Self-esteem instability and affective instability in everyday life after remission from borderline personality disorder

Abstract

Background Borderline personality disorder (BPD) is defined by a pervasive pattern of instability. According to prior findings and clinical theories, self-esteem instability and affective instability are key features of BPD. Previous e-diary studies showed that instability in self-esteem is heightened and that it is highly intertwined with affective instability in BPD in comparison to healthy controls (HC). The present study sought to extend these findings by adding symptomatologically remitted BPD patients (BPD-REM), i.e. former patients with BPD who met four or fewer BPD criteria within the past year, as a comparison group. Methods To examine differences regarding self-esteem instability and affective instability, we used e-diaries for repeatedly collecting data on self-esteem, valence, and tense arousal 12 times a day for four consecutive days while participants underwent their daily life activities. Determining three different state-of-the-art instability indices and applying multilevel analyses, we compared 35 BPD-REM participants with previously reported 60 acute BPD patients (BPD-ACU) and 60 HC. Results Our results revealed that self-esteem instability was significantly lower in the BPD-REM compared to the BPD-ACU group, irrespective of the instability index. In contrast, there were no significant differences regarding affective instability between the BPD-REM participants and those in the BPD-ACU group. The comparison between the BPD-REM with the HC indicated both a significantly higher instability in self-esteem as well as significantly heightened affective instability in the BPD-REM participants. Moreover, even though the associations were not significant, we found tentative support for the assumption that affective changes that are accompanied by changes in self-esteem are experienced as more burdensome and negatively impact the quality of life of remitted BPD participants. Conclusions This study builds on growing evidence for the importance of self-esteem instability in BPD. Whereas affective instability has been reported in various psychiatric disorders and might indeed constitute a transdiagnostic marker of affective dysregulation, our results indicate that self-esteem instability might be a specific symptom that construes the unique pathology in BPD.

Self-esteem instability might be more characteristic of borderline personality disorder than affective instability: Findings from an e-diary study with clinical and healthy controls.

“…These patterns were evident independent of the statistical approach, and they were also robust in exploratory analyses, in which categorical group membership was replaced with a dimensional indicator of BPD symptom severity. In a synopsis of our findings and those of Santangelo, Kockler, et al (2020), namely, that self-esteem instability, unlike affective instability, is lower after remission from BPD, particularly heightened self-esteem instability might differentiate patients in acute BPD disorder stages from those with acute ADs and those in remitted BPD stages.…”

“…Participants’ ages ranged between 18 and 48 years. Because we published papers with an identical sampling strategy with patients with BPD, we highlight that there is no overlap with those samples (Santangelo et al, 2017; Santangelo, Kockler, et al, 2020). A subset BPD patients was investigated in a study that aimed to predict dysfunctional behavior in BPD (Santangelo, Holtmann, et al, 2020), but this study addressed neither self-esteem instability nor affective instability and did not include any clinical or healthy control participants.…”

“…Santangelo, Kockler, et al (2020) expanded these findings, extending the sample used by Santangelo et al (2017) by including 35 additional participants with remitted BPD symptomatology. Cross-sectional comparisons between acute and remitted patients with BPD stages showed that self-esteem instability in patients with remitted BPD, albeit still heightened compared to that of HCs, was significantly lower than that of patients with acute BPD.…”

Clinical trials in personality disorders: Recommendations for study design and conduct.

“…However, long-term longitudinal studies have consistently shown that a mere symptom reduction or diagnostic remission is commonly seen, but not indicative of full recovery (Gunderson et al, 2011; Zanarini et al, 2012). Some symptoms (e.g., impulsivity-related) seem to tend to diminish over time, while others (e.g., self-esteem, affective instability, and chronic feelings of emptiness) tend to remain (Miller et al, 2020; Santangelo et al, 2020). Moreover, people with lived experience report that there are important goals beyond symptomatic recovery, like improving self-acceptance and self-confidence, gaining control over emotions, improving relationships, vocational functioning, and making meaningful progress in life (Katsakou et al, 2012).…”

Relationship between childhood physical abuse and clinical severity of treatment-resistant depression in a geriatric population

“…Thus, we posit the hypothesis that there is an association between childhood maltreatment (CM) and the severity of depression, specifically in an elderly TRD population. Moreover, given the role of personality traits as well as self-esteem in the symptomatology and course of the depressive disorder [ 20 , 21 ], we postulate that personality traits and self-esteem could mediate the association between CM and the severity of depressive symptoms.…”