The specificity of emotional switching in borderline personality disorder in comparison to other clinical groups

Antidepressant emergent mood switch in major depressive disorder: onset, clinical correlates and impact on suicidality

Antidepressant (AD)- emergent mood switch (AEMS) is a common complication of bipolar depression. This study aimed to investigate the prevalence and clinical correlates of subthreshold AEMS (i.e. not fulfilling DSM criteria for hypomanic episodes) in major depressive disorder (MDD) and, prognostically, its impact on AD treatment outcome and suicidality. The study involved 425 outpatients with MDD followed during the acute phase (12 weeks) and continuation (weeks 13-28) AD treatment. AEMS was assessed through the Altman Self-Rating Mania scale (ASRM ≥ 6). Several clinical features differentiated individuals with or without subthreshold AEMS (n = 204 vs. 221): negative self-perception [odds ratio (OR) 1.017-1.565]; panic disorder (OR 1.000-1.091); subthreshold hypomanic episodes (OR 1.466-13.352); childhood emotional abuse (OR 1.053-2.447); lifetime suicidal behaviour (OR 1.027-1.236); AD-related remission (χ 2  = 22.903 P  < 0.0001) and suicide ideation (χ 2  = 16.701 P  < 0.0001). In AEMS earlier onset showed a strong correlation with bipolar spectrum disorder (overall score: P  = 0.0053; mixed depression: P  = 0.0154; subthreshold hypomania: P  = 0.0150) whereas late-onset was associated with more severe suicidal behaviour ( P  < 0.001). In conclusion, our results demonstrate that subthreshold mood switches occur frequently in unipolar depression during acute AD treatment as well as in continuation phase. Time of switch onset seems to have the greatest diagnostic and prognostic value.

The role of emotional instability in borderline personality disorder: a systematic review

BACKGROUND

The emotional regulation process plays a pivotal role in daily-life functioning, modulating goal-directed and adaptive behavior. Conversely, altering this cognitive function can disrupt self-regulation and bring emotional dysregulation. Emotional instability could represent a core characteristic of BPD, also modulating the BPD symptom's onset. This systematic review aims to summarize the existing literature reporting the role of emotional instability in BPD to better define the role of the impairment of the emotional processes in the onset of the cognitive and behavioral symptoms of this complex mental disorder.

METHODS

MEDLINE, Scopus and Web of Science were independently searched for relevant studies. Eligible studies had to be identifiable through database searching, published and accessible. This systematic review was conducted according to PRISMA guidelines. The search period was from 2012 to 14 September 2022.

RESULTS

A pool of 120 studies was identified, out of which 11 met the selection criteria and were included. Overall, the studies confirm a relationship between emotional instability and borderline personality disorder.

CONCLUSIONS

The evidences retrieved seem to point out the role of the emotional impairment not only in worsening of the disorder, but could also be one of the risk factors for its onset.

Emotion Dynamics and Emotion Regulation in Anorexia Nervosa: A Systematic Review of Ecological Momentary Assessment Studies

Altered emotion dynamics and emotion regulation (ER) have been indicated in theoretical descriptions of abnormal emotional functioning, which contributes to the development and maintenance of anorexia nervosa (AN). Ecological momentary assessment (EMA) has recently become popular in research on eating disorders. It is a source of new insights into the psychopathology of AN as it enables intensive long-term tracking of everyday experiences and behaviours of individuals through repeated self-reports. The following systematic review aims to synthesize research on the use of EMA when evaluating emotion dynamics and ER in AN. Specific studies were identified with the use of MEDLINE, PsycINFO, and Scopus databases. A supplemental search was performed in reference lists of the relevant publications. As a result, 27 publications were identified and included in the systematic review. The findings from the reviewed studies point to various disturbed components of emotion dynamics as well as to unique associations of maladaptive ER strategies with specific abnormalities in emotion dynamics in AN. Limitations of the studies were discussed as well. An outlook for further research in the field was provided in the last section of the paper.

