ESCAP Expert Article: borderline personality disorder in adolescence: an expert research review with implications for clinical practice

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.

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.

Taking stock to move forward: Where the field of developmental psychopathology might be heading

In this paper, dedicated to Dante Cicchetti's contributions and enduring influence, we explore the prospective directions of developmental psychopathology. Our focus centers on key domains where Cicchetti's significant achievements have continually shaped our evolving thinking about psychological development. These domains include (a) the concepts of equifinality and multifinality, along with the challenges in predicting developmental trajectories, (b) the imperative to integrate wider sociocultural viewpoints into developmental psychopathology frameworks, (c) the interplay of genetic and environmental influences in developmental courses, (d) the significance of mental state language, and (e) the progress, or its absence, in the development of prevention and intervention tactics for children, adolescents, and their caregivers. While many of our forecasts regarding the future of developmental psychopathology may not materialize, we maintain optimistic that the essential ideas presented will influence the research agenda in this field and contribute to its growth over the next fifty years.

The relationship between mood disorders, personality disorder and suicidality in adolescence: does general personality disturbance play a significant role in predicting suicidal behavior?

INTRODUCTION

Current research points to the importance personality pathology and Major Depression e as relevant psycopathological risk factors for understanding suicidal risk in adolescence. Literature has mainly focused on the role of BPD, however current orientations in personality pathological functioning suggest that BPD may be the representative of a general personality disturbance, a factor of vulnerability underlying diverse psychopathological variants and aspects of maladaptive functioning. However, recent studies seem to have neglected the contributions that other specific personality disorders and personality pathology as a general factor of vulnerability for suicidality; and only marginally investigated the interaction of personality disorder (PD) as an overall diagnosis and individual PDs and major depression (MDD). In this paper, the independent and cumulative effects of MDD and DSM-IV PDs on suicidal risk are investigated in a sample of adolescents observed in a longitudinal window of observation ranging from three months preceding the assessment to a six-month follow up period of clinical monitoring.

METHODS

A sample of 118 adolescents (mean age = 15.48 ± 1.14) referred for assessment and treatment on account of suicidal ideation or behavior were administered the CSSRS, SCID II, Kiddie-SADS at admission at inpatient and outpatient Units. All subjects included in the study had reported suicidal ideation or suicide attempts at the C-SSRS; The CSSRS was applied again to all patients who reported further suicidal episodes during the six-months follow-up period of clinical monitoring. Dimensional diagnoses of PDs was obtained by summing the number of criteria met by each subject at SCID-%-PD 5, In order, to test the significance of the associations between the variables chosen as predictors (categorical and dimensional PDs and MD diagnosis), and the suicidal outcomes variables suicide attempts, number of suicide attempts and potential lethality of suicide attempt, non-parametric bivariate correlations, logistic regression models and mixed-effects Poisson regression were performed PD.

RESULTS

The categorical and dimensional diagnosis of PD showed to be a significant risk factors for suicide attempt and their recurrence, independently of BPD, that anyway was confirmed to be a specific significant risk factor for suicidal behaviors. Furthermore, PD assessed at a categorical and dimensional level and Major Depression exert an influence on suicidal behaviors and their lethality both as independent and cumulative risk factors.

LIMITATIONS

Besides incorporating dimensional thinking into our approach to assessing psychopathology, our study still relied on traditionally defined assessment of PD. Future studies should include AMPD-defined personality pathology in adolescence to truly represent dimensional thinking.

CONCLUSION

These results point to the importance of early identification of the level of severity of personality pathology at large and its co-occurrence with Major Depression for the management of suicidal risk in adolescence.

The effectiveness of a day hospital mentalization-based therapy programme for adolescents with borderline personality traits: Findings from Touchstone-Child and Adolescent Mental Health Service

BACKGROUND

Individuals with borderline personality disorder (BPD) are at a substantial risk of harm to themselves and others, experience high levels of functional impairment and typically are high users of tertiary healthcare to address their mental health concerns. As indicators for BPD typically emerge in adolescence, a day therapy service in Bentley, Western Australia, Touchstone Child and Adolescent Mental Health Service (CAMHS), was developed as an intensive intervention for adolescents with indicators for BPD and its associated symptomology. Touchstone utilizes mentalization-based therapy (MBT) in a therapeutic community setting, where the current study sought to document the anecdotal outcomes using the data provided at Touchstone, to enable a greater understanding of this treatment approach for adolescents with indicators for BPD.

METHOD

Forty-six participants attended the Touchstone programme between 2015 and 2020. The programme involved 6 months of MBT (group and individual), occupational therapy, education and creative therapies. Measures of self-injury, mood and emergency department presentations were collected pre- and post-programme.

RESULTS

Results indicate that participants show a reduction in non-suicidal acts and thoughts, as well as a reduction in negative moods and feelings from pre-Touchstone to post-Touchstone. There is also a decrease in participant presentation to tertiary emergency departments for mental health concerns.

CONCLUSIONS

The current study shows evidence for the efficacy of Touchstone as an MBT therapeutic community intervention to reduce symptoms of emerging BPD and effectively reduce presentations to emergency departments for mental health presentations, alleviating pressure on tertiary hospitals and reducing economic impact of adolescents within this demographic.

Sub-threshold or full-syndrome borderline personality disorder in adolescents with recurrent self-harm - distinctly or dimensionally different?

BACKGROUND

Borderline personality disorder (BPD) is a severe mental disorder frequently seen in individuals with recurrent self-harm behaviour. To what extent there are distinguishing characteristics between self-harming adolescents who meet the criteria for a full diagnosis of BPD, a sub-threshold number of BPD criteria and those who don't have BPD, with respect to clinical characteristics, is still uncertain and could have important clinical implications.

METHODS

Data from 103 adolescents with recurrent self-harm behaviour recruited from child and adolescent psychiatric outpatient clinics were collected through clinical interviews and self-reports. Bivariate analyses comparing participants with or without a diagnosis of BPD were performed. Group differences based on the number of BPD criteria fulfilled (few-if-any BPD: 0-2 criteria, sub-threshold BPD: 3-4 criteria, full-syndrome BPD: 5 or more criteria) were tested and regression analyses performed.

RESULTS

Adolescents with a diagnosis of BPD (28.2%) had significantly higher numbers of co-morbid DSM-5 disorders, suicide attempts and self-harm methods. They also reported significantly higher levels of suicidal ideation, depression, anxiety and impulsivity, compared with adolescents without BPD. Adolescents with sub-threshold BPD (20.4%) place themselves in the intermediate position between participants with full-syndrome BPD and participants with few-if-any BPD, in terms of these symptoms. Higher levels of emotional regulation difficulties and a lower level of global functioning were significantly associated with fulfilling a higher number of BPD criteria.

CONCLUSION

Adolescents with recurrent self-harm who meet diagnostic criteria for a full-syndrome BPD or sub-threshold BPD seem to have difficulties within the same spectrum. They seem dimensionally, but not categorically, different with respect to the severity of their difficulties. These adolescents need interventions aimed at their dysfunctional self-harm behaviour, emotional regulation difficulties and BPD symptoms at an earlier, rather than at a later stage of symptom development.

