"Feeling Invisible": Individuals With Borderline Personality Disorder Underestimate the Transparency of Their Emotions.

The present study investigated transparency estimation, that is, the ability to estimate how observable one's emotions are, in patients diagnosed with borderline personality disorder (BPD) (n = 35) and healthy controls (HCs; n = 35). Participants watched emotionally evocative video clips and estimated the transparency of their own emotional experience while watching the clip. Facial expression coding software (FaceReader) quantified their objective transparency. BPD patients felt significantly less transparent than HCs, but there were no differences in objective transparency. BPD patients tended to underestimate the transparency of their emotions compared to HCs, who in turn overestimated their transparency. This suggests that BPD patients expect that others will not know how they feel, irrespective of how observable their emotions actually are. We link these findings to low emotional awareness and a history of emotional invalidation in BPD, and we discuss their impact on BPD patients' social functioning.

Do my emotions show or not? Problems with transparency estimation in women with borderline personality disorder features.

Transparency estimation, that is, estimating the extent to which one's mental states are observable to others, requires the simultaneous representation of the self and of others' perspective on the self. Individuals with borderline personality disorder (BPD) have difficulty integrating multiple perspectives when mentalizing, which may be reflected in impaired transparency estimation. A total of 62 participants high and low in BPD features watched emotionally evocative video clips and estimated the transparency of their emotional experience while facial expression coding software (FaceReader) quantified their objective transparency. Individuals high in BPD features showed a larger discrepancy between estimated and objective transparency than individuals low in BPD features, showing that they both over- and underestimated their transparency. Indeed, estimated transparency positively predicted objective transparency in individuals low in BPD features, but not in individuals high in BPD features. Moreover, the ability to estimate intraindividual variability in one's own objective transparency was moderated by self-reported arousal in the participants high in BPD features. Impairments in transparency estimation were correlated with self-report measures of borderline features, attachment, and mentalizing. In conclusion, we found that borderline features relate to a reduced capacity to estimate the extent to which one's own emotional states are observable to others. Although replication in clinical samples of BPD patients is needed, the present study provides evidence for problems in mentalizing the (embodied) self from another person's perspective in BPD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Borderline We-Space? The Phenomenology of the Background of Safety in Borderline Personality Disorder.

Borderline personality disorder (BPD) is a severe psychiatric condition characterized by instability in identity, relationships, and affect. Individuals, with BPD typically lack a coherent sense of self, are highly sensitive to interpersonal stressors, experience intense fluctuations in mood, and frequently engage in impulsive and self-destructive behaviors. Although both empirical research and development of effective psychotherapy have evidently progressed over the past years, many aspects regarding the structure of experience and the life-world typical for persons with BPD are not yet fully understood. Somewhat surprisingly, phenomenological psychopathology has only recently started to pay more attention to the disorder. A comprehensive elaboration of the phenomenology of BPD is therefore still lacking. This article aimed to contribute to such a phenomenological understanding by focusing on what we think is an essential aspect that has yet not been sufficiently addressed: the background of safety. To clarify what this means, we depart from Sandler's [Int J Psychoan. 1960;41:352-6] psychoanalytic concept and elaborate on it phenomenologically. This leads us to argue that the development of a background of safety requires a particular embodied presence of others, which, in turn, contributes to the constitution of a safe we-space, a shared and familiar environment providing a matrix for the experience of a stable world. However, even when established, the background of safety remains in need of a continuous reconfirmation through corresponding experiences within a sufficiently reliable and controllable environment. The background of safety is vulnerable and open to (interpersonal) disruptions like trauma or neglect. In BPD, we suggest 3 aspects regarding the phenomenology of the background of the safety need to be considered: first, typically, patients with BPD did not develop a robust background of safety in infancy; second, weakening of the background of safety gives rise to symptoms and dynamics typical for BPD; third, these symptoms and dynamics further undermine the possible development of a background of safety in adult life and thus gravitate toward a petrification of the borderline condition, a "stable instability." To conclude, we examine whether this concept should be understood as a trouble générateur and, last, consider its clinical implications.

The role of impairments in self-other distinction in borderline personality disorder: A narrative review of recent evidence.

