The nature (and nurture) of personality disorders

Impact of congenital heart disease on personality disorders in adulthood

AIMS

Adults with congenital heart disease (ACHD) constitute an ever-growing patient population characterized by high risks for cardiovascular- and mental disorders. Personality disorders (PDs) are associated with adverse physical and mental health. Studies assessing PD prevalence in ACHD are lacking.

METHODS AND RESULTS

Personality disorder point prevalence was assessed in 210 ACHD by Structured Clinical Interview for Axis-II Personality Disorders (SCID-II) and compared to meta-analytical data from the general population (GP). Depression and anxiety were measured by self-report (Hospital Anxiety and Depression Scale, HADS) and clinician rating (Montgomery-Åsberg depression rating scale, MADRS). Childhood maltreatment was assessed with the Childhood Trauma Questionnaire and quality-of-life (QOL) with the World Health Organization QOL Scale. PD prevalence was markedly higher in ACHD compared to GP (28.1 vs. 7.7%). Particularly borderline (4.8 vs. 0.9%) and cluster C (i.e. anxious or fearful; 17.1 vs. 3.0%) PDs were overrepresented. PD diagnosis was associated with a surgery age ≤12 years (χ²(1) = 7.861, ϕ = 0.195, P = 0.005) and higher childhood trauma levels (U = 2583.5, Z = -3.585, P < 0.001). ACHD with PD reported higher anxiety (HADS-A: U = 2116.0, Z = -5.723, P < 0.001) and depression (HADS-D: U = 2254.5, Z = -5.392, P < 0.001; MADRS: U = 2645.0, Z = -4.554, P < 0.001) levels and lower QOL (U = 2538.5, Z = -4.723, P < 0.001).

CONCLUSION

Personality disorders, particularly borderline- and cluster C, are significantly more frequent in ACHD compared to GP and associated with depression, anxiety, and decreased QOL. Data from the GP suggest an association with adverse cardiometabolic and mental health. To ensure guideline-based treatment, clinicians should be aware of the increased PD risk in ACHD.

Brief admission by self-referral as an add-on to usual care for individuals with self-harm at risk of suicide: cost-effectiveness and 4-year health-economic consequences after a Swedish randomized controlled trial

BACKGROUND

Brief Admission by self-referral (BA) is a crisis-management intervention standardized for individuals with self-harm at risk of suicide. We analyzed its health-economic consequences.

MATERIALS AND METHODS

BA plus treatment as usual (TAU) was compared with TAU alone in a 12-month randomized controlled trial with 117 participants regarding costs for hospital admissions, coercive measures, emergency care and health outcomes (quality-adjusted life years; QALYs). Participants were followed from 12 months before baseline to up to five years after.

RESULTS

Over one year BA was associated with a mean annual cost reduction of 4800 or incremental cost of 4600 euros, depending on bed occupancy assumption. Cost-savings were greatest for individuals with >180 admission days in the year before baseline. In terms of health outcomes BA was associated with a QALY gain of 0.078. Uncertainty analyses indicated a significant QALY gain and ambiguity in costs, resulting in BA either dominating TAU or costing 59 000 euros per gained QALY.

CONCLUSION

BA is likely to produce QALY gains for individuals living with self-harm and suicidality. Cost-effectiveness depends on targeting high-need individuals and comparable bed utilization between BA and other psychiatric admissions. Future research should elaborate the explanatory factors for individual variations in the usage and benefit of BA.

In search of hidden threats: A scoping review on paranoid presentations in personality disorders

Recent diagnostic developments suggest that paranoia is a transdiagnostic characteristic common to several personality disorders rather than a personality disorder per se. Nonetheless, empirical literature fails to provide comprehensive and univocal findings on whether and how paranoid presentations relate to different personality disorders. In the present scoping review, we map the empirical literature on paranoid presentations in personality disorders, considering the entire spectrum of paranoid manifestations (i.e., the paranoia hierarchy). In selecting original quantitative studies on paranoid presentations in personality-disordered patients, we screened 4,433 records in PsycArticles, PsycInfo and PUBMED. We eventually included 47 eligible studies in the review. Our synthesis indicates consistent empirical evidence of a wide range of paranoid presentations in Paranoid, Schizotypal and Borderline personality disorders. Conversely, little empirical literature exists on paranoid presentations in other personality disorders. Preliminary findings suggest broad-severity paranoid presentations, ranging from milder to severe forms, in Paranoid, Schizotypal and Borderline personality disorders. There is also some evidence of milder forms of paranoia in Avoidant, Antisocial and Narcissistic personality disorders. Conversely, there is poor evidence of paranoid presentations in Schizoid, Histrionic, Dependent or Obsessive-compulsive personality disorders. Research gaps and recommendations for improving empirical research on paranoid presentations in personality disorders are discussed.

The cultural change narrative as a core component of therapeutic change

Introduction

Research indicates a similar effect of Mentalization-based treatment (MBT) and Dialectical behavior therapy (DBT) for borderline personality disorder (BPD). However, there is a paucity in studies investigating the change narrative received from and developed in these treatments. The aim of the present study is to investigate similarities and differences in the change narratives provided by MBT and DBT, and how these narratives reflect the rationale, explanations, and procedures of the provided treatment.

Methods

The study is a qualitative analysis of seven interviews conducted by the authors. Three of the participants had received MBT, and four of the participants had received DBT. This study presents an Interpretative Phenomenological Analysis (IPA) of the change narratives received in two specialized treatments for BPD.

Results

The main findings from the IPA were that the change narratives described by the participants reflected the treatment they received. The DBT participants highlighted explicit learning of tools and techniques, with predictable and safe therapists. In contrast, the MBT participants emphasized a long-lasting process of exploring to create procedural learning with therapists who followed their lead.

Discussion

The participants' stories of change shed light on how a change narrative was developed, and therefore how the rationale, explanations and procedures were conveyed differently by MBT and DBT.

Protective factors in borderline personality disorder: A multi-study analysis of conscientiousness, distress tolerance, and self-compassion

BACKGROUND

Despite a growing literature characterizing risk factors associated with the development and maintenance of borderline personality disorder (BPD), substantially less is known about potentially protective factors in BPD.

