Borderline personality disorder in the primary care setting

"You sure she's not making this up?": A qualitative investigation of stigma toward adults with borderline personality disorder in physical healthcare settings

Borderline personality disorder (BPD) is associated with pervasive stigma that contributes to several consequences, such as inaccessible and inadequate healthcare. Existing literature concerning the experiences of BPD stigma within healthcare settings predominantly centers on mental healthcare contexts. However, individuals with BPD also present with elevated physical disabilities and health concerns, demonstrating a need for regular contact with medical professionals to manage and coordinate physical healthcare. The current qualitative study analyzes the dynamics of stigma and consequences in medical settings for physical healthcare among individuals diagnosed with BPD. Community adults (N = 16, Mage = 29.50, 44% cisgender women) provided qualitative responses describing their experiences with stigma in medical settings other than for mental health purposes. The inductive thematic analysis generated six key themes: (1) Dismissal and Misattribution of Physical Symptoms, (2) Delayed or Inappropriate Medical Diagnosis and Intervention, (3) Communication and Advocacy Challenges, (4) Invalidation of Emotional Well-Being and Distress, (5) Self-Harm Stigma, and (6) Presumed Drug-Seeking Behavior. This article demonstrates the persistent and complex role of stigma across physical healthcare settings for individuals with BPD, affecting their physical and mental healthcare outcomes. It also identifies areas for future research and improvement and offers insights to ameliorate these issues.

Antisocial traits and neuroticism as predictors of suicidal behaviour in borderline personality disorder: A retrospective study

INTRODUCTION

The spectrum of suicidal behaviour (SB) is nuclear in the clinic and management of borderline personality disorder (BPD). The pathological personality traits of BPD intervene as risk factors for SB in confluence with other clinical and sociodemographic variables associated with BPD. The objective of this work is to evaluate the specific personality traits of BPD that are related to SB.

METHODS

A cross-sectional, observational and retrospective study was carried out on a sample of 134 patients diagnosed with BPD according to DSM-5 criteria. The Millon-II, Zuckerman-Kuhlman and Barrat questionnaires were used to assess different personality parameters. Variable comparisons were made using the χ² test and the Student's t-test. The association between variables was analysed using multivariate logistic regression.

RESULTS

Statistically significant differences were observed between SB and related factors and the neuroticism-anxiety dimension in the Zuckerman-Kuhlman test. It is also significantly related to the phobic and antisocial subscale of the Millon-II. Impulsivity measured with the Zuckerman-Kuhlman and Barrat tests does not appear to be related to SB.

CONCLUSIONS

The results presented raise the role of phobic, antisocial and neuroticism traits as possible personality traits of BPD related to SB, suggesting an even greater importance within the relationship between BPD and SB than that of impulsivity. Looking to the future, longitudinal studies would increase the scientific evidence for the specified findings.

Borderline Personality Disorder: A Review

IMPORTANCE

Borderline personality disorder (BPD) affects approximately 0.7% to 2.7% of adults in the US. The disorder is associated with considerable social and vocational impairments and greater use of medical services.

OBSERVATIONS

Borderline personality disorder is characterized by sudden shifts in identity, interpersonal relationships, and affect, as well as by impulsive behavior, periodic intense anger, feelings of emptiness, suicidal behavior, self-mutilation, transient, stress-related paranoid ideation, and severe dissociative symptoms (eg, experience of unreality of one's self or surroundings). Borderline personality disorder is typically diagnosed by a mental health specialist using semistructured interviews. Most people with BPD have coexisting mental disorders such as mood disorders (ie, major depression or bipolar disorder) (83%), anxiety disorders (85%), or substance use disorders (78%). The etiology of BPD is related to both genetic factors and adverse childhood experiences, such as sexual and physical abuse. Psychotherapy is the treatment of choice for BPD. Psychotherapy such as dialectical behavior therapy and psychodynamic therapy reduce symptom severity more than usual care, with medium effect sizes (standardized mean difference) between -0.60 and -0.65. There is no evidence that any psychoactive medication consistently improves core symptoms of BPD. For discrete and severe comorbid mental disorders, eg, major depression, pharmacotherapy such as the selective serotonin reuptake inhibitors escitalopram, sertraline, or fluoxetine may be prescribed. For short-term treatment of acute crisis in BPD, consisting of suicidal behavior or ideation, extreme anxiety, psychotic episodes, or other extreme behavior likely to endanger a patient or others, crisis management is required, which may include prescription of low-potency antipsychotics (eg, quetiapine) or off-label use of sedative antihistamines (eg, promethazine). These drugs are preferred over benzodiazepines such as diazepam or lorazepam.

