Elisabeth A. Arens

Borderline personality disorder and psychosis: a review.

Early views of borderline personality disorder (BPD) were based on the idea that patients with this pathology were “on the border” of psychosis. However, more recent studies have not supported this view, although they have found evidence of a malevolent interpersonal evaluation and a significant proportion of BPD patients showing psychotic symptoms. For example, in one study, 24% of BPD patients reported severe psychotic symptoms and about 75% had dissociative experiences and paranoid ideation. Thus, we start with an overview regarding the prevalence of psychotic symptoms in BPD patients. Furthermore, we report findings of studies investigating the role of comorbidity (eg, post-traumatic stress disorder) in the severity and frequency of psychotic symptoms in BPD patients. We then present results of genetic and neurobiological studies comparing BPD patients with patients with schizophrenia or nonschizophrenic psychotic disorders. In conclusion, this review reveals that psychotic symptoms in BPD patients may not predict the development of a psychotic disorder but are often permanent and severe and need careful consideration by clinicians. Therefore, adequate diagnosis and treatment of psychotic symptoms in BPD patients is emphasized.

Detaching from the negative by reappraisal: the role of right superior frontal gyrus (BA9/32)

The ability to reappraise the emotional impact of events is related to long-term mental health. Self-focused reappraisal (REAPPself), i.e., reducing the personal relevance of the negative events, has been previously associated with neural activity in regions near right medial prefrontal cortex, but rarely investigated among brain-damaged individuals. Thus, we aimed to examine the REAPPself ability of brain-damaged patients and healthy controls considering structural atrophies and gray matter intensities, respectively. Twenty patients with well-defined cortex lesions due to an acquired circumscribed tumor or cyst and 23 healthy controls performed a REAPPself task, in which they had to either observe negative stimuli or decrease emotional responding by REAPPself. Next, they rated the impact of negative arousal and valence. REAPPself ability scores were calculated by subtracting the negative picture ratings after applying REAPPself from the ratings of the observing condition. The scores of the patients were included in a voxel-based lesion-symptom mapping (VLSM) analysis to identify deficit related areas (ROI). Then, a ROI group-wise comparison was performed. Additionally, a whole-brain voxel-based-morphometry (VBM) analysis was run, in which healthy participants REAPPself ability scores were correlated with gray matter intensities. Results showed that (1) regions in the right superior frontal gyrus (SFG), comprising the right dorsolateral prefrontal cortex (BA9) and the right dorsal anterior cingulate cortex (BA32), were associated with patients impaired down-regulation of arousal, (2) a lesion in the depicted ROI occasioned significant REAPPself impairments, (3) REAPPself ability of controls was linked with increased gray matter intensities in the ROI regions. Our findings show for the first time that the neural integrity and the structural volume of right SFG regions (BA9/32) might be indispensable for REAPPself. Implications for neurofeedback research are discussed.

Ethnic Variation in Emotion Regulation: Do Cultural Differences End Where Psychopathology Begins?

Emotion regulation (ER) via cognitive reappraisal has been shown to be superior to the use of expressive suppression regarding several aspects of mental well-being. However, a cultural perspective suggests that the consequences of emotional suppression may be moderated by cultural values. In order to examine whether this also applies to clinical samples, we investigated healthy and depressed German women and healthy and depressed Turkish immigrants living in Germany. Groups were compared in terms of frequency of ER strategies (cognitive reappraisal and expressive suppression) and with which different aspects of mental well-being the same are associated. Healthy Turkish immigrants exhibited a greater ER balance (frequent use of suppression plus frequent use of reappraisal), which was associated with more positive outcomes of expressive suppression in Turkish than in German women. None of these differences were found in patient samples, both of which showed a greater use of emotional suppression than cognitive reappraisal. Results suggest that the cultural moderation of the link between emotional suppression and well-being is associated with a greater ER balance in healthy Turkish individuals. Depressed Turkish patients may not profit from suppression due to their more rigid use of it.

