Development of borderline personality disorder in adolescence and young adulthood: introduction to the special section

Parenting knowledge and parenting self-efficacy of mothers with borderline personality disorder and depression: "I know what to do but think I am not doing it"

Borderline personality disorder (BPD) is a complex mental health condition often associated with previous childhood adversity including maladaptive parenting. When becoming a parent themselves, mothers with BPD have difficulties with various parenting cognitions and practices, but unknown is whether they have appropriate knowledge of sensitive parenting. This study explored whether differences in parenting knowledge or self-efficacy are specific to BPD or also found in mothers with depression, and whether symptom severity or specific diagnosis better explain parenting perceptions. Mothers with BPD (n = 26), depression (n = 25) or HCs (n = 25) completed a Q-sort parenting knowledge task and a parenting self-efficacy questionnaire. Results showed mothers with BPD had the same knowledge of sensitive parenting behaviors as mothers with depression and healthy mothers. Self-reported parenting self-efficacy was lower in mothers with BPD and depression compared with healthy mothers, with symptom severity most strongly associated. A significant but low correlation was found between parenting self-efficacy and knowledge. Findings suggest that mothers with BPD and depression know what good parenting is but think they are not parenting well. Mental health difficulties are not associated with parenting knowledge, but symptom severity appears to be a common pathway to lower parenting self-efficacy. Future interventions should test whether reduction of symptom severity or positive parenting feedback could improve parenting self-efficacy.

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.

Pharmacological interventions for people with borderline personality disorder

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers up to February 2022. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication.

SELECTION CRITERIA

Randomised controlled trials comparing pharmacological treatment to placebo, other pharmacologic treatments or a combination of pharmacologic treatments in people of all ages with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. Secondary outcomes were individual BPD symptoms, depression, attrition and adverse events.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's risk of bias tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis.

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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

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

Risky Sexual Behavior Profiles in Youth: Associations With Borderline Personality Features

Adolescence and young adulthood are peak periods for risky sexual behaviors (RSB) and borderline personality disorder (BPD) features. RSB is a major public health concern and adolescents with BPD may be particularly vulnerable to RSB, but this is understudied. The aim of this study was to identify distinct RSB profiles in youth and determine whether a specific profile was associated with BPD features. Participants were 220 adolescents and young adults (age 14-21) recruited from the community. To identify groups of adolescents and young adults who engage in similar RSB, a latent profile analysis (LPA) was conducted on sexually active youth (57%). Next ANOVA was used to identify how profiles differed in terms RSB dimensions and BPD features. We identified three distinct RSB profiles: (1) a Low RSB profile that was manifested by the majority (77.7%) of youth; (2) an Unprotected Sex in Relationships profile (13.3%) and; (3) an Impulsive Sex Outside Relationships profile (12%) which was manifested by youth with significantly higher BPD features. The findings shed light on the difficulties youth with BPD manifest around integrating sexuality, intimacy, fidelity, and love. This contrasts with the majority of youth who are sexually active in the context of relationships and engage in little or no RSB. The findings have important clinical implications. Adolescent sexuality is frequently in the blind spot of clinicians. To address the elevated risk of RSB in adolescents with BPD, interventions are needed to help adolescents navigate this period and improve their understanding of the reasons for RSB while addressing difficulties in establishing sexual and attachment relationships.

Determining the key childhood and adolescent risk factors for future BPD symptoms using regularized regression: comparison to depression and conduct disorder

OBJECTIVE

Research has yielded factors considered critical to risk for borderline personality disorder (BPD). Yet, these factors overlap and are relevant to other disorders, like depression and conduct disorder (CD). Regularized regression, a machine learning approach, was developed to allow identification of the most important variables in large datasets with correlated predictors. We aimed to identify critical predictors of BPD symptoms in late adolescence (ages 16-18) and determine the specificity of factors to BPD versus disorders with putatively similar etiology.

