Pharmacotherapy for borderline personality disorder--current evidence and recent trends

Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies

Borderline personality disorder (BPD) was introduced in the DSM-III in 1980. From the DSM-III to the DSM-5, no major changes have occurred in its defining criteria. The disorder is characterized by instability of self-image, interpersonal relationships and affects. Further symptoms include impulsivity, intense anger, feelings of emptiness, strong abandonment fears, suicidal or self-mutilation behavior, and transient stress-related paranoid ideation or severe dissociative symptoms. There is evidence that BPD can be reliably diagnosed and differentiated from other mental disorders by semi-structured interviews. The disorder is associated with considerable functional impairment, intensive treatment utilization, and high societal costs. The risk of self-mutilation and suicide is high. In the general adult population, the lifetime prevalence of BPD has been reported to be from 0.7 to 2.7%, while its prevalence is about 12% in outpatient and 22% in inpatient psychiatric services. BPD is significantly associated with other mental disorders, including depressive disorders, substance use disorders, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, bipolar disorder, bulimia nervosa, and other personality disorders. There is convincing evidence to suggest that the interaction between genetic factors and adverse childhood experiences plays a central role in the etiology of BPD. In spite of considerable research, the neurobiological underpinnings of the disorder remain to be clarified. Psychotherapy is the treatment of choice for BPD. Various approaches have been empirically supported in randomized controlled trials, including dialectical behavior therapy, mentalization-based therapy, transference-focused therapy, and schema therapy. No approach has proved to be superior to others. Compared to treatment as usual, psychotherapy has proved to be more efficacious, with effect sizes between 0.50 and 0.65 with regard to core BPD symptom severity. However, almost half of the patients do not respond sufficiently to psychotherapy, and further research in this area is warranted. It is not clear whether some patients may benefit more from one psychotherapeutic approach than from others. No evidence is available consistently showing that any psychoactive medication is efficacious for the core features of BPD. For discrete and severe comorbid anxiety or depressive symptoms or psychotic-like features, pharmacotherapy may be useful. Early diagnosis and treatment of BPD can reduce individual suffering and societal costs. However, more high-quality studies are required, in both adolescents and adults. This review provides a comprehensive update of the BPD diagnosis and clinical characterization, risk factors, neurobiology, cognition, and management. It also discusses the current controversies concerning the disorder, and highlights the areas in which further research is needed.

Rethinking Clozapine: Lights and Shadows of a Revolutionary Drug

The current literature globally highlights the efficacy of Clozapine in several psychiatric disorders all over the world, with an FDA indication for reducing the risk of repeated suicidal behavior in patients with schizophrenia or schizoaffective disorder. A growing field of research is also stressing a possible broader beneficial effect of Clozapine in promoting neuroprotection and neurotrophism. However, this drug is linked to several life-threatening side effects, such as agranulocytosis, myocarditis and seizures, that limit its use in daily clinical practice. For this work, a search was performed on PubMed using the terms "Clozapine indications", "Clozapine adverse effects", "Clozapine regenerative effects", and "Clozapine neuroplasticity" with the aim of reviewing the scientific literature on Clozapine's treatment indications, adverse effects and potential regenerative role. The results confirmed the efficacy of clozapine in clinical practice, although limited by its adverse effects. It appears crucial to raise awareness among clinicians about the potential benefits of using Clozapine, as well educating medical personnel about its risks and the early identification of possible adverse effects and their management.

Three-level containment model of hospitalized adolescents with borderline pathology: a holistic therapeutic perspective

Borderline personality disorders account for 50% of adolescent hospitalization cases in psychiatry. The severity and psychopathological complexity of these symptoms indicate the need for inclusive models of understanding. Adopting a holistic approach allows for the consideration of not only the patient's environment, but also their position within that environment and their life history. In this article, a model based on the concept of therapeutic containment at three levels is presented. Global containment refers to the mindset and organization of the institution that provides care, which is itself a part of society at a specific time. Local containment focuses on understanding and therapeutic interventions within the immediate social environment of the individual. Lastly, individual containment encompasses the development of independent processes during the course of care. These three levels are integrated in the hospital treatment of borderline personality disorders, forming a trans-theoretical approach.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

The Role of Cognitive Deficits in Borderline Personality Disorder with Early Traumas: A Mediation Analysis

(1) Background: although studies of cognitive functions are still limited in borderline personality disorder (BPD), the initial evidence suggested that BPD patients have deficits of executive functions and social cognition. In addition, patients who report physical and psychic traumatic experiences in childhood and adolescence show considerable neurocognitive impairment and severe BPD symptoms. The present study has a twofold aim: (1) to evaluate the differences in neurocognitive performances between BPD patients and healthy controls and (2) to verify in the BPD patients group whether neurocognitive deficits have the role of mediating the effect of early traumas on BPD psychopathology. (2) Methods: 69 subjects were enrolled: 38 outpatients with a diagnosis of BPD (DSM-5) and 31 healthy controls. BPD patients were tested with the Borderline Personality Disorder Severity Index (BPDSI), and the Childhood Trauma Questionnaire-Short Form (CTQ-SF). All subjects were evaluated with the Iowa Gambling task (IGT), the Berg card sorting test (BCST), the Tower of London task (ToL), and the Reading-the-mind-in-the-eyes-test (RMET). Statistical analysis was performed with the analysis of variance to compare the cognitive performances between BPD patients and controls. A mediation analysis was conducted with the Sobel Test in the BPD patients group. The significance level was p ≤ 0.05. (3) Results: significant differences between the two groups were found for several parameters of all the cognitive tests examined: BCST, IGT, ToL, and RMET. Mediation analysis with the Sobel test demonstrated that the percentage of correct answers in the BCST (BCSTc) and the RMET score significantly mediated the relation between the CTQ total score and BPDSI total score. (4) Conclusions: BPD patients showed an impairment of the following executive functions: set shifting, decision making, planning and problem solving, and social cognition abilities, in comparison with controls. Our results suggested that the effect of early trauma on BPD psychopathology was mediated by a deficit in two cognitive domains: cognitive flexibility and social cognition.

Pharmacological interventions for people with borderline personality disorder

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.

Demystifying borderline personality disorder in primary care

Borderline personality disorder (BPD) is a common mental health diagnosis observed in the primary care population and is associated with a variety of psychological and physical symptoms. BPD is a challenging disorder to recognize due to the limitations of accurate diagnosis and identification in primary care settings. It is also difficult to treat due to its complexity (e.g., interpersonal difficulties and patterns of unsafe behaviors, perceived stigma) and healthcare professionals often feel overwhelmed when treating this population. The aim of this article is to describe the impact of BPD in primary care, review current state of knowledge, and provide practical, evidence-based treatment approaches for these patients within this setting. Due to the lack of evidence-based pharmacological treatments, emphasis is placed on describing the framework for treatment, identifying psychotherapeutic opportunities, and managing responses to difficult clinical scenarios. Furthermore, we discuss BPD treatment as it relates to populations of special interest, including individuals facing societal discrimination and adolescents. Through this review, we aim to highlight gaps in current knowledge around managing BPD in primary care and provide direction for future study.

Association between quetiapine use and self-harm outcomes among people with recorded personality disorder in UK primary care: A self-controlled case series analysis

BACKGROUND

Quetiapine is frequently prescribed to people with personality disorder diagnoses, but this is not supported by evidence or treatment guidelines.

AIMS

To examine associations between periods of quetiapine prescribing and self-harm events in people with personality disorder.