METHODS

In a sample of online (N = 272) participants with likely BPD, major depressive disorder (MDD), or no disorder (ND) and an independent sample of in-person (N = 90) participants diagnosed with BPD, MDD, or ND, we tested the cross-sectional and longitudinal associations among BPD features and three putatively protective personality, cognitive, and affective-behavioral factors: conscientiousness, self-compassion, and distress tolerance.

RESULTS

Only conscientiousness was significantly lower in BPD than MDD (ds: .67-.73) across both studies and more strongly related to BPD features (rs: -.68 to -.59) than MDD symptoms (rs: -.49 to -.43) in dimensional analyses across both studies. However, in a multiple regression analysis including all three factors in Study 1, only self-compassion predicted decreases in BPD features (β = -.28) and MDD symptoms (β = -.21) over one month.

LIMITATIONS

Study 1 participants completed all measures online and exhibited some differential attrition at one month follow-up. Study 2 participants were all diagnosed by one trained assessor and the smaller sample size limited our power to detect effects.

CONCLUSIONS

Low conscientiousness may be most strongly related to BPD, whereas self-compassion may be a prospective transdiagnostic protective factor.

Comparison of Cognitive Behavioral Therapy and Cognitive Behavioral Group Therapy in the Treatment of Avoidant Personality Disorder

The primary aim of this study is to compile studies on cognitive behavioral therapy method in the treatment of avoidant personality disorder and present their data. Another aim is to discuss with the reasons, cognitive behavior group therapies may be more effective on this disorder than cognitive behavioral individual therapies, since the main problem in avoidant personality disorder stems from interpersonal communication and because the cognitive behavioral therapies applied as a group were found to be quite effective when the avoidant personality disorder was first defined. The aim of this study is to present recommendations together and to compile studies in which cognitive behavioral group therapies were applied on avoidant personality disorder. In this study, studies in domestic and foreign sources, which were conducted with a sample group with avoidant personality disorder and social anxiety disorder, were examined and the study was prepared by reviewing the literature, which is one of the secondary data collection techniques. Since there are not many studies on avoidant personality disorder in the literature, considering the high similarity and comorbidity of avoidant personality disorder with social anxiety disorder, studies on cognitive behavioral group therapies related to social anxiety disorder have also been compiled. As a result of the studies examined, it has been found that the symptoms of avoidant personality disorder are related to the distorted cognition of individuals and cognitive behavioral therapies are a very effective approach because they increase the awareness of the automatic thoughts in the minds of the clients, question their correctness and provide alternative thoughts to replace them.

Less is more: Decreasing the frequency of maladaptive coping predicts improvements in DBT more consistently than increasing the frequency of adaptive coping

It is well-established that participation in dialectical behavior therapy (DBT) results in patients using adaptive coping strategies more frequently. Although coping skill instruction may be necessary to promote decreases in symptoms and behavioral targets in DBT, it is unclear if the frequency with which patients use adaptive coping skills leads to these outcomes. Alternatively, it is possible that DBT also leads patients to use maladaptive strategies less frequently and that these reductions more consistently predict improvements in treatment. We recruited 87 participants with elevated emotion dysregulation (Mage = 30.56; 83.9% female; 75.9% White) to participate in a 6-month course of full-model DBT delivered by advanced graduate students. Participants completed measures of adaptive and maladaptive strategy use, emotion dysregulation, interpersonal problems, distress tolerance, and mindfulness at baseline and after three DBT skills training modules. Both within- and between-person maladaptive strategy use significantly predicted module-to-module changes in all outcomes whereas adaptive strategy use significantly predicted changes in emotion dysregulation and distress tolerance, although the size of these effects did not significantly differ between adaptive and maladaptive strategy use. We discuss the limitations and implications of these results for optimizing DBT.

Maladaptive personality traits may link childhood trauma history to current internalizing symptoms

Research supports a strong relationship between childhood maltreatment and internalizing psychopathology (e.g., anxiety and depression), and features of personality are assumed to explain some of this relationship. In this study, we proposed a model in which maladaptive traits mediate the effect of childhood trauma history on internalizing symptoms in adult individuals. A mixed sample (N = 462) composed of 142 psychiatric patients and 320 community-dwelling individuals completed the Childhood Trauma Questionnaire (CTQ), the Personality Inventory for DSM-5 (PID-5), and the Symptom Checklist (SCL-27) for internalizing psychopathology. The effect of childhood traumas explained 34% of the variance in internalizing symptoms while controlling for the influence of age and gender. The traits accounted for 78% of this effect, which was predominantly exerted through the domains of Negative Affectivity, Detachment, and Psychoticism, and specifically through the facets of Depressivity, Suspiciousness, Anxiousness, Perceptual Dysregulation, and Distractibility. This finding provides preliminary support for the proposed model indicating that the aforementioned maladaptive trait domains potentially function as mediating links by which childhood traumas are translated into internalizing symptoms in adulthood. However, these findings must be interpreted with caution due to the cross-sectional and retrospective mono-method design of this study. Clinical implications are discussed in relation to transdiagnostic treatment and the potential value of specifying trait domain specifiers in ICD-11 and DSM-5 models of personality disorders.

Toward Developing Clinical cut-off for the Grandiosity Scale of the Dimensional Clinical Personality Inventory 2

OBJECTIVE

The present study aims to establish a clinical cut-off for the Grandiosity dimension, using item-level evaluation procedures.

METHODS

Participants were 5,387 adults, including outpatients diagnosed with narcissistic personality disorder (NPD), outpatients diagnosed with other personality disorders, and adults from the community. We administered the self-reported Grandiosity scale from the Dimensional Clinical Personality Inventory 2 (IDCP-2). The equating procedure was applied to generate theta scores for participants who did not answer all items.

RESULTS

The Wright map revealed that outpatients scored high on the latent continuum of the Grandiosity scale. Group comparison showed large effect sizes for the mean difference between patients and non-patients. The ROC curve supports a cut off at a -0.45 score in theta standardisation, which yields a high sensitivity (91%) and moderate specificity (58%). Moreover, the PPP (71%) and NPP (79%) values suggest that the scale is able to identify NPD patients in 71% of cases, and people without NPD in 79% of cases.

