Heritability of borderline personality disorder features is similar across three countries

Overlapping genetic influences between creativity and borderline personality symptoms in a large Dutch sample

Creativity and mental disorders are sometimes seen as intertwined, but research is still unclear on whether, how much, and why. Here we explore the potential role of shared genetic factors behind creativity and symptoms of borderline personality disorder (BPD, characterized by mood swings and randomness of thoughts). Data were collected from 6745 twins (2378 complete pairs) by the Netherlands Twin Register on BPD scores (PAI-BOR questionnaire) and working in a creative profession (proxy for creativity). First, we tested whether there is an association between BPD symptoms and creative professions. Results confirmed that individuals scoring higher on the BPD spectrum are more likely to have a creative profession (Cohen's d = 0.16). Next, we modeled how much of this association reflects underlying genetic and/or environmental correlations-by using a bivariate classical twin design. We found that creativity and BPD were each influenced by genetic factors (heritability = 0.45 for BPD and 0.67 for creativity) and that these traits are genetically correlated rG = 0.17. Environmental influences were not correlated. This is evidence for a common genetic mechanism between borderline personality scores and creativity which may reflect causal effects and shed light on mechanisms.

Distribution of self-reported borderline personality disorder traits symptoms in a large-scale clinical population

Introduction

Borderline Personality Disorder (BPD) traits play a crucial role in the prognosis of psychiatric disorders, as well as in assessing risks associated with negativity and impulsivity. However, there is a lack of data regarding the distribution characteristics of BPD traits and symptoms within clinical populations.

Methods

A total of 3015 participants (1321 males, 1694 females) were consecutively sampled from outpatients at the psychiatric and psycho-counseling clinics at the Shanghai Mental Health Center. BPD symptoms were assessed using a self-reported personality diagnostic questionnaire. Having BPD traits is defined as having five or more positive items in self-reported BPD characteristics. Participants were stratified into male and female groups, age groups, and diagnostic groups (schizophrenia, mood disorders, anxiety disorders). Exploratory factor analysis using principal components analysis was conducted. Three factors were identified: "F1: Affective Instability and Impulsivity", "F2: Interpersonal Unstable and Extreme Reactions", and "F3: Identity Disturbance".

Results

Among 3015 participants, 45.9% of the patients self-reported BPD traits. Comparing of male and female patients, there was no statistically significant difference in the occurrence rate of BPD traits (χ2 = 1.835, p=0.176). However, in terms of symptoms, female patients reported more symptoms than male patients. Female patients also exhibited more pronounced features on F2 compared to male patients (t =-1.972, p=0.049). There is a general decrease in BPD traits, symptoms, and factors with increasing age. Specifically, the proportion of positive BPD traits is approximately halved before the age of 30 and decreases to around one-third after the age of 30. BPD traits were most common in the Mood Disorders group at 55.7%, followed by the Anxiety Disorders group at 44.4%, and Schizophrenia group at 41.5% (χ2 = 38.084, p<0.001).

Discussion

Our study revealed the pervasive presence of BPD traits and symptoms among psychiatric outpatients, exhibiting distinctive distributions across gender, age, and diagnostic categories. These findings emphasize the significance of identifying and addressing BPD pathology in the clinical care of psychiatric outpatients.

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.

Examining the Construct Validity of Borderline Personality Traits Using Familial Aggregation and Other External Validators

Numerous studies have questioned the reliability and validity of borderline personality disorder's (BPD) categorical conceptualization. DSM-5 Section III's alternative trait-based model of BPD may better capture borderline pathology, but aspects of its validity should be further established. Thus, the authors examined whether a latent BPD factor derived from Section III traits exhibits (1) familial aggregation among siblings and (2) association with constructs related to borderline pathology. The authors also tested whether gender moderated associations. A total of 498 community-recruited adults completed the Personality Inventory for DSM-5, a behavioral assessment of risk-taking, and reported their history of childhood maltreatment, substance use, nonsuicidal self-injury, and suicidal ideation. Familial aggregation was assessed among 232 sibling pairs. Siblings' BPD scores were significantly correlated and most external validators were significantly associated with BPD, with the exception of risk-taking. Results did not vary by gender. Findings further support the construct validity of Section III's BPD trait profile.

Cannabis-Based Medicinal Products in the Management of Emotionally Unstable Personality Disorder (EUPD): A Narrative Review and Case Series

Emotionally unstable personality disorder (EUPD) is a common mental health disorder, manifesting with a range of chronic and debilitating symptoms, including impaired social functioning, unstable mood, and risky impulsive or self-injurious behaviour. Whilst the exact aetiology has not been fully elucidated, implicated factors seem to include genetic factors, environmental causes such as trauma, and neurotransmitter deficits. The literature suggests that impaired functioning of the endocannabinoid system in key brain regions responsible for emotional processing and stress response may underlie the manifestation of EUPD symptoms. The National Institute for Health and Care Excellence (NICE) 2009 guidelines state that “no drugs have established efficacy in treating or managing EUPD”, and yet, patients are commonly prescribed medication which includes antipsychotics, antidepressants, and mood stabilisers. Here we present a case series of seven participants diagnosed with EUPD and treated with cannabis-based medicinal products (CBMPs). Participants were given an initial assessment and followed up one month after CBMPs prescription. Improvement in symptoms was assessed by the completion of ratified rating scales by the participant and psychiatrist. Our results indicate that CBMPs were effective and well tolerated, as six participants reported a noticeable improvement in their symptoms and functioning. Although promising, further research is needed to ascertain the long-term tolerability, efficacy, and dosing strategy for CBMPs in EUPD.