CONCLUSIONS AND RELEVANCE

Borderline personality disorder affects approximately 0.7% to 2.7% of adults and is associated with functional impairment and greater use of medical services. Psychotherapy with dialectical behavior therapy and psychodynamic therapy are first-line therapies for BPD, while psychoactive medications do not improve the primary symptoms of BPD.

Barriers to Client Engagement and Strategies to Improve Participation in Mental Health and Supported Employment Services

OBJECTIVE

A few clients in every mental health center present challenging behaviors, have difficulty engaging in services, and create stress within the treatment team. The authors provided consultations on clients with these characteristics over 4 years in the Social Security Administration's Supported Employment Demonstration (SED).

METHODS

Four experienced community mental health leaders provided consultations on 105 of nearly 2,000 clients receiving team-based behavioral health and employment services in the SED. Using document analysis, consultants coded their notes and identified themes that described barriers to client engagement and strategies teams used to overcome them.

RESULTS

Clients who were difficult to engage experienced complex and interacting behavioral health, medical, and social conditions, which made it hard for therapists to develop therapeutic relationships and help clients find employment. Faced with engagement barriers, staff were often discouraged and felt hopeless about achieving success. To address these barriers, consultants and teams developed several strategies: using supervisors and teammates for support, providing persistent outreach, pursuing referrals and consultations to help with complex conditions, and developing realistic goals.

CONCLUSIONS

Supervisors, team leaders, and consultants in community mental health settings should help staff develop realistic strategies to manage the small number of clients whose behaviors present the greatest challenges. Effective strategies involve providing team-based outreach and support, fostering staff morale, obtaining specialist consultations regarding complex conditions, and calibrating realistic goals.

Demystifying borderline personality disorder in primary care

Borderline personality disorder (BPD) is a common mental health diagnosis observed in the primary care population and is associated with a variety of psychological and physical symptoms. BPD is a challenging disorder to recognize due to the limitations of accurate diagnosis and identification in primary care settings. It is also difficult to treat due to its complexity (e.g., interpersonal difficulties and patterns of unsafe behaviors, perceived stigma) and healthcare professionals often feel overwhelmed when treating this population. The aim of this article is to describe the impact of BPD in primary care, review current state of knowledge, and provide practical, evidence-based treatment approaches for these patients within this setting. Due to the lack of evidence-based pharmacological treatments, emphasis is placed on describing the framework for treatment, identifying psychotherapeutic opportunities, and managing responses to difficult clinical scenarios. Furthermore, we discuss BPD treatment as it relates to populations of special interest, including individuals facing societal discrimination and adolescents. Through this review, we aim to highlight gaps in current knowledge around managing BPD in primary care and provide direction for future study.

[Borderline Personality Disorder in the Somatic Hospital Setting]

Borderline Personality Disorder in the Somatic Hospital Setting Abstract. The Borderline Personality Disorder is a common mental illness characterized by emotional instability, interactional difficulties, an unstable sense of self and impulsive behaviour which is often self-destructive. Since these problems frequently occur in the doctor-patient relationship, patients might be regarded as "difficult" or even manipulative. This may lead to stigmatization and medical undertreatment when due to common mental and somatic comorbidities the condition requires thorough high-standard medical care. Whereas the core symptoms of BPD are well treatable by specific evidence-based psychotherapy, pharmacological interventions are less effective and should be restricted to crisis management. Through a better understanding of the disorder, proactive communication with all involved care providers and a collaborative doctor-patient relationship providing support and boundaries simultaneously the quality of medical care can be improved with long-lasting effects.

Patients With Personality Disorders in Everyday Clinical Practice–Implications of the ICD-11

BACKGROUND

Patients with difficult personalities or personality disorders are a special challenge for primary care physicians. Their style of interpersonal interaction is often difficult. As the ICD-11 classification comes into use, a new systematic approach to diagnosis is being introduced that focuses on the patient's functional impairments in everyday life. We describe the implications for the diagnosis and treatment of patients of this type.

METHODS

This review is based on pertinent publications retrieved by a selective search, with particular attention to primary care and to somatic morbidity and mortality.