CONCLUSIONS

The findings suggest the IDCP-2 Grandiosity scale is useful as an NPD screening tool. Possible clinical applications for the scale are described and the limitations of the study are discussed.

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.

Homocysteine as a potential indicator of endothelial dysfunction and cardiovascular risk in female patients with borderline personality disorder

BACKGROUND

There is increasing evidence suggesting that patients with Borderline Personality Disorder (BPD) are at greater risk of developing cardiovascular diseases (CVD) compared to the general population. Homocysteine (Hcy) has been discussed as a serum marker for endothelial dysfunction as a mechanism involved in CVD and has been shown to be associated with numerous psychiatric conditions. Pathophysiologically, there seems to be a link between Hcy and psychological stress mediated by abnormal activity of the autonomic nervous system. Accordingly, the present study sought to examine Hcy in BPD and to explore possible associations with clinical parameters.

METHODS

Plasma Hcy levels as well as conventional cardiovascular risk factors, such as blood pressure, BMI, smoking habits, HbA_1c, HDL, LDL, and cholesterol, were examined in 49 young female in-patients diagnosed with BPD and 50 psychologically healthy control subjects matched for age and sex. Assessment of borderline symptom severity, childhood trauma, exposure to chronic stress, and quality of sleep was performed using self-reported questionnaires.

RESULTS

BPD patients showed significantly higher mean plasma Hcy concentrations compared to controls, though below ranges considered pathological. Moreover, Hcy correlated significantly with the severity of childhood trauma, chronic stress, and subjective sleep disturbances. In a regression model BPD diagnosis was found to predict Hcy levels best.

CONCLUSION

In conclusion, young female BPD patients with no history of CVD show higher, though non-pathological, Hcy levels compared to healthy controls. Our findings seem to support the assumption that BPD is associated with increased risk of CVD, and that Hcy could serve as potential marker for risk evaluation of midlife CVD in BPD patients.

Risk of Neuropsychiatric Diseases According to the use of a Leukotriene Receptor Antagonist in Middle-Aged and Older Adults with Asthma: a Nationwide Population-Based Study Using Health Claims Data in Korea

BACKGROUND

Although a leukotriene receptor antagonist (LTRA) is an effective drug for asthma, there has been increasing concern regarding neuropsychiatric (NP) adverse reactions. However, evidence for this association is not sufficient, especially in adults.

OBJECTIVE

To investigate the association between the use of an LTRA and the risk of developing NP diseases in adults with asthma.

METHODS

We performed a nationwide, retrospective, cohort study using data from the National Health Insurance Service-Health Screening Cohort (NHIS-HEALS). We selected asthma patients with no previous use of an LTRA, and NP outcomes were defined by the registration of certain International Classification of Diseases, 10th Revision codes (F00-F59) during follow-up. We obtained the hazard ratio (HR) for NP diseases according to the use of an LTRA.

RESULTS

Overall, 61,571 asthma patients without LTRA experience were enrolled, and 12,168 of them took an LTRA during the follow-up period. In the adjusted model, the HR for newly diagnosed NP diseases showed no significant difference according to use of an LTRA (HR 1.01; 95% confidence interval 0.83-1.23; P = .952). Subgroup analysis for associations between duration of LTRA use and risk of NP disease indicated no significance for all groups (<6, 6 to <12, 12 to <24, and ≥24 months). Common NP diseases included dementia (75.4% vs 76.1%), mood disorders (12.68% vs 12.80%), and panic disorders (5.63% vs 3.53%) in LTRA users and non-LTRA users, respectively, and there was no significant difference in the prevalence of each NP disease in either group.

CONCLUSIONS

The current study showed the use or duration of LTRA exposure was not associated with the occurrence of NP diseases in Korean adult asthmatics.

Impact of Childhood Maltreatment in Borderline Personality Disorder on Treatment Response to Intensive Dialectical Behavior Therapy

Childhood maltreatment (CM), including emotional, physical, and sexual abuse and emotional and physical neglect, is associated with severity of borderline personality disorder (BPD). However, knowledge on the impact of CM on treatment response is scarce. The authors investigated whether self-reported CM or one of its subtypes affected treatment retention, depressive symptoms, and impulsivity throughout short-term intensive dialectical behavior therapy (I-DBT) in 333 patients with BPD. Data were analyzed with linear and logistic regressions and linear mixed models, using a Bayesian approach. Patients who reported childhood emotional abuse had a higher dropout rate, whereas it was lower in patients who reported childhood emotional neglect. Emotional neglect predicted a greater decrease of depressive symptoms, and global CM predicted a greater decrease of impulsivity. The authors concluded that patients with BPD who experienced CM might benefit from I-DBT in specific symptom domains. Nonetheless, the impact of emotional abuse on higher dropout needs to be considered.

Looking at the bigger picture: Cortical volume, thickness and surface area characteristics in borderline personality disorder with and without posttraumatic stress disorder

Borderline personality disorder (BPD) is a severe psychiatric disorder accompanied by multiple comorbidities. Neuroimaging studies have identified structural abnormalities in BPD with most findings pointing to gray matter volume reductions in the fronto-limbic network, although results remain inconsistent. Similar alterations were found in posttraumatic stress disorder (PTSD), a common comorbidity of BPD. Only a small number of studies have investigated structural differences in BPD patients regarding comorbid PTSD specifically and studies conducting additional surface analyses are scarce. We investigated structural differences in women with BPD with and without PTSD and non-patient controls. Automated voxel-based and region-based volumetric analyses were applied. Additionally, four surface-based measures were analyzed: cortical thickness, gyrification index, fractal dimension, and sulcus depth. Analyses did not identify cortical volume alterations in the fronto-limbic network. Instead, hypergyrification was detected in the right superior parietal cortex in BPD patients compared to non-patient controls. No distinction was revealed between BPD patients with and without PTSD. These findings underline the importance of a holistic investigation examining volumetric and surface measures as these might enhance the understanding of structural alterations in BPD.

Effectiveness of dialectical behavior therapy skills training group for adults with borderline personality disorder

OBJECTIVE

This study evaluated the effectiveness of the Dialectical Behavior Therapy Skills Training Group (DBT-ST) component of DBT.

