Gender differences and similarities in aggression, suicidal behaviour, and psychiatric comorbidity in borderline personality disorder

Inpatient staff experiences of providing treatment for males with a diagnosis of borderline personality disorder: A thematic analysis

WHAT IS KNOWN ON THE SUBJECT?: We know that there are similar rates of borderline personality disorder (BPD) diagnosed in both men and women; however, some research suggests that BPD is diagnosed later and less frequently in men. Some research suggests that males diagnosed with BPD present differently to women, but not much is known about how this influences the care men receive in inpatient mental health hospitals. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This paper is the first to specifically ask inpatient staff about men diagnosed with BPD, and to hear about their perceptions and experiences. It identified that some staff do not feel as knowledgeable in identifying and treating BPD in men compared to women. Some staff talked about how emotional difficulties like BPD are often not the first thought when men present with distress compared to women. Staff also talked about needing a safe, open and transparent working culture to be able to ask questions and to be questioned on their own assumptions, biases or lack of training. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This paper suggests that inpatient staff may hold some assumptions about men and their emotions, such as assuming that they are less likely to struggle with emotional difficulties like BPD. Staff anxieties about risk management may influence how they perceive and care for men in inpatient wards. The findings suggest that male-specific training in identifying and treating BPD should be provided for staff on inpatient wards, to improve knowledge and confidence.

ABSTRACT

INTRODUCTION: Research highlights discrepancies in recognition of borderline personality disorder (BPD) in men, despite similar rates of prevalence across genders.

AIM

To investigate inpatient mental health professionals' experiences of delivering treatment for males with a diagnosis of BPD.

METHOD

Six mental health professionals working within adult acute inpatient wards completed a semi-structured interview. All participants were members of the nursing team. Thematic analysis was used to analyse the data.

RESULTS

Five themes were identified: Gender Differences, Stereotyping, Facilitators to Care Delivery, Barriers to Care Delivery and Ways to Improve Care. Participants talked of a lack of awareness and understanding of BPD in males impacting both diagnosis and treatment in an acute inpatient setting.

DISCUSSION

There may be factors ranging from gender stereotypes, limited knowledge and understanding of gender differences in presentations, and personal/organisational cultures influencing the formulation and treatment of males with a diagnosis of BPD in inpatient settings.

IMPLICATIONS FOR PRACTICE

The findings suggest that gender stereotypes such as masculine norms may influence how male patients' emotional difficulties are understood and managed, and that additional training in male-specific issues to improve knowledge and care provision. This research will support inpatient staff, service leads and clinical educators to identify ways to adapt care provision for men.

Cluster B personality disorders and psychotropic medications: a focused analysis of trends and patterns across sex and age groups

PURPOSE

This study investigated sex and age differences in patterns of psychotropic medication use before and after the initial diagnosis of Cluster B personality disorders (PDs) and analyzed trends over time.

METHODS

Analyzing data from the Quebec Integrated Chronic Disease Surveillance System for individuals newly diagnosed with Cluster B PD (≥ 14 years) between 2002 and 2018 and under the provincial public drug plan, we calculated yearly and monthly proportions of individuals exposed to psychotropic medications during the year before and after their diagnosis by sex and age. Robust Poisson regression models assessed the association between sex and exposure to psychotropic medications after the diagnosis of Cluster B PD.

RESULTS

Among 87,778 individuals with a first Cluster B PD diagnosis (mean age: 44.5 years; 57.5% women), the proportion of users increased post-diagnosis. Notably, after diagnosis, females were more likely to receive psychiatric medications (between 78.9% and 83.7% during the study period vs. 72.8% and 76.8%). Males were less likely than females to receive antidepressants (adjusted prevalence ratio (aPR): 0.83; 99% confidence interval (CI): 0.82-0.85) and anxiolytics (aPR: 0.86; 99%CI: 0.84-0.88), whereas they had higher exposure to antipsychotics (aPR: 1.04; 99%CI: 1.02-1.06) and ADHD medications (aPR: 1.14; 99%CI: 1.07-1.2). Age-specific trends showed increased ADHD medication use among younger patients (14-24 years), and anxiolytic use predominated in those aged ≥ 65 years.

CONCLUSIONS

Psychotropic medication use was high among Cluster B PD patients, with differences in medication classes according to age and sex. The marked sex and age differences in psychotropic medication use among Cluster B PD patients underscore the need for a sex-sensitive and age-specific approach in psychiatric care.

Systematic Review of the Effectiveness and Experiences of Treatment for Men With Borderline Personality Disorder

In clinical settings, among individuals diagnosed with borderline personality disorder (BPD), typically 75% are female and 25% male, although this discrepancy is not reported in the community. In the literature, little is known of the effectiveness and experiences of treatment of men with BPD. We aimed to review the effectiveness and experiences of treatment for men with BPD and outline future research priorities to promote better recovery. We searched Ovid MEDLINE and PsycINFO for eligible studies from inception until July 29, 2022. Peer-reviewed primary research articles on treatment effectiveness or experience for men with BPD were included. Data from eligible studies were synthesized in a narrative review. The protocol of our review was pre-registered on PROSPERO (CRD42022351908). Seventeen studies met the inclusion criteria, and men with BPD from eight countries were represented. Psychological therapies included Dialectical Behavioral Therapy, Systems Training for Emotional Predictability and Problem Solving, Mentalization Based Therapy, and psychoanalytic therapy. Pharmacologic treatment included topiramate, divalproex Extended-Release, and high-dose baclofen. Five studies investigated the service utilization of men with BPD. Compared to women, men were less likely to access treatment for BPD or find treatment helpful. Our findings demonstrated the potential efficacy of psychotherapy and pharmacologic interventions in reducing anger, aggression, and rule-breaking behavior, with limited evidence for reduction in suicide-related outcomes. Our findings are limited by inadequate power and heterogeneity of the included studies. Further research with larger sample sizes and qualitative studies is needed to better understand the treatment experience for men with BPD.

