Aggressive behavior and self-harm in Borderline Personality Disorder: The role of impulsivity and emotion dysregulation in a sample of outpatients

Dimensions of family stress and repetitive nonsuicidal self-injury in adolescence: Examining the interactive effects of impulsivity and emotion dysregulation

BACKGROUND

Repetitive non-suicidal self-injury (R-NSSI) in adolescence represents a significant risk factor for suicide. Although exposure to family stress is robustly associated with the risk of non-suicidal self-injury (NSSI), studies have not examined the potential mechanisms linking different forms of family stress and R-NSSI.

OBJECTIVE

This study examined how unique dimensions of family stress (threat and deprivation) relate to R-NSSI via interactions between impulsivity and emotion dysregulation.

PARTICIPANTS AND SETTING

The current sample included 3801 middle-school adolescents (42.2 % girls, Mage = 13.21 years).

METHODS

We conducted a two-wave study with 6-month intervals. Participants completed self-report measures assessing family stress, impulsivity, emotion dysregulation, and NSSI.

RESULTS

Moderate mediation analyses showed that threat was indirectly associated with NSSI frequency through the interaction of impulsivity and emotion dysregulation in the R-NSSI group and indirectly through impulsivity in the occasional NSSI (O-NSSI) group. Deprivation did not predict subsequent NSSI frequency in either group.

CONCLUSIONS

These findings lend empirical support to dimensional models of adversity and suggest that adolescents who experience threat-related family stress may have greater impulsivity and are more likely to report R-NSSI in the context of emotion dysregulation.

Depression with comorbid borderline personality disorder - could ketamine be a treatment catalyst?

Borderline personality disorder (BPD) is diagnosed in 10-30% of patients with major depressive disorder (MDD), and the frequency of MDD among individuals with BPD reaches over 80%. The comorbidity of MDD and BPD is associated with more severe depressive symptoms and functional impairment, higher risk of treatment resistance and increased suicidality. The effectiveness of ketamine usage in treatment resistant depression (TRD) has been demonstrated in numerous studies. In most of these studies, individuals with BPD were not excluded, thus given the high co-occurrence of these disorders, it is possible that the beneficial effects of ketamine also extend to the subpopulation with comorbid TRD and BPD. However, no protocols were developed that would account for comorbidity. Moreover, psychotherapeutic interventions, which may be crucial for achieving a lasting therapeutic effect in TRD and BPD comorbidity, were not included. In the article, we discuss the results of a small number of existing studies and case reports on the use of ketamine in depressive disorders with comorbid BPD. We elucidate how, at the molecular and brain network levels, ketamine can impact the neurobiology and symptoms of BPD. Furthermore, we explore whether ketamine-induced neuroplasticity, augmented by psychotherapy, could be of use in alleviating core BPD-related symptoms such as emotional dysregulation, self-identity disturbances and self-harming behaviors. We also discuss the potential of ketamine-assisted psychotherapy (KAP) in BPD treatment. As there is no standard approach to the application of ketamine or KAP in individuals with comorbid TRD and BPD, we consider further research in the field as imperative. The priorities should include development of dedicated protocols, distinguishing subpopulations that may benefit most from such treatment and investigating factors that may influence its effectiveness and safety.

Borderline personality disorder vs. schizophrenia spectrum disorders in young people recruited within an "Early Intervention in Psychosis" service: clinical and outcome comparisons

Borderline Personality Disorder (BPD) is under-recognized in First-Episode Psychosis (FEP) and its psychotic manifestations are difficult to differentiate from Schizophrenia Spectrum Disorders (SSD). The aim of this investigation was to compare clinical, sociodemographic, and outcome characteristics between FEP patients with BPD vs. FEP subjects with SSD both at baseline and across a 2-year follow-up period. Participants completed the Health of the Nation Outcome Scale (HoNOS), the Positive And Negative Syndrome Scale (PANSS), and the Global Assessment of Functioning (GAF) scale both at entry and every 12 months during the follow-up. A mixed-design ANOVA model was conducted to investigate the temporal stability of clinical scores within and between the two subgroups. Among 356 FEP participants, 49 had a BPD diagnosis. Compared to FEP/SSD (n = 307), FEP/BPD patients showed higher prevalence of employment, current substance use, and past attempted suicide. They had a lower equivalent dose of antipsychotic medication at entry and lower levels of negative symptoms. Finally, they had a higher 2-year drop-out rate and a significant improvement in psychopathological scores limited to the first year of treatment. BPD as categorical entity represents a FEP subgroup with specific clinical challenges. Appropriate treatment guidelines for this FEP subgroup are thus needed.

