Drawing your way out: Imagery rehearsal based art therapy (IR-AT) for post-traumatic nightmares in borderline personality disorder

Posttraumatic nightmares (PTN) are a frequent symptom after a traumatic event and often play part in the psychopathology of patients with borderline personality disorder (BPD). Imagery rehearsal therapy (IRT) currently offers the best evidence for an effective treatment to reduce PTNs, although high drop-out rates are common. Art therapy in IRT may counteract this, by its indirect, nonverbal, and often playful approach that helps to break through avoidance. This case study focusses on the perception of a patient with BPD in an art therapy based IRT treatment for patients with PTNs. It tells the story of Aurelia, a 40-year-old woman who, within this treatment, processes traumatic contents of her childhood like physical and sexual violence, but also current interactional problems that manifest themselves in her nightmares. Following the IR-AT treatment for PTNs Aurelia noticed a reduction in her nightmares, was less afraid of them and felt calmer towards her trauma. She expressed herself in the art medium and by this developed more self-efficacy. Her process resulted in an integration of the trauma and a perceived decrease in borderline symptoms. Future research can build on this basis to further explore the mechanisms and effects of IR-AT for PTNs.

A case report of the treatment of narcissistic personality disorder with transference focused psychotherapy

The following case study provides a description of the transference-focused psychotherapy (TFP) treatment of a young man diagnosed with narcissistic personality disorder (NPD). TFP is an individual, psychodynamic therapy developed to treat a range of personality disorders. TFP is evidence-based for the treatment of borderline personality disorder and has been adapted for the treatment of NPD. This case illustrates the application of the strategies and techniques of TFP to treatment of NPD as well as challenges clinicians may face in arriving at timely diagnosis of the disorder. Although no specific treatment for NPD has been empirically validated, TFP utilizes the therapeutic techniques identified across modalities for successful treatment of pathological narcissism. This report describes how treatment interventions such as goal setting, developing a therapeutic alliance, using a treatment contract and addressing treatment interfering behaviors contributed to this patient's improvement in self-reflection, formation of healthier and more flexible ideas about self and other, increased self-agency, tolerance of normative disillusionments and increase in empathy.

The (cost-)effectiveness of early intervention (MBT-early) versus standard protocolized treatment (CBT) for emerging borderline personality disorder in adolescents (the EARLY study): a study protocol for a randomized controlled trial

BACKGROUND

Although clinical guidelines prioritize the treatment of depression and anxiety in young persons, there is accumulating evidence that the presence of symptoms of borderline personality disorder (BPD) is associated with the limited effectiveness of these standard treatments. These findings stress the need for interventions addressing early-stage BPD in young people with presenting symptoms of anxiety and depressive disorders. The aim of this study is to investigate the (cost-)effectiveness of an early intervention programme for BPD (MBT-early) compared to first-choice psychological treatment for depression and anxiety according to Dutch treatment guidelines (CBT), in adolescents with either depression, anxiety, or both, in combination with early-stage BPD.

METHODS

This study is a multi-centre randomized controlled trial. A total of 132 adolescents, presenting with either depression, anxiety, or both and significant BPD features will be randomized to either MBT-early or CBT. The severity of BPD, symptoms of depression and anxiety, personality, social and academic functioning, and quality of life will be assessed at baseline, end of treatment, and at 12-, 18-, and 24-month follow-up, along with medical costs and costs of productivity losses for cost-effectiveness analyses.

DISCUSSION

This study will provide an empirical evaluation of the potential surplus value of early intervention in young people for whom treatment oriented at common mental disorders like anxiety and depression may be insufficient given their underlying personality problems.

TRIAL REGISTRATION

Netherlands Trial Register, NL9569. Registered on June 15, 2021.

What impact can brain stimulation interventions have on borderline personality disorder?

INTRODUCTION

Borderline personality disorder (BPD) is a severe mental disorder characterized by emotion dysregulation, impulsivity, neuropsychological impairment, and interpersonal instability, presenting with multiple psychiatric comorbidities, functional disability and reduced life expectancy due suicidal behaviors.

AREAS COVERED

In this perspective, the authors explore the application of noninvasive brain stimulation (NIBS) (rTMS, tDCS, and MST) in BPD individuals by considering a symptom-based approach, focusing on general BPD psychopathology, impulsivity and neuropsychological impairments, suicidality and depressive/anxious symptoms, and emotion dysregulation.

EXPERT OPINION

According to a symptoms-based approach, NIBS interventions (particularly rTMS and tDCS) are promising treatment options for BPD individuals improving core symptoms such as emotional and behavioral dysregulation, neuropsychological impairments and depressive symptoms. However, the heterogeneity of stimulation protocols and of assessment tools used to detect these changes limits the possibility to provide definitive recommendations according to a symptom-based approach. To implement such armamentarium in clinical practice, future NIIBS studies should further consider a lifespan perspective due to clinical variability over time, the role of psychiatric comorbidities affecting BPD individuals and the need to combine NIBS with specialized psychotherapeutic approaches for BPD patients and with functional neuroimaging studies.

Physical health, primary care utilization and long-term quality of life in borderline personality disorder: A 10-year follow-up study in a Spanish sample

OBJECTIVE

We aimed to study physical health and primary care utilization in the long-term course of borderline personality disorder (BPD) and their impact on quality of life (QOL) in a Spanish clinical sample.

METHODS

This study is part of a longitudinal study following a clinical cohort with BPD. A total of 41 participants were re-evaluated at 10-year follow-up, when current medical conditions, primary care utilization, and quality of life were assessed. Comparative population data were extracted from the Catalan Health Survey ESCA.

RESULTS

68% of BPD patients reported physical health problems, and 32% informed of multiple medical illnesses at follow-up. Higher rates of musculoskeletal disorders and frequent use of general practitioner (GP) consultations were reported by BPD patients compared to the general population. Differences in physical health and use of primary care services between remitted and non-remitted BPD patients were not significant. BPD remission was independently associated with better long-term QOL. Comorbid somatic diseases worsened the long-term QOL of non-remitted BPD patients.

CONCLUSION

Chronic somatic conditions are prevalent in people with BPD and interact negatively with persistent BPD pathology, worsening their QOL in the long-term. Health care strategies in the assistance of long-lasting BPD patients are recommended.

Outcomes for pregnant women with Borderline Personality Disorder who attended a specialist antenatal service

OBJECTIVE

Our study focussed on the obstetric and psychosocial outcomes of pregnant women with Borderline Personality Disorder (BPD) who received care via a specialist antenatal clinic in Western Australia.

METHOD

This study is a retrospective examination of outcomes for 80 women with a confirmed diagnosis of BPD, with findings compared with published population outcome data for the state.

RESULTS

Pregnant women with BPD appeared to be at a risk of complications including pre-eclampsia and special care nursery admission for their newborns when compared to population data. Furthermore, the studied women had elevated rates of psychiatric admissions during pregnancy, child protection involvement, and domestic violence. Polypharmacy exposure was frequent, with the likely impact on obstetric and neonatal outcomes requiring further study.

CONCLUSION

The findings reinforced the notion that pregnant women with BPD experience complex multifaceted vulnerabilities and require enhanced multidisciplinary care. Our study further calls for the development of clinical practice guidelines for managing BPD in the perinatal period.

