All-Cause Mortality of Hospital-Treated Borderline Personality Disorder: A Nationwide Cohort Study

Physical multimorbidity in psychiatric patients with personality disorders: Insights within the ICD-11 framework

OBJECTIVE

Recent research has revealed poor physical health among individuals with personality disorders (PDs). We aimed to compare chronic physical illnesses (CPI) and chronic physical multimorbidity (CPM) prevalence between the general population (GEP) and PD patients, and to explore the relationship between CPM and various aspects of PD, predominantly within the ICD-11 framework.

METHODS

This cross-sectional study included 126 PD patients and 126 matched controls from the GEP. Patients were evaluated for the ICD-11 PD severity and maladaptive personality domains, subjective emptiness, and reflective functioning. CPI was assessed using a standardized self-report questionnaire.

RESULTS

PD patients had a higher mean number of CPIs (2.05 vs. 1.02) and a more frequent CPM occurrence (49.2% vs. 26.2%) compared to the matched controls (p < .001). The ICD-11 PD severity (OR = 1.143, p = .007) and maladaptive domain Negative affectivity (OR = 4.845, p = .002), and poor reflective functioning (OR = 1.694, p = .007) were significant predictors of CPM, independent of sociodemographic, clinical and lifestyle factors. Negative affectivity showed the most robust effect on CPM, while smoking did not significantly mediate these relationships.

CONCLUSION

Our study found increased CPM burden in PD patients and a link between CPM and various PD aspects under the ICD-11 framework, highlighting the need for more integrated healthcare.

Borderline personality disorder and the diagnostic co-occurrence of mental health disorders and somatic diseases: A controlled prospective national register-based study

OBJECTIVE

Information on borderline personality disorder (BPD) and its comorbidities is often limited to concentrate on a few diagnoses. The aim of the study was to use national register data to investigate all diagnostic co-occurring mental health disorders and somatic diseases 3 years before and after initial BPD diagnosis compared with a matched control group.

METHOD

The study was a register-based cohort of 2756 patients with incident BPD (ICD F60.3) and 11,024 matched controls, during 2002-2016. Comorbidity data were classified into main disease groups, in accordance with the World Health Organization ICD-10 criteria.

RESULTS

Almost half the patients had been diagnosed with mental and behavioral disorders before the BPD diagnosis as compared to 3% in the control group. Further, the co-occurrence of diseases due to external causes of morbidity, including injury, self-harm, and poisoning were more represented in the BPD group before diagnosis as compared to the control group. In addition, co-occurring morbidity related to diseases in the circulatory, the respiratory, the digestive, the musculoskeletal, and the genitourinary system was more represented in the BPD group. After diagnosis, the proportion of patients with co-occurring morbidity increased further in all main disease groups in the BPD group. As many as 87% of patients had mental and behavioral co-occurring morbidity and 15% nervous diseases as compared with 3% and 4%, respectively, in the control group. Also, comorbidities related to external causes of morbidity, including for example, injury and self-harm were more represented in the BPD group. The BPD group had more somatic co-occurring morbidity, especially digestive, respiratory, circulatory, and endocrine diseases. Finally, the mortality over 12 years was statistically significantly higher in people with BPD than in the control group.

CONCLUSION

Patients with BPD have higher odds for multiple physical health conditions and co-occurrence of mental health disorders.

Treating emotion dysregulation in patients with borderline personality disorder using imagery rescripting: A two-session randomized controlled trial

Studies on Emotionally Dysregulated Behavior (EDB) demonstrated that the conduct thereof is associated with emotion dysregulation and preceded by mental imagery of EDB, which can direct future behavior. These findings are specifically important within the context of Borderline Personality Disorder (BPD), where emotion dysregulation and EDB are at the core of the disorder. The present study aims to evaluate the efficacy of imagery rescripting (IR) in treating emotion dysregulation associated with EDB in patients diagnosed with BPD. Forty-eight females diagnosed with BPD were randomly allocated to the IR intervention or treatment-as-usual group. Assessment took place one week before the first treatment session, as well as one week, and twelve weeks after the last treatment session evaluating emotion regulation strategies, borderline-symptomatology, EDB, depressiveness, impulsivity, mental imagery, and illness severity. Within-, and between subject, intention-to-treat-, and per-protocol analysis were conducted. Results showed decreased maladaptive emotion regulation strategies and increased adaptive emotion regulation strategies within the intervention group. Borderline-symptomatology improved immediately after treatment for the intervention group. Additionally, BPD patients within the intervention group improved regarding their impulsivity, depressiveness, and EDB symptomatology in comparison to patients in the TAU group. The presented intervention has proven to be effective in improving BPD-related symptomatology, such as emotion regulation, EDB, depressiveness, and impulsivity. Imagery rescripting could be routinely applied when EDB related images are present. TRIAL REGISTRATION: German Clinical Trials Registry (DRKS) ID: DRKS00010620.

