Avoiding Misdiagnosis When Auditory Verbal Hallucinations Are Present in Borderline Personality Disorder

The Subjective Experience of the Punitive Parent Mode in Individuals With Borderline Personality Disorder Following Schema Therapy: A Qualitative Study

Borderline personality disorder (BPD) is often characterized by self-critical and punitive thoughts, emotions, beliefs and behaviours, conceptualized in schema therapy (ST) as the punitive parent mode (PPM). This mode involves internalized punitive messages from childhood from the behaviour and reactions of significant others, leading to self-hatred, guilt and self-denial. Although patients with BPD frequently report auditory verbal hallucinations (AVHs) as manifestations of the PPM, this phenomenon is often overlooked in ST studies. We conducted semistructured interviews with 16 (ex)patients (63% female) from two Dutch mental health institutions to explore their experiences with the PPM before, during and after ST. An independent, double-coded systematic content analysis was performed. Approximately half of the participants reported AVHs linked to the PPM before therapy. The patients characterized the PPM by pervasive self-critical messages, contributing to intense emotional and physical distress and maladaptive coping strategies. Participants reported that ST techniques, including group therapy, imagery rescripting (ImRs) and the empty chair technique (ECT), effectively reduced the power and credibility of the PPM, including AVHs. The self-reported improvements included more adaptive coping mechanisms, increased social support and a general experience of reduced PPM. This study highlights the prevalence of the PPM as AVHs in individuals with BPD and demonstrates the efficacy of ST in reducing the impact of PPM, including in cases involving AVHs. Clinical implications include the need for relapse prevention plans and further exploration into how ST's effects can be enhanced. Future research should explore the broader spectrum of psychotic experiences in BPD and consider integrating PPM-related AVHs into the assessment and treatment of BPD.

Facial expression analysis using convolutional neural network for drug-naive and chronic schizophrenia

OBJECTIVE

Facial images have been shown to convey mental conditions as clinical symptoms. This study aimed to use facial images to detect patients with drug-naive schizophrenia (DN-SCZ) or chronic schizophrenia (C-SCZ) from healthy controls (HCs), and to investigate differences in facial expressions among these 3 groups, as well as relationships between facial expressions and psychiatric symptoms.

METHODS

We recruited 45 DN-SCZ patients, 106 C-SCZ patients and 101 HCs for the study, and videotaped their facial expressions through a fixed experimental paradigm. The video data was converted to facial images and divided into two sets: one for training a group classification-convolutional neural network (CNN) with the classification of DN-SCZ patient, C-SCZ patient and HC as output, and the other for evaluating classification results of the group classification-CNN. Subsequently, we extracted and evaluated 300 labeled facial images for each basic facial expression. These labeled images were employed to train separate facial expression-CNNs for each group (DN-SCZ, C-SCZ, and HCs). All facial images from the videos were then processed by their facial expression-CNNs to output the most probable facial expressions. The psychiatric symptoms were assessed using the Positive and Negative Syndrome Scale. Statistical analyses were conducted on the predicted facial expressions to identify differences among the groups, and to examine relationships between the predicted facial expressions and the clinical data of DN/C-SCZ patients.

RESULTS

The group classification-CNN achieved an accuracy of 90.99% in correctly classifying participants based on facial images. The 3 facial expression-CNNs achieved accuracies of 95.95%, 87.23%, and 92.11% in predicting 8 basic facial expressions within the 3 groups. Facial images of HCs were rated higher in valence, arousal and attractiveness, but lower in deviation from normal face than those of DN/C-SCZ patients. Happy images of DN-SCZ patients were rated lower in valence and arousal than those of C-SCZ patients, while their angry images were rated higher in arousal, attractiveness and deviation from normal images than those of C-SCZ patients. Within the fixed experimental paradigm, DN-SCZ patients exhibited sadder, more surprised expressions, while displaying fewer happy, angry and disgusted expressions, statistical metrics of their fearful and angry expressions were correlated with their total positive symptom score and total general psychopathology score, respectively. C-SCZ patients exhibited happier, more content, angry and neutral expressions, while showing fewer surprised expressions, no significant relationships were observed between their facial expressions and clinical data.

