R-EMOTION SLEEP STUDY
DISTURBED SLEEP: A “NEGLECTED” SYMPTOM OF BORDERLINE PERSONALITY DISORDER AND PARTICIPANTS WITH CORE EMOTIONAL DYSREGULATION PROBLEMS?
Data finalized… stayed tuned for the results! 📣
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MSc Mariana Mendoza Alvarez¹²³
PhD MD Livia De Picker¹²³, Prof. PhD MD Manuel Morrens¹²³ , Prof. Marie Vandekerckhove⁴ , Prof. Dr. Johan Verbraecken², Prof. Laurence Claes²⁵
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Chronic insomnia is among the most consistent complaints in Borderline Personality Disorder (BPD) and has been linked to increased suicidal behaviours, unfavourable illness course, and poorer response to psychotherapeutic treatment, independent of comorbidity with other psychiatric disorders known to be associated with sleep problems (i.e. depression or PTSD)(1– 4). Nonetheless, subjective and objective sleep disturbances represent an incredibly prominent though “neglected” symptom of BPD. Only few studies have examined chronic sleep disturbances in those with BPD, regardless of the fact that an association has been shown between subjective sleep disturbance and recovery status among BPD patients (5) and that up to 95.5 % of BPD patients report subjective sleep problems (compared to 4-10% in the general population), mainly difficulties falling asleep, sleep interruptions and nightmares (6). These findings indicate that a systematic assessment of sleep and sleep disturbances in patients with BPD is highly important to bridge this scientific and clinical knowledge gap.
Importantly, sleep problems are not just a symptom of the disorder, but could also precede and worsen psychopathology (7). Recent research findings have identified REM instability as an important dimension of sleep which is both associated with subjective sleep quality and daytime emotion dysregulation. More specifically, recent findings suggest that restless REM sleep reflects a process that impedes overnight resolution of emotional distress (8). Examining REM fragmentation in BPD has high relevance due to its essential role in the overnight processing of emotions (9) and to the evidence of disturbed emotion processing and severe difficulties in emotion regulation being the core symptom of BPD pathology.
The identification of specific macro- and microstructural sleep disturbances as a core symptom
and early biological substrate of BPD can serve as a marker for earlyidentification of at-risk
individuals, providing clues to etiological factors involved in BPD. It will also allow to
increase the cost-effectiveness of currently available evidence-based psychotherapy
interventions by better prediction of treatment response and enrichment of treatment protocols
with add-on (both pharmacological and non-pharmacological) interventions targeting sleep
difficulties. Providing clarity into the association between sleep disturbances in BPD and
overnight resolution of emotional distress may be pertinent to draw a more coherent picture
of the phenomenological and biological nature of this complex disorder and to enrich treatment
protocols, which currently place rather limited emphasis on sleep difficulties (10).
Particularly as there is preliminary evidence that non-recovered BPD patients show longer
sleep onset latency and increased daytime dysfunction as a result of their sleep disturbance,
suggesting that poor sleep quality impairs recovery (5).
Objectives: This research project aims to investigate: (1) The impact of macro and microstructural sleep abnormalities in BPD phenotype; (2) The effect of REM and transition to REM sleep abnormalities on emotional downregulation and memory consolidation in BPD patients compared to healthy controls (HC) and (3) Examine predictors of REM malfunction (i.e. psychopathology, clinical severity of emotion dysregulation, medication,...) 4) Examine if baseline sleep quality are predictors of symptom severity change in BPD patients enrolled in DBT treatment and on waiting lists, and finally 5) examine the stability of sleep symptoms across time in BPD patients on DBT treatment and in waiting lists.
Research Design: This is a longitudinal study, which has been organized into two work packages (WP1 and WP2). In WP1, a cross-sectional case-control study will evaluate the effect of macro- and microstructural REM and NREM sleep abnormalities on overnight emotional downregulation and memory consolidation in 65 BPD patients compared to 65 aged matched healthy controls at baseline (T1). In WP2, participants from the clinical group will be followed up at two time points: (5-8 weeks; T2) and (20-24 weeks; T3).
