Improved prognosis for borderline personality disorder

Diagnosing borderline personality disorder: Reports and recommendations from people with lived experience

Borderline personality disorder (BPD) is a severe mental health condition marked by impairments in self and interpersonal functioning. Stigma from health staff may often result in a reluctance to diagnose, impacting recovery trajectories. Qualitative interviews were conducted with participants (N = 15; M Age = 36.4 years, SD = 7.5; 93.3% female) with lived experience of BPD exploring topics of illness onset, insight, experience of diagnosis and treatment. Qualitative responses were analysed within a co-design framework with a member of the research team who identifies as having a lived experience of BPD. On average, participant symptoms emerged at 12.1 years of age (SD = 6.6 years, range 1.5-27), but diagnoses of BPD were delayed until 30.2 years (SD = 7.8 years, range 18-44) resulting in a 'diagnosis gap' of 18.1 years (SD = 9.6 years, range 3-30). Participant explanations for BPD emergence varied from biological, psychological and social factors. Benefits of diagnosis (e.g., fostering insight, aiding treatment planning and reducing isolation) were contrasted with challenges (e.g., stigma and treatment unavailability). Delay in diagnosis was common, and no participants reported receiving a diagnosis of BPD during their adolescence yet 85% felt they would have benefited from a diagnosis in adolescence. Only a quarter (27%) felt highly supported in the diagnostic process. An ideal four-step diagnosis procedure was outlined based on recommendations from participants with a lived experience; this involved the following: (1) explain the process, (2) assess thoroughly, (3) explore how the features are active in everyday life and (4) link diagnosis to evidence-based treatment planning.

Implementing a whole-of-service stepped care approach to personality disorder treatment: Impact of training and service redesign on clinician attitudes and skills

Personality disorders are a highly prevalent mental health condition. Historically, clinician attitudes have been negative, and only a small number have specialised training. This study evaluated clinician attitudes and confidence in working with people with personality disorder following the combination of training and implementation of a stepped care whole-of-service approach. A total of 102 multidisciplinary mental health clinicians were trained to implement the stepped care approach, and completed surveys prior to implementation and at 12 months follow up. Clinicians delivered manualised structured psychological therapy as part of the model. Measures assessed changes in attitudes and confidence, and impact of the service changes and therapy approach. Qualitative responses elucidated core themes. Evaluation at 12 months post training and service redesign showed improvements in clinician skills, confidence, theoretical knowledge and attitudes. Qualitative thematic analysis found core themes of improved understanding, clinical skills and improvements in the accessibility and timeliness of treatment. Implementing a whole-of-service model featuring stepped care therapies enhanced clinician attitudes, confidence, skills and knowledge in working with people with personality disorders. Clinicians identified that the whole-of-service model also improved accessibility to treatment, and quality of clinical care to the consumer and their carers.

Evaluation of a skills-based peer-led art therapy online-group for people with emotion dysregulation

OBJECTIVE

We developed and piloted a novel art-based online skills program led by a peer mental health professional with lived experience of complex mental health, including Borderline Personality Disorder (BPD). Key challenges of living with BPD and emotion dysregulation were addressed through artmaking informed by a dialectical framework and skills, to evaluate acceptability and efficacy.

METHOD

A structured, manualised 2-hour weekly arts-based skills program was piloted for people with BPD over 18 weeks. Evaluation included both quantitative and qualitative measures at commencement and completion.

RESULTS

Thirty-eight participants enrolled in the program (89.5% identified she/her pronouns, average age 33.6 years), and 31 completed (82% retention). Multilevel modelling analysis of the primary outcome variable Difficulties in Emotion Regulation Scale (DERS) demonstrated a large improvement over time (effect size Cohen's d = 1.77). Qualitative thematic analysis found participants had improved capacity to regulate emotions and tolerate distress, improved connection with others, enhanced understanding of the self, and higher hope for living well. We found that artmaking facilitated processes and helped the expression of difficult emotions, symbolise challenging relationships, and facilitate greater self-understanding. Participants reported high levels of satisfaction, and 77.4% reported that the program had increased wellbeing.

