Identity disturbance in borderline personality disorder: an empirical investigation

Detecting the Presence of a Personality Disorder Using Interpersonal and Self-Dysfunction

Calls have increased to place interpersonal and self-disturbance as defining features of personality disorders (PDs). Findings from a methodologically diverse set of studies suggest that a common factor undergirds all PDs. The nature of this core of PDs, however, is not clear. In the current study, interviews were completed for DSM-IV PD diagnosis and interpersonal dysfunction independently with 272 individuals (PD = 191, no-PD = 91). Specifically, we evaluated interpersonal dysfunction across social domains. In addition, we empirically assessed the structure of self-dysfunction in PDs. We found dysfunction in work and romantic domains, and unstable identity uniquely predicted variance in the presence of a PD. Using receiver operating characteristic analysis, we found that the interpersonal dysfunction and self-dysfunction scales each predicted PDs with high accuracy. In combination, the scales resulted in excellent sensitivity (.90) and specificity (.88). The results support interpersonal and self-dysfunction as general factors of PD.

Autobiographical memories, identity disturbance and brain functioning in patients with borderline personality disorder: An fMRI study

Identity disturbance is a core feature of borderline personality disorder (BPD). Autobiographical memory is a process of reflective thinking through which we form links between elements of life and self. It can be considered as an indirect index of identity integration. The present study was aimed to investigate the differences in brain activity patterns between BPD patients with identity diffusion and healthy controls using fMRI. We enrolled 24 BPD patients and 24 healthy controls. Identity integration in patients and controls was assessed with the Identity Disturbance Questionnaire (IDQ) score and was significantly different (p = 0.001). We analysed hemodynamic response in the regions of interest during presentation of resolved and unresolved life events. With reference to the condition "resolved", increased cerebral activity in right anterior cingulate cortex (ACC), right medial prefrontal cortex (MPFC), right dorsolateral prefrontal cortex (DLPFC), and bilateral insula was registered in BPD patients compared with controls. In the condition "unresolved", increased brain activity was observed in patients in bilateral ACC, bilateral DLPFC, and right temporo-parietal junction. Hyperactivity in ACC and DLPFC in BPD patients with both conditions (resolved and unresolved contexts) may be due to an inefficient attempt to reconstruct a coherent narrative of life events (resolved or not).

Personal and parents' life stories in patients with borderline personality disorder

Patients with borderline personality disorder (BPD) display disturbances in understanding self and others. We examined whether these disturbances extended to how patients described their personal and parents' life stories and to measures of identity, alexithymia, empathy, and emotional intelligence. Thirty BPD patients and 30 matched control participants described personal and parents' life stories and completed measures of identity disturbance, alexithymia, empathy, and emotional intelligence. Compared to the controls, patients with BPD described their personal and their parents' life stories more negatively and with fewer themes of agency and communion fulfillment. Patients and controls showed equally complex reasoning about their personal life stories, but patients displayed less complexity and more self-other confusion, when reasoning about their parents' stories. Patients also differed from controls on identity disturbance, alexithymia, and empathy. The results suggest that patients' storied understanding of themselves and others are disturbed and should be taken into account to better understand BPD.

Facets of identity disturbance reported by patients with borderline personality disorder and personality-disordered comparison subjects over 20 years of prospective follow-up

This study had two objectives. The first was to determine the levels of identity disturbance reported by 290 patients with borderline personality disorder (BPD) and 72 personality-disordered comparison subjects over 20 years of prospective follow-up. The second aim was to describe the levels of identity disturbance reported by 152 ever recovered vs. 138 never recovered borderline patients over 20 years of prospective follow-up. Participants were followed and re-assessed every two years for a total of 20 years of follow-up. Borderline patients reported levels of these states that were more than three times higher than personality-disordered comparison subjects, with both groups demonstrating significant declines in these states over time. For three of these inner states ("I feel like I am worthless," "I feel like a complete failure," and "I feel like I am evil"), recovered borderline patients had lower baseline scores and significantly different patterns of decline than non-recovered patients. For the fourth state, "I feel like I am a bad person," recovered patients had lower scores over time, but the groups declined at the same rate. These results suggest that borderline patients report experiencing inner states related to having a negative identity less often over time. Additionally, recovery status is significantly associated with decreased time experiencing these states.

Biological and Behavioral Mechanisms of Identity Pathology Development: An Integrative Review

Although identity disturbance is a transdiagnostic mental health problem, modern explanatory models for its emergence are limited. To date, the social, developmental, clinical, and neuropsychological literatures exploring identity processes are also largely disconnected. Existing theories have laid the foundation for understanding important components of identity pathology, yet many overlook biological, behavioral, and interactive processes by which these difficulties may emerge. In this integrative review, we explore how broad transdiagnostic vulnerabilities for psychopathology and more specific risky behavioral processes may reciprocally interact and be refined over time into an identity disturbance profile. Our primary purpose is to review behavioral and biosocial theories and derive a testable conceptual framework for how identity disturbance emerges over the course of development. We aim to describe and integrate several disparate lines of theory and research in order to illuminate potential etiological pathways to identity pathology.

Borderline personality disorder: does its clinical features show specificity to differing developmental risk factors?

OBJECTIVES

To determine if differing developmental factors show specificity to differing manifestations of borderline personality disorder (BPD).