METHOD

We used a prospective longitudinal dataset (n = 2,450) of adolescent girls assessed on a range of clinical, psychosocial, and demographic factors, highlighted by previous research on BPD. Predictors were grouped by developmental periods: late childhood (8-10) and early (11-13) and mid-adolescence (14-15), yielding 128 variables from 41 constructs. The same variables were used in models predicting depression and CD symptoms.

RESULTS

The best-fitting model for BPD symptoms included 19 predictors and explained 33.2% of the variance. Five constructs - depressive and anxiety symptoms, self-control, harsh punishment, and poor social and school functioning - accounted for most of the variance explained. BPD was differentiated from CD by greater problems with mood and anxiety in BPD and differences in parenting risk factors. Whereas the biggest parenting risk for BPD was a punitive style of parenting, CD was predicted by both punitive and disengaged styles. BPD was differentiated from MDD by greater social problems and poor behavioral control in BPD.

CONCLUSIONS

The best predictors of BPD symptoms in adolescence are features suggesting complex comorbidity, affective activation, and problems with self-control. Though some risk factors were non-specific (e.g., inattention), the disorders were distinguished in clinically significant ways.

Interactive Effects of Parent Emotion Socialization and Child Physiological Reactivity in Predicting Adolescent Borderline Personality Disorder Features

Theories suggest that a transaction between child biological vulnerability and parent emotion socialization underlies the development of borderline personality disorder (BPD) features. Yet, few studies have examined the interaction between these factors prospectively in at-risk samples. Consequently, this study tested whether parental reactions to children's negative emotions moderated the effect of the child's physiological reactivity to stress in predicting adolescent BPD features in a sample of youth with and without clinical elevations in attention deficit/hyperactivity disorder (ADHD). Participants were 61 children (52% female) and parents (90% mothers). When children were 9-13 years old, their physiological reactivity to a social stressor was assessed based on respiratory sinus arrhythmia (RSA) and skin conductance level (SCL) reactivity; parents also reported on their supportive and non-supportive reactions to their child's negative emotions. Children were followed-up four to five years later at ages 14-18 years old and their BPD features were assessed based on parent and adolescent report. Significant interactions between children's SCL reactivity and parental reactions to children's negative emotions were found in predicting adolescent BPD features. Children with low SCL reactivity to social stress and parents high in supportive/low in non-supportive reactions were lowest in adolescent BPD features. However, greater SCL reactivity predicted greater adolescent BPD features specifically when the parent was high in support or low in non-support. Childhood ADHD symptoms also significantly predicted greater adolescent BPD features. Findings suggest that children with different patterns of SCL reactivity may respond differently to parental reactions to their emotions.

Too Much Too Soon?: Borderline Personality Disorder Symptoms and Romantic Relationships in Adolescent Girls

Despite the centrality of adult romantic relationships to the conceptualization of borderline personality disorder (BPD), little is known about the earlier development of this interdependency during adolescence. Thus, we examined the co-development of romantic relationships and BPD symptoms from ages 15 to 19 in a large urban sample of girls (N = 2310) in the Pittsburgh Girls Study. We had two major aims. First, we sought to examine associations between BPD symptoms and romantic relationship involvement (number of partners, importance of relationship) and relational insecurity (concerns about infidelity and tactics to maintain relationship) during adolescence. Second, we investigated mutual influences and temporal precedence of BPD symptoms and four specific romantic relationship characteristics (perceived support and antagonism, verbal and physical aggression) during adolescence using latent growth curve models (LGCMs). Results indicated that BPD symptoms were associated with increased involvement in romantic relationships and heightened relational insecurity across adolescence. Furthermore, higher BPD symptoms at age 15 predicted increases in antagonism, verbal aggression, and physical aggression across ages 15 to 19. Conversely, perceptions of higher levels of relationship support at age 15 predicted steeper increases in BPD symptoms across ages 15 to 19, suggesting a potential negative influence of early involvement in close romantic relationships. These findings demonstrate the reciprocal nature of romantic relationship functioning and BPD symptoms during adolescence and suggest novel prevention targets for youth at risk for BPD.

