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Namgung E, Ha E, Yoon S, Song Y, Lee H, Kang HJ, Han JS, Kim JM, Lee W, Lyoo IK, Kim SJ. Identifying unique subgroups in suicide risks among psychiatric outpatients. Compr Psychiatry 2024; 131:152463. [PMID: 38394926 DOI: 10.1016/j.comppsych.2024.152463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/27/2024] [Accepted: 02/16/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND The presence of psychiatric disorders is widely recognized as one of the primary risk factors for suicide. A significant proportion of individuals receiving outpatient psychiatric treatment exhibit varying degrees of suicidal behaviors, which may range from mild suicidal ideations to overt suicide attempts. This study aims to elucidate the transdiagnostic symptom dimensions and associated suicidal features among psychiatric outpatients. METHODS The study enrolled patients who attended the psychiatry outpatient clinic at a tertiary hospital in South Korea (n = 1, 849, age range = 18-81; 61% women). A data-driven classification methodology was employed, incorporating a broad spectrum of clinical symptoms, to delineate distinctive subgroups among psychiatric outpatients exhibiting suicidality (n = 1189). A reference group of patients without suicidality (n = 660) was included for comparative purposes to ascertain cluster-specific sociodemographic, suicide-related, and psychiatric characteristics. RESULTS Psychiatric outpatients with suicidality (n = 1189) were subdivided into three distinctive clusters: the low-suicide risk cluster (Cluster 1), the high-suicide risk externalizing cluster (Cluster 2), and the high-suicide risk internalizing cluster (Cluster 3). Relative to the reference group (n = 660), each cluster exhibited distinct attributes pertaining to suicide-related characteristics and clinical symptoms, covering domains such as anxiety, externalizing and internalizing behaviors, and feelings of hopelessness. Cluster 1, identified as the low-suicide risk group, exhibited less frequent suicidal ideation, planning, and multiple attempts. In the high-suicide risk groups, Cluster 2 displayed pronounced externalizing symptoms, whereas Cluster 3 was primarily defined by internalizing and hopelessness symptoms. Bipolar disorders were most common in Cluster 2, while depressive disorders were predominant in Cluster 3. DISCUSSION Our findings suggest the possibility of differentiating psychiatric outpatients into distinct, clinically relevant subgroups predicated on their suicide risk. This research potentially paves the way for personalizing interventions and preventive strategies that address cluster-specific characteristics, thereby mitigating suicide-related mortality among psychiatric outpatients.
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Affiliation(s)
- Eun Namgung
- Asan Institute for Life Sciences, Asan Medical Center, Seoul, South Korea
| | - Eunji Ha
- Ewha Brain Institute, Ewha Womans University, Seoul, South Korea
| | - Sujung Yoon
- Ewha Brain Institute, Ewha Womans University, Seoul, South Korea; Department of Brain and Cognitive Sciences, Ewha Womans University, Seoul, South Korea
| | - Yumi Song
- Ewha Brain Institute, Ewha Womans University, Seoul, South Korea; Department of Brain and Cognitive Sciences, Ewha Womans University, Seoul, South Korea
| | - Hyangwon Lee
- Ewha Brain Institute, Ewha Womans University, Seoul, South Korea; Department of Brain and Cognitive Sciences, Ewha Womans University, Seoul, South Korea
| | - Hee-Ju Kang
- Department of Psychiatry, Chonnam National University Medical School, Gwangju, South Korea
| | - Jung-Soo Han
- Department of Biological Sciences, Konkuk University, Seoul, South Korea
| | - Jae-Min Kim
- Department of Psychiatry, Chonnam National University Medical School, Gwangju, South Korea
| | - Wonhye Lee
- Department of Psychiatry, Sungkyunkwan University College of Medicine, Samsung Medical Center, Seoul, South Korea
| | - In Kyoon Lyoo
- Ewha Brain Institute, Ewha Womans University, Seoul, South Korea; Department of Brain and Cognitive Sciences, Ewha Womans University, Seoul, South Korea; Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, South Korea.
| | - Seog Ju Kim
- Department of Psychiatry, Sungkyunkwan University College of Medicine, Samsung Medical Center, Seoul, South Korea.
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Sanza M, Monzio Compagnoni M, Caggiu G, Allevi L, Barbato A, Campa J, Carle F, D'avanzo B, Di Fiandra T, Ferrara L, Gaddini A, Saponaro A, Scondotto S, Tozzi VD, Lorusso S, Giordani C, Corrao G, Lora A. Assessing the quality of the care offer for people with personality disorders in Italy: the QUADIM project. A multicentre research based on the database of use of Mental Health services. Int J Ment Health Syst 2023; 17:31. [PMID: 37833745 PMCID: PMC10571410 DOI: 10.1186/s13033-023-00603-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Italy can be viewed as a laboratory to assess the quality of mental healthcare delivered in a community-oriented system, especially for severe mental disorders, such as personality disorders. Although initiatives based on clinical indicators for assessing the quality of mental healthcare have been developed by transnational-organisations, there is still no widespread practice of measuring the quality of care pathways delivered to patients with severe mental disorders in a community-oriented system, especially using administrative healthcare databases. The aim of the study is to evaluate the quality of care delivered to patients with personality disorders taken-in-care by mental health services of four Italian regions (Lombardy, Emilia-Romagna, Lazio, Sicily). METHODS A set of thirty-three clinical indicators, concerning accessibility, appropriateness, continuity, and safety of care, was implemented using regional healthcare utilization databases, containing data on mental health treatments and diagnosis, hospital admissions, outpatient interventions and exams and drug prescriptions. RESULTS 31,688 prevalent patients with personality disorders treated in 2015 were identified, of whom 2,331 newly taken-in-care. One-in-10 patients received a standardized assessment, the treatment discontinuity affected half of the cases. 12.7% of prevalent patients received at least one hospitalization, 10.6% in the newly taken-in-care cohort. 6-out-of-10 patients had contact with community-services within 14 days from hospital discharge. Access to psychotherapy and psychoeducational treatments was low and delivered with a low intensity. The median of psychosocial interventions per person-year was 19.1 and 9.4, respectively, in prevalent and newly taken-in-care cases. Nearly 50% of patients received pharmacological treatments. CONCLUSIONS Healthcare utilization databases were used to systematically evaluate and assess service delivery across regional mental health systems; suggesting that in Italy the public mental health services provide to individuals with personality disorders suboptimal treatment paths.
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Affiliation(s)
- Michele Sanza
- Department of Mental Health and Addiction Disorders Forlì-Cesena, AUSL Romagna, Cesena, Italy
| | - Matteo Monzio Compagnoni
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy.
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy.
| | - Giulia Caggiu
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
- Department of Mental Health and Addiction Services, ASST Lecco, Lecco, Italy
| | - Liliana Allevi
- Department of Mental Health and Addiction Services, ASST Lecco, Lecco, Italy
| | - Angelo Barbato
- Department of Health Policy, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | | | - Flavia Carle
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
- Center of Epidemiology and Biostatistics, Polytechnic University of Marche, Ancona, Italy
| | - Barbara D'avanzo
- Department of Health Policy, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Teresa Di Fiandra
- Psychologist, previously General Directorate for Health Prevention, Ministry of Health, Rome, Italy
| | - Lucia Ferrara
- Centre of Research on Health and Social Care Management, CERGAS SDA Bocconi School of Management (Bocconi University, Milan, Italy
| | | | - Alessio Saponaro
- General Directorate of Health and Social Policies, Emilia-Romagna Region, Bologna, Italy
| | - Salvatore Scondotto
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
- Department of Health Services and Epidemiological Observatory, Regional Health Authority, Sicily Region, Palermo, Italy
| | - Valeria D Tozzi
- Centre of Research on Health and Social Care Management, CERGAS SDA Bocconi School of Management (Bocconi University, Milan, Italy
| | - Stefano Lorusso
- Department of Health Planning, Italian Health Ministry, Rome, Italy
| | | | - Giovanni Corrao
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
| | - Antonio Lora
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
- Department of Mental Health and Addiction Services, ASST Lecco, Lecco, Italy
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Scheunemann J, Kühn S, Biedermann SV, Lipp M, Peth J, Gallinat J, Jelinek L. Implicit cognitions on self-injurious and suicidal behavior in borderline personality disorder. J Behav Ther Exp Psychiatry 2023; 79:101836. [PMID: 36709601 DOI: 10.1016/j.jbtep.2023.101836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 01/12/2023] [Accepted: 01/19/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Performance on implicit measures of suicidality has been associated with suicidal and nonsuicidal self-injury. Despite the high prevalence of self-harm in patients with borderline personality disorder (BPD), no previous study has assessed implicit measures in this patient group. METHODS Forty patients with BPD and 25 healthy controls completed three implicit association tests (IATs) (Death words - Me/Others words, Self-Harm pictures - Me/Others, and Self-Harm pictures - Good/Bad words) and a subliminal priming task (effect of the primes "dying"/"growing" on the categorization speed of positive/negative adjectives) as well as measures of psychopathology (suicidal ideation, previous nonsuicidal self-injury, borderline symptomatology, depression, and hopelessness). RESULTS Patients with BPD had higher scores on all three IATs than healthy controls. The subliminal priming procedure did not reveal group differences. Correlations between implicit measures and psychopathology among patients with BPD were mostly weak and nonsignificant with a few exceptions: Positive correlations were observed between IAT Self-Harm - Good/Bad and lifetime frequency of nonsuicidal self-injury, between IAT Self-Harm - Me/Others and depression, and between IAT Death - Me/Others and depression. Correlations between implicit measures were weak to moderate. LIMITATIONS The study was cross-sectional only, and the study had reduced power as the sample size was limited. CONCLUSIONS As expected, patients with BPD had higher scores than healthy controls on the IATs, which indicates higher implicit self-identification with self-harm and death as well as stronger implicit positive attitudes towards self-harm. The mostly weak correlations between implicit and explicit measures speak against the discriminative value of IATs in patients with BPD.
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Affiliation(s)
- Jakob Scheunemann
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Germany.
| | - Simone Kühn
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Germany; Lise Meitner Group for Environmental Neuroscience, Max Planck Institute for Human Development, Germany
| | - Sarah V Biedermann
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Germany
| | - Michael Lipp
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Germany
| | - Judith Peth
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Germany
| | - Jürgen Gallinat
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Germany
| | - Lena Jelinek
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Germany
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Jayakody K, Gallagher P, Lloyd AJ, Cousins DA. A quantitative analysis of the relationship between affective state and personality ratings in inpatient depression (RAPID). Psychol Med 2023; 53:3416-3425. [PMID: 35238291 DOI: 10.1017/s003329172100547x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The relationship between major depressive disorder (MDD) and personality disorders is complex, with implications for diagnosis and treatment. We sought to explore the relationship between these disorders quantitatively in an inpatient setting. METHODS We conducted a structured observational study exploring symptoms of depression and selected neurocognitive functions over the span of an inpatient admission in those with depression and personality disorders. Sixty inpatients presenting with symptoms of depression completed ratings of mood and neurocognitive function. Diagnosis was confirmed by structured clinical interview (SCID-5-RV) at discharge and used to allocate patients to one of the two groups for analysis: those with MDD-only and those with a personality disorder (with or without MDD). RESULTS On admission, observer-based ratings of depression were significantly higher in the MDD-only group while subjective ratings were higher in the personality disorder group. Depression rating scores lessened in both groups during the admission, but at discharge, the personality disorder group continued to report higher subjective ratings. The personality disorder group also rated themselves as more cognitively impaired than the MDD-only group and unlike the MDD-only group, they did not report subjective improvements in cognitive function over the course of admission. Objective assessment of cognitive function demonstrated improvements in both groups. CONCLUSIONS In this study, the presence of a personality disorder was associated with greater subjective severity of depressive symptomatology and selected neurocognitive functioning, despite similar or lower objective severity in comparison with those with MDD. This finding has implications for understanding the patient journey through health care settings.
