Biosocial correlates of identity disturbance among suicidal youth

The current study was designed to examine biosocial correlates of identity disturbance in a sample of suicidal youth at high risk for borderline personality disorder compared with community controls. We used a multimethod, multi-informant design to examine vulnerability and risk for identity disturbance, including biological assessments, self- and informant-report. Participants' electrodermal responding (EDR), respiratory sinus arrhythmia (RSA), and fundamental frequency were collected during a motherchild discussion task regarding adolescents' personality characteristics. We predicted (1) suicidal adolescents would endorse greater overall identity distress across more domains compared with community controls, and (2) that biological vulnerabilities (e.g., EDR, RSA) and contextual risks (e.g., parent emotional arousal assessed with digital signal processing) would interact to predict higher self-reported identity distress among suicidal adolescents. Results indicate significant differences on identity scales for control and self-injuring adolescents. However, indices of biological and contextual risk did not interact to predict identity problems. Methodological limitations of the current study are discussed, along with implications for future research.

BIOSOCIAL CORRELATES OF IDENTITY DISTURBANCE AMONG SUICIDAL YOUTH by Erin A. Kaufman A thesis submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Master of Science Department of Psychology The University of Utah August 2014 Copyright © Erin A. Kaufman 2014 All Rights Reserved The Univ e r s i t y of Utah Graduat e School STATEMENT OF THESIS APPROVAL The thesis of Erin A. Kaufman has been approved by the following supervisory committee members: Sheila Crowell Chair 4.22.2014 Date Approved Patricia Kerig Member 4.22.2014 Date Approved Brian Baucom Member 4.22.2014 Date Approved and by Carol Sansone Chair of the Department of ________________________ Psychology and by David B. Kieda, Dean of The Graduate School. ABSTRACT The current study was designed to examine biosocial correlates of identity disturbance in a sample of suicidal youth at high risk for borderline personality disorder compared with community controls. We used a multimethod, multi-informant design to examine vulnerability and risk for identity disturbance, including biological assessments, self- and informant-report. Participants' electrodermal responding (EDR), respiratory sinus arrhythmia (RSA), and fundamental frequency were collected during a mother-child discussion task regarding adolescents' personality characteristics. We predicted (1) suicidal adolescents would endorse greater overall identity distress across more domains compared with community controls, and (2) that biological vulnerabilities (e.g., EDR, RSA) and contextual risks (e.g., parent emotional arousal assessed with digital signal processing) would interact to predict higher self-reported identity distress among suicidal adolescents. Results indicate significant differences on identity scales for control and self-injuring adolescents. However, indices of biological and contextual risk did not interact to predict identity problems. Methodological limitations of the current study are discussed, along with implications for future research. To my many mentors who have encouraged my pursuit of science and the study of the vulnerable populations. TABLE OF CONTENTS ABSTRACT........................................................................................................................... iii ACKNOWLEDGMENTS......................................................................................................vi INTRODUCTION...................................................................................................................1 Adolescent Self-Injury and Risk for B PD ................................................................ 3 Identity Disturbance and Risk for BPD.................................................................... 4 Psychophysiological Correlates.................................................................................7 Family Process.......................................................................................................... 10 The Current Study.....................................................................................................11 METHOD.............................................................................................................................. 12 Participants.................................................................................................................12 Measures....................................................................................................................13 Procedure....................................................................................................................17 Analytic Plan............................................................................................................. 18 RESULTS.............................................................................................................................. 23 DISCUSSION.......................................................................................................................32 REFERENCES 36 ACKNOWLEDGMENTS I would like to express my appreciation for my advisor, Dr. Sheila Crowell, who has guided me through this research. I would also like to thank my committee members, Drs. Patricia Kerig and Brian Baucom, who have challenged me through thought provoking questions. I have the deepest appreciation for their generosity with their time and professional guidance. Finally, I would like to thank the research participants and the many undergraduate research assistants without whom this study would not have been possible. INTRODUCTION Borderline personality disorder (BPD) is one of the most costly and debilitating mental conditions (Trull, Distel, & Carpenter, 2011). The diagnosis is characterized by marked disturbances in self-concept and persistent interpersonal, emotional, cognitive, and behavioral dysfunction (American Psychiatric Association [APA], 2000). BPD is the most common personality disorder (PD), affecting around 2% of community adults, 10% of outpatients, and 20% of inpatients (Lenzenweger, Lane, Loranger, & Kessler, 2007; Trull, Jahng, Tomko, Wood, & Sher, 2010; Widiger & Trull, 1993). Over half of those with BPD engage in repetitive self-inflicted injury (SII) and as many as 10% eventually commit suicide (APA, 2006; Selby, Bender, Gordon, Nock, & Joiner, 2012). Although there are very few prospective studies of borderline personality development, self-injuring adolescents are one population that may be at elevated risk for the adult diagnosis (Crowell, Beauchaine, & Linehan, 2009). BPD is defined as a disorder that typically emerges in late adolescence or early adulthood (APA, 2000). Although research on childhood borderline pathology (BP) developed in tandem with adult literature, existing research with youth is very limited in scope (Crowell, Kaufman, & Lenzenweger, 2012). This is disappointing since earlier identification of those at risk could lead to targeted intervention and prevention efforts. Indeed, many BPD features appear prior to age 18, including impulsive behaviors, repetitive self-inflicted injury, poor self-concept, and extreme emotional lability (Crowell, et al., 2012; Kernberg, 1990; Shiner, 2009). All of these features are under­examined as risk factors for the adult condition, in spite of a growing interest in the etiology and pathogenesis of borderline traits (see Lenzenweger & Cicchetti, 2005). In particular, identity disturbance, or a "markedly and persistently unstable self-image or sense of self' has received relatively little empirical attention in the clinical literature, despite its inclusion as one of the nine diagnostic criteria for BPD (APA, 2000). Some scholars assert that identity disturbance is a "core" feature of BPD, making its under­examination even more surprising (Meares, Gerull, Stevenson, & Korner, 2011; Wilkinson-Ryan & Westen, 2000). Diagnostic criteria for BPD were designed specifically for adults. However, establishing a coherent identity has long been considered a normative developmental task undertaken during adolescence (Erikson, 1950; Erikson, 1968). Sense of self appears to develop much earlier, by the age of 6 or 7 (Davies, 2010). Therefore, it seems logical to study youth during these developmental time points in order to elucidate difficulties in the identity formation process. Developmental theories of identity disturbance and borderline personality highlight the interactive effects of child vulnerabilities and contextual risk factors (Crowell, et al., 2009; Linehan, 1993). Biological vulnerabilities, such as trait impulsivity, may lead to more severe psychopathology for youth raised within high-risk environments (Beauchaine, Klein, Crowell, Derbidge, & Gatzke-Kopp, 2009). In contrast, families, schools, and communities that adapt and provide support may be protective for vulnerable youth, leading to especially good developmental outcomes (Boyce & Ellis, 2005; Rutter, 2006). Research on family context indicates that risk for psychopathology is elevated when vulnerable youth are raised in high-conflict environments (Beauchaine, 2 et al., 2009; Crowell et al., under review). These biology x environment interactions not only shape child behaviors, but may also affect internal processes such as identity development (Linehan, 1993). Research examining the biological correlates of BPD has also emerged recently. For example, measures of autonomic nervous system (ANS) functioning