Patterns of interpersonal problems in borderline personality disorder

Relationship Dysfunction in Couples When One Partner Is Diagnosed with Borderline Personality Disorder: Findings from a Pilot Study

Relationship dysfunction—marked by frequent conflicts—is one of the hallmark features of borderline personality disorder (BPD). However, the BPD couple as a dyad and partner-related features have rarely been taken into account. The aim of the present study was to investigate hormonal, personality, and relationship relevant factors, such as relationship satisfaction, attachment, and trauma in both partners within a dyad where one partner is diagnosed with BPD. The total sample consisted of 26 heterosexual couples. All studies were conducted at 2 p.m. Primary outcomes: Neo-Five-Factor-Inventory, Childhood Trauma Questionnaire, Experiences in Close Relationships Scale. Secondary outcomes: Problem List, Partnership Questionnaire, Questionnaire for Assessing Dyadic Coping. Upon questionnaire completion, one saliva sample was taken via passive drool to assess baseline cortisol and testosterone levels. Results showed that females with BPD have higher scores on childhood maltreatment, dysfunctional attachment styles, and neuroticism than mentally healthy females. Furthermore, they have more relationship-related problems and are less satisfied in their romantic relationship. Male partners of women with BPD showed lower testosterone levels, higher levels of childhood maltreatment, dysfunctional attachment styles, neuroticism, and openness compared with the healthy control partners. Furthermore, childhood trauma, neuroticism as well as dysfunctional attachment styles displayed a significant positive correlation with relationship-related problems. Traumatic childhood experiences, insecure attachment styles as well as neurotic personality characteristics contribute to increased relationship disruptions in couples. Relevant hormonal and psychosocial parameters in BPD partners should be taken into account when treating females with BPD.

Interpersonal traits and the neural representations of cognitive control in the prefrontal cortex

Adaptive interpersonal functioning relies on the effectiveness of behavioral and neural systems involved in cognitive control. Whether different subcomponents of cognitive control and their neural representations are associated with distinctive interpersonal dispositions has yet to be determined. The present study investigated the relationships between prefrontal cortex (PFC) activation associated with two subcomponents of cognitive control and individual differences in interpersonally relevant traits and facets within the Five-Factor Model of personality. Undergraduate participants (n = 237) provided self-ratings of interpersonal traits and underwent functional near-infrared spectroscopy to measure activation in regions-of-interest linked to subcomponents of cognitive control: the right lateral PFC and its involvement in response selection and inhibition/suppression (RS) during a go/no-go task, and the left lateral PFC associated with goal selection, updating, representation, and maintenance (GS) on a tower planning task. Multilevel models revealed that during both RS and GS, Neuroticism and Extraversion were associated with lower and higher levels of activation, respectively. Higher Agreeableness was related to lower activation during RS but also with greater activation during GS. More narrowly defined interpersonal facets subsumed within the broader trait domains were differentially associated with RS- and GS-related neural responses. Taken together, these findings highlight potential avenues of future research to better understand the ways in which the neural processes that subserve cognitive control may underlie interpersonal dispositions.

Patient personality characteristics and therapeutic integration: treating borderline personality and emotionally dysregulated-dysphoric personality features

This study examines the relationship between patient personality characteristics and therapeutic integration. Within a sample of patients (N=93) receiving outpatient psychodynamically- oriented psychotherapy, we assessed patient Borderline and Emotionally Dysregulated personality features through the Shedler-Westen Assessment Procedure (SWAP-200), and therapeutic technique using the Comparative Psychotherapy Process Scale (CPPS) during an early treatment session. We examined personality dimensionally, psychotherapy interventions across different theoretical orientations, as well as psychotherapy integration. These analyses revealed an overlap between the Borderline Clinical Prototype and the Emotionally Dysregulated-Dysphoric Q-factor, with the former associated with higher use of integration and the latter associated with higher use of either psychodynamicinterpersonal or cognitive-behavioural interventions. Secondary analyses also indicated the greater presence of interventions oriented towards emotional exploration and to the didactic instruction of effective symptom coping techniques across both of these personality subtypes early in treatment. The key differences between these personality types, as well as the theoretical, empirical, and clinical implications of these findings are discussed.

