- Email: [email protected]
Antagonism and borderline personality disorder
Antagonism and borderline personality disorder
16
Neil A. Meyer, Jiwon Min, Stephanie N. Mullins-Sweatt Department of Psychology, Oklahoma State University, Stillwater, OK, United States
As described throughout this book, the five-factor model (FFM) of personality is a well-validated model of general personality that describes adaptive and maladaptive personality functioning. The FFM has been used to examine personality disorders in over 100 research studies (Widiger, Gore, Crego, Rojas, & Oltmanns, 2017). A number of these studies have specifically examined the relationship of the FFM with borderline personality disorder (BPD), one of the most commonly researched personality disorders in the Diagnostic and Statistical Manual of Mental Disorders (5th ed., DSM-5; American Psychiatric Association, 2013). This chapter will review how antagonism relates to the BPD diagnosis as well as to the individual symptoms and associated correlates of BPD. Next, this chapter will examine existing literature that has compared the FFM with self-report measures of BPD and transdiagnostic characteristics of BPD (e.g., emotion dysregulation). Finally, the clinical utility and implications of antagonism’s relationship with BPD will be explored.
Antagonism and BPD defined BPD is a highly debilitating disorder characterized by interpersonal dysfunction, unstable identity, emotion dysregulation, and behavioral impulsivity (see Table 1; American Psychiatric Association, 2013). The median estimate of BPD’s prevalence in the general population is between 1.6% (Lenzenweger, Lane, Loranger, & Kessler, 2007) and 5.9% (Grant et al., 2008). Research has indicated that these symptoms are experienced more intensely earlier in the lifespan (Distel et al., 2008), with approximately 75% of treatment-receiving individuals no longer meeting diagnostic criteria 15 years after their initial diagnosis (Paris, Brown, & Nowlis, 1987). Zanarini, Frankenburg, Hennen, and Silk (2003) found that nearly 70% of patients with BPD were in remission at 6-year follow-up. BPD is also highly heritable, even after controlling for environmental effects (Torgersen, 1984; Torgersen et al., 2000). Recently, Distel et al. (2008) demonstrated that biological factors account for 42% of the variance in BPD symptom severity within 5496 monozygotic and dizygotic twins (using samples from The Netherlands, Belgium, and Australia). Within the last 25 years, a number of studies have examined the relationship of BPD with the FFM. BPD is characterized by high scores on the neuroticism domain and all six facets of neuroticism (Samuel & Widiger, 2008). However, given that a The Handbook of Antagonism. https://doi.org/10.1016/B978-0-12-814627-9.00016-5 © 2019 Elsevier Inc. All rights reserved.
238
The Handbook of Antagonism
Table 1 DSM-5 diagnostic criteria for borderline personality disorder. A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Frantic efforts to avoid real or imagined abandonment 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation 3. Identity disturbance: notably and persistently unstable self-image or sense of self 4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance misuse, reckless driving, binge eating) 5. Recurrent suicidal gestures, or threats or self-mutilating behavior 6. Affective instability caused by a distinct reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) 7. Chronic feelings of emptiness 8. Inappropriate intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) 9. Transient, stress-related paranoid ideation or severe dissociative symptoms
number of PDs are characterized by high neuroticism (e.g., avoidant, dependent, schizotypal; Samuel & Widiger, 2008), antagonism is an important trait that distinguishes BPD from these disorders. Recent efforts have compared each of the nine DSM-5 BPD symptoms with the domains of the FFM by comparing the mean differences in NEO-PI-R domain scores in those who did and did not meet criteria for a given BPD symptom (S€a€am€anen et al., 2016). Using the Structured Clinical Interview for DSM-IV Axis II Personality Questionnaire (SCID-II-PQ; First, Benjamin, Gibbon, Spitzer, & Williams, 1997) in a sample of 43 psychiatric inpatients, antagonism related most strongly to the “inappropriate anger” symptom (r ¼ 0.68). Antagonism also was related to “affective instability” (r ¼ 0.64) and “impulsivity” (r ¼ 0.64; S€a€am€anen et al., 2016). Notably, neuroticism related to nearly all symptoms, with the exception of “chronic feelings of emptiness” and “unstable relationships,” while extraversion related to “impulsivity” and “affective instability.” While antagonism was not significantly related to the total number of BPD symptoms, it was significantly related to the total number of questions endorsed in SCID-II-PQ BPD (r ¼ 0.39). The authors report that their results support previous studies that indicate a relationship between antagonism, neuroticism, and BPD, though the associations between BPD and antagonism found in their study may not generalize outside of an inpatient sample (S€a€am€anen et al., 2016). Within the antagonism domain, several of its facets are related to symptoms of BPD. Analyses of BPD symptoms suggest that four symptoms (i.e., frantic efforts to avoid real or imagined abandonment, pattern of unstable relationship, suicidality, and identity disturbances) were positively related to antagonism using DSM-III criteria (Clarkin, Hull, & Hurt, 1993).
Antagonism and borderline personality disorder
239
FFM conceptualization of BPD As implied before, while a categorical diagnosis of BPD remains in DSM-5, an emerging body of research suggests that BPD also can be conceptualized as maladaptive variants of the FFM (Madsen, Parsons, & Grubin, 2006; Miller, Reynolds, & Pilkonis, 2004; Nestadt et al., 2008; Rolland & De Fruyt, 2003). Lynam and Widiger (2001) surveyed 24 BPD experts to develop a consensus profile of BPD. Using a 1 to 5 point scale (with 1 being “very low” and 5 being “very high”), the mean consensus profile indicated that BPD was described as high neuroticism, low agreeableness, and low conscientiousness. At the facet level, agreeableness traits were generally rated between “low” and “neither high nor low.” Trust, deception, altruism, and compliance were described as relatively “low.” Samuel and Widiger (2004) expanded this research by recruiting 154 private practitioners to develop a clinician-based FFM consensus of BPD. Using the same Likert scale, Samuel and Widiger’s (2004) results were congruent with those of Lynam and Widiger (2001). For example, trust, straightforwardness, altruism, compliance, modesty, and tender-mindedness all ranged between “extremely low” and “neither high nor low.” Additionally, all but one facet of neuroticism (self-consciousness) was characteristic of BPD, as was one facet from extraversion (excitement seeking) and openness to experience (fantasy) (Table 2). Following these hypothesis-driven ratings among experts and clinicians, a growing body of empirical work enabled Saulsman and Page (2004) to examine how the FFM relates to BPD and other personality disorders by conducting a meta-analysis. The authors compared 12 studies and found that BPD was positively related to neuroticism and antagonism and negatively related to conscientiousness. Samuel and Widiger (2008) furthered this research by conducting a meta-analysis on 16 studies to provide facet-level data on these relationships. This research found that BPD was characterized by high neuroticism, high antagonism, and low conscientiousness. At the facet level, 27 of 30 facets were significantly related to BPD, including 3 antagonism facets (mistrust, deception, and oppositionality) were related (Samuel & Widiger, 2008). More recently, Samuel, Lynam, Widiger, and Ball (2012) solicited expert ratings utilizing the DSM-5 Alternative Model of Personality Disorder. Experts described a prototypic case or narrative description of PD in terms of the 37 traits proposed for inclusion in DSM-5. Experts who described a prototypic case of BPD indicated high levels of negative emotionality as well as the DSM-5 antagonism facets of hostility and aggression. Taken together, these results suggest that while high neuroticism seems to be most characteristic of BPD, antagonism distinguishes BPD from other personality disorders that are high in neuroticism (Samuel & Widiger, 2008).
Antagonism and self-report measures of BPD The measures used to assess BPD have a direct influence on which facets of antagonism relate to the disorder. Costa and McCrae (1992a, 1992b) initially proposed two facets of antagonism as conceptually and theoretically related to BPD: oppositionality—which they believed was related to the DSM-III-R description of BPD, and deception—which
240
The Handbook of Antagonism
Table 2 Theoretical and empirical traits of borderline personality disorder.
Neuroticism Anxiety Hostility Depression Self-consciousness Impulsiveness Vulnerability Extraversion Warmth Gregariousness Assertiveness Activity Excitement-seeking Positive emotions Openness to experience Fantasy Aesthetics Feelings Actions Ideas Values Agreeableness Trust Straightforwardness Altruism Compliance Modesty Tender-mindedness Conscientiousness Competence Order Dutifulness Achievement striving Self-discipline Deliberation
Lynam and Widiger (2001)
Saulsman and Page (2004)
Samuel and Widiger (2008)
4.12 4.04 4.75 4.17 3.17 4.79 4.17 3.18 3.21 2.92 3.17 3.29 3.88 2.63 3.39 3.29 2.96 4.00 4.00 3.21 2.88 2.40 2.21 2.08 2.46 2.00 2.83 2.79 2.35 2.71 2.38 2.29 2.50 2.33 1.88
0.49 – – – – – – 0.09 – – – – – – 0.02 – – – – – – 0.23 – – – – – – 0.23 – – – – – –
0.54 0.38 0.48 0.50 0.35 0.34 0.39 0.12 0.20 0.12 0.09 0.10 0.06 0.26 0.10 0.13 0.05 0.09 0.03 0.01 0.05 0.24 0.29 0.21 0.18 0.27 0.03 0.09 0.29 0.29 0.10 0.22 0.19 0.29 0.27
Widiger, Costa, Gore, and Crego (2012)
High High High High High High
High
Low Low Low
Low
they posited in response to their experience of the literature and their clinical work. Their conceptual analysis also included the six facets of neuroticism, three from extraversion and one from conscientiousness. Widiger and Costa (1994) reviewed literature to examine how the FFM related to measures of BPD. In 11 of the studies outlined,
Antagonism and borderline personality disorder
241
antagonism was significantly related (small to medium effect sizes) to DSM-III measures of BPD in all but two of the studies. A number of studies demonstrate that antagonism consistently relates to BPD, even utilizing different measures of personality pathology. For example, MullinsSweatt, Jamerson, Samuel, Olson, and Widiger (2006) evaluated the psychometric properties of the FFM Rating Form (FFMRF), correlating it with domains and facets of BPD. They constructed BPD scale scores using the average coefficients of three measures of personality pathology (the OMNI, PDQ-4, and SNAP), collected over four different studies. The three facets of antagonism were significantly correlated (small effect sizes) with the average of those BPD scales: oppositionality, arrogance, and tough-mindedness. Mistrust, deception, and exploitation were not significantly related. While previous studies demonstrate variance in the way that individual measures of BPD relate with the FFM, Mullins-Sweatt et al. (2012) developed a measure of BPD specifically from the perspective of the FFM. The Five-Factor Borderline Inventory (FFBI) contains one total scale score and 12 subscales. Seven subscales assess the six facets of neuroticism (the vulnerability facet is split into Affective Dysregulation and Fragility), one subscale assesses openness (Dissociative Tendencies), three subscales assess facets of antagonism (Distrust, Manipulativeness, Oppositional), and one subscale assesses conscientiousness (Rashness). Mullins-Sweatt et al. (2012) provided initial validation data for the measure within two samples (an undergraduate sample and a female residential substance abuse facility). A study seeking to further test the construct validity of the FFBI (DeShong, Lengel, Sauer-Zavala, O’Meara, & MullinsSweatt, 2015) correlated the FFBI with their parent facets of agreeableness from the NEO-PI-R (Distrust, Manipulativeness, Oppositional) and the IPIP-NEO (Distrust, Manipulativeness, Oppositional), demonstrating strong relationships with both FFM measures. Notably, the FFBI facet scales also strongly correlated with their parent facets in neuroticism, openness to experience, and conscientiousness. An abbreviated version of the measure was subsequently developed by DeShong et al. (2015). The short form was moderately to strongly correlated with antagonism in three of five samples. Neuroticism and conscientiousness also were correlated with the FFBI (openness to experience was the least consistently correlated domain in only one of five samples).
