Borderline personality disorder and traits in veterans: psychiatric comorbidity, healthcare utilization, and quality of life along a continuum of severity

Adjustment disorder in the Armed Forces: a systematic review

BACKGROUND

In the UK military, adjustment disorder (AjD) is reported as one of the most diagnosed mental disorders, alongside depression, in personnel presenting to mental health services. Despite this, little is understood about what may predict AjD, common treatment or outcomes for this population.

AIM

The systematic review aimed to summarise existing research for AjD in Armed Forces (AF) populations, including prevalence and risk factors, and to outline clinical and occupational outcomes.

METHOD

A literature search was conducted in December 2020 to identify research that investigated AjD within an AF population (serving or veteran) following the PRISMA guidelines.

RESULTS

Eighty-three studies were included in the review. The AjD prevalence estimates in AF populations with a mental disorder was considerably higher for serving AF personnel (34.9%) compared to veterans (12.8%). Childhood adversities were identified as a risk factor for AjD. AjD was found to increase the risk of suicidal ideation, with one study reporting a risk ratio of 4.70 (95% Confidence Interval: 3.50-6.20). Talking therapies were the most common treatment for AjD, however none reported on treatment effectiveness.

CONCLUSION

This review found that AjD was commonly reported across international AF. Despite heterogeneity in the results, the review identifies several literature gaps.

Treatment outcomes of Veteran men in a comprehensive dialectical behavior therapy program: Characterizing sex differences in symptom trajectories

Dialectical Behavior Therapy (DBT) is one of the primary psychosocial treatments for reducing suicidal behaviors and improving psychosocial outcomes among patients with borderline personality disorder (BPD) and has been shown to reduce BPD symptoms when delivered in a Veteran Affairs medical center setting. Despite evidence of similar rates of BPD in both men and women, the vast majority of treatment outcome research in BPD has focused on women. We sought to characterize sex differences in symptom trajectories among Veterans participating in a comprehensive DBT program. We found that Veteran men and women who entered the DBT program were diagnostically and demographically similar. Participants exhibited reductions in BPD symptoms and improvements in emotion regulation over the course of treatment. Moreover, Veteran men reported BPD symptom reductions that were not statistically inferior to those of Veteran women and exhibited a sharper reduction in these symptoms. This research provides support for the use of DBT as a psychosocial treatment for Veteran men with BPD symptoms.

Psychopathological Determinants of Quality of Life in People with Borderline Personality Disorder

BACKGROUND

Subjective quality of life (SQOL) in people with borderline personality disorder (BPD) is a marker of disease burden; a crucial treatment outcome; an indicator of psychosocial functioning; and a measure of interventions' effectiveness. Given the dearth of consolidated data, the current study examined psychopathological determinants of global and domain-specific SQOL in people with BPD.

METHODS

Hierarchical regression models were employed to examine in BPD patients (n = 150) the relationships of the number of BPD diagnostic criteria; the co-occurrence of other personality disorders (PDs); depression; state and trait anxiety; suicidality; self-harming; alcohol and substance use disorders with SQOL indices, namely physical health, psychological health, social relationships, environment, overall QOL and overall health. SQOL was estimated using the WHOQOL-BREF instrument.

RESULTS

Co-existing symptomatology such as depression, state and trait anxiety, and personality pathology, namely the co-occurrence of other PDs, exhibited significant associations with global and domain-specific SQOL, albeit depression was the strongest determinant of the most SQOL domains. In contrast, the number of BPD diagnostic criteria and central illness features such as suicidality, self-harming behaviour, and impulsivity manifested through alcohol and substance use did not exhibit significant associations with any SQOL dimension.

CONCLUSIONS

Comprehensive assessment of depressive symptoms should be regularly implemented in BPD services to facilitate early detection and treatment, thereby ensuring patients' SQOL. Accordingly, tackling anxiety and other PDs co-occurrence through appropriate interventions can facilitate more effectively SQOL improvement. Our findings can be explained by the hypothesis that co-existing psychopathology such as depression, anxiety and co-occurrence of other PDs in BPD patients represent illness severity indices rather than comorbid disorders, and might fully mediate the effect of BPD traits on SQOL. Future mediation analysis is required to elucidate this hypothesis.

