Pharmacological interventions for people with borderline personality disorder

Culture and ICD-11 personality disorder: Implications for clinical practice across diverse ethnic groups

BACKGROUND

Personality disorder (PD) in ICD-11 is defined primarily by self and interpersonal dysfunction and optionally by other qualifiers. This definition is inseparable from relativism of cultural determinants.

AIMS

This review aimed to synthesize the relevant aspects of the influence of culture on clinical practice and health management for this condition, aligning them to the ICD-11 PD model.

METHOD

In Scopus, we systematically searched for studies that included the text strings: cultur* | personality AND (disorder* OR patholog*) without any restrictions on publication date or language or other exclusion criteria, up to November 2022.

RESULTS

Evidence suggests that cultural variables in ethnic groups (Western and non-Western) such as the individualist/collectivist philosophy, historical/generational trauma, immigration, acculturation, religion, and gender influence the etiology, semiology, epidemiology, evaluation, diagnosis, treatment, and management of health services for ICD-11 PD. We discuss the limitations and propose future lines of research on this topic based on our knowledge and experience. In this review, we provide the scientific community and clinicians with relevant cultural information to guide their practice and propose strategies to manage PD from the ICD-11 model.

CONCLUSIONS

More research is needed using mixed study methodologies on stigma, the experiences of patients, clinicians, and health agencies, to reduce the care gaps and achieve a culturally comprehensive, inclusive, and competent use of this new model.

Can atypical antipsychotics alleviate Deficits in psychosocial impairments in patients with a diagnosis of Borderline Personality? A systematic review and meta-analysis

Patients with a diagnosis of Borderline Personality Disorder (BPD) often experience difficulties in psychosocial functioning, which reduces the ability of individuals to engage socially. This review seeks to determine whether atypical antipsychotics (AAPs) are more effective than placebo at alleviating these difficulties in adults with a diagnosis of BPD. We identified six Randomized Control Trials, conducted between 1994 and 2024, with 1012 patients that were treated with either: Olanzapine, Quetiapine, Ziprasidone or Aripiprazole. Using a meta-analysis, we found evidence that atypical antipsychotics induce a small improvement treating psychosocial functioning in patients with a diagnosis of border line personality. In particular, AAPs improved General Assessment of Functioning (GAF) more than placebo. Combining GAFs P-values from several studies indicated this effect was significant. AAPs were also superior to placebo at improving quality of interpersonal relationships, occupational functioning and family life. There was a positive improvement tendency in social life and leisure activities. AAPs also induced known secondary effects like weight gain and sedation as previously described. AAPs were beneficial for improving general functioning and its subcomponents. However, the magnitude of the benefit above that of placebo was small and its clinical meaningfulness is thus debatable. More randomised-controlled trials are required.

Characterizing psychopharmacological prescribing practices in a large cohort of adolescents with borderline personality disorder

BACKGROUND

Psychiatric medications are not efficacious for treating borderline personality disorder (BPD), yet many patients with BPD are prescribed multiple psychiatric medications. This study aimed to (1) characterize psychiatric medication prescribing practices in adolescents with BPD and (2) assess whether demographic features are associated with prescribing practices.

METHOD

This sample was N = 2950 pediatric patients with BPD (ages 10-19) across the U.S. Data came from the NeuroBlu database, which includes data from 30 U.S. healthcare systems and hundreds of hospitals. Poisson regressions and chi-squared tests determined whether gender, race, and ethnicity were associated with (1) number of unique psychiatric medications prescribed and (2) number of unique medication classes prescribed.

RESULTS

Roughly two-thirds (64.85%) of youth were prescribed any medications. Of these youth, 79.40% were prescribed ≥ 2 unique medications and 72.66% were prescribed ≥ 2 unique medications classes. The mean number of unique medications was 3.50 (SD = 2.50). The mean number of unique medication classes was 2.35 (SD = 1.15). The most commonly prescribed medication classes were antidepressants and antipsychotics, which were often prescribed in combination. Poisson regressions showed that boys were prescribed more unique medications (M = 3.67) than girls (M = 3.47). Non-Latinx youth were prescribed significantly more unique medications (M = 44.12) than Latinx youth (M = 3.60, p = .01).