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Affiliation(s)
- Kaushadh Jayakody
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Peter Gallagher
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Northern Centre for Mood Disorders, Newcastle University, Newcastle upon Tyne, UK
| | - Adrian J Lloyd
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
- Northern Centre for Mood Disorders, Newcastle University, Newcastle upon Tyne, UK
| | - David Andrew Cousins
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
- Northern Centre for Mood Disorders, Newcastle University, Newcastle upon Tyne, UK
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Stoffers-Winterling JM, Storebø OJ, Pereira Ribeiro J, Kongerslev MT, Völlm BA, Mattivi JT, Faltinsen E, Todorovac A, Jørgensen MS, Callesen HE, Sales CP, Schaug JP, Simonsen E, Lieb K. Pharmacological interventions for people with borderline personality disorder. Cochrane Database Syst Rev 2022; 11:CD012956. [PMID: 36375174 PMCID: PMC9662763 DOI: 10.1002/14651858.cd012956.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Among people with a diagnosis of borderline personality disorder (BPD) who are engaged in clinical care, prescription rates of psychotropic medications are high, despite the fact that medication use is off-label as a treatment for BPD. Nevertheless, people with BPD often receive several psychotropic drugs at a time for sustained periods. OBJECTIVES To assess the effects of pharmacological treatment for people with BPD. SEARCH METHODS For this update, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers up to February 2022. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication. SELECTION CRITERIA Randomised controlled trials comparing pharmacological treatment to placebo, other pharmacologic treatments or a combination of pharmacologic treatments in people of all ages with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. Secondary outcomes were individual BPD symptoms, depression, attrition and adverse events. DATA COLLECTION AND ANALYSIS At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's risk of bias tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis. MAIN RESULTS We included 46 randomised controlled trials (2769 participants) in this review, 45 of which were eligible for quantitative analysis and comprised 2752 participants with BPD in total. This is 18 more trials than the 2010 review on this topic. Participants were predominantly female except for one trial that included men only. The mean age ranged from 16.2 to 39.7 years across the included trials. Twenty-nine different types of medications compared to placebo or other medications were included in the analyses. Seventeen trials were funded or partially funded by the pharmaceutical industry, 10 were funded by universities or research foundations, eight received no funding, and 11 had unclear funding. For all reported effect sizes, negative effect estimates indicate beneficial effects by active medication. Compared with placebo, no difference in effects were observed on any of the primary outcomes at the end of treatment for any medication. Compared with placebo, medication may have little to no effect on BPD symptom severity, although the evidence is of very low certainty (antipsychotics: SMD -0.18, 95% confidence interval (CI) -0.45 to 0.08; 8 trials, 951 participants; antidepressants: SMD -0.27, 95% CI -0.65 to 1.18; 2 trials, 87 participants; mood stabilisers: SMD -0.07, 95% CI -0.43 to 0.57; 4 trials, 265 participants). The evidence is very uncertain about the effect of medication compared with placebo on self-harm, indicating little to no effect (antipsychotics: RR 0.66, 95% CI 0.15 to 2.84; 2 trials, 76 participants; antidepressants: MD 0.45 points on the Overt Aggression Scale-Modified-Self-Injury item (0-5 points), 95% CI -10.55 to 11.45; 1 trial, 20 participants; mood stabilisers: RR 1.08, 95% CI 0.79 to 1.48; 1 trial, 276 participants). The evidence is also very uncertain about the effect of medication compared with placebo on suicide-related outcomes, with little to no effect (antipsychotics: SMD 0.05, 95 % CI -0.18 to 0.29; 7 trials, 854 participants; antidepressants: SMD -0.26, 95% CI -1.62 to 1.09; 2 trials, 45 participants; mood stabilisers: SMD -0.36, 95% CI -1.96 to 1.25; 2 trials, 44 participants). Very low-certainty evidence shows little to no difference between medication and placebo on psychosocial functioning (antipsychotics: SMD -0.16, 95% CI -0.33 to 0.00; 7 trials, 904 participants; antidepressants: SMD -0.25, 95% CI -0.57 to 0.06; 4 trials, 161 participants; mood stabilisers: SMD -0.01, 95% CI -0.28 to 0.26; 2 trials, 214 participants). Low-certainty evidence suggests that antipsychotics may slightly reduce interpersonal problems (SMD -0.21, 95% CI -0.34 to -0.08; 8 trials, 907 participants), and that mood stabilisers may result in a reduction in this outcome (SMD -0.58, 95% CI -1.14 to -0.02; 4 trials, 300 participants). Antidepressants may have little to no effect on interpersonal problems, but the corresponding evidence is very uncertain (SMD -0.07, 95% CI -0.69 to 0.55; 2 trials, 119 participants). The evidence is very uncertain about dropout rates compared with placebo by antipsychotics (RR 1.11, 95% CI 0.89 to 1.38; 13 trials, 1216 participants). Low-certainty evidence suggests there may be no difference in dropout rates between antidepressants (RR 1.07, 95% CI 0.65 to 1.76; 6 trials, 289 participants) and mood stabilisers (RR 0.89, 95% CI 0.69 to 1.15; 9 trials, 530 participants), compared to placebo. Reporting on adverse events was poor and mostly non-standardised. The available evidence on non-serious adverse events was of very low certainty for antipsychotics (RR 1.07, 95% CI 0.90 to 1.29; 5 trials, 814 participants) and mood stabilisers (RR 0.84, 95% CI 0.70 to 1.01; 1 trial, 276 participants). For antidepressants, no data on adverse events were identified. AUTHORS' CONCLUSIONS This review included 18 more trials than the 2010 version, so larger meta-analyses with more statistical power were feasible. We found mostly very low-certainty evidence that medication may result in no difference in any primary outcome. The rest of the secondary outcomes were inconclusive. Very limited data were available for serious adverse events. The review supports the continued understanding that no pharmacological therapy seems effective in specifically treating BPD pathology. More research is needed to understand the underlying pathophysiologic mechanisms of BPD better. Also, more trials including comorbidities such as trauma-related disorders, major depression, substance use disorders, or eating disorders are needed. Additionally, more focus should be put on male and adolescent samples.
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Affiliation(s)
| | - Ole Jakob Storebø
- Psychiatric Research Unit, Psychiatry Region Zealand, Slagelse, Denmark
- Child and Adolescent Psychiatric Department, Region Zealand, Roskilde, Denmark
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Johanne Pereira Ribeiro
- Psychiatric Research Unit, Psychiatry Region Zealand, Slagelse, Denmark
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Mickey T Kongerslev
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- District Psychiatric Services Roskilde, Region Zealand Mental Health Services, Roskilde, Denmark
| | - Birgit A Völlm
- Department of Forensic Psychiatry, Center for Neurology, University Rostock, Rostock, Germany
| | - Jessica T Mattivi
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Erlend Faltinsen
- Psychiatric Research Unit, Psychiatry Region Zealand, Slagelse, Denmark
| | - Adnan Todorovac
- Psychiatric Research Unit, Psychiatry Region Zealand, Slagelse, Denmark
| | - Mie S Jørgensen
- Psychiatric Research Unit, Psychiatry Region Zealand, Slagelse, Denmark
| | | | - Christian P Sales
- Duncan MacMillan House, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
- Institute of Mental Health, Department of Psychiatry & Applied Psychology, Nottingham, UK
| | - Julie Perrine Schaug
- Region Zealand Psychiatry, Center for Evidence Based Psychiatry, Slagelse, Denmark
| | - Erik Simonsen
- Research Unit, Mental Health Services, Copenhagen University Hospital, Psychiatry Region Zealand, Roskilde, Denmark
| | - Klaus Lieb
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
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Hersh RG. Review of Contemporary Risk Management Challenges in the Treatment of Patients With Borderline Personality Disorder. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2022; 20:353-357. [PMID: 37200872 PMCID: PMC10187396 DOI: 10.1176/appi.focus.20220054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Standard psychiatric risk management challenges are routinely amplified in the treatment of patients with primary or co-occurring borderline personality disorder diagnosis. Most psychiatrists receive limited guidance during training or as part of continuing medical education about specific risk management concerns in work with this patient population; nevertheless, these concerns can occupy a disproportionate amount of time and energy in clinical practice. The goal of this article is to review the frequently observed risk management quandaries encountered in work with this patient population. The more familiar risk management dilemmas related to management of suicidality, potential boundary violations, and patient abandonment, are considered. In addition, salient contemporary trends in prescribing, hospitalization, training, diagnostic classification, models of psychotherapeutic treatment, and use of emerging technologies in provision of care, are explored in terms of their impact on risk management.
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Kippe YD, Adam M, Finck A, Moran JK, Schouler-Ocak M, Bermpohl F, Gutwinski S, Goldschmidt T. Suicidality in psychiatric emergency department situations during the first and the second wave of COVID-19 pandemic. Eur Arch Psychiatry Clin Neurosci 2022; 273:311-323. [PMID: 36071277 PMCID: PMC9451117 DOI: 10.1007/s00406-022-01486-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/29/2022] [Indexed: 11/26/2022]
Abstract
Psychiatric patients are prone to mental health deterioration during the Covid-19 pandemic. Little is known about suicidality in psychiatric patients during the Covid-19 pandemic. This study is a retrospective chart review of psychiatric emergency department (pED) presentations with present or absent suicidality (5634 pED attendances, 4110 patients) in an academic pED in Berlin, Germany. Poisson regression analysis was performed on the effect of Covid-19 period on suicidality (suicidal ideation (SI), suicide plans (SP) or suicide attempt (SA)) during the first (3/2/2020-5/24/2020 "first-wave") and second (9/15/2020-3/1/2021 "second-wave") wave of the Covid-19 pandemic compared to the same periods one year earlier. During the first-wave the number of pED visits per person with SI, SP and SA was higher compared to one year earlier (SI RR = 1.614; p = 0.016; SP RR = 2.900; p = 0.004; SA RR = 9.862; p = 0.003). SI and SP were predicted by interaction between substance use disorder (SUD) and second-wave (SI RR = 1.305, p = 0.043; SP RR = 1.645, p = 0.018), SA was predicted by interaction between borderline personality disorder (BPD) and second-wave (RR = 7.128; p = 0.012). Suicidality increased during the first-wave of Covid-19 pandemic in our sample. In the second-wave this was found in patients with SUD and BPD. These patients may be at particular risk of suicidality during the Covid-19 pandemic.
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Affiliation(s)
- Yann David Kippe
- Psychiatrische Universitätsklinik der Charité Im St. Hedwig Krankenhaus, Große Hamburger Str. 5-11, 10115 Berlin, Germany
| | - Maia Adam
- Psychiatrische Universitätsklinik der Charité Im St. Hedwig Krankenhaus, Große Hamburger Str. 5-11, 10115 Berlin, Germany
| | - Anna Finck
- Psychiatrische Universitätsklinik der Charité Im St. Hedwig Krankenhaus, Große Hamburger Str. 5-11, 10115 Berlin, Germany
| | - James Kenneth Moran
- Psychiatrische Universitätsklinik der Charité Im St. Hedwig Krankenhaus, Große Hamburger Str. 5-11, 10115 Berlin, Germany
| | - Meryam Schouler-Ocak
- Psychiatrische Universitätsklinik der Charité Im St. Hedwig Krankenhaus, Große Hamburger Str. 5-11, 10115 Berlin, Germany
| | - Felix Bermpohl
- Psychiatrische Universitätsklinik der Charité Im St. Hedwig Krankenhaus, Große Hamburger Str. 5-11, 10115 Berlin, Germany
| | - Stefan Gutwinski
- Psychiatrische Universitätsklinik der Charité Im St. Hedwig Krankenhaus, Große Hamburger Str. 5-11, 10115 Berlin, Germany
| | - Thomas Goldschmidt
- Psychiatrische Universitätsklinik der Charité Im St. Hedwig Krankenhaus, Große Hamburger Str. 5-11, 10115, Berlin, Germany.
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Uhlmann C, Tschöke S, Steinert T, Schmid P. [Can you See and Hear How Bad I Feel Right Now? - Self-Injury and Suicidal Communication in Borderline Personality Disorder - A Secondary Analysis]. PSYCHIATRISCHE PRAXIS 2022; 49:329-333. [PMID: 35595492 DOI: 10.1055/a-1820-0438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Non-suicidal self-injurious behavior (NSSV) and suicide attempts are well-known features of borderline personality disorder; communicative behavior is poorly studied. Differences between patients with and without NSSV as well as differences in current suicide attempts regarding suicidal communication and NSSV were investigated.In a secondary analysis, data on current and anamnestic NSSV, suicide attempts, suicidal communication, and clinical symptomatology of 87 inpatients were studied.Patients with and without current NSSV did not differ in anamnestic but did differ in current suicide attempts and suicidal communication. In regard to the current inpatient stay, it was observed that patients with and without suicide attempts differed considerably in the variables NSSV (100 vs. 32.5 %) and suicidal communication (71.4 vs. 7.5 %).Current self-injury and suicidal communication are highly significant for risk assessment of current suicidality.
