Psychological distress in caretakers or relatives of patients with borderline personality disorder

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Adolescent Young Carers Who Provide Help and Support to Friends

Prior studies emphasize the value of friends' support for children/adolescents who have a disability or suffer from mental ill-health or a long-term illness. However, few studies have explored how a caring role affects those young friend carers themselves. This paper addresses a gap in the research by focusing on this hitherto neglected group of young carers to explore the impact of providing care to friends. An online survey was employed for a cross-national study conducted in 2018-2019 in Sweden, Italy, Slovenia, the Netherlands, Switzerland, and the United Kingdom to examine the incidence of adolescent young friend carers, the extent of care they provide, and their self-reported health, well-being, and school situation. The survey was completed by 7146 adolescents, aged 15-17, and 1121 of them provided care to a friend with a health-related condition, most frequently mental ill-health. They carried out high levels of caring activities, and a quarter of them also provided care to a family member. They experienced both positive and negative aspects of caring. Nevertheless, in comparison with adolescents who provided care to family members, they reported more health problems, with a dominance of mental ill-health, and they received lower levels of support. Since adolescent friends play a valuable role for young people with health-related conditions, especially mental ill-health, it is important to find ways of optimizing their caring experiences in order that those adolescents who choose to care for a friend can do so without it having a negative impact on their own mental health, well-being, and life situation.

The relationship between social support, coping strategies and psychological distress and positive mental well-being in carers of people with borderline personality disorder

BACKGROUND

Informal carers of people with BPD experience high levels of burden and psychological distress relative to other populations. There is a scarcity of research evidencing the influence of modifiable factors on carer outcomes to inform interventions. This study aimed to investigate the relationship between social support, coping strategies and psychological distress and positive mental well-being in this carer population.

METHODS

In this cross-sectional study, 1207 carers completed the McLean Screening Instrument for BPD-Carer Version, the Brief COPE, the Multidimensional Scale of Perceived Social Support, the Kessler Psychological Distress scale, the WHO-5 Well-being Index, and the Coronavirus Anxiety Scale. Data for 863 participants who met the inclusion criteria were analysed.

RESULTS

Carers reported low positive mental well-being and high psychological distress. Perceived social support and several coping strategies were significant unique predictors of psychological distress and positive mental well-being. Perceived social support and positive reframing were the strongest predictors of higher positive mental well-being and lower psychological distress. Self-blame, behavioural disengagement and substance use were the strongest predictors of adverse outcomes.

CONCLUSIONS

The findings evidence modifiable factors that may be used to improve informal carer outcomes and indicate that carer interventions may be improved by focusing on reducing the use of self-blame, behavioural disengagement and substance use, and development of quality social support and skills to positively reframe caregiving situations.

Parent and Carer Skills Groups in Dialectical Behaviour Therapy for High-Risk Adolescents with Severe Emotion Dysregulation: A Mixed-Methods Evaluation of Participants' Outcomes and Experiences

BACKGROUND

There is an established evidence-base for dialectical behaviour therapy for adolescents (DBT-A) in the treatment of young people with severe emotion dysregulation and related problems, including repeated self-harm and suicidal behaviours. However, few studies have reported on parental involvement in such treatments. This study aims to explore the outcomes and experiences of participants of a dedicated skills group for parents and carers embedded within an adapted DBT-A programme in the United Kingdom.

METHOD

This study was conducted within a specialist outpatient Child and Adolescent Mental Health Services (CAMHS) DBT programme in the National Health Service (NHS) in London. Participants were parents and carers of adolescents engaged in the DBT-A programme. Participants attended a 6-month parent and carer skills group intervention and completed self-report measures relating to carer distress, communication and family functioning, at pre-intervention and post-intervention. Following the intervention, semi-structured interviews were also completed with a subgroup of participants to explore their experiences of the skills group and how they perceived its effectiveness. Quantitative and qualitative methods were used to analyse the data collected from participants.

RESULTS

Forty-one parents and carers completed the intervention. Participants reported a number of statistically significant changes from pre- to post-intervention: general levels of distress and problems in family communication decreased, while perceived openness of family communication and strengths and adaptability in family functioning increased. A thematic analysis of post-intervention interviews examining participant experiences identified six themes: (1) experiences prior to DBT; (2) safety in DBT; (3) experiences with other parents and carers; (4) new understandings; (5) changes in behaviours; and (6) future suggestions.

