need help with research paper and research experiment

2 part paper 5  page research paper 5 page research experiment ( hypothetical) so 10 pages in all. i already have the sources i want to be used i’ve put the instructions, the schoraly sources and a example of an apa research paper in a folder for everything to be viewed.

PSYC 365

Research Project Instructions

The Research Project consists of two parts: 1) a 5-page research paper, and 2) a 5-page research experiment.  Both parts of this Project will address a single topic, share an abstract and a reference page, and will be submitted together in a single document.  The research paper will focus on synthesizing various scholarly sources to support a thesis statement and will conclude by posing an original research question for further study.  The research experiment follows directly from the conclusion of the research paper by explaining a plan for answering the proposed research question.  The experiment may be hypothetically explained based on educated predictions, or it may be literally conducted and recorded.  If you want to literally conduct the experiment, then you will need to plan in advance.

Book reference for the class is human learning author; Jeanne ellis ormrod

Research Paper

The research paper should be at least 5 pages long and should incorporate information from the textbook, the Bible, and at least five scholarly sources. By the time you begin writing your paper, your topic should be well defined and the information from your research sources should be clearly integrated into your outline. The paper serves the following three purposes for this course: 1) to increase your knowledge in a specific area, 2) to make you more proficient in forming and expressing knowledge, and 3) to help raise your grade in the course by providing an alternative to the tests. Since this course covers a large amount of content, it is impossible to become expert in every area, but by focusing your research and writing in the area of your greatest interest, you can gain some level of expertise and sophistication.

A good 5-page paper will probably have about 5 sections: an introduction, 3–4 main points, and a conclusion. The paper should summarize and synthesize what you found while researching other authors’ writings and studies; thus, your paper should not contain any direct quotes, but should properly and eloquently paraphrase your sources. Cite the source for every idea stated in the paper, using this format: (Brown, Smith, & Young, 2000). Use a new citation only when the source changes; do not repeat a citation until the source is cited again after a change of source.

Begin the paper by introducing the learning problem and presenting some background information. Then, discuss about 3–4 main points about your topic/problem and what the latest research is saying about it. At least one of the main point sections should include an application of one of the theories presented in this course and a discussion of how it relates to, explains, and/or helps to solve your chosen learning problem. The final paragraph of your paper should point to your original research experiment by exposing a lack of research in a specific area and posing a research question that you would like to solve through your original research experiment. You can either state formal hypotheses or informal intentions for research.

Research Experiment

The original research experiment should be a 5-page report, describing and explaining a test or survey that could lead to original research for your chosen topic. The original research articles that you use for the research paper are examples of research experiments. Every published research article was originally someone’s idea for gaining more information, and it was gradually refined to its published form. You will with an idea for a paper, and then conduct some original research to further investigate your topic.

You do not literally have to conduct your experiment—it can be hypothetical or literal. If you only propose a hypothetical the research experiment, then you can make it as large and scientific as you like. For example, you may propose collecting data from hundreds of people in several states and countries to avoid levels of bias. If you plan to literally collect data from real people, consider the time and expense involved in contacting the people. The easiest way to perform data collection for an 8-week class is to use a survey format. Give a survey to people around you or email surveys to friends, family members, classmates, and acquaintances. If you choose to conduct the actual research for this project, use the Sample Permission for Research form.

Since you are not required to literally conduct the experiment, you are only responsible for your description of the experiment, not the results. In other words, you must create a design for the experiment (in your Methods section), record the results––whether from your completion of the test, or based on your best hypothetical projections from your research––(in the Results section), and then discuss what you found and where more research could be done (in your Discussion section).

Carefully plan the people (Subjects) you will test, the instruments (Materials: e.g., survey, scores, game, test) you will use with the subjects, and the time, place, and steps involved in the Procedure. Describe these aspects of the Method in minute detail; this will likely use the minimum page requirement and it will give more complete information for the Discussion. The Results should only state the numbers, scores, or other responses without comment or explanation. The Discussion should explain the Results by means of the research sources cited in the research paper and in the References. These sources will give credibility to your explanation of why the Results exist, based on the Subjects who were chosen, the Materials that were used, and the Procedure that was followed. The Results would change if parts of the Method were changed. That is why you are more responsible for choosing and reporting the Method, and less responsible for the outcomes of the Results. The goal of this assignment is to make you more analytical in your own thinking and in the acceptance of the articles and information published by others.

Even though there will be some bias, you may still compose your own survey. It will not be valid or reliable, and you must state that bias in the Discussion. Your survey items must be based on information in your research sources; you must cite the source of the information in those items in the Materials section of the Method. The instrument should have 10–15 items, usually in a forced-choice or Likert scale format; there should be responses from 15–20 subjects. There may be additional items of demographic, or background, information which may become the independent variables.

Page 1 of 2

Running head: ATHLETICS AND SELF-CONCEPT Athletics 1

 

 

 

The Relationship Between Number of Years in

Youth Athletics and Adult Self-Concept

Your Name

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Abstract

A large number of individuals are involved in athletics, sometimes beginning during childhood. Many studies have found that athletics offer various benefits. One of these benefits seems to be that those involved tend to have a healthy self-concept. The purpose of this investigation was to examine the relationship between the number of years people might be involved in youth athletics and their adult self-concept. The number of years the individuals were involved and levels of self-concept were studied in 38 subjects all of whom were college students attending a university in the Southeastern United States. These subjects used the SPPCS to determine their level of self-concept. It was hypothesized that there would be a positive correlation between the number of years in athletics as a youth and adult self-concept.

 

This is the abstract of a research proposal. It is written in past tense, even though the data haven’t been collected.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The Relationship between Number of Years in
Youth Athletics and Adult Self-concept

Self-concept affects various areas of an adult’s life. This fact is widely accepted in the field of psychology. Athletics are believed to play a role in self-concept, in that athletics have some affect upon it. Generally this effect is a positive one, although the exact degree that athletics affects self-concept is debatable. Various studies have researched these concepts both separately and together and the results vary.

Self-concept is an awareness of physical and psychological individuality (Keltinkingas-Jarvinen, 1990). It plays a primary role in many psychological functions. It has an effect on individuals’ self-perceptions and their perceptions of other people (Rauste-v Wright, 1987). Self-concept also regulates goal setting and achievements (Dusek & Flaherty, 1981), social cognition, and causal thinking (Watkins & Astille, 1979). A positive self-concept is associated with a high level of school achievement (Keltinkingas-Jarvinen, submitted for publication), psychic stability, and ego strength (Kawash, 1982); a negative self-concept, with school failure (Rauste-v Wright, 1987), dropout (Keltinkingas-Jarvinen, submitted for publication) and situation-specific anxiety (Coopersmith, 1967). Thus self-concept is an important asset to all individuals.

 
 

Once you have built a case for the importance of your first concept, then you include a transitional paragraph to your next concept, and review that relevant literature.

According to the studies that have been reviewed, self-concept does have a large impact upon individuals. It is beneficial to have a high self-concept. Athletics are also highly beneficial to an individual. There are numerous ways in which an individual can benefit from physical activity and more specifically from athletics.

An example of ways that athletics can positively affect an individual was found in a recent article by Rhea (1998) who speculated that a high quality athletic program should allow high school students to take much more with them, following graduation, than a letter. She felt that it is key that the capabilities and successes of female athletes’ roles, specifically, promoted diverse body images and built confidence in female youths. It is important for female adolescents to recognize that participants with bodies of different sizes and shapes can be successful and …

 
 

Now that you have reviewed the relevant literature, you very briefly restate your main idea and offer the hypothesis you are planning to investigate

 

After review of this literature, it can be concluded that having a positive self-concept is ideal for all individuals. There are various ways in which self-concept is expressed. It is, however, difficult to determine how it is achieved. Athletics is also seen to play an important role in attaining body esteem, in academic achievement, in anxiety reduction, along with various other benefits.

Self-concept is a relatively broad definition of the construct that includes cognitive, affective, and behavioral aspects; self esteem is thought to be a more limited evaluative component of the broader self-concept term (Blascovich & Tomaka, 1991; Wells & Marwell, 1976). Despite the claims that support the distinctiveness of self-concept and self-esteem, construct validity research to date has been unsuccessful in providing empirical evidence of such discriminability. (Marsh, 1986; Shepard, 1979). This reconfirms the fact that these words can, and they will, be used interchangeably in this study as they have been in various other studies (Hughes, 1984).

In the present study, the effect of athletics on adult self-concept specifically was investigated by comparing the number of years one was involved in youth athletics to a self-concept score. Although there seem to be benefits of a child being involved in athletics, do these benefits, specifically in the area of higher self-concept, carry through into adulthood? In this study it was hypothesized that the number of years in youth athletics would correlate with the self-concept scores. It was also hypothesized that with more years of participation in youth athletics, the adults’ self-concept scores will be higher. This may indicate that involving children and adolescents in athletics may improve their adult levels of self-concept.

NOTE: large portions of this actual paper have been deleted. Therefore, there are many more references listed in the Reference section than you will find in the actual text. Be sure to include everything you cite in the text.

 
 
 

Method

Participants

A sample of thirty-five students attending a private university located in the Southeastern United States were asked to participate. The participants ranged in age from seventeen to twenty-three. The students were enrolled in a developmental psychology course. All students enrolled in the classes who chose to participate were allowed to replace an existing poor homework score or just boost their homework average. Participants were all given an informed consent (see Appendix A), and assured of anonymity.

 

Note: If the paper is merely proposing to do a study, all of this method section is in future tense,i.e., “subjects will be…” . If the study is completed, all of this method section is in the past tense.

Instruments

The Self-Perception Profile for College Students (SPPCS) was used to evaluate self-concept (Nemann & Harter, 1986). This test was chosen because it was designed to fill an important instrument void that has existed between the measurement of the self-concepts of adolescents and of adults. College students are often regarded as adults. Legally, however, they do straddle a boundary between adolescence and adulthood. They often live away from home but are not always working full time and normally are not responsible for the nurturance of others or for the management of a household as many adults are. This is the reason that the Self-Perception Profile for College Students was designed as a multidimensional scale that consists of sub-scales which were designed to research important areas of the lives of a college population (Byrne, 1996). This test drew heavily from three other Self-Perception Profiles designed to measure preadolescent (Harter, 1985), adolescent (Harter, 1988), and adult (Messer & Harter, 1986) self-concepts.

The SPPCS was designed for specific use with full-time undergraduate college students with ages ranging from seventeen to twenty-three. Neeman & Harter (1986) suggested that it would also be useful in testing older, single full-time undergraduate students, as well as graduate students. For other non-traditional students, the Adult Self-Perception Profile is suggested.

The SPPCS is a fifty-four item self-report scale that comprised 13 sub-scales. Twelve of these sub-scales are designed to measure self-perceptions that relate to specific domains of one’s life, and one scale taps perception of self in general which is known as Global Self-Worth. Neeman and Harter (1986) noted that all items are based on a four point structured alternative format so that socially desirable responding will be offset.

The second form students were asked to complete was a demographic questionnaire (see Appendix B). This was used in order to determine each student’s age and number of years in athletics.

Procedures

In order to administer this test, the instructor for each of the classes was contacted prior to the beginning of the semester to allow the instructor to incorporate participation into the semester schedule. Permission to participate during class time and to replace a missed homework or poor homework grade was obtained from the instructor. The students were then asked to stay until the end of class regardless of when they completed the surveys.

First the consent form was distributed by their instructor. Secondly the Self-Perception Profile for College Students was given. This took about 30 minutes to complete. Once this wass completed the general information questionnaire was distributed and when that wass completed, the students turned in all three of these things at the same time.

The sample Method section was in the past tense, as in a completed study. The Results are only predicted in the future tense, as in a proposal.

Results

It is predicted that there will be a significant relationship between the number of years individuals had been involved in youth athletics and their self-concept scores in adulthood . It is also predicted that more years of athletic participation will correlate with higher self-concept scores.

Should you actually want to collect some data and analyze it, these next two pages show the format for tables and figures. Pay particular attention to the headings for each.

 

Table 1

The relationship between number of years in youth athletics

and self-concept scores

 

 

Figure 1. The Relationship between number of years in youth athletics and
self-concept scores
 
 
 
 
 
 
 
 

References
Billie, K. (1998, November/December). What I learned in gym. Psychology

Today
, 18.
Blascovich, J., & Tomaka, J. (1991). Measures of self-esteem. In J.P. Robinson, P. R.
Shave, & L. S. Wrightsman (Eds.), Measures of personality and social

psychological attitudes. San Diego: Academic Press.
Byrne, B. M., (1996). Academic self-concept: Its structure, measurement, and relation
with academic achievement. In B. A. Bracken (Ed.), Handbook of self-concept:

Developmental, social and clinical considerations. New York: Wiley.
Chambers, S.T. (1991). Factors affecting elementary school students’ participation in
sport. The Elementary School Journal, 97, 415-419.
Coopersmith, S. (1967). The antecedents of self-esteem
. San Francisco: W.H. Freeman
and Company.
DiNucci, J.M., Finkenberg, M. E., McCune, S. L., McCune, E. D. (1994).
Perceptual & Motor Skills, 78, 315-319.
Douvan, E., & Gould, M. G. (1966). Modal patterns in American adolescence. In L. W.
Hoffman and M. L. Hoffman (Eds.), Review of child development research (pp. 67-113). New York: Russell Sage Foundation.
Dusek, J.B., & Flaherty, F.F. (1981). The development of the self-concept during the
adolescent years. Monographs of the Society for Research in Child Development, 46
, 1-440.
Fielstein, Ellio. (1985). Self-esteem and causal attributions for success and failure in
children. Cognitive Therapy & Research, 9
, 381-398.
Fine, G. A. (1987). With the boys: Little league baseball and preadolescent culture
.
Chicago: University of Chicago Press.
Harter, S. (1985). Manual for the Self-Perception Profile for Children. Denver, CO:
University of Denver.
Harter, S. (1988). Manual for the Self-Perception Profile for Adolescents. Denver, CO:
University of Denver.
Hayes, D., & Ross, C. (1986). The effects of exercise, over-weight and physical health
on psychological well being. Journal of Health and Social Behavior, 27
, 387-400.
Hughes, H. MM. (1984). Measures of self-concept and self-esteem for children age 3-12
years: A review and recommendations. Clinical Psychology Review, 657-692.
Jacobson, Dr. S. (1996). Girls Scouts launch national sports initiative. Women’s Health

Weekly, 12, 16.
Kawash, G.G. (1982). A structural analysis of self-esteem from preadolescence through
young adulthood: Anxiety and extroversion as agents in the development of self-esteem. Journal of Clinical Psychology, 38, 231-244.
Keltinkingas-Jarvinen, L. (1990). The stability of self-concept during adolescence and
early adulthood: A six –year follow-up study. Journal of General Psychology, 117
, 361-369.
Larson, R. (1994). Youth organizations, hobbies, and sports as developmental contexts.
Adolescence in context. New York: Springer-Verlag.
Maccoby, E. E. (1980). Social development: Psychological growth and the parent-child

relationship. New York: Harcourt Brace Jovanovich.
Marble, M. (1996). Girl Scouts launch national sports initiative. Women’s Health