Antagonism and underlying theoretical components of BPD Borderline personality’s etymological origins are in early psychoanalytic theory (Kernberg, 1967; Stern, 1938). Kernberg’s (1967) theory of borderline personality organization posited that individuals with this personality organization lie on the delineating line (or “border line”) between neurosis and psychosis. Linehan’s (1993) theoretical model of BPD sought to integrate these clinical observations and descriptions within an empirically based cognitive-behavioral framework. Linehan’s biosocial theory of BPD states that individuals with BPD (1) have a biological vulnerability (or proclivity) to experience negative emotions, (2) have experienced chronic environmental invalidation, and (3) have difficulty regulating their emotions.
242
The Handbook of Antagonism
This results in a vulnerability to a combination of unhelpful (or lack of ) coping strategies used to regulate emotion, a heightened sensitivity to emotions, and difficulty physiologically returning to baseline after experiencing a negative emotion (Linehan, 1993). It would make sense that individuals who are more sensitive to emotional information and respond more intensely would self-report antagonistic personality traits. For example, Linehan (1993) describes problematic behavioral patterns of “shutting down, blocking, and avoiding” (p. 263) that may put pressures on an individual’s social support system, leading an individual to resort to deceptive or exploitative behaviors in order to maintain that support. In the long-term, those behaviors may then further exacerbate underlying impairment while supporting the belief that others cannot be counted on, and that all people will inevitably abandon them. Similarly, the perpetuation of the belief that others will inevitably abandon them may also lead them to believe that others cannot be trusted. Chronic environmental invalidation references the discrepancy between how one internally labels and experiences an emotion and how others label, judge, or diminish that emotional experience (Linehan, 1993). The chronic parental invalidation in childhood and individual experiences may be linked to antagonism. DeShong et al. (2015) correlated the FFBI with a measure of childhood invalidation, finding that the FFBI Oppositional subscale significantly associated with maternal and paternal invalidation. As emotion dysregulation is believed to be a core component of BPD, research examining the strategies one uses to regulate their emotions has evolved into an area of increasing focus within the clinical psychology literature. Given that as many as 75% of all DSM-5 clinical disorders are associated with emotion dysregulation, this research interest is needed (Werner & Gross, 2010). Gratz and Roemer’s (2004) theoretical model of emotion regulation was developed in the context of BPD and in response to Gross and John’s (2003) cognitively based theoretical model. According to Gratz and Roemer (2004), Gross and John’s (2003) model relies heavily on cognition and does not account for important other components (e.g., emotional acceptance). Gratz and Roemer’s (2004) theoretical model contains six domains: nonacceptance of emotional responses, difficulties engaging in goal-directed behavior, impulse control difficulties, lack of emotional awareness, limited access to emotion regulation strategies, and lack of emotional clarity. Some research has related these constructs with the FFM; for example, a three-part study conducted by Stanton, Rozek, Stasik-O’Brien, Ellickson-Larew, and Watson (2016) sought to examine how FFM domains relate with the Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004) in a community sample (n ¼ 299). Factor analyses indicated a two-factor solution for the DERS. The first factor, Problematic Responses, consists of DERS subscales that measure how one responds to strong negative emotion (i.e., limited access to emotion regulation strategies, nonacceptance of emotional responses, difficulties engaging in goal-directed behavior, and impulse control difficulties). The second factor, Poor Recognition, contains subscales related to insight or awareness of emotional experiences (i.e., lack of emotional awareness and lack of emotional clarity). Both factors were moderately correlated with antagonism (Problematic Responses, r ¼ 0.41; Poor Recognition, r ¼ 0.38), strongly correlated
Antagonism and borderline personality disorder
243
with neuroticism, and negatively correlated with conscientiousness. These results suggest that antagonism and neuroticism are meaningful personality variables that further establish a connection between emotion dysregulation and BPD. An important caveat to the results of this study is that participants completed the DERS an average of 306.5 days after completing measures of general personality, though the authors attempted to address this by comparing correlations of similar measures across the time points. DeShong et al. (2015) also examined the DERS within an FFM framework by correlating the FFBI subscales with each subscale of the DERS. While facet subscales related to neuroticism were clearly most strongly and consistently correlated, FFBI Distrust correlated with five of the six DERS subscales (i.e., nonacceptance of emotional responses, difficulties engaging in goal-directed behavior, impulse control difficulties, limited access to emotion regulation strategies, and lack of emotional clarity).
Natural changes in antagonism and BPD over time There are a number of studies that suggest some personality trait change over the course of one’s lifetime (e.g., Neyer & Asendorpf, 2001; Robins, Fraley, Roberts, & Trzesniewski, 2001; Srivastava, John, Gosling, & Potter, 2003). Meta-analysis of longitudinal studies (Roberts, Walton, & Viechtbauer, 2006) found that facets of extraversion (social dominance), conscientiousness, and emotional stability significantly increased across the lifespan, especially in early adulthood. Roberts et al. (2006) showed that antagonism decreases over the lifespan, though this decrease was statistically significant for only one age period (i.e., from 50 to 60). Soto, John, Gosling, and Potter (2011) found that antagonism and neuroticism tend to decrease in adulthood, while conscientiousness tends to increase. Given that antagonism, neuroticism, and conscientiousness are frequently associated with BPD, it is perhaps unsurprising that previously reviewed studies suggest that symptoms of BPD decrease over time (Distel et al., 2008; Zanarini et al., 2003). In a longitudinal study following patients with personality disorders, Gunderson et al. (2011) found that the number of criteria met for BPD decreased steadily for 10 years in the sample. Only 9% of the patients with BPD met diagnostic criteria for BPD after 10 years. Also, the percentage prevalence of each criterion decreased steadily, suggesting that all three phenotypes of BPD (affective, behavioral, and interpersonal) show similar pattern of stability. Wright, Hopwood, and Zanarini (2015) furthered this research by examining the underlying assumption that BPD symptoms and FFM traits change over time in tandem with each other. They found that reductions in BPD symptoms are strongly associated with reductions in neuroticism and antagonism, increases in conscientiousness, and are moderately associated with increases in extraversion. Given that individuals are less likely to meet criteria for BPD as they age, there appears to be a direct relationship with how personality traits and BPD symptoms change over time.
