Towards an informed research agenda for the field of personality disorders by experts with lived and living experience and researchers.

BACKGROUND: We describe a collection of themes for a research agenda for personality disorders that was originally formulated for the ESSPD Borderline Congress in 2022. METHODS: Experts with lived and living experience (EE), researchers and clinicians met virtually, exchanged ideas and discussed research topics for the field of personality disorders. The experts - patients, relatives, significant others - named the topics they thought most relevant for further research in the field. These topics were presented at the ESPPD conference in October 2022. RESULTS: The five top themes were: 1. Prevention, early detection and intervention, 2. Recovery beyond symptom improvement, 3. Involvement of relatives in treatment, 4. Gender dysphoria, and 5. Stigma. CONCLUSIONS: In general, the topics reflect current issues and changes in societal values. Overarching aims of research on these topics are the improvement of social participation and integration in society, better dissemination of research, and better information of the general public and political stakeholders.

The Self-Concept and Identity Measure in Patients with Personality Disorders: A Psychometric Evaluation and Associations With Identity Processes, Core Domains of Self-Functioning, and Personality Disorder Symptoms.

As developmental and clinical research on identity has largely developed in disconnect, scholars recommend adopting a developmental psychopathology perspective on identity, which considers adaptive and pathological identity functioning. Such a perspective has also been introduced in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) Alternative Model for Personality Disorders (AMPD), which suggests that all personality disorders (PDs) are marked by moderate to extreme deficits in self-functioning (i.e., identity and self-direction). The present study aims to validate the Dutch Self-Concept and Identity Measure (SCIM), a 27-item self-report questionnaire that assesses consolidated identity, disturbed identity, and lack of identity, in 153 psychiatric inpatients with PDs (75.2% female; Mage = 31.73). We investigated the factor structure and reliability of the SCIM, and examined associations of SCIM scales with typical identity processes, AMPD domains of self-functioning, and symptoms of all PDs. Results indicated that a 23-item Dutch SCIM produced valid and reliable scores among patients with PDs. Furthermore, SCIM scales were significantly and differentially related to identity commitment processes, ruminative identity exploration, domains of self-functioning, and symptoms of all PDs. Moreover, findings indicated that PDs varied regarding the severity of identity impairment.

Hospital-wide SARS-CoV-2 antibody screening of staff in a university psychiatric centre in Belgium.

In this first serosurvey among psychiatric healthcare providers, only 3.2% of a sample of 431 staff members of a Belgian University Psychiatric Centre, screened 3-17 June 2020, had SARS-CoV-2 immunoglobulin G antibodies, which is considerably lower compared with both the general population and other healthcare workers in Belgium. The low seroprevalence was unexpected, given the limited availability of personal protective equipment and the high amount of COVID-19 symptoms reported by staff members. Importantly, exposure at home predicted the presence of antibodies, but exposure at work did not. Measures to prevent transmission from staff to patients are warranted in psychiatric facilities.

Euthanasia and assisted suicide in patients with personality disorders: a review of current practice and challenges.

BACKGROUND: Over the last two decades an increasing number of countries have legalized euthanasia and physician-assisted suicide (EAS) leading to considerable debate over the inherent ethical dilemmas. Increasing numbers of people with personality disorders, faced with unbearable suffering, have requested and received assistance in terminating their lives. EAS in people with personality disorders has, however, received very sparse attention from clinicians and researchers. In this paper, we examine the literature on the practice and prevalence of EAS in people with personality disorders to date and discuss the associated challenges for research and practice. METHODS: Narrative review of the literature combined with the authors' collective experience and knowledge of personality disorders. RESULTS: In six of the eight countries where EAS is currently legal, mental disorders are accepted as disorders for which EAS may be granted. In four of these countries, EAS in minors with mental disorders is also accepted. Our literature search resulted in 9 papers on the subject of EAS in people with personality disorders. These studies suggest that most clinicians who grant EAS have indeed perceived their patients' suffering as chronic, unbearable and untreatable without prospect of improvement. The majority of patients with personality disorders had tried some form of psychotherapy, but very few had received any of the relevant evidence-based treatments. The decision to grant EAS based on a perception of the patient's illness as being untreatable with no prospect of improvement, could, thus, in many cases fail to meet the due care criteria listed in EAS laws. People with personality disorders more often wish for death for extended periods of time than people without these disorders. However, there is ample empirical data to show that suicidal tendencies and behaviour can be treated and that they fluctuate rapidly over time. CONCLUSIONS: In light of our findings, we believe that the current legislation and practice of EAS for people with personality disorders is based on an inadequate understanding of underlying psychopathology and a lack of awareness about the contemporary treatment literature. Moreover, we assert that this practice neglects the individual's potential for having a life worth living.

