Is dimensional scoring of borderline personality disorder important only for subthreshold levels of severity?

Childhood emotional abuse and alcohol use disorders in a national Nepali women sample: The mediating role of borderline personality traits

While many studies have found an association between childhood emotional abuse and alcohol use disorders (AUD) during adulthood, underlying psychological mechanisms linking the two remain inadequately understood. Drawing on the developmental psychopathology perspective, this study examined the relationship between childhood emotional abuse and AUD during adulthood with a national sample of women in Nepal (N = 1,100, M age = 37.73), focusing on the mediating role of borderline personality traits. Mediation analyses were performed using the Karlson-Holm-Breen (KHB) method and bootstrapping confidence intervals. Results indicated that Nepali women's borderline personality traits significantly mediated the relationship between childhood emotional abuse and AUD. Hence, emotional abuse in childhood increases the risk for AUD during adulthood for Nepali women by increasing the risk of borderline personality traits. Findings underscore the necessity of continued emphasis on developing and implementing early interventions for childhood emotional abuse and therapeutic interventions for borderline personality traits in reducing AUD among vulnerable women in Nepal.

Maternal Borderline Personality Disorder Severity and Parenting Behaviors During Conflict Discussions With Adolescent Offspring

Examining the impact of maternal borderline personality disorder (BPD) on parent-child interactions could elucidate pathways of intergenerational risk and inform intervention. The current study used an expanded version of the Observing Mediational Interactions to investigate (a) associations between maternal BPD symptom severity and mediational parenting behaviors during conflict discussions with clinically referred early adolescent offspring (N = 56, age = 10-15, 54% female) and their mothers, and (b) the potential moderating role of early adolescent BPD symptom severity in those associations. Consistent with hypotheses, mothers with higher levels of BPD symptom severity engaged in fewer positive emotional/attachment-based behaviors and more negative (i.e., invalidating, controlling, coercive, or insensitive) parenting behaviors. Only parent-reported, but not self-reported, adolescent BPD severity moderated these associations; maternal BPD severity was significantly associated only with negative parenting in dyads with low-to-moderate levels of parent-reported adolescent BPD severity. We discuss implications including targeting attachment-based and negative parenting behaviors in intervention.

ICD-11 personality disorder features in the danish general population: Cut-offs and prevalence rates for severity levels

INTRODUCTION

Prevalence rates and correlates of personality disorders (PD) are relevant to health care policy and planning.

OBJECTIVES

To present normative data for self-reported ICD-11 personality disorder (PD) features including tentative cut-off scores and prevalence rates for severity levels along with psychosocial correlates.

METHODS

The Personality Disorder Severity ICD-11 (PDS-ICD-11) scale and criterion measures of impairment were administered to a social-demographically stratified sample of Danish citizens (N = 8,941) of which 3,044 delivered complete data. Item-Response Theory (IRT) was employed to indicate cut-offs based on standard deviations from the latent mean.

RESULTS

The unidimensionality of the PDS-ICD-11 score was supported and IRT analysis suggested norm-based thresholds at latent severity levels. Expected associations with criterion measures were found.

CONCLUSION

The normative data portray ICD-11 PD features in the general population and allow for interpretation of PDS-ICD-11 scores (e.g., scores of 12, 16, and 19 may indicate mild, moderate, and severe dysfunction), which may inform health care policy and planning. A total weighted prevalence of 6.9 % of the Danish general population is estimated to have clinically significant personality dysfunction, proportionally composed of Mild (4.8 %), Moderate (1.2 %), and Severe (0.9 %) levels. Future research should corroborate these findings using relevant clinical samples and methods.

[The relationship of functional and symptomatic changes after multimodal psychodynamic treatment]

Objectives: Personality organization or functioning describes biographically acquired characteristics for the regulation of psychological processes. Limitations correlate with symptom load. This study examines whether significant improvement in personality functioning can be achieved in the framework of a multimodal psychodynamic treatment and its influence on the psychological symptoms. Methods: In this naturalistic study design (N = 318) personality organization was measured with the OPD-SQS and the symptoms were obtained using PHQ-9, GAD-7, SCL-9 and mini- Spin. Changes in the functioning levels were calculated using a t-test. The associations between the functional and symptom improvements were calculated using hierarchical regressionmodels. ANOVAs for dependent samples were used to calculate the association of the personality organization changes on symptom reduction Results: Treatment resulted in significant improvement in personality structure.The greater the changes, the lower the symptom burden at the end of treatment. Patients with lower personality structure benefited equally well from treatment. Conclusions: Personality functioning improves with multimodal psychodynamic therapy and is accompanied by reduction of psychological symptoms. Structural changes proceed equally in high and low structured patients.

Do self and interpersonal dysfunction cross-sectionally mediate the association between adverse childhood experiences and personality pathology?

