Suicidality and Personality Pathology in Adolescence: A Systematic Review

This work presents a review of research papers examining the role of emerging personality pathology in suicidal ideation and behaviours in adolescence. Initially, 226 studies were selected in line with PRISMA guidelines, and 33 articles were finally included in this review. The data show percentages of any personality disorder diagnosis ranging from 19.5 to 22.8% in suicide attempters, while in autopsy studies, the rate of personality disorder diagnosis varied between 29.6 and 42.1%. The overwhelming majority of the studies focus on the role of borderline personality disorder (BPD) in suicidal behaviours, also highlighting its predictive role at a longitudinal level. Furthermore, the literature review shows that personality traits supposed to underlie BPD, such as affective instability, impulsivity and identity diffusion, have specific predictive links with suicidal conduct. Other personality pathology dimensions, such as aggressiveness, sadism and perfectionism that are associated with other personality disorders, namely, antisocial and narcissistic personality disorders, have also shown a significant mediating role for suicidal risk. Overall, these results seem to parallel the role of personality pathology in predicting suicide in adulthood and point to the relevance of assessing the presence of emerging patterns of personality disorders for the clinical management of suicidal risk in adolescence.

Pharmacological interventions for people with borderline personality disorder

BACKGROUND

Among people with a diagnosis of borderline personality disorder (BPD) who are engaged in clinical care, prescription rates of psychotropic medications are high, despite the fact that medication use is off-label as a treatment for BPD. Nevertheless, people with BPD often receive several psychotropic drugs at a time for sustained periods.

OBJECTIVES

To assess the effects of pharmacological treatment for people with BPD.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers up to February 2022. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals.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 pharmacological treatment to placebo, other pharmacologic treatments or a combination of pharmacologic treatments in people of all ages with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. Secondary outcomes were individual BPD symptoms, depression, attrition and adverse events.

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 46 randomised controlled trials (2769 participants) in this review, 45 of which were eligible for quantitative analysis and comprised 2752 participants with BPD in total. This is 18 more trials than the 2010 review on this topic. Participants were predominantly female except for one trial that included men only. The mean age ranged from 16.2 to 39.7 years across the included trials. Twenty-nine different types of medications compared to placebo or other medications were included in the analyses. Seventeen trials were funded or partially funded by the pharmaceutical industry, 10 were funded by universities or research foundations, eight received no funding, and 11 had unclear funding. For all reported effect sizes, negative effect estimates indicate beneficial effects by active medication. Compared with placebo, no difference in effects were observed on any of the primary outcomes at the end of treatment for any medication. Compared with placebo, medication may have little to no effect on BPD symptom severity, although the evidence is of very low certainty (antipsychotics: SMD -0.18, 95% confidence interval (CI) -0.45 to 0.08; 8 trials, 951 participants; antidepressants: SMD -0.27, 95% CI -0.65 to 1.18; 2 trials, 87 participants; mood stabilisers: SMD -0.07, 95% CI -0.43 to 0.57; 4 trials, 265 participants). The evidence is very uncertain about the effect of medication compared with placebo on self-harm, indicating little to no effect (antipsychotics: RR 0.66, 95% CI 0.15 to 2.84; 2 trials, 76 participants; antidepressants: MD 0.45 points on the Overt Aggression Scale-Modified-Self-Injury item (0-5 points), 95% CI -10.55 to 11.45; 1 trial, 20 participants; mood stabilisers: RR 1.08, 95% CI 0.79 to 1.48; 1 trial, 276 participants). The evidence is also very uncertain about the effect of medication compared with placebo on suicide-related outcomes, with little to no effect (antipsychotics: SMD 0.05, 95 % CI -0.18 to 0.29; 7 trials, 854 participants; antidepressants: SMD -0.26, 95% CI -1.62 to 1.09; 2 trials, 45 participants; mood stabilisers: SMD -0.36, 95% CI -1.96 to 1.25; 2 trials, 44 participants). Very low-certainty evidence shows little to no difference between medication and placebo on psychosocial functioning (antipsychotics: SMD -0.16, 95% CI -0.33 to 0.00; 7 trials, 904 participants; antidepressants: SMD -0.25, 95% CI -0.57 to 0.06; 4 trials, 161 participants; mood stabilisers: SMD -0.01, 95% CI -0.28 to 0.26; 2 trials, 214 participants). Low-certainty evidence suggests that antipsychotics may slightly reduce interpersonal problems (SMD -0.21, 95% CI -0.34 to -0.08; 8 trials, 907 participants), and that mood stabilisers may result in a reduction in this outcome (SMD -0.58, 95% CI -1.14 to -0.02; 4 trials, 300 participants). Antidepressants may have little to no effect on interpersonal problems, but the corresponding evidence is very uncertain (SMD -0.07, 95% CI -0.69 to 0.55; 2 trials, 119 participants). The evidence is very uncertain about dropout rates compared with placebo by antipsychotics (RR 1.11, 95% CI 0.89 to 1.38; 13 trials, 1216 participants). Low-certainty evidence suggests there may be no difference in dropout rates between antidepressants (RR 1.07, 95% CI 0.65 to 1.76; 6 trials, 289 participants) and mood stabilisers (RR 0.89, 95% CI 0.69 to 1.15; 9 trials, 530 participants), compared to placebo. Reporting on adverse events was poor and mostly non-standardised. The available evidence on non-serious adverse events was of very low certainty for antipsychotics (RR 1.07, 95% CI 0.90 to 1.29; 5 trials, 814 participants) and mood stabilisers (RR 0.84, 95% CI 0.70 to 1.01; 1 trial, 276 participants). For antidepressants, no data on adverse events were identified.

