Impulsivity in BPD
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Emotional Cascades as Prospective Predictors of Dysregulated Behaviors in
Borderline Personality Disorder – Selby, Joiner, 2013
I. A major symptom of borderline personality disorder (BPD) involves
dysregulated behaviors, which have been defined as behaviors that are:
difficult to control and result in harm to the individual or impairment in
functioning, especially when engaged in on a chronic basis (Selby & Joiner,
2009). These behaviors, although not restricted to those with diagnoses of
BPD, have been found to be prevalent in BPD psychopathology and can
include non-suicidal self-injury (NSSI; Brown et al., 2002), binging
and purging (Cassin & von Ranson, 2005), substance use
(Bornovalova, Lejuez, Daughters, Rosenthal, & Lynch, 2005),
shoplifting, reckless driving, and impulsive spending.
II. Many of these behaviors have been found to have emotion- regulating
properties (among many different motivations for different behaviors) and
people often report engaging in these behaviors as a method of
reducing or avoiding the experience of negative emotion (Selby &
Joiner, 2009).
 Dysregulated behaviors, in this model, may then be used to distract
from rumination through shifting attention to intense physical
sensations. These physical sensations may vary according to the
behavior, but examples could include feelings of pain or the sight of
blood in NSSI (Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein,
2006), or the tastes or textures of food or feeling of fullness in
binge eating (Mitchell et al., 1999).
 Decreases rumination – immediate feelings of relief.
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Behavior caused by emotional cascade, including rumination, less
effective distractions may not pull attention away from the problem
enough to bring emotional relief.
because BPD is highly characterized by a wide range of
dysregulated behaviors and frequent lability of emotion, BPD may
be viewed as the extreme continuum of emotional cascades.
III. Study
A. Method
 47 female participants, with self-report of dysregulation, some with
BPD.
 Inclusion Criteria: 1) a report of four or more dysregulated
behaviors (any combination), which were “difficult to control” over
the last 2 weeks (NSSI, arguments, physical fights, binge eating,
marijuana use, alcohol binges, impulsive shopping, throwing things,
reckless driving), and 2) no imminent risk of suicide, 3)endorsed at
least five BPD symptoms.
 PDA to alert participants five times a day. Participants were to rate
their positive and negative emotions at the current moment. Also
were to record their rate of rumination about the problem.
 Participants were asked whether they had engaged in any of the
following since the previous signal: NSSI, alcohol use, marijuana
use, physical fights, reckless driving, impulsive shopping, binge
eating, yelling, throw- ing something, slamming a door, hanging up
on someone, and insulting someone.
B. Results
 BPD group rated higher on rumination than controls.
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Average participant reported ten dysregulated behaviors.
BPD participants reported more dysregulated behaviors, as
expected.
Lag rumination was a significant predictor, whereas lag negative
emotion was not.
BPD symptoms, at high lag levels of lag-rumination and lagnegative emotion, significantly predicted increased probability of a
behavior occurring (t � 3.39, p � .001). When the interaction was
examined at high BPD symptoms, with high levels of negative
emotion and low levels of rumination, the interaction was not
significant (t � 1.44, p � .15). The interaction for high BPD
symptoms with low negative emotion and high rumination also was
not significant (t � 1.62, p � .11).
a significant three-way interaction was found, which indicated that
at high levels of negative emotion and rumination, those with BPD
had an elevated probability of engaging in a dysregulated behavior
beyond those with low levels of BPD symptom

From Negative to Positive and Back Again: Polarized Affective and
Relational Experience in Borderline Personality Disorder
I. Dichotomous Thinking
A. A hallmark feature of BPD is the tendency to evaluate one’s
experience with extreme polarity (i.e., feeling all good or all bad),
and with difficulty synthesizing disparate feelings into a complex,
unified experience. Often termed dichotomous thinking (DT) or
splitting, this phenomenon is considered to be a core feature of
the disorder (Beck et al., 2004; Kernberg, 1975; Linehan, 1993)
B. Criteria 4 and 5 (impulsive behaviors, suicidality and self-injury) may
also be linked to highly polarized experiences as they are theorized to
be, in part, consequences of heightened or extreme negative affect
(APA, 2000; Stiglmayr et al., 2005).
