Multimodal assessment of emotional reactivity in borderline personality pathology: the moderating role of posttraumatic stress disorder symptoms

The Hypothalamus-Pituitary-Adrenal Axis and Social Cognition in Borderline Personality Disorder

Borderline personality disorder (BPD) is characterized by emotional instability, impulsivity and unstable interpersonal relationships. Patients experience discomforting levels of distress, inducing symptoms like dissociation, aggression or withdrawal. Social situations are particularly challenging, and acute social stress can reduce patients' cognitive and social functioning. In patients with Major Depressive Disorder or Posttraumatic Stress Disorder, which show high comorbidity with BPD, the endocrine stress response is characterized by Hypothalamus-Pituitary-Adrenal (HPA) axis dysfunction, which affects cognitive functioning. Compared to these clinical groups, research on HPA-axis function in BPD is relatively scarce, but evidence points towards a blunted cortisol reactivity to acute stress. Since BPD patients are particularly prone to social stress and experience high subjective difficulties in these situations, it seems plausible that HPA-axis dysregulation might contribute to decreased social cognition in BPD. The present review summarizes findings on the HPA-axis function in BPD and its association with social cognition following acute social stress. For this purpose, we review literature that employed a widely used social stressor (Trier Social Stress Test, TSST) to study the effects of acute social stress on social cognition and the HPA-axis response. We contrast these findings with studies on social cognition that employed Cyberball, another widely used social stressor that lacks HPA-axis involvement. We conclude that research on social cognition in BPD reveals heterogeneous results with no clear relationship between social functioning and HPA-axis response. More research is needed to better understand the psychophysiological underpinnings of impaired social cognition in BPD.

The influence of sleep on emotion dysregulation in borderline personality disorder, generalized anxiety disorder, and healthy controls

Emotion dysregulation is central to borderline personality disorder (BPD) and exacerbated by sleep disruptions. This study investigated whether homeostatic (i.e., sleep efficiency), circadian (i.e., chronotype), and subjective (i.e., sleep quality) sleep elements predict emotion dysregulation in BPD, healthy controls (HCs), and a generalized anxiety disorder (GAD) group. Participants (N = 120) with BPD, GAD, and HCs completed daily sleep measures for seven days prior to an experiment wherein baseline emotion, emotional reactions to stressors (i.e., reactivity), and the extent to which they can decrease their emotion using mindfulness and distraction (i.e., emotion regulation) were measured across self-reported, sympathetic, and parasympathetic emotion. Across groups, earlier chronotypes and higher sleep quality predicted less self-reported baseline negative emotion, and higher sleep quality predicted better parasympathetic emotion regulation. For HCs, higher sleep efficiency and lower sleep quality predicted higher parasympathetic baseline emotion, and higher sleep efficiency predicted more self-reported baseline negative emotion. Also in HCs, earlier chronotype predicted better sympathetic emotion regulation, and there was a quadratic relationship between sleep efficiency and self-reported emotion regulation. Optimizing sleep quality and improving alignment between chronotype and daily living may improve baseline emotion and emotion regulation. Healthy individuals may be particularly vulnerable to high or low sleep efficiency.

Is borderline personality disorder really an emotion dysregulation disorder and, if so, how? A comprehensive experimental paradigm

BACKGROUND

Leading theories suggest that borderline personality disorder (BPD) is an emotion dysregulation disorder involving lower basal vagal tone, higher baseline emotion, heightened emotional reactivity, delayed emotional recovery, and emotion regulation deficits. However, the literature to date lacks a unifying paradigm that tests all of the main emotion dysregulation components and comprehensively examines whether BPD is an emotion dysregulation disorder and, if so, in what ways. This study addresses the empirical gaps with a unified paradigm that assessed whether BPD is characterized by five leading emotion dysregulation components compared to generalized anxiety disorder (GAD) and healthy control (HC) groups.

