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

Differential methylation of OPRK1 in borderline personality disorder is associated with childhood trauma

According to a growing body of neurobiological evidence, the core symptoms of borderline personality disorder (BPD) may be linked to an opioidergic imbalance between the hedonic and stimulatory activity of mu opioid receptors (MOR) and the reward system inhibiting effects of kappa opioid receptors (KOR). Childhood trauma (CT), which is etiologically relevant to BPD, is also likely to lead to epigenetic and neurobiological adaptations by extensive activation of the stress and endogenous opioid systems. In this study, we investigated the methylation differences in the promoter of the KOR gene (OPRK1) in subjects with BPD (N = 47) and healthy controls (N = 48). Comparing the average methylation rates of regulatorily relevant subregions (specified regions CGI-1, CGI-2, EH1), we found no differences between BPD and HC. Analyzing individual CG nucleotides (N = 175), we found eight differentially methylated CG sites, all of which were less methylated in BPD, with five showing highly interrelated methylation rates. This differentially methylated region (DMR) was found on the falling slope (5') of the promoter methylation gap, whose effect is enhanced by the DMR hypomethylation in BPD. A dimensional assessment of the correlation between disease severity and DMR methylation rate revealed DMR hypomethylation to be negatively associated with BPD symptom severity (measured by BSL-23). Finally, analyzing the influence of CT on DMR methylation, we found DMR hypomethylation to correlate with physical and emotional neglect in childhood (quantified by CTQ). Thus, the newly identified DMR may be a biomarker of the risks caused by CT, which likely epigenetically contribute to the development of BPD.

Childhood adversity modulates structural brain changes in borderline personality but not in major depression disorder

Adverse childhood experiences (ACEs) negatively affect the function and structure of emotion brain circuits, increasing the risk of various psychiatric disorders. It is unclear if ACEs show disorder specificity with respect to their effects on brain structure. We aimed to investigate whether the structural brain effects of ACEs differ between patients with major depression (MDD) and borderline personality disorder (BPD). These disorders share many symptoms but likely have different etiologies. To achieve our goal, we obtained structural 3T-MRI images from 20 healthy controls (HC), 19 MDD patients, and 18 BPD patients, and measured cortical thickness and subcortical gray matter volumes. We utilized the Adverse Childhood Experiences (ACE) questionnaire to quantify self-reported exposure to childhood trauma. Our findings suggest that individuals with MDD exhibit a smaller cortical thickness when compared to those with BPD. However, ACEs showed a significantly affected relationship with cortical thickness in BPD but not in MDD. ACEs were found to be associated with thinning in cortical regions involved in emotional behavior in BPD, whereas HC showed an opposite association. Our results suggest a potential mechanism of ACE effects on psychopathology involving changes in brain structure. These findings highlight the importance of early detection and intervention strategies.

Borderline Personality Disorder With Atypical Traits in a 30-Year-Old Female: A Case Report

In this paper, we report an atypical presentation of borderline personality disorder (BPD) in a 30-year-old female with a history of childhood molestation and trauma and a prior diagnosis of post-traumatic stress disorder (PTSD). The patient was hospitalized due to anxiety, depression, and guilt over her relapse into alcohol use disorder. During her hospital stay, we diagnosed her with BPD based on psychiatric examination, clinical interviews, and patient history. While the patient exhibited some of the typical characteristics of BPD, such as an instability of interpersonal and romantic relationships, there were numerous findings that were atypical of BPD. These include a demonstration of mature defense mechanisms such as sublimation and altruism, high levels of occupational functioning, strong maternal caregiving behavior, and no history of self-harm. Further analysis of the patient's personality traits helped us identify that this presentation could be best characterized as a high-functioning internalizing subtype of BPD as identified in prior literature.

Psychometric properties of the Hungarian childhood trauma questionnaire short form and its validity in patients with adult attention-deficit hyperactivity disorder or borderline personality disorder

BACKGROUND

Compelling evidence supports the role of childhood traumatization in the etiology of psychiatric disorders, including adult attention-deficit hyperactivity disorder (aADHD) and borderline personality disorder (BPD). The aim of this study was to examine the psychometric properties of the Hungarian version of the Childhood Trauma Questionnaire Short Form (H-CTQ-SF) and to investigate the differences between patients diagnosed with aADHD and BPD in terms of early traumatization.

METHODS

Altogether 765 (mean age = 32.8 years, 67.7% women) patients and control subjects were enrolled from different areas of Hungary. Principal component analysis and confirmatory factor analysis were carried out to explore the factor structure of H-CTQ-SF and test the validity of the five-factor structure. Discriminative validity was assessed by comparing clinical and non-clinical samples. Subsequently, aADHD and BPD subgroups were compared with healthy controls to test for the role of early trauma in aADHD without comorbid BPD. Convergent validity was explored by measuring correlations with subscales of the Personality Inventory for DSM-5 (PID-5).

RESULTS

The five scales of the H-CTQ-SF demonstrated adequate internal consistency and reliability values. The five-factor model fitted the Hungarian version well after exclusion of one item from the physical neglect scale because of its cross-loading onto the emotional neglect subscale. The H-CTQ-SF effectively differentiated between the clinical and non-clinical samples. The BPD, but not the aADHD group showed significant differences in each CTQ domain compared with the healthy control group. All CTQ domains, except for physical abuse, demonstrated medium to high correlations with PID-5 emotional lability, anxiousness, separation insecurity, withdrawal, intimacy avoidance, anhedonia, depressivity, suspiciousness, and hostility subscales.

CONCLUSIONS

Our study confirmed the psychometric properties of the H-CTQ-SF, an easy-to-administer, non-invasive, ethically sound questionnaire. In aADHD patients without comorbid BPD, low levels of traumatization in every CTQ domain were comparable to those of healthy control individuals. Thus, the increased level of traumatization found in previous studies of aADHD might be associated with the presence of comorbid BPD. Our findings also support the role of emotional neglect, emotional abuse and sexual abuse in the development of BPD.

miR-124-3p target genes identify globus pallidus role in suicide ideation recovery in borderline personality disorder

Borderline personality disorder (BPD) is characterized by patterns of unstable affect, unstable interpersonal relationships, and chronic suicidal tendencies. Research on the genetics, epigenetics, and brain function of BPD is lacking. MicroRNA-124-3p (miR-124-3p) was recently identified in a Genome-Wide Association Study as likely associated with BPD. Here, we identified the anatomical brain expression of genes likely modulated by miR-124-3p and compared morphometry in those brain regions in BPD inpatients vs. controls matched for psychiatric comorbidities. We isolated lists of targets likely modulated by miR-124-3p from TargetScan (v 8.0) by their preferentially conserved targeting (Aggregate PCT > 0.99, see Supplementary Table 1). We applied Process Genes List (PGL) to identify regions of interest associated with the co-expression of miR-124-3p target genes. We compared the gray matter volume of the top region of interest co-expressing those genes between BPD inpatients (n = 111, 46% female) and psychiatric controls (n = 111, 54% female) at The Menninger Clinic in Houston, Texas. We then correlated personality measures, suicidal ideation intensity, and recovery from suicidal ideation with volumetrics. Gene targets of miR-124-3p were significantly co-expressed in the left Globus Pallidus (GP), which was smaller in BPD than in psychiatric controls. Smaller GP volume was negatively correlated with agreeableness and with recovery from suicidal ideation post-treatment. In BPD, GP volume may be reduced through miR-124-3p regulation and suppression of its target genes. Importantly, we identified that a reduction of the GP in BPD could serve as a potential biomarker for recovery from suicidal ideation.

