Gardner DL, Cowdry RW. Suicidal and parasuicidal behav- ior in borderline personality disorder. Psychiatr Clin N Am 1985;8:389–403.

184 Paris Harv Rev Psychiatry

May/June 2005

53. Seroczynski AD, Bergeman CS, Coccaro EF. Etiology of the im- pulsivity/aggression relationship: genes or environment? Psy- chiatry Res 1999;86:41–57.

54. Oquendo MA, Mann JJ. The biology of impulsivity and suici- dality. Psychiatr Clin N Am 2002;23:11–25.

55. Coccaro EF, Siever LJ, Klar HM, et al. Serotonergic studies in patients with affective and personality disorders. Arch Gen Psychiatry l989;46:587–99.

56. Jang KL, Livesley WJ, Vernon PA, Jackson DN. Heritabil- ity of personality traits: a twin study. Acta Psychiatr Scand 1996;94:438–44.

57. Zweig-Frank H, Paris J, Guzder J. Psychological risk fac- tors for dissociation in female patients with borderline and non-borderline personality disorders. J Personal Disord 1994;8:203–9.

58. Brodsky BS, Cloitre M, Dulit RA. Relationship of dissociation to self-mutilation and childhood abuse in borderline personal- ity disorder. Am J Psychiat 1995;152:1788–92.

59. Fossati A, Madeddu F, Maffei C. Borderline personality dis- order and childhood sexual abuse: a meta-analytic study. J Personal Disord 1999;13:268–80.

60. Brodsky BS, Oquendo M, Ellis SP, Haas GL, Malone KM, Mann JJ. The relationship of childhood abuse to impulsivity and suicidal behavior in adults with major depression. Am J Psychiatry 2001;158:1871–7.

61. Goodman M, Weiss DS, Koenigsberg H, et al. The role of child- hood trauma in differences in affective instability in those with personality disorders. CNS Spectr 2003;8:763–70.

62. Livesley WJ, Jang KL, Vernon PA. Phenotypic and genetic structure of traits delineating personality disorder. Arch Gen Psychiatry 1998;55:941–8.

63. Taiminen TJ, Kallio-Soukainen K, Nokso-Koivisto H, Kaljonen A, Helenius H. Contagion of deliberate self-harm among adolescent inpatients. J Am Acad Child Adolesc Psychiatry 1998;37:211–7.

64. Levy DA, Nail PR. Contagion. a theoretical and empirical re- view and reconceptualization. Genet Soc Gen Psychol Monogr 1993;119:233–84.

65. Crandall CS. Social contagion of binge eating. J Pers Soc Psy- chol 1988;55:588–98.

66. Hull JW, Yeomans F, Clarkin J, Li C, Goodman G. Factors associated with multiple hospitalizations of patients with borderline personality disorder. Psychiatr Serv 1996;47:638– 41.

67. Paris J. Is hospitalization useful for suicidal patients with bor- derline personality disorder? J Personal Disord 2004;18:240– 7.

68. Koerner K, Linehan MM. Research on dialectical behavior therapy for patients with borderline personality disorder. Psy- chiatr Clin N Am 2000;23:151–67.

69. Bohus M, Haaf B, Stiglmayr C, Pohl U, Bohme R, Linehan M. Evaluation of inpatient dialectical-behavioral therapy for borderline personality disorder—a prospective study. Behav Res Ther 2000;38:875–87.

70. Verheul R, Van Den Bosch LM, Koeter MW, De Ridder MA, Stijnen T, Van Den Brink W. Dialectical behaviour therapy for women with borderline personality disorder: 12-month, ran-

domized clinical trial in The Netherlands. Br J Psychiatry 2003;182:135–40.

71. Young JE. Cognitive therapy for personality disorders: a schema-focused approach. 3rd ed. Sarasota, FL: Professional Resource, 1999.

72. Kern RS, Kuehnel TG, Teuber J, Hayden JL. Multimodal cognitive-behavior therapy for borderline personality disor- der with self-injurious behavior. Psychiatr Serv 1997;48:1131– 3.

73. Tyrer P, Thompson S, Schmidt U, et al. Randomized controlled trial of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: the POPMACT study. Psychol Med 2003;33:969–76.

74. Perry JC, Banon E, Ianni F. Effectiveness of psychotherapy for personality disorders. Am J Psychiatry 1999;156:1312– 21.

75. Leichsenring, F Leibing, E. The effectiveness of psychody- namic therapy and cognitive behavior therapy in the treat- ment of personality disorders: a meta-analysis. Am J Psychi- atry 2003;160:1223–32.

76. Bateman A, Fonagy P. Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a random- ized controlled trial. Am J Psychiatry 1999;156:1563–9.

77. Bateman A, Fonagy P. Treatment of borderline personality dis- order with psychoanalytically oriented partial hospitalization: an 18-month follow-up. Am J Psychiatry 2001;158:36–42.

