Etiological features of borderline personality related characteristics in a birth cohort of 12-year-old children

Compatibility of Linehan's biosocial theory and the DSM-5 Alternative Model of Personality Disorders for borderline personality disorder

Borderline personality disorder (BPD) is characterized by affective, interpersonal, and identity instability, as well as marked impulsivity. There is evidence that BPD may be best operationalized dimensionally using models such as the Alternative Model for Personality Disorders (AMPD) described in Section III of the Diagnostic and Statistical Manual for Mental Disorders (DSM). Moreover, biosocial theory is a well-known etiological theory of BPD emphasizing emotion dysregulation, inherited impulsivity, and development within invalidating contexts as key etiological mechanisms. Given that current research and clinical efforts for BPD are informed by both nosology and etiology, this narrative review examined how well biosocial theory (a) aligns with AMPD conceptualizations, (b) accounts for psychiatric comorbidity, and (c) accounts for heterogeneity in BPD presentation. Findings suggested that tenets of biosocial theory align well with Criteria A and B of the AMPD; however, biosocial theory focuses narrowly on roles of emotion dysregulation, impulsivity, and invalidating contexts, and empirical support is lacking in some ways for several etiological explanations proposed by biosocial theory. Additionally, although biosocial theory captures empirically supported features of BPD and emphasizes high-risk subgroups, the theory may not account for lower-risk subgroups. Finally, the theory accounts for diagnostic co-occurrence via the central role of emotion dysregulation, but biosocial theory may not be specific to BPD and may broadly apply to a range of psychopathology. Based on the literature reviewed, implications for future research and clinical efforts are highlighted.

Validating the biosocial model of borderline personality disorder: Findings from a longitudinal study

This longitudinal study aimed to validate the biosocial theory of borderline personality disorder (BPD) by examining the transactional relationship between individual vulnerabilities and parental invalidation, and their links to BPD symptoms. We recruited a sample of 332 adolescents (mean age = 14.18 years; 58.3% female) residing in Singapore and administered self-report measures across three time-points (six months apart). Results from our path analytic model indicated that parental invalidation, impulsivity, and emotional vulnerability exhibited unique predictive associations with emotion dysregulation six months later. There was also a reciprocal prospective relationship between emotion regulation difficulties and BPD symptoms. Using random-intercepts cross-lagged panel models, we found partial evidence for a within-individual reciprocal relationship between parental invalidation and emotional vulnerability, and a unidirectional relationship of within-individual changes in impulsivity positively predicting changes in parental invalidation six months later. Overall, the study provided partial empirical support for the biosocial model in a Singaporean context.

Childhood emotional abuse and alcohol use disorders in a national Nepali women sample: The mediating role of borderline personality traits

While many studies have found an association between childhood emotional abuse and alcohol use disorders (AUD) during adulthood, underlying psychological mechanisms linking the two remain inadequately understood. Drawing on the developmental psychopathology perspective, this study examined the relationship between childhood emotional abuse and AUD during adulthood with a national sample of women in Nepal (N = 1,100, M age = 37.73), focusing on the mediating role of borderline personality traits. Mediation analyses were performed using the Karlson-Holm-Breen (KHB) method and bootstrapping confidence intervals. Results indicated that Nepali women's borderline personality traits significantly mediated the relationship between childhood emotional abuse and AUD. Hence, emotional abuse in childhood increases the risk for AUD during adulthood for Nepali women by increasing the risk of borderline personality traits. Findings underscore the necessity of continued emphasis on developing and implementing early interventions for childhood emotional abuse and therapeutic interventions for borderline personality traits in reducing AUD among vulnerable women in Nepal.

Borderline personality disorder is an innate empathy anomaly: a scoping and narrative review

BACKGROUND

Studying empathy in borderline personality disorder (BPD) is essential because difficulties with interpersonal functioning are integral.

OBJECTIVES

This scoping and narrative review explores the aetiological theory that BPD is an innate anomaly of cognitive empathy, with a normal or heightened emotional empathy.

ELIGIBILITY CRITERIA AND SOURCES OF EVIDENCE

Ovid MEDLINE(R) ALL was searched using the terms empathy; theory of mind; mentalisation or mentalising; borderline empathy; emotion recognition and BPD. For inclusion in the scoping review, articles needed to empirically assess an empathic skill in people with BPD, or self-reported empathy in a BPD group compared to controls, or empathic skill as a 'borderline feature' in a nonclinical sample.

CHARTING METHOD

The results of empirical studies were categorised as per their methodological approach, with results in the BPD group reported as comparable, enhanced or reduced compared to controls.

RESULTS

320 articles were returned, with 38 eligible. The majority affirmed that people with BPD have an anomalous empathetic ability, especially a deficient cognitive empathy. Furthermore, this is trait, evident early in development, correlates with syndrome severity, and is mediated by atypical neural networks.

CONCLUSIONS

This substantiates the theory that BPD is, at least in major part, an innate empathy anomaly.

The role of youths' cardiac autonomic balance and parental responses to youth emotion in vulnerability to borderline personality disorder development

Developmental models of borderline personality disorder (BPD) emphasize the effects of youths' biological vulnerabilities and their experiences of parental responses to emotion, as well as the interaction between these two elements. The current study evaluated the independent and interactive effects of two indices of autonomic nervous system response and parental responses to youth negative emotions on severity and exacerbation of youths' BPD features during the transition to adolescence. The sample consisted of 162 psychiatric youth (10-14 years; 47.2% female) and their parents. At baseline, youth and their parents completed a lab-based conflict discussion during which parasympathetic and sympathetic nervous system response were measured and indices of sympathetic-parasympathetic balance and coactivation/coinhibition were calculated. Youth also reported on supportive and non-supportive parental responses. At baseline and after 9 months, youth self-reported on their BPD features. Results demonstrated that shifting toward sympathetic dominance independently predicted exacerbation of BPD across 9 months. Additionally, fewer experiences of supportive parental responses and more non-supportive parental responses were associated with greater severity of BPD features in youth. This study highlights the role of autonomic response to parent-child conflict as well as the significance of parental responses to youth emotion for the development of BPD during this developmental window.

Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies

Borderline personality disorder (BPD) was introduced in the DSM-III in 1980. From the DSM-III to the DSM-5, no major changes have occurred in its defining criteria. The disorder is characterized by instability of self-image, interpersonal relationships and affects. Further symptoms include impulsivity, intense anger, feelings of emptiness, strong abandonment fears, suicidal or self-mutilation behavior, and transient stress-related paranoid ideation or severe dissociative symptoms. There is evidence that BPD can be reliably diagnosed and differentiated from other mental disorders by semi-structured interviews. The disorder is associated with considerable functional impairment, intensive treatment utilization, and high societal costs. The risk of self-mutilation and suicide is high. In the general adult population, the lifetime prevalence of BPD has been reported to be from 0.7 to 2.7%, while its prevalence is about 12% in outpatient and 22% in inpatient psychiatric services. BPD is significantly associated with other mental disorders, including depressive disorders, substance use disorders, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, bipolar disorder, bulimia nervosa, and other personality disorders. There is convincing evidence to suggest that the interaction between genetic factors and adverse childhood experiences plays a central role in the etiology of BPD. In spite of considerable research, the neurobiological underpinnings of the disorder remain to be clarified. Psychotherapy is the treatment of choice for BPD. Various approaches have been empirically supported in randomized controlled trials, including dialectical behavior therapy, mentalization-based therapy, transference-focused therapy, and schema therapy. No approach has proved to be superior to others. Compared to treatment as usual, psychotherapy has proved to be more efficacious, with effect sizes between 0.50 and 0.65 with regard to core BPD symptom severity. However, almost half of the patients do not respond sufficiently to psychotherapy, and further research in this area is warranted. It is not clear whether some patients may benefit more from one psychotherapeutic approach than from others. No evidence is available consistently showing that any psychoactive medication is efficacious for the core features of BPD. For discrete and severe comorbid anxiety or depressive symptoms or psychotic-like features, pharmacotherapy may be useful. Early diagnosis and treatment of BPD can reduce individual suffering and societal costs. However, more high-quality studies are required, in both adolescents and adults. This review provides a comprehensive update of the BPD diagnosis and clinical characterization, risk factors, neurobiology, cognition, and management. It also discusses the current controversies concerning the disorder, and highlights the areas in which further research is needed.