Reflective Function and Borderline Traits in Adolescents

Despite the developmental roots of the relation between attachment-based reflective function (RF) and borderline pathology, there is a lack of empirical studies examining this link in youth. We examined this link taking into account potential relations between RF and internalizing and externalizing pathology. A total of 421 clinical adolescents between the ages of 12 and 17 completed the Child Attachment Interview (CAI; Shmueli-Goetz, Target, Fonagy, & Datta, 2008), which was coded using the Child and Adolescent Reflective Functioning Scale (CARFS; Ensink, Target, & Oandasan, 2013), alongside a self-report measure of borderline pathology and parent-reported measures of internalizing and externalizing pathology. Exploratory analyses revealed no direct relation between RF and borderline features or internalizing psychopathology but a negative relation with externalizing pathology. Moderation analyses showed that externalizing pathology moderated the relation between RF and borderline pathology. Implications for understanding the various ways in which impaired RF may present in adolescents with BPD are discussed.

Psychological therapies for people with borderline personality disorder

BACKGROUND

Over the decades, a variety of psychological interventions for borderline personality disorder (BPD) have been developed. This review updates and replaces an earlier review (Stoffers-Winterling 2012).

OBJECTIVES

To assess the beneficial and harmful effects of psychological therapies for people with BPD.

SEARCH METHODS

In March 2019, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication.

SELECTION CRITERIA

Randomised controlled trials comparing different psychotherapeutic interventions with treatment-as-usual (TAU; which included various kinds of psychotherapy), waiting list, no treatment or active treatments in samples of all ages, in any setting, with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. There were 11 secondary outcomes, including individual BPD symptoms, as well as attrition and adverse effects.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's 'Risk of bias' tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis.

