Comorbid mood disorders as modifiers of treatment response among inpatients with borderline personality disorder

[Evidence-based inpatient psychotherapy in borderline personality disorder]

BACKGROUND

Borderline personality disorder (BPD) is frequent (prevalence in Germany between 0.7% and 4.5%) [11] and is associated with a high level of psychological stress and frequent emergency inpatient admissions. The provision of disorder-specific outpatient psychotherapy is still insufficient also in Germany.

OBJECTIVE

This article provides an overview of the available data on the effectiveness of inpatient psychotherapy for BPD.

MATERIAL AND METHODS

A qualitative review on the effectiveness and therapy outcome predictors was conducted based on a literature search in PubMed.

RESULTS

Overall, very few randomized controlled trials are available; in contrast uncontrolled studies are predominant. Most evidence is available for dialectical behavior therapy (DBT) but other approaches, including psychodynamic procedures, have also been studied.

DISCUSSION

The currently available data suggest an efficacy of inpatient psychotherapy for BPD; however, randomized trials with larger samples and sufficient representation including male patients are largely lacking. There is also no substantial direct evidence for the superiority of inpatient compared to outpatient psychotherapy.

Patients with borderline personality disorder and bipolar disorder: a descriptive and comparative study

BACKGROUND

Bipolar disorder and borderline personality disorder (BPD) are each significant public health problems. It has been frequently noted that distinguishing BPD from bipolar disorder is challenging. Consequently, reviews and commentaries have focused on differential diagnosis and identifying clinical features to distinguish the two disorders. While there is a burgeoning literature comparing patients with BPD and bipolar disorder, much less research has characterized patients with both disorders. In the current report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compare psychiatric outpatients with both BPD and bipolar disorder to patients with BPD without bipolar disorder and patients with bipolar disorder without BPD.

METHODS

Psychiatric outpatients presenting for treatment were evaluated with semi-structured interviews. The focus of the current study is the 517 patients with both BPD and bipolar disorder (n = 59), BPD without bipolar disorder (n = 330), and bipolar disorder without BPD (n = 128).

RESULTS

Compared to patients with bipolar disorder, the patients with bipolar disorder and BPD had more comorbid disorders, psychopathology in their first-degree relatives, childhood trauma, suicidality, hospitalizations, time unemployed, and likelihood of receiving disability payments. The added presence of bipolar disorder in patients with BPD was associated with more posttraumatic stress disorder in the patients as well as their family, more bipolar disorder and substance use disorders in their relatives, more childhood trauma, unemployment, disability, suicide attempts, and hospitalizations.

CONCLUSIONS

Patients with both bipolar disorder and BPD have more severe psychosocial morbidity than patients with only one of these disorders.

Terminology and assessment tools of psychosis: A systematic narrative review

AIM

Phenomena within the psychosis continuum that varies in frequency/duration/intensity have been increasingly identified. Different terms describe these phenomena, however there is no standardization within the terminology. This review evaluated the definitions and assessment tools of seven terms - (i) 'psychotic experiences'; (ii) 'psychotic-like experiences'; (iii) 'psychotic-like symptoms'; (iv) 'attenuated psychotic symptoms'; (v) 'prodromal psychotic symptoms'; (vi) 'psychotic symptomatology'; and (vii) 'psychotic symptoms'.

METHODS

EMBASE, MEDLINE, and CINAHL were searched during February-March 2019. Inclusion criteria included 1989-2019, full text, human, and English. Papers with no explicit definition or assessment tool, duplicates, conference abstracts, systematic reviews, meta-analyses, or no access were excluded.

RESULTS

A total of 2238 papers were identified and of these, 627 were included. Definitions and assessment tools varied, but some trends were found. Psychotic experiences and psychotic-like experiences were transient and mild, found in the general population and those at-risk. Psychotic-like symptoms were subthreshold and among at-risk populations and non-psychotic mental disorders. Attenuated psychotic symptoms were subthreshold but associated with distress, risk, and help-seeking. Prodromal psychotic symptoms referred to the prodrome of psychotic disorders. Psychotic symptomatology included delusions and hallucinations within psychotic disorders. Psychotic symptoms was the broadest term, encompassing a range of populations but most commonly involving hallucinations, delusions, thought disorder, and disorganization.

DISCUSSION

A model for conceptualizing the required terms is proposed and future directions needed to advance this field of research are discussed.

