Borderline personality disorder, substance abuse, and dialectical behavior therapy van den Bosch, L.M.C.

Transcription

1 UvA-DARE (Digital Academic Repository) Borderline personality disorder, substance abuse, and dialectical behavior therapy van den Bosch, L.M.C. Link to publication Citation for published version (APA): van den Bosch, L. M. C. (2003). Borderline personality disorder, substance abuse, and dialectical behavior therapy General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam ( Download date: 24 Dec 2017

2 CHAPTERR 2 Louisaa M.C van den Bosch Roell Verheul Wimm van den Brink Substancee Abuse in Borderline Personality Disorder:: Clinical and Etiological Correlates JournalJournal of personality disorders. 200/; is(s):4i6-424

3 Summary y Objective:ToObjective:To study differences between female borderline patients with and without substancee abuse problems and between borderline patients from different treatment settings.. Method:: Sixty-four female borderline patients were recruited from mental health servicess (n=44) and addiction treatment services (n=2o); 35 had a substance abuse problem.. Patient groups were compared with regard to both clinical and etiological factorss using MANOVA for 47 continuous variables and logistic regression for 15 dichotomouss variables. Results:Results: Borderline patients with substance abuse problems reported less hostility, suspicionn and anger, but more anxiety, insufficiency and suicide attempts. Patients fromm addiction treatment services reported less avoidant and more antisocial behaviour.. Conclusion:Conclusion:TheThe differences between borderline patients with and without subst abusee problems are limited in number and size. Therefore, there is no empirical justificationn for the exclusion of borderline patients with substance abuse problems fromm general treatment services or clinical trials BPD,, SUBSTANCE ABUSE, AND DBT - VAN DEN BOSCH

4 Introduction n Severall studies have shown high comorbidity between borderline personality disorder (BPD)) and substance use disorders (SUD) (Trull et al.,2000; Linksetal., 1995; Oldham et al.,, 1995). Reported prevalence rates of SUD among patients with BPD range from 39% too 84 % with a median rate of 67% (Dulit et al., 1990; Links et al., 1995; Zanarini et al., 1990,1998).. Within substance abuse populations, the prevalence of BPD ranges from 1%1% to 66% with a median rate of 18% (Verheul et al., 1995). The observed comorbidity cann partly be accounted for by overlapping diagnostic criteria, but prevalence rates off BPD remain high even when substance-related characteristics are not taken into accountt (e.g., Dulit et al., 1990; Rounsaville et al., 1998). It has been suggested that the comorbidityy results from causal links between SUD and BPD (Verheul et al., 1997). For example,, it has been hypothesized that both conditions share common aetiologies and,, consequently, are in the same domain of psychopathology, i.e. impulse control disorderss (Siever 8L Davis, 1991; Zanarini, 1993). Not surprisingly, many authors considerr substance use as a manifestation of impulsivity that is seen as a core feature off borderline personality disorder (van Reekum et al., 1994; Links et al., 1999). Sincee substance abuse is generally considered a typical borderline manifestation ratherr than an independent comorbid condition, it is rather striking that borderline patientss with SUD tend to be treated differently from those without SUD. The differentiall treatment occurs both in scientific studies and in clinical practice. First, substancee abusers tend to be excluded from studies examining efficacy of treatments designedd to target borderline symptoms. For example, three of four randomised controlledd trials of psychosocial interventions addressing BPD have excluded borderlinee patients with SUD (Evans et al., 1999; Linehan et al., 1991,1999; Marziali and Munroe-Blum,, 1994). Second, it has often been observed and reported that borderline patientss with SUD experience great difficulties when applying for treatment. Anecdotal dataa indicate that this group may be caught in a therapeutic 'Catch-22' situation, in whichh they cannot enter the mental health service system until they stop using substancess and cannot enter substance abuse treatment until suicidal and other selfdestructivee behaviours are under control (e.g., Verheul, 1997; van den Bosch, 1996; NiAAA,t993).. Thee differential exclusion of borderline patients with SUD from both treatment programss and treatment efficacy studies is, however, poorly explained. Exclusion of substancee abusers from BPD treatment research is often justified as a strategy to preservee the homogeneity in cohorts (Hull et al., 1996; Hull et al., f993; Plakun, 1991). Itt could be argued that the observed differential exclusion practices might not be warrantedd if borderline patients with and without SUD do not differ in clinical CHAPTERR 2

