10-Year Outcome of Suicidal Behavior in Borderline Personality Disorder

Borderline Personality Traits Do Not Moderate the Relationship Between Depression, Beliefs, and Suicidal Thoughts and Behaviors

Adults with clinically significant borderline personality disorder traits (BPTs) are at high risk of experiencing suicidal thoughts and behaviors (STBs). STBs among those with BPTs have been associated with suicidal beliefs (e.g., that one is unlovable or that distress is intolerable). However, the extent to which suicidal beliefs uniquely mediate the relationship between emotional distress and STBs among individuals with BPTs is not known. Individuals admitted to an inpatient unit (N = 198) with recent STBs completed assessments of BPTs, depression, suicidal beliefs, suicidal ideation, and suicide attempt history. Moderated mediation models were used to explore whether suicidal beliefs mediated the relationship between depression and STBs conditional on BPTs. Suicidal patients with versus without BPTs reported stronger suicidal beliefs and more severe STBs (i.e., suicidal ideation, lifetime attempts). Exploratory moderated mediation analysis demonstrated that suicidal beliefs mediated the relationship between depression and suicidal ideation as well as suicide attempts. The mediation effect of suicidal beliefs on the depression-ideation and depression-attempt relationship was not significantly moderated by BPTs. This study was cross-sectional and therefore the estimated mediation models must be considered exploratory. Longitudinal research will be needed to assess the potential causal mediation of suicidal beliefs on the relationship between depression and STBs. The results of this study suggest that suicidal beliefs may play a significant role in the relationship between depression and STBs for inpatients with a history of suicidality regardless of BPTs. This suggests suicidal beliefs may be an important treatment target for adults with a history of STBs.

The Pathogenesis of Borderline Personality Disorder: Evolution of Evidence and Treatment Implications for Two Prominent Models

Since Stern first started his work in 1938, the field has recognized several empirically supported models of the etiology of borderline personality disorder (BPD). Two such models are the Tripartite Model of the Development of BPD and the Biosocial Development Model of BPD. The Tripartite Model of the Development of BPD suggests that it is a combination of a hyperbolic temperament, traumatic childhood experiences, and an event or series of events that trigger the onset of BPD. Whereas the Biosocial Development Model of BPD elaborates on the work of Linehan's Biosocial Theory. This model suggests a combination of an emotionally vulnerable temperament and an invalidating environment cause BPD. Over 70 years of research support these models. This article covers a detailed description of each of these models, the decades of research supporting these models, similarities, differences, treatment implications, the latest research, and future directions.

Non-response to psychotherapy for borderline personality disorder: A systematic review

HIGHLIGHT

This is the first systematic review to investigate non-response to psychotherapy for borderline personality disorder.

BACKGROUND

Psychotherapy is the recommended treatment for borderline personality disorder. While systematic reviews have demonstrated the effectiveness of psychotherapy for borderline personality disorder, effect sizes remain small and influenced by bias. Furthermore, the proportion of people who do not respond to treatment is seldom reported or analysed.

OBJECTIVE

To obtain an informed estimate of the proportion of people who do not respond to psychotherapy for borderline personality disorder.

METHODS

Systematic searches of five databases, PubMed, Web of Science, Scopus, PsycINFO and the Cochrane Library, occurred in November 2020. Inclusion criteria: participants diagnosed with borderline personality disorder, treated with psychotherapy and data reporting either (a) the proportion of the sample that experienced 'reliable change' or (b) the percentage of sample that no longer met criteria for borderline personality disorder at conclusion of therapy. Exclusion criteria: studies published prior to 1980 or not in English. Of the 19,517 studies identified, 28 met inclusion criteria.

RESULTS

Twenty-eight studies were included in the review comprising a total of 2436 participants. Average treatment duration was 11 months using well-known evidence-based approaches. Approximately half did not respond to treatment; M = 48.80% (SD = 22.77).

LIMITATIONS

Data regarding within sample variability and non-response are seldom reported. Methods of reporting data on dosage and comorbidities were highly divergent which precluded the ability to conduct predictive analyses. Other limitations include lack of sensitivity analysis, and studies published in English only.

