Aversive tension in patients with borderline personality disorder: a computer-based controlled field study

Twenty years of research on borderline personality disorder: a scientometric analysis of hotspots, bursts, and research trends

Borderline personality disorder (BPD), a complex and severe psychiatric disorder, has become a topic of considerable interest to current researchers due to its high incidence and severity of consequences. There is a lack of a bibliometric analysis to visualize the history and developmental trends of researches in BPD. We retrieved 7919 relevant publications on the Web of Science platform and analyzed them using software CiteSpace (6.2.R4). The results showed that there has been an overall upward trend in research interest in BPD over the past two decades. Current research trends in BPD include neuroimaging, biological mechanisms, and cognitive, behavioral, and pathological studies. Recent trends have been identified as "prevention and early intervention", "non-pharmacological treatment" and "pathogenesis". The results are like a reference program that will help determine future research directions and priorities.

The riddle of deliberate self-harm: Physiological and subjective effects of self-cutting cues in patients with borderline personality disorder and healthy controls

Self-harming behavior is a core symptom of borderline personality disorder. Self-report studies show a correlation between a lack of self-reported negative feelings toward self-cutting cues and the likelihood of future self-destructive behavior. Despite these findings, there has so far been insufficient investigation into the implicit emotional processes evoked by this stimulus type. Forty patients with borderline personality disorder and 35 healthy controls between 20 and 50 years of age were confronted with pictures of self-cutting cues and affective reference pictures. A startle reflex paradigm was used for measuring implicit emotional responses, and the Self-Assessment Manikin was used for subjective responses. In line with previous studies, the patients rated the self-cutting pictures significantly less negatively than healthy individuals. On the physiological level, a significant startle inhibition was observed, indicating an activation of the behavioral approach system. A more detailed analysis showed that this startle inhibition effect was specific to scary pictures, whereas no such effect was observed for bloody wounds and self-cutting instruments. For pleasant standard pictures, in contrast, no startle reflex inhibition and no increase in emotional arousal parameters were found. The data replicate the findings of previous studies, demonstrating a generally diminished emotional reactivity to pleasant stimuli in patients with borderline personality disorder. In addition, a physiological approach reaction to self-cutting pictures was found, especially for the scary pictures. These results might indicate a positive identification with the long-lasting consequences of self-cutting behavior in the patients. Implications for therapy are discussed.

Does self-harm have the desired effect? Comparing non-suicidal self-injury to high-urge moments in an ambulatory assessment design

All theoretical models of non-suicidal self-injury (NSSI) posit that regulation of negative affect (NA) is a central motive for NSSI, and cross-sectional work supports this. However, previous ambulatory assessment (AA) studies that examined NSSI found mixed results. We investigated the affect regulation function of NSSI in 51 women with DSM-5 NSSI disorder in a 15-day AA study with five random daily prompts and self-initiated NSSI prompts. We extend previous work by i) comparing NSSI moments to moments of a high-urge for NSSI, ii) adding high-frequency sampling following NSSI and high-urge moments, and iii) including tension as a dependent variable. We hypothesized that NA and tension would show a steeper decrease following NSSI than following high-urge moments, if NSSI was effective in reducing NA and tension. Results showed that the significant linear NA decline following NSSI was not steeper than that following high-urge moments. For aversive tension, we found that NSSI was associated with a significant linear decrease in tension, whereas resisting an urge was not. High-urge moments were better described by an inverted U-shaped pattern, likewise leading to decreased NA and tension following the reported urge. In exploratory analyses, we provide visualized clustering of the NA and tension trajectories surrounding NSSI using k-means and relate these to participants' self-rated effectiveness of the NSSI events. Findings indicate that resisting an urge may also be effective in managing NA and tension and underline the utility of interventions such as urge-surfing.

Pharmacological interventions for people with borderline personality disorder

BACKGROUND

Among people with a diagnosis of borderline personality disorder (BPD) who are engaged in clinical care, prescription rates of psychotropic medications are high, despite the fact that medication use is off-label as a treatment for BPD. Nevertheless, people with BPD often receive several psychotropic drugs at a time for sustained periods.

OBJECTIVES

To assess the effects of pharmacological treatment for people with BPD.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers up to February 2022. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication.

SELECTION CRITERIA

Randomised controlled trials comparing pharmacological treatment to placebo, other pharmacologic treatments or a combination of pharmacologic treatments in people of all ages with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. Secondary outcomes were individual BPD symptoms, depression, attrition and adverse events.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's risk of bias tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis.

MAIN RESULTS

We included 46 randomised controlled trials (2769 participants) in this review, 45 of which were eligible for quantitative analysis and comprised 2752 participants with BPD in total. This is 18 more trials than the 2010 review on this topic. Participants were predominantly female except for one trial that included men only. The mean age ranged from 16.2 to 39.7 years across the included trials. Twenty-nine different types of medications compared to placebo or other medications were included in the analyses. Seventeen trials were funded or partially funded by the pharmaceutical industry, 10 were funded by universities or research foundations, eight received no funding, and 11 had unclear funding. For all reported effect sizes, negative effect estimates indicate beneficial effects by active medication. Compared with placebo, no difference in effects were observed on any of the primary outcomes at the end of treatment for any medication. Compared with placebo, medication may have little to no effect on BPD symptom severity, although the evidence is of very low certainty (antipsychotics: SMD -0.18, 95% confidence interval (CI) -0.45 to 0.08; 8 trials, 951 participants; antidepressants: SMD -0.27, 95% CI -0.65 to 1.18; 2 trials, 87 participants; mood stabilisers: SMD -0.07, 95% CI -0.43 to 0.57; 4 trials, 265 participants). The evidence is very uncertain about the effect of medication compared with placebo on self-harm, indicating little to no effect (antipsychotics: RR 0.66, 95% CI 0.15 to 2.84; 2 trials, 76 participants; antidepressants: MD 0.45 points on the Overt Aggression Scale-Modified-Self-Injury item (0-5 points), 95% CI -10.55 to 11.45; 1 trial, 20 participants; mood stabilisers: RR 1.08, 95% CI 0.79 to 1.48; 1 trial, 276 participants). The evidence is also very uncertain about the effect of medication compared with placebo on suicide-related outcomes, with little to no effect (antipsychotics: SMD 0.05, 95 % CI -0.18 to 0.29; 7 trials, 854 participants; antidepressants: SMD -0.26, 95% CI -1.62 to 1.09; 2 trials, 45 participants; mood stabilisers: SMD -0.36, 95% CI -1.96 to 1.25; 2 trials, 44 participants). Very low-certainty evidence shows little to no difference between medication and placebo on psychosocial functioning (antipsychotics: SMD -0.16, 95% CI -0.33 to 0.00; 7 trials, 904 participants; antidepressants: SMD -0.25, 95% CI -0.57 to 0.06; 4 trials, 161 participants; mood stabilisers: SMD -0.01, 95% CI -0.28 to 0.26; 2 trials, 214 participants). Low-certainty evidence suggests that antipsychotics may slightly reduce interpersonal problems (SMD -0.21, 95% CI -0.34 to -0.08; 8 trials, 907 participants), and that mood stabilisers may result in a reduction in this outcome (SMD -0.58, 95% CI -1.14 to -0.02; 4 trials, 300 participants). Antidepressants may have little to no effect on interpersonal problems, but the corresponding evidence is very uncertain (SMD -0.07, 95% CI -0.69 to 0.55; 2 trials, 119 participants). The evidence is very uncertain about dropout rates compared with placebo by antipsychotics (RR 1.11, 95% CI 0.89 to 1.38; 13 trials, 1216 participants). Low-certainty evidence suggests there may be no difference in dropout rates between antidepressants (RR 1.07, 95% CI 0.65 to 1.76; 6 trials, 289 participants) and mood stabilisers (RR 0.89, 95% CI 0.69 to 1.15; 9 trials, 530 participants), compared to placebo. Reporting on adverse events was poor and mostly non-standardised. The available evidence on non-serious adverse events was of very low certainty for antipsychotics (RR 1.07, 95% CI 0.90 to 1.29; 5 trials, 814 participants) and mood stabilisers (RR 0.84, 95% CI 0.70 to 1.01; 1 trial, 276 participants). For antidepressants, no data on adverse events were identified.

