[Development of the Borderline Symptom List]

Treating emotion dysregulation in patients with borderline personality disorder using imagery rescripting: A two-session randomized controlled trial

Studies on Emotionally Dysregulated Behavior (EDB) demonstrated that the conduct thereof is associated with emotion dysregulation and preceded by mental imagery of EDB, which can direct future behavior. These findings are specifically important within the context of Borderline Personality Disorder (BPD), where emotion dysregulation and EDB are at the core of the disorder. The present study aims to evaluate the efficacy of imagery rescripting (IR) in treating emotion dysregulation associated with EDB in patients diagnosed with BPD. Forty-eight females diagnosed with BPD were randomly allocated to the IR intervention or treatment-as-usual group. Assessment took place one week before the first treatment session, as well as one week, and twelve weeks after the last treatment session evaluating emotion regulation strategies, borderline-symptomatology, EDB, depressiveness, impulsivity, mental imagery, and illness severity. Within-, and between subject, intention-to-treat-, and per-protocol analysis were conducted. Results showed decreased maladaptive emotion regulation strategies and increased adaptive emotion regulation strategies within the intervention group. Borderline-symptomatology improved immediately after treatment for the intervention group. Additionally, BPD patients within the intervention group improved regarding their impulsivity, depressiveness, and EDB symptomatology in comparison to patients in the TAU group. The presented intervention has proven to be effective in improving BPD-related symptomatology, such as emotion regulation, EDB, depressiveness, and impulsivity. Imagery rescripting could be routinely applied when EDB related images are present. TRIAL REGISTRATION: German Clinical Trials Registry (DRKS) ID: DRKS00010620.

ICD-11 complex posttraumatic stress disorder and subclasses of borderline personality disorder in a South Korean adult population with childhood abuse experiences: a latent class analysis

BACKGROUND

Complex posttraumatic stress disorder (CPTSD) and borderline personality disorder (BPD), which are distinctive diagnoses, share the common risk factor of childhood abuse experiences. However, additional evidence is needed to determine which factors contribute to the manifestation of different symptoms.

METHOD

Participants were 499 South Korean early and midlife adults with primarily college level education who reported experiences of childhood abuse. They were enrolled from an online panel using a stratified sampling considering gender, age, and residence information. A latent class analysis (LCA) was conducted to identify the patterns of CPTSD and BPD symptoms. We adopted a three-step LCA to compare types of childhood abuse, invalidating environments, attachment styles, and pathological personality traits among different classes.

RESULTS

The LCA revealed four classes. Class 1 showed the highest scores in all symptoms and risk factors. Class 2 was distinguished from Class 3 by the externalizing versus internalizing associated pathological personality traits. Class 3 experienced high emotional neglect in addition to other types of abuse and it also showed an additional avoidant attachment style. Class 4 showed low symptomatology.

CONCLUSION

Class 1 was named as a CPTSD and BPD "comorbid" class, Class 2 as an "externalizing BPD" class, Class 3 as an "avoidant BPD" class, and Class 4 as a "low symptom" class. Childhood abuse may heighten the risk for high comorbidity of CPTSD and BPD as well as externalizing-internalizing subgroups of BPD. Beyond the identification of CPTSD and BPD, assessing attachment styles and pathological personality traits based on dimensional approaches would benefit the tailoring of effective treatment.

Differentiating between intrapsychic symptoms and behavioral expressions of borderline personality disorder in relation to childhood emotional maltreatment and emotion dysregulation: an exploratory investigation

BACKGROUND

Borderline personality disorder (BPD) is a severe mental disorder, characterized by pronounced instability in emotions, self-image, and interpersonal relationships. Experiences of childhood maltreatment are among the risk factors for BPD. While self-damaging and aggressive acts often occur, not every person with the disorder shows markedly dysregulated behaviour. Internalized symptoms, such as shame, loneliness, and self-disgust tend to be more pervasive and persist after clinical remission.

OBJECTIVE

Here we investigated associations between BPD symptom severity, childhood maltreatment, and emotion regulation difficulties. We further explored if the Borderline Symptom List (BSL) could potentially be used to differentiate between internalized symptoms (intrapsychic strain) and externalized symptoms (dysregulated behaviours) in future research.

METHOD

187 women with at least mild BPD symptoms (65% having a diagnosis of BPD) completed the BSL 23 including its 11-item supplement (BSL-S), the Childhood Trauma Questionnaire (CTQ), and Difficulties in Emotion Regulation Scale (DERS). Participants further underwent a semi-structured clinical interview to assess BPD criteria (International Personality Disorder Examination, IPDE). Multivariate models and regression-based bootstrapping analyses were performed to test direct and indirect effects.

RESULTS

Childhood trauma severity, especially emotional abuse, positively predicted BPD symptom severity. A significant indirect effect through emotion regulation difficulties was found (k2=.56). When exploring associations with BPD criteria (IPDE), the BSL-23 mean significantly correlated with separation anxiety, identity and mood problems, chronic emptiness, suicidal ideation, and dissociation, while the BSL-S correlated with self-harming impulsive behaviour and anger outbursts.

CONCLUSIONS

Findings complement previous research, highlighting the role of childhood maltreatment and emotion regulation difficulties in BPD. While our findings need to be seen as preliminary and interpreted with caution, they suggest that the BSL may be used to differentiate between internalized symptoms and behavioural expressions of BPD in future research. Such a distinction might help to deepen the understanding of this complex heterogenous disorder.

One Year of Outpatient Dialectical Behavioral Therapy and Its Impact on Neuronal Correlates of Attachment Representation in Patients with Borderline Personality Disorder Using a Personalized fMRI Task

(1) Background: BPD is characterized by affect dysregulation, interpersonal problems, and disturbances in attachment, but neuroimaging studies investigating attachment representations in BPD are rare. No study has examined longitudinal neural changes associated with interventions targeting these impairments. (2) Methods: We aimed to address this gap by performing a longitudinal neuroimaging study on n = 26 patients with BPD treated with Dialectic Behavioral Therapy (DBT) and n = 26 matched healthy controls (HCs; post intervention point: n = 18 BPD and n = 23 HCs). For functional imaging, we applied an attachment paradigm presenting attachment related scenes represented in drawings paired with related neutral or personalized sentences from one's own attachment narratives. In a prior cross-sectional investigation, we identified increased fMRI-activation in the human attachment network, in areas related to fear response and the conflict monitoring network in BPD patients. These were especially evident for scenes from the context of loneliness (monadic pictures paired with individual narrative sentences). Here, we tested whether these correlates of attachment representation show a near-to-normal development over one year of DBT intervention. In addition, we were interested in possible associations between fMRI-activation in these regions-of-interest (ROI) and clinical scores. (3) Results: Patients improved clinically, showing decreased symptoms of borderline personality organization (BPI) and increased self-directedness (Temperament and Character Inventory, TCI) over treatment. fMRI-activation was increased in the anterior medial cingulate cortex (aMCC) and left amygdala in BPD patients at baseline which was absent after intervention. When investigating associations between scores (BPI, TCI) and functional activation, we found significant effects in the bilateral amygdala. In contrast, aMCC activation at baseline was negatively associated with treatment outcome, indicating less effective treatment effects for those with higher aMCC activation at baseline. (4) Conclusions: Monadic attachment scenes with personalized sentences presented in an fMRI setup are capable of identifying increased activation magnitude in BPD. After successful DBT treatment, these increased activations tend to normalize which could be interpreted as signs of a better capability to regulate intensive emotions in the context of "social pain" towards a more organized/secure attachment representation. Amygdala activation, however, indicates high correlations with pre-treatment scores; activation in the aMCC is predictive for treatment gain. Functional activation of the amygdala and the aMCC as a response to attachment scenes representing loneness at baseline might be relevant influencing factors for DBT-intervention outcomes.

Botulinum Toxin Therapy for Psychiatric Disorders in Clinical Practice: A Retrospective Case Study

Inhibiting the facial expression of negative emotions via botulinum toxin A (BTX) has been shown to mitigate symptoms of clinical depression in randomized controlled trials. This retrospective case study sought to reproduce the beneficial effects of BTX in a naturalistic setting for major depressive disorder and collect casuistic data on its effect on other mental disorders. Moreover, we describe symptom development across multiple treatment cycles with BTX, and assess the implementation of additional injection targets in the lower face region. Participants were N = 51 adult psychiatric outpatients mainly seeking treatment for depression. Over 50% suffered from comorbid psychiatric conditions, predominantly generalized anxiety disorder (GAD) or borderline personality disorder (BPD). A pre-post case series design was adapted. All participants received BTX-injections in the glabellar region on at least one occasion. Some received additional injections in the mouth region and over multiple treatment cycles. Treatment response was followed up by self-rated scales at varying time intervals post treatment. The results showed that BTX may yield favorable outcomes across multiple and comorbid mental disorders, especially, however, for patients suffering from depression. It potentially prevents the recurrence of clinical symptoms if applied regularly. Adding additional regions of the face does not seem to be superior over applying it to the glabellar region alone. The results add to the growing evidence that BTX therapy is effective in alleviating symptoms of depression. Positive effects can be sustained and reinstated, when applied over multiple treatment cycles. Observed symptom reduction in other psychiatric disorders was less pronounced. Further research is needed to understand the mechanisms by which BTX therapy reduces psychiatric symptoms.

