Borderline personality disorder: ontogeny of a diagnosis

Stubborn Families: Logics of Care of a Family Member with Borderline Personality Disorder

This study conducted in-depth, largely unstructured interviews with 31 involved family members in a metropolitan area of the United States (US) Midwest on their experiences of BPD in a close relative. Narrative analysis employing concepts from anthropology (the logic of care and family assemblage) was used to examine the nature and quality of care practices and identify human, environmental, and cultural supports needed for family recovery. Findings indicate that these US family caregivers provided intensive and extensive care over the long term. They acted in situations of risk to their relative, and often disconnected from professional support. Parents labored under unforgiving normalizations: judgments (real or perceived) of not properly raising or "launching" their children and norms of parental self-sacrifice. The dearth of housing options for the young person hindered recovery. While duly recognizing the care practices provided by family members for a relative with BPD, I argue that there is a significant omission. Our conceptualizing of supports for family members of a relative with BPD needs to encompass supports for their own recovery. Respite, mental health care for caregivers, housing, support groups, and collaborative care (with professionals, peers and family members) could productively assist recovery of all family members.

Childhood maltreatment and subsequent offending behaviors in Australian women: Exploring the role of borderline personality disorder

BACKGROUND

Childhood Maltreatment (CM) is linked to adverse outcomes, including Borderline Personality Disorder (BPD) and increased propensity for offending behaviors. However, research on the specific role that BPD plays between the two is limited and highly relevant given the high prevalence of CM in Australia.

OBJECTIVE

The present study aimed to investigate (1) the relationship between CM and subsequent offending behaviors, (2) whether BPD mediates the relation between CM and offending behaviors, and (3) which type of CM (physical, sexual, emotional abuse, neglect, exposure to domestic violence, multitype maltreatment) predicts BPD.

PARTICIPANTS

The sample comprised 106 self-identified Australian female survivors of interpersonal violent crimes.

METHODS

Participants completed an online survey consisting of the Adverse Childhood Events Questionnaire, the McLean Screening Instrument for BPD, and a self-created questionnaire to measure offending behaviors. Regression, mediation analysis, and logistic regression were conducted.

RESULTS

CM significantly predicted offending behaviors (path c, B = 1.39, p <. 001) with BPD partially mediating the relationship (path c', B = 1.04, 95 % CI [0.31, 1.77], p = .006; path a, B = 0.47, 95 % CI [0.12, 0.83], p = .009, path b, B = 0.34, 95 % CI [0.07, 0.61], p = .014). Emotional abuse and multitype exposure were identified as predictors of BPD symptom development (OR = 9.42, 95 % CI OR [2.58, 34.40]; OR = 3.81, 95 % CI OR [1.41; 10.28], respectively).

CONCLUSION

These findings indicate the necessity of early interventions addressing CM, with a particular focus on emotional abuse and exposure to more than one type of maltreatment, to reduce the risk of developing BPD symptomatology and mitigate future offending behaviors.

Borderline personality disorder and stigma: Lived experience perspectives on helpful and hurtful language

Borderline personality disorder (BPD) is a severe mental health disorder that is subject to significant stigmatisation. With language being a key reinforcer of stigma, this co-produced study aims to explore the language use regarding BPD and its effect on those with BPD and carers. Recommendations to reduce stigmatisation are provided for both clinicians and researchers. Participants with BPD (consumer n = 33) and those supporting someone with BPD (carer n = 30) discussed their experience of hurtful and helpful language. Reflexive thematic analysis was used to analyse written and verbal responses into core conflictual relationship themes (CCRT) reflecting how different words were heard and experienced. All consumers and carers in the study reported experiences with stigmatising language. Feelings of inadequacy and frustration were common amongst consumers, specifically when they perceived others as trivialising their needs or not seeing them as a unique individual. Carers often reported feelings of frustration when they perceived others as blaming them or not acknowledging their needs. Both consumers and carers reported helpful language as being connecting, validating and accepting. Unhelpful communication patterns have negative consequences for the person's self-understanding (i.e., self-stigma) and their relationships with others, including the therapeutic alliance. A consideration of these communication patterns may foster the use of reflective positive language that is compassionate and hopeful.

The course of borderline personality disorder from adolescence to early adulthood: A 5-year follow-up study

BACKGROUND

Studies of the medium- to long-term clinical and functional course for treatment-seeking adolescents with borderline personality disorder (BPD) are lacking. This study aims to outline the psychopathological and functional status of participants, five years after being diagnosed with BPD during adolescence.

METHODS

Participants were originally enrolled in a randomized clinical trial that compared mentalization-based group treatment with treatment as usual for adolescents with BPD. Semi-structured interview assessments at five-year follow-up included the Schedules for Clinical Assessment in Neuropsychiatry and the Structured Clinical Interview for DSM-5 Personality Disorders. Attention deficit hyperactivity disorder (ADHD), alcohol, substance and tobacco use, posttraumatic stress disorder (PTSD), complex PTSD, and general functioning were assessed using self-report instruments.

RESULTS

97 of the original sample of 111 participants (87%) participated. They were aged 19-23 years. The most prevalent disorders were ADHD (59%), any personality disorder (47%) of which half continued to meet criteria for BPD (24%), anxiety disorders (37%), depressive disorders (32%), PTSD or complex PTSD (20%), schizophrenia (16%), and eating disorders (13%). Only 16% did not meet criteria for any mental disorder. Approximately half of the sample were in psychological and/or psychopharmacological treatment at the time of follow-up. Their general functioning remained impaired, with 36% not engaged in education, employment or training (NEET), which is nearly four times the rate of NEET in the same age group in the general population.

CONCLUSIONS

Although stability of the categorical BPD diagnosis is modest, adolescents meeting diagnostic criteria for BPD show a broad range of poor outcomes at five-year follow-up. BPD appears to be a marker of general maladjustment during adolescence and a harbinger of severe problems during the transition to young adulthood. Early intervention programs for adolescents diagnosed with BPD should focus upon a broad range of functional and psychopathological outcomes, especially social and vocational support, rather than the narrow BPD diagnosis.

Evaluation of the level of training of French psychiatrists on borderline personality disorder: An online survey

BACKGROUND

Borderline personality disorder is a common and treatable personality disorder that is often underdiagnosed and untreated, mainly due to a lack of training of psychiatrists and to a lack of accessibility to specialized therapies. However, no study has been conducted in France regarding this issue. Thus, we aimed to evaluate on a national scale the level of training, knowledge, and general attitude toward BPD diagnosis of French psychiatrists.

METHODS

We conducted an online survey in an unselected population of residents and senior French psychiatrists between January and March 2022, the results of which are presented descriptively.