are associated with some of the core vulnerabilities that confer risk for BPD, including trait impulsivity and emotion dysregulation (Beauchaine, Katkin, Strassberg, & Snarr, 2001; Crowell et al., 2005). These traits can be indexed through sympathetic and parasympathetic nervous system responding when the experiment and stimulus conditions are controlled carefully (Beauchaine, 2012; Crowell et al., 2012; Crowell, et al., 2005; Thorell, 2009). Despite increasing research on biological and psychosocial correlates of borderline personality development, no one has examined the relation between identity disturbance and psychophysiological responding, much less during parent-child conflict. Adolescent Self-Injury and Risk for BPD One behavioral marker of BPD that has received considerable attention is self­inflicted injury (SII), which can be divided into injury with and without suicidal intent (Zlotnick, Mattia, & Zimmerman, 1999). SII has traditionally been studied by suicide researchers, yet it may also be a developmental precursor to BPD (Crowell et al., 2009; Lamph, 2011). BPD and SII share many biological and contextual vulnerabilities, personality traits, and coping strategies (see Crowell, Kaufman & Lenzenweger, in press for a review). Thus, although SII and BPD are distinct clinical issues (Centers for Disease Control and Prevention [CDC], 2009; Nock et al., 2008; Zanarini, Laudate, Frankenburg, 3 Reich, & Fitzmaurice, 2011), they may derive from a common etiology (Crowell et al., in press). In fact, Crowell and colleagues have proposed that SII and BPD may represent two points along a heterotypically continuous borderline trajectory (Crowell, Derbidge, & Beauchaine, in press), and that SII increases vulnerability to other BPD features (Crowell et al., 2009). Trait impulsivity and emotional sensitivity are early-emerging biological vulnerabilities that confer risk for SII and BPD and co-aggregate in families of those affected by these conditions (Crowell, et al., 2009; Crowell, Kaufman, et al., in press; White, Gunderson, Zanarini, & Hudson, 2003). These traits may be related to other important risk factors like identity disturbance, which occurs earlier in development and likely precedes BP. Since self-injurious behaviors typically arise in adolescence (CDC, 2008), studying families of these at-risk youth could elucidate whether biological vulnerabilities and contextual risks (e.g., family dynamics) interact to predict higher identity distress among suicidal adolescents. Identity Disturbance and Risk for BPD Despite the dearth of empirical evidence, there is a rich theoretical literature outlining the importance of identity disturbance in borderline personality development. Psychodynamic theorists (e.g., Kernberg, 1975; 2005), claim that identity diffusion in BPD derives from a "splitting" of a purely positive (idealized) and a purely negative (persecutory or paranoid) self-representation. The person fails to integrate various aspects of the self into a meaningful whole (Fonagy, Luyten, & Strathearn, 2011; Kernberg, 2005). As a result, individuals with BPD develop a vague and chaotic view of the self, 4 5 with abrupt discontinuities and rapid changes, disjointed thinking, and a sense of inner emptiness (Adler & Buie, 1979; Buie & Adler, 1982; Kernberg, 2006). Empirical studies conducted by Westen and colleagues lend some validation to this conceptualization (Westen & Cohen, 1993; Westen, Lohr, Silk, Gold, & Kerber, 1990). They devised a coding system and analyzed responses to projective tests from adolescents with BP features. These youths struggled to differentiate themselves from others and also described self-other relationships as malevolent, victimizing, and unempathic. They often responded in an "all-good" or "all-bad" fashion to prompts and expressed unstable, severely negative, self-representations. Mahler, Pine, and Bergman (1994) hypothesize that this splitting process begins within the early child-caregiver relationship. In fact, many identity-related problems among persons with BPD have been conceptualized as arising within the family context. Taking a developmental approach, Sroufe (e.g., 1990) and Sander (1975) conceptualize the self as stemming from the infant-caregiver relationship, where dyadic regulation precedes self-regulation abilities (see also Hughes, Crowell, Uyeji, & Coan, 2012). Autonomy and ownership of the self arise through the gradual formulation of an inner framework of attitudes, expectations, and feelings based on social, interactive experiences with the caregiver (see Sroufe, 1990 for a review of self-development during early life stages). Carlson, Byron, and Sroufe (2009) linked attachment problems during infancy with eventual self-concept disruption and later BP features in adulthood in a low-income community sample. Further, they found that a better self-representation in childhood and adolescence mediated the relation between attachment disorganization (assessed in infancy) and BPD symptoms in adulthood. Thought distortions common to BPD are also thought to begin within the primary attachment relationship. Persons with BPD appear to have distorted beliefs concerning others' perceptions of them and/or a diminished capacity to conceptualize the way others experience them (King-Casas et al., 2008). Fonagy hypothesizes that we learn about who we are when we see ourselves through another's perspective (Fonagy, Steele, Steele, & Moran, 1991). Children who are vulnerable to later BPD may have difficulty seeing themselves through the eyes of others, which may affect their ability to develop a coherent sense of identity. Similarly, Linehan claims that the process of identity formation requires self­observation and observing other's reactions to your behavior. In order to develop a coherent sense of self, individuals require emotional consistency and predictability over time and across similar situations (Heard & Linehan, 1993). According to Linehan's theory, identity disturbance and BPD itself develop within an emotionally invalidating environment (1993). An invalidating environment is one in which a child's expressions of private emotional experiences are dismissed or rejected. Extreme emotional expressions may be intermittently reinforced, and the child learns that he should cope with emotional experiences alone. The invalidating environment often leads to erratic emotional lability in the child, which interferes with identity development by leading to unpredictable patterns of behavior and incongruent cognitions. Further, the child often fails to develop the skills necessary to understand, label, regulate, or tolerate emotional responses. If the child's interpretation of events is never judged as "correct" by those around him, then he may also develop an overdependence on others, further impeding identity formation. To summarize, Westen and Cohen (1993) have outlined key components of identity 6 7 disturbance in BPD. These include (1) inconsistent investment in goals, values, ideals, and relationships; (2) temporary hyperinvestments in roles, value systems, world views, and relationships; (3) dramatically inconsistent behavior over time and across situations; (4) difficulty integrating multiple self-representations; (5) an incoherent life narrative or sense of continuity; and (6) discontinuity of relationships that leaves the person with a past that is replete with people who are no longer part of their life, and, therefore, missing the shared memories that help to define the self over time. Given that identity distress may be a key feature of BPD and other maladaptive outcomes, research in this area could benefit from the development of prevention efforts targeting at-risk youth. Researchers should utilize young samples since identity consolidation takes place largely during adolescence (Erikson, 1968). Identity disturbance appears to be a multifaceted and multiply determined construct. Based on current theories, the processes that disrupt healthy identity formation may overlap with those that shape emotional and behavioral control (Heard & Linehan, 1993). Perhaps an interaction between biological and contextual risks will predict identity-related problems, as is the case with emotion dysregulation and impulsivity (Beauchaine, Hinshaw, & Pang, 2010). Biologically vulnerable youth raised in high-conflict environment may be at especially high risk for disturbed/lack of identity. Psychophysiological Correlates Psychophysiological measures of ANS functioning have been linked to behavioral features that confer risk for BPD (Crowell, et al., 2012). Electrodermal and cardiac measures are among the most commonly used indices. Electrodermal responding (EDR) is the product of eccrine sweat gland activation, which is almost exclusively triggered by the sympathetic nervous system (SNS). EDR is considered a reliable index of SNS responding to affective stimuli, and the neural pathways that control EDR have been explored across several animal and human studies (Roy, Sequeira, & Delerm, 1993; Sequeira & Roy, 1993; Shields, MacDowell, Fairchild, & Campbell, 1987; Wallin, 1981; Williams et al., 2000). EDR is correlated with brain activation across regions that assess the significance of the stimuli (e.g., the anterior cingulated, the ventromedial prefrontal cortex, and the right inferior parietal region), and when the stimulus has an emotional valence, the amygdala and orbitofrontal cortex are also activated. This often results in a more pronounced electrodermal response. Eccrine glands are less responsive to thermal changes in the environment, making EDR a more reliable marker of psychological processes like arousal and emotion. This is particularly true when the