DISCUSSION

Parents and carers who attended a dedicated DBT skills groups, adapted for local needs, reported improvements in their wellbeing, as well as interactions with their adolescents and more general family functioning, by the end of the intervention. Further studies are needed which report on caregiver involvement in DBT.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Psychological assessment of parents of people diagnosed with borderline personality disorder and comparison with parents of people without psychological disorders

Background

To date, several evidence-based interventions have been created to help relatives of people with Borderline Personality Disorder (BPD), but few studies have analyzed the clinical situation of the family members. The aim of this study was twofold: (1) to explore the clinical symptomatology in a sample of parents of people diagnosed with BPD and compare them with a sample of a sample of people without a relative with a personality disorder, (2) to explore whether the parents of people diagnosed with BPD have psychopathology related to personality disorders (PD) or meet the diagnostic criteria for PD.

Method

Participants were 42 (39.6%) fathers and 64 (60.4%) were mothers and mothers (n = XX, −%) of people diagnosed with BPD, who were selected from a specialized PD unit for treatment. The sample of people without a relative with a PD was obtained from social network announcements. To test for differences between the two groups, Student’s t tests were performed for quantitative variables, and Chi-square tests were performed for categorical variables. Cohen’s d was calculated as a measure of the effect size.

Results

Parents of people with BPD showed greater depressive and anxious symptomatology, higher levels of expressed emotion, and worse quality of life than the sample of people without a relative with a personality disorder. In addition, a high percentage of the parents of people diagnosed with BPD (50%) met the diagnostic criteria for different PD.

Conclusion

Parents of people diagnosed with BPD may need psychological help in various aspects. Therapists are therefore advised to bear in mind the importance of carrying out a psychological assessment of family members and, if necessary, to offer psychological intervention. It is crucial to invite the family to be part of the treatment, since they can be part of the solution.

Clinical Trial registration: ClinicalTrials.gov ID, NCT04160871 (registered November 15, 2019).

Prädiktion von Behandlungsabbrüchen bei Adoleszenten mit Borderline-Persönlichkeitsstörung

Zusammenfassung: Theoretischer Hintergrund: Die Borderline-Persönlichkeitsstöurng (BPS) kann bereits in der Adoleszenz zuverlässig diagnostiziert und wirksam behandelt werden. Eine möglichst frühe Behandlung der BPS durch störungsspezifische Therapien (z. B. Dialektisch-Behaviorale Therapie), erscheint ist sinnvoll, weil hierdurch selbstschädigende Verhaltensweisen und chronische Verläufe mit häufigen suizidalen Krisen verhindert und die langfristige psychosoziale Entwicklung verbessert werden kann. Mehrere Therapiestudien zur Wirksamkeit der Behandlung in der Adoleszenz zeigten sehr hohe Abbruchraten (bis zu 75 %), bisher sind allerdings nur wenig konsistente Ergebnisse zur Prädiktion von Therapieabbrüchen vorhanden. Fragestellung: Das Hauptziel der vorliegenden Studie war daher im Rahmen einer Beobachtungsstudie a) die Abbruchrate in der Realversorgung und b) die möglichen Prädiktoren (klinische und demographische Variablen) des Abbruchs einer stationären Behandlung mit DBT für Adoleszente an N = 172 Patient_innen im Alter von 15 – 18 Jahren zu untersuchen. Methode: In einer logistischen Regression wurden 18 Prädiktoren (u. a. Alter, Anzahl der Diagnosen, Schwere der Symptomatik) in SPSS untersucht, die im Rahmen einer drei monatigen stationären Behandlung in der Routineversorgung erhoben wurden. Ergebnisse: Lediglich ein jüngeres Alter der Patient_innen war statistisch signifikant mit einem erhöhten Risiko für einen Therapieabbruch assoziiert. Keine statistisch bedeutsamen Zusammenhänge mit einem Therapieabbruch fanden sich hingegen für die untersuchten psychiatrischen Komorbiditäten (bspw. für das Vorliegen einer Essstörung), für die Schwere der BPS-spezifischen Psychopathologie und für BPS-typische problematische Verhaltensweisen (bspw. selbstschädigendes Verhalten oder Hochrisikoverhalten). Diskussion und Schlussfolgerung: Unsere Untersuchung ergibt keinen Anhalt dafür, dass bei stark ausgeprägter Symptombelastung eine erhöhte Gefahr für einen Abbruch einer Behandlung mit DBT besteht. Sollte das Ergebnis einer erhöhten Abbruchrate bei jüngeren Jugendlichen in weiteren Studien repliziert werden, wären systematische Untersuchungen zu Variablen notwendig, die bei jüngeren Jugendlichen eine besondere Bedeutung besitzen und mit einem Therapieabbruch in Zusammenhang stehen könnten (bspw. die Beziehung zu wichtigen Bezugspersonen). Hieraus ließen sich ggf. gezielte Therapiemodifikationen ableiten, die Therapieabbrüchen entgegenwirken.