METHODS

A clinical sample of 73 females diagnosed with BPD undertook a psychiatrist interview and completed self-report questionnaires, including the semi-structured Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV) assessing for BPD status. A set of negative and potentially traumatic developmental factors were included in the assessment.

RESULTS

Childhood sexual abuse, affirmed by 49% of the sample, showed specificity in being linked with DIPD-defined affective instability. DIPD-defined identity disturbance also showed specificity in being associated only with reporting significant non-sexual developmental trauma. DIPD-defined anger and paranoia/dissociation showed minimal specificity and were associated with most antecedent developmental factors in adulthood.

CONCLUSIONS

Differing manifestations of BPD are likely to be shaped by specific and non-specific developmental events. Clarification of such links has the potential to shape more specific therapeutic interventions.

Borderline personality disorder and sexual abuse: A systematic review

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

Elucidating DSM-5 and ICD-11 Diagnostic Features of Borderline Personality Disorder Using Schemas and Modes

BACKGROUND

Borderline personality disorder (BPD) comprises a heterogeneous constellation of problems operationalized in the DSM-5 and the forthcoming ICD-11. In schema therapy, schemas and modes are employed to conceptualize and treat these problems.

AIM

The current study investigated whether the 9 diagnostic BPD features are associated with schemas and modes.

METHOD

Psychiatric outpatients with predominant BPD features (n = 142; 68% females) were administered the Structured Clinical Interview for DSM-IV Axis II (SCID-II) and self-report inventories for schemas and modes. Associations were investigated by means of bivariate point-biserial correlations and multiple logistic regression analysis.

RESULTS

BPD features were largely associated with conceptually related schemas and modes. Consistent with the schema therapy literature and previous research, we found schemas of Abandonment/Instability and Mistrust/Abuse along with modes of Angry/Enraged Child, (internalized) Punitive Parent, and Impulsive Child to uniquely predict thematically related BPD features including fear of abandonment, self-destructiveness, feelings of emptiness, stress-related paranoid ideation, inappropriate anger, and impulsivity.

CONCLUSION

Most of the 9 BPD features were related to conceptually meaningful schemas/modes, suggesting that BPD is composed of dormant themes along with salient affective-behavioral responses. Consequently, individual BPD features may be differentially conceptualized and targeted in therapy by means of schemas and modes.

The Role of Negative Affect and Self-Concept Clarity in Predicting Self-Injurious Urges in Borderline Personality Disorder Using Ecological Momentary Assessment

Deficits in identity as well as negative affect have been shown to predict self-injurious and suicidal behaviors in individuals with borderline personality disorder (BPD). However, less is known about the interactive effects of these two predictors. We examined the moderating effect of a particular component of identity, self-concept, on the relationship between negative affect and self-injurious urges utilizing ecological momentary assessments. Outpatients diagnosed with either BPD (n = 36) or any anxiety disorder but no BPD (n = 18) completed surveys throughout the day over a 21-day period. Higher levels of momentary negative affect predicted greater subsequent urges to self-injure, but only when self-concept clarity was low (z = -3.60, p < .01). This effect did not differ between diagnostic groups. The results suggest that self-concept clarity has a protective effect against self-injurious urges in light of high negative affect, and that this effect may be transdiagnostic.

Mentalizing and interpersonal problems in borderline personality disorder: The mediating role of identity diffusion

Individuals with borderline personality disorder (BPD) are characterized by problems in interpersonal functioning and their long-term social integration often remains problematic. Extant theories have linked identity diffusion to many of the interpersonal problems characteristic of BPD patients. Recent theoretical accounts have suggested that identity diffusion results from problems with mentalizing or reflective functioning, that is, the capacity to understand oneself and others in terms of intentional mental states. In this study we tested these assumptions, i.e., whether identity diffusion plays a mediating role in the relationship between mentalizing difficulties and interpersonal problems, in a sample of 167 BPD patients. Highly significant correlations were found between mentalizing impairments, identity diffusion and interpersonal problems. Mediation analyses showed that identity diffusion fully mediated the relationship between mentalizing difficulties and interpersonal problems. This study provides preliminary evidence that impairments in mentalizing are related to identity diffusion, which in turn is related to interpersonal problems in BPD. Further longitudinal research is needed to further substantiate these conclusions.

Awareness of identity alteration and diagnostic preference between borderline personality disorder and dissociative disorders

AIM

This study inquires into identity alteration among college students and its relationship to borderline personality disorder (BPD) and/or dissociative disorders (DDs).

METHODS

Steinberg Identity Alteration Questionnaire (SIAQ), Childhood Trauma Questionnaire (CTQ), and self-report screening tool of the BPD section of the Structured Clinical Interview for DSM-IV (SCID-BPD) were administered to 1301 college students. Participants who fit the diagnostic criteria of BPD (n = 80) according to the clinician-administered SCID-BPD and 111 non-BPD controls were evaluated using the Structured Clinical Interview for DSM-IV DDs (SCID-D) by two psychiatrists blind to the group membership and scale scores.

RESULTS

Test-retest evaluations and internal consistency analyses suggested that SIAQ was a reliable instrument. Of the participants, 11.3% reported a SIAQ score 25 or above alongside some impairment. SIAQ scores differentiated participants who fit the diagnostic criteria for a DD from those who did not. While self-report identity alteration was correlated with all childhood trauma types, clinician-assessed identity alteration was correlated with childhood sexual abuse only. Those who fit criteria for both disorders had the highest identity alteration scores in self-report and clinician-assessment. Although both syndromes had significant effect on self-report identity alteration total scores, in contrast to DD, BPD did not have an effect on the clinician-administered evaluation.

