Societal costs of Borderline Personality Disorders: a matched-controlled nationwide study of patients and spouses

Symptom domains and psychosocial functioning in borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is often characterized by severe functional impairment, even after a decrease in symptoms. A comprehensive understanding of psychosocial functioning in BPD is necessary to tailor treatment offer, which should address relevant aspects of daily life. The aims of the present study are to (1) conduct a cross-sectional comparison of functioning of a group with BPD and a non-BPD clinical comparison group at service entry, and to (2) assess the relationship between intensity of BPD symptom domains and psychosocial functioning.

METHODS

The sample consists of N = 65 participants with BPD and N = 57 participants from the clinical comparison group without BPD (non-BPD group). The Revised Borderline Follow-up Interview (BFI-R) was used to evaluate psychosocial functioning and the Revised Diagnostic Interview for Borderlines (DIB-R) to assess BPD symptoms. Linear, logistic, and multinomial regression models were run separately for each aspect of functioning as a function of BPD status or BPD symptom domains.

RESULTS

Only 23% of participants in the BPD group fulfilled criteria for good overall psychosocial functioning, compared to 53% in the non-BPD group. Furthermore, participants in the BPD group were less likely to have completed a high number of years of education, to work consistently, to be financially independent, to be in a cohabiting relationship and have a good relationship with parents. In addition, various links were identified between BPD symptom domains and functional impairments.

CONCLUSIONS

Consistent with prior research, the main impairments in functioning in the BPD group are found in the educational and vocational domains. Though some domains show impairment, others, like friendships, may act as potential resources. Further investigation on the relationships with symptom domains is required.

Prevalence and incidence of personality disorders among children and adolescents in Danish mental health services: a nationwide register study

A few epidemiological studies have examined personality disorders (PDs) among children and adolescents in secondary mental health services. This study aims to describe the prevalence and incidence of PDs among children and adolescents who have attended Danish child and adolescent psychiatric services (CAPS). Using register-based data, we studied all patients under the age of 18 years who were admitted to in- and outpatient CAPS (N = 115,121) in Denmark from 2007 to 2017. A total of 4952 patients were diagnosed with a PD during the study period. The mean prevalence was 859 patients per year, and the mean incidence was 274 patients per year, including an increased incidence and prevalence of borderline, anxious, and unspecified PDs over the decade. The number of patients diagnosed with PDs increased from 700 to 851 per year, but the proportion of patients with PDs compared to all psychiatric diagnoses decreased from 4.2% to 2.8% over the study period. The PD population had an older age (14.8 years vs. 11.3 years; p < 0.001), a higher likelihood of being female (74% vs. 44%; p < 0.001), and four times more contacts with the psychiatric emergency departments than other patients with a psychiatric diagnosis. Future studies should focus on (a) implementing further epidemiological studies in different countries; (b) tracking diagnostic practices to facilitate comparisons and provide feedback for training clinicians and raising awareness; and (c) estimating trajectories of PDs, including costs within the CAPS, to facilitate informed decision-making regarding the future organization and provision of services to these children, adolescents, and their families.

Treating Narcissistic Disorders in General Psychiatry: Practical Application of Transference-Focused Psychotherapy Principles

Patients with primary or co-occurring narcissistic disorders are seen routinely in general psychiatry settings. Contemporary trends in training and practice have impacted psychiatrists' skills and confidence in identifying and treating these disorders, which can range from relatively benign to high-acuity presentations. The goal of this article is to introduce key principles derived from transference-focused psychotherapy (TFP) for use by clinicians in general practice in their work with patients with narcissistic disorders, even when those clinicians do not routinely provide individual psychotherapy. Practical application of TFP principles in work with patients with narcissistic disorders in general psychiatry are proposed, including in diagnostic evaluation, family engagement, prescribing, and safety assessment and risk management calculus. Many psychiatrists whose practices are focused primarily on psychopharmacology, or a "medical model," may not appreciate fully the impact of pathological narcissism in their work. Clinicians who may benefit from familiarity with TFP principles in work with patients with narcissistic disorders include the approximately one-half of U.S. psychiatrists who do not offer psychotherapy in their practice.

Personality Disorders and Attachment Trauma in Adolescent Patients with Psychiatric Disorders

This study examined how personality disorders (PD) differ with respect to gender, attachment status and traumatic childhood experiences in adolescent psychiatric inpatients. In particular, we investigated attachment-related traumatic material underlying adolescent PD. Our sample consisted of 175 inpatient adolescents aged 14 to 18 years (77% female, Mage = 15.13, SD = 1.35; 23% male, Mage =14.85, SD = 1.41). Thirty-nine patients (22%) fulfilled the diagnostic criteria for a PD according to the SCID-II PD: 51% avoidant, 13% obsessive-compulsive, 13% antisocial, 19% borderline, 2% paranoid and 2% histrionic. In the total sample, eighty-three (47%) of our inpatients were classified with an unresolved attachment status using the Adult Attachment Projective Picture System (AAP). We did not find any significant gender differences for patients with and without a PD. Our results revealed a higher percentage of unresolved attachment status in patients with a PD. The in-depth analysis of the total sample showed that patients with a PD demonstrated more traumatic material in their attachment interviews indicating a greater severity of attachment trauma. Furthermore, patients with a PD reported higher scores on emotional and physical neglect. Intervention strategies targeting traumatic attachment-related themes might be useful to treat adolescents with PD.

Borderline personality disorder and the diagnostic co-occurrence of mental health disorders and somatic diseases: A controlled prospective national register-based study

OBJECTIVE

Information on borderline personality disorder (BPD) and its comorbidities is often limited to concentrate on a few diagnoses. The aim of the study was to use national register data to investigate all diagnostic co-occurring mental health disorders and somatic diseases 3 years before and after initial BPD diagnosis compared with a matched control group.

METHOD

The study was a register-based cohort of 2756 patients with incident BPD (ICD F60.3) and 11,024 matched controls, during 2002-2016. Comorbidity data were classified into main disease groups, in accordance with the World Health Organization ICD-10 criteria.

RESULTS

Almost half the patients had been diagnosed with mental and behavioral disorders before the BPD diagnosis as compared to 3% in the control group. Further, the co-occurrence of diseases due to external causes of morbidity, including injury, self-harm, and poisoning were more represented in the BPD group before diagnosis as compared to the control group. In addition, co-occurring morbidity related to diseases in the circulatory, the respiratory, the digestive, the musculoskeletal, and the genitourinary system was more represented in the BPD group. After diagnosis, the proportion of patients with co-occurring morbidity increased further in all main disease groups in the BPD group. As many as 87% of patients had mental and behavioral co-occurring morbidity and 15% nervous diseases as compared with 3% and 4%, respectively, in the control group. Also, comorbidities related to external causes of morbidity, including for example, injury and self-harm were more represented in the BPD group. The BPD group had more somatic co-occurring morbidity, especially digestive, respiratory, circulatory, and endocrine diseases. Finally, the mortality over 12 years was statistically significantly higher in people with BPD than in the control group.

CONCLUSION

Patients with BPD have higher odds for multiple physical health conditions and co-occurrence of mental health disorders.

Societal costs of personality disorders among treatment-seeking patients in Norway: the relative contribution of specific DSM-5 categories

Personality disorders (PDs) are associated with high levels of societal costs, regardless of whether a single PD or a broad range of PDs have been studied. However, research on the relative contribution of specific PD-types on societal costs is limited. The aim of this study was to explore the possible contributions of the individual DSM-5 categories of PDs on the level of societal costs and its components (health service costs and productivity loss), while controlling for the impact of comorbid mental health and substance use disorders on these outcomes. Participants (n = 798) were retrieved from the quality register of the Norwegian Network for Personality Disorders-a collaboration of PD-treatment units within specialist mental health services. The patients were referred to treatment in the time-period 2017-2020. Costs were assessed using a structured interview covering the 6-month period prior to assessment. Diagnoses were determined by semi-structured diagnostic interviews (SCID-5-PD and M.I.N.I.). Statistics included multiple regression analyses. The main result was that no specific PD had a unique contribution to the high level of societal costs generally found among treatment-seeking patients with PDs. Borderline PD (BPD) was the only PD with significantly higher health service costs than the other PDs, while BPD, avoidant PD, and unspecified PD were independently associated with enhanced productivity loss. The differential cost-effects of specific PDs on the cost components were small. Several comorbid mental health and substance use disorders were significant contributors to costs, irrespective of PD status. The results underscore the importance of developing and implementing effective treatments for a broader range of PDs, to reduce the high levels of societal costs associated with all PDs.