Etiopathogenesis in the Development of Borderline Personality Characteristics in Children and Adolescents

The validity and clinical significance of the characteristics of borderline personality disorder (BPD) in adolescents are increasingly being recognized. The persistence of BPD characteristics in adolescence is high and is associated with negative interpersonal, academic, professional, and financial outcomes. In the literature, BPD characteristics observed in children and adolescents are explained with psychodynamic theories, developmental models, and evolutionary approaches. Emotional dysregulation, interpersonal dysfunction, impulsivity, and self-harming behavior, negative life events, temperament characteristics, neuropsychological dysfunctions, neuroanatomical, genetic, hormonal, and immunological factors may play a role in BPD etiopathogenesis. This review aims to address different approaches and relevant factors for the development of BPD. The articles published between 1968-2021 in the PubMed database were reviewed, and prominent studies were selected for evaluation. The importance of invalidating environment, epistemic freezing and hypermentalization, complex or attachment trauma is emphasized in psychodynamic and developmental literature. In the evolutionary approach, on the other hand, romantic relationships and the onset of reproduction are emphasized as the reason for the emergence of symptoms during adolescence, and it is argued that BPD is related to the rapid life history strategy. It is stated that a decrease in volume in the orbitofrontal cortex and anterior cingulate cortex, which are involved in top-down emotional processing, and an increase in the activity of thalamus and hippocampus regions, which are involved in bottom-up emotional processing are observed in adolescents with BPD characteristics when compared to healthy controls. It is thought that the increase in activation in the superior temporal gyrus and precuneus observed in adolescents with BPD features is a neural indicator of hypermentalization, and the increase in activation in the insula is a neural indicator of social pain. It has been reported that the decrease in resting heart rate and the increase in heart rate variability observed in adolescents with BPD symptoms are associated with the activation of the parasympathetic system. BPD in adolescents is a disorder that challenges clinicians in terms of diagnosis, differential diagnosis, and treatment. It is crucial to evaluate the factors related to etiopathogenesis in BPD in a multifaceted and detailed manner. Keywords: Borderline Personality Disorder, Difficulty in Emotion Regulation, Mentalization, Trauma, Self-harming Behavior, Temperamental Characteristics.

Neighbourhood characteristics and the treated incidence rate of borderline personality pathology among young people

OBJECTIVE

The impact of the wider social environment, such as neighbourhood characteristics, has not been examined in the development of borderline personality disorder. This study aimed to determine whether the treated incidence rate of full-threshold borderline personality disorder and sub-threshold borderline personality disorder, collectively termed borderline personality pathology, was associated with the specific neighbourhood characteristics of social deprivation and social fragmentation.

METHOD

This study included young people, aged 15-24 years, who attended Orygen's Helping Young People Early programme, a specialist early intervention service for young people with borderline personality pathology, from 1 August 2000-1 February 2008. Diagnoses were confirmed using the Structured Clinical Interview for DSM-IV Personality Disorders, and census data from 2006 were used to determine the at-risk population and to obtain measures of social deprivation and fragmentation.

RESULTS

The study included 282 young people, of these 78.0% (n = 220) were female and the mean age was 18.3 years (SD = ±2.7). A total of 42.9% (n = 121) met criteria for full-threshold borderline personality disorder, and 57.1% (n = 161) had sub-threshold borderline personality disorder, defined as having three or four of the nine Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) borderline personality disorder criteria. There was more than a sixfold increase in the treated incidence rate of borderline personality pathology in the neighbourhoods of above average deprivation (Quartile 3) (incidence rate ratio = 6.45, 95% confidence interval: [4.62, 8.98], p < 0.001), and this was consistent in the borderline personality disorder sub-groups. This association was also present in the most socially deprived neighbourhood (Quartile 4) (incidence rate ratio = 1.63, 95% confidence interval: [1.10, 2.44]), however, only for those with sub-threshold borderline personality disorder. The treated incidence of borderline personality pathology increased incrementally with the level of social fragmentation (Quartile 3: incidence rate ratio = 1.93, 95% confidence interval: [1.37, 2.72], Quartile 4: incidence rate ratio = 2.38, 95% confidence interval: [1.77, 3.21]).

CONCLUSION

Borderline personality pathology has a higher treated incidence in the more socially deprived and fragmented neighbourhoods. These findings have implications for funding and location of clinical services for young people with borderline personality pathology. Prospective, longitudinal studies should examine neighbourhood characteristics as potential aetiological factors for borderline personality pathology.

Mother-child interactions in adolescents with borderline personality disorder traits and the impact of early life maltreatment

BACKGROUND

Early detection and intervention of borderline personality disorder (BPD) in adolescence has become a public health priority. Theoretical models emphasize the role of social interactions and transgenerational mechanisms in the development of the disorder suggesting a closer look at caregiver-child relationships.

METHODS

The current study investigated mother-adolescent interactions and their association with adolescent BPD traits by using a case-control design. Thirty-eight adolescent patients with ≥ 3 BPD traits and their mothers (BPD-G) were investigated in contrast to 35 healthy control dyads (HC-G). Maternal, adolescent and dyadic behavior was coded using the Coding Interactive Behavior Manual (CIB) during two interactions: a fun day planning and a stress paradigm. Additional effects of maternal and/or adolescent early life maltreatment (ELM) on behavior were also explored.

RESULTS

BPD-G displayed a significantly lower quality of maternal, adolescent and dyadic behavior than the HC-G during both interactions. Maternal and adolescent behavior was predicted by BPD traits alone, whilst dyadic behavior was also influenced by general adolescent psychopathology. Exploratory analyses of CIB subscales showed that whilst HC-G increased their reciprocal behavior during stress compared to the fun day planning, BPD-G dyads decreased it. Maternal ELM did not differ between groups or have any effect on behavior. Adolescent ELM was correlated with behavioral outcome variables, but did not explain behavioral outcomes above and beyond the effect of clinical status.

DISCUSSION/CONCLUSION

Our data suggest a stronger focus on parent-child interactions in BPD-specific therapies to enhance long-term treatment outcomes in adolescent BPD patients. Further research employing study designs that allow the analyses of bidirectional transactions (e.g. longitudinal design, behavioral microcoding) is needed.

Heterotypic and homotypic continuity in psychopathology: a narrative review

Psychopathology is a process: it unfolds over time and involves several different factors. To extend our knowledge of such process, it is vital to understand the trajectories that lead to developing and maintaining a specific disorder. The construct of continuity appears very useful to this aim. It refers to the consistency, similarity, and predictability of behaviors or internal states across different developmental phases. This paper aims to present a narrative review of the literature on homotypic and heterotypic continuity of psychopathology across the lifespan. A detailed search of the published literature was conducted using the PsycINFO Record and Medline (PubMed) databases. Articles were included in the review based on the following criteria: (1) publication dates ranging from January 1970 to October 2022; and (2) articles being written in the English language. To ensure a thorough investigation, multiple combinations of keywords such as "continuity," "psychopathology," "infancy," "childhood," "adolescence," "adulthood," "homotypic," and "heterotypic" were used. Articles were excluded if exclusively focused on epidemiologic data and if not specifically addressing the topic of psychopathology continuity. The literature yielded a total of 36 longitudinal studies and an additional 190 articles, spanning the research published between 1970 and 2022. Studies on continuity focus on the etiology of different forms of mental disorders and may represent a fundamental resource from both a theoretical and clinical perspective. Enhancing our understanding of the different trajectories beneath psychopathology may allow clinicians to implement more effective strategies, focusing both on prevention and intervention. Since literature highlights the importance of early detection of clinical signs of psychopathology, future research should focus more on infancy and pre-scholar age.

Alignment of Borderline Personality Disorder and Complex Post-traumatic Stress Disorder With Complex Developmental Symptomatology

Cluster analysis of maltreatment-related mental health symptoms manifested by adolescents in foster care suggest the absence of an underlying taxonomic structure. To test this further, we investigated alignment between mental health symptom profiles derived through cluster analysis and nominal diagnosis of Borderline Personality Disorder (BPD) and Complex Post-traumatic Stress Disorder (C-PTSD), among a sample of 230 adolescents in long-term foster care. Nominal DSM-V BPD and ICD-11 C-PTSD caseness was estimated from Child Behaviour Checklist and Assessment Checklist for Adolescents score algorithms, and alignment of case assignment with previously-derived symptom profiles was examined. Nineteen BPD and three C-PTSD nominal cases were identified. Low C-PTSD prevalence reflected low concordance between PTSD and 'disturbances in self organization' (DSO) case assignment. The BPD and C-PTSD cases were aligned to more complex and severe symptom profiles. While the complex and severe presentations identified in the present study included core symptoms and clinical signs of BPD, they were also characterised by clinical-level inattention/over-activity and conduct problems. The present findings provide some support for the validity of the BPD construct for describing complex and severe psychopathology manifested by adolescents in foster care, and no support for the C-PTSD construct. However, the symptom profiles point to high variability in combinations of multiple symptom types that does not conform to traditional definitions of a 'diagnosable' mental disorder. Further research is needed to determine if complex post-maltreatment symptomatology can be validly conceptualised as one or more complex disorders.

