Borderline personality disorder

Emotional Regulation in Teens and Improvement of Constructive Skills (EmoTIConS): study protocol for a randomized controlled trial

BACKGROUND

Emotional dysregulation (ED) constitutes a relevant factor involved in the onset and maintenance of many mental disorders. Targeting ED during adolescence could be a determinant both to identify high-risk individuals and to promote preventive interventions. This study will aim to evaluate the impact of a brief Dialectical Behavioral Therapy (DBT)-based intervention for adolescent students by measuring changes in emotional regulation skills and impulsive behaviors. Moreover, alterations in biological features related to stress response and inflammation will be assessed as potential biological variables associated with ED.

METHODS

This is a randomized trial. A total of 20 classes of adolescent students will be recruited among high schools in Brescia, a city in northern Italy. They will be randomized to the psychoeducational intervention (experimental group) or to a control condition (control group). The intervention will be based on DBT Skills Training for Emotional Problem Solving for Adolescents, and will consist of four monthly, 2-h sessions (for a total of 8 h) scheduled during regular school time. Participants will be assessed at baseline, post-intervention, and at 3 and 6 months of follow-up. The primary outcome measures will be represented by changes in the use of emotional regulation skills and by changes in the frequency of impulsive behaviors. Salivary samples will be collected at baseline and post-intervention to explore possible biological features underlying ED.

DISCUSSION

Data from the present project will offer the opportunity to better understand the complex phenomenon of ED. Repeated assessment will cover several domains (emotional, behavioral, social, biological) as potential factors associated with ED. Moreover, it will be possible to establish the effect of the proposed intervention, thus helping to improve knowledge on the impact of school-based universal preventive programs. Finally, the current trial will propose an integrated screening and intervention-based model. Ultimately, this could reduce barriers to youths' mental health care by fostering collaboration between schools and mental health services.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04349709 . Registered on April 16, 2020.

The Statistical Specificity of Emotion Dynamics in Borderline Personality Disorder

Persons with borderline personality disorder (BPD) experience heightened emotional instability. Different components underlie instability, and the relation between instability and well-being could be confounded by average emotionality and within-person standard deviation across emotional states, reflecting variability. Therefore, the goal was to examine which pattern of emotion dynamics parsimoniously captures the emotional trajectories of persons with BPD. Forty persons with BPD, 38 clinical controls in a major depressive episode, and 40 healthy controls rated the intensity of their emotions 10 times a day for 1 week. After correction for differences in average emotionality, persons with BPD showed heightened emotional instability compared to both control groups. When additionally correcting for emotional variability, the authors found that instability indices did not differ between groups anymore. This shows that persons with BPD differ from control groups in the magnitude of emotional deviations from the emotional baseline, and not necessarily in the degree of abruptness of these deviations.

Epicardial adipose tissue and adrenal gland volume in patients with borderline personality disorder

Borderline personality disorder (BPD) is associated with an elevated mortality risk that is partially attributed to suicide, but few studies examined other possible causes of premature death. The present study compared epicardial adipose tissue (EAT) volume as a known early predictor of premature cardiovascular morbidity, cardiovascular risk indices, and adrenal gland volume (AGV) as an indicator for chronic hypothalamus-pituitary-adrenal (HPA) axis activation in females with borderline personality disorder (BPD), major depressive disorder (MDD) and in healthy individuals. Twenty-eight patients with BPD comorbid with MDD (BPD/MDD), 22 MDD patients and 26 healthy females (CTRL) of comparable age were included. EAT and AGV were assessed by magnetic resonance tomography; 10-year cardiovascular risk and diabetes risk were determined by PROCAM and FINDRISK score; metabolic syndrome was defined following National Cholesterol Education Adult Treatment Panel III R (NCEP/ATP III) criteria. MADRS was used to assess depression severity. After adjustment for age, body mass index (BMI), and physical activity, EAT and AGV were significantly increased in BPD/MDD compared to MDD and CTRL. EAT and AGV displayed a positive correlation. Finally, diabetes risk in BPD/MDD was elevated compared to CTRL and MDD. The present study highlights the increased cardiometabolic risk of BPD patients. We identify EAT accumulation as an early predictor and potential mediator of cardiovascular disease in BPD that appears to be driven at least in part by HPA axis dysregulation. Therefore, interventions that reduce EAT volume (i.e. exercise and diet) should be considered in the clinical management of BPD.

Effects of dialectical behaviour therapy on reducing self-harming behaviours and negative emotions in patients with borderline personality disorder: A meta-analysis

INTRODUCTION

Dialectical behaviour therapy(DBT) has been widely used for borderline personality disorder(BPD). Existing studies are limited to behaviours such as self-harm, and the results for reducing self-harm were controversial. Few have systematically evaluated the effect of DBT on self-harming behaviours and negative emotions.

AIM

This study aims to evaluate the effects of DBT on self-harming behaviours and negative emotions in patients with BPD.

METHODS

RCTs on DBT for BPD were searched from PubMed, Embase, etc., and the results were performed by RevMan 5.3.

RESULTS

The meta-analysis demonstrated that DBT reduced self-harming behaviours, and alleviated depression, but had a negligible effect on suicidal ideation and anger. One subgroup revealed that standard DBT improved depression significantly, but DBT skills training improved poorly. Another subgroup revealed that there was a significant reduction in depression among patients receiving DBT for 4 months to 14 months, but not at 4 months.

DISCUSSION AND IMPLICATIONS FOR PRACTICE

Findings indicate that DBT can reduce self-harming behaviours and improve depression, but effects on suicidal ideation and anger are insignificant. Subgroup analysis suggests that standard DBT and DBT-ST lasting beyond 4 months benefits on BPD. Given the quality and quantity restrictions of RCTs, more high-quality RCTs need to verify these effects.

Lessons Learned Conducting Dialectical Behavior Therapy via Telehealth in the Age of COVID-19

Given the severity and suicide risk of patients typically treated by Dialectical Behavior Therapy (DBT) and the absence of guidelines regarding delivery of DBT via telehealth, it is crucial that the DBT treatment community gather and rapidly disseminate information about effective strategies for delivering DBT via telehealth. The current study surveyed DBT providers (N = 200) to understand challenges and lessons learned as they transitioned to conducting DBT via telehealth during the COVID-19 pandemic. Open-ended responses to challenges and lessons-learned were coded. Most frequently noted challenges were Therapy-Interfering Behaviors and elements related to the provision of Individual Therapy and Skills Training Group. The majority of providers offered advice for implementing group skills training, avoiding or overcoming therapist burnout, and emphasized continued adherence to treatment principles, even in the context of this new treatment modality. Overall, this qualitative study marks a starting point on identifying best practices delivering DBT via telehealth for which it is anticipated that clinical recommendations in this area will evolve, informed by clinician, researcher, and consumer input.

Borderline personality disorder

Borderline personality disorder (BPD) is a mental disorder with a high burden on patients, family members, and health-care systems. The condition was previously regarded as untreatable, but progress in understanding and management has resulted in earlier diagnosis and better treatment outcomes. A coherent syndrome of BPD typically onsets during adolescence (after age 12 years). BPD is often preceded by or co-develops with symptoms of internalising disorders (depression and anxiety), externalising disorders (conduct problems, hyperactivity, and substance use), or both. BPD is associated with various poor outcomes, including low occupational and educational attainment, lack of long-term relationships, increased partner conflict, sexual risk-taking, low levels of social support, low life satisfaction, and increased service use. Psychotherapy is the main treatment for BPD; drug treatment is only indicated for comorbid conditions that require medication, or during a crisis if psychosocial interventions are insufficient. Awareness of BPD by non-specialists, as well as specialists, is key to appropriate early intervention.