Brain functional abnormality in drug treated and drug naïve adolescents with borderline personality disorder: Evidence for default mode network dysfunction

BACKGROUND

Patients with borderline personality disorder (BPD) have been found to show functional brain abnormality, including in the medial frontal cortex and other areas of the default mode network (DMN). The current study aimed to examine activations and de-activations in drug treated and medication-free female adolescents with the disorder.

METHODS

39 DSM-5 adolescent female patients with BPD without psychiatric comorbidity and 31 matched healthy female adolescents underwent fMRI during the performance of 1-back and 2-back versions of the n-back working memory task. Linear models were used to obtain maps of within-group activations and de-activations and areas of differences between the groups.

RESULTS

On corrected whole-brain analysis, the BPD patients showed failure to de-activate a region of the medial frontal cortex in the 2-back > 1-back comparison. The 30 never-medicated patients additionally showed a failure to de-activate the right hippocampus in the 2-back versus baseline contrast.

CONCLUSIONS

Evidence of DMN dysfunction was observed in adolescent patients with BPD. Because the relevant medial frontal and hippocampal changes were seen in unmedicated young patients without comorbidity, they might be considered intrinsic to the disorder.

A Systematic Review of the Association Between Early Childhood Trauma and Borderline Personality Disorder

Borderline personality disorder (BPD) is a debilitating clinical disorder associated with adverse impacts on multiple levels. While a high prevalence of childhood trauma has been noted, the ways such trauma impacts the development of BPD symptomatology remain unclear. In this systematic review, the authors examine the literature from 2000 to 2020, focusing on the association between trauma and BPD, and offer a comprehensive synthesis of possible etiological implications related to either one specific or multiple trauma types. In addition, results are analyzed based on commonly tested trauma parameters, including repeated exposure, polytrauma, onset, perpetrators, and gender. The authors also note some limitations in areas of sampling, measurement, causal inference methods, and data analyses. Results of this review point to several parameters of trauma that can be used to inform training for practitioners as well as enhance current interventions.

Pathophysiological aspects of complex PTSD - a neurobiological account in comparison to classic posttraumatic stress disorder and borderline personality disorder

Despite a great diagnostic overlap, complex posttraumatic stress disorder (CPTSD) has been recognised by the ICD-11 as a new, discrete entity and recent empirical evidence points towards a distinction from simple posttraumatic stress disorder (PTSD) and borderline personality disorder (BPD). The development and maintenance of these disorders is sustained by neurobiological alterations and studies using functional magnetic resonance imaging (fMRI) may further contribute to a clear differentiation of CPTSD, PTSD and BPD. However, there are no existing fMRI studies directly comparing CPTSD, PTSD and BPD. In addition to a summarization of diagnostic differences and similarities, the current review aims to provide a qualitative comparison of neuroimaging findings on affective, attentional and memory processing in CPTSD, PTSD and BPD. Our narrative review alludes to an imbalance in limbic-frontal brain networks, which may be partially trans-diagnostically linked to the degree of trauma symptoms and their expression. Thus, CPTSD, PTSD and BPD may underlie a continuum where similar brain regions are involved but the direction of activation may constitute its distinct symptom expression. The neuronal alterations across these disorders may conceivably be better understood along a symptom-based continuum underlying CPTSD, PTSD and BPD. Further research is needed to amend for the heterogeneity in experimental paradigms and sample criteria.

Demystifying borderline personality disorder in primary care

Borderline personality disorder (BPD) is a common mental health diagnosis observed in the primary care population and is associated with a variety of psychological and physical symptoms. BPD is a challenging disorder to recognize due to the limitations of accurate diagnosis and identification in primary care settings. It is also difficult to treat due to its complexity (e.g., interpersonal difficulties and patterns of unsafe behaviors, perceived stigma) and healthcare professionals often feel overwhelmed when treating this population. The aim of this article is to describe the impact of BPD in primary care, review current state of knowledge, and provide practical, evidence-based treatment approaches for these patients within this setting. Due to the lack of evidence-based pharmacological treatments, emphasis is placed on describing the framework for treatment, identifying psychotherapeutic opportunities, and managing responses to difficult clinical scenarios. Furthermore, we discuss BPD treatment as it relates to populations of special interest, including individuals facing societal discrimination and adolescents. Through this review, we aim to highlight gaps in current knowledge around managing BPD in primary care and provide direction for future study.

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

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

Childhood symptoms of attention-deficit/hyperactivity disorder and borderline personality disorder

OBJECTIVE

Childhood attention-deficit /hyperactivity disorder (ADHD) is known to be associated with adult Borderline Personality Disorder (BPD). We investigated if any of the subdimensions of childhood ADHD, that is, impulsivity, inattention, or hyperactivity was more prominent in this association.

METHODS

In a nation-wide cohort (N = 13,330), we utilized parent reported symptoms of childhood ADHD and clinically ascertained adult BPD diagnoses. The summed total scores of ADHD symptoms and its three subdimensions were used and standardized for effect size comparison. Associations were analyzed using Cox regression with sex and birth-year adjustments. Secondary outcomes were BPD-associated traits (i.e., self-harm and substance use) analyzed using logistic- and linear regression respectively.

RESULTS

ADHD symptom severity was positively associated with BPD with a hazard ratio (HR) of 1.47 (95% confidence interval [CI]: 1.22-1.79) per standard deviation increase in total ADHD symptoms. Impulsivity was the most prominent subdimension with the only statistically significant association when analyzed in a model mutually adjusted for all ADHD subdimensions-HR for inattention: 1.15 (95% CI: 0.85-1.55), hyperactivity: 0.94 (95% CI: 0.69-1.26), impulsivity: 1.46 (95% CI: 1.12-1.91). In secondary analyses, weak positive associations were seen between total ADHD symptom score and self-harm and substance use. In analyses by subdimensions of ADHD, associations were weak and most prominent for inattention in the model with self-harm.

CONCLUSION

Childhood ADHD symptoms were associated with subsequent development of BPD diagnosis and appeared to be driven primarily by impulsivity. Our findings are important for understanding the association between childhood symptoms of ADHD and subsequent BPD.

