Enduring Effects of One-Day Training in Good Psychiatric Management on Clinician Attitudes About Borderline Personality Disorder

Good Psychiatric Management of Borderline Personality Disorder: Foundations and Future Challenges

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.

Good psychiatric management for borderline personality disorder: A qualitative study of its implementation in a supported employment team

INTRODUCTION

People with borderline personality disorder have difficulties with work. The Individual Placement and Support model has shown its worldwide effectiveness in terms of vocational rehabilitation for individuals with psychiatric disorders. However, only a few recent studies have explored its results for people with personality disorders, and the findings were mitigated. Additionally, Individual Placement and Support job coaches reported difficulties in supporting this population. An evidence-based psychotherapeutic method, also applicable in a case management context, called Good Psychiatric Management for borderline personality disorder, could potentially overcome these obstacles. This study aimed to evaluate the initial integration of Good Psychiatric Management in Individual Placement and Support practice.

METHODS

Individual Placement and Support practitioners of Lausanne University Hospital, Switzerland, were trained in Good Psychiatric Management in January 2022. Five of them participated in a focus group to collect their impressions about the training, and six were interviewed 9 months later to assess the initial adoption of Good Psychiatric Management into their practice. Thematic analyses were conducted.

RESULTS

Job coaches were positive about this new tool. All of them found it useful and beneficial both for them and their patients. They were able to follow the main Good Psychiatric Management principles in their practice However, the findings also suggested some additional improvements in the implementation process.

CONCLUSIONS

Integrating Good Psychiatric Management in Individual Placement and Support seems feasible, and the team who appreciated it adopted it. The method offers new perspectives in community support for people living with borderline personality disorder.

Attitudes of psychiatry trainees towards patients with borderline personality disorder: Does the stigma begin during training?

Research suggests there is a widespread stigma among clinicians towards patients with borderline personality disorder (BPD) and that this contributes to poor treatment outcomes. Given the influence of learning environments in shaping perceptions, this study investigated the attitude of South Australian psychiatry trainees towards patients with BPD. A questionnaire was distributed to 89 South Australian doctors, from both The Adelaide Prevocational Psychiatry Program (TAPPP) and psychiatry trainees of The Royal Australian and New Zealand College of Psychiatrists (RANZCP). This questionnaire investigated the domains of treatment optimism, clinician attitude and empathy towards patients with BPD. Results indicated that psychiatry trainees near the end of training scored significantly lower across all domains, indicating a more negative perception of patients with BPD, when compared to early- and mid-stage trainees. This study identifies a need to understand why trainees closer to qualifying as psychiatrists have increased stigma towards patients with BPD. Improved education and training surrounding patients with BPD is warranted to reduce negative stigma and improve clinical outcomes.

Neuropragmatics: A scientometric review

Neuropragmatics investigates brain functions and neural activities responsible for pragmatic language abilities, often impaired in disorders such as hemisphere damage, autism, schizophrenia, and neurodegenerative disorders. This study examined the development of neuropragmatics and existing neuroimaging evidence using bibliometric and scientometric indicators, analyzing 4,247 documents published between 1967 and 2022 with CiteSpace and VOSviewer. Our cluster analysis revealed key themes. 1) Language comprehension loss due to brain injury: Studies exploring the impact of brain injuries on language comprehension and underlying neural mechanisms. 2) Right hemisphere damage and pragmatic language skills: Research focusing on the relationship between right hemisphere damage and pragmatic language abilities, investigating impairments in social language use and potential neural correlates. 3) Traumatic brain injury and social communication assessment: Research on traumatic brain injury effects on social communication skills, using various assessment tools to evaluate communication effectiveness in social situations. These clusters provide valuable insights into the neuropragmatics field and serve as a framework for future investigations. By building upon existing knowledge, researchers can improve our understanding of brain functions, language behavior, and enhance rehabilitation for individuals with pragmatic language impairments.

A pilot randomized controlled trial of ketamine in Borderline Personality Disorder