5 characteristicss and/or etiological background. In this respect, it is at least remarkable thatt this issue has been rarely focused on empirically. Using multiple literature search strategies,, we could not find studies that have addressed potential etiological differencess between borderline patients with and without SUD, nor of studies that comparedd patients across treatment settings, e.g. psychiatric versus addiction treatmentt services. Only two studies compared the clinical characteristics of borderlinee patients with and without SUD admitted to acute psychiatric inpatient facilitiess (Links et al., 1995; Dulit et al., 1990), but the findings from these studies are nott entirely consistent. Inn the study of Links et al. (1995), including 34 borderline patients with and 53 without suu D, it was found that the two groups did not differ significantly in terms of social adaptation,, affect, psychosis, interpersonal problems, and overall dysfunction. However,, those with comorbid substance abuse more often showed a history of poor schooll performance, and tended to enter treatment for the first time at ayounger age andd expressed higher levels of borderline psychopathology, especially self-mutilation andd parasuicidal ideation. In addition, comorbid borderline patients showed somewhat moree impulse decontrol. However, the paper does not report on whether this finding remainedd after controllingfor substance abuse as one ofthe indicators of impulsivity. Applyingg chart review as a diagnostic method, Dulit et al. (1990) compared 45 borderlinee patients without SUD (pure BPO) versus 92 with SUD, while the latter group wass subdivided into those who still met criteria for BPD after exclusion of substance usee as a borderline criterion (substance-independent BPD diagnoses; n=6o) and those whoo did not (substance-dependent BPD diagnoses; n=32). Patients with a substancedependentt borderline diagnosis were slightly older at first outpatient treatment and firstt hospitalisation, and less impulsive than pure borderline patients. Furthermore, patientss with substance-dependent borderline diagnoses reported less identity disturbance,, were less tolerant of being alone, and experienced less minipsychotic episodes.. Patients with substance-independent borderline diagnoses, however, were foundd to be more similar to pure borderline patients, suggesting that those with substance-dependentt borderline diagnoses constitute a rather specific, less severe subgroupp of borderline patients. Thee present study aims to investigate differences and similarities in clinical characteristicss and etiological factors between female borderline patients with and withoutt SUD. Clinical characteristics will include borderline symptom severity, Axis-i comorbidity,, and treatment history. Etiological variables will include family history off SUD, and history of childhood trauma (e.g. emotional neglect, sexual abuse, and physicall abuse) and adult victimization. This is the first study to include a mixed sample off borderline patients recruited from addiction treatment services and from general psychiatricc services. 388 BPD, SUBSTANCE ABUSE, AND DBT - VAN DEN BOSCH

6 Method d Participants Participants Participantss were recruited from a pool of 92 clinical referrals from mental health andd addiction treatment services within the greater Amsterdam area. Those female patientss who met criteria for DSM-IV borderline personality disorder according to bothboth the Personality Diagnostic Questionnaire (PDQ-4+) and the Structural Clinical InterviewforDSM-ivv Axis-11 Personality Disorders (SCID-II) were eligible. In addition, alll research subjects were required to have sufficient command of the Dutch language, residee within a 25-mile radius of Amsterdam, and agree to the study conditions. Subjectss under 18 years of age, who met DSM-IV criteria for bipolar or chronic psychotic disorder,, or suffered from severe cognitive impairments were excluded. Of the remainingg 64 patients, 20 (31%) were referred by addiction treatment services and 444 (69%) were referred by mental health services. Instruments Instruments PDQ-4+.Thee Personality Diagnostic Questionnaires (Hyler, 1994; Dutch translationn by Akkerhuis et al.^1996]) is an update version of the PDQ-R. The PDQ-4+ iss a 99-item, self-administered, forced-choice, true/false questionnaire, designed to assesss the DSM-IV personality disorders. SCID-II.SCID-II. The Structured Clinical Interview for DSM-IV Axis-11 Personality Disorders (Firstt et al, 1996; Dutch translation by Weertman et at., 1996) is a (semi) structured intervieww of 108 questions, arranged according to diagnosis, yielding both categorical diagnosess and dimensional scores for each of the «o DSM-IV personality disorders. BPDSI.BPDSI.TheThe Borderline Personality Disorder Severity Index (Arntz, 1996) is a 52-item semii structured interview measuring the frequency of borderline symptoms in the previouss 3-month period. The instrument is an adaptation of an interview developed byy Weaver and Clum (1993), and has proven to be highly reliable and internally consistent,, and to have excellent concurrent validity (Arntz et al., 2003). It consists off nine separate sections, each including several items reflecting the manifestations of thee personality traits underlying the respective nine DSM-IV diagnostic criteria of BPD. sc1.-90.thee Symptom Check List (Derogatis, 1977; Dutch translation by Arrindell andd Ettema, 1986) is a 90-item self-report questionnaire covering eight domains of psychopathology:: anxiety, agoraphobia, depression, somatization, feelings of insufficiency,, interpersonal sensitivity, and hostility and sleep problems. scid-i.scid-i. The Structured Clinical Interview for DSM-I I I-R (Spitzer et al., 1990; Dutch translationn by Arntz et al., 1992) is a semi structured interview, yielding both Axis-i lifetimee diagnoses (i.e. ever in life) and Axis-i current diagnoses (i.e. past month). EuropAsi.EuropAsi.TheThe EuropASi (Kokkevi and Hartgers, 1995) is an European adaptation CHAPTERR 2 39

