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Links PS, Ross J. Good Psychiatric Management of Borderline Personality Disorder: Foundations and Future Challenges. Am J Psychother 2024:appipsychotherapy20230044. [PMID: 38952224 DOI: 10.1176/appi.psychotherapy.20230044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
Borderline personality disorder is a common condition characterized by numerous comorbid conditions, frequent use of clinical services, and an elevated lifetime risk for suicide. Good psychiatric management (GPM) was developed for patients with borderline personality disorder with the purpose of supporting wider community adoption and dissemination compared with existing therapies. The authors aimed to review the foundations and development of GPM, in particular the initial Canadian study assessing the therapy. They then reviewed the progress in research arising from the initial study and explored the research and educational opportunities needed to further the development of GPM for patients with borderline personality disorder. Research has indicated that patients with borderline personality disorder with complex comorbid conditions and impulsivity may benefit from GPM. Future research needs include noninferiority and equivalence studies comparing GPM with another evidence-based treatment; studies demonstrating that evidence-based therapies for borderline personality disorder improve functioning; and research on more accessible therapies, mechanisms of action for evidence-based therapies, extending therapies to patients with borderline personality disorder and significant comorbid conditions, and modifying therapies for men with borderline personality disorder. Attention should be directed toward testing stepped care models and integrating therapies such as GPM into psychiatric training programs. GPM is in development but shows promise as a therapy that is effective and accessible and that can be widely disseminated.
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Affiliation(s)
- Paul S Links
- Department of Psychiatry and Behavioural Neurosciences, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada (Links); Department of Psychiatry, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada (Ross)
| | - James Ross
- Department of Psychiatry and Behavioural Neurosciences, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada (Links); Department of Psychiatry, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada (Ross)
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Cavelti M, Blaha Y, Lerch S, Hertel C, Berger T, Reichl C, Koenig J, Kaess M. The evaluation of a stepped care approach for early intervention of borderline personality disorder. Borderline Personal Disord Emot Dysregul 2024; 11:12. [PMID: 38886843 PMCID: PMC11184763 DOI: 10.1186/s40479-024-00256-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 06/05/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND The current study evaluated the stepped care approach applied in AtR!Sk; a specialized outpatient clinic for adolescents with BPD features that offers a brief psychotherapeutic intervention (Cutting Down Program; CDP) to all patients, followed by a more intensive Dialectical Behavioral Therapy for Adolescents (DBT-A) for those whose symptoms persist. METHODS The sample consisted of 127 patients recruited from two AtR!Sk clinics. The number of BPD criteria, psychosocial functioning, severity of overall psychopathology, number of days with non-suicidal self-injury (NSSI; past month), and the number of suicide attempts (last 3 months) were assessed at clinic entry (T0), after CDP (T1), and at 1- and 2-year follow-up (T2, T3). Based on the T1 assessment (decision criteria for DBT-A: ≥ 3 BPD criteria & ZAN-BPD ≥ 6), participants were allocated into three groups; CDP only (n = 74), CDP + DBT-A (eligible and accepted; n = 36), CDP no DBT-A (eligible, but declined; n = 17). RESULTS CDP only showed significantly fewer BPD criteria (T2: β = 3.42, p < 0.001; T3: β = 1.97, p = 0.008), higher levels of psychosocial functioning (T2: β = -1.23, p < 0.001; T3: β = -1.66, p < 0.001), and lower severity of overall psychopathology (T2: β = 1.47, p < 0.001; T3: β = 1.43, p = 0.002) over two years compared with CDP no DBT-A, while no group differences were found with regard to NSSI and suicide attempts. There were no group differences between CDP + DBT-A and CDP no DBT-A, neither at T2 nor at T3. DISCUSSION The findings support the decision criterion for the offer of a more intense therapy after CDP. However, there was no evidence for the efficacy of additional DBT-A, which might be explained by insufficient statistical power in the current analysis.
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Affiliation(s)
- Marialuisa Cavelti
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bolligenstrasse 111, Bern 60, 3000, Switzerland
| | - Yasmine Blaha
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bolligenstrasse 111, Bern 60, 3000, Switzerland
| | - Stefan Lerch
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bolligenstrasse 111, Bern 60, 3000, Switzerland
| | - Christian Hertel
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bolligenstrasse 111, Bern 60, 3000, Switzerland
| | - Thomas Berger
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
| | - Corinna Reichl
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bolligenstrasse 111, Bern 60, 3000, Switzerland
| | - Julian Koenig
- Faculty of Medicine and University Hospital Cologne, Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University of Cologne, Cologne, Germany
| | - Michael Kaess
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bolligenstrasse 111, Bern 60, 3000, Switzerland.
- Department of Child and Adolescent Psychiatry, University Hospital Heidelberg, Heidelberg, Germany.
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Hertel C, Cavelti M, Lerch S, Mürner-Lavanchy I, Reichl C, Koenig J, Kaess M. Does personality dysfunction add incremental utility over general psychopathology when modeling previous suicide attempts in adolescent patients? J Affect Disord 2024; 361:465-471. [PMID: 38897305 DOI: 10.1016/j.jad.2024.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 05/24/2024] [Accepted: 06/14/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Identifying patients at risk for a suicide attempt (SA) is critical in adolescents with mental disorders. The current study aimed to 1) examine whether personality dysfunction (PD) is associated with previous SA, 2) explore the incremental utility of PD over psychiatric disorders in modeling previous SA. METHODS The sample comprised of n = 498 adolescent patients (mean age = 15.41 years, 79.12 % females, inpatient 48.8 %, outpatient 51.2 %). SA in the past year, PD according to the alternative DSM-5 model for personality disorders, and psychiatric diagnoses were assessed using semi-structured interviews. Logistic regression and principal component analysis examining the associations and specific patterns of PD and SA in the past year were conducted. Hierarchical (stepwise) logistic regression was applied to investigate the incremental utility of PD over that of psychiatric diagnoses to identify individuals with SA in the past year. RESULTS Including all facets of PD revealed a significant model with SA in the past year as outcome (χ2(12) = 106.65, McFaddens Pseudo-R2 = 0.17, p < 0.01). Adding PD to the model explained a significant amount of variance in past SA over that of psychiatric diagnoses (Pseudo-R2 = 0.18, Wald χ2 = 43.05, p < 0.01). LIMITATIONS As we only studied past SA and due to the cross-sectional design, no conclusion regarding the prediction of future SA can be drawn. DISCUSSION PD should routinely be assessed in adolescent patients since individuals with PD are more likely to have attempted suicide even when controlling for comorbid psychiatric disorders. PD may represent an important target for intervention in those with suicidal thoughts and behaviors.
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Affiliation(s)
- C Hertel
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - M Cavelti
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - S Lerch
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - I Mürner-Lavanchy
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - C Reichl
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - J Koenig
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - M Kaess
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland; Clinic of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany.
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Tracy M, Penney E, Norton AR. Group schema therapy for personality disorders: Systematic review, research agenda and treatment implications. Psychother Res 2024:1-20. [PMID: 38862126 DOI: 10.1080/10503307.2024.2361451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 05/22/2024] [Indexed: 06/13/2024] Open
Abstract
OBJECTIVE There are significant temporal and financial barriers for individuals with personality disorders (PD) receiving evidence-based psychological treatments. Emerging research indicates Group Schema Therapy (GST) may be an accessible, efficient, and cost-effective PD intervention, however, there has been no synthesis of the available evidence to date. This review therefore aimed to investigate the efficacy of GST for PDs by systematically synthesizing available literature. METHOD Five electronic databases were screened with resulting studies subjected to a specific eligibility criteria, which yielded fourteen relevant studies. Characteristics were extracted and methodological quality rigorously assessed. RESULTS Strong support was evidenced for GST's ability to reduce Cluster B and C symptomology, particularly for Borderline and Avoidant PD. GST appeared to improve global symptom severity, quality of life and functional capacity, as well as treatment targets such as schemas and modes. CONCLUSION Although not without limitations and a moderate risk of bias, the current body of evidence supports GST as a potential solution to current service deficits in economical and evidence-based care for individuals with PD. Implications for treatment and future research are discussed.
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Affiliation(s)
- Mikaela Tracy
- Discipline of Clinical Psychology, Graduate School of Health, University of Technology Sydney, Sydney, Australia
- Faculty of Science, School of Psychology, The University of Sydney, Sydney, Australia
| | - Erika Penney
- Discipline of Clinical Psychology, Graduate School of Health, University of Technology Sydney, Sydney, Australia
| | - Alice R Norton
- Discipline of Clinical Psychology, Graduate School of Health, University of Technology Sydney, Sydney, Australia
- Faculty of Science, School of Psychology, The University of Sydney, Sydney, Australia
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Kramer U. Good-Enough Therapy: A Review of the Empirical Basis of Good Psychiatric Management. Am J Psychother 2024:appipsychotherapy20230041. [PMID: 38853525 DOI: 10.1176/appi.psychotherapy.20230041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
In this review, the question of whether good psychiatric management (GPM) has a sufficient, or good-enough, evidence base is examined from two complementary perspectives. First, the author reviews research that has investigated whether GPM reduces symptoms of borderline personality disorder. Analyses at the group and individual levels have indicated that symptoms may decrease among patients receiving GPM. Second, the author reviews research that has investigated the processes through which change occurs in GPM. Studies that have shown process changes toward emotional balance, interpersonally effective functioning, and a more coherent and reality-based autobiographical narrative are discussed. To fully answer the question of whether GPM is good enough, more controlled trials are needed to demonstrate effectiveness, mechanisms of change, and broad implementation in culturally diverse populations.
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Affiliation(s)
- Ueli Kramer
- Department of Psychiatry, University of Lausanne, Lausanne, Switzerland; Department of Psychology, University of Windsor, Windsor, Ontario, Canada
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Blay M, Verne M, Durpoix A, Benmakhlouf I, Labaume L. Clinical specificities of patients with substance use disorder and comorbid borderline personality disorder compared to patients with substance use disorder only: a retrospective study. J Addict Dis 2024:1-7. [PMID: 38835113 DOI: 10.1080/10550887.2024.2363038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
INTRODUCTION Substance use disorder (SUD) is a common condition often associated with borderline personality disorder (BPD), and patients with both disorders (SUD + BPD) have more complex presentations and poorer outcomes in treatment. Thus, there is a need to identify more clearly the clinical differences between patients with SUD + BPD and those with SUD only to help clinicians in their diagnostic process. METHODS Data from medical files of 92 patients with SUD (SUD only: n = 42; SUD + BPD: n = 50) treated in an outpatient psychiatry and addiction treatment center were extracted to compare the differences in terms of sociodemographic characteristics, substance used, psychopathological dimensions, comorbidity prevalence, and functional impairment. RESULTS Compared to the SUD only group, patients in the SUD + BPD group were younger, more disabled, and less satisfied with their social life. Regarding substance used, the comorbid group had more frequently cannabis use disorder and poly nonalcoholic SUD. Regarding psychopathological dimensions, the comorbid group had higher levels of impulsivity, emotion regulation difficulties and alexithymia. Finally, regarding comorbidities, the comorbid group had a higher risk of comorbid anxiety, obsessive-compulsive, and post-traumatic stress disorders. CONCLUSION While being only exploratory, these results add evidence on the impact of the BPD comorbidity in patients with SUD and underline important dimensions that should be considered by clinicians working with this population.
