Executive Function in Borderline Personality Disorder in Children and Adolescents
Lina Flues*, Franz Resch, Eva Moehler
Institute for Child and Adolescent Psychiatry, Heidelberg University, Heidelberg,
Germany
*Corresponding author: Lina Flüs, Institute for child and adolescent psychiatry, Heidelberg University, Hauptstraße 94, 69117 Heidelberg, Germany. Tel: +491774918414: Email: Lina.Flues@stud.uni-heidelberg.de
Received Date: 11 September, 2018; Accepted
Date: 27 September, 2018; Published
Date: 03 October, 2018
Citation: Flues L, Resch F, Moehler E (2018) Executive Function in Borderline Personality Disorder in Children and Adolescents. Res Adv Brain Disord Ther: RABDT-110. DOI: 10.29011/RABDT-110. 100010
1. Abstract
1.1 Background: Borderline Personality Disorder (BPD) is one of the most frequently diagnosed but also most differently characterized disorders in the field of child and adolescent psychiatry. Although negative side effects of executive dysfunction are often seen in BPD patients, statistical proof of an association between symptoms of executive dysfunction and BPD is missing thus far.
1.2 Methods: From 2011 until 2015, 194 young patients aged 12 to 21 years were examined and treated in an inpatient setting of an institute for child and adolescent psychiatry. Patients were divided into two groups (BPD and pre-BPD) and aspects of executive functions were documented via questionnaires.
1.3 Results: The results confirmed the clinical idea of defining BPD as a special complex of emotional dysregulation (subscales: "expression of anger" [p=0.0120], "trait anger" [p<0.0001], "aggressive behavior" [p=0.0183]); dysfunctions in interpersonal relationships (subscale: "problem solving" [p=0.0045]); and high impulsivity (subscale: "control of anger" [p=0.0028], "regulation of impulses" [p<0.0001], "experiencing self-control" [p=0.0325]). The subscale "adaptive strategies total" [p=0.0016] was significantly different between the two groups as well.
The "suppression of anger" [p=0.0358] subscale was significantly higher in the BPD group than in the pre-BPD group; this was most likely due to the answers provided by the patients themselves. Although emotional dysregulation is considered to be characteristic of BPD, "experiencing a regulation of emotions" [p=0.8620] did not differ between the two groups.
1.4 Conclusions: Most of these results are statistical proof for the observations made by treating experts, and they offer the possibility for use as elements of the general psychiatric diagnostic approach, serving as verified indicators for the existence of BPD in children and adolescents. Such an approach can aid in everyday clinical practice. Some features of borderline personality disorder differ in a pertinent way from the expectations that have emerged from clinical observations. Studies with larger groups of patients are required to further explore this complex issue.
2. Keywords: Adolescents; Borderline Personality Disorder; Child Development; Executive Function; Personality Disorders
3. Abbreviations
AIDA : Assessment of Identity Development in Adolescence
BPD : Borderline Personality Disorder
DBT-A : Dialectic-Behavioral Therapy for
Adolescent
HAWIK-IV : Hamburg-Wechsler-Intelligenztest
Fuer Kinder
SD : Standard Deviation
SED : Standard Error of Difference
SEM : Standard Error of the Mean,
Standard Error of the Mean
SKID : Structured Clinical Interview for
DSM-IV
WIE : Wechsler Intelligenztest Fuer Erwachsene
(Engl.: Wechsler Intelligence Test for Adults)
4.
Introduction
The prevalence of
borderline personality disorder is given at 0.9% of adolescents in the general population,
up to 10% of outpatients and up to 50% of all children and adolescents under
inpatient treatment in psychiatric institutes [1-3]. In reaction to this high
and increasing prevalence of personality disorders in young patients, it is
necessary to improve the specificity of diagnostic instruments for them [4].
Studies showed that personality disorder diagnoses are valid and reliable for
adolescents older than 14 years [5-9]. Many trained therapists refuse to
diagnose young patients to avoid the unnecessary risk of stigmatization and
therapeutic nihilism [10]. To avoid a false diagnosis and unnecessary risks, it
is important to collect more detailed characterizations of this specific
disease.
In the Diagnostic and
Statistical Manual of Mental Disorders, 4th edition DSM-IV (American
Psychiatric Association, 2000), [11] as well as in the International
Statistical Classification of Diseases and Related Health Problems ICD-10 [12],
attempts have been made to identify specific characterizations of borderline
personality disorder. Furthermore, there are different characterizations of
borderline personality disorder. Sanislow, Grilo and McGlashan described the
three homogeneous factors -a disturbed ability to maintain relationships,
affective dysregulation and behavioral dysregulation - that can be used to
differentiate BPD and non-BPD patients [13].