Two primary limitations of research on the association between adverse childhood experiences (ACEs) and personality disorder (PD) are (1) failure to consider mechanisms of association and (2) inconsistent results due, in part, to inconsistent approaches to quantifying ACE exposure. The current study will address these limitations by examining the cross-sectional mediating role of self- and interpersonal dysfunction on the association between ACE and three PDs (antisocial, schizotypal, and borderline) using three quantifications of ACE exposure (cumulative, individual, and unique risk). Participants were 149 current or recent psychiatric patients, and data analyses were performed through estimation of a series of cross-sectional mediation models. Taken together, results suggest that (1) the association between ACE and PD is moderate, (2) self- and interpersonal dysfunction cross-sectionally mediate this association, (3) after accounting for variance shared among ACEs, associations between specific ACE subtypes and PD were negligible, (4) much of the association between ACE and PD is accounted for by general processes impacted by all forms of ACE and implicated in all forms of PD, and (5) emotional neglect may uniquely contribute to self- and interpersonal dysfunction and thereby, PD risk.

Psychopathological Determinants of Quality of Life in People with Borderline Personality Disorder

BACKGROUND

Subjective quality of life (SQOL) in people with borderline personality disorder (BPD) is a marker of disease burden; a crucial treatment outcome; an indicator of psychosocial functioning; and a measure of interventions' effectiveness. Given the dearth of consolidated data, the current study examined psychopathological determinants of global and domain-specific SQOL in people with BPD.

METHODS

Hierarchical regression models were employed to examine in BPD patients (n = 150) the relationships of the number of BPD diagnostic criteria; the co-occurrence of other personality disorders (PDs); depression; state and trait anxiety; suicidality; self-harming; alcohol and substance use disorders with SQOL indices, namely physical health, psychological health, social relationships, environment, overall QOL and overall health. SQOL was estimated using the WHOQOL-BREF instrument.

RESULTS

Co-existing symptomatology such as depression, state and trait anxiety, and personality pathology, namely the co-occurrence of other PDs, exhibited significant associations with global and domain-specific SQOL, albeit depression was the strongest determinant of the most SQOL domains. In contrast, the number of BPD diagnostic criteria and central illness features such as suicidality, self-harming behaviour, and impulsivity manifested through alcohol and substance use did not exhibit significant associations with any SQOL dimension.

CONCLUSIONS

Comprehensive assessment of depressive symptoms should be regularly implemented in BPD services to facilitate early detection and treatment, thereby ensuring patients' SQOL. Accordingly, tackling anxiety and other PDs co-occurrence through appropriate interventions can facilitate more effectively SQOL improvement. Our findings can be explained by the hypothesis that co-existing psychopathology such as depression, anxiety and co-occurrence of other PDs in BPD patients represent illness severity indices rather than comorbid disorders, and might fully mediate the effect of BPD traits on SQOL. Future mediation analysis is required to elucidate this hypothesis.

The prevalence of subthreshold psychiatric symptoms and associations with alcohol and substance use disorders: from a nationally representative survey of 36,309 adults

BACKGROUND

Our aim was to describe a broad number of subthreshold psychiatric symptoms (SPS) in a nationally representative population and evaluate associations with substance use. SPS describe groups of symptoms with significant pathology, but that do not quite meet full psychiatric diagnostic criteria. They have been associated with significant impairment and cost.

METHODS

The National Epidemiologic Survey on Alcohol and Related Conditions-III was a multistage, weighted, cross-sectional survey completed in the United States in 2013 comprising 36,309 noninstitutionalized adults. We report lifetime prevalence rates of 14 SPS related to mood, anxiety, trauma, eating, and personality disorders. We then evaluate associations with lifetime alcohol use disorders (AUD) and all substance use disorders (SUD) using logistic regression and adjusted odds ratios. SPS and psychiatric diagnoses were mutually exclusive (could not co-occur).

RESULTS

Lifetime prevalence of having at least one of 14 SPS was 57% compared with 37% for the related psychiatric disorders. This was similar for males and females, in contrast to psychiatric disorders in which prevalence was 42% in females and 31% in males. Otherwise, overall SPS and disorders had similar prevalence patterns across sociodemographic characteristics. Subthreshold personality symptoms had the highest prevalence rates (schizotypal 21.3%, antisocial 18.3%, and borderline 17.6%), followed by posttraumatic stress (13.1%). Subthreshold bipolar and depression had lifetime prevalence rates of 2.7 and 8.5%, respectively. Prevalence rates of subthreshold anxiety symptoms ranged from 2.2% (agoraphobia) to 9.8% (specific phobia). Subthreshold eating disorder related symptoms had the lowest prevalence rates (anorexia 1.5% and bulimia 1.7%). Half (seven) of the SPS had significantly increased odds of lifetime AUD. This number increased to 12 for all SUD. Subthreshold antisocial personality symptoms had the highest odds of AUD (2.2; 95% CI 2.00-2.37) and SUD (3.5; 95% CI 3.22-3.81).

CONCLUSIONS

We found high lifetime SPS prevalence rates and significant associations with AUD and SUD. To our knowledge, this is the first published study evaluating a broad number of SPS. This indicates possible opportunities for early intervention and prevention but requires additional research and development of infrastructure and guidelines to better understand and manage patients who experience SPS.

Potential mechanisms underlying sleep disturbance in young people with borderline personality disorder features: an exploratory study

BACKGROUND

Sleep disturbance is common among young people (15-25 years) with features of borderline personality disorder (BPD). However, the mechanisms underlying sleep disturbance in BPD remain unknown. Understanding these underlying processes is essential to guide the development of sleep-improvement interventions and to optimise their efficacy through identifying beneficial treatment targets. This exploratory study aimed to investigate potential underlying mechanisms to inform future hypotheses, research development, and provide insight into potential treatment targets to improve sleep in young people with BPD. This study explored the indirect roles of emotion regulation difficulties, depression, anxiety and stress in the relationship between BPD features and sleep disturbance in young people.