METHOD

Participants (N = 114) attended an 18-20-week DBT-ST. The study utilized a quasi-experimental design with a within-persons control group for a measure of borderline personality disorder (BPD) symptoms (at referral), and emergency department (ED) presentations, and psychiatric bed-days (both assessed for 6 months pre- and post-intervention). Primary outcomes were the number of BPD symptoms, psychological distress, depression, rate of ED presentations, and psychiatric inpatient bed-days.

RESULTS

After completing DBT-ST, participants had reduced BPD symptoms, psychological distress, and depression (p < 0.001). The waitlist control group showed no improvement in BPD symptoms (p = 0.085). The rate of ED presentations was reduced (p = 0.001). There was no reduction in psychiatric inpatient bed-days (p = 0.160), likely due to insufficient power.

CONCLUSIONS

DBT-ST participation in addition to treatment-as-usual is an effective treatment for people with BPD.

A Day in the Life of Borderline Personality Disorder: A Preliminary Analysis of Within-Day Emotion Generation and Regulation

In Linehan's (1993) biosocial theory, borderline personality disorder (BPD) results in part from frequent, intense, negative emotions and maladaptive behavioral responses to those emotions. We conducted a secondary data analysis of an intensive single-case experimental design to explore hourly relations among behavioral responses and emotions in BPD. Eight participants with BPD (M _age = 21.57, 63% female; 63% Asian) reported their emotions and behaviors hourly on two days. Participants reported a neutral-to-negative average emotional state with substantial variability each day. This emotional state was characterized most frequently by anxiety and joy. Participants tended to "dig into", or savor, experiences of joy, but problem-solve around, push away, or accept anxiety. Acceptance predicted hour-by-hour increases in negative emotion intensity, and pushing emotions away predicted hour-by-hour increases in positive emotion intensity. These results suggest that anxiety dominates the emotional experiences of people with BPD and co-occurs with a variety of emotion regulation strategies, while joy co-occurs with strategies designed to prolong emotional experiences. Despite its general adaptiveness, acceptance may be less effective, and pushing emotions away may be more effective, than other emotion regulation strategies at improving momentary negative emotions for those with BPD. We discuss the preliminary nature of these findings and encourage future researchers to build on them in larger samples with more severe presentations of BPD.

Toward Developing Clinical cut-off for the Grandiosity Scale of the Dimensional Clinical Personality Inventory 2

OBJECTIVE

The present study aims to establish a clinical cut-off for the Grandiosity dimension, using item-level evaluation procedures.

METHODS

Participants were 5,387 adults, including outpatients diagnosed with narcissistic personality disorder (NPD), outpatients diagnosed with other personality disorders, and adults from the community. We administered the self-reported Grandiosity scale from the Dimensional Clinical Personality Inventory 2 (IDCP-2). The equating procedure was applied to generate theta scores for participants who did not answer all items.

RESULTS

The Wright map revealed that outpatients scored high on the latent continuum of the Grandiosity scale. Group comparison showed large effect sizes for the mean difference between patients and non-patients. The ROC curve supports a cut off at a -0.45 score in theta standardisation, which yields a high sensitivity (91%) and moderate specificity (58%). Moreover, the PPP (71%) and NPP (79%) values suggest that the scale is able to identify NPD patients in 71% of cases, and people without NPD in 79% of cases.

CONCLUSIONS

The findings suggest the IDCP-2 Grandiosity scale is useful as an NPD screening tool. Possible clinical applications for the scale are described and the limitations of the study are discussed.

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.

Developmental Trajectories of Adolescent Girls' Borderline Personality Symptoms and Sexual Risk Behaviors

Adolescence is a developmental period during which youth tend to initiate sexual behavior, which may include sexual risk behavior. Symptoms of borderline personality disorder (BPD) are associated with increased rates of risky behaviors. However, little is known about longitudinal associations between BPD symptoms and sexual risk behaviors during adolescence. This study examines developmental trajectories of adolescent girls' BPD symptoms and sexual risk behaviors in a community sample of Black and White girls from the Pittsburgh Girls Study (n = 1620). Dual trajectory modeling provided insights into the temporal precedence and co-development of BPD symptoms and sexual risk behaviors from ages 14 to 18. In order to examine the unique association between BPD symptoms and sexual risk behaviors, analyses controlled for symptoms of depression and conduct disorder, as well as race, sexual orientation, and pubertal development. Girls with more BPD symptoms at age 14 showed steeper growth over time in sexual risk behaviors from ages 14 to 18. Additionally, adolescents who showed steeper increases in BPD symptoms over time also showed steeper increases in sexual risk behaviors across adolescence. Notably, however, sexual risk behavior at age 14 was not significantly associated with longitudinal trajectories of BPD symptoms. Results suggest that adolescent girls with early symptoms of BPD are at heightened risk for the development of sexual risk behaviors during adolescence, while the reverse association does not hold. Implications for adolescent development and sexual risk behavior are discussed.

Subcortical brain morphometry of avoidant personality disorder

BACKGROUND

Avoidant personality disorder (AvPD) is a condition typified by social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. AvPD has a high comorbidity rate with other personality disorders and other psychological diagnostic categories. There is very little research investigating subcortical volumetry in AvPD. We studied subcortical brain morphometry in AvPD as compared to both healthy controls and comorbidity-matched psychiatric controls (patients in the same clinic matched for age, sex and all psychiatric diagnoses except for AvPD).

METHODS

We compared volumetric measures of 9 bilateral subcortical brain regions between AvPD patients, healthy controls, and psychiatric controls (n = 100 each group). The Bonferroni correction was used to control for multiple comparisons across regions (p < 0.0028).

RESULTS

Compared to healthy controls, AvPD patients had lower volume of the left accumbens and left thalamus. However, no significant results were found when comparing AvPD patients and psychiatric controls. An exploratory study of cortical regions showed similar results: statistically significant differences between HC and AvPD (left lateral occipital, left and right pericalcarine smaller in AvPD) but no differences between AvPD and PC.

LIMITATIONS

MRI and neuroimaging provides correlational information, and no causal claims can be made.

CONCLUSIONS

These results suggest there may be no overt subcortical volumetric differences specific to AvPD, and provide strong cautionary advice when comparing patients to healthy controls, a common practice in psychiatry biomarker research.

