Sleep and borderline personality disorder: a review

The Predictive Role of Personality Disorders and Personality Traits in Death Anxiety

The current study investigates the interplay between personality traits, personality disorders, and death anxiety in a sample of 2331 participants (49% males; 51% females) across two phases. The Death Anxiety Scale, the Psychosocial Personality Inventory, and the Personality Diagnostic Questionnaire were utilized. The findings revealed significant predictive relationships between personality disorders and death anxiety. Positive correlations were observed between death anxiety and nine personality disorders, including avoidant (r = .227), borderline (r = .123), dependent (r = .157), depressive (r = .098), histrionic (r = .074), narcissistic (r = .111), negativistic (r = .103), obsessive-compulsive (r = .126), and schizotypal (r = .078) personality disorders (p < .001). Death anxiety had significant inverse correlations with leadership (r = -.101) and spirituality (r = -.099) traits (p < .005). Avoidant personality disorder projected the highest prediction for death anxiety (β = .227; p = .000). Leadership as a personality trait demonstrated an outstanding ability to prevent death anxiety (β = -.101; p = .013). These findings make a unique contribution to the literature of death anxiety, personality disorders, and personality traits.

Guided internet-based cognitive behavioral therapy for insomnia in patients with borderline personality disorder: Study protocol for a randomized controlled trial

Borderline personality disorder (BPD) is a highly disabling psychiatric disorder with emotion dysregulation at its core, resulting in affective instability, impulsivity and sometimes self-harming or suicidal behavior. Sleep is increasingly recognized to play a crucial role in emotion regulation. BPD patients often suffer from (severe) insomnia, potentially aggravating symptoms and preventing recovery from BPD. Yet, the effects of insomnia treatments have not been investigated in context of BPD. Guided internet-based cognitive behavioral therapy for insomnia (iCBT-I; i-Sleep) has been proven effective in improving both insomnia and affective symptoms. In this randomized controlled trial among 96 patients with a DSM-5 diagnosis of BPD (or other personality disorder with ≥4 BPD traits) and insomnia symptoms, we will test the effectiveness of iCBT-I before regular BPD treatment starts, during the waitlist period, on BPD symptoms. Patients in the control group monitor their sleep through a sleep diary during the waitlist period and also receive standard BPD treatment after that. Using linear mixed models we will test the hypothesis that the iCBT-I group improves more than the control group on BPD symptoms (primary outcome), insomnia severity, additional subjective and objective sleep variables, emotion regulation, comorbid anxiety and depression complaints, and quality of life. These effects are thought to arise from a direct effect of improved sleep on emotion regulation and a synergistic effect on the consolidation and internalization of the BPD treatment effect. To our knowledge, this is the first trial assessing effectiveness of CBT-I in patients with BPD (traits). The accessibility of the studied intervention greatly facilitates clinical implication in case of positive results.

Adult ADHD and sleep disorders: Prevalence, severity and predictors of sleep disorders in a sample of Italian psychiatric outpatients

OBJECTIVE

Sleep disorders are frequent in adult subjects diagnosed with ADHD. The aims of the present study were to assess the prevalence and the severity of sleep disorders in a sample of Italian psychiatric outpatients, to compare the prevalence and severity of sleep disorders in patients with and without diagnosis of adult ADHD, and to evaluate the role of ADHD as an individual predictor of sleep disturbances severity.

METHOD

634 outpatients accessing psychiatric services were assessed with the Mini-International Neuropsychiatric Interview (MINI) Plus V. 5.0.0 interview and the Adult ADHD self-report Scale Symptoms Checklist (ASRS)-V 1.1 Short Form. Patients positive to the ASRS-V 1.1 were assessed with the Diagnostic Interview for ADHD in Adults (DIVA) 2.0. Sleep disorders and sleep disturbances' severity were assessed with the PROMIS Adult Sleep Disturbance Scale.

RESULTS

Sleep disorders were more frequent (p < 0.001) and sleep disturbances were more severe (d = 1.26, p < 0.001) in subjects diagnosed with adult ADHD compared to other outpatients. Among the 44 subjects diagnosed with ADHD, 15 (34.1%) reported no or slight sleep disturbances, 9 (20.5%) a mild sleep disorder, 17 (38.6%) a moderate sleep disorder and 3 (6.8%) a severe sleep disorder. ADHD diagnosis, multiple psychiatric comorbidity and history of suicide attempts emerged as individual predictors of worse sleep disturbances.

