Borderline personality disorder: health service use and social functioning among a national household population

What predicts psychosocial functioning in borderline personality disorder? Investigating the association with reflective functioning

OBJECTIVES

The aim of this study was to investigate factors associated with functioning in participants with and without borderline personality disorder (BPD). In particular, we were interested whether mentalizing and related social cognitive capacities, as factors of internal functioning, are important in predicting psychosocial functioning, in addition to other psychopathological and sociodemographic factors.

METHOD

This is a cross-sectional study with N = 53 right-handed females with and without BPD, without significant differences in age, IQ, and socioeconomic status, who completed semi-structured diagnostic and self-report measures of social cognition. Mentalizing was assessed using the Reflective Functioning Scale based on transcribed Adult Attachment Interviews. A regularized regression with the elastic net penalty was deployed to investigate whether mentalizing and social cognition predict psychosocial functioning.

RESULTS

Borderline personality disorder symptom severity, sexual abuse trauma, and social and socio-economic factors ranked as the most important variables in predicting psychosocial functioning, while reflective functioning (RF) was somewhat less important in the prediction, social cognitive functioning and sociodemographic variables were least important.

CONCLUSIONS

Borderline personality disorder symptom severity was most important in determining functional impairment, alongside trauma related to sexual abuse as well as social and socio-economic factors. These findings verify that BPD symptoms themselves most robustly predict functional impairment, followed by history of sexual abuse, then contextual factors (e.g. housing, financial, physical health), and then RF. These results lend marginal support to the conceptualization that mentalizing may enhance psychosocial functioning by facilitating social learning, but emphasize symptom reduction and stabilization of life context as key intervention targets.

Clinical effectiveness and cost-effectiveness of Structured Psychological Support for people with probable personality disorder in mental health services in England: study protocol for a randomised controlled trial

INTRODUCTION

Evidence-based psychological treatments for people with personality disorder usually involve attending group-based sessions over many months. Low-intensity psychological interventions of less than 6 months duration have been developed, but their clinical effectiveness and cost-effectiveness are unclear.

METHODS AND ANALYSIS

This is a multicentre, randomised, parallel-group, researcher-masked, superiority trial. Study participants will be aged 18 and over, have probable personality disorder and be treated by mental health staff in seven centres in England. We will exclude people who are: unwilling or unable to provide written informed consent, have a coexisting organic or psychotic mental disorder, or are already receiving psychological treatment for personality disorder or on a waiting list for such treatment. In the intervention group, participants will be offered up to 10 individual sessions of Structured Psychological Support. In the control group, participants will be offered treatment as usual plus a single session of personalised crisis planning. The primary outcome is social functioning measured over 12 months using total score on the Work and Social Adjustment Scale (WSAS). Secondary outcomes include mental health, suicidal behaviour, health-related quality of life, patient-rated global improvement and satisfaction, and resource use and costs. The primary analysis will compare WSAS scores across the 12-month period using a general linear mixed model adjusting for baseline scores, allocation group and study centre on an intention-to-treat basis. In a parallel process evaluation, we will analyse qualitative data from interviews with study participants, clinical staff and researchers to examine mechanisms of impact and contextual factors.

ETHICS AND DISSEMINATION

The study complies with the Helsinki Declaration II and is approved by the London-Bromley Research Ethics Committee (IRAS ID 315951). Study findings will be published in an open access peer-reviewed journal; and disseminated at national and international conferences.

TRIAL REGISTRATION NUMBER

ISRCTN13918289.

Physical health, primary care utilization and long-term quality of life in borderline personality disorder: A 10-year follow-up study in a Spanish sample

OBJECTIVE

We aimed to study physical health and primary care utilization in the long-term course of borderline personality disorder (BPD) and their impact on quality of life (QOL) in a Spanish clinical sample.

METHODS

This study is part of a longitudinal study following a clinical cohort with BPD. A total of 41 participants were re-evaluated at 10-year follow-up, when current medical conditions, primary care utilization, and quality of life were assessed. Comparative population data were extracted from the Catalan Health Survey ESCA.

RESULTS

68% of BPD patients reported physical health problems, and 32% informed of multiple medical illnesses at follow-up. Higher rates of musculoskeletal disorders and frequent use of general practitioner (GP) consultations were reported by BPD patients compared to the general population. Differences in physical health and use of primary care services between remitted and non-remitted BPD patients were not significant. BPD remission was independently associated with better long-term QOL. Comorbid somatic diseases worsened the long-term QOL of non-remitted BPD patients.

CONCLUSION

Chronic somatic conditions are prevalent in people with BPD and interact negatively with persistent BPD pathology, worsening their QOL in the long-term. Health care strategies in the assistance of long-lasting BPD patients are recommended.

Assessing the quality of the care offer for people with personality disorders in Italy: the QUADIM project. A multicentre research based on the database of use of Mental Health services

BACKGROUND

Italy can be viewed as a laboratory to assess the quality of mental healthcare delivered in a community-oriented system, especially for severe mental disorders, such as personality disorders. Although initiatives based on clinical indicators for assessing the quality of mental healthcare have been developed by transnational-organisations, there is still no widespread practice of measuring the quality of care pathways delivered to patients with severe mental disorders in a community-oriented system, especially using administrative healthcare databases. The aim of the study is to evaluate the quality of care delivered to patients with personality disorders taken-in-care by mental health services of four Italian regions (Lombardy, Emilia-Romagna, Lazio, Sicily).

METHODS

A set of thirty-three clinical indicators, concerning accessibility, appropriateness, continuity, and safety of care, was implemented using regional healthcare utilization databases, containing data on mental health treatments and diagnosis, hospital admissions, outpatient interventions and exams and drug prescriptions.

RESULTS

31,688 prevalent patients with personality disorders treated in 2015 were identified, of whom 2,331 newly taken-in-care. One-in-10 patients received a standardized assessment, the treatment discontinuity affected half of the cases. 12.7% of prevalent patients received at least one hospitalization, 10.6% in the newly taken-in-care cohort. 6-out-of-10 patients had contact with community-services within 14 days from hospital discharge. Access to psychotherapy and psychoeducational treatments was low and delivered with a low intensity. The median of psychosocial interventions per person-year was 19.1 and 9.4, respectively, in prevalent and newly taken-in-care cases. Nearly 50% of patients received pharmacological treatments.

CONCLUSIONS

Healthcare utilization databases were used to systematically evaluate and assess service delivery across regional mental health systems; suggesting that in Italy the public mental health services provide to individuals with personality disorders suboptimal treatment paths.

Correlates of Homelessness Among Adults with Personality Disorder

Although personality disorders (PDs) are more common among persons experiencing homelessness than the general population, few studies have investigated the risk of experiencing homelessness among persons with PDs. This study seeks to identify the demographic, socioeconomic, and behavioral health correlates of past-year homelessness among persons with antisocial, borderline, and schizotypal PDs. Nationally representative data of the civilian, noninstitutionalized population of the United States was used to identify correlates of homelessness. Descriptive statistics and bivariate associations between variables and homeless status were summarized prior to conducting several multivariate logistic regression models to identify correlates of homelessness. Main findings revealed positive associations between poverty, relationship dysfunction, and lifetime suicide attempt with homelessness. In the antisocial PD (ASPD) and borderline PD (BPD) models, comorbid BPD and ASPD, respectively, were associated with higher odds of past-year homelessness. Findings underscore the importance of poverty, interpersonal difficulties, and behavioral health comorbidities on homelessness among persons with ASPD, BPD, and schizotypal PD. Strategies to promote economic security, stable relationships, and interpersonal functioning may buffer against the effects of economic volatility and other systemic factors that could contribute to homelessness and persons with PD.

Patient perspectives on non-response to psychotherapy for borderline personality disorder: a qualitative study

BACKGROUND

Despite increasing evidence for the effectiveness of psychotherapy for Borderline Personality Disorder (BPD), estimates show that approximately half of those in treatment do not clinically improve or reach reliable change criteria. There are limited qualitative descriptions of treatment factors associated with non-response from the perspectives of those struggling to improve.

METHOD

Eighteen people (72.2% female, mean age 29.4 (SD = 8)) with experience of receiving psychotherapeutic treatment for BPD were interviewed to obtain their perspectives on hindering factors in treatment and what may be helpful to reduce non-response. The data in this qualitative study was analysed thematically.

RESULTS

Four domains were created from the insights patients shared on non-response and what may be needed to mitigate it. The focus of Domain 1 was that therapy cannot be effective until two factors are in place. First, the patient needs sufficient safety and stability in their environment in order to face the challenges of therapy. Second, they need to be able to access therapy. Domain 2 described factors the patients themselves contribute. The themes in this domain were described as phases that need to be progressed through before therapy can be effective. These phases were ceasing denial that help is warranted and deserved, taking responsibility for behaviours that contribute to unwellness, and committing to the hard work that is required for change. Domain 3 described how the lack of a safe alliance and ruptures in the safety of the relationship with the therapist can contribute to non-response. Domain 4 was comprised of factors that patients identified as supportive of moving through the barriers to response. The first theme in this domain was prioritising the safety of the therapy relationship. The second theme was giving a clear diagnosis and taking a collaborative approach in sessions. The final theme described the importance of focusing on practical goals with the patient to create tangible life changes.