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Affiliation(s)
- Carmen Uhlmann
- ZfP Südwürttemberg, Klinik für Psychiatrie und Psychotherapie I der Universität Ulm (Weissenau), Forschung und Lehre
| | - Stefan Tschöke
- ZfP Südwürttemberg, Klinik für Psychiatrie und Psychotherapie I der Universität Ulm (Weissenau), Forschung und Lehre
| | - Tilman Steinert
- ZfP Südwürttemberg, Klinik für Psychiatrie und Psychotherapie I der Universität Ulm (Weissenau), Forschung und Lehre
| | - Petra Schmid
- ZfP Südwürttemberg, Klinik für Psychiatrie und Psychotherapie I der Universität Ulm (Weissenau), Forschung und Lehre
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9
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Chang TH, Liu SI, Korslund K, Lin CJ, Lin Y, Huang HC, Chen SC, Chang YH, Sun FJ, Wu SI. Adapting dialectical behavior therapy in Mandarin-speaking Chinese patients with borderline personality disorder: An open pilot trial in Taiwan. Asia Pac Psychiatry 2022; 14:e12451. [PMID: 33686804 DOI: 10.1111/appy.12451] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 02/01/2021] [Accepted: 02/13/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Dialectical behavior therapy (DBT) is the most commonly used treatment for patients suffering from borderline personality disorder (BPD). However, data on its applications in Asian countries remain lacking. This pilot study aims to evaluate the feasibility and effectiveness of applying Mandarin-translated DBT among suicidal Chinese patients with BPD in Taiwan. METHODS An open-label trial design was implemented for the 1-year standard DBT model. Patients from a psychiatric outpatient department in a general hospital in Taiwan with a history of ≥2 episodes of suicidal behavior within the previous year and who scored >40 on the Borderline Symptom List were invited to participate in this trial. Outcomes of suicidal behaviors, severity of BPD and depression symptoms, suicidal ideation, hopelessness, and quality of life were assessed at the beginning of the treatment and every 3 months until 12 months. RESULTS Eighteen patients participated, three of whom (16.7%) dropped out. Significant improvements were found in the frequency and severity of suicidal behaviors and ideations, depressive symptoms, and BPD symptoms beginning as early as the third month after initiating DBT. DISCUSSION This pilot study found that DBT may be an effective and feasible intervention for Mandarin-speaking individuals with a recent history of suicidal behaviors with BPD. Future randomized controlled trials with comparison groups are needed to further determine the efficacy of DBT on this population.
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Affiliation(s)
- Ting-Hsin Chang
- Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shen-Ing Liu
- Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
| | | | - Chen-Ju Lin
- Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan
| | - Ying Lin
- Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan
| | - Hui-Chun Huang
- Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shu-Chin Chen
- Suicide Prevention Center, Mackay Memorial Hospital, Taipei, Taiwan
| | - Yi-Hung Chang
- Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan
| | - Fang-Ju Sun
- Department of Medical Research, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shu-I Wu
- Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan.,Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
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10
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Enoksson M, Hultsjö S, Wärdig RE, Strömberg S. Experiences of how brief admission influences daily life functioning among individuals with borderline personality disorder (BPD) and self-harming behaviour. J Clin Nurs 2021; 31:2910-2920. [PMID: 34854159 DOI: 10.1111/jocn.16118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/14/2021] [Accepted: 10/18/2021] [Indexed: 12/20/2022]
Abstract
AIMS AND OBJECTIVES The aim of this study was to explore experiences of how brief admission influences daily life functioning among individuals with borderline personality disorder (BPD) and self-harming behaviour. BACKGROUND Brief admission (BA) is a crisis nursing intervention designed to reduce long hospitalisations and the risk of suicide. The intention of the intervention is to develop autonomy and to encourage the patient to take responsibility for and control over their own care and treatment. There are studies in the area that target individuals with psychosis and bipolar disorders, but no previous studies have been found examining how BA impacts upon daily life functioning among people with BPD who self-harm. DESIGN A descriptive qualitative design was chosen. METHODS Data were collected using qualitative individual interviews with 16 patients with BPD and self-harming behaviour who had been assigned to BA. The data were analysed using conventional content analysis. The study was conducted in accordance with COREQ guidelines. RESULTS The results show that BA was perceived as a functioning nursing intervention that promoted self-determination and self-care. This contributed to increased security in daily life. BA made it possible for individuals to maintain everyday routines, employment and relationships more easily. CONCLUSIONS Our findings suggest that BA was experienced to have a positive impact on daily life functioning. RELEVANCE TO CLINICAL PRACTICE Brief admission enabled the balance of power to be shifted from the nurse to the patient, and provides conditions for patients to take responsibility for their mental condition and to become aware of early signs of deterioration, in line with the basic ideas of person-centred care.
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Affiliation(s)
- Maria Enoksson
- Department of Psychiatry, Ryhov County Hospital, Jönköping, Sweden
| | - Sally Hultsjö
- Department of Psychiatry, Ryhov County Hospital, Jönköping, Sweden.,Division of Nursing and Reproductive Health, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Rikard Erik Wärdig
- Division of Nursing and Reproductive Health, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Sandra Strömberg
- Department of Psychiatry, Ryhov County Hospital, Jönköping, Sweden
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11
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Bühlmann V, Schlüter-Müller S, Fürer L, Steppan M, Birkhölzer M, Schmeck K, Koenig J, Kaess M, Zimmermann R. Therapists' emotional state after sessions in which suicidality is addressed: need for improved management of suicidal tendencies in patients with borderline personality pathology. BMC Psychiatry 2021; 21:590. [PMID: 34814860 PMCID: PMC8609732 DOI: 10.1186/s12888-021-03549-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 10/07/2021] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Patient suicidality is a frequently experienced topic for psychotherapists. Especially adolescents with borderline personality pathology (BPP) often exhibit suicidal tendencies. Previous research which examined therapists' countertransference towards suicidal patients suggested that therapists are negatively affected and distressed by them. We hypothesize that this emotional response of the therapists is related to specific sessions in which suicidality came up as a topic. Accordingly, the objective of this study consists in examining therapists' emotional state on a session level of analysis. METHODS The sample consisted of N = 21 adolescents (age 13-19 years) with BPD or subthreshold BPD. Therapists' emotional states were measured in n = 418 sessions using the Session Evaluation Questionnaire. Principal component analysis was used to reduce dimensionality of the therapist response. The emotional states were compared depending on whether suicidality has been addressed in the session (SS) or not (NSS). RESULTS Two components could be identified. Firstly, therapists were more aroused, excited, afraid, angry and uncertain after SS than after NSS. Secondly, therapists were more aroused, excited, definite and pleased after SS than after NSS. DISCUSSION Suicidality does not always have to be a burden for therapists: Both a "distress" and an "eustress" component occur in this context from which the latter is supposed to help clinicians master a difficult situation. Since countertransference feelings are often not fully conscious, it is necessary to do research on therapists' emotional states after sessions in which suicidality is addressed. This is crucial to both prevent the therapeutic process from being endangered and preserve clinicians' mental health. Clinical implications and limitations are discussed.
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Affiliation(s)
- Vera Bühlmann
- Child and Adolescent Psychiatric Research Department, Psychiatric University Hospital, University of Basel, Basel, Switzerland
| | - Susanne Schlüter-Müller
- Child and Adolescent Psychiatric Research Department, Psychiatric University Hospital, University of Basel, Basel, Switzerland
| | - Lukas Fürer
- Child and Adolescent Psychiatric Research Department, Psychiatric University Hospital, University of Basel, Basel, Switzerland
| | - Martin Steppan
- Child and Adolescent Psychiatric Research Department, Psychiatric University Hospital, University of Basel, Basel, Switzerland
| | - Marc Birkhölzer
- Child and Adolescent Psychiatric Research Department, Psychiatric University Hospital, University of Basel, Basel, Switzerland
- Juvenile Forensic Department, Psychiatric University Hospital, University of Basel, Basel, Switzerland
| | - Klaus Schmeck
- Child and Adolescent Psychiatric Research Department, Psychiatric University Hospital, University of Basel, Basel, Switzerland
| | - Julian Koenig
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
- Department of Child and Adolescent Psychiatry, Center for Psychosocial Medicine, University Hospital Heidelberg, Heidelberg, Germany
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Michael Kaess
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
- Department of Child and Adolescent Psychiatry, Center for Psychosocial Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Ronan Zimmermann
- Child and Adolescent Psychiatric Research Department, Psychiatric University Hospital, University of Basel, Basel, Switzerland.
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland.
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12
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Wasserman D, Carli V, Iosue M, Javed A, Herrman H. Suicide prevention in psychiatric patients. Asia Pac Psychiatry 2021; 13:e12450. [PMID: 33605074 DOI: 10.1111/appy.12450] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 01/12/2021] [Accepted: 02/02/2021] [Indexed: 01/21/2023]
Abstract
An increased risk of suicide has been reported for psychiatric patients. In several world regions, an underlying psychiatric disorder is reported in up to 90% of people who die from suicide, though this rate seems to be considerably lower in low- and middle-income countries. Major psychiatric conditions associated with suicidality are mood disorders, alcohol and substance use disorders, borderline personality disorder, and schizophrenia. Comorbidity between different disorders is frequently associated with a higher suicide risk. A history of suicide attempts, feelings of hopelessness, impulsivity and aggression, adverse childhood experiences, severe psychopathology, and somatic disorders are common risk factors for suicide among psychiatric patients. Stressful life events and interpersonal problems, including interpersonal violence, are often triggers. A comprehensive and repeated suicide risk assessment represents the first step for effective suicide prevention. Particular attention should be paid during and after hospitalization, with the first days and weeks after discharge representing the most critical period. Pharmacological treatment of mood disorders and schizophrenia has been shown to have an anti-suicidal effect. A significant reduction of suicidal thoughts and behavior has been reported for cognitive behavioral therapy and dialectical behavior therapy. Brief interventions, including psychoeducation and follow-ups, are associated with a decrease in suicide deaths. Further development of suicide prevention in psychiatric patients will require a better understanding of additional risk and protective factors, such as the role of a person's decision-making capacity and social support, the role of spiritual and religious interventions, and the reduction of the treatment gap in mental health care.
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Affiliation(s)
- Danuta Wasserman
- National Centre for Suicide Research and Prevention of Mental Ill-Health, Karolinska Institutet, Stockholm, Sweden.,World Psychiatric Association (WPA)-Section on Suicidology, Geneva, Switzerland
| | - Vladimir Carli
- National Centre for Suicide Research and Prevention of Mental Ill-Health, Karolinska Institutet, Stockholm, Sweden.,World Psychiatric Association (WPA)-Section on Suicidology, Geneva, Switzerland
| | - Miriam Iosue
- National Centre for Suicide Research and Prevention of Mental Ill-Health, Karolinska Institutet, Stockholm, Sweden.,World Psychiatric Association (WPA)-Section on Suicidology, Geneva, Switzerland
| | - Afzal Javed
- Coventry and Warwickshire Partnership NHS Trust, Nuneaton Coventry, Coventry, UK
| | - Helen Herrman
- Orygen, and Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
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13
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Furnes D, Gjestad R, Mehlum L, Hodgekins J, Kroken RA, Oedegaard K, Mellesdal L. Borderline Personality Disorder: What Predicts Acute Psychiatric Readmissions? J Pers Disord 2021; 35:481-493. [PMID: 31682191 DOI: 10.1521/pedi_2019_33_459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Individuals diagnosed with borderline personality disorder (BPD) often struggle with chronic suicidal thoughts and behaviors and have frequent acute psychiatric admissions. Prevention of serial admissions and disruptions in long-term treatment strategies is needed. This study explored predictors of how frequently and how quickly patients diagnosed with BPD are readmitted after an index psychiatric admission. The authors identified self-harming behavior as a predictor of readmission frequency, whereas depression and hallucinations and delusions predicted time elapsed between the index admission and the first readmission. The authors recommend that predictors of readmissions should be carefully monitored and treated following index admission.
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Affiliation(s)
- Desiré Furnes
- Centre for Research and Education in Forensic Psychiatry, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway.,Research Department, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Rolf Gjestad
- Centre for Research and Education in Forensic Psychiatry, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway.,Research Department, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Lars Mehlum
- Research Department, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Joanne Hodgekins
- Department of Clinical Psychology, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Rune A Kroken
- Norment, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Norway
| | - Ketil Oedegaard
- Norment, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Norway.,K. G. Jebsen Centre for Research on Neuropsychiatric Disorders, Bergen, Norway
| | - Liv Mellesdal
- National Centre for Suicide Research and Prevention, University of Oslo, Oslo, Noway
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14
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Fitzpatrick SJ, Read D, Brew BK, Perkins D. A sociological autopsy lens on older adult suicide in rural Australia: Addressing health, psychosocial factors and care practices at the intersection of policies and institutions. Soc Sci Med 2021; 284:114196. [PMID: 34271402 DOI: 10.1016/j.socscimed.2021.114196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 06/20/2021] [Accepted: 06/30/2021] [Indexed: 11/24/2022]
Abstract
This paper examines the interrelationship between suicide, health, socioeconomic, and psychosocial factors in contributing to suicide in older adults in rural Australia. Drawing on a coronial dataset of suicide cases and a mixed methods sociological autopsy approach, our study integrated a quantitative analysis of 792 suicide cases with a qualitative analysis of medico-legal reports from 30 cases. The sociological autopsy provided novel insights into the entanglement of policy and service provision at the state-level with individual end-of-life decisions. Particular attention is drawn to age and gendered dimensions of suicide, especially in relation to health and social issues. The study showed a continuity between suicide and the patterning of an individual's life course, including experiences and consequences of inequality and marginality; a desire to meet culturally-normative ideals of autonomy; and a fragmented, under-funded, and intimidating social care system that offered limited options.
