The aetiological and psychopathological validity of borderline personality disorder in youth: A systematic review and meta-analysis

Borderline personality disorder: course and outcomes across the lifespan

This article presents an overview of the current literature on the course and outcomes of BPD. It begins with an overview of our changing understanding of BPD in terms of age of onset and prognosis over time. Recent research on clinical, functional and social recovery from BPD in youth and adult populations is then summarised. This is followed by an overview of contemporary prospective studies of adolescent BPD in community populations which seek to unravel complex pathways and the co-development of BPD symptoms and psychosocial problems. Studies of older populations are then described to shed light on how BPD manifests in middle to old age. The review concludes by bringing together these research strands to develop a picture of BPD across the lifespan and highlight areas for future research.

Developmental Pathways to BPD-Related Features in Adolescence: Infancy to Age 15

The self-damaging behaviors central to borderline personality disorder (BPD) become prominent in adolescence. Current developmental theories cite both early family processes and childhood dysregulation as contributors to BPD, but longitudinal data from infancy are rare. Using the National Institute of Child Health and Human Development (NICHD) Study of Early Child Care and Youth Development database (SECCYD; N = 1,364), we examined path models to evaluate parent and child contributors from infancy/preschool, middle childhood, and adolescence to adolescent BPD-related features. In addition, person-centered latent class analyses (LCA) investigated whether adolescent BPD-related features were more strongly predicted by particular patterns of maladaptive parenting. Path modeling identified unique influences of maternal insensitivity and maternal depression on BPD-related features, first, through social-emotional dysregulation in middle childhood, and second, through continuity from infancy in maternal insensitivity and depression. LCA results indicated that early withdrawn parenting was particularly predictive of BPD-related features in adolescence. Results suggest multiple points of intervention to alter pathways toward adolescent borderline psychopathology.

Personality pathology in adolescents as a new line of scientific inquiry in Lithuania: mapping a research program development

Mental health of adolescents is an important public health concern in Lithuania. The detection and treatment of early personality pathology are almost non-existent in the mental health system on the national level. While various mental health problems have been sporadically researched, there is no prior research on personality disorders overall. This paper describes the steps taken in the past years in Lithuania to develop a research program on personality pathology in adolescents. It presents a theoretical background, key objectives, and design of the current longitudinal project focused on the developmental course of personality functioning (based on Alternative DSM-5 Model for Personality Disorders) over a two-year period as well as the factors that may shape its trajectories during adolescence.

Parameters of reported childhood sexual abuse and assault in adolescents and adults with borderline personality disorder

OBJECTIVE

Prior research has demonstrated a link between childhood sexual abuse and borderline personality disorder (BPD) in adolescents and adults and has indicated that more severe abuse is related to poorer psychosocial functioning. The present study describes the overall severity of sexual abuse/assault in adolescents and adults with BPD and compares both groups on specific parameters of abusive and assaultive experiences.

METHODS

Participants included 104 adolescent (aged 13-17 years) inpatients with BPD and 290 adult inpatients with BPD. All participants completed two interviews that assessed the presence and severity of sexual abuse/assault.

RESULTS

Of the studied patients with BPD, 26.0% of adolescents and 62.4% of adults reported a childhood history of sexual abuse/assault before the age of 18. Adults had higher scores on an index of sexual abuse severity than adolescents, and a higher proportion of adults reported scores in the severe range. Adults with BPD were also more likely than adolescents to report having experienced sexual abuse/assault that occurred at multiple developmental stages, was frequent (i.e. weekly basis or more), was longer in duration (i.e. a year or more) and was perpetrated by a parent. The groups did not differ on other parameters.

CONCLUSIONS

Taken together, these results suggest that adults with BPD are more likely to report childhood sexual abuse/assault than adolescents with BPD. Additionally, adults report histories of sexual abuse/assault that are more severe than adolescents with BPD, with specific differences observed in timing, frequency, duration and perpetrator. © 2020 John Wiley & Sons, Ltd.

Mentalization-based treatment in groups for adolescents with borderline personality disorder: a randomized controlled trial

BACKGROUND

Borderline personality disorder (BPD) typically onsets in adolescence and predicts later functional disability in adulthood. Highly structured evidence-based psychotherapeutic programs, including mentalization-based treatment (MBT), are first choice treatment. The efficacy of MBT for BPD has mainly been tested with adults, and no RCT has examined the effectiveness of MBT in groups (MBT-G) for adolescent BPD.

METHOD

A total of 112 adolescents (111 females) with BPD (106) or BPD symptoms ≥4 DSM-5 criteria (5) referred to child and adolescent psychiatric outpatient clinics were randomized to a 1-year MBT-G, consisting of three introductory, psychoeducative sessions, 37 weekly group sessions, five individual case formulation sessions, and six group sessions for caregivers, or treatment as usual (TAU) with at least 12 monthly individual sessions. The primary outcome was the score on the borderline personality features scale for children (BPFS-C); secondary outcomes included self-harm, depression, externalizing and internalizing symptoms (all self-report), caregiver reports, social functioning, and borderline symptoms rated by blinded clinicians. Outcome assessments were made at baseline, after 10, 20, and 30 weeks, and at end of treatment (EOT). The ClinicalTrials.gov identifier is NCT02068326.

RESULTS

At EOT, the primary outcome was 71.3 (SD = 15.0) in the MBT-G group and 71.3 (SD = 15.2) in the TAU group (adjusted mean difference 0.4 BPFS-C units in favor of MBT-G, 95% confidence interval -6.3 to 7.1, p = .91). No significant group differences were found in the secondary outcomes. 29% in both groups remitted. 29% of the MBT group completed less than half of the sessions compared with 7% of the control group.