Components of event-related potentials and borderline personality disorder: a meta-analysis

Background: Borderline personality disorder (BPD) is characterized by symptoms associated with difficulties in emotion regulation, altered self-image, impulsivity, and instability in personal relationships. A relationship has been found between BPD symptoms and altered neuropsychological processes. Studies of event-related potentials (ERP) measured with electroencephalogram (EEG) have found neural correlates related to BPD symptoms. Of note is the P300 component, considered a potential mental health biomarker for trauma-associated disorders. However, no meta-analysis has been found to demonstrate this relationship.Objectives: To evaluate the relationship between the P300 component and BPD symptoms. To evaluate the relationship of other ERP components with BPD symptoms.Methods: The method and procedure were adjusted to the PRISMA checklist. The search was performed in three databases: WOS, Scopus and PubMed. A Random Effects Model was used to perform the analysis of the studies. In addition, a meta-regression was performed with % women, Gini and GDP. Finally, a descriptive analysis of the main results found between P300, other ERP components (LPP, P100 and ERN/Ne) and BPD symptoms was performed.Results: From a review of 485 articles, a meta-analysis was performed with six articles that met the inclusion criteria. A moderate, positive relationship was found between the P300 component and BPD symptoms (REM = .489; p < .001). It was not possible to perform meta-analyses for other ERP components (LPP, P100 and ERN/Ne) due to the low number of articles found.Conclusion: The idea that P300 could be considered for use as a biomarker to identify altered neural correlates in BPD is reinforced. In addition, a moderating effect of inequality (Gini) was detected.

Personality functioning and self-disorders in individuals at ultra-high risk for psychosis, with first-episode psychosis and with borderline personality disorder

BACKGROUND

Assessment of personality functioning in different stages of psychotic disorders could provide valuable information on psychopathology, course of illness and treatment planning, but empirical data are sparse.

AIMS

To investigate personality functioning and sense of self in individuals at ultra-high risk (UHR) for psychosis and with first-episode psychosis (FEP) in comparison with a clinical control group of individuals with borderline personality disorder (BPD) and healthy controls.

METHOD

In a cross-sectional design, we investigated personality functioning (Structured Interview of Personality Organization, STIPO; Level of Personality Functioning Scale, LPFS) and disturbances of the basic self (Examination of Anomalous Self-Experience, EASE) in 107 participants, comprising 24 individuals at UHR, 29 individuals with FEP, 27 individuals with BPD and 27 healthy controls.

RESULTS

The UHR, FEP and BPD groups had moderate to severe deficits in personality organisation (STIPO) compared with the healthy control group. Self-functioning with its subdomain (facet) 'self-direction' (LPFS) was significantly worse in participants with manifest psychosis (FEP) compared with those at-risk for psychosis (UHR). The FEP group showed significantly worse overall personality functioning than the UHR group and significantly higher levels of self-disturbance (EASE) than the BPD group, with the UHR group lying between these diagnostic groups. Hierarchical cluster analysis based on the seven STIPO domains yielded three clusters differing in level of personality functioning and self-disturbances.

CONCLUSIONS

Our data demonstrate that psychotic disorders are associated with impaired personality functioning and self-disturbances. Assessment of personality functioning can inform treatment planning for patients at different stages of psychotic disorder.

The impact of schizophrenia spectrum disorder, bipolar disorder and borderline personality disorder on radiotherapy treatment and overall survival in cancer patients: A matched pair analysis

Introduction

The effect of a psychiatric disorder (PD) on the choice of radiotherapy regimens and subsequent cancer control outcomes is largely unknown. In this study, we evaluated differences in radiotherapy regimens and overall survival (OS) between cancer patients with a PD in comparison with a control population of patients without a PD.

Methods

Referred patients with a PD (i.e. schizophrenia spectrum disorder, bipolar disorder or borderline personality disorder) were included through a text-based search of the electronic patient database of all the patients that received radiotherapy between 2015 and 2019 at a single centre. Each patient was matched to a patient without a PD. Matching was based on cancer type, staging, performance score (WHO/KPS), non-radiotherapeutic cancer treatment, gender and age. Outcomes were the amount of fractions received, total dose, and OS.

