Borderline Personality: Traits & Disorder

1. Borderline Personality: Traits & Disorder Morey and Zanarini (2000)

2. Introduction to BPD • Patients with BPD described as having unstable emotions, difficulty maintaining relationships & a higher probability of self inflicting damage. • DSM- IV (Diagnostic and statistical manual of mental disorders, 4th edition) is used to classify borderline personality disorder. • Recent research suggests using a normal personality test to diagnose BPD - specifically the FFM.

3. BPD & the Five Factor Model • Present study looked to compare the FFM with the categorical model currently in use • Also examined what, if anything, the FFM missed in diagnosing patients with BPD via antecedent, concurrent and predictive validity as criteria.

4. Method • Initial screening gathered 378 participants between 18 and 35 years of age, who had normal or better intelligence, with no previous symptoms of schizophrenia or bipolar l disorder and had been assigned a definite or probable Axis 2 diagnosis. • All participants tested on: - Structured Clinical Interview for DSM-III-R Axis 1 disorders - The revised diagnostic interview for borderlines (DIB-R) - The diagnostic interview for DSM-III-R personality disorders (DIPD-R) - NEO-Five Factor Model - Revised childhood experiences questionnaire - Revised Family History Questionnaire - The Dissociative Experiences Scale - Dysphoric affect Scale

5. Method • 290 met both DIB-R and DSM-III-R criteria for BPD • 72 met DSM-III-R criteria for non-borderline personality disorder (Control group) • Borderline and control participants similar in age, marital status and racial background. • However, BPD patients came from significantly lower socioeconomic backgrounds. • Also, there was a significantly larger number of female participants with BPD than in the control group.

6. Results • NEO Five-Factor Inventory Descriptive and Regression Statistics for Patient Groups

7. Results • Can see neuroticism provides largest difference between borderline and nonborderline patients. • However there was still some variance not accounted for in the NEO-FFI. • Of the four content areas from the DIB-R, impulse action patterns was least well represented in the NEO-FFI • Thus they correlated the NEO-FFI representation of BPD and the full BPD diagnosis with a number of external markers, e.g. historical data, and found the NEO-FFI explained a significant amount of the variance in historical and outcome variables. • However, it did not explain the variance for concurrent symptoms and history of sexual abuse.

8. Discussion • Three main findings: • The diagnosis of BPD is related to the five-factor-model of personality (in particular neuroticism). • Some definitional aspects of BPD are not fully captured in a FFM as shown by the NEO-FFI (particularly those under the domain impulse actions). • Diagnostic elements independent of the FFM are still valid elements of BPD.

9. ADHD children with a 7-repeat allele of the dopamine receptor D4 gene have extreme behavior but normal performance on critical neuropsychological tests of attention Swanson et al 2000

10. *I did French at school so this is all goes over my head. If you can read German/Dutch(?!) please feel free to let everyone else in on the joke…..

11. Dopamine • Plays an important role in attention. • Candidate gene approach-looked at dopamine receptor D4 (DRD4) on chromosome 11p15.5. • Initial studies suggested that the DRD4 7-repeat allele is associated with ADHD, but with a small relative risk. • DRD4 7-repeat isn’t necessary (1/2 ADHD cases don’t have it) or sufficient (some non-ADHD-ers have it!)

12. Lots of stimulant drugs get to work in the dopamine synapse • Results in decreased activity, inattention and impulsivity (i.e. ADHD symptoms) • Their theory…DRD4 7-repeat allele might code for subsensitive dopamine receptors in the frontal lobes and produce underactivity in the neural networks involved in executive functions • So, ADHD-ers with the 7-repeat should show more attention deficits than ADHD-ers without it.

13. Methods • Subjects-96 ADHD, 48 age and gender matched controls • ADHD-ers were not medicated at least a day pre-exp • Inclusion criteria for ADHD subjects; • “DSM-I V diagnosis of ADHD-Combined Type, including the endorsement of at least six of nine symptoms of inattentionand six of nine symptoms of hyperactivity/impulsivity.”

14. Theory behind the task • ANT (Posner and Raichle, 1994) • Tasks probe functions of three brain regions implicated in the attentional deficits in ADHD • (anterior cingulate, right dorsolateral prefrontal and posterior parietal cortex).