Prevalence and incidence of personality disorders among children and adolescents in Danish mental health services: a nationwide register study

A few epidemiological studies have examined personality disorders (PDs) among children and adolescents in secondary mental health services. This study aims to describe the prevalence and incidence of PDs among children and adolescents who have attended Danish child and adolescent psychiatric services (CAPS). Using register-based data, we studied all patients under the age of 18 years who were admitted to in- and outpatient CAPS (N = 115,121) in Denmark from 2007 to 2017. A total of 4952 patients were diagnosed with a PD during the study period. The mean prevalence was 859 patients per year, and the mean incidence was 274 patients per year, including an increased incidence and prevalence of borderline, anxious, and unspecified PDs over the decade. The number of patients diagnosed with PDs increased from 700 to 851 per year, but the proportion of patients with PDs compared to all psychiatric diagnoses decreased from 4.2% to 2.8% over the study period. The PD population had an older age (14.8 years vs. 11.3 years; p < 0.001), a higher likelihood of being female (74% vs. 44%; p < 0.001), and four times more contacts with the psychiatric emergency departments than other patients with a psychiatric diagnosis. Future studies should focus on (a) implementing further epidemiological studies in different countries; (b) tracking diagnostic practices to facilitate comparisons and provide feedback for training clinicians and raising awareness; and (c) estimating trajectories of PDs, including costs within the CAPS, to facilitate informed decision-making regarding the future organization and provision of services to these children, adolescents, and their families.

The Influence of Family Intervention on the Treatment of Adolescent Patients With Borderline Personality Disorder: A Literature Review

Borderline personality disorder (BPD) is a widespread mental disorder linked to functional impairment and a high suicide rate. Adolescent BPD is now recognized as a reliable and valid diagnosis in psychiatric classification systems and national treatment guidelines. Family issues, such as parental underinvolvement or neglect, may affect the mentalization process and attachment styles. Thus, the family is crucial to understanding the etiology of BPD in adolescents. Family intervention was primarily used as a component of the psychotherapy strategy in the current treatment of BPD, including pharmacological and psychotherapy measures. The primary objective of this study is to review previous research on the effectiveness of family intervention in treating adolescents with BPD. Although there is currently little data, studies in this paper show that family intervention is a realistic treatment option for adolescents with BPD.

Alternation in functional connectivity within default mode network after psychodynamic psychotherapy in borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is characterized by impairments in emotion regulation, impulse control, and interpersonal and social functioning along with a deficit in emotional awareness and empathy. In this study, we investigated whether functional connectivity (FC) within the default mode network (DMN) is affected by 1-year psychodynamic psychotherapy in patients with BPD.

METHODS

Nine BPD patients filled out the demography, Interpersonal Reactive Index (IRI), Toronto Alexithymia Scale 20 (TAS 20), the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), and the Borderline Evaluation Severity over Time (BEST) questionnaire. The BPD group (9F) and the control group (9F) had a mean ± SD age of 28.2 ± 5.3 years and 30.4 ± 6.1 years, respectively. BPD subjects underwent longitudinal resting-state fMRI before psychodynamic psychotherapy and then every 4 months for a year after initiating psychotherapy. FC in DMN was characterized by calculating the nodal degree, a measure of centrality in the graph theory.

RESULTS

The results indicated that patients with BPD present with aberrant DMN connectivity compared to healthy controls. Over a year of psychotherapy, the patients with BPD showed both FC changes (decreasing nodal degree in the dorsal anterior cingulate cortex and increasing in other cingulate cortex regions) and behavioral improvement in their symptoms and substance use. There was also a significant positive association between the decreased nodal degree in regions of the dorsal cingulate cortex and a decrease in the score of the TAS-20 indicating difficulty in identifying feelings after psychotherapy.

CONCLUSION

In BPD, there is altered FC within the DMN and disruption in self-processing and emotion regulation. Psychotherapy may modify the DMN connectivity and that modification is associated with positive changes in BPD emotional symptoms.

The diagnosis that should speak its name: why it is ethically right to diagnose and treat personality disorder during adolescence

Although national guidelines explicitly state that personality disorder can be diagnosed and treated in young people aged 12 to 18 years (adolescents), most clinicians remain hesitant. This creates a gap between science and practice, which we argue is largely motivated by moral reasons and, therefore, is best challenged by ethical arguments. We provide seven arguments in support of the notion that it is ethically right to diagnose and treat personality disorder when it occurs in adolescents. Central to these arguments is the scientific evidence that features of personality disorder are among the best predictors of a complex cluster of psychopathology leading to impairments in many areas of current and future mental, social and vocational functioning. We argue that intervention during adolescence and young adulthood is not only humane, but also critical for efforts to avert the longstanding psychosocial and health problems that seem refractory to treatment in adults with personality disorder. Moreover, we argue that regular services are often inadequately equipped to meet the needs of young people with personality disorder and that the common 'stepped-care' approach should be replaced by a 'staged-care' approach. Finally, we argue that early detection and intervention might have anti-stigmatizing effects, similar to other areas of healthcare in which stigmatizing labels have changed meaning when the conditions to which they refer have become more amenable to treatment.

A systematic review and meta-analysis of digital interventions targeted at individuals with borderline personality disorder (BPD), emotionally unstable personality disorder (EUPD), and related symptoms

OBJECTIVES

The present review investigates the impact of digital interventions for individuals with features of borderline personality disorder (BPD)/emotional unstable personality disorder (EUPD) as digital interventions show promise as therapeutic tools in underserved groups. BPD/EUPD features are identified as clinically relevant, yet previous reviews on the use of digital interventions fail to include subthreshold symptomatology.

METHODS

Five online databases were searched for terminology in three categories: BPD/EUPD and related symptoms, mental-health interventions, and digital technology. Additionally, four relevant journals and two trial registers were searched for additional papers meeting the inclusion criteria.

RESULTS

Twelve articles met all inclusion criteria. Meta-analyses revealed statistically significant differences in symptom measures between intervention and control groups at postintervention and decreases in BPD/EUPD symptomatology and well-being from pre- to postintervention. Service users' engagement, satisfaction, and acceptability of interventions were high. Results support the previous literature on the value of using digital interventions in populations with BPD/EUPD.

CONCLUSION

Overall, it was identified that digital interventions show promise for successful implementation with this population.

Drop-out and ineffective treatment in youth with severe and enduring mental health problems: a systematic review

Youth with severe and enduring mental health problems (SEMHP) tend to drop out of treatment or insufficiently profit from treatment in child and adolescent psychiatry (CAP). Knowledge about factors related to treatment failure in this group is scarce. Therefore, the aim of this systematic review was to thematically explore factors associated with dropout and ineffective treatment among youth with SEMHP. After including 36 studies, a descriptive thematic analysis was conducted. Themes were divided into three main categories: client, treatment, and organizational factors. The strongest evidence was found for the association between treatment failure and the following subthemes: type of treatment, engagement, transparency and communication, goodness of fit and, perspective of practitioner. However, most other themes showed limited evidence and little research has been done on organizational factors. To prevent treatment failure, attention should be paid to a good match between youth and both the treatment and the practitioner. Practitioners need to be aware of their own perceptions of youth's perspectives, and transparent communication with youth contributes to regaining their trust.