Cluster analysis of personality traits in psychiatric patients with borderline personality disorder

BACKGROUND

Though the heterogeneous expression of symptoms of borderline personality disorder (BPD) is well-known, it is far from fully understood. Hybrid models combining dimensional and categorical ways of diagnosing BPD have been suggested to better handle this heterogeneity, but more research is needed. The aim of this study was to identify potential clusters in BPD, and evaluate if these clusters differed in diagnostic composition, severity, psychiatric symptoms, emotion regulation and control, or sociodemographic features.

METHODS

Clusters were based on personality traits measured with the Swedish universities Scales of Personality (SSP) in 141 psychiatric patients diagnosed with BPD. Hierarchical cluster analysis was performed using Ward's method. We used one-way analysis of variance to explore the different clusters' properties. Effect sizes were calculated using partial eta squared.

RESULTS

We found three distinct clusters: the lower psychopathology cluster (N = 67), the externalizing cluster (N = 28), and the internalizing cluster (N = 46). The clusters differed regarding trait composition, severity, and emotion regulation and control.

CONCLUSIONS

Our findings support hybrid models for diagnosing BPD by showing that clusters differed in terms of both severity (lower and higher psychopathology) and personality traits/style (internalizing and externalizing). Assessment of personality traits may be a feasible way to differentiate between clusters. In the future, this knowledge might be used to personalize treatment.

Early Maladaptive Schemas and the Accuracy of Facial Emotion Recognition: A Preliminary Investigation

Different developmental experiences related to deep-rooted beliefs about oneself and others may significantly affect individual social emotional competencies, such as the accuracy of facial emotion recognition and detection. This study presents a preliminary examination of the relationship between early maladaptive schemas (EMSs) and the accuracy of recognizing facial expressions showing basic emotions, neutral faces, and discrimination between neutral and emotional faces. The sample consisted of 138 psychology students (M = 20.33; SD = 1.33, 27 of the respondents were male). JACFEE and JACNeuF (Matsumoto & Ekman, 1988) were used as stimulus material for assessing the facial emotion recognition of seven basic emotions (anger, contempt, disgust, fear, sadness, happiness, and surprise) and neutral faces. The Young Schema Questionnaire - Short Form 3 (YSQ-S3; Young, 2005) was administered as a measure of EMSs. The findings demonstrate that all schema domains affect the accuracy of recognizing facial expressions showing negative emotions (anger, contempt, disgust, fear, and sadness). The Dependence/Incompetence, Entitlement/Grandiosity schemas were significant predictors for detecting neutral faces and discriminating between faces with and without emotion, while the Abandonment/Instability schema additionally proved significant for recognizing neutral faces. Limitations and suggestions for future elaboration are acknowledged.

Latent profiles of patients with borderline pathology based on the alternative DSM-5 model for personality disorders

BACKGROUND

There have been multiple attempts to try to parse out heterogeneity within borderline pathology by identifying patient subtypes; thus far, these works have yielded few consistent results. Recent developments in the operationalization of borderline pathology may provide new opportunities to identify clinically and conceptually meaningful subgroups of patients. The Alternative DSM-5 Model for Personality Disorders (AMPD) offers a categorical-dimensional operationalization of Borderline personality disorder (BPD) that has yet to be tested for identification of patient subgroups. The purpose of the present study is to test whether the combination of the Criterion A elements (pertaining to level of severity) and the seven pathological facets from Criterion B that define BPD in the AMPD can yield meaningful patient profiles.