Weekly, 12, 16.
Marsh, H. W. (1986). The bias of negatively worded items in rating scales for young
children: A cognitive-developmental phenomenon. Developmental Psychology, 22,
37-49.
Messer, B., & Harter, S. (1985). Manual for the Adult Self-Perception Profile. Denver,
CO: University of Denver.
Neeman, J., & Harter, S. (1986). Manual for the Self-Perception Profile for College

Students. Denver, CO: University of Denver.
Rauste-v. Wright, M.L. (1987). On the life–process among Finnish adolescents.
Summary report of a longitudinal study. Commentationes Scientiarium Socialium 35, 1153-1159.
Rhea, D. (1998, May/June). Physical activity and body image of female adolescents.
JOPERD, 69, 27-31.
Rosenberg, F., & Simmons, R.G. (1975). Sex differences in the self-concepts in
adolescence. Sex Roles, I, 147-159.
Scanlan, T. K. (1998). Social evaluation and the competition process: A developmental
perspective. Children in Sport, 3, 135-148.
Shavelson, R. J., Hubner, J. J., & Stanton, G. C. (1976). Self-concept: Validation of
construct interpretations. Review of Educational Research, 46, 407-441.
Shepard, L.A. (1979). Self-acceptance: The evaluative component of the self–concept
construct. American Educational Research Journal, 16, 139-160. Smith, R. E.,
Smoll F. L., & Curtis, B. (1978). Coaching behaviors in Little League Baseball.
Psychological perspectives in youth sports, 173-201.
Snyder, E. E. (1975). Athletic team involvement, educational plans, and the coach-player
relationship. Adolescence, 10, 191-200.
Spirduso, W. (1983). Exercise and the aging brain. Research Quarterly for Exercise and

Sport, 54, 208-218.
Watkins, D., & Astille, E. (1979). Stability of self-esteem in Filipino girls.
Psychological Reports, 45, 993-994.
Wells, L. E., & Marwell, G. (1976). Self-esteem: Its conceptualization and

measurement. Beverly Hills, CA: Sage.
Zimmerman, J. & Reavill, G. (1998). Raising our athletic daughters: How sports can

build self-esteem and save girls’ lives. New York: Doubleday.
 
 
 
 
 
 
 
 
 

Appendix A
Informed Consent Form
I have been informed that the study in which I have been asked to participate involves my personal self-concept. I have also been informed that I will be asked to fill out a general background questionnaire and a SPPCS profile. I also understand that the study will take approximately 35 minutes of my time.
I understand that the responses I give will be kept confidential. Although the researchers may write up the results of this study, my name will never be used.
I understand that I can withdraw from the study at any time without any problems. I also understand that unless I do withdraw, my involvement in this survey will replace a homework grade in this class.
I understand that, after I have finished the study, the researcher will gladly answer any questions I might have. If I have any questions after that, I should feel free to call (your name) at (434) .
I have read this statement and have had all my questions answered. Therefore I give my written consent to participate in this study.
Signature _______________________________ Date: ________
 
Signature of person obtaining consent

________________________________________ Date: ________

 
 
 
Appendix B: Background Questionnaire
1. Gender M F
2. Age 17 18 19 20 21 22 23 older than 23
3. Classification Freshman Sophomore Junior Senior
4. # of years involved in a church 1 2 3 4 5 6 7 8 9 10 more
5. # of years involved in athletics before college from age 4 1 2 3 4 5 6 7 8 9 10 more
6. # of members in family (including self) 1 2 3 4 5 6 7 8 9 10 more
7. # of years since graduating from high school 1 2 3 4 5 6 7 8 9 10 more
 
 

PSYC 365

Paper Outline and References Instructions

You are required to submit the outline for your research paper and a reference page with at least 5 scholarly sources. This assignment will give you an opportunity to practice conducting and reporting research. As you begin the research phase of your Project, you may need to redefine or refocus your topic. If you spend the time now finding sources that you will actually use in your Research Project, then a big portion of the work will be finished early in the course and you will be able to improve your paper by implementing the suggested changes from your instructor. At this stage in the project, you only need to outline the paper, not the experiment. Both the outline and the reference page should be formatted in APA style in one document.

Review the Paper Outline and References Grading Rubric to improve the quality of your work. The outline and references are due by the end of Module/Week 2.

Developing the Outline and Reference Page

Although the reference page is one of the last things included in the organization of your paper, finding your sources is one of the first things you must do. You must include the textbook, the Bible, and at least 5 scholarly research sources on your list. Two of the research sources must be original research (author conducted a study, with Method, Results, and Discussion sections), with an asterisk (*) next to each original research entry. The instructor will correct the format of the citations and of the references so that you will have those parts correct in the paper.

In the outline, every heading level must have at least two entries (A, B; 1, 2). Likewise, in the paper there should be at least 2 headings in each topic category. The outline should be built around the research sources that you have found for your paper. Include research citations of the sources at the appropriate points in the outline.

Review an APA style guide in order to ensure your outline and citations are correctly formatted.

Finding Scholarly Sources

Begin by searching for information that will help to increase your knowledge about your chosen topic. Your initial research may or may not be confined to a scholarly database. Once you have familiarized yourself with the basic information surrounding your topic, access the Liberty University Library Research Portal through the Services/Support link on the course menu. When you are looking for the scholarly research articles, think of several surrounding issues and several synonyms for those issues. Then, enter various combinations of those terms into the research database. Popular writing and web pages will have useful and interesting information also, but your minimum of five Research Paper sources must be scientifically reviewed sources such as those published in journals. Keep a list of every combination that you use so that you will not have to repeat your searches. Make use of the interlibrary loan tool and contact the library or your instructor with any research questions.

______________________________

Author info: Correspondence should be sent to: Dr. Jean Gagnon, Ph.D.,

Department of Psychology, University of Montreal C.P. 6128, Centre-ville

Station, Montreal, Quebec, Canada H3C 3J7 jean.gagnon@umontreal.ca

North American Journal of Psychology, 2013, Vol. 15, No. 1, 165-178..

 NAJP

Correlations of Impulsivity with Dysfunctional

Beliefs Associated with Borderline Personality

Jean Gagnon
1,2,3,4

Sacha Daelman
1,2

Pierre McDuff
1

1
Department of Psychology, University of Montreal, Canada

2
Centre for Interdisciplinary Research in Rehabilitation of Greater

Montreal (CRIR), Canada
3
Department of Psychology, University of Sherbrooke, Canada

4
Centre de recherche en neuropsychologie et cognition (CERNEC),

Canada

Beck’s cognitive model is widely acknowledged in the explanation of

some psychopathologies related to impulsivity, and recent studies on

cognitive distortions have shown that this model can explain the

cognitive processes underlying impulsivity. Our study examined the

relationships between dysfunctional beliefs and four dimensions of

impulsivity from the UPPS Impulsive Behavior Scale: Urgency, Lack of

Premeditation, Lack of Perseverance and Sensation Seeking. Regression

analyses revealed that borderline dysfunctional beliefs were correlated

with Negative Urgency even after controlling for age, gender, depression,

anxiety and borderline personality disorder symptomatology. These

results suggest that the Negative Urgency trait is associated with

dysfunctional beliefs that make an individual more prone to adopt

ineffective affect-regulation strategies. In contrast to Cyders’ and Smith’s

(2008) impulsivity model, Beck’s model focuses more on cognitive

processes and gives them precedence over the intensity of emotional

reactions in the dynamics of impulsive behaviors associated with

Negative Urgency.

Impulsivity has been defined as a predisposition toward reacting

quickly and without planning to internal or external stimuli, with no

thought to the consequences of these reactions for the impulsive

individual or for others (Moeller, Barratt, Dougherty, Schmitz, & Swann,

2001). Whiteside and Lynam’s (2001) model of impulsivity identified

four dimensions measured by the UPPS Impulsive Behavior Scale (see

also Whiteside, Lynam, Miller, & Reynolds, 2005): (a) Urgency refers to

the tendency to experience strong impulses in situations of intense

negative or positive emotions (e.g., negative and positive urgency,

166 NORTH AMERICAN JOURNAL OF PSYCHOLOGY

respectively) to which the individual responds by behaving impulsively

in an effort to rid himself of these emotions, regardless of any potential

consequences or risk of injury, (b) Lack of Premeditation is the tendency

to act without considering the consequences, (c) Lack of Perseverance

refers to the difficulty of concentrating on a boring or difficult task, and

(d) Sensation Seeking refers to the tendency to enjoy and pursue exciting

activities, as well as the willingness to try new experiences that may or

may not be dangerous. The UPPS Impulsive Behavior Scale has been

validated in several clinical populations and its factor structure has been

replicated in men and women, adults and adolescents, and in several

languages (d’Acremont & Van der Linden, 2005; Van der Linden et al.,

2006; Whiteside & Lynam, 2003).

The conceptualization of Urgency trait that is dominant in the

literature postulates that this trait is an emotion-based disposition and the

emergence of individual differences can be identified in the relationship

between emotion and behavior (Cyders & Smith, 2008). According to

this view, emotion has a primary role in the production of dysfunctional

impulsive behaviour associated with Urgency trait. The loss of available

cognitive resources and the interference with rational decision-making

comes as a consequence of the intensity of the emotions (Cyders &

Smith, 2008). This point of view seems in contrast to Beck’s cognitive

perspective.

Beck’s cognitive model has been empirically supported for treatment

of a variety of Axis I and Axis II disorders (Beck, 2005; Beck & Dozois,

2011; Butler, Chapman, Forman, & Beck, 2006), including disorders

associated with marked impulsivity such as borderline personality

disorders (Brown, Newman, Charlesworth, Crits-Christoph, & Beck,

2004) and pathological gambling (Fortune & Goodie, 2012). From the

perspective of cognitive theory, cognitive distortions and dysfunctional

beliefs represent central aspects of the phenomenology of these disorders.

Fundamental beliefs or cognitive schemas are deep, unconscious and

stable structures that influence our assessment of reality and guide all

cognitive processes, from encoding to the selection and expression of

behavioral responses. Although Beck’s model was not designed to

explain impulsive behaviors, several components of the model refer to

these behaviors (Ivanoff, Linehan, & Brown, 2001). First, the model

posits that when a schema becomes rigid and dysfunctional, it becomes

hypervalent, or easily activated by a trivial stimulus. A dysfunctional,

hypervalent schema can also become prepotent and inhibit other schemas

that are better adjusted to reality. In such a case, the schema can generate

an intense emotional response, create attentional biases and decrease the

processing of information needed for affective and behavioral regulation.

Second, Beck’s model views personality as a stable organization

Gagnon, Daelman, & McDuff DYSFUNCTIONAL BELIEFS 167

composed of different interrelated systems, each composed of several

schemas with their own function: cognitive schemas (interpretation),

affective schemas (generalization of feelings), motivational schemas

(desires), action schemas (preparing the action), and control schemas.

Functioning alongside the action system, the “control” system modulates,

modifies and inhibits impulses. This system is comprised of beliefs that

outline what we can or cannot do and can be translated into commands. It

also governs the processes of anticipation that inhibit action when the

expected result is unfavorable. Among the control systems are the self-

schemas, which form the basis of how we evaluate and judge ourselves,

favorably or unfavorably, realistically or unrealistically (Beck, Freeman,

& Davis, 2004).

The existence of a relationship between impulsivity traits and

dysfunctional cognitions has received some support. Two studies by

Mobini and colleagues (Mobini, Grant, Kass, & Yeoman, 2007; Mobini,

Pearce, Grant, Mills, & Yeoman, 2006) have shown that age and

impulsivity, as measured with the Barratt Impulsiveness Scale–11th

version (BIS-11; Patton, Stanford, & Barratt, 1995), were significant

predictors of the incidence of cognitive distortions and that cognitive

distortions were associated with dysfunctional impulsivity. A recent

study (Gagnon, Daelman, McDuff, & Kocka, 2013), conducted on

undergraduates, examined the relationships between cognitive

distortions, childhood maltreatment and the four dimensions of

impulsivity of the UPPS Impulsive Behavior Scale. Analyses revealed

that Premature Processing, a term applied to a group of seven cognitive

distortions (such as emotional reasoning and confusing needs and wants),

as well as childhood maltreatment, was able to predict significantly and

independently, the Negative Urgency dimension of impulsivity above

and beyond gender and the three other subscales of the UPPS Impulsive

Behavior Scale. These results suggest that Negative Urgency trait is

associated with cognitive distortions that can undermine thought

processes in a variety of ways, increasing the likelihood of acting rashly.

From a cognitive perspective, these results seem to support the view that

cognition has a primary role in the production of dysfunctional impulsive

behaviour associated with Urgency trait. One question open to further

investigation is whether dysfunctional beliefs (schemas) are related to

UPPS dimensions of impulsivity. However, to our knowledge, there is no

direct evidence of a relationship between trait impulsivity and

dysfunctional beliefs.

We chose to study the relationship between Negative Urgency and

dysfunctional schemas associated with borderline personality disorder for

several reasons. Unlike the other subscales of the UPPS Impulsive

Behaviors Scale, Negative Urgency was specifically predicted by a group

168 NORTH AMERICAN JOURNAL OF PSYCHOLOGY

of cognitive distortions (Gagnon et al., 2013). Moreover, the nature of

cognitive schemas or core beliefs linked to Negative Urgency remains

unknown. However, Negative Urgency has been strongly and uniquely

related to borderline features (Whiteside et al., 2005), which in turn are

associated with specific core beliefs (Butler, Brown, Beck, & Grisham,

2002). These core beliefs, as measured by the Borderline Personality

Disorder subscale of the Personality Beliefs Questionnaire (PBQ-BPD),

reflect themes of dependency, helplessness, distrust, fears of

rejection/abandonment/losing emotional control, and extreme attention-

seeking behaviors (Butler et al., 2002). A study examining the factor

structure of the PBQ-BPD in a sample of patients with borderline

personality disorder yielded three factors relating to beliefs of self as

helpless and others as untrustworthy, and the belief that one should

engage pre-emptively in defensive behaviors to avoid being hurt,

exploited or harmed (Bhar, Brown, & Beck, 2008). Butler et al. (2002)

hypothesized that these beliefs motivate the self-defeating and self-

destructive behaviors associated with borderline personality disorder and

that beliefs about the need to act pre-emptively to protect oneself may be

associated with different types of psychopathology such as anger and

poor impulse control. A previous study on borderline features among

undergraduate students showed that 37.9% had committed potentially

destructive impulsive behaviors, 39.8% had experienced intense and

inappropriate rages, and 10.7% had carried out suicidal acts or threatened

to commit suicide on more than one occasion (Trull, 1995). The question

remains whether the Negative Urgency associated with these impulsive

behaviors is associated as well with borderline dysfunctional beliefs.