Clinical differences between bipolar disorder and borderline personality disorder: a case report

The clinical difference between bipolar disorder and borderline personality disorder has always been a diagnostic challenge, especially with type II bipolar disorder and subthreshold symptoms, opening a diagnostic bias with the consequent repercussions of inappropriate treatment. Both pathologies are often misdiagnosed initially. The objective of this article is to emphasise the main clinical differences between the two pathologies. We present the case of a patient with a long history of psychiatric symptoms that started in childhood, with considerable functional impairment, who met the criteria for both disorders, pointing to comorbidity. During follow-up, she responded favourably to psychotropic drugs, pushing the diagnosis towards the bipolar spectrum, due to the notable improvement. However, comorbidity should not be neglected due to its high presentation.

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.

The role of sense of coherence and loneliness in borderline personality disorder traits: a longitudinal twin study

BACKGROUND

Borderline personality disorder (BPD) implies having problems with identity and relations with other people. However, not much is known about whether these indications of BPD are present in adolescence, i.e., before personality disorders usually are diagnosed. In this study, we examined the prediction of an aspect of identity (i.e., sense of coherence [SOC]) and social relations (i.e., perceived loneliness) throughout adolescence on BPD traits in young adulthood. In addition, we examined to what degree the predictive ability could be attributed to genetic and environmental factors. We also examined whether life events in adolescence were related to BPD traits.

METHODS

Three thousand three hundred ninety-one twins, consisting of seven national birth cohorts from Norway, participated in the study. SOC, loneliness and life events were measured three times throughout adolescence with self-report questionnaires, with 2 years in between measurements. BPD traits were measured at the end of adolescence around the age of 19 with a structured interview. Regression analyses were performed to examine the prediction of SOC, loneliness and life events on BPD traits. Cholesky decomposition models were then used to determine to what degree the associations were due to genetic and environmental influences.

RESULTS

The prediction of SOC and loneliness on BPD traits increased from R = .25 (when measured 6 years prior to the assessment of BPD traits) to R = .45 (when measured shortly before the assessment of BPD traits). In addition, negative life events considered dependent on a person's behavior were related to BPD traits. Negative independent and positive dependent life events did not contribute to the prediction of BPD traits. Cholesky decomposition models showed that SOC and loneliness were associated with BPD traits mainly due to shared genetic influences (i.e., the proportion due to genetic influences ranged from 71 to 86%). Adding negative dependent life events to the prediction of BPD traits did not change these percentages.

CONCLUSIONS

These findings indicate that the weaker SOC, the stronger feelings of loneliness, and the negative life events associated with BPD traits are mainly consequences of the genetic aspects of BPD traits, rather than having direct effects on levels of BPD symptoms.

Executive functioning in adults with borderline personality disorder and first-degree biological relatives

OBJECTIVES

Behavioural dysregulation is a heritable core symptom domain in borderline personality disorder (BPD) that is likely influenced by the integrity of executive functions (EFs). However, the extent to which familial risk for BPD confers decrement to EFs has yet to be comprehensively studied.

METHODS

In this family study, probands with BPD (n = 73), first-degree biological relatives (n = 65), and healthy controls without psychiatric diagnoses (n = 77) were assessed in abstraction, attentional vigilance, working memory, cognitive flexibility, interference resolution, planning, problem solving, and response inhibition.

RESULTS

In univariate analyses, probands demonstrated lower response inhibition than relatives. Comparatively, discriminant function analyses revealed that lower interference resolution and response inhibition jointly discriminated probands from relatives and controls, whereas a combination of less efficient problem solving and difficulty manipulating mental information discriminated probands and relatives from controls. Moreover, the subset of psychiatrically non-affected relatives demonstrated a pattern of resilience to psychiatric morbidity substantiated by stronger response inhibition and abstraction abilities despite less efficient problem solving.

CONCLUSIONS

Familial risk for BPD is represented predominantly by a pattern of problem-solving and working memory deficits. Resilience to a psychiatric disorder in non-affected relatives reflects both EF weaknesses and strengths, highlighting potential protective factors that should be considered in future neurocognitive research on BPD families.

Trauma and Outcomes of Mentalization-Based Therapy for Individuals With Borderline Personality Disorder

OBJECTIVE

Recent meta-analyses suggest that many patients with borderline personality disorder have a history of complex trauma. Although trauma is central in mentalization-based approaches to the understanding of borderline personality disorder, surprisingly little is known about the effects of trauma on outcomes of mentalization-based treatment (MBT). This article investigates the prevalence and impact of childhood trauma among patients with borderline personality disorder participating in a randomized controlled trial (RCT) comparing day hospital MBT (MBT-DH) and intensive outpatient MBT (MBT-IOP).

METHODS

All 114 patients from the original multicenter RCT in the Netherlands were included in this study. Childhood trauma was assessed at baseline (with the Childhood Trauma Questionnaire), and its impact on symptom severity, interpersonal functioning, and borderline pathology was investigated through multilevel modeling for 36 months after the start of treatment.

RESULTS

Childhood trauma was common among patients with borderline personality disorder referred to MBT, with more than 85% meeting cutoff criteria for substantial childhood trauma. Childhood trauma had little impact on outcomes of either MBT-DH or MBT-IOP in terms of improved borderline personality disorder features or interpersonal functioning. However, patients with substantial childhood trauma seemed to improve more rapidly with MBT-DH, as compared with MBT-IOP, in terms of symptom severity. In addition, patients with a history of emotional neglect showed more rapid changes in symptoms of borderline personality disorder with MBT-DH compared with MBT-IOP.

CONCLUSIONS

Findings are discussed in the context of a social communicative approach to borderline personality disorder, with a focus on the need to address trauma in MBT.

