Borderline personality disorder: associations with psychiatric disorders, somatic illnesses, trauma, and adverse behaviors

Borderline personality disorder and antisocial traits in justice-involved males: Associations with aggression, violent crime, and adverse childhood experiences

Borderline personality disorder (BPD) and antisocial traits are common in justice-involved samples, but research on their dynamics, precursors, and aftereffects regarding aggressive and violent behavior is scarce. In order to enlarge the current knowledge needed for effective risk assessment and reduction, the present study examined patterns of BPD and antisocial traits in a sample of 315 justice-involved males who had undergone psychological/psychiatric evaluation, focusing on their relations with adverse childhood experiences (ACEs), self-reported physical aggression, as well as officially registered previous and future violent crime. Based on a comprehensive analysis of psychiatric/psychological evaluation reports and individuals' self-ratings, latent class analysis identified three distinct classes with (1) high probability of BPD and antisocial traits (n = 63), (2) high probability of antisocial traits only (n = 150), and (3) low probability of either (n = 102). Compared to the latter, both symptomatic classes were characterized by high ACE burden. Whereas the borderline-antisocial class showed associations with increased self-reported physical aggression but not with convictions for violent crimes, the antisocial class was related to both aggression ratings and registered violent offending. Moreover, elevated ACE scores indicated incremental predictability for physical aggression ratings and violent criminality over class membership. The present findings highlight the need to carefully assess personality disturbances and ACEs in justice-involved populations in order to apply the most effective intervention measures to address each individual's criminogenic needs as accurately as possible.

Clinical Needs of Older Adults With Personality Disorders: Insights From State-Funded Mental Health Care Systems

OBJECTIVES

Due to a longstanding focus on early to middle adulthood, research into the clinical needs of older adults with personality disorders remains limited. This study sought to further understandings into the potentially unique needs of this population.

METHODS

Analyses compared comorbid psychiatric diagnoses, settings of utilized mental health treatment, and sociodemographic variables among older (aged 65+, n = 11,426) and younger (aged 18-35, n = 57,847) adults diagnosed with a personality disorder who received state-funded mental health care in the United States in 2022.

RESULTS

Older adults with personality disorder diagnoses were more likely to have comorbid psychotic and delirium/dementia disorder diagnoses, less likely to have comorbid trauma and stressor, anxiety, and attention-deficit/hyperactivity disorder diagnoses, and less likely to experience homelessness than younger adults with personality disorder diagnoses.

CONCLUSIONS

Findings highlight the importance of interventions to address co-occurring cognitive disorganization among older adults experiencing personality disorder pathology.

Characteristics and outcomes of individuals screening positive for borderline personality disorder on an adult inpatient psychiatry unit: a cross-sectional study

BACKGROUND

Outpatient psychotherapies are gold standard interventions for borderline personality disorder (BPD); however, in clinical reality, higher rates of psychiatric hospitalization and more severe symptoms, including suicidality and self-harm, occur for those with BPD compared to those with other psychiatric disorders in inpatient units.

METHODS

This study aims to distinguish the clinical profile and outcomes of patients screening positive for a threshold of BPD traits in the inpatient psychiatric setting using the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD), from those who do not.

RESULTS

Compared to those screening negative on the MSI-BPD (MSI-BPD-), those who screen positive (MSI-BPD +) are younger, more likely to be female, and more likely to report a range of health and psychosocial risk factors such as unstable housing, reduced educational attainment, physical health problems, past trauma, and problematic drug and alcohol use. MSI-BPD + patients report significantly higher severity of anxiety, depression, suicidality, self-harm, and global symptoms on admission than MSI-BPD- patients. In terms of response to inpatient care, they also self-report significantly greater improvements and higher proportions of reliable change on measures of anxiety, depression, and general psychiatric severity. At discharge, MSI-BPD + patients no longer report significantly higher suicidality but do report greater levels of thoughts of self-harm.

