2005:

Dr. Kim Gratz

Description of Dr. Gratz’s Clinical Research Interests:

Dr. Gratz’s clinical and research interests focus on the role of emotion dysregulation and experiential avoidance in borderline personality disorder (BPD) and deliberate self-harm. In particular, her research focuses on understanding the nature and consequences of emotional dysregulation and avoidance in BPD and self-harm (through the use of novel behavioral/experimental paradigms), and applying this understanding to the development of innovative treatments for these conditions. Current projects include: (1) experimental investigations of emotion dysregulation and emotional avoidance in BPD and antisocial personality disorder; (2) an experimental investigation of the role of distress intolerance and impulsivity in self-harm behavior, including the moderating role of interpersonally-related distress in this relationship; (3) development of a longitudinal study examining the factors associated with BPD-related pathology and behaviors among children and adolescents; and (4) further development of her acceptance-based, emotion regulation group therapy for self-harm behavior among women with BPD.

Abstract of Dr. Gratz’s Paper: 

“Preliminary Data on an Acceptance-Based Emotion Regulation Group Intervention for Deliberate Self-Harm among Women with Borderline Personality Disorder”

Borderline personality disorder (BPD) and deliberate self-harm are clinically-important conditions for which additional economically and clinically feasible interventions are needed. Literature on both the emotion regulating and experientially avoidant function of self-harm and the role of emotional dysfunction in BPD provided the rationale for developing a group intervention targeting emotion dysregulation among self-harming women with BPD. This study provides preliminary data on the efficacy of this new, 14-week, emotion regulation group intervention, designed to teach self-harming women with BPD more adaptive ways of responding to their emotions so as to reduce the frequency of their self-harm behavior. Participants were matched on level of emotion dysregulation and lifetime frequency of self-harm and randomly assigned to receive this group in addition to their current outpatient therapy (N=12), or to continue with their current outpatient therapy alone for 14 weeks (N=10). Results indicate that the group intervention had positive effects on self-harm, emotion dysregulation, experiential avoidance, and BPD-specific symptoms, as well as symptoms of depression, anxiety, and stress. Participants in the group treatment condition evidenced significant changes over time on all measures, and reached normative levels of functioning on most. While these preliminary results are promising, the study’s limitations require their replication in a larger-scale randomized controlled trial.

Biographical Information:

Dr. Gratz is Research Assistant Professor and Director of the Personality Disorders Division of the Center for Addictions, Personality, and Emotion Research (CAPER) in the Department of Psychology at the University of Maryland. Dr. Gratz received her Ph.D. in Clinical Psychology from the University of Massachusetts Boston in 2003, where her research focused on the risk factors for and functions of self-harm behavior. She completed her pre-doctoral internship training, with an emphasis on the treatment of BPD, at McLean Hospital/Harvard Medical School. In July 2003, she was awarded the Psychosocial Fellowship from McLean Hospital/Harvard Medical School. In her role as Clinical and Research Fellow under the mentorship of John G. Gunderson, MD, Dr. Gratz conducted a study examining the efficacy of a new emotion regulation group therapy for the treatment of self-harm among women with BPD and developed a research program to assess the effectiveness of the Borderline Center, McLean Hospital’s specialty clinical services for BPD. During this time, she also served as a primary clinician within McLean Hospital’s DBT program, providing individual and group DBT to clients with BPD and related disorders. In 2004, Dr. Gratz received a grant from the Psychosocial Foundation of McLean Hospital to conduct a preliminary experimental investigation of emotion dysregulation in BPD. She joined the Clinical Psychology Program at the University of Maryland in September 2005.

Selected Publications:

Bornovalova, M. A., Gratz, K. L., Delany-Brumsey, A., Paulson, A., & Lejuez, C. W. (in press). Temperamental and environmental risk factors for borderline personality disorder among inner-city substance users in residential treatment. Journal of Personality Disorders.

Fliege, H., Kocalevent, R., Walter, O. B., Beck, S., Gratz, K. L., Gutierrez, P., & Klapp, B. F. (in press). Three assessment tools for deliberate self-harm and suicide behavior: Evaluation and psychopathological correlates. Journal of Psychosomatic Research.

Gratz, K. L. (in press). Risk for repeated deliberate self-harm among female college students: The role and interaction of childhood maltreatment, emotional inexpressivity, and affect intensity/reactivity. American Journal of Orthopsychiatry.  

Gratz, K. L., & Gunderson, J. G. (in press). Preliminary data on an acceptance-based emotion regulation group intervention for deliberate self-harm among women with borderline personality disorder. Behavior Therapy.

