20131202 exeter
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Testing the CaR-FA-X model: Overgeneral memories in borderline patients.
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20131202 exeter
- 1. Overgeneral memory in borderline patients Van den Broeck, K.*, Claes, L., Pieters, G., Berens, A., & Raes, F. 9th Autobiographical Memory and Psychopathology Meeting Exeter, 02/12/2013 A Research Programme of the Research Foundation-Flanders (FWO) (G.0339.08) 1
- 2. Williams & Broadbent (1986) Often replicated in (previously) depressed and traumatized samples Associated with rumination, avoidant coping, reduced executive functioning, impaired social problem solving Relevant theoretical frameworks: ◦ CaR-FA-X (Williams et al., 2007) ◦ Self Memory System (Conway et al., 2004) 2
- 3. Williams et al. (2007) 3
- 4. Clinical burden BPD patients often report: ◦ Co-morbid MDD (19.3%) (Grant et al., 2008) ◦ Co-morbid PTSD (31.6%) (Grant et al., 2008) ◦ Mood-state independent rumination ◦ Disturbed executive functioning ◦ An unstable sense of self (Smith et al., 2006) (Maurex, 2009) (APA, 1994) ◦ Difficulties solving problems (Kremers et al., 2006) 4
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- 6. BPD related BPD diagnosis Associated with OGM Not associated with OGM BPD severity • Jones et al. (1999) • Maurex et al. (2010) • Reid & Startup (2010) • Reid & Startup (2010) • Renneberg et al. (2005) • Artnz et al. (2002) MDD in BPD MDD diagnosis in BPD MDD severity in BPD • Arntz et al. (2002) • Kremers et al. (2004) • Van den Broeck et al. (2012) • Kremers et al. (2006) • Maurex et al. (2010) • Jones et al. (1999) • Kremers et al. (2004) • Kremers et al. (2006) • Maurex et al. (2010) • Renneberg et al. (2005) PTSD diagnosis in BPD • Van den Broeck (2012) • Maurex et al. (2010) • Reid & Startup (2010) • Renneberg et al. (2005) PTSD / trauma in BPD Exposure to violence in BPD • Maurex et al. (2010) • Kremers et al. (2004) • Renneberg et al. (2005) • Kremers et al. (2004) • Arntz et al. (2002) 6
- 7. CaR FA Rumination Avoidance towards intrusions Intrusions X Various tests (Education) • Jones et al. (1999) (+GC) • Van den Broeck et al. (2012) (-S) Dissociation • Arntz et al. (2002) • Maurex et al. (2010) • Reid & Startup (2010) • Spinhoven et al. (2007) • Arntz et al. (2002) • Maurex et al. (2010) • Spinhoven et al. (2007 Associated with OGM Not associated with OGM • Van den Broeck et al. (r.BDI=ns) • Maurex et al. (2010) • Kremers et al. 2004) • Maurex et al. (2010) • Kremers et al. 2004) • Kremers et al. (2006) • Kremers et al. (2004) • Kremers et al. (2006) • Renneberg et al. (2005) 7
- 8. Other Self-injurious behaviour Associated with OGM Not associated with OGM Problem solving abilities Age • Startup et al. (2001) (-GC) • Maurex et al. (2010) (+S) • Arntz et al. (2002) • Maurex et al. (2010) • Spinhoven et al. (2007) (with cue-discrepancy) • Maurex et al. (2010) • Renneberg et al. (2005) • Kremers et al. (2006) • Kremers et al. (2004) • Renneberg et al. (2005) No associations with gender/marital status 8
- 9. N=72 Instruments ◦ All PDs, 55 diagnosed with BPD ◦ SCID-II, SCID-I (MDD/PTSD) ◦ 13 males ◦ AMT (18 items; 9+, 9-) ◦ 56 inpatients; 14 day treatment; 2 outreach ◦ RRS ◦ MAge = 30.76 (SD = 8.39) ◦ Most of them were ◦ BDI-II, TEQ ◦ IES, DIS-Q, WBSI, AAQ-II ◦ NART, WAIS-III-LNS single (59,4%); inactive due to illness (50,0%); and finished high school (48,6%). 9
- 10. Other # Specific memories # Categoric memories Age # Specific memories - -.569** -.359** -.124 # Categoric memories -.717** - .266** -.068 Age -.364** .340** -.158 .083 Education level Education level - .247* .296* - * p < .05; ** p < .01 Table 1. Correlations between specificity variables, age, and educational level in the total sample (above diagonal) and in the BPD subsample (beneath diagonal). Controlling for age in further analyses! 10
