Personality Disorders: Theory, Research, and Treatment 2015, Vol. 6, No. 3, 294 –295
© 2015 American Psychological Association 1949-2715/15/$12.00 http://dx.doi.org/10.1037/per0000134
COMMENTARY
Defining the Construct of Reactive Aggression in Borderline Personality Disorder: Commentary on “Aggression in Borderline Personality Disorder—A Multidimensional Model” Janine D. Flory This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
James J. Peters Veterans Affairs Medical Center, Bronx, New York, and Icahn School of Medicine at Mount Sinai
construct validity. Is reactive aggression in BPD different from reactive aggression in people without BPD? The issues involved in choosing control groups in biological psychiatry will not be elaborated here because they are described succinctly by Schwartz, Susser, and Gorman (2006). The review by Mancke et al. (2015) also highlights the fact that there is a general lack of research establishing predictive validity of aggression in BPD, with most research comparing two groups sampled at one time point. There are some exceptions; for example, two prospective studies cited in the review that indicate that affective instability mediates the association between BPD and aggression (Newhill, Eack, & Mulvey, 2012; Scott, Stepp, & Pilkonis, 2014). However, there is an obvious need for more longitudinal research to establish predictive validity, including establishing the effects of treatment (or even naturalistic symptom change) on behavioral and biological factors associated with aggression in BPD. There is strong interest in and optimism for the use of biomarkers to aid in the diagnosis, risk, and prognosis for psychiatric diseases (e.g., Davis et al., 2015; Yehuda, Neylan, Flory, & McFarlane, 2013). The complexity of the BPD phenotype and its overlap with other conditions makes this a challenging task, but the lessons learned from work with other disorders should be incorporated into research on biomarkers for BPD. The literature reviewed by Mancke et al. (2015) shows that most studies examine single biological markers (again, at only one time point). Mancke et al. (2015) group biological and behavioral indicators together under single constructs (i.e., affective dysregulation, impulsivity, threat hypersensitivity, impairments in cognitive empathy, selfother differentiation); however, current research does not indicate that it is common practice to examine sets of biological markers in the context of BPD. Because no psychiatric disorder is likely to be associated with a single diagnostic biomarker, it is important that studies of BPD not focus on single biological markers, but begin to incorporate big data approaches, including genome-wide approaches (e.g., Prados et al., 2015). The methods and technology required for identification of biomarkers is emerging rapidly, and these approaches have the capability of identifying whole biological systems or networks that are involved in conferring risk for BPD (e.g., Neylan, Schadt, & Yehuda, 2014). To the extent that BPD consists of subtypes, including an aggression subtype (Hallquist & Pilkonis, 2012) as described in Mancke et al. (2015), these approaches are likely to assist in identifying such subtypes.
Aggressive behavior is characteristic of borderline personality disorder (BPD) and likely contributes in large part to the interpersonal dysfunction observed in people with this disorder (Lazarus, Cheavens, Festa, & Zachary Rosenthal, 2014). The paper authored by Mancke, Herpertz, and Bertsch (2015) presents a multidimensional model of aggression in the context of BPD, with a selective review of the research literature. BPD is arguably the most widely researched personality disorder, and the review suggests that there has been extensive progress in characterizing behavioral and biological correlates of aggression. What is not clear from the review, and indeed, the broader literature, is whether the research cited in this review is specific to BPD or can generally be applied to reactive aggression in the context of other disorders (or by extension into the normative range of the behavior). This is largely an unanswered question because clinical samples in behavioral and biological studies of BPD and its constituent traits tend to be small and heterogeneous. It is well known that with the Diagnostic and Statistical Manual of Mental Disorders (5th edition; DSM–5) “5 of 9 rule” for meeting a diagnosis of BPD, two people in the same patient group may have only one overlapping symptom. In establishing construct validity for reactive aggression in