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Cavicchioli M, Scalabrini A, Vai B, Palumbo I, Benedetti F, Galli F, Maffei C. Antecedents and risk factors for borderline personality disorder: Etiopathogenic models based on a multi-level meta-analysis. J Affect Disord 2024; 367:442-452. [PMID: 39243819 DOI: 10.1016/j.jad.2024.08.236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 07/22/2024] [Accepted: 08/31/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND Empirically-based developmental psychopathology approach identified three domains involved in the emergence of borderline personality disorder (BPD): i) underlying liabilities to develop psychopathology (i.e., early patterns of internalizing and externalizing manifestations); ii) invalidating relational experiences (e.g., childhood traumatic experiences, maladaptive parenting, problematic peer relationships); iii) regulatory mechanisms of emotions and behaviors. Nevertheless, no studies have quantitatively summarized empirical findings concerning how and to what extent these domains might be temporally associated to the emergence of BPD features from adolescence to adulthood. METHODS The current multi-level meta-analysis included 106 studies (N = 86,871 participants) assessing the role of previously mentioned antecedents and risk factors for BPD. RESULTS The analysis showed moderate effect sizes capturing temporal associations between early internalizing/externalizing psychopathological manifestations, different invalidating relational experiences, emotion/behavior regulation processes with later BPD features. The effect sizes of these domains were not statistically different from each other. CONCLUSION This evidence supports a transactional developmental model of BPD. Consistently, the emergence of BPD could be viewed in the light of dynamic interplays between an underlying liability to psychopathology and invalidating relational experiences across different stages of development, which are progressively reinforced through increasing alterations of emotion and behavior regulation mechanisms.
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Affiliation(s)
- Marco Cavicchioli
- Department of Dynamic and Clinical Psychology, and Health Studies, Faculty of Medicine and Psychology SAPIENZA University of Rome, Italy; Faculty of Psychology, Sigmund Freud University, Ripa di Porta Ticinese 77, Milan, Italy.
| | - Andrea Scalabrini
- Department of Human and Social Science, University of Bergamo, Italy Mental Health, Bergamo, Italy
| | - Benedetta Vai
- Psychiatry and Clinical Psychobiology Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | | | - Francesco Benedetti
- Psychiatry and Clinical Psychobiology Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Federica Galli
- Department of Dynamic and Clinical Psychology, and Health Studies, Faculty of Medicine and Psychology SAPIENZA University of Rome, Italy
| | - Cesare Maffei
- Faculty of Psychology, Sigmund Freud University, Ripa di Porta Ticinese 77, Milan, Italy
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Stelmach-Lask L, Glebov-Russinov I, Henik A. What is high rumination? Acta Psychol (Amst) 2024; 248:104331. [PMID: 38878469 DOI: 10.1016/j.actpsy.2024.104331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 05/12/2024] [Accepted: 06/06/2024] [Indexed: 08/24/2024] Open
Abstract
OBJECTIVE The current paper tries to illuminate the need for standard cutoff points. INTRODUCTION rumination is considered to be a transdiagnostic process leading to a variety of consequences. But, what is prominent ruminative tendency? Are there agreed-upon specifications or cutoff points that distinguish between high and low tendency to ruminate? In an attempt to answer these questions, we reviewed 25 works that compared people characterized as high or low in rumination. We found numerous inconsistencies in the characterization criteria and a great variability in cutoff points. Most studies did not provide enough information about the cutoff criteria or values. METHOD We examined a sample of 454 participants using the RRS (Ruminative Response Scale), from which we tried to identify standard cutoff points. RESULTS SHOWED 1) distributions of RRS, brooding and reflective pondering; 2) most studies used median split, which might explain the differences among studies; 3) examination of standard scores for the various cutoffs presented big variability among the studies; and 4) women had higher scores of rumination and brooding than men. CONCLUSION Our paper highlights the need for homogeneity in the field. It suggests addressing the RRS, brooding and reflective pondering distributions as references for future studies. We recommend specifying: cutoff criteria, cutoff values, range, means and standard deviations. Researchers should consider the specific population (i.e., men vs. women or clinical vs. non clinical) of interest and infer specific cutoff points accordingly. Importantly, researchers should consider the implications of their choice of cutoff points and apply their criterion accordingly.
