Family study of borderline personality disorder and its sectors of psychopathology

What predicts psychosocial functioning in borderline personality disorder? Investigating the association with reflective functioning

OBJECTIVES

The aim of this study was to investigate factors associated with functioning in participants with and without borderline personality disorder (BPD). In particular, we were interested whether mentalizing and related social cognitive capacities, as factors of internal functioning, are important in predicting psychosocial functioning, in addition to other psychopathological and sociodemographic factors.

METHOD

This is a cross-sectional study with N = 53 right-handed females with and without BPD, without significant differences in age, IQ, and socioeconomic status, who completed semi-structured diagnostic and self-report measures of social cognition. Mentalizing was assessed using the Reflective Functioning Scale based on transcribed Adult Attachment Interviews. A regularized regression with the elastic net penalty was deployed to investigate whether mentalizing and social cognition predict psychosocial functioning.

RESULTS

Borderline personality disorder symptom severity, sexual abuse trauma, and social and socio-economic factors ranked as the most important variables in predicting psychosocial functioning, while reflective functioning (RF) was somewhat less important in the prediction, social cognitive functioning and sociodemographic variables were least important.

CONCLUSIONS

Borderline personality disorder symptom severity was most important in determining functional impairment, alongside trauma related to sexual abuse as well as social and socio-economic factors. These findings verify that BPD symptoms themselves most robustly predict functional impairment, followed by history of sexual abuse, then contextual factors (e.g. housing, financial, physical health), and then RF. These results lend marginal support to the conceptualization that mentalizing may enhance psychosocial functioning by facilitating social learning, but emphasize symptom reduction and stabilization of life context as key intervention targets.

Attachment and borderline personality disorder as the dance unfolds: A quantitative analysis of a novel paradigm

Current research on personality disorders strives to identify key behavioural and cognitive facets of patient functioning, to unravel the underlying root causes and maintenance mechanisms. This process often involves the application of social paradigms - however, these often only include momentary affective depictions rather than unfolding interactions. This constitutes a limitation in our capacity to probe core symptoms, and leaves potential findings uncovered which could help those who are in close relationships with affected individuals. Here, we deployed a novel task in which subjects interact with four unknown virtual partners in a turn-taking paradigm akin to a dance, and report on their experience with each. The virtual partners embody four combinations of low/high expressivity of positive/negative mood. Higher scores on our symptomatic measures of attachment anxiety, avoidance, and borderline personality disorder (BPD) were all linked to a general negative appraisal of all the interpersonal experiences. Moreover, the negative appraisal of the partner who displayed a high negative/low positive mood was tied with attachment anxiety and BPD symptoms. The extent to which subjects felt responsible for causing partners' distress was most strongly linked to attachment anxiety. Finally, we provide a fully-fledged exploration of move-by-move action latencies and click distances from partners. This analysis underscored slower movement initiation from anxiously attached individuals throughout all virtual interactions. In summary, we describe a novel paradigm for second-person neuroscience, which allowed both the replication of established results and the capture of new behavioural signatures associated with attachment anxiety, and discuss its limitations.

The cultural change narrative as a core component of therapeutic change

Introduction

Research indicates a similar effect of Mentalization-based treatment (MBT) and Dialectical behavior therapy (DBT) for borderline personality disorder (BPD). However, there is a paucity in studies investigating the change narrative received from and developed in these treatments. The aim of the present study is to investigate similarities and differences in the change narratives provided by MBT and DBT, and how these narratives reflect the rationale, explanations, and procedures of the provided treatment.

Methods

The study is a qualitative analysis of seven interviews conducted by the authors. Three of the participants had received MBT, and four of the participants had received DBT. This study presents an Interpretative Phenomenological Analysis (IPA) of the change narratives received in two specialized treatments for BPD.

Results

The main findings from the IPA were that the change narratives described by the participants reflected the treatment they received. The DBT participants highlighted explicit learning of tools and techniques, with predictable and safe therapists. In contrast, the MBT participants emphasized a long-lasting process of exploring to create procedural learning with therapists who followed their lead.

Discussion

The participants' stories of change shed light on how a change narrative was developed, and therefore how the rationale, explanations and procedures were conveyed differently by MBT and DBT.

Examining the Construct Validity of Borderline Personality Traits Using Familial Aggregation and Other External Validators

Numerous studies have questioned the reliability and validity of borderline personality disorder's (BPD) categorical conceptualization. DSM-5 Section III's alternative trait-based model of BPD may better capture borderline pathology, but aspects of its validity should be further established. Thus, the authors examined whether a latent BPD factor derived from Section III traits exhibits (1) familial aggregation among siblings and (2) association with constructs related to borderline pathology. The authors also tested whether gender moderated associations. A total of 498 community-recruited adults completed the Personality Inventory for DSM-5, a behavioral assessment of risk-taking, and reported their history of childhood maltreatment, substance use, nonsuicidal self-injury, and suicidal ideation. Familial aggregation was assessed among 232 sibling pairs. Siblings' BPD scores were significantly correlated and most external validators were significantly associated with BPD, with the exception of risk-taking. Results did not vary by gender. Findings further support the construct validity of Section III's BPD trait profile.

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

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

Clinical differences between bipolar disorder and borderline personality disorder: a case report

The clinical difference between bipolar disorder and borderline personality disorder has always been a diagnostic challenge, especially with type II bipolar disorder and subthreshold symptoms, opening a diagnostic bias with the consequent repercussions of inappropriate treatment. Both pathologies are often misdiagnosed initially. The objective of this article is to emphasise the main clinical differences between the two pathologies. We present the case of a patient with a long history of psychiatric symptoms that started in childhood, with considerable functional impairment, who met the criteria for both disorders, pointing to comorbidity. During follow-up, she responded favourably to psychotropic drugs, pushing the diagnosis towards the bipolar spectrum, due to the notable improvement. However, comorbidity should not be neglected due to its high presentation.

