See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/267924220

Psychopharmacological Treatments for Emotion Dysregulation in

Borderline Personality Disorder

Article

CITATIONS READS

2 582

4 authors, including:

Elena I Nica
University of Toronto
6 PUBLICATIONS   270 CITATIONS   

SEE PROFILE

All content following this page was uploaded by Elena I Nica on 01 April 2015.

The user has requested enhancement of the downloaded file.

 MIND & BRAIN, THE JOURNAL OF PSYCHIATRY REVIEW ARTICLE

Psychopharmacological Treatments for Emotion

Dysregulation in Borderline Personality Disorder
Elena I Nica1 and Paul S Links2
Affiliations: 1Faculty of Medicine, University of Toronto, Ontario, Canada and 2Arthur Sommer Rotenberg Chair in Suicide Studies at St. Michael’s Hospital,
Toronto, Ontario, Canada and Professor of Psychiatry in the Department of Psychiatry, Faculty of Medicine, University of Toronto, and the Centre for Research in
Inner City Health in The Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada.

A B S T R A C T

C
The drug treatment of affective symptoms in borderline personality disorder (BPD) has been the subject of four recent meta-analyses of
randomized controlled studies (RCTs). This paper reviews the current evidence-based recommendations for the psychopharmacological

LL
treatment of the affective symptoms in BPD: affective instability, anger, depression, and anxiety. There was not enough data on affective
instability as an outcome measure to make a good conclusion. Most of the evidence point to a large reduction of anger with mood stabilizers
and antipsychotics. Mood stabilizers are also moderately effective against depressed mood and anxiety. Contrary to prior guidelines, selective
serotonin reuptake inhibitors (SSRIs) were shown to be minimally effective against depression in BPD. Omega 3 fatty acids helped reduce
depression. These results suggest that clinicians should raise their threshold for prescribing medication for affective instability, anxiety, and
depression, but not for anger. Clinicians must also weigh the benefits of medication over their side effects in the neurologic and metabolic
al,
domains. The meta-analyses were limited by the heterogeneity in methodology, by the small number of RCTs for each drug and small sample
sizes, and by the exclusion of patients with comorbidities that are common in this population.

Keywords: borderline personality disorder, affective instability, emotion dysregulation, anger, anxiety, depression, drug therapy, evidence
dic
based practice

Correspondence: Elena I. Nica, Faculty of Medicine, University of Toronto, St. Michael’s Hospital, 30 Bond Street, Shutter Wing, Room
2010d, Toronto, Ontario M5B1W8, Canada. Tel.:  416 997 1605; Fax: 1 416 864 5996; e-mail: irina.nica@utoronto.ca
Me

Affective instability is part of the core pathology in border-
line personality disorder (BPD; alongside other symptom
domains such as impulsivity, unstable interpersonal relation-
ships, and cognitive defects), and the underlying cause for
severe clinical manifestations such as impulsive behaviors,
self-injury, and suicide.1
4
as
psychotropic medication is higher in BPD than in major
depressive disorder or other personality disorders.14
16 In a
sample of 130 participants recruited from the community in
an American study, patients with BPD had an average lifetime
use of 3.58 psychiatric medications. This medication usage
is the highest when the BPD group is compared to groups

As a DSM
IV diagnostic criterion for BPD, affective
instability is described as ‘‘marked reactivity of mood (ie,
intense episodic dysphoria, irritability, or anxiety usually
lasting a few hours and only rarely more than a few days).’’5
uc
with other personality disorders (1.58 medications), with
depression (1.07 medications), or of healthy controls (0.03
medications).14 In a prospective 6-year US study of 290
patients with BPD, 70% were taking three or more psycho-

