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Lau P, Amestoy ME, Roth M, Monson C. Patient-related factors associated with patient retention and non-completion in psychosocial treatment of borderline personality disorder: A systematic review. Personal Ment Health 2024. [PMID: 38807472 DOI: 10.1002/pmh.1627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 02/22/2024] [Accepted: 05/12/2024] [Indexed: 05/30/2024]
Abstract
The potential efficacy of psychosocial interventions in the treatment of borderline personality disorder (BPD) is impacted by significant treatment non-completion (TNC), with meta-analytic studies reporting rates of attrition of between 25% and 28%. Increasing patient retention could facilitate outcomes and improve resource utilization, given limited healthcare services. A systematic search of PsycINFO, CINAHL, EMBASE, CENTRAL, and Web of Science Core Collection identified 33 articles that met the criteria for inclusion. Although substantial heterogeneity in terms of methodology and quality of analysis limited conclusions that could be drawn in the narrative review, a few consistent patterns of findings were elucidated, such as Cluster B personality disorder comorbidities and lower therapeutic alliance were associated with TNC. Interestingly, the severity of BPD symptoms was not a predictor of TNC. These findings are discussed in terms of their potential theoretical contribution to TNC. Clinically, there may be value in applying mindfulness and motivational interviewing strategies early on in treatment for individuals who present uncertainty about engaging in treatment. Further research to develop this empirical landscape includes focusing on high-powered replications, examining burgeoning lines of research, and investigating dynamic predictors of TNC.
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Affiliation(s)
- Parky Lau
- Toronto Metropolitan University (formerly Ryerson University), Toronto, ON, Canada
| | - Maya E Amestoy
- University of Toronto Scarborough, Scarborough, ON, Canada
| | - Maya Roth
- Toronto Metropolitan University (formerly Ryerson University), Toronto, ON, Canada
- St Joseph's Healthcare London, London, ON, Canada
- Department of Psychiatry, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Candice Monson
- Toronto Metropolitan University (formerly Ryerson University), Toronto, ON, Canada
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2
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Gammino L, Pelizza L, Emiliani R, D'Adda F, Lupoli P, Pellegrini L, Berardi D, Menchetti M. Cognitive disturbances basic symptoms in help-seeking patients with borderline personality disorder: Characteristics and association with schizotypy. Early Interv Psychiatry 2024. [PMID: 38778517 DOI: 10.1111/eip.13557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 02/04/2024] [Accepted: 05/08/2024] [Indexed: 05/25/2024]
Abstract
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.
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Affiliation(s)
- Lorenzo Gammino
- Department of Mental Health and Addiction DSM-DP, Azienda USL di Bologna, Bologna, Italy
| | - Lorenzo Pelizza
- Department of Biomedical and Neuromotor Sciences DIBINEM, University of Bologna, Bologna, Italy
| | - Roberta Emiliani
- Department of Mental Health and Addiction DSM-DP, Azienda USL di Imola, Imola, Italy
| | - Francesca D'Adda
- Department of Mental Health and Addiction DSM-DP, Azienda USL di Bologna, Bologna, Italy
| | - Pasqualino Lupoli
- Department of Mental Health and Addiction DSM-DP, Azienda USL di Bologna, Bologna, Italy
| | - Luca Pellegrini
- Hertfordshire Partnership NHS University Foundation Trust, Welwyn Garden City, UK
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
- Centre for Psychedelic Research, Imperial College London, London, UK
| | - Domenico Berardi
- Department of Biomedical and Neuromotor Sciences DIBINEM, University of Bologna, Bologna, Italy
| | - Marco Menchetti
- Department of Biomedical and Neuromotor Sciences DIBINEM, University of Bologna, Bologna, Italy
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3
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Smits ML, Feenstra DJ, Blankers M, Kamphuis JH, Bales DL, Dekker JJM, Verheul R, Busschbach JJV, Luyten P. Impact of clinical severity on treatment response in a randomized controlled trial comparing day hospital and intensive outpatient mentalization-based treatment for borderline personality disorder. Personal Ment Health 2024; 18:148-156. [PMID: 38298020 DOI: 10.1002/pmh.1603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/23/2023] [Accepted: 01/02/2024] [Indexed: 02/02/2024]
Abstract
This study examined the impact of clinical severity on treatment outcome in two programs that differ markedly in treatment intensity: day hospital mentalization-based treatment (MBT-DH) and intensive outpatient mentalization-based treatment (MBT-IOP) for borderline personality disorder (BPD). A multicenter randomized controlled trial was conducted. Participants include the full intention-to-treat sample of the original trial of N = 114 randomized BPD patients (MBT-DH n = 70, MBT-IOP n = 44), who were assessed at baseline and subsequently every 6 up to 36 months after start of treatment. Outcomes were general symptom severity, borderline features, and interpersonal functioning. Clinical severity was examined in terms of severity of BPD, general symptom severity, comorbid symptom disorders, comorbid personality disorders, and cluster C personality features. None of the severity measures was related to treatment outcome or differentially predicted treatment outcome in MBT-DH and MBT-IOP, with the exception of a single moderating effect of co morbid symptom disorders on outcome in terms of BPD features, indicating less improvement in MBT-DH for patients with more symptom disorders. Overall, patients with varying levels of clinical severity benefited equally from MBT-DH and MBT-IOP, indicating that clinical severity may not be a useful criterion to differentiate in treatment intensity.
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Affiliation(s)
| | | | - Matthijs Blankers
- Department of Research, Arkin Mental Health Care, Amsterdam, Netherlands
- Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, Netherlands
- Amsterdam UMC, Location AMC, Department of Psychiatry, University of Amsterdam, Amsterdam, Netherlands
| | - Jan H Kamphuis
- Department of Psychology, University of Amsterdam, Amsterdam, Netherlands
| | - Dawn L Bales
- GGZ Breburg, Breda, Netherlands
- MBT-Expertise, Breda, Netherlands
| | - Jack J M Dekker
- Department of Research, Arkin Mental Health Care and Department of Clinical Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | - Jan J V Busschbach
- Department of Psychiatry, Section of Medical Psychology and Psychotherapy, Erasmus MC, Rotterdam, Netherlands
| | - Patrick Luyten
- Faculty of Psychology and Educational Sciences, University of Leuven, Leuven, Belgium
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
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4
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Thomson M, Cavelti M, Lerch S, Koenig J, Reichl C, Mürner-Lavanchy I, Wyssen A, Kaess M. Clinical profiles of adolescent personality pathology: a latent structure examination of the Semi-Structured Interview for Personality Functioning DSM-5 (STiP-5.1) in a help-seeking sample. Borderline Personal Disord Emot Dysregul 2024; 11:9. [PMID: 38589974 PMCID: PMC11003081 DOI: 10.1186/s40479-024-00252-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/25/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Despite the introduction of dimensional conceptualisations of personality functioning in the latest classification systems, such as Criterion A of the Alternative Model of Personality Disorders in the DSM-5, heterogeneous clinical presentation of personality pathology remains a challenge. Relatedly, the latent structure of personality pathology as assessed by the Semi-Structured Interview for Personality Functioning DSM-5 (STiP-5.1) has not yet been comprehensively examined in adolescents. Therefore, this study aimed to examine the latent structure of the STiP-5.1, and, based on those findings, to describe any unique clinical profiles that might emerge. METHODS The final sample comprised 502 participants aged 11-18 years consecutively recruited from a specialised personality disorder outpatient service, as well as general day clinic and inpatient wards at the University Hospital University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University Hospital Bern, Switzerland. Participants were assessed using the STiP-5.1, as well as a battery of other psychological measures by clinical psychologists or trained doctoral students. Variations of Factor Analysis, Latent Class Analysis and Factor Mixture Models (FMM) were applied to the STiP-5.1 to determine the most appropriate structure. RESULTS The best fitting model was an FMM comprising four-classes and two factors (corresponding to self- and interpersonal-functioning). The classes differed in both overall severity of personality functioning impairment, and in their scores and clinical relevance on each element of the STiP-5.1. When compared to the overall sample, classes differed in their unique clinical presentation: class 1 had low impairment, class 2 had impairments primarily in self-functioning with high depressivity, class 3 had mixed levels of impairment with emerging problems in identity and empathy, and class 4 had severe overall personality functioning impairment. CONCLUSIONS A complex model incorporating both dimensional and categorical components most adequately describes the latent structure of the STiP-5.1 in our adolescent sample. We conclude that Criterion A provides clinically useful information beyond severity (as a dimensional continuum) alone, and that the hybrid model found for personality functioning in our sample warrants further attention. Findings can help to parse out clinical heterogeneity in personality pathology in adolescents, and help to inform early identification and intervention efforts.
