Association of white matter microstructural alteration with non-suicidal self-injury behavior and visual working memory in adolescents with borderline personality disorder.

BACKGROUND: Non-suicidal self-injurious behavior (NSSI) is the core characteristic of adolescent borderline personality disorder (BPD) and visual working memory is involved in the pathological processes of BPD. This study aimed to investigate alterations in white matter microstructure and their association with NSSI and visual working memory in adolescents with BPD. METHODS: 53 adolescents diagnosed with BPD and 39 healthy controls (HCs) were enrolled. White matter microstructure was assessed with the fractional anisotropy (FA) and mean diffusivity (MD) from diffusion tensor imaging (DTI). Correlation analysis was performed to assess the association between FA/MD and core features of BPD. A mediation analysis was performed to test whether the effects of white matter alterations on NSSI could be mediated by visual working memory. RESULTS: Adolescents with BPD showed a reduced FA and an increased MD in the cortical-limbic and cortical-thalamus circuit when compared to the HCs (p < 0.05). Increased MD was positively correlated with NSSI, impulse control and identity disturbance (p < 0.05), and was negatively correlated with the score of visual reproduction. Reserved visual working memory masked the effects of white matter microstructural alterations on NSSI behavior. CONCLUSIONS: White matter microstructural deficits in the cortical-limbic and cortical-thalamus circuits may be associated with NSSI and visual working memory in adolescents with BPD. Reserved visual working memory may protect against NSSI.

Altered amygdalar emotion space in borderline personality disorder normalizes following dialectical behaviour therapy.

BACKGROUND: Borderline personality disorder (BPD) is a mental health condition characterized by an inability to regulate emotions or accurately process the emotional states of others. Previous neuroimaging studies using classical univariate analyses have tied such emotion dysregulation to aberrant activity levels in the amygdala of patients with BPD. However, multivariate analyses have not yet been used to investigate how representational spaces of emotion information may be systematically altered in patients with BPD. METHODS: Patients with BPD performed an emotional face matching task while undergoing MRI before and after a 10-week inpatient program of dialectical behavioural therapy. Representational similarity analysis (RSA) was applied to activity patterns (evoked by angry, fearful, neutral and surprised faces) in the amygdala and temporo-occipital fusiform gyrus of patients with BPD and in the amygdala of healthy controls. RESULTS: We recruited 15 patients with BPD (8 females, 6 males, 1 transgender male) to participate in the study, and we obtained a neuroimaging data set for 25 healthy controls for a comparative analysis. The RSA of the amygdala revealed a negative bias in the underlying affective space (in that activity patterns evoked by angry, fearful and neutral faces were more similar to each other than to patterns evoked by surprised faces), which normalized after therapy. This bias-to-normalization effect was present neither in activity patterns of the temporo-occipital fusiform gyrus of patients nor in amygdalar activity patterns of healthy controls. LIMITATIONS: Larger samples and additional questionnaires would help to better characterize the association between specific aspects of therapy and changes in the neural representational space. CONCLUSION: Our findings suggest a more refined role for the amygdala in the pathological processing of perceived emotions and may provide new diagnostic and prognostic imaging-based markers of emotion dysregulation and personality disorders.Clinical trial registration: DRKS00019821, German Clinical Trials Register (Deutsches Register Klinischer Studien).

Modeling vulnerability and intervention targets in the Borderline Personality Disorder system: A network analysis of in silico and in vivo interventions.