The DSM
V revision of BPD diagnostic criteria proposes
describing affective instability as ‘‘rapidly changing, intense,
unpredictable, and reactive emotions’’ including shifts into
extreme anxiety, depression, and anger.6 This definition
nL
tropic medications at 2-, 4-, or 6-year follow-up after
discharge from a hospital admission.16 The Canadian data
are similar. In a one year Canadian study of 180 patients with
BPD, the average number of psychotropic medications used

shares the view that affective instability is a dynamic process
characterized by multiple parameters: intensity of affect,
frequent shifts in affect, magnitude of mood change, rapid
raise emotion time with slow return to baseline, reactivity to
external triggers, and reactivity to endogenous stimuli.7
10
Sa
was 2.33, with 64% of the patients being on one or more
medications (most often antidepressants and antipsychotics,
followed by mood stabilizers and sedatives).17
In spite of the wide use of medications to treat patient with
BPD, there are no up-to-date clinical guidelines on drug

Given the complexity and the clinical significance of
affective instability, the treatment of patients with severely
dysregulated affect is challenging. While psychotherapy is
considered the standard of care for the management of
BPD,11
13 many patients with BPD are treated with psycho-
tropic medications. Most of the data on treatment utilization
comes from US studies, and they show that the use of
therapy for the core symptoms of this condition. The NICE
guidelines13 only recommend psychopharmacological treat-
ment of comorbid depression, post-traumatic stress disorder,
and anxiety. They advise against the use of medications
for BPD or for individual symptoms, including for affective
instability. They also specifically recommend against the use
of antipsychotics for the moderate or long-term management

