Personality Disorders

The course of borderline personality disorder from adolescence to early adulthood: A 5-year follow-up study

BACKGROUND

Studies of the medium- to long-term clinical and functional course for treatment-seeking adolescents with borderline personality disorder (BPD) are lacking. This study aims to outline the psychopathological and functional status of participants, five years after being diagnosed with BPD during adolescence.

METHODS

Participants were originally enrolled in a randomized clinical trial that compared mentalization-based group treatment with treatment as usual for adolescents with BPD. Semi-structured interview assessments at five-year follow-up included the Schedules for Clinical Assessment in Neuropsychiatry and the Structured Clinical Interview for DSM-5 Personality Disorders. Attention deficit hyperactivity disorder (ADHD), alcohol, substance and tobacco use, posttraumatic stress disorder (PTSD), complex PTSD, and general functioning were assessed using self-report instruments.

RESULTS

97 of the original sample of 111 participants (87%) participated. They were aged 19-23 years. The most prevalent disorders were ADHD (59%), any personality disorder (47%) of which half continued to meet criteria for BPD (24%), anxiety disorders (37%), depressive disorders (32%), PTSD or complex PTSD (20%), schizophrenia (16%), and eating disorders (13%). Only 16% did not meet criteria for any mental disorder. Approximately half of the sample were in psychological and/or psychopharmacological treatment at the time of follow-up. Their general functioning remained impaired, with 36% not engaged in education, employment or training (NEET), which is nearly four times the rate of NEET in the same age group in the general population.

CONCLUSIONS

Although stability of the categorical BPD diagnosis is modest, adolescents meeting diagnostic criteria for BPD show a broad range of poor outcomes at five-year follow-up. BPD appears to be a marker of general maladjustment during adolescence and a harbinger of severe problems during the transition to young adulthood. Early intervention programs for adolescents diagnosed with BPD should focus upon a broad range of functional and psychopathological outcomes, especially social and vocational support, rather than the narrow BPD diagnosis.

Psychopathology and psychosocial functioning among young people with first-episode psychosis and/or first-presentation borderline personality disorder

BACKGROUND

One in five young people with first-episode psychosis (FEP) also presents with borderline personality disorder (BPD) features. Among people diagnosed with BPD, auditory verbal hallucinations occur in 29-50 % and delusions in 10-100 %. Co-occurrence of psychotic symptoms and BPD is associated with greater clinical severity and greater difficulty accessing evidence based FEP care. This study aimed to investigate psychotic symptoms and psychosocial functioning among young people presenting to an early intervention mental health service.

METHOD

According to the presence or absence of either FEP or BPD, 141 participants, aged 15-25 years, were assigned to one of four groups: FEP, BPD, combined FEP + BPD, or clinical comparison (CC) participants with neither FEP nor BPD. Participants completed semi-structured diagnostic interviews and interviewer and self-report measures of psychopathology and psychosocial functioning.

RESULTS

The FEP + BPD group had significantly more severe psychopathology and poorer psychosocial functioning than the FEP group on every measure, apart from intensity of hallucinations. Comparing the FEP or BPD groups, the BPD group had greater psychopathology, apart from intensity of psychotic symptoms, which was significantly greater in the FEP group. These two groups did not significantly differ in their overall psychosocial functioning. Compared with CC young people, both the FEP + BPD and BPD groups differed significantly on every measure, with medium to large effect sizes.

CONCLUSIONS

Young people with co-occurring FEP and BPD experience more severe difficulties than young people with either diagnosis alone. This combination of psychosis and severe personality pathology has been longitudinally associated with poorer outcomes among adults and requires specific clinical attention.

Practical implications of ICD-11 personality disorder classifications

Personality disorders (PDs) are associated with an inferior quality of life, poor health, and premature mortality, leading to heavy clinical, familial, and societal burdens. The International Classification of Diseases-11 (ICD-11) makes a thorough, dramatic paradigm shift from the categorical to dimensional diagnosis of PD and expands the application into adolescence. We have reviewed the recent literature on practical implications, and severity and trait measures of ICD-11 defined PDs, by comparing with the alternative model of personality disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), by mentioning the relevance in forensic and social concerns, and by referencing the developmental implication of life span, especially in adolescence. Study results strongly support the dimensional utility of ICD-11 PD diagnosis and application in adolescence which warrants early detection and intervention. More evidence-based research is needed along the ICD-11 PD application, such as its social relevance, measurement simplification, and longitudinal design of lifespan observation and treatment.

Evidence from a meta-analysis and systematic review reveals the global prevalence of mild cognitive impairment

Objective

Mild cognitive impairment (MCI) is a preclinical and transitional stage between healthy ageing and dementia. The purpose of our study was to investigate the recent pooled global prevalence of MCI.

