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

Social cognition in borderline personality disorder

Many typical symptoms of borderline personality disorder (BPD) occur within interpersonal contexts, suggesting that BPD is characterized by aberrant social cognition. While research consistently shows that BPD patients have biases in mental state attribution (e.g., evaluate others as malevolent), the research focusing on accuracy in inferring mental states (i.e., cognitive empathy) is less consistent. For complex and ecologically valid tasks in particular, emerging evidence suggests that individuals with BPD have impairments in the attribution of emotions, thoughts, and intentions of others (e.g., Preißler et al., 2010). A history of childhood trauma and co-morbid PTSD seem to be strong additional predictors for cognitive empathy deficits. Together with reduced emotional empathy and aberrant sending of social signals (e.g., expression of mixed and hard-to-read emotions), the deficits in mental state attribution might contribute to behavioral problems in BPD. Given the importance of social cognition on the part of both the sender and the recipient in maintaining interpersonal relationships and therapeutic alliance, these impairments deserve more attention.

Enhanced detection of emotional facial expressions in borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is commonly proposed to be characterized by an enhanced sensitivity for emotional stimuli. In the present study, we investigated whether BPD patients show a superior detection of emotional facial expressions relative to healthy controls. The detection of emotional information in the environment represents an important facet of emotional sensitivity.

SAMPLING AND METHODS

Twenty patients with BPD were compared with 25 healthy controls. The participants were presented a rapid, continuous stream of neutral and randomly inserted emotional facial expressions and were asked to report the presentation of an emotional facial stimulus after each trial. Availability of cognitive resources was manipulated via two different task demands.

RESULTS

The participants with BPD performed significantly better in the detection of positive and negative facial expressions compared to the healthy controls. False alarm rates did not differ significantly between the two groups.

CONCLUSIONS

The BPD participants showed an enhanced detection of emotional expressions that might be related to the emotional disturbances they experience. In particular, we will discuss the role of this superior emotion detection (in combination with previously reported deficits in the labeling of emotional states) for the understanding of emotional instability in BPD.

Effects of suppression and acceptance of sadness on the urge for non-suicidal self-injury and self-punishment

The present study wanted to test the course of the urge for non-suicidal self-injury (UNSSI) and the urge for self-punishment (USP) when suppressing or accepting upcoming emotions in response to a sadness-inducing film clip in female participants with borderline personality disorder (BPD). Thirty-six women with BPD were allocated either to a condition in which they were asked to engage in expressive suppression or acceptance while watching a sadness-inducing film clip. Ratings of UNSSI, USP, and positive and negative emotions were assessed prior to the clip (baseline), immediately after it (t1) and after a 5min waiting period (t2), during which participants viewed landscape pictures. Additionally, physiological measures were obtained. Main results revealed a significant increase in UNSSI from baseline to t2 in the acceptance, but not in the suppression group. Furthermore, USP scores significantly increased from baseline to t2 in the acceptance, but not in the suppression condition. However, there was no differential impact on the sympathetic and parasympathetic branch depending on strategy. The results are in line with recent literature showing that expressive suppression in BPD may also have an adaptive function.

Physiological and self-assessed emotional responses to emotion-eliciting films in borderline personality disorder

According to Linehan's biosocial model, the core characteristic of borderline personality disorder (BPD) is emotional dysregulation. In the present study, we investigated two components of this model: baseline emotional intensity and emotional reactivity. A total of 60 women, 30 with BPD diagnosis and 30 age and sex-matched healthy subjects (HCs), participated in two experiments. In the first experiment, we evaluated emotional responses to six films designed to elicit discrete emotions (anger, fear, sadness, disgust, amusement and neutral). The second experiment evaluated emotional reactions to three emotion-eliciting films containing BPD-specific content (sexual abuse, emotional dependence and abandonment/separation). Skin conductance level, heart rate, and subjective emotional response were recorded for each film. Although self-reported data indicated that negative emotions at baseline were stronger in the BPD group, physiological measures showed no differences between the groups. Physiological results should be interpreted with caution since most BPD participants were under pharmacological treatment. BPD subjects presented no subjective heightened reactivity to most of the discrete emotion-eliciting films. Subjective responses to amusement and "BPD-specific content" films revealed significant between-group differences. These findings suggest that the main characteristic of BPD might be negative emotional intensity rather than heightened emotional reactivity.

Observer-rated coping associated with borderline personality disorder: an exploratory study

BACKGROUND

Little is known about coping specificities, as operationalization of the concept of affect regulation, in borderline personality disorder (BPD). It is most important to take into account methodological criticisms addressed to the self-report questionnaire approach and to compare BPD coping specificities to the ones of neighbouring diagnostic categories, such as bipolar disorder (BD).

SAMPLING AND METHODS

The present exploratory study compared the coping profiles of N = 25 patients presenting BPD to those of N = 25 patients presenting BD and to those of N = 25 healthy controls. All participants underwent a clinical interview that was transcribed and rated using the Coping Patterns observer-rater system.

RESULTS

Results partially confirmed study hypotheses and showed differences between BPD patients and healthy controls in all coping domains (competence, resources and autonomy), whereas the only coping domain presenting a BPD-specific lack of skills, compared with the BD patients, was autonomy, a set of coping strategies facing stress appraised as challenge. These coping processes were linked to general and BPD symptomatology.

CONCLUSIONS

These results extend conclusions of earlier studies on affect regulation processes in BPD and bear important clinical implications, in the context of dialectical behavior therapy and other therapeutic approaches. Limitations of this exploratory study, such as the small sample size, are acknowledged.

