Evidence of practice gaps in emergency psychiatric care for borderline personality disorder: how can this be explained?

Diagnostic profiles among suicide decedents with and without borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is a debilitating condition characterized by pervasive instability across multiple major domains of functioning. The majority of persons with BPD engage in self-injury and up to 10% die by suicide - rendering persons with this condition at exceptionally elevated risk of comorbidity and premature mortality. Better characterization of clinical risk factors among persons with BPD who die by suicide is urgently needed.

METHODS

We examined patterns of medical and psychiatric diagnoses (1580 to 1700 Phecodes) among persons with BPD who died by suicide (n = 379) via a large suicide death data resource and biobank. In phenotype-based phenome-wide association tests, we compared these individuals to three other groups: (1) persons who died by suicide without a history of BPD (n = 9468), (2) persons still living with a history of BPD diagnosis (n = 280), and (3) persons who died by suicide with a different personality disorder (other PD n = 589).

RESULTS

Multivariable logistic regression models revealed that persons with BPD who died by suicide were more likely to present with co-occurring psychiatric diagnoses, and have a documented history of self-harm in the medical system prior to death, relative to suicides without BPD. Posttraumatic stress disorder was more elevated among those with BPD who died by suicide relative to the other PD group.

CONCLUSIONS

We found significant differences among persons with BPD who died by suicide and all other comparison groups. Such differences may be clinically informative for identifying high-risk subtypes and providing targeted intervention approaches.

A systematic review and meta-analysis of digital interventions targeted at individuals with borderline personality disorder (BPD), emotionally unstable personality disorder (EUPD), and related symptoms

OBJECTIVES

The present review investigates the impact of digital interventions for individuals with features of borderline personality disorder (BPD)/emotional unstable personality disorder (EUPD) as digital interventions show promise as therapeutic tools in underserved groups. BPD/EUPD features are identified as clinically relevant, yet previous reviews on the use of digital interventions fail to include subthreshold symptomatology.

METHODS

Five online databases were searched for terminology in three categories: BPD/EUPD and related symptoms, mental-health interventions, and digital technology. Additionally, four relevant journals and two trial registers were searched for additional papers meeting the inclusion criteria.

RESULTS

Twelve articles met all inclusion criteria. Meta-analyses revealed statistically significant differences in symptom measures between intervention and control groups at postintervention and decreases in BPD/EUPD symptomatology and well-being from pre- to postintervention. Service users' engagement, satisfaction, and acceptability of interventions were high. Results support the previous literature on the value of using digital interventions in populations with BPD/EUPD.

CONCLUSION

Overall, it was identified that digital interventions show promise for successful implementation with this population.

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

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

Factors associated with a borderline personality disorder diagnosis in the emergency department

INTRODUCTION

Research on borderline personality disorder (BPD) has shown that less intensive care is especially effective when patients have been told about their condition. However, problems with diagnosing the disorder are also described in the literature. This study thus aims to explore the factors associated with the challenges of identifying and then communicating a BPD diagnosis to patients.

METHODS

We analyzed a database of 202 patients of Toulouse University Hospital (France) who had a CIM-10 F60.3 diagnosis. This data was used to identify the sociodemographic and clinical benchmarks associated with patients who had received an established BPD diagnosis prior to their attendance at the hospital's emergency department (ED) in the study period.

RESULTS

Sixty-three percentage of the patients admitted to our psychiatric ED had been given an earlier diagnosis of BPD. Those who had not been diagnosed were more likely to: not have undergone any psychiatric follow-up; not have been hospitalized in the psychiatry department; and not have previously attended at the ED. Patients with BPD and a comorbidity of MDD were also less likely to have received a BPD diagnosis before their ED admission.

CONCLUSION

This study found that patients without an established BPD diagnosis who present at the ED are more likely to not be known to the psychiatric care system. This suggests that EDs have a specific role to play in making a diagnosis and the subsequent orientation of care.

Developing and Testing a Local Expert-Based Reading Process for Use to Examine Discrepancies Between Guidelines and Current Clinical Practices

The use of relevant guidelines is critical in psychiatric clinical practice to ensure the homogeneity of the global care provided. Consequently, it is important to identify whether they are utilized successfully and, if not, why. This would enable pragmatic solutions to be agreed to improve the organization of care and the removal of any barriers to the guidelines' implementation. The first step in this process, before any exploration of the limitations of the guidelines themselves, involves a determination of whether they are actually applied in clinical practice. We therefore evaluated discrepancies between the guidelines relating to patients with borderline personality disorder and current practices in the psychiatric Emergency Department at Toulouse University Hospital. This was achieved using a reading process involving a panel of eight local experts who analyzed relevant medical files extracted from a database. They were guided by, and instructed to answer, six standardized questions in relation to each file to determine the method's feasibility. A total of 333 files were analyzed to determine whether, in the local experts' judgment, the care provided reflected current guidance. This reading process revealed substantial agreement (0.85%; Fleiss Kappa -0.69), which is a promising outcome and suggests that such methods could be used in future protocols. Moreover, the process is practical and reliable and requires very few materials.