Social cognition deficits in borderline personality disorder: Clinical relevance

Interpersonal difficulties in borderline personality disorder (BDP) have been suggested to be related to impairments in Social Cognition (SC), mainly due to deficits in Theory of Mind (ToM). However, literature is scarce and ambiguous. This work aims to study the SC impairments in BPD patients, by the specific assessment of ToM deficits, and to investigate the relationship between these SC impairments and clinical variables. 82 BPD patients with BPD and 47 control subjects were assessed with the Movie for the Assessment of Social Cognition (MASC). Clinical variables of severity, chronicity, functionality and anxious-depressive symptomatology were recorded. BPD patients had fewer correct mentalization responses and more overmentalization, undermentalization, and absence of mentalization errors than controls. Chronicity was negatively correlated with overmentalization and positively correlated with undermentalization and absence of mentalization errors. Functionality was indirectly correlated with absence of mentalization. These results confirm previous reports of alterations in SC in BPD patients. Furthermore, this study shows that SC impairments in patients with BPD are dependent on characteristics such as chronicity or degree of functionality. The different ToM profiles in patients with BPD indicate the necessity of developing variants of mentalization therapy depending on the deficits of each patient.

The experiences of parents in an early-intervention program for young people with borderline personality disorder features

Previous research demonstrates that parents' communication skills may contribute to the development and maintenance of their young person's borderline personality disorder (BPD). Carers of people with BPD also experience their own psychosocial stressors and feel unsupported. Consequently, Dialectical Behavior Therapy for adolescents (DBT-A) invites parents to partake in group therapy alongside their young person. Despite this involvement, little research exists examining parents' perspective of engaging in a DBT-A program, and specifically whether they experience their own benefits and changes from being part of the program. To examine this, the current study interviews 34 parents who engaged in an early intervention DBT-A program. Thematic analysis resulted in seven key themes and 16 subthemes beginning with parents' expectations of the program, followed by the key elements of the program that facilitated change, and the actual changes and benefits attributed to these elements. Overall, parents were surprised by their own gains from the program, and how the skills they learned facilitated personal development that improved family communication and functioning with their young person and more broadly. This study addresses the gap in understanding the parent perspective with clinical implications for the benefits of involving parents in therapy more generally.

Personality disorders: the impact of severity on societal costs

Personality disorders (PDs) are associated with high levels of societal costs. However, previous research has found limited or no evidence of unique contributions of individual PD categories on the overall level of societal costs. Recent research supports the validity of PD as a dimensional construct, and PD severity may be a better predictor of societal costs than specific PD categories. The aim of this study was to explore if PD severity could predict the level of societal costs among treatment-seeking patients with PDs, while controlling for the impact of comorbid mental health and substance use disorders. Four different severity indicators were explored: the number of PDs, the total number of PD criteria, the number of BPD criteria, and the Level of Personality Functioning Scale (LPFS) from the alternative model in DSM-5. Participants (n = 798/794) were retrieved from the quality register of the Norwegian Network for Personality Disorders for the period 2017-2020. Societal costs were assessed using a structured interview covering the six-month period prior to assessment. Diagnoses and diagnostic criteria were determined using a semi-structured diagnostic interview (SCID-5-PD and M.I.N.I), and the LPFS was assessed by the LPFS-Brief Form 2.0 (LPFS-BF 2.0) questionnaire. Statistics included multiple regression analyses. None of the severity indicators were significant predictors of overall societal costs among treatment-seeking patients, and effect sizes were small.

Altered emotional response pattern related to complex trauma in patients with borderline personality disorder

INTRODUCTION

This work aims to demonstrate, through the International Affective Picture System (IAPS) responses, an altered emotional pattern in borderline personality disorder (BPD) patients and to find a specific emotional response pattern by understanding their relationship with traumatic experiences and attachment bonds towards their primary caregivers.

METHOD

A total of 50 BPD patients and 39 control patients were evaluated using the IAPS, and its assessment was carried out through the Self-Assessment Manikin (SAM). Paternal and maternal attachment bonds as well as traumatic experiences in BPD patients were evaluated. Statistical associations were analysed in the different variables.

RESULTS

Significant differences between BPD and control patients were found in all emotional response components for pleasant, unpleasant and neutral images (p < .01), with one exception, the arousal in pleasant images. Patients' experience of traumatic experiences was positively related to scores on the happiness component of pleasant imagery (p = .057) and on the arousal component of unpleasant imagery (p = .058). Poorer maternal bonding in BPD patients was significantly related to lower scores on happiness (p < .01) and dominance (p < .05) components of pleasant imagery and all emotional response components for unpleasant imagery (p < .01).

CONCLUSIONS

The results of the study confirm an impaired emotional response pattern in patients with borderline personality disorder (BPD), showing an emotional response to pleasant images similar to that of depression, while the pattern found to unpleasant images could be related to the complex trauma observed in these patients, which includes PTSD experiences such as sexual abuse and attachment trauma experiences.

Association of mental disorders with costs of somatic admissions in France

OBJECTIVES

Mentally ill patients have worse health outcomes when they suffer from somatic conditions compared to other patients. The objective of this study was to assess the association of mental illness with hospital inpatient costs for somatic reasons.

METHODS

All adult inpatient stays for somatic reasons in acute care hospitals between 2009 and 2013 were included using French exhaustive hospital discharge databases. Total inpatient costs were calculated from the all-payer perspective and compared in patients with and without a mental disorder. Only patients who had been admitted at least once for a mental disorder (either full-time or part-time) were considered to be mentally ill in this study. Generalized linear models with and without interaction terms studied the factors associated with hospital inpatient costs.

RESULTS

17,728,424 patients corresponding to 37,458,810 admissions were included. 1,163,972 patients (6.57%) were identified as having a mental illness. A previous full-time or part-time admission for a mental disorder significantly increased hospital inpatient costs (+32.64%, 95%CI=1.3243-1.3284). Interaction terms found an increased impact of mental disorders on costs in patients with low socio-economic status, as well as in men, patients aged between 45 and 60, and patients with a cardiovascular disease or diabetes.

CONCLUSION

Mentally ill patients have higher hospital costs than non-mentally ill patients. Improving curative and preventive treatments in those patients could improve their health and decrease the burden on healthcare systems.

[Towards a pragmatic cohabitation of theoretical and clinical models: The example of "Good Psychiatric Management" in the treatment of borderline personality disorder]

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.

Societal costs of personality disorders: A cross-sectional multicenter study of treatment-seeking patients in mental health services in Norway

OBJECTIVE

There is a relatively small body of research on the cost-of-illness of personality disorders (PDs). Most studies only include borderline PD. The aim of this study was to investigate mean societal costs, including its components, (direct) health service costs and (indirect) productivity loss, among treatment-seeking patients with the broad range of all PDs according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

METHODS

Cross-sectional data from 911 patients diagnosed with at least 1 PD were retrieved from the quality register of the Norwegian Network for Personality Disorders-a collaboration of PD treatment units within specialist mental health services. The patients were referred in the time period 2017-2020. Estimation of costs was based on a bottom-up approach, using information from a structured interview covering the 6-month period before assessment, whereas unit costs were retrieved from public reports, public records, or public agencies. The human capital approach was used to calculate productivity loss. Diagnoses were determined by semi-structured diagnostic interviews (Structured Clinical Interview for DSM-5-PD [SCID-5-PD]).

RESULTS

The mean societal costs were €20.260 during the 6-month period before specialized treatment. The largest cost component was productivity loss (65%), whereas health service costs constituted 35%. The main contributors to societal costs from the underlying health service cost components were inpatient treatment (20.5%) and individual outpatient treatment (10.5%).

