Borderline personality disorder from the perspective of general personality functioning

The authors extended previous work on the hypothesis that borderline personality disorder (BPD) can be understood as a maladaptive variant of personality traits included within the 5-factor model (FFM) of personality. In each of 3 samples, an empirically derived prototypic FFM borderline profile was correlated with individuals' FFM profiles to yield a similarity score, an FFM borderline index. Results across all samples indicated that the FFM borderline index correlated as highly with existing borderline measures as they correlated with one another, and the FFM borderline index correlated as highly with measures of dysfunction, history of childhood abuse, and parental psychopathology as did traditional measures of BPD. Findings support the hypothesis that BPD is a maladaptive variant of FFM personality traits.     

Do deficits in mindfulness underlie borderline personality features and core difficulties?

The current study investigated whether deficits in mindfulness (the awareness, attention, and acceptance of the present moment) can account for variability in borderline personality (BPD) features and characteristic difficulties in emotion regulation, interpersonal effectiveness, and impulsivity. Structural equation modeling and hierarchical regressions were utilized to examine the associations of trait mindfulness with BPD features, interpersonal problem-solving, impulsive and passive emotion-regulation strategies, and neuroticism in a sample of young adults (N = 342). As hypothesized, mindfulness was related inversely to BPD features and core areas of difficulty, and these associations continued even when controlling for neuroticism. Additionally, mindfulness deficits continued to predict borderline features even when interpersonal effectiveness, passive and impulsive emotion-regulation, and neuroticism were controlled. It is concluded that deficits in mindfulness may be integral to BPD features. Difficulties with attention, awareness, and acceptance of internal and external experience appear to explain borderline pathology even when controlling for problems with negative affectivity, behavioral dyscontrol, and emotional and interpersonal dysfunction--which have been described as definitional of this disorder. Thus, attention to mindfulness deficits may enhance clinical formulation of BPD symptomatology, as well as provide a vital component of effective BPD treatment.     

Hypermentalizing in Borderline Personality Disorder: A Model and Data

Interpersonal difficulties are a widely accepted characteristic of borderline personality disorder (BPD). However, the results of empirical findings of deficits in social-cognitive abilities that may underlie interpersonal difficulties in this population have been mixed. In this paper, we review the literature on social-cognitive impairment in BPD by organizing studies based on patterns of positive and negative of findings. We provide a new model of mentalizing impairment in BPD by integrating findings into one framework that suggests hypermentalizing as the core feature of social-cognitive impairment in BPD. We review data in support of a hypermentalizing model of BPD and situate this data in the broader context of current work on hypermentalizing.     

From negative to positive and back again: Polarized affective and relational experience in borderline personality disorder

A core feature of borderline personality disorder (BPD) is the tendency to evaluate one's experience with extreme polarity (i.e., feeling all good or all bad; Beck, Freeman, & Davis, 2004; Kernberg, 1975; Linehan, 1993). In this investigation, we examined the polarity of within-person reports of experience in individuals with BPD and healthy adults over the course of a 21-day, experience-sampling diary. We applied multilevel modeling techniques (Rafaeli, Rogers, & Ravelle, 2007) to capture the within-person covariance of momentary reports of negative and positive features of experience, either affective or relational. Our data indicated significantly greater polarity in reports of affective and relational experiences in BPD that increased during heightened interpersonal stress. We also examined the association of affective and relational polarity to reports of impulsive behaviors (e.g., self-injury, substance use, etc.) and found evidence that increased polarity in reports of affective (in low-stress contexts) and relational experiences (in high-stress contexts) predicted increased rate of reports of impulsive behaviors. Together, these data present strong evidence for the role of polarized experiences in BPD, and have implications for the treatment of individuals with this disorder. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

Inter-rater and test-retest reliability of the Revised Diagnostic Interview for Borderlines

The baseline inter-rater reliability, test-retest reliability, follow-up inter-rater reliability, and follow-up longitudinal reliability (interrater reliability between generations of raters) of borderline symptoms and the diagnosis of borderline personality disorder (BPD) were assessed using the Revised Diagnostic Interview for Borderlines (DIB-R). Excellent kappa s (> .75) were found in each of these reliability substudies for the diagnosis of BPD itself. Excellent kappa s were also found in each of the three inter-rater reliability substudies for the vast majority of borderline symptoms assessed by the DIB-R. Test-retest reliability for these symptoms was somewhat lower but still very good. More specifically, one-third of the BPD symptoms assessed had a kappa in the excellent range and the remaining two-thirds had a kappa in the fair-good range (.57-.73). The dimensional reliability of BPD symptom areas was somewhat higher than for categorical measures of the subsyndromal phenomenology of BPD. More specifically, all five dimensional measures of borderline psychopathology had intraclass correlation coefficients in the excellent range for all four reliability substudies. Taken together, the results of this study suggest that both the borderline diagnosis and the symptoms of BPD can be diagnosed reliably when using the DIB-R. They also suggest that excellent reliability, once achieved, can be maintained over time for both the syndromal and subsyndromal phenomenology of BPD.     