AUTHORS' CONCLUSIONS

This review included 18 more trials than the 2010 version, so larger meta-analyses with more statistical power were feasible. We found mostly very low-certainty evidence that medication may result in no difference in any primary outcome. The rest of the secondary outcomes were inconclusive. Very limited data were available for serious adverse events. The review supports the continued understanding that no pharmacological therapy seems effective in specifically treating BPD pathology. More research is needed to understand the underlying pathophysiologic mechanisms of BPD better. Also, more trials including comorbidities such as trauma-related disorders, major depression, substance use disorders, or eating disorders are needed. Additionally, more focus should be put on male and adolescent samples.

Momentary interpersonal processes of suicidal surges in borderline personality disorder

BACKGROUND

Suicide rates are high in borderline personality disorder (BPD) where interpersonal problems trigger intense affective dysregulation and impulses to act on suicidal thoughts. To date, however, no study has examined how interpersonal stressors contribute to momentary within-person links among affect and impulsivity with suicidal ideation (SI), and how those links vary over time in people's daily lives.

METHODS

A total of 153 individuals diagnosed with BPD and 52 healthy controls completed a 21-day ecological momentary assessment protocol. Of these 153 individuals with BPD, 105 had a history of suicide attempts. Multilevel structural equation modeling was used to examine dynamic links among interpersonal perceptions, affect, state impulsivity, and suicidal intent.

RESULTS

Aggregated across interactions, lower perceived warmth in others was associated with SI. This direct relationship, however, did not extend to momentary within-person associations. Instead, interpersonal conflicts were linked to SI indirectly via greater negative affect and lower positive affect. While a robust within-person link between interpersonal perceptions and impulsivity emerged, impulsivity did not account for the relationship between interpersonal perceptions and SI.

CONCLUSION

This intensive longitudinal study illustrates momentary interpersonal signatures of an emerging suicidal crisis. Among people with BPD at high risk for suicide, interpersonal triggers initiate a cascade of affective dysregulation, which in turn gives rise to SI.

The Influence of Attachment Style, Self-protective Beliefs, and Feelings of Rejection on the Decline and Growth of Trust as a Function of Borderline Personality Disorder Trait Count

Borderline personality disorder (BPD) is associated with paradoxical trust behaviours, specifically a faster rate of trust growth in the face of trust violations. The current study set out to understand whether attachment style, self-protective beliefs, and feelings of rejection underpin this pattern. Young adults (N=234) played a 15-round trust game in which partner cooperation was varied to create three phases of trust: formation, dissolution, and restoration. Discontinuous growth modelling was employed to observe whether the effect of BPD trait count on trust levels and growth is moderated by fearful or preoccupied attachment style, self-protective beliefs, and feelings of rejection. Results suggest that the slower rate of trust formation associated with BPD trait count was accounted for by feelings of rejection or self-protective beliefs, both of which predicted a slower rate of trust growth. The faster rate of trust growth in response to trust violations associated with BPD trait count was no longer significant after self-protective beliefs were accounted for. Interventions targeting self-protective beliefs and feelings of rejection may address the trust-based interpersonal difficulties associated with BPD.

Reciprocal effects between daily situational perceptions and borderline personality symptoms in young adulthood: the role of childhood parenting experiences

BACKGROUND

Recent research has emphasized the importance of within-person transactions between situational perceptions and borderline symptomatology. The current study extends current evidence by evaluating a broad range of situational perceptions and their transactions with borderline symptomatology across both private and professional contexts. Additionally, it explores whether early experiences of parental harsh punishment and emotional support during childhood, two well-established etiological factors in developmental theories of borderline symptomatology, influence the effect of daily situation perception in adulthood on borderline symptom presentation.

METHODS

N = 131 young adults (Mage = 20.97, s.d.age = 1.64) completed end-of-day diaries of their borderline symptoms and perceptions of the home and school or work environment for 14 days. During their mid-childhood, reports of maternal strategies of harsh punishment and emotional support were collected.

RESULTS

Findings revealed that on the same day, borderline symptoms were associated with more negative and stressful, and less positive perceptions of both the private and professional context. Additionally, borderline symptoms predicted more negative and stressful perceptions of school/work on subsequent days. Finally, while early harsh punishment predicted overall increases in daily borderline symptoms 10 years later, emotionally supportive parenting in childhood predicted decreases in borderline symptom expression in less positive and more stressful contexts.

CONCLUSIONS

The current study points to the importance of managing BPD symptoms to reduce subsequent negative perceptions of the environment, and also indicates the relevance of exploring adult person-situation processes based on early parenting experiences.

Childhood Maltreatment, Borderline Personality Features, and Coping as Predictors of Intimate Partner Violence

Intimate partner violence (IPV) is a serious mental and physical health concern worldwide. Although previous research suggests that childhood maltreatment increases the risk for IPV, the underlying psychological mechanisms of this relationship are not yet entirely understood. Borderline personality (BP) features may play an important role in the cycle of violence, being associated with interpersonal violence in both childhood and adult relationships. The present study investigated whether BP features mediate the relationship between childhood maltreatment and IPV, differentiating between perpetration and victimization, and taking maladaptive stress coping and gender into account. Self-reports on IPV, childhood trauma, BP features, and maladaptive stress coping were collected in a mixed (nonclinical and clinical) sample of 703 adults (n = 537 female, n = 166 male), using an online survey. A serial mediation analysis (PROCESS) was performed to quantify the direct effect of childhood maltreatment on IPV and its indirect effects through BP features and maladaptive coping. Childhood maltreatment severity significantly positively predicted IPV perpetration as well as victimization. BP features, but not coping, partially mediated this relationship. Follow-up analyses suggest that affective instability and interpersonal disturbances (e.g., separation concerns) play an important role in IPV perpetration, while interpersonal and identity disturbances may mediate the effect of childhood maltreatment on IPV victimization. In clinical practice, attention should be paid not only to histories of childhood abuse and neglect but also to BP features, which may be possible risk factors for IPV.

Perspectives of crisis intervention for people diagnosed with "borderline personality disorder": An integrative review

WHAT IS KNOWN ON THE SUBJECT?: People diagnosed with "BPD" often experience crisis and use services "BPD" is a controversial diagnosis, and the experience of crisis and crisis intervention is not well understood WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: People diagnosed with "BPD" have different experiences of crisis, and using the diagnosis alone as a basis for deciding care and treatment is not appropriate There are many human factors which can influence how professionals deliver care to people diagnosed with "BPD" WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The education of staff, views on responsibility, team conflicts and access to clinical supervision can have an impact on how care is delivered, and should be addressed by organizations providing crisis care. Access to care often occurs when a person is self-harming or suicidal, but does not address underlying distress. Crisis care should go beyond managing behaviour and address any underlying needs. ABSTRACT: Introduction "Borderline personality disorder" ("BPD") is associated with frequent use of crisis intervention services. However, no robust evidence base supports specific interventions, and people's experiences are not well understood. Aim To explore the experiences of stakeholders involved in the crisis care of people diagnosed with "BPD." Method Integrative review with nine databases searched January 2000 to November 2017. The search filtered 3,169 titles and abstracts with 46 full-text articles appraised and included. Results Four themes were constructed from thematic analysis: crisis as a recurrent multidimensional cycle, variations and dynamics impacting on crisis intervention, impact of interpersonal dynamics and communication on crisis, and balancing decision-making and responsibility in managing crisis. Discussion Crisis is a multidimensional subjective experience, which also contributes to distress for family carers and professionals. Crisis interventions had limited and subjective benefit. They are influenced by accessibility of services, different understandings of "BPD" and human dynamics in complex decision-making, and can be experienced as helpful or harmful. Implications for practice Subjectivity of crisis experiences shows limitations of the diagnostic model of "BPD," emphasizing that interventions should remain person-centred. While thresholds for intervention are often met after self-harm or suicidality, professionals should review approaches to care and support people with underlying distress.