Dual harm among patients attending a mental health unit in Uganda: a hospital based retrospective study

BACKGROUND

Dual harm encompasses the complex interplay of the co-occurrence of self-harm and aggression. Individuals with dual harm may display a more hazardous pattern of harmful behaviors like homicide-suicide compared to people with sole harm. This study aimed to examine the presence of dual harm among general psychiatry inpatients in a mental health unit in Uganda.

METHODS

A retrospective chart review of 3098 inpatients from January 2018 to December 2021. Dual harm reported experience at admission was based on experiences of self-harm with harm to people or property or both. Logistic regression assessed the association between dual harm and sociodemographics and clinical characteristics.

RESULTS

A total of 29 (1%) patients experienced dual harm, with five having experienced self-harm with both harm to others and property, 23 with harm to people, and one with harm to property. Dual harm was statistically significantly associated with the male gender at bivariate analysis. However, there were no statistically significant factors associated with dual harm at multivariate analysis or sensitivity analysis with the specific types of dual harm.

CONCLUSION

General psychiatry inpatients in Uganda experience dual harm before admission at lower prevalence than in previous literature. However, no investigated sociodemographic and clinical factors could explain these experiences. Further studies looking at dual harm are warranted to understand these unfortunate experiences with serious consequences among patients in Uganda.

[Alexithymia and self-harm in people with borderline personality disorder]

OBJECTIVE

To estimate the prevalence of alexithymia and self-harm in patients with borderline personality disorder (BPD). To assess the role of alexithymia in the emergence of self-harm in patients with BPD.

MATERIAL AND METHODS

We studied 104 patients (85 women, 19 men aged 21 to 25 years (64.4%)), including 54 patients with and 50 patients without BPD. Most of them had incomplete higher education (55%). We used the Russian version of the 20-item Toronto Alexithymia Scale (TAS-20) to reveal alexithymia and SCID-II to diagnose BPD. The presence of self-harm behavior was confirmed by the subjects' anamnesis data.

RESULTS

The prevalence of alexithymia in patients with BPD was 83.3%, in the control group it was 52% (p=0.001). The prevalence of self-aggression was 70.3% (n=38) in patients with BPD, and 12% (n=6) in people without BPD. Self-harm among persons with alexithymia was noted in 62.5% (n=45). During the analysis, a connection between auto-aggression and alexithymia was found at the level of a statistical trend (p=0.051).

CONCLUSION

Alexithymia and self-harm are more common in patients with BPD than in healthy people. This type of emotional dysregulation mediates self-harm in patients with BPD.

The comorbidity between Borderline Personality Disorder (BPD) and Generalized Anxiety Disorder (GAD): A systematic review and meta-analysis

Borderline personality disorder (BPD) is a psychiatric condition characterized by severe instability in affect, impulse control, and interpersonal functioning. Existing literature has confirmed that BPD is highly comorbid with other psychiatric conditions, including anxiety disorders. Despite this, little research has investigated the nature of the relationship between generalized anxiety disorder (GAD) and BPD. The aim of this systematic review and meta-analysis is to synthesize the literature concerning the prevalence and clinical outcomes of BPD and GAD comorbidity in adults. The following three databases were searched on October 27, 2021: PsycINFO, PubMed, and Embase. Twenty-four studies were included (n = 21 reporting on prevalence of the comorbidity, n = 4 reporting on clinical outcomes associated with the comorbidity), 9 of which were included in a meta-analysis. The meta-analysis showed that the pooled prevalence for current GAD in individuals with BPD was 16.4% (CI 95%: 1.9%; 66.1%) in inpatient samples, and 30.6% (CI 95%: 21.9%; 41.1%) in outpatient or community samples. The pooled lifetime prevalence of GAD in individuals with BPD was 11.3% (CI 95%: 8.9%; 14.3%) in inpatient samples, and 13.7% (CI 95%: 3.4%; 41.4%) in outpatient or community samples. Comorbidity between BPD and GAD was associated with worse outcomes on measures of BPD severity, impulsivity, anger, and hopelessness. In conclusion, this systematic review and meta-analysis indicate that comorbid GAD and BPD is highly prevalent, although the pooled prevalence rates should be interpreted with caution considering the large and overlapping confidence intervals. Further, this comorbidity is associated with worse BPD symptom severity.