METHODS

Sleep was measured subjectively (self-report questionnaires) and objectively (10 days wrist actigraphy) in 40 young people with BPD features and 38 healthy young people. Participants also completed the Difficulties in Emotion Regulation Scale and the Depression, Anxiety and Stress Scale.

RESULTS

Mediation analyses revealed that impulse control difficulties, limited emotion regulation strategies and anxiety indirectly affected the relationship between group (BPD vs. healthy) and subjective sleep disturbance in young people. Lack of emotional awareness and anxiety contributed to associations between group and objectively longer time in bed and bedtime variability, respectively.

CONCLUSIONS

These preliminary findings suggest that targeting emotional dysregulation (impulse control, strategies, emotional awareness) and anxiety might be beneficial for improving sleep in this population.

Perceived Parenting and Borderline Personality Features during Adolescence

This study investigates the associations between perceived parenting and borderline personality disorder (BPD) in adolescents. The relations between components of parenting and BPD features were explored. Participants (N = 270; mean age = 15.3) assessed their own BPD features (Personality Assessment Inventory) and both of their parents' parenting practices (Parents as Social Context Questionnaire; Perceived Parental Autonomy Support Scale). SEM results suggest that controlling, rejecting and chaotic parenting all predicted global BPD, and all these parenting components were significantly associated with at least one BPD feature. Chaotic parenting, a relatively neglected construct in the BPD literature, seems to play an important role in early BPD.

Borderline personality disorder in young people: associations with support and negative interactions in relationships with mothers and a best friend

BACKGROUND

Impaired interpersonal functioning has been highlighted as a core feature of borderline personality disorder (BPD). Adolescence and young adulthood form important developmental stages within both the emergence of BPD and the development of interpersonal functioning, which takes place mostly in relationships with parents and friends. This study aimed to: (i) investigate relations between BPD symptoms and both supportive and negative interactions with mothers and best friends; (ii) investigate whether the relations were moderated by age; (iii) test the robustness of our findings by comparing the results based on self-reports with results from a subsample in which supportive and negative interactions with mothers were rated by the mother.

METHODS

312 young people referred to mental healthcare completed self-report measures on BPD and supportive and negative interactions. Multiple regression analyses were conducted to examine the relations between BPD features and perceived supportive and negative interactions with mothers and a best friend, and to investigate whether these relations were moderated by age. Robustness of our findings was studied in a subsample (n = 104), by using a multi-informant design in maternal report on supportive and negative interactions with mothers.

RESULTS

Multiple regression analyses demonstrated that negative interactions with mothers as well as with a best friend were related to more BPD symptoms in young people. Supportive interactions were not related to BPD symptoms. Both BPD and quality of relations were not related to age. In a subsample in which supportive and negative interactions with mothers were rated by the mother, the maternal report showed slightly different results. In this model, both supportive and negative interactions with a best friend were positively related, whereas interactions with mothers were not related to BPD symptoms in young people.

CONCLUSIONS

Results highlight the importance of relationships with mothers and a best friend during adolescence and young adulthood. Given that BPD often emerges during this developmental phase, future research is needed to clarify how quality of relationships could alter pathways toward BPD in young people.

TRIAL REGISTRATION

Not applicable.

Borderline Personality Disorder: Risk Factors and Early Detection

Personality disorders (PDs) exert a great toll on health resources, and this is especially true for borderline personality disorder (BPD). As all PDs, BPD arises during adolescence or young adulthood. It is therefore important to detect the presence of this PD in its earlier stages in order to initiate appropriate treatment, thus ameliorating the prognosis of this condition. This review aims to highlight the issues associated with BPD diagnosis in order to promote its early detection and treatment. To do so, we conducted a search on PubMed database of current evidence regarding BPD early diagnosis, focusing on risk factors, which represent important conditions to assess during young patient evaluation, and on diagnostic tools that can help the clinician in the assessment process. Our findings show how several risk factors, both environmental and genetic/neurobiological, can contribute to the onset of BPD and help identify at-risk patients who need careful monitoring. They also highlight the importance of a careful clinical evaluation aided by psychometric tests. Overall, the evidence gathered confirms the complexity of BDP early detection and its crucial importance for the outcome of this condition.

Catastrophizing, negative affectivity, and borderline personality disorder

The core features of borderline personality disorder (BPD) include problematic interpersonal relationships, behavioral and affective dysregulation, identity problems, and cognitive dysregulation. Cognitive dysregulation, such as catastrophizing, rumination, and thought suppression, contributes to emotion dysregulation in BPD. Previous research suggested that thought suppression fully mediated the relationship between negative affect intensity/reactivity and BPD symptoms. We predicted that catastrophizing similarly will serve as a mediator between negative affect intensity/reactivity and BPD symptoms. Two samples completed the study. First, students (N = 191) self-selected to participate in an online study through the university psychology research recruitment system. Additionally, a second sample using Amazon Mechanical Turk (MTurk; N = 172) was utilized. Catastrophizing partially mediated the relationship between negative affect intensity/reactivity and BPD symptoms. Across these samples, results suggest that catastrophizing may have a significant role in understanding BPD symptoms, which is similar with rumination. Limitations and future directions are also discussed.