CONCLUSION

Societal costs were substantial among treatment-seeking patients with the broad range of DSM-5 PDs, comparable to the societal costs of schizophrenia, and significantly higher than the societal costs of both depression and anxiety disorders. The cost estimates converged with recent, register-based cost-of-illness studies of different PDs but exceeded previous findings from other bottom-up studies. Furthermore, the results underscore the importance of implementing effective and specialized treatment for patients with a broad range of PDs, not only to alleviate individual suffering but also to reduce the level of societal costs. The emphasis on productivity loss as a main contributor to the overall societal costs is substantiated, hence underlining the relevance of interventions focusing on improving occupational functioning.

Relationship Dysfunction in Couples When One Partner Is Diagnosed with Borderline Personality Disorder: Findings from a Pilot Study

Relationship dysfunction—marked by frequent conflicts—is one of the hallmark features of borderline personality disorder (BPD). However, the BPD couple as a dyad and partner-related features have rarely been taken into account. The aim of the present study was to investigate hormonal, personality, and relationship relevant factors, such as relationship satisfaction, attachment, and trauma in both partners within a dyad where one partner is diagnosed with BPD. The total sample consisted of 26 heterosexual couples. All studies were conducted at 2 p.m. Primary outcomes: Neo-Five-Factor-Inventory, Childhood Trauma Questionnaire, Experiences in Close Relationships Scale. Secondary outcomes: Problem List, Partnership Questionnaire, Questionnaire for Assessing Dyadic Coping. Upon questionnaire completion, one saliva sample was taken via passive drool to assess baseline cortisol and testosterone levels. Results showed that females with BPD have higher scores on childhood maltreatment, dysfunctional attachment styles, and neuroticism than mentally healthy females. Furthermore, they have more relationship-related problems and are less satisfied in their romantic relationship. Male partners of women with BPD showed lower testosterone levels, higher levels of childhood maltreatment, dysfunctional attachment styles, neuroticism, and openness compared with the healthy control partners. Furthermore, childhood trauma, neuroticism as well as dysfunctional attachment styles displayed a significant positive correlation with relationship-related problems. Traumatic childhood experiences, insecure attachment styles as well as neurotic personality characteristics contribute to increased relationship disruptions in couples. Relevant hormonal and psychosocial parameters in BPD partners should be taken into account when treating females with BPD.

Construct Validity of the Dutch, English, French, and Spanish LPFS-BF 2.0: Measurement Invariance Across Language and Gender and Criterion Validity

With the introduction of the Alternative Model of Personality Disorders in the DSM-5, the need for short measures of the level of personality functioning has emerged, both for screening purposes and for assessing change during treatment. The Level of Personality Functioning Scale-Brief Form 2.0 (LPFS-BF 2.0) was constructed for this and has received support for its two-factor structure and criterion validity. The authors aimed to provide additional construct validity evidence for the LPFS-BF 2.0 by examining its factor structure and measurement invariance across the Dutch, English, French, and Spanish versions and across gender, and its criterion validity. Results showed that the two-factor model had a good fit to the data in the four linguistic versions. Configural and metric invariance were supported across linguistic versions and gender, while scalar invariance was partially supported. Reporting a mental health disorder and having consulted with a mental health professional were associated with higher LPFS-BF 2.0 scores.

Pharmacological interventions for people with borderline personality disorder

BACKGROUND

Among people with a diagnosis of borderline personality disorder (BPD) who are engaged in clinical care, prescription rates of psychotropic medications are high, despite the fact that medication use is off-label as a treatment for BPD. Nevertheless, people with BPD often receive several psychotropic drugs at a time for sustained periods.

OBJECTIVES

To assess the effects of pharmacological treatment for people with BPD.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers up to February 2022. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication.

SELECTION CRITERIA

Randomised controlled trials comparing pharmacological treatment to placebo, other pharmacologic treatments or a combination of pharmacologic treatments in people of all ages with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. Secondary outcomes were individual BPD symptoms, depression, attrition and adverse events.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's risk of bias tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis.

MAIN RESULTS

We included 46 randomised controlled trials (2769 participants) in this review, 45 of which were eligible for quantitative analysis and comprised 2752 participants with BPD in total. This is 18 more trials than the 2010 review on this topic. Participants were predominantly female except for one trial that included men only. The mean age ranged from 16.2 to 39.7 years across the included trials. Twenty-nine different types of medications compared to placebo or other medications were included in the analyses. Seventeen trials were funded or partially funded by the pharmaceutical industry, 10 were funded by universities or research foundations, eight received no funding, and 11 had unclear funding. For all reported effect sizes, negative effect estimates indicate beneficial effects by active medication. Compared with placebo, no difference in effects were observed on any of the primary outcomes at the end of treatment for any medication. Compared with placebo, medication may have little to no effect on BPD symptom severity, although the evidence is of very low certainty (antipsychotics: SMD -0.18, 95% confidence interval (CI) -0.45 to 0.08; 8 trials, 951 participants; antidepressants: SMD -0.27, 95% CI -0.65 to 1.18; 2 trials, 87 participants; mood stabilisers: SMD -0.07, 95% CI -0.43 to 0.57; 4 trials, 265 participants). The evidence is very uncertain about the effect of medication compared with placebo on self-harm, indicating little to no effect (antipsychotics: RR 0.66, 95% CI 0.15 to 2.84; 2 trials, 76 participants; antidepressants: MD 0.45 points on the Overt Aggression Scale-Modified-Self-Injury item (0-5 points), 95% CI -10.55 to 11.45; 1 trial, 20 participants; mood stabilisers: RR 1.08, 95% CI 0.79 to 1.48; 1 trial, 276 participants). The evidence is also very uncertain about the effect of medication compared with placebo on suicide-related outcomes, with little to no effect (antipsychotics: SMD 0.05, 95 % CI -0.18 to 0.29; 7 trials, 854 participants; antidepressants: SMD -0.26, 95% CI -1.62 to 1.09; 2 trials, 45 participants; mood stabilisers: SMD -0.36, 95% CI -1.96 to 1.25; 2 trials, 44 participants). Very low-certainty evidence shows little to no difference between medication and placebo on psychosocial functioning (antipsychotics: SMD -0.16, 95% CI -0.33 to 0.00; 7 trials, 904 participants; antidepressants: SMD -0.25, 95% CI -0.57 to 0.06; 4 trials, 161 participants; mood stabilisers: SMD -0.01, 95% CI -0.28 to 0.26; 2 trials, 214 participants). Low-certainty evidence suggests that antipsychotics may slightly reduce interpersonal problems (SMD -0.21, 95% CI -0.34 to -0.08; 8 trials, 907 participants), and that mood stabilisers may result in a reduction in this outcome (SMD -0.58, 95% CI -1.14 to -0.02; 4 trials, 300 participants). Antidepressants may have little to no effect on interpersonal problems, but the corresponding evidence is very uncertain (SMD -0.07, 95% CI -0.69 to 0.55; 2 trials, 119 participants). The evidence is very uncertain about dropout rates compared with placebo by antipsychotics (RR 1.11, 95% CI 0.89 to 1.38; 13 trials, 1216 participants). Low-certainty evidence suggests there may be no difference in dropout rates between antidepressants (RR 1.07, 95% CI 0.65 to 1.76; 6 trials, 289 participants) and mood stabilisers (RR 0.89, 95% CI 0.69 to 1.15; 9 trials, 530 participants), compared to placebo. Reporting on adverse events was poor and mostly non-standardised. The available evidence on non-serious adverse events was of very low certainty for antipsychotics (RR 1.07, 95% CI 0.90 to 1.29; 5 trials, 814 participants) and mood stabilisers (RR 0.84, 95% CI 0.70 to 1.01; 1 trial, 276 participants). For antidepressants, no data on adverse events were identified.

AUTHORS' CONCLUSIONS

This review included 18 more trials than the 2010 version, so larger meta-analyses with more statistical power were feasible. We found mostly very low-certainty evidence that medication may result in no difference in any primary outcome. The rest of the secondary outcomes were inconclusive. Very limited data were available for serious adverse events. The review supports the continued understanding that no pharmacological therapy seems effective in specifically treating BPD pathology. More research is needed to understand the underlying pathophysiologic mechanisms of BPD better. Also, more trials including comorbidities such as trauma-related disorders, major depression, substance use disorders, or eating disorders are needed. Additionally, more focus should be put on male and adolescent samples.

