Axis II comorbidity in borderline personality disorder is influenced by sex, age, and clinical severity

Cognitive impairment in patients with bipolar disorder alone versus those with bipolar disorder comorbid with borderline personality disorder

BACKGROUND

Bipolar disorder (BD) is a severe mental illness. BD often coexists with borderline personality disorders, making the condition more complex.

AIM

To explore the differences in cognitive impairment between patients with BD and those with BD comorbid with borderline personality disorder.

METHODS

Eighty patients with BD and comorbid borderline personality disorder and 80 patients with BD alone were included in groups A and B, respectively, and 80 healthy volunteers were included as controls. Cognitive function in each group was evaluated using the Chinese version of the repeatable battery for the assessment of neuropsychological status (RBANS), the Stroop color-word test, and the Wechsler intelligence scale-revised (WAIS-RC).

RESULTS

The indices of the RBANS, Stroop color-word test, and WAIS-RC in groups A and B were significantly lower than those of the control group (P < 0.05). Group A had significantly longer Stroop color-word test times for single-character, single-color, double-character, and double-color, lower scores of immediate memory, visual breadth, verbal function dimensions and total score of the RBANS, as well as lower scores of verbal IQ, performance IQ, and overall IQ of the WAIS-RC compared with group B (P < 0.05). Compared to group B, group A exhibited significantly longer single-character time, single-color time, double-character time, and double-color time in the Stroop color-word test (P < 0.05).

CONCLUSION

The cognitive function of patients with BD complicated with borderline personality disorder is lower than that of patients with BD.

Systematic Review of the Effectiveness and Experiences of Treatment for Men With Borderline Personality Disorder

In clinical settings, among individuals diagnosed with borderline personality disorder (BPD), typically 75% are female and 25% male, although this discrepancy is not reported in the community. In the literature, little is known of the effectiveness and experiences of treatment of men with BPD. We aimed to review the effectiveness and experiences of treatment for men with BPD and outline future research priorities to promote better recovery. We searched Ovid MEDLINE and PsycINFO for eligible studies from inception until July 29, 2022. Peer-reviewed primary research articles on treatment effectiveness or experience for men with BPD were included. Data from eligible studies were synthesized in a narrative review. The protocol of our review was pre-registered on PROSPERO (CRD42022351908). Seventeen studies met the inclusion criteria, and men with BPD from eight countries were represented. Psychological therapies included Dialectical Behavioral Therapy, Systems Training for Emotional Predictability and Problem Solving, Mentalization Based Therapy, and psychoanalytic therapy. Pharmacologic treatment included topiramate, divalproex Extended-Release, and high-dose baclofen. Five studies investigated the service utilization of men with BPD. Compared to women, men were less likely to access treatment for BPD or find treatment helpful. Our findings demonstrated the potential efficacy of psychotherapy and pharmacologic interventions in reducing anger, aggression, and rule-breaking behavior, with limited evidence for reduction in suicide-related outcomes. Our findings are limited by inadequate power and heterogeneity of the included studies. Further research with larger sample sizes and qualitative studies is needed to better understand the treatment experience for men with BPD.

Distribution of self-reported borderline personality disorder traits symptoms in a large-scale clinical population

Introduction

Borderline Personality Disorder (BPD) traits play a crucial role in the prognosis of psychiatric disorders, as well as in assessing risks associated with negativity and impulsivity. However, there is a lack of data regarding the distribution characteristics of BPD traits and symptoms within clinical populations.

Methods

A total of 3015 participants (1321 males, 1694 females) were consecutively sampled from outpatients at the psychiatric and psycho-counseling clinics at the Shanghai Mental Health Center. BPD symptoms were assessed using a self-reported personality diagnostic questionnaire. Having BPD traits is defined as having five or more positive items in self-reported BPD characteristics. Participants were stratified into male and female groups, age groups, and diagnostic groups (schizophrenia, mood disorders, anxiety disorders). Exploratory factor analysis using principal components analysis was conducted. Three factors were identified: "F1: Affective Instability and Impulsivity", "F2: Interpersonal Unstable and Extreme Reactions", and "F3: Identity Disturbance".

Results

Among 3015 participants, 45.9% of the patients self-reported BPD traits. Comparing of male and female patients, there was no statistically significant difference in the occurrence rate of BPD traits (χ2 = 1.835, p=0.176). However, in terms of symptoms, female patients reported more symptoms than male patients. Female patients also exhibited more pronounced features on F2 compared to male patients (t =-1.972, p=0.049). There is a general decrease in BPD traits, symptoms, and factors with increasing age. Specifically, the proportion of positive BPD traits is approximately halved before the age of 30 and decreases to around one-third after the age of 30. BPD traits were most common in the Mood Disorders group at 55.7%, followed by the Anxiety Disorders group at 44.4%, and Schizophrenia group at 41.5% (χ2 = 38.084, p<0.001).