M&B 2010; 000:(000). Month 2010 1 www.slm-psychiatry.com

Mind & Brain, the Journal of Psychiatry
of patients with BPD, but allow for the use of short-term drug
therapy during an acute crisis. The 2001 APA guidelines11 on
the other hand recommend the use of antidepressants (SSRIs
being the first-line) to treat affective disturbances. Newer
meta-analyses18
21 however seem to suggest a switch from
antidepressants to mood-stabilizers and antipsychotics as the
medication of choice in affective instability. This paper brings
to focus the current evidence for the psychopharmacological
treatment of the symptoms of emotional dysregulation
included in the DSM
V for BPD: affective instability, anger,
depression, and anxiety.
Data on the effectiveness of drugs in the treatment of
emotional dysregulation in BPD were obtained from the four
most recent meta-analyses of placebo-controlled double-
blind randomized controlled studies (RCTs).18
21 They looked
at the effectiveness of antidepressants, mood stabilizers, and
antipsychotics at treating specific symptoms of BPD. The
largest meta-analysis is the Cochrane systematic review of 28
RCTS of drug treatment for BPD published by 2009.18 The
second meta-analysis looked at placebo-controlled double-
blind RCTs of drug effectiveness for symptom clusters in
severe BPD and/or schizotypal personality disorders, includ-
ing affective dysregulation (depressed mood, anxiety, anger,
affective lability).19 The third meta-analysis looked at 18
placebo-controlled double-blind RCTs of drug effectiveness
for depression and anger symptoms in BPD.20 The fourth
dic
meta-analysis looked at 22 placebo-controlled, double-
blind RCTs of drug effectiveness for specific symptoms in
BPD including affective instability, anxiety, depression, and
anger.21 The four meta-analyses overlap greatly in terms of
Me
the RCTs included in their statistical analyses and, thus, many
of their conclusions converge. Based on these RCTs, the
effectiveness of psychotropic drugs on affective instability,
anger, depression, and anxiety in BPD is described below
based on the magnitude of the effect size reported (small,
moderate, or large).
as
AFFECTIVE INSTABILITY
Most studies did not look at affective instability as a separate
measure. Due to lack of direct measurement, only a meta-
uc
analysis of studies on olanzepine was performed.18 Olanzepine
showed a small improvement in affective instability when
compared with the placebo, based on a meta-analysis of
three RCTs (n631). One study did not find a difference
nL
in effect on affective instability between olanzepine and
placebo.22 Olanzepine treatment was accompanied by signi-
ficant side effects compared to the placebo: weight gain,
increased appetite, somnolence, mouth dryness, changes
in liver transaminases, altered lipid profile, increase in
Sa
prolactin, changes in blood cell count, and decrease in blood
calcium.18
There was no effect on affective instability with ziprasidone
in one RCT.18
One placebo-controlled RCT (n 27) showed that lamotri-
gine was also effective in reducing affective instability.18
M&B 2010; 000:(000). Month 2010
One placebo controlled RCT (n 38)23 showed a significant
decrease in rapid mood shifts after 6 weeks of treatment with
fluvoxamine (150
200 mg/day). The effect was maintained at
24 weeks. Mood shifts were defined as a change from a
neutral mood to a negative mood.
ANGER
Mood stabilizers as a class had the largest effect on
reducing anger in all four meta- analyses.18
21 For example,
the pooled data from seven RCTs (n 230) showed a very
large effect of mood stabilizers (carbamazepine, valproate
semisodium, topiramate, and lamotrigine).19 The evidence for
selecting one mood stabilizer over another is based on single
studies or small studies and is therefore weaker. It seems to
C
suggest that lamotrigine, topiramate, and carbamazepine had
the largest reduction in anger for the short-term (6
10 weeks)
compared to a placebo. Side effects and tolerability should
LL
also be considered. The large effect of topiramate was shown
in a group of 42 male participants and separately in a group
of 85 female participants from three RCTs. Topiramate was
accompanied by weight loss compared with the placebo.18
Lamotrigine was shown to reduce anger in one RCT (n 18)
al,
and carbamazepine was shown to reduce anger in one RCT
(n 25).20 Valproate semisodium was effective after 10 weeks
of treatment in a small RCT (n 16), but the effect was lost at
12 months and 24 weeks in another two larger studies.18,20
The effect of mood stabilizers on reducing anger is com-
plemented by their effect on reducing impulsive behaviors.19
Antipsychotics as a class showed a small to moderate effect
on anger in the short- and medium-term, in the meta-analysis
of six RCTs (n 274 participants)20 and the meta-analysis of
four of the seven RCTs (n 201).19 A separate meta-analysis
of three RCTs (n 631, two RCTs belong to the same research
group) for olanzepine showed that it had only a small effect
of anger. Olanzepine maintained its effect on anger at
24-months follow-up.20 Aripiprazole was investigated in
one RCT (n 52) and it showed a moderate effect on anger,
which was highest among antipsychotics. Its effect was
maintained at 18-months follow-up.20 Haloperidol was
shown to have a small to medium effect over 5 weeks of
treatment in a meta-analysis of two RCTs (n114) conducted
by same research group.18
Antidepressants (SSRIs and MAO inhibitors, but not
amitriptyline) have a small to moderate effect on anger
during short-term therapy.20
DEPRESSION AND ANXIETY
There is little evidence to support the use of psychotropic
medication for depression in the context of affective
instability without a major mood disorder.18
20 Only mood
stabilizers had a moderate effect on depression, as showed by
a meta-analysis of five RCTs (n 148) on carbamazepine,
valproate, and topiramate.19 Antipsychotics and antidepres-
sants had no significant effect. Furthermore, haloperidol was
found to worsen depression.20 Supplementary omega 3 fatty
acids were found to reduce depression.18
2 www.slm-psychiatry.com

