Discriminating the panic disorder patient from patients with borderline personality disorder

Pergamon

Journal of Anxiety Disorders, Vol. 8, No. 1, pp. 49-61.1994 Copyright 0 1994 Else& Science Ltd Printed in the USA. Au rightsreserved

0887-6185/94 $6.00+ .oO

Discriminating the Panic Disorder Patient from Patients with Borderline Personality Disorder STEVEN FRIEDMAN, PH.D. AND LESLIE CHERNEN, PH.D. State University of New York, Health Science Center at Brooklyn

Abstract - A discriminant function analysis of 72 patients with Panic Disorder (PD) and agoraphobia, and 68 patients with Borderline Personality Disorder (BPD) and PD revealed five main factors that discriminated the two groups at a 94% accuracy rate. BPD patients were more likely to he female, single, and of lower socio-economic status. They reported a high rate of suicide attempts (25% vs. 0%). panic attacks that lasted longer witb more fearful thoughts, more social phobia, and “‘anger.”They were also more likely to report a history of substance abuse, a cbildbocd with familial conflict including sexual and/or physical abuse, mom medical emergency room visits, an overall poorer treatment response, more adverse reactions to relaxation training and, not surprisingly, more multiple chronic stresses.

The purpose of this study was to determine discriminating characteristics of those patients with a primary diagnosis of Panic Disorder (PD) vs. those patients who were comorbid for both Borderline Personality Disorder (BPD) and PD. The ability to make this crucial determination has not received much empirical attention and could greatly enhance treatment efficiency and efficacy. It has long been known that patients with BPD are at increased risk for suicidal behavior (Gunderson, 1984), and generally have a poor treatment outcome (Stone, 1987). Increased publicity for the treatment efficacy for panic disorder (Barlow, 1988) is likely to encourage many patients with BPD who are comorbid for panic disorder and/or attacks to present for specialized treatment of their panic attacks, rather than the intensive long-term therapy they require.

This work was supported in part by NIMH grant MH 42545. The authors would like to thank Dr. Margolis for his help in the statistical analysis, and two anonymous reviewers for their suggestions. An earlier version of this paper was presented at tbe 24th annual meeting of the Association for Advancement of Behavior Therapy. Correspondence should be addressed to Steven Friedman, Ph.D., State University of New York, Health Science Center at Brooklyn, Department of Psychiatry/Box 1203, 450 Clarkson Avenue, Brooklyn, NY 11203. 49

50

S. FRIEDMAN AND L. CHERNEN

Prior to development of DSM-III-R (1987), Roth and colleagues (Roth, 1959; Harper & Roth, 1962; Roth & Harper, 1962) reported on the characteristic features of a group of patients who met criteria for what was described as the phobic anxiety-depersonalization syndrome. Patients were described as experiencing a neurotic illness in which there was a combination of phobias and depersonalization. Onset of this illness followed soon after some traumatic event. Patients were described as having a protracted course, sustained emotional disturbance, and considerable social disability. They were also described as having variable depressive, obsessional, hysterical, and hypochondriacal symptoms. In one study, Harper and Roth (1962) compared 30 patients with phobic anxiety-depersonalization syndrome to 30 patients with temporal lobe epilepsy. In patients with phobic anxiety-depersonalization syndrome, one third described suicidal ideation. The authors also stated, “In addition to the central features of phobic anxiety and depersonalization, other neurotic symptoms are significantly more common in the phobic anxiety-depersonalization syndrome and completes the picture of a pan-neurosis” (p. 142). In another paper, Roth & Harper (1962) described their findings that some patients with this disorder may at times experience a transient psychotic disorder. In retrospect, many of the patients with phobic anxiety-depersonalization syndrome may have met current DSM-III-R criteria for BPD. Panic attacks have also been demonstrated to be a frequent occurrence in normal populations (Telch, Lucas, & Nelson, 1989). in a variety of anxiety disorders (Barlow, Vermilyea, Blanchard, Vermilyea, DiNardo, & Cerny, 1985), and affective disorders (Pollard, Detrick, Flynn, & Frank, 1990). However, historically panic attacks were often seen as one of the pan-neurotic symptoms in the patient with BPD. BPD is characterized by a mixture of relationship and affective instability, impulsivity and excesses in behaviors, identity disturbance, emptiness/boredom, fear of abandonment, and recurrent suicidal threats and behavior (APA, 1987). In a large-scale study (Links, Steiner, Offord, & Eppel, 1988), it was reported that 85% of patients with BPD were female and all suffered from a host of psychiatric conditions, including major depression (68%), mania (6%), bipolar disorder (1 l%), panic disorder (12%), alcoholism (31%), and drug use (23%). Gunderson (1984) has suggested that parasuicidal behavior may be the best representation of the “behavioral specialty” of this personality disorder (p. 262). In addition to increased risks for suicide and substance abuse, patients with BPD have long been noted to have poor compliance to treatment. The therapeutic relationship is often experienced as “stormy” and fraught with difficulties (Horwitz, 1987; Stone, 1987). A recent study (Zanarini, Gunderson, Frankenburg, & Chauncey, 1990) has demonstrated that BPD patients were significantly more likely than other personality disordered patients to exhibit features of chronic feelings of helplessness, hopelessness, worthlessness, and guilt. The authors concluded that patients with BPD were more likely to “report chronic feelings of anxiety than control subjects with other Axis-II disorders, a finding that, in turn, confirms the clinical impressions of numerous early observers of the borderline condition” (p. 163). Given that panic attacks are one of the many “neurotic” symptoms that BPD patients may suffer from, it is likely that patients with a diagnosis of PD may