Five Failures and Five Challenges for Prevention and Early Intervention for Personality Disorder

Despite global consensus regarding the early detection of personality disorder, current approaches to early intervention have failed to deliver for the majority of young people. This only serves to reinforce the enduring effects of personality disorder on functioning, mental and physical health, resulting in a reduction of quality of life and life expectancy. Here, we describe five significant challenges facing prevention and early intervention for personality disorder: identification, access to treatment, research translation, innovation and functional recovery. These challenges highlight the need for early intervention to shift from niche programmes in specialist services for a select few young people to become established in mainstream primary care and specialist youth mental health services. Reprinted from Curr Opin Psychol 2021; 37:134-138, with permission from Elsevier. Copyright © 2021.

The relationship between borderline personality disorder and occupational participation: An integrative review

This integrative review explores the impact of borderline personality disorder (BPD) symptomology and behaviours on occupational capacity, participation, and sustainability. The disorder has also been associated with lower education levels, higher levels of attrition in tertiary education populations, and low occupational participation and employment rates. Personality traits and symptomology have been found to substantially detract from employability. Articles were identified from CINAHL (Cumulative Index to Nursing and Allied Health Literature), PsycINFO/Ovid, ProQuest, and PubMed databases. The Joanna Briggs' Institute (JBI) critical appraisal tools were used to evaluate the quality of evidence, and inductive thematic analysis used to extract main themes. Four themes regarding 'barriers', 'enablers', 'treatment', and 'benefits' emerged amongst the 11 eligible articles. The negative symptomology was a barrier to occupational participation, and people with BPD engaged in self-stigmatizing and non-disclosure. However, the positive symptomology such as boldness and honesty were enablers. Treatment was found to be a key element, and occupational engagement was also found to have positive effectives. The evidence indicates that employment improved the symptoms, and a long-term treatment plan is a key element. Some upskilling of mental health workers may be required, including a focus on possible positive symptomology as a way of dealing with the stigmatization. Some awareness raising of the disorder, including for employers, may be needed, with education programmes that deal with the stigmatization. Future funding should focus on specialized programmes targeting unemployment for this group.

Crisis interventions for adults with borderline personality disorder

BACKGROUND

People diagnosed with borderline personality disorder (BPD) frequently present to healthcare services in crisis, often with suicidal thoughts or actions. Despite this, little is known about what constitutes effective management of acute crises in this population and what type of interventions are helpful at times of crisis. In this review, we will examine the efficacy of crisis interventions, defined as an immediate response by one or more individuals to the acute distress experienced by another individual, designed to ensure safety and recovery and lasting no longer than one month. This review is an update of a previous Cochrane Review examining the evidence for the effects of crisis interventions in adults diagnosed with BPD.

OBJECTIVES

To assess the effects of crisis interventions in adults diagnosed with BPD in any setting.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, nine other databases and three trials registers up to January 2022. We also checked reference lists, handsearched relevant journal archives and contacted experts in the field to identify any unpublished or ongoing studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing crisis interventions with usual care, no intervention or waiting list, in adults of any age diagnosed with BPD.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included two studies with 213 participants. One study (88 participants) was a feasibility RCT conducted in the UK that examined the effects of joint crisis plans (JCPs) plus treatment as usual (TAU) compared to TAU alone in people diagnosed with BPD. The primary outcome was self-harm. Participants had an average age of 36 years, and 81% were women. Government research councils funded the study. Risk of bias was unclear for blinding, but low in the other domains assessed. Evidence from this study suggested that there may be no difference between JCPs and TAU on deaths (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.06 to 14.14; 88 participants; low-certainty evidence); mean number of self-harm episodes (mean difference (MD) 0.30, 95% CI -36.27 to 36.87; 72 participants; low-certainty evidence), number of inpatient mental health nights (MD 1.80, 95% CI -5.06 to 8.66; 73 participants; low-certainty evidence), or quality of life measured using the EuroQol five-dimension questionnaire (EQ-5D; MD -6.10, 95% CI -15.52 to 3.32; 72 participants; very low-certainty evidence). The study authors calculated an Incremental Cost Effectiveness Ratio of GBP -32,358 per quality-adjusted life year (QALY), favouring JCPs, but they described this result as "hypothesis-generating only" and we rated this as very low-certainty evidence.  The other study (125 participants) was an RCT conducted in Sweden of brief admission to psychiatric hospital by self-referral (BA) compared to TAU, in people with self-harm or suicidal behaviour and three or more diagnostic criteria for BPD. The primary outcome was use of inpatient mental health services. Participants had an average age of 32 years, and 85% were women. Government research councils and non-profit foundations funded the study. Risk of bias was unclear for blinding and baseline imbalances, but low in the other domains assessed. The evidence suggested that there is no clear difference between BA and TAU on deaths (RR 0.49, 95% CI 0.05 to 5.29; 125 participants; low-certainty evidence), mean number of self-harm episodes (MD -0.03, 95% CI -2.26 to 2.20; 125 participants; low-certainty evidence), violence perpetration (RR 2.95, 95% CI 0.12 to 71.13; 125 participants; low-certainty evidence), or days of inpatient mental health care (MD 0.70, 95% CI -14.32 to 15.72; 125 participants; low-certainty evidence). The study suggested that BA may have little or no effect on the mean number of suicide attempts (MD 0.00, 95% CI -0.06 to 0.06; 125 participants; very low-certainty evidence). We also identified three ongoing RCTs that met our inclusion criteria. The results will be incorporated into future updates of this review.

AUTHORS' CONCLUSIONS

A comprehensive search of the literature revealed very little RCT-based evidence to inform the management of acute crises in people diagnosed with BPD. We included two studies of two very different types of intervention (JCP and BA). We found no clear evidence of a benefit over TAU in any of our main outcomes. We are very uncertain about the true effects of either intervention, as the evidence was judged low- and very low-certainty, and there was only a single study of each intervention. There is an urgent need for high-quality, large-scale, adequately powered RCTs on crisis interventions for people diagnosed with BPD, in addition to development of new crisis interventions.

A DSM-5 AMPD and ICD-11 compatible measure for an early identification of personality disorders in adolescence–LoPF-Q 12–18 latent structure and short form

The LoPF-Q 12–18 (Levels of Personality Functioning Questionnaire) was designed for clinical use and to promote early detection of personality disorder (PD). It is a self-report measure with 97 items to assess personality functioning in adolescents from 12 years up. It operationalizes the dimensional concept of personality disorder (PD) severity used in the Alternative DSM-5 Model for Personality Disorders and the ICD-11. In this study, we investigated the factorial structure of the LoPF-Q 12–18. Additionally, a short version was developed to meet the need of efficient screening for PD in clinical and research applications. To investigate the factorial structure, several confirmatory factor analysis models were compared. A bifactor model with a strong general factor and four specific factors showed the best nominal fit (CFI = .91, RMSEA = .04, SRMR = .07). The short version was derived using the ant colony optimization algorithm. This procedure resulted in a 20-item version with excellent fit for a hierarchical model with four first order factors to represent the domains and a secondary higher order factor to represent personality functioning (CFI = .98, RMSEA = .05, SRMR = .04). Clinical validity (effect size d = 3.1 between PD patients and controls) and clinical utility (cutoff ≥ 36 providing 87.5% specificity and 80.2% sensitivity) for detecting patients with PD were high for the short version. Both, the long and short LoPF-Q 12–18 version are ready to be used for research and diagnostic purposes.

Current state of the evidence on community treatments for people with complex emotional needs: a scoping review

BACKGROUND

Improving the quality of care in community settings for people with 'Complex Emotional Needs' (CEN-our preferred working term for services for people with a "personality disorder" diagnosis or comparable needs) is recognised internationally as a priority. Plans to improve care should be rooted as far as possible in evidence. We aimed to take stock of the current state of such evidence, and identify significant gaps through a scoping review of published investigations of outcomes of community-based psychosocial interventions designed for CEN.