Discussion

Our study revealed the pervasive presence of BPD traits and symptoms among psychiatric outpatients, exhibiting distinctive distributions across gender, age, and diagnostic categories. These findings emphasize the significance of identifying and addressing BPD pathology in the clinical care of psychiatric outpatients.

Gender differences in borderline personality disorder: a narrative review

Borderline personality disorder (BPD) is a severe and complex mental disorder that traditionally has been found to be more frequent in the female gender in clinical samples. More recently, epidemiological studies have provided conflicting data about the prevalence of borderline disorder in the two genders in community samples. In order to explain this heterogeneity, some authors hypothesized the presence of a bias in the diagnostic criteria thresholds (more prevalent in one gender than another), in the population sampling (community versus clinical), in the instruments of evaluation (clinician versus self-report measures), and in the diagnostic construct of BPD. Beyond the question of the different prevalence of the disorder between genders, the debate remains open as to how personality and clinical characteristics, and attitude toward treatments express themselves in the two genders. This narrative review is aimed to provide an updated overview of the differences among genders in BPD in terms of diagnosis, temperamental and clinical characteristics, comorbidities, findings of neuroimaging, and treatment attitudes. Studies that specifically investigated the gender differences in BPD patients are rather limited. Most of the investigations did not consider gender as a variable or were characterized by a significant imbalance between the two genders (more commonly in favor the female gender). The main results indicated that men were more likely to endorse the criteria "intense and inappropriate anger" and "impulsivity," whereas women endorsed the criteria "chronic feelings of emptiness," "affective instability," and "suicidality/self-harm behaviors." These findings reflect differences in temperament and symptoms of the two genders. Other relevant differences concern pattern of comorbidity, specific neurobiological mechanisms and attitude to treatments. Main limitations were that only one database was searched, time of publications was limited, non-English manuscripts were excluded, and the quality of each paper was not commented.

The impact of a telephone hotline on suicide attempts and self-injurious behaviors in patients with borderline personality disorder

Background

Borderline personality disorder is often associated with self-injurious behaviors that cause personal suffering, family distress, and substantial medical costs. Mental health hotlines exist in many countries and have been shown to be effective in some contexts, but none have been specifically designed for borderline patients. The aim of the present study is to evaluate the impact of a 24/7 hotline dedicated to patients with borderline personality disorder on suicide attempts and self-injurious behaviors.

Methods

We conducted a single-blind, multicenter (9 French centers) clinical trial with stratified randomization (by age, sex and center). Patients (N = 315) with a diagnosis of borderline personality disorder (according to the SIDP-IV) were randomized into two groups with or without access to the hotline in addition to treatment as usual. The number of suicide attempts and self-injurious behaviors in each group within 12 month were analyzed in the "per protocol" population (Student's t-tests, 5% significance threshold), adjusting for possible confounders in a multivariate analysis (using Poisson regression). The percentage of patients with suicide attempts and with self-injurious behaviors (and other percentages) were analyzed in the per protocol population (χ2-tests or exact Fischer tests, 5% significance threshold).

Results

The mean number of suicide attempts was 3 times lower in the hotline group (0.41 vs. 1.18, p = 0.005) and the mean number of self-injurious behaviors was 9 times lower (0.90 vs. 9.5, p = 0.006). Multivariate analysis confirmed the effectiveness of the hotline in reducing suicide attempts and self-harm.

Conclusion

This study supports the effectiveness of hotlines in reducing self-aggressive behavior in patients with borderline personality disorder. Such support is easy to use, cheap and flexible, and therefore easy to implement on a large scale.

Efficacy and Safety of Aripiprazole in Borderline Personality Disorder: A Systematic Review

Aripiprazole is an atypical antipsychotic medication, and its use in treating borderline personality disorder (BPD) is debatable because it is not FDA-approved for treating BPD. This study aimed to investigate the efficacy and safety of aripiprazole in patients with BPD. On July 2, 2021, the protocol (CRD42021256647) was registered in PROSPERO. PubMed, Scopus, Web of Science, Ovid-Medline, Embase, PsycINFO, and Cochrane (CENTRAL) were searched without regard for language or publication date. We also searched trial registries on ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform. Randomized clinical trials with adult patients diagnosed with BPD met the inclusion criteria. The Cochrane risk of bias for randomized trials (RoB-2) method was used to assess the quality of the included studies. We included two previously published randomized clinical trials. There were 76 patients with BPD, with 38, 12, and 26 assigned to the aripiprazole, olanzapine, and placebo groups, respectively. Most patients (88.16%) were females, with ages ranging from 22.1 to 28.14 yr. Aripiprazole has been proven to reduce anxiety, depression, anger, hostility, clinical severity, and obsessive-compulsive behavior, insecurity, melancholy, anxiety, aggressiveness/hostility, phobic anxiety, paranoid thinking, psychoticism, and somatization. The adverse effects were headache, insomnia, restlessness, tremor, and akathisia. The risk of bias was considerable in both trials, which is somewhat problematic considering that prejudice can lead to incorrect outcomes and conclusions. Aripiprazole has demonstrated encouraging outcomes in the treatment of patients with BPD. More randomized controlled studies are needed.