"Holding in Anger" as a Mediator in the Relationship between Attachment Orientations and Borderline Personality Features

Insecure attachment and difficulties in regulating anger have both been put forward as possible explanations for emotional dysfunction in borderline personality (BP). This study aimed to test a model according to which the influence of attachment on BP features in a subclinical population is mediated by anger regulation. In a sample of 302 participants, BP features were assessed with the Borderline features scale of the Personality Assessment Inventory (PAI-BOR), attachment was measured with the Experiences in Close Relationships-12 (ECR-12), and trait anger and anger regulation were assessed with the State and Trait Anger Expression Inventory-2 (STAXI-2). The results indicated that anger suppression emerged as a significant mediator of the associations between both anxious and avoidant attachment and BP traits, while anger control resulted as a marginal mediator in the association between attachment avoidance and BP. Suppressing anger may reflect different forms of cognitive or behavioural avoidance of anger, which may differ on the basis of attachment orientations. We argue that these results may have important clinical implications: the promotion of anger regulation in BP should be considered a critical treatment goal.

A systematic review of the co-occurrence of self-harm and aggression: Is dual harm a unique behavioural construct?

Introduction

Dual harm is the co-occurrence of self-harm and aggression during an individual's lifetime. It is unclear whether sufficient evidence exists for dual harm as a unique clinical entity. This systematic review aimed to examine whether there are psychological factors that are uniquely associated with dual harm when compared to those who have engaged in sole harm (self-harm alone, aggression alone) and no harmful behaviours. Our secondary aim was to conduct a critical appraisal of the literature.

Methods

The review searched PsycINFO, PubMed, CINAHL, and EThOS on September 27, 2022, resulting in 31 eligible papers that represented 15,094 individuals. An adapted version of the Agency for Healthcare Research and Quality was used to assess risk of bias and a narrative synthesis was conducted.

Results

The included studies assessed differences in mental health problems, personality, and emotion related factors between the different behavioural groups. We found weak evidence that dual harm is an independent construct with unique psychological characteristics. Rather, our review suggests that dual harm results from the interaction of psychological risk factors that are associated with self-harm and aggression.

Discussion

The critical appraisal identified numerous limitations within the dual harm literature. Clinical implications and recommendations for future research are provided.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=197323, identifier CRD42020197323.

Personality characteristics, defense styles, borderline symptoms, and non-suicidal self-injury in first-episode major depressive disorder

Background

Non-suicidal self-injury (NSSI) is commonly seen in adolescents with depression and is a high-risk factor leading to suicide. The psychological mechanisms underlying depression with NSSI are still unclear. The purpose of this study was to explore the differences in personality traits, defensive styles, and borderline symptoms among first-episode youth patients with depression and self-injury compared with patients with depression without self-injury and healthy populations.

Methods

The current study recruited 188 participants, including 64 patients with depression and NSSI, 60 patients with depression without NSSI, and 64 healthy control subjects. Eysenck Personality Questionnaire, the Defense Style Questionnaire, the short version of the Borderline Symptom List, the Beck Depression Inventory, and the Ottawa Self-Injury Inventory were used to assess all participants.

Results

Patients with depression and NSSI showed more psychoticism than patients with depression without NSSI and healthy control subjects. Patients with depression and NSSI presented more intermediate defense styles than healthy control subjects. In the patients with depression and NSSI group, the frequency of self-injury in the last week was negatively correlated with mature defense styles and positively correlated with depressive symptoms and borderline symptoms. Further regression analysis showed that EPQ-psychoticism and depressive symptoms were independent risk factors for NSSI in patients with depression.

Conclusion

This study found that patients with depression and self-injury presented more neuroticism, introversion, EPQ-psychoticism, immature defenses, intermediate defenses, and borderline symptoms. Self-injury frequency was negatively correlated with mature defense styles and positively correlated with depressive symptoms and borderline symptoms. EPQ-Psychoticism and depressive symptoms are risk factors for predicting non-suicidal self-injury in patients with depression.