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Affiliation(s)
- Scott J Fitzpatrick
- Centre for Rural and Remote Mental Health, University of Newcastle, Orange, Australia.
| | - Donna Read
- Centre for Rural and Remote Mental Health, University of Newcastle, Orange, Australia
| | - Bronwyn K Brew
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health, School of Women and Children's Health, University of New South Wales, Sydney, Australia
| | - David Perkins
- Centre for Rural and Remote Mental Health, University of Newcastle, Orange, Australia
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15
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[Disease burden of borderline personality disorder: cost of illness, somatic comorbidity and mortality]. DER NERVENARZT 2021; 92:660-669. [PMID: 34097089 DOI: 10.1007/s00115-021-01139-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 04/30/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Severe mental illnesses (SMI) are characterized by high psychosocial impairment as well as by increased somatic morbidity and mortality. The term SMI commonly includes psychotic, bipolar and severe unipolar depressive disorders but borderline personality disorder (BPD) also shows severe sequelae of the disease. MATERIAL AND METHODS Published reviews and studies since 2010 examining disease burden of BPD, in terms of direct and indirect costs of illness, somatic comorbidity, and mortality were included. Furthermore, administrative data (clinically recorded billing data in Germany), comorbidity and mortality from a comprehensive analysis (n > 59 million, age ≥ 18 years) are reported. RESULTS International studies reveal an increased disease burden, comorbidity, and mortality for BPD. In Germany BPD (administrative 1‑year prevalence 0.34%) is associated with increased rates of somatic sequelae of trauma, hepatitis, HIV, COPD, asthma, and obesity. The estimated reduced life expectancy is 5.0-9.3 years of life lost (depending on age and sex). DISCUSSION The burden of disease in BPD is clearly increased (cost of illness, somatic comorbidity and mortality). The increased mortality can mainly be explained by deaths as a consequence of poor physical health and associated BPD-related health behavior and only to a lesser degree by suicide. These results highlight the importance of classifying BPD as an SMI and the necessity to provide not only psychotherapeutic and psychiatric but also adequate somatic prevention and treatment. Individual improvement of everyday care as well as establishing new interdisciplinary and multiprofessional services could enhance health equality for people with BPD.
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16
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Emergency psychiatric management of borderline personality disorder: Towards an articulation of modalities for personalised integrative care. Encephale 2020; 46:463-470. [PMID: 32571544 DOI: 10.1016/j.encep.2020.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 03/27/2020] [Accepted: 04/07/2020] [Indexed: 11/20/2022]
Abstract
Building on existing literature, the authors draw the landscape of psychiatric emergencies, and focus on borderline personality disorder, frequently encountered, and strongly linked to death by suicide. A review of knowledge in terms of diagnosis, prognosis, etiology, and treatment, as well as their own experiences, lead them to propose areas of progress that would secure the patient's care pathway. The evolution of society has led psychiatric emergency departments to play the role of a safety net and an entry point to the mental health system. Borderline personality disorder is one of the most common pathologies encountered in psychiatric emergencies. It represents a major concern, long characterized by an often dramatic evolution, and by the human and economic stress it generates. However, since the 1990s, knowledge of this disorder has been refined, and today there are various means of evaluation, good clinical practices and psychotherapeutic treatments, thanks to which significant and lasting improvement is possible. Recent studies highlight the crucial role of hospital caregivers, and the benefit of consolidating their skills by providing them with the knowledge and tools specific to this disorder. They also converge on the interest of setting up specific emergency treatment modalities, particularly highly structured, safe and empowering for the patient, in order to improve their effectiveness. The authors suggest that a case formulation model for persons with borderline personality disorder in emergency would make it possible to activate these two levers of progress, while improving collaboration between hospital and outpatient care. This would also address their main concern of optimizing the patient's therapeutic pathway and reinforcing adherence to treatment that could bring remission, and should be supported by data from empirical research.
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17
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Storebø OJ, Stoffers-Winterling JM, Völlm BA, Kongerslev MT, Mattivi JT, Jørgensen MS, Faltinsen E, Todorovac A, Sales CP, Callesen HE, Lieb K, Simonsen E. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev 2020; 5:CD012955. [PMID: 32368793 PMCID: PMC7199382 DOI: 10.1002/14651858.cd012955.pub2] [Citation(s) in RCA: 112] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Over the decades, a variety of psychological interventions for borderline personality disorder (BPD) have been developed. This review updates and replaces an earlier review (Stoffers-Winterling 2012). OBJECTIVES To assess the beneficial and harmful effects of psychological therapies for people with BPD. SEARCH METHODS In March 2019, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication. SELECTION CRITERIA Randomised controlled trials comparing different psychotherapeutic interventions with treatment-as-usual (TAU; which included various kinds of psychotherapy), waiting list, no treatment or active treatments in samples of all ages, in any setting, with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. There were 11 secondary outcomes, including individual BPD symptoms, as well as attrition and adverse effects. DATA COLLECTION AND ANALYSIS At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's 'Risk of bias' tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis. MAIN RESULTS We included 75 randomised controlled trials (4507 participants), predominantly involving females with mean ages ranging from 14.8 to 45.7 years. More than 16 different kinds of psychotherapy were included, mostly dialectical behaviour therapy (DBT) and mentalisation-based treatment (MBT). The comparator interventions included treatment-as-usual (TAU), waiting list, and other active treatments. Treatment duration ranged from one to 36 months. Psychotherapy versus TAU Psychotherapy reduced BPD symptom severity, compared to TAU; standardised mean difference (SMD) -0.52, 95% confidence interval (CI) -0.70 to -0.33; 22 trials, 1244 participants; moderate-quality evidence. This corresponds to a mean difference (MD) of -3.6 (95% CI -4.4 to -2.08) on the Zanarini Rating Scale for BPD (range 0 to 36), a clinically relevant reduction in BPD symptom severity (minimal clinical relevant difference (MIREDIF) on this scale is -3.0 points). Psychotherapy may be more effective at reducing self-harm compared to TAU (SMD -0.32, 95% CI -0.49 to -0.14; 13 trials, 616 participants; low-quality evidence), corresponding to a MD of -0.82 (95% CI -1.25 to 0.35) on the Deliberate Self-Harm Inventory Scale (range 0 to 34). The MIREDIF of -1.25 points was not reached. Suicide-related outcomes improved compared to TAU (SMD -0.34, 95% CI -0.57 to -0.11; 13 trials, 666 participants; low-quality evidence), corresponding to a MD of -0.11 (95% CI -0.19 to -0.034) on the Suicidal Attempt Self Injury Interview. The MIREDIF of -0.17 points was not reached. Compared to TAU, psychotherapy may result in an improvement in psychosocial functioning (SMD -0.45, 95% CI -0.68 to -0.22; 22 trials, 1314 participants; low-quality evidence), corresponding to a MD of -2.8 (95% CI -4.25 to -1.38), on the Global Assessment of Functioning Scale (range 0 to 100). The MIREDIF of -4.0 points was not reached. Our additional Trial Sequential Analysis on all primary outcomes reaching significance found that the required information size was reached in all cases. A subgroup analysis comparing the different types of psychotherapy compared to TAU showed no clear evidence of a difference for BPD severity and psychosocial functioning. Psychotherapy may reduce depressive symptoms compared to TAU but the evidence is very uncertain (SMD -0.39, 95% CI -0.61 to -0.17; 22 trials, 1568 participants; very low-quality evidence), corresponding to a MD of -2.45 points on the Hamilton Depression Scale (range 0 to 50). The MIREDIF of -3.0 points was not reached. BPD-specific psychotherapy did not reduce attrition compared with TAU. Adverse effects were unclear due to too few data. Psychotherapy versus waiting list or no treatment Greater improvements in BPD symptom severity (SMD -0.49, 95% CI -0.93 to -0.05; 3 trials, 161 participants), psychosocial functioning (SMD -0.56, 95% CI -1.01 to -0.11; 5 trials, 219 participants), and depression (SMD -1.28, 95% CI -2.21 to -0.34, 6 trials, 239 participants) were observed in participants receiving psychotherapy versus waiting list or no treatment (all low-quality evidence). No evidence of a difference was found for self-harm and suicide-related outcomes. Individual treatment approaches DBT and MBT have the highest numbers of primary trials, with DBT as subject of one-third of all included trials, followed by MBT with seven RCTs. Compared to TAU, DBT was more effective at reducing BPD severity (SMD -0.60, 95% CI -1.05 to -0.14; 3 trials, 149 participants), self-harm (SMD -0.28, 95% CI -0.48 to -0.07; 7 trials, 376 participants) and improving psychosocial functioning (SMD -0.36, 95% CI -0.69 to -0.03; 6 trials, 225 participants). MBT appears to be more effective than TAU at reducing self-harm (RR 0.62, 95% CI 0.49 to 0.80; 3 trials, 252 participants), suicidality (RR 0.10, 95% CI 0.04, 0.30, 3 trials, 218 participants) and depression (SMD -0.58, 95% CI -1.22 to 0.05, 4 trials, 333 participants). All findings are based on low-quality evidence. For secondary outcomes see review text. AUTHORS' CONCLUSIONS Our assessments showed beneficial effects on all primary outcomes in favour of BPD-tailored psychotherapy compared with TAU. However, only the outcome of BPD severity reached the MIREDIF-defined cut-off for a clinically meaningful improvement. Subgroup analyses found no evidence of a difference in effect estimates between the different types of therapies (compared to TAU) . The pooled analysis of psychotherapy versus waiting list or no treatment found significant improvement on BPD severity, psychosocial functioning and depression at end of treatment, but these findings were based on low-quality evidence, and the true magnitude of these effects is uncertain. No clear evidence of difference was found for self-harm and suicide-related outcomes. However, compared to TAU, we observed effects in favour of DBT for BPD severity, self-harm and psychosocial functioning and, for MBT, on self-harm and suicidality at end of treatment, but these were all based on low-quality evidence. Therefore, we are unsure whether these effects would alter with the addition of more data.
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Affiliation(s)
- Ole Jakob Storebø
- Child and Adolescent Psychiatric Department, Region Zealand, Roskilde, Denmark
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Department of Psychology, Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | | | - Birgit A Völlm
- Department of Forensic Psychiatry, Center for Neurology, University Rostock, Rostock, Germany
| | - Mickey T Kongerslev
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Department of Psychology, Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | - Jessica T Mattivi
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Mie S Jørgensen
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
| | - Erlend Faltinsen
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
| | - Adnan Todorovac
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
| | - Christian P Sales
- Duncan MacMillan House, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
- Institute of Mental Health, Department of Psychiatry & Applied Psychology, Nottingham, UK
| | | | - Klaus Lieb
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Erik Simonsen
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
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18
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Lorca F, Pérez S, Giner F, Marco JH. What Dimension of Meaning in Life is the Stronger Predictor of Borderline Personality Disorder Symptom? JOURNAL OF CONSTRUCTIVIST PSYCHOLOGY 2019. [DOI: 10.1080/10720537.2019.1697912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Fátima Lorca
- Escuela de doctorado, Universidad Católica de Valencia “San Vicente Martir”, Facultad de Psicología, Magisterio y Ciencias de la Educación, Valencia, España
| | - Sandra Pérez
- Facultad de Psicología, Magisterio y Ciencias de la Educación, Universidad Católica de Valencia “San Vicente Mártir”, Valencia, España
| | - Francesc Giner
- Unidad de Salud Mental de Sueca, Hospital Universitario de La Ribera, Sueca, Valencia, España
| | - José H. Marco
- Facultad de Psicología, Departamento de Personalidad, Evaluación y Tratamiento Psicológico, Universidad de Valencia, Valencia, España
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Paris J. Suicidality in Borderline Personality Disorder. MEDICINA (KAUNAS, LITHUANIA) 2019; 55:E223. [PMID: 31142033 PMCID: PMC6632023 DOI: 10.3390/medicina55060223] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 02/01/2019] [Accepted: 05/15/2019] [Indexed: 11/16/2022]
Abstract
Borderline personality disorder (BPD) is associated with suicidal behaviors and self-harm. Up to 10% of BPD patients will die by suicide. However, no research data support the effectiveness of suicide prevention in this disorder, and hospitalization has not been shown to be useful. The most evidence-based treatment methods for BPD are specifically designed psychotherapies.