METHOD

Self-controlled case series using linked primary care and hospital records covering the period 2007-2017. We calculated incidence rates and incidence rate ratios (IRRs) for self-harm events during periods when people were prescribed (exposed to) quetiapine, as well as periods when they were unexposed or pre-exposed to quetiapine.

RESULTS

We analysed data from 1,082 individuals with established personality disorder diagnoses, all of whom had at least one period of quetiapine prescribing and at least one self-harm episode. Their baseline rate of self-harm (greater than 12 months before quetiapine treatment) was 0.52 episodes per year. Self-harm rates were elevated compared to the baseline rate in the month after quetiapine treatment was commenced (IRR 1.85; 95% confidence interval (CI) 1.46-2.34) and remained raised throughout the year after quetiapine treatment was started. However, self-harm rates were highest in the month prior to quetiapine initiation (IRR 3.59; 95% CI 2.83-4.55) and were elevated from 4 months before quetiapine initiation, compared to baseline.

CONCLUSION

Self-harm rates were elevated throughout the first year of quetiapine prescribing, compared to the baseline rate. However, rates of self-harm reduced in the month after patients commenced quetiapine, compared to the month before quetiapine was initiated. Self-harm rates gradually dropped over a year of quetiapine treatment. Quetiapine may acutely reduce self-harm. Longer-term use and any potential benefits need to be balanced with the risk of adverse events.

Efficacy of Noninvasive Brain Stimulation on Borderline Personality Disorder Core Symptoms: A Systematic Review

Although psychotherapy is the first-line treatment of borderline personality disorder (BPD), psychopharmacological agents have not been approved yet. Modulating brain functions with noninvasive brain stimulation (NIBS) interventions, such as repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), may have a role in the treatment of BPD. In light of the limited knowledge available and the emerging interest in the possible role of NIBS as a therapeutic tool, the authors' main aim is to systematically review the literature on the effect of both rTMS and tDCS on BPD symptoms, specifically affective dysregulation, impulsive-behavioral dyscontrol, and cognitive-perceptual difficulties. The review process was conducted in accordance with PRISMA guidelines. The research methods were registered on PROSPERO (id code CRD42020209491). Eleven studies were included in the review. Despite the limited number of studies retrieved, preliminary data showed an improvement in all domains. Further studies are needed to understand potential long-term advantages of NIBS.

Key stakeholders’ experiences and expectations of the care system for individuals affected by borderline personality disorder: An interpretative phenomenological analysis towards co-production of care

Background

The diagnosis of borderline personality disorder (BPD) consists of extreme emotional dysregulation and long-term disability when left untreated. It is associated with ineffective use of health care systems and mismanaged care in emergency departments, which can result in a revolving door phenomenon of urgent system usage, poor treatment outcomes, or patients falling out of care entirely–all of which primarily affect patients with BPD as well as their caregivers and clinicians. This crisis must be addressed with a comprehensive understanding of key stakeholder perspectives on the challenges of the system and potential solutions.

Objective

This study explored the perspectives of three key stakeholder groups (i.e., patients, clinicians, and caregivers) in relation to their experiences with and future expectations of the care system for those affected by BPD.

Methods

Four patients with BPD, three generalist clinicians with experience treating BPD, and three caregivers of individuals with BPD participated in individual semi-structured interviews. Participants were asked about their experiences with the current healthcare system and their suggestions for improvement. Responses were analyzed using interpretative phenomenological analysis.

Findings

In-depth analysis of the qualitative data revealed twelve shared themes and three themes that were unique to each key stakeholder group. These themes are discussed and used to inform recommendations for promising practices, policies, and training in this area.

Conclusion

Findings support the importance of a comprehensive mental health system approach for improving the accessibility, effectiveness, and acceptability of the management and treatment of BPD.

The efficacy of psychotherapies and pharmacotherapies for mental disorders in adults: an umbrella review and meta-analytic evaluation of recent meta-analyses

Mental disorders represent a worldwide public health concern. Psychotherapies and pharmacotherapies are recommended as first line treatments. However, evidence has emerged that their efficacy may be overestimated, due to a variety of shortcomings in clinical trials (e.g., publication bias, weak control conditions such as waiting list). We performed an umbrella review of recent meta-analyses of randomized controlled trials (RCTs) of psychotherapies and pharmacotherapies for the main mental disorders in adults. We selected meta-analyses that formally assessed risk of bias or quality of studies, excluded weak comparators, and used effect sizes for target symptoms as primary outcome. We searched PubMed and PsycINFO and individual records of the Cochrane Library for meta-analyses published between January 2014 and March 2021 comparing psychotherapies or pharmacotherapies with placebo or treatment-as-usual (TAU), or psychotherapies vs. pharmacotherapies head-to-head, or the combination of psychotherapy with pharmacotherapy to either monotherapy. One hundred and two meta-analyses, encompassing 3,782 RCTs and 650,514 patients, were included, covering depressive disorders, anxiety disorders, post-traumatic stress disorder, obsessive-compulsive disorder, somatoform disorders, eating disorders, attention-deficit/hyperactivity disorder, substance use disorders, insomnia, schizophrenia spectrum disorders, and bipolar disorder. Across disorders and treatments, the majority of effect sizes for target symptoms were small. A random effect meta-analytic evaluation of the effect sizes reported by the largest meta-analyses per disorder yielded a standardized mean difference (SMD) of 0.34 (95% CI: 0.26-0.42) for psychotherapies and 0.36 (95% CI: 0.32-0.41) for pharmacotherapies compared with placebo or TAU. The SMD for head-to-head comparisons of psychotherapies vs. pharmacotherapies was 0.11 (95% CI: -0.05 to 0.26). The SMD for the combined treatment compared with either monotherapy was 0.31 (95% CI: 0.19-0.44). Risk of bias was often high. After more than half a century of research, thousands of RCTs and millions of invested funds, the effect sizes of psychotherapies and pharmacotherapies for mental disorders are limited, suggesting a ceiling effect for treatment research as presently conducted. A paradigm shift in research seems to be required to achieve further progress.

[Borderline Personality Disorder in the Somatic Hospital Setting]

Borderline Personality Disorder in the Somatic Hospital Setting Abstract. The Borderline Personality Disorder is a common mental illness characterized by emotional instability, interactional difficulties, an unstable sense of self and impulsive behaviour which is often self-destructive. Since these problems frequently occur in the doctor-patient relationship, patients might be regarded as "difficult" or even manipulative. This may lead to stigmatization and medical undertreatment when due to common mental and somatic comorbidities the condition requires thorough high-standard medical care. Whereas the core symptoms of BPD are well treatable by specific evidence-based psychotherapy, pharmacological interventions are less effective and should be restricted to crisis management. Through a better understanding of the disorder, proactive communication with all involved care providers and a collaborative doctor-patient relationship providing support and boundaries simultaneously the quality of medical care can be improved with long-lasting effects.

Efficacy of naltrexone in borderline personality disorder, a retrospective analysis in inpatients

OBJECTIVE

The endogenous opioid system is assumed to be involved in the pathophysiology of borderline personality disorder (BPD), and opioid antagonists may improve core features of BPD. The aim of this retrospective chart analysis was to evaluate the relative contribution of the opioid antagonist naltrexone and other psychotropic drugs in the improvement of overall symptomatology in BPD.

METHODS

One hundred sixty-one inpatients with BPD treated between January 2010 and October 2013 were classified as either treatment responders or non-responders. Treatment responders were defined as subjects with significant improvements in four or more symptoms from a defined symptom list. The relative contribution of all psychotropic drugs to improvement of BPD symptomatology was assessed by means of a stepwise logistic regression.