Borderline Personality Disorder in Four Different Age Groups: A Cross-Sectional Study of Community Residents in Germany

Studies examining the natural course of borderline personality disorder (BPD) over the life span have yielded declining prevalence rates in older age groups. However, there is evidence that different BPD symptoms have different longitudinal patterns, with impulsivity decreasing with advancing age and negative affect remaining stable into late adulthood. However, since all studies dealt with treated, clinical samples of BPD patients, it is not yet known whether this represents the natural course of BPD symptoms or just mirrors difference in treatability of these symptoms. The authors addressed this issue by investigating a nonclinical population and compared prevalence of BPD, impulsivity, and depressivity in various age groups from adolescence to late adulthood (N = 2,488); all individuals were assessed by standardized clinical interviews. Syndromal and subsyndromal BPD rates sharply decreased between adolescents and young adults and remained stable thereafter. Whereas the same course was found for impulsivity, depressivity increased between young, middle-aged, and older adults. The present results support the hypothesis that age-related decreases in BPD diagnosis might be attributable to declining levels of impulsivity, whereas the persistence of a subsyndromal BPD might be attributable to an enduring negative affect.

Emotional hyper-reactivity in borderline personality disorder is related to trauma and interpersonal themes

Heightened emotional reactivity is one of the core features of borderline personality disorder (BPD). However, recent findings could not provide evidence for a general emotional hyper-reactivity in BPD. The present study examines the emotional responding to self-relevant pictures in dependency of the thematic category (e.g., trauma, interpersonal interaction) in patients with BPD. Therefore, women with BPD (n=31), women with major depression disorder (n=29) and female healthy controls (n=33) rated pictures allocated to thematically different categories (violence, sexual abuse, interaction, non-suicidal self-injury, and suicide) regarding self-relevance, arousal, valence and the urge of non-suicidal self-injury. Compared to both control groups, patients with BPD reported higher self-relevance regarding all categories, but significantly higher emotional ratings only for pictures showing sexual abuse and interpersonal themes. In addition, patients with BPD and comorbid posttraumatic stress disorder showed higher emotional reactivity in violence pictures. Our data provide clear evidence that patients with BPD show a specific emotional hyper-reactivity with respect to schema-related triggers like trauma and interpersonal situations. Future studies are needed to investigate physiological responses to these self-relevant themes in patients with BPD.

Does emotion dysregulation mediate the relationship between early maltreatment and later substance dependence? Findings of the CANSAS Study.

Background/Aims: Maltreatment in childhood and adolescence is a risk factor for substance use disorders (SUDs) in adulthood. This association has rarely been investigated in the light of emotion dysregulation. To fill this gap, this study examines emotion dysregulation and SUDs among adults with a history of early maltreatment. Methods: Comparison of emotion dysregulation in adults with a history of early abuse and neglect who developed either an SUD (n = 105) or no mental disorder (n = 54). Further, a mediation model for the association between the severity of early maltreatment and SUDs was tested. Participants completed research diagnostic interviews for psychopathology, the Difficulties in Emotion Regulation Scale, and the Childhood Trauma Questionnaire. Results: By using hierarchical regression techniques and mediational analyses controlling for age and gender, it was possible to provide evidence for the mediating role of emotion dysregulation between early emotional and physical maltreatment and later SUDs. Conclusions: Emotion dysregulation is a potential mechanism underlying the relationship between early emotional and physical maltreatment and the development of SUDs. In light of these findings, focusing on the early training of adaptive emotion regulation strategies after childhood maltreatment might be of considerable relevance to prevent the development of SUDs.

Exploring the relevance of autonomy and relatedness for mental health in healthy and depressed women from two different cultures: When does culture matter?