KEY PRACTITIONER MESSAGE

Coping can be reliably assessed in the narrative process in an non-structured interview frame. Patients with borderline personality disorder present with a specific lack of skills in affect regulation related to autonomy issues, compared to patients with bipolar disorder and healthy controls. Lack of skills in accommodation to distressing emotions in borderline personality disorder is related to symptom gravity and may be treated using radical acceptance strategies.

Alterations in default mode network connectivity during pain processing in borderline personality disorder

CONTEXT

Recent neuroimaging studies have associated activity in the default mode network (DMN) with self-referential and pain processing, both of which are altered in borderline personality disorder (BPD). In patients with BPD, antinociception has been linked to altered activity in brain regions involved in the cognitive and affective evaluation of pain. Findings in healthy subjects indicate that painful stimulation leads to blood oxygenation level-dependent signal decreases and changes in the functional architecture of the DMN.

OBJECTIVES

To connect the previously separate research areas of DMN connectivity and altered pain perception in BPD and to explore DMN connectivity during pain processing in patients with BPD.

DESIGN

Case-control study.

SETTING

University hospital.

PARTICIPANTS

Twenty-five women with BPD, including 23 (92%) with a history of self-harm, and 22 age-matched control subjects.

INTERVENTIONS

Psychophysical assessment and functional magnetic resonance imaging during painful heat vs neutral temperature stimulation.

MAIN OUTCOME MEASURE

Connectivity of DMN as assessed via independent component analysis and psychophysiological interaction analysis.

RESULTS

Compared with control subjects, patients with BPD showed less integration of the left retrosplenial cortex and left superior frontal gyrus into the DMN. Higher BPD symptom severity and trait dissociation were associated with an attenuated signal decrease of the DMN in response to painful stimulation. During pain vs neutral, patients with BPD exhibited less posterior cingulate cortex seed region connectivity with the left dorsolateral prefrontal cortex.

CONCLUSIONS

Patients with BPD showed significant alterations in DMN connectivity, with differences in spatial integrity and temporal characteristics. These alterations may reflect a different cognitive and affective appraisal of pain as less self-relevant and aversive as well as a deficiency in the switching between baseline and task-related processing. This deficiency may be related to everyday difficulties of patients with BPD in regulating their emotions, focusing mindfully on 1 task at a time, and efficiently shifting their attention from one task to another.

What does sadness mean to BPD patients?

Dysphoria is a core feature of Borderline Personality Disorder. Although a few studies have examined the nature of dysphoria in those patients, no research has focused on their experience of sadness. Considering the adaptive value of this emotion, an understanding of how BPD patients experience sadness is relevant to treatment. We conducted a qualitative analysis of the narratives of seven individuals with a diagnosis of BPD that have participated in a semi-structured interview describing sadness experiences in a relational context. Fourteen episodes were analyzed jointly by two doctoral students following Interpretative Phenomenological Analysis principles. Five themes were found: (1) aggression, (2) relationship broken off by the other, (3) undifferentiated negative affect, (4) self being defective, and (5) overwhelming experience. Surprisingly, sadness in a relational context was not associated with a representation of loss. The results suggest instead that sadness in those episodes is a non-mentalized experience that should not be conceptualized as sadness proper.

Mental state decoding abilities in young adults with borderline personality disorder traits

Previous studies have demonstrated that patients with borderline personality disorder (BPD) tend to misattribute malevolence to benign social stimuli, including facial expressions. Yet, facial emotion recognition studies examining those with BPD have yielded mixed results, with some studies showing impaired accuracy and others demonstrating enhanced accuracy in the recognition of emotions or mental states. The current study examined the ability to decode mental states from photographs of just the eye region of faces in a nonclinical sample of young adults who exhibited BPD traits (high BPD) compared with those who did not (low BPD). Group differences in mental state decoding ability depended on the valence of the stimuli. The high-BPD group performed better for negative stimuli compared with the low-BPD group, but did not perform significantly different from the low-BPD group for stimuli of neutral or positive valence. The high-BPD group also demonstrated a response bias for attributing negative mental states to facial stimuli. In addition, findings suggested that the group difference in accuracy for negative stimuli could not be explained by response bias, because the group difference in response bias for negative stimuli did not reach significance. These findings suggest that BPD traits may be associated with enhanced ability to detect negative emotions and a bias for attributing negative emotions to nonnegative social stimuli.

Functional connectivity of pain-mediated affect regulation in Borderline Personality Disorder

Affective instability and self-injurious behavior are important features of Borderline Personality Disorder. Whereas affective instability may be caused by a pattern of limbic hyperreactivity paired with dysfunctional prefrontal regulation mechanisms, painful stimulation was found to reduce affective arousal at the neural level, possibly underlying the soothing effect of pain in BPD.We used psychophysiological interactions to analyze functional connectivity of (para-) limbic brain structures (i.e. amygdala, insula, anterior cingulate cortex) in Borderline Personality Disorder in response to painful stimulation. Therefore, we re-analyzed a dataset from 20 patients with Borderline Personality Disorder and 23 healthy controls who took part in an fMRI-task inducing negative (versus neutral) affect and subsequently applying heat pain (versus warmth perception).Results suggest an enhanced negative coupling between limbic as well as paralimbic regions and prefrontal regions, specifically with the medial and dorsolateral prefrontal cortex, when patients experienced pain in addition to emotional arousing pictures. When neutral pictures were combined with painful heat sensation, we found positive connectivity in Borderline Personality Disorder between (para-)limbic brain areas and parts of the basal ganglia (lentiform nucleus, putamen), as well areas involved in self-referential processing (precuneus and posterior cingulate).We found further evidence for alterations in the emotion regulation process in Borderline Personality Disorder, in the way that pain improves the inhibition of limbic activity by prefrontal areas. This study provides new insights in pain processing in BPD, including enhanced coupling of limbic structures and basal ganglia.

