Aggression in borderline personality disorder

Neural correlates of aggression in personality disorders from the perspective of DSM-5 maladaptive traits: a systematic review

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published in 2013, includes an alternative model of personality disorders (AMPD) focusing on a maladaptive trait model utilized to diagnose several personality disorders. Borderline personality disorder (BPD) and antisocial personality disorder (ASPD) are two conditions categorized by AMPD that exhibit high rates of violence and aggression. Several of the traits outlined in the AMPD, including hostility, impulsivity, risk-taking, and callousness, have been previously linked to aggression in BPD and ASPD. However, to the best of our knowledge, there has never been a synthesis of neuroimaging studies that have investigated links between these traits and aggression in BPD and ASPD. To overcome this gap, we conducted a systematic review under the PRISMA framework to locate neuroimaging articles published since the release of AMPD linking trait anger/hostility, impulsivity, risk-taking, and callousness to aggression in BPD and ASPD. Key findings included the following: i) anger/hostility, associated with alterations in the interplay between prefrontal and subcortical regions (primarily the amygdala), may be a common factor explaining aggressive reactions to response to interpersonal threat or provocation; ii) alterations of fronto-temporal-limbic regions and serotonergic and endocannabinoid signaling systems may link impulsivity to aggression in BPD and ASPD; iii) weaker cortico-striatal connectivity could relate to greater risk taking and greater proclivity for violence. Insufficient evidence from neuroimaging articles was discerned to describe a relationship between callousness and aggression. Overall, results of this review reveal a relative paucity of neuroimaging studies examining AMPD traits relevant to aggression in BPD and ASPD. In addition to encouraging further investigation of neuroimaging markers of AMPD traits linked to aggression, we recommend multi-methodological designs, including the incorporation of other biomarkers, such as hormones and indices of physiological arousal, to fully expand our understanding of aggression in BPD and ASPD.

An exploratory study of problematic shopping and problematic video gaming in adolescents

Problematic video gaming (PVG) and problematic shopping (PS) are addictive behaviors prevalent in adolescents, characterized by positive and negative reinforcement, and associated with psychosocial impairment. This study examined how PS and PVG relate in adolescents. It also examined how PS interacts with PVG in relation to health/functioning measures. Survey data from 3,657 Connecticut high-school students were evaluated. Chi-square analyses and logistic regression models were used to assess relationships between PS and measures of PVG. Interaction analyses measured effects of PS on relationships between PVG and health/functioning measures. Relative to adolescents without PS, those with PS had 8.79-fold higher odds of exhibiting PVG and were more likely to endorse gaming to relieve anxiety and impairment due to gaming. Interaction analyses revealed that in adolescents with PS, the relationships between PVG and aggressive behaviors, including fighting, serious fighting leading to physical injury, and weapon-carrying, were stronger than in adolescents without PS. PS strongly relates to PVG, and among youth reporting PS, there are stronger associations between PVG and aggressive behaviors. Prevention efforts for adolescents should consider the co-occurrence of PS and PVG. PS and PVG may be linked by negative reinforcement and propensities for aggressive and addictive behaviors, suggesting that further research should explore possible interventions targeting stress management and maladaptive coping.

Aggression in borderline personality disorder: A systematic review of neuroimaging studies

Aggressive behaviors are prevalent among patients with Borderline Personality Disorder (BPD). Neuroimaging studies have linked aggression in BPD patients to neurochemical, structural, functional, and metabolic alterations in various brain regions, especially in frontal-limbic areas. This systematic review summarizes current neuroimaging results on aggression among BPD patients and provides an overview of relevant brain mechanisms. A systematic search of PubMed and Web of Science databases, in addition to manual check of references, identified thirty-two eligible articles, including two magnetic resonance spectrum (MRS), thirteen structural magnetic resonance imaging (sMRI), six functional magnetic resonance imaging (fMRI), and eleven positron emission tomography (PET) studies. The reviewed studies have highlighted the abnormalities in prefrontal cortices and limbic structures including amygdala and hippocampus. Less studies have zoomed in the roles of parietal and temporal regions or taken a network perspective. Connectivity studies have shed light on the importance of the frontal-limbic interactions in regulating aggression. Conflicted findings might be attributed to disparity in controlling gender, anatomical subdivisions, and comorbidities, which shall be considered in future studies.

Prevalence and correlates of aggressive behavior in psychiatric inpatient populations

Aggressive behavior in patients with psychiatric disorders is attracting increasing research interest. One reason for this is that psychiatric patients are generally considered more likely to be aggressive, which raises a related question of whether diagnoses of psychiatric disorders predict the prevalence of aggressive behavior. Predicting aggression in psychiatric wards is crucial, because aggressive behavior not only endangers the safety of both patients and staff, but it also extends the hospitalization times. Predictions of aggressive behavior also need careful attention to ensure effective treatment planning. This literature review explores the relationship between aggressive behavior and psychiatric disorders and syndromes (dementia, psychoactive substance use, acute psychotic disorder, schizophrenia, bipolar affective disorder, major depressive disorder, obsessive-compulsive disorder, personality disorders and intellectual disability). The prevalence of aggressive behavior and its underlying risk factors, such as sex, age, comorbid psychiatric disorders, socioeconomic status, and history of aggressive behavior are discussed as these are the components that mostly contribute to the increased risk of aggressive behavior. Measurement tools commonly used to predict and detect aggressive behavior and to differentiate between different forms of aggressive behavior in both research and clinical practice are also reviewed. Successful aggression prevention programs can be developed based on the current findings of the correlates of aggressive behavior in psychiatric patients.