Borderline Personality Disorder in Patients With Medical Illness: A Review of Assessment, Prevalence, and Treatment Options

OBJECTIVE

Borderline personality disorder (BPD) occurs in 0.7% to 3.5% of the general population. Patients with BPD experience excessive comorbidity of psychiatric and somatic diseases and are known to be high users of health care services. Because of a range of challenges related to adverse health behaviors and their interpersonal style, patients with BPD are often regarded as "difficult" to interact with and treat optimally.

METHODS

This narrative review focuses on epidemiological studies on BPD and its comorbidity with a specific focus on somatic illness. Empirically validated treatments are summarized, and implementation of specific treatment models is discussed.

RESULTS

The prevalence of BPD among psychiatric inpatients (9%-14%) and outpatients (12%-18%) is high; medical service use is very frequent, annual societal costs vary between &OV0556;11,000 and &OV0556;28,000. BPD is associated with cardiovascular diseases and stroke, metabolic disease including diabetes and obesity, gastrointestinal disease, arthritis and chronic pain, venereal diseases, and HIV infection as well as sleep disorders. Psychotherapy is the treatment of choice for BPD. Several manualized treatments for BPD have been empirically validated, including dialectical behavior therapy, transference-focused psychotherapy, mentalization-based therapy, and schema-focused therapy.

CONCLUSIONS

Health care could be substantially improved if all medical specialties would be familiar with BPD, its pathology, medical and psychiatric comorbidities, complications, and treatment. In mental health care, several empirically validated treatments that are applicable in a wide range of clinical settings are available.

Nonsuicidal Self-Injury and Borderline Personality Features as Risk Factors for Suicidal Ideation Among Male Veterans With Posttraumatic Stress Disorder

U.S. veterans are at increased risk for suicide compared to their civilian counterparts and account for approximately 20% of all deaths by suicide. Posttraumatic stress disorder (PTSD) and borderline personality features (BPF) have each been associated with increased suicide risk. Additionally, emerging research suggests that nonsuicidal self-injury (NSSI) may be a unique risk factor for suicidal behavior. Archival data from 728 male veterans with a PTSD diagnosis who were receiving care through an outpatient Veterans Health Administration (VHA) specialty PTSD clinic were analyzed. Diagnosis of PTSD was based on a structured clinical interview administered by trained clinicians. A subscale of the Personality Assessment Inventory was used to assess BPF, and NSSI and suicidal ideation (SI) were assessed by self-report. Findings revealed that NSSI (58.8%) and BPF (23.5%) were both relatively common in this sample of male veterans with PTSD. As expected, each condition was associated with significantly increased odds of experiencing SI compared to PTSD alone, odds ratios (ORs) = 1.2-2.6. Moreover, co-occurring PTSD, NSSI, and BPF were associated with significantly increased odds of experiencing SI compared with PTSD, OR = 5.68; comorbid PTSD and NSSI, OR = 2.57; and comorbid PTSD and BPF, OR = 2.13. The present findings provide new insight into the rates of NSSI and BPF among male veterans with PTSD and highlight the potential importance of these factors in suicide risk.

Obsessive-Compulsive Personality Symptoms Predict Poorer Response to Gamma Ventral Capsulotomy for Intractable OCD