METHODS

We conducted a scoping review with systematic searches. We searched six bibliographic databases, including forward and backward citation searching, and reference searching of relevant systematic reviews. We included studies using quantitative methods to test for effects on any clinical, social, and functioning outcomes from community-based interventions for people with CEN. The final search was conducted in November 2020.

RESULTS

We included 226 papers in all (210 studies). Little relevant literature was published before 2000. Since then, publications per year and sample sizes have gradually increased, but most studies are relatively small, including many pilot or uncontrolled studies. Most studies focus on symptom and self-harm outcomes of various forms of specialist psychotherapy: most result in outcomes better than from inactive controls and similar to other specialist psychotherapies. We found large evidence gaps. Adaptation and testing of therapies for significant groups (e.g. people with comorbid psychosis, bipolar disorder, post-traumatic stress disorder, or substance misuse; older and younger groups; parents) have for the most part only reached a feasibility testing stage. We found little evidence regarding interventions to improve social aspects of people's lives, peer support, or ways of designing effective services.

CONCLUSIONS

Compared with other longer term mental health problems that significantly impair functioning, the evidence base on how to provide high quality care for people with CEN is very limited. There is good evidence that people with CEN can be helped when specialist therapies are available and when they are able to engage with them. However, a much more methodologically robust and substantial literature addressing a much wider range of research questions is urgently needed to optimise treatment and support across this group.

The Use of Computer-Driven Technologies in the Treatment of Borderline Personality Disorder: A Systematic Review

The objective of this study was to perform a systematic review of the effectiveness of computer-driven technologies for treatment of patients suffering from BPD. A systematic literature review was conducted using the Pubmed, EMBASE, PsycNET (PsycINFO), CINAHL and Google Scholar electronic databases for the period from their inception dates until 2022. Thirty studies were selected for abstract screening. Seven studies were excluded for not meeting inclusion criteria. The remaining 23 studies were fully assessed, and 12 were excluded. Therefore, 11 studies were included in the analysis of the effectiveness of computer-driven technologies, which encompassed mobile applications, telehealth interventions, internet-based interventions, virtual reality MBT and dialogue-based integrated interventions. Computer-driven interventions are showing signs of effectiveness in the treatment of BPD symptoms. The limited number of articles found on the subject demonstrates a need for further exploration of this subject.

Improving treatment outcomes for adolescents with borderline personality disorder through a socioecological approach

BACKGROUND

There is a dearth of studies evaluating treatment efficacy for adolescents diagnosed with borderline personality disorder. The few available randomized controlled trials that have been conducted show modest results and treatments appear to have equivalent effects. The current paper draws on (a) the lessons learnt from the last 50 years of psychotherapy research in general and (b) recent advances in mentalization-based understanding of why treatment works, which together point to the importance of following a socioecological approach in the treatment of personality problems in adolescence - a developmental period that insists on a treatment approach that goes beyond the therapist-client dyad.

CASE PRESENTATION

Here, we describe such an approach, and offer a clinical case example with a young 16-year old girl diagnosed with borderline personality disorder, to illustrate what a shift toward a more socioecological approach would entail.

CONCLUSIONS

The clinical impact of the socioecological approach and the potential benefits as illustrated in the current case illustration, offers a framework that justifies and allows for the expansion of service delivery for youth with borderline personality disorder beyond dyadic therapist-client work.

Efficacy and tolerability of Brain Stimulation interventions in Borderline Personality Disorder: state of the art and future perspectives - A systematic review

Treating Borderline Personality Disorder (BPD) is a major challenge for psychiatrists. As Brain Stimulation represents an alternative approach to treat psychiatric disorders, our systematic review is the first to focus on both invasive and Non-Invasive Brain Stimulation (NIBS) interventions in people living with BPD, examining clinical effects over core features and comorbid conditions. Following PRISMA guidelines, out of 422 original records, 24 papers were included regarding Deep Brain Stimulation (n = 1), Electroconvulsive therapy (n = 5), Transcranial Magnetic Stimulation (n = 13) and transcranial Direct Current Stimulation (n = 5). According to impulsivity and emotional dysregulated domain improvements, NIBS in BPD appears to restore frontolimbic network deficiencies. NIBS seems also to modulate depressive features. Safety and tolerability profiles for each technique are discussed. Despite encouraging results, definitive recommendations on Brain Stimulation in BPD are mitigated by protocols heterogeneity, lack of randomized controlled trials and poor quality of included studies, including high risk of methodological biases. To serve as guide for future systematic investigations, protocols optimization proposals are provided, focusing on alternative stimulation sites and suggesting a NIBS symptom-based approach.

Welfare consequences of early-onset Borderline Personality Disorder: a nationwide register-based case-control study

Information regarding welfare consequences of early onset of Borderline Personality Disorder (BPD) is limited. This nationwide study aimed to estimate the educational and employment outcome and health care costs of patients with early-onset BPD compared with matched controls. All patients (< 19 years) with first diagnosis of BPD in the Danish Patient Register (NPR) during the period 1983-2015 were included. Health care costs and socioeconomic variables were extracted from national registers. A total of 171 patients was compared with 677 controls. At the age of 20 years, BPD patients had reached a statistically significantly lower educational level (including lower primary school grades) and employment status compared with the controls. When adjusting for the parents' educational level, BPD patients were nearly 22 times more likely to be unemployed (OR = 21.7, 95% CI 11.9, 39.6), and nearly 15 times more likely to be on disability pension (OR = 14.8, 95% CI 5.0, 43.9) than controls. Furthermore, the total health care costs were more than 8 times higher in the BPD group. Early onset of BPD was associated with lower educational and vocational outcome and increased health care costs as early as at the age of 20 years. Even after controlling for parents' lower socioeconomic status, the patients have poorer outcome than the control group. This underlines that initiatives to support patients in finishing school and secondary education is highly needed. Future prevention and early intervention programs should target patients with early-onset BPD and their families.

The societal cost of treatment-seeking patients with borderline personality disorder in Germany

According to previous research, borderline personality disorder (BPD) is associated with high cost-of-illness. However, there is still a shortage of cost-of-illness-studies assessing costs from a broad societal perspective, including direct and indirect costs. Further, there are considerable differences in the results among the existing studies. In the present study, 167 German men and women seeking specialized outpatient treatment for BPD were included. We assessed societal cost-of-illness bottom-up through structured face-to-face interviews and encompassed a wide range of cost components. All costs were calculated for the 2015 price level. Cost-of-illness amounted to € 31,130 per patient and year preceding disorder-specific outpatient treatment. € 17,044 (54.8%) were direct costs that were mostly related to hospital treatment. Indirect costs amounted to € 14,086 (45.2%). Within indirect costs, costs related to work disability were the most crucial cost driver. The present study underlines the tremendous economic burden of BPD. According to the present study, both the direct and indirect costs are of significant importance for the societal costs associated with BPD. Besides the need for more disorder-specific treatment facilities for men and women with BPD, we assume that education and employment are topics that should be specifically targeted and individually supported at an early stage of treatment.Trial Registration: German Clinical Trial Registration, DRKS00011534, Date of Registration: 11/01/2017, retrospectively registered.

Utilization of Health Care Services by Patients With Cluster B Personality Disorders or Schizophrenia

OBJECTIVE

The comparable severities of cluster B personality disorders and schizophrenia are increasingly recognized. The authors sought to compare the general medical and psychiatric comorbid conditions and use of medical services among individuals with one or both of these disorders.

METHODS

Data were collected from the linked health administrative databases of Quebec's universal health plan in the Quebec Integrated Chronic Disease Surveillance System, which covers 99% of Quebec's population. The study cohort of 2016-2017 included almost 7.05 million people, and the study covered the 1996-2017 period.

RESULTS

Comorbid conditions were extremely prevalent in the three groups studied-persons with cluster B personality disorders, schizophrenia, or both-compared with the general population. People having both disorders had the highest prevalence of comorbid conditions. Psychiatric services were used more frequently by individuals in all three groups than among those in the general population, and use was especially high among people with both disorders. Medical care service use was heterogeneous, with patients with cluster B personality disorders using more medical care services but fewer specialized outpatient treatments and psychotherapy than those with schizophrenia or with both disorders.

