Testing the Biosocial Theory of Borderline Personality Disorder: The Association of Temperament, Early Environment, Emotional Experience, Self-Regulation and Decision-Making

Borderline Personality Disorder (BPD), as defined by the DSM-IV-TR (APA, 2000), is a multifaceted mental illness characterized by pervasive instability of interpersonal relationships, self-image, affect and behavior. Despite a growing consensus that the etiological basis of BPD stems from a combination of biological vulnerability and an early developmental history characterized by invalidation, abuse and/or neglect (e.g., Clarkin, Marziali, & Munroe-Blum, 1991; Linehan, 1993), the reasons for the diversity of troubling symptoms (e.g., self-injury, suicidality, mood reactivity, relationship difficulties) remain unclear. Psychopathology theorists differ in their conceptualization of the fundamental problems (e.g., impulsivity vs. identity disturbance vs. emotion dysregulation) underlying BPD and further research is needed to clarify which features are central to the maintenance of the difficulties associated with the disorder. In the current research, the some of the tenets of Linehan’s (1993) biosocial theory of BPD and the core constructs implicated in her conceptualization of the disorder were explored empirically in several samples of undergraduate university students. According to the biosocial theory, difficulties regulating emotions represent the core pathology in the disorder and contribute causally to the development and expression of all other BPD features. The emotional dysregulation is proposed to emerge from transactional interactions between individuals with biological vulnerabilities (i.e., a highly arousable temperament, sensitive to both positive and negative emotional stimuli) and specific environmental influences (i.e., a childhood environment that invalidates their emotional experience). The theory asserts that the dysregulation affects all aspects of emotional responding, resulting in (i) heightened emotional sensitivity, (ii) intense and more frequent responses to emotional stimuli, and (iii) slow return to emotional baseline. Furthermore, Linehan proposed that individuals with BPD lack clarity with respect to their emotions, have difficulties tolerating intense affect, and engage in maladaptive and inadequate emotion modulation strategies. As a result of their dysfunctional response patterns during emotionally challenging events , individuals with BPD fail to learn how to solve the problems contributing to these emotional reactions. In accordance with this theory, a number of hypotheses were tested. First, it was hypothesized that the interaction between temperamental sensitivity and an adverse childhood environment would predict BPD features over and above that predicted by either construct independently. Second, it was hypothesized that BPD traits would be predicted by high levels of emotional dysregulation (affect lability), problems across different aspects of emotional experience (e.g., intensity, awareness, clarity), and deficits in emotion regulation skills (e.g., poor distress tolerance, self-soothing). Based on the initial findings of the research, a series of competing hypotheses were tested that addressed the nature of the emotional, cognitive and motivational mechanisms that may underlie maladaptive behavior in BPD more directly. Prior to testing these hypotheses, it was important to select a set of measures that would best represent these constructs within an undergraduate population. The purpose of Studies 1a and 1b (N = 147 and N = 56, respectively) was to determine the reliability and validity of a series of self-report measures that assess BPD features and to select one questionnaire with high sensitivity (percentage of cases correctly identified) and high specificity (percentage of noncases correctly identified) as a screener for BPD within undergraduate students by comparing the results of the questionnaires against a “gold standard” criterion diagnosis of BPD (as assessed by two semi-structured interviews: DIB-R and IPDE-I). The second goal of these studies was to conduct a preliminary exploratory analysis of the association of scores on the BPD measures and constructs that have been hypothesized to be relevant to the development and maintenance of BPD symptoms (e.g., “Big Five” personality factors, emotional experience, impulsivity). Overall, the findings of Studies 1a and 1b indicated that screening for BPD in an undergraduate population is feasible and there are several questionnaires that may help in the identification of participants for future studies. Specifically, the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD; Zanarini et al., 2003), International Personality Disorder Examination DSM-IV Screening Questionnaire (IPDE-S; Loranger, 1999) and Borderline Personality Questionnaire (BPQ; Poreh et al., 2006) were all found to be internally consistent and valid screening measures. Furthermore, the results of correlation and regression analyses between dimensions of the “Big Five” and scores on the BPD measures were consistent with previous findings in the literature that BPD is associated with higher scores on neuroticism, lower scores on agreeableness, and to a lesser degree, lower scores on conscientiousness and extraversion. The similarity in results between the current and past studies suggested that individuals in the present samples showed characteristics consistent with that seen in both clinical and nonclinical populations with BPD traits. The results also provided support for the notion that individuals with BPD have a lower threshold (i.e., greater sensitivity) for both sensory and affective stimuli, as well as higher amplitude of emotional response (i.e., greater reactivity) to such stimuli. Furthermore, the findings suggested that those with BPD traits may lack understanding of their emotional state, may be unable to effectively regulate their emotional state, and that their impulsive behavior may be driven by negative affect. The purpose of Study 2 (N = 225) was to test some of the specific tenets of Linehan’s (1993) biosocial theory. The results suggested that BPD traits are associated with numerous dimensions of temperament [e.g., higher levels of negative affect; lower levels of positive affect; lower levels of effortful control; low sensory threshold (i.e., greater sensitivity) for both sensory and affective stimuli; ease of excitation (i.e., greater reactivity to sensory and affective stimuli)] and childhood environment (e.g., authoritarian parenting style, invalidating parenting, neglect, abuse). An examination of the interactions between dimensions of temperament and childhood environment suggested that interactions between (i) ease of excitation (greater reactivity to sensory and affective stimuli) and environment and (ii) trait negative affect and environment, predicted BPD symptoms over and above the temperament and environment variables alone. The results also suggested that a number of other factors are associated with BPD symptoms, including: increased attention to (or absorption in) emotional states, poor emotional clarity, affect lability (particularly anger), poor distress tolerance, and negative urgency (impulsive behavior in the context of negative affect). The association between BPD symptoms and difficulties identifying feelings seemed to be mediated by affect lability and negative urgency. Self-soothing and self-attacking did not predict BPD traits over and above the other variables. Wagner and Linehan (1999) also proposed that the intense emotions (and emotional dysregulation) experienced by those with BPD interferes with cognitive functioning and effective problem solving, resulting in poor decisions and the observed harmful behaviors. Other researchers have suggested that the repetitive, self-damaging behavior occurring in the context of BPD may reflect impairments in planning and failure to consider future consequences (e.g., van Reekum et al., 1994). Proponents of this view suggest that individuals with BPD show greater intensity and lability in their emotional response to their environment because they are unable to inhibit or moderate their emotional urges (i.e., impulsivity is at the core of the disorder). The purpose of Study 3 (N = 220) was to characterize decision making in an undergraduate sample of individuals with BPD traits and to ascertain the relative contribution of individual differences in the following areas to any deficits identified in decision making: emotional experience (e.g., increased affective reactivity or lability); reinforcement sensitivity (e.g., sensitivity to reward and/or punishment); impulsivity; executive functioning (measured by an analogue version of the Wisconsin Card Sorting Test); and reversal learning. Decision making was assessed using modified versions of two Iowa Gambling Tasks (IGT-ABCD and IGT-EFGH; Bechara, Damasio, Damasio, & Anderson, 1994; Bechara, Tranel, & Damasio, 2000) that included reversal learning components (i.e., Turnbull et al., 2006). The results of Study 3 showed that participants in the BPD group demonstrated deficits in decision-making as measured by the IGT-ABCD but not on the IGT-EFGH. The results [interpreted in the context of reinforcement sensitivity models, the somatic marker hypothesis (Damasio, 1994) and the “frequency of gain” model e.g., Chiu et al. 2008)] suggested that decision making under uncertainty may be guided by gain-loss frequency rather than long-term outcome for individuals with BPD traits. The results failed to show consistent associations between BPD symptoms and performance on either version of the IGT. Individual differences in emotional experience, executive functioning or reversal learning did not account for the decision-making problems of the BPD group on the IGT-ABCD

