Barriers to care for adolescents with borderline personality disorder

The evaluation of a stepped care approach for early intervention of borderline personality disorder

BACKGROUND

The current study evaluated the stepped care approach applied in AtR!Sk; a specialized outpatient clinic for adolescents with BPD features that offers a brief psychotherapeutic intervention (Cutting Down Program; CDP) to all patients, followed by a more intensive Dialectical Behavioral Therapy for Adolescents (DBT-A) for those whose symptoms persist.

METHODS

The sample consisted of 127 patients recruited from two AtR!Sk clinics. The number of BPD criteria, psychosocial functioning, severity of overall psychopathology, number of days with non-suicidal self-injury (NSSI; past month), and the number of suicide attempts (last 3 months) were assessed at clinic entry (T0), after CDP (T1), and at 1- and 2-year follow-up (T2, T3). Based on the T1 assessment (decision criteria for DBT-A: ≥ 3 BPD criteria & ZAN-BPD ≥ 6), participants were allocated into three groups; CDP only (n = 74), CDP + DBT-A (eligible and accepted; n = 36), CDP no DBT-A (eligible, but declined; n = 17).

RESULTS

CDP only showed significantly fewer BPD criteria (T2: β = 3.42, p < 0.001; T3: β = 1.97, p = 0.008), higher levels of psychosocial functioning (T2: β = -1.23, p < 0.001; T3: β = -1.66, p < 0.001), and lower severity of overall psychopathology (T2: β = 1.47, p < 0.001; T3: β = 1.43, p = 0.002) over two years compared with CDP no DBT-A, while no group differences were found with regard to NSSI and suicide attempts. There were no group differences between CDP + DBT-A and CDP no DBT-A, neither at T2 nor at T3.

DISCUSSION

The findings support the decision criterion for the offer of a more intense therapy after CDP. However, there was no evidence for the efficacy of additional DBT-A, which might be explained by insufficient statistical power in the current analysis.

Diagnosing borderline personality disorder: Reports and recommendations from people with lived experience

Borderline personality disorder (BPD) is a severe mental health condition marked by impairments in self and interpersonal functioning. Stigma from health staff may often result in a reluctance to diagnose, impacting recovery trajectories. Qualitative interviews were conducted with participants (N = 15; M Age = 36.4 years, SD = 7.5; 93.3% female) with lived experience of BPD exploring topics of illness onset, insight, experience of diagnosis and treatment. Qualitative responses were analysed within a co-design framework with a member of the research team who identifies as having a lived experience of BPD. On average, participant symptoms emerged at 12.1 years of age (SD = 6.6 years, range 1.5-27), but diagnoses of BPD were delayed until 30.2 years (SD = 7.8 years, range 18-44) resulting in a 'diagnosis gap' of 18.1 years (SD = 9.6 years, range 3-30). Participant explanations for BPD emergence varied from biological, psychological and social factors. Benefits of diagnosis (e.g., fostering insight, aiding treatment planning and reducing isolation) were contrasted with challenges (e.g., stigma and treatment unavailability). Delay in diagnosis was common, and no participants reported receiving a diagnosis of BPD during their adolescence yet 85% felt they would have benefited from a diagnosis in adolescence. Only a quarter (27%) felt highly supported in the diagnostic process. An ideal four-step diagnosis procedure was outlined based on recommendations from participants with a lived experience; this involved the following: (1) explain the process, (2) assess thoroughly, (3) explore how the features are active in everyday life and (4) link diagnosis to evidence-based treatment planning.

Attitudes, Clinical Practices, and Perceived Advocacy Needs of Professionals With Interests in Personality Disorders

Experts in personality disorders (PDs) generally prefer dimensional diagnostic systems to categorical ones, but less is known about experts' attitudes toward personality pathology diagnoses in adolescents, and little is known about public health shortfalls and advocacy needs and how these might differ geographically. To fill these gaps, the International Society for the Study of Personality Disorders surveyed 248 professionals with interests in PDs about their attitudes toward different diagnostic systems for adults and adolescents, their PD-related clinical practices, and perceived advocacy needs in their area. Results suggested that dimensional diagnostic systems are preferable to categorical and that skepticism about personality pathology in adolescents may not be warranted. The most pressing advocacy need was the increased availability of PD-related services, but many other needs were identified. Results provide a blueprint for advocacy and suggest ways that professional societies can collaborate with public health bodies to expand the reach of PD expertise and services.

