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OBJECTIVE Impulsivity impacts life domains and in a psychiatric context is often associated with disorders severity and stigmatization. Borderline personality disorder's (BPD), Schizophrenic disorder's (SZD), and obsessional compulsive disorder's (OCD) impulsivity issues relate to worse prognosis. This study aims to compare these disorders assessing their proneness to impulsivity and urgency. METHODS We recruited 90 patients among them OCD (n = 25), SZD (n = 23), and BPD (n = 50), and 24 healthy control participants (HC). We assessed the diagnosis according and measured the impulsivity level. RESULTS Our results showed that BPD was significantly more impulsive than HC, SZD, and OCD. HC, SZD, and OCD being equivalent on their global Urgency-Premeditation-Perseverance-Sensation seeking scores. For urgency, BPD was also superior to others, OCD was superior to HC, but SZD and HC were equivalent. The urgency was correlated to SZD's scale for SZD, no link appeared between borderline personality questionnaire and Yale-Brown Obsessive-Compulsive Scale's score. CONCLUSION These results question the existent literature relating impulsivity and SZD.

Objectives: This study aimed to understand therapists’ lived experiences of delivering mentalisation-based therapy (MBT), including their experiences of service user change. \ud Method: One-to-one semi-structured interviews or focus groups were conducted with 14 MBT therapists and analysed using interpretative phenomenological analysis (IPA).\ud Results: Four superordinate themes were identified: 1) experiencing the challenges and complexities of being with service users during MBT; 2) being on a journey of discovery and change; 3) being an MBT therapist: a new way of working and developing a new therapeutic identity; and 4) being a therapist in the group: seeing it all come together\ud Conclusion: Our findings highlight the complexity, challenges and individualised experience of working therapeutically with service users with a diagnosis of BPD. The study provides a perspective of service use change that is enriched by idiosyncrasies within the therapeutic encounter. We conclude with a consideration of implications for MBT research and clinical practice.

OBJECTIVE: Distress tolerance is an important but understudied construct for those with schizophrenia-spectrum disorders. This study compared levels of distress tolerance between people diagnosed with schizophrenia and borderline personality disorder in order to better characterize distress tolerance in schizophrenia-spectrum disorders. METHOD: Using cross-sectional data, we examined group differences in distress tolerance in people with schizophrenia-spectrum disorders (N=55) and borderline personality disorder (N=32) through mean comparison and equivalence analyses. RESULTS: Our results indicate that, in our data, distress tolerance did not differ between those with schizophrenia and those with borderline personality disorder, and was in fact statistically equivalent between groups. In contrast, those with borderline personality disorder tended to report more difficulty on some aspects of emotion regulation. CONCLUSION: Findings from this study suggest that increased focus on distress tolerance is called for in research on schizophrenia. Furthermore, people with schizophrenia-spectrum disorders may benefit from interventions targeting distress tolerance.

OBJECTIVE This study investigated the co-occurrence of borderline personality disorder (BPD), attention-deficit/hyperactivity disorder (ADHD), and oppositional defiant disorder (ODD) features in elementary-aged youth. METHOD Latent profile analysis characterized subgroups of youth based on the presence of BPD, ADHD, and ODD features, and subgroups were compared on academic, social, and emotional impairment. RESULTS Seven subgroups were identified, including subgroups with slight, subclinical, clinical, and severe levels of co-occurring BPD, ADHD, and ODD features, and a subgroup of youth with no elevations in these symptom domains. Subgroups of youth with only clinical elevations in ADHD and only clinical levels in BPD features were also identified. Groups differed on level and type of impairment. CONCLUSION Youth with ADHD and ODD represent a high-risk group likely to also show early prodromal clinical elevations in BPD. Future work is needed to examine the longitudinal outcomes of these subgroups to inform prevention and treatment.

Objective The current study used network analysis to explore associations between specific groupings of borderline personality disorder (BPD) and eating disorder (ED) symptoms, and other transdiagnostic variables including insecure attachment, rejection sensitivity, emotion dysregulation, a theory of mind, and emotion recognition. Method Network analysis was undertaken on self-report data from 753 adults (81.5% women), of whom 109 reported a lifetime ED diagnosis. Results Comorbidity between BPD and ED symptoms was only partially conceptualized through the transdiagnostic variables. The centrality indices from the network analysis indicated that emotion dysregulation and abandonment were the most central elements in the network. Conversely, the theory of mind and emotion recognition had very few connections with the other transdiagnostic variables in the network. Discussion The findings provide empirical insight into the nature of the observed co-occurrence between BPD and ED symptoms and serve to improve clinical decision-making regarding psychological interventions for both problem sets.

Objective(s) Interpersonal problems are one of the most persistent difficulties facing those with personality disorders (PDs) and are linked with dysfunction across numerous social domains. Using an interpersonal model of PDs, we examined the indirect effects of Avoidant PD (AvPD) symptoms and social dysfunction through interpersonal problems, as well as Borderline PD (BPD) symptoms and social dysfunction. Methods Participants were 226 adults taking part in an outpatient treatment program. Results Using cross-sectional data from self-reported measures, we found that cold (b = 0.10, 95% confidence interval (CI) [0.038, 0.176]) and overly nurturant (b = 0.04, 95% CI [0.001, 0.090]) interpersonal problems showed an indirect association between AvPD symptoms and social dysfunction. The only significant indirect association between BPD symptoms and social dysfunction was overly nurturant (b = 0.05, 95% CI [0.001, 0.120]). Conclusions Results may aid in the development of more individualized treatments for AvPD and BPD symptoms.