RESULTS

None of the drugs applied contributed significantly to improvement, with the exception of naltrexone (odds ratio [OR] 43.2, p ≤ 0.0001). Patients treated with naltrexone (N = 55, 34%) recovered significantly more often. Higher doses of naltrexone were more effective (OR 791.8, p ≤ 0.0001) than lower doses (OR 26.6, p ≤ 0.0001); however, even low-dose treatment was better than any other pharmacological treatment.

CONCLUSIONS

Naltrexone was associated with improvement in BPD in a dose-dependent manner. The present study provides additional evidence that dysregulation of the endogenous opioid system is implicated in the pathophysiology of BPD symptoms.

Borderline personality disorder

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

Differences in antipsychotic treatment between depressive patients with and without a suicide attempt

BACKGROUND

Depressed suicide attempters are, according to some earlier studies, treated more often with antipsychotics than depressive non-suicide attempters. Cluster B personality disorders, especially borderline personality disorder, are associated with a high suicide risk, and antipsychotics are commonly used for the reduction of symptoms. However, no previous study has taken comorbid personality disorders into account when assessing the use of antipsychotics in patients with unipolar depression. Therefore, the aim of this study was to investigate the clinical selection of pharmacotherapy in unipolar depression with and without a previous suicide attempt, taking into account potential confounders such as cluster B personality disorders.

METHODS

The study sample consisted of 247 patients with unipolar depression. The study was approved by the Regional Ethical Review Board in Lund, Sweden. Study participants were recruited from 4 different secondary psychiatric care clinics in Sweden and were diagnosed according to the DSM-IV-TR with the MINI and SCID II. Previous and ongoing psychiatric treatments were investigated in detail and medical records were assessed.

RESULTS

Thirty percent of the patients had made previous suicide attempts. Depressed suicide attempters underwent both lifetime treatment with antipsychotics and an ongoing antipsychotic treatment significantly more often than non-attempters. Significances remained after a regression analysis, adjusting for cluster B personality disorders, symptom severity, age at the onset of depression, and lifetime psychotic symptoms.

CONCLUSIONS

This is the first study to consider the effect of comorbidity with cluster B personality disorders when comparing treatment of depressive suicide and non-suicide attempters. Our findings suggest that suicide attempters are more frequently treated with antipsychotics compared to non-suicide attempters, regardless of cluster B personality disorder comorbidity. These findings are important for clinicians to consider and would also be relevant to future studies evaluating reduction of suicide risk with antipsychotics in patients with psychiatric comorbidity and a history of attempted suicide.

Mental Health in Childhood and Adolescence: The Role of Polyunsaturated Fatty Acids

There is increasing awareness of the importance of polyunsaturated fatty acids (PUFAs) for optimal brain development and function. In recent decades, researchers have confirmed the central role of PUFAs in a variety of patho-physiological processes. These agents modulate the mechanisms of brain cell signalling including the dopaminergic and serotonergic pathways. Therefore, nutritional insufficiencies of PUFAs may have adverse effects on brain development and developmental outcomes. The role of n-3 PUFAs has been studied in several psychiatric disorders in adulthood: schizophrenia, major depression, bipolar disorder, anxiety disorders, obsessive-compulsive disorder, post-traumatic stress disorder, attention deficit hyperactivity disorder (ADHD), autism spectrum disorders, eating disorders, substance use disorder, and borderline personality disorder. In contrast to the great number of studies conducted in adults, there are only limited data on the effects of n-3 PUFA supplementation in children and adolescents who suffer from mental disorders or show a high risk of developing psychiatric disorders. The aim of this review is to provide a complete and updated account of the available evidence of the impact of polyunsaturated fatty acids on developmental psychopathology in children and adolescents and the effect of fatty acid supplementation during developmental milestones, particularly in high-risk populations of children with minimal but detectable signs or symptoms of mental disorders.

Body connection mediates the relationship between traumatic childhood experiences and impaired emotion regulation in borderline personality disorder

BACKGROUND

Previous studies revealed an association between traumatic childhood experiences and emotional dysregulation in patients with borderline personality disorder (BPD). However, possible mediating pathways are still not fully understood. The aim of the present study was to investigate the potential mediating role of body connection, describing the awareness of the relationship of bodily and mental states, for the association between a history of traumatic childhood experiences and BPD core symptomatology.

METHODS

One-hundred-twelve adult female individuals with BPD and 96 healthy female controls (HC) were included. Impaired emotion regulation, traumatic childhood experiences, and BPD symptomatology were assessed with self-report questionnaires. The Scale of Body Connection was used to assess two dimensions of body connection, that is body awareness, describing attendance to bodily information in daily life and noticing bodily responses to emotions and/or environment and body dissociation, describing a sense of separation from one's own body, due to avoidance or emotional disconnection. Mann-Whitney U tests were employed to test for group differences (BPD vs. HC) on the two SBC subscales and associations with clinical symptoms were analyzed with Spearman correlations. We performed mediation analyses in the BPD group to test the assumption that body connection could act as a mediator between a history of traumatic childhood experiences and emotion dysregulation.

RESULTS

Individuals with BPD reported significantly lower levels of body awareness and significantly higher levels of body dissociation compared to HC. Body dissociation, traumatic childhood experiences, and emotion dysregulation were significantly positively associated. Further analyses revealed that body dissociation, but not body awareness, significantly and fully mediated the positive relationship between traumatic childhood experiences and impaired emotion regulation in the BPD sample. This mediation survived when trait dissociation, i.e., general dissociative experiences not necessarily related to the body, was statistically controlled for.

CONCLUSION

Certain dimensions of body connection seem to be disturbed in BPD patients, with body dissociation being an important feature linking a history of traumatic childhood experiences to current deficits in emotion regulation.

Optimizing treatment for comorbid borderline personality disorder and posttraumatic stress disorder: A systematic review of psychotherapeutic approaches and treatment efficacy

Comorbid borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) is a severe and complicated clinical presentation characterized by especially high rates of suicide, healthcare utilization, and psychosocial impairment. Although guidelines exist for treating each of these disorders alone, there remains limited guidance on the optimal treatment in cases where BPD and PTSD co-occur. Therefore, this systematic review synthesizes the existing research on the treatment of BPD-PTSD with the aim of optimizing treatment for this population. First, the prevalence and clinical severity of comorbid BPD-PTSD is reviewed. Next, we describe the results of our systematic review, which identified 21 articles that examined treatment outcomes in the context of BPD-PTSD or subclinical BPD-PTSD. Based on our results, we describe existing psychotherapeutic approaches, including BPD-specific treatments, trauma-focused and non-trauma-focused treatments for PTSD, and stage-based treatments for BPD-PTSD. We also summarize BPD-PTSD treatment outcomes, including whether each disorder interferes with treatment and recovery of the other. Results related to treatment safety and concerns regarding conducting trauma-focused treatment for BPD-PTSD are addressed. We end by highlighting important gaps in the literature and provide recommendations for further research.

Comparing psychotropic medication prescribing in personality disorder between general mental health and psychological services: retrospective cohort study

BACKGROUND

Although no drugs are licensed for the treatment of personality disorder, pharmacological treatment in clinical practice remains common.

AIMS

This study aimed to estimate the prevalence of psychotropic drug use and associations with psychological service use among people with personality disorder.