How childhood maltreatment alters perception and cognition - the predictive processing account of borderline personality disorder

Borderline personality disorder (BPD) is a severe mental disorder, comprised of heterogeneous psychological and neurobiological pathologies. Here, we propose a predictive processing (PP) account of BPD to integrate these seemingly unrelated pathologies. In particular, we argue that the experience of childhood maltreatment, which is highly prevalent in BPD, leaves a developmental legacy with two facets: first, a coarse-grained, alexithymic model of self and others - leading to a rigidity and inflexibility concerning beliefs about self and others. Second, this developmental legacy leads to a loss of confidence or precision afforded beliefs about the consequences of social behavior. This results in an over reliance on sensory evidence and social feedback, with concomitant lability, impulsivity and hypersensitivity. In terms of PP, people with BPD show a distorted belief updating in response to new information with two opposing manifestations: rapid changes in beliefs and a lack of belief updating despite disconfirmatory evidence. This account of distorted information processing has the potential to explain both the instability (of affect, self-image, and interpersonal relationships) and the rigidity (of beliefs about self and others) which is typical of BPD. At the neurobiological level, we propose that enhanced levels of dopamine are associated with the increased integration of negative social feedback, and we also discuss the hypothesis of an impaired inhibitory control of the prefrontal cortex in the processing of negative social information. Our account may provide a new understanding not only of the clinical aspects of BPD, but also a unifying theory of the corresponding neurobiological pathologies. We conclude by outlining some directions for future research on the behavioral, neurobiological, and computational underpinnings of this model, and point to some clinical implications of it.

Potential epigenetic mechanisms in psychotherapy: a pilot study on DNA methylation and mentalization change in borderline personality disorder

Genetic and early environmental factors are interwoven in the etiology of Borderline Personality Disorder (BPD). Epigenetic mechanisms offer the molecular machinery to adapt to environmental conditions. There are gaps in the knowledge about how epigenetic mechanisms are involved in the effects of early affective environment, development of BPD, and psychotherapy response. We reviewed the available evidence of the effects of psychotherapy on changes in DNA methylation and conducted a pilot study in a sample of 11 female adolescents diagnosed with BPD, exploring for changes in peripheral DNA methylation of FKBP5 gene, which encodes for a stress response protein, in relation to psychotherapy, on symptomatology and underlying psychological processes. For this purpose, measures of early trauma, borderline and depressive symptoms, psychotherapy outcome, mentalization, and emotional regulation were studied. A reduction in the average FKBP5 methylation levels was observed over time. Additionally, the decrease in FKBP5 methylation observed occurred only in those individuals who had early trauma and responded to psychotherapy. The results suggest an effect of psychotherapy on epigenetic mechanisms associated with the stress response. The finding that epigenetic changes were only observed in patients with early trauma suggests a specific molecular mechanism of recovery. The results should be taken with caution given the small sample size. Also, further research is needed to adjust for confounding factors and include endocrinological markers and therapeutic process variables.

Altered Left Ventricular Myocardial Deformation in Young Women With Borderline Personality Disorder: An Echocardiographic Study

OBJECTIVE

Borderline personality disorder (BPD) is characterized by intense mood swings, impulsivity, self-injurious behavior, poor anger control, fear of abandonment, and unstable interpersonal relationships. BPD is also associated with a heightened risk of cardiovascular disease, whereby the underlying mechanisms are insufficiently understood. Accordingly, the present study set out to examine whether individuals with BPD would show abnormal myocardial deformation and to explore the role of potential risk factors, including maladaptive stress responsivity, childhood trauma, and current stress exposure.

METHODS

Fifty female patients diagnosed with BPD and 50 controls matched for sex and age underwent echocardiography to determine the global longitudinal strain (GLS) of the left ventricle. In addition, childhood trauma, chronic stress, and "allostatic load" were determined, as well as borderline symptom severity and common risk factors for cardiovascular disease.

RESULTS

Aside from a significantly greater GLS in BPD patients, a multivariable regression analysis revealed that allostatic load (β = 0.225, p = .048) was significantly associated with GLS, with childhood trauma (β = 0.279, p = .062) approaching significance. Conversely, smoking (p = .867), chronic stress (p = .193), and borderline symptom severity (p = .342) were not associated with GLS, even though bivariate correlations were significant.

CONCLUSIONS

Somatically healthy women with BPD display subtle signs of increased GLS, which is associated with allostatic load as an indicator of the "wear-and-tear" of the body. The association between childhood trauma with GLS was of similar strength but did not reach the threshold for statistical significance. This finding may support the need for primary prevention of somatic consequences of maladaptive stress responsivity in psychiatric patients.

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

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

Borderline Personality Disorder: Risk Factors and Early Detection

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

Overlap of autism spectrum disorder and borderline personality disorder: A systematic review and meta-analysis

Autism spectrum disorder (ASD) and borderline personality Disorder (BPD) share features, including social and emotion regulation difficulties. The evidence for the overlap in prevalence and clinical characteristics was systematically reviewed. Ovid Medline, PsycInfo, and PubMed were searched until November 30, 2020 using keywords relating to BPD and ASD. Studies that reported on the overlap of ASD and BPD diagnoses or traits and used a case, cohort, or case-controlled design were included. Of 1633 screened studies, 19 were included, of which 12 reported data suitable for meta-analysis. Most samples were of small, clinically ascertained groups, with 11 having high risk of bias. The pooled prevalence of BPD in ASD was 4% [95% CI 0%-9%] and of ASD in BPD, 3% [95% CI 1%-8%]. There were inconsistent findings across clinical areas. The prevalence of a dual diagnosis of BPD in ASD cohorts and of ASD in BPD cohorts was within population prevalence estimates of each disorder. Based on this data we were not able to assess whether there is misdiagnosis of one in favor of the other. Neurocognitive differences may underlie similar behavioral symptoms, but further research using larger, well-validated samples is needed. LAY SUMMARY: Autism spectrum disorder (ASD) and borderline personality disorder (BPD) have overlaps in their symptoms. The overlap in how frequently they co-occur and their presentation was systematically reviewed. We searched the key databases and including all studies that reported on the overlap of ASD and BPD diagnoses or traits and used a case, cohort or case-controlled design. Of 1633 studies, 19 were included, of which 12 reported data suitable for pooling. Most samples were of small, clinical groups, with 11 having high risk of bias. The pooled prevalence of BPD in ASD was 4% [95% CI 0%-9%] and of ASD in BPD, 3% [95% CI 1%-8%]. There were inconsistent findings across studies comparing ASD and BPD related symptoms and problems. The prevalence of a dual diagnosis of BPD in ASD cohorts and of ASD in BPD cohorts was similar to the population prevalence of each disorder. Further research using larger, well-validated samples is needed.

Joint associations of parental personality traits and socio-economic position with trajectories of offspring depression: Findings from up to 6925 families in a UK birth cohort

Background

Parental personality may influence the course of offspring depression but epidemiological evidence for associations is lacking. It is also unknown whether associations between parental personality and offspring depression differ by socio-economic position (SEP). Our aims were to describe the trajectories of depressive symptoms across adolescence of offspring of parents with and without maladaptive personality traits and to test for effect modification by SEP.

Methods

A longitudinal study in the Avon Longitudinal Study of Parents and Children birth cohort (ns = 3054-7046). Exposures were binary measures of maladaptive maternal and paternal personality traits. The outcome was depressive symptoms measured over nine occasions (ages 11-24) using the short mood and feelings questionnaire (SMFQ; range: 0-26). Effect modifiers were parental education and self-reported material hardship. Multilevel growth curve models were used to estimate trajectories.