AUTHORS' CONCLUSIONS

This review included 18 more trials than the 2010 version, so larger meta-analyses with more statistical power were feasible. We found mostly very low-certainty evidence that medication may result in no difference in any primary outcome. The rest of the secondary outcomes were inconclusive. Very limited data were available for serious adverse events. The review supports the continued understanding that no pharmacological therapy seems effective in specifically treating BPD pathology. More research is needed to understand the underlying pathophysiologic mechanisms of BPD better. Also, more trials including comorbidities such as trauma-related disorders, major depression, substance use disorders, or eating disorders are needed. Additionally, more focus should be put on male and adolescent samples.

Adolescence as a peak period of borderline personality features? A meta-analytic approach

This meta-analysis of cross-sectional data aimed to shed light on the often assumed peak in mean-level of borderline personality features during middle to late adolescence (i.e. age 17–22). Borderline personality features were operationalized through the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). Search terms were entered into PsycINFO and Scopus. A total of 168 samples were included in the analyses, comprising 25,053 participants. Mean age ranged from 14.35 to 51.47 years ( M = 29.01, SD = 8.52) and mean number of borderline personality features from 0 to 8.10 ( M = 4.59, SD = 2.34). The hypothesized peak between age 17 and 22 was not substantiated by the confirmatory ANOVA analysis. However, subsequent exploratory GAM analysis provided evidence for a peak at 29.4 years. Caution is needed in interpreting these findings given that different trends appeared when GAM models were constructed separately for community, patient and borderline personality disorder (BPD) samples. Age differences in community samples indicated a significant linear decline in mean-level of borderline personality features over time. A linear rising trend was found in BPD samples. As a between-person mean-level approach was used in the current study, future longitudinal studies are needed to substantiate if between-person age difference generalize to within-person changes.

Inter-Rater Reliability of the Structured Interview of DSM-IV Personality (SIDP-IV) in an Adolescent Outpatient Population

Personality disorders (PDs) are a class of mental disorders which are associated with subjective distress, decreased quality of life and broad functional impairment. The presence of one or several PDs may also complicate the course and treatment of symptom disorders such as anxiety and depression. Accurate and reliable means of diagnosing personality disorders are thus crucial to ensuring efficient treatment planning and resource allocation, a fact which is widely acknowledged within the adult mental health field. In adolescents, on the other hand, the consensus view has been that the rapid and discontinuous processes of normal personality development render the construct of PD in adolescents clinically unhelpful and conceptually dubious. However, recent research has established the reliability and validity of the construct, heralding an increased interest in the field, with important conceptual and clinical implications. The present article presents reliability data for the Structured Interview of DSM-IV Personality (SIDP-IV) in an adolescent outpatient population. For this study, 25 interviews conducted by experienced clinicians were blindly re-scored based on sound recordings, which allowed for the calculation of intra-class correlation metrics. The intra-class correlation coefficient for categorical diagnosis of specific personality disorders was found to be 0.876 (95% CI 0.718-0.945); Cohen's kappa for presence/absence of personality diagnosis was found to be 0.896. The present study found excellent intra-rater reliability for the sample, which suggests that the SIDP-IV is a suitable instrument for assessing personality pathology in adolescent populations.