Subjective experience of the origin and development of avoidant personality disorder

OBJECTIVE

To better understand how persons diagnosed with avoidant personality disorder (AVPD) make sense of the origin and development of their current everyday struggles.

METHODS

Persons with AVPD (N = 15) were interviewed twice using semi-structured qualitative interviews, which were analyzed through interpretative-phenomenological analysis. Persons with the first-hand experience of AVPD were included in the research.

RESULTS

The superordinate theme, "a story of becoming forlorn," encompassed three main themes: "it goes all the way back to when I was little," "there was a distance between others and me," and "transitions made it worse."

CONCLUSIONS

Though the results are not necessarily specific to AVPD, the findings clarify how people with AVPD can make sense of their current struggles by constructing developmental life stories in the interplay between themselves as persons and the growing demands of their social world. Furthermore, childhood relational vulnerabilities may challenge the ongoing development of social cognition and skills.

Adult attachment anxiety moderates the relation between self-reported childhood maltreatment and borderline personality disorder features

Childhood maltreatment is one of many risk factors for borderline personality disorder (BPD). However, not all individuals with BPD report histories of childhood maltreatment. Therefore, it is necessary to identify factors that contextualize the relation between childhood maltreatment and BPD features. With its emphasis on the developmental origins of emotion regulation, attachment theory provides a useful framework to understand how people are differentially affected by early life stress. The present study examined self-reported adult attachment as a moderator in the relation between childhood maltreatment and BPD features in a large undergraduate sample (n = 1 033). Attachment anxiety, but not attachment avoidance, moderated the relation between childhood maltreatment and BPD features, and this relation was non-significant among participants low (-1 standard deviation) in attachment anxiety. These results support the hypothesis that secure attachment in adulthood may buffer against the otherwise deleterious effects of distal risk factors on personality pathology. Future research should continue to examine this question across risk factors and across disorders. Furthermore, we suggest that researchers who have historically examined attachment as a mediator cross-sectionally should re-examine their data for evidence of a moderation effect. © 2019 John Wiley & Sons, Ltd.

Quality or quantity? A multistudy analysis of emotion regulation skills deficits associated with borderline personality disorder

Linehan's (1993) biosocial theory posits that people with borderline personality disorder (BPD) have emotion regulation skills deficits characterized by (a) less frequent use of adaptive emotion regulation strategies, (b) more frequent use of maladaptive strategies, or (c) poorer quality strategy implementation (i.e., strategies implemented less skillfully). We tested these possibilities among participants with BPD, major depressive disorder (MDD), or no disorder (controls). Study 1 participants (N = 272) were recruited online; Study 2 participants (N = 90) completed in-person diagnostic assessments. The BPD groups reported greater use of maladaptive strategies than the MDD (d = .35) and control (d = 1.54) groups and lower quality implementation than the MDD (d = -.33) and control groups (d = -.97). BPD participants reported similar use of adaptive strategies as the MDD group (d = -.09) but less use than controls (d = -.47). BPD may be uniquely characterized by overuse of maladaptive strategies and poorer quality emotion regulation implementation. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Individuals' experiences with brief admission during the implementation of the brief admission skåne RCT, a qualitative study

BACKGROUND

Brief admission (BA) is an adjunctive treatment option for individuals with self-harming behavior, having traits of borderline personality disorder (BPD). It is offered alongside outpatient psychotherapy for the purpose of strengthening autonomy, self-reflection and self-care and to increase the likelihood of being able to stay in therapy by avoiding lengthy inpatient hospitalizations.

AIMS

To investigate participants' experiences with BA during the pilot phase of the Brief Admission Skåne Randomized Controlled Trial (BASRCT), in order to detect possible strengths and limitations of the intervention and gain knowledge to facilitate implementation of BA at other treatment centers.

METHOD

Eight participants randomized to BA were interviewed to obtain their experience of BA, or alternatively their reasons for choosing not to use BA. Thematic analysis was conducted upon their transcribed interviews.

RESULTS

Reported as most helpful by the participants was the structure/routines at the ward and the positive attitudes from the staff. However, some individuals reported problems with perceived negative attitudes from the staff administering BA and negative rumination about themselves. The reported reasons to request BA were: preventing urges to self-harm from escalating; ending isolation; preventing longer admissions and forced admission; feelings of emotional exhaustion, and the need for rest and support in re-creating a daily routine. Reasons for not requesting BA were fear of rejection, questioning the method; presumed room shortage; difficulties in deciding whether one's problems are serious enough; experiencing the situation to be too clinically acute.

CONCLUSION

The results from this study indicated the importance of repeated staff education on all aspects of BA when it is being newly implemented, as well as the importance of working with attitudes of staff delivering BA. These were the key ingredients in making BA implementation successful. Our findings may be of value to other treatment centers implementing BA for the first time.

TRIAL REGISTRATION

NCT02985047.

Components of Brief Admission as a Crisis Intervention for Patients With a Borderline Personality Disorder: Results of a Delphi Study

BACKGROUND

Brief admission (BA) is a widely used intervention for patients with a borderline personality disorder but it has not yet clearly defined and still lacks clear operational standards. To fully develop this intervention, the relevant components need to be identified and clearly documented.

OBJECTIVE

To obtain consensus on the components of BA as a crisis intervention for patients with a borderline personality disorder.

DESIGN

Modified Delphi study.

RESULTS

Consensus of 100% was reached for the components: "BA plan must be developed together with the patient"; "The BA intervention should be mentioned in the care plan for the patient"; "Not all behavior on the part of the patient has to be accepted during a BA"; and "The BA can only be offered together with treatment by a community care professional."

CONCLUSION

Consensus on the components of BA was reached for 82 of the 90 components. This indicates a substantial degree of agreement on what BA should entail.