CONCLUSION

This study found that non-response is complex and multifaceted. First, it is clear that systems need to be in place to support access to adequate care and foster life stability. Second, considerable effort may be needed at the engagement phase of therapy to clarify expectations. Third, attention to specific interpersonal challenges between patients and therapists is an important focus. Finally, structured work to improve relationships and vocational outcomes is indicated.

Crisis resolution home treatment team Clinicians' perceptions of using a recovery approach with people with a diagnosis of borderline personality disorder

WHAT IS KNOWN ON THE SUBJECT?: It is known that people with a diagnosis of borderline personality disorder often experience crises in their mental wellbeing. There is little evidence about the approaches of mental health nurses in community-based crisis teams when working with people with a diagnosis of BPD. WHAT THE PAPER ADDS TO THE EXISTING KNOWLEDGE?: This paper highlights that limited resources, work-patterns and issues of stigma present challenges to delivering recovery-oriented care. The paper highlights that nurses typically try to navigate the challenges to continue to provide individualized care, though their self-assessment is that this is with mixed success. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The findings suggest that support is needed to develop brief interventions specific to teams working with people with a diagnosis of BPD who are at a point of crisis. ABSTRACT: Introduction People with a diagnosis of borderline personality disorder (BPD) are often in contact with mental health services at a point of crisis, and in the UK, this includes Crisis Resolution Home Treatment teams (CRHTT). There is a drive for services to be recovery orientated; however, there is little evidence about the degree to which community services achieve this for people with a diagnosis of BPD when in crisis. Research Aim To understand the perceptions held by CRHTT clinicians about their provision of recovery-orientated acute care, for people with a diagnosis of BPD. Method From a purposive sample of a single CRHTT, seven registered mental health nurses were interviewed and Braun and Clarke's thematic analysis framework was used to interpret the data. Results Five themes emerged: person-centred care; the timing is wrong; inconsistent staffing; the risks are too great; and BPD as a label. Discussion The results demonstrate tensions between a drive to deliver person-centred care and a range of challenges that inhibit this, with the possibility of reframing a recovery approach as "recovery-ready". Implications for Practice A whole-system approach is required to enable a consistent recovery-oriented approach, but research is also needed for brief interventions specific to this context.

Crisis interventions for adults with borderline personality disorder

BACKGROUND

People diagnosed with borderline personality disorder (BPD) frequently present to healthcare services in crisis, often with suicidal thoughts or actions. Despite this, little is known about what constitutes effective management of acute crises in this population and what type of interventions are helpful at times of crisis. In this review, we will examine the efficacy of crisis interventions, defined as an immediate response by one or more individuals to the acute distress experienced by another individual, designed to ensure safety and recovery and lasting no longer than one month. This review is an update of a previous Cochrane Review examining the evidence for the effects of crisis interventions in adults diagnosed with BPD.

OBJECTIVES

To assess the effects of crisis interventions in adults diagnosed with BPD in any setting.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, nine other databases and three trials registers up to January 2022. We also checked reference lists, handsearched relevant journal archives and contacted experts in the field to identify any unpublished or ongoing studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing crisis interventions with usual care, no intervention or waiting list, in adults of any age diagnosed with BPD.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included two studies with 213 participants. One study (88 participants) was a feasibility RCT conducted in the UK that examined the effects of joint crisis plans (JCPs) plus treatment as usual (TAU) compared to TAU alone in people diagnosed with BPD. The primary outcome was self-harm. Participants had an average age of 36 years, and 81% were women. Government research councils funded the study. Risk of bias was unclear for blinding, but low in the other domains assessed. Evidence from this study suggested that there may be no difference between JCPs and TAU on deaths (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.06 to 14.14; 88 participants; low-certainty evidence); mean number of self-harm episodes (mean difference (MD) 0.30, 95% CI -36.27 to 36.87; 72 participants; low-certainty evidence), number of inpatient mental health nights (MD 1.80, 95% CI -5.06 to 8.66; 73 participants; low-certainty evidence), or quality of life measured using the EuroQol five-dimension questionnaire (EQ-5D; MD -6.10, 95% CI -15.52 to 3.32; 72 participants; very low-certainty evidence). The study authors calculated an Incremental Cost Effectiveness Ratio of GBP -32,358 per quality-adjusted life year (QALY), favouring JCPs, but they described this result as "hypothesis-generating only" and we rated this as very low-certainty evidence.  The other study (125 participants) was an RCT conducted in Sweden of brief admission to psychiatric hospital by self-referral (BA) compared to TAU, in people with self-harm or suicidal behaviour and three or more diagnostic criteria for BPD. The primary outcome was use of inpatient mental health services. Participants had an average age of 32 years, and 85% were women. Government research councils and non-profit foundations funded the study. Risk of bias was unclear for blinding and baseline imbalances, but low in the other domains assessed. The evidence suggested that there is no clear difference between BA and TAU on deaths (RR 0.49, 95% CI 0.05 to 5.29; 125 participants; low-certainty evidence), mean number of self-harm episodes (MD -0.03, 95% CI -2.26 to 2.20; 125 participants; low-certainty evidence), violence perpetration (RR 2.95, 95% CI 0.12 to 71.13; 125 participants; low-certainty evidence), or days of inpatient mental health care (MD 0.70, 95% CI -14.32 to 15.72; 125 participants; low-certainty evidence). The study suggested that BA may have little or no effect on the mean number of suicide attempts (MD 0.00, 95% CI -0.06 to 0.06; 125 participants; very low-certainty evidence). We also identified three ongoing RCTs that met our inclusion criteria. The results will be incorporated into future updates of this review.

AUTHORS' CONCLUSIONS

A comprehensive search of the literature revealed very little RCT-based evidence to inform the management of acute crises in people diagnosed with BPD. We included two studies of two very different types of intervention (JCP and BA). We found no clear evidence of a benefit over TAU in any of our main outcomes. We are very uncertain about the true effects of either intervention, as the evidence was judged low- and very low-certainty, and there was only a single study of each intervention. There is an urgent need for high-quality, large-scale, adequately powered RCTs on crisis interventions for people diagnosed with BPD, in addition to development of new crisis interventions.

Expressed Emotion and Health Care Use in Borderline Personality Disorder Patients and Relatives

Introduction: Expressed emotion (EE) is a global index of attitudes, emotions, and behaviors of relatives who have family members with a mental or psychiatric disorder. The objective of this cross-sectional study was to study EE in relatives and patients’ perceived EE in a borderline personality disorder (BPD) outpatient sample. Methods: The sample was composed of 134 relatives and 111 BPD outpatients who were receiving psychological treatment. Relevant clinical outcomes, number of medical visits, EE in relatives and perceived EE in BPD patients were measured. Subsequently, descriptive statistical analyses, dependent-samples t tests, and correlation analyses were performed. Results: Relatives' EE was not significantly different than patients' perceived EE. Expressed emotion factors were weakly associated to emergency department visits and hospital admissions. Discussion: Contrary to EE studies in other diagnoses, results show that the BPD patients' emotional climate in their proximate relationships might not influence health care use.

Clinician perspectives on what constitutes good practice in community services for people with complex emotional needs: A qualitative thematic meta-synthesis

INTRODUCTION

The need to improve the quality of community mental health services for people with Complex Emotional Needs (CEN) (who may have a diagnosis of 'personality disorder') is recognised internationally and has become a renewed policy priority in England. Such improvement requires positive engagement from clinicians across the service system, and their perspectives on achieving good practice need to be understood.

AIM

To synthesise qualitative evidence on clinician perspectives on what constitutes good practice, and what helps or prevents it being achieved, in community mental health services for people with CEN.

METHODS

Six bibliographic databases were searched for studies published since 2003 and supplementary citation tracking was conducted. Studies that used any recognised qualitative method and reported clinician experiences and perspectives on community-based mental health services for adults with CEN were eligible for this review, including generic and specialist settings. Meta-synthesis was used to generate and synthesise over-arching themes across included studies.

RESULTS

Twenty-nine papers were eligible for inclusion, most with samples given a 'personality disorder' diagnosis. Six over-arching themes were identified: 1. The use and misuse of diagnosis; 2. The patient journey into services: nowhere to go; 3. Therapeutic relationships: connection and distance; 4. The nature of treatment: not doing too much or too little; 5. Managing safety issues and crises: being measured and proactive; 6. Clinician and wider service needs: whose needs are they anyway? The overall quality of the evidence was moderate.