Background: It is well known that the absence of both autonomy and social support (relatedness) are two important etiologic pathways to major depressive disorder (MDD). However, cross-cultural researchers state that the implications of autonomy and relatedness for mental health vary across cultures. Aim: To test these assumptions, the current study investigated the relevance of autonomy and relatedness for mental health in healthy and depressed women from two different cultures (Germans and Turkish immigrants in Germany). Methods: One hundred and eight (108) women were evaluated for their levels of autonomy/relatedness satisfaction, for overall psychopathological complaints including depression, for affectivity and for perceived loneliness through self-report measures. Results: Among healthy groups, relatedness satisfaction predicted better mental health in Turkish women, whereas in German women, autonomy satisfaction was the better mental health predictor. Within depressed groups however, cultural differences in mental health outcomes regarding autonomy were no longer evident. Autonomy was associated with higher levels of mental health in Turkish as well as in German patients. Conclusions: Our findings indicate that the relationship between autonomy and mental health is culture-specific in healthy women, but disappears in depressed women. These findings are discussed with consideration of clinical implications and an outlook regarding further research.

Association of Anandamide with altered Binocular Depth Inversion Illusion in Schizophrenia

Abstract Objectives: Binocular depth inversion illusion (BDII) represents an illusion of visual perception that involves higher-order visual and cognitive processes. Its impairment has been linked to psychotic conditions and identified as a marker for at-risk mental states. The endogenous cannabinoid system (ECS) is involved in various neurophysiological processes. One of its key components, anandamide, is involved in the pathophysiology of schizophrenia. Little is known about its impact on BDII alterations. Therefore, we explored associations between BDII and anandamide levels. Methods: BDII was conducted and blood and CSF were taken in 28 first-episode antipsychotic-naïve schizophrenia (SZ) patients and 81 healthy controls (HC). Serum and CSF anandamide levels were determined by high-performance liquid chromatography/mass spectrometry. Results: BDII scores were significantly elevated in SZ versus HC, indicating a disruption of illusionary revision of percepts in SZ. Anandamide levels were significantly higher in CSF of SZ compared to HC, while serum anandamide was not. However, we found specific association differences of anandamide levels and BDII scores between schizophrenia patients and controls in serum. Conclusions: These findings support the hypothesis of an involvement of anandamide in cognitive processes impaired in schizophrenia and are consistent with a protective effect of elevated anandamide levels herein.

Substance use to regulate intense posttraumatic shame in individuals with childhood abuse and neglect

Childhood abuse and neglect (CAN) is considered as a risk factor for substance use disorder (SUD). Based on the drinking to cope model, this study investigated the association of two trauma-relevant emotions (shame and sadness) and substance use. Using ecological momentary assessment we compared real-time emotion regulation in situations with high and low intensity of shame and sadness in currently abstinent patients with CAN and lifetime SUD (traumaSUD group), healthy controls with CAN (traumaHC group), and without CAN (nontraumaHC group). Multilevel analysis showed a positive linear relationship between high intensity of both emotions and substance use for all groups. The traumaSUD group showed heightened substance use in low, as well as in high, intensity of shame and sadness. In addition, we found an interaction between type of emotion, intensity, and group: the traumaHC group exhibited a fourfold increased risk for substance use in high intense shame situations relative to the traumaSUD group. Our findings provide evidence for the drinking to cope model. The traumaSUD group showed a reduced distress tolerance for variable intensity of negative emotions. The differential effect of intense shame for the traumaHC group emphazises its potential role in the development of SUD following CAN. In addition, shame can be considered a relevant focus for therapeutic preinterventions and interventions for SUD after CAN.

Der Zusammenhang zwischen Selbstkonzept und psychischer Belastung bei türkischen und deutschen Frauen mit Depression

OBJECTIVE The current study aims to analyze cultural differences in the patterns of self-construals (interdependent vs. independent) and their relation to mental distress in a sample of depressed Turkish migrants and German women. METHODS A total number of 56 in-patients with a diagnosis of major depression were compared in terms of self-construals and their relations to different aspects of mental distress. RESULTS Turkish patients exhibited a stronger interdependent self-construal compared to Germans, whereas no group differences were observed with respect to independence. While for Turkish patients a higher level of interdependence was associated with lower levels of mental distress, the reverse was true for German patients. However, there were no significant ethnic differences in the associations between independence and mental distress. CONCLUSIONS The current study provides evidence that the relation between self-construal and mental distress is moderated by patients cultural background. The findings have implications for integrating self-construals into psychotherapy practice with culturally diverse populations, in order to adjust therapy goals and intervention techniques.