Sex differences in borderline personality disorder: A scoping review

Borderline Personality Disorder (BPD) is often perceived to be a female-predominant disorder in both research and clinical contexts. Although there is growing recognition of possible sex differences, the current literature remains fragmented and inconclusive. This scoping review aimed to synthesize available research evidence on potential sex differences in BPD. PsycINFO, PubMed, Scopus and Web-of-Science were searched from January 1982 to July 2022 surrounding the key concepts of sex and BPD. Data searching and screening processes followed the Joanna Briggs Institute methodology involving two independent reviewers, and a third reviewer if necessary, and identified 118 papers. Data regarding BPD symptoms, comorbid disorders, developmental factors, biological markers, and treatment were extracted. Data was summarized using the vote counting method or narrative synthesis depending on the availability of literature. Males with BPD were more likely to present externalizing symptoms (e.g., aggressiveness) and comorbid disorders (e.g., substance use), while females with BPD were more likely to present internalizing symptoms (e.g., affective instability) and comorbid disorders (e.g., mood and eating disorders). This review also revealed that substantially more research attention has been given to overall sex differences in baseline BPD symptoms and comorbid disorders. In contrast, there is a dearth of sex-related research pertaining to treatment outcomes, developmental factors, and possible biological markers of BPD. The present scoping review synthesized current studies on sex differences in BPD, with males more likely to present with externalizing symptoms in contrast to females. However, how this might change the prognosis of the disorder or lead to modifications of treatment has not been investigated. Most studies were conducted on western populations, mainly North American (55%) or European (33%), and there is a need for future research to also take into consideration genetic, cultural, and environmental concomitants. As the biological construct of 'sex' was employed in the present review, future research could also investigate the social construct 'gender'. Longitudinal research designs are needed to understand any longer-term sex influence on the course of the disorder.

Emergency department utilisation by patients with a diagnosis of borderline personality disorder: An acute response to a chronic disorder

OBJECTIVE

Patients with borderline personality disorder (BPD) are likely to attend the ED while experiencing crises and associated self-injury and suicidality. Our study describes the prevalence, features, and outcomes associated with ED presentations by patients diagnosed with BPD in Outer Eastern Melbourne, Australia.

METHODS

A retrospective electronic audit of 157 364 ED attendances identified 700 unique BPD-related ED presentations between May 2015 and April 2016. For the purpose of comparison, 583 (81% female) of these 700 cases were matched with 'depression only' cases. ED re-presentation data were also extracted.

RESULTS

The 583 matched BPD patients attended ED a total of 2807 times during the audit year compared with 1092 attendances for matched depression-only patients. BPD patients were more likely to: arrive by ambulance (50%); have comorbid substance abuse (44%); have a psychotic (15%) or bipolar disorder (17%); be under the care of a psychiatrist (31%); be case-managed (42%); and be admitted to an inpatient unit (21%). ED doctors saw 38% of BPD or depression patients within the recommended time according to their triage category. The majority (73%) of BPD patients attended ED more than once during the audit year (average 4.81 ± 6.63 times; range 2-78).

CONCLUSION

Repeated ED attendance of a subset of patients diagnosed with BPD highlights both the severity of their presentation and the inadequacy of community mental health services for meeting their complex needs. Development of effective ED referral pathways with follow-up to engage patients in BPD-appropriate treatment will reduce the likelihood of crises and reliance on hospital EDs for acute episodic care.

Mentalization-Based Treatment Versus Specialist Treatment as Usual for Borderline Personality Disorder: Economic Evaluation Alongside a Randomized Controlled Trial With 36-Month Follow-Up

The authors present an economic evaluation performed alongside a randomized controlled trial of mentalization-based treatment in a day hospital setting (MBT-DH) versus specialist treatment as usual (S-TAU) for borderline personality disorder (BPD) with a 36-month follow-up period. Ninety-five patients from two Dutch treatment institutes were randomly assigned. Societal costs were compared with the proportion of BPD remissions and quality-adjusted life years (QALYs) measured using the five-dimensional EuroQol instrument. The incremental societal costs for one additional QALY could not be calculated. The costs for one additional BPD remission with MBT-DH are approximately €29,000. There was a 58% likelihood that MBT-DH leads to more remitted patients at additional costs compared with S-TAU, and a 35% likelihood that MBT-DH leads to more remissions at lower costs. MBT-DH is not cost-effective compared with S-TAU with QALYs as the outcome, and slightly more cost-effective than S-TAU at 36 months with BPD symptoms as the outcome.