RESULTS

228 psychiatrists fully answered the questionnaire, and 21 more psychiatrists answered it partially. We found that most of the responders were unsatisfied with the residency training or the continuing medical education offered regarding BPD, a lack of training resulting in a low level of self-confidence regarding BPD management, in a low number of evidence-based therapies trained psychiatrists in issues regarding diagnostic disclosure, and in misconceptions regarding some aspects of the disorder.

CONCLUSIONS

These results underlie a clear lack of training of French psychiatrists, as well as a request from the latter for more opportunities to learn. This calls for a rethinking of the teaching system to incorporate more knowledge and tools related to BPD.

Treating depression in patients with borderline personality disorder: clinical clues on the use of antidepressants

Personality disorders (PD) are described as enduring patterns of markedly deviant and pervasive inner experiences and behaviors, with onset in adolescence, which lead to severe distress or impairment. Patients suffering from major depressive disorder (MDD) display higher rates of comorbidity with personality disorders, often complicating the treatment, and worsening the outcomes. Borderline personality disorder (BPD) is the most common of PD and is frequently associated with MDD, with which shares several features. The most part of research agrees on the fact that comorbid BPD in MDD patients quite doubles the poor response to treatments. Moreover, no treatment strategy stands out currently to emerge as more effective in these cases, thus urging the call for the need of new approaches. Herein, we revise the current literature on BPD, its neurobiology and comorbidity with MDD, as well as the more recent treatment strategies used. Then, based on its pharmacology, we propose a possible role of trazodone as a valuable tool to approach comorbid BPD-MDD.

Cognitive disturbances basic symptoms in help-seeking patients with borderline personality disorder: Characteristics and association with schizotypy

AIM

Although the presence of psychotic symptoms has been widely recognized in Borderline Personality Disorder (BPD), no study previously investigated cognitive Basic Symptoms (BS) and their clinical implications in patients with BPD.

METHODS

This cross-sectional study specifically examined the prevalence of COGDIS (cognitive disturbances) BS criteria in 93 help-seeking outpatients with BPD by using the Schizophrenia Proneness Instrument-Adult Version (SPI-A). We then explored associations of COGDIS with personality traits, functioning and core psychopathological features of BPD.

RESULTS

The prevalence rates of COGDIS criterion were 62.4%. BPD patients meeting COGDIS criteria reported higher levels of schizotypal personality traits, dissociative experiences and work/social functional impairment compared to individuals without COGDIS criteria. Furthermore, the number of cognitive BSs showed a positive correlation with severity levels of schizotypy.

CONCLUSIONS

Cognitive BS are common in BPD. Cognitive disturbances are associated with schizotypal personality traits and specific clinical features. The presence of cognitive BSs may identify a more severe subgroup of patients with BPD, potentially vulnerable to psychotic symptoms and reliably identifiable through assessment of schizotypal traits.

Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies

Borderline personality disorder (BPD) was introduced in the DSM-III in 1980. From the DSM-III to the DSM-5, no major changes have occurred in its defining criteria. The disorder is characterized by instability of self-image, interpersonal relationships and affects. Further symptoms include impulsivity, intense anger, feelings of emptiness, strong abandonment fears, suicidal or self-mutilation behavior, and transient stress-related paranoid ideation or severe dissociative symptoms. There is evidence that BPD can be reliably diagnosed and differentiated from other mental disorders by semi-structured interviews. The disorder is associated with considerable functional impairment, intensive treatment utilization, and high societal costs. The risk of self-mutilation and suicide is high. In the general adult population, the lifetime prevalence of BPD has been reported to be from 0.7 to 2.7%, while its prevalence is about 12% in outpatient and 22% in inpatient psychiatric services. BPD is significantly associated with other mental disorders, including depressive disorders, substance use disorders, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, bipolar disorder, bulimia nervosa, and other personality disorders. There is convincing evidence to suggest that the interaction between genetic factors and adverse childhood experiences plays a central role in the etiology of BPD. In spite of considerable research, the neurobiological underpinnings of the disorder remain to be clarified. Psychotherapy is the treatment of choice for BPD. Various approaches have been empirically supported in randomized controlled trials, including dialectical behavior therapy, mentalization-based therapy, transference-focused therapy, and schema therapy. No approach has proved to be superior to others. Compared to treatment as usual, psychotherapy has proved to be more efficacious, with effect sizes between 0.50 and 0.65 with regard to core BPD symptom severity. However, almost half of the patients do not respond sufficiently to psychotherapy, and further research in this area is warranted. It is not clear whether some patients may benefit more from one psychotherapeutic approach than from others. No evidence is available consistently showing that any psychoactive medication is efficacious for the core features of BPD. For discrete and severe comorbid anxiety or depressive symptoms or psychotic-like features, pharmacotherapy may be useful. Early diagnosis and treatment of BPD can reduce individual suffering and societal costs. However, more high-quality studies are required, in both adolescents and adults. This review provides a comprehensive update of the BPD diagnosis and clinical characterization, risk factors, neurobiology, cognition, and management. It also discusses the current controversies concerning the disorder, and highlights the areas in which further research is needed.

Dimensional model of adolescent personality pathology, reflective functioning, and emotional maltreatment

Introduction

Childhood emotional abuse (CEA) is a recognized risk factor for adolescent mentalizing challenges. However, there's limited understanding about how CEA might influence personality development and elevate the risk of adolescent personality pathology. A deeper grasp of these pathways is crucial, given that adolescence is a pivotal developmental phase for identity integration, personality consolidation, and the emergence of personality disorders. As the emphasis shifts to dimensional perspectives on adolescent personality pathology, the spotlight is increasingly on adolescents' evolving personality organization (PO). Within this framework, personality disorder manifestations stem from inherent vulnerabilities in PO. A comprehensive understanding of how CEA leads to these inherent vulnerabilities in PO can inform enhanced interventions for at-risk adolescents. Nonetheless, our comprehension lacks insight into potential pathways to PO, especially those involving external factors like maltreatment and individual traits like mentalizing. This study sought to bridge these gaps by employing latent factor analysis and structural equation modeling to explore connections between emotional maltreatment, adolescent mentalizing, and PO.

Methods

A community-based cohort of 193 adolescents (aged 12-17) took part in self-report assessments: the Childhood Experience of Care and Abuse Questionnaire (CECA.Q), the Reflective Functioning Questionnaire for Youth (RFQ-Y), and the Inventory for Personality Organization for Adolescents (IPO-A).

Results

The structural equation model revealed a significant direct influence of CEA on both RFQ-Confusion and PO, and a noteworthy direct effect of RFQ-Confusion on PO. Remarkably, the model accounted for 76.9% of the PO variance. CEA exhibited a significant indirect impact on PO through RFQ-Confusion, which was accountable for 52.3% of the CEA effect on PO, signifying a partial mediation by mentalizing.

