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

Need of support for significant others to persons with borderline personality disorder-A Swedish focus group study

BACKGROUND

Being a significant other (SO) to a person with borderline personality disorder (BPD) affect their health. High incidence of substance use disorder, post-traumatic stress disorder, stress, fear, anxiety, depression, family burden and grief are common. Some specific therapies for BPD, have included support to SOs, however resources are scarce and to participate in the support it assumes that the person with BPD is included in these therapies. Although the SO support has been shown to be helpful, they all have a similar structure, and only a small exclusive group of SOs have access to the support.

AIM

The aim was to describe experiences and need of support for significant others to persons with borderline personality disorder from the perspective of themselves and of health care workers.

METHODS

Data was collected via two focus groups. One with five SOs to persons with BPD, one with five health care workers. Two interview sessions in each group were conducted and data were analysed with qualitative content analysis. The study was approved by the research ethics committee of Lund (2016-1026).

RESULTS

The results revealed four themes; not being seen by health care professionals creates hopelessness, being seen by healthcare professionals creates trust, experience of support - helpful or shameful and the step from loosely structured support to a structured support group. Both groups expressed a need for further support as a complement to already existing support.

CONCLUSIONS

The need of support is extensive. The results suggest a professional coordinator intended for SOs and peer support groups not linked to a particular psychiatric treatment yet offering support in a structured way. Further studies examining these complements to existing support, is therefore recommended.

The Co-occurrence of Personality Disorders and Substance Use Disorders

PURPOSE OF REVIEW

Despite significant negative outcomes, the co-occurrence of personality disorders (PDs) and substance use disorders (SUDs) continues to be underrecognized, and the mechanisms contributing to this co-occurrence remain unclear. This review summarizes recent work on PD-SUD co-occurrence, with a focus on borderline and antisocial PDs, general substance use patterns among those with PDs, and the association of personality traits with SUDs.

RECENT FINDINGS

The prevalence of co-occurring PD-SUD is generally high, with estimates ranging depending on the type of PD and SUD, the population assessed, and the sampling methods and measures used. Current theoretical explanations for co-occurrence include shared etiology and predisposition models, with research highlighting the importance of transactional processes. Potential underlying mechanisms include personality traits and transdiagnostic characteristics. Recent research has increased focus on substances besides alcohol, dimensional models of personality pathology, and transactional explanations of co-occurrence, but more research is needed to disentangle the nuanced PD-SUD relationship.

Neurocognition of females with substance use disorder and comorbid personality disorder: Divergence in subjective and objective cognition

At least one in four patients with substance use disorder (SUD) meet criteria for personality disorder and overlapping neurocognitive deficits may reflect shared neurobiological mechanisms. We studied neurocognition in females attending residential SUD treatment by comparing SUD with (n = 20) or without (n = 30) comorbid personality disorder. Neuropsychological testing included working memory, inhibition, shifting, verbal fluency, design fluency, psychomotor speed, immediate and delayed verbal memory, processing speed, premorbid functioning, cognitive screening, and self-reported executive function. As expected, whole-sample deficits included working memory (d = -.91), self-reported executive function (d = -.87), processing speed (d = -.40), delayed verbal memory recall (d = -.39), premorbid functioning (d = -.51), and cognitive screening performance (d = -.61). Importantly, the comorbid personality disorder group showed greater self-reported executive dysfunction (d = -.67) and poorer shifting performance (d = -.65). However, they also evidenced better working memory (d = .84), immediate (d = .95) and delayed (d = .83) verbal memory, premorbid functioning (d = .90), and cognitive screening performance (d = .77). Overall executive dysfunction deficits were concordant with those observed in previous SUD studies. Surprisingly, comorbid personality disorder was associated with a pattern indicating poorer subjective (self-report) but better objective performance on a number of tasks, apart from shifting deficits that may relate to emotion dysregulation. Subjective emotional dysfunction may influence the cognitive deficits observed in the personality disorder group.

Improving treatment outcomes for borderline personality disorder: what can we learn from biomarker studies of psychotherapy?