Integrating and differentiating personality and psychopathology: A psychodynamic perspective

Several strands of research converge to suggest that personality and psychopathology can be integrated in the form of a hierarchical model of individual differences. The notion that personality and psychopathology are intrinsically linked has a long tradition within psychodynamic approaches. In this article, we first summarize empirical evidence supporting two related key assumptions of psychodynamic approaches to personality and psychology: that a developmental, person-centered approach is needed to complement a static, disorder-centered approach in the conceptualization and treatment of psychopathology; and that personality and psychopathology are best conceptualized as dynamic attempts at adaptation. Research in each of these areas supports the notion that personality and psychopathology are difficult to separate and may be moderated by severity (i.e., general psychopathology) such that increasing levels of severity result in increased intrinsic coupling between the two. We then discuss these findings in the context of a newly emerging social-communicative approach to human development that suggests that personality and psychopathology are better conceptualized in terms of a disorder of social communication, and that the purported rigidity and stability typically attributed to them are largely explained by the stability of the environmental mechanisms that underpin them, rather than by stable intrapersonal traits. The implications of these new views for the future of the science of personality and psychopathology, and for treatment strategies, are discussed.

Nature and nurture? A review of the literature on childhood maltreatment and genetic factors in the pathogenesis of borderline personality disorder

BACKGROUND

Borderline Personality Disorder (BPD) is a psychiatric disorder associated with significant morbidity and mortality. However, the neurobiological alterations underlying the condition remain poorly understood. As a result, existing treatments remain inadequate. One of the main risk factors for the development of BPD is a history of childhood maltreatment. However, it is considered neither causative nor specific to the condition. Current theory is therefore increasingly moving toward a 'Gene x Environment' (GxE) model of the condition. The purpose of the current work was to conduct a systematic literature review, which comprehensively identifies all published molecular level GxE studies that have explored the role of specific genetic loci, in influencing the risk of BPD following exposure to childhood abuse or neglect.

METHODS

Four electronic databases were used to systematically search for molecular level GxE studies of any design, which focused on the development of BPD following exposure to childhood abuse or neglect, without language or date restrictions. Articles were screened independently by two reviewers and results were synthesized narratively.

RESULTS

A total of 473 articles were screened of which sixteen were selected for inclusion in our review. Implicated genes were categorised according to their influence on; Neurotransmitter Systems, Neurodevelopment and Neuroendocrine Systems.

CONCLUSIONS

The identified studies have produced several relevant and statistically significant results. Of particular note, is the repeated finding that genes involved in HPA axis regulation, may be altered by exposure to childhood maltreatment, influencing subsequent susceptibility to BPD. This is both biologically plausible and of potential clinical significance.

Clinical Differences between Bipolar Disorder and Borderline Personality Disorder: A Case Report

The clinical difference between bipolar disorder and borderline personality disorder has always been a diagnostic challenge, especially with type II bipolar disorder and subthreshold symptoms, opening a diagnostic bias with the consequent repercussions of inappropriate treatment. Both pathologies are often misdiagnosed initially. The objective of this article is to emphasise the main clinical differences between the two pathologies. We present the case of a patient with a long history of psychiatric symptoms that started in childhood, with considerable functional impairment, who met the criteria for both disorders, pointing to comorbidity. During follow-up, she responded favourably to psychotropic drugs, pushing the diagnosis towards the bipolar spectrum, due to the notable improvement. However, comorbidity should not be neglected due to its high presentation.

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.

Genetic and Environmental Causes of Individual Differences in Borderline Personality Disorder Features and Loneliness are Partially Shared

Loneliness is related to mental and somatic health outcomes, including borderline personality disorder. Here, we analyze the sources of variation that are responsible for the relationship between borderline personality features (including four dimensions, affective instability, identity disturbance, negative relationships, self-harm and a total score) and loneliness. Using genetically informative data from two large nonclinical samples of adult twin pairs from Australia and the Netherlands (N = 11,329), we estimate the phenotypic, genetic and environmental correlations between self-reported borderline personality features and loneliness. Individual differences in borderline personality and loneliness were best explained by additive genetic factors with heritability estimates h2 = 41% for the borderline personality total score and h2 = 36% for loneliness, with the remaining variation explained by environmental influences that were not shared by twins from the same pair. Genetic and environmental factors influencing borderline personality (total score and four subscales separately) were also partial causes of loneliness. The correlation between loneliness and the borderline personality total score was rph = .51. The genetic correlation was estimated at rg = .64 and the environmental correlation at re = .40. Our study suggests common etiological factors in loneliness and borderline personality features.

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.

The Mentalizing Approach to Psychopathology: State of the Art and Future Directions

Mentalizing is the capacity to understand others and oneself in terms of internal mental states. It is assumed to be underpinned by four dimensions: automatic–controlled, internally–externally focused, self–other, and cognitive–affective. Research suggests that mental disorders are associated with different imbalances in these dimensions. Addressing the quality of mentalizing as part of psychosocial treatments may benefit individuals with various mental disorders. We suggest that mentalizing is a helpful transtheoretical and transdiagnostic concept to explain vulnerability to psychopathology and its treatment. This review summarizes the mentalizing approach to psychopathology from a developmental socioecological evolutionary perspective. We then focus on the application of the mentalizing approach to personality disorders, and we review studies that have extended this approach to other types of psychopathology, including depression, anxiety, and eating disorders. We summarize core principles of mentalization-based treatments and preventive interventions and the evidence for their effectiveness. We conclude with recommendations for future research.