Borderline Personality Disorder Diagnosis and Symptoms in Outpatient Youth as Risk Factors for Criminal Offenses and Interpersonal Violence

The aim of the current study was to examine the risk for offending among outpatient youth with borderline pathology. Demographic and diagnostic data from 492 outpatients who attended a public mental health service for 15-to 25-year-olds between January 1998 and March 2008 were linked with information regarding criminal offenses and intervention orders collected from a statewide police database between March 1993 and June 2017. BPD diagnosis and number of BPD criteria were both associated with an elevated risk for violent and nonviolent offenses and family violence intervention orders. Moderation analyses revealed that the number of BPD criteria might affect males and females differently in terms of offending. Both impulsivity and anger independently predicted the risk for violent and nonviolent offenses and family violence intervention orders. Early detection of increased risk of offending among youth with BPD features is essential to develop targeted treatments for criminal or violent behavior.

Development and initial evaluation of the ICD-11 personality disorder severity scale: PDS-ICD-11

AIM

No measure has formally been developed to assess the published ICD-11 model of Personality Disorder (PD) severity. We therefore set out to develop and evaluate the 14-item Personality Disorder Severity ICD-11 (PDS-ICD-11) scale.

METHOD

A representative U.S. community sample (N = 428; 50.9% women) and a New Zealand mental health sample (N = 87; 61.5% women) completed the PDS-ICD-11 scale along with a series of established PD and impairment measures.

RESULTS

Item response theory supported the unidimensionality of PDS-ICD-11 (median item loading of 0.68) and indicated that a PDS-ICD-11 score of 17.5 may serve as a benchmark for pronounced dysfunction. Correlation and regression analyses supported both criterion validity and incremental validity in predicting impairment and PD symptoms. The PDS-ICD-11 was particularly associated with measures of Level of Personality Functioning Scale (LPFS), Global PD severity, and Borderline PD symptom score. A comparison between clinical individuals diagnosed with an ICD-11 PD vs. no PD supported diagnostic validity.

CONCLUSION

This initial construction study suggests that the PDS-ICD-11 constitutes a promising instrument that provides a quick impression of the severity of personality dysfunction according to the official ICD-11 PD guidelines. Clearly, more research is needed to corroborate its validity and utility. The PDS-ICD-11 scale is provided as online supporting information.

Subthreshold personality disorder: how feasible is treatment in primary care?

Individuals with subthreshold borderline personality disorder (BPD) are commonly encountered in primary care settings, yet the psychological treatments they receive are rarely tailored to their needs. In an effort to capture and treat this group of individuals in a targeted and meaningful way, some primary care settings offer Systems Training for Emotional Predictability and Problem Solving – Emotional Intensity (STEPPS-EI). This evaluation sought to assess the feasibility of STEPPS-EI within NHS primary care services. Employing an uncontrolled design, the evaluation examined recruitment, retention, effectiveness and group appraisal. Findings supported three out of four evaluation objectives for feasibility: uptake of the group was high at 74%, the group was well received by the group and significantly effective at reducing symptoms of BPD, depression and anxiety. However, retention rates were low, with only 43% classed as ‘completers’ of the programme. The results indicate preliminary evidence for STEPPS-EI as a potentially feasible intervention with possible modification to enhance retention and avenues for further study.

Key learning aims

After reading this paper, the reader will be aware of: (1)

Emotion regulation and borderline personality features in daily life: The role of social context

BACKGROUND

Borderline personality disorder (BPD) is associated with emotional dysfunction and interpersonal sensitivity. Yet, little work has characterized how BPD features predicts emotional reactivity and emotion regulation behaviors in response to interpersonal stress relative to other forms of stress.

METHODS

Participants were 152 university students who completed baseline measures of BPD features and complied with two-week daily diary procedures assessing daily emotion regulation strategy use in response to social and non-social stressors.

RESULTS

Generalized estimating equations revealed that BPD features predicted greater negative and positive emotions in response to daily stressors, and interacted with type of stressor in predicting urges and behaviors. Elevated BPD features was associated with greater urges for dysfunctional emotion regulatory behaviors and fewer functional emotion regulatory behaviors to a greater extent in response to social (versus non-social) stressors.

LIMITATIONS

This study was limited by its focus on past-day retrospective recall. Further, the student sample limits the generalizability of these findings.

CONCLUSIONS

These findings suggest that individuals with elevated BPD features may have less functional emotion regulation in social contexts.

How does level of personality functioning inform clinical management and treatment? Implications for ICD-11 classification of personality disorder severity

PURPOSE OF REVIEW

The International Classification of Diseases, 11th Edition (ICD-11) classifies personality disturbance according to levels of severity. This article reviews the literature on levels of personality functioning in relation to clinical management and treatment, and proposes how these findings apply to the ICD-11 classification of personality disorders.

RECENT FINDINGS

Findings were primarily derived from studies using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) Level of Personality Functioning Scale (LPFS), Kernberg's Level of Personality Organization, and the general P-factor of personality disorder. Severity of personality dysfunction is related to treatment outcome, risk of dropout, therapeutic alliance, readiness for treatment, risk of harm to self or others, risk of dissociation and psychotic-like breaks, coherence in narrative identity, reflective functioning, and epistemic trust.

