Emotional instability and borderline personality disorder

Affective instability is widely regarded as being the core problem in patients with borderline personality disorder (BPD) and the driving force behind the severe clinical manifestations of BPD symptoms. In ICD-10, BPD is even labelled as emotionally unstable personality disorder. In the last years, the advent of electronic diaries, in combination with sophisticated statistical analyses, enabled studying affective instability in everyday life. Surprisingly, most recent studies using state-of-the-art methodology to assess and model affective instability in BPD failed to show any specificity, supporting the idea of a transdiagnostic construct. In addition, dysfunctional emotion regulation strategies revealed results contradictory to current clinical beliefs. Using multiple data sets and multilevel modelling, we will demonstrate that to understand affective instability it is important:

– to statically model basic subcomponents of affective dynamics simultaneously;

– in combination with dysfunctional regulation strategies;

– cognitive processes in everyday life.

Altogether, current research suggests that the dynamics of affective states and their intentional regulation are even more important to psychological health and maladjustment, than the affective states itself. Current initiatives to fundamentally improve psychopathological research are looking at basic physiological processes spanning across disorders. However, these approaches do fall short in understanding human behaviours as dynamical processes that unfold in the broadest setting imaginable – everyday life. Only the combination of basic physiological processes and methods assessing dynamical affective mechanisms in everyday life will enhance our understanding how dysregulations and dysfunctions of fundamental aspects of behaviour cut across traditional disorders.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Effects and moderators of exercise on sleep in adults with cancer: Individual patient data and aggregated meta-analyses

OBJECTIVES

To evaluate the effects of exercise interventions on sleep disturbances and sleep quality in patients with mixed cancer diagnoses, and identify demographic, clinical, and intervention-related moderators of these effects.

METHODS

Individual patient data (IPD) and aggregated meta-analyses of randomized controlled trials (RCTs). Using data from the Predicting OptimaL cAncer RehabIlitation and Supportive care project, IPD of 2173 adults (mean age = 54.8) with cancer from 17 RCTs were analyzed. A complementary systematic search was conducted (until November 2018) to study the overall effects and test the representativeness of analyzed IPD. Effect sizes of exercise effects on self-reported sleep outcomes were calculated for all included RCTs. Linear mixed-effect models were used to evaluate the effects of exercise on post-intervention outcome values, adjusting for baseline values. Moderator effects were studied by testing interactions for demographic, clinical and intervention-related characteristics.

RESULTS

For all 27 eligible RCTs from the updated search, exercise interventions significantly decreased sleep disturbances in adults with cancer (g = -0.09, 95% CI [-0.16; -0.02]). No significant effect was obtained for sleep quality. RCTs included in IPD analyses constituted a representative sample of the published literature. The intervention effects on sleep disturbances were not significantly moderated by any demographic, clinical, or intervention-related factor, nor by sleep disturbances.

CONCLUSIONS

This meta-analysis provides some evidence that, compared to control conditions, exercise interventions may improve sleep disturbances, but not sleep quality, in cancer patients, although this effect is of a small magnitude. Among the investigated variables, none was found to significantly moderate the effect of exercise interventions on sleep disturbances.

Generalization of fear in post-traumatic stress disorder

Overgeneralization (i.e., the transfer of fear to stimuli not related to an aversive event) is part of alterations in associative fear learning in mental disorders. In the present experimental study, we investigated whether this holds true for post-traumatic stress disorder (PTSD) related to childhood abuse. We expected that fear generalization under experimental conditions reflects generalization of aversive stimuli to different social domains in real life. Sixty-four women with PTSD after childhood abuse and 30 healthy participants (HC) underwent a differential fear conditioning and generalization paradigm. Online risk ratings, reaction time, and fear-potentiated startle served as dependent variables. Based on the subjectively assessed generalization of triggered intrusions across different domains of life, PTSD participants were split into two groups reporting low (low-GEN) and high (high-GEN) generalization. PTSD patients reported a higher expectation of an aversive event. During fear conditioning, they assessed the risk of danger related to a safety cue slower and showed a blunted fear-potentiated startle toward the danger cue. During generalization testing, reaction time increased in the high-GEN patients and decreased in the HC group with increasing similarity of a stimulus with the conditioned safety cue. Alterations of fear learning in PTSD suggest impaired defensive responses in case of a high threat probability. Moreover, our findings bridge the gap between the generalization of aversive cues during everyday life and laboratory-based experimental parameters: impairments in the processing of cues signaling safety generalize particularly in those patients who report a spreading of PTSD symptoms across different domains of everyday life.

Affective instability across the lifespan in borderline personality disorder - a cross-sectional e-diary study

OBJECTIVE

Longitudinal and cross-sectional studies suggest that affective instability is inversely related to greater age in borderline personality disorder (BPD). However, existing studies relied on retrospective self-reports of perceived instability. We examined affective instability in everyday life in patients with BPD and healthy controls (HCs) by age in a cross-sectional e-diary study.

METHODS

Two hundred and sixty female participants between 14 and 53 years of age (130 patients with BPD and 130 HCs) carried an e-diary over 4 days. The e-diaries emitted a prompting signal in approximately hourly intervals asking participants to rate their current affective state, that is valence (ranging from pleasant to unpleasant) and tense arousal (ranging from calm/relaxed to restless/under tension).

RESULTS

Multilevel analyses revealed a significant interaction of age and group predicting affective instability (valence: F_(1,255.6)  = 7.59; P < 0.01; tense arousal: F_(1,252)  = 6.08; P < 0.01), suggesting that affective instability significantly declines with greater age in patients with BPD. Controlling for the number of comorbid disorders and BPD severity did not change the results, illustrating an inverse relationship between age and affective instability in BPD (significant interaction of age*group for valence: F_(1,238.7)  = 5.74; P < 0.02 and tense arousal: F_(1,235.2)  = 5.28; P < 0.02).

