Blaha Yasmine, Cavelti Marialuisa, Sele Silvano, Koenig Julian, Zimmermann Ronan, Schmeck Klaus, Kaess Michael
University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland.
Faculty of Medicine and University Hospital Cologne, Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University of Cologne, Cologne, Germany.
Psychother Psychosom. 2025 Aug 24:1-13. doi: 10.1159/000547941.
Psychotherapy is the primary treatment for adolescent borderline personality pathology (BPP), yet its mechanisms remain unclear. Given potential self-report biases due to alexithymia and impaired interoception, this study examined cortisol responses as a physiological stress marker alongside session ratings from adolescent BPP patients and their therapists to assess its potential as a complementary measure in psychotherapy process research.
N = 56 adolescents (94.6% female) with BPP (≥3 DSM-IV BPD criteria) receiving Adolescent Identity Treatment or Dialectical Behavioral Therapy and their therapists provided pre- and post-session salivary cortisol samples and completed the Session Evaluation Questionnaire. Residual Dynamic Structural Equation Modeling examined associations between cortisol responses and session ratings, with moderation by age, depression, BPP severity, identity diffusion, and trauma.
Cortisol responses did not correlate with session ratings in patients. In therapists, higher cortisol responses were associated with lower session smoothness (r = -0.164; p < 0.001) and deepness (r = -0.086; p = 0.004), as well as with lower positivity (r = -0.145; p < 0.001) and higher arousal (r = 0.072; p = 0.012) post-session. Higher depression levels moderated the association between cortisol responses and session deepness in patients (β = -0.009, p = 0.007).
While session ratings and cortisol responses correlated in therapists, no such correlation was found in patients. Possible mechanisms include altered interoceptive abilities, dysregulated hypothalamic-pituitary-adrenal (HPA) axis function, or increased variability in self-ratings or cortisol due to BPP. While physiological markers and self-reports offer complementary insights into psychotherapy processes, future studies should include healthy and clinical controls and baseline investigation of HPA axis function (i.e., stress reactivity) in both groups, along with additional hormonal markers.
心理治疗是青少年边缘型人格病理（BPP）的主要治疗方法，但其机制仍不清楚。鉴于述情障碍和内感受性受损可能导致自我报告偏差，本研究将皮质醇反应作为一种生理应激标志物进行检测，并结合青少年BPP患者及其治疗师的 session 评分，以评估其在心理治疗过程研究中作为补充测量方法的潜力。
56名患有BPP（符合≥3条DSM-IV边缘型人格障碍标准）的青少年（94.6%为女性）接受青少年身份治疗或辩证行为疗法，他们及其治疗师在治疗前和治疗后提供唾液皮质醇样本，并完成 session 评估问卷。残差动态结构方程模型检验了皮质醇反应与 session 评分之间的关联，并以年龄、抑郁、BPP严重程度、身份扩散和创伤作为调节因素。
患者的皮质醇反应与 session 评分不相关。在治疗师中，较高的皮质醇反应与较低的 session 流畅性（r = -0.164；p < 0.001）和深度（r = -0.086；p = 0.004）相关，同时与较低的积极性（r = -0.145；p < 0.001）和治疗后较高的唤醒水平（r = 0.072；p = 0.012）相关。较高的抑郁水平调节了患者皮质醇反应与 session 深度之间的关联（β = -0.009，p = 0.007）。
虽然治疗师的 session 评分与皮质醇反应相关，但在患者中未发现这种相关性。可能的机制包括内感受能力改变、下丘脑 - 垂体 - 肾上腺（HPA）轴功能失调，或由于BPP导致自我评分或皮质醇的变异性增加。虽然生理标志物和自我报告为心理治疗过程提供了互补的见解，但未来的研究应纳入健康对照组和临床对照组，并对两组的HPA轴功能（即应激反应性）进行基线调查，以及增加其他激素标志物。