Gratz, K. L., Lacroce, D., & Gunderson, J. G. (in press). Measuring changes in BPD-relevant symptoms following short-term treatment at the partial hospital and intensive outpatient levels of care. Journal of Psychiatric Practice.

Tull, M. T., Gratz, K. L., & Lacroce, D. (in press). The role of anxiety sensitivity and lack of emotional approach coping in the presence of depressive symptom severity among non-clinical uncued panickers. Cognitive Behaviour Therapy.

Chapman, A. L., Gratz, K. L., & Brown, M. Z. (2006). Solving the puzzle of deliberate self-harm: The experiential avoidance model. Behaviour Research and Therapy, 44, 371-394.

Gratz, K. L., Tull, M. T., & Wagner, A. W. (2005). Applying DBT mindfulness skills to the treatment of clients with anxiety disorders. In L. Roemer & S. M. Orsillo (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualizations and treatment (pp. 147-161). New York: Springer.

Gunderson, J. G., Gratz, K. L., Neuhaus, E., & Smith, G. (2005). Levels of care in the treatment of personality disorders. In  J. M. Oldham, A. E. Skodol, & D. E. Bender (Eds.), Textbook of Personality Disorders (pp. 239-255). Washington, DC: American Psychiatric Publishing.

Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment, 26, 41-54.

Tull, M. T., Gratz, K. L., Salters, K., & Roemer, L. (2004). The role of experiential avoidance in posttraumatic stress symptoms and symptoms of depression, anxiety, and somatization. Journal of Nervous and Mental Disease, 192, 754-761.

Gratz, K. L. (2003). Risk factors for and functions of deliberate self-harm: An empirical and conceptual review. Clinical Psychology: Science and Practice, 10, 192-205.

Gratz, K. L., & Orsillo, S. M. (2003). Scientific expert testimony in CSA cases: Legal, ethical, and scientific considerations. Clinical Psychology: Science and Practice, 10, 358-363.

Gratz, K. L., Conrad, S. D., & Roemer, L. (2002). Risk factors for deliberate self-harm among college students. American Journal of Orthopsychiatry, 72, 128-140. 

Gratz, K. L. (2001). Measurement of deliberate self-harm: Preliminary data on the Deliberate Self-Harm Inventory. Journal of Psychopathology and Behavioral Assessment, 23, 253-263. 

2004: Christian Schmahl

Introduction – “Lay” explanation – Formal abstract – More biography – Selected peer publications

Alan Fruzzetti, PhD, Young Investigator Award Committee Chairperson and NEA-BPD Research Advisor had the pleasure of presenting Christian Schmahl, MD the YIA Award and introducing him to the audience at the 3rd Family Perspectives conference in Los Angeles on Sunday October 17, 2004.

Introduction

Since 1996, Dr. Schmahl has served as Director of Neurobiology Research Program at the Borderline Research Unit, Department of Psychiatry and Psychotherapy, University of Freiberg, and since 2003 as Assistant Medical Director Research Coordinator, and also as group leader of “Functional Imaging,” at the Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health, Mannheim, Germany.

A “lay” explanation of Dr. Schmahl’s work

Of his work, Dr. Schmahl writes: “My interest is a double one. First, I had been working with BPD patients for several years and one of the things that first caught my interest was the near complete absence of pain that most of these patients reported when they hurt themselves. This was different from other patients I had seen so far. Also, I saw how these patients suffered from their states of inner tension and that often self-injuries were the only way to resolve these states. The more research we did on disturbed pain perceptions and processing, the more it became clear that there is some fundamental alteration that makes pain and pain processing such an important part of the BPD symptomatology. This is my second interest, from a basic research point of view, to search for the basis of this alteration, which may lie in brain physiology.

Basically, we found: That patients with BPD feel less pain than do other people that the higher the tension and dissociation, the less pain the BPD patients feel that there is some fundamental alteration in brain physiology when BPD patients process painful stimuli that (probably) the better the patients get through therapy, the more normal their pain processing becomes.”

