Marginalization of borderline personality disorder

Readiness and Personality Disorders: Considering Patients' Readiness for Change and Our System's Readiness for Patients

ABSTRACT

The culture around personality disorder treatment has changed drastically in the past generation. While once perceived as effectively untreatable, there are now numerous evidence-based treatment approaches for personality disorders (especially borderline personality disorder). The questions, however, of who should be matched to which treatment approach, and when, remain largely unanswered. In other areas of psychiatry, particularly substance use disorders and eating disorders, assessing patient treatment readiness is viewed as indispensable for treatment planning. Despite this, relatively little research has been done with respect to readiness and personality disorder treatment. In this article, we propose multiple explanations for why this may be the case, relating to both the unique features of personality disorders and the current cultural landscape around their treatment. While patients with personality disorders often face cruel stigmatization, and much more work needs to be done to expand access to care (i.e., our system's readiness for patients), even gold-standard treatment options are unlikely to work if a patient is not ready for treatment. Further study of readiness in the context of personality disorders could help more effectively match patients to the right treatment, at the right time. Such research could also aid development of strategies to enhance patient readiness.

Crisis and acute mental health care for people who have been given a diagnosis of a 'personality disorder': a systematic review

BACKGROUND

People who have been given a diagnosis of a 'personality disorder' need access to good quality mental healthcare when in crisis, but the evidence underpinning crisis services for this group is limited. We synthesised quantitative studies reporting outcomes for people with a 'personality disorder' diagnosis using crisis and acute mental health services.

METHODS

We searched OVID Medline, PsycInfo, PsycExtra, Web of Science, HMIC, CINAHL Plus, Clinical Trials and Cochrane CENTRAL for randomised controlled trials (RCTs) and observational studies that reported at least one clinical or social outcome following use of crisis and acute care for people given a 'personality disorder' diagnosis. We performed a narrative synthesis of evidence for each model of care found.

RESULTS

We screened 16,953 records resulting in 35 studies included in the review. Studies were published between 1987-2022 and conducted in 13 countries. Six studies were RCTs, the remainder were non randomised controlled studies or cohort studies reporting change over time. Studies were found reporting outcomes for crisis teams, acute hospital admission, acute day units, brief admission, crisis-focused psychotherapies in a number of settings, Mother and Baby units, an early intervention service and joint crisis planning. The evidence for all models of care except brief admission and outpatient-based psychotherapies was assessed as low or very low certainty.

CONCLUSION

The literature found was sparse and of low quality. There were no high-quality studies that investigated outcomes following use of crisis team or hospital admission for this group. Studies investigating crisis-focused psychological interventions showed potentially promising results.

Structural stigma and its impact on healthcare for borderline personality disorder: a scoping review

BACKGROUND

People with Borderline Personality Disorder (BPD) and their carers/families continue to experience structural stigma when accessing health services. Structural stigma involves societal-level conditions, cultural norms, and organizational policies that inhibit the opportunities, resources, and wellbeing of people living with attributes that are the object of stigma. BPD is a serious mental illness characterized by pervasive psychosocial dysfunction including, problems regulating emotions and suicidality. This scoping review aimed to identify, map, and explore the international literature on structural stigma associated with BPD and its impact on healthcare for consumers with BPD, their carers/families, and health practitioners.

METHODS

A comprehensive search of the literature encompassed MEDLINE, CINAHL, PsycINFO, Scopus, Cochrane Library, and JBI Evidence-Based databases (from inception to February 28th 2022). The search strategy also included grey literature searches and handsearching the references of included studies. Eligibility criteria included citations relevant to structural stigma associated with BPD and health and crisis care services. Quality appraisal of included citations were completed using the Mixed Methods Appraisal Tool 2018 version (MMAT v.18), the Joanna Briggs Institute (JBI) Checklist for Systematic Reviews and Research Syntheses Tool, and the AGREE II: advancing guideline development, reporting, and evaluation in health care tool. Thematic Analysis was used to inform data extraction, analysis, interpretation, and synthesis of the data.

RESULTS

A total of 57 citations were included in the review comprising empirical peer-reviewed articles (n = 55), and reports (n = 2). Studies included quantitative, qualitative, mixed methods, and systematic review designs. Review findings identified several extant macro- and micro-level structural mechanisms, challenges, and barriers contributing to BPD-related stigma in health systems. These structural factors have a substantial impact on health service access and care for BPD. Key themes that emerged from the data comprised: structural stigma and the BPD diagnosis and BPD-related stigma surrounding health and crisis care services.