SUMMARY

The overall level of personality disorder severity indicates risk of negative outcomes and may be used as decision tool for 'personalized medicine' and required treatment intensity (e.g., strength of alliance and the need for establishing epistemic trust). Beyond the ICD-11 guidelines for determining personality disorder severity, these implications also apply to practitioners using comparable frameworks such as the DSM-5 LPFS and Kernberg's Level of Personality Organization. Future research should focus on the interaction of severity with trait qualifiers in relation to clinical management.

Number of Borderline Personality Disorder Criteria and Depression Predict Poor Functioning and Quality of Life in Outpatient Youth

This study aimed to investigate which factors contribute to poor functioning and poor quality of life in youth (aged 15-25 years) with borderline personality disorder (BPD), and whether the number of BPD criteria might be an independent predictor of these outcomes. A sample of 499 help-seeking outpatient youth, aged 15-25 years, was assessed. Stepwise multiple regression analyses showed that the number of BPD criteria was the best predictor of poor functioning, followed by number of mental health visits in the past month, female sex, and a current diagnosis of depression. Current depression was the best predictor of Assessment of Quality of Life utility score, followed by the number of BPD criteria. These findings underscore the clinical significance of DSM-IV BPD features (even when subthreshold for a categorical diagnosis) in youth and their effects upon social and occupational functioning and quality of life early in the course of BPD.

Maternal personality traits, antenatal depressive symptoms and the postpartum mother-infant relationship: a prospective observational study

PURPOSE

Maternal depression has been associated with bonding difficulties and lower maternal sensitivity in observed mother-infant interactions. However, little research has examined the impact of disordered personality traits in mothers on these outcomes. We investigated the association between disordered personality traits in mothers measured during pregnancy and postnatal (a) self-reported bonding with infant; (b) observational mother-infant interactions.

METHODS

Five hundred fifty-six women were recruited during early pregnancy and subsequently followed up at mid-pregnancy (approximately 28 weeks' gestation) and when infants were aged approximately 3 months (n = 459). During early pregnancy, data were collected on disordered personality traits (using the Standardised Assessment of Personality Abbreviated Scale) and depressive symptoms (using the Edinburgh Postnatal Depression Scale). At 3 months postpartum, self-reported perceived bonding (using the Postpartum Bonding Questionnaire) were collected. A sub-sample of women additionally provided observational mother-infant interaction data (n = 206) (coded using the Child-Adult Relationship Experimental Index).

RESULTS

Higher disordered personality traits was not associated with maternal perceptions of bonding impairment, but was associated with reduced maternal sensitivity during observational mother-infant interactions [adjusted for age, education, having older children, substance misuse prior to pregnancy, infant sex and gestational age: coefficient = - 0.28, 95% CI = - 0.56 to - 0.00, p < 0.05]. After adjusting for depressive symptoms, the association was attenuated [coefficient = - 0.19, 95% CI = - 0.48 to 0.11, p = 0.217].

CONCLUSIONS

Mothers with disordered personality traits did not perceive themselves as having bonding impairments with their infants but were less sensitive during observed interactions, though depressive symptoms attenuated this relationship. Both depression and disordered personality traits need to be addressed to optimize mother-infant interactions.

Diagnosis and Treatment of Borderline Personality Disorder in Young People

PURPOSE OF REVIEW

We review recent research concerning the diagnosis and treatment of borderline personality disorder (BPD) in young people. We examine evidence for the need to define an appropriate age for detection, and the suitability of current classification methods and treatment.

RECENT FINDINGS

Evidence supports early detection and intervention for subsyndromal borderline pathology or categorical BPD across an extended developmental period. A range of structured treatments are effective for BPD in young people, although the role of treatment components in successful outcomes is unclear. Substantial evidence suggests that a stronger focus on functional outcomes, especially social and vocational outcomes, is warranted. Effective treatments for BPD are rarely available internationally. There is a need to assess whether less complex interventions might be developed that are scalable across health systems. A clinical staging model should be considered, addressing clinical distress and co-occurring psychopathology, as well as diagnosis.

Thought control strategies as predictors of borderline personality disorder and suicide risk

BACKGROUND

Borderline Personality Disorder (BPD) is characterized by a pattern of instability in interpersonal relationships, affect, self-image and is marked by behavioral impulsivity including suicidal ideation and attempts. Additionally, individuals with BPD tend to engage in maladaptive ruminative thinking that is also related to suicidal ideation and attempts. Given these relations, this study aims to understand the 5 strategies of thought control (distraction, punishment, reappraisal, worry, and social control) as predictors of BPD symptoms and suicide risk.

METHODS

The sample was collected at a Southeastern University using a convenience sample of undergraduate participants. The final sample (n = 403) had an age range of 18 to 27 (M  = 19.67, SD = 1.45), was 74.4% female and 25.6% male, and was primarily Caucasian (69.7%) and African American (24.8%).

RESULTS

Results demonstrate that distraction was negatively associated with BPD and suicide risk while worry and punishment were positively associated with BPD and suicide risk across three different measures of BPD. Social control was negatively associated with suicide risk and BPD but only on one of the BPD measures. Lastly, reappraisal was positively related to BPD symptoms on two measures.