Objective The development of a constructive therapeutic alliance may represent an important feature of interpersonal adaptation in clients with Borderline Personality Disorder (BPD). The present study explores cognitive heuristics as dynamic features of change in relationship with the therapeutic alliance in the treatment of BPD. Method In total, N = 60 clients with BPD, are included in the present study. In the context of brief therapy, the therapeutic alliance (WAI) is assessed from the client and the therapist perspectives after each therapy session; cognitive heuristics are assessed three times (CERS). The data analyses are on the basis of non-parametric clusters (kml3d) linked with the therapeutic alliance. Results The results showed that clusters of cognitive heuristics trajectories are linked with the client's therapeutic alliance (t(55) = 2.30, p = .03), but they remained unrelated with the evolution of the therapist's alliance. Conclusions These results are discussed with regard to the interpersonal adaptiveness of cognitive heuristics in the context of BPD undergoing treatment.

Objective This study examined whether a history of childhood abuse (CA) strengthened the association between borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) in the aftermath of intimate partner violence (IPV). This hypothesis arises from clinical literature but has not been examined empirically. We predicted that a history of CA would enhance associations between BPD features and PTSD symptoms. Method Dimensional assessment of both PTSD and BPD was made in a sample of 211 women who sought mental health services following IPV. Two analyses were conducted using clinician-assessed DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th ed.) PTSD symptoms: (a) total score and (b) symptom clusters. Results Using path analysis, results indicated significant associations between BPD features and PTSD symptoms, but no significant interaction between BPD and CA in either analysis. Conclusions Results are discussed given current understanding of comorbidities involving PTSD, with particular attention to potential implications for clinical practice. Areas for future research are proposed.

OBJECTIVE We tested whether negative interpersonal events (NIEs) precipitate rumination at times of distress in the daily lives of those with borderline personality disorder (BPD) features and whether such responses mediate associations between BPD and the reactivity and recovery components of emotion dysregulation. MATERIALS AND METHOD One hundred twenty-one women completed clinical interviews, survey measures, and a 7-day ecological momentary assessment. RESULTS Elevated BPD features predicted ruminative response deployment only in the context of NIEs. Though elevated BPD features and NIEs predicted heightened distress reactivity, the indirect effect of BPD on distress reactivity via ruminative responses was conditional on NIE occurrence. Ruminative responses also mediated the conditional effects of BPD features on prolonged recovery from distress; trait rumination served as a second indirect pathway between BPD features and distress recovery. CONCLUSION Results suggest that though contextual, rumination is a common pathway for emotional hyperarousal and slow recovery from distress for those with elevated BPD features.

Objective We examined the relationship between mindfulness skills acquisition and symptom reduction. Method Participants were adults (n = 35) with a diagnosis of borderline personality disorder (BPD) who completed a 20-week dialectical behaviour therapy (DBT) skills training group program in a community mental health setting. We used the Five Facet Mindfulness Questionnaire, which measures five dimensions of mindfulness: observing, describing, acting with awareness, nonjudging of inner experience, and nonreactivity to inner experience. Results Linear mixed model results suggested that increases in some mindfulness facets, especially in acting with awareness and nonjudging of inner experience were more strongly related to changes during treatment including reductions in BPD symptomology, depression, and distress with increases in nonjudging also predicting a reduction in the hospital use. Conclusions These results suggest the usefulness of emphasising mindfulness skills that develop awareness and encourage a nonjudgmental stance.

Objective To examine pathways to borderline personality disorder (BPD), focusing on childhood abuse and emotional attention and clarity. Method Among 293 community residents (mean age = 43.1; 53.9% female), measured associations between the BPD symptom factors of disturbed relatedness, affective dysregulation, and behavioral dysregulation and (a) childhood abuse (emotional, physical, and sexual); (b) emotional attention and clarity; and (c) negative affect, using structured interviews, the Schedule for Non-Adaptive and Adaptive Personality-2, the Trait Meta Mood Scale, and the Positive and Negative Affect Scale, respectively. Results All forms of childhood abuse were associated with BPD symptom factors. Emotional attention and clarity moderated the effects of childhood physical and emotional abuse on behavioral dysregulation and disturbed relatedness. All results held when controlling for negative affect. Conclusion The relations between childhood abuse and BPD are robust. Emotional attention and clarity may help elucidate the links between childhood abuse and BPD.

Objectives Some researchers suggest that borderline personality disorder (BPD) is characterized by elevated negative emotion; others argue that BPD involves both reduced positive and increased negative emotion. This study characterizes the emotional experiences of individuals with BPD symptoms in a combined university and community sample. Method Participants (N = 150) completed a clinical interview assessing BPD symptoms and self-report measures of positive and negative emotion. A subset (n = 106) completed a measure of emotion daily for 2 weeks. Pearson's correlations and multilevel modeling were used to examine the cross-sectional and longitudinal relationships between BPD symptoms and emotions. Results BPD symptoms were robustly related to increased negative emotion; this relationship remained after accounting for positive emotion. BPD symptoms were weakly related to decreased positive emotion; this relationship was no longer significant after accounting for negative emotion. BPD symptoms predicted higher levels of negative and not positive emotion over 14 days. These patterns held for subscales assessing intensity, frequency, and duration of negative and positive emotions. Conclusion Findings suggest that individuals with BPD features are chiefly distinguished by elevated negative emotional experience.

