Comorbidity of Borderline Personality Disorder and Lifetime Substance Use Disorders in a Nationally Representative Sample

Virtual patients with substance use disorders in healthcare professional education: a scoping review

Background and objective

Virtual patient simulations are cost-effective methods for training health professionals. Yet, this teaching method is rarely used with clinicians who work or plan on working with people with substance use disorders. This scoping review summarizes the current state of the literature concerning virtual substance use disorder patient simulations in health professionals' training and provides suggestions for future directions.

Methods

Online databases were searched for peer-reviewed articles published between January 2010 and June 2024.

Results

Twelve studies were included. The development, administration, and evaluation of performance of the simulations are diverse. Most simulations aim to develop screening, brief interventions or referring skill, they target a variety of health professionals' disciplines and report positive learning outcomes. Virtual simulations have good acceptance rates from learners.

Conclusions

Enhancing the diversity of clinical skills and patient populations portrayed in simulations, alongside adherence to best practices in simulation development and implementation is suggested to optimize training outcomes in this critical area of healthcare education.

Distribution of self-reported borderline personality disorder traits symptoms in a large-scale clinical population

Introduction

Borderline Personality Disorder (BPD) traits play a crucial role in the prognosis of psychiatric disorders, as well as in assessing risks associated with negativity and impulsivity. However, there is a lack of data regarding the distribution characteristics of BPD traits and symptoms within clinical populations.

Methods

A total of 3015 participants (1321 males, 1694 females) were consecutively sampled from outpatients at the psychiatric and psycho-counseling clinics at the Shanghai Mental Health Center. BPD symptoms were assessed using a self-reported personality diagnostic questionnaire. Having BPD traits is defined as having five or more positive items in self-reported BPD characteristics. Participants were stratified into male and female groups, age groups, and diagnostic groups (schizophrenia, mood disorders, anxiety disorders). Exploratory factor analysis using principal components analysis was conducted. Three factors were identified: "F1: Affective Instability and Impulsivity", "F2: Interpersonal Unstable and Extreme Reactions", and "F3: Identity Disturbance".

Results

Among 3015 participants, 45.9% of the patients self-reported BPD traits. Comparing of male and female patients, there was no statistically significant difference in the occurrence rate of BPD traits (χ2 = 1.835, p=0.176). However, in terms of symptoms, female patients reported more symptoms than male patients. Female patients also exhibited more pronounced features on F2 compared to male patients (t =-1.972, p=0.049). There is a general decrease in BPD traits, symptoms, and factors with increasing age. Specifically, the proportion of positive BPD traits is approximately halved before the age of 30 and decreases to around one-third after the age of 30. BPD traits were most common in the Mood Disorders group at 55.7%, followed by the Anxiety Disorders group at 44.4%, and Schizophrenia group at 41.5% (χ2 = 38.084, p<0.001).

Discussion

Our study revealed the pervasive presence of BPD traits and symptoms among psychiatric outpatients, exhibiting distinctive distributions across gender, age, and diagnostic categories. These findings emphasize the significance of identifying and addressing BPD pathology in the clinical care of psychiatric outpatients.

Clinical specificities of patients with substance use disorder and comorbid borderline personality disorder compared to patients with substance use disorder only: a retrospective study

INTRODUCTION

Substance use disorder (SUD) is a common condition often associated with borderline personality disorder (BPD), and patients with both disorders (SUD + BPD) have more complex presentations and poorer outcomes in treatment. Thus, there is a need to identify more clearly the clinical differences between patients with SUD + BPD and those with SUD only to help clinicians in their diagnostic process.

METHODS

Data from medical files of 92 patients with SUD (SUD only: n = 42; SUD + BPD: n = 50) treated in an outpatient psychiatry and addiction treatment center were extracted to compare the differences in terms of sociodemographic characteristics, substance used, psychopathological dimensions, comorbidity prevalence, and functional impairment.

RESULTS

Compared to the SUD only group, patients in the SUD + BPD group were younger, more disabled, and less satisfied with their social life. Regarding substance used, the comorbid group had more frequently cannabis use disorder and poly nonalcoholic SUD. Regarding psychopathological dimensions, the comorbid group had higher levels of impulsivity, emotion regulation difficulties and alexithymia. Finally, regarding comorbidities, the comorbid group had a higher risk of comorbid anxiety, obsessive-compulsive, and post-traumatic stress disorders.

CONCLUSION

While being only exploratory, these results add evidence on the impact of the BPD comorbidity in patients with SUD and underline important dimensions that should be considered by clinicians working with this population.

Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies

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.