Impairments in maintaining a differentiated sense of "self" and "other" are thought to be a central feature of borderline personality disorder (BPD). However, studies directly focusing on self-other distinction (SOD) in BPD are scarce, and these findings have not yet been integrated with novel insights into the neural mechanism involved in SOD. Here, we present a narrative review of recent behavioral and neuroimaging findings focusing on impairments in SOD in BPD. Behavioral findings of SOD at the embodied level provide preliminary evidence for impairments in multisensory integration in BPD. Furthermore, both behavioral and neuroscientific data converge to suggest that SOD impairments in BPD reflect an inability to shift between self and other representations according to task demands. Research also suggests that disruptions in infant-caregiver synchrony may play a role in the development of these impairments. Based on these findings, we present a new, integrative model linking impairments in SOD to reduced neural and behavioral synchrony in BPD. The implications of these findings for future research and clinical interventions are outlined.

Self-other distinction and borderline personality disorder features: Evidence for egocentric and altercentric bias in a self-other facial morphing task.

Self-other distinction (SOD) refers to the ability to distinguish one's own body, actions, and mental representations from those of others. Problems with SOD are considered to be a key feature of borderline personality disorder (BPD). However, empirical studies on SOD in BPD are scarce. Here, we present a study providing preliminary support for the usefulness and validity of a self-other facial morphing task to capture the capacity for SOD in a sample of nonclinical participants high (n = 30) and low (n = 32) in BPD features. Participants had to watch a video sequence in which their own face was gradually morphed into the face of an unfamiliar other (self-to-other) or vice versa (other-to-self), requiring them to indicate at which point they judged the morph to look more like the target face than the starting face. Consistent with predictions, results showed that participants in the high-BPD group judged the morph to look like themselves for longer in the self-to-other direction (suggestive of egocentric bias), but only with a relatively more attractive target face. In the other-to-self direction, the high-BPD group had more difficulty recognizing their own face (i.e., an altercentric bias), but this time only with the relatively less attractive face. Further research is needed to replicate these findings in clinical samples, but overall they suggest that the current task might be suited to investigate SOD problems in BPD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Mentalizing Based on External Features in Borderline Personality Disorder Compared With Healthy Controls: The Role of Attachment Dimensions and Childhood Trauma.

Extant research suggests that borderline personality disorder (BPD) is associated with impairments in mentalizing, that is, comprehending behavior in terms of underlying mental states. However, the precise nature of these impairments remains unclear. The literature is mixed concerning mental-izing based on external features of others, and specifically facial emotion recognition (FER) in BPD patients. This study investigated FER differences in 79 BPD patients and 79 matched healthy controls using the Reading the Mind in the Eyes Test (RMET). The authors also investigated attachment dimensions and childhood trauma in relation to mentalizing based on external features. Results showed that BPD patients performed worse on positive and negative emotions. Furthermore, avoidant attachment was negatively related to FER for neutral emotions, particularly in the control group. Trauma was negatively related to FER at trend level, particularly in BPD patients. The implications for this understanding of mentalizing based on external features in BPD are discussed.

Mentalizing as a mechanism of change in the treatment of patients with borderline personality disorder: A parallel process growth modeling approach.

Although a number of effective psychotherapeutic treatments have been developed for borderline personality disorder (BPD), little is known about the mechanisms of change explaining the effects of these treatments. There is increasing evidence that impairments in mentalizing or reflective functioning-the capacity to reflect on the internal mental states of the self and others-are a central feature of BPD. To date, no study has directly investigated the core assumption of the mentalization-based approach to BPD, that changes in this capacity are associated with treatment outcome in BPD patients. This study is the first to directly investigate this assumption in a sample of 175 patients with BPD who received long-term hospitalization-based psychodynamic treatment. Using a parallel process growth modeling approach, this study investigated whether (a) treatment was related to changes in mentalizing capacity as measured with the Reflective Functioning Questionnaire; (b) these changes could be explained by pretreatment levels of mentalizing and/or symptomatic distress; and (c) changes in mentalizing capacity over time were associated with symptomatic improvement. Mentalizing and symptomatic distress were assessed at admission, 12 and 24 weeks into treatment, and at discharge. Results showed that treatment was associated with significant decreases in mentalizing impairments (i.e., uncertainty about mental states) and symptomatic distress. Pretreatment levels of mentalizing and symptomatic distress did not predict these changes. However, improvements in mentalizing were strongly associated with the rate of decrease in symptomatic distress over time (r = .89). These findings suggest that increases in mentalizing may indeed in part explain therapeutic change in the treatment of BPD, but more research is needed to further substantiate these conclusions. (PsycINFO Database Record

Mentalizing and interpersonal problems in borderline personality disorder: The mediating role of identity diffusion.