Distribution of self-reported borderline personality disorder traits symptoms in a large-scale clinical population

Introduction

Borderline Personality Disorder (BPD) traits play a crucial role in the prognosis of psychiatric disorders, as well as in assessing risks associated with negativity and impulsivity. However, there is a lack of data regarding the distribution characteristics of BPD traits and symptoms within clinical populations.

Methods

A total of 3015 participants (1321 males, 1694 females) were consecutively sampled from outpatients at the psychiatric and psycho-counseling clinics at the Shanghai Mental Health Center. BPD symptoms were assessed using a self-reported personality diagnostic questionnaire. Having BPD traits is defined as having five or more positive items in self-reported BPD characteristics. Participants were stratified into male and female groups, age groups, and diagnostic groups (schizophrenia, mood disorders, anxiety disorders). Exploratory factor analysis using principal components analysis was conducted. Three factors were identified: "F1: Affective Instability and Impulsivity", "F2: Interpersonal Unstable and Extreme Reactions", and "F3: Identity Disturbance".

Results

Among 3015 participants, 45.9% of the patients self-reported BPD traits. Comparing of male and female patients, there was no statistically significant difference in the occurrence rate of BPD traits (χ2 = 1.835, p=0.176). However, in terms of symptoms, female patients reported more symptoms than male patients. Female patients also exhibited more pronounced features on F2 compared to male patients (t =-1.972, p=0.049). There is a general decrease in BPD traits, symptoms, and factors with increasing age. Specifically, the proportion of positive BPD traits is approximately halved before the age of 30 and decreases to around one-third after the age of 30. BPD traits were most common in the Mood Disorders group at 55.7%, followed by the Anxiety Disorders group at 44.4%, and Schizophrenia group at 41.5% (χ2 = 38.084, p<0.001).

Discussion

Our study revealed the pervasive presence of BPD traits and symptoms among psychiatric outpatients, exhibiting distinctive distributions across gender, age, and diagnostic categories. These findings emphasize the significance of identifying and addressing BPD pathology in the clinical care of psychiatric outpatients.

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.

An Exploration of Depression and Aggression Among Patients with Schizophrenia in China Rural Community

Purpose

In schizophrenia, aggressive conduct is frequent. And depressed mood can also contribute to the occurrence of aggressive behaviors. The aim of this study was to investigate the risk factors for the occurrence of aggression in stable schizophrenia patients in rural China, mainly to investigate the role of depressed mood in the occurrence of aggression in schizophrenia patients.

Patients and Methods

This is a cross-sectional study conducted in the townships surrounding Chaohu City, Anhui Province, China. Patients' depressive mood was evaluated using the PHQ-9 (The 9-item Patient Health Questionnaire). Patients' aggressiveness was evaluated using the Modified Overt Aggression Scale (MOAS). A score of ≥4 was used as a threshold and divided into aggressive and non-aggressive groups.

Results

This study comprised a total of 821 schizophrenia patients. Among them, the prevalence of having aggressive behavior was 18.8%. After correcting for confounders, logistic regression analysis showed that low education level (OR=0.470, 95% CI 0.254-0.870; p=0.016), living with family (OR=0.383, 95% CI 0.174-0.845; p=0.017) depressed mood (OR=1.147, 95% CI 1.112-1.184; p<0.001) was significantly associated with the risk of aggressive behavior in patients with schizophrenia. Multivariate linear regression indicated that higher levels of aggression were linked with lower levels of education and higher depressive mood.

Conclusion

This study suggests that aggression is more common in patients with stable schizophrenia, and lower levels of education and higher levels of depression are associated risk factors for its occurrence. Living alone may be helpful in reducing the likelihood of aggression.

Recognizing Borderline Personality Disorder in Men: Gender Differences in BPD Symptom Presentation

Women are predominantly diagnosed with BPD, with studies estimating a 3:1 female-to-male diagnostic ratio in clinical settings. Previous studies present conflicting findings regarding gender-level criterion differences, with some indicating differences in contradictory criteria. These studies primarily utilize outpatient samples, highlighting gaps in the literature. Thus, the current study investigates gender-level criterion differences, functioning, and impairment within a novel, partial hospital sample. Participants included (a) a sample of 1,153 individuals from the total population of partial hospital patients regardless of BPD diagnosis and (b) 365 BPD-positive patients who were assessed via semistructured clinical interview and provided consent for data collection during the intake process. Results indicated that (a) women endorsed higher relationship instability than men and (b) there were no significant differences in level of functioning across the gender subsamples. Examining gender differences in BPD symptomatology has clinical implications in improving recognition and addressing potential biases associated with men and mental health.