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Affiliation(s)
- Joel Paris
- Institute of Community and Family Psychiatry, McGill University, 4333 Chemin de la Cote Ste. Catherine, Montreal, QC H3T1E4, Canada.
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20
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Van Veen M, Wierdsma AI, van Boeijen C, Dekker J, Zoeteman J, Koekkoek B, Mulder CL. Suicide risk, personality disorder and hospital admission after assessment by psychiatric emergency services. BMC Psychiatry 2019; 19:157. [PMID: 31122268 PMCID: PMC6533743 DOI: 10.1186/s12888-019-2145-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 05/06/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The main objectives of the mobile Psychiatric Emergency Services (PES) in the Netherlands are to assess the presence of a mental disorder, to estimate risk to self or others, and to initiate continuity of care, including psychiatric hospital admission. The aim of this study was to assess the associations between the level of suicidality and risk of voluntary or involuntary admission in patients with and without a personality disorder who were presented to mobile PES. METHODS Observational data were obtained in three areas of the Netherlands from 2007 to 2016. In total, we included 71,707 contacts of patients aged 18 to 65 years. The outcome variable was voluntary or involuntary psychiatric admission. Suicide risk and personality disorder were assessed by PES-clinicians. Multivariable regression analysis was used to explore associations between suicide risk, personality disorder, and voluntary or involuntary admission. RESULTS Independently of the level of suicide risk, suicidal patients diagnosed with personality disorder were less likely to be admitted voluntarily than those without such a diagnosis (admission rate .37 versus .46 respectively). However, when the level of suicide risk was moderate or high, those with a personality disorder who were admitted involuntarily had the same probability of involuntary admission as those without such a disorder. CONCLUSIONS While the probability of voluntary admission was lower in those diagnosed with a personality disorder, independent of the level of suicidality, the probability of involuntary admission was only lower in those whose risk of suicide was low. Future longitudinal studies should investigate the associations between (involuntary) admission and course of suicidality in personality disorder.
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Affiliation(s)
- Mark Van Veen
- Research Group for Social Psychiatry and Mental Health Nursing, University of Applied Science, Nijmegen, The Netherlands.
- Altrecht Mental Health Services, Utrecht, The Netherlands.
| | - André I Wierdsma
- Epidemiological and Social Psychiatric Research Institute, Department of Psychiatry, Erasmus MC, Rotterdam, The Netherlands
| | | | - Jack Dekker
- Faculty of Behavioural and Movement Sciences, VU Faculties, Amsterdam, The Netherlands
| | - Jeroen Zoeteman
- Faculty of Behavioural and Movement Sciences, VU Faculties, Amsterdam, The Netherlands
- Arkin Mental Health Care, Department of Emergency Psychiatry, Amsterdam, The Netherlands
| | - Bauke Koekkoek
- Research Group for Social Psychiatry and Mental Health Nursing, University of Applied Science, Nijmegen, The Netherlands
- Pro Persona Mental Health Services, Wolfheze, The Netherlands
| | - Cornelis L Mulder
- Epidemiological and Social Psychiatric Research Institute, Department of Psychiatry, Erasmus MC, Rotterdam, The Netherlands
- Parnassia Psychiatric Institute, Rotterdam, The Netherlands
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21
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Bittencourt AA, de Barcellos ED, Serralta FB. Handling suicidal crises in psychodynamic psychotherapy: A process case study. J Clin Psychol 2019; 75:846-858. [PMID: 30817004 DOI: 10.1002/jclp.22761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 12/20/2018] [Accepted: 02/20/2019] [Indexed: 11/08/2022]
Abstract
The core characteristics of patients with a borderline personality disorder (BPD) affect the therapeutic relationship and frequently lead psychodynamic therapists to adapt interventions to manage crises. This study aims to increase knowledge of how such crises affect the therapeutic process. Using her therapist's notes, combined with the Psychotherapy Process Q-Set, we studied the therapeutic process of the first 44 therapy sessions of a female BPD patient with many depressive-like symptoms, including a disruptive period that included hospitalization. We found marked differences between different phases of therapy (before a crisis, acute disorganization, hospitalization, and back to the consulting room). The analysis suggests that a crisis and hospitalization may occur without necessarily damaging the therapeutic process. The therapist's ability to tolerate aggression, to explore and contain suicide wishes and behaviors, and to flexibly adapt techniques to patient needs, are among the therapeutic attitudes and behaviors that can help restore an effective psychodynamic process.
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22
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Sher L, Rutter SB, New AS, Siever LJ, Hazlett EA. Gender differences and similarities in aggression, suicidal behaviour, and psychiatric comorbidity in borderline personality disorder. Acta Psychiatr Scand 2019; 139:145-153. [PMID: 30353921 DOI: 10.1111/acps.12981] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/17/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We examined gender differences and similarities in aggression, impulsivity, suicidal behaviour, and psychiatric comorbidity in men and women with borderline personality disorder (BPD) compared with healthy controls. METHOD A community sample of 511 participants (healthy controls: 81 men and 82 women; BPD patients: 145 men and 203 women) were rigorously characterized using structured diagnostic interviews and symptom severity assessments. RESULTS In comparison with women with BPD, men were less educated, had higher total Barratt Impulsivity Scale (BIS), BIS-motoric impulsiveness and BIS-non-planning impulsiveness subscale, total Buss-Perry Aggression Questionnaire (BPAQ), and BPAQ-physical aggression subscale scores. Men with BPD were more likely to have comorbid narcissistic, antisocial, paranoid, and schizotypal personality disorders, alcohol and substance use disorders but less likely to have dependent and obsessive-compulsive personality disorders compared to women with BPD. There was a trend toward higher maximum lethality of suicide attempts in men suicide attempters compared with women suicide attempters but no difference between men and women with regard to the proportion of suicide attempters or the number of suicide attempts. CONCLUSION Men with BPD are more impaired and may be at higher risk of dying by suicide compared to women with BPD.
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Affiliation(s)
- L Sher
- James J. Peters Veterans' Administration Medical Center, Bronx, New York, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - S B Rutter
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - A S New
- James J. Peters Veterans' Administration Medical Center, Bronx, New York, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - L J Siever
- James J. Peters Veterans' Administration Medical Center, Bronx, New York, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - E A Hazlett
- James J. Peters Veterans' Administration Medical Center, Bronx, New York, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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23
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Lin TJ, Ko HC, Wu JYW, Oei TP, Lane HY, Chen CH. The Effectiveness of Dialectical Behavior Therapy Skills Training Group vs. Cognitive Therapy Group on Reducing Depression and Suicide Attempts for Borderline Personality Disorder in Taiwan. Arch Suicide Res 2019. [PMID: 29528807 DOI: 10.1080/13811118.2018.1436104] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In this study the effectiveness of the condensed Dialectical Behavior Therapy Skills Training Group (DBTSTG) was compared to the Cognitive Therapy Group (CTG) in reducing depression and suicide reattempt and modifying emotion regulation strategies among those with borderline personality disorder (BPD). A total of 82 depressed BPD college students with a suicidal history within the past 6-months were randomly allocated to DBTSTG or CTG. Both groups had similar reductions in suicide reattempts and depression after the intervention and 6-month follow-ups. However, the CTG showed improvements in cognitive errors, but the DBTSTG revealed increases in acceptance and decreases in suppression scores. Both groups were effective in decreasing depression and suicide reattempt in BPD college students, probably through increasing adaptive antecedent-focused or response-focused strategies of emotion regulation, respectively.
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Salles J, Calonge J, Franchitto N, Bougon E, Schmitt L. Factors associated with hospitalization after self-poisoning in France: special focus on the impact of alcohol use disorder. BMC Psychiatry 2018; 18:287. [PMID: 30189841 PMCID: PMC6127999 DOI: 10.1186/s12888-018-1854-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 08/16/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Previous studies have identified factors associated with admission to hospital after suicide spectrum behaviors. In this study, we aim to identify specific factors associated with psychiatric hospitalization after self-poisoning. Given earlier findings suggesting that alcohol use disorder is not associated with hospital admission, we also aim to consider its impact, as well as blood alcohol concentrations, on hospitalization decisions after a suicide attempt. METHODS We studied the association between demographic features, suicide intent, psychiatric characteristics and admission to hospital in self-poisoning patients in an emergency department in France. RESULTS Suicide intent, a past history of suicide attempts, bipolar disorder and depression were associated with psychiatric hospital admissions. Despite alcohol use disorder being known to be associated with a suicide risk, it was not linked with psychiatric hospitalization. A positive blood alcohol concentration in the emergency department likewise had no association with admission to a psychiatric ward for inpatient care. CONCLUSIONS Our findings were similar to those reported for other suicide spectrum behaviors. Alcohol use disorder was not associated with admission for inpatient psychiatric care, whereas depression clearly was. The cause of this discrepancy must be determined in future research.
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Affiliation(s)
- Juliette Salles
- Université de Toulouse III, F-31000 Toulouse, France
- CHU Toulouse, Service de Psychiatrie eSt Psychologie, Psychiatrie, F-31000 Toulouse, France
- CHU Toulouse, Service d’addictologie clinique, urgences réanimation médecine, F-31000 Toulouse, France
| | - Julie Calonge
- Université de Toulouse III, F-31000 Toulouse, France
| | - Nicolas Franchitto
- Université de Toulouse III, F-31000 Toulouse, France
- CHU Toulouse, Service d’addictologie clinique, urgences réanimation médecine, F-31000 Toulouse, France
| | - Emmanuelle Bougon
- Université de Toulouse III, F-31000 Toulouse, France
- CHU Toulouse, Service de Psychiatrie eSt Psychologie, Psychiatrie, F-31000 Toulouse, France
| | - Laurent Schmitt
- Université de Toulouse III, F-31000 Toulouse, France
- CHU Toulouse, Service de Psychiatrie eSt Psychologie, Psychiatrie, F-31000 Toulouse, France
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25
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Bachmann S. Epidemiology of Suicide and the Psychiatric Perspective. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E1425. [PMID: 29986446 PMCID: PMC6068947 DOI: 10.3390/ijerph15071425] [Citation(s) in RCA: 642] [Impact Index Per Article: 107.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 06/28/2018] [Accepted: 07/01/2018] [Indexed: 12/12/2022]
Abstract
Suicide is a worldwide phenomenon. This review is based on a literature search of the World Health Organization (WHO) databases and PubMed. According to the WHO, in 2015, about 800,000 suicides were documented worldwide, and globally 78% of all completed suicides occur in low- and middle-income countries. Overall, suicides account for 1.4% of premature deaths worldwide. Differences arise between regions and countries with respect to the age, gender, and socioeconomic status of the individual and the respective country, method of suicide, and access to health care. During the second and third decades of life, suicide is the second leading cause of death. Completed suicides are three times more common in males than females; for suicide attempts, an inverse ratio can be found. Suicide attempts are up to 30 times more common compared to suicides; they are however important predictors of repeated attempts as well as completed suicides. Overall, suicide rates vary among the sexes and across lifetimes, whereas methods differ according to countries. The most commonly used methods are hanging, self-poisoning with pesticides, and use of firearms. The majority of suicides worldwide are related to psychiatric diseases. Among those, depression, substance use, and psychosis constitute the most relevant risk factors, but also anxiety, personality-, eating- and trauma-related disorders as well as organic mental disorders significantly add to unnatural causes of death compared to the general population. Overall, the matter at hand is relatively complex and a significant amount of underreporting is likely to be present. Nevertheless, suicides can, at least partially, be prevented by restricting access to means of suicide, by training primary care physicians and health workers to identify people at risk as well as to assess and manage respective crises, provide adequate follow-up care and address the way this is reported by the media. Suicidality represents a major societal and health care problem; it thus should be given a high priority in many realms.
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Affiliation(s)
- Silke Bachmann
- Clienia Littenheid AG, Hauptstrasse 130, 9573 Littenheid, Switzerland.
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Faculty of Medicine, University Halle (Saale), Julius-Kühn-Strasse 7, 6112 Halle (Saale), Germany.