Aktualne cele, możliwości i perspektywy leczenia młodzieńczego idiopatycznego zapalenia stawów w Polsce i na świecie

  Młodzieńcze idiopatyczne zapalenie stawów (MIZS) to najczęstsza artropatia zapalna wieku dziecięcego. Przewlekły proces zapalny, uszkadza chrząstkę stawową, nasady kostne oraz powoduje powikłania pozastawowe. Ważnym problemem nadal jest jak najwcześniejsze rozpoznanie choroby, zwłaszcza u dzieci w najmłodszej grupie wiekowej. Nadal kluczowym zagadnieniem jest znalezienie optymalnego sposobu leczenia u każdego dziecka chorującego na MIZS. Aktualne zasady i cele leczenia MIZS omówiono zgodnie z najnowszymi rekomendacjami European League Against Rheumatism/American College of Rheumatology (EULAR/ACR). Osiągnięcie optymalnych efektów i określonych celów terapii jest bardziej prawdopodobne, gdy jest ona zastosowana tak wcześnie jak to tylko możliwe, z uwzględnieniem postaci choroby, aktywności procesu chorobowego oraz czynników złej prognozy. Forum Reumatol. 2016, tom 2, nr 1, 14–20 Słowa kluczowe: MIZS; powikłania; predyktory złego rokowania; biomarkery; rekomendacje terapeutyczne