CONCLUSION

Results of this review suggest that a large proportion of people are not responding to psychotherapy for borderline personality disorder and that factors relating to non-response are both elusive and inconsistently reported. Novel, tailored or enhanced interventions are needed to improve outcomes for individuals not responding to current established treatments.

Associations between symptoms of borderline personality disorder and suicidality in inpatient adolescents: The significance of identity disturbance

Several studies report that borderline personality disorder (BPD) is a risk factor for suicidality in adults. However, this issue requires further research in adolescents, as it is not clear which individual BPD symptoms are significant correlates of suicidality in this age group. The main aim of the current study was to test which symptoms of BPD are associated with suicidality in adolescent inpatients, even when controlling for age, gender, and depressive symptoms. Inpatient adolescents (N = 339) aged 12-17 years completed the Childhood Interview for DSM-IV Borderline Personality Disorder, the Beck Depression Inventory-II, the Modified Scale for Suicidal Ideation, and reported their number of lifetime suicide attempts. Multivariable regression analyses showed that, after controlling for confounding variables, overall BPD symptom severity was positively related to suicidal ideation and suicide attempts. Of the individual BPD symptoms, identity disturbance, chronic emptiness, avoid abandonment, and transient paranoia were the most robust correlates of suicidal ideation intensity, and only identity disturbance was associated with the number of lifetime suicide attempts. To assess the risk of suicidality in youth, it is essential to assess for BPD symptoms; it is important to focus on adolescents' subjective feelings to assess the severity of identity disturbance and chronic emptiness.

Borderline personality disorder and the big five: molecular genetic analyses indicate shared genetic architecture with neuroticism and openness

Both environmental (e.g. interpersonal traumatization during childhood and adolescence) and genetic factors may contribute to the development of Borderline Personality Disorder (BPD). Twin studies assessing borderline personality symptoms/features in the general population indicate that genetic factors underlying these symptoms/features are shared in part with the personality traits of the Five Factor Model (FFM) of personality-the "Big Five". In the present study, the genetic overlap of BPD with the Big Five -Openness to Experience, Conscientiousness, Extraversion, Agreeableness, and Neuroticism- was assessed. Linkage disequilibrium score regression was used to calculate genetic correlations between a genome-wide association study (GWAS) in central European populations on BPD (N = 2543) and GWAS on the Big Five (N = 76,551-122,886, Neuroticism N = 390,278). Polygenic scores (PGS) were calculated to test the association of the genetic disposition for the personality traits with BPD case-control status. Significant positive genetic correlations of BPD were found with Neuroticism (rg = 0.34, p = 6.3*10-5) and Openness (rg = 0.24, p = 0.036), but not with the other personality traits (all | rg | <0.14, all p > 0.30). A cluster and item-level analysis showed positive genetic correlations of BPD with the Neuroticism clusters "Depressed Affect" and "Worry", and with a broad range of Neuroticism items (N = 348,219-376,352). PGS analyses confirmed the genetic correlations, and found an independent contribution of the personality traits to BPD risk. The observed associations indicate a partially shared genetic background of BPD and the personality traits Neuroticism and Openness. Larger GWAS of BPD and the "Big Five" are needed to further explore the role of personality traits in the etiology of BPD.

Towards optimal treatment selection for borderline personality disorder patients (BOOTS): a study protocol for a multicenter randomized clinical trial comparing schema therapy and dialectical behavior therapy

BACKGROUND

Specialized evidence-based treatments have been developed and evaluated for borderline personality disorder (BPD), including Dialectical Behavior Therapy (DBT) and Schema Therapy (ST). Individual differences in treatment response to both ST and DBT have been observed across studies, but the factors driving these differences are largely unknown. Understanding which treatment works best for whom and why remain central issues in psychotherapy research. The aim of the present study is to improve treatment response of DBT and ST for BPD patients by a) identifying patient characteristics that predict (differential) treatment response (i.e., treatment selection) and b) understanding how both treatments lead to change (i.e., mechanisms of change). Moreover, the clinical effectiveness and cost-effectiveness of DBT and ST will be evaluated.

