Referential Activity Differentially Mediates Expression of Positive and Negative Emotions in Borderline Personality Disorder.

Borderline Personality Disorder (BPD) is a high risk and prevalent personality disorder that is associated with increased negative emotions, decreased positive emotions, and impairments in symbolization and impaired reflective functioning. These dimensions, while they may impact one another, have not been investigated concurrently from qualitative, linguistic narratives. We hypothesized a BPD group would have lower expression of positive emotions and greater expression of negative emotions and less reflective function than healthy controls. Additionally, we explored the role of referential activity (an index of symbolic capacity) between BPD and healthy controls in the context of valenced emotional expression. An adult, female BPD group (n = 13) and a demographically matched healthy control group (n = 14) were recruited and administered the Adult Attachment Interview and/or the Object Relations Inventory. Computerized text analyses were used to assess positive emotion and negative emotion, the Weighted Referential Activity Dictionaries to assess referential activity, and the Computerized Reflective Function dictionary. On the Object Relations Inventory, the BPD group expressed more frequent negative emotions and less frequent positive emotions; on the Adult Attachment Interview, the BPD group exhibited less expression of positive emotions. There were no differences between BPD and controls on referential activity or reflective functioning on either interview. However, BPD status fully mediated the significant relationship between referential activity and negative emotion expression. The BPD group utilized more referential activity when expressing negative emotions than controls. Conversely, the control group utilized more referential activity when expressing positive emotions than controls. Referential activity seems to play an important role in explaining the BPD versus control difference in valenced linguistic emotional expression. Furthermore, these results suggest the object relations inventory elicits more robust linguistic features relevant to BPD.

Emotional Processes in Borderline Personality Disorder: An Update for Clinical Practice.

Despite prior assumptions about poor prognosis, the surge in research on borderline personality disorder (BPD) over the past several decades shows that it is treatable and can have a good prognosis. Prominent theories of BPD highlight the importance of emotional dysfunction as core to this disorder. However, recent empirical research suggests a more nuanced view of emotional dysfunction in BPD. This research is reviewed in the present article, with a view towards how these laboratory-based findings can influence clinical work with individuals suffering from BPD.

Interpersonal Trust and Borderline Personality Disorder: Insights From Clinical Practice and Research: Introduction.

Individuals suffering from borderline personality disorder (BPD) show a pervasive sense that others cannot be trusted, are vulnerable to negative therapeutic reactions, and can oscillate between idealized and persecutory interactions with others. These trust processing impairments impact both the immediate and wider social milieu of individuals with BPD, including therapist-patient interactions. Recently, research started unraveling the social-cognitive mechanisms of these impairments in BPD. In this Special Issue, we attempt to close the gap between research findings and clinical theories on trust processing impairment in BPD. The first section includes five original studies on trust processing in BPD. The second section includes five articulations of trust processing impairment as a treatment target in evidence-based treatments for BPD and as an indispensable "common factor" in the treatment of BPD. These cutting-edge research and clinical contributions advance a potential integrative, clinical science framework for conceptualizing and intervening effectively with those who struggle with BPD.

Atypical Neural Plasticity and Behavioral Effects of Trustworthiness Learning in Borderline Personality Disorder Features.

This study distinguishes interpersonal trust learning with a novel trust learning paradigm in participants high (H-BPD) and low (L-BPD) in BPD features. Neutral faces were paired with trust-relevant behaviors in four conditions: trustworthy, untrustworthy, ambiguously trustworthy, and mixed trustworthiness. After training, participants rated faces on untrustworthiness as electroencephalographic measures were recorded. H-BPD rated neutral faces as significantly more untrustworthy than L-BPD at both time periods. Negative and ambiguous trustworthiness pairing conditions led to higher ratings of untrustworthiness, whereas trustworthy and mixed descriptors led to lower ratings of untrustworthiness. Learning enhanced the amplitude of an early sensory event-related potential (ERP) component (i.e., P1) for both groups. The slow-wave ERP, an index of sustained attention, revealed greater focus after learning to trustworthy descriptors in H-BPD and to untrustworthy descriptors in L-BPD. H-BPD utilized greater effort to overcome an inherent mistrust bias and L-BPD to overcome unexpected untrustworthy information.