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26
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Young C, Habarth J, Bongar B, Packman W. Disorder in the Court: Cluster B Personality Disorders in United States Case Law. PSYCHIATRY, PSYCHOLOGY, AND LAW : AN INTERDISCIPLINARY JOURNAL OF THE AUSTRALIAN AND NEW ZEALAND ASSOCIATION OF PSYCHIATRY, PSYCHOLOGY AND LAW 2018; 25:706-723. [PMID: 31984047 PMCID: PMC6818303 DOI: 10.1080/13218719.2018.1474816] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Previous research has shown that antisocial, borderline, narcissistic and histrionic personality disorders, also known as the Cluster B personality disorders in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5), are commonly raised in lawsuits. Cluster B disorders are characterized by problems with emotion regulation, impulsivity and interpersonal conflicts. Without question, individuals diagnosed with a Cluster B disorder possess traits that make them more susceptible to becoming involved in litigation; however, to date there has been no research on how the disorders interact with the judicial system. This study surveyed litigant success of Cluster B personality disorders in United States federal and state case law. Results showed that both criminal and civil litigants tended to be unsuccessful in their cases. Overall, this study demonstrated that court opinions can provide a window into the psychology of trial litigants and how personality can affect trial outcomes.
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Affiliation(s)
- Catherine Young
- Clinical Psychology, Palo Alto University, Palo Alto, CA, USA
| | - Janice Habarth
- Clinical Psychology, Palo Alto University, Palo Alto, CA, USA
| | - Bruce Bongar
- Clinical Psychology, Palo Alto University, Palo Alto, CA, USA
| | - Wendy Packman
- Clinical Psychology, Palo Alto University, Palo Alto, CA, USA
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Storebø OJ, Stoffers-Winterling JM, Völlm BA, Kongerslev MT, Mattivi JT, Kielsholm ML, Nielsen SS, Jørgensen MP, Faltinsen EG, Lieb K, Simonsen E. Psychological therapies for people with borderline personality disorder. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2018. [DOI: 10.1002/14651858.cd012955] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Ole Jakob Storebø
- Region Zealand; Child and Adolescent Psychiatric Department; Birkevaenget 3 Roskilde Denmark 4300
- Region Zealand Psychiatry; Psychiatric Research Unit; Slagelse Denmark
| | - Jutta M Stoffers-Winterling
- University Medical Center Mainz; Department of Psychiatry and Psychotherapy; Untere Zahlbacher Straße 8 Mainz Germany D-55131
| | - Birgit A Völlm
- University of Nottingham Innovation Park; Division of Psychiatry & Applied Psychology; Institute of Mental Health Triumph Road Nottingham UK NG7 2TU
| | | | - Jessica T Mattivi
- University Medical Center Mainz; Department of Psychiatry and Psychotherapy; Untere Zahlbacher Straße 8 Mainz Germany D-55131
| | | | | | - Mie Poulsgaard Jørgensen
- Region Zealand; Child and Adolescent Psychiatric Department; Birkevaenget 3 Roskilde Denmark 4300
| | | | - Klaus Lieb
- University Medical Center Mainz; Department of Psychiatry and Psychotherapy; Untere Zahlbacher Straße 8 Mainz Germany D-55131
| | - Erik Simonsen
- Region Zealand Psychiatry; Psychiatric Research Unit; Slagelse Denmark
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28
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Stoffers‐Winterling JM, Storebø OJ, Völlm BA, Mattivi JT, Nielsen SS, Kielsholm ML, Faltinsen EG, Simonsen E, Lieb K. Pharmacological interventions for people with borderline personality disorder. Cochrane Database Syst Rev 2018; 2018:CD012956. [PMCID: PMC6491315 DOI: 10.1002/14651858.cd012956] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the beneficial and harmful effects of pharmacological treatment for adolescents and adults with borderline personality disorder (BPD).
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Affiliation(s)
- Jutta M Stoffers‐Winterling
- University Medical Center MainzDepartment of Psychiatry and PsychotherapyUntere Zahlbacher Straße 8MainzGermanyD‐55131
| | | | - Birgit A Völlm
- University of Nottingham Innovation ParkDivision of Psychiatry & Applied PsychologyInstitute of Mental HealthTriumph RoadNottinghamUKNG7 2TU
| | - Jessica T Mattivi
- University Medical Center MainzDepartment of Psychiatry and PsychotherapyUntere Zahlbacher Straße 8MainzGermanyD‐55131
| | | | | | | | - Erik Simonsen
- Region Zealand PsychiatryPsychiatric Research UnitSlagelseDenmark
| | - Klaus Lieb
- University Medical Center MainzDepartment of Psychiatry and PsychotherapyUntere Zahlbacher Straße 8MainzGermanyD‐55131
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29
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Dellazizzo L, Dugré JR, Berwald M, Stafford MC, Côté G, Potvin S, Dumais A. Distinct pathological profiles of inmates showcasing cluster B personality traits, mental disorders and substance use regarding violent behaviors. Psychiatry Res 2018; 260:371-378. [PMID: 29247923 DOI: 10.1016/j.psychres.2017.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 12/04/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
Abstract
High rates of violence are found amid offenders with severe mental illnesses (SMI), substance use disorders (SUDs) and Cluster B personality disorders. Elevated rates of comorbidity lead to inconsistencies when it comes to this relationship. Furthermore, overlapping Cluster B personality traits have been associated with violence. Using multiple correspondence analysis and cluster analysis, this study was designed to differentiate profiles of 728 male inmates from penitentiary and psychiatric settings marked by personality traits, SMI and SUDs following different violent patterns. Six significantly differing clusters emerged. Cluster 1, "Sensation seekers", presented recklessness with SUDs and low prevalence's of SMI and auto-aggression. Two clusters committed more sexual offenses. While Cluster 2, "Opportunistic-sexual offenders", had more antisocial lifestyles and SUDs, Cluster 6, "Emotional-sexual offenders", displayed more emotional disturbances with SMI and violence. Clusters 3 and 4, representing "Life-course-persistent offenders", shared early signs of persistent antisocial conduct and severe violence. Cluster 3, "Early-onset violent delinquents", emerged as more severely antisocial with SUDs. Cluster 4, "Early-onset unstable-mentally ill delinquents", were more emotionally driven, with SMI and auto-aggression. Cluster 5, "Late-start offenders", was less severely violent, and emotionally driven with antisocial behavior beginning later. This study suggests the presence of specific psychopathological organizations in violent inmates.
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Affiliation(s)
- Laura Dellazizzo
- Centre de recherche de l'Institut Universitaire en Santé Mentale de Montréal, Montreal, Canada; Department of Psychiatry, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Jules R Dugré
- Centre de recherche de l'Institut Universitaire en Santé Mentale de Montréal, Montreal, Canada; Department of Psychiatry, Faculty of Medicine, Université de Montréal, Montreal, Canada; School of Criminology, Faculty of Arts and Science, Université de Montréal, Montreal, Canada
| | - Marieke Berwald
- Centre de recherche de l'Institut Universitaire en Santé Mentale de Montréal, Montreal, Canada; Department of Psychiatry, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | | | - Gilles Côté
- Department of Psychology, Université du Québec, Trois-Rivières, Canada; Centre de recherche de l'Institut Philippe-Pinel de Montréal, Montreal, Canada
| | - Stéphane Potvin
- Centre de recherche de l'Institut Universitaire en Santé Mentale de Montréal, Montreal, Canada; Department of Psychiatry, Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Alexandre Dumais
- Centre de recherche de l'Institut Universitaire en Santé Mentale de Montréal, Montreal, Canada; Department of Psychiatry, Faculty of Medicine, Université de Montréal, Montreal, Canada; Centre de recherche de l'Institut Philippe-Pinel de Montréal, Montreal, Canada.
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Stiles BM, Fish AF, Vandermause R, Malik AM. The Compelling and Persistent Problem of Bipolar Disorder Disguised as Major Depression Disorder: An Integrative Review [Formula: see text]. J Am Psychiatr Nurses Assoc 2018; 24:415-425. [PMID: 29952230 DOI: 10.1177/1078390318784360] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Up to 40% of patients with bipolar disorder are misdiagnosed, usually with major depression disorder. OBJECTIVE The purpose was to describe the current state of the science of the misdiagnosis of bipolar disorder, with the ultimate goal of improving psychiatric diagnostic workups including screening. DESIGN An integrative review was conducted using standard criteria for evaluating research articles. RESULTS Forty-nine articles met the eligibility criteria. Articles explored patient-related and health care provider-related factors contributing to the misdiagnosis of bipolar disorder as well as consequences of misdiagnosis. Clinically oriented, reliable, and valid screening tools for bipolar disorder also were reviewed. CONCLUSIONS Awareness of multiple, challenging patient-related factors and more comprehensive assessment and screening by health care providers may reduce misdiagnosis.
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Affiliation(s)
- Brandie M Stiles
- 1 Brandie M. Stiles, PhD, MSN, PMHNP-BC, University of Missouri-St. Louis, St. Louis, MO, USA; Centerpointe Hospital, St. Louis, MO, USA
| | - Anne F Fish
- 2 Anne F. Fish, PhD, RN, FAHA, University of Missouri-St. Louis, St. Louis, MO, USA
| | - Roxanne Vandermause
- 3 Roxanne Vandermause, PhD, RN, University of Missouri-St. Louis, St. Louis, MO, USA
| | - Azfar M Malik
- 4 Azfar M. Malik, MD, MBA, Centerpointe Hospital, St. Louis, MO, USA
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Bernanke J, McCommon B. Training in Good Psychiatric Management for Borderline Personality Disorder in Residency: An Aide to Learning Supportive Psychotherapy for Challenging-to-Treat Patients. Psychodyn Psychiatry 2018; 46:181-200. [PMID: 29809114 DOI: 10.1521/pdps.2018.46.2.181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Given many competing demands, psychotherapy training to competency is difficult during psychiatric residency. Good Psychiatric Management for borderline personality disorder (GPM) offers an evidence-based, simplified, psychodynamically informed framework for the outpatient management of patients with borderline personality disorder, one of the most challenging disorders psychiatric residents must learn to treat. In this article, we provide an overview of GPM, and show that training in GPM meets a requirement for training in supportive psychotherapy; builds on psychodynamic psychotherapy training; and applies to other severe personality disorders, especially narcissistic personality disorder. We describe the interpersonal hypersensitivity model used in GPM as a straightforward way for clinicians to collaborate with patients in organizing approaches to psychoeducation, treatment goals, case management, use of multiple treatment modalities, and safety. A modification of the interpersonal hypersensitivity model that includes intra-personal hypersensitivity can be used to address narcissistic problems often present in borderline personality disorder. We argue that these features make GPM ideally suited for psychiatry residents in treating their most challenging patients, provide clinical examples to illustrate these points, and report the key lessons learned by a psychiatry resident after a year of GPM supervision.
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Affiliation(s)
- Joel Bernanke
- Department of Psychiatry, Columbia University
- New York State Psychiatric Institute
| | - Benjamin McCommon
- Department of Psychiatry, Columbia University
- New York State Psychiatric Institute
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32
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Rao S, Broadbear JH, Thompson K, Correia A, Preston M, Katz P, Trett R. Evaluation of a novel risk assessment method for self-harm associated with Borderline Personality Disorder. Australas Psychiatry 2017; 25:460-465. [PMID: 28488884 DOI: 10.1177/1039856217707390] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Borderline personality disorder (BPD) is associated with frequent self-harm and suicidal behaviours. This study compared physician-assessed self-harm risk and intervention choice according to a (i) standard risk assessment and (ii) BPD-specific risk assessment methods. METHODS Forty-five junior and senior mental health physicians were assigned to standard or BPD-specific risk training groups. The assessment utilized a BPD case vignette containing four scenarios describing high/low lethality self-harm and chronic/new patterns of self-harm behaviour. Participants chose from among four interventions, each corresponding to a risk category. RESULTS Standard and BPD-specific groups were alike in their assessment of self-harm risk. Divergence occurred on intervention choice for assessments of low lethality, chronic risk ( p<.01) and high lethality, chronic risk ( p<.005). Overall, psychiatrists were more likely than their junior colleagues to correctly assess risk and management options. CONCLUSIONS Although standard and BPD-specific methods are well aligned for assessing self harm-associated risk, BPD-specific training raised awareness of BPD-appropriate interventions, particularly in the context of chronic patterns of self-harm behaviour. Wider dissemination of BPD-specific risk training may enhance the confidence of mental health clinicians in identifying the nature of self-harm risk as well as the most clinically appropriate interventions for clients with BPD.