Modeling psychopathology as a complex dynamic system represents Borderline Personality Disorder (BPD) as a constellation of symptoms (e.g., nodes) that feedback and self-sustain each other shaping a network structure. Through in silico interventions, we simulated the evolution of the BPD system by manipulating: 1) the connectivity strength between nodes (i.e., vulnerability), 2) the external disturbances (i.e., stress) and 3) the predisposition of symptoms to manifest. Similarly, using network analysis we evaluated the effect of an in vivo group psychotherapy to detect the symptoms modified by the intervention. We found that a network with greater connectivity strength between nodes (more vulnerable) showed a higher number of activated symptoms than networks with less strength connectivity. We also found that increases in stress affected more vulnerable networks compared to less vulnerable ones, while decreases in stress revealed a hysteresis effect in the most strongly connected networks. The in silico intervention to symptom alleviation revealed the relevance of nodes related to difficulty in anger regulation, nodes which were also detected as impacted by the in vivo intervention. The complex systems methodology is an alternative to the common cause model with which research has approached the BPD phenomenon.

Organizaciones límite en la infancia. Estudio de caso desde la psicoterapia focalizada en la transferencia. / Organitzacions límit a la infantesa. Estudi de cas des de la psicoteràpia focalitzada en la transferència / Borderline organizations in childhood. Case study from transference-focused psychotherapy

En el presente trabajo, se plantea si pudiera estar indicado aplicar lo que sabemos sobre la psicoterapia focalizada en la transferencia (TFP) a niños con personalidad límite, a partir de las ideas de Paulina y Otto Kernberg. Se presenta el caso de una niña de seis años en la que se observa una falta de integración interna que, como consecuencia principal, generaba graves conflictos en sus relaciones. Se le indicó una psicoterapia con frecuenciasemanal centrada en las técnicas descritas para la TFP. A través del análisis del caso, se discuten sus peculiaridades técnicas a la luz de los resultados.(AU)

n this paper, it isconsidered whether it could be indicated to apply what we know about transference-focused psychotherapy (TFP)to children with borderline personality, based on the ideas of Paulina and Otto Kernberg. The case of a six-yearold girl is presented in which a lack of internal integration was observed which, as a main consequence, generatedserious conflicts in her relationships. She was prescribed weekly psychotherapy focused on the techniques described for TFP. Through the analysis of the case, its technical peculiarities are discussed in the light of the results.(AU)

En aquesttreball, es planteja si pogués estar indicat aplicar el que sabem sobre la psicoteràpia focalitzada en la transferència (TFP) a nens amb personalitat límit, a partir de les idees de Paulina i Otto Kernberg. Es presenta el cas d'unanena de sis anys en què s'observa una manca d'integració interna que, com a conseqüència principal, generavagreus conflictes en les seves relacions. Se li va indicar una psicoteràpia amb freqüència setmanal centrada enles tècniques descrites per a la TFP. Mitjançant l'anàlisi del cas, es discuteixen les seves peculiaritats tècniquesa la llum dels resultats.(AU)

Rejection Distress Suppresses Medial Prefrontal Cortex in Borderline Personality Disorder.

BACKGROUND: Borderline personality disorder (BPD) is characterized by an elevated distress response to social exclusion (i.e., rejection distress), the neural mechanisms of which remain unclear. Functional magnetic resonance imaging studies of social exclusion have relied on the classic version of the Cyberball task, which is not optimized for functional magnetic resonance imaging. Our goal was to clarify the neural substrates of rejection distress in BPD using a modified version of Cyberball, which allowed us to dissociate the neural response to exclusion events from its modulation by exclusionary context. METHODS: Twenty-three women with BPD and 22 healthy control participants completed a novel functional magnetic resonance imaging modification of Cyberball with 5 runs of varying exclusion probability and rated their rejection distress after each run. We tested group differences in the whole-brain response to exclusion events and in the parametric modulation of that response by rejection distress using mass univariate analysis. RESULTS: Although rejection distress was higher in participants with BPD (F1,40 = 5.25, p = .027, η2 = 0.12), both groups showed similar neural responses to exclusion events. However, as rejection distress increased, the rostromedial prefrontal cortex response to exclusion events decreased in the BPD group but not in control participants. Stronger modulation of the rostromedial prefrontal cortex response by rejection distress was associated with higher trait rejection expectation, r = -0.30, p = .050. CONCLUSIONS: Heightened rejection distress in BPD might stem from a failure to maintain or upregulate the activity of the rostromedial prefrontal cortex, a key node of the mentalization network. Inverse coupling between rejection distress and mentalization-related brain activity might contribute to heightened rejection expectation in BPD.