Antisocial and borderline personality disorders in the offspring of antenatally depressed mothers - a follow-up until mid-adulthood in the Northern Finland 1966 birth cohort

Background: Maternal depression is common during pregnancy, affecting 10-15% of mothers. In previous reports, the offspring of antenatally depressed mothers have had an elevated risk for antisocial, criminal and violent behaviour in adolescence, and for borderline personality features in childhood, but long-term outcomes are unknown.Aims: To study whether the adult offspring of antenatally depressed mothers have an elevated risk for antisocial (ASPD) or borderline personality disorder (BPD) when followed until mid-adulthood.Methods: In the general population-based Northern Finland 1966 Birth Cohort, mothers of 12,058 children were asked during mid-gestation if they felt depressed. Of the mothers, 14% reported being depressed. The offspring were followed for 49 years. The diagnoses of in- and outpatient-treated ASPD and BPD in the offspring were detected using the Finnish Care Register for Healthcare. Maternal antenatal smoking, newborn´s low birthweight or short gestational age, father's social class, and family type at birth were considered as confounding variables. Logistic regression analyses on the potential confounders were performed. Maternal postnatal depression and paternal ASPD information was not available.Results: In the male offspring of antenatally depressed mothers, the risk for ASPD was elevated (adjusted odds ratio 5.6; 95% confidence interval 1.8-17.8), but not in female offspring. The risk for BPD was not elevated in the offspring of antenatally depressed mothers in this study.Conclusions: The sons of antenatally depressed mothers had an increased risk for ASPD. Prevention and treatment of antenatal depression might present an opportunity to decrease the risk of antisocial personality in the offspring.

Differential Diagnosis of Bipolar II Disorder and Borderline Personality Disorder

PURPOSE OF REVIEW

Differentiating bipolar (BP) disorders (in particular BP II) from borderline personality disorder (BPD) is a common diagnostic dilemma. We sought to critically examine recent studies that considered clinical differences between BP II and BPD, which might advance their delineation.

RECENT FINDINGS

Recent studies focused on differentiating biological parameters-genetics, epigenetics, diurnal rhythms, structural and functional neuroimaging-with indicative differences not yet sufficient to guide diagnosis. Key differentiating factors include family history, developmental antecedents, illness course, phenomenological differences in mood states, personality style and relationship factors. Less differentiating factors include impulsivity, neuropsychological profiles, gender distribution, comorbidity and treatment response. This review details parameters offering differentiation of BP II from BPD and should assist in resolving a frequent diagnostic dilemma. Future studies should specifically examine the BP II subtype directly with BPD, which would aid in sharpening the distinction between the disorders.

Parenting and personality disorder: An overview and meta-synthesis of systematic reviews

BACKGROUND/OBJECTIVES

Maladaptive parenting (including childhood maltreatment, abuse and neglect) has been implicated in the scientific literature exploring the aetiology of personality disorder, particularly borderline personality disorder (BPD). Our primary objective was to summarise the evidence on the relationship between parenting and personality disorder, assisting clinical decision-makers to translate this research into clinical policy and practice.

METHODS

We conducted an overview of systematic reviews that assessed individuals with personality disorder pathology for experiences of maladaptive parenting, compared to psychiatric or healthy comparisons/controls, and the impact on psychopathological and relational outcomes. Systematic literature searches were conducted in Scopus, Web of Science, MEDLINE, PsycINFO, and by hand in August 2018. Methodological quality was assessed using the CASP systematic review checklist, and results were qualitatively synthesised. A pre-determined protocol was registered in Prospective Register of Systematic Reviews (PROSPERO 2019:CRD42018096177).

RESULTS

Of the 312 identified records, 293 abstracts were screened, 36 full-text articles were retrieved and eight systematic reviews met pre-determined criteria for qualitative synthesises. The majority of studies reported outcomes related to BPD (n = 7), and study design, methodology and quality varied. Within the eight systematic reviews there were 211 primary studies, of which 140 (66.35%) met eligibility criteria for inclusion in this overview. Eligible primary studies reported on 121,895 adult, child/adolescent and parent-offspring participants, with most studies focused on borderline personality pathology (n = 100, 71.43%). Study design and methodology also varied for these studies. Overall, five systematic reviews overwhelming found that maladaptive parenting was a psychosocial risk factor for the development of borderline personality pathology, and three studies found that borderline personality pathology was associated with maladaptive parenting, and negative offspring and parenting-offspring outcomes.

CONCLUSIONS

In light of these findings, we recommend greater emphasis on parenting in clinical practice and the development of parenting interventions for individuals with personality disorder. However, our understanding is limited by the heterogeneity and varying quality of the evidence, and as such, future research utilising more rigorous research methodology is needed.

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.

Psychiatric disorders among offspring of patients with Bipolar and Borderline Personality Disorder

Objective

As part of a larger study investigating biological risk factors for bipolar disorder (BD) and borderline personality disorder (BPD), we investigated the prevalence of psychiatric diagnoses presented by young BD or BPD offspring. With respect to the scarcity of studies interested in psychiatric disorders among BPD offspring, we have chosen to report these results despite the small sample size for a prevalence study.

Method

We recruited 21 BD and 22 BPD offspring and 23 control subjects. All subjects were assessed with a structured interview.

Results

Our main finding suggests that BPD offspring present a higher rate of psychiatric disorders compared to BD offspring. Attention deficit and hyperactivity disorder was the most prevalent disorder.

Conclusion

Our results contribute to the evidence that offspring of patients with BPD, are at high risk with regard to their mental health and deserve both more research and special attention at the clinical level.

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.

Current Knowledge on Gene-Environment Interactions in Personality Disorders: an Update

PURPOSE OF REVIEW

We review the existing literature on gene-environment interactions (G×E) and epigenetic changes primarily in borderline personality disorder (BPD) but also in antisocial, schizotypal, and avoidant personality disorders.

RECENT FINDINGS

Research supports that susceptibility genes to BPD or its underlying traits may be expressed under certain environmental conditions such as physical or childhood sexual abuse. Epigenetic modifications of neurodevelopment- and stress-related genes are suggested to underlie the relationship between early life adversary and borderline personality disorder. Only limited studies have investigated the role of gene-environment interactions and epigenetic changes in the genesis of antisocial, schizotypal, and avoidant personality disorders. Considering the lack of pharmacological treatment for most personality disorders, the emerging evidence on the critical role of G×E and epigenetic changes in the genesis of personality disorders could help develop more biologically oriented therapeutic approaches. Future studies should explore the potential of this new therapeutic dimension.

