Registered prevalence of borderline personality disorder in primary care databases

Physical health, primary care utilization and long-term quality of life in borderline personality disorder: A 10-year follow-up study in a Spanish sample

OBJECTIVE

We aimed to study physical health and primary care utilization in the long-term course of borderline personality disorder (BPD) and their impact on quality of life (QOL) in a Spanish clinical sample.

METHODS

This study is part of a longitudinal study following a clinical cohort with BPD. A total of 41 participants were re-evaluated at 10-year follow-up, when current medical conditions, primary care utilization, and quality of life were assessed. Comparative population data were extracted from the Catalan Health Survey ESCA.

RESULTS

68% of BPD patients reported physical health problems, and 32% informed of multiple medical illnesses at follow-up. Higher rates of musculoskeletal disorders and frequent use of general practitioner (GP) consultations were reported by BPD patients compared to the general population. Differences in physical health and use of primary care services between remitted and non-remitted BPD patients were not significant. BPD remission was independently associated with better long-term QOL. Comorbid somatic diseases worsened the long-term QOL of non-remitted BPD patients.

CONCLUSION

Chronic somatic conditions are prevalent in people with BPD and interact negatively with persistent BPD pathology, worsening their QOL in the long-term. Health care strategies in the assistance of long-lasting BPD patients are recommended.

One-year prevalence and psychiatric comorbidity of borderline personality disorder in a medical certificate population: a registry study of psychiatric outpatients in community mental health care in the city of Oulu

OBJECTIVE

Borderline personality disorder (BPD) is a common disorder in healthcare settings but estimates of BPD prevalence vary greatly. This study aimed to estimate the one-year prevalence of BPD in psychiatric outpatients and analyze the psychiatric comorbidity presented with BPD.

METHOD

The data comprised 18-60-year-old patients who had a BPD diagnosis recorded in their medical certificate B (mcB) and were treated in specialized psychiatric outpatient services in the city of Oulu, northern Finland, in 2014. An mcB is a comprehensive summary of a patient's medical history written by a doctor, and patients need it in the Finnish healthcare system when applying for social benefits and rehabilitation measures.

RESULTS

The prevalence of BPD was 12.8% among patients with an mcB treated in the psychiatric outpatient services. BPD was 3.0 times more common in female than male psychiatric outpatients with an mcB. The most common comorbid psychiatric disorders written in mcBs of BPD patients were mood (81.0%) and anxiety (39.2%) disorders. The only statistically significant gender difference was found in behavioral and emotional disorders (16.7% in men, 1.6% in women).

CONCLUSIONS

The mcB-based BPD prevalence estimate and psychiatric comorbidity was consistent with previous studies researching psychiatric outpatients with BPD. McBs appear to be a reliable and comprehensive data source for diagnostic information in research.

The Prevalence and Clinical Characteristics of Borderline Personality Disorder in South Korea Using National Health Insurance Service Customized Database

PURPOSE

The purpose of the present study was to identify the prevalence and clinical characteristics of borderline personality disorder (BPD) in South Korea using the Korean National Health Insurance database (DB).

MATERIALS AND METHODS

We used the National Health Insurance Service (NHIS)'s research DB (NHIS-2021-1-790) from January 1, 2010 to December 31, 2019, to make customized DB including sociodemographic information and absence or presence of BPD and other psychiatric disorders. The prevalence and the age of onset of BPD was estimated. To compare medical service utilization between the BPD group and the control group, a 1:1:1 propensity score matching was employed, and the regression analysis was conducted.

RESULTS

The prevalence of BPD per 10000 people was 0.96 in 2010 and 1.06 in 2019. The prevalence ratio of males to females was 1:1.38 in 2010 and 1:1.65 in 2019, showing that BPD was more prevalent in females. The patients' overall average age of onset was 33.19±14.6 years, with the highest prevalence shown in 8503 people in their 20s. By administrative district, the highest prevalence of BPD per 10000 people was shown in Seoul with 8.71 and the lowest in Jeollanam-do with 2.35. The BPD patients showed a pattern of extensive use of general and mental healthcare services.

CONCLUSION

This study identified the prevalence of BPD on a national DB set in South Korea. Although the prevalence of BPD in South Korea was relatively low compared to other countries, there was a steady increase in the number of BPD patients over a decade, which may be possibly due to an increased awareness of mental health and campaigns among healthcare providers and users in the country.

