Impulsivity and Cluster B Personality Disorders

Risk factors of suicide re-attempt: A two-year prospective study

BACKGROUND

History of suicide attempt (SA) is the strongest predictor of a new SA and suicide. It is primordial to identify additional risk factors of suicide re-attempt. The aim of this study was to identify risk factors of suicide re-attempt in patients with recent SA followed for 2 years.

METHODS

In this multicentric cohort of adult inpatients, the median of the index SA before inclusion was 10 days. Clinicians assessed a large panel of psychological dimensions using validated tools. Occurrence of a new SA or death by suicide during the follow-up was recorded. A cluster analysis was used to identify the dimensions that best characterized the population and a variable "number of personality traits" was created that included the three most representative traits: anxiety, anger, and anxious lability. Risk factors of re-attempt were assessed with adjusted Cox regression models.

RESULTS

Among the 379 patients included, 100 (26.4 %) re-attempted suicide and 6 (1.6 %) died by suicide. The two major risk factors of suicide re-attempt were no history of violent SA and presenting two or three personality traits among trait anxiety, anger and anxious lability.

LIMITATIONS

It was impossible to know if treatment change during follow-up occur before or after the re-attempt.

DISCUSSION

One of the most important predictors of re-attempt in suicide attempters with mood disorders, was the presence of three personality traits (anger, anxiety, and anxious lability). Clinicians should provide close monitoring to patients presenting these traits and proposed treatments specifically targeting these dimensions, especially anxiety.

Implications of Impulsivity on Criminal Behavior in Individuals With Substance Use Disorder

OBJECTIVE

Our aim was to analyze the association between criminal behavior and impulsivity in individuals with drug addiction and investigate whether impulsiveness mediates the relationship between drug use severity and legal problems.

METHODS

This cross-sectional study included 773 men diagnosed with addiction (295 alcohol users and 478 users of crack/polysubstance) while undergoing addiction treatment. The BIS-11 and ASI-6 were applied to assess impulsivity, criminal behavior, and drug use.

RESULTS

The prevalence of criminal behavior was 41.7% (n = 123) in alcohol users and 64.9% (n = 310) in users of crack/polysubstance. Earlier use of different substances and higher impulsivity scores were observed in individuals with criminal history. Mediation analyses revealed that impulsiveness acts as a mediator factor between substance use and criminal behavior, enhancing the severity of legal problems.

CONCLUSION

Our findings can help in deciding on tailored treatment strategies, focusing not only on substance use, but also on the prevention of social problems, criminality, and impulsivity.

Clinical specificities of patients with substance use disorder and comorbid borderline personality disorder compared to patients with substance use disorder only: a retrospective study

INTRODUCTION

Substance use disorder (SUD) is a common condition often associated with borderline personality disorder (BPD), and patients with both disorders (SUD + BPD) have more complex presentations and poorer outcomes in treatment. Thus, there is a need to identify more clearly the clinical differences between patients with SUD + BPD and those with SUD only to help clinicians in their diagnostic process.

METHODS

Data from medical files of 92 patients with SUD (SUD only: n = 42; SUD + BPD: n = 50) treated in an outpatient psychiatry and addiction treatment center were extracted to compare the differences in terms of sociodemographic characteristics, substance used, psychopathological dimensions, comorbidity prevalence, and functional impairment.

RESULTS

Compared to the SUD only group, patients in the SUD + BPD group were younger, more disabled, and less satisfied with their social life. Regarding substance used, the comorbid group had more frequently cannabis use disorder and poly nonalcoholic SUD. Regarding psychopathological dimensions, the comorbid group had higher levels of impulsivity, emotion regulation difficulties and alexithymia. Finally, regarding comorbidities, the comorbid group had a higher risk of comorbid anxiety, obsessive-compulsive, and post-traumatic stress disorders.

CONCLUSION

While being only exploratory, these results add evidence on the impact of the BPD comorbidity in patients with SUD and underline important dimensions that should be considered by clinicians working with this population.

What impact can brain stimulation interventions have on borderline personality disorder?

INTRODUCTION

Borderline personality disorder (BPD) is a severe mental disorder characterized by emotion dysregulation, impulsivity, neuropsychological impairment, and interpersonal instability, presenting with multiple psychiatric comorbidities, functional disability and reduced life expectancy due suicidal behaviors.

AREAS COVERED

In this perspective, the authors explore the application of noninvasive brain stimulation (NIBS) (rTMS, tDCS, and MST) in BPD individuals by considering a symptom-based approach, focusing on general BPD psychopathology, impulsivity and neuropsychological impairments, suicidality and depressive/anxious symptoms, and emotion dysregulation.

EXPERT OPINION

According to a symptoms-based approach, NIBS interventions (particularly rTMS and tDCS) are promising treatment options for BPD individuals improving core symptoms such as emotional and behavioral dysregulation, neuropsychological impairments and depressive symptoms. However, the heterogeneity of stimulation protocols and of assessment tools used to detect these changes limits the possibility to provide definitive recommendations according to a symptom-based approach. To implement such armamentarium in clinical practice, future NIIBS studies should further consider a lifespan perspective due to clinical variability over time, the role of psychiatric comorbidities affecting BPD individuals and the need to combine NIBS with specialized psychotherapeutic approaches for BPD patients and with functional neuroimaging studies.

Cognition in adults with borderline personality disorder

OBJECTIVE

Borderline personality disorder (BPD) is a common and disabling mental health disorder and has detrimental effects on affected individuals across multiple domains. We aimed to investigate whether individuals with BPD differ from control subjects in terms of cognitive functions, and to see if there is a relationship between cognitive functions, impulsivity, and BPD symptom severity.

METHODS

BPD individuals (n = 26; mean age = 26.7; 69.2% female) and controls (n = 58; mean age = 25.3; 51.7% female) were enrolled. Intra/Extra-Dimensional Set Shift (IED) and One Touch Stockings of Cambridge (OTS) tasks from the Cambridge Neuropsychological Test Automated Battery (CANTAB) were used to assess cognitive functions. Barratt Impulsivity Scale-version 11 (BIS-11) was administered to measure impulsivity and both the Zanarini Scale for Borderline Personality Disorder self-report and the clinician-administered versions were used to assess BPD symptom severity.