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Affiliation(s)
- Martin Blay
- ADDIPSY, Outpatient Addictology and Psychiatry Center, Lyon, France
- UVSQ, INSERM, Centre de recherche en Epidémiologie et Santé des Populations Team "DevPsy", Université Paris-Saclay, Villejuif, France
| | - Manon Verne
- Lyon-Est Medical School, Claude Bernard University Lyon 1, Lyon, France
| | - Amaury Durpoix
- Department of psychiatry, University Hospital of Strasbourg, Strasbourg, France
| | - Inès Benmakhlouf
- ADDIPSY, Outpatient Addictology and Psychiatry Center, Lyon, France
| | - Laura Labaume
- ADDIPSY, Outpatient Addictology and Psychiatry Center, Lyon, France
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Blay M, Nicot P, Durpoix A, Leaune E, Poulet E, Ulm J, Perroud N. Evaluation of the level of training of French psychiatrists on borderline personality disorder: An online survey. L'ENCEPHALE 2024; 50:257-264. [PMID: 37604716 DOI: 10.1016/j.encep.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/04/2023] [Accepted: 06/08/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Borderline personality disorder is a common and treatable personality disorder that is often underdiagnosed and untreated, mainly due to a lack of training of psychiatrists and to a lack of accessibility to specialized therapies. However, no study has been conducted in France regarding this issue. Thus, we aimed to evaluate on a national scale the level of training, knowledge, and general attitude toward BPD diagnosis of French psychiatrists. METHODS We conducted an online survey in an unselected population of residents and senior French psychiatrists between January and March 2022, the results of which are presented descriptively. RESULTS 228 psychiatrists fully answered the questionnaire, and 21 more psychiatrists answered it partially. We found that most of the responders were unsatisfied with the residency training or the continuing medical education offered regarding BPD, a lack of training resulting in a low level of self-confidence regarding BPD management, in a low number of evidence-based therapies trained psychiatrists in issues regarding diagnostic disclosure, and in misconceptions regarding some aspects of the disorder. CONCLUSIONS These results underlie a clear lack of training of French psychiatrists, as well as a request from the latter for more opportunities to learn. This calls for a rethinking of the teaching system to incorporate more knowledge and tools related to BPD.
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Affiliation(s)
- Martin Blay
- ADDIPSY, Addictology and Psychiatry Outpatient Center, Santé Basque Development group, Lyon, France.
| | - Pierre Nicot
- Université Claude Bernard Lyon 1, CNRS, INSERM, Centre de Recherche en Neurosciences de Lyon CRNL U1028 UMR5292, PSYR2, 69500 Bron, France
| | - Amaury Durpoix
- University Hospital of Strasbourg, Strasbourg, France; University of Strasbourg, Strasbourg, France
| | - Edouard Leaune
- Suicide Prevention Center, Vinatier Hospital Center, Bron, France; Université Claude Bernard Lyon 1, CNRS, INSERM, Centre de Recherche en Neurosciences de Lyon CRNL U1028 UMR5292, PSYR2, 69500 Bron, France
| | - Emmanuel Poulet
- Psychiatry Crisis Unit, Edouard Herriot Hospital, Lyon, France; Université Claude Bernard Lyon 1, CNRS, INSERM, Centre de Recherche en Neurosciences de Lyon CRNL U1028 UMR5292, PSYR2, 69500 Bron, France
| | - Justin Ulm
- Percy Army Instruction Hospital, Clamart, France; Val de Grâce School, Paris, France
| | - Nader Perroud
- Service of Psychiatric Specialties, Department of Mental Health and Psychiatry, University Hospitals of Geneva, Geneva, Switzerland; University of Geneva, Geneva, Switzerland
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Dahlenburg SC, Bartsch DR, Giles JA, Koehne KA, O'Sullivan J. Experiences of a peer group for people diagnosed with borderline personality disorder: A qualitative interview study. Personal Ment Health 2024; 18:166-176. [PMID: 38311730 DOI: 10.1002/pmh.1604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 11/23/2023] [Accepted: 01/09/2024] [Indexed: 02/06/2024]
Abstract
There is a notable lack of literature evaluating peer support for people with a diagnosis of borderline personality disorder (BPD). Peer-led groups have been shown to positively impact outcomes related to empowerment, hope, and self-efficacy beliefs for consumers diagnosed with serious mental illness and may also be a helpful option for those experiencing personality disorder symptoms. We outline the coproduction of a peer group for people with a lived experience of BPD and a qualitative analysis of feedback post-group participation. Twenty-two consumers participated in post-group interviews and described their experiences of peer support. Interview transcripts were coded, and three main themes were identified: growth and change, connection and feeling understood, and creating safety. The findings suggested that participation in a coproduced peer support group for people with a diagnosis of BPD facilitated positive personal transformation as well as opportunities to develop connection through shared experiences in a safe environment grounded in mutuality. These themes were particularly powerful for participants because they countered previous experiences of not feeling safe, understood, or equal when seeking treatment. These findings support the acceptability of implementing a coproduced group for people diagnosed with BPD in a community mental health setting.
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Affiliation(s)
- Sophie C Dahlenburg
- Borderline Personality Disorder Collaborative, SA Health, 1/100 Greenhill Road, Unley, South Australia, 5061, Australia
- School of Psychology, The University of Adelaide, Hughes Building, North Terrace, Adelaide, South Australia, 5005, Australia
| | - Dianna R Bartsch
- Borderline Personality Disorder Collaborative, SA Health, 1/100 Greenhill Road, Unley, South Australia, 5061, Australia
- School of Psychology, The University of Adelaide, Hughes Building, North Terrace, Adelaide, South Australia, 5005, Australia
| | - Jessica A Giles
- Borderline Personality Disorder Collaborative, SA Health, 1/100 Greenhill Road, Unley, South Australia, 5061, Australia
| | - Kristy A Koehne
- Borderline Personality Disorder Collaborative, SA Health, 1/100 Greenhill Road, Unley, South Australia, 5061, Australia
| | - Judy O'Sullivan
- Borderline Personality Disorder Collaborative, SA Health, 1/100 Greenhill Road, Unley, South Australia, 5061, Australia
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Grenyer BFS, Bailey RC. Implementing a whole-of-service stepped care approach to personality disorder treatment: Impact of training and service redesign on clinician attitudes and skills. Personal Ment Health 2024; 18:93-106. [PMID: 38504144 DOI: 10.1002/pmh.1612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/21/2023] [Accepted: 09/16/2023] [Indexed: 03/21/2024]
Abstract
Personality disorders are a highly prevalent mental health condition. Historically, clinician attitudes have been negative, and only a small number have specialised training. This study evaluated clinician attitudes and confidence in working with people with personality disorder following the combination of training and implementation of a stepped care whole-of-service approach. A total of 102 multidisciplinary mental health clinicians were trained to implement the stepped care approach, and completed surveys prior to implementation and at 12 months follow up. Clinicians delivered manualised structured psychological therapy as part of the model. Measures assessed changes in attitudes and confidence, and impact of the service changes and therapy approach. Qualitative responses elucidated core themes. Evaluation at 12 months post training and service redesign showed improvements in clinician skills, confidence, theoretical knowledge and attitudes. Qualitative thematic analysis found core themes of improved understanding, clinical skills and improvements in the accessibility and timeliness of treatment. Implementing a whole-of-service model featuring stepped care therapies enhanced clinician attitudes, confidence, skills and knowledge in working with people with personality disorders. Clinicians identified that the whole-of-service model also improved accessibility to treatment, and quality of clinical care to the consumer and their carers.
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Affiliation(s)
- Brin F S Grenyer
- School of Psychology, University of Wollongong, Wollongong, New South Wales, Australia
| | - Rachel C Bailey
- School of Psychology, University of Wollongong, Wollongong, New South Wales, Australia
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Bartsch DR, Cooke-O'Connor L, Connerty TJ, van Roekel H, Cammell P. Acceptability and feasibility of a short-term group therapy for people with borderline personality disorder symptoms. Australas Psychiatry 2024:10398562241246485. [PMID: 38621694 DOI: 10.1177/10398562241246485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
OBJECTIVE This study evaluated the acceptance, feasibility and safety of a short-term group program for adults (18 years and older) and youth (16 to 18 years) with borderline personality disorder (BPD) symptoms. Termed Road Maps, the content and development were informed by common treatment factors identified from evidence-based therapies for BPD. METHOD Two-hundred and eight people consented to participate in the research trial and completed baseline measures. Intervention participants rated the acceptability and subjective experience of the group. Attrition rates informed feasibility, and serious adverse events were tracked to identify potential harms. RESULTS Participant post-group ratings of the group's acceptability and subjective experience were above average across both adult and youth populations. Attrition rate after commencement of group was 38% for adults and 27% among youth. The incidence rate of emergency department presentations was reduced by 41% in the 6 months post-group, relative to 6 months pre-group. CONCLUSIONS The current study provides preliminary support for the acceptability and feasibility of a short-term group therapy program for people with a diagnosis of BPD. Road Maps may be a useful intermediate intervention in a broader model of stepped care. Australian New Zealand Clinical Trials Registry, https://www.anzctr.org.au/ACTRN12622000849796.aspx, (ACTRN12622000849796).
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Affiliation(s)
- Dianna R Bartsch
- Borderline Personality Disorder Collaborative, Barossa Hills Fleurieu Local Health Network, SA Health, Adelaide, SA, Australia; and School of Psychology, The University of Adelaide, Adelaide, SA, Australia
| | - Laura Cooke-O'Connor
- Borderline Personality Disorder Collaborative, Barossa Hills Fleurieu Local Health Network, SA Health, Adelaide, SA, USA
| | - Tracy J Connerty
- Borderline Personality Disorder Collaborative, Barossa Hills Fleurieu Local Health Network, SA Health, Adelaide, SA, USA
| | - Helen van Roekel
- Borderline Personality Disorder Collaborative, Barossa Hills Fleurieu Local Health Network, SA Health, Adelaide, SA, USA
| | - Paul Cammell
- Borderline Personality Disorder Collaborative, Barossa Hills Fleurieu Local Health Network, SA Health, Adelaide, SA, USA
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Beghi M, Sanza M. Editorial: Case reports in personality disorders. Front Psychiatry 2024; 15:1358775. [PMID: 38356907 PMCID: PMC10864637 DOI: 10.3389/fpsyt.2024.1358775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/19/2024] [Indexed: 02/16/2024] Open
Affiliation(s)
- Massimiliano Beghi
- Department of Mental Health and Addictions, Azienda Unità Sanitaria della Romagna (AUSL), Cesena, Italy
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Kernot J, Baker A, Oster C, Petrakis M, Dawson S. Employment interventions to assist people who experience borderline personality disorder: A scoping review. Int J Soc Psychiatry 2023; 69:1845-1855. [PMID: 37497932 PMCID: PMC10685697 DOI: 10.1177/00207640231189424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
BACKGROUND Employment is an important social determinant of health and is associated with positive health outcomes. However, individuals who have been diagnosed with borderline personality disorder (BPD) are significantly underrepresented in the workforce. Whilst there is an array of evidence based therapeutic interventions, there remains a gap in knowledge regarding the most effective ways to enhance employment outcomes for people with a diagnosis of BPD. AIM To explore employment interventions for people with BPD, map the available evidence and identify key concepts and knowledge gaps. METHODS A scoping review was conducted to identify and map the relevant literature. Findings were summarised using a narrative approach. Consultation was provided by a reference group including peer support workers with lived experience of BPD and mental health clinicians. RESULTS Seven articles met the inclusion criteria, including non-randomised and case study/series designs and a randomised controlled trial protocol, with participant numbers generally low. All programmes combined a psychotherapeutic component with work related goals; however, there were notable differences in relation to the conceptual/theoretical approach of the psychotherapeutic component and delivery of the work-related components. Barriers and enablers to programme participation and success are explored. CONCLUSIONS This review provides important insights into the characteristics of vocational rehabilitation interventions for people diagnosed with BPD. The findings will inform the co-production of approaches to support people with BPD to engage in employment.
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Affiliation(s)
- Jocelyn Kernot
- Allied Health & Human Performance Academic Unit, University of South Australia, Adelaide, Australia
| | - Amy Baker
- Allied Health & Human Performance Academic Unit, University of South Australia, Adelaide, Australia
| | - Candice Oster
- Caring Futures Institute, Flinders University, Bedford Park, SA, Australia
| | - Melissa Petrakis
- Department of Social Work, Monash University, Melbourne, VIC, Australia
| | - Suzanne Dawson
- Caring Futures Institute, Flinders University, Bedford Park, SA, Australia
- Southern Adelaide Local Health Network, Adelaide, SA, Australia
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Liljedahl SI, Mossberg A, Grenner H, Waern M. Life experienced as worth living and beyond: a qualitative study of the pathways to recovery and flourishing amongst individuals treated for borderline personality disorder. BMC Psychiatry 2023; 23:838. [PMID: 37964237 PMCID: PMC10644482 DOI: 10.1186/s12888-023-05357-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 11/07/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Dialectical Behaviour Therapy (DBT) is recognized as a leading evidence-based treatment, effective in reducing symptoms of borderline personality disorder (BPD), as well as co-occurring clinical syndromes. However, symptom remission may not be the same as a life experienced as worth living. The purpose of the study was to understand, from the perspective of individuals with lived experience, the concepts of recovery, life experienced as worth living and flourishing after treatment for BPD, and to describe the pathways to wellness after symptom remission. METHODS Semi-structured interviews were conducted with nine adult women previously diagnosed with BPD, co-occurring clinical syndromes and severe self-harm behaviour who self-identified as recovered for a minimum of two years, recruited from a network for individuals with lived experience. The average duration of recovery was 5.7 years with a range from 2 to 10 + years. Data were analysed using thematic analysis. RESULTS Four main themes and 14 subthemes were generated from our analyses. Main themes indicated that loved ones helped recovery and to create a life worth living, that participants identified as recovered and as healthy and beyond, and that becoming well is a long process associated in part with reclaiming a healthy identity. Participants defined recovery as separate but related to a life worth living, which in turn was separate but related to being healthy and having lives they described as being beyond health and well-being. The wellness process was described as lengthy and non-linear, including setbacks that with time no longer derailed daily life. A proposed theoretical model depicting the wellness process over time from symptom remission to the experience of a life beyond health and wellness is presented. CONCLUSIONS This qualitative study contributes knowledge of what a life experienced as worth living means, as well as how wellness progressed into flourishing for some participants within a sample of individuals with lived experience. Our findings may inform treatment development that targets more than symptom reduction, which in turn may shorten trajectories from symptom remission to health, wellness, and flourishing.