Differential outcomes of outpatient only versus combined inpatient/outpatient treatment in early intervention for adolescent borderline personality disorder

Clinical guidelines for adults with borderline personality disorder (BPD) recommend outpatient psychotherapy as first-line treatment. Little is known whether this recommendation is also applicable to adolescents. The current study examined the relationship between treatment setting and the outcome of early intervention for adolescents with BPD pathology. One-hundred and seventy-eight adolescents from a specialized outpatient clinic were assessed at baseline, and at 1- and 2-year follow-up. Sixty-three participants who received inpatient treatment during the first year were assigned to the "combined inpatient/outpatient group", 115 participants to the "outpatient only group". Generalized linear and mixed models with inverted probability weights to adjust for baseline differences were applied to examine the impact of group on clinical changes over time. Both groups demonstrated a significant decrease in BPD features, depressive symptoms, psychopathological distress, non-suicidal self-injury (NSSI), suicidal thoughts, suicide attempts, and overall illness severity, and a significant increase in quality of life and psychosocial functioning from baseline to follow-up 2. The decrease in NSSI and overall illness severity, and the increase in psychosocial functioning from baseline to follow-up 1 were greater in the outpatient only group, with comparable improvements between groups from follow-up 1 to follow-up 2. Both outpatient treatment and combined outpatient/inpatient treatment resulted in clinical improvements over time, with some indication for faster changes in the outpatient only setting. The findings provide preliminary evidence that the recommendation of outpatient psychotherapy as the first-line treatment for BPD also holds true for adolescents.

Efficacy of mentalization-based therapy in treating self-harm: A systematic review and meta-analysis

INTRODUCTION

Mentalization-based therapy (MBT) and its adapted version for adolescents (MBT-A) are repeatedly highlighted as promising treatments for reducing self-harm, particularly in borderline personality disorder (BPD). Despite the availability of publications providing evidence of their efficacy in reducing self-harm, recent meta-analyses have yielded mixed results. To inform best-practice clinical decision-making, we conducted a systematic review and meta-analysis. We aimed to disentangle findings for both adolescents and adults on the efficacy of MBT(-A) in reducing self-harm (primary outcome) and symptoms of BPD and depression (secondary outcomes).

METHODS

Web of Science, Scopus, Embase, PubMed/Medline, and Cochrane Review Database were searched for eligible studies published until September 2022. In total, 14 studies were identified, comprising 612 participants from nine MBT studies (six pre-post, three RCTs) and five MBT-A studies (two pre-post, three RCTs). Aggregated effect sizes were estimated using random-effects models. Meta-regressions were conducted to assess the effect of moderator variables (treatment duration, drop-out rates, and age) on effect sizes.

RESULTS

Overall, both MBT and MBT-A demonstrated promising effects in reducing self-harm (g = -0.82, 95% CI -1.15 to -0.50), borderline personality disorder (g = -1.08, 95% CI -1.38 to -0.77), and depression (g = -1.1, 95% CI -1.52 to -0.68) symptoms. However, when compared to control interventions (TAU, SCM), MBT(-A) did not prove to be more efficacious, with the exception of MBT showing superior effects on BPD symptoms in adults (g = -0.56, 95% CI -0.88 to -0.24).

CONCLUSION

Although the pre-post evaluations seem promising, this analysis, including RCTs, showed no superiority of MBT(-A) to control conditions, so that prioritizing the application of MBT (-A) for the treatment of self-harm is not supported. Possible explanations and further implications are discussed.

Shame, suicidal ideation, and urges for non-suicidal self-injury among individuals with borderline personality disorder receiving dialectical behavior therapy: The mediating role of anger

INTRODUCTION

Borderline personality disorder (BPD) is a disorder of pervasive emotion dysregulation associated with high rates of self-injurious thoughts and behaviors (SITB). Understanding specific emotion states in relation to SITB is important for effective intervention.

METHODS

The current study examined whether, and how, the specific emotion of shame contributes to suicide ideation and urges to engage in non-suicidal self-injury (NSSI) both directly, and indirectly via anger, among individuals with BPD. Participants (N = 100) were enrolled in a 6-month comprehensive dialectical behavior therapy (DBT) program and provided daily ratings of shame, anger, suicide ideation, and urges for NSSI.

RESULTS

We found that higher daily ratings of shame and anger were directly associated with higher same-day ratings of both suicidal ideation and urges for NSSI. Furthermore, anger partially mediated the relationships between shame and both suicidal ideation and urges for NSSI.

CONCLUSION

These findings highlight shame and anger as potential antecedents of SITB among individuals with BPD. Clinical approaches, such as DBT, that include personalized, ongoing, clinical assessment of these specific affective states may be particularly important for treatment of SITB.

Dialectical Behavior and Social Rhythm Therapy for Comorbid Bipolar Disorder and Borderline Personality Disorder

Bipolar disorder and borderline personality disorder commonly co-occur. Each disorder is associated with substantial morbidity and mortality, which are worsened by co-occurrence of the disorders. Emotional dysregulation, suicidality, and disrupted circadian rhythm are key aspects of psychopathology associated with both conditions. A novel psychotherapy combining elements of two evidence-based treatments (i.e., dialectical behavior therapy [DBT] for borderline personality disorder and social rhythm therapy [SRT] for bipolar disorder) is described. Unlike either treatment alone, the new therapy, called dialectical behavior and social rhythm therapy (DBSRT), targets all three disease-relevant processes and therefore may represent a promising new approach to treatment for individuals with these two conditions. DBSRT may also have utility for individuals with overlapping characteristics of bipolar disorder and borderline personality disorder or for those whose illness manifestation includes a mix of bipolar and borderline personality disorder traits. Strategies associated with DBSRT are described, and a brief case vignette illustrates its application.

Good psychiatric management for borderline personality disorder: A qualitative study of its implementation in a supported employment team

INTRODUCTION

People with borderline personality disorder have difficulties with work. The Individual Placement and Support model has shown its worldwide effectiveness in terms of vocational rehabilitation for individuals with psychiatric disorders. However, only a few recent studies have explored its results for people with personality disorders, and the findings were mitigated. Additionally, Individual Placement and Support job coaches reported difficulties in supporting this population. An evidence-based psychotherapeutic method, also applicable in a case management context, called Good Psychiatric Management for borderline personality disorder, could potentially overcome these obstacles. This study aimed to evaluate the initial integration of Good Psychiatric Management in Individual Placement and Support practice.

METHODS

Individual Placement and Support practitioners of Lausanne University Hospital, Switzerland, were trained in Good Psychiatric Management in January 2022. Five of them participated in a focus group to collect their impressions about the training, and six were interviewed 9 months later to assess the initial adoption of Good Psychiatric Management into their practice. Thematic analyses were conducted.

RESULTS

Job coaches were positive about this new tool. All of them found it useful and beneficial both for them and their patients. They were able to follow the main Good Psychiatric Management principles in their practice However, the findings also suggested some additional improvements in the implementation process.

CONCLUSIONS

Integrating Good Psychiatric Management in Individual Placement and Support seems feasible, and the team who appreciated it adopted it. The method offers new perspectives in community support for people living with borderline personality disorder.