Personality characteristics below facets: A replication and meta-analysis of cross-rater agreement, rank-order stability, heritability, and utility of personality nuances

Mõttus and colleagues (2017) reported evidence that the unique variance in specific personality characteristics captured by single descriptive items often displayed trait-like properties of cross-rater agreement, rank-order stability, and heritability. They suggested that the personality hierarchy should be extended below facets to incorporate these specific characteristics, called personality nuances. The present study attempted to replicate these findings, employing data from 6,287 individuals from 6 countries (Australia, Canada, Czech Republic, Denmark, Japan, and United States). The same personality measure-240-item Revised NEO Personality Inventory-and statistical procedures were used. The present findings closely replicated the original results. When the original and current results were meta-analyzed, the unique variance of nearly all items (i.e., items' scores residualized for all broader personality traits) showed statistically significant cross-rater agreement (median = .12) and rank-order stability over an average of 12 years (median = .24), and the unique variance of the majority of items had a significant heritable component (median = .14). These 3 item properties were intercorrelated, suggesting that items systematically differed in the degree of reflecting valid unique variance. Also, associations of items' unique variance with age, gender, and body mass index (BMI) replicated across samples and tracked with the original findings. Moreover, associations between item residuals and BMI obtained from one group of people allowed for a significant incremental prediction of BMI in an independent sample. Overall, these findings reinforce the hypotheses that nuances constitute the building blocks of the personality trait hierarchy, their properties are robust and they can be useful. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Borderline personality disorder is equally trait-like and state-like over ten years in adult psychiatric patients

Borderline personality disorder (PD) has historically been cast as an unabating condition. Longitudinal data, however, support a more variable time course marked by remission and relapse. In the present study, we tested the possibility that borderline PD has both stable (i.e., consistently present across time and situation, as modern diagnostic systems stipulate) and dynamic (i.e., episodic and situational) elements. Participants were 668 patients from the Collaborative Longitudinal Personality Disorders Study who were administered semistructured diagnostic interviews 5 times over a decade. Trait-state-occasion modeling dissected borderline pathology into time-invariant (i.e., trait) and time-varying (i.e., state) components. Contradicting traditional views of PD intransigence, less than half of borderline PD variability (approximately 45%) was time-invariant (i.e., perfectly stable) over the study timeframe. Furthermore, we found that the time-invariant component of borderline pathology, which we termed borderline proneness, was very closely related (r = .81) to a previously validated Five Factor Model trait composite of borderline features. Moreover, the trait versus state components showed a clear pattern of discriminant validity in relation to several putative causal agents for borderline PD (i.e., environmental pathogens, temperament dimensions). We conclude that borderline pathology contains a stable core and sizable situational components, and that both elements relate systematically to normative personality dimensions and known risk factors. These findings have key implications for etiological research, prognosis, and treatment for borderline PD. (PsycINFO Database Record

Past, present, and future of genetic research in borderline personality disorder

Borderline Personality Disorder (BPD) is a major mental illness with a lifetime prevalence of approximately 1-3%, characterized by a persistent pattern of instability in relationships, mood, impulse regulation, and sense of self. This results in impulsive self-damaging behavior, high suicide rates, and severe functional impairment. BPD has a complex, multifactorial etiology, resulting from an interaction among genetic and environmental substrates, and has moderate to high heritability based on twin and family studies. However, our understanding of the genetic architecture of BPD is very limited. This is a critical obstacle since genetics can pave the way for identifying new treatment targets and developing preventive and disease-modifying pharmacological treatments which are currently lacking. We review genetic studies in BPD, with a focus on limitations and challenges and future directions. Genetic research in BPD is still in its very early stages compared to other major psychiatric disorders. Most early genetic studies in BPD were non-replicated association studies in small samples, focused on single candidate genes. More recently, there has been one genome-wide linkage study and a genome-wide association study (GWAS) of subclinical BPD traits and a first GWAS in a relatively modest sample of patients fulfilling full diagnostic criteria for the disorder. Although there are adequate animal models for some of the core dimensions of BPD, there is a lack of translational research including data from animal models in BPD. Research in more pioneering fields, such as imaging genetics, deep sequencing and epigenetics, holds promise for elucidating the pathophysiology of BPD and identifying new treatment targets.

Calling for a Unified Redefinition of "Borderlineness": Commentary on Gunderson et al

This commentary critically evaluates the usefulness of the standards employed by Gunderson et al. (2018) for theory evaluation and comparison and calls into question their adequacy, based both on the lack of scientific evidence supporting the assertions these standards imply and on the availability of alternative standard for theory evaluation and comparison. In so doing, the commentary calls for a redefinition of "borderlineness" as well as the use of standard criteria for theory evaluation and comparison.

Genetic analysis of impulsive personality traits: Examination of a priori candidates and genome-wide variation

Impulsive personality traits are heritable risk factors and putative endophenotypes for addiction and other psychiatric disorders involving disinhibition. This study examined the genetic basis of impulsive personality traits, defined as scores on the Barratt Impulsiveness Scale (BIS-11) and the UPPS-P Impulsive Behavior Scale (UPPS-P). In 983 healthy young adults of European ancestry, the study examined genetic variation in relation to a combined phenotype of seven subscales based on high phenotypic intercorrelations. The study first tested 14 a priori loci that have previously been associated impulsive personality traits or closely related constructs. Second, the study included an exploratory genome-wide scan (i.e., GWAS), acknowledging that only relatively large effects would be detectable in a sample size of ~ 1000. A priori SNP analyses revealed a significant association between the combined impulsivity phenotype and two SNPs within the 5-HT2a receptor gene (HTR2A; rs6313 and rs6311). Follow-up analyses suggested that the effects were specific to the Motor and Non-planning subscales on the BIS-11, and also that the two loci were in linkage disequilibrium. The GWAS yielded no statistically significant findings. This study further implicates loci within HTR2A with certain forms of self-reported impulsivity and identifies candidates for future investigation from the genome-wide analyses.