Altered interaction of physiological activity and behavior affects risky decision-making in ADHD

Background

Adult attention-deficit/hyperactivity disorder (ADHD) is often associated with risky decision-making behavior. However, current research studies are often limited by the ability to adequately reflect daily behavior in a laboratory setting. Over the lifespan impairments in cognitive functions appear to improve, whereas affective functions become more severe. We assume that risk behavior in ADHD arises predominantly from deficits in affective processes. This study will therefore aim to investigate whether a dysfunction in affective pathways causes an abnormal risky decision-making (DM) behavior in adult ADHD.

Methods

Twenty-eight participants with ADHD and twenty-eight healthy controls completed a battery of questionnaires regarding clinical symptoms, self-assessment of behavior and emotional competence. Furthermore, skin conductance responses were measured during the performance in a modified version of the Balloon Analogue Risk Task. A linear mixed-effects model analysis was used to analyze emotional arousal prior to a decision and after feedback display.

Results

Results showed higher emotional arousal in ADHD participants before decision-making (β = -0.12, SE = 0.05, t = -2.63, p < 0.001) and after feedback display (β = -0.14, SE = 0.05, t = -2.66, p = 0.008). Although risky behavior was greater in HC than in ADHD, we found a significant interaction effect of group and anticipatory skin conductance responses regarding the response behavior (β = 107.17, SE = 41.91, t = 2.56, p = 0.011). Post hoc analyses revealed a positive correlation between anticipatory skin conductance responses and reaction time in HC, whereas this correlation was negative in ADHD. Self-assessment results were in line with the objective measurements.

Conclusion

We found altered changes in physiological activity during a risky decision-making task. The results confirm the assumption of an aberrant relationship between bodily response and risky behavior in adult ADHD. However, further research is needed with respect to age and gender when considering physiological activities.

The Association between Type of Dissociation and Psychotic Experiences in a Non-Psychotic Inpatient Sample

Robust evidence exists for the link between dissociation and psychotic positive symptoms. The extent to which various dissociative phenomena may contribute to this relationship is still unknown. This study aimed to investigate the association between different dissociative phenomena and psychotic experiences. For this purpose, we analyzed data from 118 consecutively admitted patients of an acute care unit for trauma-related disorders who completed the Childhood Trauma Questionnaire, the German version of the Dissociative Experiences Scale and the Symptom Check-List-90-Revised. Stepwise regression analyses revealed that derealization/depersonalization in combination with amnesia accounted for 44.5% of the variance of the psychoticism subscale of the Symptom Check-List-90-Revised. Absorption in combination with emotional abuse accounted for 24.9% of the variance of the paranoid ideation subscale of the Symptom Check-List-90-Revised. The results reveal that pathological and non-pathological types of dissociation that alter the perception of reality or memory procession may contribute to the development of psychotic experiences.

How to Treat Childhood Sexual Abuse Related PTSD Accompanied by Risky Sexual Behavior: A Case Study on the Use of Dialectical Behavior Therapy for Posttraumatic Stress Disorder (DBT-PTSD)

Childhood and adolescent sexual abuse (CSA) is a traumatic experience associated with a variety of short- and long-term negative consequences. Theoretical models assume that an abuse related and learned distorted image of sexuality might lead CSA survivors to feel obligated to provide sex or engage in unwanted sexual practices in order to gain affection or prevent abandonment. Dialectical behavioral therapy for posttraumatic stress disorder (DBT-PTSD) is tailored to people with PTSD and comorbid emotion regulation deficits. This case study presents the results of an outpatient DBT-PTSD treatment of an adult patient with posttraumatic stress disorder following sexual and physical abuse. DBT-PTSD was used to treat the patient's complex psychopathological problems and to decrease her risky sexual behavior, which manifested itself in highly dangerous sexual practices with her partner. The treatment took place over a period of 18 months, with a total of 72 sessions. At the end of the treatment, the patient no longer met criteria for PTSD as indicated by large reductions in the assessments used. Furthermore, she managed to distance herself from risky sexual practices and to remain in a satisfying relationship.

Neural Correlates of Attachment Representation in Patients With Borderline Personality Disorder Using a Personalized Functional Magnet Resonance Imaging Task

Background

Fear of abandonment and aloneness play a key role in the clinical understanding interpersonal and attachment-specific problems in patients with borderline personality disorder (BPD) and has been investigated in previous functional Magnet Resonance Imaging (fMRI) studies. The aim of the present study was to examine how different aspects of attachment representations are processed in BPD, by using for the first time an fMRI attachment paradigm including personalized core sentences from the participants’ own attachment stories. We hypothesized that BPD patients would show increased functional involvement of limbic brain regions associated with fear and pain (e.g., the amygdala and the anterior cingulate cortex) when presented personalized attachment relevant stimuli representing loneliness compared to healthy controls (HC).

Methods

We examined the attachment classifications of 26 female BPD patients and 26 female HC using the Adult Attachment Projective Picture System (AAP). We used an fMRI-adapted attachment paradigm to investigate the neural correlates of attachment. All participants were presented three personalized (vs. neutral) sentences extracted from their AAP attachment narrative, combined with standardized AAP pictures representing being alone (monadic) or in interactive (dyadic) attachment situations.

Results

As expected, the classification of unresolved attachment was significantly greater in BPD compared to HC. BPD patients showed increased fMRI-activation in brain areas associated with fear, pain, and hyperarousal than HC when presented with personalized attachment-relevant alone stimuli. In particular, pictures with monadic attachment situations induced greater anterior medial cingulate cortex, anterior insula, amygdala, thalamus and superior temporal gyrus activation in the patient group.

Conclusion

The results point to increased fMRI-activation in areas processing emotional distress and painful experiences in BPD patients. In particular, the emotional cascade reflecting attachment distress was evoked by combining monadic pictures, representing abandonment and aloneness, with the patients’ personalized narrative material. Our results confirmed and replicated previous results that illustrate once again the high relevance of aloneness and feelings of abandonment for BPD in the context of attachment trauma. Moreover, our results support the hypothesis of hypermentalization in response to attachment distress as a core feature of social-cognitive impairment in BPD associated with common treatment implications across different therapeutic orientations.

[Impact of dissociative phenomena on treatment outcome of inpatient psychotherapy of patients with borderline personality disorder]

Impact of dissociative phenomena on treatment outcome of inpatient psychotherapy of patients with borderline personality disorder Objectives: Although dissociative phenomena belong to the diagnostic criteria of borderline personality disorder (BPD) and are of high clinical relevance, their predictive significance with regard to the treatment outcome has hardly been investigated. Because some therapeutic and experimental studies suggest that dissociation can impede emotional learning and thus adversely affect the response to psychotherapy, we examined this issue in patients with BPD. Methods: In this naturalistic psychotherapy study we assessed 342 patients with BPD at the beginning and end of inpatient dialectical behavioural therapy (DBT) with self-report measures for dissociation (Questionnaire on dissociative symptoms, FDS, as German version of the Dissociative Experiences Scale, DES) as well as general and borderline specific pathology (Brief Symptom Inventory, BSI; Borderline Symptom List, BSL) and quality of life (SF-12). Results: Both the general mental distress (BSI) and the borderline-specific pathology (BSL) as well as the psychosocial quality of life improved less in patients with initially severe dissociative symptoms than in those with less pronounced symptoms; this effect was mainly driven by the subscale derealisation of the Dissociative Experience Scale (DES), and was found particularly in women. Conclusion: Consistent with earlier findings, dissociative phenomena proved to be negative predictors of the therapeutic outcome in BPD women completing inpatient DBT. Whether this also applies to outpatient and other evidence-based treatment approaches for BPD remains to be clarified. Our results indicate the necessity to identify and treat dissociative symptoms as early as possible for a successful psychotherapy.

