Hostname: page-component-76fb5796d-skm99 Total loading time: 0 Render date: 2024-04-26T03:36:21.041Z Has data issue: false hasContentIssue false
  • English
  • Français

The contribution of familial internalizing and externalizing liability factors to borderline personality disorder

Published online by Cambridge University Press:  09 January 2014

J. I. Hudson ,
M. C. Zanarini ,
K. S. Mitchell ,
L. W. Choi-Kain  and
J. G. Gunderson
J. I. Hudson*
Affiliation:
Department of Psychiatry, Harvard Medical School, McLean Hospital, Belmont, MA, USA
M. C. Zanarini
Affiliation:
Department of Psychiatry, Harvard Medical School, McLean Hospital, Belmont, MA, USA
K. S. Mitchell
Affiliation:
National Center for Posttraumatic Stress Disorder, Women's Health Sciences Division, Veterans Affairs, Boston Healthcare System and Boston University School of Medicine, Boston, MA, USA
L. W. Choi-Kain
Affiliation:
Department of Psychiatry, Harvard Medical School, McLean Hospital, Belmont, MA, USA
J. G. Gunderson
Affiliation:
Department of Psychiatry, Harvard Medical School, McLean Hospital, Belmont, MA, USA
*
*Address for correspondence: J. I. Hudson, M.D., Sc.D., McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA. (Email: jhudson@mclean.harvard.edu)
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Individuals with borderline personality disorder (BPD) frequently display co-morbid mental disorders. These disorders include ‘internalizing’ disorders (such as major depressive disorder and anxiety disorders) and ‘externalizing’ disorders (such as substance use disorders and antisocial personality disorder). It is hypothesized that these disorders may arise from latent ‘internalizing’ and ‘externalizing’ liability factors. Factor analytic studies suggest that internalizing and externalizing factors both contribute to BPD, but the extent to which such contributions are familial is unknown.

Method

Participants were 368 probands (132 with BPD; 134 without BPD; and 102 with major depressive disorder) and 885 siblings and parents of probands. Participants were administered the Diagnostic Interview for DSM-IV Personality Disorders, the Revised Diagnostic Interview for Borderlines, and the Structured Clinical Interview for DSM-IV.

Results

On confirmatory factor analysis of within-person associations of disorders, BPD loaded moderately on internalizing (factor loading 0.53, s.e. = 0.10, p < 0.001) and externalizing latent variables (0.48, s.e. = 0.10, p < 0.001). Within-family associations were assessed using structural equation models of familial and non-familial factors for BPD, internalizing disorders, and externalizing disorders. In a Cholesky decomposition model, 84% (s.e. = 17%, p < 0.001) of the association of BPD with internalizing and externalizing factors was accounted for by familial contributions.

Conclusions

Familial internalizing and externalizing liability factors are both associated with, and therefore may mutually contribute to, BPD. These familial contributions account largely for the pattern of co-morbidity between BPD and internalizing and externalizing disorders.