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Affiliation(s)
- Sophie I Liljedahl
- Region Västra Götaland, Department of Psychiatry for Affective Disorders, Sahlgrenska University Hospital, National Specialized Medical Care Unit for Severe Self-Harm Behaviour, Journalvägen 5, Gothenburg, 416 50, Sweden.
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, SU/Sahlgrenska, Blå Stråket 15, Gothenburg, 413 45, Sweden.
| | - Anni Mossberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, SU/Sahlgrenska, Blå Stråket 15, Gothenburg, 413 45, Sweden
| | - Hanna Grenner
- Region Västra Götaland, Department of Psychiatry for Affective Disorders, Sahlgrenska University Hospital, National Specialized Medical Care Unit for Severe Self-Harm Behaviour, Journalvägen 5, Gothenburg, 416 50, Sweden
| | - Margda Waern
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, SU/Sahlgrenska, Blå Stråket 15, Gothenburg, 413 45, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Psychosis Clinic, Gothenburg, 41345, Sweden
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14
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Grandjean L, Kolly S, Kramer U. Predictors of Effects in Brief Psychiatric Treatment for Borderline Personality Disorder. J Pers Disord 2023; 37:741-750. [PMID: 38038656 DOI: 10.1521/pedi.2023.37.6.741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
If evidence points to the equal efficacy of all bona fide treatments for borderline personality disorder (BPD) in general, it may not necessarily be true for a specific individual, nor do such general conclusions help in the triage of clients in clinical services. We investigated potential therapy outcome predictors for participants with a BPD diagnosis (N = 99). They were assessed on scales including the Outcome Questionnaire-45.2 (OQ-45), the Inventory of Interpersonal Problems-64, and the Borderline Symptom List. Our analyses revealed that individuals with low levels of symptom distress at intake had the smallest change in total OQ-45 score over the course of brief treatment, while the individuals with high levels of symptom distress had a mean large change in total score (-23). We observed that individuals with high symptom loads AND low levels of interpersonal problems at intake seemed to have the best progress.
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Affiliation(s)
- Loris Grandjean
- Institute of Psychotherapy, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Stéphane Kolly
- General Psychiatry Service, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Switzerland
| | - Ueli Kramer
- Institute of Psychotherapy, General Psychiatry Service, Department of Psychiatry, Lausanne University Hospital, and University of Lausanne, Switzerland, Department of Psychology, University of Windsor, Ontario, Canada
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15
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Sanza M, Monzio Compagnoni M, Caggiu G, Allevi L, Barbato A, Campa J, Carle F, D'avanzo B, Di Fiandra T, Ferrara L, Gaddini A, Saponaro A, Scondotto S, Tozzi VD, Lorusso S, Giordani C, Corrao G, Lora A. Assessing the quality of the care offer for people with personality disorders in Italy: the QUADIM project. A multicentre research based on the database of use of Mental Health services. Int J Ment Health Syst 2023; 17:31. [PMID: 37833745 PMCID: PMC10571410 DOI: 10.1186/s13033-023-00603-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Italy can be viewed as a laboratory to assess the quality of mental healthcare delivered in a community-oriented system, especially for severe mental disorders, such as personality disorders. Although initiatives based on clinical indicators for assessing the quality of mental healthcare have been developed by transnational-organisations, there is still no widespread practice of measuring the quality of care pathways delivered to patients with severe mental disorders in a community-oriented system, especially using administrative healthcare databases. The aim of the study is to evaluate the quality of care delivered to patients with personality disorders taken-in-care by mental health services of four Italian regions (Lombardy, Emilia-Romagna, Lazio, Sicily). METHODS A set of thirty-three clinical indicators, concerning accessibility, appropriateness, continuity, and safety of care, was implemented using regional healthcare utilization databases, containing data on mental health treatments and diagnosis, hospital admissions, outpatient interventions and exams and drug prescriptions. RESULTS 31,688 prevalent patients with personality disorders treated in 2015 were identified, of whom 2,331 newly taken-in-care. One-in-10 patients received a standardized assessment, the treatment discontinuity affected half of the cases. 12.7% of prevalent patients received at least one hospitalization, 10.6% in the newly taken-in-care cohort. 6-out-of-10 patients had contact with community-services within 14 days from hospital discharge. Access to psychotherapy and psychoeducational treatments was low and delivered with a low intensity. The median of psychosocial interventions per person-year was 19.1 and 9.4, respectively, in prevalent and newly taken-in-care cases. Nearly 50% of patients received pharmacological treatments. CONCLUSIONS Healthcare utilization databases were used to systematically evaluate and assess service delivery across regional mental health systems; suggesting that in Italy the public mental health services provide to individuals with personality disorders suboptimal treatment paths.
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Affiliation(s)
- Michele Sanza
- Department of Mental Health and Addiction Disorders Forlì-Cesena, AUSL Romagna, Cesena, Italy
| | - Matteo Monzio Compagnoni
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy.
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy.
| | - Giulia Caggiu
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
- Department of Mental Health and Addiction Services, ASST Lecco, Lecco, Italy
| | - Liliana Allevi
- Department of Mental Health and Addiction Services, ASST Lecco, Lecco, Italy
| | - Angelo Barbato
- Department of Health Policy, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | | | - Flavia Carle
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
- Center of Epidemiology and Biostatistics, Polytechnic University of Marche, Ancona, Italy
| | - Barbara D'avanzo
- Department of Health Policy, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Teresa Di Fiandra
- Psychologist, previously General Directorate for Health Prevention, Ministry of Health, Rome, Italy
| | - Lucia Ferrara
- Centre of Research on Health and Social Care Management, CERGAS SDA Bocconi School of Management (Bocconi University, Milan, Italy
| | | | - Alessio Saponaro
- General Directorate of Health and Social Policies, Emilia-Romagna Region, Bologna, Italy
| | - Salvatore Scondotto
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
- Department of Health Services and Epidemiological Observatory, Regional Health Authority, Sicily Region, Palermo, Italy
| | - Valeria D Tozzi
- Centre of Research on Health and Social Care Management, CERGAS SDA Bocconi School of Management (Bocconi University, Milan, Italy
| | - Stefano Lorusso
- Department of Health Planning, Italian Health Ministry, Rome, Italy
| | | | - Giovanni Corrao
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
| | - Antonio Lora
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
- Department of Mental Health and Addiction Services, ASST Lecco, Lecco, Italy
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16
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Tobiassen AH, Sundal T, Stänicke E, Folmo EJ. The cultural change narrative as a core component of therapeutic change. Front Psychiatry 2023; 14:1149984. [PMID: 37867772 PMCID: PMC10587421 DOI: 10.3389/fpsyt.2023.1149984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 09/19/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction Research indicates a similar effect of Mentalization-based treatment (MBT) and Dialectical behavior therapy (DBT) for borderline personality disorder (BPD). However, there is a paucity in studies investigating the change narrative received from and developed in these treatments. The aim of the present study is to investigate similarities and differences in the change narratives provided by MBT and DBT, and how these narratives reflect the rationale, explanations, and procedures of the provided treatment. Methods The study is a qualitative analysis of seven interviews conducted by the authors. Three of the participants had received MBT, and four of the participants had received DBT. This study presents an Interpretative Phenomenological Analysis (IPA) of the change narratives received in two specialized treatments for BPD. Results The main findings from the IPA were that the change narratives described by the participants reflected the treatment they received. The DBT participants highlighted explicit learning of tools and techniques, with predictable and safe therapists. In contrast, the MBT participants emphasized a long-lasting process of exploring to create procedural learning with therapists who followed their lead. Discussion The participants' stories of change shed light on how a change narrative was developed, and therefore how the rationale, explanations and procedures were conveyed differently by MBT and DBT.
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Affiliation(s)
| | | | - Erik Stänicke
- Department of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway
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17
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Bax OK, Chartonas D, Parker J, Symniakou S, Lee T. Personality disorder. BMJ 2023; 382:e050290. [PMID: 37666510 DOI: 10.1136/bmj-2019-050290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Affiliation(s)
- Orestis Kanter Bax
- Basildon Complex Needs Psychotherapy and Personality Disorder Service, Essex Partnership University NHS Foundation Trust, UK
- Centre for Understanding Personality (CUSP), London
| | - Dimitrios Chartonas
- Centre for Understanding Personality (CUSP), London
- Camden and Islington Personality Disorder Service, Camden and Islington NHS Foundation Trust
| | - Jennie Parker
- Centre for Understanding Personality (CUSP), London
- Berkshire Healthcare NHS Foundation Trust
| | | | - Tennyson Lee
- Centre for Understanding Personality (CUSP), London
- Deancross Personality Disorder Service, East London NHS Foundation Trust
- Institute of Psychoanalysis, British Psychoanalytical Society
- Blithdale Health Centre, Clinical Director East End Health Network
- Wolfson Institute, Queen Mary University of London
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18
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Lin D, Zona L, Seery E. Navigating Countertransference in Inpatient Settings: Optimizing Interventions for Patients with Borderline Personality Disorder and Repeated Acute Hospitalizations. Psychodyn Psychiatry 2023; 51:330-349. [PMID: 37712661 DOI: 10.1521/pdps.2023.51.3.330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Over the years, the psychiatric inpatient treatment paradigm has shifted to more brief stays focused on acute stabilization and psychopharmacologic-focused interventions, rather than individual psychotherapeutic engagement. Unfortunately, this has allowed patients with complex interpersonal dynamics, particularly borderline personality disorder, to slip through the cracks of effective treatment. This can contribute to repeated inpatient admissions, where both patients and clinicians feel trapped in a maladaptive, unhelpful cycle. In this article, we examine the evolution of inpatient treatment with de-emphasized psychotherapy practices, review the particular dynamics that patients with borderline personality disorder may evoke within an interdisciplinary treatment team, and provide a framework of clinically based vignettes for scenarios that may arise within inpatient treatment of this patient population. With attention to countertransference patterns and common pitfalls of communication, we offer alternative approaches and conversations with the hopes of improving outcomes and alliances in a new landscape of psychiatric practice.