A genetically informed prediction model for suicidal and aggressive behaviour in teens

Suicidal and aggressive behaviours cause significant personal and societal burden. As risk factors associated with these behaviours frequently overlap, combined approaches in predicting the behaviours may be useful in identifying those at risk for either. The current study aimed to create a model that predicted if individuals will exhibit suicidal behaviour, aggressive behaviour, both, or neither in late adolescence. A sample of 5,974 twins from the Child and Adolescent Twin Study in Sweden (CATSS) was broken down into a training (80%), tune (10%) and test (10%) set. The Netherlands Twin Register (NTR; N = 2702) was used for external validation. Our longitudinal data featured genetic, environmental, and psychosocial predictors derived from parental and self-report data. A stacked ensemble model was created which contained a gradient boosted machine, random forest, elastic net, and neural network. Model performance was transferable between CATSS and NTR (macro area under the receiver operating characteristic curve (AUC) [95% CI] AUC_{CATSS(test set)} = 0.709 (0.671-0.747); AUC_NTR = 0.685 (0.656-0.715), suggesting model generalisability across Northern Europe. The notable exception is suicidal behaviours in the NTR, which was no better than chance. The 25 highest scoring variable importance scores for the gradient boosted machines and random forest models included self-reported psychiatric symptoms in mid-adolescence, sex, and polygenic scores for psychiatric traits. The model's performance is comparable to current prediction models that use clinical interviews and is not yet suitable for clinical use. Moreover, genetic variables may have a role to play in predictive models of adolescent psychopathology.

Emotional dysregulation as trans-nosographic psychopathological dimension in adulthood: A systematic review

Introduction

Emotional dysregulation (ED) is characterized by inappropriate emotional reactions related to environmental or cognitive stimuli. In most recent years, increasing interest has been devoted to its definition and detection across mental disorders for its detrimental role progressively highlighted in both neurodevelopment and adult mental disorders, with implications on the severity of clinical manifestations. The aim of this systematic review was to evaluate and gather the scientific evidence about ED in adult psychiatric population to elucidate the concept of ED as trans-nosographic entity.

Methods

The electronics databases PubMed, Scopus and Web of Science was reviewed to identify studies in accordance with the PRISMA guidelines; at the end of the selection process a total of 29 studies (N = 709; N = 658; N = 1,425) was included. All studies included assessed the presence of ED symptoms, by means of a validate scale in adult (>18 years of age), in clinically diagnosed patients as well as healthy control participants.

Results

Our results suggest ED as a trans-diagnostic factor across multiple mental disorders, such as bipolar disorder, attention deficit hyperactivity disorder, autism spectrum disorder, personality disorders; a better definition of this concept could be helpful to interpret and clarify many clinical cases and improve their diagnostic and therapeutic management.

Aberrant Structural Connectivity of the Triple Network System in Borderline Personality Disorder Is Associated with Behavioral Dysregulation

Background: Core symptoms of Borderline Personality Disorder (BPD) are associated to aberrant connectivity of the triple network system (salience network [SN], default mode network [DMN], executive control network [ECN]). While functional abnormalities are widely reported, structural connectivity (SC) and anatomical changes have not yet been investigated. Here, we explored the triple network’s SC, structure, and its association with BPD clinical features. Methods: A total of 60 BPD and 26 healthy controls (HC) underwent a multidomain neuropsychological and multimodal MRI (diffusion- and T1-weighted imaging) assessment. Metrics (fractional anisotropy [FA], mean diffusivity [MD], cortical thickness) were extracted from SN, DMN, ECN (triple network), and visual network (control network) using established atlases. Multivariate general linear models were conducted to assess group differences in metrics and associations with clinical features. Results: Patients showed increased MD in the anterior SN, dorsal DMN, and right ECN compared to HC. Diffusivity increases were more pronounced in patients with higher behavioral dysregulation, i.e., suicidal attempting, self-harm, and aggressiveness. No differences were detected in network structure. Conclusions: These results indicate that the triple network system is impaired in BPD at the microstructural level. The preferential involvement of anterior and right-lateralized subsystems and their clinical association suggests that these abnormalities could contribute to behavioral dysregulation.

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

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

Impaired impulse inhibition of emotional stimuli in patients with borderline personality disorder

This study was aimed to investigate whether BPD patients showed impaired impulse inhibition of emotional and non-emotional stimuli and to explore relevant neuroelectrophysiological mechanisms. A total of 32 BPD patients and 32 matched healthy controls were recruited. Self-reported scales were used to measure psychiatric symptoms. The event-related potentials (ERPs) were recorded when subjects were performing neutral and emotional Stop Signal Task (SST). Group differences in self-reported scores, behavioral variables and ERPs were compared. The BPD group scored significantly higher on impulsivity, severity of BPD symptoms, levels of depression and anxiety than the control group. In neutral SST, no significant group differences were detected in the amplitude and latency of ERPs components induced. In emotional SST, the P2 amplitude of negative emotion was significantly larger than that of neutral emotion in Go trials. In Stop trials, the P2 amplitude of BPD group was significantly smaller than that of control group, and the N2 amplitude of BPD group was significantly greater than that of control group. BPD patients showed impaired inhibition of emotional stimuli rather than non-emotional stimuli. The deficits of emotional impulse control mainly exhibit at the early attention, stimulus evaluation and conflict detection stages.