Age effects on clinical and neurocognitive risk factors for suicide attempt in depression - Findings from the AFSP lifespan study

BACKGROUND

Studies of risk factors for suicidal behavior are typically restricted to narrow age ranges, making it difficult to determine if they have the same relevance or potency across the full adult lifespan.

METHODS

This study examined selected clinical and neurocognitive risk factors for suicidal behavior - borderline personality traits, aggression, depressive rumination, memory performance, and language fluency- in a multi-site sample (N = 309, ages 16-80) of depressed patients with a recent (last 5 years) suicide attempt or no history of attempt, and demographically similar non-psychiatric controls. We examined cross-sectional age and attempter/non-attempter differences on these risk factors, and whether certain risk factors were more prominent discriminators of past suicide attempt earlier or later in the lifespan. Correlations with age were computed, and logistic regression was used to classify attempter status based on each risk factor and its interaction with age.

RESULTS

Nearly all risk factors were negatively correlated with age. Borderline traits, aggression, memory, and category fluency each predicted attempter status (p < 0.05), but these effects were not different across ages. In contrast, the association between rumination and suicide attempt status differed across the lifespan, becoming a stronger discriminator of past suicidal behavior at older ages.

LIMITATIONS

The cross-sectional design limits our developmental findings.

CONCLUSIONS

Despite age-related changes in symptom severity or neurocognitive performance, key risk factors for suicidal behavior previously identified in studies with more restricted age-ranges are salient throughout the adult lifespan. In contrast, depressive rumination may be particularly salient in later life.

Differences in antipsychotic treatment between depressive patients with and without a suicide attempt

BACKGROUND

Depressed suicide attempters are, according to some earlier studies, treated more often with antipsychotics than depressive non-suicide attempters. Cluster B personality disorders, especially borderline personality disorder, are associated with a high suicide risk, and antipsychotics are commonly used for the reduction of symptoms. However, no previous study has taken comorbid personality disorders into account when assessing the use of antipsychotics in patients with unipolar depression. Therefore, the aim of this study was to investigate the clinical selection of pharmacotherapy in unipolar depression with and without a previous suicide attempt, taking into account potential confounders such as cluster B personality disorders.

METHODS

The study sample consisted of 247 patients with unipolar depression. The study was approved by the Regional Ethical Review Board in Lund, Sweden. Study participants were recruited from 4 different secondary psychiatric care clinics in Sweden and were diagnosed according to the DSM-IV-TR with the MINI and SCID II. Previous and ongoing psychiatric treatments were investigated in detail and medical records were assessed.

RESULTS

Thirty percent of the patients had made previous suicide attempts. Depressed suicide attempters underwent both lifetime treatment with antipsychotics and an ongoing antipsychotic treatment significantly more often than non-attempters. Significances remained after a regression analysis, adjusting for cluster B personality disorders, symptom severity, age at the onset of depression, and lifetime psychotic symptoms.

CONCLUSIONS

This is the first study to consider the effect of comorbidity with cluster B personality disorders when comparing treatment of depressive suicide and non-suicide attempters. Our findings suggest that suicide attempters are more frequently treated with antipsychotics compared to non-suicide attempters, regardless of cluster B personality disorder comorbidity. These findings are important for clinicians to consider and would also be relevant to future studies evaluating reduction of suicide risk with antipsychotics in patients with psychiatric comorbidity and a history of attempted suicide.

Treatment Refractory Internalizing Behaviour Across Disorders: An Aetiological Model for Severe Emotion Dysregulation in Adolescence

Auto-aggressive behaviour, especially treatment refractory suicidality in adolescents with psychiatric disorders, may be challenging to clinicians. In search of therapeutic possibilities, we have integrated current opinions regarding causality and interdependency of suicidality and auto-aggressive behaviour across disorders within the HiTOP framework. We propose a developmental model regarding these unsettling behaviours in youths that may help to guide future directions for research and interventions. We argue that the interdependent development of biologic factors, attachment, moral reasoning and emotion regulation in an overprotective environment may lead to social anxiety and later during development to emotion dysregulation and severe internalizing behaviour disorders. To optimize treatment efficacy for both internalizing and externalizing behaviour, we emphasize the importance transdiagnostic interventions, such as addressing non-compliance, restoration of trust between parents and their child, and limitation of avoidance behaviour. These may be seen as higher order interventions within the HiTOP framework.

Impulsivity and its Therapeutic Management in Borderline Personality Disorder: a Systematic Review

No treatment has been approved and recognized as effective in borderline personality disorder (BPD). Impulsivity is a key dimension because it is a predictor of remission but also suicide. The purpose of this review is to establish an inventory on the management of impulsivity in BPD and determine the effective treatments. A systematic review on the PubMed and Ovid databases was conducted up to September 2019 to December 2019 using the PRISMA guidelines. The inclusion criteria were: studies with patients with borderline personality disorder, were published between 1989 and 2019, used English-language and evaluated impulsivity before and after treatment. 41 articles selected were included for pharmacological treatment. 24 articles were found for psychotherapeutic management and one randomized study of transcranial magnetic stimulation. Based on this review, we must focus on psychotherapy in BPD, particularly the schema therapy, dialectical behavioral therapy, psychoeducation, system training of emotional predictability and problem solving and psychotherapy using mentalisation. The use of neuroleptics and mood stabilizers appears to be more effective than antidepressants. Another approach, such as transcranial magnetic stimulation, may prove useful in the near future if this technique is studied further.