CONCLUSION

This novel artmaking program for emotion dysregulation and BPD was acceptable and potentially effective. Peer facilitation using arts-based skills is a modality of therapy for further investigation.

Personal agency and borderline personality disorder: a longitudinal study of outcomes

BACKGROUND

Low personal agency is the concept of attributing successes and failures to external factors rather than personal characteristics. Previous research supported links between low personal agency and symptoms of borderline personality disorder (BPD). The present research followed patients in an outpatient dialectical behavioural therapy (DBT) group from intake to 12 months follow up to examine the impact of personal agency on outcome.

METHODS

Patients (N = 57, age 18-72, 91.5% female) were assessed at intake, after three months of DBT treatment, and 12 months follow up on measures of symptoms and personal agency. Three separate measures were used to assess treatment outcomes: the BPD Checklist, the Personality Inventory for DSM-5 (PID-5), and the Mental Health Inventory (MHI-5).

RESULTS

Mixed model analyses found BPD symptoms significantly reduced as a result of DBT treatment and were maintained at follow-up. However, 47% of participants continued to meet BPD criteria 12 months later, despite treatment. Regression analyses indicated that low personal agency at intake was associated with higher BPD symptom severity at post-treatment and 12 month follow up. In addition, low personal agency at intake was associated with greater levels of negative affectivity at post-treatment. Personal agency did not relate to levels of depression and anxiety.

CONCLUSIONS

Despite the reductions in BPD symptomology, personal agency did not significantly change over time. Those with lower agency at intake continued to do more poorly at follow up. We speculate that poor outcomes may be contributed to by patients' lack of engagement in recovery due to poor agency and an external locus of control. As such, therapeutic approaches, like DBT, may require additional strategies to appropriately target low personal agency. Further research is needed to understand if other treatment protocols may facilitate positive change in personal agency.

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.

To love and work: A longitudinal study of everyday life factors in recovery from borderline personality disorder

Although recovery from borderline personality disorder (BPD) is common, not all individuals improve over time. This study sought to examine the features that contribute to response or non-response for individuals at different stages of recovery from BPD over a longitudinal follow-up. Participants were individuals with a diagnosis of BPD that were followed up after 1 year of receiving psychological treatment. There were no significant differences between participants at intake across key indices; however, at 1-year follow-up, two groups were distinguishable as either 'functioning well' (n = 23) or 'functioning poorly' (n = 25) based on symptomatology and functional impairment. Participant qualitative responses were analysed thematically and via Leximancer content analysis. Thematic analysis indicated three key themes: (1) love of self and others, (2) making a contribution through work and study and (3) stability in daily life. Participants who were 'functioning well' described meaningful relationships with others, enjoyment in vocation, and described less frequent or manageable life crises. The 'functioning poorly' group described relationship conflicts, vocational challenges, feelings of aimlessness and purposelessness, instability in daily living and frequent crises. Leximancer content analysis visually depicted these divergent thematic nomological networks. Corroborating quantitative analyses indicated significant differences between these groups for social, occupational and symptom profiles. These findings highlight the centrality of achieving the capacity to 'love and work' in fostering a sense of personal recovery. Treatments may need specific focus on these factors, as they appeared to reinforce symptomatic trajectories of either improvement or poor non-response to therapy.

Searching in the dark: Shining a light on some predictors of non-response to psychotherapy for borderline personality disorder

BACKGROUND

Borderline Personality Disorder (BPD) is a prevalent and serious mental health condition. People can experience recovery or remission after receiving psychotherapy for BPD; however, it is estimated that about 45% of people in well conducted treatment trials do not respond adequately to current psychological treatments.

AIM

To further advance psychotherapies for BPD by identifying the factors that contribute to the problem of non-response.