METHODS

A total of 211 outpatients from a specialized PD treatment program (133 women, Mage = 33.66, SD = 10.97) were selected based on the presence of at least moderate borderline pathology according to cutoffs recently proposed for the Borderline Symptom List-23. Valid Criterion A (Self and Interpersonal Functioning Scale) and B (Personality Inventory for DSM-5 Faceted Brief Form) self-reports were administered to measure elements and facets that define BPD in the AMPD model; these variables were used as indicators in a latent profile analysis (LPA).

RESULTS

The optimal solution generated by LPA yielded four distinct profiles: (a) Borderline traits; (b) Moderate pathology with Impulsivity; (c) Moderate pathology with Identity problems and Depressivity; and (d) Severe pathology. Clinically meaningful distinctions emerged among profiles on AMPD indicators and external variables relevant to PD, especially aggression and impulsivity.

CONCLUSIONS

Profiles reflected both the "severity" and "style" components imbedded within Criterion A and B of the AMPD, as they were mainly distinguished by a continuum of severity but also by some meaningful qualitative differences that may have important clinical implications for treatment planning and contracting. Results also suggest that the four Criterion A elements have independent value to identify important differences in patients with borderline pathology. They also highlight that some Criterion B facets that define BPD in the AMPD may be especially important to identify subgroups of patients, mainly Impulsivity and Depressivity.

The latent structure of interpersonal problems: Validity of dimensional, categorical, and hybrid models

Interpersonal problems are key transdiagnostic constructs in psychopathology. In the past, investigators have neglected the importance of operationalizing interpersonal problems according to their latent structure by using divergent representations of the construct: (a) computing scores for severity, agency, and communion (“dimensional approach”), (b) classifying persons into subgroups with respect to their interpersonal profile (“categorical approach”). This hinders cumulative research on interpersonal problems, because findings cannot be integrated both from a conceptual and a statistical point of view. We provide a comprehensive evaluation of interpersonal problems by enlisting several large samples (Ns = 5,400, 491, 656, and 712) to estimate a set of latent variable candidate models, covering the spectrum of purely dimensional (i.e., confirmatory factor analysis using Gaussian and nonnormal latent t-distributions), hybrid (i.e., semiparametric factor analysis), and purely categorical approaches (latent class analysis). Statistical models were compared with regard to their structural validity, as evaluated by model fit (corrected Akaike’s information criterion and the Bayesian information criterion), and their concurrent validity, as defined by the models’ ability to predict relevant external variables. Across samples, the fully dimensional model performed best in terms of model fit, prediction, robustness, and parsimony. We found scant evidence that categorical and hybrid models provide incremental value for understanding interpersonal problems. Our results indicate that the latent structure of interpersonal problems is best represented by continuous dimensions, especially when one allows for nonnormal latent distributions.

This study suggests that interpersonal problems are best characterized by continuous differences in severity and interpersonal style (i.e., agency and communion), and not by “types” of people.

Subtypes of borderline personality disorder patients: a cluster-analytic approach

BACKGROUND

The borderline personality disorder (BPD) population is notably heterogeneous, and this has potentially important implications for intervention. Identifying distinct subtypes of patients may represent a first step in identifying which treatments work best for which individuals.

METHODS

A cluster-analysis on dimensional personality disorder (PD) features, as assessed with the SCID-II, was performed on a sample of carefully screened BPD patients (N = 187) referred for mentalization-based treatment. The optimal cluster solution was determined using multiple indices of fit. The validity of the clusters was explored by investigating their relationship with borderline pathology, symptom severity, interpersonal problems, quality of life, personality functioning, attachment, and trauma history, in addition to demographic and clinical features.

RESULTS

A three-cluster solution was retained, which identified three clusters of BPD patients with distinct profiles. The largest cluster (n = 145) consisted of patients characterized by "core BPD" features, without marked elevations on other PD dimensions. A second "Extravert/externalizing" cluster of patients (n = 27) was characterized by high levels of histrionic, narcissistic, and antisocial features. A third, smaller "Schizotypal/paranoid" cluster (n = 15) consisted of patients with marked schizotypal and paranoid features. Patients in these clusters showed theoretically meaningful differences in terms of demographic and clinical features.

