Emotionally unstable personality disorder (EUPD) is a mental disorder characterised by a
pervasive pattern of emotion dysregulation, inconsistent identity, and difficulties with
interpersonal functioning. It is often associated with deliberate self-harm, has a high
burden on affected individuals, family members, and health-care systems, and is
associated with low occupational and educational attainment, lack of long-term
relationships, increased partner conflict, low life satisfaction, and increased statutory
service use.
Recently, an impaired ability to understand other people's motives and perceptions ('mind
read' or empathise) has been shown to be characteristic of EUPD.
Empathy has two components; cognitive empathy (the ability to imagine someone else's
thoughts and feelings) and emotional empathy (the reciprocal emotional response). People
with EUPD score low on measures of cognitive empathy and high on measures of emotional
empathy compared to non-clinical controls. This suggests that they do not easily
understand other peoples' perspectives, but their own emotions are especially sensitive.
Healthcare services need outcome measures and predictors of treatment response to develop
evidence-based guidelines for EUPD. Hence, this study will use a computer-based empathy
assessment tool and short questionnaires to investigate whether empathy changes during
the course of EUPD, and if the extent of an empathy impairment correlates with syndrome
severity.
Many of the established empathy tests only elicit severe empathy anomalies, produce
results that do not translate into real life scenarios, do not describe cognitive and
emotional empathy separately, or are cumbersome so not routinely applicable. However, the
empathy test this study will use (multifaceted empathy test or MET) has been shown to
quantify the EUPD empathy anomaly, is ecologically valid, does not require training to
administer, can be gone through in 30 minutes in a clinic room, and has NHS IT security
clearance. The empathy questionnaire that will be used (questionnaire of cognitive and
affective empathy or QCAE) is an amalgam of other validated questionnaires which improves
on their limitations but is still concise (31 questions in total).
The MET requires participants to look at several photographs of emotive faces, then
choose the most appropriate adjective. The QCAE asks 31 questions like 'it is hard for me
to see why some things upset people so much'. To ensure that performance is not skewed by
reading ability, participants will be asked to complete the National Adult Reading Test
questionnaire (NART). This only takes a few minutes to complete and is used routinely in
NHS clinical practice.
Participants will be invited to join the study when they are diagnosed with EUPD in
consultant psychiatry outpatient appointments. Syndrome severity will be measured with
the Borderline Symptom List 23 (BSL 23) which is self-rated and takes only a few minutes
to complete. Clinical indicators of syndrome severity will be the number of self-harming
episodes per month, the number of hospital assessments per month and the number of
hospital admissions per month. The World Health Organization Disability Assessment
Schedule (WHODAS) will be used to describe any pervasive functional impairment.
The self-rated Hamilton Anxiety Rating Scale (HAM-A) and Patient Health Questionnaire 9
(PHQ-9) will describe any concurrent anxious and depressive symptoms, and the Inventory
of Depressive Symptomatology (Self-Report) (IDS-SR) will describe mood. These also only
takes a few minutes to complete and are used routinely in NHS clinical work.
It is anticipated that about 30 participants will be required because similar studies
produced significant results with about that number. Participants will be assessed at
baseline, after 6 months, 1 year, and 18 months. This should be long enough because the
established psychological therapies for EUPD take about this long.