Discussion

These insights carry substantial clinical implications, especially for devising integrated, trauma-informed strategies for adolescents with personality pathologies. This is particularly relevant for enhancing mentalizing and bolstering personality consolidation among adolescent CEA survivors.

The impact of a telephone hotline on suicide attempts and self-injurious behaviors in patients with borderline personality disorder

Background

Borderline personality disorder is often associated with self-injurious behaviors that cause personal suffering, family distress, and substantial medical costs. Mental health hotlines exist in many countries and have been shown to be effective in some contexts, but none have been specifically designed for borderline patients. The aim of the present study is to evaluate the impact of a 24/7 hotline dedicated to patients with borderline personality disorder on suicide attempts and self-injurious behaviors.

Methods

We conducted a single-blind, multicenter (9 French centers) clinical trial with stratified randomization (by age, sex and center). Patients (N = 315) with a diagnosis of borderline personality disorder (according to the SIDP-IV) were randomized into two groups with or without access to the hotline in addition to treatment as usual. The number of suicide attempts and self-injurious behaviors in each group within 12 month were analyzed in the "per protocol" population (Student's t-tests, 5% significance threshold), adjusting for possible confounders in a multivariate analysis (using Poisson regression). The percentage of patients with suicide attempts and with self-injurious behaviors (and other percentages) were analyzed in the per protocol population (χ2-tests or exact Fischer tests, 5% significance threshold).

Results

The mean number of suicide attempts was 3 times lower in the hotline group (0.41 vs. 1.18, p = 0.005) and the mean number of self-injurious behaviors was 9 times lower (0.90 vs. 9.5, p = 0.006). Multivariate analysis confirmed the effectiveness of the hotline in reducing suicide attempts and self-harm.

Conclusion

This study supports the effectiveness of hotlines in reducing self-aggressive behavior in patients with borderline personality disorder. Such support is easy to use, cheap and flexible, and therefore easy to implement on a large scale.

A Comprehensive Literature Review of Borderline Personality Disorder: Unraveling Complexity From Diagnosis to Treatment

Borderline personality disorder (BPD) is a severe mental illness marked by unpredictable feelings, behaviors, and relationships. Symptoms like emotional instability, impulsivity, and poor social connections are the basis for diagnostic criteria. A noteworthy discovery highlights the clinical overlap between BPD and several psychotic disorders by arguing that BPD and psychotic symptoms raise the risk of psychopathology. According to neuroimaging evidence, structural and functional brain changes, notably in regions controlling affective regulation and impulse control, are seen in BPD patients. Adolf Stern, a psychoanalyst, used the word "borderline" in 1938 to describe patients who exhibited increased symptoms during therapy and displayed masochistic tendencies. Modern BPD research has highlighted the complexity of symptoms like boredom, a former diagnostic criterion associated with feelings of emptiness. Though there are still unanswered problems regarding its precise, practical components, the treatment technique known as Schema therapy (ST) has shown promise in treating BPD. It's interesting to note that BPD displays complex relationships with other illnesses; for instance, some neurochemical pathways coincide with those in bulimia nervosa, pointing to a deeper level of interconnection. Concerning diagnosis, BPD's defining symptoms include, among others, the fear of abandonment, identity disruption, and recurrent suicidal conduct. The range of treatment options includes pharmacological interventions and psychotherapies like dialectical behavior therapy (DBT). Even though antidepressants like selective serotonin reuptake inhibitors (SSRIs) are routinely prescribed, research on their efficacy is ongoing, underlining the significance of thorough treatment planning. In conclusion, BPD continues to be a complex condition that calls for early detection, especially considering that it usually manifests in adolescence. While many patients report symptom relief, lingering problems still exist, emphasizing the value of comprehensive and personalized treatment strategies.

Assessing the quality of the care offer for people with personality disorders in Italy: the QUADIM project. A multicentre research based on the database of use of Mental Health services

BACKGROUND

Italy can be viewed as a laboratory to assess the quality of mental healthcare delivered in a community-oriented system, especially for severe mental disorders, such as personality disorders. Although initiatives based on clinical indicators for assessing the quality of mental healthcare have been developed by transnational-organisations, there is still no widespread practice of measuring the quality of care pathways delivered to patients with severe mental disorders in a community-oriented system, especially using administrative healthcare databases. The aim of the study is to evaluate the quality of care delivered to patients with personality disorders taken-in-care by mental health services of four Italian regions (Lombardy, Emilia-Romagna, Lazio, Sicily).

METHODS

A set of thirty-three clinical indicators, concerning accessibility, appropriateness, continuity, and safety of care, was implemented using regional healthcare utilization databases, containing data on mental health treatments and diagnosis, hospital admissions, outpatient interventions and exams and drug prescriptions.

RESULTS

31,688 prevalent patients with personality disorders treated in 2015 were identified, of whom 2,331 newly taken-in-care. One-in-10 patients received a standardized assessment, the treatment discontinuity affected half of the cases. 12.7% of prevalent patients received at least one hospitalization, 10.6% in the newly taken-in-care cohort. 6-out-of-10 patients had contact with community-services within 14 days from hospital discharge. Access to psychotherapy and psychoeducational treatments was low and delivered with a low intensity. The median of psychosocial interventions per person-year was 19.1 and 9.4, respectively, in prevalent and newly taken-in-care cases. Nearly 50% of patients received pharmacological treatments.

CONCLUSIONS

Healthcare utilization databases were used to systematically evaluate and assess service delivery across regional mental health systems; suggesting that in Italy the public mental health services provide to individuals with personality disorders suboptimal treatment paths.

Exploring the Utility of Neurostimulation Therapies in the Treatment of Borderline Personality Disorder: A Systematic Literature Review

ABSTRACT

The use of electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS) in the treatment of people diagnosed with borderline personality disorder (BPD) highlights the need for systematic review of the evidence supporting this practice. A comprehensive literature search identified seven original clinical research studies investigating the use of brain stimulation therapies in people diagnosed with BPD. The lack of consistent study design, diagnostic methodology, treatment parameters, and outcome measures precluded analysis of aggregated study results. There were no ECT studies evaluating BPD symptom outcomes; however, studies of ECT in patients with comorbid BPD and depression suggested that depressive symptoms were less responsive to ECT compared with depression-only patients. The few studies available suggest that TMS may lead to clinically and statistically significant improvements in BPD symptoms and depressive symptoms. Similar overall improvements were reported despite the use of heterogeneous TMS treatment protocols, highlighting the importance of including a sham condition to investigate the contribution of the placebo effect to overall improvement. There is still no clear evidence supporting the use of ECT for treating people with BPD (with or without depression); therefore, the use of ECT in this population should be approached with caution. Although TMS shows early promise, the low numbers of participants in the few available studies suggest the urgent need for larger randomized controlled trials to provide an evidence base for this increasingly popular treatment.