CONCLUSION

Affective instability during daily life declines with greater age in BPD. This decline is irrespective of comorbidity and BPD severity.

Abstract P6-12-06: Effect and moderators of exercise on fatigue in patients with breast cancer: Meta-analysis of individual patient data

Background - Fatigue is one of the most common and disabling complaints in patients with breast cancer and can effectively be reduced by physical exercise, with small to moderate effect sizes. To identify heterogeneity in responses to exercise and to further personalize exercise prescriptions, moderators of exercise effects on fatigue should be investigated. However, most randomized controlled trials (RCTs) are not adequately powered for such analyses. Therefore we conducted meta-analyses using the individual patient data of several exercise RCTs. The aim is to investigate the effect and moderators of physical exercise on cancer-related fatigue in patients with breast cancer.

Methods - Within the Predicting OptimaL cAncer RehabIlitation and Supportive care (POLARIS) consortium, principal investigators of 34 exercise RCTs worldwide have shared their individual patient data. Twenty-two of these RCTs included patients with breast cancer with a total sample size of 3,061. Different questionnaires to assess level of fatigue were used, which was acknowledged by using z-scores in the analysis. A one-step individual patient data meta-analysis, using a linear mixed-effect model adjusted for baseline fatigue, with a random intercept on study (to account for study clustering) was undertaken to investigate effect of exercise on fatigue. The result, a between-group difference in z-scores, corresponds to a Cohen's d effect size. An interaction term was included in the model to assess potential moderators including demographic (age, marital status, education), clinical (body mass index, presence of distant metastasis), intervention-related (intervention timing, delivery mode and duration), and exercise-related (exercise type, frequency, intensity, duration) characteristics.

Results – Exercise significantly reduced fatigue reported by women with breast cancer (β= -0.15, 95% CI -0.21;-0.09). This effect did not differ significantly between patients with different demographic and clinical characteristics (p-valuesinteraction &gt;0.05). Also, neither timing (during or post-treatment) and duration of the intervention, nor exercise-related factors moderated intervention effects on fatigue. Supervised exercise had significantly larger effects on fatigue than unsupervised exercise (βdifference= -0.17, 95%CI -0.28;-0.05). Compared to the control group, supervised exercise significantly improved fatigue (β = -0.21, 95%CI = -0.28;-0.14), while unsupervised exercise did not (β = -0.04, 95%CI = -0.14;0.06).

Conclusion – Exercise significantly reduces fatigue in patients with breast cancer across subgroups formed on the basis of age, marital status, education level, body mass index, and presence of distant metastasis. The effect of exercise is significantly larger when performed under supervision. Hence, exercise, and preferably supervised exercise, represents a viable intervention for the prevention and treatment of fatigue among patients with breast cancer.

Citation Format: van Vulpen JK, Sweegers MG, Kalter J, Peeters PH, Courneya KS, Newton RU, Aaronson NK, Jacobsen PB, Steindorf K, Stuiver MM, Hayes S, Mesters I, Knoop H, Goedendorp M, Mutrie N, Thorsen L, Schmidt M, Sonke GS, Bohus M, James EL, Oldenburg HS, Velthuis MJ, Nollet F, Wenzel J, Wiskemann J, Galvão DA, Chinapaw MJ, Irwin ML, Griffith KA, van Weert E, Daley AJ, McConnachie A, Schulz K-H, Short CE, Plotnikoff RC, Potthoff K, van Beurden M, van Harten WH, Schmitz KH, Winters-Stone KM, Taaffe DR, van Mechelen W, Kersten M-J, Verdonck-de Leeuw IM, Brug J, Buffart LM, May AM. Effect and moderators of exercise on fatigue in patients with breast cancer: Meta-analysis of individual patient data [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-06.

Genome-wide association study of borderline personality disorder reveals genetic overlap with bipolar disorder, major depression and schizophrenia

Borderline personality disorder (BOR) is determined by environmental and genetic factors, and characterized by affective instability and impulsivity, diagnostic symptoms also observed in manic phases of bipolar disorder (BIP). Up to 20% of BIP patients show comorbidity with BOR. This report describes the first case-control genome-wide association study (GWAS) of BOR, performed in one of the largest BOR patient samples worldwide. The focus of our analysis was (i) to detect genes and gene sets involved in BOR and (ii) to investigate the genetic overlap with BIP. As there is considerable genetic overlap between BIP, major depression (MDD) and schizophrenia (SCZ) and a high comorbidity of BOR and MDD, we also analyzed the genetic overlap of BOR with SCZ and MDD. GWAS, gene-based tests and gene-set analyses were performed in 998 BOR patients and 1545 controls. Linkage disequilibrium score regression was used to detect the genetic overlap between BOR and these disorders. Single marker analysis revealed no significant association after correction for multiple testing. Gene-based analysis yielded two significant genes: DPYD (P=4.42 × 10-7) and PKP4 (P=8.67 × 10-7); and gene-set analysis yielded a significant finding for exocytosis (GO:0006887, PFDR=0.019; FDR, false discovery rate). Prior studies have implicated DPYD, PKP4 and exocytosis in BIP and SCZ. The most notable finding of the present study was the genetic overlap of BOR with BIP (rg=0.28 [P=2.99 × 10-3]), SCZ (rg=0.34 [P=4.37 × 10-5]) and MDD (rg=0.57 [P=1.04 × 10-3]). We believe our study is the first to demonstrate that BOR overlaps with BIP, MDD and SCZ on the genetic level. Whether this is confined to transdiagnostic clinical symptoms should be examined in future studies.