Negativity in delayed affective recall is related to the borderline personality trait

The present study assessed selected factors that contribute to the recollection of emotional memories over time. Participants with high-trait borderline personality disorder (BPD) watched a randomly selected positive, negative, or neutral character in a video clip (stimulus) and were asked to recall the content immediately, then 2, 4, and 6 days later. In the final sample (N = 558, average age: 33 years, 65% female), general impression had the strongest effect on recall after accounting for the effect of current mood, extremity of the responses, and level of BPD, regardless of stimulus valence. The level of BPD had an effect only when negative evaluative wording (e.g., “guilty”) was used. In conclusion, people with high-trait BPD tend to remember negative stimuli more negatively over time (unlike neutral or positive stimuli), and this effect is mostly related to general impression.

The Statistical Specificity of Emotion Dynamics in Borderline Personality Disorder

Persons with borderline personality disorder (BPD) experience heightened emotional instability. Different components underlie instability, and the relation between instability and well-being could be confounded by average emotionality and within-person standard deviation across emotional states, reflecting variability. Therefore, the goal was to examine which pattern of emotion dynamics parsimoniously captures the emotional trajectories of persons with BPD. Forty persons with BPD, 38 clinical controls in a major depressive episode, and 40 healthy controls rated the intensity of their emotions 10 times a day for 1 week. After correction for differences in average emotionality, persons with BPD showed heightened emotional instability compared to both control groups. When additionally correcting for emotional variability, the authors found that instability indices did not differ between groups anymore. This shows that persons with BPD differ from control groups in the magnitude of emotional deviations from the emotional baseline, and not necessarily in the degree of abruptness of these deviations.

Investigating the stress-related fluctuations of level of personality functioning: A critical review and agenda for future research

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Classification of Diseases (ICD-11) proposed a dimensional approach to the assessment of personality disorders (PDs). Both models dictate that the clinician first determines PD severity before assessing maladaptive traits, invoking the level of personality functioning (LPF) construct. We consider LPF a promising dimensional construct for translational research because of its clinical importance and conceptual overlap with the Research Domain Criteria (RDoC) Social Processes. We aim to identify biomarkers that co-vary with fluctuations in LPF in adulthood, ultimately to predict persistent decrease in LPF, associated with suicidality and morbidity. However, a theoretical framework to investigate stress-related oscillations in LPF is currently missing. In this article, we aim to fill this hiatus with a critical review about stress and LPF. First, we discuss acute stress and LPF. We briefly present the basics of the neurophysiological stress response and review the literature on momentary and daily fluctuations in LPF, both at a subjective and physiological level. Second, we review the effects of chronic stress on brain function and social behaviour and recapitulate the main findings from prospective cohort studies. This review underlies our suggestions for multimethod assessment of stress-related oscillations in LPF and our theoretical framework for future longitudinal studies, in particular studies using the experience sampling method (ESM).

Mood-induced changes in the cortical processing of food images in bulimia nervosa

BACKGROUND

Negative mood often triggers binge eating in bulimia nervosa (BN). We investigated motivational salience as a possible underlying mechanism using event-related potentials (ERPs) as indicators of motivated attention allocation (P300) and sustained processing (LPP).

METHODS

We collected ERPs (P300: 350-400 ms; LPP: 600-1000 ms) from 21 women with full-syndrome or partially remitted BN and 21 healthy women (HC), matched for age and body mass index. Idiosyncratic negative and neutral situations were used to induce corresponding mood states (counterbalanced), before participants viewed images of high- and low-calorie foods and neutral objects, and provided ratings for pleasantness and desire to eat.

RESULTS

P300 was larger for foods than objects; LPP was largest for high-calorie foods, followed by low-calorie foods, then objects. The BN group showed an increased desire to eat high-calorie foods under negative mood and stronger mood induction effects on ERPs than the HC group, with generally reduced P300 and a small increase in LPP for high-calorie foods. Effects were limited to circumscribed electrode positions. Exploratory analyses showed clearer effects when comparing high vs. low emotional eaters.

