Presentation at the VGCt/VVGT Najaarscongres in Veldhoven, The Netherlands, at November 18, 2011, entiteled "The place and finetuning of (experiential) exposure as an intervention for borderline patients: Predictions from empirical studies"

1. Kris Van den Broeck
Psycholoog / Gedragstherapeut / Promovendus
kris.vandenbroeck@ppw.kuleuven.be
DE PLAATS EN FINESSES VAN
(EXPERIËNTIËLE) BLOOTSTELLING
ALS INTERVENTIE BIJ
BORDERLINE-PATIËNTEN:
PREDICTIES VANUIT
EMPIRISCH ONDERZOEK
In samenwerking met Jasmin Reza, Prof. Dr. Guido Pieters MD,
Sabine Nelis, Prof. Dr. Laurence Claes, & Prof. Dr. Filip Raes

2. Over vermijding en blootstelling
 2-Factorenmodel (Mowrer, 1947; 1960)
CS UCS/UCR-representatie
+S+
CR -S- FR
°S-
SΔ . R
-S+
+S- FR
°S+
 Therapie: exposure met responspreventie
(Foa & Kozak, 1986)

3. Over functionele vermijding
 Aangeleerde cognitieve copingstijl, gericht op
het vermijden van de reactivatie van pijnlijke
inhoud en gerelateerde gevoelens
(e.g., Van den Broeck, 2011; Williams et al., 2007)
+S+
-S- FR
°S-
SΔ . R
-S+
+S- FR
°S+
 Therapie: experiëntiële blootstelling
(e.g., Hayes, Strosahl & Wilson, 1999)

4. Autobiographical Memory (AM)
and Emotional Disorders
 “The aspect of memory concerned with the
recollection of personally experienced events”
(Williams et al., 2007)
 Problems with AM ~ Emotional disorders (MDD/PTSD)
 Autobiographical Memory Task (Williams & Broadbent, 1986)
 “I will give you some cues, and I would like to ask
you to retrieve, in response to each cue, a
recollection to a personally experienced event that
happened only once, and did not last longer than
one day.”

5. Autobiographical Memory (AM)
and Emotional Disorders
 Autobiographical Memory Task (Williams & Broadbent, 1986)
 Overgeneral memory (OGM)
 MDD/PTSD: “Every time I play tennis”
 Controls: “That one set I broke my racquet in that thrilling tiebreak
against my brother.”
 Vantage perspective during recall (VPR) (e.g., Kuyken & Moulds, 2009)
 Observer perspective
 Field perspective
 Discrepancy (e.g., Crane, Barnhofer, & Williams, 2007)
 “Happy” ~ HD
 “Lonely” ~ LD
 Functional Avoidance (FA) strategies?

6. Autobiographical Memory (AM)
and Borderline Symptoms
 Borderline Personality Disorder (BPD):
 1-2% in general population; 15-20% in psychiatric
residential population (Oldham, 2004)
 61% of BPD patients meets criteria of major
depression, even after treatment (Zanarini et al., 2004)
 35% of BPD patients meets criteria of PTSD, even
after treatment (Zanarini et al., 2004)
 Hypotheses: BPD complaints ~
 OGM following HD cues
 VPR (observer) following HD cues

7. Study 1: set-up
 Participants  Instruments
 N = 34  Autobiographical Memory Task (Williams & Broadbent, 1986)
 All BPD  Written, minimal instructions
 27 females  9 + cues, 9 - cues
 17-48 years
(M = 27.21;  Beck Depression Inventory (Beck, Steer & Brown, 1996)
SD = 3.22)  Depression severity (0-63)
 73.5% single
 38.2%  Self-Description Questionnaire (Crane et al., 2007)
unemployed  Id = index expressing how self-discrepant the AMT is for
 2.35 each respondent
previous «The following questionnaire is about personal characteristics and self-
residential descriptions. You will be asked to think about and describe a number of different
psychiatric ‘self-concepts’ … Your ‘ideal self’ is the kind of person you’d really like to be. It’s
treatments defined by the characteristics you would ideally like to have. It’s not necessary
that you actually have these characteristics now. Please list seven characteristics
 11 currently that describe how you would ideally like to be.»
Ideal
depressed! Assertive
Actual
Δ=Discrepancy!

8. Study 1: results
Table 1 Correlations between proportion
 Participants are depressed (MBDI = specific and general memories and
33.31; Sd = 12.97) depression severity
 The correlational pattern resembles the
% GC BDI-total
findings of depressed patients
%S -.66** -.58**
% GC .29
% S = proportion specific memories, % GC =
proportion general categoric memories; * p < .05, **
p < .01
 At first sight no relation was shown between Id and %S: rId,%S = .12, p = .50
 But when we only selected the current depressed BPD patients, the analyses
were conform our expectations: rId,%S = -.89, p < .01 (vs rId,%S = .40, p = .07 in
the non-depressed). These correlations differed significantly, z = -4.38, p < .001.
 Moreover, these results were corroborated by a multiple hierachical regression
analysis, pointing out that the interaction between depressive status and IdT is
the most important determinant, even when controlled for depression severity
scores.