Prodromal or Factitious Psychosis: A Cautionary Tale in the Era of Increasing Social Media Use by Vulnerable Individuals

Research on the prodromal phase of schizophrenia has been ongoing for several decades and, more recently, findings from this research are being incorporated into everyday psychiatric practice, such as the use of interviews to evaluate prodromal symptomatology. This evolution is happening in the midst of an explosion of social media use by teenagers and young adults, increasing the exposure of youth to portrayals of psychiatric experiences. For example, reports from around the world of "TIK-TOK tics" emphasize the role of social media in the "creation" of psychiatric symptoms. This case report highlights the importance of a full psychiatric evaluation in acute care settings where quick treatment of psychotic symptoms is the norm. A 15-year-old patient was initially diagnosed with prodromal schizophrenia but, after a more extensive evaluation during a second admission, she was diagnosed with borderline personality disorder. Her antipsychotic treatment regimen was stopped and appropriate education and treatment were started, without the recurrence of "psychotic symptoms" during follow-up. It may be that patients with borderline personality disorder, a frequent condition on inpatient units, are at particular risk of assimilating symptoms as represented on social media.

[Looking for borderline personality disorder]

AIMS

This paper aims to describe Roger Mulder's presentation on borderline personality disorder organized by the 23rd World Congress of Psychiatry, supplemented with relevant research results.

METHODS

Mulder presents the diagnostic criteria of borderline personality disorder, its comorbidity, therapeutic considerations and the phenomenon of stigmatization related to the disorder.

RESULTS

According to Mulder, the diagnostic criteria of borderline personality disorder are vague and it shows a very high comorbidity with other psychiatric disorders. Mulder draws attention to the fact that it was not possible to identify a borderline factor in previous research because the borderline symptoms disappeared during the analysis in a general ("g") personality disorder factor. According to Mulder, there is no specific psychotherapy that is effective only in borderline personality disorder, and the pharmacological treatment has also not proven to be effective in treating the core symptoms of borderline personality disorder. According to Mulder, the stigma associated with the diagnosis of borderline personality disorder hinders the recognition and treatment of other psychiatric or somatic difficulties of patients.

CONCLUSION

according to Mulder, based on modern scientific standards, borderline personality disorder has no place in the classification, however, specialists still insist on the diagnosis.

Readiness and Personality Disorders: Considering Patients' Readiness for Change and Our System's Readiness for Patients

ABSTRACT

The culture around personality disorder treatment has changed drastically in the past generation. While once perceived as effectively untreatable, there are now numerous evidence-based treatment approaches for personality disorders (especially borderline personality disorder). The questions, however, of who should be matched to which treatment approach, and when, remain largely unanswered. In other areas of psychiatry, particularly substance use disorders and eating disorders, assessing patient treatment readiness is viewed as indispensable for treatment planning. Despite this, relatively little research has been done with respect to readiness and personality disorder treatment. In this article, we propose multiple explanations for why this may be the case, relating to both the unique features of personality disorders and the current cultural landscape around their treatment. While patients with personality disorders often face cruel stigmatization, and much more work needs to be done to expand access to care (i.e., our system's readiness for patients), even gold-standard treatment options are unlikely to work if a patient is not ready for treatment. Further study of readiness in the context of personality disorders could help more effectively match patients to the right treatment, at the right time. Such research could also aid development of strategies to enhance patient readiness.

Effects of borderline personality disorder symptoms on dialectical behavior therapy outcomes for eating disorders

Existing literature on the effects of borderline personality disorder (BPD) and eating disorder (ED) comorbidity in terms of clinical presentation and treatment outcome has been limited and inconclusive. The present study examined whether clients with EDs and varying levels of BPD symptoms presented with more severe ED symptoms at admission, and whether they responded to dialectical behavior therapy (DBT)-based treatment. Participants (N = 176) were adults in a DBT-based partial hospitalization program for EDs at an academic medical center. Participants completed self-report measures at admission, 1-month postadmission, discharge, and 6-month follow-up. Results suggested that patients with elevated BPD symptoms at admission had greater ED symptoms during treatment, evidenced by small to moderate effect sizes. However, patients with high BPD symptoms demonstrated steeper declines in binge eating, fasting, and parasuicidal behavior early during treatment compared to patients with low BPD symptoms. Individuals with high BPD symptoms at admission (i.e., probable BPD diagnosis) were as likely to meet remission criteria and relapse as individuals with low BPD symptoms, though this null finding may be influenced by small cell sizes. Our findings also suggest that DBT skills use does not predict changes in symptoms. In sum, our findings suggest that while clients with higher BPD symptoms may improve during DBT-based partial hospitalization, their ED symptoms may remain more severe. Future studies are needed to determine whether adjunctive treatments improve outcomes for clients with EDs and comorbid BPD symptoms in DBT programs and whether skills use quality is a better predictor of ED symptom changes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Need of support for significant others to persons with borderline personality disorder-A Swedish focus group study

BACKGROUND

Being a significant other (SO) to a person with borderline personality disorder (BPD) affect their health. High incidence of substance use disorder, post-traumatic stress disorder, stress, fear, anxiety, depression, family burden and grief are common. Some specific therapies for BPD, have included support to SOs, however resources are scarce and to participate in the support it assumes that the person with BPD is included in these therapies. Although the SO support has been shown to be helpful, they all have a similar structure, and only a small exclusive group of SOs have access to the support.

AIM

The aim was to describe experiences and need of support for significant others to persons with borderline personality disorder from the perspective of themselves and of health care workers.

METHODS

Data was collected via two focus groups. One with five SOs to persons with BPD, one with five health care workers. Two interview sessions in each group were conducted and data were analysed with qualitative content analysis. The study was approved by the research ethics committee of Lund (2016-1026).

RESULTS

The results revealed four themes; not being seen by health care professionals creates hopelessness, being seen by healthcare professionals creates trust, experience of support - helpful or shameful and the step from loosely structured support to a structured support group. Both groups expressed a need for further support as a complement to already existing support.

CONCLUSIONS

The need of support is extensive. The results suggest a professional coordinator intended for SOs and peer support groups not linked to a particular psychiatric treatment yet offering support in a structured way. Further studies examining these complements to existing support, is therefore recommended.

The availability of dialectical behavior therapy in partial hospitalization and residential services for borderline personality disorder: An exploratory longitudinal study of the National Mental Health Services Survey from 2014 to 2021

OBJECTIVE

Treatment guidelines on borderline personality disorder (BPD) recommend day-hospital or residential treatments for patients with BPD who cannot tolerate outpatient treatment (American Psychiatric Association, 2010; National Health & Medical Research Council, 2013). However, the current literature suggests that evidence-based treatment for BPD may be difficult to access (Lohman et al., 2017). The present study aims to characterize the accessibility of dialectical behavioral therapy (DBT) in day-treatment and residential programs in the United States in the last 7 years and examines whether day-treatment and residential programs that accept state benefits (i.e., Medicaid) are significantly less likely to offer DBT.

METHOD

Using mixed logistic regression, we examined trends in the National Mental Health Services Survey data from 2014 to 2021, a survey of U.S. mental health facilities which tracks whether facilities provide DBT.

RESULTS

We found that the likelihood that a residential or day-hospital facility offers DBT has been growing over time at the national level (ORday-treatment = 1.07, SE = .03, z = 1.90, p = .05; ORresidential = 1.08, SE = .05, z = 1.77, p = .08). We also found significant variability in these trends at the state level. In addition, we found that facilities accepting state benefits were less likely to offer DBT (ORday-treatment = .66, SE = .021, z = -1.93, p = .05; ORresidential = .67, SE = .21, z = -1.91, p = .06).