[Internet-based interventions in the treatment of mental disorders : Overview, quality criteria, perspectives]

BACKGROUND

Mental disorders are frequently not or only insufficiently treated. Internet-based interventions offer the potential of closing the existing gaps in the treatment of mental disorders; however, it is very difficult for patients and providers to choose from the numerous interventions available.

OBJECTIVE

The aim of this study was to develop a set of quality criteria that can help patients and care providers to identify recommendable internet-based interventions.

METHODS

A selective literature search was carried out and the existing evidence on internet-based interventions in the treatment of mental disorders was collated. A panel of experts then developed quality criteria based on existing models for the systematic assessment of telemedicine applications.

RESULTS

Internet-based interventions are effective in the treatment of a broad range of mental disorders. The best evidence is available for depression and anxiety disorders. A set of criteria is proposed for the evaluation of available internet-based interventions using a checklist. These criteria have to be developed further with input from other stakeholders.

DISCUSSION

When taking these quality criteria into account, evidence-based interventions available on the internet can make an important contribution to improvement of the care of patients with mental disorders.

Delay discounting and response disinhibition under acute experimental stress in women with borderline personality disorder and adult attention deficit hyperactivity disorder

BACKGROUND

Impulsivity is a core feature of borderline personality disorder (BPD) and attention deficit hyperactivity disorder (ADHD). In BPD, impulsive behavior primarily occurs under acute stress; impulse control deficits under non-stress conditions may be partly related to co-morbid ADHD. We aimed to investigate whether acute experimental stress has an impact on self-reported impulsivity, response inhibition (action withholding, action cancelation) and delay discounting in BPD compared to ADHD.

METHOD

Thirty female BPD patients, 28 female ADHD patients (excluding patients with co-morbid BPD and ADHD), and 30 female healthy controls (HC) completed self-reports and behavioral measures of impulsivity (IMT, assessing action withholding; GoStop, measuring action cancelation, Delay Discounting Task) under baseline conditions and after an experimental stress induction (Mannheim Multicomponent Stress Test).

RESULTS

Both patient groups reported higher impulsivity than HC, ADHD reported higher trait impulsivity than BPD. On the IMT, ADHD showed significant action-withholding deficits under both conditions, while BPD performed significantly worse than HC under stress. In BPD but not ADHD and HC, action-withholding deficits (IMT) were significantly increased under stress compared to baseline, while no group/stress effects were found for action cancelation (GoStop). Delay discounting was significantly more pronounced in BPD than in HC (no stress effect was found).

CONCLUSIONS

In BPD, behavioral deficits in action withholding (but not in action cancelation) appear to be influenced by acute experimental stress. Delay discounting seems to be a general feature of BPD, independent of co-morbid ADHD and acute stress, possibly underlying typical expressions of behavioral impulsivity in the disorder.

Impact of stress on different components of impulsivity in borderline personality disorder

BACKGROUND

Previous research on impulsivity in borderline personality disorder (BPD) has revealed inconsistent findings. Impulsive behaviour is often observed during states of emotional distress and might be exaggerated by current attention deficit hyperactivity disorder (ADHD) symptoms in individuals with BPD. We aimed to investigate different components of impulsivity dependent on stress induction controlling for self-reported ADHD symptoms in BPD. METHOD. A total of 31 unmedicated women with BPD and 30 healthy women (healthy controls; HCs), matched for age, education and intelligence, completed self-reports and behavioural tasks measuring response inhibition (go/stop task) and feedback-driven decision making (Iowa Gambling Task) under resting conditions and after experimental stress induction. ADHD symptoms were included as a covariate in the analyses of behavioural impulsivity. Additionally, self-reported emotion-regulation capacities were assessed.

RESULTS

BPD patients reported higher impulsive traits than HCs. During stress conditions - compared with resting conditions - self-reported impulsivity was elevated in both groups. Patients with BPD reported higher state impulsivity under both conditions and a significantly stronger stress-dependent increase in state impulsivity. On the behavioural level, BPD patients showed significantly impaired performance on the go/stop task under stress conditions, even when considering ADHD symptoms as a covariate, but not under resting conditions. No group differences on the Iowa Gambling Task were observed. Correlations between impulsivity measures and emotion-regulation capacities were observed in BPD patients.

CONCLUSIONS

Findings suggest a significant impact of stress on self-perceived state impulsivity and on response disinhibition (even when considering current ADHD symptoms) in females with BPD.

Amygdala and anterior cingulate resting-state functional connectivity in borderline personality disorder patients with a history of interpersonal trauma

BACKGROUND

Studies in borderline personality disorder (BPD) have consistently revealed abnormalities in fronto-limbic brain regions during emotional, somatosensory and cognitive challenges. Here we investigated changes in resting-state functional connectivity (RSFC) of three fronto-limbic core regions of specific importance to BPD.

METHOD

Functional magnetic resonance imaging data were acquired in 20 unmedicated female BPD patients and 17 healthy controls (HC, matched for age, sex and education) during rest. The amygdala, and the dorsal and ventral anterior cingulate cortex (ACC) were defined as seeds to investigate RSFC patterns of a medial temporal lobe network, the salience network and default mode network. The Dissociation Experience Scale (DES), a measure of trait dissociation, was additionally used as a predictor of RSFC with these seed regions.

RESULTS

Compared with HC, BPD patients showed a trend towards increased RSFC between the amygdala and the insula, orbitofrontal cortex and putamen. Compared with controls, patients furthermore exhibited diminished negative RSFC between the dorsal ACC and posterior cingulate cortex, a core region of the default mode network, and regions of the dorsomedial prefrontal cortex. Last, increased negative RSFC between the ventral ACC and medial occipital regions was observed in BPD patients. DES scores were correlated with amygdala connectivity with the dorsolateral prefrontal cortex and fusiform gyrus.