A new look at the schema therapy model: organization and role of early maladaptive schemas

This study reexamined the organization of Young's 18 early maladaptive schemas and their hypothesized associations with experiences of need-thwarting parental experiences in childhood and the "vulnerable child" mode of emotional distress in adulthood. A large Danish sample (N = 1054) of 658 clinical- and 391 nonclinical adults completed measures of early maladaptive schemas, parenting styles, and the vulnerable child mode. We identified four higher-order schema domains as most appropriate in terms of interpretability and empirical indices ("Disconnection & Rejection", "Impaired Autonomy & Performance", "Excessive Responsibility & Standards", and "Impaired Limits"). All four schema domains were differentially associated with conceptually relevant need-thwarting parental experiences. Apart from "Impaired Limits", the schema domains meaningfully accounted for the association between need-thwarting parental experiences in childhood and emotional states of feeling like a "vulnerable child" in adulthood. We conclude that four domains of early maladaptive schemas are empirically and conceptually consistent with Young's schema therapy model of personality pathology and longstanding emotional disorders. Findings warrant replication using different populations and if possible a prospective multi-method design. A scoring key for computing the four schema domains is provided.

Borderline Personality Disorder and Narcissistic Personality Disorder Diagnoses From the Perspective of the DSM-5 Personality Traits: A Study on Italian Clinical Participants

To evaluate the associations between Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) Alternative Model of Personality Disorder traits and domains and categorically diagnosed narcissistic personality disorder (NPD) and borderline personality disorder (BPD), respectively, 238 inpatient and outpatient participants who were consecutively admitted to the Clinical Psychology and Psychotherapy Unit of San Raffaele Hospital in Milan, Italy, were administered the Personality Inventory for DSM-5 (PID-5) and the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). Based on SCID-II, the participants were assigned to the following groups: a) NPD (n = 49), b) BPD (n = 32), c) any other PD (n = 91), and d) no PD (n = 63). Emotional lability, separation insecurity, depressivity, impulsivity, risk taking, and hostility were significantly associated with BPD diagnosis. Attention seeking significantly discriminated participants who received an SCID-II categorical NPD diagnosis. Separation insecurity, impulsivity, distractibility, and perceptual dysregulation were the DSM-5 traits that significantly discriminated BPD participants. Domain-level analyses confirmed and extended trait-level findings.

Group schema therapy versus group cognitive behavioral therapy for social anxiety disorder with comorbid avoidant personality disorder: study protocol for a randomized controlled trial

BACKGROUND

Social anxiety disorder (SAD) with comorbid avoidant personality disorder (APD) has a high prevalence and is associated with serious psychosocial problems and high societal costs. When patients suffer from both SAD and APD, the Dutch multidisciplinary guidelines for personality disorders advise offering prolonged cognitive behavioral therapy (CBT). Recently there is increasing evidence for the effectiveness of schema therapy (ST) for personality disorders such as borderline personality disorder and cluster C personality disorders. Since ST addresses underlying personality characteristics and maladaptive coping strategies developed in childhood, this treatment might be particularly effective for patients with SAD and comorbid APD. To our knowledge, there are no studies comparing CBT with ST in this particular group of patients. This superiority trial aims at comparing the effectiveness of these treatments. As an additional goal, predictors and underlying mechanisms of change will be explored.

METHODS/DESIGN

The design of the study is a multicentre two-group randomized controlled trial (RCT) in which the treatment effect of group cognitive behavioral therapy (GCBT) will be compared to that of group schema therapy (GST) in a semi-open group format. A total of 128 patients aged 18-65 years old will be enrolled. Patients will receive 30 sessions of GCBT or GST during a period of approximately 9 months. Primary outcome measures are the Liebowitz Social Anxiety Scale Self-Report (LSAS-SR) for social anxiety disorder and the newly developed Avoidant Personality Disorder Severity Index (AVPDSI) for avoidant personality disorder. Secondary outcome measures are the MINI section SAD, the SCID-II section APD, the Schema Mode Inventory (SMI-2), the Inventory of Depressive Symptomatology Self-Report (IDS-SR), the World Health Organization Quality of Life-BREF (WHOQOL-BREF), the Difficulties in Emotion Regulation Scale (DERS), the Rosenberg Self-Esteem Scale (RSES) and the Acceptance and Action Questionnaire (AAQ-II). Data will be collected at the start, halfway and at the end of the treatment, followed by measurements at 3, 6 and 12 months post-treatment.

DISCUSSION

The trial will increase our knowledge on the effectiveness and applicability of both treatment modalities for patients suffering from both diagnoses.

TRIAL REGISTRATION

Dutch Trial Register: NTR3921 . Registered on 25 March 2013.

The Blending of Evidenced-Based Protocols in the Treatment of Borderline Personality Disorder

Borderline personality disorder (BPD) is regarded as one of the more difficult clinical presentations to treat, and psychotherapy provides the best outcomes for those suffering with BPD. Dialectical behavioral therapy (DBT) and schema-focused therapy (SFT) are two of the most common evidenced-based treatments for borderline pathology. While these treatments are often used individually, some theorists argue that blended approaches to care could provide more benefit to some clients than just one treatment package alone. The present case study illustrates a blended approach to the treatment of BPD. Specifically, DBT and SFT were used in consort to treat “Luisa,” a 34-year-old biracial woman of Caucasian and Hispanic descent who struggled with longstanding interpersonal distress, emotional lability, and identity disturbance. Her treatment course is described in detail, and the implications of this approach to care are discussed.

Co-morbidity of personality disorder in schizophrenia among psychiatric outpatients in China: data from epidemiologic survey in a clinical population

BACKGROUND

The reported rates of personality disorder (PD) in subjects with schizophrenia (SZ) are quite varied across different countries, and less is known about the heterogeneity of PD among subjects with SZ. We examined the co-morbidity of PD among patients who are in the stable phase of SZ.

METHOD

850 subjects were randomly sampled from patients diagnosed with SZ in psychiatric and psycho-counseling clinics at Shanghai Mental Health Center. Co-morbidity of PDs was assessed through preliminary screening and patients were administered several modules of the SCID-II. Evidence of heterogeneity was evaluated by comparing patients diagnosed with SZ with those who presented with either affective disorder or neurosis (ADN).