The Experience of Maltreatment in Young Children Whose Mothers Have Borderline Personality Disorder: Reflections in Their Narrative Representations

Child maltreatment is an etiological factor in borderline personality disorder (BPD), which may be transmitted to the children of mothers with BPD. We assessed maltreatment in 36 children aged 4-7 whose mothers have BPD and in 34 normative comparisons. Children whose mothers have BPD were more likely to have experienced sexual abuse, physical abuse, and neglect than were normative comparisons. Mothers' self-reported borderline features were significantly correlated with children's maltreatment. Neglect was associated with mothers' affective instability, identity disturbance, negative relationships, and self-harm; sexual abuse was associated with mothers' identity disturbance, and negative relationships; and physical abuse was associated with mothers' self-harm. Maltreatment mediated the relationship between all four of mothers' borderline features and children's narrative representations of the caregiver-child relationship, which included fear of abandonment, role reversal, and mother-child relationship expectations. The authors discuss results in the context of risk for developing BPD in early adulthood and early preventive interventions targeting children's representations.

Respiratory Sinus Arrhythmia Mediates Links Between Borderline Personality Disorder Symptoms and Both Aggressive and Violent Behavior

Although emotion dysregulation (ED) is a core symptom of borderline personality disorder (BPD), tests of associations between ED and aggression and violence-which are common to BPD-are sparse. The authors evaluated mediating effects of an autonomic vulnerability to ED on links between BPD symptoms and (a) reactive aggression, (b) proactive aggression, and (c) histories of interpersonal violence in a sample of young adults (N = 104), ages 18-22 years. Low baseline respiratory sinus arrhythmia (RSA) mediated the association between BPD symptoms and reactive aggression. In contrast, although BPD symptoms were correlated with proactive aggression, no mediational effect was found. In addition, low RSA mediated the association between BPD symptoms and histories of interpersonal violence. Collectively, these findings add evidence that neurobiological vulnerability to ED contributes to aggressive and violent behavior among those with BPD.

Cognitive-Emotional and Inhibitory Deficits as a Window to Moral Decision-Making Difficulties Related to Exposure to Violence

In the present review, we illustrate how exposure to violence results in an increased probability of developing functional impairments of decision mechanisms necessary for moral behavior. We focus in particular on the detrimental effects of exposure to violence on emotional (e.g., Empathy), cognitive (e.g., Theory of Mind), and inhibitory control abilities. Relying on studies that document impaired moral behavior in individuals with deficits in these abilities, we propose a "model" of how exposure to violence can affect moral behavior. We then discuss how impaired moral decision making can also be a factor increasing the likelihood of reiterating violence: agents who lack abilities such as understanding and resonating with others' emotions or inhibitory control, can lead to an increase of violent displays. Thus, if not properly addressed, the noxious effects of exposure to violence on morality can lead to a violence generating cycle. We conclude proposing that interventions targeted at improving moral behavior can maximize their efficacy focusing on mitigating the impact of violence on the basic cognitive, emotional, and inhibitory abilities discussed.

Suicide risk, personality disorder and hospital admission after assessment by psychiatric emergency services

BACKGROUND

The main objectives of the mobile Psychiatric Emergency Services (PES) in the Netherlands are to assess the presence of a mental disorder, to estimate risk to self or others, and to initiate continuity of care, including psychiatric hospital admission. The aim of this study was to assess the associations between the level of suicidality and risk of voluntary or involuntary admission in patients with and without a personality disorder who were presented to mobile PES.

METHODS

Observational data were obtained in three areas of the Netherlands from 2007 to 2016. In total, we included 71,707 contacts of patients aged 18 to 65 years. The outcome variable was voluntary or involuntary psychiatric admission. Suicide risk and personality disorder were assessed by PES-clinicians. Multivariable regression analysis was used to explore associations between suicide risk, personality disorder, and voluntary or involuntary admission.

RESULTS

Independently of the level of suicide risk, suicidal patients diagnosed with personality disorder were less likely to be admitted voluntarily than those without such a diagnosis (admission rate .37 versus .46 respectively). However, when the level of suicide risk was moderate or high, those with a personality disorder who were admitted involuntarily had the same probability of involuntary admission as those without such a disorder.

CONCLUSIONS

While the probability of voluntary admission was lower in those diagnosed with a personality disorder, independent of the level of suicidality, the probability of involuntary admission was only lower in those whose risk of suicide was low. Future longitudinal studies should investigate the associations between (involuntary) admission and course of suicidality in personality disorder.

Student health professionals' attitudes and experience after watching "Ida's Diary", a first-person account of living with borderline personality disorder: Mixed methods study

BACKGROUND

There is increasing interest in the use of commercial movies in nursing education, or "cinenurducation". There is a need for educational interventions which target mental health nurses' attitudes towards people with borderline personality disorder.

OBJECTIVES

To investigate and evaluate the experience and effects of attendance at a screening of the movie Ida's Diary, a first-person account of living with borderline personality disorder.

DESIGN

Mixed methods design comprising a within-subjects AB longitudinal survey, and a qualitative analysis of participant-generated data and researcher field notes from a World Café discussion group.

SETTINGS

One university in Scotland.