CONCLUSIONS

Our findings suggest alterations in resting-state networks associated with processing of negative emotions, encoding of salient events, and self-referential processing in individuals with BPD compared with HC. These results shed more light on the role of abnormal brain connectivity in BPD.

[Importance of neurobiology for modular psychotherapy]

In the context of continuing education in psychiatry and psychotherapy, modular psychotherapy is of special importance. In modular psychotherapy, general interventions, e.g. for regulation of emotions, have an important function. In this review examples are given to describe the importance of neurobiology for the understanding and the improvement of these mechanisms. In addition, the use of neurobiological investigations within classical psychotherapy trials in the fields of borderline personality disorder and posttraumatic stress disorder will be depicted.

[Mindfulness-based psychotherapy]

Mindfulness-based psychotherapy is rooted in the Far East meditation culture. In the context of psychotherapy mindfulness-based treatment programs mostly include mindfulness as modular components aiming at acceptance of aversive circumstances or emotions and on improvement of metacognitive awareness. Currently there are five mindfulness-based concepts with different proof of effectiveness: mindfulness-based cognitive therapy (MBCT) can be classified as effective in reducing the risk of relapse in patients with recurrent depression, whereas the popular mindfulness-based stress reduction program (MBSR) reveals only small effect sizes. In summary, mindfulness used as one component in modular conceptualized treatment programs seems to be both acceptable and effective.

Influence of emotional distraction on working memory performance in borderline personality disorder

BACKGROUND

Emotion dysregulation, characterized by heightened emotional arousal and increased emotional sensitivity, is a core feature of borderline personality disorder (BPD). Although current theories emphasize the disruptive potential of negative emotions on cognitive functioning in BPD, behavioral and neurobiological data on this relationship are still lacking.

METHOD

Using functional magnetic resonance imaging (fMRI), neural activity was investigated in 22 unmedicated BPD patients and 22 healthy participants (matched for age, education and intelligence) performing an adapted Sternberg working memory task, while being distracted by emotional (negatively arousing) and neutral pictures from the International Affective Picture System (IAPS).

RESULTS

Emotional distraction was associated with significantly higher activation in the amygdala and decreased activation in the dorsolateral prefrontal cortex (DLPFC), extending findings of previous studies in healthy individuals. Patients with BPD showed significantly longer reaction times (RTs) along with significantly higher activation in the amygdala and insula during emotional distraction compared to healthy participants, suggesting that they were more distracted by emotional pictures during the working memory task. Moreover, in the group of BPD patients, a significant negative correlation was found between activation in limbic brain regions and self-reports of current dissociative states.

CONCLUSIONS

Our findings suggest hyper-responsiveness to emotionally distracting pictures in BPD patients that negatively affects working memory performance. This stresses the importance of emotion dysregulation in the context of cognitive functioning. Moreover, our findings suggest that dissociative states have a dampening effect on neural reactivity during emotional challenge in BPD.

[Psychopathology and psychotherapy of borderline personality disorder: state of the art]

With a lifetime prevalence of about 3%, borderline personality disorder is a frequent and often debilitating psychiatric disorder, especially during adolescence. Most features of typical borderline pathology can be classified into three dimensions: disturbed affect regulation, identity disturbance and problems in social interaction. Within the last decade several treatment programs have been tailored to the specific needs of borderline therapy and three of them have meanwhile shown empirically proven evidence: dialectical behavior therapy (DBT), mentalization-based therapy (MBT) and schema therapy. Although the studies showed clear superiority of specifically designed treatment programs compared to non-structured standard care, implementation of these programs in the German health care system is far from sufficient. Only one out of every thousand patients suffering from borderline personality disorder receives evidence-based outpatient psychotherapy. This is mirrored by the annual costs for inpatient treatment extending to 4 billion Euros, which is approximately 20% of the total costs for psychiatric care in Germany.

Script-driven imagery of self-injurious behavior in patients with borderline personality disorder: a pilot FMRI study

OBJECTIVE

Self-injurious behavior (SIB) is one of the most distinctive features of borderline personality disorder (BPD) and related to impulsivity and emotional dysregulation.

METHOD

Female patients with BPD (n = 11) and healthy controls (n = 10) underwent functional magnetic resonance imaging while listening to a standardized script describing an act of self-injury. Experimental sections of the script were contrasted to the neutral baseline section and group-specific brain activities were compared.

RESULTS

While imagining the reactions to a situation triggering SIB, patients with BPD showed significantly less activation in the orbitofrontal cortex compared with controls. Furthermore, only patients with BPD showed increased activity in the dorsolateral prefrontal cortex during this section and a decrease in the mid-cingulate while imagining the self-injurious act itself.

CONCLUSION

This pattern of activation preliminary suggests an association with diminished emotion regulation, impulse control as well as with response selection and reappraisal during the imagination of SIB.

A cross-sectional investigation of discontinuation of self-injury and normalizing pain perception in patients with borderline personality disorder

OBJECTIVE

Several studies have shown reduced pain perception in patients with borderline personality disorder (BPD) and current self-injurious behavior (SIB). The aim of the present study was to test whether pain perception in patients with current SIB is different from that of patients who had stopped SIB, and whether pain perception of the latter group differs from healthy controls (HC).

METHOD

We investigated 24 borderline patients and 24 HC. Thirteen patients showed current SIB (BPD-SIB) and 11 patients did not exhibit SIB anymore (BPD-non-SIB). Pain thresholds were assessed using thermal stimuli and laser radiant heat pulses.

RESULTS

We found significant linear trends for all pain measures. The BPD-SIB group was less sensitive than the BPD-non-SIB group and the latter were less sensitive than HC. The pain sensitivity negatively correlated with borderline symptom severity.

