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Keywords:

  • borderline;
  • personality disorder;
  • character;
  • longitudinal follow up;
  • temperament

Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

Abstract  The purpose of the present study was to examine the developmental patterns of Cloninger's biogenetic character traits in subjects with borderline personality disorder (BPD). Study subjects met Diagnostic and Statistical Manual of Mental Disorders (3rd edn, revised; DSM-III-R) criteria for BPD without comorbid axis I or II disorders, as determined by the Diagnostic Interview for Borderlines-Revised, Structured Clinical Interview for the DSM-III-R, and Diagnostic Interview for Personality Disorders. The BPD subjects and age- and sex-matched healthy comparison subjects were initially interviewed for Cloninger's biogenetic characters and re-interviewed at an interval of 1 year for the following 3 years. There were significant differences in the developmental patterns of self-directedness, cooperativeness, and self-transcendence between BPD and healthy comparison subjects (significant group by time interaction: repeated measures manova, F = 17.3, d.f. = 3,240, P < 0.001; F = 28.5, d.f. = 3,240, P < 0.001; F = 4.7, d.f. = 3,240, P < 0.01, respectively). The BPD subjects had less changes in character-related maturity with increasing age than did healthy comparison subjects. Post-hoc tests with Duncan's statistics revealed that subjects with BPD had significantly lower scores on self-directedness at all assessment time periods (P < 0.01) and lower scores on cooperativeness at the second-year and third-year follow-up assessments as compared to healthy comparison subjects (P < 0.01). The BPD subjects had a distinctively different developmental pattern of Cloninger's character compared to healthy comparison subjects. The character development of BPD patients was more fixed and immature than those of healthy comparison subjects.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

Borderline personality disorder (BPD) is a mental illness characterized by instability in interpersonal relationships, self-image, affect, and marked impulsivity.1 Although it is relatively rare among the general population (0.2–1.8%), there has been a report that 15% of psychiatric inpatients, and 50% of psychiatric inpatients with a diagnosis of personality disorder met diagnostic criteria for BPD.2 In addition, BPD is difficult to treat and frequently co-occurs with other psychiatric disorders.3

Some previous studies of the personality characteristics associated with BPD have primarily used  the five-factor model.4–7 Although the five-factor model assesses phenotypic structures of personality well, this model does not appear to coincide with genotypic structures of personality dimensions.8 In order to understand the etiology of BPD as well as for developing possible treatment strategies, consideration of biological and social causes of personality development is important.9

Cloninger has proposed a psychobiological model of the structure and development of personality consisting of four dimensions of temperament: novelty seeking (NS), harm avoidance (HA), reward dependence (RD), and persistence (PS), and three dimensions of character: self-directedness (SD), cooperativeness (CO), and self-transcendence (ST).10 While four temperament dimensions are independently heritable and manifest early in life, the latter three character dimensions mature in adulthood and influence personal and social effectiveness.10

Briefly, NS describes a genetic disposition towards being excitable, impulsive, exploratory, and quick-tempered. In contrast, HA implies a heritable bias towards being cautious, apprehensive, and overly pessimistic. Reward dependence involves maintaining or continuing behaviors that have been previously associated with reinforcement and is manifested as sensitivity, sentimentality, and dependency on others’ approval. Finally, PS implies a heritable bias towards continuing and persevering despite fatigue and lack of reward.10 Regarding character dimensions, SD implies an autonomous self-concept and feelings of hope, honor, and self-confidence. Cooperativeness involves identification with and acceptance of others, compassion, and charity and ST is related to spirituality, patience, and self-forgetfulness.10 In order to assess these character and temperament dimensions, Cloninger developed a self-report measure called the Temperament and Character Inventory (TCI).

There have been a few prior studies that have examined the relationship between Cloninger's biogenetic temperament/character and personality disorders. There is a report that character traits can be used to diagnose the presence and severity of personality disorder.11 Low SD9,12–15 and low CO9,13,14 were reported to be related with personality disorders.

However, these studies have some limitations in generalization of their results. All previous studies include subjects with various axis I and II disorders,9,12–14 although these samples may represent more naturally occurring BPD populations. In addition, there were no previous studies of prospective follow-up investigations of development of characters or temperaments.

Development of character traits such as identity and intimacy continues during adulthood.16 Also, age has been shown to be strongly correlated with SD and CO in different age groups.8 Unlike temperament, character is moderately influenced by sociocultural learning and  matures  in  progressive  steps  throughout  life.8 Thus, prospective follow-up investigations, accordingly, would be able to better clarify the development of characters in BPD patients.