PANIC DISORDER AND BORDERLINE PERSONALITY DISORDER

51

also suffer from BPD, as well as other Axis II disorders. In fact, recent epidemiological research has shown that the majority of patients identified with PD were comorbid with a variety of Axis I and Axis II disorders (Johnson, Weissman, & Klerman, 1990). In terms of therapeutic outcome, it has been shown (Noyes, Reich, Christiansen, Suelzer, Pfohl, & Coryell, 1990) that PD patients with more abnormal personality traits have higher phobic symptoms and anxiety, as well as more social and family disability. Renneberg, Chambless, and Gracely (1992) found that of 133 agoraphobics presenting for outpatient treatment, and interviewed with a structured clinical interview, 56% met criteria for at least one Axis II personality disorder. Avoidant personality disorder was the most common diagnosis (32%). Subjects with a personality disorder had a higher likelihood of having a secondary diagnosis of social phobia, simple phobia, and dysthymia. However, in their study, a diagnosis of personality disorder was not associated with a higher frequency of panic attacks, phobic avoidance, or major affective disorder. In their study, 10% of agoraphobic patients met criteria for BPD, but none of these patients reported suicide attempts, indicating that their BPD was probably of mild severity and the diagnosis of BPD was likely to be secondary to the diagnosis of agoraphobia. Chambless, Renneberg, Goldstein, and Gracely (1992) also reported that after successful treatment for agoraphobia, any Axis-II personality disorder that was present seemed to remain stable, suggesting that persistent personality pathology seemed to go hand in hand with a chronic form of depression. The authors concluded that “a subset of agoraphobics show a complex picture of psychopathology. These patients may be more difficult to treat in the sense that additional problems in interpersonal relationships and depression may have to be addressed in treatment (p. 117): As noted above, increased publicity for the efficacy of treatment for panic disorder is likely to encourage many patients with BPD, or other severe AxisII disorders, to present for specialized treatment of their panic attacks, rather than the intensive long-term therapy they require. In addition, although recent work has suggested that some patients with PD report a history of suicidal ideation and attempts (Weissman, Klerman, Markowitz, & Ouellette, 1989) other studies (Beck, Steer, Sanderson, & Skeie, 1991; Friedman, Jones, Chemen, and Barlow, 1992) have not replicated this finding. The recognition and management of suicidal risk in patients with PD remains an important clinical issue. Given that patients with BPD are at increased risk for suicide and generally have a poor treatment response, it is critical that clinicians offering pharmacological treatment, as well as short term behavioral treatment for PD, be able to discriminate correctly the patients with PD from the patient suffering from BPD who has comorbid PD. METHOD Subjects Two groups of patients, both diagnosed with PD, were used for this study. The first group consisted of 72 patients with an Axis I diagnosis of PD with

52

S. FRIEDMAN AND

L. CHERNEN

moderate to severe agoraphobia, and with or without an Axis II personality disorder including: histrionic, avoidant, dependent, passive-aggressive, and not otherwise specified. The second group consisted of 68 patients who met DSM III-R diagnostic criteria for both PD and BPD, in which clinically BPD was considered the primary diagnosis.