experiment is well controlled and stimulus conditions are designed to effectively elicit emotional responses (Dawson, Schell, & Filion, 2007). Low skin conductance and reduced EDR reactivity have been found among those with both SII (for a meta-analysis, see Thorell, 2009) and BPD (Ebner-Priemer et al., 2005; Herpertz, Kunert, Schwenger, & Sass, 1999; Schmahl et al., 2004). Self-injuring adolescents exhibit lower resting EDR than both a depressed and typical control groups (Crowell et al., 2012). Researchers have also consistently found that attenuated EDR is a biomarker for deficits in inhibitory capacity, which is a key symptom of BPD (Beauchaine, 2001; Crowell et al., 2012; Fowles, 1988). These patterns of low EDR among those with BPD and SII is consistent with known deficits in biological systems governing behavioral inhibition - specifically serotonergic dysfunction (5HT; Arango, 8 Huang, Underwood, & Mann, 2003; Paris et al., 2004). Serotonergic signals stemming from the raphe nuclei have effects on brain regions including the amygdala and septo-hippocampal system. These structures interact to inhibit prepotent behaviors when a person faces competing motivational goals (Brenner, Beauchaine, & Sylvers, 2005; Fowles, 2000). For example, persons who self-injure often feel unable to stop their behavior, despite the negative consequences associated with SII (e.g., interpersonal conflict, scarring, or death; Crowell et al., 2012). Low EDR is also a reliable biomarker of poor behavioral inhibition among those with severe externalizing disorders (Beauchaine, 2001; Beauchaine et al., 2001; Crowell et al., 2006; Lorber, 2004). Parasympathetic influences on the body are often assessed through cardiac activity. Respiratory sinus arrhythmia (RSA) is a frequently used measure of heart rate (HR) variability that is mediated by the vagus nerve (Beauchaine, 2001). This nerve applies an inhibitory effect on HR during low stress conditions, maintaining a flexible regulatory state within the body. HR is relatively slow and consistent during these periods. Vagal control is withdrawn during periods of stress (i.e., in the presence of threatening stimuli). In these situations, HR increases so the person can meet environmental demands. Once the provoking stressor is removed, vagal activity should return to a tonic inhibitory state and HR should return to baseline. High RSA is typically associated with high attentional and self-regulatory capacity among young adults (Porges, 2007). Low RSA and more pronounced decreases in RSA during exposure to stressors are often observed among clinical samples and under conditions that provoke emotion dysregulation (Beauchaine, 2001; Crowell et al., 2005). ! 9 Family Process Developmental psychopathology researchers have theorized that BP features arise from failing important early childhood tasks that are shaped within the family context, including attachment, self-regulation, and self-development (Macfie, 2009; Macfie & Swan, 2009; Sroufe, Egeland, Carlson, & Collins, 2005). BP features such as aggression, emotional dysregulation, and emotional lability are often promoted and maintained through family processes characterized by emotional invalidation and conflict escalation (Beauchaine, Gatzke-Kopp, & Mead, 2007; Crowell et al., under review). Both parents and children may contribute to the dysfunctional family patterns. Children with biological predispositions for challenging behaviors may elicit poor reactions from caregivers, escalating risk for developing more severe problems (e.g., O'Connor, Deater-Deckard, Fulker, Rutter, & Plomin, 1998). Families may fall into a pattern where coercive interactions frequently occur, impacting the development and maintenance of internalizing and externalizing problems among youth (Patterson, 2002; Snyder, Edwards, McGraw, & Kilgore, 1994; Snyder, Schrepferman, & St. Peter, 1997). Coercive interactions are driven by principles of negative operant reinforcement. One family member uses aversive tactics in an attempt to reduce unpleasant or unwanted behaviors of other family members. An example would be a mother yelling at her child to lower his voice. These families may learn that the most successful way to end a disagreement is to escalate the conflict. In this way, the other family member is motivated to escape and the conflict is temporarily resolved. However, eventually the child in the previous example may raise the conflict himself by yelling over his mother. The mother has a choice to either abandon the disagreement (reinforcing 10 11 the child's response), or to up the intensity of the conflict by engaging in an even more aversive behavior (such as spanking the child). Intermittent success of these behaviors makes it difficult for families to alter or discontinue their patterns. Family processes and biological vulnerabilities that contribute to BPD's emergence are just beginning to be examined, and hold great promise for identifying at risk youth. Thus, using physiological measures in conjunction with direct assessments of family interactions could elucidate developmental antecedents to BPD. The Current Study The purpose of the current study is to examine biosocial correlates of identity disturbance within a sample of suicidal youth at high risk for borderline personality disorder. We will also examine patterns of identity dysfunction in this sample as compared with typical community controls. We will use a multimethod, multi-informant design to examine vulnerability and risk for borderline pathology, including biological assessments, self- and informant-report, and diagnostic interviews. We have two hypotheses. First, suicidal adolescents will endorse greater overall identity distress across more domains compared with community controls. Second, biological vulnerabilities (e.g., EDR, RSA) and contextual risks (e.g., parent emotional arousal assessed with digital signal processing) will interact to predict higher self-reported identity distress among suicidal adolescents METHOD Participants Thirty 14-17-year-old community adolescents and 30 adolescents who have recently attempted suicide (i.e., within 2 months prior to study participation) were invited to participate with their biological mothers (see Table 1 for demographic information). Inclusion criteria for suicidal adolescents will include a minimum threshold of (1) moderate lethality and (2) some suicidal intent on the Lifetime Suicide Attempt Self-Injury Interview (L-SASII), described below. Our lethality threshold was represented by a minimum score of 3 on the SASH (e.g., overdose on 11-50 pills; deep cuts anywhere but neck; igniting flammable substance on limb). Our intent threshold for inclusion was represented by a score of 4 or higher on the SASH (e.g., I was thinking about it and was somewhat serious). Suicidal adolescents with mental retardation, psychosis, or a schizophrenia spectrum diagnosis were excluded as the etiology and function of suicide attempts may be distinct within these populations (APA, 2000). Control participants were excluded if they had a history of any Axis I or Axis II diagnosis, or any suicidal behavior. Persons in both groups were excluded if they have a history of epilepsy, seizures, heart disease, or asthma, or if they were taking major tranquilizers, tricyclics, antihistamines, or beta blockers, as these may have interfered with physiological measures. Suicidal participants and their mothers were recruited from both outpatient and inpatient psychiatry at a local neuropsychiatric hospital, adolescent medicine, and online classifieds (e.g., Criagslist). Eligible participants recruited from the community or outpatient clinics were screened over the phone or during a convenient time. Trained graduate and undergraduate research assistants conducted inpatient recruitment on the unit several times a week. Parents were called for permission to screen their children, when in-person permission could not be easily obtained. Adolescents were approached for study screening during appropriate times (e.g., unstructured free time and visitation). The screening interview consisted of the L-SASII (described below), inclusion/exclusion criteria, and demographic survey. Because hospitalized adolescents and their families were often distressed while on the unit, lab-based visits were scheduled to occur post­hospitalization. Community controls were recruited through fliers distributed to households in the community, online community postings, and word of mouth. Households for direct mailers were selected by a mailing service that identifies addresses for families with children within the target age range. Participants were compensated with $40 for their time, or $50 if they arrived with a total of four family members to complete a larger study protocol. This study was approved by the Institutional Review Board at the University of Utah. Measures Screening The Lifetime Suicide Attempt Self-Injury Interview (L-SASII; formerly the Lifetime Parasuicide Count; Linehan & Comtois, 1996) is a 20-minute interview that captures the 13 frequency, lethality, suicidal intent, and level of medical care for all lifetime self-injurious acts. Internal consistency on the subscales of the SASII range from excellent to fair (a = .93 for suicide intent; a = .63 for suicide communication). Interrater reliability has also been reportedly high using this instrument (Mdn = .956, range = .871 to .978). Adult Report on Child Psychopathology and Personality Traits Mothers completed the NEO Five Factor Inventory-3 (NEO-FFI-3) Form R (observer rating) Adolescent version. The NEO-FFI-3 is a 60-item instrument that provides a quick, reliable, and accurate measure of five domains of personality (neuroticism, extraversion, openness, agreeableness, and conscientiousness). Mothers filled out the observer rating form about their adolescent who recently attempted suicide (if recruited from the inpatient unit) or an age matched control (if recruited from the community). Internal consistency coefficients for the NEO-PI-3 form R range from .78 to .88, and 2-week test-retest reliability coefficients range from .86 to .90. Evidence of good to excellent convergent and discriminant validity have also been established (see McCrae & Costa, 2010 for a summary of available evidence). Diagnostic Interviews Borderline personality symptoms were assessed using the Structured Clinical Interview for DSM-IV personality disorders (SCID-II; First, Spitzer, Gibbon, & Williams, 1996). The SCID-II is a widely used semistructured interview with excellent reliability. Barnow and colleagues (2006) used the BPD criteria section of the interview and found a k of 0.83 for the interrater agreement between the two independent 14 15 interviewers. Self-Report Questionnaires The Child Depression Inventory (CDI) is a 27-item measure of depressive symptoms that comprises five subscales, including negative mood, interpersonal problems, ineffectiveness, and negative self-esteem (Kovacs, 1992). Psychometric properties of the CDI are adequate (a values ranging from .61 to .91 for internal consistency and test-retest reliability; Gadow et al, 2002). The Positive and Negative Affect Schedule (PANAS) is a trait measure of positive and negative affectivity scored on a 5-point Likert scale (Watson, Clark, & Tellegen, 1988). The PANAS consists of 10 negative affect items (e.g., "irritable," "guilty") and 10 positive affect items (e.g., "proud," "enthusiastic") and participants are asked to rate how much they feel/have felt these emotions in a specified period of time. For this study, adolescents completed two versions of the PANAS. One that inquires about their affect over the previous 2 weeks, and another that inquires about their current affect. The PANAS has good test-retest reliability (.79-.81) and high internal consistency with a values ranging from .85 to .90 (Watson et al., 1988). The Difficulties in Emotion Regulation Scales (DERS) is a self-report measure to assess difficulties in emotion regulation across multiple dimensions (Gratz & Roemer, 2004). The DERS has high internal consistency (a = .93), good test-retest reliability (p/ = 88, P < .01), and adequate construct and predictive validity. Adolescents also completed the NEO Five Factor Inventory-3 (NEO-FFI-3) Form S (self-report) Adolescent version (described above). Finally, participants completed the Self-Concept and Identity Measure (SCIM), which assesses identity disturbance (Kaufman, Cundiff, & Crowell, under review). Internal consistency of the scale is excellent (Cronbach's a = .89). Test-retest reliability is also excellent (a = .93, r = .88) with an intraclass correlation coefficient (ICC) of .88. The SCIM has three subscales: consolidated identity, disturbed identity, and lack of identity. It assesses the core aspects of identity such as self-concept and role continuity across environments and with different persons, consistencies in values and interests, self-worth, self-differentiation, and self-cohesion (summarized in Table 2). Psychophysiological Measures EDR and RSA were collected using Mindware hardware and scored using the Mindware EDA v. 3.0.9 and Mindware HRV 3.0.10 software packages. This equipment can time link the stimulus presentation, physiological recording, and participant facial expressions for behavioral coding and behavior-physiology concordance. EDR data were acquired with two standard 0.8-cmAg- AgCl electrodes attached to the thenar eminence of the participant's nondominant hand with adhesive electrode washers and a 0.05 molar NaCl solution. Nonspecific skin conductance responses were scored as fluctuations exceeding 0.05 p,S. Change scores were calculated for EDR reactivity by subtracting baseline values from those obtained during the task. RSA was calculated using spectral analysis at a sampling rate of 1000 hz. 16 17 Digital Signal Processing Emotional arousal during a family discussion task was measured though nonverbal, paralinguistic properties of speech using digital signal processing (DSP). During speech production, vocal folds in the larynx create patterns of vibration, measured in Hertz (Hz) The listener perceives this vibration as the pitch of a given sound (faster vibration corresponds to higher pitch). DSP uses computer algorithms to extract parameters from digital waveforms from recorded speech (Baucom, Atkins, & Christensen, 2009; Owren & Bachorowski, 2007). When examining emotional arousal, these algorithms focus on measuring the fundamental frequency (f0) of family member's speech from audio recordings. F0 refers to the lowest frequency harmonic (or overtone) of vocal patterns of vibration (Juslin & Scherer, 2005). Higher f0 levels have been linked to higher levels of emotional arousal (see Scherer, 2003 for a review). Audio files were analyzed using Praat, which produces mean, minimum, and maximum f0 values that are needed to calculate range of f0 for mothers during a family discussion task (Boersma & Weenink, 2005). Procedure During the lab-based procedure, adolescents and their mothers completed their respective assessment materials independently on secure computers in private rooms. Trained graduate and undergraduate research assistants conducted diagnostic interviews and risk assessment protocols. Adolescents and their mothers each completed a copy of the PANAS to assess their affect over the past 2 weeks. Following these procedures, participants were asked to fill out The NEO-FFI-3, rating the adolescent's personality traits on a Likert scale. Research assistants compared adolescent and parent responses to identify the item with the most disagreement (the largest discrepancy in selected responses to the same item) and the item with the greatest agreement (the most convergence between the 3 individuals' responses). When multiple items were rated equally discrepantly or consistently, discussion topics were chosen based on which were most likely to produce a lengthy discussion consistent with the purpose of each task. For example, agreement items were chosen such that their discussion would surround adolescents' positive qualities. Disagreement items were selected with the purpose for promoting moderate conflict. Family dyads then engaged in a discussion task where they were instructed to discuss their reasoning for selecting their own response to the discrepant NEO item. EDR, RSA, and nonverbal, vocal responses were measured for mother adolescent pairs over the course of the discussion. Following the discussion, participants filled out a copy of the PANAS to assess their current affective experience. This process was then repeated for the convergent NEO item. Analytic Plan Our first hypothesis, "suicidal adolescents will endorse greater overall identity distress across more domains compared with community controls," was examined with a Multivariate Analysis of Variance (MANOVA), comparing the high-risk group and control group on total and subscale scores from the SCIM. Our second hypothesis is that biological vulnerabilities (e.g., EDR, RSA) and contextual risks (mother's emotional arousal assessed with digital signal processing) will 18 interact to predict higher self-reported identity distress among suicidal adolescents. In order to test this hypothesis, we ran two multiple linear regression models. The first examined the interactive and main effects of adolescent RSA and mother f0. RSA and EDR values were calculated by subtracting participants' mean resting baseline values from their mean responses across the 5-minute disagree task. The variable mother f represents the mean of mother f0 ranges during the disagreement portion of the discussion task. The second model will examine the interactive and main effects of mother f and EDA on adolescent SCIM total score. To test for interactions, we regressed the dependent variable (SCIM total score) on the two predictors for each equation (RSA, mother f0; EDR, mother f0 ) and on the Predictor x Predictor Product vector (i.e., RSA x mother f), EDR x mother f0). An interaction model is supported when the product vector is significant, regardless of the significance of the main effects. 