CONCLUSION

An impression of personality disorder rather than a DD may seem more likely when identity alteration remains subtle in clinical assessment, notwithstanding its presence in self-report. Lack of recognition of identity alteration may lead to overdiagnosis of BPD among individuals who have a DD.

Self and identity in borderline personality disorder: Agency and mental time travel

We consider how conceptions of the self and identity from the philosophical literature can help us to understand identity disturbance in borderline personality disorder (BPD). We present 3 philosophical approaches: connectedness, narrative, and agency. We show how these map on to 3 different ways in which the self can be temporally extended. The connectedness approach is dominant in philosophy, and the narrative approach has been used by psychiatry, but we argue that the lesser-known agency approach provides a promising way to theorize some aspects of identity disturbance in BPD. It relates the 2 diagnostic criteria of identity disturbance and disinhibition and is consistent with evidence of memory deficits and altered self-processing in BPD patients.

Identity: Recent Findings and Clinical Implications

After a review of foundational contributions to the concept of identity, including Erikson's, the author discusses the research methods and findings of the Personality Disorders Institute of the Joan and Sanford I. Weill Medical College of Cornell University regarding the concepts of normal identity and identity diffusion, toward an elucidation of the psychopathology of personality disorders--their etiology, diagnosis, and treatment. The application of an object relations theory model to analyze the development of identity clarifies the relationship of individual identity with the social and cultural frame that influences identity formation and may amplify the effects of pathological identity development. Detailed excerpts are presented from a diagnostic structural interview at the Personality Disorders Institute.

Sexual Orientation Self-Concept Ambiguity: Scale Adaptation and Validation

The current article describes the adaptation of a measure of sexual orientation self-concept ambiguity (SSA) from an existing measure of general self-concept clarity. Latent "trait" scores of SSA reflect the extent to which a person's beliefs about their own sexual orientation are perceived as inconsistent, unreliable, or incongruent. Sexual minority and heterosexual women ( n = 348), ages 18 to 30, completed a cross-sectional survey. Categorical confirmatory factor analysis guided the selection of items to form a 10-item, self-report measure of SSA. In the current report, we also examine (a) reliability of the 10-item scale score, (b) measurement invariance based on respondents' sexual identity status and age group, and (c) correlations with preexisting surveys that purport to measure similar constructs and theoretical correlates. Evidence for internal reliability, measurement invariance (based on respondent sex), and convergent validity was also investigated in an independent, validation sample. The lowest SSA scores were reported by women who self-ascribed an exclusively heterosexual or exclusively lesbian/gay sexual identity, whereas those who reported a bisexual, mostly lesbian/gay, or mostly heterosexual identity, reported relatively higher SSA scores.

Self-Control Capacity as a Predictor of Borderline Personality Disorder Features, Problematic Drinking, and Their Co-occurrence

Borderline personality disorder (BPD) and alcohol use disorder (AUD) share impulsivity as an etiological factor. However, impulsivity is ill-defined, often overlapping with self-control capacity. This study attempts to disentangle these constructs and their associations with alcohol use and BPD. Undergraduates (n = 192) completed the Five Factor Model Rating Form, which generated two-dimensional scales of BPD, the Self-Control Scale, the UPPS-P (self-reported impulsivity), and the stop-signal and delay discounting tasks (laboratory-measured impulsivity). Self-control appeared as a major predictor of BPD features and drinking, explaining as much or more variance in outcome than impulsivity. Co-occurrence of elevated BPD features and problem drinking was also best explained by self-control. Laboratory measures of impulsivity were not correlated with BPD scales or alcohol use. Self-regulatory capacity may be an important but overlooked factor in BPD and alcohol use and should be considered alongside impulsivity in future research.

Bioelectrical brain effects of one's own voice identification in pitch of voice auditory feedback

Control of voice fundamental frequency (F0) relies in part on comparison of the intended F0 level and auditory feedback. This comparison impacts "sense of agency", or SoA, commonly defined as being the agent of one's own actions and plays a key role for self-awareness and social interactions. SoA is aberrant in several psychiatric disorders. Knowledge about brain activity reflecting SoA can be used in clinical practice for these disorders. It was shown that perception of voice feedback as one's own voice, reflecting the recognition of SoA, alters auditory sensory processing. Using a voice perturbation paradigm we contrasted vocal and bioelectrical brain responses to auditory stimuli that differed in magnitude: 100 and 400 cents. Results suggest the different magnitudes were perceived as a pitch error in self-vocalization (100 cents) or as a pitch shift generated externally (400 cents). Vocalizations and neural responses to changes in pitch of self-vocalization were defined as those made to small magnitude pitch-shifts (100 cents) and which did not show differential neural responses to upward versus downward changes in voice pitch auditory feedback. Vocal responses to large magnitude pitch shifts (400 cents) were smaller than those made to small pitch shifts, and neural responses differed according to upwards versus downward changes in pitch. Our results suggest that the presence of SoA for self-produced sounds may modify bioelectrical brain responses reflecting differences in auditory processing of the direction of a pitch shift. We suggest that this modification of bioelectrical response can be used as a biological index of SoA. Possible neuronal mechanisms of this modification of bioelectrical brain response are discussed.