Keywords

Borderline personality disorderexternalizing disordersfamily studyinternalizing disorders
Type
Original Articles
Information
Psychological Medicine , Volume 44 , Issue 11 , August 2014 , pp. 2397 - 2407
Copyright
Copyright © Cambridge University Press 2014 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Aggen, SH, Neale, MC, Roysamb, E, Reichborn-Kjennerud, T, Kendler, KS (2009). A psychometric evaluation of the DSM-IV borderline personality disorder criteria: age and sex moderation of criterion functioning. Psychological Medicine 39, 1967–1978.CrossRefGoogle ScholarPubMed
Arnold, LM, Hudson, JI, Keck, PE, Auchenbach, MB, Javaras, KN, Hess, EV (2006). Comorbidity of fibromyalgia and psychiatric disorders. Journal of Clinical Psychiatry 67, 1219–1225.CrossRefGoogle ScholarPubMed
Baron, M, Gruen, R, Asnis, L, Lord, S (1985). Familial transmission of schizotypal and borderline personality disorders. American Journal of Psychiatry 142, 927–934.Google ScholarPubMed
Bornovalova, MA, Hicks, BM, Iacono, WG, McGue, M (2009). Stability, change, and heritability of borderline personality disorder traits from adolescence to adulthood: a longitudinal twin study. Developmental Psychopathology 21, 1335–1353.CrossRefGoogle ScholarPubMed
Chanen, AM, Kaess, M (2012). Developmental pathways to borderline personality disorder. Current Psychiatry Reports 14, 45–53.CrossRefGoogle ScholarPubMed
Crowell, SE, Beauchaine, TP, Linehan, MM (2009). A biosocial developmental model of borderline personality: elaborating and extending Linehan's theory. Psychological Bulletin 135, 495–510.CrossRefGoogle ScholarPubMed
Distel, MA, Trull, TJ, Derom, CA, Thiery, EW, Grimmer, MA, Martin, NG, Willemsen, G, Boomsma, DI (2008). Heritability of borderline personality disorder features is similar across three countries. Psychological Medicine 38, 1219–1229.CrossRefGoogle ScholarPubMed
Distel, MA, Willemsen, G, Ligthart, L, Derom, CA, Martin, NG, Neale, MC, Trull, TJ, Boomsma, DI (2010). Genetic covariance structure of the four main features of borderline personality disorder. Journal of Personality Disorders 24, 427–444.CrossRefGoogle ScholarPubMed
Eaton, NR, Krueger, RF, Keyes, KM, Skodol, AE, Markon, KE, Grant, BF, Hasin, DS (2011). Borderline personality disorder co-morbidity: relationship to the internalizing–externalizing structure of common mental disorders. Psychological Medicine 41, 1041–1050.CrossRefGoogle Scholar
First, MB, Spitzer, RL, Gibbons, M, Williams, JBW (1996). Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). New York State Psychiatric Institute: New York.Google Scholar
Gunderson, JG, Zanarini, MC, Choi-Kain, LW, Mitchell, KS, Jang, KL, Hudson, JI (2011). Family study of borderline personality disorder and its sectors of psychopathology. Archives of General Psychiatry 68, 753–762.CrossRefGoogle ScholarPubMed
Hettema, JM, Neale, MC, Kendler, KS (2001). A review and meta-analysis of the genetic epidemiology of anxiety disorders. American Journal of Psychiatry 158, 1568–1578.CrossRefGoogle ScholarPubMed
Hicks, BM, Krueger, RF, Iacono, WG, McGue, M, Patrick, CJ (2004). Family transmission and heritability of externalizing disorders: a twin-family study. Archives of General Psychiatry 61, 922–928.CrossRefGoogle ScholarPubMed
Hudson, JI, Javaras, KN, Laird, NM, VanderWeele, TJ, Pope, HG, Hernan, MA (2008). A structural approach to the familial coaggregation of disorders. Epidemiology 19, 431–439.CrossRefGoogle Scholar
Hudson, JI, Mangweth, B, Pope, HG Jr, De Col, C, Hausmann, A, Gutweniger, S, Laird, NM, Biebl, W, Tsuang, MT (2003). Family study of affective spectrum disorder. Archives of General Psychiatry 60, 170–177.CrossRefGoogle ScholarPubMed