CONCLUSION

We argue that negative mood decreased the availability of cognitive resources (decreased P300) in BN, thereby facilitating disinhibition and food cravings (increased desire-to-eat ratings). Increased sustained processing might be linked to emotional eating tendencies rather than BN pathology per se, and reflect approach motivation, conflict, or regulatory processes. Negative mood appears to induce complex changes in food image processing, whose understanding may contribute to the development of tailored interventions in the future.

Ego-resiliency in borderline personality disorder and the mediating role of positive and negative affect on its associations with symptom severity and quality of life in daily life

Borderline personality disorder (BPD) is a serious mental health condition associated with severe symptoms of distress and poor quality of life (QoL). Research outside the field of BPD suggests that ego-resiliency is negatively associated with psychopathology and positively associated with a range of positive life outcomes. Thus, ego-resiliency may be a valuable construct for furthering our understanding and treatment of BPD. However, the mechanisms linking ego-resiliency to psychopathology and QoL in relation to BPD have not been examined and explored by research. This study has addressed this gap in the collective knowledge by evaluating whether within-person associations between daily reports of positive affect (PA) and negative affect (NA) mediated the relationship between ego-resiliency, BPD symptom severity, and QoL. For 21 consecutive days, 72 women diagnosed with BPD completed end-of-day electronic assessments regarding ego-resiliency, PA and NA, symptom severity, and QoL. Multilevel structural equation modelling established that PA and NA were parallel mediators linking ego-resiliency with BPD symptom severity and QoL. As hypothesized, the path to QoL was stronger through PA than through NA. The mediation paths through NA and PA to BPD symptom severity were both significant, but their strength did not differ. Our findings align with the assertions of theories on emotion, thus suggesting a two-factor approach to PA and NA. Future research can build on these findings by developing psychotherapeutic interventions designed not only to reduce symptom severity but also to enhance PA in individuals with BPD and determine whether an increase in PA is associated with improved QoL.

Specific or transdiagnostic? The occurrence of emotions and their association with distress in the daily life of patients with borderline personality disorder compared to clinical and healthy controls

Borderline personality disorder (BPD) is characterized by more frequent and more intense negative emotions and less frequent positive emotions in daily life than healthy controls (HC) experience, but there is limited empirical evidence regarding whether this is a transdiagnostic or disorder-specific finding and which specific emotions are especially distressing in BPD. We assessed participants' current emotions and distress every 15 min over a 24-h period using e-diaries to investigate the frequency, intensity, and the associated distress of specific emotions. To test the disorder specificity, we used multilevel modeling to compare 43 female patients with BPD, 28 patients with posttraumatic stress disorder (PTSD), 20 patients with bulimia nervosa (BN), and 28 HC. Patients with BPD exhibited anger more frequently than any of the clinical or healthy control groups, demonstrating specificity. The quality of anger accounted for additional distress beyond the pure emotional intensity. In patients with BPD, joy was associated with reduced distress, which was not the case in HC or PTSD. However, the majority of the comparisons (anxiety, sadness, shame, disgust, jealousy, guilt, interest) revealed transdiagnostic patterns. The distress-enhancing or distress-reducing effects of anger and joy might represent an important part of affective dysregulation in BPD.

Examining the role of borderline personality traits in the relationship between major depression and nonsuicidal self-injury

BACKGROUND

Depression and borderline personality disorder (BPD) are highly comorbid conditions that are both associated with nonsuicidal self-injury (NSSI).

AIMS

The purpose of this study was to determine if depression is associated with NSSI after controlling for BPD traits. A distinction was made between NSSI for emotional regulation and NSSI for interpersonal motives.

METHOD

Logistic regression analyses were conducted on cross-sectional data from a general population sample of 7370 adults who completed the 2007 Adult Psychiatric Morbidity Survey. Depressive symptoms were assessed with the revised Clinical Interview Schedule. NSSI and motives for NSSI were also assessed during clinical interviews. BPD traits were assessed with the participant-completed Structured Clinical Interview for DSM-IV Axis II Personality Disorders.

