Associations in the Course of Personality Disorders and Axis I Disorders Over Time.

In this study, the authors examined time-varying associations between schizotypal (STPD), borderline (BPD), avoidant (AVPD), or obsessive-compulsive (OCPD) personality disorders and co-occurring Axis I disorders in 544 adult participants from the Collaborative Longitudinal Personality Disorders Study. The authors tested predictions of specific longitudinal associations derived from a model of crosscutting psychobiological dimensions (L. J. Siever & K. L. Davis, 1991) with participants with the relevant Axis I disorders. The authors assessed participants at baseline and at 6-, 12-, and 24-month follow-up evaluations. BPD showed significant longitudinal associations with major depressive disorder and posttraumatic stress disorder. AVPD was significantly associated with anxiety disorders (specifically social phobia and obsessive-compulsive disorder). Two of the four personality disorders under examination (STPD and OCPD) showed little or no association with Axis I disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Preliminary relationships between adherence and outcome in dynamic deconstructive psychotherapy.

This study examined adherence to specific psychotherapeutic techniques as a predictor of outcome in dynamic deconstructive psychotherapy (DDP), a new psychodynamic therapy for treatment-resistant clients with borderline personality disorder (BPD). Ten clients dually diagnosed with BPD and alcohol use disorders underwent 12 months of DDP. Outcome indexes included measures of borderline symptoms, depression, dissociation, social support, alcohol misuse, parasuicide, and institutional care. Independent raters coded videorecorded sessions on adherence to DDP techniques, using a scale developed for this study, as well as therapeutic alliance and standard cognitive–behavioral and psychodynamic techniques. The adherence instrument demonstrated excellent interrater and test–retest reliability. Adherence to DDP techniques was positively related to improvement in BPD symptoms (ρ = .64) and most secondary outcomes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Exploring associations between borderline personality disorder, crack/cocaine dependence, gender, and risky sexual behavior among substance-dependent inpatients.

Engagement in self-destructive and impulsive behaviors is considered to be a cardinal symptom of borderline personality disorder (BPD), and many of the behaviors enumerated in this criterion have been the focus of extensive empirical research. However, very few studies have examined risky sexual behavior (RSB) in particular in BPD. Given evidence that BPD patients with a co-occurring substance use disorder (SUD) may be at increased risk for RSB relative to BPD patients without a SUD, the present study examined the association between BPD and past-year engagement in RSB (particularly, penetrative sex and nonuse of condoms with casual and commercial partners) within a mixed-gender sample of 94 SUD patients in residential treatment, as well as the moderating role of gender in this association. Given past findings of an association between crack/cocaine use and RSB, we also examined the moderating role of lifetime crack/cocaine dependence on the relationship between BPD and RSB. Results demonstrated a significant main effect of BPD on past-year penetrative sex with casual and commercial partners. Significant 3-way interactions between BPD status, lifetime crack/cocaine dependence, and gender were also found for past-year penetrative sex with casual and commercial partners, as well as the likelihood of not using a condom during sex with a casual partner. Post hoc analyses indicated that women with co-occurring BPD and lifetime crack/cocaine dependence were at greatest risk for RSB. Findings replicate extant findings pertaining to the association between BPD and RSB and extend research by identifying relevant factors that may moderate this association. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Refining behavioral dysregulation in borderline personality disorder using a sample of women with anorexia nervosa.

One of the primary facets of borderline personality disorder (BPD) is behavioral dysregulation, a wide array of behaviors that are difficult to control and harmful to the individual. The purpose of this study was to explore the association between BPD and a variety of dysregulated behaviors, some of which have received little empirical attention. Using a large sample of individuals diagnosed with anorexia nervosa, 41 individuals diagnosed with BPD were compared to the rest of the sample on the presence of dysregulated behaviors using logistic regression analyses. Anorexia nervosa subtypes, age, and other Cluster B personality disorders were used as covariates. Results support an association between BPD and alcohol misuse, hitting someone/breaking things, provoking fights/arguments, self-injury, overdosing, street drug use, binge-eating, impulsive spending, shoplifting/stealing, and risky sexual behaviors. Differences between dichotomous and continuous measures of BPD yielded somewhat different results. Information on co-occurring anorexia nervosa and BPD was generated. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treating co-occurring Axis I disorders in recurrently suicidal women with borderline personality disorder: A 2-year randomized trial of dialectical behavior therapy versus community treatment by experts.