Pathologische Dissoziation bei Patienten mit einer Borderline-Persönlichkeitsstörung

Trotz der hohen Relevanz dissoziativer Phänomene bei der Borderline-Persönlichkeitsstörung (BPS) ist das Konzept der pathologischen Dissoziation bisher kaum in diesem Kontext untersucht worden. Zur Operationalisierung von pathologischer Dissoziation wurden diverse Indizes vorgeschlagen, deren klinische Nützlichkeit in der vorliegenden Studie ebenso untersucht wurde wie ihre Häufigkeit, klinischen Korrelate und prädiktive Bedeutung. Hierzu bearbeiteten 487 stationäre BPS-Patienten bei Aufnahme Selbstbeurteilungsverfahren zu Dissoziation (Dissociative Experiences Scale, DES-28) sowie allgemeiner und Borderline-typischer Pathologie (Gesundheitsfragebogen für Patienten [PHQ-D], Borderline Symptom Liste [BSL-95]). Diejenigen Patienten, die mindestens 6 Wochen an der stationären Dialektisch-Behavioralen Therapie (DBT) teilgenommen hatten, füllten am Ende erneut den PHQ‑D und die BSL-95 aus (n zwischen 342 und 361). Je nach Operationalisierung der Dissoziation litten zwischen knapp 20 % und 37 % der BPS-Patienten unter pathologischer Dissoziation. Diese war eng mit allgemeiner und Borderline-typischer Symptomatik bei Aufnahme assoziiert. Ein hohes Ausmaß an pathologischer Dissoziation zu Behandlungsbeginn prädizierte ein schlechteres symptombezogenes Therapieergebnis. Konsistent mit einer Vielzahl anderer Studien unterstreichen diese Befunde die Relevanz von Dissoziation bei der BPS. Die aus nur 8 Items der DES-28 bestehende DES-Taxon (DES-T) kann pathologische Dissoziation anwendungs- und auswertungsfreundlich erheben, erweist sich als mindestens ebenso relevant wie die DES-28 und hat für das symptombezogene Behandlungsergebnis sogar eine höhere prädiktive Relevanz. Daher empfiehlt sich ein Screening aller BPS-Patienten auf pathologische Dissoziation mit der DES‑T.

Change of Emotional Experience in Major Depression and Borderline Personality Disorder During Psychotherapy: Associations With Depression Severity and Personality Functioning

This study examines emotional experience in major depressive disorder (MDD) with and without comorbid borderline personality disorder (BPD). It investigates if depression severity or personality functioning mediates group differences and which aspects of emotional experience change during psychotherapy. The emotional experience of MDD-BPD patients (n = 44) was compared to MDD-only patients (n = 35) before and after multimodal short-term psychotherapy. Emotions were classified based on valence and an active/passive polarity. MDD-BPD patients exhibited more active-negative emotions. This group difference was mediated by the level of personality functioning, but not by depression severity. Although passive-negative emotions decreased and positive emotions increased during therapy, there was no significant change in active-negative emotions. The two patient groups did not significantly differ in the change of emotional experience. Lower levels of personality functioning in depressed patients with BPD are associated with a broader spectrum of negative emotions, specifically more active-negative emotions.

History of Childhood Trauma and Association With Borderline and Dissociative Features

ABSTRACT

Both borderline personality features and dissociative symptoms have been associated with different types of childhood trauma. The aim of this investigation was to analyze to what extent emotional, physical, and sexual child maltreatment predict borderline personality features and dissociative symptoms. For this purpose, we analyzed data from 86 consecutively admitted patients who completed the Borderline Symptom List, the Childhood Trauma Questionnaire, and the German version of the Dissociative Experiences Scale for differential diagnosis of a borderline personality disorder. Hierarchical regression analyses revealed that borderline features were mainly predicted by emotional abuse, whereas pathological dissociation was best predicted by sexual and physical abuse. This evidence supports the hypothesis that different kinds of maltreatment may lead to different psychopathological symptoms in adulthood and should be taken into account in the therapy.

[Convergent and Factorial Validity of the Impulsivity and Emotion Dysregulation Scale (IED-27) for Borderline Personality Disorder]

There is a growing consensus that emotion dysregulation is the defining feature of borderline personality disorder, but there are also persisting competing views on the pathology and dimensional structure of the disorder. The "Impulsivity and Emotion Dysregulation Scale" (IED-27) is already being used for assessing patients with borderline personality disorder. The particular aim of this study was to gain evidence of the dimensional structure of the disorder by confirmatory factorial analysis. A heterogeneous sample of patients with borderline personality disorder (n=484), attention deficit (hyperactivity) disorder (n=191) and eating disorders (n=197) of a psychosomatic clinic were given general and specific self-assessment inventories via computer-assisted testing system, including the IED-27. Results showed a bifactor model with a general factor and three specific factors: "emotional dysregulation", "relationship difficulties" and "self-injuries and suicidal behaviours", to be the model with the best fit (ΔCFI=0,032). The internal consistency of the sample seems to be good (ω=0,83-0,93) and expected correlations to similar subscales could be proved. Good psychometric criteria of the IED-27 were replicated in this study. Prospectively, the subscales allow a more detailed representation and specific treatment planning.

Aberrant functional connectivity profiles of brain regions associated with salience and reward processing in female patients with borderline personality disorder

Recent resting-state functional connectivity studies have shown significant group differences in several networks between patients suffering from borderline personality disorder (BPD) and healthy controls. However, reliable and consistent findings have not been reported yet. Several methodological factors might be responsible for the discrepant findings, including the heterogeneity of patient samples in terms of symptom severity. In the current study, we combined investigations of the whole-brain resting-state functional connectivity patterns of BPD patients with seed-based connectivity measures and then computed the correlation of connectivity measures with borderline symptom severity. Correlation-based connectivity analysis was performed on resting-state functional magnetic resonance imaging (fMRI) data from 26 female BPD patients and 26 healthy controls. Increased intrinsic connectivity was found in clusters involving part of the caudate nucleus and the left insula in the patient group, indicating greater integration of each region. Further seed-based connectivity analyses revealed that with the caudate seed, the patient data exhibited an increased resting-state functional connectivity in the bilateral ventral striatum and the midline prefrontal regions extending to the ACC, a network associated with reward processing. The left insula seed showed significantly increased connectivity with the bilateral fronto-orbital/insula, the inferior parietal lobule and the mid-cingulate cortex, a network involved in attention and salience encoding, in the patient population. Moreover, symptom severity, as assessed with the BSL-95 outside the scanner, was negatively correlated with the coupling of the insula and the striatum in the BPD group. Overall, an increased functional connectivity within two large-scale circuitries underlying reward and salience processing was evident in patients, as compared to healthy participants. When correlated with borderline symptom severity, a reduced connectivity between key regions belonging to the reward system and salience network was observed in the patients. These findings may be helpful for facilitating further understanding of the potential mechanisms underlying the BPD pathophysiology and thereby delineate potential treatment targets.

Dialectical Behavior Therapy for Posttraumatic Stress Disorder (DBT-PTSD) Compared With Cognitive Processing Therapy (CPT) in Complex Presentations of PTSD in Women Survivors of Childhood Abuse: A Randomized Clinical Trial

IMPORTANCE

Childhood abuse significantly increases the risk of developing posttraumatic stress disorder (PTSD), often accompanied by symptoms of borderline personality disorder (BPD) and other co-occurring mental disorders. Despite the high prevalence, systematic evaluations of evidence-based treatments for PTSD after childhood abuse are sparse.

OBJECTIVE

To compare the efficacy of dialectical behavior therapy for PTSD (DBT-PTSD), a new, specifically designed, phase-based treatment program, against that of cognitive processing therapy (CPT), one of the best empirically supported treatments for PTSD.

DESIGN, SETTING, AND PARTICIPANTS

From January 2014 to October 2016, women who sought treatment were included in a multicenter randomized clinical trial with blinded outcome assessments at 3 German university outpatient clinics. The participants were prospectively observed for 15 months. Women with childhood abuse-associated PTSD who additionally met 3 or more DSM-5 criteria for BPD, including affective instability, were included. Data analysis took place from October 2018 to December 2019.

INTERVENTIONS

Participants received equal dosages and frequencies of DBT-PTSD or CPT, up to 45 individual sessions within 1 year and 3 additional sessions during the following 3 months.

MAIN OUTCOMES AND MEASURES

The predefined primary outcome was the course of the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) score from randomization to month 15. Intent-to-treat analyses based on dimensional CAPS-5 scores were complemented by categorical outcome measures assessing symptomatic remission, reliable improvement, and reliable recovery.