The rejection-rage contingency in borderline personality disorder

Though long-standing clinical observation reflected in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) suggests that the rage characteristic of borderline personality disorder (BPD) often appears in response to perceived rejection, the role of perceived rejection in triggering rage in BPD has never been empirically tested. Extending basic personality research on rejection sensitivity to a clinical sample, a priming-pronunciation experiment and a 21-day experience-sampling diary examined the contingent relationship between perceived rejection and rage in participants diagnosed with BPD compared with healthy controls. Despite the differences in these 2 assessment methods, the indices of rejection-contingent rage that they both produced were elevated in the BPD group and were strongly interrelated. They provide corroborating evidence that reactions to perceived rejection significantly explain the rage seen in BPD.

Aberrant connectivity of resting-state networks in borderline personality disorder

BACKGROUND

Several functional neuroimaging studies have reported regionally abnormal activation of the frontal cortex in individuals with borderline personality disorder (BPD) during cognitive and affective task performance. However, little is known about neural function in individuals with BPD during the resting state. Using functional magnetic resonance imaging (fMRI), this study investigated the functional connectivity of prefrontal and limbic networks in patients with BPD.

METHODS

Between January 2009 and March 2010, we investigated patients with BPD according to DSM-IV criteria and healthy controls by means of resting-state fMRI. The data were analyzed using a spatial group independent component analysis, and random effects t tests were used to compare spatial components between groups (p < 0.005, uncorrected).

RESULTS

There were 17 women with BPD and 17 female healthy controls enrolled in this study. Within a network comprising cortical midline regions ("default mode network"), patients with BPD showed an increase in functional connectivity in the left frontopolar cortex (FPC) and the left insula, whereas decreased connectivity was found in the left cuneus. Within a network comprising predominantly right lateral prefrontal and bilateral parietal regions, patients with BPD showed decreased connectivity of the left inferior parietal lobule and the right middle temporal cortex compared with healthy controls. Two networks comprising lateral prefrontal and cingulate regions did not exhibit significant between-group differences. We found correlations between functional connectivity of the FPC and measures of impulsivity as well as between connectivity of the insula/cuneus and dissociation tension.

LIMITATIONS

Co-occurrent axis I disorders and medication use in this sample of patients with BPD have to be considered as potential limitations.

CONCLUSION

These data suggest that abnormal functional connectivity of temporally coherent resting-state networks may underlie certain symptom clusters in patients with 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.

Neuronal correlates of cognitive reappraisal in borderline patients with affective instability

BACKGROUND

Borderline personality disorder has been characterized by enhanced emotional reactivity and deficient emotion regulation in behavioral and functional imaging studies. We aimed to validate patients' difficulties in the cognitive regulation of negative emotions and investigated if emotion regulation deficits are restricted to the decrease of negative emotions. A cognitive reappraisal paradigm was used and hence a regulation strategy that is typically applied in cognitive-behavioral therapy.

METHODS

Fifteen unmedicated female borderline patients with affective instability and 15 healthy female control subjects underwent functional magnetic resonance imaging during a delayed reappraisal paradigm. Hemodynamic responses were measured in response to aversive pictures in an initial viewing phase and a subsequent reappraisal phase with three different conditions: decreasing, increasing, and maintaining the initial emotional reaction.

RESULTS

Patients demonstrated enhanced activation of left amygdala and right insula during the initial viewing of aversive stimuli. During attempting to decrease the initial emotional reaction, patients showed attenuated activation of the left orbitofrontal cortex and increased activation of the bilateral insula. The attempt to increase negative emotions resulted in enhanced activity in amygdala and insula, whereas no group differences were found.

CONCLUSIONS

The results point to the role of two distinguishable processes of emotional difficulties in borderline personality disorder: enhanced emotional reactivity as well as deficits of voluntarily decreasing aversive emotions by means of cognitive reappraisal. The results suggest the neuronal substrate of deficits in explicit emotion regulation in the orbitofrontal cortex, which is in line with previous findings of a dysfunctional prefrontal network in borderline personality disorder.

Emotional vulnerability in borderline personality disorder is cue specific and modulated by traumatization

BACKGROUND

A general emotional vulnerability (intense, easily triggered affective reactions) is considered a core symptom in borderline personality disorder (BPD), but evidence from psychophysiological studies for this hypothesis is not very consistent. Given the high comorbidity of posttraumatic stress disorder (PTSD) in BPD patients, current comorbid PTSD might also modulate emotional reactivity. In the present study using a script-driven imagery paradigm, idiographic aversive, disorder-specific (scenes about rejection and abandonment), and standard unpleasant, neutral, and pleasant scripts were presented to investigate emotional reactivity in patients with BPD.

METHODS

Forty nonmedicated BPD patients and 32 healthy control subjects first read and then imagined the scripts. Acoustic startle probes were presented during reading and imagery and the eye-blink responses, as well as changes in heart rate and skin conductance level were recorded.