Aggression in borderline personality disorder: A systematic review of neuroimaging studies.

Aggressive behaviors are prevalent among patients with Borderline Personality Disorder (BPD). Neuroimaging studies have linked aggression in BPD patients to neurochemical, structural, functional, and metabolic alterations in various brain regions, especially in frontal-limbic areas. This systematic review summarizes current neuroimaging results on aggression among BPD patients and provides an overview of relevant brain mechanisms. A systematic search of PubMed and Web of Science databases, in addition to manual check of references, identified thirty-two eligible articles, including two magnetic resonance spectrum (MRS), thirteen structural magnetic resonance imaging (sMRI), six functional magnetic resonance imaging (fMRI), and eleven positron emission tomography (PET) studies. The reviewed studies have highlighted the abnormalities in prefrontal cortices and limbic structures including amygdala and hippocampus. Less studies have zoomed in the roles of parietal and temporal regions or taken a network perspective. Connectivity studies have shed light on the importance of the frontal-limbic interactions in regulating aggression. Conflicted findings might be attributed to disparity in controlling gender, anatomical subdivisions, and comorbidities, which shall be considered in future studies.

Identifying Disease-Specific Neural Reactivity to Psychosocial Stress in Borderline Personality Disorder.

BACKGROUND: Patients with borderline personality disorder (BPD) typically present emotion dysregulation (ED) when faced with adversity. However, it is argued that altered stress response may be more influenced by ED than BPD-specific traits. Here, we investigated this issue with functional magnetic resonance imaging using another ED condition as clinical control, i.e., bipolar disorder (BD), and controlling for ED traits. METHODS: We recruited 17 patients with BD, 24 patients with BPD, and 32 healthy control (HC) subjects. We adapted a functional magnetic resonance imaging-compatible psychosocial stressor task (Montreal Imaging Stress Task) in which participants are placed under time pressure when performing mental calculations and then receive immediate performance feedback (positive, negative, and neutral). ED traits were measured via self-report questionnaires targeting cognitive emotion dysregulation, affective lability, and trait anger and anxiety. RESULTS: Relative to patients with BD and HC subjects, patients with BPD exhibited overactive corticolimbic reactivity across all conditions, particularly in self-monitoring and emotion regulation regions such as the orbitofrontal cortex and anterior insula, even when controlling for ED. Conversely, patients with BD exhibited hypoactive corticolimbic reactivity to all feedback conditions compared with patients with BPD and HC subjects, even after controlling for ED. HC subjects exhibited significantly lower amygdala/hippocampus activity compared with both clinical groups, although this did not survive when controlling for ED. CONCLUSIONS: This study provides new insight into BPD-specific neural stress responding, suggesting hyperactive self- and emotion-regulatory neural psychosocial stress responding, independent of ED traits. The findings also highlight the importance of considering BPD as a diagnostic profile distinguishable from other ED disorder clinical groups.

Searching in the dark: Shining a light on some predictors of non-response to psychotherapy for borderline personality disorder.