244
The Handbook of Antagonism
Antagonism’s role in describing disorders comorbid with BPD There appears to be a direct relationship with antagonism and interpersonal dysfunction across psychopathology, including in BPD. An examination of antagonism’s function in other psychological disorders may demonstrate similar mechanisms of impairment (e.g., interpersonal dysfunction). A high percentage of individuals with BPD meet criteria for other disorders (Zanarini, Frankenburg, Hennen, Reich, & Silk, 2004). These comorbid diagnoses may impede treatment. The most common comorbidities cited include mood disorders (48%–54%) and substance use disorders (SUD) (14%–56%). Zanarini et al. (2004) examined comorbidity rates in 6 years of prospective follow-up in individuals with BPD. These results suggested that while comorbidity rates declined, at the 6-year follow-up, 75% of patients with BPD met criteria for a mood disorder, 60% for an anxiety disorder, 34% for an eating disorder, and 19% for a SUD. Interestingly, the strongest predictor of remission from BPD was the absence of a SUD. Although speculative, it is possible that shared traits with antagonism might explain this relationship. Interpersonal antagonism has been implicated in the initiation of substance use, the development of substance use, and the maintenance of substance dependence (Ball, 2005). Trull and Sher (1994) examined how Axis I disorders (e.g., substance use, substance dependence, posttraumatic stress disorder, social phobia, agoraphobia, simple phobia, major depression) related to domains of the FFM. Using a series of regression analyses, antagonism significantly predicted Substance Use Disorder and Alcohol Dependence, but did not significantly predict other Axis I psychopathology. Substance use’s relationship with antagonism was also implicated in a series of metaanalyses examining the FFM’s relationship with a broad range of psychopathology in 175 studies (Kotov, Gamez, Schmidt, & Watson, 2010). They found significant relationships between antagonism and two specifiers of SUD, specifically drugs and mixed substances. Unsurprisingly, neuroticism related to all of the evaluated disorders (e.g., Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), Posttraumatic Stress Disorder (PTSD), Obsessive-Compulsive Disorder (OCD), Panic Disorder, Agoraphobia, Social Anxiety Disorder, SUD) and conscientiousness related to all disorders except Specific Phobia. In order to statistically control for neuroticism, the average effect size estimates were converted into Pearson correlation coefficients. Before controlling for neuroticism, they found that SUD, SUD Mixed Substances, and SUD Drugs were significantly related to antagonism. After controlling for neuroticism, Agoraphobia and Specific Phobia, and the two previously noted subtypes of SUD were significantly related with antagonism (SUD Mixed Substances; SUD Drugs), while SUD failed to reach statistical significance. Kotov et al. (2010) provide strong evidence to support the unique role of antagonism in the etiology of SUD, Agoraphobia, and Specific Phobia, when statistically isolated from neuroticism. Studies also suggest positive associations of BPD symptoms with interpersonal aggression (e.g.,Newhill, Eack, & Mulvey, 2012; Sansone & Sansone, 2012; Scott
Antagonism and borderline personality disorder
245
et al., 2017; Stepp, Smith, Morse, Hallquist, & Pilkonis, 2012; Zanarini et al., 2017). Stepp et al. (2012) demonstrated the role of interpersonal functioning in BPD symptoms and three types of aggression (physical, interpersonal, psychological). Researchers found that individuals with BPD symptoms who were higher in interpersonal sensitivity were significantly less likely to experience physical aggression. Similarly, individuals with BPD symptoms higher in interpersonal aggression were more likely to be on the receiving end of physical aggression and more likely physically and psychologically aggressive with others. Further reinforcing the notion that antagonism’s function in BPD is a maladaptive one, Miller, Zeichner, and Wilson (2012) correlated facets of the FFM with another three types of aggression: relational aggression, reactive aggression, and proactive aggression. They found that each type of aggression positively correlated with neuroticism and antagonism, and negatively correlated with conscientiousness. Additionally, using a series of regression equations to account for any shared variance among the three types of aggression, Miller et al. (2012) found that antagonism has a central role in each type of aggression. Comorbidity of BPD with other “Cluster B” personality disorders also may be due to antagonism. A meta-analysis of personality disorders and the FFM revealed that BPD, antisocial personality disorder, and narcissistic personality disorder were positively related to antagonism (Saulsman & Page, 2004). Samuel and Widiger (2008) also replicated these findings, reporting that BPD, Antisocial Personality Disorder (ASPD), and Narcissistic Personality Disorder (NPD) were associated with high antagonism. Specifically, BPD, ASPD, and NPD were associated with several facets of antagonism, such as mistrust, deception, and oppositionality. Antagonism has also been associated with traits of the Dark Triad. The Dark Triad (Paulhus & Williams, 2002) refers to the common co-occurrence of traits in narcissism, psychopathy, and Machiavellianism. Each component of the Dark Triad has been associated with antagonism (Paulhus & Williams, 2002). Miller et al. (2011) hypothesized a second (or alternate) model of the Dark Triad (known as the vulnerable dark triad; VDT), which consists of BPD, vulnerable narcissism, and factor 2 psychopathy (i.e., “social deviance”; Hare, 2003; Miller et al., 2011). They created composite scales of each of the VDT constructs, using a variety of existing measures. Specifically, the BPD composite scale was moderately correlated with antagonism and its four facets: mistrust, deception, exploitation, and oppositionality. The results of this study indicate that the VDT is comprised of antagonistic interpersonal style and emotional vulnerability (Miller et al., 2011), suggesting that antagonism has an important function in the VDT and in BPD. Miller et al.’s (2011) exploration of the VDT is helpful in elucidating BPD’s relationship with psychopathy. BPD appears to have some behavioral overlap with psychopathy (Kraus & Reynolds, 2001). In fact, BPD and BPD traits appear to be highly common among prison populations, with Black et al. (2007) reporting that nearly 30% of inmates newly entering the prison system met diagnostic criteria for BPD and 93.2% endorse at least one BPD symptom. Conn et al. (2010) found similar prevalence rates, with nearly 45% of inmate participants scoring above clinical threshold on the Personality Assessment Inventory (PAI) (i.e., T scores greater than 65). This is likely due to the antagonism and disinhibition that characterizes BPD and psychopathy.
246
The Handbook of Antagonism
Antagonism and treatment planning Antagonism has significant implications in treatment settings. Widiger and Presnall (2013) suggest that clients high in antagonism are more likely to resist therapists’ efforts to establish rapport and to oppose therapists’ decisions. Further, they are more likely to be dishonest and to blame others for their own problems. While the use of this information could potentially result in biased action taken toward a client, informing therapists may enable them to take steps that benefit the therapeutic alliance. Indeed, antagonism is related to difficulties in social situations (Hopwood et al., 2009; Ozer & Benet-Martinez, 2006), and that those who are high in antagonism are also unlikely to have healthy relationships (Widiger & Presnall, 2013) and report less satisfaction in their relationships (Malouff, Thorsteinsson, Schutte, Bhullar, & Rooke, 2010). For example, individuals who are high in antagonism could be dishonest and manipulative in treatment settings as an extension of these problematic relationships. Widiger and Presnall (2013) stated that in these cases, clinicians should consciously avoid engaging in power struggles and defensiveness when challenged. Additionally, those who are particularly antagonistic may not be suitable for group therapy. Additionally, in marital-family therapy or group therapy settings, antagonism may be useful in anticipating certain conflicts and problems among group members. For those with BPD, this may be an important consideration, as a significant portion of Dialectical Behavior Therapy includes skills groups.
Targeting antagonism in treatment Researchers have also investigated associations between personality traits and psychological treatment. Bagby et al. (2008) conducted randomized controlled trial comparing personality traits to outcomes (i.e., depression severity) following cognitive behavioral therapy (CBT) and pharmacotherapy. Their results indicated that individuals high in tough-mindedness were more likely to respond to CBT over pharmacotherapy, while those who were high in mistrust and deception had less depression severity following pharmacotherapy than CBT. Glinski and Page (2010) found that group CBT for a group of participants with social anxiety disorder reduced neuroticism and the antagonism facet of mistrust. Additionally, all five domains of the FFM changed significantly following a 6-week drug rehabilitation program. Specifically, antagonism and neuroticism significantly decreased, while conscientiousness significantly increased. These changes held when assessed at 15-month follow-up. On a related note, group member disengagement also may be associated with antagonism (Krueger & Eaton, 2010; Widiger & Mullins-Sweatt, 2009). Significant changes in personality traits also have also been observed in treatment studies targeting BPD. Davenport, Bore, and Campbell (2010) examined personality differences between individuals with a primary diagnosis of BPD who had not completed Dialectical Behavior Therapy (DBT) to those who had successfully completed DBT. They found that the pretreatment group reported higher antagonism and lower conscientiousness than the posttreatment group. In fact, posttreatment scores in
Antagonism and borderline personality disorder
247
antagonism, extraversion, conscientiousness, and openness to experience were comparable to previously established norms for the NEO-PI-R. It is possible that these personality trait scores changed due to DBT; however, it is unclear if these changes are due to the treatment or due to inherent differences among those who successfully completed treatment. Some studies show promise for the prospect of feasibly targeting individual personality traits; however, no known treatments have been developed or evaluated to do this specifically. Additionally, while a body of research suggests that personality assessment can be an important and valuable step in aiding a clinician’s treatment decisions (Lengel, Helle, DeShong, Meyer, & Mullins-Sweatt, 2016), it is not entirely clear how such a treatment would differ from other therapies. Conversely, it may be that the empirical literature has failed to adequately test this idea in extant psychotherapies, such that perhaps some therapy modules of manualized treatments already target personality change, albeit inadvertently. In DBT, for example, the Interpersonal Effectiveness may unintentionally target antagonism by guiding clients to a more balanced perspective on interpersonal exchanges. While some research suggests these changes may occur in response to completed treatment (Davenport et al., 2010), future studies may provide valuable information regarding change at the module or session level.
Conclusions This chapter sought to review how antagonism relates to BPD, its transdiagnostic characteristics, and its implications for treating BPD. The continued inclusion of FFM measures in studies of BPD will provide valuable information furthering the understanding of how antagonism functions in the context of BPD. Such knowledge might inform assessment and intervention efforts.
References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5). Washington, DC: American Psychiatric Press. Bagby, R. M., Quilty, L. C., Segal, Z. V., McBride, C. C., Kennedy, S. H., & Costa, P. T., Jr. (2008). Personality and differential treatment response in major depression: a randomized controlled trial comparing cognitive-behavioural therapy and pharmacotherapy. The Canadian Journal of Psychiatry, 53(6), 361–370. Ball, S. A. (2005). Personality traits, problems, and disorders: clinical applications to substance use disorders. Journal of Research in Personality, 39(1), 84–102. Black, D. W., Gunter, T., Allen, J., Blum, N., Arndt, S., Wenman, G., et al. (2007). Borderline personality disorder in male and female offenders newly committed to prison. Comprehensive Psychiatry, 48(5), 400–405. Clarkin, J. F., Hull, J. W., & Hurt, S. W. (1993). Factor structure of borderline personality disorder criteria. Journal of Personality Disorders, 7(2), 137–143. Conn, C., Warden, R., Stuewig, J., Kim, E. H., Harty, L., Hastings, M., et al. (2010). Borderline personality disorder among jail inmates: how common and how distinct? Corrections Compendium, 35(4), 6.
248
The Handbook of Antagonism
Costa, P. T., & McCrae, R. R. (1992a). Four ways five factors are basic. Personality and Individual Differences, 13(6), 653–665. Costa, P. T., & McCrae, R. R. (1992b). Normal personality assessment in clinical practice: the NEO Personality Inventory. Psychological Assessment, 4(1), 5. Davenport, J., Bore, M., & Campbell, J. (2010). Changes in personality in pre- and postdialectical behaviour therapy borderline personality disorder groups: a question of selfcontrol. Australian Psychologist, 45(1), 59–66. DeShong, H. L., Lengel, G. J., Sauer-Zavala, S. E., O’Meara, M., & Mullins-Sweatt, S. N. (2015). Construct validity of the five factor borderline inventory. Assessment, 22(3), 319–331. Distel, M. A., Trull, T. J., Derom, C. A., Thiery, E. W., Grimmer, M. A., Martin, N. G., et al. (2008). Heritability of borderline personality disorder features is similar across three countries. Psychological Medicine, 38(9), 1219–1229. First, M. B., Benjamin, L. S., Gibbon, M., Spitzer, R. L., & Williams, J. B. (1997). Structured clinical interview for DSM-IV axis II personality disorders. American Psychiatric Press. Glinski, K., & Page, A. C. (2010). Modifiability of neuroticism, extraversion, and agreeableness by group cognitive behaviour therapy for social anxiety disorder. Behaviour Change, 27(1), 42–52. Grant, B. F., Chou, S. P., Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T. D., et al. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. The Journal of Clinical Psychiatry, 69(4), 533. Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 41–54. Gross, J. J., & John, O. P. (2003). Individual differences in two emotion regulation processes: implications for affect, relationships, and well-being. Journal of Personality and Social Psychology, 85(2), 348. Gunderson, J. G., Stout, R. L., McGlashan, T. H., Shea, M. T., Morey, L. C., Grilo, C. M., et al. (2011). Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorders study. Archives of General Psychiatry, 68(8), 827–837. Hare, R. D. (2003). The psychopathy checklist–revised. Toronto, ON: Multi-Health Systems. Hopwood, C. J., Morey, L. C., Ansell, E. B., Grilo, C. M., Sanislow, C. A., McGlashan, T. H., et al. (2009). The convergent and discriminant validity of five-factor traits: current and prospective social, work, and recreational dysfunction. Journal of Personality Disorders, 23(5), 466–476. Kernberg, O. (1967). Borderline personality organization. Journal of the American Psychoanalytic Association, 15(3), 641–685. Kotov, R., Gamez, W., Schmidt, F., & Watson, D. (2010). Linking “big” personality traits to anxiety, depressive, and substance use disorders: a meta-analysis. Psychological Bulletin, 136(5), 768. Kraus, G., & Reynolds, D. J. (2001). The “A-BC’s” of the Cluster B’s: identifying, understanding, and treating Cluster B personality disorders. Clinical Psychology Review, 3(21), 345–373. Krueger, R. F., & Eaton, N. R. (2010). Personality traits and the classification of mental disorders: toward a more complete integration in DSM–5 and an empirical model of psychopathology. Personality Disorders: Theory, Research, and Treatment, 1(2), 97.
