Outcome of crisis intervention for borderline personality disorder and post traumatic stress disorder: a model for modification of the mechanism of disorder in complex post traumatic syndromes

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Crisis-focused psychosocial interventions for borderline personality disorder: systematic review and narrative synthesis

BACKGROUND

Mental health crisis presentations are common in those who have a diagnosis of borderline personality disorder (BPD), and psychosocial interventions should be provided. However, there is limited evidence outlining what a crisis-focused psychosocial intervention for this population should include.

AIMS

To conduct a systematic review and narrative synthesis of crisis-focused psychosocial interventions for people diagnosed with BPD.

METHOD

Three databases (MEDLINE, Embase, PsycInfo) were searched for eligible studies. Studies were included if they were quantitative studies comparing a crisis-focused intervention with any control group and they included adults (18+ years of age) who were diagnosed with BPD (or with equivalent experiences). A narrative synthesis was undertaken to analyse results.

RESULTS

A total of 3711 papers were initially identified, 95 full texts were screened and 5 studies were included in the review. Two of five studies reported on the same trial, so four individual trials were included. Overall moderate risk of bias across studies was identified. The review tentatively demonstrated that crisis-focused psychosocial interventions are feasible and acceptable to people with BPD and that they have potential impacts on outcomes such as self-harm and number of days spent in hospital. There is limited consensus on what outcome measures should be used to assess the impact of interventions.

CONCLUSIONS

There is presently insufficient data to recommend any specific psychosocial crisis intervention for people with BPD. Given the relationship between BPD and the high frequency of crises experienced by this group, further large-scale trials examining crisis-focused psychosocial interventions are required.

STATEMENT ON LANGUAGE

We acknowledge that the term personality disorder can be controversial and stigmatising. As the term borderline personality disorder has been retained in DSM-5 and is used in the research evidence base we have decided to use this term throughout this review. However, we recognise that this term may not be acceptable to all.

The disorder-specific psychological impairment in complex PTSD: A flawed working model for restoration of trust

This article methodically gathers concepts and findings from related disciplines to propose that there is a fundamental, disorder-specific psychological impairment, which defines Complex Posttraumatic Stress Disorder (PTSD) as etiologically different from simple PTSD. This impairment is a flawed working model for restoration of trust when one partner fears betrayal. This working model is legacy of childhood relationships with manipulative caretakers who kept the child powerless to test the trustworthiness of their reasons to break promises and to fail the child's expectations. Manipulative caretakers invert the respective roles and responsibilities for restoration of trust, which constitutes perversion of intimacy. This article describes how that fundamental flaw becomes the cause of patients' disorder, by episodically rendering them powerless to ascertain a perception of grave betrayal as true or false in later relationships. Repeated failure with experiments for certainty about others' love explains the characteristic personality traits and beliefs of persons with Complex PTSD, i.e., cynicism about the world's benevolence, self-derogation and sense of a foreshortened future. This article closes with reference to a study that investigated the efficacy of a crisis intervention designed to remediate this fundamental impairment.

Does response to the STEPPS program differ by sex, age, or race in offenders with borderline personality disorder?

Systems Training for Emotional Predictability and Problem Solving (STEPPS) is an evidence-based group treatment program for ambulatory patients with borderline personality disorder (BPD). The program was introduced to the Iowa correctional system in 2005, and groups have been ongoing ever since. In this analysis, we examine whether response to the STEPPS program differs based on sex, age (<40/≥40 years), or race/ethnicity (minority/non-minority) using data collected in Iowa prisons and in community corrections. Subjects were recruited and assessed by correctional staff. Offenders with BPD were offered the opportunity to participate in the STEPPS program. The presence of BPD was assessed using a module from the Structured Interview for DSM-IV Personality. Efficacy assessments included the Borderline Evaluation of Severity Over Time Scale, the Beck Depression Inventory, and the Positive and Negative Affectivity Scale. The Client Satisfaction Questionnaire-8 assessed program satisfaction. Data on 77 offenders were analyzed. All participated in the STEPPS program and 53% completed all 20 weeks. The analysis showed that there were no significant differences in response to STEPPS in terms of sex, age, or race/ethnicity on any of the three efficacy measures. Women expressed greater satisfaction than men, but there were no differences with regard to age or race/ethnicity. The implications of the findings are discussed.

Outcome Trajectories and Prognostic Factors for Suicide and Self-Harm Behaviors in Patients With Borderline Personality Disorder Following One Year of Outpatient Psychotherapy

This study examined suicide and self-harm trajectories in 180 individuals with BPD receiving dialectical behavior therapy or general psychiatric management in a randomized controlled trial. Suicide and self-harm behaviors were assessed at baseline, every four months throughout treatment, and every 6 months over 2 years of follow-up. Latent class growth mixture modeling identified suicide and self-harm trajectories. Multinomial logistic regression analyses examined baseline patient characteristics. Three latent subgroups were identified. The largest responded rapidly to treatment and sustained a favorable response post-discharge. The second progressed slowly during treatment but achieved and maintained a favorable response. A third subgroup showed a rapid favorable response during treatment, however symptoms returned to near baseline levels post-discharge. This third subgroup had higher baseline depression, emergency department visits, and unemployment. BPD patients with high baseline health care utilization, depression, and unemployment may benefit from modifications to treatment specifically targeting these issues.