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Affiliation(s)
- Madelyn Thomson
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Marialuisa Cavelti
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Stefan Lerch
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Julian Koenig
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Corinna Reichl
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Ines Mürner-Lavanchy
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Andrea Wyssen
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Michael Kaess
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland.
- Department of Child and Adolescent Psychiatry, Centre for Psychosocial Medicine, University of Heidelberg, Heidelberg, Germany.
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5
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Natividad A, Huxley E, Townsend ML, Grenyer BFS, Pickard JA. What aspects of mindfulness and emotion regulation underpin self-harm in individuals with borderline personality disorder? J Ment Health 2024; 33:141-149. [PMID: 36916308 DOI: 10.1080/09638237.2023.2182425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 11/16/2022] [Indexed: 03/16/2023]
Abstract
BACKGROUND Self-harm presents significant risk for individuals with borderline personality disorder (BPD). Both self-harm and BPD are associated with deficits in mindfulness and emotion dysregulation. Previous research suggests that thought suppression and emotional inexpressivity may underpin self-harm in people with BPD, suggesting potential links to self-harm functions common for those with BPD. More research is needed to strengthen our understanding of this relationship. AIMS This study examines how BPD symptoms, mindfulness, emotion dysregulation and self-harm functions are related. METHODS Australian community outpatients diagnosed with BPD (N = 110) completed measures of mindfulness, emotion dysregulation and self-harm functions. Serial mediation analyses were conducted to examine relationships between variables. RESULTS BPD symptoms, chronic emptiness, mindfulness skills, describing and non-reacting, emotion dysregulation areas of emotion regulation strategies and poor emotional clarity were associated with recent self-harm. Various combinations of describing, strategies and clarity mediated the path between emptiness and self-harm functions more likely to be endorsed by individuals with a diagnosis of BPD. Describing was associated with all but anti-suicide function, while strategies was associated with all but anti-dissociation. CONCLUSION The study highlights how individuals with BPD experiencing chronic emptiness may benefit from treatment targeting describing skills and adaptive emotion regulation strategies.
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Affiliation(s)
- Ana Natividad
- School of Psychology, University of Wollongong, Wollongong, Australia
| | - Elizabeth Huxley
- School of Psychology, University of Wollongong, Wollongong, Australia
| | | | - Brin F S Grenyer
- School of Psychology, University of Wollongong, Wollongong, Australia
| | - Judy A Pickard
- School of Psychology, University of Wollongong, Wollongong, Australia
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Pelizza L, Leuci E, Quattrone E, Azzali S, Paulillo G, Pupo S, Pellegrini P, Gammino L, Biancalani A, Menchetti M. Borderline personality disorder vs. schizophrenia spectrum disorders in young people recruited within an "Early Intervention in Psychosis" service: clinical and outcome comparisons. Eur Arch Psychiatry Clin Neurosci 2024:10.1007/s00406-024-01772-5. [PMID: 38472469 DOI: 10.1007/s00406-024-01772-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 01/28/2024] [Indexed: 03/14/2024]
Abstract
Borderline Personality Disorder (BPD) is under-recognized in First-Episode Psychosis (FEP) and its psychotic manifestations are difficult to differentiate from Schizophrenia Spectrum Disorders (SSD). The aim of this investigation was to compare clinical, sociodemographic, and outcome characteristics between FEP patients with BPD vs. FEP subjects with SSD both at baseline and across a 2-year follow-up period. Participants completed the Health of the Nation Outcome Scale (HoNOS), the Positive And Negative Syndrome Scale (PANSS), and the Global Assessment of Functioning (GAF) scale both at entry and every 12 months during the follow-up. A mixed-design ANOVA model was conducted to investigate the temporal stability of clinical scores within and between the two subgroups. Among 356 FEP participants, 49 had a BPD diagnosis. Compared to FEP/SSD (n = 307), FEP/BPD patients showed higher prevalence of employment, current substance use, and past attempted suicide. They had a lower equivalent dose of antipsychotic medication at entry and lower levels of negative symptoms. Finally, they had a higher 2-year drop-out rate and a significant improvement in psychopathological scores limited to the first year of treatment. BPD as categorical entity represents a FEP subgroup with specific clinical challenges. Appropriate treatment guidelines for this FEP subgroup are thus needed.
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Affiliation(s)
- Lorenzo Pelizza
- Department of Biomedical and Neuromotor Sciences, Psychiatry Institute, "Alma Mater Studiorum" Università degli Studi di Bologna, Via Pepoli 5, 40123, Bologna, BO, Italy.
- Department of Mental Health and Pathological Addictions, Azienda USL di Parma, Largo Palli 1/a, 43100, Parma, Italy.