Interpersonal dysfunction in personality disorders: A meta-analytic review

Personality disorders are defined in the current psychiatric diagnostic system as pervasive, inflexible, and stable patterns of thinking, feeling, behaving, and interacting with others. Questions regarding the validity and reliability of the current personality disorder diagnoses prompted a reconceptualization of personality pathology in the most recent edition of the psychiatric diagnostic manual, in an appendix of emerging models for future study. To evaluate the construct and discriminant validity of the current personality disorder diagnoses, we conducted a quantitative synthesis of the existing empirical research on associations between personality disorders and interpersonal functioning, defined using the interpersonal circumplex model (comprising orthogonal dimensions of agency and communion), as well as functioning in specific relationship domains (parent-child, family, peer, romantic). A comprehensive literature search yielded 127 published and unpublished studies, comprising 2,579 effect sizes. Average effect sizes from 120 separate meta-analyses, corrected for sampling error and measurement unreliability, and aggregated using a random-effects model, indicated that each personality disorder showed a distinct profile of interpersonal style consistent with its characteristic pattern of symptomatic dysfunction; specific relationship domains affected and strength of associations varied for each personality disorder. Overall, results support the construct and discriminant validity of the personality disorders in the current diagnostic manual, as well as the proposed conceptualization that disturbances in self and interpersonal functioning constitute the core of personality pathology. Importantly, however, contradicting both the current and proposed conceptualizations, there was not evidence for pervasive dysfunction across interpersonal situations and relationships. (PsycINFO Database Record

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.

The wandering mind in borderline personality disorder: Instability in self- and other-related thoughts

Diagnostic criteria for borderline personality disorder (BPD) include instability in identity and interpersonal relationships. Here, we probed whether instability is already present in BPD patients' thoughts about themselves and others. We tested BPD patients (N=27) and healthy controls (N=25) with a mind-wandering task that assesses content and variability of stimulus-independent self-generated thoughts. Multi-level modeling revealed that while BPD patients and healthy controls mind-wander to a similar extent, BPD patients' thoughts are colored predominantly negatively. Most importantly, although their thoughts concerned the self and others as much as in controls, they fluctuated more strongly in the degree to which their thoughts concerned themselves and others and also gave more extreme ratings. Self- and other related thoughts that were more extreme were also more negative in valence. The increased variability supports current conceptualizations of BPD and may account for the instability in identity and interpersonal relationships.

Self and identity in women with symptoms of borderline personality: A qualitative study

Identity disturbance has been suggested to be a core feature of borderline personality disorder (BPD). However, there is little known about the identity of individuals with symptoms of BPD from the participant's perspective. This study availed of in-depth lightly structured life story interviews with five female participants. Thematic analysis was utilized to derive three themes of identity: connection, distance between us, and hurt and healing. Results provided support for multiple and flexible conceptualizations of identity in comparison to the idea of a unitary self/identity. Results also suggested that participants were able to establish differing connections to others ranging from disconnection to intimacy and care. Participants reported that their identities were impacted upon by historical and current family/relationship dysfunction, but life stories also illustrated the positive impact of healing relationship experiences. Findings provide support for psychological theories that consider a multiple and relational self/identity and the empowerment of healthy aspects of the self in BPD recovery. Studies that assess the association between insight and change may further our knowledge into this complex population.

The specificity of mental pain in borderline personality disorder compared to depressive disorders and healthy controls

BACKGROUND

Individuals with Borderline Personality Disorder (BPD) may experience a qualitatively distinct depression which includes "mental pain." Mental pain includes chronic, aversive emotions, negative self-concept, and a sense of pervasive helplessness. The present study investigated whether mental pain is elevated in BPD compared to Depressive Disorders (DD) without BPD.

METHODS

The Orbach and Mikulincer Mental Pain Scale (OMMP) was administered to BPD (N = 57), DD (N = 22), and healthy controls (N = 31). The OMMP assesses total mental pain, comprised of nine subtypes: irreversibility, loss of control, narcissistic wounds, emotional flooding, freezing, self-estrangement, confusion, social distancing, and emptiness. Co-occurring psychiatric diagnoses, depression severity, and other potentially confounding clinical and demographic variables were also assessed.

RESULTS

The total Mental Pain score did not differentiate BPD from DD. Moreover, most of the subscales of the OMMP were not significantly different in BPD compared to DD. However, the elevation of mental pain subscale "narcissistic wounds," characterized by feeling rejected and having low self-worth, was a specific predictor of BPD status and the severity of BPD symptoms.

CONCLUSION

On OMMP total score, mental pain was similarly elevated in BPD and DD. However, the narcissistic wounds sub-type of mental pain was a sensitive and specific diagnostic indicator of BPD and, therefore, may be an important aspect of BPD in need of increased focus in assessment and theoretical models.

Social feedback processing in borderline personality disorder

BACKGROUND

Patients with borderline personality disorder (BPD) show negative and unstable self- and other-evaluations compared to healthy individuals. It is unclear, however, how they process self- and other-relevant social feedback. We have previously demonstrated a positive updating bias in healthy individuals: When receiving social feedback on character traits, healthy individuals integrate desirable more than undesirable feedback. Here, our aim was to test whether BPD patients exhibit a more negative pattern of social feedback processing.