The aim of the present study was to examine the following hypothesis. On baseline and three follow-up assessments, BPD subjects will show different pattern of character development from healthy comparison subjects. The BPD subjects will show more ‘fixed’ patterns of character development than healthy comparison subjects.

METHOD

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

Subjects

Subjects with BPD were recruited from the four women's and five co-ed high schools (total number of first-year students was over 3600) in Seoul metropolitan and Kyunggi provincial areas in South Korea. Inclusion criteria for the BPD subjects were (i) being a first-year female high school student; (ii) presence of borderline personality disorders, as determined by the Diagnostic Interview for Borderlines-Revised (DIB-R).17 Exclusion criteria for the current study included (i) current comorbid axis I disorders and past history of schizophrenia and bipolar disorder, as determined by the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (3rd edn, revised; DSM-III-R) non-patient version (SCID-NP);18 (ii) comorbid DSM-III-R axis II personality disorders, as determined by the Diagnostic Interview for Personality Disorders (DIPD);19 (iii) concurrent neurological or other significant medical illnesses and past history of brain trauma, encephalitis, seizure, or attention-deficit hyperactive disorder/learning disabilities, as evaluated by history, school reports, physical examination, and laboratory testing (complete blood count, liver function test, serology, and urine analysis).

Healthy comparison subjects were also recruited from first-year female high school students without any current or lifetime DSM-III-R axis I or II disorders. There was no significant difference in social class, as determined by Hollingshead and Redlich social class,20 between BPD subjects and healthy comparison subjects (2.1 ± 0.9 vs 1.9 ± 0.8).

Sample size analysis

Sample size calculations were based on expected differences in three character mean scores with an alpha level of 0.05. Because there were no previous studies on differences between subjects with and without BPD from which to infer an effect size, the medium effect size of 0.5 SD for mean differences was presumed. To provide an expected statistical power of 0.80 or greater for detecting differences in developmental pattern between subjects with and without BPD, the sample size for each group should be a minimum of 40 at follow up. With a yearly expected dropout rate of 5.0% in a sample of female high school students, the authors determined that the minimum sample size at baseline should be ≥47 for both groups with and without BPD.

Diagnostic procedure

Of 143 subjects who were originally recruited by the authors with the possible diagnosis of BPD, 91 were diagnosed to have BPD on the DIB-R. Among these subjects, 31 subjects with axis I disorders (dysthymia, n = 15; panic disorder, n = 8; generalized anxiety disorder, n = 5; eating disorder, n = 4; obsessive–compulsive disorder, n = 3; major depression, n = 3; schizophrenia, n = 2) and 25 subjects with comorbid axis II disorders (narcissistic personality disorder, n = 9; histrionic, n = 8; dependent, n = 7; schizotypal, n = 4; schizoid, n = 2; antisocial, n = 1; paranoid, n = 1) were excluded from the study, leaving a BPD sample size of 48.

At the initial assessment, the DIB-R and DIPD were administered by one psychiatrist and the SCID was administered by a different psychiatrist. All were blind to ratings obtained by the other raters.

Temperament and Character Inventory measurement

The Korean version of the TCI, a self-report questionnaire, was used to measure temperament and character dimensions. It consisted of 240 items, four dimensions of temperament (i.e. NS, HA, RD, PS) and three dimensions of character (i.e. SD, CO, ST). Reliability and validity of the Korean version of the TCI were successfully tested in a recent study using a sample of 550 non-clinical subjects.21

Follow-up assessment

Of the 48 initially recruited BPD subjects at baseline, 46 subjects were re-interviewed at approximately 1 year, within 1 month period, after initial interviews. At second-year follow-up assessments, there were 44 BPD subjects. Finally, there were 40 BPD subjects at third-year follow-up assessments. This report concerns the 40 subjects completing all four assessments. Out of the 45 healthy comparison subjects initially recruited, one and two subjects did not complete the second and third-year follow-up assessments, respectively, resulting in 42 comparison subjects. After complete description of the study to the subjects and their parents, written informed consent was obtained.

Statistical analysis

Group differences in demographic variables involving continuous data (age, educational level, baseline TCI scale scores) were computed using independent t-tests. Between-group comparisons involving categorical data were assessed using Fisher's exact tests.