METHODS

Emotion was assessed across self-report, sympathetic, and parasympathetic indices. Participants with BPD, GAD, and HCs (N = 120) first underwent baseline periods assessing basal vagal tone and baseline emotional intensity, followed by rejection-themed stressors assessing emotional reactivity. Participants then either reacted normally to assess emotional recovery or attempted to decrease emotion using mindfulness or distraction to assess emotion regulation implementation deficits.

RESULTS

Individuals with BPD and GAD exhibited higher self-reported and sympathetic baseline emotion compared to HCs. The BPD group also exhibited self-reported emotion regulation deficits using distraction only compared to the GAD group.

CONCLUSIONS

There is minimal support for several emotion dysregulation components in BPD, and some components that are present appear to be pervasive across high emotion dysregulation groups rather than specific to BPD. However, BPD may be characterized by problems disengaging from emotion using distraction.

A mixed methods examination of emotional expression and its impact on emotion regulation effectiveness in borderline personality disorder

BACKGROUND AND OBJECTIVES

Emotional expression (i.e., identifying and labeling emotion using specific words), is theorized to reduce negative emotion and facilitate emotion regulation. However, it remains unclear how individuals with borderline personality disorder express emotion, and whether this influences their emotion regulation. This study examined whether: 1) emotional expression in borderline personality disorder differed from healthy controls based on word valence, emotionality, and vocabulary; and 2) whether such characteristics predict emotion regulation effectiveness across self-reported and physiological emotion domains differentially across these groups.

METHODS

Individuals with borderline personality disorder (n = 29) and age and sex-matched healthy controls (n = 30) listened to an evocative story, expressed emotion, and regulated emotion by applying Mindfulness or Cognitive Reappraisal. Emotion regulation was measured by changes in self-report, parasympathetic, and sympathetic emotion, while implementing the emotion regulation strategies. The words used to express emotion were coded based on valence, emotionality, and depth of vocabulary.

RESULTS

Generalized estimating equations revealed no differences between groups in valence, emotionality, and vocabulary. Additionally, using a larger emotional vocabulary predicted more effective sympathetic emotion regulation, and using more negatively valenced words predicted more effective parasympathetic emotion regulation across groups.

LIMITATIONS

Among other things, this study is limited by its predominantly female sample, and that it does not determine whether valence, emotionality, or vocabulary independently predict emotional expression effectiveness.

CONCLUSIONS

Emotional expression may not be deficient in borderline personality disorder across the indices studied. Using more negative words and broadening vocabulary while expressing emotion may offer emotion regulation benefits.

The borderline interpersonal-affective systems (BIAS) model: Extending understanding of the interpersonal context of borderline personality disorder

Prominent explanatory models for borderline personality disorder (BPD) are intrapersonal in nature and hold that it is an emotional disorder. However, the empirical support for emotional models of BPD is mixed. Refinements to BPD explanatory models are needed to increase the precision with which BPD can be understood and treated. Drawing on existing theoretical and empirical research in BPD, this manuscript presents the Borderline Interpersonal-Affective Systems (BIAS) model. The BIAS model purports that harmful early life relationships and subsequent conflictual relationships lead individuals with BPD to develop a sensitivity to interpersonal threat in the form of attentional and appraisal biases. Individuals with BPD are posited to 1) experience heightened emotional reactivity specifically to perceived interpersonal threat and 2) engage in destructive behaviors both to regulate increasing emotion and to meet interpersonal needs. We review the empirical support for each component of the BIAS model, along with the role of the cognitions, emotions, and behaviors of significant others in influencing BIAS model processes in individuals with BPD over time. The BIAS model highlights a novel way of understanding and integrating interpersonal and emotional components of the disorder. Key directives for future research and clinical implications are discussed.

