Borderline Personality Disorder Features and Sensitivity to Injustice

Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies

Borderline personality disorder (BPD) was introduced in the DSM-III in 1980. From the DSM-III to the DSM-5, no major changes have occurred in its defining criteria. The disorder is characterized by instability of self-image, interpersonal relationships and affects. Further symptoms include impulsivity, intense anger, feelings of emptiness, strong abandonment fears, suicidal or self-mutilation behavior, and transient stress-related paranoid ideation or severe dissociative symptoms. There is evidence that BPD can be reliably diagnosed and differentiated from other mental disorders by semi-structured interviews. The disorder is associated with considerable functional impairment, intensive treatment utilization, and high societal costs. The risk of self-mutilation and suicide is high. In the general adult population, the lifetime prevalence of BPD has been reported to be from 0.7 to 2.7%, while its prevalence is about 12% in outpatient and 22% in inpatient psychiatric services. BPD is significantly associated with other mental disorders, including depressive disorders, substance use disorders, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, bipolar disorder, bulimia nervosa, and other personality disorders. There is convincing evidence to suggest that the interaction between genetic factors and adverse childhood experiences plays a central role in the etiology of BPD. In spite of considerable research, the neurobiological underpinnings of the disorder remain to be clarified. Psychotherapy is the treatment of choice for BPD. Various approaches have been empirically supported in randomized controlled trials, including dialectical behavior therapy, mentalization-based therapy, transference-focused therapy, and schema therapy. No approach has proved to be superior to others. Compared to treatment as usual, psychotherapy has proved to be more efficacious, with effect sizes between 0.50 and 0.65 with regard to core BPD symptom severity. However, almost half of the patients do not respond sufficiently to psychotherapy, and further research in this area is warranted. It is not clear whether some patients may benefit more from one psychotherapeutic approach than from others. No evidence is available consistently showing that any psychoactive medication is efficacious for the core features of BPD. For discrete and severe comorbid anxiety or depressive symptoms or psychotic-like features, pharmacotherapy may be useful. Early diagnosis and treatment of BPD can reduce individual suffering and societal costs. However, more high-quality studies are required, in both adolescents and adults. This review provides a comprehensive update of the BPD diagnosis and clinical characterization, risk factors, neurobiology, cognition, and management. It also discusses the current controversies concerning the disorder, and highlights the areas in which further research is needed.

Moral Injury and Shame Mediate the Relationship Between Childhood Trauma and Borderline Personality Disorder, PTSD, and Complex PTSD Symptoms in Psychiatric Inpatients

Moral injury (MI) has received increased research attention in the past decades. However, despite its detrimental mental health consequences, MI has not been studied in psychiatric patients. We aimed to establish the relationship between childhood trauma, MI, and borderline personality disorder (BPD), posttraumatic stress disorder (PTSD), and disturbances in self-organization symptoms (DSO), a core diagnostic criterion of complex PTSD besides PTSD symptoms, and shame as a moral emotion in an inpatient psychiatric sample (N = 240). We found that the impact of childhood trauma on present BPD, PTSD, and DSO symptoms was mediated by MI and shame; the models accounted for up to 31% of variance in symptomatology. To our knowledge, this study is the first to investigate MI in a psychiatric sample, and our results highlight the importance of considering MI as a critical factor of patient experiences in relation to childhood trauma that potentially contributes to the development of psychiatric symptoms.

Development and Validation of the Certainty About Mental States Questionnaire (CAMSQ): A Self-Report Measure of Mentalizing Oneself and Others

The Certainty About Mental States Questionnaire (CAMSQ) is a self-report measure of the perceived capacity to understand mental states of the self and others (i.e., mentalizing). In two studies (total N = 1828), we developed the CAMSQ in both English and German as a two-dimensional measure of Self- and Other-Certainty, investigated associations with other measures of mentalizing, and explored relationships to personality functioning and mental health. The CAMSQ performed well in terms of convergent and discriminant validity, internal consistency, test-retest reliability, and measurement invariance across the United States and Germany. The present research indicates that the CAMSQ assesses maladaptive forms of having too little or too much certainty about mental states (consistent with hypomentalizing and hypermentalizing). A psychologically adaptive profile of perceived mentalizing capacity appears to be characterized by high Self-Certainty that exceeds Other-Certainty, suggesting that imbalances between Self-Certainty and Other-Certainty (Other-Self-Discrepancy) play an important role within personality pathology.

