Insensitivity to the Magnitude of Potential Gains or Losses When Making Risky Choices: Women With Borderline Personality Disorder Compared With Bipolar Disorder and Controls

Optimizing differential diagnostics and identifying transdiagnostic treatment targets using virtual reality

Accurate diagnosis in psychiatry remains a significant challenge, often delaying appropriate treatment and resulting in poorer clinical outcomes. Identifying precise biomarkers for differential diagnosis is therefore crucial. This study aimed to identify distinct behavioral and psychophysiological markers of emotional reactivity in virtual reality (VR) settings among individuals with bipolar disorder (BD), borderline personality disorder (BPD), schizophrenia spectrum disorders (SSD), and healthy controls (HC). Participants (BD: n = 32, BPD: n = 21, SSD: n = 17, HC: n = 30) aged 19-60 were exposed to six immersive 360-degree social VR scenarios, ranging from neutral to highly emotional contexts (e.g., an elevator ride, a crying baby). Emotional responses were self-rated on a 1-5 scale, while galvanic skin response (GSR) was continuously recorded. Scenarios assessed feelings of unpleasantness, pleasantness, being observed, and the urge to comfort. Across diagnoses, individuals with mental health conditions reported more negative emotional responses (greater unpleasantness) across both neutral and negative scenarios (ps ≤ 0.02) despite similar GSR levels to HC. Specifically, in the elevator scenario, BPD and SSD experienced greater unpleasantness and feelings of being observed, coupled with stronger GSRs compared to BD (ps ≤ 0.03). SSD reported higher unpleasantness in the canteen scenario, less pleasantness in the happy baby scenario, and overall higher GSR than BD (ps ≤ 0.049). Negative emotional reactivity was consistent across BD, BPD, and SSD, with heightened emotional and physiological responses distinguishing SSD and BPD from BD in specific VR contexts. VR-based assessments of emotional and physiological markers show promise for improving differential diagnosis and identifying transdiagnostic treatment targets.

COVID-19 prevention behaviour is differentially motivated by primary psychopathy, grandiose narcissism and vulnerable Dark Triad traits

Dark Triad traits (psychopathy, narcissism) are associated with nonadherence to COVID-19 prevention measures such as social distancing and wearing face masks, although the psychological mechanisms underpinning this relationship remain unclear. In contrast, high threat-sensitivity may motivate compliance, and maybe seen in relation to vulnerable dark traits (secondary psychopathy, vulnerable narcissism and borderline personality disorder). The relationship between vulnerable dark traits and COVID-19 prevention behaviour has not been examined. During April 2021, participants (n = 263) completed an online psychometric study assessing engagement with COVID-19 prevention behaviour, traditional DT traits (primary psychopathy; grandiose narcissism) and vulnerable DT traits. Potential indirect effects were fear of COVID-19, perceived coronavirus severity, belief in COVID-19 conspiracy theories and altruism. Model of path analysis identified predictors of engagement in disease prevention behaviour. Primary psychopathy, grandiose narcissism, secondary psychopathy and BPD were associated with less COVID-19 prevention behaviour, with an indirect effect of reduced coronavirus severity. Grandiose narcissism and BPD were also motivated by COVID-19 conspiracy theories, and increased prevention behaviour when fear of COVID-19 was higher. No direct or indirect effects were observed for vulnerable narcissism. The current study is the first to elucidate psychological mechanisms linking vulnerable dark traits with COVID-19 prevention behaviour.

The influence of borderline personality traits on clinical outcomes in bipolar disorder

OBJECTIVES

Systematic reviews suggest comorbid borderline personality disorder is present in approximately 20% of individuals who have bipolar disorder, but current diagnostic systems demonstrate a move towards dimensional rather than categorical approaches to classifying personality pathology. We aimed to examine the presence and severity of borderline personality traits in bipolar I and bipolar II disorder, and to explore associations between the presence/severity of borderline personality traits and clinical outcomes in bipolar disorder.

METHODS

Borderline personality traits were measured in 1447 individuals with DSM-IV bipolar disorder (1008 bipolar I disorder and 439 bipolar II disorder) using the Borderline Evaluation of Severity over Time (BEST) questionnaire. Lifetime clinical outcomes were assessed via Schedules for Clinical Assessment in Neuropsychiatry (SCAN) semi-structured interview and clinical case notes.

RESULTS

Borderline personality traits were common in both bipolar disorder groups, with 86.2% participants reporting at least one trait. These included traits that overlap with (eg mood instability) and those that are distinct from the symptoms of bipolar disorder (eg fear of abandonment). Borderline personality traits were significantly more frequent and more severe in bipolar II disorder compared to bipolar I disorder. More severe borderline traits, and even the presence of a single borderline personality trait, were significantly associated with younger age of bipolar disorder onset and higher prevalence of lifetime alcohol misuse in both bipolar disorder groups.

CONCLUSIONS

The presence of comorbid borderline personality traits should be considered in the management of all patients with bipolar disorder irrespective of whether criteria for a categorical borderline personality disorder diagnosis are met.