Diagnose- und Behandlungsbereitschaft der Borderline-Persönlichkeitsstörung im Jugendalter unter Therapierenden

Zusammenfassung: Theoretischer Hintergrund: Eine eingeschränkte Diagnosebereitschaft der Borderline-Persönlichkeitsstörung (BPS) im Jugendalter verhindert möglicherweise deren Früherkennung und -behandlung. Fragestellung: Die Studie zielt auf eine Quantifizierung von Diagnose- und Behandlungsbereitschaft der BPS im Jugendalter bei kinder- und jugend-/psychotherapeutischen/-psychiatrischen Therapierenden ab. Methode: Die Studie basiert auf einer Onlinebefragung von 207 Therapierenden. Ergebnisse: 32 % der Therapierenden würden ab dem 14. Lebensjahr, 56 % ab der Volljährigkeit und 12 % gar keine Diagnose einer BPS vergeben. Die Vorbehalte „mangelnde Stabilität der Persönlichkeit“ und „Sorge um Pathologisierung“ waren mit geringer Diagnosebereitschaft assoziiert. Insgesamt sind 72 % der Therapierenden bereit, Jugendliche mit BPS-Symptomatik zu behandeln. Diskussion und Schlussfolgerung: Mixed-Methods Ansätze könnten die Diskrepanz zwischen der Diagnose- und Behandlungsbereitschaft aufklären.

Persönlichkeitsstörung im Jugendalter

Zusammenfassung: Die kategoriale Klassifikation der Persönlichkeitsstörungen (PS) wurde im letzten Jahrzehnt durch eine „Perspektive der Lebensspanne“ mit zunehmend dimensionaler Sichtweise abgelöst. Für den Kinder- und Jugendbereich ist maßgeblich, dass die PS als Ergebnis dieses Prozesses als Erkrankungen angesehen werden, welche die gesamte Lebensspanne betreffen können. Diese Neuerung bereitet den Weg zu einer möglichen Frühbehandlung und ggf. sogar Prävention der PS bei Kindern und Jugendlichen. Im klinischen Alltag jedoch wird die Vergabe von PS in dieser Altersgruppe bis heute oft als kritisch angesehen. Das Themenheft möchte einen Beitrag zur Aufklärung über PS im Jugendalter leisten. Ziel ist es, dass die Vergabe von PS nicht als eine Stigmatisierung junger Menschen angesehen wird, sondern vielmehr als Chance schwerwiegende Entwicklungsverläufe früh zu erkennen und zielgerichtet zu verhindern oder zu behandeln. Der Fokus der Beiträge des Themenheftes liegt dabei auf der Borderline-Persönlichkeitsstörung (BPS) im Jugendalter.

Prädiktion von Behandlungsabbrüchen bei Adoleszenten mit Borderline-Persönlichkeitsstörung

Zusammenfassung: Theoretischer Hintergrund: Die Borderline-Persönlichkeitsstöurng (BPS) kann bereits in der Adoleszenz zuverlässig diagnostiziert und wirksam behandelt werden. Eine möglichst frühe Behandlung der BPS durch störungsspezifische Therapien (z. B. Dialektisch-Behaviorale Therapie), erscheint ist sinnvoll, weil hierdurch selbstschädigende Verhaltensweisen und chronische Verläufe mit häufigen suizidalen Krisen verhindert und die langfristige psychosoziale Entwicklung verbessert werden kann. Mehrere Therapiestudien zur Wirksamkeit der Behandlung in der Adoleszenz zeigten sehr hohe Abbruchraten (bis zu 75 %), bisher sind allerdings nur wenig konsistente Ergebnisse zur Prädiktion von Therapieabbrüchen vorhanden. Fragestellung: Das Hauptziel der vorliegenden Studie war daher im Rahmen einer Beobachtungsstudie a) die Abbruchrate in der Realversorgung und b) die möglichen Prädiktoren (klinische und demographische Variablen) des Abbruchs einer stationären Behandlung mit DBT für Adoleszente an N = 172 Patient_innen im Alter von 15 – 18 Jahren zu untersuchen. Methode: In einer logistischen Regression wurden 18 Prädiktoren (u. a. Alter, Anzahl der Diagnosen, Schwere der Symptomatik) in SPSS untersucht, die im Rahmen einer drei monatigen stationären Behandlung in der Routineversorgung erhoben wurden. Ergebnisse: Lediglich ein jüngeres Alter der Patient_innen war statistisch signifikant mit einem erhöhten Risiko für einen Therapieabbruch assoziiert. Keine statistisch bedeutsamen Zusammenhänge mit einem Therapieabbruch fanden sich hingegen für die untersuchten psychiatrischen Komorbiditäten (bspw. für das Vorliegen einer Essstörung), für die Schwere der BPS-spezifischen Psychopathologie und für BPS-typische problematische Verhaltensweisen (bspw. selbstschädigendes Verhalten oder Hochrisikoverhalten). Diskussion und Schlussfolgerung: Unsere Untersuchung ergibt keinen Anhalt dafür, dass bei stark ausgeprägter Symptombelastung eine erhöhte Gefahr für einen Abbruch einer Behandlung mit DBT besteht. Sollte das Ergebnis einer erhöhten Abbruchrate bei jüngeren Jugendlichen in weiteren Studien repliziert werden, wären systematische Untersuchungen zu Variablen notwendig, die bei jüngeren Jugendlichen eine besondere Bedeutung besitzen und mit einem Therapieabbruch in Zusammenhang stehen könnten (bspw. die Beziehung zu wichtigen Bezugspersonen). Hieraus ließen sich ggf. gezielte Therapiemodifikationen ableiten, die Therapieabbrüchen entgegenwirken.

[Borderline personality disorder in young adults: features of psychopathology and patterns of course]

OBJECTIVE

To identify the psychopathological features of borderline personality disorder (BPD) in adolescence, determine the trajectory of its further course, and develop criteria for differential diagnosis.

MATERIAL AND METHODS

Clinical/psychopathological and psychometric methods were used to study 143 patients. The patients were divided into two groups: a clinical group - 73 patients, who were inpatients or outpatients in the clinical departments of the Mental Health Research Center (MHRC) in 2019-2022, and a follow-up group - 70 patients who were inpatients or outpatients in the MHRC clinic in 2006-2010.