A Day in the Life of Borderline Personality Disorder: A Preliminary Analysis of Within-Day Emotion Generation and Regulation

In Linehan's (1993) biosocial theory, borderline personality disorder (BPD) results in part from frequent, intense, negative emotions and maladaptive behavioral responses to those emotions. We conducted a secondary data analysis of an intensive single-case experimental design to explore hourly relations among behavioral responses and emotions in BPD. Eight participants with BPD (M _age = 21.57, 63% female; 63% Asian) reported their emotions and behaviors hourly on two days. Participants reported a neutral-to-negative average emotional state with substantial variability each day. This emotional state was characterized most frequently by anxiety and joy. Participants tended to "dig into", or savor, experiences of joy, but problem-solve around, push away, or accept anxiety. Acceptance predicted hour-by-hour increases in negative emotion intensity, and pushing emotions away predicted hour-by-hour increases in positive emotion intensity. These results suggest that anxiety dominates the emotional experiences of people with BPD and co-occurs with a variety of emotion regulation strategies, while joy co-occurs with strategies designed to prolong emotional experiences. Despite its general adaptiveness, acceptance may be less effective, and pushing emotions away may be more effective, than other emotion regulation strategies at improving momentary negative emotions for those with BPD. We discuss the preliminary nature of these findings and encourage future researchers to build on them in larger samples with more severe presentations of BPD.

Emotion regulation, mindfulness, and self-compassion among patients with borderline personality disorder, compared to healthy control subjects

Objectives

Emotion regulation difficulties are a major characteristic of personality disorders. Our study investigated emotion regulation difficulties that are characteristic of borderline personality disorder (BPD), compared to a healthy control group.

Methods

Patients with BPD (N = 59) and healthy participants (N = 70) filled out four self-report questionnaires (Cognitive Emotion Regulation Questionnaire, Difficulties in Emotion Regulation Scale, Five Facet Mindfulness Questionnaire, Self-Compassion Scale) that measured the presence or lack of different emotion-regulation strategies. Differences between the BPD and the healthy control group were investigated by Multivariate Analysis of Variance (MANOVA) and univariate post-hoc F-test statistics.

Results

People suffering from BPD had statistically significantly (p<0.05) higher levels of emotional dysregulation and used more maladaptive emotion-regulation strategies, as well as lower levels of mindfulness and self-compassion compared to the HC group.

Conclusion

In comparison to a healthy control group, BPD patients show deficits in the following areas: mindfulness, self-compassion and adaptive emotion-regulation strategies. Based on these results, we suggest that teaching emotion-regulation, mindfulness, and self-compassion skills to patients can be crucial in the treatment of borderline personality disorder.

Emotion regulation and borderline personality features in daily life: The role of social context

BACKGROUND

Borderline personality disorder (BPD) is associated with emotional dysfunction and interpersonal sensitivity. Yet, little work has characterized how BPD features predicts emotional reactivity and emotion regulation behaviors in response to interpersonal stress relative to other forms of stress.

METHODS

Participants were 152 university students who completed baseline measures of BPD features and complied with two-week daily diary procedures assessing daily emotion regulation strategy use in response to social and non-social stressors.

RESULTS

Generalized estimating equations revealed that BPD features predicted greater negative and positive emotions in response to daily stressors, and interacted with type of stressor in predicting urges and behaviors. Elevated BPD features was associated with greater urges for dysfunctional emotion regulatory behaviors and fewer functional emotion regulatory behaviors to a greater extent in response to social (versus non-social) stressors.

LIMITATIONS

This study was limited by its focus on past-day retrospective recall. Further, the student sample limits the generalizability of these findings.

CONCLUSIONS

These findings suggest that individuals with elevated BPD features may have less functional emotion regulation in social contexts.

Mindreading and metacognition patterns in patients with borderline personality disorder: experimental study

Current psychopathology attempts to understand personality disorders in relation to deficits in higher cognition such as mindreading and metacognition. Deficits in mindreading are usually related to limitations in or a complete lack of the capacity to understand and attribute mental states to others, while impairments in metacognition concern dysfunctional control and monitoring of one's own processes. The present study investigated dysfunctional higher cognition in the population of patients with borderline personality disorder (BPD) by analyzing the accuracy of metacognitive judgments in a mindreading task [reading the mind in the eyes Test (RMET)] and a subsequent metacognitive task based on self-report scales: a confidence rating scale (CR) versus a post-decision wagering scale (PDW). It turned out that people from the BPD group scored lower in the RMET. However, both groups had the same levels of confidence on the PDW scale when giving incorrect answers in the RMET test. As initially hypothesized, individuals with BPD overestimated their confidence in incorrect answers, regardless of the type of metacognitive scales used. The present findings indicate that BPD individuals show dysfunctional patterns between instances of mindreading and metacognition.

Comorbidity Between Non-suicidal Self-Injury Disorder and Borderline Personality Disorder in Adolescents: A Graphical Network Approach

In 2013, DSM-5 urged for further research on non-suicidal self-injury (NSSI) and defined NSSI disorder (NSSI-D) for the first time separate from borderline personality disorder (BPD). However, research on the comorbidity between NSSI-D and BPD symptoms is still scarce, especially in adolescent populations. The current study selected 347 adolescents who engaged at least once in NSSI (78.4% girls, M age = 15.05) and investigated prevalence, comorbidity, gender differences, and bridge symptoms of NSSI-D and BPD. Network analysis allowed us to visualize the comorbidity structure of NSSI-D and BPD on a symptom-level and revealed which bridge symptoms connected both disorders. Our results supported NSSI-D as significantly distinct from, yet closely related to, BPD in adolescents. Even though girls were more likely to meet the NSSI-D criteria, our findings suggested that the manner in which NSSI-D and BPD symptoms were interconnected, did not differ between girls and boys. Furthermore, loneliness, impulsivity, separation anxiety, frequent thinking about NSSI, and negative affect prior to NSSI were detected as prominent bridge symptoms between NSSI-D and BPD. These bridge symptoms could provide useful targets for early intervention in and prevention of the development of comorbidity between NSSI-D and BPD. Although the current study was limited by a small male sample, these findings do provide novel insights in the complex comorbidity between NSSI-D and BPD symptoms in adolescence.