A genome-wide methylation study reveals X chromosome and childhood trauma methylation alterations associated with borderline personality disorder

Borderline personality disorder (BPD) is a severe and highly prevalent psychiatric disorder, more common in females than in males and with notable differences in presentation between genders. Recent studies have shown that epigenetic modifications such as DNA methylation may modulate gene × environment interactions and impact on neurodevelopment. We conducted an epigenome wide study (Illumina Infinium HumanMethylation450k beadchip) in a group of BPD patients with (N = 49) and without (N = 47) childhood traumas and in a control group (N = 44). Results were confirmed in a replication cohort (N = 293 BPD patients and N = 114 controls) using EpiTYPER assays. Differentially methylated CpG sites were observed in several genes and intragenic regions in the X chromosome (PQBP1, ZNF41, RPL10, cg07810091 and cg24395855) and in chromosome 6 (TAP2). BPD patients showed significantly lower methylation levels in these CpG sites than healthy controls. These differences seemed to be increased by the existence of childhood trauma. Comparisons between BPD patients with childhood trauma and patients and controls without revealed significant differences in four genes (POU5F1, GGT6, TNFRSF13C and FAM113B), none of them in the X chromosome. Gene set enrichment analyses revealed that epigenetic alterations were more frequently found in genes controlling oestrogen regulation, neurogenesis and cell differentiation. These results suggest that epigenetic alterations in the X chromosome and oestrogen-regulation genes may contribute to the development of BPD and explain the differences in presentation between genders. Furthermore, childhood trauma events may modulate the magnitude of the epigenetic alterations contributing to BPD.

Comorbid personality disorders and their impact on severe dissociative experiences in Mexican patients with borderline personality disorder

Objective: To identify personality disorders comorbid with borderline personality disorder (BPD) that may confer greater risk for the presence of severe dissociative experiences. Method: Three hundred and one outpatients with a primary diagnosis of BPD were evaluated using the Structured Clinical Interview for DSM-IV Axis II personality disorders, the Borderline Evaluation of Severity Over Time (BEST) and the Dissociative Experiences Scale (DES). Results: The most frequent personality disorders comorbid to BPD were paranoid (83.2%, n = 263) and depressive (81.3%, n = 257). The mean BEST and DES total score were 43.3 (SD = 11.4, range 15-69) and 28.6 (SD = 19.8, range 0-98), respectively. We categorized the sample into patients with and without severe dissociative experiences (41% were positive). A logistic regression model revealed that Schizotypal, Obsessive-compulsive and Antisocial personality disorders conferred greater risk for the presence of severe dissociative experiences. Discussion: Our results suggest that a large proportion of patients with BPD present a high rate of severe dissociative experiences and that some clinical factors such as personality comorbidity confer greater risk for severe dissociation, which is related to greater dysfunction and suffering, as well as a worse progression of the BPD.

Short-term versus long-term mentalization-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder: a protocol for a randomized clinical trial

Background

Psychotherapy for borderline personality disorder is often lengthy and resource-intensive. However, the current length of outpatient treatments is arbitrary and based on trials that never tested if the treatment intensity could be reduced. As a result, there is insufficient evidence to inform the decision between short-term and long-term psychotherapy for borderline personality disorder. Mentalization-based therapy is one treatment option for borderline personality disorder and consists traditionally of an 18-month treatment program.

Methods/design

This trial is an investigator-initiated single-center randomized clinical superiority trial of short-term (20 weeks) compared to long-term (14 months) mentalization-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder. Participants will be recruited from the Outpatient Clinic for Personality Disorders at Stolpegaard Psychotherapy Centre, Mental Health Services, Capital Region of Denmark. Participants will be included if they meet a minimum of four DSM-V criteria for borderline personality disorder. Participants will be assessed before randomization, and at 8, 16, and 24 months after randomization. The primary outcome is severity of borderline symptomatology assessed with the Zanarini Rating Scale for borderline personality disorder. Secondary outcomes include self-harm incidents, functional impairment (Work and Social Adjustment Scale, Global Assessment of Functioning) and quality of life (Short-Form Health Survey 36). Severity of psychiatric symptoms (Symptom Checklist 90-R) will be included as an exploratory outcome. Measures of personality functioning, attachment, borderline symptoms, group alliance, and mentalization skills will be included to explore potential predictors and mechanisms of change.

Discussion

This trial will provide evidence of the beneficial and harmful effects of short-term compared to long-term mentalization-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder.

Trial registration

ClinicalTrials.gov, NCT03677037. Registered on September 19, 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3306-7) contains supplementary material, which is available to authorized users.

