Elements of affective instability associated with suicidal behaviour in patients with borderline personality disorder

An In-Depth Exploration of the Relationship Between Suicidal Ideation and Emotion Processes in Adolescents

Previous research has shown a relationship between proximal (i.e., close-in-time) emotion experiences and suicidal ideation (SI). Yet, it remains unclear which emotion processes (i.e., the level of the emotion [intensity], how much emotions vary [variability], emotional consistency [inertia], how specific emotions are [differentiation]) and which emotions (i.e., sadness, hopelessness, anger, nervousness, happiness) are most potent predictors of SI. Seventy-seven adolescents (67.5% assigned female at birth) completed daily diaries for 4 weeks after psychiatric hospitalization. Levels of the above-mentioned emotions and frequency of SI were recorded. For each week and each emotion, mean (intensity), standard deviation (variability), autocorrelation (inertia), and intraclass correlation coefficients (ICCs; negative emotion differentiation) were calculated (i.e., four observations/person). Multilevel models examined whether (a) mean intensity, variability, and their interaction; and (b) mean intensity, inertia, and their interaction, were related to mean weekly SI frequency. A separate model examined whether negative emotion differentiation was related to mean weekly SI frequency after adjusting for mean intensity. A significant interaction between mean intensity of anger and variability of anger emerged (B = 0.54, SE = 0.24, p = .023); a positive relationship between mean anger and mean SI frequency was present at moderate or high levels of anger variability but not at its low levels. Mean intensity of most emotions was related to SI frequency in the expected directions. No other statistically significant findings emerged. Results revealed the importance of considering multiple emotion features, their dynamic nature, and their combined effect. Future research should explore mechanisms accounting for anger being related to heightened proximal SI, along with an examination of effective intervention strategies to reduce anger intensity and variability.

One-Week Suicide Risk Prediction Using Real-Time Smartphone Monitoring: Prospective Cohort Study

BACKGROUND

Suicide is a major global public health issue that is becoming increasingly common despite preventive efforts. Though current methods for predicting suicide risk are not sufficiently accurate, technological advances provide invaluable tools with which we may evolve toward a personalized, predictive approach.

OBJECTIVE

We aim to predict the short-term (1-week) risk of suicide by identifying changes in behavioral patterns characterized through real-time smartphone monitoring in a cohort of patients with suicidal ideation.

METHODS

We recruited 225 patients between February 2018 and March 2020 with a history of suicidal thoughts and behavior as part of the multicenter SmartCrisis study. Throughout 6 months of follow-up, we collected information on the risk of suicide or mental health crises. All participants underwent voluntary passive monitoring using data generated by their own smartphones, including distance walked and steps taken, time spent at home, and app usage. The algorithm constructs daily activity profiles for each patient according to these data and detects changes in the distribution of these profiles over time. Such changes are considered critical periods, and their relationship with suicide-risk events was tested.

RESULTS

During follow-up, 18 (8%) participants attempted suicide, and 14 (6.2%) presented to the emergency department for psychiatric care. The behavioral changes identified by the algorithm predicted suicide risk in a time frame of 1 week with an area under the curve of 0.78, indicating good accuracy.

CONCLUSIONS

We describe an innovative method to identify mental health crises based on passively collected information from patients' smartphones. This technology could be applied to homogeneous groups of patients to identify different types of crises.

Predictors of suicidal ideation severity among treatment-seeking young people with major depressive disorder: The role of state and trait anxiety

OBJECTIVE

Depression and suicidal ideation are closely intertwined. Yet, among young people with depression, the specific factors that contribute to changes in suicidal ideation over time are uncertain. Factors other than depressive symptom severity, such as comorbid psychopathology and personality traits, might be important contributors. Our aim was to identify contributors to fluctuations in suicidal ideation severity over a 12-week period in young people with major depressive disorder receiving cognitive behavioural therapy.

METHODS

Data were drawn from two 12-week randomised, placebo-controlled treatment trials. Participants (N = 283) were 15-25 years old, with moderate to severe major depressive disorder. The primary outcome measure was the Suicidal Ideation Questionnaire, administered at baseline and weeks 4, 8 and 12. A series of linear mixed models was conducted to examine the relationship between Suicidal Ideation Questionnaire score and demographic characteristics, comorbid psychopathology, personality traits and alcohol use.

RESULTS

Depression and anxiety symptom severity, and trait anxiety, independently predicted higher suicidal ideation, after adjusting for the effects of time, demographics, affective instability, non-suicidal self-injury and alcohol use.

CONCLUSIONS

Both state and trait anxiety are important longitudinal correlates of suicidal ideation in depressed young people receiving cognitive behavioural therapy, independent of depression severity. Reducing acute psychological distress, through reducing depression and anxiety symptom severity, is important, but interventions aimed at treating trait anxiety could also potentially be an effective intervention approach for suicidal ideation in young people with depression.

The moderating role of sexual minority status in the associations of the experience and tolerance of shame-related emotions to suicide risk

OBJECTIVE

This study examined the associations of the experience and tolerance of shame-related emotions to suicide risk, as well as the moderating role of sexual minority status.