RESULTS PD patients did not differ from BPD patients in age, ethnic breakdown, and length of illness (age: PD 38.3 f 12.0; BPD 36.6 + 12.7; PD patients: 65.3% were white, 23.6% were black, and 9.7% were hispanic and others; BPD

PANIC DISORDER AND BORDERLINE PERSONALITY

53

DISORDER

patients: 61.8% were white, 30.9% were black, 5.9% were hispanic and others; length of illness/years: PD 12.0 C!I11.1, BPD 14.7 + 11.4). BPD patients, however, were more likely to be female (94% vs. 76%, X2 = 8.62, df = 1, p < .Ol) and unmarried (79% vs. 46%, X2 = 21.52, df = 1, p c .Ol). Table 1 presents the data on some clinical characteristics of the two groups of patients. As seen in Table 1, BPD patients were much more likely to report a history of suicide attempts (25% vs. O%, X2 = 20.49, df = 1, p < .OOl), and were more likely to report that their panic attacks lasted longer (71.0 f 129 TABLE 1 PSYCHIATRICSY~WIQ~~ATOL~GY AND SELECXEDCLINKXL CHARA~ISTICS

OF PATIENTSwrr~ PD

ALONE COMPAREDTO PATENIX WITHPD AND BPD

PD (N = 72)

x= SD=

Duration of panic attack (min)

Mobility atone

Mobility accomp.

Agoraphobic cog&ions

Body sensations

17 (X2 = 20.49, df= 1.p < .001)

0

Suicide attempts No. of panic attacks/wk

PD and BPD (N = 69)

5.90 4.1

X = 28.0

x=

SD = 48.42

SD = 129.6

X=

X=

86.4

ns

4.14 5.67

X= SD=

t = 1.8, df = 52,~ < .07

71.0

r = .35, df = 81, ns

91.8

SD = 47.7

SD = 88.5

n=

40

n=

43

X=

59.6

X=

72.5 75.6 42

t = 1.00, df = 80, ns

38.1 10.5 46

I = 3.14, df = 86, p < .Ol

48.9 17.9 42

t = .62, df =80, ns

SD = 28.6

SD=

n=

40

n=

x=

30.9

x=

SD = 11.1

SD=

n=

42

n=

X=

46.5

x=

SD = 17.6

SD =

n=

n=

Psychiatric symptoms (O-8 scale) Intrusive thoughts Depersonalization Tension Depression Anger Fear questionnaire (O-40 scale) Agoraphobia score Blood illness Social phobia Lower score means less impaired.