CONCLUSIONS

These findings suggest that patients with self-reported BPD symptoms experience acute symptom relief during short-term inpatient hospitalization, including for suicidality-related symptoms. Our study also demonstrates the feasibility of utilizing the MSI-BPD screening tool within a large adult inpatient psychiatric population to identify individuals likely to have BPD with distinct clinical profiles.

Injury recidivism in women with personality disorders reflects an increased risk for both natural and unnatural death

BACKGROUND

A small proportion of patients account for a disproportionate use of emergency healthcare services and exhibit an increased mortality. This group includes individuals with different conditions and risk-taking behaviors. Among them are persons diagnosed with personality disorders, who are particularly susceptible to injuries and intoxications-factors that contribute to an increased risk of premature death, especially from unnatural causes.. In this study in women with a personality disorder diagnosis, we hypothesized that the number of inpatient episodes due to injuries or intoxications would be independently related to the mortality risk for both natural and unnatural causes.

METHODS

A cohort of all women who received a personality disorder diagnosis in the Swedish National Patient Register during the years 1997-2015 (n = 44,221) was followed up until December 31, 2015. All inpatient treatment periods with diagnoses of injuries or intoxications were documented. Information on all deaths was obtained from The Swedish Cause of Death Register.

RESULTS

Multivariable Cox proportional hazards regressions, adjusted for relevant confounders revealed that the number of inpatient care episodes due to injuries or intoxications was independently related to later all-cause mortality, as well as mortality from unnatural and natural causes, and suicidal actions.

CONCLUSIONS

The results motivate particular attention to women with recurrent injuries or intoxications with an assessment of the need for non-emergent measures to decrease the risk of early death, including suicide.

Adverse Childhood Events, Personality Disorders, and Multimorbidity in Older Adults: Exploring the Connections

OBJECTIVES

We investigated the association between adverse childhood events, personality disorders and multimorbidity in older adults.

METHODS

This is a cross-sectional analysis in a population of older adults including 40 people with a personality disorder and 75 healthy controls. The Childhood Traumatic Events Scale was used to assess adverse childhood events. Multimorbidity was defined as the presence of 2 or more predetermined chronic somatic and psychiatric disorders. Logistic regression analysis was used to assess the association between adverse childhood events, personality disorders and multimorbidity.

RESULTS

No significant association was found between adverse childhood events and multimorbidity (OR = 1.03, 95% CI = 0.96-1.09). The presence of a personality disorder was significantly associated with multimorbidity (OR = 12.95, 95% CI = 4.28-39.14).

CONCLUSIONS

Overall, we did not find an association between adverse childhood events and multimorbidity in older adults. Multimorbidity was more prevalent in subjects with personality disorders compared to healthy controls.

CLINICAL IMPLICATIONS

The findings suggest that personality disorders are associated with both mental and physical health challenges, underscoring the importance of integrated care approaches to address both aspects in clinical practice.

A predictive model of non-suicidal self-injury - a study based on the construction and validation of a nomogram

Background

The issue of psychological maladjustment, particularly Non-Suicidal Self-Injury (NSSI), is prevalent among vocational high school students. Therefore, timely identification of high-risk individuals is important in providing further intervention.

Methods

A survey was conducted among 2081 students from a vocational high school in Wuhan, China. The students were divided into two groups: those who had engaged in Non-Suicidal Self-Injury (NSSI) within the past two weeks and those who had not. Lasso regression and logistic regression were employed to identify significant risk factors associated with NSSI. Subsequently, a nomogram was developed to enhance the accuracy and efficiency of identifying individuals at high risk for NSSI. The performance of the model was assessed through various validation methods including Area Under the Curve (AUC), calibration curves, and Decision Curve Analysis (DCA).

Results

The significant predictors of NSSI encompassed gender, problem behavior, depressive mood, and borderline personality tendencies. Based on these predictors, a nomogram was constructed. The model's accuracy was validated using AUC, calibration curves, and DCA, showing high accuracy.

Conclusion

A nomogram prediction tool for NSSI among vocational high school students was constructed, providing an accurate and quick method for predicting adolescent NSSI behavior.