This study evaluated whether dialectical behavior therapy (DBT) was more efficacious than treatment by nonbehavioral psychotherapy experts in reducing co-occurring Axis I disorders among suicidal individuals with borderline personality disorder (BPD). Women with BPD and recent and repeated suicidal and/or self-injurious behavior (n = 101) were randomly assigned to 1 year of DBT or community treatment by experts (CTBE), plus 1 year of follow-up assessment. For substance dependence disorders (SDD), DBT patients were more likely to achieve full remission, spent more time in partial remission, spent less time meeting full criteria, and reported more drug- and alcohol-abstinent days than did CTBE patients. These findings suggest that improvements in co-occurring SDD among suicidal BPD patients are specific to DBT and cannot be attributed to general factors associated with nonbehavioral expert psychotherapy. Further, group differences in SDD remission were not explained by either psychotropic medication usage or changes in BPD criterion behaviors. DBT and CTBE did not significantly differ in the reduction of anxiety disorders, eating disorders, or major depressive disorder. (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)     

Functional imaging of emotion reactivity in opiate-dependent borderline personality disorder.

Opiate dependence (OD) and borderline personality disorder (BPD), separately and together, are significant public health problems with poor treatment outcomes. BPD is associated with difficulties in emotion regulation, and brain-imaging studies in BPD individuals indicate differential activation in prefrontal cingulate cortices and their interactions with limbic regions. Likewise, a similar network is implicated in drug cue responsivity in substance abusers. The present, preliminary study used functional MRI to examine activation of this network in comorbid OD/BPD participants when engaged in an “oddball” task that required attention to a target in the context of emotionally negative distractors. Twelve male OD/BPD participants and 12 male healthy controls participated. All OD/BPD participants were taking the opiate replacement medication Suboxone, and a subset of participants was positive for substances of abuse on scan day. Relative to controls, OD/BPD participants demonstrated reduced activation to negative stimuli in the amygdala and anterior cingulate. Unlike previous studies that demonstrated hyperresponsivity in neural regions associated with affective processing in individuals with BPD versus healthy controls, comorbid OD/BPD participants were hyporesponsive to emotional cues. Future studies that also include BPD-only and OD-only groups are necessary to help clarify the individual and potentially synergistic effects of these two conditions. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Emotional granularity and borderline personality disorder.

This study examined the affective dysregulation component of borderline personality disorder (BPD) from an emotional granularity perspective, which refers to the specificity in which one represents emotions. Forty-six female participants meeting criteria for BPD and 51 female control participants without BPD and Axis I pathology completed tasks that assessed the degree to which participants incorporated information about valence (pleasant–unpleasant) and arousal (calm–activated) in their semantic/conceptual representations of emotions and in using labels to represent emotional reactions. As hypothesized, participants with BPD emphasized valence more and arousal less than control participants did when using emotion terms to label their emotional reactions. Implications and future research directions are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder.

Changes in attachment organization and reflective function (RF) were assessed as putative mechanisms of change in 1 of 3 year-long psychotherapy treatments for patients with borderline personality disorder (BPD). Ninety patients reliably diagnosed with BPD were randomized to transference-focused psychotherapy (TFP), dialectical behavior therapy, or a modified psychodynamic supportive psychotherapy. Attachment organization was assessed with the Adult Attachment Interview and the RF coding scale. After 12 months of treatment, participants showed a significant increase in the number classified secure with respect to attachment state of mind for TFP but not for the other 2 treatments. Significant changes in narrative coherence and RF were found as a function of treatment, with TFP showing increases in both constructs during treatment. No changes in resolution of loss or trauma were observed across treatments. Findings suggest that 1 year of intensive TFP can increase patients' narrative coherence and RF. Future research should establish the relationship between these 2 constructs and relevant psychopathology, identify treatment components responsible for effecting these changes, and examine the long-term outcome of these changes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Heightened sensitivity to facial expressions of emotion in borderline personality disorder.

Individuals with borderline personality disorder (BPD) have been hypothesized to exhibit significant problems associated with emotional sensitivity. The current study examined emotional sensitivity (i.e., low threshold for recognition of emotional stimuli) in BPD by comparing 20 individuals with BPD and 20 normal controls on their accuracy in identifying emotional expressions. Results demonstrated that, as facial expressions morphed from neutral to maximum intensity, participants with BPD correctly identified facial affect at an earlier stage than did healthy controls. Participants with BPD were more sensitive than healthy controls in identifying emotional expressions in general, regardless of valence. These findings could not be explained by participants with BPD responding faster with more errors. Overall, results appear to support the contention that heightened emotional sensitivity may be a core feature of BPD. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relative roles of bipolar disorder and psychomotor agitation in substance dependence.

