Recent developments in borderline personality disorder

'Commanded to be ill, accused of being well' a lived-experience-led, qualitative investigation of service user perspectives on the impact of emotionally unstable personality disorder diagnosis on self-concept

BACKGROUND

Emotionally unstable personality disorder (EUPD) is a mental disorder impairing health and functioning and increasing suicide risk and it is a stigmatised condition among healthcare professionals. EUPD diagnosis may significantly affect self-concept, yet no previous investigation has explicitly examined this.

AIMS

To explore service user perspectives on (a) the impact of EUPD diagnosis on self-concept and (b) mediators of positive and negative impacts.

METHODS

Service user-led, qualitative semi-structured interviews with n = 10 participants with EUPD.

RESULTS

Perceived impacts of diagnosis on self-concept were, broadly, negative. Factors mediating between positive and negative impacts included: exposure to online stigma and public understanding, the responses of relatives, friends, intimate partners and trusted communities, and the attitudes and behaviours of healthcare staff. There were indications that recent guideline and practice developments (guidelines recommending alternatives to inpatient admissions for people with EUPD and "recovery-focused" approaches to self-harm) may have worsened inpatient staff attitudes and led to more rejecting service user experiences.

CONCLUSION

Mitigating negative impacts of EUPD diagnosis on self-concept may require addressing hateful, online content related to EUPD; revisiting use of the personality disorder label; improving medical communication around diagnosis and improving practice and policy in the management of EUPD in inpatient settings.

Cortical haemodynamic response measured by functional near infrared spectroscopy during a verbal fluency task in patients with major depression and borderline personality disorder

BACKGROUND

Functional near infrared spectroscopy (fNIRS) provides a direct and quantitative assessment of cortical haemodynamic function during a cognitive task. This functional neuroimaging modality may be used to elucidate the pathophysiology of psychiatric disorders, and identify neurophysiological differences between co-occurring psychiatric disorders. However, fNIRS research on borderline personality disorder (BPD) has been limited. Hence, this study aimed to compare cerebral haemodynamic function in healthy controls (HC), patients with major depressive disorder (MDD) and patients with BPD.

METHODS

fNIRS signals during a verbal fluency task designed for clinical assessment was recorded for all participants. Demographics, clinical history and symptom severity were also noted.

FINDINGS

Compared to HCs (n = 31), both patient groups (MDD, n = 31; BPD, n = 31) displayed diminished haemodynamic response in the frontal, temporal and parietal cortices. Moreover, haemodynamic response in the right frontal cortex is markedly lower in patients with MDD compared to patients with BPD.

INTERPRETATION

Normal cortical function in patients with BPD is disrupted, but not as extensively as in patients with MDD. These results provide further neurophysiological evidence for the distinction of patients with MDD from patients with BPD.

Principles of managing patients with personality disorder

The management of individuals with personality disorder is one of the most challenging and sometimes controversial areas of psychiatry. This paper describes the principles involved in identifying the clinical problems and formulating a management plan for patients with personality disorder in everyday clinical practice. It demonstrates that the principles of assessing and managing personality disorders and the clinical skills required are no different from those of treating any other chronic mental disorder.

Constructivist Simultaneous Treatment of Borderline Personality Disorder, Trauma, and Addiction Comorbidity: A Qualitative Case Study

This qualitative case study explored one client's recovery from borderline personality disorder, trauma, and problem gambling. The client attended 18 months of integrative treatment and was followed for 5 years. The study included 106 data points of both client and therapist data. We identified three phases to treatment. First, alliance formation and normalization appeared as mechanisms, and the client experienced dependence. Second, working alliance and countertransference appeared as mechanisms, and the client experienced reduced gambling and suicidal ideation. Third, external controls and increased opportunity appeared as mechanisms, and "moving into the world" was the client experience. The findings give preliminary support to a phase-based constructivist treatment including trauma assessment to normalize self-feelings, countertransference work to support motivation for restraint, and case management principles to support continuity of change efforts.

A qualitative study exploring female patients' experiences of self-harm in a medium secure unit

This study utilized a social constructivist model and reports upon interviews conducted with five female patients in a medium secure service. Their perception of self-harm is considered. Six themes emerged from the data, 'the traumatized individual', 'interrupted maturation process', 'the hidden experience', 'crossing the line', 'individual and systemic repercussions', 'nascent potential protection'. In addition to the six themes that emerged, we concluded that, although individual perceptions of self-harm varied, commonalities existed across accounts and that individual formulation may assist both patients and staff to gain a personalized understanding, thus, enabling less harmful ways of coping to be established.

