Long-term outcomes in borderline psychopathology: old assumptions, current findings, and new directions

Self-esteem instability and affective instability in everyday life after remission from borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is defined by a pervasive pattern of instability. According to prior findings and clinical theories, self-esteem instability and affective instability are key features of BPD. Previous e-diary studies showed that instability in self-esteem is heightened and that it is highly intertwined with affective instability in BPD in comparison to healthy controls (HC). The present study sought to extend these findings by adding symptomatologically remitted BPD patients (BPD-REM), i.e. former patients with BPD who met four or fewer BPD criteria within the past year, as a comparison group.

METHODS

To examine differences regarding self-esteem instability and affective instability, we used e-diaries for repeatedly collecting data on self-esteem, valence, and tense arousal 12 times a day for four consecutive days while participants underwent their daily life activities. Determining three different state-of-the-art instability indices and applying multilevel analyses, we compared 35 BPD-REM participants with previously reported 60 acute BPD patients (BPD-ACU) and 60 HC.

RESULTS

Our results revealed that self-esteem instability was significantly lower in the BPD-REM compared to the BPD-ACU group, irrespective of the instability index. In contrast, there were no significant differences regarding affective instability between the BPD-REM participants and those in the BPD-ACU group. The comparison between the BPD-REM with the HC indicated both a significantly higher instability in self-esteem as well as significantly heightened affective instability in the BPD-REM participants. Moreover, even though the associations were not significant, we found tentative support for the assumption that affective changes that are accompanied by changes in self-esteem are experienced as more burdensome and negatively impact the quality of life of remitted BPD participants.

CONCLUSIONS

This study builds on growing evidence for the importance of self-esteem instability in BPD. Whereas affective instability has been reported in various psychiatric disorders and might indeed constitute a transdiagnostic marker of affective dysregulation, our results indicate that self-esteem instability might be a specific symptom that construes the unique pathology in BPD.

Specific or transdiagnostic? The occurrence of emotions and their association with distress in the daily life of patients with borderline personality disorder compared to clinical and healthy controls

Borderline personality disorder (BPD) is characterized by more frequent and more intense negative emotions and less frequent positive emotions in daily life than healthy controls (HC) experience, but there is limited empirical evidence regarding whether this is a transdiagnostic or disorder-specific finding and which specific emotions are especially distressing in BPD. We assessed participants' current emotions and distress every 15 min over a 24-h period using e-diaries to investigate the frequency, intensity, and the associated distress of specific emotions. To test the disorder specificity, we used multilevel modeling to compare 43 female patients with BPD, 28 patients with posttraumatic stress disorder (PTSD), 20 patients with bulimia nervosa (BN), and 28 HC. Patients with BPD exhibited anger more frequently than any of the clinical or healthy control groups, demonstrating specificity. The quality of anger accounted for additional distress beyond the pure emotional intensity. In patients with BPD, joy was associated with reduced distress, which was not the case in HC or PTSD. However, the majority of the comparisons (anxiety, sadness, shame, disgust, jealousy, guilt, interest) revealed transdiagnostic patterns. The distress-enhancing or distress-reducing effects of anger and joy might represent an important part of affective dysregulation in BPD.

[Descriptive examination of inpatient stays of patients with emotionally unstable personality disorder in Austria between 2001 and 2016 with special consideration of age, gender and length of stay]

BACKROUND

Emotionally unstable personality disorder (EUPD) has a high prevalence worldwide and especially in in-patient psychiatric settings, varying in age and gender. Due to the complex clinical picture, repeated admissions and high costs, health systems are facing great challenges.

METHODS

For the calculations Statistik Austria data of inpatient stays of patients with mental and behavioral disorders with special regard to EUPD as main discharge diagnosis in Austria in the period 2001-2016 were used. Included were patients with age over 14 years, admission to a psychiatric clinic in acute care and maximum length of stay of 365 days. Age, gender and length of stay were analyzed with SPSS®, evaluated in descriptive form and related to each other.