CONCLUSIONS

The three cohorts had higher rates of comorbid conditions and health care service use than individuals in the general population. Patients with cluster B personality disorders used fewer psychiatric services than patients with schizophrenia or with both disorders. One explanation for this difference may be that people with cluster B personality disorders encounter more obstacles in accessing mental health care services.

A double-blind placebo-controlled study of brexpiprazole for the treatment of borderline personality disorder

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.

Effectiveness and safety of the adjunctive use of an internet-based self-management intervention for borderline personality disorder in addition to care as usual: results from a randomised controlled trial

IMPORTANCE

Borderline personality disorder (BPD) is a severe mental disorder that is often inadequately treated.

OBJECTIVE

To determine if adding a self-management intervention to care as usual (CAU) is effective and safe.

DESIGN

Randomised, controlled, rater-blind trial. Duration of treatment and assessments: 12 months.

SETTING

Secondary care, recruited mainly via the internet.

PARTICIPANTS

Patients with BPD and BPD Severity Index (BPDSI) of at least 15.

INTERVENTIONS

CAU by treating psychiatrist and/or psychotherapist alone or adjunctive use of an internet-based self-management intervention that is based on schema therapy (priovi).

MAIN OUTCOME MEASURE

Outcomes were assessed by trained raters. The primary outcome was change in BPDSI. The safety outcome was the number of serious adverse events (SAEs). The primary outcome time point was 12 months after randomisation.

RESULTS

Of 383 participants assessed for eligibility, 204 were included (91.7% female, mean age: 32.4 years; 74% were in psychotherapy and 26% were in psychiatric treatment). The slope of BPDSI change did not differ significantly between groups from baseline to 12 months (F_3,248= 1.857, p=0.14). At 12 months, the within-group effect sizes were d=1.38 (95% CI 1.07 to 1.68) for the intervention group and d=1.02 (95% CI 0.73 to 1.31) for the control group. The between-group effect size was d=0.27 (95% CI 0.00 to 0.55) in the intention-to-treat sample and d=0.39 (95% CI 0.09 to 0.68) for those who used the intervention for at least 3 hours (per-protocol sample). We found no significant differences in SAEs.

CONCLUSIONS

We have not found a significant effect in favour of the intervention. This might be due to the unexpectedly large effect in the group receiving CAU by a psychiatrist and/or psychotherapist alone.

TRIAL REGISTRATION

NCT03418142.

Burden and Treatment Satisfaction among Caregivers of Adolescents with Borderline Personality Disorder

Despite the fact that family involvement is encouraged in early interventions for borderline personality disorder (BPD), there is a limited knowledge on the experience of caring for adolescents with BPD. This is an exploratory retrospective study nested within a randomized controlled trial that compared mentalization-based treatment (MBT) in groups to treatment as usual for adolescents with BPD. Caregivers received six MBT-Parents sessions or standard care over one year. Three months after end of treatment (EOT), 75 caregivers (35 in MBT, 40 in TAU) filled out the Burden Assessment Scale, and 71 (34 in MBT, 37 in TAU) the Family Satisfaction Survey. The adolescents filled out the Borderline Personality Features Scale for Children at baseline and after twelve months at EOT. We tested whether caregiver demographics, adolescents' severity of BPD, treatment and adolescents' dropout from treatment predicted levels of caregiver burden and satisfaction with treatment. The caregivers reported high levels of burden on the BAS (M = 40.3, SD = 12.2). Our study suggests that higher BPD severity at EOT among the adolescents predicted caregiver burden (p = .03), whereas higher baseline BPD severity predicted satisfaction with treatment (p = .04) and that biological mothers could be more burdened than other types of caregivers but also might be more satisfied with treatment. Treatment and adolescents' dropout from treatment were not related to caregiver burden or satisfaction with treatment. To help inform future research and to devise appropriate interventions for caregivers and adolescents with BPD, it is important to identify possible predictors of caregiver burden. The results of this initial exploratory study indicate that caregivers (and particularly biological mothers) of adolescents with more severe levels of BPD could be particularly vulnerable toward feelings of burden and therefore are in need of support.

Validation of a French Translation of the McLean Screening Instrument for Borderline Personality Disorder, Invariance Across Genders, and Association With Depression, Trauma Symptoms, and Substance Use Among University Students

The present study investigated psychometric properties of a French translation of the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD; Zanarini et al., 2003) in a large sample of university students (N = 1,350). A confirmatory factor analysis supported the single-factor structure of the MSI-BPD, and its configural, metric and scalar invariance across gender was established. Internal consistency was high (tetrachoric α = .88; Ω = .88). MSI-BPD scores were significantly correlated to depressive symptoms (r = .57), trauma symptoms (r = .40), negative consequences of substance use (r = .25), and frequency of drug use (r = .11). Finally, 9.5% of the sample reached the clinical cutoff, which is similar to the pooled prevalence for BPD reported in a recent meta-analysis of university students. The present study showed that the French translation of the MSI-BPD is a psychometrically sound screening tool for BPD in both men and women.

Costs of schizotypal disorder: A matched-controlled nationwide register-based study of patients and spouses

OBJECTIVE

Information on societal cost of patients with schizotypal disorder is limited. The aim was to investigate the societal costs of schizotypal disorder before and after initial diagnosis including both patients and their spouses.

METHODS

A register-based cohort study of 762 patients with incident schizotypal disorder (ICD-10; F21) including their spouses and 3048 matched controls, during 2002 to 2016. Total healthcare costs, home care costs, and costs of lost productivity of patients and spouses were included in the analysis.

RESULTS

Total costs amounted €47,215 per year for patients with schizotypal disorder, which was fifteen times higher than the matched controls. Of these, 41% were healthcare and home care costs and 59% were costs of lost productivity. Healthcare costs and costs of lost productivity were increased during five years before initial diagnosis of schizotypal disorder. Total costs of spouses to patients were €21,384 compared with € 2519 among spouses of controls. 75% of the total costs of spouses to patients were related to lost productivity. The total costs were higher than the costs of borderline personality disorder, but on the same level as the costs of schizophrenia identified in earlier comparable studies.

CONCLUSIONS

The total societal costs of patients with schizotypal disorder drawn from national registers differed substantially from the controls representing the general population. As evidence-based recommendations for diagnoses and treatment of patients with schizotypal disorder do not exist, future research should focus on developing effective treatment for this group of patients to reduce cost of illness.

Individual participant data systematic reviews with meta-analyses of psychotherapies for borderline personality disorder

INTRODUCTION

The heterogeneity in people with borderline personality disorder (BPD) and the range of specialised psychotherapies means that people with certain BPD characteristics might benefit more or less from different types of psychotherapy. Identifying moderating characteristics of individuals is a key to refine and tailor standard treatments so they match the specificities of the individual participant. The objective of this is to improve the quality of care and the individual outcomes. We will do so by performing three systematic reviews with meta-analyses of individual participant data (IPD). The aim of these reviews is to investigate potential predictors and moderating patient characteristics on treatment outcomes for patients with BPD.

METHODS AND ANALYSIS

We performed comprehensive searches in 22 databases and trial registries up to October 6th 2020. These will be updated with a top-up search up until June 2021. Our primary meta-analytic method will be the one-stage random-effects approach. To identify predictors, we will use the one-stage model that accounts for interaction between covariates and treatment allocation. Heterogeneity in case-mix will be assessed with a membership model based on a multinomial logistic regression where study membership is the outcome. A random-effects meta-analysis is chosen to account for expected levels of heterogeneity.

ETHICS AND DISSEMINATION

The statistical analyses will be conducted on anonymised data that have already been approved by the respective ethical committees that originally assessed the included trials. The three IPD reviews will be published in high-impact factor journals and their results will be presented at international conferences and national seminars.

PROSPERO REGISTRATION NUMBER

CRD42021210688.

[Disease burden of borderline personality disorder: cost of illness, somatic comorbidity and mortality]

BACKGROUND

Severe mental illnesses (SMI) are characterized by high psychosocial impairment as well as by increased somatic morbidity and mortality. The term SMI commonly includes psychotic, bipolar and severe unipolar depressive disorders but borderline personality disorder (BPD) also shows severe sequelae of the disease.