Transference-Focused Psychotherapy and Trust Processing in BPD: Exploring Possible Mechanisms of Change.

Individuals with borderline personality disorder (BPD) struggle to identify whom they can safely trust, and this struggle contributes to profound emotional turmoil in their close relationships. Transference-focused psychotherapy (TFP) is an application of object relations theory (ORT) that posits that polarized mental representations of self and other define the personality organization of BPD. TFP aims to utilize a clear treatment frame coupled with an analysis of the therapeutic relationship (i.e., the transference) to help individuals with BPD integrate their polarized mental representations. Improvement in the capacity to trust others is inherent in the mechanisms of change in TFP. In this article, a social cognitive model of trust processing provides a new lens through which we formulate how TFP may enhance trust processing in BPD. Recent evidence from randomized clinical trials supports the argument that TFP may intervene with BPD in a way that is concordant with uniquely improved trust processing.

Evaluating Change in Transference, Interpersonal Functioning, and Trust Processes in the Treatment of Borderline Personality Disorder: A Single-Case Study Using Ecological Momentary Assessment.

Transference-focused psychotherapy (TFP) is an empirically supported treatment for borderline personality disorder (BPD) that improves functioning via targeting representations of self affectively relating to others, particularly as evoked in the therapeutic relationship. If change in TFP operates as theorized, then shifts in patterns of "self affectively relating to others" should be observed in the transference prior to shifts in daily relationships. Using ecological momentary assessment (EMA), a patient with BPD rated daily interpersonal events for 2-week periods during 18 months of TFP; at 9 and 18 months these ratings included interactions with the therapist. Results suggest that positive perceptions of her therapist that ran counter to her negatively biased perception in other relationships preceded changes in her perceptions of others. EMA shifts corresponded to improvements in self-reported symptoms, interview-based personality functioning, and therapist assessments. Implications for assimilation of a trusting experience with the therapist as a mechanism of change in TFP are discussed.

Identifying Splitting Through Sentiment Analysis.

In Kernerg's Object Relations Theory model of personality pathology, splitting, the mutual polarization of aspects of experience, is thought to result in a failure of identity integration. The authors sought to identify a clinician-independent, automated measure of splitting by examining 54 subjects' natural speech. Splitting in these individuals, recruited from the community, was investigated and evaluated with a shortened version of the Structured Interview of Personality Organization (STIPO-R). A type of automated sentiment textual analysis called VADER was applied to transcripts from the section of the STIPO-R that probes identity integration. Higher variability in speech valence, more negative minimum valence, and more frequent shifts in valence polarity were associated with more severe identity disturbance. The authors concluded that the degree of splitting elicited during the description of self and others is related to the degree of identity disturbance, and to the degree of negativity and instability of these descriptions of self and others.

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.

Higher executive control and visual memory performance predict treatment completion in borderline personality disorder.

BACKGROUND: Non-completion of a prescribed course of treatment occurs in 20-60% of individuals diagnosed with borderline personality disorder (BPD). While symptom severity, personality traits and environmental factors have been implicated as predictors of treatment non-completion (TNC), there have been no studies of neuropsychological predictors in this population. METHODS: From a randomized controlled trial, a subsample of 31, unmedicated outpatients diagnosed with BPD with recent self-injurious behavior was assessed on 5 neuropsychological domains. Patients were also assessed for general IQ, demographic and other salient clinical variables. Patients were randomized to one of four treatment conditions, which lasted up to 1 year. Number of weeks in treatment (WIT) up to 1 year was utilized as the index of TNC. RESULTS: Thirty-three percent of the subsample (n = 12) did not complete 1 year of treatment. However, more WIT were predicted by better baseline executive control (Trails B; p < 0.01) and visual memory performance (Benton visual retention; p < 0.001); other neuropsychological domains did not predict WIT. CONCLUSION: In the treatment of outpatients with BPD, better executive control and visual memory performance predict more WIT. Assessing and addressing these neurocognitive factors in treatment may reduce TNC in this high-risk population.

Development and criterion validity of a computerized text analysis measure of reflective functioning.

