Does coding internal working models of attachment have to be so hard?

The Child Attachment Interview (CAI) has demonstrated promise in youth, yet widespread use is thwarted by the need for interview transcription, face-to-face training, and reliability certification. The present study sought to examine the empirical basis for these barriers. Thirty-five archival CAIs were re-coded by: (1) expert coders (i.e., trained and reliable) without access to transcripts, (2) trained coders who had not completed reliability training, and (3) novice coders who had no formal training. Agreement with consensus classifications was computed with the expectation of moderate agreement. Results supported coding by experts without transcription of the interview. Near-moderate agreement preliminarily supported the use of trained coders who have not attempted reliability certification with appropriate caveats. While moderate agreement was not achieved for novice raters, findings suggest that self-paced training options for the CAI may hold future promise. These contributions erode a number of significant barriers to the current use of the CAI.

Adolescent Sleep Disturbance, Emotion Regulation and Borderline Features in an Inpatient Setting.

Objective: The current study aimed to examine the relation between sleep disturbance, emotion dysregulation and borderline personality features in adolescent inpatients.Method: N = 217 adolescents (67.1% female; ages 12-17) with the following racial/ethnic breakdown: 67.4% White, 3.7% Hispanic, 2.8% Asian, 1.8% African American, and 6.4% multiracial) completed self-report measures of sleep disturbance, emotion dysregulation and borderline personality symptoms at admission to, discharge from, and at 6-months-post discharge from an inpatient psychiatric hospital. Group comparison and path analyses were conducted to examine differences in sleep disturbance between those with and without borderline personality disorder and the mediating role of emotion dysregulation in the relation between sleep disturbance and borderline personality features.Results: Borderline personality features and emotion dysregulation were significantly related to indices of sleep disturbance. Path models revealed that some sleep disturbance indices at admission directly predicted levels of borderline features at discharge and at 6-months-post-discharge. However, none of the indirect pathways between sleep disturbance at admission, emotion dysregulation at discharge, and borderline features at discharge or 6-months post-discharge were significant.Conclusions: Findings are consistent with prior literature which suggest that a unique relation exists between sleep disturbance and BPD, beyond comorbid depression symptoms. However, contrary to our hypotheses, the current study did not provide empirical support for the mediating role of emotion regulation in this relation. These findings have implications for existing personality disorder and sleep interventions and suggest further research into the mechanisms underlying the relation between sleep disturbance and borderline personality pathology is necessary.

Exploring mentalizing in adolescents with anorexia nervosa and borderline personality disorder: A comparative study of psychiatric inpatients and healthy controls.

BACKGROUND: Impaired mentalizing, i.e., difficulties in understanding oneself and others in terms of mental states, has been associated with the development of Anorexia Nervosa (AN), mainly among adults. However, few studies have addressed this question in clinical samples of adolescents with AN. Moreover, no study has explored mentalizing abilities among inpatient adolescents presenting with AN and Borderline Personality Disorder (BPD), despite their high comorbidity in a highly relevant age group. OBJECTIVE: This study attempted, for the first time, to further examine differences in mentalizing abilities and to identify specific mentalizing impairments in different psychiatric inpatient groups and healthy adolescents. METHODS: Using samples of female adolescents aged 12-17, comparison analyses were performed between psychiatric inpatient adolescents with AN (n = 44), BPD (n = 101), AN+BPD (n = 48), other psychopathology (n = 163) and healthy adolescents (n = 129). Structured and semi-structured clinical interviews, and two experimental tasks were administered to assess AN, BPD and mentalizing, respectively. RESULTS: Comparison analyses showed that patients with BPD and other psychiatric disorders evidenced higher levels of hypermentalizing compared to healthy adolescents. Hypermentalizing was also reported among inpatients with AN+BPD, although to a lesser extent. BPD and AN scores were positively correlated with hypermentalizing responses. CONCLUSIONS: Our results suggest that hypermentalizing is a specific mentalization impairment in inpatient adolescents, particularly with BPD and both AN+BPD. Further investigation into the efficacy of mentalization based treatments for adolescents with BPD and AN+BPD is recommended. Prospective studies are needed to assess mentalizing using experimental tasks among adolescents with AN, taking into account the potential influence of temporality and severity of the disorders' symptoms.