Gamma ventral capsulotomy (GVC) is a radiosurgical procedure which aims to create lesions in the ventral part of the anterior limb of the internal capsule (ALIC). It has been used as a treatment option for patients with intractable obsessive-compulsive disorder (OCD) who do not respond to several first-line treatments attempts. However, changes in personality disorder symptoms after GVC have not been investigated. The aims of this study are to investigate changes in personality disorder symptoms after GVC and to search for baseline personality disorder symptoms that may predict clinical response to GVC. Fourteen treatment-intractable OCD patients who underwent GVC completed the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II) at baseline and one year after the procedure. Wilcoxon signed-rank test was performed to investigate personality disorder symptom changes before and after surgery. Linear regression models were utilized to predict treatment response, using baseline personality disorder symptoms as independent variables. We did not observe any quantitative changes in personality disorder symptoms after GVC, compared with baseline. Higher severity of obsessive-compulsive personality disorder symptoms at baseline was correlated with worse treatment response after GVC for OCD (β = -0.085, t-value = -2.52, p-value = 0.027). These findings advocate for the safety of the GVC procedure in this specific population of intractable OCD patients, in terms of personality disorder symptom changes. They also highlight the importance of taking into account the severity of obsessive-compulsive personality disorder symptoms when GVC is indicated for intractable OCD patients.

Risk Factors for Suicidal Behavior Depend on Age for Veterans in the Pacific Islands

We examined whether risk factors for suicidal behavior depend on age among military veterans in the Pacific Islands (N = 29,595). For veterans under 54 years old, having a diagnosis of posttraumatic stress disorder, borderline personality disorder, a drug use disorder, and having a service-related disability predicted suicidal behavior. For veterans 54 years old or older, having a mood disorder predicted suicidal behavior. Having a history of suicidal behavior and a high number of VA health care visits were associated with suicidal behavior for both age groups. Our findings suggest that the predictive value of certain risk factors in veterans in the Pacific Islands may depend on age.

Role of Borderline Personality Disorder in the Treatment of Military Sexual Trauma-related Posttraumatic Stress Disorder with Cognitive Processing Therapy

Cognitive Processing Therapy (CPT) is an effective evidence-based treatment for many, but not all, veterans with posttraumatic stress disorder (PTSD). Understanding the factors that contribute to poorer response to CPT is important for providing the best care to veterans diagnosed with PTSD. Researchers investigating the effectiveness of CPT for individuals with comorbid personality symptoms have found that borderline personality disorder (BPD) characteristics do not negatively affect treatment outcome; however, participants in those studies were not diagnosed with BPD. The current pilot study investigated the effect of a BPD diagnosis on CPT dropout and outcomes. Data were compiled from a larger randomized clinical trial. Twenty-seven female veterans with military sexual trauma-related PTSD received CPT. Dropout was evaluated by treatment completion and number of sessions attended. Treatment outcome was assessed by the Clinician Administered PTSD Scale (CAPS) and the PTSD Checklist (PCL). No significant differences were observed between veterans with and without BPD comorbidity for number of treatment sessions attended, and there was not a significant relationship between comorbidity status and treatment completion. A hierarchical linear modeling approach was used with BPD entered as a level 2 predictor of outcome. In our sample, veterans with BPD had higher PTSD symptom severity on the CAPS at baseline compared to veterans without BPD comorbidity. CPT was effective in reducing PTSD symptoms; however, BPD diagnosis did not influence treatment response over time on the CAPS or PCL. Our results provide initial support for the use of CPT in female veterans with MST-related PTSD and comorbid BPD.

Elevated Monoamine Oxidase-A Distribution Volume in Borderline Personality Disorder Is Associated With Severity Across Mood Symptoms, Suicidality, and Cognition

BACKGROUND

Monoamine oxidase-A (MAO-A) is a treatment target in neurodegenerative illness and mood disorders that increases oxidative stress and predisposition toward apoptosis. Increased MAO-A levels in prefrontal cortex (PFC) and anterior cingulate cortex (ACC) occur in rodent models of depressive behavior and human studies of depressed moods. Extreme dysphoria is common in borderline personality disorder (BPD), especially when severe, and the molecular underpinnings of severe BPD are largely unknown. We hypothesized that MAO-A levels in PFC and ACC would be highest in severe BPD and would correlate with symptom magnitude.

METHODS

[(11)C] Harmine positron emission tomography measured MAO-A total distribution volume (MAO-A VT), an index of MAO-A density, in severe BPD subjects (n = 14), moderate BPD subjects (n = 14), subjects with a major depressive episode (MDE) only (n = 14), and healthy control subjects (n = 14). All subjects were female.