the context of BPD, it is important for researchers to present comprehensive descriptive information about which (and how many) of the nine DSM–5 criteria are related to the behavioral or biological outcome(s) of interest. Although there are inherent problems in using single-item constructs in research, the low rater reliability of structured interview assessments of personality disorder diagnoses represents a problem in the DSM–5 conceptualization of personality disorders, rather than a measurement problem as Clark (2013) has asserted. Along with specific criteria, the heterogeneity of the sample should be described with respect to co-occurring conditions (including other personality disorders). Attention to the choice of the comparison group (i.e., “healthy” vs. psychiatric controls) is also of great importance in establishing
Janine D. Flory, James J. Peters Veterans Affairs Medical Center, Bronx, New York, and Department of Psychiatry, Icahn School of Medicine at Mount Sinai. Correspondence concerning this article should be addressed to Janine D. Flory, James J. Peters Veterans Affairs Medical Center, 526 OOMH PTSD 116/A, 130 West Kingsbridge Road, Bronx, NY 10468. E-mail: [email protected] 294
REACTIVE AGGRESSION
There has been extensive progress in refining the phenotype of BPD using relatively large samples and advanced modeling techniques (e.g., Hallquist & Pilkonis, 2012). Large-scale efforts are needed that will incorporate assessment of biological and behavioral systems or networks together with state-of-the-art measurement models of the BPD construct. The incorporation of behavioral and biological markers into such models could considerably advance the understanding of BPD and, ultimately, identify treatment targets.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
References Clark, L. A. (2013). A critique of Gunderson’s views of DSM–5: Commentary on “seeking clarity for future revisions of the personality disorders in DSM–5.” Personality Disorders: Theory, Research, and Treatment, 4, 379 –380. http://dx.doi.org/10.1037/per0000050 Davis, J., Maes, M., Andreazza, A., McGrath, J. J., Tye, S. J., & Berk, M. (2015). Towards a classification of biomarkers of neuropsychiatric disease: From encompass to compass. Molecular Psychiatry, 20, 152–153. Hallquist, M. N., & Pilkonis, P. A. (2012). Refining the phenotype of borderline personality disorder: Diagnostic criteria and beyond. Personality Disorders: Theory, Research, and Treatment, 3, 228 –246. http:// dx.doi.org/10.1037/a0027953 Lazarus, S. A., Cheavens, J. S., Festa, F., & Zachary Rosenthal, M. (2014). Interpersonal functioning in borderline personality disorder: A systematic review of behavioral and laboratory-based assessments. Clinical Psychology Review, 34, 193–205. http://dx.doi.org/10.1016/j.cpr.2014 .01.007
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Mancke, F., Herpertz, S. C., & Bertsch, K. (2015). Aggression in borderline personality disorder: A multidimensional model. Personality Disorders: Theory, Research, and Treatment, 6, 278 –291. http://dx.doi.org/ 10.1037/per0000098 Newhill, C. E., Eack, S. M., & Mulvey, E. P. (2012). A growth curve analysis of emotion dysregulation as a mediator for violence in individuals with and without borderline personality disorder. Journal of Personality Disorders, 26, 452– 467. http://dx.doi.org/10.1521/pedi.2012.26 .3.452 Neylan, T. C., Schadt, E. E., & Yehuda, R. (2014). Biomarkers for combat-related PTSD: Focus on molecular networks from highdimensional data. European Journal of Psychotraumatology, 5, 23938. http://dx.doi.org/10.3402/ejpt.v5.23938 Prados, J., Stenz, L., Courtet, P., Prada, P., Nicastro, R., Adouan, W., . . . Perroud, N. (2015). Borderline personality disorder and childhood maltreatment: A genome-wide methylation analysis. Genes, Brain, and Behavior, 14, 177–188. http://dx.doi.org/10.1111/gbb.12197 Schwartz, S., Susser, E., & Gorman, J. M. (2006). Choosing controls in biologic psychiatry. In S. Schwartz, A. Morabia, & E. J. Bromet (Eds.), Psychiatric epidemiology: Searching for the causes of mental disorders (pp. 247–262). New York, NY: Oxford University Press. Scott, L. N., Stepp, S. D., & Pilkonis, P. A. (2014). Prospective associations between features of borderline personality disorder, emotion dysregulation, and aggression. Personality Disorders: Theory, Research, and Treatment, 5, 278 –288. http://dx.doi.org/10.1037/per0000070 Yehuda, R., Neylan, T. C., Flory, J. D., & McFarlane, A. C. (2013). The use of biomarkers in the military: From theory to practice. Psychoneuroendocrinology, 38, 1912–1922. http://dx.doi.org/10.1016/j.psyneuen .2013.06.009