| | - Emanuela Leuci
- Department of Mental Health and Pathological Addictions, Azienda USL di Parma, Largo Palli 1/a, 43100, Parma, Italy
| | - Emanuela Quattrone
- Department of Mental Health and Pathological Addictions, Azienda USL di Parma, Largo Palli 1/a, 43100, Parma, Italy
| | - Silvia Azzali
- Department of Mental Health and Pathological Addictions, Azienda USL-IRCCS di Reggio Emilia, Via Amendola 2, 43100, Reggio Emilia, Italy
| | - Giuseppina Paulillo
- Department of Mental Health and Pathological Addictions, Azienda USL di Parma, Largo Palli 1/a, 43100, Parma, Italy
| | - Simona Pupo
- Division of Pain Medicine, Department of Medicine and Surgery, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43100, Parma, Italy
| | - Pietro Pellegrini
- Department of Mental Health and Pathological Addictions, Azienda USL di Parma, Largo Palli 1/a, 43100, Parma, Italy
| | - Lorenzo Gammino
- Department of Mental Health and Pathological Addictions, Azienda USL di Bologna, Via Castiglione 29, 40124, Bologna, Italy
| | - Arianna Biancalani
- Department of Biomedical and Neuromotor Sciences, Psychiatry Institute, "Alma Mater Studiorum" Università degli Studi di Bologna, Via Pepoli 5, 40123, Bologna, BO, Italy
| | - Marco Menchetti
- Department of Biomedical and Neuromotor Sciences, Psychiatry Institute, "Alma Mater Studiorum" Università degli Studi di Bologna, Via Pepoli 5, 40123, Bologna, BO, Italy
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7
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Duda JM, Fineberg SK, Deng W, Ma Y, Everaert J, Cannon TD, Joormann J. Borderline personality disorder features are associated with inflexible social interpretations. J Affect Disord 2024; 348:78-87. [PMID: 38110156 DOI: 10.1016/j.jad.2023.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 12/06/2023] [Accepted: 12/13/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Borderline personality disorder (BPD) is thought to involve aberrant social learning, including impaired revision of social interpretations with new evidence (social interpretation inflexibility). However, this topic has received little empirical attention outside of specific literatures, such as moral inference or behavioral economics. Further, the contribution of comorbid depression to BPD-related interpretation inflexibility has not yet been assessed. METHODS In two independent samples (Study 1: N = 213; Study 2: N = 210, oversampled for BPD features), we assessed the associations between BPD symptoms, depressive symptoms, and task-based measures of social interpretation flexibility. RESULTS We found that BPD symptoms, particularly volatility of identity and relationships, were associated with less revision of social interpretations with both positive and negative evidence. Meanwhile, depressive symptoms were associated with a pattern of less revision of social interpretations with positive versus negative information. LIMITATIONS The use of cross-sectional, crowdsourced samples limits causal interpretations. Translation to clinical populations should be assessed in future studies. CONCLUSIONS Results suggest that inflexible social interpretations across valences may be a feature of BPD-related pathology, and could be connected to symptoms involving volatility in social contexts. Future studies should investigate whether treatments geared toward increasing the flexibility of social interpretations are effective in treating BPD symptoms, especially those involving interpersonal difficulties.
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Affiliation(s)
- Jessica M Duda
- Department of Psychology, Yale University, New Haven, CT, USA.
| | - Sarah K Fineberg
- Department of Psychiatry, Yale University, New Haven, CT, USA; Connecticut Mental Health Center, New Haven, CT, USA
| | - Wisteria Deng
- Department of Psychology, Yale University, New Haven, CT, USA
| | - Yvette Ma
- Department of Psychology, Yale University, New Haven, CT, USA
| | - Jonas Everaert
- Department of Medical and Clinical Psychology, Tilburg University, the Netherlands; Research Group of Quantitative Psychology and Individual Differences, KU, Leuven, Belgium
| | - Tyrone D Cannon
- Department of Psychology, Yale University, New Haven, CT, USA; Department of Psychiatry, Yale University, New Haven, CT, USA
| | - Jutta Joormann
- Department of Psychology, Yale University, New Haven, CT, USA
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8
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Leichsenring F, Fonagy P, Heim N, Kernberg OF, Leweke F, Luyten P, Salzer S, Spitzer C, Steinert C. Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies. World Psychiatry 2024; 23:4-25. [PMID: 38214629 PMCID: PMC10786009 DOI: 10.1002/wps.21156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2024] Open
Abstract
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.
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Affiliation(s)
- Falk Leichsenring
- Department of Psychosomatics and Psychotherapy, University of Giessen, Giessen, Germany
- Department of Psychosomatics and Psychotherapy, University of Rostock, Rostock, Germany
| | - Peter Fonagy
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Nikolas Heim
- International Psychoanalytic University, Berlin, Germany
| | - Otto F Kernberg
- Personality Disorders Institute, Weill Cornell Medical College, New York, NY, USA
| | - Frank Leweke
- Department of Psychosomatics and Psychotherapy, University of Giessen, Giessen, Germany
| | - Patrick Luyten
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
- Faculty of Psychology and Educational Sciences, University of Leuven, Leuven, Belgium
| | - Simone Salzer
- International Psychoanalytic University, Berlin, Germany
| | - Carsten Spitzer
- Department of Psychosomatics and Psychotherapy, University of Rostock, Rostock, Germany
| | - Christiane Steinert
- Department of Psychosomatics and Psychotherapy, University of Giessen, Giessen, Germany
- International Psychoanalytic University, Berlin, Germany
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9
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Garikana S, Jain P, Megna JL, Leontieva L. Borderline Personality Disorder With Atypical Traits in a 30-Year-Old Female: A Case Report. Cureus 2024; 16:e55166. [PMID: 38558669 PMCID: PMC10980538 DOI: 10.7759/cureus.55166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2024] [Indexed: 04/04/2024] Open
Abstract
In this paper, we report an atypical presentation of borderline personality disorder (BPD) in a 30-year-old female with a history of childhood molestation and trauma and a prior diagnosis of post-traumatic stress disorder (PTSD). The patient was hospitalized due to anxiety, depression, and guilt over her relapse into alcohol use disorder. During her hospital stay, we diagnosed her with BPD based on psychiatric examination, clinical interviews, and patient history. While the patient exhibited some of the typical characteristics of BPD, such as an instability of interpersonal and romantic relationships, there were numerous findings that were atypical of BPD. These include a demonstration of mature defense mechanisms such as sublimation and altruism, high levels of occupational functioning, strong maternal caregiving behavior, and no history of self-harm. Further analysis of the patient's personality traits helped us identify that this presentation could be best characterized as a high-functioning internalizing subtype of BPD as identified in prior literature.
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Affiliation(s)
- Sarah Garikana
- Psychiatry, State University of New York Upstate Medical University, Syracuse, USA
| | - Pratik Jain
- Psychiatry, State University of New York Upstate Medical University, Syracuse, USA
| | - James L Megna
- Psychiatry and Behavioral Sciences, State University of New York Upstate Medical University, Syracuse, USA
| | - Luba Leontieva
- Psychiatry, State University of New York Upstate Medical University, Syracuse, USA
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10
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Lee J, Choi H. ICD-11 complex posttraumatic stress disorder and subclasses of borderline personality disorder in a South Korean adult population with childhood abuse experiences: a latent class analysis. Borderline Personal Disord Emot Dysregul 2023; 10:36. [PMID: 38098052 PMCID: PMC10722676 DOI: 10.1186/s40479-023-00242-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 12/06/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Complex posttraumatic stress disorder (CPTSD) and borderline personality disorder (BPD), which are distinctive diagnoses, share the common risk factor of childhood abuse experiences. However, additional evidence is needed to determine which factors contribute to the manifestation of different symptoms. METHOD Participants were 499 South Korean early and midlife adults with primarily college level education who reported experiences of childhood abuse. They were enrolled from an online panel using a stratified sampling considering gender, age, and residence information. A latent class analysis (LCA) was conducted to identify the patterns of CPTSD and BPD symptoms. We adopted a three-step LCA to compare types of childhood abuse, invalidating environments, attachment styles, and pathological personality traits among different classes. RESULTS The LCA revealed four classes. Class 1 showed the highest scores in all symptoms and risk factors. Class 2 was distinguished from Class 3 by the externalizing versus internalizing associated pathological personality traits. Class 3 experienced high emotional neglect in addition to other types of abuse and it also showed an additional avoidant attachment style. Class 4 showed low symptomatology. CONCLUSION Class 1 was named as a CPTSD and BPD "comorbid" class, Class 2 as an "externalizing BPD" class, Class 3 as an "avoidant BPD" class, and Class 4 as a "low symptom" class. Childhood abuse may heighten the risk for high comorbidity of CPTSD and BPD as well as externalizing-internalizing subgroups of BPD. Beyond the identification of CPTSD and BPD, assessing attachment styles and pathological personality traits based on dimensional approaches would benefit the tailoring of effective treatment.
