Severity of reported childhood sexual abuse and its relationship to severity of borderline psychopathology and psychosocial impairment among borderline inpatients

Parenting knowledge and parenting self-efficacy of mothers with borderline personality disorder and depression: "I know what to do but think I am not doing it"

Borderline personality disorder (BPD) is a complex mental health condition often associated with previous childhood adversity including maladaptive parenting. When becoming a parent themselves, mothers with BPD have difficulties with various parenting cognitions and practices, but unknown is whether they have appropriate knowledge of sensitive parenting. This study explored whether differences in parenting knowledge or self-efficacy are specific to BPD or also found in mothers with depression, and whether symptom severity or specific diagnosis better explain parenting perceptions. Mothers with BPD (n = 26), depression (n = 25) or HCs (n = 25) completed a Q-sort parenting knowledge task and a parenting self-efficacy questionnaire. Results showed mothers with BPD had the same knowledge of sensitive parenting behaviors as mothers with depression and healthy mothers. Self-reported parenting self-efficacy was lower in mothers with BPD and depression compared with healthy mothers, with symptom severity most strongly associated. A significant but low correlation was found between parenting self-efficacy and knowledge. Findings suggest that mothers with BPD and depression know what good parenting is but think they are not parenting well. Mental health difficulties are not associated with parenting knowledge, but symptom severity appears to be a common pathway to lower parenting self-efficacy. Future interventions should test whether reduction of symptom severity or positive parenting feedback could improve parenting self-efficacy.

Emotional Dysregulation and Post-Traumatic Stress Symptoms: Which Interaction in Adolescents and Young Adults? A Systematic Review

Emotional dysregulation (ED) has recently been conceptualized as a transnosographic entity in major mental disorders, and increasing evidence has suggested association between ED and post-traumatic stress symptoms (PTSS), though the nature of this association is unclear. The aim of the present review was to examine the possible interplay between ED and trauma exposure in the literature, as well as a possible role for the comorbidity of PTSD or PTSS in adolescents and young adults. In particular, we explored whether ED may represent a risk factor for PTSD or, conversely, a consequence of traumatic exposure. This systematic review was conducted according to PRISMA 2020 guidelines in three databases (PubMed, Scopus, and Embase). The 34 studies included showed a wide heterogeneity in terms of the populations selected and outcomes examined. Most studies used the Difficulties in Emotion Regulation Scale (DERS) and examined the relationship between ED, trauma, and psychopathological manifestations after the occurrence of trauma, with a focus on child abuse. Although current data in the literature are heterogeneous and inconclusive, this research highlights the role of ED as a mechanism that may mediate vulnerability to PTSD, but also as a predictor of severity and maintenance of typical, atypical, or associated PTSD symptoms, suggesting prevention programs for PTSD and other mental disorders should support the development of emotion regulation strategies.

Accuracy and Bias in Facial Trustworthiness Appraisals in Borderline Personality Disorder

Individuals with borderline personality disorder (BPD) have shown a negativity bias, whereas the general population has shown a positivity bias in their trustworthiness appraisal of others. We tested if individuals with BPD are more negative but also more realistic with their appraisals. Trustworthiness was objectified on an external criterion. The influence of childhood trauma was investigated. Facial photographs of peace prize laureates and sentenced murderers were presented. Participants with BPD and healthy controls (HC) rated the trustworthiness of the targets. Bias and sensitivity were measured using signal detection theory. The BPD group was more negatively biased compared to HC, but not more sensitive in discriminating between the two groups. When correcting for experienced childhood abuse and neglect, the authors found that group differences in bias disappeared. Individuals with BPD might not be more sensitive in discriminating between, on average, more or less trustworthy targets, but they have developed a negativity bias to ensure the detection of untrustworthiness.

A Systematic Review of the Association Between Early Childhood Trauma and Borderline Personality Disorder

Borderline personality disorder (BPD) is a debilitating clinical disorder associated with adverse impacts on multiple levels. While a high prevalence of childhood trauma has been noted, the ways such trauma impacts the development of BPD symptomatology remain unclear. In this systematic review, the authors examine the literature from 2000 to 2020, focusing on the association between trauma and BPD, and offer a comprehensive synthesis of possible etiological implications related to either one specific or multiple trauma types. In addition, results are analyzed based on commonly tested trauma parameters, including repeated exposure, polytrauma, onset, perpetrators, and gender. The authors also note some limitations in areas of sampling, measurement, causal inference methods, and data analyses. Results of this review point to several parameters of trauma that can be used to inform training for practitioners as well as enhance current interventions.

Late manifestation of borderline personality disorder: Characterization of an under-recognized phenomenon

Although uncommon, borderline personality disorder (BPD) may manifest for the first time later in life. A retrospective clinical file audit was used to identify the clinical manifestation of BPD for the first time at or above the age of 30, and to examine whether particular clinical and psychosocial factors may be associated with a later-in-life manifestation of BPD. Twenty-three cases of late manifestation BPD were identified. People with late manifestation of BPD had similar risk factors and vulnerabilities, including childhood trauma, to the broader BPD population. They were distinguished by having higher levels of education, employment, and long-term intimate relationships. Interpersonal problems, loss of employment and reminders of past sexual trauma were key precipitating factors. The findings underscore the legitimacy of a late-manifestation diagnosis of BPD by demonstrating that BPD does not present exclusively during adolescence and early adulthood. BPD may present for the first time in later life in response to loss of protective factors or triggering of past trauma. This understanding may reduce misdiagnosis or delayed diagnosis, prescription of inappropriate treatments or delays in receiving BPD-appropriate treatments.

Adverse Childhood Experiences and Neurocognition in Borderline Personality Disorder: A Call-to-Action Perspective Review

Adverse childhood experiences (ACEs) contribute to the development of personality traits leading to adult borderline personality disorder (BPD). Neurocognitive changes could partly mediate the association between ACEs and BPD. We discuss how exposure to ACEs could induce alterations in neurocognition, which, in turn, would contribute to the development of BPD. We conducted a review of MEDLINE articles through 2021, documenting a link between ACEs, neurocognitive impairments, and BPD, and also focusing on the pairwise associations. ACEs appear to have a strong impact on neurocognition and are a predictive factor for BPD. Maltreated, abused, and emotionally invalidated children are more likely to present BPD traits. Neurocognitive impairments in adults exposed to ACEs and in patients with BPD arise from similar brain alterations in the amygdala, hippocampus, and prefrontal cortex. These impairments seem to be linked with clinical dimensions of BPD: increased impulsivity to altered inhibitory control; dissociative experiences to nonspecific autobiographical memory; and emotionally biased facial recognition to unstable interpersonal relationships. This perspective review highlights the contributory role of neurocognition in the association between ACEs and BPD. Additional research is needed, however, on the interconnections among ACEs, neurocognition, and BPD. Future studies could also focus on developing tools to assess early adversity in BPD specifically and on psychotherapeutic approaches to promptly remedy neurocognitive impairments.