METHOD

We employed a character trait task in which BPD patients interacted with four healthy participants in a real-life social interaction. Afterwards, all participants rated themselves and one other participant on 80 character traits before and after receiving feedback from their interaction partners. We compared how participants updated their ratings after receiving desirable and undesirable feedback. Our analyses included 22 BPD patients and 81 healthy controls.

RESULTS

Healthy controls showed a positivity bias for self- and other-relevant feedback as previously demonstrated. Importantly, this pattern was altered in BPD patients: They integrated undesirable feedback for themselves to a greater degree than healthy controls did. Other-relevant feedback processing was unaltered in BPD patients.

CONCLUSIONS

Our study demonstrates an alteration in self-relevant feedback processing in BPD patients that might contribute to unstable and negative self-evaluations.

Borderline Personality Disorder and Automatic Processing of Valence and Self-Other Relevance Information

BACKGROUND

Enhanced sensitivity to emotion stimuli and poor differentiation between self and others have been proposed to be important features of borderline personality disorder (BPD). Automatic processing of affective stimuli provides information about valence (positive vs. negative) and relevance of valence (self vs. other). The objectives of our study were to investigate the efficiency of automatic processing of valence and relevance at a semantic level in BPD compared to healthy individuals.

SAMPLING AND METHODS

A masked affective priming task, varying the valence and relevance of prime and target adjectives, was administered to 33 women with BPD and 33 healthy women. The forward and backward masked primes were shown for 50 ms. Subjects had the task of evaluating target words.

RESULTS

In the whole sample, a significant affective priming effect and a significant relevance priming effect occurred. BPD patients did not significantly differ from healthy individuals in affective priming or relevance priming after controlling for age, education, and intelligence. The presence of comorbid somatoform disorders was associated with increased affective priming and reduced relevance priming in BPD patients.

CONCLUSIONS

The efficiency of automatic recognition and the processing of valence information at a semantic level are not impaired in BPD. Moreover, BPD patients are able to perceive and differentiate automatically self- versus other-relevance during the perception of affective information like healthy controls. Thus, there is no evidence for enhanced sensitivity to emotion stimuli or poor differentiation between self and others in BPD at a very early stage of processing. The presence of somatoform disorders appears to influence affective as well as relevance priming in BPD.

Childhood sexual abuse in adult patients with borderline personality disorder

BACKGROUND

Researchers have found elevated rates of childhood sexual abuse (CSA) in borderline personality disorder (BPD) patients. They have also implicated the role of CSA later in BPD. However, there has been a scarcity of studies regarding this in Indian population.

OBJECTIVES

To profile the occurrence of CSA and its parameters in BPD patients and to document symptomatology of BPD associated with CSA.

MATERIALS AND METHODS

Thirty-six consecutive patients with BPD were administered with a two-staged semi-structured interview by different interviewers with the first stage for collecting sociodemographic details and confirming BPD diagnosis and the second stage for collecting information about CSA.

RESULTS

Of 36 BPD patients, 16 (44.44%) reported a history of definite CSA. The majority of CSA associated with BPD were having characteristics of onset at 7-12 years, <10 occasions of abuse, perpetrator being a close relative or a close acquaintance and genital type of CSA. Identity disturbances (P = 0.0354), recurrent suicidal/self-harm behavior (P = 0.0177), and stress-related paranoid/dissociative symptoms (P = 0.0177) were significantly associated with the presence of CSA while unstable interpersonal relationships (P = 0.001) were significantly associated with the absence of CSA.

CONCLUSION

Significant proportion of BPD patients reported CSA. The specific symptom profile of BPD patients can be used to predict the presence of CSA in these patients, which has a direct implication in the treatment of these patients.

Meaning in Life in People with Borderline Personality Disorder

Low feelings of meaning in life are associated with depression, hopelessness and suicide, substance abuse and emotional dysregulation. The aim of this study is to offer results about the importance of the construct meaning in life in the psychopathology of BPD. In study 1, the sample was made up of 223 participants, 141 participants with BPD and 82 participants with another mental disorder but without BPD. In study 2, the sample was made up of 80 participants with BPD. Study 1 indicated that the participants with BPD had a lower feeling of meaning in life than the participants with mental disorders but without a BPD. Study 2 indicated that meaning in life was highly negatively correlated with the symptoms of BPD. The model composed of emotional dysregulation, and meaning in life was significantly associated with BPD psychopathology. The present study supports the association between meaning in life with the psychopathology of BPD. Copyright © 2015 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

The results of this study suggest that meaning in life is a relevant variable in the psychopathology of BPD The results of this study suggest that meaning in life is associated with non-suicide self injuries This study suggests that current therapies for BPD should focus on increasing the meaning in life in these patients.

Parenting in mothers with borderline personality disorder and impact on child outcomes

QUESTION

This systematic review explores two questions: what parenting difficulties are experienced by mothers with borderline personality disorder (BPD); and what impact do these have on her children?

STUDY SELECTION AND ANALYSIS

Studies had to include mothers with a diagnosis of BPD, who was the primary caregiver to a child/children under 19 years. PsycINFO and MEDLINE were screened (update: July 2014), yielding 17 relevant studies.