Genetic Influences on Outcomes of Psychotherapy in Borderline Personality Disorder: A Narrative Review of Implications for Personalized Treatment

Borderline personality disorder (BPD) manifests as instability in mood, relationships, self-image, and behavior, representing a challenging mental health issue. This review scrutinizes genetic factors influencing BPD and the corresponding treatment outcomes. The primary objective of this narrative review is to illuminate the association between genetic factors and BPD treatment outcomes, discussing the potential of genetic testing for personalized therapy. The review is derived from observational and experimental studies on BPD, genetic factors, and psychotherapy from 2000 to 2023, sourced primarily through PubMed. Reviews and meta-analyses were excluded. Our review suggests that genetic factors account for 40-60% of BPD variation, with significant roles played by epigenetic alterations like DNA methylation and microRNAs, particularly in the context of childhood trauma. Gene-environment interactions are also vital for BPD's development. Treatments such as dialectical behavior therapy, mentalization-based therapy, and schema therapy have shown efficacy, with success variability possibly linked to genetic factors. However, existing research is constrained by recall bias, diverse methodologies, and limited sample sizes. Future research necessitates long-term follow-up, diverse populations, and controlled variables to enhance our comprehension of BPD treatment outcomes' genetic foundations. The review underlines the promise of personalized medicine in BPD treatment, driven by genetic insights.

One Year of Outpatient Dialectical Behavioral Therapy and Its Impact on Neuronal Correlates of Attachment Representation in Patients with Borderline Personality Disorder Using a Personalized fMRI Task

(1) Background: BPD is characterized by affect dysregulation, interpersonal problems, and disturbances in attachment, but neuroimaging studies investigating attachment representations in BPD are rare. No study has examined longitudinal neural changes associated with interventions targeting these impairments. (2) Methods: We aimed to address this gap by performing a longitudinal neuroimaging study on n = 26 patients with BPD treated with Dialectic Behavioral Therapy (DBT) and n = 26 matched healthy controls (HCs; post intervention point: n = 18 BPD and n = 23 HCs). For functional imaging, we applied an attachment paradigm presenting attachment related scenes represented in drawings paired with related neutral or personalized sentences from one's own attachment narratives. In a prior cross-sectional investigation, we identified increased fMRI-activation in the human attachment network, in areas related to fear response and the conflict monitoring network in BPD patients. These were especially evident for scenes from the context of loneliness (monadic pictures paired with individual narrative sentences). Here, we tested whether these correlates of attachment representation show a near-to-normal development over one year of DBT intervention. In addition, we were interested in possible associations between fMRI-activation in these regions-of-interest (ROI) and clinical scores. (3) Results: Patients improved clinically, showing decreased symptoms of borderline personality organization (BPI) and increased self-directedness (Temperament and Character Inventory, TCI) over treatment. fMRI-activation was increased in the anterior medial cingulate cortex (aMCC) and left amygdala in BPD patients at baseline which was absent after intervention. When investigating associations between scores (BPI, TCI) and functional activation, we found significant effects in the bilateral amygdala. In contrast, aMCC activation at baseline was negatively associated with treatment outcome, indicating less effective treatment effects for those with higher aMCC activation at baseline. (4) Conclusions: Monadic attachment scenes with personalized sentences presented in an fMRI setup are capable of identifying increased activation magnitude in BPD. After successful DBT treatment, these increased activations tend to normalize which could be interpreted as signs of a better capability to regulate intensive emotions in the context of "social pain" towards a more organized/secure attachment representation. Amygdala activation, however, indicates high correlations with pre-treatment scores; activation in the aMCC is predictive for treatment gain. Functional activation of the amygdala and the aMCC as a response to attachment scenes representing loneness at baseline might be relevant influencing factors for DBT-intervention outcomes.

The Role of Gender in Patients with Borderline Personality Disorder: Differences Related to Hopelessness, Alexithymia, Coping Strategies, and Sensory Profile

Background and Objectives: Gender differences are poorly investigated in patients with borderline personality disorder (BPD), although they could be useful in determining the most appropriate pharmacological and non-pharmacological treatment. The aim of the present study was to compare sociodemographic and clinical characteristics and the emotional and behavioral dimensions (such as coping, alexithymia, and sensory profile) between males and females with BPD. Material and Methods: Two hundred seven participants were recruited. Sociodemographic and clinical variables were collected through a self-administered questionnaire. The Adolescent/Adult Sensory Profile (AASP), Beck Hopelessness Scale (BHS), Coping Orientation to Problems Experienced (COPE), and Toronto Alexithymia Scale (TAS-20) were administered. Results: Male patients with BPD showed more involuntary hospitalizations and greater use of alcohol and illicit substances compared to females. Conversely, females with BPD reported more frequent medication abuse than males. Furthermore, females had high levels of alexithymia and hopelessness. Regarding coping strategies, females with BPD reported higher levels of "restraint coping" and "use of instrumental social support" at COPE. Finally, females with BPD had higher scores in the Sensory Sensitivity and Sensation Avoiding categories at the AASP. Conclusions: Our study highlights gender differences in substance use, emotion expression, future vision, sensory perception, and coping strategies in patients with BPD. Further gender studies may clarify these differences and guide the development of specific and differential treatments in males and females with BPD.

[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.

Differential associations between childhood maltreatment types and borderline personality disorder from the perspective of emotion dysregulation

BACKGROUND

Borderline Personality Disorder (BPD) is characterized by pervasive instability in a range of areas including interpersonal relationships, self-image, and affect. Extant studies have consistently identified significant correlations between childhood maltreatment (CM) and BPD. While exploring this CM-BPD link, a number of cross-sectional studies commonly emphasize the role of emotion dysregulation (ED). A better understanding of the associations between BPD and (1) CM and (2) ED are essential in formulating early, effective intervention approaches, and in addressing varied adverse impacts.

METHODS

This cross-sectional study analyzed a subset of baseline data collected for a larger community-based longitudinal study. Given that our current focus on CM and ED, only those participants who completed the baseline CM assessment and ED measure (N = 144) were included for the primary analyses. We conducted stepwise multivariate linear models to examine the differential relationships between BPD features, ED, and multiple CM types. A path analysis with latent factors using the structural equation modeling (SEM) method was performed to test the indirect effect from CM to BPD features via ED.

RESULTS

Linear regression models revealed that only emotional abuse (relative to other trauma types) was significantly associated with high BPD features. The SEM, by constructing direct and indirect effects simultaneously, showed that (1) ED partially mediated the path from CM to BPD features; and (2) CM played an important role in which the direct effect remained significant even after accounting for the indirect effect through ED.

CONCLUSIONS

Our results highlight a most consistent association between emotional abuse and BPD, indicating its unique role in understanding BPD features in the context of CM. Further, shame-related negative appraisal and ED were found critical when examining the association between CM and BPD, possibly providing promising treatment targets for future practices.