METHOD

Using data from a large, anonymised mental healthcare database, we identified all adult patients with a diagnosis of personality disorder and ascertained psychotropic medication use between 1 August 2015 and 1 February 2016. Multivariable logistic regression models were constructed, adjusting for sociodemographic, clinical and service use factors, to examine the association between psychological services use and psychotropic medication prescribing.

RESULTS

Of 3366 identified patients, 2029 (60.3%) were prescribed some form of psychotropic medication. Patients using psychological services were significantly less likely to be prescribed psychotropic medication (adjusted odds ratio 0.48, 95% CI 0.39-0.59, P<0.001) such as antipsychotics, benzodiazepines and antidepressants. This effect was maintained following several sensitivity analyses. We found no difference in the risk for mood stabiliser (adjusted odds ratio 0.79, 95% CI 0.57-1.10, P = 0.169) and multi-class psychotropic use (adjusted odds ratio 0.80, 95% CI 0.60-1.07, P = 0.133) between patients who did and did not use psychological services.

CONCLUSIONS

Psychotropic medication prescribing is common in patients with personality disorder, but significantly less likely in those who have used psychological services. This does not appear to be explained by differences in demographic, clinical and service use characteristics. There is a need to develop clear prescribing guidelines and conduct research in clinical settings to examine medication effectiveness for this population.

Trauma and psychopathology associated with early onset BPD: an empirical contribution

Prodromal symptoms of borderline personality disorder (BPD) often arise in young age, especially in early adolescence. Several factors for early BPD onset have been identified to consent a precocious detection of high-risk population. The present study is aimed: (1) to identify what psychopathological, traumatic, and functional factors are significantly associated to early onset in a sample of BPD patients and (2) to evaluate what factors are associated to the time interval between symptoms onset and first psychiatric visit (Δ age). Participants were enrolled from BPD outpatients attending the Center for Personality Disorder of the University of Turin, Italy. Patients were tested with assessment instruments for specific BPD symptoms, exposure to traumatic experiences, global functioning, and perception of quality of life. All variables that were found significant at a bivariate analysis were included in two multiple regressions (stepwise backward), with the age of onset and the Δ age as dependent variables. Significance level was P ≤ 0.05. Seventy patients were included in the study (68 completers). Factors that were found related to age of onset were: CTQ-SF emotional abuse (P = 0.001); ACE-IQ bully victimization (P = 0.005), alcohol/drug abuser in the household (P = 0.001), and physical neglect (P = 0.006); BIS non-planning impulsivity (P = 0.005); and SOFAS score (P = 0.033). Factors that were found related to Δ age were: ACE-IQ total score (P = 0.001) and BIS total score (P = 0.001). Earlier onset of BPD is mainly associated to traumatic events, including abuse, neglect, dysfunction in household environment, and bullying. Earlier onset is also related to a worse social functioning. Among BPD symptoms only non-planning impulsivity was found associated to early onset. A higher number of traumatic events and worse impulsive dyscontrol induce a significant reduction of the time interval between onset and first psychiatric observation.

Borderline Personality Disorder: To diagnose or not to diagnose? That is the question

There is considerable controversy around psychiatric diagnosis generally and personality disorders specifically. Since its conception, borderline personality disorder has been controversial because of the stigma associated with the diagnosis and the therapeutic nihilism held by practitioners who encounter people with this high prevalence problem in acute settings. This paper reviews the history of the diagnosis of BPD and summarizes some of the controversy surrounding the categorical nature of diagnosis. Both the DSM 5 and ICD-11 will be discussed; however, for the purposes of this paper, the DSM 5 will take the primary focus due to greater cultural significance. Recent developments in the treatment of borderline personality disorder suggest that it is a highly treatable condition and that full clinical recovery is possible. This paper formulates an argument that despite problems with psychiatric diagnosis that are unlikely to be resolved soon, a diagnosis should be made with an accompanying formulation to enable people to receive timely and effective treatment to enable personal and clinical recovery.

Borderline personality disorder in Irish Travellers: a cross-sectional study of an ultra-high-risk group

BACKGROUND

Irish Travellers are a marginalised ethnic minority with poor health outcomes, especially in mental health: the suicide rate in this population is 6-7 times that in the general population. There is a paucity of research into associated clinical risk factors including self-harm and mental illnesses.

AIMS

To examine the prevalence and treatments of mental disorders among Travellers attending a community mental health team (CMHT) in Galway.

METHODS

This is a cross-sectional study of the CMHT database, and included all Travellers who were active cases on the study day were included in this study.

RESULTS

Travellers formed 12.4% (51 out of 410) of the active caseload of the mental health service. The mean age was 35.7 years (SD 13.1). The most common mental disorder was depressive disorder (16/51, 31.4%). Of 51 patients, 25.5% (13/51) were diagnosed with BPD: 7 had other comorbid mental disorders. Patients diagnosed with BPD are significantly more likely to be prescribed psychopharmacotherapy (t = 2.834, p = 0.007). A diagnosis of BPD was significantly associated with history of self-harm after controlling for age and gender (OR 2.3, p = 0.005).

CONCLUSION

This study shows that there is a significant overrepresentation of Travellers in mental health services, suggesting significant need for accessible and acceptable interventions. Those with a BPD diagnosis have a significantly higher risk of self-harm, representing an ultra-high-risk population. These findings can be used to plan future service development projects to better meet the needs of this population: they may require specially adapted version of the mentalisation-based treatment programme.

Pharmacotherapy for Borderline Personality Disorder: an Update of Published, Unpublished and Ongoing Studies

PURPOSE OF THE REVIEW

We aim to identify the most recent evidence of randomised controlled trials evaluating continued drug treatments in people with a diagnosis of BPD, review the most recent findings, highlight trends in terms of currently ongoing studies and comment on the overall body of evidence.

RECENT FINDINGS

We identified seven new RCTs, plus newly available data for an older RCT. Only three of these RCTs have been published in full text, while we found study data posted at trial registry platforms for the others. The new findings do not support fluoxetine as a treatment option for suicide and self-harm prevention. A large effectiveness study did not detect beneficial effects of lamotrigine in routine care. The prevalent use of medications in BPD is still not reflected or supported by the current evidence. More research is needed regarding the most commonly used substances and substance classes, i.e. SSRIs, and quetiapine, but also with respect to people presenting with distinct comorbid conditions.

Collaborative Deprescribing in Borderline Personality Disorder: A Narrative Review

After participating in this activity, learners should be better able to:• Assess medication management in patients with borderline personality disorder (BPD)• Evaluate the role of deprescribing as an active intervention in patients with BPD treated with polypharmacy ABSTRACT: Psychopharmacology in borderline personality disorder (BPD) is complicated by comorbid disorders, substance use, sensitivity to side effects, risk of self-harm through medication misuse, and intense but transient symptoms. Patients' relationships with medications may range from tenuous to highly enmeshed, and may profoundly influence the response to treatment. For these reasons, awareness of current evidence and flexible approaches are particularly relevant to prescribing in BPD. In this narrative review, we illustrate the current status of medication management in BPD by focusing on polypharmacy. We use a single vignette to explore the limitations of prescribing multiple medications and the factors contributing to polypharmacy. With the same vignette, and using the framework of deprescribing, we describe how medication regimens can be reduced to a necessary minimum. Deprescribing, originally developed in geriatric medicine, is an active intervention that involves a risk-benefit analysis for each medication, keeping in mind the patient's medical and psychiatric status and his or her preferences and values. Deprescribing lends itself well to use in psychiatry and especially in BPD because of its emphasis on the patient's preferences and on repeated conversations to revisit and update decisions. In addition to elaborating on the deprescribing framework, we provide recommendations for conducting these critical discussions about medications in BPD, with particular attention to the patient's relationship to the medication. Finally, we summarize our recommendations and strategies for implementing flexible and responsive medication management for patients with BPD. We suggest areas of future research, including testing the efficacy of targeted intermittent medication treatments.