CONCLUSION

Sleep disorders are more frequent and severe in subjects diagnosed with ADHD compared to other adult outpatients. Sleep disturbances might represent an intrinsic feature in adult ADHD subjects, presenting important clinical repercussions, and should be routinely evaluated and monitored in this population.

Potential mechanisms underlying sleep disturbance in young people with borderline personality disorder features: an exploratory study

BACKGROUND

Sleep disturbance is common among young people (15-25 years) with features of borderline personality disorder (BPD). However, the mechanisms underlying sleep disturbance in BPD remain unknown. Understanding these underlying processes is essential to guide the development of sleep-improvement interventions and to optimise their efficacy through identifying beneficial treatment targets. This exploratory study aimed to investigate potential underlying mechanisms to inform future hypotheses, research development, and provide insight into potential treatment targets to improve sleep in young people with BPD. This study explored the indirect roles of emotion regulation difficulties, depression, anxiety and stress in the relationship between BPD features and sleep disturbance in young people.

METHODS

Sleep was measured subjectively (self-report questionnaires) and objectively (10 days wrist actigraphy) in 40 young people with BPD features and 38 healthy young people. Participants also completed the Difficulties in Emotion Regulation Scale and the Depression, Anxiety and Stress Scale.

RESULTS

Mediation analyses revealed that impulse control difficulties, limited emotion regulation strategies and anxiety indirectly affected the relationship between group (BPD vs. healthy) and subjective sleep disturbance in young people. Lack of emotional awareness and anxiety contributed to associations between group and objectively longer time in bed and bedtime variability, respectively.

CONCLUSIONS

These preliminary findings suggest that targeting emotional dysregulation (impulse control, strategies, emotional awareness) and anxiety might be beneficial for improving sleep in this population.

Sleep in Young People With Features of Borderline Personality Disorder: A Scoping Review

Sleep disturbance is commonly reported in young people with features of borderline personality disorder (BPD). Examining sleep quality and sleep-wake patterns in young people with features of BPD is essential to inform the development of sleep-improvement interventions. A scoping review was conducted according to the Joanna Briggs Institute methodology. The objectives were to map the literature regarding sleep in young people with features of BPD, highlight areas for further investigation, and provide methodological recommendations for future research. Seven data sets were included in the review. Young people with features of BPD had poorer objective and subjective sleep quality, disturbed sleep architecture (particularly rapid-eye-movement sleep), an increased vulnerability to delayed sleep phase syndrome, and more nightmares and dream anxiety, compared with healthy individuals. Future research should use both objective and subjective sleep measures, include clinical comparison groups, and focus specifically on young people with BPD.

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

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

Insomnia partially mediates the relationship between pathological personality traits and depression: a case-control study

Background and Objective

Personality disorders are frequently associated with insomnia and depression, but little is known about the inter-relationships among these variables. Therefore, this study examined these inter-relationships and the possible mediating effect of insomnia on the association between specific personality pathologies and depression severity.

Methods

There were 138 study participants, including 69 individuals with depression and 69 healthy controls. The main variables were measured by the Hamilton Depression Rating Scale-24 (HAMD-24), Athens Sleep Insomnia Scale (AIS), and the Personality Diagnostic Questionnaire (PDQ-4+). Multivariate linear regression and mediation analysis were conducted.

Results

With the exception of the antisocial personality score, all the PDQ-4+ scores and AIS scores were significantly higher in the depression group than in the healthy control group (p < 0.001). In the total sample, all personality pathology scores (p < 0.001), except the antisocial personality score, had significant positive correlations with the AIS scores and HAMD-24 scores, and the AIS scores and HAMD-24 scores were positively correlated (r = 0.620, p < 0.001). Regression analysis revealed that borderline personality, passive-aggressive personality, and insomnia positively predicted the severity of depression, after adjusting for sociodemographic covariates, and that insomnia partially mediated the associations of borderline personality and passive-aggressive personality with depression severity.

Conclusions

Borderline personality, passive-aggressive personality, and insomnia tend to increase the severity of depression, and the effect of borderline and passive-aggressive personality on depression severity may be partially mediated by insomnia. This is the first study to report these findings in a Chinese sample, and they may help researchers to understand the pathways from specific personality pathologies to the psychopathology of depression better, which should be useful for designing interventions to relieve depression severity, as the impact of specific personality pathology and insomnia should be considered.

