The 24-year course of major depression in patients with borderline personality disorder and personality-disordered comparison subjects

Course and clinical correlates of obsessive-compulsive disorder with or without comorbid personality disorder

BACKGROUND

Personality disorders (PDs) are often comorbid with obsessive-compulsive disorder (OCD) which may influence symptom presentation and course. This investigation sought to examine the impact of comorbid PDs on clinical presentation and symptom chronicity in a large, prospective longitudinal OCD study.

METHODS

Participants (n = 263) were treatment-seeking adults with a primary diagnosis of OCD separated into two groups: individuals with and without a co-occurring PD. We conducted two-tailed t-tests to compare symptom severity, functioning, and quality of life between the OCD + PD group (n = 117) and the OCD w/o PD group (n = 146). Chronicity analyses were conducted to compare the amount of time in-episode for OCD and major depressive disorder (MDD) between the two groups.

RESULTS

The OCD + PD group reported greater OCD and depression severity, lower levels of psychosocial functioning and worse quality of life than the OCD w/o PD group. The OCD + PD group exhibited greater OCD and MDD symptom chronicity; over 5 years the OCD + PD group spent 16.2 % weeks longer at full criteria for OCD and three times as many weeks in episode for MDD than the OCD w/o PD group.

LIMITATIONS

Focusing on PDs as a group limited our ability to make observations about specific PDs. Further, the participants in our sample were predominantly White and all were treatment seeking which limits the generalizability of our findings.

CONCLUSIONS

Our results suggest that those with OCD and comorbid PDs present with greater overall impairment and may require additional considerations during treatment conceptualization and planning.

Mental health disorders, functioning and health-related quality of life among extensively hospitalized patients due to severe self-harm - results from the Extreme Challenges project

Background

Severe self-harm leading to extensive hospitalization generates extreme challenges for patients, families, and health services. Controversies regarding diagnoses and health care often follow. Most evidence-based treatments targeting self-harm are designed for borderline personality disorder (BPD). However, current knowledge about mental health status among individuals with severe self-harm is limited.

Objectives

To investigate psychopathology among patients extensively hospitalized due to severe or frequent self-harming behaviors.

Method

A cross sectional study (period 2019-2021) targeting psychiatric inpatients (>18 years) with frequent (>5) or long (>4 weeks) admissions last year due to self-harm. The target sample (N = 42, from 12 hospitals across all Norwegian health regions) was compared to individuals admitted to outpatient personality disorder (PD) treatment within specialist mental health services in the same period (N = 389). Clinicians performed interviews on self-harm and psychopathology, supplemented by self-report.

Results

The target sample were young adults, mainly female, with considerable hospitalization and self-harming behaviors, both significantly more extensive than the comparison group. The majority in both groups reported self-harm onset <18 years. The target sample reported increasing severity of self-harm acts and suicidal intention over time. Both samples had high levels of childhood trauma, impaired personality functioning, and a majority fulfilled criteria for PD. In the target sample, comorbid depression, PTSD, anxiety disorders, and substance use occurred more frequently and in 50%, psychosis/dissociative disorder/autism spectrum disorder/ADHD was reported (outpatient comparison sample: 9%). 35% in the target sample screened over cut-off for possible intellectual disability. The target sample reported poor psychosocial functioning and health-related quality of life - greater impairment than the outpatient comparison sample.

Conclusion

The study reveals that severe self-harm inpatients have complex psychopathology and highlights the importance of individualized and thorough assessment among patients with severe and/or repetitive self-harm.

Course and predictors of social security disability insurance in patients with borderline personality disorder over 24 years of prospective follow-up

BACKGROUND

The utilization of Social Security Disability Insurance (SSDI) is frequent in patients with borderline personality disorder (BPD) and may represent a meaningful marker of a patient's symptom severity, poor psychosocial functioning, and/or inner suffering. Over 24 years of prospective follow-up, the present study aims to describe the course of SSDI and assess the role of clinically relevant predictors.

METHODS

A total of 290 inpatients with BPD were interviewed at baseline and 12 consecutive follow-up waves, each separated by two years, after index hospitalization. Included were also 72 inpatients with other personality disorders. Surviving patients were reinterviewed. A series of interviews and self-report measures were used to assess psychosocial functioning and treatment history, axis I and II disorders, and childhood/adult adversity.