Sex Differences in Personality Disorders

PURPOSE OF REVIEW

This review aims to give an overview on the current literature on sex differences in personality disorders and to highlight the potential of dimensional approaches.

RECENT FINDINGS

Empirical findings on sex differences in personality disorders are inconsistent and appear to be highly dependent on study settings. Current studies have mainly focused on borderline and antisocial personality disorder and the question whether these are sex-specific representations of a common substrate. In general, sexes differ in the manifestation of personality disorders as well as in comorbidities. Criticism of the established categorical model led to an additional dimensional model of personality disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Investigations on sex differences in personality disorders are sparse and mainly limited to antisocial and borderline personality disorder. The introduction of a dimensional model offers the chance to re-think the construct of "personality disorder" and thereby also opens the possibility for a better understanding of sex differences.

Substance Use in Youth With Borderline Personality Disorder

Co-occurring substance misuse and borderline personality disorder (BPD) in adults is associated with more severe dysfunction and poorer prognosis than BPD alone. However, it is unknown to what extent substance use in youth with BPD is normative for this age group or pathological. This study compared substance use in 117 help-seeking youth (aged 15-25 years) with their first presentation for treatment of BPD, with an epidemiological general population sample and with healthy, age- and gender-matched controls. Established instruments were used to diagnose BPD and assess substance use. Alcohol dependence, daily tobacco use, and use of illicit substances in the past month were between four and nine times more prevalent in the BPD group than in the general population. Similarly, the prevalence of substance use was disproportionately higher in youth with BPD than in matched controls. The findings indicate a non-normative, alarmingly high rate of substance use among youth with BPD.

Personality organization and its association with clinical and functional features in borderline personality disorder

Patients with borderline personality disorder (BPD) show poor psychosocial functioning over the course of their lives. To date, predictors of functionality in BPD patients have remained mostly unexplored. In this study, we aimed to assess the association between personality organization and clinical and functional features in a sample of 50 patients with BPD referred to a specialized outpatient clinic. We used the Structured Interview of Personality Organization (STIPO) to assess personality organization and the Global Assessment of Functioning (GAF) scale to measure functionality. Clinical and demographic associations with personality organization were also explored. STIPO scores were negatively correlated with GAF scores (i.e. higher scores in the STIPO dimensions, which reflected greater personality pathology, were significantly associated with lower psychosocial functioning). After controlling for potential confounders, the STIPO domain "identity" significantly accounted for 26.7% of the variance in the GAF, while the STIPO subscale "sense of self" significantly accounted for 31.2% of the variance in the GAF. These findings suggest that identity and its pathological correlate, identity diffusion, may play a key role in the functional prognosis of BPD patients.

Substance Use in Youth With Borderline Personality Disorder

Co-occurring substance misuse and borderline personality disorder (BPD) in adults is associated with more severe dysfunction and poorer prognosis than BPD alone. However, it is unknown to what extent substance use in youth with BPD is normative for this age group or pathological. This study compared substance use in 117 help-seeking youth (aged 15-25 years) with their first presentation for treatment of BPD, with an epidemiological general population sample and with healthy age- and gender-matched controls. Established instruments were used to diagnose BPD and assess substance use. Alcohol dependence, daily tobacco use, and use of illicit substances in the past month were between four and nine times more prevalent in the BPD group than in the general population. Similarly, the prevalence of substance use was disproportionately higher in youth with BPD than in matched controls. The findings indicate a non-normative, alarmingly high rate of substance use among youth with BPD.

Emotion Dysregulation and Trait Anger Sequentially Mediate the Association Between Borderline Personality Disorder and Aggression

Emotion dysregulation and trait anger are seen as central aspects of aggression in borderline personality disorder (BPD); their interplay in aggression of BPD, however, remains unclear. Using a cross-sectional design, we conducted a mediation analysis in a well-characterized sample of female and male BPD patients (n = 95). We found that emotion dysregulation and trait anger sequentially mediate the association between BPD and aggression. In accordance with major theories of BPD, emotion dysregulation may thus constitute an underlying factor that gives rise to anger and in turn to aggression in BPD. These findings may help to develop mechanism-based anti-aggressive interventions for patients with BPD, which should target emotion dysregulation and anger proneness.

