A naturalistic longitudinal study of extended inpatient treatment for adults with borderline personality disorder: An examination of treatment response, remission and deterioration

Women with disabilities, body image, and wellbeing: Assessing the effectiveness of dance sessions

INTRODUCTION

There is growing research evidence on bodily discourses and body image issues of women with disabilities. Within the art-based intervention repertoire for persons with disabilities, dance and movement-based therapies and interventions are gaining prominence. The aim of this study was to examine the impact of dance sessions (delivered online) on body image, body satisfaction/dissatisfaction, and wellbeing of women with disabilities.

METHOD

A quasi-experimental waitlist control design study was conducted with data collected at two time points: baseline or pre-test and five-months later or post-test. Outcomes were measured using the Body Image Scale and the WHO-5-Wellbeing Index.

RESULTS

The dance sessions were effective (Hedges' g = -0.56 -0.88; p < 0.01) and post-test body dissatisfaction scores were lower and wellbeing scores were higher for participants with a college degree or postgraduate degree, self-employed or students, and whose intervention compliance was above threshold (>50% dance sessions attended and corresponding homework sessions completed). Tobit regression models indicated that it was possible to estimate post-test outcomes due to dance sessions alone, controlling for significant socio-demographics.

DISCUSSION

The domain knowledge of non-pharmacological art-based interventions for persons with disabilities, particularly women, is supported.

CONCLUSIONS

Findings commend dance sessions as effective psychotherapeutic mechanisms to mitigate body dissatisfaction, improve body image and wellbeing of women with disabilities. Future research may focus on large-scale cross-sectional trials, variations in the repertoire for women with different disability types and histories, and qualitative narratives.

Therapeutic and Preventive Interventions in Adolescents with Borderline Personality Disorder: Recent Findings, Current Challenges, and Future Directions

BACKGROUND

Borderline personality disorder (BPD) has long suffered from overshadowing in adolescents and hopelessness from the psychiatrists themselves. Comprehensive guidelines for this age group are lacking.

AIMS

This narrative review aims to describe current recommendations for BPD and recent empirical evidence on effective treatments (both pharmacological and non-pharmacological) and preventive approaches. Innovative approaches, based on recent and original research on BPD adolescents, are also discussed.

RESULTS

Very low-certainty evidence has supported that medication has a positive effect on core BPD symptoms in adolescents. Medication prescribed for suicidal crises or associated disorders should be included in a global therapeutic plan, including efficacy reassessment, treatment duration, and a security plan. The overall benefit of structured psychotherapy for adolescents with BPD (cognitive behavioral therapy, mentalization-based therapy, dialectic behavioral therapy, and group therapy) is more important for self-harm behaviors than other BPD symptoms. Their specific efficacy, although difficult to distinguish from the overall non-specific effect of integrative care.

CONCLUSIONS

structured care of young BPD individuals should be based on the following principles: (1) setting the frame of care, including recognition of the diagnosis, and sharing information with patients and families about symptoms, prognosis, and putative psychological mechanisms involved; and (2) promoting comprehensive approaches, including both specific and non specific therapy, ecological interventions, community care, and preventive interventions in at-risk groups.

[Towards a pragmatic cohabitation of theoretical and clinical models: The example of "Good Psychiatric Management" in the treatment of borderline personality disorder]