CONCLUSION

Consistent with previous literature, our study suggests that these programs are very scarce across the United States and difficult to access for those with Medicaid.guidelines on borderline personality disorder (BPD) recommend day-hospital or residential treatments for patients with BPD who cannot tolerate outpatient treatment (American Psychiatric Association, 2010; National Health & Medical Research Council, 2013). However, the current literature suggests that evidence-based treatment for BPD may be difficult to access (Lohman et al., 2017). The present study aims to characterize the accessibility of dialectical behavioral therapy (DBT) in day-treatment and residential programs in the United States in the last 7 years and examines whether day-treatment and residential programs that accept state benefits (i.e., Medicaid) are significantly less likely to offer DBT.

METHOD

Using mixed logistic regression, we examined trends in the National Mental Health Services Survey data from 2014 to 2021, a survey of U.S. mental health facilities which tracks whether facilities provide DBT.

RESULTS

We found that the likelihood that a residential or day-hospital facility offers DBT has been growing over time at the national level (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The role of mindfulness and emotion regulation in dialectical behavioral therapy for borderline personality disorder

Despite nearly 30 years of research demonstrating its effectiveness in the treatment of borderline personality disorder (BPD) and related problems, few studies have investigated mechanisms of change for dialectical behavior therapy (DBT; Linehan, 1993a). Improvements in mindfulness and emotion regulation have been highlighted as key potential mechanisms of change in DBT (Lynch et al., 2006). The present study examined the time course of and associations between mindfulness, emotion regulation, and BPD symptoms during DBT. Participants were 240 repeatedly and recently self-harming adults (Mage = 27.75) with BPD who were randomly assigned to receive either 6 or 12 months of standard DBT. Primary hypotheses were that: (a) changes in mindfulness would occur before changes in emotion regulation, and (b) changes in emotion regulation would mediate the association of changes in mindfulness with changes in BPD symptoms. Results from changepoint analysis illuminated the proportion of participants for whom first changes occurred in emotion regulation (40.7%), mindfulness (32.4%), or both (26.9%). Contrary to hypotheses, five-wave, cross-lagged analyses did not indicate mediational effects of either mindfulness or emotion regulation on the association of either variable with change in BPD symptoms. Supplemental analyses, however, suggested that changes in emotion regulation mediated the inverse association of changes in mindfulness with changes in BPD symptoms. Findings highlight patterns of change in key, proposed mechanisms of change in DBT and suggest important future research directions. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

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.

Psychiatric providers' attitudes toward patients with borderline personality disorder and possible ways to improve them

OBJECTIVE

Tending to patients with a diagnosis of borderline personality disorder (BPD) is a challenging task for clinicians due to stigma and differences in opinion within the psychiatric community. Various symptoms of BPD including affective instability, mood reactivity, and extremes of idealization are associated with challenging emotions toward patients with BPD. This observational research study utilized an adaptation of the 37-question Attitude to Personality Disorder Questionnaire (APDQ) to assess the attitudes of clinicians toward patients with BPD.

METHODS

This questionnaire was distributed to 139 clinicians including psychiatry attendings, psychiatry residents, registered nurses, nurse practitioners, social workers, recreation and art therapists, and psychologists who worked with patients diagnosed with BPD on an inpatient unit. Responses of participants were compared based on occupation, gender, and duration of years worked on an inpatient psychiatric unit.

RESULTS

Results show that individuals employed in occupations under the "other health professionals" category had more positive transference (which included feelings of respect toward BPD patients along with feelings of closeness and warmth) toward patients with BPD, and nurses had an increased total score for lack of valid difficulties compared with other health professionals. When grouping by gender and duration of year spent working on an inpatient unit, there were no significant differences in the response toward patients with BPD in affective situations.

CONCLUSION

Clinical implications are discussed, as well as the need for training to help improve staff attitudes toward this patient population.

[On the Admission of Patients with Borderline Personality Disorder to Outpatient Psychotherapy]

BACKGROUND

Patients with borderline personality disorder (BPD) present difficulties in self-regulation and interaction, which is a challenge for psychotherapists that is also addressed in BPD-specific interventions. Against this background, outpatient psychotherapists were surveyed about the factors playing a decisive role in their treatment offer for patients with BPD.

METHODS

Psychotherapists for adults were contacted via their email address published on the website of the Kassenärztliche Vereinigung (Association of Statutory Health Insurance Physicians), 231 of whom answered an online questionnaire. The results were analysed descriptively and examined inferentially with regard to the psychotherapists' admission behaviour.

RESULTS

Almost 90% reported that they would generally accept patients with BPD in therapy. However, of those, 85% did not have a therapy slot available. The psychotherapists' learned approach of treatment was not a decisive factor in determining whether they were willing to provide treatment. Most of the psychotherapists (85%) recommended a BPD disorder-specific therapy such as Dialectical Behavior Therapy (DBT), Mentalization-Based Treatment (MBT), Transference-Focused Psychotherapy (TFP) or Schema Therapy (ST). However, only just under 7% were certified in such a disorder-specific approach. Significant individual stress factors described by the psychotherapists were suicidal risk (70%) and potential other-directed aggression (59%). In addition, it was shown that it played a role whether the psychotherapists were trained in an additional therapy approach (with at least 16 teaching units) or not.

CONCLUSION

The care situation for people with BPD seeking an outpatient psychotherapy place is clearly in need of improvement. This is mainly due to a general lack of available therapy places as well as various fears and anxieties, such as increased suicidality, which in turn can have a negative impact on the provision of outpatient therapy. Psychotherapists who have undergone disorder-specific further training feel less burdened by suicidal behaviour. However, since only a small number of them are able to offer BPD-specific therapies, it is essential to expand and (financially) support specific training programmes. In order to meet the demand for care, professional changes are urgently needed.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Theta burst stimulation add on to dialectical behavioral therapy in borderline-personality-disorder: methods and design of a randomized, single-blind, placebo-controlled pilot trial

Specialized psychotherapeutic treatments like dialectical behavioral therapy (DBT) are recommended as first treatment for borderline personality disorder (BPD). In recent years, studies have emerged that focus on repetitive transcranial magnetic stimulation (rTMS) in BPD. Both have independently demonstrated efficacy in the treatment of BPD. Intermitted theta burst stimulation (iTBS), a modified design of rTMS, is thought to increase the excitability of neurons and could be a supplement to psychotherapy in addition to being a standalone treatment. However, no studies to date have investigated the combination of DBT and rTMS/iTBS. This study protocol describes the methods and design of a randomized, single-blinded, sham-controlled clinical pilot study in which BPD patients will be randomly assigned to either iTBS or sham during four consecutive weeks (20 sessions in total) in addition to standardized DBT treatment. The stimulation will focus on the unilateral stimulation of the left dorsolateral prefrontal cortex (DLPFC), which plays an important role in the control of impulsivity and risk-taking. Primary outcome is the difference in borderline symptomatology, while secondary target criteria are depressive symptoms, general functional level, impulsivity and self-compassion. Statistical analysis of therapy response will be conducted by Mixed Model Repeated Measurement using a 2 × 2-factorial between-subjects design with the between-subject factor stimulation (TMS vs. Sham) and the within-subject factor time (T0 vs. T1). Furthermore, structural magnetic resonance imaging (MRI) will be conducted and analyzed. The study will provide evidence and insight on whether iTBS has an enhancing effect as add-on to DBT in BPD.Trial registration: drks.de (DRKS00020413) registered 13/01/2020.