Borderline Personality Disorder: Clinical Guidelines for Treatment

Borderline personality disorder (BPD) is fundamentally a syndrome composed of symptoms (primarily of emotional dysregulation) and a number of true personality traits (such as inordinate anger, impulsivity, and a tendency to stress-related paranoid ideation). Whereas schizotypal personality disorder, with its cognitive peculiarities (ideas of reference, odd beliefs, eccentric speech), is closely linked as a genetic condition-"borderline" to the major condition schizophrenia-BPD is less closely linked to bipolar disorder. Some cases of BPD are linked genetically to and are in the "border" of bipolar disorder. But the condition can also arise from adverse post-natal factors: parental cruelty or neglect, or incest. In some BPD patients, both are present: risk genes for bipolar disorder and adverse conditions within the family. The genetic risk is often overlooked. To avoid this, initial evaluations should always include a careful and extensive family history for mood disorders, and should extend out to grandparents, aunts, uncles, and cousins. Where the history suggests a genetic link to bipolar disorder, a mood stabilizer such as lithium or lamotrigine, even in modest doses, may be particularly beneficial, more so than conventional antidepressants. In some patients, ADHD was present in childhood, BPD was diagnosed during or after puberty, and a form of bipolar disorder becomes apparent during their 20s. As for the psychotherapeutic component, the patient's cognitive style and capacity for introspection will help determine whether a primarily expressive (psychoanalytically oriented) technique is preferable or a primarily cognitive-behavioral technique. Flexibility is necessary, since during emotional crises, supportive and limit-setting interventions will be needed, along with psychotropic medications, and where necessary, programs to help combat substance abuse (which is common among patients with BPD).

Structural Features Predict Sexual Trauma and Interpersonal Problems in Borderline Personality Disorder but Not in Controls: A Multi-Voxel Pattern Analysis

Child trauma plays an important role in the etiology of Bordeline Personality Disorder (BPD). Of all traumas, sexual trauma is the most common, severe and most associated with receiving a BPD diagnosis when adult. Etiologic models posit sexual abuse as a prognostic factor in BPD. Here we apply machine learning using Multiple Kernel Regression to the Magnetic Resonance Structural Images of 20 BPD and 13 healthy control (HC) to see whether their brain predicts five sources of traumas: sex abuse, emotion neglect, emotional abuse, physical neglect, physical abuse (Child Trauma Questionnaire; CTQ). We also applied the same analysis to predict symptom severity in five domains: affective, cognitive, impulsivity, interpersonal (Zanarini Rating Scale for Borderline Personality Disorder; Zan-BPD) for BPD patients only. Results indicate that CTQ sexual trauma is predicted by a set of areas including the amygdala, the Heschl area, the Caudate, the Putamen, and portions of the Cerebellum in BPD patients only. Importantly, interpersonal problems only in BPD patients were predicted by a set of areas including temporal lobe and cerebellar regions. Notably, sexual trauma and interpersonal problems were not predicted by structural features in matched healthy controls. This finding may help elucidate the brain circuit affected by traumatic experiences and connected with interpersonal problems BPD suffer from.

[Pilot Evaluation of a New Treatment Concept for Children to Improve Emotion Regulation and Stress Resilience. START-Kids: Stress-Arousal-Regulation-Treatment for Kids]

Emotional Dysregulation is a frequent challenge in clinical child psychiatric contexts. The Stress-Arousal-Regulation-Treatment for Children aged six to twelve (START-Kids, Dixius u. Möhler, 2021a), was developed as low threshold treatment tool for children with emotional dysregulation. The program is based on principles of dialectic behavioral therapy. The present article focuses feasibility and a first evaluation of this innovative treatment tool for emotionally dysregulated children. 23 child psychiatric patients aged six to twelve years took part in this eight weeks program with two group sessions at 60 min per week. Immediately before and after treatment personality functioning was assessed with the Levels of Personality Functioning Questionnaire LoPF-Q E and OPD-KJ2-SF E. There was no drop-out. Significant positive changes could be found after treatment with regard to therapists' and a trend for parent's ratings. Limitations are small sample size and lack of a treatment-as-usual-control group. START-Kids is an innovative program with high amount of feasibility and a positive influence on aspects of personality functions in children. Future studies, specifically a randomized controlled trial of START-Kids is warranted.

Psychosocial functioning in adolescents with non-suicidal self-injury: the roles of childhood maltreatment, borderline personality disorder and depression

BACKGROUND

There is a lack of studies examining psychosocial functioning in patients with non-suicidal self-injury (NSSI), especially in adolescents, and rates of impaired functioning in existing literature vary considerably. These variations may be attributable to further risk factors that influence psychosocial functioning. Thus, the aim of the study was to examine whether adolescent NSSI patients with childhood maltreatment (CM), a known risk factor for lower psychosocial functioning, may differ from adolescent NSSI patients without CM, and whether these differences may be explained by the severity of comorbid disorders. Specifically, we examined whether severity of borderline personality disorder (BPD), depression and posttraumatic stress disorder may explain differences in psychosocial functioning in NSSI patients with and without CM.

METHODS

Data of 368 adolescents with NSSI disorder from an outpatient clinic were analyzed using structural equation modeling. Clinicans' rating of the Global Assessment of Functioning Scale (GAF) was collected, in addition to clinical interviews.

RESULTS

Results indicate that GAF scores were lower among NSSI patients with CM and that the difference in psychosocial functioning between these groups was explained by BPD and depression severity.

CONCLUSIONS

Psychosocial functioning in NSSI patients varies depending on whether they have experienced CM or not. Specifically, these differences seem to be attributable to higher BPD and depression severity in adolescent NSSI patients with CM. Clinicians should ensure to assess CM and focus on BPD and depression severity in this population. Treatment of BPD and depression may notably reduce psychosocial impairment in NSSI patients with CM.

Looking at the bigger picture: Cortical volume, thickness and surface area characteristics in borderline personality disorder with and without posttraumatic stress disorder

Borderline personality disorder (BPD) is a severe psychiatric disorder accompanied by multiple comorbidities. Neuroimaging studies have identified structural abnormalities in BPD with most findings pointing to gray matter volume reductions in the fronto-limbic network, although results remain inconsistent. Similar alterations were found in posttraumatic stress disorder (PTSD), a common comorbidity of BPD. Only a small number of studies have investigated structural differences in BPD patients regarding comorbid PTSD specifically and studies conducting additional surface analyses are scarce. We investigated structural differences in women with BPD with and without PTSD and non-patient controls. Automated voxel-based and region-based volumetric analyses were applied. Additionally, four surface-based measures were analyzed: cortical thickness, gyrification index, fractal dimension, and sulcus depth. Analyses did not identify cortical volume alterations in the fronto-limbic network. Instead, hypergyrification was detected in the right superior parietal cortex in BPD patients compared to non-patient controls. No distinction was revealed between BPD patients with and without PTSD. These findings underline the importance of a holistic investigation examining volumetric and surface measures as these might enhance the understanding of structural alterations in BPD.

Impulse control under emotion processing: an fMRI investigation in borderline personality disorder compared to non-patients and cluster-C personality disorder patients

Impulsivity is a characteristic syndromal and neurobehavioral feature of borderline personality disorder (BPD). Research suggests an important interaction between high negative emotions and low behavioral inhibition in BPD. However, knowledge about the generalizability across stimulus categories and diagnosis specificity is limited. We investigated neural correlates of hypothesized impaired response inhibition of BPD patients to negative, positive and erotic stimuli, by comparing them to non-patients and cluster-C personality disorder patients. During fMRI scanning, 53 BPD patients, 34 non-patients and 20 cluster-C personality disorder patients completed an affective go/no-go task, including social pictures. BPD patients showed more omission errors than non-patients, independent of the stimulus category. Furthermore, BPD patients showed higher activity in the inferior parietal lobule and frontal eye fields when inhibiting negative versus neutral stimuli. Activity of the inferior parietal lobule correlated positively with the BPD checklist subscale impulsivity. When inhibiting emotional stimuli, BPD patients showed an altered brain activity in the inferior parietal lobe and frontal eye fields, whereas previously shown dysfunctional prefrontal activity was not replicated. BPD patients showed a general responsivity across stimulus categories in the frontal eye fields, whereas effects in the inferior parietal lobe were specific for negative stimuli. Results of diagnosis specificity support a dimensional rather than a categorical differentiation between BPD and cluster-C patients during inhibition of social emotional stimuli. Supported by behavioral results, BPD patients showed no deficiencies in emotionally modulated response inhibition per se but the present findings rather hint at attentional difficulties for emotional information.