Integrating Psychosocial Risks With Emerging Evidence for Borderline Personality Disorders in Adolescence: An Update for Clinicians

Borderline personality disorder (BPD) has seen significant advances in the knowledge of its developmental phenomenology during late childhood and adolescence. Various genetic, neurobiological, psychological, and social factors are implicated in the etiology of BPD. With emerging evidence on BPD development in adolescence, the review focused on recent literature to understand the role of psychosocial risk factors. The effects of adverse familial environment, physical, emotional, verbal, and sexual abuse, intergenerational transmission of psychopathological traits, maternal neglect and rejection, low socioeconomic status, bullying victimization, and dating violence were reviewed to understand their role in the development of BPD. BPD is a highly complex, serious, and enduring mental illness that has now been widely accepted to have symptoms that onset in early adolescence and could be diagnosed as early as age 12. BPD symptoms are stable, phenomenologically distinct from externalizing and internalizing disorders, and often present with co-occurring disorders, which during assessment could not explain impairments associated with BPD. New measures like the Difficulties in Emotion Regulation Scale (DERS), detailed developmental histories, understanding of psychosocial risks, shared decision-making, and psychoeducation could assist in early diagnosis and improvement of long-term outcomes. The implementation of evidence-based treatments is a challenge given higher costs and access to services; therefore, modifications in the treatment based on the core principles of these strategies should be considered. It is imperative to screen for psychosocial factors early in higher-risk groups. The assessment of familial factors, parental histories of psychopathologies, and histories of childhood abuse is important in context with impairing symptoms of clinical presentation and dimensional aspects of self-functioning. The role of family therapies, parental psychoeducation, and the integration of trauma-informed care approaches are important for clinical outcomes. Also, coordinated efforts with multiple stakeholders like school awareness programs, anti-bullying policies, legislation, and enforcement of existing laws might be instrumental in addressing issues related to victimization by peers.

Cognitive impairment and factors influencing depression in adolescents with suicidal and self-injury behaviors: a cross-sectional study

BACKGROUND

Non-suicidal self-injury (NSSI) and suicide attempts (SAs) by adolescent patients with depression have become serious public health problems. There is still insufficient research evidence on the effects of NSSI and SAs on neurocognitive functioning in adolescents. Cognitive function alterations may be associated with SAs and self-injury. NSSI and SAs have different influencing factors.

METHODS

Participants were recruited from outpatient clinics and included 142 adolescent patients with depression (12-18 years old). This cohort included the SAs group (n = 52), NSSI group (n = 65), and depression without SAs/NSSI control group (n = 25). All participants underwent a clinical interview and neuropsychological assessment for group comparisons, and post-hoc tests were performed. Finally, partial correlation analysis was used to explore factors related to changes in cognitive function.

RESULTS

The SAs group performed significantly worse than the control group in executive function and working memory. The depression score was directly proportional to the executive function of the SAs group, whereas cognitive functioning in the NSSI group was associated with borderline traits and rumination.

CONCLUSIONS

These findings suggest that impairment of executive function and working memory may be a common pattern in adolescent depressed patients with SAs. However, borderline traits and rumination may be indicative of NSSI but not SAs.

Abnormal Brain Circuits Characterize Borderline Personality and Mediate the Relationship between Childhood Traumas and Symptoms: A mCCA+jICA and Random Forest Approach

Borderline personality disorder (BPD) is a severe personality disorder whose neural bases are still unclear. Indeed, previous studies reported inconsistent findings concerning alterations in cortical and subcortical areas. In the present study, we applied for the first time a combination of an unsupervised machine learning approach known as multimodal canonical correlation analysis plus joint independent component analysis (mCCA+jICA), in combination with a supervised machine learning approach known as random forest, to possibly find covarying gray matter and white matter (GM-WM) circuits that separate BPD from controls and that are also predictive of this diagnosis. The first analysis was used to decompose the brain into independent circuits of covarying grey and white matter concentrations. The second method was used to develop a predictive model able to correctly classify new unobserved BPD cases based on one or more circuits derived from the first analysis. To this aim, we analyzed the structural images of patients with BPD and matched healthy controls (HCs). The results showed that two GM-WM covarying circuits, including basal ganglia, amygdala, and portions of the temporal lobes and of the orbitofrontal cortex, correctly classified BPD against HC. Notably, these circuits are affected by specific child traumatic experiences (emotional and physical neglect, and physical abuse) and predict symptoms severity in the interpersonal and impulsivity domains. These results support that BPD is characterized by anomalies in both GM and WM circuits related to early traumatic experiences and specific symptoms.

Borderline Personality Disorder: A Review

IMPORTANCE

Borderline personality disorder (BPD) affects approximately 0.7% to 2.7% of adults in the US. The disorder is associated with considerable social and vocational impairments and greater use of medical services.

OBSERVATIONS

Borderline personality disorder is characterized by sudden shifts in identity, interpersonal relationships, and affect, as well as by impulsive behavior, periodic intense anger, feelings of emptiness, suicidal behavior, self-mutilation, transient, stress-related paranoid ideation, and severe dissociative symptoms (eg, experience of unreality of one's self or surroundings). Borderline personality disorder is typically diagnosed by a mental health specialist using semistructured interviews. Most people with BPD have coexisting mental disorders such as mood disorders (ie, major depression or bipolar disorder) (83%), anxiety disorders (85%), or substance use disorders (78%). The etiology of BPD is related to both genetic factors and adverse childhood experiences, such as sexual and physical abuse. Psychotherapy is the treatment of choice for BPD. Psychotherapy such as dialectical behavior therapy and psychodynamic therapy reduce symptom severity more than usual care, with medium effect sizes (standardized mean difference) between -0.60 and -0.65. There is no evidence that any psychoactive medication consistently improves core symptoms of BPD. For discrete and severe comorbid mental disorders, eg, major depression, pharmacotherapy such as the selective serotonin reuptake inhibitors escitalopram, sertraline, or fluoxetine may be prescribed. For short-term treatment of acute crisis in BPD, consisting of suicidal behavior or ideation, extreme anxiety, psychotic episodes, or other extreme behavior likely to endanger a patient or others, crisis management is required, which may include prescription of low-potency antipsychotics (eg, quetiapine) or off-label use of sedative antihistamines (eg, promethazine). These drugs are preferred over benzodiazepines such as diazepam or lorazepam.

CONCLUSIONS AND RELEVANCE

Borderline personality disorder affects approximately 0.7% to 2.7% of adults and is associated with functional impairment and greater use of medical services. Psychotherapy with dialectical behavior therapy and psychodynamic therapy are first-line therapies for BPD, while psychoactive medications do not improve the primary symptoms of BPD.

Developmental predictors of young adult borderline personality disorder: a prospective, longitudinal study of females with and without childhood ADHD

BACKGROUND

Research on the precursors of borderline personality disorder (BPD) reveals numerous child and adolescent risk factors, with impulsivity and trauma among the most salient. Yet few prospective longitudinal studies have examined pathways to BPD, particularly with inclusion of multiple risk domains.

METHODS

We examined theory-informed predictors of young-adult BPD (a) diagnosis and (b) dimensional features from childhood and late adolescence via a diverse (47% non-white) sample of females with (n = 140) and without (n = 88) carefully diagnosed childhood attention-deficit hyperactivity disorder (ADHD).

RESULTS

After adjustment for key covariates, low levels of objectively measured executive functioning in childhood predicted young adult BPD diagnostic status, as did a cumulative history of childhood adverse experiences/trauma. Additionally, both childhood hyperactivity/impulsivity and childhood adverse experiences/trauma predicted young adult BPD dimensional features. Regarding late-adolescent predictors, no significant predictors emerged regarding BPD diagnosis, but internalizing and externalizing symptoms were each significant predictors of BPD dimensional features. Exploratory moderator analyses revealed that predictions to BPD dimensional features from low executive functioning were heightened in the presence of low socioeconomic status.

CONCLUSIONS

Given our sample size, caution is needed when drawing implications. Possible future directions include focus on preventive interventions in populations with enhanced risk for BPD, particularly those focused on improving executive functioning skills and reducing risk for trauma (and its manifestations). Replication is required, as are sensitive measures of early emotional invalidation and extensions to male samples.