METHOD

184 consecutive participants with BPD in community treatment were naturalistically followed up over 12 months and measures of personality and social functioning were examined. Logistic regressions were used to determine which baseline factors were associated with the likelihood of being a non-responder after 12 months of psychotherapy. After 12 months, 48.4% of participants were classed as non-responders due to a lack of reduction in BPD symptoms according to the Reliable Change Index (RCI) method.

RESULTS

At baseline intake, patients who endorsed an adult preoccupied attachment relationship style and increased anger were more likely to be a non-responder regarding BPD symptoms at 12 months. In addition, those with preoccupied attachment patterns in their adult relationships were more likely to be non-responders regarding general psychological distress at follow up. Higher baseline levels of paranoia and endorsement of a dismissive adult relationship style was associated with being a non-responder in regard to global functioning.

CONCLUSIONS

Consistent with previous research, almost half of the sample did not achieve reliable change at 12-month follow up. A relationship style characterised by preoccupied insecurity and high anger seemed to be particularly challenging in being able to benefit from psychotherapy. This style may have affected both relationships outside, but also inside therapy, complicating treatment engagement and alliance with the therapist. Early identification and modification of treatment based on challenges from these relationship styles may be one way to improve psychotherapy outcomes for BPD.

Evaluation of a brief intervention within a stepped care whole of service model for personality disorder

BACKGROUND

Although there is growing evidence that stepped models of care are useful for providing appropriate, person centered care, there are very few studies applied to personality disorders. A brief, four session, psychological treatment intervention for personality disorder within a whole of service stepped care model was evaluated. The intervention stepped between acute emergency crisis mental health services and longer-term outpatient treatments.

METHODS

Study 1 used service utilization data from 191 individuals referred to the brief intervention at a single community health site in a metropolitan health service. Proportions of individuals retained across the intervention and the referral pathways accessed following the intervention were examined. Study 2 examined 67 individuals referred to the brief intervention across 4 different sites in metropolitan health services. A range of measures of symptoms and quality of life were administered at the first and last session of the intervention. Effect sizes were calculated to examine mean changes across the course of the intervention.

RESULTS

Study 1 found that 84.29% of individuals referred to the intervention attended at least 1 session, 60.21% attended 2 sessions or more and 41.89% attended 3 or more sessions. 13.61% of the sample required their care to be "stepped up" within the service, whereas 29.31% were referred to other treatment providers following referral to the intervention. Study 2 found a significant reduction in borderline personality disorder symptom severity and distress following the intervention, and an increase in quality of life. The largest reduction was found for suicidal ideation (d = 1.01).

CONCLUSIONS

Brief psychological intervention was a useful step between acute services and longer-term treatments in this stepped model of care for personality disorder. Suicide risk and symptom severity reduced and quality of life improved, with only a small proportion of individuals requiring ongoing support from the health service following the intervention.

Barriers and facilitators to the implementation of a stepped care intervention for personality disorder in mental health services

BACKGROUND

Individuals with personality disorders-particularly borderline personality disorder-are high users of mental health treatment services. Emergency service responses often focus on crisis management, and there are limited opportunities to provide appropriate longer term evidence-based treatment. Many individuals with personality disorders find themselves in a revolving cycle between emergency departments and waiting for community treatment. A stepped care approach may help to triage clients and allow access to interventions with minimal client, clinician and system burden. This study aims to understand the facilitators and barriers to real-world implementation of a stepped care approach to treating personality disorders.

METHODS

Managers and clinicians of health services engaged in implementation were interviewed to obtain accounts of experiences. Interviews were transcribed and thematically analysed to generate themes describing barriers and facilitators.

RESULTS

Participants identified personal attitudes, knowledge and skills as important for successful implementation. Existing positive attitudes and beliefs about treating people with a personality disorder contributed to the emergence of clinical champions. Training facilitated positive attitudes by justifying the psychological approach. Management support was found to bi-directionally effect implementation.

CONCLUSIONS

This study suggests specific organizational and individual factors may increase timely and efficient implementation of interventions for people with personality disorders. © 2019 John Wiley & Sons, Ltd.