Divergent mentalization types in adolescent borderline personality disorder and attention deficit/hyperactivity disorder.

BACKGROUND: Attention deficit/hyperactivity disorder (ADHD) and borderline personality disorder (BPD) have several similarities and it is difficult to distinguish these disorders in adolescents. We aimed to identify the unique correlates of mentalization abilities that may distinguish these two disorders, and to investigate the mentalization abilities of adolescents with ADHD, BPD and ADHD + BPD in an inpatient sample to determine the effect of co-morbidity on mentalization abilities. METHODS: We have explored the relationship between Child Eye Test (CET) scores, Movie for the Assessment of Social Cognition (MASC) subscales, and ADHD and BPD symptoms in adolescent inpatients. In addition, we compared ADHD, BPD and ADHD + BPD groups in terms of their mentalization abilities. RESULTS: Correct MASC scores were negatively associated with both ADHD and BPD symptoms in girls, and negatively associated with ADHD symptoms in boys. In addition, hypermentalization scores were associated with BPD symptoms in girls, and hypomentalization and no mentalization scores were associated with ADHD symptoms in girls. CET scores were negatively associated with ADHD symptoms in girls, but no relations with BPD were found. Group comparisons revealed no significant difference among groups. LIMITATIONS: We included only inpatient sample without considering their medication condition, we did not compare the mentalization scores of the patient groups with healthy controls and we used self-report measures for several assessments. CONCLUSION: Mentalization patterns in ADHD and BPD are distinct. ADHD may be related to hypomentalization, instead, BPD may be related to hypermentalization.

DSM-5 Level of Personality Functioning: Refocusing Personality Disorder on What It Means to Be Human.

Level of Personality Functioning (LPF) represents the entry criterion (Criterion A) of the Alternative Model for Personality Disorders (AMPD) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). It is defined as a dimensional general severity criterion common to all personality disorders and conceptually independent of personality types or traits, and it represents maladaptive self (identity and self-direction) and interpersonal (empathy and intimacy) functioning. We review the history, measurement, and significance of LPF. We show that the inclusion of LPF in the AMPD is well justified if it is defined as a general adaptive failure of a subjective intrapsychic system needed to fulfill adult life tasks. If so defined, LPF distinguishes itself from maladaptive traits (Criterion B of the AMPD) and captures the contribution humans make as agentic authors to the interpretation and management of the self. While Criterion B maladaptive traits provide important descriptive nuance to manifestations of personality pathology, maladaptive LPF is conditional to the diagnosis of personality disorder.

Barriers to care for adolescents with borderline personality disorder.

Intervention for borderline personality disorder (BPD) in adolescence is crucial as early onset of the disorder predicts more severe course, and intervention 'late' in the course of the disorder is associated with more negative outcomes. In spite of this, access to services is poor. This is because several unique barriers to accessing care exist for adolescents with BPD. In this article we highlight key barriers to care for adolescents with BPD utilizing a conceptual model for understanding health care access that emphasizes the interaction between patient and health care system characteristics. We conclude with proposed recommendations to address these identified barriers.

Borderline personality disorder and attention deficit/hyperactivity disorder in adolescence: overlap and differences in a clinical setting.