RESULTS

Of 955 consecutive individuals assessed for eligibility, 193 were randomized (DBT-PTSD, 98; CPT, 95; mean [SD] age, 36.3 [11.1] years) and included in the intent-to-treat analyses. Analysis revealed significantly improved CAPS-5 scores in both groups (effect sizes: DBT-PTSD: d, 1.35; CPT: d, 0.98) and a small but statistically significant superiority of DBT-PTSD (group difference: 4.82 [95% CI, 0.67-8.96]; P = .02; d, 0.33). Compared with the CPT group, participants in the DBT-PTSD group were less likely to drop out early (37 [39.0%] vs 25 [25.5%]; P = .046) and had higher rates of symptomatic remission (35 [40.7%] vs 52 [58.4%]; P = .02), reliable improvement (53 [55.8%] vs 73 [74.5%]; P = .006), and reliable recovery (34 [38.6%] vs 52 [57.1%]; P = .01).

CONCLUSIONS AND RELEVANCE

These findings support the efficacy of DBT-PTSD and CPT in the treatment of women with childhood abuse-associated complex PTSD. Results pertaining to the primary outcomes favored DBT-PTSD. The study shows that even severe childhood abuse-associated PTSD with emotion dysregulation can be treated efficaciously.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00005578.

Kindheitstraumatisierungen bei Patienten mit Borderline-Persönlichkeitsstörung

Während Kindheitstraumatisierungen zentrale psychosoziale Risikofaktoren für die Entwicklung einer Borderline-Persönlichkeitsstörung (BPS) darstellen, ist ihre Relevanz für die Symptomschwere der Erkrankung und das Therapieergebnis bisher unzureichend und mit inkonsistenten Ergebnissen untersucht worden. In dieser naturalistischen Studie an 482 stationären Psychotherapiepatienten mit einer BPS wurde daher der differenzielle Einfluss verschiedener Kindheitstraumatisierungen (gemessen mit dem Childhood Trauma Questionnaire, CTQ) auf die selbstberichtete Psychopathologie hinsichtlich Depressivität (Beck-Depressions-Inventar II [BDI-II], Gesundheitsfragebogen für Patienten [PHQ]), Ängstlichkeit und Somatisierung (PHQ), BPS-spezifischer Symptomatik (Borderline-Symptom-Liste, BSL) sowie gesundheitsbezogener Lebensqualität (Kurzform des Fragebogens zum Gesundheitszustand, SF-12) zu Behandlungsbeginn und bei Abschluss einer Dialektisch-Behavioralen Therapie analysiert. Weil sich Frauen und Männer in Symptomschwere und Häufigkeit verschiedener Kindheitstraumatisierungen unterscheiden, erfolgten geschlechtsdifferenzielle Analysen. Bei Patientinnen trugen Kindheitstraumatisierungen bis maximal knapp 7 % zur Varianzaufklärung der Symptombelastung bei Aufnahme bei; lediglich emotionaler Missbrauch hatte einen signifikanten und unabhängigen Einfluss. Bei Männern fanden sich keine relevanten Zusammenhänge zwischen dem CTQ und den Ergebnismaßen. Weder bei Männern noch bei Frauen wirkten sich Kindheitstraumatisierungen auf das symptombezogene Behandlungsergebnis aus. Die Ergebnisse werden im Kontext der bisherigen Befundlage zum Zusammenhang zwischen Kindheitstraumatisierungen, Symptomschwere und Therapieergebnis bei psychischen Störungen im Allgemeinen und der BPS im Besonderen diskutiert.

Investigating the psychological mechanisms underlying the relationship between nightmares, suicide and self-harm

Evidence suggests that nightmares increase the risk of suicide and self-harm, independently of insomnia, PTSD, anxiety and depression. A better understanding of this relationship is vital for the development of effective suicide and self-harm interventions. A systematic review of the research investigating the mechanisms underlying the nightmare and suicide/self-harm relationship was therefore conducted. Findings from twelve studies were critically appraised and synthesised under the headings of affect/emotion regulation, cognitive appraisals, psychosocial factors, acquired capability and depression. Despite clear variability in the methodology employed by the studies, the initial evidence suggests cognitive appraisals and affect/emotion regulation play a key role in the nightmare and suicide/self-harm relationship. Consideration is given for the first time to the differences in the mechanisms underlying the relationship between nightmares and suicide. In order to further elucidate and support these findings however, future research utilising longitudinal designs, objective measures of sleep disturbance and investigating the emotional content of nightmares is vital. There is also a call for studies investigating the impact of nightmare interventions on subsequent suicidal thoughts and behaviours, and self-harm. This is especially so given that individuals might find it easier to seek help for nightmares than for suicidality or self-harm.

Altered functional connectivity during evaluation of self-relevance in women with borderline personality disorder

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Appraisal of self-relevance is disturbed in borderline personality disorder (BPD).

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We introduce the first neuroimaging study about self-relevance processing in BPD.

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Besides the CMS, the MNS and the SMA are involved in self-relevance processing.

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Functional connectivity of CMS is altered in BPD during self-relevance evaluations.

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In BPD, valence affects the functional connectivity during self-relevance ratings.

Self-relevant functional abnormalities and identity disorders constitute the core psychopathological components in borderline personality disorder (BPD). Evidence suggests that appraising the relevance of environmental information to the self may be altered in BPD. However, only a few studies have examined self-relevance (SR) in BPD, and the neural correlates of SR processing has not yet been investigated in this patient group. The current study sought to evaluate brain activation differences between female patients with BPD and healthy controls during SR processing. A task-based fMRI paradigm was applied to evaluate SR processing in 23 female patients with BPD and 23 matched healthy controls. Participants were presented with a set of short sentences and were instructed to rate the stimuli. The differences in fMRI signals between SR rating (task of interest) and valence rating (control task) were examined. During SR rating, participants showed elevated activations of the cortical midline structures (CMS), known to be involved in the processing of self-related stimuli. Furthermore, we observed an elevated activation of the supplementary motor area (SMA) and the regions belonging to the mirror neuron system (MNS). Using whole-brain, seed-based connectivity analysis on the task-based fMRI data, we studied connectivity of networks anchored to the main CMS regions. We found a discrepancy in the connectivity pattern between patients and controls regarding connectivity of the CMS regions with the basal ganglia-thalamus complex. These observations have two main implications: First, they confirm the involvement of the CMS in SR evaluations of our stimuli and add evidence about the involvement of an extended network including the MNS and the SMA in this task. Second, the functional connectivity profile observed in BPD provides evidence for an altered functional interplay between the CMS and the brain regions involved in salience detection and reward evaluation, including the basal ganglia and the thalamus.

Drawing the borderline: Predicting treatment outcomes in patients with borderline personality disorder

BACKGROUND

A routinely collected big data set was analyzed to determine the effectiveness of naturalistic inpatient treatment and to identify predictors of treatment outcome and discontinuation.

METHODS

The sample included 878 patients with borderline personality disorder who received non-manualized dialectic behavioral therapy in a psychosomatic clinic. Effect sizes (Hedge's g) were calculated to determine effectiveness. A bootstrap-enhanced regularized regression with 91 potential predictors was used to identify stable predictors of residualized symptom- and functional change and treatment discontinuation. Results were validated in a holdout sample and repeated cross validation.

RESULTS

Effect sizes were small to medium (g = 0.28-0.51). Positive symptom-related outcome was predicted by low affect regulation skills and no previous outpatient psychotherapy. Lower age, absence of work disability, high emotional and physical role limitations and low bodily pain were associated with greater improvement in functional outcome. Higher education and comorbid recurrent depressive disorder were the main predictors of treatment completion. The predictive quality of the models varied, with the best being found for symptom-related outcome (R2 = 18%).

CONCLUSION

While the exploratory process of variable selection replicates previous findings, the validation results suggest that tailoring treatment to the individual patient might not be based solely on sociodemographic, clinical and psychological baseline data.

Measuring the shadows: A systematic review of chronic emptiness in borderline personality disorder

BACKGROUND

Chronic feelings of emptiness is an under-researched symptom of borderline personality disorder (BPD), despite indications it may be central to the conceptualisation, course, and outcome of BPD treatment. This systematic review aimed to provide a comprehensive overview of chronic feelings of emptiness in BPD, identify key findings, and clarify differences between chronic feelings of emptiness and related constructs like depression, hopelessness, and loneliness.

METHOD

A PRISMA guided systematic search of the literature identified empirical studies with a focus on BPD or BPD symptoms that discussed chronic feelings of emptiness or a related construct.

RESULTS

Ninety-nine studies met criteria for inclusion in the review. Key findings identified there were significant difficulties in defining and measuring chronic emptiness. However, based on the studies reviewed, chronic emptiness is a sense of disconnection from both self and others. When experienced at frequent and severe levels, it is associated with low remission for people with BPD. Emptiness as a construct can be separated from hopelessness, loneliness and intolerance of aloneness, however more research is needed to explicitly investigate these experiences. Chronic emptiness may be related to depressive experiences unique to people with BPD, and was associated with self-harm, suicidality, and lower social and vocational function.

