Self-Harming and Sense of Agency in Patients With Borderline Personality Disorder

Sensory Attenuation Deficit and Auditory Hallucinations in Schizophrenia: A Causal Mechanism or a Risk Factor? Evidence From Meta-Analyses on the N1 Event-Related Potential Component

BACKGROUND

Sensory attenuation (SA), the dampened perception of self-generated sensory information, is typically associated with reduced event-related potential signals, such as for the N1 component of auditory event-related potentials. SA, together with efficient monitoring of intentions and actions, should facilitate the distinction between self-generated and externally generated sensory events, thereby optimizing interaction with the world. According to many, SA is deficient in schizophrenia. The question arises whether altered SA reflects a sufficient mechanism to explain positive symptoms such as auditory hallucinations. A systematic association of reduced auditory SA in hallucinating patients would support this hypothesis.

METHODS

We conducted a series of meta-analyses on 15 studies on auditory SA in which the N1 component of event-related potential-electroencephalogram signals was measured during talking (self-generated sensory signals condition) or when listening to prerecorded vocalizations (externally generated sensory signals condition).

RESULTS

We found that individuals with schizophrenia did show some auditory SA because their N1 signal was significantly attenuated in talking conditions compared with listening conditions. However, the magnitude of such attenuation was reduced in individuals with schizophrenia compared to healthy control participants. This phenomenon generalizes independently from the stage of the disease, the severity of positive symptoms, and whether patients have auditory hallucinations or not.

CONCLUSIONS

These findings suggest that reduced SA cannot be a sufficient mechanism for explaining positive symptoms such as auditory hallucinations in schizophrenia. Because reduced SA was also present in participants at risk of schizophrenia, reduced SA may represent a risk factor for the disorder. We discuss the implications of these results for clinical-cognitive models of schizophrenia.

When time does not matter: cultures differ in their use of temporal cues to infer agency over action effects

Sense of agency (SoA) is the sense of having control over one's own actions and through them events in the outside world. Sometimes temporal cues, that is temporal contiguity between action and effect, or temporal expectation regarding the occurrence of the effect are used to infer whether one has agency over an effect. This has mainly been investigated in Western cultures. However, Western and Eastern cultures differ in their time concepts and thus their usage of temporal cues may also differ. We investigated whether Western and Eastern cultures (Austrian vs. Mongolian students) use temporal cues differently. Participants performed adaption blocks in which actions were followed by immediate (immediate effect group) or by delayed (delayed effect group) effects. In subsequent test blocks the action-effect delay was varied and participants' SoA over the effect was assessed. In Austrian students, the immediate effect group experienced more SoA for short action-effect delays, whereas the reverse was true for the delayed effect group. Thus, temporal expectation rather than temporal contiguity is used as predominant agency cue. In Mongolian students, SoA did not significantly differ between different action-effect delays in both groups, indicating that Mongolian students hardly rely on temporal cues. In conclusion, due to linear time concepts in Western cultures, the timing of an effect may be an important agency cue in Austrian students. However, due to cyclical time concepts in some Eastern cultures, it may be a less important agency cue in Mongolian students. Thus, the use of temporal agency cues is culture-dependent.

Abnormal sense of agency in eating disorders

The feeling of controlling one's own actions and, through them, impacting the external environment (i.e. Sense of Agency-SoA) can be relevant in the eating disorders (EDs) symptomatology. Yet, it has been poorly investigated. This study aims to implicitly assess SoA exploiting the Sensory Attenuation paradigm in two groups of EDs patients (Anorexia Nervosa Restrictive and Anorexia Nervosa Binge-Purging or Bulimia Nervosa) compared to a control group. We find that controls perceive self-generated stimuli as less intense than other-generated ones showing the classic pattern of sensory attenuation. By contrast, EDs patients show the opposite pattern, with self-generated perceived as more intense than other-generated stimuli. This result indicates an alteration of the implicit component of the feeling of control in EDs patients, thus suggesting a potential implication of these results for the clinical practice and the treatment of EDs symptomatology.