METHODS

Community adults (N = 360) were recruited via MTurk and completed self-report questionnaires. Hierarchical regression analyses examined the main and interactive associations of sexual minority status and shame-related variables to suicide risk.

RESULTS

Results revealed significant positive associations between self-disgust and suicide risk for sexual minority and heterosexual participants, although the magnitude was greater for sexual minority participants. Additionally, tolerance of shame was significantly negatively related to suicide risk only among sexual minority participants. Finally, exploratory analyses examining the three-way interaction of self-disgust, shame tolerance, and sexual minority status revealed a significant negative association between shame tolerance and suicide risk only among sexual minority participants with high levels of self-disgust.

CONCLUSION

Results highlight the relevance of shame-related experiences to suicide risk among sexual minorities.

Sex and age moderate the trajectory of guilt among children and adolescents with and without recent suicidal ideation

We aimed to examine whether the trajectories of ecologically derived guilt differ among a transdiagnostic sample of youth with and without recent suicidal ideation and whether sex and age moderated this association. We assessed guilt 3 times a day over a 2-week period via ecological momentary assessment (EMA) technology in 102 children recruited from the community, outpatient, and inpatient settings. The average age of children was 10.95 y.o. (SD = 2.26, range 8-16) and the majority were male (54.9%) and White (76.5%). We found that the real-world guilt during a two-week EMA period was higher among youth with greater suicidal ideation severity in the past six months. Moreover, there was a significant moderating effect of sex and age on this association, such that the association between suicidal ideation severity and guilt was particularly strong among females compared to males and youth who were 10 years old or older. The findings were maintained when we adjusted for the relevant demographic and clinical characteristics, including age, minority status, parental income, EMA response rate, and current internalising symptoms. These preliminary findings highlight the clinical relevance of assessing and targeting feelings of guilt in the day-to-day lives of youth, particularly for females and older youth.

Mood instability, depression, and anxiety in pregnancy and adverse neonatal outcomes

Background

Antenatal women experience an increased level of mood and anxiety symptoms, which have negative effects on mothers’ mental and physical health as well as the health of their newborns. The relation of maternal depression and anxiety in pregnancy with neonate outcomes is well-studied with inconsistent findings. However, the association between antenatal mood instability (MI) and neonatal outcomes has not been investigated even though antenatal women experience an elevated level of MI. We sought to address this gap and to contribute to the literature about pregnancy neonate outcomes by examining the relationship among antenatal MI, depression, and anxiety and neonatal outcomes.

Methods

A prospective cohort of women (n = 555) participated in this study at early pregnancy (T1, 17.4 ± 4.9 weeks) and late pregnancy (T2, 30.6 ± 2.7 weeks). The Edinburgh Postnatal Depression Scale (EPDS) was used to assess antenatal depressive symptoms, anxiety was measured by the EPDS anxiety subscale, and mood instability was measured by a visual analogue scale with five questions. These mood states together with stress, social support, as well as lifestyle were also examined in relation to neonatal outcomes using chi-square tests and logistic regression models.

Results

Mood instability, depression, and anxiety were unrelated to adverse neonatal outcomes. Only primiparous status was associated with small for gestational age after Bonferroni correction.

Conclusions

We report no associations between antenatal mood symptoms including MI, depression, and anxiety and neonatal outcomes. More studies are required to further explore the relationship between antenatal mood instability, depression, and anxiety and neonatal outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04021-y.

Tweet Classification to Assist Human Moderation for Suicide Prevention

Social media platforms are already engaged in leveraging existing online socio-technical systems to employ just-in-time interventions for suicide prevention to the public. These efforts primarily rely on self-reports of potential self-harm content that is reviewed by moderators. Most recently, platforms have employed automated models to identify self-harm content, but acknowledge that these automated models still struggle to understand the nuance of human language (e.g., sarcasm). By explicitly focusing on Twitter posts that could easily be misidentified by a model as expressing suicidal intent (i.e., they contain similar phrases such as "wanting to die"), our work examines the temporal differences in historical expressions of general and emotional language prior to a clear expression of suicidal intent. Additionally, we analyze time-aware neural models that build on these language variants and factors in the historical, emotional spectrum of a user's tweeting activity. The strongest model achieves high (statistically significant) performance (macro F1=0.804, recall=0.813) to identify social media indicative of suicidal intent. Using three use cases of tweets with phrases common to suicidal intent, we qualitatively analyze and interpret how such models decided if suicidal intent was present and discuss how these analyses may be used to alleviate the burden on human moderators within the known constraints of how moderation is performed (e.g., no access to the user's timeline). Finally, we discuss the ethical implications of such data-driven models and inferences about suicidal intent from social media. Content warning: this article discusses self-harm and suicide.

Use of Ecological Momentary Assessment to Study Suicidal Thoughts and Behavior: a Systematic Review

PURPOSE OF REVIEW

Ecological momentary assessment (EMA) is a recently introduced approach to patient evaluation that consists of asking patients questions in real time and in their usual habitat. This method seeks to contribute to suicide prevention by providing psychiatrists with detailed information about suicidal thoughts and behavior, how these fluctuate over short periods of time, and the short-term risk factors presented by patients. We conducted a systematic review of published research using EMA to study suicidal thoughts and behavior.