MAIN RESULTS

We included 75 randomised controlled trials (4507 participants), predominantly involving females with mean ages ranging from 14.8 to 45.7 years. More than 16 different kinds of psychotherapy were included, mostly dialectical behaviour therapy (DBT) and mentalisation-based treatment (MBT). The comparator interventions included treatment-as-usual (TAU), waiting list, and other active treatments. Treatment duration ranged from one to 36 months. Psychotherapy versus TAU Psychotherapy reduced BPD symptom severity, compared to TAU; standardised mean difference (SMD) -0.52, 95% confidence interval (CI) -0.70 to -0.33; 22 trials, 1244 participants; moderate-quality evidence. This corresponds to a mean difference (MD) of -3.6 (95% CI -4.4 to -2.08) on the Zanarini Rating Scale for BPD (range 0 to 36), a clinically relevant reduction in BPD symptom severity (minimal clinical relevant difference (MIREDIF) on this scale is -3.0 points). Psychotherapy may be more effective at reducing self-harm compared to TAU (SMD -0.32, 95% CI -0.49 to -0.14; 13 trials, 616 participants; low-quality evidence), corresponding to a MD of -0.82 (95% CI -1.25 to 0.35) on the Deliberate Self-Harm Inventory Scale (range 0 to 34). The MIREDIF of -1.25 points was not reached. Suicide-related outcomes improved compared to TAU (SMD -0.34, 95% CI -0.57 to -0.11; 13 trials, 666 participants; low-quality evidence), corresponding to a MD of -0.11 (95% CI -0.19 to -0.034) on the Suicidal Attempt Self Injury Interview. The MIREDIF of -0.17 points was not reached. Compared to TAU, psychotherapy may result in an improvement in psychosocial functioning (SMD -0.45, 95% CI -0.68 to -0.22; 22 trials, 1314 participants; low-quality evidence), corresponding to a MD of -2.8 (95% CI -4.25 to -1.38), on the Global Assessment of Functioning Scale (range 0 to 100). The MIREDIF of -4.0 points was not reached. Our additional Trial Sequential Analysis on all primary outcomes reaching significance found that the required information size was reached in all cases. A subgroup analysis comparing the different types of psychotherapy compared to TAU showed no clear evidence of a difference for BPD severity and psychosocial functioning. Psychotherapy may reduce depressive symptoms compared to TAU but the evidence is very uncertain (SMD -0.39, 95% CI -0.61 to -0.17; 22 trials, 1568 participants; very low-quality evidence), corresponding to a MD of -2.45 points on the Hamilton Depression Scale (range 0 to 50). The MIREDIF of -3.0 points was not reached. BPD-specific psychotherapy did not reduce attrition compared with TAU. Adverse effects were unclear due to too few data. Psychotherapy versus waiting list or no treatment Greater improvements in BPD symptom severity (SMD -0.49, 95% CI -0.93 to -0.05; 3 trials, 161 participants), psychosocial functioning (SMD -0.56, 95% CI -1.01 to -0.11; 5 trials, 219 participants), and depression (SMD -1.28, 95% CI -2.21 to -0.34, 6 trials, 239 participants) were observed in participants receiving psychotherapy versus waiting list or no treatment (all low-quality evidence). No evidence of a difference was found for self-harm and suicide-related outcomes. Individual treatment approaches DBT and MBT have the highest numbers of primary trials, with DBT as subject of one-third of all included trials, followed by MBT with seven RCTs. Compared to TAU, DBT was more effective at reducing BPD severity (SMD -0.60, 95% CI -1.05 to -0.14; 3 trials, 149 participants), self-harm (SMD -0.28, 95% CI -0.48 to -0.07; 7 trials, 376 participants) and improving psychosocial functioning (SMD -0.36, 95% CI -0.69 to -0.03; 6 trials, 225 participants). MBT appears to be more effective than TAU at reducing self-harm (RR 0.62, 95% CI 0.49 to 0.80; 3 trials, 252 participants), suicidality (RR 0.10, 95% CI 0.04, 0.30, 3 trials, 218 participants) and depression (SMD -0.58, 95% CI -1.22 to 0.05, 4 trials, 333 participants). All findings are based on low-quality evidence. For secondary outcomes see review text.

AUTHORS' CONCLUSIONS

Our assessments showed beneficial effects on all primary outcomes in favour of BPD-tailored psychotherapy compared with TAU. However, only the outcome of BPD severity reached the MIREDIF-defined cut-off for a clinically meaningful improvement. Subgroup analyses found no evidence of a difference in effect estimates between the different types of therapies (compared to TAU) . The pooled analysis of psychotherapy versus waiting list or no treatment found significant improvement on BPD severity, psychosocial functioning and depression at end of treatment, but these findings were based on low-quality evidence, and the true magnitude of these effects is uncertain. No clear evidence of difference was found for self-harm and suicide-related outcomes. However, compared to TAU, we observed effects in favour of DBT for BPD severity, self-harm and psychosocial functioning and, for MBT, on self-harm and suicidality at end of treatment, but these were all based on low-quality evidence. Therefore, we are unsure whether these effects would alter with the addition of more data.

Relationships between the frequency and severity of non-suicidal self-injury and suicide attempts in youth with borderline personality disorder

AIM

Non-suicidal self-injury (NSSI) is a recognized indicator of suicide risk. Yet, the ubiquity of this behaviour in borderline personality disorder (BPD) limits its utility as a predictor of risk. Consequently, this study aimed to elucidate the relationship between other features of NSSI, including frequency and severity, and suicide attempts.

METHOD

Participants included 107 youth (15 to 25 year olds) with BPD who were assessed for BPD severity, depressive symptoms, 12-month frequency of NSSI and suicide attempts, as well as the levels of treatment sought following each self-harm event.