The Reflective Functioning scale (RF) is a narrative-based assessment of the capacity to coherently conceptualize one's own and others' subjective motivations, emotions, beliefs, and desires. We report the preliminary results of an effort to develop a computerized text analysis version (CRF) of the RF assessment system. A sample of 113 clinical and non-clinical Adult Attachment Interviews (AAI) were utilized to develop the CRF measure. Using the Marker Approach (Mergenthaler & Bucci, 1999), 54 linguistic markers of high RF language were identified. The associations between CRF and RF were significant in both a clinical sample of patients diagnosed with Borderline Personality Disorder (BPD) (Spearman rho=.57, p<.0001) and a non-clinical sample of adults (Spearman rho=.57, p=.002). These results suggest that a CRF rating scale is feasible, has preliminary criterion validity, and, therefore, has potential to facilitate the efficient assessment of RF.

A unifying translational framework to advance treatment research for comorbid PTSD and substance use disorders.

We provide a unifying translational framework that can be used to synthesize extant lines of human laboratory research in four neurofunctional domains that underlie the co-occurrence of posttraumatic stress and substance use disorders (PTSD+SUD). We draw upon the Alcohol and Addiction Research Domain Criteria (AARDOC) to include executive functioning, negative emotionality, reward, and added social cognition from the National Institute of Mental Health (NIMH) Research Domain Criteria into our framework. We review research findings across each of the four domains, emphasizing human experimental studies in PTSD, SUD, and PTSD+SUD for each domain. We also discuss the implications of research findings for treatment development by considering new ways of conceptualizing risk factors and outcomes at the level of the individual patient, which will enhance treatment matching and advance innovations in intervention.

Hypothalamic-pituitary-adrenal axis functioning in borderline personality disorder: A meta-analysis.

Borderline Personality Disorder (BPD) has been associated with altered hypothalamic-pituitary-adrenal (HPA) axis functioning. However, evidence is inconsistent. Therefore, the present series of meta-analyses aimed to quantify HPA axis functioning in BPD patients based on singular and continuous cortisol assessments and measures of reactivity to pharmacological and psychosocial stress. Case-control studies comparing adult BPD patients and healthy and clinical controls were considered for inclusion. The search resulted in 804 publications, of which 37 studies (k = 81; BPD n = 803, controls n = 1092) were included. Analyses were based on random effect models using standardized mean differences. BPD patients displayed elevated continuous cortisol output and blunted cortisol following psychosocial challenges. Singular cortisol assessments and cortisol after pharmacological challenges were not significantly different. Meta-analyses were limited by inconsistent reporting in individual studies and small samples for some comparisons. Due to the debilitating nature of stress-related symptoms in BPD, more research on elevated continuous cortisol output and blunted cortisol responses to psychosocial stress is warranted.

Trustworthiness appraisal deficits in borderline personality disorder are associated with prefrontal cortex, not amygdala, impairment.

BACKGROUND: Borderline Personality Disorder (BPD) is associated with sensitivity to signals of interpersonal threats and misplaced trust in others. The amygdala, an integral part of the threat evaluation and response network, responds to both fear- and trust-related stimuli in non-clinical samples, and is more sensitive to emotional stimuli in BPD compared to controls. However, it is unknown whether the amygdalar response can account for deficits of trust and elevated sensitivity to interpersonal threat in BPD. METHODS: Facial stimuli were presented to 16 medication-free women with BPD and 17 demographically-matched healthy controls (total n = 33). Participants appraised fearfulness or trustworthiness of the stimuli while BOLD fMRI was obtained. RESULTS: Though BPD participants judged stimuli as less trustworthy compared to controls, trustworthiness did not correlate with amygdalar activity in either group. Trustworthiness correlated with prefrontal regional activity in the insula and lateral prefrontal cortex. Prefrontal BOLD activity while appraising trustworthiness was smaller in BPD compared to controls, and the size of the reduction was proportional to each participant's response bias. CONCLUSIONS: Neural substrates of trustworthiness appraisal are associated with the lateral prefrontal cortex and insula, not amygdala, suggesting that untrustworthy stimuli do not elicit a subcortical threat response. Current models of BPD and its treatment may need to include a focus on improving impairments in frontally mediated trustworthiness appraisal in addition to amygdala- driven emotional hyper-reactivity.