7 off the Addiction Severity Index (ASI; McLellan et al., 1980), a multidimensional (semi) structuredd instrument for assessment of broad range of domains that could be affected byy substance abuse (treatment), i.e. medical, employment, alcohol, drug, legal, family/social,, psychiatric problems, and a section concerning family history of substancee abuse. For each domain, a severity rating (range 0-9) reflects the interviewer'ss estimate of the problem severity within that section. In line with the manual,, subjects who had an alcohol or drug severity score of five or more were consideredd to have clinically relevant substance abuse problems. THI.THI. The Treatment History Interview (Linehan, 1987) is a structured interview measuringg the patient's current and past health care consumption. Both number andd type of all treatments for psychiatric symptoms, substance abuse problems, andd somatic complaints are examined. sri.sri. The Structured Trauma Interview, short version (Drayer, 1996), is a semistructuredd interview measuring the frequency and severity of childhood and adulthoodd traumatic experiences such as sexual abuse and physical abuse. Procedure Procedure Afterr consent and prior to randomisation, all patients were evaluated with a comprehensivee assessment battery, including several (semi) structured interviews andd self-report questionnaires, administered by clinically experienced and trained diagnosticians.. The assessments were administered during a two-day intake session. Clinicall variables were measured using the SCID-II,BPDSI,SCL-90, and the TH). Etiologicall variables were measured with the EuropASi and the STI. Differencess between groups with regard to continuous variables were examined usingg general factorial A NOVA. F-values for the main and interaction effects of substancee abuse problems and referral setting are reported. Dichotomous variables weree examined using chi-square and logistic regression. First, saturated models were testedd including both main effects and the interaction effect. If the interaction effect (addiction*referral)) appeared to be not significant, selective models were tested examiningg the main effects only. None of the interaction effects were significant. Thus, thee logistic regression data are the result of selective models only. Odds ratios (OR'S), degreess of freedom (df) and 95% confidence intervals (ci's) are reported. Thiss is an explorative study with a relatively small sample size. In order to prevent typee II errors in this early stage of the investigation of this issue, we are reporting differencess with a rather lenient level of significance (p<os) and without correction for thee multiple comparisons. All analyses were conducted using SPSS 8.0 for Windows SPD,, SUBSTANCE ABUSE, AND DBT - VAN DEN BOSCH

