Enhanced 'Reading the Mind in the Eyes' in borderline personality disorder compared to healthy controls.

BACKGROUND: Borderline personality disorder (BPD) is partly characterized by chronic instability in interpersonal relationships, which exacerbates other symptom dimensions of the disorder and can interfere with treatment engagement. Facial emotion recognition paradigms have been used to investigate the bases of interpersonal impairments in BPD, yielding mixed results. We sought to clarify and extend past findings by using the Reading the Mind in the Eyes Test (RMET), a measure of the capacity to discriminate the mental state of others from expressions in the eye region of the face. METHOD: Thirty individuals diagnosed with BPD were compared to 25 healthy controls (HCs) on RMET performance. Participants were also assessed for depression severity, emotional state at the time of assessment, history of childhood abuse, and other Axis I and personality disorders (PDs). RESULTS: The BPD group performed significantly better than the HC group on the RMET, particularly for the Total Score and Neutral emotional valences. Effect sizes were in the large range for the Total Score and for Neutral RMET performance. The results could not be accounted for by demographics, co-occurring Axis I or II conditions, medication status, abuse history, or emotional state. However, depression severity partially mediated the relationship between RMET and BPD status. CONCLUSIONS: Mental state discrimination based on the eye region of the face is enhanced in BPD. An enhanced sensitivity to the mental states of others may be a basis for the social impairments in BPD.

The relationship of childhood abuse to impulsivity and suicidal behavior in adults with major depression.

OBJECTIVE: This study investigated whether a higher frequency of reported childhood trauma would be found in depressed adults with higher levels of trait impulsivity, aggression, and suicidal behavior. METHOD: In 136 depressed adult inpatients, the authors assessed trait impulsivity, aggression history, and number of lifetime suicide attempts as well as the medical lethality and the intent to die associated with the most lethal attempt. These variables were then compared between those with and those without a reported history of childhood physical or sexual abuse. RESULTS: Subjects who reported an abuse history were more likely to have made a suicide attempt and had significantly higher impulsivity and aggression scores than those who did not report an abuse history. Impulsivity and aggression scores were significantly higher in subjects with a history of at least one suicide attempt. A logistic regression analysis revealed that abuse history remained significantly associated with suicide attempt status after adjustment for impulsivity, aggression history, and presence of borderline personality disorder. Among those who attempted suicide, there were no significant differences in severity of suicidal behavior between those with and without a childhood history of abuse. CONCLUSIONS: Abuse in childhood may constitute an environmental risk factor for the development of trait impulsivity and aggression as well as suicide attempts in depressed adults. Alternatively, impulsivity and aggression may be inherited traits underlying both childhood abuse and suicidal behavior in adulthood disorders. Additional research is needed to estimate the relative contributions of heredity and environmental experience to the development of impulsivity, aggression, and suicidal behavior.

Neuropsychological dysfunction in depressed suicide attempters.

OBJECTIVE: Neuropsychological deficits in the context of psychiatric disease may be associated with suicide risk. In this study, neuropsychological performance was compared among depressed patients with at least one prior suicide attempt of high lethality, depressed patients with low-lethality prior attempts, depressed patients with no prior suicide attempts, and nonpatients. METHOD: Fifty unmedicated patients in a major depressive episode (21 with no history of suicide attempts and 14 and 15 patients with previous attempts of low and high lethality, respectively) and 22 nonpatients were assessed. Groups were comparable in age, education, occupational level, and estimated premorbid intelligence. The neuropsychological battery produced scores within five composite domains: general intellectual functioning (current), motor functioning, attention, memory, and executive functioning. RESULTS: Patients whose prior suicide attempts were of high lethality performed significantly worse than all groups on tests of executive functioning and were the only group to perform significantly worse than nonpatients on tests of general intellectual functioning, attention, and memory. A discriminant function analysis revealed two prominent dimensions in the data: one that discriminated high-lethality suicide attempters from all other groups (primarily associated with performance on tests of executive functioning) and another that discriminated all depressed patient groups from nonpatients (associated with performance on measures of attention and memory). For the patients with high-lethality prior suicide attempts, deficits did not appear to reflect diffuse brain damage from past attempts, since the results of tests commonly affected by diffuse injury were not selectively impaired. CONCLUSIONS: Neuropsychological deficits in depressed patients with high-lethality prior suicide attempts suggest impairment of executive functioning beyond that typically found in major depression. This more extensive neuropsychological impairment in the context of depression may be a risk factor for severe suicide attempts.