Borderline personality disorder (BPD) is a common disorder in general and clinical populations and is related to potentially severe medical and socio-professional consequences. Treatment of BPD is based on evidence-based psychotherapies (such as Dialectical Behavioral Therapy, Mentalization-Based Therapy, Schema-Focused Therapy or Transference Focused Psychotherapy), which have been shown effective but are poorly available in France. Pharmacological treatments, which are more easily available, are not effective in treating symptoms of the disorder but can be useful in management of comorbidities. In this context, recently called "generalist" models have been developed, which every well-trained psychiatrist can implement in their daily practice, combining practical elements from evidence-based psychotherapies and elements of pharmacological management of symptoms and comorbidities. The purpose of this article is to present one of these models, the Good Psychiatric Management (GPM) and its basic principles and its applications, and to provide one of the first French-speaking resources about this model. In addition, beyond the practical elements proposed by the GPM, we discuss the deeper question that it raises, namely the question of a pragmatic integration of different theoretical and clinical models. Indeed, the treatment of BPD patients is at the junction of different conceptualizations of mental pathology (psychopathological, neurobiological) and different modalities of practice (psychotherapy, biological psychiatry). In a French context, that sometimes separates these two models, and in our opinion GPM constitutes an example of clinical collaboration which shows the interest of the combined role of psychiatrist-psychotherapist.

Borderline Personality Disorder: Comparison of Two Treatment Modalities

ABSTRACT

The aim of this study was to compare the effectiveness of two treatment modalities for patients diagnosed with borderline personality disorder (BPD). A total of 100 psychiatric patients diagnosed with BPD participated in this study. Among them, 50 patients were outpatients who attended the Reason and Emotion (RIO) program, and the remaining 50 were inpatients who were treated on psychotherapeutic ward at the same hospital. All the participants filled out the following battery of tests when entering the program/psychotherapy ward and 3 months later: Rosenberg's Self-Esteem Scale, Tennessee Self-Concept Scale (2nd ed), Barratt Impulsiveness Scale, The COPE Inventory, and the WHOQOL-BREF scale. The results showed significant positive effects of both treatment modalities on patients' self-esteem, different domains of self-concept, impulsivity, and different domains of subjective quality of life. No significant changes were observed in terms of coping strategies. Thus, the results speak in favor of the outpatient RIO program, which is more cost-effective than the inpatient ward treatment.

Pilot Study: Cut the Cut-A Treatment Program for Adolescent Inpatients with Nonsuicidal Self-Injury

Non-suicidal-self-injury (NSSI) in adolescents needing inpatient treatment is a serious health risk behaviour. NSSI-specific treatment programs for inpatients hardly exist. "Cut the Cut" (CTC) is a new treatment program in intervals, addressing this problem. Aim of this pilot-study was to evaluate acceptability and feasibility of CTC. 23 female inpatients (12 CTC, 11 control, aged 15-17; mean = 16.80, SD.70) engaging in NSSI were evaluated for service user satisfaction, frequency, and severity of NSSI at T1 (admission), T2 (discharge after interval 1, CTC-group) and T3 (discharge). A qualitative interview was performed at T3. Significant improvement in NSSI-frequency was given (T1-T3: CTC p = 0.010; control p = 0.038). Severity of NSSI reduced slightly (mild NSSI: CTC p = 0.022, control p = 0.087; severe NSSI: CTC p = 0.111, control p = 0.066). Satisfaction of parents (T3 mean 28.38) and adolescents (T3 mean 26.11) in CTC was rated high. CTC is a feasible treatment option for inpatients engaging in NSSI. Further studies over time are needed.Trial registration Number DRKS00016762, 05.03.2019, retrospectively registered.

Predicting depression outcomes throughout inpatient treatment using the general and specific personality disorder factors

BACKGROUND

Clinical intuition suggests that personality disorders hinder the treatment of depression, but research findings are mixed. One reason for this might be the way in which current assessment measures conflate general aspects of personality disorders, such as overall severity, with specific aspects, such as stylistic tendencies. The goal of this study was to clarify the unique contributions of the general and specific aspects of personality disorders to depression outcomes.

METHODS

Patients admitted to the Menninger Clinic, Houston, between 2012 and 2015 (N = 2352) were followed over a 6-8-week course of multimodal inpatient treatment. Personality disorder symptoms were assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th edition Axis II Personality Screening Questionnaire at admission, and depression severity was assessed using the Patient Health Questionnaire-9 every fortnight. General and specific personality disorder factors estimated with a confirmatory bifactor model were used to predict latent growth curves of depression scores in a structural equation model.