Treatment of personality disorder using a whole of service stepped care approach: A cluster randomized controlled trial

BACKGROUND AND OBJECTIVES

People with personality disorders are prevalent in emergency and inpatient mental health services. We examined whether implementing a stepped care model of psychological therapy reduces demand on hospital units by people with personality disorder, in a cluster randomized controlled trial.

METHOD

A total of 642 inpatients (average age 36.8, 50.5% female) with a primary ICD-10 personality disorder were recruited during 18 months baseline, then monitored during an 18 month active trial phase. In the active trial phase two equivalent sites were randomised to either treatment as usual (TAU), or a whole of service intervention that diverted people away from hospital and into stepped care psychological therapy clinics. The study design was cost neutral, with no additional staff or resources deployed between sites. A linear mixed models analysis evaluated outcomes.

RESULTS

As predicted, demand on hospital services reduced significantly in the intervention compared to TAU site. The intervention site evidenced shorter bed days, from an average of 13.46 days at baseline to 4.28 days per admission, and patients were 1.3 times less likely to re-present to the emergency department compared to TAU. Direct cost savings for implementing the approach was estimated at USD$2,720 per patient per year. Limitations included not directly comparing individual symptom changes.

CONCLUSIONS

Using a whole of service stepped care model of treatment for personality disorder significantly reduced demand on hospital services.

Clinician attitudes towards borderline personality disorder: A 15-year comparison

Stigma towards people with borderline personality disorder has been a common theme reported within mental health services staff. A longitudinal, mixed method design investigated attitudes of mental health staff working at the same public health service in 2000 and 2015. Participants from both the 2000 and 2015 samples completed a short 10-item version of the Attitude to Personality Disorders Questionnaire and identical qualitative questions. The 2015 sample also completed the Attitude to Deliberate Self-Harm Questionnaire and the Attitude and Skills Questionnaire. Qualitatively, the 2000 sample endorsed much more negative descriptions (e.g. 'attention seeking' and 'manipulative'), and the 2015 sample focused more on treatment approaches and skills (e.g. 'management plan' and 'empathy'). Quantitatively, the 2015 sample endorsed more positive attitudes than the 2000 sample. This positive attitudinal shift is an encouraging step in successful treatment of borderline personality disorder and may reflect a changing landscape of the mental health system and greater awareness and use of effective treatments. © 2018 John Wiley & Sons, Ltd.

A 1-year follow-up study of capacity to love and work: What components of borderline personality disorder most impair interpersonal and vocational functioning?

BACKGROUND

For individuals with borderline personality disorder (BPD), both the reduction in symptoms and the improvement of vocational and interpersonal function (psychosocial function) are important for recovery. Research suggests that some components of BPD make it harder to achieve functional recovery; however, findings are varied and inconclusive. The present study assesses recovery over time in BPD, investigates which symptoms make it harder to function and explores the relationships between these symptoms.

METHOD

One hundred ninety-nine consecutively recruited individuals in psychological treatment for personality disorder were studied over 12 months. Measures of BPD symptom severity at intake were used to predict improvements in social and vocational function at follow-up. Exploratory modelling was conducted to understand the relationships between symptoms and function.

RESULTS

Following 12 months of treatment, symptoms and functioning improved. Those who experienced more severe emptiness, impulsivity and self-harm had worse outcomes. A relationship between chronic emptiness at intake and impaired vocational outcome (days out of work) at follow-up was found, mediated by severity of impulsivity and frequency of self-harm.

CONCLUSION

Chronic emptiness is associated with dysfunctional behaviours such as impulsivity and self-harm, and poor psychosocial improvement. Interventions targeting chronic emptiness in those most vulnerable may improve functional outcomes. © 2018 John Wiley & Sons, Ltd.