Integrating Early Intervention for Borderline Personality Disorder and Mood Disorders

Borderline personality disorder (BPD) has been demonstrated to be a reliable and valid construct in young people (adolescents and young adults). Both borderline- and mood-related psychopathology become clinically apparent from puberty through to young adulthood, frequently co-occur, can reinforce one another, and can be difficult to differentiate clinically. This Gordian knot of overlapping clinical features, common risk factors, and precursors to both BPD and mood disorders complicates clinical assessment, prevention, and treatment. Regardless of whether an individual crosses an arbitrary diagnostic threshold, a considerable proportion of young people with borderline- and mood-related psychopathology will develop significant and persistent functional, vocational, and interpersonal impairment and disability during this critical risk and developmental period. There is a clear need for early intervention, but spurious diagnostic certainty risks stigma, misapplication of diagnostic labels, inappropriate treatment, and unfavorable outcomes. This article aims to integrate early intervention for BPD and mood disorders in the clinical context of developmental and phenomenological change and evolution. "Clinical staging," similar to disease staging in general medicine, is presented as a pragmatic, heuristic, and trans-diagnostic framework to guide prevention and intervention. It acknowledges that the early stages of these disorders cannot be disentangled sufficiently to allow for disorder-specific preventive measures and early interventions. Clinical staging defines an individual's location along the continuum of the evolving temporal course of a disorder. Such staging aids differentiation of early or milder clinical phenomena from those that accompany illness progression and chronicity, and suggests the application of appropriate and proportionate intervention strategies.

Borderline Personality Disorder: Why 'fast and furious'?

The term 'Borderline Personality Disorder' (BPD) refers to a psychiatric syndrome that is characterized by emotion dysregulation, impulsivity, risk-taking behavior, irritability, feelings of emptiness, self-injury and fear of abandonment, as well as unstable interpersonal relationships. BPD is not only common in psychiatric populations but also more prevalent in the general community than previously thought, and thus represents an important public health issue. In contrast to most psychiatric disorders, some symptoms associated with BPD may improve over time, even without therapy, though impaired social functioning and interpersonal disturbances in close relationships often persist. Another counterintuitive and insufficiently resolved question is why depressive symptoms and risk-taking behaviors can occur simultaneously in the same individual. Moreover, there is an ongoing debate about the nosological position of BPD, which impacts on research regarding sex differences in clinical presentation and patterns of comorbidity.In this review, it is argued that many features of BPD may be conceptualized within an evolutionary framework, namely behavioral ecology. According to Life History Theory, BPD reflects a pathological extreme or distortion of a behavioral 'strategy' which unconsciously aims at immediate exploitation of resources, both interpersonal and material, based on predictions shaped by early developmental experiences. Such a view is consistent with standard medical conceptualizations of BPD, but goes beyond classic 'deficit'-oriented models, which may have profound implications for therapeutic approaches.

Relation of borderline personality features to preincarceration HIV risk behaviors of jail inmates: Evidence for gender differences?

The present study explored the relationship between borderline personality disorder (BPD) features and preincarceration HIV risk behaviors in a sample of 499 (70% male) jail inmates, as well as gender differences in these associations. Elevated levels of BPD symptomatology were present among male and female participants, though there was considerable variance observed in participants' BPD symptoms and HIV risk behaviors. In the full sample, BPD features were positively associated with a variety of HIV risk behaviors, including injection drug use and frequency of unprotected sex with high risk partners and under high risk circumstances. Gender moderated only 2 relationships between BPD features and HIV risk behaviors, with a stronger association between BPD features and number of sexual partners, and BPD features and frequency of unprotected sex while under the influence of alcohol or drugs for women, relative to men. Taken together, these findings suggest that programs targeting HIV risk within correctional populations may benefit from considering the role of BPD features, particularly emotion regulation difficulties and impulsivity, in influencing HIV risk behaviors among both women and men.

Experiences of care by Australians with a diagnosis of borderline personality disorder

Borderline personality disorder (BPD) is a complex and challenging mental health condition for the person and service providers who support them. This paper reports on the results of a survey of 153 people with a diagnosis of BPD about their experiences of attempting to receive support in managing this mental health condition. It provides their perceptions of a range of experiences not reported in the existing literature, including general practitioner roles, urban and rural differences, public and private hospital differences, and comparison of usefulness of support across multiple support types. People with a diagnosis of BPD continue to experience significant discrimination when attempting to get their needs met within both public and private health services. Further education for nurses and other health professionals is indicated to address pervasive negative attitudes towards people with a diagnosis of BPD. There is limited understanding of the experience of seeking and receiving treatment and care by people with a diagnosis of borderline personality disorder (BPD), their perceptions of barriers to care and the quality of services they receive. This study aimed to explore these experiences from the perspective of Australians with this diagnosis. An invitation to participate in an online survey was distributed across multiple consumer and carer organizations and mental health services, by the Private Mental Health Consumer Carer Network (Australia) in 2011. Responses from 153 people with a diagnosis of BPD showed that they experience significant challenges and discrimination when attempting to get their needs met within both public and private health services, including general practice. Seeking help from hospital emergency departments during crises was particularly challenging. Metropolitan and rural differences, and gender differences, were also apparent. Community supports were perceived as inadequate to meet their needs. This study provides data on a range of experiences not reported in existing literature, including general practitioner roles, urban and rural differences, public and private hospital differences, and comparison of usefulness of support across multiple support types. Its findings can help inform better training for health professionals and better care for this population.