Borderline personality disorder, therapeutic privilege, integrated care: is it ethical to withhold a psychiatric diagnosis?

Once common, therapeutic privilege-the practice whereby a physician withholds diagnostic or prognostic information from a patient intending to protect the patient-is now generally seen as unethical. However, instances of therapeutic privilege are common in some areas of clinical psychiatry. We describe therapeutic privilege in the context of borderline personality disorder, discuss the implications of diagnostic non-disclosure on integrated care and offer recommendations to promote diagnostic disclosure for this patient population.

Amygdala response predicts clinical symptom reduction in patients with borderline personality disorder: A pilot fMRI study

Borderline personality disorder (BPD) is a prevalent, devastating, and heterogeneous psychiatric disorder. Treatment success is highly variable within this patient group. A cognitive neuroscientific approach to BPD might contribute to precision psychiatry by identifying neurocognitive factors that predict who will benefit from a specific treatment. Here, we build on observations that BPD is accompanied by the enhanced impact of the aversive effect on behavior and abnormal neural signaling in the amygdala. We assessed whether BPD is accompanied by abnormal aversive regulation of instrumental behavior and associated neural signaling, in a manner that is predictive of symptom reduction after therapy. We tested a clinical sample of 15 female patients with BPD, awaiting dialectical behavior therapy (DBT), and 16 matched healthy controls using fMRI and an aversive Pavlovian-to-instrumental transfer (PIT) task that assesses how instrumental behaviors are influenced by aversive Pavlovian stimuli. Patients were assessed 1 year after the start of DBT to quantify changes in BPD symptom severity. At baseline, behavioral aversive PIT and associated neural signaling did not differ between groups. However, the BOLD signal in the amygdala measured during aversive PIT was associated with symptom reduction at 1-year follow-up: higher PIT-related aversive amygdala signaling before treatment was associated with reduced clinical improvement at follow-up. Thus, within the evaluated group of BPD patients, the BOLD signal in the amygdala before treatment was related to clinical symptom reduction 1 year after the start of treatment. The results suggest that less PIT-related responsiveness of the amygdala increases the chances of treatment success. We note that the relatively small sample size is a limitation of this study and that replication is warranted.

Emotional dysregulation as trans-nosographic psychopathological dimension in adulthood: A systematic review

Introduction

Emotional dysregulation (ED) is characterized by inappropriate emotional reactions related to environmental or cognitive stimuli. In most recent years, increasing interest has been devoted to its definition and detection across mental disorders for its detrimental role progressively highlighted in both neurodevelopment and adult mental disorders, with implications on the severity of clinical manifestations. The aim of this systematic review was to evaluate and gather the scientific evidence about ED in adult psychiatric population to elucidate the concept of ED as trans-nosographic entity.

Methods

The electronics databases PubMed, Scopus and Web of Science was reviewed to identify studies in accordance with the PRISMA guidelines; at the end of the selection process a total of 29 studies (N = 709; N = 658; N = 1,425) was included. All studies included assessed the presence of ED symptoms, by means of a validate scale in adult (>18 years of age), in clinically diagnosed patients as well as healthy control participants.

Results

Our results suggest ED as a trans-diagnostic factor across multiple mental disorders, such as bipolar disorder, attention deficit hyperactivity disorder, autism spectrum disorder, personality disorders; a better definition of this concept could be helpful to interpret and clarify many clinical cases and improve their diagnostic and therapeutic management.

Non-response to psychotherapy for borderline personality disorder: A systematic review

HIGHLIGHT

This is the first systematic review to investigate non-response to psychotherapy for borderline personality disorder.

BACKGROUND

Psychotherapy is the recommended treatment for borderline personality disorder. While systematic reviews have demonstrated the effectiveness of psychotherapy for borderline personality disorder, effect sizes remain small and influenced by bias. Furthermore, the proportion of people who do not respond to treatment is seldom reported or analysed.

OBJECTIVE

To obtain an informed estimate of the proportion of people who do not respond to psychotherapy for borderline personality disorder.

METHODS

Systematic searches of five databases, PubMed, Web of Science, Scopus, PsycINFO and the Cochrane Library, occurred in November 2020. Inclusion criteria: participants diagnosed with borderline personality disorder, treated with psychotherapy and data reporting either (a) the proportion of the sample that experienced 'reliable change' or (b) the percentage of sample that no longer met criteria for borderline personality disorder at conclusion of therapy. Exclusion criteria: studies published prior to 1980 or not in English. Of the 19,517 studies identified, 28 met inclusion criteria.

RESULTS

Twenty-eight studies were included in the review comprising a total of 2436 participants. Average treatment duration was 11 months using well-known evidence-based approaches. Approximately half did not respond to treatment; M = 48.80% (SD = 22.77).

LIMITATIONS

Data regarding within sample variability and non-response are seldom reported. Methods of reporting data on dosage and comorbidities were highly divergent which precluded the ability to conduct predictive analyses. Other limitations include lack of sensitivity analysis, and studies published in English only.

CONCLUSION

Results of this review suggest that a large proportion of people are not responding to psychotherapy for borderline personality disorder and that factors relating to non-response are both elusive and inconsistently reported. Novel, tailored or enhanced interventions are needed to improve outcomes for individuals not responding to current established treatments.

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.

Relationships of Homophobic Bullying Victimization during Childhood with Borderline Personality Disorder Symptoms in Early Adulthood among Gay and Bisexual Men: Mediating Effect of Depressive Symptoms and Moderating Effect of Family Support

This study investigated (1) the associations of homophobic bullying victimization in childhood with borderline personality disorder (BPD) symptoms in early adulthood among gay and bisexual men; (2) the mediating effect of depressive symptoms on the association between homophobic bullying victimization and BPD symptoms, and (3) the moderating effects of perceived family support on the association between homophobic bullying victimization and BPD symptoms. A total of 500 gay or bisexual men aged between 20 and 25 years were recruited into this study. The experiences of physical, verbal and social relationship bullying victimization during childhood were evaluated using the Mandarin Chinese version of the School Bullying Experience Questionnaire. The experiences of cyberbullying victimization during childhood were evaluated using the Cyberbullying Experiences Questionnaire. BPD symptoms were assessed using the Borderline Symptom List. Depressive symptoms were examined using the Center for Epidemiologic Studies Depression Scale. Perceived family support was evaluated using the Family Adaptation, Partnership, Growth, Affection, and Resolve index. The results of mediation analyses demonstrated that all the types of homophobic bullying victimization in childhood were directly associated with BDP symptoms in young adulthood as well as indirectly associated with BPD symptoms through the mediation of depressive symptoms. The results of moderation analyses demonstrated that the association between homophobic bullying victimization and BPD symptoms decreased when the individuals had more family support. Intervention programs to reduce homophobic bullying victimization and enhance family support for gay and bisexual men and their families are necessary. Interventions to improve depressive and BPD symptoms among gay and bisexual men are also necessary, especially for those who experienced homophobic bullying victimization during childhood.