Seven-Year Course of Borderline Personality Disorder Features: Borderline Pathology Is as Unstable as Depression during Adolescence

Borderline personality disorder (PD) historically is construed as an unremitting condition with poor prognosis. The present study takes a new approach to examining stability and change in borderline PD by explaining symptom expression in terms of an unchanging foundation-termed borderline proneness-on one hand, and transitory influences on the other. We monitored borderline PD symptoms annually in a large sample of high-risk adolescent girls (N = 2,450) from ages 14 to 20. Trait-state-occasion modeling revealed that just over half (52-57%) of borderline PD symptom variation was attributable to fixed borderline proneness, whereas the remainder was subject to change across yearly measurement occasions. This degree of stability was no larger than the corresponding estimate for depression, a condition known for its variable course. Our results indicate that, contrary to its reputation, borderline pathology is not set in stone, and it fluctuates in response to situational influences.

Genetic and environmental influences on the codevelopment among borderline personality disorder traits, major depression symptoms, and substance use disorder symptoms from adolescence to young adulthood

Although borderline personality disorder (BPD) traits decline from adolescence to adulthood, comorbid psychopathology such as symptoms of major depressive disorder (MDD), alcohol use disorder (AUD), and drug use disorders (DUDs) likely disrupt this normative decline. Using a longitudinal sample of female twins (N = 1,763), we examined if levels of BPD traits were correlated with changes in MDD, AUD, and DUD symptoms from ages 14 to 24. A parallel process biometric latent growth model examined the contributions of genetic and environmental factors to the relationships between developmental components of these phenotypes. Higher BPD trait levels predicted a greater rate of increase in AUD and DUD symptoms, and higher AUD and DUD symptoms predicted a slower rate of decline of BPD traits from ages 14 to 24. Common genetic influences accounted for the associations between BPD traits and each disorder, as well as the interrelationships of AUD and DUD symptoms. Both genetic and nonshared environmental influences accounted for the correlated levels between BPD traits and MDD symptoms, but solely environmental influences accounted for the correlated changes between the two over time. Results indicate that higher levels of BPD traits may contribute to an earlier onset and faster escalation of AUD and DUD symptoms, and substance use problems slow the normative decline in BPD traits. Overall, our data suggests that primarily genetic influences contribute to the comorbidity between BPD features and substance use disorder symptoms. We discuss our data in the context of two major theories of developmental psychopathology and comorbidity.

Children's Emotion Regulation Difficulties Mediate the Association Between Maternal Borderline and Antisocial Symptoms and Youth Behavior Problems Over 1 Year

Borderline personality disorder (BPD) and antisocial personality disorder (ASPD) are among the most debilitating psychiatric conditions. Behaviors and traits associated with these disorders can have profound influences on those surrounding the affected individual. Accordingly, researchers have begun to examine effects of these symptoms on parent-child relationships. Theoretical and empirical work suggests that one mechanism linking maternal psychopathology to child symptoms is familial transmission of emotion dysregulation. The authors examined children's emotion regulation difficulties as a mediator between maternal BPD/ASPD symptoms and child behavior problems 1 year later. Analyses revealed that a composite of maternal BPD/ASPD symptoms had a direct effect on child internalizing, externalizing, and total symptoms. Associations between maternal BPD/ASPD symptoms and youth problems were partially mediated by child emotion regulation difficulties, even with maternal depression and other relevant covariates included in the models. Thus, maternal BPD/ASPD symptoms and child emotion regulation difficulties represent potential targets for prevention of psychopathology among youth.

What we have changed our minds about: Part 1. Borderline personality disorder as a limitation of resilience

This paper sets out a recent transition in our thinking in relation to psychopathology associated with personality disorder, in an approach that integrates our thinking about attachment, mentalizing (understanding ourselves and others in terms of intentional mental states) and epistemic trust (openness to the reception of social communication that is personally relevant and of generalizable significance) with recent findings on the structure of both adult and child psychopathology and resilience. In this paper - the first of two parts - we review evidence suggesting that a general psychopathology or p factor underlies vulnerability for psychopathology. We link this p factor to a lack of resilience using Kalisch and colleagues' positive appraisal style theory of resilience (PASTOR). We argue that vulnerability for (severe) psychopathology results from impairments in three central mechanisms underlying resilience - positive situation classification, retrospective reappraisal of threat, and inhibition of retraumatizing triggers - which in turn result from a lack of flexibility in terms of social communicative processes. We suggest that, from this perspective, personality disorders, and borderline personality disorder (BPD) in particular, can be considered to be the prototype of disorders characterized by a lack of resilience. Part 2 proposes an evolutionary developmental psychopathology account linking this inflexibility in social communication to problems with the development of epistemic trust - that is, an evolutionary pre-wired social communication system that normally facilitates resilience through salutogenesis, that is, the capacity to learn and derive benefit from the (social) environment.

Parents' childhood experiences of bonding and parental psychopathology predict borderline personality disorder during adolescence in offspring

Previous studies on borderline personality disorder (BPD) development suggest a transgenerational transmission of parent-child relationship quality, which may also be influenced by parents' mental health status. The aim of this study was twofold. First, we aimed to investigate the transgenerational effect of parental bonding experiences on the development of BPD in their offspring. Second, we examined the association between parents' mental health status and BPD in offspring. Ninety-one female adolescent psychiatric inpatients along with 87 mothers and 59 fathers were enrolled in the study. Adolescent BPD was assessed with the Structured Clinical Interview for DSM-IV-II, parental bonding with the Parental Bonding Instrument, and parents´ psychiatric symptoms with the Patient Health Questionnaire. We found that low parental care produced a transgenerational effect from mother to BPD in offspring. Further, significant associations were found between paternal psychiatric symptoms and adolescent BPD. High paternal stress levels mediated the association between maternal affect reported by fathers and BPD in daughters. There is evidence of a transgenerational effect of parental bonding specifically for female adolescents with BPD, compared with other clinical control subjects. Our findings highlight the importance of including both parents in future research and in early clinical treatment in adolescents with BPD.