CONCLUSIONS

Three meaningful subtypes of BPD patients were identified with distinct profiles. Differences were small, even when controlling for severity of PD pathology, suggesting a strong common factor underlying BPD. These results may represent a stepping stone toward research with larger samples aimed at replicating the findings and investigating differential trajectories of change, treatment outcomes, and treatment approaches for these subtypes.

TRIAL REGISTRATION

The study was retrospectively registered 16 April 2010 in the Nederlands Trial Register, no. NTR2292.

Family history of suicide and interpersonal functioning in suicide attempters

Difficulties in interpersonal relationships are associated with a wide range of psychiatric diagnoses and have been reported as a trigger for suicidal behavior, too. The aim of this study was to examine the relationship between interpersonal problems and family history of suicide in suicide attempters and to describe relevant patterns of interpersonal problems in this patient group. The study involves 181 patients having their clinical follow-up after a suicide attempt. Family history of suicide was assessed by using the Karolinska Self Harm History Interview or retrieved in patient records. The Inventory of Interpersonal Problems was used to assess personal style in an interpersonal context. Suicide attempters with a family history of suicide had significantly more often an intrusive personal style. The results remained significant after adjustment for personality disorder. The specific interpersonal patterns associated with family history of suicide may interfere with the ability to create stable, long-lasting relationships. In regards to treatment, these personal qualities could cause difficulties in the alliance with health care personnel and make it harder for suicide attempters to accept or benefit from treatment. Attention to suicide attempters' interpersonal problems is of importance to lower their distress.

Empirically Derived Relational Pattern Prototypes in the Treatment of Personality Disorders

BACKGROUND

Patient transference patterns play a central role in the psychotherapy of personality disorders.

OBJECTIVE

The aims of this study were to: (1) explore the relationship between patients' personality disorders and specific relational patterns and (2) construct empirically derived prototypes of relational patterns for each personality disorder.

SAMPLING AND METHODS

A random national sample of 314 clinicians completed the Psychotherapy Relationship Questionnaire, which evaluates patients' relational patterns, and the Shedler-Westen Assessment Procedure-200, which assesses personality disorders in a randomly selected patient currently in the clinician's care and with whom the clinician has worked for a minimum of 8 sessions and a maximum of 6 months (1 session per week).

RESULTS

The avoidant/counterdependent transference pattern was associated with all cluster A personality disorders; the angry/entitled transference pattern was strongly positively associated with all cluster B personality disorders, and the anxious/preoccupied transference pattern was positively associated in a significant way with all cluster C personality disorders. Moreover, our empirically derived prototypes showed how the transference phenomena characteristic of each personality disorder are strongly coherent with the personality traits and mental and relational functioning of each specific disorder.

CONCLUSIONS

The results strongly support a fundamental hypothesis that the patterns emerging in the therapeutic relationship are not arbitrary, and they clearly reflect patterns seen elsewhere in patients' lives that can be crucial to address. Regarding limitations, the same clinician provided data on both the personality pathology and the transference phenomena for each patient.

Personality Pathology and Interpersonal Problem Stability

Personality disorders (PDs) are often described as stable, which ignores the important dynamic processes and shifts that are observed clinically in individuals with PD. The current study examined patterns of variability in problematic interpersonal functioning, a core feature of personality pathology. Participants (N = 150) were assessed for personality pathology at baseline and also completed the Inventory of Interpersonal Problems-Circumplex Scales at baseline and every 3 months over the course of a year. Baseline PD was used to predict individual means and variability parameters in generalized interpersonal distress, agentic problems, and communal problems across repeated assessments. Disorders associated with disinhibition predicted variability in generalized distress and agentic problems, whereas only antagonism-related disorders predicted variability in communal problems. These associations reveal dynamic processes involved in multiple dimensions of personality pathology and suggest that future research on instability is needed that expands beyond the historical focus on borderline PD.