Insomnia in Patients with Borderline Personality Disorder

OBJECTIVE

Both sleep disorders and BPD are prevalent in the population, and one is often a comorbidity of the other. This narrative review aims to assess contemporary literature and scientific databases to provide the current state of knowledge about sleep disorders in patients with borderline personality disorder (BPD) and clinical suggestions for managing sleep disorders in BPD patients and future research direction.

METHODS

Articles were acquired via PubMed and Web of Science, and papers published between January 1980 and October 2020 were extracted. Authors made a series of literature searches using the keywords: Sleep problems, Insomnia, Nightmares, Obstructive sleep apnea, Borderline personality disorder. The inclusion criteria were: published in peer-reviewed journals; studies in humans; or reviews on the related topic; English language. The exclusion criteria were: abstracts from conferences; commentaries; subjects younger than 18 years. After an inspection of the full texts, 42 papers from 101 were selected. Secondary documents from the reference lists of the primary designated papers were searched, assessed for suitability, and included. In total, 71 papers were included in the review process.

RESULTS

Sleep disturbance is common among patients with BPD. Nevertheless, the number of investigations is limited, and the prevalence differs between 5-45%. Studies assessing objective changes in sleep architecture in BPD show inconsistent results. Some of them identify REM sleep changes and a decrease in slow-wave sleep, while other studies found no objective sleep architecture changes. There is also a higher prevalence of nightmares in patients with BPD. Untreated insomnia can worsen BPD symptoms via interference with emotional regulation. BPD itself seems to influence the subjective quality of sleep significantly. Proper diagnosis and treatment of sleep disorders in patients with BPD could lead to better results in therapy. Psychotherapeutic approaches can improve both sleep disorders and BPD symptoms.

CONCLUSION

Recognising and managing sleep disorders in patients with BPD may help alleviate the disorder's symptoms. Treatment of people with BPD may be more effective if the treatment plan explicitly addresses sleep problems. Further research is needed to reach reliable conclusions.

Nightmare experience and personality disorder functioning styles in healthy volunteers and nightmare disorder patients

Nightmares are prevalent in psychiatric disorders, and personality disorder features might be associated with nightmare experience, especially in nightmare disorder patients. The authors invited 219 healthy volunteers and 118 nightmare disorder patients to undergo tests of the Nightmare Experience Questionnaire (NEQ), the Parker Personality Measure (PERM), and the Plutchik-van Praag Depression Inventory. Compared to healthy volunteers, nightmare disorder patients scored significantly higher on annual nightmare frequency and NEQ Physical Effect, Negative Emotion, Meaning Interpretation, and Horrible Stimulation, and higher on PERM Paranoid, Schizotypal, Borderline, Histrionic, Narcissistic, Avoidant, and Dependent styles. Borderline, Schizotypal, and Passive-Aggressive styles in healthy volunteers and Dependent, Avoidant, Histrionic, and Paranoid in patients were significant predictors of some NEQ scales. Higher annual nightmare frequency, higher scale scores of nightmare experience and personality disorder styles, and more associations between the two were found in nightmare disorder patients, implying the need for personality-adjustment therapy for nightmare disorder.

EEG-vigilance regulation in Borderline Personality Disorder

BACKGROUND

Borderline Personality Disorder (BPD) is characterized by emotional instability, impulsivity, disturbed cognition, sleeplessness and states of high inner tension. Altered arousal regulation which is regarded as a higher domain of functioning according to the research domain criteria of the NIMH and which has previously been reported in several psychiatric disorders, such as mania or major depression could be involved in these features of BPD.

METHODS

40 unmedicated patients with BPD and 42 matched healthy volunteers participated in a twenty minute resting-state EEG measurement with closed eyes. EEG-vigilance regulation was assessed with VIGALL2.0 (Vigilance Algorithm Leipzig), which allows a classification of consecutive 1-s segments in different vigilance stages ranging from high alertness/relaxed wakefulness (stages 0, A1, A2, A3) to drowsiness (B1, B2/3) and sleep onset (C).