RESULTS

Severe BPD was associated with greater PFC and ACC MAO-A VT compared with moderate BPD, MDE, and healthy control subjects (multivariate analysis of variance group effect: F6,102 = 5.6, p < .001). In BPD, PFC and ACC MAO-A VT were positively correlated with mood symptoms (PFC: r = .52, p = .005; ACC: r = .53, p = .004) and suicidality (PFC: r = .40, p = .037; ACC: r = .38, p = .046), while hippocampus MAO-A VT was negatively correlated with verbal memory (r = -.44, p = .023).

CONCLUSIONS

These results suggest that elevated MAO-A VT is associated with multiple indicators of BPD severity, including BPD symptomatology, mood symptoms, suicidality, and neurocognitive impairment.

Quality of life in borderline patients comorbid with anxiety spectrum disorders - a cross-sectional study

INTRODUCTION

Borderline personality disorder (BPD) significantly reduces the quality of life (QoL) in mental, social, and work domains. Patients with BPD often suffer from depressive anxiety symptoms. The purpose of this cross-sectional study was to compare the QoL and demographic and clinical factors of inpatients diagnosed with BPD and comorbid anxiety spectrum disorders, and healthy controls.

METHODS

Ninety-two hospitalized patients treated in the psychotherapeutic department and 40 healthy controls were included. Subjects were assessed by the Quality of Life Satisfaction and Enjoyment Questionnaire (Q-LES-Q), Dissociative Experiences Scale, Beck Depression Inventory (BDI)-II, Beck Anxiety Inventory, Clinical Global Impression, demographic questionnaire, Sheehan Disability Scale (SDS), and Sheehan Anxiety Scale.

RESULTS

BPD patients suffered from comorbid anxiety disorders, panic disorder (18.5%), social phobia (20.7%), generalized anxiety disorder/mixed anxiety depression disorder (17.4%), adjustment disorder (22.8%), and posttraumatic stress disorder (8.7%); 19.6% patients had two or more anxiety disorder comorbidities. Patients score in Q-LES-Q (general) was 36.24±9.21, which was significantly lower in comparison to controls (57.83±10.21) and similar in all domains (physical health, feelings, work, household, school/study, leisure, social activities). The subjective level of depression measured by BDI and SDS (social life and family subscales) negatively correlated with all Q-LES-Q domains.

CONCLUSION

Patients suffering from BPD and comorbid anxiety disorders have a lower level of QoL compared to healthy controls in all measured domains. Negative correlations of the Q-LES-Q domains with clinical scales (Dissociative Experiences Scale, BDI, Beck Anxiety Inventory, Sheehan Anxiety Scale, Clinical Global Impression, and SDS) are noticeable.

Mood instability is a common feature of mental health disorders and is associated with poor clinical outcomes

OBJECTIVES

Mood instability is a clinically important phenomenon but has received relatively little research attention. The objective of this study was to assess the impact of mood instability on clinical outcomes in a large sample of people receiving secondary mental healthcare.

DESIGN

Observational study using an anonymised electronic health record case register.

SETTING

South London and Maudsley NHS Trust (SLaM), a large provider of inpatient and community mental healthcare in the UK.

PARTICIPANTS

27,704 adults presenting to SLaM between April 2006 and March 2013 with a psychotic, affective or personality disorder.

EXPOSURE

The presence of mood instability within 1 month of presentation, identified using natural language processing (NLP).

MAIN OUTCOME MEASURES

The number of days spent in hospital, frequency of hospital admission, compulsory hospital admission and prescription of antipsychotics or non-antipsychotic mood stabilisers over a 5-year follow-up period.