A whole of school intervention for personality disorder and self-harm in youth: a pilot study of changes in teachers' attitudes, knowledge and skills

BACKGROUND

The school environment offers an ideal opportunity for early identification and intervention for youth with self-harm and complex mental health issues, such as borderline personality disorder (BPD). Yet, class teachers often report minimal knowledge, feeling ill-equipped to respond, and experience high levels of stress when exposed to such challenges. Research is required to understand how training and development activities led by school counsellors may enhance teacher attitudes, confidence and knowledge of self-harm and complex mental health issues, such as BPD. We aimed to explore the extent that a whole of school initiative might enhance capacity for early identification and intervention.

METHOD

18 secondary schools implemented a manualised program, Project Air Strategy for Schools. N = 400 class teachers (71.3% female, mean age 42 years) across city and rural locations were evaluated before and after program implementation on attitudes, knowledge and skills.

RESULTS

Providing class teachers with additional training on complex mental health issues and associated behaviours such as self-harm was well received. Participants reported post-program improvements in their optimism (d = .35), confidence (d = .63), knowledge (d = .73) and skills (d = 0.67) in working with young people with complex mental health issues, such as BPD.

CONCLUSIONS

Providing school counsellor led structured approaches, to help class teachers identify and respond to youth in distress, closed identified gaps. Results indicated improvements in class teachers' knowledge and attitudes towards self-harm and BPD. The intervention also improved the capacity of schools to plan and implement strategies to reduce the impact of mental health problems on the young person and their peers. A stay-at-school psychological care approach was fostered by enhancing partnerships between class teachers and school counsellors.

Cultural Aspects in Symptomatology, Assessment, and Treatment of Personality Disorders

PURPOSE OF REVIEW

This review discusses cultural trends, challenges, and approaches to assessment and treatment of personality traits and disorders. Specific focus include current developments in the Asian, Italian, Iranian, and Australian societies, as well as the process of acculturation, following moves between cultures with the impact on healthy and disordered personality function.

RECENT FINDINGS

Each culture with its specific history, dimensions, values, and practices influences and gears the individual and family or group in unique ways that affect personality functioning. Similarly, each culture provides means of protection and assimilation as well as norms for acceptance and denunciations of specific behaviors and personality traits. The diagnosis of personality disorders and their treatment need to take into consideration the individual in the context of the culture and society in which they live. Core personality problems, especially emotion dysregulation and interpersonal functioning are specifically influenced by cultural norms and context.

Personality disorder: A mental health priority area

Personality disorders have received limited recognition as a public health priority, despite the publication of treatment guidelines and reviews showing effective treatments are available. Inclusive approaches to understanding and servicing personality disorder are required that integrate different service providers. This viewpoint paper identifies pertinent issues surrounding early intervention, treatment needs, consumer and carer experiences, and the need for accurate and representative data collection in personality disorder as starting points in mental health care reform.

Transference-Focused Psychotherapy in Australian psychiatric training and practice

OBJECTIVE

This article discusses Transference-Focused Psychotherapy, a contemporary evidence-based and manualised form of psychoanalytic psychotherapy for borderline personality disorder. Transference focused psychotherapy has evolved from decades of research in the object-relations approach developed by Professor Otto Kernberg and his collaborators. It is being adopted increasingly throughout North and South America and Europe, and this article explores the role its adoption might play in psychiatric training as well as public and private service provision contexts in Australia.

CONCLUSIONS

Transference focused psychotherapy is readily applicable in a range of training, research and public and private service provision contexts in Australia. A numbers of aspects of current Australian psychiatric training and practice, such as the Royal Australian and New Zealand College of Psychiatrists advanced training certificate, and the Australian medicare schedule, make it especially relevant for this purpose.

The value of psychological treatment for borderline personality disorder: Systematic review and cost offset analysis of economic evaluations

Aim

Borderline Personality Disorder (BPD) is a common mental health condition with high patterns of service utilisation of inpatient and community treatment. Over the past five years there has been significant growth in research with economic data, making this systematic review a timely update.