Heritability of Justice Sensitivity

Abstract. Justice is one of the fundamental principles in human evolution, and justice sensitivity from the pro-self (e.g., as a victim) and the prosocial perspective (e.g., as an observer, beneficiary, and perpetrator) matters in mental wellness and social interaction. However, the extent to which individual difference in justice sensitivity is influenced by genetic versus environmental factors remains unclear. Using a sample with 244 twin pairs, the present research attempts to determine the extent to which genetic factors play a role in the inter-individual difference of justice sensitivity as well as whether different facets of justice sensitivity, namely, pro-self and prosocial perspectives, share a common genetic basis. Results showed that (1) all facets of justice sensitivity were moderately heritable (21–33%) and that the non-shared environmental factors plus measurement error accounted for the rest of the variations (67–79%); (2) associations between the prosocial facets of justice sensitivity were driven by common genetic ( rg = .50–.65) and non-shared environmental (plus measurement error; re = .24–.65) influences, whereas no significant genetic link was found between the pro-self and prosocial facets. The current findings provide novel evidence that sensitivity to injustice, especially to others’ suffering, is fundamentally grounded upon genetic origin, thereby shedding light on the nature and nurture aspects of justice behavior.

Expectation of Selfishness From Others in Borderline Personality Disorder

Social difficulties are apparent in borderline personality disorder (BPD). Behavior in BPD is characterized by mistrust and expectations of malevolence from others. We examined whether there is an asymmetry between their social behavior and their belief about other people’s social motivations. Subjects completed a task where they had to allocate money between themselves and an imagined other they will not meet and interact with. In addition they also had to report their expectations about how the imagined other would solve the task. We hypothesized that even though BPD patients will act in a prosocial way, they will expect selfish behavior from the other. We used the Slider Measure of social value orientation (SVO) and also created a modified version of the measure to examine the discrepancy between the subjects’ own SVO and their expectations from other people. We compared the results of thirty clinically diagnosed BPD patients to a matched sample of healthy participants. Our results show that the BPD group’s selfishness expectations significantly outweigh the expectations of selfishness in the HC group (U = 269, p = 0.007). This result further supports the mistrust and negativity bias observed in various aspects of social interactions in BPD.

Consider others better than yourself: Social decision-making and partner preference in Borderline Personality Disorder

BACKGROUND AND OBJECTIVES

Patients with Borderline Personality Disorder (BPD) suffer from interpersonal difficulties. They have been shown to be distrustful and yet involved in abusive relationships. In this study, we want to examine whether the perception of fairness and partner preference are altered in BPD.

METHODS

We employed a coalition formation game in which a participant can choose whether to interact in dyads or triads, thus exclusion or inclusion of a third potential interaction partner. Furthermore, triads get a higher endowment, such that dyads are not only unfair to one partner, but also economically inefficient, as the participant reduces the overall amount of money available for distribution. Subsequently, we compared how participants predicted another person's game strategy (inclusive, exclusive, or mixed) and rated its fairness, and which partner the participant would select.

RESULTS

The majority of the BPD group (n = 26) as well as of the healthy group (n = 29) preferred triads over dyads and offered a near-to-equal split to their interaction partners in the first two rounds. In contrast to the healthy group, the BPD group did not show a drop of the average level of investment in the final round. In both groups, the inclusive strategy was perceived as the fairest strategy. Most interestingly, despite a similar perception of fairness, half of the BPD group preferred an interaction partner with an exclusive or mixed strategy while the majority of the HC group would choose an interaction partner with an inclusive strategy.

LIMITATIONS

This is a preliminary study which needs further replications before strong conclusions can be drawn.

CONCLUSIONS

Our study demonstrates no differences in fairness perception but an alteration in partner preference of patients with BPD which might contribute to unfavorable partner choices and impairments of interpersonal functioning in BPD.

Specific or transdiagnostic? The occurrence of emotions and their association with distress in the daily life of patients with borderline personality disorder compared to clinical and healthy controls

Borderline personality disorder (BPD) is characterized by more frequent and more intense negative emotions and less frequent positive emotions in daily life than healthy controls (HC) experience, but there is limited empirical evidence regarding whether this is a transdiagnostic or disorder-specific finding and which specific emotions are especially distressing in BPD. We assessed participants' current emotions and distress every 15 min over a 24-h period using e-diaries to investigate the frequency, intensity, and the associated distress of specific emotions. To test the disorder specificity, we used multilevel modeling to compare 43 female patients with BPD, 28 patients with posttraumatic stress disorder (PTSD), 20 patients with bulimia nervosa (BN), and 28 HC. Patients with BPD exhibited anger more frequently than any of the clinical or healthy control groups, demonstrating specificity. The quality of anger accounted for additional distress beyond the pure emotional intensity. In patients with BPD, joy was associated with reduced distress, which was not the case in HC or PTSD. However, the majority of the comparisons (anxiety, sadness, shame, disgust, jealousy, guilt, interest) revealed transdiagnostic patterns. The distress-enhancing or distress-reducing effects of anger and joy might represent an important part of affective dysregulation in BPD.