Measurement invariance of the Personality Inventory for DSM-5 across sex

Introduction

There has been an international movement towards dimensional models of personality disorders (PDs) in the last decades, which culminated in the publication of the Alternative Model of Personality Disorders (AMPD) in the Emerging Measures and Models section of the DSM-5. This model was accompanied by a APA-sanctioned Personality Inventory for DSM-5 (PID-5) for the assessment of the AMPD pathological personality traits. One major issue with the assessment of personality disorders pertains to sex differences, and measurement invariance across sex in assessment instruments for PDs is necessary in order to ensure non-biased evaluations and to make valid comparisons between men and women. This study aimed to provide more information on measurement invariance across sex for the PID-5, using both the original scoring approach provided by the authors of the instrument and the scoring approach suggested by the APA in the published version of the PID-5.

Methods

This study was conducted with a sample of 2273 participants from the general Québec (Canada) adult population aged 18 to 90 years (M = 46.59; SD = 16.32; 51.8% women).

Results

The original scoring approach model showed good fit to data after freeing paths between certain traits and reached strict invariance. The APA scoring approach also showed good fit to data and reached strict invariance, but needed an adjustment (path freed between Emotional lability and Impulsivity in men) to reach scalar invariance.

Discussion

In line with previous research, the PID-5 is invariant across sex and the five-factor structure adjusts well to data. The APA scoring approach appears to attenuate the cross-loading problem observed with the original scoring approach. In light of these results, we recommend using the APA scoring approach to derive domain scores.

Gender differences in borderline personality disorder: a narrative review

Borderline personality disorder (BPD) is a severe and complex mental disorder that traditionally has been found to be more frequent in the female gender in clinical samples. More recently, epidemiological studies have provided conflicting data about the prevalence of borderline disorder in the two genders in community samples. In order to explain this heterogeneity, some authors hypothesized the presence of a bias in the diagnostic criteria thresholds (more prevalent in one gender than another), in the population sampling (community versus clinical), in the instruments of evaluation (clinician versus self-report measures), and in the diagnostic construct of BPD. Beyond the question of the different prevalence of the disorder between genders, the debate remains open as to how personality and clinical characteristics, and attitude toward treatments express themselves in the two genders. This narrative review is aimed to provide an updated overview of the differences among genders in BPD in terms of diagnosis, temperamental and clinical characteristics, comorbidities, findings of neuroimaging, and treatment attitudes. Studies that specifically investigated the gender differences in BPD patients are rather limited. Most of the investigations did not consider gender as a variable or were characterized by a significant imbalance between the two genders (more commonly in favor the female gender). The main results indicated that men were more likely to endorse the criteria "intense and inappropriate anger" and "impulsivity," whereas women endorsed the criteria "chronic feelings of emptiness," "affective instability," and "suicidality/self-harm behaviors." These findings reflect differences in temperament and symptoms of the two genders. Other relevant differences concern pattern of comorbidity, specific neurobiological mechanisms and attitude to treatments. Main limitations were that only one database was searched, time of publications was limited, non-English manuscripts were excluded, and the quality of each paper was not commented.

Co-occurrence of borderline and schizotypal personality disorders: a scoping review

BACKGROUND

The historical concept of borderline conditions refers to the pathology on the border between neurosis and psychosis. In DSM-III the conditions were divided into specific but also somewhat overlapping diagnostic criteria for Borderline Personality Disorder (BPD) and Schizotypal Personality Disorder (SPD). This phenomenological overlap, which results in co-occurrence of the two diagnoses, remains a clinical challenge to this day.

METHODS

To address this issue we examined the co-occurrence of SPD and BPD according to the established DSM-IV/-5 diagnostic criteria. A literature search was conducted including studies that employed a structured interview with defined BPD and SPD criteria.

RESULTS

Studies from 20 samples were included (i.e. 15 patients, 3 community and 2 forensic samples). For patients diagnosed primarily with BPD, 1-27% also met the criteria for SPD and for patients diagnosed primarily with SPD, 5 - 33% showed co-occurrence with BPD. In the forensic samples, co-occurrence for primary BPD was 10% and 67 - 82% for primary SPD. In the community samples, co-occurrence for primary BPD was 29% and 50% for primary SPD. The pattern of co-occurrence across community samples was particularly heterogeneous.

CONCLUSION

The identified co-occurrences for BPD and SPD were considerably sample-dependent, and samples and measurements were generally too heterogeneous for a precise meta-analysis. Forensic and community samples generally showed higher co-occurrences, but these findings were characterized by potential methodological limitations.

Evaluation of Asymmetric Dimethylarginine, Malondialdehyde, and Vitamin Levels of Borderline Personality Disorder Patients With and Without Self-Mutilation

OBJECTIVE

Believing that oxidative stress may be increased in borderline personality disorder (BPD) patients with self-mutilating behaviors (SMB), we aimed to measure serum asymmetric dimethylarginine (ADMA) and malondialdehyde (MDA) levels in these patients.

METHODS

The study included 60 patients diagnosed with BPD and 30 healthy controls. BPD patients were divided into two groups: 30 female patients with SMB and 30 female patients with no-self-mutilating behavior (NSMB). ADMA, MDA, vitamin A, and vitamin E levels were analyzed. Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI) were conducted with the participants.

RESULTS

Serum ADMA and MDA levels were higher in SMB and NSMB group compared to control group. Serum vitamin E levels were also lower in the SMB group compared to the control group. Positive correlations were determined between both ADMA and MDA, and between BDI and BAI scores. Also, BAI scores were statistically higher in SMB group compared to NSMB group.

CONCLUSION

It was discovered that levels of ADMA and MDA, which reflected oxidative stress, were elevated in patients with BPD who exhibited SMB. Accordingly, future studies should investigate the role of oxidative stress in a more comprehensive way in terms of the different mechanisms underlying and treatments involved in borderline personality disorder.

