Comorbidity study of borderline personality disorder: applying association rule mining to the Taiwan national health insurance research database

Elevated risk of sexually transmitted infections among adolescents and young adults with borderline personality disorder: a retrospective longitudinal nationwide population-based study

In this study, we examined the risk of sexually transmitted infections (STIs) among adolescents and young adults (AYAs) with borderline personality disorder (BPD). A total of 4649 AYAs with BPD and 46,490 age-, sex-, and socioeconomic-matched controls without BPD were enrolled from the National Health Insurance Research Database of Taiwan from 2001 to 2009 and were followed up until the end of 2011. Participants who contracted any STI during the follow-up period were identified. Cox regression analysis was conducted to examine the risk of contracting any STI among both patients and controls. A total of 4649 AYAs with BPD and 46,490 age-, sex-, and socioeconomic-matched controls without BPD were enrolled from the National Health Insurance Research Database of Taiwan from 2001 to 2009 and were followed up until the end of 2011. Participants who contracted any STI (ICD-9-CM code 042, 091-097, 087.11, 078.8, 078.88, 131, and 054.1) during the follow-up period were identified. Cox regression and sub-analyses stratified by sex, age, psychiatric comorbidity subgroups, and psychotropic medication usage were conducted to assess STI risk. AYAs with BPD were at a higher risk of contracting any STI (hazard ratio [HR] = 50.79, 95% confidence interval [CI] = 33.45-77.11) in comparison with controls, including HIV, syphilis, genital warts, gonorrhea, chlamydia, trichomoniasis, and genital herpes. The association of BPD with an increased risk of any STI was prevalent in both sexes, adolescents, and young adult patients. BPD with or without psychiatric comorbid subgroup were all associated with an elevated risk of contracting any STI relative to the control group. AYAs with BPD are highly susceptible to contracting STIs. Future studies should examine the role of the core symptoms of BPD, sexual orientation, risky sex behaviors, depressive and anxiety symptoms, and substance use before sex in the risk of STIs among AYAs with BPD.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Cholesterol alone or in combination is associated with frailty among community-dwelling older adults: A cross-sectional study

BACKGROUND

Biological markers contribute to the precise intervention across the continuum of frailty severity. Few studies have explored the advantages of biological markers collected as part of primary care data among community-dwelling older adult population and controversy remains regarding the classic biological markers for frailty.

METHODS

We recruited a total of 8791 adults with a mean age of 71.95 years who met the inclusion and exclusion criteria in Guancheng District and Dalang Town, Dongguan, China. Frailty was assessed by a Chinese frailty evaluation scale. Frailty status was classified with 33-item modified frailty index and latent class analysis was applied to explore the latent classes (subtypes) of frailty. We measured biological markers on blood samples collected. We identify association between specific biological markers or patterns and frailty by logistic regression and association rule mining (ARM) based on the Apriori algorithm.

RESULTS

Multivariable analysis of our data showed that an elevated white blood cell (WBC) count and high cholesterol (CHOL) level were associated with pre-frailty (adjusted odds ratio [aOR] = 1.231, 95 % confidence interval [CI] = 1.009-1.501; aOR = 0.703, 95 % CI = 0.623-0.793) and frailty (aOR = 1.500, 95 % CI = 1.130-1.993; aOR = 0.561, 95 % CI = 0.461-0.684) compared with the normal groups. Importantly, significantly high level of CHOL was associated with a lower risk of four frailty subtypes compared with relatively healthy participants with the most power of association in the multi-frail group (aOR = 0.182, 95 % CI = 0.086-0.386). Based on ARM technique to develop correlation analysis to identify important high-risk clusters among older adult transitions from non-frail to frailty, patterns for normal level of CHOL co-occurred with an elevated creatinine (CREA) level have a significant association with the risk of frailty (aOR = 7.787, 95 % CI = 1.978-30.648) after adjusting for targeted confounders.

CONCLUSIONS

Our study highlights the correlation between classic biological markers, especially CHOL and frailty status and subtypes among community-dwelling older adult, in the primary care setting. Further large-scale prospective studies are still needed to confirm the role of classic biological markers in frailty.

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.

Comorbidity combinations in schizophrenia inpatients and their associations with service utilization: A medical record-based analysis using association rule mining

BACKGROUND

Comorbidities are common among patients with schizophrenia yet the prevalence of comorbidity combinations and their associations with inpatient service utilization and readmission have been scarcely explored.

METHODS

Data were extracted from discharge summaries of patients whose primary diagnosis was schizophrenia spectrum disorders (ICD-10: F20-F29). We identified 30 most frequent comorbidities in patients' secondary diagnoses and then used the association rule mining (ARM) method to derive comorbidity combinations associated with length of stay (LOS), daily expense and one-year readmission.