Culture and psychopathology: An attempt at reconsidering the role of social learning

This paper proposes a model for developmental psychopathology that is informed by recent research suggestive of a single model of mental health disorder (the p factor) and seeks to integrate the role of the wider social and cultural environment into our model, which has previously been more narrowly focused on the role of the immediate caregiving context. Informed by recently emerging thinking on the social and culturally driven nature of human cognitive development, the ways in which humans are primed to learn and communicate culture, and a mentalizing perspective on the highly intersubjective nature of our capacity for affect regulation and social functioning, we set out a cultural-developmental approach to psychopathology.

Shame in Borderline Personality Disorder: Meta-Analysis

Shame has been found to be a core feature of borderline personality disorder (BPD). To date, there is no existing systematic review or meta-analysis examining shame in individuals with BPD as compared to healthy controls (HCs). A meta-analysis of 10 studies comparing reported shame in BPD patients to HCs was carried out. Demographic and clinical moderator variables were included to see if they have a relationship with the effect size. Results showed that those with BPD had more reported shame than healthy controls. In addition, in BPD patients and HCs, higher education level was related to lower reported shame. In HCs, it was found that those who were younger reported a higher level of shame. Finally, among BPD patients, there was a relationship between levels of reported shame and elevated PTSD symptomatology. These findings emphasize the clinical relevance of shame in individuals with BPD and the need to formulate psychotherapeutic strategies that target and decrease shame.

Childhood Sexual Trauma and Antiretroviral Therapy Adherence: A Mixed-Methods Systematic Review

Childhood sexual abuse (CSA) has been shown to be more prevalent among populations living with HIV. Antiretroviral therapy (ART) adherence is crucial for populations living with HIV as it significantly increases the likelihood of attaining and maintaining viral suppression. Previous findings on the association between CSA and ART adherence have been mixed. The current mixed-methods systematic review aimed to identify quantitative and qualitative studies from CINAHL, PsycInfo, PubMed, and Web of Science examining the relationship between CSA and ART adherence. Authors were also contacted if relevant data were unpublished. Studies had to be published from January 1, 2000 to April 1, 2019, written in English, and examined CSA as an exposure and ART adherence as an outcome. Four domains were combined: 1) childhood sexual abuse; 2) child; 3) antiretroviral; and 4) adherence. Eight quantitative and two qualitative studies were retained. The results showed that four quantitative studies found no association while the other four found factors such as timing of victimization, mental health and gender influenced the association between CSA and ART adherence. Themes emerging from the qualitative studies included use of ART evoking memories of CSA; CSA impacting mental health; and mental health treatment improving ART adherence. Mixed insights included the intricate links between CSA and ART adherence and the role of external factors on the relationship. ART adherence intervention programs may be needed for people who have experienced CSA. However, future studies are needed that will examine the association between CSA and ART adherence and include subgroup analyses.

Pain sensitivity and plasma beta-endorphin in adolescent non-suicidal self-injury

BACKGROUND

Beta-endorphin (BE) has been suggested to play a central role as to why people engage in NSSI. To our knowledge, no study has systematically assessed this potential relationship in adolescents with NSSI.

METHODS

94 adolescents with NSSI (according to DSM-5 criteria) and 35 healthy controls (HC) were enrolled. All participants received heat pain stimulation, with pain threshold and tolerance measured in °C. Plasma BE levels were assessed. Sociodemographic and clinical characteristics were obtained via semi-structured interviews and self-report questionnaires.

RESULTS

Adolescents with NSSI showed increased pain thresholds (t₍₁₂₇₎=2.071, p=.040), lower pain intensity (t₍₁₁₄₎==2.122, p=.036) and lower plasma BE levels (t₁₂₇==3.182, p=.002) compared to HC. Groups did not differ on pain tolerance (t₍₁₂₇₎=0.911, p=.364). Greater pain threshold correlated positively with borderline personality disorder (BPD) symptoms (r=0.182, p=.039), while pain intensity (r=-0.206, p=.033) and BE levels (r=-0.246, p=.007) correlated negatively with depression severity. No significant relationship was found between pain threshold and plasma BE (r=-0.013, p=.882).

LIMITATIONS

Future studies should implement repeated plasma BE measures to assess BE release in association with pain in NSSI. Validity of plasma BE measures compared to central measures should be considered. Assessing the association between pain sensitivity (PS) and BE in a naturalistic setting presents a promising avenue for future research in NSSI.

CONCLUSIONS

Findings support both reduced PS and basal opioid deficiency as independent biological correlates and potential risk-factors for NSSI. Further longitudinal and experimental studies are needed to investigate the role of BE levels and PS as well as their potential association.

The mediating effect of difficulties in emotion regulation on the association between childhood maltreatment and borderline personality disorder

BACKGROUND

Childhood maltreatment and difficulties in emotion regulation are common in patients with Borderline Personality Disorder (BPD) and Depressive Disorders (DD).

OBJECTIVE

This study examines differences between patients with BPD and patients with DD, regarding childhood maltreatment and difficulties in emotion regulation as well as the mediating effect of different aspects of emotion regulation deficits on the association between childhood maltreatment and BPD-symptoms.

METHOD

A total of 305 participants, 177 with BPD and 128 with DD completed an assessment including the Childhood Trauma Questionnaire (CTQ), the Emotion Regulation Scale (DERS), the Brief Symptom Inventory (BSI), and the Structured Clinical Interview for DSM-IV (SCID). Data was analyzed using multiple analyses of variances and mediation analyses.

RESULTS

Patients with BPD reported more childhood maltreatment and more difficulties in emotion regulation than patients with DD. When general symptom severity, age, and gender were included in the analysis as covariates only group differences regarding 'impulse control difficulties' (F(1,299) = 38.97, p < .001, η_p² = .115), 'limited access to emotion regulation strategies' (F(1,299) = 4.66, p = .032, η_p² = .015), and 'lack of emotional clarity' (F(1,299) = 9.38, p = .002, η_p² = .030) remained statistically significant. A mediation analysis, including above-mentioned covariates, indicated an association between emotional abuse and BPD-symptoms, which was mediated by difficulties in emotion regulation (indirect effect B = .012, 95% CI [.001; .031], R² = .429). Subscale analyses revealed 'impulse control difficulties' as the aspect of difficulties in emotion regulation that has the greatest impact on this association (B = .021, 95% CI [.003; .045]).

CONCLUSIONS

Patients with BPD display more childhood maltreatment and difficulties in emotion regulation than patients with DD. Difficulties in emotion regulation, especially difficulties in impulse control, seem to play an important role in the association between childhood emotional abuse and BPD-symptoms.