Mental Health Workers' Knowledge and Attitude Towards Borderline Personality Disorder: A Saudi Multicenter Study

Background Borderline personality disorder (BPD) is a mental illness characterized by emotional instability. Its prevalence can be as high as 1.8% among the general population. Poor knowledge and negative perceptions of the disorder by mental health workers (MHWs) can affect patients' care and their help-seeking behavior. This study aims to explore MHW's knowledge and attitudes toward BPD. Method A cross-sectional study was conducted on MHWs across the five regions of Saudi Arabia (SA) using a questionnaire that assessed knowledge, attitude, and training regarding BPD. Results  Data collected from 1028 MHWs showed a good knowledge level. Superior knowledge was observed among females, residents in the central region, physicians, those who received specific BPD training, and MHWs who had more experience and frequent interactions with BPD patients. Participants had moderate to high levels of perceived knowledge and confidence regarding the identification, assessment, and management of BPD patients. Undergraduate training programs were the most reported source of information on the disorder. While 66% of participants admitted that they find dealing with BPD patients more difficult and thought patient management was inadequate, 71% were willing to attend further BPD training. Conclusion MHWs in SA have moderate knowledge of but negative perceptions of BPD; specific training is needed to improve the care provided for BPD patients.

Five Failures and Five Challenges for Prevention and Early Intervention for Personality Disorder

Despite global consensus regarding the early detection of personality disorder, current approaches to early intervention have failed to deliver for the majority of young people. This only serves to reinforce the enduring effects of personality disorder on functioning, mental and physical health, resulting in a reduction of quality of life and life expectancy. Here, we describe five significant challenges facing prevention and early intervention for personality disorder: identification, access to treatment, research translation, innovation and functional recovery. These challenges highlight the need for early intervention to shift from niche programmes in specialist services for a select few young people to become established in mainstream primary care and specialist youth mental health services. Reprinted from Curr Opin Psychol 2021; 37:134-138, with permission from Elsevier. Copyright © 2021.

The Pathogenesis of Borderline Personality Disorder: Evolution of Evidence and Treatment Implications for Two Prominent Models

Since Stern first started his work in 1938, the field has recognized several empirically supported models of the etiology of borderline personality disorder (BPD). Two such models are the Tripartite Model of the Development of BPD and the Biosocial Development Model of BPD. The Tripartite Model of the Development of BPD suggests that it is a combination of a hyperbolic temperament, traumatic childhood experiences, and an event or series of events that trigger the onset of BPD. Whereas the Biosocial Development Model of BPD elaborates on the work of Linehan's Biosocial Theory. This model suggests a combination of an emotionally vulnerable temperament and an invalidating environment cause BPD. Over 70 years of research support these models. This article covers a detailed description of each of these models, the decades of research supporting these models, similarities, differences, treatment implications, the latest research, and future directions.

Patients With Personality Disorders in Everyday Clinical Practice–Implications of the ICD-11

BACKGROUND

Patients with difficult personalities or personality disorders are a special challenge for primary care physicians. Their style of interpersonal interaction is often difficult. As the ICD-11 classification comes into use, a new systematic approach to diagnosis is being introduced that focuses on the patient's functional impairments in everyday life. We describe the implications for the diagnosis and treatment of patients of this type.

METHODS

This review is based on pertinent publications retrieved by a selective search, with particular attention to primary care and to somatic morbidity and mortality.

RESULTS

10-12% of the population suffers from personality disorders. A high degree of psychiatric comorbidity is typical; somatic diseases are also more than twice as common as in the general population. In emergency medicine, persons with personality disorders are more likely than others to present with a suicide attempt. Their lifetime risk of suicide is between 1.4% and 4.5% (the latter for persons with borderline personality disorder).

CONCLUSION

Primary care physicians have an important role in the initial diagnosis of patients with personality disorders and in the planning of their treatment. Such patients require special care and attention from their physicians in view of their elevated somatic morbidity and mortality. In everyday clinical practice, physicians who encounter patients with complex and persistent mental problems, or just with a difficult style of interpersonal interaction, should consider the possibility of a personality disorder and motivate such patients to undergo psychotherapy, if indicated.

Five failures and five challenges for prevention and early intervention for personality disorder

Despite global consensus regarding the early detection of personality disorder, current approaches to early intervention have failed to deliver for the majority of young people. This only serves to reinforce the enduring effects of personality disorder on functioning, mental and physical health, resulting in a reduction of quality of life and life expectancy. Here, we describe five significant challenges facing prevention and early intervention for personality disorder: identification, access to treatment, research translation, innovation and functional recovery. These challenges highlight the need for early intervention to shift from niche programmes in specialist services for a select few young people to become established in mainstream primary care and specialist youth mental health services.