Dissociation proneness and pain hyposensitivity in current and remitted borderline personality disorder

BACKGROUND

Stress-related dissociation has been shown to negatively co-vary with pain perception in current borderline personality disorder (cBPD). While remission of the disorder (rBPD) is associated with normalized pain perception, it remains unclear whether dissociation proneness is still enhanced in this group and how this feature interacts with pain sensitivity.

METHODS

Twenty-five cBPD patients, 20 rBPD patients and 24 healthy controls (HC) participated in an experiment using the script-driven imagery approach. We presented a personalized stressful and neutral narrative. After listening to the scripts, dissociation and heat pain thresholds (HPT) were assessed.

RESULTS

Compared to HC, cBPD patients showed enhanced dissociation and exhibited significantly enhanced HPT in the neutral condition, whereas rBPD participants were in between. After listening to the stress script, both clinical groups exhibited enhanced dissociation scores. Current BPD participants responded with significantly higher HPT, whereas rBPD only showed a trend in the same direction. However, both BPD groups showed significantly increased HPT compared to the HC in the stress condition, but did not differ from each other. Dissociation proneness correlated significantly positively with pain hyposensitivity only in cBPD.

CONCLUSION

Dissociation proneness is enhanced in both BPD groups. This feature is clearly positively related to pain hyposensitivity in cBPD, but not in rBPD. However, the data indicate that stress causes the pain perception in rBPD to drift away from that obtained in HC. These results highlight the volatile state of BPD remission and might have important implications for the care of BPD patients in the remitted stage.

SIGNIFICANCE

Both current (cBPD) and remitted borderline personality disorder (rBPD) patients show enhanced proneness to dissociation. This feature is significantly linked with pain hyposensitivity in cBPD in a paradigm that induces stress using a script-driven imagery approach, whereas this connection cannot be observed in rBPD. However, in the stress compared to the neutral condition, rBPD participants also show pain hyposensitivity compared to healthy controls. This study provides new insights into the pain processing mechanisms of BPD and its remission.

A pill for every ill?

Purpose

National guidelines in the UK for emotionally unstable personality disorder and antisocial personality disorder (PD) do not recommend treatment with medication, suggesting instead psychotherapy. There is little evidence that medication has benefit from the literature. Despite this, many patients with PDs are prescribed medications. This study aims to quantify medication prescriptions within the therapeutic community for those with PD and assess if treatment led to changes in prescription.

Design/methodology/approach

An audit tool was designed in Microsoft Excel; 30 most recent patients discharged from the authors’ service since November 2018 were identified. Their discharge summaries were scrutinised for changes in medication comparing the beginning of treatment to the end. These were then analysed in terms of changes in class of medication and dose as well as total number of medications prescribed.

Findings

In total, 31 patients’ notes were scrutinised. Then, 25 patients were prescribed psychiatric medication at the start of their treatment, 24 had medications changed falling to 17 at the end of treatment. Antidepressants were the most commonly prescribed medications. By class, antidepressant prescriptions fell by 35 per cent, antipsychotics by 43 per cent, anxiolytics by 40 per cent. The prescription of mood stabilisers and Z drugs remained the same.

Originality/value

The assessment of medication changes during psychotherapeutic treatment within a therapeutic community is unique in the literature. Understanding and hypothesising the dynamics involved within this process has also received little attention in research. This study highlights the potential from which further research into this neglected but pertinent area could be conducted.

Cortical haemodynamic response measured by functional near infrared spectroscopy during a verbal fluency task in patients with major depression and borderline personality disorder

BACKGROUND

Functional near infrared spectroscopy (fNIRS) provides a direct and quantitative assessment of cortical haemodynamic function during a cognitive task. This functional neuroimaging modality may be used to elucidate the pathophysiology of psychiatric disorders, and identify neurophysiological differences between co-occurring psychiatric disorders. However, fNIRS research on borderline personality disorder (BPD) has been limited. Hence, this study aimed to compare cerebral haemodynamic function in healthy controls (HC), patients with major depressive disorder (MDD) and patients with BPD.

METHODS

fNIRS signals during a verbal fluency task designed for clinical assessment was recorded for all participants. Demographics, clinical history and symptom severity were also noted.

FINDINGS

Compared to HCs (n = 31), both patient groups (MDD, n = 31; BPD, n = 31) displayed diminished haemodynamic response in the frontal, temporal and parietal cortices. Moreover, haemodynamic response in the right frontal cortex is markedly lower in patients with MDD compared to patients with BPD.

INTERPRETATION

Normal cortical function in patients with BPD is disrupted, but not as extensively as in patients with MDD. These results provide further neurophysiological evidence for the distinction of patients with MDD from patients with BPD.

Interpersonal Psychotherapy as a Single Treatment for Borderline Personality Disorder: A Pilot Randomized-Controlled Study

Recent guidelines share the recommendations that psychotherapy plays a central role in the treatment of borderline personality disorder (BPD). In recent years, interpersonal psychotherapy adapted for treating BPD (IPT-BPD) was added to specific psychotherapies and was tested in combination with pharmacotherapy. The present study is aimed to assess the efficacy of IPT-BPD revised (IPT-BPD-R) as single treatment in a sample of BPD patients. Results obtained in a group of patients receiving IPT-BPD-R were compared with those observed in a control group in waiting list plus clinical management (WL/CM). Forty-three BPD subjects were randomly allocated to one of the two arms. Patients were assessed at baseline and after 10 months with the following assessment instruments: Clinical Global Impression Scale, Severity item (CGI-S), Social Occupational Functioning Assessment Scale (SOFAS), Borderline Personality Disorder Severity Index (BPDSI), Barratt Impulsiveness Scale, version 11 (BIS-11), Modified Overt Aggression Scale (MOAS), and Self Harm Inventory (SHI). Statistical analysis was performed with one-way analysis of variance (ANOVA) or chi-square test to compare baseline characteristics of the two treatment groups. Comparison of score changes at the end of the trial between the two groups was calculated for each rating scale with the analysis of variance for repeated measures. Seven patients (16.3%) discontinued the treatment in the first month of the trial for non-adherence. We found a significant effect within subjects (trial duration) for all rating scales, except for the MOAS. A significant effect between subjects (treatment modality) was found for CGI-S; SOFAS; BIS-11 total score and subscale "non-planning impulsivity"; BPDSI total score and items "interpersonal relationships," "impulsivity," and "identity." So, results showed differences between groups in favor of psychotherapy in terms of reduction of severity of general psychopathology, improvement of social and occupational functioning, and decrease of global BPD symptoms and three specific domains. On the other hand, we did not find any differences between groups for self-harm behaviors and aggressive behaviors.

Pharmacotherapy of borderline personality disorder: what has changed over two decades? A retrospective evaluation of clinical practice

BACKGROUND

The purpose of this study was to assess the pharmacological treatment strategies of inpatients with borderline personality disorder between 2008 and 2012. Additionally, we compared pharmacotherapy during this period to a previous one (1996 to 2004).

METHODS

Charts of 87 patients with the main diagnosis of borderline personality disorder receiving inpatient treatment in the University Medical Center of Goettingen, Germany, between 2008 and 2012 were evaluated retrospectively. For each inpatient treatment, psychotropic drug therapy including admission and discharge medication was documented. We compared the prescription rates of the interval 2008-2012 with the interval 1996-2004.