Results

88 patients with PD were identified; 44 patients with schizophrenia spectrum disorder, 34 with bipolar disorder, and 10 with borderline personality disorder. Matched patients without a PD showed similar baseline characteristics. No statistically significant difference was observed regarding the number of fractions with a median of 16 (interquartile range [IQR] 3-23) versus 16 (IQR 3-25), respectively (p = 0.47). Additionally, no difference in total dose was found. Kaplan-Meier curves showed a statistically significant difference in OS between the patients with a PD versus those without a PD, with 3-year OS rates of 47 % versus 61 %, respectively (hazard ratio 1.57, 95 % confidence interval 1.05-2.35, p = 0.03). No clear differences in causes of death were observed.

Conclusion

Cancer patients referred for radiotherapy with schizophrenia spectrum disorder, bipolar disorder or borderline personality disorder receive similar radiotherapy schedules for a variety of tumour types but attain worse survival.

Effect of comorbid ADHD on mortality in women with borderline personality disorder

BACKGROUND

Many similarities exist between borderline personality disorder (BPD) and attention-deficit/hyperactivity disorder (ADHD), more so in women than in men. People with comorbid ADHD and BPD represent a subgroup of BPD patients with distinct symptom expression and, consequently, a different prognosis. We used Swedish national high quality registers to assess whether such comorbidity is related to increased mortality risk. The study focused on women with BPD because they are more likely than men to be clinically diagnosed with BPD and present a higher mortality risk, especially for unnatural causes of death, including suicide.

FINDINGS

In a cohort of 15 847 women diagnosed with BPD a subsequent clinical diagnosis of ADHD did not influence the overall risk of mortality, including suicide.

CONCLUSIONS

Women with comorbid ADHD and BPD have a similar mortality risk as those only diagnosed with BPD.

The relationship between borderline personality disorder and occupational participation: An integrative review

This integrative review explores the impact of borderline personality disorder (BPD) symptomology and behaviours on occupational capacity, participation, and sustainability. The disorder has also been associated with lower education levels, higher levels of attrition in tertiary education populations, and low occupational participation and employment rates. Personality traits and symptomology have been found to substantially detract from employability. Articles were identified from CINAHL (Cumulative Index to Nursing and Allied Health Literature), PsycINFO/Ovid, ProQuest, and PubMed databases. The Joanna Briggs' Institute (JBI) critical appraisal tools were used to evaluate the quality of evidence, and inductive thematic analysis used to extract main themes. Four themes regarding 'barriers', 'enablers', 'treatment', and 'benefits' emerged amongst the 11 eligible articles. The negative symptomology was a barrier to occupational participation, and people with BPD engaged in self-stigmatizing and non-disclosure. However, the positive symptomology such as boldness and honesty were enablers. Treatment was found to be a key element, and occupational engagement was also found to have positive effectives. The evidence indicates that employment improved the symptoms, and a long-term treatment plan is a key element. Some upskilling of mental health workers may be required, including a focus on possible positive symptomology as a way of dealing with the stigmatization. Some awareness raising of the disorder, including for employers, may be needed, with education programmes that deal with the stigmatization. Future funding should focus on specialized programmes targeting unemployment for this group.

Crisis interventions for adults with borderline personality disorder

BACKGROUND

People diagnosed with borderline personality disorder (BPD) frequently present to healthcare services in crisis, often with suicidal thoughts or actions. Despite this, little is known about what constitutes effective management of acute crises in this population and what type of interventions are helpful at times of crisis. In this review, we will examine the efficacy of crisis interventions, defined as an immediate response by one or more individuals to the acute distress experienced by another individual, designed to ensure safety and recovery and lasting no longer than one month. This review is an update of a previous Cochrane Review examining the evidence for the effects of crisis interventions in adults diagnosed with BPD.