General psychiatric management for patients with borderline personality disorder was devised to be an outpatient intervention that could be readily learned and easily delivered by independent community mental health professionals. To disseminate the approach, Drs. Gunderson and Links developed the Handbook of Good Psychiatric Management for Borderline Personality Disorder (Gunderson & Links, ) that presented the basics of the approach, videos to illustrate the appropriate clinical skills, and case examples to practice adherence to the approach. Unfortunately, the inclusion of "psychiatric" in the treatment's name may discourage psychologists and other mental health professionals from using this therapy. In this article, we review the basic principles and approaches related to general psychiatric management. With a case example, we illustrate how psychologists can use all the general psychiatric management principles for their patients with BPD, except medications and, as a result, provide and deliver this approach effectively.

Objective Extant literature has documented a significant relationship between borderline symptoms and substance use disorders. As supported in past work, there is a significant theoretical relationship between borderline symptoms and compulsive sexual behaviors because both disorders share common underlying behaviors and traits. There is no known research that has examined the empirical relationship between borderline symptoms and compulsive sexual behaviors in a population with substance use disorders. To fill this important gap in the literature, this relationship was examined in the current study. Method Medical records from 120 women admitted to a private, residential treatment program for substance use disorders were reviewed for the current study. Results Hierarchical multiple regression analysis demonstrated that borderline symptoms were significantly associated with compulsive sexual behaviors after controlling for alcohol use and problems, drug use and problems, age, and positive impression management. Conclusion Results from this study provide potentially important research and clinical implications, which could ultimately aid treatment and reduce relapse. However, continued research is needed to further examine the relationship between symptoms and compulsive sexual behaviors.

The past few decades have seen major progress in the treatment of borderline personality disorder (BPD), a condition that historically has been viewed as difficult to treat. Currently, several evidence-based psychotherapies are available that have generated excitement and hope, yet these developments have also raised new problems that must be addressed. In this special issue, experts in the field of BPD have been invited to share their ideas on some viable directions in the treatment field. This commentary reviews the challenges we currently face and describes the treatment directions presented by the contributors.

Borderline personality disorder (BPD) is a severe, highly prevalent mental disorder. Effective psychological treatments for BPD are available. However, most patients do not receive evidence-based treatments partly because of high treatment delivery costs and lack of specialized therapists. By integrating specialized e-health tools into BPD-specific treatments, treatment intensity can be increased, frequency of face-to-face sessions and burden for psychotherapists can be reduced, and implementation of new skills and experiences in the everyday life of these patients can be promoted. This bears great potential to increase the availability of evidenced-based psychotherapy for BPD patients and close the gap between demand and supply. In this article we present such an innovative e-health tool, priovi, which has been developed for schema therapy. The concept and application of priovi are described and illustrated with a case example.

Although borderline personality disorder (BPD) usually has its onset in young people, its diagnosis and treatment is often delayed. The past 2 decades have seen a rapid increase in evidence establishing that BPD can be diagnosed before 18 years of age and that BPD in young people is both continuous with BPD in adults and more notable for its similarities than for any differences. This knowledge has led to the first wave of controlled treatment trials, which have established that early intervention through appropriate BPD diagnosis and treatment leads to clinically meaningful improvements for patients. However, there is still much work to do in terms of treatment development and innovation and overcoming challenges to successful translation of evidence into practice. To advance early intervention for BPD, access to evidence-based treatments needs to improve, the variety of available treatments (including novel pharmacotherapies) needs to increase, treatments need to be matched to individual development and to the phase and stage of disorder, and workforce development strategies need to update knowledge, culture, and practice in relation to BPD in young people.

Borderline personality disorder (BPD) frequently co-occurs with mood disorders and each influences the course and response to treatment of the other, potentially reducing beneficial outcome. Mentalizing, the ability to infer one's own and others' mental states, is a key factor in both disorders, being a major component of affect regulation and self-identity as well as a central aspect of interpersonal relationships and social function. In this article, we suggest that using mentalization-based treatment may lead to better outcome by addressing the mentalizing problems arising from the dual pathway that leads from depressed mood and BPD to disruption of mentalizing. Some clinical interventions are described to address the mentalizing problems associated with depression and BPD.

Objective This pilot study evaluated a manualized group forgiveness module within dialectical behavior therapy (DBT). Method The study utilized a quasi-experimental double pretest design with adults (N = 40; 88.1% female, 11.9% male) diagnosed with borderline personality disorder in outpatient DBT. Measures of forgiveness, attachment, and psychiatric symptoms were completed at 4 time points. Results Participants showed increases in all measures of forgiveness and decreases in attachment insecurity and psychiatric symptoms during the forgiveness module and maintained to the 6-week follow-up. These effects were not observed during the prior distress tolerance module. Latent change score modeling showed reductions in anxious attachment mediated the effect of changes in benevolent motivations to forgive and trait forgiveness scores on reductions in psychiatric symptoms. Conclusions Effect sizes were similar to meta-analytic findings on (a) forgiveness interventions and (b) reductions in psychiatric symptoms in DBT. Participant feedback suggested elements for further development. A randomized controlled trial is needed.