Insel, T, Cuthbert, B, Garvey, M, Heinssen, R, Pine, DS, Quinn, K, Sanislow, C, Wang, P (2010). Research Domain Criteria (RDoC): toward a new classification framework for research on mental disorders. American Journal of Psychiatry 167, 748–751.CrossRefGoogle Scholar
James, LM, Taylor, J (2008). Revisiting the structure of mental disorders: borderline personality disorder and the internalizing/externalizing spectra. British Journal of Clinical Psychology 47, 361–380.CrossRefGoogle ScholarPubMed
Jang, KL, Livesley, WJ, Vernon, PA, Jackson, DN (1996). Heritability of personality disorder traits: a twin study. Acta Psychiatrica Scandinavica 94, 438–444.CrossRefGoogle ScholarPubMed
Javaras, KN, Hudson, JI, Laird, NM (2010 a). Fitting ACE structural equation models to case–control family data. Genetic Epidemiology 34, 238–245.CrossRefGoogle ScholarPubMed
Javaras, KN, Laird, NM, Hudson, JI, Ripley, BD (2010 b). Estimating disease prevalence using relatives of case and control probands. Biometrics 66, 214–221.CrossRefGoogle ScholarPubMed
Javaras, KN, Laird, NM, Reichborn-Kjennerud, T, Bulik, CM, Pope, HG Jr, Hudson, JI (2008 a). Familiality and heritability of binge eating disorder: results of a case–control family study and a twin study. International Journal of Eating Disorders 41, 174–179.CrossRefGoogle Scholar
Javaras, KN, Pope, HG, Lalonde, JK, Roberts, JL, Nillni, YI, Laird, NM, Bulik, CM, Crow, SJ, McElroy, SL, Walsh, BT, Tsuang, MT, Rosenthal, NR, Hudson, JI (2008 b). Co-occurrence of binge eating disorder with psychiatric and medical disorders. Journal of Clinical Psychiatry 69, 266–273.CrossRefGoogle ScholarPubMed
Johansen, M, Karterud, S, Pedersen, G, Gude, T, Falkum, E (2004). An investigation of the prototype validity of the borderline DSM-IV construct. Acta Psychiatrica Scandinavica 109, 289–298.CrossRefGoogle ScholarPubMed
Kendler, KS (2012). Levels of explanation in psychiatric and substance use disorders: implications for the development of an etiologically based nosology. Molecular Psychiatry 17, 11–21.CrossRefGoogle ScholarPubMed
Kendler, KS, Aggen, SH, Czajkowski, N, Roysamb, E, Tambs, K, Torgersen, S, Neale, MC, Reichborn-Kjennerud, T (2008). The structure of genetic and environmental risk factors for DSM-IV personality disorders: a multivariate twin study. Archives of General Psychiatry 65, 1438–1446.CrossRefGoogle ScholarPubMed
Kendler, KS, Aggen, SH, Knudsen, GP, Roysamb, E, Neale, MC, Reichborn-Kjennerud, T (2011 a). The structure of genetic and environmental risk factors for syndromal and subsyndromal common DSM-IV Axis I and all Axis II disorders. American Journal of Psychiatry 168, 29–39.CrossRefGoogle ScholarPubMed
Kendler, KS, Davis, CG, Kessler, RC (1997). The familial aggregation of common psychiatric and substance use disorders in the National Comorbidity Survey: a family history study. British Journal of Psychiatry 170, 541–548.CrossRefGoogle ScholarPubMed
Kendler, KS, Eaves, LJ (2005). Psychiatric Genetics (Review of Psychiatry). American Psychiatric Association: Washington, DC.Google Scholar
Kendler, KS, Myers, J, Reichborn-Kjennerud, T (2011 b). Borderline personality disorder traits and their relationship with dimensions of normative personality: a web-based cohort and twin study. Acta Psychiatrica Scandinavica 123, 349–359.CrossRefGoogle ScholarPubMed
Kendler, KS, Prescott, CA, Myers, J, Neale, MC (2003). The structure of genetic and environmental risk factors for common psychiatric and substance use disorders in men and women. Archives of General Psychiatry 60, 929–937.CrossRefGoogle ScholarPubMed
Kendler, KS, Silberg, JL, Neale, MC, Kessler, RC, Heath, AC, Eaves, LJ (1991). The family history method: whose psychiatric history is measured? American Journal of Psychiatry 148, 1501–1504.Google ScholarPubMed