40

5.3-+ 2.8f 6.3 + 4.0+ 2.9f

2.7 2.7 2.1 2.3 2.2

20.9+ 11.9 12.6f 8.4 11.9+ 8.4

5.1+ 3.22 6.5f 4.7f 4.5f

2.7 3.1 2.0 2.5 2.3

20.9 + 12.8 13.1 f 8.1 15.6f 10.1

r = .38, df = I = .65, df= i = .36, df= I = 1.74, df = t = 4.02, df=

135, ns 135, ns 135, ns 135, ns 135, p < .OOl

r = .O,

136, ns

df=

f = .29, df = 136, ns -

r = 2.37, df = 136, p < .Ol

54

S. FRIEDMAN

AND L. CHERNEN

min, range l-725 min, median 23 min, vs. 28 + 48 min. range l-200, median 15 mm, t = 1.8, df = 52, p c .07). On a variety of symptom rating scales, there were no significant differences between the groups, with the exception that BPD patients reported more cognitive fears during panic attacks (38.1 f 10.5 vs. 30.9 f 11.1, ? = 3.14, df= 86, p c .Ol), as well as being both more socially phobic (t = 2.37, df = 136, p < .Ol) and reporting more angry feelings (t = 4.02, df= 135, p < .OOl). A factor analysis (SPSS Reference Guide, 1990) was performed to determine the factor structure of the data. The principal component analysis utilized 61 variables, including subject demographics (i.e., age, sex, race, etc.), family history measures (i.e., familial mental illness, physical and sexual abuse, etc.), psychiatric symptoms (dysphoria, anxiety, etc.), phobic avoidance (i.e., response to fear questionnaires), life stress data (i.e., clinician rating of the presence of both acute and chronic stressors), and subject’s response to treatment (as indicated by therapist report). The 16 remaining variables were either analyzed separately or deleted due to the small number of subjects with data in these areas, the small number of positive responses to the item in either group, or the unreliability of the item as determined by difficulty in scoring. Table 2 describes the eight factors with minimum eigenvalues of 2 and factor loadings greater than .4 that emerged from the data. The eight factors were: (1) Emotional Instability: clinician ratings of chaotic life, affective instability, self-destructive behavior, suicidal ideation, history of alcohol and/or drug abuse, and marital status; (2) Traumatic Early Environment: sexual and physical abuse by parents, severe family conflict, and parental psychiatric symptoms; (3) Treatment Response: receptivity to relaxation training, requisite treatment adjuncts in addition to the standard behavior therapy protocol for panic disorder and overall treatment response; (4) Separation and Loss: separation from father and/or mother, parental history of schizophrenia, parental divorce, and history of separation anxiety in patient; (5) Current Life Stresses: chronic and acute, race of patient, medical emergency room visits; (6) Family history/mental health; (7) Psychiatric Symptoms/Self Ratings; and (8) Phobic Avoidance/Self-Ratings: agoraphobia, social phobia, and blood/illness fears. A between-groups t-test was initially performed to compare the two groups on each of the factors. The t-test indicated that only factors 1 (t = 18.41, df = 138, p < .OOOOl) and 2 (t = 2.05, df = 138, p < .04) significantly discriminated between the groups, with factor 3 just missing significance at the .05 level (t = 1.95, df = 138, p < .052). A discriminant analysis was performed in order to further establish which criteria were most relevant in distinguishing the groups, and to evaluate the accuracy of the classification (SPSS, 1990). The function that emerged from the analysis (Eigenvalue = 3.50) accounted for 88% of the variance and was highly significant (p < .OOOOl). Five of the factors were significant predictors of group membership. These five factors described the emotional instability, conflictual early environment, treatment response, separations, and life stresses that differentiated PD from BPD patients. Table 3 shows the five discriminant factors and the percentage of PD and BPD patients with positive ratings on the variables associated with each factor.