19 Table 1 Participant Demographics. Control Clinical Mothers Adolescents Mothers Adolescents Age M(SD) 42.03(5.43) 15.47(1.04) 40.89(5.76) 15.76(1.21) Gender Female 30(100.0%) 17(56.7%) 30(100.0%) 22(73.3%) Male 13(43.3%) 8(26.7%) Ethnicity Hispanic 3(10.0%) 4 (13.3%) 2(6.7%) 3(10.0%) Non-Hispanic 26(86.7%) 26 (86.7%) 25(83.3%) 26(86.7%) Decline 3(10.0%) Missing 1(3.3%) 1(3.3%) Race Asian 1(3.3%) Black 1(3.3%) Caucasian 28(93.3%) 25(83.3%) 27(90.0%) 26(86.7%) Native Hawaiian or Pacific 1(3.3%) Islander Other 3(10.0%) 2(6.7%) 2(6.7%) Missing 1(3.3%) 1(3.3%) Decline to answer 1(3.3%) 1(3.3%) Sexual Orientation Heterosexual 28(93.3%) 22(73.3%) 30(100.0%) 13(43.3%) Lesbian 1(3.3%) Gay 1(3.3%) Bisexual 6(20.0%) Other 1(3.3%) 5(16.7%) Unsure 1(3.3%) 2(6.7%) 1(3.3%) Decline to answer 4(13.3%) 3(10.0%) Missing 1(3.3%) 1(3.3%) Table 2 Central Identity-Related Terms. Term___________________________Description____________________ Identity Individuals begin to make commitments to others and take on consolidation roles they internalize as self-defining. They experience themselves as consistent over time and across contexts, and demonstrate stable beliefs, attitudes and values. (Erikson, 1968; Marcia, 1994; Westen, 1985) Identity crisis A transitory period when identity is no longer in sync with past self-concept (Erikson, 1956). Identity Pathological in nature and manifests as sustained incoherence diffusion or confusion about who one is, difficulty committing to typical roles, and a tendency to acquire the thoughts, feelings, and beliefs of others in place of establishing one's own (Erikson, 1956; Kernberg, 2006; Westen & Heim, 2003; Wilkinson- Ryan & Westen, 2000). Self-concept The process by which a person learns to behave differently in differentiation different contexts. Identity When persons fail to integrate their various social experiences fragmentation into a core self (Donahue, Robins, Roberts, & John, 1993). _____________ Implications____________ A functioning identity allows the person to navigate major life tasks, achieve intimacy with others, and find a place in society. This period of change often results in an inconsistency between how those who are close to the adolescent view him or her, and how the individual views him or herself May lead to an incapacity for intimate relationships, indecision about major life choices, and a sense of inner emptiness (Erikson, 1956; Kernberg, 2006) Higher levels of SCD have been linked with poor psychological adjustment (Donahue et al., 1993). Higher levels of have been linked with poor psychological adjustment (Donahue et al., 1993). Table 2 Continued Term Description Self­complexity The false-self Self-concept clarity (SCC) Self continuity The adaptive form of the identity differentiation process (Lutz & Ross, 2003). Adolescents may create several ‘identities' in order to conform with expectations from different relationships and effectively enact their social roles. The false-self can develop as a result of taking on contradictory attributes in various social roles (Harter, 1997, 2006; Harter et al., 1997; Harter & Monsour, 1992). The differentiation process can incur doubt about one's true self, or which identity is authentic. False-self behaviors can develop, where an individual acts in ways that are inconsistent with how the individual truly views him or herself. The extent to which beliefs about the self are clearly defined, consistent with self-knowledge, and temporally stable (Campbell et al., 1996). There is a demonstrated link between SCC and global-self esteem (Campbell, 1990; Campbell, Chew, & Scratchley, 1991; Campbell & Fehr, 1990). Stability of identity across persons and environments. Implications Opposing self-attributes may cause internal conflict (especially during mid­adolescence), yet these should diminish and the individual should become more integrated over time (Harter, Bresnick, Bouchey, & Whitesell, 1997). Low self-esteem combined with false-self behavior are predicative of depressive symptoms (Harter, 1998; Harter, Marold, Whitesell, & Cobbs, 1996) Improvements to SCC and self-esteem may play a role in alleviating identity disturbance among BPD clients (Roepke et al., 2011). Has been consistently linked to psychological wellbeing among Western cultures (Campbell, Assanand, & Di Paula, 2003; Diehl, Hastings, & Stanton, 2001; Erikson, 1968; Lutz & Ross, 2003; Sheldon, Ryan, Rawsthorne, & Ilardi, 1997) RESULTS In order to characterize our sample, participant means and standard deviations on clinical scales and fundamental frequency are reported in Table 3. One-way ANOVAs comparing means by group on these scales are also reported. Since the SCIM is a novel measure, we performed an independent samples Mest to examine potential differences in adult and adolescent SCIM total scores. There was a significant difference in mother (M=54.78, SD= 16.09) and adolescent scores, (M=90.48, SD=32.66); t(\\6)=-7.53,p = 0.00, with adolescents receiving higher scores than mothers. This finding was replicated when clinical families were excluded, t(57)=-3.6$,p = 0.02; however, there were no significant differences in total SCIM scores among mothers and adolescents in the clinical group only, t(57)=-9.83,p = 0.21. In order to assess the effectiveness of the discussion task for evoking emotional arousal, we examined PANAS and NEO scores by group, across task phases (baseline, agree, and disagree). A MANOVA indicated mother and adolescent scores did not differ significantly on NEO reports (i.e., mother and adolescent reports of adolescent personality factors did not differ significantly across either the control or clinical group; see Table 4). Clinical and control group participants did differ on positive and negative affect ratings at all three task stages (see MANOVA results in Table 5); however, only control participants' PANAS ratings appear to have changed across discussion task phases (see ANOVA results in Table 6). Adolescent total and subscale SCIM scores were examined with a MANOVA to compare the high-risk self-injuring and control groups. Results of evaluation of assumptions of normality and homogeneity of variance-covariance matrices all were satisfactory. Most research on parent-child interaction tasks with self-injuring adolescents has only included female participants. As we recruited both male and female participants, we chose to control for the effects of sex. A one-way analysis of variance (ANOVA) demonstrated there were no significant differences in the number of males and females by group, F(1, 59) = 2.61, p > .05; therefore, it was deemed acceptable for adolescent sex to be covaried out of our model. This procedure ensured results are not better attributable to effects of participant sex. MANOVA results demonstrated significant effects by group for our overall model (Wilks' Lambda = .421, multivariate effects F (2, 59) = 24.729), SCIM total score F(1, 59) = 56. 40, p = .00, qp2 = .50, and each of the three subscales (SCIM stable subscale; F(1, 59) = 26.33, p = .00, qp2= .32; SCIM unstable; F(1, 59) = 25.18, p = .00, qp2= .31; SCIM lack of identity; F(1, 59) = 75.79, p = .00, qp2= .58). Effect sizes ranged from moderate to large with SCIM total and SCIM lack of self scales producing the largest effects. These findings indicate there are differences on the SCIM by group status and provide evidence in favor of our first hypothesis (see Table 3). We ran two multiple linear regression equations to assess the effects of adolescent psychophysiology, mother fundamental frequency, and their interaction. Predictors were mean centered and evaluation of assumptions of normality, linearity, and homoscedasticity were satisfactory for both tests. The main and interactive effects of mother f0 and adolescent RSA during the disagree portion of the discussion task on 24 adolescent SCIM scores were tested with a linear multiple regression model. The main effects for mother f0 , F (3, 50) = 0.04, p > .05, and adolescent RSA, F (3, 50) = .15, p >.05 were not significant. Their interactive effect was also nonsignificant, F (3, 50) = - 0.05, p > .05 with an R squared value of .001. The main and interactive effects of mother f and adolescent EDA during the disagree portion of the discussion task on adolescent SCIM scores were also tested with a linear multiple regression model. The main effects for mother f), (F (3, 40) = 0.13, p > .05), and adolescent EDA, (F (3, 40) = -0.63, p >.05) were not significant. Their interactive effect was also nonsignificant, F (3, 40) = 0.07, p > .05 with an R squared value of .01. These results indicate the interactive effects of mother f and child psychophysiology did not predict adolescent SCIM scores. 25 Table 3 Clinical Scales and Fundamental Frequency by Group. n Mother M(SD) n Adolescent M(SD) n Mother M(SD) CDI raw scores N/A N/A 30 5.2(4.90) N/A N/A SCIM Total 29 50.79(12.48) 23 67.77(21.57) 30 58.63(18.34) SCIM Stable 29 21.31(5.40) 23 25.80(7.21) 30 23.70(5.00) SCIM Unstable 29 19.45(5.20) 30 30.37(12.62) 30 22.23(8.84) SCIM Lack of identity 29 10.03(4.97) 30 11.60(6.34) 30 12.70(6.91) DERS Total 29 66.35(17.79) 30 64.57(18.56) 30 75.03(19.85) DERS Non-acceptance 29 10.86(4.20) 30 9.23(4.24) 30 11.33(3.46) DERS Goals 29 11.04(4.37) 30 10.10(4.26) 30 12.23(4.32) DERS Impulse 29 9.45(3.56) 30 8.97(3.20) 30 10.10(3.94) DERS Awareness 29 13.10(5.14) 30 15.17(5.67) 30 16.57(5.12) n 29 18 18 29 29 29 29 29 29 29 Adolescent Adolescent Mother M(SD) ANOVA ANOVA _____________ ^(significance) ^(significance) 26.83(8.82) 113.97(24.56) 38.14(10.36) 46.00(11.25) 29.83(9.06) 121.52(22.85) 19.00(6.72) 18.83(4.09) 17.38(5.89) 21.41(5.54) 136.66(0.00)* 59.04(0.00)* 28.34(0.00)* 25.17(0.00)* 80.63(0.00)* 110.82(0.00)* 44.91(0.00)* 64.35(0.00)* 46.19(0.00)* 18.31(0.00)* N/A 3.66(0.06) 3.11(0.08) 2.16(0.15) 2.88(0.10) 3.13(0.08) 0.22(0.64) 1.12(0.29) 0.44(0.51) 6.73(0.01)* to O n Table 3 Continued n Mother M(SD) n Adolescent M(SD) n Mother M(SD) n Adolescent M(SD) Adolescent ANOVA F(significance) Mother ANOVA F(significance) DERS Strategies 29 11.52(470) 30 10.13(4.68) 30 12.73(4.45) 29 24.86(5.87) 113.90(0.00)* 1.04(0.31) DERS Clarity 29 8.52(2.94) 30 9.20(2.85) 30 9.93(3.17) 29 16.10(4.90) 44.14(0.00)* 3.16(0.08) SCID BPD (9-27 scale) 29 12.00(3.82) 30 10.33(1.95) 30 14.50(4.34) 30 17.45(4.87) 199.53(0.00)* 5.61(0.02)* SCID MDD (9-27) 30 12.63(4.45) 30 10.87(2.75) 30 16.97(3.70) 30 20.40(3.38) 77.77(0.00)* 16.81(0.00)* Self-inflicted injury (yes or no) 30 N/A 30 N/A 30 N/A 30 N/A 188.50(0.00)* 16.52(0.00)* FO mean across discussion 28 144.65(23.12) 27 150.55(42.73) 29 136.16(26.97) 29 167.48(39.11) 2.40(0.13) 1.68(0.20) to Table 4 NEO Subscale Scores for Adolescent Personality Factors by Group. Control Clinical Mother Report of Adolescent M(SD) Adolescent Report M(SD) Difference M(SD) Mother Report of Adolescent M(SD) Adolescent Report M(SD) Difference M(SD) One-way ANOVAs (comparing factors by group) MANOVA by group F-value (significance) Neuroticism 2.70(0.37) 2.63(0.37) 0.38(0.25) 3.22 (0.49) 3.24 (0.24) 0.43 (0.30) 0.53(0.47) 0.53 (0.47) Extroversion 3.32(0.28) 3.29(0.22) 0.28(0.19) 3.00 (0.36) 3.13 (0.34) 0.38 (0.29) 2.47(0.12) 2.47 (0.12) Contentiousness 3.32(0.32) 3.46(0.24) 0.28(0.31) 3.07 (0.34) 3.11 (0.39) 0.38 (0.23) 1.69(0.20) 1.69 (0.20) Agreeableness 2.79(0.38) 2.78(0.34) 0.36(0.26) 2.89 (0.45) 2.93 (0.47) 0.44 (0.30) 1.12(0.30) 1.12(0.30) Openness 3.07(0.26) 3.14(0.23) 0.29(0.23) 3.01 (0.33) 3.07 (0.30) 0.31 (0.23) 0.14(0.71) 0.14(0.71) to 00 Table 5 PANAS means, standard deviations, and MANOVA results comparing clinical and control participants. ____________ Control_________________________ Clinical__________________________________________ Mother Adolescent Mother M(SD) Adolescent MANOVA by Effect size M(SD) M(SD) M(SD) group F-value (significance) PANAS Baseline* Positive 39.57(8.54) 45.33(8.12) 31.83(7.35) 26.28(9.75) 69.32(0.00)** 0.37 Negative 24.80(6.96) 21.77(5.81) 34.20(11.80) 40.69(13.00) 59.53(0.00)** 0.34 PANAS Disagree Positive 30.67(11.96) 29.23(13.02) 26.57(9.63) 22.72(7.81) 7.27(0.01)** 0.06 Negative 16.23(2.39) 18.17(3.02) 20.03(7.57) 22.48(8.48) 13.49(0.00)** 0.10 PANAS Agree Positive 33.47(11.50) 29.70(13.19) 27.97(9.64) 26.59(9.56) 4.90(0.03)** 0.04 Negative 16.33(3. 