Burden and support needs of carers of persons with borderline personality disorder: a systematic review

Family Connections: The Impact of an Education Program for Carers of Individuals With Borderline Personality Disorder in Italian Mental Health Services

Borderline personality disorder (BPD) has a strong impact not only on patients' lives but also on their families. The presence of an invalidating environment is one of the key factors in the etiology of BPD. This study evaluated the impact of the Family connections (FC) program on burden, grief, and other clinical variables in 202 caregivers and identified the profiles of participants who improved/deteriorated their levels of burden and grief. Findings from generalized linear mixed models showed significant reductions in burden, grief, depression, global psychological distress, and suppressed and expressed anger after FC intervention. Two classification trees were applied to test whether improvements in burden and grief were associated with age, gender and the improvements in other clinical variables. Caregivers reporting reduced depression were more likely to improve in both burden and grief. Moreover, younger participants showing increased depression had a 72.7% probability of being part of the improvement in burden and a 66.7% probability of being part of the improvement in grief. A decrease in depression and having a younger age were associated with positive gains for caregiving burden and grief. Longitudinally, ANOVAs showed positive changes in burden and grief as well as decreased depression, global psychological distress and suppressed anger were maintained at 4-month follow-up. Present findings improve our understanding of the utility of the FC program for caregivers of people with BPD. The impact of depressive symptoms' reduction and being younger on perceived burden and grief highlight the importance of exploring additional possible moderators of outcomes in FC intervention. Trial Registration: NCT06076343; NCT06074289. Registered 10/10/2023.

Transgender and Gender Diverse Patients Are Diagnosed with Borderline Personality Disorder More Frequently Than Cisgender Patients Regardless of Personality Pathology

Purpose

Borderline personality disorder (BPD) is a severe form of psychopathology associated with a host of negative outcomes. Some literature suggests elevated prevalence among transgender and gender diverse (TGD) samples. Elevated BPD prevalence among TGD populations could be due to factors other than BPD-specific psychopathology. Studies of TGD samples typically omit assessment of BPD, making it difficult to understand elevated BPD diagnosis. The current study explored (1) differences in BPD diagnosis among TGD patients versus cisgender patients, (2) if differences were explained by BPD-specific pathology, and (3) if BPD diagnostic disparities existed based on assessment modality.

Methods

Data from TGD (n=74) and cisgender heterosexual (n=920) patients who presented for treatment at one partial hospitalization program from 2014 to 2019 were compared to investigate differences in the frequency of BPD diagnosis.

Results

A larger proportion of TGD patients were diagnosed with BPD than cisgender patients (odds ratio [OR]=4.05, p<0.001). The disparity in diagnosis persisted even after controlling for BPD-specific personality pathology (OR=2.98, p<0.001). BPD diagnostic disparity occurred when assessed using structured (OR=4.78, p<0.001) and unstructured (OR=3.61, p<0.001) interview methods. There was no disparity, however, when BPD was diagnosed using an algorithm based on BPD-specific personality pathology purported to underlie the diagnosis.

Conclusions

Clinical providers appear inclined to assign a BPD diagnosis to TGD patients that may not correspond with group differences in underlying personality pathology. That some BPD symptoms might be more likely in TGD samples, future research can examine criterion-level biases in BPD diagnosis among TGD individuals.

Hopelessness for family members of individuals with borderline personality disorder

Family members and loved ones of individuals with Borderline Personality Disorder (BPD) can experience high levels of distress. Types of distress reported by family members include burden, grief, depression, guilt, and powerlessness. Hopelessness is a construct that has received little attention despite its potential relevance for this group. This study sought to examine, and assess potential change in, hopelessness among individuals attending a 12-week Family Connections (FC) program. Participants were 75 family members, 29 men and 46 women. Most participants were parents (n = 43; 57%). Data were collected at four time-points and outcomes included hopelessness, burden, and grief. The majority of participants (82%) reported scores within the 'minimal' or 'mild' ranges of hopelessness before the FC program. A greater proportion of participants in the 60-70 year age group reported scores in the 'moderate/severe' category when compared with younger age groups. The mean hopelessness score for all participants before FC was 4.61 which is considered mild. There was no significant difference in hopelessness scores after program completion. Although mean scores increased at both 3-month and 12-month follow-ups, they continued to remain in the 'mild' category. Hopelessness scores in the current study are similar to those reported in previous studies, although no significant change was found after FC completion. Concepts of personal vs. situational hopelessness should be considered, as well as the relevance of assessing personal hopelessness for this participant group. Further research is needed to determine the relationship between family member hopelessness and index client wellbeing.

Group intervention for family members of people with borderline personality disorder based on Dialectical Behavior Therapy: Implementation of the Family Connections® program in France and Switzerland

BACKGROUND

Families and significant others of people with borderline personality disorder (BPD) show increased levels of psychological distress. Family Connections®, a 12-week group intervention based on the principles of Dialectical Behavior Therapy, was designed to provide families with both information about the disorder and emotion regulation skills. It has been progressively implemented in French-speaking European countries.

METHODS

We conducted an observational, multicenter study in France and Switzerland. In total, 149 participants of the Family Connections program were included among five centers. Burden, depression, coping, and emotion regulation were assessed before and after the intervention.

RESULTS

One-way repeated measures MANOVA showed that the burden, depressive symptoms, emotion regulation and coping all changed significantly after the intervention (p < 0.001, partial η2 = 0.297). T-tests showed that the burden significantly decreased after the intervention (p < 0.0001, d = -0.48), as did depressive symptoms (p < 0.0001, d = -0.36) and difficulties in emotion regulation (p < 0.0001, d =-0.32) whereas coping improved (p < 0.0001, d = 0.53). Two-way mixed ANOVA showed that burden reduction was stronger among female than male participants (p = 0.048, η2 = 0.027). Before the intervention, the burden was higher for female than male participants (p < 0.001). An initial linear regression showed the burden reduction to be associated with a decrease in the resignation of the participants (β = 0.19, p = 0.047). A second linear regression showed the burden reduction to be associated with the intensity of the relatives' symptoms at baseline (β = 0.22, p = 0.008) and improvement of emotional clarity of the participants (β = 0.25, p = 0.006).

CONCLUSION

This Dialectical Behavior Therapy-Based psychoeducational intervention is an appropriate way to support French-speaking European families of people with BPD.

Effect of Dialectical Behavior Therapy on Negative Affect, and Symptoms of Depression and Anxiety in Individuals with Borderline Personality Disorder during COVID-19 Pandemic

Background: This study investigated the effectiveness of dialectical behavior therapy (DBT) in patients with borderline personality disorder (BPD) during the COVID-19 pandemic, assessing negative affect, depression, and anxiety levels as indicators of health. Methods: A total of 287 participants were recruited, including BPD patients at different stages of treatment and the general population without a diagnosis of BPD. Questionnaires were used to assess the fear of COVID-19 and the referenced health indicators. Results: No differences were observed between groups in levels of fear of COVID-19, but there were differences in the health indicators studied. BPD patients in long-term treatment showed levels of negative affect similar to those of the general population, while those in early treatment stages exhibited significantly higher levels. However, no significant improvements were observed in levels of depression and anxiety in the long-term treatment group compared to those who underwent the initial treatment phase. Conclusions: These findings underscore the importance of effectively intervening in BPD, especially in stress-inducing situations such as the pandemic, and suggest the need to explore complementary approaches to addressing depression and anxiety in this clinical context.

