Living with personality disorder and seeking mental health treatment: patients and family members reflect on their experiences

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

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

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

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

Towards an informed research agenda for the field of personality disorders by experts with lived and living experience and researchers

BACKGROUND

We describe a collection of themes for a research agenda for personality disorders that was originally formulated for the ESSPD Borderline Congress in 2022.

METHODS

Experts with lived and living experience (EE), researchers and clinicians met virtually, exchanged ideas and discussed research topics for the field of personality disorders. The experts - patients, relatives, significant others - named the topics they thought most relevant for further research in the field. These topics were presented at the ESPPD conference in October 2022.

RESULTS

The five top themes were: 1. Prevention, early detection and intervention, 2. Recovery beyond symptom improvement, 3. Involvement of relatives in treatment, 4. Gender dysphoria, and 5. Stigma.

CONCLUSIONS

In general, the topics reflect current issues and changes in societal values. Overarching aims of research on these topics are the improvement of social participation and integration in society, better dissemination of research, and better information of the general public and political stakeholders.

The lived experience of French parents concerning the diagnosis of their children with borderline personality disorder

BACKGROUND

Psychiatrists often hesitate to diagnose borderline personality disorder (BPD). While individuals with BPD have reported both positive and negative experiences upon receiving their diagnosis, no study has specifically explored this issue among parents. Parents of children diagnosed with BPD can benefit from recently developed family-support interventions such as the Family Connections program. Our study aimed to explore the experiences of parents learning about their child's BPD diagnosis and to investigate the impact of the Family Connections program on their experiences.

METHODS

This qualitative study, conducted in France following the five-stage IPSE method, involved parents of children with BPD recruited through the Family Connections association in Versailles. We conducted semi-structured interviews and used purposive sampling for data collection until data saturation was reached. Data analysis was performed using a descriptive and structuring approach with NVivo 12 software to elucidate the structure of lived experiences.

RESULTS

The study included 21 parents. The structure of the lived experiences was characterized by three central axes: (1) the long and difficult road to diagnosis; (2) communicating the BPD diagnosis to parents: a necessary step; (3) the pitfalls of receiving the diagnosis. The Family Connections program provided significant support in these areas, particularly in understanding the diagnosis, enhancing communication with their child, and reducing social isolation.

CONCLUSION

These findings highlight the challenges parents face when receiving a BPD diagnosis for their child and underscore the need for an early, clear, and detailed explanation of the diagnosis. The specific experiences of receiving the diagnosis are indicative of the broader care experience parents undergo and highlight their need and right to be informed, supported, and guided throughout their child's treatment.

Diagnosing borderline personality disorder: Reports and recommendations from people with lived experience

Borderline personality disorder (BPD) is a severe mental health condition marked by impairments in self and interpersonal functioning. Stigma from health staff may often result in a reluctance to diagnose, impacting recovery trajectories. Qualitative interviews were conducted with participants (N = 15; M Age = 36.4 years, SD = 7.5; 93.3% female) with lived experience of BPD exploring topics of illness onset, insight, experience of diagnosis and treatment. Qualitative responses were analysed within a co-design framework with a member of the research team who identifies as having a lived experience of BPD. On average, participant symptoms emerged at 12.1 years of age (SD = 6.6 years, range 1.5-27), but diagnoses of BPD were delayed until 30.2 years (SD = 7.8 years, range 18-44) resulting in a 'diagnosis gap' of 18.1 years (SD = 9.6 years, range 3-30). Participant explanations for BPD emergence varied from biological, psychological and social factors. Benefits of diagnosis (e.g., fostering insight, aiding treatment planning and reducing isolation) were contrasted with challenges (e.g., stigma and treatment unavailability). Delay in diagnosis was common, and no participants reported receiving a diagnosis of BPD during their adolescence yet 85% felt they would have benefited from a diagnosis in adolescence. Only a quarter (27%) felt highly supported in the diagnostic process. An ideal four-step diagnosis procedure was outlined based on recommendations from participants with a lived experience; this involved the following: (1) explain the process, (2) assess thoroughly, (3) explore how the features are active in everyday life and (4) link diagnosis to evidence-based treatment planning.

Don´t set us aside!Experiences of families of people with BPD who have access to Brief admission:a phenomenological perspective

AIM

To highlight the experiences of family members of people with borderline personality disorder (BPD) and self-harming behaviour who have access to brief admission.