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Affiliation(s)
- Sathya Rao
- Executive Clinical Director, Spectrum, Eastern Health, Ringwood East, VIC, Australia
| | - Jillian H Broadbear
- Senior Research Fellow, Spectrum, Eastern Health, Ringwood East, VIC, Australia
| | - Katherine Thompson
- Senior Research Fellow, Orygen, Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Anna Correia
- Associate Director, Spectrum, Statewide Service for Personality Disorder, Eastern Health, Ringwood East, VIC, and; current affiliation: Psychoanalytic Practice, Melbourne, VIC, Australia
| | - Martin Preston
- Consultant Psychiatrist, Mental Health Program, Monash Health, Melbourne, VIC, Australia
| | - Paul Katz
- Executive Clinical Director, Mental Health Program, Eastern Health, Box Hill, VIC, Australia
| | - Robert Trett
- Associate Clinical Director, Spectrum, Eastern Health, Ringwood East, VIC, and; Lecturer, Centre for Psychiatric Nursing, University of Melbourne, Melbourne, VIC, Australia
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Sher L, Grunebaum MF, Burke AK, Chaudhury S, Mann JJ, Oquendo MA. Depressed Multiple-SuicideAttempters – A High-Risk Phenotype. CRISIS 2017; 38:367-375. [DOI: 10.1027/0227-5910/a000475] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Abstract. Background: There is compelling evidence that suicide attempts are among the strongest predictors of suicide and future suicide attempts. Aim: This study aimed to examine psychopathology in multiple-suicide attempters. Method: We compared the demographic and clinical features of three groups: depressed patients without a history of suicide attempts (non-attempters), depressed patients with a history of one to three suicide attempts (attempters), and depressed patients with a history of four or more suicide attempts (multiple attempters). Results: We found that attempters and multiple attempters had higher levels of depression, hopelessness, aggression, hostility, and impulsivity and were more likely to have borderline personality disorder and family history of major depression or alcohol use disorder compared with non-attempters, but did not differ between each other on these measures. Multiple attempters had greater suicidal ideation at study entry and were more likely to have family history of suicide attempt compared with attempters. Importantly, multiple attempters had greater suicide intent at the time of the most medically serious suicide attempt and more serious medical consequences during their most medically serious suicide attempt compared with attempters. Limitations: The cross-sectional design of the study. Conclusion: Our data suggest that multiple-suicide attempters require careful evaluation as their behavior can have serious medical consequences.
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Affiliation(s)
- Leo Sher
- New York State Psychiatric Institute and Columbia University College of Physicians and Surgeons, New York, NY, USA
- James J. Peters Veterans' Administration Medical Center and Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael F. Grunebaum
- New York State Psychiatric Institute and Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Ainsley K. Burke
- New York State Psychiatric Institute and Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Sadia Chaudhury
- New York State Psychiatric Institute and Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - J. John Mann
- New York State Psychiatric Institute and Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Maria A. Oquendo
- New York State Psychiatric Institute and Columbia University College of Physicians and Surgeons, New York, NY, USA
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Ayre K, Owen GS, Moran P. Mental capacity and borderline personality disorder. BJPsych Bull 2017; 41:33-36. [PMID: 28184315 PMCID: PMC5288091 DOI: 10.1192/pb.bp.115.052753] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 02/02/2016] [Accepted: 02/24/2016] [Indexed: 11/23/2022] Open
Abstract
The use of the Mental Capacity Act 2005 in assessing decision-making capacity in patients with borderline personality disorder (BPD) is inconsistent. We believe this may stem from persisting confusion regarding the nosological status of personality disorder and also a failure to recognise the fact that emotional dysregulation and characteristic psychodynamic abnormalities may cause substantial difficulties in using and weighing information. Clearer consensus on these issues is required in order to provide consistent patient care and reduce uncertainty for clinicians in what are often emergency and high-stakes clinical scenarios.
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Affiliation(s)
- Karyn Ayre
- South London and Maudsley NHS Foundation Trust, London
| | - Gareth S. Owen
- Institute of Psychiatry, Psychology and Neuroscience, King's College London
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Braden JB, Edlund MJ, Sullivan MD. Suicide Deaths With Opioid Poisoning in the United States: 1999-2014. Am J Public Health 2017; 107:421-426. [PMID: 28103068 DOI: 10.2105/ajph.2016.303591] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To describe trends in suicides with opioid poisoning noted as a contributing cause of death. METHODS Using National Vital Statistics data (1999-2014), we calculated age-adjusted rates of suicide with opioid poisoning (International Classification of Diseases, Tenth Revision codes T40.0-T40.4) per 100 000 population per year and annual percentage change (APC) in rates. We used Joinpoint regression to examine trends in suicide rates and proportion of suicides involving opioids. RESULTS The annual age-adjusted death rate from suicide with opioid poisoning as a contributing cause of death increased from 0.3 per 100 000 in 1999 to 0.7 per 100 000 in 2009 (APC = 8.1%; P < .001), and remained at 0.6 to 0.7 per 100 000 through 2014. The percentage of all suicides with opioid poisoning listed as a contributing cause of death increased from 2.2% in 1999 to 4.4% in 2010 (P < .001). Rates were similar for men and women, higher among Whites than non-Whites, higher in the West, and highest for individuals aged 45 to 64 years. CONCLUSIONS Opioid involvement in suicides has doubled since 1999. These analyses underscore the need for health care providers to assess suicidal risk in patients receiving opioids.
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Affiliation(s)
- Jennifer Brennan Braden
- Jennifer Brennan Braden and Mark D. Sullivan are with the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle. Mark J. Edlund is with the Research Triangle Institute International, Research Triangle Park, NC
| | - Mark J Edlund
- Jennifer Brennan Braden and Mark D. Sullivan are with the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle. Mark J. Edlund is with the Research Triangle Institute International, Research Triangle Park, NC
| | - Mark D Sullivan
- Jennifer Brennan Braden and Mark D. Sullivan are with the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle. Mark J. Edlund is with the Research Triangle Institute International, Research Triangle Park, NC
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Sher L, Fisher AM, Kelliher CH, Penner JD, Goodman M, Koenigsberg HW, New AS, Siever LJ, Hazlett EA. Clinical features and psychiatric comorbidities of borderline personality disorder patients with versus without a history of suicide attempt. Psychiatry Res 2016; 246:261-266. [PMID: 27728869 DOI: 10.1016/j.psychres.2016.10.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 07/31/2016] [Accepted: 10/02/2016] [Indexed: 11/18/2022]
Abstract
Patients with borderline personality disorder (BPD) are at high risk for suicidal behavior. However, many BPD patients do not engage in suicidal behavior. In this study, we compared clinical features of BPD patients with or without a history of suicide attempts and healthy volunteers. Compared with healthy volunteers, both BPD groups had higher Affective Lability Scale (ALS), ALS - Depression-Anxiety Subscale, Barratt Impulsivity Scale (BIS), and Lifetime History of Aggression (LHA) scores and were more likely to have a history of temper tantrums. BPD suicide attempters had higher ALS, ALS - Depression-Anxiety Subscale and LHA scores and were more likely to have a history of non-suicidal self-injury or temper tantrums compared to BPD non-attempters. Also, BPD suicide attempters were more likely to have a history of comorbid major depressive disorder and less likely to have comorbid narcissistic personality disorder (NPD) in comparison to BPD non-attempters. About 50% of study participants in each BPD group had a history of comorbid substance use disorder (SUD). Our study indicates that BPD patients with a history of suicide attempt are more aggressive, affectively dysregulated and less narcissistic than BPD suicide non-attempters.
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Affiliation(s)
- Leo Sher
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Inpatient and Outpatient Psychiatry, James J. Peters VA Medical Center, Bronx, NY, United States.
| | - Amanda M Fisher
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Caitlin H Kelliher
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Justin D Penner
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Inpatient and Outpatient Psychiatry, James J. Peters VA Medical Center, Bronx, NY, United States; Mental Illness Research, Education, and Clinical Center (MIRECC; VISN 2 South), James J. Peters VA Medical Center, Bronx, NY, United States
| | - Marianne Goodman
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Inpatient and Outpatient Psychiatry, James J. Peters VA Medical Center, Bronx, NY, United States; Mental Illness Research, Education, and Clinical Center (MIRECC; VISN 2 South), James J. Peters VA Medical Center, Bronx, NY, United States
| | - Harold W Koenigsberg
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Inpatient and Outpatient Psychiatry, James J. Peters VA Medical Center, Bronx, NY, United States
| | - Antonia S New
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Larry J Siever
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Inpatient and Outpatient Psychiatry, James J. Peters VA Medical Center, Bronx, NY, United States; Mental Illness Research, Education, and Clinical Center (MIRECC; VISN 2 South), James J. Peters VA Medical Center, Bronx, NY, United States
| | - Erin A Hazlett
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, United States; Mental Illness Research, Education, and Clinical Center (MIRECC; VISN 2 South), James J. Peters VA Medical Center, Bronx, NY, United States
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Abstract
Suicide attempters differ in the degree of planning for their suicide attempts. The purpose of this study was to identify differences between individuals who make planned (≥3 hours of planning) and unplanned (<3 hours of planning) suicide attempts. Depressed suicide attempters (n = 110) were compared based on degree of planning of their most recent suicide attempt on demographic and clinical variables. Participants who made planned suicide attempts were more likely to have family history of completed suicide, more severe and frequent suicidal ideation, greater trait impulsivity, and greater suicidal intent and more severe medical consequences for both their most recent and most serious suicide attempts. These results suggest clear clinical differences based on the degree of suicide attempt planning. Severe suicidal ideation, high suicide intent, family history of suicide completion, and high levels of motor impulsivity contribute to a phenotype that is at greater risk of planned, highly lethal suicide attempts.
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Mellesdal L, Gjestad R, Johnsen E, Jørgensen HA, Oedegaard KJ, Kroken RA, Mehlum L. Borderline Personality Disorder and Posttraumatic Stress Disorder at Psychiatric Discharge Predict General Hospital Admission for Self-Harm. J Trauma Stress 2015; 28:556-62. [PMID: 26581019 DOI: 10.1002/jts.22053] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We investigated whether posttraumatic stress disorder (PTSD) was predictor of suicidal behavior even when adjusting for comorbid borderline personality disorder (BPD) and other salient risk factors. To study this, we randomly selected 308 patients admitted to a psychiatric hospital because of suicide risk. Baseline interviews were performed within the first days of the stay. Information concerning the number of self-harm admissions to general hospitals over the subsequent 6 months was retrieved through linkage with the regional hospital registers. A censored regression analysis of hospital admissions for self-harm indicated significant associations with both PTSD (β = .21, p < .001) and BPD (β = .27, p < .001). A structural model comprising two latent BPD factors, dysregulation and relationship problems, as well as PTSD and several other variables, demonstrated that PTSD was an important predictor of the number of self-harm admissions to general hospitals(B = 1.52, p < .01). Dysregulation predicted self-harm directly (B = 0.28, p < .05), and also through PTSD [corrected]. These results suggested that PTSD and related dysregulation problems could be important treatment targets for a reduction in the risk of severe self-harm in high-risk psychiatric patients.
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Affiliation(s)
- Liv Mellesdal
- Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Rolf Gjestad
- Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Erik Johnsen
- Division of Psychiatry, Haukeland University Hospital, Bergen, Norway.,Clinical Institute 1, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Hugo A Jørgensen
- Clinical Institute 1, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Ketil J Oedegaard
- Division of Psychiatry, Haukeland University Hospital, Bergen, Norway.,Clinical Institute 1, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Rune A Kroken
- Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Lars Mehlum
- National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Björkenstam E, Björkenstam C, Holm H, Gerdin B, Ekselius L. Excess cause-specific mortality in in-patient-treated individuals with personality disorder: 25-year nationwide population-based study. Br J Psychiatry 2015; 207:339-45. [PMID: 26159601 DOI: 10.1192/bjp.bp.114.149583] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 11/27/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND Although personality disorders are associated with increased overall mortality, less is known about cause of death and personality type. AIMS To determine causes of mortality in ICD personality disorders. METHOD Based on data from Swedish nationwide registers, individuals admitted to hospital with a primary diagnosis of personality disorder between 1987 and 2011 were followed with respect to mortality until 31 December 2011. Standardised mortality ratios (SMRs) with 95% confidence intervals and underlying causes of death were calculated. RESULTS All-cause SMRs were increased, overall and in all clusters, for natural as well as unnatural causes of death. The overall SMR was 6.1 in women and 5.0 in men, as high as previously reported for anorexia nervosa, with higher rates in cluster B and mixed/other personality disorders. The SMR for suicide was 34.5 in women and 16.0 in men for cluster B disorders. Somatic and psychiatric comorbidity increased SMRs. CONCLUSIONS The SMR was substantially increased for all personality disorder clusters. Thus, there was an increased premature mortality risk for all personality disorders, irrespective of category.