Repetitive transcranial magnetic stimulation in patients with borderline personality disorder: A systematic review

The literature on the application of repetitive transcranial magnetic stimulation (rTMS) in Borderline Personality Disorder (BPD) is unclear, even though its neuromodulatory effects on underlying neural circuitry involved in BPD symptoms suggest that it could be a potential treatment option. We sought to review the evidence on rTMS as a treatment option in BPD. PubMed (for Medline database), Google Scholar, and Scopus were systematically searched following the PRISMA guidelines for studies of any design examining the application of the rTMS treatment in adult patients with precise and primary diagnosis of BPD written in the English language. The systematic review has been registered on PROSPERO (CRD42020215927). Forty one records were screened, and eight fulfilled inclusion criteria (total of 63 patients). The existing studies suggest that rTMS is a well-tolerated treatment in patients with BPD. Double-blind randomized controlled studies are necessary to help elucidate the effects of rTMS in the different symptoms in BPD and establish efficacy and the best cortical targets and stimulation protocols. Longitudinal studies that combine evidenced based psychotherapy with rTMS may be a future line of investigation that could potentially improve outcomes for this population.

Validity and Reliability of the Urdu Version of the McLean Screening Instrument for Borderline Personality Disorder

Introduction: Although the translation and the validation of the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) are performed in various languages and samples, no study has established the validity and reliability of the Urdu version of MSI-BPD in individuals with cardiac problems. Materials and Methods: The Urdu version of the MSI-BPD was prepared through the standard back-translation method. The translation and adaption were completed in four steps: forward translation, adaption and translation, back translation and committee approach, and cross-language validation. The sample, selected through the purposive sampling method, comprised of 150 adults with cardiac problems (men = 75 and women = 75), with an age range of 23-78 years (M = 55, SD = 10.6). The Cronbach alpha reliability and factorial validity of the MSI-BPD were assessed through confirmatory factor analysis (CFA) and Pearson correlation analyses. Internal consistency and test-retest reliability (at 2 weeks' interval) were used to evaluate the reliability. Statistical analyses were performed, using SPSS (version 22) and Structural Equation Modeling (SEM) software. Results: Preliminary analysis revealed that the overall instrument had good internal consistency (Urdu MSI-BPD α = 0.79; English MSI-BPD α = 0.77) as well as test-retest correlation coefficients for 15 days (r = 0.94). Conclusions: Findings suggested that the MSI-BPD, with important limitations, can be used as an effective preliminary screening tool to measure BPD in Urdu-speaking adults with cardiac problems. Further validations should be conducted to make the translated version of the MSI-BPD an appropriate tool to screen BPD in hospitals and mental health care settings.

Autonomic nervous system activity and dialectical behavioral therapy outcome in adolescent borderline personality pathology

OBJECTIVES

We aimed to investigate whether pre-treatment cardiac autonomic nervous system (ANS) activity, indexed by heart rate (HR) and heart rate variability (HRV) predicts clinical outcome and therapy drop-outs in adolescents with borderline personality (BPD) pathology receiving dialectical behavioural therapy (DBT-A). We further tested for an association between changes in ANS function and clinical outcome over time. Traumatic experiences were considered as potential confounding factor.

METHODS

N = 43 (95.4% female, M_age = 15.5 years) adolescents fulfilling at least sub-threshold criteria for BPD (≥3) were investigated before and after outpatient DBT-A as well as at follow-up. N = 10 patients dropped out of treatment (<50% of treatment sessions). Latent growth curve models were used for analyses.

RESULTS

Greater pre-treatment resting HRV significantly predicted clinical improvement (decrease in BPD pathology/increase of global functioning) over time. Pre-treatment ANS activity was unrelated to treatment drop-out. Further, changes in ANS activity over treatment were associated with changes in clinical outcome.

CONCLUSION

This study is the first providing evidence that pre-treatment HRV predicts and is related to treatment response in adolescent borderline personality pathology. Implications for the use of ANS measures in clinical practice and directions for future research are discussed.

Prevalence and characteristics of women with borderline personality pathology referred to a perinatal consultation liaison service

OBJECTIVE

To examine the prevalence and characteristics of pregnant women with borderline personality pathology (defined as borderline personality disorder and borderline personality traits) referred to a perinatal consultation-liaison psychiatry service.

METHOD

Socio-demographic and clinical data, and diagnoses made according to Diagnostic and Statistical Manual of Mental Disorders (5th ed.) criteria were recorded for all women referred to and seen by the perinatal consultation-liaison psychiatry service over an 18-month period. Data were analysed using descriptive statistics and logistic regression analysis.

RESULTS

A total of 318 women were seen. The most common diagnoses found were depressive disorder (25.5%) and anxiety disorder (15.1%). Borderline personality disorder was found in 10.1% of women and almost one in five women had two or more borderline personality traits (19.5%). When compared to women with other diagnoses, women with borderline personality pathology had higher rates of unplanned pregnancy, being unpartnered, substance use during pregnancy and higher rates of child safety services involvement as a child or in a previous pregnancy. Over 40% of women with borderline personality pathology were referred to child safety services in the current pregnancy and a diagnosis of borderline personality pathology increased the risk of child safety services involvement by almost sixfold (odds ratio: 5.5; 95% confidence interval = [1.50, 20.17]).

CONCLUSION

The prevalence of borderline personality pathology in antenatal women identified at antenatal screening and the recognition that women with borderline personality pathology are 'high-risk' caregivers argue for borderline personality pathology to be recognised as a high priority for investment in service development.

Subjective and objective sleep in young people with borderline personality disorder features

Characterising sleep in young people (aged 15-25 years) with borderline personality disorder (BPD) features is crucial given the association between BPD features and sleep disturbance, negative consequences of poor sleep, and normative developmental sleep changes that occur in this age group. The present study aimed to characterise the sleep profile of young people with BPD to determine whether this profile is non-normative and specific to BPD. Participants were 96 young people (40 with BPD features, 38 healthy individuals, and 18 young people seeking help for mental health difficulties without BPD). Sleep was measured subjectively (self-report questionnaires) and objectively (10 days of actigraphy). Young people with BPD features reported poorer subjective sleep quality, greater insomnia symptoms and later chronotype than same-age healthy and clinical comparison groups. Young people with BPD features also displayed irregular sleep timing, later rise times, greater time in bed and longer sleep durations than healthy young people. Those with BPD features had superior sleep quality (greater sleep efficiency, less wake after sleep onset) and longer sleep durations than the clinical comparison group. Sleep profiles were similar across young people with BPD features with and without co-occurring depression. Overall, the findings revealed a subjective-objective sleep discrepancy and suggest that sleep-improvement interventions might be beneficial to improve subjective sleep in young people with BPD features.

Childhood maltreatment and suicidality among women seeking mental health care: the mediating effect of borderline personality features, moderated by age

Although childhood maltreatment is known to elevate women's risk for suicidal ideation and behavior, research concerning the mechanisms involved remains limited. While borderline personality disorder (BPD) has been implicated as mediating this association, such effects may differ depending on women's age. The present study examined borderline personality features as a dispositional mediator of the relationship between childhood maltreatment and suicidality, with the moderating effect of age, among help-seeking women. A sample of 151 women attending community mental health clinics completed measures of childhood maltreatment, BPD features, suicidality, and psychological distress. Regression analyses tested moderated mediation, controlling for psychological distress across each path. Results indicated a significant interaction between childhood maltreatment and age in predicting borderline personality features, and significant moderated mediation in predicting suicidality. Borderline personality features significantly mediated the association between maltreatment and suicidality among younger--but not among older--women, with the mediation effect becoming stronger as women were younger. The findings indicate borderline personality features as particularly salient among young women in accounting for the maltreatment-suicidality association. Thus, interventions addressing BPD may warrant consideration for young women with suicidal ideation and history of childhood adversity.