- 11. Total sample Non-BPD # Specific memories # Categoric memories BPD diagnosed F p 12.82 14.59 7.24 .009 1.06 0.96 .07 .797 BPD patients only Non-depressed (n=18) Currently depressed (n=36) F P # Specific memories 15.00 13.78 3.27 .076 # General memories 0.78 1.33 2.82 .099 BPD patients only Non-PTSD (n=33) Currently PTSD (n=19) F p # Specific memories 14.64 14.47 .53 .819 # General memories 1.00 0.95 .02 .879 11
- 12. BPD related MDD in BPD Trauma in BPD BPD severity Depression severity (BDI-II) Trauma exposure (TEC) # Specific memories # Specific memories # Categoric memories BPD severity Depression severity (BDI-II) # Categoric memories - -.708** -.016 -.267$ - -.228 .218 .249 -.045 .193 - -.155 * p < .05; ** p < .01; .182 $ Table 2. Correlations between specificity variables, BPD severity, depression severity, and trauma exposure in the BPD subsample, controlled for age. p = .055 12
- 13. Trauma in BPD Emotional Neglect # Specific memories Emotional Abuse Physical Threats Sexual Intimidat Sexual Abuse -.345* Tot Composite -.139 -.021 .066 -.082 # Categoric memories .163 -.067 -.048 .205 .412** .127 Emotional Neglect - .188 .062 .674 Emotional Abuse Physical Threats Sexual Intimidat Sexual Abuse .463** - .286* .422** - -.103 .293* .195 .772** .164 .257 .752** - .391** .507** - .452** Table 3. Correlations between specificity variables, and TEQ composite scores in the BPD subsample, contr olled for age. * p < .05; ** p < .01 13
- 14. CaR RRS total # Specific memories RRS Brooding RRS Reflection -.087 .028 -.192 # Categoric memories .037 -.180 .224 RRS total - RRS brooding .606** - .414** .003 * p < .05; ** p < .01 Table 4. Correlations between specificity variables and rumination measures in the BPD subsample, controlled for age. 14
- 15. FA IES Intrusions IES Avoidance -.064 # Categoric memories .060 IES Intrusions - # Specific memories IES Avoidance DIS-Q WBSI DIS-Q WBSI AAQ-II -.099 -.148 .017 .072 .042 .207 .032 -.030 .602** .202 .543** - .228 - Table 5. Correlations between specificity variables and .507** -.360** measures of functional .470** -.545** avoidance in the BPD -.523** subsample, controll * p < .05; ** p < .01 ed for age. -.491** 15
- 16. X NART # Specific memories # Categoric memories NART WAIS-II-LNS .247 .131 -.208 .041 - .301* * p < .05; ** p < .01 Table 6. Correlations between specificity variables and measures expressing executive functioning in the BPD subsample, controll ed for age. 16
- 17. Compared to BPDMDD respondents, BPD+MDD patients reported ◦ more rumination (RRStotal); ◦ more intrusions (IES-intrusions); ◦ less experiential avoidance (AAQ); and ◦ higher composite scores for sexual abuse. Nevertheless, the hypothesized CaR-FA-X associations were not found in these subsamples. 17
- 18. OGM in BPD is ◦ Strongly associated with age; ◦ Marginally associated with depressive status (p = .076) / depression severity (p = .055) . OGM in BPD is unrelated to ◦ A co-morbid diagnosis PTSD (replication); ◦ BPD severity or exposure to trauma (replication of majority of studies); ◦ All CaR-FA-X variables (replication, except for X). Additionally, we found that memory specificity ◦ Is higher in patients diagnosed with BPD (contrary to previous findings – ER?); ◦ Is strongly associated with sexual abuse (composite) in BPD patients. 18
- 19. CaR-FA-X only in currently depressed? ◦ But not in our BPD+MDD subsample?! ◦ Probably many BPD patients included in earlier studies (e.g., Williams & Broadbent, 1986)? What can we learn about OGM in MDD, based on studies in BPD patients? … 19