RESULTS

BPD group showed significantly impaired cognitive performance on the IED task versus controls, but there was not a significant difference in the OTS task. BPD symptom severity was positively correlated with trait (BIS-11) impulsivity and no correlation was found between BPD symptom severity and cognitive functions.

CONCLUSIONS

This study suggests people with BPD experience impaired cognitive flexibility and heightened impulsivity. Only impulsivity appeared to be directly related to symptom severity, perhaps indicating that cognitive inflexibility could be a vulnerability marker. Future research should focus on a longitudinal approach to extend clinical and theoretical knowledge in this area.

Differentiating between intrapsychic symptoms and behavioral expressions of borderline personality disorder in relation to childhood emotional maltreatment and emotion dysregulation: an exploratory investigation

BACKGROUND

Borderline personality disorder (BPD) is a severe mental disorder, characterized by pronounced instability in emotions, self-image, and interpersonal relationships. Experiences of childhood maltreatment are among the risk factors for BPD. While self-damaging and aggressive acts often occur, not every person with the disorder shows markedly dysregulated behaviour. Internalized symptoms, such as shame, loneliness, and self-disgust tend to be more pervasive and persist after clinical remission.

OBJECTIVE

Here we investigated associations between BPD symptom severity, childhood maltreatment, and emotion regulation difficulties. We further explored if the Borderline Symptom List (BSL) could potentially be used to differentiate between internalized symptoms (intrapsychic strain) and externalized symptoms (dysregulated behaviours) in future research.

METHOD

187 women with at least mild BPD symptoms (65% having a diagnosis of BPD) completed the BSL 23 including its 11-item supplement (BSL-S), the Childhood Trauma Questionnaire (CTQ), and Difficulties in Emotion Regulation Scale (DERS). Participants further underwent a semi-structured clinical interview to assess BPD criteria (International Personality Disorder Examination, IPDE). Multivariate models and regression-based bootstrapping analyses were performed to test direct and indirect effects.

RESULTS

Childhood trauma severity, especially emotional abuse, positively predicted BPD symptom severity. A significant indirect effect through emotion regulation difficulties was found (k2=.56). When exploring associations with BPD criteria (IPDE), the BSL-23 mean significantly correlated with separation anxiety, identity and mood problems, chronic emptiness, suicidal ideation, and dissociation, while the BSL-S correlated with self-harming impulsive behaviour and anger outbursts.

CONCLUSIONS

Findings complement previous research, highlighting the role of childhood maltreatment and emotion regulation difficulties in BPD. While our findings need to be seen as preliminary and interpreted with caution, they suggest that the BSL may be used to differentiate between internalized symptoms and behavioural expressions of BPD in future research. Such a distinction might help to deepen the understanding of this complex heterogenous disorder.

The Initial Efficacy of Stand-Alone DBT Skills Training for Treating Impulsivity Among Individuals With Alcohol and Other Substance Use Disorders

Impulsivity is considered a core feature of substance use disorders (SUDs), including personological (i.e., negative urgency, positive urgency, lack of premeditation) and neuropsychological (i.e., cognitive and motor disinhibition, impulsive choice) dimensions. Dialectical Behavior Therapy Skills Training (DBT-ST) as a stand-alone treatment is an effective intervention for alcohol use disorder (AUD) and other SUDs. However, there are no studies that have investigated changes in impulsivity levels during a DBT-ST program, especially testing the therapeutic effects of DBT skills. Twenty-nine patients with AUD and other SUDs were admitted to a 3-month DBT-ST program. Self-report (i.e., UPPS-P) and computerized neuropsychological (i.e., Attentional Network test; Go/No-Go task; Iowa Gambling Task) measures of impulsivity were administered at the beginning and end of the DBT-ST. Distress tolerance (DTS), mindfulness (MAAS, FFMQ) and emotion regulation (DERS) were also assessed pre- and post-intervention. The study included two age- and gender-matched control groups: (a) untreated patients with SUDs (N = 29); (b) healthy controls (HCs) (N = 29). Twenty-four (82.7%) patients concluded the DBT-ST program. Emotion-based forms of impulsivity significantly improved during the program. At the end of treatment, impulsivity levels were significantly lower than those of untreated patients with SUDs and they were not significantly different from HCs. Cognitive disinhibition significantly decreased during the treatment. The improvement in impulsivity was explained by pre- posttreatment changes in distress tolerance, mindfulness and emotion regulation. Motor disinhibition did not improve during the treatment. These findings supported the initial efficacy of the DBT-ST program for addressing different features of impulsivity among individuals with AUD and other SUDs. Future follow-up studies should demonstrate the role of impulsivity domains in long-term relapse prevention.

Body modifications in borderline personality disorder patients: prevalence rates, link with non-suicidal self-injury, and related psychopathology

BACKGROUND

Borderline Personality Disorder (BPD) is a potentially severe personality disorder, characterized by difficulties in emotion regulation and control of behaviors. It is often associated with non-suicidal self-injury (NSSI). Borderline personality features have also been linked to body modifications (BMs). However, the prevalence of BMs, the link between BMs and NSSI, and between BMs and several psychopathology dimensions (e.g. borderline severity, emotion regulation, impulsivity …) remains understudied in patients with BPD. This study aims to fill this gap, and to provide further evidence on the link between NSSI and BMs.

METHODS

We used data from a psychiatric outpatient center located in Switzerland (n = 116), specialized in the assessment and treatment of BPD patients. Patients underwent several semi-structured interviews and self-report psychometric scales at the arrival, and the data were retrospectively analyzed.