CONCLUSIONS

Facial expressions can potentially serve as indicative signs for detecting DN-SCZ and C-SCZ patients. There are objective differences in certain facial expressions among the 3 groups, and certain facial expressions in DN-SCZ patients are associated with some of their psychiatric symptoms.

Contrasting characteristics of psychosis in outpatients with borderline personality disorder or schizophrenia at a tertiary care institution

Summary and objectives

Borderline personality disorder (BPD) and schizophrenia can present with psychotic symptoms, such as delusions and hallucinations. This study, conducted at a tertiary care center, compared the characteristics of psychotic symptoms in patients diagnosed with BPD and patients diagnosed with schizophrenia, as well as the prevalence of self-harm, suicide attempts, and hospitalizations within these groups.

Method

In this comparative study, 50 individuals diagnosed with BPD and 50 with Schizophrenia, aged between 18 and 45 years, were assessed for intensity of psychotic symptoms with the Psychotic Symptom Assessment Scale (PSYRATS) and the Cardiff Abnormal Perceptions Scale (CAPS). Data were analyzed with IBM SPSS v25.0.

Results

On the PSYRATS, the schizophrenia group scored higher in auditory hallucinations and in the number of voices, while in the BPD group the auditory hallucinations score was correlated with the number of suicide attempts (P=0.025). On the CAPS, the BPD group showed higher scores on positive abnormal perceptions in all dimensions compared to the schizophrenia group (P=0.002).

Conclusions

Our study suggests that patients with BPD experienced a more intense burden of psychotic-like experiences compared to those with Schizophrenia, with a greater frequency, interference, and distress reported. Although patients with Schizophrenia had higher scores on the PSYRATS, the BPD group's scores were also notable, and a correlation was identified between auditory hallucinations and suicide attempts in the BPD group.

Elevated risk of sexually transmitted infections among adolescents and young adults with borderline personality disorder: a retrospective longitudinal nationwide population-based study

In this study, we examined the risk of sexually transmitted infections (STIs) among adolescents and young adults (AYAs) with borderline personality disorder (BPD). A total of 4649 AYAs with BPD and 46,490 age-, sex-, and socioeconomic-matched controls without BPD were enrolled from the National Health Insurance Research Database of Taiwan from 2001 to 2009 and were followed up until the end of 2011. Participants who contracted any STI during the follow-up period were identified. Cox regression analysis was conducted to examine the risk of contracting any STI among both patients and controls. A total of 4649 AYAs with BPD and 46,490 age-, sex-, and socioeconomic-matched controls without BPD were enrolled from the National Health Insurance Research Database of Taiwan from 2001 to 2009 and were followed up until the end of 2011. Participants who contracted any STI (ICD-9-CM code 042, 091-097, 087.11, 078.8, 078.88, 131, and 054.1) during the follow-up period were identified. Cox regression and sub-analyses stratified by sex, age, psychiatric comorbidity subgroups, and psychotropic medication usage were conducted to assess STI risk. AYAs with BPD were at a higher risk of contracting any STI (hazard ratio [HR] = 50.79, 95% confidence interval [CI] = 33.45-77.11) in comparison with controls, including HIV, syphilis, genital warts, gonorrhea, chlamydia, trichomoniasis, and genital herpes. The association of BPD with an increased risk of any STI was prevalent in both sexes, adolescents, and young adult patients. BPD with or without psychiatric comorbid subgroup were all associated with an elevated risk of contracting any STI relative to the control group. AYAs with BPD are highly susceptible to contracting STIs. Future studies should examine the role of the core symptoms of BPD, sexual orientation, risky sex behaviors, depressive and anxiety symptoms, and substance use before sex in the risk of STIs among AYAs with BPD.