RESULTS

Mood instability was documented in 12.1% of people presenting to mental healthcare services. It was most frequently documented in people with bipolar disorder (22.6%), but was common in people with personality disorder (17.8%) and schizophrenia (15.5%). It was associated with a greater number of days spent in hospital (β coefficient 18.5, 95% CI 12.1 to 24.8), greater frequency of hospitalisation (incidence rate ratio 1.95, 1.75 to 2.17), greater likelihood of compulsory admission (OR 2.73, 2.34 to 3.19) and an increased likelihood of prescription of antipsychotics (2.03, 1.75 to 2.35) or non-antipsychotic mood stabilisers (2.07, 1.77 to 2.41).

CONCLUSIONS

Mood instability occurs in a wide range of mental disorders and is not limited to affective disorders. It is generally associated with relatively poor clinical outcomes. These findings suggest that clinicians should screen for mood instability across all common mental health disorders. The data also suggest that targeted interventions for mood instability may be useful in patients who do not have a formal affective disorder.

Neurobiological and behavioural studies of affective instability in clinical populations: a systematic review

OBJECTIVES

To evaluate the neurobiological, psychophysical and behavioural measures of affective instability in clinical populations.

DATA SOURCES

A range of medical and psychological science electronic databases were searched (including MEDLINE, EMBASE, and PsycINFO). Hand searching and reference checking are also included.

REVIEW METHODS

Reviews, systematic reviews, experimental and cross-sectional studies, providing affective instability in neurobiological and behavioural measurements in clinical populations. Studies were selected, data were extracted and quality was appraised.

RESULTS

Twenty-nine studies were included, 6 of which were review studies (one a meta-analysis) and 23 of which were primary studies, across a wide variety of disorders including ADHD, bipolar affective disorder, schizophrenia, severe mood dysregulation, major depression, and borderline personality disorder.

CONCLUSIONS

The bulk of the studies converge on the role of the amygdala, particularly in borderline personality disorders, and how it connects with other areas of the brain. Future research needs to extend these findings across diagnoses and development.

How is affective instability defined and measured? A systematic review

BACKGROUND

Affective instability (AI) is poorly defined but considered clinically important. The aim of this study was to examine definitions and measures of AI employed in clinical populations.

METHOD

This study was a systematic review using the PRISMA guidelines. MEDLINE, Embase, PsycINFO, PsycArticles and Web of Science databases were searched. Also five journals were hand searched. Primary empirical studies involving randomized controlled trials (RCTs), non-RCTs, controlled before and after, and observational investigations were included. Studies were selected, data extracted and quality appraised. A narrative synthesis was completed.

RESULTS

A total of 11 443 abstracts were screened and 37 studies selected for final analysis on the basis that they provided a definition and measure of AI. Numbers of definitions for each of the terms employed in included studies were: AI (n = 7), affective lability (n = 6), affective dysregulation (n = 1), emotional dysregulation (n = 4), emotion regulation (n = 2), emotional lability (n = 1), mood instability (n = 2), mood lability (n = 1) and mood swings (n = 1); however, these concepts showed considerable overlap in features. A total of 24 distinct measures were identified that could be categorized as primarily measuring one of four facets of AI (oscillation, intensity, ability to regulate and affect change triggered by environment) or as measuring general emotional regulation.

CONCLUSIONS

A clearer definition of AI is required. We propose AI be defined as 'rapid oscillations of intense affect, with a difficulty in regulating these oscillations or their behavioural consequences'. No single measure comprehensively assesses AI and a combination of current measures is required for assessment. A new short measure of AI that is reliable and validated against external criteria is needed.

The relationship of chronic medical illnesses, poor health-related lifestyle choices, and health care utilization to recovery status in borderline patients over a decade of prospective follow-up

BACKGROUND

The interaction of borderline personality disorder (BPD) with physical health has not been well characterized. In this longitudinal study, we investigated the long-term relationship of chronic medical illnesses, health-related lifestyle choices, and health services utilization to recovery status in borderline patients over a decade of prospective follow-up.

METHOD

264 borderline patients were interviewed concerning their physical health at 6-year follow-up in a longitudinal study of the course of BPD. This sample was then reinterviewed five times at two-year intervals over the next ten years. We defined recovery from BPD based on a Global Assessment of Functioning score of 61 or higher, which required BPD remission, one close relationship, and full-time competent and consistent work or school attendance. We controlled for potentially confounding effects of time-varying major depressive disorder.