Personality, Schizophrenia, and Violence: A Longitudinal Study: The Second Wave of the VIORMED Project

This study investigated the association between maladaptive personality traits, personality disorders (PDs), schizophrenia, and the risk of aggressive behavior. Ninety-four patients with a history of violence and 92 patients with no history of violence underwent a multidimensional baseline assessment. Aggressive behavior was monitored during a 1-year follow-up through the Modified Overt Aggression Scale. The Violent group scored significantly higher than the Control group on the Millon Clinical Multiaxial Inventory (MCMI-III) Antisocial, Sadistic, Borderline, and Paranoid personality scales. Irrespective of any history of violence, patients with PD as a primary diagnosis displayed more aggressive behaviors than those with a primary diagnosis of schizophrenia during the follow-up. Furthermore, the most significant predictor of aggressive behaviors over time was endorsing a primary diagnosis of PD. Identifying the crucial risk factors for violent recidivism would contribute to reducing aggressive behavior in this population.

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

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

The Co-occurrence of Self-Harm and Aggression: A Cognitive-Emotional Model of Dual-Harm

There is growing evidence that some individuals engage in both self-harm and aggression during the course of their lifetime. The co-occurrence of self-harm and aggression is termed dual-harm. Individuals who engage in dual-harm may represent a high-risk group with unique characteristics and pattern of harmful behaviours. Nevertheless, there is an absence of clinical guidelines for the treatment and prevention of dual-harm and a lack of agreed theoretical framework that accounts for why people may engage in this behaviour. The present work aimed to address this gap in the literature by providing a narrative review of previous research of self-harm, aggression and dual-harm, and through doing so, presenting an evidence-based theory of dual-harm – the cognitive-emotional model of dual-harm. This model draws from previous studies and theories, including the General Aggression Model, diathesis-stress models and emotional dysregulation theories. The cognitive-emotional model highlights the potential distal, proximal and feedback processes of dual-harm, the role of personality style and the possible emotional regulation and interpersonal functions of this behaviour. In line with our theory, various clinical and research implications for dual-harm are suggested, including hypotheses to be tested by future studies.

Cessation of Deliberate Self-Harm Behavior in Patients With Borderline Personality Traits Treated With Outpatient Dialectical Behavior Therapy

The first aim of the study was to identify when deliberate self-harm (DSH) behavior ceased in patients with borderline symptoms undergoing dialectical behavioral treatment (DBT). The second aim was to compare patients who ceased their self-harm behavior early or late in the course of treatment, with regard to demographics, comorbidity, and symptom severity. The study used a naturalistic design and included 75 treatment completers at an outpatient DBT clinic. Of these 75 patients, 46 presented with self-harming behavior at pre-treatment. These 46 participants where split into two groups, based on median amount of time before ceasing self-harm behavior, termed early (up to 8 weeks) and late (8+ weeks) responders. Treatment duration varied from 16 to 160 weeks. Patients were assessed pre- and post-treatment using measures of depression, hopelessness, personality traits, quality of life, and global assessment of symptoms and functioning. The majority (93.5%) ceased their self-harming within the first year, and the average number of weeks was 15.5 (SD = 17.8). Twenty-five percent of patients ceased their DSH behavior during the first week of treatment. For the remaining patients, the cessation of DSH continued gradually across a 1 year period. We found no differences between early and late responders with respect to demographics, comorbidity, symptom severity, or treatment outcome. None of the patients committed suicide. The findings indicate that self-harming behavior decreases gradually across the first year after starting DBT.

Don't Make Me Angry: Frustration-Induced Anger and Its Link to Aggression in Women With Borderline Personality Disorder

Aggression is a prominent interpersonal dysfunction of individuals with borderline personality disorder (BPD). In BPD aggression is predominantly reactive in nature, often triggered by frustration, provocation, or social threat and is associated with intense anger and an inability to regulate this strong, negative emotion. Building on previous research, we were interested in investigating negative emotionality in general and anger in particular in women with BPD before and after frustration induction. To achieve this, 60 medication-free women with BPD and 32 healthy women rated the intensity of negative emotions (angry, frustrated, upset, embarrassed, nervous) before and after performing a Titrated Mirror Tracing Task, which reliably induces frustration and distress. As expected, women with BPD reported significantly greater intensity of negative emotions before and after frustration than healthy women. Specifically, they showed a significantly stronger frustration-induced increase in anger, while other negative emotions remained unaffected by frustration induction. This anger increase was significantly related to aggressive behavior reported in the 2 weeks prior to the experiment, as well as to the level of frustration experienced in the experiment itself, but not with emotion dysregulation. The current data confirm the important role of frustration-induced anger independent of emotion dysregulation in BPD, in particular with regard to aggression, a prominent interpersonal dysfunction of this disorder. These findings underline the importance of interventions with particular focus on anger.

