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Masland SR, Victor SE, Peters JR, Fitzpatrick S, Dixon-Gordon KL, Bettis AH, Navarre KM, Rizvi SL. Destigmatizing Borderline Personality Disorder: A Call to Action for Psychological Science. PERSPECTIVES ON PSYCHOLOGICAL SCIENCE 2023; 18:445-460. [PMID: 36054911 DOI: 10.1177/17456916221100464] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite recognition that borderline personality disorder (BPD) is one of the most stigmatized psychological disorders, destigmatization efforts have thus far focused on the views and actions of clinicians and the general public, neglecting the critical role that psychological science plays in perpetuating or mitigating stigma. This article was catalyzed by recent concerns about how research and editorial processes propagate stigma and thereby fail people with BPD and the scientists who study BPD. We provide a brief overview of the BPD diagnosis and its history. We then review how BPD has been stigmatized in psychological science, the gendered nature of BPD stigma, and the consequences of this stigmatization. Finally, we offer specific recommendations for researchers, reviewers, and editors who wish to use science to advance our understanding of BPD without perpetuating pejorative views of the disorder. These recommendations constitute a call to action to use psychological science in the service of the public good.
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Affiliation(s)
| | - Sarah E Victor
- Department of Psychological Sciences, Texas Tech University
| | - Jessica R Peters
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University
| | | | | | - Alexandra H Bettis
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center
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2
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Ellison WD, Huprich S, Behn A, Goodman M, Kerr S, Levy KN, Nelson SM, Sharp C. Attitudes, Clinical Practices, and Perceived Advocacy Needs of Professionals With Interests in Personality Disorders. J Pers Disord 2023; 37:1-15. [PMID: 36723421 DOI: 10.1521/pedi.2023.37.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Experts in personality disorders (PDs) generally prefer dimensional diagnostic systems to categorical ones, but less is known about experts' attitudes toward personality pathology diagnoses in adolescents, and little is known about public health shortfalls and advocacy needs and how these might differ geographically. To fill these gaps, the International Society for the Study of Personality Disorders surveyed 248 professionals with interests in PDs about their attitudes toward different diagnostic systems for adults and adolescents, their PD-related clinical practices, and perceived advocacy needs in their area. Results suggested that dimensional diagnostic systems are preferable to categorical and that skepticism about personality pathology in adolescents may not be warranted. The most pressing advocacy need was the increased availability of PD-related services, but many other needs were identified. Results provide a blueprint for advocacy and suggest ways that professional societies can collaborate with public health bodies to expand the reach of PD expertise and services.
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Affiliation(s)
| | - Steven Huprich
- Department of Psychology, University of Detroit Mercy, Detroit, Michigan
| | - Alex Behn
- School of Psychology, Pontificia Universidad Católica de Chile and Millennium Institute for Research in Depression and Personality, Santiago, Chile
| | - Marianne Goodman
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, Bronx, New York
| | - Sophie Kerr
- Department of Psychology, University of Houston, Houston, Texas
| | - Kenneth N Levy
- Department of Psychology, The Pennsylvania State University, University Park, Pennsylvania
| | - Sharon M Nelson
- Serious Mental Illness Treatment, Resource, and Evaluation Center, Veterans Health Administration, Ann Arbor, Michigan
| | - Carla Sharp
- Department of Psychology, University of Houston, Houston, Texas
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Wu T, Hu J, Davydow D, Huang H, Spottswood M, Huang H. Demystifying borderline personality disorder in primary care. Front Med (Lausanne) 2022; 9:1024022. [PMID: 36405597 PMCID: PMC9668888 DOI: 10.3389/fmed.2022.1024022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 10/12/2022] [Indexed: 11/05/2022] Open
Abstract
Borderline personality disorder (BPD) is a common mental health diagnosis observed in the primary care population and is associated with a variety of psychological and physical symptoms. BPD is a challenging disorder to recognize due to the limitations of accurate diagnosis and identification in primary care settings. It is also difficult to treat due to its complexity (e.g., interpersonal difficulties and patterns of unsafe behaviors, perceived stigma) and healthcare professionals often feel overwhelmed when treating this population. The aim of this article is to describe the impact of BPD in primary care, review current state of knowledge, and provide practical, evidence-based treatment approaches for these patients within this setting. Due to the lack of evidence-based pharmacological treatments, emphasis is placed on describing the framework for treatment, identifying psychotherapeutic opportunities, and managing responses to difficult clinical scenarios. Furthermore, we discuss BPD treatment as it relates to populations of special interest, including individuals facing societal discrimination and adolescents. Through this review, we aim to highlight gaps in current knowledge around managing BPD in primary care and provide direction for future study.