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- 22. The confusing image of OGM in BPD Present study: ◦ Is OGM in BPD associated with syndrome status (MDD/PTSD) or severity (BPD/MDD/PTSD)? ◦ Is the CaR-FA-X model applicable in BPD? Conclusions Discussion 22
Editor's Notes
- Testing the CaR-FA-X model: Overgeneral memory in borderline patients.Van den Broeck, K., Claes, L., Pieters, G., Beerens, A., & Raes, F.Overgeneral memory (OGM), the tendency to retrieve categories of events rather than specific memories in response to cue words, is a robust finding in depressed and traumatized patients. In contrast, OGM has not been consistently found in patients suffering from borderline personality disorder (BPD), despite the fact that these patients often report mood disturbances and past traumatic experiences. The CaR-FA-X model, a framework on autobiographical memory organization, suggests that OGM is caused by an interplay of ruminative processes, functional avoidance strategies, and lowered executive functioning. We will present preliminary data on the associations between OGM on the one hand, and rumination, executive functioning, and avoidance measures on the other hand in a sample of 70 BPD patients, hypothesizing analogous associations as in depressed samples.
- Onceupon a time, two excellent researchersdiscoveredthatsuicidalpatientstendedtoretrievelessspecific memories and more categoric memories comparedtohealthycontrols. It is a story we are allfamiliarwith. Theycalledtheirfindingsovergeneral memory. Andovergeneral memory was found manytimes in many samples of depressedandtraumatizedpatients. Moreover, it was found tobeassociatedwithrumination, anavoidant coping style, reduced executive functioning, andimpairedsocialproblemsolving.
- In 2007 Williams andcolleaguesintroducedthe CaR-FA-X model, in anattempttoexplain non-specificity in depressedandtraumatizedpatientsanditsassociationswithothersymptomsandprocesses.Theysuggest OGM resultsfromruminativeandself-focusedprocesses, in whichpeoplemay get entangled, whenthey are excessively present;a functionalavoidantstyletowards memories, probablylearned in response towardspainful memories, but generalizedtowards memories of all kinds; andexecutive capacity, which is knowntobereduced in depressedandtraumatizedpatients, but necessaryforguided search processes.These processes are supposedto hinder adequate searching. Furthermore, they are believedtocontributetoothersymptoms of depressionand trauma, togetherwith RMS.
- We, in our research, focus on OGM in BPD patients.BPD is a severe mental disorder, characterizedbyemotionalandbehaviouraldysregulationandinstableinterpersonalrelationships. It is a clinicalburdenforpatients as well as fortheirrelatives. BPD is rather common – up to 4% in generalpopulation –, andalsoanexpensive disorder for society, given the number of hospitaladmissions these patients go through.BPD patients are hypothesizedto are overgeneral as well, given high comorbidityrates of depressionandtraumaticexperiences, andgiven the presence of processesthat are hypothesizedtounderlie OGM in MDD/trauma.
- On the other hand, this picture from the veryfamous BPD-blog healingfrombpd.org wouldsuggesthigherspecificityrates in BPD patients. Linehanalsosuggest BPD patients show higheremotionalreactivity.
- Reviewing the literature, we only found 12 studies, conducted in 8 different samples. Results are veryscattered.As youcansee, someresearchers found OGM tobeassociatedwith a diagnosis of BPD – identicalto the associations found in MDD, so BPD patientsshowinglessspecificity or higherfrequencies of general memories. Depressive state is probably at least in part associatedwith OGM in BPD. Severity of symptoms is probablyunrelatedto OGM in BPD, as is PTSD.