RESULTS

We found that 70.69% of the patients had one piercing or more, and 69.83% were tattooed. The total score of body modifications and the total number of piercings score of piercings were significantly positively associated with NSSI and the SCID BPD total score. The association with the SCID score was mainly driven by the "suicide and self-damaging behaviors" item and the "chronic feeling of emptiness" item. A significant association was found between total number of piercings and emotion dysregulation. On the other hand, the self-reported percentage of body covered by tattoos score was specifically associated with the sensation seeking subscale of the UPPS-P.

CONCLUSION

This study provides evidence on the prevalence of BMs in BPD patients, and on the link between BMs and NSSI in this population, suggesting a role of emotion regulation in the link between both constructs. These results also suggests that tattoos and piercings may be differentially linked to specific underlying psychological mechanisms. This calls for further considerations of body modifications in the assessment and care of BPD patients.

Dissecting the cross-trait effects of the FOXP2 GWAS hit on clinical and brain phenotypes in adults with ADHD

The Forkhead box P2 (FOXP2) encodes for a transcription factor with a broad role in embryonic development. It is especially represented among GWAS hits for neurodevelopmental disorders and related traits, including attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, neuroticism, and risk-taking behaviors. While several functional studies are underway to understand the consequences of FOXP2 variation, this study aims to expand previous findings to clinically and genetically related phenotypes and neuroanatomical features among subjects with ADHD. The sample included 407 adults with ADHD and 463 controls. Genotyping was performed on the Infinium PsychArray-24 BeadChip, and the FOXP2 gene region was extracted. A gene-wide approach was adopted to evaluate the combined effects of FOXP2 variants (n = 311) on ADHD status, severity, comorbidities, and personality traits. Independent risk variants presenting potential functional effects were further tested for association with cortical surface areas in a subsample of cases (n = 87). The gene-wide analyses within the ADHD sample showed a significant association of the FOXP2 gene with harm avoidance (P = 0.001; P_FDR = 0.015) and nominal associations with hyperactivity symptoms (P = 0.026; P_FDR = 0.130) and antisocial personality disorder (P = 0.026; P_FDR = 0.130). An insertion/deletion variant (rs79622555) located downstream of FOXP2 was associated with the three outcomes and nominally with the surface area of superior parietal and anterior cingulate cortices. Our results extend and refine previous GWAS findings pointing to a role of FOXP2 in several neurodevelopment-related phenotypes, mainly those involving underlying symptomatic domains of self-regulation and inhibitory control. Taken together, the available evidence may constitute promising insights into the puzzle of the FOXP2-related pathophysiology.

Diagnostic progression to schizophrenia: A nationwide cohort study of 11 170 adolescents and young adults with autism spectrum disorder

AIMS

Previous studies have suggested an increased risk of developing schizophrenia later in life in children with autism spectrum disorder (ASD). This study aims to investigate the diagnosis stability and the potential predictors for progression to schizophrenia in ASD.

METHODS

We recruited 11 170 adolescents (10-19 years) and young adults (20-29 years) with ASD between 2001 and 2010. They were followed up to the end of 2011 to identify newly diagnosed schizophrenia. The Kaplan-Meier method and Cox regression with age as a time scale were employed to estimate incidence rates and the significance of candidate predictors.

RESULTS

The progression rate from ASD to schizophrenia was 10.26% for 10 years of follow-up. Among 860 progressors, 580 (67.44%) occurred within the first 3 years after a diagnosis of ASD. The identified predictors were age (reported as hazard ratio with 95% confidence interval: 1.13; 1.11-1.15), depressive disorder (1.36; 1.09-1.69), alcohol use disorder (3.05; 2.14-4.35), substance use disorder (1.91; 1.18-3.09), cluster A personality disorder (2.95; 1.79-4.84), cluster B personality disorder (1.86; 1.05-3.28), and a family history of schizophrenia (2.12; 1.65-2.74).

CONCLUSION

More than two-thirds of the progressors developed schizophrenia within the first 3 years. Demographic characteristics, physical and psychiatric comorbidities, and psychiatric family history were significant predictors of progression.

Impulsive Lifestyle Counselling versus treatment as usual to reduce offending in people with co-occurring antisocial personality disorder and substance use disorder: a post hoc analysis

OBJECTIVES

To assess the impact of a short psychoeducation intervention for antisocial personality disorder on offending after randomization to treatment.

DESIGN

Multicentre, superiority, non-blinded randomized controlled trial. Random assignment was conducted in blocks of varying sizes at a central randomization centre. Participants were followed using national register data until 365 days after randomization, migration, or death, whichever occurred first.

SETTING

Thirteen outpatient uptake areas in Denmark.

PARTICIPANTS

Patients with antisocial personality disorder in treatment for substance use disorders were randomized to treatment as usual (TAU, n = 80) or Impulsive Lifestyle Counselling (ILC, n = 96). A total of 165 patients could be linked to criminal records (TAU, n = 74; ILC, n = 91).

INTERVENTION

ILC is a brief psychoeducational program targeting antisocial behavior. The trial was conducted between January 2012 and June 2014.

OUTCOMES

Number of criminal offences leading to convictions based on national registers.

RESULTS

The mean number of offences was 2.76 in the TAU group (95% Poisson confidence interval [CI] = 2.39, 3.16) and 1.87 in the ILC group (95% CI = 0.97, 1.43). Negative binomial regression was used to assess total number of convictions, as well as convictions for violent, property, driving under the influence, and drug-related crimes. In both adjusted and unadjusted analyses, random assignment to ILC was associated with a lower number of total offences (incidence rate risk ratio [IRR] = 0.43, p = .013; adjusted IRR = 0.45, p < .001) and convictions related to violence (IRR = 0.19, p = .001 adjusted IRR = 0.19, p = .007) and property offences (unadjusted IRR = 0.30, p = 0.003, adjusted IRR = 0.42, p = 0.010). Differences between conditions were not significant for driving under the influence (unadjusted IRR = 0.49, p = .370; adjusted IRR = 0.53, p = .417) or drug offences (unadjusted IRR = 1.06, p = .907; adjusted IRR = 0.55, p = .223).