RESULTS

Never-recovered borderline patients were significantly more likely than ever-recovered borderline patients to have a medical syndrome, obesity, osteoarthritis, diabetes, urinary incontinence, or multiple medical conditions (p<0.0063). They were also significantly more likely to report pack-per-day smoking, weekly alcohol use, no regular exercise, daily sleep medication use, or pain medication overuse (p<0.0083). In addition, never-recovered borderline patients were significantly more likely than ever-recovered borderline patients to undergo a medical emergency room visit, medical hospitalization, X-ray, CT scan, or MRI scan (p<0.0063).

CONCLUSIONS

Over a decade of prospective follow-up, failure to recover from BPD seems to be associated with a heightened risk of chronic medical illnesses, poor health-related lifestyle choices, and costly health services utilization.

Mood instability, mental illness and suicidal ideas: results from a household survey

PURPOSE

There is weak and inconsistent evidence that mood instability (MI) is associated with depression, post traumatic stress disorder (PTSD) and suicidality although the basis of this is unclear. Our objectives were first to test whether there is an association between depression and PTSD, and MI and secondly whether MI exerts an independent effect on suicidal thinking over and above that explained by common mental disorders.

METHODS

We used data from the Adult Psychiatric Morbidity Survey 2007 (N = 7,131). Chi-square tests were used to examine associations between depression and PTSD, and MI, followed by regression modelling to examine associations between MI and depression, and with PTSD. Multiple logistic regression analyses were used to assess the independent effect of MI on suicidal thinking, after adjustment for demographic factors and the effects of common mental disorder diagnoses.

RESULTS

There are high rates of MI in depression and PTSD and the presence of MI increases the odds of depression by 10.66 [95% confidence interval (CI) 7.51-15.13] and PTSD by 8.69 (95% CI 5.90-12.79), respectively, after adjusting for other factors. Mood instability independently explained suicidal thinking, multiplying the odds by nearly five (odds ratio 4.82; 95% CI 3.39-6.85), and was individually by some way the most important single factor in explaining suicidal thoughts.

CONCLUSIONS

MI is strongly associated with depression and PTSD. In people with common mental disorders MI is clinically significant as it acts as an additional factor exacerbating the risk of suicidal thinking. It is important to enquire about MI as part of clinical assessment and treatment studies are required.

Transference-focused psychotherapy in the general psychiatry residency: a useful and applicable model for residents in acute clinical settings

Transference-focused psychotherapy (TFP) is a manualized, psychodynamic treatment for severe personality disorders. Training in TFP during residency can provide a readily applicable model for understanding and treating personality pathology in a variety of settings, even for residents who do not obtain additional training in psychodynamic treatments or go on to practice psychotherapy. Although TFP was developed as a long-term outpatient treatment, the authors have found the diagnostic and theoretical framework and the clinical techniques described in the TFP treatment manual to be useful in acute settings, even when the clinician does not have a clearly established relationship with the patient. In the authors' experience, residents find this model of understanding and working with patients with personality disorders enjoyable to learn and easy to apply.

The prevalence and clinical associations of mood instability in adults living in England: results from the Adult Psychiatric Morbidity Survey 2007

Mood instability is underinvestigated but potentially clinically important. This study aimed to describe the prevalence of mood instability in adults living in England and test whether it is important in explaining the extent of symptoms of common mental disorders, suicidality and healthcare use. An analysis of data from the adult psychiatric morbidity survey 2007, a household survey of private households in England (N=7403), was completed. The prevalence of mood instability was 13.9%. In univariate analysis it was strongly associated with socio-demographic and clinical variables. In regression modelling mood instability was independently associated with non-psychotic psychopathology, increasing the odds by 9.89. It was also linked with suicidal ideas (odds ratios (OR): 2.04) but not suicidal acts, and associated with being in receipt of medication, counselling or therapy for mental health problems (OR: 1.88), independent of a diagnosis of borderline personality disorder. Mood instability is relatively common in the adult population, occurs frequently in common mental disorders and appears to be an important symptom in its own right. It is associated with two important measures in psychiatry, namely suicidal thinking and healthcare service use. It warrants more widespread recognition and further research is required to understand if, when and how to intervene.