Parental Reports of Physically Self-Destructive Behavior in the Offspring of Patients With Borderline Personality Disorder and Other Personality Disorders

The main aim of this article is to compare the prevalence of four forms of physically self-destructive behavior in the offspring of parents with borderline personality disorder (BPD) and compare them to the offspring of parents with other personality disorders (OPD). At the 4- and 6-year waves in a prospective study of the long-term course of BPD, participants were asked to report on the self-destructive behaviors of their children using the Childhood Self-Destructiveness Scale. A total of 68 parents were interviewed regarding 131 children, 104 of whom were offspring of parents with BPD (n = 55) and 27 were offspring of parents with OPD (n = 13). BPD parents reported significantly more self-injury and substance abuse in their children than OPD parents. The results from this study suggest that both direct and indirect forms of self-destructive behavior are both more common and quite specific for the children of parents with BPD.

Novel splice‑site variants c.393G>A, c.278_2A>G in exon 2 and Q705K variant in exon 3 of NLRP3 gene are associated with bipolar I disorder

NOD‑like receptor pyrin domain‑containing 3 (NLRP3) has been considered to play a crucial role in triggering the host's immune and inflammatory responses. Genetic variants are critical determinants of interindividual variances in inflammatory responses and clinical outcomes. The role of NLRP3 gene variations in bipolar I (BPI) disorder, which is known to include genetic factors in its aetiology, has not been previously reported, at least to the best of our knowledge. The present study aimed to determine the role and frequency ofta exon 2 and exon 3 variants of NLRP3 in BPI disorder and to evaluate the association between different phenotypic traits. A case‑control study with 123 patients and 107 healthy controls was conducted to investigate the association of variants identified in the exon 2 and exon 3 regions of NLRP3, with the risk of BPI. Regions of interest were sequenced using a PCR‑based Sanger sequencing method. Three BPI‑related variants were identified. The genotype Q705K CA was detected more frequently in BPI patients, as compared to the control group [P<0.001; odds ratio (OR), 0.202; 95% confidence interval (CI), 0.080‑0.508]. In addition, two novel splice‑site variants (c.393G>A and c.278_2A>G) that, to the best of our knowledge, have not been previously reported in any database, were detected only in the BPI patient group [P<0.001; OR, 0.846; 95% CI, 0.784‑0.912; P<0.001; OR, 0.886; 95% CI, 0.832‑0.944, respectively]. There was no significant association between the Q795K variant and phenotypic traits (P>0.05). However, there was a significant association between those carrying the heterozygous c.393G>A variant and a positive family history (P=0.043). It was also observed that those with the heterozygous c.278‑2A>G variant presented with a significantly early‑onset (P=0.003). On the whole, the data of the present study suggested that NLRP3 plays a crucial role in the pathogenesis of BPI and may be a potential risk factor. However, further functional studies and repeated studies in other populations are required to properly comprehend the roles of the NLRP3 variants in the risk of developing BPI.

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

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

Neurophysiological biomarkers of response inhibition and the familial risk for borderline personality disorder

Understanding of the biological factors that run in families affected with borderline personality disorder (BPD) is limited. The authors investigated the familial aggregation of neurophysiological biomarkers of response inhibition in the first-degree biological relatives of probands with BPD and associations with psychiatric diagnosis and impulsive traits. In the present study, psychiatric diagnoses and impulsive traits were measured in BPD probands (n = 86), psychiatrically affected and non-affected relatives (n = 60) and controls (n = 83). While undergoing neuroimaging using functional near-infrared spectroscopy, prefrontal cortex (PFC) activation was measured during a go/no-go response inhibition task and compared between probands, relatives and controls. Additionally, non-psychiatrically affected relatives and controls were contrasted to examine the potential impact of familial risk for BPD on response inhibition-related PFC activation in the absence of confounding psychiatric morbidity. Probands showed bilateral decreases in PFC activation during response inhibition compared to relatives and controls. Conversely, both affected and non-affected relatives displayed higher activation than controls and probands in left lateral/medial and right medial PFC, although non-affected relatives showed a lesser extent of activation than affected relatives. Probands and controls reporting greater impulsive traits displayed deactivation across the PFC during response inhibition, whereas relatives showed increased activation. In this first family study of neuroimaging biomarkers in BPD, we show that the familial risk for BPD is reflected in activation of the PFC during response inhibition, with lifetime psychiatric diagnosis and higher impulsive traits in relatives associated with larger increases in PFC activity. Higher PFC activity during response inhibition including among non-affected relatives could reflect a neurophysiological compensatory mechanism.

Borderline Personality Disorder: Risk Factors and Early Detection

Personality disorders (PDs) exert a great toll on health resources, and this is especially true for borderline personality disorder (BPD). As all PDs, BPD arises during adolescence or young adulthood. It is therefore important to detect the presence of this PD in its earlier stages in order to initiate appropriate treatment, thus ameliorating the prognosis of this condition. This review aims to highlight the issues associated with BPD diagnosis in order to promote its early detection and treatment. To do so, we conducted a search on PubMed database of current evidence regarding BPD early diagnosis, focusing on risk factors, which represent important conditions to assess during young patient evaluation, and on diagnostic tools that can help the clinician in the assessment process. Our findings show how several risk factors, both environmental and genetic/neurobiological, can contribute to the onset of BPD and help identify at-risk patients who need careful monitoring. They also highlight the importance of a careful clinical evaluation aided by psychometric tests. Overall, the evidence gathered confirms the complexity of BDP early detection and its crucial importance for the outcome of this condition.

Clinical Differences between Bipolar Disorder and Borderline Personality Disorder: A Case Report

The clinical difference between bipolar disorder and borderline personality disorder has always been a diagnostic challenge, especially with type II bipolar disorder and subthreshold symptoms, opening a diagnostic bias with the consequent repercussions of inappropriate treatment. Both pathologies are often misdiagnosed initially. The objective of this article is to emphasise the main clinical differences between the two pathologies. We present the case of a patient with a long history of psychiatric symptoms that started in childhood, with considerable functional impairment, who met the criteria for both disorders, pointing to comorbidity. During follow-up, she responded favourably to psychotropic drugs, pushing the diagnosis towards the bipolar spectrum, due to the notable improvement. However, comorbidity should not be neglected due to its high presentation.

