Out of the frying pan, into the fire: mixed affective reactions to social proximity in borderline and avoidant personality disorders in daily life

Agency in avoidant personality disorder: a narrative review

Objectives

Avoidant personality disorder (AvPD) is a highly prevalent personality disorder, especially in clinical settings, yet scarcely researched. People diagnosed with AvPD have severe impairments in functioning and suffer greatly, yet we still lack meta-analytic evidence for therapy and only a few RCTs are conducted. Patient factors are the most important for outcome in therapy, in general. Lack of agency might be a core deficit in people diagnosed with AvPD. Their conditions might be improved if we understand their agency better. We review previous research regarding psychological mechanisms and interpersonal relationships that facilitate or hinder agency in AvPD in daily life and psychotherapy.

Methods

Summarizing original literature in a narrative review with reflexive thematic analysis.

Results

People diagnosed with AvPD seem to have significant impairments in their sense of agency due to a lack of emotional awareness, an overweight of inhibiting vs. activating emotions, and difficulties regulating emotions. Difficulties also seem related to high levels of attachment avoidance and fear, creating strong ambivalence in social needs, in addition to a strong tendency to subordinate to others. A weak sense of self with a poor narrative, self-doubt, and harsh self-critique makes a reflexive and intentional stand increasingly difficult for these people.

Conclusion

This review gives a clinically meaningful understanding of core strengths and deficits in the personality functioning of AvPD that can help clinicians map out important therapeutic work, identify barriers to client-agency in therapy, and work through relational difficulties in the therapeutic alliance.

Shame, self-disgust, and envy: An experimental study on negative emotional response in borderline personality disorder during the confrontation with the own face

Background

A markedly negative self-image and pervasive shame proneness have consistently been associated with borderline personality disorder (BPD). The present experimental study investigated the intensity of negative emotional responses with a focus on shame in BPD compared to healthy control persons (HCs) during an experimental paradigm promoting self-awareness, self-reflection, and self-evaluation. Furthermore, the relationship between levels of state shame during the experiment and shame proneness in BPD compared to HCs was examined.

Methods

A sample of 62 individuals with BPD and 47 HCs participated in the study. During the experimental paradigm, participants were presented with photos of (i) the own face, (ii) the face of a well-known person, and (iii) of an unknown person. They were asked to describe positive facets of these faces. Participants rated the intensity of negative emotions induced by the experimental task as well the pleasantness of the presented faces. Shame-proneness was assessed using the Test of the Self-Conscious Affect (TOSCA-3).

Results

Individuals with BPD experienced significantly higher levels of negative emotions than HCs both before and during the experimental task. While HC participants responded to their own face particularly with an increase in shame compared to the other-referential condition, the BPD patients responded above all with a strong increase of disgust. Furthermore, the confrontation with an unknown or well-known face resulted in a strong increase of envy in BPD compared to HC. Individuals with BPD reported higher levels of shame-proneness than HCs. Higher levels of shame-proneness were related to higher levels of state shame during the experiment across all participants.

Conclusion

Our study is the first experimental study on negative emotional responses and its relationship to shame proneness in BPD compared to HC using the own face as a cue promoting self-awareness, self-reflection, and self-evaluation. Our data confirm a prominent role of shame when describing positive features of the own face, but they emphasize also disgust and envy as distinct emotional experience characterizing individuals with BPD when being confronted with the self.

The Influence of Attachment Style, Self-protective Beliefs, and Feelings of Rejection on the Decline and Growth of Trust as a Function of Borderline Personality Disorder Trait Count

Borderline personality disorder (BPD) is associated with paradoxical trust behaviours, specifically a faster rate of trust growth in the face of trust violations. The current study set out to understand whether attachment style, self-protective beliefs, and feelings of rejection underpin this pattern. Young adults (N=234) played a 15-round trust game in which partner cooperation was varied to create three phases of trust: formation, dissolution, and restoration. Discontinuous growth modelling was employed to observe whether the effect of BPD trait count on trust levels and growth is moderated by fearful or preoccupied attachment style, self-protective beliefs, and feelings of rejection. Results suggest that the slower rate of trust formation associated with BPD trait count was accounted for by feelings of rejection or self-protective beliefs, both of which predicted a slower rate of trust growth. The faster rate of trust growth in response to trust violations associated with BPD trait count was no longer significant after self-protective beliefs were accounted for. Interventions targeting self-protective beliefs and feelings of rejection may address the trust-based interpersonal difficulties associated with BPD.