II. Impulsive Behavior
A.
Extreme swings in affective or relational experience can
trigger risky/impulsive behaviors (e.g., self-injury, substance
B.
C.
abuse) in an attempt to regulate moods associated with
these experiences.
Considerable evidence suggesting an important association
between affect, relational experiences, and maladaptive
behavior in BPD (e.g., Ebner-Priemer et al., 2007; Russell,
Moskowitz, Zuroff, Sookman, & Paris, 2007; Selby, Anestis,
Bender, & Joiner, 2009; Trull et al., 2008), alongside an
ongoing debate as to whether these components should be
thought of as independent factors (e.g., Glenn & Klonsky,
2009; Koenigsberg et al., 2001; Linehan, 1993). For example,
Linehan (1993) and others have argued that the key
underlying component of BPD is emotion dysregulation, and
that other components, including relational instability and
impulsive behavior, can be understood as concomitants
of an underlying emotion-regulation disorder.
Extreme increases in negative affect were moderated by selfinjurious behavior in BPD. Both pieces of evidence are
consistent with theories suggesting that the risky/impulsive
behaviors characteristic of the disorder are enacted as
maladaptive yet powerful attempts at mood regulation
when individuals become overwhelmed with negative affect
(e.g., Beck et al., 2004; Linehan, 1993).
II. Study
Participants reported their affective and relational experiences as well as
risky/impulsive behaviors commonly associated with BPD. Experimenters
were particularly interested in exploring what impact interpersonal stress
has on the polarity of self-reported experiences, and how polarity and
interpersonal stress might be associated with risky/ impulsive behavior.
Hypothesis: anticipate that greater polarity in affective and relational
experience will be associated with increased rates of reported risky/
impulsive behaviors, and that this association will be strongest during high
inter-personal stress. In this case, we would predict that during high
interpersonal stress, relational polarity would have the strongest
association to impulsive behavior and that during low interpersonal
stress, affective polarity would have the strongest association.
A. Procedure
BPD group must meet six criteria for BPD. No symptoms for healthy control
group.
Psychotropic medication or BPD group was okay.
65 BPD, 61 healthy controls.
B. PDA diaries
For each diary entry, participants recorded affective experience,
interpersonal stress, and if they had engaged in any of five domains of
risky/impulsive behaviors.
Also asked to identify one important person in their life, and asked to
respond to a series of items assessing his or her relational experiences with
this person across 6 items on a 5-point Likert scale (0 � not at all, 4 �
extremely).
Types of risky/impulsive behaviors: excessive spending, binge eating, risky
sexual behavior, substance use and self-injury.
B. Results
- Polarity of relational experience was significantly associated with the
rate of reports of impulsive behavior during high stress in the final
model, such that the more polarized the relational experience, the
greater the rate of reports of impulsive behavior.
- During low stress, results indicated that the polarity of affective experience
was significantly associated with the rate of reports of impulsive behaviors
during low stress in the final model.
- During interpersonal stress, polarity increased for the BPD group in
contrast with controls. Finally, heightened polarity in affective and relational
experiences was significantly associated with risky/ impulsive behaviors.
- During heightened interpersonal stress, relational polarity was the sole
predictor (beyond group) of impulsive behavior, whereas during low
interpersonal stress, affective polarity was the sole predictor.
Characteristics of Borderline Personality Disorder Associated with
Suicidal Behavior
Beth S. Brodsky, Ph.D., Kevin M. Malone, M.D., Steven P. Ellis, Ph.D.,
Rebecca A. Dulit, M.D., J. John Mann, M.D.