Long-Acting Injectable Antipsychotics: Analysis of Prescription Patterns and Patient Characteristics in Mental Health from a Spanish Real-World Study

BACKGROUND AND OBJECTIVE

Long-acting injectable antipsychotics (LAIs) have been widely studied in schizophrenia and evidence suggests that they could be also used for the treatment of bipolar and schizoaffective disorders. Nonetheless, there are no studies evaluating their role in other psychiatric disorders. We aimed to evaluate the use of the newest monthly and 3-monthly LAIs-aripiprazole once monthly, paliperidone 1- and 3-monthly (PP1M, PP3M)-against the 2-weekly LAIs, using the following clinical outcomes: (1) the number of hospital re-admissions, (2) the number of documented suicidal behaviors/attempts, and (3) the use of concomitant treatments, including benzodiazepines, oral antipsychotics, and biperiden.

METHODS

A total of 431 patients were included who were treated with the corresponding LAI over at least 12 months and were previously diagnosed with a psychiatric disorder. Statistical analyses were performed using an ANCOVA model, Student's t test, and the Pearson's r test.

RESULTS

Our results showed significantly decreased re-admissions using PP3M versus the bi-weekly LAIs and aripiprazole once monthly, while no significant differences were found in suicidal behavior. Furthermore, we found a significantly lower intake of benzodiazepines in PP1M and PP3M groups versus the bi-weekly and aripiprazole once-monthly groups. In addition, patients treated with PP1M and PP3M used a significantly lower dose of haloperidol equivalents versus the bi-weekly LAIs group. Finally, significantly higher doses of biperiden were used by the bi-weekly LAIs group.

CONCLUSION

In conclusion, paliperidone LAIs reduced hospital re-admissions and, as aripiprazole once monthly, lowered concomitant psychiatric medication versus the bi-weekly LAIs. Further research and analysis of subgroups are needed; however, these findings might be useful for clinicians.

Cost of borderline personality disorder in Catalonia (Spain)

Introduction

The available information on the cost of illness of Borderline Personality Disorder (BPD) is overtly insufficient for policy planning. Our aim was to estimate the costs of illness for BPD in Catalonia (Spain) for 2006.

Methods

This is a multilevel cross-design synthesis study combining a qualitative nominal approach, quantitative ‘top-down’ analysis of multiple health databases, and ‘bottom-up’ data of local surveys. Both direct and indirect costs have been estimated from a governmental and societal perspective.

Results

Estimated year-prevalence of BPD was 0.7% (41,921 cases), but only 9.6% of these cases were treated in the mental health system (4033 cases). The baseline of the total cost of BPD in Catalonia was 45.6 million €, of which 15.8 million € (34.7%) were direct costs related to mental health care. The cost distribution was 0.4% in primary care; 4% in outpatient mental health care; 4.7% in hospitalisation; 0.7% in emergency care; and 24.9% in pharmacotherapy. Additionally, the cost of drug addiction treatment for persons with BPD was 11.2%; costs associated with sheltered employment were 23.9% and those of crime and justice were 9.7%. Indirect costs – including temporary sick leave and premature death (suicide) – represented 20.5% of total costs. The average annual cost per patient was 11,308 €.

Conclusions

An under-reporting of BPD was identified by the experts in all health databases and official registries. Most of the BPD costs were not related to mental health care. Amongst the direct cost categories, pharmacotherapy had the largest proportion despite the lack of specificity for BPD. This distribution of costs reinforces the idea of BPD complexity related to an inadequate and inefficient use of health resources.

Exploring General Practitioners' Views and Experiences of Providing Care to People with Borderline Personality Disorder in Primary Care: A Qualitative Study in Australia

The prevalence of people seeking care for Borderline Personality Disorder (BPD) in primary care is four to five times higher than in the general population. Therefore, general practitioners (GPs) are important sources of assessment, diagnosis, treatment, and care for these patients, as well as important providers of early intervention and long-term management for mental health and associated comorbidities. A thematic analysis of two focus groups with 12 GPs in South Australia (in discussion with 10 academic, clinical, and lived experience stakeholders) highlighted many challenges faced by GPs providing care to patients with BPD. Major themes were: (1) Challenges Surrounding Diagnosis of BPD; (2) Comorbidities and Clinical Complexity; (3) Difficulties with Patient Behaviour and the GP⁻Patient Relationship; and (4) Finding and Navigating Systems for Support. Health service pathways for this high-risk/high-need patient group are dependent on the quality of care that GPs provide, which is dependent on GPs' capacity to identify and understand BPD. GPs also need to be supported sufficiently in order to develop the skills that are necessary to provide effective care for BPD patients. Systemic barriers and healthcare policy, to the extent that they dictate the organisation of primary care, are prominent structural factors obstructing GPs' attempts to address multiple comorbidities for patients with BPD. Several strategies are suggested to support GPs supporting patients with BPD.

