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Letter to the Editor   |    
Drs. Zanarini and Frankenburg Reply
MARY C. ZANARINI, ED.D.; FRANCES R. FRANKENBURG, M.D.
Am J Psychiatry 1998;155:1626ab-1626.
View Author and Article Information
Belmont, Mass.

Letters to the Editor

To the Editor: We appreciate the comments of Dr. Salzman, who brings up the important issue of whether sexual abuse is associated with the etiology of borderline personality disorder per se or only with that of severe inpatient cases of borderline personality disorder. Previous research has found that the rates of childhood sexual abuse are about the same for criteria-defined borderline outpatients and inpatients R6815511CHDEBGDGR6815511CHDDCBFI. Dr. Salzman and her colleagues, however, found a substantially lower rate of abuse in a group of symptomatic volunteers R6815511CHDCFIID.

Clinical experience suggests that the boundary between outpatients and inpatients with borderline personality disorder is quite permeable, with today’s outpatient being tomorrow’s inpatient and vice versa. In this regard, it is important to note that studies have consistently found that a substantial percentage of outpatients with borderline personality disorder have a history of prior hospitalization R6815511CHDCHIDJR6815511CHDBCEJH.

Thus, Dr. Salzman is highlighting the existence of a third group of patients—mild outpatient cases of borderline personality disorder with no history of psychiatric hospitalization. In our clinical experience, patients with the diagnosis of borderline personality disorder who have never been hospitalized lack the impulsivity of those patients who have been inpatients, since patients with borderline personality disorder are typically hospitalized for their own protection during periods of intense self-destructiveness. This raises the question of whether "borderline" patients who have never been hospitalized are, in fact, borderline at all or whether they should be considered patients with borderline traits or features. To phrase the question another way: should nonimpulsive patients who manifest the intense dysphoria, suspiciousness and dissociation, and difficult, stormy relationships characteristic of borderline personality disorder be considered borderline? Should someone without a history of deliberate physical self-harm, help-seeking suicidal efforts, or both be thought of as a borderline patient?

Further research is needed to untangle these issues. Until that time, we can only reiterate that even in the most severely impaired of borderline subjects, we have found that childhood sexual abuse is neither necessary nor sufficient for the development of borderline personality disorder.

Herman JL, Perry JC, van der Kolk BA: Childhood trauma in borderline personality disorder. Am J Psychiatry  1989; 146:490–495
[PubMed]
 
Links PS, Steiner M, Offord DR, Eppel A: Characteristics of borderline personality disorder: a Canadian study. Can J Psychiatry  1988; 33:336–340
[PubMed]
 
Ogata SN, Silk KR, Goodrich S, Lohr NE, Westen D, Hill EM: Childhood sexual and physical abuse in adult patients with borderline personality disorder. Am J Psychiatry  1990; 147:1008–1013
[PubMed]
 
Paris J, Zweig-Frank H, Guzder J: Psychological risk factors for borderline personality disorder in female patients. Compr Psychiatry  1994; 35:301–305
[PubMed]
[CrossRef]
 
Paris J, Zweig-Frank H, Guzder J: Risk factors for borderline personality in male outpatients. J Nerv Ment Dis  1994; 182:375–380
[PubMed]
[CrossRef]
 
Shearer SL, Peters CP, Quaytman MS, Ogden RL: Frequency and correlates of childhood sexual and physical abuse histories in adult female borderline inpatients. Am J Psychiatry  1990; 147:214–216
[PubMed]
 
Westen D, Ludolph P, Misle B, Ruffins S, Block J: Physical and sexual abuse in adolescent girls with borderline personality disorder. Am J Orthopsychiatry  1990; 60:55–66
[PubMed]
[CrossRef]
 
Zanarini MC, Gunderson JG, Marino MF, Schwartz EO, Frankenburg FR: Childhood experiences of borderline patients. Compr Psychiatry  1989; 30:18–25
[PubMed]
[CrossRef]
 
Zanarini MC, Williams AA, Lewis RE, Reich DB, Vera SC, Marino MF, Levin A, Yong L, Frankenburg FR: Reported pathological childhood experiences associated with the development of borderline personality disorder. Am J Psychiatry  1997; 154:1101–1106
[PubMed]
 
Salzman JP, Salzman C, Wolfson AN, Albanese M, Looper J, Ostacher M, Schwartz J, Chinman G, Land W, Miyawaki E: Association between borderline personality structure and history of childhood abuse in adult volunteers. Compr Psychiatry  1993; 34:254–257
[PubMed]
[CrossRef]
 
Skodol AE, Buckley P, Charles E: Is there a characteristic pattern to the treatment history of clinic outpatients with borderline personality? J Nerv Ment Dis  1983; 171:405–410
 
Swartz M, Blazer D, George L, Winfield I: Estimating the prevalence of borderline personality disorder in the community. J Personality Disorders  1990; 4:257–272
[CrossRef]
 
+

References

Herman JL, Perry JC, van der Kolk BA: Childhood trauma in borderline personality disorder. Am J Psychiatry  1989; 146:490–495
[PubMed]
 
Links PS, Steiner M, Offord DR, Eppel A: Characteristics of borderline personality disorder: a Canadian study. Can J Psychiatry  1988; 33:336–340
[PubMed]
 
Ogata SN, Silk KR, Goodrich S, Lohr NE, Westen D, Hill EM: Childhood sexual and physical abuse in adult patients with borderline personality disorder. Am J Psychiatry  1990; 147:1008–1013
[PubMed]
 
Paris J, Zweig-Frank H, Guzder J: Psychological risk factors for borderline personality disorder in female patients. Compr Psychiatry  1994; 35:301–305
[PubMed]
[CrossRef]
 
Paris J, Zweig-Frank H, Guzder J: Risk factors for borderline personality in male outpatients. J Nerv Ment Dis  1994; 182:375–380
[PubMed]
[CrossRef]
 
Shearer SL, Peters CP, Quaytman MS, Ogden RL: Frequency and correlates of childhood sexual and physical abuse histories in adult female borderline inpatients. Am J Psychiatry  1990; 147:214–216
[PubMed]
 
Westen D, Ludolph P, Misle B, Ruffins S, Block J: Physical and sexual abuse in adolescent girls with borderline personality disorder. Am J Orthopsychiatry  1990; 60:55–66
[PubMed]
[CrossRef]
 
Zanarini MC, Gunderson JG, Marino MF, Schwartz EO, Frankenburg FR: Childhood experiences of borderline patients. Compr Psychiatry  1989; 30:18–25
[PubMed]
[CrossRef]
 
Zanarini MC, Williams AA, Lewis RE, Reich DB, Vera SC, Marino MF, Levin A, Yong L, Frankenburg FR: Reported pathological childhood experiences associated with the development of borderline personality disorder. Am J Psychiatry  1997; 154:1101–1106
[PubMed]
 
Salzman JP, Salzman C, Wolfson AN, Albanese M, Looper J, Ostacher M, Schwartz J, Chinman G, Land W, Miyawaki E: Association between borderline personality structure and history of childhood abuse in adult volunteers. Compr Psychiatry  1993; 34:254–257
[PubMed]
[CrossRef]
 
Skodol AE, Buckley P, Charles E: Is there a characteristic pattern to the treatment history of clinic outpatients with borderline personality? J Nerv Ment Dis  1983; 171:405–410
 
Swartz M, Blazer D, George L, Winfield I: Estimating the prevalence of borderline personality disorder in the community. J Personality Disorders  1990; 4:257–272
[CrossRef]
 
+
+

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