Juror decision-making regarding a defendant diagnosed with borderline personality disorder

Stigma is an established consequence of the Borderline Personality Disorder (BPD) diagnosis. This diagnosis is subject to revision in the International Classification of Diseases-11th Revision (ICD-11). Using the legal issue of diminished responsibility, this study applied an experimental mock-jury methodology to explore the impact of diagnostic stigma of BPD on jury decision-making. Participants were allocated to one of two versions of a simplified fictitious homicide trial. The group whose defendant was described as having a 'severe personality disorder, borderline pattern' rated the defendant as more dangerous, and more in need of segregation and coercive treatment, than controls where the defendant was described as having a 'complex mental health problem'. Between-group differences in other measures, including the decision to agree a verdict of diminished responsibility, were not found. The ICD-11 'severe personality disorder, borderline pattern' diagnosis may adversely impact the attitudes of jurors considering the question of diminished responsibility.

Treatment selection in borderline personality disorder between dialectical behavior therapy and psychodynamic psychiatric management

BACKGROUND

No evidence-based therapy for borderline personality disorder (BPD) exhibits a clear superiority. However, BPD is highly heterogeneous, and different patients may specifically benefit from the interventions of a particular treatment.

METHODS

From a randomized trial comparing a year of dialectical behavior therapy (DBT) to general psychiatric management (GPM) for BPD, long-term (2-year-post) outcome data and patient baseline variables (n = 156) were used to examine individual and combined patient-level moderators of differential treatment response. A two-step bootstrapped and partially cross-validated moderator identification process was employed for 20 baseline variables. For identified moderators, 10-fold bootstrapped cross-validated models estimated response to each therapy, and long-term outcomes were compared for patients randomized to their model-predicted optimal v. non-optimal treatment.

RESULTS

Significant moderators surviving the two-step process included psychiatric symptom severity, BPD impulsivity symptoms (both GPM > DBT), dependent personality traits, childhood emotional abuse, and social adjustment (all DBT > GPM). Patients randomized to their model-predicted optimal treatment had significantly better long-term outcomes (d = 0.36, p = 0.028), especially if the model had a relatively stronger (top 60%) prediction for that patient (d = 0.61, p = 0.004). Among patients with a stronger prediction, this advantage held even when applying a conservative statistical check (d = 0.46, p = 0.043).

CONCLUSIONS

Patient characteristics influence the degree to which they respond to two treatments for BPD. Combining information from multiple moderators may help inform providers and patients as to which treatment is the most likely to lead to long-term symptom relief. Further research on personalized medicine in BPD is needed.

The Association Between Childhood Trauma and Attachment Functioning in Patients With Personality Disorders

Attachment (mal)functioning and a history of childhood trauma (CT) are both considered psychological determinants of personality disorders (PDs). Their interaction, however, remains largely uninvestigated. In this study, the authors assessed adult and childhood attachment style in a sample of patients with diverse PDs (N = 75) and determined the relation with both occurrence and severity of CT. The authors found that the sample was characterized by severe attachment malfunctioning and high levels of CT. Using cross-tabulations and analysis of variance, the authors showed that patients with a fearful or dismissive attachment style experienced more severe CT than patients with a preoccupied attachment style. Patients reporting an affectionless control bonding style to either parent suffered frequent and severe CT. Although temporal causality cannot be determined, these findings stress the necessity to screen for CT in PDs and suggest that attachment-centered psychotherapy for these patients may benefit from preceding or concurrent trauma treatment.

Hormonal Contraception and Violent Death: The Physiological and Psychological Links

In the past decade, two large prospective cohort studies of British and American women have been conducted which found a statistically significant increase in the risk of violent death in ever-users of hormonal contraceptives. Research on the effects of hormonal contraceptives upon the behaviors of intimate partners and on the physiology of women using hormonal contraceptives has provided insight into the possible basis for the resulting increase in violent death. This review examines the changes that are potential contributors to the reported increase.

A cross-sectional study of auditory verbal hallucinations experienced by people with a diagnosis of borderline personality disorder

BACKGROUND

The presence of auditory verbal hallucinations (AVHs) does not currently feature in the main diagnostic criteria for borderline personality disorder (BPD). However, there is accumulating evidence that a high proportion of BPD patients report longstanding and frequent AVHs which constitute a significant risk factor for suicide plans and attempts, and hospitalization.

AIM

This study addressed questions about the validity and phenomenology of AVHs in the context of BPD. The longer-term aim is to facilitate the development and translation of treatment approaches to address the unmet need of this population.

METHOD

This was a cross-sectional study, combining phenomenological and psychological assessments administered in person and online. We explored the experiences of 48 patients with a diagnosis of BPD who were hearing AVHs.

RESULTS

Participants gave 'consistent' reports on the measure of AVH phenomenology, suggesting that these experiences were legitimate. Similar to AVHs in a psychosis context, AVHs were experienced as distressing and appraised as persecutory. AVHs were found to be weakly associated with BPD symptoms. AVHs were also rated highly as a treatment priority by the majority of participants.

CONCLUSION

The findings suggest that AVH is a legitimate and distressing symptom of BPD and a treatment priority for some patients. The relative independence of AVHs from other BPD symptoms and emotional states suggests that psychological treatment may need to be targeted specifically at the symptom of AVHs. This treatment could be adapted from cognitive behaviour therapy, the psychological intervention that is recommended for the treatment of AVHs in the context of psychosis.

Brief coping strategy enhancement for the treatment of distressing voices in the context of borderline personality disorder: A comparison with outcomes in the context of psychosis

BACKGROUND

Voice hearing in the context of Borderline Personality Disorder (BPD) has traditionally been regarded as transient and an experience that lacks legitimacy. Consequently, there are no evidence-based treatments for the voices reported by BPD patients. Contrary to the traditional view, there is a growing literature suggesting that voice hearing in the context of BPD can be an enduring and distressing experience which shares similarities with voice hearing in the context of psychosis. Given these similarities, the aim of this study was to explore whether brief Coping Strategy Enhancement developed in the context of psychosis can be used to treat distressing voice hearing in the context of BPD.

METHOD

This was a service evaluation carried out in a specialist NHS service delivering psychological therapies for distressing voices. Patients with either a BPD (n = 46) or a psychosis diagnosis (n = 125) received four sessions of Coping Strategy Enhancement (CSE). The primary outcome was voice-related distress. The pre-post outcomes for BPD patients were explored and compared with those achieved by the psychosis patients.

RESULTS

Both the BPD and psychosis groups experienced a significant reduction in voice-related distress after CSE compared with baseline. The interaction between diagnosis group and time was small and statistically non-significant.

CONCLUSION

These findings suggest a brief CSE intervention developed in the context of psychosis can be an effective starting point in the treatment of distressing voice hearing in the context of BPD. Such interventions have the potential to be integrated into broader BPD treatment programmes for those who hear voices.