78. Bateman A, Fonagy P. Psychotherapy for borderline person- ality disorder: mentalization-based treatment. Oxford: Oxford University Press, 2004.

79. Fonagy P. An update on BPD treatment evaluation research in England. Presented to the NIMH International Think Tank for the More Effective Treatment of Borderline Personality Disorder, Lincthinum, MD, July 2004.

80. Linehan, MM. The application of dialectical behavior therapy (DBT) to chronic suicidality in borderline personality disorder. Presented to the International Society for the Study of Person- ality Disorders, Florence, Italy, October 2003.

81. Soloff PH, Cornelius J, George A, Nathan S, Perel JM, Ulrich RF. Efficacy of phenelzine and haloperidol in borderline per- sonality disorder. Arch Gen Psychiatry 1993;50:377–85.

82. Chengappa KN, Ebeling T, Kang JS, Levine J, Parepally H. Clozapine reduces severe self-mutilation and aggression in psychotic patients with borderline personality disorder. J Clin Psychiatry 1999;60:477–84.

83. Hough DW. Low-dose olanzapine for self-mutilation behavior in patients with borderline personality disorder. J Clin Psy- chiatry 2001;62:296–7.

84. Zanarini MC, Frankenburg FR. Olanzapine treatment of fe- male borderline personality disorder patients: a double-blind, placebo-controlled pilot study. J Clin Psychiatry 2001;62:849– 54.

85. Markovitz PJ, Calabrese JR, Schulz SC. Meltzer HY. Fluoxe- tine in the treatment of borderline and schizotypal personality disorders. Am J Psychiatry 1991;148:1064–7.

86. Rinne T, van den Brink W, Wouters L, van Dyck R. SSRI treatment of borderline personality disorder: a random- ized, placebo-controlled clinical trial for female patients with

Harv Rev Psychiatry

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borderline personality disorder. Am J Psychiatry 2002;159: 2048–54.

87. Gardner DL, Cowdry RW. Positive effects of carbamazepine on behavioral dyscontrol in borderline personality disorder. Am J Psychiatry 1986;143:519–22.

88. Pinto O, Akiskal H . Lamotrigine as a promising approach to borderline personality. J Affect Disord 1998;51:333–43.

89. Hollander E, Allen A, Lopez RP, et al. A preliminary double- blind, placebo-controlled trial of divalproex sodium in bor- derline personality disorder. J Clin Psychiatry 2001;62:199– 203.

90. Frankenburg FR, Zanarini MC. Divalproex sodium treatment of women with borderline personality disorder and bipolar II disorder: a double-blind, placebo-controlled pilot study. J Clin Psychiatry 2002;63:442–6.

91. Roth AS, Ostroff RB, Hoffman RE. Naltrexone as a treatment for repetitive self-injurious behaviour: an open-label trial. J Clin Psychiatry 1996;57:233–7.

92. Soloff P. Psychopharmacological treatment of borderline per- sonality disorder. Psychiatr Clin N Am 2000;23:169–92.

93. Paris J. Personality disorders over time. Washington, DC: American Psychiatric Press, 2003.

94. Livesley WJ. The practical management of personality disor- der. New York: Guilford, 2003.

95. Rockland LH. A supportive approach: psychodynamically ori- ented supportive therapy of borderline patients who self- mutilate. J Personal Disord 1987;1:350–5.

96. Garner DM. Cognitive therapy for bulimia nervosa. Adolesc Psychiatry 1986;13:358–90.

97. Ciccheti D, Rogosch FA. A developmental psychopathology per- spective on adolescence. J Consult Clin Psychol 2002;70:6– 20.

98. Paris J, Zweig-Frank H. A 27-year follow-up of borderline pa- tients. Compr Psychiatry 2001;42:482–7.

99. Stone MH. The fate of borderline patients. New York: Guilford, 1990.

100. Zanarini MC, Frankenburg FR, Hennen J, Silk KR. The longi- tudinal course of borderline psychopathology: 6-year prospec- tive follow-up of the phenomenology of borderline personality disorder. Am J Psychiatry 2003;160:274–83.

101. Links PS, Heslegrave R, van Reekum R. Prospective follow- up study of borderline personality disorder: prognosis, predic- tion of outcome, and Axis II comorbidity. Can J Psychiatry 1998;43:265–70.

102. McGlashan TH. The Chestnut Lodge follow-up study III: long- term outcome of borderline personalities. Arch Gen Psychiatry 1986;43:2–30.

103. Gunderson JG, Bender D, Sanislow C, et al. Plausibility and possible determinants of sudden “remissions” in borderline patients. Psychiatry 2003;66:111–9.

104. McGlashan TH. Implications of outcome research for the treat- ment of borderline personality disorder. In Paris J, ed. Border- line personality disorder: etiology and treatment. Washington. DC: American Psychiatric Press, 1993:235–60.