BACKGROUND: Borderline Personality Disorder (BPD) is a prevalent and serious mental health condition. People can experience recovery or remission after receiving psychotherapy for BPD; however, it is estimated that about 45% of people in well conducted treatment trials do not respond adequately to current psychological treatments. AIM: To further advance psychotherapies for BPD by identifying the factors that contribute to the problem of non-response. METHOD: 184 consecutive participants with BPD in community treatment were naturalistically followed up over 12 months and measures of personality and social functioning were examined. Logistic regressions were used to determine which baseline factors were associated with the likelihood of being a non-responder after 12 months of psychotherapy. After 12 months, 48.4% of participants were classed as non-responders due to a lack of reduction in BPD symptoms according to the Reliable Change Index (RCI) method. RESULTS: At baseline intake, patients who endorsed an adult preoccupied attachment relationship style and increased anger were more likely to be a non-responder regarding BPD symptoms at 12 months. In addition, those with preoccupied attachment patterns in their adult relationships were more likely to be non-responders regarding general psychological distress at follow up. Higher baseline levels of paranoia and endorsement of a dismissive adult relationship style was associated with being a non-responder in regard to global functioning. CONCLUSIONS: Consistent with previous research, almost half of the sample did not achieve reliable change at 12-month follow up. A relationship style characterised by preoccupied insecurity and high anger seemed to be particularly challenging in being able to benefit from psychotherapy. This style may have affected both relationships outside, but also inside therapy, complicating treatment engagement and alliance with the therapist. Early identification and modification of treatment based on challenges from these relationship styles may be one way to improve psychotherapy outcomes for BPD.

Motives for opioid use explain the relation between borderline personality disorder pathology and opioid use problems.

Despite the established relations between borderline personality disorder (BPD) and substance use problems in general, there is a dearth of research on the relation between BPD pathology and opioid use problems, as well as factors that may explain this relation. Therefore, this study examined the indirect relations of BPD pathology to opioid use problems (i.e., prescription opioid misuse, apprehension about prescription opioid use, and opioid cravings) through motives for opioid use (i.e., coping, enhancement, social, and conformity motives) among 68 patients endorsing prescription opioid misuse in a residential correctional substance use disorder (SUD) treatment facility. Participants completed measures of BPD pathology, motives for opioid use, and opioid use problems. Findings revealed significant indirect relations of BPD pathology to opioid misuse through coping and enhancement motives, apprehension about opioid use through coping, enhancement, and social motives, and opioid cravings through coping motives within this SUD sample. Results illustrate the relevance of both emotion- and interpersonal-related motives for opioid use to opioid use problems among patients with BPD pathology in SUD treatment.

The significance of anxiety symptoms in predicting psychosocial functioning across borderline personality traits.

Emotion regulation is a central task of daily life. Difficulty regulating emotions is a core feature of borderline personality disorder (BPD), one of the most common and impairing personality disorder diagnoses. While anger and symptoms of depression are instantiated in the criteria for BPD, anxiety is not, despite being among the most common psychiatric symptoms. In a sample of online respondents (N = 471), we explored the interactions between anxiety symptoms and BPD traits in predicting well-being (WHO-5) as well as poorer work and social adjustment (WSAS), while controlling for anger and depression. We hypothesized that anxiety would lead to more impairment (i.e., lower well-being and poorer work and more difficulties with work and social adjustment) as BPD traits increased. BPD traits and symptoms of anxiety both contributed to overall lower levels well-being and higher levels of psychosocial dysfunction. However, contrary to our expectations, at higher (vs. lower) levels of BPD traits, symptoms of anxiety were less conducive to lower well-being on the WHO-5. For the WSAS, there was no consistent evidence for an interaction between BPD traits and anxiety in predicting functioning. By and large, our results do not support the idea that anxiety contributes to more impairment at higher levels of BPD traits.

Common and distinct patterns of gray matter alterations in borderline personality disorder and posttraumatic stress disorder: A dual meta-analysis.