DISCUSSION

Through summarising the literature on clinician perspectives on good practice for people with CEN, over-arching priorities were identified on which there appears to be substantial consensus. In their focus on needs such as for a long-term perspective on treatment journeys, high quality and consistent therapeutic relationships, and a balanced approach to safety, clinician priorities are mainly congruent with those found in studies on service user views. They also identify clinician needs that should be met for good care to be provided, including for supervision, joint working and organisational support.

Welfare consequences of early-onset Borderline Personality Disorder: a nationwide register-based case-control study

Information regarding welfare consequences of early onset of Borderline Personality Disorder (BPD) is limited. This nationwide study aimed to estimate the educational and employment outcome and health care costs of patients with early-onset BPD compared with matched controls. All patients (< 19 years) with first diagnosis of BPD in the Danish Patient Register (NPR) during the period 1983-2015 were included. Health care costs and socioeconomic variables were extracted from national registers. A total of 171 patients was compared with 677 controls. At the age of 20 years, BPD patients had reached a statistically significantly lower educational level (including lower primary school grades) and employment status compared with the controls. When adjusting for the parents' educational level, BPD patients were nearly 22 times more likely to be unemployed (OR = 21.7, 95% CI 11.9, 39.6), and nearly 15 times more likely to be on disability pension (OR = 14.8, 95% CI 5.0, 43.9) than controls. Furthermore, the total health care costs were more than 8 times higher in the BPD group. Early onset of BPD was associated with lower educational and vocational outcome and increased health care costs as early as at the age of 20 years. Even after controlling for parents' lower socioeconomic status, the patients have poorer outcome than the control group. This underlines that initiatives to support patients in finishing school and secondary education is highly needed. Future prevention and early intervention programs should target patients with early-onset BPD and their families.

The Added Burden of Personality Disorder on Subsidized Australian Health Service Utilization Among Women With Mental State Disorder

This study aimed to investigate health service utilization among women with mental state disorder only (MSD-PD), mental state disorder plus personality disorder (MSD+PD), and controls in a population-based sample. Women (n = 635) from the Geelong Osteoporosis Study completed mental health assessments and were categorized into groups (MSD-PD, MSD+PD, controls). General practitioner (mental and non-mental health encounters) and specialized mental health service utilization was ascertained from data linkage to the Medicare Benefits Schedule, Australia (01/09/2008-31/12/2012). Negative binomial and binary logistic regression models were employed to assess health service utilization differences between groups. Results indicated that women with MSD+PD had more encounters of non-mental health service utilization than women with MSD-PD and controls. Age significantly modified these relationships: women with MSD+PD and MSD-PD had more encounters of health service utilization at midlife and in the seventh decade of life. No significant differences were found in the frequency of general practitioner mental health service utilization or specialized mental health service utilization between groups. These data suggest that the presence of co-occurring PD is associated with increased health service utilization among women with other common mental health problems. Healthcare providers should be vigilant to the presence of PD when establishing management plans with patients presenting with common mental health problems.

Costs of schizotypal disorder: A matched-controlled nationwide register-based study of patients and spouses

OBJECTIVE

Information on societal cost of patients with schizotypal disorder is limited. The aim was to investigate the societal costs of schizotypal disorder before and after initial diagnosis including both patients and their spouses.

METHODS

A register-based cohort study of 762 patients with incident schizotypal disorder (ICD-10; F21) including their spouses and 3048 matched controls, during 2002 to 2016. Total healthcare costs, home care costs, and costs of lost productivity of patients and spouses were included in the analysis.

RESULTS

Total costs amounted €47,215 per year for patients with schizotypal disorder, which was fifteen times higher than the matched controls. Of these, 41% were healthcare and home care costs and 59% were costs of lost productivity. Healthcare costs and costs of lost productivity were increased during five years before initial diagnosis of schizotypal disorder. Total costs of spouses to patients were €21,384 compared with € 2519 among spouses of controls. 75% of the total costs of spouses to patients were related to lost productivity. The total costs were higher than the costs of borderline personality disorder, but on the same level as the costs of schizophrenia identified in earlier comparable studies.

CONCLUSIONS

The total societal costs of patients with schizotypal disorder drawn from national registers differed substantially from the controls representing the general population. As evidence-based recommendations for diagnoses and treatment of patients with schizotypal disorder do not exist, future research should focus on developing effective treatment for this group of patients to reduce cost of illness.

EEG Markers in Emotionally Unstable Personality Disorder-A Possible Outcome Measure for Neurofeedback: A Narrative Review

Objectives. There is growing evidence for the use of biofeedback (BF) in affective disorders, dissocial personality disorder, and in children with histories of abuse. Electroencephalogram (EEG) markers could be used as neurofeedback in emotionally unstable personality disorder (EUPD) management especially for those at high risk of suicide when emotionally aroused. This narrative review investigates the evidence for EEG markers in EUPD. Methods. PRISMA guidelines were used to conduct a narrative review. A structured search method was developed and implemented in collaboration with an information specialist. Studies were identified via 3 electronic database searches of MEDLINE, Embase, and PsycINFO. A predesigned inclusion/exclusion criterion was applied to selected papers. A thematic analysis approach with 5 criteria was used. Results. From an initial long list of 5250 papers, 229 studies were identified and screened, of which 44 met at least 3 of the predesigned inclusion criteria. No research to date investigates EEG-based neurofeedback in EUPD. A number of different EEG biomarkers are identified but there is poor consistency between studies. Conclusions. The findings heterogeneity may be due to the disorder complexity and the variable EEG related parameters studied. An alternative explanation may be that there are a number of different neuromarkers, which could be clustered together with clinical symptomatology, to give new subdomains. Quantitative EEGs in particular may be helpful to identify more specific abnormalities. EEG standardization of neurofeedback protocols based on specific EEG abnormalities detected may facilitate targeted use of neurofeedback as an intervention in EUPD.

Clinical characteristics and care pathways of patients with personality disorder who died by suicide

BACKGROUND

It is estimated that 1 in 10 people have a personality disorder. People with emotionally unstable personality disorder are at high risk of suicide. Despite being frequent users of mental health services, there is often no clear pathway for patients to access effective treatments.

AIMS

To describe the characteristics of patients with personality disorder who died by suicide, examine clinical care pathways and explore whether the care adhered to National Institute for Health and Care Excellence guidance.

METHOD

National consecutive case series (1 January 2013 to 31 December 2013). The study examined the health records and serious incident reports of patients with personality disorder who died by suicide in the UK.

RESULTS

The majority had a diagnosis of borderline/emotionally unstable or antisocial personality disorder. A high proportion of patients had a history of self-harm (n = 146, 95%) and alcohol (n = 101, 66%) or drug misuse (n = 79, 52%). We found an extensive pattern of service contact in the year before death, with no clear pathway for patients. Care was inconsistent and there were gaps in service provision. In 99 (70%) of the 141 patients with data, the last episode of care followed a crisis. Access to specialised psychological therapies was limited; short-term in-patient admissions was adhered to; however, guidance on short-term prescribing for comorbid conditions was not followed for two-thirds of patients.

CONCLUSIONS

Continuity and stability of care is required to prevent, rather than respond to individuals in crisis. A comprehensive audit of services for people with personality disorder across the UK is recommended to assess the quality of care provided.

Structured Psychological Support for people with personality disorder: feasibility randomised controlled trial of a low-intensity intervention

BACKGROUND

National guidance cautions against low-intensity interventions for people with personality disorder, but evidence from trials is lacking.

AIMS

To test the feasibility of conducting a randomised trial of a low-intensity intervention for people with personality disorder.

METHOD

Single-blind, feasibility trial (trial registration: ISRCTN14994755). We recruited people aged 18 or over with a clinical diagnosis of personality disorder from mental health services, excluding those with a coexisting organic or psychotic mental disorder. We randomly allocated participants via a remote system on a 1:1 ratio to six to ten sessions of Structured Psychological Support (SPS) or to treatment as usual. We assessed social functioning, mental health, health-related quality of life, satisfaction with care and resource use and costs at baseline and 24 weeks after randomisation.

RESULTS

A total of 63 participants were randomly assigned to either SPS (n = 33) or treatment as usual (n = 30). Twenty-nine (88%) of those in the active arm of the trial received one or more session (median 7). Among 46 (73%) who were followed up at 24 weeks, social dysfunction was lower (-6.3, 95% CI -12.0 to -0.6, P = 0.03) and satisfaction with care was higher (6.5, 95% CI 2.5 to 10.4; P = 0.002) in those allocated to SPS. Statistically significant differences were not found in other outcomes. The cost of the intervention was low and total costs over 24 weeks were similar in both groups.

CONCLUSIONS

SPS may provide an effective low-intensity intervention for people with personality disorder and should be tested in fully powered clinical trials.