Physical Activity, Sleep and Eating in Young People With Borderline Personality Disorder

Previous research suggests a connection between borderline personality disorder (BPD) and somatic comorbidities, underscoring the importance of lifestyle and health-related behaviour (LHRB) in the emergence of BPD. We investigated LHRBs-physical activity, sleeping and overeating-among young people at different BPD stages compared to a matched community sample. Furthermore, we explored whether problematic LHRBs intensify in later BPD stages. Participants included 55 young people exhibiting BPD features from a specialized mental health care institution, matched with a community control group based on age, self-reported and education. A MANOVA assessed differences in physical activity, sleep disturbance, sleep-related impairment and emotional overeating between the BPD and control group. A second MANOVA explored these behaviours across BPD stages within the clinical group. Results revealed significantly higher levels of sleep-related problems among young people with BPD features compared to controls. However, no significant differences were found in physical activity or emotional overeating. Furthermore, problematic LHRBs did not show a significant association with BPD stage. These findings contribute to a better understanding of the relationship between BPD and problematic LHRBs, emphasizing the importance of early intervention targeting sleep-related problems in young people with BPD, alongside addressing other aspects of BPD and associated LHRBs.

Borderline Personality Disorder and Loneliness: Broadening the Scope of Treatment for Social Rehabilitation

ABSTRACT

Borderline personality disorder (BPD) has been described as a condition of intolerance of aloneness. This characteristic drives distinguishing criteria, such as frantic efforts to avoid abandonment. Both BPD and loneliness are linked with elevated mortality risk and multiple negative health outcomes. Psychodynamic theories of BPD emphasize fundamental impairment in attachment and interpersonal functioning. Empirical research demonstrates an association between BPD diagnosis and increased loneliness. Individuals with BPD experience higher levels of loneliness than the general population, and their social networks are systematically smaller, less diverse, and less satisfying. Differences in the subjective experience of loneliness persist when controlling for these relevant social network features, indicating that people with BPD experience more loneliness than others in the same objective social circumstances. According to patients with BPD, increased social connection is often a primary treatment goal and marker of satisfying recovery. There are, however, few evidence-based approaches that primarily target loneliness and building life structures that support durable connections with others. Therefore, loneliness persists as an intractable problem, often failing to remit alongside other symptoms, and few resources are routinely implemented to address this problem. In this article, we argue that loneliness is central to the symptomatic oscillations and subjective experiences of many patients with BPD. We propose that treatment extend beyond the overemphasized therapeutic alliance relationship to also promote socialization and group and vocational settings to enhance patients' social networks. Building larger social networks that rely less on exclusive caregiving and/or romantic relationships and more on role-bound identity building and community relationships would more directly target long-term identity diffusion and relational instability. Such interventions can harness nonclinical community resources, such as group treatment, vocational supports, and peer supports.

C-L Case Conference: The Interaction Between Emotional Dysregulation and Chronic Critical Illness in a Patient With a Terminal Personality Disorder

We present a case of a patient who presented for endocarditis and subsequently had a prolonged and challenging hospital course, with much of it spent in the intensive care unit (ICU). Throughout their hospitalization, personality factors, combined with impaired communication and pain in severe medical illness, led to challenging behaviors of disengagement, impulsivity, splitting, agitation, and suicidal statements. Experts in critical care psychiatry review the case and its key elements, including principles of critical care psychiatry and pharmacologic management of ICU patients; communication problems in ICU patients and associated psychiatric distress; the benefits of proactive consultation for challenging patients; and the construct of post-intensive care syndrome. Patients with personality disorders often struggle to cope with severe medical illness, leading to challenging, self-defeating behaviors. Such acts are even more difficult to manage in intensive care, where a patient's tenuous medical status depends on smooth interactions between them and the medical team. We address how these challenges may be mitigated in collaboration with a psychiatric consult team.

Personality disorders, violence and antisocial behaviour: updated systematic review and meta-regression analysis

BACKGROUND

Links between personality disorders and antisocial outcomes has not examined individual personality disorders, and the contribution of comorbidities remain uncertain. Previous systematic reviews are dated.