Die Borderline-Persönlichkeitsstörung im Jugendalter

Zusammenfassung: Die Borderline-Persönlichkeitsstörung (BPS) ist eine schwere psychische Erkrankung, die durch hohe Morbidität und Mortalität gekennzeichnet ist sowie mit einem niedrigen psychosozialen Funktionsniveau einhergeht. Die BPS zeigt sich oft mit Beginn der frühen Adoleszenz (ab dem 12. Lebensjahr). Neben repetitiver Selbstverletzung und Suizidalität bestehen häufig sowohl Symptome internalisierender (Depression und Angst) als auch externalisierender Störungen (Hyperaktivität und Substanzkonsum). Daher kommt einer differentialdiagnostischen Abklärung und der Diagnosestellung mit dem Ziel der Frühintervention im klinischen Alltag eine besondere Rolle zu. Die Psychotherapie stellt bei der BPS eine äußerst wirksame Behandlungsmethode dar, Belege für die Wirksamkeit von pharmakologischen Intervention fehlen. Der Schlüssel zu einer Verbesserung der Versorgung für Jugendliche mit BPS liegt in einer Generierung von Wissen zu Vorläufersymptomen sowie einer evidenzbasierten, stadienspezifischen Behandlung (frühe Behandlung bereits subklinischer BPS mit Behandlungsintensität abgestuft nach dem Schweregrad). Dieser Übersichtsartikel beleuchtet den aktuellen Stand der Forschung und gibt Empfehlungen für die therapeutische Arbeit in der klinischen Praxis.

Understanding a Mutually Destructive Relationship Between Individuals With Borderline Personality Disorder and Their Favorite Person

OBJECTIVE

Individuals with borderline personality disorder (BPD) commonly have a favorite person (FP), whom they are heavily emotionally attached to and dependent on. This study aims to identify and illustrate the patterns of destructive FP relationships based on actual experiences described by those with BPD.

METHODS

A data mining process was conducted using raw data collected from online communities, such as blogs and social networks. An in-depth review of the information to better understand the natural course of the FP relationship was also conducted.

RESULTS

Individuals with BPD form an intense and insecure attachment toward their FP, from which they enormously suffer. FPs can be their friends, romantic or life partners, or family members. As their feelings go beyond their control, being increasingly obsessed with their FP, they make their FP gradually lose hope in continuing the relationship and want to quit trying to fulfill their needs. The relationship finally ends when the FP stops being responsible for meeting their expectations and eventually drifts away.

CONCLUSION

This study suggests that certain FPs, distinctively named Teddy Bear Person, may behave in a particular manner to increase the likelihood of the FP relationship becoming more destructive. Moreover, the rejection sensitivity model should be discussed to understand their dysfunctional interaction.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Psychoeducational groups for close relatives of patients with borderline personality disorder

Psychoeducational groups for family members of patients with schizophrenia have proven to be effective. Borderline personality disorder (BPD) implies serious impairment in interpersonal relationships. Close relatives of individuals with BPD also show high levels of burden and need support. Psychoeducational groups could help to cope with the interactional problems in a relationship with a person with BPD. A manualised psychoeducational programme of 10 group sessions for close relatives of patients with BPD was tested. Measures administered at pretest and after 10 sessions were: perceived burden (IEQ-EU), knowledge about the disorder (WFB_BPS-A) and quality of life (WHOQOL-BREF). For formative evaluation, a "Group Therapy Session Questionnaire" (participant and therapist version; GTS-A, GTS-T) was used. A total of 33 persons in three groups took part. Pre-post evaluations revealed a significantly lower level of burden and a significantly better knowledge about the disorder after participating in the psychoeducational group. Reduction of burden correlated significantly with the assessment of patients' symptom severity and carers' level of burden at study entry. There was no change in the quality of life. The participants and therapists generally rated the psychoeducational sessions very positively. The highest ratings were found in the sessions about communication skills and coping with crises. Findings indicate that the psychoeducational programme is well accepted and supportive for persons with close relationships to patients with BPD.