Object Relations Treatment of a Woman With Borderline Personality Disorder From a Mahlerian Perspective

This article presents the treatment of a female patient with borderline personality disorder which draws on the principles of Margret Mahler’s object relations theory. Common characteristics of this disorder include fear of abandonment, unstable relationships, lack of identity, impulsiveness, pervasive emptiness, excessive anger, and the inability to regulate emotions. These symptoms are rooted in the dynamic, ambivalent, and prevailing struggle between the merger and individualization during the rapprochement subphase. Psychotherapy that utilizes transference within the treatment helps the patient to increase awareness of how she participates in a dyadic relationship based on early internalizations. The unconscious reenactment of early object relations is understood by uncovering defenses (splitting, projection, and projective identification) that play out in the therapist/patient relationship. This offers the patient the opportunity to integrate parts of the self and other, and hold ambivalent feelings without splitting or distorting. Consequently the therapeutic relationship is the vehicle for change.

Cognitive analytic therapy for borderline personality disorder: therapist competence and therapeutic effectiveness in routine practice

This study sought to examine the competency of cognitive analytic therapy (CAT) delivered under routine care conditions and to identify the effectiveness of CAT for patients with borderline personality disorder (BPD). Ten cognitive analytic therapists in six National Health Service Trust sites treated 19 patients with BPD using the standard CAT BPD contract of 24 sessions plus four follow-ups. The methodology was small N repeated measures deign, with patients interviewed at the third follow-up session using the Change Interview. Results indicate a high treatment and follow-up compliance rate (89.47%). Significant reductions in psychological distress, risk and dissociation over the time course of the CAT occurred, with a significant increase in personality integration. Most sessions (92.85%) were delivered in a competent manner. Reductions to psychological distress occurred early in treatment and were sustained, whereas increases in personality integration typically occurred later on in treatment. Patients tended to attribute change to the therapy received. Benchmarking against extant CAT BPD evidence notes a moderate effect size across routine care and trial contexts. The results are discussed in terms of identified methodological shortcomings, clinical implications and the contribution made by the CAT model to the treatment of BPD.

Medication for borderline personality disorder: a survey at a secure hospital

OBJECTIVES

To study the use of medication in the treatment of inpatients with borderline personality disorder (BPD). To survey clinicians' views on the UK National Institute for Health and Clinical Excellence (NICE) Guideline on BPD.

METHODS

Cross-sectional survey of the use of psychotropics purely for BPD at a large secure UK psychiatric hospital, together with interviews with the treating psychiatrists.

RESULTS

A total of 79 patients had a DSM diagnosis of BPD, of whom 80% were receiving one or more psychotropics and 48% were receiving two or more. Most prescriptions were off-label. Antipsychotics followed by antidepressants were the most frequent class of drug prescribed for BPD. Clozapine was the most commonly prescribed drug and according to the treating psychiatrists the one most likely to lead to a major improvement in target symptoms. Other psychotropics were generally rated as resulting in minor improvement or no change. Clinicians were aware they were prescribing contrary to NICE but justified this on the basis of having to treat severe and complex cases.

CONCLUSIONS

Use of psychotropics (especially clozapine), off-label prescribing and polypharmacy were very common in these inpatients with BPD. Randomised controlled trials of the use of clozapine in severe BPD are needed.

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

BACKGROUND

This study investigates the outcome of crisis intervention for chronic post traumatic disorders with a model based on the theory that such crises manifest trauma in the present. The sufferer's behavior is in response to the current perception of dependency and entrapment in a mistrusted relationship. The mechanism of disorder is the sufferer's activity, which aims to either prove or disprove the perception of entrapment, but, instead, elicits more semblances of it in a circular manner. Patients have reasons to keep such activity private from therapy and are barely aware of it as the source of their symptoms.

METHODS

The hypothesis is that the experimental intervention will reduce symptoms broadly within 8 to 24 h from initiation of treatment, compared to treatment as usual. The experimental intervention sidesteps other symptoms to engage patients in testing the trustworthiness of the troubled relationship with closure, thus ending the circularity of their own ways. The study compares 32 experimental subjects with 26 controls at similar crisis stabilization units.

RESULTS

The results of the Brief Psychiatric Rating Scale (BPRS) supported the hypothesis (both in total score and for four of five subscales), as did results with Client Observation, a pilot instrument designed specifically for the circular behavior targeted by the experimental intervention. Results were mostly non-significant from two instruments of patient self-observation, which provided retrospective pretreatment scores.

CONCLUSIONS

The discussion envisions further steps to ascertain that this broad reduction of symptoms ensues from the singular correction that distinguishes the experimental intervention.

TRIAL REGISTRATION

Protocol Registration System NCT00269139. The PRS URL is https://register.clinicaltrials.gov.

Development of a specialised forensic service for women with learning disability: the first three years

In recent years there has been growing interest in the fate of those women with mental disorder who come into contact with the criminal justice system. This interest has stemmed from growing recognition that traditional forensic services could not offer the appropriate care required by this group in a conventional mixed‐gender environment. Women‐only services have begun to be developed in generic psychiatric settings, spurred on by the national service framework (NSF) which set a time limit for the development of segregated in‐patient facilities. Forensic services for those with learning disability have been slower to take up the challenge of how best to place women with learning disability who offend and require an in‐patient secure environment. This article describes how one such service attempted to rise to this challenge and build a service for this often neglected group