Negative affect moderates the effect of social rejection on frontal and anterior cingulate cortex activation in borderline personality disorder

Patients with borderline personality disorder (BPD) have a heightened sensitivity to social exclusion. Experimental manipulations have produced inconsistent findings and suggested that baseline negative affect (NA) might influence the experience of exclusion. We administered a standardized social exclusion protocol (Cyberball paradigm) in BPD (n = 39) and age-matched and sex-matched healthy controls (n = 29) to investigate the association of NA on social exclusion and activation in brain regions previously implicated in this paradigm. Compared with controls, patients with BPD showed higher activation during social exclusion in the anterior cingulate cortex (ACC), the medial prefrontal cortex (mPFC), and in the right precuneus. Prescan NA ratings were associated with higher brain activation in the ACC and mPFC over all conditions, and post hoc t tests revealed that differences between the groups were only significant when controlling for NA. Brain activation during exclusion was correlated with NA separately for each group. Only BPD patients showed a significant association of NA and exclusion related precuneus activation (r = .52 p = .001). Additionally, BPD patients experienced less feelings of belonging compared with a healthy control (HC) group during inclusion and exclusion, although they estimated their ball possessions significantly higher than did the HC. These findings suggest that baseline NA has a crucial impact on Cyberball-related brain activation. The results underscore the importance of considering levels of NA in social exclusion protocols for participants high in this trait.

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.

Psychological therapies for people with borderline personality disorder

BACKGROUND

Over the decades, a variety of psychological interventions for borderline personality disorder (BPD) have been developed. This review updates and replaces an earlier review (Stoffers-Winterling 2012).

OBJECTIVES

To assess the beneficial and harmful effects of psychological therapies for people with BPD.

SEARCH METHODS

In March 2019, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication.

SELECTION CRITERIA

Randomised controlled trials comparing different psychotherapeutic interventions with treatment-as-usual (TAU; which included various kinds of psychotherapy), waiting list, no treatment or active treatments in samples of all ages, in any setting, with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. There were 11 secondary outcomes, including individual BPD symptoms, as well as attrition and adverse effects.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's 'Risk of bias' tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis.

MAIN RESULTS

We included 75 randomised controlled trials (4507 participants), predominantly involving females with mean ages ranging from 14.8 to 45.7 years. More than 16 different kinds of psychotherapy were included, mostly dialectical behaviour therapy (DBT) and mentalisation-based treatment (MBT). The comparator interventions included treatment-as-usual (TAU), waiting list, and other active treatments. Treatment duration ranged from one to 36 months. Psychotherapy versus TAU Psychotherapy reduced BPD symptom severity, compared to TAU; standardised mean difference (SMD) -0.52, 95% confidence interval (CI) -0.70 to -0.33; 22 trials, 1244 participants; moderate-quality evidence. This corresponds to a mean difference (MD) of -3.6 (95% CI -4.4 to -2.08) on the Zanarini Rating Scale for BPD (range 0 to 36), a clinically relevant reduction in BPD symptom severity (minimal clinical relevant difference (MIREDIF) on this scale is -3.0 points). Psychotherapy may be more effective at reducing self-harm compared to TAU (SMD -0.32, 95% CI -0.49 to -0.14; 13 trials, 616 participants; low-quality evidence), corresponding to a MD of -0.82 (95% CI -1.25 to 0.35) on the Deliberate Self-Harm Inventory Scale (range 0 to 34). The MIREDIF of -1.25 points was not reached. Suicide-related outcomes improved compared to TAU (SMD -0.34, 95% CI -0.57 to -0.11; 13 trials, 666 participants; low-quality evidence), corresponding to a MD of -0.11 (95% CI -0.19 to -0.034) on the Suicidal Attempt Self Injury Interview. The MIREDIF of -0.17 points was not reached. Compared to TAU, psychotherapy may result in an improvement in psychosocial functioning (SMD -0.45, 95% CI -0.68 to -0.22; 22 trials, 1314 participants; low-quality evidence), corresponding to a MD of -2.8 (95% CI -4.25 to -1.38), on the Global Assessment of Functioning Scale (range 0 to 100). The MIREDIF of -4.0 points was not reached. Our additional Trial Sequential Analysis on all primary outcomes reaching significance found that the required information size was reached in all cases. A subgroup analysis comparing the different types of psychotherapy compared to TAU showed no clear evidence of a difference for BPD severity and psychosocial functioning. Psychotherapy may reduce depressive symptoms compared to TAU but the evidence is very uncertain (SMD -0.39, 95% CI -0.61 to -0.17; 22 trials, 1568 participants; very low-quality evidence), corresponding to a MD of -2.45 points on the Hamilton Depression Scale (range 0 to 50). The MIREDIF of -3.0 points was not reached. BPD-specific psychotherapy did not reduce attrition compared with TAU. Adverse effects were unclear due to too few data. Psychotherapy versus waiting list or no treatment Greater improvements in BPD symptom severity (SMD -0.49, 95% CI -0.93 to -0.05; 3 trials, 161 participants), psychosocial functioning (SMD -0.56, 95% CI -1.01 to -0.11; 5 trials, 219 participants), and depression (SMD -1.28, 95% CI -2.21 to -0.34, 6 trials, 239 participants) were observed in participants receiving psychotherapy versus waiting list or no treatment (all low-quality evidence). No evidence of a difference was found for self-harm and suicide-related outcomes. Individual treatment approaches DBT and MBT have the highest numbers of primary trials, with DBT as subject of one-third of all included trials, followed by MBT with seven RCTs. Compared to TAU, DBT was more effective at reducing BPD severity (SMD -0.60, 95% CI -1.05 to -0.14; 3 trials, 149 participants), self-harm (SMD -0.28, 95% CI -0.48 to -0.07; 7 trials, 376 participants) and improving psychosocial functioning (SMD -0.36, 95% CI -0.69 to -0.03; 6 trials, 225 participants). MBT appears to be more effective than TAU at reducing self-harm (RR 0.62, 95% CI 0.49 to 0.80; 3 trials, 252 participants), suicidality (RR 0.10, 95% CI 0.04, 0.30, 3 trials, 218 participants) and depression (SMD -0.58, 95% CI -1.22 to 0.05, 4 trials, 333 participants). All findings are based on low-quality evidence. For secondary outcomes see review text.

AUTHORS' CONCLUSIONS

Our assessments showed beneficial effects on all primary outcomes in favour of BPD-tailored psychotherapy compared with TAU. However, only the outcome of BPD severity reached the MIREDIF-defined cut-off for a clinically meaningful improvement. Subgroup analyses found no evidence of a difference in effect estimates between the different types of therapies (compared to TAU) . The pooled analysis of psychotherapy versus waiting list or no treatment found significant improvement on BPD severity, psychosocial functioning and depression at end of treatment, but these findings were based on low-quality evidence, and the true magnitude of these effects is uncertain. No clear evidence of difference was found for self-harm and suicide-related outcomes. However, compared to TAU, we observed effects in favour of DBT for BPD severity, self-harm and psychosocial functioning and, for MBT, on self-harm and suicidality at end of treatment, but these were all based on low-quality evidence. Therefore, we are unsure whether these effects would alter with the addition of more data.

Testing an emotion regulation model of physical activity in adolescents with anorexia nervosa: A pilot ecological momentary assessment

OBJECTIVE

Adolescents with anorexia nervosa (AN) often show increased levels of exercise and physical activity. Psychological models suggest that physical activity in AN might attenuate momentary negative affect. However, this has not been directly tested in adolescents with AN, and it remains unclear whether this is a distinct mechanism of physical activity in AN compared with healthy controls (HCs).

METHOD

In a 1-day ecological momentary assessment, 32 adolescent inpatients with AN and 30 HCs responded to hourly questions on momentary affect while wearing an actigraph to objectively assess physical activity.

RESULTS

Linear mixed models identified that adolescents with AN experienced more aversive tension, more negative affect, and less positive affect throughout the day than HCs. Preliminary evidence for a momentary association of higher levels of physical activity with positive affect were found for both groups, whereas higher levels of physical activity were associated with less negative affect in adolescents with AN only. When correcting for multiple testing, interactions did not hold statistical significance.