Control interventions in randomised trials among people with mental health disorders

BACKGROUND

Control interventions in randomised trials provide a frame of reference for the experimental interventions and enable estimations of causality. In the case of randomised trials assessing patients with mental health disorders, many different control interventions are used, and the choice of control intervention may have considerable impact on the estimated effects of the treatments being evaluated.

OBJECTIVES

To assess the benefits and harms of typical control interventions in randomised trials with patients with mental health disorders. The difference in effects between control interventions translates directly to the impact a control group has on the estimated effect of an experimental intervention. We aimed primarily to assess the difference in effects between (i) wait-list versus no-treatment, (ii) usual care versus wait-list or no-treatment, and (iii) placebo interventions (all placebo interventions combined or psychological, pharmacological, and physical placebos individually) versus wait-list or no-treatment. Wait-list patients are offered the experimental intervention by the researchers after the trial has been finalised if it offers more benefits than harms, while no-treatment participants are not offered the experimental intervention by the researchers.

SEARCH METHODS

In March 2018, we searched MEDLINE, PsycInfo, Embase, CENTRAL, and seven other databases and six trials registers.

SELECTION CRITERIA

We included randomised trials assessing patients with a mental health disorder that compared wait-list, usual care, or placebo interventions with wait-list or no-treatment .

DATA COLLECTION AND ANALYSIS

Titles, abstracts, and full texts were reviewed for eligibility. Review authors independently extracted data and assessed risk of bias using Cochrane's risk of bias tool. GRADE was used to assess the quality of the evidence. We contacted researchers working in the field to ask for data from additional published and unpublished trials. A pre-planned decision hierarchy was used to select one benefit and one harm outcome from each trial. For the assessment of benefits, we summarised continuous data as standardised mean differences (SMDs) and dichotomous data as risk ratios (RRs). We used risk differences (RDs) for the assessment of adverse events. We used random-effects models for all statistical analyses. We used subgroup analysis to explore potential causes for heterogeneity (e.g. type of placebo) and sensitivity analyses to explore the robustness of the primary analyses (e.g. fixed-effect model).

MAIN RESULTS

We included 96 randomised trials (4200 participants), ranging from 8 to 393 participants in each trial. 83 trials (3614 participants) provided usable data. The trials included 15 different mental health disorders, the most common being anxiety (25 trials), depression (16 trials), and sleep-wake disorders (11 trials). All 96 trials were assessed as high risk of bias partly because of the inability to blind participants and personnel in trials with two control interventions. The quality of evidence was rated low to very low, mostly due to risk of bias, imprecision in estimates, and heterogeneity. Only one trial compared wait-list versus no-treatment directly but the authors were not able to provide us with any usable data on the comparison. Five trials compared usual care versus wait-list or no-treatment and found a SMD -0.33 (95% CI -0.83 to 0.16, I² = 86%, 523 participants) on benefits. The difference between all placebo interventions combined versus wait-list or no-treatment was SMD -0.37 (95% CI -0.49 to -0.25, I² = 41%, 65 trials, 2446 participants) on benefits. There was evidence of some asymmetry in the funnel plot (Egger's test P value of 0.087). Almost all the trials were small. Subgroup analysis found a moderate effect in favour of psychological placebos SMD -0.49 (95% CI -0.64 to -0.30; I² = 53%, 39 trials, 1656 participants). The effect of pharmacological placebos versus wait-list or no-treatment on benefits was SMD -0.14 (95% CI -0.39 to 0.11, 9 trials, 279 participants) and the effect of physical placebos was SMD -0.21 (95% CI -0.35 to -0.08, I² = 0%, 17 trials, 896 participants). We found large variations in effect sizes in the psychological and pharmacological placebo comparisons. For specific mental health disorders, we found significant differences in favour of all placebos for sleep-wake disorders, major depressive disorder, and anxiety disorders, but the analyses were imprecise due to sparse data. We found no significant differences in harms for any of the comparisons but the analyses suffered from sparse data. When using a fixed-effect model in a sensitivity analysis on the comparison for usual care versus wait-list and no-treatment, the results were significant with an SMD of -0.46 (95 % CI -0.64 to -0.28). We reported an alternative risk of bias model where we excluded the blinding domains seeing how issues with blinding may be seen as part of the review investigation itself. However, this did not markedly change the overall risk of bias profile as most of the trials still included one or more unclear bias domains.