17.13(4.42) 17.27(3.67) 18.48(6.51) 1.82(0.18)** 0.02 to VO Table 5 Continued Control Adolescent M(SD) Clinical Mother M(SD) Adolescent M(SD) MANOVA by group F-value (significance) Effect size Change score Disagree task Positive -8.90(10.86) -16.10(11.24) -5.27(9.79) -3.55(11.59) 16.31(0.00)* 0.12 Negative -8.57(7.07) -3.60(6.27) -14.17(10.80) -18.21(13.57) 30.94(0.00)* 0.21 Change score agree task Positive -6.10(9.56) -15.63(11.10) -3.87(9.35) 0.31(8.62) 22.93(0.00)* 0.16 Negative -8.47(8.23) -4.63(6.10) -16.93(12.09) -22.21(12.37) 49.03(0.00)* 0.29 Table 6 One-way ANOVAs Comparing Baseline PANAS Scale to Agree and Disagree PANAS Scores. Control /'-value Clinical /'-value _______________________________ (significance)___________(significance)___________ PANAS agree Positive 1.79(0.06) 1.10(0.40) Negative 2.63(0.00)* 0.74(0.80) PANAS Disagree Positive 2.43(0.01)* 0.70(0.824) Negative 1.10(0.39) 0.877(0.64) DISCUSSION The current study aimed to investigate biosocial correlates of identity disturbance within a sample of suicidal youth and community controls. Our first hypothesis that identity dysfunction ratings would vary by group was supported, as there appear to be significant differences on SCIM total and subscale scores for control and self-injuring adolescents. Additionally, adolescents in the control condition received higher SCIM scores than control mothers (indicating more identity-related problems). These results are consistent with developmental literature, which claims a certain degree of identity distress is developmentally normative among adolescents, and should subside by adulthood (Erikson, 1956; Harter, Bresnick, Bouchey, & Whitesell, 1997). However, our results also demonstrate self-injuring adolescents are struggling above and beyond their age matched peers. The SCIM has previously been validated among adults (Kaufman et al., under review), and these preliminary findings indicate it may also be useful for identifying identity problems among youth. Our second hypothesis that child biological vulnerabilities would interact with environmental stressors to predict SCIM scores was not supported. This may be a valid finding, however, several methodological limitations may also have contributed to this outcome. First, the discussion task may not have been poignant enough to elicit sufficient emotional arousal or coercive family processes. Previously validated parent-child interaction tasks often employ discussion topics that are more conflictual and evocative than NEO-FFI-3 items. For example, Crowell et al. (2008) found physiological differences between self-injuring and control adolescents when discussing items rated as highly contentious for mother/child dyads on topics such as chores and curfew. Such topics are likely to be more salient than many NEO items as they typically arise with some frequently. Per our observation, families rarely discussed disagreement or agreement items for the allotted time (5 minutes) before straying to other subjects or becoming silent. Additionally, few families exhibited observable symptoms of distress during the disagreement task (raised voices, negative affect, etc.), lending further evidence to the hypothesis that the task failed to produce adequate emotional reactions. Further, many dyads made similar item ratings (e.g., within one or two likert options as opposed to opposite ends of the scale), making it challenging to identify "disagree" discussion topics. In fact, our results indicate mother and adolescent scores did not differ significantly on NEO reports (see Table 4). Occasionally, adolescents did not understand the content of a selected item (e.g., misunderstanding the term "egocentric"), rendering the discussion task invalid. Our results also show that although control and clinical participants differed on their self-report experiences of positive and negative affect across the discussion task, only control participants' PANAS ratings changed across discussion task phases (see Tables 5-6). Had this study utilized a previously validated instrument in mother-child interaction tasks, we may have found group differences on biological and environmental measures. Small sample size coupled with missing physiological data could also have contributed in part to our null results. Electrodermal responding and respiratory sinus 33 34 arrhythmia values were compromised for several participants. This could be due to several reasons, including researcher error (e.g., poor electrode placement), participant characteristics (e.g., obesity), and behaviors (e.g., medication usage, excessive fidgeting). Given that our clinical sample was largely recruited from an inpatient setting, many of these participants were taking multiple medications in moderate to heavy doses. Although we excluded participants taking medications with well-documented effects on psychophysiological responding (e.g., beta-blockers), many participants were taking a combination of medications that could have influenced our results. The results of the present study did little to elucidate the mechanisms by which clinically significant identity disturbance emerge. However, our findings point to the importance of assessing identity-related outcomes among youth. Suicidal adolescents are more likely to experience identity problems across multiple domains compared to age matched controls. Further, these symptoms appear to accompany other important markers of behavioral and emotional dyscontrol (see Table 3). Further research on identity disturbance across the developmental lifespan is sorely needed. Identity-related research has flourished for decades, yet important questions remain unanswered. The distinction between normative identity-related struggles (e.g., crisis) and pathological identity disturbance is largely unexamined and warrants investigation. Future research should examine how early in the developmental trajectory these problems surface, how responsive these individuals are to identity interventions (e.g., cite), and what proportion of these individuals will go on to experience clinical problems in adulthood. Identity and identity dysfunction are important constructs for mental health practitioners and researchers interested in personality, psychopathology, and emotional development. Longitudinal research is needed to establish where identity problems fall developmentally in a borderline trajectory. 35 REFERENCES Adler, G., & Buie, D. H. (1979). Aloneness and borderline psychopathology: The possible relevance of child development issues. The International Journal o f Psychoanalysis, 60, 83-96. American Psychiatric Association. (2000). Diagnostic and Statistical Manual ofMental Disorders. Fourth Edition, Text Revision. Washington, D.C.: Author. American Psychiatric Association. (2006). Practice guidelines for the treatment o f psychiatric disorders: Compendium. Arlington, VA: Author. Arango, V., Huang, Y.-Y., Underwood, M. D., & Mann, J. J. (2003). Genetics of the serotonergic system in suicidal behavior. Journal o f Psychiatric Research, Brain Imaging, and Post-Mortem Studies in Affective Disorders, 37, 375-386. Barnow, S., Spitzer, C., Grabe, H. J., Kessler, C., & Freyberger, H. J. (2006). Individual characteristics, familial experience, and psychopathology in children of mothers with borderline personality disorder. Journal o f the American Academy o f Child and Adolescent Psychiatry, 45, 965-972. doi: 10.1097/01.chi.0000222790.41853.b9 Baucom, B. R., Atkins, D. C., & Christensen, A. (2009). Digital signal processing and computational linguistic methods for measuring emotional arousal and power processes during interaction, Couples Special Interest Group o f ABCTNewsletter. Beauchaine, T. P. (2001). Vagal tone, development, and Gray's motivational theory: Toward an integrated model of autonomic nervous system functioning in psychopathology. Development and Psychopathology, 13, 183-214. doi: 10.1017/S0954579401002012 Beauchaine, T. P. (2012). Physiological markers of emotion and behavior dysregulation in externalizing psychopathology. Monographs o f the Society for Research in Child Development, 77, 79-86. doi: 10.1111/j.1540-5834.2011.00665.x Beauchaine, T. P., Gatzke-Kopp, L., & Mead, H. K. (2007). Polyvagal theory and developmental psychopathology: Emotion dysregulation and conduct problems from preschool to adolescence. Biological Psychology, 74, 174-184. doi: 10.1016/j.biopsycho.2005.08.008 37 Beauchaine, T. P., Hinshaw, S., & Pang, K. C. (2010). Comorbidity of attention-deficit/ hyperactivity disorder