BACKGROUND: Borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) are severe psychiatric disorders and often co-occur, either of the two will seriously threaten to public health. However, we lack ample evidences to understand the potential pathophysiologic mechanisms of gray matter (GM) alterations in the two disorders. METHODS: We performed a meta-analysis in both BPD (15 datasets including 442 BPD subjects versus 441 healthy controls) and PTSD (11 datasets including 214 PTSD subjects versus 258 healthy controls) applying anisotropic effect-size-based algorithms (AES-SDM) method. RESULTS: Conjunction analysis found relative GM volume reductions in both disorders in the orbitofrontal gyrus and anterior cingulate cortex, contrarily, differences were predominantly observed that GM volume increased in the posterior cingulate gyrus and precuneus in BPD subjects, and GM volume decreased in the amygdala-hippocampal fear circuit, fusiform gyrus in PTSD subjects. CONCLUSIONS: Group comparisons and conjunction analyses in BPD and PTSD identified same regions of GM volume reductions in the orbitofrontal gyrus and anterior cingulate cortex, which may provide clues for the neurobiological mechanisms and clinical diagnosis underpinning two disorders.

White matter pathology in patients with borderline personality disorder: A review of controlled DTI studies.

BACKGROUND: Neuroimaging, especially diffusion tensor imaging (DTI), has emerged as a helpful tool in assessing and characterizing white matter (WM) integrity. The resultant early treatment from early diagnosis is crucial because treatment is often more efficacious. Borderline personality disorder (BPD) is a challenging disorder to diagnose and treat, and has been reported to have various neurobiologic abnormalities. We conducted a search of the literature to review WM pathology findings in BPD. METHODS: A search was conducted to identify systematic reviews and meta-analyses published from January 2000 to September 2019 that assessed WM integrity in BPD. RESULTS: Four studies were included. One study demonstrated no difference in WM between BPD and healthy controls. Another study found decreased fractional anisotropy (FA) within the corpus callosum (CC) and orbitofrontal regions. A subsequent randomized controlled trial reported a decrease in FA within the fornix, CC, and right superior/anterior corona radiata with associated increase in radial diffusivity in the left anterior thalamic radiation. The fourth study found a decrease in the axial diffusivity within the cingulum, inferior longitudinal fasciculus, and inferior frontoccipital fasciculus. CONCLUSIONS: Our review concludes that BPD is associated with measurable WM pathology. Methods such as DTI might emerge as useful tools in the management of BPD. More controlled studies are needed to validate our conclusions.

In smiles we trust? Smiling in the context of antisocial and borderline personality pathology.

Research suggests that people behave more cooperatively towards those who smile and less cooperatively towards those with personality pathology. Here, we integrated these two lines of research to model the combined effects of smiles and personality pathology on trust. In two experiments, participants read vignettes portraying a person with either borderline personality disorder, antisocial personality disorder, or no personality pathology. These portrayals were paired with a brief video clip that showed a person with either a neutral expression or a smile. Participants then played a Trust game with the "person" presented using each vignette and video clip combination. In Experiment 1, rates of trust were lower in response to the borderline and antisocial personality disorder vignettes compared with the control vignette. Interestingly, the effect of smiles was dependent upon personality. Although participants were more trusting of smiling confederates portrayed as having borderline personality disorder or no pathology, they were less trusting of confederates portrayed as having antisocial personality disorder if they smiled. In Experiment 2, run with a second set of personality vignettes, rates of trust were lower in response to both personality disorder vignettes and higher in response to smiles with no significant interaction. Together, these results suggest that information regarding both the current emotional state as well as the personality traits of a partner are important for creating trust.

Brain structure and symptom dimensions in borderline personality disorder.

BACKGROUND: Borderline personality disorder (BPD) presents with symptoms across different domains, whose neurobiology is poorly understood. METHODS: We applied voxel-based morphometry on high-resolution magnetic resonance imaging scans of 19 female BPD patients and 50 matched female controls. RESULTS: Group comparison showed bilateral orbitofrontal gray matter loss in patients, but no significant changes in the hippocampus. Voxel-wise correlation of gray matter with symptom severity scores from the Borderline Symptom List (BSL-95) showed overall negative correlation in bilateral prefrontal, right inferior temporal/fusiform and occipital cortices, and left thalamus. Significant (negative) correlations with BSL-95 subscores within the patient cohort linked autoaggression to left lateral prefrontal and insular cortices, right inferior temporal/temporal pole, and right orbital cortex; dysthymia/dysphoria to right orbitofrontal cortex; self-perception to left postcentral, bilateral inferior/middle temporal, right orbitofrontal, and occipital cortices. Schema therapy-based Young Schema Questionnaire (YSQ-S2) scores of early maladaptive schemas on emotional deprivation were linked to left medial temporal lobe gray matter reductions. CONCLUSIONS: Our results confirm orbitofrontal structural deficits in BPD, while providing a framework and preliminary findings on identifying structural correlates of symptom dimensions in BPD, especially with dorsolateral and orbitofrontal cortices.