PARTICIPANTS

N = 66 undergraduate and postgraduate mental health nursing and counselling students.

METHODS

Participants completed measures of cognitive and emotional attitudes towards, and knowledge about, people with borderline personality disorder before and after one of two film screenings. We conducted a World Café discussion group after the second screening. Resulting data were subject to a qualitative thematic analysis.

RESULTS

Quantitative analysis revealed a five-factor cognitive and a single-factor emotional attitude structure. Cognitive-attitudinal items related to treatment deservingness and value of mixed treatment approaches improved across iterations. Total knowledge score did not change, but one item about borderline personality disorder as a precursor to schizophrenia received considerably more incorrect endorsement post-screening. Qualitative analysis revealed five themes: Facilitation and inhibition of learning; promotion but not satiation of appetite for knowledge; challenging existing understanding; prompting creativity and anxiety; and initiating thinking about the bigger picture.

CONCLUSIONS

Participants found the film thought provoking; it increased their appetite for knowledge. Findings suggest that screening should be delivered in conjunction with more didactic information about borderline personality disorder.

Asenapine in the management of impulsivity and aggressiveness in bipolar disorder and comorbid borderline personality disorder: an open-label uncontrolled study

Borderline personality disorder (BPD) often co-occurres with bipolar disorder (BD). Impulsivity and aggressiveness represent core shared features and their pharmacological management is mainly based on mood stabilizers and antipsychotics, although scarce evidence is available for this context of comorbidity. The aim of the present study was to evaluate the role of Asenapine as an adjunctive drug for reducing aggressiveness and impulsivity in a sample of Italian BD type I outpatients with or without a comorbid BPD. This was an observational 12-week open-label uncontrolled clinical study carried out from April to October 2014 in two psychiatric clinics in Sicily. Each patient was treated with asenapine at two dose options, 5 mg (twice daily) or 10 mg (twice daily), and concomitant ongoing medications were not discontinued. We measured impulsivity using the Barratt Impulsiveness Scale (BIS) and aggressiveness using the Aggressive Questionnaire (AQ). For the analysis of our outcomes, patients were divided into two groups: with or without comorbid BPD. Adjunctive therapy was associated with a significant decrease of BIS and AQ overall scores in the entire bipolar sample. Yet, there was no significant difference in BIS and AQ reductions between subgroups. Using a regression model, we observed that concomitant BPD played a negative role on the Hostility subscale and overall AQ score variations; otherwise, borderline co-diagnosis was related positively to the reduction of physical aggression. According to our post-hoc analysis, global aggressiveness scores are less prone to decrease in patients with a dual diagnosis, whereas physical aggressiveness appears to be more responsive to the add-on therapy in patients with comorbidity.

Exploring the Moderating Role of Problematic Substance Use in the Relations Between Borderline and Antisocial Personality Features and Intimate Partner Violence

Borderline and antisocial personality features relate to multiple externalizing behaviors, including intimate partner violence (IPV). However, not all individuals with borderline and antisocial traits perpetrate IPV. The strength of the personality-IPV link may be related to problematic substance use. We examined borderline and antisocial personality features, problematic substance use, and IPV in a community sample of couples. Positive relations between both borderline and antisocial features and IPV were stronger in conditions of high problematic alcohol use relative to low problematic alcohol use. Alcohol misuse may be an important factor to consider for IPV reduction in men with these personality features.

Anger and aggression in borderline personality disorder and attention deficit hyperactivity disorder - does stress matter?

BACKGROUND

The impact of stress on anger and aggression in Borderline Personality Disorder (BPD) and Attention Deficit Hyperactivity Disorder (ADHD) has not been thoroughly investigated. The goal of this study was to investigate different aspects of anger and aggression in patients with these disorders.

METHODS

Twenty-nine unmedicated female BPD patients, 28 ADHD patients and 30 healthy controls (HC) completed self-reports measuring trait anger, aggression and emotion regulation capacities. A modified version of the Point Subtraction Aggression Paradigm and a state anger measurement were applied under resting and stress conditions. Stress was induced by the Mannheim Multicomponent Stress Test (MMST).

RESULTS

Both patient groups scored significantly higher on all self-report measures compared to HCs. Compared to ADHD patients, BPD patients reported higher trait aggression and hostility, a stronger tendency to express anger when provoked and to direct anger inwardly. Furthermore, BPD patients exhibited higher state anger than HCs and ADHD patients under both conditions and showed a stress-dependent anger increase. At the behavioral level, no significant effects were found. In BPD patients, aggression and anger were positively correlated with emotion regulation deficits.

CONCLUSIONS

Our findings suggest a significant impact of stress on self-perceived state anger in BPD patients but not on aggressive behavior towards others in females with BPD or ADHD. However, it appears to be pronounced inwardly directed anger which is of clinical importance in BPD patients.

Experiences of women in secure care who have been prescribed clozapine for borderline personality disorder

BACKGROUND

Clozapine is an atypical antipsychotic medicine which can cause significant side-effects. It is often prescribed off-license in severe cases of borderline personality disorder contrary to national treatment guidelines. Little is known about the experiences of those who take clozapine for borderline personality disorder. We explored the lived-experience of women in secure inpatient care who were prescribed clozapine for borderline personality disorder.

FINDINGS

Adult females (N = 20) participated in audio-taped semi-structured interviews. Transcripts were subject to thematic analysis. The central themes related to evaluation, wellbeing, understanding and self-management; for many, their subjective wellbeing on clozapine was preferred to prior levels of functioning and symptomatology, sometimes profoundly so. The negative and potentially adverse effects of clozapine were explained as regrettable but relatively unimportant.

