10c
Alexander L. Chapman, Nora H. Hope, and Brianna J. Turner
We appreciate the astute commentaries by Scott and Pilkonis (this volume) and Niedtfeld, Paret, and Schmahl (this volume). Scott and Pilkonis address some very important big picture themes regarding the conceptualization, etiology, and treatment of BPD, and Niedtfeld et al. comment on innovative research highlighting the interplay of neuroscience and psychotherapy.
Clarifying the BPD Construct and Etiological Pathways
Scott and Pilkonis suggest the overarching construct of BPD is best conceptualized as unidimensional and assessed on a continuum of severity. To further clarify the BPD construct and its possible etiology, we believe studies should continue to examine the interplay of heritable and environmental influences on BPD. Findings are beginning to illuminate the nature of the BPD construct and the heritable and environmental influences on the development of BPD and its features. Reichborn-Kjennerud et al. (2013), for example, found that BPD features were best accounted for by a model including a moderately heritable latent BPD factor, with heritable and unique environmental factors accounting for 55 percent and 45 percent of this factor, respectively. The subset of interpersonal BPD symptoms had low heritability (2.2 percent), and the heritability of affective instability was 29.3 percent. Findings suggested that unique environmental influences carry most of the weight when it comes to interpersonal symptoms and substantially influence affective instability.
As suggested by both commentaries, an integrative approach to theory and research can be immensely helpful in understanding and helping those with BPD. Studies using a variety of innovative methods have highlighted the nature of the BPD construct as well as neurobiological factors related to problems with emotion dysregulation among adults with BPD. We would further argue that, consistent with a developmental psychopathology approach, continued research is needed to understand the biopsychosocial processes operating at various levels of development to contribute to BPD and its serious behavioral and functional problems.
A Developmental Psychopathology Framework for Understanding BPD
Increasingly, studies over the past several years have examined key precursors, heritable and environmental influences, and symptom patterns of BPD over time. Some contemporary developmental theories of BPD suggest that heritable vulnerabilities manifest heterotypically at various stages of development and transact with environmental risk factors to contribute to the development of BPD (e.g., see Beauchaine, Hinshaw, & Bridge, 2019; Crowell, Kaufman & Beauchaine, 2014).
Crowell et al. (2014; see also Beauchaine, Hinshaw, & Bridge, 2019), for example, have proposed that trait impulsivity (a) is a key heritable influence associated with a heterotypic set of childhood and adolescent behavioral problems (e.g., oppositional defiant disorder, attention-deficit hyperactivity disorder, adolescent mental health problems) and (b) makes children particularly vulnerable to the effects of adverse environments. Further, this model proposes that invalidating rearing environments shape the development of emotion dysregulation. In adolescence, the development of self-injury and other behavioral problems signify worsening emotion dysregulation and have adverse interpersonal and intrapersonal consequences that further contribute to the development of BPD.
Over the past several years, findings have indicated that developmental psychopathology models of BPD have promise and suggest directions for prevention and treatment. These models suggest that (a) we should be able to identify at-risk children and adolescents well before they begin to engage in seriously self-damaging behaviors and (b) key prevention and treatment targets include socialization factors (parenting), emotion dysregulation, and self-injury (as suggested by Beauchaine, Hinshaw, & Bridge, 2019). One randomized clinical trial (RCT) applied DBT to children with disruptive mood dysregulation disorder (DMRD), finding an advantage of DBT over treatment as usual in terms of dropout rates, positive treatment response, and remission from DMRD (Perepletchikova et al., 2017). It remains to be seen whether DBT or other approaches can curtail the later development of nonsuicidal self-injury (NSSI), suicidal behavior, or BPD. Further, findings from two large studies have supported the efficacy of DBT for reducing suicide attempts, self-injury, suicidal ideation, and depression among self-injuring adolescents (e.g., McCauley et al., 2018; Mehlum et al., 2014). It will be important to determine whether treatment or prevention strategies occurring before BPD is crystallized can curb a trajectory toward worsening behavioral problems and eventual BPD.