Perceived Caretaker Malevolence During Childhood Reported by Borderline Patients and Personality-Disordered Comparison Subjects: Description and Prediction

This study has two purposes. The first is to assess the rates of childhood malevolence by caretakers reported by a well-defined sample of inpatients with borderline personality disorder (BPD) and comparison subjects with other personality disorders. The second purpose is to determine the relationship between reported malevolence of caretakers and possible risk factors for this experience. Two reliable interviews were administered to 290 borderline inpatients and 72 personality-disordered comparison subjects to address these aims. Malevolence was reported by a significantly higher percentage of borderline patients than comparison subjects (58% vs. 33%). In multivariate analyses, severity of other forms of abuse, severity of neglect, and a family history of a dramatic cluster personality disorder were found to significantly predict perceived malevolence. Taken together, the results of this study suggest that experiencing malevolence is common and distinguishing for BPD, and that the risk factors for reported childhood malevolence are multifactorial in nature.

Child sexual abuse: An examination of individual and abuse characteristics that may impact delays of disclosure

BACKGROUND

Nondisclosure in cases of child sexual abuse (CSA) can lead to numerous aversive outcomes for children who have been sexually abused, the most serious of which include untreated psychological symptoms and possible further abuse. While victim testimony is often required for perpetrator conviction or disruption of contact, children face multiple barriers to reporting abuse. Research suggests the likelihood of disclosure is impacted by both characteristics of children (i.e., age and gender), as well as abuse characteristics (i.e., relation to perpetrator, severity and frequency of abuse).

OBJECTIVE

Although these factors have been studied in relation to rates of disclosure, relatively little is known about their impact on temporal delays in reporting CSA.

PARTICIPANTS AND SETTING

Special access was obtained to review classified RCMP case files on CSA drawn from the greater Okanagan area, British Columbia, Canada (n = 164).

METHODS

Cases were coded according to victim and abuse characteristics. A multivariate Cox regression analysis was used in order to analyze the impact each variable of interest had on time until a disclosure was made.

RESULTS

All predictors were found to significantly impact delays of disclosure, x2(6) = 65.558, p = .000. Delays of disclosure were decreased as age of the child increased or if the child was female. Alternatively, if abuse was more severe, occurred at a higher frequency, or if perpetrators were more closely related, delays of disclosure increased.

CONCLUSIONS

The current study provides potential for tailored approaches according to individual characteristics and vulnerabilities in CSA investigations and treatments.

Parameters of reported childhood sexual abuse and assault in adolescents and adults with borderline personality disorder

OBJECTIVE

Prior research has demonstrated a link between childhood sexual abuse and borderline personality disorder (BPD) in adolescents and adults and has indicated that more severe abuse is related to poorer psychosocial functioning. The present study describes the overall severity of sexual abuse/assault in adolescents and adults with BPD and compares both groups on specific parameters of abusive and assaultive experiences.

METHODS

Participants included 104 adolescent (aged 13-17 years) inpatients with BPD and 290 adult inpatients with BPD. All participants completed two interviews that assessed the presence and severity of sexual abuse/assault.

RESULTS

Of the studied patients with BPD, 26.0% of adolescents and 62.4% of adults reported a childhood history of sexual abuse/assault before the age of 18. Adults had higher scores on an index of sexual abuse severity than adolescents, and a higher proportion of adults reported scores in the severe range. Adults with BPD were also more likely than adolescents to report having experienced sexual abuse/assault that occurred at multiple developmental stages, was frequent (i.e. weekly basis or more), was longer in duration (i.e. a year or more) and was perpetrated by a parent. The groups did not differ on other parameters.

CONCLUSIONS

Taken together, these results suggest that adults with BPD are more likely to report childhood sexual abuse/assault than adolescents with BPD. Additionally, adults report histories of sexual abuse/assault that are more severe than adolescents with BPD, with specific differences observed in timing, frequency, duration and perpetrator. © 2020 John Wiley & Sons, Ltd.

The vicious circle of social exclusion and psychopathology: a systematic review of experimental ostracism research in psychiatric disorders

Social exclusion (ostracism) is a major psychosocial factor contributing to the development and persistence of psychiatric disorders and is also related to their social stigma. However, its specific role in different disorders is not evident, and comprehensive social psychology research on ostracism has rather focused on healthy individuals and less on psychiatric patients. Here, we systematically review experimental studies investigating psychological and physiological reactions to ostracism in different responses of psychiatric disorders. Moreover, we propose a theoretical model of the interplay between psychiatric symptoms and ostracism. A systematic MEDLINE and PsycINFO search was conducted including 52 relevant studies in various disorders (some of which evaluated more than one disorder): borderline personality disorder (21 studies); major depressive disorder (11 studies); anxiety (7 studies); autism spectrum disorder (6 studies); schizophrenia (6 studies); substance use disorders (4 studies); and eating disorders (2 studies). Psychological and physiological effects of ostracism were assessed with various experimental paradigms: e.g., virtual real-time interactions (Cyberball), social feedback and imagined scenarios. We critically review the main results of these studies and propose the overall concept of a vicious cycle where psychiatric symptoms increase the chance of being ostracized, and ostracism consolidates or even aggravates psychopathology. However, the specificity and stability of reactions to ostracism, their neurobiological underpinnings, determinants, and moderators (e.g., attachment style, childhood trauma, and rejection sensitivity) remain elusive.

Emotion Dysregulation and Early Trauma in Borderline Personality Disorder: An Exploratory Study

BACKGROUND

Borderline personality disorder (BPD) research is in its nascent stage in India though studies have estimated its prevalence in psychiatric conditions. Trauma experiences and emotion regulation difficulties are well documented in BPD in the international literature. Thus, it is imperative to examine the role of trauma experiences and their relation to emotion dysregulation in BPD in the Indian context.

MATERIALS AND METHODS

This study used both self-report and semistructured interview data from 34 adults with BPD who presented for outpatient or inpatient psychiatric treatment and compared them with a gender-matched control group. The tools used were the International Personality Disorder Examination, Kessler-10, Early Trauma Inventory Self Report-Short Form, modified-Positive And Negative Affect Scale, Cognitive Emotion Regulation Questionnaire, and Difficulties in Emotion Regulation Scale (DERS).

RESULTS

The BPD group reported higher negative affect, increased use of maladaptive emotion regulation strategies and a deficit of adaptive strategies, after depression scores were controlled for. General abuse, physical punishment, and emotional abuse were significantly higher in the BPD group. The high occurrence of childhood emotional abuse and negative affect in BPD patients emerged as a major correlate accounting for 68.4% of the variance in DERS scores.

CONCLUSIONS

Although we obtained results similar to the western literature on BPD pathology, sociocultural factors such as family and economic conditions, cultural differences in symptom expression of BPD, and treatment forms used in India warrant further research.

Mediating role of borderline personality disorder traits in the effects of childhood maltreatment on suicidal behaviour among mood disorder patients

Background:

Substantial evidence supports an association between childhood maltreatment and suicidal behaviour. However, few studies have examined factors mediating this relationship among patients with unipolar or bipolar mood disorders.

Methods:

Depressive disorder and bipolar disorder (ICD-10-DCR) patients (n = 287) from the Helsinki University Psychiatric Consortium (HUPC) Study were surveyed on self-reported childhood experiences, current depressive symptoms, borderline personality disorder traits, and lifetime suicidal behaviour. Psychiatric records served to complement the information on suicide attempts. We examined by formal mediation analyses whether (1) the effect of childhood maltreatment on suicidal behaviour is mediated through borderline personality disorder traits and (2) the mediation effect differs between lifetime suicidal ideation and lifetime suicide attempts.