RESULTS

Results show that rates of SSDI utilization were relatively stable over 24 years of follow-up (on average, 47.2% of the patients with BPD were on SSDI). Patients with BPD were three times more likely to be on SSDI than patients with other PDs. Patients with BPD displayed flexibility in their usage of SSDI. By 24 years, 46% of patients remitted, out of which 85% experienced recurrence and 50% of the patients had a new onset over time. In multivariate analyses, four variables were found to predict SSDI status in patients with BPD over time. These variables were: age 26 or older, lower IQ, severity of non-sexual childhood abuse, and presence of PTSD.

CONCLUSIONS

The results of this study suggest that a combination of a demographic factors, childhood adversity, natural endowment, and comorbidity are significant predictors of receiving SSDI over time. On a group level, there is a relative stability of SSDI usage over time, but on the individual level, the present study found a high fluctuation in receiving SSDI over 24 months of prospective follow-up.

Clinical determinants of hospital treated deliberate self-harm repetition: A time to recurrent event analysis

INTRODUCTION

Psychiatric disorders are strongly associated with hospital treated deliberate self-harm (DSH). However, the effect of specific disorders on risk for DSH repetition in sex-age-subgroups is understudied. The present study aims to assess the influence of various specific psychiatric disorders on risk for subsequent DSH repetition by way of time to recurrent event analysis on a national cohort of DSH patients.

MATERIAL AND METHODS

Individuals aged 18 and older presenting to somatic hospital for DSH during the period 2008-2018 was identified through national registers. A parametric shared frailty survival analysis was used to investigate the impact of various psychiatric disorders on risk of DSH repetition.

RESULTS

The cohort consisted of 39,508 individuals of which 8634 (21.8%) presented with 24,028 repeated episodes of hospital treated DSH. Borderline personality disorder increased the risk of DSH repetition in females (adjusted HR 1.49, CI 1.41-1.57), while alcohol use disorder (HR 1.12, CI 1.04-1.19) and substance use disorders (adjusted HR 1.22, CI 1.14-1.32) increased the risk of repetition in males. The strongest impact of psychiatric disorder on risk of repetition was found among the elderly. Previous history of DSH was associated with the highest increased risk of repetition.

CONCLUSION

Prior history of DSH was strongly associated with DSH repetition, but the influence of psychiatric disorder varied significantly by specific diagnoses and by sex and age of the patients. Efforts to prevent DSH repetition should be age and gender specific and designed to meet the needs of people with different specific psychiatric disorders.

Personality change in the Nottingham Study of Neurotic Disorder: 30-Year cohort study

BACKGROUND

Persistence is said to be a feature of personality disorder, but there are few long-term prospective studies of the condition. A total of 200 patients with anxiety and depressive disorders involved in a randomised controlled trial initiated in 1983 had full personality status assessed at baseline. We repeated assessment of personality status on three subsequent occasions over 30 years.

METHODS

Personality status was recorded using methods derived from the Personality Assessment Schedule, which has algorithms for allocating Diagnostic and Statistical Manual of Mental Disorders (DSM) and the 11th International Classification of Diseases (ICD-11) categories. The category and severity of personality diagnosis were recorded at baseline in the randomised patients with DSM-III anxiety and depressive diagnoses. The same methods of assessing personality status was repeated at 2, 12 and 30 years after baseline.

RESULTS

Using the ICD-11 system, 47% of patients, mainly those with no personality disturbance at baseline, retained their personality status; of the others 16.8% improved and 20.4% worsened to more severe disorder. In DSM-III diagnosed patients, those diagnosed as Cluster A and Cluster C increased in frequency (from 14% to 40%, p < 0.001, and 21.5% to 36%, p < 0.001, respectively) over follow-up, while those with Cluster B showed little change in frequency (22% to 18%, p = 0.197).

CONCLUSION

In this population of patients with common mental disorders, personality status showed many changes over time, inconsistent with the view that personality disorder is a persistent or stable condition. The increase in diagnoses within the Cluster A and C groups suggests personality disorder generally increases in frequency as people age.

Mental Health Workers' Attitudes Towards Individuals With a Diagnosis of Borderline Personality Disorder: A Systematic Literature Review

The attitudes of mental health workers toward individuals with mental health conditions can impact the quality of care they provide. Negative attitudes among mental health workers seem particularly common in response to people diagnosed with borderline personality disorder (BPD). The current review aimed to identify and review the literature regarding mental health workers' attitudes toward individuals diagnosed with BPD, specifically focusing on studies comparing workers' attitudes toward BPD with attitudes toward other mental health diagnoses. The findings suggest that mental health workers have more negative attitudes toward individuals labeled as having BPD than toward individuals with other diagnoses, such as depression. This is likely due to factors associated with the label itself, in addition to workers' perceptions of BPD symptoms and previous experiences of delivering treatment. The implications of these findings are considered, with a particular focus on how mental health services can effectively address negative attitudes toward BPD.