Heart rate reactivity to trauma-related imagery as a measure of PTSD symptom severity: Examining a new cohort of Veterans

For over three decades, there has been considerable research documenting increased physiological reactivity to trauma-related stimuli as a characteristic feature of posttraumatic stress disorder (PTSD). The present study explored the potential for physiological assessment to aid in defining and validating screening criteria for the presence of significant PTSD-related symptoms in a sample of OEF/OIF/OND Veterans seeking care in a VA post-deployment health clinic. Heart rate reactivity scores during the imagining phase of the script-driven imagery paradigm were compared across groups of individuals with and without probable PTSD diagnoses, as defined by PCL-IV cutoff scores ranging from 40 to 60. Significant differences were found for groups defined by PCL-IV cutoff scores of 50 and 60, with 50 producing the largest effect size. Diagnosing PTSD is made challenging by the presence of overlapping symptoms shared with other diagnoses, as well as by the necessity for patients to accurately report their symptoms. An objective physiological measure capable of accurately differentiating individuals with and without PTSD provides potential adjunctive diagnostic and treatment information to clinicians. The present findings support the validity of physiological reactivity during SDI as a NIMH RDoC measure that can be used in research and clinical applications assessing trauma-related symptom severity.

How Do Stress Exposure and Stress Regulation Relate to Borderline Personality Disorder?

Borderline personality disorder (BPD) is a severe and frequent disorder characterized by a pervasive pattern of instability affecting impulse control, emotional regulation, cognitive processing, self-image and interpersonal relationships. Patients’ personal histories are often marked by stressful or traumatic experiences, either unique or repeated. Moreover, while clinical signs of the disorder include both chronic and acute features, acute features are mostly triggered by acute stressful situations. Such features include transient cognitive distortion, intense anger, uncontrollable impulsivity, and self-harm behavior – including suicide – and contribute to the burden of the disease. In this paper, we review the various aspects (epidemiological, clinical, and physiological) contributing to the relationship between BDP and stress. In particular, we explore the statistical association between stress exposure and the emergence of BPD while taking into account other psychopathologies, such as post-traumatic stress disorder. Then, the different aspects of stress responses (namely, the phenomenological, behavioral, hormonal, neuro-vegetative and neural responses) are reviewed in BPD patients. Pathophysiological hypotheses are formulated to explain the differences in responses between BPD patients and healthy subjects and their relation to BPD symptoms. Although the pathogenesis remains uncertain, our conclusions seem to reflect a specific biological and neural pattern of altered stress perception and regulation in BPD.

Association Between Borderline Personality Features and Temporal Summation of Second Pain: A Cross-Sectional Study

Individuals with greater borderline personality features may be vulnerable to chronic pain. Because pain is an unpleasant sensory and emotional experience, affect dysregulation as the core personality feature may be linked to pain hypersensitivity. Studies have found that greater borderline features are associated with increased intensity in clinical and experimental pain, and that depression mediates this increase. The current study further examined the association between borderline features and heat pain sensitivity, the contribution of affect dysregulation and the other borderline personality factors (identity problems, negative relationships, self-harming/impulsivity) to the association, and depression as a mediator. Additionally, we examined whether blunted sympathetic responses mediate the association between borderline features and temporal summation of second pain (TSSP). Thermal pain threshold, thermal TSSP and aftersensations pain were assessed in 79 healthy individuals with varying degrees of borderline features. TSSP is a proxy measure for central sensitization and refers to the gradual increase in pain to repeated nociceptive stimuli. A regression analysis showed that greater borderline features predicted greater TSSP (β = .22, p = .050, R² = .05). Borderline features were unrelated to pain threshold and TSSP decay. A stepwise regression showed greater TSSP in individuals with greater borderline features was accounted for by the negative relationships factor rather than the affect dysregulation factor. The results of mediational analyses showed depression and blunted sympathetic skin conductance responses mediated the positive association between TSSP and borderline features.