AIMS

To synthesise evidence from observational studies on the risk of antisocial outcomes and recidivism associated with personality disorders.

METHOD

We searched six bibliographic databases (up to March 2024) for observational studies examining the risk of antisocial behaviour, interpersonal violence and recidivism in individuals diagnosed with personality disorders, compared to controls. We explored sources of heterogeneity using subgroup analyses and meta-regression.

RESULTS

We identified 21 studies involving 83 418 individuals with personality disorders from 10 countries examining antisocial and violent outcomes (Aim 1), and 39 studies of 14 131 individuals from 13 countries with recidivism (or repeat offending) as the outcome (Aim 2). We found increased risks of violence among individuals with any personality disorder (odds ratio 4.5, 95% CI 3.0-6.7), particularly antisocial personality disorder (odds ratio 7.6, 95% CI 5.1-11.5) and borderline personality disorder (odds ratio 2.6, 95% CI 1.8-3.9). Individuals with any personality disorder (odds ratio 2.3, 95% CI 2.0-2.6) and antisocial personality disorder (odds ratio 2.8, 95% CI 1.6-4.9) also demonstrated an elevated risk of recidivism. Personality disorder types and comorbid substance use disorder were associated with between-study heterogeneity.

CONCLUSIONS

The assessment and management of personality disorders should be considered as part of violence prevention strategies. Improving identification and treatment of comorbid substance misuse may reduce adverse outcomes in individuals with personality disorders.

Identity and Temporal Fragmentation in Borderline Personality Disorder: A Systematic Review

BACKGROUND

Borderline Personality Disorder (BPD) is a prevalent psychopathological condition, affecting 0.7-2.7% of the general population. Given the known link between identity formation and the temporal, metacognitive, and narrative processes that contribute to its coherence, the aim of the present systematic review is to synthesize the current literature about the relationship between identity diffusion and lived time in adult patients with BPD. This would enhance knowledge and treatments, leading to a better understanding of the implications of time processes on identity diffusion in BPD.

METHODS

According to PRISMA guidelines, the main databases were consulted, and specific eligibility criteria were applied. The selection leads to the inclusion of 15 articles, investigating through integrated techniques the lived time, memory, self-reported narratives, and metacognition in BPD subjects.

RESULTS

A general agreement among researchers was found, confirming greater difficulty for BPD subjects in producing autobiographical stories, logically and temporally integrated, characterized by positive content. Functional and structural alterations were detected to explain narrative incoherence, as well as symptoms such as emotional dysregulation and cognitive biases.

CONCLUSIONS

The difficulty for BPD subjects in producing a coherent personal narrative has been interpreted as a correlation of anomalies in autobiographical memories and consequently identities, which were equally compromised by the experience of discontinuity in the temporal structure. This would confirm the hypothesis of the temporal fragmentation of the self in BPD. Although some limitations have been encountered, we suggest that the understanding of identity diffusion and lived time in BPD subjects could represent a useful guide for further research.

Brief Psychotic Episodes and Depressed Mood in a Patient With Borderline Personality Disorder and Antiphospholipid Syndrome

Psychiatric disorders are reported to be associated with systemic inflammatory conditions and autoimmune diseases. Antiphospholipid syndrome (APS) is a rare condition with poorly understood prevalence and incidence in the general population. Case reports have described co-occurrences of psychiatric conditions and APS. Previous case reports have indicated that patients with APS can have comorbid psychosis, anxiety, depression, and other psychiatric conditions. The association between APS and psychiatric illness, however, remains under-investigated in longitudinal studies. In this report, we present the case of a woman in her 40s who was voluntarily admitted to the psychiatric inpatient unit for treatment of auditory hallucinations within the context of borderline personality disorder. She reported a rather extensive medical and psychiatric history of several previous illnesses, musculoskeletal injuries, and hospitalizations. Due to the significant social stress and multiple comorbidities, she may be at increased vulnerability to acute exacerbations of both APS and brief psychotic episodes. In this case report, the patient had a history of three hypercoagulability incidents that were shortly followed by psychiatric admissions. This report highlights the importance of considering systemic conditions such as APS in patients presenting with psychiatric illness. Patients with APS and concomitant psychosis may benefit from screening for APS flares in the case of a psychotic break.