Facial Emotion Perception in Families Affected With Borderline Personality Disorder

Emotion perception biases may precipitate problematic interpersonal interactions in families affected with borderline personality disorder (BPD) and lead to conflictual relationships. In the present study, the authors investigated the familial aggregation of facial emotion recognition biases for neutral, happy, sad, fearful, and angry expressions in probands with BPD (n = 89), first-degree biological relatives (n = 67), and healthy controls (n = 87). Relatives showed comparable accuracy and response times to controls in recognizing negative emotions in aggregate and most discrete emotions. For sad expressions, both probands and relatives displayed slower response latencies, and they were more likely than controls to perceive sad expressions as fearful. Nonpsychiatrically affected relatives were slower than controls in responding to negative emotional expressions in aggregate, and fearful and sad facial expressions more specifically. These findings uncover potential biases in perceiving sad and fearful facial expressions that may be transmitted in families affected with BPD.

Familial risk and heritability of diagnosed borderline personality disorder: a register study of the Swedish population

Family and twin studies of Borderline Personality Disorder (BPD) have found familial aggregation and genetic propensity for BPD, but estimates vary widely. Large-scale family studies of clinically diagnosed BPD are lacking. Therefore, we performed a total-population study estimating the familial aggregation and heritability of clinically diagnosed BPD. We followed 1,851,755 individuals born 1973-1993 in linked Swedish national registries. BPD-diagnosis was ascertained between 1997 and 2013, 11,665 received a BPD-diagnosis. We identified relatives and estimated sex and birth year adjusted hazard ratios, i.e., the rate of BPD-diagnoses in relatives to individuals with BPD-diagnosis compared to individuals with unaffected relatives, and used structural equation modeling to estimate heritability. The familial association decreased along with genetic relatedness. The hazard ratio was 11.5 (95% confidence interval (CI) = 1.6-83.8) for monozygotic twins; 7.4 (95% CI = 1.0-55.3) for dizygotic twins; 4.7 (95% CI = 3.9-5.6) for full siblings; 2.1 (95% CI = 1.5-3.0) for maternal half-siblings; 1.3 (95% CI = 0.9-2.1) for paternal half-siblings; 1.7 (95% CI = 1.4-2.0) for cousins whose parents were full siblings; 1.1 (95% CI = 0.7-1.8) for cousins whose parents were maternal half-siblings; and 1.9 (95% CI = 1.2-2.9) for cousins whose parents were paternal half-siblings. Heritability was estimated at 46% (95% CI = 39-53), and the remaining variance was explained by individually unique environmental factors. Our findings pave the way for further research into specific genetic variants, unique environmental factors implicated, and their interplay in risk for BPD.

Validation of computerized reflective function: A replication study

Objective: The Reflective Function (RF) Scale is the original validated measure of mentalizing, applied to Adult Attachment Interview (AAI) transcripts. This study aimed to replicate the preliminary validation of Computerized RF (CRF), a computerized text analysis measure of RF.Methods: 49 women with borderline personality disorder (BPD; n = 20) and without (n = 29) completed diagnostic interviews and the AAI. AAIs were scored by certified coders using the RF Scale, and by computerized text analysis software using CRF dictionaries.Results: CRF significantly correlated with RF. The frequency of High CRF words had moderate-to-strong correlations with RF in the total sample (r_s = .47), BPD group (r_s = .61), and non-BPD group (r_s = .41). Adding the frequency of Low CRF words to create a proportion of High and Low CRF words, and applying CRF to AAIs trimmed to include only items that "demand" RF, both produced significant, but not stronger, correlations with RF.Conclusion: CRF is an efficient alternative to the RF Scale that can estimate mentalization. Near average levels, neither RF nor CRF significantly differentiated between groups, indicating mentalizing deficits may not always be present, detectable, or defining in BPD samples. While more research is needed, CRF is a valid assessment of RF when codable text is available.

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

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

General psychiatric management for adolescents (GPM-A) with borderline personality disorder

While borderline personality disorder (BPD) has its onset in youth and is highly prevalent in young people, diagnosis and treatment are frequently delayed, leading to disruptions in development. The few treatments for this population are specialized, resource-intensive, and not widely implemented. Generalist treatments could broadly increase early intervention and access to care, at a less intensive level, when symptoms are milder and developmental arrests can be avoided. One generalist treatment for adults with BPD, General Psychiatric Management, has been adapted for adolescents (GPM-A). GPM-A can be flexibly implemented in different settings, and emphasizes psychoeducation, medicalization of the disorder, life-building activities, and conservative prescribing. This paper introduces GPM-A and proposes it serve as a primary intervention for adolescents with BPD.

Sense of Self: Its Place in Personality Disturbance, Psychopathology, and Normal Experience

Sense of self (SOS) is a cornerstone of psychological inquiry and therapy and is a defining feature of a range of psychological conditions including borderline personality disorder, yet it is poorly understood. SOS is that continuous experience of being a complete and authentic person who feels in control of their own activities. It is a part of normal development of the self and, when weakened by trauma or developmental neglect, is a vulnerability for developing many different disorders, including depression and dissociative, personality, and eating disorders. This review aims to provide a working definition and description of SOS and to summarize its transdiagnostic role in contributing to psychological disorders. To achieve this aim, the article encompasses and unites the literature from various theoretical domains including developmental psychology, identity theory, cognitive psychology, personality disorders, and psychodynamic theories. Implications are raised for psychological therapy and research into psychopathology and its underpinnings.

Clinical, personality, and neurodevelopmental phenotypes in borderline personality disorder: a family study

BACKGROUND

Borderline personality disorder (BPD) is characterized by a heterogeneous clinical phenotype that emerges from interactions among genetic, biological, neurodevelopmental, and psychosocial factors. In the present family study, we evaluated the familial aggregation of key clinical, personality, and neurodevelopmental phenotypes in probands with BPD (n = 103), first-degree biological relatives (n = 74; 43% without a history of psychiatric disorder), and non-psychiatric controls (n = 99).

METHODS

Participants were assessed on DSM-IV psychiatric diagnoses, symptom dimensions of emotion dysregulation and impulsivity, 'big five' personality traits, and neurodevelopmental characteristics, as part of a larger family study on neurocognitive, biological, and genetic markers in BPD.