OBJECTIVES

To assess the effects of crisis interventions in adults diagnosed with BPD in any setting.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, nine other databases and three trials registers up to January 2022. We also checked reference lists, handsearched relevant journal archives and contacted experts in the field to identify any unpublished or ongoing studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing crisis interventions with usual care, no intervention or waiting list, in adults of any age diagnosed with BPD.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included two studies with 213 participants. One study (88 participants) was a feasibility RCT conducted in the UK that examined the effects of joint crisis plans (JCPs) plus treatment as usual (TAU) compared to TAU alone in people diagnosed with BPD. The primary outcome was self-harm. Participants had an average age of 36 years, and 81% were women. Government research councils funded the study. Risk of bias was unclear for blinding, but low in the other domains assessed. Evidence from this study suggested that there may be no difference between JCPs and TAU on deaths (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.06 to 14.14; 88 participants; low-certainty evidence); mean number of self-harm episodes (mean difference (MD) 0.30, 95% CI -36.27 to 36.87; 72 participants; low-certainty evidence), number of inpatient mental health nights (MD 1.80, 95% CI -5.06 to 8.66; 73 participants; low-certainty evidence), or quality of life measured using the EuroQol five-dimension questionnaire (EQ-5D; MD -6.10, 95% CI -15.52 to 3.32; 72 participants; very low-certainty evidence). The study authors calculated an Incremental Cost Effectiveness Ratio of GBP -32,358 per quality-adjusted life year (QALY), favouring JCPs, but they described this result as "hypothesis-generating only" and we rated this as very low-certainty evidence.  The other study (125 participants) was an RCT conducted in Sweden of brief admission to psychiatric hospital by self-referral (BA) compared to TAU, in people with self-harm or suicidal behaviour and three or more diagnostic criteria for BPD. The primary outcome was use of inpatient mental health services. Participants had an average age of 32 years, and 85% were women. Government research councils and non-profit foundations funded the study. Risk of bias was unclear for blinding and baseline imbalances, but low in the other domains assessed. The evidence suggested that there is no clear difference between BA and TAU on deaths (RR 0.49, 95% CI 0.05 to 5.29; 125 participants; low-certainty evidence), mean number of self-harm episodes (MD -0.03, 95% CI -2.26 to 2.20; 125 participants; low-certainty evidence), violence perpetration (RR 2.95, 95% CI 0.12 to 71.13; 125 participants; low-certainty evidence), or days of inpatient mental health care (MD 0.70, 95% CI -14.32 to 15.72; 125 participants; low-certainty evidence). The study suggested that BA may have little or no effect on the mean number of suicide attempts (MD 0.00, 95% CI -0.06 to 0.06; 125 participants; very low-certainty evidence). We also identified three ongoing RCTs that met our inclusion criteria. The results will be incorporated into future updates of this review.

AUTHORS' CONCLUSIONS

A comprehensive search of the literature revealed very little RCT-based evidence to inform the management of acute crises in people diagnosed with BPD. We included two studies of two very different types of intervention (JCP and BA). We found no clear evidence of a benefit over TAU in any of our main outcomes. We are very uncertain about the true effects of either intervention, as the evidence was judged low- and very low-certainty, and there was only a single study of each intervention. There is an urgent need for high-quality, large-scale, adequately powered RCTs on crisis interventions for people diagnosed with BPD, in addition to development of new crisis interventions.

Borderline personality disorder: associations with psychiatric disorders, somatic illnesses, trauma, and adverse behaviors

In one of the largest, most comprehensive studies on borderline personality disorder (BPD) to date, this article places into context associations between this diagnosis and (1) 16 different psychiatric disorders, (2) eight somatic illnesses, and (3) six trauma and adverse behaviors, e.g., violent crime victimization and self-harm. Second, it examines the sex differences in individuals with BPD and their siblings. A total of 1,969,839 Swedish individuals were identified from national registers. Cumulative incidence with 95% confidence intervals (CI) was evaluated after 5 years of follow-up from BPD diagnosis and compared with a matched cohort. Associations were estimated as hazard ratios (HR) with 95% CIs from Cox regression. 12,175 individuals were diagnosed with BPD (85.3% female). Individuals diagnosed with BPD had higher cumulative incidences and HRs for nearly all analyzed indicators, especially psychiatric disorders. Anxiety disorders were most common (cumulative incidence 95% CI 33.13% [31.48-34.73]). Other notable findings from Cox regressions include psychotic disorders (HR 95% CI 24.48 [23.14-25.90]), epilepsy (3.38 [3.08-3.70]), violent crime victimization (7.65 [7.25-8.06]), and self-harm (17.72 [17.27-18.19]). HRs in males and females with BPD had overlapping CIs for nearly all indicators. This indicates that a BPD diagnosis is a marker of vulnerability for negative events and poor physical and mental health similarly for both males and females. Having a sibling with BPD was associated with an increased risk for psychiatric disorders, trauma, and adverse behaviors but not somatic disorders. Clinical implications include the need for increased support for patients with BPD navigating the health care system.

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.

Momentary borderline personality disorder symptoms in youth as a function of parental invalidation and youth-perceived support

BACKGROUND

Parental invalidation is central to etiological models of borderline personality disorder (BPD). Previous studies relied on retrospective accounts or laboratory observations to examine these associations. There is a dearth of research assessing these constructs in daily life, and limited studies have tested the effect of parental invalidation on BPD symptoms during early adolescence, when BPD onsets. The current study took a dynamic approach to assess parents' validating and invalidating behavior and its effect on youths' BPD symptom expression in daily life, while accounting for parent-perceived helpfulness of these behaviors and youth-perceived support.

METHODS

A psychiatric sample of 162 early adolescents (age range = 10-14 years; 47% female) and their parent completed a four-day ecological momentary assessment study. Parents reported on the use of validating and invalidating (e.g. punishing and ignoring) behaviors during parent-child conflict, as well as perceived helpfulness of these behaviors. Youth reported on their BPD symptoms and perceived parental support. Multilevel models were used to test the between- and within-person effects of parents' validating and invalidating behaviors, parent-perceived helpfulness and youth-perceived support, and their interaction on youth's momentary expression of BPD symptoms.

