Age differences in DSM-IV borderline personality disorder symptom expression: Results from a national study using item response theory (IRT)

Clinical Staging for Personality Disorders in Older Adults

OBJECTIVE

This scientific research aimed to investigate the feasibility of implementing a clinical staging (CS) model for personality disorders (PDs) in older adults. The CS model could provide valuable insights into the life course of personality pathology, prognosis, and treatment decisions for PDs in older adults.

METHODS/DESIGN

The study employed an international Delphi methodology with three rounds and involved 21 experts.

RESULTS

Consensus was achieved on 12 out of 17 statements, confirming the viability of a CS model for PDs in older adults. The proposed model incorporates the Alternative Model for PDs, criterion A, and integrates life course information, distinguishing between chronic PD, re-emergent PD, late-onset PD, and past PD.

CONCLUSION

The findings suggest that international experts support the implementation of a CS model for PDs in older adults, considering both the severity of personality functioning and the retrospective life course of PD expression.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Approximating defense mechanisms in a national study of adults: prevalence and correlates with functioning

Despite the clinical relevance of defense mechanisms, there are no published studies in nationally representative samples of their prevalence, correlates, and association with psychosocial functioning. We sought to estimate the prevalence and correlates of 12 defense mechanisms in the general adult population by approximating from items used to assess personality traits in the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), a representative sample of US adults (N = 36,653). We examined the associations between sociodemographic characteristics and prevalence of 3 types of defenses mechanisms (pathological, immature, and neurotic). For each defense mechanism, we used the Short-Form 12 to compare psychosocial functioning among 3 groups: those who (1) endorsed the mechanism with self-recognized impairment, (2) endorsed the mechanism without self-recognized impairment, and (3) did not endorse the defense mechanism. The prevalence of defense mechanisms ranged from 13.2% (splitting) to 44.5% (obsessive/controlling behavior). Pathological defenses were more strongly associated with immature defenses (OR = 5.4, 95% CI = 5.2-5.6) than with neurotic defenses (OR = 2.0, 95% CI = 1.9-2.0), whereas the association between immature and neurotic defenses had an intermediate value between the other two (OR = 2.2, 95% CI = 2.1-2.2). Pathological and immature defenses were associated with younger age, having been never married, lower educational attainment, and lower income. After adjusting the crude results for age and sex, individuals who did not endorse a given defense generally had higher scores on the mental health component of the SF-12 than those who endorsed the defense without self-recognized impairment who, in turn, had on average higher scores than those with self-recognized impairment. These results suggest that neurotic, immature, and pathological defense mechanisms are prevalent in the general population and associated with psychosocial impairment. Recognizing defense mechanisms may be important in clinical practice regardless of treatment modality.

The contribution of skills to the effectiveness of dialectical behavioral therapy

OBJECTIVE

The present study investigated the effectiveness of dialectical behavioral therapy (DBT) and the effect of improvement in DBT skills on clinical outcomes.

METHOD

Participants included 57 adults who attended a community mental health service and underwent one of two modes of DBT. Twenty-six adults had been diagnosed with borderline personality disorder (BPD) and participated in comprehensive DBT (DBT-C; including group skills training, individual therapy, and phone coaching). Thirty-one adults had BPD traits and participated in DBT skills training (DBT-S; group skills training only). In the present study, the DBT skills examined were mindfulness, emotion regulation, and interpersonal effectiveness; the clinical outcomes examined were borderline symptoms, psychological distress, and quality of life.

RESULTS

Six 2 × 2 analysis of covariances indicated significant improvements in psychological distress, quality of life, mindfulness, and interpersonal effectiveness (but not borderline symptoms and emotion regulation), over a 6-month period. Mode of delivery of DBT did not impact on the improvement in DBT skills and clinical outcomes over the 6-month period. Hierarchical multiple regression results indicated that improvement in DBT skills (mindfulness, emotion regulation, and interpersonal effectiveness) were associated with reductions in borderline symptoms and psychological distress, with emotion regulation the only skill uniquely associated with improvements in clinical outcomes.

CONCLUSIONS

The results of the present study support the effectiveness of DBT and the specific role of emotion regulation for favorable clinical outcomes over a 6-month period, independent of the mode of delivery of DBT.

Clinical Staging as a Novel Approach for Selecting Psychological Treatment Levels for Older Adults with Borderline Personality Disorder

OBJECTIVES

In this paper, a novel approach is presented for selecting psychological treatment levels for older adults with borderline personality disorder (BPD). BPD tends to be a lifelong disorder persisting into old age, with a specific presentation of BPD symptoms in later life, which is illustrated by three different clinical cases.

METHODS

Recently, a clinical staging and health management model for BPD was presented to assist in selecting appropriate treatment approaches.

RESULTS

We combined this clinical staging model for BPD across the lifespan with psychotherapeutic treatment levels for older adults with personality disorders.

CONCLUSIONS

This may allow for a more accurate treatment selection for older adults with BPD and was applied to the three clinical cases. Finally, implications for research and clinical practice are discussed.