PANIC DISORDER AND BORDERLINE PERSONALITY DISORDER

55

Based on the canonical discriminant coefficients of the function, the discriminant score for each case was calculated. From these scores, the percentage of “grouped” cases correctly classified by the factors was determined. The overall percentage of cases correctly classified as either PD or BPD was 94.3%. indicating that the variables utilized were able to discriminate between the groups with a high degree of accuracy. A jackknife classification, using BMDP program (1990). gave the same result. Since the two groups differed on whether a comorbid major depressive episode was present, we attempted to statistically control for the potentially confounding effect of depression by repeating our analysis using the self-ratings of depression by the patient as a covariant. We found that the variables of affective instability, length of panic attacks, more fearful thoughts during panic attacks, more medical emergency room visits, chaotic lifestyle, anger, suicidal ideation, other self-destructive behavior, severe family conflict, and the necessity of adjusting treatment still successfully discriminated the two groups. However, the variables of social phobia, adverse response to relaxation training, and report of multiple chronic stressors no longer discriminated between the two groups, thereby indicating that for some variables the difference between our two groups could be explained by difference in levels of depression. DISCUSSION The robust clinical and historical features of BPD patients found in this study were highly discriminating and specific to the BPD patient. These features are critical markers for BPD disorder, and can be used to discriminate these patients. The first and broadest discrimination involved the characteristic clinical features of the BPD group (i.e., affective instability, chaotic life style, suicidal thoughts and gestures, and drug/alcohol abuse). These data support the findings of numerous previous studies (Zanarini et al., 1990) and provide further descriptive validation for the BPD. The BPD patients did not differ from PD patients in self report of phobic avoidance and/or frequency of panic attacks, similar to findings by Renneberg et al., (1992), who found that panic disordered patients with an Axis II disorder did not report more phobic avoidance or more frequent panic attacks. Standard measures of psychiatric symptoms, with the exceptions of the degree of cognitive fear during a panic attack and the patient’s report of anger, did not discriminate between the groups. Even the degree of self-reported depression did not significantly discriminate between our two groups. These data concur with those of Benjamin, Silk, Lohr, & Westen (1989), who found that on standardized inventories, borderlines did not report more anxiety than patients with either “pure” anxiety or depression. However, our data indicated that the patients’ self-reports of the duration of panic attacks were considerably greater for the BPD group. In addition, amount of cognitive fear during an attack was greater in the BPD group and, along with the patients’ report of problems with anger, provide support for Benjamin et al’s (1989) contention that the BPD patient experiences a “primitive diffuse arousal,” which may often be reported as “anxiety.”

Z

Physical .63385

Affec- .80120 tive instability

Severe 44126 family conflict

Psych- .40727 iatric symptoms in parents

.67265 destructive behavior

Suicidal .65300 ideation

Self

Sexual .76635 abuse

Chaotic .84750 Lie

abUX.

Factor loading

Traumatic Early Enviroment

loading

Factor

Emotional Instability

*

(2)

*

(1)

* 1

Factor loading

separation and Loss

(4)

Overall treatment response

Treatment additions

Parental divorce

.50845

51270 .49421 Parental history/ schizophrenia .47019

Response to .54416 Separation .70540 relaxation from father training Separation .63174 from mother

Factor loading

Treatment Response

(3)

TABLE 2

Factor loading

.56699 Family 64169 history of panic attacks

Family .65771 history of anx. disorder

Level of .43203 Family .62712 acute stress history of schizophrenia

Race

Levelof 71593 chronic stress

Q

Tension

Factor 1oadiig

.I2221

.61127 Blood .62172 illness phobia

Social .63020 phobia

SCOIZ

Total .76173

.91452 Agom.77165 phobia score

Depersotud.69386 ization

Intrusive thoughts

Dysphoria

Facta loading

(8) Phobic Family History Psychiatric Symptoms/ Avoidance of Mental Health Self-Ratings Self-Ratings

(6)

Multiple .73627 Parent .69760 chronic stress b~pitalitXl

Factor loading

Current Life Stress

(5)

*

FACKJRLOADINGS OFVARIABLES INFACTORANALYSIS

Y

Minimum Factor Loading: .4. *Significant group predictors from discriminant analysis.

Marital .400@4 status

Hiitory 40434 of drug/ alcohol abuse

Patients S4109 status as parent Separation .49960 anxiety

Medical .40701 emergency room visits

Drug/ .40155 Alcohol abuse in parents

Family .46158 history of psychiatric disorders

Death 46705 of mother

Other .47863 psychiatric symptoms in parents

Severe .49043 chronic illness in childhood

Death SO261 of family member

Parental SO956 anxiety

Death S3610 of father

Family .61790 Depression 60080 history of mood disorder

S. FRIEDMANAND L. CHERNEN

58

TABLE 3 FA(TIYIRS DISCRIMINATING PD FROMPD ANDBPD PATIE~S

Panic Disorder (N = 12)

1. Emotional instability Life is “chaotic” Affective instability Self destructive Thoughts of suicide History of aIcol~ol/d~g abuse Patients’ status as parent and SES were also signitlcant 2. Traumatic early environment Sexual abuse Physical abuse Severe family conflict in childhood Other psychiatric symptoms in parents 3. Treatment response Initial response to relaxation training Positive Negative Treatment response