CONCLUSIONS

There is no indication for superiority of either therapy method. The low remission rate points to the importance of continued research into early intervention. Specifically, retention problems need to be addressed.

Psychopathological outcomes of adolescent borderline personality disorder symptoms

OBJECTIVE

Despite considerable morbidity and functional losses associated with adolescent borderline personality disorder, little is known about psychopathological outcomes. This study examined associations between adolescent borderline personality disorder symptoms and subsequent depressive, psychotic and hypomanic symptoms.

METHODS

We used data from the Avon Longitudinal Study of Parents and Children. Participants were adolescents living in the community who had data for all longitudinal outcomes (N = 1758). We used logistic regression and path analysis to investigate associations between borderline personality disorder (five or more probable/definite symptoms) reported at age 11-12 years and depressive and psychotic symptoms reported at age 12 and 18, and lifetime hypomanic symptoms reported at age 22-23 years.

RESULTS

Adolescent borderline personality disorder symptoms were associated with psychotic symptoms (odds ratio: 2.36, confidence interval: [1.82, 3.06]), diagnosis of depression at age 18 years (odds ratio: 1.30, confidence interval: [1.03, 1.64]) and hypomanic symptoms (odds ratio: 2.89, confidence interval: [2.40, 3.48]) at 22-23 years. Path analysis controlling for associations between all outcomes indicated that borderline personality disorder symptoms were independently associated with depressive symptoms (β = 0.97, p < 0.001) at 12 years and hypomanic (β = 0.58, p < 0.01) symptoms at 22-23 years. Borderline personality disorder symptoms were also associated with psychotic symptoms at age 12 years (β = 0.58, p < 0.01), which were linked (β = 0.34, p < 0.01) to psychotic symptoms at age 18 years.

CONCLUSION

Adolescents with borderline personality disorder symptoms are at future risk of psychotic and hypomanic symptoms, and a diagnosis of depression. Future risk is independent of associations between psychopathological outcomes, indicating that adolescent borderline personality disorder symptoms have multifinal outcomes. Increasing awareness of borderline personality disorder in early adolescence could facilitate timely secondary prevention of these symptoms subsequently, helping to prevent future psychopathology.

The prevalence of personality disorders in the community: a global systematic review and meta-analysis

BACKGROUND

Personality disorders are now internationally recognised as a mental health priority. Nevertheless, there are no systematic reviews examining the global prevalence of personality disorders.

AIMS

To calculate the worldwide prevalence of personality disorders and examine whether rates vary between high-income countries and low- and middle-income countries (LMICs).

METHOD

We systematically searched PsycINFO, MEDLINE, EMBASE and PubMed from January 1980 to May 2018 to identify articles reporting personality disorder prevalence rates in community populations (PROSPERO registration number: CRD42017065094).

RESULTS

A total of 46 studies (from 21 different countries spanning 6 continents) satisfied inclusion criteria. The worldwide pooled prevalence of any personality disorder was 7.8% (95% CI 6.1-9.5). Rates were greater in high-income countries (9.6%, 95% CI 7.9-11.3%) compared with LMICs (4.3%, 95% CI 2.6-6.1%). In univariate meta-regressions, significant heterogeneity was partly attributable to study design (two-stage v. one-stage assessment), county income (high-income countries v. LMICs) and interview administration (clinician v. trained graduate). In multiple meta-regression analysis, study design remained a significant predictor of heterogeneity. Global rates of cluster A, B and C personality disorders were 3.8% (95% CI 3.2, 4.4%), 2.8% (1.6, 3.7%) and 5.0% (4.2, 5.9%).

CONCLUSIONS

Personality disorders are prevalent globally. Nevertheless, pooled prevalence rates should be interpreted with caution due to high levels of heterogeneity. More large-scale studies with standardised methodologies are now needed to increase our understanding of population needs and regional variations.

Childhood adversity and borderline personality disorder: a meta-analysis

OBJECTIVE

The aim of this meta-analysis was to better understand the magnitude and consistency of the association between childhood adversity and borderline personality disorder (BPD) across case-control, epidemiological and prospective cohort studies.

METHOD

Following the review protocol (reference: CRD42017075179), search terms pertaining to adversity and BPD were entered into three search engines. Random-effects meta-analysis synthesised the size and consistency of the effects.

RESULTS

A total of 97 studies compared BPD to non-clinical (k = 40) and clinical (k = 70) controls. Meta-analysis of case-control studies indicated that individuals with BPD are 13.91 (95% CI 11.11-17.43) times more likely to report childhood adversity than non-clinical controls. This effect was smaller when considering retrospective cohort (OR: 2.59; 95% CI 0.93-7.30) and epidemiological (OR: 2.56, 95% CI 1.24-5.30) studies. Findings were significant across adversity subtypes with emotional abuse (OR: 38.11, 95% CI: 25.99-55.88) and neglect (OR: 17.73, 95% CI = 13.01-24.17) demonstrating the largest effects. Individuals with BPD were 3.15 (95% CI 2.62-3.79) times more likely to report childhood adversity than other psychiatric groups.

CONCLUSIONS

This meta-analysis corroborates theoretical proposals that exposure to adverse life experiences is associated with BPD. It highlights the importance of considering childhood adversity when treating people diagnosed with BPD.

A history of prolonged childhood sexual abuse is associated with more severe clinical presentation of borderline personality disorder in adolescent female inpatients - A naturalistic study

BACKGROUND

Borderline personality disorder (BPD) is associated with high rates of suicidal and self-injurious behaviors and a substantial proportion of BPD patients have a history of trauma, particularly childhood sexual abuse (CSA).

OBJECTIVE

To compare the clinical presentation severity in female adolescent inpatients with BPD with and without history of prolonged CSA.