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Affiliation(s)
- Tina Wu
- Warren Alpert Medical School, Brown University, Providence, RI, United States
- Butler Hospital, Providence, RI, United States
- *Correspondence: Tina Wu,
| | - Jennifer Hu
- Duke University Hospital, Durham, NC, United States
- Jennifer Hu,
| | | | - Heather Huang
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Margaret Spottswood
- Community Health Centers of Burlington, Burlington, VT, United States
- Department of Psychiatry, University of Vermont College of Medicine, Burlington, VT, United States
| | - Hsiang Huang
- Cambridge Health Alliance, Cambridge, MA, United States
- Harvard Medical School, Boston, MA, United States
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Broadbear JH, Rotella J, Lorenze D, Rao S. Emergency department utilisation by patients with a diagnosis of borderline personality disorder: An acute response to a chronic disorder. Emerg Med Australas 2022; 34:731-737. [PMID: 35352872 PMCID: PMC9790754 DOI: 10.1111/1742-6723.13970] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/03/2022] [Accepted: 03/07/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Patients with borderline personality disorder (BPD) are likely to attend the ED while experiencing crises and associated self-injury and suicidality. Our study describes the prevalence, features, and outcomes associated with ED presentations by patients diagnosed with BPD in Outer Eastern Melbourne, Australia. METHODS A retrospective electronic audit of 157 364 ED attendances identified 700 unique BPD-related ED presentations between May 2015 and April 2016. For the purpose of comparison, 583 (81% female) of these 700 cases were matched with 'depression only' cases. ED re-presentation data were also extracted. RESULTS The 583 matched BPD patients attended ED a total of 2807 times during the audit year compared with 1092 attendances for matched depression-only patients. BPD patients were more likely to: arrive by ambulance (50%); have comorbid substance abuse (44%); have a psychotic (15%) or bipolar disorder (17%); be under the care of a psychiatrist (31%); be case-managed (42%); and be admitted to an inpatient unit (21%). ED doctors saw 38% of BPD or depression patients within the recommended time according to their triage category. The majority (73%) of BPD patients attended ED more than once during the audit year (average 4.81 ± 6.63 times; range 2-78). CONCLUSION Repeated ED attendance of a subset of patients diagnosed with BPD highlights both the severity of their presentation and the inadequacy of community mental health services for meeting their complex needs. Development of effective ED referral pathways with follow-up to engage patients in BPD-appropriate treatment will reduce the likelihood of crises and reliance on hospital EDs for acute episodic care.
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Affiliation(s)
- Jillian H Broadbear
- Spectrum Personality Disorder ServiceMelbourneVictoriaAustralia,Faculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourneVictoriaAustralia
| | | | - Donna Lorenze
- School of Nursing, Midwifery and Social SciencesCentral Queensland UniversityMackayQueenslandAustralia
| | - Sathya Rao
- Spectrum Personality Disorder ServiceMelbourneVictoriaAustralia,Faculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourneVictoriaAustralia
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Hooke GR, Savani P, Stewart B, Araujo S, Page AC. Illustrating routine outcomes monitoring at different points in a patient's journey: Inpatient then daypatient treatment of a patient with depressive and borderline symptoms. J Clin Psychol 2022; 78:2041-2053. [PMID: 35909385 PMCID: PMC9546316 DOI: 10.1002/jclp.23426] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 07/12/2022] [Accepted: 07/19/2022] [Indexed: 11/08/2022]
Abstract
Routine outcomes monitoring (ROM), combined with a psychotherapeutic intervention, can improve outcomes by assisting therapists in supporting patients who are off track to achieve a better treatment endpoint. While many ROM systems are suitable for particular clinical contexts, psychotherapy delivered in a hospital setting presents unique challenges. People can be treated as inpatients and daypatients, and psychotherapy may be delivered in multiple formats (e.g., closed and open groups; group and individual). The present case study will illustrate the adaptation of ROM to this environment with an 18-year-old woman with Borderline Personality Disorder. The patient was successfully treated with Dialectical Behavior Therapy as both an inpatient and daypatient. The case demonstrates the use of ROM systems and illustrate they are sufficiently flexible to accommodate these complexities of routine care.
