Mentalizing on the edge: borderline traits and their association with real-time self-reflection - an ecological momentary assessment study

BackgroundAnger and aggression are core features of Borderline Personality Disorder (BPD), contributing strongly to the individual as well as the societal burden caused by the disorder. Across studies, patients with BPD have shown increased, more frequent and prolonged episodes of anger and reported an increased prevalence of reactive aggression. However, only a few studies have investigated anger and aggression in the patients’ everyday lives and did not consider anger instability. In order to contribute knowledge about aggression and its association with anger intensity and anger instability in real-life in BPD the aim of the present study was to better characterize days with and without aggressive behaviors with regard to the patients’ experienced anger.MethodsPatients with BPD and high aggression as well as healthy participants took part in an ecological momentary assessment (EMA) study assessing state anger and aggression three times per day over two weeks. Multilevel modeling was conducted and anger instability was operationalized by squared successive differences.ResultsAs expected, patients with BPD reported greater instability in their experienced anger compared to healthy participants. Most interestingly, in the BPD group the occurrence of aggressive behavior was significantly associated with anger intensity as well as anger instability. More precisely, on days when patients with BPD acted out aggressively, they reported higher anger intensity as well as greater anger instability than on days when they did not act out aggressively.ConclusionKnowledge about what characterizes days with aggressive behaviors may help to improve interventions to reduce aggressive behavior and thus relieve the burden aggression causes for patients with BPD, their surroundings and society.

Since the 2001 publication of APA’s Practice Guideline for the Treatment of Patients With Borderline Personality Disorder (1), more studies have been published on borderline personality disorder (BPD) than on any other personality disorder (2, 3). New analyses of the validity of the DSMIV-TR criteria–defined construct of BPD have been published, new data on the prevalence of BPD are available, risk factors for and biological characteristics of BPD are being elucidated, and new studies on the treatment of BPD have been carried out. This guideline watch highlights the most important of these developments.

BackgroundThis study aimed to investigate what therapeutic interventions were being applied by clinicians working with young people with a diagnosis of Borderline Personality Disorder or borderline traits in Australian primary mental health care settings. Given the current lack of evidence-based guidelines for treatment with this client population, investigating what is being implemented is needed. The study also aimed to determine whether the interventions clinicians are using are effective in reducing distress and increasing functioning for these clients.MethodsParticipant data came from the national minimum data set for headspace youth mental health centers across Australia. Young people’s data were included in the study if the young person was diagnosed with Borderline Personality Disorder or borderline traits during their first episode of care (N = 701). Clinician data that indicated the type of intervention used at each client session and outcome measures routinely captured were analyzed to determine interventions used and outcomes achieved.ResultsResults demonstrated that CBT was the most frequently used modality of intervention followed by supportive counselling and IPT, but that most clients received a variety of intervention types. There were no or only weak relationships between changes in outcomes and the amount of any type of intervention that was provided. No significant relationship was found with the amount of CBT a client received and changes in symptoms or functioning, despite being the most commonly employed modality.ConclusionsThe study highlights the need for evidence-based treatment guidelines for early intervention in young people with borderline personality disorder traits.

This thesis comprises a literature review, “A systematic review of the relationship between borderline personality disorder or traits and alcohol use: active components, mediators and common risk factors”; an empirical paper, “Borderline personality disorder traits and the effect of a rejection experience on attentional bias towards alcohol” and relevant appendices. Borderline personality disorder is a controversial diagnosis which has been linked with alcohol use and misuse (Trull et al., 2000). A gap in the research was highlighted as no systematic review has explored the active components of borderline personality disorder (BPD) or borderline traits in predicting alcohol misuse, and the mechanisms by which these may influence alcohol misuse. The aim of the literature review was therefore to identify components and mechanisms through mediation, moderation or common-cause analysis. Ten studies were reviewed. Active components were affective instability and impulsivity, mechanisms were mediation through negative emotionality, anti-social personality disorder and social support, common risk factors were genetic factors, which had a stronger influence in later adolescence, shared and non-shared environmental influences, attachment and emotional clarity. This study concludes that traits of impulsivity and affective instability may create a vulnerability to using alcohol as a way of regulating emotions. It was proposed that causal influences can be better understood through longitudinal studies rather than cross-sectional studies. The literature review shows linkages between these variables, but does not explain how affective instability may cause drinking. The empirical paper argued that sensitivity to rejection may increase vulnerability to using alcohol as a way of regulating difficult emotions, and hence is a possible trigger for harmful alcohol (Gratz & Roemer, 2004). The empirical paper reported a study which aimed to explore whether borderline traits would interact with a social exclusion manipulation to predict an attentional bias towards alcohol in 111 students. This was studied using an experimental social exclusion experience and a dot probe task. Results did not show an interaction between borderline traits and exclusion in predicting attentional bias or any main effects. The failure to support the hypothesis may be attributable to the failure of the exclusion experience to elicit affective change and the insensitivity of the dot-probe task. Methodological refinements are suggested.