Remission of Suicidal Ideation in Emotionally Unstable Personality Disorder with Flupenthixol

There are currently no licensed pharmacological treatments for Emotionally Unstable Personality Disorder. This case report describes a 50-year-old male who two years previously had been brought to the attention of psychiatric services following an overdose with intention to end his life. He was subsequently diagnosed with Emotionally Unstable Personality Disorder (EUPD) and, following further suicide attempts and trials of mainstream pharmacological treatments, responded to flupenthixol IM 20 mg fortnightly, experiencing complete remission from his suicidal ideation. Clinicians should be aware of EUPD presenting in later life and should consider the role of typical antipsychotics, including flupenthixol, in the treatment of suicidal ideation in patients with EUPD. Age-specific guidance on EUPD management would be of use to clinicians, especially in the management of older patients, as current guidance is based on findings within a narrow age group.

Borderline personality disorder and ageing: myths and realities

PURPOSE OF REVIEW

Although mental health issues in ageing individuals have been receiving more attention, borderline personality disorder (BPD) in older adults and the elderly has been relatively neglected. This article aims to review the current state of knowledge about BPD in these age groups.

RECENT FINDINGS

Studies have consistently reported decreasing prevalence rates of BPD among ageing individuals. This may be attributed to the ageing process itself and/or different clinical features due to which meeting the diagnostic criteria for BPD becomes more difficult. Ageing individuals with BPD often present in a way that makes them look 'atypical' compared to younger individuals with the same condition. In particular, this pertains to somewhat attenuated and less overt manifestations of impulsivity. However, the basic pattern of overall symptoms instability continues to characterize ageing individuals with BPD, in addition to depressive symptoms, feeling of emptiness, anger, unstable interpersonal relationships, turbulent responses when needs are not met, various somatic complaints and other symptoms.

SUMMARY

Clinicians should be aware of different clinical features of BPD as patients get older. Diagnostic criteria for BPD may need to be revised to reflect this reality, allow accurate diagnosis and minimize the risk of overlooking BPD in ageing individuals.

Heterogeneity of borderline personality disorder symptoms in help-seeking adolescents

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Development and validation of a screening instrument for borderline personality disorder (SI-Bord) for use among university students

BACKGROUND

The screening instrument for borderline personality disorder (SI-Bord) consists of a 5-item self-reported questionnaire on the key features of BPD from the DSM-5 using a 5-point Likert scale. This study investigated its validity and reliability in screening for BPD in university students.

METHODS

A cross-sectional study was conducted on a sample of university students in Thailand between November and December 2019. An online assessment gathered demographic data and results from the SI-Bord, the Perceived Stress Scale-10 (PSS-10) and the Patient Health Questionnaire-9 (PHQ-9). Participants whose SI-Bord scores were ≥ 1 were randomly selected to be interviewed and assessed for a BPD diagnosis by four psychiatrists using the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) as a reference point. An intraclass correlation coefficient (ICC) of 0.925 (95% CI, 0.805-0.979) ensured inter-rater reliability between the four psychiatrists. The diagnostic sensitivity and specificity of the SI-Bord, as compared to that of the SCID-II, were determined to indicate the cut-off score. The Receiver Operating Characteristics (ROC) was analyzed to evaluate its diagnostic accuracy.

RESULTS

The study included 342 students aged 18-25 years (the mean age was 20.25 ± 1.4 years), 80.4% of whom were female. Among the 68 participants selected for an online interview, 16 were diagnosed with BPD. The cut-off score of the SI-Bord was > 9, as suggested by the Youden index, yielding a sensitivity of 56.3% and a specificity of 92.3%. It had a positive predictive value of 69.2% and negative predictive value of 87.3%. The SI-Bord had adequate discriminative power between cases and non-cases of BPD, with the area under the ROC curve being 0.83. Cronbach's alpha for the SI-Bord was 0.76, indicating acceptable internal consistency. The SI-Bord score was positively correlated to PHQ-9 and PSS-10 scores (r = 0.67 and r = 0.69, p < 0.001, respectively) and negatively correlated to MSPSS (r = - 0.50, p < 0.001). The prevalence of BPD in the sample was 6.4%, according to the cut-off score > 9.

CONCLUSION

The SI-Bord demonstrated good reliability and validity for screening BPD in university students. However, a study in non-Thai and other population groups should be warranted.

A Life Span Perspective on Borderline Personality Disorder

PURPOSE OF REVIEW

To provide an update of a life span perspective on borderline personality disorder (BPD). We address the life span course of BPD, and discuss possible implications for assessment, treatment, and research.

RECENT FINDINGS

BPD first manifests itself in adolescence and can be distinguished reliably from normal adolescent development. The course of BPD from adolescence to late life is characterized by a symptomatic switch from affective dysregulation, impulsivity, and suicidality to maladaptive interpersonal functioning and enduring functional impairments, with subsequent remission and relapse. Dimensional models of BPD appear more age neutral and more useful across the entire life span. There is a need for age-specific interventions across the life span. BPD symptoms and impairments tend to wax and wane from adolescence up to old age, and presentation depends on contextual factors. Our understanding of the onset and early course of BPD is growing, but knowledge of BPD in late life is limited. Although the categorical criteria of DSM allow for reliable diagnosis of BPD in adolescence, dimensional models appear both more age neutral, and useful up to late life. To account for the fluctuating expression of BPD, and to guide development and selection of treatment across the life span, a clinical staging model for BPD holds promise.