Features of YouTube™ videos produced by individuals who self-identify with borderline personality disorder

Objectives

Many individuals use YouTube™ to seek out information and share first-hand experiences about mental illnesses, as well as to gain a sense of community. YouTube™ use may be especially appealing when offline supports are lacking or difficult to access, and when there is a fear of stigmatisation. Borderline personality disorder (BPD), also referred to as emotionally unstable personality disorder (EUPD), is a complex and often stigmatised mental-health disorder. The primary objective of this study was to describe the dominant messages that individuals who self-identify with the diagnosis of BPD present through YouTube™ videos.

Methods

The content analysis method was used to review 349 first-person YouTube™ uploads. Videos were coded for information regarding video and vlogger characteristics, video type, vlogger motivation and video content. Associations between video features including upload date and style and vlogger experience and motivation were examined.

Results

Findings indicate that more people who self-identify as being diagnosed with BPD are creating YouTube™ videos about their experiences, and these videos have shifted over time from being mostly anonymous multimedia productions to being monologues where the vlogger speaks directly to their audience. Discussions related to DSM-5 symptoms, treatment, effective coping and hope for the future are elements found in the uploads.

Conclusion

The nature and content of BPD first-person YouTube™ uploads has increased and changed over time. Increased awareness of these changes may assist mental-health practitioners to support clients and direct them to explore uploads that offer hope and promote engagement in help-seeking and effective coping behaviours.

Societal costs of Borderline Personality Disorders: a matched-controlled nationwide study of patients and spouses

OBJECTIVE

Information on societal cost of patients with Borderline Personality Disorder (BPD) and spouses is limited. The aim was to investigate factual societal costs before and after initial BPD diagnosis.

METHOD

A register-based cohort study of 2756 patients with incident BPD (ICD F60.3) with spouses and 11 024 matched controls, during 2002-2016.

RESULTS

Total direct healthcare costs and lost productivity costs amounted €40 441 for patients with BPD, which was more than 16 times higher than the matched controls. Somatic and psychiatric health care costs and costs of lost productivity were increased during 5 years before initial diagnosis of BPD. Before and after initial diagnosis, health care costs and lost productivity were increased among spouses of patients with BPD.

CONCLUSION

Patients with BPD differed substantially from the general population with respect to all included costs. The study documented a significant burden on their spouses. Besides the early onset of BPD, which implies that patients are affected before they finish school and enter labor market, the neurocognitive impairment and fundamental symptoms of BPD, e.g. unstable, intense relationships, impulsivity, and lack of stable sense of self together with psychiatric and somatic comorbidity are part of explanation of the excess costs of BPD.

Borderline Personality Disorder in Patients With Medical Illness: A Review of Assessment, Prevalence, and Treatment Options

OBJECTIVE

Borderline personality disorder (BPD) occurs in 0.7% to 3.5% of the general population. Patients with BPD experience excessive comorbidity of psychiatric and somatic diseases and are known to be high users of health care services. Because of a range of challenges related to adverse health behaviors and their interpersonal style, patients with BPD are often regarded as "difficult" to interact with and treat optimally.

METHODS

This narrative review focuses on epidemiological studies on BPD and its comorbidity with a specific focus on somatic illness. Empirically validated treatments are summarized, and implementation of specific treatment models is discussed.

RESULTS

The prevalence of BPD among psychiatric inpatients (9%-14%) and outpatients (12%-18%) is high; medical service use is very frequent, annual societal costs vary between &OV0556;11,000 and &OV0556;28,000. BPD is associated with cardiovascular diseases and stroke, metabolic disease including diabetes and obesity, gastrointestinal disease, arthritis and chronic pain, venereal diseases, and HIV infection as well as sleep disorders. Psychotherapy is the treatment of choice for BPD. Several manualized treatments for BPD have been empirically validated, including dialectical behavior therapy, transference-focused psychotherapy, mentalization-based therapy, and schema-focused therapy.

CONCLUSIONS

Health care could be substantially improved if all medical specialties would be familiar with BPD, its pathology, medical and psychiatric comorbidities, complications, and treatment. In mental health care, several empirically validated treatments that are applicable in a wide range of clinical settings are available.

Treatment of Borderline Personality Disorder: Is Supply Adequate to Meet Public Health Needs?

OBJECTIVES

This study aimed to assess the supply of and demand for treatment of borderline personality disorder (BPD) to inform current standards of care and training in the context of available resources worldwide.

METHODS

The total supply of mental health professionals and mental health professionals certified in specialist evidence-based treatments for BPD was estimated for 22 countries by using data from publicly available sources and training programs. BPD prevalence and treatment-seeking rates were drawn from large-scale national epidemiological studies. Ratios of treatment-seeking patients to available providers were computed to assess whether current systems are able to meet demand. Training and certification requirements were summarized.

RESULTS

The ratio of treatment-seeking patients with BPD to mental health professionals (irrespective of professionals' interest or training in treating BPD) ranged from approximately 4:1 in Australia, the Netherlands, and Norway to 192:1 in Singapore. The ratio of treatment-seeking patients to clinicians certified in providing evidence-based care ranged from 49:1 in Norway to 148,215:1 in Mexico. Certification requirements differed by treatment and by country.

CONCLUSIONS

Shortages of both providers available to treat BPD and providers certified in specialist treatments of BPD exist in most of the 22 countries studied. In well-resourced countries, training clinicians to provide generalist or abbreviated treatments for BPD, in addition to specialist treatments, could help address the current implementation gap. More resource-efficient alternatives must be considered in countries with insufficient staff to implement even generalist treatments. Consideration of realistic allocation of care may shape future guidelines and standards of BPD treatments, beyond intensive evidence-based psychotherapies.

Barriers and facilitators to employment in borderline personality disorder: A qualitative study among patients, mental health practitioners and insurance physicians

Background

Borderline personality disorder (BPD) is associated with unemployment and impaired functioning. However, a comprehensive understanding of barriers and facilitators to employment from a multidisciplinary perspective is currently lacking. Therefore, the aim of this qualitative study was to explore barriers and facilitators in gaining and maintaining employment in BPD from the perspectives of patients, mental health practitioners (MHPs) and insurance physicians (IPs).

Methods

Fifteen semi-structured interviews were conducted in patients with BPD and two focus groups were carried out among MHPs (n = 7) and IPs (n = 6) following a thematic content analysis approach.

Results

All participants described barriers and facilitators relating to three overall themes: characteristics of BPD, stigma, and support to employment. Barriers to employment mainly related to characteristics of BPD, such as low self-image, difficulty posing personal boundaries, difficulty regulating emotions, and lack of structure. MHPs and IPs additionally mentioned externalization and overestimation of competencies on the part of patients. Enhancing emotion regulation and self-reflection by successful treatment was suggested as a facilitator to enhance employment. Increasing collaboration between mental health and vocational rehabilitation services, and increasing knowledge about BPD, were suggested to increase sustainable employment and decrease stigma.

Conclusions

The present findings revealed that both facilitators and barriers are important in gaining and maintaining employment in BPD in which diminishing symptoms, examining stigma and increasing support to employment are key. As a next step, supported employment strategies that follow patient preferences and integrate employment and mental health services, should be studied in the context of BPD.

Personality disorders of drivers killed in fatal motor vehicle accidents in Finland during 1990-2011

OBJECTIVE

To examine the association of personality disorders (PDs) to deaths of drivers in fatal motor vehicle accidents (FMVAs) and analyze gender differences in lifetime psychiatric disorders and medico-legal findings at the time of accident.

METHOD

The study sample consisted of 4810 Finnish drivers killed in FMVAs in Finland between 1990 and 2011. Doctor-diagnosed PD was found in 146 drivers (118 men and 28 women). The information of psychiatric morbidity was obtained from the Finnish Care Register for Health Care.

RESULTS

The proportion of deceased drivers with PDs had increased significantly over the study period, particularly among females and those with PD not otherwise specified (NOS). Suicidality and use of medication affecting driving ability were more common among females with PD compared to males with PD. 88% of all deceased drivers with PD had comorbid psychiatric disorders.

CONCLUSION

Our findings indicate that PDs may predispose drivers to FMVAs, particularly females. This study emphasizes the importance of evaluating the fitness-to-drive of subjects with PD and especially comorbid substance use disorders, which may relate to an increased risk of fatal motor accidents.

Low Vocational Outcome Among People Diagnosed With Borderline Personality Disorder During First Admission to Mental Health Services in Denmark: A Nationwide 9-Year Register-Based Study

Earlier studies report that although people with borderline personality disorder (BPD) experience symptom reduction in the long term, they continue to have difficulties in work recovery. This nationwide 9-year register-based study (N = 67,075) investigated the long-term labor-market attachment of all individuals diagnosed with BPD during first admission to Danish mental health services in comparison with other psychiatric disorders. Controlling for baseline characteristics and co-occurring secondary psychiatric diagnoses, the BPD group had 32% lower odds (OR = 0.68; 95% CI [0.61, 0.76]) of being in work/under education after 9 years. Individuals diagnosed with BPD also showed more impairment in long-term vocational outcome than other personality disorders, and lower labor-market attachment than other psychiatric disorders except for schizophrenia, schizotypal and delusional disorders, and mental and behavioral disorders due to psychoactive substance use. Intervention programs addressing social psychiatric aspects of BPD in terms of work functioning is henceforth an important area for future research.