CONCLUSIONS

When psychological interventions are, at least initially, ineffective then clozapine treatment is likely to be evaluated positively by a group of women with borderline personality disorder in secure care despite the potential disadvantages.

Quality of life in borderline patients comorbid with anxiety spectrum disorders - a cross-sectional study

INTRODUCTION

Borderline personality disorder (BPD) significantly reduces the quality of life (QoL) in mental, social, and work domains. Patients with BPD often suffer from depressive anxiety symptoms. The purpose of this cross-sectional study was to compare the QoL and demographic and clinical factors of inpatients diagnosed with BPD and comorbid anxiety spectrum disorders, and healthy controls.

METHODS

Ninety-two hospitalized patients treated in the psychotherapeutic department and 40 healthy controls were included. Subjects were assessed by the Quality of Life Satisfaction and Enjoyment Questionnaire (Q-LES-Q), Dissociative Experiences Scale, Beck Depression Inventory (BDI)-II, Beck Anxiety Inventory, Clinical Global Impression, demographic questionnaire, Sheehan Disability Scale (SDS), and Sheehan Anxiety Scale.

RESULTS

BPD patients suffered from comorbid anxiety disorders, panic disorder (18.5%), social phobia (20.7%), generalized anxiety disorder/mixed anxiety depression disorder (17.4%), adjustment disorder (22.8%), and posttraumatic stress disorder (8.7%); 19.6% patients had two or more anxiety disorder comorbidities. Patients score in Q-LES-Q (general) was 36.24±9.21, which was significantly lower in comparison to controls (57.83±10.21) and similar in all domains (physical health, feelings, work, household, school/study, leisure, social activities). The subjective level of depression measured by BDI and SDS (social life and family subscales) negatively correlated with all Q-LES-Q domains.

CONCLUSION

Patients suffering from BPD and comorbid anxiety disorders have a lower level of QoL compared to healthy controls in all measured domains. Negative correlations of the Q-LES-Q domains with clinical scales (Dissociative Experiences Scale, BDI, Beck Anxiety Inventory, Sheehan Anxiety Scale, Clinical Global Impression, and SDS) are noticeable.

Impulsivity and Aggression in Female BPD and ADHD Patients: Association with ACC Glutamate and GABA Concentrations

Borderline personality disorder (BPD) and attention-deficit-hyperactivity disorder (ADHD) are both characterized by high impulsivity and difficulties in controlling anger and aggression. In BPD, comorbid ADHD may further increase impulsivity. For both disorders, altered MR spectroscopy levels of the neurotransmitters glutamate and GABA as well as some correlations with impulsivity were previously reported. The objective of this study was to investigate the neurotransmitters glutamate and GABA in relation to impulsivity and aggression as expressed in the anterior cingulate cortex (ACC) in groups of female patients with BPD and ADHD, respectively. Associations of glutamate and GABA levels with further BPD (symptom severity) and ADHD aspects (hyperactivity and inattention) were exploratively evaluated. 1H MR spectra were acquired at 3T to determine glutamate to total creatine ratios (Glu/tCr) and GABA levels from the ACC in a BPD group (n=26), an ADHD group (n=22), and a healthy control (HC) group (n=30); all participants were females. Both patient groups showed higher scores on self-reported impulsivity, anger, and aggression compared with HCs. ACC GABA levels were significantly lower in ADHD than HC. Although measures of impulsivity were positively related to glutamate and negatively to GABA, for aggression only a negative correlation with GABA could be demonstrated. These data provide human in vivo evidence for the role of ACC Glu/tCr and GABA in impulsivity and aggression. If distinct associations of Glu/tCr and GABA for BPD and ADHD can be confirmed in future studies, this might yield implications for more specific pharmacological treatments.

The Association between Mental Health and Violence among a Nationally Representative Sample of College Students from the United States

Objectives

Recent violent attacks on college campuses in the United States have sparked discussions regarding the prevalence of psychiatric disorders and the perpetration of violence among college students. While previous studies have examined the potential association between mental health problems and violent behavior, the overall pattern of findings flowing from this literature remain mixed and no previous studies have examined such associations among college students.

Methods

The current study makes use of a nationally representative sample of 3,929 college students from the National Epidemiologic Study on Alcohol and Related Conditions (NESARC) to examine the prevalence of seven violent behaviors and 19 psychiatric disorder diagnoses tapping mood, anxiety, personality, and substance use disorders. Associations between individual and composite psychiatric disorder diagnoses and violent behaviors were also examined. Additional analyses were adjusted for the comorbidity of multiple psychiatric diagnoses.

Results

The results revealed that college students were less likely to have engaged in violent behavior relative to the non-student sample, but a substantial portion of college students had engaged in violent behavior. Age- and sex-standardized prevalence rates indicated that more than 21% of college students reported at least one violent act. In addition, more than 36% of college students had at least one diagnosable psychiatric disorder. Finally, the prevalence of one or more psychiatric disorders significantly increased the odds of violent behavior within the college student sample.

Conclusions

These findings indicate that violence and psychiatric disorders are prevalent on college campuses in the United States, though perhaps less so than in the general population. In addition, college students who have diagnosable psychiatric disorders are significantly more likely to engage in various forms of violent behavior.