AUTHORS' CONCLUSIONS

We found marked variations in effects between placebo versus no-treatment and wait-list and between subtypes of placebo with the same comparisons. Almost all the trials were small with considerable methodological and clinical variability in factors such as mental health population, contents of the included control interventions, and outcome domains. All trials were assessed as high risk of bias and the evidence quality was low to very low. When researchers decide to use placebos or usual care control interventions in trials with people with mental health disorders it will often lead to lower estimated effects of the experimental intervention than when using wait-list or no-treatment controls. The choice of a control intervention therefore has considerable impact on how effective a mental health treatment appears to be. Methodological guideline development is needed to reach a consensus on future standards for the design and reporting of control interventions in mental health intervention research.

Metacognitive interpersonal group therapy for adolescents with avoidant personality disorder: The case of Sofia

INTRODUCTION

Early intervention studies for adolescents and early adults are required to explore the acceptability and effectiveness of psychological therapies across the full range of personality disorders (PDs) beyond just borderline PD. The main aim of the current paper was to describe a Metacognitive Interpersonal Therapy group adaptation for adolescents (MIT-GA) presenting with PDs featuring overcontrol and social inhibition, and in particular Avoidant PD characteristics.

METHODS

We report findings from a single case of a female adolescent diagnosed with Avoidant PD providing preliminary data on feasibility and the possible effectiveness of MIT-GA.

RESULTS

Evidence of acceptability and meaningful clinical gains are described.

CONCLUSIONS

Results suggest that MIT-GA could be a powerful treatment option in patients with generalized social avoidance who do not currently receive gold-standard psychotherapeutic treatments. This intervention also appears to be effective and cost-effective in initiating significant clinical changes in profiles of young patients with non-borderline PD symptoms.

Personality Disorders in Childhood: Validity of the Coolidge Personality and Neuropsychological Inventory for Children (CPNI)

BACKGROUND

A growing body of evidence has shown that maladaptive traits and emerging patterns of personality can be traced to an early stage of development and may be assessed in childhood. The goal of present study was to provide preliminary data on the validity of the Coolidge Personality and Neuropsychological Inventory for Children (CPNI), an instrument designed to assess personality pathologies and other clinical conditions in childhood.

METHOD

A sample of 146 clinicians completed the CPNI, as well as the Child Behavior Checklist (CBCL) to evaluate the behavioral problems and social competencies, regarding a child (aged 6-11 years) who had been in their care between 2 and 12 months. The clinicians also filled out a clinical questionnaire to provide information on the children, their families, and psychotherapies.

RESULTS

There were significant and clinically consistent associations between the CPNI and CBCL. They confirmed the good concurrent (convergent and discriminant) validity of the CPNI.

CONCLUSIONS

The findings seem to support the validity of the CPNI as diagnostic instrument, taking children's PDs and behavioral problems into account. Despite some limitations, the CPNI represents a helpful measure to evaluate the children's personality configurations according to the DSM model. It may be employed along with other tools based on other diagnostic frameworks within the context of a multi-method and multi-informant assessment to provide an accurate and comprehensive formulation of children's overall functioning.