RESULTS

The structure of BPD in adolescence was clinically heterogeneous, which allowed distinguishing three typological varieties: with phenomena of «affective storm», which was characterized by the dominance of affective disorders, including after completion of adolescence, with some stabilization of personality structure (type I); with the dominance of addictive patterns of the type of «adrenalinomania», in which one of the key positions was occupied by craving impairments, with a constant need to search for new extreme hobbies, the use of psychoactive substances, which persisted after the end of adolescence (type II); with the predominance of «cognitive dissociation», which was characterized by the most polymorphic picture of disorders, with the predominance of self-identification disorders with dissociative disorders that retain their severity after the end of adolescence (type III). An integrative assessment of outcomes showed that rather favorable results (47.37%) (χ²=23.37, p=0.001) prevailed at type I, type II was characterized by rather unfavorable (59.26%) and unfavorable results (22.22%) (χ²=12.75, p=0.013) and type III by rather unfavorable (79.17%) and unfavorable (8.33%) outcomes (χ²=16.75, p=0.002). In the nosological evaluation of the follow-up group, 80.0% of patients were diagnosed with BPD, in the rest of the patients there was a change in diagnosis: in 14.3% for schizotypal disorder, in 5.7% for an attack-like form of schizophrenia (χ²=13.8, p=0.008; χ²=14.5, p=0.006).

CONCLUSION

BPD in adolescence was confirmed in the majority of cases in adulthood. The results confirm that the typological variants of BPD are of prognostic value and can serve to further develop therapeutic and socio-rehabilitation measures.

Die Borderline-Persönlichkeitsstörung im Jugendalter

Zusammenfassung: Die Borderline-Persönlichkeitsstörung (BPS) ist eine schwere psychische Erkrankung, die durch hohe Morbidität und Mortalität gekennzeichnet ist sowie mit einem niedrigen psychosozialen Funktionsniveau einhergeht. Die BPS zeigt sich oft mit Beginn der frühen Adoleszenz (ab dem 12. Lebensjahr). Neben repetitiver Selbstverletzung und Suizidalität bestehen häufig sowohl Symptome internalisierender (Depression und Angst) als auch externalisierender Störungen (Hyperaktivität und Substanzkonsum). Daher kommt einer differentialdiagnostischen Abklärung und der Diagnosestellung mit dem Ziel der Frühintervention im klinischen Alltag eine besondere Rolle zu. Die Psychotherapie stellt bei der BPS eine äußerst wirksame Behandlungsmethode dar, Belege für die Wirksamkeit von pharmakologischen Intervention fehlen. Der Schlüssel zu einer Verbesserung der Versorgung für Jugendliche mit BPS liegt in einer Generierung von Wissen zu Vorläufersymptomen sowie einer evidenzbasierten, stadienspezifischen Behandlung (frühe Behandlung bereits subklinischer BPS mit Behandlungsintensität abgestuft nach dem Schweregrad). Dieser Übersichtsartikel beleuchtet den aktuellen Stand der Forschung und gibt Empfehlungen für die therapeutische Arbeit in der klinischen Praxis.

The Effects of Childhood Emotional and Physical Maltreatment on Adolescents' Disordered Eating Behaviors: The Mediating Role of Borderline Personality Features

Over time, a complex crossroad between disordered eating behaviors (DEBs) and borderline personality features (BPFs) and their association with childhood emotional and physical maltreatment have been established. The present study aimed at evaluating the direct and indirect effect of physical and emotional abuse and neglect on DEB via BPF in a nonclinical adolescent sample. A total of 786 adolescents (48.3% male; mean age, 16.25 years; SD, 1.76) participated in the study. The mediation model suggested the pivotal predictive role of emotional maltreatment compared with the physical one. Indeed, both emotional abuse and neglect directly and indirectly predicted disordered eating via BPF ( β = 0.097; p < 0.001 and β = 0.042; p < 0.01, respectively). Likely, the emotional maltreatment represents the beginning of a developmental cascade that culminates in DEB as a maladaptive coping strategy in response to negative emotions, through BPF. On the contrary, physical maltreatment seems to be less involved in the developmental cascade.

Smartphone-assisted guided self-help cognitive behavioral therapy for young people with distressing voices (SmartVoices): study protocol for a randomized controlled trial

Background

The long-standing view that auditory verbal hallucinations (AVH) or hearing voices is a sign of schizophrenia has been challenged by research demonstrating that they lie on a continuum ranging from normal to pathological experience related to distress and need for care. Hearing voices is more prevalent in adolescence than in later life, and hearing voices during adolescence indicates a risk for severe psychopathology, functional impairments, and suicide later in life. While there is increasing evidence for the efficacy of cognitive behavioral therapy for voices (CBTv) in adults with schizophrenia, research on psychological treatments for youth with distressing voices has been scarce. The aim of the current study is to examine the efficacy of CBTv, delivered using smartphone-based Ecological Momentary Assessment Intervention (EMI) in a transdiagnostic sample of youth.

Methods

This is a superiority randomized controlled trial comparing 8 weeks of CBTv-based EMI in addition to treatment as usual (TAU) versus TAU only. TAU covers both no treatment and any form of psychiatric/psychological treatment. In the EMI condition, participants will be prompted twice a day to complete an EMA survey, and receive one intervention proposal per assessment. One-hundred fifty-four youth aged 14–25 years with distressing voices will be recruited from psychiatric clinics, local private practices, internet forums, and advertisements in print and social media. Before and after the intervention phase, participants will undergo a 9-day EMA. Single-blinded assessments will be conducted at baseline (T0) and at 3-month (T1) and 6-month (T2) follow-up. The primary outcome is the distress dimension of the Auditory Hallucinations subscale of the Psychotic Symptom Rating Scales at T1. Secondary outcomes include perceived hostile intention, power, and dominance of voices, passive, aggressive, and assertive relating to voices, and negative core beliefs about the self.

Discussion

Adolescence provides a crucial window of opportunity for early intervention for hearing voices. However, youth are notoriously reluctant help-seekers. This study offers a low-intensity psychological intervention for youth with distressing voices beyond diagnostic boundaries that, using a mobile technology approach, may match the treatment preferences of the generation of “digital natives.”

Trial registration

German Clinical Trials Register DRKS00026243. Registered on 2 September 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06846-0.

[Prevention of mental health disorders in primary care: Pregnancy in adolescence]

Adolescent pregnancy is generally an unwanted pregnancy, a situation that involves significant biological, psychological and social overloads, with repercussions on the health of the mother and the child. But the psychosocially important fact is that an unwanted pregnancy in its entirety gives rise to the birth of an ambivalently wanted child, a high-risk child. Those born in Spain in 2020 to women under 20 years of age were 8,305, which corresponds to 1.97% of all births. This review presents measures and recommendations for the protection and prevention of the mental health of the mother and child when pregnancy takes place in adolescence.

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

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

A bifactor model of personality organization in adolescence: the validity of a brief screening measure assessing severity and core domains of functioning

BACKGROUND

Both the latest edition of the DSM-5 as well as the new ICD-11 have established a new focus in the diagnosis of personality disorders: the assessment of personality functioning. This recent shift in focus converges with long-standing psychodynamic conceptualizations of personality pathology, particularly Kernberg's object relations model. Although a significant amount of research supports these models in adults, much less is known about the validity of these frameworks in youth. Considering the paucity of brief measures of personality functioning in adolescents, the current study aimed to develop and investigate the validity of the Inventory of Personality Organization for Adolescents-Short Form, a theoretically-informed measure assessing severity and core domains of functioning in adolescents.