In terms of effect on anxiety, mood stabilizers were shown
to have a moderate effect and antidepressants a small effect.19
Among antipsychotics, olanzepine and aripiprazole were
shown to improve anxiety in single RCTs, but the pooled
effect size was not significant.19,20
In summary, the four meta-analyses highlight general
effects of major classes of drugs on emotional dysregulation.
They are limited in their conclusions on individual drugs due
to the small number of trials for each drug. In meta-analyses
of combined trials of lamotrigine, carbamazepine, topira-
mate, and valproate semisodium, mood stabilizers had a
large effect on anger and moderate effects on depression and
anxiety. In a meta-analysis of combined trials of haloperidol,
olanzepine, and aripiprazole, antipsychotics showed a
moderate effect on anger, also maintained in single RCTs
of these drugs. The SSRIs were shown to be minimally
effective against depression in BPD. Omega 3 fatty acids
helped reduce depression.
These meta-analyses are limited in their conclusions by
significant factors. First, the studies are heterogeneous in
their assessment instruments, outcome measures, and sam-
ple sizes. Second, there was a limited number of studies per
drug assessed and RCTs on one drug often came from the
same research group, making it challenging to make a strong
conclusion as to its effects. There was also a limited number
of drugs investigated, especially among the antipsychotics.
dic
Third, the exclusion criteria for most studies limit the
applicability of the results to the clinical context: most
studies excluded participants with substance use disorders,
axis I comorbidity, or suicidal ideation. Fourth, the duration
of the studies varied between 6 to 10 weeks, and only on
Me
occasion were studies extended to 12 or 24 months. This
raises the question of the long-term effect of medication and
appropriate duration of treatment, which the meta-analyses
could not address.
A major limitation to our paper is the poor representation
of measures of affective instability in these studies. The use
as
of affective instability as an outcome measure was limited to
few studies, which used traditional semistructured inter-
views (Structured Clinical Interview for DSM
IV Axis II
Personality Disorders for BPD)24 and retrospective self-
uc
ratings such as the Affective Lability Scale.25 Research has
shown that these traditional cross-sectional measures are
not adequate to capture daily changes in mood: trait
questionnaires, retrospective reports, and one time scales
nL
of affective instability correlate poorly with measures of
affective instability derived from real-time daily recordings
of mood taken with experience sampling methodology
(ESM).10,26 Also referred to as ecological momentary
assessment, ESM uses signaling devices such as telephone
Sa
beepers, pagers, or handheld electronic units to sample
peoples’ internal states, external events, and reactivity to
external events as it occurs in real time in the individual’s
natural environment, thus eliminating recall bias.27
30 The
ESM seems to also have an advantage over traditional
measures when it comes to capturing response to treatment
in depression: daily diary measures were shown to detect
www.slm-psychiatry.com
Psychopharmacological treatments for emotion dysregulation
changes in mood faster than weekly retrospective measures
of mood, and allowed the collection of information related
to other variables such as motor activity, experience of side
effects, and adherence to treatment.8 This methodology has
not yet been implemented in drug RCTs for BPD but should
be considered as an outcome to include in future trials.
For interested researchers, Trull and Ebner-Priemer31 and
Ebner-Priemer et al32 offer a good overview of the ESM’s
advantages and strategies to implement it in research
programs of affective instability.
While the tendency is to choose drugs that worked in
treating axis I symptoms, it is important to think of the