Gender differences in aggression of borderline personality disorder

Aggression is a core feature of borderline personality disorder (BPD). Well-replicated results from the general population indicate that men engage in aggression more frequently than women. This article addresses the question of whether gender also influences aggression in BPD, and whether the neurobiological mechanisms underlying aggressive behavior differ between male and female BPD patients. Data show that most self-reports, interviews and behavioral tasks investigating samples of BPD patients do not find enhanced aggressiveness in male patients, suggesting that BPD attenuates rather than aggravates gender differences usually present in the general population. Neurobiological studies comparing BPD patients with gender-matched healthy controls, however, reveal a number of interesting gender differences: On the one hand, there are well-replicated findings of reduced amygdala and hippocampal gray matter volumes in female BPD patients, while these findings are not shared by male patients with BPD. On the other hand, only male BPD patients exhibit reduced gray matter volume of the anterior cingulate cortex, increased gray matter volume of the putamen, reduced striatal activity during an aggression task, and a more pronounced deficit in central serotonergic responsivity. These neurobiological findings point to a particular importance of impulsivity for the aggression of male BPD patients. Limitations include the need to control for confounding influences of comorbidities, particularly as male BPD patients have been consistently found to show higher percentages of aggression-predisposing comorbid disorders, such as antisocial personality disorder, than female BPD patients. In the future, studies which include systematic comparisons between females and males are warranted in order to disentangle gender differences in aggression of BPD patients with the aim of establishing gender-sensitive treatments where needed.

Day hospital Mentalization-based treatment versus intensive outpatient Mentalization-based treatment for patients with severe borderline personality disorder: protocol of a multicentre randomized clinical trial

BACKGROUND

Borderline personality disorder (BPD) is associated with a high socioeconomic burden. Although a number of evidence-based treatments for BPD are currently available, they are not widely disseminated; furthermore, there is a need for more research concerning their efficacy and cost-effectiveness. Such knowledge promises to lead to more efficient use of resources, which will facilitate the effective dissemination of these costly treatments. This study focuses on the efficacy and cost-effectiveness of Mentalization-Based Treatment (MBT), a manualized treatment for patients with BPD. Studies to date have either investigated MBT in a day hospitalization setting (MBT-DH) or MBT offered in an intensive outpatient setting (MBT-IOP). No trial has compared the efficacy and cost-effectiveness of these MBT programmes. As both interventions differ considerably in terms of intensity of treatment, and thus potentially in terms of efficacy and cost-effectiveness, there is a need for comparative trials. This study therefore sets out to investigate the efficacy and cost-effectiveness of MBT-DH versus MBT-IOP in patients with BPD. A secondary aim is to investigate the association between baseline measures and outcome, which might improve treatment selection and thus optimize efficacy and cost-effectiveness.

METHODS/DESIGN

A multicentre randomized controlled trial comparing MBT-DH versus MBT-IOP in severe BPD patients. Patients are screened for BPD using the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, and are assessed before randomization, at the start of treatment and 6, 12, 18, 24, 30 and 36 months after the start of treatment. Patients who refuse to participate will be offered care as usual in the same treatment centre. The primary outcome measure is symptom severity as measured by the Brief Symptom Inventory. Secondary outcome measures include parasuicidal behaviour, depression, substance use, social, interpersonal, and personality functioning, attachment, mentalizing capacities, and quality of life. All analyses will be conducted based on the intention-to-treat principle. Cost-effectiveness will be calculated based on costs per quality-adjusted life-year.

DISCUSSION

This multisite randomized trial will provide data to refine criteria for treatment selection for severe BPD patients and promises to optimize (cost-)effectiveness of the treatment of BPD patients.

TRIAL REGISTRATION

NTR2292 . Registered 16 April 2010.

Sex and age differences in symptoms in borderline personality symptomatology

OBJECTIVE

Variations in the symptoms of borderline personality disorder (BPD) as a function of sex and age remain unclear. In this study, we examined sex and age differences with regard to various symptoms encountered in BPD.

METHODS

Using a compilation of four samples, all cross-sectional from the same recruitment site and with identical self-report measures for borderline personality symptomatology (BPS), we examined sex- and age-related differences with regard to borderline personality among 1,503 primary care patients.

RESULTS

Men and women did not differ significantly in their overall scores or rates of BPS. With regard to sex differences in symptoms among respondents with substantial BPS, engagement in sexually abusive relationships was more common among women than men. Overall scores and rates of BPS were greater among younger respondents compared to older respondents. With regard to age differences among those with substantial BPS, self-cutting and scratching were more common in younger individuals whereas finding life dull and meaningless was more common among older individuals.