RESULTS

The prevalence of EUPD within all mental and behavioral disorders was 4.0%. Of all personality and behavioral disorders, as well as specific personality disorders, EUPD had the highest prevalence (65.3% and 79.3%). About four times more women (79.8%) than men (20.2%) received inpatient treatment. Most patients (23.1%) were admitted at the age of 20-24 years. From 40 years of age the number of admissions clearly decreased. The largest percentage of men was found to be in the age group over 45 years (27.0%) and 183-365 inpatient days (27.0%), those of women aged 15-19 (83.4%) and 0 and 14-182 inpatient days (81.4% each). The average length of stay was 13 days for women and 12 days for men. 11.3% of patients left the clinic on the day of admission, 61.2% were treated for 1-13 days, 27.2% for 14-182 days, and 0.2% for 183-365 days.

Affective instability across the lifespan in borderline personality disorder - a cross-sectional e-diary study

OBJECTIVE

Longitudinal and cross-sectional studies suggest that affective instability is inversely related to greater age in borderline personality disorder (BPD). However, existing studies relied on retrospective self-reports of perceived instability. We examined affective instability in everyday life in patients with BPD and healthy controls (HCs) by age in a cross-sectional e-diary study.

METHODS

Two hundred and sixty female participants between 14 and 53 years of age (130 patients with BPD and 130 HCs) carried an e-diary over 4 days. The e-diaries emitted a prompting signal in approximately hourly intervals asking participants to rate their current affective state, that is valence (ranging from pleasant to unpleasant) and tense arousal (ranging from calm/relaxed to restless/under tension).

RESULTS

Multilevel analyses revealed a significant interaction of age and group predicting affective instability (valence: F_(1,255.6)  = 7.59; P < 0.01; tense arousal: F_(1,252)  = 6.08; P < 0.01), suggesting that affective instability significantly declines with greater age in patients with BPD. Controlling for the number of comorbid disorders and BPD severity did not change the results, illustrating an inverse relationship between age and affective instability in BPD (significant interaction of age*group for valence: F_(1,238.7)  = 5.74; P < 0.02 and tense arousal: F_(1,235.2)  = 5.28; P < 0.02).

CONCLUSION

Affective instability during daily life declines with greater age in BPD. This decline is irrespective of comorbidity and BPD severity.

Long-Term Course of Borderline Personality Disorder: A Prospective 10-Year Follow-Up Study

The aim of this prospective study was to expand previously reported evidence on the 10-year clinical and functional course of borderline personality disorder (BPD) in a Spanish sample. Participants diagnosed with BPD were assessed at baseline and at 10-year follow-up to evaluate BPD symptomatology and other relevant clinical measures, suicidal behavior, dimensional personality traits, Axis I and II comorbidity, use of mental health resources, and psychosocial functioning. At the 10-year follow up, significant improvements were observed on BPD domains, suicidal behavior, and other clinical measures. Neuroticism, impulsiveness, and aggression-hostility features trended toward normalization, whereas activity and sociability were impaired over time. Comorbidity with Axis I and personality disorders remained high. Social functioning and occupational functioning were largely unchanged. These findings confirm the tendency toward a symptomatic remission of BPD over the long term with regard to symptom criteria and characteristic dimensional traits. However, psychosocial functioning remains impaired.

Analyzing subcomponents of affective dysregulation in borderline personality disorder in comparison to other clinical groups using multiple e-diary datasets

BACKGROUND

Affective dysregulation is widely regarded as being the core problem in patients with borderline personality disorder (BPD). Moreover, BPD is the disorder mainly associated with affective dysregulation. However, the empirical confirmation of the specificity of affective dysregulation for BPD is still pending. We used a validated approach from basic affective science that allows for simultaneously analyzing three interdependent components of affective dysregulation that are disturbed in patients with BPD: homebase, variability, and attractor strength (return to baseline).

METHODS

We applied two types of multilevel models on two e-diary datasets to investigate group differences regarding three subcomponents between BPD patients (n = 43; n = 51) and patients with posttraumatic stress disorder (PTSD; n = 28) and those with bulimia nervosa (BN; n = 20) as clinical control groups in dataset 1, and patients with panic disorder (PD; n = 26) and those with major depression (MD; n = 25) as clinical control groups in dataset 2. In addition, healthy controls (n = 28; n = 40) were included in the analyses. In both studies, e-diaries were used to repeatedly collect data about affective experiences during participants' daily lives. In study 1 a high-frequency sampling strategy with assessments in 15 min-intervals over 24 h was applied, whereas the assessments occurred every waking hour over 48 h in study 2. The local ethics committees approved both studies, and all participants provided written informed consent.