PARTICIPANTS AND SETTING

Female adolescent BPD patients admitted to a psychiatric inpatient unit.

METHODS

A retrospective analysis of records of the inpatients, divided into two groups: with (n = 38) and without (n = 40) a history of prolonged CSA. Prolonged CSA was defined as sexual abuse continuing for at least 3 months. Demographic and clinical data, including number and duration of psychiatric hospitalizations until the age 19, non-suicidal self-injury (NSSI), suicide attempts, cigarette smoking, alcohol and drug use, and sexual impulsivity were compared between the two groups.

RESULTS

The BPD + prolonged CSA group had a larger duration of the first psychiatric hospitalization, number of hospitalizations and cumulative length of hospitalizations compared with the control group. Furthermore, the BPD + prolonged CSA group had a higher number of suicidal attempts, and higher rates of severe NSSI events, cigarette smoking, alcohol use, and sexual impulsivity.

CONCLUSIONS

This study demonstrated for the first time that adolescent female BPD inpatients with a history of prolonged CSA, manifest more severe clinical presentation compared to those without prolonged CSA. Hence, it appears essential to encourage therapists to inquire about history of CSA and refer adolescent female BPD inpatients with prolonged CSA to appropriate intensive therapy.

Assessing child abuse: "We need to talk!"

BACKGROUND

This discussion paper adds to the recent critical debate concerning retrospective measurement of childhood abuse and adverse experiences. A series of recent articles found only modest overlap of prospective informant-based records with retrospective self-report questionnaires, with biases evident in the latter. However, this literature has omitted the use of investigator-based interviews as an alternative retrospective tool for triangulation of measurement. Validated interview approaches can ascertain accurate data using expert scoring that can be used to test both dose-effect and specificity analyses for further research and treatment purposes.

OBJECTIVE

Arguments for the retention and further promotion of intensive interview measures for retrospective assessment of childhood neglect and abuse in relation to lifetime clinical outcomes are presented, with illustrative analyses.

METHOD AND RESULTS

A network analytic approach is outlined, with six types of childhood abuse or neglect experiences scored via a well-validated interview (the Childhood Experiences of Care and Abuse). This indicates distinct pathways between types of neglect and abuse, but also from more common emotional abuse (antipathy, critical parenting) through to more pernicious psychological abuse (coercive, sadistic control) involving physical abuse or sexual abuse pathways. This is supplemented by a case vignette to illustrate the different pathways indicated.

CONCLUSIONS

The interview approach gives victims a voice with their narrative (chance to talk) needed for better understanding of the specific dynamics of child abuse and neglect and for an entry into psychotherapeutic work. We need to ensure that such methods are retained in the research and practitioner portfolio of measurement tools.

Parenting and personality disorder: An overview and meta-synthesis of systematic reviews

BACKGROUND/OBJECTIVES

Maladaptive parenting (including childhood maltreatment, abuse and neglect) has been implicated in the scientific literature exploring the aetiology of personality disorder, particularly borderline personality disorder (BPD). Our primary objective was to summarise the evidence on the relationship between parenting and personality disorder, assisting clinical decision-makers to translate this research into clinical policy and practice.

METHODS

We conducted an overview of systematic reviews that assessed individuals with personality disorder pathology for experiences of maladaptive parenting, compared to psychiatric or healthy comparisons/controls, and the impact on psychopathological and relational outcomes. Systematic literature searches were conducted in Scopus, Web of Science, MEDLINE, PsycINFO, and by hand in August 2018. Methodological quality was assessed using the CASP systematic review checklist, and results were qualitatively synthesised. A pre-determined protocol was registered in Prospective Register of Systematic Reviews (PROSPERO 2019:CRD42018096177).

RESULTS

Of the 312 identified records, 293 abstracts were screened, 36 full-text articles were retrieved and eight systematic reviews met pre-determined criteria for qualitative synthesises. The majority of studies reported outcomes related to BPD (n = 7), and study design, methodology and quality varied. Within the eight systematic reviews there were 211 primary studies, of which 140 (66.35%) met eligibility criteria for inclusion in this overview. Eligible primary studies reported on 121,895 adult, child/adolescent and parent-offspring participants, with most studies focused on borderline personality pathology (n = 100, 71.43%). Study design and methodology also varied for these studies. Overall, five systematic reviews overwhelming found that maladaptive parenting was a psychosocial risk factor for the development of borderline personality pathology, and three studies found that borderline personality pathology was associated with maladaptive parenting, and negative offspring and parenting-offspring outcomes.

CONCLUSIONS

In light of these findings, we recommend greater emphasis on parenting in clinical practice and the development of parenting interventions for individuals with personality disorder. However, our understanding is limited by the heterogeneity and varying quality of the evidence, and as such, future research utilising more rigorous research methodology is needed.

Neurophysiological activity following rewards and losses among female adolescents and young adults with borderline personality disorder

Borderline personality disorder (BPD) is a complex and debilitating psychiatric illness. Prior research in adults has shown that neurophysiological deficits in feedback processing and learning from rewards may be central to the development of BPD; however, little research has examined these markers in adolescents and young adults with BPD. The present study used event-related potentials and time-frequency decomposition analysis to probe neural responses to wins and losses in a guessing task among 68 females (13 to 23 years old) either with BPD (n = 35) or no history of mental disorders (healthy control [HC]; n = 33). Participants completed a guessing task wherein they won and lost money at equal frequencies while electroencephalogram (EEG) data were acquired. Adolescents and young adults with BPD showed a smaller differentiation between wins and losses in the reward positivity (RewP) relative to HCs. Using time-frequency decomposition, we isolated distinct frequency bands sensitive to wins (delta = < 3Hz) and losses (theta = 4 Hz to 7 Hz). Compared with BPD participants, HCs showed significantly larger delta power to wins, specifically. The groups did not differ in delta power to losses, nor theta power to wins or losses. Collectively, findings implicate altered reward processing in the pathophysiology of BPD and may inform early identification and targeted intervention. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Recent developments in psychosocial interventions for borderline personality disorder