15. Ss checked frequently while doing tasks. • Experimenter redirected if necessary. • Ss given frequent rest periods.

16. Gene stuff • Blood taken from 32 ADHD Ss. • DNA extracted. • 40.6% had at least one 7-repeat allele. • ‘7-present’ • This statistic is slightly lower than other reports • 59.4% did not have a 7-repeat allele. • ‘7-absent’

17. Results • ADHD and controls compared on all three tasks. • RT and SD (variability) of performance revealed large group differences. • ADHD slower and more variable than controls in all tasks. (Moderate to large effect sizes.) • 7-repeat absent vs. present (ADHD) • Didn’t differ statistically on ADHD symptom severity, IQ, meds, ethnicity etc etc. • ‘Present’s didn’t differ from controls in attention tasks. • ‘absent’s performed worse than ‘present’s…..unexpected.

18. Discussion • So…7-present genotype is not necessary for the manifestation of ADHD-typical cognitive abnormalities. • 7-present ADHD-ers are a subgroup. • ✔ behavioural aspects of ADHD • ✖ cognitive aspects

19. So what about DRD4? • 7-repeat allele on DRD4 gene might be associated with extreme placement on personality/temperament dimension. • ‘Absent’ group is heterogeneous, possibly with other genetic abnormalities, e.g. other alterations on DRD4 (or similar) genes.

20. Study limitations • Small sample size-not a huge turnout for the blood tests • Other studies have failed to replicate the present vs. absent findings. • Strict ADHD criteria used means results might not be representative ADHD inattentive type or hyperactive/impulsive type . • It’s not all about DRD4.

21. The Association between Attentional and Executive Controls in the Expression of BPD features: A preliminary study Fertuck et al., 2002

22. A change in research methods • Posner et al. • Attention Network Task (ANT) • Alerting • Orienting • Conflict/executive control • Heaton et al. • Wisconsin card sorting task

23. The current research • Correlation between WCST and conflict scores of the ANT • Compare their performance with diagnostic criteria for BPD and GAF • 22 female BPD patients • Met DSM-IV BPD criteria • Aged between 18-50

24. The current research • Computerised version of WCST and ANT • IPDE – generate 3 scores: • 1: categorical • 2: No. of criteria met • 3: dimensional score

25. Results • They found that more impaired, higher ANT alertness scores were correlated with more percent perseverative errors and responses on the WCST. • More impaired, higher ANT conflict scores were correlated with increased percent nonperseverative errors and fewer conceptual level responses on the WCST. • The found that poorer performances on both the alertness and orienting scores, but not the conflict score, were significantly correlated with higher levels of BPD symptomology. In contrast, the WCST variables were not related to the extent of BPD symptomology. • Regression analysis and correlations

26. Discussion • 2 separate lab assays of executive and attentional control were correlated with one another. • Failure on the WCST may be caused by poor sustained attention. • Construct validity of the ANT task. • Lab based tasks

27. Limitations and future research • Does not differentiate between subtypes of BPD features • All females • How do basic neurocognitive functions interrelate with the attachment system and other higher-order personality variables such as identity and moral values? • A developmental perspective might point to the precursors and risk factors of BPD.

28. Attentional mechanisms of borderline personality disorder Posner et al, 2002

29. Background • Kandel (1998/9) argued that new concepts in neuroscience make it possible to relate higher level cognition to brain systems • Due to its complexity and lack of organic markers, BPD poses one of the greatest challenges to this goal • Present study examines whether patients with BPD show a systematic deficit in a circuit known from neuroimaging studies to be involved in regulation of cognition and emotion

30. Hypotheses • That BPD patients will be high in negative affect and low in effortful control • That BPD patients might exhibit a specific disorder of mechanisms related to effortful control

31. Participants • 39 individuals diagnosed with BPD by trained psychiatrists • 22 individuals that showed similar levels of negative affect and effortful control as measured by the Adult Temperament Questionnaire (ATQ) • 70 individuals that showed mean levels of these two temperamental variables

32. Procedure • All completed the attention network test (ANT) – reaction time test that provides evaluation of efficiency on alerting, orientation and conflict resolution • For all participants correlated ANT scores with effortful control measures of the ATQ. • Previous studies shown that effortful control as measured by a child version of the ATQ correlates with the ability to resolve conflicts

33. Results • ANOVAs showed no difference between groups on overall RT, error rate, alerting or orientating scores • However patients were found to differ significantly from average controls but not temperamental controls on conflict resolution, controlling for age and medication.

