A mechanism-based group-psychotherapy approach to aggressive behaviour in borderline personality disorder: findings from a cluster-randomised controlled trial.

BACKGROUND: Aggressive behaviour is a prevalent and harmful phenomenon in patients with borderline personality disorder (BPD). However, no short-term, low-cost programme exists that specifically focuses on aggression. AIMS: Attuning therapy modules to pathogenetic mechanisms that underlie reactive aggression in BPD, we composed a 6 week mechanism-based anti-aggression psychotherapy (MAAP) approach for the group setting, which we tested against a non-specific supportive psychotherapy (NSSP). METHOD: A cluster-randomised two-arm parallel-group phase II trial of N = 59 patients with BPD and overt aggressive behaviour was performed (German Registry for Clinical Trials, DRKS00009445). The primary outcome was the externally directed overt aggression score of the Modified Overt Aggression Scale (M-OAS) post-treatment (adjusted for pre-treatment overt aggression). Secondary outcomes were M-OAS irritability, M-OAS response rate and ecological momentary assessment of anger post-treatment and at 6 month follow-up, as well as M-OAS overt aggression score at follow-up. RESULTS: Although no significant difference in M-OAS overt aggression between treatments was found post-treatment (adjusted difference in mean 3.49 (95% CI -5.32 to 12.31, P = 0.22), the MAAP group showed a clinically relevant decrease in aggressive behaviour of 65% on average (versus 33% in the NSSP group), with particularly strong improvement among those with the highest baseline aggression. Most notably, significant differences in reduction in overt aggression between MAAP and NSSP were found at follow-up. CONCLUSIONS: Patients with BPD and aggressive behaviour benefited from a short group psychotherapy, with improvements particularly visible at 6 month follow-up. Further studies are required to show whether these effects are specific to MAAP.

Emotional responses in patients with borderline as compared with avoidant personality disorder.

The aim of this study was to assess psychophysiological affect correlates, in addition to the usual self-report in borderline personality disorder (BPD) compared with avoidant personality disorder (APD) and normal controls (NCs), when responding to standardized experimental stimuli. In 24 BPD female patients, 23 APD female patients, and 27 female NCs, skin conductance response (SCR), heart rate (HR) change, and startle response were recorded while the subjects viewed slides with emotional content. Neither the self-report nor the psychophysiological data supported the hypothesis that affective responses of BPD individuals are generally stronger than those with APD. BPD patients showed no potentiation of the affective modulation of the startle reflex and their electrodermal reactivity was lower than in either the APD subjects or the NCs. The hypothesis of a general affective hyperresponsivity could not be confirmed. Low somatic arousal in BPD can interfere with the anticipation of signal stimuli and may explain the exaggerated openness borderline personalities show to stimuli, particularly in interpersonal situations.

Affective responsiveness in borderline personality disorder: a psychophysiological approach.

OBJECTIVE: The aim of the study was to investigate affective responses to emotional stimuli in subjects with borderline personality disorder. METHOD: Twenty-four female patients with borderline personality disorder and 27 normal female comparison subjects were examined. The test stimuli were a set of standardized photographic slides with pleasant, neutral, or unpleasant emotional valence. In addition to self-reports, emotional reactions to the slides were measured by heart rate, skin conductance, and startle response. Psychometric tests for various aspects of impulsiveness were also completed. RESULTS: Neither self-report nor physiological data gave any evidence that the borderline patients showed more intense affective responses than did the normal subjects. The borderline subjects did not produce higher levels of startle amplitude, and while viewing unpleasant slides, they showed a startle potentiation effect that was largely similar to that of the comparison group. In fact, the borderline patients showed low electrodermal responses to all three stimulus categories, which points to physiological underarousal. CONCLUSIONS: The results do not agree with the hypothesis that there is a fundamental, biologically based affective hyperresponsiveness in borderline personality disorder, as is suggested by current theories of affect dysregulation in the disorder. Autonomic underarousal may seriously interfere with a flexible adaptation to environmental stimuli.