Physical multimorbidity in psychiatric patients with personality disorders: Insights within the ICD-11 framework

OBJECTIVE

Recent research has revealed poor physical health among individuals with personality disorders (PDs). We aimed to compare chronic physical illnesses (CPI) and chronic physical multimorbidity (CPM) prevalence between the general population (GEP) and PD patients, and to explore the relationship between CPM and various aspects of PD, predominantly within the ICD-11 framework.

METHODS

This cross-sectional study included 126 PD patients and 126 matched controls from the GEP. Patients were evaluated for the ICD-11 PD severity and maladaptive personality domains, subjective emptiness, and reflective functioning. CPI was assessed using a standardized self-report questionnaire.

RESULTS

PD patients had a higher mean number of CPIs (2.05 vs. 1.02) and a more frequent CPM occurrence (49.2% vs. 26.2%) compared to the matched controls (p < .001). The ICD-11 PD severity (OR = 1.143, p = .007) and maladaptive domain Negative affectivity (OR = 4.845, p = .002), and poor reflective functioning (OR = 1.694, p = .007) were significant predictors of CPM, independent of sociodemographic, clinical and lifestyle factors. Negative affectivity showed the most robust effect on CPM, while smoking did not significantly mediate these relationships.

CONCLUSION

Our study found increased CPM burden in PD patients and a link between CPM and various PD aspects under the ICD-11 framework, highlighting the need for more integrated healthcare.

Identity Formation in Individuals between 16 and 25 Years Old with Borderline Personality Disorder

Background/Objectives: Identity disruption is a key feature of borderline personality disorder (BPD), characterized by disturbances in self-image. This study aimed to use the Dimensions of Identity Development Scale (DIDS) in a population aged 16-25, to assess differences in identity status and correlations with BPD features as well as whether a correlation exists between the BPD features, the scores obtained on the DIDS and the scores of the different dimensions of this disorder. Methods: We analyzed data from 132 individuals: 44 with BPD using the Diagnostic Interview for Borderline-Revised (DIB-R). Statistical analyses included quantile regression to determine the differences in the DIDS after adjusting for confounding factors identified during group comparisons and Spearman correlation between the DIDS, the BPD features and the DIB-R. Results: Results indicated significantly lower DIDS scores in the BPD group, particularly in commitment making, exploration breadth (EB), identity with commitment (IM) and ruminative exploration (RE). After adjusting, only EB differs significantly between the two groups. All dimensions of the DIDS except for the exploration in depth (ED) are correlated with BPD features. Significant correlations could be demonstrated between cognitive dimension and ED, between the total DIDS and the number of suicide attempt (SA) and between the IM and the number of SA. Conclusions: Our clinical sample showed distinct identity formation compared to controls, with a lower EB associated with BPD. RE correlated with BPD, suggesting that the individuals engage in repetitive exploratory processes. SA was negatively associated with overall identity development and commitment, indicating impulsive behaviors in BPD intersect with identity struggles.

What impact can brain stimulation interventions have on borderline personality disorder?

INTRODUCTION

Borderline personality disorder (BPD) is a severe mental disorder characterized by emotion dysregulation, impulsivity, neuropsychological impairment, and interpersonal instability, presenting with multiple psychiatric comorbidities, functional disability and reduced life expectancy due suicidal behaviors.

AREAS COVERED

In this perspective, the authors explore the application of noninvasive brain stimulation (NIBS) (rTMS, tDCS, and MST) in BPD individuals by considering a symptom-based approach, focusing on general BPD psychopathology, impulsivity and neuropsychological impairments, suicidality and depressive/anxious symptoms, and emotion dysregulation.