CONCLUSIONS AND IMPLICATIONS

We conclude that understanding chronic feelings of emptiness is central to the experience of people with BPD and treatment focusing on connecting with self and others may help alleviate a sense of emptiness. Further research is required to provide a better understanding of the nature of chronic emptiness in BPD in order to develop ways to quantify the experience and target treatment. Systematic review registration number: CRD42018075602.

Brain structure and symptom dimensions in borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) presents with symptoms across different domains, whose neurobiology is poorly understood.

METHODS

We applied voxel-based morphometry on high-resolution magnetic resonance imaging scans of 19 female BPD patients and 50 matched female controls.

RESULTS

Group comparison showed bilateral orbitofrontal gray matter loss in patients, but no significant changes in the hippocampus. Voxel-wise correlation of gray matter with symptom severity scores from the Borderline Symptom List (BSL-95) showed overall negative correlation in bilateral prefrontal, right inferior temporal/fusiform and occipital cortices, and left thalamus. Significant (negative) correlations with BSL-95 subscores within the patient cohort linked autoaggression to left lateral prefrontal and insular cortices, right inferior temporal/temporal pole, and right orbital cortex; dysthymia/dysphoria to right orbitofrontal cortex; self-perception to left postcentral, bilateral inferior/middle temporal, right orbitofrontal, and occipital cortices. Schema therapy-based Young Schema Questionnaire (YSQ-S2) scores of early maladaptive schemas on emotional deprivation were linked to left medial temporal lobe gray matter reductions.

CONCLUSIONS

Our results confirm orbitofrontal structural deficits in BPD, while providing a framework and preliminary findings on identifying structural correlates of symptom dimensions in BPD, especially with dorsolateral and orbitofrontal cortices.

Short Imagery Rescripting Intervention to Treat Emotionally Dysregulated Behavior in Borderline Personality Disorder: An Exploratory Study

BACKGROUND

Current research on borderline personality disorder report an association between emotionally dysregulated behaviors and intrusive mental imagery depicting similar scenes. Imagery rescripting techniques have proven effective in reducing intrusive mental imagery in numerous contexts. We developed a two session-short intervention in which intrusive mental images are identified, analyzed, and modified for daily rehearsal at home. This study aimed to reduce the negative emotions and cognitions associated with self-injurious behaviors by replacing unhealthy imagery with more adaptive content.

METHODS

Seven females diagnosed with borderline personality disorder who reported intrusive mental imagery of dysregulated behaviors were recruited for participation. Each participant engaged in two individualized treatment sessions and daily homework requiring the rehearsal of modified imagery. Emotion regulation strategies, borderline symptom severity, and depressiveness were assessed before and after treatment.

RESULTS

Acceptance was positive, as no patient dropped out from treatment. Symptom exacerbation was not observed. Borderline symptom reduction was noted and indicia of emotional dysregulation and negative affect declined.

LIMITATIONS

The generalizability of results is limited by the small sample size and the absence of a control group. Conclusions: This new two-session short intervention was shown to decrease the emotionally dysregulated behaviors that accompany negative feelings in females with borderline personality disorder.

Mental images, entrapment and affect in young adults meeting criteria of nonsuicidal self-injury disorder (NSSID) - a daily diary study

BACKGROUND

Incidents of nonsuicidal self-injury (NSSI) are often accompanied by mental images which could be perceived as distressing and/or soothing; yet existing data is derived from participants with a history of NSSI using retrospective methods. This study investigated mental images related to NSSI ("NSSI-images"), and their relationship to the proposed Nonsuicidal Self-Injury Disorder (NSSID).

METHODS

An e-mail was sent to all female students of the local University providing the link to an online screening and 201 students with a history of repetitive NSSI responded. Nineteen eligible participants meeting criteria of NSSID (mean age = 25; 32% with migrant background) further completed a baseline interview and a ten-day-diary protocol.

RESULTS

Among the sample of N = 201, 83.6% reported NSSI-images. In the subsample of n = 19 diagnosed with NSSID, the frequencies of NSSI and NSSI-images were correlated; about 80% of the most significant NSSI-images were either of NSSI or of an instrument associated with NSSI (i.e., a razorblade). In the diary, 53% of the sample self-injured. NSSI-images were reported on 94% of NSSI-days, and on days with NSSI and NSSI-images, the images almost always occurred first; the images were overall perceived as twice more distressing than comforting. Images on NSSI-days were characterized by more comfort, intrusiveness and compellingness yet less vividness, and increased subsequent positive and negative affect compared to non-NSSI days. NSSI-days were further marked by increased entrapment beliefs and increased negative yet decreased positive affect at night. These results were non-significant.

LIMITATIONS

Due to non-significant results among a small sample size and a low rate of NSSI among the NSSID-group, results remain preliminary.

CONCLUSIONS

The study provides information on feasibility and methodological challenges such as intervention effects of the diary. NSSI-images may be common among individuals who engage in NSSI; they may capture ambivalent (positive and negative) appraisals of NSSI and thus play a role in NSSI and possibly a disorder such as NSSID. The preoccupation with NSSI (Criterion C of NSSID in DSM-5) may as well be imagery-based.

REGISTRATION

The study was retrospectively registered with the DRKS under the number DRKS00011854.

Implicit and explicit self-concept of neuroticism in borderline personality disorder

PURPOSE

In the past, research on personality in borderline personality disorder (BPD) used primarily questionnaires suggesting heightened neuroticism in BPD. Self-report instruments inform about the conscious or explicit self-concept. BPD patients are known to show negative distortion with exaggeration of negative affect in the self-report. Neuroticism represents a risk factor for mental disorders. Indirect measures are available that tap into the implicit self-concept of neuroticism. The implicit self-concept refers to individual differences in associative representations of the self. The present study examined for the first time the implicit in addition to the explicit self-concept of neuroticism in BPD.

MATERIALS AND METHODS

Female BPD patients (N = 35) and healthy women (N = 39) completed an implicit association test and the NEO-FFI personality inventory.

RESULTS

BPD patients showed higher implicit and explicit neuroticism compared to controls. The group difference for explicit neuroticism was four times larger than that for implicit neuroticism. Presence of comorbid depressive disorder was positively correlated with implicit neuroticism. The IAT neuroticism showed excellent split-half reliability for BPD patients.

CONCLUSIONS

The present data suggest that BPD patients with comorbid clinical depression but not those without clinical depression differ from healthy individuals in their implicit self-concept of neuroticism. In the associative network, BPD patients with comorbid clinical depression exhibit stronger associations of the self with neuroticism-related characteristics, such as nervousness, fearfulness, and uncertainty than healthy individuals. Regardless of depression, BPD patients show increased explicit neuroticism. Our findings provide evidence that the IAT neuroticism can be applied reliably to BPD patients.

A research programme to evaluate DBT-PTSD, a modular treatment approach for Complex PTSD after childhood abuse

BACKGROUND

Posttraumatic stress disorder (PTSD) after childhood abuse (CA) is often related to severe co-occurring psychopathology, such as symptoms of borderline personality disorder (BPD). The ICD-11 has included Complex PTSD as a new diagnosis, which is defined by PTSD symptoms plus disturbances in emotion regulation, self-concept, and interpersonal relationships. Unfortunately, the empirical database on psychosocial treatments for survivors of CA is quite limited. Furthermore, the few existing studies often have either excluded subjects with self-harm behaviour and suicidal ideation - which is common behaviour in subjects suffering from Complex PTSD. Thus, researchers are still trying to identify efficacious treatment programmes for this group of patients.We have designed DBT-PTSD to meet the specific needs of patients with Complex PTSD. The treatment programme is based on the rules and principles of dialectical behavioural therapy (DBT), and adds interventions derived from cognitive behavioural therapy, acceptance and commitment therapy and compassion-focused therapy. DBT-PTSD can be provided as a comprehensive residential programme or as an outpatient programme. The effects of the residential programme were evaluated in a randomised controlled trial. Data revealed significant reduction of posttraumatic symptoms, with large between-group effect sizes when compared to a treatment-as-usual wait list condition (Cohen's d = 1.5).The first aim of this project on hand is to evaluate the efficacy of the outpatient DBT-PTSD programme. The second aim is to identify the major therapeutic variables mediating treatment efficacy. The third aim is to study neural mechanisms and treatment sensitivity of two frequent sequelae of PTSD after CA: intrusions and dissociation.

METHODS

To address these questions, we include female patients who experienced CA and who fulfil DSM-5 criteria for PTSD plus borderline features, including criteria for severe emotion dysregulation. The study is funded by the German Federal Ministry of Education and Research, and started in 2014. Participants are randomised to outpatient psychotherapy with either DBT-PTSD or Cognitive Processing Therapy. Formal power analysis revealed a minimum of 180 patients to be recruited. The primary outcome is the change on the Clinician-Administered PTSD Scale for DSM-5.