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Affiliation(s)
- Jisu Lee
- Chungbuk National University, Cheongju, South Korea
| | - Hyunjung Choi
- Chungbuk National University, Cheongju, South Korea.
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11
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Biancalani A, Pelizza L, Menchetti M. Borderline personality disorder and early psychosis: a narrative review. Ann Gen Psychiatry 2023; 22:44. [PMID: 37919718 PMCID: PMC10623785 DOI: 10.1186/s12991-023-00475-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 10/22/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND The purpose of the present review was to summarize the main literature contribution on the relationship between borderline personality disorder (BPD) and early psychosis. While retracing the historical path of the term "borderline", specific attention was paid to psychotic and psychotic-like symptoms in BPD. Its relationship with At Risk Mental State was evaluated, as well. METHODS This search was conducted on PUBMED/MEDLINE and PsycInfo, looking for "Borderline personality disorder, First Episode Psychosis, Early Psychosis, Ultra-High Risk AND/OR Clinical High Risk" for psychosis. RESULTS Eight pertinent papers were identified on this topic. Their main findings were then discussed. The term "borderline" has undergone different changes in meaning and use, despite always referring to states considered on the fence between neurosis and psychosis. However, considering the history of psychopathology and its relationship with diagnostic manuals, little attention has been given to its psychotic features. Being those symptoms highly burdensome, this neglect has often led to misdiagnosis and under-treatment. CONCLUSIONS Psychotic symptoms in BPD can be severe and distressing. Nonetheless they can be easily neglected, and when found they challenge clinicians in defining a differential diagnosis to distinguish between BPD and Psychosis Spectrum Disorders. Given specific needs and interventions for these different conditions, a dimensional, rather than categorical, approach should be considered, as well as specific care pathways and monitoring should be advised.
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Affiliation(s)
- Arianna Biancalani
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, Università Di Bologna, Via Zamboni 33, 40106, Bologna, BO, Italy
| | - Lorenzo Pelizza
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, Università Di Bologna, Via Zamboni 33, 40106, Bologna, BO, Italy.
| | - Marco Menchetti
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, Università Di Bologna, Via Zamboni 33, 40106, Bologna, BO, Italy
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12
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Dhar A, Hay P, Meade T. Social and Occupational Functioning in Individuals With BPD: A Systematic Review. J Pers Disord 2023; 37:691-723. [PMID: 38038659 DOI: 10.1521/pedi.2023.37.6.691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
This systematic review aimed to explore social and occupational functioning levels in individuals with BPD and whether this varies according to symptomatic status, age, or gender. A multi-database search was conducted for articles, and of the 1164 records identified, 19 were included in this review. Of the 15 studies reporting on social functioning, 13 indicated significant levels of impairment, and of the 14 studies reporting on global functioning, all indicated significant impairment across both clinical and in-remission populations. Occupational functioning was primarily assessed as either a part of global functioning or by subscales within social functioning, highlighting a lack of use of dedicated measures for its assessment. This systematic review found that individuals with BPD experience a range of significant impairments in functioning persisting across the lifespan. Further studies are warranted to explore levels of functional impairment across all functional domains and factors associated with continual functional impairment in this population.
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Affiliation(s)
- Abhijatya Dhar
- School of Psychology, Western Sydney University, NSW, Australia
| | - Phillipa Hay
- School of Medicine, Western Sydney University, NSW, Australia
- Translational Health Research Institute, Western Sydney University, NSW, Australia
| | - Tanya Meade
- School of Psychology, Western Sydney University, NSW, Australia
- Translational Health Research Institute, Western Sydney University, NSW, Australia
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13
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Langerbeck M, Baggio T, Messina I, Bhat S, Grecucci A. Borderline shades: Morphometric features predict borderline personality traits but not histrionic traits. Neuroimage Clin 2023; 40:103530. [PMID: 37879232 PMCID: PMC10618757 DOI: 10.1016/j.nicl.2023.103530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/09/2023] [Accepted: 10/12/2023] [Indexed: 10/27/2023]
Abstract
Borderline personality disorder (BPD) is one of the most diagnosed disorders in clinical settings. Besides the fully diagnosed disorder, borderline personality traits (BPT) are quite common in the general population. Prior studies have investigated the neural correlates of BPD but not of BPT. This paper investigates the neural correlates of BPT in a subclinical population using a supervised machine learning method known as Kernel Ridge Regression (KRR) to build predictive models. Additionally, we want to determine whether the same brain areas involved in BPD are also involved in subclinical BPT. Recent attempts to characterize the specific role of resting state-derived macro networks in BPD have highlighted the role of the default mode network. However, it is not known if this extends to the subclinical population. Finally, we wanted to test the hypothesis that the same circuitry that predicts BPT can also predict histrionic personality traits. Histrionic personality is sometimes considered a milder form of BPD, and making a differential diagnosis between the two may be difficult. For the first time KRR was applied to structural images of 135 individuals to predict BPT, based on the whole brain, on a circuit previously found to correctly classify BPD, and on the five macro-networks. At a whole brain level, results show that frontal and parietal regions, as well as the Heschl's area, the thalamus, the cingulum, and the insula, are able to predict borderline traits. BPT predictions increase when considering only the regions limited to the brain circuit derived from a study on BPD, confirming a certain overlap in brain structure between subclinical and clinical samples. Of all the five macro networks, only the DMN successfully predicts BPD, confirming previous observations on its role in the BPD. Histrionic traits could not be predicted by the BPT circuit. The results have implications for the diagnosis of BPD and a dimensional model of personality.
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Affiliation(s)
- Miriam Langerbeck
- Faculty of Psychology and Neuroscience (FPN), Maastricht University, Netherlands
| | - Teresa Baggio
- Department of Psychology and Cognitive Sciences (DiPSCo), University of Trento, Italy.
| | - Irene Messina
- Department of Psychology and Cognitive Sciences (DiPSCo), University of Trento, Italy; Universitas Mercatorum, Rome, Italy.
| | - Salil Bhat
- Department of Cognitive Neuroscience, Faculty of Psychology and Cognitive Neuroscience (FPN), Maastricht University, Netherlands.
| | - Alessandro Grecucci
- Department of Psychology and Cognitive Sciences (DiPSCo), University of Trento, Italy; Centre for Medical Sciences (CISMed), University of Trento, Italy.