CONCLUSION

Narrative synthesis of the findings provide evidence about the impact of structural stigma on healthcare for BPD. It is anticipated that results of this review will inform future research, policy, and practice to address BPD-related stigma in health systems, as well as approaches for improving the delivery of responsive health services and care for consumers with BPD and their carers/families.

REVIEW REGISTRATION

Open Science Framework ( https://osf.io/bhpg4 ).

Validation of the Three-Item Screener for Personality Disorders From the Inventory of Interpersonal Problems (IIP-3)

We previously developed a three-item screener for identifying respondents with any personality disorder (PD) using the Inventory of Interpersonal Problems (IIP). The current goal was to examine the convergent validity of the IIP-3 with other PD screeners and diagnostic tools and to investigate its relationship to measures of adult attachment and emotion regulation. The sample consisted of participants from five studies (total N = 852), with data from collateral informants available for a subsample (N = 353). Despite its brevity, the IIP-3 showed moderate to strong relationships with other longer PD screeners, with PD symptom scores from the Structured Interview for DSM-IV Personality (SIDP-IV), and with a global rating of PD severity. It was most sensitive to the stylistic aspects of PD typical of the traditional DSM cluster B (dramatic, expressive) PDs. These results emerged with data from both participants and informants, although correlations using informant data were generally smaller.

The prevalence of severe personality disorder in perpetrators of homicide

BACKGROUND

Current UK evidence on the prevalence of personality disorder in homicide is lacking. The aims were to estimate the prevalence of personality disorder in homicide perpetrators from court reports and carry out a dimensional assessment in keeping with the new ICD-11 classification of the prevalence of severe personality disorder. Associations between severe personality disorder and sociodemographic, historical and offence-related characteristics were then explored.

METHODS

Six hundred court reports from a national case series of homicide perpetrators in England and Wales were analysed using a document-derived version of the Personality Assessment Schedule (PAS-DOC), providing categorical and dimensional personality assessments. The prevalence of personality disorder and severe personality disorder was estimated. Factors associated with the diagnosis of severe personality disorder were examined.

RESULTS

The prevalence of personality disorder using the PAS-DOC was 56.3% (95% confidence interval 52.3%, 60.3%), compared with 16% as diagnosed in reports. Severe personality disorder was present in 62% (n = 338) of all those with a personality disorder and was significantly associated with homicides of strangers and previous violence.

CONCLUSIONS

Severe personality disorder is highly prevalent among perpetrators of homicide, and the finding that it is more prevalent when strangers are the victims stresses both the need for early identification of those at risk of developing severe personality disorder and the development of appropriate early preventive interventions. There is also a need for the development of effective treatment and interventions for those with established severe personality disorder and better identification of this level of disorder by psychiatrists. The forthcoming ICD-11 classification should help in this endeavour. © 2021 The Authors Personality and Mental Health Published by John Wiley & Sons Ltd.

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

Background

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

Methods

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

Results

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

Conclusions

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

The Parenting Experience of Those With Borderline Personality Disorder Traits: Practitioner and Parent Perspectives

Background

Borderline Personality Disorder (BPD) is associated with challenges around emotional intensity and interpersonal difficulties. The children of parents with BPD are at risk of poorer outcomes in terms of their own mental health, educational outcomes and wellbeing. The challenges of being a parent can also exacerbate the symptoms of those with BPD traits. There is a pressing need to understand the experience of these parents and to determine what support would be appropriate and useful.

Aim

To explore and compare the experiences and support needs of parents with BPD traits with the experiences and understanding of practitioners who work with them.

Methods

Interviews with 12 parents with BPD traits and 21 practitioners with experience of working with individuals with BPD. The two strands of interviews were analyzed independently using a thematic framework approach, after which the superordinate and subordinate themes were subject to comparison.

Results

Parents with BPD traits represent themselves as experiencing considerable challenges in their role as a parent. These included the impact of emotional intensity, social isolation and lack of a positive parenting models to draw upon. Practitioners demonstrated a strong degree of shared understanding into these difficulties. Both groups highlighted a lack of appropriate support for these parents.

Conclusion

This research highlights the clinical need for parenting-focused support for individuals with BPD traits. Preliminary suggestions for format and content are given.