Kessler, RC, Ormel, J, Petukhova, M, McLaughlin, KA, Green, JG, Russo, LJ, Stein, DJ, Zaslavsky, AM, Aguilar-Gaxiola, S, Alonso, J, Andrade, L, Benjet, C, de Girolamo, G, de Graaf, R, Demyttenaere, K, Fayyad, J, Haro, JM, Hu, C, Karam, A, Lee, S, Lepine, JP, Matchsinger, H, Mihaescu-Pintia, C, Posada-Villa, J, Sagar, R, Ustun, TB (2011). Development of lifetime comorbidity in the World Health Organization world mental health surveys. Archives of General Psychiatry 68, 90–100.CrossRefGoogle ScholarPubMed
Klein, DN, Riso, LP, Donaldson, SK, Schwartz, JE, Anderson, RL, Ouimette, PC, Lizardi, H, Aronson, TA (1995). Family study of early-onset dysthymia. Mood and personality disorders in relatives of outpatients with dysthymia and episodic major depression and normal controls. Archives of General Psychiatry 52, 487–496.CrossRefGoogle ScholarPubMed
Kotov, R, Ruggero, CJ, Krueger, RF, Watson, D, Yuan, Q, Zimmerman, M (2011). New dimensions in the quantitative classification of mental illness. Archives of General Psychiatry 68, 1003–1011.CrossRefGoogle ScholarPubMed
Krueger, RF (1999). The structure of common mental disorders. Archives of General Psychiatry 56, 921–926.CrossRefGoogle ScholarPubMed
Krueger, RF, Caspi, A, Moffitt, TE, Silva, PA (1998). The structure and stability of common mental disorders (DSM-III-R): a longitudinal-epidemiological study. Journal of Abnormal Psychology 107, 216–227.CrossRefGoogle ScholarPubMed
Links, PS, Steiner, M, Huxley, G (1988). The occurrence of borderline personality disorder in the families of borderline patients. Journal of Personality Disorders 2, 14–20.CrossRefGoogle Scholar
Livesley, WJ, Jang, KL (2008). The behavioral genetics of personality disorder. Annual Review of Clinical Psychology 4, 247–274.CrossRefGoogle ScholarPubMed
Loranger, AW, Tulis, EH (1985). Family history of alcoholism in borderline personality disorder. Archives of General Psychiatry 42, 153–157.CrossRefGoogle ScholarPubMed
Muthén, LK, Muthén, BO (1998–2010). Mplus Users Guide, 6th edn. Muthén & Muthén: Los Angeles.Google Scholar
Paris, J (2007). The nature of borderline personality disorder: multiple dimensions, multiple symptoms, but one category. Journal of Personality Disorders 21, 457–473.CrossRefGoogle ScholarPubMed
Pope, HG Jr, Jonas, JM, Hudson, JI, Cohen, BM, Gunderson, JG (1983). The validity of DSM-III borderline personality disorder. A phenomenologic, family history, treatment response, and long-term follow-up study. Archives of General Psychiatry 40, 23–30.CrossRefGoogle ScholarPubMed
Riso, LP, Klein, DN, Anderson, RL, Ouimette, PC (2000). A family study of outpatients with borderline personality disorder and no history of mood disorder. Journal of Personality Disorders 14, 208–217.CrossRefGoogle ScholarPubMed
Roy, MA, Walsh, D, Kendler, KS (1996). Accuracies and inaccuracies of the family history method: a multivariate approach. Acta Psychiatrica Scandinavica 93, 224–234.CrossRefGoogle Scholar
Roysamb, E, Kendler, KS, Tambs, K, Orstavik, RE, Neale, MC, Aggen, SH, Torgersen, S, Reichborn-Kjennerud, T (2011). The joint structure of DSM-IV Axis I and Axis II disorders. Journal of Abnormal Psychology 120, 198–209.CrossRefGoogle ScholarPubMed
Ruocco, AC (2005). Reevaluating the distinction between Axis I and Axis II disorders: the case of borderline personality disorder. Journal of Clinical Psychology 61, 1509–1523.CrossRefGoogle ScholarPubMed
Ruocco, AC, Laporte, L, Russell, J, Guttman, H, Paris, J (2012). Response inhibition deficits in unaffected first-degree relatives of patients with borderline personality disorder. Neuropsychology 26, 473–482.CrossRefGoogle ScholarPubMed
