Affective instability: Measuring a core feature of borderline personality disorder with ecological momentary assessment.

Ecological momentary assessment (EMA; Stone & Shiffman, 1994) was used to characterize and quantify a dynamic process--affective instability in borderline personality disorder (BPD). Sixty outpatients (34 with BPD and affective instability; 26 with current depressive disorder but not with BPD or affective instability) carried electronic diaries for approximately 1 month and were randomly prompted to rate their mood state up to 6 times a day. Results indicated that BPD patients (a) did not report significantly different mean levels of positive or negative affect; (b) displayed significantly more variability over time in their positive and negative affect scores; (c) demonstrated significantly more instability on successive scores (i.e., large changes) for hostility, fear, and sadness than did patients with depressive disorders; and (d) were more likely to report extreme changes across successive occasions (≥90th percentile of change scores across participants) for hostility scores. Results illustrate different analytic approaches to quantifying variability and instability of affect based on intensive longitudinal data. Further, results suggest the promise of electronic diaries for collecting data from individuals in their natural environment for purposes of clinical research and assessment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Affect and alcohol use: An ecological momentary assessment study of outpatients with borderline personality disorder.

Alcohol use may be viewed as an attempt (albeit maladaptive) to regulate negative emotional states. We examined associations between both negative and positive affects and alcohol use in outpatient women diagnosed with borderline personality disorder (BPD; n = 74), a prototype of emotional dysregulation, as well as a psychiatric control group of women with current depressive disorder (major depressive disorder/dysthymic disorder [MDD\DYS]; n = 50). Participants completed randomly prompted reports of mood and alcohol use up to six times a day over a 28-day period using electronic diaries. Mean levels of either positive or negative affects did not distinguish between drinkers and nondrinkers in either diagnostic group. However, levels of both negative and positive affects were positively associated with alcohol use at the momentary level in BPD drinkers. More robust findings were obtained with respect to within-person affective variability, which was related to alcohol use in multiple ways. BPD drinkers showed higher within-person variability for most negative affects than BPD nondrinkers; MDD\DYS drinkers in general showed less within-person variability than MDD\DYS nondrinkers for negative affects. Multilevel lagged analyses for BPD drinkers indicated that alcohol use was positively related to variability in all affects, concurrently, but fewer significant effects of affect variability on the next day's drinking or significant effects of alcohol use on the next day's affect variability were observed. Among MDD\DYS drinkers, we observed more significant associations between affect variability on next day's alcohol use and of alcohol use on next day's affect variability. We discuss theoretical and methodological issues relevant to these findings as well as implications for future research. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Analysis of affective instability in ecological momentary assessment: Indices using successive difference and group comparison via multilevel modeling.

Temporal instability of affect is a defining characteristic of psychological disorders such as borderline personality disorder (BPD) and mood cycling disorders. Ecological momentary assessment (EMA) enables researchers to directly assess such frequent and extreme fluctuations over time. The authors examined 4 operationalizations of such temporal instability: the within-person variance (WPV), the first-order autocorrelation, the mean square successive difference (MSSD), and the probability of acute change (PAC). It is argued that the MSSD and PAC measures are preferred indices of affective instability because they capture both variability and temporal dependency in a time series. Additionally, the performance of these 2 measures in capturing within- and between-day instability is discussed. To illustrate, the authors present EMA data from a study of negative mood in BPD and major depressive disorder patients. In this study, MSSD and PAC captured affective instability better than did WPV. Given that MSSD and PAC are individual difference measures, the authors propose that group differences on these indices be explored using generalized multilevel models. Versions of MSSD and PAC that adjust for randomly elapsed time interval between assessments are also presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ecological momentary assessment of mood disorders and mood dysregulation.

In this review, we discuss ecological momentary assessment (EMA) studies on mood disorders and mood dysregulation, illustrating 6 major benefits of the EMA approach to clinical assessment: (a) Real-time assessments increase accuracy and minimize retrospective bias; (b) repeated assessments can reveal dynamic processes; (c) multimodal assessments can integrate psychological, physiological, and behavioral data; (d) setting- or context-specific relationships of symptoms or behaviors can be identified; (e) interactive feedback can be provided in real time; and (f) assessments in real-life situations enhance generalizability. In the context of mood disorders and mood dysregulation, we demonstrate that EMA can address specific research questions better than laboratory or questionnaire studies. However, before clinicians and researchers can fully realize these benefits, sets of standardized e-diary questionnaires and time sampling protocols must be developed that are reliable, valid, and sensitive to change. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Analytic strategies for understanding affective (in)stability and other dynamic processes in psychopathology.