Borderline personality features among individuals at clinical high risk for psychosis (CHR-P): A brief report

AIM

This exploratory study reports on borderline symptomatology within a sample of individuals at clinical high risk for psychosis (CHR-P) through a validated, self-report instrument, the short version of the Borderline Symptom List (BSL-23).

METHODS

The sample consisted of 44 help-seeking CHR-P youth (ages 14-29 years) who completed an initial evaluation at a specialized clinic for psychosis-risk.

RESULTS

The mean BSL-23 score was 1.5 (SD = 1.0, range 0.1-4.0). Higher scores were strongly associated with greater reported depressive symptoms (r = 0.84, p < 0.001). Additionally, borderline symptoms associated with attenuated positive symptoms (r = 0.32, p = 0.034) and social anxiety (r = 0.34, p = 0.027). Borderline symptomatology was not associated with role or social functioning.

CONCLUSIONS

This study is one of the first examinations of borderline symptomatology within a CHR-P sample through a validated self-report measure. Future research replicating these results is required to determine their robustness.

Gender-Specific Significance of Peer Abuse during Childhood and Adolescence on Physical and Mental Health in Adulthood-Results from a Cross-Sectional Study in a Sample of Hospital Patients

Peer abuse (PA) is a widespread and gender-sensitive form of Adverse Childhood Experiences (ACEs). However, research on its influence on physical and mental health in adulthood remains scarce. The aim of this study was to investigate gender-specific associations between PA and physical and mental health in adulthood in a sample of general hospital patients. A cross-sectional study at the University Hospital of Innsbruck was conducted. Data on ACEs, physical and mental health were collected using self-report questionnaires. We compared patients with no ACEs, PA only, ACEs without PA, and ACEs with PA using gender-specific binary logistic regressions to investigate the association of PA with physical and mental health. A total of 2,392 patients were included in the analyses. Women reported more emotional PA (13.1% vs. 9.4%; p = 0.006), while men reported more physical PA (8.3% vs. 5.2%; p = 0.003). PA was associated with a higher likelihood for depression (OR = 2.6), somatization (OR = 2.1), as well as worse physical health (OR = 2.1) in women but not in men. This study is the first to present data on the gender-specific detrimental effect of PA on physical and mental health in adulthood. Especially for women, PA poses a significant health risk. Thus, we should be aware of these effects and offer adequate support for affected individuals.

Early Intervention for Personality Disorder

Both the DSM-5 Section III Alternative Model for Personality Disorders and the ICD-11 have introduced a genuinely developmental approach to personality disorder. Among young people with personality disorder, compelling evidence demonstrates a high burden of disease, substantial morbidity, and premature mortality, as well as response to treatment. Yet, early diagnosis and treatment for the disorder have struggled to emerge from its identity as a controversial diagnosis to a mainstream focus for mental health services. Key reasons for this include stigma and discrimination, lack of knowledge about and failure to identify personality disorder among young people, along with the belief that personality disorder must always be addressed through lengthy and specialized individual psychotherapy programs. In fact, evidence suggests that early intervention for personality disorder should be a focus for all mental health clinicians who see young people and is feasible by using widely available clinical skills.

Identifying moderating factors during the preschool period in the development of borderline personality disorder: a prospective longitudinal analysis

BACKGROUND

Despite a growing literature detailing early childhood risk factors for borderline personality disorder (BPD), few studies have examined moderating factors that might mitigate or exacerbate the effects of those risk factors. The current study examined whether three preschool-age characteristics-impulsivity, emotional lability, and initiative-taking-moderated the relationship between known preschool-age risk factors and adolescent BPD symptoms.

METHODS

We performed multilevel modeling analyses in a sample (n = 151) from the Preschool Depression Study, a prospective longitudinal study with assessments from preschool through adolescence. Preschool risk factors included adverse childhood experiences, internalizing symptoms, and externalizing symptoms measured with parent clinical interviews. Preschool moderating factors were assessed via parent report and observational coding of temperament and behavior. The Borderline Personality Features Scale for Children measured BPD symptoms in adolescence.

RESULTS

We found that observed initiative-taking moderated the relationship between preschool internalizing symptoms and adolescent BPD symptoms (b = 0.57, p = .011) and moderated the relationship between preschool externalizing symptoms and adolescent BPD symptoms (b = 1.42, p = .013). Greater initiative-taking was associated with lower BPD risk for children with high internalizing or externalizing symptoms. Conversely, for children with low internalizing or externalizing symptoms, greater initiative-taking was associated with increased BPD risk.

CONCLUSIONS

We identify a potential moderating factor in BPD development, offer novel targets for screening and intervention, and provide a framework for using early childhood observational assessments in BPD research. Our findings suggest the need for future research on early moderating factors in BPD development, which could inform early childhood interventions targeting those factors to mitigate the effects of potentially less malleable risk factors.

The role of sense of coherence and loneliness in borderline personality disorder traits: a longitudinal twin study

BACKGROUND

Borderline personality disorder (BPD) implies having problems with identity and relations with other people. However, not much is known about whether these indications of BPD are present in adolescence, i.e., before personality disorders usually are diagnosed. In this study, we examined the prediction of an aspect of identity (i.e., sense of coherence [SOC]) and social relations (i.e., perceived loneliness) throughout adolescence on BPD traits in young adulthood. In addition, we examined to what degree the predictive ability could be attributed to genetic and environmental factors. We also examined whether life events in adolescence were related to BPD traits.

METHODS

Three thousand three hundred ninety-one twins, consisting of seven national birth cohorts from Norway, participated in the study. SOC, loneliness and life events were measured three times throughout adolescence with self-report questionnaires, with 2 years in between measurements. BPD traits were measured at the end of adolescence around the age of 19 with a structured interview. Regression analyses were performed to examine the prediction of SOC, loneliness and life events on BPD traits. Cholesky decomposition models were then used to determine to what degree the associations were due to genetic and environmental influences.

RESULTS

The prediction of SOC and loneliness on BPD traits increased from R = .25 (when measured 6 years prior to the assessment of BPD traits) to R = .45 (when measured shortly before the assessment of BPD traits). In addition, negative life events considered dependent on a person's behavior were related to BPD traits. Negative independent and positive dependent life events did not contribute to the prediction of BPD traits. Cholesky decomposition models showed that SOC and loneliness were associated with BPD traits mainly due to shared genetic influences (i.e., the proportion due to genetic influences ranged from 71 to 86%). Adding negative dependent life events to the prediction of BPD traits did not change these percentages.

CONCLUSIONS

These findings indicate that the weaker SOC, the stronger feelings of loneliness, and the negative life events associated with BPD traits are mainly consequences of the genetic aspects of BPD traits, rather than having direct effects on levels of BPD symptoms.

Adverse Childhood Experiences and Neurocognition in Borderline Personality Disorder: A Call-to-Action Perspective Review

Adverse childhood experiences (ACEs) contribute to the development of personality traits leading to adult borderline personality disorder (BPD). Neurocognitive changes could partly mediate the association between ACEs and BPD. We discuss how exposure to ACEs could induce alterations in neurocognition, which, in turn, would contribute to the development of BPD. We conducted a review of MEDLINE articles through 2021, documenting a link between ACEs, neurocognitive impairments, and BPD, and also focusing on the pairwise associations. ACEs appear to have a strong impact on neurocognition and are a predictive factor for BPD. Maltreated, abused, and emotionally invalidated children are more likely to present BPD traits. Neurocognitive impairments in adults exposed to ACEs and in patients with BPD arise from similar brain alterations in the amygdala, hippocampus, and prefrontal cortex. These impairments seem to be linked with clinical dimensions of BPD: increased impulsivity to altered inhibitory control; dissociative experiences to nonspecific autobiographical memory; and emotionally biased facial recognition to unstable interpersonal relationships. This perspective review highlights the contributory role of neurocognition in the association between ACEs and BPD. Additional research is needed, however, on the interconnections among ACEs, neurocognition, and BPD. Future studies could also focus on developing tools to assess early adversity in BPD specifically and on psychotherapeutic approaches to promptly remedy neurocognitive impairments.