A Cross-Sectional Study Investigating the Relationship Between Alexithymia and Suicide, Violence, and Dual Harm in Male Prisoners

Background: Suicide and violence are common within male prisoners. One suggested risk factor for both behaviors is alexithymia. Alexithymia describes a deficit in identifying and describing feelings and is also related to externally oriented thinking. This study aimed to explore the relationship between alexithymia, suicide, violence and dual harm in male prisoners. Methods: Eighty male prisoners were recruited from three prisons. Participants were asked to complete a battery of questionnaires including measures of alexithymia (TAS-20), suicide ideation (ASIQ), suicide behavior, violence ideation (SIV), violence behavior, depression (BDI-II), hopelessness (BHS), impulsivity (DII) and anger (NAS-PI). Regression analyses and ANOVAS were conducted to assess the association between alexithymia (and its subcomponents) with six outcomes; suicide ideation, suicide behavior, violence ideation, violence behavior, dual harm ideation and dual harm behavior. Results: Alexithymia was a univariate predictor of suicide ideation, though was not a significant predictor when considered in a multivariate model. Alexithymia was a significant multivariate predictor of suicide behavior. Alexithymia was not a significant multivariate predictor of violence ideation or behavior. There were no significant differences in alexithymia or subscales between those with suicide ideation/behavior alone, violence ideation/behavior alone and those with dual harm ideation/behavior. Conclusion: In male prisoners, alexithymia appears an important univariate predictor of suicide and violence, though the current study suggests no significant contribution above other well-known correlates of suicide and violence.

Borderline personality disorder and prior suicide attempts define a severity gradient among hospitalized adolescent suicide attempters

BACKGROUND

Borderline personality disorder (BPD) and history of prior suicide attempt (SA) have been shown to be high predictors for subsequent suicide. However, no previous study has examined how both factors interact to modify clinical and suicide severity among adolescents.

METHODS

This study presents a comprehensive assessment of 302 adolescents (265 girls, mean age = 14.7 years) hospitalized after a SA. To test clinical interactions between BPD and history of prior SA, the sample was divided into single attempters without BPD (non-BPD-SA, N = 80), single attempters with BPD (BPD-SA, N = 127) and multiple attempters with BPD (BPD-MA, N = 95).

RESULTS

Univariate analyses revealed a severity gradient among the 3 groups with an additive effect of BPD on the clinical and suicide severity already conferred by a history of SA. This gradient encompassed categorical (anxiety and conduct disorders and non-suicidal-self-injury [NSSI]) and dimensional comorbidities (substance use and depression severity) and suicide characteristics (age at first SA). According to regression analyses, the BPD-MA group that was associated with the most severe clinical presentation also showed specific features: the first SA at a younger age and a higher prevalence of non-suicidal self-injury (NSSI) and anxiety disorders. The BPD-MA group was not associated with higher impulsivity or frequency of negative life events.

CONCLUSIONS

Based on these findings and to improve youth suicide prevention, future studies should systematically consider BPD and the efficacy of reinforcing early interventions for anxiety disorders and NSSI.

Women With Borderline Personality Disorder Show Reduced Identification of Emotional Facial Expressions and a Heightened Negativity Bias

Individuals with borderline personality disorder (BPD) frequently display impairments in the identification of emotional facial expressions paralleled by a negativity bias. However, it remains unclear whether misperception of facial expressions is a key psychopathological marker of BPD. To address this question, the authors examined 43 women diagnosed with BPD and 56 healthy female controls using an emotion face identification task and a face dot-probe task together with measures on psychopathology. Compared to controls, women with BPD showed impaired identification of disgusted and angry faces concurrent with a bias to misclassify faces as angry, and a faster preconscious vigilance for fearful relative to happy facial expressions. Increased severity of borderline symptoms and global psychopathology in BPD patients were associated with reduced ability to identify angry facial expressions and a stronger negativity bias to anger. The findings indicate that BPD patients who misperceive face emotions have the greatest mental health issues.