Between-group differences in developmental patterns of SD, CO, and ST were assessed using a repeated-measures multivariate analysis of variance (manova). Post-hoc tests with Duncan's statistics were performed to assess significant differences between diagnostic groups at each time period and between times in each diagnostic group. Statistical significances were defined at the 0.01 level, two-tailed, considering the fact that multiple comparisons were performed. spss 10.0 for Windows (SPSS, Chicago, IL, USA) was used for most computations except power calculations, which were done by Sample Power 1.2 (SPSS).

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

The TCI subscale scores on four temperament and three character factors for BPD and comparison subjects are reported in Table 1. The results of the current study are as follows: at baseline, subjects with BPD had significantly higher scores on NS and HA among four temperament dimensions and lower scores on SD among three character dimensions as compared to psychiatrically healthy comparison subjects (Table 1).

Table 1.  Findings from the temperament and character scales in subjects with and without borderline personality disorder at baseline
SubscaleBorderline personality disorder (n = 40)Healthy comparison (n = 42)
MeanSDMeanSD
  1. Significant differences between groups: †independent t-test, d.f. = 80, t = 2.26, P = 0.027; ‡independent t-test, d.f. = 80, t = 2.53, P = 0.013; §independent t-test, d.f. = 80, t = 2.74, P = 0.008.

Novelty seeking22.56.619.55.4
Harm avoidance21.65.218.36.5
Reward dependence15.84.416.73.6
Persistence 4.52.6 3.81.9
Self-directedness§15.54.318.55.5
Cooperativeness24.54.925.44.4
Self-transcendence12.74.312.14.2

There was a significant difference in the developmental pattern of SD between BPD subjects and healthy  comparison  subjects  (significant  group  by time interaction: repeated measures manova, F = 17.3, d.f. = 3,240, P < 0.001, Fig. 1a). Healthy comparison subjects showed significantly greater SD score increase than BPD subjects at follow-up assessments (healthy comparison, 3rd > 2nd > 1st and baseline assessment; BPD, 3rd > baseline assessment). In addition, post-hoc tests revealed that subjects with BPD had significantly lower scores on SD at all four assessments as compared to healthy comparison subjects (P < 0.01).

imageimageimage

Figure 1. (a) Patterns of change in self-directedness scores in (•) 40 borderline personality disorder (BPD) subjects and (○) 42 healthy comparison subjects. Significant diagnostic group by time interaction (repeated measures manova, F = 17.3, d.f. = 3,240, P < 0.001). Post-hoc tests with Duncan's statistics (P < 0.01); significant differences between diagnostic groups: baseline, 1st, 2nd, and 3rd years; significant differences between times; BPD group: 3rd year > baseline; comparison group: 3rd year > 2nd year > 1st year, baseline. Error bars show standard  error of means (SEM). (b) Patterns of change in cooperativeness scores in (•) 40 BPD subjects and (○) 42 healthy comparison subjects. Significant diagnostic group by time interaction (repeated measures manova, F = 28.5, d.f. = 3,240, P < 0.001). Post-hoc tests with Duncan's statistics (P < 0.01). Significant differences between diagnostic groups: 2nd and 3rd years; significant differences between times; BPD group: no significant differences; comparison group: 3rd year > 2nd year > 1st year, baseline. Error bars show standard error of means (SEM). (c) Patterns of change in self-transcendence scores in (•) 40 BPD subjects and (○) 42 healthy comparison subjects. Significant diagnostic group by time interaction (repeated measures manova, F = 4.7, d.f. = 3,240, P < 0.01). Post-hoc tests with  Duncan's  statistics  (P < 0.01);  no significant differences between diagnostic groups at all assessments; significant differences between times; BPD group: no significant differences; comparison group: 3rd year > 2nd year, 1st year, 2nd year > baseline. Error bars show standard error of means (SEM).

The BPD subjects had a significantly different developmental pattern of CO as compared to healthy comparison subjects (significant group by time interaction, repeated measures manova, F = 28.5, d.f. = 3,240, P < 0.001, Fig. 1b). While BPD subjects had a non-significant increase in CO scores at follow-up assessments, CO scores in healthy comparison subjects were significantly higher than previous assessment (healthy comparison subjects, 3rd > 2nd > 1st and baseline assessment; BPD, no difference between assessments). Post-hoc tests revealed that subjects with BPD had significantly lower scores on CO at second-year and third-year follow-up assessments as compared to healthy comparison subjects (P < 0.01).

There was a significant difference in the developmental pattern of ST between BPD subjects and healthy comparison subjects (significant group by time interaction, repeated measures manova, F = 4.7, d.f. = 3,240, P < 0.01, Fig. 1c). Subjects with BPD had no significant differences in ST between times while healthy comparison subjects had a significant increase in ST scores (healthy comparison, 3rd > 2nd and 1st, 2nd > baseline assessment; BPD, no difference between assessments). According to the results of the post-hoc tests, there were no significant differences in ST between healthy comparison and BPD subjects at all assessments.