Daily Interpersonal and Affective Dynamics in Personality Disorder

In this naturalistic study, the authors adopt the lens of interpersonal theory to examine between- and within-person differences in dynamic processes of daily affect and interpersonal behaviors among individuals (N = 101) previously diagnosed with personality disorders who completed daily diaries over the course of 100 days. Dispositional ratings of interpersonal problems and measures of daily stress were used as predictors of daily shifts in interpersonal behavior and affect in multilevel models. Results indicate that ∼40%-50% of the variance in interpersonal behavior and affect is due to daily fluctuations, which are modestly related to dispositional measures of interpersonal problems but strongly related to daily stress. The findings support conceptions of personality disorders as a dynamic form of psychopathology involving the individuals interacting with and regulating in response to the contextual features of their environment.

Assessment of patient interpersonal behavior: Development and validation of a rating scale

OBJECTIVE

Patient in-session interpersonal behavior, as part of the therapeutic alliance, is an important aspect of the psychotherapy process and impacts treatment outcome. In the present study, the development and validation of a rating scale of patient in-session interpersonal behavior is described.

METHOD

A 10-item rating scale, the Assessment Form of Patient Interpersonal Behavior (AFPIB), was developed using an inductive procedure. The AFPIB was then validated in a sample of patients with hypochondriasis (N = 30), by having two independent raters assess patients' interpersonal behaviors shown in videotaped psychotherapy sessions (N = 60).

RESULTS

The AFPIB demonstrated good reliability and validity.

CONCLUSIONS

Thus, the AFPIB seems to be a promising rating scale for the assessment of patient interpersonal behavior shown in psychotherapy sessions.

Borderline personality pathology and the stability of interpersonal problems

Features of borderline personality disorder (BPD) are associated with the presence and severity of interpersonal problems. At the same time, individuals with BPD are heterogeneous with regard to the types of interpersonal problems they display. BPD is also associated with temporal instability in various domains (e.g., affective lability), and this characteristic raises questions about whether BPD is associated with changes in the expression of interpersonal dysfunction over time, which may contribute to the observed heterogeneity. The focus of the present study was to evaluate the relationship between BPD features and the stability of interpersonal problems over the course of 1 year. Participants (N = 150) were assessed for borderline personality pathology at baseline and also completed the Inventory of Interpersonal Problems-Circumplex Scales at baseline and every 3 months over the course of a year. Baseline BPD was used to predict structured (i.e., latent growth trajectories) and unstructured (i.e., mean square of successive differences) change parameters in generalized interpersonal distress, agentic problems, and communal problems across assessment waves. Baseline BPD predicted individual means in generalized distress and unstructured change (i.e., instability) in agentic and communal problems across the year. Baseline BPD was not predictive, however, of structured change (i.e., linear change trajectories) for any aspect of interpersonal problems. These findings support the conclusion that interpersonal dysfunction in borderline pathology is stable in its severity but unstable in the style of its manifestation.

Clarifying interpersonal heterogeneity in borderline personality disorder using latent mixture modeling

Significant interpersonal impairment is a cardinal feature of borderline personality disorder (BPD). However, past research has demonstrated that the interpersonal profile associated with BPD varies across samples, which is evidence for considerable interpersonal heterogeneity. The current study used inventory of interpersonal problems-circumplex (IIP-C; Alden, Wiggins, & Pincus, 1990) scale scores to investigate interpersonal inhibitions and excesses in a large sample (N = 255) selected for significant borderline pathology. Results indicated that BPD symptom counts were unrelated to the primary dimensions of the IIPC, but were related to generalized interpersonal distress. A latent class analysis clarified this finding by revealing six homogeneous interpersonal classes with prototypical profiles associated with Intrusive, Vindictive, Avoidant, Nonassertive, and moderate and severe Exploitable interpersonal problems. These classes differed in clinically relevant features (e.g., antisocial behaviors, self-injury, past suicide attempts). Findings are discussed in terms of the incremental clinical utility of the interpersonal circumplex model and the implications for developmental and nosological models of BPD.