Characteristics of borderline personality disorder associated with suicidal behavior.

OBJECTIVE: This study examined the relationship between characteristics of borderline personality disorder and suicidal behavior. The authors hypothesized that a specific feature of borderline personality disorder, impulsivity, and childhood trauma, a possible etiological factor in the development of impulsivity, would be associated with suicidal behavior. METHOD: Information on lifetime history of suicidal behavior was obtained from 214 inpatients diagnosed with borderline personality disorder by structured clinical interview. The authors examined the relationship between DSM-III-R criteria met and the following measures of suicidal behavior: presence or absence of a previous suicide attempt, number of previous attempts, and lethality and intent to die associated with the most lethal lifetime attempt. RESULTS: Impulsivity was the only characteristic of borderline personality disorder (excluding the self-destructive criterion) that was associated with a higher number of previous suicide attempts after control for lifetime diagnoses of depression and substance abuse. Global severity of pathology of borderline personality disorder was not associated with suicidal behavior. History of childhood abuse correlated significantly with number of lifetime suicide attempts. CONCLUSIONS: The trait of impulsivity is associated with number of lifetime suicide attempts and may therefore be a putative risk factor for a future suicide attempt. If so, impulsivity is a potential target therapeutically for prevention of future suicide attempts. The association between childhood abuse and number of lifetime suicide attempts is consistent with the hypothesis that childhood abuse is an etiological factor in the development of self-destructive behaviors.

Relationship of dissociation to self-mutilation and childhood abuse in borderline personality disorder.

OBJECTIVE: This study sought to document the prevalence of dissociative experiences in adult female inpatients with borderline personality disorder and to explore the relationship between dissociation, self-mutilation, and childhood abuse history. METHOD: A treatment history interview, the Dissociative Experiences Scale, the Sexual Experiences Questionnaire, and the Hamilton Depression Rating Scale were administered to 60 consecutively admitted female inpatients with borderline personality disorder as diagnosed by the Structured Clinical Interview for DSM-III-R Personality Disorders. RESULTS: Fifty percent of the subjects had a score of 15 or more on the Dissociative Experiences Scale, indicating pathological levels of dissociation. Fifty-two percent reported a history of self-mutilation, and 60% reported a history of childhood physical and/or sexual abuse. The subjects who dissociated were more likely than those who did not to self-mutilate and to report childhood abuse. They also had higher levels of current depressive symptoms and psychiatric treatment. Multiple regression analysis demonstrated that each of these variables predicted dissociation when each of the others was controlled for, and that self-mutilation was the most powerful predictor of dissociation. CONCLUSIONS: Female inpatients with borderline personality disorder who dissociate may represent a sizable subgroup of patients with the disorder who are at especially high risk for self-mutilation, childhood abuse, depression, and utilization of psychiatric treatment. The strong correlation between dissociation and self-mutilation independent of childhood abuse history should alert clinicians to address these symptoms first while exercising caution in attributing them to a history of abuse.

Clinical correlates of self-mutilation in borderline personality disorder.

OBJECTIVE: This exploratory study sought demographic and clinical correlates of self-mutilation (self-injury without suicidal intent) in borderline personality disorder. METHOD: Among 124 consecutively admitted inpatients with borderline personality disorder, there were 62 who did not mutilate themselves, 23 who mutilated themselves infrequently (fewer than five lifetime events), and 39 who mutilated themselves frequently (five or more lifetime events); each received ratings on numerous measures of psychopathology. RESULTS: Compared to nonmutilators, frequent mutilators were significantly more likely to be in outpatient treatment at the time of admission and had more weeks of prior outpatient and inpatient treatment; they were also more likely to receive comorbid diagnoses of current major depression, anorexia nervosa, and bulimia nervosa. Frequent mutilators had significantly higher group means on the Beck Scale for Suicidal Ideation, were more likely to have attempted suicide, and were more likely to have attempted suicide more often than both infrequent mutilators and nonmutilators. The adjusted odds ratios from logistic regression analyses demonstrated that major depression, bulimia nervosa, number of prior suicide attempts, and acute suicidal ideation were each associated with greater risk of frequent mutilation. CONCLUSIONS: Borderline patients who frequently mutilate themselves may represent a subgroup of especially high utilizers of psychiatric treatment who are at particularly high risk for suicidal behavior and for comorbid major depression and eating disorders. Clinicians should consider aggressive treatment of comorbid axis I disorders and careful assessment of suicide risk in these patients.