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14
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Sauer-Zavala S, Southward MW, Hood CO, Elhusseini S, Fruhbauerova M, Stumpp NE, Semcho SA. Conceptual development and case data for a modular, personality-based treatment for borderline personality disorder. Personal Disord 2023; 14:369-380. [PMID: 35084872 PMCID: PMC9748867 DOI: 10.1037/per0000520] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Borderline personality disorder (BPD) is a heterogenous condition, and variations in its presentation may be accounted for by individual differences in personality dimensions. Extant treatments for BPD are long term and intensive; it is possible that prioritizing the personality-based difficulties that underlie an individual's symptoms may improve the efficiency of care. This article describes the conceptual background for the development of a novel, personality-based intervention for BPD (BPD Compass), which was informed by recent research on personality mechanisms maintainin this condition, and was designed to address gaps left by existing treatments and to be maximally efficient and disseminable. BPD Compass is a comprehensive, short-term package with a fully modular design that allows for personalization (e.g., all skills can be presented in isolation or in any order based on pretreatment assessment). We discuss the theoretical background for its development, an overview of the skills included in the treatment, as well as preliminary efficacy data. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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15
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Profiles of patients with a personality disorder admitted in a day hospital treatment program: Revealing spectra from the Hierarchical Taxonomy of Psychopathology. CURRENT PSYCHOLOGY 2023. [DOI: 10.1007/s12144-023-04388-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
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16
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Black DW, Blum N, Allen J. Factor structure of borderline personality disorder and response to Systems Training for Emotional Predictability and Problem Solving. Personal Ment Health 2022; 16:263-275. [PMID: 35081671 DOI: 10.1002/pmh.1538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/03/2021] [Accepted: 01/04/2022] [Indexed: 11/07/2022]
Abstract
Differential response to the Systems Training for Emotional Predictability and Problem Solving (STEPPS) program was compared in subgroups identified through latent class analysis (LCA). STEPPS is an evidence-based group treatment program for patients with borderline personality disorder (BPD). A reanalysis of data was conducted using data from a 20-week randomized controlled trial and 1-year follow-up. Subjects (n = 164) with DSM-IV BPD were assessed for comorbid Axis I and II disorders and selected clinical variables. Severity was assessed using the Zanarini Rating Scale for BPD (ZAN-BPD) and the Borderline Evaluation of Severity Over Time (BEST). Three- and four-class models were identified with the four-class model having the better fit. The latter included a high severity (HS) class (26%), an affective instability/substance abuse (AISA) class (16%), an empty/dissociation/identity disturbance (EDID) class (27%), and a low severity (LS) class (30%). High impulsiveness predicted membership in the HS class. Improvement was determined using a linear mixed-effects model. Those most likely to benefit were those in the HS group characterized by high symptom severity, Axis I and II comorbidity, problem relationships, abandonment fears, and intense anger. This work should help further efforts to match patients with treatments based on sociodemographic, diagnostic, and other illness characteristics.
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Affiliation(s)
- Donald W Black
- Department of Psychiatry, The University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa, USA
- Mental Health Service Line, Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Nancee Blum
- Department of Psychiatry, The University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa, USA
| | - Jeff Allen
- Department of Psychiatry, The University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa, USA
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17
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Maffly-Kipp J, McCredie MN, Morey LC. The self-reference effect as a behavioral indicator of identity disturbances associated with borderline personality features in a non-clinical sample. Borderline Personal Disord Emot Dysregul 2022; 9:20. [PMID: 35854373 PMCID: PMC9297558 DOI: 10.1186/s40479-022-00189-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 06/22/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Identity disturbances are a common feature of personality pathology and BPD. The Self-Reference Effect paradigm is a method used to measure the impact of self-relevant processing on encoding/memory, whereby self-relevant information is typically advantaged in cognitive processes. We postulated that difficulties with identity might impede the process by which one encodes self-relevant information. Based on this reasoning, we predicted that high levels of identity disturbance could be associated with atypical impact of the SRE. METHODS Undergraduate participants were randomized into one of three groups where they were exposed to 60 trait adjectives for seven seconds each. Depending on condition, participants either indicated whether a word was/wasn't capitalized (Capitalization condition), whether it was a good synonym for "openness" (Synonyms condition), or whether it described them as a person (Self-reference condition). After a brief delay, all participants were asked to recall as many of the 60 words as possible. Finally, we measured identity disturbance using the Borderline Features-Identity Problems (BOR-I) scale from the Personality Assessment Inventory. RESULTS We found significant but modest correlations between Recall and scores on the BOR-I subscale in the Self-Reference condition, but not the two control conditions. Contrary to expectations, the interaction between BOR-I and Condition was not a significant predictor of Recall, suggesting that identity disturbance did not significantly moderate the SRE. CONCLUSIONS While our primary hypothesis was not supported, there is a need for multimethod approaches to studying personality pathology. Future research should continue to examine the extent to which behavioral paradigms like the SRE might be useful indicators of identity disturbance/personality pathology, with an emphasis on the use of clinical populations.
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Affiliation(s)
- Joseph Maffly-Kipp
- Department of Psychological and Brain Sciences, Texas A&M University, 4235 TAMU, College Station, TX, 77843, USA.
| | - Morgan N McCredie
- Department of Psychological and Brain Sciences, Texas A&M University, 4235 TAMU, College Station, TX, 77843, USA
| | - Leslie C Morey
- Department of Psychological and Brain Sciences, Texas A&M University, 4235 TAMU, College Station, TX, 77843, USA
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18
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Bliton CF, Rosenstein LK, Pincus AL. Trading Patients: Applying the Alternative Model for Personality Disorders to Two Cases of DSM-5 Borderline Personality Disorder Over Time and Across Therapists. Front Psychol 2022; 13:794624. [PMID: 35237208 PMCID: PMC8884405 DOI: 10.3389/fpsyg.2022.794624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/03/2022] [Indexed: 11/16/2022] Open
Abstract
The DSM-5 Alternative Model for Personality Disorders (AMPD) dimensionally defines personality pathology using severity of dysfunction and maladaptive style. As the empirical literature on the clinical utility of the AMPD grows, there is a need to examine changes in diagnostic profiles and personality expression in treatment over time. Assessing these changes in individuals diagnosed with borderline personality disorder (BPD) is complicated by the tendency for patients to cycle through multiple therapists over the course of treatment leaving the potential for muddled diagnostic clarity and disjointed case conceptualizations. Following patient trajectories across therapists offers a unique opportunity to examine the AMPD’s sensitivity to and utility for capturing personality stability and change over time for patients with BPD. This article demonstrates the utility of the AMPD for two clinical cases in three distinct ways: (i) highlighting heterogeneity in BPD between patients, (ii) comparing improvements in personality severity and style over time, and (iii) elucidating profile change across therapist ratings. We present two patients diagnosed with DSM-5 Section II BPD, crossing between two therapists over the course of 3 years of psychodynamic psychotherapy. Treating clinicians rated patients for their respective treatment phases using the Level of Personality Functioning Scale (LPFS), capturing severity, and the Personality Inventory for the DSM-5 (PID-5), capturing style. AMPD diagnostic profiles differentiated patients with BPD in both severity and style, and captured within-patient change beyond within-therapist response bias. Results indicated greater improvements in personality severity while personality style remained more stable. Implications for the patients’ treatment progress and associated challenges are discussed, as are considerations for the utility of the AMPD in therapy.
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Affiliation(s)
- Chloe F Bliton
- Department of Psychology, The Pennsylvania State University, University Park, PA, United States
| | - Lia K Rosenstein
- Department of Psychology, The Pennsylvania State University, University Park, PA, United States
| | - Aaron L Pincus
- Department of Psychology, The Pennsylvania State University, University Park, PA, United States
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19
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Cluster analysis of personality traits in psychiatric patients with borderline personality disorder. Borderline Personal Disord Emot Dysregul 2022; 9:7. [PMID: 35130981 PMCID: PMC8822819 DOI: 10.1186/s40479-022-00178-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 01/16/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Though the heterogeneous expression of symptoms of borderline personality disorder (BPD) is well-known, it is far from fully understood. Hybrid models combining dimensional and categorical ways of diagnosing BPD have been suggested to better handle this heterogeneity, but more research is needed. The aim of this study was to identify potential clusters in BPD, and evaluate if these clusters differed in diagnostic composition, severity, psychiatric symptoms, emotion regulation and control, or sociodemographic features. METHODS Clusters were based on personality traits measured with the Swedish universities Scales of Personality (SSP) in 141 psychiatric patients diagnosed with BPD. Hierarchical cluster analysis was performed using Ward's method. We used one-way analysis of variance to explore the different clusters' properties. Effect sizes were calculated using partial eta squared. RESULTS We found three distinct clusters: the lower psychopathology cluster (N = 67), the externalizing cluster (N = 28), and the internalizing cluster (N = 46). The clusters differed regarding trait composition, severity, and emotion regulation and control. CONCLUSIONS Our findings support hybrid models for diagnosing BPD by showing that clusters differed in terms of both severity (lower and higher psychopathology) and personality traits/style (internalizing and externalizing). Assessment of personality traits may be a feasible way to differentiate between clusters. In the future, this knowledge might be used to personalize treatment.
