رابطه شناخت ناسازگارانه در مورد خواب و بهبود در بیماران مبتلا به اختلال شخصیت مرزی

Borderline personality disorder (BPD) has been associated with maladaptive cognitive processes including dysfunctional attitudes and a negative attribution style. Comorbid insomnia affects the course of multiple psychiatric disorders, and has been associated with the absence of recovery from BPD. Because dysfunctional beliefs and attitudes are common among patients with insomnia, the purpose of this study was to evaluate the association between maladaptive sleep-related cognitions and recovery status (symptomatic remission plus good concurrent psychosocial functioning) in patients with BPD. Two hundred and twenty three BPD patients participating in the McLean Study of Adult Development (MSAD) were administered the Dysfunctional Beliefs and Attitudes about Sleep questionnaire (DBAS-16) as part of the 16-year follow-up wave. Maladaptive sleep cognitions were compared between recovered (n=105) and non-recovered (n=118) BPD participants, in analyses that adjusted for age, sex, depression, anxiety, and primary sleep disorders. Results demonstrated that non-recovered BPD patients had significantly more severe maladaptive sleep-related cognitions as measured by the overall DBAS-16 score. These results demonstrate an association between dysfunctional beliefs and attitudes about sleep and recovery status among BPD patients. Further research is warranted to evaluate treatments targeted towards maladaptive sleep-related cognitions, and their subsequent effects on the course of BPD.

Borderline personality disorder (BPD) is a common psychiatric disorder, that is a significant cause of morbidity and mortality, and is associated with considerable societal costs (Grant et al., 2008 and Soeteman et al., 2008). As a disorder, BPD is characterized by pervasive patterns of identity disturbance, interpersonal difficulties, impulsivity, and affective dysregulation that result in significant functional impairment (American Psychiatric Association, 2000). In addition, BPD patients demonstrate disturbed cognitive processes, including non-psychotic thinking (e.g., non-delusional paranoia, unusual perceptions [e.g., depersonalization], and odd thinking [e.g., ideas of reference centering on beliefs that one is stupid, bad, or evil]) and more rarely, quasi-psychotic thinking, which improve, but variably resolve, over the longitudinal course of the disorder (Zanarini et al., 1990 and Zanarini et al., 2013). Moreover, patients with BPD may attend to negative stimuli, make biased evaluations, and endorse a range of critical beliefs about themselves and their experiences (Baer et al., 2012). However, it is not clear how such maladaptive cognitive strategies may be related to the development and maintenance of BPD over time (Baer et al., 2012). Insomnia is an important factor that affects the course of multiple psychiatric disorders. Prospective morbidity studies have demonstrated that untreated insomnia is associated with an increased risk of major depressive disorder (MDD) and anxiety disorders (Ford and Kamerow, 1989, Breslau et al., 1996, Chang et al., 1997, Weissman et al., 1997, Morphy et al., 2007, Neckelmann et al., 2007, Buysse et al., 2008, Jansson-Frojmark and Lindblom, 2008 and Szklo-Coxe et al., 2010). In addition, insomnia is a highly treatment-resistant symptom (Carney et al., 2007 and Dombrovski et al., 2007), increases the risk of relapse to depressive episodes (Paykel et al., 1995, Karp et al., 2004 and Dombrovski et al., 2007), and increases suicidal ideation and the risk of suicide (Goldstein et al., 2008, Wojnar et al., 2009 and Fitzgerald et al., 2011). Although not part of the current diagnostic criteria for BPD (American Psychiatric Association, 2000), sleep-related complaints are common in the disorder, with several studies demonstrating subjective sleep disturbance in BPD (Philipsen et al., 2005, Bastien et al., 2008 and Schredl et al., 2012). Given the associations between insomnia and the course of other psychiatric disorders, and cross-sectional data which has correlated subjective sleep quality with measures of BPD symptomatology and self-harm inventories (Sansone et al., 2010), research that examines the role of sleep in the course of BPD is an important area of investigation. The cognitive model of psychopathology, which has been applied to myriad psychiatric disorders, including BPD, suggests that the processing of external events and internal stimuli is biased, leading to distortion of a patient's construction of his/her experiences and resultant cognitive errors. Dysfunctional beliefs become incorporated into cognitive schemas, which tend to bias information processing and produce typical cognitive content of a given disorder (Beck, 2005). Cognitive models for insomnia have also been developed (Harvey, 2002), in which individuals with insomnia tend to be overly worried about their sleep and the consequences associated with their sleep disturbance, resulting in counterproductive behaviors and erroneous beliefs about sleep, which, in turn, exacerbate and perpetuate insomnia. Targeting dysfunctional beliefs about sleep is an important component of cognitive–behavioral therapy for insomnia (CBT-I), a highly efficacious therapy for both primary insomnia and insomnia comorbid with psychiatric disorders (Edinger et al., 2009 and Morin and Benca, 2012). Notably, CBT-I results in decreases in maladaptive cognitions about sleep that further correlate with other areas of clinical improvement in insomnia sufferers, such as enhanced sleep efficiency and quality, suggesting that interventions targeted toward maladaptive sleep cognitions may have broad therapeutic effects (Edinger et al., 2001 and Morin et al., 2002). Despite the predisposition for maladaptive cognitive processes among BPD patients, and reports of sleep disturbance in the disorder, to our knowledge, prior studies have neither examined dysfunctional beliefs about sleep in BPD, nor assessed the association between maladaptive sleep cognitions and recovery from the disorder. Longitudinal data, collected over 16 years of prospective follow-up, from the McLean Study of Adult Development (MSAD), one of two longitudinal studies to investigate the course of BPD, suggests that 40–60% of BPD patients attain recovery from BPD, defined as remission of symptoms as well as good social and vocational functioning, but that 20–44% of BPD patients have a subsequent loss of recovery status (Zanarini et al., 2012). Recent cross-sectional analysis of MSAD data from the 16-year follow-up wave has further demonstrated an association between sleep disturbance, as measured by the Pittsburgh Sleep Quality Index (Buysse et al., 1989), and recovery status, such that non-recovered BPD patients were more likely to demonstrate impairments in global sleep quality, increased difficulties with sleep initiation, and higher rates of sedative-hypnotic use compared to recovered BPD patients, even when age, sex, and comorbid sleep and psychiatric disorders were included as covariates in adjusted analyses (Plante et al., 2013). Given the role dysfunctional sleep-related cognitions play in the development and perpetuation of insomnia, the contribution insomnia makes to the course of other psychiatric disorders, and cross-sectional data demonstrating association between sleep disturbance and absence of recovery from BPD, we examined maladaptive sleep-related cognitions in subjects participating in MSAD to explore the relationship between these dysfunctional thought processes and recovery from BPD. We hypothesized that non-recovered BPD patients would have more severe maladaptive cognitions about sleep compared to participants who had attained recovery from the disorder.