The Co-occurrence of Personality Disorders and Substance Use Disorders

PURPOSE OF REVIEW

Despite significant negative outcomes, the co-occurrence of personality disorders (PDs) and substance use disorders (SUDs) continues to be underrecognized, and the mechanisms contributing to this co-occurrence remain unclear. This review summarizes recent work on PD-SUD co-occurrence, with a focus on borderline and antisocial PDs, general substance use patterns among those with PDs, and the association of personality traits with SUDs.

RECENT FINDINGS

The prevalence of co-occurring PD-SUD is generally high, with estimates ranging depending on the type of PD and SUD, the population assessed, and the sampling methods and measures used. Current theoretical explanations for co-occurrence include shared etiology and predisposition models, with research highlighting the importance of transactional processes. Potential underlying mechanisms include personality traits and transdiagnostic characteristics. Recent research has increased focus on substances besides alcohol, dimensional models of personality pathology, and transactional explanations of co-occurrence, but more research is needed to disentangle the nuanced PD-SUD relationship.

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

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

The Role of Gender in Patients with Borderline Personality Disorder: Differences Related to Hopelessness, Alexithymia, Coping Strategies, and Sensory Profile

Background and Objectives: Gender differences are poorly investigated in patients with borderline personality disorder (BPD), although they could be useful in determining the most appropriate pharmacological and non-pharmacological treatment. The aim of the present study was to compare sociodemographic and clinical characteristics and the emotional and behavioral dimensions (such as coping, alexithymia, and sensory profile) between males and females with BPD. Material and Methods: Two hundred seven participants were recruited. Sociodemographic and clinical variables were collected through a self-administered questionnaire. The Adolescent/Adult Sensory Profile (AASP), Beck Hopelessness Scale (BHS), Coping Orientation to Problems Experienced (COPE), and Toronto Alexithymia Scale (TAS-20) were administered. Results: Male patients with BPD showed more involuntary hospitalizations and greater use of alcohol and illicit substances compared to females. Conversely, females with BPD reported more frequent medication abuse than males. Furthermore, females had high levels of alexithymia and hopelessness. Regarding coping strategies, females with BPD reported higher levels of "restraint coping" and "use of instrumental social support" at COPE. Finally, females with BPD had higher scores in the Sensory Sensitivity and Sensation Avoiding categories at the AASP. Conclusions: Our study highlights gender differences in substance use, emotion expression, future vision, sensory perception, and coping strategies in patients with BPD. Further gender studies may clarify these differences and guide the development of specific and differential treatments in males and females with BPD.

Sex differences in borderline personality disorder: A scoping review

Borderline Personality Disorder (BPD) is often perceived to be a female-predominant disorder in both research and clinical contexts. Although there is growing recognition of possible sex differences, the current literature remains fragmented and inconclusive. This scoping review aimed to synthesize available research evidence on potential sex differences in BPD. PsycINFO, PubMed, Scopus and Web-of-Science were searched from January 1982 to July 2022 surrounding the key concepts of sex and BPD. Data searching and screening processes followed the Joanna Briggs Institute methodology involving two independent reviewers, and a third reviewer if necessary, and identified 118 papers. Data regarding BPD symptoms, comorbid disorders, developmental factors, biological markers, and treatment were extracted. Data was summarized using the vote counting method or narrative synthesis depending on the availability of literature. Males with BPD were more likely to present externalizing symptoms (e.g., aggressiveness) and comorbid disorders (e.g., substance use), while females with BPD were more likely to present internalizing symptoms (e.g., affective instability) and comorbid disorders (e.g., mood and eating disorders). This review also revealed that substantially more research attention has been given to overall sex differences in baseline BPD symptoms and comorbid disorders. In contrast, there is a dearth of sex-related research pertaining to treatment outcomes, developmental factors, and possible biological markers of BPD. The present scoping review synthesized current studies on sex differences in BPD, with males more likely to present with externalizing symptoms in contrast to females. However, how this might change the prognosis of the disorder or lead to modifications of treatment has not been investigated. Most studies were conducted on western populations, mainly North American (55%) or European (33%), and there is a need for future research to also take into consideration genetic, cultural, and environmental concomitants. As the biological construct of 'sex' was employed in the present review, future research could also investigate the social construct 'gender'. Longitudinal research designs are needed to understand any longer-term sex influence on the course of the disorder.

Pharmacological interventions for people with borderline personality disorder

BACKGROUND

Among people with a diagnosis of borderline personality disorder (BPD) who are engaged in clinical care, prescription rates of psychotropic medications are high, despite the fact that medication use is off-label as a treatment for BPD. Nevertheless, people with BPD often receive several psychotropic drugs at a time for sustained periods.

OBJECTIVES

To assess the effects of pharmacological treatment for people with BPD.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers up to February 2022. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication.

SELECTION CRITERIA

Randomised controlled trials comparing pharmacological treatment to placebo, other pharmacologic treatments or a combination of pharmacologic treatments in people of all ages with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. Secondary outcomes were individual BPD symptoms, depression, attrition and adverse events.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's risk of bias tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis.