The Development of Neurobiological Characteristics of BPD
Niedtfeld et al. summarize findings broadly suggesting poor frontal regulation of the limbic system in BPD. Findings have begun to suggest that the aberrations in brain structure or function observed among adults with BPD may begin to appear, albeit in a narrower fashion, among at-risk adolescents (e.g., Beauchaine, Sauder, Derbidge, & Uyeji, 2019). Researchers have proposed that adolescence is an important period for the development of limbic and prefrontal regions and the stress-response system (Ahmed, Bittencourt-Hewitt, & Sebastian, 2015; Miller & Prinstein, 2019). Abnormalities in the development of these systems can, in turn, contribute to the development of self-injury (Miller & Prinstein, 2019), a key indicator of future BPD. Future research should examine whether psychosocial and other approaches (e.g., neurofeedback) can influence neurobiological development and reduce the risk of broader emotion regulation problems throughout later adolescence and adulthood.
Conclusions
In conclusion, Scott and Pilkonis (this volume) and Niedtfeld et al. (this volume) have provided insightful contributions to the continuing and sometimes confusing conversation about the nature of BPD. To best understand the nature of BPD and the complex person × environment transactions that contribute to this disorder, we should conceptualize and examine BPD developmentally across the lifespan, using a biopsychosocial framework. We should also continue to develop and examine ways to help at-risk individuals and people with BPD reduce suffering and build lives that are worth living.
References
Ahmed, S. P., Bittencourt-Hewitt, A., & Sebastian, C. L. (2015). Neurocognitive bases of emotion regulation development in adolescence. Developmental Cognitive Neuroscience, 15, 11–25.
Beauchaine, T. P., Hinshaw, S. P., & Bridge, J. A. (2019). Nonsuicidal self-injury and suicidal behaviors in girls: The case for targeted prevention in preadolescence. Clinical Psychological Science, 7, 643–667.
Beauchaine, T. P., Sauder, C. L., Derbidge, C. M., & Uyeji, L. L. (2019). Self-injuring adolescent girls exhibit insular cortex volumetric abnormalities that are similar to those observed in adults with borderline personality disorder. Development and Psychopathology. doi:10.1017/S0954579418000822
Crowell, S. E., Kaufman, E. A., & Beauchaine, T. P. (2014). A biosocial model of BPD: Theory and empirical evidence. In C. Sharp & J. L. Tackett (Eds.), Handbook of Borderline Personality Disorder in Children and Adolescents (pp. 143–157). New York: Springer.
McCauley, E., Berk, M. S., Asarnow, J. R., Adrian, M., Cohen, J., Korslund, K., … Linehan, M. M. (2018). Efficacy of dialectical behavior therapy for adolescents at high risk for suicide: A randomized clinical trial. JAMA Psychiatry, 75, 777–785.
Mehlum, L., Tørmoen, A. J., Ramberg, M., Haga, E., Diep, L. M., Laberg, S., … Grøholt, B. (2014). Dialectical behavior therapy for adolescents with repeated suicidal and self-harming Adolescent Psychiatry, 53, 1082–1091.
Miller, A. B., & Prinstein, M. J. (2019). Adolescent suicide as a failure of acute stress-response systems. Annual Review of Clinical Psychology, 15, 21.1–21.26.
Perepletchikova, F., Nathanson, D., Axelrod, S. R., Merrill, C., Walker, A., Grossman, M., … Walkup, J. (2017). Randomized clinical trial of dialectical behavior therapy for preadolescent children with disruptive mood dysregulation disorder: Feasibility and outcomes. Journal of the American Academy of Child & Adolescent Psychiatry, 56, 832–840.
Reichborn-Kjennerud, T., Ystrom, E., Neale, M. C., Aggen, S. H., Mazzeo, S. E., Knudsen, G. P., … Kendler, K. S. (2013). Structure of genetic and environmental risk factors for symptoms of DSM-IV borderline personality disorder. JAMA Psychiatry, 70, 1206–1214.