RESULTS

Three-quarters (75.7%) of youth with BPD reported NSSI and two-thirds (66.4%) reported a suicide attempt over the previous 12 months. The frequency of NSSI over the previous 12 months did not show a linear or quadratic relationship with the number of suicide attempts when adjusting for severity of depression, impulsivity and interpersonal problems. NSSI severity was not associated with more frequent suicide attempts. Only impulsivity and depression were uniquely predictive of suicide attempt frequency. A relative increase in the frequency and severity of NSSI occurred in the months prior to a suicide attempt.

CONCLUSION

The prevalence of NSSI and suicide attempts among youth presenting for their first treatment of BPD appear to be perilously high, considerably higher than rates reported by adults with BPD. Findings suggest that clinicians should give more weight to average levels of impulsivity and depression, rather than the absolute frequency and severity of NSSI, when assessing for risk of suicide attempts. Notwithstanding this, a relative increase in the frequency and severity of NSSI appears to be predictive of a forthcoming suicide attempt.

Perceived pubertal timing and borderline personality pathology in female adolescent inpatients

Borderline personality pathology typically onsets during adolescence. An important consideration in understanding adolescent psychopathology is pubertal development. Perceived pubertal timing is one facet of puberty that is especially relevant to adolescent psychopathology, especially when timing is perceived to be early. Despite links between early pubertal timing and core features of borderline personality disorder, and between early pubertal timing and disruptions in the interpersonal context, perceived pubertal timing has yet to be studied in relation to adolescent borderline pathology. This preliminary study aimed to test the association between perceived pubertal timing and borderline symptoms in adolescent girls, controlling for internalizing and externalizing pathology. Forty-two female adolescent inpatients (ages 12-15, Mage = 14.02, 81% White) completed measures of perceived pubertal development and borderline symptoms and a diagnostic interview. Results indicated that earlier perceived pubertal timing was uniquely associated with higher borderline symptoms even when internalizing and externalizing disorders were covaried.

Pharmacological interventions for people with borderline personality disorder

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

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

Association between childhood invalidation and borderline personality symptoms: self-construal and conformity as moderating factors

BACKGROUND

Linehan (1993)'s biosocial model posits that borderline personality disorder (BPD) symptoms develop as a result of a transactional relationship between pre-existing emotional vulnerability and an invalidating childhood environment. Little work, however, has investigated cultural factors that may influence the relationship between childhood invalidation and BPD symptoms. The present study investigated the association between parental invalidation and BPD symptoms, and the role of conformity and self-construal as potential moderators of this association.

METHODS

Two hundred and ninety undergraduate students were recruited from a large university in Singapore and administered questionnaires measuring Asian values, self-construal, parental invalidation, and BPD symptomatology.

RESULTS

Multiple regression analysis demonstrated a significant positive association between BPD symptoms and maternal invalidation. Moderation analyses revealed a 3-way interaction, indicating that the maternal invalidation and BPD symptoms association varied by degree of conformity and self-construal. Among participants with interdependent self-construal, maternal invalidation was associated with BPD symptoms only at high conformity levels. No significant moderating effect was found among participants with independent self-construal.

CONCLUSIONS

Overall, the study found empirical support for aspects of Linehan's biosocial model in an Asian context, and has implications for developing a culturally-informed understanding of BPD.

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.

Development of self-inflicted injury: Comorbidities and continuities with borderline and antisocial personality traits