The objective of this study was to verify the existence of relationships

between borderline dysfunctional beliefs and the four UPPS dimensions

of impulsivity. It is hypothesized that dysfunctional beliefs associated

with borderline personality disorder would distinctively predict Negative

Urgency even after controlling for the effects of age, gender, anxiety,

depression and borderline psychopathology.

METHOD

Participants

The sample was composed of 150 undergraduate university students

(126 female, 24 male) in a large Canadian metropolitan area, whose

average age was 23.34 years (SD=5.93; ranging from 18 to 53 years).

The participants were recruited among students from several different

courses in social sciences programs. Taking into consideration that the

subject sample was not balanced in terms of gender and varied in terms

of age, age was controlled in the main analysis, as well as gender.

Gagnon, Daelman, & McDuff DYSFUNCTIONAL BELIEFS 169

Measures

Personality Beliefs Questionnaire—Borderline Personality Subscale

(PBQ-BPD). The PBQ is a self-report questionnaire measuring beliefs

related to personality disorders (Beck et al., 2001). For the present study,

only the PBQ-BPD was used to measure beliefs related to borderline

psychopathology. This instrument was developed with 14 PBQ items,

rated on a 5-point Likert scale (0 to 4) that discriminated BPD patients

from others with personality disorders (Butler et al., 2002). A total score

(M=12.68; SD=9.02; α=.88) is obtained by summing the items. The

beliefs related to BPD measured by the questionnaire reflect dependency,

helplessness, distrust, rejection, abandonment, losing emotional control

and histrionic behavior.

UPPS Impulsive Behavior Scale. The UPPS Impulsive Behavior

Scale (Whiteside & Lynam, 2001) and its French version (Van der

Linden et al., 2006) are a 45-item self-report questionnaire that measures

impulsive behaviors according to dimensions of Negative Urgency

(M=26.22; SD=7.08; α=0.90), Lack of Premeditation (M=20.88;

SD=5.21; α=.86), Lack of Perseverance (M=18.50; SD=5.25; α=.87) and

Sensation Seeking (M=30.23; SD=7.69; α=.88; see definitions of each

dimension in the introduction), with each item describing a way of

behaving or thinking. Respondents indicate their degree of agreement or

disagreement with each item on a Likert scale ranging from 1 (strongly

agree) to 4 (strongly disagree).

The Borderline Symptoms List (BSL-23). The BSL-23 (Bohus et al.,

2009) is a questionnaire used to assess the degree of symptoms of BPD,

such as poor self-esteem, dysphoric emotions, suicidal intention and

impulsive behaviors. A total score for borderline symptoms (M=15.24;

SD=12.16; α=.91) is obtained by summing 23 items on a 5-point Likert

scale (0 to 4). This questionnaire was used in the present study to

statistically control for the effect of borderline symptomatology on

impulsivity traits (Whiteside et al., 2005).

Beck Depression Inventory (BDI-II). The BDI-II (Beck, Steer, &

Brown, 1996) is a self-report questionnaire comprising 21 items

measuring symptoms or manifestations of depression in adolescents and

adults. The symptoms are rated on a 4-point scale (0 to 3), each value

representing increasing levels of severity, and the questionnaire is scored

by summing the highest ratings for each symptom (M=10.32; SD=8.36;

α=0.90). A number of studies have investigated the psychometric

characteristics of the BDI-II through clinical and non-clinical populations

(for a review, see Steer & Beck, 2004).

Beck Anxiety Inventory (BAI). The BAI is a 21-item self-report

questionnaire measuring the manifestations and severity of anxiety (Beck

& Steer, 1993). Each of its symptoms is rated on a 4-point scale ranging

170 NORTH AMERICAN JOURNAL OF PSYCHOLOGY

from 0 to 3. The questionnaire is scored by summing the scores for each

item (M=10.51; SD=8.44; α=0.88). Psychometric characteristics have

been examined in several studies with clinical and non-clinical

populations (e.g. Beck & Steer, 1993; Kabacoff, Segal, Hersen, & Van

Hasselt, 1997; Osman, Barrios, Aukes, Osman, & Markway, 1993).

Along with the BDI-II, this questionnaire was used in the present study

to statistically control for the effect of depression and anxiety on

impulsivity traits, since they are generally related to impulsivity (Clark,

2006; Miller, Flory, Lynam, & Leukefeld, 2003; Steinberg et al., 2008;

Van der Linden et al., 2006).

RESULTS

Examination of the skewness and kurtosis statistics and their standard

error for each variables showed that, as expected with a sample

composed of undergraduate students, many clinical variables of the study

presented positively skewed distributions. Thus, square root data

transformations were performed on Negative Urgency, Lack of

Perseverance, BSL-23, BAI, and BDI-II scores. Moreover, only a

logarithmic data transformation on PBQ-BPD allowed obtaining a

normal distribution (Tabachnick & Fidell, 2001). After these

transformations, all the variables showed normal distributions: Negative

Urgency, BSL-23, PBQ-BPD and BAI by using Kolmogorov-Smirnov

test (p>.10) and Lack of Perseverance and BDI by using examination of

skewness and its standard error (Tabachnick & Fidell, 2001).

Table 1 presents Pearson correlations between age, depression (BDI-

II), anxiety (BAI), borderline personality disorder symptomatology

(BSL-23), dysfunctional beliefs associated with borderline personality

disorder (PBQ-BPD) and each UPPS dimension. Notably, Negative

Urgency showed significant correlations with all clinical variables

whereas Lack of Perseverance showed moderate positive correlations

with borderline beliefs and symptomatology as well as with depression

symptoms. However, Lack of Premeditation was only weakly correlated

to anxiety and none of the clinical variables were correlated to Sensation

Seeking.

Hierarchical multiple regression was used to assess the ability of the

dysfunctional beliefs measure (PBQ-BPD score) to predict Negative

Urgency, after controlling for age, gender, depression (BDI-II score),

anxiety (BAI score) and borderline symptoms (BSL-23 score; see Table

2). To test the specific relationship between dysfunctional beliefs and

Negative Urgency, the same hierarchical multiple regression was

conducted on Lack of Perseverance, given that it was the only other

subscale (besides Negative Urgency) on the UPPS Impulsive Behavior

Scale significantly correlated with PBQ-BPD. Preliminary analyses were

Gagnon, Daelman, & McDuff DYSFUNCTIONAL BELIEFS 171

conducted to ensure there was no violation of the assumptions of

normality, linearity, multicollinearity and homoscedasticity. Even though

there was a strong correlation between BDI-II and BSL-23, both

variables were included in the analysis as control measures, since

Variance Inflation Factors were in the acceptable range (under 4; ‘Brien,

2007).

To predict the Negative Urgency subscale, Step 1 involved entering

age, gender, BDI-II score and BAI score, since they are related to

impulsivity (Clark, 2006; Miller et al., 2003; Steinberg et al., 2008; Van

der Linden et al., 2006); these variables explained 30% of the variance in

Negative Urgency (R
2

adj=0.30). Then, in Step 2, since borderline

personality disorder symptomatology is specifically associated with

Negative Urgency (Whiteside et al., 2005), the BSL-23 score was

entered, bringing the explanation of the variance of Negative Urgency to

31% (R
2

adj=0.31). The BSL-23 score thus explained a significantly addi-

tional 1% of the variance of Negative Urgency (p<.05), after controlling

for age, gender, BDI score and BAI score. Finally, after the PBQ-

BPD

score was entered in Step 3 to verify the unique contribution of

borderline dysfunctional beliefs to Negative Urgency, the total variance

explained by the model as a whole was 38% (R
2

adj=0.38; F(6,142)=16.11,

TABLE 1 Correlations between Age, Depression, Anxiety, Borderline

Symptomatology, Borderline Dysfunctional Beliefs & UPPS Impulsivity

Age BDI-II BAI BSL-

23

PBQ-

BPD

UU Lpers Lprem

Age 1.0

BDI-II 0.03 1.0

BAI -0.22
**

0.64
***

1.0

BSL-23 -0.12 0.80
***

0.70
***

1.0

PBQ-

BPD -0.09 0.64
***

0.58
***

0.64
***

1.0

U -0.04 0.54
***

0.47
***

0.53
***

0.59
***

1.0

Lpers 0.02 0.30
***

0.15 0.34
***

0.24
**

0.38
***

1.0

Lprem 0.01 0.12 0.16
*
0.14 0.12 0.47

***
0.39

***
1.0

SS -0.02 0.11 0.01 0.11 0.07 0.25
**

0.11 0.38
***

*
p<.05;

**
p<.01;

***
p<.001; Beck Depression Inventory = BDI-II; Beck Anxiety Inventory =

BAI; Borderline Symptoms List = BSL-23; Personality Beliefs Questionnaire-Borderline

Personality Subscale = PBQ-BPD; Negative Urgency = U; Lack of Perseverance = Lpers;

Lack of Premeditation = Lprem; Sensation Seeking=SS; n=150.

172 NORTH AMERICAN JOURNAL OF PSYCHOLOGY

p<.001). The PBQ-BPD score thus explained a significantly additional

7.1% of the variance of Negative Urgency (p<.001), after controlling for

the BSL-23 score. In the final model, only the PBQ-BPD score was

statistically significant (β=0.37, p<.001).

To predict the Lack of Perseverance subscale, again age, gender,

BDI-II score and BAI score were entered in Step 1, explaining 7.5% of

the variance of Lack of Perseverance (R
2

adj=0.075). The BSL-23 score

was entered in Step 2, raising the explanation of the variance of Lack of

Perseverance to 11% (R
2

adj=0.11). The BSL-23 score thus explained a

TABLE 2 Multiple Regression on Negative Urgency

Beta (β) t p R
2

adj

Step 1 0.30

Age -0.012 -0.159 0.874

Gender 0.066 0.944 0.347

BDI-II 0.407 4.394 0.000
***

BAI 0.189 1.963 0.052
*

Step 2 0.31

Age 0.007 0.090 0.928

Gender 0.081 1.159 0.248

BDI-II 0.256 2.137 0.034
*

BAI 0.117 1.142 0.256

BSL-23 0.246 1.964 0.051
*

Step 3 0.38

Age 0.014 0.209 0.835

Gender 0.101 1.517 0.131

BDI-II 0.146 1.256 0.211

BAI 0.041 0.419 0.675

BSL-23 0.145 1.200 0.232

PBQ-

BPD 0.374 4.177 0.000
***

Note. R²=0.41; F(6,142)=16.110;
*
p<.05;

***
p<.001.

Gagnon, Daelman, & McDuff DYSFUNCTIONAL BELIEFS 173

significantly additional 3.5% of the variance of Lack of Perseverance

(p<.01), after controlling for age, gender, BDI score and BAI score.

Finally, after the PBQ-BPD score was entered in Step 3, the total

variance explained by the model as a whole was 10.5% (R
2

adj=0.105;

F(6,142)=3.90, p<.001). The PBQ-BPD score thus did not explain a

significant additional variance in Lack of Perseverance, after controlling

for the BSL-23 score. In the final model, only the BSL-23 score was

statistically significant (β=0.35, p<.05).

DISCUSSION

This is the first study that has demonstrated the unique contribution of

borderline dysfunctional beliefs to the prediction of the Negative

Urgency dimension of impulsivity, even after controlling for the effects

of age, gender, anxiety, depression and borderline symptomatology. In

addition, the results suggest that this contribution is specific to Negative

Urgency, compared to the other subscales on the UPPS Impulsive

Behavior Scale. The results provide evidence for a strong association

between Negative Urgency and borderline personality features

(Whiteside et al., 2005) and suggest that core beliefs reflecting themes of

dependency, helplessness, distrust, fears of rejection/abandonment/losing

emotional control and extreme attention-seeking behavior (Butler et al.,

2002) are associated with the tendency to act rashly in situations of

negative emotions independently of negative emotions such as anxiety,

depression or those found in borderline symptomatology. Previous data

have indicated that Negative Urgency and Lack of Premeditation are two

specific facets of impulsivity which were associated with overall BPD

features in undergraduate students, even while controlling for variance

explained by affective instability (Tragesser & Robinson, 2009).

Following this line of data, Negative Urgency could be understood as a

tendency to act rashly to rid oneself of intense negative emotions, but

such actions are most likely influenced by cognitive processes that lead

the individual to believe pre-emptive action is needed for self-protection.

In the current analysis, dysfunctional beliefs were associated with

Lack of Perseverance, but this association was no longer significant after

controlling for the effects of age, gender, depression, anxiety and

borderline psychopathology. Moreover, these beliefs have no relationship

with the two other subscales on the UPPS Impulsive Behavior Scale.

Considering that Negative Urgency and Lack of Premeditation are both

associated with borderline personality traits (Tragesser & Robinson,

2009), it could be expected that Lack of Premeditation would also relate

to dysfunctional beliefs associated with borderline personality disorder.

Perhaps Negative Urgency relates to borderline personality traits through

executive dysfunctions as well as the activation of dysfunctional beliefs

174 NORTH AMERICAN JOURNAL OF PSYCHOLOGY

that impulsive behavior is needed to rid oneself of intense negative

emotions, whereas Lack of Premeditation only relates to borderline

personality traits through executive dysfunctions and non-planning

impulsiveness (van Reekum et al., 1996).

In our previous study (Gagnon et al., 2013) examining the

relationships between cognitive distortions, childhood maltreatment and

the four dimensions of impulsivity from the UPPS Impulsive Behavior

Scale, analyses revealed that a group of cognitive distortions, the

Premature Processing group, was the best predictor of Negative Urgency,

along with childhood maltreatment, above and beyond gender and the

other subscales on the UPPS Impulsive Behavior Scale. In the current

study, regression analyses revealed that borderline dysfunctional beliefs

significantly predicted Negative Urgency even after controlling for age,

gender, depression, anxiety and borderline personality disorder

symptomatology. On the whole, these results are consistent with the idea

that Negative Urgency is associated with several cognitive vulnerabilities

in affect regulation.

Emotion has been considered to serve a primary role in the

production of dysfunctional impulsive behavior. According to Cyders

and Smith’s (2008) model, individual differences in Negative Urgency

trait can be identified in the relationship between emotion and behavior.