Utilization of primary care physicians in borderline personality

OBJECTIVE

Individuals with borderline personality disorder (BPD) consistently demonstrate high patterns of utilization in both mental health and non-psychiatric settings. However, utilization of primary care physicians by these individuals has not been examined. In this study, we examined physician use patterns and hypothesized that primary care outpatients with BPD features would evidence higher numbers of primary care physicians seen, primary care treatment settings experienced, and specialists seen.

METHOD

Using a cross-sectional consecutive sample of 389 internal medicine outpatients and a self-report survey methodology, we examined the number of primary care physicians seen, primary care treatment settings experienced, and specialists seen by participants during the past 5 years in relationship to two self-report measures for BPD, the BPD scale of the Personality Diagnostic Questionnaire-4 and the Self-Harm Inventory.

RESULTS

There were statistically significant between-group differences in the number of primary care physicians and specialists seen (not the number of primary care treatment settings) over 5 years, and BPD status according to both measures of BPD, with BPD patients reporting higher rates.

CONCLUSIONS

Patients with borderline personality symptomatology appear to see a greater number of primary care physicians and specialists than patients without these Axis II symptoms. These findings may reflect the underlying psychological processes of the disorder as well as a general pattern of over-utilization of healthcare services by these types of patients.

Health-related quality of life in bereaved HIV-positive adults: relationships between HIV symptoms, grief, social support, and Axis II indication

OBJECTIVE

This study evaluated a model of the impact of borderline and antisocial personality disorder indications on HIV symptoms and health-related quality of life (HRQoL) in AIDS-bereaved adults, accounting for grief severity, social support, and years since HIV diagnosis.

DESIGN

Structural equation modeling was used to test the proposed model in a sample of 268 HIV-seropositive adults enrolled in an intervention for coping with AIDS-related bereavement.

MAIN OUTCOME MEASURES

Functional assessment of HIV infection, HIV symptoms.

RESULTS

The proposed model demonstrated excellent fit with study data and all hypothesized paths were supported. Personality disorder indication was directly related to HIV symptoms and HRQoL and indirectly related through both social support and grief severity. Social support was negatively related to HIV symptoms and positively related to HRQoL, while grief severity was positively related to HIV symptoms and negatively related to HRQoL. Finally, HIV symptoms had a direct negative relationship with HRQoL.

CONCLUSION

Personality disorders have a direct negative effect on HIV symptoms and HRQoL and indirect effects through grief severity and social support.

The prediction of healthcare utilization by three self-report measures for borderline personality

Objective. In this study, we explored the ability of three self-report measures for borderline personality disorder (BPD) to predict psychiatric and medical (i.e. non-psychiatric) healthcare utilization. Methods. Using a sample of convenience and survey methodology, we asked participants (N=120) to complete the borderline personality scale of the Personality Diagnostic Questionnaire-4 (PDQ-4), the Self-Harm Inventory (SHI), the McLean Screening Inventory for Borderline Personality Disorder (MSI-BPD), and several variables relating to psychiatric and medical healthcare utilization. Results. The SHI demonstrated the greatest number of correlations with healthcare utilization, particularly with regard to psychiatric care. Conclusions. The SHI provides several functions for clinicians including the identification of self-harm behaviors, confirmation of the diagnosis BPD, and prediction of psychiatric healthcare utilization.

Association of personality disorders, family conflicts and treatment with quality of life in opiate addiction

AIM

The purpose of this study was to investigate the association of the current status and longitudinal changes in different clinical and social variables with quality of life (QOL) in opiate addiction. Our hypotheses were that drug use, comorbid personality disorders and social problems are associated with worse QOL.