LIMITATIONS

Given the sample characteristics, there may be limitations in the generalizability of the findings.

CONCLUSIONS

The findings represent a first step towards examining thought control strategies as possible predictors of BPD symptoms and suicide that can inform clinical interventions designed to increase or decrease utilization of these specific strategies.

Is It Personal? Context Moderates BPD Effects on Spontaneous Rumination and Distress

Borderline personality disorder (BPD) is associated with the use of maladaptive emotion regulation (ER) that predicts unstable interpersonal relationships and emotion dysregulation. Rumination, a maladaptive cognitive ER response, may be one mechanism by which those with BPD experience emotion dysregulation. However, it remains unclear whether emotion dysregulation is linked to rumination in general, or to rumination during interpersonal situations that often prove challenging for those with BPD. The present study examined whether interpersonal exclusion conferred an increased risk to spontaneously ruminate among those with elevated BPD features relative to an impersonal negative mood induction, and whether spontaneous rumination mediated the effects of BPD features on distress reactivity. Overall, BPD features predicted stronger tendencies to spontaneously ruminate and higher levels of distress following interpersonal exclusion; spontaneous rumination following interpersonal exclusion mediated the effects of BPD features on distress. These findings highlight the importance of context when examining ER outcomes.

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.

The intergenerational transmission of childhood maltreatment: Nonspecificity of maltreatment type and associations with borderline personality pathology

One generation's experience of childhood maltreatment is associated with that of the next. However, whether this intergenerational transmission is specific to distinct forms of maltreatment and what factors may contribute to its continuity remains unclear. Borderline personality pathology is predicted by childhood maltreatment and characterized by features (e.g., dysregulated emotion, relationship instability, impulsivity, and inconsistent appraisals of others) that may contribute to its propagation. Among 364 older adults and 573 of their adult children (total n = 937), self-reported exposure to distinct forms of childhood maltreatment (i.e., emotional, physical, and sexual abuse, and emotional and physical neglect as assessed by the Childhood Trauma Questionnaire) showed homotypic and heterotypic associations across generations with little evidence that latent factors unique to specific forms of maltreatment show generational continuity. General nonspecific indices of childhood maltreatment showed evidence of intergenerational transmission after accounting for demographic factors and parent socioeconomic status (b = 0.126, p = 9.21 × 10−4). This continuity was partially mediated by parental borderline personality pathology (assessed longitudinally through a variety of measures and sources, indirect effect: b = 0.031, 95% confidence interval [0.003, 0.060]). The intergenerational continuity of childhood maltreatment may largely represent general risk for nonspecific maltreatment that may, in part, be propagated by borderline personality pathology and/or shared risk factors.

The Clinical Significance of Subthreshold Borderline Personality Disorder Features in Outpatient Youth

Studies among adult patients have found that subthreshold borderline personality disorder (BPD) features are associated with elevated psychosocial morbidity compared with patients with no BPD features. However, the clinical significance of subthreshold features of BPD has not been investigated among real-world patients during the clinical emergence of the disorder, which is usually between puberty and emerging adulthood. This study aimed to replicate and extend previous research by comparing outpatient youth aged 15-25 years with subthreshold BPD features with youth with no BPD features. The sample included 499 potential participants, of whom 111 had no DSM-IV BPD features at all, and 155 had between one and four features. Results indicated that the group with subthreshold BPD features had more severe mental illness and poorer social and occupational functioning. These findings suggest that subthreshold BPD features are clinically important and should be a focus of clinical intervention to reduce continuing disability and improve outcome.

A New Test for Irony Detection: The Influence of Schizotypal, Borderline, and Autistic Personality Traits

Irony has repeatedly been suggested as a language based social cognition task. It has been argued to show specific variances in psychiatric disorders and healthy adults with certain personality traits. Above that, irony comprehension is based on a complex interplay of the informational context, the relationship of the conversational partners, and the personality of the recipient. The present study developed a video-based German language test for a systematic examination of irony detection accuracy (Tuerony). The test includes (i) a stereotypical conversation partner (doctor, actor) in (ii) different perspectives (direct interaction, neutral observer) and (iii) a bilateral chat history on a conventional messenger service interface with ironic criticism, ironic praise, literal criticism, and literal praise. Based on the continuous approach of psychiatric symptoms, schizotypal, borderline, and autistic personality traits were associated with irony detection accuracy in a healthy sample. Given the often reported role of mentalization in irony detection, these associations were also investigated. First, a broad variance of irony comprehension in our healthy sample could be shown. Second, schizotypal and borderline, but not autistic traits were significantly negatively associated with irony detection accuracy. Finally, in the current healthy sample, neither variation of the conversational context nor mentalization characteristics were significantly associated with performance beyond personality traits. The current results therefore highlight two aspects for future research in irony comprehension: the importance of ecological valid tests and the role of the individual personality of the recipient.