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.

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.

Consumer perspective from people with a diagnosis of Borderline Personality Disorder (BPD) on BPD management-How are the Australian NHMRC BPD guidelines faring in practice?

WHAT IS KNOWN ON THE SUBJECT?: Internationally, stigma towards people with mental illness has reduced due to greater understanding, education and advocacy in the community, and more focus on recovery-oriented care within practice guidelines. However, many people with a diagnosis of BPD continue to experience stigma and difficulty accessing health services. Contributing factors include lack of understanding of BPD and effective management by health professionals, stigma from the general population and within healthcare services, and financial and geographical barriers. Mental health nurses comprise a large part of the healthcare workforce responsible for the day-to-day care of people diagnosed with BPD. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE: This paper investigates how Australian consumer perspectives on BPD management have changed over time. Comments from a large survey, delivered to consumers in 2011 (N = 153) and 2017 (N = 424), were analysed for common themes. Themes were broadly related to NHMRC BPD Guidelines sections released in 2013. These data sets therefore present an opportunity to evaluate changes in consumer perspectives pre- and post-Guideline release. Although no direct causal relationship can be drawn, analysing these changes can potentially assist with understanding the impact of the Guidelines in practice. No such analysis of the Australian Guidelines has been conducted to date in the existing literature. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Many people diagnosed with BPD continue to experience stigma, barriers to treatment and difficulty accessing appropriate services. Widespread practical implementation of the Guidelines was not apparent; however, improved general awareness and understanding of BPD from consumers and health professionals were evident. Improved education and practice across each and all aspects of the Guidelines are indicated. The Guidelines need review to ensure they are in-line with current evidence-based practice, as well as effective health professional education, support and funding to embed the revised Guidelines into practice. ABSTRACT: Introduction Internationally, many individuals diagnosed with BPD continue to experience stigma within health care and are more likely to be viewed as manipulative and evoke negative responses from clinicians, compared with other mental health consumers. Aim/Question To understand Australian consumer perspectives regarding BPD management, and how these have changed between 2011 and 2017. To comment on how NHMRC BPD Guidelines, released 2013, are faring in practice. Method Individuals who identified a BPD diagnosis completed a 75-question survey, delivered online Australia-wide, in 2011 (N = 153) and 2017 (N = 424), providing comparative data sets to evaluate changes in consumer perspective on BPD management. Results Many people diagnosed with BPD experience difficulties when seeking help, stigma within health services and barriers to treatment. Improved general awareness, communication and understanding of BPD from consumers and health professionals were evident. Discussion Consumers demonstrated increased BPD-literacy and help-seeking behaviours in 2017, providing opportunity for health professionals to build stronger therapeutic relationships. Widespread practical implementation of the Guidelines does not appear to have been achieved. More health professional education, updated Guidelines, funding and strategies to embed these Guidelines into practice are needed. Implications for Practice Mental health nurses regularly provide care to people diagnosed with BPD; with practical education and support, they and other health professionals can improve their confidence in practice and provide better quality care to consumers.

Self-report screening instruments differentiate bipolar disorder and borderline personality disorder

BACKGROUND

Bipolar disorder (BD) and borderline personality disorder (BPD) share overlapping phenomenology and are frequently misdiagnosed. This study investigated the diagnostic accuracy of the Mood Disorder Questionnaire (MDQ) and McLean Screening Instrument for Borderline Personality Disorder (MSI) in a clinical inpatient setting and whether individual screening items could differentiate BD from BPD.

METHODS

757 sequential inpatients admitted to a Mood Disorder Unit completed both the MDQ and MSI. Screen positive for the MDQ was defined as ≥7/13 symptoms endorsed with concurrence and at least moderate impact. Screen positive for the MSI was defined as a score of ≥7. The clinical discharge summary diagnosis completed by a board-certified psychiatrist was used as the reference standard to identify concordance rates of a positive screen with clinical diagnosis. Individual items predicting one disorder and simultaneously predicting absence of other disorder by odds ratio (OR>and <1) were identified.

RESULTS

Both screening instruments were more specific than sensitive (MDQ 83.7%/ 67.8%, MSI 73.2% / 63.3%). MDQ individual items (elevated mood, grandiosity, increased energy, pressured speech, decreased need for sleep, hyperactivity) were significant predictors of BD diagnosis and non-predictors of BPD diagnosis. Whereas MSI subitem, self-harm behaviors/suicidal attempts predicted BPD in the absence of BD; distrust and irritability were additional predictors of BPD.

CONCLUSION

While this study is limited by the lack of structured diagnostic interview, these data provide differential symptoms to discriminate BD and BPD. Further work with larger datasets and more rigorous bioinformatics machine learning methodology is encouraged to continue to identify distinguishing features of these two disorders to guide diagnostic precision and subsequent treatment recommendations.

Editorial: The Developmental Science of Borderline Personality Disorder

In a seminal review article on borderline personality disorder (BPD) for the American Journal of Psychiatry, John Gunderson once made the allusion that "borderline personality disorder is to psychiatry what psychiatry is to medicine," suggesting that the condition is frequently neglected, even among mental health professionals and researchers.¹ For instance, BPD-related research received less than one-tenth of the US National Institutes of Health funding compared to bipolar disorder research, despite sharing similar rates of prevalence, impairment, and mortality.² Along those lines, one could argue that borderline personality features in adolescence share the same hierarchical relationship with their counterparts in adults, being even more stigmatized and overlooked, even in the child and adolescent psychiatry community. Accordingly, only 1 of 4 randomized trials with psychosocial interventions for BPD were conducted in youth.^3,4.

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.

Are Impairments in Theory of Mind Specific to Borderline Personality Disorder?

Impaired theory of mind (ToM) is an assumed feature of borderline personality disorder (BPD). Yet, no studies have compared ToM abilities in patients with BPD, other personality disorders, and healthy controls, or investigated the relationship between ToM and severity of psychopathology and interpersonal problems. In this study, ToM was investigated by the Movie for the Assessment of Social Cognition. No differences were found between the three groups in overall ToM abilities. The BPD group was, however, characterized by more excessive ToM (interpreted as hypermentalization). Yet, when differentiating between BPD and further severity indicators, excessive ToM was not specifically associated with a BPD diagnosis per se. Finally, there was a moderate association between hypermentalization and interpersonal problems in the BPD group. This study suggests that BPD patients tend to hypermentalize when they misinterpret social information, and that this tendency is related to the severity of their psychopathology.