Self-inflicted injury (SII) is a continuum of intentionally self-destructive behaviors, including nonsuicidal self-injuries, suicide attempts, and death by suicide. These behaviors are among the most pressing yet perplexing clinical problems, affecting males and females of every race, ethnicity, culture, socioeconomic status, and nearly every age. The complexity of these behaviors has spurred an immense literature documenting risk and vulnerability factors ranging from individual to societal levels of analysis. However, there have been relatively few attempts to articulate a life span developmental model that integrates ontogenenic processes across these diverse systems. The objective of this review is to outline such a model with a focus on how observed patterns of comorbidity and continuity can inform developmental theories, early prevention efforts, and intervention across traditional diagnostic boundaries. Specifically, when SII is viewed through the developmental psychopathology lens, it becomes apparent that early temperamental risk factors are associated with risk for SII and a range of highly comorbid conditions, such as borderline and antisocial personality disorders. Prevention efforts focused on early-emerging biological and temperamental contributors to psychopathology have great potential to reduce risk for many presumably distinct clinical problems. Such work requires identification of early biological vulnerabilities, behaviorally conditioned social mechanisms, as well as societal inequities that contribute to self-injury and underlie intergenerational transmission of risk.

Social disadvantage and borderline personality disorder: A study of social networks

Examining differences in social integration, social support, and relationship characteristics in social networks may be critical for understanding the character and costs of the social difficulties experienced of borderline personality disorder (BPD). We conducted an ego-based (self-reported, individual) social network analysis of 142 participants recruited from clinical and community sources. Each participant listed the 30 most significant people (called alters) in their social network, then rated each alter in terms of amount of contact, social support, attachment strength and negative interactions. In addition, measures of social integration were determined using participant's report of the connection between people in their networks. BPD was associated with poorer social support, more frequent negative interactions, and less social integration. Examination of alter-by-BPD interactions indicated that whereas participants with low BPD symptoms had close relationships with people with high centrality within their networks, participants with high BPD symptoms had their closest relationships with people less central to their networks. The results suggest that individuals with BPD are at a social disadvantage: Those with whom they are most closely linked (including romantic partners) are less socially connected (i.e., less central) within their social network. (PsycINFO Database Record

Negative emotional reactivity as a marker of vulnerability in the development of borderline personality disorder symptoms

Negative emotionality is a distinguishing feature of borderline personality disorder (BPD). However, this person-level characteristic has not been examined as a marker of vulnerability in the development of this disorder. The current study utilized a multimethod approach to examine the interplay between negative emotional reactivity and cumulative exposure to family adversity on the development of BPD symptoms across 3 years (ages 16-18) in a diverse, at-risk sample of adolescent girls (N = 113). A latent variable of negative emotional reactivity was created from multiple assessments at age 16: self-report, emotion ratings to stressors from ecological assessments across 1 week, and observer-rated negative affectivity during a mother-daughter conflict discussion task. Exposure to family adversity was measured cumulatively between ages 5 and 16 from annual assessments of family poverty, single parent household, and difficult life circumstances. The results from latent growth curve models demonstrated a significant interaction between negative emotional reactivity and family adversity, such that exposure to adversity strengthened the association between negative emotional reactivity and BPD symptoms. In addition, family adversity predicted increasing BPD symptoms during late adolescence. These findings highlight negative emotional reactivity as a marker of vulnerability that ultimately increases risk for the development of BPD symptoms.

Characterizing adult attention-deficit/hyperactivity-disorder and comorbid borderline personality disorder: ADHD symptoms, psychopathology, cognitive functioning and psychosocial factors

OBJECTIVE

To characterize adults with comorbid attention-deficit/hyperactivity-disorder (ADHD) and borderline personality disorder (BPD) with regard to ADHD symptoms, psychopathology, cognitive functioning and psychosocial factors.

METHOD

A between-group design compared a group of individuals diagnosed with ADHD (n=40) with a group diagnosed with BPD and who also met the criteria for ADHD (ADHD+BPD) (n=20).

RESULTS

Significant differences were observed for both childhood and current impulsivity symptoms, whereby ADHD+BPD exhibited increased impulsivity; no differences on self-report and cognitive measures of impulsivity were reported. The ADHD+BPD group scored significantly higher on measures of depression, anxiety and numerous other axis I and II conditions. The ADHD+BPD group scored significantly lower on most measures of intellectual functioning and attention, however largely not on those relating to response inhibition. Furthermore, group differences were observed for psychosocial factors, including education, substance use and criminal record.