Objectives We sought to test the Biosocial Theory of borderline personality disorder (BPD) that posits that borderline traits are due to emotional dysregulation, caused by the interaction between childhood emotional vulnerability and invaliding parenting. Method A total of 250 adults (76% female, median age = 32.06 years) from a nonclinical population completed self-report measures assessing current levels of borderline traits and emotional dysregulation. They also completed retrospective measures of childhood emotional vulnerability and parental invalidation. Results Invalidating parenting and emotional vulnerability independently predicted emotion dysregulation, but an interaction effect was not found. Having experienced validating parenting was found to be a protective factor for developing borderline traits but was not significantly related to emotional dysregulation. Conclusion Data in this sample did not support the underlying genesis of BPD proposed by the Biosocial Theory and a model that more parsimoniously explains the development of BPD is proposed.

Objective The aim of the current study was to evaluate the effectiveness of a 6-month course of comprehensive dialectical behavior therapy (DBT) provided in a training clinic with doctoral students as therapists and assessors. Method Clinical outcomes for 50 individuals with borderline personality disorder (80% female, Mage = 29.52 [SD = 9.64]) are reported. Reliable change indices and clinical significance were calculated for measures. Finally, our results were benchmarked against a “gold standard” randomized clinical trial (RCT; McMain et al., 2009). Results Analyses with both the full sample and the treatment completers indicate significant reductions in mental health symptomatology that were reliable, clinically and statistically significant, and comparable in effect size to the benchmarked RCT. Conclusion This DBT training clinic produced good outcomes, comparable to that of a large RCT. Results have implications for who can provide DBT treatment, as well as improving access to DBT in community settings where training clinics may be located.

Objectives The current preliminary study investigated whether deficits in mindfulness (awareness, attentiveness, and acceptance of the present experience) may underlie the relationship of borderline personality disorder (BPD) features to self-injury and overall acts of harmful dysregulated behavior. Method Nonparametric bootstrapping procedures were used to examine theoretical relationships among variables in a psychiatric sample of adults (N = 70). Participants were asked to imagine themselves in distress-inducing situations and then write what they would actually do to decrease distress in such situations. Results As hypothesized, mindfulness statistically mediated the relationship of BPD features to reported acts of (a) self-injury and (b) overall harmful dysregulated behaviors. Conclusions Difficulties in the ability to be aware, attentive, and accepting of ongoing experience may play a role in the relationship of BPD features to harmful dysregulated behaviors. Future research should clarify potential reciprocal effects between BPD features and mindfulness with prospective, multioccasion designs.

Borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) are commonly co-occurring disorders with comorbidity rates up to 58% (Harned, Rizvi, & Linehan, 2010; Zanarini, Frankenberg, Hennen, Reich, & Silk, 2004; Yen et al., 2002). Individuals with BPD and PTSD are more impaired in a variety of areas than those with either disorder alone (Bolton, Mueser, & Rosenberg, 2006; Harned et al., 2010; Pagura et al., 2010), and PTSD often maintains or exacerbates BPD criterion behaviors such as suicidal and nonsuicidal self-injury (NSSI), other impulsive, self-destructive behaviors (e.g., substance use), emotion dysregulation, and dissociation (for a review see Harned, in press). Accordingly, PTSD has been found to decrease the likelihood of remitting from BPD over 10 years of naturalistic follow-up (Zanarini, Frankenburg, Hennen, Reich, & Silk, 2006). Despite the severity and chronicity of impairment in this population, little research has evaluated effective approaches for treating PTSD among BPD patients, particularly those with a severe level of disorder (e.g., suicidal and self-injuring patients). One approach is to provide treatment focused primarily on PTSD. Although several empirically supported treatments for PTSD exist that have been found effective with less severe BPD patients (Feeny, Zoellner, & Foa, 2002; Clarke, Rizvi, & Resick, 2008), these treatments remain largely inaccessible to patients with severe BPD. Exposure-based treatments such as prolonged exposure (PE; Foa, Hembree, & Rothbaum, 2007) have the most empirical support for PTSD (Institute of Medicine, 2007; Powers, Halpern, Ferenschak, Gillihan, & Foa, 2010), but severe BPD patients are likely to be excluded due to safety concerns (e.g., acute suicidality, recent serious self-injury) or other severe comorbidities (e.g., substance dependence, dissociative disorders; Foa et al., 2007). Clinicians in routine practice often use even broader exclusionary criteria for PE that would rule out most if not all BPD patients, including suicidality, dissociation, depression, a history of multiple childhood traumas, and any comorbid diagnosis (Becker, Zayfert, & Anderson, 2004; van Minnen, Hendriks, & Olff, 2010). Similarly, the consensus among PTSD experts is that a treatment approach based primarily on memory processing (such as PE) is inappropriate for cases of “complex PTSD” (i.e., PTSD with associated features that are common in severe BPD such as emotion dysregulation, behavioral dysregulation, and dissociative symptoms; Cloitre et al., 2011). Given the common practice of excluding severe BPD patients from PTSD treatment, little is known about the efficacy of these treatments for this population. A second approach is to provide treatment focused primarily on BPD. Dialectical behavior therapy (DBT; Linehan, 1993) is the most empirically supported treatment available for BPD and has been found effective in reducing suicide attempts, nonsuicidal self-injury (NSSI), general psychological distress, crisis service use, and treatment dropout (Kliem, Kroger, & Kosfelder, 2010; Leichsenring, Leibing, Kruse, New, & Leweke, 2011). DBT focuses primarily on helping BPD patients achieve behavioral control by increasing behavioral skills, and does not typically directly target PTSD. When PTSD is not directly targeted, the rate of PTSD remission during DBT is relatively low (35%; Harned et al., 2008). Nonetheless, treatments such as DBT that focus on teaching coping skills (e.g., emotion regulation, interpersonal effectiveness) are viewed by PTSD experts as safer and more appropriate than treatments focused on memory processing for patients with “complex PTSD” (Cloitre et al., 2011). Thus, DBT may be a reasonable and effective alternative to PTSD-focused treatment for severe BPD patients with PTSD. A third approach is to provide an integrated treatment that targets BPD and PTSD simultaneously. In this case, integrating DBT and PE would represent the best evidence synthesis of the available treatments for BPD and PTSD, respectively. In addition, DBT has been shown to be effective in reducing behaviors commonly used as exclusion criteria for PE among severe BPD patients with PTSD, including imminent suicide risk, suicide attempts, NSSI, severe dissociation, and substance dependence (Harned, Jackson, Comtois, & Linehan, 2010). Thus, an integrated treatment approach that utilizes DBT to increase behavioral skills and achieve stabilization prior to and during PE may be optimal for severe BPD patients with PTSD, and a recent open trial of an integrated DBT and PE treatment showed promising results (Harned, Korslund, Foa, & Linehan, 2012). This type of phase-based treatment (coping skills followed by memory processing) is also endorsed by a majority of PTSD experts as a frontline treatment for “complex PTSD” (Cloitre et al., 2011). Although clinicians and PTSD experts generally believe that PE alone is inappropriate for severe BPD patients and that a skills-focused treatment such as DBT, possibly combined with PE, is preferable, it is unknown whether severe BPD patients share these beliefs. Current best practice standards emphasize the importance of considering patient preferences in the treatment decision-making process (American Psychological Association, 2006), and research indicates that providing patients with their preferred treatment improves outcomes and reduces dropout (Swift & Callahan, 2009). Studies of treatment preferences for PTSD have found that exposure therapy, including PE, is a preferred treatment in undergraduate, trauma-exposed, and treatment-seeking PTSD samples (Angelo, Miller, Zoellner, & Feeny, 2008; Becker, Darius, & Schaumberg, 2007; Cochran, Pruitt, Fukuda, Zoellner, & Feeney, 2008; Feeny, Zoellner, Mavissakalian, & Roy-Byrne, 2009; Tarrier, Liversidge, & Gregg, 2006; Zoellner, Feeny, & Bittinger, 2009; Zoellner, Feeny, Cochran, & Pruitt, 2003), and preliminary evidence suggests that providing PTSD patients with their preferred treatment enhances outcomes (Feeny et al., 2009). These findings suggest that the underutilization of exposure treatments for PTSD, including PE, appears to be primarily due to therapist factors (e.g., lack of training, concerns about PE) rather than client factors (e.g., unwillingness to participate in PE). Several of these studies have also begun to examine predictors of treatment preference, finding that demographic factors (higher education, nonminority status) predict a preference for PE over sertraline, whereas psychopathology factors (more severe PTSD, depression, and anxiety) predict a preference for sertraline over PE (Angelo et al., 2009; Feeny et al., 2009; Zoellner et al., 2009). To date, no research has examined treatment preferences among BPD patients with PTSD specifically, and understanding the treatment preferences of these patients may help to inform and enhance treatment for this difficult-to-treat population. The present study examines this issue in a treatment-seeking sample of suicidal and self-injuring women with BPD and PTSD. Our three primary aims were to (a) determine whether suicidal and self-injuring BPD women with PTSD prefer DBT, PE, or a combined DBT and PE treatment, (b) evaluate the reasons underlying treatment preference, and (c) examine potential predictors of treatment preference that have been evaluated in prior studies (i.e., demographics, PTSD severity, psychological distress/comorbidity) as well as ones new to this study and client population (i.e., intentional self-injury history, emotional experiencing).

Objective Theories point to different mechanisms through which borderline personality disorder (BPD) symptoms may be developed and maintained: (a) emotion regulation dysfunction, (b) problematic relations, and (c) nonintegrated self. However, researchers have not investigated the relative contribution of these mechanisms simultaneously in accounting for the variance observed in BPD symptoms. Method Drawing from university students and Internet users, 462 adults (63% female, 77% Caucasian) completed self-report measures of emotion regulation, interpersonal problems, sense of self, BPD symptoms, and depressive symptoms. Results All predictors were independently associated with BPD symptoms, with emotion regulation difficulties having the strongest relation. For high BPD individuals (N = 94), emotional regulation difficulties was the only predictor uniquely associated with BPD symptoms and interpersonal problems was the sole unique predictor of depressive symptoms. Conclusion These results suggest that emotion regulation difficulties and interpersonal problems may be particularly problematic for those with high BPD symptoms in different ways. Implications and future directions are discussed.

This article describes the rationale for applying interpersonal psychotherapy (IPT) to the treatment of patients who have borderline personality disorder and explains the adaptation of standard IPT to that end. The authors describe the preliminary stages of adapting IPT for a pilot study to test its feasibility and potential efficacy and speculate on potentially therapeutic mechanisms for IPT in treating patients who have borderline personality disorder.