Borderline Personality Disorder Symptoms in College Students: The Complex Interplay between Alexithymia, Emotional Dysregulation and Rumination

Both Emotional Cascade Theory and Linehan’s Biosocial Theory suggest dysregulated behaviors associated with Borderline Personality Disorder (BPD) emerge, in part, because of cycles of rumination, poor emotional recognition and poor emotion regulation. In this study we examined relationships between rumination, alexithymia, and emotion regulation in predicting dysregulated behaviors associated with BPD (e.g. self-harm, substance use, aggression), and explored both indirect and moderating effects among these variables. The sample comprised 2261 college students who completed self-report measures of the aforementioned constructs. BPD symptoms, stress, family psychological illness, and alexithymia exerted direct effects on behaviors. Symptoms had an indirect effect on behaviors through rumination, alexithymia and emotional dysregulation. In addition, the relationship between symptoms and dysregulated behaviors was conditional on level of rumination and alexithymia. Implications for early identification and treatment of BPD and related behaviors in college settings are discussed.

Genetic and Neuroimaging Features of Personality Disorders: State of the Art

Personality disorders often act as a common denominator for many psychiatric problems, and studies on personality disorders contribute to the etiopathology, diagnosis, and treatment of many mental disorders. In recent years, increasing evidence from various studies has shown distinctive features of personality disorders, and that from genetic and neuroimaging studies has been especially valuable. Genetic studies primarily target the genes encoding neurotransmitters and enzymes in the serotoninergic and dopaminergic systems, and neuroimaging studies mainly focus on the frontal and temporal lobes as well as the limbic-paralimbic system in patients with personality disorders. Although some studies have suffered due to unclear diagnoses of personality disorders and some have included few patients for a given personality disorder, great opportunities remain for investigators to launch new ideas and technologies in the field.

Differentiating the bipolar disorders from borderline personality disorder

OBJECTIVE

To identify features differentiating bipolar disorder (BP) from borderline personality disorder (BPD) and with each condition variably defined.

METHOD

Participants were assigned a BP or BPD diagnosis on the basis of DSM criteria and, separately, by clinical judgment, and undertook a diagnostic interview and completed self-report measures.

RESULTS

Predictors of BPD status varied according to diagnostic decisions, but with the most consistent items being childhood sexual abuse, childhood depersonalization, personality variables relating to relationship difficulties and sensitivity to criticism, and the absence of any BP family history. Across diagnostic groups, personality measure items alone predicted diagnostic allocation with an accuracy of 81-84%, the refined study variables other than hypo/manic features improved the classification rates to 88%, and when the presence or absence of hypo/manic features was added, classification rates increased to 92-95%.

CONCLUSION

Study findings indicate that BPD can be differentiated from BP with a high degree of accuracy.

A common NTRK2 variant is associated with emotional arousal and brain white-matter integrity in healthy young subjects

Dysregulation of emotional arousal is observed in many psychiatric diseases such as schizophrenia, mood and anxiety disorders. The neurotrophic tyrosine kinase receptor type 2 gene (NTRK2) has been associated with these disorders. Here we investigated the relation between genetic variability of NTRK2 and emotional arousal in healthy young subjects in two independent samples (n1=1171; n2=707). In addition, diffusion tensor imaging (DTI) data in a subgroup of 342 participants were used to identify NTRK2-related white-matter structure differences. After correction for multiple testing, we identified a NTRK2 single nucleotide polymorphism associated with emotional arousal in both samples (n1: Pnominal=0.0003, Pcorrected=0.048; n2: Pnominal=0.0141, Pcorrected=0.036). DTI revealed significant, whole-brain corrected correlations between emotional arousal and brain white-matter mean diffusivity (MD), as well as significant, whole-brain corrected NTRK2 genotype-related differences in MD (PFWE<0.05). Our study demonstrates that genetic variability of NTRK2, a susceptibility gene for psychiatric disorders, is related to emotional arousal and-independently-to brain white-matter properties in healthy individuals.

Practitioner Review: Borderline personality disorder in adolescence--recent conceptualization, intervention, and implications for clinical practice

BACKGROUND

The past decade has seen an unprecedented increase in research activity on personality disorders (PDs) in adolescents. The increase in research activity, in addition to major nosological systems legitimizing the diagnosis of borderline personality disorder (BPD) in adolescents, highlights the need to communicate new research on adolescent personality problems to practitioners.

SCOPE

In this review, we provide up-to-date information on the phenomenology, prevalence, associated clinical problems, etiology, and intervention for BPD in adolescents. Our aim was to provide a clinically useful practitioner review and to dispel long-held myths about the validity, diagnostic utility, and treatability of PDs in adolescents.

FINDINGS AND CONCLUSION

Alongside providing up-to-date information on the phenomenology, prevalence, and etiology, we also report on associated clinical problems and interventions for adolescent BPD. It is only through early active assessment and identification of youngsters with these problems that a lifetime of personal suffering and health system burden can be reduced or altogether avoided. A variety of evidence-based approaches are now available to treat BPD and related clinical problems in young people. Future research should focus on establishing optimal precision in the diagnostic processes in different treatment settings.