MAIN RESULTS

We included 46 randomised controlled trials (2769 participants) in this review, 45 of which were eligible for quantitative analysis and comprised 2752 participants with BPD in total. This is 18 more trials than the 2010 review on this topic. Participants were predominantly female except for one trial that included men only. The mean age ranged from 16.2 to 39.7 years across the included trials. Twenty-nine different types of medications compared to placebo or other medications were included in the analyses. Seventeen trials were funded or partially funded by the pharmaceutical industry, 10 were funded by universities or research foundations, eight received no funding, and 11 had unclear funding. For all reported effect sizes, negative effect estimates indicate beneficial effects by active medication. Compared with placebo, no difference in effects were observed on any of the primary outcomes at the end of treatment for any medication. Compared with placebo, medication may have little to no effect on BPD symptom severity, although the evidence is of very low certainty (antipsychotics: SMD -0.18, 95% confidence interval (CI) -0.45 to 0.08; 8 trials, 951 participants; antidepressants: SMD -0.27, 95% CI -0.65 to 1.18; 2 trials, 87 participants; mood stabilisers: SMD -0.07, 95% CI -0.43 to 0.57; 4 trials, 265 participants). The evidence is very uncertain about the effect of medication compared with placebo on self-harm, indicating little to no effect (antipsychotics: RR 0.66, 95% CI 0.15 to 2.84; 2 trials, 76 participants; antidepressants: MD 0.45 points on the Overt Aggression Scale-Modified-Self-Injury item (0-5 points), 95% CI -10.55 to 11.45; 1 trial, 20 participants; mood stabilisers: RR 1.08, 95% CI 0.79 to 1.48; 1 trial, 276 participants). The evidence is also very uncertain about the effect of medication compared with placebo on suicide-related outcomes, with little to no effect (antipsychotics: SMD 0.05, 95 % CI -0.18 to 0.29; 7 trials, 854 participants; antidepressants: SMD -0.26, 95% CI -1.62 to 1.09; 2 trials, 45 participants; mood stabilisers: SMD -0.36, 95% CI -1.96 to 1.25; 2 trials, 44 participants). Very low-certainty evidence shows little to no difference between medication and placebo on psychosocial functioning (antipsychotics: SMD -0.16, 95% CI -0.33 to 0.00; 7 trials, 904 participants; antidepressants: SMD -0.25, 95% CI -0.57 to 0.06; 4 trials, 161 participants; mood stabilisers: SMD -0.01, 95% CI -0.28 to 0.26; 2 trials, 214 participants). Low-certainty evidence suggests that antipsychotics may slightly reduce interpersonal problems (SMD -0.21, 95% CI -0.34 to -0.08; 8 trials, 907 participants), and that mood stabilisers may result in a reduction in this outcome (SMD -0.58, 95% CI -1.14 to -0.02; 4 trials, 300 participants). Antidepressants may have little to no effect on interpersonal problems, but the corresponding evidence is very uncertain (SMD -0.07, 95% CI -0.69 to 0.55; 2 trials, 119 participants). The evidence is very uncertain about dropout rates compared with placebo by antipsychotics (RR 1.11, 95% CI 0.89 to 1.38; 13 trials, 1216 participants). Low-certainty evidence suggests there may be no difference in dropout rates between antidepressants (RR 1.07, 95% CI 0.65 to 1.76; 6 trials, 289 participants) and mood stabilisers (RR 0.89, 95% CI 0.69 to 1.15; 9 trials, 530 participants), compared to placebo. Reporting on adverse events was poor and mostly non-standardised. The available evidence on non-serious adverse events was of very low certainty for antipsychotics (RR 1.07, 95% CI 0.90 to 1.29; 5 trials, 814 participants) and mood stabilisers (RR 0.84, 95% CI 0.70 to 1.01; 1 trial, 276 participants). For antidepressants, no data on adverse events were identified.

AUTHORS' CONCLUSIONS

This review included 18 more trials than the 2010 version, so larger meta-analyses with more statistical power were feasible. We found mostly very low-certainty evidence that medication may result in no difference in any primary outcome. The rest of the secondary outcomes were inconclusive. Very limited data were available for serious adverse events. The review supports the continued understanding that no pharmacological therapy seems effective in specifically treating BPD pathology. More research is needed to understand the underlying pathophysiologic mechanisms of BPD better. Also, more trials including comorbidities such as trauma-related disorders, major depression, substance use disorders, or eating disorders are needed. Additionally, more focus should be put on male and adolescent samples.

Effect of comorbid ADHD on mortality in women with borderline personality disorder

BACKGROUND

Many similarities exist between borderline personality disorder (BPD) and attention-deficit/hyperactivity disorder (ADHD), more so in women than in men. People with comorbid ADHD and BPD represent a subgroup of BPD patients with distinct symptom expression and, consequently, a different prognosis. We used Swedish national high quality registers to assess whether such comorbidity is related to increased mortality risk. The study focused on women with BPD because they are more likely than men to be clinically diagnosed with BPD and present a higher mortality risk, especially for unnatural causes of death, including suicide.

FINDINGS

In a cohort of 15 847 women diagnosed with BPD a subsequent clinical diagnosis of ADHD did not influence the overall risk of mortality, including suicide.

CONCLUSIONS

Women with comorbid ADHD and BPD have a similar mortality risk as those only diagnosed with BPD.