Borderline personality disorder (BPD) is a serious psychiatric disorder that affects multiple symptomatic domains and is associated with an increased risk of suicidality. Several empirically supported treatments for BPD have been developed in recent years for adults with BPD. More recent work has focused on tailoring or applying (or both) these existing treatments to specific patient populations, including patients with certain types of comorbidity (for example, BPD and post-traumatic stress disorder or antisocial personality disorder) and younger patients. Other work has involved developing treatments and models of treatment delivery that address concerns related to access of care. Relatedly, new adjunctive and technology-assisted interventions have been developed, adding to the growing repertoire of treatment options for these patients. Advances in the last several years address specific treatment needs and offer cost-efficient options for this diverse patient population.

Perceived Invalidation in Adolescent Borderline Personality Disorder: An Investigation of Parallel Reports of Caregiver Responses to Negative Emotions

Childhood experiences of emotional invalidation are commonly reported by adults with borderline personality disorder (BPD). This study aimed to compare perceptions of emotional invalidation between adolescents with and adolescents without BPD, and their primary caregivers. Participants were 51 adolescents subdivided into a clinical group of 26 adolescents with BPD and a community-control group of 25 adolescents, each with their primary caregivers. To examine perceptions of invalidation, adolescents and caregivers completed parallel reports assessing caregiver responses to adolescents' negative emotions. Adolescents with BPD reported more punitive and less supportive responses to their negative emotions than their caregivers. In the control group, by contrast, differences between caregiver and adolescent reports were due to caregivers rating themselves more harshly than did adolescents. Findings demonstrated that adolescents with BPD perceived their caregivers to be relatively less supportive and more invalidating than did adolescents without BPD. Results highlight the importance of adolescents' subjective experiences of caregiving to enduring borderline psychopathology.

The Clinical Significance of Subthreshold Borderline Personality Disorder Features in Outpatient Youth

Studies among adult patients have found that subthreshold borderline personality disorder (BPD) features are associated with elevated psychosocial morbidity compared with patients with no BPD features. However, the clinical significance of subthreshold features of BPD has not been investigated among real-world patients during the clinical emergence of the disorder, which is usually between puberty and emerging adulthood. This study aimed to replicate and extend previous research by comparing outpatient youth aged 15-25 years with subthreshold BPD features with youth with no BPD features. The sample included 499 potential participants, of whom 111 had no DSM-IV BPD features at all, and 155 had between one and four features. Results indicated that the group with subthreshold BPD features had more severe mental illness and poorer social and occupational functioning. These findings suggest that subthreshold BPD features are clinically important and should be a focus of clinical intervention to reduce continuing disability and improve outcome.

Childhood physical abuse and emotional neglect are specifically associated with adult mental disorders

Background: Childhood adversities and trauma (CAT) are associated with adult mental disorders. Nevertheless, although CAT of different domains mostly co-occurs, and co-morbidity is common, the associations between CAT and mental disorders, when taking these interrelations into account, are not well known.Aims: We aimed to study differential associations between the five core domains of CAT and current axis-I disorders, taking into consideration their interrelations.Methods: Four hundred and fifteen outpatients attending adult primary (n = 255) and psychiatric care (n = 160) were assessed with the Trauma and Distress Scale (TADS) and the Mini International Neuropsychiatric Interview (MINI). Associations between CAT core domains and diagnostic categories were examined by path analyses.Results: At least some infrequent experience of CAT (83.6%), mostly of neglect, and current mental disorders (49.4%), mostly depression, was frequent, as were co-morbidities and co-occurrence of CAT domains. Considering these interrelations in a path model of excellent fit, physical abuse predicted depressive, manic, psychotic and anxiety disorders, whereas emotional neglect predicted depressive, anxiety and substance misuse disorders.Conclusions: Of all five CAT core domains, physical abuse and emotional neglect had the strongest association with adult psychiatric disorders and might have transmitted earlier reported main effects of other CAT domains onto mental disorders.

Parsing cyclothymic disorder and other specified bipolar spectrum disorders in youth

OBJECTIVE

Most studies of pediatric bipolar disorder (BP) combine youth who have manic symptoms, but do not meet criteria for BP I/II, into one "not otherwise specified" (NOS) group. Consequently, little is known about how youth with cyclothymic disorder (CycD) differ from youth with BP NOS. The objective of this study was to determine whether youth with a research diagnosis of CycD (RDCyc) differ from youth with operationalized BP NOS.

METHOD

Participants from the Course and Outcome of Bipolar Youth study were evaluated to determine whether they met RDCyc criteria. Characteristics of RDCyc youth and BP NOS youth were compared at baseline, and over eight-years follow-up.

RESULTS

Of 154 youth (average age 11.96 (3.3), 42% female), 29 met RDCyc criteria. RDCyc youth were younger (p = .04) at baseline. Over follow-up, RDCyc youth were more likely to have a disruptive behavior disorder (p = .01), and were more likely to experience irritability (p = .03), mood reactivity (p = .02), and rejection sensitivity (p = .03). BP NOS youth were more likely to develop hypomania (p = .02), or depression (p = .02), and tended to have mood episodes earlier in the eight-year follow-up period.

LIMITATIONS

RDCyc diagnoses were made retrospectively and followed stringent criteria, which may highlight differences that, under typical clinical conditions and more vague criteria, would not be evident.