Off-label use of second-generation antipsychotics in borderline personality disorder: a comparative real-world study among oral and long-acting injectables in Spain

The aim of the present study was to evaluate the use of oral vs. long-acting injectables (LAIs) antipsychotics, as well as, to compare the effectiveness of different LAI antipsychotics [aripiprazole-1-month, paliperidone-1-month (PP1M), paliperidone-3-month (PP3M) and risperidone long-acting injectable (RLAI)] in patients diagnosed with borderline personality disorder (BPD), by evaluating the following clinical outcomes: (1) the number of hospital admissions; (2) the number of documented suicidal behaviour/attempts; and (3) the use of concomitant treatments, including benzodiazepines, oral antipsychotics and biperiden. We included a total of 116 patients diagnosed with BPD and treated with antipsychotic medication: 50 using a LAI antipsychotic formulation and 66 using the equivalent main oral antipsychotic. Patients treated with LAIs showed a decreased ratio of visits to emergency compared with the oral treatment group, and between LAIs, PP3M vs. aripiprazole-1-month group. Furthermore, patients treated with LAIs used lower number and dose of concomitant antipsychotics compared with patients treated with oral antipsychotics. Moreover, PP1M and PP3M used lower daily dose of diazepam equivalents compared with the aripiprazole-1-month and RLAI treatment groups. In conclusion, the use of LAIs may play a role in the management of BPD.

Childhood abuse and borderline personality disorder features in Chinese undergraduates: the role of self-esteem and resilience

BACKGROUND

Although childhood abuse is considered to be related to borderline personality disorder (BPD), few studies have elaborated on the mediating role of self-esteem and resilience in it. Thus, the present study aimed to explore the potential mediating role of resilience and self-esteem between childhood abuse and BPD.

METHODS

This cross-sectional study was conducted with 4034 college students in Anhui Province, China. Participants were asked to complete Chinese versions of the following instruments: Childhood Trauma Questionnaire-Short Form (CTQ-SF), Mclean Screening Instrument for Borderline Personality Disorder (MSI-BPD), Connor-Davidson Resilience Scale (CD-RISC), and Rosenberg Self-Esteem Scale (RSES). Structural equation modeling (SEM) was used to test the mediation effects.

RESULTS

Resilience and self-esteem were found to be mediators of all three types of childhood abuse (emotional abuse, physical abuse and sexual abuse) when the types were examined separately; however, when all three types of childhood abuse were entered into the model simultaneously, neither the indirect effects nor direct effects of physical abuse or sexual abuse were found to be significant, only the association between emotional abuse and BPD features was partially mediated by resilience and self-esteem.

CONCLUSIONS

Self-esteem and resilience mediate the links between childhood abuse and BPD features, and emotional abuse is uniquely associated with BPD features.

EEG Markers in Emotionally Unstable Personality Disorder-A Possible Outcome Measure for Neurofeedback: A Narrative Review

Objectives. There is growing evidence for the use of biofeedback (BF) in affective disorders, dissocial personality disorder, and in children with histories of abuse. Electroencephalogram (EEG) markers could be used as neurofeedback in emotionally unstable personality disorder (EUPD) management especially for those at high risk of suicide when emotionally aroused. This narrative review investigates the evidence for EEG markers in EUPD. Methods. PRISMA guidelines were used to conduct a narrative review. A structured search method was developed and implemented in collaboration with an information specialist. Studies were identified via 3 electronic database searches of MEDLINE, Embase, and PsycINFO. A predesigned inclusion/exclusion criterion was applied to selected papers. A thematic analysis approach with 5 criteria was used. Results. From an initial long list of 5250 papers, 229 studies were identified and screened, of which 44 met at least 3 of the predesigned inclusion criteria. No research to date investigates EEG-based neurofeedback in EUPD. A number of different EEG biomarkers are identified but there is poor consistency between studies. Conclusions. The findings heterogeneity may be due to the disorder complexity and the variable EEG related parameters studied. An alternative explanation may be that there are a number of different neuromarkers, which could be clustered together with clinical symptomatology, to give new subdomains. Quantitative EEGs in particular may be helpful to identify more specific abnormalities. EEG standardization of neurofeedback protocols based on specific EEG abnormalities detected may facilitate targeted use of neurofeedback as an intervention in EUPD.

Exploring How UK Adults' Attachment Style in Romantic Relationships Affects Engagement in Controlling Behaviours

Copious studies have identified a link between disorganised attachment and engagement in controlling caregiving or controlling punitive behaviours. Studies have suggested that consistently engaging in these behaviours can cause difficulties within relationships and contribute to the development of a personality disorder. Most of the literature thus far has focused on engagement in controlling behaviours by children with a disorganised attachment style, despite there being theoretical grounds to suggest they may also be used by adults and across all types of insecure attachment. This study aimed to address these gaps by looking at adult attachment style and engagement in controlling behaviours in romantic relationships, across all insecure attachment styles; avoidant, anxious and disorganised. The current study recruited a non-clinical sample; specifically, 149 English-speaking adults, living in the UK, between the ages of 18 and 77 years old (M = 34.28, SD = 14.90). The participants answered an anonymous online questionnaire containing four self-report measures which assessed the participants' attachment security and organisation, caregiving style and engagement in punitive behaviours. The results indicated that participants who scored higher in disorganised attachment were more likely to use controlling punitive behaviours in their romantic relationships. Moreover, participants who reported a more insecure-anxious attachment style were more likely to use compulsive caregiving behaviours in their romantic relationships. In contrast, participants who reported a higher insecure avoidant attachment style were less likely to use compulsive caregiving behaviours in their romantic relationships. These results have implications for adult attachment theory and aid the understanding of some of the behaviours that can be harmful within romantic relationships. The findings could be used to help at-risk individuals develop healthy interpersonal relationship going forward.

Metaphors in Mentalization-Based Treatment: Reintroducing the Language of Change in “Plain Old Therapy”

Metaphors, a central conduit of change in psychotherapy, have not been taken adequately into account in Mentalization-Based Treatment (MBT). Despite successfully utilized by other evidence-based treatments for borderline personality disorder (BPD), MBT considers metaphors confusing for patients with low mentalizing abilities. For metaphors and teaching stories to stimulate growth within the window of tolerance, interventions should be responsively tailored (e.g., explained). Metaphors might be a route to making spoken matter more apprehensible, and bridge emotions with cognitive content. They hold the potential for challenging without being too confronting, and to translate knowledge between different range of understanding. This theoretical article presents why the use of metaphors in MBT—in the hands of a responsive therapists—may prove a powerful tool to open social trust, despite being considered a “high risk” intervention. The timeless lens of the metaphor may help us connect with archetypical versions of our own narratives, hence understanding our subjectivity in a larger perspective. By reaching towards concepts beyond our normal reasoning, typically denoted perennial philosophy or wisdom, they may substitute and/or supplement mentors in a memorable way.

Resilience as a predictor of quality of life in participants with borderline personality disorder before and after treatment

BACKGROUND

Studies have suggested that psychotherapy improves the Quality of Life (QoL) of participants with Borderline Personality Disorder (BPD). However, there are no studies on the differential efficacy of treatments on the QoL of participants with BPD. Moreover, the relationship between QoL and resilience has rarely been studied in participants with BPD.

OBJECTIVES

a) to examine whether people with BPD have worse QoL than the non-clinical population; b) to examine whether there are statistically significant differences between Dialectical Behavioural Therapy (DBT), Systems Training for Emotional Predictability and Problem Solving (STEPPS), or Cognitive Behavioural Therapy-Treatment at Usual (CBT-TAU) in the improvement of QoL; c) to examine whether participants show clinically significant improvements in QoL after treatment; d) to analyse whether resilience is associated with QoL before and after the BPD treatment; e) to analyse whether resilience is a predictor of QoL at pre-treatment and posttreatment.

METHOD

The sample comprised 403 participants (n = 202 participants diagnosed with BPD and n = 201 non-clinical). Participants filled out the Quality of Life Index, Resilience Scale, and Beck Depression Inventory. The clinical participants received one of these possible treatments, DBT, STEPPS, or CBT-TAU. MANOVA and regression analyses were performed.