METHODS

To understand the families lived experience a phenomenological lifeworld perspective was adopted to this study. Twelve in-depht interviews were performed in November and December 2021 with family members of people with BPD and self-harming behaviour who have accessed BA. The phenomenological life-world perspective guided the analysis.

RESULTS

Families' life-world was characterized by anxiety and constant protection of their loved one. They live with constant fear of how their loved ones are feeling and whether they will injure themselves. When access to BA was available this gave hope and provided conditions for families to maintain everyday routines and also enhanced relationships among family members. When families' loved ones were denied BA, they felt betrayed which contributed to negative feelings towards the medical profession, and the families lost confidence in psychiatry.

CONCLUSION

By interviewing families of people with BPD and self-harming behaviour who had access to BA, it emerged they possess valuable knowledge. BA can be developed if the needs of families are taken into consideration, and if families are given the opportunity to share emotions and the high burden of responsibility with staff or families in similar situations. If health care staff gives family members a more central role in care and makes their shared life-world visible it could thereby hopefully increase well-being and benefits for the whole family.

A randomised controlled trial of a psychoeducational group intervention for family and friends of young people with borderline personality disorder features

OBJECTIVE

Preliminary evidence indicates that interventions designed to support family and friends ('carers') of young people with early-stage borderline personality disorder effectively improve carer outcomes. None of these interventions have been tested in a randomised controlled trial.

METHOD

This clustered, partially nested, randomised controlled trial was conducted at Orygen, Melbourne, Australia. Carers of young people (aged 15-25 years) with borderline personality disorder features were randomly assigned as a unit in a 1:1 ratio, balanced for young person's sex and age, to receive a 15-day intervention comprising: (1) the three-session, in-person, Making Sense of BPD (MS-BPD) multi-family group programme, plus two self-directed online psychoeducational modules (MS-BPD + Online, n = 38), or (2) the two self-directed online psychoeducational modules alone (Online, n = 41). The primary outcome was 'negative experiences of care', measured with the Experience of Caregiving Inventory, at the 7-week endpoint.

RESULTS

A total of 79 carers were randomised (pool of 281, 197 excluded, 94 declined) and 73 carers (51 females [69.9%], Mage = 43.8 years [standard deviation, SD = 12.9], MS-BPD + Online n = 35 [47.9%], Online n = 38 [52.1%]) provided follow-up data and were included in the intent-to-treat analysis. The intent-to-treat (and per protocol) analyses did not find any significant differences between the groups on the primary (d = -0.32; 95% confidence interval = [-17.05, 3.97]) or secondary outcomes. Regardless of treatment group, caregivers improved significantly in their personality disorder knowledge.

CONCLUSION

Delivering MS-BPD in conjunction with an online psychoeducational intervention was not found to provide additional benefit over and above access to an online intervention alone. In accordance with national guidelines, carer interventions should be routinely offered by youth mental health services as part of early intervention programmes for borderline personality disorder. Further research is warranted into which interventions work for whom, carers' preferences for support and barriers to care.

Commentary: Commentary on the Twitter comments evoked by the May 2022 debate on diagnosing personality disorders in adolescents

The debate about the value and utility of personality disorder (PD) diagnosis in adolescence published in the May 2022 issue of CAMH generated fervent Twitter discussion. This commentary addresses some points raised in the Twitter discussion that represent important social and/or cultural beliefs that are often presented in day-to-day practice but are rarely tested in the context of scientific evidence. This includes, in particular, the assertion that symptoms used to diagnose personality disorder are better described as sequelae of trauma, and the assertion that effective treatment for PD is possible without a diagnosis. The call for a fundamental transformation of mental health services that currently do not meet the needs of people with PD and for the involvement of people with lived experience as equal partner in this process is supported by evidence and might represent common ground among those clinician-scientist advocating for early intervention for PD and those expressing their concerns about this issue.

Patient-Initiated Brief Admission for Individuals with Emotional Instability and Self-Harm: An Evaluation of Psychiatric Symptoms and Health-Related Quality of Life

Patient-initiated brief admission (PIBA) was developed for patients with emotional instability and self-harm, to cope with crises. The hypothesis was that psychiatric symptoms would decrease, and health-related quality of life (HRQoL) increase, after 1-3 days at hospital. One hundred and thirteen patients were recruited from a psychiatric clinic in Stockholm during 2016-2020. At admission and discharge, the patients completed the Hospital Anxiety and Depression Scale (HADS) and the EuroQoL-5 Dimension Questionnaire (EQ-5D). The patients also evaluated PIBA as a crisis intervention. A significant decrease in symptoms of anxiety and depression was found. HRQoL increased significantly assessed with EQ-5D and 95.2% of the participants found PIBA to be a constructive intervention.