METHODS

The BOOTS trial is a multicenter randomized clinical trial conducted in a routine clinical setting in several outpatient clinics in the Netherlands. We aim to recruit 200 participants, to be randomized to DBT or ST. Patients receive a combined program of individual and group sessions for a maximum duration of 25 months. Data are collected at baseline until three-year follow-up. Candidate predictors of (differential) treatment response have been selected based on the literature, a patient representative of the Borderline Foundation of the Netherlands, and semi-structured interviews among 18 expert clinicians. In addition, BPD-treatment-specific (ST: beliefs and schema modes; DBT: emotion regulation and skills use), BPD-treatment-generic (therapeutic environment characterized by genuineness, safety, and equality), and non-specific (attachment and therapeutic alliance) mechanisms of change are assessed. The primary outcome measure is change in BPD manifestations. Secondary outcome measures include functioning, additional self-reported symptoms, and well-being.

DISCUSSION

The current study contributes to the optimization of treatments for BPD patients by extending our knowledge on "Which treatment - DBT or ST - works the best for which BPD patient, and why?", which is likely to yield important benefits for both BPD patients (e.g., prevention of overtreatment and potential harm of treatments) and society (e.g., increased economic productivity of patients and efficient use of treatments).

TRIAL REGISTRATION

Netherlands Trial Register, NL7699 , registered 25/04/2019 - retrospectively registered.

Prevalence and correlates of suicide attempts in Chinese individuals with borderline personality disorder

BACKGROUND

To date, few empirical studies have examined the clinical characteristics of suicide attempts (SA) in individuals with borderline personality disorder (BPD) in China.

AIMS

To examine the prevalence and factors associated with SA in Chinese individuals with BPD.

METHODS

In this cross-sectional study, 84 patients with BPD were recruited from a large public psychiatric hospital in Wuhan, China, between 2013 and 2015. Trained experienced psychiatrists interviewed participants to collect clinical data, including demographics, axis I and axis II diagnoses of mental disorders according to the DSM-IV-TR, number of hospitalizations, and history of SA. An interview outline was used to identify the existence of lifetime SA. In addition, the Beck Depression Inventory-II, Buss & Perry Aggression Questionnaire, Child Trauma Questionnaire-Short Form, and Beck Hopelessness Scale were administered to assess respondents' depressive symptoms, aggression, childhood traumatic experiences, and hopelessness.

RESULTS

Fifty-two (61.9%) patients reported attempting suicide during their lifetime. Univariate logistic regression analysis screened 7 factors associated with SA in individuals with BPD into Multiple logistic regression analysis: female sex, unemployment, major depressive disorder (MDD), hostility, self-aggression, depressive symptoms, and emotional neglect. Multiple logistic regression analysis identified 3 significant and independent correlates of SA: MDD [odds ratio (OR) = 26.773, 95% confidence interval (CI) = 3.914-183.132, P = 0.001], hostility (OR = 1.073, CI = 1.019-1.130, P = 0.007), and self-aggression (OR = 1.056, CI = 0.998-1.119, P = 0.060).

CONCLUSION

Chinese individuals with BPD have a high risk of suicide. Correlates of SA in this population differ to some extent from those in Western populations as reported in the literature. Paying attention to MDD and some types of aggression in Chinese individuals with BPD may help identify their risk of suicide. Future large-sample cohort study may improve the limitations of this study and further confirm the point of view above.

Differences in Comorbidities Between Children and Youth With Suicide Attempts Versus Ideation Presenting to the Emergency Department

OBJECTIVE

The aim of this work was to explore identified risk factors for suicidal ideations and attempts and the differences in these risk factors between emergency department encounters among youth seeking medical care for suicide attempt and those with suicidal ideation.

METHOD

This was a retrospective analysis of suicide-related claims for emergency department visits from nine state-level Healthcare Cost and Utilization Project databases for youth aged 5 through 19 years. Risk factors were estimated by identifying comorbidities recorded in first five diagnosis codes. Odds ratios comparing rates of these comorbidities in encounters for suicide attempts compared to encounters for suicidal ideation were estimated using multivariate logistic regression.

RESULTS

In all, 169,047 encounters for suicide-related behavior were identified. We found higher odds of concurrent anxiety, personality disorders, and alcohol-related diagnoses and lower odds of a comorbid psychosis diagnosis, attention deficit hyperactivity disorder, and other substance-related diagnoses in the population of suicide attempters compared to patients with suicidal ideation alone.