pathophysiology of affective instability in its own right when
guiding our choice of drug treatments. Recent reviews of
C
neuroimaging findings in BPD9,33,34 suggest that affective
instability is accompanied by underlying structural and
functional changes in brain systems responsible for attention
LL
and perception of negative or ambiguous social information,
as well as for emotion regulation.
On one hand, when compared with healthy study partici-
pants, people with BPD show greater activation of amygdala,
temporal cortex, and occipital visual cortex when presented
al,
with emotional faces35 or pictures depicting social interac-
tions.36 The increased activation of visual and temporal cortex
is an expression of increased processing of visual stimuli
perceived as potentially dangerous. On the other hand, the
up-down modulation of this exaggerated emotional response
is impaired. People with affective instability have difficulties
engaging brain regions (prefrontal cortex, cingulate cortex,
and parietal cortex) that help dampen emotional response,
distance oneself from an emotional situation, and shift
attention away from perceived negative stimuli.
Unsurprisingly, there is also some evidence that major
neurotransmitter systems in the brain play a role in affective
instability.9,33 For example, the overactivity of amygdala is
linked to cholinergic hyperarousal in a bidirectional feedback
loop, and cholinergic hyperarousal was shown to lead to
rapid increase in emotional intensity and to dysphoria.9
Amygdala is also linked to the serotoninergic and adrenergic
arousal systems generated in the brain stem.9,33 Some studies
suggest that dopamine dysfunction may be related to affective
instability as well.33
The treatment of affective instability in the clinical context is
challenging, especially that the current clinical guidelines do
not reflect the evidence-based psychopharmacology of the
latest meta-analyses. There is no doubt that psychotherapy is
the standard of care for treating BPD. However, as the
treatment utilization data in the United States and Canada
show, clinicians often make use of psychotropic medications
to help treat symptoms in this patient population. The
following conclusions would be helpful in assisting clinicians
choose appropriate treatments. As shown by the most recent
meta-analyses, psychotropic drugs have a modest effect on
depression and anxiety in the context of BPD. There was not
enough data on affective instability as an outcome measure to
make a conclusion. Contrary to prior guidelines, SSRIs were
3 M&B 2010; 000:(000). Month 2010
Mind & Brain, the Journal of Psychiatry
shown to be minimally effective against depression in BPD.
Omega 3 fatty acids helped reduce depression. Most of the
evidence point to a large reduction of anger with mood
stabilizers and a moderate reduction in anger with some
antipsychotics (olanzepine, aripiprazole, or haloperidol).
These results suggest that clinicians should raise their
threshold for prescribing medication for affective instability,
anxiety, and depression, but not for anger. Mood stabilizers
seem to have the best effect for overall emotion dysregula-
tion in BPD. As a class, they are particularly effective in
reducing anger and impulsive behaviors, and they are also
moderately effective against depressed mood and anxiety.
However, the recommendations for individual mood stabi-
lizers are based on the results of a limited number of small
studies. Clinicians should be aware that these recommenda-
tions should be considered in conjunction with other clinical
information. According to the current and limited evidence,
lamotrigine and topiramate seem to be good first-line
treatment choices for anger. For example, lamotrigine was
shown in a placebo-controlled RCT37 (n 18) to reduce
anger in doses titrated from 50 mg to 200 mg over an 8-
week course of treatment. A placebo-controlled RCT (n 27)
showed that lamotrigine in daily doses ranging between 25