Effects of animal-assisted psychotherapy incorporating mindfulness and self-compassion in neurorehabilitation: a randomized controlled feasibility trial

Transdiagnostic psychotherapeutic approaches are increasingly used in neurorehabilitation to address psychological distress. Animal-assistance is thought to increase efficacy. The present study evaluates a psychotherapeutic mindfulness- and self-compassion-based group intervention (MSCBI) with and without animal-assistance for patients with acquired brain injury. Patients (N = 31) were randomly assigned to the 6-week intervention with (n = 14) or without animal-assistance (n = 17). Primary outcome was psychological distress at post- and follow-up treatment, secondary outcomes were changes within-session of patients’ emotional states, adherence to treatment and attrition. Psychological distress significantly decreased in both groups from pre- to follow-up treatment with no difference between groups. Patients in the animal-assisted MSCBI group reported significantly higher increases in feeling secure, accepted, comforted, grateful, motivated and at ease during the sessions compared to patients in the MSCBI group without animal-assistance. Adherence to sessions was significantly higher in the animal-assisted MSCBI group. Attrition did not significantly differ between groups. Our results show that both MSCBIs with and without animal-assistance are feasible and effective in reducing psychological distress in patients with acquired brain injury. The significant changes within-sessions mainly in relationship-based emotional states and the higher treatment adherence suggest additional effects of animal-assistance. Animal-assistance might increase acceptability and patients’ commitment to psychotherapy.

Experiences of crisis care among service users with complex emotional needs or a diagnosis of 'personality disorder', and other stakeholders: systematic review and meta-synthesis of the qualitative literature

BACKGROUND

Mental health crises are common in people with complex emotional needs (our preferred working term for people diagnosed with a 'personality disorder'), yet this population is often dissatisfied with the crisis care they receive. Exploring their experiences and views on what could be improved, and those of carers and healthcare staff, is key to developing better services.

AIMS

We aimed to synthesise the relevant qualitative literature.

METHOD

Five databases were searched. Eligible studies included service users with a diagnosis of personality disorder and their carers or relevant staff, focused on crisis responses and used a qualitative design. Data were analysed with thematic synthesis.

RESULTS

Eleven studies were included, most focusing on emergency departments. Four meta-themes emerged: (a) acceptance and rejection when presenting to crisis care: limited options and lack of involvement of carers; (b) interpersonal processes: importance of the therapeutic relationship and establishing a framework for treatment; (c) managing recovery from a crisis: clear recovery plan and negotiating collaboration; and (d) equipping and supporting staff: training and emotional support.

CONCLUSIONS

Our findings suggest that emergency departments have major limitations as settings to provide crisis care for people with complex emotional needs, but there is a lack of research exploring alternatives. The quality of the therapeutic relationship was central to how care was experienced, with collaborative and optimistic staff highly valued. Staff reported feeling poorly supported in responding to the needs of this population. Research looking at experiences of a range of care options and how to improve these is needed.

Effect of 3 Forms of Early Intervention for Young People With Borderline Personality Disorder: The MOBY Randomized Clinical Trial

Importance

Clinical trials have neither focused on early intervention for psychosocial impairment nor on the contribution of components of borderline personality disorder (BPD) treatment beyond individual psychotherapy.

Objective

To evaluate the effectiveness of 3 early interventions for BPD of differing complexity.

Design, Settings, and Participants

This single-blinded randomized clinical trial recruited young people between March 17, 2011, and September 30, 2015, into parallel groups. The study took place at 2 government-funded mental health services for young people in Melbourne, Australia. Inclusion criteria were age 15 to 25 years (inclusive), recent DSM-IV-TR BPD diagnosis, and never receiving evidence-based BPD treatment. A total of 139 participants were randomized (pool of 876; 70 declined, 667 excluded), balanced for sex, age, and depressive symptomatology. Data analysis completed May 2020.

