Eric A. Fertuck

Rejection Sensitivity Is a Mediator Between Borderline Personality Disorder Features and Facial Trust Appraisal

Individuals with borderline personality disorder (BPD) fear abandonment and exhibit instability in their close relationships. These interpersonal difficulties may be influenced by the propensity to interpret neutral social stimuli (e.g., nonemotional faces) as untrustworthy. This study evaluated the hypothesis that BPD features are associated with attributions of untrustworthiness to neutral faces. Additionally, the authors hypothesized that the trait of rejection sensitivity (RS) is also associated with BPD features and mediates the relationship between BPD features and untrustworthy facial trait appraisal. An undergraduate, nonclinical sample (N = 95) was assessed for BPD features, RS, and trust appraisal of neutral faces. Higher BPD features were associated with lower ratings of trustworthiness of the faces and higher scores on RS. Furthermore, as hypothesized, the association between BPD features and trust appraisal was mediated by RS. Results are discussed in the context of a proposed model of the social cognitive mechanisms of interpersonal hypersensitivity 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.

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.

The Interaction between Rejection Sensitivity and Emotional Maltreatment in Borderline Personality Disorder

Background: Borderline personality disorder (BPD) is a prevalent psychiatric disorder associated with significant distress, dysfunction, and treatment utilization. Though, theoretically, BPD is posited to arise from a combination of trait and environmental risk factors, few studies have tested trait-by-environment interactions in BPD. We investigated the roles of rejection sensitivity (RS) and childhood emotional neglect and abuse (ENA) as well as their interaction in BPD. Sampling and Methods: Eighty-five adults with a lifetime mood disorder who were recruited for outpatient studies in a psychiatric clinic were assessed for ENA using the Childhood Trauma Questionnaire and for RS with the Adult Rejection Sensitivity Questionnaire. BPD diagnoses were made by consensus using data collected on the Structured Clinical Interview for DSM-IV. Hierarchical logistic regression was used to test associations between RS, ENA, their interaction and BPD. Results: RS and ENA interacted to predict co-occurring BPD in our sample of mood-disordered patients, with the strength of the relationship between RS and BPD depending on the severity of ENA. In the context of little or no ENA, RS and BPD were more strongly related than when ENA was more severe. Conclusions: Our results extend previous findings suggesting RS and ENA are risk factors for BPD. They also provide preliminary support for contemporary theories of BPD positing trait-by-environment interactions in the development of BPD. Prospective studies are needed to confirm these findings.

Heart rate variability and suicidal behavior

Identification of biological indicators of suicide risk is important given advantages of biomarker-based models. Decreased high frequency heart rate variability (HF HRV) may be a biomarker of suicide risk. The aim of this research was to determine whether HF HRV differs between suicide attempters and non-attempters. Using the Trier Social Stress Test (TSST), we compared HF HRV between females with and without a history of suicide attempt, all with a lifetime diagnosis of a mood disorder. To investigate a potential mechanism explaining association between HF HRV and suicide, we examined the association between self-reported anger and HF HRV. Results of an Area under the Curve (AUC) analysis showed attempters had a lower cumulative HF HRV during the TSST than non-attempters. In addition, while there was no difference in self-reported anger at baseline, the increase in anger was greater in attempters, and negatively associated with HF HRV. Results suggest that suicide attempters have a reduced capacity to regulate their response to stress, and that reduced capacity to regulate anger may be a mechanism through which decreased HF HRV can lead to an increase in suicide risk. Our results have implications for the prevention of suicidal behavior in at-risk populations.