RECENT FINDINGS

Several systematic reviews of EMA in mental health have been conducted to date, and the literature contains numerous theoretical papers and compilations on EMA and suicide phenomena. To date, however, no systematic reviews have explored the use of this tool to study suicidal thoughts and behavior. We performed a systematic review of five databases (i.e., PubMed, Embase, Scopus, Web of Science, and PsycINFO) to identify studies on EMA and suicidal thoughts and behavior. An initial search revealed 544 articles. Following the study selection process, 35 studies were included in the review. Almost three-quarters of the studies were published in the last 4 years. The studies reviewed concluded that EMA was generally feasible and well accepted. EMA findings correlated well with the results of a retrospective assessment, though tended to over-represent symptom severity. Our review points to important aspects of suicidal thoughts and behavior, such as its wide fluctuation over short periods of time. Negative affect and disturbed sleep, among others, emerged as short-term predictors of suicidal thoughts and behavior. Therefore, EMA is a potentially useful tool in clinical practice, although not without drawbacks, such as participant fatigue with questionnaires and ethical concerns.

Role of affective instability on suicidal risk in complex regional pain syndrome: a diary approach (preliminary report)

Background

Many patients with complex regional pain syndrome (CRPS) have been known to be at risk of suicide, due to severe pain and its comorbid conditions. The risk of suicide may be associated with affective instability, which is an indicator of emotional dysregulation. Particularly, unstable shifts in negative emotions are difficult to cope with, which may result in individuals feeling uncontrollable, hopeless, and entrapped. This study aimed to examine the role of affective instability in the relationship between pain intensity and suicide risk (suicidal ideation and impulsivity) in patients with CRPS, by employing a daily diary.

Methods

Twenty-three patients registered at the CRPS Association in Korea were asked to complete a day-to-day routine for 15 days, followed by a diary composed of pain intensity, suicidal ideation, impulsivity, and positive and negative affects.

Results

Results showed that the interactions between negative affective instability and daily pain intensity were statistically significant on daily suicidal ideation (coefficient = 0.41, t (21) = 2.56, P < 0.050) and daily impulsiveness (coefficient = 1.20, t (19) = 3.35, P < 0.010). However, those between positive affective instability and daily pain intensity were not.

Conclusions

This study is the first attempt to investigate the role of affective instability on the relationship between daily pain intensity and daily suicide risk in patients with CRPS. Our findings suggest that health professionals pay considerable attention to the instability of negative affects when assessing and managing patients with CRPS at risk of suicide.

Mood instability during pregnancy and postpartum: a systematic review

Perinatal mood instability (MI) is a common clinical observation in perinatal women, and existing research indicates that MI is strongly associated with a variety of mental disorders. The purpose of this study is to review the evidence of perinatal MI systematically, with a focus on perinatal MI, its relation to perinatal depression, and its effects on children. A systematic search of the literature using PRISMA guidelines was conducted on seven academic health databases to identify any peer-reviewed articles published in English from 1985 to July 2017. Studies were screened, data were extracted, and quality of the selected studies was assessed. A total of 1927 abstracts were returned from the search, with 1063 remaining for abstract screening after duplicate removal, and 4 quantitative studies were selected for final analysis. The selected studies addressed perinatal MI (n = 2), the relation of perinatal MI to perinatal depression (n = 1), and the effects of perinatal MI on children (n = 1). The selected studies identified that perinatal women experienced a significantly higher level of MI than non-perinatal women, MI is a prominent feature in perinatal women with and without depression, mood lability during the early postpartum predicts psychopathology up to 14 months postpartum, and maternal emotion dysregulation, rather than maternal psychopathology, increases the risk of heightened facial affect synchrony in mother-infant interaction. The study reveals a significant gap in the literature of perinatal MI.

Relationships between the frequency and severity of non-suicidal self-injury and suicide attempts in youth with borderline personality disorder

AIM

Non-suicidal self-injury (NSSI) is a recognized indicator of suicide risk. Yet, the ubiquity of this behaviour in borderline personality disorder (BPD) limits its utility as a predictor of risk. Consequently, this study aimed to elucidate the relationship between other features of NSSI, including frequency and severity, and suicide attempts.

METHOD

Participants included 107 youth (15 to 25 year olds) with BPD who were assessed for BPD severity, depressive symptoms, 12-month frequency of NSSI and suicide attempts, as well as the levels of treatment sought following each self-harm event.

RESULTS

Three-quarters (75.7%) of youth with BPD reported NSSI and two-thirds (66.4%) reported a suicide attempt over the previous 12 months. The frequency of NSSI over the previous 12 months did not show a linear or quadratic relationship with the number of suicide attempts when adjusting for severity of depression, impulsivity and interpersonal problems. NSSI severity was not associated with more frequent suicide attempts. Only impulsivity and depression were uniquely predictive of suicide attempt frequency. A relative increase in the frequency and severity of NSSI occurred in the months prior to a suicide attempt.