© 2015 American Psychological Association 1949-2715/15/$12.00 http://dx.doi.org/10.1037/per0000134
COMMENTARY
Defining the Construct of Reactive Aggression in Borderline Personality Disorder: Commentary on “Aggression in Borderline Personality Disorder—A Multidimensional Model” Janine D. Flory This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
James J. Peters Veterans Affairs Medical Center, Bronx, New York, and Icahn School of Medicine at Mount Sinai
construct validity. Is reactive aggression in BPD different from reactive aggression in people without BPD? The issues involved in choosing control groups in biological psychiatry will not be elaborated here because they are described succinctly by Schwartz, Susser, and Gorman (2006). The review by Mancke et al. (2015) also highlights the fact that there is a general lack of research establishing predictive validity of aggression in BPD, with most research comparing two groups sampled at one time point. There are some exceptions; for example, two prospective studies cited in the review that indicate that affective instability mediates the association between BPD and aggression (Newhill, Eack, & Mulvey, 2012; Scott, Stepp, & Pilkonis, 2014). However, there is an obvious need for more longitudinal research to establish predictive validity, including establishing the effects of treatment (or even naturalistic symptom change) on behavioral and biological factors associated with aggression in BPD. There is strong interest in and optimism for the use of biomarkers to aid in the diagnosis, risk, and prognosis for psychiatric diseases (e.g., Davis et al., 2015; Yehuda, Neylan, Flory, & McFarlane, 2013). The complexity of the BPD phenotype and its overlap with other conditions makes this a challenging task, but the lessons learned from work with other disorders should be incorporated into research on biomarkers for BPD. The literature reviewed by Mancke et al. (2015) shows that most studies examine single biological markers (again, at only one time point). Mancke et al. (2015) group biological and behavioral indicators together under single constructs (i.e., affective dysregulation, impulsivity, threat hypersensitivity, impairments in cognitive empathy, selfother differentiation); however, current research does not indicate that it is common practice to examine sets of biological markers in the context of BPD. Because no psychiatric disorder is likely to be associated with a single diagnostic biomarker, it is important that studies of BPD not focus on single biological markers, but begin to incorporate big data approaches, including genome-wide approaches (e.g., Prados et al., 2015). The methods and technology required for identification of biomarkers is emerging rapidly, and these approaches have the capability of identifying whole biological systems or networks that are involved in conferring risk for BPD (e.g., Neylan, Schadt, & Yehuda, 2014). To the extent that BPD consists of subtypes, including an aggression subtype (Hallquist & Pilkonis, 2012) as described in Mancke et al. (2015), these approaches are likely to assist in identifying such subtypes.
Aggressive behavior is characteristic of borderline personality disorder (BPD) and likely contributes in large part to the interpersonal dysfunction observed in people with this disorder (Lazarus, Cheavens, Festa, & Zachary Rosenthal, 2014). The paper authored by Mancke, Herpertz, and Bertsch (2015) presents a multidimensional model of aggression in the context of BPD, with a selective review of the research literature. BPD is arguably the most widely researched personality disorder, and the review suggests that there has been extensive progress in characterizing behavioral and biological correlates of aggression. What is not clear from the review, and indeed, the broader literature, is whether the research cited in this review is specific to BPD or can generally be applied to reactive aggression in the context of other disorders (or by extension into the normative range of the behavior). This is largely an unanswered question because clinical samples in behavioral and biological studies of BPD and its constituent traits tend to be small and heterogeneous. It is well known that with the Diagnostic and Statistical Manual of Mental Disorders (5th edition; DSM–5) “5 of 9 rule” for meeting a diagnosis of BPD, two people in the same patient group may have only one overlapping symptom. In establishing construct validity for reactive aggression in the context of