Associations among ADHD symptoms, ODD symptoms, and borderline personality features: A network analysis

Attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) are common childhood syndromes that exhibit a high degree of comorbidity. Both ADHD and ODD symptoms in childhood predict higher levels of borderline personality features (BPF) later in development. Yet ADHD, ODD, and BPF each consist of a heterogeneous group of symptoms, and symptom-level associations between these groups remain unclear. The present study examined symptom-level associations, as well as sex differences in symptom-level associations, among ADHD, ODD, and BPF using network analysis. Caregivers of 962 children between the ages of 5 and 12 completed rating scales of ADHD, ODD, and BPF. Assessment of Bridge Expected Influence indicated a number of bridge symptoms linking ADHD to ODD; these bridge symptoms were primarily from the hyperactive-impulsive (rather than the inattentive) dimension of ADHD (e.g., blurts out answers, leaves seat, runs excessively). A smaller number of bridge symptoms were identified linking ADHD and ODD to BPF, and these bridge symptoms were different for girls versus boys. Overall, several ADHD hyperactive-impulsive symptoms were related to the BPF item gets in trouble for doing things without thinking, and the ODD item touchy/easily annoyed was related to the BPF item goes back and forth between different feelings. Moreover, whereas we observed stronger links between ODD antagonistic symptoms (e.g., blames others) and BPF among girls, we observed stronger links between ODD oppositional symptoms (e.g., defies/refuses to comply) and BPF among boys. Taken together, results provide a more nuanced, symptom-level understanding of the overlap among ADHD, ODD, and BPF.

Dissociation, trauma, and borderline personality disorder

Dissociation is a complex phenomenon, which occurs in various clinical conditions, including dissociative disorders, (complex) post-traumatic stress disorder (CPTSD, PTSD), and borderline personality disorder (BPD). Traumatic stress is considered an important risk factor, while the etiology of dissociation is still debated. Next to traumatic experiences, temperamental and neurobiological vulnerabilities seem to contribute to the development of dissociation. Stress-related dissociation is a prevalent symptom of BPD, which may interfere with psychosocial functioning and treatment outcome. More research in the field is strongly needed to improve the understanding and management of this complex phenomenon. This article collection brings together research on dissociation and trauma, with a special focus on BPD or sub-clinical expressions of BPD. In this editorial, recent conceptualizations of dissociation and relevant previous research are introduced in order to provide a framework for this novel research.

Trauma and Outcomes of Mentalization-Based Therapy for Individuals With Borderline Personality Disorder

OBJECTIVE

Recent meta-analyses suggest that many patients with borderline personality disorder have a history of complex trauma. Although trauma is central in mentalization-based approaches to the understanding of borderline personality disorder, surprisingly little is known about the effects of trauma on outcomes of mentalization-based treatment (MBT). This article investigates the prevalence and impact of childhood trauma among patients with borderline personality disorder participating in a randomized controlled trial (RCT) comparing day hospital MBT (MBT-DH) and intensive outpatient MBT (MBT-IOP).

METHODS

All 114 patients from the original multicenter RCT in the Netherlands were included in this study. Childhood trauma was assessed at baseline (with the Childhood Trauma Questionnaire), and its impact on symptom severity, interpersonal functioning, and borderline pathology was investigated through multilevel modeling for 36 months after the start of treatment.

RESULTS

Childhood trauma was common among patients with borderline personality disorder referred to MBT, with more than 85% meeting cutoff criteria for substantial childhood trauma. Childhood trauma had little impact on outcomes of either MBT-DH or MBT-IOP in terms of improved borderline personality disorder features or interpersonal functioning. However, patients with substantial childhood trauma seemed to improve more rapidly with MBT-DH, as compared with MBT-IOP, in terms of symptom severity. In addition, patients with a history of emotional neglect showed more rapid changes in symptoms of borderline personality disorder with MBT-DH compared with MBT-IOP.

CONCLUSIONS

Findings are discussed in the context of a social communicative approach to borderline personality disorder, with a focus on the need to address trauma in MBT.

Perceived Parenting and Borderline Personality Features during Adolescence

This study investigates the associations between perceived parenting and borderline personality disorder (BPD) in adolescents. The relations between components of parenting and BPD features were explored. Participants (N = 270; mean age = 15.3) assessed their own BPD features (Personality Assessment Inventory) and both of their parents' parenting practices (Parents as Social Context Questionnaire; Perceived Parental Autonomy Support Scale). SEM results suggest that controlling, rejecting and chaotic parenting all predicted global BPD, and all these parenting components were significantly associated with at least one BPD feature. Chaotic parenting, a relatively neglected construct in the BPD literature, seems to play an important role in early BPD.

Investigation of the Factor Structure of the Reflective Functioning Questionnaire (RFQ-8): One or Two Dimensions?

There is a need to have reliable and accessible screening measures of mentalizing ability to investigate the role of this capacity in social functioning and its development, emergence of psychopathological conditions, as well as to understand its role in psychotherapeutic processes. The 8-itemed Reflective Functioning Questionnaire (RFQ-8) has been developed for this purpose, however its factor structure and psychometric properties are unclear. The aim of the current study was to further investigate the factor structure of the RFQ-8 and explore its psychometric properties in a Polish sample. 538 participants aged 17-50 (M = 21.44, SD = 2.92) took part in the study. They were asked to complete the RFQ-8, Difficulties in Emotion Regulation Scale (DERS), General Health Questionnaire (GHQ-28), the Relationship Structures (ECR-RS) questionnaire and the Borderline Personality Inventory (BPI). Results of both exploratory and confirmatory analysis indicated that the RFQ-8 may be regarded as a scale measuring a unidimensional construct. Our results confirmed good construct validity for the unidimensional RFQ-8, suggesting that the one-dimensional RFQ specifically assesses uncertainty concerning mental states. Our findings highlight the need for further studies investigating the factor structure and psychometric properties of the RFQ-8.

Factors associated with pharmacological and psychotherapy treatments adherence in patients with borderline personality disorder

BACKGROUND

Borderline personality disorder is a major mental illness characterized by sustained relationship instability, impulsive behavior, and intense affects. Adherence is a complex behavior, from minor refusals to abandonment of treatment, which can be affected by various factors. Therefore, the present study aimed to investigate the factors affecting pharmacological and psychotherapy adherence, patients' attitude toward medication, and assessing medication and treatment adherence in patients with borderline personality disorder referred to an outpatient referral clinic in Tehran, Iran.

METHODS

The study was a cross-sectional study. The files of patients with borderline personality disorder referred to the outpatient clinic of the Tehran Psychiatric Institute were reviewed as the first step. Data were collected using the Drug Attitude Inventory-10 (DAI-10) questionnaire and a questionnaire to determine the attitude of patients toward pharmacological and psychotherapy treatment as well as therapeutic adherence. After collecting data, patients' therapeutic adherence was divided into poor, partial, and good compliance.

RESULTS

Ninety-four patients were involved in the study, and fifty-four were women. Findings of DAI showed that 54 (57.4%) participants had negative attitudes toward medication, while 38 (40.4%) participants showed a negative attitude toward psychotherapy treatment. Additionally, the percentage of patients with good psychotherapy adherence (44.7%) was higher than that of patients with good medication adherence (31.9%). The most common reasons for discontinuation of treatment were medication side effects (53.1%), dissatisfaction with the therapist (40.3%), and then fear of medication dependence (40%). Patients with higher education levels and a positive history of hospitalization in a psychiatric ward had better adherence to psychotherapy (P < 0.05).

CONCLUSION

Results of the current study show that attitude toward psychotherapy is more favorable than pharmacotherapy among patients with BPD. The rationale may be that medications are mainly prescribed for comorbid conditions and do not have substantial effects on the BPD symptoms, resulting in low medication adherence.

Female Forensic Patients May Be an Atypical Sub-type of Females Presenting Aggressive and Antisocial Behavior

The percentage of forensic psychiatric patients who are female varies from 5 to 13% in Europe, rises to 18% in England and Wales, and sits at 15% in Canada. Similarly, many fewer women than men are incarcerated in correctional facilities. While these statistics supposedly reflect less antisocial and aggressive behavior (AAB) among females than males, not all findings support this supposition. Data from prospective longitudinal studies show that aggressive and antisocial behavior onsets in childhood, and in a small group of females it remains stable across the life-span. Unlike similar males, few of these females are convicted of crimes. This article begins with a review of descriptive studies of females sentenced by criminal courts to treatment in forensic psychiatric hospitals and moves on to present evidence showing that most female AAB does not lead to criminal prosecution. Next, studies of female AAB are reviewed, noting that it onsets in early childhood and, that in a small group remains stable across the life-span. Subsequent sections of the article focus on the two most common mental disorders presented by female forensic patients, schizophrenia and borderline personality disorder, highlighting what is known about the sub-groups of women with these disorders who present AAB. The article concludes with recommendations for earlier identification by psychiatric services of women presenting mental disorders and AAB, treatments to reduce both the symptoms of their mental disorders and their life-long AAB, and the research that is needed in order to improve the effectiveness of these treatments. The real possibilities of prevention of the development of AAB, and even perhaps aspects of the mental disorders that plague female forensic patients, are described.