CONCLUSIONS

The ILC program shows promise in reducing offending behavior in people with comorbid substance use and antisocial personality disorder.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN67266318 , 15/10/2012.

Efficacy and tolerability of Brain Stimulation interventions in Borderline Personality Disorder: state of the art and future perspectives - A systematic review

Treating Borderline Personality Disorder (BPD) is a major challenge for psychiatrists. As Brain Stimulation represents an alternative approach to treat psychiatric disorders, our systematic review is the first to focus on both invasive and Non-Invasive Brain Stimulation (NIBS) interventions in people living with BPD, examining clinical effects over core features and comorbid conditions. Following PRISMA guidelines, out of 422 original records, 24 papers were included regarding Deep Brain Stimulation (n = 1), Electroconvulsive therapy (n = 5), Transcranial Magnetic Stimulation (n = 13) and transcranial Direct Current Stimulation (n = 5). According to impulsivity and emotional dysregulated domain improvements, NIBS in BPD appears to restore frontolimbic network deficiencies. NIBS seems also to modulate depressive features. Safety and tolerability profiles for each technique are discussed. Despite encouraging results, definitive recommendations on Brain Stimulation in BPD are mitigated by protocols heterogeneity, lack of randomized controlled trials and poor quality of included studies, including high risk of methodological biases. To serve as guide for future systematic investigations, protocols optimization proposals are provided, focusing on alternative stimulation sites and suggesting a NIBS symptom-based approach.

Impulsivity and Emotional Dysregulation Predict Choice Behavior During a Mixed-Strategy Game in Adolescents With Borderline Personality Disorder

Impulsivity and emotional dysregulation are two core features of borderline personality disorder (BPD), and the neural mechanisms recruited during mixed-strategy interactions overlap with frontolimbic networks that have been implicated in BPD. We investigated strategic choice patterns during the classic two-player game, Matching Pennies, where the most efficient strategy is to choose each option randomly from trial-to-trial to avoid exploitation by one’s opponent. Twenty-seven female adolescents with BPD (mean age: 16 years) and twenty-seven age-matched female controls (mean age: 16 years) participated in an experiment that explored the relationship between strategic choice behavior and impulsivity in both groups and emotional dysregulation in BPD. Relative to controls, BPD participants showed marginally fewer reinforcement learning biases, particularly decreased lose-shift biases, increased variability in reaction times (coefficient of variation; CV), and a greater percentage of anticipatory decisions. A subset of BPD participants with high levels of impulsivity showed higher overall reward rates, and greater modulation of reaction times by outcome, particularly following loss trials, relative to control and BPD participants with lower levels of impulsivity. Additionally, BPD participants with higher levels of emotional dysregulation showed marginally increased reward rate and increased entropy in choice patterns. Together, our preliminary results suggest that impulsivity and emotional dysregulation may contribute to variability in mixed-strategy decision-making in female adolescents with BPD.

The Transdiagnostic Relevance of Self-Other Distinction to Psychiatry Spans Emotional, Cognitive and Motor Domains

Self-other distinction refers to the ability to distinguish between our own and other people's physical and mental states (actions, perceptions, emotions etc.). Both the right temporo-parietal junction and brain areas associated with the human mirror neuron system are likely to critically influence self-other distinction, given their respective contributions to theory of mind and embodied empathy. The degree of appropriate self-other distinction will vary according to the exact social situation, and how helpful it is to feel into, or remain detached from, another person's mental state. Indeed, the emotional resonance that we can share with others affords the gift of empathy, but over-sharing may pose a downside, leading to a range of difficulties from personal distress to paranoia, and perhaps even motor tics and compulsions. The aim of this perspective paper is to consider how evidence from behavioral and neurophysiological studies supports a role for problems with self-other distinction in a range of psychiatric symptoms spanning the emotional, cognitive and motor domains. The various signs and symptoms associated with problematic self-other distinction comprise both maladaptive and adaptive (compensatory) responses to dysfunction within a common underlying neuropsychological mechanism, compelling the adoption of more holistic transdiagnostic therapeutic approaches within Psychiatry.

Fibroblast growth factor 21 associating with serotonin and dopamine in the cerebrospinal fluid predicts impulsivity in healthy subjects

Background

Impulsivity is more commonly reported in subjects with mental disorders compared to healthy subjects, suggesting a potential application of impulsivity in predicting impulsivity-related mental disorders. However, no biomarker of impulsivity available so far. This study explored the association between cerebrospinal fluid (CSF) fibroblast growth factor 21 (FGF21), a key hormonal mediator of the stress response, and impulsivity in healthy subjects.

Methods

A total of 126 healthy persons subjected to surgery of anterior cruciate ligament were recruited in the present study. The impulsiveness of the subjects was evaluated by the Chinese version of the Barratt Impulsiveness Scale (BIS)-11 before surgery. CSF and blood samples of the subjects were collected before spinal anesthesia for surgery. The levels of FGF21, serotonin and dopamine in CSF and the level of FGF21 in blood of the subjects were measured by ELISA using commercial kits.

Results

Negative correlations were found between BIS-11 total score and either FGF21, serotonin or dopamine in CSF. However, BIS-11 total score was not correlated with FGF21 in blood. In addition, FGF21 was positively correlated with serotonin and dopamine in CSF, respectively. Multivariable linear regression models indicated that the decrease of FGF21 level associating with the decrease of serotonin and dopamine level in CSF contributed to the higher impulsivity. Furthermore, receiver operating characteristic curve (ROC) analysis indicated an important role of CSF FGF21 predicting high impulsivity.

Conclusions

FGF21, serotonin and dopamine in CSF associate with impulsivity in opposite directions. The decrease of CSF FGF21 is related to higher impulsivity, and indicate that CSF FGF21 may predict impulsivity in healthy subjects.