Alterations in the fronto-limbic network and corpus callosum in borderline-personality disorder.

Neuroimaging research provides evidence of grey matter changes in the prefrontal-limbic network in borderline personality disorder (BPD), yet research scarcely examines the white matter (WM) within this circuitry. The present study aimed to explore WM in prefrontal-limbic brain networks within BPD. Quantitative diffusion tensor imaging (DTI-MRI) measures of fractional anisotropy (FA) and mean diffusion (MD) were used to analyze the neural pathways in fifteen individuals with BPD (M = 25, SD = 6.76), in comparison to thirteen healthy individuals (M = 27.92, SD = 8.41). Quantitative DTI-MRI measures of FA and MD were evaluated for the cingulum, the fornix, the corpus callosum (CC), the inferior longitudinal fasciculus (ILF), the superior longitudinal fasciculus (SLF) and the uncinate fasciculus (UF). Lower FA values for both the left and the right cingulum, the genu, body, and splenium of the CC, left ILF and right SLF were found in BPD, compared to healthy individuals. MD values were higher for the genu and splenium of the CC in BPD. The findings indicate that a large-scale emotional brain network is affected in BPD with alterations in MD and FA of WM prefrontal-limbic pathways of the heteromodal association cortex involved in emotion processing and emotion regulation.

Whole-brain microstructural white matter alterations in borderline personality disorder patients.

BACKGROUND: Borderline personality disorder (BPD) is a psychiatric condition associated with the impairment of the frontolimbic network. However, a growing body of studies suggests that brain dysfunction underling BPD could involve other brain areas. We explored the whole-brain white matter (WM) organization in BPD patients to clarify the structural pattern underlying the disease and its relationship with clinical features. METHODS: Fourteen BPD patients and 14 healthy controls underwent a multidimensional clinical assessment and diffusion tensor imaging acquisition. Measures of fractional anisotropy (FA) and mean, axial and radial (RD) diffusivity were collected, and alterations in the WM were assessed using the voxelwise approach, including substance and alcohol abuse as covariates. Voxelwise regression analysis was performed to identify associations between microstructural changes and clinical feature in BPD. RESULTS: Group comparisons showed alterations only for FA and RD: FA decreased in the right posterior hemisphere, while RD increased bilaterally and widespread in anterior and posterior areas (p < 0.05, threshold-free cluster enhancement corrected). Moreover, WM alterations of the corpus callosum were related to anxiety in BPD group. DISCUSSION: Our data support the idea that structural alterations underling BPD also involve cortico-cortical pathways, corticothalamic and corticostriatal tracts, suggesting that the frontolimbic model should be reinterpreted. © 2019 John Wiley & Sons, Ltd.

Common and distinct patterns of grey matter alterations in borderline personality disorder and bipolar disorder: voxel-based meta-analysis.