CONCLUSION

The results suggest an association between the termination of SIB, decline of psychopathology and normalization of pain perception in borderline patients.

Dialectical Behavioral Therapy for Patients with Borderline Features and Posttraumatic Stress Disorder After Childhood Sexual Abuse (DBT-P)

Several randomised clinical trials (RCT) have demonstrated the efficacy of cognitive behavioral therapy in the treatment of Posttraumatic Stress Disorder (PTSD). However, the external validity of these studies is limited with regard to PTSD related to childhood sexual abuse which often results in severe and complex sympomatology accompanied by a variety of concurrent disorders or symptoms, for example self-mutilation, suicidal ideation, or severe dissociation. Nearly 30% of patients with PTSD have a co-occuring borderline personality disorder (BPD). The prevalence rates of PTSD in patients with BPD vary between 40% and 60%.

Several RCTs have shown the efficacy of Dialectical Behavioral Therapy (DBT) in the treatment of borderline patients, who exaggerate severe behavioural dyscontrol. However specific treatment for co-occuring PTSD has been lucking.

Clinical lore suggests that exposure to trauma-relevant memories can potentially aggravate dysfunctional behaviour in patients with BPD. Empirical research however reports discrepant results with two studies documenting deleterious effects of comorbid BPD on treatment outcome, whereas one study did not find an impact.

DBT-P was specifically tailored to treat patients with PTSD after sexual abuse during childhood. DBT-P includes training in emotion regulation and mindfulness, cognitive interventions and exposure elements, usually in combination with the use of skills. To evaluate the efficacy of DBT-P as compared to a wait list control group a RCT is currently carried out. Preliminary data, which will be presented, revealed large between effect sizes for the primary outcome measures (PDS, CAPS).

Sequences of emotions in patients with borderline personality disorder

OBJECTIVE

To investigate sequences of emotions (temporal dependence of emotions) to identify specific patterns of borderline personality disorder (BPD).

METHOD

The perceived emotions of 50 BPD patients and 50 healthy controls (HC) were monitored by using a hand-held computer system for a 24-h period in a daily life setting. Participants were prompted four times per hour to assess their current perceived emotions. Differences between BPD patients and HC in terms of activation, persistence and down-regulation of emotions were analyzed.

RESULTS

Healthy controls in contrast to BPD patients more often activated joy and interest. BPD patients more often experienced persistence of anxiety and sadness. BPD patients more frequently switched from anxiety to sadness, from anxiety to anger and from sadness to anxiety. Anger was predominantly preceded by anxiety.

CONCLUSION

Persistence of sadness and anxiety, as well as emotional oscillating between anxiety, sadness and anger are important aspects of the emotional dysregulation in BPD patients.

Oligodipsia and dissociative experiences in borderline personality disorder

OBJECTIVE

To test the frequency of attenuated fluid intake behavior (oligodipsia) in patients with borderline personality disorder (BPD) and to test if there is an inverse correlation between oligodipsia and the intensity of current dissociative experience in a pilot study.

METHOD

Analyses were based on a sample of 15 BPD patients and 15 healthy controls. Fluid intake per diem and intensity of dissociative experience were measured by standardized self-reports daily for 7 days.

RESULTS

The BPD patients ingested a significantly lower fluid volume per diem when compared with healthy controls (P < 0.001). We found a strong correlation between intensity of co-occurring dissociative experience and fluid intake or urine osmolality (r = 0.762 and 0.665), independently of sleep quality and general BPD symptom severity.

CONCLUSION

The results indicate that oligodipsia may constitute a serious problem at least for a subgroup of BPD patients, and may be correlated with some of the most problematic symptoms of BPD.

[Psychopathology and treatment of borderline personality disorder]

Borderline personality disorder (BPD) is a severe psychiatric disorder accounting for about 30% of the total cost for psychiatric inpatient care in the Federal Republic of Germany. Suicidality, self-harm, and severe deterioration of self-esteem lead to chronic suffering for patients and the social environment. With a prevalence rate of 1.5%, BPD is more frequent than schizophrenic disorders. Within the last years, empirically based knowledge concerning the psychopathology, etiopathogenesis, and treatment of BPD have significantly improved. Today most researchers postulate pervasive affective dysregulation at the core of borderline symptomatology and see it as the consequence of an interplay between genetic vulnerability, sociobiographic experience, and dysfunctional behavior. Disorder-specific psychotherapeutic treatments, especially dialectical behavior therapy, show significant improvements in both in- and outpatient settings. Studies on psychopharmacological treatment with promising results have also recently been published. Sufficient outpatient treatment by trained psychotherapists is underdeveloped. Hence, specialized inpatient centers assume this task.

Dissociative symptoms are positively related to stress in borderline personality disorder

OBJECTIVE

According to DSM-IV criteria, dissociative symptoms in borderline personality disorder (BPD) occur in response to stress. Empirical evidence is, however, lacking.

METHOD

Using ambulatory monitoring, we assessed dissociative symptoms and subjective ratings of stress every 60 min for 48 h on a palmtop computer in BPD-patients (n = 51), clinical controls (CC; major depression n = 25; panic disorder n = 26), and healthy controls (HC; n = 40). Data analyses were primarily based on hierarchical linear models.

RESULTS

In all groups, states of increased stress were paralleled by increased scores of dissociation, thus confirming the hypothesized association between stress and dissociation. The increase in dissociation was more pronounced in BPD-patients when compared with CC and HC. Additionally, BPD-patients reported heightened dissociative experience compared with CC and HC, even after controlling for stress.

CONCLUSION

Our data suggest that BPD-patients might be prone to dissociation when experiencing stress and are characterized by a generally heightened level of dissociation.