CONCLUSION

The prevalence of NSSI and suicide attempts among youth presenting for their first treatment of BPD appear to be perilously high, considerably higher than rates reported by adults with BPD. Findings suggest that clinicians should give more weight to average levels of impulsivity and depression, rather than the absolute frequency and severity of NSSI, when assessing for risk of suicide attempts. Notwithstanding this, a relative increase in the frequency and severity of NSSI appears to be predictive of a forthcoming suicide attempt.

Neuroticism and suicide in a general population cohort: results from the UK Biobank Project

BACKGROUND

Neuroticism has often been linked to suicidal thoughts and behaviour.

AIMS

To examine whether neuroticism is associated with suicide deaths after adjusting for known risks.

METHOD

UK Biobank participants (n = 389 365) were assessed for neuroticism as well as social, demographic and health-related variables at study entry and followed for up to 10 years. Suicide risk was modelled using Cox regression stratified by gender.

RESULTS

Neuroticism increased the risk of suicide in both men (hazard ratio (HR) = 1.15, 95% CI 1.09-1.22) and women (HR = 1.16, 95% CI 1.06-1.27). In a subsample who were assessed for mood disorders, neuroticism remained a significant predictor for women (HR 1.25, 95% CI 1.03-1.51) but not for men.

CONCLUSIONS

Screening and therapeutic interventions for neuroticism may be important for early suicide prevention.

DECLARATION OF INTEREST

None.

Affect in response to stressors and coping strategies: an ecological momentary assessment study of borderline personality disorder

BACKGROUND

Affect instability is a core symptom of borderline personality disorder (BPD). Ecological momentary assessment allows for an understanding of real-time changes in affect in response to various daily stressors. The purpose of this study was to explore changes in affect in response to specific stressors and coping strategies in subjects with BPD utilizing ecological momentary assessment (EMA) methodology.

METHODS

Subjects (n = 50) with BPD were asked to complete real-time assessments about stressors experienced, affect felt, and coping strategies employed six times per day for a 1-week period. Mixed effect regression models were used to measure the effect of stressors and coping strategies on affect change.

RESULTS

While most stressors led to experiencing more negative affect, only being in a disagreement was independently associated with increased negative affect. Among coping strategies, only doing something good for oneself independently reduced negative affect, controlling for all other coping strategies used.

CONCLUSIONS

These findings provide valuable insights into affective instability in BPD and can help inform treatment with individuals with the disorder.

Clinical features and psychiatric comorbidities of borderline personality disorder patients with versus without a history of suicide attempt

Patients with borderline personality disorder (BPD) are at high risk for suicidal behavior. However, many BPD patients do not engage in suicidal behavior. In this study, we compared clinical features of BPD patients with or without a history of suicide attempts and healthy volunteers. Compared with healthy volunteers, both BPD groups had higher Affective Lability Scale (ALS), ALS - Depression-Anxiety Subscale, Barratt Impulsivity Scale (BIS), and Lifetime History of Aggression (LHA) scores and were more likely to have a history of temper tantrums. BPD suicide attempters had higher ALS, ALS - Depression-Anxiety Subscale and LHA scores and were more likely to have a history of non-suicidal self-injury or temper tantrums compared to BPD non-attempters. Also, BPD suicide attempters were more likely to have a history of comorbid major depressive disorder and less likely to have comorbid narcissistic personality disorder (NPD) in comparison to BPD non-attempters. About 50% of study participants in each BPD group had a history of comorbid substance use disorder (SUD). Our study indicates that BPD patients with a history of suicide attempt are more aggressive, affectively dysregulated and less narcissistic than BPD suicide non-attempters.

Characterizing emotional dysfunction in borderline personality, major depression, and their co-occurrence

This research aimed to characterize patterns of emotional reactivity and dysregulation in borderline personality, depression, and their co-occurrence. In study 1, 488 young adult women from the community were categorized into four groups based on self-reported major depressive disorder (MDD) and borderline personality disorder (BPD) symptoms (Low BPD/Low MDD; Low BPD/High MDD; High BPD/Low MDD; High BPD/High MDD). Immediate and prolonged subjective emotional reactivity to a laboratory stressor were assessed, and participants completed self-report and behavioral measures of emotion dysregulation. Study 2 extended these findings, examining emotional reactivity and dysregulation in a clinical population of 176 substance dependent patients with diagnoses of BPD and MDD and including a biological index of emotional reactivity. Results revealed greater prolonged fear reactivity in the High BPD/High MDD (vs. Low BPD/Low MDD) group in study 1, and greater prolonged anxiety and negative affect reactivity in both High BPD groups (vs. Low BPD/Low MDD and Low BPD/High MDD groups) in study 2 (but no differences in cortisol reactivity). Results also demonstrated greater subjective (but not behavioral) emotion dysregulation in the High BPD/High MDD (vs. Low BPD/Low MDD) group in study 1 and both High BPD groups (vs. both Low BPD groups) in study 2. Finally, the High BPD/High MDD group reported greater difficulties controlling impulsive behaviors compared with all other groups in study 1 and the Low BPD groups in study 2. Findings suggest that BPD pathology (but not MDD pathology alone) is characterized by greater prolonged emotional (especially anxiety/fear-related) reactivity and heightened emotion dysregulation.