Zalecenia ACR 2019 leczenia młodzieńczego idiopatycznego zapalenia stawów a możliwości terapii w warunkach polskich

W niniejszym opracowaniu przedstawiono zasady leczenia młodzieńczego idiopatycznego zapalenia stawów (MIZS) z uwzględnieniem koncepcji Treat to Target, czyli terapii zmierzającej do uzyskania remisji bądź, gdy jest to niemożliwe, alternatywnie niskiej aktywności choroby na podstawie opublikowanych w 2019 roku rekomendacji American College of Rheumatology (ACR). Autorzy pracy odnoszą się jednocześnie do możliwości realizacji tych zaleceń w warunkach polskich, z uwzględnieniem programu lekowego B.33 i podkreślają, że opcje terapeutyczne w MIZS powinny uwzględniać zarówno indywidualny przebieg choroby, jak i dostępne możliwości leczenia w obowiązującym w Polsce systemie prawnym i organizacyjnym

Comparing depression screening tools in persons with multiple sclerosis (MS)

Objective: Depression is more common among persons with multiple sclerosis (MS) than the general population. Depression in MS is associated with reduced quality of life, transition to unemployment, and cognitive impairment. Two proposed screening measures for depression in MS populations are the Hospital Anxiety and Depression Scale (HADS) and the Beck Depression Inventory-Fast Screen (BDI-FS). Our objective was to compared the associations of the BDI-FS and the HADS-D scores with history of depressive symptoms, fatigue, and functional outcomes to determine the differential clinical utility of these screening measures among persons with MS. Method: We reviewed charts of 133 persons with MS for demographic information; scores on the HADS, BDI-FS, a fatigue measure, and a processing speed measure; and employment status. Results: Structural equation modeling results indicated the HADS-D predicted employment status, disability status, and processing speed more effectively than did the BDI-FS, whereas both measures predicted fatigue. Conclusions: This study suggests the HADS-D is more effective than the BDI-FS in predicting functional outcomes known to be associated with depression among persons with MS. (PsycInfo Database Record (c) 2023 APA, all rights reserved

Pląsawica u 13-letniej dziewczynki jako pierwszy objaw tocznia rumieniowatego układowego, a może innej zapalnej choroby tkanki łącznej? Opis przypadku

Pląsawicę określa się jako mimowolne hiperkinetyczne zaburzenia, polegające na nagłych, nieregularnych, bezcelowych ruchach dotyczących obwodowych części ciała. Wśród wyodrębnionych w klasyfikacji American College of Rheumatology (ACR) zaburzeń ruchowych w przebiegu tocznia rumieniowatego układowego (SLE) pląsawica odgrywa wiodącą rolę. Przyczyną pląsawicy są zmiany zwyrodnieniowe bądź naciekowo-zapalne w strukturach zwojów podstawnych, których zajęcie obserwuje się również w zespołach antyfosfolipidowych (APS). W pracy przedstawiono nietypowy przypadek 13-letniej dziewczynki, u której przez kilka tygodni obserwowano nasilające się ruchy mimowolne dotyczące prawej kończyny górnej. Po przeprowadzeniu szerokiej diagnostyki różnicowej wykluczono przyczyny neurologiczne objawów, zaś z uwagi na zaburzenia koagulologiczne oraz obciążający wywiad rodzinny w kierunku chorób autoimmunologicznych u pacjentki wysunięto podejrzenie SLE. W badaniach dodatkowych, poza utrzymującymi się zaburzeniami w zakresie układu krzepnięcia, stwierdzano graniczne miano przeciwciał ANA, bez obecności przeciwciał anytgenowo-swoistych. Pacjentka spełniała kryteria laboratoryjne APS. Wobec nasilania się objawów pląsawiczych pod postacią powłóczenia kończyny dolnej i bełkotliwej mowy, u pacjentki zdecydowano o rozszerzeniu diagnostyki obrazowej o badanie SPECT uwidaczniając rozsiane ogniska niedokrwienne. Pomimo że pacjentka nie spełniała kryteriów rozpoznania SLE, w leczeniu zastosowano pulsy z metylprednizolonu, uzyskując spektakularną poprawę kliniczną