Are PID-5 personality traits and self-harm attitudes related? A study on a young adult sample pre-post COVID-19 pandemic

Introduction

Different studies confirm a stronger link between maladaptive personality traits and Non-suicidal Self-injury (NSSI). Additionally, the interest in the relationship between the experience of the COVID-19 pandemic and NSSI is growing. The present study aims (a) to investigate differences in personality traits between individuals with NSSI, suicidal ideation, NSSI and suicidal ideation co-occurrence and none; (b) to observe which personality traits predominantly influence the occurrence of self-harm acts; (c) to evaluate the difference in self-harm attitudes pre and post COVID-19 pandemic.

Method

270 (108 males and 162 females) participants aged between 18 and 25 were included in the study. Everyone participated in a clinical interview and completed an assessment consisting of the Personality Inventory for DSM-5 (PID-5) and the Health of the Nation Outcome Scales (HoNOS). A multivariate analysis of variance (MANOVA), a multiple hierarchical regression analysis, controlling for age and gender and a T-test for independent samples were conducted.

Results

The individuals with the highest levels of negative affectivity, detachment, antagonism, and psychoticism are those who simultaneously present suicidal ideation and NSSI. Moreover, age and detachment predicted higher scores in self-harm attitudes. Our results unexpectedly do not confirm an upward trend of NSSI and suicidal ideation during the pandemic period.

Limitations

The study is cross-sectional, and no causal links can be assumed; the groups involved were not homogeneous for numerosity.

Conclusions

The results testify that the study of maladaptive traits is fundamental to a greater understanding of NSSIs. Working clinically on those could potentially reduce.

Spatial proximity to others induces plastic changes in the neural representation of the peripersonal space

Peripersonal space (PPS) is a highly plastic "invisible bubble" surrounding the body whose boundaries are mapped through multisensory integration. Yet, it is unclear how the spatial proximity to others alters PPS boundaries. Across five experiments (N = 80), by recording behavioral and electrophysiological responses to visuo-tactile stimuli, we demonstrate that the proximity to others induces plastic changes in the neural PPS representation. The spatial proximity to someone else's hand shrinks the portion of space within which multisensory responses occur, thus reducing the PPS boundaries. This suggests that PPS representation, built from bodily and multisensory signals, plastically adapts to the presence of conspecifics to define the self-other boundaries, so that what is usually coded as "my space" is recoded as "your space". When the space is shared with conspecifics, it seems adaptive to move the other-space away from the self-space to discriminate whether external events pertain to the self-body or to other-bodies.

Developmental and Momentary Dynamics in the Onset and Maintenance of Nonsuicidal Self-Injurious Behavior and Borderline Personality Disorder

PURPOSE OF REVIEW

Traditional conceptualizations of both nonsuicidal self-injury (NSSI) and borderline personality disorder (BPD) typically rely on static and unidirectional, linear associations between key biopsychosocial vulnerabilities. Instead, we argue that utilizing a complex dynamic systems view of NSSI and BPD will advance the field, as such conceptual models allow for analysis of bottom-up effects for key vulnerabilities on disorder and behavior emergence, as well as top-down effects of the emergent disorder on underlying vulnerabilities.

RECENT FINDINGS

Following the presentation of a novel framework highlighting momentary and developmental dynamics, we explore several advances in the field that exhibit key dynamic qualities or inform dynamic conceptualizations of NSSI and BPD. At the momentary dynamic level, several advances are being made with multimethod and repeated assessment approaches, as well as advanced bidirectional and complex modeling procedures. Additional progress is being made at the developmental dynamic level, although several questions have arisen regarding the problem of onset and subsequent trajectory, particularly with issues such as pain perception and the interplay between interpersonal, emotional, and behavioral symptoms before and after treatment. Self-injury and BPD both exhibit substantial momentary and developmental dynamics in underlying vulnerabilities, including potential variance in momentary dynamics as a function of psychopathological developmental stage (e.g., onset versus maintenance versus recovery). Recent work has highlighted the necessity of utilizing multimodal research to encapsulate a holistic view of the interplay of several vulnerability factors, the developmental importance of assessment timing, and the need to examine the dynamic interplay between affect, behavior, and interpersonal experiences in BPD and/or NSSI. Research also indicated substantial variation in key vulnerability factors at both between- and within-person levels, highlighting the utility of harnessing statistical models that allow for the simultaneous incorporation of numerous variables at both levels and across several time points. As such, by using a complex dynamic systems conceptualization, we can begin to better understand integrated connections between key vulnerabilities, how they collectively interact in the short term, and how changes in the dynamic interplay between vulnerabilities may arise over the long term and with successful treatment.