The Pathogenesis and Treatment of Emotion Dysregulation in Borderline Personality Disorder

Uncontrollable emotional lability and impulsivity are a paramount phenomenon of Borderline Personality Disorder (BPD). This paper aims to review theories that entertain emotion dysregulation as the core deficit of BPD and a key factor in the etiology of BPD, in order, then, to propose the author's own theory, which arguably transcends certain limitations of the earlier ones. The author asserts that his psychodynamic theory explains the symptoms of BPD more thoroughly and it inspires a more parsimonious interpretation of brain imaging findings. In closing, the author draws implications of the proposed theory for clinical practice. He reports an efficacy study for treatment of emotion dysregulation based on that theory.

Psychotic symptoms in patients with borderline personality disorder: prevalence and clinical management

PURPOSE OF REVIEW

The aim of this article is to review findings on the prevalence, phenomenology and treatment of psychotic features in borderline personality disorder (BPD), and to discuss factors that might be related to their occurrence.

RECENT FINDINGS

Of patients with BPD about 20-50% report psychotic symptoms. Hallucinations can be similar to those in patients with psychotic disorders in terms of phenomenology, emotional impact, and their persistence over time. Although more research is needed on the exact nature of psychotic phenomena in patients with BPD, terms like pseudo-psychotic or quasi-psychotic are misleading and should be avoided. Childhood trauma might play an important role in the development of psychotic symptoms in patients with BPD, as in other populations. More research is necessary on the role of comorbid disorders, especially posttraumatic stress disorder (PTSD). Atypical antipsychotics seem to be beneficial in some patients; evidence on psychotherapy of psychotic symptoms is sparse.

SUMMARY

Psychotic symptoms, especially hallucinations, seem to be an important feature of BPD. More research on potential mediators and adequate treatment approaches for psychotic symptoms in BPD is needed, and current diagnostic systems might require revision to emphasise psychotic symptoms.

Crisis interventions for people with borderline personality disorder

BACKGROUND

People with borderline personality disorder (BPD) frequently present to health services in crisis, often involving suicidal thoughts or actions. Despite this, little is known about what constitutes effective management of acute crises in this population.

OBJECTIVES

To review the evidence for the effectiveness of crisis interventions for adults with BPD in any setting. For the purposes of the review, we defined crisis intervention as 'an immediate response by one or more individuals to the acute distress experienced by another individual, which is designed to ensure safety and recovery and lasts no longer than one month.'

SEARCH METHODS

We searched the following databases in September 2011: CENTRAL (The Cochrane Library 2011, Issue 3), MEDLINE (1948 to August Week 5 2011), MEDLINE In Process & Other Non-indexed Citations (8 September 2011), EMBASE (1980 to Week 36 2011), PsycINFO (1806 to September Week 1 2011), CINAHL (1937 to current), Social Services Abstracts (1979 to current), Social Care Online (12 September 2011), Science Citation Index (1970 to current), Social Science Citation Index (1970 to current), Conference Proceedings Citation Index - Science (1990 to current), Conference Proceedings Citation Index - Social Science and Humanities (1990 to current) and ZETOC Conference proceedings (12 September 2011). We searched for dissertations in WorldCat (12 September 2011), Australasian Digital Theses Program (ADTP; 12 September 2011), Networked Digital Library of Theses and Dissertations (NDLTD), 12 September 2011 and Theses Canada Portal (12 September 2011). We searched for trials in the International Clinical Trials Registry Platform (ICTRP) and searched reference lists from relevant literature. We contacted the 10 most published researchers in the field of BPD (as indexed by BioMed Experts), in addition to contacting topic experts, Marsha Linehan, Arnoud Arntz and Paul Links, about ongoing trials and unpublished data.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing crisis interventions with usual care or no intervention or a waiting list control for adults of any age with BPD.

DATA COLLECTION AND ANALYSIS

Two authors independently screened titles, abstracts and full-text articles and assessed these against the inclusion criteria.

MAIN RESULTS

The search identified 15 studies, 13 of which we excluded. Reasons for exclusion were: lack of randomisation (N = 8); retrospective design (N = 2); or the intervention was a complex psychological therapy lasting longer than one month (N = 3). We identified two ongoing RCTs that met the inclusion criteria, with a combined predicted sample size of 688. These trials are ongoing and the results are therefore not included in the review, although they will be incorporated into future updates.

AUTHORS' CONCLUSIONS

A comprehensive search of the literature showed that currently there is no RCT-based evidence for the management of acute crises in people with BPD and therefore we could not reach any conclusions about the effectiveness of any single crisis intervention. High-quality, large-scale, adequately powered RCTs in this area are urgently needed.