Relational Aggression in Women during Emerging Adulthood: A Social Process Model

Two studies investigated potential mediators of the association between relational victimization and relational aggression. Self-report measures of aggressive behavior among peers, exclusivity, hostile attribution biases, and borderline personality disorder (BPD) symptoms were collected. In study 1, participants were 180 female emerging adults (M = 18.82, SD = 1.18). Both exclusivity and hostile attribution biases for relational provocations were found to partially mediate the association between relational victimization and relational aggression. In study 2, participants were 54 female emerging adults (M = 19.16, SD = 1.11). Symptoms of BPD were not found to mediate the association between relational victimization and relational aggression, yet unique associations with relational aggression were observed. The results add to recent research guided by a social process model in which links between victimization and aggression are more clearly understood. Copyright © 2011 John Wiley & Sons, Ltd.     

Alliance rupture and repair processes in borderline personality disorder: A case study using dialogical sequence analysis

Objective: This study examined alliance rupture and repair processes in borderline personality disorder (BPD) and how the content of sessions interacts with the quality of the alliance.

Design: A mixed methods single case study design was employed incorporating quantitative and qualitative measures of process and outcome.

Methods: This case study examined a 22-year-old female with BPD who received 16 sessions of Cognitive Analytic Therapy. Measures of alliance, symptoms and global functioning were taken across multiple time-points. Selected sessions were analysed using dialogical sequence analysis (DSA), a theory-driven method of psychotherapy research that analyses utterances according to their author, addressee and referential object.

Results: Quantitative data indicated symptom reduction without functional improvement. DSA demonstrated that the first exchanges in therapy were reflective of key relational themes. The case suggests that, rather than simply negotiating tasks and goals, repairing ruptures involves systematically linking the manifest topic to the client’s core problems.

Conclusions: This case study points to the mediating role that the content of sessions has on alliance quality. Results underline the importance of the therapist stance, the need for a shared formulation to make sense of relational processes and the use of responsively timed interventions to decrease desperation and improve self-reflection.     

Ferenczi’s Concept of Identification with The Aggressor: Understanding Dissociative Structure with Interacting Victim and Abuser Self-States

No one has described more passionately than Ferenczi the traumatic induction of dissociative trance with its resulting fragmentation of the personality. Ferenczi introduced the concept and term, identification with the aggressor in his seminal “Confusion of Tongues” paper, in which he described how the abused child becomes transfixed and robbed of his senses. Having been traumatically overwhelmed, the child becomes hypnotically transfixed by the aggressor’s wishes and behavior, automatically identifying by mimicry rather than by a purposeful identification with the aggressor’s role. To expand upon Ferenczi’s observations, identification with the aggressor can be understood as a two-stage process. The first stage is automatic and initiated by trauma, but the second stage is defensive and purposeful. While identification with the aggressor begins as an automatic organismic process, with repeated activation and use, gradually it becomes a defensive process. Broadly, as a dissociative defense, it has two enacted relational parts, the part of the victim and the part of the aggressor. This paper describes the intrapersonal aspects (how aggressor and victim self-states interrelate in the internal world), as well as the interpersonal aspects (how these become enacted in the external). This formulation has relevance to understanding the broad spectrum of the dissociative structure of mind, borderline personality disorder, and dissociative identity disorder.     

A Developmental Neuroscience of Borderline Pathology: Emotion Dysregulation and Social Baseline Theory

Theoretical and empirical research has linked poor emotion regulation abilities with dysfunctional frontolimbic circuitry. Consistent with this, research on borderline personality disorder (BPD) finds that frontolimbic dysfunction is a predominant neural substrate underlying the disorder. Emotion regulation is profoundly compromised in BPD. However, BPD is also associated with broad impairment across multiple domains, including impulse control, interpersonal relationships, and cognitive functioning. To date, BPD research has focused largely on single areas of dysfunction, failing to account for overlap at either the biological or behavioral levels of analysis. We examine the literature on frontolimbic dysfunction in BPD within the context of Coan’s social baseline theory. Social baseline theory proposes that healthy human functioning is dependent upon adequate social support and that, at baseline, biological systems are adapted to operate interdependently rather than independently. The social baseline perspective is particularly useful for understanding borderline personality development because the impulsive and emotionally dysregulated behaviors common among those with BPD occur almost invariably within an interpersonal context. We discuss clinical and research implications of this work.     