RESULTS

The most common psychiatric diagnoses in probands and relatives were major depression, substance use disorders, post-traumatic stress disorder, anxiety disorders, and avoidant personality disorder. There was evidence of familial aggregation for specific dimensions of impulsivity and emotion dysregulation, and the big five traits neuroticism and conscientiousness. Both probands and relatives reported an elevated neurodevelopmental history of attentional and behavioral difficulties.

CONCLUSIONS

These results support the validity of negative affectivity- and impulse-spectrum phenotypes associated with BPD and its familial risk. Further research is needed to investigate the aggregation of neurocognitive, neural and genetic factors in families with BPD and their associations with core phenotypes underlying the disorder.

A Recurrent Question: What Is Borderline?

The status of borderline personality disorder (BPD) as a diagnostic category is a matter of continuing controversy. In the United States, BPD is one of the most frequent diagnoses of psychiatric inpatients, and a similar tendency emerges in Europe. Nearly all theoretical aspects of BPD have been questioned, including its very position as a personality disorder. In this article, we trace the evolution of the borderline concept from the beginning of the 20th century to the current psychometric research. We argue that the status of BPD is fraught with conceptual difficulties, including an unrecognized semantic drift of major phenomenological terms (e.g., identity), a lack of general principles for the distinction of BPD and the major psychiatric syndromes (e.g., schizophrenia spectrum disorders), and insufficient definitions of key nosological concepts. These difficulties illustrate general problems in today's psychiatry that require consideration.

Borderline Personality Disorder (BPD): In the Midst of Vulnerability, Chaos, and Awe

Borderline personality disorder (BPD) is a chronic psychiatric disorder characterized by pervasive affective instability, self-image disturbances, impulsivity, marked suicidality, and unstable interpersonal relationships as the core dimensions of psychopathology underlying the disorder. Across a wide range of situations, BPD causes significant impairments. Patients with BPD suffer considerable morbidity and mortality compared with other populations. Although BPD is more widely studied than any other personality disorder, it is not understood sufficiently. This paper briefly reviews the recent evidence on the prevalence, etiology, comorbidity, and treatment approaches of borderline personality disorder (BPD) by examining published studies, and aims to offer a more coherent framework for the understanding and management of borderline personality disorder.

Increased BDNF methylation in saliva, but not blood, of patients with borderline personality disorder

Background

The importance of epigenetic alterations in psychiatric disorders is increasingly acknowledged and the use of DNA methylation patterns as markers of disease is a topic of ongoing investigation. Recent studies suggest that patients suffering from Borderline Personality Disorder (BPD) display differential DNA methylation of various genes relevant for neuropsychiatric conditions. For example, several studies report differential methylation in the promoter region of the brain-derived neurotrophic factor gene (BDNF) in blood. However, little is known about BDNF methylation in other tissues.

Results

In the present study, we analyzed DNA methylation of the BDNF IV promoter in saliva and blood of 41 BPD patients and 41 matched healthy controls and found significant hypermethylation in the BPD patient’s saliva, but not blood. Further, we report that BDNF methylation in saliva of BPD patients significantly decreased after a 12-week psychotherapeutic intervention.

Conclusions

Providing a direct comparison of BDNF methylation in blood and saliva of the same individuals, our results demonstrate the importance of choice of tissue for the study of DNA methylation. In addition, they indicate a better suitability of saliva for the study of differential BDNF methylation in BPD patients. Further, our data appear to indicate a reversal of disease-specific alterations in BDNF methylation in response to psychotherapy, though further experiments are necessary to validate these results and determine the specificity of the effect.

Electronic supplementary material

The online version of this article (10.1186/s13148-018-0544-6) contains supplementary material, which is available to authorized users.

Borderline personality disorder is equally trait-like and state-like over ten years in adult psychiatric patients

Borderline personality disorder (PD) has historically been cast as an unabating condition. Longitudinal data, however, support a more variable time course marked by remission and relapse. In the present study, we tested the possibility that borderline PD has both stable (i.e., consistently present across time and situation, as modern diagnostic systems stipulate) and dynamic (i.e., episodic and situational) elements. Participants were 668 patients from the Collaborative Longitudinal Personality Disorders Study who were administered semistructured diagnostic interviews 5 times over a decade. Trait-state-occasion modeling dissected borderline pathology into time-invariant (i.e., trait) and time-varying (i.e., state) components. Contradicting traditional views of PD intransigence, less than half of borderline PD variability (approximately 45%) was time-invariant (i.e., perfectly stable) over the study timeframe. Furthermore, we found that the time-invariant component of borderline pathology, which we termed borderline proneness, was very closely related (r = .81) to a previously validated Five Factor Model trait composite of borderline features. Moreover, the trait versus state components showed a clear pattern of discriminant validity in relation to several putative causal agents for borderline PD (i.e., environmental pathogens, temperament dimensions). We conclude that borderline pathology contains a stable core and sizable situational components, and that both elements relate systematically to normative personality dimensions and known risk factors. These findings have key implications for etiological research, prognosis, and treatment for borderline PD. (PsycINFO Database Record

Borderline personality disorder

Caretakers are often intimidated or alienated by patients with borderline personality disorder (BPD), compounding the clinical challenges posed by the severe morbidity, high social costs and substantial prevalence of this disorder in many health-care settings. BPD is found in ∼1.7% of the general population but in 15-28% of patients in psychiatric clinics or hospitals and in a large proportion of individuals seeking help for psychological problems in general health facilities. BPD is characterized by extreme sensitivity to perceived interpersonal slights, an unstable sense of self, intense and volatile emotionality and impulsive behaviours that are often self-destructive. Most patients gradually enter symptomatic remission, and their rate of remission can be accelerated by evidence-based psychosocial treatments. Although self-harming behaviours and proneness to crisis can decrease over time, the natural course and otherwise effective treatments of BPD usually leave many patients with persistent and severe social disabilities related to depression or self-harming behaviours. Thus, clinicians need to actively enquire about the central issues of interpersonal relations and unstable identity. Failure to correctly diagnose patients with BPD leads to misleading pharmacological interventions that rarely succeed. Whether the definition of BPD should change is under debate that is linked to not fully knowing the nature of this disorder.

