Associations of emotional arousal, dissociation and symptom severity with operant conditioning in borderline personality disorder

Dissociation As a Mechanism of Risk for Interpersonal Victimization Among Adolescent Girls

Childhood interpersonal violence exposure (IVE) is associated with repeated victimization in adolescence and adulthood. Research suggests dissociation, a psychological phenomenon characterized by alterations and disruptions to consciousness, memory, and perceptions of the environment, and out-of-body experiences, increases the risk of revictimization. Self-report data from a longitudinal study of 92 violence-exposed adolescent girls from a large, urban area were analyzed to assess whether dissociation predicts polyvictimization or exposure to multiple types of interpersonal violence across adolescence. Participants' mental and interpersonal health was assessed at four in-person laboratory visits scheduled across 3.5 years (i.e., T1-T4). IVE included direct or indirect victimization experienced at home, school, the neighborhood, or town, such as child maltreatment, domestic violence, peer victimization, dating aggression, and community violence. Polyvictimization was operationalized as a composite score of the different types of IVE endorsed by the participant or caregiver. A random-intercept cross-lagged panel model was used to test the bidirectional relationships between dissociation and polyvictimization longitudinally. Cross-lagged regressions were analyzed to determine whether dissociation and polyvictimization predicted subsequent dissociation symptoms and polyvictimization. Concurrent and previous dissociation significantly accounted for polyvictimization at T2, T3, and T4. Polyvictimization did not significantly predict future dissociation symptoms. The results from this study provide support for dissociation's unique contribution to polyvictimization among violence-exposed girls, making it an important target for clinical assessment and treatment.

A systematic scoping review of dissociation in borderline personality disorder and implications for research and clinical practice: Exploring the fog

BACKGROUND

Borderline Personality Disorder (BPD) is frequently complicated by the presence of dissociative symptoms. Pathological dissociation is linked with earlier and more severe trauma exposure, emotional dysregulation and worse treatment outcomes in Posttraumatic Stress Disorder and Dissociative Disorders, with implications for BPD.

OBJECTIVE

A systematic scoping review was conducted to assess the extent of current literature regarding the impact of dissociation on BPD and to identify knowledge gaps.

METHODS

Four electronic databases (MEDLINE, APA PsycINFO, EMBASE, CINAHL Plus) were searched, and English peer-reviewed studies with adults with BPD were included, following Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) extension for scoping reviews (PRISMA-ScR) 2018 guidelines.

RESULTS

Most of the 70 included studies were observational (98%) with first authors from Germany (59%). Overall, dissociation was associated with increased BPD symptom severity, self-harm and reduced psychotherapy treatment response; findings regarding suicide risk were mixed. Dissociation was associated with working memory and cognitive deficits, decreased pain perception, altered body ownership, no substance abuse or the abuse of sedative substances, increased fantasy proneness, personality fragmentation, fearful attachment, dream anxiety, perceived stress and altered stress responses, increased cumulative body mass index, decreased water consumption, several neurological correlates and changes in gene expression.

CONCLUSION

BPD with significant dissociative symptoms may constitute a more severe and at-risk subgroup of BPD patients. However, there are significant research gaps and methodological issues in the area, including the possibility of unrecognized Dissociative Disorders in BPD study populations confounding results. Further studies are needed to better understand the impact of dissociation on BPD course and treatment, and to clarify the most appropriate assessment tools for clinical practice. In addition, interventional studies are needed to develop dissociation-specific BPD treatments to determine whether targeting dissociation in BPD can improve treatment outcomes.

Dissociation, trauma, and borderline personality disorder

Dissociation is a complex phenomenon, which occurs in various clinical conditions, including dissociative disorders, (complex) post-traumatic stress disorder (CPTSD, PTSD), and borderline personality disorder (BPD). Traumatic stress is considered an important risk factor, while the etiology of dissociation is still debated. Next to traumatic experiences, temperamental and neurobiological vulnerabilities seem to contribute to the development of dissociation. Stress-related dissociation is a prevalent symptom of BPD, which may interfere with psychosocial functioning and treatment outcome. More research in the field is strongly needed to improve the understanding and management of this complex phenomenon. This article collection brings together research on dissociation and trauma, with a special focus on BPD or sub-clinical expressions of BPD. In this editorial, recent conceptualizations of dissociation and relevant previous research are introduced in order to provide a framework for this novel research.

Learning from gain and loss: Links to suicide risk

Despite preliminary evidence that people with suicide attempt histories demonstrate deficits in processing feedback, no studies have examined the interrelations of learning from feedback and emotional state on suicide risk. This study examined the influence of suicide risk and negative emotions on learning accuracy and rates among individuals with a range of borderline personality features (N = 145). Participants completed a reinforcement learning task after neutral and negative emotion inductions. Results revealed interactions between suicide risk and emotion condition, with elevated risk linked to greater increases in loss learning rate (training phase models) and gain learning rate (test phase models) post-negative emotion induction. Emotion-dependent fluctuations in learning performance may be markers of decision-making that are associated with greater suicide risk. This line of work has the potential to identify the contexts that confer greater risk for suicidal behaviors.