8 Results s SampleSample Characteristics Thee mean age of this all female sample was 34.9 years (sd. 7.7; range 28.6). More than halff of the patients were on disability pension (58%) and were unmarried (63%). Less thann half lived alone (35%) and had less than an elementary school education (30%). Thirty-fivee of the 64 subjects (55%) showed clinically significant addiction problems ('BPD/SUD++ group'), Ieaving29 subjects (45%) to the'bpd/sud-'group. Substances usedd during the last thirty days were cannabis (30 %), heroin (9%), cocaine (17%), methadonee (13%), alcohol (50%) and medication (mostly sedatives, 64%). Polydrug usee rated as high as 56%. The average number of years of substance abuse was 7.6 years;; the average number of treatments for substance use was 4, ranging from detoxificationn only to long-term residential treatment. Twentyy females (31%) were referred by addiction treatment services (BPD/ATS), whereass 44 subjects (69%) were referred by mental health services (BPD/MHS). Strikingly,, the proportion of BPD+SUD patients in the addiction treatment services groupp was not significantly larger than in the mental health services group (70% versus 47%; 2 =2.7,, d/=i, p=o.io). Six patients turned out not to be substance users [ASI > 5] althoughh referred by the substance abuse services. Neitherr the presence of addiction problems nor the referral setting appeared to be associatedd with the demographic characteristics. ClinicalClinical Variables Noo significant differences between subgroups (BPD/SUD+ VS. BPD/SUD- and BPD/ATS VS.. BPD/MHS) were observed with regard to the problem domains of the EuropASi, withh the exception of alcohol and drug problem severity. Within the domain of Axis-i psychopathologyy (SCID-I; scl-90; EuropASi) BPD/SUD+ differed significantly from BPD/SUD-inn only fourout of 38 indicators: BPD/SUD+patients were 9.5 times (ci )) more likely to meet criteria for an anxiety disorder than were BPD/SUD- patients, BPD-SUU D+ also reported somewhat more feelings of insufficiency (F=4.8, df=i, p= 0.03) andd less hostility (F=6.o, df=1, p= 0.02), and they were four times more likely to have attemptedd to commit suicide (011=4.3; df=i, Cl ) than those without addiction problems.. No significant differences in Axis-i psychopathology were observed betweenn the B P S/ATS and the BPD/MHS group. Comparisonn for type and severity of Axis-i 1 psychopathology (SCID-II and BPDSI) resultedd in only five significant differences between groups (out of 46 comparisons). Individualss in the BPD/SUD+ group reported less paranoid personality disorder (F=5-3, df=i,, p=o.o3) and slightly less uncontrolled anger outbursts (F=8.8, df=i, p=o.oo4) CHAPTERR 2

9 thann their non-substance abusing counterparts. Inaddition, BPD/SUD+ patients seemedd to be more impulsive (F=8.3, df=i, p=o.oo5). However, this difference was partlyy attributable to three out of the n items examining alcohol and drug intake as manifestationss of impulsivity. When these three items are excluded, the difference wass no longer statistically significant ( =3.3, df=i, p=o.07). Finally, BPD/MHS patients showedd significantly more avoidant personality traits ( =11.5, df=i, p= 0.001) and less adultt antisocial behaviour ( =7.9, df=i, p=o.oo7). Theree was no association between the presence of addiction problems and referral settingg with the individual's treatment history, as measured by the TH 1. The groups appearedd to be very similar in terms of the proportion of subjects with a history of psychiatricc hospitalisation, the age of first outpatient treatment and of first hospitalisation,, the numberof (different) treatments, and the number of crisis admissions.. EtiologicalEtiological Factors Thee presence or absence of addiction problems and referral setting were not significantlyy associated with the individual's history of traumatic events. However, thee possibility that BPD/ATS patients are more frequently the victims of adult physical abusee than BPD/MHS patients could not be ruled out completely (OR 3.5; df=i; ci ( )).. It is important to notice that borderline patients with and without substancee abuse do not differ significantly in terms of a family history of alcoholism orr childhood sexual abuse. Discussion n Inn summary, this study revealed that the differences between BPD patients with and withoutt SUD and between BPD patients recruited from different treatment settings weree limited in number and rather small in size. Out of the 124 comparisons made in total,, only 12 (10%) reached statistical significance. Comparisons between BPD/SUD+ andd BPD/SU D- produced only 9 (15%) significant differences. It should be noted that thesee few significant results left would not have been detected if a correction for multiplee testing had been applied Accordingly, the findings should be considered with thee necessary caution. Ourr data corroborate earlier studies in which BPD/SUD+ patients were found to be moree impulsive (Linksetal., 1999; van Reekum etal., 1994). However, this difference disappearedd when corrected for impulsive substance abuse. That however does not meann that impulsivity is not one of the core aspects of borderline personality 4* * BPD,, SUBSTANCE ABUSE, AND DBT - VAN DEN BOSCH