METHODS

107 participants with long-term opiate addiction were included and interviewed at entry with the Europ-ASI and the PDQ-R. QOL (SF-36) and changes in different domains of the Europ-ASI were assessed after 2 years.

RESULTS

Personality disorders, interpersonal conflicts with the family or partner and ongoing need for somatic and psychiatric treatment were significantly associated with worse subjective QOL, whereas changes in drug and alcohol use, the economic situation, legal problems and social problems with persons outside of the family showed no relevant association with QOL.

CONCLUSION

Our results provide support for an emphasis in treatment on helping clients to reduce intra- and interpersonal conflicts according to comorbid conditions and among family members and partnerships. In addition, the present data provide further support for the advantages of extended interventions in long-term opiate addiction.

Relationship of sex to symptom severity, psychiatric comorbidity, and health care utilization in 163 subjects with borderline personality disorder

OBJECTIVE

The objective of the study was to compare symptom severity, frequency, and pattern of psychiatric comorbidity, quality of life, and health care utilization in men and women with borderline personality disorder (BPD).

METHODS

The analysis is based on a sample of 163 subjects with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition BPD recruited for participation in a clinical trial at an academic medical center. Subjects were administered structured interviews and questionnaires of known reliability.

RESULTS

Men (n = 25) and women (n = 138) with BPD were compared across multiple domains. Men were significantly older than women (34.5 vs 30.4 years), but subjects were otherwise similar in their demographic characteristics. Overall syndrome severity and frequency of past suicide attempts and self-harm behaviors were also similar. Women were more likely than men to have an anxiety disorder (particularly generalized anxiety disorder), somatoform disorders, and histrionic personality disorder. Antisocial personality disorder was more common in men. Women had higher dimensional ratings of depression, anxiety, obsessive-compulsiveness, work dysfunction, and negative affectivity; they were also more likely to endorse the "paranoia/dissociation" BPD criterion. On the Short Form-36 Health Survey, women reported significantly worse emotional role, social role, and mental health functioning than men. Contrary to expectation, there were no significant cross sex differences in the use of health care resources.

CONCLUSION

Men and women with BPD show important differences in their pattern of psychiatric comorbidity, dimensional symptom ratings, and in quality of life variables. Women have more negative views of themselves, and worse overall emotional and social role functioning. Implications for clinicians and researchers are discussed.

Borderline personality disorder in male and female offenders newly committed to prison

BACKGROUND

The objective of the study was to estimate the rate of borderline personality disorder (BPD) in male and female offenders newly committed to the Iowa Department of Corrections. We also compared clinical and demographic characteristics of offenders with and without BPD.

METHODS

A random sample of 220 offenders entering Iowa's prison system were evaluated by using a version of the Mini International Neuropsychiatric Interview, the BPD module of the Structured Interview for DSM-IV Personality Disorders, the Medical Outcome Survey Short Form-36 Health Survey, and the Level of Service Inventory-Revised.

RESULTS

Borderline personality disorder was present in 65 (29.5%) subjects, although 93.2% had at least one Diagnostic and Statistical Manual of Mental Disorders-IV BPD trait. The percentage of women meeting criteria for BPD was more than twice that for men. Subjects with BPD were more likely than those without to be married, employed, and to have a high suicide risk score. Offenders with BPD were more likely than others to report prior mental health treatment, and to have reported high levels of interference from their mental disorder. Offenders with BPD had worse quality of life than offenders without BPD as assessed with the Medical Outcome Survey Short Form 36 Health Survey, and higher rates of mood, anxiety, psychotic, and eating disorders; antisocial personality disorder; and attention deficit hyperactivity disorder. Borderline personality disorder was also associated with higher Level of Service Inventory-Revised total scores, which indicates their having a greater risk for recidivism than nonborderline offenders. These relationships were observed after adjusting for sex, age, race/ethnicity, and presence of antisocial personality disorder.

CONCLUSION

Borderline personality disorder is relatively common among both male and female offenders in prison, and is associated with substantial psychologic stress and impaired quality of life. Early recognition and treatment of BPD in prisons may be warranted.