Tell Me about yourself: Analyzing self-referential language use in borderline personality disorder

Depression and some other illnesses are associated with increased self-reference and negative emotion in language. Research findings on lexical patterns in Borderline Personality Disorder (BPD) have been inconsistent. We conducted two studies to evaluate lexical markers of distress in BPD: First compared to healthy controls (HC), and later compared to Post-Traumatic stress disorder (PTSD) patients and trauma-exposed controls (TC). Study 1 compared language use in BPD (n = 23) to HC (n = 22). Study 2 featured a new sample comprised of 4 subgroups: BPD (n = 26), Post-Traumatic Stress Disorder (PTSD; n = 17), comorbid BPD + PTSD (n = 22), and one non-psychiatric trauma control group (TC; n = 29). All participants responded to a standardized prompt from an interviewer and language was analyzed using Linguistic Inquiry Word Count (LIWC) software to assess for self-referential language, negative emotion words, and physical words, as well as several other language signatures of interest. No consistent significant between-group differences were found for LIWC categories of self-reference, negative emotion, or physical words, though negative tone words were significantly more frequent in BPD than non-psychiatric controls in both studies. There were also no consistent differences in sample length (either talking time or word count) or social measures across studies. These data suggest that there are fewer lexical markers of distress in BPD language samples compared to previously reported depression and physical illness samples. Future work using longitudinal approaches to define changes in emotional and cognitive states will be important to clarify the disorder- and state-specificity of lexical markers.

Time to put aside the false dichotomy between personality disorders and psychotic symptoms

Unlike internalizing and externalizing symptoms, psychotic symptoms (e.g., hallucinations, delusions) are manifestations of personality disorders (PDs) that are more controversial and poorly understood. This leaves clinicians with very little guidance for clinical practice, especially for diagnosis. What is more, most reviews have focused strictly on the links between psychotic symptoms and the categorically defined borderline PD, which contrasts with the growing movement that emphasizes a dimensional perspective (especially in psychology). Thus, the objectives of this critical review will be to (a) expose typical cases where PDs and psychotic symptoms might cooccur; (b) assess the state of scientific knowledge surrounding PD and psychotic symptoms; and (c) provide clinicians and researchers with recommendations to keep the field moving forward. We conclude that researchers and clinicians should move past the false "PD or psychosis" dichotomy since they often cooccur, avoid (as far as possible) making psychotic symptoms an exclusion criterion in PD research to enhance ecological validity, and consider dimensional PD diagnosis as a potential unifying solution to the dilemma posed by this cooccurrence.

Forensic aspects of dissociative positive symptoms in trauma-related disorders and borderline personality disorder

A psychotically motivated act or an act committed under impaired insight and control of action in the midst of an acute psychosis is the standard for lack of criminal responsibility. There is now increasing evidence that positive symptoms, particularly in the form of hallucinations and delusions, in trauma-related disorders and borderline personality disorder (BPD) are comparable to positive symptoms in psychotic disorders, posing a challenge for differential diagnosis and forensic assessment of the relevance of positive symptoms to insight and self-control. Due to the indistinguishability of the phenomena, there is both a risk of misdiagnosis of a psychotic disorder and also trivialization with the use of pseudo-hallucinations or quasi-psychotic labels. Essential phenomenological differences that may be helpful in forensic assessments are the usually preserved reality testing in trauma-related disorders and BPD, as well as differences in psychopathological symptom constellations. Because of these differences relevant to forensic assessments, it seems useful to distinguish trauma-related disorders and BPD with positive symptoms from psychotic disorders.

Psychotic Experiences and Daily Functioning in Borderline Personality Disorder and Schizophrenia

ABSTRACT

Psychotic experiences have been shown to be comparable in borderline personality disorder (BPD) and schizophrenia. Preliminary evidence suggests differences in the impact of psychotic experiences on daily functioning. Therefore, in this study, we aimed to investigate the role of psychotic experiences in daily functioning in BPD compared with schizophrenia. We performed post hoc analyses on data from 23 inpatients with BPD and 21 inpatients with schizophrenia, for whom results from the Psychotic Symptom Rating Scales were available. No differences were found in frequency, intensity, and disruption of life in relation to auditory verbal hallucinations and the amount of preoccupation and conviction with regard to delusions. Significant differences were found in the disruption of life due to delusions. The results emphasize that the quality of psychotic experiences in BPD and schizophrenia is comparable, but the impact of delusions on daily life is different, which may improve differential diagnosis.