Twenty years of research on borderline personality disorder: a scientometric analysis of hotspots, bursts, and research trends

Borderline personality disorder (BPD), a complex and severe psychiatric disorder, has become a topic of considerable interest to current researchers due to its high incidence and severity of consequences. There is a lack of a bibliometric analysis to visualize the history and developmental trends of researches in BPD. We retrieved 7919 relevant publications on the Web of Science platform and analyzed them using software CiteSpace (6.2.R4). The results showed that there has been an overall upward trend in research interest in BPD over the past two decades. Current research trends in BPD include neuroimaging, biological mechanisms, and cognitive, behavioral, and pathological studies. Recent trends have been identified as "prevention and early intervention", "non-pharmacological treatment" and "pathogenesis". The results are like a reference program that will help determine future research directions and priorities.

"I'm fighting with BPD instead of my partner": A dyadic interpretative phenomenological analysis of the lived experience of couples navigating borderline personality disorder

Borderline personality disorder (BPD) is associated with romantic relationship distress and dissolution. The complex interaction between BPD and romantic relationships warrants further attention. Dyadic interviews (N = 10) were conducted to examine the experience and impact of BPD on couples' relationships. The results of interpretative phenomenological analysis consisted of two superordinate themes describing the couple experience of navigating BPD: (a) the shared experience of BPD as a relational stressor; and (b) adaptive dyadic coping in the context of BPD. Although BPD was experienced as a relational stressor, dyadic coping and shared externalization of BPD emerged as central components to adaptive couple functioning. Most couples reported that therapy was a critical external resource in their journey toward adaptively functioning in the context of BPD, both intrapersonally and interpersonally. The lived experiences of these couples provides therapists with an increased understanding of the resources that support adaptive dyadic coping with BPD.

Don´t set us aside!Experiences of families of people with BPD who have access to Brief admission:a phenomenological perspective

AIM

To highlight the experiences of family members of people with borderline personality disorder (BPD) and self-harming behaviour who have access to brief admission.

METHODS

To understand the families lived experience a phenomenological lifeworld perspective was adopted to this study. Twelve in-depht interviews were performed in November and December 2021 with family members of people with BPD and self-harming behaviour who have accessed BA. The phenomenological life-world perspective guided the analysis.

RESULTS

Families' life-world was characterized by anxiety and constant protection of their loved one. They live with constant fear of how their loved ones are feeling and whether they will injure themselves. When access to BA was available this gave hope and provided conditions for families to maintain everyday routines and also enhanced relationships among family members. When families' loved ones were denied BA, they felt betrayed which contributed to negative feelings towards the medical profession, and the families lost confidence in psychiatry.

CONCLUSION

By interviewing families of people with BPD and self-harming behaviour who had access to BA, it emerged they possess valuable knowledge. BA can be developed if the needs of families are taken into consideration, and if families are given the opportunity to share emotions and the high burden of responsibility with staff or families in similar situations. If health care staff gives family members a more central role in care and makes their shared life-world visible it could thereby hopefully increase well-being and benefits for the whole family.

The experiences of parents in an early-intervention program for young people with borderline personality disorder features

Previous research demonstrates that parents' communication skills may contribute to the development and maintenance of their young person's borderline personality disorder (BPD). Carers of people with BPD also experience their own psychosocial stressors and feel unsupported. Consequently, Dialectical Behavior Therapy for adolescents (DBT-A) invites parents to partake in group therapy alongside their young person. Despite this involvement, little research exists examining parents' perspective of engaging in a DBT-A program, and specifically whether they experience their own benefits and changes from being part of the program. To examine this, the current study interviews 34 parents who engaged in an early intervention DBT-A program. Thematic analysis resulted in seven key themes and 16 subthemes beginning with parents' expectations of the program, followed by the key elements of the program that facilitated change, and the actual changes and benefits attributed to these elements. Overall, parents were surprised by their own gains from the program, and how the skills they learned facilitated personal development that improved family communication and functioning with their young person and more broadly. This study addresses the gap in understanding the parent perspective with clinical implications for the benefits of involving parents in therapy more generally.

Difficulties in emotional regulation mediates the impact of burden on quality of life and mental health in a sample of family members of people diagnosed with Borderline Personality Disorder

Background

Although it has been suggested that family members of persons suffering from Borderline Personality Disorder (BPD) endure high levels of burden, however, the process and the impact of this burden in their lives, and specifically the relation between the burden and emotional regulation has not been broadly investigated among this population. The main objective of this study is to examine the impact of burden on quality of life and depression, anxiety and stress, as mediated by difficulties in emotional regulation in family members of persons diagnosed with BPD.

Method

Participants were 167 family members of persons diagnosed with BPD. The Burden Assessment Scale, Difficulties in Emotion Regulation Scale, Multicultural Quality of Life Index, and Depression Anxiety Stress Scale-21 were filled out. Mediation analysis was conducted using the Maximum Likelihood estimator, bootstrap method and listwise deletion for missing data.

Results

Burden showed a significant, negative effect on quality of life and positive on depression, anxiety and stress. Difficulties in emotion regulation significantly mediated these relations. After accounting for the mediating role of difficulties in emotion regulation, burden still had an impact on quality of life, depression, anxiety and stress. Women showed a higher level in both burden and stress than men. The caregivers with secondary and higher studies showed higher levels in burden than those with no studies. Not significant differences in burden, emotion regulation, depression, anxiety and stress were found related to marital status.

Conclusion

Difficulties in emotion regulation mediate the relations between burden and quality of life, depression, anxiety, and stress. Family members could engage in group interventions designed specifically for family members of people with BPD, oriented toward understanding the disorder or learning skills.

A randomised controlled trial of a psychoeducational group intervention for family and friends of young people with borderline personality disorder features

OBJECTIVE

Preliminary evidence indicates that interventions designed to support family and friends ('carers') of young people with early-stage borderline personality disorder effectively improve carer outcomes. None of these interventions have been tested in a randomised controlled trial.

METHOD

This clustered, partially nested, randomised controlled trial was conducted at Orygen, Melbourne, Australia. Carers of young people (aged 15-25 years) with borderline personality disorder features were randomly assigned as a unit in a 1:1 ratio, balanced for young person's sex and age, to receive a 15-day intervention comprising: (1) the three-session, in-person, Making Sense of BPD (MS-BPD) multi-family group programme, plus two self-directed online psychoeducational modules (MS-BPD + Online, n = 38), or (2) the two self-directed online psychoeducational modules alone (Online, n = 41). The primary outcome was 'negative experiences of care', measured with the Experience of Caregiving Inventory, at the 7-week endpoint.

RESULTS

A total of 79 carers were randomised (pool of 281, 197 excluded, 94 declined) and 73 carers (51 females [69.9%], Mage = 43.8 years [standard deviation, SD = 12.9], MS-BPD + Online n = 35 [47.9%], Online n = 38 [52.1%]) provided follow-up data and were included in the intent-to-treat analysis. The intent-to-treat (and per protocol) analyses did not find any significant differences between the groups on the primary (d = -0.32; 95% confidence interval = [-17.05, 3.97]) or secondary outcomes. Regardless of treatment group, caregivers improved significantly in their personality disorder knowledge.