Unstable
relationships, chronic feelings of emptiness and an identity disorder
characterize the disturbed ability to have relationships. Identity disorder -
frequently postulated to co-occur with BPD -develops through an identity
diffusion that is described as a labialization in experiencing one’s own
identity that is created by breaks in relationships to social surroundings. The
self-perception and feedback of surroundings become incongruent, and the
following loss of a feeling of stable identity creates disorientation,
perplexity and uncertainty in actions and decisions [14]. Regarding borderline
personality disorder, it is especially difficult to separate a regular identity
crisis in adolescence from the personality disorder-specific identity diffusion
[15-17]. Various authors have already
reported observations of deficits in the executive function in the context of
borderline personality disorder [18-21].
Executive function
contains all top-down domain-specific regulation and control mechanisms
providing the ability for goal-oriented and situation-adapted actions that are
necessary for situations alternating from a regular routine [22]. The idea of
an executive function based on a single mechanism or domain-crossing control
factor is controversial [23,24], even though most authors define executive
function as a complex of different processes that can be disabled or limited
selectively [22]. Executive function unites higher, complex cognitive processes
or, rather, a multidimensional complex of different, separated control and
regulation mechanisms that regulate the thinking and acting for new, unknown
and complex situations or tasks when normal and everyday automatism is not
purposeful or useful [25]. For this function, a “working memory” that updates
new representations for future actions, a “preparatory set” to keep the
organism ready for future operations and “inhibition” for the ability to
suppress inappropriate reactions are necessary [26].
A study of patients
with differently located injuries resulted in the conclusion that executive
function separates into the following three independent processes of attention
control: the process of "energization" that initiates and maintains
behavior, the process of "task-setting" that mentally connects a
stimulus and a response, and the process of "monitoring" that
oversees the tasks and improves the adaptation of a behavior [27].
To explain and
understand the complexity of acting and behavior regulation in everyday life,
it is not sufficient to mainly focus on executive processes based only on
cognitive factors [22]. Because
executive function depends on current emotions, impulsion and motivation, a
strict separation between cognitive and emotional regulation is artificial and
describes a false version of real phenomena [28-30]. This discrimination
between "cold", cognitive executive functions in the form of the
regulation of acting and thinking and the "hot" emotional or
motivational executive function relating to the regulation of emotions is made
by many authors [31-33]. The possibility of differentiating hot and cold
executive functions is not known yet [34]. An existing correlation between hot
and cold executive function [35,36] and a positive trend in children between 3
and six years old in both sectors of executive function [37] has already been
found in various studies.
As already mentioned,
executive function is part of borderline personality disorder symptoms.
According to Putnam and Silk, borderline personality disorder is most likely a
disorder of the emotional regulation within emotional responses that are
inflexible or rigid and accompanied by a decreased or increased level of
arousal [38]. In this context, it is known that impulsivity can be seen as one
of the core elements that leads to an executive dysfunction [39,40]. Other
studies that focused on executive function related to borderline personality
disorder showed that neurocognitive deficits play an essential role in the
development of this disorder [41,42]. A comparison between the symptoms of
schizophrenia and borderline personality disorder regarding executive function
performed by Hurtado pointed out that BPD-patients more than those in the
schizophrenia-group are more limited in their everyday life due to the
increased operational capacity of the borderline-personality disorder.
Surprisingly, in the BPD-group, a significant relation between working memory
and the management branch was detected. Therefore, the researcher concluded
that problems of executive function mainly exist in metacognitive tasks of
correctly updating and managing emotional information [19].
Angry outbursts,
impulsivity, maladaptive coping mechanisms, suicide attempts and subsequent
inpatient treatments show the substantial negative effects on the daily contact
of patients and therapists [43]. Up to now, the intensity and the significant
relation between symptoms of executive dysfunction and borderline personality
disorder have not been described in great detail. This study examines the
interrelation of these factors in 194 adolescent patients admitted for
treatment of emotional instability with dialectic behavior therapy.
5.
Methods
5.1
Methods: Procedure
The Idar-Oberstein clinic for child
and adolescent psychiatry specializes in and is certified for the Dialectic-Behavioral
Therapy for Adolescent (DBT-A). The clinic treats emotionally unstable
adolescents from Germany, Austria and Switzerland. From 12 January 2011 until
21 August 2015, trained psychologists in the inpatient-unit of the clinic for
child and adolescent psychiatry in Idar-Oberstein collected data from possible
participants for this study. During their admission or while treatment was
ongoing, all potential participants were informed about this study and the data
to be collected.
To be included in the study, patients had to fulfill the following
criteria: age between 12 and 21 years old, signs of Para suicidal behavior patterns in the last 16 weeks or
current existing suicidal thoughts or self-harming behavior, a
diagnosis of a borderline personality disorder or at least three confirmed
DMS-IV criteria for a borderline personality disorder and admission for
inpatient or outpatient treatment in the child and adolescent psychiatry clinic
of Idar-Oberstein.