Ecological momentary assessment (EMA) of depression-related phenomena

Ecological momentary assessment (EMA) is one research method increasingly employed to better understand the processes that underpin depression and related phenomena. In particular, EMA is well suited to the study of affect (e.g., positive and negative affect), affective responses to stress (e.g., emotion reactivity), and behaviors (e.g., activity level, sleep) that are associated with depression. Additionally, EMA can provide insights into self-harm behavior (i.e. suicide and non-suicidal self-injury), and other mood disorders (e.g. bipolar disorder) commonly associated with depressive episodes. Given the increasing availability and affordability of handheld computing devices such as smartphones, EMA is likely to play an increasingly important role in the study of depression and related phenomena in the future.

Examining Accumulated Emotional Traits in Suicide Blogs With an Emotion Topic Model

Suicide has been a major cause of death throughout the world. Recent studies have proved a reliable connection between the emotional traits and suicide. However, detection and prevention of suicide are mostly carried out in the clinical centers, which limit the effective treatments to a restricted group of people. To assist detecting suicide risks among the public, we propose a novel method by exploring the accumulated emotional information from people's daily writings (i.e., Blogs), and examining these emotional traits that are predictive of suicidal behaviors. A complex emotion topic model is employed to detect the underlying emotions and emotion-related topics in the Blog streams, based on eight basic emotion categories and five levels of emotion intensities. Since suicide is caused through an accumulative process, we propose three accumulative emotional traits, i.e., accumulation, covariance, and transition of the consecutive Blog emotions, and employ a generalized linear regression algorithm to examine the relationship between emotional traits and suicide risk. Our experiment results suggest that the emotion transition trait turns to be more discriminative of the suicide risk, and that the combination of three traits in linear regression would generate even more discriminative predictions. A classification of the suicide and nonsuicide Blog articles in our additional experiment verifies this result. Finally, we conduct a case study of the most commonly mentioned emotion-related topics in the suicidal Blogs, to further understand the association between emotions and thoughts for these authors.

Dialectical behavior therapy alters emotion regulation and amygdala activity in patients with borderline personality disorder

OBJECTIVE

Siever and Davis' (1991) psychobiological framework of borderline personality disorder (BPD) identifies affective instability (AI) as a core dimension characterized by prolonged and intense emotional reactivity. Recently, deficient amygdala habituation, defined as a change in response to repeated relative to novel unpleasant pictures within a session, has emerged as a biological correlate of AI in BPD. Dialectical behavior therapy (DBT), an evidence-based treatment, targets AI by teaching emotion-regulation skills. This study tested the hypothesis that BPD patients would exhibit decreased amygdala activation and improved habituation, as well as improved emotion regulation with standard 12-month DBT.

METHODS

Event-related fMRI was obtained pre- and post-12-months of standard-DBT in unmedicated BPD patients. Healthy controls (HCs) were studied as a benchmark for normal amygdala activity and change over time (n = 11 per diagnostic-group). During each scan, participants viewed an intermixed series of unpleasant, neutral and pleasant pictures presented twice (novel, repeat). Change in emotion regulation was measured with the Difficulty in Emotion Regulation (DERS) scale.

RESULTS

fMRI results showed the predicted Group × Time interaction: compared with HCs, BPD patients exhibited decreased amygdala activation with treatment. This post-treatment amygdala reduction in BPD was observed for all three pictures types, but particularly marked in the left hemisphere and during repeated-emotional pictures. Emotion regulation measured with the DERS significantly improved with DBT in BPD patients. Improved amygdala habituation to repeated-unpleasant pictures in patients was associated with improved overall emotional regulation measured by the DERS (total score and emotion regulation strategy use subscale).

CONCLUSION

These findings have promising treatment implications and support the notion that DBT targets amygdala hyperactivity-part of the disturbed neural circuitry underlying emotional dysregulation in BPD. Future work includes examining how DBT-induced amygdala changes interact with frontal-lobe regions implicated in emotion regulation.

Ecological momentary assessment in borderline personality disorder: a review of recent findings and methodological challenges

The use of Ecological Momentary Assessment (EMA) has led to increased insight into borderline personality disorder (BPD) symptoms, especially regarding affective instability. EMA is characterized by a series of repeated assessments of current affective, behavioral, and contextual experiences or physiological processes while participants engage in normal daily activities. EMA has several advantages. It enables researchers to avoid biased recollection, to investigate within-person processes, and to enhance real-life generalizability. This review is dedicated to four main objectives: (1) to discuss the characteristics of EMA in studying BPD symptomatology; (2) to provide an extensive overview of EMA findings in BPD structured into findings regarding DSM-IV criteria and findings regarding emotional dysregulation as stated in the biosocial theory of Linehan; (3) to discuss challenges of EMA and to give recommendations for the proper use of it; and (4) to highlight prospects and promising applications that should be addressed.

How is affective instability defined and measured? A systematic review

BACKGROUND

Affective instability (AI) is poorly defined but considered clinically important. The aim of this study was to examine definitions and measures of AI employed in clinical populations.