Cyders and Smith consider emotions to have adaptive value in helping us

identify our needs and the actions required to satisfy them. In addition,

more intense needs are thought to be accompanied by equally more

intense emotions, leading the individual to concentrate even more on the

immediate situation (e.g., to avoid an imminent threat) and to adopt more

extreme adaptive behavioral strategies to act on the situation (e.g., run

away). This reasoning implies: (a) that strong emotions will diminish

cognitive resources such as decision-making and the ability to anticipate

the long-term consequences of actions, and (b) that some individuals

might adopt dysfunctional behavioral strategies to regulate intense

emotions. Adopting such maladjusted strategies could lead the individual

to take impulsive actions that are increasingly likely to be repeated

because of reinforcement either from reduced negative affects (Negative

Urgency) or increased positive affects (Positive Urgency).

At the theoretical level, the findings of our two studies suggest that

Beck’s cognitive model is a useful framework to better understand

certain cognitive processes underlying the Negative Urgency dimension

of impulsivity. Moreover, our research suggests that dysfunctional

cognitive processes, and not necessarily emotional intensity as it is

conceived by Cyders and Smith (2008), contribute to Negative Urgency

trait. Independently from the intensity of negative emotion, we postulate

that these cognitive processes associated with the Negative Urgency trait

Gagnon, Daelman, & McDuff DYSFUNCTIONAL BELIEFS 175

make an individual more prone to reacting strongly to socio-affective

stimuli and to adopting ineffective affect-regulation strategies, leading to

impulsive reactions under those types of conditions. Indeed, this

dimension would be associated with cognitive distortions such as

Premature Processing distortions resulting from control schemas

comprised of dysfunctional beliefs about the self as helpless and others

as untrustworthy, and the need to act pre-emptively to avoid threat. These

errors of reasoning arising from dysfunctional beliefs activated in an

emotional context could cause some automatic thoughts that produce an

intense emotional response (e.g., emotional reasoning) and other

automatic thoughts that weaken the information processing required for

affective and behavioral regulation. As in Beck’s model, the Negative

Urgency dimension could be conceived as dysfunctional strategies for

adjusting to painful emotions arising from dysfunctional cognitive

processes. These strategies are maintained and reinforced by reducing

negative affect, regardless of any potential consequences or risk of

injury. In short, Beck’s model appears to complement Cyders and

Smith’s model of the Urgency dimension. Indeed, the neurological

emotion-based dispositions underlying Urgency could lead to the

development of dysfunctional control schemas. These schemas would

produce cognitive distortions that, in addition to increasing the intensity

of affects, would lower tolerance for delayed gratification and encourage

decision-making to obtain immediate affective relief with no

consideration of long-term negative consequences. However, in contrast

to Cyders’ and Smith’s (2008) conception, Beck’s model focuses more

on cognitive processes which take precedence over the intensity of

emotional reactions in the dynamics of impulsive behaviors associated

with Negative Urgency. Further research is needed to identify the

specific manner in which the cognitive processes and dysfunctional

beliefs underlying the Negative Urgency dimension function.
The present study has limitations. First, further research is needed to

explore the extent to which our findings apply to other populations.

Because our sample consisted of undergraduate students, the majority of

whom were female, the generalizability of the conclusions to other non-

clinical populations is constrained. Also, the small size of our sample

lessens the statistical power of some of the analyses, and the present

correlational study design precludes any conclusions on causal

relationships between dysfunctional beliefs and UPPS dimensions.

Finally, it would be useful to investigate cognitive distortions and

dysfunctional beliefs together in a single study to better understand their

respective roles and how these factors interact with each other when an

individual acts on impulses in the context of negative affects.

176 NORTH AMERICAN JOURNAL OF PSYCHOLOGY

The study’s findings contribute conceptually to the current literature

by indicating that Negative Urgency trait is associated with borderline

dysfunctional beliefs. Indeed, dysfunctional beliefs can make an

individual more prone to reacting strongly to socio-affective stimuli and

to adopting ineffective affect-regulation strategies.

REFERENCES

Beck, A.T. (2005). The current state of cognitive therapy: A 40-year

retrospective. Archives of General Psychiatry, 62, 953-959.

Beck, A.T., Butler, A.C., Brown, G.K., Dahlsgaard, K.K., Newman, C.F., &

Beck, J. (2001). Dysfunctional beliefs discriminate personality disorders.

Behaviour Research and Therapy, 39, 1213-1225.

Beck, A.T., & Dozois, D.J.A. (2011). Cognitive therapy: Current status and

future directions. Annual Review of Medicine, 62, 397-409.

Beck, A.T., Freeman, A., & Davis, D.D. (2004). Cognitive therapy of personality

disorders (2nd ed.). New York: The Guilford Press.

Beck, A.T., & Steer, R. A. (1993). Beck Anxiety Inventory. San Antonio:

Harcourt Brace & Company.

Beck, A.T., Steer, R.A. , & Brown, G.K. (1996). Manual for the Beck Depression

Inventory-II. San Antonio, TX: Psychological Corporation.

Bhar, S.S., Brown, G.K., & Beck, A.T. (2008). Dysfunctional beliefs and

psychopathology in borderline personality disorder. Journal of Personality

Disorders, 22(2), 165-177.

Bohus, M., Kleindienst, N., Limberger, M.F., Stieglitz, R.D., Domsalla, M., &

Chapman, A. L. (2009). The short version of the Borderline Symptom List

(BSL-23): Development and initial data on psychometric properties.

Psychopathology, 42, 32-39.

Brown, G. K., Newman, C. F., Charlesworth, S. E., Crits-Christoph, P., & Beck,

A. T. (2004). An open clinical trial of cognitive therapy for borderline

personality disorder. Journal of Personality Disorders, 18(3), 257-271.

Butler, A.C., Brown, G.K., Beck, A.T., & Grisham, J.R. (2002). Assessment of

dysfunctional beliefs in borderline personality disorder. Behaviour Research

and Therapy, 40, 1231-1240.

Butler, A.C., Chapman, J.E., Forman, E.M., & Beck, A.T. (2006). The empirical

status of cognitive-behavioral therapy: A review of meta-analyses. Clinical

Psychology Review, 26(1), 17-31.

Clark, D. (2006). Impulsivity as a mediator in the relationship between

depression and problem gambling. Personality and Individual Differences,

40(1), 5-15.

Cyders, M.A., & Smith, G.T. (2008). Emotion-based dispositions to rash action:

Positive and negative urgency. Psychological Bulletin, 134, 807-828.

d’Acremont, M., & Van der Linden, M. (2005). Adolescent impulsivity: Findings

from a community sample. Journal of Youth and Adolescence, 34(5), 427-

435.

Fortune, E.E., & Goodie, A.S. (2012). Cognitive distortions as a component and

treatment focus of pathological gambling: A review. Psychology of Addictive

Behaviors, 26, 298-310.

Gagnon, Daelman, & McDuff DYSFUNCTIONAL BELIEFS 177

Gagnon, J., Daelman, S., McDuff, P., & Kocka, A. (2013). UPPS dimensions of

impulsivity: Relationships with cognitive distortions and childhood

maltreatment. Journal of Individual Differences, 34, 48-55.

Ivanoff, A, Linehan, Marsha M., & Brown, M. (2001). Dialectical behavior

therapy for impulsive self-injurious behaviors. In D. Simeon & E. Hollander

(Eds.), Self-injurious behaviors: Assessment and treatment (pp. 149-174).

Washington, DC: American Psychiatric Publishing.

Kabacoff, R. I., Segal, D. L., Hersen, M., & Van Hasselt, V. B. (1997).

Psychometric properties and diagnostic utility of the Beck Anxiety Inventory

and the State-Trait Anxiety Inventory with older adult psychiatric outpatients.

Journal of Anxiety Disorders, 11(1), 33-47.

Miller, J., Flory, K., Lynam, D., & Leukefeld, C. (2003). A test of the four-factor

model of impulsivity-related traits. Personality and Individual Differences,

34(8), 1403-1418.

Mobini, S., Grant, A., Kass, A.E., & Yeoman, M.R. (2007). Relationships

between functional and dysfunctional impulsivity, delay discounting and

cognitive distortions. Personality and Individual Differences, 43, 1517-1528.

Mobini, S., Pearce, M., Grant, A., Mills, J., & Yeoman, M.R. (2006). The

relationship between cognitive distortions, impulsivity and sensation seeking

in a non-clinical population sample. Personality and Individual Differences,

40, 1153-1163.

Moeller, F., Barratt, E.S., Dougherty, D.M., Schmitz, J.M., & Swann, A.C.

(2001). Psychiatric aspects of impulsivity. The American Journal of

Psychiatry, 158(11), 1783-1793.

O’Brien, R.M. (2007). A caution regarding rules of thumb for variance inflation

factors. Quality and Quantity, 41, 673-690.

Osman, A., Barrios, F.X., Aukes, D., Osman, J.R., & Markway, K. (1993). The

Beck Anxiety Inventory: Psychometric properties in a community population.

Journal of Psychopathology and Behavioral Assessment, 15, 287-297.

Patton, J.H., Stanford, M.S., & Barratt, E.S. (1995). Factor structure of the

Barratt Impulsiveness Scale. Journal of Clinical Psychology, 51(6), 768-774.

Steer, R. A., & Beck, A. T. (2004). The Beck Depression Inventory-II. In W. E.

Craighead & C. B. Nemeroff (Eds.), The concise Corsini encyclopedia of

psychology and behavioral science (3rd ed., pp. 104-105). New York: Wiley.

Steinberg, L., Dustin, A., Cauffman, E., Banich, M., Graham, S., & Woolard, J.

(2008). Age differences in sensation seeking and impulsivity as indexed by

behavior and self-report: Evidence for a dual systems model. Developmental

Psychology, 44(6), 1764-1778.

Tabachnick, B.G., & Fidell, L.S. (2001). Using mutivariate statistics (4th ed.).

Needham, Heights: Allyn and Bacon.

Tragesser, S.L., & Robinson, J. (2009). The role of affective instability and UPPS

impulsivity in borderline personality disorder features. Journal of Personality

Disorders, 23(4), 370-383.

Trull, T.J. (1995). Borderline personality disorder features in nonclinical young

adults: 1. Identification and validation. Psychological Assessment, 7(1), 33-

41.

Van der Linden, M., d’Acremont, M., Zermatten, A., Jermann, F., Laroi, F.,

Willems, S., Bechara, A. (2006). A French adaptation of the UPPS Impulsive

178 NORTH AMERICAN JOURNAL OF PSYCHOLOGY

Behavior Scale: Confirmatory factor analysis in a sample of undergraduate

students. European Journal of Psychological Assessment, 22(1), 38-42.

van Reekum, R., Links, P.S., Finlayson, M., Boyle, M., Boiago, I., & Ostrander,

L.A. (1996). Repeat neurobehavioral study of borderline personality disorder.

Journal of Psychiatry & Neuroscience, 21(1), 13-20.

Whiteside, S.P., & Lynam, D.R. (2001). The Five Factor Model and impulsivity:

Using a structural model of personality to understand impulsivity. Personality

and Individual Differences, 30, 669-689.

Whiteside, S.P., & Lynam, D.R. (2003). Understanding the role of impulsivity

and externalizing psychopathology in alcohol abuse: Application of the UPPS

Impulsive Behavior Scale. Experimental and Clinical Psychopharmacology,

11(3), 210-217.

Whiteside, S.P., Lynam, D.R., Miller, J.D., & Reynolds, S.K. (2005). Validation

of the UPPS impulsive behaviour scale: A four-factor model of impulsivity.

European Journal of Personality, 19(7), 559-574.

Acknowledgements: We wish to express our appreciation to the Centre for

Interdisciplinary Research in Rehabilitation of Greater Montreal for its support

during the research. This study was supported by a research grant to JG from the

Fonds de recherche sur la société et la culture (FQRSC).

Copyright of North American Journal of Psychology is the property of North American Journal of Psychology

and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright

holder’s express written permission. However, users may print, download, or email articles for individual use.

Archives of Psychiatry and Psychotherapy, 2013; 1 : 55–60

lyane Trepanier1, John Christopher Perry2, Annett Koerner1,2,

C o n s t a n t i n a S t a m o u l o s 1, A m a n d a S h e p t y c k i 1, M a r t i n
drapeau1,3: 1 Counselling Psychology, McGill University; 2 Institute
of Community and Family Psychiatry, Sir Mortimer B. Davis Jew-
ish General hospital; 3 Department of Psychiatry, McGill Universi-
ty. Correspondence address: Martin Drapeau, MPPRG – McGill
University, 3700 McTavish, Montreal, Quebec, h3A 1Y2, Canada.
E-mail: martin.drapeau@mcgill.ca
This research report has been aided by the Social Sciences and
humanities Research Council of Canada

A study of the similarity between three models of
interpersonal functioning of patients with borderline
personality disorder. Submitted as a brief research
report

Lyane Trepanier, John Christopher Perry, Annett Koerner, Constantina
Stamoulos, Amanda Sheptycki, Martin Drapeau

Summary
Dysfunctional interpersonal patterns are a defining feature of Borderline Personality Disorder (BPD).
A number of studies have aimed to determine if there are specific patterns in the interpersonal functioning
of patients with BPD. The vast majority of these studies have used a widely-used rating system called the
Core Conflictual Relationship Theme method [1]. To date, three main models of interpersonal functioning
of patients with BPD have been developed using the CCRT [2, 3] including one model developed by our
team [4]. The aim of this study was to examine to what extent these three empirically-derived models of
interpersonal functioning in patients with BPD overlap.

borderline personality disorder / core conflictual relationship theme / CCrT / BPd / personality
disorders / Interpersonal Functioning

Borderline personality disorder (BPD) is char-
acterized by significant and pervasive impair-
ment in interpersonal functioning [5]. Indeed,
studies have shown that a diagnosis of BPD can
be established with near-perfect certainty based
on two features: identity disturbance and inten-
se and unstable relationships [6, 7, 8]. Proposed
amendments to the diagnostic criteria for BPD in
the DSM-V also specify that a person must have
significant impairment in ‘personality function-
ing in relation to self’ and impairments in ‘inter-
personal functioning’ [9]. The ‘self’ is described
as how patients perceive themselves and how

they identify and venture toward their goals in
daily life. The criteria for ‘interpersonal func-
tioning’ relates to how well the patient under-
stands the viewpoint of another [9].

Interpersonal functioning is therefore a key de-
terminate for the diagnosis of BDP. However, re-
searchers have moved beyond determining that
patients with BPD have impaired interpersonal
functioning; they have also attempted to identi-
fy interpersonal templates or patterns that dis-
tinguish patients with BPD from other patients.
A number, if not most of these studies did so
using the Core Conflictual Relationship Theme
(CCRT) method [10, 11], a widely-used system
to rate and document the interpersonal function-
ing of individuals. The rating process begins by
soliciting narratives referred to as relationship
episodes from the research participants or pa-
tients, then transcribing these narratives ver-
batim. These transcriptions are then rated by
trained raters on three components defined in
the CCRT method: the Wish, the Response from

56 Lyane Trepanier et al.

Archives of Psychiatry and Psychotherapy, 2013; 1 : 55–60

Other (RO), and the Response from Self (RS). A
“Wish” is defined by Luborsky and Crits-Chris-
toph [1] as any expression of desire, need, or in-
tention expressed by the patient. An RO refers to
statements describing how the other person re-
sponded or reacted to the patient’s Wish [6]. Fi-
nally, RS statements include the thoughts, feel-
ings, and reactions the patient had as an out-
come to the other person’s response. For each of
the three components (Wish, RO, and RS), the
method describes eight clusters that each reflect
different behaviors, feelings or thoughts (see
Tab. 1 – next page).