Borderline personality features are associated with worse perceptions of (but not compliance with) chronic pain treatment

Treating chronic illness requires ongoing patient-provider cooperation, but individual differences in patients' negative perceptions of care can undermine this cooperation. Research suggests people high on borderline personality disorder (BPD) features may react negatively to and comply less with mental health and medical treatment. This might be particularly problematic in chronic pain treatment, where BPD features are over-represented and the dysregulation typifying BPD likely undermines consistent care. In a sample of 147 chronic pain patients, we investigated whether higher levels of BPD features - both in general and by specific facets - predicted worse perceptions of treatment and lower patient-reported compliance with treatment recommendations. Participants higher (vs. lower) on borderline features viewed treatment more negatively but did not report complying less with recommendations. We found evidence that this may reflect the unstable relationships facet of BPD. Our results indicate that, consistent with other treatment settings, BPD features may undermine care for chronic pain. Furthermore, our results highlight the importance of collaborative provider-patient relationships and patient agreement with the treatment of chronic pain, particularly among individuals higher on BPD features.

Social cognition deficits in borderline personality disorder: Clinical relevance

Interpersonal difficulties in borderline personality disorder (BDP) have been suggested to be related to impairments in Social Cognition (SC), mainly due to deficits in Theory of Mind (ToM). However, literature is scarce and ambiguous. This work aims to study the SC impairments in BPD patients, by the specific assessment of ToM deficits, and to investigate the relationship between these SC impairments and clinical variables. 82 BPD patients with BPD and 47 control subjects were assessed with the Movie for the Assessment of Social Cognition (MASC). Clinical variables of severity, chronicity, functionality and anxious-depressive symptomatology were recorded. BPD patients had fewer correct mentalization responses and more overmentalization, undermentalization, and absence of mentalization errors than controls. Chronicity was negatively correlated with overmentalization and positively correlated with undermentalization and absence of mentalization errors. Functionality was indirectly correlated with absence of mentalization. These results confirm previous reports of alterations in SC in BPD patients. Furthermore, this study shows that SC impairments in patients with BPD are dependent on characteristics such as chronicity or degree of functionality. The different ToM profiles in patients with BPD indicate the necessity of developing variants of mentalization therapy depending on the deficits of each patient.

"I'm fighting with BPD instead of my partner": A dyadic interpretative phenomenological analysis of the lived experience of couples navigating borderline personality disorder

Borderline personality disorder (BPD) is associated with romantic relationship distress and dissolution. The complex interaction between BPD and romantic relationships warrants further attention. Dyadic interviews (N = 10) were conducted to examine the experience and impact of BPD on couples' relationships. The results of interpretative phenomenological analysis consisted of two superordinate themes describing the couple experience of navigating BPD: (a) the shared experience of BPD as a relational stressor; and (b) adaptive dyadic coping in the context of BPD. Although BPD was experienced as a relational stressor, dyadic coping and shared externalization of BPD emerged as central components to adaptive couple functioning. Most couples reported that therapy was a critical external resource in their journey toward adaptively functioning in the context of BPD, both intrapersonally and interpersonally. The lived experiences of these couples provides therapists with an increased understanding of the resources that support adaptive dyadic coping with BPD.

Online psychoeducation and digital assessments as a first step of treatment for borderline personality disorder: A protocol for a pilot randomized controlled trial

BACKGROUND

Treatment trials for borderline personality disorder (BPD) have consistently demonstrated that approaches that are diagnostically tailored are superior to those which are not. Currently, gold standard treatments for BPD are highly intensive, lengthy, and specialized, leading to a critical gap between the supply and demand of effective, evidence-based treatment for patients who receive a diagnosis of BPD. Psychoeducation, which is a common component of most treatments known to be effective, is a low-cost, low-burden intervention proven to relieve symptoms. The present study builds on psychoeducation research, assessing online video prescriptions as a means of disseminating information patients need to know about their diagnosis and care.

METHODS

This article presents the study protocol for a safety, feasibility, and preliminary efficacy trial of psychoeducational video prescriptions and online assessment with feedback for newly diagnosed individuals with BPD. We aim to recruit 100 adults recently diagnosed with BPD to be randomly assigned to receive videos about BPD or videos about non-BPD mental health topics that are matched in length in the first step of the study. All participants will complete daily surveys about their emotions, interpersonal interactions, and behaviors, as well as self-report assessments and cognitive tests at 4 different time points. Half of the participants in the intervention group will receive feedback on their symptom ratings and cognitive test performance to assess whether there is incremental value in tailoring this online set of interventions with individualized feedback unique to each participant. This study aims to assess the effects of BPD-focused psychoeducational videos with and without personalized feedback, on BPD and depressive symptom severity as well as core mechanisms of the disorder such as loneliness, rejection sensitivity, cognitive control difficulties, and self-clarity. Results will inform efforts to progress to a larger, more definitive trial.

TRIAL REGISTRATION

Clinical trials registration: The protocol is registered with ClinicalTrials.gov NCT05358925.

Effective management of patients with borderline personality disorder in a busy acute inpatient ward using dialectical behaviour therapy principles

OBJECTIVE

The study aimed to highlight principles of Dialectical Behaviour Therapy (DBT) that can provide a framework in the management of patients with borderline personality disorder (BPD) and outline some guiding principles in the effective management of these patients on a busy acute inpatient ward.

CONCLUSIONS

The inpatient environment is often a place where invalidating experiences can occur. These include feeling ignored, misunderstood and where private experiences are trivialised or denied. Patients with BPD are extremely sensitive to these experiences and are likely to decompensate if strategies are not in place to facilitate a more validating experience during admission. The proposed guidelines are feasible to implement and support a cohesive treatment team and collaborative patient-centred care which is likely to improve patient outcomes.

How to target disturbed identity in borderline patients? Self-identification program: A case study

Borderline personality disorder (BPD) is a severe and relatively prevalent psychiatric disorder, responsible for high rates of suicidal behaviors. Disturbed identity appears as at the very core of this disorder, being inter-related with all other BPD features. Notably, from a dimensional perspective on mental disorders, one should realize that it is from our usual self-representation that we live all our daily experiences. Then, if the understanding of self-concept (or identity) is impaired, all the interventions implemented to decrease the self's suffering will subsequently be impaired. The purpose of the present case study was to illustrate the nine identity diffusion categories described by Jørgensen & Bøye (2022) and how the level of identity function can be improved in a third-wave cognitive and behavioral therapy targeting progressive correct self-identification.