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Affiliation(s)
| | | | - Avishai Henik
- Department of Psychology, Ben-Gurion University of the Negev, Israel
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Leichsenring F, Fonagy P, Heim N, Kernberg OF, Leweke F, Luyten P, Salzer S, Spitzer C, Steinert C. Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies. World Psychiatry 2024; 23:4-25. [PMID: 38214629 PMCID: PMC10786009 DOI: 10.1002/wps.21156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2024] Open
Abstract
Borderline personality disorder (BPD) was introduced in the DSM-III in 1980. From the DSM-III to the DSM-5, no major changes have occurred in its defining criteria. The disorder is characterized by instability of self-image, interpersonal relationships and affects. Further symptoms include impulsivity, intense anger, feelings of emptiness, strong abandonment fears, suicidal or self-mutilation behavior, and transient stress-related paranoid ideation or severe dissociative symptoms. There is evidence that BPD can be reliably diagnosed and differentiated from other mental disorders by semi-structured interviews. The disorder is associated with considerable functional impairment, intensive treatment utilization, and high societal costs. The risk of self-mutilation and suicide is high. In the general adult population, the lifetime prevalence of BPD has been reported to be from 0.7 to 2.7%, while its prevalence is about 12% in outpatient and 22% in inpatient psychiatric services. BPD is significantly associated with other mental disorders, including depressive disorders, substance use disorders, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, bipolar disorder, bulimia nervosa, and other personality disorders. There is convincing evidence to suggest that the interaction between genetic factors and adverse childhood experiences plays a central role in the etiology of BPD. In spite of considerable research, the neurobiological underpinnings of the disorder remain to be clarified. Psychotherapy is the treatment of choice for BPD. Various approaches have been empirically supported in randomized controlled trials, including dialectical behavior therapy, mentalization-based therapy, transference-focused therapy, and schema therapy. No approach has proved to be superior to others. Compared to treatment as usual, psychotherapy has proved to be more efficacious, with effect sizes between 0.50 and 0.65 with regard to core BPD symptom severity. However, almost half of the patients do not respond sufficiently to psychotherapy, and further research in this area is warranted. It is not clear whether some patients may benefit more from one psychotherapeutic approach than from others. No evidence is available consistently showing that any psychoactive medication is efficacious for the core features of BPD. For discrete and severe comorbid anxiety or depressive symptoms or psychotic-like features, pharmacotherapy may be useful. Early diagnosis and treatment of BPD can reduce individual suffering and societal costs. However, more high-quality studies are required, in both adolescents and adults. This review provides a comprehensive update of the BPD diagnosis and clinical characterization, risk factors, neurobiology, cognition, and management. It also discusses the current controversies concerning the disorder, and highlights the areas in which further research is needed.