Slower adaptation of control strategies in individuals with high impulsive tendencies

Flexible use of reactive and proactive control according to environmental demands is the key to adaptive behavior. In this study, forty-eight adults performed ten blocks of an AX-CPT task to reveal the strength of proactive control by the calculation of the proactive behavioral index (PBI). They also filled out the UPPS questionnaire to assess their impulsiveness. The median-split method based on the global UPPS score distribution was used to categorize participants as having high (HI) or low (LI) impulsiveness traits. The analyses revealed that the PBI was negatively correlated with the UPPS scores, suggesting that the higher is the impulsiveness, the weaker the dominance of proactive control processes. We showed, at an individual level, that the PBI increased across blocks and suggested that this effect was due to a smaller decrease in reactive control processes. Notably, the PBI increase was slower in the HI group than in the LI group. Moreover, participants who did not adapt to task demands were all characterized as high impulsive. Overall, the current study demonstrates that (1) impulsiveness is associated with less dominant proactive control due to (2) slower adaptation to task demands (3) driven by a stronger reliance on reactive processes. These findings are discussed in regards to pathological populations.

Prefrontal and striatal dopamine D2/D3 receptors correlate with fMRI BOLD activation during stopping

D₂-like dopamine receptors in animals and humans have been shown to be linked to impulsive behaviors that are highly relevant for several psychiatric disorders. Here, we investigate the relationship between the fronto-striatal D₂/D₃ dopamine receptor availability and response inhibition in a selected population of healthy OPRM1 G-allele carriers. Twenty-two participants successively underwent blood-oxygen level dependent functional magnetic resonance imaging (fMRI) while performing a stop-signal task and a separate positron emission tomography (PET) scan. Striatal and extrastriatal D₂/D₃ dopamine receptor availability was measured using the radiotracer [¹⁸F]fallypride. Caudate D₂/D₃ dopamine receptor availability positively correlated with stopping-related fronto-striatal fMRI activation. In addition, right prefrontal D₂/D₃ dopamine receptor availability correlated positively with stopping-related striatal fMRI BOLD signal. Our study partially replicates previous findings on correlations between striatal D₂/D₃ dopamine receptor availability and response inhibition in a population selected for its genetic determination of dopamine response to alcohol and as a modulator of impulse control via the endogenous opioid system. We confirm the important role of D₂/D₃ dopamine receptor availability in the fronto-striatal neural circuit for response inhibition. Moreover, we extend previous findings suggesting that dopamine receptor availability in the right inferior frontal cortex, a crucial region of the stopping network, is also strongly associated with stopping-related striatal fMRI activity in healthy OPRM1 G-allele carriers.

Mind-body approaches targeting the psychological aspects of opioid use problems in patients with chronic pain: evidence and opportunities

Opioids are commonly prescribed for the management of patients with chronic noncancer pain. Despite the potential analgesic benefits of opioids, long-term opioid therapy (LTOT) may be accompanied by problems such as opioid misuse and opioid use disorder (OUD). In this review, we begin with a description of opioid misuse and OUD and the patient-specific factors associated with these problems among patients with chronic pain. We will focus primarily on highlighting the predominant role played by psychological factors in the occurrence of opioid misuse and OUD in these patients. Several psychological factors have been found to be associated with opioid use problems in patients with chronic pain, and evidence indicates that patients presenting with psychological disturbances are particularly at risk of transitioning to long-term opioid use, engaging in opioid misuse behaviors, and developing OUD. The biological factors that might underlie the association between psychological disturbances and opioid use problems in patients with chronic pain have yet to be fully elucidated, but a growing number of studies suggest that dysfunctions in reward, appetitive, autonomic, and neurocognitive systems might be involved. We end with an overview of specific types of psychological interventions that have been put forward to prevent or reduce the occurrence of opioid misuse and OUD in patients with chronic pain who are prescribed LTOT.

Comparing impulsivity in borderline personality, schizophrenia and obsessional-compulsive disorders: Who is ahead?

OBJECTIVE

Impulsivity impacts life domains and in a psychiatric context is often associated with disorders severity and stigmatization. Borderline personality disorder's (BPD), Schizophrenic disorder's (SZD), and obsessional compulsive disorder's (OCD) impulsivity issues relate to worse prognosis. This study aims to compare these disorders assessing their proneness to impulsivity and urgency.

METHODS

We recruited 90 patients among them OCD (n = 25), SZD (n = 23), and BPD (n = 50), and 24 healthy control participants (HC). We assessed the diagnosis according and measured the impulsivity level.

RESULTS

Our results showed that BPD was significantly more impulsive than HC, SZD, and OCD. HC, SZD, and OCD being equivalent on their global Urgency-Premeditation-Perseverance-Sensation seeking scores. For urgency, BPD was also superior to others, OCD was superior to HC, but SZD and HC were equivalent. The urgency was correlated to SZD's scale for SZD, no link appeared between borderline personality questionnaire and Yale-Brown Obsessive-Compulsive Scale's score.

CONCLUSION

These results question the existent literature relating impulsivity and SZD.

Interpersonal Problems in Borderline Personality Disorder: Associations With Mentalizing, Emotion Regulation, and Impulsiveness

Interpersonal problems are a core symptom of borderline personality disorder (BPD). This study investigated the relationship between emotion dysregulation, impulsiveness, and impaired mentalizing in the context of predicting interpersonal problems in BPD. A total of 210 patients with BPD completed the Difficulties in Emotion Regulation Scale (DERS), Barratt Impulsiveness Scale (BIS-11), Reflective Functioning Questionnaire (RFQ), and Inventory of Interpersonal Problems (IIP-32). The authors conducted three path models, with either mentalizing, emotion regulation, or impulsiveness as the exogenous variable. Emotion dysregulation and attentional impulsiveness predicted interpersonal problems directly, whereas hypomentalizing predicted interpersonal problems only indirectly throughout emotion dysregulation and attentional impulsiveness. The results suggest that these domains contribute significantly to interpersonal problems in BPD. Moreover, hypomentalizing might affect on interpersonal problems via its effect on impulsiveness and emotion regulation. The authors argue that focusing on emotion regulation and mentalizing in BPD treatments might have interlinked beneficial effects on interpersonal problems.