Negative urgency, distress tolerance, and symptoms of substance use, eating, and borderline personality disorders in treatment-seeking young people

OBJECTIVE

Negative urgency (NU) and distress tolerance (DT) are two similar yet distinct constructs with putative transdiagnostic relevance, particularly across psychopathology characterized by impulsivity (e.g., substance use disorders [SUD], eating disorders featuring binging and/or purging ED-B/P, and borderline personality disorder [BPD]). Yet, there remains a lack of research into NU and DT across SUD, ED-B/P, and BPD symptomatology in clinical populations. The present study sought to elucidate the transdiagnostic utility of NU and DT across impulsive-type psychology by examining the unique and interactive roles of NU and DT across SUD, ED-B/P, and BPD symptomatology within a treatment-seeking sample of young people.

METHOD

Participants (N = 385; 62.3% female; aged 16-25 years) were recruited from youth health services across Melbourne, Australia. Participants completed an online survey including self-report measures of NU and DT as well as SUD, ED-B/P, and BPD symptoms. Mixed effects logistic regression was used to explore unique and interactive associations of NU and DT with symptoms.

RESULTS

Both NU (adjusted odds ratio [ORadj ] = 1.22; 95% confidence interval [CI] = [1.16, 1.28]) and global DT (ORadj  = 0.59; 95% CI = [0.47, 0.74]) uniquely predicted symptoms. However, associations with global DT and most of its components differed across psychopathology types. No significant interactions between NU and DT in predicting symptoms were found.

CONCLUSIONS

These results support the transdiagnostic utility of NU across SUD, ED-B/P, and BPD, while suggesting the role of DT across these disorders is more nuanced. These findings have important implications for NU and DT as potential intervention targets.

Uncovering the role of substance use in suicide attempts using a mixed-methods approach

INTRODUCTION

Substance use is an established risk factor for suicide attempt. Clarifying the role of substance use in suicide attempts may identify modifiable treatment targets. This study used mixed methods to associate substance use with suicide attempt history and identify pathways through which substance use contributes to attempts.

METHODS

Study 1 included 213 adult inpatients (n = 127 with substance use disorder [SUD]), who completed assessments of suicide attempt history as well as demographic and clinical suicide risk factors. Study 2 was a narrative analysis of suicide attempt stories described by 20 inpatients diagnosed with SUD.

RESULTS

In Study 1, patients with co-occurring alcohol and drug use disorders reported more actual lifetime suicide attempts than did those without SUD. In addition, alcohol and drug use disorders were independently associated with lifetime suicide attempts after controlling for demographic and clinical confounders. In Study 2, substance use played a role in all suicide attempts through at least one pathway before, during, or after a triggering stressor, or as suicide attempt method.

CONCLUSIONS

Substances play a role in suicide attempt baseline risk, acute risk and as means. It is important to target chronic and acute substance use in suicide prevention treatment plans.

Unhealthy behaviors associated with mental health disorders: a systematic comparative review of diet quality, sedentary behavior, and cannabis and tobacco use

Background

There are well-established literatures documenting the associations between mental disorders and unhealthy behaviors such as poor diet quality, sedentary behavior, and cannabis and tobacco use. Few studies have attempted to understand the respective findings in light of each other, however.

Objective

The purpose of this review was to assemble comparable data for each behavior-disorder association and assess the associations in terms of their overall strength. The review aimed to include a representative, but not exhaustive, range of studies that would allow for explorative comparisons.

Methods

Eligible studies were identified via Pubmed searches and citation searching, restricted to publications no older than 2015 written in English. To obtain comparable data, only studies that reported findings as odds ratios were included, and risk of bias related to study samples, behavioral measurement disparities, and control variables was assessed via sensitivity analyses. Findings for each disorder were compared on the basis of different measures of central tendency.

Results

From 3,682 records, 294 studies were included. The review found evidence of associations between each of the four unhealthy behaviors and psychosis, depression, anxiety, bipolar disorder, attention-deficit/hyperactivity disorder (ADHD), and post-traumatic stress disorder (PTSD), while personality disorder was only investigated in relation to cannabis and tobacco use. In overall comparison, the associations were generally of similar strength, and only the association between cannabis use and personality disorder was exceptional in terms of being significantly stronger than its counterparts across disorders and across behaviors. Analyses of bias risk identified some influence from behavioral measurement disparities and lack of adequate statistical control, but findings were generally robust across a range of sensitivity analyses.

Conclusion

This explorative and comparative review found that poor diet quality, sedentary behavior, and cannabis and tobacco use are about equally strongly associated with a range of different mental disorders. Given the general nature of these associations, we should probably understand them to reflect a general and shared etiology. However, the findings in this review should be regarded as tentative until confirmed by more comprehensive investigations.

The Co-occurrence of Personality Disorders and Substance Use Disorders

PURPOSE OF REVIEW

Despite significant negative outcomes, the co-occurrence of personality disorders (PDs) and substance use disorders (SUDs) continues to be underrecognized, and the mechanisms contributing to this co-occurrence remain unclear. This review summarizes recent work on PD-SUD co-occurrence, with a focus on borderline and antisocial PDs, general substance use patterns among those with PDs, and the association of personality traits with SUDs.