Self-criticism and dependency predict affective variability in borderline personality disorder: An ecological momentary assessment study.

Affective variability is a defining feature of borderline personality disorder (BPD). We hypothesize that patients with BPD who score higher on self-criticism and/or dependency-patients with a relative emphasis on self-definition and interpersonal relatedness, respectively-are characterized by more affective variability in positive and negative emotions. To examine this hypothesis, a sample of 32 patients with BPD reported their momentary feelings of anger, depression, anxiety, cheerfulness, and relaxation in an experience sampling study with 10 random signals scheduled per day for 8 days. Using heterogeneous linear mixed models, results indicate that patients with BPD who score higher on self-criticism show more within-person variance (WPV) in anger, depression, anxiety, cheerfulness, and feeling relaxed, whereas patients who score higher on dependency show more WPV in anger but less WPV in anxiety and feeling relaxed. Consequently, individual differences in affective variability in BPD are, after adjustment for the confounding between the mean and WPV of affect, related to personality vulnerabilities like self-criticism and dependency. These results add evidence to two-polarities models of personality and the existing view that there is substantial heterogeneity in BPD. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Emotional reactivity to appraisals in patients with a borderline personality disorder: a daily life study.

BACKGROUND: Emotional instability, consisting of patterns of strong emotional changes over time, has consistently been demonstrated in daily life of patients with a borderline personality disorder (BPD). Yet, little empirical work has examined emotional changes that occur specifically in response to emotional triggers in daily life, so-called emotional reactivity. The goal of this study was to examine emotional reactivity in response to general emotional appraisals (i.e. goal congruence or valence, goal relevance or importance, and emotion-focused coping potential) and BPD-specific evaluations (trust and disappointment in self and others) in daily life of inpatients with BPD. METHODS: Thirty inpatients with BPD and 28 healthy controls participated in an experience sampling study and repeatedly rated the intensity of their current emotions, emotional appraisals, and evaluations of trust and disappointment in self and others. RESULTS: Results showed that the BPD group exhibited stronger emotional reactivity in terms of negative affect than healthy controls, however only in response to disappointment in someone else. BPD patients also showed weaker reactivity in positive affect in response to the appraised importance of a situation; the more a situation was appraised as important, the higher the subsequent positive affect for healthy controls only, not the patient group. CONCLUSIONS: These findings show that appraisals can trigger strong emotional reactions in BPD patients, and suggest that altered emotional reactivity might be a potential underlying process of emotional instability in the daily life.

Do treatment outcomes differ after 3 months DBT inpatient treatment based on borderline personality disorder subtypes?

Heterogeneity in borderline personality disorder (BPD) drives the search for BPD subtypes to optimize the assessment and treatment of these patients. Therefore, the aims of the present study were (1) to replicate previously identified BPD subtypes based on reactive and regulative temperament; (2) to compare them on symptomatology and coping; and (3) to investigate whether these subtypes show different treatment responses after 3 months of inpatient dialectical behaviour therapy (DBT). A total of 145 BPD inpatients were assessed by means of measures of temperament, symptomatology and coping. Through model-based clustering on the Behavioural Inhibition and Behavioural Activation Scales (BISBAS) and Effortful Control Scale (ECS), we identified three BPD subtypes: an Emotional/Disinhibited subtype (15%, high BAS and low ECS); a Low Anxiety subtype (41%, low BIS) and an Inhibited subtype (44%, low BAS). After 3 months of DBT, 75 patients completed the measures for a second time. Repeated measure ANOVAs demonstrated a general improvement on all symptoms and coping strategies. In addition, the BPD subtypes showed trajectory differences in clinical and borderline specific symptomatology and dissociation. These findings indicate that BPD subtypes based on temperament demonstrate different treatment responses, which can contribute to the search of more BPD subtype tailored treatment interventions. © 2018 John Wiley & Sons, Ltd.

Are emotional action tendencies and attentional bias related to temperament dimensions in patients with borderline personality disorder?