The formal abstract of Dr. Schmahl’s paper

Neural correlates of antinociception in borderline personality disorder

Borderline personality disorder (BPD) is characterized by reduced pain sensitivity in conjunction with self-injurious behaviour. Our findings from a study using laser-evoked pain potentials suggest that sensory-discriminative pain components seem to be unaffected in this patient population and affective or cognitive pain components may be altered in BPD. To assess dysfunction of these components we used painful heat stimuli in combination with psychophysical evaluation and functional magnetic resonance imaging to examine neural processes underlying pathologically reduced pain sensitivity in BPD. Patients with BPD and healthy, age matched controls were investigated under two stimulus conditions: A fixed temperature (43°C) and a temperature matched to yield the same perceived pain intensity. Compared to normal controls, patients had higher pain thresholds and showed less brain activation when stimulated with the fixed temperature. With the same perceived pain intensity, the overall volume of activation was similar, but regional patterns differed significantly: BPD patients exhibited stronger activation signals in the dorsolateral prefrontal cortex and weaker signals in the posterior parietal cortex. In patients but not in controls, we found that pain induced a signal decrease in the perigenual anterior cingulate gyrus and in the amygdala. Our data suggest that reduced pain sensitivity in BPD may be related to recruitment of antinociceptive circuits in the anterior cingulate and dorsolateral prefrontal cortex accompanied by reduced activity in cognitive evaluative networks.

Further biographical information

Dr. Schmahl earned his MD in 1996 at the Universities of Mainz and Giessen in basic brain research; from 1996-2003 he did his residency and training in psychiatry and behavioral therapy at Freiberg, followed by work in Intensive DBT training at the University of Washington 1997-1998, and in 2000 a Research Fellowship at Yale in neuroimaging. Honors include 1996 Magna cum laude, University of Mainz; 2003 Young Investigator Award, Borderline Personality Research Foundation.

Research support from 2000 to present include Research Grant of the German Research Foundation: Funding of Research Fellowship at Yale University, Dr. J.D. Bremner, to learn methods of neuroimaging and script-driven imagery; Research Grant of the University of Freiburg: Funding for the instalment of neuroimaging research methods;Travel Grant of the German Research Foundation for participation at the XIIth World Congress of Psychiatry, Yokohama, Japan. Current research support is the 2003–2005 Young Investigator Award of the Borderline Personality Disorder Research Foundation, Title: “Investigation of pain processing in patients with BPD,” funding for research of pain processing in patients with BPD using Psychophysiological as well as neuroimaging (fMRI) methods; and 2004- 2007 Collaborative Research Grant 636, German Research Foundation, Title: “Learning, Memory and Brain Plasticity: Implications for Psychopathology”, coinvestigator. This project involves multiple programs investigating cognitive, affective, and psychophysiological aspects of behavioral learning in psychiatric disorders.

Selected peer-reviewed publications

1. Schmahl, C.G., Böhmer, G.: Effects of excitatory amino acids and neuropeptide Y on the discharge activity of suprachiasmatic neurons in rat brain slices. Brain Research 746 (1997) 151-163

 2. Bohus, M.J., Landwehrmeyer, G.B., Stiglmayr, C.E., Limberger, M.F., Böhme, E.R., Schmahl, C.G.: Naltrexone in the treatment of dissociative symptoms in patients with Borderline Personality Disorder: An open-label trial. Journal of Clinical Psychiatry 60 (1999) 598-603

 3. Schmahl, C., Bohus, M.: Symptomorientierte Pharmakotherapie bei Borderline-Persönlichkeitsstörung (Symptom-focussed pharmacotherapy in borderline Personality disorder). Fortschritte der Neurologie und Psychiatrie 69 (2001) 310-321

 4. Schmahl, C.G., McGlashan, T.H., Bremner, J.D.: Neurobiological correlates of borderline personality disorder. Psychopharmacology Bulletin 36 (2002) 69-87

 5. Schmahl, C.1, Juengling, F.D.1, Heßlinger, B., Ebert, D., Bremner, J.D., Gostomzyk, J., Bohus, M., Lieb, K.: Positron emission tomography in female patients with Borderline Personality Disorder. Journal of Psychiatric Research 37 (2003) 109-115 (1 Both authors contributed equally to this work)

 6. Schmahl, C.G., Vermetten, E., Elzinga, B.M., Bremner, J.D.: Magnetic Resonance Imaging of Hippocampal and Amygdala Volume in Women with Childhood Abuse and Borderline Personality Disorder. Psychiatry Research: Neuroimaging 122 (2003) 109-115

 7. Schmahl, C.G., Elzinga, B.M., Vermetten, E., Sanislow, C., McGlashan, T.H., Bremner, J.D.: Neural Correlates of memories of abandonment in Women with and without Borderline Personality Disorder. Biological Psychiatry 54 (2003) 142-151

 8. Rüsch, N., Tebartz van Elst, L., Wilke, M., Thiel, T., Ludaescher, P., Huppertz, H.-J., Schmahl, C., Bohus, M., Lieb, K., Heßlinger, B., Hennig, J., Ebert, D.: A Voxel-based Morphometric MRI Study in Female Patients with Borderline Personality Disorder. NeuroImage 20 (2003) 385-392

 9. Elzinga, B.M., Schmahl, C.G., Vermetten, E., Van Dyck, R., Bremner, J.D.: Higher cortisol levels following exposure to traumatic reminders in abuse-related PTSD. Neuropsychopharmacology 28 (2003)1656-1665.