CONCLUSIONS

Results characterize psychiatric medication prescribing practices in youth with BPD. Prescribing practices vary by demographics, such that boys and non-Latinx youth are prescribed more medications than girls and Latinx youth, respectively. These demographic differences suggest that prescribers may treat BPD differently based on patient demographic characteristics.

Long-lasting symptoms in borderline personality disorder: Defining an emergent population with differential clinical and therapeutic features

Although the clinical symptoms of borderline personality disorder (BPD) tend to remit over time, a substantial proportion continues to present "long-lasting symptoms" (LLS). This term refers to individuals who present some degree of clinical improvement, but low mood, feelings of emptiness, and poor psychosocial adjustment typically persist. The aim of this study was to compare the sociodemographic, clinical, and therapeutic variables in individuals with BPD with and without LLS. A total of 620 participants with BPD were included and subdivided into two groups: non-LLS group (n = 549, mean age = 28.02 [6.1] and range, 18-40 years) and LLS group (n = 71, mean age = 44.69 [3.6] and range, 41-56 years). The groups were compared in sociodemographic, clinical, and drug treatment characteristics. We also evaluated the impact of dialectical behavioral therapy-skills training (DBT-ST) on polypharmacy. The prevalence of individuals with long-lasting BPD symptoms increased significantly over a 20-year period (from <1% to 16%). The LLS group was characterized by less clinical severity, higher comorbidity with affective disorders but lower comorbidity with eating disorders, more disability, and more medication taking. Patients with LLS who received DBT-ST experienced a significant decrease in the use of benzodiazepines and the number of medications prescribed compared with those who did not receive DBT-ST. Clinicians should be aware of the specific features of older patients with BPD in order to better identify and address their specific therapeutic needs.

Systematic Review of the Effectiveness and Experiences of Treatment for Men With Borderline Personality Disorder

In clinical settings, among individuals diagnosed with borderline personality disorder (BPD), typically 75% are female and 25% male, although this discrepancy is not reported in the community. In the literature, little is known of the effectiveness and experiences of treatment of men with BPD. We aimed to review the effectiveness and experiences of treatment for men with BPD and outline future research priorities to promote better recovery. We searched Ovid MEDLINE and PsycINFO for eligible studies from inception until July 29, 2022. Peer-reviewed primary research articles on treatment effectiveness or experience for men with BPD were included. Data from eligible studies were synthesized in a narrative review. The protocol of our review was pre-registered on PROSPERO (CRD42022351908). Seventeen studies met the inclusion criteria, and men with BPD from eight countries were represented. Psychological therapies included Dialectical Behavioral Therapy, Systems Training for Emotional Predictability and Problem Solving, Mentalization Based Therapy, and psychoanalytic therapy. Pharmacologic treatment included topiramate, divalproex Extended-Release, and high-dose baclofen. Five studies investigated the service utilization of men with BPD. Compared to women, men were less likely to access treatment for BPD or find treatment helpful. Our findings demonstrated the potential efficacy of psychotherapy and pharmacologic interventions in reducing anger, aggression, and rule-breaking behavior, with limited evidence for reduction in suicide-related outcomes. Our findings are limited by inadequate power and heterogeneity of the included studies. Further research with larger sample sizes and qualitative studies is needed to better understand the treatment experience for men with BPD.

Distribution of self-reported borderline personality disorder traits symptoms in a large-scale clinical population

Introduction

Borderline Personality Disorder (BPD) traits play a crucial role in the prognosis of psychiatric disorders, as well as in assessing risks associated with negativity and impulsivity. However, there is a lack of data regarding the distribution characteristics of BPD traits and symptoms within clinical populations.