DISCUSSION

Our results indicate a down-regulation effect of physical activity on negative affect for AN and a more general up-regulation effect of positive affect. However, our sample size was small, and replication of our findings is needed.

Differential perception of sharp pain in patients with borderline personality disorder

BACKGROUND

Cutting is the most common method of non-suicidal self-injury (NSSI) to reduce inner tension in patients with Borderline Personality Disorder (BPD). Aim of this study was to compare pain perception induced by an incision and by application of a surrogate model for sharp mechanical pain (a non-invasive "blade") in BPD.

METHODS

22 female patients and 20 healthy controls (HC) received a small incision into the volar forearm, a 7s-blade application on the same side, and non-invasive phasic stimuli (pinprick, blade, laser, tactile). Pain intensity as well as affective versus sensory components were assessed.

RESULTS

Incision was rated similarly by both groups (BPD: 28.6 ± 5.5 vs. HC: 33.9 ± 6.6; mean maximum pain ± SEM; p > 0.8), without significant difference for "7-s-blade" (BPD: 18.1 ± 3.8 vs. HC: 25.3 ± 3.6; mean maximum pain ± SEM; p > 0.17) or between "7-s-blade" and incision (BPD: p > 0.12; HC: p > 0.84). However, patients' intensity ratings returned significantly faster to baseline after incision (BPD: 38.9 ± 12.6 s vs. HC: 74.52 ± 11.5 s; p < 0.05), and patients evaluated "blade" and incision without any affective and with different sensory descriptors, indicating an altered evaluation of NSSI-like stimulation with qualitative in addition to quantitative differences-especially for the sharp pain component.

CONCLUSIONS

The reduced perception of suprathreshold nociceptive stimuli is based on a missing affective component and specific loss of the perception of "sharpness" as part of the sensory component of pain. The results further demonstrate the usefulness of the "blade" for the perception of sharpness in patients.

SIGNIFICANCE

Patients with Borderline Personality Disorder (BPD) who engage in non-suicidal self-injury (NSSI) report less pain in response to phasic nociceptive stimuli. In comparing an invasive pain stimulus to phasic nociceptive stimuli in BPD patients, the "blade" as non-invasive surrogate model for sharp mechanical pain in psychiatric patients is used. In contrast to healthy volunteers, BPD patients do not report significant affective ratings and specifically display a reduced sensory component for sharpness.

EEG-vigilance regulation in Borderline Personality Disorder

BACKGROUND

Borderline Personality Disorder (BPD) is characterized by emotional instability, impulsivity, disturbed cognition, sleeplessness and states of high inner tension. Altered arousal regulation which is regarded as a higher domain of functioning according to the research domain criteria of the NIMH and which has previously been reported in several psychiatric disorders, such as mania or major depression could be involved in these features of BPD.

METHODS

40 unmedicated patients with BPD and 42 matched healthy volunteers participated in a twenty minute resting-state EEG measurement with closed eyes. EEG-vigilance regulation was assessed with VIGALL2.0 (Vigilance Algorithm Leipzig), which allows a classification of consecutive 1-s segments in different vigilance stages ranging from high alertness/relaxed wakefulness (stages 0, A1, A2, A3) to drowsiness (B1, B2/3) and sleep onset (C).

RESULTS

Across 20 min, both groups showed a similar decline from higher to lower vigilance stages, but patients with BPD remained in higher stages of vigilance compared to healthy volunteers across the whole measurement (p = .013). Contrary to this, pre-experimental ratings indicated enhanced subjective sleepiness but no differences in self-reported sleep quantity in the previous night in patients with BPD compared to healthy volunteers.

CONCLUSIONS

The results of an elevated arousal regulation (in combination with increased subjective sleepiness) might reflect several symptoms, such as aversive inner tension and impoverished sense of self in patients with BPD. As arousal is linked to the noradrenergic system, further investigations in this field seem to be promising.

Reviewing the clinical significance of 'fear of abandonment' in borderline personality disorder

OBJECTIVES:

To review and highlight the clinical significance of the symptom 'fear of abandonment' in borderline personality disorder (BPD).

METHODS:

A systematic search of the literature was conducted using MEDLINE and PubMed, employing search terms including 'fear of abandonment', 'borderline personality disorder' and 'rejection'. The most relevant English-language articles and books were selected for this review.

RESULTS:

Fear of abandonment is widely recognised as a core symptom in BPD; a biopsychosocial explanation for the occurrence of the symptom is presented. While fear of abandonment may differ in its clinical presentation, it has a significant impact on therapeutic engagement, suicidal behaviour and non-suicidal self-injury, clinical management and prognosis. Most evidence based psychotherapies for BPD address the phenomenon of fear of abandonment; however, the lack of specifically targeted treatment interventions is disproportionate to its prominence and clinical significance.

CONCLUSIONS:

Given its defining role in BPD, we recommend fear of abandonment as an important subject of future research and a specific therapy target.

Conceptual Models of Borderline Personality Disorder, Part 1: Overview of Prevailing and Emergent Models

Borderline personality disorder (BPD) is a debilitating condition with significant personal and societal costs. Throughout the history of the conceptualization of borderline pathology as a form of psychopathology, there has been debate concerning the essential attributes of this disorder, which has significant implications for its assessment and treatment. The first of this 2-part review evaluates the major approaches to conceptualizing BPD, from the traditional DSM diagnosis through the more recent Alternative Model in DSM-5, Section III, and the research domain criteria initiative of the National Institute of Mental Health that was articulated largely in response to limitations of the DSM.

Treatment-induced brain plasticity in borderline personality disorder: review of functional MRI studies

Although neural substrates of symptoms expression in borderline personality disorder (BPD) have been studied extensively, neural mechanisms mediating post treatment amelioration of symptoms remain poorly characterized. Herein present review sheds a critical light on all here-to-date functional MRI findings of brain changes in BPD patients following a treatment with psychotherapy or drugs. Preliminary evidence points to downregulation of neuronal activity within the insula and amygdala, together with differential employment of prefrontal areas, mainly orbitofrontal cortex, anterior cingulate cortex and dorsolateral prefrontal cortex, as well as enhanced functional connectivity between limbic and prefrontal regions induced by dialectical behavioral therapy. Identifying neural circuits behind treatment processes may refine strategies to target specific symptoms, thereby resolving some of the controversies over BPD treatment.

Cognitive control and daily affect regulation in major depression and borderline personality disorder: protocol for an experimental ambulatory assessment study in Berlin, Germany

INTRODUCTION

Affective disturbances and difficulty in affect regulation are core features of major depressive disorder (MDD) as well as borderline personality disorder (BPD). Whereas depressed individuals are characterised by affective inertia, individuals with BPD are characterised by affective instability. Both groups have been found to use more maladaptive affect regulation strategies than healthy controls. Surprisingly, however, there have been hardly any studies directly comparing these two disorders to disentangle shared and disorder-specific deficits in affective dynamics and affect regulation.Furthermore, theoretical models link deficits in affect regulation to deficits in cognitive control functions. Given that individuals with MDD or BPD are both characterised by impairments in cognitive control, the present study will further examine the link between individual differences in cognitive control and disturbances in affect dynamics and regulation in the daily life of individuals with MDD or BPD.

METHODS AND ANALYSES

We will use a smartphone application to assess negative and positive affect as well as affect regulation strategies at eight times a day for 7 days. We will further employ four computerised tasks to assess two cognitive control functions, namely interference control and discarding irrelevant information from working memory. Our hypotheses will be tested using a multimethod approach. Power analyses determined a sample size of 159 (53 MDD, 53 BPD, 53 controls) to detect medium effect sizes.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the Freie Universität Berlin. Data collection started in January 2017 and will last until the end of 2018. Results will be disseminated to relevant psychotherapeutic and patient communities in peer-reviewed journals, and at scientific conferences.