METHOD

This study was a systematic review using the PRISMA guidelines. MEDLINE, Embase, PsycINFO, PsycArticles and Web of Science databases were searched. Also five journals were hand searched. Primary empirical studies involving randomized controlled trials (RCTs), non-RCTs, controlled before and after, and observational investigations were included. Studies were selected, data extracted and quality appraised. A narrative synthesis was completed.

RESULTS

A total of 11 443 abstracts were screened and 37 studies selected for final analysis on the basis that they provided a definition and measure of AI. Numbers of definitions for each of the terms employed in included studies were: AI (n = 7), affective lability (n = 6), affective dysregulation (n = 1), emotional dysregulation (n = 4), emotion regulation (n = 2), emotional lability (n = 1), mood instability (n = 2), mood lability (n = 1) and mood swings (n = 1); however, these concepts showed considerable overlap in features. A total of 24 distinct measures were identified that could be categorized as primarily measuring one of four facets of AI (oscillation, intensity, ability to regulate and affect change triggered by environment) or as measuring general emotional regulation.

CONCLUSIONS

A clearer definition of AI is required. We propose AI be defined as 'rapid oscillations of intense affect, with a difficulty in regulating these oscillations or their behavioural consequences'. No single measure comprehensively assesses AI and a combination of current measures is required for assessment. A new short measure of AI that is reliable and validated against external criteria is needed.

Mood variability predicts the course of suicidal ideation in individuals with first and second episode psychosis

Suicide risk is high in early psychosis. Recent research has suggested that mood variability may be associated with levels of suicidal thoughts and behaviour. This has not been investigated in individuals during and following a first or second episode of non-affective psychosis. Repeated-measures data over 18 months from a large randomised controlled trial for cognitive behaviour therapy (N=309) were analysed using latent growth curve modelling, whereby both the variability and the level of depression, anxiety and guilt were entered as predictors of suicidality. The variability of depression, but not guilt and anxiety, predicted the course of suicidality even when controlling for a large range of potential confounders. The level of depression, anxiety and guilt for each participant also strongly predicted the development of suicidality. The findings support the theory that variability in depression may contribute to the formation of suicidal ideation and related behaviour. More variable depression may be harder to predict and intervene against, and therefore increase the likelihood that suicidality escalates. The levels of emotions may also be an important determinant. This has implications for the treatment and assessment of suicidality in early psychosis.

Affective instability prior to and after thoughts about self-injury in individuals with and at-risk of psychosis: a mobile phone based study

It has been proposed that affective instability may be associated with thoughts about self-injury. The aim of this study was to test the hypotheses that instability in feelings of depression, but not anxiety, guilt, or hostility, would predict greater concurrent and subsequent thoughts about self-injury. Thirty-six individuals with psychosis completed questions on touch-screen mobile phones at semi-random times each day for one week. The instability of depression predicted greater concurrent and subsequent levels of thoughts about self-injury, even when controlling for depression level. Conversely, self-injurious thoughts predicted more stable depression. The instability of guilt, anxiety, and hostility did not significantly predict levels of thoughts about self-injury. Results indicate that a variable depressive state may trigger the onset of thoughts about self-injury, which increases the risk of its subsequent recurrence. The onset of self-injurious thoughts may, however, have a stabilizing effect on subsequent depression.

Does unstable mood increase risk of suicide? Theory, research and practice

BACKGROUND

Suicide represents a substantial problem, with significant societal and personal impact. The identification of factors influencing suicide risk is an important step in preventing self-harming behaviour. In this article the authors explore whether emotional instability increases risk of suicide, beyond that of mood intensity.

METHOD

This article provides a summary of existing theory and indirect evidence in support of an association between emotional instability and suicidality. A systematic literature search (Embase, Medline, PsychInfo) was carried out on literature conducted up to October, 2011. Meta-analysis was used to assess the strength of the proposed association.

RESULTS

The systematic search identified 20 journal articles meeting the inclusion criteria, including retrospective questionnaire design studies and research conducted across several time-points. Meta-analysis revealed a moderate association, which remained statistically significant even when only including studies conducted over multiple time-points. This effect was attenuated, but remained significant, when controlling for study selection bias.

LIMITATIONS

Retrospective questionnaire studies failed to adequately control for mood level. Little is still currently understood about the types of emotional instability (e.g., dysoria, anxiety) most associated with suicidality.

CONCLUSIONS

Future avenues of investigation include micro- to macro-longitudinal research and the differentiation of emotion subtypes and instability metrics. Momentary assessment techniques may help to detect subtle fluctuations in mood leading to more effective and immediate intervention. Psychosocial intervention strategies for treating unstable emotions are discussed.

Toward a definition of affective instability

Affective instability is a psychophysiological symptom observed in some psychopathologies. It is a complex construct that encompasses (1) primary emotions, or affects, and secondary emotions, with each category having its own characteristics, amplitude, and duration, (2) rapid shifting from neutral or valenced affect to intense affect, and (3) dysfunctional modulation of emotions. Affective instability is often confused with mood lability, as in bipolar disorders, as well as with other terms. To clarify the concept, we searched databases for the term affective instability and read related articles on the topic. In this article we situate the term within the current affective nomenclature and human emotional experience, explore its psychophysiological features, and place it within the context of psychopathology. We explain why the term can potentially be confused with mood pathology and then define affective instability as an inherited temperamental trait modulated by developmental experience.