Results:

The impact of childhood maltreatment in multivariate models on either lifetime suicidal ideation or lifetime suicide attempts showed comparable total effects. In formal mediation analyses, borderline personality disorder traits mediated all of the total effect of childhood maltreatment on lifetime suicide attempts, but only one fifth of the total effect on lifetime suicidal ideation. The mediation effect was stronger for lifetime suicide attempts than for lifetime suicidal ideation (P = 0.002) and independent of current depressive symptoms.

Conclusions:

The mechanisms of the effect of childhood maltreatment on suicidal ideation versus suicide attempts may diverge among psychiatric patients with mood disorders. Borderline personality disorder traits may contribute to these mechanisms, although the influence appears considerably stronger for suicide attempts than for suicidal ideation.

Parenting stress and competence in borderline personality disorder is associated with mental health, trauma history, attachment and reflective capacity

BACKGROUND

Individuals with borderline personality disorder (BPD) may experience additional challenges in their parenting role, including increased stress and lower self-efficacy and satisfaction. These difficulties have been shown to impact their children, and may be implicated in the potential intergenerational transmission of personality vulnerabilities.

METHODS

Parental stress and competence variables were examined in a cross-sectional study of 284 parents (94.72% female, M = 37.37, SD = 8.04 years), of which 69 (24.30%) met caseness for BPD criteria. We completed a multivariate analysis of variance to test how parents with 'high BPD features' (meeting caseness for BPD) compared to those with 'low BPD features' on a range of parenting and mental health variables. Multivariate linear regression modelling was then utilised to explore whether these parenting variables were associated with personality and psychological wellbeing, recalled trauma history, orientation to attachment relationships and reflective capacity.

RESULTS

Individuals high in BPD features experienced more stress and lower competence in their parenting role than those low in BPD features. These parents also reported more personality vulnerabilities, poorer psychological wellbeing, recalled more traumatic experiences in their childhood, were more likely to endorse insecure attachment styles and had poorer reflective capacity. In the regression model, parenting stress and competence was associated with personality traits, general psychological wellbeing, recalled trauma history, attachment style and reflective capacity variables. Parental reflective capacity had the strongest association with parenting stress, satisfaction, efficacy, the perception of having a difficult child and a difficult parent-child relationship, and psychological wellbeing had the greatest association with parenting distress.

CONCLUSIONS

Parents who were able to imaginatively enter the subjective world of the child and hold the child's mind in mind with less certainty, reported reduced parenting stress and greater parenting satisfaction and efficacy. Helping to improve personality and mental health functioning, increasing parental reflective capacity and strengthening parent-child attachment relationships, may reduce parenting stress and increase parenting competence in individuals with BPD.

A history of prolonged childhood sexual abuse is associated with more severe clinical presentation of borderline personality disorder in adolescent female inpatients - A naturalistic study

BACKGROUND

Borderline personality disorder (BPD) is associated with high rates of suicidal and self-injurious behaviors and a substantial proportion of BPD patients have a history of trauma, particularly childhood sexual abuse (CSA).

OBJECTIVE

To compare the clinical presentation severity in female adolescent inpatients with BPD with and without history of prolonged CSA.

PARTICIPANTS AND SETTING

Female adolescent BPD patients admitted to a psychiatric inpatient unit.

METHODS

A retrospective analysis of records of the inpatients, divided into two groups: with (n = 38) and without (n = 40) a history of prolonged CSA. Prolonged CSA was defined as sexual abuse continuing for at least 3 months. Demographic and clinical data, including number and duration of psychiatric hospitalizations until the age 19, non-suicidal self-injury (NSSI), suicide attempts, cigarette smoking, alcohol and drug use, and sexual impulsivity were compared between the two groups.

RESULTS

The BPD + prolonged CSA group had a larger duration of the first psychiatric hospitalization, number of hospitalizations and cumulative length of hospitalizations compared with the control group. Furthermore, the BPD + prolonged CSA group had a higher number of suicidal attempts, and higher rates of severe NSSI events, cigarette smoking, alcohol use, and sexual impulsivity.

CONCLUSIONS

This study demonstrated for the first time that adolescent female BPD inpatients with a history of prolonged CSA, manifest more severe clinical presentation compared to those without prolonged CSA. Hence, it appears essential to encourage therapists to inquire about history of CSA and refer adolescent female BPD inpatients with prolonged CSA to appropriate intensive therapy.

Is mentalization-based therapy effective in treating the symptoms of borderline personality disorder? A systematic review

OBJECTIVE

This review sought to systematically review evidence on the efficacy of mentalization-based therapy (MBT) for the treatment of borderline personality disorder (BPD), in particular, in decreasing psychiatric symptoms associated with BPD and its comorbid disorders.

METHOD

Fourteen papers were included in the review which examined the effectiveness of MBT in the context of BPD; these included 11 original studies and three follow-up papers.

RESULTS

Mentalization-based therapy was found to achieve either superior or equal reductions in psychiatric symptoms when compared with other treatments (supportive group therapy, treatment as usual/standard psychiatric care, structured clinical management, and specialized clinical management).

DISCUSSION

Mentalization-based therapy can achieve significant reductions in BPD symptom severity and the severity of comorbid disorders as well as increase quality of life. However, caution is required, as the need for better quality research such as randomized controlled trials is pressing. Research is also needed on the proposed mediators of MBT.

PRACTITIONER POINTS

Mentalization-based therapy (MBT) is increasingly being considered as a treatment for people with borderline personality disorder (BPD), and a systematic review was required to investigate its effectiveness. MBT was found to be equally as effective or superior to well-established comparison treatments of BPD, however, the majority of studies was of unsatisfying quality. Little is known about the mechanisms of MBT. Further, better quality trials are needed to investigate its efficacy in treating BPD.

Substance use and borderline personality disorder: fostering hope in the face of complexity

OBJECTIVE

Impulsivity and emotional dysregulation are common characteristics of patients presenting with co-occurring borderline personality disorder (BPD) and substance use disorder (SUD). This article aims to provide an overview of the clinical approaches psychiatrists should consider when treating patients with these conditions.

CONCLUSIONS

Co-occurring BPD and SUD can be effectively treated within a staged, transdiagnostic approach with an emphasis on the therapeutic alliance.

Adult attachment anxiety moderates the relation between self-reported childhood maltreatment and borderline personality disorder features

Childhood maltreatment is one of many risk factors for borderline personality disorder (BPD). However, not all individuals with BPD report histories of childhood maltreatment. Therefore, it is necessary to identify factors that contextualize the relation between childhood maltreatment and BPD features. With its emphasis on the developmental origins of emotion regulation, attachment theory provides a useful framework to understand how people are differentially affected by early life stress. The present study examined self-reported adult attachment as a moderator in the relation between childhood maltreatment and BPD features in a large undergraduate sample (n = 1 033). Attachment anxiety, but not attachment avoidance, moderated the relation between childhood maltreatment and BPD features, and this relation was non-significant among participants low (-1 standard deviation) in attachment anxiety. These results support the hypothesis that secure attachment in adulthood may buffer against the otherwise deleterious effects of distal risk factors on personality pathology. Future research should continue to examine this question across risk factors and across disorders. Furthermore, we suggest that researchers who have historically examined attachment as a mediator cross-sectionally should re-examine their data for evidence of a moderation effect. © 2019 John Wiley & Sons, Ltd.

Parenting and personality disorder: An overview and meta-synthesis of systematic reviews

BACKGROUND/OBJECTIVES

Maladaptive parenting (including childhood maltreatment, abuse and neglect) has been implicated in the scientific literature exploring the aetiology of personality disorder, particularly borderline personality disorder (BPD). Our primary objective was to summarise the evidence on the relationship between parenting and personality disorder, assisting clinical decision-makers to translate this research into clinical policy and practice.