Panic Disorder + Borderline (N = 68)

5 9 8 6 11

(6.9) (12.5) (11.1) (8.3) (15.3)

67 67 47 44 31

(98.5) (98.5) (69.1) (64.7) (45.6)

2 6 16 21

(2.8) (8.3) (22.2) (29.2)

10 13 33 42

(14.7) (19.1) (48.5) (61.8)

N=38

N=32

33 (86.8) 5 (13.2)

22 (68.8) 10 (31.2)

N=55

N=60

9 (16.4) 4 (7.3) 42 (76.4)

18 (30.0) 14 (23.3) 28 (46.7)

4. Separation and loss Separation from father Separation from mother Family history of schizophrenia Separation anxiety

21 12 10 27

23 11 7 34

5. Current life stresses Multiple chronic stresses Medical emergency room visits

24 (33.3) 26 (36.1)

Drop out/No improvement Slight improvement Moderate or better improvement

(29.2) (16.7) (13.9) (37.5)

(33.8) (16.2) (10.3) (50.0)

28 (41.2) 32 (47.1)

Recent reanalysis of data from the Epidemiologic Catchment Area (ECA) study (Weissman et al., 1989) found that 20% of PD patients had made a suicide attempt. However, in another study surveying patients presenting to an outpatient clinic, it was found that 7% of patients with affective disorder, in contrast to fewer than 1% of patients with PD. with or without agoraphobia, reported making a suicidal attempt (Beck et al., 1991). A recent longitudinal study, which followed 74 panic disordered patients for up to seven years, also

PANIC DISORDER AND BORDERLINE PERSONALITY DISORDER

59

found that patients who made serious suicide attempts were younger, single, and more likely to be personality disordered (with a coexisting major depression). The authors concluded that among patients with panic disorder, serious suicidal behavior is associated with more severe psychopathology (Noyes, Christiansen, Clancy, Garvey, Suelzer, dc Anderson, 1991). In the current study, as reported in more detail elsewhere (Friedman et al., 1992), we found that both suicidal ideation and attempts, when present in panic disordered patients, were more likely to be associated with a comorbid diagnosis of BPD. Chambless et al. (1992) found that of 165 agoraphobic outpatients who completed the Millon Clinical Multiaxial Inventory (Millon, 1987), over 90% met criteria for one or more Axis II personality disorders. However, the scores on personality scales were correlated with social phobia and dysphoria, rather than simple agoraphobic avoidance or panic frequency. In this study, 26.7% of the patients met criteria for BPD. Raw scores on the BPD subscale correlated significantly with passive, repressive, avoidant, schizotypal, paranoid, schizoid, and histrionic subscales, indicating once again that patients with PD and BPD tend to suffer from a “pan-neurosis” (Hoch & Palatin, 1949). Childhood antecedents emerged as a second major discriminating criterion. Our data, similar to others (Links et al., 1988), indicated that BPD patients were more likely to report a tumultuous early environment, marked by family conflict as well as physical and sexual abuse. Early life deprivations, evidenced by parental separations and concomitant separation anxiety, additionally characterized the BPD patients. Previous studies (Jacobson, 1989) have shown that psychiatric patients often have a history of physical and sexual assaults, both as children and adults. Data from the ECA study have also suggested that a history of sexual assault was a risk factor for five psychiatric disorders, including panic disorder (Winfield, George, Swartz, & Blazer, 1990). As with other studies (Berger, 1987; Stone, 1987). the problems and failures inherent in the treatment of the BPD patients were another consistent finding. Use of multiple psychopharmacological agents, in an attempt to ameliorate the BPD patient’s symptoms, indicated the trial and error nature of treatment for this group. Those patients who historically or currently were substance abusers had an even lesser likelihood of treatment success. Multiple chronic life stresses (such as family discord, poverty, and joblessness) were also characteristic of our BPD sample (Gunderson & Kolb, 1978; Links et al., 1988). Hereditary characteristics (i.e., family histories of mental and physical illness) did not discriminate between our two groups of patients. This surprising finding may be due to our obtaining the history from the patient rather than direct interviews of the family. It also may be indicative of the subpopulations of patients that exist within the BPD diagnosis, and the multiple etiologies and genetic diatheses that may be characteristic of this group (Lahmeyer, Reynolds, Kupfer, & Kings, 1989; Pope, Jonas, Hudson, Cohen, & Gunderson, 1983). In addition, although the patients with BPD in this study were seen as suffering from moderate to severe psychopathology, only a distinct minority of these patients had a history of psychiatric hospitalizations, suggesting caution in generalizing the results from this study and the need to replicate our findings.