10 pathology.. In fact, impulsivity may influence the decision in BPD patients to use psychoactivee substances, to lose control over substance use and to cause long terms substancee abuse problems. In addition, we found that BPD/SUD+ patients were four timess more likely to have attempted suicide than BPD/SUD- patients. Since we did not examinee the temporal relationship between substance abuse and suicide attempts, this findingg might either indicate that substance abuse lowers the threshold to engage in self-destructivee behaviour and suicide attempts or reflect that non-intentional overdosess were mistaken for suicide attempts. Neither our study nor the studies of Linkss (1995) and Dulit (1990) are conclusive about the nature of the suicide attempts. Ourr data show slightly lower levels of suspicion, anger and hostility and more maladaptive/self-destructivee coping behaviour in BPD/SUD+ patients, while no differencee is found when it comes to be sexually traumatized. This seems to indicate thatt BPD/SUD+ patients can at the most be defined as'more pathetic' BPD patients. Thee differences between groups discriminated by referral setting are even more limitedd than those between borderline patients with and without substance abuse problems.. The findings suggest that conflict avoiding BPD patients are referred to or selectt themselves into the mental health circuit, whereas antisocial BPD patients are moree often found in the addiction treatment circuit. Borderline patients with su D can,, however, are found in both circuits: 70% of the borderline patients in addiction treatmentt services and 47% of the borderline patients in mental health services. These dataa indicate that treatment allocation is a complex process in which the presence of aa co morbid su Dis only one factor, and perhaps one of mi nor importance. Inn conclusion, several studies have failed to find any consistent major differences betweenn borderline patients with and without SUD in terms of clinical characteristics andd etiological background. It seems fair to state that these empirical findings do at leastt not support the exclusion of borderline patients with substance abuse problems fromm regular treatment services or from clinical trials. CHAPTERR

11 References References Akkerhuiss GW, Kupka RW, Groenestijn MAC van & Nolen WA. PDQ-4+, Vragenlijst voor Persoonlijkheidskenmerken.Persoonlijkheidskenmerken. Utrecht: H.C. Rümke groep Arntzz A. BPDSI. Borderline Personality Disorder Severity Index. Maastricht: University of Limburg, Departmentt of Medical, Clinical and Experimental Psychology Arntzz A, Bögels S & Hoekstra R. Gestructureerd klinisch interview voor de vaststelling van DSM-III-R. Maastricht:: University of Limburg, Department of Medical, Clinical and Experimental Psychology Arntzz A, Hoorn M van den, Cornells J, et al. Reliability and validity of the Borderline Personality Disorder Severityy Index.J Person disord2003;17: Arrindelll WA & EttemaJHM. Klachtenlijst (scl-go). Lisse: Swets & Zeitlinger BV ig86. Boschh LMC van den. Dialectische gedragstherapie bij verslaafden met een B PS. In: Handboek Verslaving (BB ). Houten: Bohn Stafleu Van Loghum Derogatiss LR. scl-go: administration, scoring and procedures manual-lfor the revisedversion. Baltimore: Johnn Hopkins University School of Medicine, Clinical Psychometrics Research Unit Draijerr N. Vragenlijstjeugdervaringen (korte versie). Amsterdam: Free University, department of psychiatryy Dulitt RA, Fyer MR, Haas GL, Sullivan T &. Frances AJ. Substance use in Borderline personality disorder. Am)Am) Psychiatry 1990; 147: Evanss K,TyrerP, Catalan J, Schmidt U, Davidson K, Dent J,, Tata P.Thornton S, BarberJ, Thompsonn S. Manual-assisted cognitive-behaviourtherapy (MACT): A randomised controlled trial of a brief interventionn with bibliotherapy in the treatment of recurrent deliberate self-harm. Psychol Medicine 1999;29: Firstt MB, Spitzer RL, Gibbons M, WilliamsJBW, Benjamin L. The Structured Clinical Interviewfor DSM-IV Axis-itAxis-it Personality Disorders (scid-11). New York: Biometrics Research Department New York State Psychiatricc Institute Hulll JW.CIarkin JF, Yeomans F. Borderline personality disorder and impulsive sexual behaviour. HospHosp Com Psychiatry 1993; 44(10): Hulll JW, Yeomans F, Clarkin J, Li C, Goodman G. Factors associated with multiple hospitalisations of patients withh borderline personality disorder. Psychol Serv 1996; 47: Hylerr SE &. Reider RC. Personality Diagnostic Questionnaire Revised. New York: New York State Psychiatric Institutee Kokkevii A, Hartgers C. EuropASi: European adaptation of a multidimensional assessment instrument for drugg and alcohol dependence. Eur Add Res 1995;): Linehann MM &. Heard HL. Treatment history interview (THI). Seattle, WA: University of Washington Linehann MM, Armstrong HE, Suarez A, Alimon D& Heard HL. Cognitive-behavioural treatment of chronicallyy parasuicidal borderline patients. Arch Gen Psychiatry 1991; 48: Linehann MM, Schmidt H, Dimeff LA, Craft JC, Kanter J, Comtois KA. Dialectical Behavior Therapy for patientss with borderline personality disorder and drug-dependence. Am j Add 1999; 8(4):279-2g2 Links PS,, Heslegrave RJ, Mitton JE, van Reekum R, PatricJ. Borderline psychopathology and recurrences of clinicall disorders.) Nervous and Mental Disease 1995; 183(9): BPD,, SUBSTANCE ABUSE, AND DBT - VAN DEN BOSCH