Mentalization-based treatment for adolescents with conduct disorder (MBT-CD): a feasibility study

Conduct disorder (CD) is a common psychiatric disorder in youth characterized by persisting norm-violating or aggressive behavior. Considering high individual and societal burden, feasible and effective psychotherapeutic treatment is desirable. Yet, treatments and research in this patient group are scarce. This study investigates the feasibility of mentalization-based treatment for adolescents with CD (MBT-CD) in terms of acceptability of MBT-CD and scientific assessments by participants as well as necessary organizational resources to conduct a consecutive randomized controlled trial (RCT). Recruitment, adherence and treatment session numbers were descriptively analyzed. Treatment evaluation interviews were qualitatively analyzed. A subset of sessions of therapists without prior MBT experience was rated for MBT adherence. Quantitative data were used to plan a consecutive RCT. Pre to post treatment changes in diagnosis and self-reported aggression, mentalizing and personality functioning were preliminarily analyzed. N = 45 adolescents with CD were recruited. 43% dropped out. Acceptance of scientific assessments was somewhat lower than therapy adherence (questionnaires filled out by ~ 80% of adolescents in treatment), and low at follow-up (25% of treatment completers). Mean session number was 30.3. Most treatment completers were satisfied with MBT-CD. Referrals mainly came from child and youth services and psychiatry. Nine of 16 sessions rated for MBT adherence were adherent. A priori sample size estimation for a prospective RCT with a drop-out rate of 43% yielded a sample of N = 158 to detect an effect f = .15 with 80% power in a repeated measures ANOVA. Pre-post analyses revealed diagnostic improvement in 68%. Of self-reported data, empathy pathology improved. Findings provide a sound basis for a consecutive feasibility and pilot RCT. TRIAL REGISTRATION: Clinicaltrials.gov, registration number NCT02988453, November 30, 2016, https://clinicaltrials.gov/ct2/show/NCT02988453.

The experiences of parents in an early-intervention program for young people with borderline personality disorder features

Previous research demonstrates that parents' communication skills may contribute to the development and maintenance of their young person's borderline personality disorder (BPD). Carers of people with BPD also experience their own psychosocial stressors and feel unsupported. Consequently, Dialectical Behavior Therapy for adolescents (DBT-A) invites parents to partake in group therapy alongside their young person. Despite this involvement, little research exists examining parents' perspective of engaging in a DBT-A program, and specifically whether they experience their own benefits and changes from being part of the program. To examine this, the current study interviews 34 parents who engaged in an early intervention DBT-A program. Thematic analysis resulted in seven key themes and 16 subthemes beginning with parents' expectations of the program, followed by the key elements of the program that facilitated change, and the actual changes and benefits attributed to these elements. Overall, parents were surprised by their own gains from the program, and how the skills they learned facilitated personal development that improved family communication and functioning with their young person and more broadly. This study addresses the gap in understanding the parent perspective with clinical implications for the benefits of involving parents in therapy more generally.

Life experienced as worth living and beyond: a qualitative study of the pathways to recovery and flourishing amongst individuals treated for borderline personality disorder

BACKGROUND

Dialectical Behaviour Therapy (DBT) is recognized as a leading evidence-based treatment, effective in reducing symptoms of borderline personality disorder (BPD), as well as co-occurring clinical syndromes. However, symptom remission may not be the same as a life experienced as worth living. The purpose of the study was to understand, from the perspective of individuals with lived experience, the concepts of recovery, life experienced as worth living and flourishing after treatment for BPD, and to describe the pathways to wellness after symptom remission.

METHODS

Semi-structured interviews were conducted with nine adult women previously diagnosed with BPD, co-occurring clinical syndromes and severe self-harm behaviour who self-identified as recovered for a minimum of two years, recruited from a network for individuals with lived experience. The average duration of recovery was 5.7 years with a range from 2 to 10 + years. Data were analysed using thematic analysis.

RESULTS

Four main themes and 14 subthemes were generated from our analyses. Main themes indicated that loved ones helped recovery and to create a life worth living, that participants identified as recovered and as healthy and beyond, and that becoming well is a long process associated in part with reclaiming a healthy identity. Participants defined recovery as separate but related to a life worth living, which in turn was separate but related to being healthy and having lives they described as being beyond health and well-being. The wellness process was described as lengthy and non-linear, including setbacks that with time no longer derailed daily life. A proposed theoretical model depicting the wellness process over time from symptom remission to the experience of a life beyond health and wellness is presented.

CONCLUSIONS

This qualitative study contributes knowledge of what a life experienced as worth living means, as well as how wellness progressed into flourishing for some participants within a sample of individuals with lived experience. Our findings may inform treatment development that targets more than symptom reduction, which in turn may shorten trajectories from symptom remission to health, wellness, and flourishing.

Delphi consensus study to develop guidelines for the management of adults with borderline personality disorder in the emergency department: a protocol

INTRODUCTION

Clinicians caring for adults with borderline personality disorder (BPD) in acute settings such as the emergency department (ED) have little evidence/guidance to base decisions on. Specific/detailed guidance for managing BPD in the ED is needed given the morbidity and mortality risks, high service utilisation, unique challenges and risk of iatrogenic interventions. The primary objective of this study is to use a consensus method to develop a guideline for managing adults with BPD in the ED. This protocol and the key questions for the guideline were developed with the advice of people with BPD and their family members/support persons.

METHODS AND ANALYSIS

We will perform a four-phase Delphi study of an expert panel of clinicians, researchers, adults with BPD and their family members/support persons. Various disciplines (psychiatry, psychology, emergency medicine, nursing, social work) and treatment approaches will be included in the expert panel. An online questionnaire will be developed from systematic reviews, qualitative assessments of pivotal literature, and opinions suggested by the panel (phase 1). The panel will rate their agreement on opinions for each key question covering areas of emergency care of adults with BPD using two rounds of this questionnaire (phases 2 and 3). Opinions meeting predefined thresholds for consensus will be brought to consensus meetings moderated by an independent chair (phase 4). The purpose of these meetings is to finalise the set and phrasing of the opinions for each area of emergency care. These final opinions will be the recommendations in the guideline. If there are significant differences of opinion, the guideline will present both recommendations alongside one another.

ETHICS AND DISSEMINATION

This study has received ethics approval by the Hamilton Integrated Research Ethics Board in Hamilton, Ontario, Canada. The results of this study will be disseminated through peer-reviewed publications, conferences and national professional and patient/family/support associations.

Short-Term versus Long-Term Mentalization-Based Therapy for Borderline Personality Disorder: A Randomized Clinical Trial (MBT-RCT)

INTRODUCTION

Borderline personality disorder (BPD) is a severe and prevalent psychiatric disorder. Mentalization-based therapy (MBT) is an evidence-based intervention for BPD, and several countries offer treatment programs for BPD lasting for years, which is resource demanding. No previous trial has compared short-term with long-term MBT.

OBJECTIVE

The aim of the study was to assess the efficacy and safety of short-term versus long-term MBT for outpatients with BPD.

METHODS

Adult outpatients (≥18 years) with subthreshold or diagnosed BPD were randomly assigned (1:1) to short-term MBT (5 months) or long-term MBT (14 months). The primary outcome was BPD symptoms assessed with the Zanarini Rating Scale for Borderline Personality Disorder. Secondary outcomes were functional impairment, quality of life, global functioning, and severe self-harm. All outcomes were primarily assessed at 16 months after randomization. This trial was prospectively registered at ClinicalTrials.gov, NCT03677037.