Welfare consequences of early-onset Borderline Personality Disorder: a nationwide register-based case-control study

Information regarding welfare consequences of early onset of Borderline Personality Disorder (BPD) is limited. This nationwide study aimed to estimate the educational and employment outcome and health care costs of patients with early-onset BPD compared with matched controls. All patients (< 19 years) with first diagnosis of BPD in the Danish Patient Register (NPR) during the period 1983-2015 were included. Health care costs and socioeconomic variables were extracted from national registers. A total of 171 patients was compared with 677 controls. At the age of 20 years, BPD patients had reached a statistically significantly lower educational level (including lower primary school grades) and employment status compared with the controls. When adjusting for the parents' educational level, BPD patients were nearly 22 times more likely to be unemployed (OR = 21.7, 95% CI 11.9, 39.6), and nearly 15 times more likely to be on disability pension (OR = 14.8, 95% CI 5.0, 43.9) than controls. Furthermore, the total health care costs were more than 8 times higher in the BPD group. Early onset of BPD was associated with lower educational and vocational outcome and increased health care costs as early as at the age of 20 years. Even after controlling for parents' lower socioeconomic status, the patients have poorer outcome than the control group. This underlines that initiatives to support patients in finishing school and secondary education is highly needed. Future prevention and early intervention programs should target patients with early-onset BPD and their families.

Difficulties in Emotion Regulation Mediated the Relationship Between Reflective Functioning and Borderline Personality Symptoms Among Non-Clinical Adolescents

The literature has established the associations between reflective functioning (RF), affect regulation, and the development of borderline personality disorder (BPD) symptoms. We aimed to examine the mediator role of difficulties in emotion regulation on the relationship between RF and BPD symptoms in a non-clinical adolescent sample. The sample was composed of 546 Turkish adolescents with a mean age of 16.18 (SD = 1.67). Of the sample, 62.5% were adolescent girls and 37.5% of boys. In the present cross-sectional research, volunteer adolescents along with parental permission filled out Socio-Demographics Form, Reflective Functioning Questionnaire, Difficulties in Emotion Regulation Scale, and Borderline Personality Inventory on paper during counseling sessions at schools. Process macro was used to conduct mediation analyses. Compromised RF was related to an increase in adolescent borderline personality symptoms, both directly and indirectly via difficulties in emotion regulation. In this non-clinical adolescent sample, a lower degree of certainty, as well as a higher degree of uncertainty about the mental states, were related to a propensity to emotion dysregulation, specifically experiencing emotions less clearly, approaching emotions impulsively, and facing emotions without a modulation strategy. These associations were in turn related to an increase in borderline personality symptoms. The present research results suggest RF and emotion regulation problems as one field of early intervention for adolescents with BPD symptoms.

Risikofaktoren für und Stabilität einer Persönlichkeitsstörung vom Jugendalter bis ins junge Erwachsenenalter in einer Hochrisikopopulation

Zusammenfassung. Theoretischer Hintergrund: Studien zeigen, dass Persönlichkeitsstörungen (PS) weniger stabil und bei einer frühzeitigen Erkennung gut behandelbar sind. Fragestellung: Ziel dieser Studie ist, 1) die Prävalenz von PS bei ehemalig fremdplatzierten jungen Erwachsenen zu beschreiben, 2) die kategoriale Stabilität von PS vom Jugendalter bis ins junge Erwachsenenalter zu bestimmen und 3) prospektive Risikofaktoren für eine PS im Erwachsenenalter zu identifizieren. Methoden: 180 ehemalig fremdplatzierte junge Erwachsene ( M = 26.3 Jahre) aus einer schweizweiten Längsschnittstudie wurden untersucht. Ergebnisse: 35 % der Teilnehmenden wiesen eine PS auf. Die kategoriale Stabilität belief sich auf 47 %. Folgende Risikofaktoren für eine PS im Erwachsenenalter wurden identifiziert: vorangehende PS, psychopathische Persönlichkeitszüge, Substanzmissbrauch, emotionale Vernachlässigung, kumulierte Misshandlungserfahrungen und Deliktschwere. Diskussion und Schlussfolgerung: Die kategoriale Stabilität irgendeiner PS in dieser Stichprobe gilt als mittelgradig. Dies unterstreicht die Notwendigkeit, PS nicht mehr mit einem lebenslangen, unveränderbaren Schicksal gleichzusetzen. Das Erkennen möglicher Risikofaktoren ist eine wichtige Voraussetzung, um individuelle Behandlungsmöglichkeiten zu gewährleisten und einer Chronifizierung entgegenzuwirken.