Patients who fulfilled five or more BPD diagnostic criteria [44,45] or
had a SKID score over 4 for "borderline personality
disorder" [46] or had a total value of Identity Diffusion (from the AIDA)
of 70 or more [47] were selected for the borderline-group.
Patients who were categorized in the non-borderline-group (as a control
group) were characterized by fulfilling four or fewer BPD diagnostic criteria [44,45]
or had a SKID score under 5 for "borderline personality
disorder" [46] or had a total value of Identity Diffusion (from the AIDA)
less than 70 [47].
Patients were excluded from this study in the case of unfinished
diagnostics, a cognitive performance according to an intelligence quotient less
than 70 (HAWIK-IV / WIE), current psychotic illness or a major depressive episode or mania,
addiction as a first diagnosis, significant difficulty reading or expressing
oneself verbally, schizophrenic disorder or bipolar disorder or organic brain
disease.
5.2.1
Eating Disorder Inventory -2 [48]
The Eating Disorder Inventory-2
is an instrument for multidimensional descriptions of specific
psychopathologies in patients with symptoms of an anorexia or bulimia nervosa
and other pathological eating habits. The inventory is separated into 11 scales
(struggles to lose weight, bulimia, dissatisfaction with the body,
ineffectiveness, perfectionism, mistrust, interceptive perception, fear of
growing up, asceticism, impulse regulation and social insecurity).
5.2.1.1 Reliability: Retests show a reliability of rtt=0.81-0.89. Tests of a sample of
patients with anorectic and bulimic symptoms reached an internal consistency
(Cronbach's alpha) of α=0.73 and α=0.93, respectively.
5.2.1.2 Validity: Good criterion and factorial validity were proved through discriminant
analyses to separate different diagnosis-sets, calculating correlations with
other test instruments and factor analysis.
5.2.1.3 Standards: A sample of 246 patients with anorectic symptoms, a sample of 217
bulimic patients and a control group (n=288) were used to perform the
standardization of this instrument.
5.2.1.4 Usability: This diagnostic instrument is designed for adults and adolescents
older than 14 years. Currently, this instrument may be applied to diagnostic
use, therapy planning, change measurement, psychotherapy and pharmaceutic
studies.
5.2.2
SEE: Scales for Experiencing Emotions [49]
The Emotional Experience Scales
(SEE) are designed for use in individual and group examinations with
adolescents age 14 years and older and adults. It is a theory-based, multidimensional
measuring instrument for the central constructs of patient-centered personality
theory and the concept of emotional intelligence. The scales contain 42 items,
which include the following seven independent scales:
1.
Acceptance of own emotions
2.
Experience of emotion transfer
3.
Experiencing emotional deficiency
4.
Body-related symbolization of emotions
5.
Imaginative symbolization of emotions
6.
Experiencing regulation of emotions
7.
Experiencing self-control
These scales aim to measure how
patients perceive, evaluate and address their feelings.
5.2.2.1 Reliability: The scales show an internal consistency of 0.70 - 0.86 (Cronbach's
alpha), as well as a retest reliability of 0.60 - 0.090 over intervals of 2, 3,
4, 10 and 14 weeks.
5.2.2.2 Validity: Comparisons with other methods of emotion perception, with clinical
tests including self-concept inventories and with plans for the assessment of
interpersonal relationships show the hypothesis- and theory-corresponding
correlation of the scales. The scale values for men and women differ just as
hypothetically as a clinical sample differs from a random sample.
5.2.2.3 Norms: There are z-values, T-values, percentile rankings and values of the
standard scores with nine categories (N=1,047) for different gender- and
age-groups; the scales provide similar benefits for patients in psychotherapy
and for those using the Italian and Turkish versions.
5.2.2.4 Usability: The scales are to be used for personality and disorder diagnostics in
clinical, occupational, organizational, social and emotional psychology, as
well as for psychotherapy, personal development and communication psychology.
Single or group examinations are possible for patients older than 14 years.
5.2.3
STAXI: State-Trait Anger Expression Inventory [50]
The state-trait expression
inventory is a tool for measuring situational anger and four dispositional
anger dimensions (ownership anger, inward anger, outward anger, and anger
control). Based on the original American method according to Spiel Berger, this
inventory was redesigned for use in those speaking German.
5.2.3.1 Reliability: The individual subscales have an internal consistency of α=0.71 to
α=0.95.
5.2.3.2 Validity: There are several findings of convergent and discriminant validity.
Factor analysis can separate the three scales of the anger expressions
dimensions, as well as the anger state and the anger disposition scales.
5.2.3.3 Norms: The calculation of the age- and gender-specific stain and percentile
ranking values were determined with a group of 990 probands. n for comparison
values for the new federal states of Germany, a sample of 106 subjects was
used.
5.2.3.4 Usability: The STAXI is used in clinical diagnostics (especially in the
psychosomatic field), for therapeutic progress studies and in first science
examinations for adolescents from the age of 14 years and adults.