Disturbances in emotion regulation have been identified as a core feature of patients with a borderline personality disorder (BPD). Findings of studies using experimental measures of emotion processing are mixed, which may be partially explained by the heterogeneity of the BPD population. To address this issue, we investigated differences in experimental measures of emotional action tendencies (approach-avoidance behaviour) and attentional bias to emotional stimuli in BPD subtypes. Data of the Approach-Avoidance Task (AAT) and the Emotional Stroop Task (EST) were collected in 140 BPD patients, previously clustered into four BPD subtypes based on temperament dimensions. We investigated (1) the relationship between temperament dimensions and the performance on the AAT and EST and (2) compared performance on these tasks in previous defined BPD subtypes. The results of the present study demonstrated a positive relationship between effortful control (EC) and AAT effect-scores. A higher level of EC was positively associated with a general emotional action tendency towards faces with directed gaze, even when controlling for gender, age and BPD severity. Preliminary results on the comparison of the BPD subtypes demonstrated no significant differences in AAT and EST performance. These findings emphasize the relevance of EC in emotional action tendencies in BPD patients.

Age of onset of non-suicidal self-injury in Dutch-speaking adolescents and emerging adults: An event history analysis of pooled data.

OBJECTIVE: Non-Suicidal Self-Injury (NSSI) has emerged as an important mental-health concern. However, epidemiological features like age of onset of NSSI have remained understudied. Therefore, the current study investigated the distribution of age of onset of NSSI in pooled sample of Dutch-speaking adolescents and emerging adults using event history analysis. METHOD: Eleven datasets measuring age at first NSSI in community and clinical participants collected by researchers in the Dutch-speaking part of Belgium were pooled together. The final dataset consisted of 1973 community males, 1901 community females, and 505 clinical females. Discrete-time event history analysis was used to model the effect of gender and psychiatric disorders on the age of onset of NSSI. RESULTS: Twenty-one percent of adolescents from the community samples engaged in at least one episode of NSSI by the age of 25years. Irrespective of the type of sample (community or psychiatric disorder), the probability of age of onset peaked around the age of 14-15years. A second peak was observed around the age of 20 and 24years in the community and psychiatric samples respectively. CONCLUSIONS: Psychosocial interventions for prevention of NSSI should not only target adolescence through school mental health programs but also target emerging adults at the university level.

The relationship between non-suicidal self-injury and alexithymia in borderline personality disorder: "Actions instead of words".

INTRODUCTION: Borderline personality disorder (BPD) is a serious mental illness that centers on the inability to effectively regulate emotions. A large amount of BPD patients engage in non-suicidal self-injury (NSSI). Given the NSSI contributes to serious health risks, it is important to know why some BPD patients engage in NSSI and others do not. A possible associated factor of NSSI in BPD may be alexithymia, which reflects difficulties in identifying and communicating feelings. Therefore the aim of the present study was to investigate whether NSSI was associated with alexithymia and whether this association still stood when controlling for gender and depression. METHODS: The current study explored the relationship between NSSI and alexithymia in 185 BPD patients by means of the Self-Injury Questionnaire-Treatment Related and the Toronto Alexithymia Scale-20 (TAS). RESULTS: Of the 185 BPD inpatients, 82.7% reported life-time NSSI, of whom 52.9% were still engaging in current NSSI; and 71.3% scored in the alexithymic range (cut-off score≥61). Current NSSI was significantly associated with TAS-total. Additionally, when considering the separate TAS subscales Difficulties Describing Feelings (DDF), Difficulties Identifying Feelings (DIF) and Externally Oriented Thinking (EOT), only DDF was significantly associated with NSSI, even after controlling for gender and depression. CONCLUSION: These results suggest that NSSI in BPD patients is associated with alexithymia. More specific, difficulties describing feelings can lead to NSSI, independently of the depressive status of the BPD patient. The implications for clinical treatment of self-injurious BPD patients will be discussed.

The affect stabilization function of nonsuicidal self injury in Borderline Personality Disorder: An Ecological Momentary Assessment study.

Nonsuicidal Self-Injury (NSSI) is prominent in individuals with Borderline Personality Disorder (BPD), and there is abundant evidence that affect regulation plays an important role in NSSI in the majority of patients. Affective variability is a core feature of BPD, and thus, we hypothesize that NSSI has an affect stabilization function in BPD. Affect stabilization is a process through which individuals attempt to make their affect more stable by reducing affective variability. We tested this hypothesis in 32 participants with BPD who reported on their NSSI and affect -using a displeasure-pleasure (valence) and activation-deactivation (activation) dimension- in an experience sampling study with 10 random signals scheduled per day for 8 days. Results indicated that individuals who engaged in NSSI show more Within Subject (WS) variance in valence and activation than individuals who did not engage in NSSI. However, within the NSSI patients, individuals who engaged more frequently in NSSI during the study showed less WS variance in valence and activation than patients who engaged less frequently in NSSI. This suggests that NSSI may be reinforced by its affect stabilization function. In the discussion, we explore alternative explanations for the relation between NSSI and affective variability, and consider the clinical implications.