CONCLUSION

Comorbid ADHD and BPD is characterized by more symptoms of impulsivity, additional psychopathology, comparatively lower intellectual and attentional functioning and increased psychosocial difficulties.

Covariance and specificity in adolescent schizotypal and borderline trait expression

AIMS

The first aim of the present study is to assess the overlap between borderline and schizotypal traits during adolescence. The second objective is to examine whether some psychological factors (i.e. cognitive coping mechanisms, impulsivity and encoding style) are differentially related to borderline and schizotypal traits and may therefore improve the efficiency of clinical assessments.

METHODS

One hundred nineteen community adolescents (57 male) aged from 12 to 19 years completed a set of questionnaires evaluating the expression of borderline and schizotypal traits as well as cognitive emotion regulation (CER), impulsivity and encoding style.

RESULTS

Our data first yielded a strong correlation between borderline and schizotypal scores (r = 0.70, P < 0.001). Secondly, linear regression models indicated that the 'catastrophizing' CER strategy and the 'lack of premeditation' impulsivity facet accounted for the level of borderline traits, whereas an internal encoding style predominantly explained schizotypal traits.

CONCLUSIONS

Our results support the abundant literature showing that borderline and schizotypal traits frequently co-occur. Moreover, we provide original data indicating that borderline and schizotypal traits during adolescence are linked to different specific psychological mechanisms. Thus, we underline the importance of considering these mechanisms in clinical assessments, in particular to help disentangle personality disorder traits in youths.

The impact of childhood temperament on the development of borderline personality disorder symptoms over the course of adolescence

BACKGROUND

The purpose of this study was to characterize the development of BPD symptoms across adolescence by evaluating the fit of several latent variable growth models to annual assessments of symptoms obtained from girls when they were ages 14 through 19 years. After determining the best fitting model, we examined prospective associations between the temperament dimensions of emotionality, activity, low sociability, and shyness and BPD symptom development.

METHODS

We utilized longitudinal data from the Pittsburgh Girls Study; one of the few large-scale, prospective studies of girls (N = 2,450) in the United States. Parent- and teacher-reports of girls' temperament were collected at Wave 1, when girls were ages 5-8 years. Child-reports of BPD symptoms were collected annually beginning at age 14 through 19 years.

RESULTS

We found that a free curve slope intercept model provided the best model fit, with the course of BPD symptoms characterized by a large component of inter-individual stability and a smaller component representing within-individual changes across adolescence. Symptoms appeared to peak by age 15, decline through age 18, and remain steady between ages 18 and 19 years. Both parent- and teacher-reports of temperament emotionality, activity, low sociability, and shyness predicted the developmental course of symptoms.

CONCLUSIONS

BPD symptoms in adolescence reflect trait-like differences between youth with less within-person variability across time. Childhood temperament dimensions of emotionality, activity, low sociability, and shyness predict adolescent BPD symptom development. Parent- and teacher-informants provide unique information about the course of BPD symptoms, underscoring the utility of collecting child assessments using multiple informants.

Diagnosing Borderline Personality Disorder During Adolescence: A Review of the Published Literature

Borderline personality disorder (BPD) is a debilitating disorder that occurs in approximately 1% to 3% of the general population. BPD is not only relatively prevalent; it is also associated with significant public health and security concerns. The clinical and social burden of adult BPD diagnosis has resulted in the desire for early diagnosis and the implementation of early intervention programs. A qualitative review of the scientific literature suggested that adolescence is a critical point for the early identification and therapeutic treatment of BPD. Although findings are far from conclusive, the inter-rater reliability and internal consistency of the Diagnostic and Statistical Manual of Mental Disorders symptom criteria for BPD during adolescence seem adequate. Recent studies based on a rigorous methodology of BPD assessment and large community samples reported prevalence rates for BPD diagnosis during adolescence that were less suspect than previous findings. A number of research studies addressed the construct validity of BPD in adolescents (i.e., whether a BPD diagnosis during adolescence actually measures what is intending to measure) and reported consistent relationships between BPD and associated areas of dysfunction and distress as evidence of the validity of the BPD diagnosis. Research evidence indicates that there is no single symptom that is predictive of later BPD diagnosis during adolescence; rather, a pattern of two to three selected BPD symptoms that are evident during adolescence seemed to be highly predictive of later BPD diagnosis, particularly when measures that were specifically designed to assess for BPD during adolescence were used as part of the assessment process.