Working with People Presenting with Symptoms of Borderline Personality Disorder: The Attitudes, Knowledge and Confidence of Mental Health Nurses in Crisis Response Roles in Australia

Many people diagnosed with or presenting with borderline personality disorder (BPD) attend the emergency department (ED) when in crisis, and are often referred to mental health nurses for further assessment, and to arrange appropriate follow-up (MHNs). Little is known about the knowledge, skills, confidence and competence of MHNs working with this group in these specialist roles. This study sought to describe the attitudes of MHNs working in EDs and crisis services towards people who present with symptoms characteristic of BPD and to explore their knowledge of the diagnostic criteria of BPD. A descriptive survey tool comprised of 23 questions was adapted from a previously used survey with clinicians in a mental health service in Australia. Fifty-four nurses who identified as MHNs and were currently employed in EDs or crisis settings completed the survey online. These MHNs were found to hold positive attitudes towards people with BPD including being optimistic about recovery and treatment. The experience and education of MHNs now employed in EDs may have contributed to positive attitudes and self-reported confidence relative to other nurses. Further research ought to focus on how MHNs assist people with a diagnosis of BPD who present in crisis meet immediate needs and facilitate access to effective ongoing care and treatment.

A systematic scoping review of dissociation in borderline personality disorder and implications for research and clinical practice: Exploring the fog

BACKGROUND

Borderline Personality Disorder (BPD) is frequently complicated by the presence of dissociative symptoms. Pathological dissociation is linked with earlier and more severe trauma exposure, emotional dysregulation and worse treatment outcomes in Posttraumatic Stress Disorder and Dissociative Disorders, with implications for BPD.

OBJECTIVE

A systematic scoping review was conducted to assess the extent of current literature regarding the impact of dissociation on BPD and to identify knowledge gaps.

METHODS

Four electronic databases (MEDLINE, APA PsycINFO, EMBASE, CINAHL Plus) were searched, and English peer-reviewed studies with adults with BPD were included, following Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) extension for scoping reviews (PRISMA-ScR) 2018 guidelines.

RESULTS

Most of the 70 included studies were observational (98%) with first authors from Germany (59%). Overall, dissociation was associated with increased BPD symptom severity, self-harm and reduced psychotherapy treatment response; findings regarding suicide risk were mixed. Dissociation was associated with working memory and cognitive deficits, decreased pain perception, altered body ownership, no substance abuse or the abuse of sedative substances, increased fantasy proneness, personality fragmentation, fearful attachment, dream anxiety, perceived stress and altered stress responses, increased cumulative body mass index, decreased water consumption, several neurological correlates and changes in gene expression.

CONCLUSION

BPD with significant dissociative symptoms may constitute a more severe and at-risk subgroup of BPD patients. However, there are significant research gaps and methodological issues in the area, including the possibility of unrecognized Dissociative Disorders in BPD study populations confounding results. Further studies are needed to better understand the impact of dissociation on BPD course and treatment, and to clarify the most appropriate assessment tools for clinical practice. In addition, interventional studies are needed to develop dissociation-specific BPD treatments to determine whether targeting dissociation in BPD can improve treatment outcomes.

Factors associated with pharmacological and psychotherapy treatments adherence in patients with borderline personality disorder

BACKGROUND

Borderline personality disorder is a major mental illness characterized by sustained relationship instability, impulsive behavior, and intense affects. Adherence is a complex behavior, from minor refusals to abandonment of treatment, which can be affected by various factors. Therefore, the present study aimed to investigate the factors affecting pharmacological and psychotherapy adherence, patients' attitude toward medication, and assessing medication and treatment adherence in patients with borderline personality disorder referred to an outpatient referral clinic in Tehran, Iran.