Results

offspring of mothers with high (vs. low) maladaptive traits showed higher levels of depressive symptoms at multiple ages of adolescence, the greatest of which was observed at age 22 (predicted SMFQ difference age 10 = 0.66, 95% confidence intervals [CIs]: 0.25 to 1.28; age 22 = 1.00, CI: 0.51 to 1.50). There was weaker and inconsistent evidence of an association between paternal maladaptive personality and offspring depressive symptoms (SMFQ difference age 10 = 0.21, CI: -0.58 to 0.99; age 22 = 0.02, CI: -0.94 to 0.90). Lower SEP was also associated with higher offspring depressive symptoms (SMFQ difference material hardship vs. no hardship age 10 = 0.79, 95% CI: 0.46 to 1.13; age 22 = 0.96, CI: 0.56 to 1.36). There was minimal statistical evidence for effect modification.

Conclusions

The offspring of mothers with high levels of maladaptive personality traits show evidence of greater depressive symptoms throughout adolescence although the absolute increase in symptoms is small. Evidence for the associations with fathers' personality was weaker. Socio-economic position and maladaptive personality traits appear to be independent risk factors for offspring depressive symptoms.

The Cognitive, Ecological, and Developmental Origins of Self-Disturbance in Borderline Personality Disorder

Self-disturbance is recognized as a key symptom of Borderline Personality Disorder (BPD). Although it is the source of significant distress and significant costs to society, it is still poorly specified. In addition, current research and models on the etiology of BPD do not provide sufficient evidence or predictions about who is at risk of developing BPD and self-disturbance, and why. The aim of this review is to lay the foundations of a new model inspired by recent developments at the intersection of social cognition, behavioral ecology, and developmental biology. We argue that the sense of agency is an important dimension to consider when characterizing self-disturbances in BPD. Second, we address the poorly characterized relation between self-disturbances and adverse life conditions encountered early in life. We highlight the potential relevance of Life-History Theory-a major framework in evolutionary developmental biology-to make sense of this association. We put forward the idea that the effect of early life adversity on BPD symptomatology depends on the way individuals trade their limited resources between competing biological functions during development.

Comorbid early psychosis and borderline personality disorder: Conceptualizing clinical overlap, etiology, and treatment

Despite substantial efforts aimed at the detection and intervention for early symptoms of mental illness, there is relatively limited research on the clinical overlap between borderline personality disorder (BPD) and early psychosis, for example, clinical high risk (CHR) for psychosis, in young people. We present a narrative review of the clinical overlap between BPD and psychosis spectrum symptoms. Both conditions have unstable temporal course, and both are marked by functional impairment, increased suicide risk, and higher rates of psychiatric inpatient services. We then review evidence-based treatments for psychosis and BPD, emphasizing treatments for early presentations of these symptoms and initial research considering treatments for the overlap. Psychotherapies with the strongest empirical support include cognitive behavioral models, with BPD showing limited response to adjunctive pharmacotherapy. We end by discussing specific recommendations for future research, including longitudinal studies to determine the predictors of the course of illness and the development of treatments to target comorbid BPD and CHR symptoms.

Borderline Personality Disorder in a "Life History Theory" Perspective: Evidence for a Fast "Pace-of-Life-Syndrome"

"Borderline Personality Disorder" (BPD) is associated with heightened risk for cardiovascular disease and other stress-associated somatic consequences, which is poorly understood in terms of causal mechanisms, such as childhood trauma. Here, we tested the hypothesis suggesting that BPD reflects a fast "Pace-of-Life-Syndrome" (PoLS). Ninety-five women (44 diagnosed with BPD) were recruited to examine psychological correlates of PoLS, including life history features, personality dimensions, aggressiveness, chronic stress, borderline symptom severity, childhood trauma, and allostatic load (AL). In line with expectations, BPD patients had significantly higher scores suggestive of a fast PoLS than controls, they were more aggressive, more burdened with chronic stress and were exposed to more severe childhood adversity. Childhood trauma predicted PoLS, which in turn predicted AL. The present study thus provides direct evidence of psychological and somatic traits associated with the fast end of the PoLS spectrum in females with BPD. Findings are discussed with regard to clinical implications.

Borderline personality disorder (BPD) and attention deficit hyperactivity disorder (ADHD) revisited - a review-update on common grounds and subtle distinctions

BACKGROUND

Overlap in symptom domains particularly in the field of impulsivity and emotional dysregulation in attention deficit hyperactivity disorder (ADHD) and borderline personality disorder (BPD) have stimulated further research activities since our last review from 2014.

MAIN BODY

Disentangling features of impulsivity in ADHD and BPD revealed that impulsivity is a feature of both disorders with patients suffering from both ADHD and BPD having highest impulsivity ratings. BPD individuals have more problems using context cues for inhibiting responses and their impulsivity is stress-dependent, whereas ADHD patients have more motor impulsivity and therefore difficulties interrupting ongoing responses. For emotion regulation difficulties the ranking order ranges from ADHD to BPD to the comorbid condition, again with the patients suffering from both, ADHD and BPD, having the most pronounced emotion regulation problems. Environmental influences namely adverse childhood events were shown to be linked to both ADHD and BPD. Traumatic experiences seem independently linked to impulsivity features. Thus, some authors point to the risk of misdiagnosis during childhood and the necessity to screen for traumatic experiences in both patient groups. Genetic research confirmed genetic overlap of BPD with bipolar disorder (BD) and schizophrenic disorders, as well as genetic overlap of BD and ADHD. A population-based study confirmed the high co-occurrence and familial co-aggregation of ADHD and BPD. Interesting questions in the field of gene-environment-interactions are currently dealt with by genetic and epigenetic research. Few studies have investigated treatment strategies for the comorbid condition, though the issue is highly important for the management of patients suffering from both disorders and presenting with the highest symptom scores.

CONCLUSION

Research on the different impulsivity features might point to a necessity of disorder-specific treatment strategies in the field of impulse control. Future research is needed to base treatment decisions for the comorbid condition on an evidence basis.

Looking at the bigger picture: Cortical volume, thickness and surface area characteristics in borderline personality disorder with and without posttraumatic stress disorder

Borderline personality disorder (BPD) is a severe psychiatric disorder accompanied by multiple comorbidities. Neuroimaging studies have identified structural abnormalities in BPD with most findings pointing to gray matter volume reductions in the fronto-limbic network, although results remain inconsistent. Similar alterations were found in posttraumatic stress disorder (PTSD), a common comorbidity of BPD. Only a small number of studies have investigated structural differences in BPD patients regarding comorbid PTSD specifically and studies conducting additional surface analyses are scarce. We investigated structural differences in women with BPD with and without PTSD and non-patient controls. Automated voxel-based and region-based volumetric analyses were applied. Additionally, four surface-based measures were analyzed: cortical thickness, gyrification index, fractal dimension, and sulcus depth. Analyses did not identify cortical volume alterations in the fronto-limbic network. Instead, hypergyrification was detected in the right superior parietal cortex in BPD patients compared to non-patient controls. No distinction was revealed between BPD patients with and without PTSD. These findings underline the importance of a holistic investigation examining volumetric and surface measures as these might enhance the understanding of structural alterations in BPD.