Thyroid hormones and adult interpersonal violence among women with borderline personality disorder

Elevated T3 levels have been reported in men with antisocial behavior. The aim of the present study was to investigate the relationship between thyroid hormones and expressed adult interpersonal violence in female patients with borderline personality disorder (BPD). Furthermore, expressed adult interpersonal violence in female BPD patients was compared to healthy female controls. A total of 92 clinically euthyroid women with BPD and 57 healthy women were assessed with the Karolinska Interpersonal Violence Scales (KIVS). Baseline thyroid function was evaluated by measuring plasma free and bound triiodothyronine (FT3 and T3), thyroxine (FT4 and T4), and thyroid-stimulating hormone (TSH) with immunoassays in patients. Plasma cortisol was also measured. Among females with BPD, expressed interpersonal violence as an adult showed a significant positive correlation with the T3 levels. The mean expression of interpersonal violence as an adult was significantly higher in BPD patients as compared to healthy controls. The multiple regression model indicated that two independent predictors of KIVS expressed interpersonal violence as an adult: T3 and comorbid diagnosis of alcohol abuse. Association between T3 levels and violent/aggressive behavior earlier reported exclusively in male samples may be valid also in females with BPD.

Significance of borderline personality-spectrum symptoms among adolescents with bipolar disorder

BACKGROUND

Little is known regarding correlates of borderline personality-spectrum symptoms (BPSS) among adolescents with bipolar disorder (BP).

METHODS

Participants were 90 adolescents, 13-19 years of age, who fulfilled DSM-IV-TR criteria for BP using semi-structured diagnostic interviews. BPSS status was ascertained using the Life Problems Inventory which assessed identity confusion, interpersonal problems, impulsivity, and emotional lability. Analyses compared adolescents with "high" versus "low" BPSS based on a median split.

RESULTS

Participants with high, relative to low, BPSS were younger, and had greater current and past depressive episode severity, greater current hypo/manic episode severity, younger age of depression onset, and reduced global functioning. High BPSS participants were more likely to have BP-II, and had higher rates of social phobia, generalized anxiety disorder, conduct disorder, oppositional defiant disorder, homicidal ideation, assault of others, non-suicidal self-injury, suicidal ideation, and physical abuse. Despite greater illness burden, high BPSS participants reported lower rates of lithium use. The most robust independent predictors of high BPSS, identified in multivariate analyses, included lifetime social phobia, non-suicidal self-injury, reduced global functioning, and conduct and/or oppositional defiant disorder.

LIMITATIONS

The study design is cross-sectional and cannot determine causality.

CONCLUSIONS

High BPSS were associated with greater mood symptom burden and functional impairment. Presence of high BPSS among BP adolescents may suggest the need to modify clinical monitoring and treatment practices. Future prospective studies are needed to examine the direction of observed associations, the effect of treatment on BPSS, and the effect of BPSS as a moderator or predictor of treatment response.

Associations Between Dysfunctional Personality Traits and Intimate Partner Violence in Perpetrators and Victims

In the current study, the role of borderline and antisocial personality traits and psychological and physical forms of intimate partner violence were examined. Using self- and partner-reports, 30 perpetrators (28 males) and 30 victims (29 females) of partner violence, including 23 (former) couples, were interviewed. Results showed that perpetrators (i.e., males) were higher on antisocial personality traits than victims (i.e., females), but the two groups did not differ on borderline traits and self-reported violence. Moreover, borderline traits were associated with partner violence in general, whereas antisocial personality traits were associated with physical, but not psychological, partner violence. Analyses on (former) couples suggest that there is little congruence between perpetrators' and victims' reports of partner violence. In conclusion, the findings of the current study not only emphasized the complex nature of intimate partner violence but also showed that dysfunctional personality traits and gender play a significant role in both the display and reporting of partner violence.

Risk factors for adult interpersonal violence in suicide attempters

BACKGROUND

Suicidal and violent behaviours are interlinked and share common biological underpinnings. In the present study we analysed the association between violent behaviour as a child, childhood trauma, adult psychiatric illness, and substance abuse in relation to interpersonal violence as an adult in suicide attempters with mood disorders.

METHODS

A total of 161 suicide attempters were diagnosed with Structured Clinical Interviews and assessed with the Karolinska Interpersonal Violence Scale (KIVS) measuring exposure to violence and expressed violent behaviour in childhood (between 6-14 years of age) and during adult life (15 years or older). Ninety five healthy volunteers were used as a comparison group. A logistic regression analysis was conducted with the two KIVS subscales, expressed violent behaviour as a child and exposure to violence in childhood together with substance abuse, personality disorder diagnoses and age as possible predictors of adult interpersonal violence in suicide attempters.

RESULTS

Violent behaviour as a child, age and substance abuse were significant predictors of adult interpersonal violence. ROC analysis for the prediction model for adult violence with the KIVS subscale expressed violence as a child gave an AUC of 0.79. Using two predictors: violent behaviour as a child and substance abuse diagnosis gave an AUC of 0.84. The optimal cut-off for the KIVS subscale expressed violence as a child was higher for male suicide attempters.

CONCLUSIONS

Violent behaviour in childhood and substance abuse are important risk factors for adult interpersonal violent behaviour in suicide attempters.