The Polish version of the Juvenile Arthritis Multidimensional Assessment Report (JAMAR)

The Juvenile Arthritis Multidimensional Assessment Report (JAMAR) is a new parent/patient-reported outcome measure that enables a thorough assessment of the disease status in children with juvenile idiopathic arthritis (JIA). We report the results of the cross-cultural adaptation and validation of the parent and patient versions of the JAMAR in the Polish language. The reading comprehension of the questionnaire was tested in 10 JIA parents and patients. Each participating centre was asked to collect demographic, clinical data and the JAMAR in 100 consecutive JIA patients or all consecutive patients seen in a 6-month period and to administer the JAMAR to 100 healthy children and their parents. The statistical validation phase explored descriptive statistics and the psychometric issues of the JAMAR: the 3 Likert assumptions, floor/ceiling effects, internal consistency, Cronbach\u2019s alpha, interscale correlations, test\u2013retest reliability, and construct validity (convergent and discriminant validity). A total of 154 JIA patients (10.4% systemic, 50.0% oligoarticular, 24.7% RF-negative polyarthritis, 14.9% other categories) and 91 healthy children, were enrolled in two centres. The JAMAR components discriminated well healthy subjects from JIA patients. All JAMAR components revealed good psychometric performances. In conclusion, the Polish version of the JAMAR is a valid tool for the assessment of children with JIA and is suitable for use both in routine clinical practice and clinical research

Secukinumab in the treatment of patients with juvenile idiopathic arthritis categories of enthesitis-related arthritis and juvenile psoriatic arthritis — an experts’ opinion of the Polish Society of Rheumatology and the Section of Developmental Age Rheumatology of the Polish Society for Rheumatology

According to the juvenile idiopathic arthritis (JIA) classification criteria there are two categories of the disease within the spondyloarthropathies spectrum — enthesitis-related arthritis (ERA) and juvenile psoriatic arthritis (JPsA). These are chronic rheumatic paediatric diseases, that manifest themselves with heterogeneous clinical symptoms and comorbidities, resulting in pain, growth and development impairment, deteriorated physical fitness and lowered health-related quality of life. Juvenile spondyloarthropathies may occur in 25 percent of patients with JIA. The age of onset usually is above 10, but it happens that correct diagnosis is delayed by a few years. Problems with a diagnosis of axial spondyloarthropathy in children may arise from the fact, that inflammation of the sacroiliac joints may be clinically silent at the beginning of the disease, which results in lesser sensitivity of the Assessment in SpondyloArthritis international Society classification criteria for axial spondyloarthropathies in paediatric practice. Concurrently it is key to rapidly introduce effective treatment, that should enable proper development and further life without active inflammation and its long-term complications. Guidelines for the pharmacotherapy of children with JIA include the use of non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticosteroids (GCSs), classic disease-modifying anti-rheumatic drugs (cDMARDs) and biological treatment. Amongst biologics, drugs that for a long time are used in various categories of JIA are medications out of the TNF alpha inhibitors group. Unfortunately, there is a large group of patients for whom such therapy is inadequate or unavailable (no biological therapy is currently reimbursed in the ERA and JPsA categories). This leads to prolonged corticosteroid therapy, the complications of which are drastic for a growing child. Out of therapies with a different mechanism of action, in the population of patients with ERA and JPsA inhibiting interleukin 17 (IL-17) proved to be effective. One medication out of this group — secukinumab (SEC) — in June 2022 was granted market authorization for use in these disease categories based on the findings of the JUNIPERA clinical registration trial. This study demonstrated that SEC (added to the option to use conventional disease-modifying anti-rheumatic drugs — SEC ± cDMARDs) allows a statistically significant reduction of the disease flare risk by 72% in comparison to the PLC ± cDMARDs group. What is more, better results have been attained in the SEC group with regard to such clinical symptoms as: JIA ACR 30, 50, 70, 90, and 100 responses, inactive disease status, enthesitis count, or the active joint count. During the JUNIPERA trial no deaths have been recorded. Differences in the adverse events rates between the SEC and placebo groups were small and clinically insignificant. The rate of serious adverse events was low both in the SEC treatment group as well as placebo. The above results show that patients with ERA and JPsA have gained a new effective and safe therapeutic option, that addresses an unmet medical need in that group of patients. Adequately rapid implementation of IL-17 inhibitors may prevent mobile disability and extraarticular damage in patients with ERA and JPsA