Emotion regulation choice in female patients with borderline personality disorder: Findings from self-reports and experimental measures

Emotion dysregulation is a core feature of borderline personality disorder (BPD). So far, many studies have tested the consequences of the implementation of certain emotion regulation (ER) strategies, but there have been no investigations about ER choices in BPD. Thus, the aim of this study was to investigate habitual ER choices by self-report questionnaires and experimentally by testing the preference to select between distraction and reappraisal when facing different emotional intensities (high vs. low) and contents (borderline-specific vs. unspecific negative) in patients with BPD (n=24) compared with clinical controls (patients with major depression, n=19) and a healthy control group (n=32). Additionally, heart rate (HR) responses were continuously assessed. Main results revealed that both patient groups showed maladaptive self-reported ER choice profiles compared with HC. We found, however, no differences between the groups in the choice of distraction and reappraisal on the behavioral level and in HR responses. In BPD, within-group analyses revealed a positive correlation between symptom severity and the preference for distraction under high-intensity borderline-specific stimuli. Our findings provide preliminary evidence of ER choices in BPD and show the robustness of the choice effect in patients with affective disorders.

Acoustic Emotional Processing in Patients With Borderline Personality Disorder: Hyper- or Hyporeactivity?

Earlier studies have demonstrated emotional overreactions to affective visual stimuli in patients with borderline personality disorder (BPD). However, contradictory findings regarding hyper- versus hyporeactivity have been reported for peripheral physiological measures. In order to extend previous results, the authors investigated emotional reactivity and long-term habituation in the acoustic modality. Twenty-two female BPD patients and 19 female nonclinical controls listened to emotionally negative, neutral, and positive sounds in two identical sessions. Heart rate, skin conductance, zygomaticus/corrugator muscle, and self-reported valence/arousal responses were measured. BPD patients showed weaker skin conductance responses to negative sounds than controls. The elevated zygomaticus activity in response to positive sounds observed in controls was absent in BPD patients, and BPD patients assigned lower valence ratings to positive sounds than controls. In Session 2, patients recognized fewer positive sounds than controls. Across both groups, physiological measures habituated between sessions. These findings add to growing evidence toward partial affective hyporeactivity in BPD.

Characterizing emotional dysfunction in borderline personality, major depression, and their co-occurrence

This research aimed to characterize patterns of emotional reactivity and dysregulation in borderline personality, depression, and their co-occurrence. In study 1, 488 young adult women from the community were categorized into four groups based on self-reported major depressive disorder (MDD) and borderline personality disorder (BPD) symptoms (Low BPD/Low MDD; Low BPD/High MDD; High BPD/Low MDD; High BPD/High MDD). Immediate and prolonged subjective emotional reactivity to a laboratory stressor were assessed, and participants completed self-report and behavioral measures of emotion dysregulation. Study 2 extended these findings, examining emotional reactivity and dysregulation in a clinical population of 176 substance dependent patients with diagnoses of BPD and MDD and including a biological index of emotional reactivity. Results revealed greater prolonged fear reactivity in the High BPD/High MDD (vs. Low BPD/Low MDD) group in study 1, and greater prolonged anxiety and negative affect reactivity in both High BPD groups (vs. Low BPD/Low MDD and Low BPD/High MDD groups) in study 2 (but no differences in cortisol reactivity). Results also demonstrated greater subjective (but not behavioral) emotion dysregulation in the High BPD/High MDD (vs. Low BPD/Low MDD) group in study 1 and both High BPD groups (vs. both Low BPD groups) in study 2. Finally, the High BPD/High MDD group reported greater difficulties controlling impulsive behaviors compared with all other groups in study 1 and the Low BPD groups in study 2. Findings suggest that BPD pathology (but not MDD pathology alone) is characterized by greater prolonged emotional (especially anxiety/fear-related) reactivity and heightened emotion dysregulation.