EXPERT OPINION

According to a symptoms-based approach, NIBS interventions (particularly rTMS and tDCS) are promising treatment options for BPD individuals improving core symptoms such as emotional and behavioral dysregulation, neuropsychological impairments and depressive symptoms. However, the heterogeneity of stimulation protocols and of assessment tools used to detect these changes limits the possibility to provide definitive recommendations according to a symptom-based approach. To implement such armamentarium in clinical practice, future NIIBS studies should further consider a lifespan perspective due to clinical variability over time, the role of psychiatric comorbidities affecting BPD individuals and the need to combine NIBS with specialized psychotherapeutic approaches for BPD patients and with functional neuroimaging studies.

The impact of childhood trauma on borderline personality organization in a community sample of Greek emerging adults

There is limited research on the role of childhood trauma in personality pathology according to Kernberg's psychodynamic model of internalized object relations. Because childhood trauma reflects the disruptions of these relations, it is expected to predict borderline personality organization, especially at the threshold of adulthood. Therefore, the main aim of this retrospective study was to examine the impact of childhood trauma on borderline personality organization in a community sample of emerging adults. Participants were 543 Greek individuals aged 18-29 (M = 21.45; 58.6 % females; 85.1 % university students). They completed the Greek versions of the Traumatic Antecedents Questionnaire (TAQ) and the Inventory of Personality Organization (IPO), which were tested for their factorial structure, reliability, and measurement invariance across gender, as few empirical data exist on the psychometric properties of these measures. Confirmatory factor analyses showed that the TAQ consisted of four factors, namely positive experiences, abuse, traumatic life events, and family chaos. The five-factor theoretical structure of the IPO, namely primitive defenses, identity diffusion, reality testing, aggression, and moral values, was confirmed. Low to moderate links between childhood trauma and borderline personality organization were found, with stronger links emerging for abuse and family chaos. Structural equation modeling showed that the various forms of childhood trauma across the age periods studied (i.e., 0-6, 7-12, 13-18) significantly and differentially predicted the dimensions of borderline personality organization. The finding that stronger links emerged when trauma occurred in older ages may be attributed to the retrospective method of the study. Gender differences were also found; for example, personality pathology was more likely in men when abuse and traumatic life events occurred in younger ages and abuse was a more important risk factor for personality pathology in women. This study highlights the impact of childhood adversity on personality pathology in emerging adulthood, provides empirical support for Kernberg's psychodynamic model, and has useful implications for trauma-informed early screening, prevention, and intervention regarding personality pathology in young people. Limitations of this study and suggestions for future research are outlined.

Clinical characteristics of over-the-counter (OTC) drug abusers in psychiatric practice in Japan: Comparison of single and multiple OTC product abusers

OBJECTIVE

To examine the clinical characteristics of over-the-counter (OTC) drug abusers in psychiatric practice in Japan.

METHOD

We examined the attributes, ICD-10 subcategory, and comorbid mental disorders of patients who mainly abuse OTC products and compared the clinical characteristics of single product and multiple products abusers, using the database of the "2022 Nationwide Mental Hospital Survey of Drug-related Disorders."

RESULTS

Among the 2468 subjects included in this survey, 273 (11.1%) used OTC products as main drugs. Of these, 209 (78.3%) and 58 (21.7%) were classified into the single product group and the multiple products group, respectively. Six were excluded for unknown ingredients. By comparing these groups, we found that many of the multiple products group consisted of young women who were recently treated for drug problems. Many subjects in the group also had a short treatment period. No differences were observed between the groups regarding the ICD-10 F1 subcategory, but many subjects in the multiple products group fulfilled the criteria of F6 "disorders of adult personality and behavior."

CONCLUSION

OTC products are easily accessible drugs of abuse for young women in Japan. The results of this study indicate the necessity to reconsider the educational approach for preventing drug abuse, which has focused on illicit drugs. The study also indicates that some OTC products, which contain ingredients banned overseas due to their harmful effects, are still sold in Japan and that abusers for those products exist. Measures by the government are considered urgently needed.