Impulsiveness and Emotional Dysregulation as Stable Features in Borderline Personality Disorder Outpatients Over Time

Large-scale longitudinal studies show that specific borderline personality disorder (BPD) symptoms are more likely to remit over time, suggesting that clinical features of BPD may vary between younger patients and older ones. The objective of the present report is to provide a direct comparison between younger (age 18-25 years; n = 44) and older (age 40-59 years; n = 49) BPD patients on the nine DSM-4 BPD criteria (self-harm, emotional dysregulation, impulsiveness, and work and social functioning). Younger and older patients reported similar levels of impulsiveness, emotional dysregulation, and work and social functional impairment. Younger adults were more likely to show anger and self-damaging behaviors compared with older patients, which in turn were more likely to endorse chronic emptiness. In conclusion, older patients with BPD are still impaired in impulsiveness, emotional regulation, and social functioning; treatments for older BPD population should be long term and focused on emotion dysregulation and impulsive behaviors.

Cannabis and Complex Posttraumatic Stress Disorder: A Narrative Review With Considerations of Benefits and Harms

Despite substantial controversies concerning patients' reports of benefits from cannabis for posttraumatic stress disorder (PTSD) and inconsistent research findings regarding its efficacy and adverse risks, some states have already recognized PTSD as a qualifying condition for medical cannabis. Consequently, medical cannabis can also be provided for patients with complex PTSD who experience additional posttraumatic symptoms of affective dysregulation, negative perception of the self, and difficulties in relationships due to a history of repetitive trauma. In this article, we explore cannabis use in relation to benefits versus harms that might occur relative to specific complex PTSD symptoms and comorbidities. Whereas some symptoms related to PTSD per se (e.g., anxiety, insomnia, nightmares) may be benefited, others that are more characteristic of complex PTSD (e.g., dissociation, reckless behavior, and substance abuse associated with dysregulated affect) may be aggravated. Therefore, clinicians treating patients with complex PTSD who use or seek cannabis should carefully assess patients' motivations and the impacts of particular use patterns on specific symptoms. Clinicians and patients should be aware of and fully discuss the significant number of potential adverse effects of cannabis use, several of which might impede patients' participation in beneficial psychotherapeutic, social, and medical interventions.

Impulsivity issues in borderline personality disorder and it's links with insight: the role of urgency

Objective

Impulsivity plays a major role in a wide range of disorders including Borderline Personality Disorder. Another crucial clinical dimension is insight. This clinical dimension is linked with symptomatology and treatment issue. The present study aims to investigate the impact of positive and negative urgency on insight in Borderline Personality Disorder.

Methods

We recruited eighty-one women with Borderline Personality Disorder and assessed insight level and impulsivity scores using the Beck Cognitive insight scale and the UPPS-short form scale.

Results

Our results showed interesting links between positive urgency and insight quality.

Conclusion

Negative emotions play a fundamental role for the insight quality, but positive emotions are surprisingly related to clinical insight. We discuss the possible therapeutical impact of this results on treatment adaptation.

A retrospective analysis of determinants of involuntary psychiatric in-patient treatment

BACKGROUND

The purpose of our study was to identify predictors of a high risk of involuntary psychiatric in-patient treatment.

METHODS

We carried out a detailed analysis of the 1773 mental health records of all the persons treated as in-patients under the PsychKG NRW (Mental Health Act for the state of North Rhine-Westphalia, Germany) in a metropolitan region of Germany (the City of Cologne) in 2011. 3991 mental health records of voluntary in-patients from the same hospitals served as a control group. We extracted medical, sociodemographic and socioeconomic data from these records. Apart from descriptive statistics, we used a prediction model employing chi-squared automatic interaction detection (CHAID).

RESULTS

Among involuntary patients, organic mental disorders (ICD10: F0) and schizophrenia and other psychotic disorders (ICD10: F2) were overrepresented. Patients treated as in-patients against their will were on average older, they were more often retired and had a migratory background. The Exhaustive CHAID analysis confirmed the main diagnosis to be the strongest predictor of involuntary in-patient psychiatric treatment. Other predictors were the absence of outpatient treatment prior to admission, admission outside of regular service hours and migratory background. The highest risk of involuntary treatment was associated with patients with organic mental disorders (ICD 10: F0) who were married or widowed and patients with non-organic psychotic disorders (ICD10: F2) or mental retardation (ICD10: F7) in combination with a migratory background. Also, referrals from general hospitals were frequently encountered.