Competing Theories of Borderline Personality Disorder

The authors review four theories that propose different conceptualizations of borderline personality disorder's (BPD) core psychopathology: excess aggression, emotional dysregulation, failed mentalization, and interpersonal hypersensitivity. The theories are compared in their ability to explain BPD's coaggregation of four usually distinct sectors of psychopathology, their high overlap with other disorders, their ability to distinguish BPD from other disorders, their integration of heritability, and their clinical applicability. The aims of this review are to increase awareness of these theories, to stimulate improved theories, and to f ster testable hypotheses so that research can advance our knowledge about BPD's core.

Emotion dysregulation in attention-deficit/hyperactivity disorder and borderline personality disorder

There is ongoing debate on the overlap between Attention-Deficit/Hyperactivity Disorder (ADHD) and Borderline Personality Disorder (BPD), particularly regarding emotion dysregulation (ED). In this paper, we present a narrative review of the available evidence on the association of these two disorders from several standpoints. First, we discuss the unique and shared diagnostic criteria for ADHD and BPD, focusing particularly on ED. We consider the methodology of ecological momentary assessment and discuss why this approach could be an alternative and more accurate way to qualitatively distinguish between ADHD and BPD. We summarise key findings on the genetic and environmental risk factors for ADHD and BPD and the extent to which there are shared or unique aetiological and neurobiological risk factors. Finally, we discuss the clinical relevance of considering both disorders in the assessment of patients presenting with trait-like behavioural syndromes, distinguishing the two conditions and implications for treatment.

Dissociation in patients with borderline personality disorder in acute inpatient care - A latent profile analysis

PURPOSE

Dissociation is a common symptom in Borderline Personality disorder (BPD) and its consideration is important for the therapeutic outcome. The aim of this cross-sectional study was to scrutinize the co-occurrence of BPD symptoms and dissociative experiences. In particular, we were interested in the occurrence of specific symptom clusters characterizing qualitatively different patient groups in a clinical sample of BPD patients.

BASIC PROCEDURES

We analyzed the data of 103 patients in a specialized acute inpatient care crisis intervention unit. Measures were the Borderline Symptom List (BSL-95), a German adaption of the Dissociative Experience Scale (FDS), and the Symptom Checklist SCL-90-R. We applied a Latent Profile Analysis (LPA) using the subscales of BSL-95 and FDS to investigate the existence of distinct latent classes of symptom profiles. Afterwards, we related the obtained profiles to other clinical and demographic characteristics.

MAIN FINDINGS

Dissociative experiences of moderate to severe intensity were common among patients with BPD. LPA revealed that a model of three classes fitted the data best: one class was characterized by co-occurrence of severe borderline symptoms and frequent dissociative experiences, one class showed low symptom burden in both measures, and one class showed considerable borderline symptoms but only moderate dissociative experiences. The classes were closely related to the severity of other self-rated psychological problems and showed significantly different occurrences of stress-related comorbid disorders.

PRINCIPAL CONCLUSIONS

The results underline that dissociation is an important factor in many (but not all) BPD patients. This should be addressed by increased attention to dissociative symptoms in the diagnostic process and the adjustment of treatment plans.

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

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

Functional outcomes in community-based adults with borderline personality disorder

Many individuals in clinical samples with borderline personality disorder (BPD) experience high levels of functional impairment. However, little is known about the levels of functional impairment experienced by individuals with BPD in the general community. To address this issue, we compared overall and domain-specific (educational/occupational; social; recreational) functioning in a sample of community-based individuals with BPD (n = 164); community-based individuals without BPD (n = 901); and clinically-ascertained individuals with BPD (n = 61). BPD diagnoses and functional outcomes were based on well-accepted, semi-structured interviews. Community-based individuals with BPD were significantly less likely to experience good overall functioning (steady, consistent employment and ≥1 good relationship) compared to community-based individuals without BPD (BPD: 47.4%; Non- BPD: 74.5%; risk difference -27.1%; p < 0.001), even when compared directly to their own non-BPD siblings (risk difference -35.5%; p < 0.001). Community-based individuals with BPD versus those without BPD did not differ significantly on most domain-specific outcomes, but the former group experienced poorer educational/occupational performance and lower quality relationships with parents, partners, and friends. However, community-based individuals with BPD were significantly more likely to experience good overall functioning than clinically-based individuals with BPD (risk difference -35.2%; p < 0.001), with the latter group more likely to experience reduced employment status, very poor quality relationships with partners, and social isolation. In conclusion, community-based individuals with BPD experienced marked functional impairment, especially in the social domain, but were less likely to experience the more extreme occupational and social impairments seen among patients with BPD.

Children's Emotion Regulation Difficulties Mediate the Association Between Maternal Borderline and Antisocial Symptoms and Youth Behavior Problems Over 1 Year

Borderline personality disorder (BPD) and antisocial personality disorder (ASPD) are among the most debilitating psychiatric conditions. Behaviors and traits associated with these disorders can have profound influences on those surrounding the affected individual. Accordingly, researchers have begun to examine effects of these symptoms on parent-child relationships. Theoretical and empirical work suggests that one mechanism linking maternal psychopathology to child symptoms is familial transmission of emotion dysregulation. The authors examined children's emotion regulation difficulties as a mediator between maternal BPD/ASPD symptoms and child behavior problems 1 year later. Analyses revealed that a composite of maternal BPD/ASPD symptoms had a direct effect on child internalizing, externalizing, and total symptoms. Associations between maternal BPD/ASPD symptoms and youth problems were partially mediated by child emotion regulation difficulties, even with maternal depression and other relevant covariates included in the models. Thus, maternal BPD/ASPD symptoms and child emotion regulation difficulties represent potential targets for prevention of psychopathology among youth.

Mentalization-based treatment in groups for adolescents with borderline personality disorder (BPD) or subthreshold BPD versus treatment as usual (M-GAB): study protocol for a randomized controlled trial

Background

Evidence-based outpatient psychotherapeutic programs are first-line treatment of borderline personality disorder (BPD). Early and effective treatment of BPD is crucial to the prevention of its individual, psychosocial, and economic consequences. However, in spite of recent advantages in diagnosing adolescent BPD, there is a lack of cost-effective evidence-based treatment programs for adolescents. Mentalization-based treatment is an evidence-based program for BPD, originally developed for adults.