Possible role of a dysregulation of the endogenous opioid system in antisocial personality disorder

Around half the inmates in prison institutions have antisocial personality disorder (ASPD). A recent theory has proposed that a dysfunction of the endogenous opioid system (EOS) underlies the neurobiology of borderline personality disorder (BPD). In the present theoretical paper, based on a comprehensive database and hand search of the relevant literature, this hypothesis is extended to ASPD, which may be the predominant expression of EOS dysfunction in men, while the same pathology underlies BPD in women. According to evidence from human and animal studies, the problematic behaviours of persons with antisocial, callous, or psychopathic traits may be seen as desperate, unconscious attempts to stimulate their deficient EOS, which plays a key role in brain reward circuits. If the needs of this system are not being met, the affected persons experience dysphoric mood, discomfort, or irritability, and strive to increase binding of endogenous opioids to receptors by using the rewarding effects of aggression by exertion of physical or manipulative power on others, by abusing alcohol or substances that have the reward system as target, by creating an "endorphin rush" by self-harm, by increasing the frequency of their sexual contacts, or by impulsive actions and sensation seeking. Symptoms associated with ASPD can be treated with opioid antagonists like naltrexone, naloxone, or nalmefene.

ESCAP Expert Article: borderline personality disorder in adolescence: an expert research review with implications for clinical practice

Borderline personality disorder (BPD) has onset in adolescence, but is typically first diagnosed in young adulthood. This paper provides a narrative review of the current evidence on diagnosis, comorbidity, phenomenology and treatment of BPD in adolescence. Instruments available for diagnosis are reviewed and their strengths and limitations discussed. Having confirmed the robustness of the diagnosis and the potential for its reliable clinical assessment, we then explore current understandings of the mechanisms of the disorder and focus on neurobiological underpinnings and research on psychological mechanisms. Findings are accumulating to suggest that adolescent BPD has an underpinning biology that is similar in some ways to adult BPD but differs in some critical features. Evidence for interventions focuses on psychological therapies. Several encouraging research studies suggest that early effective treatment is possible. Treatment development has just begun, and while adolescent-specific interventions are still in the process of evolution, most existing therapies represent adaptations of adult models to this developmental phase. There is also a significant opportunity for prevention, albeit there are few data to date to support such initiatives. This review emphasizes that there can be no justification for failing to make an early diagnosis of this enduring and pervasive problem.

Distinguishing bipolar disorder from borderline personality disorder: A study of current clinical practice

BACKGROUND

Diagnosing mental illness is a central role for psychiatrists. Correct diagnosis informs both treatment and prognosis, and facilitates accurate communication. We sought to explore how psychiatrists distinguished two common psychiatric diagnoses: bipolar disorder (BD) and borderline personality disorder (BPD).

METHODS

We conducted a qualitative study of psychiatrists to explore their practical experience. We then sought to validate these results by conducting a questionnaire study testing the theoretical knowledge and practical experience of a large number of UK psychiatrists. Finally we studied the assessment process in NHS psychiatric teams by analysing GP letters, assessments by psychiatrists, and assessment letters.

RESULTS

There was broad agreement in both the qualitative and questionnaire studies that the two diagnoses can be difficult to distinguish. The majority of psychiatrists demonstrated in survey responses a comprehensive understanding DSM-IV-TR criteria although many felt that these criteria did not necessarily assist diagnostic differentiation. This scepticism about diagnostic criteria appeared to strongly influence clinical practice in the sample of clinicians we observed. In only a minority of assessments were symptoms of mania or BPD sufficiently assessed to establish the presence or absence of each diagnosis.

CONCLUSION

Clinical diagnostic practice was not adequate to differentiate reliably BD and BPD. The absence of reliable diagnostic practice has widespread implications for patient care, service provision and the reliability of clinical case registries.

A longitudinal twin study of borderline and antisocial personality disorder traits in early to middle adulthood

BACKGROUND

Antisocial personality disorder (ASPD) and borderline personality disorder (BPD) share genetic and environmental risk factors. Little is known about the temporal stability of these etiological factors in adulthood.

METHOD

DSM-IV criteria for ASPD and BPD were assessed using structured interviews in 2282 Norwegian twins in early adulthood and again approximately 10 years later. Longitudinal biometric models were used to analyze the number of endorsed criteria.

RESULTS

The mean criterion count for ASPD and BPD decreased 40% and 28%, respectively, from early to middle adulthood. Rank-order stability was 0.58 for ASPD and 0.45 for BPD. The best-fitting longitudinal twin model included only genetic and individual-specific environmental factors. Genetic effects, both those shared by ASPD and BPD, and those specific to each disorder remained completely stable. The unique environmental effects, however, changed substantially, with a correlation across time of 0.19 for the shared effects, and 0.39 and 0.15, respectively, for those specific to ASPD and BPD. Genetic effects accounted for 71% and 72% of the stability over time for ASPD and BPD, respectively. The genetic and environmental correlations between ASPD and BPD were 0.73, and 0.43, respectively, at both time points.

CONCLUSION

ASPD and BPD traits were moderately stable from early to middle adulthood, mostly due to genetic risk factors which did not change over the 10-year assessment period. Environmental risk factors were mostly transient, and appear to be the main source of phenotypic change. Genetic liability factors were, to a large extent, shared by ASPD and BPD.

Epistemic Petrification and the Restoration of Epistemic Trust: A New Conceptualization of Borderline Personality Disorder and Its Psychosocial Treatment

A new developmental model of borderline personality disorder (BPD) and its treatment is advanced based on evolutionary considerations concerning the role of attachment, mentalizing, and epistemic trust in the development of psychopathology. We propose that vulnerability to psychopathology in general is related to impairments in epistemic trust, leading to disruptions in the process of salutogenesis, the positive effects associated with the capacity to benefit from the social environment. BPD is perhaps the disorder par excellence that illustrates this view. We argue that this conceptualization makes sense of the presence of both marked rigidity and instability in BPD, and has far-reaching implications for intervention.