When less is more: The perception of psychotherapy techniques as a function of patient personality disorder

OBJECTIVE

Psychopathology research suggests that individuals with higher levels of personality disorder (PD) traits, especially those with a comorbid major depressive disorder (MDD), tend to be highly aroused in interpersonal contexts, manifested by an intensified perception of interpersonal interactions. Little is known about the way this tendency manifests in the process of psychotherapy. The current study explored the patient's perception of techniques in psychotherapy among patients with higher vs. lower levels of PD, as well as the patient-therapist agreement on techniques used.

DESIGN

The study used an integration of qualitative and quantitative methodology on data from a randomized controlled trial (RCT) for the treatment of depression.

METHOD

Sixty-nine patients with MDD participated in the study and were evaluated for PD symptoms prior to treatment. A set of multilevel analyses were conducted to assess the association between PD and perception of techniques, as well as a zoom-in exploration within a case study.

RESULTS

Patients with higher levels of PD reported more techniques implemented by the therapist than patients with lower levels. In addition, the agreement between patient and therapist on techniques was lower, such that patients with PDs reported more techniques than their therapist. The case study supported these findings and illustrates the potential for patients with PDs to perceive a greater use of techniques as a sign of therapist investment.

CONCLUSION

Consistent with psychopathology research, the findings suggest that patients with PDs tend to experience techniques as more intense than the therapist, in comparison with patients without PD.

PRACTITIONER POINTS

There are indications that patients with higher levels of personality disorder traits will tend to experience the techniques in psychotherapy in a more intense manner than patients with lower level personality disorder traits. It is likely that patients with higher levels of personality disorder traits will experience their therapists as more active than therapists think they are. Therapists of patients with higher levels of personality disorders should be sensitive of each of their patients' experiences. As the case study demonstrated at least in some cases patients with higher levels of personality disorder may experience the techniques in an intense manner as a sign of therapist investment, however, other patients may experience this differently. Therefore, it is crucial for the therapist to be aware of how the patient experienced the encounter - investment or intrusiveness.

Paradoxes in Borderline Emotional Dysregulation in Adolescence: Influence of Parenting, Stressful Life Events, and Attachment

Introduction: Borderline personality disorder (BPD) in adolescents is characterized by emotional dysregulation, insecure attachment, a history of stressful life events (SLEs) as well as dysfunctional parent-child interactions. The respective contribution of each of these factors on BPD affective symptoms is not yet clear. The purpose of this study is to assess the distinct impact of parental adversity and SLEs on BPD affective symptoms and the role of attachment and alexithymia in such emotional processes. Method: This study explored parental dysfunction and SLEs as predictors of affective symptoms of BPD and of attachment insecurity in BPD adolescents (n = 85) and healthy controls (n = 84) aged 13-19 years from the European Research Network on BPD. The links between adversity and BPD symptoms were also investigated by emotional dysregulation assessment, as measured by alexithymia and hopelessness. Results: Dysfunctional parental interactions were linked to affective symptoms, hopelessness, and anxious attachment in healthy controls but not in BPD. Cumulative SLEs were positively correlated with affective symptoms and avoidant attachment in the control group but negatively correlated with both these variables in BPD. Multivariate regression analysis revealed that, in BPD, affective symptoms were independent of dysfunctional parenting but depended on attachment, whereas in controls, a maternal affectionless control style directly predicted affective symptoms. Moreover, increasing numbers of SLEs reduced affective symptoms in BPD, independently of parental interactions or attachment, and were associated with growing use of operative thinking. Discussion: BPD patients showed paradoxical emotional reactions: there was no increase of hopelessness and affective symptoms with an increased parental dysfunction, but a decrease in affective symptoms and hopelessness with cumulative SLE. Two pathways arose, one involving attachment as an emotional dysregulation process for parent-child interactions and a second one for SLE, with a more direct pathway to affective symptoms, independent of attachment but dependent on early interactions, and involving alexithymia. In summary, adversity factors have distinct effects in BPD, and attachment is partly accountable for affective symptoms independently of adversity. Our results suggest that in highly insecure conditions, cumulative adversity may produce paradoxical effects, including a lesser expression of affective symptoms and hopelessness.