Outcome Trajectories and Prognostic Factors for Suicide and Self-Harm Behaviors in Patients With Borderline Personality Disorder Following One Year of Outpatient Psychotherapy

This study examined suicide and self-harm trajectories in 180 individuals with BPD receiving dialectical behavior therapy or general psychiatric management in a randomized controlled trial. Suicide and self-harm behaviors were assessed at baseline, every four months throughout treatment, and every 6 months over 2 years of follow-up. Latent class growth mixture modeling identified suicide and self-harm trajectories. Multinomial logistic regression analyses examined baseline patient characteristics. Three latent subgroups were identified. The largest responded rapidly to treatment and sustained a favorable response post-discharge. The second progressed slowly during treatment but achieved and maintained a favorable response. A third subgroup showed a rapid favorable response during treatment, however symptoms returned to near baseline levels post-discharge. This third subgroup had higher baseline depression, emergency department visits, and unemployment. BPD patients with high baseline health care utilization, depression, and unemployment may benefit from modifications to treatment specifically targeting these issues.

Developing a decision tool to identify patients with personality disorders in need of highly specialized care

BACKGROUND

Current guidelines recommend referral to highly specialized care for patients with severe personality disorders. However, criteria for allocation to highly specialized care are not clearly defined. The aim of the present study was to develop a decision tool that can support clinicians to identify patients with a personality disorder in need of highly specialized care.

METHODS

Steps taken to develop a decision tool were a literature search, concept mapping, a meeting with experts and a validation study.

RESULTS

The concept mapping method resulted in six criteria for the decision tool. The model used in concept mapping provided a good fit (stress value = 0.30) and reasonable reliability (ρ = 0.49). The bridging values were low, indicating homogeneity. The decision tool was subsequently validated by enrolling 368 patients from seven centers. A multilevel model with a Receiver Operating Characteristic Curve (ROC) was applied. In this way, an easily implementable decision tool with relatively high sensitivity (0.74) and specificity (0.69) was developed.

CONCLUSIONS

A decision tool to identify patients with personality disorders for highly specialized care was developed using advanced methods to combine the input of experts with currently available scientific knowledge. The tool appeared to be able to accurately identify this group of patients. Clinicians can use this decision tool to identify patients who are in need of highly specialized treatment.

Comorbidity between bipolar disorder and borderline personality disorder: Prevalence, explanatory theories, and clinical impact

BACKGROUND

The relationship between bipolar disorder (BD) and borderline personality disorder (BPD) has been controversial and widely debated. Specifically, the comorbidity between both disorders has yielded a plethora of research, but there are no comprehensive reviews on this issue.

OBJECTIVE

To determine the empirical evidence regarding the comorbidity between BD and BPD based on prevalence data, explanatory theories for their co-occurrence, and clinical impact of one disorder in the other.

METHOD

A comprehensive search of databases (PubMed and PsycINFO) was performed. Published manuscripts between January 1985 and August 2015 were identified. Overall, 70 studies fulfilled inclusion criteria.

RESULTS

Over a fifth of subjects showed comorbidity between BPD and BD. Empirical evidence from common underlying factors was inconclusive, but BPD appears to be a risk factor for BD. Data also indicated that the negative impact of BPD in BD (e.g., suicidality, worse mood course) was greater than vice verse.

CONCLUSIONS

Given the high prevalence of comorbidity between BD and BPD and the negative effects of BPD in subjects with BD, further studies are needed to clarify the factor associated with the comorbidity between these two disorders. This information is important to develop appropriate treatments for subjects with both disorders, improve their clinical course, and prevent the increased risk of suicidality commonly found in these subjects.

The relation between prototypical processes and psychological distress in psychodynamic therapy of five inpatients with borderline personality disorder

Five inpatients with borderline personality disorder (BPD) participated in 6 months of three times per week psychodynamic therapy (PDT). Patients completed a measure of psychological distress every week. A total of 127 sessions were audiotaped and coded using the psychotherapy process Q-set (PQS) and correlated with PQS prototypes of five treatment models-PDT, cognitive-behaviour therapy (CBT), interpersonal therapy, transference focused psychotherapy and dialectical behaviour therapy. Prototypical CBT process was most prevalent in three of the five PDT-labelled treatments. Prototypical PDT process significantly decreased over time in three of the five treatments. Prototypical process correlations with time were inversely proportional to prototypical process correlations with distress levels. In a multiple regression model that included all five prototypical process correlations across these three treatments, CBT and transference focused psychotherapy predicted distress reduction, whereas PDT predicted increases in distress. PQS items most negatively correlated with distress included the therapist's emphasis on feelings, empathic attunement and control over the interaction. Discussion of dreams or fantasies and therapist aloofness were most positively correlated with distress. An effective PDT treatment model for severely disturbed BPD inpatients requires technical flexibility to supplement CBT processes such as control over the interaction that can structure intense interpersonal dysregulation and stabilize distress.