34. Conclusions • Seems to be a specific abnormality in BPD patients in an attentional network involved in conflict resolution only • However were unable to indentify abnormalities in candidate genes. • Suggested that difficulties in socialization might produce inappropriate development of attentional mechanisms

35. Further Conclusions • Neuroimaging studies show the conflict resolution network involves the anterior cingulate gyrus, which develops between ages 2-7. • In children and adults, lesions in this area, produce a tendency towards poor interpersonal relationships, a common symptom of BDP.

36. Limitations • BPD patients did not differ significantly from temperamental controls • No indication that children who fail to develop conflict resolution mechanisms end up with BPD • Unable to indentify abnormalities in candidate genes related to conflict resolution in BPD patients.

37. Defining the Mechanisms of BorderlinePersonality Disorder Clarkin & Posner (2005)

38. Introduction • Personality disorders allow for examining the mental structures of people experiencing difficulty in interacting with their social environment • Borderline Personality Disorder (BPD) is characterized by turbulent, angry, and depressive emotional states, unstable interpersonal relationships, an incoherent and often contradictory self-concept, and impulsive and often dangerous behaviours such as self-injury. • It is complex and lacks clear organic markers, making it difficult to understand it psychobiological development • Unique paper as a collaboration of researchers with different areas of expertise

39. BPD Symptomatology • 5 or more of the 9 criteria for BPD in DSM-IV • Grinker (1968) suggests impulsivity and negative affectivity are the core personality traits • Must go beyond the symptom level though as this does not explain the mechanisms of action

40. BPD Symptoms • Temperament and its relationship to biological systems provide an organising scheme for the investigation of the development of BPD • This research has been guided by a model of temperament with it relating to: -negative effect -evolving self control -internal sense of self and others

41. BPD Symptoms • Negative Affect and Defective Self Regulation: Negative affect invades information processing and organisation of personal experiences. There is poor regulation of negative affect and this inability is seen in impulsive behaviours • Identity Diffusion: In DSM-IV criteria and is the lack of integration of the concept of self and others. These poor integrations derive from excessive dissociations between positive and negative affect • Attachment: Insecure attachments developed in childhood

42. A Working Model of BPD • BPD is an interaction of: -temperament -low effortful control -lack of sense of self and others -insecure, anxious attachment style • Treatments should focus on the information processing system that results from this symptom interaction

43. Research Plan & Subsequent Findings • Temperament: Used the Adult Temperament Questionnaire and BPD (high neg. Affect, low effortful control) were compared to 2 control groups- 1. Temperamentally matched controls 2. Average controls • Attentional Network Task: Patients differed from both control groups in the conflict network only suggesting abnormality in the attentional network. Temperament may play a role in the disorder • Conceptualization of Interpersonal Relations: Effortful control is developed via childhood attachment

44. Treatment • Psychotherapy is the primary technique • Alternatives include: -Psychodynamic treatment -Dialectical-Behavioural therapy -Transference-Focused Psychotherapy • The variables investigated in this research paper should be incorporated into treatment plans

45. Treatment Influences • Interaction between patient and therapist: The interaction can be seen as a primary vehicle for change. Treatments are aware but have a differing degree of emphasis • Neurocognitive Impediments to Treatment • Emotion Processing: Enhancement of emotional regulation • Sense of Self and Others Examine interactions and if infused with hostility then give corrective perception

46. Summary • Model developed to better understand the development of the neural networks that underlie the abnormalities found in BPD • Hopefully this will bring research a step closer to working out the interaction between temperament, genes and experience that produce the disorder

47. Fertuck et al. (2006) • Review of research on BPD • They agree identifying underlying mechanisms is important in the research of BPD. Its characterised by turbulent fluctuations and hopefully this work can help de-mystify and de-stigmatize this disorder • Future studies may want to look at task performance in relation to actual social behaviour e.g. suicidality rather than just its associations with diagnosis

48. Cognitive abnormalities in PTSD McNally (2006)

49. PTSD • Anxiety disorder- usually in response to a terrifying event. • Hallmark characteristic-sufferers relive their trauma in the form of involuntary recollection. • This mediated research on examining the cognitive mechanisms of PTSD.

50. Phenomenological & meta-cognitive findings • Phenomenological research has provided clues as to how memory for a trauma is represented in memory- e.g. repetitive, unwanted thoughts, vivid flashbacks. • Vivid flashbacks of stimuli that preceded the most frightening part of the trauma as opposed to the most terrifying part of the trauma per se. • Visual flashbacks= most common. • Halligan et al. (2003)- memories of trauma are more disorganised in PTSD patients than those without PTSD and the severity of the disorganisation predicts subsequent PTSD pathology.