CONCLUSION

Delivering MS-BPD in conjunction with an online psychoeducational intervention was not found to provide additional benefit over and above access to an online intervention alone. In accordance with national guidelines, carer interventions should be routinely offered by youth mental health services as part of early intervention programmes for borderline personality disorder. Further research is warranted into which interventions work for whom, carers' preferences for support and barriers to care.

Differentiating between intrapsychic symptoms and behavioral expressions of borderline personality disorder in relation to childhood emotional maltreatment and emotion dysregulation: an exploratory investigation

BACKGROUND

Borderline personality disorder (BPD) is a severe mental disorder, characterized by pronounced instability in emotions, self-image, and interpersonal relationships. Experiences of childhood maltreatment are among the risk factors for BPD. While self-damaging and aggressive acts often occur, not every person with the disorder shows markedly dysregulated behaviour. Internalized symptoms, such as shame, loneliness, and self-disgust tend to be more pervasive and persist after clinical remission.

OBJECTIVE

Here we investigated associations between BPD symptom severity, childhood maltreatment, and emotion regulation difficulties. We further explored if the Borderline Symptom List (BSL) could potentially be used to differentiate between internalized symptoms (intrapsychic strain) and externalized symptoms (dysregulated behaviours) in future research.

METHOD

187 women with at least mild BPD symptoms (65% having a diagnosis of BPD) completed the BSL 23 including its 11-item supplement (BSL-S), the Childhood Trauma Questionnaire (CTQ), and Difficulties in Emotion Regulation Scale (DERS). Participants further underwent a semi-structured clinical interview to assess BPD criteria (International Personality Disorder Examination, IPDE). Multivariate models and regression-based bootstrapping analyses were performed to test direct and indirect effects.

RESULTS

Childhood trauma severity, especially emotional abuse, positively predicted BPD symptom severity. A significant indirect effect through emotion regulation difficulties was found (k2=.56). When exploring associations with BPD criteria (IPDE), the BSL-23 mean significantly correlated with separation anxiety, identity and mood problems, chronic emptiness, suicidal ideation, and dissociation, while the BSL-S correlated with self-harming impulsive behaviour and anger outbursts.

CONCLUSIONS

Findings complement previous research, highlighting the role of childhood maltreatment and emotion regulation difficulties in BPD. While our findings need to be seen as preliminary and interpreted with caution, they suggest that the BSL may be used to differentiate between internalized symptoms and behavioural expressions of BPD in future research. Such a distinction might help to deepen the understanding of this complex heterogenous disorder.

Mother-child interactions in adolescents with borderline personality disorder traits and the impact of early life maltreatment

BACKGROUND

Early detection and intervention of borderline personality disorder (BPD) in adolescence has become a public health priority. Theoretical models emphasize the role of social interactions and transgenerational mechanisms in the development of the disorder suggesting a closer look at caregiver-child relationships.

METHODS

The current study investigated mother-adolescent interactions and their association with adolescent BPD traits by using a case-control design. Thirty-eight adolescent patients with ≥ 3 BPD traits and their mothers (BPD-G) were investigated in contrast to 35 healthy control dyads (HC-G). Maternal, adolescent and dyadic behavior was coded using the Coding Interactive Behavior Manual (CIB) during two interactions: a fun day planning and a stress paradigm. Additional effects of maternal and/or adolescent early life maltreatment (ELM) on behavior were also explored.

RESULTS

BPD-G displayed a significantly lower quality of maternal, adolescent and dyadic behavior than the HC-G during both interactions. Maternal and adolescent behavior was predicted by BPD traits alone, whilst dyadic behavior was also influenced by general adolescent psychopathology. Exploratory analyses of CIB subscales showed that whilst HC-G increased their reciprocal behavior during stress compared to the fun day planning, BPD-G dyads decreased it. Maternal ELM did not differ between groups or have any effect on behavior. Adolescent ELM was correlated with behavioral outcome variables, but did not explain behavioral outcomes above and beyond the effect of clinical status.

DISCUSSION/CONCLUSION

Our data suggest a stronger focus on parent-child interactions in BPD-specific therapies to enhance long-term treatment outcomes in adolescent BPD patients. Further research employing study designs that allow the analyses of bidirectional transactions (e.g. longitudinal design, behavioral microcoding) is needed.

The diagnosis that should speak its name: why it is ethically right to diagnose and treat personality disorder during adolescence

Although national guidelines explicitly state that personality disorder can be diagnosed and treated in young people aged 12 to 18 years (adolescents), most clinicians remain hesitant. This creates a gap between science and practice, which we argue is largely motivated by moral reasons and, therefore, is best challenged by ethical arguments. We provide seven arguments in support of the notion that it is ethically right to diagnose and treat personality disorder when it occurs in adolescents. Central to these arguments is the scientific evidence that features of personality disorder are among the best predictors of a complex cluster of psychopathology leading to impairments in many areas of current and future mental, social and vocational functioning. We argue that intervention during adolescence and young adulthood is not only humane, but also critical for efforts to avert the longstanding psychosocial and health problems that seem refractory to treatment in adults with personality disorder. Moreover, we argue that regular services are often inadequately equipped to meet the needs of young people with personality disorder and that the common 'stepped-care' approach should be replaced by a 'staged-care' approach. Finally, we argue that early detection and intervention might have anti-stigmatizing effects, similar to other areas of healthcare in which stigmatizing labels have changed meaning when the conditions to which they refer have become more amenable to treatment.

Spanish adaptation of the Burden Assessment Scale in family caregivers of people diagnosed with borderline personality disorder

BACKGROUND

Caregiving is a strong source of stress and leads the family caregiver to experience the burden of being responsible for the care of a severely mentally ill family member. The Burden Assessment Scale (BAS) assesses burden in family caregivers. This study aimed to analyze the psychometric properties of the BAS in a sample of family caregivers of people diagnosed with Borderline Personality Disorder (BPD).

METHODS

Participants were 233 Spanish family caregivers (157 women and 76 men aged between 16-76 years old, M = 54.44, SD = 10.09) of people diagnosed with BPD. The BAS, the Multicultural Quality of Life Index, and the Depression Anxiety Stress Scale-21 were used.

RESULTS

An exploratory analysis resulted in a three-factor 16-item model (Disrupted Activities; Personal and Social Dysfunction; Worry, Guilt, and Being Overwhelmed) with an excellent fit (χ²(101) = 56.873, p = 1.000, CFI = 1.000, TLI = 1.000, RMSEA = .000, SRMR = .060), good internal consistency (ω = .93), a negative correlation with quality of life, and a positive correlation with anxiety, depression, and stress.

CONCLUSION

The model obtained for the BAS is a valid, reliable, and useful tool for assessing burden in family caregivers of relatives diagnosed with BPD.