RESULTS

The general factor predicted higher initial depression scores but not different rates of change. By contrast, the specific borderline factor predicted slower rates of decline in depression scores, while the specific antisocial factor predicted a U shaped pattern of change.

CONCLUSIONS

Personality disorder symptoms are best represented by a general factor that reflects overall personality disorder severity, and specific factors that reflect unique personality styles. The general factor predicts overall depression severity while specific factors predict poorer prognosis which may be masked in prior studies that do not separate the two.

Validation of the WHO-5 Well-Being Scale among Adolescents in Ghana: Evidence-Based Assessment of the Internal and External Structure of the Measure

The WHO-5 well-being measure happens to be one of the most renowned measures of subjective well-being across the globe. Although the instrument has been calibrated in different countries, its psychometric properties and applicability in Africa, especially in Ghana, are not known. In this study, the WHO-5 well-being scale was validated among adolescents in Ghana by assessing the validity evidence of the measure based on the internal and external structure. In particular, the study examined the (1) dimensionality of the WHO-5 well-being scale, (2) quality of the items (including the scale functioning) for the measure, and (3) criterion validity of the well-being measure. Using a survey approach, 997 adolescents were recruited in secondary schools across the northern belt of Ghana. The study found a one-factor structure of the scale, which supports the factor solution of the original measure. The items were found to be of high quality, except for one item. The WHO-5 well-being measure was found to have sufficient evidence regarding convergent and divergent validity. The outcome of this validation study provides support for the validity and reliability of the WHO-5 well-being scale’s utility and use among adolescents in Ghana. The study encourages further validation studies to be conducted in Ghana to widen the reproducibility of the WHO-5 well-being measure.

Psychiatric admissions after hospital presented deliberate self-harm in the young: A national study

Follow-up psychiatric care is crucial for young adults presenting to hospitals because of deliberate self-harm (DSH). However, who receives such care is not sufficiently understood. We therefore investigated the clinical and sociodemographic correlates of admissions to psychiatric inpatient treatment immediately following general hospital treatment of DSH in this age band. All episodes of hospital presented DSH among patients aged 18-35 years during the period 2008-2018 were identified from the Norwegian Patient Register. The outcome was admissions to psychiatric inpatient treatment immediately after discharge from the general hospital. The correlates of such admissions were calculated using binomial generalized estimating equation. Of 26.166 identified DSH episodes, 21.4% were admitted to psychiatric inpatient treatment. Admissions were most common for patients with a history of psychiatric treatment and a recorded diagnosis of psychosis-, mood- or personality disorders. Adjusted for other psychiatric factors, alcohol- or substance misuse diagnoses and repeated presentations of DSH were inversely associated with admissions to psychiatric inpatient treatment. Young adults admitted to psychiatric inpatient treatment following DSH have a high burden of psychiatric morbidity and risk factors for suicide. However, the inverse association seen for two important risk factors for suicide, alcohol- or substance misuse and repeated DSH, warrants further attention.

Improving treatment outcomes for adolescents with borderline personality disorder through a socioecological approach

BACKGROUND

There is a dearth of studies evaluating treatment efficacy for adolescents diagnosed with borderline personality disorder. The few available randomized controlled trials that have been conducted show modest results and treatments appear to have equivalent effects. The current paper draws on (a) the lessons learnt from the last 50 years of psychotherapy research in general and (b) recent advances in mentalization-based understanding of why treatment works, which together point to the importance of following a socioecological approach in the treatment of personality problems in adolescence - a developmental period that insists on a treatment approach that goes beyond the therapist-client dyad.

CASE PRESENTATION

Here, we describe such an approach, and offer a clinical case example with a young 16-year old girl diagnosed with borderline personality disorder, to illustrate what a shift toward a more socioecological approach would entail.