A palliative care approach in psychiatry: clinical implications

Background

Traditionally, palliative care has focused on patients suffering from life-threatening somatic diseases such as cancer or progressive neurological disorders. In contrast, despite the often chronic, severely disabling, and potentially life-threatening nature of psychiatric disorders, there are neither palliative care units nor clinical guidelines on palliative measures for patients in psychiatry.

Main text

This paper contributes to the growing literature on a palliative approach in psychiatry and is based on the assumption that a change of perspective from a curative to a palliative approach could help promote patient-centeredness and increase quality of life for severely ill patients in psychiatry as well as in somatic medicine. To exemplify this, we offer three different clinical scenarios: severe and enduring anorexia nervosa, treatment-refractory schizophrenia, and chronic suicidality and persistent self-injury in borderline personality disorder.

Conclusion

We emphasize that many typical interventions for treatment-refractory psychiatric disorders may indeed be of a palliative nature. Furthermore, introducing traditional features of palliative care, e.g. so-called goals of care conversations, could aid even further in ensuring that caregivers, patients, and families agree on which treatment goals are to be prioritized in order to optimize quality of life in spite of severe, persistent mental disorder.

Screening for Personality Disorders: A Three-Item Screener From the Inventory of Interpersonal Problems (IIP-3)

To encourage screening for personality disorders (PDs), we developed (in previous work) self-report scales for PDs using the Inventory of Interpersonal Problems (IIP). The combined score from three of the scales-inter-personal sensitivity, interpersonal ambivalence, and aggression-requiring 15 items (IIP-15) did the best job of distinguishing between respondents with any versus no PD. The goals for the present work were (a) to cross-validate the IIP-15 by examining its performance using receiver operating characteristics (ROC) analyses in a new sample (N = 410), and (b) to investigate the utility of a brief three-item variant (IIP-3). The present results again documented the good operating characteristics of the IIP-15. Sensitivity, specificity, and positive and negative predictive values were all above. 70. The operating characteristics of the IIP-3 were nearly as good despite its brevity and support its use as an initial screen for PDs.

Implicit Bias and the Feedback Paradox: Exploring How Health Professionals Engage With Feedback While Questioning Its Credibility

PURPOSE

Learners and practicing health professionals may dismiss emotionally charged feedback related to self, yet little research has examined how to address feedback that threatens an individual's identity. The implicit association test (IAT) provides feedback to individuals regarding their implicit biases. Anticipating feedback about implicit bias might be emotionally charged for mental health professionals, this study explored their experience of taking the IAT and receiving their results, to better understand the challenges of identity-threatening feedback.

METHOD

The researchers sampled 32 psychiatry nurses, psychiatrists, and psychiatric residents at Western University in Ontario, Canada, after they completed the mental illness IAT and received their results. Using constructivist grounded theory, semistructured interviews were conducted from April to October 2017 regarding participants' experience of taking the IAT. Using constant comparative analysis, transcripts were iteratively coded and analyzed for results.

RESULTS

While most participants critiqued the IAT and questioned its credibility, many also described the experience of receiving feedback about their implicit biases as positive or neutral. Most justified their implicit biases while acknowledging the need to better manage them.

CONCLUSIONS

These findings highlight a feedback paradox, calling into question assumptions regarding self-related feedback. Participants' reactions to the IAT suggest that potentially threatening self-related feedback may still be useful to participants who question its credibility. Further exploration of how the feedback conversation influences engagement with self-related feedback is needed.

Borderline Personality Disorder: Barriers to Borderline Personality Disorder Treatment and Opportunities for Advocacy

Patients experience difficulty in accessing the evidence-based treatments that exist for borderline personality disorder. This article identifies barriers to treatment within the US structural, economic, and political landscape and how families have created an advocacy movement to address this problem. It explores how the United States has addressed such barriers, in comparison to other countries. Finally, it offers recommendations for future advocacy to increase access to treatment for borderline personality disorder.

Marginalization: Conceptualizing patient vulnerabilities in the framework of social determinants of health-An integrative review

Scientific advances in health care have been disproportionately distributed across social strata. Disease burden is also disproportionately distributed, with marginalized groups having the highest risk of poor health outcomes. Social determinants are thought to influence health care delivery and the management of chronic diseases among marginalized groups, but the current conceptualization of social determinants lacks a critical focus on the experiences of people within their environment. The purpose of this article was to integrate the literature on marginalization and situate the concept in the framework of social determinants of health. We demonstrate that social position links marginalization and social determinants of health. This perspective provides a critical lens to assess the societal power dynamics that influence the construction of the socio-environmental factors affecting health. Linking marginalization with social determinants of health can improve our understanding of the inequities in health care delivery and the disparities in chronic disease burden among vulnerable groups.