Out of the BPD group (n = 40), 33 subjects (82.5%) retained the diagnosis of BPD at the 3 year follow up. Out of the healthy comparison group (n = 42), 39 subjects (92.9%) were without BPD and two (4.8%) met the diagnostic criteria for BPD at the 3 year follow up. When differences in developmental patterns of SD, CO, and ST were analyzed between subjects who did and did not meet the diagnostic criteria for BPD at the 3 year follow up (n = 35 and 47, respectively), similar patterns of interactions for SD, CO, and ST were found (F = 11.5, 21.9, 5.6, respectively; d.f. = 3,240; P < 0.001).

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

Subjects with BPD had low scores on SD at all assessments as compared to healthy comparison subjects. This result is in line with the results of previous studies.9,12,14 Subjects with BPD had low scores on CO at second-year and third-year follow-up assessments as compared to healthy comparison subjects. This result accords well with the result of Svrakic et al., who found a negative correlation between BPD symptom and CO,9 considering that subjects of their study were mainly adults.

As an additional point different from previous investigations, the current long-term longitudinal study examined differences in the developmental patterns of character in BPD and healthy comparison subjects. There were significant differences in the developmental patterns of the three character dimensions between BPD subjects and healthy comparison subjects.

Regarding the first character dimension, SD, we found that healthy comparison subjects had significantly increasing scores on SD from baseline and first-year assessments to third-year assessment whereas subjects with BPD had higher scores only at third-year assessments than at baseline. These results indicate that BPD subjects had little change in SD-related maturity with increasing age, while healthy comparison subjects tended to become more responsible, goal-oriented, and effective in personality development with aging.

On CO, healthy comparison subjects had significantly increasing scores from baseline and first-year assessments to third-year assessment whereas subjects with BPD had no significant increases. This indicates that psychiatrically healthy individuals tend to become more empathetic, tolerant, compassionate, supportive, and cooperative with increasing age while subjects with BPD do not develop these characteristics in spite of growing older.

Regarding the other character dimension of ST, BPD subjects had a significantly different developmental pattern from healthy comparison subjects. Subjects with BPD had no significant changes in ST scores while healthy comparison subjects had gradually increasing scores from baseline to third-year assessment.

A brief comment on temperamental differences between groups with and without BPD at baseline assessment is as follows. Subjects with BPD had higher scores on HA and NS as compared with healthy comparison subjects. These results of the current study may be in line with the previous result.9 High scores on HA and NS suggest that subjects with BPD may have frequent approach–avoidance conflicts.8 They tend to  be  cautious,  shy,  and  fatiguable  but  at  the  same time, quick-tempered, impulsive, extravagant, and disorderly.

Differences in character development may make individuals with similar temperament profiles exhibit different behaviors.8 Therefore, understanding the temperament and character patterns in adolescent BPD patients may help individualize therapeutic approach. The present study suggests that appropriate psychosocial treatment may be needed and helpful for character development of adolescent BPD patients because sociocultural learning can influence character.8

To the best of our knowledge, this is the first study to evaluate the differences in developmental patterns of Cloninger's character dimensions between comparison and BPD subjects. The present study's sample of female, Korean subjects may limit the generalizability of the current findings. However, as aforementioned, investigations of an American sample found a similar pattern of results linking the number of symptoms for BPD and biogenetic temperament and character factors.9 Thus, the current findings may offer a contribution to understanding of the development of character and temperament from late adolescence into early adulthood, especially in relation to the diagnosis and course of BPD.

In conclusion, the results of the present study report differences in developmental patterns of the Cloninger's biogenetic character dimensions between subjects with and without BPD. This finding may offer a basis of understanding developmental patterns in character in women with and without BPD. Future research is recommended to investigate the developmental patterns of characters in other personality disorders as well as to verify the current findings as unique to BPD.

ACKNOWLEDGMENTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

This work was supported, in part, by grants from the Seoul National University Hospital (04-2002-010-0), the Dae-Ho Award of the Korean Neuropsychiatric Association, the National Alliance for Research on Schizophrenia and Depression (NARSAD) Young Investigator Award, and the Harvard–MIT Clinical Investigator Training Program Fellowship (IKL).

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. METHOD
  5. RESULTS
  6. DISCUSSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES
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