Systems Training for Emotional Predictability and Problem Solving for borderline personality disorder: A systematic review

Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a group treatment program for patients with borderline personality disorder (BPD). The program was intended to be highly accessible, both for patients and therapists. During STEPPS, patients are taught emotion regulation and behavior management skills. This systematic review synthesizes the current empirical status of STEPPS, focusing on research designs, quality of studies, target groups, protocols, and outcome. We selected 20 studies, with three randomized controlled trials. Patients with BPD, subthreshold BPD, and patients with BPD and comorbid antisocial personality disorder were investigated. One study was conducted in adolescents. There were no studies in older adults. Results demonstrated STEPPS to be associated with reduced BPD symptoms, improved quality of life, decreased depressive symptoms, and decreased negative affectivity. Mixed results were found for impulsivity and suicidal behaviors. STEPPS has both been studied as an add-on therapy to patients' ongoing treatment, and, with the addition of individual STEPPS sessions, as a stand-alone treatment. High attrition rates were found in patients attending STEPPS, complicating the generalizability of the results. Although the evidence for STEPPS is promising, further research is needed before firm conclusions can be drawn. Recommendations for future research are discussed.

Demystifying borderline personality disorder in primary care

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

Five Failures and Five Challenges for Prevention and Early Intervention for Personality Disorder

Despite global consensus regarding the early detection of personality disorder, current approaches to early intervention have failed to deliver for the majority of young people. This only serves to reinforce the enduring effects of personality disorder on functioning, mental and physical health, resulting in a reduction of quality of life and life expectancy. Here, we describe five significant challenges facing prevention and early intervention for personality disorder: identification, access to treatment, research translation, innovation and functional recovery. These challenges highlight the need for early intervention to shift from niche programmes in specialist services for a select few young people to become established in mainstream primary care and specialist youth mental health services. Reprinted from Curr Opin Psychol 2021; 37:134-138, with permission from Elsevier. Copyright © 2021.

Structural stigma and its impact on healthcare for borderline personality disorder: a scoping review

BACKGROUND

People with Borderline Personality Disorder (BPD) and their carers/families continue to experience structural stigma when accessing health services. Structural stigma involves societal-level conditions, cultural norms, and organizational policies that inhibit the opportunities, resources, and wellbeing of people living with attributes that are the object of stigma. BPD is a serious mental illness characterized by pervasive psychosocial dysfunction including, problems regulating emotions and suicidality. This scoping review aimed to identify, map, and explore the international literature on structural stigma associated with BPD and its impact on healthcare for consumers with BPD, their carers/families, and health practitioners.

METHODS

A comprehensive search of the literature encompassed MEDLINE, CINAHL, PsycINFO, Scopus, Cochrane Library, and JBI Evidence-Based databases (from inception to February 28th 2022). The search strategy also included grey literature searches and handsearching the references of included studies. Eligibility criteria included citations relevant to structural stigma associated with BPD and health and crisis care services. Quality appraisal of included citations were completed using the Mixed Methods Appraisal Tool 2018 version (MMAT v.18), the Joanna Briggs Institute (JBI) Checklist for Systematic Reviews and Research Syntheses Tool, and the AGREE II: advancing guideline development, reporting, and evaluation in health care tool. Thematic Analysis was used to inform data extraction, analysis, interpretation, and synthesis of the data.

RESULTS

A total of 57 citations were included in the review comprising empirical peer-reviewed articles (n = 55), and reports (n = 2). Studies included quantitative, qualitative, mixed methods, and systematic review designs. Review findings identified several extant macro- and micro-level structural mechanisms, challenges, and barriers contributing to BPD-related stigma in health systems. These structural factors have a substantial impact on health service access and care for BPD. Key themes that emerged from the data comprised: structural stigma and the BPD diagnosis and BPD-related stigma surrounding health and crisis care services.

CONCLUSION

Narrative synthesis of the findings provide evidence about the impact of structural stigma on healthcare for BPD. It is anticipated that results of this review will inform future research, policy, and practice to address BPD-related stigma in health systems, as well as approaches for improving the delivery of responsive health services and care for consumers with BPD and their carers/families.

REVIEW REGISTRATION

Open Science Framework ( https://osf.io/bhpg4 ).

Co-occurring first-episode psychosis and borderline personality pathology in an early intervention for psychosis cohort

INTRODUCTION

Borderline personality disorder (BPD) is common among people diagnosed with first episode of psychosis (FEP), but is often under-recognized and under-researched. This study aimed to determine: (i) the prevalence of borderline personality pathology (subthreshold features and categorical disorder) in a FEP cohort (termed FEP + BPP); (ii) demographic and clinical factors associated with FEP + BPP; (iii) the symptomatic and functional outcomes.

METHODS

This study was conducted within the Early Psychosis Prevention and Intervention Centre (EPPIC) at Orygen over the 30-month period between 2014 and 2016. BPP was evaluated by using the Structured Clinical Interview for DSM-IV Axis II Personality Questionnaire BPD criteria.

RESULTS

In a cohort of 457 young people with a FEP (mean age 19.5 years, 56% male), 18.4% had borderline personality pathology (BPP). Compared with FEP alone, young people with FEP + BPP were more likely to be female, younger, Australian-born. In addition, young people with FEP + BPP were more likely to be diagnosed with Psychosis NOS, present with more severe hallucinations, and have alcohol abuse. Young people with FEP + BPP had more relationship difficulties at presentation and they were more likely to suffer of depression and to engage in self-harm throughout the follow-up. In relation to outcome, FEP + BPP was not associated with different rates of remission or relapse, however they were less likely to be admitted to hospital at presentation or involuntarily during their episode of care.

CONCLUSION

BPP is a common occurrence in psychotic disorders and is associated with more severe hallucinations and depression with higher risks of self-harm. Specific interventions need to be developed.

Key stakeholders’ experiences and expectations of the care system for individuals affected by borderline personality disorder: An interpretative phenomenological analysis towards co-production of care

Background

The diagnosis of borderline personality disorder (BPD) consists of extreme emotional dysregulation and long-term disability when left untreated. It is associated with ineffective use of health care systems and mismanaged care in emergency departments, which can result in a revolving door phenomenon of urgent system usage, poor treatment outcomes, or patients falling out of care entirely–all of which primarily affect patients with BPD as well as their caregivers and clinicians. This crisis must be addressed with a comprehensive understanding of key stakeholder perspectives on the challenges of the system and potential solutions.

Objective

This study explored the perspectives of three key stakeholder groups (i.e., patients, clinicians, and caregivers) in relation to their experiences with and future expectations of the care system for those affected by BPD.

Methods

Four patients with BPD, three generalist clinicians with experience treating BPD, and three caregivers of individuals with BPD participated in individual semi-structured interviews. Participants were asked about their experiences with the current healthcare system and their suggestions for improvement. Responses were analyzed using interpretative phenomenological analysis.

Findings

In-depth analysis of the qualitative data revealed twelve shared themes and three themes that were unique to each key stakeholder group. These themes are discussed and used to inform recommendations for promising practices, policies, and training in this area.

Conclusion

Findings support the importance of a comprehensive mental health system approach for improving the accessibility, effectiveness, and acceptability of the management and treatment of BPD.