This article presents the Schema Therapy (Young, Klosko, & Weishaar, 2003) approach to the treatment of borderline personality disorder. Schema therapy draws on the cognitive-behavioral, attachment, psychodynamic, and emotion-focused traditions and conceptualizes patients who have borderline personality disorder as being under the sway of five modes or aspects of the self. The goal of the therapy is to reorganize this inner structure. To this end, there are four core mechanisms of change that are used in this therapy: (1) limited reparenting, (2) experiential imagery and dialogue work, (3) cognitive restructuring and education, and (4) behavioral pattern breaking. These interventions are used during the three phases of treatment: (1) bonding and emotional regulation, (2) schema mode change, and (3) development of autonomy.

Mentalization is the process by which we implicitly and explicitly interpret the actions of ourselves and others as meaningful based on intentional mental states (e.g., desires, needs, feelings, beliefs, and reasons). This process is disrupted in individuals with comorbid antisocial (ASPD) and borderline personality disorder (BPD), who tend to misinterpret others' motives. Antisocial characteristics stabilize mentalizing by rigidifying relationships within prementalistic ways of functioning. However, loss of flexibility makes the person vulnerable to sudden collapse when the schematic representation is challenged. This exposes feelings of humiliation, which can only be avoided by violence and control of the other person. The common path to violence is via a momentary inhibition of the capacity for mentalization. In this article, the authors outline their current understanding of mentalizing and its relation to antisocial characteristics and violence. This is illustrated by a clinical account of mentalization-based treatment adapted for antisocial personality disorder. Treatment combines group and individual therapy. The focus is on helping patients maintain mentalizing about their own mental states when their personal integrity is challenged. A patient with ASPD does not have mental pain associated with another's state of mind; thus, to generate conflict in ASPD by thinking about the victim will typically be ineffective in inducing behavior change.

Alterations in hypothalamic-pituitary-adrenal axis feedback regulation have been repeatedly reported in patients with borderline personality disorder (BPD). Due to the cross-sectional design of these studies, little is known about the longitudinal course of HPA axis functioning. In a sample of 13 patients with BPD, the dexamethasone suppression test (DST) has been used in a one-year follow-up study. There were no changes of cortisol concentrations before or after dexamethasone intake between baseline and follow-up examination. Patients with comorbid posttraumatic stress disorder (PTSD) showed more pronounced cortisol suppression compared to those without PTSD. The DST seems to be a stable marker of alterations in HPA axis feedback regulation in BPD, which is also reflected by substantial correlations between percentage of cortisol suppression at baseline and follow-up examination.

Preliminary evidence suggests that cognitive therapy (CT) is effective in treating borderline personality disorder (BPD). According to cognitive theory, BPD patients are characterized by dysfunctional beliefs that are relatively enduring and inflexible and that lead to cognitive distortions such as dichotomous thinking. When these beliefs are activated, they lead to extreme emotional and behavioral reactions, which provide additional confirmation for the beliefs. It is hypothesized that a change in dysfunctional beliefs is the primary mechanism of change associated with CT. However, additional mechanisms of change are likely also at work in CT, including enhancement of skills, reduction in hopelessness, and improvement in attitude toward treatment. Each of these mechanisms is discussed in light of cognitive theory, data from an open clinical CT trial, relevant literature, and therapeutic interventions. Findings from the CT trial support the role of cognitive change during therapy and its continuation after termination.

A major development in the field of psychotherapy research is the growing recognition of the need for evidence on the mechanisms of change in psychotherapy. The empirical evidence that psychotherapy has a positive and significant effect must be amplified with data on the mechanisms of action in the various psychotherapies. This special issue is devoted to the articulation of putative mechanisms of change in the psychotherapy of patients with borderline personality disorder by leading researchers in this field.

Although results have been variable, studies suggest that individuals with borderline personality disorder (BPD) exhibit cognitive deficits suggestive of frontal- and temporal-lobe dysfunction. Patients diagnosed with BPD (n = 18) using two structured interviews, and who were carefully screened for neurological and substance-use disorders, were compared to depressed patients (n = 18) and a nonpsychiatric control group (n = 18) on a series of neuropsychological tasks. The role of emotion on cognitive functioning was assessed by including emotional stimuli and interference on several of the tasks. Little support was found for the neurobehavioral hypothesis of BPD. The BPD group performance did not differ from the normal group on most tasks of executive functioning or memory, and the introduction of emotional stimuli did not impair performance. The depressed group performed less effectively than the other groups. Reasons for variable findings and factors affecting the cognitive functioning of patients with BPD are discussed. There may be considerable heterogeneity in the cognitive functioning of BPD patients, with those exhibiting significant cognitive deficits comprising only a subgroup.

The purpose of this study was to examine psychotherapists' differential countertransference reactions toward either clients diagnosed with either Major Depression or Borderline Personality Disorder. Specifically, psychotherapists' personal perceptions and emotional reactions to these clients were assessed utilizing the Impact Message Inventory and the Stress Appraisal Scale (N = 155). Direct feelings, action tendencies, cognitive attributions, and perceived anxiety were evaluated. Results indicated that clients with Borderline Personality Disorder are perceived as significantly more dominant and hostile, whereas clients with Major Depression were considered significantly more submissive, friendly, and salient. In addition, it was found that as clinicians' years of experience increased, degree of countertransference decreased. These results suggest that countertransference reactions can be measured empirically, that differential countertransference reactions are evoked toward clients manifesting different symptoms, and that awareness of countertransference may be important for positive therapeutic outcome.