Antagonism and borderline personality disorder
249
Lengel, G. J., Helle, A. C., DeShong, H. L., Meyer, N. A., & Mullins-Sweatt, S. N. (2016). Translational applications of personality science for the conceptualization and treatment of psychopathology. Clinical Psychology: Science and Practice, 23(3), 288–308. Lenzenweger, M. F., Lane, M. C., Loranger, A. W., & Kessler, R. C. (2007). DSM-IV personality disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 62(6), 553–564. Linehan, M. M. (1993). Cognitive behavioral therapy of borderline personality disorder. Vol. 51. New York: Guilford Press. Lynam, D. R., & Widiger, T. A. (2001). Using the five-factor model to represent the DSM-IVTR personality disorders: an expert consensus approach. Journal of Abnormal Psychology, 110(3), 401–412. Madsen, L., Parsons, S., & Grubin, D. (2006). The relationship between the five-factor model and DSM personality disorder in a sample of child molesters. Personality and Individual Differences, 40(2), 227–236. Malouff, J. M., Thorsteinsson, E. B., Schutte, N. S., Bhullar, N., & Rooke, S. E. (2010). The five-factor model of personality and relationship satisfaction of intimate partners: a meta-analysis. Journal of Research in Personality, 44(1), 124–127. Miller, J. D., Hoffman, B. J., Gaughan, E. T., Gentile, B., Maples, J., & Keith Campbell, W. (2011). Grandiose and vulnerable narcissism: a nomological network analysis. Journal of Personality, 79(5), 1013–1042. Miller, J. D., Reynolds, S. K., & Pilkonis, P. A. (2004). The validity of the five-factor model prototypes for personality disorders in two clinical samples. Psychological Assessment, 16(3), 310. Miller, J. D., Zeichner, A., & Wilson, L. F. (2012). Personality correlates of aggression: evidence from measures of the five-factor model, UPPS model of impulsivity, and BIS/ BAS. Journal of Interpersonal Violence, 27(14), 2903–2919. Mullins-Sweatt, S. N., Edmundson, M., Sauer-Zavala, S., Lynam, D. R., Miller, J. D., & Widiger, T. A. (2012). Five-factor measure of borderline personality traits. Journal of Personality Assessment, 94(5), 475–487. Mullins-Sweatt, S. N., Jamerson, J. E., Samuel, D. B., Olson, D. R., & Widiger, T. A. (2006). Psychometric properties of an abbreviated instrument of the five-factor model. Assessment, 13(2), 119–137. Nestadt, G., Costa, P. T., Hsu, F. C., Samuels, J., Bienvenu, O. J., & Eaton, W. W. (2008). The relationship between the five-factor model and latent Diagnostic and Statistical Manual of Mental Disorders, personality disorder dimensions. Comprehensive Psychiatry, 49(1), 98–105. 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(3), 452–467. Neyer, F. J., & Asendorpf, J. B. (2001). Personality–relationship transaction in young adulthood. Journal of Personality and Social Psychology, 81, 1190–1204. Ozer, D. J., & Benet-Martinez, V. (2006). Personality and the prediction of consequential outcomes. Annual Review of Psychology, 57, 401–421. Paris, J., Brown, R., & Nowlis, D. (1987). Long-term follow-up of borderline patients in a general hospital. Comprehensive Psychiatry, 28(6), 530–535. Paulhus, D. L., & Williams, K. M. (2002). The dark triad of personality: narcissism, Machiavellianism, and psychopathy. Journal of Research in Personality, 36(6), 556–563. Roberts, B. W., Walton, K. E., & Viechtbauer, W. (2006). Patterns of mean-level change in personality traits across the life course: a meta-analysis of longitudinal studies. Psychological Bulletin, 132, 1–25.
250
The Handbook of Antagonism
Robins, R. W., Fraley, R. C., Roberts, B. W., & Trzesniewski, K. H. (2001). A longitudinal study of personality change in young adulthood. Journal of Personality, 69, 617–640. Rolland, J. P., & De Fruyt, F. (2003). The validity of FFM personality dimensions and maladaptive traits to predict negative affects at work: a six month prospective study in a military sample. European Journal of Personality, 17(S1), S101–S121. S€a€am€anen, T. S., Voutilainen, J., Lahti, J. M. T., Isomets€a, E. T., Heikkinen, M., & Lahti, M. (2016). The associations of borderline personality disorder symptoms, five-factor model personality dimensions, and personality fragmentation among depressed inpatients. Journal of Psychiatry, 19(3), 1–8. Samuel, D. B., Lynam, D. R., Widiger, T. A., & Ball, S. A. (2012). An expert consensus approach to relating the proposed DSM-5 types and traits. Personality Disorders: Theory, Research, and Treatment, 3, 1–16. Samuel, D. B., & Widiger, T. A. (2004). Clinicians’ personality descriptions of prototypic personality disorders. Journal of Personality Disorders, 18(3), 286–308. Samuel, D. B., & Widiger, T. A. (2008). A meta-analytic review of the relationships between the five-factor model and DSM-IV-TR personality disorders: a facet level analysis. Clinical Psychology Review, 28(8), 1326–1342. Sansone, R. A., & Sansone, L. A. (2012). Borderline personality and externalized aggression. Innovations in Clinical Neuroscience, 9(3), 23. Saulsman, L. M., & Page, A. C. (2004). The five-factor model and personality disorder empirical literature: a meta-analytic review. Clinical Psychology Review, 23(8), 1055–1085. Scott, L. N., Wright, A. G., Beeney, J. E., Lazarus, S. A., Pilkonis, P. A., & Stepp, S. D. (2017). Borderline personality disorder symptoms and aggression: a within-person process model. Journal of Abnormal Psychology, 126(4), 429. Soto, C. J., John, O. P., Gosling, S. D., & Potter, J. (2011). Age differences in personality traits from 10 to 65: Big Five domains and facets in a large cross-sectional sample. Journal of Personality and Social Psychology, 100, 330–348. Srivastava, S., John, O. P., Gosling, S. D., & Potter, J. (2003). Development of personality in early and middle adulthood: set like plaster or persistent change? Journal of Personality and Social Psychology, 84(5), 1041–1053. Stanton, K., Rozek, D. C., Stasik-O’Brien, S. M., Ellickson-Larew, S., & Watson, D. (2016). A transdiagnostic approach to examining the incremental predictive power of emotion regulation and basic personality dimensions. Journal of Abnormal Psychology, 125(7), 960. Stepp, S. D., Smith, T. D., Morse, J. Q., Hallquist, M. N., & Pilkonis, P. A. (2012). Prospective associations among borderline personality disorder symptoms, interpersonal problems, and aggressive behaviors. Journal of Interpersonal Violence, 27(1), 103–124. Stern, A. (1938). Psychoanalytic investigation of and therapy in the border line group of neuroses. The Psychoanalytic Quarterly, 7(4), 467–489. Torgersen, S. (1984). Genetic and nosological aspects of schizotypal and borderline personality disorders: a twin study. Archives of General Psychiatry, 41(6), 546–554. Torgersen, S., Lygren, S., Øien, P. A., Skre, I., Onstad, S., Edvardsen, J., et al. (2000). A twin study of personality disorders. Comprehensive Psychiatry, 41(6), 416–425. Trull, T. J., & Sher, K. J. (1994). Relationship between the five-factor model of personality and Axis I disorders in a nonclinical sample. Journal of Abnormal Psychology, 103(2), 350–360. Werner, K., & Gross, J. J. (2010). Emotion regulation and psychopathology: a conceptual framework. In A. M. Kring & D. M. Sloan (Eds.), Emotion regulation and psychopathology: A transdiagnostic approach to etiology and treatment (pp. 13–37). New York: Guilford Press.
Antagonism and borderline personality disorder
251
Widiger, T. A., & Costa, P. T., Jr. (1994). Personality and personality disorders. Journal of Abnormal Psychology, 103(1), 78. Widiger, T. A., Costa, P. T., Gore, W. L., & Crego, C. (2012). Five-factor model personality disorder research. In T. A. Widiger & P. T. Costa, Jr., (Eds.), Personality disorders and the five-factor model of personality. (3rd ed.). American Psychological Association. Widiger, T. A., Gore, W. L., Crego, C., Rojas, S. L., & Oltmanns, J. R. (2017). Five Factor Model and personality disorder. In The Oxford handbook of the Five Factor Model (p. 449). Oxford, UK: Oxford University Press. Widiger, T. A., & Mullins-Sweatt, S. N. (2009). Five-factor model of personality disorder: a proposal for DSM-V. Annual Review of Clinical Psychology, 5, 197–220. Widiger, T. A., & Presnall, J. R. (2013). Clinical application of the Five Factor Model. Journal of Personality, 81(6), 515–527. Wright, A. G., Hopwood, C. J., & Zanarini, M. C. (2015). Associations between changes in normal personality traits and borderline personality disorder symptoms over 16 years. Journal of Personality Disorders, 6(1), 1–11. Zanarini, M. C., Frankenburg, F. R., Hennen, J., Reich, D. B., & Silk, K. R. (2004). Axis I comorbidity in patients with borderline personality disorder: 6-year follow-up and prediction of time to remission. American Journal of Psychiatry, 161, 2108–2114. Zanarini, M. C., Frankenburg, F. R., Hennen, J., & Silk, K. R. (2003). The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder. American Journal of Psychiatry, 160(2), 274–283. Zanarini, M. C., Temes, C. M., Ivey, A. M., Cohn, D. M., Conkey, L. C., Frankenburg, F. R., et al. (2017). The 10-year course of adult aggression toward others in patients with borderline personality disorder and axis II comparison subjects. Psychiatry Research, 252, 134–138.