Methods/Design

Aims/hypotheses: We will investigate whether a specifically designed mentalization-based treatment in groups is an efficacious treatment for adolescents with BPD or subthreshold BPD compared to treatment as usual. The trial is a four-center, two-armed, parallel-group, assessor-blinded randomized clinical superiority trial. One hundred twelve patients aged 14 to 17 referred to Child and Adolescent Psychiatric Clinics in Region Zealand are randomized to 1 year of either mentalization-based treatment in groups or treatment as usual. Patients will be included if they meet at least four DSM-5 criteria for BPD. The primary outcome is self-reported borderline features at discharge. Secondary outcomes will include self-harm, depression, BPD criteria, externalizing and internalizing symptoms, and social functioning, together with parental reports on borderline features, externalizing and internalizing symptoms. Measures of attachment and mentalization will be included as mediational variables. Follow-up assessment will take place at 3 and 12 months after end of treatment.

Discussion

This is the first randomized controlled trial to test the efficacy of a group-based mentalization-based treatment for adolescents with BPD or subthreshold BPD. If the results confirm our hypothesis, this trial will add to the treatment options of cost-effective treatment of adolescent BPD.

Trial registration

Clinicaltrials.gov NCT02068326, February 19, 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1431-0) contains supplementary material, which is available to authorized users.

ESCAP Expert Article: borderline personality disorder in adolescence: an expert research review with implications for clinical practice

Borderline personality disorder (BPD) has onset in adolescence, but is typically first diagnosed in young adulthood. This paper provides a narrative review of the current evidence on diagnosis, comorbidity, phenomenology and treatment of BPD in adolescence. Instruments available for diagnosis are reviewed and their strengths and limitations discussed. Having confirmed the robustness of the diagnosis and the potential for its reliable clinical assessment, we then explore current understandings of the mechanisms of the disorder and focus on neurobiological underpinnings and research on psychological mechanisms. Findings are accumulating to suggest that adolescent BPD has an underpinning biology that is similar in some ways to adult BPD but differs in some critical features. Evidence for interventions focuses on psychological therapies. Several encouraging research studies suggest that early effective treatment is possible. Treatment development has just begun, and while adolescent-specific interventions are still in the process of evolution, most existing therapies represent adaptations of adult models to this developmental phase. There is also a significant opportunity for prevention, albeit there are few data to date to support such initiatives. This review emphasizes that there can be no justification for failing to make an early diagnosis of this enduring and pervasive problem.

Distinguishing bipolar disorder from borderline personality disorder: A study of current clinical practice

BACKGROUND

Diagnosing mental illness is a central role for psychiatrists. Correct diagnosis informs both treatment and prognosis, and facilitates accurate communication. We sought to explore how psychiatrists distinguished two common psychiatric diagnoses: bipolar disorder (BD) and borderline personality disorder (BPD).

METHODS

We conducted a qualitative study of psychiatrists to explore their practical experience. We then sought to validate these results by conducting a questionnaire study testing the theoretical knowledge and practical experience of a large number of UK psychiatrists. Finally we studied the assessment process in NHS psychiatric teams by analysing GP letters, assessments by psychiatrists, and assessment letters.

RESULTS

There was broad agreement in both the qualitative and questionnaire studies that the two diagnoses can be difficult to distinguish. The majority of psychiatrists demonstrated in survey responses a comprehensive understanding DSM-IV-TR criteria although many felt that these criteria did not necessarily assist diagnostic differentiation. This scepticism about diagnostic criteria appeared to strongly influence clinical practice in the sample of clinicians we observed. In only a minority of assessments were symptoms of mania or BPD sufficiently assessed to establish the presence or absence of each diagnosis.

CONCLUSION

Clinical diagnostic practice was not adequate to differentiate reliably BD and BPD. The absence of reliable diagnostic practice has widespread implications for patient care, service provision and the reliability of clinical case registries.

Severity of borderline personality symptoms in adolescence: relationship with maternal parenting stress, maternal psychopathology, and rearing styles

The development of borderline personality disorder (BPD) has been associated with parenting styles and parental psychopathology. Only a few studies have examined current parental rearing styles and parental psychopathology in relationship to BPD symptoms in adolescents. Moreover, parenting stress has not been examined in this group. The current study examined 101 adolescents (14-19 years old) with BPD symptoms and their mothers. Assessments were made on severity of BPD symptoms, youth-perceived maternal rearing styles, and psychopathology and parenting stress in mothers. Multiple regression analyses were used to examine potential predictors of borderline severity. No correlation was found between severity of BPD symptoms in adolescents and parenting stress. Only youth-perceived maternal overprotection was significantly related to BPD severity. The combination of perceived maternal rejection with cluster B traits in mothers was significantly related to BPD severity in adolescents. This study provides a contribution to the disentanglement of the developmental pathways that lead to BPD.

Adolescent precursors of adult borderline personality pathology in a high-risk community sample

Longitudinal studies of the exact environmental conditions and personal attributes contributing to the development of borderline personality disorder (BPD) are rare. Furthermore, existing research typically examines risk factors in isolation, limiting our knowledge of the relative effect sizes of different risk factors and how they act in concert to bring about borderline personality pathology. The present study investigated the prospective effects of diverse acute and chronic stressors, proband psychopathology, and maternal psychopathology on BPD features in a high-risk community sample (N = 700) of youth followed from mid-adolescence to young adulthood. Multivariate analyses revealed significant effects of maternal externalizing disorder history, offspring internalizing disorder history, family stressors, and school-related stressors on BPD risk. Contrary to expectations, no interactions between chronically stressful environmental conditions and personal characteristics in predicting borderline personality features were detected. Implications of these findings for etiological theories of BPD and early screening efforts are discussed.

Improvements in depression severity in hospitalized patients with and without borderline personality features

INTRODUCTION

Patients with borderline personality disorder (BPD) often struggle with treatment-resistant depression. To date, few studies have specifically assessed the rate of improvement of depressive symptoms during an acute inpatient hospitalization in patients who screen positive for BPD compared with those who do not.

METHODS

A sample of 245 psychiatric inpatients was divided into 2 groups on the basis of whether or not they tested positive on the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD). Hamilton Depression Rating Scale (Ham-D) scores were compared from admission to discharge.