Evidence of disturbed amygdalar energy metabolism in patients with borderline personality disorder

In order to detect possible links between structural and neurochemical brain abnormalities we applied high resolution morphometric imaging and short-echo time absolute-quantification magnetic resonance spectroscopy (MRS) at the left hand side to the amygdala in 12 patients with borderline personality disorder (BPD) and 10 group-matched healthy controls. Confirming earlier reports we found a significant 11-17% reduction of amygdalar volumes in patients with BPD. In addition there was a significant 17% increase of left amygdalar creatine concentrations in BPD patients. Left amygdalar creatine concentration correlated positively with measures of anxiety and negatively with amygdalar volume. This pilot study of simultaneous amygdalar morphometry and spectroscopy in BPD reveals a possible link between amygdalar volume loss, psychopathology and neurochemical abnormalities in terms of creatine signals.

Schmerzverarbeitung bei Borderline-Persönlichkeitsstörung, Fibromyalgie und Posttraumatischer Belastungsstörung

The authors review relevant experimental studies on pain perception and processing in psychiatric disorders with traumatic stress as an etiological factor. In borderline personality disorder, post-traumatic stress disorder, and fibromyalgia neurophysiological and neuropsychological patterns of pain processing appear to be different. Experimental studies in borderline patients show a desensitization of pain thresholds whereas patients with fibromyalgia show an opposite pattern, which could be explained by a central augmentation of pain processing. Furthermore, the authors outline methods to assess pain perception (peripheral and central) and describe the neurobiological mechanisms of pain processing, particularly the distinction between the sensory-discriminative lateral system and the affective-motivational medial system. Finally, suggestions for further research and implications for therapy are proposed.

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

OBJECTIVE

This study was designed to examine the subjective appraisal of aversive tension under conditions of daily life in patients with borderline personality disorder (BPD).

METHOD

A sample of 63 female subjects with BPD and 40 mentally healthy controls were each given a hand-held computer. For two consecutive days, participants were prompted at hourly intervals to record their current state of aversive tension and prompting events.

RESULTS

Compared with controls, states of aversive tension occurred significantly more frequently in BPD patients. The average levels of aversive tension were significantly higher, and the rate of increase in tension was markedly more rapid. Furthermore, states of aversive tension persisted for a longer period. Among BPD subjects three events (rejection, being alone, and failure) account for 39% of all events preceding states of tension.

CONCLUSION

The study provides support for the theory that patients with BPD experience more frequent, stronger, and longer-lasting states of aversive tension.

A voxel-based morphometric MRI study in female patients with borderline personality disorder

Subtle prefrontal and limbic structural abnormalities have been reported in borderline personality disorder (BPD). In order to further validate the previously reported findings and to more precisely describe the nature of the structural change we performed a voxel-based morphometric (VBM) study in patients with BPD. Twenty female patients with BPD and 21 female healthy controls were investigated. High-resolution 3-D datasets were acquired and analyzed following an optimized protocol of VBM in the framework of statistical parametric mapping (SPM99). Gray matter volume loss was found in the left amygdala. No other differences in gray or white matter volume or density were found anywhere else in the brain. Our findings support the hypothesis that temporolimbic abnormalities play a role in the pathophysiology of BPD. Prefrontal structural alterations in BPD were not observed in this study.

Positron emission tomography in female patients with borderline personality disorder

The pathology of Borderline personality disorder (BPD) is poorly understood and its biological basis remains largely unknown. One functional brain imaging study using [(18)F]Deoxyglucose-PET previously reported frontal and prefrontal hypometabolism. We studied brain metabolism at baseline in 12 medication-free female patients with BPD without current substance abuse or depression and 12 healthy female controls by [(18)F]Deoxyglucose-PET and statistical parametric mapping. We found significant frontal and prefrontal hypermetabolism in patients with BPD relative to controls as well as significant hypometabolism in the hippocampus and cuneus. This study demonstrated limbic and prefrontal dysfunction under resting conditions in patients with BPD by FDG-PET. Dysfunction in this network of brain regions, which has been implicated in the regulation of emotion, may underlie symptoms of BPD.

Subtle prefrontal neuropathology in a pilot magnetic resonance spectroscopy study in patients with borderline personality disorder

The authors examined the brains of patients with borderline personality disorder (BPD) by using short echo time single voxel spectroscopy and found a significant 19% reduction of absolute N-acetylaspartate concentrations in the dorsolateral prefrontal cortex in BPD (P=0.01) compared with control subjects.

[Symptom-focussed drug therapy in borderline personality disorder]

Borderline Personality Disorder (BPD) is a common and serious psychiatric illness. Psychopathological symptoms often are heterogenous and difficult to influence. Psychotherapy stands in the core of treatment efforts. However, during the treatment of these patients often situations occur that make the use of drug treatment necessary. Symptoms such as depression, impulsivity, or dissociation can be difficult to deal with in this population. There appears to be no treatment of choice for the disorder as a whole. Reviews so far have organized the literature by groups of pharmacological agents. In this review we give an overview over psychopathological symptoms in BPD, i.e. depression, affective dysregulation, aggression, impulsivity, dissociation, self-injuries, suicidality, psychotic symptoms, anxiety, obsessions and compulsions, and sleep disturbance. Effectivity of different drugs in influencing these symptoms is presented and significances of findings are used to assess the relevance of these findings. We conclude that certain symptoms such as depression or impulsivity can be successfully treated. Serotonin reuptake inhibitors play a decisive role in pharmacological treatment of Borderline Personality Disorder. Finally, recommendations for effective drug treatment of BPD symptoms are presented. Comorbid depression should be treated with Selective Serotonin Reuptake Inhibitors. These substances could also be shown to be effective in the treatment of impulsive and aggressive behavior. Intermittent psychotic symptoms are a target for atypical neuroleptics. Benzodiazepines are no longer viewed to be useful in the treatment of BPD.