Antisocial Personality Disorder in Bipolar Disorder: A Systematic Review

Background and Objectives: Bipolar Disorder (BD) is a severe psychiatric disorder that worsens quality of life and functional impairment. Personality disorders (PDs), in particular Cluster B personality, have a high incidence among BD patients and is considered a poor prognostic factor. The study of this co-morbidity represents an important clinical and diagnostic challenge in psychiatry. Particularly, clinical overlap has been shown between antisocial personality disorder (ASPD) and BD that could worsen the course of both disorders. We aimed to detect the frequency of ASPD in bipolar patients with greater accuracy and the impact of ASPD on the clinical course of BD. Materials and Methods: A systematic literature search was conducted in PubMed, Embase, MEDLINE and the Cochrane Library through December 2020 without language or time restriction, according to PRISMA statement guidelines. Results: Initially, 3203 items were identified. After duplicates or irrelevant paper deletion, 17 studies met the inclusion criteria and were included in this review. ASPD was more frequent among BD patients, especially in BD type I. BD patients with ASPD as a comorbidity seemed to have early onset, higher number and more severe affective episodes, higher levels of aggressive and impulsive behaviors, suicidality and poor clinical outcome. ASPD symptoms in BD seem to be associated with a frequent comorbidity with addictive disorders (cocaine and alcohol) and criminal behaviors, probably due to a shared impulsivity core feature. Conclusions: Considering the shared symptoms such as impulsive and dangerous behaviors, in patients with only one disease, misdiagnosis is a common phenomenon due to the overlapping symptoms of ASPD and BD. It may be useful to recognize the co-occurrence of the disorders and better characterize the patient with ASPD and BD evaluating all dysfunctional aspects and their influence on core symptoms.

Dimensions of Impulsivity in Healthy People, Patients with Borderline Personality Disorder, and Patients with Attention-Deficit/Hyperactivity Disorder

Objective: Impulsivity, observed in patients with various psychiatric disorders, is a heterogeneous construct with different behavioral manifestations. Through confirmatory factor analysis (CFA), this study tests hypotheses about relationships between dimensions of impulsivity measured using personality questionnaires and behavioral tests. Method: The study included 200 healthy people, 40 patients with borderline personality disorder, and 26 patients with attention-deficit/hyperactivity disorder (ADHD) who underwent a comprehensive impulsivity test battery including the Barratt Impulsiveness Scale (BIS), UPPS-P Impulsive Behavior Scale, a Go-NoGo task, a stop-signal task, and a delay discounting task. Results: A CFA model comprising three self-reported and three behavioral latent variables reached a good fit. Both patient groups scored higher in the self-reported dimensions and impulsive choice; only the ADHD patients displayed impaired waiting and stopping impulsivity. Conclusions: Using the developed CFA model, it is possible to describe relations between impulsivity dimensions and show different impulsivity patterns in patient populations.

Neurological soft signs correlation with symptom severity in borderline personality disorder

Background

Borderline personality disorder (BPD) is a severe psychiatric disorder with multiple psychopathological domains; so studying the correlation of clinical or behavioral data with underlying structural and functional neurological findings in BPD is the focus of interest in recent years.

The aim of our study was to compare the presence of neurological soft signs (NSS) in patients with borderline personality disorder with their presence in normal controls, and to correlate the severity of different symptoms of BPD with the presence of NSS through a case-control study which was conducted on 30 patients and 30 matching controls recruited from Al Kasr Al Ainy Hospital, Cairo University, Egypt. All subjects were assessed by the Borderline Personality Questionnaire, the Barratt Impulsivity Scale-11, the Brief Non-Suicidal Self-Injury Assessment tool, and the Cambridge Neurological Inventory.

Results

The BPD group had significantly higher total NSS scores, primitive reflexes subscale score, and sensory integration subscale scores. There was also a positive correlation between NSS and overall severity of borderline symptoms.

Conclusions

The increased rates of NSS were associated with specific clinical symptoms in BPD including suicidality, self-harm, emptiness, and quasi-psychosis. Impulsivity was found to have the highest correlation with NSS.

The Effects of Non-invasive Brain Stimulation on Impulsivity in People with Mental Disorders: a Systematic Review and Explanatory Meta-Analysis

Impulsivity is a multi-faceted construct that underpins various mental health disorders. Impulsive behavior exacts a substantial health and economic burden, hence the importance of developing specific interventions to target impulsivity. Two forms of non-invasive brain stimulation, namely transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS), have been used to modulate impulsivity. To date, no reviews have systematically examined their effects on modulating impulsivity in people with mental health disorders. We conducted a systematic review and meta-analysis of the literature from AMED, Embase, Medline and PsycINFO databases on the use of rTMS and tDCS to modulate impulsivity in people with mental health disorders. Results from 11 tDCS and 18 rTMS studies indicate that tDCS has a significant, albeit small, effect on modulating impulsivity (g = 0.29; 95% CI, 0.09 to 0.48; p = .004) whereas rTMS has no significant effect on impulsivity (g = -0.08; 95% Cl, -0.35 to 0.19; p = .550). Subgroup analyses identified the key parameters required to enhance the effects of tDCS and rTMS on impulsivity. Gender and stimulation intensity acted as significant moderators for effects of rTMS on impulsivity. There is insufficient evidence to support the use of tDCS or rTMS in clinical practice to reduce impulsivity in people with mental health disorders. The use of standardized non-invasive brain stimulation protocols and outcome measures in patients with the same diagnosis is advised to minimize methodological heterogeneity.