Alexithymia, Affective Lability, Impulsivity, and Childhood Adversity in Borderline Personality Disorder

Long-standing theories of borderline personality disorder (BPD) suggest that symptoms develop at least in part from childhood adversity. Emotion dysregulation may meaningfully mediate these effects. The current study examined three factors related to emotion dysregulation-alexithymia, affective lability, and impulsivity-as potential mediators of the relation between childhood adversity and BPD diagnosis in 101 individuals with BPD and 95 healthy controls. Path analysis compared three distinct models informed by the literature. Results supported a complex mediation model wherein (a) alexithymia partially mediated the relation of childhood adversity to affective lability and impulsivity; (b) affective lability mediated the relation of childhood adversity to BPD diagnosis; and (c) affective lability and impulsivity mediated the relation of alexithymia to BPD diagnosis. Findings suggest that affective lability and alexithymia are key to understanding the relationship between childhood adversity and BPD. Interventions specifically targeting affective lability, impulsivity, and alexithymia may be particularly useful for this population.

Meta-Analysis of white matter diffusion tensor imaging alterations in borderline personality disorder

Borderline personality disorder (BorPD) is characterized by instability and mood dysregulation, unstable relationships and distorted self-image. Identification of underlying anatomical and physiological changes is crucial to refine current treatments and develop new ones. In this perspective, previous magnetic resonance imaging studies have highlighted alterations associated with BorPD phenotype. In particular, diffusion-weighted imaging/Diffusion tensor imaging (DWI/DTI) has identified many white matter structural alterations in individuals with this diagnosis. Although in its infancy, limiting this line of investigation is a lack of direction at the field level. Hence, the present paper aims to conduct a meta-analysis of DWI/DTI findings in individuals with a diagnosis of BorPD, testing the hypothesis that there are specific white matter alterations associated with BorPD. To this end, we performed a meta-analysis of the existing literature of DWI/DTI in BorPD representing a total of 123 individuals with BorPD and 117 Controls. Our results indicated that individuals with BorPD show regions of reduced fractional anisotropy in the corpus callosum and fornix. These results survived all jack-knife reshuffles and showed no publication bias. This suggests that alterations in these structures may contribute to psychopathology. Further, the present results lend support to extant psychological and biological models of BorPD.

A genome-wide methylation study reveals X chromosome and childhood trauma methylation alterations associated with borderline personality disorder

Borderline personality disorder (BPD) is a severe and highly prevalent psychiatric disorder, more common in females than in males and with notable differences in presentation between genders. Recent studies have shown that epigenetic modifications such as DNA methylation may modulate gene × environment interactions and impact on neurodevelopment. We conducted an epigenome wide study (Illumina Infinium HumanMethylation450k beadchip) in a group of BPD patients with (N = 49) and without (N = 47) childhood traumas and in a control group (N = 44). Results were confirmed in a replication cohort (N = 293 BPD patients and N = 114 controls) using EpiTYPER assays. Differentially methylated CpG sites were observed in several genes and intragenic regions in the X chromosome (PQBP1, ZNF41, RPL10, cg07810091 and cg24395855) and in chromosome 6 (TAP2). BPD patients showed significantly lower methylation levels in these CpG sites than healthy controls. These differences seemed to be increased by the existence of childhood trauma. Comparisons between BPD patients with childhood trauma and patients and controls without revealed significant differences in four genes (POU5F1, GGT6, TNFRSF13C and FAM113B), none of them in the X chromosome. Gene set enrichment analyses revealed that epigenetic alterations were more frequently found in genes controlling oestrogen regulation, neurogenesis and cell differentiation. These results suggest that epigenetic alterations in the X chromosome and oestrogen-regulation genes may contribute to the development of BPD and explain the differences in presentation between genders. Furthermore, childhood trauma events may modulate the magnitude of the epigenetic alterations contributing to BPD.

Neural Changes in Borderline Personality Disorder After Dialectical Behavior Therapy-A Review

The biological component of the biosocial theory of emotion regulation stipulates that borderline personality disorder (BPD) arises from biological vulnerabilities to heightened emotional reactivity. Comprehensive reviews have consistently implicated abnormalities in the amygdala, anterior cingulate cortex, and hippocampus in the neurobiology of BPD. While Dialectical Behavior Therapy (DBT) is the leading evidence-based psychotherapy for the treatment of BPD, there remains a paucity of literature examining changes in the neurobiology of BPD following DBT treatment. Nine studies were identified that examined neurobiological changes in BPD after the completion of DBT. Results indicated that there was significant deactivation of amygdala activity as well as the anterior cingulate cortex in patients with BPD after DBT treatment. As well, several studies found after DBT treatment, BPD patients had a decreased activity in the inferior frontal gyrus in response to arousing stimuli and increased activity in response to inhibitory control. Future research on the neurobiological change after DBT treatment can help clarify biological mechanisms of change in BPD.

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

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

How to understand and help a person with borderline personality. Case report and literature review on the therapeutic possibilities

Introduction: The study aims to present 1) a case report of an 18-year-old female patient with borderline personality disorder (BPD) 2) the diagnostic and treatment difficulties in BPD patients.

Materials and methods: The review of the literature from the years 1953-2020 searched from PubMed, Google Scholar, and Web of Science databases.

Discussion: Patient, 18-years old, hospitalized five times for psychiatric care, presenting self-injurious behaviours, hurting herself within forearms. A patient attempted suicide eight times. She is living with her divorced parents. The patient’s father has a new partner with whom he has children. The patient used marijuana and she was experiencing psychotic symptoms under its influence. She smokes 10 cigarettes per day and drinks alcohol once a week since she was 16 years old. Psychiatric problems appeared when the patient started learning in high school.

Conclusions:

1. Borderline personality disorder (BPD) is a serious psychiatric condition of a difficult diagnosis that should be differentiated with many other psychiatric disorders such as an atypical or subclinical course of psychosis, affective disorders, or dissocial personality.

2. A therapeutic process of a person with BPD is based on psychotherapy and personalized treatment strategies, whereas, pharmacological treatment plays only a supporting role during BPD treatment.