Adverse Effects of Outcome Monitoring Feedback in Patients With Personality Disorders: A Randomized Controlled Trial in Day Treatment and Inpatient Settings

This study aimed to evaluate the differential effect of outcome monitoring feedback to therapists and to patients on outcomes in cluster B, cluster C, and personality disorder not otherwise specified (PD-NOS) patients. Day treatment patients (n = 112) and inpatients (n = 94) were randomly assigned to a feedback to therapist (FbT), feedback to therapist and patient (FbTP), or no feedback (NFb) condition. Feedback was based on weekly administrations of the Outcome Questionnaire-45 (OQ-45). In cluster B and PD-NOS patients FbTP resulted in increased OQ-45 scores during the first 6 months of therapy for not on track (NOT) patients. In cluster C patients, no adverse effects of feedback were found. These results suggest that for certain personality disorder patient groups, providing feedback during treatment may not always be beneficial, although more research is needed to further assess these effects.

Divergent effects of oxytocin on (para-)limbic reactivity to emotional and neutral scenes in females with and without borderline personality disorder

Borderline personality disorder (BPD) patients’ hypersensitivity for emotionally relevant stimuli has been suggested be due to abnormal activity and connectivity in (para-)limbic and prefrontal brain regions during stimulus processing. The neuropeptide oxytocin has been shown to modulate activity and functional connectivity in these brain regions, thereby optimizing the processing of emotional and neutral stimuli. To investigate whether oxytocin would be capable of attenuating BPD patients’ hypersensitivity for such stimuli, we recorded brain activity and gaze behavior during the processing of complex scenes in 51 females with and 48 without BPD after intranasal application of either oxytocin or placebo. We found divergent effects of oxytocin on BPD and healthy control (HC) participants’ (para-)limbic reactivity to emotional and neutral scenes: Oxytocin decreased amygdala and insula reactivity in BPD participants but increased it in HC participants, indicating an oxytocin-induced normalization of amygdala and insula activity during scene processing. In addition, oxytocin normalized the abnormal coupling between amygdala activity and gaze behavior across all scenes in BPD participants. Overall, these findings suggest that oxytocin may be capable of attenuating BPD patients’ hypersensitivity for complex scenes, irrespective of their valence.

Exclusion-Proneness in Borderline Personality Disorder Inpatients Impairs Alliance in Mentalization-Based Group Therapy

Interpersonal sensitivity, particularly threat of potential exclusion, is a critical condition in borderline personality disorder (BPD) which impairs patients’ social adjustment. Current evidence-based treatments include group components, such as mentalization-based group therapy (MBT-G), in order to improve interpersonal functioning. These treatments additionally focus on the therapeutic alliance since it was discovered to be a robust predictor of treatment outcome. However, alliance is a multidimensional factor of group therapy, which includes the fellow patients, and may thus be negatively affected by the exclusion-proneness of BPD patients. The aim of this pilot study was to examine the predictive value of threat of social exclusion for the therapeutic alliance in MBT-G. In the first part of the study, social exclusion was experimentally induced in 23 BPD inpatients and 28 healthy subjects using the Cyberball paradigm, a virtual ball tossing game. The evoked level of threat was measured with the Need-Threat Scale (NTS) which captures four dimensions of fundamental human needs, i.e., the need for belongingness, for self-esteem, for control, and for a meaningful existence. In the second part of the study, therapeutic alliance was measured on three dimensions, the therapists, the fellow patients and the group as a whole, using the Group-Questionnaire (GQ-D). BPD patients scored higher in their level of threat according to the NTS in both, the inclusion and the exclusion condition. The level of threat after exclusion predicted impairments of the therapeutic alliance in MBT-G. It was associated with more negative relationships, lower positive bonding and a lower positive working alliance with the fellow patients and lower positive bonding to the group as a whole whilst no negative prediction of the alliance to the therapists was found. Consequently, our translational study design has shown that Cyberball is an appropriate tool to use as an approach for clinical questions. We further conclude that exclusion-proneness in BPD is a critical feature with respect to alliance in group treatments. In order to neutralize BPD patients’ exclusion bias, therapists may be advised to provide an “inclusive stance,” especially in initial sessions. It is also recommendable to strengthen patient to patient relations.

Pharmacological interventions for people with borderline personality disorder

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To assess the beneficial and harmful effects of pharmacological treatment for adolescents and adults with borderline personality disorder (BPD).

Pain-mediated affect regulation is reduced after dialectical behavior therapy in borderline personality disorder: a longitudinal fMRI study

Borderline Personality Disorder (BPD) is characterized by affective instability, but self-injurious behavior appears to have an emotion-regulating effect. We investigated whether pain-mediated affect regulation can be altered at the neural level by residential Dialectical Behavior Therapy (DBT), providing adaptive emotion regulation techniques. Likewise, we investigated whether pain thresholds or the appraisal of pain change after psychotherapy. We investigated 28 patients with BPD undergoing DBT (self-referral), 15 patients with treatment as usual and 23 healthy control subjects at two time points 12 weeks apart. We conducted an fMRI experiment eliciting negative emotions with picture stimuli and induced heat pain to investigate the role of pain in emotion regulation. Additionally, we assessed heat and cold pain thresholds.

At first measurement, patients with BPD showed amygdala deactivation in response to painful stimulation, as well as altered connectivity between left amygdala and dorsal anterior cingulate cortex. These effects were reduced after DBT, as compared with patients with treatment as usual. Pain thresholds did not differ between the patient groups. We replicated the role of pain as a means of affect regulation in BPD, indicated by increased amygdala coupling. For the first time, we could demonstrate that pain-mediated affect regulation can be changed by DBT.

Interpersonal stressors and negative affect in individuals with borderline personality disorder and community adults in daily life: A replication and extension

Affective instability and interpersonal stress are key features of borderline personality disorder (BPD). They were shown to covary in the daily lives of patients in a recent ambulatory assessment study (Hepp et al., 2017) that observed comparatively larger positive associations between interpersonal stressors and negative affect in individuals with BPD than those with depressive disorders. The present study sought to replicate these findings, collecting data on hostility, sadness, fear, and rejection or disagreement events from 56 BPD and 60 community control participants for 21 days, 6 times a day. Using identical statistical procedures, the positive associations between momentary rejection/disagreement and hostility, sadness, and fear were replicated. Again replicating the original study, the rejection-hostility, rejection-sadness, and disagreement-hostility associations were significantly stronger in the BPD group. Time-lagged analyses extended the original study, revealing that rejection was associated with subsequent hostility and sadness more strongly in the BPD group, as was disagreement with subsequent hostility and fear. Though small, we argue that the observed group differences reflect meaningful pervasive responses in a daily life context. Future research should consider these when implementing affect regulation strategies that are applicable in interpersonal contexts for all individuals, but particularly those with BPD. (PsycINFO Database Record

Stress reactivity and pain-mediated stress regulation in remitted patients with borderline personality disorder

Objective

Patients with borderline personality disorder (BPD) use nonsuicidal self-injury (NSSI) to cope with states of elevated inner tension. It is unclear to what extent remitted BPD patients experience these states and whether the experience of pain still regulates emotion. The purpose of this study was the investigation of baseline stress levels, stress reactivity, and pain-mediated stress regulation in remitted BPD patients.