BACKGROUND: Whether borderline personality disorder (BPD) and bipolar disorder are the same or different disorders lacks consistency.AimsTo detect whether grey matter volume (GMV) and grey matter density (GMD) alterations show any similarities or differences between BPD and bipolar disorder. METHOD: Web-based publication databases were searched to conduct a meta-analysis of all voxel-based studies that compared BPD or bipolar disorder with healthy controls. We included 13 BPD studies (395 patients with BPD and 415 healthy controls) and 47 bipolar disorder studies (2111 patients with bipolar disorder and 3261 healthy controls). Peak coordinates from clusters with significant group differences were extracted. Effect-size signed differential mapping meta-analysis was performed to analyse peak coordinates of clusters and thresholds (P < 0.005, uncorrected). Conjunction analyses identified regions in which disorders showed common patterns of volumetric alteration. Correlation analyses were also performed. RESULTS: Patients with BPD showed decreased GMV and GMD in the bilateral medial prefrontal cortex network (mPFC), bilateral amygdala and right parahippocampal gyrus; patients with bipolar disorder showed decreased GMV and GMD in the bilateral medial orbital frontal cortex (mOFC), right insula and right thalamus, and increased GMV and GMD in the right putamen. Multi-modal analysis indicated smaller volumes in both disorders in clusters in the right medial orbital frontal cortex. Decreased bilateral mPFC in BPD was partly mediated by patient age. Increased GMV and GMD of the right putamen was positively correlated with Young Mania Rating Scale scores in bipolar disorder. CONCLUSIONS: Our results show different patterns of GMV and GMD alteration and do not support the hypothesis that bipolar disorder and BPD are on the same affective spectrum.Declaration of interestNone.

Self-injuring adolescent girls exhibit insular cortex volumetric abnormalities that are similar to those seen in adults with borderline personality disorder.

Self-inflicted injury (SII) in adolescence is a serious public health concern that portends prospective vulnerability to internalizing and externalizing psychopathology, borderline personality development, suicide attempts, and suicide. To date, however, our understanding of neurobiological vulnerabilities to SII is limited. Behaviorally, affect dysregulation is common among those who self-injure. This suggests ineffective cortical modulation of emotion, as observed among adults with borderline personality disorder. In borderline samples, structural and functional abnormalities are observed in several frontal regions that subserve emotion regulation (e.g., anterior cingulate, insula, dorsolateral prefrontal cortex). However, no volumetric analyses of cortical brain regions have been conducted among self-injuring adolescents. We used voxel-based morphometry to compare cortical gray matter volumes between self-injuring adolescent girls, ages 13-19 years (n = 20), and controls (n = 20). Whole-brain analyses revealed reduced gray matter volumes among self-injurers in the insular cortex bilaterally, and in the right inferior frontal gyrus, an adjacent neural structure also implicated in emotion and self-regulation. Insular and inferior frontal gyrus gray matter volumes correlated inversely with self-reported emotion dysregulation, over-and-above effects of psychopathology. Findings are consistent with an emotion dysregulation construal of SII, and indicate structural abnormalities in some but not all cortical brain regions implicated in borderline personality disorder among adults.

Augmenting Psychiatric Risk Management: Practical Applications of Transference- Focused Psychotherapy (TFP) Principles.

Risk management challenges in psychiatry are made more complicated when they involve the treatment of patients with primary or co-occurring personality disorder pathology. Principles of transference-focused psychotherapy (TFP), a treatment empirically validated for borderline personality disorder (BPD) and with utility for patients with varying personality disorder presentations, are practical, commonsense measures that can guide clinicians in these difficult matters. Applied TFP principles are useful in this area even when clinicians are not engaged in an extended individual psychotherapy. Central to the TFP approach are: (1) an openness to identifying personality disorder pathology; (2) a deliberate process to assess personality disorder diagnoses with attention to severity of illness; (3) an emphasis on the informed consent process, which includes sharing fully with the patient the clinician's diagnostic impression with germane psychoeducation; (4) an expectation for timely contacts at the outset of treatment with prior practitioners and with family members, when indicated; and (5) the development and maintenance of a treatment frame. TFP stresses the active monitoring of three channels of communication (what the patient says, how the patient behaves, and the clinician's countertransference) as a guiding precept that informs clinical decision-making. TFP principles can serve as a useful risk management "checklist" by organizing a clinician's approach to inherently confounding material.