FINDINGS

Mothers with BPD are often parenting in the context of significant additional risk factors, such as depression, substance use and low support. Interactions between mothers with BPD and their infants are at risk of low sensitivity and high intrusiveness, and mothers have difficulty in correctly identifying their emotional state. Levels of parenting stress are high, and self-reported competence and satisfaction are low. The family environment is often hostile and low in cohesion, and mothers with BPD show low levels of mind-mindedness but high levels of overprotection of older children. Outcomes for children are poor compared with both children of healthy mothers, and mothers with other disorders. Infants of mothers with BPD have poorer interactions with their mother (e.g., less positive affect and vocalising, more dazed looks and looks away). Older children exhibit a range of cognitive-behavioural risk factors (e.g., harm avoidance, dysfunctional attitudes and attributions), and have poorer relationships with their mothers. Unsurprisingly, given these findings, children of mothers with BPD have poorer mental health in a range of domains.

CONCLUSIONS

This review highlights the elevated need for support in these mother-child dyads.

Identidades inestables: el síndrome borderline y la condición postmoderna

Partiendo de un análisis de las profundas transformaciones sociales y culturales que justifican lo que se describe como la nueva subjetividad expresiva propia de la modernidad tardía, el presente ensayo trata de mostrar su afinidad constitutiva con la patología de la identidad que numerosos autores consideran central no solo en el síndrome borderline o narcisista, sino también en buena parte de los trastornos mentales más frecuentes y representativos de nuestro tiempo.

Self-concept structure and borderline personality disorder: evidence for negative compartmentalization

BACKGROUND AND OBJECTIVES

Borderline personality disorder (BPD) is characterized by an unstable and incongruent self-concept. However, there is a dearth of empirical studies investigating self-concept in BPD. In order to bridge this research gap, the purpose of this study was to apply an in-depth analysis of structural aspects of the self-concept in BPD.

METHODS

We examined the degree of compartmentalization, i.e., a tendency to organize knowledge about the self into discrete, extremely valenced (i.e., either positive or negative) categories (Showers, 1992).

RESULTS

We hypothesized and found that BPD patients had the most compartmentalized self-concept structure and a higher proportion of negative self-attributes relative to both a non-clinical and a depressed control group. Moreover, BPD patients rated negative self-aspects as more important than positive ones relative to non-clinical controls.

LIMITATIONS

We cannot determine whether causal relationships exist between psychological symptoms and self-concept structure. Moreover, further comparisons to patients with other psychiatric disorders are necessary in order to further confirm the clinical specificity of our results.

CONCLUSIONS

Our findings indicate that a negative compartmentalized self-concept is a specific feature of BPD. Implications for future research, psychological assessment, and psychotherapeutic treatment are discussed.

Self-Based Concepts and Obsessive-Compulsive Phenomena

BACKGROUND/AIMS

Using a cognitive framework, this paper examined self-perceptions as a vulnerability to phenomena in obsessive-compulsive disorder. Specifically, Guidano and Liotti's model of self-ambivalence (from 1983) and the notion of self-worth contingent upon moral standards were investigated as possible mechanisms to explain how individuals come to notice their unwanted intrusions.

METHOD

Using an analogue framework, participants were first-year undergraduate psychology students (95 females, mean age = 22.49 years, SD = 7.96, and 25 males, mean age = 21.64 years, SD = 7.26) who were administered a battery of self-report questionnaires.

RESULTS

Results indicated that self-ambivalence moderated the relationship between high moral standards and obsessive-compulsive (OC) phenomena; individuals who had high moral standards and high self-ambivalence showed increased OC vulnerability.

CONCLUSIONS

The findings suggest that ambivalence about moral self-worth may constitute a particular vulnerability to OC symptoms. Directions for future research are discussed and implications of the findings explored.

The 'Self' and Borderline Personality Disorder: Conceptual and Clinical Considerations

Some concept of self has been used by many, although not all, researchers and clinicians as an 'organising construct' for borderline personality disorder (BPD). There is considerable variation in this usage and how clearly researchers have defined the self. Given this diversity, and that 'self' is often used interchangeably with parallel concepts (e.g., psyche, brain-mind, 'person') or with features of self (e.g., self-awareness, identity), unqualified use of the term is problematic. This is further complicated by the heterogeneity and 'comorbidity' of BPD and the limitations of syndromally based psychiatric nosology. Still, BPD remains in current classification systems and can be reliably diagnosed. A considerable body of research on self and BPD has accrued, including a recent profusion and confluence of neuroscientific and sociopsychological findings. These have generated supporting evidence for a supra-ordinate, functionally constituted entity of the self ranging over multiple, interacting levels from an unconscious, 'core' self, through to a reflective, phenotypic, 'idiographic' and relational self constituted by interpersonal and sociocultural experience. Important insights have been generated regarding emotional and social-cognitive dysregulation, disorder of self-awareness, relationality, identity, and coherence and continuity of the self. Many of these are shared by various trauma-related, dissociative disorders. A construct of the self could be useful as an explanatory principle in BPD, which could be construed as a 'self-state' (and relational) disorder, as opposed to a less severe disorder of aspects of the self (e.g., mood or memory). We offer a tentative description of 'Self' in this context, noting that any such construct will require a clear definition and to be evaluable.

Identity disturbance and problems with emotion regulation are related constructs across diagnoses

OBJECTIVE

This study examined the relation between identity disturbance and emotion dysregulation in a cross-diagnostic sample. We assessed whether these constructs are related and relevant beyond borderline personality disorder (BPD).