French version of the Inventory of Personality Organization (IPO-fr): psychometric properties in young adults

BACKGROUND

The Inventory of Personality Organization (IPO) is a self-assessment instrument designed to measure the level of personality organization. In the present study, we developed and validated a French version (IPO-fr) of this instrument in a population of young adults. Its validity was established on the basis of two studies examining (1) its internal structure, and (2) its convergent validity with the Personality Diagnostic Questionnaire-4+, the Positive and Negative Affect Schedule (PANAS), the Hospital Anxiety and Depression Scale (HADS), and the Aggression Questionnaire (AQ).

PARTICIPANTS AND PROCEDURE

In the first study, we assessed the reliability of the internal structure of the French form of the IPO (IPO-fr) in a nonclinical population. Our sample comprised 602 first- and second-year psychology students, with a mean age of 19.40 years (SD = 1.95). The second study assessed the convergent validity of the questionnaire in nonclinical samples, with regard to the three clusters (A, B, and C) of personality disorders, positive and negative affect, and aggression and depressive symptoms. The sample for this second study consisted of 305 first-, second- and third-year psychology students, with a mean age of 19.83 years (SD = 2.12).

RESULTS

The French version of the IPO is shorter than the English: 40 items instead of 57. Its internal clarity and its discriminative capacity make it easier to interpret.

CONCLUSIONS

This study has established the relevance of the IPO-fr as a reliable and brief instrument for assessing individual personality. It could make a major contribution to the screening of personality pathology in the French population and to the assessment of treatment programs.

Contrasting social knowledge and theory of mind patterns in adults with personality disorders, schizophrenia spectrum disorders, and healthy controls

INTRODUCTION

Personality disorders (PD) and schizophrenia spectrum disorders (SSD) are distinct conditions displaying common symptoms, like impairments in social cognition, that make them hard to distinguish, especially in severe cases. To date, few studies have compared theory of mind skills in these two disorders, and none have compared social knowledge skills. This study aims to compare the social cognitive abilities of patients with these conditions.

METHOD

Non-parametric analyses of covariance were used to compare severe PD patients (n = 37), SSD patients (n = 44), and healthy controls (HC; n = 49) on the Social Knowledge Test and two measures of theory of mind: the Reading the Mind in the Eyes Test and the Combined Stories Test, which incorporates items from various widely used tests.

RESULTS

While no significant group differences were found on the Social Knowledge Test, SSD patients performed lower than the HC group on both theory of mind tests. PD patients only had lower performance than the HC group on specific items from the Combined Stories Test.

CONCLUSIONS

PD and SSD patients demonstrated distinctive patterns of social cognitive impairments, with items of greater complexity or with an affective orientation being the most discriminant for PD.

Alteration of surface morphology and core features in adolescents with borderline personality disorder

BACKGROUND

Accurate early diagnosis of adolescent borderline personality disorder (BPD) is critical for prompt treatment. The aim of this study was to assess the alteration of brain surface morphology and to evaluate its relationship with core features in adolescent BPD.

METHODS

A total of 52 adolescents with BPD aged 12-17 years and 39 age- and sex-matched healthy controls (HCs) were prospectively enrolled into the study. Brain magnetic resonance imaging (MRI) was obtained with both 3D-T1 weighted structural sequence and resting-state functional data. The structural data was analyzed for surface morphology parameters including the local gyrification index (LGI), mean curvature and surface area. The functional MRI data was analyzed for seed-based functional connectivity (FC). Correlative analysis of surface morphology and core features of adolescent BPD was performed.

RESULTS

Adolescents with BPD showed the following altered surface morphology in the limbic-cortical circuit when compared to the HCs: (1) reduced LGI in the left fusiform and right superior temporal gyrus; (2) reduced mean curvature in the left precentral gyrus and right rostral anterior cingulate cortex, and increased mean curvature in the bilateral pericalcarine; and (3) reduced surface area in the left paracentral gyrus, left pars triangularis, right insula and right lateral orbitofrontal gyrus (P < 0.05, FWE correction). In addition, these brain regions with altered surface morphology were significantly correlated with several core features including the mood instability, self-identity problems, and non-suicidal self-injury behavior in adolescents with BPD (P < 0.05). Furthermore, there was enhanced functional connectivity among these altered brain regions within the limbic-cortical circuit (voxel P < 0.001, cluster P < 0.05, FWE corrected).