This study is the first randomized controlled trial to test the effects of ketamine in Borderline Personality Disorder (BPD). BPD remains undertreated in the community and no medication has FDA approval for this indication. People with BPD experience chronic mood disturbances with depressed mood, suicidal ideation, and severe social difficulties. In this double-blind, randomized controlled pilot study, we tested the effects of one infusion of ketamine (0.5 mg/kg, n = 10) or the psychoactive comparator drug midazolam (0.04 mg/kg, n = 12) in adults with BPD. Infusions were well tolerated in both groups. Dissociative symptoms during infusion were more intense with ketamine than midazolam (t(12.3) = 3.61, p = 0.01), but they resolved by 40 min after infusion in both groups. Post-infusion adverse events were at the expected low levels in both groups. For our primary outcome measure of suicidal ideation and our secondary outcome measure of depression, we found numerical reduction but not significant group or group x timepoint difference (p > 0.05). For our secondary outcome measures of anxiety and BPD symptoms, we did not observe group or group x timepoint differences. There was a group x timepoint effect for socio-occupational functioning (F(1,20.12) = 5.16, p = 0.03, at Day 14, ketamine group showed more improvement than midazolam group). An exploratory analysis revealed that improvement in socio-occupational functioning was correlated with improvement in depression in the ketamine group (r(8) = 0.65, p = 0.04) but not midazolam group (r(9) = 0.41, p = 0.216). This pilot study provides the first randomized controlled evidence of the effects of antidepressant-dosed ketamine in people with BPD. Our results provide reason for optimism that antidepressant-dosed ketamine will be well-tolerated in larger studies and may provide clinical benefit for mood symptoms and related impairments in people with BPD.

Destigmatizing Borderline Personality Disorder: A Call to Action for Psychological Science

Despite recognition that borderline personality disorder (BPD) is one of the most stigmatized psychological disorders, destigmatization efforts have thus far focused on the views and actions of clinicians and the general public, neglecting the critical role that psychological science plays in perpetuating or mitigating stigma. This article was catalyzed by recent concerns about how research and editorial processes propagate stigma and thereby fail people with BPD and the scientists who study BPD. We provide a brief overview of the BPD diagnosis and its history. We then review how BPD has been stigmatized in psychological science, the gendered nature of BPD stigma, and the consequences of this stigmatization. Finally, we offer specific recommendations for researchers, reviewers, and editors who wish to use science to advance our understanding of BPD without perpetuating pejorative views of the disorder. These recommendations constitute a call to action to use psychological science in the service of the public good.

Mental Health Workers' Knowledge and Attitude Towards Borderline Personality Disorder: A Saudi Multicenter Study

Background Borderline personality disorder (BPD) is a mental illness characterized by emotional instability. Its prevalence can be as high as 1.8% among the general population. Poor knowledge and negative perceptions of the disorder by mental health workers (MHWs) can affect patients' care and their help-seeking behavior. This study aims to explore MHW's knowledge and attitudes toward BPD. Method A cross-sectional study was conducted on MHWs across the five regions of Saudi Arabia (SA) using a questionnaire that assessed knowledge, attitude, and training regarding BPD. Results  Data collected from 1028 MHWs showed a good knowledge level. Superior knowledge was observed among females, residents in the central region, physicians, those who received specific BPD training, and MHWs who had more experience and frequent interactions with BPD patients. Participants had moderate to high levels of perceived knowledge and confidence regarding the identification, assessment, and management of BPD patients. Undergraduate training programs were the most reported source of information on the disorder. While 66% of participants admitted that they find dealing with BPD patients more difficult and thought patient management was inadequate, 71% were willing to attend further BPD training. Conclusion MHWs in SA have moderate knowledge of but negative perceptions of BPD; specific training is needed to improve the care provided for BPD patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

REVIEW REGISTRATION

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

Judging Personality Disorder: A Systematic Review of Clinician Attitudes and Responses to Borderline Personality Disorder

BACKGROUND

It has been suggested that the diagnosis of borderline personality disorder (BPD) is associated with particularly stigmatizing connotations, particularly among mental health professionals. The goal of this study was to synthesize quantitative studies investigating the attitudes and responses of clinicians to BPD and to appraise the methodological quality of these studies.

METHODS

A systematic search was carried out using MEDLINE Complete, CINAHL Complete, PsychoINFO, PsychARTICLES, Scopus, Social Sciences Citation Index, and Academic Search Complete. Study quality was rated using an adapted tool.

RESULTS

This review included 37 papers involving an estimated 8196 participants: 21 cross-sectional survey studies, 5 studies assessing training workshops, 5 studies assessing countertransference, and 6 experimental studies. The methodological quality of the studies was mixed, with many differing measures with questionable validity used.

CONCLUSIONS

Negative attitudes toward BPD continue to be a problem to differing degrees among clinical staff. Although this issue is most prominent among psychiatric nurses, the results of this review highlight evidence of negative attitudes across all mental health professions as well as potentially in professionals working in physical health settings. Various clinician-level factors may play a role in the development and maintenance of such attitudes. Greater exposure to patients with BPD and attendance at training programs have been found to be associated with improved attitudes. Professionals require regular training concerning BPD that is sufficiently evidence-based.