5.2.4
FEEL-KJ: Questionnaire for the assessment of emotion regulation for
children and adolescents [51]
The questionnaire for the
evaluation of emotion regulation in children and adolescents, FEEL-KJ (German:
"Fragebogen zur Erhebung der Emotionsregulation bei Kindern und
Jugendlichen"), focuses on the multi-dimensional and emotion-specific
strategies of emotion regulation for fear, grief and anger. It explores
adaptive strategies such as problem-oriented action, dispersion, mood-raising,
acceptance, forgetting, revaluation, and cognitive problem-solving, as well as
maladaptive strategies such as abandonment, aggressive behavior, withdrawal,
self-devaluation and perseveration. It also identifies procedures that do not
assign with either of the two groups (expression, social support and emotion
control). The FEEL-KJ aims to provide a valuation of risk regarding the
development of psychopathological abnormalities. Therefore, it is used to
create a profile of personal resources.
5.2.4.1 Reliability: The test has a retest reliability (6-week reliability) of rtt=0.62 -
trr=0.81 for the strategy scales, rtt=0.81 for the adaptive strategies and
rtt=0.73 for the maladaptive strategies. The 15 comprehensive emotion strategy
scales show an internal consistency (Cronbach's alpha) of α=0.69 (for
"giving up") and α=0.91 (for "social support"). The internal
consistency (Cronbach's alpha) for the secondary scales of comprehensive
emotion is α=0.93 (adaptive strategies) and α=0.82 (maladaptive strategies).
5.2.4.2 Validity: The calibration and validation were done with a sample of N=1,446
children and adolescents. The findings on the construct validity, factorial
structure, and the differential and criteria-related validity are available.
5.2.4.3 Standards: T-values, T-value bands and percentile values (standardization sample
N=800) are available.
5.2.4.4 Usability: The questionnaire is focused on children aged 10 to 19.11 years.
Single and group testing is possible. In practice, one can find the FEEL-KJ in
use in psychotherapy, educational counselling, school psychology research on
primary and secondary prevention, and in the clinical-psychological and
pedagogical-psychological practice and study.
For the calculations in this
study, exploratory data analyses were used. Between the 12 January 2011 and the
21 August 2015, trained professionals collected the data for the child and
adolescent psychiatry patients in the clinic at Idar-Oberstein. These data were
processed to meet the criteria for the BPD- or pre-BPD-group.
To explore executive function,
the modalities "experiencing a regulation of emotions" and
"experiencing self-control" from the Scales For Experiencing Emotions
(SEE); "control of anger", "suppression of anger" and
"expression of anger" from the State-Trait-Anger Expression-Inventory
(STAXI); the "regulation of impulses" from the Eating Disorder
Inventory (EDI-2); and the "problem solving", "aggressive
actions" and "adaptive strategies total" that contain the
adaptive strategies of anger, fear and grief from the questionnaire for the
assessment of Emotion Regulation For Children And Adolescents (FEEL-KJ) were
examined.
For the further calculation,
the distribution of the data was estimated with IBM SPSS Statistics for each
modality. In the next step, the BPD and the pre-BPD groups were compared by the
T-test (when the data showed normality of distribution) or a Mann-Whitney
U-test (when the data showed no normality of distribution).
Both analyses will provide an
arithmetic mean of the questionnaires that will be compared between the two
groups. The results are calculated using IBM SPSS Statistics and Microsoft
Excel.
6.
Results
This study included 171 females
and 23 male patients who contacted the institute for child and adolescent
psychiatry Idar-Oberstein for inpatient (n=169) or outpatient or ambulatory
therapy. The treatment setting of one patient was unknown.
Most of the patients received
primary diagnoses of "borderline-personality-disorder" (n=60),
"anorexia nervosa" (n=35), "posttraumatic stress disorder"
(n=25), "depressive disorder" (n=24), "anxiety disorder"
(n=13) or "bulimia nervosa" (n=9). There were 28 patients with a
primary diagnosis described as "other disorders" (n=28).
The patients were between 12.7
years (152 months) and 20.9 years (251 months) old. The average age was 16,64
years or 199.6 months (SD=1.44 years or SD=17.33 months). The majority of the
patients (n=91) were between 16 and 18 years old. In the sample, 66 patients
were younger, and only 37 patients were older than the group of 16- to
18-year-olds. The children and adolescents were students in the 6th to 12th
grades in high schools (German: "Gymnasium", n=47), vocational
schools (German: "Berufsschule", n=10), schools for vocational
preparation (German: "Berufsvorbereitungsjahr", n=3), vocational
elementary schools (German: "Berufsgrundschule", n=5), junior high
schools or extended junior high schools (German: "Realschule / Realschule
Plus", n=59), middle schools (German: "Hauptschule", n=15),
state special schools (German: "Staatliche Förderschule", n=3)
comprehensive schools (German: "Gesamtschule"; n=25) or
pre-vocational initiatives in business (German: "Handelsschule"; n=2)
or individual schools for children with difficulties in learning (German:
"Sonderschule"; n=6).