Reward and Punishment Sensitivity in Borderline and Avoidant Personality Disorders

The authors compared self-reported and behavioral responses to reward and punishment in individuals diagnosed with borderline personality disorder (BPD) or avoidant personality disorder (APD) relative to a healthy comparison (HC) group. As predicted, self-reported sensitivity to reward was significantly higher in the BPD group than in the APD and HC groups. Also as predicted, self-reported sensitivity to punishment was significantly elevated in both disordered groups but significantly higher in APD than in BPD. These hypothesized patterns were also evident in responses to behavioral tasks: Participants with BPD made more errors of commission and fewer errors of omission than HC participants on a passive avoidance learning task, and participants with APD showed greater reactivity to losses than other participants on a probabilistic reversal learning task. Results help characterize differences between these two disorders.

Investigating the stress-related fluctuations of level of personality functioning: A critical review and agenda for future research

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Classification of Diseases (ICD-11) proposed a dimensional approach to the assessment of personality disorders (PDs). Both models dictate that the clinician first determines PD severity before assessing maladaptive traits, invoking the level of personality functioning (LPF) construct. We consider LPF a promising dimensional construct for translational research because of its clinical importance and conceptual overlap with the Research Domain Criteria (RDoC) Social Processes. We aim to identify biomarkers that co-vary with fluctuations in LPF in adulthood, ultimately to predict persistent decrease in LPF, associated with suicidality and morbidity. However, a theoretical framework to investigate stress-related oscillations in LPF is currently missing. In this article, we aim to fill this hiatus with a critical review about stress and LPF. First, we discuss acute stress and LPF. We briefly present the basics of the neurophysiological stress response and review the literature on momentary and daily fluctuations in LPF, both at a subjective and physiological level. Second, we review the effects of chronic stress on brain function and social behaviour and recapitulate the main findings from prospective cohort studies. This review underlies our suggestions for multimethod assessment of stress-related oscillations in LPF and our theoretical framework for future longitudinal studies, in particular studies using the experience sampling method (ESM).

Ego-resiliency in borderline personality disorder and the mediating role of positive and negative affect on its associations with symptom severity and quality of life in daily life

Borderline personality disorder (BPD) is a serious mental health condition associated with severe symptoms of distress and poor quality of life (QoL). Research outside the field of BPD suggests that ego-resiliency is negatively associated with psychopathology and positively associated with a range of positive life outcomes. Thus, ego-resiliency may be a valuable construct for furthering our understanding and treatment of BPD. However, the mechanisms linking ego-resiliency to psychopathology and QoL in relation to BPD have not been examined and explored by research. This study has addressed this gap in the collective knowledge by evaluating whether within-person associations between daily reports of positive affect (PA) and negative affect (NA) mediated the relationship between ego-resiliency, BPD symptom severity, and QoL. For 21 consecutive days, 72 women diagnosed with BPD completed end-of-day electronic assessments regarding ego-resiliency, PA and NA, symptom severity, and QoL. Multilevel structural equation modelling established that PA and NA were parallel mediators linking ego-resiliency with BPD symptom severity and QoL. As hypothesized, the path to QoL was stronger through PA than through NA. The mediation paths through NA and PA to BPD symptom severity were both significant, but their strength did not differ. Our findings align with the assertions of theories on emotion, thus suggesting a two-factor approach to PA and NA. Future research can build on these findings by developing psychotherapeutic interventions designed not only to reduce symptom severity but also to enhance PA in individuals with BPD and determine whether an increase in PA is associated with improved QoL.