Emotion dysregulation as a maintenance factor of borderline personality disorder features

We examined within-individual changes in emotion dysregulation over the course of one year as a maintenance factor of borderline personality disorder (BPD) features. We evaluated the extent to which (1) BPD symptom severity at baseline predicted within-individual changes in emotion dysregulation and (2) within-individual changes in emotion dysregulation predicted four BPD features at 12-month follow-up: affective instability, identity disturbances, negative relationships, and impulsivity. The specificity of emotion dysregulation as a maintaining mechanism of BPD features was examined by controlling for a competing intervening variable, interpersonal conflict. BPD symptoms at baseline predicted overall level and increasing emotion dysregulation. Additionally, increasing emotion dysregulation predicted all four BPD features at 12-month follow-up after controlling for BPD symptoms at baseline. Further, overall level of emotion dysregulation mediated the association between BPD symptom severity at baseline and both affective instability and identity disturbance at 12-month follow-up, consistent with the notion of emotion dysregulation as a maintenance factor. Future research on the malleability of emotion dysregulation in laboratory paradigms and its effects on short-term changes in BPD features is needed to inform interventions.

Prospective associations between features of borderline personality disorder, emotion dysregulation, and aggression

Difficulties with emotion regulation and behavioral instability, including impulsive aggression, are seen as core dimensions underlying borderline personality disorder (BPD). Although both BPD and antisocial personality disorder (ASPD) are associated with impulsivity and aggressive behavior, difficulties regulating emotions may be associated uniquely with BPD and may explain distinctive associations between BPD and aggression. This study was designed to examine the unique prospective associations between BPD symptoms at baseline, difficulties with emotion regulation and trait impulsivity, and psychological and physical aggression (both perpetration and victimization) over the course of a year after controlling for ASPD symptoms in a mixed clinical and community sample of adults (N = 150). Results of a multivariate path analysis demonstrated that associations between BPD symptoms at baseline and later psychological and physical aggression were fully mediated by difficulties with emotion regulation. Although BPD symptoms also predicted trait impulsivity, impulsivity did not predict aggression after controlling for emotion dysregulation. ASPD symptoms were directly associated with physical assault perpetration and victimization but were not associated with emotion dysregulation, impulsivity, or psychological aggression. These findings suggest that although both BPD and ASPD are associated with aggressive behaviors, associations between BPD symptoms and aggression are mediated uniquely by difficulties regulating emotions.

Comorbid personality disorders and violent behavior in psychotic patients

Schizophrenia without any comorbidity confers a modest, but statistically significant elevation of the risk for violence. That risk is considerably increased by comorbid antisocial personality disorder or psychopathy as well as by comorbid substance use disorders. These comorbidities are frequent. Conduct disorder and conduct disorder symptoms elevate the risk for aggressive behavior in patients with schizophrenia. Violence among adults with schizophrenia may follow at least two distinct pathways-one associated with premorbid conditions, including antisocial conduct, and another associated with the acute psychopathology of schizophrenia. Aggressive behavior in bipolar disorder occurs mainly during manic episodes, but it remains elevated in euthymic patients in comparison with controls. The risk of violent behavior is increased by comorbidity with borderline personality disorder, antisocial personality disorder, and substance use disorders. These comorbidities are frequent. Borderline personality disorder and bipolar disorder are related in their phenomenology and response to medication. These two disorders share a tendency to impulsiveness, and impulsive behavior, including impulsive aggression, is particularly expressed when they co-occur.

Aggression in Psychoses

Most individuals diagnosed with a mental illness are not violent, but some mentally ill patients commit violent acts. PubMed database was searched for articles published between 1980 and November 2013 using the combination of key words “schizophrenia” or “bipolar disorder” with “aggression” or “violence.” In comparison with the general population, there is approximately a twofold increase of risk of violence in schizophrenia without substance abuse comorbidity and ninefold with such comorbidity. The risk in bipolar disorder is at least as high as in schizophrenia. Most of the violence in bipolar disorder occurs during the manic phase. Violence among adults with schizophrenia may follow two distinct pathways: one associated with antisocial conduct and another associated with the acute psychopathology, particularly anger and delusions. Clozapine is the most effective treatment of aggressive behavior in schizophrenia. Emerging evidence suggests that olanzapine may be the second most effective treatment. Treatment nonadherence greatly increases the risk of violent behavior, and poor insight as well as hostility is associated with nonadherence. Nonpharmacological methods of treatment of aggression in schizophrenia and bipolar disorder are increasingly important. Cognitive behavioral approaches appear to be effective in cases where pharmacotherapy alone is not sufficient.

Childhood abuse is associated with structural impairment in the ventrolateral prefrontal cortex and aggressiveness in patients with borderline personality disorder

Volume reduction and functional impairment in areas of the prefrontal cortex (PFC) have been found in borderline personality disorder (BPD), particularly in patients with a history of childhood abuse. These abnormalities may contribute to the expression of emotion dysregulation and aggressiveness. In this study we investigated whether the volume of the PFC is reduced in BPD patients and whether a history of childhood abuse would be associated with greater PFC structural changes. Structural MRI data were obtained from 18 BPD patients and 19 healthy individuals matched for age, sex, handedness, and education and were analyzed using voxel based morphometry. The Child Abuse Scale was used to elicit a past history of abuse; aggression was evaluated using the Buss-Durkee Hostility Inventory (BDHI). The volume of the right ventrolateral PFC (VLPFC) was significantly reduced in BPD subjects with a history of childhood abuse compared to those without this risk factor. Additionally, right VLPFC gray matter volume significantly correlated with the BDHI total score and with BDHI irritability and negativism subscale scores in patients with a history of childhood abuse. Our results suggest that a history of childhood abuse may lead to increased aggression mediated by an impairment of the right VLPFC.