Cortical haemodynamic response during the verbal fluency task in patients with bipolar disorder and borderline personality disorder: a preliminary functional near-infrared spectroscopy study

BACKGROUND

Functional near-infrared spectroscopy (fNIRS) is an emerging neuroimaging modality that provides a direct and quantitative assessment of cortical haemodynamic response during a cognitive task. It may be used to identify neurophysiological differences between psychiatric disorders with overlapping symptoms, such as bipolar disorder (BD) and borderline personality disorder (BPD). Hence, this preliminary study aimed to compare the cerebral haemodynamic function of healthy controls (HC), patients with BD and patients with BPD.

METHODS

Twenty-seven participants (9 HCs, 9 patients with BD and 9 patients with BPD) matched for age, gender, ethnicity and education were recruited. Relative oxy-haemoglobin and deoxy-haemoglobin changes in the frontotemporal cortex was monitored with a 52-channel fNIRS system during a verbal fluency task (VFT). VFT performance, clinical history and symptom severity were also noted.

RESULTS

Compared to HCs, both patient groups had lower mean oxy-haemoglobin in the frontotemporal cortex during the VFT. Moreover, mean oxy-haemoglobin in the left inferior frontal region is markedly lower in patients with BPD compared to patients with BD. Task performance, clinical history and symptom severity were not associated with mean oxy-haemoglobin levels.

CONCLUSIONS

Prefrontal cortex activity is disrupted in patients with BD and BPD, but it is more extensive in BPD. These results provide further neurophysiological evidence for the separation of BPD from the bipolar spectrum. fNIRS could be a potential tool for assessing the frontal lobe function of patients who present with symptoms that are common to BD and BPD.

Clinical Features, Neuropsychology and Neuroimaging in Bipolar and Borderline Personality Disorder: A Systematic Review of Cross-Diagnostic Studies

Background: Bipolar Disorder (BD) and Borderline Personality Disorder (BPD) have clinically been evolving as separate disorders, though there is still debate on the nosological valence of both conditions, their interaction in terms of co-morbidity or disorder spectrum and their distinct pathophysiology. Objective: The objective of this review is to summarize evidence regarding clinical features, neuropsychological performance and neuroimaging findings from cross-diagnostic studies comparing BD and BPD, to further caracterize their complex interplay. Methods: Using PubMed, PsycINFO and TripDataBase, we conducted a systematic literature search based on PRISMA guidelines of studies published from January 1980 to September 2019 which directly compared BD and BPD. Results: A total of 28 studies comparing BD and BPD were included: 19 compared clinical features, 6 neuropsychological performance and three neuroimaging abnormalities. Depressive symptoms have an earlier onset in BPD than BD. BD patients present more mixed or manic symptoms, with BD-I differing from BPD in manic phases. BPD patients show more negative attitudes toward others and self, more conflictive interpersonal relationships, and more maladaptive regulation strategies in affective instability with separate pathways. Impulsivity seems more a trait in BPD rather than a state as in BD. Otherwise, BD and BPD overlap in depressive and anxious symptoms, dysphoria, various abnormal temperamental traits, suicidal ideation, and childhood trauma. Both disorders differ and share deficits in neuropsychological and neuroimaging findings. Conclusion: Clinical data provide evidence of overlapping features in both disorders, with most of those shared symptoms being more persistent and intense in BPD. Thus, categorical classifications should be compared to dimensional approaches in transdiagnostic studies investigating BPD features in BD regarding their respective explanatory power for individual trajectories. Systematic Review Registration: The search strategy was pre-registered in PROSPERO: CRD42018100268.

Actigraphic patterns, impulsivity and mood instability in bipolar disorder, borderline personality disorder and healthy controls

OBJECTIVES

To differentiate the relation between the structure and timing of rest-activity patterns and symptoms of impulsivity and mood instability in bipolar disorder (BD), borderline personality disorder (BPD) and healthy controls (HC).

METHODS

Eighty-seven participants (31 BD, 21 BPD and 35 HC) underwent actigraph monitoring for 28 days as part of the Automated Monitoring of Symptom Severity (AMoSS) study. Impulsivity was assessed at study entry using the BIS-11. Mood instability was subsequently longitudinally monitored using the digital Mood Zoom questionnaire.

RESULTS

BPD participants show several robust and significant correlations between non-parametric circadian rest-activity variables and worsened symptoms. Impulsivity was associated with low interdaily stability (r = -0.663) and weak amplitude (r = -0.616). Mood instability was associated with low interdaily stability (r = -0.773), greater rhythm fragmentation (r = 0.662), weak amplitude (r = -0.694) and later onset of daily activity (r = 0.553). These associations were not present for BD or HCs. Classification analysis using actigraphic measures determined that later L5 onset reliably distinguished BPD from BD and HC but did not sufficiently discriminate between BD and HC.

CONCLUSIONS

Rest-activity pattern disturbance indicative of perturbed sleep and circadian function is an important predictor of symptom severity in BPD. This appears to validate the greater subjective complaints of BPD individuals that are sometimes regarded as exaggerated by clinicians. We suggest that treatment strategies directed towards improving sleep and circadian entrainment may in the future be investigated in BPD.