RESULTS

At the between-person level, invalidating behaviors, specifically punishing behaviors, were related to greater BPD symptoms in daily life, while ignoring behaviors were associated with fewer BPD symptoms. Youth-perceived support predicted fewer BPD symptoms.

CONCLUSIONS

Results underscore the importance of parental invalidation for the expression of BPD symptoms in daily life and also highlight the importance of youth's subjective experience of parental support. Findings are discussed in terms of etiological and intervention models that emphasize a dyadic framework.

Mentalization-Based Treatment in a Naturalistic Setting in Ireland: A Cohort Study

OBJECTIVE

This study evaluated the real-world effectiveness of mentalization-based treatment by assessing the clinical status of patients before and after completing the treatment program, which was nested within a general adult community mental health service, and by comparing these patients with a treatment-as-usual group.

METHODS

In this retrospective longitudinal naturalistic study, patients with a primary diagnosis of borderline personality disorder received either mentalization-based treatment (N=34) or treatment as usual (N=51). Data were collected from clinical charts and hospital databases. Presentations to the emergency department (ED), psychiatric and medical hospitalizations, and rates of loss to follow-up were analyzed for both groups.

RESULTS

In the 2 years after a course of mentalization-based treatment, significant reductions were noted in psychiatric hospitalizations (p=0.018). Compared with the treatment-as-usual group, the intervention group had significant reductions in ED presentations (p=0.004) and medical admissions (p=0.040), when the analysis controlled for age and gender. At study endpoint, the proportion of patients lost to follow-up in the treatment-as-usual group was larger (χ²=7.59, df=1, p=0.006), with three deaths in the treatment-as-usual group and none in the mentalization-based treatment group.

CONCLUSIONS

Mentalization-based treatment embedded within a community mental health team may have a positive effect, with significant improvements in unscheduled service use and notable reductions in ED presentations, hospitalizations, loss to follow-up, and mortality. There may be value in building on this study with more prospective, systematic research and patient-reported outcomes to assess the practical significance of this intervention in general psychiatric settings.

Mobile Diary App Versus Paper-Based Diary Cards for Patients With Borderline Personality Disorder: Economic Evaluation

Background

The cost-effectiveness of using a mobile diary app as an adjunct in dialectical behavior therapy (DBT) in patients with borderline personality disorder is unknown.

Objective

This study aims to perform an economic evaluation of a mobile diary app compared with paper-based diary cards in DBT treatment for patients with borderline personality disorder in a psychiatric outpatient facility.

Methods

This study was conducted alongside a pragmatic, multicenter, randomized controlled trial. The participants were recruited at 5 Danish psychiatric outpatient facilities and were randomized to register the emotions, urges, and skills used in a mobile diary app or on paper-based diary cards. The participants in both groups received DBT delivered by the therapists. A cost-consequence analysis with a time horizon of 12 months was performed. Consequences included quality-adjusted life years (QALYs), depression severity, borderline severity, suicidal behavior, health care use, treatment compliance, and system usability. All relevant costs were included. Focus group interviews were conducted with patients, therapists, researchers, and industry representatives to discuss the potential advantages and disadvantages of using a mobile diary app.

Results

A total of 78 participants were included in the analysis. An insignificantly higher number of participants in the paper group dropped out before the start of treatment (P=.07). Of those starting treatment, participants in the app group had an average of 37.1 (SE 27.55) more days of treatment and recorded an average of 3.16 (SE 5.10) more skills per week than participants in the paper group. Participants in both groups had a QALY gain and a decrease in depression severity, borderline severity, and suicidal behavior. Significant differences were found in favor of the paper group for both QALY gain (adjusted difference −0.054; SE 0.03) and reduction in depression severity (adjusted difference −1.11; SE 1.57). The between-group difference in total costs ranged from US $107.37 to US $322.10 per participant during the 12 months. The use of services in the health care sector was similar across both time points and groups (difference: psychiatric hospitalization <5 and <5; general practice −1.32; SE 3.68 and 2.02; SE 3.19). Overall, the patients showed high acceptability and considered the app as being easy to use. Therapists worried about potential negative influences on the therapist-patient interaction from new work tasks accompanying the introduction of the new technology but pointed at innovation potential from digital database registrations.

Conclusions

This study suggests both positive and negative consequences of mobile diary apps as adjuncts to DBT compared with paper diary cards. More research is needed to draw conclusions regarding its cost-effectiveness.