16
Neil A. Meyer, Jiwon Min, Stephanie N. Mullins-Sweatt Department of Psychology, Oklahoma State University, Stillwater, OK, United States
As described throughout this book, the five-factor model (FFM) of personality is a well-validated model of general personality that describes adaptive and maladaptive personality functioning. The FFM has been used to examine personality disorders in over 100 research studies (Widiger, Gore, Crego, Rojas, & Oltmanns, 2017). A number of these studies have specifically examined the relationship of the FFM with borderline personality disorder (BPD), one of the most commonly researched personality disorders in the Diagnostic and Statistical Manual of Mental Disorders (5th ed., DSM-5; American Psychiatric Association, 2013). This chapter will review how antagonism relates to the BPD diagnosis as well as to the individual symptoms and associated correlates of BPD. Next, this chapter will examine existing literature that has compared the FFM with self-report measures of BPD and transdiagnostic characteristics of BPD (e.g., emotion dysregulation). Finally, the clinical utility and implications of antagonism’s relationship with BPD will be explored.
Antagonism and BPD defined BPD is a highly debilitating disorder characterized by interpersonal dysfunction, unstable identity, emotion dysregulation, and behavioral impulsivity (see Table 1; American Psychiatric Association, 2013). The median estimate of BPD’s prevalence in the general population is between 1.6% (Lenzenweger, Lane, Loranger, & Kessler, 2007) and 5.9% (Grant et al., 2008). Research has indicated that these symptoms are experienced more intensely earlier in the lifespan (Distel et al., 2008), with approximately 75% of treatment-receiving individuals no longer meeting diagnostic criteria 15 years after their initial diagnosis (Paris, Brown, & Nowlis, 1987). Zanarini, Frankenburg, Hennen, and Silk (2003) found that nearly 70% of patients with BPD were in remission at 6-year follow-up. BPD is also highly heritable, even after controlling for environmental effects (Torgersen, 1984; Torgersen et al., 2000). Recently, Distel et al. (2008) demonstrated that biological factors account for 42% of the variance in BPD symptom severity within 5496 monozygotic and dizygotic twins (using samples from The Netherlands, Belgium, and Australia). Within the last 25 years, a number of studies have examined the relationship of BPD with the FFM. BPD is characterized by high scores on the neuroticism domain and all six facets of neuroticism (Samuel & Widiger, 2008). However, given that a The Handbook of Antagonism. https://doi.org/10.1016/B978-0-12-814627-9.00016-5 © 2019 Elsevier Inc. All rights reserved.
238
The Handbook of Antagonism
Table 1 DSM-5 diagnostic criteria for borderline personality disorder. A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Frantic efforts to avoid real or imagined abandonment 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation 3. Identity disturbance: notably and persistently unstable self-image or sense of self 4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance misuse, reckless driving, binge eating) 5. Recurrent suicidal gestures, or threats or self-mutilating behavior 6. Affective instability caused by a distinct reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) 7. Chronic feelings of emptiness 8. Inappropriate intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) 9. Transient, stress-related paranoid ideation or severe dissociative symptoms
number of PDs are characterized by high neuroticism (e.g., avoidant, dependent, schizotypal; Samuel & Widiger, 2008), antagonism is an important trait that distinguishes BPD from these disorders. Recent efforts have compared each of the nine DSM-5 BPD symptoms with the domains of the FFM by comparing the mean differences in NEO-PI-R domain scores in those who did and did not meet criteria for a given BPD symptom (S€a€am€anen et al., 2016). Using the Structured Clinical Interview for DSM-IV Axis II Personality Questionnaire (SCID-II-PQ; First, Benjamin, Gibbon, Spitzer, & Williams, 1997) in a sample of 43 psychiatric inpatients, antagonism related most strongly to the “inappropriate anger” symptom (r ¼ 0.68). Antagonism also was related to “affective instability” (r ¼ 0.64) and “impulsivity” (r ¼ 0.64; S€a€am€anen et al., 2016). Notably, neuroticism related to nearly all symptoms, with the exception of “chronic feelings of emptiness” and “unstable relationships,” while extraversion related to “impulsivity” and “affective instability.” While antagonism was not significantly related to the total number of BPD symptoms, it was significantly related to the total number of questions endorsed in SCID-II-PQ BPD (r ¼ 0.39). The authors report that their results support previous studies that indicate a relationship between antagonism, neuroticism, and BPD, though the associations between BPD and antagonism found in their study may not generalize outside of an inpatient sample (S€a€am€anen et al., 2016). Within the antagonism domain, several of its facets are related to symptoms of BPD. Analyses of BPD symptoms suggest that four symptoms (i.e., frantic efforts to avoid real or imagined abandonment, pattern of unstable relationship, suicidality, and identity disturbances) were positively related to antagonism using DSM-III criteria (Clarkin, Hull, & Hurt, 1993).
Antagonism and borderline personality disorder
239
FFM conceptualization of BPD As implied before, while a categorical diagnosis of BPD remains in DSM-5, an emerging body of research suggests that BPD also can be conceptualized as maladaptive variants of the FFM (Madsen, Parsons, & Grubin, 2006; Miller, Reynolds, & Pilkonis, 2004; Nestadt et al., 2008; Rolland & De Fruyt, 2003). Lynam and Widiger (2001) surveyed 24 BPD experts to develop a consensus profile of BPD. Using a 1 to 5 point scale (with 1 being “very low” and 5 being “very high”), the mean consensus profile indicated that BPD was described as high neuroticism, low agreeableness, and low conscientiousness. At the facet level, agreeableness traits were generally rated between “low” and “neither high nor low.” Trust, deception, altruism, and compliance were described as relatively “low.” Samuel and Widiger (2004) expanded this research by recruiting 154 private practitioners to develop a clinician-based FFM consensus of BPD. Using the same Likert scale, Samuel and Widiger’s (2004) results were congruent with those of Lynam and Widiger (2001). For example, trust, straightforwardness, altruism, compliance, modesty, and tender-mindedness all ranged between “extremely low” and “neither high nor low.” Additionally, all but one facet of neuroticism (self-consciousness) was characteristic of BPD, as was one facet from extraversion (excitement seeking) and openness to experience (fantasy) (Table 2). Following these hypothesis-driven ratings among experts and clinicians, a growing body of empirical work enabled Saulsman and Page (2004) to examine how the FFM relates to BPD and other personality disorders by conducting a meta-analysis. The authors compared 12 studies and found that BPD was positively related to neuroticism and antagonism and negatively related to conscientiousness. Samuel and Widiger (2008) furthered this research by conducting a meta-analysis on 16 studies to provide facet-level data on these relationships. This research found that BPD was characterized by high neuroticism, high antagonism, and low conscientiousness. At the facet level, 27 of 30 facets were significantly related to BPD, including 3 antagonism facets (mistrust, deception, and oppositionality) were related (Samuel & Widiger, 2008). More recently, Samuel, Lynam, Widiger, and Ball (2012) solicited expert ratings utilizing the DSM-5 Alternative Model of Personality Disorder. Experts described a prototypic case or narrative description of PD in terms of the 37 traits proposed for inclusion in DSM-5. Experts who described a prototypic case of BPD indicated high levels of negative emotionality as well as the DSM-5 antagonism facets of hostility and aggression. Taken together, these results suggest that while high neuroticism seems to be most characteristic of BPD, antagonism distinguishes BPD from other personality disorders that are high in neuroticism (Samuel & Widiger, 2008).
Antagonism and self-report measures of BPD The measures used to assess BPD have a direct influence on which facets of antagonism relate to the disorder. Costa and McCrae (1992a, 1992b) initially proposed two facets of antagonism as conceptually and theoretically related to BPD: oppositionality—which they believed was related to the DSM-III-R description of BPD, and deception—which
240
The Handbook of Antagonism
Table 2 Theoretical and empirical traits of borderline personality disorder.
Neuroticism Anxiety Hostility Depression Self-consciousness Impulsiveness Vulnerability Extraversion Warmth Gregariousness Assertiveness Activity Excitement-seeking Positive emotions Openness to experience Fantasy Aesthetics Feelings Actions Ideas Values Agreeableness Trust Straightforwardness Altruism Compliance Modesty Tender-mindedness Conscientiousness Competence Order Dutifulness Achievement striving Self-discipline Deliberation
Lynam and Widiger (2001)
Saulsman and Page (2004)
Samuel and Widiger (2008)
4.12 4.04 4.75 4.17 3.17 4.79 4.17 3.18 3.21 2.92 3.17 3.29 3.88 2.63 3.39 3.29 2.96 4.00 4.00 3.21 2.88 2.40 2.21 2.08 2.46 2.00 2.83 2.79 2.35 2.71 2.38 2.29 2.50 2.33 1.88
0.49 – – – – – – 0.09 – – – – – – 0.02 – – – – – – 0.23 – – – – – – 0.23 – – – – – –
0.54 0.38 0.48 0.50 0.35 0.34 0.39 0.12 0.20 0.12 0.09 0.10 0.06 0.26 0.10 0.13 0.05 0.09 0.03 0.01 0.05 0.24 0.29 0.21 0.18 0.27 0.03 0.09 0.29 0.29 0.10 0.22 0.19 0.29 0.27
Widiger, Costa, Gore, and Crego (2012)
High High High High High High
High
Low Low Low
Low
they posited in response to their experience of the literature and their clinical work. Their conceptual analysis also included the six facets of neuroticism, three from extraversion and one from conscientiousness. Widiger and Costa (1994) reviewed literature to examine how the FFM related to measures of BPD. In 11 of the studies outlined,
Antagonism and borderline personality disorder
241
antagonism was significantly related (small to medium effect sizes) to DSM-III measures of BPD in all but two of the studies. A number of studies demonstrate that antagonism consistently relates to BPD, even utilizing different measures of personality pathology. For example, MullinsSweatt, Jamerson, Samuel, Olson, and Widiger (2006) evaluated the psychometric properties of the FFM Rating Form (FFMRF), correlating it with domains and facets of BPD. They constructed BPD scale scores using the average coefficients of three measures of personality pathology (the OMNI, PDQ-4, and SNAP), collected over four different studies. The three facets of antagonism were significantly correlated (small effect sizes) with the average of those BPD scales: oppositionality, arrogance, and tough-mindedness. Mistrust, deception, and exploitation were not significantly related. While previous studies demonstrate variance in the way that individual measures of BPD relate with the FFM, Mullins-Sweatt et al. (2012) developed a measure of BPD specifically from the perspective of the FFM. The Five-Factor Borderline Inventory (FFBI) contains one total scale score and 12 subscales. Seven subscales assess the six facets of neuroticism (the vulnerability facet is split into Affective Dysregulation and Fragility), one subscale assesses openness (Dissociative Tendencies), three subscales assess facets of antagonism (Distrust, Manipulativeness, Oppositional), and one subscale assesses conscientiousness (Rashness). Mullins-Sweatt et al. (2012) provided initial validation data for the measure within two samples (an undergraduate sample and a female residential substance abuse facility). A study seeking to further test the construct validity of the FFBI (DeShong, Lengel, Sauer-Zavala, O’Meara, & MullinsSweatt, 2015) correlated the FFBI with their parent facets of agreeableness from the NEO-PI-R (Distrust, Manipulativeness, Oppositional) and the IPIP-NEO (Distrust, Manipulativeness, Oppositional), demonstrating strong relationships with both FFM measures. Notably, the FFBI facet scales also strongly correlated with their parent facets in neuroticism, openness to experience, and conscientiousness. An abbreviated version of the measure was subsequently developed by DeShong et al. (2015). The short form was moderately to strongly correlated with antagonism in three of five samples. Neuroticism and conscientiousness also were correlated with the FFBI (openness to experience was the least consistently correlated domain in only one of five samples).