The data of the
modules "experiencing a regulation of emotions" and
"experiencing self-control" from the Scales For Experiencing Emotions
(SEE); "control of anger", "suppression of anger",
"expression of anger" and "trait-anger" from the State-Trait-Anger
Expression-Inventory (STAXI); "regulation of impulses" from the
Eating Disorder Inventory (EDI-2); and "problem solving",
"adaptive strategies total" and "aggressive actions" from
the questionnaire for the assessment of emotion regulation for Children And Adolescents
(FEEL-KJ) in the BPD and the pre-BPD group showed a normality of distribution.
Therefore, the data of the groups were compared by an independent samples
t-test.
The modality
"control of anger" (STAXI) of the BPD group (n=91, M=18.23, SD=4.51, SEM=0.47)
showed a very statistically significant difference (t (127) =3.0469, p=0.0028,
SED=0.926) compared to the pre-BPD group (n=38, M=21.05, SD=5.42, SEM=0.88)
when compared through the two tailed t-test for independent samples. The
expectancy mean value of a verifiable random sample is 22.4 ± 3.5 [50].
The comparison of the
"Suppression of Anger" (STAXI) between the BPD group (n=91, M=20.32,
SD=4.70, SEM=0.49) and the pre-BPD group (n=38, M=18.00, SD=7.49, SEM=1.21)
resulted in a statistically significant difference (t (127) =2.1223, p=0.0358,
SED=1.093). A verifiable random sample shows an expectancy mean value of 16.0 ±
3.6 [50].
When the
"expression of anger" (STAXI) of the BPD group (n=91, M=16.98,
SD=6.04, SEM=0.63) and the pre-BPD group (n=38, M=13.98, SD=6.20, SEM=1.01)
were collated in a two-tailed t-test for independent samples, the results were
statistically significant as well (t (127) =2.5479, p=0.0120, SED=1.176). The
expectancy mean value of a verifiable random sample amounted to 13.0 ± 3.0 [50].
Only the collation of
the STAXI-modality "trait-anger" among the BPD group (n=70, M=24.71,
SD=7.21, SEM=0.86) and the pre-BPD group (n=27, M=17.52, SD=6.23, SEM=1.20)
resulted in an extremely statistically significant outcome (t (95) =4.5671, p <
0.0001, SED=1.576). A verifiable random sample resulted in an expectancy mean
value of 18.1 ± 3.6 [50].
In terms of
"problem solving" (FEEL-KJ), the BPD group (n=124, M=15.13, SD=4.70,
SEM=0.42) and the pre-BPD group (n=67, M=17.22, SD=4.99, SEM=0.61) differed
with results that were very statistically significant (t (189) =2.8747,
p=0.0045, SED=0.729). A study of the validity of the FEEL-KJ with 1102
Dutch-speaking Belgian children and adolescents between the ages of 8 and 18
years old showed a mean value of "problem solving" of 20.19 ± 4.48
[52].
A similar
statistically significant difference (t (189) =2.3804, p=0.0183, SED=0.869) was
observed regarding "aggressive actions" (FEEL-KJ) among the BPD group
(n=124, M=13.22, SD=5.97, SEM=0.54) and the pre-BPD group (n=67, M=11.15,
SD=5.26, SEM=0.64). The aforementioned study shows a mean value for
"aggressive actions" of 17.45 ± 4.37 in 1102 Dutch-speaking Belgian
children and adolescents between 8 and 18 years old [52].
The collation of the
modality "adaptive strategies total" (FEEL-KJ) showed a very
statistically significant distinction (t (189) =3.2040, p=0.0016, SED=4.383)
between the BPD group (n=124, M=101.23, SD=28.18, SEM=2.53) and pre-BPD group
(n=67, M=115.27, SD=30.21, SEM=3.69). The modality "adaptive strategies
total" provides units for the scales of the adaptive strategies for anger,
fear and grief. Therefore, the mean has to be divided into thirds; the adjusted
mean amounted to approximately 33.74 for the BPD group (n=124) and 38.42 for the
pre-BPD group (n=67). Values of the adaptive strategies lower than 40 are
related to a subnormal, deficit use of the analogical strategy of emotion
regulation [53].
When the aspect
"experiencing a regulation of emotions" (SEE) was compared between
the BPD group (n=121, M=10.08, SD=3.49, SEM=0.32) and the pre-BPD group (n=64,
M=10.17, SD=2.95, SEM=0.37), there was no statistically significant difference
detected (t (183) =0.1740, p=0.8620, SED=0.513).
