Borderline personality disorder associates with violent criminality in women: A population based follow-up study of adolescent psychiatric inpatients in Northern Finland

Neural correlates of aggression in personality disorders from the perspective of DSM-5 maladaptive traits: a systematic review

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published in 2013, includes an alternative model of personality disorders (AMPD) focusing on a maladaptive trait model utilized to diagnose several personality disorders. Borderline personality disorder (BPD) and antisocial personality disorder (ASPD) are two conditions categorized by AMPD that exhibit high rates of violence and aggression. Several of the traits outlined in the AMPD, including hostility, impulsivity, risk-taking, and callousness, have been previously linked to aggression in BPD and ASPD. However, to the best of our knowledge, there has never been a synthesis of neuroimaging studies that have investigated links between these traits and aggression in BPD and ASPD. To overcome this gap, we conducted a systematic review under the PRISMA framework to locate neuroimaging articles published since the release of AMPD linking trait anger/hostility, impulsivity, risk-taking, and callousness to aggression in BPD and ASPD. Key findings included the following: i) anger/hostility, associated with alterations in the interplay between prefrontal and subcortical regions (primarily the amygdala), may be a common factor explaining aggressive reactions to response to interpersonal threat or provocation; ii) alterations of fronto-temporal-limbic regions and serotonergic and endocannabinoid signaling systems may link impulsivity to aggression in BPD and ASPD; iii) weaker cortico-striatal connectivity could relate to greater risk taking and greater proclivity for violence. Insufficient evidence from neuroimaging articles was discerned to describe a relationship between callousness and aggression. Overall, results of this review reveal a relative paucity of neuroimaging studies examining AMPD traits relevant to aggression in BPD and ASPD. In addition to encouraging further investigation of neuroimaging markers of AMPD traits linked to aggression, we recommend multi-methodological designs, including the incorporation of other biomarkers, such as hormones and indices of physiological arousal, to fully expand our understanding of aggression in BPD and ASPD.

Sex differences in borderline personality disorder: A scoping review

Borderline Personality Disorder (BPD) is often perceived to be a female-predominant disorder in both research and clinical contexts. Although there is growing recognition of possible sex differences, the current literature remains fragmented and inconclusive. This scoping review aimed to synthesize available research evidence on potential sex differences in BPD. PsycINFO, PubMed, Scopus and Web-of-Science were searched from January 1982 to July 2022 surrounding the key concepts of sex and BPD. Data searching and screening processes followed the Joanna Briggs Institute methodology involving two independent reviewers, and a third reviewer if necessary, and identified 118 papers. Data regarding BPD symptoms, comorbid disorders, developmental factors, biological markers, and treatment were extracted. Data was summarized using the vote counting method or narrative synthesis depending on the availability of literature. Males with BPD were more likely to present externalizing symptoms (e.g., aggressiveness) and comorbid disorders (e.g., substance use), while females with BPD were more likely to present internalizing symptoms (e.g., affective instability) and comorbid disorders (e.g., mood and eating disorders). This review also revealed that substantially more research attention has been given to overall sex differences in baseline BPD symptoms and comorbid disorders. In contrast, there is a dearth of sex-related research pertaining to treatment outcomes, developmental factors, and possible biological markers of BPD. The present scoping review synthesized current studies on sex differences in BPD, with males more likely to present with externalizing symptoms in contrast to females. However, how this might change the prognosis of the disorder or lead to modifications of treatment has not been investigated. Most studies were conducted on western populations, mainly North American (55%) or European (33%), and there is a need for future research to also take into consideration genetic, cultural, and environmental concomitants. As the biological construct of 'sex' was employed in the present review, future research could also investigate the social construct 'gender'. Longitudinal research designs are needed to understand any longer-term sex influence on the course of the disorder.

Lifetime psychiatric diagnoses among adolescents with severe conduct problems - A register-based follow-up study

BACKGROUND

Both delinquency and out-of-home care (OOHC) are associated with a wide spectrum of psychiatric disorders. Reform schools (RS) are Finnish OOHC institutions for adolescents with severe conduct problems.

OBJECTIVE

We investigated the prevalence of psychiatric diagnoses among individuals with a history of RS placement.

PARTICIPANTS AND SETTING

The data consisted of individuals placed in a RS on the last day of the years 1991, 1996, 2001, 2006 or 2011 (N = 1074) and a matched comparison group (N = 5313).

METHODS

Information on lifetime psychiatric diagnoses, grouped into eight categories, was collected from the nationwide health care registry. The follow-up time ranged from 17 to 44 years.