S. FRIEDMAN AND L. CHERNEN

60

Discriminating the BPD from the PD patient has significant treatment implications as pharmacological and cognitive-behavioral therapies for PD become even more widespread and accepted as treatments of choice (Barlow, 1988). It is clear that such standard protocols will need to be modified for those patients whose panic attacks are part of a more global “pan-anxiety” (Hoch & Polatin, 1949) syndrome. Clinicians need to be aware that panic attacks may be associated with very severe psychopathology that may leave the patient at serious risk for both suicide and chronic substance abuse (Noyes et al., 1990, Weissman et al., 1989), and such patients will often need more comprehensive treatment than is necessary for the minority of patients with uncomplicated PD.

REFERENCES AUI~~~CUI Psychiatric Association (1987). Diagnostic

and statistical manual of mental disorders

(3rd edition, rev.). Washington,D.C.: Author. Barlow, D. H. Anxiety and its disorders: The nuture and treatment of anxiety and panic. New York: Guilford Press. Barlow, D. H., Vermilyea, J. A., BIanchard, E. B., Vermilyea, B. B., DiNardo, P. A., & Cemy, J. A. (1985). The phenomenon of panic. Journal of Abnormal Psychology, 94.320-328. Beck, A. T., Steer, R. A., Sanderson, W. C., & Skeie, T. M. (1991). Panic disorder and suicidality: Discrepant findings in psychiatric outpatients. American Journal of Psychiatry, 148, 1195-1199.

Benjamin, J., SiIk, K. R., Lobr, N. E., & Westen, D. (1989). The relationship between borderline personality disorder and anxiety disorders. American Journal of Psychiatry, 147(2), 161-167. Berger, P. A. (1987). Pharmacological treatment for borderline personality disorder. Bulletin of the Meninger Clinic, 51(3), 277-284. BMDP Statistical Sojtware Manual (1990). Berkeley, Los Angeles: University of California Press.

Chambless, D. L., Caputo, G. C., Bright, P., & Gallagher, R. (1984). Assessment of fear of fear in agoraphobics: The body sensations questionnaire and the agoraphobia cognitions questionnaire. Journal of Consulting and Clinical Psychology, 52, 1090-1097. Chambless, D. L., Caputo, G. C., Jasin, S. E., Gracely, E. J., & Williams, C. (1985). The mobility inventory for agoraphobia. Behaviour Research and Therapy, 23,35-44. Chambless, D. L., Renneberg, B., Goldstein, A., & Gracely, E. J. (1992). MCMI-diagnosed personality disorders among agoraphobic outpatients: Prevalence and relationship to severity and treatment outcome. Journal ofAnxiety Disorders, 6, 193-212. DiNardo, P. A., & Barlow, D. H. (1988). Anxiety Disorders Interview Schedule-Revised (ADIS-R). State University of New York at Albany: Phobia and Anxiety Disorders Clinic. Friedman, S., Jones, J., Chemen L.. & Barlow, D. H. (1992). Suicidal ideation and attempts in panic disorder patients: A survey of two outpatient clinics. American Journal of Psychiatry, 149,680-685.

Gunderson, J. G. (1984). Borderline Personality Disorder. Washington, D.C.: American Psychiatric Press. Gunderson, J. G., & Kolb, J. E. (1978). Discriminating features of borderline patients. American Journal of Psychiatry, 135,792-7%.