Exploring the connection between childhood trauma, dissociation, and borderline personality disorder in forensic psychiatry: a comprehensive case study

This case study examines the complex relationship between childhood trauma, dissociation, and Borderline Personality Disorder (BPD) within the context of forensic psychiatry. It focuses on a young murder defendant named "Paul," who has experienced various traumatic events, including childhood maltreatment and domestic violence. These experiences have led to dissociative states marked by high emotional intensity, particularly of an aggressive nature, and impaired impulse control, resulting in violent behavior during dissociative episodes. The study employs advanced assessment tools like Raven's Standard Progressive Matrices (SPM), the Millon Clinical Multiaxial Inventory-III (MCMI-III), and the Level of Service/Case Management Inventory (LS/CMI) to gain a comprehensive understanding of Paul's psychopathological condition, risk factors, and rehabilitation needs. The LS/CMI assessment highlights a high risk of recidivism, mainly influenced by family relationships, educational challenges, interpersonal connections, and aggressive tendencies. To address the multifaceted needs of individuals like Paul, the study emphasizes the importance of using transdiagnostic models for trauma and dissociation. This approach informs tailored treatment programs that include processing past traumatic experiences, improving self-identity, nurturing healthy relational patterns, and enhancing emotional regulation. Although this study is based on a single case, it serves as a model for integrating assessment tools and theoretical-clinical models in the field of forensic psychiatry. Understanding the intricate dynamics of childhood trauma, dissociation, and BPD is crucial for making informed decisions, conducting risk assessments, and developing rehabilitation programs within the justice system. Future research should expand the scope of cases and further validate assessment tools to advance our understanding of this complex relationship.

Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies

Borderline personality disorder (BPD) was introduced in the DSM-III in 1980. From the DSM-III to the DSM-5, no major changes have occurred in its defining criteria. The disorder is characterized by instability of self-image, interpersonal relationships and affects. Further symptoms include impulsivity, intense anger, feelings of emptiness, strong abandonment fears, suicidal or self-mutilation behavior, and transient stress-related paranoid ideation or severe dissociative symptoms. There is evidence that BPD can be reliably diagnosed and differentiated from other mental disorders by semi-structured interviews. The disorder is associated with considerable functional impairment, intensive treatment utilization, and high societal costs. The risk of self-mutilation and suicide is high. In the general adult population, the lifetime prevalence of BPD has been reported to be from 0.7 to 2.7%, while its prevalence is about 12% in outpatient and 22% in inpatient psychiatric services. BPD is significantly associated with other mental disorders, including depressive disorders, substance use disorders, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, bipolar disorder, bulimia nervosa, and other personality disorders. There is convincing evidence to suggest that the interaction between genetic factors and adverse childhood experiences plays a central role in the etiology of BPD. In spite of considerable research, the neurobiological underpinnings of the disorder remain to be clarified. Psychotherapy is the treatment of choice for BPD. Various approaches have been empirically supported in randomized controlled trials, including dialectical behavior therapy, mentalization-based therapy, transference-focused therapy, and schema therapy. No approach has proved to be superior to others. Compared to treatment as usual, psychotherapy has proved to be more efficacious, with effect sizes between 0.50 and 0.65 with regard to core BPD symptom severity. However, almost half of the patients do not respond sufficiently to psychotherapy, and further research in this area is warranted. It is not clear whether some patients may benefit more from one psychotherapeutic approach than from others. No evidence is available consistently showing that any psychoactive medication is efficacious for the core features of BPD. For discrete and severe comorbid anxiety or depressive symptoms or psychotic-like features, pharmacotherapy may be useful. Early diagnosis and treatment of BPD can reduce individual suffering and societal costs. However, more high-quality studies are required, in both adolescents and adults. This review provides a comprehensive update of the BPD diagnosis and clinical characterization, risk factors, neurobiology, cognition, and management. It also discusses the current controversies concerning the disorder, and highlights the areas in which further research is needed.

Predictors of psychotherapy dropout in patients with borderline personality disorder: A systematic review

INTRODUCTION

Borderline personality disorder (BPD) is a highly debilitating psychiatric condition. Despite the expansion of new BPD specific forms of psychotherapy in the last few decades, high dropout rates have been reported in these treatments. Treatment discontinuation is associated with poor patient outcomes, inefficient resource utilization and the demoralization of healthcare providers.