Psychological Support for Personality (PSP) versus treatment as usual: study protocol for a feasibility randomized controlled trial of a low intensity intervention for people with personality disorder

Background

Previous research has demonstrated the clinical effectiveness of long-term psychological treatment for people with some types of personality disorder. However, the high intensity and cost of these interventions limit their availability. Lower-intensity interventions are increasingly being offered to people with personality disorder, but their clinical and cost effectiveness have not been properly tested in experimental studies. We therefore set out to develop a low intensity intervention for people with personality disorder and to test the feasibility of conducting a randomized controlled trial to compare the clinical effectiveness of this intervention with that of treatment as usual (TAU).

Methods

A two-arm, parallel-group, single-blind, randomized controlled trial of Psychological Support for Personality (PSP) versus TAU for people aged over 18 years, who are using secondary care mental health services and have personality disorder. We will exclude people with co-existing organic or psychotic mental disorders (dementia, bipolar affective disorder, delusional disorder, schizophrenia, schizoaffective disorder, or schizotypal disorder), those with cognitive or language difficulties that would preclude them from providing informed consent or compromise participation in study procedures, and those who are already receiving psychological treatment for personality disorder. Participants will be randomized via a remote system in a ratio of PSP to TAU of 1:1. Randomization will be stratified according to the referring team and gender of the participant.

A single follow-up assessment will be conducted by masked researchers 24 weeks after randomization to assess mental health (using the Warwick and Edinburgh Well-Being Schedule), social functioning (using the Work and Social Adjustment Scale), health-related quality of life (EQ-5D-5 L), incidence of suicidal behavior, satisfaction with care (Client Satisfaction Questionnaire), and resource use and costs using a modified version of the Adult Service Use Schedule. In addition to this, each participant will be asked to complete the patient version of the Clinical Global Impression Scale.

Feasibility and acceptability will primarily be judged by study recruitment rate and engagement and retention in treatment. The analysis will focus principally on descriptive data on the rate of recruitment, characteristics of participants, attrition, adherence to therapy, and follow-up. We will explore the distribution of study outcomes to investigate assumptions of normality in order to plan the analysis and sample size of a future definitive trial.

Discussion

Most people with personality disorder do not currently receive evidence-based interventions. While a number of high intensity psychological treatments have been shown to be effective, there is an urgent need to develop effective low intensity approaches to help people unable to use existing treatments. PSP is a low intensity intervention for individuals, which was developed following extensive consultation with users and providers of services for people with personality disorder. This study aims to examine the feasibility of a randomized trial of PSP compared to TAU for people with personality disorder.

Trial registration

ISRCTN Registry, ISRCTN14994755. Registered on 18 July 2017.

Borderline personality symptoms and work performance: a population-based survey

BACKGROUND

This study aims to elucidate the interplay between borderline personality symptoms and working conditions as a pathway for impaired work performance among workers in the general population.

METHODS

Cross-sectional data from the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2) were used, including 3672 workers. Borderline personality symptoms were measured with the International Personality Disorder Examination (IPDE) questionnaire. Working conditions (decision latitude, psychological job demands, job security and co-worker support) were assessed with the Job Content Questionnaire (JCQ). Impaired work performance was assessed as total work loss days per month, defined as the sum of days of three types of impaired work performance (inability to work, cut-down to work, and diminished quality at work). These were assessed with the WHO Disability Assessment Schedule (WHO-DAS). Common mental disorders (CMD) were assessed with the Composite International Diagnostic Interview (CIDI).

RESULTS

Number of borderline personality symptoms was consistently associated with impaired work performance, even after controlling for type or number of adverse working conditions and co-occurrence of CMD. Borderline personality symptoms were associated with low decision latitude, job insecurity and low co-worker support. The relationship between borderline personality symptoms and work performance diminished slightly after controlling for type or number of working conditions.

CONCLUSIONS

The current study shows that having borderline personality symptoms is a unique determinant of work performance. This association seems partially explained through the impact of borderline personality symptoms on working conditions. Future studies are warranted to study causality and should aim at diminishing borderline personality symptoms and coping with working conditions.

The Relationship between Survival Sex and Borderline Personality Disorder Symptoms in a High Risk Female Population

Engaging in survival sex and mental illness are overrepresented within homeless populations. This article assesses the relationship between symptoms of borderline personality disorder (BPD) and engaging in survival sex among homeless women. One hundred and fifty-eight homeless women completed surveys on self-reported BPD symptomology and sexual history. Bivariate and multivariate analyses conducted in this study provided insights into the association of experiencing BPD symptoms and engaging in survival sex. Results indicate that some symptoms of BPD are robustly correlated with engaging in survival sex among homeless adult women. Implications for service agencies and others working with at-risk female populations are discussed.

The prevalence, age distribution and comorbidity of personality disorders in Australian women

OBJECTIVE

We aimed to describe the prevalence and age distribution of personality disorders and their comorbidity with other psychiatric disorders in an age-stratified sample of Australian women aged ⩾25 years.

METHODS

Individual personality disorders (paranoid, schizoid, schizotypal, histrionic, narcissistic, borderline, antisocial, avoidant, dependent, obsessive-compulsive), lifetime mood, anxiety, eating and substance misuse disorders were diagnosed utilising validated semi-structured clinical interviews (Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Non-patient Edition and Structured Clinical Interview for DSM-IV Axis II Personality Disorders). The prevalence of personality disorders and Clusters were determined from the study population ( n = 768), and standardised to the Australian population using the 2011 Australian Bureau of Statistics census data. Prevalence by age and the association with mood, anxiety, eating and substance misuse disorders was also examined.

RESULTS

The overall prevalence of personality disorders in women was 21.8% (95% confidence interval [CI]: 18.7, 24.9). Cluster C personality disorders (17.5%, 95% CI: 16.0, 18.9) were more common than Cluster A (5.3%, 95% CI: 3.5, 7.0) and Cluster B personality disorders (3.2%, 95% CI: 1.8, 4.6). Of the individual personality disorders, obsessive-compulsive (10.3%, 95% CI: 8.0, 12.6), avoidant (9.3%, 95% CI: 7.1, 11.5), paranoid (3.9%, 95% CI: 3.1, 4.7) and borderline (2.7%, 95% CI: 1.4, 4.0) were among the most prevalent. The prevalence of other personality disorders was low (⩽1.7%). Being younger (25-34 years) was predictive of having any personality disorder (odds ratio: 2.36, 95% CI: 1.18, 4.74), as was being middle-aged (odds ratio: 2.41, 95% CI: 1.23, 4.72). Among the strongest predictors of having any personality disorder was having a lifetime history of psychiatric disorders (odds ratio: 4.29, 95% CI: 2.90, 6.33). Mood and anxiety disorders were the most common comorbid lifetime psychiatric disorders.

CONCLUSIONS

Approximately one in five women was identified with a personality disorder, emphasising that personality disorders are relatively common in the population. A more thorough understanding of the distribution of personality disorders and psychiatric comorbidity in the general population is crucial to assist allocation of health care resources to individuals living with these disorders.

A prospective, longitudinal, study of men with borderline personality disorder with and without comorbid antisocial personality disorder

BACKGROUND

Some evidence suggests that the prevalence of Borderline Personality Disorder (BPD) is elevated among male criminal offenders. It is not presently known whether offending, and violent offending, are limited to those presenting comorbid Antisocial Personality Disorder (ASPD) who have a childhood history of conduct problems and whether offending is linked to psychopathic traits.

METHODS

A community sample of 311 males followed from age 6 to 33 years, one third of whom had a criminal charge between ages 18 and 24, completed diagnostic interviews and the Psychopathy Checklist-Revised interview. Information on childhood included parent-reported family characteristics and teacher-rated of hurtful and uncaring behaviours, conduct problems, hyperactivity and inattention, and anxiety at age 6, 10, and 12 years. Health files were obtained as were records of criminal convictions from age 12 to 33.

RESULTS

At age 33, 4% of the men presented BPD and not ASPD, 16% ASPD and not BPD, 8% BPD + ASPD, and 72% neither disorder (ND). Comorbid disorders were common: BPD were distinguished by high levels of anxiety disorders, BPD and BPD + ASPD by depression disorders, and BPD, BPD + ASPD, and ASPD by substance dependence. Official files indicated use of health services by all participants. One-third of participants with BPD and BPD + ASPD acquired a diagnosis of a personality disorder. More than one-third of participants with BPD + ASPD obtained scores indicative of the syndrome of psychopathy. Convictions for violent crimes varied across groups: In adolescence, BPD none, BPD + ASPD 16%, ASPD 16%, and ND 3.6%; from age 18 to 33, BPD 18%, ASPD 19%, BPD + ASPD 52%, and ND 4.4%. Offenders with BPD + ASPD were convicted, on average, for four times more violent crimes than offenders with ASPD and seven times more than ND offenders. In childhood, men with BPD + ASPD and with ASPD had obtained similarly elevated ratings for disruptive behaviours as compared to ND.