Functional Impairment in Borderline Personality Disorder: The Mediating Role of Perceived Social Support

Borderline personality disorder (BPD) is characterized by instability in relationships, mood fluctuations, and erratic behavior. This study investigates the relationship between pathological personality traits and functional disability, the status of perceived social support in BPD, as well as its mediating role in this relationship. In this cross-sectional study, 192 Spanish women (BPD group, N = 97; healthy control group, N = 95) completed, through two online platforms, a battery of tests including: the Personality Inventory for DSM-5 Brief Form (PID-5-BF), the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) and the Perceived Social Support subscale of the Quality of Life Questionnaire (QLQ). The results show that perceived social support was significantly lower in the BPD group, which also presented a significantly higher disability score than the control group. Pathological personality traits affected functionality both directly and indirectly through perceived social support, as this variable was a significant mediator in both groups. We conclude that perceived social support is impaired in BPD patients, and enhancing it as a complementary therapy to evidence-based treatments could help preserve the functionality of patients while pathological traits are regulated. This study also encourages future research to delve into the relevance of other psychosocial variables on the functionality of subjects with BPD, and the need of enhancing them in therapy.

Aggression in borderline personality disorder: A systematic review of neuroimaging studies

Aggressive behaviors are prevalent among patients with Borderline Personality Disorder (BPD). Neuroimaging studies have linked aggression in BPD patients to neurochemical, structural, functional, and metabolic alterations in various brain regions, especially in frontal-limbic areas. This systematic review summarizes current neuroimaging results on aggression among BPD patients and provides an overview of relevant brain mechanisms. A systematic search of PubMed and Web of Science databases, in addition to manual check of references, identified thirty-two eligible articles, including two magnetic resonance spectrum (MRS), thirteen structural magnetic resonance imaging (sMRI), six functional magnetic resonance imaging (fMRI), and eleven positron emission tomography (PET) studies. The reviewed studies have highlighted the abnormalities in prefrontal cortices and limbic structures including amygdala and hippocampus. Less studies have zoomed in the roles of parietal and temporal regions or taken a network perspective. Connectivity studies have shed light on the importance of the frontal-limbic interactions in regulating aggression. Conflicted findings might be attributed to disparity in controlling gender, anatomical subdivisions, and comorbidities, which shall be considered in future studies.

Validity and Reliability of the Urdu Version of the McLean Screening Instrument for Borderline Personality Disorder

Introduction: Although the translation and the validation of the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) are performed in various languages and samples, no study has established the validity and reliability of the Urdu version of MSI-BPD in individuals with cardiac problems. Materials and Methods: The Urdu version of the MSI-BPD was prepared through the standard back-translation method. The translation and adaption were completed in four steps: forward translation, adaption and translation, back translation and committee approach, and cross-language validation. The sample, selected through the purposive sampling method, comprised of 150 adults with cardiac problems (men = 75 and women = 75), with an age range of 23-78 years (M = 55, SD = 10.6). The Cronbach alpha reliability and factorial validity of the MSI-BPD were assessed through confirmatory factor analysis (CFA) and Pearson correlation analyses. Internal consistency and test-retest reliability (at 2 weeks' interval) were used to evaluate the reliability. Statistical analyses were performed, using SPSS (version 22) and Structural Equation Modeling (SEM) software. Results: Preliminary analysis revealed that the overall instrument had good internal consistency (Urdu MSI-BPD α = 0.79; English MSI-BPD α = 0.77) as well as test-retest correlation coefficients for 15 days (r = 0.94). Conclusions: Findings suggested that the MSI-BPD, with important limitations, can be used as an effective preliminary screening tool to measure BPD in Urdu-speaking adults with cardiac problems. Further validations should be conducted to make the translated version of the MSI-BPD an appropriate tool to screen BPD in hospitals and mental health care settings.

[Disease burden of borderline personality disorder: cost of illness, somatic comorbidity and mortality]

BACKGROUND

Severe mental illnesses (SMI) are characterized by high psychosocial impairment as well as by increased somatic morbidity and mortality. The term SMI commonly includes psychotic, bipolar and severe unipolar depressive disorders but borderline personality disorder (BPD) also shows severe sequelae of the disease.

MATERIAL AND METHODS

Published reviews and studies since 2010 examining disease burden of BPD, in terms of direct and indirect costs of illness, somatic comorbidity, and mortality were included. Furthermore, administrative data (clinically recorded billing data in Germany), comorbidity and mortality from a comprehensive analysis (n > 59 million, age ≥ 18 years) are reported.

RESULTS

International studies reveal an increased disease burden, comorbidity, and mortality for BPD. In Germany BPD (administrative 1‑year prevalence 0.34%) is associated with increased rates of somatic sequelae of trauma, hepatitis, HIV, COPD, asthma, and obesity. The estimated reduced life expectancy is 5.0-9.3 years of life lost (depending on age and sex).

DISCUSSION

The burden of disease in BPD is clearly increased (cost of illness, somatic comorbidity and mortality). The increased mortality can mainly be explained by deaths as a consequence of poor physical health and associated BPD-related health behavior and only to a lesser degree by suicide. These results highlight the importance of classifying BPD as an SMI and the necessity to provide not only psychotherapeutic and psychiatric but also adequate somatic prevention and treatment. Individual improvement of everyday care as well as establishing new interdisciplinary and multiprofessional services could enhance health equality for people with BPD.

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.