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

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

Dissociation in Borderline Personality Disorder: Recent Experimental, Neurobiological Studies, and Implications for Future Research and Treatment

PURPOSE OF REVIEW

The aim of this review article is to give an overview over recent experimental neurobiological research on dissociation in borderline personality disorder (BPD), in order to inform clinicians and to stimulate further research. First, we introduce basic definitions and models that conceptualize dissociation from a transdiagnostic perspective. Then, we discuss recent findings in BPD.

RECENT FINDINGS

Stress-related dissociation is a key symptom of BPD, closely linked to other core domains of the disorder (emotion dysregulation, identity disturbances, and interpersonal disturbances). The understanding of neurobiological correlates of dissociation across different psychiatric disorders (e.g., dissociative disorders, post-traumatic stress disorder) is steadily increasing. At the same time, studies explicitly focusing on dissociation in BPD are still scarce. There is evidence for adverse effects of dissociation on affective-cognitive functioning (e.g., interference inhibition), body perception, and psychotherapeutic treatment response in BPD. On the neural level, increased activity in frontal regions (e.g., inferior frontal gyrus) and temporal areas (e.g., inferior and superior temporal gyrus) during symptom provocation tasks and during resting state was observed, although findings are still diverse and need to be replicated. Conceptual differences and methodological differences in study designs and sample characteristics (e.g., comorbidities, trauma history) hinder a straightforward interpretation and comparison of studies. Given the potentially detrimental impact of dissociation in BPD, more research on the topic is strongly needed to deepen the understanding of this complex clinical condition.

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

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

Impulsivity in patients with borderline personality disorder: a comprehensive profile compared with healthy people and patients with ADHD

BACKGROUND

Impulsivity is a core symptom of borderline personality disorder (BPD). Impulsivity is a heterogeneous concept, and a comprehensive evaluation of impulsivity dimensions is lacking in the literature. Moreover, it is unclear whether BPD patients manifest impaired cognitive functioning that might be associated with impulsivity in another patient group, such as ADHD, a frequent comorbidity of BPD.

METHODS

We tested 39 patients with BPD without major psychiatric comorbidities and ADHD, 25 patients with ADHD, and 55 healthy controls (HC) using a test battery consisting of a self-report measure of impulsivity (UPPS-P questionnaire), behavioral measures of impulsivity - impulsive action (Go/NoGo task, stop signal task) and impulsive choice (delay discounting task, Iowa gambling task), and standardized measures of attention (d2 test), working memory (digit span), and executive functioning (Tower of London).

RESULTS

Patients with BPD and ADHD, as compared with HC, manifested increased self-reported impulsivity except sensation seeking and increased impulsive choice; patients with ADHD but not BPD showed increased impulsive action and deficits in cognitive functioning. Negative urgency was increased in BPD as compared to both HC and ADHD groups and correlated with BPD severity.

CONCLUSIONS

Patients with BPD without ADHD comorbidity had increased self-reported impulsivity and impulsive choice, but intact impulsive action and cognitive functioning. Controlling for ADHD comorbidity in BPD samples is necessary. Negative urgency is the most diagnostically specific impulsivity dimension in BPD.

Ciliary neurotrophic factor signaling in the rat orbitofrontal cortex ameliorates stress-induced deficits in reversal learning

Deficits in cognitive flexibility, i.e. the ability to modify behavior in response to changes in the environment, are present in several psychiatric disorders and are often refractory to treatment. However, improving treatment response has been hindered by a lack of understanding of the neurobiology of cognitive flexibility. Using a rat model of chronic stress (chronic intermittent cold stress, CIC) that produces selective deficits in reversal learning, a form of cognitive flexibility dependent on orbitofrontal cortex (OFC) function, we have previously shown that JAK2 signaling is required for optimal reversal learning. In this study we explore the molecular basis of those effects. We show that, within the OFC, CIC stress reduces the levels of phosphorylated JAK2 and of ciliary neurotrophic factor (CNTF), a promoter of neuronal survival and an activator of JAK2 signaling, and that neutralizing endogenous CNTF with an intra-OFC microinjection of a specific antibody is sufficient to produce reversal-learning deficits similar to stress. Intra-OFC delivery of recombinant CNTF to CIC-stressed rats, at a dose that induces JAK2 and Akt but not STAT3 or ERK, ameliorates reversal-learning deficits, and Akt blockade prevents the positive effects of CNTF. Further analysis revealed that CNTF may exert its beneficial effects by inhibiting GSK3β, a substrate of Akt and a regulator of protein degradation. We also revealed a novel mechanism of CNTF action through modulation of p38/Mnk1/eIF4E signaling. This cascade controls translation of select mRNAs, including those encoding several plasticity-related proteins. Thus, we suggest that CNTF-driven JAK2 signaling corrects stress-induced reversal learning deficits by modulating the steady-state levels of plasticity-related proteins in the OFC.