DISCUSSION

The expected results will be a major step forward in establishing empirically supported psychological treatments for survivors of CA suffering from Complex PTSD.

TRIAL REGISTRATION

German Clinical Trials Register: registration number DRKS00005578, date of registration 19 December 2013.

[Adult ADHD and borderline personality disorder: A pilot study on differences in attachment and early traumatization]

Adult ADHD and borderline personality disorder: A pilot study on differences in attachment and early traumatization Objective: Attention-deficit/hyperactivity disorder (ADHD) in adulthood and borderline personality disorder (BPD) share commondiagnostic criteria.The present study examined how ADHD in adulthood can be distinguished from BPDregarding attachment style and traumatic experiences.

METHOD

The sample consists of N = 30 persons with 50% (n = 15) ADHD patients and 50% (n = 15) BPD patients. The patients were asked to fill out different questionnaires to investigate the criteria for specific symptoms.

RESULTS

The results show that most of the patients are insecurely attached. In addition, 80% of both the ADHD and BPD sample claimed traumatic experiences in their childhood or adolescence. Most frequently, patients reported traumatisation following emotional neglect and emotional abuse. No group-specific differences concerning traumatic experiences and the individual attachment style were determined.

CONCLUSION

The etiological factors attachment style and traumatic experiences are not suitable for differentiating ADHD in adulthood and BPD.

Effect of negative valence on assessment of self-relevance in female patients with borderline personality disorder

Background

A disturbed self-image is central to the characteristic symptoms of borderline personality disorder (BPD). Evaluations of self-relevance (SR) are highly important in cognitive and emotional processing of information and adaptive behavior.

Method

In the current study, we used affective statements to investigate if SR is altered in patients with higher scores on Borderline Symptom List (BSL-95). Forthyfemale adults with BPD and 20 healthy participants assessed a set of stimuli consisting of sentences in third-person for relevance to self.

Results

BPD patients exhibited a higher SR for negative contents as compared to healthy controls (p < .001). Furthermore, a significant positive correlation coefficient was found between the increased bias in evaluating the SR of stimuli and borderline symptom severity scores, as measured by BSL-95 questionnaire (r = 0.67, p < .001). This effect persisted after controlling for depressive symptoms by a partial correlation analysis.

Conclusion

Our results revealed an enhanced SR for negative statements, which was related to the severity of individuals’ BPD symptoms. These findings add to the diagnostic information regarding the disturbed organization of self in this clinical population. We suggest the maladaptive evaluation of SR offers an important treatment target for therapeutic approaches to BPD.

Examining components of emotion regulation in relation to sleep problems and suicide risk

BACKGROUND

Sleep has emerged as an important factor in elevated risk for suicide and suicidal behaviors; however, the mechanisms accounting for this relationship are poorly understood. Emotion regulation is a well-established correlate of self-injurious behaviors; however, the broad construct has recently been shown to provide limited predictive utility. More nuanced investigations into the processes involved in emotion regulation may address this gap. This study sought to examine the mediating role of emotion regulation between sleep disturbances and suicide risk, as well as to evaluate a moderated mediation model in which down- and up-regulation of emotions would moderate this mediation.

METHODS

Participants were 972 adults recruited from a crowdsourcing website (Amazon's Mechanical Turk) who completed self-report questionnaires regarding nightmares, suicide risk, and emotion regulation.

RESULTS

Emotion regulation mediated the direct effect of nightmares on suicide risk and suicide attempts. Downregulation of negative affect moderated the mediation of nightmares on suicide risk more clearly than upregulation of positive affect, and neither component of emotion regulation exhibited moderated mediation in the suicide attempt model.

LIMITATIONS

Generalizability of our findings from an online community sample will need to be established with replication in other samples. Additionally, we used cross-sectional measures in our mediation models.

CONCLUSIONS

Downregulation of negative emotions may be particularly salient in relation to the severity of suicide risk and, as a result, relative deficits in this area should be considered when making risk determinations.

Extending research on Emotion Regulation Individual Therapy for Adolescents (ERITA) with nonsuicidal self-injury disorder: open pilot trial and mediation analysis of a novel online version

BACKGROUND

Nonsuicidal self-injury (NSSI) is common among adolescents and associated with negative outcomes. However, treatments developed specifically for NSSI and the proposed NSSI disorder (NSSID) are scarce, and access to empirically supported treatments for NSSI in many areas is limited. Online treatments carry the potential to increase the availability of evidence-based treatments. Emotion regulation individual therapy for adolescents (ERITA) has shown promise in the treatment of adolescents with NSSID.

METHOD

The present study examined the feasibility, acceptability, and utility of an online version of ERITA. Twenty-five adolescents (aged 13-17) with NSSID and their parents were included in an uncontrolled open trial. Self-report and clinician-rated assessments of outcomes such as NSSI, self-destructive behaviors, emotion dysregulation, and global functioning were administered at pre-treatment, post-treatment, 3- and 6- month follow-up. Measures of NSSI, self-destructive behaviors, and emotion dysregulation were also assessed weekly during treatment.

RESULTS

Ratings of treatment credibility, expectancy, and satisfaction were acceptable, and the therapeutic alliance and treatment completion rate (96%) were high. Adolescent participation in the treatment was associated with a statistically significant increase in past-month NSSI abstinence (p = .007), large-sized improvements in past-month NSSI frequency (55% reduction, 95% confidence interval [CI]: 29, 72; Cohen's d = 0.88, 95% CI: 0.73, 1.06) and global functioning (d = 1.01, 95% CI: 0.77, 1.32), and medium-sized improvements in emotion dysregulation (d = 0.75, 95% CI: 0.59, 0.90) and NSSI versatility (d = 0.63, 95% CI: 0.54, 0.77) from pre- to post-treatment. These improvements were further strengthened at 3-month follow-up and maintained at 6-month follow-up. The online therapist-guided parent program was associated with small- to large-sized (ds = 0.47-1.22) improvements in adaptive parent behaviors, and these improvements were maintained or further improved upon at 6-month follow-up. Moreover, in line with the theoretical model underlying ERITA, change in emotion dysregulation mediated changes in both NSSI frequency and self-destructive behaviors over the course of treatment.

CONCLUSIONS

Together, results suggest that online ERITA is an acceptable, feasible, and promising low-intensity treatment for adolescents with NSSID. The results of this open trial must be replicated in controlled studies.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT02697019 ). Registered 2 March 2016.

Psychometric Properties of the Chinese Version of the Brief Borderline Symptom List in Undergraduate Students and Clinical Patients

The brief version of the Borderline Symptom List (BSL-23) is a self-rated scale developed from the initial 95-item version of Borderline Symptom List (BSL-95). The current study aimed to evaluate the psychometric properties of the Chinese version of the BSL-23. A total of 570 undergraduate students and 323 clinical patients completed the BSL-23, the borderline subscale of the Personality Diagnostic Questionnaire (PDQ-4+), the Center for Epidemiologic Studies Depression Scale (CES-D), the Barratt Impulsiveness Scale, 11th version (BIS-11), the Childhood Trauma Questionnaire (CTQ) and the Attachment Style Questionnaire (ASQ). A Confirmatory Factor Analysis (CFA) was conducted to test the one-factor structure of the BSL-23. Cronbach’s alpha, Omega coefficient, Split-Half coefficient, Mean Inter-Item Correlation (M_IC) and test-retest reliability were also measured. The correlations between the BSL-23 and other psychological variables were used to assess criterion-related validity and convergent validity. Participants who scored ≥ 5 on the borderline subscale of the PDQ-4+ were placed into the borderline personality disorder (BPD) screening-positive group, while the others were placed into the screening-negative group. Independent sample t-tests were performed to examine the differences in BSL-23 scores between the BPD screening-positive group and the BPD screening-negative group. The CFA results supported the one-factor structure of the BSL-23 in both samples. The internal consistency was high both in the undergraduate sample (Cronbach’s α = 0.93, Omega = 0.95, Split-Half coefficient = 0.89, M_IC = 0.38) and the clinical sample (Cronbach’s α = 0.97, Omega = 0.97, Split-Half coefficient = 0.96, M_IC = 0.56). The test-retest reliability within 2 weeks was 0.62. The BSL-23 displayed moderate to high correlations with the PDQ-4+-Borderline subscale, the CES-D, the BIS-11, the CTQ and the ASQ (r = 0.35 – 0.70). In addition, the BSL-23 discriminated between the BPD screening-positive and the BPD screening-negative participants, and also between the patient sample and undergraduate sample. In conclusion, the Chinese version of the BSL-23 has satisfactory psychometric properties to assess BPD symptoms.