Borderline personality disorder

Caretakers are often intimidated or alienated by patients with borderline personality disorder (BPD), compounding the clinical challenges posed by the severe morbidity, high social costs and substantial prevalence of this disorder in many health-care settings. BPD is found in ∼1.7% of the general population but in 15-28% of patients in psychiatric clinics or hospitals and in a large proportion of individuals seeking help for psychological problems in general health facilities. BPD is characterized by extreme sensitivity to perceived interpersonal slights, an unstable sense of self, intense and volatile emotionality and impulsive behaviours that are often self-destructive. Most patients gradually enter symptomatic remission, and their rate of remission can be accelerated by evidence-based psychosocial treatments. Although self-harming behaviours and proneness to crisis can decrease over time, the natural course and otherwise effective treatments of BPD usually leave many patients with persistent and severe social disabilities related to depression or self-harming behaviours. Thus, clinicians need to actively enquire about the central issues of interpersonal relations and unstable identity. Failure to correctly diagnose patients with BPD leads to misleading pharmacological interventions that rarely succeed. Whether the definition of BPD should change is under debate that is linked to not fully knowing the nature of this disorder.

Maternal mental health and child problem behaviours: disentangling the role of depression and borderline personality dysfunction

BACKGROUND

It is not known whether associations between child problem behaviours and maternal depression can be accounted for by comorbid borderline personality disorder (BPD) dysfunction.

AIM

To examine the contributions of maternal depression and BPD symptoms to child problem behaviours.

METHOD

Depression trajectories over the first-year postpartum were generated using repeated measurement from a general population sample of 997 mothers recruited in pregnancy. In a stratified subsample of 251, maternal depression and BPD symptoms were examined as predictors of child problem behaviours at 2.5 years.

RESULTS

Child problem behaviours were predicted by a high maternal depression trajectory prior to the inclusion of BPD symptoms. This association was no longer significant after the introduction of BPD symptoms.

CONCLUSIONS

Risks for child problem behaviours currently attributed to maternal depression may arise from more persistent and pervasive difficulties found in borderline personality dysfunction.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017, this is an open access article distributed under the terms of the Creative Commons Attribution (CC BY) license.

Preliminary Evidence for Emotion Dysregulation as a Mechanism Underlying Poor Sleep Quality in Borderline Personality Disorder

Sleep disturbance is common in borderline personality disorder (BPD), yet the reasons for this association are not clear. The present study sought to extend prior studies by testing emotion dysregulation as a mechanism underlying this association. We administered self-report measures of sleep quality (SQ), emotion dysregulation, and borderline features to two cross-sectional samples of undergraduates (sample 1: N = 293; sample 2: N = 188). In addition to replicating prior studies linking BPD features to poor SQ, analyses indicated that BPD features related to emotion dysregulation were most strongly correlated with poorer global SQ across both samples. Further, bootstrapping techniques revealed indirect associations by total score on the Difficulties in Emotion Regulation Scale (DERS), as well as for several of its facets (lack of strategies, lack of emotional clarity, lack of awareness). We discuss the potential clinical relevance of emotion dysregulation in the treatment of co-occurring sleep problems in BPD.

Differences in mental health among young adults with borderline personality symptoms of various severities

PURPOSE

This study examined the differences in mental health and behavioral problems among young adults with borderline personality symptoms of various severities.

METHODS

500 college students participated in this study. Borderline personality symptoms were evaluated using the Taiwanese version of the Borderline Symptom List (BSL-23). Mental health problems were assessed using the Symptom Checklist-90-Revised Scale. Suicidality and other behavioral problems were assessed using questions from the epidemiological version of the Kiddie Schedule for Affective Disorders and Schizophrenia and BSL-23 Supplement. According to the distribution of BSL-23 scores at the 25th, 50th, and 75th percentiles, the participants were divided into 4 groups: No/Mild, Moderate, Severe, and Profound. Analysis of variance and the chi-square test were used to compare mental health and behavioral problems among the 4 groups.

RESULTS

All mental health problems differed significantly among the 4 groups. The severity of nearly all mental health problems increased with that of borderline personality symptoms. The proportions of most behavioral problems differed significantly among the 4 groups. The Profound group was more likely to have behavioral problems than the other 3 groups.

CONCLUSION

Young adults who had more severe borderline personality symptoms had more severe mental health and behavioral problems.

Gender Differences in Borderline Personality Disorder Features in an Epidemiological Sample of Adults Age 55-64: Self Versus Informant Report

The literature on the prevalence of borderline personality disorder (BPD) across gender reveals multiple trends. A number of studies indicate that women have a higher prevalence. Others indicate no difference, and a few even reveal that men have a higher prevalence. Yet existing studies are plagued by sampling biases, use mainly self-reported information, and tend to report general prevalence of BPD categorically defined. The current investigation attempted to shed new light on this literature by analyzing BPD features dimensionally in a representative epidemiological sample of adults ages 55-64, using both self- and informant-reported perspectives. Data from the St. Louis Personality and Aging Network study revealed a significant interaction across gender and perspective, F(1, 1360) = 23.46, p < .01. Gender differences were found for self-report only, such that men reported greater BPD severity. Meanwhile, informant report indicated no gender difference. Trends underscore the importance of epidemiological sampling and multiple assessment perspectives when analyzing BPD.