- With respect to the CaR-FA-X variables, studies suggeststableassociationsbetween RMS and executive functioning in BPD patients. However, with respect to FA, most studies suggestedthatavoidanceand OGM wereunrelated in BPD. As far as we know, onlyonestudyreportedassociationswithrumination. In our 2012 paper, we reportedthatrumination was negativelyassociatedwith the proportion of specific memories retrieved, but p-level droppedbeneathsignificance level once we controlledfordepressionseverity.
- Often, OGM in BPD patientsseemedtocorrelatewithage, but itsometimesdidnot. Also, for SIB and SPS, associationsdiffer over studies.Thisscatteredpattern of associations… We triedto get a clearer view on these associationswith a new study.
- We questionned 72 males, who had al been diagnosedwithpersonality disorders. Weadministered a SCID, and 55 patientsfulfilled criteria for BPD. Most patientswereinpatients, single andinactiveduetoillness.We administered the SCID-II (personality disorders), and the SCID I modules on MDD and PTSD.For depressionseverity, we administered the BDI II and in order toexplore trauma, we administered the Trauma Experiences Questionnaire.Our AMT consisted of 18 cues, half werenegativeand half werepositive.The Ruminative Response Scalemeasuresrumination, and has twosubscales (broodingandreflection).The IES measuresintrusionsandavoidancetowardsintrusions.DISQ : dissociationWBSI: measure of thoughtsuppressionAAQ: Acceptanceand Action questionnaire, higher scores reflect more experientalavoidance.NART: estimation of VIQLetter-Number-Sequencing Test = estimation of X.
- Table 1 shows the correlationsbetween the number of S and GC memories and Age andeducational level. In the total sample, but also in the BPD subsample, memory specificitysignificantlycorrelateswith Age, suggestinglessspecificity in older subjects.We thereforedecidedto control forage in allfurther analyses.
- F-ratio shows that a diagnosis of BPD was associatedwith memory specificity. Contrarytopreviousfindings, we found that BPD subjects report more specific memories.Further analyses wereconducted in the BPD subsample.We found a trend, suggestingthat the currentlydepressed BPD patientsretrievelessspecific memories (and more categoric memories).A comorbid diagnosis of PTSD, on the other hand,seemedtobeunrelatedtoreduced memory specificity. (Again in line withearlierfindings).
- With respect tosyndromeseverity, we noticedthatdepressionseverity was negativelyassociatedwith memory specificity. P-level = ,055.R(#S, BDI).age = -,267, p = ,055.
- The TEQallowsustocalculatecomposite scores on different kinds of traumatic events. A composite score includes, besidespresence or abscence of the traumatic event, also the subjectivefeelings of distressassociatiedwith the trauma, as well as the age at which the trauma happenedand the relationshiptowards the perpetrator.Onlysexualabuse was associatedwithreduced memory specificity in BPD patients.
- Whentesting theCaR-FA-X model, we first investigatedassocationswithrumination.Rumination was unrelatedtospecificitymeasures in our sample.
- Second, westudiedwhetheravoidancemeasuresand memory specificitywererelated.Again, no associationswere found.
- Finally, we also found no associationbetweenmeasures of IQ or X and memory specificity in BPD patients. (Contrarytosomepreviousfindings).
- Whencomparing BPDpatientswithand without comorbiddepression, we noticedthat the depressed BPD patientsshowed more ruminationandintrusions. Nevertheless, we failedtoreplicate the associationshypothesized in the CaR-FA-X model in these patients.
- Toconclude;Analogousresuls have been found usingproportions of S and GC, thuscorrectingfor no responses.
- Severe, common, expensive
- Remarks:Right affective state? Take stableunstabilityinto account.BPDs miss the cognitivemechanismstoregulate, andtoitbybehaviour.Whydid we notfindanyassociationwith X – we did, but notwhencontrolledforage.Pierre Philippot: strangethatsexualabuse was unrelatedtoother TEQ-composite scores.Mark: in the 1986 study, participantsweremainly overdose patients, not cutters or burners, making itlessprobablethatthey had BPD.