BPD, it is important for researchers to present comprehensive descriptive information about which (and how many) of the nine DSM–5 criteria are related to the behavioral or biological outcome(s) of interest. Although there are inherent problems in using single-item constructs in research, the low rater reliability of structured interview assessments of personality disorder diagnoses represents a problem in the DSM–5 conceptualization of personality disorders, rather than a measurement problem as Clark (2013) has asserted. Along with specific criteria, the heterogeneity of the sample should be described with respect to co-occurring conditions (including other personality disorders). Attention to the choice of the comparison group (i.e., “healthy” vs. psychiatric controls) is also of great importance in establishing
Janine D. Flory, James J. Peters Veterans Affairs Medical Center, Bronx, New York, and Department of Psychiatry, Icahn School of Medicine at Mount Sinai. Correspondence concerning this article should be addressed to Janine D. Flory, James J. Peters Veterans Affairs Medical Center, 526 OOMH PTSD 116/A, 130 West Kingsbridge Road, Bronx, NY 10468. E-mail: [email protected] 294
REACTIVE AGGRESSION
There has been extensive progress in refining the phenotype of BPD using relatively large samples and advanced modeling techniques (e.g., Hallquist & Pilkonis, 2012). Large-scale efforts are needed that will incorporate assessment of biological and behavioral systems or networks together with state-of-the-art measurement models of the BPD construct. The incorporation of behavioral and biological markers into such models could considerably advance the understanding of BPD and, ultimately, identify treatment targets.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
References Clark, L. A. (2013). A critique of Gunderson’s views of DSM–5: Commentary on “seeking clarity for future revisions of the personality disorders in DSM–5.” Personality Disorders: Theory, Research, and Treatment, 4, 379 –380. http://dx.doi.org/10.1037/per0000050 Davis, J., Maes, M., Andreazza, A., McGrath, J. J., Tye, S. J., & Berk, M. (2015). Towards a classification of biomarkers of neuropsychiatric disease: From encompass to compass. Molecular Psychiatry, 20, 152–153. Hallquist, M. N., & Pilkonis, P. A. (2012). Refining the phenotype of borderline personality disorder: Diagnostic criteria and beyond. Personality Disorders: Theory, Research, and Treatment, 3, 228 –246. http:// dx.doi.org/10.1037/a0027953 Lazarus, S. A., Cheavens, J. S., Festa, F., & Zachary Rosenthal, M. (2014). Interpersonal functioning in borderline personality disorder: A systematic review of behavioral and laboratory-based assessments. Clinical Psychology Review, 34, 193–205. http://dx.doi.org/10.1016/j.cpr.2014 .01.007
295
Mancke, F., Herpertz, S. C., & Bertsch, K. (2015). Aggression in borderline personality disorder: A multidimensional model. Personality Disorders: Theory, Research, and Treatment, 6, 278 –291. http://dx.doi.org/ 10.1037/per0000098 Newhill, C. E., Eack, S. M., & Mulvey, E. P. (2012). A growth curve analysis of emotion dysregulation as a mediator for violence in individuals with and without borderline personality disorder. Journal of Personality Disorders, 26, 452– 467. http://dx.doi.org/10.1521/pedi.2012.26 .3.452 Neylan, T. C., Schadt, E. E., & Yehuda, R. (2014). Biomarkers for combat-related PTSD: Focus on molecular networks from highdimensional data. European Journal of Psychotraumatology, 5, 23938. http://dx.doi.org/10.3402/ejpt.v5.23938 Prados, J., Stenz, L., Courtet, P., Prada, P., Nicastro, R., Adouan, W., . . . Perroud, N. (2015). Borderline personality disorder and childhood maltreatment: A genome-wide methylation analysis. Genes, Brain, and Behavior, 14, 177–188. http://dx.doi.org/10.1111/gbb.12197 Schwartz, S., Susser, E., & Gorman, J. M. (2006). Choosing controls in biologic psychiatry. In S. Schwartz, A. Morabia, & E. J. Bromet (Eds.), Psychiatric epidemiology: Searching for the causes of mental disorders (pp. 247–262). New York, NY: Oxford University Press. Scott, L. N., Stepp, S. D., & Pilkonis, P. A. (2014). Prospective associations between features of borderline personality disorder, emotion dysregulation, and aggression. Personality Disorders: Theory, Research, and Treatment, 5, 278 –288. http://dx.doi.org/10.1037/per0000070 Yehuda, R., Neylan, T. C., Flory, J. D., & McFarlane, A. C. (2013). The use of biomarkers in the military: From theory to practice. Psychoneuroendocrinology, 38, 1912–1922. http://dx.doi.org/10.1016/j.psyneuen .2013.06.009