RECENT FINDINGS

The prevalence of co-occurring PD-SUD is generally high, with estimates ranging depending on the type of PD and SUD, the population assessed, and the sampling methods and measures used. Current theoretical explanations for co-occurrence include shared etiology and predisposition models, with research highlighting the importance of transactional processes. Potential underlying mechanisms include personality traits and transdiagnostic characteristics. Recent research has increased focus on substances besides alcohol, dimensional models of personality pathology, and transactional explanations of co-occurrence, but more research is needed to disentangle the nuanced PD-SUD relationship.

Chronic Pain and Psychiatric Conditions

Introduction

Chronic pain is a common condition with high socioeconomic and public health burden. A wide range of psychiatric conditions are often comorbid with chronic pain and chronic pain conditions, negatively impacting successful treatment of either condition. The psychiatric condition receiving most attention in the past with regard to chronic pain comorbidity has been major depressive disorder, despite the fact that many other psychiatric conditions also demonstrate epidemiological and genetic overlap with chronic pain. Further understanding potential mechanisms involved in psychiatric and chronic pain comorbidity could lead to new treatment strategies both for each type of disorder in isolation and in scenarios of comorbidity.

Methods

This article provides an overview of relationships between DSM-5 psychiatric diagnoses and chronic pain, with particular focus on PTSD, ADHD, and BPD, disorders which are less commonly studied in conjunction with chronic pain. We also discuss potential mechanisms that may drive comorbidity, and present new findings on the genetic overlap of chronic pain and ADHD, and chronic pain and BPD using linkage disequilibrium score regression analyses.

Results

Almost all psychiatric conditions listed in the DSM-5 are associated with increased rates of chronic pain. ADHD and BPD are significantly genetically correlated with chronic pain. Psychiatric conditions aside from major depression are often under-researched with respect to their relationship with chronic pain.

Conclusion

Further understanding relationships between psychiatric conditions other than major depression (such as ADHD, BPD, and PTSD as exemplified here) and chronic pain can positively impact understanding of these disorders, and treatment of both psychiatric conditions and chronic pain.

Are Borderline Personality Disorder Features Differentially Related to Pre-Incarceration Alcohol, Cannabis, Cocaine, and Opioid Dependence Among People Recently Incarcerated in Jail?

Borderline personality disorder (BPD) and substance use disorders (SUDs) commonly co-occur across various settings. However, little research has examined how BPD features relate to specific types of SUDs. This study examined whether BPD features assessed shortly after incarceration were differentially related to symptoms of dependence on alcohol, cannabis, cocaine, and opioids experienced in the 12 months prior to incarceration among 510 people recently incarcerated in jail. Follow-up multigroup analyses evaluated whether gender or race moderated the relation of BPD features to the four SUDs. Using structural equational modeling, the relationships of BPD features were compared to each of the four preincarceration dependence symptoms. BPD features were significantly related to dependence on each of the four substances, but the link between BPD features and cocaine dependence was stronger than BPD's association with alcohol, cannabis, or opioid dependence. These findings generalized across men and women and across White and Black people.

Co-use of medication and alcohol: The influence on subjective effects of intoxication and affect

Co-use of alcohol and medication can have serious negative health effects (e.g., overdose risk, liver damage). Research has primarily focused on older adults or the pharmacokinetics of specific medication-alcohol combinations. Little work has focused on the subjective experience of persons who take alcohol-interactive (AI) medications and also drink alcohol, particularly in psychiatric samples at high risk for problematic alcohol use and high rates of prescription medication use, such as individuals with borderline personality disorder (BPD). Data from a larger ecological momentary assessment study of alcohol use in 52 persons diagnosed with BPD (83% women; Mage = 26 years) were used to examine the influence of alcohol intoxication (i.e., estimated blood alcohol concentration [eBAC]) and medication co-use on momentary subjective experience while drinking. Participants reported AI medication use at baseline and completed multiple ecological momentary assessment reports per day over 21 days, which included reports of alcohol use, subjective effects of alcohol (e.g., pleasure, feeling worse), and negative and positive affect. AI medications significantly moderated the association between eBAC and pleasurable effects of alcohol, such that at higher levels of eBAC, those taking AI medications experienced blunted subjective pleasure compared with those not taking AI medications. AI medications did not moderate the associations between eBAC and subjective relief, feeling worse, positive affect, or negative affect. Attenuated pleasure during drinking could lead to increased drinking in an attempt to achieve a desirable state among individuals who co-use psychiatric medications and alcohol, and therefore may represent a useful target for prevention and intervention. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Borderline personality disorder and adolescent suicide attempt: the mediating role of emotional dysregulation

BACKGROUND

Emotional dysregulation seems to be a core feature of Borderline Personality Disorders (BPD). In addition, recent research in the adolescent population has shown that suicidal behaviours have been associated with maladaptive strategies of emotion regulation.