RESULTS

Across 20 min, both groups showed a similar decline from higher to lower vigilance stages, but patients with BPD remained in higher stages of vigilance compared to healthy volunteers across the whole measurement (p = .013). Contrary to this, pre-experimental ratings indicated enhanced subjective sleepiness but no differences in self-reported sleep quantity in the previous night in patients with BPD compared to healthy volunteers.

CONCLUSIONS

The results of an elevated arousal regulation (in combination with increased subjective sleepiness) might reflect several symptoms, such as aversive inner tension and impoverished sense of self in patients with BPD. As arousal is linked to the noradrenergic system, further investigations in this field seem to be promising.

Borderline personality disorder traits and suicide risk: The mediating role of insomnia and nightmares

BACKGROUND

Borderline personality disorder (BPD) is associated with high rates of suicide risk and problems related to sleep, including insomnia and nightmares. The purpose of the current study was to assess the potential indirect effect of BPD traits on suicide risk through both/either insomnia and nightmares.

METHODS

Participants (N = 281) were recruited via Amazon's Mechanical Turk to complete the study remotely online. Participants completed measures of BPD traits and symptoms, suicide risk (history of suicidal thoughts and behaviors), insomnia symptoms, and distress and impairment related to nightmares.

RESULTS

BPD traits and symptoms were moderately to highly correlated to suicide risk, insomnia, and nightmares. In parallel mediation models, BPD traits had a significant indirect effect on suicide risk through insomnia symptoms but not nightmares.

LIMITATIONS

The current study assessed problems within the general population and not in a clinical sample. Second, the study relied solely on self-report measures. Futures studies would benefit from investigating these relations in clinical samples utilizing observer-report and interview methods.

CONCLUSIONS

BPD traits appear to relate to increased risk for suicide through the relation with sleep concerns, particularly insomnia symptoms. Therefore, assessing and treating sleep problems within individuals with BPD may result in a lower risk for suicide.

Sleep Problems in Childhood and Borderline Personality Disorder Symptoms in Early Adolescence

Sleep disorders, such as insomnia and nightmares, are commonly associated with Borderline Personality Disorder (BPD) in adulthood. Whether nightmares and sleep-onset and maintenance problems predate BPD symptoms earlier in development is unknown. We addressed this gap in the literature using data from the Avon Longitudinal Study of Parents and Children (ALSPAC). Participants included 6050 adolescents (51.4 % female) who completed the UK Childhood Interview for DSM-IV BPD at 11 to 12 years of age. Nightmares and sleep onset and maintenance problems were prospectively assessed via mother report when children were 2.5, 3.5, 4.8 and 6.8 years of age. Psychopathological (i.e., emotional temperament; psychiatric diagnoses; and emotional and behavioural problems) and psychosocial (i.e., abuse, maladaptive parenting, and family adversity) confounders were assessed via mother report. In logistic regressions, persistent nightmares (i.e., regular nightmares at 3 or more time-points) were significantly associated with BPD symptoms following adjustment for sleep onset and maintenance problems and all confounders (Adjusted Odds Ratio = 1.62; 95 % Confidence Interval = 1.12 to 2.32). Persistent sleep onset and maintenance problems were not significantly associated with BPD symptoms. In path analysis controlling for all associations between confounders, persistent nightmares independently predicted BPD symptoms (Probit co-efficient [β] = 0.08, p = 0.013). Emotional and behavioural problems significantly mediated the association between nightmares and BPD (β =0.016, p < 0.001), while nightmares significantly mediated associations between emotional temperament (β = 0.001, p = 0.018), abuse (β = 0.015, p = 0.018), maladaptive parenting (β = 0.002, p = 0.021) and subsequent BPD. These findings tentatively support that childhood nightmares may potentially increase the risk of BPD symptoms in early adolescence via a number of aetiological pathways. If replicated, the current findings could have important implications for early intervention, and assist clinicians in the identification of children at risk of developing BPD.

Poor Sleep and Its Relation to Impulsivity in Patients with Antisocial or Borderline Personality Disorders

Studies investigating sleep and personality disorders consistently demonstrate a relation between personality disorders characterized by behavioral disinhibition and/or emotional dysregulation (traditionally termed cluster B personality disorders) and poor sleep. This finding is in line with previous studies associating insomnia with impulsive behavior, since this is a core characteristic of both antisocial and borderline personality disorder. The current study investigates a group (n = 112) of forensic psychiatric inpatients with antisocial or borderline personality disorder or traits thereof. Subjective sleep characteristics and impulsivity were assessed with the Pittsburgh Sleep Quality Index, the Sleep Diagnosis List, and the Barratt Impulsiveness Scale, respectively. More than half of the patients (53.6%) report poor sleep quality and 22.3% appears to suffer from severe chronic insomnia. Both poor sleep quality and chronic insomnia are significantly associated with self-reported impulsivity, in particular with attentional impulsiveness. This association was not significantly influenced by comorbid disorders. Actively treating sleep problems in these patients may not only improve sleep quality, mental health, and physical well-being, but may also have impact on impulsivity-related health risks by increasing self-control.