Trial Registration

ClinicalTrials.gov NCT03191565; http://clinicaltrials.gov/ct2/show/NCT03191565

International Registered Report Identifier (IRRID)

RR2-10.2196/17737

Borderline Personality Disorder in a "Life History Theory" Perspective: Evidence for a Fast "Pace-of-Life-Syndrome"

"Borderline Personality Disorder" (BPD) is associated with heightened risk for cardiovascular disease and other stress-associated somatic consequences, which is poorly understood in terms of causal mechanisms, such as childhood trauma. Here, we tested the hypothesis suggesting that BPD reflects a fast "Pace-of-Life-Syndrome" (PoLS). Ninety-five women (44 diagnosed with BPD) were recruited to examine psychological correlates of PoLS, including life history features, personality dimensions, aggressiveness, chronic stress, borderline symptom severity, childhood trauma, and allostatic load (AL). In line with expectations, BPD patients had significantly higher scores suggestive of a fast PoLS than controls, they were more aggressive, more burdened with chronic stress and were exposed to more severe childhood adversity. Childhood trauma predicted PoLS, which in turn predicted AL. The present study thus provides direct evidence of psychological and somatic traits associated with the fast end of the PoLS spectrum in females with BPD. Findings are discussed with regard to clinical implications.

Total and cause-specific mortality in patients with personality disorders: the association between comorbid severe mental illness and substance use disorders

PURPOSE

To investigate the mortality in both in- and outpatients with personality disorders (PD), and to explore the association between mortality and comorbid substance use disorder (SUD) or severe mental illness (SMI).

METHODS

All residents admitted to Norwegian in- and outpatient specialist health care services during 2009-2015 with a PD diagnosis were included. Standardized mortality ratios (SMRs) with 95% confidence intervals (CI) were estimated in patients with PD only and in patients with PD and comorbid SMI or SUD. Cox proportional hazards models were used to estimate adjusted hazard ratios (HRs) with 95% CIs in patients with PD and comorbid SMI or SUD compared to patients with PD only.

RESULTS

Mortality was increased in both in- and outpatients with PD. The overall SMR was 3.8 (95% CI 3.6-4.0). The highest SMR was estimated for unnatural causes of death (11.0, 95% CI 10.0-12.0), but increased also for natural causes of death (2.2, 95% CI 2.0-2.5). Comorbidity was associated with higher SMRs, particularly due to poisoning and suicide. Patients with comorbid PD & SUD had almost four times higher all-cause mortality HR than patients with PD only; young women had the highest HR.

CONCLUSION

The SMR was high in both in- and outpatients with PD, and particularly high in patients with comorbid PD & SUD. Young female patients with PD & SUD were at highest risk. The higher mortality in patients with PD cannot, however, fully be accounted for by comorbidity.

Borderline personality disorder in Irish Travellers: a cross-sectional study of an ultra-high-risk group

BACKGROUND

Irish Travellers are a marginalised ethnic minority with poor health outcomes, especially in mental health: the suicide rate in this population is 6-7 times that in the general population. There is a paucity of research into associated clinical risk factors including self-harm and mental illnesses.

AIMS

To examine the prevalence and treatments of mental disorders among Travellers attending a community mental health team (CMHT) in Galway.

METHODS

This is a cross-sectional study of the CMHT database, and included all Travellers who were active cases on the study day were included in this study.

RESULTS

Travellers formed 12.4% (51 out of 410) of the active caseload of the mental health service. The mean age was 35.7 years (SD 13.1). The most common mental disorder was depressive disorder (16/51, 31.4%). Of 51 patients, 25.5% (13/51) were diagnosed with BPD: 7 had other comorbid mental disorders. Patients diagnosed with BPD are significantly more likely to be prescribed psychopharmacotherapy (t = 2.834, p = 0.007). A diagnosis of BPD was significantly associated with history of self-harm after controlling for age and gender (OR 2.3, p = 0.005).

CONCLUSION

This study shows that there is a significant overrepresentation of Travellers in mental health services, suggesting significant need for accessible and acceptable interventions. Those with a BPD diagnosis have a significantly higher risk of self-harm, representing an ultra-high-risk population. These findings can be used to plan future service development projects to better meet the needs of this population: they may require specially adapted version of the mentalisation-based treatment programme.

Psychological therapies for people with borderline personality disorder

BACKGROUND

Over the decades, a variety of psychological interventions for borderline personality disorder (BPD) have been developed. This review updates and replaces an earlier review (Stoffers-Winterling 2012).

OBJECTIVES

To assess the beneficial and harmful effects of psychological therapies for people with BPD.

SEARCH METHODS

In March 2019, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication.