 10. Schmahl, C.G., Vermetten, E., Elzinga, B.M., Bremner, J.D.: A PET study of memories of childhood abuse in Borderline Personality Disorder. Biological Psychiatry 55 (2004) 759-765

 11. Schmahl, C.G., Greffrath, W., Baumgärtner, U., Schlereth, T., Magerl, W., Philipsen, A., Lieb, K., Bohus, M., Treede, R.-D.: Differential nociceptive deficit in patients with borderline personality disorder and self-injurious behavior: Laser-evoked potentials, spatial discrimination of noxious stimuli, and pain ratings. In press

 12. Schmahl, C.G., Elzinga, B.M., Ebner, U., Simms, T., Sanislow, C., Vermetten, E., McGlashan, T.H., Bremner, J.D.: Psychophysiological reactivity to traumatic and abandonment scripts in Borderline Personality Disorder and PTSD. Psychiatry Research 126 (2004) 33-42

 13. Bremner, J.D., Vermetten, E., Vythilingam, M., Afzal, N., Schmahl, C., Elzinga, B., Charney, C.S.: Neural correlates of the classical neutral and emotional stroop in women with abuse-related posttraumatic stress disorder. Biological Psychiatry 55 (2004) 612-620

 14. Bohus, M., Haaf, B., Simms, T., Schmahl, C., Unckel, C., Linehan, M.: Effectiveness of inpatient dialectical behavioral therapy for borderline personality disorder – a randomized controlled trial. Behavior Research and Therapy 42 (2004) 487-499

 15. Philipsen, A., Schmahl, C., Lieb, K.: Naloxone in the Treatment of Acute Dissociative States in Female Patients with Borderline Personality Disorder. Pharmacopsychiatry 37 (2004) 196-199

 16. Lieb, K., Zanarini, M., Schmahl, C., Linehan, M., Bohus M.: Borderline Personality Disorder. Lancet 364 (2004) 453-461

17. Berlis, A., Scheufler, K.-M., Schmahl, C., Rauer, S., Götz, F., Schumacher, M.: Solitary spinal artery aneurysms as a rare source of spinal SAH: Discussion of potential etiology and treatment strategy. American Journal of Neuroradiology in press

 18. Philipsen, A., Richter, H., Schmahl, C., Peters, J., Rüsch, N., Bohus, M., Lieb, K.: Clonidine in acute aversive inner tension and self-injurious behavior in female patients with borderline personality disorder. Journal of Clinical Psychiatry 65 (2004) 1414-1419

2004: Dr. Catherine DeSoto

Introduction – Personal interest - Formal abstract – Biographical information – Published works / articles

Introduction

Dr. DeSoto received her PhD in 2001 at the University of Missouri under the supervision of Dr. David C. Geary. She believes that BPD is a poorly understood disorder that disrupts the lives of not only those so diagnosed, but their family and friends and hopes that her basic science research will eventually lead to a more comprehensive understanding of the causes and  influencing factors, and ultimately, better treatment options and outcomes for sufferers. Her research, which has been featured in journals ranging from Science to First for Women, suggests that changing levels of estrogen might make the symptoms of borderline personality worsen, at least among women who have at least some pre-existing symptoms associated with BPD. Although the findings would be characterized as preliminary, women who have noted their symptoms may seem to worsen with hormonal changes (such as with commencing oral contraceptive use) might consider discussing these findings with their doctors.

Personal interest

Dr. DeSoto is interested in exploring the links between hormone levels, neural mechanisms and traits that have been shown to differ across males and females. Although borderline personality disorder is a much-researched disorder, it is still one whose etiology is not well understood. Having spent a year running a homeless shelter for women before going to graduate school, she worked first-hand with women whose lives and those of their families had been turned upside down. She was struck by the rather sharp changes in functioning across time, and realized that the factors that cause the waxing and waning of problem behaviors were not well understood. In graduate school, she became again interested in understanding all the factors, especially those that have to do with brain function, that come together to bring about worsening of symptoms in individuals with various types of mental health problems. Her recent research findings suggest that estrogen may play a significant role in the expression of borderline personality traits. In addition to the basic research finding that hormonal fluctuations may be a biological mechanism that contributes to the expression of this disorder, her research has important practical implications as well. If borderline personality is exacerbated by estrogen, then there may be pharmacological interventions that could be more effective than those currently available. Furthermore, the use of synthetic estrogen, such as those found in birth control pills, may be contra-indicated among certain populations. Secondary areas of research interest include mathematical development, eating behavior, and language development. Broadly interested in how brain function affects behavior, Dr. DeSoto has done research involving various brain imaging techniques, including ERP's, optical imaging and MRI.