CONCLUSION

The odds of diagnoses of specific comorbidities differed in youth encounters for suicide attempts compared to encounters for suicidal ideation.

Borderline Personality Disorder Diagnosis and Symptoms in Outpatient Youth as Risk Factors for Criminal Offenses and Interpersonal Violence

The aim of the current study was to examine the risk for offending among outpatient youth with borderline pathology. Demographic and diagnostic data from 492 outpatients who attended a public mental health service for 15-to 25-year-olds between January 1998 and March 2008 were linked with information regarding criminal offenses and intervention orders collected from a statewide police database between March 1993 and June 2017. BPD diagnosis and number of BPD criteria were both associated with an elevated risk for violent and nonviolent offenses and family violence intervention orders. Moderation analyses revealed that the number of BPD criteria might affect males and females differently in terms of offending. Both impulsivity and anger independently predicted the risk for violent and nonviolent offenses and family violence intervention orders. Early detection of increased risk of offending among youth with BPD features is essential to develop targeted treatments for criminal or violent behavior.

Childhood maltreatment and suicidality among women seeking mental health care: the mediating effect of borderline personality features, moderated by age

Although childhood maltreatment is known to elevate women's risk for suicidal ideation and behavior, research concerning the mechanisms involved remains limited. While borderline personality disorder (BPD) has been implicated as mediating this association, such effects may differ depending on women's age. The present study examined borderline personality features as a dispositional mediator of the relationship between childhood maltreatment and suicidality, with the moderating effect of age, among help-seeking women. A sample of 151 women attending community mental health clinics completed measures of childhood maltreatment, BPD features, suicidality, and psychological distress. Regression analyses tested moderated mediation, controlling for psychological distress across each path. Results indicated a significant interaction between childhood maltreatment and age in predicting borderline personality features, and significant moderated mediation in predicting suicidality. Borderline personality features significantly mediated the association between maltreatment and suicidality among younger--but not among older--women, with the mediation effect becoming stronger as women were younger. The findings indicate borderline personality features as particularly salient among young women in accounting for the maltreatment-suicidality association. Thus, interventions addressing BPD may warrant consideration for young women with suicidal ideation and history of childhood adversity.

Self-harm in the context of borderline personality disorder

The present article gives a selective overview of recent studies on the role of nonsuicidal self-injury (NSSI) and suicidal behavior in the context of borderline personality disorder (BPD). Previous research found self-harming behavior, particularly NSSI, to constitute an easily accessible marker in the early detection of individuals at risk of development of BPD. The review further summarizes studies that investigated inter-relations between BPD features and self-harming behavior over time. Mainly, affective instability has been shown to play a role in the maintenance of NSSI and the increased risk of suicidal behavior among individuals with BPD. Finally, results about the effectiveness of treatment programs on the reduction of self-harming behavior among individuals with BPD are presented.

Abandonment Psychotherapy and Psychosocial Functioning Among Suicidal Patients With Borderline Personality Disorder: A 3-Year Naturalistic Follow-Up

The authors present the results from a 3-year follow-up among 170 patients who had participated in the original randomized study, which consisted of three treatment conditions: (a) 3-month abandonment psychotherapy (AP) delivered by certified psychotherapists, (b) AP delivered by nurses, and (c) treatment as usual in a psychiatric crisis center. All subjects were recruited at the emergency room after a suicide attempt and met diagnostic criteria for borderline personality disorder and major depression. Psychotic symptoms, bipolar disorder, and mental retardation were exclusion criteria. At 3-year follow-up, 134 (78.8%) subjects had blind, reliable assessment by clinical psychologists. The intent-to-treat analysis indicated that those patients who had received AP during acute treatment had better global functioning, improved work adjustment, and less unemployment/disability at 3-year follow-up. No differences were found as a function of type of therapist delivering AP. The data confirm that short-term AP gains in psychosocial functioning are sustained over the longer term.

Association of Borderline Personality Disorder Criteria With Suicide Attempts: Findings From the Collaborative Longitudinal Study of Personality Disorders Over 10 Years of Follow-up

IMPORTANCE

Borderline personality disorder (BPD) has been identified as a strong risk factor for suicidal behavior, including suicide attempts. Delineating specific features that increase risk could inform interventions.