CONCLUSION

There were few differences between RDCyc and BP NOS youth. However, the ways in which the groups diverged could have implications; chronic subsyndromal mood symptoms may portend a severe, but ultimately non-bipolar, course. Longer follow-up is necessary to determine the trajectory and outcomes of CycD symptoms.

Differential relations of executive functioning to borderline personality disorder presentations in adolescents

Borderline personality disorder (BPD) in adolescents is highly complex and heterogeneous. Within the disorder, research has suggested the existence of at least two subgroups: one with predominantly internalizing psychopathology features and one with predominantly externalizing psychopathology features. One process that may differentiate these groups is executive functioning (EF), given that poor EF is linked to externalizing psychopathology. Against this background, the current study used a multi-informant approach to examine whether adolescent patients with predominantly externalizing BPD presentations experience greater deficits in EF than adolescent patients with predominantly internalizing presentations. The sample included inpatient adolescents ages 12-17 (M = 15.26; SD = 1.51). Analyses revealed that multiple EF domains distinguished the BPD subgroups. More specifically, adolescents with externalizing presentations exhibited greater difficulties in broad domains related to global executive functioning, metacognition and behavioural regulation and specific domains related to inhibitory control, working memory, planning/organizing, monitoring and organization of materials. While this study is the first to examine EF and adolescent BPD in the context of internalizing and externalizing psychopathology, alternative approaches to examining this question are discussed. Copyright © 2018 John Wiley & Sons, Ltd.

Borderline personality disorder and sexual abuse: A systematic review

Although sexual abuse (SA) is known to be frequent among borderline personality disorder (BPD) patients, few reviews evaluating that relationship have been published. This systematic review aimed to investigate SA (including adulthood) as a predictor of BPD diagnosis, clinical presentation and prognosis. Studies written in English or Portuguese from January 1997 until January 2017 were identified by searching the following keywords in three international databases: "borderline personality disorder" OR "borderline disorder" AND "sexual abuse" OR "sexual violence" OR "sexual victimization" OR "sexual assault" OR "rape". Forty articles met the eligibility criteria. Overall, SA was found to play a major role in BPD, particularly in women. Childhood sexual abuse (CSA) is an important risk factor for BPD. Adult sexual abuse (ASA) rates are significantly higher in BPD patients compared with other personality disorders (PDs). SA history predicts more severe clinical presentation and poorer prognosis. Suicidality has the strongest evidence, followed by self-mutilation, post-traumatic stress disorder (PTSD), dissociation and chronicity of BPD. Future research should study more ASA and include more males, milder BPD patients and documented or corroborated SA cases. The impact of other traumatic experiences (e.g., emotional abuse) on BPD must also be systematically reviewed.

Heightened Salience of Anger and Aggression in Female Adolescents With Borderline Personality Disorder-A Script-Based fMRI Study

Background: Anger and aggression belong to the core symptoms of borderline personality disorder. Although an early and specific treatment of BPD is highly relevant to prevent chronification, still little is known about anger and aggression and their neural underpinnings in adolescents with BPD.

Method: Twenty female adolescents with BPD (age 15–17 years) and 20 female healthy adolescents (age 15–17 years) took part in this functional magnetic resonance imaging (fMRI) study. A script-driven imagery paradigm was used to induce rejection-based feelings of anger, which was followed by descriptions of self-directed and other-directed aggressive reactions. To investigate the specificity of the neural activation patterns for adolescent patients, results were compared with data from 34 female adults with BPD (age 18–50 years) and 32 female healthy adults (age 18–50 years).

Results: Adolescents with BPD showed increased activations in the left posterior insula and left dorsal striatum as well as in the left inferior frontal cortex and parts of the mentalizing network during the rejection-based anger induction and the imagination of aggressive reactions compared to healthy adolescents. For the other-directed aggression phase, a significant diagnosis by age interaction confirmed that these results were specific for adolescents.

Discussion: The results of this very first fMRI study on anger and aggression in adolescents with BPD suggest an enhanced emotional reactivity to and higher effort in controlling anger and aggression evoked by social rejection at an early developmental stage of the disorder. Since emotion dysregulation is a known mediator for aggression in BPD, the results point to the need of appropriate early interventions for adolescents with BPD.

Complex posttraumatic stress disorder: The need to consolidate a distinct clinical syndrome or to reevaluate features of psychiatric disorders following interpersonal trauma?

Complex posttraumatic stress disorder (Complex PTSD) has been recently proposed as a distinct clinical entity in the WHO International Classification of Diseases, 11^th version, due to be published, two decades after its first initiation. It is described as an enhanced version of the current definition of PTSD, with clinical features of PTSD plus three additional clusters of symptoms namely emotional dysregulation, negative self-cognitions and interpersonal hardship, thus resembling the clinical features commonly encountered in borderline personality disorder (BPD). Complex PTSD is related to complex trauma which is defined by its threatening and entrapping context, generally interpersonal in nature. In this manuscript, we review the current findings related to traumatic events predisposing the above-mentioned disorders as well as the biological correlates surrounding them, along with their clinical features. Furthermore, we suggest that besides the present distinct clinical diagnoses (PTSD; Complex PTSD; BPD), there is a cluster of these comorbid disorders, that follow a continuum of trauma and biological severity on a spectrum of common or similar clinical features and should be treated as such. More studies are needed to confirm or reject this hypothesis, particularly in clinical terms and how they correlate to clinical entities’ biological background, endorsing a shift from the phenomenologically only classification of psychiatric disorders towards a more biologically validated classification.