METHODS

This study examined the relative contributions of emotional dysregulation to suicide attempt history in a clinical sample of borderline adolescents. Data were analyzed from 85 participants of the Collaborative European Research Network on Borderline Personality Disorder. Participants completed measures of BPD traits and symptoms, suicide behaviours, emotional dysregulation, attachment styles and lifetime depressive disorders.

RESULTS

In an SEM model, lifetime depressive disorders and insecure attachment styles have a significant direct effect on lifetime suicide attempt, but only lifetime depressive disorders have an indirect effect through emotion dysregulation. The results suggest that emotional dysregulation has a mediating role in suicide attempts among BPD adolescents.

CONCLUSIONS

These findings call for the development of interventions targeting the role of emotion dysregulation in effectively predicting and preventing suicidality in borderline adolescents.

Efficacy of Dialectical Behavioral Therapy for Emotion Dysregulation in Patients with Dual Diagnosis of Borderline Personality Disorder and Substance Use Disorder

Background:

The published evidence supports the efficacy of dialectical behavioral therapy (DBT) to treat patients with borderline personality disorder and particular emphasis on emotion dysregulation as a psychopathological construct.

Aim:

To assess the efficacy of DBT for improving emotion dysregulation among patients with dual diagnosis of borderline personality disorder and substance use disorder.

Methods:

We recruited 40 patients meeting DSM-5 criteria for borderline personality disorder and substance use disorder and assigned them to one of two groups of 20 participants each. One group underwent DBT therapy and the other group followed a treatment-as-usual (TAU) protocol over one year. We used the scores of the difficulties in emotion regulation scale (DERS) at baseline, immediately after therapy, and 4 months after therapy to assess emotion dysregulation.

Results:

We found significant improvements (p<0.05) in the DBT group after therapy that were maintained at least for 4 months afterwards based on the DERS scores (including subscale scores). More patients dropped out of the treatment in the TAU group than in the DBT group.

Conclusion:

DBT is a potentially efficacious psychological intervention to treat emotion dysregulation in patients with borderline personality disorder and substance use disorder.

Borderline Personality Disorder Features and Risk for Prescription Opioid Misuse in a Chronic Pain Sample: Roles for Identity Disturbances and Impulsivity

Although borderline personality disorder (BPD) is associated with both chronic pain and substance abuse, little research examines how BPD features in chronic pain patients may constitute a risk factor for misuse of prescription opioids, and no prior research has examined which particular component(s) of BPD might put chronic pain patients at risk-an oversight that undermines prevention and treatment of such problematic opioid use. In a cross-sectional study of patients in treatment for chronic pain (N = 147), BPD features were associated with several measures of prescription opioid misuse, even controlling for pain severity and interference. Specifically, the identity disturbances and self-harmful impulsivity facets of BPD were most consistently associated with opioid misuse, and exploratory analyses suggested that these factors may be interactive in their effects. Together, these results suggest that BPD features-especially unstable identity and self-harmful impulsivity-play a unique role in problematic prescription opioid use in chronic pain settings.

Presentation of Borderline Personality Disorder Symptoms in Adulthood: Development of Depression Mediates the Effect of Childhood and Adolescent Exposure to Violence

ABSTRACT

Past research has linked the development of borderline personality disorder to earlier exposure to violence. However, the causal link by which this relationship exists has not yet been fully identified. The present study sought to examine how exposure to violence predicted heterogeneity in the development of depressive systems and results in the arousal of borderline personality disorder symptoms in adulthood. The Pathways to Desistance data were used in the analyses. This data set consisted of the responses of 1354 juvenile offenders followed across 7 years. Group-based trajectory modeling was used to identify latent trajectories of depressive symptoms. Ordinary least squares regression was used to model covariate effects on borderline personality disorder symptoms in adulthood. Results indicated that a three-group depression trajectory model best fit the data. Direct victimization early in life was associated with increased borderline personality disorder symptoms in adulthood. When trajectory group assignment was accounted for in the model, the relationship between direct victimization and borderline personality disorder symptoms was attenuated by around 30%. Implications are discussed.

Motives for opioid use explain the relation between borderline personality disorder pathology and opioid use problems

Despite the established relations between borderline personality disorder (BPD) and substance use problems in general, there is a dearth of research on the relation between BPD pathology and opioid use problems, as well as factors that may explain this relation. Therefore, this study examined the indirect relations of BPD pathology to opioid use problems (i.e., prescription opioid misuse, apprehension about prescription opioid use, and opioid cravings) through motives for opioid use (i.e., coping, enhancement, social, and conformity motives) among 68 patients endorsing prescription opioid misuse in a residential correctional substance use disorder (SUD) treatment facility. Participants completed measures of BPD pathology, motives for opioid use, and opioid use problems. Findings revealed significant indirect relations of BPD pathology to opioid misuse through coping and enhancement motives, apprehension about opioid use through coping, enhancement, and social motives, and opioid cravings through coping motives within this SUD sample. Results illustrate the relevance of both emotion- and interpersonal-related motives for opioid use to opioid use problems among patients with BPD pathology in SUD treatment.