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Affiliation(s)
- Deborah Lin
- Psychiatry Resident Physician PGY-3, Medical University of South Carolina
| | - Luke Zona
- Psychiatry Resident Physician PGY-2, Medical University of South Carolina
| | - Erin Seery
- Associate Program Director and Assistant Professor, Medical University of South Carolina
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19
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Flechsig A, Bernheim D, Buchheim A, Domin M, Mentel R, Lotze M. One Year of Outpatient Dialectical Behavioral Therapy and Its Impact on Neuronal Correlates of Attachment Representation in Patients with Borderline Personality Disorder Using a Personalized fMRI Task. Brain Sci 2023; 13:1001. [PMID: 37508932 PMCID: PMC10377139 DOI: 10.3390/brainsci13071001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/22/2023] [Accepted: 06/27/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Background: BPD is characterized by affect dysregulation, interpersonal problems, and disturbances in attachment, but neuroimaging studies investigating attachment representations in BPD are rare. No study has examined longitudinal neural changes associated with interventions targeting these impairments. (2) Methods: We aimed to address this gap by performing a longitudinal neuroimaging study on n = 26 patients with BPD treated with Dialectic Behavioral Therapy (DBT) and n = 26 matched healthy controls (HCs; post intervention point: n = 18 BPD and n = 23 HCs). For functional imaging, we applied an attachment paradigm presenting attachment related scenes represented in drawings paired with related neutral or personalized sentences from one's own attachment narratives. In a prior cross-sectional investigation, we identified increased fMRI-activation in the human attachment network, in areas related to fear response and the conflict monitoring network in BPD patients. These were especially evident for scenes from the context of loneliness (monadic pictures paired with individual narrative sentences). Here, we tested whether these correlates of attachment representation show a near-to-normal development over one year of DBT intervention. In addition, we were interested in possible associations between fMRI-activation in these regions-of-interest (ROI) and clinical scores. (3) Results: Patients improved clinically, showing decreased symptoms of borderline personality organization (BPI) and increased self-directedness (Temperament and Character Inventory, TCI) over treatment. fMRI-activation was increased in the anterior medial cingulate cortex (aMCC) and left amygdala in BPD patients at baseline which was absent after intervention. When investigating associations between scores (BPI, TCI) and functional activation, we found significant effects in the bilateral amygdala. In contrast, aMCC activation at baseline was negatively associated with treatment outcome, indicating less effective treatment effects for those with higher aMCC activation at baseline. (4) Conclusions: Monadic attachment scenes with personalized sentences presented in an fMRI setup are capable of identifying increased activation magnitude in BPD. After successful DBT treatment, these increased activations tend to normalize which could be interpreted as signs of a better capability to regulate intensive emotions in the context of "social pain" towards a more organized/secure attachment representation. Amygdala activation, however, indicates high correlations with pre-treatment scores; activation in the aMCC is predictive for treatment gain. Functional activation of the amygdala and the aMCC as a response to attachment scenes representing loneness at baseline might be relevant influencing factors for DBT-intervention outcomes.
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Affiliation(s)
- Ariane Flechsig
- Functional Imaging Unit, Department of Diagnostic Radiology and Neuroradiology, University of Greifswald, 17475 Greifswald, Germany
| | - Dorothee Bernheim
- Department of Psychiatry and Psychotherapy, University Hospital of Greifswald, 17475 Greifswald, Germany
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Ulm, 89075 Ulm, Germany
| | - Anna Buchheim
- Department of Psychology, University of Innsbruck, 6020 Innsbruck, Austria
| | - Martin Domin
- Functional Imaging Unit, Department of Diagnostic Radiology and Neuroradiology, University of Greifswald, 17475 Greifswald, Germany
| | - Renate Mentel
- Department of Psychiatry and Psychotherapy, University Hospital of Greifswald, 17475 Greifswald, Germany
| | - Martin Lotze
- Functional Imaging Unit, Department of Diagnostic Radiology and Neuroradiology, University of Greifswald, 17475 Greifswald, Germany
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20
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Kvarstein EH, Frøyhaug M, Pettersen MS, Carlsen S, Ekberg A, Fjermestad-Noll J, Ulvestad DA, Gikling EL, Hjermann E, Lindberget K, Omvik S, Eikenæs IUM, Hummelen B, Morken KTE, Wilberg T, Pedersen GAF. Improvement of personality functioning among people treated within personality disorder mental health services. A longitudinal, observational study. Front Psychiatry 2023; 14:1163347. [PMID: 37229394 PMCID: PMC10203961 DOI: 10.3389/fpsyt.2023.1163347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 04/21/2023] [Indexed: 05/27/2023] Open
Abstract
Objective Evidence-based personality disorder (PD) treatments are dominated by interventions targeting Borderline PD, although clinical populations characteristically include different PD features and severity. Personality functioning is a new concept intended to capture common features across PDs. This study aimed to investigate longitudinal improvement of personality functioning in a clinical sample assigned to PD treatment. Method An observational, large, longitudinal study of patients in PD treatments on specialist mental health service levels (N = 1,051). DSM-5 PDs were systematically assessed on referral. Personality functioning was repeatedly assessed (LPFS-BF-2.0), supplemented by symptom distress (anxiety: PHQ-GAD-7, depression: PHQ-9), and social/occupational activity (WSAS, work/study activity). Statistics were linear mixed models. Results Thirty per cent had personality difficulties below PD threshold. Among PDs, 31% had Borderline (BPD), 39% Avoidant (AvPD), 15% not otherwise specified, 15% other PDs, and 24% > one PD. More severe initial LPFS-BF was associated with younger age, presence of PD and increasing number of total PD criteria. Across PD conditions, LPFS-BF, PHQ-9 and GAD-7 improved significantly (overall effect size 0.9). Mean duration of PD treatment was 15 (SD 9) months. Drop-out rates were low (12%). LPFS-BF improvement-rates were higher for BPD. Younger age was moderately associated with slower PHQ-9 improvement. Work/study activity was initially poor, poorer levels associated with AvPD and younger age, and improvement was non-significant across PD conditions. AvPD was associated with slower WSAS improvement-rates. Conclusion Personality functioning improved across PD conditions. The results highlight BPD improvements. The study points to challenges concerning AvPD treatment, poor occupational activity and age-related differences.
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Affiliation(s)
- Elfrida H. Kvarstein
- Section for Personality Psychiatry and Specialized Treatment, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Mathias Frøyhaug
- Groruddalen District Psychiatric Center, Akershus University Hospital, Akershus, Norway
| | | | - Sara Carlsen
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway
| | - Andreas Ekberg
- Section for Personality Psychiatry and Specialized Treatment, Oslo University Hospital, Oslo, Norway
- Department for Adult Psychiatry, Diakonhjemmet Hospital, Oslo, Norway
| | - Jane Fjermestad-Noll
- Section for Personality Psychiatry and Specialized Treatment, Oslo University Hospital, Oslo, Norway
| | - Dag A. Ulvestad
- Section for Personality Psychiatry and Specialized Treatment, Oslo University Hospital, Oslo, Norway
| | | | - Eirik Hjermann
- Kronstad District Psychiatric Center, Haukeland University Hospital, Bergen, Norway
| | - Kenneth Lindberget
- Strømme District Psychiatric Center, Sørlandet Hospital, Kristiansand, Norway
| | - Siri Omvik
- Kronstad District Psychiatric Center, Haukeland University Hospital, Bergen, Norway
| | - Ingeborg U-M. Eikenæs
- Section for Personality Psychiatry and Specialized Treatment, Oslo University Hospital, Oslo, Norway
| | - Benjamin Hummelen
- Department of Research and Innovation, Oslo University Hospital, Oslo, Norway
| | - Katharina T. E. Morken
- Department of Addiction Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Psychology, University of Bergen, Bergen, Norway
| | - Theresa Wilberg
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Research and Innovation, Oslo University Hospital, Oslo, Norway
| | - Geir A. F. Pedersen
- Section for Personality Psychiatry and Specialized Treatment, Oslo University Hospital, Oslo, Norway
- Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
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21
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Blay M, Cohen S, Jan M, Perroud N, Speranza M, Charbon P. [Towards a pragmatic cohabitation of theoretical and clinical models: The example of "Good Psychiatric Management" in the treatment of borderline personality disorder]. L'ENCEPHALE 2023:S0013-7006(23)00042-8. [PMID: 37088579 DOI: 10.1016/j.encep.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 01/16/2023] [Accepted: 01/31/2023] [Indexed: 04/25/2023]
Abstract
Borderline personality disorder (BPD) is a common disorder in general and clinical populations and is related to potentially severe medical and socio-professional consequences. Treatment of BPD is based on evidence-based psychotherapies (such as Dialectical Behavioral Therapy, Mentalization-Based Therapy, Schema-Focused Therapy or Transference Focused Psychotherapy), which have been shown effective but are poorly available in France. Pharmacological treatments, which are more easily available, are not effective in treating symptoms of the disorder but can be useful in management of comorbidities. In this context, recently called "generalist" models have been developed, which every well-trained psychiatrist can implement in their daily practice, combining practical elements from evidence-based psychotherapies and elements of pharmacological management of symptoms and comorbidities. The purpose of this article is to present one of these models, the Good Psychiatric Management (GPM) and its basic principles and its applications, and to provide one of the first French-speaking resources about this model. In addition, beyond the practical elements proposed by the GPM, we discuss the deeper question that it raises, namely the question of a pragmatic integration of different theoretical and clinical models. Indeed, the treatment of BPD patients is at the junction of different conceptualizations of mental pathology (psychopathological, neurobiological) and different modalities of practice (psychotherapy, biological psychiatry). In a French context, that sometimes separates these two models, and in our opinion GPM constitutes an example of clinical collaboration which shows the interest of the combined role of psychiatrist-psychotherapist.
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Affiliation(s)
- Martin Blay
- ADDIPSY, Centre ambulatoire d'addictologie et de psychiatrie, Groupe santé basque développement, 164, avenue Jean-Jaurès, 69007 Lyon, France; Université Claude-Bernard Lyon 1, Lyon, France.
| | - Satchel Cohen
- Centre hospitalier de Versailles, Service universitaire de psychiatrie de l'enfant et de l'adolescent, Le Chesnay, France
| | - Marlène Jan
- Centre hospitalier de Versailles, Service universitaire de psychiatrie de l'enfant et de l'adolescent, Le Chesnay, France
| | - Nader Perroud
- Service des spécialités psychiatriques, Département de psychiatrie, Hôpitaux universitaires de Genève, Genève, Suisse; Département de psychiatrie, Université de Genève, Genève, Suisse
| | - Mario Speranza
- Centre hospitalier de Versailles, Service universitaire de psychiatrie de l'enfant et de l'adolescent, Le Chesnay, France; Université Paris-Saclay, UVSQ, Inserm, Centre de recherche en épidémiologie et santé des populations Team "DevPsy", 94807 Villejuif, France
| | - Patrick Charbon
- Service des spécialités psychiatriques, Département de psychiatrie, Hôpitaux universitaires de Genève, Genève, Suisse; Cabinet de groupe « D'un Monde à l'Autre », Lausanne, Suisse
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22
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van der Hout R, Barnasconi F, Noorloos J, de Bruin R, van Slobbe-Maijer K, Legerstee J, Oort F, Utens E. Treatment outcomes of dialectical behaviour therapy for adolescents presenting with characteristics of borderline personality disorder: A naturalistic study. Clin Child Psychol Psychiatry 2023; 28:707-720. [PMID: 35767707 DOI: 10.1177/13591045221109871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This naturalistic study investigated treatment outcomes of Dutch dialectical behaviour therapy for adolescents (DDBT-A) in a sample of 93 adolescents (95.4% female, mean age = 16.20 years) presenting with borderline characteristics, treated at Levvel (a Dutch mental health institution). From baseline to posttreatment significant decreases were found on severity of the borderline symptoms, passive coping style, internalizing and externalizing behavioural problems, and a significant increase on self-worth. Overall, three different therapy formats (outpatient, part-time therapy, and day therapy) showed similar improvements at posttreatment. Concluding, DDBT-A seems promising in reducing borderline related symptoms for adolescents.
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Affiliation(s)
- Rebecca van der Hout
- Levvel, Specialists for Youth and Family, The Netherlands.,Research Institute of Child Development and Education, 1234University of Amsterdam, The Netherlands
| | | | - Janet Noorloos
- Levvel, Specialists for Youth and Family, The Netherlands
| | - Rosanne de Bruin
- Levvel, Specialists for Youth and Family, The Netherlands.,176084LUMC Curium, The Netherlands
| | | | - Jeroen Legerstee
- Department of Child and Adolescent Psychiatry/Psychology, 6993Erasmus MC-Sophia Children's Hospital, The Netherlands
| | - Frans Oort
- Research Institute of Child Development and Education, 1234University of Amsterdam, The Netherlands
| | - Elisabeth Utens
- Levvel, Specialists for Youth and Family, The Netherlands.,Research Institute of Child Development and Education, 1234University of Amsterdam, The Netherlands.,Department of Child and Adolescent Psychiatry/Psychology, 6993Erasmus MC-Sophia Children's Hospital, The Netherlands
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23
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Martin S, Del-Monte J. Metacognition and insight dynamics exploration in borderline personality disorder: Exploring the underlying dynamics. J Psychiatr Res 2023; 160:225-231. [PMID: 36863299 DOI: 10.1016/j.jpsychires.2023.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/14/2023] [Accepted: 02/22/2023] [Indexed: 03/04/2023]
Abstract
Metacognition and Insight are related to hard-to-treat disorders and among them is Borderline Personality Disorder (BPD). We recruited 190 BPD patients and measured Insight, Metacognition, Impulsivity, and BPD traits. Results showed BPD's significant links with Insight and Metacognition. Metacognition significantly correlated with two Impulsivity dimensions, whereas Insight significantly correlated with most of them. Regressions analysis revealed a significant relationship between Insight and Metacognition on Impulsivity and Borderline traits. Mediation analysis proved the indirect effect of Metacognition/Insight on Borderline traits through Impulsivity at a significative level. Both seem relevant for research and therapeutic application in BPD following different dynamics even if the limitation of our study stands in its gender ratio and possible comorbidity issues. Urgency appears as a critical factor to assess, notably with Positive emotion-based impulsivity.
