Cognitive Conflict in Borderline Personality Disorder

Study Overview
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Brief Summary
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Background: Borderline personality disorder (BPD) is a severe psychological condition characterized by emotional, interpersonal and self-image instability in addition to impulsive behaviour. Although there have been several explanatory models and psychotherapy approaches that have been designed to comprehend and intervene on BPD, most seem not to recognize idiosyncratic cognitive conflict as an important feature on this disorder. Adding personal dilemmas, such as those conceptualized in personal construct theory, as a key element to BPD's explanatory model could provide a better picture to understand this disorder and possibly to enhance effectiveness of current psychotherapy approaches. Despite the fact that constructivist explanatory models have been used and tested in several clinical populations, there is little work done studying the relevance of inner conflicts in BPD. According to the prototypical symptomatology manifested by these patients, psychological instability can be assumed as a transversal feature present in this disorder; therefore, a larger amount of cognitive conflict can be expected in BPD patients. Method and Analysis: In order to test this assumption, this study aims to examine the characteristics of the interpersonal cognitive system of patients diagnosed with BPD and note their potential differences with the general population using the repertory grid technique, a complex assessment tool derived from personal construct theory. Statistical analyses will be performed to examine whether the clinical sample tends to present with more cases and with higher number of cognitive conflicts than the control group. Likewise, the association between cognitive conflict and symptom severity will be explored. Results will be a first step to determine if cognitive conflicts have an important role in the explanation of BPD. This will also help to value the convenience to further investigate the efficacy of conflict resolution psychotherapy interventions with these patients. This research work is undertaken in the context of a funded predoctoral research program.

Detailed Description
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Out of all personality disorders, BPD is one of the most life-threatening and psychological distressful due the symptomatic manifestation of impulsive behavior along with emotional, interpersonal and self-image instability. Suicidality and Non-Suicidal Self-Injury (NSSI) rates in this population are extremely high, and worrying for the families and mental health professionals. Over the last decades, BPD has obtained broad attention and many psychological treatments have been proposed to deal with its main symptoms. Although some treatments have been proven to be empirically effective in some domains, clearly not all experienced symptoms are successfully targeted, and some cases seem not to be helped even when treated by the more efficacious approaches. Perhaps, the explanatory models from which these psychotherapies emerge could have underestimated important aspects such as personal dilemmas. Cognitive conflict has been defined and conceptualized by different psychological orientations, but only a few have included this phenomenon as an influential factor in the understanding of the origin and nature of psychological disorders and their psychotherapy proposals. Those that have considered inner conflicts have mainly focused on theoretical based dilemmas the academics would perceive relevant or common instead of exploring potential ideographic conflicts patients may have. Being a disorder that is noticeably characterized by identity disturbances, finding relevant unresolved cognitive conflicts regarding self and others in these patients is expected. Addressing these issues could be potentially useful to further develop an explanatory model for this disorder as well as to increase therapeutic resources to help with these unattended potential necessities. The central aim of this research is to assess cognitive conflicts in BPD diagnosed individuals to determine their role in the explanatory model of this disorder. These findings would permit the consideration of adapting a dilemma-focused intervention module which could complement existing treatments for these patients. In addition, exploring other characteristics of self-construction and the construction of others that are assessed with the RGT would be of interest. The specific objectives of this study are: To test the hypothesis that patients with BPD present more cognitive conflicts (i.e., implicative dilemmas and dilemmatic constructs) than a general population sample. To explore the content of cognitive conflicts in patients with BPD. To examine whether presence and/or frequency of cognitive conflicts is associated with severity of emotional symptoms in BPD patients. To explore whether the presence and number of cognitive conflicts has any capacity to predict treatment outcome. To examine the relevance of other aspects of the construction of the self and others to explain the psychological functioning of patients with a BPD diagnosis. The hypothesis of this study are: The percentage of participants with implicative dilemmas and/or dilemmatic constructs will be superior in the group of patients diagnosed with BPD compared to a control group (community sample). The number of implicative dilemmas and/or dilemmatic constructs will be higher in the BPD group than in the control group. Presence and higher number of cognitive conflicts will be associated with greater levels of general clinical symptomatology (such as depression, anxiety, etc.). Presence and higher number of individual cognitive conflicts will predict poor treatment outcome one year after the initial assessment. For exploratory purposes, the content of implicative dilemmas and dilemmatic constructs will be studied, as well as the differences with the control group regarding self-construction measures (self-ideal discrepancy, self-others discrepancy, ideal-others discrepancy) and other characteristics of the construction system (interpersonal cognitive differentiation and polarization) and its association with other clinical and sociodemographic variables.