Epicardial adipose tissue and adrenal gland volume in patients with borderline personality disorder

Borderline personality disorder (BPD) is associated with an elevated mortality risk that is partially attributed to suicide, but few studies examined other possible causes of premature death. The present study compared epicardial adipose tissue (EAT) volume as a known early predictor of premature cardiovascular morbidity, cardiovascular risk indices, and adrenal gland volume (AGV) as an indicator for chronic hypothalamus-pituitary-adrenal (HPA) axis activation in females with borderline personality disorder (BPD), major depressive disorder (MDD) and in healthy individuals. Twenty-eight patients with BPD comorbid with MDD (BPD/MDD), 22 MDD patients and 26 healthy females (CTRL) of comparable age were included. EAT and AGV were assessed by magnetic resonance tomography; 10-year cardiovascular risk and diabetes risk were determined by PROCAM and FINDRISK score; metabolic syndrome was defined following National Cholesterol Education Adult Treatment Panel III R (NCEP/ATP III) criteria. MADRS was used to assess depression severity. After adjustment for age, body mass index (BMI), and physical activity, EAT and AGV were significantly increased in BPD/MDD compared to MDD and CTRL. EAT and AGV displayed a positive correlation. Finally, diabetes risk in BPD/MDD was elevated compared to CTRL and MDD. The present study highlights the increased cardiometabolic risk of BPD patients. We identify EAT accumulation as an early predictor and potential mediator of cardiovascular disease in BPD that appears to be driven at least in part by HPA axis dysregulation. Therefore, interventions that reduce EAT volume (i.e. exercise and diet) should be considered in the clinical management of BPD.

Altered immediate behavioral response to partial social exclusion: A cross-diagnostic study in patients with borderline personality disorder and persistent depressive disorder

Borderline personality disorder (BPD) and persistent depressive disorder (PDD) are related to interpersonal dysfunction which might become particularly apparent in situations of social exclusion (SE). While emotional responses to SE have been widely explored, behavioral data in clinical samples are lacking. In this cross-diagnostic study, we applied a variant of the Cyberball paradigm to investigate the dynamic behavioral response to partial SE in BPD and PDD. BPD patients (n = 36), PDD patients (n = 34) and age and gender matched healthy controls (HC) (total n = 70) played experimental (i.e. partial SE Cyberball) and control (i.e. inclusion only) conditions in randomized order. While all groups tended to increase ball tosses towards the excluder in response to SE, this behavioral turn was significantly lower in PDD (p = .03, d = -.30) and trendwise in BPD patients (p = .06, d = -.28). Thus, an altered immediate response to partial SE was observed in BPD and PDD, in addition to the emotional reactions. This study supports the hypothesis of a behavioral coping with SE in BPD and PDD that might be problematic in the long run and provides an experimental paradigm for future research on interpersonal dysfunction.

The Impact of Attachment on Depression in Married Seniors: Chain Mediating Effects of Self-Esteem and Rumination

In this study, we discuss the effects of attachment on depression and the mediating roles of self-esteem and rumination in Chinese seniors. We assessed 431 using the Experiences in Close Relationships Inventory, the Rosenberg Self-Esteem Scale, the Ruminative Responses Scale, and the Short Form of Center for Epidemiologic Studies Depression Scale. Both attachment anxiety and attachment avoidance significantly predicted depression in seniors. Attachment anxiety and attachment avoidance positively predicted rumination but negatively predicted self-esteem. Structural equation models showed that rumination and self-esteem fully mediated the effects of attachment anxiety and attachment avoidance on depression. The attachment of seniors is related to depression, and self-esteem and rumination have chain mediating effects between attachment and depression.

Personality Disorders and Their Relation to Treatment Outcomes in Cognitive Behavioural Therapy for Depression: A Systematic Review and Meta-analysis

Background

Previous reviews indicate that depressed patients with a comorbid personality disorder (PD) tend to benefit less from psychotherapies for depression and thus personality pathology needs to be the primary focus of treatment. This review specifically focused on studies of Cognitive Behavioural Therapy (CBT) for depression examining the influence of comorbid PD on post-treatment depression outcomes.

Methods

This was a systematic review and meta-analysis of studies identified through PubMed, PsychINFO, Web of Science, and Scopus. A review protocol was pre-registered in the PROSPERO database (CRD42019128590).