METHOD

We recruited 127 participants who completed measures assessing identity disturbance, emotion dysregulation, anxiety, and depression. The sample included primarily depressed adults meeting criteria for multiple diagnoses as well as psychiatrically healthy participants.

RESULTS

Identity disturbance was significantly higher among psychiatric participants with and without BPD compared to healthy controls. Emotion dysregulation was a significant predictor of identity disturbance, even when controlling for BPD diagnosis, depression, and anxiety. In particular, clarity in emotional situations and problems using emotion regulation strategies were most closely related to identity disturbance.

CONCLUSION

The results of this study suggest that future research should examine identity disturbance and its relation with emotion regulation transdiagnostically.

An empirically derived classification of adolescent personality disorders

OBJECTIVE

This study describes an empirically derived approach to diagnosing adolescent personality pathology that is clinically relevant and empirically grounded.

METHOD

A random national sample of psychiatrists and clinical psychologists (N = 950) described a randomly selected adolescent patient (aged 13-18 years, stratified by age and gender) in their care using the Shedler-Westen Assessment Procedure-II-A for Adolescents (SWAP-II-A) and several additional questionnaires.

RESULTS

We applied a form of factor analysis to identify naturally occurring personality groupings within the patient sample. The analysis yielded 10 clinically coherent adolescent personality descriptions organized into 3 higher-order clusters (internalizing, externalizing, and borderline-dysregulated). We also obtained a higher-order personality strengths factor. These factors and clusters strongly resembled but were not identical to factors similarly identified in adult patients. In a second, independent sample from an intensive day treatment facility, 2 clinicians (the patients' treating clinician and the medical director) independently completed the SWAP-II-A, the Child Behavior Checklist (CBCL), and a measure of adaptive functioning. Two additional clinicians, blinded to the data from the first 2 clinicians, independently rated patients' ward behavior using a validated measure of interpersonal behavior. Clinicians diagnosed the personality syndromes with high agreement and minimal comorbidity among diagnoses, and SWAP-II-A descriptions strongly correlated in expected ways with the CBCL, adaptive functioning, and ward ratings.

CONCLUSION

The results support the importance of personality diagnosis in adolescents and provide an approach to diagnosing adolescent personality that is empirically based and clinically useful.

Dimensions of personality and personality pathology: factor structure of the Shedler-Westen assessment procedure-II (SWAP-II)

Researchers have proposed replacing the current system for diagnosing personality disorders with a dimensional trait model. Proposed trait models have been derived primarily from data provided by untrained lay informants (often via self-report questionnaires) using item sets derived from lay conceptions of personality. An alternative is to derive personality trait dimensions from data provided by clinically expert informants using an instrument that includes personality features salient to clinicians who treat personality dysfunction. The authors report the factor structure of the latest edition of the Shedler-Westen Assessment Procedure (SWAP-II) using a normative clinical sample of 1,201 North American patients assessed by experienced psychologists and psychiatrists. Factor analysis identified 14 clinically and empirically coherent factors. The findings highlight dimensions of personality and personality pathology that have not emerged in personality item sets designed for lay personality description.

What Can Psychiatric Disorders Tell Us about Neural Processing of the Self?

Many psychiatric disorders are associated with abnormal self-processing. While these disorders also have a wide-range of complex, and often heterogeneous sets of symptoms involving different cognitive, emotional, and motor domains, an impaired sense of self can contribute to many of these. Research investigating self-processing in healthy subjects has facilitated identification of changes in specific neural circuits which may cause altered self-processing in psychiatric disorders. While there is evidence for altered self-processing in many psychiatric disorders, here we will focus on four of the most studied ones, schizophrenia, autism spectrum disorder (ASD), major depression, and borderline personality disorder (BPD). We review evidence for dysfunction in two different neural systems implicated in self-processing, namely the cortical midline system (CMS) and the mirror neuron system (MNS), as well as contributions from altered inter-hemispheric connectivity (IHC). We conclude that while abnormalities in frontal-parietal activity and/or connectivity in the CMS are common to all four disorders there is more disruption of integration between frontal and parietal regions resulting in a shift toward parietal control in schizophrenia and ASD which may contribute to the greater severity and delusional aspects of their symptoms. Abnormalities in the MNS and in IHC are also particularly evident in schizophrenia and ASD and may lead to disturbances in sense of agency and the physical self in these two disorders. A better future understanding of how changes in the neural systems sub-serving self-processing contribute to different aspects of symptom abnormality in psychiatric disorders will require that more studies carry out detailed individual assessments of altered self-processing in conjunction with measurements of neural functioning.