A Systematic Review of Personality Disorders and Health Outcomes

Personality disorders have been associated with a wide swath of adverse health outcomes and correspondingly high costs to healthcare systems. To date, however, there has not been a systematic review of the literature on health conditions among individuals with personality disorders. The primary aim of this article is to review research documenting the associations between personality disorders and health conditions. A systematic review of the literature revealed 78 unique empirical English-language peer-reviewed articles examining the association of personality disorders and health outcomes over the past 15 years. Specifically, we reviewed research examining the association of personality disorders with sleep disturbance, obesity, pain conditions, and other chronic health conditions. In addition, we evaluated research on candidate mechanisms underlying health problems in personality disorders and potential treatments for such disorders. Results underscore numerous deleterious health outcomes associated with PD features and PD diagnoses, and suggest potential biological and behavioural factors that may account for these relations. Guidelines for future research in this area are discussed.

Dream-reality confusion in borderline personality disorder: a theoretical analysis

This paper presents an analysis of dream-reality confusion (DRC) in relation to the characteristics of borderline personality disorder (BPD), based on research findings and theoretical considerations. It is hypothesized that people with BPD are more likely to experience DRC compared to people in non-clinical population. Several variables related to this hypothesis were identified through a theoretical analysis of the scientific literature. Sleep disturbances: problems with sleep are found in 15–95.5% of people with BPD (Hafizi, 2013), and unstable sleep and wake cycles, which occur in BPD (Fleischer et al., 2012), are linked to DRC. Dissociation: nearly two-thirds of people with BPD experience dissociative symptoms (Korzekwa and Pain, 2009) and dissociative symptoms are correlated with a fantasy proneness; both dissociative symptoms and fantasy proneness are related to DRC (Giesbrecht and Merckelbach, 2006). Negative dream content: People with BPD have nightmares more often than other people (Semiz et al., 2008); dreams that are more likely to be confused with reality tend to be more realistic and unpleasant, and are reflected in waking behavior (Rassin et al., 2001). Cognitive disturbances: Many BPD patients experience various cognitive disturbances, including problems with reality testing (Fiqueierdo, 2006; Mosquera et al., 2011), which can foster DRC. Thin boundaries: People with thin boundaries are more prone to DRC than people with thick boundaries, and people with BPD tend to have thin boundaries (Hartmann, 2011). The theoretical analysis on the basis of these findings suggests that people who suffer from BPD may be more susceptible to confusing dream content with actual waking events.

Nightmares affect the experience of sleep quality but not sleep architecture: an ambulatory polysomnographic study

BACKGROUND

Nightmares and bad dreams are common in people with emotional disturbances. For example, nightmares are a core symptom in posttraumatic stress disorder and about 50% of borderline personality disorder patients suffer from frequent nightmares. Independent of mental disorders, nightmares are often associated with sleep problems such as prolonged sleep latencies, poorer sleep quality, and daytime sleepiness. It has not been well documented whether this is reflected in objectively quantifiable physiological indices of sleep quality.

METHODS

Questionnaires regarding subjective sleep quality and ambulatory polysomnographic recordings of objective sleep parameters were collected during three consecutive nights in 17 individuals with frequent nightmares (NM) and 17 healthy control participants (HC).

RESULTS

NM participants reported worse sleep quality, more waking problems and more severe insomnia compared to HC group. However, sleep measures obtained by ambulatory polysomnographic recordings revealed no group differences in (a) overall sleep architecture, (b) sleep cycle duration as well as REM density and REM duration in each cycle and (c) sleep architecture when only nights with nightmares were analyzed.

CONCLUSIONS

Our findings support the observation that nightmares result in significant impairment which is independent from disturbed sleep architecture. Thus, these specific problems require specific attention and appropriate treatment.