Methods

This meta-analysis was in line with the recommendations of Cochrane's Handbook and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020. We conducted a comprehensive search using the PubMed, Embase, Web of Science, CNKI, WFD, VIP, and CBM from their inception to March 1, 2023. Quality assessment was guided by the Agency for Healthcare Research and Quality (AHRQ) methodology checklist. The pooled global prevalence of MCI was synthesized using meta-analysis via random effect model. Subgroup analyses were performed to examine considered factors potentially associated with MCI prevalence.

Results

We identified 233 studies involving 676,974 individuals aged above 50 years. All the studies rated as moderated-to-high quality. The overall prevalence of MCI was 19.7% [95% confidence interval (95% CI): 18.3-21.1%]. Subgroup analyses revealed that the global prevalence of MCI increased over time, with a significant rise [32.1% (95% CI: 22.6-41.6%)] after 2019. Additionally, MCI prevalence in hospitals [34.0% (95% CI: 22.2-45.7%)] was higher than in nursing homes [22.6% (95% CI: 15.5-29.8%)] and communities [17.9% (95% CI: 16.6-19.2%)], particularly after the epidemic of coronavirus disease 2019 (COVID-19).

Conclusion

The global prevalence of MCI was 19.7% and mainly correlated with beginning year of survey and sample source. The MCI prevalence increased largely in hospitals after 2019 may be related to the outbreak of COVID-19. Further attention to MCI is necessary in the future to inform allocation of health resources for at-risk populations.

Bringing personality disorder in from the cold: Why personality disorder is a fundamental concern for youth mental health

OBJECTIVE

Personality disorder (PD) has its peak incidence between puberty and young adulthood. By any measure, it is among the most severe mental health problems occurring in young people, uniquely predicting debilitating current problems and acting as a 'gateway' to diverse and serious future problems. Yet, PD still struggles for legitimacy and parity of access to services, including early intervention.

CONCLUSION

Addressing PD is fundamental to youth mental health, and early intervention for PD has reached 'proof of concept'. Yet, reform is hindered by bigotry and sectarianism. Successful early intervention calls for a shift in the culture of services, countering damaging myths, addressing bigotry, and fostering hope. Such reforms are well within the reach of youth mental health.

Commentary: Commentary on the Twitter comments evoked by the May 2022 debate on diagnosing personality disorders in adolescents

The debate about the value and utility of personality disorder (PD) diagnosis in adolescence published in the May 2022 issue of CAMH generated fervent Twitter discussion. This commentary addresses some points raised in the Twitter discussion that represent important social and/or cultural beliefs that are often presented in day-to-day practice but are rarely tested in the context of scientific evidence. This includes, in particular, the assertion that symptoms used to diagnose personality disorder are better described as sequelae of trauma, and the assertion that effective treatment for PD is possible without a diagnosis. The call for a fundamental transformation of mental health services that currently do not meet the needs of people with PD and for the involvement of people with lived experience as equal partner in this process is supported by evidence and might represent common ground among those clinician-scientist advocating for early intervention for PD and those expressing their concerns about this issue.

On the interplay of borderline personality features, childhood trauma severity, attachment types, and social support

BACKGROUND

Adverse childhood experiences (ACE) have consistently been associated with borderline personality disorder (BPD). Still, it is not yet entirely understood if and how different types of ACE (emotional, physical, sexual abuse, neglect) relate to different BPD subdomains (affective instability, identity disturbance, negative relationships, self-harm). Insecure attachment and lower perceived social support are associated with both ACE and BPD and may therefore contribute to their relationship. No study so far integrated all these variables in one model, while accounting for their mutual influence on each other. We investigated the interplay of BPD subdomains, ACE, attachment, and perceived social support using a graph-theoretical approach.

METHODS

An international sample of 1692 participants completed the Childhood Trauma Questionnaire (CTQ), the Borderline Feature Scale from the Personality Assessment Inventory (PAI-BOR), the Adult Attachment Scale (AAS), and Multidimensional Scale of Perceived Social Support (MSPSS) via an online survey. We estimated a partial correlation network including subscales of the CTQ and the PAI-BOR as nodes. We extended the network by including subscales of the AAS and MSPSS as additional nodes.

RESULTS

Emotional abuse was the most central node in both networks and a bridge between other types of ACE and BPD features. All domains of BPD except affective instability were associated with emotional abuse. Identity disturbances was the most central node in the BPD network. The association between ACE and BPD features was partly but not fully explained by attachment and social support.

CONCLUSION

Our findings suggest that emotional abuse is an important link in the association between ACE and BPD features, also when taking attachment and social support into account. Findings further suggest an outstanding role of identity disturbance, linking emotional abuse to affective instability and being strongly associated with attachment anxiety.