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Affiliation(s)
- Sylvia Martin
- Center for Research and Bioethics, Uppsala University, Sweden.
| | - Jonathan Del-Monte
- Nîmes University, Department of Clinical Psychology, France; Psychosocial Laboratory, Aix-Marseille University, France
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24
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Ali F. The Substitute Therapist. Am J Psychother 2022; 75:194-196. [PMID: 36052451 DOI: 10.1176/appi.psychotherapy.20220006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Fairouz Ali
- State University of New York, Upstate Medical University, Syracuse
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25
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Jewell M, Bailey RC, Curran RL, Grenyer BFS. Evaluation of a skills-based peer-led art therapy online-group for people with emotion dysregulation. Borderline Personal Disord Emot Dysregul 2022; 9:33. [PMID: 36447216 PMCID: PMC9708140 DOI: 10.1186/s40479-022-00203-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 07/13/2022] [Accepted: 10/11/2022] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE We developed and piloted a novel art-based online skills program led by a peer mental health professional with lived experience of complex mental health, including Borderline Personality Disorder (BPD). Key challenges of living with BPD and emotion dysregulation were addressed through artmaking informed by a dialectical framework and skills, to evaluate acceptability and efficacy. METHOD A structured, manualised 2-hour weekly arts-based skills program was piloted for people with BPD over 18 weeks. Evaluation included both quantitative and qualitative measures at commencement and completion. RESULTS Thirty-eight participants enrolled in the program (89.5% identified she/her pronouns, average age 33.6 years), and 31 completed (82% retention). Multilevel modelling analysis of the primary outcome variable Difficulties in Emotion Regulation Scale (DERS) demonstrated a large improvement over time (effect size Cohen's d = 1.77). Qualitative thematic analysis found participants had improved capacity to regulate emotions and tolerate distress, improved connection with others, enhanced understanding of the self, and higher hope for living well. We found that artmaking facilitated processes and helped the expression of difficult emotions, symbolise challenging relationships, and facilitate greater self-understanding. Participants reported high levels of satisfaction, and 77.4% reported that the program had increased wellbeing. CONCLUSION This novel artmaking program for emotion dysregulation and BPD was acceptable and potentially effective. Peer facilitation using arts-based skills is a modality of therapy for further investigation.
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Affiliation(s)
- Mahlie Jewell
- School of Psychology and Illawarra Health and Medical Research Institute, University of Wollongong, 2522, Sydney, NSW, Australia.,Western Sydney University, Sydney, Australia
| | - Rachel C Bailey
- School of Psychology and Illawarra Health and Medical Research Institute, University of Wollongong, 2522, Sydney, NSW, Australia
| | | | - Brin F S Grenyer
- School of Psychology and Illawarra Health and Medical Research Institute, University of Wollongong, 2522, Sydney, NSW, Australia.
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26
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Wu T, Hu J, Davydow D, Huang H, Spottswood M, Huang H. Demystifying borderline personality disorder in primary care. Front Med (Lausanne) 2022; 9:1024022. [PMID: 36405597 PMCID: PMC9668888 DOI: 10.3389/fmed.2022.1024022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 10/12/2022] [Indexed: 11/05/2022] Open
Abstract
Borderline personality disorder (BPD) is a common mental health diagnosis observed in the primary care population and is associated with a variety of psychological and physical symptoms. BPD is a challenging disorder to recognize due to the limitations of accurate diagnosis and identification in primary care settings. It is also difficult to treat due to its complexity (e.g., interpersonal difficulties and patterns of unsafe behaviors, perceived stigma) and healthcare professionals often feel overwhelmed when treating this population. The aim of this article is to describe the impact of BPD in primary care, review current state of knowledge, and provide practical, evidence-based treatment approaches for these patients within this setting. Due to the lack of evidence-based pharmacological treatments, emphasis is placed on describing the framework for treatment, identifying psychotherapeutic opportunities, and managing responses to difficult clinical scenarios. Furthermore, we discuss BPD treatment as it relates to populations of special interest, including individuals facing societal discrimination and adolescents. Through this review, we aim to highlight gaps in current knowledge around managing BPD in primary care and provide direction for future study.
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Affiliation(s)
- Tina Wu
- Warren Alpert Medical School, Brown University, Providence, RI, United States
- Butler Hospital, Providence, RI, United States
- *Correspondence: Tina Wu,
| | - Jennifer Hu
- Duke University Hospital, Durham, NC, United States
- Jennifer Hu,
| | | | - Heather Huang
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Margaret Spottswood
- Community Health Centers of Burlington, Burlington, VT, United States
- Department of Psychiatry, University of Vermont College of Medicine, Burlington, VT, United States
| | - Hsiang Huang
- Cambridge Health Alliance, Cambridge, MA, United States
- Harvard Medical School, Boston, MA, United States
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27
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Stoffers-Winterling JM, Storebø OJ, Simonsen E, Sedoc Jørgensen M, Pereira Ribeiro J, Kongerslev MT, Lieb K. Perspectives on Dialectical Behavior Therapy and Mentalization-Based Therapy for Borderline Personality Disorder: Same, Different, Complementary? Psychol Res Behav Manag 2022; 15:3179-3189. [PMID: 36329713 PMCID: PMC9624210 DOI: 10.2147/prbm.s342257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 09/11/2022] [Indexed: 11/16/2022] Open
Abstract
Current evidence suggests that individuals with borderline personality disorder (BPD) are likely to benefit from specialized, or BPD-specific, treatments. Dialectical behavior therapy (DBT) and mentalization-based treatment (MBT) are currently the most intensively researched BPD treatments. Reviewing the current research, this paper highlights similarities and differences between the two treatments, and discusses possible ways they could complement each other. As the effectiveness of specialized treatments for BPD in general has been determined with some certainty, research now tends towards individualized approaches, identifying predictors of optimal treatment response. However, it is still to be settled who might profit from a combination of or sequential treatment with DBT and MBT.
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Affiliation(s)
- Jutta M Stoffers-Winterling
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Ole Jakob Storebø
- Psychiatric Research Unit, Psychiatry Region Zealand, Slagelse, Denmark,Department of Psychology, University of Southern Denmark, Odense, Denmark,Correspondence: Ole Jakob Storebø, Psychiatric Research Unit, Psychiatry Region Zealand, Fælledvej 6, Slagelse, 4200, Denmark, Tel +45 24965917, Email
| | - Erik Simonsen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark,Mental Health Services East, Psychiatry Region Zealand, Roskilde, Denmark
| | | | - Johanne Pereira Ribeiro
- Psychiatric Research Unit, Psychiatry Region Zealand, Slagelse, Denmark,Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Mickey T Kongerslev
- Psychiatric Research Unit, Psychiatry Region Zealand, Slagelse, Denmark,Department of Psychology, University of Southern Denmark, Odense, Denmark,Mental Health Services East, Psychiatry Region Zealand, Roskilde, Denmark
| | - Klaus Lieb
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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28
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Choi-Kain LW, Sahin Z, Traynor J. Borderline Personality Disorder: Updates in a Postpandemic World. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2022; 20:337-352. [PMID: 37200886 PMCID: PMC10187392 DOI: 10.1176/appi.focus.20220057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Progress in understanding borderline personality disorder has unfolded in the last decade, landing in a new COVID-19-influenced world. Borderline personality disorder is now firmly established as a valid diagnosis, distinct from its co-occurring mood, anxiety, trauma-related, and behavioral disorders. Further, it is also understood as a reflection of general personality dysfunction, capturing essential features shared among all personality disorders. Neuroimaging research, representing the vast neurobiological advances made in the last decade, illustrates that the disorder shares frontolimbic dysfunction with many psychiatric diagnoses but has a distinct signature of interpersonal and emotional hypersensitivity. This signature is the conceptual basis of the psychotherapies and clinical management approaches proven effective for the disorder. Medications remain adjunctive and are contraindicated by some guidelines internationally. Less invasive brain-based therapeutics show promise. The most significant change in the treatment landscape is a focus on briefer, less intensive formats of generalist management. Shorter variants of therapies, such as dialectical behavior therapy and mentalization-based treatment, are in the process of being shown to be adequately effective. Earlier intervention and greater emphasis on functional improvement are needed to more effectively curb the disabilities and risks of borderline personality disorder for patients and their families. Remote interventions show promise in broadening access to care.
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Affiliation(s)
- Lois W Choi-Kain
- Gunderson Personality Research Institute, McLean Hospital, Belmont, Massachusetts, and Faculty of Medicine, Harvard Medical School, Boston
| | - Zeynep Sahin
- Gunderson Personality Research Institute, McLean Hospital, Belmont, Massachusetts, and Faculty of Medicine, Harvard Medical School, Boston
| | - Jenna Traynor
- Gunderson Personality Research Institute, McLean Hospital, Belmont, Massachusetts, and Faculty of Medicine, Harvard Medical School, Boston
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29
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Friesen L, Gaine G, Klaver E, Burback L, Agyapong V. Key stakeholders’ experiences and expectations of the care system for individuals affected by borderline personality disorder: An interpretative phenomenological analysis towards co-production of care. PLoS One 2022; 17:e0274197. [PMID: 36137103 PMCID: PMC9499299 DOI: 10.1371/journal.pone.0274197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 08/23/2022] [Indexed: 11/24/2022] Open
Abstract
Background The diagnosis of borderline personality disorder (BPD) consists of extreme emotional dysregulation and long-term disability when left untreated. It is associated with ineffective use of health care systems and mismanaged care in emergency departments, which can result in a revolving door phenomenon of urgent system usage, poor treatment outcomes, or patients falling out of care entirely–all of which primarily affect patients with BPD as well as their caregivers and clinicians. This crisis must be addressed with a comprehensive understanding of key stakeholder perspectives on the challenges of the system and potential solutions. Objective This study explored the perspectives of three key stakeholder groups (i.e., patients, clinicians, and caregivers) in relation to their experiences with and future expectations of the care system for those affected by BPD. Methods Four patients with BPD, three generalist clinicians with experience treating BPD, and three caregivers of individuals with BPD participated in individual semi-structured interviews. Participants were asked about their experiences with the current healthcare system and their suggestions for improvement. Responses were analyzed using interpretative phenomenological analysis. Findings In-depth analysis of the qualitative data revealed twelve shared themes and three themes that were unique to each key stakeholder group. These themes are discussed and used to inform recommendations for promising practices, policies, and training in this area. Conclusion Findings support the importance of a comprehensive mental health system approach for improving the accessibility, effectiveness, and acceptability of the management and treatment of BPD.