Borderline personality disorder (BPD) is a highly disabling psychiatric disorder with emotion dysregulation at its core, resulting in affective instability, impulsivity and sometimes self-harming or suicidal behavior. Sleep is increasingly recognized to play a crucial role in emotion regulation. BPD patients often suffer from (severe) insomnia, potentially aggravating symptoms and preventing recovery from BPD. Yet, the effects of insomnia treatments have not been investigated in context of BPD. Guided internet-based cognitive behavioral therapy for insomnia (iCBT-I; i-Sleep) has been proven effective in improving both insomnia and affective symptoms. In this randomized controlled trial among 96 patients with a DSM-5 diagnosis of BPD (or other personality disorder with ≥4 BPD traits) and insomnia symptoms, we will test the effectiveness of iCBT-I before regular BPD treatment starts, during the waitlist period, on BPD symptoms. Patients in the control group monitor their sleep through a sleep diary during the waitlist period and also receive standard BPD treatment after that. Using linear mixed models we will test the hypothesis that the iCBT-I group improves more than the control group on BPD symptoms (primary outcome), insomnia severity, additional subjective and objective sleep variables, emotion regulation, comorbid anxiety and depression complaints, and quality of life. These effects are thought to arise from a direct effect of improved sleep on emotion regulation and a synergistic effect on the consolidation and internalization of the BPD treatment effect. To our knowledge, this is the first trial assessing effectiveness of CBT-I in patients with BPD (traits). The accessibility of the studied intervention greatly facilitates clinical implication in case of positive results.

Borderline Behavior in Adolescence: An Adjective in Search of a Treatment

BackgroundBorderline personality disorder (BPD) is characterized by frequent and intense moment-to-moment changes in affect, behavior, identity, and interpersonal relationships, which typically result in significant and negative deterioration of the person’s overall functioning and well-being. Measuring and characterizing the rapidly changing patterns of instability in BPD dysfunction as they occur in a person’s daily life can be challenging. Ecological momentary assessment (EMA) is a method that can capture highly dynamic processes in psychopathology research and, thus, is well suited to study intense variability patterns across areas of dysfunction in BPD. EMA studies are characterized by frequent repeated assessments that are delivered to participants in real-life, real-time settings using handheld devices capable of registering responses to short self-report questions in daily life. Compliance in EMA research is defined as the proportion of prompts answered by the participant, considering all planned prompts sent. Low compliance with prompt schedules can compromise the relative advantages of using this method. Despite the growing EMA literature on BPD in recent years, findings regarding study design features that affect compliance with EMA protocols have not been compiled, aggregated, and estimated.ObjectiveThis systematic meta-analytic review aimed to investigate the relationship between study design features and participant compliance in EMA research of BPD.MethodsA systematic review was conducted on November 12, 2021, following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and MOOSE (Meta-analyses of Observational Studies in Epidemiology) guidelines to search for articles featuring EMA studies of BPD that reported compliance rates and included sufficient data to extract relevant design features. For studies with complete data, random-effect models were used to estimate the overall compliance rate and explore its association with design features.ResultsIn total, 28 peer-reviewed EMA studies comprising 2052 participants were included in the study. Design features (sampling strategy, average prompting frequency, number of items, response window, sampling device, financial incentive, and dropout rate) showed a large variability across studies, and many studies did not report design features. The meta-analytic synthesis was restricted to 64% (18/28) of articles and revealed a pooled compliance rate of 79% across studies. We did not find any significant relationship between design features and compliance rates.ConclusionsOur results show wide variability in the design and reporting of EMA studies assessing BPD. Compliance rates appear to be stable across varying setups, and it is likely that standard design features are not directly responsible for improving or diminishing compliance. We discuss possible nonspecific factors of study design that may have an impact on compliance. Given the promise of EMA research in BPD, we also discuss the importance of unifying standards for EMA reporting so that data stemming from this rich literature can be aggregated and interpreted jointly.

The role of borderline personality disorder traits in predicting longitudinal variability of major depressive symptoms among a sample of depressed adults

Antisocial personality disorder (ASPD) and borderline personality disorder (BPD) share genetic and environmental risk factors. Little is known about the temporal stability of these etiological factors in adulthood. DSM-IV criteria for ASPD and BPD were assessed using structured interviews in 2282 Norwegian twins in early adulthood and again approximately 10 years later. Longitudinal biometric models were used to analyze the number of endorsed criteria. The mean criterion count for ASPD and BPD decreased 40% and 28%, respectively, from early to middle adulthood. Rank-order stability was 0.58 for ASPD and 0.45 for BPD. The best-fitting longitudinal twin model included only genetic and individual-specific environmental factors. Genetic effects, both those shared by ASPD and BPD, and those specific to each disorder remained completely stable. The unique environmental effects, however, changed substantially, with a correlation across time of 0.19 for the shared effects, and 0.39 and 0.15, respectively, for those specific to ASPD and BPD. Genetic effects accounted for 71% and 72% of the stability over time for ASPD and BPD, respectively. The genetic and environmental correlations between ASPD and BPD were 0.73, and 0.43, respectively, at both time points. ASPD and BPD traits were moderately stable from early to middle adulthood, mostly due to genetic risk factors which did not change over the 10-year assessment period. Environmental risk factors were mostly transient, and appear to be the main source of phenotypic change. Genetic liability factors were, to a large extent, shared by ASPD and BPD.