In a first CCRT-based study, Chance and col-
leagues [2] investigated the interpersonal pat-
terns of 11 patients with BPD with a history of
suicidal attempts and 11 individuals with BPD
with no history of suicidal behavior (see Tab.
1). Results showed that patients with BPD who
were hospitalized for suicide attempts generally
had similar relationship patterns as those with
no history of a suicide attempt. Chance and col-
leagues [2] found that in interpersonal situations,
the most prevalent wish of patients with BPD
was a wish to be loved and understood (Wish
Cluster 6). The second most prevalent wish was
a wish to be close and accepting of others (Wish
Cluster 5). The most prevalent RO (Response of
Other) cluster was RO-5 (others are rejecting and
opposing), followed by RO-7 (others like me).
For the Response of Self component, the most
prevalent was RS-7 (I feel disappointed and de-
pressed), and RS-2 (I am unreceptive).

In a second study, Diguer and colleagues [3]
investigated differences between psychotic, bor-
derline, and neurotic personality organizations
(POs), as defined by Kernberg [12, 13]. A total of
120 participants were assigned to each of the three
PO groups; the Psychotic group (n = 20) group in-
cluded schizoid, schizotypal, and paranoid sub-
types; the Borderline group (n = 31) included nar-
cissistic, dependent, passive-aggressive, infan-
tile, borderline and antisocial subtypes; and the
Neurotic group (n = 31) included masochistic-de-
pressive, obsessive-compulsive disorder, hyster-
ical subtypes, and an absence of BPD character-
istics. The two most prevalent wishes in the BPO
group were a wish to be distant and avoid con-
flict (W-4) and a wish to be loved and understood
(W-6). The most prevalent responses from other
were rejection and opposition (RO-5) and others

getting upset (RO-3). In interpersonal situations,
patients with a BPO most often ended up feeling
disappointed and depressed (RS-7) and anxious
and ashamed (RS-8).

More recently, we [14, 15] examined the nar-
ratives from a total of 158 patients, 77 of whom
had a diagnosis of BPD (see also [4]; Tab. 1). The
remaining 81 patients had been diagnosed with
other personality disorders. Like in the previous
two studies, the CCRT method was employed to
score the relationship episodes described in the
participants’ narratives. The results showed that
patients with BPD wished to be loved and un-
derstood (Wish-6) but also wished to be distant
from others and to avoid conflicts (Wish-4) in in-
terpersonal situations. For the Response of Oth-
ers (RO) component, RO-5 (others are rejecting
and opposing) and RO-8 (others are understand-
ing) were most prevalent. For the Response of
Self component of the CCRT, the most prevalent
were RS-7 (I am disappointed and depressed)
and RS-8 (I am anxious and ashamed [15].

While our model led to a number of follow-
up studies that aimed to further examine the in-
terpersonal functioning of patients with BPD
[14, 16, 17] , the question remained as to how
this model was comparable to those of Chance
and colleagues [2] and of Diguer and colleagues
[3]. Indeed, given a number of differences in the
findings of the three research teams, it is im-
portant to determine to what extent our model
is comparable to the other two models. Failing
to find similarities between our model and the
models of Chance and Diguer could indicate not
only differences in the samples used or possible
differences in the use of the CCRT method, but
also that there is more randomness in the inter-
personal functioning of patients with BPD than
previously. Hence, this study aimed to examine
how the model proposed by Drapeau and col-
leagues [4] is correlated with those of Chance
and colleagues [2] and Diguer and colleagues
[3]. This study also examined if the latter two
models are correlated.

METHOd

A complete description of the three studies ex-
amined here, the samples, and the CCRT meth-
od can be found in the original material of the
three research teams [2, 3, 4, 14, 16, 18, 19].

A study of the similarity between three models of interpersonal functioning of patients 57
with borderline personality disorder

Archives of Psychiatry and Psychotherapy, 2013; 1 : 55–60

chance et al. [2] diguer et al. [3] drapeau et al. [4]

cluster

Mean

%
rank

within

c.i. ?

Mean
%
rank
within
c.i. ?
Mean
%
rank

w 1. To assert and

be independent
9.2 6 n.a. 7 n.a. 10.7 5

w 2. To oppose, hurt

and control others
4.0 7 n.a. 6 n.a. 5.1 7

w 3. To be

controlled, hurt, not

responsible

18.1 3

n.a. 8 n.a. 5.2 6

w 4. To be distant

and avoid conflict
10 4

n.a. 1 n.a. 20.4 2

w 5. To be close and

accepting
19.5 2 n.a. 3.5 n.a. 20 3

w 6. To be loved

and understood
27.3 1

n.a. 2 n.a. 23.5 1

w 7. To feel good

and comfortable
9.7 5

n.a. 5 n.a. 3.9 8

w 8. To achieve and

help others

2.2

8 n.a. 3.5 n.a. 11.2 4

Spearman

between drapeau [4]

and …

0.52 .76**

ro 1. Strong 1 8

n.a. 8 n.a. 3.8 8

ro 2. controlling 5.3 5 n.a. 7 n.a. 7 6

ro 3. upset 12.2 3 n.a. 2 n.a. 13.1 3

ro 4. Bad 5 6 n.a. 5 n.a. 3.9 7

ro 5. rejecting and

opposing
54 1

n.a. 1 n.a. 36.8 1

ro 6. helpful 5.6 4

n.a. 6 n.a. 13 4

ro 7. likes me 12.6 2

n.a. 3 n.a. 9 5

ro 8. understanding
4.3

7

n.a. 4 n.a. 13.4 2

Table 1. Wish, RO, and RS Cluster distributions according to Drapeau et al. [4], Chance et al. [2], and Diguer et al. [3]:
Mean %, Rank ordering, Confidence Intervals, and Correlations

table continued on next page

58 Lyane Trepanier et al.

Archives of Psychiatry and Psychotherapy, 2013; 1 : 55–60

Spearman

between drapeau [4]

and …

0.57 .79**

rS 1. helpful 9.2 4

n.a. 5 n.a. 6 7

rS 2. unreceptive 14.4 2

n.a. 6 n.a. 9.2 5

rS 3. respected and

accepted
7.5 6

n.a. 3.5 n.a. 15.5 3

rS 4. oppose and

hurt other
6.6 7 n.a. 7 n.a. 7 6

rS 5. Self-controlled

and self-confident
3.5 8

n.a. 8 n.a. 5.6 8

rS 6. helpless 10.4 3

n.a. 3.5 n.a. 13.7 4

rS 7. disappointed

and depressed
40.5 1

n.a. 1 n.a. 26.5 1

rS 8. anxious and

ashamed
7.9 5

n.a. 2 n.a.

16.5

2

Spearman
between drapeau [4]
and …

0.55 .93***

Spearman correlations were used to examine
to what extent our model is correlated with the
other two models. Although Diguer and colla-
borators [3] did not report relative frequencies
for each CCRT cluster, they provided sufficient
information for us to rank order the different
CCRT Clusters, hence making the use of Spear-
man correlations possible. Chance and collea- Chance and collea-Chance and collea-
gues [2] did report the percentage of subjects
presenting each component. The relative fre-
quency for each component was calculated in
order to compare our model with theirs. As rank
ordering was now possible, both Spearman and
Pearson correlations were used to determine
how Chance’s model was correlated with ours.
Chance and colleagues also reported sufficient
data for us to examine confidence intervals at
the 95% level.

rESUlTS

For the Wish Clusters, our findings correlat-
ed significantly with Diguer’s findings, rSpearman
=0.76, p=0.01 (see Tab. 1), but not with Chance’s
model, with rSpearman=0.52, p=0.09 and rPearson=0.55,
p=0.07. However, the mean percentages of Wish
Clusters 1, 2, and 5 proposed by Chance fell
within the confidence intervals derived from our
data. For the Wish Clusters, Diguer and Chance’s
models were not significantly correlated
(rSpearman= 0.29, p=0.25). Results were similar for
the RO Clusters. Spearman correlations showed
that our model is significantly correlated with
Diguer ’s (rSpearman=0.79, p=0.01). A trend was
found when correlating our model with Chance
and colleagues’ model (rSpearman=0.57, p=0.07).
When comparing relative means of the RO Clus-

p value < *0.05; **0.01; ***0.001; N.A. = not available; C.I. = confidence interval within 95% . The clusters were rank ordered based on mean %.

A study of the similarity between three models of interpersonal functioning of patients 59
with borderline personality disorder

Archives of Psychiatry and Psychotherapy, 2013; 1 : 55–60

ters, our model and Chance’s model, though not
found to be correlated using the Spearman’s co-
efficient, were highly correlated using the Pear-
son coefficient (rPearson=0.94, p = 0.001) with RO
Clusters 2, 3, and 4 falling within our confi-
dence intervals. Diguer’s and Chance’s models
were also significantly correlated (rSpearman=0.76,
p=0.01).

For the RS Clusters, our model correlated high-
ly with Diguer’s model (rSpearman=0.92, p=0.001).
A trend was found with Chance’s model (rSpear-
man= 0.55, p=0.08). When comparing mean per-
centages per se, the findings for our Cluster
distributions were not significantly correlated
with Chance’s model using the Spearman coeffi-
cient, but were highly correlated using Pearson’s
(rPearson=0.80, p=0.01), with RS Cluster 4 falling
within our confidence intervals. Diguer and
Chance’s models were also significantly corre-
lated (rSpearman=0.61, p=0.05).

dISCUSSION

Our findings for the CCRT Wish Cluster dis-
tribution generally matched Diguer ’s [3] and
Chance’s [2] findings. The Wish “to be loved and
understood” was the most prevalent cluster for
both Drapeau [4] and Diguer [3], and was the
second most prevalent cluster for Chance and
colleagues [2]. The Wish “to be distant and avoid
conflict” was also among the top two most prev-
alent clusters for Drapeau [4] and Diguer [3].
The overall cluster rankings between Drapeau
[4] and Diguer [3] were significantly correlated,
suggesting that both models corroborate one an-
other. Interestingly, the two most prevalent Wish
clusters identified in the narratives of patients
with BPD were contradictory in nature, that is
the Wish “to be loved and understood” is op-
posite in nature to the Wish to be “distant and
avoid conflict,” the latter suggesting a retreat
from the interaction. These inconsistent Wish
patterns are believed to lead to the communica-
tion of mixed messages between patients with
BPD and significant others, which in turn may
contribute to unstable relationships [6, 7, 20].

For the Response of Others (RO) Clusters,
“others are rejecting and opposing” was found
to be the most prevalent response of others in all
three models. This is consistent with the research

of Gunderson and others [7, 8] who reported
that sensitivity to rejection is an important el-
ement to the interpersonal phenotype associat-
ed with BPD. Although there were no matches
found for the second most prevalent ROs among
any the studies, the overall rankings for the Dra-
peau [4] and the Diguer [3] studies were signif-
icantly correlated.

Finally, the Response of Self “I am disappoint-
ed and depressed” (RS-7) was the most prevalent
across all three models. A match for the second
most prevalent cluster “anxious and ashamed”
was also found between Drapeau [4] and Diguer
[3]. These findings are congruent with the work
of Kernberg [13] who identified characteristics
such as narcissism, shame, anxiety, and fear of
potential abandonment, to be contributing ele-
ments shaping borderline functioning. It is pos-
sible that Responses of Self involving anxiety
and shame are the results of others being (RO)
“rejecting and opposing” which in turn lead to
the Wish to “be distant and avoid conflict,” thus
leaving them with the unanswered Wish to “be
loved and understood.”

These findings are also generally congruent
with a number of follow-up studies examining
different aspects of the interpersonal function-
ing of patients with BPD. For example, Drapeau
and Perry [14] investigated whether the interper-
sonal patterns of patients with BPD were differ-
ent from those found in individuals with oth-
er personality disorders. The researchers found
that the former expressed more “wishes to be
distant” and to “be like others,” as well as more
wishes to “to be hurt by others,” than patients
diagnosed with other personality disorders. Pa-
tients with BPD had a higher tendency to per-
ceive others as controlling and bad [8]. Patients
with BPD were also shown to be less open and
helpful than those diagnosed with a personali-
ty disorder other than BPD [16]. The same study
showed that BPDs were less self-confident than
non-BPDs [16]. Other significant group differ-
ences included: patients with BPD having more
wishes to be distant, being less open, and ROs
that were generally more negative, when com-
pared to the patients with other personality dis-
orders. Finally, consistent with Chance and col-
leagues [2], patients with BPD reported others
as controlling significantly more often than pa-
tients with other Axis II disorders.

60 Lyane Trepanier et al.

Archives of Psychiatry and Psychotherapy, 2013; 1 : 55–60

8. Gunderson J, Lyons-Ruth K. BPD’s interpersonal hypersen-
sitivity phenotype: A gene environment transactional model.
J Pers Disord. 2008; 22(1): 22–41.

9. American Psychiatric Association DSM-5 Development.
DSM-5 Revisions for Personality Disorders Reflect Major
Change APA News Release [Internet]. [updated: 2011 July
7; cited: 2011 release No. 11-36]. Available from: http://
www.dsm5.org/Newsroom/Documents/DSM-5-Revisions-
for-Personality-Disorders-Reflect-Major-Change-

10. Barber JP, et al. A comparison of core conflictual relationship
themes before psychotherapy and during early sessions. J
Consult Clin Psych. 1995; 63(1): 145–148.

11. Luborsky L, Crits-Christoph P. Understanding transference;
The Core Conflictual Relationship Theme method. Ameri-
can Psychological Association: Washington, DC, US; 1998.
p. 379.

12. Kernberg OF. Severe personality disorders: Psychotherapeu-
tic strategies, New haven, CT: Yale University Press. 1984.

13. Kernberg OF. A psychoanalytic theory of personality disor-
ders. Major theories of personality disorder, New York: Guil-
ford Press. 1996.

14. Drapeau M, Perry JC. The core conflictual relationship
themes (CCRT) in Borderline Personality Disorder. J Pers
Disord. 2009; 23(4): 425–431.

15. Drapeau M, Perry JC, Lefebvre R. An examination of core
conflictual relationship theme components in adults with BPD
in Society for Psychotherapy Research (SPR) International
Metting, Montevideo, Uruguay. 2001.