Candidate Biomarkers of Suicide Crisis Syndrome: What to Test Next? A Concept Paper

BACKGROUND

There has been increasing interest in both suicide-specific diagnoses within the psychiatric nomenclature and related biomarkers. Because the Suicide Crisis Syndrome-an emotional crescendo of several interrelated symptoms-seems to be promising for the identification of individuals at risk of suicide, the aim of the present paper is to review the putative biological underpinnings of the Suicide Crisis Syndrome symptoms (entrapment, affective disturbance, loss of cognitive control, hyperarousal, social withdrawal).

METHODS

A PubMed literature search was performed to identify studies reporting a link between each of the 5 Suicide Crisis Syndrome symptoms and biomarkers previously reported to be associated with suicidal outcomes.

RESULTS

Disturbances in the hypothalamic-pituitary-adrenal axis, with dysregulated corticotropin-releasing hormone and cortisol levels, may be linked to a sense of entrapment. Affective disturbance is likely mediated by alterations in dopaminergic circuits involved in reward and antireward systems as well as endogenous opioids. Loss of cognitive control is linked to altered neurocognitive function in the areas of executive function, attention, and decision-making. Hyperarousal is linked to autonomic dysregulation, which may be characterized by a reduction in both heart rate variability and electrodermal activity. Social withdrawal has been associated with oxytocin availability. There is also evidence that inflammatory processes may contribute to individual Suicide Crisis Syndrome symptoms.

CONCLUSION

The Suicide Crisis Syndrome is a complex syndrome that is likely the consequence of distinct changes in interconnected neural, neuroendocrine, and autonomic systems. Available clinical and research data allow for development of empirically testable hypotheses and experimental paradigms to scrutinize the biological substrates of the Suicide Crisis Syndrome.

Supportive hand-holding attenuates pupillary responses to stress in adult couples

BACKGROUND

Social relationships, particularly marriage, have been shown to ameliorate the potentially pathogenic impact of stressful events but prior research has been mostly aimed at downstream effects, with less research on real-time reactivity. Pupillometry is an innovative procedure that allows us to see the effects of acute stress in real time. The muscles that control pupil size are linked to the autonomic nervous system, so that when stressed, the pupils dilate; this occurs within 200ms. This quick response allows us to see the immediate effects of acute stress on the autonomic nervous system (ANS), and the real-time effects of social support in buffering stress.

PURPOSE

The purpose of this study is to examine the dampening effects of received social support on the ANS's pupillary response.

METHODS

Eighty individuals (40 couples) were randomly assigned to either a spousal support (i.e., spouse hand-holding) or non-support condition (i.e., alone) and administered a Stroop task while pupil dilation was measured.

RESULTS

The Stroop task elicited a stress reaction in terms of pupil dilation in response to the incongruent task trials. Participants in the support condition showed accelerated habituation to the stress task (p < .001), and less pupil reactivity (p < .001) providing evidence for buffering effects of social support via spousal presence and hand-holding.

CONCLUSIONS

These results reveal the speed at which stress-buffering occurs, suggesting that pupillometry could be a good method to address the immediate dampening effects of social support.

Attributions for Rejection and Acceptance in Young Adults With Borderline and Avoidant Personality Features

Individuals with borderline and avoidant personality disorders show interpersonal dysfunction that includes maladaptive responses to rejection and reduced emotional benefits from acceptance. To identify the attributional styles that may underlie these difficulties, we examined causal attributions for rejection and acceptance among undergraduates high in features of each disorder and a healthy comparison group. In Study 1, participants rated how likely they were to attribute hypothetical rejection and acceptance experiences to positive and negative qualities of the self and others, as well as external circumstances. In Study 2, we examined these same attributions in daily diary assessments of real rejection and acceptance experiences. Although the two studies showed some differences in results, they both linked borderline personality features with suspicious, selfbolstering responses and avoidant personality features with perceived inferiority. Distinct attributional styles may contribute to the distinct interpersonal problems characteristic of these conditions.