RESULTS

a) participants diagnosed with BPD had statistically significant lower resilience than the non-clinical population; b) all three forms of psychotherapy statistically improved QoL, but there were no statistically significant differences between DBT, STEPPS, and CBT-TAU in the improvement of QoL; c) participants did not show clinically significant improvements in QoL after treatment; d) resilience was associated with QoL before and after treatment; and e) resilience was a predictor of QoL before and after treatment.

CONCLUSION

It is necessary to assess QoL and Resilience in studies on psychotherapy with BPD patients.

At the Junction of Clinical and Developmental Science: Associations of Borderline Identity Disturbance Symptoms With Identity Formation Processes in Adolescence

Developmental scientists describe the role confusion that can occur for adolescents as they are forming a personal identity. Clinical psychologists describe low self-worth, lack of self-clarity, feelings of emptiness, and dissociation as the key elements of identity disturbance, and they link these to borderline personality disorder. In this study, the authors aimed to work at the juncture of these approaches by considering interrelations between four elements of identity disturbance, typical identity formation processes reflective of identity commitment and confusion, and borderline features. Australian youth (N = 505, 63% female and aged 12-20 years) recruited from clinical and community settings reported on identity commitment, exploration and reconsideration, four elements of identity disturbance, and borderline features. Identity confusion (especially reconsideration) and disturbance were associated with elevated borderline symptoms. Emptiness stood out as the strongest correlate of borderline symptoms. Youth reporting greater emptiness were nearly twice as likely to report a high borderline symptom profile.

Interpersonal Problems in Parents and Adolescent Borderline Personality Disorder Features

Research shows that parental personality pathology is associated with borderline personality disorder features and internalizing/externalizing symptoms in offspring. However, studies have been limited by DSM-IV-based assessments of parental personality pathology. The authors leveraged evidence that interpersonal problems described by the Interpersonal Circumplex align with Criterion A of the DSM-5 Alternative Model for Personality Disorders and therefore used a measure of interpersonal problems to capture parental personality pathology. The authors hypothesized that parental interpersonal problems would be associated with a latent variable of borderline features in adolescent offspring. They also examined whether this relation with offspring borderline features existed above and beyond relations with offspring internalizing/externalizing symptoms, age, and gender. The sample included 524 inpatient adolescents (M_age = 15.31, 62.4% female) and their parents (80.5% female). Parental interpersonal problems demonstrated unique relationships with adolescent borderline features and externalizing symptoms, but not internalizing symptoms. Implications of the results, limitations, and future directions are discussed.

Diffusion tensor imaging of corpus callosum in adolescent females with borderline personality disorder

OBJECTIVES

The aim of this study was to assess the structural alteration of corpus callosum (CC) in adolescent females with Borderline Personality Disorder (BPD) and detect the relationship between these changes and BPD symptoms.

METHODS

A comparative case control study was conducted on 50 adolescent females that were divided into 2 groups; 25 outpatients suffering from BPD (according to DSM-IV-TR diagnostic criteria) compared to 25 healthy adolescents. All subjects were assessed by Borderline Personality Questionnaire, Barratt impulsivity scale-11, Brief Non-Suicidal Self-Injury Assessment tool, Beck Scale for Suicidal Ideation, and Diffusion tensor imaging.

RESULTS

Relative to control subjects, BPD patients had significantly lower fractional anisotropy (FA) values in the genu and lower mean diffusivity (MD) values in the body of CC. There was a negative correlation between FA values in the genu and body of CC and impulsivity. MD in the body of CC was positively correlated with motor impulsiveness and negatively correlated with suicidality.

CONCLUSION

Adolescent females with BPD show structural alterations in the CC that are related to symptoms of emotional dysregulation and impulsivity.

Effects of pharmacological treatments on emotional tasks in borderline personality disorder: A review of functional magnetic resonance imaging studies

BACKGROUND

Borderline personality disorder (BPD) is a common mental disorder characterized by instability in interpersonal relationships, impaired self-image, impulsivity and aggressive behaviors that often requires pharmacological treatments. Neuroimaging alterations have been extensively reported in BPD, especially in regions within the fronto-limbic system. Although medications can be an important confounding factor in functional Magnetic Resonance Imaging (fMRI) studies, their role on brain function in BPD patients still remains uncertain. Therefore, this review aims to improve our understanding on the potential effect of the most commonly prescribed drugs for BPD on brain function during processing of emotional tasks.

METHODS

A search on PubMed, Scopus and Web of Science of fMRI studies exploring the effect of antipsychotics, antidepressants and mood stabilizers on brain activity during processing of emotional tasks on BPD was conducted.

RESULTS

Overall the studies showed small or no effect of pharmacological treatments on brain activity and connectivity in BPD patients during processing of emotional tasks.

LIMITATIONS

The small sample size, the observational design, the elevated percentage of women, the concomitant use of psychostimulants, anticholinergics and opioids substitute treatments and the high rate of comorbidities limit the conclusion of this review.

CONCLUSIONS

Pharmacological treatments seem to have minor role on brain activity/connectivity in BPD patients during emotional tasks, ultimately suggesting that in BPD patients brain deficits seem not be influenced by medications. This might be due to functional brain specificities of BPD and to the differences in pharmacological regimens and compliance to therapy between BPD and other common psychiatric disorders.

Off-Label Use of Second-Generation Antipsychotics in Borderline Personality Disorder: A Survey of Italian Psychiatrists

The guidelines for borderline personality disorder (BPD) treatment suggest non-pharmacological treatment as the first option, but second-generation antipsychotics (SGAs) are among the overprescribed medications. This study aimed to explore Italian psychiatrists' attitudes toward off-label use of SGAs in BPD. A randomly selected sample of Italian psychiatrists completed a questionnaire regarding off-label prescription of SGAs. Most respondents reported the off-label use of SGAs. Among the reasons supporting the prescription of SGAs, the presence of strong published data was the most determining factor (51.5%). The SGA olanzapine is considered the most appropriate, followed by quetiapine and aripiprazole. Although off-label prescription of SGAs represents a common clinical practice in accordance with a worldwide trend, the use of long-acting injection formulations was considered inappropriate by 69% of psychiatrists in our sample. Our results reiterate the discrepancy between everyday clinical practice and international recommendations, and show how relevant the literature is in off-label drug prescription.

Mentalization-Based Treatment Versus Specialist Treatment as Usual for Borderline Personality Disorder: Economic Evaluation Alongside a Randomized Controlled Trial With 36-Month Follow-Up

The authors present an economic evaluation performed alongside a randomized controlled trial of mentalization-based treatment in a day hospital setting (MBT-DH) versus specialist treatment as usual (S-TAU) for borderline personality disorder (BPD) with a 36-month follow-up period. Ninety-five patients from two Dutch treatment institutes were randomly assigned. Societal costs were compared with the proportion of BPD remissions and quality-adjusted life years (QALYs) measured using the five-dimensional EuroQol instrument. The incremental societal costs for one additional QALY could not be calculated. The costs for one additional BPD remission with MBT-DH are approximately €29,000. There was a 58% likelihood that MBT-DH leads to more remitted patients at additional costs compared with S-TAU, and a 35% likelihood that MBT-DH leads to more remissions at lower costs. MBT-DH is not cost-effective compared with S-TAU with QALYs as the outcome, and slightly more cost-effective than S-TAU at 36 months with BPD symptoms as the outcome.