Personality subtypes in adolescents with anorexia nervosa

The aims of this study are to (1) empirically identify the personality subtypes of adolescents with anorexic disorders and (2) investigate the personality disorders, identity disturbances, and affective features associated with the different subtypes. We assessed 102 adolescent patients with Eating Disorders (anorexia nervosa and eating disorder not otherwise specified) using three clinical instruments: the Shedler-Westen Assessment Procedure for Adolescents (SWAP-200-A) (Westen D, Shedler J, Durrett C, Glass S, Martens A. Personality diagnoses in adolescence: DSM-IV Axis II diagnoses and an empirically derived alternative. Am J Psychiatry 2003;160:952-966), the Affective Regulation and Experience Questionnaire (AREQ) (Zittel Conklin C, Bradley R, Westen D. Affect regulation in borderline personality disorder. J Nerv Ment Dis 2006;194:69-77), and the Identity Disorder Questionnaire (IDQ) (Wilkinson-Ryan T, Westen D. Identity disturbance in borderline personality disorder: An empirical investigation. Am J Psychiatry 2000;157:528-541). We performed a Q factor analysis of the SWAP-200-A descriptions of our sample to identify personality subtypes. We correlated these personality styles with AREQ and IDQ factors and explored the personality differences among individuals with the different types of ED. The Q factor analysis identified three personality subtypes: high-functioning/perfectionist, emotionally dysregulated, and overcontrolled/constricted. Each subtype showed specific identity and affective features, comorbidities with different personality disorders, and clinical implications. These results contribute to the understanding of adolescents with ED and seem to be relevant for treatment planning.

On identity: from a philosophical point of view

BACKGROUND

The term "identity" has a much longer tradition in Western philosophy than in psychology. However, the philosophical discourse addresses very different meanings of the term, which should be distinguished to avoid misunderstandings, but also to sharpen the key meanings of the term in psychological contexts. These crucial points in the philosophical concepts of identity in the sense of singularity, individuality, or self-sameness may structure the ongoing discussion on identity in psychiatric diagnoses (as in DSM-5, Child Adolesc Psychiatry Ment, this issue, 2013), in psychology, psychoanalysis, but also neuroscience and neurophilosophy (Child Adolesc Psychiatry Ment, this issue, 2013).

METHOD

The concept of identity is subjected to a systematic philosophical analysis following some milestones in its history to provide a background for recent discussions on identity in psychiatry and psychology.

RESULTS

The article focuses first on the philosophical core distinctions of identity in the different meanings to be addressed, second, briefly on some of the diverse psychological histories of the concept in the second half of the 20th century. Finally some reflections are presented on borderline personality disorder, considered as a mental disorder with a disturbance or diffusion of identity as core feature, and briefly on a newly developed instrument assessing identity development and identity diffusion in adolescence, the AIDA that is also presented in the special issue of this journal (Child Adolesc Psychiatry Ment, this issue, 2013).

CONCLUSION

As a conclusion, different points of view concerning identity are summarized in respect to treatment planning, and different levels of description of identity in phenomenology, philosophy of mind, cognitive science, and social science and personality psychology are outlined.

Prenatal adversity: a risk factor in borderline personality disorder?

BACKGROUND

Patients with borderline personality disorder (BPD) show a high prevalence of early adversity, such as childhood trauma. It has also been reported that prenatal adverse conditions, such as prenatal maternal stress, drug taking, tobacco smoking or medical complications, may be associated with an increased risk of mental disorders in the offspring. Prenatal adversity is investigated here for the first time as a potential risk factor in the diagnosis of BPD. Method A total of 100 patients with a DSM-IV diagnosis of BPD and 100 matched healthy controls underwent semi-structured interviews about the course of pregnancy, maternal stressors, birth complications and childhood trauma. Further information was obtained from the participants' mothers and from prenatal medical records.

RESULTS

Borderline patients were significantly more often exposed to adverse intrauterine conditions, such as prenatal tobacco exposure (p=0.004), medical complications (p=0.008), prenatal maternal traumatic stress (p=0.015), familial conflicts (p=0.004), low social support (p=0.004) and partnership problems during pregnancy (p=0.014). Logistic regression analyses revealed that the reported prenatal risk factors accounted for 25.7% of the variance in BPD. Prenatal tobacco exposure [odds ratio (OR) 3.37, 95% confidence interval (CI) 1.49-7.65, p=0.004] and medical complications (OR 2.87, 95% CI 1.29-6.38, p=0.010) emerged as important predictors. After controlling for childhood adversity and parental socio-economic status (SES), prenatal risk factors predicted relevant borderline subdomains, such as impulsivity, affective instability, identity disturbance, dissociation and severity of borderline symptoms.

CONCLUSIONS

This study provides evidence of an association between prenatal adversity and the diagnosis of BPD. Our findings suggest that prenatal adversity may constitute a potential risk factor in the pathogenesis of BPD.

Refining the phenotype of borderline personality disorder: Diagnostic criteria and beyond

Borderline personality disorder (BPD) is a heterogeneous disorder, and previous analyses have parsed its phenotype in terms of subtypes or underlying traits. We refined the BPD construct by testing a range of latent variable models to ascertain whether BPD is composed of traits, latent classes, or both. We also tested whether subtypes of BPD could be distinguished by anger, aggressiveness, antisocial behavior, and mis-trustfulness, additional putative indicators drawn from Kernberg's (1967, 1975) theory of BPD. In a mixed clinical and nonclinical sample (N = 362), a factor mixture model consisting of two latent classes (symptomatic and asymptomatic) and a single severity dimension fit the BPD criteria, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), data better than latent class or factor analytic approaches. In the second analytic phase, finite mixture modeling of the symptomatic latent class (n = 100) revealed four BPD subtypes: angry/aggressive, angry/mistrustful, poor identity/low anger, and prototypical. Our results support a hybrid categorical-dimensional model of the BPD DSM-IV criteria. The BPD subtypes emerging from this model have important implications for treatment and etiological research.