Previous studies have shown that both bipolar disorder (BPD) and psychomotor agitation (PMA) are associated with substance dependence. These two findings have yet to be integrated, despite evidence that PMA is closely linked with the bipolar spectrum. Accordingly, the current study examined whether BPD and PMA had unique or overlapping associations with substance dependence disorders. Participants were 2,300 individuals seeking outpatient psychiatric treatment. Before treatment, participants were assessed using structured clinical interviews, which yielded DSM-IV psychiatric diagnoses and clinical ratings of mood symptoms. Current PMA and lifetime BPD were present in 483 and 172 (bipolar I, n = 71; bipolar II, n = 101) participants, respectively. Current PMA and lifetime BPD each were associated with increased prevalence of lifetime nicotine, alcohol, and drug dependence (ORs ≥ 1.52, ps ≤ .0004). These associations remained significant when controlling for demographic characteristics and comorbid psychiatric disorders, except the link between agitation and alcohol dependence, which was reduced to a trend (p = .058). Although BPD and PMA were associated with each other, these two factors demonstrated unique, nonoverlapping relationships to nicotine, alcohol, and drug dependence. Individuals with both PMA and BPD exhibited especially high rates of comorbid substance dependence. The present results replicate and extend previous findings documenting the relations of BPD and PMA to substance dependence. BPD and PMA may represent independent psychopathological correlates of substance dependence. Future research should explore the theoretical and clinical significance of these potentially distinct relations to substance dependence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An experimental investigation of emotion dysregulation in borderline personality disorder.

Despite the prominent role of emotion dysregulation in theoretical accounts of borderline personality disorder (BPD), few studies have examined emotion dysregulation in BPD. This study extends extant research by providing an experimental investigation of emotion dysregulation among outpatients with BPD. Specifically, this study modified an experimental measure of distress tolerance to examine differences between outpatients with BPD (n = 17) and those without a personality disorder (n = 18) in 2 aspects of emotion dysregulation: (a) the unwillingness to experience emotional distress in order to pursue goal-directed behavior and (b) the inability to engage in goal-directed behavior when distressed. As hypothesized, BPD participants were less willing to experience distress in order to pursue goal-directed behavior. However, BPD participants did not evidence greater difficulties engaging in goal-directed behavior when distressed. Results highlight directions for future research and suggest that particular aspects of emotion dysregulation may be more or less relevant to BPD. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Structural relations between borderline personality disorder features and putative etiological correlates.

This study assessed the structural relations between borderline personality disorder (BPD) features and purported etiological correlates. Approximately 5,000 18-year-old nonclinical young adults were screened for BPD features, and 2 cohorts of participants (total N?=?421; approximately one half of whom endorsed significant borderline features) completed the laboratory phase of the study. Measures included self-report and interview-based assessments of BPD psychopathology, personality, psychopathology in biological parents, and childhood physical and sexual abuse. Significant relations between BPD features and purported etiological correlates of BPD were found. A multivariate model that included parental psychopathology, childhood abuse, and personality factors provided an adequate fit to the data and supported the contention that the personality traits disinhibition and negative affectivity underlie BPD features. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Nontraumatic pathways to borderline personality disorder.

Clinicians who treat borderline personality disorder (BPD) generally assume that this disorder is caused by childhood abuse. This assumption is strongly supported in the BPD literature, which indicates that the majority of individuals with BPD have suffered emotional, physical, and sexual abuse. What is often missed or simply ignored in discussions of BPD is that this same body of research also suggests that a significant minority of borderline individuals have not suffered childhood abuse. This article reviewed the literature on the prevalence of childhood abuse and BPD, offered a number of hypotheses about nontraumatic pathways to BPD, and briefly considered treatment implications for nontraumatized BPD individuals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Impulsivity and risk-taking in borderline personality disorder with and without substance use disorders.