Methods

A total of 3015 participants (1321 males, 1694 females) were consecutively sampled from outpatients at the psychiatric and psycho-counseling clinics at the Shanghai Mental Health Center. BPD symptoms were assessed using a self-reported personality diagnostic questionnaire. Having BPD traits is defined as having five or more positive items in self-reported BPD characteristics. Participants were stratified into male and female groups, age groups, and diagnostic groups (schizophrenia, mood disorders, anxiety disorders). Exploratory factor analysis using principal components analysis was conducted. Three factors were identified: "F1: Affective Instability and Impulsivity", "F2: Interpersonal Unstable and Extreme Reactions", and "F3: Identity Disturbance".

Results

Among 3015 participants, 45.9% of the patients self-reported BPD traits. Comparing of male and female patients, there was no statistically significant difference in the occurrence rate of BPD traits (χ2 = 1.835, p=0.176). However, in terms of symptoms, female patients reported more symptoms than male patients. Female patients also exhibited more pronounced features on F2 compared to male patients (t =-1.972, p=0.049). There is a general decrease in BPD traits, symptoms, and factors with increasing age. Specifically, the proportion of positive BPD traits is approximately halved before the age of 30 and decreases to around one-third after the age of 30. BPD traits were most common in the Mood Disorders group at 55.7%, followed by the Anxiety Disorders group at 44.4%, and Schizophrenia group at 41.5% (χ2 = 38.084, p<0.001).

Discussion

Our study revealed the pervasive presence of BPD traits and symptoms among psychiatric outpatients, exhibiting distinctive distributions across gender, age, and diagnostic categories. These findings emphasize the significance of identifying and addressing BPD pathology in the clinical care of psychiatric outpatients.

What impact can brain stimulation interventions have on borderline personality disorder?

INTRODUCTION

Borderline personality disorder (BPD) is a severe mental disorder characterized by emotion dysregulation, impulsivity, neuropsychological impairment, and interpersonal instability, presenting with multiple psychiatric comorbidities, functional disability and reduced life expectancy due suicidal behaviors.

AREAS COVERED

In this perspective, the authors explore the application of noninvasive brain stimulation (NIBS) (rTMS, tDCS, and MST) in BPD individuals by considering a symptom-based approach, focusing on general BPD psychopathology, impulsivity and neuropsychological impairments, suicidality and depressive/anxious symptoms, and emotion dysregulation.

EXPERT OPINION

According to a symptoms-based approach, NIBS interventions (particularly rTMS and tDCS) are promising treatment options for BPD individuals improving core symptoms such as emotional and behavioral dysregulation, neuropsychological impairments and depressive symptoms. However, the heterogeneity of stimulation protocols and of assessment tools used to detect these changes limits the possibility to provide definitive recommendations according to a symptom-based approach. To implement such armamentarium in clinical practice, future NIIBS studies should further consider a lifespan perspective due to clinical variability over time, the role of psychiatric comorbidities affecting BPD individuals and the need to combine NIBS with specialized psychotherapeutic approaches for BPD patients and with functional neuroimaging studies.

Interventions to improve the sleep quality of adults with personality disorder: A systematic review

Poor quality sleep is common for people who have a diagnosis of personality disorder (PD). Core cognitive and behavioral features of PD may cause and perpetuate poor sleep, but to date, no review has collated the evidence on the efficacy of interventions to improve sleep quality for people with PD. Structured searches for interventional studies among adults with PD and reporting validated measures of sleep quality were conducted up to November 2022 in multiple databases. Single-case reports were excluded. Study quality was assessed with standardized risk of bias tools. Unreported data was sought systematically from authors. This review was pre-registered with an international prospective register of systematic reviews (PROSPERO) (CRD42021282105). Of the 3503 identified studies, nine met inclusion criteria, representing a range of psychological, pharmaceutical, and other interventions and outcome measures. Meta-analytic methods were not feasible because of the serious risk of bias in all studies, and results were therefore synthesized narratively. There is limited and low-quality evidence of the effects of a variety of interventions to improve the sleep quality of people living with PD. Further research might consider specifically including people diagnosed with PD in trials of sleep interventions and using sleep outcome measures in trials of established PD treatments.