Individuals with borderline personality disorder (BPD) are characterized by problems in interpersonal functioning and their long-term social integration often remains problematic. Extant theories have linked identity diffusion to many of the interpersonal problems characteristic of BPD patients. Recent theoretical accounts have suggested that identity diffusion results from problems with mentalizing or reflective functioning, that is, the capacity to understand oneself and others in terms of intentional mental states. In this study we tested these assumptions, i.e., whether identity diffusion plays a mediating role in the relationship between mentalizing difficulties and interpersonal problems, in a sample of 167 BPD patients. Highly significant correlations were found between mentalizing impairments, identity diffusion and interpersonal problems. Mediation analyses showed that identity diffusion fully mediated the relationship between mentalizing difficulties and interpersonal problems. This study provides preliminary evidence that impairments in mentalizing are related to identity diffusion, which in turn is related to interpersonal problems in BPD. Further longitudinal research is needed to further substantiate these conclusions.

Self-critical perfectionism, dependency, and symptomatic distress in patients with personality disorder during hospitalization-based psychodynamic treatment: A parallel process growth modeling approach.

There is growing evidence for the efficacy and effectiveness of psychotherapy in patients with personality disorder (PD), but very little is known about the factors underlying these effects. Two-polarities models of personality development provide an empirically supported approach to studying therapeutic change. Briefly, these models argue that personality pathology is characterized by an imbalance between development of the capacity for self-definition and for relatedness, with an exaggerated emphasis on issues regarding self-definition and relatedness being expressed in high levels of self-critical perfectionism (SCP) and dependency, respectively. This study used data from a study of 111 patients with PD who received long-term hospitalization-based psychodynamic treatment to investigate whether (a) treatment was related to changes in SCP, dependency, and symptomatic distress; (b) these changes could be explained by pretreatment levels of SCP, dependency, and/or symptomatic distress; and (c) changes in these personality dimensions over time were associated with symptomatic improvement. SCP, dependency, and symptomatic distress were assessed at admission (baseline), at 12 and 24 weeks into treatment, and at discharge. Parallel process multilevel growth modeling showed that (a) treatment was associated with a significant decrease in levels of SCP, dependency, and symptomatic distress, whereas (b) pretreatment levels of each of these three factors did not predict the decreases observed, and (c) changes in SCP, but not dependency, were associated with the rate of decrease in symptomatic distress over time. Implications of these findings for our understanding of therapeutic change in the treatment of PD are discussed. (PsycINFO Database Record

Development and Validation of a Self-Report Measure of Mentalizing: The Reflective Functioning Questionnaire.

Reflective functioning or mentalizing is the capacity to interpret both the self and others in terms of internal mental states such as feelings, wishes, goals, desires, and attitudes. This paper is part of a series of papers outlining the development and psychometric features of a new self-report measure, the Reflective Functioning Questionnaire (RFQ), designed to provide an easy to administer self-report measure of mentalizing. We describe the development and initial validation of the RFQ in three studies. Study 1 focuses on the development of the RFQ, its factor structure and construct validity in a sample of patients with Borderline Personality Disorder (BPD) and Eating Disorder (ED) (n = 108) and normal controls (n = 295). Study 2 aims to replicate these findings in a fresh sample of 129 patients with personality disorder and 281 normal controls. Study 3 addresses the relationship between the RFQ, parental reflective functioning and infant attachment status as assessed with the Strange Situation Procedure (SSP) in a sample of 136 community mothers and their infants. In both Study 1 and 2, confirmatory factor analyses yielded two factors assessing Certainty (RFQ_C) and Uncertainty (RFQ_U) about the mental states of self and others. These two factors were relatively distinct, invariant across clinical and non-clinical samples, had satisfactory internal consistency and test-retest stability, and were largely unrelated to demographic features. The scales discriminated between patients and controls, and were significantly and in theoretically predicted ways correlated with measures of empathy, mindfulness and perspective-taking, and with both self-reported and clinician-reported measures of borderline personality features and other indices of maladaptive personality functioning. Furthermore, the RFQ scales were associated with levels of parental reflective functioning, which in turn predicted infant attachment status in the SSP. Overall, this study lends preliminary support for the RFQ as a screening measure of reflective functioning. Further research is needed, however, to investigate in more detail the psychometric qualities of the RFQ.