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Affiliation(s)
- Geoff R Hooke
- Perth Clinic, West Perth, Western Australia, Australia.,School of Psychological Science, University of Western Australia, Perth, Western Australia, Australia
| | - Prachi Savani
- Perth Clinic, West Perth, Western Australia, Australia
| | - Brent Stewart
- Perth Clinic, West Perth, Western Australia, Australia
| | | | - Andrew C Page
- School of Psychological Science, University of Western Australia, Perth, Western Australia, Australia
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The prevalence of borderline personality features and borderline personality disorder during the perinatal period: a systematic review and meta-analysis. Arch Womens Ment Health 2022; 25:277-289. [PMID: 35217928 DOI: 10.1007/s00737-022-01218-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/20/2022] [Indexed: 11/02/2022]
Abstract
Borderline personality disorder (BPD) is a psychiatric disorder marked by severe affective instability and poor interpersonal functioning. Existing literature has highlighted that individuals with BPD are at greater risk for a wide range of adverse physiological and psychosocial outcomes in the perinatal period compared to perinatal individuals without BPD. However, to date, no systematic review has addressed the prevalence of BPD and borderline personality features (BPF) in pregnant and postpartum individuals. A systematic review and meta-analysis was conducted by searching three databases (PubMed, PsycINFO, and Embase) on April 6th, 2021. Research articles and conference abstracts that evaluated BPF or BPD in pregnant, postpartum, or mixed perinatal populations were included. Sixteen publications were included in the systematic review (n = 14 research articles, n = 2 conference abstracts), seven of which were included in the meta-analysis. Among non-clinical samples, prevalence rates of BPF during pregnancy ranged from 6.9 to 26.7%, while rates of BPD across the perinatal period ranged from 0.7 to 1.7%. Among clinical samples, rates of BPF and BPD across the perinatal period spanned 9.7-34% and 2.0-35.2%, respectively. Results from the meta-analysis revealed that the pooled prevalence rate of BPD in clinical samples during the perinatal period is 14.0% (95% CI [7.0, 22.0]). Among clinical perinatal samples, there is a high prevalence of borderline personality pathology. This review highlights the need for appropriate validated screening methods to identify and treat BPD in the perinatal population.
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Shapiro-Thompson R, Fineberg SK. The State of Overmedication in Borderline Personality Disorder: Interpersonal and Structural Factors. CURRENT TREATMENT OPTIONS IN PSYCHIATRY 2022; 9:1-13. [PMID: 36185615 PMCID: PMC9524237 DOI: 10.1007/s40501-021-00255-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Purpose of review a)This review paper describes the state of prescribing practice in Borderline Personality Disorder (BPD), wherein medications are prescribed far more than either evidence or practice guideline would recommend. First, we describe the frequencies of medication use and polypharmacy in people with BPD. Recent findings b)In subsequent sections, we elaborate two main categories of factors that lead to overmedication of people with BPD: the interpersonally mediated and the structural. We consider interpersonally mediated factors to arise from communications of patients in distress and the well-meaning efforts of their prescribers to provide relief for certain overwhelming affective states. We are particularly focused on patterns of countertransference in prescribing that are directly linked to specific aspects of BPD pathology. We consider structural factors to arise from the complexities of medical and medicolegal systems and the contemporary patterns of financing medical care; we postulate that these complexities often compel prescribers to start medications, with associated disincentives for decreasing or discontinuing those medications over time. Summary c)More research is needed to understand how to best use medications in BPD, for example in targeted combination with psychotherapeutic and psychosocial interventions. However, current practice often departs markedly from the evidence. We recommend the dissemination of accessible, generalist BPD-treatment models in outpatient and inpatient practice; increased early detection of BPD; and increased diagnostic disclosure. We also recommend for individual providers and systems to implement prospective treatment plans that draw from BPD-specific psychosocial models. This approach can employ tiers of interventions to minimize reactive prescribing by anticipating high affect and offering BPD patients steadily empathic evidence-supported care.
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Wall K, Kerr S, Sharp C. Barriers to care for adolescents with borderline personality disorder. Curr Opin Psychol 2020; 37:54-60. [PMID: 32853877 DOI: 10.1016/j.copsyc.2020.07.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 07/29/2020] [Indexed: 12/22/2022]
Abstract
Intervention for borderline personality disorder (BPD) in adolescence is crucial as early onset of the disorder predicts more severe course, and intervention 'late' in the course of the disorder is associated with more negative outcomes. In spite of this, access to services is poor. This is because several unique barriers to accessing care exist for adolescents with BPD. In this article we highlight key barriers to care for adolescents with BPD utilizing a conceptual model for understanding health care access that emphasizes the interaction between patient and health care system characteristics. We conclude with proposed recommendations to address these identified barriers.