Treatment of personality disorder using a whole of service stepped care approach: A cluster randomized controlled trial

BACKGROUND AND OBJECTIVES

People with personality disorders are prevalent in emergency and inpatient mental health services. We examined whether implementing a stepped care model of psychological therapy reduces demand on hospital units by people with personality disorder, in a cluster randomized controlled trial.

METHOD

A total of 642 inpatients (average age 36.8, 50.5% female) with a primary ICD-10 personality disorder were recruited during 18 months baseline, then monitored during an 18 month active trial phase. In the active trial phase two equivalent sites were randomised to either treatment as usual (TAU), or a whole of service intervention that diverted people away from hospital and into stepped care psychological therapy clinics. The study design was cost neutral, with no additional staff or resources deployed between sites. A linear mixed models analysis evaluated outcomes.

RESULTS

As predicted, demand on hospital services reduced significantly in the intervention compared to TAU site. The intervention site evidenced shorter bed days, from an average of 13.46 days at baseline to 4.28 days per admission, and patients were 1.3 times less likely to re-present to the emergency department compared to TAU. Direct cost savings for implementing the approach was estimated at USD$2,720 per patient per year. Limitations included not directly comparing individual symptom changes.

CONCLUSIONS

Using a whole of service stepped care model of treatment for personality disorder significantly reduced demand on hospital services.

Qualitative Analysis of Resources and Barriers Related to Treatment of Borderline Personality Disorder in the United States

OBJECTIVE

Resources and treatment for individuals with borderline personality disorder (BPD) are limited and often difficult to obtain. This article aimed to identify key resources for and barriers to obtaining supportive and treatment services for BPD from the perspective of individuals seeking information or services related to BPD ("BPD care seekers").

METHODS

Data came from transcripts of resource requests to the Borderline Personality Disorder Resource Center from January 2008 to December 2015 (N=6,253). Basic statistics, including the type of service requested, demographic information for the BPD care seeker, and national distribution of requests, were generated for all eligible transcripts. Qualitative analysis of a random subset of 500 transcripts was used to identify themes, challenges, and common experiences reported by BPD care seekers.

RESULTS

The greatest number of requests for primary services or resources among the random subset of transcripts was for outpatient services (51%), informational materials (13%), and day programs (9%). Family services, crisis intervention, and mental health literacy were identified as areas where available resources did not meet current demand and that could be improved or expanded. Factors identified as potential barriers to finding and obtaining appropriate treatment for BPD included stigmatization and marginalization within mental health care systems, financial concerns, and comorbidity with psychiatric or medical disorders.

CONCLUSIONS

BPD care seekers face numerous barriers to obtaining appropriate care. Expanded services and resources to connect individuals with treatment are needed to meet the current demands and preferences of those seeking care.

Likelihood and predictors of detention in patients with personality disorder compared with other mental disorders: A retrospective, quantitative study of Mental Health Act assessments

BACKGROUND

The UK guidelines on the treatment of personality disorder recommend avoiding compulsory treatment except in extreme situations. Little is known about how often patients with personality disorder are detained or how this compares with the treatment of other mental disorders.

OBJECTIVES

Our aim is to test the hypothesis that people with personality disorder are infrequently detained under the Mental Health Act (MHA) and that risk factors associated with detention are the same as those for people with other mental disorders.

METHOD

We used a retrospective, quantitative study of MHA assessments.

RESULTS

Of the 2 087 assessments undertaken, 204 (9.8%) patients had a diagnosis of personality disorder; 40.7% of assessments in the personality disorder group resulted in detention, as did 69.7% of patients with other mental disorders. A higher proportion of people with personality disorder received no intervention following assessment compared with those with other mental disorders (20.6% vs. 4.7%, p < 0.001). Study centre and a history of admission were risk factors for detention in both groups. Risk was a predictor of detention in those with other mental disorders.

CONCLUSIONS

Detention rates in patients with personality disorder are lower than those for other disorders but are still substantial. Risk factors for detention in patients with personality disorder differ from those with other mental disorders. Copyright © 2016 John Wiley & Sons, Ltd.