Social Cognition and Borderline Personality Disorder: Splitting and Trust Impairment Findings.

The Borderline personality disorder (BPD) diagnosis has its origins in the concept of borderline personality organization (BPO). BPO is rooted in psychoanalytic object relations theory (ORT) which conceptualizes BPD and BPO to exhibit a propensity to view significant others as either idealized or persecutory (splitting) and a trait-like paranoid view of interpersonal relations. From the ORT model, those with BPD think that they will ultimately be betrayed, abandoned, or neglected by significant others, despite periodic idealizations. This article synthesizes the extant literature splitting and trust impairments in BPD, identifies avenues for further investigation, and discusses the relative promise of different methods to evaluate these clinical processes.

Regulation of threat in post-traumatic stress disorder: Associations between inhibitory control and dissociative symptoms.

The current study investigated links between trauma exposure, Post-traumatic Stress Disorder (PTSD) symptoms, and inhibitory control assessed using a modified version of the visual flanker task. The study had three aims: (1) specifically confirm general non-affective deficits in sustained attention in PTSD; (2) probe the influence of threatening and trauma-related stimuli on inhibitory control; and (3) explore neural correlates connecting PTSD, facets of dissociation, and inhibitory control. Participants with PTSD (n = 16), trauma-exposed individuals without PTSD (TE; n = 14), and healthy controls (n = 15) discriminated line orientations while ignoring temporally flanking lines and images depicting threatening or non-threatening scenes or faces. Electrophysiological recordings were made during task performance. Relative to TE participants, PTSD participants had poor sustained non-affective attention, but nevertheless exhibited greater inhibition of distractors (i.e., high event-related potential [ERP] Rejection Positivity [RP]) to threatening (versus non-threatening) stimuli. RP was associated with greater self-reported depersonalization in PTSD participants, but with less depersonalization in TE participants. Dipole source analysis localized RP to the posterior cingulate cortex in both PTSD and TE (and healthy controls), but with an additional source in the ventromedial prefrontal cortex in TE, components of the default mode network. Results suggest a paradox in the executive control of distraction in PTSD: Whereas individuals with PTSD experience a general impairment in non-affective inhibitory control, their enhanced control of threat is associated with more severe symptoms of dissociation.

Review of Evidence-based Psychotherapy: Where Theory and Practice Meet.

Reviews the book, Evidence-based Psychotherapy: Where Theory and Practice Meet edited by Carol D. Goodheart, Alan E. Kazdin, and Robert J. Sternberg (see record 2006-02969-000). The distinguished editors and authors of Evidence-Based Psychotherapy: Where Theory and Practice Meet have created an intellectual atmosphere in the book that paves the way for generative development of evidence-based practice (EBP) in psychotherapy in the future. The book is organized into three sections: 1) "The Practice Perspective," 2) "The Research Perspective," and 3) "Training, Policy, and Cautions." This book is an important addition to the debate on EBP in psychotherapy and highlights issues that extend well beyond the role of psychotherapy in EBP. It is highly recommended for practitioners and researchers alike and is likely to invite thoughtful questioning and reflection on core assumptions at both ends of the spectrum. Moreover, the book would serve as a useful primer on the issues germane to EBP in psychotherapy training for graduate students and psychiatric residents. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Romantic relationship dysfunction in borderline personality disorder-a naturalistic approach to trustworthiness perception.

Patients with borderline personality disorder (BPD) suffer greatly from their unstable interpersonal relationships. Studies on explanatory mechanisms driving social dysfunctions in patients' real-life relationships are, however, lacking. Here, we aimed to investigate one of the most central aspects of close relationships, interpersonal trust, in romantic relationships of persons with BPD. We tested the hypothesis that patients with BPD show unstable trustworthiness perception toward their partner, which we expected to be most pronounced after a relationship-threatening situation. Thirty-one heterosexual couples in which the women were diagnosed with BPD and 36 healthy control (HC) couples (total N = 134) each discussed three different topics that where (a) neutral (favorite films), (b) personally threatening (personal fears), and (c) relationship threatening (possible reasons for separation from partner). Trustworthiness appraisal of the partner was assessed after each conversation by self-report. BPD patients did not differ from HC women on trustworthiness perception after the neutral conversation but reported diminished trustworthiness perception after both threatening situations compared to HCs. BPD patients' trustworthiness perception was by trend decreased after the separation versus fear condition. The perceived tenderness in the relationship was a protective factor. The inability to maintain a stable image of a trustworthy partner during threatening situations might lead to difficulties in interpersonal relationships of patients with BPD. Although relationship threats possibly play a particular role in this context, trustworthiness perception decreases are not limited to this kind of threat. (PsycINFO Database Record

Executive neurocognition, memory systems, and borderline personality disorder.