RESULTS

Imagery of disorder-specific scripts resulted in a clear potentiation of the startle responses and increased autonomic arousal in BPD patients but not in control subjects. Borderline personality disorder patients with current comorbid PTSD (n = 26 out of 40) showed attenuated startle potentiation during aversive imagery that was not the case in BPD patients without current PTSD. This effect was most pronounced in BPD patients with severe PTSD.

CONCLUSIONS

Scenes about rejection and abandonment are specifically able to activate defensive response mobilization in BPD patients. These findings suggest that BPD patients are not more physiologically reactive to emotional cues in general but show increased emotional vulnerability if borderline-specific schemas are activated. Moreover, emotional reactivity is attenuated in BPD patients with PTSD.

Emotion identification and tension in female patients with borderline personality disorder

OBJECTIVES

This study investigates the identification of emotions in patients with borderline personality disorder (BPD), when compared with mentally healthy control subjects. The inability to identify different emotions is considered as an essential component of affect dysregulation in BPD that has rarely been empirically investigated.

METHODS

In this study, 30 female borderline patients and 28 healthy control participants received a handheld-PC for a 24-hour period that reminded them hourly to enter data.

RESULTS

When compared with the control group, patients showed pronounced difficulties in emotion identification. Moreover, the data revealed a significant relationship between difficulties in identifying emotions and levels of aversive inner tension for BPD patients, but not for control subjects.

CONCLUSIONS

Results indicate that the inability to identify different emotions is a problem that characterizes borderline patients in real-life situations. Treatment programs should, therefore, focus on the improvement of emotion identification and regulation.

Discrepancies between explicit and implicit self-esteem are linked to symptom severity in borderline personality disorder

The present study examined whether discrepancies between explicit and implicit self-esteem are associated with symptom severity in a sample of patients with borderline personality disorder (BPD). We hypothesized that implicit-explicit self-esteem discrepancies foster autoaggressive behavior and dysphoria, and impair self-perception. We found that the two forms of self-esteem discrepancies, damaged and fragile self-esteem were related to the severity of overall borderline symptoms, autoaggression, dysphoria, and deficits in self-perception. In contrast, more general psychopathological impairment, such as depression, was not related to self-esteem discrepancies. Taken together our results indicate that discrepancies between explicit and implicit self-esteem are associated with certain borderline symptoms that may be based on internal tension. The findings can be interpreted within the framework of self-discrepancies and dichotomous attitudes in patients with BPD.

Revising the borderline diagnosis for DSM-V: an alternative proposal

The changes in the borderline personality disorder (BPD) diagnosis proposed by the DSM-V personality disorder work group involve radical changes in format (prototype and dimensions) and descriptive characteristics (traits). Changes of this magnitude will create an unwelcome and potentially harmful discontinuity with the definition that has guided BPD research and the development of disorder-specific therapies. This paper offers an alternative proposal that was developed in collaboration with clinical and research leaders. It includes modification of existing criteria, use of a diagnostic algorithm based on phenotypes, and giving BPD a hierarchical relationship vis-à-vis other personality disorders. These changes are incremental, diminish overlap and heterogeneity, sustain clinical and research development, and will improve utilization.

Increased psychological and attenuated cortisol and alpha-amylase responses to acute psychosocial stress in female patients with borderline personality disorder

OBJECTIVE

Borderline personality disorder (BPD) is characterized by increased self-reported stress and emotional responding. Knowledge about the psychological and physiological mechanisms that underlie these experiences in BPD patients is scarce. The objective was to assess both psychological and endocrinological responses to a standardized psychosocial stressor in female BPD patients and healthy controls.

METHODS

A total of 15 female BPD patients and 17 healthy control subjects were included in a case-control study. All subjects were free of any medication, had a regular menstrual cycle, and were investigated during the luteal phase of their menstrual cycle. Co-occurring current major depression, current substance abuse/dependence, and lifetime schizophrenia or bipolar I disorder were excluded. Psychological measures of stress, salivary cortisol, salivary alpha-amylase, plasma ACTH, plasma norepinephrine and epinephrine concentrations were measured before, during, and after exposure to a standardized psychosocial stress protocol.

RESULTS

BPD patients displayed maladaptive cognitive appraisal processes regarding the upcoming stressor as well as significantly higher subjective stress, coupled with a substantial cortisol and alpha-amylase hyporeactivity to the stressor in comparison to the controls. No significant differences for ACTH and catecholaminergic responses were observed, while the ACTH:cortisol ratio was higher in BPD patients than in controls.

CONCLUSIONS

Attenuated cortisol responsiveness in BPD patients might in part be explained by decreased adrenal responsiveness to endogenous ACTH and altered central noradrenergic activation as reflected by alpha-amylase.

Affect regulation and pain in borderline personality disorder: a possible link to the understanding of self-injury

BACKGROUND

Patients with borderline personality disorder (BPD) experience intense emotions and often show a deficiency of emotion regulation skills. Moreover, they display high prevalence rates of self-injurious behavior. Patients report engaging in self-injurious behavior due to its immediate relief effects of emotional tension. Pain in BPD has further been observed to lead to a reduction in neural activity in the amygdala and anterior cingulate cortex, which may be attributed to patients' perception of relaxation.

METHODS

To investigate the potential role of self-inflicted pain as a means of affect regulation in patients with BPD, we conducted a functional magnetic resonance imaging study using picture stimuli to induce negative (vs. neutral) affect and thermal stimuli to induce heat pain (vs. warmth perception). The painful heat stimuli were administrated at an individual temperature for each subject. Twenty patients with BPD and 23 healthy control subjects were included in the study.