The aetiology of borderline personality disorder (BPD): contemporary theories and putative mechanisms

This article presents an overview of current knowledge regarding the aetiology of Borderline Personality Disorder (BPD). It begins with a brief synopsis of early research and theory, and discusses how changing conceptualisations of BPD have impacted on our aetiological knowledge. Contemporary theories are described and presented within a developmental psychopathology framework. Deficient co-regulation and social communication in infancy are purported to underpin emotional dysregulation and social cognition deficits across development. These mechanisms are further potentiated by maladaptive social experiences in a series of positive feedback loops. Prospective research provides preliminary evidence for the reciprocal (or mediating) effects of maladaptive experiences and childhood dysregulation. Moving forward, cohort studies may incorporate neurobiological assessments to examine the biological systems underpinning phenotypic (e.g., impulsivity, disturbed relatedness) covariation.

Reflective function mediates the relationship between emotional maltreatment and borderline pathology in adolescents: A preliminary investigation

Deficits in mentalizing, particularly within the context of attachment relationships i.e., reflective function (RF), are posited to result from childhood maltreatment and to influence the development of borderline personality disorder (BPD). Whilst a mentalization-based model of BPD provides a theoretical explanation, direct empirical support for this model, in linking childhood maltreatment to borderline pathology remains limited. This study examined the interrrelationships between childhood maltreatment, RF, and borderline pathology in a mixed adolescent sample, consisting of adolescents with BPD (n=26) and a group of non-clinical adolescents (n=25). With the aim of directly testing the mentalization-based model of BPD, we additionally investigated the influence of each form of childhood maltreatment within this developmental pathway. Self-report data supported the hypothesized indirect effect of childhood maltreatment on elevated borderline pathology through lowered RF in adolescents. Both emotional abuse and emotional neglect were found to indirectly influence borderline pathology through adolescent RF, however, only emotional abuse indirectly influenced borderline pathology through RF, after all other maltreatment types were controlled for. Findings support the promotion of mentalization, within attachment-related contexts, as an intervention target for adolescents with borderline pathology and as a potential target of prevention for at-risk children and adolescents with histories of childhood maltreatment, especially emotional abuse. Future research should delineate other underlying mechanisms, independent of RF, which may also link the influence of childhood maltreatment, and in particular, emotional abuse, to BPD.

Sleep Problems in Childhood and Borderline Personality Disorder Symptoms in Early Adolescence

Sleep disorders, such as insomnia and nightmares, are commonly associated with Borderline Personality Disorder (BPD) in adulthood. Whether nightmares and sleep-onset and maintenance problems predate BPD symptoms earlier in development is unknown. We addressed this gap in the literature using data from the Avon Longitudinal Study of Parents and Children (ALSPAC). Participants included 6050 adolescents (51.4 % female) who completed the UK Childhood Interview for DSM-IV BPD at 11 to 12 years of age. Nightmares and sleep onset and maintenance problems were prospectively assessed via mother report when children were 2.5, 3.5, 4.8 and 6.8 years of age. Psychopathological (i.e., emotional temperament; psychiatric diagnoses; and emotional and behavioural problems) and psychosocial (i.e., abuse, maladaptive parenting, and family adversity) confounders were assessed via mother report. In logistic regressions, persistent nightmares (i.e., regular nightmares at 3 or more time-points) were significantly associated with BPD symptoms following adjustment for sleep onset and maintenance problems and all confounders (Adjusted Odds Ratio = 1.62; 95 % Confidence Interval = 1.12 to 2.32). Persistent sleep onset and maintenance problems were not significantly associated with BPD symptoms. In path analysis controlling for all associations between confounders, persistent nightmares independently predicted BPD symptoms (Probit co-efficient [β] = 0.08, p = 0.013). Emotional and behavioural problems significantly mediated the association between nightmares and BPD (β =0.016, p < 0.001), while nightmares significantly mediated associations between emotional temperament (β = 0.001, p = 0.018), abuse (β = 0.015, p = 0.018), maladaptive parenting (β = 0.002, p = 0.021) and subsequent BPD. These findings tentatively support that childhood nightmares may potentially increase the risk of BPD symptoms in early adolescence via a number of aetiological pathways. If replicated, the current findings could have important implications for early intervention, and assist clinicians in the identification of children at risk of developing BPD.

Prevalence and severity of childhood adversity in adolescents with BPD, psychiatrically healthy adolescents, and adults with BPD

OBJECTIVE

Existing research has demonstrated that both adolescents and adults with borderline personality disorder (BPD) report higher rates of childhood adversity than their same-age peers; no studies have examined if adolescents and adults with BPD differ based on the extent of these experiences. In the present study, we compared the prevalence rates and severity of multiple forms of abuse and neglect in adolescents and adults with BPD and in psychiatrically healthy adolescents.

METHODS

Participants included 104 adolescent (aged 13-17 years) inpatients with BPD, 60 age-matched, psychiatrically healthy adolescents, and 290 adult inpatients with BPD. All participants completed an interview that assessed the presence and severity of multiple forms of childhood abuse and neglect.

RESULTS

A significantly higher percentage of adolescents with BPD reported 5 of 12 pathological childhood experiences and described more severe abusive experiences than their psychiatrically healthy peers. In comparison with adolescents with BPD, a significantly higher percentage of adults with BPD reported nearly all forms of childhood adversity and rated these experiences as more severe.

CONCLUSIONS

Taken together, these results suggest that adults with BPD report more severe profiles of abuse and neglect than adolescents with the disorder, even though adolescents with BPD differ from healthy peers. Copyright © 2017 John Wiley & Sons, Ltd.