The comparison of the
modality "experiencing self-control" (SEE) revealed a statistically
significant difference (t (183) =2.1548, p=0.0325, SED=0.731) between the BPD
group (n=121, M=17.05, SD=4.66, SEM=0.42) and the pre-BPD group (n=64, M=18.63,
SD=4.86, SEM=0.61).
The "regulation
of impulses" (EDI-2) of the BPD-group (n=119, M=35.92, SD=9.79, SEM=0.897)
and of the pre-BPD group (n=55, M=25.50, SD=9.11, SEM=1.229) differed even more
extremely in their statistical significance (t (172) =6.6682, p< 0.0001,
SED=1.562). A standardization with a German non-clinical group of 1754 students
aged between 10 and 20 years showed a mean of the "regulation of
impulses" measures of 13.96 (SD=4.25) for female and 13.54 (SD=4.02) for
male students [54].
7.
Discussion
These data reveal a
close association between an executive function deficit and BPD in adolescents.
The scales used to verify the significant characteristics of these patient
groups are standardized and validated for research on borderline personality disorder
in the form of instruments to test the effects of therapy. For example, the
STAXI scales "state-anger", "trait-anger", "expression
of anger" and "suppression of anger" were used to verify the
success of topiramate treatment for aggression in female patients with
borderline personality disorder [55].
The finding of a
statistically significant difference regarding "Suppression of Anger"
(STAXI) between the BPD and pre-BPD groups aligns with current research
results. Patients diagnosed with borderline personality disorder and high
values of identity diffusion show a significantly higher level of psychiatric
symptoms and higher scores for anxiety, anger and depression than do patients
with lower levels of diffusion [56]. When one implies that the number of
symptoms increases while the level of identity diffusion rises, then it is
surprising that probands of the BPD group show a statistically significantly
higher mean in "suppression of anger" than do those in the pre-BPD
group. An explanation of this result could be a limitation inherent in the
questionnaires due to their self-administered format. In the future, it is
necessary to explore this phenomenon in more detail in a more extensive sample.
On the other hand,
the mean value of outside-directed "expression of anger" (STAXI) in
the BPD group is statistically significantly higher than the mean of this
modality in the pre-BPD group. This finding fits the hypothesis that the number
of symptoms or, rather, the prevalence of typical symptoms such as outbursts of
rage increase with the level of identity diffusion and the seriousness of the
illness.
The third examined
modality of the STAXI in this study is "trait-anger". This modality
showed an extremely statistically significant difference between the higher mean
value of the BPD group and the lower mean of the pre-BPD group. This result is
congruent with observations of young BPD-patients who show a higher intensity
and frequency of angry outbursts than do children and adolescents in the
general population.
Impulsivity and
outbursts of anger are two of the core symptoms of a disorder in executive
function [39,40]. This hypothesis is proven by this study. The mean value of
the modality "control of anger" in the BPD group is significantly
lower than this modality in the pre-BPD group. This result could lead to the
assumption that there is a decreasing control of anger in the course of disease
development. For more detailed statements in terms of the importance and
formation of this modality, a prospective study with more probands could be
helpful.
Drechsler defined
executive function as a mechanism of regulation and control that provides the
ability to act purposefully and appropriately [22]. Up to now, emotional
dysregulation, dysfunctions in interpersonal relationships and high impulsivity
characterize borderline personality disorder [57]. This study shows that
patients with the more intense symptoms of borderline personality disorder
complex show significantly higher "regulation of impulses" (EDI-2),
on average, than do patients in the pre-BPD group but a significantly lower
mean of the modality "Experiencing Self-Control" (SEE). One
explanation could be a higher frequency of inner anger outbursts experienced by
patients of the BPD group. Patients with a higher intensity level of BPD
symptoms perceive a proper regulation of their impulses subjectively due to
habituation to the disorder and its symptoms such as intense inner tension. On
the other hand, these patients do not feel like controlling their thinking and
acting, owing to maladaptive strategies in the form of self-harming and
suicidal thought or actions.
Additionally, the
modality "Adaptive Strategies Total" (FEEL-KJ) containing all
adaptive strategies regarding anger, anxiety or grief differs significantly
between the lower mean value of the BPD group and the higher mean of the
pre-BPD group. This result could also explain the lower mean of the modality
"experiencing self-control" of the BPD group regarding missing coping
mechanisms to control or regulate impulses and outbursts.
Regarding the
regulation and control of emotions, in this study, it is fascinating that there
was no statistically significant difference visible between the BPD and the
pre-BPD group regarding the modality "Experiencing A Regulation of
Emotions" (SEE). The mean value of the BPD group was just fractionally
lower than the mean value in the pre-BPD group. This result is surprising
because, as mentioned above, emotional dysregulation is one of three central
characteristics of borderline personality disorder [57]. On the other hand, the
higher mean of the mode "Aggressive Behavior" (FEEL-KJ) in the BPD
group compared to pre-BPD group harmonizes with the hypothesis or, rather, with
the characterization of the three main features of borderline personality
disorder by Drechsler (2007) [22].