METHODS

We conducted an overview of systematic reviews that assessed individuals with personality disorder pathology for experiences of maladaptive parenting, compared to psychiatric or healthy comparisons/controls, and the impact on psychopathological and relational outcomes. Systematic literature searches were conducted in Scopus, Web of Science, MEDLINE, PsycINFO, and by hand in August 2018. Methodological quality was assessed using the CASP systematic review checklist, and results were qualitatively synthesised. A pre-determined protocol was registered in Prospective Register of Systematic Reviews (PROSPERO 2019:CRD42018096177).

RESULTS

Of the 312 identified records, 293 abstracts were screened, 36 full-text articles were retrieved and eight systematic reviews met pre-determined criteria for qualitative synthesises. The majority of studies reported outcomes related to BPD (n = 7), and study design, methodology and quality varied. Within the eight systematic reviews there were 211 primary studies, of which 140 (66.35%) met eligibility criteria for inclusion in this overview. Eligible primary studies reported on 121,895 adult, child/adolescent and parent-offspring participants, with most studies focused on borderline personality pathology (n = 100, 71.43%). Study design and methodology also varied for these studies. Overall, five systematic reviews overwhelming found that maladaptive parenting was a psychosocial risk factor for the development of borderline personality pathology, and three studies found that borderline personality pathology was associated with maladaptive parenting, and negative offspring and parenting-offspring outcomes.

CONCLUSIONS

In light of these findings, we recommend greater emphasis on parenting in clinical practice and the development of parenting interventions for individuals with personality disorder. However, our understanding is limited by the heterogeneity and varying quality of the evidence, and as such, future research utilising more rigorous research methodology is needed.

Toward an animal model of borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is a pervasive psychiatric disorder characterized by emotion dysregulation, impulsivity, impaired self-perceptions, and interpersonal relationships and currently affects 1-3% of the US population as reported by Torgersen et al. (Arch Gen Psychiatry 58:590-596, Torgersen et al. 2001), Lenzenweger et al. (Biol Psychiatry 62:553-564, Lenzenweger et al. 2007), and Tomko et al. (J Personal Disord 28:734-750, Tomko et al. 2014). One major obstacle to our understanding of the neural underpinnings of BPD is a lack of valid animal models that translate the key known features of the disorder to a system that is amenable to study.

OBJECTIVE

To summarize the etiology, major symptoms, and symptom triggers of BPD and then propose a blueprint for building an animal model of BPD by choosing key components of the disorder that can be implemented in rodents.

RESULTS

We identify the role of early life stress and subsequent mild stress in adulthood as contributing etiological factors and the potential use of altered communication between frontal cortices and the amygdala in extinction and habituation, increased impulsivity, dysregulation of the hypothalamic pituitary axis (HPA), and increased neuroinflammation as biological markers of BPD. Building upon these features of BPD, we propose a two-hit animal model that uses maternal abandonment to alter maturation of the HPA axis and mild secondary adult stress to evoke behavioral symptoms such as increased impulsivity and impaired extinction, habituation, and social interactions.

CONCLUSION

Through exploration of the etiology, symptom presentation, and altered neurological function, we propose an animal model of BPD. We believe that a number of existing animal paradigms that model other mental health disorders should be combined in a unique way to reflect the etiology, symptom presentation, and altered neurological function that is evident in BPD. These model, when compared with available human data, will inform research and treatment in humans for better understanding of systems from the micro-molecular level to more global physiology underlying BPD.

Predictors of short- and long-term recurrence of suicidal behavior in borderline personality disorder

OBJECTIVE

To evaluate the incidence of suicidal outcomes and risk factors for short- and long-term recurrence of suicidal behavior (SB) among high-risk borderline personality disorder (BPD) patients during a 24-month prospective follow-up period.

METHODS

A multicenter prospective cohort study was designed to compare data obtained from 136 patients admitted to the emergency department for current suicidal ideation (SI) or a recent suicide attempt (SA). Subjects were clinically evaluated and monitored for a new SA or suicide.

RESULTS

The incidence of a new SA was 25.63 events/100 persons-year, and one patient died by suicide. Child sexual abuse (CSA) was the only significant predictor throughout the complete follow-up period. The absence of prior psychiatric treatment predicts the recurrence of SB in the first 6 months of follow-up. Patient age, poor psychosocial functioning before hospitalization, age at first SA, and having multiple suicide attempts increased risk of SB recurrence at the long-term period (24th months). In addition, there was an interaction between CSA and poor psychosocial functioning that increased risk of SB.

CONCLUSION

The risk of recurrence was higher during the first 6 months. Risk factors at 6 and 24 months vary. These findings are important for implementing suicide strategies.

Cognitive-Emotional and Inhibitory Deficits as a Window to Moral Decision-Making Difficulties Related to Exposure to Violence

In the present review, we illustrate how exposure to violence results in an increased probability of developing functional impairments of decision mechanisms necessary for moral behavior. We focus in particular on the detrimental effects of exposure to violence on emotional (e.g., Empathy), cognitive (e.g., Theory of Mind), and inhibitory control abilities. Relying on studies that document impaired moral behavior in individuals with deficits in these abilities, we propose a "model" of how exposure to violence can affect moral behavior. We then discuss how impaired moral decision making can also be a factor increasing the likelihood of reiterating violence: agents who lack abilities such as understanding and resonating with others' emotions or inhibitory control, can lead to an increase of violent displays. Thus, if not properly addressed, the noxious effects of exposure to violence on morality can lead to a violence generating cycle. We conclude proposing that interventions targeted at improving moral behavior can maximize their efficacy focusing on mitigating the impact of violence on the basic cognitive, emotional, and inhibitory abilities discussed.

Borderline personality disorder and emotion dysregulation

Borderline personality disorder (BPD) is a severe and complex disorder characterized by instability across many life domains, including interpersonal relations, behavior, and emotions. A core feature and contributor to BPD, emotion dysegulation (ED), consists of deficits in the ability to regulate emotions in a manner that allows the individual to pursue important goals or behave effectively in various contexts. Biosocial developmental models of BPD have emphasized a transaction of environmental conditions (e.g., invalidating environments and adverse childhood experiences) with key genetically linked vulnerabilities (e.g., impulsivity and emotional vulnerability) in the development of ED and BPD. Emerging evidence has begun to highlight the complex, heterotypic pathways to the development of BPD, with key heritable vulnerability factors possibly interacting with aspects of the rearing environment to produce worsening ED and an adolescent trajectory consisting of self-damaging behaviors and eventual BPD. Adults with BPD have shown evidence of a variety of cognitive, physiological, and behavioral characteristics of ED. As the precursors to the development of ED and BPD have become clearer, prevention and treatment efforts hold great promise for reducing the long-term suffering, functional impairment, and considerable societal costs associated with BPD.