Living from day to day - qualitative study on borderline personality disorder in adolescence

OBJECTIVE

The purpose of this study was to assess how far identity and self-image disturbances are features of borderline personality disorder (BPD) in adolescence.

METHOD

Face-to-face interviews were carried out with a total of 50 adolescents with BPD and 50 controls, with a median age of 16 (SD 1.1; range 13 to 18) years. Data was analysed using a qualitative methodology, interpretative phenomenological analysis (IPA). Thematic statements representative of adolescents' lived experience were extracted from the interviews.

RESULTS

Four main themes representing the day-to-day experiences of adolescents with BPD were identified: emotional experiences characterised by the feelings of fear, sadness and pessimism; interpersonal relationships characterised by the feelings of solitude and hostility from others; a conformist self-image characterised by a feeling of normality and difficulty in projecting into time; and, a structuring of discourse characterised by discontinuity in the perception of experiences.

CONCLUSION

This qualitative study suggests that the day-to-day experiences of adolescents with borderline personality disorder is centred on the experience of the present. Discontinuity in self-image, alongside marked dysphoric manifestations, leads to distress and hinders compliance with care. These issues are highly relevant in psychotherapy and could lead to more effective treatment of the disorder in adolescents.

Burden and support needs of carers of persons with borderline personality disorder: a systematic review

BACKGROUND

A major feature of personality disorders is significant impairment in interpersonal functioning, which may create challenges in close relationships. This article aims to systematically review the experience of carers of persons with personality disorders.

METHOD

The PRISMA systematic review method was followed, and empirical studies written in English, published between 1996 and 2011, and cited in major electronic databases were searched. Studies meeting the following selection criteria were included: (1) carers or families of persons with personality disorders; (2) intervention involving the carers or families; (3) burden or related construct used. Studies were required to meet either criteria 1 and 3 or criteria 2 and 3. Reference lists were scanned, and experts were consulted for further studies.

RESULTS

Six studies met inclusion criteria, representing data on 465 carers. Five of the six studies focused on carers of persons with borderline personality disorder. The findings indicated that carers experience elevated objective and subjective burden, grief, impaired empowerment, and mental health problems, including depression and anxiety. Scores on objective and subjective burden were half a standard deviation above the mean compared to carers of inpatients with other serious mental illnesses.

CONCLUSIONS

This study is the first to report data on a large, aggregated sample of carers of persons with personality disorders. Significant gaps in the literature remain, and it is recommended that future research focus on the burden and support needs of carers of persons across different personality disorders, that attention be paid to the gender balance of patients, and that data be reported in a way to allow meta-analysis.

Borderline personality disorder in adolescents: the He-who-must-not-be-named of psychiatry

This article reviews the possibility and pertinence of diagnosing borderline personality disorder in adolescents. The etiology and clinical manifestations of this disorder in adolescents are discussed, and its management is addressed in terms of psychotherapy, pharmacology, hospitalization issues, and family involvement considerations.

Borderline personality disorder in adolescents: the He-who-must-not-be-named of psychiatry

This article reviews the possibility and pertinence of diagnosing borderline personality disorder in adolescents. The etiology and clinical manifestations of this disorder in adolescents are discussed, and its management is addressed in terms of psychotherapy, pharmacology, hospitalization issues, and family involvement considerations.