METHODS

The study was a cross-sectional study. The files of patients with borderline personality disorder referred to the outpatient clinic of the Tehran Psychiatric Institute were reviewed as the first step. Data were collected using the Drug Attitude Inventory-10 (DAI-10) questionnaire and a questionnaire to determine the attitude of patients toward pharmacological and psychotherapy treatment as well as therapeutic adherence. After collecting data, patients' therapeutic adherence was divided into poor, partial, and good compliance.

RESULTS

Ninety-four patients were involved in the study, and fifty-four were women. Findings of DAI showed that 54 (57.4%) participants had negative attitudes toward medication, while 38 (40.4%) participants showed a negative attitude toward psychotherapy treatment. Additionally, the percentage of patients with good psychotherapy adherence (44.7%) was higher than that of patients with good medication adherence (31.9%). The most common reasons for discontinuation of treatment were medication side effects (53.1%), dissatisfaction with the therapist (40.3%), and then fear of medication dependence (40%). Patients with higher education levels and a positive history of hospitalization in a psychiatric ward had better adherence to psychotherapy (P < 0.05).

CONCLUSION

Results of the current study show that attitude toward psychotherapy is more favorable than pharmacotherapy among patients with BPD. The rationale may be that medications are mainly prescribed for comorbid conditions and do not have substantial effects on the BPD symptoms, resulting in low medication adherence.

Behavioural evidence of altered sensory attenuation in obesity

Body ownership (i.e., the conscious belief of owning a body) and sense of agency (i.e., being the agent of one's own movements) are part of a pre-reflective experience of bodily self, which grounds on low-level complex sensory-motor processes. Although previous literature had already investigated body ownership in obesity, sense of agency was never explored. Here, we exploited the sensory attenuation effect (i.e., an implicit marker of the sense of agency; SA effect) to investigate whether the sense of agency was altered in a sample of 18 individuals affected by obesity as compared with 18 healthy-weight individuals. In our experiment, participants were asked to rate the perceived intensity of self-generated and other-generated tactile stimuli. Healthy-weight individuals showed a significantly greater SA effect than participants affected by obesity. Indeed, while healthy-weight participants perceived self-generated stimuli as significantly less intense as compared to externally generated ones, this difference between stimuli was not reported by affected participants. Our results relative to the SA effect pinpointed an altered sense of agency in obesity. We discussed this finding within the motor control framework with reference to obesity. We encouraged future research to further explore such effect and its role in shaping the clinical features of obesity.

Sense of agency disturbances in movement disorders: A comprehensive review

Sense of agency refers to the experience that one's self-generated action causes an event in the external environment. Here, we review the behavioural and brain evidence of aberrant experiences of agency in movement disorders, clinical conditions characterized by either a paucity or an excess of movements unrelated to the patient's intention. We show that specific abnormal agency experiences characterize several movement disorders. Those manifestations are typically associated with structural and functional brain abnormalities. However, the evidence is sometimes conflicting, especially when considering results obtained through different agency measures. The present review aims to create order in the existing literature on sense of agency investigations in movement disorders and to provide a coherent overview framed within current neurocognitive models of motor awareness.

The Cognitive, Ecological, and Developmental Origins of Self-Disturbance in Borderline Personality Disorder

Self-disturbance is recognized as a key symptom of Borderline Personality Disorder (BPD). Although it is the source of significant distress and significant costs to society, it is still poorly specified. In addition, current research and models on the etiology of BPD do not provide sufficient evidence or predictions about who is at risk of developing BPD and self-disturbance, and why. The aim of this review is to lay the foundations of a new model inspired by recent developments at the intersection of social cognition, behavioral ecology, and developmental biology. We argue that the sense of agency is an important dimension to consider when characterizing self-disturbances in BPD. Second, we address the poorly characterized relation between self-disturbances and adverse life conditions encountered early in life. We highlight the potential relevance of Life-History Theory-a major framework in evolutionary developmental biology-to make sense of this association. We put forward the idea that the effect of early life adversity on BPD symptomatology depends on the way individuals trade their limited resources between competing biological functions during development.