Borderline Personality Disorder: Risk Factors and Early Detection

Personality disorders (PDs) exert a great toll on health resources, and this is especially true for borderline personality disorder (BPD). As all PDs, BPD arises during adolescence or young adulthood. It is therefore important to detect the presence of this PD in its earlier stages in order to initiate appropriate treatment, thus ameliorating the prognosis of this condition. This review aims to highlight the issues associated with BPD diagnosis in order to promote its early detection and treatment. To do so, we conducted a search on PubMed database of current evidence regarding BPD early diagnosis, focusing on risk factors, which represent important conditions to assess during young patient evaluation, and on diagnostic tools that can help the clinician in the assessment process. Our findings show how several risk factors, both environmental and genetic/neurobiological, can contribute to the onset of BPD and help identify at-risk patients who need careful monitoring. They also highlight the importance of a careful clinical evaluation aided by psychometric tests. Overall, the evidence gathered confirms the complexity of BDP early detection and its crucial importance for the outcome of this condition.

Prevalence and comorbidity of borderline personality traits in the Quebec general population aged 12-14 years

PURPOSE

The early identification of borderline personality traits (BPT) in adolescents helps to prevent their progression. Data are available for the clinical population, but little has been published on the general population, especially regarding age and sex distribution in adolescence. Even less is known about the comorbidity of BPT with other mental disorders.

METHODS

We estimated the prevalence of BPT, by sex, age, and comorbidity, in a sample of adolescents aged 12-14 years (n = 799) from the Quebec Mental Health Survey. A complex sampling design was used to ensure representativeness. BPT was assessed with the abbreviated-diagnostic interview for borderlines-revised, with the adolescent as an informant. Reliability coefficients were above 0.80. Several levels of severity were explored using an independent criterion, defined by impairment according to the Columbia impairment scale.

RESULTS

The overall prevalence of BPT was 6.3%. Prevalence estimates for the most impaired were 3.2% for the entire sample and 1.3% for 12-year-olds. Prevalence increased significantly with age for most impairment levels but did not differ significantly between the sexes. In adolescents, BPT displayed moderate-to-strong comorbidity with anxiety (AD) and insomnia disorders, and very strong comorbidity with depressive (DD), attention deficit hyperactivity (ADHD), and oppositional defiant/conduct disorders (ODD/CD).

CONCLUSION

We, therefore, make two clinical recommendations for child psychiatry practice: (1) with respect to the lower rate of male adolescents attending BPT Health Programs, increase BPT screening in male adolescents; (2) evaluate BPT when children with ADHD or ODD/CD develop AD or DD during adolescence.

Borderline personality disorder

Borderline personality disorder (BPD) is a mental disorder with a high burden on patients, family members, and health-care systems. The condition was previously regarded as untreatable, but progress in understanding and management has resulted in earlier diagnosis and better treatment outcomes. A coherent syndrome of BPD typically onsets during adolescence (after age 12 years). BPD is often preceded by or co-develops with symptoms of internalising disorders (depression and anxiety), externalising disorders (conduct problems, hyperactivity, and substance use), or both. BPD is associated with various poor outcomes, including low occupational and educational attainment, lack of long-term relationships, increased partner conflict, sexual risk-taking, low levels of social support, low life satisfaction, and increased service use. Psychotherapy is the main treatment for BPD; drug treatment is only indicated for comorbid conditions that require medication, or during a crisis if psychosocial interventions are insufficient. Awareness of BPD by non-specialists, as well as specialists, is key to appropriate early intervention.

Paradoxes in Borderline Emotional Dysregulation in Adolescence: Influence of Parenting, Stressful Life Events, and Attachment

Introduction: Borderline personality disorder (BPD) in adolescents is characterized by emotional dysregulation, insecure attachment, a history of stressful life events (SLEs) as well as dysfunctional parent-child interactions. The respective contribution of each of these factors on BPD affective symptoms is not yet clear. The purpose of this study is to assess the distinct impact of parental adversity and SLEs on BPD affective symptoms and the role of attachment and alexithymia in such emotional processes. Method: This study explored parental dysfunction and SLEs as predictors of affective symptoms of BPD and of attachment insecurity in BPD adolescents (n = 85) and healthy controls (n = 84) aged 13-19 years from the European Research Network on BPD. The links between adversity and BPD symptoms were also investigated by emotional dysregulation assessment, as measured by alexithymia and hopelessness. Results: Dysfunctional parental interactions were linked to affective symptoms, hopelessness, and anxious attachment in healthy controls but not in BPD. Cumulative SLEs were positively correlated with affective symptoms and avoidant attachment in the control group but negatively correlated with both these variables in BPD. Multivariate regression analysis revealed that, in BPD, affective symptoms were independent of dysfunctional parenting but depended on attachment, whereas in controls, a maternal affectionless control style directly predicted affective symptoms. Moreover, increasing numbers of SLEs reduced affective symptoms in BPD, independently of parental interactions or attachment, and were associated with growing use of operative thinking. Discussion: BPD patients showed paradoxical emotional reactions: there was no increase of hopelessness and affective symptoms with an increased parental dysfunction, but a decrease in affective symptoms and hopelessness with cumulative SLE. Two pathways arose, one involving attachment as an emotional dysregulation process for parent-child interactions and a second one for SLE, with a more direct pathway to affective symptoms, independent of attachment but dependent on early interactions, and involving alexithymia. In summary, adversity factors have distinct effects in BPD, and attachment is partly accountable for affective symptoms independently of adversity. Our results suggest that in highly insecure conditions, cumulative adversity may produce paradoxical effects, including a lesser expression of affective symptoms and hopelessness.

Divergent mentalization types in adolescent borderline personality disorder and attention deficit/hyperactivity disorder

BACKGROUND

Attention deficit/hyperactivity disorder (ADHD) and borderline personality disorder (BPD) have several similarities and it is difficult to distinguish these disorders in adolescents. We aimed to identify the unique correlates of mentalization abilities that may distinguish these two disorders, and to investigate the mentalization abilities of adolescents with ADHD, BPD and ADHD + BPD in an inpatient sample to determine the effect of co-morbidity on mentalization abilities.

METHODS

We have explored the relationship between Child Eye Test (CET) scores, Movie for the Assessment of Social Cognition (MASC) subscales, and ADHD and BPD symptoms in adolescent inpatients. In addition, we compared ADHD, BPD and ADHD + BPD groups in terms of their mentalization abilities.

RESULTS

Correct MASC scores were negatively associated with both ADHD and BPD symptoms in girls, and negatively associated with ADHD symptoms in boys. In addition, hypermentalization scores were associated with BPD symptoms in girls, and hypomentalization and no mentalization scores were associated with ADHD symptoms in girls. CET scores were negatively associated with ADHD symptoms in girls, but no relations with BPD were found. Group comparisons revealed no significant difference among groups.

LIMITATIONS

We included only inpatient sample without considering their medication condition, we did not compare the mentalization scores of the patient groups with healthy controls and we used self-report measures for several assessments.

CONCLUSION

Mentalization patterns in ADHD and BPD are distinct. ADHD may be related to hypomentalization, instead, BPD may be related to hypermentalization.

Comorbid early psychosis and borderline personality disorder: Conceptualizing clinical overlap, etiology, and treatment

Despite substantial efforts aimed at the detection and intervention for early symptoms of mental illness, there is relatively limited research on the clinical overlap between borderline personality disorder (BPD) and early psychosis, for example, clinical high risk (CHR) for psychosis, in young people. We present a narrative review of the clinical overlap between BPD and psychosis spectrum symptoms. Both conditions have unstable temporal course, and both are marked by functional impairment, increased suicide risk, and higher rates of psychiatric inpatient services. We then review evidence-based treatments for psychosis and BPD, emphasizing treatments for early presentations of these symptoms and initial research considering treatments for the overlap. Psychotherapies with the strongest empirical support include cognitive behavioral models, with BPD showing limited response to adjunctive pharmacotherapy. We end by discussing specific recommendations for future research, including longitudinal studies to determine the predictors of the course of illness and the development of treatments to target comorbid BPD and CHR symptoms.

Specific Pathways From Adverse Experiences to BPD in Adolescence: A Criteria-Based Approach of Trauma

Within the European Research Network on BPD (EURNET-BPD; n = 85 BPD adolescents, n = 84 healthy controls, aged 13-19), this study explored the combination of three types of adversity-maltreatment, stressful life events (early separation from parents, parental suicide attempt, parental chronic disease) and parental bonding-as predictors of BPD, on a criteria-based approach. Results indicated that cumulative traumatic experiences largely characterize borderline adolescent's history; and, in the multivariate regression models, all adversity experiences were likely to contribute to BPD symptoms. The role of emotional abuse, parental suicide attempt, and a decrease in paternal level of care were particularly prominent. Moreover, adversities combinations were different for each criterion, suggesting that specific sets of traumatic experiences are leading to BPD. These findings argue for a further criteria-based exploration of trauma in borderline patients, as well as a more accurate and efficient prevention.