9. Study 1: to conclude…
 As in depressed patients: the more the AMT-cue
approaches themes that are highly discrepant for the
respondent, the more likely it is that the respondent
experiences difficulties in retrieving specific
information, at least when the BPD patients is currently
depressed.
 Limitations

10. Autobiographical Memory (AM)
and Borderline Symptoms
 Exploration: Effortful Control ~ OGM/VPR in BPD
 Effortful Control (EC)
 Temperamental variable, mediating between temperament and final
affect
 “The ability to inhibit a dominant response to perform a subdominant
response” (Rothbart & Bates, 2006)
 3 factors:
 Attentional Control: the capacity to focus as well as to shift attention
when desired
 Activation Control: the capacity to perform an action when there is a
strong tendency to avoid it
 Inhibitory Control: the capacity to suppress inappropriate approach
behaviour
 Lower levels in personality disorders (Claes et al., 2009)
 Links with social competence (Spinrad et al., 2007), development of
conscience (Kochanska et al., 1996), sympathy/empathy (Eisenberg et al., 1996;
Valiente et al., 2004)
 Associations between EC and OGM, VPR, BPD symptoms?

11. Study 2: set-up
 Participants  Instruments
 N = 149  Autobiographical Memory Task (Williams & Broadbent, 1986)
 Community  Written, minimal instructions
sample  10 HD cues, 10 LD cues
 82 females
 17-30 years  Borderline Syndrome Index (Vertommen & Van de Wygaert, 1988)
(M = 21.32;  52 items, yes/no
SD = 3.22)  4 factors:
 76% finished  Failing Social Skills (FSS)
higher  Difficult Interpersonal Relationships (DIR)
education  Negative Self-Concept (NSC)
 Anxiety (ANX)
 Effortful Control scale of Adult Temperament Questionnaire
(Hartman & Rothbart, 2001)
 19 items, 8-point Likert scale
 3 factors:
 Attentional Control (ATT)
 Activation Control (ACT)
 Inhibitory Control (INH)

12. Study 2: results
 Results (hypotheses)
%catHD %catLD %obs %obsHD %obsLD BSI-tot BSI-FSS BSI-DIR BSI-NSC BSI-ANX
%cat .86** .85** -.05 -.08 -.03 .07 .11 -.03 .01 .10
%catHD .47** -.07 -.11 -.03 .10 .13 .01 .05 .12
%catLD -.01 -.02 -.02 .02 .06 -.06 -.02 .04
%obs .90** .88** .14 .17* .14 .04 .11
%obsHD .60** .16 .20* .19* .06 .10
%obsLD .07 .09 .06 .00 .09
BSI-tot .79** .77** .90** .84**
BSI-FSS .51** .62** .53**
BSI-DIR .64** .49**
BSI-NSC .67**
BSI-ANX
 No associations between OGM and BPD!
 VPR following HD cues associated with social BPD complaints!

13. Study 2: results
 Results (exploration EC)
EC-ATT EC-ACT EC-INH %obsHD BSI-tot BSI-FSS BSI-DIR BSI-NSC BSI-ANX
EC-tot .79** .79** .72** -.18* -.43** -.40** -.34** -.30** -.36**
EC-ATT .53** .39** -.18* -.51** -.47** -.37** -.41** -.44**
EC-ACT .24** -.22** -.38** -.40** -.36** -.25** -.25**
EC-INH -.05 -.19* -.13 -.10 -.16 -.23**
%obsHD -.15 .06 .19* .19* .09
BSI-tot .90** .77** .79** .84**
BSI-FSS .65** .62** .67**
BSI-DIR .51** .49**
BSI-NSC .54**
BSI-ANX
 EC negatively associated with BPD symptoms (not INH)
 EC negatively associated with VPR (observer) (not INH)
 Mediation of EC between BPD symptoms and VPR?

14. Study 2: results
 Results (exploration EC)
 Preacher & Hayes bootstrapping
 5000 resamples
 .0006 < c-c’ < .0049 (90% CI)
 Yes, mediation!
Borderline c’ = .00 Observer
symptoms perspective
a = -.05** b = -.04**
Activation
control

15. Study 2: to conclude…
 Discussion
 No association between OGM and BPD symptoms
 Community sample?
 BPD patients use other avoidance strategies?
 Future studies
 Association between BPD symptoms and observer perspective during
retrieval
 VPR as avoidance mechanism?
 VPR especially associated with interpersonal problems: what is the role
of field perspective in interpersonal relationships?
 EC mediates relationship between BPD symptoms and VPR
 Therapeutic strategies that enlarge EC and diminish avoidance (MBT,
MBCT, ACT, but also exposure) should work in BPD patients
Van den Broeck, Reza, Nelis, Claes, Pieters, & Raes (submitted). Effortful Control mediates
between Borderline Symptoms and Vantage Perspective during Autobiographical Memory
Retrieval.

16. Algemene conclusie
 Moderne therapeutische strategieën, gericht
op het maximaliseren van EC en het
minimaliseren van FV, zijn wellicht ook
werkzaam bij BPD-patiënten.
 Echter: bij exposure verdienen
perspectiefname en discrepantie de nodige
aandacht!