KEY PRACTITIONER MESSAGE

Practitioners and their patients sense which prototypical processes to increase or decrease over time to reduce patients' distress. An effective PDT treatment model for severely disturbed BPD patients needs to integrate and encourage the emergence of empathically attuned interactions in the context of a highly structured therapy experience. Practitioners need to be flexible enough to change intervention strategies when they seem to be increasing distress in severely disturbed BPD patients.

Predictors of treatment response to an adjunctive emotion regulation group therapy for deliberate self-harm among women with borderline personality disorder

Despite evidence for the efficacy of several treatments for deliberate self-harm (DSH) within borderline personality disorder (BPD), predictors of response to these treatments remain unknown. This study examined baseline demographic, clinical, and diagnostic predictors of treatment response to an adjunctive emotion regulation group therapy (ERGT) for DSH among women with BPD. A recent RCT provided evidence for the efficacy of this ERGT (relative to a treatment-as-usual only waitlist condition). Participants in this study include the full intent-to-treat sample who began ERGT (across treatment and waitlist conditions; n = 51). Baseline diagnostic and clinical data were collected at the initial assessment, and outcome measures of DSH and self-destructive behaviors, emotion dysregulation/avoidance, and BPD symptoms (among others) were administered at pretreatment, posttreatment, and 3- and 9-months posttreatment. Notably, both demographic variables and characteristics of participants' ongoing therapy in the community had minimal impact on treatment response. However, several indicators of greater severity in domains relevant to this ERGT (i.e., baseline emotion dysregulation and BPD criteria, lifetime and recent DSH, and past-year hospitalization and suicide attempts) predicted better responses during treatment and follow-up across the primary targets of treatment. Likewise, several co-occurring disorders (i.e., social phobia, panic disorder, and a cluster B personality disorder) predicted greater improvements in BPD symptoms during treatment or follow-up. Finally, although co-occurring generalized anxiety disorder, posttraumatic stress disorder, and cluster A and C personality disorders were associated with poorer treatment response during follow-up, most of these effects reflected a lack of continued improvements during this period (vs. worsening of symptoms).

Interaction structures formed in the psychodynamic therapy of five patients with borderline personality disorder in crisis

OBJECTIVES

To identify interaction structures (i.e., patterns of reciprocal interaction) that characterize the treatments of patients with borderline personality disorder (BPD) in crisis.

DESIGN

A 6-month naturalistic psychotherapy process and outcome study in which interaction structures were correlated with outcome data.

METHODS

Five BPD patients in crisis participated in 6 months of three-times-per-week psychodynamic therapy. Patients completed a measure of psychological distress every week. One hundred and twenty-seven sessions were audiotaped and coded using the Psychotherapy Process Q-Set.

RESULTS

Four interaction structures were identified: (1) collaborative relationship with supportive, reassuring therapist (IS1), (2) therapist empathic attunement (IS2), (3) erotized therapeutic relationship (IS3) and (4) directive therapist with compliant patient (IS4). The magnitude of these four interaction structures varied within and between the five therapist-patient dyads over time. Interaction structures correlations with time were inversely proportional to interaction structures correlations with distress levels. IS2 was correlated with two different outcomes in patient 3's and patient 5's treatments--a positive outcome for patient 3's treatment and a negative outcome for patient 5's treatment.

CONCLUSIONS

An effective treatment model for BPD patients in crisis needs to promote the emergence of empathically attuned interactions as well as supportive and directive interventions as dictated by the patient's individual needs. These treatments require flexibility to accommodate the patient's unique presentation in crisis. The therapeutic dyad senses which interaction structures to increase or decrease over time to reduce the patient's distress.

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

BACKGROUND

It is unclear whether Axis II psychopathology or co-morbid clinical syndromes result in the treatment-seeking behaviour and social impairment of patients with borderline personality disorder (BPD). This study examined the independent associations between social functioning and service use and Axis I and Axis II disorders in persons with BPD in the national household population of Britain.

METHOD

The study was a cross-sectional survey of adults aged 16-74 years in households (n=8397). Data included self-reported consultations with health-care professionals and behavioural problems. Diagnosis was determined by computer-assisted interviews. Analyses included logistic regression adjusting for demography, co-morbid Axis I clinical syndromes and other Axis II disorders.

RESULTS

Consultation in the past year was reported by 57.5% of persons with BPD but only 13.4% reported lifetime psychiatric admission. BPD was not independently associated with impaired functioning but was associated with co-morbid psychotic, depressive and anxiety disorders. Only general practitioners (GPs) were consulted for problems independently due to BPD.

CONCLUSIONS

Functional effects of BPD are mediated through co-morbid clinical syndromes, not Axis II psychopathology. A subgroup do not have co-morbid disorders or seek treatment, and are high functioning.