Emotional lability and affective synchrony in borderline personality disorder

Extant research on emotional lability in borderline personality disorder (BPD) has focused almost exclusively on lability of individual emotions or emotion types, with limited research considering how different types of emotions shift together over time. Thus, this study examined the temporal dynamics of emotion in BPD at the level of both individual emotions (i.e., self-conscious emotions [SCE], anger, and anxiety) and mixed emotions (i.e., synchrony between emotions). One hundred forty-four women from the community completed a diagnostic interview and laboratory study involving 5 emotion induction tasks (each of which was preceded and followed by a 5-min resting period or neutral task). State ratings of SCE, anger, and anxiety were provided at 14 time points (before and after each laboratory task and resting period). Hierarchical linear modeling results indicate that women with BPD reported greater mean levels of SCE and Anxiety (but not Anger), and greater lability of Anxiety. Women with BPD also exhibited greater variability in lability of all 3 emotions (suggestive of within-group differences in the relevance of lability to BPD). Results also revealed synchrony (i.e., positive relations) between each possible pair of emotions, regardless of BPD status. Follow-up regression analyses suggest the importance of accounting for lability when examining the role of synchrony in BPD, as the relation of SCE-Anger synchrony to BPD symptom severity was moderated by Anger and SCE lability. Specifically, synchronous changes in SCE and Anger were associated with greater BPD symptom severity when large shifts in SCE were paired with minor shifts in Anger. (PsycINFO Database Record

Interpersonal problems and negative affect in Borderline Personality and Depressive Disorders in daily life

Theories of Borderline Personality Disorder (BPD) suggest that interpersonal problems in BPD act as triggers for negative affect and, at the same time, are a possible result of affective dysregulation. Therefore, we assessed the relations between momentary negative affect (hostility, sadness, fear) and interpersonal problems (rejection, disagreement) in a sample of 80 BPD and 51 depressed outpatients at 6 time-points over 28 days. Data were analyzed using multivariate multi-level modeling to separate momentary-, day-, and person-level effects. Results revealed a mutually reinforcing relationship between disagreement and hostility, rejection and hostility, and between rejection and sadness in both groups, at the momentary and day level. The mutual reinforcement between hostility and rejection/disagreement was significantly stronger in the BPD group. Moreover, the link between rejection and sadness was present at all three levels of analysis for the BPD group, while it was localized to the momentary level in the depressed group.

Emotional Processes in Borderline Personality Disorder: An Update for Clinical Practice

Despite prior assumptions about poor prognosis, the surge in research on borderline personality disorder (BPD) over the past several decades shows that it is treatable and can have a good prognosis. Prominent theories of BPD highlight the importance of emotional dysfunction as core to this disorder. However, recent empirical research suggests a more nuanced view of emotional dysfunction in BPD. This research is reviewed in the present article, with a view towards how these laboratory-based findings can influence clinical work with individuals suffering from BPD.

Affective Instability and Reactivity in Depressed Patients With and Without Borderline Pathology

The quality of depression in borderline personality disorder (BPD) was reported to differ from that in patients with major depressive disorder (MDD) only. However, little is known about affect dynamics in "borderline-depression." The authors assessed affective instability and reactivity in 20 MDD patients with BPD and in 21 MDD patients without BPD by Ambulatory Assessment. Participants reported on current affect, daily events, and attribution of affective states to events five times per day over a 7-day period. The results do not indicate higher affective instability in MDD patients with BPD comorbidity. Depressed patients with BPD reported less subjectively perceived affective reactivity, while observed associations between events and affect were not different between groups, except for one finding: In depressed patients with BPD, overall mood was lower after being alone. These findings suggest impaired attribution of mood changes and less tolerance of being alone as specific for depression in BPD.

Identification of mental states and interpersonal functioning in borderline personality disorder