The interactive role of distress tolerance and borderline personality disorder in suicide attempts among substance users in residential treatment

The primary purpose of this study was to examine the interactive effect of borderline personality disorder (BPD) and distress tolerance (DT) on suicidal behavior across levels of intent to die (clear vs ambiguous) and medical severity. One hundred seventy-six adult patients in residential substance use disorder treatment were administered a series of structured interviews, behavioral assessments, and self-report questionnaires. A series of analyses of covariance and multiple regression analyses were conducted to test hypotheses using both categorical and dimensional measures of BPD and DT. Analyses supported hypotheses, indicating that patients with BPD who exhibit high DT are at the greatest risk for engaging in chronic and medically serious suicidal behavior. Although high DT is unlikely to be inherently problematic, results suggest that within the context of severe psychopathology (eg, co-occurring BPD-substance use disorder), the ability to withstand aversive internal states in pursuit of a goal (eg, one's own death) may enable individuals to persist in otherwise unsustainable behavior. In this sense, DT may function in a manner consistent with the acquired capability for suicide (a component of the interpersonal-psychological theory of suicidal behavior defined by a diminished fear of death and enhanced tolerance for pain that, in the presence of suicidal desire, enables individuals to enact lethal self-injury).

Differential diagnosis of bipolar affective disorder type II and borderline personality disorder: analysis of the affective dimension

BACKGROUND

Differential diagnosis between bipolar affective disorder type II and borderline personality disorder can be problematic yet a priority for effective treatment planning. Diagnosis is problematic when symptoms do not present enough intensity or duration to clear the issue but also when there is a relative overlap of criteria between both disorders. If for many patients, the diagnosis is more easily differentiated, confounding conditions are found in 20% of cases for which it becomes a significant issue.

METHOD

A research with the key words affective instability, borderline personality disorder, and bipolar disorder on Medline and Psych-Info was done. Other references were found through this review in related articles. Comparison of data about the affective dimensions concerning bipolar disorder and borderline personality disorder was noted.

RESULTS

Affective instability is a confounding factor: quality and intensity of affects, speed of fluctuations, affective response to social stress, and its modulation are core elements of affective instability that need to be analyzed to clarify a proper diagnosis.

LIMITATIONS

There is further necessity for research about affective instability in the 2 diagnoses.

CONCLUSIONS

Making a valid differential diagnosis has an important clinical value in order for the clinician to plan proper treatment. Analysis of the affective experience and its qualitative and quantitative facets can help establish it.

Affective variability predicts suicidal ideation in individuals at ultra-high risk of developing psychosis: an experience sampling study

OBJECTIVE

There is a suggestion in the literature that more variable affect increases suicidal ideation through the repeated re-activation of latent suicidal cognitions. The hypothesis that affective variability would be a better predictor of suicidal ideation and related behaviour than affect level was tested in individuals at ultra-high risk of developing psychosis. This study also examined the prediction that affective variability is a suicide-specific mechanism and would not predict levels of attenuated psychotic phenomena.

METHOD

Twenty-seven ultra-high risk individuals were required to complete ambulant ratings of their affect when prompted by an electronic wristwatch for six days (the experience sampling method). In the debriefing session, participants were assessed with a semi-structured interview (the Comprehensive Assessment of At-Risk Mental State), which assessed the severity and frequency of suicidality and psychosis-related phenomena.

RESULTS

The variability of negative and positive affect was predictive of the frequency of suicidal thoughts and behaviour. More variable negative, but not positive affect, was also associated with more severe suicidal ideation and related behaviour. Affect variability was not significantly related to the severity of attenuated psychotic phenomena.

CONCLUSION

Affective variability appears to be a specific risk factor for suicidal ideation in individuals at ultra-high risk of developing psychosis. Early intervention should focus on providing individuals with skills for regulating their own affect.

The Zuckerman-Kuhlman Personality Questionnaire predicts functioning styles of personality disorder: a trial in healthy subjects and personality-disorder patients

Normal personality traits, as measured by the Zuckerman-Kuhlman Personality Questionnaire (ZKPQ), predicted some personality disorders in a sample of healthy volunteers. Whether these predictions could be more pronounced in patients with personality disorders remains unknown. We administered the ZKPQ and the Parker Personality Measure (PERM), which describes the functioning styles of personality disorder, in 134 patients with a range of personality disorders and in 268 age-, gender- and education level-matched healthy volunteers. Cluster A patients scored lowest on Sociability, cluster B highest on Impulsive Sensation Seeking and Aggression-Hostility, cluster C1 (Avoidant and Dependent types) highest on Neuroticism-Anxiety, and cluster C2 (Obsessive-Compulsive type) highest on Activity. Most of the predictors were consistent across both the healthy and patient groups. The variances that accounted for predicting most PERM styles by the ZKPQ traits in the patient group were higher than those in the healthy group. Our results showed that the ZKPQ traits could specifically predict the PERM styles in both healthy subjects and personality-disorder patients. This result was more pronounced in the latter group. The most powerful predictions were obtained for Antisocial, Dependent, Borderline and Avoidant styles, and the weakest for the Schizotypal and Schizoid styles in the patient group.