Cognitive Conflict in Borderline Personality Disorder: A Study Protocol

Borderline personality disorder (BPD) represents a severe mental condition that is usually characterized by distressing identity disturbances. Although most prevailing explanatory models and psychotherapy approaches consider and intervene on self-concept, they seem not to recognize or explore idiosyncratic cognitive conflicts that patients may experience. These conflicts, which have been conceptualized as “implicative dilemmas” and “dilemmatic constructs” by personal construct theorists, could be considered as key elements of the explanatory model for BPD to provide a better understanding of this disorder and possibly enhance the effectiveness of contemporary psychotherapeutic approaches. The current study (Identifier: NCT04498104) aims to examine the characteristics of the interpersonal cognitive system of a group of patients diagnosed with BPD, using the repertory grid technique, and to compare them with those of a community sample. We will test if BPD participants are more affected by cognitive conflicts than controls. Additionally, we will gauge the association between cognitive conflicts and symptom severity as well as their predictive capacity of treatment outcome. The obtained results will be a necessary step to determine if cognitive conflicts have a substantial role on the explanation of BPD. It could also help to consider the development of a conflict resolution intervention module for this disorder.

Moving forward: closing the gap between research and practice for young people with BPD

The study of personality disorders has come a long way, and this is characterized by the optimism prevalent within the community dedicated to its study. Outside this community - delays in intervention, ostracism, and ignorance remain common place. With a significant burden of disease and high costs at individual, social, and societal levels there is an urgent need to translate research into practice. Proposed solutions include educating the workforce to improve attitudes and developing more sustainable treatment alternatives. This paper brings forward a user perspective on the need to close the gap between what we know from research and what is done in policy and clinical practice.

Change in core symptoms of borderline personality disorder by tDCS: A pilot study

Borderline personality disorder (BPD) recognizes several psychopathological dimensions related to prefrontal cortex impairments. Transcranial Direct Current Stimulation (tDCS) targeting the right prefrontal dorsolateral cortex (DLPFC) positively influence cognitive functions related to impulsivity in healthy subjects. A randomized double-blind study was designed to investigate whether tDCS could modulate core dimensions (impulsivity, aggression, affective dysregulation) of BPD. Also effects on decision making process and substances craving was assessed. Patients were randomized to receive active-tDCS at 2 mA versus sham-tDCS, once a day for 15 sessions. Anode was placed on the right DLPFC (F4), cathode on the left DLPFC (F3). Impulsivity and aggression measures were significantly reduced only in patients treated with active-tDCS. Decision-making process was marginally influenced by the active current. Craving intensity was reduced only in the active-tDCS sample. Both groups showed improvements in the affective dysregulation dimension and anxious and depressive symptoms. The application of bilateral tDCS targeting right DLPFC with anodal stimulation seems to improve core dimensions of BPD (mainly impulsivity and aggression) probably by restoring prefrontal activity. tDCS might be a potential tool for preventing self-harming behaviors.

All the Faces of Research on Borderline Personality Pathology: Drawing Future Trajectories through a Network and Cluster Analysis of the Literature

"Borderline Personality Disorder is a severe condition that affects self and interpersonal dimensions and emotional and behavioral regulation. Since the last decades of the 20th century, an impressive amount of research and clinical contributions on BPD came from specific fields such as psychiatry, clinical psychology, psychopharmacology, and, more recently, cognitive neuroscience. All contributions tackled the challenges of finding reliable diagnostic categories, highlighting detailed developmental trajectories, and fostering effective treatment protocols. However, as results come from different areas, it is often challenging to depict a coherent and yet multifaceted framework on this topic. In this study, we conducted a scientometric analysis of the available literature on BPD to provide a systematic and comprehensive overview of research on BPD and emphasize historical changes, intertwining between fields and new areas of investigation. Results clearly show the evolution of research on BPD starting from the initial development of the construct, passing through the studies on treatment efficacy, the results of longitudinal studies, the advances in cognitive neurosciences, and the recent dimensional conceptualization in DSM-5. Moreover, it emphasizes promising areas of investigation, such as the relations of BPD with NSSI, ADHD, and vulnerable features of narcissism."

Emergency psychiatric management of borderline personality disorder: Towards an articulation of modalities for personalised integrative care

Building on existing literature, the authors draw the landscape of psychiatric emergencies, and focus on borderline personality disorder, frequently encountered, and strongly linked to death by suicide. A review of knowledge in terms of diagnosis, prognosis, etiology, and treatment, as well as their own experiences, lead them to propose areas of progress that would secure the patient's care pathway. The evolution of society has led psychiatric emergency departments to play the role of a safety net and an entry point to the mental health system. Borderline personality disorder is one of the most common pathologies encountered in psychiatric emergencies. It represents a major concern, long characterized by an often dramatic evolution, and by the human and economic stress it generates. However, since the 1990s, knowledge of this disorder has been refined, and today there are various means of evaluation, good clinical practices and psychotherapeutic treatments, thanks to which significant and lasting improvement is possible. Recent studies highlight the crucial role of hospital caregivers, and the benefit of consolidating their skills by providing them with the knowledge and tools specific to this disorder. They also converge on the interest of setting up specific emergency treatment modalities, particularly highly structured, safe and empowering for the patient, in order to improve their effectiveness. The authors suggest that a case formulation model for persons with borderline personality disorder in emergency would make it possible to activate these two levers of progress, while improving collaboration between hospital and outpatient care. This would also address their main concern of optimizing the patient's therapeutic pathway and reinforcing adherence to treatment that could bring remission, and should be supported by data from empirical research.

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.

Smartphone Apps for the Treatment of Mental Disorders: Systematic Review

BACKGROUND

Smartphone apps are an increasingly popular means for delivering psychological interventions to patients suffering from a mental disorder. In line with this popularity, there is a need to analyze and summarize the state of the art, both from a psychological and technical perspective.

OBJECTIVE

This study aimed to systematically review the literature on the use of smartphones for psychological interventions. Our systematic review has the following objectives: (1) analyze the coverage of mental disorders in research articles per year; (2) study the types of assessment in research articles per mental disorder per year; (3) map the use of advanced technical features, such as sensors, and novel software features, such as personalization and social media, per mental disorder; (4) provide an overview of smartphone apps per mental disorder; and (5) provide an overview of the key characteristics of empirical assessments with rigorous designs (ie, randomized controlled trials [RCTs]).

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for systematic reviews were followed. We performed searches in Scopus, Web of Science, American Psychological Association PsycNET, and Medical Literature Analysis and Retrieval System Online, covering a period of 6 years (2013-2018). We included papers that described the use of smartphone apps to deliver psychological interventions for known mental disorders. We formed multidisciplinary teams, comprising experts in psychology and computer science, to select and classify articles based on psychological and technical features.