225 mg (mean 106.7 mg) was also effective in reducing
affective instability.38 The side effects of lamotrigine should
be closely monitored: rash, sedation, confusion, headache,
dic
dizziness, ataxia, tremor, insomnia, and irritability.37,38
Likewise, three small trials of 8 and 10 weeks duration
showed that topiramate in doses titrated from 25 to 250 mg
(mean daily doses of 200
250 mg) led to a large reduction in
anger in both men (n 42) and in women (n 85). The
Me
weight loss associated with topiramate may be a factor to
consider when selecting this drug over another. While
topiramate is associated with side effects at the higher
doses used to treat epilepsy (eg, acute myopia, angle closure
glaucoma, urinary tract stones, and cognitive difficulties), it
seems to be well tolerated in the doses used to treat anger in
as
BPD.39 One must also recognize that these studies were 8-10
weeks duration and they do not inform about the long-term
effects of pharmacological treatment.
uc
These meta-analyses summarize the current state of evi-
dence for pharmacological treatment of emotional dysregula-
tion and inform the clinical decision making, but they should
be regarded critically. The lack of systematic investigation of
nL
major drugs in large scale RCTs prevents us from making
definite recommendations. Clinicians must also weigh the
benefits of medication over their side effects in the neurologic
and metabolic domains.
The psychopharmacology of affective instability requires
Sa
more investigation both as a clinical and as a basic science.
Future RCTs should focus on using appropriate measures of
affective instability such as the ones suggested by proponents
of ESM methods. Researchers and clinicians should also join
forces to understand better the neuropathophysiology and
neurochemistry of affective instability and how that guides
the choice of psychopharmacological treatment.
M&B 2010; 000:(000). Month 2010
Disclosure: Paul S. Links has received an unrestricted educational
grant from Eli Lilly Canada Inc. and the views expressed in this
publication are the views of the authors and do not necessarily reflect
the views of the Ontario Ministry of Health and Long-Term Care.
REFERENCES
1. Linehan MM, Kehrer CA. Borderline Personality Disorder. New York: Guilford
Press; 1993.
2. Paris J. The diagnosis of borderline personality disorder: problematic but
better than the alternatives. Ann Clin Psychiatry. 2005;17:41
46.
3. Yen S, Shea MT, Sanislow CA, et al. Borderline personality disorder
criteria associated with prospectively observed suicidal behavior. Am J
Psychiatry. 2004;161:1296
1298.
4. Links PS, Eynan R, Heisel MJ, Nisenbaum R. Elements of affective
instability associated with suicidal behaviour in patients with borderline
C
personality disorder. Can J Psychiatry. 2008;53:112
116.
5. American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders. 4th ed (text revision). Washington, DC: American
Psychiatric Association; 2000.
LL
6. American Psychiatric Association. DSM V Development. Available at: http://
www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid17#.
Accessed on September 24, 2010.
7. Ebner-Priemer UW, Kuo J, Kleindienst N, et al. State affective instability
in borderline personality disorder assessed by ambulatory monitoring.
al,Psychol Med. 2007;37:961
970.
8. Ebner-Priemer UW, Trull TJ. Ecological momentary assessment of mood
disorders and mood dysregulation. Psychol Assess. 2009;21:463-475.
9. Koenigsberg HW. Affective instability: toward an integration of neu-
roscience and psychological perspectives. J Pers Disord. 2010;24:60-82.
10. Links PS, Eynan R, Heisel MJ, et al. Affective instability and suicidal
ideation and behavior in patients with borderline personality disorder.
J Personal Disord. 2007;21:72
86.
11. American Psychiatric Association. Practice guideline for the treatment of
patients with borderline personality disorder. American Psychiatric
Association. Am J Psychiatry. 2001;158:1
52.
12. Paris J. The treatment of borderline personality disorder: implications of
research on diagnosis, etiology, and outcome. Annu Rev Clin Psychol.
2009;5:277
90.
13. National Collaborating Centre for Mental Health. Borderline Personality
Disorder: Treatment and Management. Full Guideline. Clinical Guideline
78. NICE. 2009. Available at: http://guidance.nice.org.uk/CG78. Accessed
on September 24, 2010.
14. Ansell EB, Sanislow CA, McGlashan TH, Grilo CM. Psychosocial
impairment and treatment utilization by patients with borderline
personality disorder, other personality disorders, mood and anxiety
disorders, and a healthy comparison group. Compr Psychiatry.
2007;48:329
336.
15. Bender DS, Dolan RT, Skodol AE, et al. Treatment utilization by patients
with personality disorders. Am J Psychiatry. 2001;158:295
302.
16. Zanarini MC, Frankenburg FR, Hennen J, Silk KR. Mental health service
utilization by borderline personality disorder patients and Axis II
comparison subjects followed prospectively for 6 years. J Clin Psychiatry.
2004;65:28
36.
17. Kolla N, Links P, McMain S, Streiner D, Cardish R, Cook M.
Demonstrating adherence to guidelines for the treatment of patients
with borderline personality disorder. Can J Psychiatry. 2009;54:181
189.
18. Stoffers J, Völlm BA, Rücker G, Timmer A, Huband N, Lieb K.
Pharmacological interventions for borderline personality disorder. Co-
chrane Database Syst Rev 2010, Issue 6. Art. No.: CD005653. DOI:
10.1002/14651858.CD005653.pub2.
19. Ingenhoven T, Lafay P, Rinne T, et al. Effectiveness of pharmacotherapy
for severe personality disorders: meta-analyses of randomized controlled
trials. J Clin Psychiatry. 2010;71:14
25.
20. Mercer D, Douglass AB, Links PS. Meta-analyses of mood stabilizers,
antidepressants and antipsychotics in the treatment of borderline
personality disorder: effectiveness for depression and anger symptoms.
J Pers Disord. 2009;23:156
174.
4 www.slm-psychiatry.com
 Psychopharmacological treatments for emotion dysregulation