Early Intervention for Personality Disorder

Both the DSM-5 Section III Alternative Model for Personality Disorders and the ICD-11 have introduced a genuinely developmental approach to personality disorder. Among young people with personality disorder, compelling evidence demonstrates a high burden of disease, substantial morbidity, and premature mortality, as well as response to treatment. Yet, early diagnosis and treatment for the disorder have struggled to emerge from its identity as a controversial diagnosis to a mainstream focus for mental health services. Key reasons for this include stigma and discrimination, lack of knowledge about and failure to identify personality disorder among young people, along with the belief that personality disorder must always be addressed through lengthy and specialized individual psychotherapy programs. In fact, evidence suggests that early intervention for personality disorder should be a focus for all mental health clinicians who see young people and is feasible by using widely available clinical skills.

Dificultades en la regulación emocional de pacientes con trastorno límite de personalidad atendidos en un centro de terapia dialéctico conductual de Medellín, Colombia

La desregulación emocional puede expresarse de distinta manera en el trastorno límite de personalidad (TLP), posiblemente por la influencia del contexto cultural. El objetivo de este estudio fue caracterizar las dificultades en la regulación emocional en pacientes con TLP que consultan a un centro especializado en Terapia Dialéctico Conductual (DBT) en la ciudad de Medellín, Colombia. Se realizó un estudio de corte transversal con 54 pacientes, principalmente mujeres jóvenes, solteras y de estrato socioeconómico alto con TLP que ingresaron a tratamiento y se les aplicó la “Escala de Dificultades en la Regulación Emocional” (DERS). Se calcularon la mediana (M) y rango intercuartílico (RIQ) y valor de p con la U de Mann-Whitney y el tamaño del efecto (valor r). El puntaje total en la DERS fue alto (M=134; RIQ=117-142). Se encontraron diferencias entre hombres y mujeres, con un tamaño de efecto intermedio (Mmujer=135,5 versus Mhombre=119; p=0,047; r=-0,26). No se encontraron diferencias entre grupos etarios, pero las dificultades en la regulación emocional sí fueron diferentes en los pacientes que cursaban además con TDAH, ansiedad, depresión y ansiedad combinados, y trastorno bipolar. Esto indicaría que en pacientes de una ciudad de Colombia en tratamiento con DBT, las dificultades en la regulación emocional son altas y parecen ser mayores en las mujeres. La presencia de ansiedad, depresión, TDAH y trastorno bipolar podría influir en la intensidad de la desregulación emocional y en las facetas en la que se manifiesta, lo que sugiere alta variabilidad dentro del diagnóstico.

Exploring the comorbidity between personality and musculoskeletal disorders among adults: A scoping review

INTRODUCTION

There is growing awareness of the comorbidity between mental and musculoskeletal disorders (MSDs) and their associated burden. We aimed to explore what is known regarding the existing epidemiological clinical-and population- based literature on the comorbidity between personality disorders (PDs) and MSDs specifically. In addition, we aimed to investigate their associated burden by examining a range of outcomes including morbidity/mortality, patient- and clinical-reported outcomes, work-related outcomes, hospital admissions, and financial costs. Finally, we sought to identify gaps in the literature and provide recommendations for further research.

METHODS

Studies with participants 15 years of age were eligible. Categorical PDs/features (DSM-III/IV/5 or ICD 9/10), identified by a health care professional, medical records, diagnostic interviews, or self-administered questionnaires. The definitions/groupings of MSDs were guided by the ICD-10 including conditions of the back, joints, and soft tissue, and disorders of bone density and structure. Published peer-reviewed and gray literature were considered. Eligible study designs were cohort, case-control, and cross-sectional studies, and existing reviews of observational studies. Identification and selection of articles, data extraction and the presentation of the results was conducted according to the Joanna Briggs Institute methodological guidance and the PRISMA extension for scoping reviews.

RESULTS

In total, 57 articles were eligible including 10 reviews and 47 individual studies. Across clinical and population settings, we detected evidence of comorbidity between PDs and chronic back/neck/spine conditions, arthritis, and fibromyalgia, and emerging evidence of associations between PDs and reduced bone mineral density. In terms of knowledge gaps, the burden associated with PDs and MSDs is poorly understood, as is their underlying mechanisms.

DISCUSSION

This scoping review might prompt further research into PDs and MSDs as separate groups of disorders, along with their comorbidity and the mechanisms that may link them.

SYSTEMATIC REVIEW REGISTRATION

https://osf.io/mxbr2/registrations.