12 Linkss PS, Heslegrave R, van Reekum R. Impulsivity: core aspect of borderline personality disorder.} Person disorddisord 1999;13:1-9. Marzialii E, Munroe-Blum H. Interpersonal Group Psychotherapyfor Borderline Personality Disorder. Neww York: Basic Books McLellann AT, Luborsky L, Woody EG, O'Brien CR An improved diagnostic evaluation instrument for substancee abuse patients: The addition severity index J Nervous and Mental Disease 1980; 168: Nll AAA (National Institute of Alcohol Abuse and Alcoholism). Psychiatric comorbidity with alcohol use disorders.. In: Eighth special report to the US congress on alcohol and health, N I A A A, 1993: Oldhamm JM, Skodol AE, Keilman HD, Hyler SE, Doidge N, Rosnick L, Gallaher PE.Comorbidity of Axis-t and Axis-iii disorders. Am) Psychiatry 1995; 4: Plakunn EM. Prediction of outcome in borderline personality disorder,) Person Disord 1991; 5(2): vann Reekum R, Links PS, Fedorov C. Impulsivity in borderline personality disorder. In: K.R. Silk (Ed.) BiologicalBiological and neurobehavioural studies of borderline personality disorder (pp. 1-22). Washington, DC: Americann Psychiatric Press Rounsavillee BJ, Kranzler HR, Ball S, Tennen H, PolingJ, Triffleman E. Personality disorders in substance abusers:: Relation to substance use.) Nervous and Mental Disease 1998; 186(2): Sieverr LJ, Davis KL. A psychobiological perspective on the personality disorders. Am) Psychiatry 1991:148: Spitzerr RL, WilliamsJBW, Gibbon M & First M. Structured Clinical interviewfor OSM-IU-R (SCID). Washington,, DC: American Psychiatric Press spss8.oforspss8.ofor Windows., Marketing department SPSS, Chicago Trulll Tj, Sher KJ, Minks-Brown C, Durbin J & Burr R. Borderline personality disorder and substance use disorders:: A review and integration. Clin Psychol Review 2000; 20(2): Verheull R, van den Brink W, Hartgers C. Prevalence of personality disorders among alcoholics and drug addicts:: an overview. EurAddic Res 1995; 1: Verheull R, Ball SA,&vanden Brink W. Substance abuse and personality disorders. In H.R. Kranzler & B.J.. Rounsaville (Eds), Dual diagnosis and treatment; Substance abuse andcomorbid medical and psychiatricpsychiatric disorders (pp ). New York: Marcel Dekker Weaverr TL, Clum GA. Early family environments and traumatic experiences associated with borderline personalityy disorder.) Cons Clin Psychol 1993; 61: Weertmann A, Arntz A, Kerkhofs MLM. Gestructureerd klinisch interview voor DSM-IV persoonlijkheidsstoornissenpersoonlijkheidsstoornissen (SCID-II). Amsterdam: Swets Zanarinii MC, GundersonJG, Frankenburg FR & Chauncey DL. Discriminating borderline personality disorderr from other Axis-11 disorders. Am) Psychiatry 1990; 147: Zanarinii MC. Borderline personality disorder as an impulse spectrum disorder. In: J Paris, (ed). Borderline personalitypersonality disorder: etiology and treatment (67-86).Washington, DC: American Psychiatric Press Zanarinii MC, Frankenburg FR,Dubo ED, Sickel AE.Trikha A, Levin A, Reynolds V. Axis-i comorbidity of borderlinee personality disorder. Am) Psychiatry 1998:155(12): CHAPTERR

13