Borderline Personality Disorder: Clinical Guidelines for Treatment

Borderline personality disorder (BPD) is fundamentally a syndrome composed of symptoms (primarily of emotional dysregulation) and a number of true personality traits (such as inordinate anger, impulsivity, and a tendency to stress-related paranoid ideation). Whereas schizotypal personality disorder, with its cognitive peculiarities (ideas of reference, odd beliefs, eccentric speech), is closely linked as a genetic condition-"borderline" to the major condition schizophrenia-BPD is less closely linked to bipolar disorder. Some cases of BPD are linked genetically to and are in the "border" of bipolar disorder. But the condition can also arise from adverse post-natal factors: parental cruelty or neglect, or incest. In some BPD patients, both are present: risk genes for bipolar disorder and adverse conditions within the family. The genetic risk is often overlooked. To avoid this, initial evaluations should always include a careful and extensive family history for mood disorders, and should extend out to grandparents, aunts, uncles, and cousins. Where the history suggests a genetic link to bipolar disorder, a mood stabilizer such as lithium or lamotrigine, even in modest doses, may be particularly beneficial, more so than conventional antidepressants. In some patients, ADHD was present in childhood, BPD was diagnosed during or after puberty, and a form of bipolar disorder becomes apparent during their 20s. As for the psychotherapeutic component, the patient's cognitive style and capacity for introspection will help determine whether a primarily expressive (psychoanalytically oriented) technique is preferable or a primarily cognitive-behavioral technique. Flexibility is necessary, since during emotional crises, supportive and limit-setting interventions will be needed, along with psychotropic medications, and where necessary, programs to help combat substance abuse (which is common among patients with BPD).

[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.

Longitudinal development of risk-taking and self-injurious behavior in association with late adolescent borderline personality disorder symptoms

Self-injurious behavior and risk-taking behaviors are associated with adolescent borderline personality disorder (BPD). Developmental trajectories of self-injurious and risk-taking behavior in predicting BPD have not been fully understood. The aim of the present study was to examine self-injurious and risk-taking behavior development and their prospective influence on BPD symptoms in adolescence. Data (n = 506; 62.06 % females, 14.53 years) from the German Saving and Empowering Young Lives in Europe cohort were analyzed. Self-injurious and risk-taking behaviors were assessed at baseline and one-year follow-up. BPD symptoms were assessed at two-year follow-up. In fully adjusted stepwise binominal regression analyses, recent onset, termination and maintenance of risky alcohol use and self-injurious behavior remained as significant predictors of BPD. Highest ORs were found for alcohol termination and maintenance of self-injurious behavior. Other facets of risk-taking behavior were not associated with increased ORs of BPD symptoms at two-year follow-up. These findings highlight the importance of self-injurious behavior and specific facets of risk-taking behavior in the development of adolescent BPD. Clinicians should focus on efforts in preventing adolescents from risk-taking and self-injurious behavior, since engaging in young age and therefore in potentially longer periods of these behaviors is associated with the highest risk of BPD.

Mirror neuron activations in encoding of psychic pain in borderline personality disorder

Borderline personality disorder (BPD) is characterized by pronounced emotional instability in interpersonal relations. Previous studies have shown increased activity in the amygdala, an imaging phenotype of negative affect. However, clinical accounts of BPD have drawn attention to deficits in social cognition and their likely role in engendering emotional instability. BPD patients show enhanced sensitivity to other people's emotions, while being less proficient in reading motives and reasons. In the present functional imaging study, we exposed BPD participants to stylized scenes of individuals affected by loss or separation, an issue to which these patients are particularly sensitive. Previously shown to activate the mirror neuron system, these mourning scenes were here also used to assess differential amygdala activity in stimuli of negative valence, but low arousal. Relative to controls, BPD patients were found to activate sensorimotor areas, a part of the mirror neuron system thought to encode basic aspects of the perception of motoric activity and pain. This contrasted with the activity of areas related to more complex aspects of social cognition, such as the inferior frontal gyrus. The amygdala was more active in patients when viewing these scenes, but this effect also showed a strong association with levels of depressiveness and neuroticism. After adjusting for these covariates, differences in amygdala activation were no longer significant. These findings are consistent with models of social cognition in BPD that attribute emotional sensitivity to emotional contagion through the mirror neuron system, in contrast to areas associated with more sophisticated forms of social cognition. These effects were accompanied by increased amygdala reactivity, consistently with the common occurrence of affective symptoms in these patients.

Predictors of Slower Time-to-Cessation of Individual Therapy for Borderline Patients Over 16 Years of Prospective Follow-Up

The current study assesses time-to-cessation of individual therapy for patients with borderline personality disorder (BPD) and comparison subjects with other personality disorders (OPD) after 16 years of prospective follow-up. It also details the multivariate factors that predict this outcome for those with BPD. At baseline, 290 patients met criteria for BPD and 72 met criteria for OPD. Individuals with BPD had a significantly slower time-to-cessation of individual therapy than OPD comparison subjects. Seven baseline variables were found to be significant multivariate predictors of a slower time-to-cessation of individual therapy: older age, being white, severity of childhood neglect, history of a mood disorder, an IQ less than 90, poor vocational record prior to index admission, and higher level of trait neuroticism. The results of this study suggest that prediction of slower time-to-cessation of individual therapy is multifactorial in nature, involving factors related to demographics, childhood adversity, comorbidity, individual competence, and temperament.

Bipolar affective disorder and borderline personality disorder: Differentiation based on the history of early life stress and psychoneuroendocrine measures

INTRODUCTION

Borderline Personality Disorder (BPD) and Bipolar Affective Disorder (BD) have clinical characteristics in common which often make their differential diagnosis difficult. The history of early life stress (ELS) may be a differentiating factor between BPD and BD, as well as its association with clinical manifestations and specific neuroendocrine responses in each of these diagnoses.

OBJECTIVE

Assessing and comparing patients with BD and BPD for factors related to symptomatology, etiopathogenesis and neuroendocrine markers.

METHODOLOGY

The study sample consisted of 51 women, divided into 3 groups: patients with a clinical diagnosis of BPD (n = 20) and BD (n = 16) and healthy controls (HC, n = 15). Standardized instruments were used for the clinical evaluation, while the history of ELS was quantified with the Childhood Trauma Questionnaire (CTQ), and classified according to the subtypes: emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect. The functioning of the hypothalamic-pituitary-adrenal (HPA) axis was evaluated by measuring a single plasma cortisol sample.

RESULTS

Patients with BPD presented with more severe psychiatric symptoms of: anxiety, impulsivity, depression, hopelessness and suicidal ideation than those with BD. The history of ELS was identified as significantly more prevalent and more severe in patients (BPD and BP) than in HC. Emotional abuse, emotional neglect and physical neglect also showed differences and were higher in BPD than BD patients. BPD patients had greater severity of ELS overall and in the subtypes of emotional abuse, emotional neglect and physical neglect than BD patients. The presence of ELS in patients with BPD and BP showed significant difference with lower cortisol levels when compared to HC. The endocrine evaluation showed no significant differences between the diagnoses of BPD and BD. Cortisol measured in patients with BPD was significantly lower compared to HC in the presence of emotional neglect and physical neglect. A significant negative correlation between the severity of hopelessness vs cortisol; and physical neglect vs cortisol were found in BPD with ELS. The single cortisol sample showed a significant and opposite correlations in the sexual abuse diagnosis-related groups, being a negative correlation in BD and positive in BPD.

DISCUSSION

Considering the need for a multi-factorial analysis, the differential diagnosis between BPD and BD can be facilitated by the study of psychiatric symptoms, which are more severe in the BPD patients with a history of early life stress. The function of the HPA axis assessed by this cortisol measure suggests differences between BPD and BP with ELS history.

CONCLUSION

The integrated analysis of psychopathology, ELS and neuroendocrine function may provide useful indicators to differentiate BPD and BD diagnoses. These preliminary data need to be replicated in a more significant sample with improved and multiple assessments of HPA axis activity.