The Modulating Role of Self-Referential Stimuli and Processes in the Effect of Stress and Negative Emotion on Inhibition Processes in Borderline Personality Disorder: Proposition of a Model to Integrate the Self-Concept and Inhibition Processes

Impulsivity is an important clinical and diagnostic feature of borderline personality disorder (BPD). Even though it has been reported that BPD individuals' inhibition performance is significantly reduced in the context of negative emotion or stress, this literature shows mixed results, raising questions about the possible role played by other factors. Winter (2016) proposed that negative emotion stimuli can be more disruptive for BPD individuals' attention control performance because they induce higher distractibility self-referential processes. This article aimed to systematically review the literature regarding the effect of stress and negative emotions on three main inhibition processes-prepotent response inhibition, resistance to distractor interference, and resistance to proactive interference-in BPD and to verify the putative modulating role of self-referential stimuli and processes on these inhibition processes. All English and French experimental studies published until August 2018 were searched in PsychINFO and PubMED databases. The following keywords were used: "borderline* AND inhibit* OR interference* OR forget* OR task* AND emotion* OR stress* OR affect*". A total of 1215 articles were included in the study. After full text revision, twenty-six papers were selected for review. The results of this review indicate that when stimuli or procedures involve self-reference stimuli or processes, BPD individuals' performance seems to be more disrupted in all three inhibition processes. A model based on Winter's and Kernberg's models is proposed with the aim of integrating the self-concept with inhibition processes in BPD.

Altered Oscillatory Responses to Feedback in Borderline Personality Disorder are Linked to Symptom Severity

Several studies using electroencephalography (EEG) demonstrate that the processing of feedback in patients suffering from borderline personality disorder (BPD) is altered in comparison to healthy controls. Differences occur in the theta (ca. 5 Hz) and high-beta frequency-ranges (ca. 20 Hz) of oscillations in response to negative and positive feedback, respectively. However, alpha (ca. 10 Hz) and low-beta (ca. 15 Hz) oscillations have also been shown to be involved in feedback processing. We hypothesized that additional alterations might occur in these frequency ranges in BPD. Eighteen patients with BPD and twenty-two healthy controls performed a gambling task while 64-channel-EEG was recorded. Induced oscillatory responses to positive (i.e. gain) and negative (i.e. loss) feedback in the alpha and low-beta frequency range were investigated. No significant differences were found in the alpha frequency range. Regarding the low-beta frequency range a significant Group (i.e. BPD vs. healthy controls) × Valence (i.e. gain vs. loss) interaction in the time frame between 600 and 700 milliseconds after feedback was found. This effect showed a significant correlation with symptom severity (assessed with the BSL-23). The results indicate that feedback processing in BPD could be more heavily altered than previously expected, with more severe symptomatology being linked to stronger alterations in oscillatory responses to feedback in the low-beta range.

Self-reported impulsivity in women with borderline personality disorder: the role of childhood maltreatment severity and emotion regulation difficulties

BACKGROUND

Childhood maltreatment, such as severe emotional, physical, and sexual abuse and neglect, has been linked to impulse control problems and dysfunctional emotional coping. In borderline personality disorder (BPD), a history of childhood maltreatment may worsen difficulties in emotion regulation, which may in turn give rise to impulsive behaviours. The aim of this self-report study was to investigate associations between childhood maltreatment severity, emotion regulation difficulties, and impulsivity in women with BPD compared to healthy and clinical controls.

METHODS

Sixty-one female patients with BPD, 57 clinical controls (CC, women with Attention Deficit Hyperactivity Disorder and/or Substance Use Disorder, without BPD), and 60 female healthy controls (HC) completed self-report scales on childhood trauma (Childhood Trauma Questionnaire, CTQ), difficulties in emotion regulation (Difficulties in Emotion Regulation Scale, DERS), and impulsivity (UPPS Impulsive Behaviour Scale). A conditional process analysis was performed to investigate whether emotion dysregulation statistically mediated the effect of childhood maltreatment severity on impulsivity depending on group (BPD vs. CC vs. HC).

RESULTS

Childhood maltreatment, particularly emotional maltreatment, was positively associated with impulsivity and emotion regulation difficulties across all groups. Difficulties in emotion regulation statistically mediated the effect of childhood maltreatment on impulsivity in BPD, but not in the other groups.