SELECTION CRITERIA

Randomised controlled trials comparing different psychotherapeutic interventions with treatment-as-usual (TAU; which included various kinds of psychotherapy), waiting list, no treatment or active treatments in samples of all ages, in any setting, with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. There were 11 secondary outcomes, including individual BPD symptoms, as well as attrition and adverse effects.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's 'Risk of bias' tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis.

MAIN RESULTS

We included 75 randomised controlled trials (4507 participants), predominantly involving females with mean ages ranging from 14.8 to 45.7 years. More than 16 different kinds of psychotherapy were included, mostly dialectical behaviour therapy (DBT) and mentalisation-based treatment (MBT). The comparator interventions included treatment-as-usual (TAU), waiting list, and other active treatments. Treatment duration ranged from one to 36 months. Psychotherapy versus TAU Psychotherapy reduced BPD symptom severity, compared to TAU; standardised mean difference (SMD) -0.52, 95% confidence interval (CI) -0.70 to -0.33; 22 trials, 1244 participants; moderate-quality evidence. This corresponds to a mean difference (MD) of -3.6 (95% CI -4.4 to -2.08) on the Zanarini Rating Scale for BPD (range 0 to 36), a clinically relevant reduction in BPD symptom severity (minimal clinical relevant difference (MIREDIF) on this scale is -3.0 points). Psychotherapy may be more effective at reducing self-harm compared to TAU (SMD -0.32, 95% CI -0.49 to -0.14; 13 trials, 616 participants; low-quality evidence), corresponding to a MD of -0.82 (95% CI -1.25 to 0.35) on the Deliberate Self-Harm Inventory Scale (range 0 to 34). The MIREDIF of -1.25 points was not reached. Suicide-related outcomes improved compared to TAU (SMD -0.34, 95% CI -0.57 to -0.11; 13 trials, 666 participants; low-quality evidence), corresponding to a MD of -0.11 (95% CI -0.19 to -0.034) on the Suicidal Attempt Self Injury Interview. The MIREDIF of -0.17 points was not reached. Compared to TAU, psychotherapy may result in an improvement in psychosocial functioning (SMD -0.45, 95% CI -0.68 to -0.22; 22 trials, 1314 participants; low-quality evidence), corresponding to a MD of -2.8 (95% CI -4.25 to -1.38), on the Global Assessment of Functioning Scale (range 0 to 100). The MIREDIF of -4.0 points was not reached. Our additional Trial Sequential Analysis on all primary outcomes reaching significance found that the required information size was reached in all cases. A subgroup analysis comparing the different types of psychotherapy compared to TAU showed no clear evidence of a difference for BPD severity and psychosocial functioning. Psychotherapy may reduce depressive symptoms compared to TAU but the evidence is very uncertain (SMD -0.39, 95% CI -0.61 to -0.17; 22 trials, 1568 participants; very low-quality evidence), corresponding to a MD of -2.45 points on the Hamilton Depression Scale (range 0 to 50). The MIREDIF of -3.0 points was not reached. BPD-specific psychotherapy did not reduce attrition compared with TAU. Adverse effects were unclear due to too few data. Psychotherapy versus waiting list or no treatment Greater improvements in BPD symptom severity (SMD -0.49, 95% CI -0.93 to -0.05; 3 trials, 161 participants), psychosocial functioning (SMD -0.56, 95% CI -1.01 to -0.11; 5 trials, 219 participants), and depression (SMD -1.28, 95% CI -2.21 to -0.34, 6 trials, 239 participants) were observed in participants receiving psychotherapy versus waiting list or no treatment (all low-quality evidence). No evidence of a difference was found for self-harm and suicide-related outcomes. Individual treatment approaches DBT and MBT have the highest numbers of primary trials, with DBT as subject of one-third of all included trials, followed by MBT with seven RCTs. Compared to TAU, DBT was more effective at reducing BPD severity (SMD -0.60, 95% CI -1.05 to -0.14; 3 trials, 149 participants), self-harm (SMD -0.28, 95% CI -0.48 to -0.07; 7 trials, 376 participants) and improving psychosocial functioning (SMD -0.36, 95% CI -0.69 to -0.03; 6 trials, 225 participants). MBT appears to be more effective than TAU at reducing self-harm (RR 0.62, 95% CI 0.49 to 0.80; 3 trials, 252 participants), suicidality (RR 0.10, 95% CI 0.04, 0.30, 3 trials, 218 participants) and depression (SMD -0.58, 95% CI -1.22 to 0.05, 4 trials, 333 participants). All findings are based on low-quality evidence. For secondary outcomes see review text.