PURPOSE OF REVIEW

Borderline personality disorder (BPD) is a severe and common psychiatric disorder and though evidence-based psychotherapies are effective, rates of treatment nonresponse are as high as 50%. Treatment studies may benefit from interdisciplinary approaches from neuroscience and genetics research that could generate novel insights into treatment mechanisms and tailoring interventions to the individual.

RECENT FINDINGS

We provide a timely update to the small but growing body of literature investigating neurobiological and epigenetic changes and using biomarkers to predict outcomes from evidence-based psychotherapies for BPD. Using a rapid review methodology, we identified eight new studies, updating our earlier 2018 systematic review. Across all studies, neuroimaging ( n  = 18) and genetics studies ( n  = 4) provide data from 735 participants diagnosed with BPD (mean sample size across studies = 33.4, range 2-115).

SUMMARY

We report further evidence for psychotherapy-related alterations of neural activation and connectivity in regions and networks relating to executive control, emotion regulation, and self/interpersonal functioning in BPD. Emerging evidence also shows epigenetic changes following treatment. Future large-scale multisite studies may help to delineate multilevel treatment targets to inform intervention design, selection, and monitoring for the individual patient via integration of knowledge generated through clinical, neuroscience, and genetics research.

An exploratory study of functional brain activation underlying response inhibition in major depressive disorder and borderline personality disorder

Cognitive control is associated with impulsive and harmful behaviours, such as substance abuse and suicidal behaviours, as well as major depressive disorder (MDD) and borderline personality disorder (BPD). The association between MDD and BPD is partially explained by shared pathological personality traits, which may be underpinned by aspects of cognitive control, such as response inhibition. The neural basis of response inhibition in MDD and BPD is not fully understood and could illuminate factors that differentiate between the disorders and that underlie individual differences in cross-cutting pathological traits. In this study, we sought to explore the neural correlates of response inhibition in MDD and BPD, as well as the pathological personality trait domains contained in the ICD-11 personality disorder model. We measured functional brain activity underlying response inhibition on a Go/No-Go task using functional magnetic resonance imaging in 55 female participants recruited into three groups: MDD without comorbid BPD (n = 16), MDD and comorbid BPD (n = 18), and controls with neither disorder (n = 21). Whereas response-inhibition-related activation was observed bilaterally in frontoparietal cognitive control regions across groups, there were no group differences in activation or significant associations between activation in regions-of-interest and pathological personality traits. The findings highlight potential shared neurobiological substrates across diagnoses and suggest that the associations between individual differences in neural activation and pathological personality traits may be small in magnitude. Sufficiently powered studies are needed to elucidate the associations between the functional neural correlates of response inhibition and pathological personality trait domains.

The Development of Criterion A Personality Pathology: The Relevance of Childhood Social Functioning for Young Adult Daily Self-Functioning

The DSM-5 alternative model for the diagnosis of personality disorders (AMPD) states that self- and interpersonal (Criterion A) dysfunction is necessary to diagnose a personality disorder, qualified by maladaptive personality trait profiles (Criterion B). This study tested whether childhood maladaptive personality traits predict interpersonal dysfunction during adolescence, which further predicts lower self-functioning in young adulthood. A mixed clinical-community sample of 157 10-year-olds participated for ten years. Social problems and personality traits were rated by parents at age 10 and 12. At age 20, young adults completed 14 daily ratings of self-functioning. Traits of emotional instability and disagreeableness predicted social problems and self-problems. Social problems predicted worse self-functioning in adulthood. An indirect effect of childhood narcissistic traits on higher levels of self-functioning via lower levels of social problems was found. Results are discussed in terms of their contribution to our understanding of the AMPD from a developmental perspective.

The Pathogenesis of Borderline Personality Disorder: Evolution of Evidence and Treatment Implications for Two Prominent Models

Since Stern first started his work in 1938, the field has recognized several empirically supported models of the etiology of borderline personality disorder (BPD). Two such models are the Tripartite Model of the Development of BPD and the Biosocial Development Model of BPD. The Tripartite Model of the Development of BPD suggests that it is a combination of a hyperbolic temperament, traumatic childhood experiences, and an event or series of events that trigger the onset of BPD. Whereas the Biosocial Development Model of BPD elaborates on the work of Linehan's Biosocial Theory. This model suggests a combination of an emotionally vulnerable temperament and an invalidating environment cause BPD. Over 70 years of research support these models. This article covers a detailed description of each of these models, the decades of research supporting these models, similarities, differences, treatment implications, the latest research, and future directions.