Comment on responses to her research article:

"I have been honored to receive a surprisingly large number of emails from women diagnosed with BPD-- and also from their family members -- who have anecdotally reported that a worsening of symptoms either after starting birth control pills or during other times of hormonal changes. I very much hope that research on BPD continues to broaden the knowledge base of the disorder, and that findings reach the larger community of those affected by it."

Abstract of Dr. DeSoto’s paper:

The results from three studies with three different samples are reported and suggest the importance of a previously unknown factor in the expression of borderline personality disorder (BPD). Estrogen, which has been shown to relate to a wide variety of behavioral traits and pathologies, may play a significant role in the expression of BPD. The first study included a non-clinical sample of 226 women. Symptoms of BPD were assessed by means of the personality assessment inventory, borderline scales (PAI-BOR; L.C. Morey, 1991). The results showed that women exhibit more BPD symptoms during times in their menstrual cycle when estrogen is rising and women who were using oral contraceptives showed more symptoms of BPD, as well. Study two employed a within subjects design in which 52 women were measured four times across their menstrual cycle and provided salivary samples at each test session. The samples were assayed and estrogen levels were obtained. The principle finding was that variation in estrogen levels predicted the presence of BPD symptoms (r =.4, p < .01). Further support for the hypothesis that estrogen mediates the expression of BPD was provided by the finding that this relationship remained significant when a general increase in negative symptoms was statistically controlled. Study three employed a pre-post Oral Contraceptive (OC) design with a control group. It was found that among women who have high levels of BPD symptoms prior to beginning OC, symptoms became significantly worse after starting the pill (F (3,42) = 4.7; p < .01). Research findings that link the serotonin system and estrogen are reviewed and theoretical and practical implications of the findings are discussed.

Biographical information

Catherine was born in Birmingham, Alabama and grew up in Carterville, Illinois. She is married to Dr. Robert Hitlan. She will be speaking on her research regarding hormonal influences on BPD as an invited speaker at the Midwest Psychological Association’s Annual Meeting in Chicago, in May 2005.

Education:

1989 BA Summa Cum Laude Southern Illinois University-Carbondale

Major: Psychology

1998 MA University of Missouri-Columbia

Major: Experimental Psychology

Thesis: The event-related optical signal and motor cortex activation

2001 PhD University of Missouri under the supervision of Dr. David C. Geary.

Dissertation: The influence of estrogen on borderline personality disorder.

Publications

Geary, D. C., Hoard, M. K., Craven, J.B & DeSoto, M.C. (2004). Strategy choices in simple and complex addition: Contributions of working memory and counting knowledge for children with mathematical disability. Journal of Experimental Child Psychology.

DeSoto, M.C. (2003). Drops in estrogen levels affect brain and behavior: reported relationships between attitudes and menopausal symptoms. Maturitas, 45.

DeSoto, M.C. & Buelow-Kopp, K. (2003). Evolutionary theory, waist-to-hip ratio and predicting female attractiveness. Psychology, Evolution and Gender, 5, 83-88.

DeSoto, M.C. Geary, D.C., Hoard, M.K., Sheldon, M. & Cooper, M. L. (2003). Estrogen variation, oral contraceptives and borderline personality. Psychoneuroendocrinology, 28. 751-766.

DeSoto, M.C. (2003). A brief reply to Bloch: The issue is women's health. Maturitas, 45, 299-301.

Geary, D.C., DeSoto, M.C., Hoard, M.K., Sheldon, M. & Cooper, L (2002). Estrogens and relationship jealousy. Human Nature , 12, 299-320.

Geary, D.C. & DeSoto, M.C. (2001). Sex differences in spatial abilities among adults from Unites States and mainland China Implications for Evolutionary Theory. Evolution and Cognition.

DeSoto, M.C., Fabiani, M., Geary, D., & Gratton, G. (2001) When in doubt do it both ways: Brain evidence of simultaneous activation of conflicting motor responses in a spatial Stroop task. Journal of Cognitive Neuroscience.

Gratton, G., Fabiani, M., Goodman-Wood, M. R., & DeSoto, M. C. (1998). Memory-driven processing in human medial occipital cortex: An event-related optical signal (EROS) study. Psychophysiology., 35, 348-51. 

For details on Dr. DeSoto’s peer reviewed published abstracts, conference presentations, and works in progress, and further biographical information, see her web site: http://fp.uni.edu/desoto/