Method

Subjective and objective stress parameters were assessed in 30 remitted BPD patients, 30 current BPD patients, and 30 healthy controls. After stress induction, a non-nociceptive tactile stimulus, a tissue-injuring, or a noninvasive pain stimulus was applied to the right volar forearm.

Results

Baseline stress levels of remitted BPD patients lie in between the stress levels of current BPD patients and healthy controls. Urge for NSSI increased significantly more in current than remitted BPD patients. The experience of pain led to a greater decrease of arousal in current compared to remitted BPD patients and healthy controls.

Conclusions

States of increased tension still seem to appear in remitted BPD patients. The role of pain-mediated stress regulation appears to be reduced in remitted patients.

Rest, Reactivity, and Recovery: A Psychophysiological Assessment of Borderline Personality Disorder

Difficulty regulating emotion is a cardinal feature of borderline personality disorder (BPD), yet little is known about the automatic psychophysiological processes involved in this phenotype. Inconsistent findings have emerged from studies that employed limited assessments (e.g., heart rate variability, skin conductance) of autonomic nervous system response to emotional contexts, and compared groups based on the presence or absence of BPD as a categorical diagnosis. This exploratory study assessed a comprehensive set of autonomic nervous system processes in 44 individuals (22 with BPD) at rest, in response to emotionally evocative stimuli, and during a subsequent recovery period. BPD was characterized with a dimensional measure of BPD symptom severity, as a well by categorical diagnosis. At baseline and across experimental tasks, higher heart rate was observed in those diagnosed with BPD compared to controls, and in those expressing greater BPD symptom severity. These effects, however, were fully mediated by differences in physical exercise. In contrast, during recovery from emotional activation, greater symptom severity predicted consistently higher levels of multiple sympathetic and parasympathetic processes compared to lower symptom severity. Overall, these findings suggest that the heart rate elevations sometimes observed in those diagnosed with BPD may be associated with individual and group differences in levels of physical exercise. Results further indicate that adaptive psychophysiological recovery responses following emotional challenge may be disrupted in proportion to BPD symptom severity, independently of exercise. Results highlight the utility of considering lifestyle factors and symptom severity in studies of emotional activation and regulation processes in BPD.

Ambulatory Assessment of Borderline Personality Disorder

Ambulatory assessment (AA) is an important tool that promises to minimize retrospective biases while gathering ecologically valid data, including self-reports, physiological or biological data, and observed behavior, for example, from daily life experiences. AA is well suited for studying borderline personality disorder (BPD) because it can measure moods and emotion (as well as dynamic mood processes, mood changes, and mood instability), problematic behaviors (including interpersonal conflicts, addictive behaviors, binge and purge episodes, and motoric activity), and problematic cognitions/expectancies/urges (e.g., rejection sensitivity, cravings, and self-harm urges) as they occur in daily life. In this article, I review existing AA research on BPD, and I discuss future applications of AA as well as limitations and considerations for future use.

Emotional reactivity to appraisals in patients with a borderline personality disorder: a daily life study

BACKGROUND

Emotional instability, consisting of patterns of strong emotional changes over time, has consistently been demonstrated in daily life of patients with a borderline personality disorder (BPD). Yet, little empirical work has examined emotional changes that occur specifically in response to emotional triggers in daily life, so-called emotional reactivity. The goal of this study was to examine emotional reactivity in response to general emotional appraisals (i.e. goal congruence or valence, goal relevance or importance, and emotion-focused coping potential) and BPD-specific evaluations (trust and disappointment in self and others) in daily life of inpatients with BPD.

METHODS

Thirty inpatients with BPD and 28 healthy controls participated in an experience sampling study and repeatedly rated the intensity of their current emotions, emotional appraisals, and evaluations of trust and disappointment in self and others.

RESULTS

Results showed that the BPD group exhibited stronger emotional reactivity in terms of negative affect than healthy controls, however only in response to disappointment in someone else. BPD patients also showed weaker reactivity in positive affect in response to the appraised importance of a situation; the more a situation was appraised as important, the higher the subsequent positive affect for healthy controls only, not the patient group.

CONCLUSIONS

These findings show that appraisals can trigger strong emotional reactions in BPD patients, and suggest that altered emotional reactivity might be a potential underlying process of emotional instability in the daily life.

The role of nociceptive input and tissue injury on stress regulation in borderline personality disorder

Approximately 60% to 90% of patients with borderline personality disorder (BPD) show nonsuicidal self-injurious behavior (NSSI) with cutting being the most frequently applied method. One of NSSI's functions is to reduce aversive tension. Previous studies have found a tension-reducing effect of painful tissue injury by an incision. It is still unclear whether this effect is based on the effect of tissue injury or the effect of pain experience, or both. The aim of this study was to determine whether tissue injury leads to a stronger stress reduction than a sole pain stimulus in patients with BPD. After stress induction, 57 BPD patients and 60 healthy controls (HCs) received either an incision or a non-tissue-injuring mechanical nociceptive stimulus ("blade") typically perceived as painful or a non-nociceptive tactile sham stimulus (blunt end of scalpel). Participants were unaware of which procedure was applied. For stress assessment, subjective and objective parameters were measured. As immediate response to the stimulus application, we found greater stress reduction after both painful stimuli (incision and blade) in BPD patients but no difference in stress decrease between the tissue-injuring incision and the non-tissue-injuring pain stimulus (blade). Compared with HCs, incision and blade were followed by greater immediate decrease of arousal in BPD patients. Our findings confirm that among BPD patients, the nociceptive input leads to stress reduction. In contrast, the impact of tissue damage on stress reduction was relatively small. In addition, the results suggest that painful stimuli lead to a greater stress reduction in BPD patients compared with HCs.

Emotion Regulation in Borderline Personality Disorder: An Experimental Investigation of the Effects of Instructed Acceptance and Suppression

Difficulties with emotion regulation are central to borderline personality disorder (BPD). Recent research suggests that avoidance of emotions in general, and emotion suppression specifically, may be commonly used among those who meet criteria for the disorder. Contemporary behavioral interventions for BPD incorporate cognitive and behavioral skills to increase emotional experiencing and acceptance while decreasing behaviors that function to escape or avoid from emotions. Few studies, however, have experimentally examined the effects of instructed emotion suppression and acceptance in BPD. The present study examined the effects of instructed use of different emotion regulation strategies on emotions, psychophysiology, and behavior in BPD. Participants with BPD, major depressive disorder (MDD), and nonpsychiatric controls (N = 193) were randomly assigned to either suppress or accept emotions during an audio recording of a social rejection scenario, and completed a behavioral measure of distress tolerance. BPD participants exhibited greater heart rate variability in the acceptance (vs. suppression) condition; this pattern was not evident within the other groups. These results suggest that deliberate use of acceptance-based emotion regulation strategies may have unique physiological effects among individuals with BPD.

Smartphone-Enhanced Low-Threshold Intervention for adolescents with Anorexia Nervosa (SELTIAN) waiting for outpatient psychotherapy: study protocol of a randomised controlled trial

INTRODUCTION

As smartphones are widely distributed nowadays, mental health apps seem to be a promising treatment tool. First self-help apps for eating disorders have been developed recently. However, studies assessing the efficacy of such apps are scarce. A smartphone app could prevent further weight reduction and increase commitment during waiting time for outpatient treatment, especially for adolescents with anorexia nervosa (AN). In this study protocol, a randomised controlled trial to assess the efficacy of a smartphone-enhanced low-threshold intervention for AN during waiting time is described.