CONCLUSIONS

The clinical impact of the socioecological approach and the potential benefits as illustrated in the current case illustration, offers a framework that justifies and allows for the expansion of service delivery for youth with borderline personality disorder beyond dyadic therapist-client work.

Functional Rehabilitation: An Integrated Treatment Model for Patients With Complex Physical and Psychiatric Conditions

The health care delivery system in the United States, structured to provide single-disease care, presents unique challenges for patients with complex physical and psychiatric comorbidities. Patients in these populations are often referred to multiple specialty clinics, encounter little continuity of care or collaboration among their providers, incur high health care costs, and experience poor treatment outcomes. Given these barriers, questions remain about the extent to which siloed and fragmented care, as opposed to the complex nature of the illnesses themselves, contribute to poor outcomes. If given the opportunity to receive well-integrated, consistent, and personalized care, can patients with historically difficult-to-treat comorbid medical and mental illnesses make progress? This article describes an innovative model of care called functional rehabilitation that is designed to address existing barriers in treatment. The functional rehabilitation program seeks to disrupt the escalating effects of interacting comorbidities by offering highly collaborative treatment from a small team of clinicians, personalized interventions using a shared decision-making framework, multipronged treatment options, colocation in a large hospital system, and significant 1:1 time with patients. The article includes a case example with longitudinal outcome data that illustrates how progress can be made with appropriate programmatic supports. Future research should examine the cost-effectiveness of this model of care.

Trajectory Curves for Purposes of Benchmarking and Predicting Clinical Outcomes: A Scoping Review

Trajectory curves are valuable tools to benchmark patient health status and predict future outcomes. A longitudinal study is underway to examine social participation after burn injury using the Life Impact Burn Recovery Evaluation (LIBRE) Profile with the goal of developing trajectory curves for specific domains that focus on social reintegration. We conducted a scoping review to inform and understand trajectory curves applied in clinical settings to compare outcomes for an individual to a matched cohort of comparable patients or predicted expected outcomes over time. This scoping review utilized a PubMed search from January 2014 to August 2019 for the following terms: "trajectory curves" or "trajectory models" and "clinic" or "clinical." Only articles that specifically referenced longitudinal and clinical research designs were included in the scoping review. Articles were assessed using standard scoping review methods and categorized based on clinical application of trajectory curves for either benchmarking or prediction. The initial literature review identified 141 manuscripts and 34 met initial inclusion criteria. The reviewed articles support the clinical use of trajectory curves. Findings provide insight into several key determinants involved with the successful development and implementation of trajectory curves in clinical settings. These findings will inform efforts to use the LIBRE Profile to model social participation recovery and assist in developing effective strategies using trajectory curves to promote social reintegration after burn injury.

Short-term and 1-year outcome of patients' with borderline personality admitted to a short-term recovery-oriented residential service

OBJECTIVES

Given the paucity of literature, this study investigated whether a prevention and recovery care (PARC) service supported recovery in patients with borderline personality disorder (BPD).

METHOD

This retrospective study included patients with BPD who had their first (index) admission to North West PARC between 2011 and 2016. Patient medical records and the state-wide database were the sources of information.

RESULTS

Of the 67 patients included, over 70% attended group activities. All patients achieved their recovery goals, either fully or partially. Compared to admission, the frequency of substance use and the Health of the Nation Outcome Scale (HoNOS) scores at discharge were significantly less. A significantly smaller number of patients needed inpatient treatment during the 12 months following their PARC admission.

CONCLUSION

The PARC service appears to promote clinical and psychosocial recovery in patients with BPD.

Communicating suicide risk to families of chronically suicidal borderline personality disorder patients to mitigate malpractice risk

OBJECTIVE

The distinction between acute and chronic suicidality is important, because interventions designed to address acute suicidality can worsen chronic suicidality, resulting in an escalating cycle of suicide threats, suicide attempts, and futile hospitalizations. Though most chronically suicidal borderline personality disorder patients improve and do not complete suicide, the potential for suicide contributes to these hospitalizations and a paucity of outpatient services due to treaters' concern over malpractice lawsuits in case of suicide. Communicating with patients' families about the suicide risk has been suggested as a means to mitigate this malpractice risk, but the approach to such communication has not been described.