The Lifetime Course of Borderline Personality Disorder

Borderline personality disorder (BPD) has historically been seen as a lifelong, highly disabling disorder. Research during the past 2 decades has challenged this assumption. This paper reviews the course of BPD throughout life, including childhood, adolescence, and adulthood. BPD can be accurately identified in adolescence, and the course of the disorder, in adolescence and adulthood, is generally similar, with reductions in symptoms over time. Functional recovery is less consistent, and further research on factors or treatments that may improve the long-term functional outcome of patients with BPD is warranted.

Patient-controlled hospital admission in psychiatry: A systematic review

BACKGROUND

Patient-controlled admission is a concept that invites patients with long-term mental illness to decide for themselves when inpatient treatment is necessary without a clinician serving as gatekeeper.

AIM

To review the current knowledge of patient-controlled hospital admission in adult psychiatry.

METHOD

A systematic literature search was conducted in PubMed/MEDLINE, EMBASE and the Cochrane Library with the aim of identifying all relevant scientific papers from 1990 onwards.

RESULTS

Six articles reporting on four different study sites were identified. Detailed account of the models is given and quantitative and qualitative outcome data is reviewed. Rationales behind the concept include increased patient autonomy, promotion of coping skills, early help-seeking, avoidance of power struggles, establishment of an asylum function, reduced time spent in inpatient care and prevention of coercive measures. Quantitative data points toward a dramatic reduction of total time spent in inpatient care and of involuntary admissions in patients with previously high inpatient care consumption, whereas qualitative data indicates that the concept increases patient autonomy, responsibility and confidence in daily life.

CONCLUSION

Patient-controlled admission is a promising novel approach to inpatient care in psychiatry. However, available studies are small and quality of evidence is generally low.

Psychiatric assessment of mood instability: qualitative study of patient experience

BACKGROUND

Mood instability is a common reason for psychiatric referral. Very little is known about how patients with unstable mood experience assessment and diagnosis.

AIMS

To investigate the experiences of assessment and diagnosis among patients with mood instability and to suggest improvements to this process.

METHOD

Qualitative study, gathering data through individual interviews with 28 people experiencing mood instability and receiving a psychiatric assessment in secondary care.

RESULTS

Participants described the importance of receiving an explanation for their symptoms; the value of a good interpersonal relationship with their clinician(s); being listened to and acknowledged; and being involved in and informed about clinical decisions. These needs were not, however, consistently met. Receiving a psychiatric diagnosis, including a diagnosis of bipolar disorder or borderline personality disorder, evoked both positive and negative responses among participants, relating to stigma, personal understanding and responsibility, prognosis and treatment.

CONCLUSIONS

Patients with mood instability seek explanation for their symptoms and difficulties, empathetic care and consistent support as much as cure. Clinicians may incorrectly assume what patients' attitudes towards diagnosis are, a mismatch which may hamper the development of a strong therapeutic relationship. Clear, patient-centred communication, which acknowledges the patient's experience, may result in greater patient engagement and satisfaction.

Improving services for people with personality disorders: views of experienced clinicians

People with personality disorders are frequent users of both inpatient and outpatient psychiatric services, representing a significantly large proportion of all mental health clients. Despite this, most services find it a challenge to offer the most appropriate and effective treatment models for people with personality disorders. This paper is a report of a study of clinician opinions about how organizations can improve the delivery of services to people with personality disorders. Data was collected from experienced clinicians attending a personality disorders clinical and scientific meeting who were asked to work together in groups and present solutions for how organizations can improve the services provided to people with personality disorders. Qualitative data was collected and thematically and semantically analyzed using Nvivo and Leximancer. The Nvivo analysis revealed five main areas in which clinicians believe organizations can improve services for people with personality disorders. These focused on: (i) more training and education for health professionals and carers; (ii) better support through supervision and leadership; (iii) adoption of a more consistent evidence-based approach to client management and treatment; (iv) clearer guidelines and protocols; and (v) changed attitudes about personality disorder to decrease stigma. The Leximancer analysis of responses indicated the identified themes were not distinct; rather they were interconnected and related to one another, semantically. In summary, clinicians across a large and diverse geographical area developed a consensus that mainstream management of personality disorder is largely poor and inadequate. The findings lend support to an integrative and collaborative whole-service approach that enhances evidence-based practice in the community.

Getting the word out about treating borderline personality disorder: an online information resource

This column reviews the need for greater awareness among mental health clinicians regarding evidence-based treatments for borderline personality disorder (BPD) and describes an online resource that has been developed to partially address this need. This resource is the Borderline Personality Disorder Clinician Resource Centre, which can be accessed at http://www.treatingBPD.ca.