and conduct disorder: Biological, environmental, and developmental mechanisms. Clinical Psychology Science and Practice, 17, 327-336. Beauchaine, T. P., Katkin, E. S., Strassberg, Z., & Snarr, J. (2001). Disinhibitory psychopathology in male adolescents: Discriminating conduct disorder from attention-deficit/hyperactivity disorder through concurrent assessment of multiple autonomic states. Journal o f Abnormal Psychology, 110, 610-624. doi: 10.1037//0021-843X.110.4.610 Beauchaine, T. P., Klein, D. N., Crowell, S. E., Derbidge, C., & Gatzke-Kopp, L. (2009). Multifinality in the development of personality disorders: A biology x sex x environment interaction model of antisocial and borderline traits. Development and Psychopathology, 21, 735-770. doi: 10.1017/s0954579409000418 Boersma, P., & Weenink, D. (2005). Praat: Doing phonetics by computer (Version 4.3.27). Boyce, W. T., & Ellis, B. J. (2005). Biological sensitivity to context: I. An evolutionary-developmental theory of the origins and functions of stress reactivity. Development and Psychopathology, 17, 271-301. Brenner, S. L., Beauchaine, T. P., & Sylvers, P. D. (2005). A comparison of psychophysiological and self-report measures of BAS and BIS activation. Psychophysiology, 42, 108-115. doi: 10.1111/j.1469-8986.2005.00261.x Buie, D. H., & Adler, G. (1982). Definitive treatment of the borderline personality. International Journal O f Psychoanalytic Psychotherapy, 9, 51-87. Campbell, J. D. (1990). Self-esteem and clarity of the self-concept. Journal o f Personality and Social Psychology, 59, 538-549. Campbell, J. D., Assanand, S., & Di Paula, A. (2003). The structure of the self-concept and its relation to psychological adjustment. Journal o f Personality, 71, 115-140. doi: 10.1111/1467-6494.t01-1-00002 Campbell, J. D., Chew, B., & Scratchley, L. S. (1991). Cognitive and emotional reactions to daily events: The effects of self-esteem and self-complexity. Journal o f Personality, 59, 473-505. Campbell, J. D., & Fehr, B. (1990). Self-esteem and perceptions of conveyed impressions: Is negative affectivity associated with greater realism? Journal o f Personality and Social Psychology, 58, 122-133. 38 Campbell, J. D., Trapnell, P. D., Heine, S. J., Katz, I. M., Lavallee, L. F., & Lehman, D. R. (1996). Self-concept clarity: Measurement, personality correlates, and cultural boundaries. Journal o f Personality and Social Psychology, 70, 141-156. doi: 10.1037/0022-3514.70.1.141 Carlson, E. A., Egeland, B., & Sroufe, L. A. (2009). A prospective investigation of the development of borderline personality symptoms. Development and Psychopathology, 21, 1311-1334. doi: 10.1017/s0954579409990174 Centers for Disease Control and Prevention. (2008). National Hospital Ambulatory Medical Care Survey: 2008 Emergency Department Summary Tables. 1-32. Retrieved from http://www.cdc.gov/nchs/fastats/suicide.htm Centers for Disease Control and Prevention. (2009). Injury prevention & control: Violence prevention. Retrieved March 1st, 2012, from http://www.cdc.gov/ViolencePrevention/pub/youth_suicide.html Crowell, S. E., Baucom, B. R., Potapova, N. V., McCauley, E., Fitelson, M., Barth, H., . . . Beauchaine, T. P. (under review). Mechanisms of contextual risk for adolescent self injury: Emotional invalidation and conflict escalation in mother-child interactions. Crowell, S. E., Beauchaine, T. P., Gatzke-Kopp, L., Sylvers, P. D., Mead, H., & Chipman- Chacon, J. (2006). Autonomic correlates of attention-deficit/hyperactivity disorder and oppositional defiant disorder in preschool children. Journal o f Abnormal Psychology, 115, 174-178. Crowell, S. E., Beauchaine, T. P., Hsiao, R. C., Vasilev, C. A., Yaptangco, M., Linehan, M. M., & McCauley, E. (2012). Differentiating adolescent self-injury from adolescent depression: Possible implications for borderline personality development. Journal o f Abnormal Child Psychology: An official publication o f the International Society for Research in Child and Adolescent Psychopathology, 40, 45-57. doi: 10.1007/s10802-011-9578-3 Crowell, S. E., Beauchaine, T. P., & Linehan, M. M. (2009). A biosocial developmental model of borderline personality: Elaborating and extending Linehan's theory. Psychological Bulletin, 135, 495-510. doi: 10.1037/a0015616 Crowell, S. E., Beauchaine, T. P., McCauley, E., Smith, C. J., Stevens, A. L., & Sylvers, P. (2005). Psychological, autonomic, and serotonergic correlates of parasuicide among adolescent girls. Development and Psychopathology, 17, 1105-1127. Crowell, S. E., Derbidge, C. M., & Beauchaine, T. P. (in press). Developmental approaches to understanding suicidal and self-injurious behaviors. In M. K. Nock (Ed.), Oxford handbook o f suicide and self-injury. Oxford: Oxford University Press. 39 Crowell, S. E., Kaufman, E. A., & Lenzenweger, M. F. (in press). The development of borderline personality disorder and self-inflicted injury. In T. P. Beauchaine & S. P. Hinshaw (Eds.), Child and adolescent psychopathology (2nd ed.). Hoboken, NJ: Wiley. Davies, D. (2010). Child development: A practitioner's guide (3rd ed.). New York: Guilford. Diehl, M., Hastings, C. T., & Stanton, J. M. (2001). Self-concept differentiation across the adult life span. Psychology and Aging, 16, 643-654. doi: 10.1037/0882­7974.16.4.643 Donahue, E. M., Robins, R. W., Roberts, B. W., & John, O. P. (1993). The divided self: Concurrent and longitudinal effects of psychological adjustment and social roles on self-concept differentiation. Journal o f Personality and Social Psychology, 64, 834-846. Ebner-Priemer, U. W., Badeck, S., Beckmann, C., Wagner, A., Feige, B., Weiss, I., . . . Bohus, M. (2005). Affective dysregulation and dissociative experience in female patients with borderline personality disorder: A startle response study. Journal o f Psychiatric Research, 39, 85-92. doi: 10.1016/j.jpsychires.2004.05.001 Erikson, E. H. (1950). Childhood and society. New York: W W Norton & Co. Erikson, E. H. (1956). The problem of ego identity. Journal o f the American Psychoanalytic Association, 4, 56-121. doi: 10.1177/000306515600400104 Erikson, E. H. (1968). Identity, youth and crisis. Oxford: Norton & Co. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1996). User's guide for the Structured Clinical Interview for DSM-IVpersonality disorders (SCID-II). Washington: American Psychiatric Press. Fonagy, P., Luyten, P., & Strathearn, L. (2011). Borderline personality disorder, mentalization, and the neurobiology of attachment. Infant Mental Health Journal, 32, 47-69. doi: 10.1002/imhj.20283 Fonagy, P., Steele, M., Steele, H., & Moran, G. S. (1991). The capacity for understanding mental states: The reflective self in parent and child and its significance for security of attachment. Infant Mental Health Journal, 12, 201-218. doi: 10.1002/1097-0355(199123)12:3<201::aid-imhj2280120307>3.0.co;2-7 Fowles, D. C. (1988). Psychophysiology and psychopathology: A motivational approach. Psychophysiology, 25, 373-391. 40 Fowles, D. C. (2000). Electrodermal hyporeactivity and antisocial behavior: Does anxiety mediate the relationship? Journal o f Affective Disorders, 61, 177-189. Gadow, K. D., Sprafkin, J., Carlson, G., Schneider, J., Nolan, E. E., Mattison, R. E., & Rundberg-Rivera, V. (2002). A DSM-IV-referenced adolescent self-report rating scale. Journal o f the American Academy o f Child and Adolescent Psychiatry, 41, 671-679. 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 o f Psychopathology and Behavioral Assessment, 26, 41-54. Harter, S. (1997). The personal self in social context: Barriers to authenticity. In R. D. Ashmore & L. J. Jussim (Eds.), Self and identity: Fundamental issues (pp. 81­105). New York: Oxford University Press. Harter, S. (1998). The development of self-representations. In N. Eisenberg & W. Damon (Eds.), Handbook o f child psychology, 5th ed.: Vol 3. Social, emotional, and personality development (pp. 553-617). Hoboken, NJ: John Wiley & Sons Inc. Harter, S. (2006). Self-processes and developmental psychopathology. In D. Cicchetti & D. J. Cohen (Eds.), Developmental psychopathology, Vol 1: Theory and method (2nd ed., pp. 370-418). Hoboken, NJ: John Wiley & Sons Inc. Harter, S., Bresnick, S., Bouchey, H. A., & Whitesell, N. R. (1997). The development of multiple role-related selves during adolescence. Development and Psychopathology, 9, 835-853. Harter, S., Marold, D. B., Whitesell, N. R., & Cobbs, G. (1996). A model of the effects of perceived parent and peer support on adolescent false self behavior. Child Development, 67, 360-374. Harter, S., & Monsour, A. (1992). Development analysis of conflict caused by opposing attributes in the adolescent self-portrait. Developmental Psychology, 28, 251-260. doi: 10.1037/0012-1649.28.2.251 Heard, H. L., & Linehan, M. M. (1993). Problems of self and borderline personality disorder: A dialectical behavioral analysis. In Z. V. Segal & S. J. Blatt (Eds.), The self in emotional distress: Cognitive and psychodynamic perspectives (pp. 301­333). New York: Guilford Press. Herpertz, S. C., Kunert, H. J., Schwenger, U. B., & Sass, H. (1999). Affective responsiveness in borderline personality disorder: A psychophysiological approach. American Journal o f Psychiatry, 156, 1550-1556. 