Can negative attitudes toward patients with borderline personality disorder be changed? The effect of attending a STEPPS workshop

We sought to determine whether negative attitudes toward patients with borderline personality disorder (BPD) can be modified through education. Mental health clinicians attended a 1-day workshop on the Systems Training for Emotional Predictability and Problem Solving (STEPPS) group treatment program for BPD. A questionnaire to assess attitudes towards BPD was given to 271 clinicians before and after the workshop. Following the workshop, clinicians endorsed having significantly greater empathy toward patients with BPD, and having greater awareness of the distress and low self-esteem associated with the disorder. Significant improvement was seen in the clinicians' attitudes toward patients with BPD and their desire to work with them. Clinicians were significantly less likely to express dislike for BPD patients. They also reported feeling more competent in their ability to treat these patients. The study offers preliminary evidence that negative attitudes toward patients with BPD can be modified through education.     

Transference Focused Psychotherapy for Patients with Comorbid Narcissistic and Borderline Personality Disorder

Clinical experience involving the treatment of patients with comorbid borderline and narcissistic personality disorders suggests that this patient population is among the more difficult to treat within the personality disorder spectrum. In this article, we present refinements of Transference Focused Psychotherapy (TFP) based on our clinical experience with and research data on patients with comorbid narcissistic personality disorder/borderline personality disorder (NPD/BPD). We briefly review object relations formulations of severe narcissistic pathology, as well as recent research in attachment and the allied concept of mentalization, which have provided a new lens through which to view narcissistic disorders. The research findings from two randomized clinical trials demonstrating the efficacy and effectiveness of TFP are presented. The data from the two Randomized Clinical Trials (RCT) allowed for the study of the characteristics of the subgroup of borderline personality disorder patients who have comorbid NPD/BPD. Findings on comorbidity, attachment status, capacity for mentalization, and level of personality organization of borderline patients with comorbid NPD/BPD, compared with borderline patients without comorbid narcissistic pathology (BPD), are presented. Clinical implications of the observed group differences are discussed, with a focus on refinements in the technique of TFP. Clinical case material is presented to illustrate the specific challenges posed by narcissistic patients to carrying out TFP in each phase of treatment.     

Narrative self-appropriation: embodiment,alienness, and personal responsibility in the context of borderline personality disorder

It is often emphasised that persons diagnosed with borderline personality disorder (BPD) show difficulties in understanding their own psychological states. In this article, I argue that from a phenomenological perspective, BPD can be understood as an existential modality in which the embodied self is profoundly saturated by an alienness regarding the person’s own affects and responses. However, the balance of familiarity and alienness is not static, but can be cultivated through, e.g., psychotherapy. Following this line of thought, I present the idea that narrativising experiences can play an important role in processes of appropriating such embodied self-alienness. Importantly, the notion of narrative used is that of a scalar conception of narrativity as a variable quality of experience that comes in degrees. From this perspective, narrative appropriation is a process of gradually attributing the quality of narrativity to experiences, thereby familiarising the moods, affects, and responses that otherwise govern ‘from behind’. Finally, I propose that the idea of a narrative appropriation of embodied self-alienness is also relevant to the much-debated question of personal responsibility in BPD, particularly as this question plays out in psychotherapeutic contexts where a narrative self-appropriation may facilitate an increase in sense of autonomy and reduce emotions of guilt and shame.     

Affect Dysregulation in Individuals With Borderline Personality Disorder: Persistence and Interpersonal Triggers

We hypothesized that affect dysregulation among individuals with borderline personality disorder (BPD) would involve greater persistence of negative affect between interpersonal events and heightened reactivity to stimuli indicating risk of rejection or disapproval, specifically perceptions of others’ communal (agreeable-quarrelsome) behaviors. A total of 38 participants with BPD and 31 controls collected information about affect and perceptions of the interaction partner's behavior during interpersonal events for a 20-day period. Negative and positive affect persisted more across interpersonal events for individuals with BPD than for controls. In addition, individuals with BPD reported a greater increase in negative affect when they perceived less communal behavior and a smaller increase in positive affect when they perceived more communal behavior in others. Findings indicate the importance of interpersonal perceptions in the affect dysregulation of individuals with BPD.     