RESULTS

Both negative and neutral pictures led to stronger activation of the amygdala, insula, and anterior cingulate cortex in patients with BPD than in healthy control subjects. Amygdala activation correlated with self-reported deficits in emotion regulation. During the sensory stimulation, we found decreased amygdala and anterior cingulate cortex activation, which was independent of painfulness.

CONCLUSIONS

The results are in line with previous findings on emotional hyperactivity in BPD and suggest that pain stimuli in BPD are processed differently depending on the arousal status. Finally, we can preliminarily support the idea of a general mechanism of attentional shift underlying the soothing effect of pain in BPD.

An experimental investigation of emotional reactivity and delayed emotional recovery in borderline personality disorder: the role of shame

Despite the emphasis on emotional reactivity and delayed emotional recovery in prominent theoretical accounts of borderline personality disorder (BPD), research in this area remains limited. This study sought to extend extant research by examining emotional reactivity (and recovery following emotional arousal) to 2 laboratory stressors (one general, and the other involving negative evaluation) and exploring the impact of these stressors on subjective responding across the specific emotions of anxiety, irritability, hostility, and shame. We hypothesized that outpatients with BPD (compared to outpatients without a personality disorder; non-PD) would demonstrate heightened subjective emotional reactivity to both stressors, as well as a delayed return to baseline levels of emotional arousal. Results provide evidence for context- and emotion-specific reactivity in BPD. Specifically, BPD participants (compared to non-PD participants) evidenced heightened reactivity to the negative evaluation but not the general stressor. Furthermore, results provide support for shame-specific reactivity in BPD, with BPD participants (vs non-PD participants) evidencing a significantly different pattern of change in shame (but not in reported anxiety, irritability, or hostility) across the course of the study. Specifically, not only did BPD participants report higher levels of shame in response to the negative evaluation, their levels of shame remained elevated following this stressor (through the post-recovery period at the end of the study). Findings suggest the importance of continuing to examine emotional reactivity in BPD within specific contexts and across distinct emotions, rather than at the general trait level.

Emotional instability, poor emotional awareness, and the development of borderline personality

Emotional instability and poor emotional awareness are cardinal features of the emotional dysregulation associated with borderline personality disorder (BPD). Most models of the development of BPD include child negative emotional reactivity and grossly inadequate caregiving (e.g., abuse, emotional invalidation) as major contributing factors. However, early childhood emotional reactivity and exposure to adverse family situations are associated with a diverse range of long-term outcomes. We examine the known effects of these risk factors on early childhood emotional functioning and their potential links to the emergence of chronic emotional instability and poor emotional awareness. This examination leads us to advocate new research directions. First, we advocate for enriching the developmental assessment of children's emotional functioning to more closely capture clinically relevant aspects. Second, we advocate for conceptualizing children's early family experiences in terms of the proximal emotional environment to which young children may be or become sensitive. Such approaches should contribute to our ability to identify risk for BPD and guide preventive intervention.

The interpersonal dimension of borderline personality disorder: toward a neuropeptide model

Borderline personality disorder is characterized by affective instability, impulsivity, identity diffusion, and interpersonal dysfunction. Perceived rejection and loss often serve as triggers to impulsive, suicidal, and self-injurious behavior, affective reactivity, and angry outbursts, suggesting that the attachment and affiliative system may be implicated in the disorder. Neuropeptides, including the opioids, oxytocin, and vasopressin, serve a crucial role in the regulation of affiliative behaviors and thus may be altered in borderline personality disorder. While clinical data are limited, the authors propose alternative neuropeptide models of borderline personality disorder and review relevant preclinical research supporting the role of altered neuropeptide function in this disorder in the hope of stimulating more basic research and the development of new treatment approaches.

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.

Neural correlates of the use of psychological distancing to regulate responses to negative social cues: a study of patients with borderline personality disorder

BACKGROUND

Emotional instability is a defining feature of borderline personality disorder (BPD); yet, little is understood about its underlying neural correlates. One possible contributing factor to emotional instability is a failure to adequately employ adaptive cognitive regulatory strategies such as psychological distancing.

METHODS

To determine whether there are differences in neural dynamics underlying this control strategy between BPD patients and healthy control (HC) subjects, blood oxygenation level-dependent (BOLD) functional magnetic resonance imaging signals were acquired as 18 BPD and 16 HC subjects distanced from or simply looked at pictures depicting social interactions. Contrasts in signal between distance and look conditions were compared between groups.

RESULTS

Borderline personality disorder patients showed a different pattern of activation compared with HC subjects when looking at negative versus neutral pictures. When distancing versus looking at negative pictures, both groups showed decreased negative affect ratings and increased activation of the dorsolateral prefrontal cortex, areas near/along the intraparietal sulcus (IPS), ventrolateral prefrontal cortex, and posterior cingulate/precuneus regions. However, the BPD group showed less BOLD signal change in dorsal anterior cingulate cortex and IPS, less deactivation in the amygdala, and greater activation in the superior temporal sulcus and superior frontal gyrus.

CONCLUSIONS

Borderline personality disorder and HC subjects display different neural dynamics while passively viewing social emotional stimuli. In addition, BPD patients do not engage the cognitive control regions to the extent that HCs do when employing a distancing strategy to regulate emotional reactions, which may be a factor contributing to the affective instability of BPD.