Borderline Personality Disorder (BPD) is a common, disabling, and burdensome psychiatric condition. It is characterized by turbulent fluctuations of negative emotions and moods, unstable and conflictual interpersonal relationships, an incoherent and often contradictory sense of self, and impulsive, potentially lethal self-injurious behaviors. The neurobehavioral facets of BPD have not been extensively studied. However, clinical theoreticians and researchers have proposed that the symptoms and behaviors of BPD are, in part, associated with disruptions in basic neurocognitive processes. This review summarizes and evaluates research that has investigated the relationship between executive neurocognition, memory systems, and BPD. Three historical phases of research are delineated and reviewed, and the methodological and conceptual challenges this body of investigation highlights are discussed. Laboratory-based assessment of executive neurocognition and memory systems is integral to an interdisciplinary approach to research in BPD. Such an approach holds promise in elucidating the neurobehavioral facets, development, diagnostic boundaries, prevention, and optimal interventions for this debilitating and enigmatic disorder.

The impact of borderline personality disorder and anxiety on neuropsychological performance in major depression.

Previous studies of neuropsychological performance in borderline personality disorder (BPD) have exhibited mixed results. The high rate of co-occurring major depressive disorder (MDD) in BPD makes it difficult to specify whether neuropsychological deficits in BPD predominantly reflect co-occurring MDD or unique aspects of their psychopathology. To address this issue, 22 participants with borderline personality disorder and concurrent major depressive disorder (BPD-MDD) and 33 participants with MDD and no concurrent personality disorder were compared on a neuropsychological battery that assessed seven domains of performance: general intellectual functioning, motor skill, psychomotor speed, attention, memory, working memory, and executive function. Neuropsychological performance did not differ between BPD-MDD and MDD. However, BPD-MDD participants reported higher levels of anger, anxiety, and of overall emotional distress compared to MDD. When levels of anxiety were controlled, BPD-MDD participants exhibited superior general intellectual performance, psychomotor speed, and attention. Deficits found in previous BPD samples may reflect their susceptibility to co-occurring MDD. The impact of anxiety on neuropsychological performance in BPD, though, indicates a need for future experimental studies of the effects of mood on cognitive function to determine whether mood dysregulation, rather than core depressive symptoms, underlie cognition impairments in BPD.

Impulsivity, suicidality and alcohol use disorders in adolescents and young adults with borderline personality disorder.

Borderline Personality Disorder (BPD) is a severe and disabling psychiatric condition that typically emerges in late adolescence or early adulthood. Nearly 50% of individuals with BPD have a co-occurring Alcohol Use Disorder (AUD) at some point in the course of their illness. This study explores clinical characteristics of adolescents and young adults (age 30 years and younger) with BPD and AUD (N=21) compared to BPD without any history of substance use disorders (N=17). Based on theoretical considerations and previous findings, we hypothesized that adolescents and young adults with BPD and AUDs would be more impulsive and exhibit higher rates of suicidal behavior than individuals with BPD and no substance use disorders. Consistent with our first hypothesis, the BPD/AUD group was more impulsive than the BPD only group. However, the two groups did not differ on measures of suicidal behavior. Overall, impulsivity was correlated with total number of suicide attempts in the adolescent/young adult group. When older BPD participants were included in the comparison (up to age 55), the BPD/AUD group exhibited more lifetime suicide attempts that were higher in medical lethality than the BPD only group, suggesting an overall increased lifetime suicide risk in the BPD/AUD group. The relationship between impulsivity, AUD, and suicidal behavior and lifetime suicide risk in adolescent and young adults with BPD is discussed.