Antagonism and underlying theoretical components of BPD Borderline personality’s etymological origins are in early psychoanalytic theory (Kernberg, 1967; Stern, 1938). Kernberg’s (1967) theory of borderline personality organization posited that individuals with this personality organization lie on the delineating line (or “border line”) between neurosis and psychosis. Linehan’s (1993) theoretical model of BPD sought to integrate these clinical observations and descriptions within an empirically based cognitive-behavioral framework. Linehan’s biosocial theory of BPD states that individuals with BPD (1) have a biological vulnerability (or proclivity) to experience negative emotions, (2) have experienced chronic environmental invalidation, and (3) have difficulty regulating their emotions.
242
The Handbook of Antagonism
This results in a vulnerability to a combination of unhelpful (or lack of ) coping strategies used to regulate emotion, a heightened sensitivity to emotions, and difficulty physiologically returning to baseline after experiencing a negative emotion (Linehan, 1993). It would make sense that individuals who are more sensitive to emotional information and respond more intensely would self-report antagonistic personality traits. For example, Linehan (1993) describes problematic behavioral patterns of “shutting down, blocking, and avoiding” (p. 263) that may put pressures on an individual’s social support system, leading an individual to resort to deceptive or exploitative behaviors in order to maintain that support. In the long-term, those behaviors may then further exacerbate underlying impairment while supporting the belief that others cannot be counted on, and that all people will inevitably abandon them. Similarly, the perpetuation of the belief that others will inevitably abandon them may also lead them to believe that others cannot be trusted. Chronic environmental invalidation references the discrepancy between how one internally labels and experiences an emotion and how others label, judge, or diminish that emotional experience (Linehan, 1993). The chronic parental invalidation in childhood and individual experiences may be linked to antagonism. DeShong et al. (2015) correlated the FFBI with a measure of childhood invalidation, finding that the FFBI Oppositional subscale significantly associated with maternal and paternal invalidation. As emotion dysregulation is believed to be a core component of BPD, research examining the strategies one uses to regulate their emotions has evolved into an area of increasing focus within the clinical psychology literature. Given that as many as 75% of all DSM-5 clinical disorders are associated with emotion dysregulation, this research interest is needed (Werner & Gross, 2010). Gratz and Roemer’s (2004) theoretical model of emotion regulation was developed in the context of BPD and in response to Gross and John’s (2003) cognitively based theoretical model. According to Gratz and Roemer (2004), Gross and John’s (2003) model relies heavily on cognition and does not account for important other components (e.g., emotional acceptance). Gratz and Roemer’s (2004) theoretical model contains six domains: nonacceptance of emotional responses, difficulties engaging in goal-directed behavior, impulse control difficulties, lack of emotional awareness, limited access to emotion regulation strategies, and lack of emotional clarity. Some research has related these constructs with the FFM; for example, a three-part study conducted by Stanton, Rozek, Stasik-O’Brien, Ellickson-Larew, and Watson (2016) sought to examine how FFM domains relate with the Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004) in a community sample (n ¼ 299). Factor analyses indicated a two-factor solution for the DERS. The first factor, Problematic Responses, consists of DERS subscales that measure how one responds to strong negative emotion (i.e., limited access to emotion regulation strategies, nonacceptance of emotional responses, difficulties engaging in goal-directed behavior, and impulse control difficulties). The second factor, Poor Recognition, contains subscales related to insight or awareness of emotional experiences (i.e., lack of emotional awareness and lack of emotional clarity). Both factors were moderately correlated with antagonism (Problematic Responses, r ¼ 0.41; Poor Recognition, r ¼ 0.38), strongly correlated
Antagonism and borderline personality disorder
243
with neuroticism, and negatively correlated with conscientiousness. These results suggest that antagonism and neuroticism are meaningful personality variables that further establish a connection between emotion dysregulation and BPD. An important caveat to the results of this study is that participants completed the DERS an average of 306.5 days after completing measures of general personality, though the authors attempted to address this by comparing correlations of similar measures across the time points. DeShong et al. (2015) also examined the DERS within an FFM framework by correlating the FFBI subscales with each subscale of the DERS. While facet subscales related to neuroticism were clearly most strongly and consistently correlated, FFBI Distrust correlated with five of the six DERS subscales (i.e., nonacceptance of emotional responses, difficulties engaging in goal-directed behavior, impulse control difficulties, limited access to emotion regulation strategies, and lack of emotional clarity).
Natural changes in antagonism and BPD over time There are a number of studies that suggest some personality trait change over the course of one’s lifetime (e.g., Neyer & Asendorpf, 2001; Robins, Fraley, Roberts, & Trzesniewski, 2001; Srivastava, John, Gosling, & Potter, 2003). Meta-analysis of longitudinal studies (Roberts, Walton, & Viechtbauer, 2006) found that facets of extraversion (social dominance), conscientiousness, and emotional stability significantly increased across the lifespan, especially in early adulthood. Roberts et al. (2006) showed that antagonism decreases over the lifespan, though this decrease was statistically significant for only one age period (i.e., from 50 to 60). Soto, John, Gosling, and Potter (2011) found that antagonism and neuroticism tend to decrease in adulthood, while conscientiousness tends to increase. Given that antagonism, neuroticism, and conscientiousness are frequently associated with BPD, it is perhaps unsurprising that previously reviewed studies suggest that symptoms of BPD decrease over time (Distel et al., 2008; Zanarini et al., 2003). In a longitudinal study following patients with personality disorders, Gunderson et al. (2011) found that the number of criteria met for BPD decreased steadily for 10 years in the sample. Only 9% of the patients with BPD met diagnostic criteria for BPD after 10 years. Also, the percentage prevalence of each criterion decreased steadily, suggesting that all three phenotypes of BPD (affective, behavioral, and interpersonal) show similar pattern of stability. Wright, Hopwood, and Zanarini (2015) furthered this research by examining the underlying assumption that BPD symptoms and FFM traits change over time in tandem with each other. They found that reductions in BPD symptoms are strongly associated with reductions in neuroticism and antagonism, increases in conscientiousness, and are moderately associated with increases in extraversion. Given that individuals are less likely to meet criteria for BPD as they age, there appears to be a direct relationship with how personality traits and BPD symptoms change over time.
244
The Handbook of Antagonism
Antagonism’s role in describing disorders comorbid with BPD There appears to be a direct relationship with antagonism and interpersonal dysfunction across psychopathology, including in BPD. An examination of antagonism’s function in other psychological disorders may demonstrate similar mechanisms of impairment (e.g., interpersonal dysfunction). A high percentage of individuals with BPD meet criteria for other disorders (Zanarini, Frankenburg, Hennen, Reich, & Silk, 2004). These comorbid diagnoses may impede treatment. The most common comorbidities cited include mood disorders (48%–54%) and substance use disorders (SUD) (14%–56%). Zanarini et al. (2004) examined comorbidity rates in 6 years of prospective follow-up in individuals with BPD. These results suggested that while comorbidity rates declined, at the 6-year follow-up, 75% of patients with BPD met criteria for a mood disorder, 60% for an anxiety disorder, 34% for an eating disorder, and 19% for a SUD. Interestingly, the strongest predictor of remission from BPD was the absence of a SUD. Although speculative, it is possible that shared traits with antagonism might explain this relationship. Interpersonal antagonism has been implicated in the initiation of substance use, the development of substance use, and the maintenance of substance dependence (Ball, 2005). Trull and Sher (1994) examined how Axis I disorders (e.g., substance use, substance dependence, posttraumatic stress disorder, social phobia, agoraphobia, simple phobia, major depression) related to domains of the FFM. Using a series of regression analyses, antagonism significantly predicted Substance Use Disorder and Alcohol Dependence, but did not significantly predict other Axis I psychopathology. Substance use’s relationship with antagonism was also implicated in a series of metaanalyses examining the FFM’s relationship with a broad range of psychopathology in 175 studies (Kotov, Gamez, Schmidt, & Watson, 2010). They found significant relationships between antagonism and two specifiers of SUD, specifically drugs and mixed substances. Unsurprisingly, neuroticism related to all of the evaluated disorders (e.g., Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD), Posttraumatic Stress Disorder (PTSD), Obsessive-Compulsive Disorder (OCD), Panic Disorder, Agoraphobia, Social Anxiety Disorder, SUD) and conscientiousness related to all disorders except Specific Phobia. In order to statistically control for neuroticism, the average effect size estimates were converted into Pearson correlation coefficients. Before controlling for neuroticism, they found that SUD, SUD Mixed Substances, and SUD Drugs were significantly related to antagonism. After controlling for neuroticism, Agoraphobia and Specific Phobia, and the two previously noted subtypes of SUD were significantly related with antagonism (SUD Mixed Substances; SUD Drugs), while SUD failed to reach statistical significance. Kotov et al. (2010) provide strong evidence to support the unique role of antagonism in the etiology of SUD, Agoraphobia, and Specific Phobia, when statistically isolated from neuroticism. Studies also suggest positive associations of BPD symptoms with interpersonal aggression (e.g.,Newhill, Eack, & Mulvey, 2012; Sansone & Sansone, 2012; Scott
Antagonism and borderline personality disorder
245
et al., 2017; Stepp, Smith, Morse, Hallquist, & Pilkonis, 2012; Zanarini et al., 2017). Stepp et al. (2012) demonstrated the role of interpersonal functioning in BPD symptoms and three types of aggression (physical, interpersonal, psychological). Researchers found that individuals with BPD symptoms who were higher in interpersonal sensitivity were significantly less likely to experience physical aggression. Similarly, individuals with BPD symptoms higher in interpersonal aggression were more likely to be on the receiving end of physical aggression and more likely physically and psychologically aggressive with others. Further reinforcing the notion that antagonism’s function in BPD is a maladaptive one, Miller, Zeichner, and Wilson (2012) correlated facets of the FFM with another three types of aggression: relational aggression, reactive aggression, and proactive aggression. They found that each type of aggression positively correlated with neuroticism and antagonism, and negatively correlated with conscientiousness. Additionally, using a series of regression equations to account for any shared variance among the three types of aggression, Miller et al. (2012) found that antagonism has a central role in each type of aggression. Comorbidity of BPD with other “Cluster B” personality disorders also may be due to antagonism. A meta-analysis of personality disorders and the FFM revealed that BPD, antisocial personality disorder, and narcissistic personality disorder were positively related to antagonism (Saulsman & Page, 2004). Samuel and Widiger (2008) also replicated these findings, reporting that BPD, Antisocial Personality Disorder (ASPD), and Narcissistic Personality Disorder (NPD) were associated with high antagonism. Specifically, BPD, ASPD, and NPD were associated with several facets of antagonism, such as mistrust, deception, and oppositionality. Antagonism has also been associated with traits of the Dark Triad. The Dark Triad (Paulhus & Williams, 2002) refers to the common co-occurrence of traits in narcissism, psychopathy, and Machiavellianism. Each component of the Dark Triad has been associated with antagonism (Paulhus & Williams, 2002). Miller et al. (2011) hypothesized a second (or alternate) model of the Dark Triad (known as the vulnerable dark triad; VDT), which consists of BPD, vulnerable narcissism, and factor 2 psychopathy (i.e., “social deviance”; Hare, 2003; Miller et al., 2011). They created composite scales of each of the VDT constructs, using a variety of existing measures. Specifically, the BPD composite scale was moderately correlated with antagonism and its four facets: mistrust, deception, exploitation, and oppositionality. The results of this study indicate that the VDT is comprised of antagonistic interpersonal style and emotional vulnerability (Miller et al., 2011), suggesting that antagonism has an important function in the VDT and in BPD. Miller et al.’s (2011) exploration of the VDT is helpful in elucidating BPD’s relationship with psychopathy. BPD appears to have some behavioral overlap with psychopathy (Kraus & Reynolds, 2001). In fact, BPD and BPD traits appear to be highly common among prison populations, with Black et al. (2007) reporting that nearly 30% of inmates newly entering the prison system met diagnostic criteria for BPD and 93.2% endorse at least one BPD symptom. Conn et al. (2010) found similar prevalence rates, with nearly 45% of inmate participants scoring above clinical threshold on the Personality Assessment Inventory (PAI) (i.e., T scores greater than 65). This is likely due to the antagonism and disinhibition that characterizes BPD and psychopathy.