Sanislow, CA, Grilo, CM, Morey, LC, Bender, DS, Skodol, AE, Gunderson, JG, Shea, MT, Stout, RL, Zanarini, MC, McGlashan, TH (2002). Confirmatory factor analysis of DSM-IV criteria for borderline personality disorder: findings from the collaborative longitudinal personality disorders study. American Journal of Psychiatry 159, 284–290.CrossRefGoogle Scholar
Siever, LJ, Torgersen, S, Gunderson, JG, Livesley, WJ, Kendler, KS (2002). The borderline diagnosis III: identifying endophenotypes for genetic studies. Biological Psychiatry 51, 964–968.CrossRefGoogle ScholarPubMed
Silverman, JM, Pinkham, L, Horvath, TB, Coccaro, EF, Klar, H, Schear, S, Apter, S, Davidson, M, Mohs, RC, Siever, LJ (1991). Affective and impulsive personality disorder traits in the relatives of patients with borderline personality disorder. American Journal of Psychiatry 148, 1378–1385.Google ScholarPubMed
Slade, T (2007). The descriptive epidemiology of internalizing and externalizing psychiatric dimensions. Social Psychiatry and Psychiatric Epidemiology 42, 554–560.CrossRefGoogle ScholarPubMed
Stepp, SD, Burke, JD, Hipwell, AE, Loeber, R (2012). Trajectories of attention deficit hyperactivity disorder and oppositional defiant disorder symptoms as precursors of borderline personality disorder symptoms in adolescent girls. Journal of Abnormal Child Psychology 40, 7–20.CrossRefGoogle ScholarPubMed
Sullivan, PF, Neale, MC, Kendler, KS (2000). Genetic epidemiology of major depression: review and meta-analysis. American Journal of Psychiatry 157, 1552–1562.CrossRefGoogle ScholarPubMed
Torgersen, S, Lygren, S, Oien, PA, Skre, I, Onstad, S, Edvardsen, J, Tambs, K, Kringlen, E (2000). A twin study of personality disorders. Comprehensive Psychiatry 41, 416–425.CrossRefGoogle ScholarPubMed
Vollebergh, WA, Ledema, J, Bijl, RV, de Graaf, R, Smit, F, Ormel, J (2001). The structure and stability of common mental disorders: the NEMESIS study. Archives of General Psychiatry 58, 597–603.CrossRefGoogle ScholarPubMed
White, CN, Gunderson, JG, Zanarini, MC, Hudson, JI (2003). Family studies of borderline personality disorder: a review. Harvard Review of Psychiatry 11, 8–19.Google ScholarPubMed
Zanarini, MC, Barison, LK, Frankenburg, FR, Reich, DB, Hudson, JI (2009). Family history study of the familial coaggregation of borderline personality disorder with Axis I and nonborderline dramatic cluster Axis II disorders. Journal of Personality Disorders 23, 357–369.CrossRefGoogle ScholarPubMed
Zanarini, MC, Frankenburg, FR, Hennen, J, Reich, DB, Silk, KR (2004 a). Axis I comorbidity in patients with borderline personality disorder: 6-year follow-up and prediction of time to remission. American Journal of Psychiatry 161, 2108–2114.CrossRefGoogle ScholarPubMed
Zanarini, MC, Frankenburg, FR, Khera, GS, Bleichmar, J (2001). Treatment histories of borderline inpatients. Comprehensive Psychiatry 42, 144–150.CrossRefGoogle ScholarPubMed
Zanarini, MC, Frankenburg, FR, Sickel, AE, Yong, L (1996). The Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV). McLean Hospital: Belmont, MA.Google Scholar
Zanarini, MC, Frankenburg, FR, Vujanovic, AA, Hennen, J, Reich, DB, Silk, KR (2004 b). Axis II comorbidity of borderline personality disorder: description of 6-year course and prediction to time-to-remission. Acta Psychiatrica Scandinavica 110, 416–420.CrossRefGoogle ScholarPubMed
Zanarini, MC, Gunderson, JG, Frankenburg, FR, Chauncey, DL (1989). The Revised Diagnostic Interview for Borderlines: discriminating BPD from other Axis II disorders. Journal of Personality Disorders 3, 10–18.CrossRefGoogle Scholar
Zanarini, MC, Gunderson, JG, Marino, MF, Schwartz, EO, Frankenburg, FR (1988). DSM-III disorders in the families of borderline outpatients. Journal of Personality Disorders 2, 292–302.CrossRefGoogle Scholar