Community and Clinical Epidemiology of Borderline Personality Disorder

Several studies of the prevalence of borderline personality disorder in community and clinical settings have been carried out to date. Although results vary according to sampling method and assessment method, median point prevalence is roughly 1%, with higher or lower rates in certain community subpopulations. In clinical settings, the prevalence is around 10% to 12% in outpatient psychiatric clinics and 20% to 22% among inpatient clinics. Further research is needed to identify the prevalence and correlates of borderline personality disorder in other clinical settings (eg, primary care) and to investigate the impact of demographic variables on borderline personality disorder prevalence.

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.

[Screening for bipolar disorder in primary care patients with psychological symptoms]

Objetivo

Estimar la proporción de resultados positivos en el cribado del trastorno bipolar (TB) entre los pacientes de atención primaria que consultan por problemas de naturaleza psicológica, y analizar sus características.

Diseño

Estudio descriptivo transversal multicéntrico.

Emplazamiento

Diecinueve consultas de atención primaria en diferentes comunidades autónomas.

Pacientes

La muestra estuvo formada por 360 pacientes consecutivos de atención primaria con edades entre 18 y 70 años visitados por síntomas psicológicos.

Mediciones

El cribado para TB se realizó mediante el Mood Disorders Questionnaire. Se obtuvieron datos sobre calidad de vida (EuroQol-5D), impacto funcional (Sheehan Disability Inventory) y, mediante revisión de historias clínicas, datos sobre comorbilidad psiquiátrica y consumo de psicofármacos.

Resultados

Se obtuvo una proporción de cribados positivos del 11,9% (IC 95%: 8,8-15,7%). Solo en 2 de estos pacientes estaba registrado el diagnóstico de TB, y aunque más de la mitad recibían tratamiento con antidepresivos, solo 2 recibían tratamiento con estabilizadores del estado de ánimo. El cribado positivo se asocia a peor calidad de vida, a disfunción laboral, social y familiar, y a mayor estrés percibido.

Conclusiones

El cribado del TB en pacientes de atención primaria con otros problemas psicológicos da lugar a una notable proporción de resultados positivos, lo que indica que puede haber una prevalencia relevante de pacientes con TB, la mayor parte de ellos no diagnosticados y no tratados adecuadamente. Es necesario profundizar en la investigación para determinar el eventual papel que puede o debe asumir la atención primaria en la detección, el diagnóstico o el manejo de este trastorno.

Sleep and borderline personality disorder: a review

Sleep problems are very common among psychiatric patients. Borderline personality disorder, as a common and severe mental disorder, is associated with different types of sleep disturbances, such as disturbances of sleep continuity, altered REM sleep regulation and nightmares. These disturbances are the result of interaction of the personality traits, concomitant and comorbid diseases and environmental factors. Despite the high prevalence of sleep related disorders in BPD patients, this aspect of BPD is still neglected in clinical and research settings. To date there has been little agreement on sleep characteristics of BPD among different studies, and presence of some uncontrolled confounding factors, make interpretation of the results difficult. However, it seems that appropriate diagnosis and treatment of sleep disorders in BPD patients might lead to better outcome. This article aimed to review the current literature of sleep studies in BPD. Some recommendations and suggestions were made for future researches in this field.

Identification and location of hot and cold spots of treated prevalence of depression in Catalonia (Spain)

Background

Spatial analysis is a relevant set of tools for studying the geographical distribution of diseases, although its methods and techniques for analysis may yield very different results. A new hybrid approach has been applied to the spatial analysis of treated prevalence of depression in Catalonia (Spain) according to the following descriptive hypotheses: 1) spatial clusters of treated prevalence of depression (hot and cold spots) exist and, 2) these clusters are related to the administrative divisions of mental health care (catchment areas) in this region.

Methods

In this ecological study, morbidity data per municipality have been extracted from the regional outpatient mental health database (CMBD-SMA) for the year 2009. The second level of analysis mapped small mental health catchment areas or groups of municipalities covered by a single mental health community centre. Spatial analysis has been performed using a Multi-Objective Evolutionary Algorithm (MOEA) which identified geographical clusters (hot spots and cold spots) of depression through the optimization of its treated prevalence. Catchment areas, where hot and cold spots are located, have been described by four domains: urbanicity, availability, accessibility and adequacy of provision of mental health care.

Results

MOEA has identified 6 hot spots and 4 cold spots of depression in Catalonia. Our results show a clear spatial pattern where one cold spot contributed to define the exact location, shape and borders of three hot spots. Analysing the corresponding domain values for the identified hot and cold spots no common pattern has been detected.

Conclusions

MOEA has effectively identified hot/cold spots of depression in Catalonia. However these hot/cold spots comprised municipalities from different catchment areas and we could not relate them to the administrative distribution of mental care in the region. By combining the analysis of hot/cold spots, a better statistical and operational-based visual representation of the geographical distribution is obtained. This technology may be incorporated into Decision Support Systems to enhance local evidence-informed policy in health system research.