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

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

Transitioning to University with a Mental Illness: Experiences of Youth and their Parent

Despite extant research suggesting the important role of family in supporting youth with disabilities (e.g., learning disabilities) making the transition to university, family relational influences on youth with mental illness undergoing this transition remains unclear. Adopting a family resilience perspective, this mixed-methods study aimed to examine (a) how parent-child relationship factors relate to youths’ mental illness symptoms and well-being and (b) youth and parent perspectives on how parents can best support youth in this transition. A total of 225 youth with mental illness (aged 17–23, M = 18.43, SD = 0.91, 87% white) completed questionnaires assessing parent-child relationship satisfaction, depressive and anxiety symptoms, and life satisfaction. For 22 of these youth, a parent (aged 45–57, M = 49.77, SD = 3.57, 100% white) completed questionnaires assessing caregiver burden and reward. Parents (and their child) completed written responses addressing what youth most need from parents during this transition. Parent-child relationship factors were moderately associated with youth mental illness and well-being. Thematic analysis indicated much agreement and some difference between youth and caregivers on the aspects of parental support most valued during this transition. Implications for supporting such youth as they adapt to university are discussed.

Interventions for Family Members and Carers of Patients with Borderline Personality Disorder: A Systematic Review

Carers of patients with borderline personality disorder (BPD) experience high levels of distress. Several studies have been carried out on interventions designed to decrease their burden. However, the evidence from these studies has not been summarized. The objective of this work is to explore the clinical utility of interventions developed for family members of patients with BPD. A systematic review was conducted following the PRISMA guidelines (registration number CRD42018107318), including psychological interventions focused on relatives of patients with BPD. The following databases were used: PsycINFO, PubMed, EBSCOhost, and Web of Science. Two independent researchers reviewed the studies to determine whether the eligibility criteria were met. A total of 2,303 abstracts were identified. After duplicates had been removed, 1,746 studies were screened. Finally, 433 full-text articles were reviewed, yielding 11 studies that satisfied the inclusion criteria. Results show that these interventions with different clinical formats and settings are effective. The quality of the included studies varies, and the empirical support for these programs is still preliminary. The results help to establish a general framework for interventions specifically developed for family members of patients with BPD, but additional efforts should be made to improve the methodological quality of this field of research and more solidly determine the utility of these interventions. Given the paucity of data so far, this information may open up new lines of research to improve the effectiveness of future programs for carers of patients with BPD and help to reduce their burden.

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

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

Factors Associated with Distress in Caregivers of People with Personality Disorders

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

Service users' experiences of receiving a diagnosis of borderline personality disorder: A systematic review

There is ongoing controversy regarding the borderline personality disorder (BPD) diagnosis. Whilst the experiences of people living with BPD have been widely acknowledged, the process of receiving the diagnosis is poorly described. This systematic review aimed to synthesize the existing research exploring people's experiences of receiving a diagnosis of BPD, as well as examining what is considered best practice in the diagnostic delivery process. The findings from 12 qualitative studies were synthesized using thematic analysis, generating two overarching themes: negative and positive experiences of receiving a diagnosis of BPD. These themes were described using the following sub-themes: the communication of diagnosis and meaning made of it, validity around diagnosis and attitudes of others. Results indicate that there is a substantial difference between a well-delivered and poorly delivered diagnosis. The diagnostic delivery process is fundamental to how people understand and interpret the BPD diagnosis. The way in which the BPD diagnosis is shared with people can ultimately shape their views about hope for recovery and their subsequent engagement with services. © 2020 John Wiley & Sons, Ltd.

'I wanted my child dead' - Physical, social, cognitive, emotional and spiritual life stories of Turkish parents who give care to their children with schizophrenia: A qualitative analysis based on empowerment approach

BACKGROUND

Schizophrenia deeply affects both the lives of patients and their families. The fact that schizophrenic patients in Turkey generally maintain their lives with their families may lead to serious problems for families and parents.

AIMS

The main purposes of this research are to determine the physical, social, cognitive, emotional and spiritual lives of parents of children with schizophrenia with the main concepts of the empowerment approach.