METHODS

A total sample of N = 525 adolescents aged 13 to 19 years were recruited through a community University-Health Psychology Clinic as current patients (n = 94) or who responded to an online research call (n = 431).

RESULTS

Results indicate that a bifactor model provided the best fit to the data and consisted of a general factor reflecting core self-other functioning and three specific factors, representing additional dimensions of personality organization.

CONCLUSIONS

A brief 15-item version of the IPO-A was successfully derived for time-efficient screening of personality pathology in youth. Similarities with the ICD-11 framework are discussed.

Impulsivity and Emotional Dysregulation Predict Choice Behavior During a Mixed-Strategy Game in Adolescents With Borderline Personality Disorder

Impulsivity and emotional dysregulation are two core features of borderline personality disorder (BPD), and the neural mechanisms recruited during mixed-strategy interactions overlap with frontolimbic networks that have been implicated in BPD. We investigated strategic choice patterns during the classic two-player game, Matching Pennies, where the most efficient strategy is to choose each option randomly from trial-to-trial to avoid exploitation by one’s opponent. Twenty-seven female adolescents with BPD (mean age: 16 years) and twenty-seven age-matched female controls (mean age: 16 years) participated in an experiment that explored the relationship between strategic choice behavior and impulsivity in both groups and emotional dysregulation in BPD. Relative to controls, BPD participants showed marginally fewer reinforcement learning biases, particularly decreased lose-shift biases, increased variability in reaction times (coefficient of variation; CV), and a greater percentage of anticipatory decisions. A subset of BPD participants with high levels of impulsivity showed higher overall reward rates, and greater modulation of reaction times by outcome, particularly following loss trials, relative to control and BPD participants with lower levels of impulsivity. Additionally, BPD participants with higher levels of emotional dysregulation showed marginally increased reward rate and increased entropy in choice patterns. Together, our preliminary results suggest that impulsivity and emotional dysregulation may contribute to variability in mixed-strategy decision-making in female adolescents with BPD.

Is age of self-harm onset associated with increased frequency of non-suicidal self-injury and suicide attempts in adolescent outpatients?

BACKGROUND

Self-harm in adolescents is an increasing public health concern and an important risk factor for suicide. We aimed to examine how age of self-harm onset in adolescents was associated with frequency of subsequent suicidal and non-suicidal self-harm (NSSI) episodes, and how age of onset and duration of self-harm may influence the frequency of self-harm.

METHODS

Data from 103 adolescents with recurrent self-harm recruited from child and adolescent psychiatric outpatient clinics were collected through clinical interviews and self-reports, and analysed with negative binomial and hurdle models.

RESULTS

A lower age of self-harm onset and a longer duration of self-harm were both significantly associated with increased frequency of subsequent episodes of NSSI and risk of a first suicide attempt. There was an increase in repeated suicide attempts when the age of onset of self-harm decreased and the duration increased, and dramatically more for long duration of NSSI before first suicide attempt.

CONCLUSION

Initiating self-harm behaviour at the youngest age had the highest risk of increased frequency of NSSI and suicide attempts. Longer duration of self-harm behaviour increased this risk. This underlines the importance of early identification of self-harm behaviour in adolescents, and the use of effective interventions.

Perceived Parenting and Borderline Personality Features during Adolescence

This study investigates the associations between perceived parenting and borderline personality disorder (BPD) in adolescents. The relations between components of parenting and BPD features were explored. Participants (N = 270; mean age = 15.3) assessed their own BPD features (Personality Assessment Inventory) and both of their parents' parenting practices (Parents as Social Context Questionnaire; Perceived Parental Autonomy Support Scale). SEM results suggest that controlling, rejecting and chaotic parenting all predicted global BPD, and all these parenting components were significantly associated with at least one BPD feature. Chaotic parenting, a relatively neglected construct in the BPD literature, seems to play an important role in early BPD.

Psychometric Properties of a Cultural Adapted Version of the Assessment of Identity Development in Adolescence in Panama

The Assessment of Identity Development in Adolescence (AIDA) is a self-report instrument to detect pathological development of Identity. In Panamá, psychometric instruments for assessment of psychopathology in adolescence are lacking. Our aim was to develop a valid and reliable version of the AIDA Inventory for Panamanian Population. AIDA was adapted to Spanish considering cultural aspects of Panamanian population. Two pilot tests were performed prior to main test to assess item-total correlation at subscale, primary scale and total scale levels and internal consistency at subscale level. A mixed sample of students and PD patients (N = 315) completed the AIDA inventory, the "Strength and Difficulties Questionnaire" and "Defense Style Questionnaire-40." AIDA was retested in a sub sample from school population (n = 98). The Structured Clinical Interview for Axis II Disorders was used for diagnosis of personality disorders in the patient sample (n = 25). Psychometric properties were tested to assess internal consistency, reliability, factorial validity, convergent validity, and criterion validity. AIDA Panama showed excellent internal consistency for the total scale Identity Diffusion with Cronbach's α:0.94 and a retest reliability of 0.84. A Bifactorial CFA was modeled to assess the dimensionality of the inventory. The proportion between OmegaH and Omega at total scales 96% of the variance is explained by a general factor. Furthermore, the Explained Common Variance for the General Factor is 73% supporting unidimensionality. In line with theory, AIDA total scale showed a high positive correlation (r = 0.67) with Total Difficulties scale and high positive correlation (r = 0.71) with Immature Defense scale. The AIDA total score differed highly significant (p = 0.000) between the patient sample and the students with a large effect size (d = 1.02).

CONCLUSION

The adaptation and validation of AIDA for Panamanian adolescent population was successful with good psychometric properties and significant correlations with related psychopathological constructs. AIDA showed high clinical validity by providing a valid discrimination between the school sample and a diagnosed PD sample, in line with the assumption that impaired identity functioning is at the core of personality disorders, especially in adolescence.

Borderline Personality Disorder: Risk Factors and Early Detection

Personality disorders (PDs) exert a great toll on health resources, and this is especially true for borderline personality disorder (BPD). As all PDs, BPD arises during adolescence or young adulthood. It is therefore important to detect the presence of this PD in its earlier stages in order to initiate appropriate treatment, thus ameliorating the prognosis of this condition. This review aims to highlight the issues associated with BPD diagnosis in order to promote its early detection and treatment. To do so, we conducted a search on PubMed database of current evidence regarding BPD early diagnosis, focusing on risk factors, which represent important conditions to assess during young patient evaluation, and on diagnostic tools that can help the clinician in the assessment process. Our findings show how several risk factors, both environmental and genetic/neurobiological, can contribute to the onset of BPD and help identify at-risk patients who need careful monitoring. They also highlight the importance of a careful clinical evaluation aided by psychometric tests. Overall, the evidence gathered confirms the complexity of BDP early detection and its crucial importance for the outcome of this condition.