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Affiliation(s)
- Falk Leichsenring
- Department of Psychosomatics and Psychotherapy, University of Giessen, Giessen, Germany
- Department of Psychosomatics and Psychotherapy, University of Rostock, Rostock, Germany
| | - Peter Fonagy
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Nikolas Heim
- International Psychoanalytic University, Berlin, Germany
| | - Otto F Kernberg
- Personality Disorders Institute, Weill Cornell Medical College, New York, NY, USA
| | - Frank Leweke
- Department of Psychosomatics and Psychotherapy, University of Giessen, Giessen, Germany
| | - Patrick Luyten
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
- Faculty of Psychology and Educational Sciences, University of Leuven, Leuven, Belgium
| | - Simone Salzer
- International Psychoanalytic University, Berlin, Germany
| | - Carsten Spitzer
- Department of Psychosomatics and Psychotherapy, University of Rostock, Rostock, Germany
| | - Christiane Steinert
- Department of Psychosomatics and Psychotherapy, University of Giessen, Giessen, Germany
- International Psychoanalytic University, Berlin, Germany
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Cavicchioli M, Ogliari A, Maffei C, Mucci C, Scalabrini A. Dissociative Dimensions and Their Implications for Emotional Dysregulation Underlying Borderline Personality Disorder Features. J Nerv Ment Dis 2023; 211:742-751. [PMID: 37734116 DOI: 10.1097/nmd.0000000000001707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
ABSTRACT Emotion dysregulation is considered a core feature of borderline personality disorder (BPD). The role of dissociation in BPD has been discussed from different perspectives. Nevertheless, implications of dissociation for BPD features are not clear. The current study estimated mediation effects of dissociative dimensions on the relationships between several emotion regulation strategies (ERSs) and BPD features among 281 adults recruited from the general population. The online survey administered a comprehensive self-report battery for the assessment of maladaptive and adaptive ERSs together with dissociative dimensions. Borderline personality disorder features were also self-report screened. Results showed significant indirect effects of dissociation on the relationships between ERSs and BPD features. Dissociation was a full mediator of the relationship between deficits with problem-solving skills and BPD criteria. The study confirmed that emotion dysregulation is a core feature of BPD and that the dissociative dimensions should be included as relevant maladaptive mechanisms sustaining BPD emotional difficulties.
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Affiliation(s)
- Marco Cavicchioli
- Department of Psychology, University "Vita-Salute San Raffaele", Milan, Italy
| | | | - Cesare Maffei
- Department of Psychology, University "Vita-Salute San Raffaele", Milan, Italy
| | - Clara Mucci
- Department of Human and Social Science, University of Bergamo, Bergamo, Italy
| | - Andrea Scalabrini
- Department of Human and Social Science, University of Bergamo, Bergamo, Italy
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Messina I, Spataro P, Sorella S, Grecucci A. "Holding in Anger" as a Mediator in the Relationship between Attachment Orientations and Borderline Personality Features. Brain Sci 2023; 13:878. [PMID: 37371358 DOI: 10.3390/brainsci13060878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/19/2023] [Accepted: 05/20/2023] [Indexed: 06/29/2023] Open
Abstract
Insecure attachment and difficulties in regulating anger have both been put forward as possible explanations for emotional dysfunction in borderline personality (BP). This study aimed to test a model according to which the influence of attachment on BP features in a subclinical population is mediated by anger regulation. In a sample of 302 participants, BP features were assessed with the Borderline features scale of the Personality Assessment Inventory (PAI-BOR), attachment was measured with the Experiences in Close Relationships-12 (ECR-12), and trait anger and anger regulation were assessed with the State and Trait Anger Expression Inventory-2 (STAXI-2). The results indicated that anger suppression emerged as a significant mediator of the associations between both anxious and avoidant attachment and BP traits, while anger control resulted as a marginal mediator in the association between attachment avoidance and BP. Suppressing anger may reflect different forms of cognitive or behavioural avoidance of anger, which may differ on the basis of attachment orientations. We argue that these results may have important clinical implications: the promotion of anger regulation in BP should be considered a critical treatment goal.
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Affiliation(s)
- Irene Messina
- Department of Economics, Mercatorum University, Piazza Mattei 10, 00186 Rome, Italy
- Department of Psychology and Cognitive Sciences, DipSCo, University of Trento and Centre for Medical Sciences, University of Trento, Bettini, 84, 38068 Rovereto, Italy
| | - Pietro Spataro
- Department of Economics, Mercatorum University, Piazza Mattei 10, 00186 Rome, Italy
| | - Sara Sorella
- Department of Psychology and Cognitive Sciences, DipSCo, University of Trento and Centre for Medical Sciences, University of Trento, Bettini, 84, 38068 Rovereto, Italy
| | - Alessandro Grecucci
- Department of Psychology and Cognitive Sciences, DipSCo, University of Trento and Centre for Medical Sciences, University of Trento, Bettini, 84, 38068 Rovereto, Italy
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