Identifying a borderline personality disorder prodrome: Implications for community screening

Elucidating early signs and symptoms of borderline personality disorder (BPD) has important implications for screening and identifying youth appropriate for early intervention. The purpose of this study was to identify dimensions of child temperament and psychopathology symptom severity that predict conversion to a positive screen for BPD over a 14-year follow-up period in a large, urban community sample of girls (n = 2 450). Parent and teacher reports of child temperament and psychopathology symptom severity assessed when girls were ages 5-8 years were examined as predictors of new-onset BPD cases when girls were ages 14-22 years. In the final model, parent and teacher ratings of emotionality remained significant predictors of new-onset BPD. Additionally, parent ratings of hyperactivity/impulsivity and depression severity, as well as teacher ratings of inattention severity, were also predictive. Results also revealed that elevations in these dimensions pose a notable increase in risk for conversion to BPD over the follow-up period. Supplementary analyses revealed that with the exception of parent-reported depression severity, these same predictors were associated with increases in BPD symptom severity over the follow-up period. These findings suggest BPD onset in adolescence and early adulthood can be detected from parent and teacher reports of temperament and symptom severity dimensions assessed in childhood. The identification of this prodrome holds promise for advancing early detection of children at risk prior to the development of the full-blown disorder. Copyright © 2017 John Wiley & Sons, Ltd.

Prevalence rates of childhood protective factors in adolescents with BPD, psychiatrically healthy adolescents and adults with BPD

OBJECTIVE

Existing literature on the aetiology of borderline personality disorder (BPD) has primarily focused on pathological childhood experiences, while little to no research has been conducted on protective factors that may serve to ameliorate these symptoms. The current study attempts to fill this gap in the literature by comparing the rates of childhood protective factors among adolescents with BPD, psychiatrically healthy adolescents and adults with BPD.

METHODS

One hundred and four subjects were adolescent inpatients between the ages of 13 and 17 who met Revised Diagnostic Interview for Borderlines and Diagnostic and Statistical Manual of Mental Disorders Fourth Edition criteria for BPD. Sixty were age-matched psychiatrically healthy comparison subjects. Two hundred and ninety subjects were adult inpatients between the ages of 18 and 35 who met Revised Diagnostic Interview for Borderlines and Revised Diagnostic and Statistical Manual of Mental Disorders Third Edition criteria for BPD. All three groups were interviewed by using the Revised Childhood Experiences Questionnaire, a semi-structured interview that assesses pathological and protective childhood experiences.

RESULTS

Psychiatrically healthy adolescents reported significantly higher rates of 4 out of 18 protective factors than adolescents with BPD. Adolescents with BPD reported significantly higher rates of 5 of these 18 protective factors than adults with BPD. Adults with BPD were significantly more likely to endorse having a steady after school or weekend work record than adolescents with BPD.

CONCLUSIONS

Taken together, the results of this study suggest that adolescents meeting criteria for BPD report lower rates of some protective factors than psychiatrically healthy adolescents. They also suggest that they have higher rates of some protective factors than adults with BPD. Copyright © 2017 John Wiley & Sons, Ltd.

Self-reported patterns of impairments in mentalization, attachment, and psychopathology among clinically referred adolescents with and without borderline personality pathology

BACKGROUND

Previous research, which primarily focused on adult samples, suggests that individuals with borderline personality disorder (BPD) display high levels of psychopathology, dysfunctional mentalization and problematic attachment to others. The current study investigated whether impairments in mentalization, attachment, and psychopathology are more severe in outpatient adolescents with BPD than in a clinical comparison group.

METHODS

Consecutive referrals to a child and adolescent psychiatric clinic were clinically assessed with a battery of self-report instruments to assess mentalization, attachment, and psychopathology. Specifically, in regard to BPD a self-report questionnaire was employed to decide if patients were classified into the BPD or the clinical comparison group. The main outcome variables of adolescents with a primary diagnosis of BPD were then compared with those of a clinical comparison group comprising patients receiving psychiatric diagnoses other than BPD.

RESULTS

Relative to the clinical group without BPD, and after controlling for sociodemographic variables, the BPD group displayed poorer mentalizing abilities, more problematic attachments to parents and peers, and higher self-reported levels of psychopathology.

CONCLUSIONS

The results of this study suggest that BPD is a severe mental condition in adolescents and is characterized by poor mentalizing abilities, attachment problems and high levels of psychopathology compared to adolescents with psychiatric disorders other than BPD. Hence, clinicians should consider BPD when conducting diagnostic assessments, and evidence-based treatments for this vulnerable group should be developed.

Aetiological pathways to Borderline Personality Disorder symptoms in early adolescence: childhood dysregulated behaviour, maladaptive parenting and bully victimisation

BACKGROUND

Developmental theories for the aetiology of Borderline Personality Disorder (BPD) suggest that both individual features (e.g., childhood dysregulated behaviour) and negative environmental experiences (e.g., maladaptive parenting, peer victimisation) may lead to the development of BPD symptoms during adolescence. Few prospective studies have examined potential aetiological pathways involving these two factors.

METHOD

We addressed this gap in the literature using data from the Avon Longitudinal Study of Parents and Children (ALSPAC). We assessed mother-reported childhood dysregulated behaviour at 4, 7 and 8 years using the Strengths and Difficulties Questionnaire (SDQ); maladaptive parenting (maternal hitting, punishment, and hostility) at 8 to 9 years; and bully victimisation (child and mother report) at 8, 9 and 10 years. BPD symptoms were assessed at 11 years using the UK Childhood Interview for DSM-IV BPD. Control variables included adolescent depression (assessed with the Short Moods and Feelings Questionnaire-SMFQ) and psychotic symptoms (assessed with the Psychosis-Like Symptoms Interview-PLIKS) at 11 to 14 years, and mother's exposure to family adversity during pregnancy (assessed with the Family Adversity Scale-FAI).