American Journal of Psychiatry, Dec 1997; 154 (12); 1715-1719.
Previous Studies:
BPD is a distinct risk factor for suicidal behavior. Rates of suicide among
patients with BPD range from 3% to 9.5%, 75% of an inpatient sample with
BPD had made at least one previous suicide gesture. Earlier studies
identified correlates of suicidal behavior in subjects with BPD that were NOT
related to personality traits, such as age, educational level, and co-morbid
axis I diagnoses of major depression, substance abuse, and eating disorders.
The number of previous suicide attempts has been found to be the strongest
predictor of suicide and future suicidal behavior in all psychiatric populations
including subjects with BPD.
These studies suggest the presence of Axis I affective and substance abuse
diagnoses are insufficient to explain suicidal behavior among patients with
BPD. Personality characteristics such as impulsivity and aggression have
been found to correlate with suicide risk in other psychiatric populations.
I. Method
- To meet the impulsivity criterion, subjects had to endorse impulsive
behavior in at least two areas of life: binge eating, shopping, gambling,
substance use or reckless driving – EXCLUDED self-destructive behaviors
such as suicide attempts or parasuicide behaviors.
Information on lifetime history of suicidal behavior was obtained from 214
patients diagnosed with BPD. Authors examined the relationship between
DSM-III-R criteria 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.
This study was undertaken to examine the relationship of individual
characteristics of BPD and overall severity of BPD to childhood abuse history
and the relationship of both to the following measures of suicidal behavior:
history of a previous suicide attempt, number of previous attempts, and
intent and lethality of the most lethal lifetime attempt.
II. Results
Impulsivity was the only characteristic of BPD (EXCLUDING THE
SELF_DESTRUCTIVE CRITERION) that was associated with a higher number
of previous suicide attempts after controlling for lifetime diagnosis of
depression and substance abuse. Global severity of pathology of BPD was
not associated with suicidal behavior. History of childhood abuse correlated
significantly with number of lifetime suicide attempts. Impulsivity may be a
risk factor for future suicide attempt. Potential therapeutic target for
prevention of future suicide attempts.
Impulsivity was the one BPD characteristic significantly correlated with
number of previous suicide attempts. In an analysis of covariance that
controlled for major depression and substance abuse diagnoses, patients
with BPD who met the impulsivity criterion had MORE past suicide attempts
than those who did not meet the impulsivity criterion. Single trait of
impulsivity, rather than global severity of BPD pathology, is associated with
suicidal behavior in BPD.
Studies looking at Suicide and Impulsivity- using
NON SELF REPORT. Saved as EBSCO search4/11/2013 11:50:00 PM
The Relationship Between Nonsuicidal Self-Injury and Attempted Suicide:
Converging Evidence From Four Samples – used UPPS Impulsive Behavior
Scale. - E David Klonsky, Alexis M May, Catherine R Glenn
Journal of Abnormal Psychology (Impact Factor: 4.86). 10/2012;
DOI:10.1037/a0030278
Source: PubMed
The Associations Between Non-Suicidal Self-Injury and Borderline
Personality Disorder Features Among Chinese Adolescents. You et al. – used
Behavioral Impulsivity Scale. Patients report frequency of engaging in
impulsive behavior.
Differentiating adolescent self-injury from adolescent depression: Possible
implications for borderline personality development. – used EDR
Electrodermal Responding, a peripheral biomarker of trait impulsivity.
Criminal Conviction, impulsivity, and course of illness in bipolar disorder,
Swann et al. Used Barratt Impulsiveness Scale (BIS-11),
1. IMMEDIATE MEMORY TASK (IMT) measures rapid-response impulsivity.
Computer task.
2. Two-Choice Impulsivity Paradigm (TCIP), measures reward-delay
impulsivity. Computer task. Short delay responses are taken as impulsive
responses.
3. Single-Key Impulsivity Paradigm (SKIP). Reward-delay impulsivity free
operant test measures ability to delay response for a larger reward.