CONCLUSIONS

Adolescents with BPD had significant alterations of brain surface morphology in the limbic-cortical circuit, which was correlated with core BPD features. These results implicated the surface morphology parameters and FC alterations may potentially serve as neuroimaging biomarkers for adolescents with BPD.

Psychotic spectrum features in borderline and bipolar disorders within the scope of the DSM-5 section III personality traits: a case control study

BACKGROUND

Psychotic spectrum features in borderline personality disorder (PD) are a long-standing phenomenon, but remarkably, to date, they have not been the focus of many empirical studies. Moreover, the comparative studies that acknowledge their links to affective psychoses are even more scarce. Likewise, the contributions of empirical research on the DSM-5 dimensional approach to this topic are also uncommon. This study seeks to identify the best set of pathological personality traits and/or symptoms that are predictors of psychotic features (psychoticism and ideation paranoid symptoms) in borderline PD and in bipolar disorder, based on the framework of the DSM-5 section III personality traits.

METHODS

A cross-sectional study of two clinical samples: 1) Borderline PD group of 63 participants; 2) Bipolar disorder group of 65 participants. Self-reported assessment: Personality Inventory for DSM-5 (PID-5); Brief Symptom Inventory (BSI). A series of linear and logistic regression analyses were computed.

RESULTS

Overall, the data emerging as common predictors are detachment, negative affectivity, psychoticism, depressivity, grandiosity, suspiciousness and interpersonal sensitivity symptoms. Borderline PD has the highest score in BSI paranoid ideation which emerges as its discriminating trait (Nagelkerke R² = .58): cognitive and perceptual dysregulation (OR: 13.02), restricted affectivity (OR: 12.09), withdrawal (OR: 11.70), anhedonia (OR: 10.98) and emotional lability (OR: 6.69).

CONCLUSIONS

Besides the commonality that appears to overlap both disorders with a psychosis superspectrum, the patterns of the pathological personality-symptoms underlying the psychotic features appear to reinforce a position between schizophrenia and bipolar disorders that borderline PD may occupy, highlighting the possibility of its intersection with schizoaffective/psychosis spectra. The pathological personality nature of the psychotic features emerges as a potential comprehensive trait of the phenomenological dimensions.

Comparison of the Phenomenology of Hallucination and Delusion Characteristics in People Diagnosed With Borderline Personality Disorder and Schizophrenia

Hallucinations and delusions in borderline personality disorder (BPD) are understudied. The authors explore the phenomenology of multisensory hallucinations and delusions in individuals with BPD and compare them to those in individuals with schizophrenia spectrum disorders (SSD). Clinical psychopathology was also explored. Eighty-nine adults participated and were categorized into four groups: BPD with voices, BPD without voices, SSD with high BPD traits, and SSD with low BPD traits. Among individuals with BPD, 81% reported visual and tactile hallucinations, 75% reported olfactory hallucinations, and 94% experienced delusions. When comparing BPD with and without voices, there were no significant differences in nonpsychotic psychopathology. Slight differences were found when hallucinations in BPD were compared with hallucinations in SSD, but overall the experiences were similar across diagnoses. The BPD group also reported significantly higher rates of paranoia/suspiciousness and delusions of guilt than the SSD group. Multisensory hallucinations and delusions occur in BPD and should be explored when treating people with BPD.

Visual hallucinations in psychiatry - what aren't we seeing?

OBJECTIVE

To increase awareness of practising clinicians and researchers to the phenomenological distinctions between visual hallucinations and trauma-based, dissociative, visual re-experiencing phenomena seen in psychiatric disease.

CONCLUSIONS

The experience of visual hallucinations is not exclusive to psychotic disorders in psychiatry. Different forms of experiences that resemble visual hallucinations may occur in patients with a trauma background and may potentially affect diagnosis. Given the paucity of literature around the subject, it is imperative that further research aims to characterise the distinction between visual hallucinations in psychosis and visual phenomena associated with trauma.

Hallucinations and Other Psychotic Symptoms in Patients with Borderline Personality Disorder

BACKGROUND

Psychotic symptoms in BPD are not uncommon, and they are diverse and phenomenologically similar to those in schizophrenia spectrum disorders. Despite their prevalence in BPD patients, knowledge about the characteristics and severity of hallucinations is limited, especially in modalities other than auditory.