METHOD

The research was carried out with the qualitative research method. In-depth interviews were conducted with 30 parents in total, that is, 15 mothers and 15 fathers, through semi-structured interview form. Maxqda 2018 was used for the analysis of the research data.

RESULTS

According to the research result, it is determined that the parents have problems due to physical, social, cognitive, emotional and spiritual disease process; gender perspective and roles; domestic functionality; social environment, social perception; and issues related to services.

CONCLUSION

Considering the parents who are affected by the disease process which is a particularly quite difficult process and who affect the process, to recognize the situations that lead them to gain strength and that make them powerless in personal, interpersonal and political aspects, to activate the existing resources and to create new resources are highly important factors for them to cope with the disease process effectively.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Stigma, Emotion Appraisal, and the Family Environment as Predictors of Carer Burden for Relatives of Individuals Who Meet the Diagnostic Criteria for Borderline Personality Disorder

There is some research exploring carers' experiences within the National Health Service in the UK, but only one has focused on carers of individuals with borderline personality disorder (BPD). Ninety-eight carers completed a questionnaire-based study; 57 carers of individuals who meet the diagnostic criteria for BPD were compared to 41 carers of individuals with other mental health problems. The study aimed to investigate whether perceived stigma, perceived threat of strong emotions, and expressed emotion (EE) within the family environment predicted carer burden. The results showed that carers of those who met the diagnosis for BPD experienced higher levels of carer burden, stigma, EE, emotional over involvement (EOI), criticism (CC), and perceived threat of strong emotions than carers of individuals with other mental health difficulties. EOI, CC, carer group (BPD and mental health), and gender of participant were predictors of carer burden, with EOI explaining the most variance of burden.

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

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

Psychometric properties of the Spanish version of the involvement evaluation questionnaire in caregivers of patients with borderline personality disorders

The involvement evaluation questionnaire (IEQ) was created to evaluate the caregiver's experience of burden and the consequences of providing care to people with psychotic disorders. To date, the IEQ has not been validated with caregivers of people diagnosed with borderline personality disorder (BPD). The main objective of the study was to confirm the psychometric properties and factorial structure of the Spanish version of the IEQ in 151 caregivers of people with BPD, with an average age of 54.52 (SD = 9.91). Two models were tested by means of confirmatory factor analysis, following the original factor structure. The Models 1 and 2 displayed adequate fit, with comparative fit index and Tucker-Lewis index > 0.90 and root-mean-square root of approximation < 0.08; however, Model 2 was more parsimonious. The Cronbach's alphas are adequate, ranging from 0.70 to 0.85. The consequences of providing care to people with BPD had a low or moderate association with the Level of Expressed Emotion scores. IEQ scores of caregivers of people diagnosed with BPD with psychiatric comorbidity did not differ from those of caregivers of people diagnosed with BPD without psychiatric comorbidity. The IEQ has adequate psychometric properties and can be utilized to assess burden in caregivers of people with BPD.

A psychoeducational group intervention for family and friends of youth with borderline personality disorder features: protocol for a randomised controlled trial

BACKGROUND

Caring for a person with borderline personality disorder is associated with poor outcomes including elevated psychological distress and burden. This study will compare the effectiveness of two brief psychoeducational programs for carers of youth presenting for early intervention for borderline personality disorder features. The protocol for this study is presented here.

METHODS

The study is a single-centre parallel group, randomised controlled trial. As a family unit, relatives, partners and friends ('carers') are randomly allocated to one of two treatment arms to receive either an online borderline personality disorder psychoeducation program, or both the online psychoeducation group and a face-to-face group program, Making Sense of Borderline Personality Disorder. Carers are assessed at baseline and follow-up (4 weeks after the intervention). It is expected that participants who received the combined group and online programs will have better outcomes than those who received the online program alone. The primary outcome is carer burden, assessed using the negative appraisal subscales of the Experience of Caregiving Inventory. Secondary outcomes include positive experiences of caregiving, coping, self-rated personality disorder knowledge, psychological distress, expressed emotion and quality of life.

DISCUSSION

This will be the first published evaluation of a psychoeducational intervention for carers of youth with borderline personality disorder features using a randomised controlled trial design. The results have the potential to inform clinicians and carers about the effectiveness of brief interventions designed to support families and friends of young people with borderline personality disorder, and what medium those interventions should utilise.