LOOK AT THEIR REFERENCE SECTION FOR VALIDITY AND RELIABILITY OF
MEASURES AND ALSO TO FIND MORE ARTICLES ON IMPULSIVITY
Pathways to high-lethality suicide attempts in individuals with borderline
personality disorder. NEED TO GET THIS ARTICLE!!!!!!!!! Chesin
Impact on suicidality of the borderline personality traits impulsivity and
affective instability. GET THIS ARTICLE
Dr. Gevirtz – Neuromechanisms of HRV
“Overall, HRV may index degree to which the mPFC (medial pre-frontal
cortex)-guided-‘core integration’ system is integrated with the brain stem,
nuclei that directly regulate the heart.” (Thayer, 2012)
Neurovisceral Integration Theory – Thayer and Lane
An integrative explanation that evolutionary forces led to the development of
a rapidly responding vagus nerve to support appropriate emotional
expression and regulation through connections with the cortex, limbic
system, and brain-stem. By inhibiting other potential responses through
synaptic activity in the brain and vagal activity in the body, the CAN acts as
a “neurophysiological command center governing cognitive, behavioral, and
physiological elements into regulated emotion states.”
Effective emotion regulation depends on being able to flexibly adjust your
physiological response to a changing environment.
Heart Rate Variability (HRV) is a measure of the continuous interplay
between sympathetic and parasympathetic influences on heart rate that
yields information about autonomic flexibility and thereby represents the
capacity for regulated emotional responding.
The central autonomic network (CAN) assists emotional regulation by
adjusting physiological arousal to appropriately match the external and
internal environments. The CAN consists of cortical, limbic, and brain-stem
components. Its output is transmitted to the sinoatrial node of the heart,
among other organs.
HRV reflects the moment-to-moment output of the CAN and, by proxy, an
individual’s capacity to generate regulated physiological responses in the
context of emotional expression. (Thayer & Lane, 2000; Thayer & Siegle,
2002)
THAYER – Psychosomatics and psychopathology: looking up and
down from the brain.
Role of Autonomic Nervous System in a wide range of mental diseases.
1. ANS Components:
a. Sympathetic: Energy mobilization – fight or fight
b. Parasympathetic – vegetative and restorative functions. calm
Health is maintained through a balance of the symptoms.
Large body of evidence to suggest that autonomic imbalance, typically the
SYMPATHETIC SYSTEM is HYPERACTIVE (energy mobilization) and
parasympathetic is hypoactive (calm, restorative) is associated with various
pathological conditions.
Prolonged state of alarm associated with negative emotions places an
excessive energy demand on the system.
Although a large range of physiologic factors determines heart rate, the ANS
is most prominent. ANS MOST PROMINENT IN DETERMINING HEART RATE.
CARDIAC VAGAL- THE PRIMARY SYMPATHETIC NERVE.
???? Resting cardiac autonomic balance favors energy conservation
by way of parasympathetic dominance over sympathetic influences.
???? Does this mean that cardiac balance is achieved when
parasympathetic system dominates???
Threat increases sympathetic ready for fight or flight.
TONIC INHIBITION???
This inhibition (inhibition of sympathetic system???) is achieved via top
down modulation from the pre-frontal cortex. Under conditions of
uncertainty and threat, pre-frontal cortex becomes HYPO active. So
prefrontal cortex is not really working strong during threat. Decrease in
prefrontal cortex is associated with INCREASE in sympathetic = fight or
fight= energy mobilization. However, when this state is PROLONGED, it
produces excess wear and tear on the system components, know as
allostatic load.
***** Pathological states such as anxiety, depression, ptsd, and
schizophrenia are associated with LOW PREFRONTAL ACTIVITY and lack of
inhibitory neural processes. This is seen by pre-attentive bias for threat
information, deficits in working memory and executive function, and poor
affective information processing and REGULATION. POOR AFFECT
REGULATION.
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