Aggression Amongst Outpatients With Schizophrenia and Related Psychoses in a Tertiary Mental Health Institution

Aims: Aggression is defined as "any behavior intended to cause physical, emotional, or psychological harm to another." The aims of the current study were to (i) examine underlying factor structure of the Buss-Perry Aggression Questionnaire (BPAQ) and (ii) explore socio-demographic and clinical correlates (symptom severity, substance use and alcohol use) among patients with schizophrenia and related psychoses in a multi-ethnic Asian population. Methods: Data collected from 397 participants who were seeking outpatient treatment for schizophrenia and related psychoses at a tertiary psychiatric hospital were included in the analyses. BPAQ, a 29-item, four-factor instrument that measures physical aggression, verbal aggression, anger and hostility was used to assess aggression. Data on socio-demographic variables, age of onset of illness, drug use, alcohol use and symptom severity were also collected. Confirmatory factor analysis (CFA) was performed to establish the underlying factor structure of the BPAQ. Multiple regression analyses were utilized to examine socio-demographic and clinical correlates of the BPAQ factors. Results: The mean age of the participants was 36.2 years (SD = 10.9, range: 21-65). Factor structure obtained from the CFA indicated that a higher order four-factor solution had an acceptable fit to the observed data (WLSMV χ² = 1,025.35, df = 320, RMSEA = 0.07, CFI = 0.94, TLI = 0.93, SRMR = 0.05). Females had lower physical aggression and hostility scores as compared to males. Those with lower education had higher physical aggression scores as compared to those with higher education. Participants who received a diagnosis after the age of 30 years had higher physical aggression and anger scores as compared to those who received a diagnosis at or before 20 years of age. Symptom severity was positively associated with higher BPAQ scores. Conclusion: The study findings demonstrated high internal consistency and applicable measurement factor structure of BPAQ in this study sample, making it an appropriate questionnaire for assessing aggressive behavior in this population. We also identified socio-demographic and clinical factors that were associated with aggression in patients with schizophrenia and related psychoses.

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.

Sex, Gender, and Suicidal Behavior

This chapter reviews gender differences in suicide, commonly known as the gender paradox in suicide. While men are more likely to complete suicide, suicide attempts are more frequent in women. Although there are exceptions, this paradox occurs in most countries over the world, and it is partially explained by the preference of men for more lethal methods. Nevertheless, there are differences in the known risk factors for suicide between men and women, and this chapter summarizes the more relevant findings for the gender paradox. Apart from previous attempts, which still is the strongest predictor of death by suicide, with a higher rate in males than in females, we will emphasize in the role of male depression. It is commonly recognized that over 90% of people who die by suicide had a psychiatric diagnosis, mostly depression, and male depression seems to be a distinct clinical phenotype challenging to recognize, which might contribute to the gender paradox. Finally, in light of all the information reviewed, some recommendations on prevention of suicide from a gender perspective in the clinical setting will be made.

The identification of a risk profile for young people with borderline personality pathology: a review of recent literature

The shift towards early intervention in borderline personality disorder (BPD) has introduced a clinical staging approach in the treatment for young persons with BPD. Complementary to staging is profiling: the identification of psychological, social and biological risk variables that may predict prognosis. The aim of this paper is to provide a risk profile for BPD by systematically reviewing literature on potential risk markers for poor prognosis for BPD. An extensive literature search revealed evidence for seven categories of risk factors: adverse childhood experiences, BPD symptom profile, associated mental disorders, personality impairments and traits, current interpersonal context, biological disposition and socio-demographics. Including these markers within the current staging approach, to compose individual risk profiles for poor BPD prognosis, may assist in personalizing treatment for young people with BPD and in refining research protocols for treatment outcome studies.

A history of prolonged childhood sexual abuse is associated with more severe clinical presentation of borderline personality disorder in adolescent female inpatients - A naturalistic study

BACKGROUND

Borderline personality disorder (BPD) is associated with high rates of suicidal and self-injurious behaviors and a substantial proportion of BPD patients have a history of trauma, particularly childhood sexual abuse (CSA).

OBJECTIVE

To compare the clinical presentation severity in female adolescent inpatients with BPD with and without history of prolonged CSA.

PARTICIPANTS AND SETTING

Female adolescent BPD patients admitted to a psychiatric inpatient unit.

METHODS

A retrospective analysis of records of the inpatients, divided into two groups: with (n = 38) and without (n = 40) a history of prolonged CSA. Prolonged CSA was defined as sexual abuse continuing for at least 3 months. Demographic and clinical data, including number and duration of psychiatric hospitalizations until the age 19, non-suicidal self-injury (NSSI), suicide attempts, cigarette smoking, alcohol and drug use, and sexual impulsivity were compared between the two groups.

RESULTS

The BPD + prolonged CSA group had a larger duration of the first psychiatric hospitalization, number of hospitalizations and cumulative length of hospitalizations compared with the control group. Furthermore, the BPD + prolonged CSA group had a higher number of suicidal attempts, and higher rates of severe NSSI events, cigarette smoking, alcohol use, and sexual impulsivity.

CONCLUSIONS

This study demonstrated for the first time that adolescent female BPD inpatients with a history of prolonged CSA, manifest more severe clinical presentation compared to those without prolonged CSA. Hence, it appears essential to encourage therapists to inquire about history of CSA and refer adolescent female BPD inpatients with prolonged CSA to appropriate intensive therapy.

Ovarian Hormones as a Source of Fluctuating Biological Vulnerability in Borderline Personality Disorder

PURPOSE OF REVIEW

To examine the potential role of ovarian hormones in biological vulnerability to borderline personality disorder (BPD). The review focuses primarily on research examining the menstrual cycle as a source of short-term lability of BPD symptom expression, while discussing the currently understudied possibility of ovarian hormone influence in the developmental course of BPD.