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20
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Borderline Personality Disorder “Discouraged Type”: A Case Report. Medicina (B Aires) 2022; 58:medicina58020162. [PMID: 35208485 PMCID: PMC8874928 DOI: 10.3390/medicina58020162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/15/2022] [Accepted: 01/18/2022] [Indexed: 12/04/2022] Open
Abstract
Borderline Personality Disorder (BPD) is a mental illness associated with a significant degree of distress and impairment because of the difficulties in effectively regulating emotions. BPD is frequently associated with Depressive Disorders, most commonly Major Depressive Disorder and Dysthymia. Here, we present a case report of an 18-year-old female patient hospitalized with a severe depressive episode and psychotic symptoms. A few months after discharge, the interpersonal difficulties, unstable self-image, fear of chronic abandonment, feeling of emptiness, paranoid ideation, helplessness, obsessive-compulsive elements, perfectionism, and social retreat led to the patient’s impaired functionality. The spectrum of signs and symptoms presented were characteristic of BPD. The specific presentation of mixed dependent/avoidant pattern of personality, with persistent feelings of guilt and shame, social anxiety, emotional attachments, obsessions, and feelings of inadequacy have further narrowed the diagnosis to discouraged BPD, as described by Theodore Millon. In our case, this particular subtype of personality disorder can be understood as BPN associated with social perfectionism. Both BPD and perfectionism, as a trait personality, were thought to exacerbate issues with self-conception and identity formation in this patient.
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21
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Guo B, Li L, Crawford MJ, Morriss R. The factor structure of the Zanarini Rating Scale for Borderline Personality Disorder: Exploratory Structural Equation Modelling and measurement invariance over time. Int J Methods Psychiatr Res 2021; 30:e1874. [PMID: 33978286 PMCID: PMC8412222 DOI: 10.1002/mpr.1874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 03/15/2021] [Accepted: 04/01/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES There is a lack of independent longitudinal evidence on the factor structure and validity of the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD). This study aimed to investigate the dimensionality of ZAN-BPD and its conceptual consistency over time. METHODS Adult BPD participants (n = 276) were recruited for a multicentre, two-arm randomised clinical trial with ZAN-BPD measured at baseline and follow up at 12, 24 and 52 weeks. The construct and stability of the ZAN-BPD across 52 weeks was examined through a measurement equivalence/invariance procedure via Exploratory Structural Equation Modelling. RESULTS Factor analysis results showed that the ZAN-BPD had a bi-2 factor structure that was stable over 52 weeks with a general factor and two specific factors. Factor loadings for eight of the nine items were greater for the general factor than the two specific factors. Factor 1 contrasts externalising distress with internalising distress. Factor 2 contrasts depression and self-destruction with interpersonal anxiety and conflict. CONCLUSION ZAN-BPD is a conceptually and empirically valid measure of total BPD symptom severity in BPD patients over time suitable for use in clinical trials. Two factors related to the expression of distress and self-harm may be utilised as possible predictors of outcome.
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Affiliation(s)
- Boliang Guo
- Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham, London, UK
| | - Lingyan Li
- Department of Nursing, Nanchang University, Nanchang, PR China
| | | | - Richard Morriss
- Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham, London, UK
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22
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Gamache D, Savard C, Leclerc P, Payant M, Côté A, Faucher J, Lampron M, Tremblay M. Latent profiles of patients with borderline pathology based on the alternative DSM-5 model for personality disorders. Borderline Personal Disord Emot Dysregul 2021; 8:4. [PMID: 33568234 PMCID: PMC7876791 DOI: 10.1186/s40479-021-00146-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There have been multiple attempts to try to parse out heterogeneity within borderline pathology by identifying patient subtypes; thus far, these works have yielded few consistent results. Recent developments in the operationalization of borderline pathology may provide new opportunities to identify clinically and conceptually meaningful subgroups of patients. The Alternative DSM-5 Model for Personality Disorders (AMPD) offers a categorical-dimensional operationalization of Borderline personality disorder (BPD) that has yet to be tested for identification of patient subgroups. The purpose of the present study is to test whether the combination of the Criterion A elements (pertaining to level of severity) and the seven pathological facets from Criterion B that define BPD in the AMPD can yield meaningful patient profiles. METHODS A total of 211 outpatients from a specialized PD treatment program (133 women, Mage = 33.66, SD = 10.97) were selected based on the presence of at least moderate borderline pathology according to cutoffs recently proposed for the Borderline Symptom List-23. Valid Criterion A (Self and Interpersonal Functioning Scale) and B (Personality Inventory for DSM-5 Faceted Brief Form) self-reports were administered to measure elements and facets that define BPD in the AMPD model; these variables were used as indicators in a latent profile analysis (LPA). RESULTS The optimal solution generated by LPA yielded four distinct profiles: (a) Borderline traits; (b) Moderate pathology with Impulsivity; (c) Moderate pathology with Identity problems and Depressivity; and (d) Severe pathology. Clinically meaningful distinctions emerged among profiles on AMPD indicators and external variables relevant to PD, especially aggression and impulsivity. CONCLUSIONS Profiles reflected both the "severity" and "style" components imbedded within Criterion A and B of the AMPD, as they were mainly distinguished by a continuum of severity but also by some meaningful qualitative differences that may have important clinical implications for treatment planning and contracting. Results also suggest that the four Criterion A elements have independent value to identify important differences in patients with borderline pathology. They also highlight that some Criterion B facets that define BPD in the AMPD may be especially important to identify subgroups of patients, mainly Impulsivity and Depressivity.
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Affiliation(s)
- Dominick Gamache
- Department of Psychology, Université du Québec à Trois-Rivières, C.P. 500, Trois-Rivières, QC, G9A 5H7, Canada.
- CERVO Brain Research Centre, Quebec City, QC, Canada.