The Relationship between Maternal Personality Disorder and Early Birth Outcomes: A Systematic Review and Meta-Analysis

(1) Background: Women with personality disorder are at risk of social and emotional problems which impact deleteriously on everyday functioning. Moreover, a personality disorder diagnosis has been established to have an adverse impact upon pregnancy outcomes and child health. Understanding this impact is critical to improving both maternal and child outcomes. This systematic review and meta-analysis will evaluate the contemporary evidence regarding these relationships. (2) Methods: Prospero and Cochrane were searched for any systematic reviews already completed on this topic. Academic Search Premier, CINAHL Complete, MEDLINE, PsycARTICLES, PsycINFO via the EBSCO host, and the Web of Science Core Collection were searched to include research articles published between 1980 and 2019. A total of 158 records were identified; 105 records were screened by reviewing the abstract; 99 records were excluded; 6 full text articles were assessed for eligibility; 5 records were included in the review. (3) Results: All the included studies reported on preterm birth. The meta-analysis indicates significant risk of preterm birth in women with personality disorder (overall odds ratio (OR) 2.62; CI 2.24–3.06; p < 0.01). Three studies reported on low birth weight, with the meta-analysis indicating a raised risk of low birth weight of the babies born to women with personality disorder (overall OR 2.00 CI 1.12–3.57 (p = 0.02)). Three studies reported on appearance, pulse, grimace, activity, and respiration (APGAR) score, with the meta-analysis of OR’s indicating a risk of low APGAR score in women with personality disorder (overall OR 2.31; CI 1.17–4.55; p = 0.02). (4) Conclusions: The infants of women with personality disorder are at elevated risk of preterm birth, low birth weight and low APGAR score.

Oxytocin receptor gene, childhood maltreatment and borderline personality disorder features among male inmates in China

BACKGROUND

Borderline personality disorder (BPD) is caused by a variety of biological and environmental factors. Accumulating evidence suggests that childhood maltreatment is a risk environmental factor in the development of BPD, but research on the genetic pathology of BPD is still in its early stages, and very little is known about the oxytocin receptor (OXTR) gene. The purpose of this study is to further explore the interactive effects between OXTR gene polymorphisms and childhood maltreatment on BPD risk.

METHODS

Among the 1804 Chinese Han male inmates, 765 inmates who had BPD or antisocial personality disorder (ASPD) or highly impulsive or violent crime were considered as high-risk inmates and included in this study. Childhood maltreatment, BPD, antisocial personality disorder (ASPD) and impulsivity were measured by self-reported questionnaires. Peripheral venous blood was collected for the genotype test.

RESULTS

Analyses revealed that the BP group (inmates with BPD features) had higher rs53576 AA genotype frequency and rs237987 AA genotype frequency than the non-BP group, while the statistical significances were lost after Bonferroni correction. Total childhood maltreatment score, emotional abuse and neglect could positively predict BPD risk. Among the high-risk samples, rs53576 GG genotype carriers had higher BPD scores at higher levels of physical abuse and sexual abuse and had lower BPD scores at lower levels of physical abuse and sexual abuse.

CONCLUSIONS

The findings suggest that the interaction between OXTR gene variations and childhood maltreatment is an important mechanism for the development of BPD. The moderating role of the OXTR gene provides evidence for gene plasticity.

Familial factors and the risk of borderline personality pathology: genetic and environmental transmission

BACKGROUND

Parental characteristics and practices predict borderline personality disorder (BPD) symptoms in children. However, it is difficult to disentangle whether these effects are genetically or environmentally mediated. The present study examines the contributions of genetic and environmental influences by comparing the effects of familial risk factors (i.e. parental psychopathology and borderline traits, maladaptive parenting, marital discord) on child BPD traits in genetically related (biological) and non-related (adoptive) families.

METHODS

Data are from 409 adoptive and 208 biological families who participated in the Siblings Interaction and Behavior Study (SIBS) and 580 twin families the Minnesota Twin Family Study (MTFS). Parent characteristics and practices included parental psychopathology (measured via structured clinical interviews), parental BPD traits, parenting behaviors, and marital discord. A series of multi-level regression models were estimated to examine the relationship of familial risk factors to child BPD traits and to test whether children's adoptive status moderated the association.

RESULTS

Symptom counts of parents' conduct disorder, adult antisocial behavior, nicotine, alcohol, and illicit drug dependence, and paternal BPD traits substantially predicted child BPD traits only in biological offspring, implying genetic transmission. Maternal BPD traits and both maternal and paternal conflict, lack of regard, and lack of involvement predicted offspring BPD traits regardless of the adoptive status, implying environmental transmission.

CONCLUSIONS

Parental externalizing psychopathology and father's BPD traits contribute genetic risk for offspring BPD traits, but mothers' BPD traits and parents' poor parenting constitute environmental risks for the development of these offspring traits.

Mediating role of borderline personality disorder traits in the effects of childhood maltreatment on suicidal behaviour among mood disorder patients

Background:

Substantial evidence supports an association between childhood maltreatment and suicidal behaviour. However, few studies have examined factors mediating this relationship among patients with unipolar or bipolar mood disorders.

Methods:

Depressive disorder and bipolar disorder (ICD-10-DCR) patients (n = 287) from the Helsinki University Psychiatric Consortium (HUPC) Study were surveyed on self-reported childhood experiences, current depressive symptoms, borderline personality disorder traits, and lifetime suicidal behaviour. Psychiatric records served to complement the information on suicide attempts. We examined by formal mediation analyses whether (1) the effect of childhood maltreatment on suicidal behaviour is mediated through borderline personality disorder traits and (2) the mediation effect differs between lifetime suicidal ideation and lifetime suicide attempts.

Results:

The impact of childhood maltreatment in multivariate models on either lifetime suicidal ideation or lifetime suicide attempts showed comparable total effects. In formal mediation analyses, borderline personality disorder traits mediated all of the total effect of childhood maltreatment on lifetime suicide attempts, but only one fifth of the total effect on lifetime suicidal ideation. The mediation effect was stronger for lifetime suicide attempts than for lifetime suicidal ideation (P = 0.002) and independent of current depressive symptoms.

Conclusions:

The mechanisms of the effect of childhood maltreatment on suicidal ideation versus suicide attempts may diverge among psychiatric patients with mood disorders. Borderline personality disorder traits may contribute to these mechanisms, although the influence appears considerably stronger for suicide attempts than for suicidal ideation.

An intervention for parents with severe personality difficulties whose children have mental health problems: a feasibility RCT

BACKGROUND

The children of parents with severe personality difficulties have greater risk of significant mental health problems. Existing care is poorly co-ordinated, with limited effectiveness. A specialised parenting intervention may improve child and parenting outcomes, reduce family morbidity and lower the service costs.

OBJECTIVES

To develop a specialised parenting intervention for parents affected by severe personality difficulties who have children with mental health problems and to conduct a feasibility trial.

DESIGN

A pragmatic, mixed-methods design to develop and pilot a specialised parenting intervention, Helping Families Programme-Modified, and to conduct a randomised feasibility trial with process evaluation. Initial cost-effectiveness was assessed using UK NHS/Personal Social Services and societal perspectives, generating quality-adjusted life-years. Researchers collecting quantitative data were masked to participant allocation.

SETTING

Two NHS mental health trusts and concomitant children's social care services.

PARTICIPANTS

Parents who met the following criteria: (1) the primary caregiver of the index child, (2) aged 18-65 years, (3) have severe personality difficulties, (4) proficient in English and (5) capable of providing informed consent. Index children who met the following criteria: (1) aged 3-11 years, (2) living with index parent and (3) have significant emotional/behavioural difficulties. Exclusion criteria were (1) having coexisting psychosis, (2) participating in another parenting intervention, (3) receiving inpatient care, (4) having insufficient language/cognitive abilities, (5) having child developmental disorder, (6) care proceedings and (7) index child not residing with index parent.