CONCLUSIONS

We identified modifiable risk factors for involuntary psychiatric in-patient treatment. This implies that preventive measures may be feasible and should be implemented to reduce the rate of involuntary psychiatric in-patient treatment. This may include efforts to establish crisis resolution teams to improve out-patient treatment, train general hospital staff in deescalation techniques, and develop special programs for patients with a migratory background.

Prevalence rates, reporting, and psychosocial correlates of stalking victimization: results from a three-sample cross-sectional study

PURPOSE

Public health and criminal justice stalking victimization data collection efforts are plagued by subjective definitions and lack of known psychosocial correlates. The present study assesses the question of stalking victimization prevalence among three groups. Psychosocial risk and protective factors associated with stalking victimization experiences were assessed.

METHODS

Archival data (n = 2159) were drawn from a three-sample (i.e., U.S. nationwide sexual diversity special interest group, college student, and general population adult) cross-sectional survey of victimization, sexuality, and health.

RESULTS

The range of endorsement of stalking-related victimization experiences was 13.0-47.9%. Reported perpetrators were both commonly known and unknown persons to the victim. Participants disclosed the victimization primarily to nobody or a family member/friend. Bivariate correlates of stalking victimization were female gender, Associates/Bachelor-level education, bisexual or other sexual orientation minority status, hypertension, diabetes, older age, higher weekly drug use, elevated trait aggression, higher cognitive reappraisal skills, lower rape myth acceptance, and elevated psychiatric symptoms. Logistic regression results showed the strongest factors in identifying elevated stalking victimization risk were: older age, elevated aggression, higher cognitive reappraisal skills, lesser low self-control, increased symptoms of suicidality and PTSD re-experiencing, and female and other gender minority status.

CONCLUSIONS

Behavioral approaches to epidemiological and criminal justice stalking victimization are recommended. Victimization under reporting to healthcare and legal professionals were observed. Further research and prevention programming is needed to capitalize on data concerning personality and coping skills, sexual diversity, and trauma-related psychiatric symptoms.

Correlates of Aggression in Personality Disorders: an Update

PURPOSE OF REVIEW

This review article aims at giving an update on studies investigating correlates of aggression in personality disorders during the last 5 years.

RECENT FINDINGS

Most data refer to borderline personality disorder (BPD) and antisocial personality disorder (ASPD). In BPD, emotion dysregulation, hypersensitivity to interpersonal rejection/threat, increased rumination, increased negative urgency, aggression-related knowledge structures, and invalidation were either corroborated or emerged as psychological correlates of aggression, while reduced ambiguity sensitivity, hyposensitivity to interpersonal threat, and reduced mindfulness were associated with aggression in ASPD. Neurobiologically, alterations of the monoaminooxidase-A-, the oxytocinergic-, and the prefrontal-limbic-system as well as increases of the thyroid hormone T3, γ-aminobutyric acid and several inflammatory markers were associated with increased aggression across various personality disorders. Our understanding of correlates of aggression in personality disorders has increased over the last 5 years. More efforts in improving the conceptualization of personality disorders and aggression are needed to develop innovative treatments for those affected.

Deliberate self-harm behavior among young violent offenders

Deliberate self-harm behavior (DSH) can have profound effects on a person's quality of life, and challenges the health care system. Even though DSH has been associated with aggressive interpersonal behaviors, the knowledge on DSH in persons exhibiting such behaviors is scarce. This study aims to (1) specify the prevalence and character of DSH, (2) identify clinical, neurocognitive, psychosocial, and criminological characteristics associated with DSH, and (3) determine predictors of DSH among young violent offenders. Data were collected from a nationally representative cohort of 270 male violent offenders, 18-25 years old, imprisoned in Sweden. Participants were interviewed and investigated neuropsychologically, and their files were reviewed for psychosocial background, criminal history, mental disorders, lifetime aggressive antisocial behaviors, and DSH. A total of 62 offenders (23%) had engaged in DSH at some point during their lifetime, many on repeated occasions, yet without suicidal intent. DSH was significantly associated with attention deficit hyperactivity disorder, mood disorders, anxiety disorders, various substance use disorders, being bullied at school, and repeated exposure to violence at home during childhood. Mood disorders, anxiety disorders, and being bullied at school remained significant predictors of DSH in a total regression model. Violent offenders direct aggressive behaviors not only toward other people, but also toward themselves. Thus, DSH must be assessed and prevented in correctional institutions as early as possible, and more knowledge is needed of the function of DSH among offenders.