The severity of psychiatric disorders

The issue of the severity of psychiatric disorders has great clinical importance. For example, severity influences decisions about level of care, and affects decisions to seek government assistance due to psychiatric disability. Controversy exists as to the efficacy of antidepressants across the spectrum of depression severity, and whether patients with severe depression should be preferentially treated with medication rather than psychotherapy. Measures of severity are used to evaluate outcome in treatment studies and may be used as meaningful endpoints in clinical practice. But, what does it mean to say that someone has a severe illness? Does severity refer to the number of symptoms a patient is experiencing? To the intensity of the symptoms? To symptom frequency or persistence? To the impact of symptoms on functioning or on quality of life? To the likelihood of the illness resulting in permanent disability or death? Putting aside the issue of how severity should be operationalized, another consideration is whether severity should be conceptualized similarly for all illnesses or be disorder specific. In this paper, we examine how severity is characterized in research and contemporary psychiatric diagnostic systems, with a special focus on depression and personality disorders. Our review shows that the DSM-5 has defined the severity of various disorders in different ways, and that researchers have adopted a myriad of ways of defining severity for both depression and personality disorders, although the severity of the former was predominantly defined according to scores on symptom rating scales, whereas the severity of the latter was often linked with impairments in functioning. Because the functional impact of symptom-defined disorders depends on factors extrinsic to those disorders, such as self-efficacy, resilience, coping ability, social support, cultural and social expectations, as well as the responsibilities related to one's primary role function and the availability of others to assume those responsibilities, we argue that the severity of such disorders should be defined independently from functional impairment.

Corticolimbic Connectivity Mediates the Relationship between Adverse Childhood Experiences and Symptom Severity in Borderline Personality Disorder

The interaction between biological and environmental factors (especially adverse childhood experiences, ACEs) plays a crucial role in the development and maintenance of borderline personality disorder (BPD). These factors act influencing BPD core features such as pervasive instability in affect regulation, impulse control, social cognition, and interpersonal relationships. In line with this perspective, abnormalities in social cognition and related neurobiological underpinnings could mediate the relationship between ACEs and psychopathological manifestations in adulthood. In a sample of 14 females, functional connectivity (FC) analyses were performed modeling the interaction between ACEs and corticolimbic dysregulation during emotional processing and its relationship with BPD symptom severity. ACEs were associated with a dampening of the negative FC between (1) the right amygdala (Amy) and right dorsolateral prefrontal cortex (DLPFC) and between (2) the left Amy and bilateral DLPFC, right precuneus, left cerebellum and left dorsomedial prefrontal cortex during emotional processing. The connectivity between right Amy and DLPFC mediates the relationship between childhood adversities and BPD symptomatology. Furthermore, the negative FC between Amy and DLPFC, postcentral gyrus, the vermis of cerebellum and precuneus was also associated with BPD symptom severity, with a weaker negative coupling between Amy and these regions being related to a worse BPD psychopathology. Our results confirm the role of ACEs in contributing to social cognition impairments in BPD and related symptomatology from a neurobiological perspective.

A Review of Child Sexual Abuse: Impact, Risk, and Resilience in the Context of Culture

Child sexual abuse is a problem with both a national and worldwide prevalence. In this review, the authors note that while empirical research has clearly shown the negative impact of child sexual abuse on social, psychological, and sexual functioning later in life, it has also been reported that some individuals remain asymptomatic despite a history of experiencing child sexual abuse. This implies that negative outcomes later in life are not inevitable and illustrates the critical need to elucidate how resilience may moderate the negative impacts of child sexual abuse. In addition to emphasising the role of resilience, this review also underscores the important role that cultural context plays in understanding child sexual abuse, as there are known risk factors and protective factors specific to different cultures. Similarly, one's culture may also influence whether abuse is reported and addressed, and the topic is given special attention in this paper because it is not widely discussed within the existing literature. The impact of child sexual abuse on mental health, sexual health, and social functioning is also discussed.

Treatment Effects following Residential Dialectical Behavior Therapy for Adolescents with Borderline Personality Disorder

Dialectical behavior therapy (DBT) is an empirically supported treatment for borderline personality disorder (BPD) in adults, however fewer studies have examined outcomes in adolescents. This study tested the effectiveness of an intensive 1-month, residential DBT treatment for adolescent girls meeting criteria for BPD. Additionally, given well-established associations between BPD symptoms and childhood abuse, the impact of abuse on treatment outcomes was assessed. Participants were female youth (n = 53) aged 13-20 years (M = 17.00, SD = 1.89) completing a 1-month residential DBT program. At pre-treatment, participants were administered a diagnostic interview and self-report measures assessing BPD, depression, and anxiety symptom severity. Following one month of treatment, participants were re-administered the self-report instruments. Results showed significant pre- to post-treatment reductions in both BPD and depression symptom severity with large effects. However, there was no significant change in general anxious distress or anxious arousal over time. The experience of childhood abuse (sexual, physical, or both) was tested as moderator of treatment effectiveness. Although experiencing multiple types of abuse was related to symptom severity, abuse did not moderate the effects of treatment. Collectively, results indicate that a 1-month residential DBT treatment with adolescents may result in reductions in BPD and depression severity but is less effective for anxiety. Moreover, while youth reporting abuse benefitted from treatment, they were less likely to achieve a clinically significant reduction in symptoms.

Borderline personality disorder and sexual abuse: A systematic review

Although sexual abuse (SA) is known to be frequent among borderline personality disorder (BPD) patients, few reviews evaluating that relationship have been published. This systematic review aimed to investigate SA (including adulthood) as a predictor of BPD diagnosis, clinical presentation and prognosis. Studies written in English or Portuguese from January 1997 until January 2017 were identified by searching the following keywords in three international databases: "borderline personality disorder" OR "borderline disorder" AND "sexual abuse" OR "sexual violence" OR "sexual victimization" OR "sexual assault" OR "rape". Forty articles met the eligibility criteria. Overall, SA was found to play a major role in BPD, particularly in women. Childhood sexual abuse (CSA) is an important risk factor for BPD. Adult sexual abuse (ASA) rates are significantly higher in BPD patients compared with other personality disorders (PDs). SA history predicts more severe clinical presentation and poorer prognosis. Suicidality has the strongest evidence, followed by self-mutilation, post-traumatic stress disorder (PTSD), dissociation and chronicity of BPD. Future research should study more ASA and include more males, milder BPD patients and documented or corroborated SA cases. The impact of other traumatic experiences (e.g., emotional abuse) on BPD must also be systematically reviewed.

Interoception and Its Interaction with Self, Other, and Emotion Processing: Implications for the Understanding of Psychosocial Deficits in Borderline Personality Disorder

PURPOSE OF REVIEW

We review evidence for the potential importance of interoception, i.e., the processing of signals arising from inside the body, for deficient psychosocial functioning in borderline personality disorder (BPD).

RECENT FINDINGS

Evidence suggests that variability in interoception interacts with higher-order psychological functions such as self, other, and emotion processing. These domains are characteristically impaired in BPD, suggesting a likely causal role of disturbed interoception in the etiology of the disorder. The inability to identify and describe one's own emotional states represents a proxy of impaired interoception which might further mediate between the perception of inner physiological conditions and psychosocial functioning in BPD. There is preliminary evidence explaining how early life stress might adversely affect central interoceptive representation and psychosocial functioning in BPD. Based on these findings and the specific pattern of disturbances in BPD, we propose the crucial role of interoception in an integrated biobehavioral model for BPD.