RESULTS

10-12% of the population suffers from personality disorders. A high degree of psychiatric comorbidity is typical; somatic diseases are also more than twice as common as in the general population. In emergency medicine, persons with personality disorders are more likely than others to present with a suicide attempt. Their lifetime risk of suicide is between 1.4% and 4.5% (the latter for persons with borderline personality disorder).

CONCLUSION

Primary care physicians have an important role in the initial diagnosis of patients with personality disorders and in the planning of their treatment. Such patients require special care and attention from their physicians in view of their elevated somatic morbidity and mortality. In everyday clinical practice, physicians who encounter patients with complex and persistent mental problems, or just with a difficult style of interpersonal interaction, should consider the possibility of a personality disorder and motivate such patients to undergo psychotherapy, if indicated.

Efficacy of naltrexone in borderline personality disorder, a retrospective analysis in inpatients

OBJECTIVE

The endogenous opioid system is assumed to be involved in the pathophysiology of borderline personality disorder (BPD), and opioid antagonists may improve core features of BPD. The aim of this retrospective chart analysis was to evaluate the relative contribution of the opioid antagonist naltrexone and other psychotropic drugs in the improvement of overall symptomatology in BPD.

METHODS

One hundred sixty-one inpatients with BPD treated between January 2010 and October 2013 were classified as either treatment responders or non-responders. Treatment responders were defined as subjects with significant improvements in four or more symptoms from a defined symptom list. The relative contribution of all psychotropic drugs to improvement of BPD symptomatology was assessed by means of a stepwise logistic regression.

RESULTS

None of the drugs applied contributed significantly to improvement, with the exception of naltrexone (odds ratio [OR] 43.2, p ≤ 0.0001). Patients treated with naltrexone (N = 55, 34%) recovered significantly more often. Higher doses of naltrexone were more effective (OR 791.8, p ≤ 0.0001) than lower doses (OR 26.6, p ≤ 0.0001); however, even low-dose treatment was better than any other pharmacological treatment.

CONCLUSIONS

Naltrexone was associated with improvement in BPD in a dose-dependent manner. The present study provides additional evidence that dysregulation of the endogenous opioid system is implicated in the pathophysiology of BPD symptoms.

Off-label use of second-generation antipsychotics in borderline personality disorder: a comparative real-world study among oral and long-acting injectables in Spain

The aim of the present study was to evaluate the use of oral vs. long-acting injectables (LAIs) antipsychotics, as well as, to compare the effectiveness of different LAI antipsychotics [aripiprazole-1-month, paliperidone-1-month (PP1M), paliperidone-3-month (PP3M) and risperidone long-acting injectable (RLAI)] in patients diagnosed with borderline personality disorder (BPD), by evaluating the following clinical outcomes: (1) the number of hospital admissions; (2) the number of documented suicidal behaviour/attempts; and (3) the use of concomitant treatments, including benzodiazepines, oral antipsychotics and biperiden. We included a total of 116 patients diagnosed with BPD and treated with antipsychotic medication: 50 using a LAI antipsychotic formulation and 66 using the equivalent main oral antipsychotic. Patients treated with LAIs showed a decreased ratio of visits to emergency compared with the oral treatment group, and between LAIs, PP3M vs. aripiprazole-1-month group. Furthermore, patients treated with LAIs used lower number and dose of concomitant antipsychotics compared with patients treated with oral antipsychotics. Moreover, PP1M and PP3M used lower daily dose of diazepam equivalents compared with the aripiprazole-1-month and RLAI treatment groups. In conclusion, the use of LAIs may play a role in the management of BPD.

Antisocial Traits and Neuroticism as Predictors of Suicidal Behaviour in Borderline Personality Disorder: a Retrospective Study

INTRODUCTION

The spectrum of suicidal behaviour (SB) is nuclear in the clinic and management of borderline personality disorder (BPD). The pathological personality traits of BPD intervene as risk factors for SB in confluence with other clinical and sociodemographic variables associated with BPD. The objective of this work is to evaluate the specific personality traits of BPD that are related to SB.

METHODS

A cross-sectional, observational and retrospective study was carried out on a sample of 134 patients diagnosed with BPD according to DSM-5 criteria. The Millon-II, Zuckerman-Kuhlman and Barrat questionnaires were used to assess different personality parameters. Variable comparisons were made using the χ2 test and the Student's t-test. The association between variables was analysed using multivariate logistic regression.