BACKGROUND: With increased consensus regarding the validity and reliability of diagnosing Borderline Personality Disorder (BPD) in adolescents, clinicians express concern over the distinction between BPD and Attention-Deficit/Hyperactivity Disorder (ADHD), and its co-morbidity in clinical settings. The goal of this study was to evaluate differences between BPD, ADHD and BPD + ADHD in terms of co-morbid psychiatric disorders and a range of self-reported behavioral problems in adolescents. METHODS: Our sample consisted of N = 550 inpatient adolescents with behavioral and emotional disorders that have not responded to prior intervention. We took a person-centered approach (for increase clinical relevance) and compared adolescents with ADHD, BPD and ADHD+BPD in terms of co-occurring psychiatric disorders and behavioral problems. We performed a regression analysis to test whether BPD symptoms make an incremental contribution to the prediction of psychiatric symptoms over ADHD symptoms. RESULTS: The severity of almost all co-occurring disorders, aggression, self-harm, suicidal thoughts, and substance use, were higher in the ADHD+BPD group. Borderline symptoms made an incremental contribution to the prediction of psychiatric symptoms beyond the contribution of ADHD. CONCLUSION: Severity and co-morbidity may be helpful factors in distinguishing between ADHD and BPD in clinical practice and the co-morbidity of these two disorders may indicate a worse clinical outcome.

The moderating role of dissociation in the relation between borderline features and factors of self-injury in adolescents.

BACKGROUND: Self-injurious behaviours (SIB) occur frequently in individuals with borderline personality disorder (BPD). While multiple factors may explain the association between SIB and BPD, studies in adults have pointed to dissociation as factor worth considering. However, this relationship has not been examined in adolescents. AIMS: The current study investigated the role of dissociation as a potential moderator between borderline features and SIB, with the expectation that this association would be stronger in the presence of dissociation. METHODS: One hundred forty-four adolescent inpatients were compared on measures of BPD, non-suicidal self-injury (NSSI) and suicidal behaviour. The relationships between borderline features and self-injury outcomes were evaluated using linear and logistic regression with dissociation as a moderator. RESULTS: Borderline features and dissociation were found to be significantly associated with history of NSSI, history of suicide attempt, suicidal ideation (SI) intensity and SI severity. However, dissociation was a significant moderator only in the relationship between borderline features and SI intensity. CONCLUSION: Higher levels of dissociation were associated with more engagement with suicidal thoughts but did not necessarily contribute to SIB. Further research into differential patterns of association of self-injury in patients with BPD may investigate other models where dissociation may more strongly factor into outcomes. © 2020 John Wiley & Sons, Ltd.

A study of risky sexual behavior, beliefs about sexual behavior, and sexual self-efficacy in adolescent inpatients with and without borderline personality disorder.

Risky sexual behavior (RSB) during adolescence increases risk for sexually transmitted diseases and teenage pregnancy. Youth with psychiatric diagnoses are more likely to engage in RSB, and borderline personality disorder (BPD) in adolescence may be particularly relevant to RSB. It is not yet clear whether adolescents with BPD engage in higher levels of RSB than adolescents with other psychiatric diagnoses. The present study examined RSB and correlates of RSB among adolescent inpatient females with and without BPD. One hundred twenty-three female adolescent inpatients (Mage = 15.15, 71.5% Caucasian, 40.6% BPD) completed an interview to assess BPD diagnosis and measures of BPD traits, RSB, attitudes and perceived norms related to RSB, and sexual self-efficacy. Results indicated no differences in RSB based on BPD diagnosis. However, the BPD group evidenced significantly lower self-efficacy to refuse sex, and riskier attitudes and perceived peer norms about sexual behavior than inpatient controls. When examined dimensionally using borderline traits and controlling for level of psychopathology, borderline traits were significantly related to lower self-efficacy to refuse sex. Results suggest that adolescent girls with BPD do not engage in higher levels of RSB than inpatient psychiatric controls; however, riskier attitudes and norms related to RSB, and particularly lower self-efficacy to refuse sex, may influence adolescent girls with BPD or BPD traits to engage in higher levels of RSB later in life and therefore present important preventative treatment targets. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Parent-Adolescent Concordance in Borderline Pathology and why it Matters.