Gender determines cortisol and alpha-amylase responses to acute physical and psychosocial stress in patients with borderline personality disorder

Borderline personality disorder (BPD) is characterized by affective instability, unstable relationships, and identity disturbance. We measured salivary alpha-amylase (sAA) and salivary cortisol levels in all participants during exposure to the Trier Social Stress Test (TSST) and an electric stimulation stress. Seventy-two BPD patients were compared with 377 age- and gender- matched controls. The State and Trait versions of the Spielberger Anxiety Inventory test (STAI-S and STAI-T, respectively), the Profile of Mood State (POMS) tests, and the Beck Depression Inventory (BDI), the Depression and Anxiety Cognition Scale (DACS) were administered to participants before electrical stimulation. Following TSST exposure, salivary cortisol levels significantly decreased in female patients and significantly increased in male patients compared with controls. POMS tension-anxiety, depression-dejection, anger-hostility, fatigue, and confusion scores were significantly increased in BPD patients compared with controls. In contrast, vigor scores were significantly decreased in BPD patients relative to controls. Furthermore, STAI-T and STAI-S anxiety scores and BDI scores were significantly increased in BPD patient compared with controls. DACS scores were significantly increased in BPD patient compared with controls. Different stressors (e.g., psychological or physical) induced different responses in the HPA and SAM systems in female or male BPD patients.

A prospective investigation of emotion dysregulation as a moderator of the relation between posttraumatic stress symptoms and substance use severity

Despite strong evidence for an association between the experience of posttraumatic stress (PTS) symptoms and substance use, little is known about the particular individuals most at-risk for problematic substance use in response to PTS symptoms. Consequently, the goal of this study was to conduct a prospective investigation of the moderating role of emotion dysregulation (assessed through self-report and behavioral measures) in the relation between PTS symptoms and substance use 8-months later within a sample of 106 young adult women. No main effect of PTS symptoms on substance use was found. Instead, PTS symptoms were only associated with later substance use in the context of heightened emotion dysregulation. Results provide support for emotion dysregulation as a key factor that may increase risk for substance use among women experiencing PTS symptoms and highlight a target for future interventions aimed at reducing risk for the development of maladaptive behaviors stemming from PTS symptoms.

Comorbidity between post-traumatic stress disorder and borderline personality disorder: a review

BACKGROUND

Traditionally, the presence of post-traumatic stress disorder (PTSD) in subjects diagnosed with borderline personality disorder (BPD) has been the object of scant empirical research. The clarification of issues related to the different areas of study for this comorbidity is not only significant from a theoretical point of view but also relevant for clinical practice. The aim of this review is to describe the main theoretical findings and research conclusions about the comorbidity between PTSD and BPD.

METHODS

A literature review was carried out via PubMed and PsycINFO for the period between 1990 and September 2013. The descriptors used were 'post-traumatic stress disorder', 'borderline personality disorder', 'PTSD', 'complex PTSD' and 'BPD'.

RESULTS

Epidemiological studies show that the risk of PTSD among BPD subjects is not regularly higher than in subjects with other personality disorders. Furthermore, there is no conclusive evidence about the main aetiopathogenic mechanism of this comorbidity, either of one disorder being a risk factor for the other one or of common underlying variables. Concerning comparative studies, several studies with PTSD-BPD subjects have found a higher severity of psychopathology and psychosocial impairment than in BPD subjects. With regard to nosological status, the main focus of controversy is the validation of 'complex PTSD', a clinical entity which may comprise a subgroup of PTSD-BPD subjects. With regard to treatment, there are preliminary evidences for the efficient treatment of psychopathology in both PTSD and BPD.

CONCLUSIONS

These findings are remarkable for furthering the understanding of the link between PTSD and BPD and their implications for treatment. The results of this review are discussed, including methodological constraints that hinder external validity and consistency of referred findings.