The impact of educational interventions on modifying health practitioners' attitudes and practice in treating people with borderline personality disorder: an integrative review

BACKGROUND

The rising prevalence of Borderline Personality Disorder (BPD) and suicidality represents substantial health burden worldwide. People with BPD experience high rates of crisis presentations and stigma when accessing health services. Educational interventions designed to modify health practitioners' attitudes and practice in treating people with BPD may assist in addressing this stigma. The current review aimed to identify and explore existing educational interventions designed to modify health practitioners' attitudes and practice in BPD; and determine what impact educational interventions have on improving health practitioners' responses towards people with BPD.

METHODS

A comprehensive search of the literature was undertaken in MEDLINE, CINAHL, PsycINFO, Scopus, Cochrane Library, and JBI Evidence-Based databases (from inception to February 2022). Secondary sources of literature included grey literature searches and handsearching the references of included studies as part of the comprehensive search strategy. The eligibility criteria included peer-reviewed empirical studies examining BPD-related educational interventions aimed at modifying health practitioners' attitudes and practice in treating people with BPD. Quality appraisal of the included studies were completed using the Mixed Methods Appraisal Tool 2018 version (MMAT v.18) or the Joanna Briggs Institute (JBI) Checklist for Systematic Reviews and Research Syntheses Tool. Thematic Analysis informed data extraction, analysis, interpretation, and narrative synthesis of the data.

RESULTS

A total of nine papers containing 991 participants across a diverse range of studies including, quantitative, qualitative, mixed methods, and a systematic review were included in this integrative review. Several BPD-related educational interventions designed to modify health practitioners' attitudes and practice in BPD exist. Findings suggest that training health practitioners in BPD-related educational interventions can enhance positive attitudes and change practice towards people with BPD; however, more high-quality studies are needed to confirm these conclusions.

CONCLUSIONS

This review collated and summarized findings from studies examining the impact of BPD-related educational interventions on changing health practitioners' attitudes and practice in treating this population. Results from this review may help inform future research, policy, and practice in stigma-reduction strategies which would improve the delivery of responsive health services and care for people with BPD.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework ( https://osf.io/7p6ez/ ).

The State of Overmedication in Borderline Personality Disorder: Interpersonal and Structural Factors

Purpose of review

a)This review paper describes the state of prescribing practice in Borderline Personality Disorder (BPD), wherein medications are prescribed far more than either evidence or practice guideline would recommend. First, we describe the frequencies of medication use and polypharmacy in people with BPD.

Recent findings

b)In subsequent sections, we elaborate two main categories of factors that lead to overmedication of people with BPD: the interpersonally mediated and the structural. We consider interpersonally mediated factors to arise from communications of patients in distress and the well-meaning efforts of their prescribers to provide relief for certain overwhelming affective states. We are particularly focused on patterns of countertransference in prescribing that are directly linked to specific aspects of BPD pathology. We consider structural factors to arise from the complexities of medical and medicolegal systems and the contemporary patterns of financing medical care; we postulate that these complexities often compel prescribers to start medications, with associated disincentives for decreasing or discontinuing those medications over time.

Summary

c)More research is needed to understand how to best use medications in BPD, for example in targeted combination with psychotherapeutic and psychosocial interventions. However, current practice often departs markedly from the evidence. We recommend the dissemination of accessible, generalist BPD-treatment models in outpatient and inpatient practice; increased early detection of BPD; and increased diagnostic disclosure. We also recommend for individual providers and systems to implement prospective treatment plans that draw from BPD-specific psychosocial models. This approach can employ tiers of interventions to minimize reactive prescribing by anticipating high affect and offering BPD patients steadily empathic evidence-supported care.

Confidence of psychiatry trainees in meeting the needs of borderline personality disorder in comparison with schizophrenia

OBJECTIVE

Borderline personality disorder (BPD) and schizophrenia are both serious and chronic mental health conditions of similar prevalence. This study was designed to assess trainees' confidence in the assessment, management and treatment of BPD in comparison with schizophrenia.

METHODS

A survey was used to assess psychiatry trainees' confidence and experience of training with regard to managing BPD and schizophrenia.

RESULTS

Eighty-two psychiatry trainees completed the survey. Overall, confidence scores of respondents with respect to BPD were significantly lower in comparison with schizophrenia. Trainees reported a preference for working with patients with schizophrenia compared with BPD. Respondents reported receiving less adequate supervision and training in the assessment, management and treatment of BPD than for schizophrenia.

CONCLUSIONS

The results suggest an urgent need to enhance training and supervision in skills related to the diagnosis, management and treatment of BPD, with a greater focus on psychotherapy to improve trainee psychiatrists' confidence in working with people diagnosed with BPD.

General psychiatric management for adolescents (GPM-A) with borderline personality disorder

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.