RESULTS

The study included data from 8252 patients. The top five most common comorbidities were extrapyramidal syndrome (EPS, 44.58%), constipation (31.63%), common cold (21.80%), hyperlipidemia (20.99%) and tachycardia (19.13%). Most comorbidity combinations identified by ARM were significantly associated with longer LOS (≥70 days), few were associated with higher daily expenses, and fewer with readmission. The 3-way combination of common cold, hyperlipidemia and fatty liver had the strongest association with longer LOS (adjusted OR (aOR): 3.38, 95% CI: 2.12-5.38). The combination of EPS and mild cognitive disorder was associated with higher daily expense (≥700 RMB) (aOR: 1.67, 95% CI: 1.20-2.31). The combination of constipation, tachycardia and fatty liver were associated with higher 1-year readmission (aOR: 2.05, 95% CI: 1.03-4.09).

CONCLUSION

EPS, constipation, and tachycardia were among the most commonly reported comorbidities in schizophrenia patients in Beijing, China. Specific groups of comorbidities may contribute to higher inpatient psychiatric service utilization and readmission. The mechanism behind the associations and potential interventions to optimize service use warrant further investigation.

Validity and Reliability of the Urdu Version of the McLean Screening Instrument for Borderline Personality Disorder

Introduction: Although the translation and the validation of the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) are performed in various languages and samples, no study has established the validity and reliability of the Urdu version of MSI-BPD in individuals with cardiac problems. Materials and Methods: The Urdu version of the MSI-BPD was prepared through the standard back-translation method. The translation and adaption were completed in four steps: forward translation, adaption and translation, back translation and committee approach, and cross-language validation. The sample, selected through the purposive sampling method, comprised of 150 adults with cardiac problems (men = 75 and women = 75), with an age range of 23-78 years (M = 55, SD = 10.6). The Cronbach alpha reliability and factorial validity of the MSI-BPD were assessed through confirmatory factor analysis (CFA) and Pearson correlation analyses. Internal consistency and test-retest reliability (at 2 weeks' interval) were used to evaluate the reliability. Statistical analyses were performed, using SPSS (version 22) and Structural Equation Modeling (SEM) software. Results: Preliminary analysis revealed that the overall instrument had good internal consistency (Urdu MSI-BPD α = 0.79; English MSI-BPD α = 0.77) as well as test-retest correlation coefficients for 15 days (r = 0.94). Conclusions: Findings suggested that the MSI-BPD, with important limitations, can be used as an effective preliminary screening tool to measure BPD in Urdu-speaking adults with cardiac problems. Further validations should be conducted to make the translated version of the MSI-BPD an appropriate tool to screen BPD in hospitals and mental health care settings.

Comorbidity Patterns of Mood Disorders in Adult Inpatients: Applying Association Rule Mining

This study explored physical and psychiatric comorbidities of mood disorders using association rule mining. There were 7709 subjects who were patients (≥19 years old) diagnosed with mood disorders and included in the data collected by the Korean National Hospital Discharge In-depth Injury Survey (KNHDS) between 2006 and 2018. Physical comorbidities (46.17%) were higher than that of psychiatric comorbidities (27.28%). The frequent comorbidities of mood disorders (F30-F39) were hypertensive diseases (I10-I15), neurotic, stress-related and somatoform disorders (F40-F48), diabetes mellitus (E10-E14), and diseases of esophagus, stomach, and duodenum (K20-K31). The bidirectional association path of mood disorders (F30-F39) with hypertensive diseases (I10-I15) and diabetes mellitus (E10-E14) were the strongest. Depressive episodes (F32) and recurrent depressive disorders (F33) revealed strong bidirectional association paths with other degenerative diseases of the nervous system (G30-G32) and organic, including symptomatic and mental disorders (F00-F09). Bipolar affective disorders (F31) revealed strong bidirectional association paths with diabetes mellitus (E10-E14) and hypertensive diseases (I10-I15). It was found that different physical and psychiatric disorders are comorbid according to the sub-classification of mood disorders. Understanding the comorbidity patterns of major comorbidities for each mood disorder can assist mental health providers in treating and managing patients with mood disorders.

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

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

DISCUSSION

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

General rather than specific: Cognitive deficits in suppressing task irrelevant stimuli are associated with buying-shopping disorder

Objective

To investigate associations between buying-shopping disorder (BSD) propensity and the performance in the Stroop Matching Task. This task measures stimulus interference, one specific component of behavioral impulsivity, using neutral (i.e. not buying related) stimuli. Deficits thus mirror a general rather than a specific deficit to resist task-irrelevant stimuli.