[Examination of body concept of female patients with borderline personality disorder]

The operationalized diagnosis of borderline personality disorder (BPD) by DSM-IV and ICD-10 (research criteria) is meanwhile considered as valid and reliable. A disturbed or inappropriate body image within the group of borderline patients is not assessed by these instruments. Using the "Frankfurter Körperkonzeptskalen" [6], we compared the body concept of 47 female patients with BPD with a group of patients with the diagnosis of Bulimia nervosa and with a representative sample of healthy subjects. We found highly significant differences between patients with BPD and the clinical controls as well as to the norm group. Neither dissociative symptoms nor sexual child abuse correlate with the extent of the negative body concept. Correlations between self-concept (Giessen-Test) and body concept as well as clinical implications of these findings are discussed.

[Development of the Borderline Symptom List]

The categorical diagnosis of borderline personality disorder (BPD) is currently discussed as sufficiently reliable and valid. However, specific standardized instruments to measure the degree of the symptomatology are currently not available. Based on the criteria of DSM-IV, the Diagnostic Interview for Borderlines (DIB-R) and the opinion of clinical experts and borderline-patients, a self-rating scale was developed to quantify the intrapsychic strain of patients with BPD. 308 female borderline-patients scored the 99 items. Factor analyses revealed seven factors: self-image, affect regulation, autoaggression, dysthymia, social isolation, intrusions and hostility. Analyses of reliability and validity revealed promising results.

Experience of aversive tension and dissociation in female patients with borderline personality disorder -- a controlled study

Assuming that the experience of strong aversive tension might be an indicator of the extent of affect dysregulation within patients with borderline personality disorder (BPD), we sought to operationalize the duration and intensity of these phenomena. In addition we studied the relationship between aversive tension and the experience of dissociative features. Seventy-two female patients with BPD, together with 55 healthy controls, completed a self-rating questionnaire covering the previous 24 h. Substantial and highly significant differences with regard to the duration and intensity of the subjectively perceived states of aversive tension were found. Amongst patients with BPD there was a strong correlation between duration and intensity of tension, and experience of dissociative features, both somatoform and psychological. The findings underline the clinical importance of states of aversive tension in BPD particularly with regard to stress-related induction of dissociative features.

Pain perception during self-reported distress and calmness in patients with borderline personality disorder and self-mutilating behavior

Self-mutilation occurs in 70-80% of patients who meet DSM-IV criteria for borderline personality disorder. Approximately 60% of these patients report that they do not feel pain during acts of self-mutilation such as cutting or burning. Findings of recent studies measuring pain perception in patients with BPD are difficult to interpret since variables such as distress, dissociation or relevant psychotropic medication have not been controlled. The Cold Pressor Test (CPT) and the Tourniquet Pain Test (TPT) were administered to 12 female patients with BPD who reported analgesia during self-mutilation and 19 age-matched healthy female control subjects. All subjects were free of psychotropic medication. The patients were studied on two occasions: during self-reported calmness and during intensive distress (strong urge to cut or burn themselves). Even during self-reported calmness, patients with BPD showed a significantly reduced perception of pain compared to healthy control subjects in both tests. During distress, pain perception in BPD patients was further significantly reduced as compared with self-reported calmness. The present findings show that self-mutilating patients with BPD who experience analgesia during self-injury show an increased threshold for pain perception even in the absence of distress. This may reflect a state-independent increased pain threshold which is further elevated during stress. Interpretation of these findings is limited by their reliance upon self-reports.

Evaluation of inpatient dialectical-behavioral therapy for borderline personality disorder--a prospective study

Dialectical-Behavioral Therapy for Borderline Personality Disorder (DBT) developed by M. Linehan is specifically designed for the outpatient treatment of chronically suicidal patients with borderline personality disorder. Research on DBT therapy, its course and its results has focused to date on treatments in an outpatient setting. Hypothesizing that the course of therapy could be accelerated and improved by an inpatient setting at the beginning of outpatient DBT, we developed a treatment program of inpatient therapy for this patient group according to the guidelines of DBT. It consists of a three-month inpatient treatment prior to long-term outpatient therapy. In this pilot study 24 female patients were compared at admission to the hospital, and at one month after discharge with respect to psychopathology and frequency of self-injuries. Significant improvements in ratings of depression, dissociation, anxiety and global stress were found. A highly significant decrease in the number of parasuicidal acts was also reported. Analysis of the average effect sizes shows a strong effect which prompts the development of a randomized controlled design.

[Recent developments in systematic evaluation of the therapeutic process. Scales for the assessment of adherence and competence]

The assessment of therapists' behaviour an essential part of psychotherapy research, especially for controlling the validity of studies. In the last decade, particularly in English-speaking countries, research has been developed that studied two constructs important in this context: adherence and competence. Adherence refers to the extent to which therapists use the strategies recommended in a therapy manual; competence refers to the quality of the use of these strategies. This article is a review of research associated with adherence and competence scales and its relevance. First of all, definitions and examples of use are presented and discussed. Secondly, some of the most important scales that have been developed in this context are described. Thirdly, aspects of realisation are presented. Finally, the pros and cons of this type of research are discussed. It is argued that despite some problems adherence and competence scales are a significant contribution to the systematic assessment of therapist behaviour.

[Treatment of dissociative symptoms in borderline patients with naltrexone]

Dissociative symptoms including flashbacks, i.e. vivid scenic recollections of traumatic episodes, in patients with Borderline Personality Disorder are a serious and often treatment-refractory problem. There is evidence suggesting changes in endogenous opioids in patients with Borderline Personality Disorder. Naltrexone, an opioid receptor antagonist, was administered to three female patients with Borderline Personality Disorder in a dosage of 50 mg (q.i.d.,p.o.) over several weeks. We observed a marked reduction in dissociative symptoms.