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Dhaliwal K, Danzig A, Fineberg SK. Improving Research Practice for Studying Borderline Personality Disorder: Lessons From the Clinic. ACTA ACUST UNITED AC 2020; 4:2470547020912504. [PMID: 32518886 PMCID: PMC7254581 DOI: 10.1177/2470547020912504] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 02/23/2020] [Indexed: 12/25/2022]
Abstract
Borderline personality disorder is an often misunderstood and underdiagnosed mental illness characterized in part by affective lability. Clinicians’ unique understanding of the disorder has allowed them to develop disorder-specific approaches to treatment. In this review, we highlight how borderline personality disorder research can benefit from greater engagement with key disorder-specific features, including symptom variability and interpersonal sensitivity. In addition, we propose that research which employs interactive tasks will be more reflective of the kinds of volatility found in the real-life situations. Finally, we discuss how mixed-methodology can serve as a way for recovery-oriented research to practice the very ideals and recommendations it suggests. We use a patient case to contextualize each section. As interest in borderline personality disorder continues to grow, an intentional emphasis on a person-centered, recovery-focused, and disorder-specific approach to research is needed.
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Affiliation(s)
- Khushwant Dhaliwal
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Ayala Danzig
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Sarah K Fineberg
- Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA
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Iliakis EA, Sonley AKI, Ilagan GS, Choi-Kain LW. Treatment of Borderline Personality Disorder: Is Supply Adequate to Meet Public Health Needs? Psychiatr Serv 2019; 70:772-781. [PMID: 31138059 DOI: 10.1176/appi.ps.201900073] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This study aimed to assess the supply of and demand for treatment of borderline personality disorder (BPD) to inform current standards of care and training in the context of available resources worldwide. METHODS The total supply of mental health professionals and mental health professionals certified in specialist evidence-based treatments for BPD was estimated for 22 countries by using data from publicly available sources and training programs. BPD prevalence and treatment-seeking rates were drawn from large-scale national epidemiological studies. Ratios of treatment-seeking patients to available providers were computed to assess whether current systems are able to meet demand. Training and certification requirements were summarized. RESULTS The ratio of treatment-seeking patients with BPD to mental health professionals (irrespective of professionals' interest or training in treating BPD) ranged from approximately 4:1 in Australia, the Netherlands, and Norway to 192:1 in Singapore. The ratio of treatment-seeking patients to clinicians certified in providing evidence-based care ranged from 49:1 in Norway to 148,215:1 in Mexico. Certification requirements differed by treatment and by country. CONCLUSIONS Shortages of both providers available to treat BPD and providers certified in specialist treatments of BPD exist in most of the 22 countries studied. In well-resourced countries, training clinicians to provide generalist or abbreviated treatments for BPD, in addition to specialist treatments, could help address the current implementation gap. More resource-efficient alternatives must be considered in countries with insufficient staff to implement even generalist treatments. Consideration of realistic allocation of care may shape future guidelines and standards of BPD treatments, beyond intensive evidence-based psychotherapies.
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Affiliation(s)
- Evan A Iliakis
- Adult Borderline Center and Training Institute, McLean Hospital, Belmont, Massachusetts (Iliakis, Ilagan, Choi-Kain); Center for Addiction and Mental Health, University of Toronto, Toronto (Sonley); Department of Psychiatry, Harvard Medical School, Boston (Choi-Kain)
| | - Anne K I Sonley
- Adult Borderline Center and Training Institute, McLean Hospital, Belmont, Massachusetts (Iliakis, Ilagan, Choi-Kain); Center for Addiction and Mental Health, University of Toronto, Toronto (Sonley); Department of Psychiatry, Harvard Medical School, Boston (Choi-Kain)
| | - Gabrielle S Ilagan
- Adult Borderline Center and Training Institute, McLean Hospital, Belmont, Massachusetts (Iliakis, Ilagan, Choi-Kain); Center for Addiction and Mental Health, University of Toronto, Toronto (Sonley); Department of Psychiatry, Harvard Medical School, Boston (Choi-Kain)
| | - Lois W Choi-Kain
- Adult Borderline Center and Training Institute, McLean Hospital, Belmont, Massachusetts (Iliakis, Ilagan, Choi-Kain); Center for Addiction and Mental Health, University of Toronto, Toronto (Sonley); Department of Psychiatry, Harvard Medical School, Boston (Choi-Kain)
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