Borderline personality disorder and adolescent suicide attempt: the mediating role of emotional dysregulation

BACKGROUND

Emotional dysregulation seems to be a core feature of Borderline Personality Disorders (BPD). In addition, recent research in the adolescent population has shown that suicidal behaviours have been associated with maladaptive strategies of emotion regulation.

METHODS

This study examined the relative contributions of emotional dysregulation to suicide attempt history in a clinical sample of borderline adolescents. Data were analyzed from 85 participants of the Collaborative European Research Network on Borderline Personality Disorder. Participants completed measures of BPD traits and symptoms, suicide behaviours, emotional dysregulation, attachment styles and lifetime depressive disorders.

RESULTS

In an SEM model, lifetime depressive disorders and insecure attachment styles have a significant direct effect on lifetime suicide attempt, but only lifetime depressive disorders have an indirect effect through emotion dysregulation. The results suggest that emotional dysregulation has a mediating role in suicide attempts among BPD adolescents.

CONCLUSIONS

These findings call for the development of interventions targeting the role of emotion dysregulation in effectively predicting and preventing suicidality in borderline adolescents.

Movement Synchrony in the Psychotherapy of Adolescents With Borderline Personality Pathology - A Dyadic Trait Marker for Resilience?

Movement synchrony describes the coordination of body movements. In psychotherapy, higher movement synchrony between therapist and patient has been associated with higher levels of empathy, therapeutic alliance, better therapy outcome, and fewer drop-outs. The current study investigated movement synchrony during the psychotherapeutic treatment of female adolescents with borderline personality disorder. It was hypothesized that there are higher levels of movement synchrony in the analyzed therapy sessions compared to pseudo-interactions. Further, we tested whether higher levels of movement synchrony correlate with stronger patients' symptom reduction and whether higher movement synchrony predicts higher post-session ratings. A total of 356 sessions from 16 completed psychotherapies of adolescent patients with BPD were analyzed. Movement synchrony was assessed with motion energy analysis and an index of synchrony was calculated by lagged cross-correlation analysis. As hypothesized, the findings support higher levels of movement synchrony in therapy sessions compared to pseudo-interactions (Cohen's d = 0.85). Additionally, a correlation of movement synchrony with better therapy outcome was found (standardized beta = -0.43 indicating stronger personality functioning impairment reduction). The post-session ratings were negatively associated with higher levels of movement synchrony (standardized beta = -0.1). The relevance of movement synchrony and potential implications for clinical practice are discussed.

Treatment Refractory Internalizing Behaviour Across Disorders: An Aetiological Model for Severe Emotion Dysregulation in Adolescence

Auto-aggressive behaviour, especially treatment refractory suicidality in adolescents with psychiatric disorders, may be challenging to clinicians. In search of therapeutic possibilities, we have integrated current opinions regarding causality and interdependency of suicidality and auto-aggressive behaviour across disorders within the HiTOP framework. We propose a developmental model regarding these unsettling behaviours in youths that may help to guide future directions for research and interventions. We argue that the interdependent development of biologic factors, attachment, moral reasoning and emotion regulation in an overprotective environment may lead to social anxiety and later during development to emotion dysregulation and severe internalizing behaviour disorders. To optimize treatment efficacy for both internalizing and externalizing behaviour, we emphasize the importance transdiagnostic interventions, such as addressing non-compliance, restoration of trust between parents and their child, and limitation of avoidance behaviour. These may be seen as higher order interventions within the HiTOP framework.

Refinement of the Reflective Function Questionnaire for Youth (RFQY) Scale B Using Item Response Theory

We conducted item response theory analyses to refine the Reflective Function Questionnaire for Youth (RFQY) Scale B. Data from a non-clinical sample of young people (n = 737; aged 18-25 years) was used to derive a shortened version of the RFQY. Results were replicated in a clinical sample of inpatient adolescents (n = 467; aged 12-17 year), resulting in a five-item measure, thereafter named the RFQY-5. The RFQY-5 item set was then scrutinized for construct validity against the original 23-item RFQY item set in a randomly selected sample of 100 inpatient adolescents not included in the item response theory replication, and 186 healthy adolescents drawn from the community. Results showed that the RFQY-5 performed similarly as the long version in terms of associations with criterion variables, and outperformed the longer version in discriminating between inpatient and community-dwelling adolescents who differed in their levels of borderline traits. The study provides evidence in support of the use of the RFQY-5 in research and clinical settings.

Heterogeneity of borderline personality disorder symptoms in help-seeking adolescents

BACKGROUND

The heterogeneous presentation of borderline personality disorder (BPD) represents a clinical challenge. There is an ongoing scientific debate whether the heterogeneity can best be understood in terms of qualitative (categorical) or quantitative (dimensional) differences between individuals. The present study examined the latent structure of BPD in adolescents.

METHODS

Five-hundred and six outpatients aged 12 to 17 years with risk-taking and/or self-harming behavior were assessed at baseline and one-year follow-up. Latent class analysis (corresponding with the categorical approach), factor analysis (corresponding with the dimensional approach), and factor mixture models (allowing for both categorical and dimensional aspects) were applied to the DSM-IV BPD criteria.

RESULTS

The best fitting model distinguished between a majority class with high probabilities for all BPD criteria ("borderline group") and a minority class with high probabilities for the impulsivity and anger criteria only ("impulsive group"). Sex significantly affected latent class membership, and both a latent factor and age explained within-class variability. The borderline group primarily consisted of females, frequently reported adverse childhood experiences, scored high on the emotion dysregulation and inhibitedness personality traits, and was associated with internalizing psychopathology. In contrast, the impulsive group primarily consisted of males, scored high on the dissocial behavior personality trait, and was associated with externalizing psychopathology. After one year, the two groups showed similar clinical improvement.

CONCLUSIONS

The study provides evidence for two distinct subgroups of adolescents with BPD features that resemble the subtypes of the ICD-10 emotionally unstable personality disorder. More research is needed to further investigate the diagnostic stability of the two groups over time and potential differential treatment indications.

Explicit and Implicit Measures of Identity Diffusion in Adolescent Girls With Borderline Personality Disorder

The present study is the first to examine both the implicit and explicit self-concept of identity diffusion in a sample of adolescent patients with borderline personality disorder (BPD). A clinical sample of adolescent girls with diagnosed BPD (N = 30; M age = 15.9 years) and a sample of girls with a healthy personality development (N = 33; M age = 16.6 years) completed an implicit association test (IAT) that was adjusted to identity diffusion, the core of BPD. Common domains of child and adolescent psychopathology and core components of BPD were assessed using self-reports on the Strengths and Difficulties Questionnaire (SDQ), the Borderline Personality Features Scale for Children-11 (BPFSC-11) and the Assessment of Identity Development in Adolescence (AIDA). BPD patients scored significantly higher on explicit measures of borderline pathology than girls with a healthy personality development. A crucial finding for this study was that girls with BPD had a significantly lower implicit preference for stability than their counterparts in the control group. Moreover, explicit measures of borderline personality pathology were significantly correlated with an implicit measure of identity diffusion, the core of BPD. However, when looking at the predictive ability of implicit and explicit measures, only explicit identity diffusion was significantly associated with borderline features. Our data suggests that adolescent girls with BPD differ from healthy individuals not only in their conscious representation but also in their implicit representation of the self with regard to BPD related characteristics, which further advances the need for the identification of at-risk adolescents.