The dynamics of psychopathological symptoms as a topic of research has been neglected for some time, likely because of the inability of cross-sectional and retrospective reports to uncover the ebb and flow of symptoms. Data gathered with the experience sampling method (ESM) enable researchers to study symptom variability and instability over time as well as the dynamic interplay between the environment, personal experiences, and psychopathological symptoms. ESM data can illuminate these dynamic processes, if time is both considered and integrated into (a) the research question itself, (b) the assessment or sampling method, and (c) the data analytic strategy. The authors highlight the complexity of assessing affective instability and unstable interpersonal relationships and explore sampling and analytic methods. Finally, they propose guidelines for future investigations. For the assessment of affective instability, the authors endorse the use of time-contingent recordings and of instability indices that address temporal dependency. For the assessment of unstable interpersonal relationships, they advocate the use of event-contingent recordings and separate analyses within and across dyads. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Affective instability, family history of mood disorders, and neurodevelopmental disturbance.

The association between affective instability and both family history of mood disorders and signs of neurodevelopmental disturbance was examined in a sample of 303 adults. Affective instability was measured using the borderline personality disorder “affective instability due to a marked reactivity of mood” diagnostic criterion as assessed dimensionally using the Personality Disorder Interview—IV. Participants were interviewed concerning family history of mood disorders, with family history coded using the Family History Research Diagnostic Criteria. Minor physical anomalies, inconsistent hand use, and dermatoglyphic asymmetries were used to index neurodevelopmental disturbance. Affective instability was associated with elevated rates of family history of mood disorders, particularly among individuals who exhibited inconsistent hand use and greater minor physical anomalies. These associations could not be accounted for by shared variance with age, gender, negative affect, or personal history of mood disorders. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Stability and variability of affective experience and interpersonal behavior in borderline personality disorder.

This study examined both mean levels and intraindividual variability in the mood and interpersonal behavior of individuals with borderline personality disorder (BPD) and nonclinical control participants over a 20-day event-contingent recording period. Individuals in the BPD group experienced more unpleasantly valenced affect and were less dominant, more submissive, more quarrelsome, and more extreme in overall levels of behavior than control participants. In addition to these mean-level differences, individuals with BPD also reported more intraindividual variability in overall affect valence and in pleasantly valenced affect; displayed greater variability in dominant, quarrelsome, and agreeable behaviors; and exhibited an increased tendency to "spin" among interpersonal behaviors relative to nonclinical control participants. The findings document behavioral and affective manifestations of BPD in the context of naturally occurring interpersonal situations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ecological momentary assessment (EMA) in studies of substance use.

Ecological momentary assessment (EMA) is particularly suitable for studying substance use, because use is episodic and thought to be related to mood and context. This article reviews EMA methods in substance use research, focusing on tobacco and alcohol use and relapse, where EMA has been most applied. Common EMA designs combine event-based reports of substance use with time-based assessments. Approaches to data organization and analysis have been very diverse, particularly regarding their treatment of time. Compliance with signaled assessments is often high. Compliance with recording of substance use appears good but is harder to validate. Treatment applications of EMA are emerging. EMA captures substance use patterns not measured by questionnaires or retrospective data and holds promise for substance use research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Using experience sampling methods/ecological momentary assessment (ESM/EMA) in clinical assessment and clinical research: Introduction to the special section.

This article introduces the special section on experience sampling methods and ecological momentary assessment in clinical assessment. We review the conceptual basis for experience sampling methods (ESM; Csikszentmihalyi & Larson, 1987) and ecological momentary assessment (EMA; Stone & Shiffman, 1994). Next, we highlight several advantageous features of ESM/EMA as applied to psychological assessment and clinical research. We provide a brief overview of the articles in this special section, each of which focuses on 1 of the following major classes of psychological disorders: mood disorders and mood dysregulation (Ebner-Priemer & Trull, 2009), anxiety disorders (Alpers, 2009), substance use disorders (Shiffman, 2009), and psychosis (Oorschot, Kwapil, Delespaul, & Myin-Germeys, 2009). Finally, we discuss prospects, future challenges, and limitations of ESM/EMA. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Two-Year Stability and Change of Schizotypal, Borderline, Avoidant, and Obsessive-Compulsive Personality Disorders.