RESULTS

Between October 4, 2018, and December 3, 2020, we randomly assigned 166 participants to short-term MBT (n = 84) or long-term MBT (n = 82). Regression analyses showed no evidence of a difference when assessing BPD symptoms (MD 0.99; 95% CI: -1.06 to 3.03; p = 0.341), level of functioning (MD 1.44; 95% CI: -1.43 to 4.32; p = 0.321), quality of life (MD -0.91; 95% CI: -4.62 to 2.79; p = 0.626), global functioning (MD -2.25; 95% CI: -6.70 to 2.20; p = 0.318), or severe self-harm (RR 1.37; 95% CI: 0.70-2.84; p = 0.335). More participants in the long-term MBT group had a serious adverse event compared with short-term MBT (RR 1.63; 95% CI: 0.94-3.07; p = 0.088), primarily driven by a difference in psychiatric hospitalizations (RR 2.03; 95% CI: 0.99-5.09; p = 0.056).

CONCLUSION

Long-term MBT did not lead to lower levels of BPD symptoms, nor did it influence any of the secondary outcomes compared with short-term MBT.

A Model of Trust Processes in Borderline Personality Disorder: A Systematic Review

PURPOSE OF REVIEW

Unstable relationships are a core feature of borderline personality disorder (BPD). Impairments in trust processes (i.e., appraisal and learning regarding others' trustworthiness) can subserve interpersonal problems associated with BPD, but the determinants, mechanisms, consequences, and variations in trust impairments among individuals with BPD remain poorly characterized. Thus, a better understanding of such impairments could help target interventions that address the interpersonal problems of individuals with BPD beyond emotion dysregulation, impulsivity, and aggression.

RECENT FINDINGS

We conducted a pre-registered systematic review of empirical studies on trust processes and BPD features (k = 29). Results are organized around a heuristic model of trust processes in BPD comprising the following stages: developmental factors, prior beliefs and dispositions, situation perception, emotional states, trust appraisal, behavioral manifestations, and trust learning. Based on the synthesis of the findings, we recommended directions for future research and clinical assessment and intervention, such as managing trust during the early stages of therapy and considering improvements in trust processes as a central mechanism of change in treating individuals with BPD.

The effectiveness of individual schema therapy in older adults with borderline personality disorder: A multiple-baseline case series design

OBJECTIVE

The aim of this study was to explore the effectiveness of schema therapy (ST) in older adults with borderline personality disorder (BPD).

METHODS

Multiple baseline case series design with five BPD patients, with a mean age of 66. After a baseline phase with random length, patients received weekly ST sessions for a year, followed by follow-up sessions during 6 months. Participants rated the credibility of negative core beliefs weekly; various secondary outcome measures were assessed every 6 months (severity of BPD, early maladaptive schemas, schema modes, personality functioning, maladaptive personality traits, psychological distress and quality of life), and BPD diagnosis was assessed before baseline and after follow-up. Data were analysed with mixed regression analyses and paired t-tests.

RESULTS

Results revealed that ST led to a significant decrease in credibility of negative core beliefs, with high effect sizes. All participants remitted from their BPD diagnosis.

CONCLUSION

This is the first study exploring the effectiveness of ST for BPD in older adults, and it suggests that ST can be a powerful intervention for this group of patients.

One-year prevalence and psychiatric comorbidity of borderline personality disorder in a medical certificate population: a registry study of psychiatric outpatients in community mental health care in the city of Oulu

OBJECTIVE

Borderline personality disorder (BPD) is a common disorder in healthcare settings but estimates of BPD prevalence vary greatly. This study aimed to estimate the one-year prevalence of BPD in psychiatric outpatients and analyze the psychiatric comorbidity presented with BPD.

METHOD

The data comprised 18-60-year-old patients who had a BPD diagnosis recorded in their medical certificate B (mcB) and were treated in specialized psychiatric outpatient services in the city of Oulu, northern Finland, in 2014. An mcB is a comprehensive summary of a patient's medical history written by a doctor, and patients need it in the Finnish healthcare system when applying for social benefits and rehabilitation measures.

RESULTS

The prevalence of BPD was 12.8% among patients with an mcB treated in the psychiatric outpatient services. BPD was 3.0 times more common in female than male psychiatric outpatients with an mcB. The most common comorbid psychiatric disorders written in mcBs of BPD patients were mood (81.0%) and anxiety (39.2%) disorders. The only statistically significant gender difference was found in behavioral and emotional disorders (16.7% in men, 1.6% in women).

CONCLUSIONS

The mcB-based BPD prevalence estimate and psychiatric comorbidity was consistent with previous studies researching psychiatric outpatients with BPD. McBs appear to be a reliable and comprehensive data source for diagnostic information in research.

[Borderline psychiatric disorder in the general hospital : specificity and clinical challenges]

Borderline personality disorder (BPD) is a psychiatric condition frequently encountered at the general hospital. This article will focus on the multiple presentation of this mental illness in the aforementioned setting, such as chronic somatic disease, multiple physical complaints as well as chronic pain, all of which that could severely alter the life quality. In this context, especially if there is an unsatisfied need for reinsurance, risk taking behavior (self-harm or harming others) may arise, as well as significant rise of medical costs through multiple medical consultations, longer average lengths of stay and additional complementary examinations. Through a variety of recommendations and a better understanding of BPD, a therapeutic link can be established to facilitate management.

[German S3 guidelines on borderline personality disorder]

Research on the understanding and especially on the treatment of borderline personality disorder (borderline PD) has made considerable progress in recent years, so that evidence-based German treatment guidelines have now been produced for the first time. This article highlights the development as well as the main content priorities and recommendations of the guidelines: first, the recommendations on the diagnostics are presented and in this context the upcoming changes to the International Classification of Diseases 11th reversion (ICD-11) are also explained. Subsequently, the most important recommendations on guideline-compliant psychotherapy, pharmacotherapy and treatment settings are presented. Finally, the recommendations concerning relatives (or other significant persons for people with borderline PD) as well as parenthood and borderline PD are presented.

A randomised controlled trial of a psychoeducational group intervention for family and friends of young people with borderline personality disorder features

OBJECTIVE

Preliminary evidence indicates that interventions designed to support family and friends ('carers') of young people with early-stage borderline personality disorder effectively improve carer outcomes. None of these interventions have been tested in a randomised controlled trial.

METHOD

This clustered, partially nested, randomised controlled trial was conducted at Orygen, Melbourne, Australia. Carers of young people (aged 15-25 years) with borderline personality disorder features were randomly assigned as a unit in a 1:1 ratio, balanced for young person's sex and age, to receive a 15-day intervention comprising: (1) the three-session, in-person, Making Sense of BPD (MS-BPD) multi-family group programme, plus two self-directed online psychoeducational modules (MS-BPD + Online, n = 38), or (2) the two self-directed online psychoeducational modules alone (Online, n = 41). The primary outcome was 'negative experiences of care', measured with the Experience of Caregiving Inventory, at the 7-week endpoint.

RESULTS

A total of 79 carers were randomised (pool of 281, 197 excluded, 94 declined) and 73 carers (51 females [69.9%], Mage = 43.8 years [standard deviation, SD = 12.9], MS-BPD + Online n = 35 [47.9%], Online n = 38 [52.1%]) provided follow-up data and were included in the intent-to-treat analysis. The intent-to-treat (and per protocol) analyses did not find any significant differences between the groups on the primary (d = -0.32; 95% confidence interval = [-17.05, 3.97]) or secondary outcomes. Regardless of treatment group, caregivers improved significantly in their personality disorder knowledge.