RESULTS

At admission, the MSI-BPD group (n=64) endorsed significantly more depressive symptoms than the MSI-BPD group (n=181), as measured by higher mean Ham-D scores (34.1 vs. 30.3, P=0.0002). Although both groups demonstrated improvements in Ham-D scores by discharge, the MSI-BPD group showed a markedly more robust change (22.1 vs. 18.2, P=0.002). This effect remained significant using a propensity score model to account for differences in baseline characteristics between the 2 groups (22.1 vs. 18.8, P=0.022).

CONCLUSIONS

These findings suggest that patients who test positive on this BPD screening tool tend to be admitted in greater distress and to subsequently improve more robustly in the setting of an inpatient hospitalization. This finding lends support to the theory that the depressive symptoms associated with borderline personality pathology emerge in the context of interpersonal hypersensitivity and relationship instability and therefore that the holding environment of the hospital can result in rapid improvement.

Borderline personality disorder in the primary care setting

Borderline personality disorder is estimated to be present in approximately 6% of outpatient primary care settings. However, the time and energy spent on this population can greatly exceed what primary care doctors are able to spend. This article gives an overview of borderline personality disorder, including the clinical characteristics, epidemiology, and comorbidities, as well as pharmacologic and most important behavioral management. It is our hope that, with improved understanding of the disorder and skills for managing this population, caring for patients with the disorder can be more satisfying and less taxing for both primary care doctors and their patients.

Prediction of time-to-attainment of recovery for borderline patients followed prospectively for 16 years

OBJECTIVE

The purpose of this study was to determine the most clinically relevant baseline predictors of time-to-recovery from borderline personality disorder.

METHOD

Two hundred and ninety in-patients meeting rigorous criteria for borderline personality disorder were assessed during their index admission using a series of semistructured interviews and self-report measures. Recovery status, which was defined as concurrent symptomatic remission and good social and full-time vocational functioning, was reassessed at eight contiguous 2-year time periods. Survival analytic methods (Cox regression), which controlled for overall baseline severity, were used to estimate hazard ratios and their confidence intervals.

RESULTS

All told, 60% of the borderline patients studied achieved a 2-year recovery. In bivariate analyses, seventeen variables were found to be significant predictors of earlier time-to-recovery. Six of these predictors remained significant in multivariate analyses: no prior psychiatric hospitalizations, higher IQ, good full-time vocational record in 2 years prior to index admission, absence of an anxious cluster personality disorder, high extraversion, and high agreeableness.

CONCLUSION

Taken together, the results of this study suggest that prediction of time-to-recovery for borderline patients is multifactorial in nature, involving factors related to lack of chronicity, competence, and more adaptive aspects of temperament.

Reliability and validity of a Chinese version of the Diagnostic Interview for Borderlines-Revised

INTRODUCTION

Borderline personality disorder (BPD) is the most studied of the axis II disorders. One of the most widely used diagnostic instruments is the Diagnostic Interview for Borderline Patients-Revised (DIB-R). The aim of this study was to test the reliability and validity of DIB-R for use in the Chinese culture.

METHODS

The reliability and validity of the DIB-R Chinese version were assessed in a sample of 236 outpatients with a probable BPD diagnosis. The Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II) was used as a standard. Test-retest reliability was tested six months later with 20 patients, and inter-rater reliability was tested on 32 patients.

RESULTS

The Chinese version of the DIB-R showed good internal global consistency (Cronbach's α of 0.916), good test-retest reliability (Pearson correlation of 0.704), good inter-rater reliability (intra-class correlation coefficient of 0.892 and kappa of 0.861). When compared with the DSM-IV diagnosis as measured by the SCID-II, the DIB-R showed relatively good sensitivity (0.768) and specificity (0.891) at the cutoff of 7, moderate diagnostic convergence (kappa of 0.631), as well as good discriminating validity.

DISCUSSION

The Chinese version of the DIB-R has good psychometric properties, which renders it a valuable method for examining the presence, the severity, and component phenotypes of BPD in Chinese samples.

Depression in patients with borderline personality disorder

Borderline personality disorder (BPD) and major depressive disorder (MDD) commonly co-occur, but the relationship between these disorders remains unclear. While BPD patients often suffer from depression, their subjective experience and treatment response are different from that experienced by MDD patients without BPD. Surveying the current literature on the interface of these two pathologies, we find that depression in BPD has distinct symptoms, treatment responses, remission predictors, and suicide risks. It tends to be subjectively more severe, more interpersonally fueled, and more persistent than MDD without BPD. BPD depression responds less well to biological treatments and may be fueled by the neurobiology of BPD. These findings suggest that clinicians should recognize the unique features of BPD depression and anticipate a clinical trajectory that may be different from MDD without BPD, keeping in mind that BPD depression tends not to improve until BPD improves.

The contribution of familial internalizing and externalizing liability factors to borderline personality disorder

BACKGROUND

Individuals with borderline personality disorder (BPD) frequently display co-morbid mental disorders. These disorders include 'internalizing' disorders (such as major depressive disorder and anxiety disorders) and 'externalizing' disorders (such as substance use disorders and antisocial personality disorder). It is hypothesized that these disorders may arise from latent 'internalizing' and 'externalizing' liability factors. Factor analytic studies suggest that internalizing and externalizing factors both contribute to BPD, but the extent to which such contributions are familial is unknown.

METHOD

Participants were 368 probands (132 with BPD; 134 without BPD; and 102 with major depressive disorder) and 885 siblings and parents of probands. Participants were administered the Diagnostic Interview for DSM-IV Personality Disorders, the Revised Diagnostic Interview for Borderlines, and the Structured Clinical Interview for DSM-IV.

RESULTS

On confirmatory factor analysis of within-person associations of disorders, BPD loaded moderately on internalizing (factor loading 0.53, S.E. = 0.10, p < 0.001) and externalizing latent variables (0.48, S.E. = 0.10, p < 0.001). Within-family associations were assessed using structural equation models of familial and non-familial factors for BPD, internalizing disorders, and externalizing disorders. In a Cholesky decomposition model, 84% (S.E. = 17%, p < 0.001) of the association of BPD with internalizing and externalizing factors was accounted for by familial contributions.