Affective vulnerabilities and self-injury in suicide

The objective of this study was to test whether self-injury moderates the relationship between affective vulnerabilities (affective lability/affective intensity) and suicidal behavior. A total of 127 participants were administered structured diagnostic interviews and filled out questionnaires. The moderation effect was significant both for affective lability and affective intensity, with individuals reporting lower levels of affective vulnerability and a more extensive history of self-injury reporting more lifetime suicide attempts. These findings were generally replicated in a subsample of participants meeting diagnostic criteria for borderline personality disorder (n = 72). When accompanied by high levels of self-injury, low levels of affective vulnerabilities may paradoxically become a risk factor for suicidal behavior, perhaps by enabling individuals to persist in the innately frightening experience of a suicide attempt.

Mood swing and mood stabilizer: how specific are these terms?

BACKGROUND

In the DSM-IIIR in 1987, the category title for depressive and bipolar disorders was changed from affective disorders to mood disorders. Within a short period of time thereafter, mood swing and mood stabilizer became very commonly used terms in psychiatry with bipolar implications.

METHODS

Terms and definitions in recent texts, articles, and dictionaries pertaining to mood fluctuations have been reviewed.

RESULTS

The term mood was seldom part of psychiatric terminology until the late 1970s. Mood swing and mood stabilizer as used in the psychiatric literature are primarily nonspecific and often misleading concepts--particularly as a basis for treatment decisions. Affective fluctuations and shifts to irritability and/or anger in persons with personality and depressive disorders are being viewed by many in the mental health field as cyclically biphasic--between depressed to elated--which is clearly at variance with research findings.

CONCLUSIONS

More data-based research on mood variations is needed to authoritatively remedy this situation.

Mismatch negativity in treatment-resistant depression and borderline personality disorder

OBJECTIVE

Cognitive dysfunctions, such as attentional impairment, are central features of both treatment-resistant depression (TRD) and borderline personality disorder (BPD). The treatment failure of TRD due to its comorbidity with BPD is debated in the literature. The mismatch negativity (MMN) of the event-related potentials provides an objective marker of involuntary stimulus selective processing, which might help shed light on this issue and provide an avenue for investigating a possible endophenotypic marker for TRD.

METHOD

We investigated MMN in 22 patients with TRD, 19 with BPD, and 22 with TRD cormorbid with BPD (TRD+BPD), as well as in 32 healthy volunteers, by employing an acoustic frequency deviance paradigm. In addition, we measured the depressive mood using the Plutchik-van Praag (PVP) depression inventory.

RESULTS

There was no significant between-group difference for the N1 latencies/amplitudes, both to the standard and deviant stimuli, and no significant between-group difference for MMN latencies. However, MMN amplitudes were higher in the TRD group than those in the other three groups. PVP scores were highest in TRD+BPD, then TRD, BPD patients, and lowest in healthy subjects. The higher MMN was not correlated with PVP score, nor with the duration of life-long depression, which can be considered as a neurophysiological marker for TRD.

CONCLUSION

An atypical lack of inhibition on the irrelevant stimuli or increased cortical neuronal activity, especially frontal area, or both, might be responsible for the finding.

Experience sampling research in psychopathology: opening the black box of daily life

A growing body of research suggests that momentary assessment technologies that sample experiences in the context of daily life constitute a useful and productive approach in the study of behavioural phenotypes and a powerful addition to mainstream cross-sectional research paradigms. Momentary assessment strategies for psychopathology are described, together with a comprehensive review of research findings illustrating the added value of daily life research for the study of (1) phenomenology, (2) aetiology, (3) psychological models, (4) biological mechanisms, (5) treatment and (6) gene-environment interactions in psychopathology. Overall, this review shows that variability over time and dynamic patterns of reactivity to the environment are essential features of psychopathological experiences that need to be captured for a better understanding of their phenomenology and underlying mechanisms. The Experience Sampling Method (ESM) allows us to capture the film rather than a snapshot of daily life reality of patients, fuelling new research into the gene-environment-experience interplay underlying psychopathology and its treatment.

Affective instability in borderline personality disorder: experience sampling findings

Affective instability, defined as repeated, rapid, and abrupt shifts in mood, is considered the core pathology in borderline personality disorder. The temporal pattern of affective instability can be best captured with the experience sampling method-longitudinal assessment of people's affective states as they occur in real time and in their natural environment. A review of the experience sampling studies published to date for borderline personality disorder suggests the following mood variability pattern: intense negative mood, more frequent and abrupt mood changes than healthy controls and patients with major depression, and partial triggering of affect by external events. The method also has great potential to investigate the links between affective instability and other psychological and behavioral correlates of the disorder, such as suicide, lack of self-esteem, and erratic behaviors. However, the method requires systematic study to determine best data collection designs and mathematical models of mood variability.