OBJECTIVE

To examine factors associated with prospectively observed suicide attempts among participants in the Collaborative Longitudinal Study of Personality Disorders (CLPS), over 10 years of follow-up, with a focus on BPD and BPD criteria.

DESIGN, SETTING, AND PARTICIPANTS

The CLPS is a multisite, naturalistic, prospective study of adult participants with 4 personality disorders (PDs) and a comparison group of adults with major depressive disorder and minimal PD features. Participants were all treatment-seeking and recruited from inpatient, partial, and outpatient treatment settings across New York, New York, Boston, Massachusetts, New Haven, Connecticut, and Providence, Rhode Island. A total of 733 participants were recruited at baseline, with 701 completing at least 1 follow-up assessment. The cohorts were recruited from September 1996 through April 1998 and September 2001 through August 2002. Data for this study using this follow-up sample (N = 701) were analyzed between March 2019 and August 2020.

MAIN OUTCOMES AND MEASURES

Participants were assessed annually using semistructured diagnostic interviews and a variety of self-report measures for up to 10 years. Multiple logistic regression analyses were used to examine baseline demographic and clinical risk factors, including BPD and individual BPD criteria, of suicide attempt assessed over 10 years of prospective follow-up.

RESULTS

Of the 701 participants, 447 (64%) identified as female, 488 (70%) as White, 527 (75%) as single, 433 (62%) were unemployed, and 512 (73%) reported at least some college education. Of all disorders, BPD emerged as the most robust factor associated with prospectively observed suicide attempt(s) (odds ratio [OR], 4.18; 95% CI, 2.68-6.52), even after controlling for significant demographic (sex, employment, and education) and clinical (childhood sexual abuse, alcohol use disorder, substance use disorder, and posttraumatic stress disorder) factors. Among BPD criteria, identity disturbance (OR, 2.21; 95% CI, 1.37-3.56), chronic feelings of emptiness (OR, 1.63; 95% CI, 1.03-2.57), and frantic efforts to avoid abandonment (OR, 1.93; 95% CI, 1.17-3.16) emerged as significant independent factors associated with suicide attempt(s) over follow-up, when covarying for other significant factors and BPD criteria.

CONCLUSIONS AND RELEVANCE

In the multisite, longitudinal study of adults with personality disorders, identity disturbance, chronic feelings of emptiness, and frantic efforts to avoid abandonment were significantly associated with suicide attempts. Identity disturbance, chronic feelings of emptiness, and frantic efforts to avoid abandonment may be clinically overlooked features of BPD in context of suicide risk assessment. In light of the high rates of BPD diagnostic remission, our findings suggest that these criteria should be independently assessed and targeted for further study as suicide risk factors.

Age-related differences in borderline personality disorder symptom networks in a transdiagnostic sample

BACKGROUND

Naturalistic longitudinal studies of Borderline Personality Disorder (BPD) indicate that symptoms improve over time. In the present study, we applied network theory to the question of how BPD symptom networks may differ as a function of age.

METHODS

In a transdiagnostic sample of 5,212 patients presenting for acute psychiatric treatment, we administered a measure of BPD symptoms and then used a novel machine learning technique to test the hypothesis that symptom networks would significantly differ across the age of participants.

RESULTS

Results supported two significant differences in the BPD symptom network that emerged at age 46. In older participants, the relationships among symptoms of non-suicidal self-injury/suicide and emptiness was weaker, yet the relationship between anger and relationship problems was stronger. No differences emerged for relationships between all other symptoms.

LIMITATIONS

Given the cross-sectional nature of this study, the potential influence of cohort effects cannot be ruled out.

CONCLUSIONS

These findings support the utility of network theory for elucidating potential pathways by which the relationships between symptoms of BPD may differ as a function of age in treatment-seeking individuals. In parallel, results of this study support the highly central role of strong emotions in BPD regardless of age.

INdividual Vocational and Educational Support Trial (INVEST) for young people with borderline personality disorder: study protocol for a randomised controlled trial

Background

The clinical onset of borderline personality disorder (BPD) usually occurs in young people (aged 12–25 years) and commonly leads to difficulty achieving and maintaining vocational (education and/or employment) engagement. While current psychosocial interventions lead to improvements in psychopathology, they have little effect upon functioning. Individual Placement and Support (IPS) is a client-driven model that assists individuals with severe mental illness to engage with education and/or employment appropriate to their personal goals, and that provides ongoing support to maintain this engagement. The objective of the INdividual Vocational and Educational Support Trial (INVEST) is to evaluate the effectiveness of adding IPS to an evidence-based early intervention programme for BPD, with the aim of improving vocational outcomes.