Emotional reactions to standardized stimuli in women with borderline personality disorder: stronger negative affect, but no differences in reactivity

Emotional dysregulation is hypothesized to be a core feature of borderline personality disorder (BPD). In this study, we investigated the course of emotions in response to standardized emotion inductions in BPD. A total of 26 female BPD patients, 28 matched healthy control subjects, and 15 female patients with major depressive disorder listened to short stories inducing an angry, joyful, or neutral mood. Before and immediately after each story as well as 3 and 6 minutes later, participants rated their current anger, joy, anxiety, shame, and sadness. All 3 groups showed the same increase and decrease of emotions. However, strong group differences in the general level of all negative emotions occurred. While sadness was stronger both in BPD and major depressive disorder as compared with healthy controls, all other negative emotions were significantly increased in BPD only independent of comorbid depression. Extreme negative affectivity may be a more appropriate description of BPD-related emotional problems than emotional hyperreactivity.

Shame as a prospective predictor of self-inflicted injury in borderline personality disorder: a multi-modal analysis

The primary aim of this study was to examine the prospective association of shame with self-inflicted injury (SII), including suicide attempts and nonsuicidal self-injury, among women with borderline personality disorder (BPD) who were enrolled in a clinical trial (N = 77). A multi-method approach was used to assess self-reported shame, nonverbal shame behaviors, and assessor ratings of shame during an interview regarding antecedents for a recent episode of SII. Higher levels of nonverbal shame behaviors predicted a higher likelihood of subsequent SII, and shorter time to SII, after controlling for past SII as well as other emotions associated with SII. Self-reported state shame and assessor ratings of shame were associated with prospective SII, but not after controlling for other emotions. These findings underscore the important role of shame in SII, particularly shame in the presence of contextual prompts for events that surround episodes of SII.

Experience sampling research in psychopathology: opening the black box of daily life

A growing body of research suggests that momentary assessment technologies that sample experiences in the context of daily life constitute a useful and productive approach in the study of behavioural phenotypes and a powerful addition to mainstream cross-sectional research paradigms. Momentary assessment strategies for psychopathology are described, together with a comprehensive review of research findings illustrating the added value of daily life research for the study of (1) phenomenology, (2) aetiology, (3) psychological models, (4) biological mechanisms, (5) treatment and (6) gene-environment interactions in psychopathology. Overall, this review shows that variability over time and dynamic patterns of reactivity to the environment are essential features of psychopathological experiences that need to be captured for a better understanding of their phenomenology and underlying mechanisms. The Experience Sampling Method (ESM) allows us to capture the film rather than a snapshot of daily life reality of patients, fuelling new research into the gene-environment-experience interplay underlying psychopathology and its treatment.

Cascades of Emotion: The Emergence of Borderline Personality Disorder from Emotional and Behavioral Dysregulation

Theories of borderline personality disorder (BPD) have often considered it a disorder involving both emotional and behavioral dysregulation (Linehan, 1993), yet the connection between these phenomena has been elusive. The following paper proposes the Emotional Cascade Model, a model that attempts to establish a clear relationship between emotional dysregulation and the wide array of dysregulated behaviors found in BPD. In this model, subsequent to an emotional stimulus, ruminative processes result in a positive feedback loop that increases emotional intensity, and this emotional intensity leads to ensuing behavioral dysregulation. These behaviors then provide negative feedback, in the form of distraction, which induces temporary reduction of negative emotion and thus relief. The model is presented in a framework in which BPD is considered an emergent phenomenon (Lewin, 1992), where the disorder arises from the total interactions of a network containing emotional cascades and other important factors. The model is then evaluated in light of various theories and therapeutic traditions, including both cognitive-behavioral and psychodynamic, indicating that it is a model that may transcend traditional theoretical and therapeutic doctrines.

Disentangling emotion processes in borderline personality disorder: physiological and self-reported assessment of biological vulnerability, baseline intensity, and reactivity to emotionally evocative stimuli

This study investigated M. Linehan's (1993) theory that individuals meeting criteria for borderline personality disorder (BPD) have high biological vulnerability to emotion dysregulation, including high baseline emotional intensity and high reactivity to emotionally evocative stimuli. Twenty individuals with BPD, 20 age-matched individuals with generalized social anxiety disorder (SAD), and 20 age-matched normal controls (NCs) participated in 2 separate emotion induction conditions, a standardized condition, and a personally relevant condition. Respiratory sinus arrhythmia (RSA), skin conductance response (SCR), and self-report measures were collected throughout the experiment. BPD participants displayed heightened biological vulnerability compared with NCs as indicated by reduced basal RSA. BPD participants also exhibited high baseline emotional intensity, characterized by heightened SCR and heightened self-reported negative emotions at baseline. However, the BPD group did not display heightened reactivity, as their physiological and self-reported changes from baseline to the emotion inductions tasks were not greater than the other 2 groups.