Change in core symptoms of borderline personality disorder by tDCS: A pilot study

Borderline personality disorder (BPD) recognizes several psychopathological dimensions related to prefrontal cortex impairments. Transcranial Direct Current Stimulation (tDCS) targeting the right prefrontal dorsolateral cortex (DLPFC) positively influence cognitive functions related to impulsivity in healthy subjects. A randomized double-blind study was designed to investigate whether tDCS could modulate core dimensions (impulsivity, aggression, affective dysregulation) of BPD. Also effects on decision making process and substances craving was assessed. Patients were randomized to receive active-tDCS at 2 mA versus sham-tDCS, once a day for 15 sessions. Anode was placed on the right DLPFC (F4), cathode on the left DLPFC (F3). Impulsivity and aggression measures were significantly reduced only in patients treated with active-tDCS. Decision-making process was marginally influenced by the active current. Craving intensity was reduced only in the active-tDCS sample. Both groups showed improvements in the affective dysregulation dimension and anxious and depressive symptoms. The application of bilateral tDCS targeting right DLPFC with anodal stimulation seems to improve core dimensions of BPD (mainly impulsivity and aggression) probably by restoring prefrontal activity. tDCS might be a potential tool for preventing self-harming behaviors.

The Effect of Response Inhibition Training on Risky Decision-Making Task Performance

Response inhibition is an important component of executive function and plays an indispensable role in decision-making and other advanced cognitive processes. At the same time, we need an effective way to improve decision-making in the face of complex and limited information. This study mainly explored the influence of response inhibition training on college students' risky decision-making. The recruited students were randomly divided into the training group (n = 28) and the control group (n = 28). The training group engaged in Go/NoGo and stop-signal tasks for 2 weeks, while the control group was given the task of reading and summarizing popular science articles related to self-control. The Stroop task and Balloon Analog Risk Task were used to evaluate the pretest and posttest performance in inhibitory control and risky decision-making tasks, respectively, for all subjects. The results showed that response inhibition training can be effectively transferred to interference control task performance. The results showed that both the reward acquired and adjusted Balloon Analog Risk Task score (adj BART) significantly improved compared to the pretest in the training group, while the control group showed no significant differences in the reward acquired and the adj BART between the pretest and the posttest. Although response inhibition training increased risky behaviors in the Balloon Analog Risk Task, it substantially reduced overly conservative behaviors and participants gained more money.

Late-Onset OCD as a Potential Harbinger of Dementia With Lewy Bodies: A Report of Two Cases

OBJECTIVES

Obsessive-compulsive disorder usually begins in adolescence or young adulthood. OCD cases appearing after the age of 50 years are rare, most often associated with inflammatory, brain lesions, or neurodegenerative comorbidities. We describe two cases of late-onset obsessive compulsive disorder followed by the development of Dementia with Lewy Bodies and review the links between these two disorders.

METHODS AND RESULTS

We describe the clinical history of two patients that first showed OCD symptoms at an atypical age (>60 years). After several failed treatment attempts, they were hospitalized in our unit. Both presented severe sensitivity to antipsychotic agents that led to a diagnosis of Dementia with Lewy Bodies. Administration of cholinesterase inhibitors was associated with decrease of psychiatric symptoms in both cases. In addition to those clinical observations, a systematic review of the literature suggests that, beyond prefrontal cortex, temporal lobe and putamen have important roles in OCD pathophysiology. Based on these findings, we discuss four hypotheses to explain the sequential appearance of OCD and DLB symptoms. First, we considered the possibility that comorbidity of OCD with DLB was coincidental. Second, we propose to interpret OCD symptoms as motor stereotypies. Third, we hypothesize that late-onset OCD might be a symptom of late-onset depression. Four, we hypothesize that through early deterioration of basal ganglia, DLB caused the onset of OCD.

CONCLUSION

In conclusion, we recommend that cases of late-onset treatment-resistant OCD should be carefully tested for possible organic etiologies, and for DLB in particular.

Relationships between the frequency and severity of non-suicidal self-injury and suicide attempts in youth with borderline personality disorder

AIM

Non-suicidal self-injury (NSSI) is a recognized indicator of suicide risk. Yet, the ubiquity of this behaviour in borderline personality disorder (BPD) limits its utility as a predictor of risk. Consequently, this study aimed to elucidate the relationship between other features of NSSI, including frequency and severity, and suicide attempts.

METHOD

Participants included 107 youth (15 to 25 year olds) with BPD who were assessed for BPD severity, depressive symptoms, 12-month frequency of NSSI and suicide attempts, as well as the levels of treatment sought following each self-harm event.

RESULTS

Three-quarters (75.7%) of youth with BPD reported NSSI and two-thirds (66.4%) reported a suicide attempt over the previous 12 months. The frequency of NSSI over the previous 12 months did not show a linear or quadratic relationship with the number of suicide attempts when adjusting for severity of depression, impulsivity and interpersonal problems. NSSI severity was not associated with more frequent suicide attempts. Only impulsivity and depression were uniquely predictive of suicide attempt frequency. A relative increase in the frequency and severity of NSSI occurred in the months prior to a suicide attempt.

CONCLUSION

The prevalence of NSSI and suicide attempts among youth presenting for their first treatment of BPD appear to be perilously high, considerably higher than rates reported by adults with BPD. Findings suggest that clinicians should give more weight to average levels of impulsivity and depression, rather than the absolute frequency and severity of NSSI, when assessing for risk of suicide attempts. Notwithstanding this, a relative increase in the frequency and severity of NSSI appears to be predictive of a forthcoming suicide attempt.

The Degree of Modulation of Beta Band Activity During Motor Planning Is Related to Trait Impulsivity

Impulsivity is a prominent personality trait, and a key modulating component of neurologic and psychiatric disorders. How impulsivity is related to the brain mechanisms associated with action planning is poorly understood. Here, we investigated the relation between impulsivity and the modulation of beta band oscillatory activity associated with action planning and execution. Given that beta power decreases during action planning and decreases further during action execution, we hypothesized that during planning the level of beta band power of more impulsive individuals would be closer to the level reached during execution than that of less impulsive individuals. This could explain the tendency to "jump the gun" (commission errors) in high impulsivity. To test this hypothesis, we recruited healthy volunteers (50 participants analyzed) and used the Barratt Impulsiveness Scale questionnaire to evaluate their impulsivity as high or low. We then recorded their brain neuromagnetic signals while they performed an instructed-delay task that induced different levels of action planning by varying the number of spatial cues, hence the uncertainty, about the location of the upcoming target. During the early cue period of the task, we found a posterior (source localized in the occipito-parietal areas) and a left fronto-central group of channels (source localized in the left sensorimotor areas) where beta power was modulated by number of cues, whereas during the late cue period only the left fronto-central group was modulated. We found that the decrease of relative beta band power during action planning in the left fronto-central group of channels was more pronounced in the high impulsivity group than in the low impulsivity group. In addition, we found that the beta band-mediated functional connectivity between the posterior and the left fronto-central groups of channels was weaker in the high impulsivity group than in the low impulsivity group during the early cue period. Furthermore, high impulsives made more commission and movement errors in the task than low impulsives. These results reveal neural mechanisms through which impulsivity affects action planning and open the way for further study of the role of beta band activity in impulsivity, especially in the context of disease and therapeutics.