A Systematic Review of Personality Disorders and Health Outcomes

Personality disorders have been associated with a wide swath of adverse health outcomes and correspondingly high costs to healthcare systems. To date, however, there has not been a systematic review of the literature on health conditions among individuals with personality disorders. The primary aim of this article is to review research documenting the associations between personality disorders and health conditions. A systematic review of the literature revealed 78 unique empirical English-language peer-reviewed articles examining the association of personality disorders and health outcomes over the past 15 years. Specifically, we reviewed research examining the association of personality disorders with sleep disturbance, obesity, pain conditions, and other chronic health conditions. In addition, we evaluated research on candidate mechanisms underlying health problems in personality disorders and potential treatments for such disorders. Results underscore numerous deleterious health outcomes associated with PD features and PD diagnoses, and suggest potential biological and behavioural factors that may account for these relations. Guidelines for future research in this area are discussed.

DSM-IV Personality Disorders: Dimensional Ordered Categorization and Associations With Disability and Selected Axis I Disorders in a General Population Survey

The DSM approach to personality disorder (PD) diagnoses has been criticized for using arbitrary thresholds. The present study evaluated one dimensional approach with ordered threshold categories of severity by examining associations with several measures of disability and Axis I disorders for 10 PDs in the general population. Data were obtained from the National Epidemiologic Survey of Alcohol and Related Conditions, Waves 1 and 2. Respondents were categorized according to PD criteria as follows: "no symptoms" for having no positive criteria, "subthreshold" for having at least one positive criterion but below the DSM-IV threshold, "at-threshold" for meeting the DSM-IV threshold and additionally having one or two more positive criteria, and "suprathreshold" for meeting the DSM-IV threshold plus three or more positive criteria. Findings from this national study provide support for dimensional approaches to diagnostic classifications for the majority of PDs and suggest that mild levels of severity indeed have clinical significance.

Personality Assessment in the Diagnostic Manuals: On Mindfulness, Multiple Methods, and Test Score Discontinuities

Recent controversies have illuminated the strengths and limitations of different frameworks for conceptualizing personality pathology (e.g., trait perspectives, categorical models), and stimulated debate regarding how best to diagnose personality disorders (PDs) in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.), and in other diagnostic systems (i.e., the International Classification of Diseases, the Psychodynamic Diagnostic Manual). In this article I argue that regardless of how PDs are conceptualized and which diagnostic system is employed, multimethod assessment must play a central role in PD diagnosis. By complementing self-reports with evidence from other domains (e.g., performance-based tests), a broader range of psychological processes are engaged in the patient, and the impact of self-perception and self-presentation biases can be better understood. By providing the assessor with evidence drawn from multiple modalities, some of which provide converging patterns and some of which yield divergent results, a multimethod assessment compels the assessor to engage this evidence more deeply. The mindful processing that ensues can help minimize the deleterious impact of naturally occurring information processing bias and distortion on the part of the clinician (e.g., heuristics, attribution errors), bringing greater clarity to the synthesis and integration of assessment data.

Maternal borderline personality disorder symptoms and convergence between observed and reported infant negative emotional expressions

To date, the influence of maternal borderline personality disorder (BPD) on perceptions of infants' emotional expressions has not been examined. This study investigated the relation of maternal BPD symptoms to discrepancies between mother-reported and observed infant expressions of fear and anger. Emotional expressions in response to fear- and anger-eliciting stimuli were observed among 101 12- to 23-month-old infants of mothers with a range of BPD symptoms. Mothers also reported on their infants' past-month fear and anger expressions. Findings from polynomial regression analyses revealed that maternal BPD symptoms (particularly BPD interpersonal symptoms) are associated with greater convergence of mother-reported and observed infant anger expressions. Furthermore, although maternal BPD symptoms were not related to discrepancies between mother-reported and observed infant fear, findings did reveal a relation between maternal BPD symptoms and observed infant fear expressions, such that maternal BPD symptoms related to both low and high (vs. moderate) levels of fear expressions in the laboratory. Moreover, BPD behavioral symptoms in particular were associated with greater convergence of mother-reported and observed infant fear expressions. Overall, findings contribute to the literature on the impact of maternal BPD on parenting and infant outcomes, and highlight the relevance of maternal BPD symptoms to discrepancies between perceived and observed infant negative emotional expressions.

Transdiagnostic factors of psychopathology and substance use disorders: a review

PURPOSE

Research on the structure of mental disorders and comorbidity indicates that many forms of psychopathology and substance use disorders are manifestations of relatively few transdiagnostic latent factors. These factors have important consequences for mental disorder research and applied practice.

METHODS

We provide an overview of the transdiagnostic factor literature, with particular focus on recent advances.

RESULTS

Internalizing and externalizing transdiagnostic factors have been well characterized in terms of their structures, links with disorders, stability, and statistical properties (e.g., invariance and distributions). Research on additional transdiagnostic factors, such as thought disorder, is quickly advancing latent structural models, as are integrations of transdiagnostic constructs with personality traits. Genetically informed analyses continue to clarify the origins of transdiagnostic factor levels, and links between these factors and important environmental exposures provide promising new avenues of inquiry.

CONCLUSIONS

Transdiagnostic factors account for the development and continuity of disorders and comorbidity over time, function as the primary links between disorders and important outcomes such as suicide, mediate associations between environmental exposures and disorders, provide an empirically supported classification system, and serve as foci for efficient, broadband intervention approaches. Overall, transdiagnostic factor research indicates the paramount importance of understanding these constructs and, thereby, broadening our understanding of mental disorder in general.