The comprehensive
modality "problem solving" (FEEL-KJ) that can be attributed to the
cognitive or "cold" executive function shows a significant difference
between the lower mean value of the BPD group and the higher mean in the
pre-BPD group. This observation is one of the basic problems in every phase of
the disease. A limited identity crisis normally dissolves when the adaption in
a new situation or surrounding is completed. In borderline personality
disorder, this adaption is never plenary. Erikson defined this problem as the
core phenomenon in borderline personality disorders [58]. The findings of this
study show that a low ability for "problem-solving" already exists in
patients with mild symptoms of borderline personality disorder and is not a
specific feature in patients with a BPD diagnosis.
8. Conclusion
As mentioned in the
introduction, the frequently observed symptoms of borderline personality
disorder complex such as angry outbursts, impulsivity, maladaptive coping
mechanisms, and suicide attempts, not only regularly following inpatient
treatments, but they also can have adverse effects on the therapy of those
patients [43]. Up to now, those behaviors represent symptoms with negative
results, but they could also be used as indicators and tools for the
discrimination between exhausting physiological phases that are necessary for
the development of a healthy self and symptoms of problematic personality
disorders. Therefore, it is imperative to explore the significance of the signs
pertinent to the patients with a high level of symptoms belonging to borderline
personality disorder.
Through the results
of this study, the definition of borderline personality disorder as a very
complex system of emotional dysregulation can be statistically verified in most
of its investigated aspects.
The verification of
the degree of statistically significant differences between patients with mild
or severe symptoms of borderline personality disorder complex in terms of other
modalities such as "expression of anger", "trait anger",
"aggressive behavior", "problem solving", "control of
anger", "regulation of impulses" "experiencing
self-control" or "adaptive strategies total” can be the impulse for
new assessments and categorizations for borderline personality disorder in
children and adolescents.
Although some
features of borderline personality disorder seem to differ from the
expectations that have emerged from clinical observations, the higher
"suppression of anger" of the BPD group and, additionally, the
similarity of the level of "experiencing a regulation of emotions" between
the two groups create new aspects of borderline personality disorder regarding
self-awareness and experiencing one’s own emotions and abilities. It is
necessary to investigate these characteristics in young patients with BPD
symptoms in more detail in a more prominent study population.
In clinical praxis,
these observations should change the assessment of adverse BPD symptoms from
adverse side effects to diagnosis indicators.
9.
Bias / Limitation
In the psychiatric and
psychological fields, questionnaires often depend on evaluation completed in
professional, private and social surroundings. These evaluations are
subjectively given information and individually defined understandings that are
not evaluable regarding objectivity and truth. The patients, their parents or
trained professionals answered most of the scores and questionnaires in this
study. It is not contestable that the answers given by the patients or their
social environment are not relentlessly exact.
The large sample size in a
consistent setting makes the study strong. Future studies on instruments for
the diagnosis of borderline personality disorder in children and adolescents
that primarily focus on executive function can be accredited by the results in
this article. More focused objectivation of the executive function in
borderline personality disorder can improve specific and effective therapy
forms to reach children and adolescents with borderline symptoms even better in
the therapeutic setting.
10. Key Points
Although the effects of a troubled executive function - often noticed
when disabling the therapeutic setting and relations - are seen mainly in BPD
patients, the association between symptoms of executive dysfunction and BPD is
unproven thus far. By comparing patients with severe and mild BPD symptoms,
this study shows that the definition of BPD as a complex of emotional
dysregulation can be mostly confirmed. Surprisingly, "suppression of
anger" in the BPD group was significantly higher than in those patients
with milder symptoms; additionally, "experiencing a regulation of
emotions" did not differ between the two groups. In clinical praxis, these
observations can change the assessment of adverse BPD-symptoms from negative
side effects to diagnosis indicators. (Table 1)
11. Ethics Approval and
Consent to Participate
The ethical approval was granted by the Ethics Committee of the Medical
Faculty Heidelberg, Germany (S-668/2017).
Applicable legal requirements were met for this study. The study follows
the provisions of the Helsinki Declaration in its current version. The study
protocol was submitted to the Ethics Committee of the Medical Faculty of
Heidelberg for professional counselling before the start of the study.
The participation of patients in the study was voluntary. Their consent
could be withdrawn at any time, without giving reasons and without any
disadvantages for further medical care. Upon withdrawal from the study, data
material already obtained were to be destroyed or there will be an inquiry
whether the patient agrees with the evaluation of the article.
The data used for this study were originally collected for another
research project by the psychiatric institution in Idar-Oberstein. Within that
research project, the patients / participants, etc., as well as their parents
or the guardian of children younger than 16 years old, were informed in writing
and orally about the nature and scope of the planned examination, in particular
about the possible benefits for the patients’ health and potential risks. They
were also informed about the possible use of the data for future studies and
research projects. A signature documenting their consent was required on a
consent form.