CONCLUSION

BPD comorbid with ASPD was associated with violent criminal offending in adolescence and most strongly in adulthood, elevated levels of psychopathic traits, and childhood disruptive behaviour. BPD showed similar characteristics but to a much less degree.

Prevalence rates of borderline personality disorder symptoms: a study based on the Netherlands Mental Health Survey and Incidence Study-2

BACKGROUND

Despite increasing knowledge of the prevalence of borderline personality disorder (BPD) in the general population, and rising awareness of mental disorders both as a categorical and a dimensional construct, research is still lacking on the prevalence of the number of BPD symptoms and their associated consequences, such as comorbidity, disability, and the use of mental health services) in the general population.

METHODS

Data were obtained from the second wave of the Netherlands Mental Health Survey and Incidence Study-2 (N = 5303), a nationally representative face-to-face survey of the general population. BPD symptoms were measured by means of questions from the International Personality Disorder Examination. Comorbidity of common mental disorders was assessed with the Composite International Diagnostic Interview version 3.0.

RESULTS

Of the total population studied, 69.9 % reported no BPD symptoms, while 25.2 % had 1-2 symptoms, 3.8 % had 3-4 symptoms, and 1.1 % had ≥ 5 BPD symptoms. The number of BPD symptoms reported was found to be positively associated with not living with a partner, having no paid job, and/or having a comorbid mood, anxiety or substance use disorder. Even after adjustment for sociodemographic characteristics and comorbidity, the number of BPD symptoms turned out to be uniquely associated with disability. It also showed a positive relationship with using services for dealing with mental health problems, although this relationship was strongly affected by the presence of comorbid disorders.

CONCLUSIONS

Because even a relatively low number of BPD symptoms appears to be associated with psychiatric comorbidity and functional disability, not only full-blown BPD but also subthreshold levels of BPD symptoms need to be identified in clinical practice and research.

The Application of an Etiological Model of Personality Disorders to Problem Gambling

Problem gambling is a significant mental health problem that creates a multitude of intrapersonal, interpersonal, and social difficulties. Recent empirical evidence suggests that personality disorders, and in particular borderline personality disorder (BPD), are commonly co-morbid with problem gambling. Despite this finding there has been very little research examining overlapping factors between these two disorders. The aim of this review is to summarise the literature exploring the relationship between problem gambling and personality disorders. The co-morbidity of personality disorders, particularly BPD, is reviewed and the characteristics of problem gamblers with co-morbid personality disorders are explored. An etiological model from the more advanced BPD literature-the biosocial developmental model of BPD-is used to review the similarities between problem gambling and BPD across four domains: early parent-child interactions, emotion regulation, co-morbid psychopathology and negative outcomes. It was concluded that personality disorders, in particular BPD are commonly co-morbid among problem gamblers and the presence of a personality disorder complicates the clinical picture. Furthermore BPD and problem gambling share similarities across the biosocial developmental model of BPD. Therefore clinicians working with problem gamblers should incorporate routine screening for personality disorders and pay careful attention to the therapeutic alliance, client motivations and therapeutic boundaries. Furthermore adjustments to therapy structure, goals and outcomes may be required. Directions for future research include further research into the applicability of the biosocial developmental model of BPD to problem gambling.

Borderline personality disorder and related constructs as risk factors for intimate partner violence perpetration

In this manuscript we systematically reviewed 29 articles from 2010 to 2014 that addressed the association between borderline personality disorder (BPD) and intimate partner violence (IPV) perpetration, with particular attention paid to the role of perpetrator sex. Our primary objective was to provide a summary of (1) the operationalization and measurement of BPD and IPV, (2) mechanisms of the BPD-IPV association, and (3)the current understanding of the role of perpetrator sex related to BPD and IPV. We observed three distinct operational definitions of BPD which are measured in a variety of ways. IPV measurement tends to be more consistent. Further, emotion perception, impulsivity, attachment, and substance use are proposed mechanisms to explain the BPD IPV relation. The findings regarding potential perpetrator sex differences in the BPD-IPV association are mixed. Finally, we also provide recommendations for future research and clinical practice.

A systematic review of the predictors of health service utilisation by adults with mental disorders in the UK

OBJECTIVES

To identify variables that predict health service utilisation (HSU) by adults with mental disorders in the UK, and to determine the evidence level for these predictors.

DESIGN

A narrative synthesis of peer-reviewed studies published after the year 2000. The search was conducted using four databases (ie, PsycINFO, CINAHL Plus with full text, MEDLINE and EMBASE) and completed on 25 March 2014.

SETTING

The majority of included studies were set in health services across primary, secondary, specialist and inpatient care. Some studies used data from household and postal surveys.

PARTICIPANTS

Included were UK-based studies that predicted HSU by adults with mental disorders. Participants had a range of mental disorders including psychotic disorders, personality disorders, depression, anxiety disorders, eating disorders and dementia.

PRIMARY OUTCOME

A wide range of HSU outcomes were examined, including general practitioner (GP) contacts, medication usage, psychiatrist contacts, psychotherapy attendances, inpatient days, accident and emergency admissions and 'total HSU'.

RESULTS

Taking into account study quality, 28 studies identified a range of variables with good preliminary evidence supporting their ability to predict HSU. Of these variables, comorbidity, personality disorder, age (heterogeneous age ranges), neurotic symptoms, female gender, a marital status of divorced, separated or widowed, non-white ethnicity, high previous HSU and activities of daily living, were associated with increased HSU. Moreover, good preliminary evidence was found for associations of accessing a primary care psychological treatment service and medication use with decreased HSU.

CONCLUSIONS

The findings can inform decisions about which variables might be used to derive mental health clusters in 'payment by results' systems in the UK. The findings also support the need to investigate whether combining broad diagnoses with care pathways is an effective method for mental health clustering, and the need for research to further examine the association between mental health clusters and HSU.

Design of an international multicentre RCT on group schema therapy for borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is a severe and highly prevalent mental disorder. Schema therapy (ST) has been found effective in the treatment of BPD and is commonly delivered through an individual format. A group format (group schema therapy, GST) has also been developed. GST has been found to speed up and amplify the treatment effects found for individual ST. Delivery in a group format may lead to improved cost-effectiveness. An important question is how GST compares to treatment as usual (TAU) and what format for delivery of schema therapy (format A; intensive group therapy only, or format B; a combination of group and individual therapy) produces the best outcomes.

METHODS/DESIGN

An international, multicentre randomized controlled trial (RCT) will be conducted with a minimum of fourteen participating centres. Each centre will recruit multiple cohorts of at least sixteen patients. GST formats as well as the orders in which they are delivered to successive cohorts will be balanced. Within countries that contribute an uneven number of sites, the orders of GST formats will be balanced within a difference of one. The RCT is designed to include a minimum of 448 patients with BPD. The primary clinical outcome measure will be BPD severity. Secondary clinical outcome measures will include measures of BPD and general psychiatric symptoms, schemas and schema modes, social functioning and quality of life. Furthermore, an economic evaluation that consists of cost-effectiveness and cost-utility analyses will be performed using a societal perspective. Lastly, additional investigations will be carried out that include an assessment of the integrity of GST, a qualitative study on patients' and therapists' experiences with GST, and studies on variables that might influence the effectiveness of GST.

DISCUSSION

This trial will compare GST to TAU for patients with BPD as well as two different formats for the delivery of GST. By combining an evaluation of clinical effectiveness, an economic evaluation and additional investigations, it will contribute to an evidence-based understanding of which treatment should be offered to patients with BPD from clinical, economic, and stakeholders' perspectives.

TRIAL REGISTRATION

Netherlands Trial Register NTR2392. Registered 25 June 2010.

Incidence and prevalence rates of personality disorders in Denmark-A register study

BACKGROUND

Personality disorders (PDs) are prevalent in about one in every 10 adults. Prior to the introduction of the ICD-10 in Denmark, the incidence rate for PD (including schizotypal) among psychiatric patients was approximately 12% and the prevalence rate 14%.

AIMS

The aim of the present clinical epidemiology study is to investigate the use of ICD-10 PD as primary and secondary diagnoses in years 1995, 2000 and 2006, comorbid disorders and their relation to age and gender.

METHODS

The study includes all adult patients admitted to any psychiatric hospital (inpatients and outpatients) in Denmark.

RESULTS

Both incidence and prevalence rates of PD diagnoses decrease over the study period. It is evident that all specific diagnoses significantly decrease or remain stable whereas the unspecified and mixed type significantly increases constituting up to 50% of diagnoses. Emotionally unstable PD stands out as the single most prevalent covering around one third of PD diagnoses. A decrease is found in the prevalence of patients receiving a PD diagnosis as a primary diagnosis, but an increase as a secondary diagnosis (most often as comorbid to depression or anxiety disorder). Differences are found in relation to gender and age.