Emotional hyper-reactivity in borderline personality disorder is related to trauma and interpersonal themes

Heightened emotional reactivity is one of the core features of borderline personality disorder (BPD). However, recent findings could not provide evidence for a general emotional hyper-reactivity in BPD. The present study examines the emotional responding to self-relevant pictures in dependency of the thematic category (e.g., trauma, interpersonal interaction) in patients with BPD. Therefore, women with BPD (n=31), women with major depression disorder (n=29) and female healthy controls (n=33) rated pictures allocated to thematically different categories (violence, sexual abuse, interaction, non-suicidal self-injury, and suicide) regarding self-relevance, arousal, valence and the urge of non-suicidal self-injury. Compared to both control groups, patients with BPD reported higher self-relevance regarding all categories, but significantly higher emotional ratings only for pictures showing sexual abuse and interpersonal themes. In addition, patients with BPD and comorbid posttraumatic stress disorder showed higher emotional reactivity in violence pictures. Our data provide clear evidence that patients with BPD show a specific emotional hyper-reactivity with respect to schema-related triggers like trauma and interpersonal situations. Future studies are needed to investigate physiological responses to these self-relevant themes in patients with BPD.

Complex PTSD, affect dysregulation, and borderline personality disorder

Complex PTSD (cPTSD) was formulated to include, in addition to the core PTSD symptoms, dysregulation in three psychobiological areas: (1) emotion processing, (2) self-organization (including bodily integrity), and (3) relational security. The overlap of diagnostic criteria for cPTSD and borderline personality disorder (BPD) raises questions about the scientific integrity and clinical utility of the cPTSD construct/diagnosis, as well as opportunities to achieve an increasingly nuanced understanding of the role of psychological trauma in BPD. We review clinical and scientific findings regarding comorbidity, clinical phenomenology and neurobiology of BPD, PTSD, and cPTSD, and the role of traumatic victimization (in general and specific to primary caregivers), dissociation, and affect dysregulation. Findings suggest that BPD may involve heterogeneity related to psychological trauma that includes, but extends beyond, comorbidity with PTSD and potentially involves childhood victimization-related dissociation and affect dysregulation consistent with cPTSD. Although BPD and cPTSD overlap substantially, it is unwarranted to conceptualize cPTSD either as a replacement for BPD, or simply as a sub-type of BPD. We conclude with implications for clinical practice and scientific research based on a better differentiated view of cPTSD, BPD and PTSD.

Post-traumatic stress disorder in DSM-5: estimates of prevalence and criteria comparison versus DSM-IV-TR in a non-clinical sample of earthquake survivors

BACKGROUND

The latest edition of DSM (DSM-5) introduced important revisions to PTSD symptomatological criteria, such as a four-factor model and the inclusion of new symptoms. To date, only a few studies have investigated the impact that the proposed DSM-5 criteria will have on prevalence rates of PTSD.

METHODS

An overall sample of 512 adolescents who survived the L'Aquila 2009 earthquake and were previously investigated for the presence of full and partial PTSD, using DSM-IV-TR criteria, were reassessed according to DSM-5 criteria. All subjects completed the Trauma and Loss Spectrum-Self Report (TALS-SR).

RESULTS

A DSM-5 PTSD diagnosis emerged in 39.8% of subjects, with a significant difference between the two sexes (p<0.001), and an overall 87.1% consistency with DSM-IV-TR. Most of the inconsistent diagnoses that fulfilled DSM-IV-TR criteria but not DSM-5 criteria can be attributed to the subjects not fulfilling the new criterion C (active avoidance). Each DSM-5 symptom was more highly correlated with its corresponding symptom cluster than with other symptom clusters, but two of the new symptoms showed moderate to weak item-cluster correlations. Among DSM-5 PTSD cases: 7 (3.4%) endorsed symptom D3; 151 (74%) D4; 28 (13.7%) both D3 and D4; 75 (36.8%) E2.

LIMITATIONS

The use of a self-report instrument; no information on comorbidity; homogeneity of study sample; lack of assessment on functional impairment; the rates of DSM-IV-TR qualified PTSD in the sample was only 37.5%.

CONCLUSIONS

This study provides an inside look at the empirical performance of the DSM-5 PTSD criteria in a population exposed to a natural disaster, which suggests the need for replication in larger epidemiological samples.