What's in a face? Mentalizing in borderline personality disorder based on dynamically changing facial expressions.

The mentalization-based approach to borderline personality disorder (BPD) argues that impairments in mentalizing are a key feature of BPD. Most previous research in this area has concentrated on potential impairments in facial emotion recognition in BPD patients. However, these studies have yielded inconsistent results, which may be attributable to methodological differences. This study aimed to address several limitations of previous studies by investigating different parameters involved in emotion recognition in BPD patients using a novel, 2-step dynamically changing facial expression paradigm, taking into account the possible influence of mood, psychotropic medication, and trauma exposure. Twenty-two BPD patients and 22 matched normal controls completed this paradigm. Parameters assessed were accuracy of emotion recognition, reaction time (RT), and level of confidence, both for first and full response and for correct and incorrect responses. Results showed (a) that BPD patients were as accurate in their first, but less accurate in their full emotion recognition than normal controls, (b) a trend for BPD patients to respond more slowly than normal controls, and (c) no significant difference in overall level of confidence between BPD patients and normal controls. Mood and psychotropic medication did not influence these results. Exposure to trauma in BPD patients, however, was negatively related to accuracy at full expression. Although further research is needed, results suggest no general emotion-recognition deficit in BPD patients using a dynamic changing facial recognition paradigm, except for a subgroup of BPD patients with marked trauma who become less accurate when they have to rely more on controlled, reflective processes.

The Construct Validity of the Dutch Personality Inventory for DSM-5 Personality Disorders (PID-5) in a Clinical Sample.

The factor structure and the convergent validity of the Personality Inventory for DSM-5 (PID-5), a self-report questionnaire designed to measure personality pathology as advocated in the fifth edition, Section III of Diagnostic and Statistical Manual of Mental Disorders (DSM-5), are already demonstrated in general population samples, but need replication in clinical samples. In 240 Flemish inpatients, we examined the factor structure of the PID-5 by means of exploratory structural equation modeling. Additionally, we investigated differences in PID-5 higher order domain scores according to gender, age and educational level, and explored convergent and discriminant validity by relating the PID-5 with the Dimensional Assessment of Personality Pathology-Basic Questionnaire and by comparing PID-5 scores of inpatients with and without a DSM-IV categorical personality disorder diagnosis. Our results confirmed the original five-factor structure of the PID-5. The reliability and the convergent and discriminant validity of the PID-5 proved to be adequate. Implications for future research are discussed.

A psychoanalytically informed hospitalization-based treatment of personality disorders.

This study presents a model of psychic change in personality disorders focusing on three dimensions: felt safety, mentalization and self-object relations. Based upon this model a hospitalization-based therapy program was created. Four scales to measure these three dimensions on the Object Relation Interview are discussed: the Felt Safety Scale, the Reflective Functioning Scale and the Bion Grid Scale and the Differentiation-Relatedness Scale. A naturalistic symptom outcome study of the program showed a large effect on both symptoms and personality functioning. Furthermore, trajectory based on pre-treatment patient characteristics (i.e., anaclitic versus introjective personality styles). Importantly, we also found a relation between symptomatic and personality change and change in felt safety and object relations. At 5-year follow-up, patients showed sustained improvement in symptomatic distress and further improvement in terms of personality and interpersonal functioning.

Levels of personality functioning and their association with clinical features and interpersonal functioning in patients with personality disorders.