RESULTS

Participants in a major depressive episode were more likely to have engaged in emotional-regulation NSSI and interpersonal NSSI than participants without depression. After controlling for BPD traits depression remained associated with emotional-regulation NSSI, whereas the association with interpersonal NSSI became nonsignificant. There were statistically significant relationships between depression and both types of NSSI occurring indirectly through BPD traits.

CONCLUSIONS

BPD traits account for a significant portion of the cross-sectional relationship between depression and past NSSI that varies in size depending on the motive for NSSI. People with depression are more likely to have engaged in NSSI for emotional regulation even in the absence of prominent BPD traits. In contrast, BPD traits may be more prominent in people with depression who have engaged in interpersonal NSSI.

Nicotine dependence, internalizing symptoms, mood variability and daily tobacco use among young adult smokers

INTRODUCTION

Cigarette use among young adults continues to rise. As young adults transition to college and assume other adult roles and responsibilities, they are at risk for the development of mental health problems and for the progression of substance use problems. Previous studies suggest that individual differences in negative and positive mood contribute to cigarette use in established college-aged smokers, but less is known whether fluctuations in mood influence daily cigarette use, controlling for trait levels of internalizing symptoms and nicotine dependence.

METHODS

Data for this study came from a sample of college students (N=39, 59% female, mean age 20.4years) who reported regular cigarette use and participated in a 21-day ecological momentary assessment (EMA) study assessing within-individual variation in cigarette use and mood.

RESULTS

A three-level hierarchical linear model accounting for the structure of 1896 occasions of cigarette use nested within days and individuals indicated that within-individual variability in positive mood was associated with cigarette use at each occasion, after taking into account baseline levels of nicotine dependence and internalizing problems.

CONCLUSIONS

Daily shifts in positive moods are importantly associated with consuming cigarettes throughout the day.

Modeling Heterogeneity in Momentary Interpersonal and Affective Dynamic Processes in Borderline Personality Disorder

Borderline personality disorder (BPD) is a diagnosis defined by impairments in several dynamic processes (e.g., interpersonal relating, affect regulation, behavioral control). Theories of BPD emphasize that these impairments appear in specific contexts, and emerging results confirm this view. At the same time, BPD is a complex construct that encompasses individuals with heterogeneous pathology. These features-dynamic processes, situational specificity, and individual heterogeneity-pose significant assessment challenges. In the current study, we demonstrate assessment and analytic methods that capture both between-person differences and within-person changes over time. Twenty-five participants diagnosed with BPD completed event-contingent, ambulatory assessment protocols over 21 days. We used p-technique factor analyses to identify person-specific psychological structures consistent with clinical theories of personality. Five exemplar cases are selected and presented in detail to showcase the potential utility of these methods. The presented cases' factor structures reflect not only heterogeneity but also suggest points of convergence. The factors also demonstrated significant associations with important clinical targets (self-harm, interpersonal violence).

Models of borderline personality disorder: recent advances and new perspectives

PURPOSE OF REVIEW

The purpose of this article is to review the most relevant conceptual models of borderline personality disorder (BPD), with a focus on recent developments in this area.

RECENT FINDINGS

Several conceptual models have been proposed with the aim of better understanding BPD: the borderline personality organization, emotion dysregulation, reflective (mentalization) dysfunction, interpersonal hypersensitivity and hyperbolic temperament models. These models have all been supported to some extent and their common components include disorganized attachment and traumatic early experiences, emotion dysregulation, interpersonal sensitivity and difficulties with social cognition. An attempt to integrate some components of the conceptual models of BPD has resulted in an emerging new perspective, the interpersonal dysphoria model, which emphasizes dysphoria as an overarching phenomenon that connects the dispositional and situational aspects of BPD.

SUMMARY

Various conceptual models have expanded our understanding of BPD, but it appears that further development entails theoretical integration. More research is needed to better understand interactions between various components of BPD, including the situational factors that activate symptoms of BPD. This will help develop therapeutic approaches that are more tailored to the heterogeneous psychopathology of BPD.