Emotion regulation individual therapy for adolescents with nonsuicidal self-injury disorder: a feasibility study

BACKGROUND

Nonsuicidal self-injury (NSSI) is a serious health risk behavior that forms the basis of a tentative diagnosis in DSM-5, NSSI Disorder (NSSID). To date, established treatments specific to NSSI or NSSID are scarce. As a first step in evaluating the feasibility, acceptability, and utility of a novel treatment for adolescents with NSSID, we conducted an open trial of emotion regulation individual therapy for adolescents (ERITA): a 12-week, behavioral treatment aimed at directly targeting both NSSI and its proposed underlying mechanism of emotion regulation difficulties.

METHODS

Seventeen girls (aged 13-17; mean = 15.31) with NSSID were enrolled in a study adopting an uncontrolled open trial design with self-report and clinician-rated assessments of NSSI and other self-destructive behaviors, emotion regulation difficulties, borderline personality features, and global functioning administered at pre-treatment, post-treatment, and 6-month follow-up. Measures of NSSI and emotion regulation difficulties were also administered weekly during treatment.

RESULTS

Ratings of treatment credibility and expectancy and the treatment completion rate (88%) were satisfactory, and both therapeutic alliance and treatment attendance were strong. Intent-to-treat analyses revealed significant improvements associated with large effect sizes in past-month NSSI frequency, emotion regulation difficulties, self-destructive behaviors, and global functioning, as well as a medium effect size in past-month NSSI versatility, from pre- to post-treatment. Further, all of these improvements were either maintained or further improved upon at 6-month follow-up. Finally, change in emotion regulation difficulties mediated improvements in NSSI over the course of treatment.

CONCLUSIONS

Results suggest the acceptability, feasibility, and utility of this treatment for adolescents with NSSID.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02326012, December 22, 2014, retrospectively registered).

Ambulante Dialektisch-Behaviorale Therapie für Adoleszente (DBT-A) mit impulsiven und selbstschädigenden Verhaltensweisen

Zusammenfassung. Die Dialektisch-Behaviorale Therapie für Adoleszente (DBT-A) zur Behandlung impulsiver und suizidaler Jugendlicher wird seit Februar 2005 in leicht abgeänderter Form ambulant im Kinder- und Jugendpsychiatrischen Dienst Zürich umgesetzt. Diese DBT-A umfasst Einzeltherapie, ein Gruppen- bzw. Skills-Training sowie einen Elternabend und dauert jeweils ein halbes Jahr. Der vorliegende Erfahrungsbericht zeigt die Umsetzung dieses Ansatzes und präsentiert eine Evaluation im Rahmen der klinikinternen Qualitätssicherung.

Die insgesamt 43 Teilnehmerinnen des Therapie-Programms waren weibliche Jugendliche im Alter von 14–19 Jahren, die impulsive und selbstschädigende Verhaltensweisen sowie Probleme in der Regulierung ihrer Emotionen und in der zwischenmenschlichen Beziehungsgestaltung aufwiesen. An einem Skills-Training nahmen jeweils 4–6 Jugendliche teil.

Unsere mehrheitlich positiven Erfahrungen mit diesem Ansatz in der Therapie wurden durch die Auswertungen der Daten aus der Qualitätssicherung von 19 Teilnehmerinnen bestätigt, welche sowohl Selbst- wie auch Fremdurteile umfassten. Es liegen Hinweise vor, dass die DBT-A mit zu einer Abnahme sowohl verschiedener Indikatoren der allgemeinen als auch der spezifischen Psychopathologie führt.

Emotion regulation group therapy for deliberate self-harm: a multi-site evaluation in routine care using an uncontrolled open trial design

OBJECTIVE

Emotion regulation group therapy (ERGT) has shown promising results in several efficacy trials. However, it has not been evaluated outside a research setting. In order to increase the availability of empirically supported treatments for individuals with borderline personality disorder and deliberate self-harm, an evaluation of ERGT in routine clinical care was conducted with therapists of different professional backgrounds who had received brief intensive training in ERGT prior to trial onset.

DESIGN

Multi-site evaluation, using an uncontrolled open trial design with assessments at pretreatment, post-treatment and 6-month follow-up.

SETTING

14 adult outpatient psychiatric clinics across Sweden.

PARTICIPANTS

Ninety-five women (mean age=25.1 years) with borderline personality disorder (both threshold and subthreshold) and repeated self-harm were enrolled in the study. Ninety-three per cent of participants completed the post-treatment assessment and 88% completed the follow-up assessment.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was self-harm frequency as measured with the Deliberate Self-Harm Inventory. Secondary outcomes included self-harm versatility, emotion dysregulation, other self-destructive behaviours, depression, anxiety, stress symptoms and interpersonal and vocational difficulties.

INTERVENTION

ERGT is an adjunctive, 14-week, acceptance-based behavioural group treatment that directly targets both self-harm and its proposed underlying mechanism of emotion dysregulation.

RESULTS

At post-treatment, intent-to-treat analyses revealed a significant improvement associated with a moderate effect size on the primary outcome of self-harm frequency (51%, reduction; Cohen's d=0.52, p<0.001) as well as significant improvements in the secondary outcomes of self-harm versatility, emotion dysregulation, other self-destructive behaviours and general psychiatric symptomatology. These results were either maintained or further improved on at 6-month follow-up.

CONCLUSIONS

ERGT appears to be a feasible, transportable and useful treatment for deliberate self-harm and other self-destructive behaviours, emotion dysregulation and psychiatric symptoms when delivered by clinicians in the community.

TRIAL REGISTRATION NUMBER

NCT01986257; results.

Relationship between borderline personality symptoms and Internet addiction: The mediating effects of mental health problems

Aim To examine the relationship between borderline personality symptoms and Internet addiction as well as the mediating role of mental health problems between them. Methods A total of 500 college students from Taiwan were recruited and assessed for symptoms of Internet addiction using the Chen Internet Addiction Scale, borderline personality symptoms using the Taiwanese version of the Borderline Symptom List and mental health problems using four subscales from the Symptom Checklist-90-Revised Scale (interpersonal sensitivity, depression, anxiety, and hostility). Structural equation modeling (SEM) was used to test our hypothesis that borderline personality symptoms are associated with the severity of Internet addiction directly and also through the mediation of mental health problems. Results SEM analysis revealed that all paths in the hypothesized model were significant, indicating that borderline personality symptoms were directly related to the severity of Internet addiction as well as indirectly related to the severity of Internet addiction by increasing the severity of mental health problems. Conclusion Borderline personality symptoms and mental health problems should be taken into consideration when designing intervention programs for Internet addiction.

Differences in mental health among young adults with borderline personality symptoms of various severities

PURPOSE

This study examined the differences in mental health and behavioral problems among young adults with borderline personality symptoms of various severities.

METHODS

500 college students participated in this study. Borderline personality symptoms were evaluated using the Taiwanese version of the Borderline Symptom List (BSL-23). Mental health problems were assessed using the Symptom Checklist-90-Revised Scale. Suicidality and other behavioral problems were assessed using questions from the epidemiological version of the Kiddie Schedule for Affective Disorders and Schizophrenia and BSL-23 Supplement. According to the distribution of BSL-23 scores at the 25th, 50th, and 75th percentiles, the participants were divided into 4 groups: No/Mild, Moderate, Severe, and Profound. Analysis of variance and the chi-square test were used to compare mental health and behavioral problems among the 4 groups.

RESULTS

All mental health problems differed significantly among the 4 groups. The severity of nearly all mental health problems increased with that of borderline personality symptoms. The proportions of most behavioral problems differed significantly among the 4 groups. The Profound group was more likely to have behavioral problems than the other 3 groups.

CONCLUSION

Young adults who had more severe borderline personality symptoms had more severe mental health and behavioral problems.

Don't Praise Me, Don't Chase Me: Emotional Reactivity to Positive and Negative Social-Evaluative Videos in Patients With Borderline Personality Disorder

Diagnostic criteria for borderline personality disorder (BPD) include interpersonal problems and high reactivity to negative social interactions. However, experimental studies on these symptoms are scarce, and it remains unclear whether reactivity is also altered in response to positive social interactions. To simulate such situations, the present study used videographic stimuli (E.Vids; Blechert, Schwitalla, & Wilhelm, 2013) in which actors express rejecting, neutral, or appreciating sentences. Twenty BPD patients and 20 healthy controls rated their emotional responses to these on pleasantness, arousal, and 11 specific emotions. In addition to elevated reactivity to negative E.Vids, patients with BPD showed marked reduction in pleasantness responses to positive E.Vids. Furthermore, they exhibited less pride, happiness, feelings of approval, and attraction/love in response to positive videos and more anger, anxiety, embarrassment, contempt, guilt, feelings of disapproval/rejection, and sadness to negative videos. Interestingly, BPD patients also reported negative emotions in response to positive videos. Implications for psychotherapy and research are discussed.