Prediction of Treatment Outcome of Adolescents With Borderline Personality Disorder: A 2-Year Follow-Up Study

This study examined prediction of various clinical outcomes in adolescents with borderline personality disorder (BPD) features. Of the 112 adolescents who participated at baseline, 97 were seen at 2-year follow-up, of which 49 (50.5%) had clinically improved, defined as a decrease in BPD pathology of minimum 12 points on the Borderline Personality Features Scale for Children (BPFS-C). Eighty-one adolescents fulfilled the diagnostic criteria for BPD and scored above clinical cutoff on the BPFS-C at baseline, of which 26 (32%) had remitted at follow-up by self-report on the BPFS-C. Results showed that adolescents with comorbid oppositional defiant disorder at baseline were less likely to have clinically improved or remitted at follow-up. Participants with increased self-reported depression and less exposure to physical abuse at baseline had increased odds of remission. Our findings suggest that more internalizing and less externalizing symptoms increase the odds of positive treatment outcome in adolescents with BPD.

Early childhood internalizing problems, externalizing problems and their co-occurrence and (mal)adaptive functioning in emerging adulthood: a 16-year follow-up study

PURPOSE

A vast amount of studies suggest that internalizing or externalizing problems are related to individual functioning, and often co-occur. Yet, a focus on their additive and interactive effects is scarce. Furthermore, most research has focused on a limited number of developmental domains and mostly on maladaptive functioning. Therefore, the current prospective study examined whether early childhood (ages 4-8) internalizing and externalizing problems and their interaction were related to a broad range of (mal)adaptive functioning outcomes in emerging adulthood (ages 20-24).

METHODS

Data from the Flemish Study on Parenting, Personality and Development were used. At Time 1 (1999) mothers of 374 children (45% boys) and fathers of 357 children (46% boys) rated internalizing and externalizing problems through the Child Behavior Checklist. Outcomes in emerging adulthood were measured through self-reports 16 years later across the following domains: psychological functioning, social functioning, work, physical health, and self-concept.

RESULTS

Early externalizing problems were related to maladaptive outcomes on the psychological and social domains. With regard to adaptive functioning, externalizing problems were associated with lower satisfaction regarding general health on the physical domain. Early internalizing problems were not associated with any emerging adulthood outcomes. The interaction of (father reported) internalizing and externalizing problems was related to aggressive behavior.

CONCLUSION

Early childhood externalizing problems were associated with maladaptive and adaptive functioning over a time span of 16 years. The results add to studies on the implementation of prevention and intervention programs in early childhood and to the value for developing personalized interventions.

The relationship between prototype ratings of personality and self and interpersonal functioning with an adolescent inpatient sample

Personality pathology is conceptualized, in part, as impairments in self and interpersonal functioning. Although most of the research has focused on adult samples, fewer have looked at this relationship in adolescent samples. This paper investigates the relationship between clinician-rated personality prototypes, the Shedler-Westen Assessment Procedure-Prototype Matching Adolescent Version (SWAP-A-P) derived from the SWAP-II-A, and a measure of self and interpersonal functioning, the Social Cognition and Object Relation Scale-Global Rating (SCORS-G). Clinicians rated 66 adolescents hospitalized at a safety net teaching hospital in the northeast. The patient's individual and group therapist rated the patients at discharge using the SWAP-A-P and the SCORS-G at discharge blind to each other's ratings. Results showed that more severe personality pathology was linked with more impairments in self and interpersonal functioning.

Developmental Course of Personality Disorder Traits in Childhood and Adolescence

Developmental patterns of personality pathology traits are not well delineated from childhood through late adolescence. In the present study, participants (N = 675, 56% female) were recruited to create three cohorts of third (n = 205), sixth (n = 248), and ninth (n = 222) graders to form an accelerated longitudinal cohort design. We assessed six PD (avoidant, dependent, histrionic, narcissistic, borderline, schizotypal) traits based on DSM-IV trait diagnostic conceptualizations via parent report at baseline, 18 months, and 36 months. According to parent report, mean levels of avoidant, dependent, histrionic, narcissistic, borderline, and schizotypal traits all declined for both boys and girls. The changes in dependent and histrionic traits were of medium effect size, and the changes in avoidant, narcissistic, borderline, and schizotypal traits were of small effect size. Over the 3 years of the study, the traits of each PD also demonstrated moderate to high rank-order stability.

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.