RESULTS

204 outpatients (24.0 %) in the stable phase of SZ met criteria for at least one type of DSM-IV PD. There was a higher prevalence of Cluster-A (odd and eccentric PD) and C (anxious and panic PD) PDs in SZ (around 12.0 %). The most prevalent PD was the paranoid subtype (7.65 %). Subjects with SZ were significantly more likely to have schizotypal PD (4.4 % vs. 2.1 %, p = 0.003) and paranoid PD (7.6 % vs. 5.4 %, p = 0.034), but much less likely to have borderline, obsessive-compulsive, depressive, narcissistic and histrionic PD.

CONCLUSIONS

These findings suggest that DSM-IV PD is common in patients with SZ than in the general population. Patterns of co-morbidity with PDs in SZ are different from ADN.

Development and Examination of the Five-Factor Obsessive-Compulsive Inventory–Short Form

The Five-Factor Obsessive-Compulsive Inventory (FFOCI) is an assessment of obsessive-compulsive personality disorder (OCPD) that is based on the conceptual framework of the five-factor model (FFM) of personality. The FFOCI has 12 subscales that assess those five-factor model facets relevant to the description of OCPD. Research has suggested that the FFOCI scores relate robustly to existing measures of OCPD and relevant scales from general personality inventories. Nonetheless, the FFOCI’s length—120 items—may limit its clinical utility. This study derived a 48-item FFOCI–Short Form (FFOCI-SF) from the original measure using item response theory methods. The FFOCI-SF scales successfully recreated the nomological network of the original measure and improved discriminant validity relative to the long form. These results support the use of the FFOCI-SF as a briefer measure of the lower-order traits associated with OCPD.

Avoidant Personality Disorder: a Current Review

This review focuses on recent research on diagnostic aspects, etiology, and treatment of avoidant personality disorder (AVPD). Current studies stress the close relation between AVPD and social anxiety disorder, the influence of genetic factors in the development of AVPD, and the relative stability of symptoms. Treatment approaches should target the pervasive patterns of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Empirical evidence for cognitive-behavior and schema therapy is promising. Few other therapeutic approaches have been developed, but until now, these have only been investigated in case studies. We conclude that AVPD qualifies as a neglected disorder and that more research specifically on avoidant personality disorder symptoms and its treatment is needed.

Personality Disorder and Changes in Affect Consciousness: A 3-Year Follow-Up Study of Patients with Avoidant and Borderline Personality Disorder

Personality disorders (PDs) are highly prevalent in patients receiving psychiatric services, and are associated with significant personal and social costs. Over the past two decades, an increasing number of treatment studies have documented the effectiveness of treatment for patients with PDs, especially when it comes to reduction of symptom distress, risk taking behavior, self-harm, or suicide attempts. However, less is known about the more complex aims of improving the personality structure itself, such as identity- and interpersonal disturbances. Emotional dysfunction is closely associated with PD pathology. The present study investigated changes in affect consciousness (AC) in patients with avoidant or borderline PD, and how these changes were associated with clinical status after 3 years of follow-up. The study included 52 individuals; 79 percent were females, and mean age was 30 years. The evaluations included the Affect Consciousness Interview, Symptom Checklist-90-R, Circumplex of Interpersonal Problems, the Index of Self-Esteem, and three domains (Identity Integration, Relational Capacities, and Self-Control) of the Severity Indices of Personality Problems (SIPP-118). There was a significant increase in the Global AC and AC scores for most of the specific affects from baseline to follow-up. As the present study did not include a control group, it cannot be concluded that changes in AC are effects of psychotherapy, and the possibility of age-related maturation processes cannot be excluded. The change in Global AC contributed significantly to explained variance in the follow-up levels of Circumplex of Interpersonal Problems, and the two SIPP-118 domains Relational Capacities and Identity Integration. Improved AC was not associated with change in the Self-Control domain or the Global Severity Index of Symptom Checklist-90-R. The results suggest that AC may be altered for patients with borderline and avoidant PDs, and this is the first study to report that improvement in AC contribute significantly to the variance in the self- and interpersonal domains of personality functioning.

Experiences of patients with borderline personality disorder with the brief admission intervention: a phenomenological study

Brief admission is a crisis intervention for patients with borderline personality disorder (BPD), and refers to a clinical admission at a psychiatric hospital for a period of 1-5 nights. Patients formulate a treatment plan together with their community mental health nurse about the maximum frequency allowed for these brief admissions. The purpose of the study was to describe the lived experiences of patients with BPD with use of the brief admission intervention. The study used a phenomenological approach. Inclusion criteria were a diagnosis of BPD, according to the Diagnostic and Statistical Manual of Mental Disorders-IV criteria; experience with brief admission, and sufficient understanding of the Dutch language. A total of 16 female patients and one male patient participated in the study. Thematic analysis of the transcripts of the interviews revealed four major meaning units: (i) organization of the brief admission; (ii) contact with a nurse; (iii) time out from daily life; and (iv) experienced value for the patient. Patients highlighted the quality of the contact with a nurse as the most important aspect of the brief admission. Nurses should be aware of the importance of connecting with patients who have BPD during a brief admission, particularly in light of the interpersonal hypersensitivity that characterizes these patients.

Association between genetic polymorphisms in the serotonergic system and comorbid personality disorders among patients with first-episode depression

Studies on the association between genetic polymorphisms and personality disorders have provided inconsistent results. Using the "enriched sample method," the authors of the present study aimed to assess the association between polymorphisms in the serotonergic transmitter system and comorbid personality disorders in patients recently diagnosed with first-episode depression. A total of 290 participants were systematically recruited via the Danish Psychiatric Central Research Register. Diagnoses of personality disorders were assessed by a SCID-II interview, and polymorphisms in the genes encoding the serotonin transporter, serotonin receptors 1A, 2A, 2C, and tryptophan hydroxylase 1 were genotyped. The authors found a significant effect of the length polymorphism in the serotonin transporter gene (5-HTTLPR) on cluster B personality disorder (mainly borderline disorder), but no influence on cluster C personality disorder, and no associations between other polymorphisms and personality disorders. The study adds evidence to the effect of the serotonin transporter gene specifically on cluster B personality disorders.

Evidence base and components of Brief Admission as an intervention for patients with borderline personality disorder: a review of the literature

PURPOSE

To review the available evidence-based literature on the components of brief inpatient psychiatric hospital admission as an intervention for patients with borderline personality disorder.