RESULTS

Among RS population, 59.5 % had some psychiatric diagnosis, which was 12-fold compared to general population peers (hazard ratio HR = 12.4). The most prevalent categories were Conduct disorders and/or ADHD (30.7 %, HR = 41.5), Substance use disorders (29.3 %, HR = 16.8,), Other childhood disorders (8.6 %, HR = 11.9) and Personality disorders (10.9 %, HR = 11.6) followed by Mental retardation (6.4 %, HR = 8.4), Schizophrenia spectrum disorders (9.7 %, HR = 7.9), Affective disorders (17.9 %, HR = 7.3), and Disorders of psychological development (6.1 %, HR = 4.4). All differences were statistically significant (p < .001).

CONCLUSIONS

RS background associates with an excess of psychiatric disorders, which adds to the burden of other known risk factors for adult age well-being. Effective screening and intervention for psychiatric problems should be available both during the RS placement and after-care.

Young People With Borderline Personality Disorder Have an Increased Lifetime Risk of Being the Victim of Interpersonal Violence

This study aimed to examine the lifetime risk of being the victim of criminal or violent offenses among young people with borderline personality disorder (BPD) features (1-9 DSM-IV criteria). Demographic and diagnostic data from 492 outpatients who attended a specialist public mental health service for 15- to 25-year-olds between January 1998 and March 2008 were linked with offending data from a state-wide police database, collected between March 1993 and June 2017, in order to establish victimization history. This included information on criminal offenses perpetrated against these young people and intervention orders implemented to protect them from being victimized by another person's violent behavior. Logistic regression analyses, adjusted for sex and co-occurring mental state disorders, were conducted on n = 378 who had complete data (76.5% females). As hypothesized, BPD diagnosis and number of BPD criteria were both significantly associated with an increased risk of being the victim of a violent offense and the complainant of a family violence intervention order. Anger and impulsivity independently predicted a higher risk of being the victim of a violent offense, while unstable relationships, impulsivity, and affective instability independently predicted a higher risk of being the complainant of a family violence intervention order. No significant association was found between BPD and the risk of being the victim of a nonviolent offense. These findings indicate that young people with any BPD features (even below the DSM diagnostic threshold) are at increased risk for victimization by interpersonal violence. Moreover, this risk increases according to the number of BPD criteria. This issue needs to be addressed by prevention and early intervention programs (e.g., by working on self-assertion and interpersonal skills, taking into account the possible influence of previous traumatizing relationship experiences).

Borderline personality disorder: associations with psychiatric disorders, somatic illnesses, trauma, and adverse behaviors

In one of the largest, most comprehensive studies on borderline personality disorder (BPD) to date, this article places into context associations between this diagnosis and (1) 16 different psychiatric disorders, (2) eight somatic illnesses, and (3) six trauma and adverse behaviors, e.g., violent crime victimization and self-harm. Second, it examines the sex differences in individuals with BPD and their siblings. A total of 1,969,839 Swedish individuals were identified from national registers. Cumulative incidence with 95% confidence intervals (CI) was evaluated after 5 years of follow-up from BPD diagnosis and compared with a matched cohort. Associations were estimated as hazard ratios (HR) with 95% CIs from Cox regression. 12,175 individuals were diagnosed with BPD (85.3% female). Individuals diagnosed with BPD had higher cumulative incidences and HRs for nearly all analyzed indicators, especially psychiatric disorders. Anxiety disorders were most common (cumulative incidence 95% CI 33.13% [31.48-34.73]). Other notable findings from Cox regressions include psychotic disorders (HR 95% CI 24.48 [23.14-25.90]), epilepsy (3.38 [3.08-3.70]), violent crime victimization (7.65 [7.25-8.06]), and self-harm (17.72 [17.27-18.19]). HRs in males and females with BPD had overlapping CIs for nearly all indicators. This indicates that a BPD diagnosis is a marker of vulnerability for negative events and poor physical and mental health similarly for both males and females. Having a sibling with BPD was associated with an increased risk for psychiatric disorders, trauma, and adverse behaviors but not somatic disorders. Clinical implications include the need for increased support for patients with BPD navigating the health care system.

Psychobiological Correlates of Aggression in Female Adolescents with Borderline Personality Disorder

INTRODUCTION

Aggressive behavior in reaction to threats, frustration, or provocation is prevalent in borderline personality disorder (BPD). This study investigated aggressive behavior and its biological correlates in adolescents with BPD.

METHODS

Twenty-one female adolescents with a DSM-IV BPD diagnosis and 25 sex- and age-matched healthy controls participated in the Taylor Aggression Paradigm (TAP), a laboratory-based experiment measuring aggressive behavior in the interpersonal context. Heart rate was measured and saliva samples were taken throughout the experiment.