A comparison of experiences of care and expressed emotion among caregivers of young people with first-episode psychosis or borderline personality disorder features

OBJECTIVE

Caregivers of individuals with severe mental illness often experience significant negative experiences of care, which can be associated with higher levels of expressed emotion. Expressed emotion is potentially a modifiable target early in the course of illness, which might improve outcomes for caregivers and patients. However, expressed emotion and caregiver experiences in the early stages of disorders might be moderated by the type of severe mental illness. The aim was to determine whether experiences of the caregiver role and expressed emotion differ in caregivers of young people with first-episode psychosis versus young people with 'first-presentation' borderline personality disorder features.

METHOD

Secondary analysis of baseline (pre-treatment) data from three clinical trials focused on improving caregiver outcomes for young people with first-episode psychosis and young people with borderline personality disorder features was conducted (ACTRN12616000968471, ACTRN12616000304437, ACTRN12618000616279). Caregivers completed self-report measures of experiences of the caregiver role and expressed emotion. Multivariate generalised linear models and moderation analyses were used to determine group differences.

RESULTS

Data were available for 265 caregivers. Higher levels of negative experiences and expressed emotion, and stronger correlations between negative experiences and expressed emotion domains, were found in caregivers of young people with borderline personality disorder than first-episode psychosis. Caregiver group (borderline personality disorder, first-episode psychosis) moderated the relationship between expressed emotion and caregiver experiences in the domains of need to provide backup and positive personal experiences.

CONCLUSION

Caregivers of young people with borderline personality disorder experience higher levels of negative experiences related to their role and expressed emotion compared with caregivers of young people with first-episode psychosis. The mechanisms underpinning associations between caregiver experiences and expressed emotion differ between these two caregiver groups, indicating that different supports are needed. For borderline personality disorder caregivers, emotional over-involvement is associated with both negative and positive experiences, so a more detailed understanding of the nature of emotional over-involvement for each relationship is required to guide action.

From the community to the emergency department: A study of hospital emergency department nursing practices from the perspective of carers of a loved one with Borderline Personality Disorder

Carers of loved ones with Borderline Personality Disorder (BPD) often present to Emergency Departments (ED) during acute crisis situations. The initial contact for the carer and consumer in distress is often an emergency nurse. By gaining a greater understanding of carers (18+) perspectives on ED nursing practices when consumers with BPD are requiring crisis support, knowledge about preferred and best practice can be gained. To obtain this knowledge, four semi-structured focus group interviews were undertaken with a purposive sample of 13 carers through existing carer networks. Transcripts were analysed thematically to identify shared experiences and perspectives across interviews. Four key themes emerged: challenges in accessing crisis support, the need for communication, stigmatising practices, and different levels of care. Findings highlight the ED is viewed as a frontline service which has the capacity to link with another specialist supports when in crisis. Despite this; Communication, confidentiality issues and stigmatising practices continue. The results of this study have implications for nursing practice in the ED, providing important insights that can potentially benefit the carer, consumer and the ED to improve the quality of care offered for people in crisis.

Effectiveness of family connections intervention for family members of persons with personality disorders in two different formats: Online vs face-to-face

INTRODUCTION

Personality disorders (PD) have a serious impact on the lives of individuals who suffer from them and those around them. It is common for family members to experience high levels of burden, anxiety, and depression, and deterioration in their quality of life. It is curious that few interventions have been developed for family members of people with PD. However, Family Connections (FC) (Hoffman and Fruzzetti, 2005) is the most empirically supported intervention for family members of people with Borderline Personality Disorder (BPD).

AIM

The aim of this study is to explore the effectiveness of online vs face-to-face FC. Given the current social constraints resulting from SARS-CoV-2, interventions have been delivered online and modified.

METHOD

This was a non-randomized pilot study with a pre-post evaluation and two conditions: The sample consisted of 45 family members distributed in two conditions: FC face-to-face (20) performed by groups before the pandemic, and FC online (25), performed by groups during the pandemic. All participants completed the evaluation protocol before and after the intervention.

RESULTS

There is a statistically significant improvement in levels of burden (η 2 = 0.471), depression, anxiety, and stress (η 2 = 0.279), family empowerment (η 2 = 0.243), family functioning (η 2 = 0.345), and quality of life (μ2 η 2 = 0.237). There were no differences based on the application format burden (η 2 = 0.134); depression, anxiety, and stress (η 2 = 0.087); family empowerment (η 2 = 0,27), family functioning (η 2 = 0.219); and quality of life (η 2 = 0.006), respectively).

CONCLUSIONS

This study provides relevant data about the possibility of implementing an intervention in a sample of family members of people with PD in an online format without losing its effectiveness. During the pandemic, and despite the initial reluctance of family members and the therapists to carry out the interventions online, this work shows the effectiveness of the results and the satisfaction of the family members. These results are particularly relevant in a pandemic context, where there was no possibility of providing help in other ways. All of this represents a great step forward in terms of providing psychological treatment.

Pilot project for a recovery-oriented, DBT-informed skill-building education course for families of adults with borderline personality, bipolar or major depressive disorders

There are a variety of educational interventions for families who have a relative with a mental health disorder. However, for those with one or more emotion dysregulation disorders, there are limited options. This article reports on the results of a pilot project using a quasi-experimental design with a sample of 270 (intervention = 217, control = 53) to assess an intervention, Getting Off the Emotional Roller Coaster Skill-Building Family Education Course (GOER Family Course), for families coping with and managing emotion regulation disorders in a loved one which are often misdiagnosed or co-occurring. This intervention was effective in reducing caregiver burden [F(1, 120) = 12.25, p = 0.001], while improving attitudes, knowledge, and skills [F(1, 170) = 6.16, p = 0.014]. It fills an important gap in available resources for families faced with challenges and responsibilities that these disorders can present, especially when inaccurately diagnosed or receiving ineffective treatment. While there is a need for further research and adaptation to virtual learning, the preliminary results show positive effects.

Borderline personality disorder in young people: associations with support and negative interactions in relationships with mothers and a best friend

BACKGROUND

Impaired interpersonal functioning has been highlighted as a core feature of borderline personality disorder (BPD). Adolescence and young adulthood form important developmental stages within both the emergence of BPD and the development of interpersonal functioning, which takes place mostly in relationships with parents and friends. This study aimed to: (i) investigate relations between BPD symptoms and both supportive and negative interactions with mothers and best friends; (ii) investigate whether the relations were moderated by age; (iii) test the robustness of our findings by comparing the results based on self-reports with results from a subsample in which supportive and negative interactions with mothers were rated by the mother.

METHODS

312 young people referred to mental healthcare completed self-report measures on BPD and supportive and negative interactions. Multiple regression analyses were conducted to examine the relations between BPD features and perceived supportive and negative interactions with mothers and a best friend, and to investigate whether these relations were moderated by age. Robustness of our findings was studied in a subsample (n = 104), by using a multi-informant design in maternal report on supportive and negative interactions with mothers.

RESULTS

Multiple regression analyses demonstrated that negative interactions with mothers as well as with a best friend were related to more BPD symptoms in young people. Supportive interactions were not related to BPD symptoms. Both BPD and quality of relations were not related to age. In a subsample in which supportive and negative interactions with mothers were rated by the mother, the maternal report showed slightly different results. In this model, both supportive and negative interactions with a best friend were positively related, whereas interactions with mothers were not related to BPD symptoms in young people.

CONCLUSIONS

Results highlight the importance of relationships with mothers and a best friend during adolescence and young adulthood. Given that BPD often emerges during this developmental phase, future research is needed to clarify how quality of relationships could alter pathways toward BPD in young people.