Identity Diffusion as the Organizing Principle of Borderline Personality Traits in Adolescents-A Non-clinical Study

Growing evidence shows that diagnosing and treating borderline personality disorder (BPD) is of high relevance for affected youths. Although identity crisis is part of the normative developmental process, identity diffusion is a potential candidate for being an appropriate concept in further developing screening tools and interventions for BPD treatment in adolescence. We hypothesized that severity of borderline traits (as indicated by the strength of their associations with identity diffusion) would be negatively associated with non-clinical adolescents' endorsement of borderline features' presence. We also hypothesized that identity diffusion had a central role in the network of borderline personality traits and could be conceived of as a latent organizing principle of borderline personality disorder. In our study, 169 non-clinical adolescents (81 girls and 88 boys; M _age = 15.38; SD_age = 1.52) filled out self-report measures of borderline personality features and identity diffusion. According to our results, having strong feelings and interpersonal sensitivity were the two most endorsed borderline personality features. Borderline personality features were positively correlated with identity diffusion. The more severe a borderline personality feature was, the less relevant it was for non-clinical adolescents. According to a network analysis, identity diffusion was the most central and least redundant element of the network of borderline personality traits. Results are discussed from a clinical point of view, further encouraging professionals to use identity diffusion screening tools to detect BPD in adolescence.

Beyond the tip of the iceberg: A narrative review to identify research gaps on comorbid psychiatric disorders in adolescents with methamphetamine use disorder or chronic methamphetamine use

BACKGROUND

Methamphetamine use disorder (MUD) frequently begins in adolescence, often accompanied by other psychiatric or mental disorders. Up to now, no comprehensive review about MUD and comorbid disorders in adolescents is available. We thus aimed to review the literature on comorbid mental disorders and MUD in adolescents in order to identify future research topics. Method: A PubMed search was conducted in July 2019. Relevant comorbidities were defined as attention-deficit disorder with/without hyperactivity, anxiety disorders, depression, eating disorders, post-traumatic stress disorder, psychosis, borderline personality disorder, conduct disorder and antisocial personality disorder, as well as other substance use disorders. For each comorbidity, we summarized prevalence rates, findings on comorbidity mechanisms, and recommended treatment options, if applicable. Results: Few articles focused on MUD in adolescents. Prevalence rates differed largely between comorbid disorders, with tobacco use disorder, conduct disorder, post-traumatic stress disorder, anxiety disorders, and attention-deficit disorders being the most prevalent comorbidities while eating disorders were rare. Examined onset patterns and comorbidity mechanisms indicated three groups of comorbidities: preexisting disorders self-medicated with methamphetamine, disorders induced by chronic methamphetamine use, and disorders arising due to risk factors shared with MUD. Reviewed comorbidities were frequently associated with worse treatment outcomes. Conclusions: The limited evidence is in stark contrast to the presumably high prevalence and relevance of comorbid mental disorders in adolescents with MUD. Suggestions for future research topics, informed by adult findings, include genetic vulnerabilities, biological changes, and consequences of different use patterns. Surprisingly few MUD treatment programs explicitly integrate comorbid mental disorder modules.

[The classification of personality disorders in ICD-11]

The classification of personality disorders in ICD-11 Abstract. In ICD-11, the classification of personality disorders (PD) is no longer categorical but dimensional, along a spectrum defined by the severity of the disorder. The definition of PD is based on the level of impairment of self-directed and interpersonal personality functioning. Only one general diagnostic category "Personality Disorder" remains (ICD-11 Code 6D10). All distinct PD diagnoses from ICD-10 are missing, with the exception of Borderline PD, which can be classified with a "trait qualifier." The type of PD is characterized by specific patterns of five maladaptive personality traits. From the perspective of child and adolescent psychiatry, the most important change from ICD-10 to ICD-11 is the removal of an age limit, meaning PDs can be diagnosed across the lifespan.

Diffusion tensor imaging in borderline personality disorder showing prefrontal white matter alterations

Borderline personality disorder (BPD) has repeatedly been linked to alterations in fronto-limbic dysfunction. In this study, we tested the hypothesis of disturbed structural connectivity in underlying fibre tracts and their relation to symptom profiles. We analysed diffusion tensor imaging (DTI) data from 18 female BPD patients and 38 female healthy controls. Group comparisons showed significant (p < .05, FDR adjusted) increase of radial diffusivity (RD) in the right frontal lobe, including the uncinate fasciculus, anterior thalamic radiation, and inferior fronto-occipital fasciculus, as well as overall apparent diffusion coefficient (ADC) increases in the anterior and posterior internal capsule. Symptom correlations, based on the BSL-95 questionnaires, within the BPD sample showed significant negative correlations of dysphoria with ADC the left and right anterior thalamic radiation, and positive correlations of fractional anisotropy with self-perception scores in the right superior corona radiata. While our findings add to the fronto-limbic dysfunction model of BPD, they provide additional evidence of links to its affective core pathology, particularly frontotemporal and fronto-thalamic systems.

QTc dispersion and interval changes in drug-free borderline personality disorder adolescents

Emotional instability and dysregulation represent a core feature of borderline personality disorder (BPD) and abnormal patterns of sympathetic/parasympathetic activity have been repeatedly investigated in individuals with this disorder. Such abnormalities may represent the substrate for an arrhythmogenic risk that could materialize the following specific drug exposure. In this work, we decided to assess basal-corrected QT interval and dispersion (QTc and QTcd) for estimating such risk in a sample of drug-free adolescents with diagnosis of BPD. In this cross-sectional comparative study, we recruited n = 70 female adolescent BPD (14.7 ± 1.3 years), free of medications, alcohol or recreational drugs. Furthermore, n = 70 matched female healthy controls (CTRL, 14.6 ± 1.5 years) were enrolled. QTc and QTcd were manually assessed on a standard 12-lead ECG by a single experienced investigator who was unaware of clinical outcomes. QTcd was increased by 7 ms on average in BPD vs. CTRL (+ 18%, p = 0.03). QTc was decreased by about 15 ms on average in BPD vs. CTRL (p = 0.003). A mild correlation was found between QTc and QTcd in BPD (r = 0.25, p = 0.03) that was not present in CTRL. No correlation was found between either QTc or QTcd, and age in both groups. Mildly increased QTcd characterizes the cardiac activity regardless of drug exposure in female adolescents with BPD. This information may be of value to clinicians striving to use neuroleptic and antidepressant drugs with a lower risk of QTcd increase.