Looking at the bigger picture: Cortical volume, thickness and surface area characteristics in borderline personality disorder with and without posttraumatic stress disorder

Borderline personality disorder (BPD) is a severe psychiatric disorder accompanied by multiple comorbidities. Neuroimaging studies have identified structural abnormalities in BPD with most findings pointing to gray matter volume reductions in the fronto-limbic network, although results remain inconsistent. Similar alterations were found in posttraumatic stress disorder (PTSD), a common comorbidity of BPD. Only a small number of studies have investigated structural differences in BPD patients regarding comorbid PTSD specifically and studies conducting additional surface analyses are scarce. We investigated structural differences in women with BPD with and without PTSD and non-patient controls. Automated voxel-based and region-based volumetric analyses were applied. Additionally, four surface-based measures were analyzed: cortical thickness, gyrification index, fractal dimension, and sulcus depth. Analyses did not identify cortical volume alterations in the fronto-limbic network. Instead, hypergyrification was detected in the right superior parietal cortex in BPD patients compared to non-patient controls. No distinction was revealed between BPD patients with and without PTSD. These findings underline the importance of a holistic investigation examining volumetric and surface measures as these might enhance the understanding of structural alterations in BPD.

Longitudinal associations between borderline personality disorder and five-factor model traits over 24 years

Are five-factor traits and borderline personality symptoms the same features with different names? The existing literature offers reasons to think they are the same and reasons to think they are different. We examined longitudinal associations between these variables in a sample of patients assessed 12 times over 24 years using latent curve models with structured residuals. Mean trajectories for all variables were in the direction of symptom reduction/personality maturation and could be parsed into an initial, rapid improvement phase and a subsequent, gradual improvement phase. We found robust between-person associations among intercepts and long-term slopes of traits and symptoms. Specifically, higher levels of neuroticism as well as lower levels of extraversion, agreeableness, and conscientiousness were associated with higher levels of borderline personality symptoms, and changes in these traits were correlated with reduction in symptoms over time. Associations among time-structured residuals allowed for examinations of within-person deflections from these general trends at briefer (two year) intervals. All variables exhibited robust within-person carry-over effects. Other within-person effects were more specific to certain traits. These results suggest that, despite their distinct theoretical and methodological bases, normal trait and psychiatric diagnostic approaches largely converged on a similar conception of borderline personality.

Investigating the Relationship between Autistic Traits, Ruminative Thinking, and Suicidality in a Clinical Sample of Subjects with Bipolar Disorder and Borderline Personality Disorder

(1) Background: Previous literature reported in both subjects with Borderline personality disorder (BPD) and Bipolar disorder (BD) higher levels of autistic traits, linked to a greater suicidality risk. The aim of this study was to evaluate and compare the presence of autistic traits in a sample of individuals with BD or BPD, with a specific focus on suicidality. (2) Methods: We recruited two clinical samples of subjects (BPD and BD) and a control group without a diagnosis according to DSM-5 (CTL). Subjects were assessed with the AdAS Spectrum, the RRS and, for evaluating suicidality, the MOODS-SR. (3) Results: The CTL group showed significantly lower scores of both BD and BPD on AdAS Spectrum, RRS, and suicidality scores. BPD subjects showed significantly lower scores than BD ones in most of AdAS Spectrum domain scores. Correlation and regression analyses highlighted specific patterns of association among AdAS Spectrum domains, RRS, and suicidality in each clinical group. (4) Conclusions: Both BPD and BD individuals show greater levels of autistic traits, which seem to be distributed in a continuum featuring the highest levels among BD subjects. In both disorders, higher autistic traits were linked to suicidal tendencies, although with different patterns of association between BD and BPD subjects.

Maladaptive behaviours in adolescence and their associations with personality traits, emotion dysregulation and other clinical features in a sample of Italian students: a cross-sectional study

BACKGROUND

Emotion Dysregulation (ED), childhood trauma and personality are linked to the occurrence of maladaptive behaviours in adolescence which, in turn, may be related to increased risk for psychopathology in the life course. We sought to explore the relationship among the occurrence of different clusters of maladaptive behaviours and ED, clinical features (i.e. impulsivity, childhood maltreatment, anxiety, depressive symptoms) and personality traits that have been found to be associated to Borderline Personality Disorder (BPD), in a sample of 179 adolescent students.

METHODS

Multiple Correspondence Analysis (MCA) was applied to detect clustered types of maladaptive behaviours and groups of students were defined as individuals engaging in these clustered behaviours (non-suicidal self-injury-NSSI, binge eating, binge drinking, cannabis use, and sexual risk behaviours). Logistic models were used to evaluate the association among clinical scales, and student groups. Mediation analysis was used to evaluate whether clinical features affected the association between personality traits and student groups.

RESULTS

MCA analysis allowed to identify three student groups: NSSI/binge eating (NSSI-BE) behaviours, other maladaptive behaviours and "none". Higher scores in ED, impulsivity, childhood maltreatment, anxiety and depressive symptoms increased the risk of belonging to the cluster of NSSI-BE behaviours compared to the other two groups. ED, depression and anxiety symptoms were found to be mediators of the relationship between specific personality traits, mainly pertaining to the negative affectivity construct, and NSSI/BE.

CONCLUSIONS

Individuals engaging in NSSI-BE behaviours represent a vulnerable adolescent population. ED, depression and anxiety were mediators of the relationship between a variety of personality traits related to BPD and NSSI and binge eating behaviours. Findings have important clinical implications in terms of prevention and interventions among adolescents engaging in self-damaging behaviours.

Mentalization-based treatment in groups for adolescents with Borderline Personality Disorder: 3- and 12-month follow-up of a randomized controlled trial

Mentalization-based treatment in groups (MBT-G) has never been tested in adolescents with Borderline Personality Disorder (BPD) in a randomized controlled trial. The current study aimed to test the long-term effectiveness of MBT-G in an adolescent sample with BPD or BPD features (≥ 4 DSM-5 BPD criteria). Hundred and eleven patients with BPD (n = 106) or BPD features (n = 5) were randomized to either (1) a 1-year modified MBT-G program comprising three MBT introductory sessions, five individual case formulation sessions, 37 weekly MBT group sessions, and six MBT-Parent sessions, or (2) treatment as usual (TAU), defined as at least 12 individual monthly treatment sessions with follow-up assessments at 3 and 12 months post treatment. The primary outcome was the score on the Borderline Personality Features Scale for Children (BPFS-C), and secondary outcomes included clinician-rated BPD symptoms and global level of functioning as well as self-reported self-harm, depression, externalizing and internalizing symptoms, and caregiver reports. There were no statistically significant differences between MBT-G and TAU on the primary outcome measure or any of the secondary outcomes. Both groups showed improvement on the majority of clinical and social outcomes at both follow-up points, although remission rates were modest with just 35% in MBT-G and 39% in TAU 2 years after inclusion into the study. MBT-G was not superior to TAU in improving borderline features in adolescents. Although improvement was observed equally in both interventions over time, the patients continued to exhibit prominent BPD features, general psychopathology and decreased functioning in the follow-up period, which points to a need for more research and better understanding of effective components in early intervention programs. The ClinicalTrials.gov identifier is NCT02068326.

The Emerging Circadian Phenotype of Borderline Personality Disorder: Mechanisms, Opportunities and Future Directions

PURPOSE OF REVIEW

We review the recent evidence suggesting that circadian rhythm disturbance is a common unaddressed feature of borderline personality disorder (BPD); amelioration of which may confer substantial clinical benefit. We assess chronobiological BPD studies from a mechanistic and translational perspective and highlight opportunities for the future development of this hypothesis.