TRIAL REGISTRATION

Prospectively registered with the Australian New Zealand Clinical Trial Registry ACTRN12616000304437 on 08 March 2016.

Evaluation of a psychoeducational group intervention for family and friends of youth with borderline personality disorder

BACKGROUND

Despite high levels of burden and distress among families with a member who has borderline personality disorder (BPD), only two BPD specific family psychoeducation groups have been empirically evaluated. Neither of these is designed specifically for the family and friends of young people who are presenting early in the course of BPD. This study aimed to evaluate Making Sense of Borderline Personality Disorder (MS-BPD), a three-session, developmentally tailored, manualised psychoeducational group for the family and friends of youth with BPD features.

METHODS

The study employed a pre- and post-intervention, repeated measures design. Twenty-three participants completed self-report measures assessing for family burden, psychological distress, and knowledge about personality disorder. Demographic data were collected for the group participants and for their associated young person with BPD. Paired-samples t-tests were conducted to evaluate the effect of the MS-BPD intervention on participants' burden, distress and personality disorder knowledge.

RESULTS

At the completion of session three (day 15), group participants reported significantly decreased subjective burden and increased personality disorder knowledge. Objective burden and distress remained unchanged.

CONCLUSIONS

Family and friends of young people with BPD features experienced subjective, but not objective, benefit from attending a brief group-based psychoeducation intervention. Longer follow-up is likely to be required to detect behavioural change. The current findings support proceeding to a randomised controlled trial of MS-BPD.

Family Connections versus optimised treatment-as-usual for family members of individuals with borderline personality disorder: non-randomised controlled study

BACKGROUND

Borderline personality disorder (BPD) is challenging for family members who are often required to fulfil multiple roles such as those of advocate, caregiver, coach and guardian. To date, two uncontrolled studies by the treatment developers suggest that Family Connections (FC) is an effective programme to support, educate and teach skills to family members of individuals with BPD. However, such studies have been limited by lack of comparison to other treatment approaches. This study aimed to compare the effectiveness of FC with an optimised treatment-as-usual (OTAU) programme for family members of individuals with BPD. A secondary aim was to introduce a long term follow-up to investigate if positive gains from the intervention would be maintained following programme completion.

METHODS

This study was a non-randomised controlled study, with assessment of outcomes at baseline (pre-intervention) and end of programme (post-intervention) for both FC and OTAU groups, and at follow-up (3 months post-intervention; 12 or 19 months post-intervention) for the FC group. Eighty family members participated in the FC (n = 51) and the OTAU (n = 29) programmes. Outcome measures included burden, grief, depression and mastery. Linear mixed-effects models were used to assess baseline differences in the outcome measures by gender, age group and type of relationship to the individual with BPD. Linear mixed-effects models were also used to estimate the treatment effect (FC versus OTAU) utilising all available data from baseline and end of programme.

RESULTS

The FC group showed changes indicating significant improvement with respect to all four outcome measures (p < 0.001). The OTAU group showed changes in the same direction as the intervention group but none of the changes were statistically significant. The intervention effect was statistically significant for total burden (including both subscales; p = .02 for subjective burden and p = .048 for objective burden) and grief (p = 0.013). Improvements were maintained at follow-up for FC participants.

CONCLUSIONS

The findings of the current study indicate that FC results in statistically significant improvements on key measures while OTAU does not yield comparable changes. Lack of significant change on all measures for OTAU suggests that a three session psycho-education programme is of limited benefit. Further research is warranted on programme components and long-term supports for family members.

When Significant Others Suffer: German Validation of the Burden Assessment Scale (BAS)

There is a need of an economical, reliable, and valid instrument in the German-speaking countries to measure the burden of relatives who care for mentally ill persons. We translated the Burden Assessment Scale (BAS) and conducted a study investigating factor structure, psychometric quality and predictive validity. We used confirmative factor analyses (CFA, maximum-likelihood method) to examine the dimensionality of the German BAS in a sample of 215 relatives (72% women; M = 32 years, SD = 14, range: 18 to 77; 39% employed) of mentally ill persons (50% (ex-)partner or (best) friend; M = 32 years, SD = 13, range 8 to 64; main complaints were depression and/or anxiety). Cronbach’s α determined the internal consistency. We examined predictive validity using regression analyses including the BAS and validated scales of social systems functioning (Experience In Social Systems Questionnaire, EXIS.pers, EXIS.org) and psychopathology (Brief Symptom Inventory, BSI). Variables that might have influenced the dependent variables (e.g. age, gender, education, employment and civil status) were controlled by their introduction in the first step, and the BAS in the second step of the regression analyses. A model with four correlated factors (Disrupted Activities, Personal Distress, Time Perspective, Guilt) showed the best fit. With respect to the number of items included, the internal consistency was very good. The modified German BAS predicted relatives’ social systems functioning and psychopathology. The economical design makes the 19-item BAS promising for practice-oriented research, and for studies under time constraints. Strength, limitations and future directions are discussed.

