Temperamental and acute symptoms of borderline personality disorder: associations with normal personality traits and dynamic relations over time.

Although broad empirical support exists for the validity of borderline personality disorder (BPD; Gunderson, 2008; Lieb et al. 2004), research also consistently demonstrates that BPD is a heterogeneous construct. The differentiation of sub-components of BPD may be important for diagnosis, intervention, and understanding the aetiology of the disorder. Common frameworks for organizing these sub-components typically involve distinctions between the phenomenological content or empirical structure of symptoms. For example, BPD measures often have sections that are organized by content areas (e.g., Morey, 1991; Zanarini et al. 1989) and factor analyses of BPD symptoms have suggested sub-components such as affective, interpersonal, or impulsivity symptoms (e.g., Sanislow et al. 2002). However, other approaches beyond content-based groupings and factor analytic techniques may also prove useful for identifying subcomponents of BPD. Most notably, temporal considerations might be particularly important for differentiating symptom sets within psychiatric disorders (e.g., see Anderluh et al. 2008). Zanarini et al. (2003; 2007) identified distinct subgroups of temperamental and acute BPD symptoms based on considerations of varying remission rates (Table 1). In their 2007 study, 20-40% of BPD patients who experienced temperamental symptoms at baseline maintained them at 10-year follow-up, whereas less than 15% of BPD patients who experienced acute symptoms maintained them for 10 years. Similar results were observed in a different clinical sample (McGlashan et al. 2005). Although these subgroups cut across content-based groupings, affective symptoms tend to be more temperamental and impulsive symptoms tend to be more acute (see Table 1), suggesting the possibility of integrating BPD conceptualizations in terms of both manifest content and temporal stability. Table 1 Content domains associated with BPD temperamental and acute symptoms. Based in part on these findings, Zanarini and Frankenburg (2007) argued that BPD emerges due to the interaction of “hyberbolic” temperamental features that represent a core feature of the disorder and ineffective strategies for modulating this temperament in the context of triggering or “kindling” events in the environment that lead to acute symptomatology. Characteristics of the hyperbolic temperament described by Zanarini and Frankenburg, such as chronic unpleasant emotions or thoughts, appear to resemble the BPD temperamental symptoms listed in Table 1, which were distinguished empirically as slower to remit in BPD patients (Zanarini et al. 2007). The second element of this model involves the kinds of malleable symptoms that result from ineffective strategies for modulating inner states in an adaptive manner, such as the acute symptoms identified as remitting more quickly (Zanarini et al. 2007) and shown in Table 1. These symptoms may also reflect the kinds of difficulties that are most likely to bring people to treatment. For example, a person with a hyperbolic temperament, in the face of a kindling event such as a romantic break up, may engage in impulsive self-damaging behavior such as a suicidal gesture, leading to hospitalization. These acute symptoms may remit more quickly because they are more closely linked to dynamic changes in the environment, perhaps even including the effects of treatment. Despite the promising empirical support for the distinction between temperamental and acute BPD symptoms, additional work is needed to further establish the validity of this distinction and to evaluate how both temperamental and acute symptoms may reinforce each other over time in those individuals with BPD. Accordingly, the present study extends the conceptual and empirical articulation of this temperamental/acute framework for BPD in two ways. First, we evaluate distinctions between temperamental and acute BPD symptoms from the perspective of a structural model of normal personality traits. A number of investigators have demonstrated specific patterns of correlations between BPD and “normal” personality traits such as the elements of the well-known Five Factor Model (FFM) of personality (see Samuel & Widiger, 2008). Research has also shown that a trait constellation linked to BPD is dynamically related to the diagnosis in a manner that suggests that trait change leads to symptom change, whereas symptom change does not lead to trait change (Warner et al., 2004). However, these studies have generally assessed these relations at the level of the BPD diagnosis, rather than potentially important sub-elements of the disorder. A better understanding of the personality factors associated with BPD and its sub-components is important given the wide body of evidence linking personality traits to other outcomes (Roberts et al., 2007) and the potential utility of personality variables for treatment planning (Harkness & Lilienfeld, 1997). A finding that different BPD symptoms have varying associations with personality domains would provide further support for the meaningful distinction between temperamental and acute aspects of this disorder. Two FFM traits, neuroticism and extraversion, would appear to be most related to temperamental features of BPD, as these factors predispose individuals to a number of mood problems (Clark et al. 1994) of the sort that appear to be relatively enduring in BPD. In general, neuroticism depicts a propensity for negative emotions such as depression, anger, and anxiety, whereas extraversion indicates the propensity for positive emotions (and thus low scores indicate limited experiences of positive emotions) and sociable behavior. Consistent with this claim, previous research has linked BPD with extremely high levels of neuroticism and low levels of extraversion (Samuel & Widiger, 2008). This constellation of traits may offer an alternative way to characterize the predisposition for negative affect and limited capacity for positive emotions that comprise the hyperbolic temperament. Two other FFM traits, agreeableness and conscientiousness, would appear to be most related to acute symptoms. Agreeableness denotes the general tendency to be trusting, friendly, and compliant as opposed to being antagonistic or hostile with others. Conscientiousness is a broad trait that includes tendencies to be dutiful, achievement-striving, and orderly. Research has consistently shown relations of BPD with low levels of both of these traits (Samuel and Widiger, 2008). Low agreeableness would be expected to link closely to some of the acute interpersonal symptoms of BPD, such as devaluation or entitlement. More generally, disagreeableness may signal an ineffective coping strategy for managing stress as it tends to strain the very relationships that could afford support and comfort during difficult times. Low conscientiousness might be associated with the impulsive behaviors that characterize many of the acute symptoms, such as substance abuse, promiscuity, or self-harming behaviors. Furthermore, low conscientiousness may limit dutiful or achievement-striving behaviors that may otherwise lead to educational and occupational successes that could buffer individuals against the difficulties associated with BPD. However, while these traits are similar to one another and to theoretical accounts of acute symptoms of BPD in that they “tap important aspects of self-regulation” (Shiner, 2009), it should also be noted that conscientiousness is linked to the temperament trait disinhibition (Clark, 2005), and perhaps it should relate to both temperamental and acute symptoms of BPD. Beyond examining the distinction between temperamental and acute BPD symptoms from the perspective of a general model of personality functioning, the second goal of this study was to examine potentially dynamic relations between temperamental and acute symptom sets across time. Temperamental difficulties would be expected to create situations that challenge one's ability to cope. It is reasonable to expect then that greater temperamental severity should be associated with increasing coping difficulties, and thus relative increases in temperamental symptoms should predispose individuals to increases in maladaptive outcomes stemming from ineffective coping, as represented by acute symptoms. At the same time, the presence of acute symptoms suggests that ineffective coping strategies have failed to manage the environment effectively. Ineffective coping and its symptomatic consequences would be expected to lead to an exacerbation of the temperamental features of BPD, including depression, anger, and anxiety. In other words, increases in maladaptive acute symptoms would be anticipated to lead to greater levels of temperamental symptoms. Accordingly, we would expect to find mutually reinforcing connections between temperamental and acute symptoms over time. In the current study, we used data that had been previously used to identify temperamental and acute symptoms of BPD based on different rates of mean-level change (Zanarini et al., 2007) over time to test two hypotheses.. First, we expected that temperamental symptoms of BPD would link to high neuroticism and low extraversion whereas acute symptoms of BPD would link to low agreeableness and conscientiousness. Second, we expected that temperamental and acute symptoms would be dynamically linked to one another over time.