MATERIAL AND METHODS

Published reviews and studies since 2010 examining disease burden of BPD, in terms of direct and indirect costs of illness, somatic comorbidity, and mortality were included. Furthermore, administrative data (clinically recorded billing data in Germany), comorbidity and mortality from a comprehensive analysis (n > 59 million, age ≥ 18 years) are reported.

RESULTS

International studies reveal an increased disease burden, comorbidity, and mortality for BPD. In Germany BPD (administrative 1‑year prevalence 0.34%) is associated with increased rates of somatic sequelae of trauma, hepatitis, HIV, COPD, asthma, and obesity. The estimated reduced life expectancy is 5.0-9.3 years of life lost (depending on age and sex).

DISCUSSION

The burden of disease in BPD is clearly increased (cost of illness, somatic comorbidity and mortality). The increased mortality can mainly be explained by deaths as a consequence of poor physical health and associated BPD-related health behavior and only to a lesser degree by suicide. These results highlight the importance of classifying BPD as an SMI and the necessity to provide not only psychotherapeutic and psychiatric but also adequate somatic prevention and treatment. Individual improvement of everyday care as well as establishing new interdisciplinary and multiprofessional services could enhance health equality for people with BPD.

A Day in the Life of Borderline Personality Disorder: A Preliminary Analysis of Within-Day Emotion Generation and Regulation

In Linehan's (1993) biosocial theory, borderline personality disorder (BPD) results in part from frequent, intense, negative emotions and maladaptive behavioral responses to those emotions. We conducted a secondary data analysis of an intensive single-case experimental design to explore hourly relations among behavioral responses and emotions in BPD. Eight participants with BPD (M _age = 21.57, 63% female; 63% Asian) reported their emotions and behaviors hourly on two days. Participants reported a neutral-to-negative average emotional state with substantial variability each day. This emotional state was characterized most frequently by anxiety and joy. Participants tended to "dig into", or savor, experiences of joy, but problem-solve around, push away, or accept anxiety. Acceptance predicted hour-by-hour increases in negative emotion intensity, and pushing emotions away predicted hour-by-hour increases in positive emotion intensity. These results suggest that anxiety dominates the emotional experiences of people with BPD and co-occurs with a variety of emotion regulation strategies, while joy co-occurs with strategies designed to prolong emotional experiences. Despite its general adaptiveness, acceptance may be less effective, and pushing emotions away may be more effective, than other emotion regulation strategies at improving momentary negative emotions for those with BPD. We discuss the preliminary nature of these findings and encourage future researchers to build on them in larger samples with more severe presentations of BPD.

Five failures and five challenges for prevention and early intervention for personality disorder

Despite global consensus regarding the early detection of personality disorder, current approaches to early intervention have failed to deliver for the majority of young people. This only serves to reinforce the enduring effects of personality disorder on functioning, mental and physical health, resulting in a reduction of quality of life and life expectancy. Here, we describe five significant challenges facing prevention and early intervention for personality disorder: identification, access to treatment, research translation, innovation and functional recovery. These challenges highlight the need for early intervention to shift from niche programmes in specialist services for a select few young people to become established in mainstream primary care and specialist youth mental health services.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

REGISTRATION

PROSPERO registration number, CRD42020194098.

Adolescent depression, early psychiatric comorbidities, and adulthood welfare burden: a 25-year longitudinal cohort study

PURPOSE

Depression at all ages is recognized as a global public health concern, but less is known about the welfare burden following early-life depression. This study aimed to (1) estimate the magnitude of associations between depression in adolescence and social transfer payments in adulthood; and (2) address the impact of major comorbid psychopathology on these associations.

METHODS

This is a longitudinal cohort study of 539 participants assessed at age 16-17 using structured diagnostic interviews. An ongoing 25-year follow-up linked the cohort (n = 321 depressed; n = 218 nondepressed) to nationwide population-based registries. Outcomes included consecutive annual data on social transfer payments due to unemployment, work disability, and public assistance, spanning from age 18 to 40. Parameter estimations used the generalized estimating equations approach.

RESULTS

Adolescent depression was associated with all forms of social transfer payments. The estimated overall payment per person and year was 938 USD (95% CI 551-1326) over and above the amount received by nondepressed controls. Persistent depressive disorder was associated with higher recipiency across all outcomes, whereas the pattern of findings was less clear for subthreshold and episodic major depression. Moreover, depressed adolescents presenting with comorbid anxiety and disruptive behavior disorders evidenced particularly high recipiency, exceeding the nondepressed controls with an estimated 1753 USD (95% CI 887-2620).

CONCLUSION

Adolescent depression is associated with considerable public expenditures across early-to-middle adulthood, especially for those exposed to chronic/persistent depression and psychiatric comorbidities. This finding suggests that the clinical heterogeneity of early-life depression needs to be considered from a longer-term societal perspective.

Therapeutic Relationship in eHealth-A Pilot Study of Similarities and Differences between the Online Program Priovi and Therapists Treating Borderline Personality Disorder

eHealth programs have been found to be effective in treating many psychological conditions. Regarding Borderline Personality Disorder (BPD), few programs have been tested; nevertheless, results are promising. The therapeutic alliance is an important factor predicting treatment outcome in BPD. However, we do not know yet to what extent BPD patients form a therapeutic alliance with an eHealth tool and how this relationship differs from the relationship with their human therapist. This study aims to address this question using priovi, an interactive schema therapy-based eHealth tool for BPD. Semi-structured interviews were conducted to explore how patients perceived the therapeutic alliance with priovi and its differences compared to the alliance with their human therapist (N = 9). Interview data were analyzed following the procedures of qualitative content analysis. Additionally, the Working Alliance Inventory (WAI-SR) was administered in two versions (regarding the human therapist and priovi, N = 16) every three months during the treatment phase of one year. Results indicate that patients were able to form a good therapeutic relationship with priovi, but it differed from the relationship to their human therapist. Important categories were “priovi is helpful, supportive and always there” and “priovi is less flexible”. WAI ratings for the task subscale were high in both relationships but significantly higher in WAI_therapist compared to WAI_priovi in two measurements (nine-months measurement: t = 2.76, df = 15, p = 0.015; twelve-months measurement: t = 3.44, df = 15, p = 0.004). These results indicate that BPD patients can form a functioning alliance with an eHealth program and that eHealth programs may be especially useful for psychoeducation and cognitive exercises.

Long non-coding RNA MALAT1 targeting STING transcription promotes bronchopulmonary dysplasia through regulation of CREB

Bronchopulmonary dysplasia (BPD) is a severe complication of preterm infants characterized by increased alveolarization and inflammation. Premature exposure to hyperoxia is believed to be a key contributor to the pathogenesis of BPD. No effective preventive or therapeutic agents have been created. Stimulator of interferon gene (STING) is associated with inflammation and apoptosis in various lung diseases. Long non-coding RNA MALAT1 has been reported to be involved in BPD. However, how MALAT1 regulates STING expression remains unknown. In this study, we assessed that STING and MALAT1 were up-regulated in the lung tissue from BPD neonates, hyperoxia-based rat models and lung epithelial cell lines. Then, using the flow cytometry and cell proliferation assay, we found that down-regulating of STING or MALAT1 inhibited the apoptosis and promoted the proliferation of hyperoxia-treated cells. Subsequently, qRT-PCR, Western blotting and dual-luciferase reporter assays showed that suppressing MALAT1 decreased the expression and promoter activity of STING. Moreover, transcription factor CREB showed its regulatory role in the transcription of STING via a chromatin immunoprecipitation. In conclusion, MALAT1 interacts with CREB to regulate STING transcription in BPD neonates. STING, CREB and MALAT1 may be promising therapeutic targets in the prevention and treatment of BPD.