INTERVENTION

The Helping Families Programme-Modified - a 16-session intervention using structured, goal-orientated strategies and collaborative therapeutic methods to improve parenting, and child and parent functioning. Usual care - standard care augmented by a single psychoeducational session.

MAIN OUTCOME MEASURES

Trial feasibility - rates of recruitment, eligibility, allocation, retention, data completion and experience. Intervention acceptability - rates of acceptance, completion, alliance (Working Alliance Inventory-Short Revised) and experience. Outcomes - child (assessed via Concerns About My Child, Eyberg Child Behaviour Inventory, Child Behaviour Checklist-Internalising Scale), parenting (assessed via the Arnold-O'Leary Parenting Scale, Kansas Parental Satisfaction Scale), parent (assessed via the Symptom Checklist-27), and health economics (assessed via the Client Service Receipt Inventory, EuroQol-5 Dimensions).

RESULTS

The findings broadly supported trial feasibility using non-diagnostic screening criteria. Parents were mainly referred from one site (75.0%). Site and participant factors delayed recruitment. An estimate of eligible parents was not obtained. Of the 86 parents referred, 60 (69.7%) completed screening and 48 of these (80.0%) were recruited. Participants experienced significant disadvantage and multiple morbidity. The Helping Families Programme-Modified uptake (87.5%) was higher than usual-care uptake (62.5%). Trial retention (66.7%, 95% confidence interval 51.6% to 79.6%) exceeded the a priori rate. Process findings highlighted the impact of random allocation and the negative effects on retention. The Helping Families Programme-Modified was acceptable, with duration of delivery longer than planned, whereas the usual-care condition was less acceptable. At initial follow-up, effects on child and parenting outcomes were detected across both arms, with a potential outcome advantage for the Helping Families Programme-Modified (effect size range 0.0-1.3). For parental quality-adjusted life-years, the Helping Families Programme-Modified dominated usual care, and child quality-adjusted life-years resulted in higher costs and more quality-adjusted life-years. At second follow-up, the Helping Families Programme-Modified was associated with higher costs and more quality-adjusted life-years than usual care. For child quality-adjusted life-years, when controlled for baseline EuroQol-5 Dimensions, three-level version, usual care dominated the Helping Families Programme-Modified. No serious adverse events were reported.

CONCLUSION

The Helping Families Programme-Modified is an acceptable specialised parenting intervention. Trial methods using non-diagnostic criteria were largely supported. For future work, a definitive efficacy trial should consider site selection, recruitment methods, intervention efficiency and revised comparator condition.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN14573230.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 14. See the NIHR Journals Library website for further project information.

SERT and BDNF polymorphisms interplay on neuroticism in borderline personality disorder

Objective

Genetic factors underlying different personality traits are not entirely understood, particularly how genes interact to modulate their effect. We studied 76 patients diagnosed with borderline personality disorder (BPD), characterized by extreme levels of personality traits, especially neuroticism (N), in which we genotyped two polymorphisms, the 5HTTLPR of the Serotonin transporter (SERT) gene, and the Val66Met of the Brain-derived neurotrophic factor (BDNF) gene.

Results

We found an association with SERT, where S-allele carriers had significantly higher levels of N than L-homozygous. Furthermore, we found that the protective effect of L-homozygosity is only evident on A-allele carriers of the BDNF Val66Met polymorphism. Genetic constitution in SERT and BDNF seems to be important in neuroticism, the most relevant personality trait on BPD.

Borderline personality disorder: part 1 – assessment and diagnosis

General adult psychiatrists are largely responsible for the care of patients with personality disorders in community and in-patient settings, and this can be associated with diagnostic and management challenges. In the first of two articles focusing specifically on borderline personality disorder (BPD), we summarise the core clinical features of the disorder and discuss appropriate diagnostic practice.

The association between childhood maltreatment and empathic perspective taking is moderated by the 5-HTT linked polymorphic region: Another example of "differential susceptibility"

Previous research has suggested that the short (S)-allele of the 5-HT transporter gene-linked polymorphic region (5-HTTLPR) may confer "differential susceptibility" to environmental impact with regard to the expression of personality traits, depressivity and impulsivity. However, little is known about the role of 5-HTTLPR concerning the association between childhood adversity and empathy. Here, we analyzed samples of 137 healthy participants and 142 individuals diagnosed with borderline personality disorder (BPD) focusing on the 5-HTTLPR genotype (S/L-carrier) and A/G SNP (rs25531), in relation to childhood maltreatment and empathy traits. Whereas no between-group difference in 5-HTTLPR genotype distribution emerged, the S-allele selectively moderated the impact of childhood maltreatment on empathic perspective taking, whereby low scores in childhood trauma were associated with superior perspective taking. In contrast, L-homozygotes seemed to be largely unresponsive to variation in environmental conditions in relation to empathy, suggesting that the S-allele confers "differential susceptibility". Moreover, a moderation analysis and tests for differential susceptibility yielded similar results when transcriptional activity of the serotonin transporter gene was taken into account. In conclusion, our findings suggest that the S-allele of the 5-HTTLPR is responsive to early developmental contingencies for "better and worse", i.e. conferring genetic plasticity, especially with regard to processes involving emotional resonance.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Borderline Personality Disorder in Patients With Medical Illness: A Review of Assessment, Prevalence, and Treatment Options

OBJECTIVE

Borderline personality disorder (BPD) occurs in 0.7% to 3.5% of the general population. Patients with BPD experience excessive comorbidity of psychiatric and somatic diseases and are known to be high users of health care services. Because of a range of challenges related to adverse health behaviors and their interpersonal style, patients with BPD are often regarded as "difficult" to interact with and treat optimally.

METHODS

This narrative review focuses on epidemiological studies on BPD and its comorbidity with a specific focus on somatic illness. Empirically validated treatments are summarized, and implementation of specific treatment models is discussed.

RESULTS

The prevalence of BPD among psychiatric inpatients (9%-14%) and outpatients (12%-18%) is high; medical service use is very frequent, annual societal costs vary between &OV0556;11,000 and &OV0556;28,000. BPD is associated with cardiovascular diseases and stroke, metabolic disease including diabetes and obesity, gastrointestinal disease, arthritis and chronic pain, venereal diseases, and HIV infection as well as sleep disorders. Psychotherapy is the treatment of choice for BPD. Several manualized treatments for BPD have been empirically validated, including dialectical behavior therapy, transference-focused psychotherapy, mentalization-based therapy, and schema-focused therapy.

CONCLUSIONS

Health care could be substantially improved if all medical specialties would be familiar with BPD, its pathology, medical and psychiatric comorbidities, complications, and treatment. In mental health care, several empirically validated treatments that are applicable in a wide range of clinical settings are available.