The authors examined the stability of schizotypal (STPD), borderline (BPD), avoidant (AVPD) and obsessive-compulsive (OCPD) personality disorders (PDs) over 2 years of prospective multiwave follow-up. Six hundred thirty-three participants recruited at 4 collaborating sites who met criteria for 1 or more of the 4 PDs or for major depressive disorder (MOD) without PD were assessed with semistructured interviews at baseline, 6, 12, and 24 months. Lifetable survival analyses revealed that the PD groups had slower time to remission than the MDD group. Categorically, PD remission rates range from 50% (AVPD) to 61% (STPD) for dropping below diagnostic threshold on a blind 24-month reassessment but range from 23% (STPD) to 38% (OCPD) for a more stringent definition of improvement. Dimensionally, these findings suggest that PDs may be characterized by maladaptive trait constellations that are stable in their structure (individual differences) but can change in severity or expression over time. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Alcohol and tobacco cessation in alcohol-dependent smokers: Analysis of real-time reports.

Alcohol-tobacco interactions and relapse precipitants were examined among alcohol-dependent smokers in a trial of concurrent alcohol and tobacco treatment. After discharge from treatment, participants completed 14 days of electronic diary (ED) assessments of mood, self-efficacy, urges to drink or smoke, and drinking and smoking behavior. ED data revealed an increase in frequency of alcohol urges after smoking episodes. Drinking relapse episodes were predicted by prior ED ratings of low self-efficacy to resist drinking and high urge to smoke. Smoking relapse episodes were predicted by high urge to smoke and high negative, high arousal mood. Results support a cross-substance cue reactivity model of multiple substance use and a limited-strength model, but not a cross-substance coping model. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ambulatory assessment in panic disorder and specific phobia.

Anxiety disorders are among the most prevalent mental disorders. In panic disorder, panic attacks often occur at unpredictable times, making it difficult to study these episodes in the laboratory. In specific phobias, symptoms occur in very circumscribed situations and specific triggers are sometimes difficult to reproduce in the laboratory. Ambulatory assessment, or ecological momentary assessment, can further the understanding of the natural course and scope of symptoms under ecologically valid circumstances. Because bodily symptoms are integral to the diagnosis of anxiety disorders, the objective assessment of physiological responses in the patients’ natural environment is particularly important. On the one hand, research has highlighted intriguing discrepancies between the experience of symptoms and physiology during panic attacks. On the other hand, it has validated symptom reporting during therapeutic exposure to phobic situations. Therefore, ambulatory assessment can yield useful information about the psychopathology of anxiety disorders, and it can be used to monitor change during clinical interventions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A comparison of interview and self-report methods for the assessment of borderline personality disorder criteria.

Interview methods are widely regarded as the standard for the diagnosis of borderline personality disorder (BPD), whereas self-report methods are considered a time-efficient alternative. However, the relative validity of these methods has not been sufficiently tested. The current study used data from the Collaborative Longitudinal Personality disorder Study to compare diagnostic base rates and the relative validity of interview and self-report methods for assessing functional outcome in BPD. Although self-report yielded higher base rates of criteria endorsement, results did not support the common assumption that diagnostic interviews are more valid than self-reports, but instead indicated the combined use of these methods optimally identifies BPD criteria. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Shorter term treatment of borderline personality disorder: A developmental, self-, and object relations approach.

After a brief summary of J. F Masterson's developmental, self-, and object relations approach to long-term, intensive psychotherapy of the borderline personality disorder, an adaptation of this approach to shorter term treatment is proposed. The time constraints of abbreviated treatment require the following limited goals for the patient: (a) increased control of maladaptive defenses, (b) learning about the fundamental dynamics related to the focal symptom or problematic behavior, and (c) improved adaptation. Requisite modifications of technique include (a) limited frequency of sessions, (b) focalized treatment, (c) an emphasis on adaptation, and (d) a reliance on confrontation as the primary therapeutic intervention. A brief case study is presented for illustrative purposes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A real-time assessment of work stress in physicians and nurses.

Objective: This study adapted ecological momentary assessment methods to: (a) examine differences in work stress between nurses and physicians, and (b) to study relationships between work stress, work activity patterns, and sleep. Design: A total of 185 physicians and 119 nurses (206 women, 98 men) working in four teaching hospitals participated in an observational study of work stress. Main Outcome Measures: Participants carried handheld computers that randomly prompted them for work activity, patient load, and work stress information. Results: Participants completed more than 9,500 random interval surveys during the study (an average of 30.8 surveys per person-week). Approximately 85% of all surveys were completed in full (73.3%) or partially (11.6%). Emotional stress scores among physicians were nearly 50% higher (26.9[19.0]) than those of nurses (18.1[14.9], r[302] = .37, p rs[159] = .14-.26, ps ps r[302] = ?.12, .17, ps Conclusions: The findings identify patterns of work stress in relationship to work activities, sleep habits, and provider differences that may be used to assist ongoing hospital work reform efforts. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of The challenge of the borderline patient: Competency in diagnosis and treatment.