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Affiliation(s)
- Laura Friesen
- Department of Educational Psychology, University of Alberta, Edmonton, Alberta, Canada
- Addiction and Mental Health, Alberta Health Services, Edmonton, Alberta, Canada
- * E-mail:
| | - Graham Gaine
- Department of Educational Psychology, University of Alberta, Edmonton, Alberta, Canada
- Addiction and Mental Health, Alberta Health Services, Edmonton, Alberta, Canada
- Department of Psychiatry, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ellen Klaver
- Department of Educational Psychology, University of Alberta, Edmonton, Alberta, Canada
- Addiction and Mental Health, Alberta Health Services, Edmonton, Alberta, Canada
| | - Lisa Burback
- Addiction and Mental Health, Alberta Health Services, Edmonton, Alberta, Canada
- Department of Psychiatry, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Vincent Agyapong
- Addiction and Mental Health, Alberta Health Services, Edmonton, Alberta, Canada
- Department of Psychiatry, Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
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30
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Juul S, Frandsen FW, Bo Hansen S, Sørensen P, Bateman A, Simonsen S. A clinical illustration of short-term mentalization-based therapy for borderline personality disorder. J Clin Psychol 2022; 78:1567-1578. [PMID: 35611456 DOI: 10.1002/jclp.23378] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 03/01/2022] [Accepted: 04/13/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Mentalization-based therapy (MBT) is an evidence-supported, long-term psychotherapy program developed to treat borderline personality disorder (BPD). A short-term, 20-week adaptation to the original MBT format including case formulation, psychoeducation, and group and individual therapy has recently been proposed. The current case material will illustrate how the recent adaptation to the mentalization-based practice can enhance personality functioning using a short-term format. METHODS Case material is presented to demonstrate the clinical application of short-term MBT in the treatment of a young woman diagnosed with BPD who has a history of failed treatment attempts and who showed signs of affective dysregulation, unstable relationships, and intense abandonment anxiety. RESULTS The case illustration shows how short-term MBT can facilitate improvement in personality functioning, specifically targeting situations in which the patient lost her temper and became overwhelmed by abandonment anxiety. By continuously employing therapeutic shifts toward greater autonomy and agency, and by maintaining a balanced empathetic therapeutic stance, the therapists were able to enhance the patients mentalizing and personality functioning. CONCLUSIONS Short-term MBT can be effectively implemented to enhance the mentalizing capacity and personality functioning in outpatients with BPD.
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Affiliation(s)
- Sophie Juul
- Stolpegaard Psychotherapy Centre, Mental Health Services, Capital Region of Denmark, Gentofte, Denmark.,Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Capital Region of Denmark, Copenhagen, Denmark
| | - Frederik W Frandsen
- Stolpegaard Psychotherapy Centre, Mental Health Services, Capital Region of Denmark, Gentofte, Denmark
| | - Sune Bo Hansen
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
| | - Per Sørensen
- Stolpegaard Psychotherapy Centre, Mental Health Services, Capital Region of Denmark, Gentofte, Denmark
| | | | - Sebastian Simonsen
- Stolpegaard Psychotherapy Centre, Mental Health Services, Capital Region of Denmark, Gentofte, Denmark
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31
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Tong K, Costello S, McCabe E, Doherty AM. Mentalization-Based Treatment in a Naturalistic Setting in Ireland: A Cohort Study. Psychiatr Serv 2022; 73:46-52. [PMID: 34106745 DOI: 10.1176/appi.ps.202000810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study evaluated the real-world effectiveness of mentalization-based treatment by assessing the clinical status of patients before and after completing the treatment program, which was nested within a general adult community mental health service, and by comparing these patients with a treatment-as-usual group. METHODS In this retrospective longitudinal naturalistic study, patients with a primary diagnosis of borderline personality disorder received either mentalization-based treatment (N=34) or treatment as usual (N=51). Data were collected from clinical charts and hospital databases. Presentations to the emergency department (ED), psychiatric and medical hospitalizations, and rates of loss to follow-up were analyzed for both groups. RESULTS In the 2 years after a course of mentalization-based treatment, significant reductions were noted in psychiatric hospitalizations (p=0.018). Compared with the treatment-as-usual group, the intervention group had significant reductions in ED presentations (p=0.004) and medical admissions (p=0.040), when the analysis controlled for age and gender. At study endpoint, the proportion of patients lost to follow-up in the treatment-as-usual group was larger (χ2=7.59, df=1, p=0.006), with three deaths in the treatment-as-usual group and none in the mentalization-based treatment group. CONCLUSIONS Mentalization-based treatment embedded within a community mental health team may have a positive effect, with significant improvements in unscheduled service use and notable reductions in ED presentations, hospitalizations, loss to follow-up, and mortality. There may be value in building on this study with more prospective, systematic research and patient-reported outcomes to assess the practical significance of this intervention in general psychiatric settings.
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Affiliation(s)
- Kezanne Tong
- East Blanchardstown Mental Health Service, Dublin (Tong); Department of Psychiatry, University Hospital Galway, Galway, Ireland (Costello, McCabe); School of Medicine, University College Dublin, and Liaison Psychiatry, Mater Misericordiae University Hospital, Dublin (Doherty)
| | - Sinead Costello
- East Blanchardstown Mental Health Service, Dublin (Tong); Department of Psychiatry, University Hospital Galway, Galway, Ireland (Costello, McCabe); School of Medicine, University College Dublin, and Liaison Psychiatry, Mater Misericordiae University Hospital, Dublin (Doherty)
| | - Evelyn McCabe
- East Blanchardstown Mental Health Service, Dublin (Tong); Department of Psychiatry, University Hospital Galway, Galway, Ireland (Costello, McCabe); School of Medicine, University College Dublin, and Liaison Psychiatry, Mater Misericordiae University Hospital, Dublin (Doherty)
| | - Anne M Doherty
- East Blanchardstown Mental Health Service, Dublin (Tong); Department of Psychiatry, University Hospital Galway, Galway, Ireland (Costello, McCabe); School of Medicine, University College Dublin, and Liaison Psychiatry, Mater Misericordiae University Hospital, Dublin (Doherty)
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32
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Grant JE, Valle S, Chesivoir E, Ehsan D, Chamberlain SR. A double-blind placebo-controlled study of brexpiprazole for the treatment of borderline personality disorder. Br J Psychiatry 2021; 220:1-6. [PMID: 35049469 PMCID: PMC7612273 DOI: 10.1192/bjp.2021.159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Borderline personality disorder is associated with impaired quality of life and has a number of untoward public health associations. There is no established first-line pharmacological treatment for borderline personality disorder, and available options are not suitable for all individuals. AIMS To evaluate brexpiprazole, which has effects on the dopaminergic and serotonergic systems, for the reduction of borderline personality disorder symptoms. METHOD Eighty adults with borderline personality disorder were recruited for a randomised, double-blind placebo-controlled study. Participants received 12-week treatment with brexpiprazole (1 mg/day for 1 week, then increasing to 2 mg/day) or placebo in a parallel design. The primary efficacy outcome measure was the clinician-rated Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD). Safety data were collected. Effects of active versus placebo treatment were characterised with linear repeated measures models. RESULTS There was a significant interaction between treatment and time on the ZAN-BPD scale (P = 0.0031), solely because of differentiation specifically at week 12. Brexpiprazole was generally well tolerated. Secondary measures did not result in statistically significant differences from placebo. CONCLUSIONS Brexpiprazole appears to have some possible effect on borderline personality disorder symptoms, but further studies are needed because of the significant effects evident, specifically at the final time point. These findings also need to be viewed cautiously, given the small sample size, large drop-out rate and robust placebo response.
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Affiliation(s)
- Jon E. Grant
- University of Chicago, Department of Psychiatry and Behavioral Neuroscience, Chicago, IL USA
| | - Stephanie Valle
- University of Chicago, Department of Psychiatry and Behavioral Neuroscience, Chicago, IL USA
| | - Eve Chesivoir
- University of Chicago, Department of Psychiatry and Behavioral Neuroscience, Chicago, IL USA
| | - Dustin Ehsan
- University of Chicago, Department of Psychiatry and Behavioral Neuroscience, Chicago, IL USA
| | - Samuel R. Chamberlain
- Department of Psychiatry, Faculty of Medicine, University of Southampton, USA; and Southern Health NHS Foundation Trust, Southampton, USA
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Kramer U, Beuchat H, Grandjean L, Seragnoli F, Djillali S, Choffat C, George E, Despland J, Kolly S, de Roten Y. Lessening of the pervasiveness of interpersonal patterns in borderline personality disorder explains symptom decrease after treatment: A process analysis. J Clin Psychol 2021; 78:772-784. [PMID: 34735740 PMCID: PMC9297848 DOI: 10.1002/jclp.23275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/31/2021] [Accepted: 10/06/2021] [Indexed: 11/07/2022]
Abstract
Background Problematic interpersonal patterns, as defined by the core conflictual relationship theme (CCRT) method, are part of the clinical presentation of clients with borderline personality disorder (BPD). So far, we do not know whether the pervasiveness of interpersonal patterns changes and if this change explains therapy outcome. Methods In a secondary analysis of a randomized controlled trial on a brief version of psychiatric treatment for BPD, a treatment with a psychodynamic focus, the present study included N = 39 clients. One early session and one late session of the treatment were transcribed and analyzed using the CCRT method. Results It appeared that pervasiveness of the predominant CCRT decreased over the course of the brief treatment; this effect was robust across treatment conditions. Change in pervasiveness in any CCRT component explained a small portion of variance of the decrease in borderline symptoms observed at the end of treatment. Discussion Lessening of pervasiveness of problematic in‐session interpersonal patterns may be hypothesized as potential mechanism of effective treatment for BPD which should be tested in controlled designs.
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Affiliation(s)
- Ueli Kramer
- Department of Psychiatry‐CHUV, Institute of PsychotherapyUniversity of LausanneLausanneSwitzerland
- Department of Psychiatry‐CHUV, General Psychiatry ServiceUniversity of LausanneLausanneSwitzerland
- Department of PsychologyUniversity of WindsorWindsorOntarioCanada
| | - Hélène Beuchat
- Department of Psychiatry‐CHUV, Institute of PsychotherapyUniversity of LausanneLausanneSwitzerland
| | - Loris Grandjean
- Department of Psychiatry‐CHUV, Institute of PsychotherapyUniversity of LausanneLausanneSwitzerland
| | - Federico Seragnoli
- Department of Psychiatry‐CHUV, Institute of PsychotherapyUniversity of LausanneLausanneSwitzerland
| | - Slimane Djillali
- Department of Psychiatry‐CHUV, Institute of PsychotherapyUniversity of LausanneLausanneSwitzerland
| | - Chloe Choffat
- Department of Psychiatry‐CHUV, Institute of PsychotherapyUniversity of LausanneLausanneSwitzerland
| | - Elisa George
- Department of Psychiatry‐CHUV, Institute of PsychotherapyUniversity of LausanneLausanneSwitzerland
| | - Jean‐Nicolas Despland
- Department of Psychiatry‐CHUV, Institute of PsychotherapyUniversity of LausanneLausanneSwitzerland
| | - Stéphane Kolly
- Department of Psychiatry‐CHUV, General Psychiatry ServiceUniversity of LausanneLausanneSwitzerland
| | - Yves de Roten
- Department of Psychiatry‐CHUV, Institute of PsychotherapyUniversity of LausanneLausanneSwitzerland
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Bohus M, Stoffers-Winterling J, Sharp C, Krause-Utz A, Schmahl C, Lieb K. Borderline personality disorder. Lancet 2021; 398:1528-1540. [PMID: 34688371 DOI: 10.1016/s0140-6736(21)00476-1] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/18/2021] [Accepted: 02/18/2021] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Martin Bohus
- Institute for Psychiatric and Psychosomatic Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; Harvard Medical School, Boston, MA, USA
| | - Jutta Stoffers-Winterling
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany; Leibniz Institute for Resilience Research, Mainz, Germany
| | - Carla Sharp
- Department of Psychology, University of Houston, Houston, TX, USA
| | - Annegret Krause-Utz
- Department of Clinical Psychology, Leiden University, Leiden Institute of Brain and Cognition, Leiden, Netherlands
| | - Christian Schmahl
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Klaus Lieb
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany; Leibniz Institute for Resilience Research, Mainz, Germany.
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35
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Gabutti I. Filling the gap between theory and practice: A pilot study on parents' perceptions of integrated care for patients with borderline personality disorder. Int J Health Plann Manage 2021; 36:2366-2375. [PMID: 34460966 PMCID: PMC9291043 DOI: 10.1002/hpm.3307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 04/28/2021] [Accepted: 08/15/2021] [Indexed: 11/18/2022] Open
Abstract
Clinical pathways are known to be key in managing chronic conditions in an effective and sustainable way. This is particularly true in psychiatry, characterized by chronicity and managerial challenges. In particular, the borderline personality disorder is a highly complicated disorder to manage. Although numerous international guidelines converge on the urge of defining clinical pathways and a stepped‐care model for its effective treatment, it is unknown to what extent these guidelines have been implemented into concrete changes in the provision of care. The objective of this study is to pursue a preliminary assessment of whether there exists coherence between the provision of formal health dispositions or guidelines and end‐users’ perception of the change they should imply. A pilot study investigating the perception of parents of patients with borderline disorder on continuity of care has been conducted in three Italian regions. Results suggest that pathways do exist and are partially able to reach their intended effects, although concrete accessibility is still a major issue. Future studies should build on these preliminary results through quantitative investigation and further explore their causes.