CONCLUSIONS

Familial internalizing and externalizing liability factors are both associated with, and therefore may mutually contribute to, BPD. These familial contributions account largely for the pattern of co-morbidity between BPD and internalizing and externalizing disorders.

Familial aggregation of candidate phenotypes for borderline personality disorder

Borderline personality disorder (BPD) and its core Diagnostic and Statistical Manual of Mental Disorders (DSM) factor-analytically derived phenotypes aggregate in families. To potentially inform future conceptualizations of BPD, this study examined the familial aggregation and co-aggregation with BPD of 3 additional candidate phenotypes for BPD psychopathology: anxiousness, aggressiveness, and cognitive dysregulation. Participants included 347 probands (126 with BPD, 128 without BPD, and 93 with major depressive disorder) and 814 parents and siblings of probands. All participants completed diagnostic assessments and scales assessing the candidate phenotypes. The familial aggregation of phenotypes (correlation of level of phenotype between family members), the familial co-aggregation of phenotypes with BPD (correlation of phenotype with BPD between family members), and the within-individual correlation of phenotypes with BPD were assessed. All 3 candidate phenotypes showed high levels of familial aggregation (rs = .14 - .53, ps < .001), the magnitudes of which were comparable with DSM-based core sectors of psychopathology. Anxiousness and cognitive dysregulation showed strong within-individual associations with BPD (rs = .55 and .46, respectively; ps < .001) and substantial familial co-aggregation with BPD (rs = .12 and .13, respectively; ps ≤ .002). In contrast, aggressiveness showed a weak within-individual association with BPD (r = .11, p = .12) and little familial co-aggregation with BPD (r = .05, p = .21). These findings suggest that anxiousness and cognitive dysregulation are promising phenotypes for BPD psychopathology that move beyond factor-analytically based conceptualizations. In contrast, aggressiveness was only weakly related to BPD, suggesting that this phenotype may not represent an essential feature of this disorder.

Emotion: empirical contribution. Maternal borderline personality pathology and infant emotion regulation: examining the influence of maternal emotion-related difficulties and infant attachment

Evidence suggests that maternal borderline personality (BP) pathology increases offspring risk. This study examined the relations between maternal BP pathology and related emotional dysfunction (including emotion regulation [ER] difficulties and emotional intensity/reactivity) and infant ER difficulties. Specifically, we examined both self-focused and caregiver-focused ER behaviors and the modulation of emotional expressions (one indicator of ER in young children) in response to fear- and anger-eliciting stimuli among 101 infants (12 to 23 months old) of mothers with and without clinically relevant BP pathology. The authors also examined the moderating role of mother-infant attachment. Findings of a series of multiple regression mediation analyses revealed an indirect effect of maternal BP pathology on infant ER difficulties through maternal emotional dysfunction, with maternal ER difficulties facilitating an indirect effect of maternal BP pathology on expressivity-related indicators of infant ER difficulties and maternal emotional intensity/reactivity linking maternal BP pathology to lower self-focused ER for infants in insecure-resistant attachment relationships.

Reflective function as a mediator between childhood adversity, personality disorder and symptom distress

A growing body of literature has indicated the central role of childhood adversity for the development in later life of personality disorder (PD) and psychiatric distress. In this investigation, we examine the role of reflective function (RF) as a mediator between childhood adversity, subsequent development of PD and psychiatric morbidity. We tested the hypothesis that adversity leads to decreased RF, which in turn is associated with PD, and both increase the likelihood of psychiatric distress. The study sample consisted of 234 individuals, drawn from a clinical PD group (n = 112) and one demographically matched non-psychiatric group (n = 122) using a shared battery of measures, which included the Structured Clinical Interview for DSM-IV, the Symptom Checklist-90-R and the Adult Attachment Interview, which was used to assess RF levels. The results indicated that childhood adversity predicted low level of RF, which in turn was associated with PD onset later in life. A combination of different early adverse experiences had a significantly greater impact on lowering RF scores than experiencing either neglect or abuse alone. Mediation analyses confirmed that RF was a significant mediator between adversity and PD diagnoses and between adversity and psychiatric distress.

Genetics of borderline personality disorder: systematic review and proposal of an integrative model

Borderline personality disorder (BPD) is one of the most common mental disorders and is characterized by a pervasive pattern of emotional lability, impulsivity, interpersonal difficulties, identity disturbances, and disturbed cognition. Here, we performed a systematic review of the literature concerning the genetics of BPD, including familial and twin studies, association studies, and gene-environment interaction studies. Moreover, meta-analyses were performed when at least two case-control studies testing the same polymorphism were available. For each gene variant, a pooled odds ratio (OR) was calculated using fixed or random effects models. Familial and twin studies largely support the potential role of a genetic vulnerability at the root of BPD, with an estimated heritability of approximately 40%. Moreover, there is evidence for both gene-environment interactions and correlations. However, association studies for BPD are sparse, making it difficult to draw clear conclusions. According to our meta-analysis, no significant associations were found for the serotonin transporter gene, the tryptophan hydroxylase 1 gene, or the serotonin 1B receptor gene. We hypothesize that such a discrepancy (negative association studies but high heritability of the disorder) could be understandable through a paradigm shift, in which "plasticity" genes (rather than "vulnerability" genes) would be involved. Such a framework postulates a balance between positive and negative events, which interact with plasticity genes in the genesis of BPD.

Mechanisms of disturbed emotion processing and social interaction in borderline personality disorder: state of knowledge and research agenda of the German Clinical Research Unit

The last two decades have seen a strong rise in empirical research in the mechanisms of emotion dysregulation in borderline personality disorder. Major findings comprise structural as well as functional alterations of brain regions involved in emotion processing, such as amygdala, insula, and prefrontal regions. In addition, more specific mechanisms of disturbed emotion regulation, e.g. related to pain and dissociation, have been identified. Most recently, social interaction problems and their underlying neurobiological mechanisms, e.g. disturbed trust or hypersensitivity to social rejection, have become a major focus of BPD research. This article covers the current state of knowledge and related relevant research goals. The first part presents a review of the literature. The second part delineates important open questions to be addressed in future studies. The third part describes the research agenda for a large German center grant focusing on mechanisms of emotion dysregulation in BPD.