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Affiliation(s)
- Emma Björkenstam
- Emma Björkenstam, PhD, Department of Public Health Sciences, Karolinska Institutet, Stockholm and the Department of Evaluation, and Analysis, Epidemiology and Methodological Support Unit, National Board of Health and Welfare, Stockholm, Sweden; Charlotte Björkenstam, PhD, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Herman Holm, MD, Department of Psychiatry, Skåne University Hospital, Malmö, Sweden; Bengt Gerdin, MD, PhD, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; Lisa Ekselius, MD, PhD, Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden
| | - Charlotte Björkenstam
- Emma Björkenstam, PhD, Department of Public Health Sciences, Karolinska Institutet, Stockholm and the Department of Evaluation, and Analysis, Epidemiology and Methodological Support Unit, National Board of Health and Welfare, Stockholm, Sweden; Charlotte Björkenstam, PhD, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Herman Holm, MD, Department of Psychiatry, Skåne University Hospital, Malmö, Sweden; Bengt Gerdin, MD, PhD, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; Lisa Ekselius, MD, PhD, Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden
| | - Herman Holm
- Emma Björkenstam, PhD, Department of Public Health Sciences, Karolinska Institutet, Stockholm and the Department of Evaluation, and Analysis, Epidemiology and Methodological Support Unit, National Board of Health and Welfare, Stockholm, Sweden; Charlotte Björkenstam, PhD, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Herman Holm, MD, Department of Psychiatry, Skåne University Hospital, Malmö, Sweden; Bengt Gerdin, MD, PhD, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; Lisa Ekselius, MD, PhD, Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden
| | - Bengt Gerdin
- Emma Björkenstam, PhD, Department of Public Health Sciences, Karolinska Institutet, Stockholm and the Department of Evaluation, and Analysis, Epidemiology and Methodological Support Unit, National Board of Health and Welfare, Stockholm, Sweden; Charlotte Björkenstam, PhD, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Herman Holm, MD, Department of Psychiatry, Skåne University Hospital, Malmö, Sweden; Bengt Gerdin, MD, PhD, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; Lisa Ekselius, MD, PhD, Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden
| | - Lisa Ekselius
- Emma Björkenstam, PhD, Department of Public Health Sciences, Karolinska Institutet, Stockholm and the Department of Evaluation, and Analysis, Epidemiology and Methodological Support Unit, National Board of Health and Welfare, Stockholm, Sweden; Charlotte Björkenstam, PhD, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Herman Holm, MD, Department of Psychiatry, Skåne University Hospital, Malmö, Sweden; Bengt Gerdin, MD, PhD, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; Lisa Ekselius, MD, PhD, Department of Neuroscience, Psychiatry, Uppsala University, Uppsala, Sweden
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Hersh RG. Using transference-focused psychotherapy principles in the pharmacotherapy of patients with severe personality disorders. Psychodyn Psychiatry 2015; 43:181-199. [PMID: 26039227 DOI: 10.1521/pdps.2015.43.2.181] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Transference-focused psychotherapy (TFP) is an evidence-based, manualized treatment for severe personality disorders. TFP provides clinicians with a comprehensive diagnostic approach, overarching theoretical orientation, and specific clinical techniques. While TFP was developed as a long-term psychodynamic psychotherapy for patients with personality disorders, the approach, orientation, and techniques used in psychotherapy treatment may be of use in pharmacotherapy with the same patients. Patients with borderline personality disorder, in particular, are high utilizers of all subtypes of psychotropic medication despite limited evidence for their effectiveness, creating multiple challenges for the prescribing clinician. The author suggests specific ways the TFP model can assist prescribers, including those who do not practice TFP psychotherapy.
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Zeng R, Cohen LJ, Tanis T, Qizilbash A, Lopatyuk Y, Yaseen ZS, Galynker I. Assessing the contribution of borderline personality disorder and features to suicide risk in psychiatric inpatients with bipolar disorder, major depression and schizoaffective disorder. Psychiatry Res 2015; 226:361-7. [PMID: 25661531 DOI: 10.1016/j.psychres.2015.01.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2014] [Revised: 01/13/2015] [Accepted: 01/19/2015] [Indexed: 11/28/2022]
Abstract
Suicidal behavior often accompanies both borderline personality disorder (BPD) and severe mood disorders, and comorbidity between the two appears to further increase suicide risk. The current study aims to quantify the risk of suicidality conferred by comorbid BPD diagnosis or features in three affective disorders: major depressive disorder (MDD), bipolar disorder (BP) and schizoaffective disorder. One hundred forty-nine (149) psychiatric inpatients were assessed by SCID I and II, and the Columbia Suicide Severity Rating Scale. Logistic regression analyses investigated the associations between previous suicide attempt and BPD diagnosis or features in patients with MDD, BP, and schizoaffective disorder, as well as a history of manic or major depressive episodes, and psychotic symptoms. Comorbid BPD diagnosis significantly increased suicide risk in the whole sample, and in those with MDD, BP, and history of depressive episode or psychotic symptoms. Each additional borderline feature also increased risk of past suicide attempt in these same groups (excepting BP) and in those with a previous manic episode. Of the BPD criteria, only unstable relationships and impulsivity independently predicted past suicide attempt. Overall, among patients with severe mood disorders, the presence of comorbid BPD features or disorder appears to substantially increase the risk of suicide attempts.
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Affiliation(s)
- Ruifan Zeng
- Department of Psychology, Long Island University-Brooklyn, 1 University Plaza, Brooklyn, NY 11201, USA.
| | - Lisa J Cohen
- Department of Psychiatry and Behavioral Sciences, Mount Sinai Beth Israel Medical Center, New York, NY 10003, USA
| | - Thachell Tanis
- Department of Psychiatry and Behavioral Sciences, Mount Sinai Beth Israel Medical Center, New York, NY 10003, USA
| | - Azra Qizilbash
- Department of Psychiatry and Behavioral Sciences, Mount Sinai Beth Israel Medical Center, New York, NY 10003, USA
| | - Yana Lopatyuk
- Department of Psychiatry and Behavioral Sciences, Mount Sinai Beth Israel Medical Center, New York, NY 10003, USA
| | - Zimri S Yaseen
- Department of Psychiatry and Behavioral Sciences, Mount Sinai Beth Israel Medical Center, New York, NY 10003, USA
| | - Igor Galynker
- Department of Psychiatry and Behavioral Sciences, Mount Sinai Beth Israel Medical Center, New York, NY 10003, USA
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Rebok F, Teti GL, Fantini AP, Cárdenas-Delgado C, Rojas SM, Derito MNC, Daray FM. Types of borderline personality disorder (BPD) in patients admitted for suicide-related behavior. Psychiatr Q 2015; 86:49-60. [PMID: 25179870 DOI: 10.1007/s11126-014-9317-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Borderline personality disorder (BPD) is determined by the presence of any five of nine diagnostic criteria, leading patients with heterogeneous clinical features to be diagnosed under the same label without an individualized clinical and therapeutic approach. In response to this problem, Oldham proposed five types of BPD: affective, impulsive, aggressive, dependent and empty. The present study categorized a sample of BPD patients hospitalized due to suicide-related behavior according to Oldham's BPD proposed subtypes, and evaluated their clinical and demographic characteristics. Data were obtained from a sample of 93 female patients admitted to the « Dr. Braulio A. Moyano » Neuropsychiatric Hospital following suicide-related behavior. A total of 87 patients were classified as affective (26%), impulsive (37%), aggressive (4%), dependent (29%), and empty (5%). Patients classified as dependent were significantly older at the time of first suicide-related behavior (p = 0.0008) and reported significantly less events of previous suicide-related behaviors (p = 0.03), while patients classified as impulsive reported significantly higher rates of drug use (p = 0.02). Dependent, impulsive and affective BPD types were observed most frequently in our sample. Findings are discussed specific to demographic and clinical implications of BPD patients reporting concurrent suicidal behavior.
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Affiliation(s)
- Federico Rebok
- 3a Cátedra de Farmacología, Facultad de Medicina, Universidad de Buenos Aires, Paraguay 2155, piso 9, C1121ABG, Ciudad de Buenos Aires, Buenos Aires, Argentina,
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Winsper C, Tang NKY. Linkages between insomnia and suicidality: prospective associations, high-risk subgroups and possible psychological mechanisms. Int Rev Psychiatry 2014; 26:189-204. [PMID: 24892894 DOI: 10.3109/09540261.2014.881330] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Insomnia can be lethal, increasing the risk of suicide and accidental death by overdose. In this review we present a synthesis of the literature investigating the insomnia-suicide link and the psychological mechanisms underpinning the association. Specifically, we review the findings of prospective epidemiological studies demonstrating the insomnia-suicide link in adult and adolescent community populations. Robust associations between insomnia and suicide are observed in clinically depressed and anxious populations, and there are indications across a number of cross-sectional and longitudinal studies that these linkages are attributable to a disrupted sleep pattern, dysfunctional beliefs about sleep and nightmares, independent of depression and anxiety symptoms. Borderline personality disorder (BPD) and chronic pain (CP) are highlighted as high-risk subgroups given the elevated rates of insomnia and suicidality in both conditions. Aside from the influence of comorbid depression and anxiety symptoms, emerging evidence has identified impulsivity and emotional dysregulation as possible mechanisms driving the insomnia-suicide link in BPD, and catastrophizing and the sense of defeat/entrapment as potential cognitive pathways through which insomnia aggravates suicidality in CP. Screening for, and interventions that tackle, insomnia and these associated psychological mechanisms, offer a novel avenue for reducing suicidality across a range of clinical and non-clinical populations.
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Affiliation(s)
- Catherine Winsper
- Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick , Coventry , UK
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Høye A, Jacobsen BK, Hansen V. Sex differences in mortality of admitted patients with personality disorders in North Norway--a prospective register study. BMC Psychiatry 2013; 13:317. [PMID: 24279812 PMCID: PMC4222551 DOI: 10.1186/1471-244x-13-317] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 11/18/2013] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND It is well established that patients with serious mental disorders have higher mortality than the general population, yet there are few studies on mortality of both natural and unnatural causes in patients with personality disorders. The aim of this study was to investigate the mortality of in-patients with personality disorder diagnosis in a 27-year follow-up cohort in North Norway, with a special focus on gender differences. METHOD Based on a hospital case register covering 1980 to 2006, 284 female and 289 male patients were included. The cohort was linked to the Norwegian Cause of Death Registry for information concerning mortality. The mortality rates were adjusted for age by applying a Poisson regression model. The relative mortality in men compared to women was tested with Cox regression with attained age as the time variable. The number of deaths to be expected among the patients if the mortality rates of the general population in Norway had prevailed was estimated and excess mortality, expressed by the standardized mortality ratio (SMR), calculated. RESULTS When compared to the mortality in the general population, men and women with personality disorder diagnoses had 4.3 (95% CI: 3.2-5.9) and 2.9 (95% CI: 1.9-4.5) times, respectively, increased total mortality. Patients with personality disorder diagnoses have particularly high mortality for unnatural deaths; 9.7 (95% confidence interval (CI): 6.3-15.1) times higher for men and 17.8 (95% CI: 10.1-30.3) for women, respectively, and even higher for suicides--15 (95% CI: 9-27) for men and 38 (95% CI: 20-70) for women. The mortality due to natural causes was not statistically significantly increased in women, whereas men had 2.8 (95% CI: 1.8-4.4) times higher mortality of natural deaths than the general population. CONCLUSION Compared to the general population, patients with a personality disorder have high mortality, particularly mortality from unnatural causes. The number of deaths caused by suicides is especially high for women. Men also have higher mortality of natural causes than the general population.
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Affiliation(s)
- Anne Høye
- Centre for Clinical Documentation and Evaluation (SKDE), University Hospital of North Norway (UNN), Mailbox 6, University Hospital of North Norway, 9037 Tromsø, Norway
| | - Bjarne K Jacobsen
- Department of Community Medicine, Faculty of Health Sciencies, University of Tromsø, 9037 Tromsø, Norway
| | - Vidje Hansen
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Tromsø and University Hospital of North Norway, 9037 Tromsø, Norway
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Hersh RG. Assessment and Treatment of Patients with Borderline Personality Disorder in the College and University Population. JOURNAL OF COLLEGE STUDENT PSYCHOTHERAPY 2013. [DOI: 10.1080/87568225.2013.824326] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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46
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Howe EG. Why Careproviders May Conclude that Treating a Patient Is Futile. THE JOURNAL OF CLINICAL ETHICS 2013. [DOI: 10.1086/jce201324201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Howe EG. A Different Approach to Patients and Loved Ones Who Request “Futile” Treatments. THE JOURNAL OF CLINICAL ETHICS 2012. [DOI: 10.1086/jce201223401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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