16. Drapeau M, Perry JC, Koerner A. Interpersonal behaviours
and BPD. Are specific interpersonal behaviours related to
borderline personality disorder? An empirical sutdy using the
Core Conflictual Relationship Theme standard. Archives of
Psychiatry and Psychotherapy. 2010; 3: 5–10.

17. Drapeau M, Perry JC. Interpersonal conflicts in borderline
personality disorder: An exploratory study using the CCRT-
LU. Swiss J Psychol. 2004; 63(1): 53–57.

18. de Roten Y, et al. Yet another look at the CCRT: The relation
between core conflictual relationship themes and defensive
functioning. Psychother Res. 2004; 14(2): 252–260.

19. Drapeau M, Perry JC, Koerner A. An Empirical Examination
of Three Models of the Interpersonal Functioning of Patients
with Borderline Personality Disorder. Psychiatry: Interperson-
al and Biological Processes. 2009; 72(2): 143–153.

20. Gunderson J. Borderline personality disorder. Washington
DC: American Psychiatric Press. 1984.

The findings for the models presented in
our study, using the CCRT method, appear to
be generally robust. Our earlier findings (Dra-
peau [4]) matched those of Diguer [3]. Howev-
er, it appears that our model was slightly less
convergent with Chance and colleagues’ mod-
el [2], possibly because of the small sample size
in this latter study. Although the CCRT method
is a widely accepted tool for clinical research on
interpersonal behaviors, the method does have
some limitations. For instance, the focus of the
CCRT method is the interpersonal patterns ex-
pressed by respondents within a therapeutic set-
ting. It is presumed that within the therapeutic
setting, a kind of “snapshot” into the patient’s
behaviors outside of therapy can be obtained.
Also, one cannot accurately assess the possible
meaning of an intention or a behavior without
considering the context. The present study does
demonstrate some convergence between differ-
ent models on key factors.

rEFErENCES

1. Luborsky L, Crits-Christoph P. Understanding transference:
The Core Conflictual Relathionship Theme. Basic Books:
New York, NY. 1990.

2. Chance SE, et al. Core conflictual relationship themes in pa-
tients diagnosed with borderline personality disorder who at-
tempted, or who did not attempt, suicide. Psychother Res.
2000; 10(3): 337–355.

3. Diguer L, et al. The core conflictual relationship theme of
psychotic, borderline, and neurotic personality organizations.
Psychother Res. 2001; 11(2): 169–186.

4. Drapeau M, et al. The interpersonal functioning of individu-
als diagnosed with borderline personality disorder: A review
of existing empirical models and suggestions for a new mod-
el, in Canadian Psychological Association 70th Annual Con-
vention. Montreal, Canada. 2009.

5. Diagnostic and Statistical Manual of Mental Disorders. 4th,
Text Revision ed2000, Washington, DC. American Psychiat-
ric Association.

6. Clarkin JF, et al. Evaluating three treatments for borderline
personality disorder: a multiwave study. Am J Psychiat. 2007;
164: 922–928.

7. Gunderson JG. Disturbed relationships as a phenotype for
borderline personality disorder. Am J Psychiat. 2007; 164(11):
1637–1640.

Copyright of Archives of Psychiatry & Psychotherapy is the property of Editorial Committee of Polish

Psychiatric Association and its content may not be copied or emailed to multiple sites or posted to a listserv

without the copyright holder’s express written permission. However, users may print, download, or email

articles for individual use.

REVIEW

Implications of Long-term Outcome Research
for the Management of Patients with

Borderline Personality Disorder

Joel Paris, MD

Fifteen- and 27-year follow-up studies of patients with borderline personality disorder show
that most of them no longer meet full criteria for the disorder by age 40, and that even more
show improvement by age 50. The mechanisms behind remission could include matura-
tion, social learning, and the avoidance of conflictual intimacy. Affective instability is slower
to change than impulsivity. Suicide rates in patients with this disorder are close to 10%, with
most completions occurring late in the course of illness; early mortality from all causes
exceeds 18%. All of these findings have clinical implications. Although treatment effects
must be assessed in the context of naturalistic improvement, therapy can hasten remission.
(HARVARD REV PSYCHIATRY 2002;10:315–323.)

From the Department of Psychiatry, McGill University, and the In-
stitute of Community and Family Psychiatry, Sir Mortimer B. Davis–
Jewish General Hospital, Montreal, Quebec, Canada.

Original manuscript received 14 March 2002; revised manuscript re-
ceived 2 May 2002, accepted for publication 9 May 2002.

Reprint requests: Joel Paris, MD, Institute of Community and
Family Psychiatry, Sir Mortimer B. Davis–Jewish General Hospital,
4333 Chemin de la Côte Ste. Catherine, Montréal, Québec H3T1E4,
Canada.

© 2002 President and Fellows of Harvard College

315

Borderline personality disorder (BPD) has long been known
to be a chronic condition.1 The purpose of this paper is to eval-
uate treatment for BPD in light of its course, as shown by
studies following patients for 15 years or more. If remission
(i.e., reduction of symptoms over time) occurs naturally, then
the effectiveness of therapy needs to measured in this
context.

The literature reviewed in this paper was located by
means of Medline and PsycInfo searches for articles published
in English between 1990 and 2002 and containing the key-
words “borderline personality disorder.” The search identi-
fied 1803 publications, of which 938 concerned treatment, and
an additional 146 concerned outcome. These publications
were supplemented by selected reports published prior to
1990 but frequently referenced in recent literature. This re-

view will specifically consider 23 papers on treatment of BPD
and 26 on its outcome that shed particular light on the links
between outcome and treatment.

FIFTEEN-YEAR FOLLOW-UP STUDIES OF BPD

In a memorable phrase, Schmideberg1 described the course
of BPD as “stably unstable.” Although Schmideberg’s clinical
impressions are correct in the medium term, they may not
apply to the long-term outcome of patients with the disorder.

The first formal follow-up studies of patients with BPD
were conducted in the 1970s.2–4 When cohorts were followed
for 5 years, patients changed very little. But this period was
too brief to determine the outcome of such a chronic disorder.

Four 15-year follow-up studies of borderline patients were
published in the 1980s (see Table 1). The Chestnut Lodge
study,5 conducted by McGlashan, and the Austen Riggs
study,6 led by Plakun, followed cohorts from private, psycho-
analytically oriented hospitals. The Columbia study,7 con-
ducted by Stone, followed patients treated on a specialized
psychotherapy ward at the New York State Psychiatric Insti-
tute. The Montreal study,8 led by Paris, followed a group of
patients treated more briefly at an urban general hospital.

Each of these investigations had strengths and weak-
nesses. The Chestnut Lodge and Columbia studies located
over 80% of patients, while the Austen Riggs and Montreal
studies assessed less than a third of their cohorts. Clearly,
the studies that located the largest percentage of the original

patients have obvious advantages for generalizability. On the
other hand, patients in the Chestnut Lodge, Columbia, and
Austen Riggs samples were highly educated and affluent.
Such populations do not resemble community profiles of BPD,
in which most patients have low educational and socio-
economic levels.9 In this respect, the sample in the Montreal
study, which included subjects from a wide range of socio-
economic backgrounds, was more typical. Another difference
among the various samples arose from treatment histories:
in the Chestnut Lodge, Columbia, and Austen Riggs studies,
all patients received long-term psychotherapy, while in the
Montreal study, many received only intermittent treatment.

Subjects in all four studies were followed into early middle
age (about age 40). In all cohorts, the majority of subjects
were female, the same proportion found in community
samples.9 In two studies (Chestnut Lodge and Montreal), out-
come was assessed through telephone interviews. In the
Columbia investigation, most patients were interviewed by
telephone, but some were assessed through information pro-
vided by informants. The Austen Riggs study relied on mailed
questionnaires.

All studies measured global outcome at follow-up, using
either the Health-Sickness Rating Scale10 or the Global As-
sessment of Functioning.11 The Montreal study also exam-
ined whether patients still met formal criteria for BPD, us-
ing the Diagnostic Interview for Borderlines.12

Despite differences in samples and methodology, all four
studies of the 15-year outcome of BPD patients produced vir-
tually identical results. Mean scores for global functioning
were all in the 60s—within the broad range of normality. In
all cohorts, rehospitalization was uncommon after the first
few years, and by the time of follow-up, most patients were
working and had a social network. The Montreal study found
that only 25% of the original sample still met diagnostic cri-
teria for BPD, with all subscales (dysphoria, impulsivity, dis-
turbed relationships, and cognition) showing improvement
over time.

Since this level of improvement had not been seen in 5-
year follow-up studies, it seems likely that remission requires
more time, probably a decade or more after first presentation.
But even with a mean time to follow-up of 15 years, each co-
hort showed a wide range of outcomes and of times to remis-
sion. The Chestnut Lodge study was the only one to examine
separate cohorts defined by postdischarge time. In a group
followed for 20 years, a significant decrease in functional level
was observed, raising the question as to whether outcome has
an “inverted U” pattern over time. (Data shedding light on
this issue are examined below.)

Suicide completions were the downside of the outcome
story. In the Columbia7 and Montreal13 cohorts, rates were
close to 9%. Similar rates of suicide completion for patients
with BPD have been confirmed in other settings: 8% in Nor-

316 Paris

Harvard Rev Psychiatry

November/December 2002

TABLE 1. Long-Term Studies of the Outcome of Borderline Personality Disorder

Study

Parameter Chestnut Lodge5,18 Columbia7 Austen Riggs6 Montreal8,31,32

Type of hospital Private State Private General
Length of follow-up (y) 15 15 15 15/27
% of cohort located 86 91 27 32/26
Number assessed 81 206 54 100/64
Mean age (y) 47 37 40 39/51
Female:male ratio 52:46 70:30 62:38 84:16/83:17
Socioeconomic status High High High Low to high
% ever married 70 F, 52; M, 29 ? 67
% with children 48 F, 25; M, 15 ? 59
Mean GAF score 64 67 67 63/63
% still meeting criteria for BPD ? ? ? 25/8
Predictors of continued dysfunction Low IQ, lengthy Low IQ, Self-harm, anger Dysthymia, problems

previous admissions, childhood abuse with mother
affective instability

% suicide 3 9 ? 9/10
Mean age at suicide (y) ? 30 ? 30/37
Predictors of suicide completion ? Substance abuse, ? Previous attempts,

major depression higher level of education
% death other than suicide 13 13 ? 13/18

F, female; GAF, Global Assessment of Functioning; M, male.

way14 and 10% in Toronto.15 Although the Chestnut Lodge co-
hort5 had a much lower rate (only 3%), McGlashan (personal
communication, 1991) believes that his sample was unrepre-
sentative, given that patients were referred following treat-
ment in general hospitals. A suicide rate around 10% would
be similar to those found in schizophrenia16 and major mood
disorders.17 Findings at 15-year follow-up also show that sui-
cide generally occurs comparatively late in the course of ill-
ness—that is, after age 30.7,13

Since outcome varies greatly in patients with BPD, it
would be highly useful to identify predictive factors. Mc-
Glashan18 reported that the two strongest correlates of posi-
tive outcome were higher intelligence and shorter length of
previous hospitalization, although neither accounted for a
large percentage of the variance. McGlashan also found that
high levels of affective instability were associated with a
lower level of functioning, a finding supported in the Mon-
treal study.

Because patients with BPD report having had many prob-
lems during childhood,19 researchers have sought to deter-
mine whether early developmental experiences are related
to outcome. One study20 compared a group of women who still
met criteria for BPD with a group of women who did not and
found that childhood sexual abuse was more frequent in the
women who remained symptomatic. In the Columbia cohort,7

“parental brutality” was linked to outcome, but this measure
was not blindly assessed and accounted for only 7% of the
variance. The Montreal study21 found a correlation between
a chart review–derived measure of problems with mothers
during childhood and lower outcome scores. But none of these
relationships is strong or consistent enough to be clinically
useful.

Research has also failed to identify clinically useful pre-
dictors for suicide. This problem is not unique to BPD: even in
very large samples of psychiatric patients, it is difficult to
identify suicide predictors of practical use.22 For example, al-
though the number of previous attempts has some relation-
ship to completion in individuals with BPD,13,14,23 most pa-
tients with multiple attempts do not complete suicide. The
Columbia study7 found that substance abuse predicted com-
pletion, but most of the subjects who abused substances did
not complete suicide. Authors of the Montreal investigation
observed that patients with higher levels of education were
more likely to complete suicide.13 This finding was not sup-
ported by a Norwegian study,14 which showed that BPD pa-
tients at all educational levels are at risk for completed sui-
cide and instead suggested a correlation between separation
or loss early in life and higher rates of completed suicide (a
correlation also seen in a psychological autopsy study of
young males with BPD who completed suicide24). Again, none
of these reports yielded predictors that account for enough of
the variance to be useful clinical markers.

PROSPECTIVE STUDIES OF BPD OUTCOME

The 15-year follow-up studies of BPD all used a “follow-back”
method. Prospective designs yield more-reliable baseline
data, allowing outcome predictors to be identified more accu-
rately. The main limitation of prospective methods is that pa-
tients with BPD who agree to be followed over time may have
unusual characteristics, such as higher compliance, that
make them different from populations clinicians see. More-
over, to reduce attrition, prospective studies of BPD have
focused on patients in long-term treatment, in whom distin-
guishing between treatment effects and naturalistic remis-
sion is difficult.

A major prospective study of patients with BPD was con-
ducted at McMaster University in Hamilton, Ontario.25 The
researchers followed a cohort of 130 former inpatients, of
whom 88 had a diagnosis of BPD and 42 had “borderline
traits.” At 7-year follow-up, approximately two thirds of the
cohort remained. Two patients had died of natural causes,
and six (5%) had committed suicide. Forty-seven percent of
the remaining cohort still met criteria for BPD, while 53%
showed symptomatic remission. That this level of improve-
ment was only about two thirds of the level observed at 15-
year follow-up in the Montreal cohort8 supports the concept
that BPD patients often require 10 years or more to attain
relatively normal levels of functioning. The McMaster study
found that severity of initial pathology was the best predic-
tor of outcome, accounting for 17% of the variance. Patients
with serious comorbid substance abuse (about a quarter of
the sample) had a much poorer outcome.26 The main limita-
tion of this otherwise informative study was that 7 years is
not long enough to observe remission or establish a definitive
suicide rate.

Zanarini’s group at McLean Hospital, in Belmont, Massa-
chusetts,27 has been conducting a prospective study of a pre-
viously admitted cohort, following 290 patients with BPD and
72 patients with other Axis II diagnoses. At 4-year follow-up,
75% of the patients with BPD were still in outpatient ther-
apy, but only 36% had been rehospitalized.28 Although these
findings are preliminary, the study will eventually provide
data on long-term outcome.