Temperament and character traits in female adolescents with nonsuicidal self-injury disorder with and without comorbid borderline personality disorder

BACKGROUND

Temperament and character traits of adolescents with nonsuicidal self-injury disorder (NSSI) might differentiate those- with and without comorbid borderline personality disorder (BPD).

METHODS

Participants were 57 female adolescents with NSSI disorder without BPD (NSSI - BPD), 14 adolescents with NSSI disorder and BPD (NSSI + BPD), 32 clinical controls (CC), and 64 nonclinical controls (NC). Temperament and character traits were assessed with the Junior Temperament and Character Inventory, and impulsivity with the Barratt Impulsiveness Scale and a Go/NoGo task.

RESULTS

Adolescents with NSSI disorder scored significantly higher on novelty seeking and harm avoidance and lower on persistence, self-directedness, and cooperativeness than CC. The NSSI + BPD group scored even higher than the NSSI - BPD group on novelty seeking and harm avoidance and lower on persistence and cooperativeness (d ≥ 0.72). Adolescents with NSSI reported higher levels of impulsivity than the CC and NC group. However, this difference was not found in a Go/NoGo task.

CONCLUSIONS

The results provide further evidence for a distinct diagnostic entity of NSSI disorder.

Impact of therapist change after initial contact and traumatic burden on dropout in a naturalistic sample of inpatients with borderline pathology receiving dialectical behavior therapy

BACKGROUND

This study focused on the predictors of therapy dropout in a naturalistic sample of patients with borderline pathology receiving dialectical behavior therapy (DBT) in an inpatient setting. We assumed that the change of the therapist between DBT-briefing and start of DBT-treatment as well as comorbid posttraumatic stress disorder (PTSD) and childhood trauma history were associated with elevated dropout.

METHODS

Eighty-nine participants with borderline pathology (≥ 3 borderline personality disorder criteria) receiving an inpatient DBT program completed a quality assurance questionnaire set assessing demographic information and pretreatment psychopathology during the days of their inpatient stay. Beyond that, changes of therapists were documented. The predictor analyses were investigated with generalized estimating equations.

RESULTS

The dropout rate was 24.7%. A change of therapist between DBT-briefing and treatment as well as high childhood emotional abuse was associated with premature termination of treatment. Higher values of physical neglect during childhood were associated with a protective effect on treatment dropout. Surprisingly, this was also true for comorbid PTSD.

CONCLUSIONS

This study supports the importance of therapy process variables as predictors of therapy dropout in borderline pathology. A change of therapist between DBT-briefing and treatment was associated with an increased vulnerability for dropping out of treatment and should therefore be avoided if possible. Against our hypotheses, a comorbid PTSD was even protective with regard to DBT dropout. Therefore, this severely suffering patient group should not be rejected from treatment assuming them to be too unstable for psychotherapy. However, results need to be replicated. ClinicalTrials.gov Identifier: NCT03018639, retrospectively registered on January 9, 2017.

A negative relationship between ventral striatal loss anticipation response and impulsivity in borderline personality disorder

Patients with borderline personality disorder (BPD) frequently exhibit impulsive behavior, and self-reported impulsivity is typically higher in BPD patients when compared to healthy controls. Previous functional neuroimaging studies have suggested a link between impulsivity, the ventral striatal response to reward anticipation, and prediction errors. Here we investigated the striatal neural response to monetary gain and loss anticipation and their relationship with impulsivity in 21 female BPD patients and 23 age-matched female healthy controls using functional magnetic resonance imaging (fMRI). Participants performed a delayed monetary incentive task in which three categories of objects predicted a potential gain, loss, or neutral outcome. Impulsivity was assessed using the Barratt Impulsiveness Scale (BIS-11). Compared to healthy controls, BPD patients exhibited significantly reduced fMRI responses of the ventral striatum/nucleus accumbens (VS/NAcc) to both reward-predicting and loss-predicting cues. BIS-11 scores showed a significant positive correlation with the VS/NAcc reward anticipation responses in healthy controls, and this correlation, while also nominally positive, failed to reach significance in BPD patients. BPD patients, on the other hand, exhibited a significantly negative correlation between ventral striatal loss anticipation responses and BIS-11 scores, whereas this correlation was significantly positive in healthy controls. Our results suggest that patients with BPD show attenuated anticipation responses in the VS/NAcc and, furthermore, that higher impulsivity in BPD patients might be related to impaired prediction of aversive outcomes.

•

We investigated striatal reward and loss anticipation in patients with Borderline Personality Disorder (BPD) and controls

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BPD patients relative to controls exhibited reduced ventral striatal / nucleus accumbens (VS/NAcc) anticipation responses

•

In healthy controls, VS responses to gains and losses correlated positively with impulsivity

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BPD patients exhibited a negative correlation between loss responses and impulsivity.

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Our results suggest that impulsivity in BPD patients may in part result from impaired anticipation of aversive outcomes.

Effectiveness and feasibility of Narrative Exposure Therapy (NET) in patients with borderline personality disorder and posttraumatic stress disorder - a pilot study

BACKGROUND

This pilot study focused on the feasibility and potential effectiveness of a protocol based on Narrative Exposure Therapy (NET) that was integrated into a standard inpatient program to treat patients with comorbid Borderline Personality Disorder (BPD) and Posttraumatic Stress Disorder (PTSD).

METHODS

Eleven patients (1 male, 10 female) without previous stabilization periods or the absence of intentional self-injury received NET during a ten-week inpatient program. Patients were assessed again at post-treatment and a 12-month follow-up.

RESULTS

Drop-out rates during treatment were low, with 90.9 % completing NET. Furthermore, acceptance of NET was high, with only one patient rejecting treatment. The program was safe because it did not lead to aggravations in symptom severity at either the post-treatment or 12-month follow-up. Additionally, the rate of self-harming behaviors throughout the treatment phase was low (18.2 %). In fact, treatment was associated with positive effects on PTSD and BPD symptom severity as well as secondary outcome measures, including depression, dissociation and quality of life.

CONCLUSIONS

The present study found that NET is feasible and safe in an inpatient setting for treating highly burdened patients with BPD and PTSD. There is also evidence for the potential effectiveness of NET in this highly burdened population.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02517723 . Registered 6 January 2014.

Real-Time Monitoring of Non-linear Suicidal Dynamics: Methodology and a Demonstrative Case Report

In recent years, a number of different authors have stressed the usefulness of non-linear dynamic systems approach in suicide research and suicide prevention. This approach applies specific methods of time series analysis and, consequently, it requires a continuous and fine-meshed assessment of the processes under consideration. The technical means for this kind of process assessment and process analysis are now available. This paper outlines how suicidal dynamics can be monitored in high-risk patients by an Internet-based application for continuous self-assessment with integrated tools of non-linear time series analysis: the Synergetic Navigation System. This procedure is illustrated by data from a patient who attempted suicide at the end of a 90-day monitoring period. Additionally, future research topics and clinical applications of a non-linear dynamic systems approach in suicidology are discussed.

Psychometric properties of the French borderline symptom list, short form (BSL-23)

BACKGROUND

The short form of the Borderline Symptom List (BSL-23) is a self-rating instrument used to assess specific symptoms of borderline personality disorder (BPD). The original German version has shown good psychometric proprieties. The BSL-23 can also be used to measure the effects of therapy on patients with BPD. The aim of this study was to assess the psychometric properties of the French version of the BSL-23.

METHODS

The French version of the BSL-23 was given to 265 subjects with BPD. Factor structure, reliability, test-retest stability, convergent validity, divergent validity, and sensitivity to change were analysed. Forty-five subjects suffering from attention-deficit hyperactivity disorder (ADHD) were used as controls to evaluate the specificity of BSL-23.

RESULTS

A one-factor structure was obtained in the French version of the BSL-23, showing high internal consistency (Cronbach's alpha = .94) and test-retest reliability (r = .841). The French version of the BSL-23 was highly correlated with depression severity, hopelessness, anger, motor impulsiveness, and BPD diagnosis. It was an efficient tool to discriminate between BPD patients and ADHD patients, and showed good sensitivity to change in a group of BPD patients who took part in a one-month DBT intervention.

CONCLUSIONS

The French version of the BSL-23 shows similar psychometric properties as the original German version. This study therefore provides clinicians and researchers with a French instrument to measure BPD symptomatology.