Recently, the DSM-5 Personality and Personality Disorders Work Group has proposed a multiple level approach toward the classification and diagnosis of personality disorders (PDs), with the first level entailing a rating of impairments in levels of personality functioning. Although a number of measures that assess levels of personality functioning have been validated, given its prominent status in the DSM-5 proposal and contemporary theories of personality pathology, the Work Group has called for more research in this area (e.g., Bender, Morey, & Skodol, 2011). In response to this call, this study investigates the relationship between two major, well-validated dimensional measures of levels of personality functioning, that is, the Differentiation-Relatedness Scale (DR-S; Diamond, Blatt, Stayner, & Kaslow, 1991), as scored on the Object Relations Inventory (ORI; Blatt, Wein, Chevron, & Quinlan, 1979), and the Inventory of Personality Organization (IPO; Lenzenweger, Clarkin, Kernberg, & Foelsch, 2001), a self-report instrument, and their relationship with different measures of clinical and interpersonal functioning in 70 patients with a PD. First, results showed that higher levels of differentiation and relatedness of descriptions of self and significant others, and of the self in particular, were negatively related to indices of personality functioning as assessed by the IPO. Lower levels of personality functioning, as measured with both the DR-S and the IPO, were positively related to severity of depression, symptomatic distress, self-harm, and interpersonal problems. Finally, results showed that the DR-S and the IPO independently predicted clinical features and interpersonal functioning. Hence, this study lends further support for the concurrent and predictive validity of the DR-S and the IPO in assessing levels of personality functioning. However, more research concerning the validity of these measures in assessing levels of personality functioning is needed. Suggestions for further research are formulated.

The impact of level of personality organization on treatment response: a systematic review.

This paper provides a systematic review of extant research concerning the association between level of personality organization (PO) and psychotherapy response. Psychotherapy studies that reported a quantifiable association between level of PO and treatment outcome were examined for eligibility. Based on stringent inclusion and exclusion criteria, we identified 18 studies from 13 original data sources. Participants in these studies had a variety of mental disorders, of which mood, anxiety, and personality disorders were the most common. The results of this systematic review converge to suggest that higher initial levels of PO are moderately to strongly associated with better treatment outcome. Some studies indicate that level of PO may interact with the type of intervention (i.e., interpretive versus supportive) in predicting treatment outcome, which suggests the importance of tailoring the level of interpretive work to the level of PO. Yet, at the same time, the limited number of studies available and the heterogeneity of measures used to assess PO in existing research stress the need for further research. Potential implications for clinical practice and guidelines for future research are discussed.

Patterns of inner change and their relation with patient characteristics and outcome in a psychoanalytic hospitalization-based treatment for personality disordered patients.

This study investigated whether different clusters of patients with personality disorders in a psychoanalytic hospitalization-based treatment were associated with: (a) different changes in personality organization (PO); (b) different pre-treatment variables; and (c) different associations between changes in PO and outcome. K-means clustering analysis identified two clusters of patients, which showed different changes in PO and mainly differed in terms of levels of anaclitic and introjective personality features, respectively. Both clusters showed a significant decrease in symptoms and an improvement in personality functioning during treatment and at 3-month follow-up. Clinical implications of these findings are discussed.

Process and outcome in psychodynamic hospitalization-based treatment for patients with a personality disorder.

This study examined the relationship between the psychotherapeutic process and outcome in 44 patients who completed hospitalization-based psychodynamic treatment for personality disorders. Using self-report and interview ratings, outcome was assessed in terms of symptoms and personality functioning, and the psychotherapeutic process in terms of self and object relations, felt safety, and reflective functioning. Symptom and process measures were administered at intake, every 3 months during treatment, and at 3 and 12 months follow-up. Personality measures were collected at intake, the end of treatment, and at 3 and 12 months follow-up. Using Piecewise Linear Growth Curve Analysis results showed improvement in symptoms, personality functioning, self and object relations and felt safety, but not in reflective functioning. Linear changes in self and object representation and felt safety, but not in reflective functioning, predicted improvement in outcome.

Outcome and outcome trajectories of personality disordered patients during and after a psychoanalytic hospitalization-based treatment.

This study aims to identify different outcome trajectories in a psychoanalytic hospitalization-based treatment in a sample of 70 patients with personality disorders using a naturalistic 12 month follow-up design. Trajectory analysis identified four groups of patients, i.e., patients showing (a) high initial symptom levels and considerable and consistent improvement late in treatment (High-Low group; HL), (b) medium initial symptom levels and a quick and sustained response (Medium-Low group; ML), (c) medium initial symptom levels but without substantial improvement (Medium-Medium group; MM), and (d) low initial symptom levels without substantial further improvement during and after treatment (Low-Low group; LL). Further, data suggested that these four trajectories were related in theoretically meaningful ways to pre-treatment variables, such as anaclitic and introjective personality styles and trauma. Results are discussed in the context of other studies showing the need for differential treatment approaches based on pretreatment characteristics.