The role of impairments in self-other distinction in borderline personality disorder: A narrative review of recent evidence

Impairments in maintaining a differentiated sense of "self" and "other" are thought to be a central feature of borderline personality disorder (BPD). However, studies directly focusing on self-other distinction (SOD) in BPD are scarce, and these findings have not yet been integrated with novel insights into the neural mechanism involved in SOD. Here, we present a narrative review of recent behavioral and neuroimaging findings focusing on impairments in SOD in BPD. Behavioral findings of SOD at the embodied level provide preliminary evidence for impairments in multisensory integration in BPD. Furthermore, both behavioral and neuroscientific data converge to suggest that SOD impairments in BPD reflect an inability to shift between self and other representations according to task demands. Research also suggests that disruptions in infant-caregiver synchrony may play a role in the development of these impairments. Based on these findings, we present a new, integrative model linking impairments in SOD to reduced neural and behavioral synchrony in BPD. The implications of these findings for future research and clinical interventions are outlined.

Borderline personality disorder, metacognition and psychotherapy

BACKGROUND

Deficits in the ability to think about own mental states and that of others (mindreading) are seen as key aspects of borderline personality disorder (BPD), which could sustain BPD symptoms. Interestingly, some studies showed that in BPD patients metacognition is selectively compromised and could improve during treatments. However, empirical findings are inconsistent, and it is debatable whether BPD presents a specific profile of mindreading impairments that could improve during treatments.

METHODS

We performed a bibliographic research on PubMed , Google Scholar and Scopus of all studies investigating a) the metacognitive functioning in the BPD patients and b) the link between psychotherapy, metacognition improvement and BPD symptomatology. A total of 11 studies met our inclusion criteria and considered metacognition following the definition proposed by Semerari.

RESULTS

Overall, the results suggest that BPD metacognitive profile mainly includes difficulties in metacognitive sub-domains of integration, differentiation and mastery. The type of treatment most appropriate to improve metacognitive abilities and reduce symptoms seemed to be a long term treatment and specifically focused on metacognitive deficits.

LIMITATIONS

Lack of a control group, small sample sizes and heterogeneity in terms of gender, age, comorbidities and other ongoing treatments are the key limits of the original studies reviewed.

CONCLUSIONS

The results sustain the hypothesis of a selective and specific metacognitive impairment in BPD patients that could improve during treatments together with their symptomatology. However, more studies are needed to further investigate the role of metacognition in the effectiveness of treatments.

Immersive virtual reality reveals that visuo-proprioceptive discrepancy enlarges the hand-centred peripersonal space

Vision and proprioception, informing the system about the body position in space, seem crucial in defining the boundary of the peripersonal space (PPS). What happens to the PPS representation when a conflict between vision and proprioception arises? We capitalize on the Immersive Virtual Reality to dissociate vision and proprioception by presenting the participants' 3D hand image in congruent/incongruent positions with respect to the participants' real hand. To measure the hand-centred PPS, we exploit multisensory integration occurring when visual stimuli are delivered simultaneously with tactile stimuli applied to a body district; i.e., visual enhancement of touch (VET). Participants are instructed to respond to tactile stimuli while ignoring visual stimuli (red LED), which can appear either near to or far from the hand receiving tactile (electrical) stimuli. The results show that, when vision and proprioception are congruent (i.e., real and virtual hand coincide), a space-dependent modulation of the VET effect occurs (with faster responses when visual stimuli are near to than far from the stimulated hand). Contrarily, when vision and proprioception are incongruent (i.e., a discrepancy between real and virtual hand is present), a comparable VET effect is observed when visual stimuli occur near to the real hand and when they occur far from it, but close to the virtual hand. These findings, also confirmed by the independent estimate of a Bayesian Causal Inference model, suggest that, when the visuo-proprioceptive discrepancy makes the coding of the hand position less precise, the hand-centred PPS is enlarged, likely to optimize reactions to external events.