Atypical identification of mental states in the self and others has been proposed to underlie interpersonal difficulties in borderline personality disorder (BPD), yet no previous empirical research has directly examined associations between these constructs. We examine 3 mental state identification measures and their associations with experience-sampling measures of interpersonal functioning in participants with BPD relative to a healthy comparison (HC) group. We also included a clinical comparison group diagnosed with avoidant personality disorder (APD) to test the specificity of this constellation of difficulties to BPD. When categorizing blended emotional expressions, the BPD group identified anger at a lower threshold than did the HC and APD groups, but no group differences emerged in the threshold for identifying happiness. These results are consistent with enhanced social threat identification and not general negativity biases in BPD. The Reading the Mind in the Eyes Test (RMET) showed no group differences in general mental state identification abilities. Alexithymia scores were higher in both BPD and APD relative to the HC group, and difficulty identifying one's own emotions was higher in BPD compared to APD and HC. Within the BPD group, lower RMET scores were associated with lower anger identification thresholds and higher alexithymia scores. Moreover, lower anger identification thresholds, lower RMET scores, and higher alexithymia scores were all associated with greater levels of interpersonal difficulties in daily life. Research linking measures of mental state identification with experience-sampling measures of interpersonal functioning can help clarify the role of mental state identification in BPD symptoms. (PsycINFO Database Record

Emotional lability and affective synchrony in borderline personality disorder

Extant research on emotional lability in borderline personality disorder (BPD) has focused almost exclusively on lability of individual emotions or emotion types, with limited research considering how different types of emotions shift together over time. Thus, this study examined the temporal dynamics of emotion in BPD at the level of both individual emotions (i.e., self-conscious emotions [SCE], anger, and anxiety) and mixed emotions (i.e., synchrony between emotions). One hundred forty-four women from the community completed a diagnostic interview and laboratory study involving 5 emotion induction tasks (each of which was preceded and followed by a 5-min resting period or neutral task). State ratings of SCE, anger, and anxiety were provided at 14 time points (before and after each laboratory task and resting period). Hierarchical linear modeling results indicate that women with BPD reported greater mean levels of SCE and Anxiety (but not Anger), and greater lability of Anxiety. Women with BPD also exhibited greater variability in lability of all 3 emotions (suggestive of within-group differences in the relevance of lability to BPD). Results also revealed synchrony (i.e., positive relations) between each possible pair of emotions, regardless of BPD status. Follow-up regression analyses suggest the importance of accounting for lability when examining the role of synchrony in BPD, as the relation of SCE-Anger synchrony to BPD symptom severity was moderated by Anger and SCE lability. Specifically, synchronous changes in SCE and Anger were associated with greater BPD symptom severity when large shifts in SCE were paired with minor shifts in Anger. (PsycINFO Database Record

Evaluation and memory of social events in borderline personality disorder: Effects of valence and self-referential context

People's memory of past social encounters influences current social interactions. Social rejection has been shown to increase people's memory for social events particularly when referring to others rather than themselves. Social rejection and neglect often characterize biographies of individuals with borderline personality disorder (BPD). Using a social memory task, we investigated whether the evaluation and memory of social events is altered in BPD and whether this depends on reference to the self or others. 30 patients with BPD and 30 healthy controls evaluated the valence of positive, neutral, and negative standardized events, which were either social or nonsocial. Subsequently, participants had to recall these events. BPD patients evaluated social events of negative and neutral valence as more negative than healthy controls. Further, only BPD patients tended to preferentially recall self-referential social events. These findings suggest altered self-referential processing of social events that affects both the evaluation and the memory for social events.

Momentary symptoms of borderline personality disorder as a product of trait personality and social context

Past studies identify Five Factor Model (FFM) domains that are characteristic of borderline personality disorder (BPD), including those associated with specific BPD symptoms, at a between-person level. The present study replicated these between-person associations and extended past research by assessing whether the FFM explains within-person variance in the manifestation of momentary BPD symptoms in the presence or absence of close social contact (CSC). We measured CSC and the BPD core symptoms negative affectivity, impulsivity, and interpersonal problems in 74 BPD patients and in a clinical control group of 40 depressed patients over the course of 28 days, 6 times a day. The FFM domains showed specificity in predicting momentary BPD symptoms and interacted with CSC in doing so. In particular, for BPD individuals only, momentary impulsivity and interpersonal problems were associated with higher neuroticism and extraversion and lower agreeableness, and these associations were especially strong in situations involving CSC. Negative affectivity was predicted by neuroticism for both groups of individuals, and this association was generally unaffected by CSC. Overall, experiencing CSC was positively associated with momentary BPD symptoms. Thus, both the FFM and CSC were associated with BPD patients' experience of symptoms in everyday life. Furthermore, specific FFM trait domains were particularly impactful in contexts where BPD symptoms are more likely to be manifested, providing further evidence that person-by-situation interactions are important for understanding BPD symptoms in the moment. (PsycINFO Database Record