Toward an animal model of borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is a pervasive psychiatric disorder characterized by emotion dysregulation, impulsivity, impaired self-perceptions, and interpersonal relationships and currently affects 1-3% of the US population as reported by Torgersen et al. (Arch Gen Psychiatry 58:590-596, Torgersen et al. 2001), Lenzenweger et al. (Biol Psychiatry 62:553-564, Lenzenweger et al. 2007), and Tomko et al. (J Personal Disord 28:734-750, Tomko et al. 2014). One major obstacle to our understanding of the neural underpinnings of BPD is a lack of valid animal models that translate the key known features of the disorder to a system that is amenable to study.

OBJECTIVE

To summarize the etiology, major symptoms, and symptom triggers of BPD and then propose a blueprint for building an animal model of BPD by choosing key components of the disorder that can be implemented in rodents.

RESULTS

We identify the role of early life stress and subsequent mild stress in adulthood as contributing etiological factors and the potential use of altered communication between frontal cortices and the amygdala in extinction and habituation, increased impulsivity, dysregulation of the hypothalamic pituitary axis (HPA), and increased neuroinflammation as biological markers of BPD. Building upon these features of BPD, we propose a two-hit animal model that uses maternal abandonment to alter maturation of the HPA axis and mild secondary adult stress to evoke behavioral symptoms such as increased impulsivity and impaired extinction, habituation, and social interactions.

CONCLUSION

Through exploration of the etiology, symptom presentation, and altered neurological function, we propose an animal model of BPD. We believe that a number of existing animal paradigms that model other mental health disorders should be combined in a unique way to reflect the etiology, symptom presentation, and altered neurological function that is evident in BPD. These model, when compared with available human data, will inform research and treatment in humans for better understanding of systems from the micro-molecular level to more global physiology underlying BPD.

Borderline personality disorder: an update for neurologists

The value and challenges of establishing and maintaining a successful doctor-patient relationship are thrown into sharp relief in the treatment of people with borderline personality disorder. We present an overview of this common and important condition, its epidemiology, cause, common comorbidities and neurological associations. We then propose a practical, psychologically informed framework for enhancing the therapeutic alliance for the jobbing neurologist in managing these patients.

Borderline personality disorder and emotion dysregulation

Borderline personality disorder (BPD) is a severe and complex disorder characterized by instability across many life domains, including interpersonal relations, behavior, and emotions. A core feature and contributor to BPD, emotion dysegulation (ED), consists of deficits in the ability to regulate emotions in a manner that allows the individual to pursue important goals or behave effectively in various contexts. Biosocial developmental models of BPD have emphasized a transaction of environmental conditions (e.g., invalidating environments and adverse childhood experiences) with key genetically linked vulnerabilities (e.g., impulsivity and emotional vulnerability) in the development of ED and BPD. Emerging evidence has begun to highlight the complex, heterotypic pathways to the development of BPD, with key heritable vulnerability factors possibly interacting with aspects of the rearing environment to produce worsening ED and an adolescent trajectory consisting of self-damaging behaviors and eventual BPD. Adults with BPD have shown evidence of a variety of cognitive, physiological, and behavioral characteristics of ED. As the precursors to the development of ED and BPD have become clearer, prevention and treatment efforts hold great promise for reducing the long-term suffering, functional impairment, and considerable societal costs associated with BPD.

Differential Susceptibility to the Environment and Borderline Personality Disorder

Evolutionary models of psychopathology can shed light on gene-environment interactions. Differential susceptibility to the environment means that heritable traits can have positive or negative effects, depending on environmental context. Thus, traits that increase risk for mental disorders when the environment is negative can be adaptive when the environment is positive. This model can be applied to borderline personality disorder, with predictors such as emotional dysregulation and impulsivity seen as temperamental variations leading to negative effects in an unfavorable environment but to positive effects in a favorable environment. This model may also be useful in conceptualizing the mechanisms of effective therapy for borderline personality disorder.

A Recurrent Question: What Is Borderline?

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

Paranoia and risk of personality disorder in the general population

BACKGROUND

We hypothesized that paranoia is associated with personality disorder (PD) in the general population.

METHOD

This was a population-based cross-sectional survey carried out in Andalusia (Spain) using a representative sample of 4 507 participants. Paranoia was measured using the Green Paranoid Thought Scale, and risk of having a PD was screened using the Standardized Assessment of Personality Abbreviated Scale whilst borderline personality disorder (BPD) was measured with the CEPER-III Exploratory Interview of Personality disorder. Adjusted Pearsons' correlations between paranoia and PD or BPD were calculated.

RESULTS

Paranoia was associated with the risk of having PD and, more robustly, with BPD. Both associations held true for both personality outcomes (PD and BPD) when tested for two Green Paranoid Thought Scale paranoia subtypes (persecutory and reference) after accounting for the effects of age, sex and child abuse.

CONCLUSIONS

Paranoia seems to either augment the risk for, or be part of, PD/BPD. © 2019 John Wiley & Sons, Ltd.

FKBP5 gene variants and borderline personality disorder

BACKGROUND

Genes associated with the physiological response to stress in the hypothalamic-pituitary-adrenal axis are considered as good candidates for genetic research in borderline personality disorder (BPD).

METHODS

In this study, five FKBP5 (a co-chaperone of the glucocorticoid receptor) SNPs (rs3800373, rs9296158, rs737054, rs1360780, rs9470080) were genotyped in a sample of 101 unrelated Caucasian patients with BPD and 111 ethnically matched healthy controls. The interaction between FKBP5 polymorphisms and childhood trauma was also tested.

RESULTS

All FKBP5 polymorphisms genotyped showed significant associations with BPD. A main effect of rs9470080 (p = 0.01) and gene x environment (physical abuse) interaction (p = 0.01) was found. A gene x environment (emotional abuse) interaction was also found for rs3800373 (p = 0.03). However, these interactions did not remain significant after multiple testing corrections.

LIMITATIONS

In this study, only 5 genetic variants were tested and thus tagging of the FKBP5 gene was incomplete. Moreover, the sample size is moderate.

CONCLUSION

BPD is associated with FKBP5 polymorphisms and several types of childhood abuse may modulate the effect between FKBP5 SNPs and this disorder.

Schizophrenia risk factors in exceptional achievers: a re-analysis of a 60-year-old database

Current medical research has focused on diseases and their associated risk factors. As such, these factors are assumed to have a deleterious effect. An alternative hypothesis is that some of these risk factors would also increase the chance for an opposite, positive outcome. To test this hypothesis, we considered exceptional social achievement and schizophrenia as opposite outcomes. Sixty years ago, researchers in France collected data on socio-demographic factors associated with exceptional social achievement. As the number of female subjects in the original database was very limited, we restricted our analyses to men. We tested the odds of achieving prominence in the presence of factors known to be associated with an increased risk of schizophrenia, namely migration, urbanicity, seasonality of birth, birth order, and paternal age. Three of the five factors tested significantly increased the odds for exceptional social achievement (urban birth, being the first-born and father’s age over 35). Our findings suggest that some of the factors that are currently considered as risk factors for schizophrenia could diversifying factors. Widening the focus of research to include all potential effects of factors associated with disease could have important consequences on our understanding of causal mechanisms and for designing public health interventions.