RESULTS

Statistically significant differences were observed between SB and related factors and the neuroticism-anxiety dimension in the Zuckerman-Kuhlman test. It is also significantly related to the phobic and antisocial subscale of the Millon-II. Impulsivity measured with the Zuckerman-Kuhlman and Barrat tests does not appear to be related to SB.

CONCLUSIONS

The results presented raise the role of phobic, antisocial and neuroticism traits as possible personality traits of BPD related to SB, suggesting an even greater importance within the relationship between BPD and SB than that of impulsivity. Looking to the future, longitudinal studies would increase the scientific evidence for the specified findings.

Defense Mechanisms and Psychological Characteristics According to Suicide Attempts in Patients with Borderline Personality Disorder

OBJECTIVE

There have been many biological studies on suicide behaviors of borderline personality disorder (BPD), however few studies have sought to psychoanalytic characteristics including defense mechanisms. Therefore, we investigated psychological, symptomatic, and personality characteristics including defense mechanisms in suicide attempters and non-suicide attempters among patients with BPD.

METHODS

We enrolled 125 patients with BPD. Forty-two patients with a history of one or more suicide attempts formed the suicide attempters group and 83 patients with no such history formed the non-suicide attempters group. We collated the differences in clinical and psychological characteristics between the two groups by using the Symptom Checklist-90-Revised (SCL-90-R), the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), the Personality Disorder Questionnaire-4+ (PDQ-4+), and the Defense Style Questionnaire (DSQ).

RESULTS

The suicide attempters group scored higher on the hostility subscale of SCL-90-R. The suicide attempters group also scored higher on the Infrequency, Back Infrequency, Lie, Masculinity-femininity, Paranoia, Psychasthenia, and Schizophrenia scales of the MMPI-2. The incidence of paranoid and antisocial personality disorders, as assessed by the PDQ-4+, was significantly different in both groups. Maladaptive, self-sacrificing defense style, splitting and affiliation on the DSQ were also higher for the suicide attempters group. In the results of the logistic regression analysis, gender, the F(B) and L scales on the MMPI-2, and 'splitting of other's image' defense mechanism on the DSQ were the factors that significantly influenced to suicide attempts.

CONCLUSION

These findings suggest that impulsive psychiatric features and maladaptive defense style may be related to suicidal risk in patients with BPD. Therefore, our findings may help clinicians in estimating the risk of suicide in patients with BPD.

GPs' views and experiences of managing patients with personality disorder: a qualitative interview study

OBJECTIVE

The aim of this study was to explore GPs' views and experiences of managing patients with personality disorder (PD), and their views on the role of the Improving Access to Psychological Therapies (IAPT) programme as a support service.

DESIGN

In-depth interviews, analysed thematically.

PARTICIPANTS

Fifteen GPs (7 women and 8 men) of varying age and clinical experience, working in practices that differed in terms of the socio-demographic characteristics of their patient populations.

SETTING

Twelve general practices based in the West of England, UK.

RESULTS

GPs described patients with PD as being challenging to work with and that this work required dedicated time and care. They described experiencing particular difficulty with monitoring their patient's mental health, as well as having little knowledge about the efficacy or availability of treatments for their attenders with PD. They were aware that this patient population often experienced poor mental health and reported a propensity for them to fall into the gap between primary and secondary mental health services, leaving GPs with little choice but to improvise their own management plans, which occasionally involved funding third-sector treatment options. In terms of IAPT services' role in managing these patients, GPs wanted shorter waiting times, better inter-agency communication, more highly trained therapists and more treatment options for patients with PD. They also wanted the service to be able to 'hold' patients with PD in treatment over a longer period than currently offered.

CONCLUSIONS

Findings suggest that, overall, GPs did not consider National Health Service mental health services to offer an effective treatment for patients with PD. While they considered the IAPT programme to be a valuable service for patients with less complex mental health needs, such as depression and anxiety; they felt that the current service provision struggled to meet the needs of patients with more complex mental health needs, as exemplified by people with PD.