RESULTS

94% of all inpatients of the interval 2008-2012 were treated with at least one psychotropic drug at time of discharge. All classes of psychotropic drugs were applied. We found high prescription rates of naltrexone (35.6%), quetiapine (19.5%), mirtazapine (18.4%), sertraline (12.6%), and escitalopram (11.5%). Compared to 1996-2004, rates of low-potency antipsychotics, tri-/tetracyclic antidepressants and mood stabilizers significantly decreased while usage of naltrexone significantly increased.

CONCLUSIONS

In inpatient settings, pharmacotherapy is still highly prevalent in the management of BPD. Prescription strategies changed between 1996 and 2012. Quetiapine was preferred, older antidepressants and low-potency antipsychotics were avoided. Opioid antagonists are increasingly used and should be considered for further investigation.

Aripiprazole compared with placebo for auditory verbal hallucinations in youth with borderline personality disorder: Protocol for the VERBATIM randomized controlled trial

AIM

Up to half of patients with borderline personality disorder report auditory verbal hallucinations that are phenomenologically indistinguishable from those in schizophrenia, occur early in the course of the disorder, and are enduring, distressing and disabling. In clinical practice, this symptom is widely assumed to be unresponsive to treatment with antipsychotic medication and early intervention is rarely offered. The Verbal Experiences Response in Borderline personality disorder to Aripiprazole TrIal Medication (VERBATIM) study aims to be the first controlled trial to investigate the effectiveness of conventional pharmacotherapy for this symptom in this patient group.

METHOD

VERBATIM is a 12-week, triple-blind, single-centre, parallel groups randomised controlled trial, with a 27-week follow-up period. Participants between the ages of 15 and 25 years receive either aripiprazole or placebo daily, commencing at 2 mg and increasing to 10 mg by day 15. Further dose escalations (up to 30 mg) may occur, as clinically indicated. This trial was prospectively registered with the Australian and New Zealand Clinical Trials Registry ACTRN12616001192471 on 30/08/2016.

RESULTS

The primary outcome is severity of auditory verbal hallucinations assessed using the Psychotic Symptom Rating Scale. Secondary outcomes include the severity of general psychopathology, borderline personality pathology, social and occupational functioning and change in brain resting state connectivity. The primary endpoint is week 12 and secondary endpoint is week 39.

CONCLUSION

The results will inform treatment decisions for individuals with borderline personality disorder who present with auditory verbal hallucinations.

Borderline Personality Disorder in Patients With Medical Illness: A Review of Assessment, Prevalence, and Treatment Options

OBJECTIVE

Borderline personality disorder (BPD) occurs in 0.7% to 3.5% of the general population. Patients with BPD experience excessive comorbidity of psychiatric and somatic diseases and are known to be high users of health care services. Because of a range of challenges related to adverse health behaviors and their interpersonal style, patients with BPD are often regarded as "difficult" to interact with and treat optimally.

METHODS

This narrative review focuses on epidemiological studies on BPD and its comorbidity with a specific focus on somatic illness. Empirically validated treatments are summarized, and implementation of specific treatment models is discussed.

RESULTS

The prevalence of BPD among psychiatric inpatients (9%-14%) and outpatients (12%-18%) is high; medical service use is very frequent, annual societal costs vary between &OV0556;11,000 and &OV0556;28,000. BPD is associated with cardiovascular diseases and stroke, metabolic disease including diabetes and obesity, gastrointestinal disease, arthritis and chronic pain, venereal diseases, and HIV infection as well as sleep disorders. Psychotherapy is the treatment of choice for BPD. Several manualized treatments for BPD have been empirically validated, including dialectical behavior therapy, transference-focused psychotherapy, mentalization-based therapy, and schema-focused therapy.

CONCLUSIONS

Health care could be substantially improved if all medical specialties would be familiar with BPD, its pathology, medical and psychiatric comorbidities, complications, and treatment. In mental health care, several empirically validated treatments that are applicable in a wide range of clinical settings are available.

[Borderline personality : Alterations to brain structure and function through psychotherapy]

BACKGROUND

There are now several scientifically evaluated psychotherapeutic methods for borderline personality disorder (BPD), all of which aim to improve the ability to regulate emotions. In recent years, there have been first studies on the neuronal correlates of the mechanisms of emotion regulation and of changes caused by psychotherapeutic interventions.

METHODS

This article reviews the data on functional and structural imaging studies that examine facets of disturbed emotion regulation before and after psychotherapy.

RESULTS

Although the overall database is still sparse, clinical improvement in psychotherapy appears to be associated with modulation of brain structure and function. Frontolimbic regulation circuits including the amygdala, insula, anterior cingulate cortex (ACC) and other prefrontal areas appear to be involved in these changes. An important finding is the reduction of initially increased amygdala activity after successful Dialectical Behavior Therapy (DBT).

CONCLUSION

The changes shown here most probably reflect an improvement in emotion regulation capacities in BPD and demonstrate the possibility of modulating disturbed emotion regulation processes. Since long-term follow-up data are still missing, the sustainability of the suggestive improvements still has to be proven in further studies.

Implicit and explicit self-concept of neuroticism in borderline personality disorder

PURPOSE

In the past, research on personality in borderline personality disorder (BPD) used primarily questionnaires suggesting heightened neuroticism in BPD. Self-report instruments inform about the conscious or explicit self-concept. BPD patients are known to show negative distortion with exaggeration of negative affect in the self-report. Neuroticism represents a risk factor for mental disorders. Indirect measures are available that tap into the implicit self-concept of neuroticism. The implicit self-concept refers to individual differences in associative representations of the self. The present study examined for the first time the implicit in addition to the explicit self-concept of neuroticism in BPD.

MATERIALS AND METHODS

Female BPD patients (N = 35) and healthy women (N = 39) completed an implicit association test and the NEO-FFI personality inventory.

RESULTS

BPD patients showed higher implicit and explicit neuroticism compared to controls. The group difference for explicit neuroticism was four times larger than that for implicit neuroticism. Presence of comorbid depressive disorder was positively correlated with implicit neuroticism. The IAT neuroticism showed excellent split-half reliability for BPD patients.

CONCLUSIONS

The present data suggest that BPD patients with comorbid clinical depression but not those without clinical depression differ from healthy individuals in their implicit self-concept of neuroticism. In the associative network, BPD patients with comorbid clinical depression exhibit stronger associations of the self with neuroticism-related characteristics, such as nervousness, fearfulness, and uncertainty than healthy individuals. Regardless of depression, BPD patients show increased explicit neuroticism. Our findings provide evidence that the IAT neuroticism can be applied reliably to BPD patients.

Moving Toward Connectedness - A Qualitative Study of Recovery Processes for People With Borderline Personality Disorder

Borderline personality disorder (BPD) is a mental health disorder estimated to affect 1–2% of the general population. As a group, people with BPD endure a high degree of suffering, often leading to suicide attempts, self-harm, and suicide. Comparatively few studies explore the first person perspective of the person suffering from any mental health disorder. This might be especially problematic for people diagnosed with BPD, as this particular diagnosis is followed by stigma potentially making help seeking harder and helping relationships more vulnerable. We interviewed 12 female participants recently diagnosed with BPD in-depth about their experiences with recovery and treatment, and used a stepwise reflective approach to rigorously analyze the data. Results show an overarching theme of working toward connectedness, with four constituent sub-themes. We discuss the findings with regard to empirical work, recovery and autonomy, and the risk of epistemic injustice that people with BPD risk facing.