RESULTS

In unadjusted logistic regression analyses, childhood dysregulated behaviour and all environmental risk factors (i.e., family adversity, maladaptive parenting, and bully victimisation) were significantly associated with BPD symptoms at 11 years. Within structural equation modelling controlling for all associations simultaneously, family adversity and male sex significantly predicted dysregulated behaviour across childhood, while bully victimisation significantly predicted BPD, depression, and psychotic symptoms. Children displaying dysregulated behaviour across childhood were significantly more likely to experience maladaptive parenting (β = 0.075, p < 0.001) and bully victimisation (β = 0.327, p < 0.001). Further, there was a significant indirect association between childhood dysregulated behaviour and BPD symptoms via an increased risk of bullying (β = 0.097, p < 0.001). While significant indirect associations between dysregulated behaviour, bully victimisation and depression (β = 0.063, p < 0.001) and psychotic (β = 0.074, p < 0.001) outcomes were also observed, the indirect association was significantly stronger for the BPD outcome (BPD - depression = 0.034, p < 0.01; BPD - psychotic symptoms = 0.023, p < 0.01).

CONCLUSIONS

Childhood dysregulated behaviour is associated with BPD in early adolescence via an increased risk of bully victimisation. This suggests that childhood dysregulation may influence the risk of bully victimisation, which in turn influences the development of BPD. Effective interventions should target dysregulated behaviour early on to reduce exposure to environmental risks and the subsequent development of BPD.

A systematic review of the neurobiological underpinnings of borderline personality disorder (BPD) in childhood and adolescence

Contemporary theories for the aetiology of borderline personality disorder (BPD) take a lifespan approach asserting that inborn biological predisposition is potentiated across development by environmental risk factors. In this review, we present and critically evaluate evidence on the neurobiology of BPD in childhood and adolescence, compare this evidence to the adult literature, and contextualise within a neurodevelopmental framework. A systematic review was conducted to identify studies examining the neurobiological (i.e. genetic, structural neuroimaging, neurophysiological, and neuropsychological) correlates of BPD symptoms in children and adolescents aged 19 years or under. We identified, quality assessed, and narratively summarised 34 studies published between 1980 and June 2016. Similar to findings in adult populations, twin studies indicated moderate to high levels of heritability of BPD, and there was some evidence for gene-environment interactions. Also consistent with adult reports is that some adolescents with BPD demonstrated structural (grey and white matter) alterations in frontolimbic regions and neuropsychological abnormalities (i.e. reduced executive function and disturbances in social cognition). These findings suggest that neurobiological abnormalities observed in adult BPD may not solely be the consequence of chronic morbidity or prolonged medication use. They also provide tentative support for neurodevelopmental theories of BPD by demonstrating that neurobiological markers may be observed from childhood onwards and interact with environmental factors to increase risk of BPD in young populations. Prospective studies with a range of repeated measures are now required to elucidate the temporal unfurling of neurobiological features and further delineate the complex pathways to BPD.

A systematic review of the parenting and outcomes experienced by offspring of mothers with borderline personality pathology: Potential mechanisms and clinical implications

There is growing interest in whether the parenting strategies and offspring outcomes of mothers with borderline personality disorder (BPD) differ from those of mothers without BPD. We searched PsychINFO, PubMed, EMBASE, Web of Science, Scopus and ASSIA databases for studies examining parenting skills and attitudes among mothers with BPD/BPD symptoms and/or offspring outcomes. PRISMA reporting guidelines were followed. Of 10,067 abstracts screened, 101 full-text articles were retrieved and 33 met pre-determined criteria for qualitative synthesis. Overall, studies suggest that mothers with BPD/BPD symptoms are more likely to engage in maladaptive interactions with their offspring characterised by insensitive, overprotective, and hostile parenting compared to mothers without BPD/BPD symptoms. Adverse offspring outcomes include BPD symptoms, internalising (including depression) and externalising problems, insecure attachment patterns, and emotional dysregulation. Findings suggest that vulnerability from mother to offspring may be partly transmitted via maladaptive parenting and maternal emotional dysfunction. Conclusions were limited by study heterogeneity in methodology and construct definitions, as well as a paucity of clinical comparison groups. Prospective studies of mothers with BPD and their offspring from pregnancy onwards may further elucidate mechanisms of transmission and identify resilience factors across development. Parenting behaviour awareness, improving attachment behaviours and emotional regulation strategies may be important intervention targets.

A latent profile analysis of childhood trauma in women with bulimia nervosa: Associations with borderline personality disorder psychopathology

OBJECTIVE

The aim of this study was to empirically examine naturally occurring groups of individuals with bulimia nervosa (BN) based on their childhood trauma (CT) histories and to compare these groups on a clinically relevant external validator, borderline personality disorder (BPD) psychopathology.

METHOD

This study examined the relationship between CT and BPD psychopathology among 133 women with BN using latent profile analysis (LPA) to classify participants based on histories of CT. Participants completed the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I/P), the Diagnostic Interview for Borderlines-Revised (DIB-R), and the Childhood Trauma Questionnaire (CTQ).

RESULTS

The LPA revealed four trauma profiles: low/no trauma, emotional trauma, sexual trauma, and polytrauma. Results indicated that the sexual and polytrauma profiles displayed significantly elevated scores on the DIB-R and that the low/no and emotional trauma profiles did not differ significantly on the DIB-R. Secondary analyses revealed elevated levels of a composite CT score among those with both BN and BPD psychopathology compared to those with BN only.

DISCUSSION

These findings suggest that both childhood sexual abuse and the additive effects of childhood polytrauma may be linked to BPD psychopathology in BN. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:689-694).