RESULTS

In contradiction to our hypotheses, BPD patients did not consistently show altered affective dysregulation compared to the clinical patient groups. The only differences in affective dynamics in BPD patients emerged with regard to one of three subcomponents, affective homebase. However, these results were not even consistent. Conversely, comparing the patients to healthy controls revealed a pattern of more negative affective homebases, higher levels of affective variability, and (partially) reduced returns to baseline in the patient groups.

CONCLUSIONS

Our results indicate that affective dysregulation constitutes a transdiagnostic mechanism that manifests in similar ways in several different mental disorders. We point out promising prospects that might help to elucidate the common and distinctive mechanisms that underlie several different disorders and that should be addressed in future studies.

Distinguishing borderline personality disorder from adult attention deficit/hyperactivity disorder: a clinical and dimensional perspective

Adult attention deficit hyperactivity disorder (ADHD) is frequently associated with borderline personality disorder (BPD). As both disorders share some core clinical features they are sometimes difficult to distinguish from one another. The present work aimed to investigate differences in the expression of impulsivity, anger and aggression, quality of life as well as the number and severity of the comorbidities between ADHD, BPD, comorbid BPD-ADHD and control subjects. ADHD and BPD-ADHD patients showed a higher level of impulsivity than BPD and control subjects. BPD-ADHD patients had higher levels of substance abuse/dependence and higher levels of aggression than the other groups. Comorbid BPD-ADHD patients showed high levels of impulsivity and aggression, a characteristic that should draw the attention of clinicians on the necessity of providing an accurate diagnosis. The question also arises as to whether they represent a distinct clinical subgroup with specific clinical characteristics, outcomes and vulnerability factors.

Psychiatric assessment of mood instability: qualitative study of patient experience

BACKGROUND

Mood instability is a common reason for psychiatric referral. Very little is known about how patients with unstable mood experience assessment and diagnosis.

AIMS

To investigate the experiences of assessment and diagnosis among patients with mood instability and to suggest improvements to this process.

METHOD

Qualitative study, gathering data through individual interviews with 28 people experiencing mood instability and receiving a psychiatric assessment in secondary care.

RESULTS

Participants described the importance of receiving an explanation for their symptoms; the value of a good interpersonal relationship with their clinician(s); being listened to and acknowledged; and being involved in and informed about clinical decisions. These needs were not, however, consistently met. Receiving a psychiatric diagnosis, including a diagnosis of bipolar disorder or borderline personality disorder, evoked both positive and negative responses among participants, relating to stigma, personal understanding and responsibility, prognosis and treatment.

CONCLUSIONS

Patients with mood instability seek explanation for their symptoms and difficulties, empathetic care and consistent support as much as cure. Clinicians may incorrectly assume what patients' attitudes towards diagnosis are, a mismatch which may hamper the development of a strong therapeutic relationship. Clear, patient-centred communication, which acknowledges the patient's experience, may result in greater patient engagement and satisfaction.

The course of personality pathology

PURPOSE OF REVIEW

Durability has traditionally been considered to be a defining feature of personality disorders, but recent studies have challenged this notion. We review the most recent findings on the stability and course of personality pathology.

RECENT FINDINGS

Personality disorders seem to remit more often and faster than previously thought, and their relapse rate is low. However, the recent optimism regarding these disorders is mitigated by the existence of highly heterogeneous trajectories among patients and traits, the identification of certain methodological shortcomings, and the maintenance of psychosocial impairment long after symptomatic relief. The causes of personality improvement are largely unknown, but involve intermingled genetic and environmental effects.

SUMMARY

Recent follow-up studies of patients with personality pathology are changing orthodox conceptions of their inevitably negative prognosis. The current taxonomies must be reviewed and future research should be integrated with adjacent fields. Treatments need to target the enduring real-life hardships of these patients, apart from their acute symptoms.

Sex differences in mortality of admitted patients with personality disorders in North Norway--a prospective register study

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.