246
The Handbook of Antagonism
Antagonism and treatment planning Antagonism has significant implications in treatment settings. Widiger and Presnall (2013) suggest that clients high in antagonism are more likely to resist therapists’ efforts to establish rapport and to oppose therapists’ decisions. Further, they are more likely to be dishonest and to blame others for their own problems. While the use of this information could potentially result in biased action taken toward a client, informing therapists may enable them to take steps that benefit the therapeutic alliance. Indeed, antagonism is related to difficulties in social situations (Hopwood et al., 2009; Ozer & Benet-Martinez, 2006), and that those who are high in antagonism are also unlikely to have healthy relationships (Widiger & Presnall, 2013) and report less satisfaction in their relationships (Malouff, Thorsteinsson, Schutte, Bhullar, & Rooke, 2010). For example, individuals who are high in antagonism could be dishonest and manipulative in treatment settings as an extension of these problematic relationships. Widiger and Presnall (2013) stated that in these cases, clinicians should consciously avoid engaging in power struggles and defensiveness when challenged. Additionally, those who are particularly antagonistic may not be suitable for group therapy. Additionally, in marital-family therapy or group therapy settings, antagonism may be useful in anticipating certain conflicts and problems among group members. For those with BPD, this may be an important consideration, as a significant portion of Dialectical Behavior Therapy includes skills groups.
Targeting antagonism in treatment Researchers have also investigated associations between personality traits and psychological treatment. Bagby et al. (2008) conducted randomized controlled trial comparing personality traits to outcomes (i.e., depression severity) following cognitive behavioral therapy (CBT) and pharmacotherapy. Their results indicated that individuals high in tough-mindedness were more likely to respond to CBT over pharmacotherapy, while those who were high in mistrust and deception had less depression severity following pharmacotherapy than CBT. Glinski and Page (2010) found that group CBT for a group of participants with social anxiety disorder reduced neuroticism and the antagonism facet of mistrust. Additionally, all five domains of the FFM changed significantly following a 6-week drug rehabilitation program. Specifically, antagonism and neuroticism significantly decreased, while conscientiousness significantly increased. These changes held when assessed at 15-month follow-up. On a related note, group member disengagement also may be associated with antagonism (Krueger & Eaton, 2010; Widiger & Mullins-Sweatt, 2009). Significant changes in personality traits also have also been observed in treatment studies targeting BPD. Davenport, Bore, and Campbell (2010) examined personality differences between individuals with a primary diagnosis of BPD who had not completed Dialectical Behavior Therapy (DBT) to those who had successfully completed DBT. They found that the pretreatment group reported higher antagonism and lower conscientiousness than the posttreatment group. In fact, posttreatment scores in
Antagonism and borderline personality disorder
247
antagonism, extraversion, conscientiousness, and openness to experience were comparable to previously established norms for the NEO-PI-R. It is possible that these personality trait scores changed due to DBT; however, it is unclear if these changes are due to the treatment or due to inherent differences among those who successfully completed treatment. Some studies show promise for the prospect of feasibly targeting individual personality traits; however, no known treatments have been developed or evaluated to do this specifically. Additionally, while a body of research suggests that personality assessment can be an important and valuable step in aiding a clinician’s treatment decisions (Lengel, Helle, DeShong, Meyer, & Mullins-Sweatt, 2016), it is not entirely clear how such a treatment would differ from other therapies. Conversely, it may be that the empirical literature has failed to adequately test this idea in extant psychotherapies, such that perhaps some therapy modules of manualized treatments already target personality change, albeit inadvertently. In DBT, for example, the Interpersonal Effectiveness may unintentionally target antagonism by guiding clients to a more balanced perspective on interpersonal exchanges. While some research suggests these changes may occur in response to completed treatment (Davenport et al., 2010), future studies may provide valuable information regarding change at the module or session level.
Conclusions This chapter sought to review how antagonism relates to BPD, its transdiagnostic characteristics, and its implications for treating BPD. The continued inclusion of FFM measures in studies of BPD will provide valuable information furthering the understanding of how antagonism functions in the context of BPD. Such knowledge might inform assessment and intervention efforts.
References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5). Washington, DC: American Psychiatric Press. Bagby, R. M., Quilty, L. C., Segal, Z. V., McBride, C. C., Kennedy, S. H., & Costa, P. T., Jr. (2008). Personality and differential treatment response in major depression: a randomized controlled trial comparing cognitive-behavioural therapy and pharmacotherapy. The Canadian Journal of Psychiatry, 53(6), 361–370. Ball, S. A. (2005). Personality traits, problems, and disorders: clinical applications to substance use disorders. Journal of Research in Personality, 39(1), 84–102. Black, D. W., Gunter, T., Allen, J., Blum, N., Arndt, S., Wenman, G., et al. (2007). Borderline personality disorder in male and female offenders newly committed to prison. Comprehensive Psychiatry, 48(5), 400–405. Clarkin, J. F., Hull, J. W., & Hurt, S. W. (1993). Factor structure of borderline personality disorder criteria. Journal of Personality Disorders, 7(2), 137–143. Conn, C., Warden, R., Stuewig, J., Kim, E. H., Harty, L., Hastings, M., et al. (2010). Borderline personality disorder among jail inmates: how common and how distinct? Corrections Compendium, 35(4), 6.
248
The Handbook of Antagonism
Costa, P. T., & McCrae, R. R. (1992a). Four ways five factors are basic. Personality and Individual Differences, 13(6), 653–665. Costa, P. T., & McCrae, R. R. (1992b). Normal personality assessment in clinical practice: the NEO Personality Inventory. Psychological Assessment, 4(1), 5. Davenport, J., Bore, M., & Campbell, J. (2010). Changes in personality in pre- and postdialectical behaviour therapy borderline personality disorder groups: a question of selfcontrol. Australian Psychologist, 45(1), 59–66. DeShong, H. L., Lengel, G. J., Sauer-Zavala, S. E., O’Meara, M., & Mullins-Sweatt, S. N. (2015). Construct validity of the five factor borderline inventory. Assessment, 22(3), 319–331. Distel, M. A., Trull, T. J., Derom, C. A., Thiery, E. W., Grimmer, M. A., Martin, N. G., et al. (2008). Heritability of borderline personality disorder features is similar across three countries. Psychological Medicine, 38(9), 1219–1229. First, M. B., Benjamin, L. S., Gibbon, M., Spitzer, R. L., & Williams, J. B. (1997). Structured clinical interview for DSM-IV axis II personality disorders. American Psychiatric Press. Glinski, K., & Page, A. C. (2010). Modifiability of neuroticism, extraversion, and agreeableness by group cognitive behaviour therapy for social anxiety disorder. Behaviour Change, 27(1), 42–52. Grant, B. F., Chou, S. P., Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T. D., et al. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. The Journal of Clinical Psychiatry, 69(4), 533. Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment, 26(1), 41–54. Gross, J. J., & John, O. P. (2003). Individual differences in two emotion regulation processes: implications for affect, relationships, and well-being. Journal of Personality and Social Psychology, 85(2), 348. Gunderson, J. G., Stout, R. L., McGlashan, T. H., Shea, M. T., Morey, L. C., Grilo, C. M., et al. (2011). Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorders study. Archives of General Psychiatry, 68(8), 827–837. Hare, R. D. (2003). The psychopathy checklist–revised. Toronto, ON: Multi-Health Systems. Hopwood, C. J., Morey, L. C., Ansell, E. B., Grilo, C. M., Sanislow, C. A., McGlashan, T. H., et al. (2009). The convergent and discriminant validity of five-factor traits: current and prospective social, work, and recreational dysfunction. Journal of Personality Disorders, 23(5), 466–476. Kernberg, O. (1967). Borderline personality organization. Journal of the American Psychoanalytic Association, 15(3), 641–685. Kotov, R., Gamez, W., Schmidt, F., & Watson, D. (2010). Linking “big” personality traits to anxiety, depressive, and substance use disorders: a meta-analysis. Psychological Bulletin, 136(5), 768. Kraus, G., & Reynolds, D. J. (2001). The “A-BC’s” of the Cluster B’s: identifying, understanding, and treating Cluster B personality disorders. Clinical Psychology Review, 3(21), 345–373. Krueger, R. F., & Eaton, N. R. (2010). Personality traits and the classification of mental disorders: toward a more complete integration in DSM–5 and an empirical model of psychopathology. Personality Disorders: Theory, Research, and Treatment, 1(2), 97.