CONCLUSIONS

There appear to be few overall symptomatic differences among individuals with borderline personality with regard to sex and age.

Day Hospital Mentalization-Based Treatment (MBT-DH) versus treatment as usual in the treatment of severe borderline personality disorder: protocol of a randomized controlled trial

BACKGROUND

Severe borderline personality disorder is associated with a very high psychosocial and economic burden. Current treatment guidelines suggest that several manualized treatments, including day hospital Mentalization-Based Treatment (MBT-DH), are effective in these patients. However, only two randomized controlled trials have compared manualized MBT-DH with treatment as usual. Given the relative paucity of data supporting the efficacy and cost-effectiveness of MBT-DH, the possible influence of researcher allegiance in one of the trials, and potential problems with the generalization of findings to mental health systems in other countries, this multi-site randomized trial aims to investigate the efficacy and cost-effectiveness of manualized MBT-DH compared to manualized specialist treatment as usual in The Netherlands.

METHODS/DESIGN

The trial is being conducted at two sites in The Netherlands. Patients with a DSM-IV-TR diagnosis of borderline personality disorder and a score of ≥ 20 on the Borderline Personality Disorder Severity Index were randomly allocated to MBT-DH or treatment as usual. The MBT-DH program consists of a maximum of 18 months' intensive treatment, followed by a maximum of 18 months of maintenance therapy. Specialist treatment as usual is provided by the City Crisis Service in Amsterdam, a service that specializes in treating patients with personality disorders, offering manualized, non-MBT interventions including family interventions, Linehan training, social skills training, and pharmacotherapy, without a maximum time limit. Patients are assessed at baseline and subsequently every 6 months up to 36 months after the start of treatment. The primary outcome measure is the frequency and severity of manifestations of borderline personality disorder as assessed by the Borderline Personality Disorder Severity Index. Secondary outcome measures include parasuicidal behaviour, symptomatic distress, social and interpersonal functioning, personality functioning, attachment, capacity for mentalizing and quality of life. Cost-effectiveness is assessed in terms of the cost per quality-adjusted life year. Outcomes will be analyzed using multilevel analyses based on intention-to-treat principles.

DISCUSSION

Severe borderline personality disorder is a serious psychological disorder that is associated with high burden. This multi-site randomized trial will provide further data concerning the efficacy and cost-effectiveness of MBT-DH for these patients.

TRIAL REGISTRATION

NTR2175.

Validation of the Spanish version of the Borderline Symptom List, short form (BSL-23)

BACKGROUND

The Borderline Symptom List-23 (BSL-23) is a reliable and valid self-report instrument for assessing Borderline Personality Disorder (BPD) severity. The psychometric properties of the original version have proven to be adequate. The aim of the present study was to validate the Spanish language version of the BSL-23.

METHODS

The BSL-23 was administered to 240 subjects with BPD diagnosis. Factor structure, reliability, test-retest stability, convergent validity, and sensitivity to change were analyzed.

RESULTS

The Spanish version of the BSL-23 replicates the one-factor structure of the original version. The scale has high reliability (Cronbach's alpha=.949), as well as good test-retest stability, which was checked in a subsample (n=74; r=.734; p<.01). The Spanish BSL-23 shows moderate to high correlations with depressive symptomatology, state and trait anxiety, hostility and impulsivity scores and BPD measures. The Spanish BSL-23 is able to discriminate among different levels of BPD severity and shows satisfactory sensitivity to change after treatment, which was verified by assessing change before and after 12 group sessions of Dialectical Behavioral Therapy in a subgroup of 31 subjects.

CONCLUSIONS

Similar to the original BSL-23, the Spanish BSL-23 is a reliable and valid instrument for assessing BPD severity and sensitivity to change.

Axis II comorbidity of borderline personality disorder in adolescents

AIMS

The objective of the present study was to explore the comorbidity of borderline personality disorder (BPD) with other personality disorders in adolescents and compare these comorbidities in male and female subjects.

METHODS

The sample was drawn from a European research project investigating the phenomenology of BPD in adolescence (EURNET BPD). A total of 85 BPD patients (11 boys and 74 girls) with a mean age of 16.3 years were included in the study.

RESULTS

According to the results of the Structured Interview for DSM-IV Disorders of Personality, obsessive-compulsive (35.3%), antisocial (22.4%), avoidant (21.2%), dependent (11.8%) and paranoid (9.4%) personality disorders had significant co-occurrences with BPD. Although none of the gender differences was statistically significant, we observed a trend towards higher rates of antisocial personality disorders in men (45.5%) than in women (19%).

CONCLUSION

The study results confirmed the frequency of Axis II comorbidity in adolescents with BPD and, for the first time, evidenced a differential pattern of comorbidity in males and females. This differential pattern must be taken into account when developing treatment strategies for adolescents with BPD.