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.

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

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

Theory of Mind in Borderline Personality Disorder: A Possible Endophenotypic Factor?

The purpose of this study is to examine whether theory of mind (ToM) is an endophenotypic marker of borderline personality disorder (BPD), thus constituting an etiopathogenic factor of the disease. This would suggest familial vulnerability to BPD. This was a case-control study involving 146 individuals with 57 BPD patients, 32 first-degree relatives, and 57 controls (median age of BPD and control = 33.4 years; relatives = 52.9 years; BPD females and controls = 91.2%; female relatives = 62.5%). All the participants completed the Spanish version of the Movie for the Assessment of Social Cognition test to evaluate the ToM subclassification: interpretation of emotions, thoughts and intentions. BPD patients and their healthy first-degree relatives exhibited significant deficits in the correct interpretation of emotions and intentions compared to healthy controls. Both patients with BPD and their healthy first-degree relatives exhibited significant deficits in ToM, which suggests that it may be an etiopathogenic factor of BPD, and ToM (interpretation of emotions, thoughts and intentions) is a possible endophenotypic marker of BPD, suggesting a genetic predisposition to the disorder. Therefore, ToM could be considered as an indicator for the early detection of the disorder of and intervention for BPD.

Attentional salience and the neural substrates of response inhibition in borderline personality disorder

BACKGROUND

Impulsivity is a central symptom of borderline personality disorder (BPD) and its neural basis may be instantiated in a frontoparietal network involved in response inhibition. However, research has yet to determine whether neural activation differences in BPD associated with response inhibition are attributed to attentional saliency, which is subserved by a partially overlapping network of brain regions.

METHODS

Patients with BPD (n = 45) and 29 healthy controls (HCs; n = 29) underwent functional magnetic resonance imaging while completing a novel go/no-go task with infrequent odd-ball trials to control for attentional saliency. Contrasts reflecting a combination of response inhibition and attentional saliency (no-go > go), saliency processing alone (oddball > go), and response inhibition controlling for attentional saliency (no-go > oddball) were compared between BPD and HC.

RESULTS

Compared to HC, BPD showed less activation in the combined no-go > go contrast in the right posterior inferior and middle-frontal gyri, and less activation for oddball > go in left-hemispheric inferior frontal junction, frontal pole, superior parietal lobe, and supramarginal gyri. Crucially, BPD and HC showed no activation differences for the no-go > oddball contrast. In BPD, higher vlPFC activation for no-go > go was correlated with greater self-rated BPD symptoms, whereas lower vlPFC activation for oddball > go was associated with greater self-rated attentional impulsivity.

CONCLUSIONS

Patients with BPD show frontoparietal disruptions related to the combination of response inhibition and attentional saliency or saliency alone, but no specific response inhibition neural activation difference when attentional saliency is controlled. The findings suggest a neural dysfunction in BPD underlying attention to salient or infrequent stimuli, which is supported by a negative correlation with self-rated impulsiveness.

Facial Emotion Perception in Families Affected With Borderline Personality Disorder

Emotion perception biases may precipitate problematic interpersonal interactions in families affected with borderline personality disorder (BPD) and lead to conflictual relationships. In the present study, the authors investigated the familial aggregation of facial emotion recognition biases for neutral, happy, sad, fearful, and angry expressions in probands with BPD (n = 89), first-degree biological relatives (n = 67), and healthy controls (n = 87). Relatives showed comparable accuracy and response times to controls in recognizing negative emotions in aggregate and most discrete emotions. For sad expressions, both probands and relatives displayed slower response latencies, and they were more likely than controls to perceive sad expressions as fearful. Nonpsychiatrically affected relatives were slower than controls in responding to negative emotional expressions in aggregate, and fearful and sad facial expressions more specifically. These findings uncover potential biases in perceiving sad and fearful facial expressions that may be transmitted in families affected with BPD.