Relationship of Borderline Personality Disorder and Bipolar Disorder

Relationship of Borderline Personality Disorder and Bipolar Disorder

Understanding Emotion Regulation in Borderline Personality Disorder: Contributions of Neuroimaging

Of 50 patients with borderline personality disorder, 100% reported disturbed but nonpsychotic thought, 40% (N = 20) reported quasi-psychotic thought, and none reported true psychotic thought during the past 2 years; only 14% (N = 7) reported ever experiencing true psychotic thought. Disturbed and quasi-psychotic thought was significantly more common among these patients than among patients with other axis II disorders or schizophrenia and normal control subjects; however, true psychotic thought was significantly more common among schizophrenic patients. While disturbed thought was also common among axis II disorder and schizophrenic patients, quasi-psychotic thought was reported by only one of these subjects, suggesting that quasi-psychotic thought may be a marker for borderline personality disorder.

BackgroundIndividuals with type 1 diabetes represent a population with important vulnerabilities to dynamic physiological, behavioral, and psychological interactions, as well as cognitive processes. Ecological momentary assessment (EMA), a methodological approach used to study intraindividual variation over time, has only recently been used to deliver cognitive assessments in daily life, and many methodological questions remain. The Glycemic Variability and Fluctuations in Cognitive Status in Adults with Type 1 Diabetes (GluCog) study uses EMA to deliver cognitive and self-report measures while simultaneously collecting passive interstitial glucose in adults with type 1 diabetes.ObjectiveWe aimed to report the results of an EMA optimization pilot and how these data were used to refine the study design of the GluCog study. An optimization pilot was designed to determine whether low-frequency EMA (3 EMAs per day) over more days or high-frequency EMA (6 EMAs per day) for fewer days would result in a better EMA completion rate and capture more hypoglycemia episodes. The secondary aim was to reduce the number of cognitive EMA tasks from 6 to 3.MethodsBaseline cognitive tasks and psychological questionnaires were completed by all the participants (N=20), followed by EMA delivery of brief cognitive and self-report measures for 15 days while wearing a blinded continuous glucose monitor. These data were coded for the presence of hypoglycemia (<70 mg/dL) within 60 minutes of each EMA. The participants were randomized into group A (n=10 for group A and B; starting with 3 EMAs per day for 10 days and then switching to 6 EMAs per day for an additional 5 days) or group B (N=10; starting with 6 EMAs per day for 5 days and then switching to 3 EMAs per day for an additional 10 days).ResultsA paired samples 2-tailed t test found no significant difference in the completion rate between the 2 schedules (t17=1.16; P=.26; Cohen dz=0.27), with both schedules producing >80% EMA completion. However, more hypoglycemia episodes were captured during the schedule with the 3 EMAs per day than during the schedule with 6 EMAs per day.ConclusionsThe results from this EMA optimization pilot guided key design decisions regarding the EMA frequency and study duration for the main GluCog study. The present report responds to the urgent need for systematic and detailed information on EMA study designs, particularly those using cognitive assessments coupled with physiological measures. Given the complexity of EMA studies, choosing the right instruments and assessment schedules is an important aspect of study design and subsequent data interpretation.

Borderline personality disorder (BPD) traits are common among those with bulimia nervosa (BN). However, how these traits impact the state experience of precipitants of BN behavior, such as stressful events and emotional reactivity, has not been determined. Thus, the purpose of this naturalistic study was to examine this trait-state association in BN. Women with DSM-IV BN (N = 133) completed a baseline measure of personality pathology traits, and subsequently recorded their affective state and the frequency and perception of 3 types of stressful events (interpersonal, work/environment, and daily hassles) several times per day for 2 weeks using ecological momentary assessment (EMA). Pearson correlations assessed the associations between BPD traits (affective lability, identity problems, insecure attachment, and cognitive dysregulation) and (a) frequency of stressful events and (b) perception of stressful events. Generalized linear models (GLM) were used to evaluate the relationship between BPD traits and changes in negative affect following stressful events. Results revealed that while all traits were significantly associated with perceived stressfulness, certain BPD traits were significantly associated with the frequency of stressful events. Individuals with higher trait insecure attachment experienced larger increases in negative affect following interpersonal stressful events. These findings suggest that interventions focused on addressing stressful events and enhancing adaptive emotional responses to interpersonal events may be particularly useful for a subset of individuals with BN with BPD-related personality characteristics, including insecure attachment, affective lability, and identity problems. (PsycINFO Database Record