TRIAL REGISTRATION

Not applicable.

A pilot trial of moderated online social therapy for family and friends of young people with borderline personality disorder features

AIM

We evaluated the acceptability, usability and safety of Kindred, a novel online intervention for carers of young people with borderline personality disorder (BPD) using a pre-post pilot trial design. The secondary aim explored whether Kindred use was associated with clinical improvements for caregivers on measures of burden of caregiving, stress, expressed emotion, family communication, disability, coping and knowledge of BPD and for patients on measures of severity of BPD symptoms and level of functional impairment.

METHODS

The trial site was the Helping Young People Early program for young people with BPD at Orygen in Melbourne, Australia. Informed consent was obtained from 20 adult carers (i.e., relatives or friends) and 10 young people aged 15-25 with BPD. Kindred, which was available for 3 months, incorporated online psychoeducation, carer-to-carer social networking and guidance from expert and peer moderators. Assessments were completed at baseline and 3 months follow-up. Multiple indicators of acceptability, usability and safety were utilized.

RESULTS

Seventeen carers were enrolled in Kindred and eight young people completed baseline measures. A priori acceptability, usability and safety criteria were met. Carer burden, stress, expressed emotion, family communication, quality of life, functioning, coping and perceived knowledge of BPD improved at follow-up. Sixty-six percent of the young people (4/6) reported that they believed Kindred had improved their carers' understanding of BPD.

CONCLUSION

Kindred was shown to be acceptable, usable and safe, with encouraging improvements in both carer and young person outcomes. Kindred warrants evaluation of its efficacy via an randomized controlled trial.

Burden and Treatment Satisfaction among Caregivers of Adolescents with Borderline Personality Disorder

Despite the fact that family involvement is encouraged in early interventions for borderline personality disorder (BPD), there is a limited knowledge on the experience of caring for adolescents with BPD. This is an exploratory retrospective study nested within a randomized controlled trial that compared mentalization-based treatment (MBT) in groups to treatment as usual for adolescents with BPD. Caregivers received six MBT-Parents sessions or standard care over one year. Three months after end of treatment (EOT), 75 caregivers (35 in MBT, 40 in TAU) filled out the Burden Assessment Scale, and 71 (34 in MBT, 37 in TAU) the Family Satisfaction Survey. The adolescents filled out the Borderline Personality Features Scale for Children at baseline and after twelve months at EOT. We tested whether caregiver demographics, adolescents' severity of BPD, treatment and adolescents' dropout from treatment predicted levels of caregiver burden and satisfaction with treatment. The caregivers reported high levels of burden on the BAS (M = 40.3, SD = 12.2). Our study suggests that higher BPD severity at EOT among the adolescents predicted caregiver burden (p = .03), whereas higher baseline BPD severity predicted satisfaction with treatment (p = .04) and that biological mothers could be more burdened than other types of caregivers but also might be more satisfied with treatment. Treatment and adolescents' dropout from treatment were not related to caregiver burden or satisfaction with treatment. To help inform future research and to devise appropriate interventions for caregivers and adolescents with BPD, it is important to identify possible predictors of caregiver burden. The results of this initial exploratory study indicate that caregivers (and particularly biological mothers) of adolescents with more severe levels of BPD could be particularly vulnerable toward feelings of burden and therefore are in need of support.

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.

B·RIGHT: usability and satisfaction with a mobile app for self-managing emotional crises in patients with borderline personality disorder

OBJECTIVE

Borderline personality disorder (BPD) is a severe mental disorder characterized by emotional crises. To date, crisis interventions for BPD have been conducted via telephone calls and emergency units, which are associated with an extra amount of resources. The aim of this research was to test the usability and satisfaction with a psychotherapeutic mobile app for self-managing crises in BPD.

METHOD

The B·RIGHT app was designed based on Artificial Intelligence psychotherapeutic algorithms. Usability and satisfaction with the app were assessed in 25 outpatients diagnosed with BPD (84% female, mean age = 35.80 years) using the System Usability Scale (SUS) and other questionnaires. Clinical features were assessed using the Borderline Symptom List, the Difficulties in Emotion Regulation Scale and Beck's Depression Inventory.

RESULTS

Patients with BPD considered the app user-friendly (mean total score = 4.03) and highly satisfactory (mean total score = 4.02), resulting in a positive user experience (mean total score = 4.09). Total usability was negatively associated with age (r = -.44), positively associated with educational level (rho = .47) and with overall emotion dysregulation (r = .51), and negatively associated with depression severity (r = -.47).

CONCLUSIONS

The usability and satisfaction testing of the B·RIGHT app showed promising findings, which warrant further research in order to validate its effectiveness.

Service user experiences of community services for complex emotional needs: A qualitative thematic synthesis

BACKGROUND

There is a recognised need to develop clear service models and pathways to provide high quality care in the community for people with complex emotional needs, who may have been given a "personality disorder" diagnosis. Services should be informed by the views of people with these experiences.

AIMS

To identify and synthesise qualitative studies on service user experiences of community mental health care for Complex Emotional Needs.

METHODS

We searched six bibliographic databases for papers published since 2003. We included peer reviewed studies reporting data on service user experiences and views about good care from community-based mental health services for adults with CEN, including generic mental health services and specialist "personality disorder" services. Studies using any qualitative method were included and thematic synthesis used to identify over-arching themes.

RESULTS

Forty-seven papers were included. Main themes were: 1) The need for a long-term perspective on treatment journeys; 2) The need for individualised and holistic care; 3) Large variations in accessibility and quality of mental health services; 4) The centrality of therapeutic relationships; 5) Impacts of 'personality disorder' diagnosis. Themes tended to recur across studies from different countries and years.

DISCUSSION

Recurrent major themes included wanting support that is individualised and holistic, provides continuity over long journeys towards recovery, and that is delivered by empathetic and well-informed clinicians who are hopeful but realistic about the prospects of treatment. Care that met these simple and clearly stated priorities tended to be restricted to often limited periods of treatment by specialist "personality disorder" services: generic and primary care services were often reported as far from adequate. There is an urgent need to co-design and test strategies for improving long-term support and treatment care for people with "personality disorders" throughout the mental health care system.

The borderline interpersonal-affective systems (BIAS) model: Extending understanding of the interpersonal context of borderline personality disorder

Prominent explanatory models for borderline personality disorder (BPD) are intrapersonal in nature and hold that it is an emotional disorder. However, the empirical support for emotional models of BPD is mixed. Refinements to BPD explanatory models are needed to increase the precision with which BPD can be understood and treated. Drawing on existing theoretical and empirical research in BPD, this manuscript presents the Borderline Interpersonal-Affective Systems (BIAS) model. The BIAS model purports that harmful early life relationships and subsequent conflictual relationships lead individuals with BPD to develop a sensitivity to interpersonal threat in the form of attentional and appraisal biases. Individuals with BPD are posited to 1) experience heightened emotional reactivity specifically to perceived interpersonal threat and 2) engage in destructive behaviors both to regulate increasing emotion and to meet interpersonal needs. We review the empirical support for each component of the BIAS model, along with the role of the cognitions, emotions, and behaviors of significant others in influencing BIAS model processes in individuals with BPD over time. The BIAS model highlights a novel way of understanding and integrating interpersonal and emotional components of the disorder. Key directives for future research and clinical implications are discussed.