21. Nose M, Cipriani A, Biancosino B, et al. Efficacy of pharmacotherapy

against core traits of borderline personality disorder: meta-analysis of
randomized controlled trials. Int Clin Psychopharmacol. 2006;21:345
353.
22. Bogenschutz MP, Nurnberg HG. Olanzapine versus placebo in the
treatment of borderline personality disorder. J Clin Psychiatry.
2004;65:104
109.
23. Rinne T, van den Brink W, Wouter L, van Dyck R. SSRI treatment of
borderline personality disorder: a randomized, placebo-controlled clin-
ical trial for female patients with borderline personality disorder. Am J
Psychiatry. 2002;159:2048
2054.
24. First MB, Gibbon M, Spitzer RL, et al Structured Clinical Interview for DSM-IV
Axis II Personality Disorders (SCID-II). Washington, DC: American Psychiatric
Press; 1997.
25. Harvey PD, Greenberg BR, Serper MR. The affective lability scales:
development, reliability, and validity. J Clin Psychol. 1989;45:786
793.
26. Solhan MB, Trull TJ, Jahng S, Wood PK. Clinical assessment of affective
instability: comparing EMA indices, questionnaire reports, and retro-

C
spective recall. Psychol Assess. 2009;21:425
436.
27. Larson R, Csikszentmihalyi M. The experience sampling method. New Dir
Methodol Soc Behav Sci. 1983;15:41
56.
28. Csikszentmihalyi M, Larson R. Validity and reliability of the experience-

LL
sampling method. J Nerv Ment Dis. 1987;175:526
536.
29. Nica EI, Links PS. Affective instability in borderline personality disorder:
experience sampling findings. Curr Psychiatry Rep. 2009;11:74
81.
30. Ebner-Priemer UW, Kuo J, Welch SS, et al. A valence-dependent group-
specific recall bias of retrospective self-reports: a study of borderline
personality disorder in everyday life. J Nerv Ment Dis. 2006;194:774
779.
31. Trull TJ, Ebner-Priemer UW. Using experience sampling methods/
ecological momentary assessment (ESM/EMA) in clinical assessment
and clinical research: introduction to the special section. Psychol Assess.
al,
2009;21:457
462.
32. Ebner-Priemer UW, Eid M, Kleindienst N, Stabenow S, Trull TJ. Analytic
dic
strategies for understanding affective (in)stability and other dynamic
processes in psychopathology. J Abnorm Psychol. 2009;118:195
202.
33. Dell’Osso B, Berlin HA, Serati M, Altamura AC. Neuropsychobiological
aspects, comorbidity patterns and dimensional models in borderline
personality disorder. Neuropsychobiology. 2010;61:169
179.
34. Mauchnik J, Schmahl C. The latest neuroimaging findings in borderline
Me

personality disorder. Curr Psychiatry Rep. 2010;12:46
55.

35. Koenigsberg HW, Siever LJ, Lee H, et al. Neural correlates of emotion
processing in borderline personality disorder. Psychiatry Res.
2009;172:192
199.
36. Koenigsberg HW, Fan J, Ochsner KN, et al. Neural correlates of the use of
psychological distancing to regulate responses to negative social cues: a
study of patients with borderline personality disorder. Biol Psychiatry.
2009;66:854
863.
as

37. Tritt K, Nickel C, Lahmann C, et al. Lamotrigine treatment of aggression

in female borderline-patients: a randomized, double-blind, placebo-
controlled study. J Psychopharmacol. 2005;19:287
291.
38. Reich DB, Zanarini MC, Bieri KA. A preliminary study of lamotrigine in
the treatment of affective instability in borderline personality disorder. Int
uc

Clin Psychopharmacol. 2009;24:270
275.

39. Varghese BS, Rajeev A, Norrish M, Khusaiby SB. Topiramate for anger
control: a systematic review. Indian J Pharmacol. 2010;42:135
141.
nL
Sa

www.slm-psychiatry.com 5 M&B 2010; 000:(000). Month 2010

View publication stats