DaJuan Ferrell AFFECT AND ALCOHOL USE IN BORDERLINE PERSONALITY DISORDER

ABSTRACT This study assessed the relationship between negative affective instability and alcohol use in borderline personality disorder. This study used ecological momentary assessment (EMA) as a means of data collection, assessing patients in their daily life.

BORDERLINE PERSONALITY DISORDER(BPD) BPD is an axis II personality disorder characterized by chronic features of impulsivity, instability of mood and interpersonal relationships, and suicidal behaviors. Individuals who suffer from borderline personality disorder (BPD) suffer from frequent instability in negative moods and relationships, generally experiencing extremes in terms of emotional states and perception of feelings towards others.

BPD CRITERIA: DSM-IV-TR Frantic efforts to avoid abandonment Unstable, intense interpersonal relationships Identity disturbance Impulsivity (e.g, spending, sex, substance abuse) Recurrent suicidal threats or behavior or self-mutilation Affective instability Chronic feelings of emptiness Inappropriate, intense anger Transient, stress-related paranoid ideation or dissociation

DISTINGUISHING FEATURE Affective instability: the experience of going from baseline mood (which may be a general state of negative affectivity) to intense negative affective states. States may last hours or a day, and are assumed to be triggered by environmental events (APA, 2000)

COMORBIDITY It is highly likely that individuals with borderline personality disorder (BPD) also have features of other disorders including Axis I clinical disorders. For example, Borderline Personality Disorder and substance use disorders such as alcohol dependence often co-occur (Widiger & Trull, 1993). Trull, Solhan et al. (in press) estimated that, on average, 16.9% of individuals with an AUD diagnosis also receive a BPD diagnosis, and 45.1% of those with BPD also receive an AUD diagnosis.

ALCOHOL USE/ABUSE These individuals may use alcohol consumption as a way to escape negative affective states or affective instability. The use of alcohol in the presence of negative affective states or instability may be an attempt to alleviate negative mood states or instability; This could cause alcohol use to become negatively reinforced. This pairing likely increases the probability of becoming alcohol dependent because once there is a belief that removal of the aversive stimulus (negative affect) is accomplished by drinking alcohol the behavior of consumption becomes reinforced.

SHAME AND GUILT Based on the literature found pertaining to the features of Borderline Personality Disorder and the possible relationship with shame and guilt we thought it would be relevant to observe these two emotions as components of negative affect.

PARTICIPANTS Participants were outpatients recruited from one of the four local psychiatric outpatient clinics and screened though chart review. These facilities serve the university, community or both populations. Eligibility of participants in the larger study examining affective instability in outpatients was established through Axis I and Axis II diagnostic interviews (see Trull et al., 2008 for details). All participants reported drinking during the EMA assessment. BPD No LT Alcohol Dep: n =38 BPD Yes LT Alcohol Dep: n=17 Total: 55

METHODS EMA is a research method that allows emotional, interpersonal, and physiological states to be reported in real time while the subject is in their natural environment.

BENEFITS OF EMA Multiple assessments can be conducted over time Assessments are done in the participant’s natural environment Researchers can monitor prompt completion

METHODS Participants were issued an electronic diary (ED; Palm Zire 31TM handheld computer), which was programmed to prompt them to record their affects, experiences, and behaviors six times a day over a 28-day period. The software program stratified the participant’s personalized waking hours into six equal intervals, and then randomly selected one moment within each interval to deliver a prompt (see Trull et al., 2008, for more details).

ELECTRONIC DIARY

MEASURES  Assessments Mood Assessment. Mood items from the Positive and Negative Affect Schedule-Extended version (PANAS-X; Watson & Clark, 1999) were used to measure positive affect (PA; 10 items) and negative affect (NA; 10 items). For each mood item, respondents were asked to rate the extent to which they felt (1=very slightly or not at all, 5=extremely) since the last prompt. Alcohol assessment. Two alcohol-related momentary experiences were assessed. Alcohol drink (0 = no, 1 = yes) was measured by participants’ response to questions like “Have you used alcohol since the last beep you answered?” at each momentary occasion. The number of drinks during each time interval was then reported (1 = one standard drink, …, 6 = six standard drinks, 7 = seven or more standard drinks).

Using MSSD To capture variability and account for bigger weighted changes we used MSSD. Which allowed us to see affective instability.

TEMPORAL INSTABILITY: MSSD MEAN SQUARED SUCCESSIVE DIFFERENCE (MSSD): ***Takes into account temporal order of data points unlike a variance or standard deviation

ASD=7 SSD=11 MSSD=2.2 MSSD allows for the assessment of momentary change. 2

RESULTS Examining the entire the BPD group, there were no significant correlations between alcohol use and indices of affective instability. However, significant correlations were obtained once the BPD group was stratified into those with a lifetime history of alcohol dependence and those without this history.

RESULTS: Group differences in drinking Mean number of drinks for the duration of the study (28 days) BPD NO LT Alcohol dependence = BPD LT Alcohol dependence = Mean drinking days for the duration of the study (28 days) BPD NO LT Alcohol dependence = 4.62 BPD LT Alcohol dependence =10.51

RESULTS: group differences in MSSD When observing the MSSD affect items ashamed, guilty, and negative affect there was no significant difference found between the means of the two groups.

RESULTS: Correlations The BPD group without lifetime alcohol dependent showed no significant correlations for negative affect instability (n=38) -.13 found for MSSD_ashamed -.15 found for MSSD_guilty.07 found for MSSD_na When observing the 28 days total in the lifetime alcohol dependent borderline personality disorder group found (n=17):.50* correlation MSSD_ashamed.49* correlation for MSSD_guilty.54* correlation MSSD_na * Correlation is significant at the 0.05 level

DISCUSSION Individuals diagnosed with Borderline Personality Disorder and a lifetime history of alcohol dependence show a positive relationship between negative affective instability and alcohol use. These findings could be the result of poorer coping skills in alcohol dependent BPD individuals. Their inability to adapt to negative affective states is a possible reason why they began to use alcohol as way to reduce these states. However, consistent alcohol consumption creates dependence without successfully fixing or treating the underlying issue of poor coping to affective states. An alternative for the instability found could be attributed to the pharmacology of alcohol and how its use can lead to affective instability.