CONCLUSION

Delivering MS-BPD in conjunction with an online psychoeducational intervention was not found to provide additional benefit over and above access to an online intervention alone. In accordance with national guidelines, carer interventions should be routinely offered by youth mental health services as part of early intervention programmes for borderline personality disorder. Further research is warranted into which interventions work for whom, carers' preferences for support and barriers to care.

Psychotherapy for patients with schizotypal personality disorder: A scoping review

BACKGROUND

Treatment of schizotypal personality disorder is complex. Currently, there are no clear evidence-based recommendations for use of psychotherapy for individuals suffering from this mental illness, and studies are sparse. Our aim in this review is to map and describe the existing research and to answer the research question: What do we know about the use of psychotherapy for people with schizotypal personality disorder?

METHODS

We conducted a scoping review using systematic searches in the Embase, MEDLINE and PsycINFO databases. Two reviewers screened possible studies and extracted data on subject samples, type of psychotherapy, outcomes and suggested mechanisms of change. The review is based on the PRISMA checklist for scoping reviews.

RESULTS

Twenty-three papers were included, and we found a wide variety of study types, psychotherapeutic orientations and outcomes. Few studies emerged that focused solely on schizotypal personality disorder.

CONCLUSION

Psychotherapy as a treatment for schizotypal personality disorder is understudied compared with diagnoses such as schizophrenia and borderline personality disorder. Our results included two randomized controlled studies, as well as mainly smaller studies with different approaches to diagnostic criteria, psychotherapeutic orientation and outcome measures. The findings are too sparse and too diverse to make any evidence-based recommendations. We found some indications that psychotherapy may support and assist individuals with schizotypal personality disorder.

Predictors of Effects in Brief Psychiatric Treatment for Borderline Personality Disorder

If evidence points to the equal efficacy of all bona fide treatments for borderline personality disorder (BPD) in general, it may not necessarily be true for a specific individual, nor do such general conclusions help in the triage of clients in clinical services. We investigated potential therapy outcome predictors for participants with a BPD diagnosis (N = 99). They were assessed on scales including the Outcome Questionnaire-45.2 (OQ-45), the Inventory of Interpersonal Problems-64, and the Borderline Symptom List. Our analyses revealed that individuals with low levels of symptom distress at intake had the smallest change in total OQ-45 score over the course of brief treatment, while the individuals with high levels of symptom distress had a mean large change in total score (-23). We observed that individuals with high symptom loads AND low levels of interpersonal problems at intake seemed to have the best progress.

Altered amygdalar emotion space in borderline personality disorder normalizes following dialectical behaviour therapy

BACKGROUND

Borderline personality disorder (BPD) is a mental health condition characterized by an inability to regulate emotions or accurately process the emotional states of others. Previous neuroimaging studies using classical univariate analyses have tied such emotion dysregulation to aberrant activity levels in the amygdala of patients with BPD. However, multivariate analyses have not yet been used to investigate how representational spaces of emotion information may be systematically altered in patients with BPD.

METHODS

Patients with BPD performed an emotional face matching task while undergoing MRI before and after a 10-week inpatient program of dialectical behavioural therapy. Representational similarity analysis (RSA) was applied to activity patterns (evoked by angry, fearful, neutral and surprised faces) in the amygdala and temporo-occipital fusiform gyrus of patients with BPD and in the amygdala of healthy controls.

RESULTS

We recruited 15 patients with BPD (8 females, 6 males, 1 transgender male) to participate in the study, and we obtained a neuroimaging data set for 25 healthy controls for a comparative analysis. The RSA of the amygdala revealed a negative bias in the underlying affective space (in that activity patterns evoked by angry, fearful and neutral faces were more similar to each other than to patterns evoked by surprised faces), which normalized after therapy. This bias-to-normalization effect was present neither in activity patterns of the temporo-occipital fusiform gyrus of patients nor in amygdalar activity patterns of healthy controls.

LIMITATIONS

Larger samples and additional questionnaires would help to better characterize the association between specific aspects of therapy and changes in the neural representational space.

CONCLUSION

Our findings suggest a more refined role for the amygdala in the pathological processing of perceived emotions and may provide new diagnostic and prognostic imaging-based markers of emotion dysregulation and personality disorders.Clinical trial registration: DRKS00019821, German Clinical Trials Register (Deutsches Register Klinischer Studien).

The impact of a combined mentalisation-based therapy and therapeutic community programme for adolescents with borderline personality disorder traits on service utilisation in Western Australia

This study assessed the effect of a mentalisation-based therapy (MBT) treatment programme on the utilisation of Western Australian public hospitals for mental health presentations over an 18-month period. Hospital data included the number of visits to the emergency department (ED), the number of inpatient admissions to hospital and length of stay of the admissions. Participants included 76 adolescents aged 13-17 years old, who presented with borderline personality disorder (BPD) traits. The Touchstone treatment programme is a time-limited intensive programme that utilises MBT in the context of a therapeutic community. Hospital data for the participants were collected and analysed from three time points; 6 months prior to attending the programme, during the 6-month programme (active treatment) and 6 months after the programme. Results found a statistically significant decrease in hospital utilisation from pre to post programme, with a decline in ED visits, inpatient admissions and admission length of stay. This study presents promising preliminary evidence for the effectiveness of an intensive MBT programme as an intervention for adolescents with BPD features and has significant implications for the public health system in terms of providing effective community-based treatment for this difficult to treat population as well as reducing pressure on tertiary care.

[Development of a self-report questionnaire for the measurement of stigmatizing attitudes of the psychiatric staff towards patients with borderline personality disorder]

OBJECTIVE

The development of a self-report questionnaire for quantitative measurement of stigmatizing attitudes of the psychiatric staff towards patients with borderline personality disorder.

METHOD

Online survey with psychiatrists, psychologists and nursing staff (n=94) in the (semi-)stationary psychiatric sector with translated items of an attitude questionnaire, followed by a principal component analysis and correlations between principal components and social distance.

RESULTS

Analyses revealed a 4-principal component structure (BPD-treatment difficulties, BPD-assessment of suicide risk, BPD-assumption of manipulative tendencies, BPD-negative emotions) with 63,60% explained variance and small to large correlations between principal components and social distance.

CONCLUSION

Results initially indicate possible validity and reliability of the developed questionnaire. Further analyses with larger sample size and confirmatory factor analysis for continued development are advised.

Attitudes of psychiatry trainees towards patients with borderline personality disorder: Does the stigma begin during training?

Research suggests there is a widespread stigma among clinicians towards patients with borderline personality disorder (BPD) and that this contributes to poor treatment outcomes. Given the influence of learning environments in shaping perceptions, this study investigated the attitude of South Australian psychiatry trainees towards patients with BPD. A questionnaire was distributed to 89 South Australian doctors, from both The Adelaide Prevocational Psychiatry Program (TAPPP) and psychiatry trainees of The Royal Australian and New Zealand College of Psychiatrists (RANZCP). This questionnaire investigated the domains of treatment optimism, clinician attitude and empathy towards patients with BPD. Results indicated that psychiatry trainees near the end of training scored significantly lower across all domains, indicating a more negative perception of patients with BPD, when compared to early- and mid-stage trainees. This study identifies a need to understand why trainees closer to qualifying as psychiatrists have increased stigma towards patients with BPD. Improved education and training surrounding patients with BPD is warranted to reduce negative stigma and improve clinical outcomes.