Intentional self-harm behavior is an important clinical phenomenon that appears highly related to borderline personality disorder (BPD). Self-harm behavior in the context of borderline personality probably exists along a continuum from graphic, self-harm behavior to milder forms of self-sabotaging behavior that might be viewed as self-defeating Relatively little attention has been paid to developing a self-report measure of intentional self-harm, particularly as a screening device for detecting BPD. In Study 1, an initial list of self-harm behaviors encountered in clinical practice was narrowed to those behaviors related to BPD in a sample comprised of adults from both a mental health and non-mental health setting. All participants (N = 221) underwent a semistructured diagnostic interview for BPD. Using a cut-off score of 5 on the resulting 22-item Self-Harm Inventory (SHI), 83.7% of research participants were correctly classified as having BPD or not. In Study 2, women (N = 285) sampled from an outpatient medical setting completed the SHI and a widely used self-report measure of BPD. The SHI cut-off score resulted in correct classification of 87.9% of the individuals. In Study 3, using a sample of adults involuntarily hospitalized for psychiatric reasons (N = 32), the SHI performed at least as well as another self-report measure of BPD in diagnosing participants (the final diagnosis was based on a semistructured interview). The results are discussed with regard to potential advantages and utility of the SHI and need for further validation.

Rorschach data has been useful in identifying the DSM Borderline Personality Disorder (BPD) and has potential for improving our understanding of this disorder. Recently, the DSM-IV BPD has been shown to be composed of 3 primary or core factors: Factor I-unstable self-other images. Factor II-deficits in affect and thought modulation, and Factor III-impulsive self-damaging actions. In a sample of outpatients with personality disorders. we explored the relationships among 6 psychoanalytically derived Rorschach scales (primitive aggression, oral dependency, self-other differentiation, splitting, devaluation, and projective identification), and the core BPD features. Significant correlations were found between 5 of the Rorschach variables and BPD total scores. Correlations between these 5 variables and the BPD core features showed that oral dependency needs were negatively associated with all 3 BPD core features, whereas the defenses of devaluation and splitting were positively associated with these core features. The clinical implications of these findings are reviewed.

This study focused on the clinical field validity of the Rorschach comprehensive system revised DEPI and CDI indices. Forty admission protocols from two inpatient adult DSM-III-R diagnosed samples, one with Major Depressive Disorder, uncomplicated, and one with Major Depressive Disorder and concurrent Borderline Personality Disorder, were compared. Hypotheses were (a) both groups would be identified by the revised DEPI and (b) if the Depressed Borderline group was not identified by the DEPI, it would be identified by the CDI. Both hypotheses were negated, raising questions regarding the validity of the indices for use in clinical diagnosis, treatment, and clinical research.

This study tested the hypothesis that borderline personality characterizes extreme violence by assessing features of borderline and schizotypal personality in three groups: Murderers, Violent, and Nonviolent adult offenders. Murderers had higher borderline personality scores than nonviolent offenders (p < .04). A test for linear trend indicated a linear increase in borderline scores with increasing degree of violence across the three groups (p < .02). No group differences were observed for schizotypal personality. Borderline traits associated with extreme violence consisted of unstable, intense relationships and affective instability. Group differences were not an artifact of group differences in age, social class, IQ, or number of previous custodies. It is concluded that borderline personality may predispose toward extreme forms of violence.

Concerns have been raised that individuals who are having difficulty coming out as gay or bisexual may be misdiagnosed with borderline personality disorder. In this analogue study, 141 psychologists evaluated a hypothetical client with problems that resembled borderline symptoms but were also consistent with a sexual identity crisis. Client descriptions varied by sexual orientation and gender. Results revealed an effect of sexual orientation for male clients, but not female clients. Male clients whom therapists perceived likely to be gay or bisexual, and male clients with partners of unspecified gender, were more likely to be diagnosed with borderline personality disorder. Therapists were more confident and willing to work with female clients and gave them a better prognosis. Therapists' responses are discussed in light of gender role bias and social desirability.

Attachment theory provides a framework for understanding and predicting critical aspects of aggression in the personality disorders. An association between borderline personality disorder (BPD) and insecure forms of adult attachment marked by high relationship anxiety has been repeatedly observed in the empirical literature. Aggression also has been linked to insecure attachment. The present study extends previous work by exploring the degree to which the underlying attachment dimensions of relationship anxiety and avoidance are associated in BPD with the following forms of hostility: (a) direct aggression (verbal or physical) initiated towards others, (b) expectation/perception of aggression from others (including "reactive" counteraggression when/if provoked), (c) aggression directed towards the self in the form of suicidality or parasuicidality, and (d) affective experience of irritability or anger. The issue was studied in a sample of 92 patients diagnosed with BPD. Results show significant association between more fearful forms of attachment (simultaneous presence of relationship anxiety and avoidance) and the more reactive form of aggression involving expectation of hostility from others. Self-harm was significantly associated only with relational avoidance while anger and irritability were associated only with relational anxiety. Implications for understanding relational aspects of BPD aggression in research and clinical work are discussed.