Methods/design

INVEST is a single-blind, parallel-groups, randomised controlled trial (RCT). The randomisation is stratified by gender and age and uses random permuted blocks. The interventions are 39 weeks of either IPS, or ‘usual vocational services’ (UVS). Participants will comprise 108 help-seeking young people (aged 15–25 years) with three or more DSM-5 BPD features and a desire to study or work, recruited from the Helping Young People Early (HYPE) early intervention programme for BPD at Orygen, in Melbourne, Australia. All participants will receive the HYPE intervention. After baseline assessment, staff who are blind to the intervention group allocation will conduct assessments at 13, 26, 39 and 52 weeks. At the 52-week primary endpoint, the primary outcome is the number of days in mainstream education/employment since baseline. Secondary outcomes include the cost-effectiveness of the intervention, quality of life, and BPD severity.

Discussion

Current treatments for BPD have little impact on vocational outcomes and enduring functional impairment is prevalent among this patient group. IPS is a targeted functional intervention, which has proven effective in improving vocational outcomes for adults and young people with psychotic disorders. This trial will investigate whether IPS is effective for improving vocational (employment and educational) outcomes among young people with subthreshold or full-syndrome BPD.

Trial registration

Australian New Zealand Clinical Trials Registry, ID: ACTRN12619001220156. 13 September 2019.

The identification of a risk profile for young people with borderline personality pathology: a review of recent literature

The shift towards early intervention in borderline personality disorder (BPD) has introduced a clinical staging approach in the treatment for young persons with BPD. Complementary to staging is profiling: the identification of psychological, social and biological risk variables that may predict prognosis. The aim of this paper is to provide a risk profile for BPD by systematically reviewing literature on potential risk markers for poor prognosis for BPD. An extensive literature search revealed evidence for seven categories of risk factors: adverse childhood experiences, BPD symptom profile, associated mental disorders, personality impairments and traits, current interpersonal context, biological disposition and socio-demographics. Including these markers within the current staging approach, to compose individual risk profiles for poor BPD prognosis, may assist in personalizing treatment for young people with BPD and in refining research protocols for treatment outcome studies.

Diagnosis and Treatment of Borderline Personality Disorder in Young People

PURPOSE OF REVIEW

We review recent research concerning the diagnosis and treatment of borderline personality disorder (BPD) in young people. We examine evidence for the need to define an appropriate age for detection, and the suitability of current classification methods and treatment.

RECENT FINDINGS

Evidence supports early detection and intervention for subsyndromal borderline pathology or categorical BPD across an extended developmental period. A range of structured treatments are effective for BPD in young people, although the role of treatment components in successful outcomes is unclear. Substantial evidence suggests that a stronger focus on functional outcomes, especially social and vocational outcomes, is warranted. Effective treatments for BPD are rarely available internationally. There is a need to assess whether less complex interventions might be developed that are scalable across health systems. A clinical staging model should be considered, addressing clinical distress and co-occurring psychopathology, as well as diagnosis.

Recovery in borderline personality disorder: time for optimism and focussed treatment strategies

PURPOSE OF REVIEW

Borderline personality disorder (BPD) is prevalent, debilitating and clinically challenging. The evolving field of intervention and outcomes in BPD research is considered with a focus on recent research.

RECENT FINDINGS

A pattern of clinical and functional improvement is to be expected in patients experiencing BPD. Specialized psychotherapies are shown to be beneficial, but generalist, low-intensity interventions in nonspecialized centres are also showing efficacy. Long-term naturalistic studies show that remission of the disorder is common and promising outcomes are not only possible, but likely. Training in vocational functioning, improving personal competence and promoting resilience needs to be further developed.

SUMMARY

BPD diagnosis does not need to overwhelm clinicians, nor does it require therapeutic pessimism. Targeted interventions, including meaningful psychoeducation, are helpful in promoting optimism and enhancing recovery-oriented treatments.