Five failures and five challenges for prevention and early intervention for personality disorder

Despite global consensus regarding the early detection of personality disorder, current approaches to early intervention have failed to deliver for the majority of young people. This only serves to reinforce the enduring effects of personality disorder on functioning, mental and physical health, resulting in a reduction of quality of life and life expectancy. Here, we describe five significant challenges facing prevention and early intervention for personality disorder: identification, access to treatment, research translation, innovation and functional recovery. These challenges highlight the need for early intervention to shift from niche programmes in specialist services for a select few young people to become established in mainstream primary care and specialist youth mental health services.

Evaluation einer Mehrfamiliengruppe für Patient_innen mit einer Borderline-Persönlichkeitsstörung und ihre Angehörigen

Zusammenfassung. Hintergrund. Familiäre Konflikte und dysfunktionale Verhaltensweisen spielen eine entscheidende Rolle bei der Entstehung und Aufrechterthaltung von Borderline-Persönlichkeitsstörungen (BPS). Auf der Grundlage der Dialektisch-Behavioralen Therapie (DBT) berücksichtigte Alan Fruzzetti die genannten Faktoren in einem transaktionalen Entstehungmodell. Um BPS-Betroffenen und deren Angehörigen Strategien für eine funktionalere Emotions- und Interaktionsbewältigung an die Hand zu geben, entwickelte Alan Fruzzetti DBT-Familien-Skills. Fragestellung. Die Wirksamkeit dieser Fertigkeiten als therapeutische Intervention im Rahmen eines Mehrfamiliensettings wurde im Rahmen der vorliegenden Pilotstudie evaluiert. Methode. Mittels Tagebuch- und Sitzungsabfragen wurden prozessuale Daten der psychischen Beanspruchung und Anwendungshäufigkeit von DBT-Familien-Skills (AFS) erhoben. Ergebnisse. Via Trendanalysen konnten Hinweise auf hypothesenkonforme Beanspruchungsreduktionen und eine Zunahme der AFS über den zeitlichen Gruppenverlauf bei BPS-Betroffenen und Angehörigen identifiziert werden. Schlussfolgerung. Die Ergebnisse der Pilotstudie liefern erste Hinweise, dass die in einem Mehrfamilienformat angebotenen DBT-Familien-Skills zu einer Reduktion der psychischen Beanspruchung der BPS-Betroffenen und Angehörigen beitragen.

Pathological Narcissism: A Study of Burden on Partners and Family

Pathological narcissism is characterized by impaired interpersonal functioning, but few studies have examined the impact of the disorder on those living in a close relationship. Participants (N = 683; comprising romantic partners [77.8%], mothers [8.5%] or other family members [10%]) in a close relationship with a relative with pathological narcissism completed measures assessing levels of grief, burden, mental health, and coping style. Participants' reported burden was over 1.5 standard deviations above comparison carers of people with mood, neurotic, or psychotic disorders, and higher than carers of people with borderline personality disorder. Similarly, caseness for depression (69% of sample) or anxiety disorders (82%) in the sample was high. Relationship type, subtype expression (vulnerable/grandiose), and coping style were all found to significantly relate to experienced psychopathology. Although limitations exist regarding sample selection that may influence interpretation of results, these findings quantify the significant interpersonal impact of pathological narcissism in this sample.

Priorities for service improvement in personality disorder in Australia: Perspectives of consumers, carers and clinicians

BACKGROUND

Improvements to service provision for personality disorder has been predominately explored through the perspectives of clinicians, with limited understanding of the views of consumers and carers. The aim of the present study was to understand the priorities for service improvement through multiple perspectives.

METHOD

Twelve roundtables, with a total of 53 consumers, clinicians and carers, discussed how organizations could improve service provision for people with personality disorder and completed a questionnaire on current and optimal service provision. Inductive thematic analysis was used to identify the priorities for service improvement, and we aimed to identify differences between what participants currently receive and what they believe to be optimal.

RESULTS

Four priorities were identified: (1) increasing consumer, carer and peer involvement in care, (2) re-orienting approaches to service provision, (3) improving access and accessibility of treatment and (4) building the capacity of services. Participants were more likely to receive individual or group treatment alone, yet believed combined individual and group treatment to be optimal. Significantly, more participants believed that long-term treatment was optimal.

CONCLUSION

A shift in focus from establishing a consistent approach to servicing, to focusing on holistic care that involves consumers and carers in care, is required. © 2020 The Authors Personality and Mental Health Published by John Wiley & Sons Ltd.

Factors Associated with Distress in Caregivers of People with Personality Disorders

The present study investigated how stressors experienced by caregivers of people with personality disorders relate to each other and psychological distress, using the Stress Process Model (Pearlin et al. in Gerontologist 30(5):583-594, https://doi.org/10.1093/geront/30.5.583 , 1990). A community sample of caregivers (N = 106) completed an online survey. Partial Least Squares Path Modelling revealed that caregivers who were male, younger, or residing with their loved one were more likely to experience stressors. Salient primary stressors included the caregivers' worry and care-receivers' levels of instrumental demands and interpersonal problems. Important secondary stressors included strains in the caregivers' schedules, family relationships, and health, as well as reduced mastery and caregiving esteem. The model provided preliminary support for a pathway from demographic and relationship characteristics, through primary and secondary stressors, to heightened psychological distress. The present study clarifies the way caregiving stressors give rise to psychological distress; directions for future research are discussed.

The Emotional Bank Account and the Four Horsemen of the Apocalypse in Romantic Relationships of People with Borderline Personality Disorder: A Dyadic Observational Study

Few studies have examined behaviors in romantic relationships associated with borderline personality disorder (BPD). We assessed critical variables from marital research: the "emotional bank account" (positive-to-negative behaviors; Gottman, 1993) and the "four horsemen of the apocalypse" (criticism, defensiveness, contempt, and stonewalling; Gottman & Silver, 1999; Gottman & Krokoff, 1989). Couples (N = 130, or 260 participants) engaged in a conflict task and reported relationship satisfaction at intake and 12-months. Clinician-rated BPD and avoidant PD (APD) criteria were examined. People with more BPD symptoms and their partners were less satisfied, which worsened by follow-up. Conflict behaviors partially explained these associations. Partners of people with more BPD symptoms had a worse emotional bank account, which then predicted (a) poorer satisfaction for both members and (b) worsening partner satisfaction. People with more BPD symptoms criticized more; their partners defended and stonewalled more. APD predicted worsening satisfaction. BPD appears to link specifically with relationship dysfunction, partly through associations with partner behavior.

Support, interventions and outcomes for families/carers of people with borderline personality disorder: A systematic review

It is clear from existent literature that families and carers of relatives and friends with borderline personality disorder (BPD) experience high levels of burden. Whilst family interventions are considered vital to improving the outcomes of those with a range of mental health difficulties, there has been limited development of direct interventions for carers of people with BPD, despite a high level of need. This systematic review aimed to appraise and synthesize the existing research evidence for interventions for carers of people with BPD. Ten studies were included that were directly related to six interventions for families and carers of people with personality disorder. The findings of these studies, whilst limited, do provide some initial evidence that interventions for carers may lead to significant outcomes for the participants, particularly in improving carer well-being and reducing carer burden. © 2019 John Wiley & Sons, Ltd.