Welfare consequences for people diagnosed with attention deficit hyperactivity disorder (ADHD): A matched nationwide study in Denmark

There is insufficient data regarding the excess direct and indirect costs associated with attention deficit hyperactivity disorder (ADHD). Using the Danish National Patient Registry (2002-2016), we identified 83,613 people of any age with a diagnosis of ADHD or who were using central-acting medication against ADHD (primarily methylphenidate, with at least two prescriptions) and matched them to 334,446 control individuals. Additionally, 18,959 partners of patients aged ≥18 years with ADHD were identified, and compared with 74,032 control partners. Direct costs were based on data from the Danish Ministry of Health. Information about the use and costs of drugs were obtained from the Danish Medicines Agency. The frequencies of visits and hospitalizations, and costs of general practice were derived from data from the National Health Security. Indirect costs were obtained from Coherent Social Statistics. The average annual health care costs for people with ADHD and their partners were, respectively, €2636 and €477 higher than those of the matched controls. A greater percentage of people with ADHD and their partners compared with respective control subjects received social services (sick pay or disability pension). Those with ADHD had a lower income from employment than did controls for equivalent periods up to five years before the first diagnosis of ADHD. The additional direct and indirect annual costs (for those aged ≥18 years) including transfers of ADHD compared with controls were €23,072 for people with ADHD and €7,997 for their partners. ADHD has substantial socioeconomic consequences for individual patients, their partners and society.

Psychological therapies for people with borderline personality disorder

BACKGROUND

Over the decades, a variety of psychological interventions for borderline personality disorder (BPD) have been developed. This review updates and replaces an earlier review (Stoffers-Winterling 2012).

OBJECTIVES

To assess the beneficial and harmful effects of psychological therapies for people with BPD.

SEARCH METHODS

In March 2019, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication.

SELECTION CRITERIA

Randomised controlled trials comparing different psychotherapeutic interventions with treatment-as-usual (TAU; which included various kinds of psychotherapy), waiting list, no treatment or active treatments in samples of all ages, in any setting, with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. There were 11 secondary outcomes, including individual BPD symptoms, as well as attrition and adverse effects.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's 'Risk of bias' tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis.

MAIN RESULTS

We included 75 randomised controlled trials (4507 participants), predominantly involving females with mean ages ranging from 14.8 to 45.7 years. More than 16 different kinds of psychotherapy were included, mostly dialectical behaviour therapy (DBT) and mentalisation-based treatment (MBT). The comparator interventions included treatment-as-usual (TAU), waiting list, and other active treatments. Treatment duration ranged from one to 36 months. Psychotherapy versus TAU Psychotherapy reduced BPD symptom severity, compared to TAU; standardised mean difference (SMD) -0.52, 95% confidence interval (CI) -0.70 to -0.33; 22 trials, 1244 participants; moderate-quality evidence. This corresponds to a mean difference (MD) of -3.6 (95% CI -4.4 to -2.08) on the Zanarini Rating Scale for BPD (range 0 to 36), a clinically relevant reduction in BPD symptom severity (minimal clinical relevant difference (MIREDIF) on this scale is -3.0 points). Psychotherapy may be more effective at reducing self-harm compared to TAU (SMD -0.32, 95% CI -0.49 to -0.14; 13 trials, 616 participants; low-quality evidence), corresponding to a MD of -0.82 (95% CI -1.25 to 0.35) on the Deliberate Self-Harm Inventory Scale (range 0 to 34). The MIREDIF of -1.25 points was not reached. Suicide-related outcomes improved compared to TAU (SMD -0.34, 95% CI -0.57 to -0.11; 13 trials, 666 participants; low-quality evidence), corresponding to a MD of -0.11 (95% CI -0.19 to -0.034) on the Suicidal Attempt Self Injury Interview. The MIREDIF of -0.17 points was not reached. Compared to TAU, psychotherapy may result in an improvement in psychosocial functioning (SMD -0.45, 95% CI -0.68 to -0.22; 22 trials, 1314 participants; low-quality evidence), corresponding to a MD of -2.8 (95% CI -4.25 to -1.38), on the Global Assessment of Functioning Scale (range 0 to 100). The MIREDIF of -4.0 points was not reached. Our additional Trial Sequential Analysis on all primary outcomes reaching significance found that the required information size was reached in all cases. A subgroup analysis comparing the different types of psychotherapy compared to TAU showed no clear evidence of a difference for BPD severity and psychosocial functioning. Psychotherapy may reduce depressive symptoms compared to TAU but the evidence is very uncertain (SMD -0.39, 95% CI -0.61 to -0.17; 22 trials, 1568 participants; very low-quality evidence), corresponding to a MD of -2.45 points on the Hamilton Depression Scale (range 0 to 50). The MIREDIF of -3.0 points was not reached. BPD-specific psychotherapy did not reduce attrition compared with TAU. Adverse effects were unclear due to too few data. Psychotherapy versus waiting list or no treatment Greater improvements in BPD symptom severity (SMD -0.49, 95% CI -0.93 to -0.05; 3 trials, 161 participants), psychosocial functioning (SMD -0.56, 95% CI -1.01 to -0.11; 5 trials, 219 participants), and depression (SMD -1.28, 95% CI -2.21 to -0.34, 6 trials, 239 participants) were observed in participants receiving psychotherapy versus waiting list or no treatment (all low-quality evidence). No evidence of a difference was found for self-harm and suicide-related outcomes. Individual treatment approaches DBT and MBT have the highest numbers of primary trials, with DBT as subject of one-third of all included trials, followed by MBT with seven RCTs. Compared to TAU, DBT was more effective at reducing BPD severity (SMD -0.60, 95% CI -1.05 to -0.14; 3 trials, 149 participants), self-harm (SMD -0.28, 95% CI -0.48 to -0.07; 7 trials, 376 participants) and improving psychosocial functioning (SMD -0.36, 95% CI -0.69 to -0.03; 6 trials, 225 participants). MBT appears to be more effective than TAU at reducing self-harm (RR 0.62, 95% CI 0.49 to 0.80; 3 trials, 252 participants), suicidality (RR 0.10, 95% CI 0.04, 0.30, 3 trials, 218 participants) and depression (SMD -0.58, 95% CI -1.22 to 0.05, 4 trials, 333 participants). All findings are based on low-quality evidence. For secondary outcomes see review text.

AUTHORS' CONCLUSIONS

Our assessments showed beneficial effects on all primary outcomes in favour of BPD-tailored psychotherapy compared with TAU. However, only the outcome of BPD severity reached the MIREDIF-defined cut-off for a clinically meaningful improvement. Subgroup analyses found no evidence of a difference in effect estimates between the different types of therapies (compared to TAU) . The pooled analysis of psychotherapy versus waiting list or no treatment found significant improvement on BPD severity, psychosocial functioning and depression at end of treatment, but these findings were based on low-quality evidence, and the true magnitude of these effects is uncertain. No clear evidence of difference was found for self-harm and suicide-related outcomes. However, compared to TAU, we observed effects in favour of DBT for BPD severity, self-harm and psychosocial functioning and, for MBT, on self-harm and suicidality at end of treatment, but these were all based on low-quality evidence. Therefore, we are unsure whether these effects would alter with the addition of more data.

Therapeutic interventions in Australian primary care, youth mental health settings for young people with borderline personality disorder or borderline traits

BACKGROUND

This study aimed to investigate what therapeutic interventions were being applied by clinicians working with young people with a diagnosis of Borderline Personality Disorder or borderline traits in Australian primary mental health care settings. Given the current lack of evidence-based guidelines for treatment with this client population, investigating what is being implemented is needed. The study also aimed to determine whether the interventions clinicians are using are effective in reducing distress and increasing functioning for these clients.

METHODS

Participant data came from the national minimum data set for headspace youth mental health centers across Australia. Young people's data were included in the study if the young person was diagnosed with Borderline Personality Disorder or borderline traits during their first episode of care (N = 701). Clinician data that indicated the type of intervention used at each client session and outcome measures routinely captured were analyzed to determine interventions used and outcomes achieved.

RESULTS

Results demonstrated that CBT was the most frequently used modality of intervention followed by supportive counselling and IPT, but that most clients received a variety of intervention types. There were no or only weak relationships between changes in outcomes and the amount of any type of intervention that was provided. No significant relationship was found with the amount of CBT a client received and changes in symptoms or functioning, despite being the most commonly employed modality.

CONCLUSIONS

The study highlights the need for evidence-based treatment guidelines for early intervention in young people with borderline personality disorder traits.