RECENT FINDINGS

The emerging circadian phenotype of BPD is characterised by a preponderance of comorbid circadian rhythm sleep-wake disorders, phase delayed and misaligned rest-activity patterns and attenuated amplitudes of usually well-characterised circadian rhythms. Such disturbances may exacerbate symptom severity, and specific maladaptive personality dimensions may produce a liability towards extremes in chronotype. Pilot studies suggest intervention may be beneficial, but development is limited. Endogenous and exogenous circadian rhythm disturbances appear to be common in BPD. The interface between psychiatry and chronobiology has led previously to novel efficacious strategies for the treatment of psychiatric disorders. We believe that better characterisation of the circadian phenotype in BPD will lead to a directed biological target for treatment in a condition where there is a regrettable paucity of accessible therapies.

Antisocial Traits and Neuroticism as Predictors of Suicidal Behaviour in Borderline Personality Disorder: a Retrospective Study

INTRODUCTION

The spectrum of suicidal behaviour (SB) is nuclear in the clinic and management of borderline personality disorder (BPD). The pathological personality traits of BPD intervene as risk factors for SB in confluence with other clinical and sociodemographic variables associated with BPD. The objective of this work is to evaluate the specific personality traits of BPD that are related to SB.

METHODS

A cross-sectional, observational and retrospective study was carried out on a sample of 134 patients diagnosed with BPD according to DSM-5 criteria. The Millon-II, Zuckerman-Kuhlman and Barrat questionnaires were used to assess different personality parameters. Variable comparisons were made using the χ2 test and the Student's t-test. The association between variables was analysed using multivariate logistic regression.

RESULTS

Statistically significant differences were observed between SB and related factors and the neuroticism-anxiety dimension in the Zuckerman-Kuhlman test. It is also significantly related to the phobic and antisocial subscale of the Millon-II. Impulsivity measured with the Zuckerman-Kuhlman and Barrat tests does not appear to be related to SB.

CONCLUSIONS

The results presented raise the role of phobic, antisocial and neuroticism traits as possible personality traits of BPD related to SB, suggesting an even greater importance within the relationship between BPD and SB than that of impulsivity. Looking to the future, longitudinal studies would increase the scientific evidence for the specified findings.

Effectiveness of brief schema group therapy for borderline personality disorder symptoms: a randomized pilot study

BACKGROUND AND OBJECTIVES

Schema group therapy is a potentially cost-effective treatment for borderline personality disorder (BPD). We piloted the feasibility and effectiveness of a 20-session schema group therapy without individual therapy among psychiatric BPD outpatients in a randomized pilot study registered as a clinical trial (ISRCTN76381242).

METHODS

Altogether 42 psychiatric outpatients diagnosed with BPD were randomized 2:1 to a 20-session weekly schema group therapy plus treatment as usual (TAU) (n = 28) vs. a control group with TAU alone (n = 14). The primary outcome was decline of BPD symptoms in the short Borderline Symptom List (BSL-23) score. Secondary outcomes were decline in symptoms of anxiety, depression, alcohol use, and improvement in functioning and schema modes. Two external experts evaluated validity of the intervention based on videotaped sessions.

RESULTS

Overall, 23 schema group therapy patients (82%) and 12 controls (86%) completed their treatment. Treatment validity good or very good. However, no significant differences emerged in the primary outcome mean BSL-23 decline (6.95 [SE 5.91] in group schema therapy vs. 12.55 [4.85] in TAU) or in any of the secondary outcome measures.

LIMITATIONS

Despite randomization, the TAU subgroup had non-significantly higher baseline scores in most measures. Small sample size predisposing to type II errors; reliance on self-reported outcomes.

CONCLUSIONS

Schema group therapy was feasible for psychiatric outpatients with BPD. However, in this small pilot study we did not find it more effective than TAU. Effectiveness of this short intervention remains open.

Emotion regulation, mindfulness, and self-compassion among patients with borderline personality disorder, compared to healthy control subjects

Objectives

Emotion regulation difficulties are a major characteristic of personality disorders. Our study investigated emotion regulation difficulties that are characteristic of borderline personality disorder (BPD), compared to a healthy control group.

Methods

Patients with BPD (N = 59) and healthy participants (N = 70) filled out four self-report questionnaires (Cognitive Emotion Regulation Questionnaire, Difficulties in Emotion Regulation Scale, Five Facet Mindfulness Questionnaire, Self-Compassion Scale) that measured the presence or lack of different emotion-regulation strategies. Differences between the BPD and the healthy control group were investigated by Multivariate Analysis of Variance (MANOVA) and univariate post-hoc F-test statistics.

Results

People suffering from BPD had statistically significantly (p<0.05) higher levels of emotional dysregulation and used more maladaptive emotion-regulation strategies, as well as lower levels of mindfulness and self-compassion compared to the HC group.

Conclusion

In comparison to a healthy control group, BPD patients show deficits in the following areas: mindfulness, self-compassion and adaptive emotion-regulation strategies. Based on these results, we suggest that teaching emotion-regulation, mindfulness, and self-compassion skills to patients can be crucial in the treatment of borderline personality disorder.

Structural brain abnormalities in borderline personality disorder correlate with clinical severity and predict psychotherapy response

Although previous imaging studies in borderline personality disorder (BPD) have found brain abnormalities, the results have been inconsistent. This study aimed to investigate structural brain abnormalities using voxel-based morphometry (VBM) and cortical thickness (Cth) analyses in a large sample of patients with BPD. Additionally, we aimed to determine the correlation between structural abnormalities and clinical severity and to assess its potential value at predicting psychotherapeutic response. Sixty-one individuals with BPD and 19 healthy controls underwent magnetic resonance imaging. Participants with BPD completed several self-report clinical scales, received dialectical-behavioral therapy skills training and post-therapy changes in clinical scores were also recorded. Gray matter volume (GMV) and Cth differences between groups were compared. Within the BPD group, we further characterized the structural brain correlates of clinical severity and investigated the relationship between pre-therapy structural abnormalities and therapeutic response. As potential confounders we included age, sex, educational level, and total intracranial volume (the latter only in VBM analyses). Compared to controls, the BPD group showed a reduced GMV/Cth in prefrontal areas but increased GMV in the limbic structures (amygdala and parahippocampal regions). Prefrontal abnormalities correlated with higher baseline scores on impulsivity and general BPD severity. Increased GMV in the parahippocampal area correlated with a greater emotion dysregulation. Importantly, several baseline structural abnormalities correlated with worse response to psychotherapy. Patients with BPD showed a reduced GMV in the prefrontal areas but a greater GMV in the limbic structures. Several structural abnormalities (i.e. middle and inferior prefrontal areas, anterior insula, or parahippocampal area) correlated with clinical severity and could potentially be used as imaging biological correlates biomarkers to predict psychotherapy response.

Rethinking Risk Assessments in a Borderline Personality Disorder Unit: Patient and Staff Perspectives

Background

The present study was undertaken in a borderline personality disorder unit in Cambridge, UK. Our aim was to evaluate patient and staff perspectives on the current risk assessment procedure and to assemble opinions on a proposed change to this procedure.

Methodology

Structured interviews were conducted with patients and risk-assessing staff. Likert-scale and open questions were asked to gather both quantitative and qualitative data on both the preexisting risk assessment procedure and the proposed change to the procedure. The qualitative data was assembled into key themes.

Results

Patients and staff were moderately satisfied with the current risk assessment process, with patients scoring it an average of 2.75 out of 5 and staff scoring it 2.5 out of 5. Six key themes emerged as relevant to the process for both staff and patients: holistic approach, autonomy and freedom, responsibility, staff-patient relationship, time taken, and chance for reflection. One theme, “triggering negativity,” emerged among patients only, while a theme exploring ideas about risk emerged only among staff.

