Nikolaus Kleindienst

The Short Version of the Borderline Symptom List (BSL-23): Development and Initial Data on Psychometric Properties

Background: The full version of the Borderline Symptom List (BSL; for clarification now labeled BSL-95) is a self-rating instrument for specific assessment of borderline-typical symptomatology. The BSL-95 items are based on criteria of the DSM-IV, the revised version of the Diagnostic Interview for Borderline Personality Disorder, and the opinions of both clinical experts and borderline patients. The BSL-95 includes 95 items. In order to reduce patient burden and assessment time, a short version with 23 items (BSL-23) was developed. Methods: The development of the BSL-23 was based on a sample of 379 borderline patients, considering the items from the BSL-95 that had the highest levels of sensitivity to change and the highest ability to discriminate borderline patients from other patient groups. In a second step, the psychometric properties of the BSL-23 were investigated and compared with the psychometric properties of the BSL-95 in 5 different samples, including a total of 659 borderline patients. Results: In all of the samples, a high correlation of the sum score was found between the BSL-23 and the BSL-95 (range: 0.958–0.963). The internal consistency was high for both versions (BSL-23/Cronbach’s α: 0.935–0.969; BSL-95/Cronbach’s α: 0.977–0.978). Both BSL-23 and BSL-95 clearly discriminated borderline personality disorder patients from patients with an axis I diagnosis (mean effect sizes were 1.13 and 0.96 for the BSL-23 and BSL-95, respectively). In addition, comparisons before and after 3 months of dialectical behavior therapy revealed a numerically larger effect size for the BSL-23 (d = 0.47) compared to the BSL-95 (d = 0.38). Conclusion: The results indicate that the BSL-23 is an efficient and convenient self-rating instrument that displays good psychometric properties comparable to those of the BSL-95. The BSL-23 also demonstrated sensitivity to the effects of therapy.

Attention Deficit/Hyperactivity Disorder as a Potentially Aggravating Factor in Borderline Personality Disorder

BACKGROUND Clinical experience suggests that people with borderline personality disorder often meet criteria for attention-deficit hyperactivity disorder (ADHD). However, empirical data are sparse. AIMS To establish the prevalence of childhood and adult ADHD in a group of women with borderline personality disorder and to investigate the psychopathology and childhood experiences of those with and without ADHD. METHOD We assessed women seeking treatment for borderline personality disorder (n=118) for childhood and adult ADHD, co-occurring Axis I and Axis II disorders, severity of borderline symptomatology and traumatic childhood experiences. RESULTS Childhood (41.5%) and adult (16.1%) ADHD prevalence was high. Childhood ADHD was associated with emotional abuse in childhood and greater severity of adult borderline symptoms. Adult ADHD was associated with greater risk for co-occurring Axis I and II disorders. CONCLUSIONS Adults with severe borderline personality disorder frequently show a history of childhood ADHD symptomatology. Persisting ADHD correlates with frequency of co-occurring Axis I and II disorders. Severity of borderline symptomatology in adulthood is associated with emotional abuse in childhood. Further studies are needed to differentiate any potential causal relationship between ADHD and borderline personality disorder.

Motives for nonsuicidal self-injury among women with borderline personality disorder.

Patients with borderline personality disorder (BPD) are known to use nonsuicidal self-injury (NSSI) as a dysfunctional strategy to regulate intense emotions. The primary purpose of this study was to clarify the motives for NSSI along with their interrelations. We further investigated the variety of emotions preceding NSSI and possible effects of NSSI on these emotions. To this end, a structured self-rating questionnaire on NSSI was administered to 101 female BPD-patients exhibiting NSSI. Most patients reported multiple motives for NSSI. The motives were more likely to compound than to exclude one another. Negative reinforcement was almost always involved in NSSI, whereas positive reinforcement (e.g., “getting a kick”) played an additional role among about half of the patients. NSSI was usually preceded by a large variety of negative feelings that were reported to clearly improve with NSSI. In conclusion, therapists should anticipate a multidimensional functional spectrum when exploring motives of NSSI.

State affective instability in borderline personality disorder assessed by ambulatory monitoring

BACKGROUND Although affective instability is an essential criterion for borderline personality disorder (BPD), it has rarely been reported as an outcome criterion. To date, most of the studies assessing state affective instability in BPD using paper-pencil diaries did not find indications of this characteristic, whereas in others studies, the findings were conflicting. Furthermore, the pattern of instability that characterizes BPD has not yet been identified. METHOD We assessed the affective states of 50 female patients with BPD and 50 female healthy controls (HC) during 24 hours of their everyday life using electronic diaries. RESULTS In contrast to previous paper-and-pencil diary studies, heightened affective instability for both emotional valence and distress was clearly exhibited in the BPD group but not in the HC group. Inconsistencies in previous papers can be explained by the methods used to calculate instability (see Appendix). In additional, we were able to identify a group-specific pattern of instability in the BPD group characterized by sudden large decreases from positive mood states. Furthermore, 48% of the declines from a very positive mood state in BPD were so large that they reached a negative mood state. This was the case in only 9% of the HC group, suggesting that BPD patients, on average, take less time to fluctuate from a very positive mood state to a negative mood state. CONCLUSION Future ambulatory monitoring studies will be useful in clarifying which events lead to the reported, sudden decrease in positive mood in BPD patients.

Analytic strategies for understanding affective (in)stability and other dynamic processes in psychopathology.