Attachment-Related Regulatory Processes Moderate the Impact of Adverse Childhood Experiences on Stress Reaction in Borderline Personality Disorder

In this study, the authors explored whether attachment insecurity moderates the effects of adverse childhood experiences on stress reactivity in the context of borderline personality disorder (BPD). Participants were 113 women (39 with BPD, 15 with some BPD criteria present, 59 without any BPD symptoms) who participated in the Trier Social Stress Test. Saliva samples were collected before and after the stressor and assayed for salivary alpha-amylase (sAA) and cortisol. Adverse childhood experiences were measured using the Childhood Trauma Questionnaire, and attachment by the Experiences in Close Relationships-Revised questionnaire. Results revealed that attachment avoidance and a combination of more adverse childhood experiences and attachment insecurity resulted in higher sAA levels and differences in reactivity to the stressor. Interactions between attachment anxiety and adverse childhood experiences were related to blunted cortisol reactivity. The results suggest that the influence of adverse childhood experiences on stress regulation in BPD may be moderated by attachment-related regulatory processes.

The specificity of emotion dysregulation in adolescents with borderline personality disorder: comparison with psychiatric and healthy controls

BACKGROUND

Research has supported the notion that emotion dysregulation is a core feature of BPD. However, given that this feature is typical of healthy adolescents as well as adolescents with other psychiatric disorders, the specificity of emotion dysregulation to BPD in this age group has not yet been determined. The overall aim of this study was to examine emotion dysregulation in adolescent inpatients with BPD compared with non-BPD inpatient adolescents and healthy non-clinical adolescents, taking into account both global emotion dysregulation deficits and more specific impairments.

METHOD

The sample included 185 adolescent inpatients with BPD (M = 15.23, SD = 1.52), 367 non-BPD psychiatric inpatient adolescents (M = 15.37, SD = 1.40), and 146 healthy adolescents (M = 15.23, SD = 1.22), all of whom were between the ages of 12 and 17. Borderline personality features were assessed, along with emotion dysregulation and psychiatric severity.

RESULTS

After controlling for age, gender, and psychiatric severity, results revealed that adolescents with BPD had higher overall emotional dysregulation compared with non-BPD psychiatric controls and healthy controls. These differences were apparent in only two domains of emotion dysregulation including limited access to emotion regulation strategies perceived as effective and impulse control difficulties when experiencing negative emotions.

CONCLUSIONS

Findings suggest BPD-specific elevations on emotion dysregulation generally, and subscales related to behavioral regulation specifically.

Specificity of emotion sequences in borderline personality disorder compared to posttraumatic stress disorder, bulimia nervosa, and healthy controls: an e-diary study

BACKGROUND

Patients with borderline personality disorder (BPD) exhibit dysregulated emotion sequences in daily life compared to healthy controls (HC). Empirical evidence regarding the specificity of these findings is currently lacking.

METHODS

To replicate dysregulated emotion sequences in patients with BPD and to investigate the specificity of the sequences, we used e-diaries of 43 female patients with BPD, 28 patients with posttraumatic stress disorder (PTSD), 20 patients with bulimia nervosa (BN), and 28 HC. To capture the rapid dynamics of emotions, we prompted participants every 15 min over a 24-h period to assess their current perceived emotions. We analyzed group differences in terms of activation, persistence, switches, and down-regulation of emotion sequences.

RESULTS

By comparing patients with BPD to HC, we replicated five of the seven previously reported dysregulated emotion sequences, as well as 111 out of 113 unaltered sequences. However, none of the previously reported dysregulated emotion sequences exhibited specificity, i.e., none revealed higher frequencies compared to the PTSD group or the BN group. Beyond these findings, we revealed a specific finding for patients with BN, as they most frequently switched from anger to disgust.

CONCLUSIONS

Replicating previously found dysregulated and unaltered emotional sequences strengthens the significance of emotion sequences. However, the lack of specificity points to emotion sequences as transdiagnostic features.