Recurrent Depression and Borderline Personality Disorder in a Patient with Ehlers-Danlos Syndrome

Ehlers-Danlos syndrome is a group of connective tissue disorders that most commonly causes joint hypermobility, skin hyperextensibility, and tissue fragility. Patients diagnosed with Ehlers-Danlos syndrome (EDS) frequently suffer from chronic pain and other comorbid conditions. In addition, there is an increased incidence of psychiatry conditions in this patient population, such as anxiety, depression, and personality disorders. We present the case of a 25-year-old female who presented to a community hospital with frequent thoughts of suicide and major depression. She was previously diagnosed with Ehlers-Danlos syndrome, borderline personality disorder, and major depressive disorder. The patient was treated with a selective serotonin reuptake inhibitor (SSRI) and gabapentin for pain associated with EDS. However, she was still suicidal and was admitted upon evaluation. Subsequently, she was prescribed lithium in order to augment the effects of the SSRI and reduce her risk of suicide. In addition to pharmacotherapy, patients with these conditions should consider enrolling in some type of therapy. 

Moderating effect of PLIN4 genetic variant on impulsivity traits in 5-year-old-children born small for gestational age

Poor fetal growth is associated with long-term behavioral, metabolic and psychiatric alterations, including impulsivity, insulin resistance, and mood disorders. However, the consumption of omega-3 polyunsaturated fatty acid (n-3 PUFA) seems to be protective for this population, improving inhibitory control and behavioral reactivity. We investigated whether the presence of the A allele of rs8887 SNP (PLIN4 gene), known to be associated with increased sensitivity to the consumption of n-3 PUFAs, interacts with fetal growth influencing inhibitory control. 152 five-year-old children were genotyped and performed the Stop Signal Task (SSRT). There was a significant interaction between birth weight and the presence of the A allele on SSRT performance, in which lower birth weight associated with poorer inhibitory control only in non-carriers. These results suggest that a higher responsiveness to n-3 PUFAS protects small for gestational age children from developing poor response inhibition, highlighting that optimizing n-3 PUFA intake may benefit this population.

Dissociations of cognitive inhibition, response inhibition, and emotional interference: Voxelwise ALE meta-analyses of fMRI studies

Inhibitory control is the stopping of a mental process with or without intention, conceptualized as mental suppression of competing information because of limited cognitive capacity. Inhibitory control dysfunction is a core characteristic of many major psychiatric disorders. Inhibition is generally thought to involve the prefrontal cortex; however, a single inhibitory mechanism is insufficient for interpreting the heterogeneous nature of human cognition. It remains unclear whether different dimensions of inhibitory processes-specifically cognitive inhibition, response inhibition, and emotional interference-rely on dissociated neural systems. We conducted systematic meta-analyses of fMRI studies in the BrainMap database supplemented by PubMed using whole-brain activation likelihood estimation. A total of 66 study experiments including 1,447 participants and 987 foci revealed that while the left anterior insula was concordant in all inhibitory dimensions, cognitive inhibition reliably activated specific dorsal frontal inhibitory system, engaging dorsal anterior cingulate, dorsolateral prefrontal cortex, and parietal areas, whereas emotional interference reliably implicated a ventral inhibitory system, involving the ventral surface of the inferior frontal gyrus and the amygdala. Response inhibition showed concordant clusters in the fronto-striatal system, including the dorsal anterior cingulate region and extended supplementary motor areas, the dorsal and ventral lateral prefrontal cortex, basal ganglia, midbrain regions, and parietal regions. We provide an empirically derived dimensional model of inhibition characterizing neural systems underlying different aspects of inhibitory mechanisms. This study offers a fundamental framework to advance current understanding of inhibition and provides new insights for future clinical research into disorders with different types of inhibition-related dysfunctions.

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.

Oxytocin improves facial emotion recognition in young adults with antisocial personality disorder

Deficient facial emotion recognition has been suggested to underlie aggression in individuals with antisocial personality disorder (ASPD). As the neuropeptide oxytocin (OT) has been shown to improve facial emotion recognition, it might also exert beneficial effects in individuals providing so much harm to the society. In a double-blind, randomized, placebo-controlled crossover trial, 22 individuals with ASPD and 29 healthy control (HC) subjects (matched for age, sex, intelligence, and education) were intranasally administered either OT (24 IU) or a placebo 45min before participating in an emotion classification paradigm with fearful, angry, and happy faces. We assessed the number of correct classifications and reaction times as indicators of emotion recognition ability. Significant group×substance×emotion interactions were found in correct classifications and reaction times. Compared to HC, individuals with ASPD showed deficits in recognizing fearful and happy faces; these group differences were no longer observable under OT. Additionally, reaction times for angry faces differed significantly between the ASPD and HC group in the placebo condition. This effect was mainly driven by longer reaction times in HC subjects after placebo administration compared to OT administration while individuals with ASPD revealed descriptively the contrary response pattern. Our data indicate an improvement of the recognition of fearful and happy facial expressions by OT in young adults with ASPD. Particularly the increased recognition of facial fear is of high importance since the correct perception of distress signals in others is thought to inhibit aggression. Beneficial effects of OT might be further mediated by improved recognition of facial happiness probably reflecting increased social reward responsiveness.