Dysfunctional personality beliefs and emotion recognition in individuals with methamphetamine dependence

Previous studies have demonstrated that individuals with methamphetamine dependence have impaired emotion recognition. However, heterogeneity in results from these studies may indicate that individual factors such as personality beliefs moderate emotion recognition deficits. Thus, we aimed to examine the relationship between dimensional estimates of dysfunctional personality beliefs and facial emotion recognition in 86 Australian treatment seekers with methamphetamine dependence. Dysfunctional beliefs were measured using the Personality Beliefs Questionnaire, and emotion recognition was measured with the Ekman's Faces Test. We applied hierarchical regression analyses to test the relationship between beliefs and emotion recognition after accounting for the effects of intelligence. Results indicated that personality beliefs reflecting antisocial and paranoid schemas together accounted for a significant increase in the variance in fear recognition (higher levels of beliefs associated with poorer fear recognition). Further, high levels of passive-aggressive personality beliefs were associated with a tendency to misclassify faces as disgust. Our findings suggest that antisocial, paranoid, and passive-aggressive dysfunctional personality beliefs may underlie inter-individual differences in emotion recognition in methamphetamine dependent individuals. Additional research is required to better understand the relationship between personality and social processing biases, and investigate the direct impact these have on the significant psychosocial impairments present in individuals with methamphetamine dependence.

Collaborative Deprescribing in Borderline Personality Disorder: A Narrative Review

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

Coping motives mediate the relationship between borderline personality features and alcohol, cannabis, and prescription opioid use disorder symptomatology in a substance use disorder treatment sample

Borderline personality disorder and substance use disorder co-occur at a high rate. However, little is known about the mechanisms driving this association. This study examined substance use motives for 3 common substance use disorders among 193 individuals in substance use disorder treatment. We found that the coping motive consistently mediated the relationship between borderline personality and alcohol, cannabis, and prescription opioid use disorders. For this substance use disorder treatment sample, our findings support the self-medication model of substance use, and that interventions aimed at coping-related substance use would be helpful among these patients. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Negative affect and emotion dysregulation among people who inject drugs: An ecological momentary assessment study

This study used ecological momentary assessment (EMA) to measure positive affect (PA) and negative affect (NA) among people who inject drugs (PWID) and examined associations with borderline personality disorder (BPD) symptoms and difficulties with emotion regulation, in the context of injection drug use. We recruited PWID, ages 18-35 years, through syringe exchange program sites in Chicago, Illinois. After completing a baseline interview including a screener for BPD and the Difficulties in Emotion Regulation Scale (DERS), participants used a mobile phone app to report mood, substance use, and injection behavior for 2 weeks. Participants who completed at least 2 EMA assessments were included in the analysis (N = 161). The mean age was 30, about 1/3 were women, 63% were non-Hispanic White, and 23% were Hispanic. In multivariable mixed-effects regression models, positive BPD screen was associated with greater momentary NA intensity and greater instability of both NA and PA. Independent of BPD screening status, DERS score was associated positively with momentary NA intensity and instability and negatively with PA intensity. This finding suggests that emotion dysregulation is an appropriate target for assessment and intervention. Whereas concurrent withdrawal was associated with both greater NA and less PA, opioid intoxication was associated with only greater PA. We did not find support for our hypothesis that emotion dysregulation would moderate the effect of withdrawal on NA. Findings support the validity of the EMA mood measure and the utility of studying mood and behavior among PWID using EMA on mobile phones. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The Roles of Emotion Regulation Difficulties and Impulsivity in the Associations between Borderline Personality Disorder Symptoms and Frequency of Nonprescription Sedative Use and Prescription Sedative/Opioid Misuse

Despite evidence of a strong relationship between BPD and substance use problems in general, little research has examined the associations of BPD symptoms with the misuse of sedatives or opioids, and no studies have explored possible factors that may underlie these associations. Thus, this study examined the relationships of BPD symptoms (i.e., the number of BPD criteria with threshold ratings on a diagnostic interview) to nonprescription sedative use, nonprescription opioid use, and prescription sedative/opioid misuse among 194 patients with alcohol and/or cocaine dependence in a residential substance use disorder treatment facility, as well as the roles of two theoretically-relevant factors in these relationships: emotion regulation (ER) difficulties and impulsivity facets. We found significant positive associations between BPD symptoms and nonprescription sedative use, nonprescription opioid use, and prescription sedative/opioid misuse. We also found significant positive indirect relationships of BPD symptoms to nonprescription sedative use through ER difficulties, ab = .04, 95% CI [.003, .09], and to prescription sedative/opioid misuse through two facets of impulsivity: lack of perseverance, ab = .05, 95% CI [.01, .11], and negative urgency, ab = .03, 95% CI [.002, .07]. Findings highlight the differential relevance of ER difficulties and impulsivity dimensions to the relationships of BPD symptoms to nonprescription sedative use and prescription sedative/opioid misuse, respectively, among patients with alcohol and/or cocaine dependence.