Maladaptive behaviours in adolescence and their associations with personality traits, emotion dysregulation and other clinical features in a sample of Italian students: a cross-sectional study

BACKGROUND

Emotion Dysregulation (ED), childhood trauma and personality are linked to the occurrence of maladaptive behaviours in adolescence which, in turn, may be related to increased risk for psychopathology in the life course. We sought to explore the relationship among the occurrence of different clusters of maladaptive behaviours and ED, clinical features (i.e. impulsivity, childhood maltreatment, anxiety, depressive symptoms) and personality traits that have been found to be associated to Borderline Personality Disorder (BPD), in a sample of 179 adolescent students.

METHODS

Multiple Correspondence Analysis (MCA) was applied to detect clustered types of maladaptive behaviours and groups of students were defined as individuals engaging in these clustered behaviours (non-suicidal self-injury-NSSI, binge eating, binge drinking, cannabis use, and sexual risk behaviours). Logistic models were used to evaluate the association among clinical scales, and student groups. Mediation analysis was used to evaluate whether clinical features affected the association between personality traits and student groups.

RESULTS

MCA analysis allowed to identify three student groups: NSSI/binge eating (NSSI-BE) behaviours, other maladaptive behaviours and "none". Higher scores in ED, impulsivity, childhood maltreatment, anxiety and depressive symptoms increased the risk of belonging to the cluster of NSSI-BE behaviours compared to the other two groups. ED, depression and anxiety symptoms were found to be mediators of the relationship between specific personality traits, mainly pertaining to the negative affectivity construct, and NSSI/BE.

CONCLUSIONS

Individuals engaging in NSSI-BE behaviours represent a vulnerable adolescent population. ED, depression and anxiety were mediators of the relationship between a variety of personality traits related to BPD and NSSI and binge eating behaviours. Findings have important clinical implications in terms of prevention and interventions among adolescents engaging in self-damaging behaviours.

Preschool Age Predictors of Adolescent Borderline Personality Symptoms

OBJECTIVE

Developmental models of borderline personality disorder (BPD) have highlighted the interplay of psychological variables (ie, impulsivity and emotional reactivity) with social risk factors, including invalidating parenting and childhood trauma. Prospective longitudinal studies have demonstrated the association of BPD with social, familial, and psychological antecedents. However, to date, few of these studies have studied the interaction of multiple risk domains and their potential manifestations in the preschool period.

METHOD

Participants were 170 children enrolled in a prospective longitudinal study of early childhood depression. Participants completed a baseline assessment between ages 3 and 6 years. Psychopathology, suicidality, and self-harm were assessed using a semistructured age-appropriate psychiatric interview before age 8 and self-report after age 8. BPD symptoms were assessed between ages 14 and 19 by self-report. Adverse childhood experiences (ACEs) and peer relationships were reported by parents. Maternal support was assessed using an observational measure between ages 3 and 6.

RESULTS

Preschool ACEs accounted for 14.9% of adolescent BPD symptom variance in a regression analysis. Controlling for gender and preschool ACEs, preschool and school-age externalizing symptoms, preschool internalizing symptoms, and low maternal support were significant predictors of BPD symptoms in multivariate analyses. Preschool and school-age suicidality composite scores significantly predicted BPD symptoms.

CONCLUSION

These findings suggest that preschool factors may be early predictors of BPD symptoms. Findings demonstrate that preschoolers with internalizing and externalizing psychopathology, high ACEs, and early suicidality are at greater risk of developing BPD symptoms. However, further research is needed to guide key factors for targeted early intervention.

Emerging child competencies and personality pathology: toward a Developmental Cascade model of BPD

The guiding principle of this synthesis is to organize research on predictors of BPD features within a developmentally specific framework (e.g. infancy, preschool, middle childhood, adolescence). In addition, studies are prioritized that have longitudinal and observational components. On the basis of current literature, a Developmental Cascade Model of BPD is offered in which specific difficulties during one developmental period contribute to specific difficulties in a succeeding period, resulting in increasingly broad areas of dysregulation over time. Furthermore, to address specificity, we contrast trajectories toward BPD with trajectories toward antisocial behavior, noting shared and divergent predictors. The review highlights the importance of locating research findings in relation to the competencies and challenges of particular developmental periods when modelling developmental trajectories toward BPD.

Pharmacological Treatments for Borderline Personality Disorder: A Systematic Review and Meta-Analysis

BACKGROUND

Borderline personality disorder (BPD) is a debilitating psychiatric disorder that affects 0.4-3.9% of the population in Western countries. Currently, no medications have been approved by regulatory agencies for the treatment of BPD. Nevertheless, up to 96% of patients with BPD receive at least one psychotropic medication.

OBJECTIVES

The objective of this systematic review was to assess the general efficacy and the comparative effectiveness of different pharmacological treatments for BPD patients.

METHODS

We conducted systematic literature searches limited to English language in MEDLINE, EMBASE, the Cochrane Library, and PsycINFO up to April 6, 2021, and searched reference lists of pertinent articles and reviews. Inclusion criteria were (i) patients 13 years or older with a diagnosis of BPD, (ii) treatment with anticonvulsive medications, antidepressants, antipsychotic medications, benzodiazepines, melatonin, opioid agonists or antagonists, or sedative or hypnotic medications for at least 8 weeks, (iii) comparison with placebo or an eligible medication, (iv) assessment of health-relevant outcomes, (v) randomized or non-randomized trials or controlled observational studies. Two investigators independently screened abstracts and full-text articles and graded the certainty of evidence based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. For meta-analyses, we used restricted maximum likelihood random effects models to estimate pooled effects.

RESULTS

Of 12,062 unique records, we included 21 randomized controlled trials (RCTs) with data on 1768 participants. Nineteen RCTs compared pharmacotherapies with placebo; two RCTs assessed active treatments head-to-head. Out of 87 medications in use in clinical practice, we found studies on just nine. Overall, the evidence indicates that the efficacy of pharmacotherapies for the treatment of BPD is limited. Second-generation antipsychotics, anticonvulsants, and antidepressants were not able to consistently reduce the severity of BPD. Low-certainty evidence indicates that anticonvulsants can improve specific symptoms associated with BPD such as anger, aggression, and affective lability but the evidence is mostly limited to single studies. Second-generation antipsychotics had little effect on the severity of specific BPD symptoms, but they improved general psychiatric symptoms in patients with BPD.

CONCLUSIONS

Despite the common use of pharmacotherapies for patients with BPD, the available evidence does not support the efficacy of pharmacotherapies alone to reduce the severity of BPD.

REGISTRATION

PROSPERO registration number, CRD42020194098.

The Role of Trauma in Early Onset Borderline Personality Disorder: A Biopsychosocial Perspective

The role of childhood trauma in the development of borderline personality disorder (BPD) in young age has long been studied. The most accurate theoretical models are multifactorial, taking into account a range of factors, including early trauma, to explain evolutionary pathways of BPD. We reviewed studies published on PubMed in the last 20 years to evaluate whether different types of childhood trauma, like sexual and physical abuse and neglect, increase the risk and shape the clinical picture of BPD. BPD as a sequela of childhood traumas often occurs with multiple comorbidities (e.g. mood, anxiety, obsessive-compulsive, eating, dissociative, addictive, psychotic, and somatoform disorders). In such cases it tends to have a prolonged course, to be severe, and treatment-refractory. In comparison with subjects who suffer from other personality disorders, patients with BPD experience childhood abuse more frequently. Adverse childhood experiences affect different biological systems (HPA axis, neurotransmission mechanisms, endogenous opioid systems, gray matter volume, white matter connectivity), with changes persisting into adulthood. A growing body of evidence is emerging about interaction between genes (e.g. FKBP5 polymorphisms and CRHR2 variants) and environment (physical and sexual abuse, emotional neglect).

Insecure attachment and maladaptive emotion regulation mediating the relationship between childhood trauma and borderline personality features

BACKGROUND

Previous studies suggested that childhood trauma is an important etiologic factor for the development of borderline personality disorder (BPD). Moreover, insecure attachment and maladaptive emotion regulation (ER) might be related to childhood trauma and BPD. This study was aimed to explore the relationships among childhood trauma, insecure attachment, maladaptive ER, and BPD features.