The specificity of mental pain in borderline personality disorder compared to depressive disorders and healthy controls

BackgroundIndividuals with Borderline Personality Disorder (BPD) may experience a qualitatively distinct depression which includes “mental pain.” Mental pain includes chronic, aversive emotions, negative self-concept, and a sense of pervasive helplessness. The present study investigated whether mental pain is elevated in BPD compared to Depressive Disorders (DD) without BPD.MethodsThe Orbach and Mikulincer Mental Pain Scale (OMMP) was administered to BPD (N = 57), DD (N = 22), and healthy controls (N = 31). The OMMP assesses total mental pain, comprised of nine subtypes: irreversibility, loss of control, narcissistic wounds, emotional flooding, freezing, self-estrangement, confusion, social distancing, and emptiness. Co-occurring psychiatric diagnoses, depression severity, and other potentially confounding clinical and demographic variables were also assessed.ResultsThe total Mental Pain score did not differentiate BPD from DD. Moreover, most of the subscales of the OMMP were not significantly different in BPD compared to DD. However, the elevation of mental pain subscale “narcissistic wounds,” characterized by feeling rejected and having low self-worth, was a specific predictor of BPD status and the severity of BPD symptoms.ConclusionOn OMMP total score, mental pain was similarly elevated in BPD and DD. However, the narcissistic wounds sub-type of mental pain was a sensitive and specific diagnostic indicator of BPD and, therefore, may be an important aspect of BPD in need of increased focus in assessment and theoretical models.

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.

Cognitive Disturbance in Borderline Personality Disorder: Phenomenologic, Social Cognitive, and Neurocognitive Findings

Borderline personality disorder (BPD) is a serious psychiatric syndrome that is most often associated with emotional instability and impulsive-aggression. However, BPD is also characterized by distinctive cognitive features. We review the empirical literature on four types of cognitive disturbance in BPD: 1) transient, quasi-psychotic cognition, 2) dissociation, 3) social cognitive biases, and 4) neurocognition. Finally, we describe a cognitive neuroscience model of BPD that can guide future empirical study of the mechanisms of the disorder and its psychosocial and pharmacologic treatment.

Improvements in Executive Attention, Rumination, Cognitive Reactivity, and Mindfulness Among High–Suicide Risk Patients Participating in Adjunct Mindfulness-Based Cognitive Therapy: Preliminary Findings

OBJECTIVE To test changes to cognitive functioning among high-suicide risk outpatients participating in an adjunct mindfulness-based intervention combining mindfulness-based cognitive therapy and safety planning (MBCT-S). DESIGN Ten outpatients with a 6-month history of suicide attempt or active suicidal ideation plus suicidal ideation at study entry received 9 weeks of adjunct group-based MBCT-S. Executive attention, sustained attention, visual memory, and semantic memory encoding were measured by neuropsychological assessment. Rumination, mindfulness, cognitive reactivity (defined as the tendency towards depressogenic information processing and thought content in response to mild mood deterioration), and self-compassion were assessed using self-report measures. Changes in pre- to post-treatment functioning on these constructs were analyzed by using dependent t-tests. Where significant improvements were found, correlations between changes to cognitive functioning and depression and suicidal ideation during treatment were calculated. RESULTS Executive attention improved with MBCT-S in high-suicide risk outpatients (Stroop interference effect = 0.39 [standard deviation (SD), 27] at baseline and 0.27 (SD, 0.15) at post-treatment, t[9] = 2.35, p = 0.04, d = 0.75). One mindfulness skill, acting with awareness, increased with MBCT-S (average change in Five Facet Mindfulness Questionnaire-acting with awareness subscale score with treatment, 3.3 [SD, 3.0], t[9] = 3.46, p < 0.01, d = 1.1). Self-reported rumination and cognitive reactivity to suicidality and hopelessness decreased among participants (Ruminative Responses Brooding subscale score change, -3.4 [SD, 1.1], t[9] = 10, p < 0.001, d = 3.2; Leiden Index of Depression Sensitivity-Revised-Hopelessness/Suicidality subscale score change, -3 [SD, 2.7], t[9] = 3.56, p < 0.01, d = 1.1). None of these changes were related to improvements in depression or reductions in suicidal ideation during treatment. CONCLUSIONS Findings from the present pilot study suggest that treatment with MBCT-S may improve cognitive deficits specific to suicide ideators and attempters among depressed patients. Future controlled trials using follow-up assessments are needed to determine the specificity of these improvements in cognitive functioning to MBCT-S and their durability and to formally test whether the observed improvements in cognitive functioning explain MBCT-S treatment gains.

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.