Antagonism and borderline personality disorder
249
Lengel, G. J., Helle, A. C., DeShong, H. L., Meyer, N. A., & Mullins-Sweatt, S. N. (2016). Translational applications of personality science for the conceptualization and treatment of psychopathology. Clinical Psychology: Science and Practice, 23(3), 288–308. Lenzenweger, M. F., Lane, M. C., Loranger, A. W., & Kessler, R. C. (2007). DSM-IV personality disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 62(6), 553–564. Linehan, M. M. (1993). Cognitive behavioral therapy of borderline personality disorder. Vol. 51. New York: Guilford Press. Lynam, D. R., & Widiger, T. A. (2001). Using the five-factor model to represent the DSM-IVTR personality disorders: an expert consensus approach. Journal of Abnormal Psychology, 110(3), 401–412. Madsen, L., Parsons, S., & Grubin, D. (2006). The relationship between the five-factor model and DSM personality disorder in a sample of child molesters. Personality and Individual Differences, 40(2), 227–236. Malouff, J. M., Thorsteinsson, E. B., Schutte, N. S., Bhullar, N., & Rooke, S. E. (2010). The five-factor model of personality and relationship satisfaction of intimate partners: a meta-analysis. Journal of Research in Personality, 44(1), 124–127. Miller, J. D., Hoffman, B. J., Gaughan, E. T., Gentile, B., Maples, J., & Keith Campbell, W. (2011). Grandiose and vulnerable narcissism: a nomological network analysis. Journal of Personality, 79(5), 1013–1042. Miller, J. D., Reynolds, S. K., & Pilkonis, P. A. (2004). The validity of the five-factor model prototypes for personality disorders in two clinical samples. Psychological Assessment, 16(3), 310. Miller, J. D., Zeichner, A., & Wilson, L. F. (2012). Personality correlates of aggression: evidence from measures of the five-factor model, UPPS model of impulsivity, and BIS/ BAS. Journal of Interpersonal Violence, 27(14), 2903–2919. Mullins-Sweatt, S. N., Edmundson, M., Sauer-Zavala, S., Lynam, D. R., Miller, J. D., & Widiger, T. A. (2012). Five-factor measure of borderline personality traits. Journal of Personality Assessment, 94(5), 475–487. Mullins-Sweatt, S. N., Jamerson, J. E., Samuel, D. B., Olson, D. R., & Widiger, T. A. (2006). Psychometric properties of an abbreviated instrument of the five-factor model. Assessment, 13(2), 119–137. Nestadt, G., Costa, P. T., Hsu, F. C., Samuels, J., Bienvenu, O. J., & Eaton, W. W. (2008). The relationship between the five-factor model and latent Diagnostic and Statistical Manual of Mental Disorders, personality disorder dimensions. Comprehensive Psychiatry, 49(1), 98–105. 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(3), 452–467. Neyer, F. J., & Asendorpf, J. B. (2001). Personality–relationship transaction in young adulthood. Journal of Personality and Social Psychology, 81, 1190–1204. Ozer, D. J., & Benet-Martinez, V. (2006). Personality and the prediction of consequential outcomes. Annual Review of Psychology, 57, 401–421. Paris, J., Brown, R., & Nowlis, D. (1987). Long-term follow-up of borderline patients in a general hospital. Comprehensive Psychiatry, 28(6), 530–535. Paulhus, D. L., & Williams, K. M. (2002). The dark triad of personality: narcissism, Machiavellianism, and psychopathy. Journal of Research in Personality, 36(6), 556–563. Roberts, B. W., Walton, K. E., & Viechtbauer, W. (2006). Patterns of mean-level change in personality traits across the life course: a meta-analysis of longitudinal studies. Psychological Bulletin, 132, 1–25.
250
The Handbook of Antagonism
Robins, R. W., Fraley, R. C., Roberts, B. W., & Trzesniewski, K. H. (2001). A longitudinal study of personality change in young adulthood. Journal of Personality, 69, 617–640. Rolland, J. P., & De Fruyt, F. (2003). The validity of FFM personality dimensions and maladaptive traits to predict negative affects at work: a six month prospective study in a military sample. European Journal of Personality, 17(S1), S101–S121. S€a€am€anen, T. S., Voutilainen, J., Lahti, J. M. T., Isomets€a, E. T., Heikkinen, M., & Lahti, M. (2016). The associations of borderline personality disorder symptoms, five-factor model personality dimensions, and personality fragmentation among depressed inpatients. Journal of Psychiatry, 19(3), 1–8. Samuel, D. B., Lynam, D. R., Widiger, T. A., & Ball, S. A. (2012). An expert consensus approach to relating the proposed DSM-5 types and traits. Personality Disorders: Theory, Research, and Treatment, 3, 1–16. Samuel, D. B., & Widiger, T. A. (2004). Clinicians’ personality descriptions of prototypic personality disorders. Journal of Personality Disorders, 18(3), 286–308. Samuel, D. B., & Widiger, T. A. (2008). A meta-analytic review of the relationships between the five-factor model and DSM-IV-TR personality disorders: a facet level analysis. Clinical Psychology Review, 28(8), 1326–1342. Sansone, R. A., & Sansone, L. A. (2012). Borderline personality and externalized aggression. Innovations in Clinical Neuroscience, 9(3), 23. Saulsman, L. M., & Page, A. C. (2004). The five-factor model and personality disorder empirical literature: a meta-analytic review. Clinical Psychology Review, 23(8), 1055–1085. Scott, L. N., Wright, A. G., Beeney, J. E., Lazarus, S. A., Pilkonis, P. A., & Stepp, S. D. (2017). Borderline personality disorder symptoms and aggression: a within-person process model. Journal of Abnormal Psychology, 126(4), 429. Soto, C. J., John, O. P., Gosling, S. D., & Potter, J. (2011). Age differences in personality traits from 10 to 65: Big Five domains and facets in a large cross-sectional sample. Journal of Personality and Social Psychology, 100, 330–348. Srivastava, S., John, O. P., Gosling, S. D., & Potter, J. (2003). Development of personality in early and middle adulthood: set like plaster or persistent change? Journal of Personality and Social Psychology, 84(5), 1041–1053. Stanton, K., Rozek, D. C., Stasik-O’Brien, S. M., Ellickson-Larew, S., & Watson, D. (2016). A transdiagnostic approach to examining the incremental predictive power of emotion regulation and basic personality dimensions. Journal of Abnormal Psychology, 125(7), 960. Stepp, S. D., Smith, T. D., Morse, J. Q., Hallquist, M. N., & Pilkonis, P. A. (2012). Prospective associations among borderline personality disorder symptoms, interpersonal problems, and aggressive behaviors. Journal of Interpersonal Violence, 27(1), 103–124. Stern, A. (1938). Psychoanalytic investigation of and therapy in the border line group of neuroses. The Psychoanalytic Quarterly, 7(4), 467–489. Torgersen, S. (1984). Genetic and nosological aspects of schizotypal and borderline personality disorders: a twin study. Archives of General Psychiatry, 41(6), 546–554. Torgersen, S., Lygren, S., Øien, P. A., Skre, I., Onstad, S., Edvardsen, J., et al. (2000). A twin study of personality disorders. Comprehensive Psychiatry, 41(6), 416–425. Trull, T. J., & Sher, K. J. (1994). Relationship between the five-factor model of personality and Axis I disorders in a nonclinical sample. Journal of Abnormal Psychology, 103(2), 350–360. Werner, K., & Gross, J. J. (2010). Emotion regulation and psychopathology: a conceptual framework. In A. M. Kring & D. M. Sloan (Eds.), Emotion regulation and psychopathology: A transdiagnostic approach to etiology and treatment (pp. 13–37). New York: Guilford Press.
Antagonism and borderline personality disorder
251
Widiger, T. A., & Costa, P. T., Jr. (1994). Personality and personality disorders. Journal of Abnormal Psychology, 103(1), 78. Widiger, T. A., Costa, P. T., Gore, W. L., & Crego, C. (2012). Five-factor model personality disorder research. In T. A. Widiger & P. T. Costa, Jr., (Eds.), Personality disorders and the five-factor model of personality. (3rd ed.). American Psychological Association. Widiger, T. A., Gore, W. L., Crego, C., Rojas, S. L., & Oltmanns, J. R. (2017). Five Factor Model and personality disorder. In The Oxford handbook of the Five Factor Model (p. 449). Oxford, UK: Oxford University Press. Widiger, T. A., & Mullins-Sweatt, S. N. (2009). Five-factor model of personality disorder: a proposal for DSM-V. Annual Review of Clinical Psychology, 5, 197–220. Widiger, T. A., & Presnall, J. R. (2013). Clinical application of the Five Factor Model. Journal of Personality, 81(6), 515–527. Wright, A. G., Hopwood, C. J., & Zanarini, M. C. (2015). Associations between changes in normal personality traits and borderline personality disorder symptoms over 16 years. Journal of Personality Disorders, 6(1), 1–11. Zanarini, M. C., Frankenburg, F. R., Hennen, J., Reich, D. B., & Silk, K. R. (2004). Axis I comorbidity in patients with borderline personality disorder: 6-year follow-up and prediction of time to remission. American Journal of Psychiatry, 161, 2108–2114. Zanarini, M. C., Frankenburg, F. R., Hennen, J., & Silk, K. R. (2003). The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder. American Journal of Psychiatry, 160(2), 274–283. Zanarini, M. C., Temes, C. M., Ivey, A. M., Cohn, D. M., Conkey, L. C., Frankenburg, F. R., et al. (2017). The 10-year course of adult aggression toward others in patients with borderline personality disorder and axis II comparison subjects. Psychiatry Research, 252, 134–138.