AIM

This review summarises the causes, phenomenology, severity, and treatment options of hallucinations and other psychotic symptoms in BPD.

METHODS

The PubMed database was used with the following key terms: "borderline personality disorder" and 'hallucinations' and "psychotic symptoms". Articles were selected between January 1990 and May 2021. The primary keyword search yielded a total of 545 papers, of which 102 articles met the inclusion criteria and were fully screened. Papers from the primary source reference lists were also screened, assessed for eligibility, and then added to the primary documents where appropriate (n = 143). After the relevance assessment, 102 papers were included in the review. We included adult and adolescent studies to gather more recent reviews on this topic.

RESULTS

Hallucinations are significantly prevalent in BPD, mainly auditory, similar to schizophrenia spectrum disorders. The relationship between hallucinations and depression, anxiety, suicidality, schizotypy, and loneliness in BPD has been discovered but requires more research. Studies for treatment options for hallucinations in BPD are lacking.

CONCLUSION

Recognition of psychotic symptoms in patients with BPD as distinguished psychopathological phenomena instead of diminishing and overlooking them is essential in the clinical assessment and can be useful in predicting complications during treatment. More focused research in this area is needed.

Borderline Personality Disorder: Risk Factors and Early Detection

Personality disorders (PDs) exert a great toll on health resources, and this is especially true for borderline personality disorder (BPD). As all PDs, BPD arises during adolescence or young adulthood. It is therefore important to detect the presence of this PD in its earlier stages in order to initiate appropriate treatment, thus ameliorating the prognosis of this condition. This review aims to highlight the issues associated with BPD diagnosis in order to promote its early detection and treatment. To do so, we conducted a search on PubMed database of current evidence regarding BPD early diagnosis, focusing on risk factors, which represent important conditions to assess during young patient evaluation, and on diagnostic tools that can help the clinician in the assessment process. Our findings show how several risk factors, both environmental and genetic/neurobiological, can contribute to the onset of BPD and help identify at-risk patients who need careful monitoring. They also highlight the importance of a careful clinical evaluation aided by psychometric tests. Overall, the evidence gathered confirms the complexity of BDP early detection and its crucial importance for the outcome of this condition.

Comorbid early psychosis and borderline personality disorder: Conceptualizing clinical overlap, etiology, and treatment

Despite substantial efforts aimed at the detection and intervention for early symptoms of mental illness, there is relatively limited research on the clinical overlap between borderline personality disorder (BPD) and early psychosis, for example, clinical high risk (CHR) for psychosis, in young people. We present a narrative review of the clinical overlap between BPD and psychosis spectrum symptoms. Both conditions have unstable temporal course, and both are marked by functional impairment, increased suicide risk, and higher rates of psychiatric inpatient services. We then review evidence-based treatments for psychosis and BPD, emphasizing treatments for early presentations of these symptoms and initial research considering treatments for the overlap. Psychotherapies with the strongest empirical support include cognitive behavioral models, with BPD showing limited response to adjunctive pharmacotherapy. We end by discussing specific recommendations for future research, including longitudinal studies to determine the predictors of the course of illness and the development of treatments to target comorbid BPD and CHR symptoms.

Exploring Identity Disturbance and Psychotic Spectrum Symptoms as Predictors of Borderline and Schizotypal Personality Disorders

INTRODUCTION

Borderline personality disorder (BPD) and schizotypal personality disorder (SPD) were introduced in DSM-III and retained in DSM-5 Section II. They often co-occur and some aspects of the clinical differentiation between the 2 diagnoses remain unclear (e.g., psychotic-like features and identity disturbance).

METHODS

The present study explored if self-reported identity disturbance and psychosis proneness could discriminate between the BPD and SPD DSM-5 diagnoses. All patients were interviewed with the Schedules for Clinical Assessment in Neuropsychiatry and the Structured Clinical Interview for DSM-5 Personality Disorders, and administered the Inventory of Personality Organization, Self-Concept and Identity Measure, Schizotypal Personality Questionnaire, Perceptual Aberration Scale, and the Magical Ideation Scale.