AUTHORS' CONCLUSIONS

Our assessments showed beneficial effects on all primary outcomes in favour of BPD-tailored psychotherapy compared with TAU. However, only the outcome of BPD severity reached the MIREDIF-defined cut-off for a clinically meaningful improvement. Subgroup analyses found no evidence of a difference in effect estimates between the different types of therapies (compared to TAU) . The pooled analysis of psychotherapy versus waiting list or no treatment found significant improvement on BPD severity, psychosocial functioning and depression at end of treatment, but these findings were based on low-quality evidence, and the true magnitude of these effects is uncertain. No clear evidence of difference was found for self-harm and suicide-related outcomes. However, compared to TAU, we observed effects in favour of DBT for BPD severity, self-harm and psychosocial functioning and, for MBT, on self-harm and suicidality at end of treatment, but these were all based on low-quality evidence. Therefore, we are unsure whether these effects would alter with the addition of more data.

Validity of the personality disorder diagnosis in the Swedish National Patient Register

AIMS

The Swedish National Patient Register (NPR) is an exceptional source of information in clinical epidemiological research. The register is, however, not validated for the diagnosis of personality disorder (PD). We therefore assessed its validity in this patient group, and the group with emotionally unstable PD (EUPD)/borderline personality disorder (BPD).

METHODS

Records from 100 random adult patients (aged 15-65 years) diagnosed with any PD in the NPR between 1987 and 2015 were analysed using a protocol based on general diagnostic criteria for PD, as well as specific criteria for EUPD/BPD in both ICD and DSM classification systems.

RESULTS

Of the 100 patients, 27 had been given a diagnosis of EUPD, 23 another specific PD and 50 an unspecified PD. Using ICD criteria, 88 of 95 evaluable patients could be confirmed to have a PD, that is an agreement rate of 93%. Using DSM criteria, the agreement was lower (77 patients or 81%). Of 26 evaluable patients with a diagnosis of EUPD/BPD, the diagnosis was confirmed in all cases when using the ICD criteria, but in only 20 when using the DSM criteria.

CONCLUSIONS

The NPR is a valid source of data for the diagnosis of PD per se and also of EUPD in women.

Prevalence and structure of self-other problems in SAPAS screening for personality disorder in a National Sample

AIM

This study investigated the prevalence and factorial structure of personality disorder features in the general community measured with the self-report form of the Standardized Assessment of Personality - Abbreviated Scale (SAPAS-SR).

METHOD

SAPAS-SR was administered to a Danish national community sample (N = 50,326; 53% women). The hierarchical latent structure was examined using exploratory factor analyses (EFA) for one to three levels.

RESULTS

We found that 11.3% of the community sample fulfilled the estimated screening criteria for a personality disorder, which was slightly higher for woman and younger people. As hypothesized, a two-factor model corresponded to aspects of self (e.g., being a worrier) and others (e.g., having difficulty making and keeping friends), whereas a three-factor model corresponded to trait domains of negative affectivity, detachment, and externalization.

CONCLUSION

These findings suggest that personality disorder features play a significant role for at least one out of ten individuals in the Danish general community. Such features are primarily organized in a pattern of self- and interpersonal functioning, which is consistent with the conceptualization of core personality dysfunction in the DSM-5 Alternative Model of Personality Disorders and the ICD-11 Classification of Personality Disorders. © 2019 John Wiley & Sons, Ltd.

Psychiatric comorbidity as a risk factor for the mortality of people with bulimia nervosa

BACKGROUND

Bulimia nervosa (BN) is associated with increased mortality. Frequent comorbidities of BN include substance use disorders, affective disorders and personality disorders (PD). These comorbidities may add an additional risk for mortality.

METHODS

We investigated the influence of these psychiatric comorbidities on all-cause mortality with demographic and socioeconomic factors considered as confounders over an observation period from January 2007 to March 2016 for 1501 people with BN using anonymised health records data from the South London and Maudsley NHS Foundation Trust (SLaM), retrieved through its Clinical Records Interactive Search (CRIS) data resource. Mortality was ascertained through monthly linkages to the nationwide tracing system administered by the Office for National Statistics (ONS). We used Cox proportional hazards regression to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). Multivariable analyses were also performed to estimate effects when controlling for confounding of age, sex, ethnicity, borough, marital status and deprivation score.

RESULTS

A total of 18 patients with BN died during the observation period. The standardised mortality ratio (SMR) for our study cohort (against the population of England and Wales in 2012 as a standard) was 2.52 (95% CI 1.49-3.97). Cox regressions revealed significant associations of mortality with older age and male gender. Comorbid PD (HR: 3.36; 95% CI 1.05-10.73) was significantly associated with all-cause mortality, even after controlling for demographic and socioeconomic covariates.

CONCLUSIONS

These results highlight increased mortality in patients with BN and the importance of recognising and treating PDs in patients with BN.