METHODS

A cohort of 637 patients with psychological disorders completed a series of psychometric instruments such as the Personality Diagnostic Questionnaire-4+ (PDQ-4+), the 23-Item Borderline Symptom List, the Childhood Trauma Questionnaire, the Attachment Style Questionnaire, and the Cognitive Emotion Regulation Questionnaire. The path analyses were conducted to investigate the experience-driven model that whether insecure attachment and maladaptive ER could mediate the relationship between childhood trauma and BPD features. The random forest regression was performed to select variables that contribute significantly to BPD features, which variables would be incorporated into the data-driven model to further confirm the experience-driven model.

RESULTS

Both the experience-driven model and the data-driven model verified that there were three significant mediation pathways (childhood trauma → insecure attachment/maladaptive ER → BPD features, childhood trauma → insecure attachment → maladaptive ER → BPD features; all p < .05), and the most weighted mediation pathway by which childhood trauma influencing the BPD features was through insecure attachment and then through maladaptive ER (weighted 53.16%).

CONCLUSION

The influence of childhood trauma on BPD features was mainly mediated by the combination of insecure attachment and maladaptive emotion regulation.

Trauma and psychopathology associated with early onset BPD: an empirical contribution

Prodromal symptoms of borderline personality disorder (BPD) often arise in young age, especially in early adolescence. Several factors for early BPD onset have been identified to consent a precocious detection of high-risk population. The present study is aimed: (1) to identify what psychopathological, traumatic, and functional factors are significantly associated to early onset in a sample of BPD patients and (2) to evaluate what factors are associated to the time interval between symptoms onset and first psychiatric visit (Δ age). Participants were enrolled from BPD outpatients attending the Center for Personality Disorder of the University of Turin, Italy. Patients were tested with assessment instruments for specific BPD symptoms, exposure to traumatic experiences, global functioning, and perception of quality of life. All variables that were found significant at a bivariate analysis were included in two multiple regressions (stepwise backward), with the age of onset and the Δ age as dependent variables. Significance level was P ≤ 0.05. Seventy patients were included in the study (68 completers). Factors that were found related to age of onset were: CTQ-SF emotional abuse (P = 0.001); ACE-IQ bully victimization (P = 0.005), alcohol/drug abuser in the household (P = 0.001), and physical neglect (P = 0.006); BIS non-planning impulsivity (P = 0.005); and SOFAS score (P = 0.033). Factors that were found related to Δ age were: ACE-IQ total score (P = 0.001) and BIS total score (P = 0.001). Earlier onset of BPD is mainly associated to traumatic events, including abuse, neglect, dysfunction in household environment, and bullying. Earlier onset is also related to a worse social functioning. Among BPD symptoms only non-planning impulsivity was found associated to early onset. A higher number of traumatic events and worse impulsive dyscontrol induce a significant reduction of the time interval between onset and first psychiatric observation.

Borderline Symptoms at Age 12 Signal Risk for Poor Outcomes During the Transition to Adulthood: Findings From a Genetically Sensitive Longitudinal Cohort Study

OBJECTIVE

Borderline personality disorder in adolescence remains a controversial construct. We addressed concerns about the prognostic significance of adolescent borderline pathology by testing whether borderline symptoms at age 12 years predict functioning during the transition to adulthood, at age 18 years, in areas critical to life-course development.

METHOD

We studied members of the Environmental Risk (E-Risk) Longitudinal Twin Study, which tracks the development of a birth cohort of 2,232 British twin children. At age 12, study members' borderline symptoms were measured using mothers' reports. At age 18, study members' personality, psychopathology, functional outcomes, and experiences of victimization were measured using self-reports, coinformant reports, and official records.

RESULTS

At age 18, study members who had more borderline symptoms at age 12 were more likely to have difficult personalities, to struggle with poor mental health, to experience poor functional outcomes, and to have become victims of violence. Reports of poor outcomes were corroborated by coinformants and official records. Borderline symptoms in study members at 12 years old predicted poor outcomes over and above other behavioral and emotional problems during adolescence. Twin analyses showed that borderline symptoms in 12-year-olds were influenced by familial risk, particularly genetic risk, which accounted for associations with most poor outcomes at age 18.

CONCLUSION

Borderline symptoms in 12-year-olds signal risk for pervasive poor functioning during the transition to adulthood. This association is driven by genetic influences, suggesting that borderline symptoms and poor outcomes are manifestations of shared genetic risk.

Developmental Pathways to BPD-Related Features in Adolescence: Infancy to Age 15

The self-damaging behaviors central to borderline personality disorder (BPD) become prominent in adolescence. Current developmental theories cite both early family processes and childhood dysregulation as contributors to BPD, but longitudinal data from infancy are rare. Using the National Institute of Child Health and Human Development (NICHD) Study of Early Child Care and Youth Development database (SECCYD; N = 1,364), we examined path models to evaluate parent and child contributors from infancy/preschool, middle childhood, and adolescence to adolescent BPD-related features. In addition, person-centered latent class analyses (LCA) investigated whether adolescent BPD-related features were more strongly predicted by particular patterns of maladaptive parenting. Path modeling identified unique influences of maternal insensitivity and maternal depression on BPD-related features, first, through social-emotional dysregulation in middle childhood, and second, through continuity from infancy in maternal insensitivity and depression. LCA results indicated that early withdrawn parenting was particularly predictive of BPD-related features in adolescence. Results suggest multiple points of intervention to alter pathways toward adolescent borderline psychopathology.

Emerging child competencies and personality pathology: toward a Developmental Cascade model of BPD

The guiding principle of this synthesis is to organize research on predictors of BPD features within a developmentally specific framework (e.g. infancy, preschool, middle childhood, adolescence). In addition, studies are prioritized that have longitudinal and observational components. On the basis of current literature, a Developmental Cascade Model of BPD is offered in which specific difficulties during one developmental period contribute to specific difficulties in a succeeding period, resulting in increasingly broad areas of dysregulation over time. Furthermore, to address specificity, we contrast trajectories toward BPD with trajectories toward antisocial behavior, noting shared and divergent predictors. The review highlights the importance of locating research findings in relation to the competencies and challenges of particular developmental periods when modelling developmental trajectories toward BPD.

Familial factors and the risk of borderline personality pathology: genetic and environmental transmission

BACKGROUND

Parental characteristics and practices predict borderline personality disorder (BPD) symptoms in children. However, it is difficult to disentangle whether these effects are genetically or environmentally mediated. The present study examines the contributions of genetic and environmental influences by comparing the effects of familial risk factors (i.e. parental psychopathology and borderline traits, maladaptive parenting, marital discord) on child BPD traits in genetically related (biological) and non-related (adoptive) families.

METHODS

Data are from 409 adoptive and 208 biological families who participated in the Siblings Interaction and Behavior Study (SIBS) and 580 twin families the Minnesota Twin Family Study (MTFS). Parent characteristics and practices included parental psychopathology (measured via structured clinical interviews), parental BPD traits, parenting behaviors, and marital discord. A series of multi-level regression models were estimated to examine the relationship of familial risk factors to child BPD traits and to test whether children's adoptive status moderated the association.

RESULTS

Symptom counts of parents' conduct disorder, adult antisocial behavior, nicotine, alcohol, and illicit drug dependence, and paternal BPD traits substantially predicted child BPD traits only in biological offspring, implying genetic transmission. Maternal BPD traits and both maternal and paternal conflict, lack of regard, and lack of involvement predicted offspring BPD traits regardless of the adoptive status, implying environmental transmission.

CONCLUSIONS

Parental externalizing psychopathology and father's BPD traits contribute genetic risk for offspring BPD traits, but mothers' BPD traits and parents' poor parenting constitute environmental risks for the development of these offspring traits.

The Mentalizing Approach to Psychopathology: State of the Art and Future Directions

Mentalizing is the capacity to understand others and oneself in terms of internal mental states. It is assumed to be underpinned by four dimensions: automatic–controlled, internally–externally focused, self–other, and cognitive–affective. Research suggests that mental disorders are associated with different imbalances in these dimensions. Addressing the quality of mentalizing as part of psychosocial treatments may benefit individuals with various mental disorders. We suggest that mentalizing is a helpful transtheoretical and transdiagnostic concept to explain vulnerability to psychopathology and its treatment. This review summarizes the mentalizing approach to psychopathology from a developmental socioecological evolutionary perspective. We then focus on the application of the mentalizing approach to personality disorders, and we review studies that have extended this approach to other types of psychopathology, including depression, anxiety, and eating disorders. We summarize core principles of mentalization-based treatments and preventive interventions and the evidence for their effectiveness. We conclude with recommendations for future research.