An evaluation of the skills group component of DBT-A for parent/guardians: a mixed methods study

OBJECTIVES

Previous research indicates that dialectical behaviour therapy for adolescents (DBT-A) is effective in treating emotionally dysregulated adolescents with self-harm and/or suicidal ideation. As part of the DBT-A programme, parents attend the weekly skills group with their child. However, few studies have evaluated parental outcomes in DBT-A. This multi-site study aims to explore the outcomes and experiences of parents who participated in a 16-week DBT-A programme in Ireland.

METHODS

This study was conducted in community-based child and adolescent mental health services (CAMHS) in the national public health system in Ireland. Participants were parent/guardians of adolescents attending a DBT-A programme in their local CAMHS. Participants attended the group skills component of the DBT-A programme. This study utilised a mixed methods approach where both quantitative and qualitative data were collected from participants. Self-report measures of burden, grief and parental stress were completed at pre-intervention, post-intervention and 16-week follow-up. Qualitative written feedback was obtained at post-intervention. The data were analysed using multi-level linear mixed-effects models and content analysis.

RESULTS

One hundred participants (76% female) took part in this study. Significant decreases were reported for objective burden, subjective burden, grief and parental stress from pre- to post-intervention (p < 0.01). Participants reported that the skills component of DBT-A was useful in meeting their own needs and the needs of their child.

DISCUSSION

DBT-A shows promise for parents as well as their adolescent child. Future studies should evaluate changes to family relationships following completion of the programme and also include controlled comparison groups.

Therapeutic interventions in Australian primary care, youth mental health settings for young people with borderline personality disorder or borderline traits

BACKGROUND

This study aimed to investigate what therapeutic interventions were being applied by clinicians working with young people with a diagnosis of Borderline Personality Disorder or borderline traits in Australian primary mental health care settings. Given the current lack of evidence-based guidelines for treatment with this client population, investigating what is being implemented is needed. The study also aimed to determine whether the interventions clinicians are using are effective in reducing distress and increasing functioning for these clients.

METHODS

Participant data came from the national minimum data set for headspace youth mental health centers across Australia. Young people's data were included in the study if the young person was diagnosed with Borderline Personality Disorder or borderline traits during their first episode of care (N = 701). Clinician data that indicated the type of intervention used at each client session and outcome measures routinely captured were analyzed to determine interventions used and outcomes achieved.

RESULTS

Results demonstrated that CBT was the most frequently used modality of intervention followed by supportive counselling and IPT, but that most clients received a variety of intervention types. There were no or only weak relationships between changes in outcomes and the amount of any type of intervention that was provided. No significant relationship was found with the amount of CBT a client received and changes in symptoms or functioning, despite being the most commonly employed modality.

CONCLUSIONS

The study highlights the need for evidence-based treatment guidelines for early intervention in young people with borderline personality disorder traits.

[Borderline Personality Disorders]

Borderline Personality Disorders Abstract. Within the framework of the German task force "Transitional Psychiatry" (DGKJP and DGPPN), a group of experts discussed the significance of adolescence for the mental healthcare of Borderline Personality Disorder (BPD) in Germany. They identified particular gaps and problems within the following areas: early detection, access to specific outpatient psychotherapy, prolonged inpatient treatment, and polypharmacy. The authors then describe various recommendations and demands regarding the generation and dissemination of knowledge about BPD as well as potential adaptations within the German healthcare system.

Assessment of Personality Functioning in Adolescents With the LoPF-Q 12-18 Self-Report Questionnaire

The classification of personality disorders (PDs) is in transition. The shortcomings of the categorical PD diagnoses led to the development of the Alternative Model for Personality Disorders (AMPD) in Section III of the DSM-5 regarding a dimensional differentiation of severity of personality pathology. Impairments in personality functioning are defined as a general Criterion A for PD. Inspired by the AMPD, the LoPF-Q 12-18 was developed to assess Levels of Personality Functioning (LoPF) dimensionally in adolescents from 12 to 18 years old in self-report. The questionnaire shows good scale reliabilities, good construct validity by demonstrating a systematic variation with pathology in line with theory, and a valuable clinical utility. The results suggest that the LoPF-Q 12-18 questionnaire is a clinically useful instrument to assess personality pathology in young people and that the concept of personality functioning is useful in detecting and describing central impairments of PD pathology at an early stage of development.

Trajectories of alliance ruptures in the psychotherapy of adolescents with borderline personality pathology: timing, typology and significance

Jeremy Safran and his research group suggest that rupture-repair processes are important for the therapeutic change in patients with personality disorders. In this exploratory study, we describe alliance ruptures and resolutions on a session-by-session basis in a clinical sample of adolescents with Borderline Personality Pathology (BPP). Three research questions are addressed: i) Is there a typical trajectory of alliance ruptures over treatment time? ii) Which rupture and resolution markers occur frequently? iii) Which rupture markers are most significant for the therapeutic alliance? Ten patients who presented with identity diffusion and at least three Borderline Personality Disorder criteria were studied and treated with Adolescent Identity Treatment. Alliance ruptures and resolutions were coded in 187 therapy sessions according to the Rupture Resolution Rating System. Mixed-effect models were used for statistical analyses. Findings supported an inverted U-shaped trajectory of alliance ruptures across treatment time. The inspection of individual trajectories displayed that alliance ruptures emerge non-linearly with particular significant alliance ruptures appearing in phases or single peak sessions. Withdrawal rupture markers emerged more often compared to confrontation markers. However, confrontation markers inflicted a higher impact or strain on the immediate collaboration between patient and therapist compared to withdrawal markers. Clinicians should expect alliance ruptures to occur frequently in the treatment of adolescents with BPP. The findings support the theory of a dynamic therapeutic alliance characterised by a continuous negotiation between patients and therapists.

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).

Early Detection and Outcome in Borderline Personality Disorder

Borderline personality disorder (BPD) is a severe and heterogeneous mental disorder that is known to have the onset in young age, often in adolescence. For this reason, it is of fundamental importance to identify clinical conditions of childhood and adolescence that present a high risk to evolve in BPD. Investigations indicate that early borderline pathology (before 19 years) predict long-term deficits in functioning, and a higher percentage of these patients continue to present some BPD symptoms up to 20 years. There is a general accordance among investigators that good competence in both childhood and early adulthood is the main predictive factor of excellent recovery in BPD patients. Some authors suggest that specific childhood personality traits can to be considered precursors of adult BPD, as well as some clinical conditions: disruptive behaviours, disturbance in attention and emotional regulation, conduct disorders, substance use disorders, and attention-deficit-hyperactivity disorder. Unfortunately, diagnosis and treatment of BPD is usually delayed, also because some clinicians are reluctant to diagnose BPD in younger individuals. Instead, the early identification of BPD symptoms have important clinical implications in terms of precocious intervention programs, and guarantees that young people with personality disorders obtain appropriate treatments. This review is aimed to collect the current evidences on early risk and protective factors in young people that may predict BPD onset, course, and outcome.