Conclusion

Our study highlights the need to introduce a new risk assessment procedure that grants patients more freedom and responsibility and encourages staff to individualize the process for each patient by taking a holistic approach. This would cultivate a ward environment that is less risk-averse and more recovery-oriented.

Exploring mentalizing in adolescents with anorexia nervosa and borderline personality disorder: A comparative study of psychiatric inpatients and healthy controls

Background:

Impaired mentalizing, i.e., difficulties in understanding oneself and others in terms of mental states, has been associated with the development of Anorexia Nervosa (AN), mainly among adults. However, few studies have addressed this question in clinical samples of adolescents with AN. Moreover, no study has explored mentalizing abilities among inpatient adolescents presenting with AN and Borderline Personality Disorder (BPD), despite their high comorbidity in a highly relevant age group.

Objective:

This study attempted, for the first time, to further examine differences in mentalizing abilities and to identify specific mentalizing impairments in different psychiatric inpatient groups and healthy adolescents.

Methods:

Using samples of female adolescents aged 12–17, comparison analyses were performed between psychiatric inpatient adolescents with AN (n = 44), BPD (n = 101), AN+BPD (n = 48), other psychopathology (n = 163) and healthy adolescents (n = 129). Structured and semi-structured clinical interviews, and two experimental tasks were administered to assess AN, BPD and mentalizing, respectively.

Results:

Comparison analyses showed that patients with BPD and other psychiatric disorders evidenced higher levels of hypermentalizing compared to healthy adolescents. Hypermentalizing was also reported among inpatients with AN+BPD, although to a lesser extent. BPD and AN scores were positively correlated with hypermentalizing responses.

Conclusions:

Our results suggest that hypermentalizing is a specific mentalization impairment in inpatient adolescents, particularly with BPD and both AN+BPD. Further investigation into the efficacy of mentalization based treatments for adolescents with BPD and AN+BPD is recommended. Prospective studies are needed to assess mentalizing using experimental tasks among adolescents with AN, taking into account the potential influence of temporality and severity of the disorders’ symptoms.

Improvement in borderline personality disorder symptomatology after repetitive transcranial magnetic stimulation of the dorsomedial prefrontal cortex: preliminary results

Objective:

Current treatment for borderline personality disorder (BPD) involves psychological and pharmacological interventions. However, neuromodulation techniques such as repetitive transcranial magnetic stimulation (rTMS) may positively affect BPD symptomatology. The objective of this study was to evaluate the clinical and neuropsychological effects of rTMS on the dorsomedial prefrontal cortex (DMPFC) in BPD patients.

Methods:

Fourteen patients with BPD were randomized into two groups (active vs. sham) for 15 sessions of rTMS on the DMPFC. Clinical effects were measured using the Borderline Symptoms List (BSL), Clinical Global Impression Scale for BPD (CGI-BPD), Borderline Evaluation of Severity over Time (BEST), Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Rating Scale (HARS), and Barratt’s Impulsiveness Scale (BIS). Neuropsychological effects were determined by a Stop-Signal Task (SST), the Wisconsin Card-Sorting Test (WCST), and the Iowa Gambling Test (IGT).

Results:

Within-group comparison showed significant differences (p < 0.05) in CGI-BPD (total score and six of nine psychopathologic domains), BEST, HDRS, HARS, and IGT scores for active modality.

Conclusion:

The 5 Hz-DMPFC rTMS technique was well tolerated and lessened the severity of BPD symptomatology, especially abandonment, affective issues, interpersonal relationships, suicidal behavior, anger, and paranoid ideation. Cognitive improvement was seen in decision-making. Additional studies are needed to fully evaluate the effects of rTMS on BPD symptomatology.

Clinical Trial Registration:

NCT03832777.

Borderline personality disorder and self-directed violence in a sample of suicidal army soldiers

There has been a sharp increase in the military suicide rates in 2004. While, borderline personality disorder (BPD) has a stronger association with suicide attempts than any other mental health disorder, there is limited evidence concerning the prevalence and scope of BPD symptoms among military personnel. This secondary data analysis compared active duty suicidal soldiers to characterize the presence-absence of BPD diagnostic criteria and lifetime history of self-directed violence in a suicidal military sample. The current study examined data of 137 active Service Members with significant suicidal ideation. Approximately one-quarter of the soldiers in this sample met full diagnostic criteria for BPD. The presence of BPD criteria was generally consistent among participants with BPD who reported past self-directed violence relative to those who did not. The number of BPD criteria was a significant predictor of the odds of reporting any nonsuicidal self-injury (NSSI) as well as the amount of NSSI, but was not associated with suicide attempt. This study demonstrated that a nontrivial proportion of suicidal soldiers meet criteria for this condition, which is strongly associated with self-directed violence. It is important to rigorously assess for the presence-absence of BPD criteria among suicidal military personnel and cultivate prevention strategies and treatment options for BPD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Childhood maltreatment, personality vulnerability profiles, and borderline personality disorder symptoms in adolescents

Adverse childhood experiences are significant risk factors in the development of adolescent borderline personality disorder symptoms (BPDs). Theorists have posited that two personality vulnerabilities factors, self-criticism and dependency, may inform our understanding of this relationship. However, no research has examined the associations between early negative experiences, personality vulnerabilities, and adolescent BPDs. The current study aimed to identify profiles of dependency and self-criticism to examine the associations of these profiles with cumulative forms of childhood maltreatment (CM) and BPDs as well as to explore the mediating and moderating role of vulnerable personality profiles in the relationship between cumulative CM and BPDs. Two hundred and forty-one nonclinical and clinical adolescents participated in the study (Mage = 16.37, SD = 1.84). The findings indicated three different profiles: average dependent profile, dependent and self-critical profile, and self-critical profile. Individuals in the average dependent profile presented lower levels of CM and BPDs. Mediation analyses showed that relative to the average dependent profile, a higher cumulative CM history predicted a higher probability of belonging in the dependent and self-critical profile or the self-critical profile and, in turn, this was associated with higher levels of BPDs. No moderating effects of profiles of dependency and self-criticism were found.

Diagnostic accuracy of DSM-5 borderline personality disorder criteria: Toward an optimized criteria set

OBJECTIVE

The polythetic system used by the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) for diagnosing borderline personality disorders (BPD) is far from optimal; however, accumulated research and clinical data are strong enough to warrant ongoing utilization. This study examined diagnostic efficiency of the nine DSM-IV BPD criteria, then explored the feasibility of an optimized criteria set in classifying BPD.

METHODS

Adults (N=1,623) completed the Structured Clinical Interviews for DSM-IV Axis II Disorders resulting in a BPD group (n=352) and an inpatient psychiatric control group (PC) with no personality disorders (n=1,271). Receiver operator characteristics and diagnostic efficiency statistics were calculated to ascertain the relative diagnostic efficiency of each DSM-5 BPD criterion in classifying BPD cases.

RESULTS

Affective instability (Criterion 6) evidenced the strongest capacity to differentiate the groups (AUC = .84, SE = .01, p < .0001). Abandonment fears (Criterion 1), unstable relationships (Criterion 2), identity disturbance (Criterion 3), impulsivity (Criterion 4), and chronic emptiness (Criterion 7) yielded good-to-moderate discrimination (AUC range = .75-.79). A composite index of these six criteria yielded excellent accuracy (AUC = .98, SE = .002, p < .0001), sensitivity (SN=.99), and specificity (SP=.90).

CONCLUSIONS

The current findings add to evidence that affective instability is a useful gate criterion for screening, and the optimized criteria set evidences equivalent accuracy to the original 9 criteria, with a substantial reduction in estimated heterogeneity (from 256 combinations with the original set to 42 combinations with the optimized set).