The emotion regulation function of nonsuicidal self-injury: A momentary assessment study in inpatients with borderline personality disorder features.

Studies using retrospective self-report or proxies of nonsuicidal self-injury (NSSI) in the lab have shown that NSSI is often preceded by intense negative emotions and followed by a decrease in negative emotions/tension, suggesting an emotion regulation function of NSSI. To investigate this emotion regulation function of NSSI in a more ecologically valid way, we used experience sampling methods to examine the temporal relationship between NSSI behavior and emotional experiences throughout the day in 30 inpatients currently staying in psychiatric hospitals. Because NSSI is especially prevalent and severe in patients with a borderline personality disorder (BPD), we focused on patients with high levels of BPD symptomatology. Results confirmed that high levels of negative emotion prospectively predicted a higher probability of engaging in NSSI in the next time interval. However, the occurrence of NSSI itself was related to concurrent increases in negative emotion and decreases in positive emotion, and even prospectively predicted an increase in negative emotion in the consecutive time interval. These preliminary results show that on a time scale of hours, instead of resulting in emotional relief, NSSI seems to be associated with a further increase in negative emotionality, shedding light on the cyclic nature of NSSI. (PsycINFO Database Record

Identity Processes and Statuses in Patients with and without Eating Disorders.

Problems with identity formation are associated with a range of psychiatric disorders. Yet, the mechanisms underlying such problems and how they are refined into specific diagnostic presentations require further investigation. The present study investigated identity processes among 123 women with eating disorders (ED) and age-matched community controls via a newly developed identity model. Several clinical outcome variables were assessed. Patients with ED scored lower on committing to and identifying with identity-related choices and scored higher on maladaptive or ruminative exploration, identity diffusion and identity disorder. They also experienced less identity achievement as compared with controls. The identity disorder status was associated with the highest scores on anxiety, depression, borderline personality disorder symptoms, and non-suicidal self-injury and the lowest scores on need satisfaction. Results indicate that patients with ED experience more identity problems than community controls and those captured by an identity disorder status experience the most problematic psychosocial functioning. Copyright © 2016 John Wiley & Sons, Ltd and Eating Disorders Association.

Overgeneral autobiographical memory predicts higher prospective levels of depressive symptoms and intrusions in borderline patients.

Overgeneral memory (OGM), the tendency to retrieve categories of events from autobiographical memory instead of single events, is found to be a reliable predictor for future mood disturbances and post-traumatic symptom severity. Patients with borderline personality disorder (BPD) often report co-morbid episodes of major depressive disorder (MDD) and post-traumatic stress disorder (PTSD). Therefore, we investigated whether OGM would predict depression severity and (post-traumatic) stress symptoms in BPD patients. At admission (N = 54) and at six-month follow-up (N ≥ 31), BPD patients completed the Structured Clinical Interview for DSM-IV Disorders, the Assessment of DSM-IV Personality Disorders, the Autobiographical Memory Test, the Beck Depression Inventory-2nd edition (BDI-II), and the Impact of Event Scale. OGM at baseline predicted (a) higher levels of depressive symptoms at follow-up and (b) more intrusions related to a stressful event over and above baseline levels of borderline symptoms, depressive symptoms, and intrusions, respectively. No association was found between memory specificity and event-related avoidance at follow-up. Despite previous findings suggesting that OGM in BPD is less robust than in MDD and PTSD, our results suggest that memory specificity in BPD patients may have some relevance for the course of depressive and stress symptomatology in BPD.

Emotional switching in borderline personality disorder: A daily life study.

Despite large efforts to understand emotional instability in borderline personality disorder (BPD), it is still unclear exactly how this is manifested in the daily lives of people suffering from the disorder. Building on theoretical and clinical observations of BPD, we propose that the emotional instability in BPD particularly consists of the occurrence of strong changes between positive and negative emotional states from 1 moment to the next, labeled emotional switching. We tested this proposal by means of an experience sampling study in which 30 BPD patients and 28 healthy controls reported in their daily lives the level of pleasantness/unpleasantness of their emotional states 10 times a day for 8 consecutive days using handheld palmtops. Results showed that although BPD patients did not differ from healthy controls regarding their overall tendency to switch from a positive to a negative emotional state or vice versa, the size of such changes between positive and negative states was found to be significantly larger in BPD patients. In contrast, the magnitude of emotional changes that remained within the negative emotional range or positive emotional range was not particularly larger for BPD patients compared with healthy participants. These findings imply that the emotional instability in BPD is particularly characterized by larger changes from positive to negative states and vice versa, rather than overall larger changes in intensity, providing insight into possible processes underlying emotion dysfunction in BPD.