RESULTS

A total of 105 patients were initially assessed, 26 were excluded, and the final sample (N = 79) was composed of 34 BPD patients, 25 SPD patients, and 20 patients with co-occurring SPD and BPD. The BPD group (n = 34) was first compared with the pure SPD group (n = 25), and secondly with the total group of patients diagnosed with SPD (n = 25 + 20). Logistic regression analyses indicated that primitive defenses and disorganization best differentiated the BPD and the pure SPD group, while primitive defenses and interpersonal factor along with perceptual aberrations best differentiated the BPD and the total SPD group.

CONCLUSION

Identity disturbance did not predict the diagnostic groups, but BPD patients were characterized by primitive defenses, which are closely related to identity disturbance. Pure SPD was characterized by oddness/eccentricity, while the lack of specificity for cognitive-perceptual symptoms suggests that the positive symptoms do not differentiate BPD from SPD.

How does level of personality functioning inform clinical management and treatment? Implications for ICD-11 classification of personality disorder severity

PURPOSE OF REVIEW

The International Classification of Diseases, 11th Edition (ICD-11) classifies personality disturbance according to levels of severity. This article reviews the literature on levels of personality functioning in relation to clinical management and treatment, and proposes how these findings apply to the ICD-11 classification of personality disorders.

RECENT FINDINGS

Findings were primarily derived from studies using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) Level of Personality Functioning Scale (LPFS), Kernberg's Level of Personality Organization, and the general P-factor of personality disorder. Severity of personality dysfunction is related to treatment outcome, risk of dropout, therapeutic alliance, readiness for treatment, risk of harm to self or others, risk of dissociation and psychotic-like breaks, coherence in narrative identity, reflective functioning, and epistemic trust.

SUMMARY

The overall level of personality disorder severity indicates risk of negative outcomes and may be used as decision tool for 'personalized medicine' and required treatment intensity (e.g., strength of alliance and the need for establishing epistemic trust). Beyond the ICD-11 guidelines for determining personality disorder severity, these implications also apply to practitioners using comparable frameworks such as the DSM-5 LPFS and Kernberg's Level of Personality Organization. Future research should focus on the interaction of severity with trait qualifiers in relation to clinical management.

Voices: Are They Dissociative or Psychotic?

Auditory hallucinations are widely regarded as symptoms of brain disease treated with medications. In an alternative paradigm, voices are understood as trauma-driven dissociated, disowned, or disavowed aspects of self; the goal is not to suppress them but to integrate them during psychotherapy. Auditory hallucinations are common in dissociative identity disorder, borderline personality disorder, and complex posttraumatic stress disorder and are not specific to psychosis. The features that differentiate psychotic from dissociative voices include the qualities of the voices themselves, as well as other symptoms: for example, compared with dissociative voices, psychotic voices are accompanied by less sociability, more formal thought disorder, more negative symptoms including blunted affect, and more delusions. The author proposes that the psychotherapy of dissociative voices can be indicated trans-diagnostically, including in a subgroup of individuals with diagnoses of schizophrenia. Psychotherapeutic strategies are illustrated with a case example.

Developments in diagnosis and treatment of people with borderline personality disorder

PURPOSE OF REVIEW

Borderline personality disorder (BPD) attracts significant attention from clinicians and researchers alike. Despite increased recognition and willingness to diagnose BPD, most effective treatment approaches remain inaccessible to most. We consider recent developments in the diagnosis and treatment of BPD.

RECENT FINDINGS

A literature search of EMBASE and PsychINFO, using the search terms 'borderline personality disorder,' 'diagnosis' and 'treatment' for publications since October 2018, yielded over 300 articles and reviews. The literature highlights the increasing awareness of the diagnostic complexity of BPD as well as the emerging significance of 'common factors' and stepped care approaches for managing and treating the disorder.

SUMMARY

Clinical practice is evolving to embrace more holistic diagnostic approaches, generalist treatment frameworks and stepped-care models that can be tailored to fit individual needs and service resources. The new frontiers in this field include expansion of timely treatment options, improved knowledge regarding the expression and management of BPD in men, adolescents and the elderly, and bridging cultural divides to create a worldwide population approach.