Preliminary Evidence for the Cognitive Model of Auditory Verbal Hallucinations in Youth With Borderline Personality Disorder

Objectives: This is the first study to explore cognitive, emotional, and behavioral responses to voices in youth with borderline personality disorder (BPD) compared with those with schizophrenia spectrum disorder (SZ), and to examine if negative appraisals of voices predict depression and anxiety across the groups. Methods: The sample comprised 43 outpatients, aged 15-25 years, who reported auditory verbal hallucinations (AVH) and were diagnosed with either Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) BPD or SZ. Data were collected using the Psychotic Symptom Rating Scales, the revised Beliefs About Voices Questionnaire, the Voice Rank Scale, and the Depression Anxiety Stress Scale. Results: Youth with BPD did not differ from youth with SZ in beliefs about the benevolence or malevolence of voices. Youth with BPD appraised their voices as more omnipotent and of higher social rank in relation to themselves, compared with youth with SZ. In both diagnostic groups, beliefs about malevolence and omnipotence of voices were correlated with more resistance toward voices, and beliefs about benevolence with more engagement with voices. In addition, perceiving the voices as being of higher social rank than oneself and negative voice content were both independent predictors of depression, irrespective of diagnostic group. In contrast, negative appraisals of voices did not predict anxiety after adjusting for negative voice content. Conclusions: This study replicated the link between negative appraisals of voices and depression that has been found in adults with SZ in a mixed diagnostic youth sample. It, thus, provides preliminary evidence that the cognitive model of AVH can be applied to understanding and treating voices in youth with BPD.

Real-World Effectiveness of Clozapine for Borderline Personality Disorder: Results From a 2-Year Mirror-Image Study

While some second-generation antipsychotics have shown efficacy on patients with borderline personality disorder (BPD), limited data exist regarding the effect of clozapine. Thus, we aimed to investigate the effects of clozapine on naturalistic outcomes in BPD patients with a 2-year mirror-image model. Among 25,916 patients with BPD, 1,107 redeemed ≥ 1 clozapine prescription. Of these, 18,188 were "specific" BPD patients, and 102 redeemed ≥ 1 clozapine prescription. During a mean observation period of 598.51 days, in all BPD patients, clozapine was associated with a significant reduction in psychiatric admissions from 2.52 (95% CI [2.31, 2.78]) to 2.00 (95% CI [1.77, 2.23]) admissions (p < .001) and a significant reduction in psychiatric bed-days from 190.08 (95% CI [176.84, 203.33]) to 65.95 (95% CI [58.27, 73.66]) bed-days (p < .001). Similar findings were found for "specific" BPD patients. The number of patients with intentional self-harm or overdose decreased significantly from 189 to 114 individuals (p < .001) after clozapine initiation. Randomized trials evaluating the risk- benefit ratio of clozapine in patients with severe BPD are warranted.

Borderline personality disorder in adolescents: prevalence, diagnosis, and treatment strategies

Using the same Diagnostic and Statistical Manual of Mental Disorders, fifth version (DSM-V) criteria as in adults, borderline personality disorder (BPD) in adolescents is defined as a 1-year pattern of immature personality development with disturbances in at least five of the following domains: efforts to avoid abandonment, unstable interpersonal relationships, identity disturbance, impulsivity, suicidal and self-mutilating behaviors, affective instability, chronic feelings of emptiness, inappropriate intense anger, and stress-related paranoid ideation. BPD can be reliably diagnosed in adolescents as young as 11 years. The available epidemiological studies suggest that the prevalence of BPD in the general population of adolescents is around 3%. The clinical prevalence of BPD ranges from 11% in adolescents consulting at an outpatient clinic to 78% in suicidal adolescents attending an emergency department. The diagnostic procedure is based on a clinical assessment with respect to developmental milestones and the interpersonal context. The key diagnostic criterion is the 1-year duration of symptoms. Standardized, clinician-rated instruments are available for guiding this assessment (eg, the Diagnostic Interview for Borderlines-Revised and the Childhood Interview for DSM-IV-TR BPD). The assessment should include an evaluation of the suicidal risk. Differential diagnosis is a particular challenge, given the high frequency of mixed presentations and comorbidities. With respect to clinical and epidemiological studies, externalizing disorders in childhood constitute a risk factor for developing BPD in early adolescence, whereas adolescent depressive disorders are predictive of BPD in adulthood. The treatment of adolescents with BPD requires commitment from the parents, a cohesive medical team, and a coherent treatment schedule. With regard to evidence-based medicine, psychopharmacological treatment is not recommended and, if ultimately required, should be limited to second-generation antipsychotics. Supportive psychotherapy is the most commonly available first-line treatment. Randomized controlled trials have provided evidence in favor of the use of specific, manualized psychotherapies (dialectic-behavioral therapy, cognitive analytic therapy, and mentalization-based therapy).

The effectiveness of 6 versus 12-months of dialectical behaviour therapy for borderline personality disorder: the feasibility of a shorter treatment and evaluating responses (FASTER) trial protocol

BACKGROUND

Although Dialectical Behaviour Therapy (DBT) is an evidence-based psychosocial treatment for borderline personality disorder (BPD), the demand for it exceeds available resources. The commonly researched 12-month version of DBT is lengthy; this can pose a barrier to its adoption in many health care settings. Further, there are no data on the optimal length of psychotherapy for BPD. The aim of this study is to examine the clinical and cost-effectiveness of 6 versus 12 months of DBT for chronically suicidal individuals with BPD. A second aim of this study is to determine which patients are as likely to benefit from shorter treatment as from longer treatment.

METHODS/DESIGN

Powered for non-inferiority testing, this two-site single-blind trial involves the random assignment of 240 patients diagnosed with BPD to 6 or 12 months of standard DBT. The primary outcome is the frequency of suicidal or non-suicidal self-injurious episodes. Secondary outcomes include healthcare utilization, psychiatric and emotional symptoms, general and social functioning, and health status. Cost-effectiveness outcomes will include the cost of providing each treatment as well as health care and societal costs (e.g., missed work days and lost productivity). Assessments are scheduled at pretreatment and at 3-month intervals until 24 months.

DISCUSSION

This is the first study to directly examine the dose-effect of psychotherapy for chronically suicidal individuals diagnosed with BPD. Examining both clinical and cost effectiveness in 6 versus 12 months of DBT will produce answers to the question of how much treatment is good enough. Information from this study will help to guide decisions about the allocation of scarce treatment resources and recommendations about the benefits of briefer treatment.

TRIAL REGISTRATION

NCT02387736 . Registered February 20, 2015.

Pharmacotherapy of borderline personality disorder: replacing confusion with prudent pragmatism

PURPOSE OF REVIEW

The article aims to examine trends in the pharmacological treatment of borderline personality disorder (BPD) and shed more light on the attendant controversies.

RECENT FINDINGS

Although specialized, BPD-centred psychotherapy is considered first-line treatment for BPD and no psychotropic drug has been licensed for BPD, medications are frequently prescribed in the management of this condition. Various classes of psychopharmacological agents are used for BPD and there is a prominent polypharmacy. Use of antidepressants for BPD has been decreasing somewhat and use of mood stabilizers and second-generation antipsychotics has been increasing. Although there is a general agreement that little evidence of efficacy of medications exists for BPD, clinicians are either advised to almost completely avoid pharmacotherapy for BPD or use a 'targeted' approach, administering specific medications for the specific symptoms of BPD. This has created some confusion in clinical practice and contributed to a variety of prescribing practices for BPD.