Impulsivity and risk taking propensity were assessed in participants with borderline personality disorder (BPD-only; n = 19), BPD and a current or past substance use disorder (BPD-SUD; n = 32), and a matched comparison group (MC; n = 28). Participants were administered behavioral measures of two facets of the multidimensional construct of impulsivity [GoStop, delay discounting task (DDT)], one measure of risk-taking propensity [Balloon Analog Risk Task (BART)], and two self-report measures of impulsivity (i.e., Barrett Impulsiveness Scale, Eysenck Impulsiveness Scale). The BPD-SUD group, but not the BPD-only group, discounted delayed rewards faster than the MC group on the DDT, suggesting that the BPD-SUD/MC group difference may be because of the SUD rather than BPD. In contrast, both the BPD-SUD and BPD-only groups exhibited poorer behavioral response inhibition compared with the MC group, but the two BPD groups did not differ from one another. This finding suggests that the differences in behavioral response inhibition may be because of BPD rather than SUD and that behavioral response disinhibition may be a core feature of BPD. None of the groups differed on the measure of risk-taking propensity (i.e., BART). On self-report questionnaires, the BPD-SUD group reported more impulsivity than the BPD-only group and both BPD groups reported more impulsivity than the MC group. Data from the DDT and self-report measures provide partial support for the hypothesis that BPD individuals with a SUD are more impulsive than BPD individuals without a SUD on some facets of impulsivity (e.g., desire to obtain a smaller immediate reward rather than wait to obtain a larger reward in the future). Results suggest that behavioral response inhibition may be a novel treatment outcome variable for BPD treatment studies. (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)     

Understanding the heterogeneity of BPD symptoms through latent class analysis: Initial results and clinical correlates among inner-city substance users.

The current study investigated the heterogeneity of borderline personality disorder (BPD) symptoms in a sample of 382 inner-city, predominantly African American male substance users through the use of latent class analysis. A 4-class model was statistically preferred, with 1 class interpreted to be a baseline class, 1 class interpreted to be a high-BPD class, and 2 classes interpreted as intermediate classes. As a secondary goal, we examined the resulting BPD classes with respect to relevant clinical correlates, including temperamental vulnerabilities (affective instability, impulsivity, and interpersonal instability), childhood emotional abuse, drug choice, and co-occurring mood and anxiety disorders. The high-BPD class evidenced the highest levels of the temperamental vulnerabilities and environmental stressors, the baseline class evidenced the lowest levels, and the 2 intermediate classes fell in between. In addition, the high-BPD class had a higher probability of cocaine and alcohol dependence, as well as mood and anxiety disorders, than did the baseline class. Rates of alcohol use and mood disorders for the intermediate classes fell in between the high-BPD and the baseline classes. Results are discussed in relation to the current diagnostic conceptualization of BPD. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A multimethod investigation of the Behavioral Activation System in bipolar disorder.

Dysregulation in behavioral activation system (BAS) activity has been implicated in the pathogenesis of bipolar disorder (BPD). To characterize BAS activity and related facets in this disorder, the authors compared 59 participants with BPD to 44 controls on multiple measures of BAS activity, including a standardized behavioral task, self-reports, and electroencephalographic indexes of regional cortical activity. Levels of putative BAS activity differed depending on assessment strategy. When a behavioral task indexing reward sensitivity was used, euthymic BPD patients showed evidence of higher BAS activity than either control participants or patients who were in a mood episode. Following a mood induction procedure designed to elicit BAS activity, currently episodic patients showed relatively greater left anterior cortical activity than either euthymic or control participants. Implications of the findings for future research on BPD vulnerability are described. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The stability of personality traits in individuals with borderline personality disorder.

Although stability and pervasive inflexibility are general criteria for Diagnostic and Statistical Manual of Mental Disorders, 4th edition (American Psychiatric Association, 1994) personality disorders (PDs), borderline PD (BPD) is characterized by instability in several domains, including interpersonal behavior, affect, and identity. The authors hypothesized that such inconsistencies notable in BPD may relate to instability at the level of the basic personality traits that are associated with this disorder. Five types of personality trait stability across 4 assessments over 6 years were compared for BPD patients (N = 130 at first interval) and patients with other PDs (N = 302). Structural stability did not differ across groups. Differential stability tended to be lower for 5-factor model (FFM) traits in the BPD group, with the strongest and most consistent effects observed for Neuroticism and Conscientiousness. Growth curve models suggested that these 2 traits also showed greater mean-level change, with Neuroticism declining faster and Conscientiousness increasing faster, in the BPD group. The BPD group was further characterized by greater individual-level instability for Neuroticism and Conscientiousness in these models. Finally, the BPD group was less stable in terms of the ipsative configuration of FFM facet-level profiles than was the other PD group over time. Results point to the importance of personality trait instability in characterizing BPD. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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)