METHODS AND ANALYSIS

30 adolescents with AN aged 12-19 years will be recruited at three child and adolescent psychiatry centres in Germany. All participants will be randomised to consultations only or consultations and the use of the Jourvie Research app. The app will be installed either on their own smartphone or on a research device. The participants will receive biweekly to monthly consultations for 3 months to review meal plans and weight management with a clinician. In addition, the Jourvie Research app for meal, behaviour and emotion protocolling will be provided to the intervention group. The protocols will be discussed with a clinician during the consultations. Dialectical behaviour therapy-informed skills for tension regulation to increase compliance with the meal plan will be taught in the intervention group and the app will remind the participant of a skill in a moment of need. The primary outcome is the age-adjusted and height-adjusted weight gain in standard deviation score after 3 months.

ETHICS AND DISSEMINATION

Results will be disseminated at conferences and through peer-reviewed publications. The trial was approved by the ethics review board of the local medical association, Mainz, Germany, under the reference number 837.338.15.

TRIAL REGISTRATION NUMBER

German clinical trials register, reference number DRKS00008946.

EMOTEO: A Smartphone Application for Monitoring and Reducing Aversive Tension in Borderline Personality Disorder Patients, a Pilot Study

PURPOSE

We developed a smartphone application (App; EMOTEO: emotion-meteo [weather forecast]) to help borderline personality disorder (BPD) patients to monitor and regulate their inner tension. The App proposes targeted mindfulness-based exercises.

DESIGN AND METHODS

We assessed the usability and efficiency of this App for monitoring and reduction of aversive tension in 16 BPD participants over a 6-month period.

FINDINGS

We recorded a mean of 318.1 sessions (SD = 166.7) per participants, with a high level of satisfaction. There was a significant decrease in aversive tension (p < .05) and the App was mainly used around 10 a.m. and 9 p.m.

PRACTICE IMPLICATIONS

EMOTEO was user-friendly and efficient in reducing aversive tension in BPD patients.

Momentary emotion identification in female adolescents with and without anorexia nervosa

Individuals with anorexia nervosa (AN) often report difficulties in identifying emotions, which have been mostly studied as an alexithymia trait. In a controlled two-day ecological momentary assessment, we studied the influence of time of day and aversive tension on self-reported momentary emotion identification. Analysis on an aggregated level revealed a significant lower mean emotion identification in the AN group. In a mixed model analysis, the AN group showed lower emotion identification than the control group (HC). Both a general and a group effect of time of day were found, indicating that emotion identification improved during the day in HC, whereas a negligible decrease of the emotion identification over time was observed in the AN group. Age was associated positively with emotion identification in general, but no specific effect on a group level was found. No effect of aversive tension was found. Our results indicate that an improvement during the day might be a natural process of emotion identification, which is hindered in AN. Future research should focus on temporal relations between emotion identification and disordered eating behavior to further evaluate the clinical relevance of emotion identification difficulties in AN.

Interpersonal problems and negative affect in Borderline Personality and Depressive Disorders in daily life

Theories of Borderline Personality Disorder (BPD) suggest that interpersonal problems in BPD act as triggers for negative affect and, at the same time, are a possible result of affective dysregulation. Therefore, we assessed the relations between momentary negative affect (hostility, sadness, fear) and interpersonal problems (rejection, disagreement) in a sample of 80 BPD and 51 depressed outpatients at 6 time-points over 28 days. Data were analyzed using multivariate multi-level modeling to separate momentary-, day-, and person-level effects. Results revealed a mutually reinforcing relationship between disagreement and hostility, rejection and hostility, and between rejection and sadness in both groups, at the momentary and day level. The mutual reinforcement between hostility and rejection/disagreement was significantly stronger in the BPD group. Moreover, the link between rejection and sadness was present at all three levels of analysis for the BPD group, while it was localized to the momentary level in the depressed group.

How do mothers with borderline personality disorder mentalize when interacting with their infants?

Mothers with borderline personality disorder (BPD) have been theorized to have decreased mentalization ability, which is the capacity to perceive and interpret mental states. This could increase the risk for troubled relationships with their infants and therefore have adverse consequences for child social and emotional development. Mind-mindedness (MM), which codes the mother's references to her infant's mental states during an interaction, is one method of indexing mothers' mentalizing ability. However, research has yet to examine MM in mothers with BPD. Our objective was to assess the MM ability of 38 mothers during interactions with their 12-month-old infants, including 10 mothers with BPD and 28 mothers without a psychiatric diagnosis. Trained observers assessed maternal MM from 2 min of videotaped mother-infant free play. BPD was assessed with the Structured Clinical Interview for DSM-III-R-Personality Disorders (SCID-II). Mothers with and without BPD did not differ in the proportion of total comments referring to infant mental states. However, mothers in the BPD group proportionately made 3.6 times more misattuned mind-related comments than control mothers. Thus, mothers with and without BPD appear equally likely to envision mental states in their infants. However, mothers with BPD also appear more likely to misread their infants' mental states. Copyright © 2016 John Wiley & Sons, Ltd.

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.

Die Dialectical Behavior Therapy Ways of Coping Checklist (DBT-WCCL)

Zusammenfassung. Ziel dieser Arbeit war die Erprobung und Validierung einer deutschen Version der Dialectical Behavior Therapy Ways of Coping Checklist (DBT-WCCL, Neacsiu, Rizui, Vitaliano, Lynch & Linehan, 2010 ), einem Fragebogen zur Erhebung der Häufigkeit der Nutzung von Skills, wie sie im Rahmen der Dialektisch-Behavioralen Therapie (DBT) vermittelt werden. Hierzu bearbeiteten 150 Patientinnen mit Borderline Persönlichkeitsstörung eine deutschsprachige Übersetzung, sowie Fragebögen zur Symptomschwere. Weitere 40 Patientinnen füllten die DBT-WCCL im Rahmen einer stationären DBT zu 5 Messzeitpunkten aus. Die drei Faktoren der Originalversion ließen sich replizieren. Weiterführende Analysen zeigten gute interne Konsistenzen und Retest-Reliabilitäten. Erwartungsgemäße Zunahmen auf der Subskala zur Erfassung von Skillsanwendung während der stationären DBT sowie erwartungsgemäße Zusammenhänge der DBT-WCCL mit der Skills- und DBT-Erfahrung geben erste Hinweise auf die Validität des Verfahrens.

Anger and aggression in borderline personality disorder and attention deficit hyperactivity disorder - does stress matter?

BACKGROUND

The impact of stress on anger and aggression in Borderline Personality Disorder (BPD) and Attention Deficit Hyperactivity Disorder (ADHD) has not been thoroughly investigated. The goal of this study was to investigate different aspects of anger and aggression in patients with these disorders.

METHODS

Twenty-nine unmedicated female BPD patients, 28 ADHD patients and 30 healthy controls (HC) completed self-reports measuring trait anger, aggression and emotion regulation capacities. A modified version of the Point Subtraction Aggression Paradigm and a state anger measurement were applied under resting and stress conditions. Stress was induced by the Mannheim Multicomponent Stress Test (MMST).

RESULTS

Both patient groups scored significantly higher on all self-report measures compared to HCs. Compared to ADHD patients, BPD patients reported higher trait aggression and hostility, a stronger tendency to express anger when provoked and to direct anger inwardly. Furthermore, BPD patients exhibited higher state anger than HCs and ADHD patients under both conditions and showed a stress-dependent anger increase. At the behavioral level, no significant effects were found. In BPD patients, aggression and anger were positively correlated with emotion regulation deficits.

CONCLUSIONS

Our findings suggest a significant impact of stress on self-perceived state anger in BPD patients but not on aggressive behavior towards others in females with BPD or ADHD. However, it appears to be pronounced inwardly directed anger which is of clinical importance in BPD patients.