RESULTS

Multilevel mixed-effects linear regression analyses revealed no significant group difference in aggressive behavior induced by the TAP. Additionally, the two groups did not differ in cortisol, testosterone, and heart rate responses to the aggression induction. The BPD group showed a significant cortisol increase in the time preceding the start of the TAP in contrast to the healthy control group, in whom a significant heart rate increase from baseline to the first block of the TAP was observed.

DISCUSSION

There was no evidence, either at the phenomenological or the biological level, of increased task-induced aggression in adolescents with BPD. The results may indicate that adolescents with BPD experienced fearful stress in anticipation of the experimental task in contrast to healthy controls who showed an adaptive response of the autonomic nervous system necessary to deal with the upcoming demand.

Borderline Personality Disorder Diagnosis and Symptoms in Outpatient Youth as Risk Factors for Criminal Offenses and Interpersonal Violence

The aim of the current study was to examine the risk for offending among outpatient youth with borderline pathology. Demographic and diagnostic data from 492 outpatients who attended a public mental health service for 15-to 25-year-olds between January 1998 and March 2008 were linked with information regarding criminal offenses and intervention orders collected from a statewide police database between March 1993 and June 2017. BPD diagnosis and number of BPD criteria were both associated with an elevated risk for violent and nonviolent offenses and family violence intervention orders. Moderation analyses revealed that the number of BPD criteria might affect males and females differently in terms of offending. Both impulsivity and anger independently predicted the risk for violent and nonviolent offenses and family violence intervention orders. Early detection of increased risk of offending among youth with BPD features is essential to develop targeted treatments for criminal or violent behavior.

The dual mediating roles of impulsivity and emotion regulation of the borderline personality disorder-violence relationship: A structural equation modeling approach

Although the past research has indicated that features of borderline personality disorder (BPD) increase the risk for violence, much less research has examined the mediators of this relationship. This study examined the mediating roles that impulsivity and emotion dysregulation may play in explaining the relationship between BPD and violence. The Pathways to Desistance data were used in analyses. Generalized structural equation modeling was used to estimate the direct effect of BPD features on violent offending risk and to examine the mediating roles of emotion dysregulation and impulsivity. Results indicated that the direct effect of BPD symptoms on violence was mediated to non-significance by key constructs, and the magnitude of the effect was reduced by around 40%. The total indirect effect was significant, and the mediation was attributed mainly to impulsivity. This indicates the importance of structuring treatment programming for BPD patients around impulsivity for reducing violence. Programming focused on improving impulsivity among individuals suffering from BPD may aid in reducing violent offending among this population, particularly those prior histories of involvement with the criminal justice system.

Exploratory comparison of auditory verbal hallucinations and other psychotic symptoms among youth with borderline personality disorder or schizophrenia spectrum disorder

OBJECTIVE

This study explored phenomenological aspects of auditory verbal hallucinations (AVH) and other psychotic symptoms among youth with borderline personality disorder (BPD).

METHODS

Sixty-eight outpatients, aged 15 to 25 years, were categorized into three groups according to their primary Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis and AVH symptom profile; BPD + AVH (n = 23), schizophrenia spectrum disorder (SZ) + AVH (n = 22) and BPD with no AVH (n = 23).

RESULTS

No differences in AVH were found between BPD + AVH and SZ + AVH. Compared with SZ + AVH, BPD + AVH scored lower on delusions and difficulty in abstract thinking and higher on hostility. BPD + AVH reported more severe self-harm, paranoid ideation, dissociation, anxiety and stress than BPD no AVH.

CONCLUSIONS

This study replicates, in a sample of youth, the finding from studies of adults that AVH in BPD are indistinguishable from those in SZ, when assessed with the Psychotic Symptom Rating Scales (PSYRATS). Clinicians should specifically enquire about AVH among youth with BPD. When present, AVH appear to be an indicator of a more severe form of BPD.

Reviewing the clinical significance of 'fear of abandonment' in borderline personality disorder

OBJECTIVES:

To review and highlight the clinical significance of the symptom 'fear of abandonment' in borderline personality disorder (BPD).

METHODS:

A systematic search of the literature was conducted using MEDLINE and PubMed, employing search terms including 'fear of abandonment', 'borderline personality disorder' and 'rejection'. The most relevant English-language articles and books were selected for this review.

RESULTS:

Fear of abandonment is widely recognised as a core symptom in BPD; a biopsychosocial explanation for the occurrence of the symptom is presented. While fear of abandonment may differ in its clinical presentation, it has a significant impact on therapeutic engagement, suicidal behaviour and non-suicidal self-injury, clinical management and prognosis. Most evidence based psychotherapies for BPD address the phenomenon of fear of abandonment; however, the lack of specifically targeted treatment interventions is disproportionate to its prominence and clinical significance.