Official Title
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Analysis of Personal Constructs in Borderline Personality Disorder and Its Relation With Severity and Therapeutic Outcome

Conditions
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Borderline Personality Disorder

Intervention / Treatment
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* Other: Psychological assessment


Participation Criteria
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Eligibility Criteria
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INCLUSION CRITERIA Aged between 18 and 60 years old. Having been diagnosed with BPD by a well-trained professional according to DSM-5 criteria. EXCLUSION CRITERIA Having been diagnosed with bipolar disorder, psychotic disorder, prevalent continued and active substance abuse, disabling physical illness, organic cerebral dysfunctions or mental developmental severe difficulties. Not able to communicate either in Spanish or Catalan. Presence of other comorbid conditions such as other personality disorders, anxiety disorders, eating disorders, depression or non-disabling physical illness, will not be an exclusion motive, but will be recorded for statistical control purposes.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 60 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Borderline Personality Disorder<br>Borderline personality disorder diagnosed participants | Other: Psychological assessment<br>* Psychological assessment with the repertory grid technique (RGT) in order to quantify cognitive conflicts.<br>|
| Control<br>Healthy participants | Other: Psychological assessment<br>* Psychological assessment with the repertory grid technique (RGT) in order to quantify cognitive conflicts.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Implicative dilemma | The repertory grid technique (RGT) is a personalized assessment procedure using a structured interview designed to make explicit the personal constructs (bipolar dimensions of subjective meaning) used to interpret and organize reality. An implicative dilemma can be identified when an individual does not perform a desired change due to the negative implications involved for their desired identity. The RGT can detect personal constructs in which the current perception of the self is similar to the ideal self (congruent constructs) and the constructs in which the subject's self-perception is contrary to their ideal construction (discrepant construct). A statistical analysis of the RGT reveals when a potential pole shift of a discrepant construct involves the pole shift of a congruent construct due to an existing association between the two constructs. Implicative dilemmas may cause dissatisfaction and psychological discomfort. | Through study completion, an average of 2 years. | 
| Dilemmatic construct | Dilemmatic constructs can be identified when an individual is not sure how would they like to be in a certain identity aspect. This type of cognitive conflict can be assessed and analyzed with the RGT in order to identify self-construction domains in which the person may find it difficult to choose how to ideally be. Indecision in regard to identity can add psychological distress to those who experience it. | Through study completion, an average of 2 years. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Diagnostic Interview for Borderlines - Revised (DIB-R) | It is a structured interview that helps to identify the potential presence of BPD by assessing 22 common statements for BPD patients. It explores aspects related to affectivity, cognition, impulsivity patterns and interpersonal relationships. The test provides an overall score from 0 to 10 that determines presence or absence of BPD (6 or higher indicates presence). | Through study completion, an average of 2 years. | 
| Structured Clinical Interview for DSM-IV-II (SCID-II) | It is a structured assessment interview aimed to identify the potential presence or absence of the personality disorders defined by the DSM-IV criteria. After completion, results show how many diagnostic criteria are met by the interviewee for each of the 13 personality disorder assesed. When evaluating BPD, scores can go from 0 to 9 (5 or higher indicates presence). | Through study completion, an average of 2 years. | 
| Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM) | It is a self-report questionnaire formed by 34 items (18 in the reduced version) that aims to assess the clinical state of the person in the following four dimensions: subjective well-being, problem/symptoms, general functioning and risk. All scales and an overall measure are computed in order to obtain scores that rank from 0 to 4 (higher scores indicates worse outcome). | Through study completion, an average of 2 years. | 
| Depression Anxiety Stress Scales (DASS-21) | It is a questionnaire created to quickly evaluate levels of depression, anxiety and stress. Respondents must score in a scale from 0 to 3 to describe the intensity or frequency they experienced about 21 different clinical symptoms during the previous week. Punctuations oscillate between 0 and 63 (higher scores indicates worse outcome). | Through study completion, an average of 2 years. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Repertory grid technique, Predictors of outcome, Implicative dilemma, Dilemmatic construct, Personal Construct Theory