CONCLUSION

In the context of current conceptualizations of BPD and previous research, findings suggest that problems with emotion regulation may be related to a history of childhood maltreatment, which may in turn enhance impulsivity. Targeting emotion dysregulation in psychotherapy and discussing it in relation to childhood maltreatment can help decreasing impulsive behaviors in individuals with BPD. Given the correlational design of our study which does not allow causal conclusions, future studies have to employ prospective, experimental designs and include larger sample sizes to corroborate associations between childhood maltreatment, emotion dysregulation, and impulsivity.

Differential Valuation and Learning From Social and Nonsocial Cues in Borderline Personality Disorder

BACKGROUND

Volatile interpersonal relationships are a core feature of borderline personality disorder (BPD) and lead to devastating disruption of patients' personal and professional lives. Quantitative models of social decision making and learning hold promise for defining the underlying mechanisms of this problem. In this study, we tested BPD and control subject weighting of social versus nonsocial information and their learning about choices under stable and volatile conditions. We compared behavior using quantitative models.

METHODS

Subjects (n = 20 BPD, n = 23 control subjects) played an extended reward learning task with a partner (confederate) that requires learning about nonsocial and social cue reward probability (the social valuation task). Task experience was measured using language metrics: explicit emotions/beliefs, talk about the confederate, and implicit distress (using the previously established marker self-referentiality). Subjects' weighting of social and nonsocial cues was tested in mixed-effect regression models. Subjects' learning rates under stable and volatile conditions were modeled (Rescorla-Wagner approach) and group × condition interactions tested.

RESULTS

Compared to control subjects, BPD subject debriefings included more mentions of the confederate and less distress language. BPD subjects also weighted social cues more heavily but had blunted learning responses to (nonsocial and social) volatility.

CONCLUSIONS

This is the first report of patient behavior in the social valuation task. The results suggest that BPD subjects expect higher volatility than control subjects. These findings lay the groundwork for a neurocomputational dissection of social and nonsocial belief updating in BPD, which holds promise for the development of novel clinical interventions that more directly target pathophysiology.

Current Understanding of the Neural Mechanisms of Dissociation in Borderline Personality Disorder

Purpose of Review

In this article, we aim to give an overview over recent neuroimaging research on dissociation in borderline personality disorder (BPD). Stress-related dissociation is highly prevalent in BPD, while so far only little is known about its neural underpinnings.

Recent Findings

Based on research in depersonalization and the dissociative subtype of posttraumatic stress disorder, it has been proposed that dissociation involves alterations in a cortico-limbic network. In BPD, neuroimaging research explicitly focusing on dissociation is still scarce.

Summary

Functional neuroimaging studies have provided preliminary evidence for an altered recruitment and interplay of fronto-limbic regions (amygdala, anterior cingulate, inferior frontal gyrus, medial and dorsolateral prefrontal cortices) and temporoparietal areas (superior temporal gyrus, inferior parietal lobule, fusiform gyrus), which may underlie disrupted affective-cognitive processing during dissociation in BPD. More neuroimaging research with larger samples, clinical control groups, and repeated measurements is needed to deepen the understanding of dissociation in BPD.

Computational Psychiatry in Borderline Personality Disorder

PURPOSE OF REVIEW

We review the literature on the use and potential use of computational psychiatry methods in Borderline Personality Disorder.

RECENT FINDINGS

Computational approaches have been used in psychiatry to increase our understanding of the molecular, circuit, and behavioral basis of mental illness. This is of particular interest in BPD, where the collection of ecologically valid data, especially in interpersonal settings, is becoming more common and more often subject to quantification. Methods that test learning and memory in social contexts, collect data from real-world settings, and relate behavior to molecular and circuit networks are yielding data of particular interest.

SUMMARY

Research in BPD should focus on collaborative efforts to design and interpret experiments with direct relevance to core BPD symptoms and potential for translation to the clinic.

Disadvantageous decision-making in borderline personality disorder: Partial support from a meta-analytic review

To achieve long-term goals, organisms evaluate outcomes and expected consequences of their behaviors. Unfavorable decisions maintain many symptoms of borderline personality disorder (BPD); therefore, a better understanding of the mechanisms underlying decision-making in BPD is needed. In this review, the current literature comparing decision-making in patients with BPD versus healthy controls is analyzed. Twenty-eight empirical studies were identified through a structured literature search. The effect sizes from studies applying comparable experimental tasks were analyzed. It was found that (1) BPD patients discounted delayed rewards more strongly; (2) reversal learning was not significantly altered in BPD; and (3) BPD patients achieved lower net gains in the Iowa Gambling Task (IGT). Current psychotropic medication, sex and differences in age between the patient and control group moderated the IGT outcome. Altered decision-making in a variety of other tasks was supported by a qualitative review. In summary, current evidence supports the altered valuation of outcomes in BPD. A multifaceted influence on decision-making and adaptive learning is reflected in this literature.