41 Hughes, A. E., Crowell, S. E., Uyeji, L., & Coan, J. A. (2012). A developmental neuroscience of borderline pathology: Emotion dysregulation and social baseline theory. Journal o f Abnormal Child Psychology, 40, 21-33. doi: 10.1007/s10802- 011-9555-x Juslin, P. N., & Scherer, K. R. (2005). Vocal expression of affect. In J. A. Harrigan, R. Rosenthal & K. R. Scherer (Eds.), The new handbook o f methods in nonverbal behavior research. (pp. 65-135). New York: Oxford University Press. Kaufman, E. A., Cundiff, J. M., & Crowell, S. E. (under review). The development, factor structure, and validation of the Self-concept and Identity Measure (SCIM): A self­report assessment of identity disturbance. Journal o f Psychopathology and Behavioral Assessment. Kernberg, O. (1975). Borderline conditions and pathological narcissism. New York: Jason Aronson. Kernberg, O. F. (2005). Identity diffusion in severe personality disorders. In S. Strack (Ed.), Handbook o f personology and psychopathology (pp. 39-49). Hoboken, NJ: John Wiley & Sons Inc. Kernberg, O. F. (2006). Identity: Recent findings and clinical implications. The Psychoanalytic Quarterly, 75, 969-1004. Kernberg, P. F. (1990). Resolved: Borderline personality exists in children under twelve. Affirmative. Journal o f the American Academy o f Child and Adolescent Psychiatry, 29, 478-482. King-Casas, B., Sharp, C., Lomax-Bream, L., Lohrenz, T., Fonagy, P., & Montague, P. R. (2008). The rupture and repair of cooperation in borderline personality disorder. Science, 321, 806-810. Kovacs, M. (1992). Children's Depression Inventory. Niagra Falls, NY: Multi-Health Systems. Lamph, G. (2011). Raising awareness of borderline personality disorder and self-injury. Nursing Standard, 26, 35-40. Lenzenweger, M. F., & Cicchetti, D. (2005). Toward a developmental psychopathology approach to borderline personality disorder. Development and Psychopathology, 17, 893-898. Lenzenweger, M. F., Lane, M. C., Loranger, A. W., & Kessler, R. C. (2007). DSM-IV personality disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 62, 553-564. 42 Linehan, M. M. (1993). Cognitive-behavioral treatment o f borderline personality disorder. New York: Guilford Press. Linehan, M. M., & Comtois, K. A. (1996). Lifetimeparasuicide count: Unpublished Manuscript. Lorber, M. F. (2004). Psychophysiology of aggression, psychopathy, and conduct problems: A meta-analysis. Psychological Bulletin, 130, 531-552. Lutz, C. J., & Ross, S. R. (2003). Elaboration versus fragmentation: Distinguishing between self-complexity and self-concept differentiation. Journal o f Social and Clinical Psychology, 22, 537-559. doi: 10.1521/jscp.22.5.537.22927 Macfie, J. (2009). Development in children and adolescents whose mothers have borderline personality disorder. Child Development Perspectives, 3, 66-71. doi: 10.1111/j.1750-8606.2008.00079.x Macfie, J., & Swan, S. A. (2009). Representations of the caregiver-child relationship and of the self, and emotion regulation in the narratives of young children whose mothers have borderline personality disorder. Development and Psychopathology, 21, 993-1011. doi: 10.1017/s0954579409000534 Mahler, M. S., Pine, F., & Bergman, A. (1994). Stages in the infant's separation from the mother. In G. Handel & G. G. Whitchurch (Eds.), The psychosocial interior o f the family (4th ed., pp. 419-448). Hawthorne, NY: Aldine de Gruyter. McCrae, R. R., & Costa, P. T. (2010). NEO inventories for NEO Personality Five-Factor Inventory-3 (NEO-FFI-3) Professional Manual. Lutz, FL: PAR. Meares, R., Gerull, F., Stevenson, J., & Korner, A. (2011). Is self disturbance the core of borderline personality disorder? An outcome study of borderline personality factors. Australian and New Zealand Journal o f Psychiatry, 45, 214-222. doi: 10.3109/00048674.2010.551280 Nock, M. K., Guilherme, B., Bromet, E. J., Cha, C. B., Kessler, R. C., & Lee, S. (2008). Suicide and suicidal behavior. Epidemiologic Reviews, 30, 133-154. Owren, M. J., & Bachorowski, J.-A. (2007). Measuring emotion-related vocal acoustics. In J. A. Coan & J. J. B. Allen (Eds.), Handbook o f emotion elicitation and assessment (pp. 239-266). New York: Oxford University Press. Paris, J., Zweig-Frank, H., Ng Ying Kin, N. M. K., Schwartz, G., Steiger, H., & Nair, N. P. V. (2004). Neurobiological correlates of diagnosis and underlying traits in patients with borderline personality disorder compared with normal controls. Psychiatry Research, 121, 239-252. 43 Patterson, G. R. (2002). The early development of coercive family process. In J. B. Reid, G. R. Patterson & J. Snyder (Eds.), Antisocial behavior in children and adolescents: A developmental analysis and model for intervention (pp. 25-44). Washington, DC US: American Psychological Association. Roepke, S., Schroder-Abe, M., Schutz, A., Jacob, G., Dams, A., Vater, A., . . . Lammers, C.-H. (2011). Dialectic behavioural therapy has an impact on self-concept clarity and facets of self-esteem in women with borderline personality disorder. Clinical Psychology & Psychotherapy, 18, 148-158. doi: 10.1002/cpp.684 Rutter, M. (2006). The promotion of resilience in the face of adversity. In A. Clarke- Stewart & J. Dunn (Eds.), Families count: Effects on child and adolescent development (pp. 26-52). New York: Cambridge University Press. Sander, L. (1975). Infant and caretaking environment. In E. J. Anthony (Ed.), Explorations in child psychiatry (pp. 103-112). New York: Plenum. Scherer, K. R. (2003). Vocal communication of emotion: A review of research paradigms. Speech Communication, 40, 227-256. doi: 10.1016/s0167-6393(02)00084-5 Schmahl, C. G., Elzinga, B. M., Ebner, U. W., Simms, T., Sanislow, C., Vermetten, E., . . . Bremner, J. D. (2004). Psychophysiological reactivity to traumatic and abandonment scripts in borderline personality and posttraumatic stress disorders: A preliminary report. Psychiatry Research, 126, 33-42. doi: 10.1016/j.psychres.2004.01.005 Selby, E. A., Bender, T. W., Gordon, K. H., Nock, M. K., & Joiner, T. E., Jr. (2012). Non-suicidal self-injury (NSSI) disorder: A preliminary study. Personality Disorders: Theory, Research, and Treatment, 3, 167-175. doi: 10.1037/a0024405 Sheldon, K. M., Ryan, R. M., Rawsthorne, L. J., & Ilardi, B. (1997). Trait self and true self: Cross-role variation in the Big-Five personality traits and its relations with psychological authenticity and subjective well-being. Journal o f Personality and Social Psychology, 73, 1380-1393. doi: 10.1037/0022-3514.73.6.1380 Shiner, R. L. (2009). The development of personality disorders: Perspectives from normal personality development in childhood and adolescence. Development and Psychopathology, 21, 715-734. doi: 10.1017/S0954579409000406 Snyder, J., Edwards, P., McGraw, K., & Kilgore, K. (1994). Escalation and reinforcement in mother-child conflict: Social processes associated with the development of physical aggression. Development and Psychopathology, 6, 305-321. Snyder, J., Schrepferman, L., & St. Peter, C. (1997). Origins of antisocial behavior: Negative reinforcement and affect dysregulation of behavior as socialization mechanisms in family interaction. Behavior Modification, 21, 187-215. doi: 44 10.1177/01454455970212004 Sroufe, L. A. (1990). An organizational perspective on the self. In D. Cicchetti & M. Beeghly (Eds.), The self in transition: Infancy to childhood (pp. 281-307). Chicago, IL: University of Chicago Press. Sroufe, L. A., Egeland, B., Carlson, E. A., & Collins, W. A. (2005). The development o f the person: The Minnesota study o f risk and adaptation from birth to adulthood. New York: Guilford Publications. Thorell, L. H. (2009). Valid electrodermal hyporeactivity for depressive suicidal propensity offers links to cognitive theory. Acta Psychiatrica Scandinavica, 119, 338-349. Trull, T. J., Distel, M. A., & Carpenter, R. W. (2011). DSM-5 Borderline personality disorder: At the border between a dimensional and a categorical view. Current Psychiatry Reports, 13, 43-49. Trull, T J., Jahng, S., Tomko, R. L., Wood, P. K., & Sher, K. J. (2010). Revised NESARC personality disorder diagnoses: Gender, prevalence, and comorbidity with substance dependence disorders. Journal o f Personality Disorders, 24, 412-426. doi: 10.1521/pedi.2010.24.4.412 Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures of positive and negative affect: The PANAS scales. Journal o f Personality and Social Psychology, 54, 1063-1070. Westen, D., & Cohen, R. P. (1993). The self in borderline personality disorder: A psychodynamic perspective. In Z. V. Segal & S. J. Blatt (Eds.), The self in emotional distress: Cognitive and psychodynamic perspectives (pp. 334-368). New York, NY US: Guilford Press. Westen, D., & Heim, A. K. (2003). Disturbances of self and identity in personality disorders. In M. R. Leary & J. P. Tangney (Eds.), Handbook o f self and identity (pp. 643-664). New York: Guilford Press. Westen, D., Lohr, N., Silk, K. R., Gold, L., & Kerber, K. (1990). Object relations and social cognition in borderlines, major depressives, and normals: A Thematic Apperception Test analysis. Psychological Assessment: A Journal o f Consulting and Clinical Psychology, 2, 355-364. doi: 10.1037/1040-3590.2.4.355 White, C. N., Gunderson, J. G., Zanarini, M. C., & Hudson, J. I. (2003). Family studies of borderline personality disorder: A review. Harvard Review o f Psychiatry, 11, 8-19. doi: 10.1080/10673220303937 Widiger, T. A., & Trull, T. J. (1993). Borderline and narcissistic personality disorders. In 45 P. B. Sutker & H. E. Adams (Eds.), Comprehensive handbook o f psychopathology (2nd ed., pp. 371-394). New York: Plenum Press. Wilkinson-Ryan, T., & Westen, D. (2000). Identity disturbance in borderline personality disorder: An empirical investigation. The American Journal o f Psychiatry, 157, 528-541. doi: 10.1176/appi.ajp.157.4.528 Zanarini, M. C., Laudate, C. S., Frankenburg, F. R., Reich, D. B., & Fitzmaurice, G. (2011). Predictors of self-mutilation in patients with borderline personality disorder: A 10-year follow-up study. Journal o f Psychiatric Research, 45, 823­828. Zlotnick, C., Mattia, J. I., & Zimmerman, M. (1999). Clinical correlates of self-mutilation in a sample of general psychiatric patients. Journal o f Nervous and Mental Disease, 187, 296-301.