- Interdisciplinary Research Centre on Intimate Relationship Problems and Sexual Abuse, Montreal, QC, Canada.
| | - Claudia Savard
- CERVO Brain Research Centre, Quebec City, QC, Canada
- Interdisciplinary Research Centre on Intimate Relationship Problems and Sexual Abuse, Montreal, QC, Canada
- Department of Educational Fundamentals and Practices, Université Laval, Quebec City, QC, Canada
| | - Philippe Leclerc
- Department of Psychology, Université du Québec à Trois-Rivières, C.P. 500, Trois-Rivières, QC, G9A 5H7, Canada
| | - Maude Payant
- Department of Psychology, Université du Québec à Montréal, Montreal, QC, Canada
| | - Alexandre Côté
- Department of Psychology, Université du Québec à Trois-Rivières, C.P. 500, Trois-Rivières, QC, G9A 5H7, Canada
| | - Jonathan Faucher
- Department of Psychology, Université du Québec à Trois-Rivières, C.P. 500, Trois-Rivières, QC, G9A 5H7, Canada
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Howard R, Hasin D, Stohl M. Substance use disorders and criminal justice contact among those with co-occurring antisocial and borderline personality disorders: Findings from a nationally representative sample. Personal Ment Health 2021; 15:40-48. [PMID: 32588546 DOI: 10.1002/pmh.1491] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/03/2020] [Accepted: 06/07/2020] [Indexed: 11/08/2022]
Abstract
One variant of borderline personality disorder (BPD), frequently encountered in forensic and correctional samples, is the 'dissocial' subtype that combines borderline and antisocial traits. We tested the hypothesis that this subtype, defined by the co-occurrence of antisocial personality disorder (ASPD) and BPD (ASPD + BPD), would be associated with high rates of substance use disorder and contact with the criminal justice (CJ) system in a large nationally representative sample of North American adults (N = 36 309). Results suggested that the dissocial variant of BPD was associated with a high risk for substance use disorders and CJ contact. The odds of these outcomes were significantly raised about fivefold in ASPD + BPD individuals in comparison with those who lacked either an ASPD or BPD diagnosis. ASPD + BPD, compared with BPD alone, was also associated with significantly (p < 0.0001) greater severity of borderline symptoms. Although CJ contact appears to be strongly driven by ASPD, substance use, primarily driven by severity of borderline symptoms, added to the risk of CJ contact. It is suggested that, in the 11th Revision of the International Classification of Diseases terms, the dissocial borderline variant is a severe form of personality disorder characterized by high levels of traits within domains of negative emotionality and dissociality. Further studies will be required to verify this suggestion. © 2020 The Authors Personality and Mental Health Published by John Wiley & Sons Ltd.
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Affiliation(s)
- Richard Howard
- Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Deborah Hasin
- Department of Psychiatry and Department of Epidemiology, Columbia University Medical Center, New York, NY, USA
| | - Malki Stohl
- New York State Psychiatric Institute, New York, NY, USA
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24
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Fruhbauerova M, DeCou CR, Crow BE, Comtois KA. Borderline personality disorder and self-directed violence in a sample of suicidal army soldiers. Psychol Serv 2021; 18:104-115. [PMID: 31180691 PMCID: PMC6901805 DOI: 10.1037/ser0000369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
There has been a sharp increase in the military suicide rates in 2004. While, borderline personality disorder (BPD) has a stronger association with suicide attempts than any other mental health disorder, there is limited evidence concerning the prevalence and scope of BPD symptoms among military personnel. This secondary data analysis compared active duty suicidal soldiers to characterize the presence-absence of BPD diagnostic criteria and lifetime history of self-directed violence in a suicidal military sample. The current study examined data of 137 active Service Members with significant suicidal ideation. Approximately one-quarter of the soldiers in this sample met full diagnostic criteria for BPD. The presence of BPD criteria was generally consistent among participants with BPD who reported past self-directed violence relative to those who did not. The number of BPD criteria was a significant predictor of the odds of reporting any nonsuicidal self-injury (NSSI) as well as the amount of NSSI, but was not associated with suicide attempt. This study demonstrated that a nontrivial proportion of suicidal soldiers meet criteria for this condition, which is strongly associated with self-directed violence. It is important to rigorously assess for the presence-absence of BPD criteria among suicidal military personnel and cultivate prevention strategies and treatment options for BPD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
| | | | - Bruce E Crow
- Department of Psychiatry and Behavioral Sciences
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Cremers H, van Zutphen L, Duken S, Domes G, Sprenger A, Waldorp L, Arntz A. Borderline personality disorder classification based on brain network measures during emotion regulation. Eur Arch Psychiatry Clin Neurosci 2021; 271:1169-1178. [PMID: 33263789 PMCID: PMC8354902 DOI: 10.1007/s00406-020-01201-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 10/14/2020] [Indexed: 12/13/2022]
Abstract
Borderline Personality Disorder (BPD) is characterized by an increased emotional sensitivity and dysfunctional capacity to regulate emotions. While amygdala and prefrontal cortex interactions are regarded as the critical neural mechanisms underlying these problems, the empirical evidence hereof is inconsistent. In the current study, we aimed to systematically test different properties of brain connectivity and evaluate the predictive power to detect borderline personality disorder. Patients with borderline personality disorder (n = 51), cluster C personality disorder (n = 26) and non-patient controls (n = 44), performed an fMRI emotion regulation task. Brain network analyses focused on two properties of task-related connectivity: phasic refers to task-event dependent changes in connectivity, while tonic was defined as task-stable background connectivity. Three different network measures were estimated (strength, local efficiency, and participation coefficient) and entered as separate models in a nested cross-validated linear support vector machine classification analysis. Borderline personality disorder vs. non-patient controls classification showed a balanced accuracy of 55%, which was not significant under a permutation null-model, p = 0.23. Exploratory analyses did indicate that the tonic strength model was the highest performing model (balanced accuracy 62%), and the amygdala was one of the most important features. Despite being one of the largest data-sets in the field of BPD fMRI research, the sample size may have been limited for this type of classification analysis. The results and analytic procedures do provide starting points for future research, focusing on network measures of tonic connectivity, and potentially focusing on subgroups of BPD.
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Affiliation(s)
- Henk Cremers
- Department of Clinical Psychology, University of Amsterdam, Nieuwe Achtergracht 129B, 1001 NK, Amsterdam, The Netherlands.
| | - Linda van Zutphen
- grid.5012.60000 0001 0481 6099Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands
| | - Sascha Duken
- grid.7177.60000000084992262Department of Clinical Psychology, University of Amsterdam, Nieuwe Achtergracht 129B, 1001 NK Amsterdam, The Netherlands
| | - Gregor Domes
- grid.12391.380000 0001 2289 1527Department of Biological and Clinical Psychology, University of Trier, Trier, Germany
| | - Andreas Sprenger
- grid.4562.50000 0001 0057 2672Department of Neurology, University of Lübeck, Lübeck, Germany
| | - Lourens Waldorp
- grid.7177.60000000084992262Department of Psychological Methods, University of Amsterdam, Amsterdam, The Netherlands
| | - Arnoud Arntz
- grid.7177.60000000084992262Department of Clinical Psychology, University of Amsterdam, Nieuwe Achtergracht 129B, 1001 NK Amsterdam, The Netherlands ,grid.5012.60000 0001 0481 6099Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands
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Aguilar-Ortiz S, Salgado-Pineda P, Vega D, Pascual JC, Marco-Pallarés J, Soler J, Brunel C, Martin-Blanco A, Soto A, Ribas J, Maristany T, Sarró S, Rodríguez-Fornells A, Salvador R, McKenna PJ, Pomarol-Clotet E. Evidence for default mode network dysfunction in borderline personality disorder. Psychol Med 2020; 50:1746-1754. [PMID: 31456534 DOI: 10.1017/s0033291719001880] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Although executive and other cognitive deficits have been found in patients with borderline personality disorder (BPD), whether these have brain functional correlates has been little studied. This study aimed to examine patterns of task-related activation and de-activation during the performance of a working memory task in patients with the disorder. METHODS Sixty-seven DSM-IV BPD patients and 67 healthy controls underwent fMRI during the performance of the n-back task. Linear models were used to obtain maps of within-group activations and areas of differential activation between the groups. RESULTS On corrected whole-brain analysis, there were no activation differences between the BPD patients and the healthy controls during the main 2-back v. baseline contrast, but reduced activation was seen in the precentral cortex bilaterally and the left inferior parietal cortex in the 2-back v. 1-back contrast. The patients showed failure of de-activation affecting the medial frontal cortex and the precuneus, plus in other areas. The changes did not appear to be attributable to previous history of depression, which was present in nearly half the sample. CONCLUSIONS In this study, there was some, though limited, evidence for lateral frontal hypoactivation in BPD during the performance of an executive task. BPD also appears to be associated with failure of de-activation in key regions of the default mode network.