Validation of the French version of the Revised Diagnostic Interview for Borderlines (DIB-R) for assessing the psychopathology of borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is frequently subject to misdiagnosis or underdiagnosis. As a matter of fact, its evaluation poses several challenges, highlighting the importance of having validated evaluation instruments. The Revised Diagnostic Interview for Borderlines (DIB-R) is widely used and recognized for its validity when it comes to assessing the psychopathology of BPD, but, as for now, no French version of the interview exists. The aim of the current work is to validate a French version of the DIB-R.

METHODS

The sample consists of N = 65 patients with borderline personality disorder (BPD) and N = 57 treatment seeking patients (non-BPD comparison group). For inter-rater reliability, a subsample of N = 84 interviews will be assessed by two raters, n = 47 for the BPD group and n = 37 for the non-BPD comparison group.

RESULTS

To assess reliability, we conducted analyses of internal consistency and inter-rater reliability. The results were good for the overall interview as well as for the four domains of the DIB-R. To assess validity, we calculated the receiver operating characteristic (ROC) curve, sensitivity, specificity, predictive values, convergent and discriminative validity. The optimal cutoff was found to be 7. Regarding convergent validity, we found strong convergence between the Borderline Symptom List (BSL-23) and the DIB-R total score. Additionally, the two groups statistically differed on all the DIB-R scores, which indicates that the interview discriminates between the two groups.

CONCLUSIONS

Our results indicate good psychometric properties of the French version of the DIB-R. This has important implications as the interview is useful both in clinical settings and for research purposes. Additionally, the present paper aims to contribute to the more general effort of demonstrating generalizability and transportability of the scale.

Association of pharmacological treatments and real-world outcomes in borderline personality disorder

OBJECTIVE

Most patients with borderline personality disorder (BPD) receive psychopharmacological treatment, but clinical guidelines on BPD lack consensus on the role of pharmacotherapy. We investigated the comparative effectiveness of pharmacological treatments for BPD.

METHODS

We identified patients with BPD with treatment contact during 2006-2018 using Swedish nationwide register databases. By leveraging within-individual design, in which each individual was used as their own control to eliminate selection bias, we assessed the comparative effectiveness of pharmacotherapies. For each medication, we calculated the hazard ratios (HRs) for the following outcomes: (1) psychiatric hospitalization and (2) hospitalization owing to any cause or death.

RESULTS

We identified 17,532 patients with BPD (2649 men; mean [SD] age = 29.8 [9.9]). Treatment with benzodiazepines (HR = 1.38, 95% CI = 1.32-1.43), antipsychotics (HR = 1.19, 95% CI = 1.14-124), and antidepressants (HR = 1.18, 95% CI = 1.13-1.23) associated with increased risk of psychiatric rehospitalization. Similarly, treatment with benzodiazepines (HR = 1.37, 95% CI = 1.33-1.42), antipsychotics (HR = 1.21, 95% CI = 1.17-1.26), and antidepressants (HR = 1.17, 95% CI = 1.14-1.21) was associated with a higher risk of all-cause hospitalization or death. Treatment with mood stabilizers did not have statistically significant associations with the outcomes. Treatment with ADHD medication was associated with decreased risk of psychiatric hospitalization (HR = 0.88, 95% CI = 0.83-0.94) and decreased risk of all-cause hospitalization or death (HR = 0.86, 95% CI = 0.82-0.91). Of the specific pharmacotherapies, clozapine (HR = 0.54, 95% CI = 0.32-0.91), lisdexamphetamine (HR = 0.79, 95% CI = 0.69-0.91), bupropion (HR = 0.84, 95% CI = 0.74-0.96), and methylphenidate (HR = 0.90, 95% CI = 0.84-0.96) associated with decreased risk of psychiatric rehospitalization.