CONCLUSIONS:

Given its defining role in BPD, we recommend fear of abandonment as an important subject of future research and a specific therapy target.

Mortality of young offenders: a national register-based follow-up study of 15- to 19-year-old Finnish delinquents referred for forensic psychiatric examination between 1980 and 2010

BACKGROUND

The mortality rate of young offenders is high. Furthermore, mortality in young offenders is associated with psychiatric and substance use disorders. The primary aim of this national register-based follow-up study was to investigate the mortality rate of Finnish delinquents who underwent a forensic psychiatric examination between 1980 and 2010. As delinquency is not a solid entity, we further aimed to compare the risk of premature death among different subgroups of the delinquents; violent versus non-violent offenders, offenders with alcohol use disorders versus those with no such diagnoses, offenders with schizophrenia spectrum disorders versus conduct- and personality-disordered offenders, under-aged versus young adult offenders, and, finally, boys versus girls.

METHODS

We collected the forensic psychiatric examination reports of all 15- to 19-year-old offenders who were born in Finland and had undergone the examination between 1.1.1980 and 31.12.2010 (n = 606) from the archives of the National Institute of Health and Welfare and retrospectively reviewed them. For each delinquent, four age-, gender- and place of birth-matched controls were randomly selected from the Central Population Register (n = 2424). The delinquents and their controls were followed until the end of 2015. The median follow-up time was 23.9 years (interquartile range 15.3-29.5). We obtained the mortality data from the causes of death register. Deaths attributable to a disease or an occupational disease were considered natural, and those attributable to an accident, suicide or homicide were considered unnatural.

RESULTS

By the end of the follow-up period, 22.1% (n = 134) of the delinquents and 3.4% (n = 82) of their controls had died (OR 8.11, 95% CI 6.05-10.86, p < 0.001). Among boys, 22.0% (n = 121) of the delinquents and 3.7% (n = 81) of the controls had died (OR 7.38, 95% CI 5.46-9.95, p < 0.001). Male delinquents' risk of unnatural death was almost 11-fold, of natural death more than twofold, and of unclear death more than fourfold compared to that of their controls. No girls had natural or unclear deaths, but 23.6% (n = 13) of the delinquents and 0.5% (n = 1) of the controls had died due to unnatural causes (OR 67.79, 95% CI 8.63-532.00, p < 0.001). The violent delinquents' risk of premature death was twice that of the non-violent delinquents. The other comparisons demonstrated no statistically significant differences between subgroups.

CONCLUSIONS

Even though the Finnish correction system prefers psychiatric treatment and rehabilitation over criminal sanctions, and the national health care system offers developmental-phase-specific psychiatric care, the mortality rate of delinquents, especially of those with a history of violent offences, is high. The excess mortality of offenders can be regarded as a specific public-health inequity that calls for more effective intervention procedures than those used thus far.

Serious delinquency and later schizophrenia: A nationwide register-based follow-up study of Finnish pretrial 15- to 19-year-old offenders sent for a forensic psychiatric examination

BACKGROUND

Aggressive and disruptive behaviors often precede the onset of schizophrenia. In this register-based follow-up study with a case-control design, we wanted to investigate if serious delinquency was associated with future diagnoses of schizophrenia or schizoaffective disorder (here, broadly defined schizophrenia) among a nationwide consecutive sample of 15- to 19-year-old Finnish delinquents sent for a forensic psychiatric examination in 1989-2010.

METHODS

The sample comprised 313 delinquents with no past or current psychotic disorder. For each delinquent, four age-, gender- and place of birth -matched controls were randomly selected from the Central Population Register. Five controls (0.4%) had been treated for schizophrenia before their respective index-dates and were thus excluded from further analysis, leaving us with a control population of 1247 individuals. The subjects were followed till death, emigration or the end of 2015, whichever occurred first. Diagnoses were obtained from the Care Register for Health Care.

RESULTS

Forty (12.8%) of the delinquents and 11 (0.9%) of the controls were diagnosed with schizophrenia later in life (HR 16.6, 95% CI 8.53-32.39, P<0.001). Almost half of the pretrial adolescents with later schizophrenia were diagnosed within 5years of the forensic psychiatric examination, but latency was longer among the other half of the sample, reaching up to 20.5years.

CONCLUSIONS

The study supports the previous research indicating a potential link between serious delinquency and later schizophrenia. Accurate psychiatric assessments should be made in correctional services but also later in life so that any possible psychotic symptoms can be detected in individuals with a history of serious delinquency even if there were no signs of psychosis before or at the time of the crime. Future research should explore which factors influence the delinquent's risk of developing later schizophrenia.