FINDINGS

Several patterns of menstrual cycle effects on BPD symptoms and relevant features in non-clinical samples have been observed in empirical studies. Most symptoms demonstrated patterns consistent with perimenstrual exacerbation; however, timing varied between high and low arousal symptoms, potentially reflecting differing mechanisms. Symptoms are typically lowest around ovulation, with an exception for proactive aggression and some forms of impulsive behaviors. Preliminary evidence suggests ovarian hormones may exert strong effects on BPD symptom expression, and further research is warranted examining mechanisms and developing interventions. Recommendations for researchers and clinicians working with BPD are provided.

Impulsivity issues in borderline personality disorder and it's links with insight: the role of urgency

Objective

Impulsivity plays a major role in a wide range of disorders including Borderline Personality Disorder. Another crucial clinical dimension is insight. This clinical dimension is linked with symptomatology and treatment issue. The present study aims to investigate the impact of positive and negative urgency on insight in Borderline Personality Disorder.

Methods

We recruited eighty-one women with Borderline Personality Disorder and assessed insight level and impulsivity scores using the Beck Cognitive insight scale and the UPPS-short form scale.

Results

Our results showed interesting links between positive urgency and insight quality.

Conclusion

Negative emotions play a fundamental role for the insight quality, but positive emotions are surprisingly related to clinical insight. We discuss the possible therapeutical impact of this results on treatment adaptation.

Toward an animal model of borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is a pervasive psychiatric disorder characterized by emotion dysregulation, impulsivity, impaired self-perceptions, and interpersonal relationships and currently affects 1-3% of the US population as reported by Torgersen et al. (Arch Gen Psychiatry 58:590-596, Torgersen et al. 2001), Lenzenweger et al. (Biol Psychiatry 62:553-564, Lenzenweger et al. 2007), and Tomko et al. (J Personal Disord 28:734-750, Tomko et al. 2014). One major obstacle to our understanding of the neural underpinnings of BPD is a lack of valid animal models that translate the key known features of the disorder to a system that is amenable to study.

OBJECTIVE

To summarize the etiology, major symptoms, and symptom triggers of BPD and then propose a blueprint for building an animal model of BPD by choosing key components of the disorder that can be implemented in rodents.

RESULTS

We identify the role of early life stress and subsequent mild stress in adulthood as contributing etiological factors and the potential use of altered communication between frontal cortices and the amygdala in extinction and habituation, increased impulsivity, dysregulation of the hypothalamic pituitary axis (HPA), and increased neuroinflammation as biological markers of BPD. Building upon these features of BPD, we propose a two-hit animal model that uses maternal abandonment to alter maturation of the HPA axis and mild secondary adult stress to evoke behavioral symptoms such as increased impulsivity and impaired extinction, habituation, and social interactions.

CONCLUSION

Through exploration of the etiology, symptom presentation, and altered neurological function, we propose an animal model of BPD. We believe that a number of existing animal paradigms that model other mental health disorders should be combined in a unique way to reflect the etiology, symptom presentation, and altered neurological function that is evident in BPD. These model, when compared with available human data, will inform research and treatment in humans for better understanding of systems from the micro-molecular level to more global physiology underlying BPD.

Genetic contribution to the phenotypic correlation between trait impulsivity and resting-state functional connectivity of the amygdala and its subregions

Trait impulsivity, a predisposition to respond to stimuli without regard for the potentially negative consequences, contributes to many maladaptive behaviors. Studies have shown that both genetic factors and interregional functional interactions underlie trait impulsivity. However, whether common genes contribute to both trait impulsivity and its neural basis is still unknown. This study investigated the phenotypic correlations between trait impulsivity and the resting-state functional connectivity (rsFC) of the amygdala as well as its subregions and the genetic contribution to the phenotypic correlations. By recruiting a sample of 292 twins in late adolescence and young adulthood, we found that trait impulsivity was positively correlated with the rsFC between the left full amygdala and the right dorsolateral prefrontal cortex (DLPFC). Further analyses on the subregions of the amygdala showed that trait impulsivity was positively correlated with the rsFCs between the left basolateral (BL) amygdala and both the right DLPFC and the right inferior frontal gyrus and with the rsFCs between the right superficial (SF) amygdala and both the dorsal anterior cingulate cortex and right anterior insula. Bivariate genetic modelling analyses found genetic overlaps between trait impulsivity and the rsFC of the left full amygdala or the left BL amygdala with the right DLPFC. The proportions of phenotypic associations accounted for by overlapping genes were 82% and 60%, respectively. These results provide evidence for the genetic overlap between trait impulsivity and the intrinsic brain functional connectivity centered at the amygdala and especially at its BL subregion.

Borderline Personality Disorder (BPD): In the Midst of Vulnerability, Chaos, and Awe

Borderline personality disorder (BPD) is a chronic psychiatric disorder characterized by pervasive affective instability, self-image disturbances, impulsivity, marked suicidality, and unstable interpersonal relationships as the core dimensions of psychopathology underlying the disorder. Across a wide range of situations, BPD causes significant impairments. Patients with BPD suffer considerable morbidity and mortality compared with other populations. Although BPD is more widely studied than any other personality disorder, it is not understood sufficiently. This paper briefly reviews the recent evidence on the prevalence, etiology, comorbidity, and treatment approaches of borderline personality disorder (BPD) by examining published studies, and aims to offer a more coherent framework for the understanding and management of borderline personality disorder.