Low Vocational Outcome Among People Diagnosed With Borderline Personality Disorder During First Admission to Mental Health Services in Denmark: A Nationwide 9-Year Register-Based Study

Earlier studies report that although people with borderline personality disorder (BPD) experience symptom reduction in the long term, they continue to have difficulties in work recovery. This nationwide 9-year register-based study (N = 67,075) investigated the long-term labor-market attachment of all individuals diagnosed with BPD during first admission to Danish mental health services in comparison with other psychiatric disorders. Controlling for baseline characteristics and co-occurring secondary psychiatric diagnoses, the BPD group had 32% lower odds (OR = 0.68; 95% CI [0.61, 0.76]) of being in work/under education after 9 years. Individuals diagnosed with BPD also showed more impairment in long-term vocational outcome than other personality disorders, and lower labor-market attachment than other psychiatric disorders except for schizophrenia, schizotypal and delusional disorders, and mental and behavioral disorders due to psychoactive substance use. Intervention programs addressing social psychiatric aspects of BPD in terms of work functioning is henceforth an important area for future research.

Pharmacological interventions for people with borderline personality disorder

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To assess the beneficial and harmful effects of pharmacological treatment for adolescents and adults with borderline personality disorder (BPD).

The Dimensional Assessment of Personality Pathology – Short Form for Adolescents (DAPP-SF-A): normative data for Flemish adolescents aged 16 to 21 years

Background

The Dimensional Assessment of Personality Pathology – Short Form for Adolescents (DAPP-SF-A) is an age-adapted version of the DAPP Basic Questionnaire (DAPP-BQ). The psychometric properties of this questionnaire were established by Tromp and Koot. However, norming data are currently available exclusively for Dutch adolescents.

Objective

The main aim of this study was to provide community-based norming data for the DAPP-SF-A in Flemish adolescents and separately for boys and girls. The second aim was to compare the Flemish norms with the Dutch norms.

Method

The sample consisted of 425 adolescents (52% girls), aged 16 to 21 years (mean, 18.6; SD, 1.16), from the general Flemish population. In 2012, all respondents completed the DAPP-SF-A and the Youth Self-Report as a part of the longitudinal Flemish Study on Parenting, Personality, and Development.

Results:

Internal consistency reliabilities of the lower-order dimensions were acceptable to good (a ranged from 0.71 to 0.87, median=0.85, mean item-rest correlations ranged from 0.44 to 0.67). The lower-order dimensions showed distinctive mean patterns for boys and girls, with higher scores for girls on Affective Instability and Insecure Attachment [effect sizes (d) were both −0.35] and higher scores for boys on all lower-order dimensions of Dissocial Behavior, Inhibitedness, and three lower-order dimensions of Emotional Dysregulation (d ranged from 0.21 to 0.79). The comparison of the Flemish scores with the Dutch scores showed substantial inter-cultural differences (d ranged from 0.13 to −1.78).

Conclusions

The DAPP-SF-A shows satisfactory reliability in a Flemish community-based sample of adolescents. Furthermore, given the differences between boys and girls, the use of gender-based norms seems appropriate. Finally, substantial differences with the Dutch general population norms warrant the use of separate norms in Flemish adolescents.

Understanding adolescent personality pathology from growth trajectories of childhood oddity

Research on developmental trajectories of early maladaptive features for understanding later personality disorders (PDs) is increasingly recognized as an important study area. The course of early odd features is highly relevant in this regard, as only a few researchers have addressed childhood oddity in the context of emerging PDs. Using latent growth modeling, the current study explores growth parameters of odd features in a mixed sample of Flemish community and referred children (N = 485) across three measurement waves with 1-year time intervals. Personality pathology was assessed at a fourth assessment point in adolescence. Beyond a general declining trend in oddity characteristics, the results demonstrated that both an early onset and an increasing trend of oddity-related characteristics over time are independent predictors of adolescent PDs. Childhood oddity tends to be the most manifest precursor for PDs with a core oddity feature (i.e., the schizotypal and borderline PD), but also appears to predict most of the other DSM-5 PDs. Results are discussed from an overarching developmental framework on PDs (Cicchetti, 2014), specifically focusing on the principle of multifinality. From a clinical perspective, the significance of increasing or steady-high childhood oddity trajectories for adolescent PDs highlights the relevance of systematic screening processes across time.