Neural correlates of emotion processing in borderline personality disorder

Emotional instability is a hallmark feature of borderline personality disorder (BPD), yet its biological underpinnings are poorly understood. We employed functional magnetic resonance imaging (fMRI) to compare patterns of regional brain activation in BPD patients and healthy volunteers as they process positive and negative social emotional stimuli. fMRI images were acquired while 19 BPD patients and 17 healthy controls (HC) viewed emotion-inducing pictures from the International Affective Pictures System set. Activation data were analyzed with SPM5 ANCOVA models to derive the effects of diagnosis and stimulus type. BPD patients demonstrated greater differences in activation than controls, when viewing negative pictures compared with rest, in the amygdala, fusiform gyrus, primary visual areas, superior temporal gyrus (STG), and premotor areas, while healthy controls showed greater differences than BPD patients in the insula, middle temporal gyrus and dorsolateral prefrontal cortex (BA46). When viewing positive pictures compared with rest, BPD patients showed greater differences in the STG, premotor cortex, and ventrolateral prefrontal cortex. These findings suggest that BPD patients show greater amygdala activity and heightened activity of visual processing regions relative to findings for HC subjects in the processing of negative social emotional pictures compared with rest. The patients activate neural networks in emotion processing that are phylogeneticall older and more reflexive than those activated by HC subjects.

Clonidine improves hyperarousal in borderline personality disorder with or without comorbid posttraumatic stress disorder: a randomized, double-blind, placebo-controlled trial

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition borderline personality disorder (BPD) seems to constitute a very heterogeneous category. Therefore, pharmacological therapy is symptom-oriented or targets comorbid conditions. A high comorbidity exists between BPD and posttraumatic stress disorder (PTSD). In a double-blind, randomized, placebo-controlled crossover study, we sought to determine whether the antinoradrenergic agent clonidine was effective in reducing hyperarousal and measures of BPD-specific and general psychopathology in a sample of 18 patients with BPD, with or without comorbid PTSD, and with a prominent hyperarousal syndrome. Hyperarousal as measured by the Clinician Administered PTSD scale improved significantly compared with placebo (P = 0.003) irrespective of PTSD comorbidity. Improvements in general and BPD-typical psychopathology were mainly seen in the PTSD-positive subgroup, whereas the subjective sleep latency (P = 0.005) and the restorative qualities of the sleep (P = 0.014) improved in the whole sample. Improvements, despite the small sample size of this pilot study, lead us to conclude that clonidine might be a useful adjunct to pharmacotherapy in patients with BPD who have marked hyperarousal and/or sleep problems and, in particular, in patients with BPD who have a PTSD comorbidity.

Comprehensive inpatient treatment of refractory chronic daily headache

OBJECTIVE

(1) To assess outcome at discharge for a consecutive series of admissions to a comprehensive, multidisciplinary inpatient headache unit; (2) To identify outcome predictors.

BACKGROUND

An evidence-based assessment (2004) concluded that many refractory headache patients appear to benefit from inpatient treatment, underscoring the need for more research, including outcome predictors.

METHODS

The authors completed a retrospective chart review of 283 consecutive admissions over 6 months. The inpatient program (mean length of stay = 13.0 days) included intravenous and oral medication protocols, drug withdrawal when indicated, cognitive-behavior therapy, and other services when needed, including anesthesiological intervention. Patient-reported pain levels and consensus of medical staff determined outcome status.

RESULTS

The 267 completers (94%) included 212 women and 55 men (mean age = 40.3 years, range = 13-74) from 43 states and Canada. The modal diagnosis was intractable, chronic daily headache (85%), predominantly migraine. Most (59%) had medication overuse headache (MOH), involving opioids (48%), triptans (16%), or butalbital-containing analgesics (10%). Psychiatric diagnoses included stress-related headache (82%), mood disorders (70%), anxiety disorders (49%), and personality disorders (PD, 26%). More patients with a PD (62%) had opioid-related MOH than those with no PD (38%), P < .005. Of the completers, 78% had moderate to significant pain reduction, with comparable improvement in mood, function, and behavior. Clinical factors predicting moderate-significant headache improvement were limited to MOH (84% vs 69%, P < .007) and presence of a PD (68% vs 81%, P < .03).

CONCLUSIONS

Most patients (78%) improved following aggressive, comprehensive inpatient treatment. Maintenance of improvement is likely to depend on multiple post-discharge factors, including continuity of care, compliance, and home or work environment.

Affective instability in borderline personality disorder: experience sampling findings

Affective instability, defined as repeated, rapid, and abrupt shifts in mood, is considered the core pathology in borderline personality disorder. The temporal pattern of affective instability can be best captured with the experience sampling method-longitudinal assessment of people's affective states as they occur in real time and in their natural environment. A review of the experience sampling studies published to date for borderline personality disorder suggests the following mood variability pattern: intense negative mood, more frequent and abrupt mood changes than healthy controls and patients with major depression, and partial triggering of affect by external events. The method also has great potential to investigate the links between affective instability and other psychological and behavioral correlates of the disorder, such as suicide, lack of self-esteem, and erratic behaviors. However, the method requires systematic study to determine best data collection designs and mathematical models of mood variability.

Time course of anger and other emotions in women with borderline personality disorder: a preliminary study

Borderline personality disorder (BPD) is characterized by emotional dysregulation including strong emotional reactions to emotional stimuli and a slow return to baseline emotions. Difficulties controlling anger are particularly prominent in BPD. To experimentally test emotional dysregulation with a special focus on anger, we investigated whether a standardized anger induction by a short story caused stronger and prolonged anger reactions in women with BPD (n=27) as compared to female healthy controls (n=26) and whether other emotions were affected by the anger induction. Although the anger reaction was not stronger in the BPD group, it was significantly prolonged. The BPD group showed also stronger negative emotions over the whole experiment. The study is the first to demonstrate prolonged anger reactions in BPD patients in an experimental setting.