Results

Eleven eligible studies (N = 769) were included in a narrative synthesis, and ten (N = 690) provided sufficient data for inclusion in random effects meta-analysis. All studies were rated as having “low” or “moderate” risk of bias and there was no significant evidence of publication bias. A small pooled effect size indicated that patients with PD had marginally higher depression severity after CBT compared to patients without PD (g = 0.26, [95% CI: 0.10, 0.43], p = .002), but the effect was not significant in controlled trials (p = .075), studies with low risk of bias (p = .107) and studies that adjusted for intake severity (p = .827). Furthermore, PD cases showed symptomatic improvements across studies, particularly those with longer treatment durations (16–20 sessions).

Conclusions

The apparent effect of PD on depression outcomes is likely explained by higher intake severity rather than treatment resistance. Excluding these patients from evidence-based care for depression is unjustified, and adequately lengthy CBT should be routinely offered.

Clinical traits of patients with major depressive disorder with comorbid borderline personality disorder based on propensity score matching

BACKGROUND

Major depressive disorder (MDD) with comorbid borderline personality disorder (BPD) makes the clinical symptoms of patients more complex and more difficult to treat, so more attention should be paid to the recognition of their clinical features. This study investigated the differences between patients with MDD with and without BPD in clinical traits.

METHODS

Propensity score matching was used to analyze the retrospective patients' data from August 2012 to September 2019. Altogether, 1381 patients with MDD were enrolled; 38 patients with MDD were matched to compare demographic data, and scores on the Hamilton Depression Scale, Hamilton Anxiety Scale (HAMA), Self-Rating Depression Scale (SDS), Modified Overt Aggression Scale (MOAS), and the frequency of nonsuicidal self-harm (NSSH).

RESULTS

Compared to patients with MDD without BPD, the age of onset of patients with MDD with comorbid BPD was significantly earlier (t = 3.25, p = .00). The scores of HAMA (t = -2.28, p = .03), SDS (t = 9.31, p = .00), MOAS (t = -13.67, p = .00), verbal aggression (t = -3.79, p = .00), aggression against objects (t = -2.84, p = .00), aggression against others (t = -6.70, p = .00), and aggression against self (t = -9.22, p = .00) were significantly higher in patients with MDD with comorbid BPD. Moreover, the frequency of NHSS in these patients was significantly higher (χ²  = 20.13, p = .00). MOAS was an independent influencing factor in these (odds ratio = 7.38, p = .00).

CONCLUSIONS

Patients with BPD showed early onset and increased complaints relative to symptoms, accompanied by obvious anxiety symptoms, impulsive behavior, and NSSH. Therefore, patients with MDD with impulsive behavior have comorbid BPD.

Reciprocal Influences of Parent and Adolescent Borderline Personality Symptoms Over 3 Years

Leading etiological theories implicate the family environment in shaping borderline personality disorder (BPD). Although a substantive literature explores familial aggregation of this condition, most studies focus on parent influence(s) on offspring symptoms without examining youth symptom influence on the parent. The current study investigated reciprocal relations between parent and adolescent BPD symptoms over time. Participants were 498 dyads composed of urban-living girls and their parents enrolled in a longitudinal cohort study (Pittsburgh Girls Study). The authors examined BPD severity scores assessed yearly when youth were ages 15-17 years in a series of cross-lagged panel models. After controlling for autoregressive effects, a measure of parent-child conflict, and an indicator of socioeconomic status, evidence of parental influence on adolescent symptoms did not emerge. However, adolescent BPD symptoms at age 16 predicted greater parent BPD symptoms at age 17 above the influence of depression. Results highlight the importance of considering the influence of youth BPD on parental symptoms.

The Effect of Hopelessness and Perceived Group Compatibility on Treatment Outcome for Patients With Personality Dysfunction

Improvement in life satisfaction is hard to achieve for any patient with personality psychopathology, and possibly even moreso for those who feel hopeless at the start of treatment. The present research investigated the potential influence of hopelessness in the treatment of patients with personality dysfunction, using data from patients who completed an intensive group therapy program designed to reduce symptom distress and support optimal psychosocial functioning (N = 80). In the present study, we sought to examine whether hopelessness would moderate (i.e., strengthen or weaken) relations between compatibility ratings and life satisfaction outcome. Hopelessness had a significant moderating effect on the relationship between compatibility and outcome, suggesting that, for patients who entered treatment feeling more hopeless, higher appraisals of fit within the group facilitated better gains in life satisfaction. If replicated, the findings underlie the importance of focusing on increasing hope and perceived group affiliation in the treatment of personality dysfunction.