METHOD

Once chronic suicidality is identified, a stepwise approach to communicating with the patient's family is described.

RESULTS

The potential benefits of this risk communication are described, for patients, families, treaters, healthcare systems, and health and malpractice insurers.

CONCLUSION

It helps to develop an alliance with families and patients around a shared understanding of outcomes in chronic suicidality - most eventually do better, but the risk of completed suicide is real. This enables patients and families to make a more fully informed choice about treatment, which in turn can reduce litigation risk in the minority of cases where the patient completes suicide.

Lifetime and prospective associations among personality trait domains and suicide-related behaviors in patients with severe mental illness

BACKGROUND

Despite extensive research and clinical efforts, the suicide rate in the United States continues to rise, driving the need for more research to identify latent factors that increase risk for suicide and to guide treatment decision-making.

METHODS

The current study examined a large cohort (N = 1,219) of high-risk psychiatric inpatients to explore associations between personality traits and suicide-related variables measured retrospectively (lifetime history prior to hospital admission) and prospectively (at discharge and 12-month follow-up).

RESULTS

Lifetime suicide-related behavior (SRB: combination of ideational severity, aborted, interrupted, actual attempts, and non-suicidal self-injury) was associated with age (younger), gender (female), and elevated scores on the Personality Inventory for DSM-5 (PID-5) negative affectivity, borderline trait composite score, and five-factor model traits of conscientiousness and neuroticism. Patients who manifested persistent suicidal ideation throughout a 6-8 week inpatient treatment (n = 162; 16.9%) tended to be younger, female, and to have elevated PID-5 borderline trait composite scores. Twelve-month post-discharge SRB was predicted by elevated PID-5 borderline trait composite scores.

LIMITATIONS

Personality traits accounted for a small amount of variance in the overall model, thus limiting prediction based on individual traits.

CONCLUSIONS

This large sample of high-risk inpatients with longitudinal outcomes provides a rare assessment of proximal personality traits in predicting lifetime SRB, persistent suicidal ideation observed during the course of a 6-8-week intensive inpatient treatment, and SRB outcomes within 12 months after discharge from hospitalization. Personality traits should be included in future attempts to create predictive algorithms that include relevant biological data (neuroimaging, genetic, microbiome).

Suicidality in Borderline Personality Disorder

Borderline personality disorder (BPD) is associated with suicidal behaviors and self-harm. Up to 10% of BPD patients will die by suicide. However, no research data support the effectiveness of suicide prevention in this disorder, and hospitalization has not been shown to be useful. The most evidence-based treatment methods for BPD are specifically designed psychotherapies.

Mental health presentations to acute psychiatric services: 3-year study of prevalence and readmission risk for personality disorders compared with psychotic, affective, substance or other disorders

BACKGROUND

The relative burden and risk of readmission for people with personality disorders in hospital settings is unknown.AimsTo compare hospital use of people with personality disorder with that of people with other mental health diagnoses, such as psychoses and affective disorders.

METHOD

Naturalistic study of hospital presentations for mental health in a large community catchment. Mixed-effects Cox regression and survival curves were generated to examine risk of readmission for each group.

RESULTS

Of 2894 people presenting to hospital, patients with personality disorder represented 20.5% of emergency and 26.6% of in-patients. Patients with personality disorder or psychoses were 2.3 times (95% CI 1.79-2.99) more likely than others to re-present within 28 days. Personality disorder diagnosis increases rate of readmission by a factor of 8.7 (s.e. = 0.31), marginally lower than psychotic disorders (10.02, s.e. = 0.31).

CONCLUSIONS

Personality disorders place significant demands on in-patient and emergency departments, similar to that of psychoses in terms of presentation and risk of readmission.Declaration of interestNone.