Methodology: In WP1, sleep was measured using standard polysomnography (PSG) assessment over two consecutive nights, of which the first night will serve to control for first night effects and to rule out exclusion criteria. On the second PSG evaluation, participants were exposed to a shame induction emotional challenge task (EC) prior to and after sleeping to study the overnight dampening of emotional distress assessed by physiological and self-reported measures of emotional reactivity. Memory and motor skill learning tasks were also implemented pre and post sleeping with the purpose of these functioning as a contrast to the EC, as memory consolidation is considered to be a function of NREM sleep while emotion regulation is impacted by REM sleep. Moreover, blood samples were collected prior to bed and at wake-up after polysomnography, in order to assess evening and early morning biomarkers, as for instance, levels of circulating inflammatory cytokines which are biological markers of stress reactivity and trauma. Finally, in WP2 outcome measures of symptom severity change were collected, this defined as % change on the BPDSI-1m, % change on specific symptom domains and treatment drop-out rates collected at two different time points during the research study (early and late treatment).
References
1. Weinhold SL, Göder R, Pabst A, Scharff AL, Schauer M, Baier PC, et al. Sleep recordings in individuals with borderline personality disorder before and after trauma therapy. Journal of Neural Transmission. 2017;124(1):99–107.
2. Sjostrom N, Hetta J, Waern M. Persistent nightmares are associated with repeat suicide attempt: a prospective study. 170(2-3): p. 208-11. Psychiatry Res,. 2009;170(2–3):208–11.
3. Winsper C, Tang NK. Linkages between insomnia and suicidality: Prospective associations, high-risk subgroups and possible psychological mechanisms. International review of psychiatry. 2014;26(2):189–204.
4. Wojnar M, et. al. Sleep problems and suicidality in the National Comorbidity Survey Replication. J Psychiatr Res. 2009;43(5):526–31.
5. Plante DT, Frankenburg GM, Fitzmaurice FR, Zanarini MC. Relationship between sleep disturbance and recovery in patients with borderline personality disorder. J Psychosom Res. 2013b;74(4):278–82.
6. Asaad T, Okasha T, Okasha A. Sleep EEG findings in ICD-10 borderline personality disorder in Egypt. J Affect Disord. 2002;71(1–3):11–8.
7. Harty L et. al. Are inmates’ subjective sleep problems associated with borderline personality, psychopathy, and antisocial personality independent of depression and substance dependence? J Forens Psychiatry Psychol,. 2010;21(1):23–39.
8. Wassing R, Lakbila-Kamal O, Ramautar JR, Stoffers D, Schalkwijk F, Van Someren EJ. Restless REM sleep impedes overnight amygdala adaptation. Current Biology. 2019;29(14):2351–8.
9. Wassing R, Benjamins JS, Dekker K, Spiegelhalder K, van der Sluis S, Van Der Werf YD, et al. Slow dissolving of emotional distress contributes to hyperarousal. Proceedings of the National Academy of Sciences of the United States of America. 2016;113(9):2538–43.
10. Selby EA. Chronic sleep disturbances and borderline personality disorder symptoms. Journal of consulting and clinical psychology. 2013;81(5):941.
The studies derived from this PhD appointment will be conducted in the Universiteit Antwerpen at the Department of Psychiatry, Faculty of Medicine. Research will be conducted at the Collaborative Antwerp Research Institute (CAPRI) (https://www.uantwerpen.be/en/research-groups/capri/) in combination with the Scientific Initiative for Neuropsychiatric and Psychopharmacological Studies (SINAPS) in Duffel (https://www.sinapsduffel.com/ ) and Vrije Universiteit Brussel (VUB). Research participants recruitment will be conducted at the UPC Duffel Hospital (https://www.pz-duffel.be/ ) and the KARUS Gent Hospital (https://www.karus.be/t).
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1 Scientific Initiative for Neuropsychiatric and Psychopharmacological Studies (SINAPS), Universitair Psychiatrisch Centrum (UPC) Duffel, geestelijk gezondheidszorg Emmaüs, Stationsstraat 22c, 2570 Duffel, Belgium.
2 Faculty of Medicine & Health Sciences, University of Antwerp (UA), Campus Drie Eiken, Universiteitsplein 1, 2610 Antwerpen, Belgium.
3 Universitair Psychiatrisch Centrum (UPC) Duffel, Geestelijk Gezondheidszorg Emmaüs, Stationsstraat 22c, 2570 Duffel, Belgium.
4 Vrije Universiteit Brussel (VUB), Boulevard de la Plaine 2, 1050 Ixelles, Belgium.
5 Katholieke Universiteit Leuven (KUL), Oude Markt 13, 3000 Leuven, Belgium.