Borderline personality disorder symptoms and exposure to violence as risk factors for opioid use in adulthood

Borderline personality disorder and exposure to violence are both risk factors for opioid use. While past research has identified these relationships, there has yet to be any study which investigates the potential that exposure to violence may help explain the relationship between borderline personality disorder symptoms and opioid use as a mediator. The present study used data from the Pathways to Desistance study to test these proposed relationships. Results indicated that greater levels of borderline personality disorder symptoms were associated with increased opioid use frequency. However, when exposure to violence variables were included in the model, the magnitude of this effect was attenuated by more than 20% and reduced to non-significance. These results indicate the importance of identifying and treating borderline personality disorder symptomatology and to provide increased oversight of the environments which juvenile offenders are exposed to upon reentry. Doing so may help to address the opioid crisis in the United States.

Impact of personality disorders on leaving hospital against medical advice among people living with HIV in British Columbia, Canada

PURPOSE

Leaving hospital against medical advice (AMA) is a significant source of morbidity, mortality, and a major burden to the healthcare system. Studies have indicated that marginalized populations, including people living with HIV (PLHIV) and those living with a personality disorder (PD), experience high hospitalization rates. We sought to identify whether being diagnosed with a PD was associated with leaving hospital AMA among PLHIV in British Columbia (BC), Canada.

METHODS

Data were derived from the STOP HIV/AIDS in BC cohort, a provincial-level linkage of a series of surveillance, laboratory, and health administrative databases of all identified PLHIV in BC. Using multivariable generalized estimating equations (GEE), we examined the relationship between diagnoses of PD and premature hospital discharge among PLHIV.

RESULTS

Among 8763 PLHIV included in the study sample, 1321 (15%) were diagnosed with a PD. The prevalence of leaving hospital AMA at least once during the study period was 9%. In multivariable GEE analyses, after adjusting for a range of demographic and clinical confounders, there remained a positive association between being diagnosed with a PD and leaving hospital prematurely. Results showed a significant and independent association between a PD diagnosis and leaving AMA among PLHIV.

CONCLUSIONS

These findings underscore the importance of identifying and addressing specific PD-related behaviour which negatively impact inpatient treatment completion among this subpopulation of PLHIV. Furthermore, these findings suggest a need to develop novel health system interventions to minimize AMA discharge among this population.

Borderline personality disorder features and drinking, cannabis, and prescription opioid motives: Differential associations across substance and sex

INTRODUCTION

Drinking motives have shown meaningful associations with borderline personality disorder (BPD) features. However, it is unknown whether other common substances of abuse (namely cannabis and prescription opioids) have the same associations with BPD features. In the present study, we tested associations between BPD features and motives across three substances: alcohol, cannabis, and prescription opioids. The purpose of the study was to determine whether BPD showed similar patterns of associations across drugs, or whether some substances serve particular functions for individuals with BPD features, and whether this also varies by sex in a college student sample.

METHOD

Five-hundred ninety-four college students completed online questionnaires measuring demographics, borderline personality disorder features, substance use, and substance specific motives for alcohol, cannabis, and prescription opioid use.

RESULTS

BPD was most strongly associated with coping motives across all substances. For both alcohol and cannabis, this was true for both males and females, along with conformity motives. For prescription opioids, coping, social, enhancement, and pain motives were only significantly related to BPD features for females. When compared statistically, it was found that the associations with coping drinking motives and opioid pain motives were higher among females.

CONCLUSIONS

This pattern of results suggests that negatively reinforcing motives (coping and conformity) play a similar functional role in borderline personality and substance use disorder pathology for alcohol and cannabis, but for prescription opioids the negative reinforcement motives (coping and pain) were only evident in females.

Testing Genetic and Environmental Associations Between Personality Disorders and Cocaine Use: A Population-Based Twin Study