[The treatment history of patients with borderline personality disorder in the Republic of Germany]

The present study was undertaken to explore the treatment history of women with borderline personality disorder and to provide an estimation of the treatment costs. Using a semi-structured interview, forty-five carefully diagnosed patients were interrogated about their lifetime treatment history with respect to every inpatient and outpatient treatment received for any psychical symptoms, including physical treatment after self-injurious behaviour. Results demonstrate an extensive and protracted use of psychiatric, psychotherapeutic and physical help, and a chaotic course of treatment with discontinuance of treatments as a characteristic feature. Treatment costs were estimated at a minimum of 24,000 DM per year and patient; 22,000 DM due to hospitalisations. The unsatisfactory treatment situation for these patients in the public health system and the socioeconomic advantages of a specified treatment programme are discussed.

[Children of mentally ill parents. A study of problem awareness in clinical routine practice]

The risk of developing clinically relevant psychiatric disorders in the lifetime course is significantly greater among children of mentally ill parents. A child-adapted programme of information concerning the nature and symptomatology of parental illness is considered to be an important preventive factor, and lies within the domain of the psychiatrist's or therapist's responsibilities. During the developmental phase of a prevention project at Freiburg University's Department of Psychiatry and Psychotherapy, both clinical practice and the level of problem awareness among patients and the therapists were evaluated. Over a period of one year, consecutive interviews involving 114 patients with children under 18 years of age, as well as their respective therapists, were conducted. The results showed that: scarcely any exchanges between children and therapists took place; the extent to which children are informed about parental illness must be considered as small; a high percentage of such children are already evaluated by their parents as disturbed, and the pressing need for support exists.

White matter lesions in patients with idiopathic normal pressure hydrocephalus and in an age-matched control group: a comparative study

OBJECTIVE

To compare the occurrence of periventricular lesions (PVLs) and deep white matter lesions (DWMLs) in elderly patients with idiopathic normal pressure hydrocephalus (NPH) and in an age-matched control group.

METHODS

PVLs and DWMLs were evaluated using T2-weighted magnetic resonance scans of 37 patients with idiopathic NPH and 35 participants from an age-matched control group. All patients with idiopathic NPH included in this study improved after shunting. The control group consisted of 16 healthy elderly persons and 19 patients with depression. To allow quantitative assessment and comparison, scores for PVLs and DWMLs were calculated. Furthermore, possible correlations between white matter lesion scores, ventricular width, and age were investigated.

RESULTS

There was a significantly higher incidence of PVLs and DWMLs in patients with idiopathic NPH. The mean total PVL was 12.1 (range, 2-24) in the NPH group and 3.9 (range, 0-10) in the control group (P < 0.001). The mean total DWML score was 12.9 (range, 3-24) in the NPH group and 4.5 (range, 0-16) in the control group (P < 0.001). There were significant correlations between the severity of PVL and DWML scores in both groups. Only a weak positive correlation between the severity of DWMLs and age was found in the NPH group, whereas this correlation was significant in the control group. There was a significant negative correlation between the width of the anterior horns and the severity of both PVLs and DWMLs in patients with NPH; however, positive correlations were found in the control group.

CONCLUSION

Elderly patients with idiopathic NPH have more frequent and more severe PVLs and DWMLs than people in age-matched control groups. Our data suggest a frequent co-occurrence of idiopathic NPH and vascular subcortical encephalopathy; however, they do not support a direct causal relationship.

Can negative self-schemes in depressives be altered through sleep deprivation?

This paper addresses the question whether negative cognitive style represents a state or trait variable of depressive patients. For this reason, it studies the influence of sleep deprivation on negative self-schemes of those patients. 10 patients suffering from DSM-III-R major depression were compared with 10 age- and sex-matched controls on a task for rating the self-descriptiveness of positive and negative adjectives as well as a subsequent word recognition task. Three sessions were involved: an initial session (baseline), the second following a night of sleep deprivation, and the third after a successive full night's sleep. During the baseline examination, depressives showed a relatively negative cognitive bias; that is, the same number of positive and negative self-scheme elements. In comparison to controls, they showed significantly more negative and significantly less positive self-scheme elements. The same pattern emerged in a word recognition task for the number of recognized self-scheme elements. These variables indicated no change in the depressive group following sleep deprivation. Depressive subjects' reaction times on self-descriptiveness rating were significantly longer for positive than for negative self-scheme elements at the baseline session. The opposite was true for controls. Here, a sleep deprivation effect was evident. There was no longer a difference in the speed of information processing for positive as compared to negative self-scheme elements. This applied to both depressive and control groups.

Premorbid personality in patients with uni- and bipolar affective disorders and controls: assessment by the Biographical Personality Interview (BPI)

The relationship between premorbid personality and subtypes of affective disorder was investigated by means of the Biographical Personality Interview (BPI) and by a self-rating scale. Interviewer and rater (BPI) were blind to diagnosis. A total of 52 patients with unipolar depression or bipolar II disorder (D/Dm), 32 bipolar-I patients (DM) and 39 control subjects (C) were examined. Expert rating of "typus melancholicus" features (BPI) were found to be more pronounced in D/Dm than in DM and C. "Typus manicus" features were also distinguished between both clinical groups, whereas anxious-insecure features were not significantly different between the groups of patients. In contrast to the expert-rated personality variants, self-rating of personality features did not reveal any significant differences between the two clinical groups. Potential sources of the discrepancies between the questionnaire data and the interview data are discussed. It is concluded that premorbid features of "typus manicus" and "typus melancholicus" predicted, respectively, a predominant manic and a predominant depressive course of an affective disorder.