DESIGN AND METHOD

Systematic literature search, narrative literature review. Content analysis.

FINDINGS

Five key components of brief admission as an intervention were identified: discussion of goals; organization of Brief Admission; clear admission procedure; specification of any other interventions during Brief Admission; and stipulation of conditions for premature (i.e., forced) discharge.

RESEARCH AND PRACTICE IMPLICATIONS

Brief Admission can be effectively used to prevent self-harm and suicide in patients with borderline personality disorder. During the Brief Admission, psychiatric nurses can support these patients achieving an active coping in dealing with their symptoms.

Comparing methods for scoring personality disorder types using maladaptive traits in DSM-5

The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th ed.) Section III will include an alternative hybrid system for the diagnosis of personality disorder (PD). This alternative system defines PD types partly through specific combinations of maladaptive traits, rather than by using a set of polythetic diagnostic criteria. The current report utilizes a large sample of undergraduates (n = 1,159) to examine three dimensional methods for comparing an individual's trait profile to each PD type. We found that the sum of an individual's scores on the assigned traits obtained large convergent correlations (Mdn r =.61) and best reproduced the patterns of PD discriminant correlations observed within the DSM-IV measure. We also tested the DSM-5 Section III model algorithms and compared them with different thresholds for assigning categorical diagnoses. Frequency rates using the algorithms were greatly reduced, whereas requiring half of the assigned traits produced rates that more closely approximated current prevalence estimates. Our research suggests that DSM-5 Section III trait model can reproduce the DSM-IV-TR PD constructs and identifies effective methods of doing so.

Novel insights into the genetic and epigenetic paternal contribution to the human embryo

The integrity of the sperm genome and epigenome are critical for normal embryonic development. The advent of assisted reproductive technology has led to an increased understanding of the role of sperm in fertilization and embryogenesis. During fertilization, the sperm transmits not only nuclear DNA to the oocyte but also activation factor, centrosomes, and a host of messenger RNA and microRNAs. This complex complement of microRNAs and other non-coding RNAs is believed to modify important post-fertilization events. Thus, the health of the sperm genome and epigenome is critical for improving assisted conception rates and the birth of healthy offspring.

Treatment for comorbid borderline personality disorder and alcohol use disorders: a review of the evidence and future recommendations

There is a high degree of comorbidity between borderline personality disorder (BPD) and alcohol use disorders (AUDs). There is some evidence that this pattern of comorbidity may be associated with poorer prognosis. Although there are many different psychotherapeutic and pharmacological treatments for BPD and AUDs when they occur alone, there are very few treatment options when they occur together. The objective of this article was to review the existing treatment options-both psychotherapeutic and pharmacological-for patients with dual diagnoses of BPD and AUDs and to explore alternative treatment options that warrant further study. There have been a number of studies that have examined the efficacy of specific psychotherapies targeting drinking among patients with comorbid BPD; however, their efficacy in reducing BPD symptoms is unknown. There are also three psychotherapies that were specifically developed for patients with BPD and substance use disorders (SUDs), but only one of these (Dynamic Deconstructive Psychotherapy) has been tested among patients with dual diagnoses of BPD and AUDs. Research on pharmacotherapy for dual diagnoses of BPD and AUD is scarce, and no study has yet explored medication options that can concurrently manage symptoms of BPD and decrease alcohol consumption. Interestingly, there is growing evidence that anticonvulsants and second generation antipsychotics, the recent medications of choice for the management of BPD symptoms, may also reduce alcohol craving and consumption. Although premature, these findings are encouraging especially for this population of patients for whom treatment options are very limited.

Conceptual changes to the definition of borderline personality disorder proposed for DSM-5

The Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 Personality and Personality Disorders Work Group proposed the elimination of diagnostic criterion sets in favor of a prototype matching system that defines personality disorders using narrative descriptions. Although some research supports this general approach, no empirical studies have yet examined the specific definitions proposed for DSM-5. Given the wide interest in borderline personality disorder (BPD), it is crucial to determine how this methodological shift might affect the content and conceptualization of the diagnosis. Eighty-two experts on BPD provided ratings of the DSM-IV-TR or DSM-5 version of BPD in terms of 37 traits proposed for DSM-5. Analyses revealed significant and meaningful differences among the two constructs, with the DSM-5 version evincing increased interpersonal dependency but a decreased emphasis on antagonism and disinhibition. A second study within a clinical sample demonstrated that both antagonism and disinhibition mediated the relationships between DSM-IV BPD and impairment, suggesting that the proposed changes might have important consequences for BPD's coverage, prevalence, and nomological network. More globally, our results illustrate that unanticipated shifts in diagnostic constructs can stem from seemingly minor revisions and suggest that research is needed to understand how these, or other changes, might affect our conceptualization, diagnosis, and treatment of BPD.

Impact of the genome on the epigenome is manifested in DNA methylation patterns of imprinted regions in monozygotic and dizygotic twins

One of the best studied read-outs of epigenetic change is the differential expression of imprinted genes, controlled by differential methylation of imprinted control regions (ICRs). To address the impact of genotype on the epigenome, we performed a detailed study in 128 pairs of monozygotic (MZ) and 128 pairs of dizygotic (DZ) twins, interrogating the DNA methylation status of the ICRs of IGF2, H19, KCNQ1, GNAS and the non-imprinted gene RUNX1. While we found a similar overall pattern of methylation between MZ and DZ twins, we also observed a high degree of variability in individual CpG methylation levels, notably at the H19/IGF2 loci. A degree of methylation plasticity independent of the genome sequence was observed, with both local and regional CpG methylation changes, discordant between MZ and DZ individual pairs. However, concordant gains or losses of methylation, within individual twin pairs were more common in MZ than DZ twin pairs, indicating that de novo and/or maintenance methylation is influenced by the underlying DNA sequence. Specifically, for the first time we showed that the rs10732516 [A] polymorphism, located in a critical CTCF binding site in the H19 ICR locus, is strongly associated with increased hypermethylation of specific CpG sites in the maternal H19 allele. Together, our results highlight the impact of the genome on the epigenome and demonstrate that while DNA methylation states are tightly maintained between genetically identical and related individuals, there remains considerable epigenetic variation that may contribute to disease susceptibility.