Until now, data have not been available to elucidate the genetic and environmental sources of comorbidity between all 10 DSM-IV personality disorders (PDs) and cocaine use. Our aim was to determine which PD traits are linked phenotypically and genetically to cocaine use. Cross-sectional data were obtained in a face-to-face interview between 1999 and 2004. Subjects were 1,419 twins (µage = 28.2 years, range = 19-36) from the Norwegian Institute of Public Health Twin Panel, with complete lifetime cocaine use and criteria for all 10 DSM-IV PDs. Stepwise multiple and Least Absolute Shrinkage and Selection Operator (LASSO) regressions were used to identify PDs related to cocaine use. Twin models were fitted to estimate genetic and environmental associations between the PD traits and cocaine use. In the multiple regression, antisocial (OR = 4.24, 95% CI [2.66, 6.86]) and borderline (OR = 2.19, 95% CI [1.35, 3.57]) PD traits were significant predictors of cocaine use. In the LASSO regression, antisocial, borderline, and histrionic were significant predictors of cocaine use. Antisocial and borderline PD traits each explained 72% and 25% of the total genetic risks in cocaine use, respectively. Genetic risks in histrionic PD were not significantly related to cocaine use. Importantly, after removing criteria referencing substance use, antisocial PD explained 65% of the total genetic variance in cocaine use, whereas borderline explained only 4%. Among PD traits, antisocial is the strongest correlate of cocaine use, for which the association is driven largely by common genetic risks.

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

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

Borderline personality disorder and substance use disorders: an updated review

For decades, clinicians and researchers have recognized that borderline personality disorder (BPD) and substance use disorders (SUDs) are often diagnosed within the same person (e.g., (Gunderson JG. Borderline personality disorder: A clinical guide. Washington, D.C.: American Psychiatric Press, 2001; Leichsenring et al., Lancet 377:74-84, 2011; Paris J. Borderline personality disorder: A multidimensional approach. American Psychiatric Pub, 1994; Trull et al., Clin Psychol Rev 20:235-53, 2000)). Previously, we documented the extent of this co-occurrence and offered a number of methodological and theoretical explanations for the co-occurrence (Trull et al., Clin Psychol Rev 20:235-53, 2000). Here, we provide an updated review of the literature on the co-occurrence between borderline personality disorder (BPD) and substance use disorders (SUDs) from 70 studies published from 2000 to 2017, and we compare the co-occurrence of these disorders to that documented by a previous review of 36 studies over 15 years ago (Trull et al., Clin Psychol Rev 20:235-53, 2000).

Differences in the Rates of Drug Polyconsumption and Psychiatric Comorbidity among Patients with Cocaine Use Disorders According to the Mental Health Service

Cocaine continues to be a worldwide public health concern in Europe. To improve prognosis and intervention, it is necessary to understand the characteristics of the patients who depend on the services where they receive care. The objective is to analyze the differences among patients who use cocaine and between ambulatory and residential resources to better adapt treatment. This is a descriptive, observational study of two populations of cocaine users in treatment: the ambulatory therapeutic community (ATC) and the therapeutic community (TC). The PRISM diagnostic interview was used for both groups. An analysis of both populations indicates a high prevalence of cocaine, heroin, cannabis, sedative, psychostimulant, and hallucinogen use disorders in the TC population compared to the ATC. In alcohol use disorder, differences between both mental health services were not observed. The degree of severity of cocaine use disorders (CUD) is greater in the TC population. The prevalence of psychiatric comorbidity is not statistically significant between the two populations, except for primary psychotic disorders, which are more prevalent in the TC population. This difference in the prevalence of psychotic disorders may be related to the high prevalence of cannabis use disorders in TC patients. Differences in the prevalence of substance use disorders, severity of CUD, and psychiatric comorbidity may limit the efficiency of mental health services involved in substance use disorder therapeutics. These results suggest the need for careful and extensive phenotyping of patients to improve intervention and prognosis in a clinical resource-dependent manner.

Use of nalmefene in patients with comorbid borderline personality disorder and alcohol use disorder: a preliminary report

Comorbidity between borderline personality disorder (BPD) and alcohol use disorder (AUD) is high and relevant as alcohol consumption seems to worsen BPD symptomatology. One of the newest treatments for AUD, nalmefene, may be useful to improve BPD symptoms not only indirectly by reducing alcohol consumption but also directly by acting on the opioid system as this system has been related to specific BPD symptoms. This open-label study aimed at evaluating the efficacy of an 8-week nalmefene treatment in reducing alcohol consumption in individuals with BPD and comorbid AUD. A secondary objective was to assess its efficacy in improving general BPD symptomatology and specific behaviors (self injury and binge eating). Eighteen out of the 25 patients with BPD and comorbid AUD enrolled in the study completed all the assessment points. After 8 weeks, a significant reduction was observed in alcohol consumption, BPD global symptomatology, self-injurious behavior, and binge eating. No serious adverse effects were reported; however, five participants experienced mild side effects, resulting in withdrawal from the study in two cases. According to our results, nalmefene may be a safe and effective drug for treating patients with BPD and comorbid AUD. Controlled clinical trials are needed to support our findings.