A momentary assessment study of the reputed emotional phenotype associated with borderline personality disorder

BACKGROUND

Stress is postulated to play an essential role in the expression of core borderline symptoms. However, the phenomenology of stress reactivity in borderline personality disorder remains unclear. The current study investigated the phenomenology of stress sensitivity in borderline personality disorder in the flow of daily life and compared this with stress sensitivity in patients suffering from psychotic disorders, a group so far known to report the largest reactivity to stress.

METHOD

A total of 44 borderline patients, 42 patients with psychotic disorder and 49 healthy controls were studied with the Experience Sampling Method (a structured diary technique assessing current context and mood in daily life) to assess: (1) appraised subjective stress related to daily events and activities; and (2) emotional reactivity conceptualized as changes in positive and negative affect.

RESULTS

Multilevel regression analysis revealed that subjects with borderline personality disorder experienced significantly more emotional reactivity to daily life stress compared with both patients with psychosis and healthy controls, as evidenced by a larger increase in negative affect and a larger decrease in positive affect following stress.

CONCLUSION

These results are the first to ecologically validate the incorporation of stress reactive symptoms in the diagnosis of borderline personality disorder. Borderline patients continually react stronger than patients with psychosis and healthy controls to small disturbances that continually happen in the natural flow of everyday life. Altered emotional stress reactivity may define borderline personality disorder.

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.

Distress and affective dysregulation in patients with borderline personality disorder: a psychophysiological ambulatory monitoring study

Borderline personality disorder (BPD) is characterized by enduring psychological distress and affective dysregulation. Several models have linked both phenomena, but are lacking empirical support. To investigate the relation between psychological distress and components of affective dysregulation (especially inability to label emotions, conflictive emotions, and physiological hyperarousal), we repeatedly assessed these components using a 24-hour ambulatory monitoring approach in a group of 50 BPD patients and 50 healthy controls. Hierarchical linear model analyses identified a clear relation between inability to label emotions and distress in the BPD group (p = 0.0009) but not across all subjects (p = 0.6492). Conflictive emotions were related to psychological distress in both groups (p < 0.0001). This relation is, however, most pertinent to the BPD group who experienced conflicting emotions more frequently. Physiological arousal (heart rate) was related to distress in both groups. Our empirical findings emphasize training in labeling emotions and distress tolerance interventions in treatment for BPD.

Motives for nonsuicidal self-injury among women with borderline personality disorder

Patients with borderline personality disorder (BPD) are known to use nonsuicidal self-injury (NSSI) as a dysfunctional strategy to regulate intense emotions. The primary purpose of this study was to clarify the motives for NSSI along with their interrelations. We further investigated the variety of emotions preceding NSSI and possible effects of NSSI on these emotions. To this end, a structured self-rating questionnaire on NSSI was administered to 101 female BPD-patients exhibiting NSSI. Most patients reported multiple motives for NSSI. The motives were more likely to compound than to exclude one another. Negative reinforcement was almost always involved in NSSI, whereas positive reinforcement (e.g., "getting a kick") played an additional role among about half of the patients. NSSI was usually preceded by a large variety of negative feelings that were reported to clearly improve with NSSI. In conclusion, therapists should anticipate a multidimensional functional spectrum when exploring motives of NSSI.

[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.

BPD's interpersonal hypersensitivity phenotype: a gene-environment-developmental model

This paper explores the development of BPD as it might emerge in the child's early interpersonal reactions and how such reactions might evolve into the interpersonal pattern that typifies BPD. It begins to bridge the relevant bodies of clinical literature on the borderline's prototypic interpersonal problems with the concurrently expanding relevant literature on early child development. We will start by considering how a psychobiological disposition to BPD is likely to include a constitutional diathesis for relational reactivity, that is, for hypersensitivity to interpersonal stressors. Data relevant to this disposition's manifestations in adult clinical samples and to its heritability and neurobiology will be reviewed. We then consider how such a psychobiological disposition for interpersonal reactivity might contribute to the development of a disorganized-ambivalent form of attachment, noting especially the likely contributions of both the predisposed child and of parents who are themselves predisposed to maladaptive responses, leading to an escalation of problematic transactions. Evidence concerning both the genetics and the developmental pathways associated with disorganized attachments will be considered. Emerging links between such developmental pathways and adult BPD will be described, in particular the potential appearance by early- to middle-childhood of controlling-caregiving or controlling-punitive interpersonal strategies. Some implications from this gene-environment interactional theory for a better developmental understanding of BPD's etiology are discussed.

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.

An experimental pilot study of response to invalidation in young women with features of borderline personality disorder

One of the leading biosocial theories of borderline personality disorder (BPD) suggests that individuals with BPD have biologically based abnormalities in emotion regulation contributing to more intense and rapid responses to emotional stimuli, in particular, invalidation [Linehan, M.M., 1993. Cognitive-Behavioral Treatment of Borderline Personality Disorder. Guilford, New York.]. This study used a 2 by 2 experimental design to test whether young women with features of BPD actually show increased physiological arousal in response to invalidation. Twenty-three women ages 18 to 29 who endorsed high levels of BPD symptoms and 18 healthy controls were randomly assigned to hear either a validating or invalidating comment during a frustrating task. Although we found preliminary support for differential response to these stimuli in self-report of valence, we found neither self-report nor physiological evidence of hyperarousal in the BPD features group, either at baseline or in response to invalidation. Interestingly, the BPD features group reported significantly lower comfort with emotion, and comfort was significantly associated with affective valence but not arousal. We discuss implications for understanding and responding to the affective intensity of this population.