Relations among symptoms of the Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR; American Psychiatric Association, 2000) borderline personality disorder (BPD) assessed using semistructured clinical interviews were examined using exploratory principal components analysis in a sample of 82 college men and women who were symptomatic for BPD (30.4% of whom met criteria for a BPD diagnosis at threshold or subthreshold certainty level). A three-component solution was found and, as expected, the first component was characterized by interpersonal instability and included unstable relationships, identity disturbance, and chronic emptiness. The second component reflected affective instability and low impulsivity. The third component reflected stress-related paranoia and low anger. Results highlight similarities in the structure of BPD criteria in clinical and nonclinical samples, and could inform future research on dimensional models of BPD. © 2007 Wiley Periodicals, Inc. J Clin Psychol 63: 805–816, 2007.

This study is an attempt to delineate symptom clusters that may be considered most distinctive of patients diagnosed with borderline personality disorder (BPD). Medical records were examined to assess the extent to which each of the eight DSM-III-R BPD criteria was present in 89 psychiatric in-patients diagnosed with BPD. Structural analysis revealed three symptom clusters that can explain symptomatology for a majority of the sample. BPD patients can be identified initially by a core factor and separated subsequently into several BPD subtypes based on the patients' remaining symptomatology. A hierarchical diagnostic scheme for delineating BPD subtypes is proposed, and the implications of these findings for a theoretical separation of several BPD subtypes are discussed.

Psychotherapists' reactions to patients with borderline personality disorder were assessed by semantic differential ratings in an analogue study. Vignettes presented one of two patients who enacted the Rewarding and Withdrawing object relations units in two separate therapy sessions. In response to the Rewarding object relations unit therapists evaluated themselves more positively and perceived themselves as more active and more potent than in response to the Withdrawing object relations unit (p less than .01). They also evaluated the patients more positively and perceived them as less active (p less than .01). These patterns were modified by some order effects and some differences in response to the two vignettes, which represented a lower and higher functioning borderline patient.

The influence of certain personality characteristics (tendency to depressive experiences, personal boundary preferences) on psychotherapist reaction to patients with borderline personality disorder was assessed by semantic differential ratings in an analogue study. Vignettes presented one of two patients enacting the Rewarding and Withdrawing object relations unit in two separate therapy sessions. Therapists higher on anaclitic depressive and fusion tendencies evaluated themselves less positively than other therapists (p less than .01) in the Withdrawing condition. They evaluated the patient less positively regardless of condition (p less than .05). High boundary therapists evaluated patients more positively (p less than .05) in the Withdrawing condition. They evaluated themselves more positively regardless of condition (p less than .05) and showed less tendency to devalue self and patient with the lower functioning borderline patient.

We address how Transference Focused Psychotherapy (TFP) conceptualizes mechanisms in the cause and maintenance of borderline personality disorder (BPD) as well as change mechanisms both within the patient and in terms of specific therapists' interventions that engender patient change. Mechanisms of change at the level of the patient involve the integration of polarized representations of self and others; mechanisms of change at the level of the therapist's interventions include the structured treatment approach and the use of clarification, confrontation, and "transference" interpretations in the here and now of the therapeutic relationship. In addition, we briefly review evidence from our group regarding the following hypothesized mechanisms of change: contract setting, integration of representations, and changes in reflective functioning (RF) and affect regulation.

Although clinical theories suggest that people with Borderline Personality Disorder (BPD) experience a confused sense of self, little empirical research has directly examined the self in BPD (Heard & Linehan, 1993; Westen & Cohen, 1993). In this study, 43 female participants, 15 with BPD and 28 without BPD, completed the closed-ended version of Markus and Wurf's (1987) Possible Selves Questionnaire (PSQ). Participants with BPD were less likely than controls to endorse positive possible selves as current, but more likely to endorse negative possible selves as current, probable, desired, and important. Participants with BPD linked negative and positive selves to their desired selves, which is consistent with the unstable sense of self characteristic of BPD.

The division between Axis I clinical syndromes and Axis II personality disorders is a long-standing distinction based primarily on three guiding principles: phenomenology, cause, and course. Clinical syndromes were generally thought to be characterized by transient symptoms with biological causes and an unstable course; personality disorders were supposed by many to be characterized by long-standing personality traits, whose roots were primarily psychological, and a stable and unremitting course. Borderline personality disorder (BPD), however, is a condition characterized by distinct clinical symptoms, varied causes, and a relatively unstable course. Past theorizing about the distinction between Axis I and Axis II disorders is presented in light of recent empirical evidence refuting the rationalization for the separation of personality disorders and clinical syndromes using BPD as a means for comparison.

To evaluate the possibility of an underlying dimension of organicity in borderline personality disorder (BPD), a carefully diagnosed group of borderline patients was assessed across a wide range of neuropsychological functions and then was compared to an age- and education-matched non-patient control group. The BPD group had significantly lower Verbal, Performance, and Full Scale IQ scores on the WAIS-R. The BPD group also was impaired significantly on motor skills, figural memory, complex visuomotor integration, social or interpersonal intelligence, and on a measure of susceptibility to interference. This pattern of deficits localized to the fronto-temporal regions and became more pronounced when a subgroup analysis was performed. This study suggests that subtle organic factors may be operative in some, but not all, BPD patients.