The aims of the current study were to: 1) identify patterns of agreement between parent-adolescent dyads on reports of adolescent borderline personality features utilizing latent class analysis (LCA) and 2) examine the clinical implications of class membership for indices of psychiatric severity and internal psychological resources. The sample included 643 adolescent inpatients. Borderline personality features were assessed by both adolescents and parents using the Borderline Personality Features Scale - Child (BPFS-C; Crick et al. 2005) and Borderline Personality Features Scale - Parent (BPFS-P; Sharp et al. 2010), respectively. Following recommended statistical approaches for evaluating rater concordance, LCA was utilized to identify distinct classes of parent-adolescent dyads based on concordance/discrepancy in BPFS reports. The subsequent classes were then related to outcome measures of psychiatric severity and internal psychological resources (emotion regulation and experiential acceptance). LCA identified 3 classes of parent-adolescent dyads: 2 convergent classes demonstrating BPFS-P and BPFS-C agreement at a moderate and high level and a divergent class consisting of dyads reporting clinically significant scores on the BPFS-P but clinically negligible BPFS-C scores. Both convergent classes evidenced higher rates of psychiatric severity and lower access to internal resources. The current study is the first to use LCA to examine the relation between informant concordance on reports of DSM-based adolescent borderline pathology in a clinical sample. The significance of the discrepancies within and between classes is discussed with relation to psychosocial outcomes, the diagnosis of borderline personality disorder and implications for what it means when parents and adolescents disagree.

Adolescence as a Sensitive Period for the Development of Personality Disorder.

Over the last 15 years, controversy over the construct of adolescent personality disorder has largely been laid to rest because of accumulating empirical evidence in support of its construct validity. In this article, four conclusions that can be drawn from recent literature on borderline disorder in adolescents are discussed, with the ultimate goal of building an argument to support the idea that adolescence is a sensitive period for the development of personality disorder.

An evaluation of the construct of emotional sensitivity from the perspective of emotionally sensitive people.

BACKGROUND: Emotional sensitivity is a construct found in major developmental models of borderline personality disorder. However, the construct remains nebulous. The patient perspective is crucially important in helping to define and conceptualize any psychological construct - especially one that plays such a large role in the developmental theories of a given disorder. The aim of the current study was to explore the meaning of emotional sensitivity from the perspective of those who identify as being emotionally sensitive. METHODS: Participants were from a community sample of adults (Mage = 32.05, range: 21-59) who responded to an advertisement for a study of emotional sensitivity. Participants completed surveys related to personality pathology and a semi-structured interview about emotional sensitivity. Emotional sensitivity interviews were independently coded by two research assistants trained in qualitative analyses for content and process. Coders were blind to the personality pathology status of participants. RESULTS: Regardless of level of personality pathology, qualitative results of the emotional sensitivity interview largely suggest that emotional sensitivity is a heightened emotional reactivity to stimuli, including the emotions of other individuals, or a tendency to have emotional reactions to even low impact stimuli. However, emotional sensitivity was regarded predominantly as a negative trait (i.e. burden) only by those who have high levels of borderline personality pathology. CONCLUSIONS: The implications of these results for the conceptualization and utility of emotional sensitivity in borderline personality disorder are discussed.

Personality pathology grows up: adolescence as a sensitive period.

There is mounting evidence that personality pathology, in particular, borderline pathology is a valid and reliable construct in adolescence, with prevalence, phenomenology, stability and risk factors similar to that of adult borderline personality disorder. Scientific evidence also delineates a marked separation of course and outcome of adolescent borderline personality disorder from other disorders and supports the efficacy of disorder-specific treatment. The current article addresses recent findings in these areas which point to adolescence as a sensitive period for the development for personality pathology. A conceptual model of psychopathology is presented wherein personality pathology is described as a qualitatively different level of psychopathology in the form of maladaptive self-other relatedness that is developmentally tied to identity formation in adolescence.