Exploring General Practitioners' Views and Experiences of Providing Care to People with Borderline Personality Disorder in Primary Care: A Qualitative Study in Australia

The prevalence of people seeking care for Borderline Personality Disorder (BPD) in primary care is four to five times higher than in the general population. Therefore, general practitioners (GPs) are important sources of assessment, diagnosis, treatment, and care for these patients, as well as important providers of early intervention and long-term management for mental health and associated comorbidities. A thematic analysis of two focus groups with 12 GPs in South Australia (in discussion with 10 academic, clinical, and lived experience stakeholders) highlighted many challenges faced by GPs providing care to patients with BPD. Major themes were: (1) Challenges Surrounding Diagnosis of BPD; (2) Comorbidities and Clinical Complexity; (3) Difficulties with Patient Behaviour and the GP⁻Patient Relationship; and (4) Finding and Navigating Systems for Support. Health service pathways for this high-risk/high-need patient group are dependent on the quality of care that GPs provide, which is dependent on GPs' capacity to identify and understand BPD. GPs also need to be supported sufficiently in order to develop the skills that are necessary to provide effective care for BPD patients. Systemic barriers and healthcare policy, to the extent that they dictate the organisation of primary care, are prominent structural factors obstructing GPs' attempts to address multiple comorbidities for patients with BPD. Several strategies are suggested to support GPs supporting patients with BPD.

[Pregnancies with somatic, psychiatric and social entanglements: a complex clinical presentation]

The mother-infant programme of Delafontaine hospital in Saint-Denis operates in a territory characterised by psychosocial deprivation and multiculturalism. The account of the immediate post-partum care of a patient with epilepsy having given birth to twins illustrates the possible unease of the healthcare manager and the need for coordination between the hospital and community teams to offer the mother and infant optimal safety and wellbeing.

Behavioral and Neurobiological Correlates of Disturbed Emotion Processing in Borderline Personality Disorder

One of the core symptoms of borderline personality disorder (BPD) is emotion dysregulation, which comprises emotion sensitivity, heightened and labile negative affect, deficient appropriate regulation strategies, and a surplus of maladaptive regulation strategies. Although earlier studies provided some evidence for threat hypersensitivity in terms of a negatively biased perception of other people ("negativity bias") and deficits in the recognition of full-blown anger, i.e., higher error rates and slower reaction times, researchers have only recently started studying effects of interindividual differences (e.g., sex, impulsivity, aggressiveness) and stimulus complexity as well as associations with early adversity, developmental aspects, or the specificity for BPD. Recent data also suggest a deficit in the detection of positive emotions, which needs to be addressed in more detail since it may prevent the patients from recognizing safety signals and from making positive interpersonal experiences. Neurobiologically, threat hypersensitivity has been related to increased and prolonged amygdala responses, while deficient emotion regulation was associated with reduced prefrontal inhibition of the amygdala. First results suggest that these neural alterations may be modulated by psychotherapeutic treatment focusing on emotion regulation.

Oxytocin and Borderline Personality Disorder

Borderline personality disorder (BPD) is a prevalent and severe mental disorder with affect dysregulation, impulsivity, and interpersonal dysfunction as its core features. Up to now, six studies have been performed to investigate the role of oxytocin in the pathogenesis of BPD. While a beneficial effect of oxytocin on threat processing and stress responsiveness was found, other studies using an oxytocin challenge design presented with rather heterogeneous results. Future studies have to include a sufficiently large sample of patients, control for gender, and focus on mechanisms known to be related to aversive early life experiences.

Psychotropic medication use in hospitalized patients with borderline personality disorder

Introduction:

Use of medications to treat symptoms of borderline personality disorder (BPD) is controversial. The purpose of this study was to describe psychotropic medication use in hospitalized patients with BPD and compare with a control group.

Methods:

A retrospective chart review was conducted on hospitalized patients aged 18-65 years having a diagnosis of BPD and compared them with a control group of patients with a diagnosis of major depressive disorder (MDD) without a personality disorder. Patients were excluded from the BPD group if other personality disorders were recorded. Charts were reviewed for demographics and psychotropic medication usage both prior to admission and at discharge.

Results:

This study included 165 patients (85 in BPD; 80 in MDD). Prior to admission and upon discharge, patients in the BPD group were prescribed significantly more psychotropic medications than patients with MDD (3.21 vs 2.10; P < .001 and 2.87 vs 2.35; P < .05, respectively). Patients in the BPD group were significantly more likely to be prescribed antipsychotics, mood stabilizers, and miscellaneous agents compared with the MDD group. On admission, significantly more BPD patients were prescribed multiple sedative agents (37.6% vs 21.3%; P < .05), but because of the discontinuation of sedative agents, this difference was nonsignificant upon discharge.

Discussion:

This study found increased medication utilization among patients with BPD. Polypharmacy may increase the risk of side effects, drug interactions, and drug toxicity for BPD patients. Clinicians need to carefully evaluate the efficacy and risk of medications prescribed in patients with BPD.