12. Competing Interests
The authors declare that they have no financial and non-financial
competing interests.
13. Funding
No funding was received for this study.
14. Consent for Publication
Not applicable.
15. Availability of Data
and Materials
The datasets generated and analyzed during the current study are not
publicity available due to the protection of individual privacy of the patients
but are available from the corresponding author on reasonable request.
16. Authors’ Contributions
L.F., E.M. and F.R.
conceived of the presented idea. L.F. developed the theory and performed the
computations.
L.F. verified the
analytical methods. E.V. encouraged L.F. to investigate the social cognition in
borderline personality disorder and supervised the findings of this work. All
authors discussed the results and contributed to the final manuscript.
17. Acknowledgement
The Institute for child and adolescent psychiatry in Idar-Oberstein
(Germany) and Heidelberg (Germany) supported this study and research. We thank
the colleagues from this institution who collected the data and gave insight and
expertise through their contact and through the specialized development of the
Dialectic-Behavioral Therapy for Adolescents with symptoms of a borderline
personality disorder that is offered by trained professionals in the Institute
for child and adolescent psychiatry in Idar-Oberstein.
5.2 Methods: Questionnaires
5.3 Methods: Statistical Methods
6.1 Results: Participants
6.2 Results: Statistics
|
“Control of anger” (STAXI) |
“Suppression of anger” (STAXI) |
“Expression of anger” (STAXI) |
“Trait-anger” (STAXI) |
“Problem solving” (FEEL-KJ) |
“Aggressive actions” (FEEL-KJ) |
“Adaptive strategies total” (FEEL-KJ) |
“Experiencing a regulation of emotions” (SEE) |
“Experiencing self-control” (SEE) |
“Regulation of impulses” (EDI-2) |
|||||||||||||
|
BPD |
Pre-BPD |
BPD |
Pre-BPD |
BPD |
Pre-BPD |
BPD |
Pre-BPD |
BPD |
Pre-BPD |
BPD |
Pre-BPD |
BPD |
Pre-BPD |
BPD |
Pre-BPD |
BPD |
Pre-BPD |
BPD |
Pre-BPD |
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
number |
91 |
38 |
91 |
38 |
91 |
38 |
70 |
27 |
124 |
67 |
124 |
67 |
124 |
67 |
121 |
64 |
121 |
64 |
119 |
55 |
|||
mean |
18.23 |
21.05 |
20.32 |
18.00 |
16.98 |
13.98 |
24.71 |
17.52 |
15.13 |
17.22 |
13.22 |
11.15 |
101.23 |
115.27 |
10.08 |
10.17 |
17.05 |
18.63 |
35.92 |
25.50 |
|||
standard deviation |
4.51 |
5.42 |
4.70 |
7.49 |
6.04 |
6.20 |
7.21 |
6.23 |
4.70 |
4.99 |
5.97 |
5.26 |
28.18 |
30.21 |
3.49 |
2.95 |
4.66 |
4.86 |
9.79 |
9.11 |
|||
SEM |
0.47 |
0.88 |
0.49 |
1.21 |
0.63 |
1.01 |
0.86 |
1.20 |
0.42 |
0.61 |
0.54 |
0.64 |
2.53 |
3.69 |
0.32 |
0.37 |
0.42 |
0.61 |
0.897 |
1.229 |
|||
Difference of mean |
-2.82 |
2.32 |
3.00 |
7.20 |
-2.09 |
2.07 |
-14.04 |
-0.09 |
-1.58 |
10.418 |
|||||||||||||
95% confidence interval of the difference |
[-4.65 ; -0.99] |
[0.16 ; 4.48] |
[0.67 ; 5.32] |
[4.07 ; 10.32] |
[-3.53 ; -0.66] |
[0.35 ; 3.78] |
[-22.69 ; -5.4] |
[-1.10 ; 0.92] |
[-3.02 ; -0.13] |
[7.33 ; 13.50] |
|||||||||||||
p-value |
0.0028 |
0.0358 |
0.0120 |
< 0.0001 |
0.0045 |
0.0183 |
0.0016 |
0.8620 |
0.0325 |
< 0.0001 |
|||||||||||||
t-value |
3.0469 |
2.1223 |
2.5479 |
4.5671 |
2.8747 |
2.3804 |
3.2040 |
0.1740 |
2.1548 |
6.6682 |
|||||||||||||
df |
127 |
127 |
127 |
95 |
189 |
189 |
189 |
183 |
183 |
172 |
|||||||||||||
Standard error of difference |
0.926 |
1.093 |
1.176 |
1.576 |
0.729 |
0.869 |
4.383 |
0.513 |
0.731 |
1.562 |
Table 1: Statistical Results.