RESULTS

We found 158 articles that met the inclusion criteria. We observed an increasing interest in smartphone-based interventions over time. Most research targeted disorders with high prevalence, that is, depressive (31/158,19.6%) and anxiety disorders (18/158, 11.4%). Of the total, 72.7% (115/158) of the papers focused on six mental disorders: depression, anxiety, trauma and stressor-related, substance-related and addiction, schizophrenia spectrum, and other psychotic disorders, or a combination of disorders. More than half of known mental disorders were not or very scarcely (<3%) represented. An increasing number of studies were dedicated to assessing clinical effects, but RCTs were still a minority (25/158, 15.8%). From a technical viewpoint, interventions were leveraging the improved modalities (screen and sound) and interactivity of smartphones but only sparingly leveraged their truly novel capabilities, such as sensors, alternative delivery paradigms, and analytical methods.

CONCLUSIONS

There is a need for designing interventions for the full breadth of mental disorders, rather than primarily focusing on most prevalent disorders. We further contend that an increasingly systematic focus, that is, involving RCTs, is needed to improve the robustness and trustworthiness of assessments. Regarding technical aspects, we argue that further exploration and innovative use of the novel capabilities of smartphones are needed to fully realize their potential for the treatment of mental health disorders.

Perspectives on person-centred care for borderline personality disorder: a critical research agenda

Borderline Personality Disorder (BPD) is a highly contentious psychiatric diagnosis with ongoing tensions over nomenclature, aetiology and treatment recommendations. This article examines a number of these tensions and assesses how greater attention to the voices of people living with BPD may help inform the delivery of new modes of person-centred care. To this end, we present a critical social science research agenda for investigating the experiences, social contexts and support needs of people living with BPD. We canvass issues pertaining to the diagnosis of BPD (including its name), the strongly gendered dimensions of BPD, and the pressing need to improve support for people living with this condition. Throughout our analysis, we indicate how critical interdisciplinary inquiry may drive new responses to these challenges. Our analysis is illustrated with reference to experiences of BPD recounted in two Australia-wide surveys conducted in 2011 and 2017. We argue that greater progress towards person-centred care requires novel forms of evidence grounded in critical social inquiry into experiences of treatment and support among people living with BPD, and the varied social, cultural and political contexts underpinning these experiences.

Childhood adversity and borderline personality disorder: a meta-analysis

OBJECTIVE

The aim of this meta-analysis was to better understand the magnitude and consistency of the association between childhood adversity and borderline personality disorder (BPD) across case-control, epidemiological and prospective cohort studies.

METHOD

Following the review protocol (reference: CRD42017075179), search terms pertaining to adversity and BPD were entered into three search engines. Random-effects meta-analysis synthesised the size and consistency of the effects.

RESULTS

A total of 97 studies compared BPD to non-clinical (k = 40) and clinical (k = 70) controls. Meta-analysis of case-control studies indicated that individuals with BPD are 13.91 (95% CI 11.11-17.43) times more likely to report childhood adversity than non-clinical controls. This effect was smaller when considering retrospective cohort (OR: 2.59; 95% CI 0.93-7.30) and epidemiological (OR: 2.56, 95% CI 1.24-5.30) studies. Findings were significant across adversity subtypes with emotional abuse (OR: 38.11, 95% CI: 25.99-55.88) and neglect (OR: 17.73, 95% CI = 13.01-24.17) demonstrating the largest effects. Individuals with BPD were 3.15 (95% CI 2.62-3.79) times more likely to report childhood adversity than other psychiatric groups.

CONCLUSIONS

This meta-analysis corroborates theoretical proposals that exposure to adverse life experiences is associated with BPD. It highlights the importance of considering childhood adversity when treating people diagnosed with BPD.

Features of borderline personality disorder as a mediator of the relation between childhood traumatic experiences and psychosis-like experiences in patients with mood disorder

Background

Psychosis-like experiences (PEs) are common in patients with non-psychotic disorders. Several factors predict reporting of PEs in mood disorders, including mood-associated cognitive biases, anxiety and features of borderline personality disorder (BPD). Childhood traumatic experiences (CEs), often reported by patients with BPD, are an important risk factor for mental disorders. We hypothesized that features of BPD may mediate the relationship between CEs and PEs. In this study, we investigated the relationships between self-reported PEs, CEs and features of BPD in patients with mood disorders.

Methods

As part of the Helsinki University Psychiatric Consortium study, McLean Screening Instrument (MSI), Community Assessment of Psychic Experiences (CAPE-42) and Trauma and Distress Scale (TADS) were filled in by patients with mood disorders (n = 282) in psychiatric care. Correlation coefficients between total scores of scales and their dimensions were estimated, multiple regression and mediation analyses were conducted.

Results

Total scores of MSI correlated strongly with scores of the CAPE-42 dimension “frequency of positive symptoms” (rho = 0.56; p ≤ 0.001) and moderately with scores of TADS (rho = 0.4; p ≤ 0.001). Total score of MSI and its dimension “cognitive symptoms”, including identity disturbance, distrustfulness and dissociative symptoms, fully mediated the relation between TADS and CAPE-42. Each cognitive symptom showed a partial mediating role (dissociative symptoms 43% (CI = 25–74%); identity disturbance 40% (CI = 30-73%); distrustfulness 18% (CI = 12-50%)).

Conclusions

Self-reported cognitive-perceptual symptoms of BPD fully mediate, while affective, behavioural and interpersonal symptoms only partially mediate the relationships between CEs and PEs. Recognition of co-morbid features of BPD in patients with mood disorders reporting PEs is essential.

Comorbid personality disorders and their impact on severe dissociative experiences in Mexican patients with borderline personality disorder

Objective: To identify personality disorders comorbid with borderline personality disorder (BPD) that may confer greater risk for the presence of severe dissociative experiences. Method: Three hundred and one outpatients with a primary diagnosis of BPD were evaluated using the Structured Clinical Interview for DSM-IV Axis II personality disorders, the Borderline Evaluation of Severity Over Time (BEST) and the Dissociative Experiences Scale (DES). Results: The most frequent personality disorders comorbid to BPD were paranoid (83.2%, n = 263) and depressive (81.3%, n = 257). The mean BEST and DES total score were 43.3 (SD = 11.4, range 15-69) and 28.6 (SD = 19.8, range 0-98), respectively. We categorized the sample into patients with and without severe dissociative experiences (41% were positive). A logistic regression model revealed that Schizotypal, Obsessive-compulsive and Antisocial personality disorders conferred greater risk for the presence of severe dissociative experiences. Discussion: Our results suggest that a large proportion of patients with BPD present a high rate of severe dissociative experiences and that some clinical factors such as personality comorbidity confer greater risk for severe dissociation, which is related to greater dysfunction and suffering, as well as a worse progression of the BPD.