Impulsivity, Rejection Sensitivity, and Reactions to Stressors in Borderline Personality Disorder

This research investigated baseline impulsivity, rejection sensitivity, and reactions to stressors in individuals with borderline personality disorder compared to healthy individuals and those with avoidant personality disorder. The borderline group showed greater impulsivity than the avoidant and healthy groups both in a delay-discounting task with real monetary rewards and in self-reported reactions to stressors; moreover, these findings could not be explained by co-occurring substance use disorders. Distress reactions to stressors were equally elevated in both personality disorder groups (relative to the healthy group). The borderline and avoidant groups also reported more maladaptive reactions to a stressor of an interpersonal vs. non-interpersonal nature, whereas the healthy group did not. Finally, self-reported impulsive reactions to stressors were associated with baseline impulsivity in the delay-discounting task, and greater self-reported reactivity to interpersonal than non-interpersonal stressors was associated with rejection sensitivity. This research highlights distinct vulnerabilities contributing to impulsive behavior in borderline personality disorder.

Avoidant personality disorder as a social anxiety phenotype: risk factors, associations and treatment

PURPOSE OF REVIEW

This article identifies research trends and synthesizes information from recent studies of avoidant personality disorder (AVPD).

RECENT FINDINGS

AVPD and social anxiety disorder (SAD) share genetic vulnerability, but may have distinct environmental risk factors that shape qualitative differences. Negative self-concept, shame proneness, and interpersonal hypersensitivity are characteristic of AVPD and may be predisposed to by heritable traits of high negative affectivity and low positive affectivity, and experiences of neglectful or emotionless parents. The interpersonal difficulties of AVPD may be associated with both anxious and avoidant attachment. Most individuals with AVPD do not also meet criteria for SAD.

SUMMARY

Integrative treatments incorporating cognitive behavioral strategies effective in SAD but also targeting shame aversion and avoidance may be most helpful for AVPD. Therapy adapted to both anxious attachment, associated with heightened interpersonal sensitivity and distress, and avoidant attachment, associated with experiential avoidance, may be optimal, though this is yet to be tested. Effective treatment of AVPD may enhance the outcome of comorbid conditions. More research is needed which compares three social anxiety groups (SAD alone, AVPD alone, and SAD plus AVPD) to further explore these disorders which are highly related, but which may have differences that are clinically relevant for individuals.

Explicit and inferred motives for nonsuicidal self-injurious acts and urges in borderline and avoidant personality disorders

Nonsuicidal self-injury (NSSI) is a perplexing phenomenon that may have differing motives. The present study used experience sampling methods (ESM) which inquired explicitly about the motives for NSSI, but also enabled a temporal examination of the antecedents/consequences of NSSI; these allow us to infer other motives which were not explicitly endorsed. Adults (n = 152, aged 18-65) with borderline personality disorder (BPD), avoidant personality disorder (APD), or no psychopathology participated in a 3-week computerized diary study. We examined 5 classes of explicit motives for engaging in NSSI, finding support primarily for internally directed rather than interpersonally directed ones. We then used multilevel regression to examine changes in affect, cognition, and behavior surrounding moments of NSSI acts/urges compared with control moments (i.e., without NSSI). We examined changes in 5 scales of inferred motives, designed to correspond to the 5 classes of explicit motives. The results highlight differing motives for NSSI among individuals with BPD and APD, with some similarities (mostly in the explicit motives) and some differences (mostly in the inferred motives) between the disorders. Despite their infrequent explicit endorsement, fluctuations in interpersonally oriented scales were found surrounding NSSI acts/urges. This highlights the need to continue attending to interpersonal aspects of NSSI in research and in clinical practice. Additionally, NSSI urges, like acts, were followed by decline in affective/interpersonal distress (although in a delayed manner). Thus, interventions that build distress tolerance and enhance awareness for affective changes, and for antecedent/consequence patterns in NSSI, could help individuals resist the urge to self-injure.