Borderline personality features and emotional reactivity: the mediating role of interpersonal vulnerabilities

BACKGROUND AND OBJECTIVES

The purpose of this study was to examine the mediating role of interpersonal vulnerabilities in the association of borderline personality (BP) features with emotional reactivity to an interpersonal stressor.

METHODS

For this study, female university students with high (N = 23), mid (N = 23), and low (N = 22) BP features completed the Inventory of Interpersonal Problems-Personality Disorders-25 (IIP-PD-25). Self-reported emotions, skin conductance responses (SCRs), interbeat intervals, and heart rate variability measured emotional reactivity to a social rejection stressor.

RESULTS

BP features were positively associated with interpersonal dysfunction and predicted greater SCR reactivity and self-reported emotional reactivity. Interpersonal dysfunction mediated the association between BP features and physiological (SCRs), but not self-reported, emotional reactivity. In particular, scores on the interpersonal ambivalence subscale of the IIP-PD-25 mediated the association of BP features with SCR reactivity.

LIMITATIONS

This study examined BP features in a non-clinical sample, and relied on a relatively small sample. Furthermore, the design of the present study does not capture the potential transaction between interpersonal vulnerabilities and emotional dysfunction.

CONCLUSIONS

The findings of this study illuminate one potential mechanism underlying the heightened reactivity of persons with BP features to rejection, suggesting that interpersonal ambivalence plays a particularly important role in physiological reactivity.

Two to tango: a dyadic analysis of links between borderline personality traits and intimate partner violence

Although research has shown links between borderline personality and intimate partner violence (IPV), few studies have examined how each partner's personality traits may influence the other's behavior (Hines, 2008). This study incorporated dimensional assessments of borderline personality organization (BPO) in both partners into a dyadic model that examined associations with IPV. In a community sample of 109 couples, an Actor-Partner Interdependence Model was used to examine links between BPO traits in each partner and victimization and perpetration of IPV. Men's level of BPO traits was associated with more IPV toward and more victimization by their partners. Women's level of BPO traits was associated with their victimization only. This study is unique in examining links between BPO and IPV in couples using analyses that account for the interdependence of these variables in dyads.

Variable maternal stress in rats alters locomotor activity, social behavior, and recognition memory in the adult offspring

Rats repeatedly exposed to variable prenatal stress (PNS) exhibit behavioral signs that are similar to those manifested in several neuropsychiatric disorders such as deficits in attention and inhibitory control, and impairments in memory-related task performance. The purpose of the study described here was to conduct a comprehensive battery of tests to further characterize the behavioral phenotype of PNS rats as well as to evaluate the sensitivity of the model to therapeutic interventions (i.e., to compounds previously shown to have therapeutic potential in neuropsychiatric disorders). The results of this study indicated that PNS in rats is associated with: 1) increased locomotor activity and stereotypic behaviors, 2) elevated sensitivity to the psychostimulant amphetamine, 3) increased aggressive behaviors toward both adult and juvenile rats and 4) delay-dependent deficits in recognition memory. There was no evidence that PNS rats exhibited deficits in other areas of motor function/learning, sensorimotor gating, spatial learning and memory, social withdrawal, or anhedonia. In addition, the results revealed that the second generation antipsychotic risperidone attenuated amphetamine-related increases in locomotor activity in PNS rats; however, the effect was not sustained over time. Furthermore, deficits in recognition memory in PNS rats were attenuated by the norepinephrine reuptake inhibitor, atomoxetine, but not by the α7 nicotinic acetylcholine receptor partial agonist, GTS-21. This study supports the supposition that important phenomenological similarities exist between rats exposed to PNS and patients afflicted with neuropsychiatric disorders thus further establishing the face validity of the model for evaluating potential therapeutic interventions.

Hurt people who hurt people: violence amongst individuals with comorbid substance use disorder and post traumatic stress disorder

AIMS

The association between substance use disorder (SUD) and the perpetration of violence has been well documented. There is some evidence to suggest that the co-occurrence of post traumatic stress disorder (PTSD) may increase the risk for violence. This study aims to determine the prevalence of violence perpetration and examine factors related to violence amongst individuals with comorbid SUD and PTSD.

DESIGN AND PARTICIPANTS

Data was collected via interview from 102 participants recruited to a randomised controlled trial of an integrated treatment for comorbid SUD and PTSD.

MEASUREMENTS

The interview addressed demographics, perpetration of violent crime, mental health including aggression, substance use, PTSD, depression, anxiety and borderline personality disorder.

FINDINGS

Over half of participants reported committing violence in their lifetime and 16% had committed violence in the past month. Bivariate associations were found between violence perpetration and trait aggression, higher levels of alcohol and cannabis use, lower levels of other opiate use, and experiencing more severe PTSD symptoms, particularly in relation to hyperarousal. When entered into a backward stepwise logistic regression however, only higher levels of physical aggression and more severe PTSD hyperarousal symptoms remained as independent predictors of violence perpetration.

CONCLUSIONS

These findings highlight the importance of assessing for PTSD amongst those with SUD particularly in forensic settings. They also indicate that it is the hyperarousal symptoms of PTSD specifically that need to be targeted by interventions aimed at reducing violence amongst individuals with SUD and PTSD.