SUMMARY

Well designed studies of the efficacy of pharmacological agents in BPD are needed. Clinicians should use medications for BPD with caution, usually short term and mainly for symptom relief. They should frequently review a need for ongoing pharmacotherapy and make every effort to avoid polypharmacy.

Pharmacotherapy of personality disorders: what we know and what we have to search for

Pharmacotherapy for personality disorders is in the early stage of development because the evidence base for effective drug treatment is insufficient, biased toward borderline personality disorder and rampant with methodological issues. In this paper, we reviewed randomized, placebo-controlled trials of drugs efficacy in patients with personality disorders published between 1990 and 2016. Overwhelming majority of studies focused on borderline personality disorder, and the accumulation of evidence resulted in seven meta-analyses, which are interpreted into better strategies for evidence-based practice. Little research attention was given to schizotypal and antisocial personality disorders, with only indirect treatment efficacy evidence for the obsessive–compulsive and avoidant personality disorders. Some avenues for future efficacy research are indicated.

Efficacy and Tolerability of Asenapine Compared with Olanzapine in Borderline Personality Disorder: An Open-Label Randomized Controlled Trial

BACKGROUND

Asenapine is a new second-generation antipsychotic that is understudied in borderline personality disorder (BPD). Only one study investigating the use of the drug in this indication (an open-label pilot study) has been conducted to date.

OBJECTIVE

The present open-label, randomized, controlled trial aimed to evaluate the efficacy and tolerability of asenapine in comparison with olanzapine, the most broadly studied antipsychotic in BPD.

METHODS

A total of 51 outpatients aged between 18 and 50 years with a diagnosis of BPD based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria were assigned for 12 weeks to asenapine (5-10 mg/day) or olanzapine (5-10 mg/day). Participants were assessed at baseline and after 12 weeks with the following instruments: the Clinical Global Impression Scale, Severity item (CGI-S), Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), Social Occupational Functioning Assessment Scale (SOFAS), Borderline Personality Disorder Severity Index (BPDSI), Barratt Impulsiveness Scale, version 11 (BIS-11), Modified Overt Aggression Scale (MOAS), Self-Harm Inventory (SHI), and Dosage Record and Treatment Emergent Symptom Scale (DOTES). Analysis of variance repeated measures was performed. Intention-to-treat analysis with last observation carried forward was conducted.

RESULTS

There were 11 drop-outs (21.57%): six patients taking asenapine and five patients receiving olanzapine. Two patients who received asenapine stopped the drug, one due to oral hypoesthesia and the other due to moderate anxiety. Two patients receiving olanzapine discontinued the treatment because of significant weight gain (≥3 kg). The remaining seven drop-outs resulted from the lack of compliance with the trial prescription. Forty out of the 51 patients (78%) completed the trial: 19 patients received asenapine, while 21 patients received olanzapine. We found a significant within-subject effect (trial duration) for all rating scales, except from the HAM-D, the MOAS, and two items of the BPDSI, namely, "identity disturbance" and "parasuicidal behaviors." A significant effect between subjects was found for the two items of the BPDSI "affective instability" and "dissociation/paranoid ideation." Asenapine was found superior to olanzapine in reducing the affective instability score (P = 0.001), whereas olanzapine was found superior to asenapine in reducing dissociation/paranoid ideation (P = 0.012). However, the study was found to be underpowered to detect a difference between the drugs on the dissociation/paranoid ideation item of the BPDSI. Two patients receiving asenapine experienced akathisia and another two restlessness/anxiety, while three patients receiving olanzapine reported somnolence and two fatigue.

CONCLUSIONS

Asenapine and olanzapine were demonstrated to have a similar efficacy. While asenapine was found to be more efficacious than olanzapine in treating affective instability, olanzapine was superior to asenapine in treating paranoid ideation and dissociation. However, the study was underpowered to detect a difference between groups on the dissociation/paranoid ideation item. Both medications were well tolerated, with asenapine being related to a higher frequency of oral hypoesthesia and akathisia, and olanzapine being prone to induce weight gain. The open-label study design, lack of a placebo group, and small sample size constitute major limitations of this trial. Our findings need to be replicated in further studies. Clinical Trials Registry code: ACTRN12614000551695.

Pharmacological treatment of borderline personality disorder: a retrospective observational study at inpatient unit in Italy

OBJECTIVE

Borderline personality disorder (BPD) is a high prevalence personality disorder. Pharmacotherapy is commonly used, however, a minority of studies investigated patterns of prescription for BPD, particularly in inpatients unit. We aimed to describe the clinical features and the prescribing practice for BPD patients, and to investigate the possible advantages of a single class of medications or of combined drug treatments in terms of length of stay in hospital.

METHODS

This is a retrospective observational study evaluating 109 BPD inpatients from June 2011 to June 2013.

RESULTS

There was evidence of an extensive use of drugs: benzodiazepines/hypnotics (85.2%), antipsychotics (78.7%), mood stabilizers (70.4%) and antidepressants (31.5%). Polypharmacy was common (83.5%). A longer length of stay in hospital was associated with the prescription of antipsychotic and/or antidepressant medication, while a shorter hospitalization was associated with the use of a mood stabilizer.

CONCLUSIONS

The rates of prescription of different classes of drugs reported in our sample and in similar 'naturalistic' studies highlight a heterogeneous pattern of prescriptions for BPD. Mood stabilizers showed a more favourable profile in terms in length of stay in hospital than antipsychotic and/or antidepressant. Our results reiterate the discrepancy between international recommendations and everyday clinical practice.

Biting the hand that feeds: current opinion on the interpersonal causes, correlates, and consequences of borderline personality disorder

Borderline personality disorder (BPD) is a complex psychiatric diagnosis characterized by dysregulated behaviors, emotions, cognitions, and interpersonal relationships. In recent years, developmental psychopathologists have sought to identify early origins of BPD, with the ultimate goal of developing and providing effective preventative interventions for those at highest risk. In addition to heritable biological sensitivities, many scholars assert that environmental and interpersonal risk factors contribute to the emergence and maintenance of key borderline traits. Nonetheless, many BPD researchers examine only affected individuals, neglecting the family, peer, couple, and other dynamic contextual forces that impinge upon individual-level behavior. In the past decade, however, theoretical and empirical research has increasingly explored the interpersonal causes, correlates, and consequences of BPD. Such work has resulted in novel research and clinical theories intended to better understand and improve interpersonal dynamics among those with borderline traits. A major objective for the field is to better characterize how interpersonal dynamics affect (and are affected by) the behaviors, emotions, and thoughts of vulnerable individuals to either reduce or heighten risk for BPD.

Borderline Personality Disorder: Therapeutic Factors

Proponents of the now half-dozen major psychotherapeutic approaches tend to claim the superiority of their different approaches-known widely by their acronyms: CBT for Cognitive Behavioral Therapy, DBT for Dialectic Behavioral Therapy, MBT for Mentalization-Based Therapy, TFP for Transference- Focused Psychotherapy, and so on. The data thus far support the utility of each method, but do not show clear-cut superiority of any one method. A large percentage of BPD patients eventually improve or even recover, but these favorable results appear to derive from a multiplicity of factors. These include the personality traits of both patient and therapist, the unpredictable life events over time, the socioeconomic and cultural background of the patient, and the placebo effect of simply being in treatment. These latter factors constitute the contextual model, which operates alongside the medical model, each playing a role in eventual outcome. The contextual model will be discussed extensively in a separate article.