Clinical features and psychiatric comorbidities of borderline personality disorder patients with versus without a history of suicide attempt

Patients with borderline personality disorder (BPD) are at high risk for suicidal behavior. However, many BPD patients do not engage in suicidal behavior. In this study, we compared clinical features of BPD patients with or without a history of suicide attempts and healthy volunteers. Compared with healthy volunteers, both BPD groups had higher Affective Lability Scale (ALS), ALS - Depression-Anxiety Subscale, Barratt Impulsivity Scale (BIS), and Lifetime History of Aggression (LHA) scores and were more likely to have a history of temper tantrums. BPD suicide attempters had higher ALS, ALS - Depression-Anxiety Subscale and LHA scores and were more likely to have a history of non-suicidal self-injury or temper tantrums compared to BPD non-attempters. Also, BPD suicide attempters were more likely to have a history of comorbid major depressive disorder and less likely to have comorbid narcissistic personality disorder (NPD) in comparison to BPD non-attempters. About 50% of study participants in each BPD group had a history of comorbid substance use disorder (SUD). Our study indicates that BPD patients with a history of suicide attempt are more aggressive, affectively dysregulated and less narcissistic than BPD suicide non-attempters.

Alcohol Craving and Consumption in Borderline Personality Disorder: When, Where, and with Whom

Substance use is highly prevalent in our society, and substance use disorders are comorbid with most psychiatric disorders, including borderline personality disorder (BPD; Grant et al., 2006, 2008). Craving is a fundamental feature of addiction and disorder, yet the contexts in which craving occurs and is associated with substance use is still under-researched. We examined alcohol craving and consumption in a sample of 56 BPD individuals and a comparison group of community drinkers (COM; n = 60) who carried electronic diaries for approximately 21 days. BPD individuals reported more craving than COM individuals in most contexts. Compared to COM individuals, elevated craving in BPD individuals was paralleled by more drinking when at work, at home, and with romantic partners, coworkers, and children. These findings identify contexts of particular relevance to those with BPD and other mood/anxiety disorders in which craving may lead to risky and maladaptive alcohol use.

Comparison of treatment outcomes in severe personality disorder patients with or without substance use disorders: a 36-month prospective pragmatic follow-up study

BACKGROUND

Concurrent personality disorder (PD) and substance use disorder (SUD) are common in clinical practice. However, SUD is the main criterion for study exclusion in most psychotherapeutic studies of PD. As a result, data on treatment outcomes in patients with concurrent PD/SUD are scarce.

METHODS

The study sample consisted of 51 patients diagnosed with severe PD and admitted for psychotherapeutic treatment as a part of routine mental health care. All patients were diagnosed with PD according to the Structured Clinical Interview for PD. Patients were further assessed (DSM-IV diagnostic criteria) to check for the presence of concurrent SUD, with 28 patients diagnosed with both disorders (PD-SUD). These 28 cases were then compared to the 23 patients without SUD (PD-nSUD) in terms of psychiatric hospitalizations and psychiatric emergency room (ER) visits before and during the 6-month therapeutic intervention and every 6 months thereafter for a total of 36 months.

RESULTS

The baseline clinical characteristics correspond to a sample of PD patients (78% met DSM-IV criteria for borderline PD) with poor general functioning and a high prevalence of suicide attempts and self-harm behaviors. Altogether, the five outcome variables - the proportion and the number of psychiatric inpatient admissions, the number of days hospitalized, and the proportion and the number of psychiatric ER visits - improved significantly during the treatment period, and this improvement was maintained throughout the follow-up period. Although PD-SUD patients had more psychiatric hospitalizations and ER visits than PD-nSUD patients during follow-up, the differences between these two groups remained stable over the study period indicating that the treatment was equally effective in both groups.

CONCLUSION

Specialized psychotherapy for severe PD can be effectively applied in patients with concurrent PD-SUD under usual practice conditions. These findings suggest that exclusion of patients with dual disorders from specialized treatments is unjustified.

Possible role of a dysregulation of the endogenous opioid system in antisocial personality disorder

Around half the inmates in prison institutions have antisocial personality disorder (ASPD). A recent theory has proposed that a dysfunction of the endogenous opioid system (EOS) underlies the neurobiology of borderline personality disorder (BPD). In the present theoretical paper, based on a comprehensive database and hand search of the relevant literature, this hypothesis is extended to ASPD, which may be the predominant expression of EOS dysfunction in men, while the same pathology underlies BPD in women. According to evidence from human and animal studies, the problematic behaviours of persons with antisocial, callous, or psychopathic traits may be seen as desperate, unconscious attempts to stimulate their deficient EOS, which plays a key role in brain reward circuits. If the needs of this system are not being met, the affected persons experience dysphoric mood, discomfort, or irritability, and strive to increase binding of endogenous opioids to receptors by using the rewarding effects of aggression by exertion of physical or manipulative power on others, by abusing alcohol or substances that have the reward system as target, by creating an "endorphin rush" by self-harm, by increasing the frequency of their sexual contacts, or by impulsive actions and sensation seeking. Symptoms associated with ASPD can be treated with opioid antagonists like naltrexone, naloxone, or nalmefene.