Method

222 participants completed the Stroop Matching Task, the Pathological Buying Screener, and various questionnaires assessing clinical background variables as well as trait-impulsivity.

Results

Correlation analyses showed that BSD propensity was associated with poorer performance in the Stroop Matching Task. Multiple regression analyses controlling for related disorders and trait-impulsivity indicated that BSD was the only significant predictor.

Conclusion

These findings indicate that BSD propensity is associated with deficits in the stimulus interference component of behavioral impulsivity, mirroring a general cognitive deficit. Since no other disorder significantly predicted the performance in the Stroop Matching Task, this deficit seems to be unique for BSD.

Collaborative Deprescribing in Borderline Personality Disorder: A Narrative Review

After participating in this activity, learners should be better able to:• Assess medication management in patients with borderline personality disorder (BPD)• Evaluate the role of deprescribing as an active intervention in patients with BPD treated with polypharmacy ABSTRACT: Psychopharmacology in borderline personality disorder (BPD) is complicated by comorbid disorders, substance use, sensitivity to side effects, risk of self-harm through medication misuse, and intense but transient symptoms. Patients' relationships with medications may range from tenuous to highly enmeshed, and may profoundly influence the response to treatment. For these reasons, awareness of current evidence and flexible approaches are particularly relevant to prescribing in BPD. In this narrative review, we illustrate the current status of medication management in BPD by focusing on polypharmacy. We use a single vignette to explore the limitations of prescribing multiple medications and the factors contributing to polypharmacy. With the same vignette, and using the framework of deprescribing, we describe how medication regimens can be reduced to a necessary minimum. Deprescribing, originally developed in geriatric medicine, is an active intervention that involves a risk-benefit analysis for each medication, keeping in mind the patient's medical and psychiatric status and his or her preferences and values. Deprescribing lends itself well to use in psychiatry and especially in BPD because of its emphasis on the patient's preferences and on repeated conversations to revisit and update decisions. In addition to elaborating on the deprescribing framework, we provide recommendations for conducting these critical discussions about medications in BPD, with particular attention to the patient's relationship to the medication. Finally, we summarize our recommendations and strategies for implementing flexible and responsive medication management for patients with BPD. We suggest areas of future research, including testing the efficacy of targeted intermittent medication treatments.

Medication Use and the Risk of Newly Diagnosed Diabetes in Patients with Epilepsy

Epilepsy is a common neurological disorder that affects millions of people worldwide. Patients with epilepsy generally require long-term antiepileptic therapy and many of them receive polypharmacy. Certain medications, including older-generation antiepileptic drugs, have been known to predispose patients to developing diabetes. Although data mining techniques have become widely used in healthcare, they have seldom been applied in this clinical problem. Here, the authors used association rule mining to discover drugs or drug combinations that may be associated with newly diagnosed diabetes. Their findings indicate in addition to the most common culprits such as phenytoin and valproic acid, prescriptions containing carbamazepine, oxcarbazepine, or lamotrigine may be related to the development of newly diagnosed diabetes. These mined rules are useful as guidance to both clinical practice and future research.

Borderline personality disorder is associated with an increased risk of sexually transmitted infections: A nationwide population-based cohort study in Taiwan

BACKGROUND

Several features of borderline personality disorder (BPD) are likely to be associated with sexual health problems, such as unstable attachment, unstable sexual identity and sexual impulsivity. Since the issue of sex is not openly discussed in Taiwanese society, sexual health needs, including screening and prevention of sexually transmitted infections (STI), are often neglected in this population.

OBJECTIVE

The study aims to determine whether BPD is associated with an increased risk of subsequent STI in Taiwan.

METHODS

Overall 669 patients with BPD and 2676 controls matched by gender and age were enrolled between 2000 and 2012 and followed until the end of 2013 using Taiwan's National Health Insurance Research Database. During the follow-up period, participants who developed STI (human immunodeficiency virus, syphilis, genital warts, gonorrhoea, chlamydia and trichomoniasis) were identified. Cox regression analysis was used to calculate the hazard ratio (HR) with 95% confidence interval (CI) of the STI incidence rate between patients with BPD and unaffected controls.

RESULTS

Patients with BPD were predisposed to developing STI (HR: 4.17, 95% CI 1.62 to 10.8) after adjusting for demographic data and psychiatric comorbidities. The stratification analysis revealed a similar risk trend with BPD and subsequent STI in each gender and age group and was significant in the subgroups of male (HR: 11.3, 95% CI 2.97 to 42.7) and those aged 18-34 years (HR: 4.85, 95% CI 1.71 to 13.7). Also, the comorbidity stratification analysis revealed that, when the effect of comorbidities was excluded, patients with pure BPD significantly exhibited the risk association for subsequent STI after adjusting for all variables (HR: 4.24, 95% CI 1.25 to 14.4).