CONCLUSIONS

ADHD medications were associated with a reduced risk of psychiatric rehospitalization or hospitalization owing to any cause or death among individuals with BPD. No such associations were found for benzodiazepines, antidepressants, antipsychotics, or mood stabilizers.

Borderline Personality Disorder: A Review

IMPORTANCE

Borderline personality disorder (BPD) affects approximately 0.7% to 2.7% of adults in the US. The disorder is associated with considerable social and vocational impairments and greater use of medical services.

OBSERVATIONS

Borderline personality disorder is characterized by sudden shifts in identity, interpersonal relationships, and affect, as well as by impulsive behavior, periodic intense anger, feelings of emptiness, suicidal behavior, self-mutilation, transient, stress-related paranoid ideation, and severe dissociative symptoms (eg, experience of unreality of one's self or surroundings). Borderline personality disorder is typically diagnosed by a mental health specialist using semistructured interviews. Most people with BPD have coexisting mental disorders such as mood disorders (ie, major depression or bipolar disorder) (83%), anxiety disorders (85%), or substance use disorders (78%). The etiology of BPD is related to both genetic factors and adverse childhood experiences, such as sexual and physical abuse. Psychotherapy is the treatment of choice for BPD. Psychotherapy such as dialectical behavior therapy and psychodynamic therapy reduce symptom severity more than usual care, with medium effect sizes (standardized mean difference) between -0.60 and -0.65. There is no evidence that any psychoactive medication consistently improves core symptoms of BPD. For discrete and severe comorbid mental disorders, eg, major depression, pharmacotherapy such as the selective serotonin reuptake inhibitors escitalopram, sertraline, or fluoxetine may be prescribed. For short-term treatment of acute crisis in BPD, consisting of suicidal behavior or ideation, extreme anxiety, psychotic episodes, or other extreme behavior likely to endanger a patient or others, crisis management is required, which may include prescription of low-potency antipsychotics (eg, quetiapine) or off-label use of sedative antihistamines (eg, promethazine). These drugs are preferred over benzodiazepines such as diazepam or lorazepam.

CONCLUSIONS AND RELEVANCE

Borderline personality disorder affects approximately 0.7% to 2.7% of adults and is associated with functional impairment and greater use of medical services. Psychotherapy with dialectical behavior therapy and psychodynamic therapy are first-line therapies for BPD, while psychoactive medications do not improve the primary symptoms of BPD.

Overdose and off-label psychotropic prescribing in patients with borderline personality disorder: A retrospective series

OBJECTIVE

Borderline personality disorder (BPD) is common and poses many clinical challenges. Despite limited evidence of effectiveness, psychotropic medications are often prescribed. We aimed to characterise overdose presentations in patients with BPD.

METHOD

This is a retrospective observational series of patients with BPD presenting to a tertiary hospital following an overdose from January 2019 to December 2020. Medical records were reviewed to determine baseline characteristics, overdose details, clinical features, treatment, and disposition.

RESULTS

There were 608 presentations in 370 people (76% female), median age 28 years (range 16-75 years). The majority (331[89%]) of patients were prescribed at least one psychotropic medication, with 129 (35%) being prescribed three or more different psychotropic agents. Of the total prescribed psychotropics, 520/1459 (36%) were for off-label indications. The majority of agents (860/1487[58%]) taken in overdose were prescribed. The commonest drug classes taken in overdose were benzodiazepines (241[16%]) and antipsychotics (229[15%]). Severe toxicity occurred in 99 (16%) cases with either coma (GCS<9) or hypotension (systolic BP <90 mmHg). The commonest agent associated with severe toxicity was quetiapine 39/99 (39%).

CONCLUSIONS

Psychotropic polypharmacy is common in BPD, often with off-label indications. Prescribed medications are commonly taken in overdose. Quetiapine is over-represented both in off-label prescribing and associated harm.