CONCLUSION

PDs are among the most prevalent disorders; however, rates are decreasing in psychiatric settings. There seem to be a rather huge gap between clinical evaluation and research data on prevalence of PDs. Clinicians need more education and sufficient time for in-depth personality assessment of PDs in all patient groups.

Characteristics of borderline personality disorder in a community sample: comorbidity, treatment utilization, and general functioning

This study provides estimates of the prevalence and demographic features of borderline personality disorder (BPD) in a community sample as well as BPD comorbidity rates with Axis I and II disorders. In addition, the authors provide data on general functioning and treatment seeking among individuals with BPD. Data from 34,481 participants in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were analyzed. Results suggest that 2.7% of adults in the United States meet diagnostic criteria for BPD, with slightly higher rates of the disorder in females, people in lower income brackets, people younger than 30, and individuals who are separated or divorced. Racial/ethnic differences were evident, with Native Americans (5.0%) and Blacks (3.5%) having significantly higher rates of the disorder, on average, and Asians having significantly lower rates (1.2%). Individuals with a BPD diagnosis were likely to have co-occurring lifetime mood disorders, anxiety disorders, substance use disorders, and other personality disorders. Specifically, 84.8% of individuals with BPD also had a lifetime anxiety disorder, 82.7% had a lifetime mood disorder/episode, and 78.2% were diagnosed with a lifetime substance use disorder. Individuals with BPD showed significant impairment in functioning and were highly likely to seek therapy or receive medication for mental health concerns.

Societal cost-of-illness in patients with borderline personality disorder one year before, during and after dialectical behavior therapy in routine outpatient care

Societal cost-of-illness in a German sample of patients with borderline personality disorder (BPD) was calculated for 12 months prior to an outpatient Dialectical Behavior Therapy (DBT) program, during a year of DBT in routine outpatient care and during a follow-up year. We retrospectively assessed resource consumption and productivity loss by means of a structured interview. Direct costs were calculated as opportunity costs and indirect costs were calculated according to the Human Capital Approach. All costs were expressed in Euros for the year 2010. Total mean annual BPD-related societal cost-of-illness was €28026 (SD = €33081) during pre-treatment, €18758 (SD = €19450) during the DBT treatment year for the 47 DBT treatment completers, and €14750 (SD = €18592) during the follow-up year for the 33 patients who participated in the final assessment. Cost savings were mainly due to marked reductions in inpatient treatment costs, while indirect costs barely decreased. In conclusion, our findings provide evidence that the treatment of BPD patients with an outpatient DBT program is associated with substantial overall cost savings. Already during the DBT treatment year, these savings clearly exceed the additional treatment costs of DBT and are further extended during the follow-up year. Correspondingly, outpatient DBT has the potential to be a cost-effective treatment for BPD patients. Efforts promoting its implementation in routine care should be undertaken.

Krankheitskosten der Borderline Persönlichkeitsstörung aus gesellschaftlicher Perspektive

Hintergrund: Bislang liegen in Deutschland keine Befunde über die krankheitsbedingten Kosten von Patienten mit einer Borderline Persönlichkeitsstörung (BPS) aus der gesellschaftlichen Perspektive vor. Fragestellung: Wie hoch sind die jährlichen Krankheitskosten pro BPS-Patient? In welchen Bereichen entstehen die höchsten Kosten? Methodik: Auf der Grundlage aktueller gesundheitsökonomischer Empfehlungen wurden die krankheitsbedingten Kosten von N = 55 BPS-Patienten in Berlin für den Zeitraum von 12 Monaten vor Beginn einer ambulanten Psychotherapie aus der gesellschaftlichen Perspektive mit einem Interview erhoben und berechnet. Ergebnisse: Die Krankheitskosten in den 12 Monaten vor der Therapie betrugen insgesamt € 26.882 (SD = € 32.275) pro BPS-Patient. € 17.976 (SD = € 23.867) davon waren direkte Kosten, € 8.906 (SD = € 15.518) wurden für indirekte Kosten berechnet. Die höchsten Kosten entstanden durch stationäre und teilstationäre Aufenthalte (M = € 13.121; SD = € 19.808) sowie durch krankheitsbedingte Erwerbsunfähigkeit (M = € 7.020; SD = € 15.099). Schlussfolgerungen: Die BPS geht mit hohen gesellschaftlichen Kosten einher, die weitaus höher sind als die durch viele andere psychische und somatische Erkrankungen bedingten Kosten.

[Psychosocial integration of inpatients with borderline personality disorder: reflection of a health care system focused on symptom remission]

BACKGROUND

Borderline personality disorder (BPD) is characterized by a profound instability of identity, by stress and affect dysregulation and impulsivity, and by cognitive-perceptual disturbances. These deficits seriously impair interpersonal experiences and social interaction. The typical impulsive style and psychosocial malfunctioning of these patients lead to grave disturbances in their everyday areas of life with numerous break-ups in all relevant areas of life and entail inadequate vocational placement. Despite vast demands on the health care system, BPD attracts little attention of care process research and reintegration measures as, for instance, exist for schizophrenia. At the LVR-Klinikum Düsseldorf as representative of a large clinic in North Rhein-Westphalia, we analysed socio-demographic characteristics of BPD inpatients. The aims of the study were to substantiate the high impact of the disease on patient's social and vocational integration and to sensitize for significant aspects of disease-specific therapy and care.

METHODS

A retrospective analysis of DGPPN-BADO of all patients (n = 9,425) who were admitted between January 2004 and December 2009 to the LVR-Klinikum Düsseldorf, department of psychiatry and psychotherapy, Heinrich Heine University Hospital, Germany. Data analysis involved the divisions general psychiatry and addictive disorders and covered 999 patients with BPD (ICD-10: F60.3) and 1,937 patients with schizophrenia (ICD-10: F20). The defined characteristics of DGPPN-BADO that depict psychosocial integration were "living situation at admission", "highest academic/professional degree achieved", "working situation" und "livelihood". Besides descriptive statistics of the elected variables, comparative analysis of the diagnoses BPD and schizophrenia involved calculating group differences after adjusting the groups for sex and age. Statistical analysis was performed by the χ2-test.

RESULTS

The comparative analysis of psychosocially relevant BADO characteristics reveals a significantly stronger impairment of patients with BPD concerning their academic and professional qualification than patients with schizophrenia. Nevertheless they more often hold a job or cover their living expenses without subsidy, respectively.

CONCLUSION

The data suggest a lack of general awareness in the significance of social and vocational disturbances in BPD. The interactional deficits of patients with BPD affect all areas of life but their illness-related nature seems to be disregarded in relevant life areas, such as educational processes and the vocational situation. Furthermore, the impact of BPD on earning capacity is not given adequate consideration in the assessment of pensions or subsidies. Consistent with the recent literature, our socio-demographic data indicate significant deficits of the present health system in handling BPD.

Psychotic symptoms in patients with borderline personality disorder: prevalence and clinical management

PURPOSE OF REVIEW

The aim of this article is to review findings on the prevalence, phenomenology and treatment of psychotic features in borderline personality disorder (BPD), and to discuss factors that might be related to their occurrence.

RECENT FINDINGS

Of patients with BPD about 20-50% report psychotic symptoms. Hallucinations can be similar to those in patients with psychotic disorders in terms of phenomenology, emotional impact, and their persistence over time. Although more research is needed on the exact nature of psychotic phenomena in patients with BPD, terms like pseudo-psychotic or quasi-psychotic are misleading and should be avoided. Childhood trauma might play an important role in the development of psychotic symptoms in patients with BPD, as in other populations. More research is necessary on the role of comorbid disorders, especially posttraumatic stress disorder (PTSD). Atypical antipsychotics seem to be beneficial in some patients; evidence on psychotherapy of psychotic symptoms is sparse.

SUMMARY

Psychotic symptoms, especially hallucinations, seem to be an important feature of BPD. More research on potential mediators and adequate treatment approaches for psychotic symptoms in BPD is needed, and current diagnostic systems might require revision to emphasise psychotic symptoms.

Axis I and II comorbidity and psychosocial functioning in female adolescents with borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is known to be associated with high rates of comorbidity and severe impairment of psychosocial functioning in adults. The aim of this study was to investigate Axis I and Axis II disorders, as well as psychosocial functioning, in a clinical sample of adolescents with BPD and to compare these with participants with mixed psychiatric diagnoses.

METHODS

Female adolescent patients were consecutively recruited from the child and adolescent psychiatry department of a university hospital. Axis I and Axis II diagnoses were assessed by experienced clinicians using well-established semistructured interviews, along with psychosocial functioning.