Harper, M., and Roth, M. (1962). Temporal lobe epilepsy and the phobic anxiety-depersonalization syndrome. Part I: A comparative study. Comprehensive Psychiatry, 3, 129-151. Hoch, F!, & Polatin, P. (1949). Pseudoneurotic forms of schizophrenia. Psychoanalytic Quarterly, 23,248-276.

Horwitz, L. (1987). Indications for group psychotherapy with borderline and narcissistic patients. Bulletin of the Meninger Clinic, 51(3), 248-260.

PANIC DISORDER AND BORDERLINE PERSONALITY DISORDER

61

Jacobson, A. (1989). Physical and sexual assault histories among outpatients. American Journal of Psychiatry, 146755-758. Johnson, J., Weissman, M. M., & Klerman, G. L. (1990). Panic disorder, comorbidity and suicide attempts. Archives of General Psychiatry, 47,805-808. Lahmeyer, H. W., Reynolds, C. F., Kupfer, D. J., & Kings, R. (1989). Biological markers in borderline personality disorder: A review. Journal of Clinical Psychiatry, 50.217-225. Links, P. S., Steiner, M., Offord, D. R., & Eppel, A. (1988). Characteristics of borderline personality disorder: A Canadian Study. Canadian Journal of Psychiatry, 33,336-340. Marks, I. M., & Mathews, A. M. (1978). Brief standard self-rating for phobic patients. Behavior Research and Therapy, 17,263~267.

Millon, T. (1987). Manualfor the MCMI-II. Minneapolis, MN; National Computer Systems. Noyes, R., Reich, J., Christiansen, J., Suelzer, M., Pfohl, B., & Coryell, W. A. (1990). Outcome of panic disorder: Relationship to diagnostic subtypes and comorbidity. Archives of General Psychiatry, 47,809-818. Noyes, R., Jr., Christiansen, J., Clancy, J., Garvey, M. J., Suelzer, M., & Anderson, D. J. (1991). Predictors of serious suicide attempts among patients with panic disorder. Comprehensive Psychiatry, 32,26X-267.

Pollard, C. A., Detrick, P, Flynn, T., & Frank, M. (1990). Panic attacks and related disorders in alcohol-dependent, depressed, and nonclinical samples. Journal of Nervous and Mental Disease, 178, 180-185. Pope, H. G., Jonas, J. M., Hudson, J. I., Cohen, B. M., & Gunderson, J. G. (1983). The validity of D.S.M. III borderline personality disorder: A phenomenologic, family history, treatment response, and long-term follow-up study. Archives of General Psychiatry, 40, 23-30. Renneberg, B., Chambless. D. L., and Gracely, E. J. (1992). Prevalence of SCID-diagnosed personality disorders in agoraphobic outpatients. Journal of Anxiety Disorders, 6,11 l-l 18. Roth, M. (1959). The phobic anxiety-depersonalization syndrome. Proc. R. Sot. Med, 52, 587-596.

Roth, M., & Harper, M. (1%2). Temporal lobe epilepsy and the phobic anxiety-depersonalization syndrome. Part II: Practical and theoretical considerations. Comprehensive Psychiatry, 3, 215-226. SPSS Reference Guide (1990). Chicago, IL: SPSS.

Stone, M. H. (1987). Psychotherapy of borderline patients in light of long-term follow-up. Bulletin of the Meninger Clinic, 51(3), 231-247.

Telch, M. J., Lucas, J. A., & Nelson, P. (1989). Non clinical panic in college students: An investigation of prevalence and symptomatology. Journal of Abnormal Psychology, 98.300-306. Weissman, M. M., Klerman, G. L., Markowitz, J. S., & Ouellette, R. (1989). Suicidal ideation and suicide attempts in panic disorder and panic attacks. New England Journal of Medicine, 321, 1209-1214.

Wmfield, I., George, L. K., Swartz, M., & Blazer, D. G. (1990). Sexual assault and psychiatric disorders among a community sample of women. American Journal of Psychiatry, 147, 335-341.

Zanarini, M. C., Gunderson, J. G., Frankenburg, F. D.. & Chauncey, D. L. (1990). Discriminating borderline personality disorder from other Axis II disorders, American Journal of Psychiatry, 147(2), 161-167.