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Affiliation(s)
- Irene Gabutti
- Department of Management, Università Cattolica del Sacro Cuore, Rome, Italy
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West ML, Guest RM, Carmel A. Comorbid early psychosis and borderline personality disorder: Conceptualizing clinical overlap, etiology, and treatment. Personal Ment Health 2021; 15:208-222. [PMID: 33955194 DOI: 10.1002/pmh.1509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 03/14/2021] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Michelle L West
- CEDAR Clinic and Research Program, Massachusetts Mental Health Center, Boston, Massachusetts, USA.,Beth Israel Deaconess Medical Center, Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry, University of Colorado School of Medicine (CUSOM), Aurora, Colorado, USA
| | - Ryan M Guest
- Department of Psychology, Emory University, Atlanta, Georgia, USA
| | - Adam Carmel
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
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Woodbridge J, Reis S, Townsend ML, Hobby L, Grenyer BFS. Searching in the dark: Shining a light on some predictors of non-response to psychotherapy for borderline personality disorder. PLoS One 2021; 16:e0255055. [PMID: 34314461 PMCID: PMC8315515 DOI: 10.1371/journal.pone.0255055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 07/08/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Borderline Personality Disorder (BPD) is a prevalent and serious mental health condition. People can experience recovery or remission after receiving psychotherapy for BPD; however, it is estimated that about 45% of people in well conducted treatment trials do not respond adequately to current psychological treatments. AIM To further advance psychotherapies for BPD by identifying the factors that contribute to the problem of non-response. METHOD 184 consecutive participants with BPD in community treatment were naturalistically followed up over 12 months and measures of personality and social functioning were examined. Logistic regressions were used to determine which baseline factors were associated with the likelihood of being a non-responder after 12 months of psychotherapy. After 12 months, 48.4% of participants were classed as non-responders due to a lack of reduction in BPD symptoms according to the Reliable Change Index (RCI) method. RESULTS At baseline intake, patients who endorsed an adult preoccupied attachment relationship style and increased anger were more likely to be a non-responder regarding BPD symptoms at 12 months. In addition, those with preoccupied attachment patterns in their adult relationships were more likely to be non-responders regarding general psychological distress at follow up. Higher baseline levels of paranoia and endorsement of a dismissive adult relationship style was associated with being a non-responder in regard to global functioning. CONCLUSIONS Consistent with previous research, almost half of the sample did not achieve reliable change at 12-month follow up. A relationship style characterised by preoccupied insecurity and high anger seemed to be particularly challenging in being able to benefit from psychotherapy. This style may have affected both relationships outside, but also inside therapy, complicating treatment engagement and alliance with the therapist. Early identification and modification of treatment based on challenges from these relationship styles may be one way to improve psychotherapy outcomes for BPD.
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Affiliation(s)
- Jane Woodbridge
- Illawarra Health and Medical Research Institute and School of Psychology, University of Wollongong, Wollongong, Australia
| | - Samantha Reis
- Illawarra Health and Medical Research Institute and School of Psychology, University of Wollongong, Wollongong, Australia
| | - Michelle L. Townsend
- Illawarra Health and Medical Research Institute and School of Psychology, University of Wollongong, Wollongong, Australia
| | - Lucy Hobby
- Illawarra Health and Medical Research Institute and School of Psychology, University of Wollongong, Wollongong, Australia
- School of Education, Western Sydney University, Penrith, Australia
| | - Brin F. S. Grenyer
- Illawarra Health and Medical Research Institute and School of Psychology, University of Wollongong, Wollongong, Australia
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McCommon B, Hersh R. Good Psychiatric Management and Transference-Focused Psychotherapy for Borderline Personality Disorder: A Spectrum of Psychodynamically Informed Treatments. Psychodyn Psychiatry 2021; 49:296-321. [PMID: 34061649 DOI: 10.1521/pdps.2021.49.2.296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Good psychiatric management for borderline personality disorder (GPM) and transference-focused psychotherapy (TFP) are evidence-supported treatments that may be used in a complementary, flexible manner to provide a spectrum of psychodynamically informed care. In this article, we provide overviews of TFP and GPM, describing GPM's eclectic approach that includes psychodynamically informed supportive psychotherapy, case management, and medication management, informed by a model of hypersensitivity to rejection, comparing it with TFP's focus on identity integration and modification of standard psychodynamic techniques for use in treating patients with borderline personality disorder. We outline convergences and divergences between TFP and GPM in assessment, establishment of treatment goals and a treatment agreement, family involvement, and moment-to-moment psychotherapeutic interventions. The options for integration of TFP and GPM theoretical principles, as well as for models of treatment sequencing, are explored. Clinical vignettes are provided that illustrate sequential uses of GPM and TFP as part of psychodynamically informed long-term clinical management.
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Affiliation(s)
- Benjamin McCommon
- Assistant Clinical Professor of Psychiatry, Department of Psychiatry, Columbia University, New York
| | - Richard Hersh
- Special Lecturer in Psychiatry, Department of Psychiatry, Columbia University, New York
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Abstract
Transference-focused psychotherapy (TFP), developed and studied as an extended individual psychotherapy for patients with borderline personality disorder (BPD), rests on a rich theoretical foundation informed by psychoanalytic object relations theory. "Applied TFP" is a developing initiative using TFP principles in multiple clinical situations other than the standard extended individual psychotherapy, which has been empirically validated and is detailed in the TFP treatment manual. The growing application of TFP principles in innovative, overlapping ways has been focused primarily in three spheres: (1) the integration of TFP principles in pluralistic theoretical approaches to treatment of patients with personality disorder pathology; (2) the use of TFP elements in multiple teaching situations as part of curricula for trainees and practicing clinicians, and (3) the employment of TFP theory and interventions in settings across a continuum of patient acuity, tailored for patients with varying diagnoses. The use of TFP principles in the situations described directly addresses needs emerging in particular contexts that reflect specific requirements of clinician practice and training and of broader public health missions.
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Affiliation(s)
- Richard G Hersh
- Special Lecturer in Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York
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Zeifman RJ, Landy MSH, Liebman RE, Fitzpatrick S, Monson CM. Optimizing treatment for comorbid borderline personality disorder and posttraumatic stress disorder: A systematic review of psychotherapeutic approaches and treatment efficacy. Clin Psychol Rev 2021; 86:102030. [PMID: 33894491 DOI: 10.1016/j.cpr.2021.102030] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/08/2021] [Accepted: 04/14/2021] [Indexed: 10/21/2022]
Abstract
Comorbid borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) is a severe and complicated clinical presentation characterized by especially high rates of suicide, healthcare utilization, and psychosocial impairment. Although guidelines exist for treating each of these disorders alone, there remains limited guidance on the optimal treatment in cases where BPD and PTSD co-occur. Therefore, this systematic review synthesizes the existing research on the treatment of BPD-PTSD with the aim of optimizing treatment for this population. First, the prevalence and clinical severity of comorbid BPD-PTSD is reviewed. Next, we describe the results of our systematic review, which identified 21 articles that examined treatment outcomes in the context of BPD-PTSD or subclinical BPD-PTSD. Based on our results, we describe existing psychotherapeutic approaches, including BPD-specific treatments, trauma-focused and non-trauma-focused treatments for PTSD, and stage-based treatments for BPD-PTSD. We also summarize BPD-PTSD treatment outcomes, including whether each disorder interferes with treatment and recovery of the other. Results related to treatment safety and concerns regarding conducting trauma-focused treatment for BPD-PTSD are addressed. We end by highlighting important gaps in the literature and provide recommendations for further research.
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Affiliation(s)
| | - Meredith S H Landy
- Department of Psychology, Ryerson University, Toronto, Canada; Mind Beacon Health Inc., Toronto, Canada
| | - Rachel E Liebman
- Department of Psychology, Ryerson University, Toronto, Canada; Department of Psychology, York University, Toronto, Canada
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Martinez LV, Hersh RG. A Novel Approach to Supervision of Transference-Focused Psychotherapy (TFP): Examining the First Three Minutes of the TFP Session. Psychodyn Psychiatry 2021; 49:110-130. [PMID: 33635109 DOI: 10.1521/pdps.2021.49.1.110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Transference focused psychotherapy (TFP), an empirically validated, manualized treatment for patients with borderline personality disorder (BPD), is arguably the most challenging to learn of the evidence-based treatments for BPD. Following an introduction to the TFP manual and the treatment's central tenets, ongoing individual, group, or peer supervision of case material, ideally with recorded video sessions, would be expected when the clinician's goal is fidelity to the prescribed approach. Our proposal for a novel supervision intervention emerges directly from the basic theoretical foundations of TFP, the process of research investigation, which has evolved over the years, with its goal of assessing both measurable patient outcomes and research clinician adherence to the model, and collective clinical experience. A deliberate assessment of the initial minutes of TFP as a supervision or self-assessment method is not meant as a substitute for more comprehensive supervision, nor is it offered as an exclusive path to mastering TFP. This approach to TFP supervision aims to distill and focus in a common-sense, accessible way the process of practicing TFP, thereby facilitating therapist consistency. Our proposed, more limited and concise tactic for TFP training can be used as an instruction building block, incrementally extending the access for practicing and mastering this intervention to a broader group of motivated providers.
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Affiliation(s)
| | - Richard G Hersh
- Columbia University College of Physicians and Surgeons, New York
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Psychopharmacological treatment in borderline personality disorder: A pilot observational study in a real-world setting. Psychiatry Res 2021; 295:113556. [PMID: 33189367 DOI: 10.1016/j.psychres.2020.113556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 10/31/2020] [Indexed: 11/22/2022]
Abstract
Psychotherapy is the cornerstone of treatment for borderline personality disorder (BPD) while pharmacotherapy should be considered only as an adjunctive intervention. In clinical practice, however, most of BPD patients only receive medication. The aim of the study is to first describe pharmacological treatment in BPD patients in Italy and secondly to evaluate if comorbidity or illness severity are associated with the prescription of different class compounds. Data on pharmacological treatment and clinical evaluation of 75 BPD patients were collected in 5 clinical settings. The association between comorbidity and medication was assessed. Moreover, we evaluated the association between pharmacotherapy and severity, defined by a cluster analysis aimed at detecting different groups of patients. Most of the participants (82.7%) were characterized by polypharmacy, with a mean of 2.4 medications per person. Interestingly, the prescription didn't seem to depend on/be based on the severity of the disorder and was only partially determined by the presence of comorbidity. In conclusion, our findings are similar to what described in other clinical studies, supporting the idea that medication management for BPD is only partially coherent with international guidelines. This pilot study confirms the need for more rigorous studies to gain greater understanding of this topic and diminish the gap between guidelines and the real clinical world.
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Mammen O, Tew J, Painter T, Bettinelli E, Beckjord J. Communicating suicide risk to families of chronically suicidal borderline personality disorder patients to mitigate malpractice risk. Gen Hosp Psychiatry 2020; 67:51-57. [PMID: 33007720 DOI: 10.1016/j.genhosppsych.2020.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The distinction between acute and chronic suicidality is important, because interventions designed to address acute suicidality can worsen chronic suicidality, resulting in an escalating cycle of suicide threats, suicide attempts, and futile hospitalizations. Though most chronically suicidal borderline personality disorder patients improve and do not complete suicide, the potential for suicide contributes to these hospitalizations and a paucity of outpatient services due to treaters' concern over malpractice lawsuits in case of suicide. Communicating with patients' families about the suicide risk has been suggested as a means to mitigate this malpractice risk, but the approach to such communication has not been described. METHOD Once chronic suicidality is identified, a stepwise approach to communicating with the patient's family is described. RESULTS The potential benefits of this risk communication are described, for patients, families, treaters, healthcare systems, and health and malpractice insurers. CONCLUSION It helps to develop an alliance with families and patients around a shared understanding of outcomes in chronic suicidality - most eventually do better, but the risk of completed suicide is real. This enables patients and families to make a more fully informed choice about treatment, which in turn can reduce litigation risk in the minority of cases where the patient completes suicide.