RESULTS

The final sample (87 participants) comprised 31 participants with a diagnosis of BPD and 56 participants with mixed psychiatric diagnoses. The most common comorbid disorders in the adolescent BPD sample were mood, eating, dissociative, and substance use disorders in Axis I, and cluster C personality disorders in Axis II. The BPD group showed a significantly higher average number of comorbid Axis I and Axis II diagnoses and significantly lower psychosocial functioning compared with the clinical control group. Regression analyses revealed that psychosocial functioning was predicted by socioeconomic status and comorbid disorders, as well as the unique influence of BPD itself.

CONCLUSION

Adolescent BPD in females is accompanied by high rates of psychiatric comorbidity and poor psychosocial functioning. This underscores the need for diagnosis of BPD at its early stages, in order to facilitate appropriate interventions.

Personality disorders, common mental disorders and receipt of disability benefits: evidence from the British National Survey of Psychiatric Morbidity

BACKGROUND

Common mental disorders (CMDs) are associated with occupational impairment and the receipt of disability benefits (DBs). Little is known about the relationship between personality disorders (PDs) and work disability, and whether the association between CMDs and work disability is affected by the presence of co-morbid PDs. The aim of this study was to examine the association between DB and individual categories of PDs, with special attention to the effect of co-morbid CMDs on this association.

METHOD

The association between DB and PD was examined using data from the 2000 British National Survey of Psychiatric Morbidity. Probable PD caseness was identified using the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II) screening questionnaire. The impact of CMDs, assessed with the revised version of the Clinical Interview Schedule (CIS-R), was examined as a covariate and in a stratified analysis of co-morbidity. Other covariates included sociodemographic factors, long-standing illnesses and substance use.

RESULTS

Probable PD was associated with DB, with the strongest associations found for borderline, dependent and schizotypal PD. Antisocial PD was not associated with DB. The relationship between PD and DB was strongly modified by CMD, reducing the association from an odds ratio (OR) of 2.84 to 1.34 [95% confidence interval (CI) 1.00-1.79)]. In the stratified analysis, co-morbid PD and CMD showed a stronger association with DB than PD without CMD but, when fully adjusted, this effect was not significantly different from the association between CMD without PD.

CONCLUSIONS

Individuals screening positive for PD are more likely to experience severe occupational outcomes, especially in the presence of co-morbid CMD.

Conceptual changes to the definition of borderline personality disorder proposed for DSM-5

The Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 Personality and Personality Disorders Work Group proposed the elimination of diagnostic criterion sets in favor of a prototype matching system that defines personality disorders using narrative descriptions. Although some research supports this general approach, no empirical studies have yet examined the specific definitions proposed for DSM-5. Given the wide interest in borderline personality disorder (BPD), it is crucial to determine how this methodological shift might affect the content and conceptualization of the diagnosis. Eighty-two experts on BPD provided ratings of the DSM-IV-TR or DSM-5 version of BPD in terms of 37 traits proposed for DSM-5. Analyses revealed significant and meaningful differences among the two constructs, with the DSM-5 version evincing increased interpersonal dependency but a decreased emphasis on antagonism and disinhibition. A second study within a clinical sample demonstrated that both antagonism and disinhibition mediated the relationships between DSM-IV BPD and impairment, suggesting that the proposed changes might have important consequences for BPD's coverage, prevalence, and nomological network. More globally, our results illustrate that unanticipated shifts in diagnostic constructs can stem from seemingly minor revisions and suggest that research is needed to understand how these, or other changes, might affect our conceptualization, diagnosis, and treatment of BPD.

Medication for borderline personality disorder: a survey at a secure hospital

OBJECTIVES

To study the use of medication in the treatment of inpatients with borderline personality disorder (BPD). To survey clinicians' views on the UK National Institute for Health and Clinical Excellence (NICE) Guideline on BPD.

METHODS

Cross-sectional survey of the use of psychotropics purely for BPD at a large secure UK psychiatric hospital, together with interviews with the treating psychiatrists.

RESULTS

A total of 79 patients had a DSM diagnosis of BPD, of whom 80% were receiving one or more psychotropics and 48% were receiving two or more. Most prescriptions were off-label. Antipsychotics followed by antidepressants were the most frequent class of drug prescribed for BPD. Clozapine was the most commonly prescribed drug and according to the treating psychiatrists the one most likely to lead to a major improvement in target symptoms. Other psychotropics were generally rated as resulting in minor improvement or no change. Clinicians were aware they were prescribing contrary to NICE but justified this on the basis of having to treat severe and complex cases.

CONCLUSIONS

Use of psychotropics (especially clozapine), off-label prescribing and polypharmacy were very common in these inpatients with BPD. Randomised controlled trials of the use of clozapine in severe BPD are needed.

Personality disorders in later life: questions about the measurement, course, and impact of disorders

Lifespan perspectives have played a crucial role in shaping our understanding of many forms of psychopathology. Unfortunately, little attention has been given to personality disorders in middle adulthood and later life. Several issues are responsible for this deficiency, including difficulty applying the diagnostic criteria for personality disorders to older people and challenges in identifying appropriate samples of older participants. The goal of this review is to explore the benefits of considering older adults in the study of personality disorders. Later life offers a unique opportunity for investigators to consider links between personality pathology and consequential outcomes in people's lives. Many domains are relevant, including health, longevity, social adjustment, marital relationships, and the experience of major life events. We review each domain and consider ways in which the study of middle-aged and older adults challenges researchers to evaluate how personality disorders in general are defined and measured.

Mental and personality disorders and abstinence from alcohol: results from a national household survey

BACKGROUND

The beneficial outcomes associated with moderate compared with low alcohol intake or abstinence may be due to the inclusion of people as 'low consumers', who have stopped consumption because of poor health. We investigated the association between alcohol abstinence and symptoms of common mental disorder and personality disorder, distinguishing between lifelong abstinence and abstinence following previous consumption.

METHOD

Analyses were based on the British National Survey of Psychiatric Morbidity 2000, which sampled 8580 residents aged 16-74 years. Hazardous drinking (Alcohol Use Disorders Identification Test) was excluded. Symptoms of common mental disorder (depression/anxiety) were identified by the Clinical Interview Schedule. The screening questionnaire of the Structured Clinical Interview for Axis II Personality Disorders was used to identify potential personality disorder. Self-reported alcohol abstinence was divided into lifelong abstinence and previous consumption. Previous consumers were asked why they had stopped. Covariates included socio-economic status, social activity and general health status.

RESULTS

After adjustment, alcohol abstinence was associated with both common mental disorder symptoms and any personality disorder, but only for previous consumers, in whom odds ratios were 1.69 (95% CI 1.23-2.32) and 1.45 (95% CI 1.09-1.94). Associations were non-specific, being apparent for most individual mental disorder symptoms and personality disorder categories. More detailed analysis indicated that associations were again limited to previous consumers who reported ceasing alcohol consumption for health reasons.

CONCLUSIONS

Worse mental health in low alcohol consumers, particularly those who have previously ceased for health reasons, should be taken into account when interpreting associations between moderate (compared with low) alcohol consumption and beneficial health outcomes.

Prisoners with psychosis in England and Wales: diversion to psychiatric inpatient services?

The prevalence of psychosis among prisoners in England and Wales is ten times that in the household population and UK government policy is that prisoners should receive equivalent care to those in the community. This study investigated the implications of policy to divert more from the criminal justice system for psychiatric treatment. Psychotic prisoners were compared with psychotic persons in households and with other prisoners in two surveys of psychiatric morbidity in representative samples of the UK population. Psychotic prisoners were younger, more from ethnic minorities, with comorbid anxiety, substance misuse, ASPD, and childhood behavioural problems compared to psychotic persons in households. Less than a third had received previous inpatient treatment. Psychotic prisoners had similar criminal histories and higher psychopathy scores than non-psychopathic prisoners. Diversion is unfeasible without improved screening for psychosis and increasing bed numbers at higher levels of security to accommodate more patients who would pose high risk to the public. Future research should investigate why UK psychiatric services fail to identify psychotic prisoners and provide aftercare.

Borderline personality disorder and psychosis: a review

Early views of borderline personality disorder (BPD) were based on the idea that patients with this pathology were "on the border" of psychosis. However, more recent studies have not supported this view, although they have found evidence of a malevolent interpersonal evaluation and a significant proportion of BPD patients showing psychotic symptoms. For example, in one study, 24% of BPD patients reported severe psychotic symptoms and about 75% had dissociative experiences and paranoid ideation. Thus, we start with an overview regarding the prevalence of psychotic symptoms in BPD patients. Furthermore, we report findings of studies investigating the role of comorbidity (eg, post-traumatic stress disorder) in the severity and frequency of psychotic symptoms in BPD patients. We then present results of genetic and neurobiological studies comparing BPD patients with patients with schizophrenia or nonschizophrenic psychotic disorders. In conclusion, this review reveals that psychotic symptoms in BPD patients may not predict the development of a psychotic disorder but are often permanent and severe and need careful consideration by clinicians. Therefore, adequate diagnosis and treatment of psychotic symptoms in BPD patients is emphasized.