Interventions

(1) The Helping Young People Early (HYPE) dedicated BPD service model for young people, combined with weekly cognitive analytic therapy (CAT); (2) HYPE combined with a weekly befriending psychotherapy control condition; and (3) a general youth mental health service (YMHS) model, combined with befriending. Therefore, the 3 treatment arms were HYPE + CAT, HYPE + befriending, and YMHS + befriending. Participants were randomly assigned both to 1 treatment arm (in a 1:1:1 ratio) and to a clinician.

Main Outcomes and Measures

Psychosocial functioning, measured with the Inventory of Interpersonal Problems Circumplex Version and the Social Adjustment Scale Self-report.

Results

One hundred twenty-eight participants (104 [81.3%] were female; mean [SD] age, 19.1 [2.8] years; HYPE + CAT: 40 [31.3%]; HYPE + befriending: 45 [35.2%]; YMHS + befriending: 43 [33.6%]) who provided postbaseline data were included in the intent-to-treat analysis. Regardless of group, from baseline to 12 months, there was a mean of 19.3% to 23.8% improvement in the primary outcomes and 40.7% to 52.7% for all secondary outcomes, except severity of substance use and client satisfaction. The latter remained high across all time points. Planned comparisons (YMHS + befriending vs HYPE; HYPE + CAT vs befriending) showed that neither the service model nor the psychotherapy intervention was associated with a superior rate of change in psychosocial functioning by the 12-month primary end point. The HYPE service model was superior to YMHS + befriending for treatment attendance (median [IQR], 22 [19] vs 3 [16] contacts; median duration, 200 [139.5] vs 94 [125] days) and treatment completion (44 of 92 [47.8%] vs 9 of 47 [19.2%]). HYPE + CAT was superior to befriending for treatment attendance (median [IQR], 12 [16.5] vs 3 [9.8] sessions) and treatment completion (24 of 46 [52.2%] vs 29 of 93 [31.2%]).

Conclusions and Relevance

In this randomized clinical trial of 3 interventions for young people with BPD, effective early intervention was not reliant on availability of specialist psychotherapy but did require youth-oriented clinical case management and psychiatric care. A dedicated early intervention BPD service model (HYPE), with or without individual psychotherapy, achieved greater treatment attendance and completion, making it more likely to meet service user, family, and community expectations of care.

Trial Registration

anzctr.org.au Identifier: ACTRN12610000100099.

It's Not That Great Anymore: The Central Role of Defense Mechanisms in Grandiose and Vulnerable Narcissism

Objectives: The concept of narcissism contains a yet unresolved paradox: Its grandiose facet depicts the psychopathological core but is often associated with life-satisfaction and overall functioning, whereas its vulnerable facet is associated with psychological distress, but still not included in the international classification systems. Our goal was to investigate the relationship between the two facets of narcissism expecting underlying defense mechanisms to be core elements. First, we aimed to identify defense mechanisms specific to grandiose and vulnerable narcissism. Second, we explored how both facets are differentially associated with psychological distress, assuming that grandiose narcissism would be associated with less psychological distress than vulnerable narcissism. Third, we investigated the mediating role of defense mechanisms between narcissism and psychological distress. Methods: In a non-clinical sample of N = 254 individuals, the Pathological Narcissism Inventory was used for the assessment of grandiose and vulnerable facets of narcissism, the Defense Style Questionnaire for defense mechanisms, and the Brief Symptom Inventory for psychological distress. Structural equation modeling was employed to identify distinct factors of grandiose and vulnerable narcissism. Associations between specific defense mechanisms and both facets were calculated. Furthermore, the direct association between both facets and psychological distress was examined. We finally explored whether defense mechanisms mediate the association between distress and both grandiose and vulnerable narcissism. Results: A distinct pattern of defense mechanisms for each facet of narcissism could be extracted: Both facets showed significant positive correlations with specific intermediate and all maladaptive defense mechanisms. Only grandiose narcissism showed significant positive correlations with adaptive defenses. Vulnerable narcissism showed negative correlations with all adaptive defenses. Specifically, grandiose narcissism was significantly related to anticipation, pseudo-altruism, rationalization, and dissociation, whereas vulnerable narcissism was negatively related to all these defense mechanisms. While grandiose narcissism was not related to psychological distress, vulnerable narcissism showed high correlations with psychological distress. Intriguingly, mediator analysis found that grandiose narcissism was related to psychological distress when mediated by maladaptive defense mechanisms. Discussion: The role of defense mechanisms is central for a differentiated understanding of the two different faces of narcissism. The relevance of assessing defense mechanisms in clinical settings, and related empirical findings are discussed.