Methods

Empirical studies written in English or German, published up to December 2015, and cited in major electronic databases were examined using the PRISMA systematic review method. Papers were included that had one of the following: data related to cost of BPD to society, the individual, the carer or families; cost benefits of interventions. Reported cost data were inflated to the year 2015 and converted into US- dollars (USD $) using purchasing power parities.

Results

We identified 30 economic evaluations providing cost data related to interventions for BPD across 134,136 patients. The methodological quality was good, almost all studies fulfilled ≥ 50% of the quality criteria. The mean cost saving for treating BPD with evidence-based psychotherapy across studies was USD $2,987.82 per patient per year. A further mean weighted reduction of USD $1,551 per patient per year (range $83 - $29,392) was found compared to treatment as usual. Evidence-based psychological treatment was both less expensive as well as more effective, despite considerable differences in health cost arrangements between individual studies and countries. Where it was able to be calculated, a significant difference in cost-savings between different types of evidence-based psychotherapies was found.

Discussion

Individuals with BPD consistently demonstrate high patterns of service utilization and therefore high costs. The findings of this review present a strong argument in favour of prioritizing BPD treatments in reimbursement decisions, both for the affected individual and the family. The provision of evidence based treatment, irrespective of the type of psychological treatment, may lead to widespread reductions in healthcare costs.

How can psychiatrists offer psychotherapeutic leadership in the public sector?

OBJECTIVE

This article reviews the forms that psychotherapeutic leadership can take for psychiatrists attempting to optimise outcomes for individuals receiving treatment in the public mental health sector. It explores a range of roles and functions that psychiatrists can take on as psychotherapy leaders, and how these can be applied in clinical, administrative and research contexts.

CONCLUSIONS

Psychiatrists need to play an increasing role in clinical, administrative and academic settings to advance service provision, resource allocation, training and research directed at psychotherapies in the public health sector.

A new intervention for people with borderline personality disorder who are also parents: a pilot study of clinician acceptability

BACKGROUND

Engaging parents who have a personality disorder in interventions designed to protect children from the extremes of the disorder supports both parenting skills and healthy child development. In line with evidence-based guidelines, a 'Parenting with Personality Disorder' brief intervention was developed, focusing on child safety, effective communication and parenting strategies.

METHOD

Ratings of acceptability for the brief intervention model were given by 168 mental health clinicians who attended training. Changes in clinician attitudes, knowledge and skills were also assessed following training.

RESULTS

Providing clinicians treating personality disorder clients with additional skills to address parenting was well received and filled a gap in service provision. Clinicians reported improvements in clinical skills, knowledge, willingness and confidence to intervene in parenting issues with clients. Qualitative responses endorsed three major modes of learning: case study analysis, reflective learning activities, and skills-based intervention practices.

CONCLUSIONS

Current treatment guidelines emphasise addressing parenting, but no evidence-based therapy includes specific parenting skills. This brief intervention model improved skills, efficacy and willingness to intervene. This approach can be readily added to current evidence-based therapy protocols and promises to improve client functioning and protect children from the extremes of the disorder. Clinical trials are now required to validate the approach in the field.

Supporting a person with personality disorder: a study of carer burden and well-being

Personality disorders are characterized by impaired interpersonal functioning. There are few studies and little data available using validated questionnaires on the impact of caring for a person with personality disorder. The 287 carers included in this study were administered the McLean Screening Instrument for Borderline Personality Disorder-Carer Version, Burden Assessment Scale, Grief Scale, Difficulties in Emotion Regulation Scale, Mental Health Inventory-5, and a qualitative question. Scores were compared to those of published comparison groups. Burden and grief were significantly higher than that reported by carers of persons with other serious mental illnesses. Carers endorsed symptoms consistent with mood, anxiety, and posttraumatic stress disorders. A qualitative concept map highlighted the impact of caregiving on the interpersonal environment. Carers of persons with personality disorder report grieving their change in life and impairment in well-being. Carers are burdened, and appear more so than carers of persons with other serious mental illnesses. The results highlight the need for interventions to support carers.