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Theories of borderline personality disorder:
A mechanisticevaluation
Julianne Wilner Tirpak, M.A. | Boston University Steven Sandage, Ph.D., M.Div. | Boston University
Shannon Sauer-Zavala, Ph.D. | University of Kentucky
COSTLY, IMPAIRING, UNDERSTUDIED
McGlashan et al., 2000 Sansone, 2004
Skodol et al., 2002
INTERFERING ACROSS SEVERAL DOMAINS
American Psychaitric Association, 2013
INTENSIVE, MULTIFACETED TREATMENTS INFORMED BY DIFFERENT THEORIES
E.g., DBT, psychodynamic
BORDERLINE PERSONALITY DISORDER
• Suggests different treatment strategies
• Informs treatment outcome and evaluation
THE PROBLEM
Lack of consensus about what drives BPD
A MICROCOSM FOR EVALUATION
Interpersonal
conflict
DEFICITS IN INTERPERSONAL FUNCTIONING IN BPD
SOCIAL COGNITION
Bland, Williams, Scharer, &
Manning, 2004; Domes et al.,
2008; Dyck et al., 2009; Merkl et
al., 2010; Unoka, Fogd, Füzy, &
Csukly, 2011
PERCEPTUAL BIASES
Arntz & Veen, 2001; Sieswerda,
Barnow, Verheul, & Arntz, 2013;
Tragesser, Lippman, Trull, &
Barrett, 2008)
HEIGHTENED REACTIVITY
Chapman, Walters, & Gordon,
2012; Renneberg et al., 2012;
Staebler, Helbing, Rosenbach, &
Renneberg, 2011; Tragesser et al.,
2008; Walter et al., 2008
TRUST & COOPERATION
Lazarus et al., 2014; Lis & Bohus,
2013
CONCEPTUALIZATIONS OF INTERPERSONAL CONFLICT IN BPD
Here you could talk a bit Here you could talk a bit Here you could talk a bit about this person about this person about this person
EMOTION DYSREGULATION DISRUPTED ATTACHMENT
Linehan, 1993
Sauer-Zavala & Barlow, 2014
Black & Blum, 2017
Caligor, Yeoans, Clarkin & Kernberg, 2018
Clarkin, Yeomans & Kernberg, 2006
Bateman & Fonagy, 2016
THE PRESENT STUDY
Does interpersonal conflict change in treatments for BPD, informed by different theoretical perspectives?
MULTIPLE BASELINE & ALTERNATING TREATMENT DESIGN
● Randomized to 2 or 4-week assessment-only baseline phase
● Randomized to 4-week theory-informed intervention
○ Emotion regulation module (Barlow et al., 2011; n = 4)
○ OR an attachment security module (Sandage et al., 2015; n = 4)
○ Phase change idiosyncratically determined based on changes in
frequency of daily interpersonal conflict
■ Responder status = 50% reduction in daily
interpersonal conflicts between phases
● 4-week assessment-only follow-up phase
● Weekly mechanism assessment measures
○ Brief Multidimensional Experiential Avoidance Questionnaire (BEAQ; Gámez et al, 2014)
○ Experiences in Close Relationships Scale (ECR-S; Wei, Russell, Mallinckrodt, & Vogel, 2007)
Participants
● N = 8 patients with BPD
○ Average age = 27 years old (SD = 12.56 years, rage 19-55 years)
○ 6 female, 1 male, 1 gender non-binary
○ 4 White, 3 South Asian, 1 Black
○ 7 Non-Hispanic, 1 Hispanic
○ 5 heterosexual, 2 queer, 1 bisexual
○ 4 single, 1 married, 1 cohabitating with partner, 1 in long-term
relationship, 1 dating
RESULTS – Daily Conflict Example
RESULTS – Interpersonal conflict with visual inspection
● 3 responders (50% reduction in interpersonal conflicts after first module)
○ 2 with attachment security module
○ 1 with emotion regulation module
● 3 partial responders (50% reduction in interpersonal conflicts after the first
module and a two week baseline)
○ 2 with attachment security module
○ 1 with emotion regulation module
● 2 non-responders (<50% reduction in interpersonal conflicts after the first
module, proceeded to alternative module)
○ 2 with emotion regulation module
RESULTS-
Mechanism Example
RESULTS –Mechanisms with Visual Inspection
● Decreasing trends in experiential avoidance for 4 out of 5 patients when
receiving the emotion tolerance module
● Decreasing trends in attachment insecurity for 3 out of 4 patients when
receiving the attachment security module
● Decreasing trends in the alternate mechanism when receiving the alternate
module for 2 out of 4 patients in measure of experiential avoidance and 4
out of 5 patients in measure of attachment insecurity
LIMITATIONS
DISCUSSION
FUTURE DIRECTIONSCONCLUSIONS
• Modules used taken from
larger interventions• Varying levels of empirical
support for theinterventions used
• Inconsistencies in
reporting conflicts (e.g., missed data)
• Sample size
• Supplemental statistical analyses to support visual inspection
• Replication
• Consider personalized treatment approaches
• Interpersonal conflict in
BPD does change in brief interventions informed by different theories
• Multiple mechanisms might be driving interpersonal conflict (i.e., equifinality)
• Idiographic factors (e.g.,severity) may influence response
THANK YOU & QUESTIONS
CONTACT:
Julianne Wilner Tirpak
@Julianne_Tirpak
Acknowledgment: Study funded by the Boston University Clara Mayo Memorial Fellowship