METHODS

In order to identify predictors of psychotherapy dropout among patients with BPD, a systematic search of Medline, the Cochrane Library, PsycInfo and PsycArticles was conducted. Studies included were randomized-controlled trials in which patients diagnosed with BPD were exposed to a therapeutic intervention consisted of an evidence-based psychotherapy. The quality of evidence in the studies was assessed through the use of revised Cochrane risk of bias tool.

RESULTS

Six articles, incorporating four types of psychotherapy programmes, were included. Overall, the studies present low risk of attrition and reporting bias and unclear risk of selection, performance and detection bias. Patients with weaker therapeutic alliance scores and higher hostility presented with higher dropout rates. In contrast, better mindfulness skills and greater performance in specific neuropsychological domains, such as memory and executive control, were identified as predictive of lower risk of dropout. Sociodemographic variables and treatment history did not influence treatment retention.

CONCLUSIONS

Factors that influence discontinuation should be taken into consideration in future treatment programmes, in an effort to optimize retention. Qualitative assessments of patients' reasons for dropping out may also help guide adjustments.

The comorbidity between Borderline Personality Disorder (BPD) and Generalized Anxiety Disorder (GAD): A systematic review and meta-analysis

Borderline personality disorder (BPD) is a psychiatric condition characterized by severe instability in affect, impulse control, and interpersonal functioning. Existing literature has confirmed that BPD is highly comorbid with other psychiatric conditions, including anxiety disorders. Despite this, little research has investigated the nature of the relationship between generalized anxiety disorder (GAD) and BPD. The aim of this systematic review and meta-analysis is to synthesize the literature concerning the prevalence and clinical outcomes of BPD and GAD comorbidity in adults. The following three databases were searched on October 27, 2021: PsycINFO, PubMed, and Embase. Twenty-four studies were included (n = 21 reporting on prevalence of the comorbidity, n = 4 reporting on clinical outcomes associated with the comorbidity), 9 of which were included in a meta-analysis. The meta-analysis showed that the pooled prevalence for current GAD in individuals with BPD was 16.4% (CI 95%: 1.9%; 66.1%) in inpatient samples, and 30.6% (CI 95%: 21.9%; 41.1%) in outpatient or community samples. The pooled lifetime prevalence of GAD in individuals with BPD was 11.3% (CI 95%: 8.9%; 14.3%) in inpatient samples, and 13.7% (CI 95%: 3.4%; 41.4%) in outpatient or community samples. Comorbidity between BPD and GAD was associated with worse outcomes on measures of BPD severity, impulsivity, anger, and hopelessness. In conclusion, this systematic review and meta-analysis indicate that comorbid GAD and BPD is highly prevalent, although the pooled prevalence rates should be interpreted with caution considering the large and overlapping confidence intervals. Further, this comorbidity is associated with worse BPD symptom severity.

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.

Borderline Personality Disorder: Updates in a Postpandemic World

Progress in understanding borderline personality disorder has unfolded in the last decade, landing in a new COVID-19-influenced world. Borderline personality disorder is now firmly established as a valid diagnosis, distinct from its co-occurring mood, anxiety, trauma-related, and behavioral disorders. Further, it is also understood as a reflection of general personality dysfunction, capturing essential features shared among all personality disorders. Neuroimaging research, representing the vast neurobiological advances made in the last decade, illustrates that the disorder shares frontolimbic dysfunction with many psychiatric diagnoses but has a distinct signature of interpersonal and emotional hypersensitivity. This signature is the conceptual basis of the psychotherapies and clinical management approaches proven effective for the disorder. Medications remain adjunctive and are contraindicated by some guidelines internationally. Less invasive brain-based therapeutics show promise. The most significant change in the treatment landscape is a focus on briefer, less intensive formats of generalist management. Shorter variants of therapies, such as dialectical behavior therapy and mentalization-based treatment, are in the process of being shown to be adequately effective. Earlier intervention and greater emphasis on functional improvement are needed to more effectively curb the disabilities and risks of borderline personality disorder for patients and their families. Remote interventions show promise in broadening access to care.