Affective cognition in bipolar disorder: A systematic review by the ISBD targeting cognition task force

BACKGROUND

Impairments in affective cognition are part of the neurocognitive profile and possible treatment targets in bipolar disorder (BD), but the findings are heterogeneous. The International Society of Bipolar Disorder (ISBD) Targeting Cognition Task Force conducted a systematic review to (i) identify the most consistent findings in affective cognition in BD, and (ii) provide suggestions for affective cognitive domains for future study and meta-analyses.

METHODS

The review included original studies reporting behavioral measures of affective cognition in BD patients vs controls following the procedures of the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) statement. Searches were conducted on PubMed/MEDLINE, EMBASE, and PsychInfo from inception until November 2018.

RESULTS

A total of 106 articles were included (of which nine included data for several affective domains); 41 studies assessed emotional face processing; 23 studies investigated reactivity to emotional words and images; 3 investigated explicit emotion regulation; 17 assessed implicit emotion regulation; 31 assessed reward processing and affective decision making. In general, findings were inconsistent. The most consistent findings were trait-related difficulties in facial emotion recognition and implicit emotion regulation, and impairments in reward processing and affective decision making during mood episodes. Studies using eye-tracking and facial emotion analysis revealed subtle trait-related abnormalities in emotional reactivity.

CONCLUSION

The ISBD Task Force recommends facial expression recognition, implicit emotion regulation, and reward processing as domains for future research and meta-analyses. An important step to aid comparability between studies in the field would be to reach consensus on an affective cognition test battery for BD.

Interpersonal dysfunction in borderline personality: a decision neuroscience perspective

Borderline personality disorder (BPD) is characterized by disadvantageous decisions that are often expressed in close relationships and associated with intense negative emotions. Although functional neuroimaging studies of BPD have described regions associated with altered social cognition and emotion processing, these correlates do not inform an understanding of how brain activity leads to maladaptive choices. Drawing on recent research, we argue that formal models of decision-making are crucial to elaborating theories of BPD that bridge psychological constructs, behavior, and neural systems. We propose that maladaptive interactions between Pavlovian and instrumental influences play a crucial role in the expression of interpersonal problems. Finally, we articulate specific hypotheses about how clinical features of BPD may map onto neural systems that implement separable decision processes.

Impulsivity in personality disorders: current views and future directions

PURPOSE OF REVIEW

Impulsivity is considered a trans-diagnostic feature of many mental disorders, yet our understanding of the concept and approaches to measurement have evolved significantly with advances in neuroimaging. This review will provide an overview of impulsivity as it is currently understood, its association with personality disorder and implications for treatment.

RECENT FINDINGS

Impulsivity is now considered to involve failure of inhibitory control, either motor or cognitive, and deficits of the reward valuation system. Inhibitory control, and discounting of rewards are both independently associated with personality disorder. The tendency to choose immediate rewards over those with an associated delay is a feature of borderline personality disorder (BPD) regardless of conditions of stress. Deficits in response inhibition were also associated with BPD and were worsened under conditions of stress. These findings indicate that state impulsivity has an important role in the expression of impulsive behaviour. Exploratory studies measuring changes in these networks following psychotherapy have confirmed such methods could be used to measuring treatment response.

SUMMARY

Understanding the discrete mechanisms of impulsive decision-making and behavior, and their implications in personality disorder, offers new targets for diagnosis and intervention. Future research should aim to understand changes of impulsivity with development. Identifying the role of psychological and pharmacological intervention in modulating the development of impulsivity may prevent progression to personality disorder, and associated adverse outcomes.

Rapid emotional response and disadvantageous Iowa gambling task performance in women with borderline personality disorder

BACKGROUND

Adults with Borderline Personality Disorder (BPD) manifest poor performance on tasks of decision making which may be congruent with their decisional and interpersonal conflicts in real life. Poor decision making is often assumed to be due to impulsive behaviour or weak inhibitory control despite inconsistent evidences of these relationships, leaving questions about the specific nature of these decisional deficits. Decision making in BPD may be compromised by different domains of impulsivity, affective dysregulatory processes or unknown co-morbid ADHD which is considered a developmental precursor to BPD.

FINDINGS

Iowa Gambling Task (IGT) decision making, 2 tasks of inhibitory control and a self report of ADHD symptoms consisting of 9 subscales were administered to 41 BPD women and 41 healthy controls. No group differences in inhibitory control were present. Net decision making performance and all ADHD subscale ratings differed significantly among BPD women and healthy controls. BPD women did not meet the threshold indicative of moderate to severe ADHD. Three subscales of attention, behaviour/ disorganized and emotive were significantly associated with poor IGT performance in 26 women with BPD. Of these 3 variables, the emotive subscale, representing a rapid emotional response, was the only significant predictor contributing 49% to the variance in poor DM.

CONCLUSIONS

This is the 1st evidence of an emotive type of impulsivity, representing a type of affective instability that is linked to poor IGT DM in BPD. Findings support the Somatic Marker Hypothesis of IGT DM and may reflect the affective dysregulation that characterizes the disorder.