A systematic review of the evidence-based psychosocial risk factors for understanding of borderline personality disorder

Borderline personality disorder (BPD) is a serious personality disorder characterized by affective instability, impulsivity and interpersonal disturbance. Currently, intensive research is being conducted concerning the aetiology of BPD, including research on neurobiological, temperamental, psychosocial and cultural risk factors. This study focuses on psychosocial risk factors while other risk factors are taken into account in the discussion of the development of BPD. To our knowledge, no systematic review of the evidence-based medicine literature concerning this theme has been made thus far. However, understanding psychosocial risk factors of BPD is important in order to develop psychotherapeutic treatment models and methods. We provide a systematic review of the literature focusing on psychosocial risk factors for BPD. Utilizing this knowledge, we discuss how these data may be used when studying the development of borderline personality disorder and the treatment of borderline personality disorder.     

Borderline psychopathology in the first-degree relatives of borderline and axis II comparison probands

The purpose of this study was to assess the prevalence of each of the nine DSM criteria for borderline personality disorder and the prevalence of the disorder itself in the first-degree relatives of borderline probands and Axis II comparison subjects. Four hundred and forty-five inpatients were interviewed about familial borderline psychopathology using the Revised Family History Questionnaire--a semistructured interview of demonstrated reliability. Of these 445 subjects, 341 met both DIB-R and DSM-III-R criteria for BPD and 104 met DSM-III-R criteria for another type of personality disorder (and neither criteria set for BPD). The psychopathology of 1,580 first-degree relatives of borderline probands and 472 relatives of Axis II comparison subjects was assessed. Both DSM-III-R and DSM-IV BPD were found to be more common among the relatives of borderline than Axis II comparison probands. However, five of the criteria for BPD (inappropriate anger, affective instability, paranoia/dissociation, general impulsivity, and intense, unstable relationships) and all four sectors of borderline psychopathology (affect, cognition, impulsivity, and interpersonal relationships) were found to be both more common and discriminating than the BPD diagnosis itself. Taken together, the results of this study suggest that the subsyndromal phenomenology of BPD may be more common than the borderline diagnosis itself.     

Directed forgetting of emotional stimuli in borderline personality disorder

On the basis of clinical literature, the authors hypothesized that individuals with borderline personality disorder (BPD) would show biased information processing when they were exposed to negative affective stimuli of a particular type. Individuals with BPD and controls were tested using a directed forgetting paradigm. Study participants were exposed to 3 types of words (borderline, neutral, positive) and were cued to either remember or forget each word as it was presented. There were no group differences on a free recall task for words in the remember condition. However, participants with BPD recalled significantly more of the borderline words from the forget condition than did controls. In other words, borderline participants remembered borderline words that they were instructed to forget. These results may be consistent with enhanced encoding of salient words and perhaps related themes in BPD individuals.     

Borderline Personality Disorder and Posttraumatic Stress Disorder: Time for Integration?

The increasing prevalence of borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) diagnoses among women illustrates problems and limitations of the medical model system (Diagnostic and Statistical Manual of Mental Disorders, fourth edition; American Psychiatric Association, 1994). In particular, diagnoses of BPD continue the trend of overpathologizing women's issues and reinforcing a patriarchal system of diagnosis and treatment. A PTSD diagnosis, with similar criteria, is preferred for traumatized women because it portrays them in a more positive context. This article explores the overlapping relationship between BPD and PTSD and critiques how both are viewed within the mental health community. Previous research on BPD and PTSD is explored, as well as concerns and limitations regarding both diagnostic categories.     

The Relation between Mind‐mindedness in Mothers with Borderline Personality Disorder and Mental State Understanding in their Children

This study investigated relations between mind‐mindedness in mothers with borderline personality disorder (BPD) and mental state understanding in their children. Participants were 20 mothers with BPD and 19 mothers without personality disorder and their children, aged 39–61 months. Children's mental state understanding was examined via a battery of theory of mind and emotion labelling tasks. Maternal mind‐mindedness was assessed by mothers' use of mental state references to describe their children relative to other attributes. Maternal BPD was associated with fewer references to children's mental states as well as poorer levels of mental state understanding in their children. Findings lend some empirical support to recent theoretical suggestions that BPD is associated with a reduced capacity for mentalization, as well as reduced capacity for mental state understanding in children of mothers with BPD. Copyright © 2012 John Wiley & Sons, Ltd.