Lived Experiences of Caregivers of Patients with Borderline Personality Disorder: A Phenomenological Study

Background

Having a patient with borderline personality disorder (BPD) in the family is a complicated and stressful experience. The caregivers' experiences and the problems they have in care of patient with BPD have remained unknown. The aim of this research was to explore the experiences of the caregivers while living with BPD patients in Iran.

Methods

This interpretive phenomenological research was performed on 10 caregivers of patients with BPD at Ibn-sina Hospital in Mashhad, Iran, in 2019. Purposeful sampling was used for sampling. Data were collected through semi-structured interviews and saturated after 16 interviews. The analysis of data was concurrently carried out using the method proposed by Diekelman (1989). The MAXQDA software (Ver.10) was used for data organization.

Results

The participants in this study were aged 25 to 55 years. After data analysis, three themes ("life in hell", "chain to the feet", and "black shadow of stigma") and six sub-themes ("disrupted from the life", "self-discrepancy", "care bottlenecks", "in the fence of restriction", "society dagger" and "resort to secrecy") emerged.

Conclusion

The results of this study showed that the caregivers of patients with BPD during the period of care were faced with a variety of problems. It is suggested that health policy-makers should pay more attention to the problems related to the mental health of caregivers.

A study comparing the experiences of family and friends of young people with borderline personality disorder features with family and friends of young people with other serious illnesses and general population adults

BACKGROUND

Family and friends ('carers') of adults with borderline personality disorder (BPD) and carers of young people with other serious illnesses experience significant adversity but research on the experiences of caring for a young person with BPD features is sparse. This study aimed to: (i) describe the experiences of carers of young people with BPD features; (ii) compare them with published data assessing carers of young people with other serious illnesses and with adults from the general population.

METHODS

Eighty-two carers (M age = 44.74, SD = 12.86) of 54 outpatient young people (M age = 18.76, SD = 3.02) who met 3 to 9 DSM-IV BPD criteria completed self-report measures on distress, experiences of caregiving, coping, and expressed emotion. Independent-samples t-tests were employed to compare scores with those reported by convenience comparison groups of general population adults or carers of young people with eating disorders, cancer, or psychosis.

RESULTS

Carers of young people with BPD features reported significantly elevated levels of distress, negative caregiving experiences, and expressed emotion, as well as maladaptive coping strategies, compared with general population adults or carers of young people with other serious illnesses.

CONCLUSIONS

Carers of young people with BPD features experience elevated levels of adversity compared with their peers in the general adult population. This adversity is similar to, or greater than, that reported by carers of young people with other severe illnesses. Research is needed to clarify factors underlying adverse caregiving experiences and to develop and evaluate interventions to support carers of young people with BPD features.

TRIAL REGISTRATION

Prospectively registered with the Australian New Zealand Clinical Trial Registry ACTRN12616000304437 on 08 March 2016, https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=369867.

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.

Confluence of Western Psychotherapy and Religious Teachings in Mental Healthcare of an Asian Buddhist Community: Sri Lanka

Buddha lived 2600 years ago in Northern India, and his teachings were established in Sri Lanka in the third-century BC. In the nineteenth century, the British established the modern mental health services in Sri Lanka. This article aimed to highlight the association between Western psychotherapeutic techniques with Buddhist teachings and the relevance of this confluence to the mental health care in the country. Many schools of Western psychotherapy employ principles which are also described in Buddhist philosophy. Understanding this connection helps to deliver a culturally acceptable and relevant mental health care to the Sri Lankan population.

Partners of Individuals with Borderline Personality Disorder: A Systematic Review of the Literature Examining Their Experiences and the Supports Available to Them

Over a third of individuals with borderline personality disorder (BPD) are in long-term romantic partnerships, yet little is known about the experiences of their partners. Because difficulties in interpersonal relationships are a hallmark of BPD, it is especially important to understand the support needs of their romantic partners. This systematic review investigates the experiences of romantic partners of adult individuals with BPD and the interventions designed to support them. Twenty-two articles were found, 13 of which pertained to partner experiences and 9 to interventions. Thematic analysis was used to identify three main themes in the descriptions of partners' experiences: emotional challenges, dual roles as both a romantic partner and parental/therapeutic figure, and lack of control. The available interventions, which consisted of educational and skills-based programs with limited efficacy data, addressed only a small portion of the subthemes identified in the literature describing partners' experiences. The discrepancy between the needs identified in the partner-experience literature and the interventions available suggests a need to develop and evaluate more partner-oriented programming. Such programming should use psychoeducation, peer support, and individual- and relationship-based skills development to address and therefore improve the experiences of partners of individuals with BPD.

A Randomized Controlled Trial of Group Psychoeducation for Carers of Persons With Borderline Personality Disorder

Carers of persons with borderline personality disorder (BPD) experience high burden. Treatment guidelines advocate involving carers in comprehensive therapy approaches. This study is a randomized controlled trial of group psychoeducation, compared to waitlist. Group psychoeducation involved 6-8 carers per group and focused on improving relationship patterns between carers and relatives with BPD, psychoeducation about the disorder, peer support and self-care, and skills to reduce burden. Carers were randomized into intervention (N = 33) or waitlist (N = 35). After 10 weeks, those in the intervention reported improvements in dyadic adjustment with their relative, greater family empowerment, and reduced expressed emotion, sustained after 12 months. There were also improvements in carers' perceptions of being able to play a more active role, such as interacting with service providers. This study demonstrates that providing structured group programs for carers can be an effective way of extending interventions to a group experiencing high burden.

Carer perspectives of people diagnosed with borderline personality disorder: A scoping review of emergency care responses

BACKGROUND

Caring for a person with borderline personality disorder remains largely stigmatised and misunderstood. When a crisis arises, carers often seek help with the person they care for in emergency care settings such as the emergency department. The aim of this review was to explore, locate and compile the literature regarding the perspectives of family carers for a person with borderline personality disorder in an emergency care setting with a focus on nursing practices. This review advances understandings of carer perspectives in emergency care settings.

METHODS

The Joanna Briggs Institute (2015) [1], methodology for scoping reviews guided this review. A search of Emcare, Medline and Ovid Nursing was performed during April 2018, to identify literature where carer views and perspectives on engaging with emergency care services were reported. A grey literature search was also conducted. A total of ten articles and reports were included in this review. Consultation with a carer support group precipitated this review, which assisted in the formulation of the research questions.

RESULTS

Papers found via the study focused on health professional responses, rather than on nursing practice. Findings indicate that carers often perceive emergency departments as the only option for emergency care in a crisis. Carers require information about how to effectively manage a crisis with their loved one more effectively.

CONCLUSION

This scoping review identified that carers are often not consulted or engaged with by health professionals. Carers often perceive that nurses and health professionals have a lack understanding about the consumer's conceptualisation of distress and the nature of BPD, which becomes a barrier to effective crisis support and management. The literature often reported that a trusting and collaborative relationship between carers, nurses and health professionals demonstrated improved outcomes for the carer and consumer.