The dynamics of psychopathological symptoms as a topic of research has been neglected for some time, likely because of the inability of cross-sectional and retrospective reports to uncover the ebb and flow of symptoms. Data gathered with the experience sampling method (ESM) enable researchers to study symptom variability and instability over time as well as the dynamic interplay between the environment, personal experiences, and psychopathological symptoms. ESM data can illuminate these dynamic processes, if time is both considered and integrated into (a) the research question itself, (b) the assessment or sampling method, and (c) the data analytic strategy. The authors highlight the complexity of assessing affective instability and unstable interpersonal relationships and explore sampling and analytic methods. Finally, they propose guidelines for future investigations. For the assessment of affective instability, the authors endorse the use of time-contingent recordings and of instability indices that address temporal dependency. For the assessment of unstable interpersonal relationships, they advocate the use of event-contingent recordings and separate analyses within and across dyads.

Dialectical Behaviour Therapy for Post-traumatic Stress Disorder after Childhood Sexual Abuse in Patients with and without Borderline Personality Disorder: A Randomised Controlled Trial

Background: Post-traumatic stress disorder (PTSD) with co-occurring severe psychopathology such as borderline personality disorder (BPD) is a frequent sequel of childhood sexual abuse (CSA). CSA-related PTSD has been effectively treated through cognitive-behavioural treatments, but it remains unclear whether success can be achieved in patients with co-occurring BPD. The aim of the present study was to determine the efficacy of a newly developed modular treatment programme (DBT-PTSD) that combines principles of dialectical behaviour therapy (DBT) and trauma-focused interventions. Methods: Female patients (n = 74) with CSA-related PTSD were randomised to either a 12-week residential DBT-PTSD programme or a treatment-as-usual wait list. About half of the participants met the criteria for co-occurring BPD. Individuals with ongoing self-harm were not excluded. The primary outcomes were reduction of PTSD symptoms as assessed by the Clinician-Administered PTSD Scale (CAPS) and by the Posttraumatic Stress Diagnostic Scale (PDS). Hierarchical linear models were used to compare improvements across treatment groups. Assessments were carried out by blinded raters at admission, at end of treatment, and at 6 and 12 weeks post-treatment. Results: Under DBT-PTSD the mean change was significantly greater than in the control group on both the CAPS (33.16 vs. 2.08) and the PDS (0.70 vs. 0.14). Between-group effect sizes were large and highly significant. Neither a diagnosis of BPD nor the severity or the number of BPD symptoms was significantly related to treatment outcome. Safety analyses indicated no increase in dysfunctional behaviours during the trial. Conclusion: DBT-PTSD is an efficacious treatment of CSA-related PTSD, even in the presence of severe co-occurring psychopathology such as BPD.

Dialectical Behavior Therapy for Posttraumatic Stress Disorder Related to Childhood Sexual Abuse: A Pilot Study of an Intensive Residential Treatment Program

Dialectical behavior therapy for posttraumatic stress disorder (DBT-PTSD) is tailored for adults with PTSD from childhood sexual abuse (CSA). It uses principles from DBT and trauma-focused cognitive-behavioral approaches. To evaluate acceptance and safety, the authors treated 29 women with chronic CSA-related PTSD plus at least one other comorbid diagnosis. The Posttraumatic Diagnostic Scale (PDS), Symptom Checklist 90-Revised, Beck Depression Inventory, and State Trait Anxiety Inventory were administered prior to, at the end of, and 6 weeks after 3 months of intensive residential treatment. An effect size of 1.22 on the PDS was found between baseline and follow-up. Effect sizes for secondary outcomes ranged from medium to large. The results suggest that DBT-PTSD has promise for reducing severe and chronic PTSD after CSA.

Dissociative symptoms are positively related to stress in borderline personality disorder

Objective:  According to DSM‐IV criteria, dissociative symptoms in borderline personality disorder (BPD) occur in response to stress. Empirical evidence is, however, lacking.

Dissociation Predicts Poor Response to Dialectial Behavioral Therapy in Female Patients with Borderline Personality Disorder

A substantial proportion of Borderline Personality Disorder (BPD) patients respond by a marked decrease of psychopathology when treated with Dialectical Behavioral Therapy (DBT). To further enhance the rate of DBT-response, it is useful to identify characteristics related to unsatisfactory response. As DBT relies on emotional learning, we explored whether dissociation-which is known to interfere with learning- predicts poor response to DBT. Fifty-seven Borderline Personality Disorder (BPD) patients (DSM-IV) were prospectively observed during a three-month inpatient DBT program. Pre-post improvements in general psychopathology (SCL-90-R) were predicted from baseline scores of the Dissociative Experiences Scale (DES) by regression models accounting for baseline psychopathology. High DES-scores were related to poor pre-post improvement (β = -0.017 ± 0.006, p = 0.008). The data yielded no evidence that some facets of dissociation are more important in predicting DBT-response than others. The results suggest that dissociation in borderline-patients should be closely monitored and targeted during DBT. At this stage, research on treatment of dissociation (e.g., specific skills training) is warranted.

Distress and affective dysregulation in patients with borderline personality disorder: a psychophysiological ambulatory monitoring study

Borderline personality disorder (BPD) is characterized by enduring psychological distress and affective dysregulation. Several models have linked both phenomena, but are lacking empirical support. To investigate the relation between psychological distress and components of affective dysregulation (especially inability to label emotions, conflictive emotions, and physiological hyperarousal), we repeatedly assessed these components using a 24-hour ambulatory monitoring approach in a group of 50 BPD patients and 50 healthy controls. Hierarchical linear model analyses identified a clear relation between inability to label emotions and distress in the BPD group (p = 0.0009) but not across all subjects (p = 0.6492). Conflictive emotions were related to psychological distress in both groups (p < 0.0001). This relation is, however, most pertinent to the BPD group who experienced conflicting emotions more frequently. Physiological arousal (heart rate) was related to distress in both groups. Our empirical findings emphasize training in labeling emotions and distress tolerance interventions in treatment for BPD.