Reviews the book, The challenge of the borderline patient: Competency in diagnosis and treatment by Jerome Kroll (see record 1988-97021-000). In this new volume on borderline psychopathology, Jerome Kroll has some axes to grind-of the kind found in DSM-III, that is. He offers a refreshing perspective on this popularized topic and casts a healthy skepticism on the current trends and trendiness reflected in the literature. Unique in its back-to-basics, common-sensical approach to diagnosis and treatment, the book, in its essence, aims at demystifying and debunking the aura that surrounds this field. Kroll's volume spans the three predominant areas of inquiry that constitute most of the published works on borderline personality disorders, namely: 1) empirically rooted efforts to establish its construct validity as a diagnostic entity, 2) psychotherapeutic strategies that are primarily enmeshed in larger, unresolved theoretical controversies between the object relations versus self psychology factions within contemporary psychoanalytic thinking, and 3) the search for the magical psychopharmacological bullet that will eradicate borderline symptomotology. For both novice and experienced clinician, this book serves as a useful counterpoint to the current directions in empirical and theoretical work on borderline pathology, a reminder of the potential dangers of getting caught up in methodological precision or overelaborated theory or high-technology psychopharmacology and, as a consequence, of losing sight of the individual, whole patient. It is supportive therapy of the best kind for those of us who face the challenge of treating the borderline patient. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical assessment: The advantage of multiple perspectives.

Reviews the book, "Assessment of Children: Behavioral and Clinical Applications," by J. Sattler (see record 2001-05360-000). A text on clinical assessment may be evaluated according to how adequately it prepares the reader to conduct a comprehensive evaluation. This text, is within the tradition of organizing data around specific diagnostic syndromes that are cast as "children's needs." However, in an effort to be comprehensive, the book also includes information about specific measures and general assessment techniques such as interviews and observational strategies and incorporates intervention planning. The author intends this book to serve as a graduate text and reference for practicing professionals and, thus, includes a cornucopia of useful forms, checklists, and recording templates throughout the various chapters and in the appendices. However, combining a teaching text with a professional reference creates a dilemma-how to manage the needs of the beginner relative to those of the practicing professional. Perhaps as a result of trying to be comprehensive, there is considerable variability within and among chapters in the complexity of the material and in the audience (novice vs. practitioner) that is addressed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Assessing clients in their natural environments with electronic diaries: Rationale, benefits, limitations, and barriers.

Increasingly, mobile technologies are used to gather diary data in basic research and clinical studies. This article considers issues relevant to the integration of electronic diary (ED) methods in clinical assessment. EDs can be used to gather rich information regarding clients' day-to-day experiences, aiding diagnosis, treatment planning, treatment implementation, and treatment evaluation. The authors review the benefits of using diary methods in addition to retrospective assessments, and they review studies assessing whether EDs yield higher quality data than conventional, less expensive paper-pencil diaries. Practical considerations--including what platforms can be used to implement EDs, what features they should have, and considerations in designing diary protocols for sampling different types of clinical phenomena--are described. The authors briefly illustrate with examples some ways in which ED data could be summarized for clinical use. Finally, the authors consider barriers to clinical adoption of EDs. EDs are likely to become increasingly popular tools in routine clinical assessment as clinicians become more familiar with the logic of diary designs; as software packages evolve to meet the needs of clinicians; and as mobile technologies become ubiquitous, robust, and inexpensive. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Features of borderline personality disorder, perceived childhood emotional invalidation, and dysfunction within current romantic relationships.

The mechanisms through which current romantic relationship dysfunction develops in individuals with borderline personality disorder (BPD) symptoms are still unclear. One possible pathway may be childhood experiences of emotional invalidation by parents, which may result in the development of poor social problem-solving skills or cognitive responses such as splitting, which impair current romantic relationships. This study examines the relationship between features of BPD and current romantic relationship dysfunction, and demonstrates that perceived emotional invalidation by parents during childhood mediates the relationship between BPD features and current romantic relationship dysfunction. Structural equations modeling was used to test the hypothesized model in 758 young adults in an ethnically diverse community sample. The proposed model fit the data well; perceived childhood emotional invalidation partially mediated the relationship between features of BPD and romantic relationship dysfunction, even when controlling for the presence of a major depressive episode in the last year. The findings of this study suggest that individuals with features of BPD experience relationship dysfunction that cannot be accounted for by comorbid depression and that perceived childhood emotional invalidation may contribute to these problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)