The largest-scale current investigation of BPD outcome is
the National Institute of Mental Health–funded Collabora-
tive Longitudinal Personality Disorders Study, now being con-
ducted in Boston, New Haven, New York, and Providence.29

The researchers have been tracking a group of patients with
BPD and other Axis II disorders for over 5 years. The most
striking finding thus far is that BPD has a waxing and wan-
ing course: when assessed every few months, patients may
or may not meet criteria, depending on what is occurring their
lives.30 This study is still in its early stages but will in time
provide data on the long-term outcome of BPD.

Harvard Rev Psychiatry

Volume 10, Number 6 Paris 317

A 27-YEAR OUTCOME STUDY OF BPD

The Montreal group has recently completed a 27-year follow-
up of patients with BPD.31,32 Data were obtained on 81 of the
100 individuals studied after 15 years. In the intervening pe-
riod, five had died from natural causes, and three had com-
mitted suicide. Nine patients known to be alive refused to be
evaluated. Thus, 64 subjects (12 men and 52 women) who had
then reached a mean age of 51 were interviewed.

Although mean global functioning scores were unchanged,
the overall rate of suicide completion increased to 10.3%. The
mean age at suicide was 37.3 ± 10.3 years. Thus, completions
occurred late in the course of illness, with few among patients
in their early 20s, when attempts were very common.

The cohort had an unusually high rate of early death, a
finding also observed in the Columbia study.7 At 27-year
follow-up, a total of 18.2% of the original sample had died, ei-
ther from natural causes or from suicide, a much higher rate
than would be expected for a population of this age.33 The high
level of mortality associated with BPD is one of the most im-
portant findings of research on long-term outcome.

The most striking change between 15 and 27 years in-
volved the number of subjects who still met criteria for BPD.
Only 8% of the total still had a borderline diagnosis at 27
years, as opposed to 25% at the 15-year point. (In the later
study, the Revised Diagnostic Interview for Borderlines,34 a
less inclusive measure than the original Diagnostic Interview
for Borderlines, was used for diagnosis, but the results would
probably have been similar even if the original instrument
had been employed.) The subscale showing the most signifi-
cant improvement between the two follow-up points involved
quality of relationships.

As for Axis I, only 5% of the remaining cohort had active
substance abuse or met criteria for major depression at 27
years. Social adjustment was also close to normative values.
The main indicator of continued problems was that 22% met
criteria for dysthymia. This diagnosis indicates low-level
chronic depression but can also be seen as a marker for affec-
tive instability. Early-onset dysthymia is found quite often in
individuals with BPD35 and is one of the most common Axis I
comorbidities in the disorder.36 The continued presence of
these symptoms suggests that affective lability changes more
slowly over time than does impulsivity. The strongest predic-
tors of 27-year outcome were levels of functioning at 15-year
follow-up.32 Childhood experiences, as measured by self-
report scales, had no relationship to outcome.

The findings of the Montreal study show that remission in
BPD continues well into middle age. The results do not sup-
port earlier concerns that outcome may follow the pattern
of an “inverted U.” By the age of 50, BPD patients were func-
tioning much better than they had been 12 years earlier,
even though about a quarter of them had residual affective
symptoms.

MECHANISMS OF REMISSION

Several mechanisms lie behind the remission process in BPD.
It is well established in community populations that impul-
sivity tends to decrease with age,37 a process that could re-
flect biological maturation. In this context, BPD patients
seem to improve in much the same way as those with other
impulsive disorders, including alcohol abuse,38 antisocial per-
sonality disorder,39 and bulimia nervosa.40

A second mechanism could involve social learning.41 Al-
though individuals with BPD are slow to learn from experi-
ence, they can still increase their skills over time. Improve-
ment could also come from finding supportive relationships
and choosing partners who exhibit less pathology.

Long-term outcome data on BPD suggest another mecha-
nism: avoidance of intimacy. Many BPD patients drop out
early from school, have difficulty in establishing a career, ex-
perience periods of unemployment, and have problems find-
ing stable friendships. Yet those who improve eventually over-
come most of these difficulties. As we have seen, most subjects
in the follow-up cohorts obtained employment and estab-
lished social networks.

Intimacy, however, is more difficult to achieve. Barden-
stein and McGlashan42 observed gender differences in out-
come among BPD patients in the Chestnut Lodge cohort.
Women with BPD had a somewhat poorer long-term outcome
than did men. Whereas men benefited from strong commit-
ments to work, intimacy for borderline women was problem-
atic; many women became increasingly symptomatic when
their marriages broke down.

The success of marriage in BPD patients may depend in
part on the personality characteristics of their partners.43 Al-
though no systematic studies have been conducted on choice
of partners in individuals with BPD, some women with the
disorder seem to be attracted to narcissistic men, who ini-
tially find them attractive and later become abusive or aban-
doning. Marriage with a spouse who assumes a care-taking
role might be more stable, although clinical experience sug-
gests that this dyad can also run into trouble due to insuffi-
cient limit-setting on impulsive behavior.

As shown in Table 1, in the Columbia cohort7 only 52% of
the women and 29% of the men had ever been married; only
25% of the women and 15% of the men had ever had children.
Among the patients who had married, the divorce rate was
33%. Although this figure is not excessive compared to the
national average, when marriages broke down, only 10%
remarried—a rate much lower than the national average.44

In the Montreal study, the marriage rate was 67% (similar to
the 70% observed in the Chestnut Lodge cohort), and the
divorce rate was 36%. But at 27-year follow-up, only
42% were then living in a stable relationship; 41% remained
childless.

We lack systematic data to confirm the hypothesis that

318 Paris
Harvard Rev Psychiatry

November/December 2002

BPD patients can achieve symptomatic improvement by
avoiding intimacy. Nonetheless, clinical interviews with
individuals who no longer meet criteria for the disorder of-
ten elicit descriptions of learning not to fall in love. Highly
charged relationships create numerous problems for young
patients with BPD. Over time, some learn that intimacy is
dangerous for them. For these patients, being comfortably
alone and finding other, less conflictual ways of establishing
social support networks and contacts reduces the chance of
serious difficulty.

Therapists may benefit from taking these observations
into account. The success of treatment is not determined
solely by the attainment of stable intimacy. On the contrary,
some patients with BPD might be encouraged to avoid such
involvement. Many who improve find that having less-
intimate friends, belonging to a social community, or having
a pet provides more stability than could have been achieved
through intimacy.

Little research has been done on the effects of parenthood
on women with BPD. A surprisingly large number remain
childless. Parenthood also requires the management of inti-
macy, and it is possible that some mothers can develop
“borderline relationships” (i.e., clinging dependency) with
their children. In one study45 the children of mothers with
BPD were found to be highly symptomatic, and family life
was observed to be very dysfunctional.46 Although systematic
observations on the subject are lacking, the author’s clinical
experience suggests the possibility that some women give up
impulsive behaviors for the sake of their children. In such
cases, they may no longer meet criteria for a diagnosis of
BPD; they “graduate” to a DSM diagnosis of “personality
disorder, not otherwise specified,” or their symptoms are
diminished.

CHRONICITY,TREATMENT, AND REMISSION

Since BPD is chronic but improves with time, treatment re-
sponse must be assessed in the context of naturalistic re-
mission. Thus, when clinicians claim that patients with BPD
improve after many years of treatment, one cannot know
whether the positive outcomes are the result of therapy or of
“waiting out” the pathology until it remits.

Nonetheless, therapy for BPD can hasten the natural pro-
cess of remission. A meta-analysis of treatment studies of pa-
tients with personality disorders47 found that whereas a
model of the natural history of BPD shows 3.7% of patients
with BPD to remit each year, active psychotherapy improves
this rate sevenfold. Although this figure is encouraging, it is
probably overly optimistic. The meta-analysis was drawn
from a small data set that included uncontrolled or partially
controlled studies of varying provenance. As noted earlier,
even in patients who receive consistent therapy, remission
rarely occurs within the first 5 years. Moreover, although

making comparisons among samples is impossible, the re-
sults in high-treatment and low-treatment follow-up cohorts
were quite similar.

To assess the long-term impact of therapy on the course of
a disorder with many remissions and relapses, patients need
to be followed over time. Most treatment studies last for a
year or less—sufficient for major depression but not for BPD.
This caution applies particularly to psychopharmacologi-
cal studies, which have demonstrated short-term sympto-
matic improvement in BPD (mainly in relation to impulsivity)
with a variety of agents, including neuroleptics, selective
serotonin-reuptake inhibitors, and mood stabilizers.48 How-
ever, research has not shown whether such improvements
are stable over time.

Time is also important in measuring the effects of psycho-
therapy. For example, Linehan’s cohort of patients in a ran-
domized controlled trial of dialectical behavior therapy con-
ducted in the 1980s49 was treated for a year and followed up a
year later.50 At the end of therapy, the patients who received
dialectical behavior therapy were overdosing less, slashing
less, and requiring less hospital care than were controls, who
received “treatment as usual,” but they did not achieve full
remission. Most continued to suffer from high levels of dys-
phoria—symptoms that were still present at follow-up. It is
unfortunate that this cohort, treated about 15 years ago, has
never received long-term follow-up.

Nonetheless, the likelihood of eventual improvement
should be reassuring for therapists. It has been suggested
that patients with BPD should be told to expect remission
over time. Clinicians clearly do take outcome into account
when they provide supportive therapy that offers a “hold” for
patients until they improve.

Despite the chronicity of BPD, it may not always be nec-
essary to treat patients continuously for years. Many move
in and out of therapy, and only about a third remain in long-
term treatment, even when it is offered.51,52 We do not know
whether patients who remain in therapy fare differently from
those who do not. But clinicians can capitalize on trajectories
of instability. Several outcome researchers,53–55 aware of the
chronicity of BPD, have recommended intermittent treat-
ment, as long as reentry is readily available when crises
occur.

OUTCOME AND AFFECTIVE INSTABILITY

Affective instability (AI) is a central feature of BPD. Individ-
uals with this disorder can be anxious in the morning, angry
in the afternoon, and suicidally depressed in the evening.
Linehan56 has hypothesized that emotional dysregulation
(a concept essentially equivalent to AI) is associated with a
rapid response to environmental stimuli and a slow recovery
time. She suggests that this trait is the core feature of BPD
and that it is constitutional.

Harvard Rev Psychiatry

Volume 10, Number 6 Paris 319

Often confused with depression or mania, AI has impor-
tant phenomenological differences from these conditions.57,58

It is highly responsive to environmental cues and involves in-
consistency of mood over time. Moreover, although mood sta-
bilizers and antidepressants in BPD often lead to declines in
impulsivity, they have fewer effects on affective symptoms.59

These observations suggest that AI could have a unique
biology.

Although much research has been done on the biology of
impulsivity, much less exists on that of affective instability.
Jang and colleagues60 used behavioral genetic methods to
measure genetic and environmental contributions to AI. As
with most traits, about 40% of the variance was genetic,
whereas another 50% was attributable to unshared environ-
ment. Yet even when traits are genetically influenced, they
may be modified by psychotherapy.61,62

Long-term outcome findings suggest that most patients
with BPD improve more slowly on the affective than on the
impulsive dimension. Although both traits are influenced by
genetic factors, impulsivity may be more likely to change with
age and life experience. These observations have clinical
implications.

When treating patients with BPD, therapists can estab-
lish a hierarchy of goals for different traits. (A similar strate-
gic framework has been recommended in clinical guides to
treatment by Linehan56 and Gunderson.63) Impulsivity is
usually the first target, since acting out prevents treatment
from addressing other goals. Once the patient is calm enough
to work in therapy, treatment can address AI in a number of
ways. These methods involve developing tolerance of emo-
tions, decentering emotions, and modifying cognitive ap-
praisals.56,64 Even if AI never entirely disappears from the
picture, it can be tamed. This happens when the circum-
stances that provoke such responses occur less often and
when patients learn to modulate emotions before they become
overwhelming.

SUICIDALITY IN BPD

Suicidality in patients with BPD can be frightening. Concern
might seem to be justified by a 10% completion rate, yet 90%
of BPD patients do not die by suicide. Even though most make
multiple threats and attempts, exactly which individuals will
eventually succeed in killing themselves cannot be predicted.

Outcome research on BPD offers a surprising degree of re-
assurance about the danger of completion. Suicide usually
occurs surprisingly late in the course of the illness—gener-
ally after age 30. This contrasts with the alarmingly high lev-
els of suicide threats and attempts seen in younger patients.
Thus, suicide in BPD does not necessarily occur in the midst
of a crisis. Although younger patients do commit suicide, the
fact that outcome studies7,13,31 found a mean age of 30–37
years among completers supports the clinical observation

that suicide becomes most likely in a state of withdrawal and
hopelessness, often after a series of failed treatments.

In light of these conclusions, the management of suicide
threats and gestures in BPD can be conservative and less in-
terventive. Alarmed clinicians tend to go out of their way to
“prevent” suicide, but there is no evidence that therapy actu-
ally prevents completion.55 Hospitalization, the most common
intervention, may provide temporary relief but can also lead
to regressive complications.63 Although managed care has
made the option of admission less available, there is no def-
inite evidence that patients with BPD are suffering as a re-
sult of this trend.

Experts on suicide65 and on the treatment of BPD63,66,67

have taken the position that constant concern about suicide
completion can derail therapy. Linehan,56 whose training is
behavioral, emphasizes the reinforcing quality of hospital-
ization or increasing the frequency of contact. Thus, inter-
ventions intended to respond to suicidal behaviors can im-
plicitly reward them. Hospital treatment was originally
designed to manage acute episodes of suicidality in patients
with a mood disorder. In such cases, admission allows clini-
cians to provide effective interventions such as antidepress-
ant and electroconvulsive therapy. But hospital stays are
much less appropriate for chronically suicidal patients with
BPD, for whom medical treatment is rarely definitive, and
among whom suicidality tends to continue after discharge.

Therapists might do better to manage suicidality by fo-
cusing on the implicit communication of distress behind
thoughts and actions.55 Since suicidality “goes with the ter-
ritory” of BPD, therapists must tolerate these patients’ anxi-
ety. By and large, threats of suicide can be understood as an
individual’s attempt to “raise the volume,” in the belief that
this is the only way to be heard. When patients discover that
therapists respond empathically to inner suffering and can
offer ways of reducing their pain, suicidality may decline.
Moreover, since BPD patients have difficulty breaking the
links between thought and action, therapists can model this
capacity by tolerating and resisting the contagion of despair
and anxiety, and not acting on these feelings (e.g., by send-
ing patients to the emergency room).

In some situations hospitalization of BPD patients is un-
avoidable—for example, after a life-threatening suicide at-
tempt, or to treat a psychotic episode.68 However, admitting
patients every time they become suicidal works against the
goals of therapy. Linehan56 advises her patients to avoid the
hospital; if they end up there nonetheless, they can be held
overnight, but no longer.