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Affiliation(s)
- Salvatore Aguilar-Ortiz
- FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain
- Benito Menni Complex Assistencial en Salut Mental, Sant Boi de Llobregat, Barcelona, Spain
- Departament de Psiquiatria i Medicina Legal, PhD Programme, Doctorat en Psiquiatria, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Pilar Salgado-Pineda
- FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain
- CIBERSAM, Barcelona, Spain
| | - Daniel Vega
- Servei de Psiquiatria i Salut Mental, Consorci Sanitari de l'Anoia, Igualada, Spain
| | - Juan C Pascual
- CIBERSAM, Barcelona, Spain
- Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Josep Marco-Pallarés
- Faculty of Psychology, University of Barcelona, Bellvitge Hospital, Barcelona, Spain
| | - Joaquim Soler
- CIBERSAM, Barcelona, Spain
- Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Cristina Brunel
- FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain
- Benito Menni Complex Assistencial en Salut Mental, Sant Boi de Llobregat, Barcelona, Spain
| | - Ana Martin-Blanco
- Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Angel Soto
- Servei de Psiquiatria i Salut Mental, Consorci Sanitari de l'Anoia, Igualada, Spain
| | - Joan Ribas
- Servei de Psiquiatria i Salut Mental, Consorci Sanitari de l'Anoia, Igualada, Spain
| | - Teresa Maristany
- Hospital Sant Joan de Déu, Esplugues de Llobregrat, Barcelona, Spain
| | - Salvador Sarró
- FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain
- CIBERSAM, Barcelona, Spain
| | | | - Raymond Salvador
- FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain
- CIBERSAM, Barcelona, Spain
| | - Peter J McKenna
- FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain
- CIBERSAM, Barcelona, Spain
| | - Edith Pomarol-Clotet
- FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Spain
- CIBERSAM, Barcelona, Spain
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Davies G, Hayward M, Evans S, Mason O. A systematic review of structural MRI investigations within borderline personality disorder: Identification of key psychological variables of interest going forward. Psychiatry Res 2020; 286:112864. [PMID: 32163818 DOI: 10.1016/j.psychres.2020.112864] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 02/09/2020] [Accepted: 02/09/2020] [Indexed: 12/19/2022]
Abstract
Existing models of Borderline Personality Disorder (BPD) suggest that a combination of genetic vulnerability, childhood trauma, and disrupted attachment can lead to the marked emotional lability, impulsivity and interpersonal difficulties observed clinically. Brain structural differences in frontal, limbic and hippocampal regions have been reported in BPD. Less clear is how specific psychological factors relate to these structural differences, and how consistently this is found across studies. This was the focus of the present review. Eighteen studies published between 2004 and 2018 met inclusion criteria encompassing 990 participants. Study quality was assessed using the Nottingham-Ottawa Scale. We also introduce a newly devised scale to assess MRI reporting quality. The most frequently investigated psychological variable were impulsivity (9 studies), depression (8), trauma (6), aggression (6), severity of symptoms (3), global functioning, abuse and dissociation (2). Study quality varied, however, a trend was observed where newer studies were higher in reporting quality. Impulsivity demonstrated greater association with frontal structures, trauma related to the hypothalamus and limbic systems, and aggression with hippocampal and frontal structures. The present review recommends greater exploration of neurocognitive and psychosis-related features such as delusions, paranoia and voice-hearing in future studies, and to investigate cortical changes in longitudinal designs.
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Affiliation(s)
- Geoff Davies
- Faculty of Health and Medical Science, University of Surrey, Guildford, UK; Surrey & Borders NHS Trust, UK.
| | - Mark Hayward
- School of Psychology, University of Sussex, UK; Sussex Partnership NHS Foundation Trust, UK
| | - Simon Evans
- Faculty of Health and Medical Science, University of Surrey, Guildford, UK
| | - Oliver Mason
- Faculty of Health and Medical Science, University of Surrey, Guildford, UK
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28
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Luyten P, Campbell C, Fonagy P. Borderline personality disorder, complex trauma, and problems with self and identity: A social‐communicative approach. J Pers 2019; 88:88-105. [DOI: 10.1111/jopy.12483] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 04/05/2019] [Accepted: 04/24/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Patrick Luyten
- Faculty of Psychology and Educational Sciences University of Leuven Leuven Belgium
- Research Department of Clinical, Educational and Health Psychology University College London London UK
| | - Chloe Campbell
- Research Department of Clinical, Educational and Health Psychology University College London London UK
| | - Peter Fonagy
- Research Department of Clinical, Educational and Health Psychology University College London London UK
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29
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Pluta A, Kulesza M, Grzegorzewski P, Kucharska K. Assessing advanced theory of mind and alexithymia in patients suffering from enduring borderline personality disorder. Psychiatry Res 2018; 261:436-441. [PMID: 29360051 DOI: 10.1016/j.psychres.2018.01.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 01/01/2018] [Accepted: 01/01/2018] [Indexed: 11/25/2022]
Abstract
Findings on the theory of mind (ToM) abilities in borderline personality disorder (BPD) have been inconsistent. Surprisingly, no studies have focused on the complex aspects of ToM while simultaneously measuring alexithymia as well as comorbid depressive and anxiety symptoms, therefore, our study aimed to fill this gap. 30 female patients with BPD and 38 healthy controls (HCs) completed the Faux Pas Test (FPT) and the Toronto Alexithymia Scale-20 (TAS-20). The clinical and intellectual assessment comprised of the Structured Clinical Interview for DSM-IV-TR Axis II Disorders (SCID-II), the Borderline Personality Inventory (BPI), the State-Trait Anxiety Inventory (STAI), the Center for Epidemiologic Studies Depression Scale-Revised (CESD-R), and the Raven's Progressive Matrices (RPM). Women with BPD scored significantly worse than HCs on overall ToM abilities. After controlling for the intelligence level, depressive symptoms, and state and trait anxiety, both groups presented a similar overall level of alexithymia. No correlation between the FPT and TAS-20 scores was found, suggesting that both constructs might be unrelated in BPD. Because ToM dysfunctions seem not to result from comorbid clinical symptoms, trait anxiety, or intellectual abilities, our study results suggest that ToM deficits might be considered a core feature of BPD.
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Affiliation(s)
- Agnieszka Pluta
- Faculty of Psychology, University of Warsaw, Warsaw, Poland, 5/7 Stawki Street, 00-183 Warsaw, Poland
| | - Maria Kulesza
- Laboratory of Brain Imaging, Neurobiology Center, Nencki Institute of Experimental Biology of the Polish Academy of Sciences, 3 Pasteura Street, 02-093 Warsaw, Poland
| | - Piotr Grzegorzewski
- Department of Neuroses, Personality Disorders, and Eating Disorders, Institute of Psychiatry and Neurology, 9 Sobieskiego Street, 02-957 Warsaw, Poland
| | - Katarzyna Kucharska
- Department of Neuroses, Personality Disorders, and Eating Disorders, Institute of Psychiatry and Neurology, 9 Sobieskiego Street, 02-957 Warsaw, Poland.
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