CONCLUSION

Given the greater potential of BPD to be associated with an increased risk of STI, there should be direct implications for the development of targeted prevention interventions in Taiwan's mental health clinics.

Statin and metformin therapy in prostate cancer patients with hyperlipidemia who underwent radiotherapy: a population-based cohort study

Purpose

To evaluate the association between the use of statins and/or metformin and patient survival in prostate cancer patients in Taiwan.

Subjects and methods

Newly diagnosed prostate cancer patients who had hyperlipidemia and received radiotherapy were identified from the National Health Insurance Research Database 2000–2010. The survival rate was estimated by the Kaplan–Meier method. Univariate and multivariate Cox regression analyses were performed to examine the association of mortality. Sensitivity analysis was performed to assess the risk of mortality in patients with diabetes.

Results

The study included 567 patients. Patients who used statins or metformin after prostate cancer diagnosis had longer average survival times (9.3 years and 8.1 years, respectively; P=0.001) compared with patients who persistently used or used the medicines prior to cancer diagnosis. Multivariate Cox regression analysis found that patients treated with statins after cancer diagnosis were significantly associated with a lower risk of mortality (aHR =0.24, 95% CI =0.09–0.66) compared to patients who did not use statins during the study period. Patients treated with metformin after cancer diagnosis were significantly associated more with an increased risk of mortality (aHR =6.78, 95% CI =2.45–18.77) compared to patients who did not use metformin during the study period. Sensitivity analysis revealed that the average survival time was similar among different medicine use groups in patients with diabetes.

Conclusion

The finding suggests that statins and metformin use after prostate cancer diagnosis may increase survival in patients with hyperlipidemia and radiotherapy.

Fluvoxamine treatment response prediction in obsessive-compulsive disorder: association rule mining approach

BACKGROUND

Obsessive-compulsive disorder (OCD) is a debilitating psychiatric disorder characterized by intrusive thoughts or repetitive behaviors. Clinicians use serotonin reuptake inhibitors (SRIs) for OCD treatment, but 40%-60% of the patients do not respond to them adequately. Here, we described an association rule mining approach for treatment response prediction using an Iranian OCD data set.

PATIENTS AND METHODS

Three hundred and thirty OCD patients fulfilling DSM-5 criteria were initially included, but 151 subjects completed their pharmacotherapy which was defined as 12-week treatment with fluvoxamine (150-300 mg). Treatment response was considered as >35% reduction in the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score. Apriori algorithm was applied to the OCD data set for extraction of the association rules predicting response to fluvoxamine pharmacotherapy in OCD patients. We considered the association of each attribute with treatment response using interestingness measures and found important attributes that associated with treatment response.

RESULTS

Results showed that low obsession and compulsion severities, family history of mental illness, illness duration less than 5 years, being married, and female were the most associated variables with responsiveness to fluvoxamine pharmacotherapy. Meanwhile, if an OCD patient reported a family history of mental illness and his/her illness duration was less than 5 years, he/she responded to 12-week fluvoxamine pharmacotherapy with the probability of 91%. We also found useful and applicable rules for resistant and refractory patients.

CONCLUSION

This is the first study where association rule mining approach was used to extract predicting rules for treatment response in OCD. Application of this method in personalized medicine may help clinicians in taking the right therapeutic decision.

Borderline Personality Disorder With Cocaine Dependence: Impulsivity, Emotional Dysregulation and Amygdala Functional Connectivity

Background: Borderline personality disorder is present in 19% of cocaine dependence cases; however, this dual pathology is poorly understood. We wished to characterize the dual pathology and find its functional connectivity correlates to better understand it. Methods: We recruited 69 participants divided into 4 groups: dual pathology (n = 20), cocaine dependence without borderline personality disorder (n = 19), borderline personality without cocaine dependence (n = 10) and healthy controls (n = 20). We used self-reported instruments to measure impulsivity and emotional dysregulation. We acquired resting state fMRI and performed seed-based analyses of the functional connectivity of bilateral amygdala. Results: Borderline personality disorder and cocaine dependence as factors had opposing effects in impulsivity and emotional dysregulation, as well as on functional connectivity between left amygdala and medial prefrontal cortex. On the other hand, in the functional connectivity between right amygdala and left insula, the effect of having both disorders was instead additive, reducing functional connectivity strength. The significant functional connectivity clusters were correlated with impulsivity and emotional dysregulation. Conclusions: In this study, we found that clinical scores of dual pathology patients were closer to those of borderline personality disorder without cocaine dependence than to those of cocaine dependence without borderline personality disorder, while amygdala-medial prefrontal cortex functional connectivity patterns in dual pathology patients were closer to healthy controls than expected.