Clinicians often justify their fear that patients with BPD
will commit suicide as a concern about “medical-legal issues.”
The implication is that a therapist whose patient commits
suicide will be held responsible for his or her death through
litigation. Yet, as reviewed elsewhere,55 the majority of law-
suits after suicide do not concern the treatment of chronically

320 Paris
Harvard Rev Psychiatry

November/December 2002

suicidal patients with BPD, but of acutely suicidal patients
with Axis I disorders.

Borderline patients may need more containment than is
possible in outpatient therapy. In such cases, there is strong
evidence for the value of day treatment.69–71 Unlike full ad-
mission, partial hospitalization provides structure that limits
regressive complications; it is also more cost effective.

DIRECTIONS FOR FUTURE RESEARCH

The remission of BPD, a disorder whose effects on functioning
can be as serious as those of a psychotic illness,72 remains
something of a mystery. Yet BPD is only one of many mental
disorders that improve over time. Many impulsive disorders
show similar recovery with age; even schizophrenia has a pat-
tern of relative remission of positive symptoms by age 50.73

(Severe mood disorders, which often continue into old age,
are an exception.74)

The main limitation of existing research is that it provides
only a “snapshot” of BPD at different time points rather than
a continuous assessment that could pinpoint mechanisms of
remission and relapse. For this reason, the ongoing work at
McLean and the Collaborative Longitudinal Personality Dis-
orders Study have the potential to shed more light on the
course and outcome of BPD and to provide more-precise
guidelines for treatment.

REFERENCES

1. Schmideberg M. The borderline patient. In: Arieti S, ed. Ameri-
can handbook of psychiatry, vol 1. New York: Basic, 1959:398–
416.

2. Werble B. Second follow-up study of borderline patients. Arch
Gen Psychiatry 1970;23:3–7.

3. Carpenter WT Jr, Gunderson JG, Strauss JS. Considerations of
the borderline syndrome: a longitudinal comparative study of
borderline and schizophrenic patients. In: Hartocollis P, ed. Bor-
derline personality disorders: the concept, the syndrome, the pa-
tient. New York: International Universities Press, 1977:231–53.

4. Pope HG Jr, Jonas JM, Hudson JI, Cohen BM, Gunderson JG.
The validity of DSM-III borderline personality disorder: a phe-
nomenologic, family history, treatment response, and long-term
follow-up study. Arch Gen Psychiatry 1983;40:23–30.

5. McGlashan TH. The Chestnut Lodge follow-up study, III: Long-
term outcome of borderline personalities. Arch Gen Psychiatry
1986;43:20–30.

6. Plakun EM, Burkhardt PE, Muller JP. 14-year follow-up of
borderline and schizotypal personality disorders. Compr Psy-
chiatry 1985;26:448–55.

7. Stone MH. The fate of borderline patients: successful outcome
and psychiatric practice. New York: Guilford, 1990.

8. Paris J, Brown R, Nowlis D. Long-term follow-up of borderline
patients in a general hospital. Compr Psychiatry 1987;28:530–5.

9. Swartz M, Blazer D, George L, Winfield I. Estimating the preva-

lence of borderline personality disorder in the community. J Per-
sonal Disord 1990;4:257–72.

10. Luborsky L. Clinicians’ judgment of mental health. Arch Gen
Psychiatry 1962;7:407–17.

11. Endicott J, Spitzer RL, Fleiss JL, Cohen J. The Global Assess-
ment Scale: a procedure for measuring overall severity of psy-
chiatric disturbance. Arch Gen Psychiatry 1976;33:766–71.

12. Gunderson JG, Kolb JE. Discriminating features of borderline
patients. Am J Psychiatry 1978;135:792–6.

13. Paris J, Nowlis D, Brown R. Predictors of suicide in borderline
personality disorder. Can J Psychiatry 1989;34:8–9.

14. Kjelsberg E, Eikeseth PH, Dahl AA. Suicide in borderline pa-
tients—predictive factors. Acta Psychiatr Scand 1991;84:283–7.

15. Silver D, Cardish R. BPD outcome studies: psychotherapy im-
plications. Presented at the 144th Annual Meeting of the Amer-
ican Psychiatric Association, New Orleans, May 1991.

16. Wilkinson DG. The suicide rate in schizophrenia. Br J Psychiatry
1982;140:138–41.

17. Guze SB, Robins E. Suicide and primary affective disorders. Br J
Psychiatry 1970;117:437–8.

18. McGlashan TH. The prediction of outcome in borderline person-
ality disorder: part V of the Chestnut Lodge Follow-up Study. In:
McGlashan TH, ed. The borderline: current empirical research.
Washington, DC: American Psychiatric Press, 1985:61–98.

19. Zanarini MC. Childhood experiences associated with the devel-
opment of borderline personality disorder. Psychiatr Clin North
Am 2000;23:89–101.

20. Paris J, Zweig-Frank H, Guzder J. Psychological risk factors in
recovery from borderline personality disorder. Compr Psychia-
try 1993;34:410–3.

21. Paris J, Nowlis D, Brown R. Developmental factors in the out-
come of borderline personality disorder. Compr Psychiatry 1988;
29:147–50.

22. Pokorny AD. Prediction of suicide in psychiatric patients: report
of a prospective study. Arch Gen Psychiatry l983;40:249–57.

23. Kullgren G. Factors associated with completed suicide in bor-
derline personality disorder. J Nerv Ment Dis 1988;176:40–4.

24. Lesage AD, Boyer R, Grunberg F, Vanier C, Morrisette R,
Ménard-Buteau C, et al. Suicide and mental disorders: a case-
control study of young men. Am J Psychiatry 1994;151:1063–8.

25. Links PS, Heslegrave R, Van Reekum R. Prospective follow-up
study of borderline personality disorder: prognosis, prediction of
outcome, and Axis II comorbidity. Can J Psychiatry 1998;43:265–
70.

26. Links PS, Heslegrave RJ, Mitton JE, Van Reekum R, Patrick J.
Borderline personality disorder and substance abuse: conse-
quences of comorbidity. Can J Psychiatry 1995;40:9–14.

27. Zanarini MC, Frankenburg FR. Attainment and maintenance of
reliability of Axis I and II disorders over the course of a longitu-
dinal study. Compr Psychiatry 2001;42:369–74.

28. Zanarini MC, Frankenburg FR, Khera GS, Bleichmar J. Treat-
ment histories of borderline inpatients. Compr Psychiatry 2001;
42:144–50.

29. Gunderson JG, Shea MT, Skodol AE, McGlashan TH, Morey LC,
et al. The Collaborative Longitudinal Personality Disorders
Study: development, aims, design, and sample characteristics.
J Personal Disord 2000;14:300–15.

30. Grilo CM, McGlashan TH, Skodol AE. Stability and course of per-

Harvard Rev Psychiatry

Volume 10, Number 6 Paris 321

sonality disorders: the need to consider comorbidities and conti-
nuities between Axis I psychiatric disorders and Axis II person-
ality disorders. Psychiatr Q 2000;71:291–307.

31. Paris J, Zweig-Frank H. A 27-year follow-up of patients with bor-
derline personality disorder. Compr Psychiatry 2001;42:482–7.

32. Zweig-Frank H, Paris J. Predictors of outcome in a 27-year fol-
low-up of patients with borderline personality disorder. Compr
Psychiatry 2002;43:103–7.

33. National Center for Health Statistics. Mortality data from the
National Vital Statistics System, 1999. [Available on the World
Wide Web at http://www.cdc.gov/nchs/about/major/dvs/mcd/
msb.htm].

34. Zanarini MC, Gunderson JG, Frankenburg FR, Chauncey DL.
The Revised Diagnostic Interview for Borderlines: discriminat-
ing BPD from other Axis II disorders. J Personal Disord 1989;
3:10–8.

35. Pepper CM, Klein DN, Anderson RL, Riso LP, Ouimette PC,
Lizardi H. DSM-III-R Axis II comorbidity in dysthymia and ma-
jor depression. Am J Psychiatry 1995;152:239–47.

36. Zanarini MC, Frankenburg FR, Dubo ED, Sickel AE, Trikha A,
Levin A, et al. Axis I comorbidity of borderline personality disor-
der. Am J Psychiatry 1998;155:1733–9.

37. Vaillant GE. Adaptation to life. Cambridge, Massachusetts: Har-
vard University Press, 1977.

38. Vaillant GE. The natural history of alcoholism revisited. Cam-
bridge, Massachusetts: Harvard University Press, 1995.

39. Black DW, Baumgard CH, Bell SE. A 16- to 45-year follow-up of
71 men with antisocial personality disorder. Compr Psychiatry
1995;36:130–40.

40. Keel PK, Mitchell JE, Miller KB, Davis TL, Crow SJ. Long-term
outcome of bulimia nervosa. Arch Gen Psychiatry 1999;56:63–9.

41. Bandura A. Social learning theory. Englewood Cliffs, New Jer-
sey: Prentice-Hall, 1977.

42. Bardenstein KK, McGlashan TH. The natural history of a resi-
dentially treated borderline sample: gender differences. J Per-
sonal Disord 1988;2:69–83.

43. Paris J, Braverman S. Successful and unsuccessful marriages in
borderline patients. J Am Acad Psychoanal 1995;23:153–66.

44. Riley G. Divorce: an American tradition. New York: Oxford Uni-
versity Press, 1991.

45. Weiss M, Zelkowitz P, Feldman RB, Vogel J, Heyman M, Paris J.
Psychopathology in offspring of mothers with borderline
personality disorder: a pilot study. Can J Psychiatry 1996;41:
285–90.

46. Feldman RB, Zelkowitz P, Weiss M, Vogel J, Heyman M, Paris J.
A comparison of the families of mothers with borderline and non-
borderline personality disorders. Compr Psychiatry 1995;36:
157–63.

47. Perry JC, Banon E, Ianni F. Effectiveness of psychotherapy for
personality disorders. Am J Psychiatry 1999;156:1312–21.

48. Soloff PH. Psychopharmacology of borderline personality disor-
der. Psychiatr Clin North Am 2000;23:169–92.

49. Linehan MM, Armstrong HE, Suarez A, Allmon D, Heard HL.
Cognitive-behavioral treatment of chronically parasuicidal bor-
derline patients. Arch Gen Psychiatry 1991;48:1060–4.

50. Linehan MM, Heard HL, Armstrong HE. Naturalistic follow-up
of a behavioral treatment for chronically parasuicidal borderline
patients. Arch Gen Psychiatry 1993;50:971–4.

51. Skodol AE, Buckley P, Charles E. Is there a characteristic pat-
tern to the treatment history of clinic outpatients with border-
line personality? J Nerv Ment Dis 1983;171:405–10.

52. Waldinger RJ, Gunderson JG. Completed psychotherapies with
borderline patients. Am J Psychother 1984;38:190–202.

53. McGlashan TH. Implications of outcome research for the treat-
ment of borderline personality disorder. In: Paris J, ed. Border-
line personality disorder: etiology and treatment. Washington,
DC: American Psychiatric Press, 1993:235–59.

54. Silver D. Psychotherapy of the characterologically difficult pa-
tient. Can J Psychiatry 1983;28:513–21.

55. Paris J. Chronic suicidality among patients with borderline per-
sonality disorder. Psychiatr Serv 2002;53:738–42.

56. Linehan MM. Cognitive-behavioral treatment of borderline per-
sonality disorder. New York: Guilford, 1993.

57. Gunderson JG, Phillips KA. A current view of the interface be-
tween borderline personality disorder and depression. Am J Psy-
chiatry 1991;148:967–75.

58. Bolton S, Gunderson JG. Distinguishing borderline personality
disorder from bipolar disorder: differential diagnosis and impli-
cations. Am J Psychiatry 1996;153:1202–7.

59. Coccaro EF, Kavoussi RJ. Fluoxetine and impulsive aggressive
behavior in personality-disordered subjects. Arch Gen Psychiatry
1997;54:1081–8.

60. Jang KL, Livesley WJ, Vernon PA, Jackson DN. Heritability of
personality disorder traits: a twin study. Acta Psychiatr Scand
1996;94:438–44.

61. Paris J. Nature and nurture in psychiatry: a predisposition-
stress model of mental disorders. Washington, DC: American
Psychiatric Press, 1999.

62. Kandel ER. A new intellectual framework for psychiatry. Am J
Psychiatry 1998;155:457–69.

63. Gunderson JG. Borderline personality disorder: a clinical guide.
Washington, DC: American Psychiatric Press, 2001.

64. Barlow DH, ed. Clinical handbook of psychological disorders: a
step-by-step treatment manual. 3rd ed. New York: Guilford,
2001.

65. Maltsberger JT. Calculated risks in the treatment of intractably
suicidal patients. Psychiatry 1994;57:199–212.

66. Fine MA, Sansone RA. Dilemmas in the management of suicidal
behavior in individuals with borderline personality disorder. Am
J Psychother 1990;44:160–71.

67. Dawson D, MacMillan HL. Relationship management of the bor-
derline patient: from understanding to treatment. New York:
Brunner/Mazel, 1993.

68. Hull JW, Yeomans F, Clarkin J, Li C, Goodman G. Factors asso-
ciated with multiple hospitalizations of patients with borderline
personality disorder. Psychiatr Serv 1996;47:638–41.

69. Piper WE, Rosie JS, Joyce AS, Azim HFA. Time-limited day
treatment for personality disorders: integration of research and
practice in a group program. Washington, DC: American Psy-
chological Association, 1996.

70. Bateman A, Fonagy P. Effectiveness of partial hospitalization in
the treatment of borderline personality disorder: a randomized
controlled trial. Am J Psychiatry 1999;156:1563–9.

71. Bateman A, Fonagy P. Treatment of borderline personality dis-
order with psychoanalytically oriented partial hospitalization:
an 18-month follow-up. Am J Psychiatry 2001;158:36–42.

322 Paris
Harvard Rev Psychiatry

November/December 2002

72. Skodol AE, Gunderson JG, McGlashan TH, Dyck IR, Stout RL,
Bender DS, et al. Functional impairment in patients with schizo-
typal, borderline, avoidant, or obsessive-compulsive personality
disorder. Am J Psychiatry 2002;159:276–83.

73. Harding CM, Brooks GW, Ashikaga T, Strauss JS, Breier A. Ver-
mont longitudinal study of persons with severe mental illness,

II: Long-term outcome of subjects who retrospectively met DSM-
III criteria for schizophrenia. Am J Psychiatry 1987;143:727–35.

74. Winokur G, Tsuang MT. The natural history of mania, depres-
sion, and schizophrenia. Washington, DC: American Psychiatric
Press, 1996.

Harvard Rev Psychiatry

Volume 10, Number 6 Paris 323

Copyright of Harvard Review of Psychiatry is the property of Taylor & Francis Ltd and its content may not be

copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written

permission. However, users may print, download, or email articles for individual use.