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Affiliation(s)
- Oommen Mammen
- University of Pittsburgh, United States of America; University of Pittsburgh Medical Center, United States of America.
| | - James Tew
- University of Pittsburgh, United States of America; University of Pittsburgh Medical Center, United States of America.
| | - Tiffany Painter
- University of Pittsburgh Medical Center, United States of America.
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Baltzersen ÅL. Moving forward: closing the gap between research and practice for young people with BPD. Curr Opin Psychol 2020; 37:77-81. [PMID: 32916475 DOI: 10.1016/j.copsyc.2020.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/06/2020] [Accepted: 08/09/2020] [Indexed: 10/23/2022]
Abstract
The study of personality disorders has come a long way, and this is characterized by the optimism prevalent within the community dedicated to its study. Outside this community - delays in intervention, ostracism, and ignorance remain common place. With a significant burden of disease and high costs at individual, social, and societal levels there is an urgent need to translate research into practice. Proposed solutions include educating the workforce to improve attitudes and developing more sustainable treatment alternatives. This paper brings forward a user perspective on the need to close the gap between what we know from research and what is done in policy and clinical practice.
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Affiliation(s)
- Åse-Line Baltzersen
- Norwegian National Advisory Unit for Personality Psychiatry, Clinic Mental Health and Addiction, Oslo University Hospital, Norway.
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45
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Wall K, Kerr S, Sharp C. Barriers to care for adolescents with borderline personality disorder. Curr Opin Psychol 2020; 37:54-60. [PMID: 32853877 DOI: 10.1016/j.copsyc.2020.07.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 07/29/2020] [Indexed: 12/22/2022]
Abstract
Intervention for borderline personality disorder (BPD) in adolescence is crucial as early onset of the disorder predicts more severe course, and intervention 'late' in the course of the disorder is associated with more negative outcomes. In spite of this, access to services is poor. This is because several unique barriers to accessing care exist for adolescents with BPD. In this article we highlight key barriers to care for adolescents with BPD utilizing a conceptual model for understanding health care access that emphasizes the interaction between patient and health care system characteristics. We conclude with proposed recommendations to address these identified barriers.
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46
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Friesen L, Gaine G, Klaver E, Klingle K, Parmar D, Hrabok M, Kelland J, Surood S, Agyapong V. Bridging the Gap in Community Care for Patients With Borderline Personality Disorder: Protocol for Qualitative Inquiry Into Patient, Caregiver, and Clinician Perspectives on Service Gaps and Potential Solutions for Severe Emotion Dysregulation. JMIR Res Protoc 2020; 9:e14885. [PMID: 32815818 PMCID: PMC7471890 DOI: 10.2196/14885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 02/28/2020] [Accepted: 03/22/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Borderline personality disorder (BPD) is characterized by severe emotion dysregulation that is often complicated by comorbid diagnoses, deliberate self-harm, and chronic suicidal ideation. Unfortunately, current care pathways for individuals with BPD are strained by limited resources, inadequate training, and an overuse of emergency departments and crisis teams. Such barriers result in delayed access to effective treatment, which increases risk of deterioration, disability, and morbidity. A first step toward addressing these limitations of the current care pathway is to understand key stakeholders' lived experiences in this pathway and their perspectives on potential solutions. OBJECTIVE The purpose of this paper is to present a protocol for a study that explores the lived experiences of the current care pathway from the perspectives of patients with BPD, as well as their caregivers and clinicians. METHODS A qualitative approach is most appropriate for the exploratory nature of the research objective. Accordingly, 3 to 6 patients with a diagnosis of BPD, 3 caregivers of individuals with BPD, and 3 clinicians of patients diagnosed with BPD will be invited to participate in individual, semistructured interviews that focus on service experiences. RESULTS It is anticipated that results will yield insight into the lived experiences of patients with BPD, caregivers, and clinicians and provide a better understanding of the perceived gaps in services and potential solutions. Results are expected to be available in 12 months. CONCLUSIONS This paper describes a protocol for a qualitative study that seeks to understand the lived experiences and perspectives of key stakeholders (patients, caregivers, and clinicians) on the current care pathway for BPD. Results will provide a basis for future research in this area and will have the potential to inform training, practice, and policy. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/14885.
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Affiliation(s)
- Laura Friesen
- Department of Educational Psychology, University of Alberta, Edmonton, AB, Canada
- Addictions and Mental Health, Alberta Health Services, Edmonton, AB, Canada
| | - Graham Gaine
- Department of Educational Psychology, University of Alberta, Edmonton, AB, Canada
- Addictions and Mental Health, Alberta Health Services, Edmonton, AB, Canada
- Department of Psychiatry, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Ellen Klaver
- Department of Educational Psychology, University of Alberta, Edmonton, AB, Canada
| | - Kirsten Klingle
- Addictions and Mental Health, Alberta Health Services, Edmonton, AB, Canada
| | - Devashree Parmar
- Addictions and Mental Health, Alberta Health Services, Edmonton, AB, Canada
| | - Marianne Hrabok
- Department of Psychiatry, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jill Kelland
- Addictions and Mental Health, Alberta Health Services, Edmonton, AB, Canada
| | - Shireen Surood
- Addictions and Mental Health, Alberta Health Services, Edmonton, AB, Canada
| | - Vincent Agyapong
- Addictions and Mental Health, Alberta Health Services, Edmonton, AB, Canada
- Department of Psychiatry, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
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Ilagan GS, Choi-Kain LW. General psychiatric management for adolescents (GPM-A) with borderline personality disorder. Curr Opin Psychol 2020; 37:1-6. [PMID: 32634737 DOI: 10.1016/j.copsyc.2020.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 05/21/2020] [Indexed: 11/18/2022]
Abstract
While borderline personality disorder (BPD) has its onset in youth and is highly prevalent in young people, diagnosis and treatment are frequently delayed, leading to disruptions in development. The few treatments for this population are specialized, resource-intensive, and not widely implemented. Generalist treatments could broadly increase early intervention and access to care, at a less intensive level, when symptoms are milder and developmental arrests can be avoided. One generalist treatment for adults with BPD, General Psychiatric Management, has been adapted for adolescents (GPM-A). GPM-A can be flexibly implemented in different settings, and emphasizes psychoeducation, medicalization of the disorder, life-building activities, and conservative prescribing. This paper introduces GPM-A and proposes it serve as a primary intervention for adolescents with BPD.
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Affiliation(s)
- Gabrielle S Ilagan
- Gunderson Personality Disorders Institute, McLean Hospital, Belmont, MA, United States
| | - Lois W Choi-Kain
- Gunderson Personality Disorders Institute, McLean Hospital, Belmont, MA, United States; Department of Psychiatry, Harvard Medical School, Boston, MA, United States.
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Kramer U, Grandjean L, Beuchat H, Kolly S, Conus P, de Roten Y, Draganski B, Despland JN. Mechanisms of change in brief treatments for borderline personality disorder: a protocol of a randomized controlled trial. Trials 2020; 21:335. [PMID: 32299512 PMCID: PMC7160891 DOI: 10.1186/s13063-020-4229-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 03/03/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Borderline personality disorder (BPD) is one of the most frequent, most debilitating and lethal mental conditions and is associated with a serious burden of disease. Treatment for patients with BPD involves structured psychotherapy, and may involve brief psychiatric treatment as first-line intervention. No controlled study has assessed the effectiveness of such brief intervention. Whereas most psychotherapy studies in patients with BPD focus on the effectiveness of the intervention, we still lack an understanding of how and why these effects are produced from a patient process perspective. It is therefore of utmost importance to study the treatment-underlying mechanisms of change. The present study plans to apply novel measurement methods for assessing change in two central psychobiological processes in BPD: emotion and socio-cognitive processing. The study uses theory-driven and ecologically valid experimental tasks, which take the patient's individual experience as the anchor, by integrating methodology from psychotherapy process and neurofunctional imagery research. METHODS The aim of this two-arm, randomized controlled study is to test the effects (i.e., symptom reduction) and the underlying mechanisms of change associated with a brief psychiatric treatment (10 sessions over 4 months), compared with treatment as usual. Participants (N = 80 patients with BPD) undergo assessments at four points (intake, 2 months, discharge, and 12-month follow up). In addition to symptom measures, individuals undergo a 2-step assessment for the potential mechanisms of change (i.e., emotion and socio-cognitive processing): (1) behavioral and (2) (for a sub-sample) neurofunctional. We hypothesize that change in the mechanisms explains the treatment effects. DISCUSSION This study uses an easy-to-implement treatment of BPD, and a sophisticated assessment procedure to demonstrate the critical role of psychobiological change in emotion and socio-cognitive processing in brief treatments. It will help increase the effectiveness of brief treatment for BPD and help diminish the societal burden of disease related to BPD, in these early stages of treatment. TRIAL REGISTRATION {2}: ClinicalTrials.gov: NCT03717818. Registered on 24 October 2018). Protocol version {3} number 2 from 9 February 2018.
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Affiliation(s)
- Ueli Kramer
- Institute of Psychotherapy and General Psychiatry Service, Department of Psychiatry, Lausanne University Clinic and University of Lausanne and Lausanne University Hospital, Place Chauderon 18, CH-1003, Lausanne, Switzerland. .,General Psychiatry Service, Department of Psychiatry, Lausanne University Clinic and University of Lausanne, Lausanne, Switzerland. .,Department of Psychology, University of Windsor, Windsor, Canada.
| | - Loris Grandjean
- Institute of Psychotherapy and General Psychiatry Service, Department of Psychiatry, Lausanne University Clinic and University of Lausanne and Lausanne University Hospital, Place Chauderon 18, CH-1003, Lausanne, Switzerland
| | - Hélène Beuchat
- Institute of Psychotherapy and General Psychiatry Service, Department of Psychiatry, Lausanne University Clinic and University of Lausanne and Lausanne University Hospital, Place Chauderon 18, CH-1003, Lausanne, Switzerland
| | - Stéphane Kolly
- General Psychiatry Service, Department of Psychiatry, Lausanne University Clinic and University of Lausanne, Lausanne, Switzerland
| | - Philippe Conus
- General Psychiatry Service, Department of Psychiatry, Lausanne University Clinic and University of Lausanne, Lausanne, Switzerland
| | - Yves de Roten
- Institute of Psychotherapy and General Psychiatry Service, Department of Psychiatry, Lausanne University Clinic and University of Lausanne and Lausanne University Hospital, Place Chauderon 18, CH-1003, Lausanne, Switzerland
| | - Bogdan Draganski
- Department of Clinical Neurosciences, Lausanne University Clinic and University of Lausanne, Lausanne, Switzerland
| | - Jean-Nicolas Despland
- Institute of Psychotherapy and General Psychiatry Service, Department of Psychiatry, Lausanne University Clinic and University of Lausanne and Lausanne University Hospital, Place Chauderon 18, CH-1003, Lausanne, Switzerland
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Kenner J, Baker FA, Treloyn S. Perspectives on musical competence for people with borderline personality disorder in group music therapy. NORDIC JOURNAL OF MUSIC THERAPY 2020. [DOI: 10.1080/08098131.2020.1728781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Jason Kenner
- Faculty of Fine Art and Music, University of Melbourne, Melbourne, Australia
| | - Felicity A. Baker
- Faculty of Fine Art and Music, University of Melbourne, Melbourne, Australia
| | - Sally Treloyn
- Faculty of Fine Art and Music, University of Melbourne, Melbourne, Australia
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50
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Abstract
Despite the growing cultural and empirical interest in pathological narcissism (PN), effective treatment guidelines for PN have not yet been established. This article develops mentalization-based treatment (MBT), a leading evidence-based therapy for borderline personality disorder, as a primary intervention for PN. Synthesizing research on parenting styles, attachment patterns, and empathy in PN, the authors propose a developmental model of narcissism centering on impairments in mentalization. Core therapeutic techniques of MBT for PN are outlined, including clinical examples to illustrate practical implementation. As an accessible, easy-to-operationalize, and resource-sensitive therapeutic approach, MBT offers considerable promise for future empirical investigation and clinical applications in the treatment of patients with pathological narcissism.
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Affiliation(s)
- Robert P Drozek
- MBT Training Clinic, McLean Hospital, Belmont, Massaschusetts, and Harvard Medical School, Boston, Massachusetts
| | - Brandon T Unruh
- MBT Training Clinic, McLean Hospital, Belmont, Massaschusetts, and Harvard Medical School, Boston, Massachusetts
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