Supporting a person with personality disorder: a study of carer burden and well-being

Personality disorders are characterized by impaired interpersonal functioning. There are few studies and little data available using validated questionnaires on the impact of caring for a person with personality disorder. The 287 carers included in this study were administered the McLean Screening Instrument for Borderline Personality Disorder-Carer Version, Burden Assessment Scale, Grief Scale, Difficulties in Emotion Regulation Scale, Mental Health Inventory-5, and a qualitative question. Scores were compared to those of published comparison groups. Burden and grief were significantly higher than that reported by carers of persons with other serious mental illnesses. Carers endorsed symptoms consistent with mood, anxiety, and posttraumatic stress disorders. A qualitative concept map highlighted the impact of caregiving on the interpersonal environment. Carers of persons with personality disorder report grieving their change in life and impairment in well-being. Carers are burdened, and appear more so than carers of persons with other serious mental illnesses. The results highlight the need for interventions to support carers.

Family skills training in dialectical behaviour therapy: the experience of the significant others

AIM

The aim was to describe significant others' experiences of dialectical behaviour therapy-family skills training (DBT-FST), their life situation before and after DBT-FST, and measurement of their levels of anxiety and depressive symptoms.

METHODS

The study had a descriptive mixed method design. Data were collected with free text questionnaires (n=44), group interviews (n=53) and the HAD scale (n=52) and analysed by qualitative content analysis and descriptive and inferential statistics.

RESULTS

The results show that life before DBT-FST was a struggle. DBT-FST gave hope for the future and provided strategies, helpful in daily life. For the subgroup without symptoms of anxiety and depression before DBT-FST, anxiety increased significantly. For the subgroup with symptoms of anxiety and depression the symptoms decreased significantly. This indicates, despite increased anxiety for one group, that DBT-FST is a beneficial intervention and most beneficial for those with the highest anxiety- and depressive symptoms.

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

BACKGROUND

A major feature of personality disorders is significant impairment in interpersonal functioning, which may create challenges in close relationships. This article aims to systematically review the experience of carers of persons with personality disorders.

METHOD

The PRISMA systematic review method was followed, and empirical studies written in English, published between 1996 and 2011, and cited in major electronic databases were searched. Studies meeting the following selection criteria were included: (1) carers or families of persons with personality disorders; (2) intervention involving the carers or families; (3) burden or related construct used. Studies were required to meet either criteria 1 and 3 or criteria 2 and 3. Reference lists were scanned, and experts were consulted for further studies.

RESULTS

Six studies met inclusion criteria, representing data on 465 carers. Five of the six studies focused on carers of persons with borderline personality disorder. The findings indicated that carers experience elevated objective and subjective burden, grief, impaired empowerment, and mental health problems, including depression and anxiety. Scores on objective and subjective burden were half a standard deviation above the mean compared to carers of inpatients with other serious mental illnesses.

CONCLUSIONS

This study is the first to report data on a large, aggregated sample of carers of persons with personality disorders. Significant gaps in the literature remain, and it is recommended that future research focus on the burden and support needs of carers of persons across different personality disorders, that attention be paid to the gender balance of patients, and that data be reported in a way to allow meta-analysis.

"Mad or bad?": burden on caregivers of patients with personality disorders

The burden on caregivers of patients with personality disorders is often greatly underestimated or completely disregarded. Possibilities for caregiver support have rarely been assessed. Thirty interviews were conducted with caregivers of such patients to assess illness-related burden. Responses were analyzed with a mixed method of qualitative and quantitative analysis in a sequential design. Patient and caregiver data, including sociodemographic and disease-related variables, were evaluated with regression analysis and regression trees. Caregiver statements (n = 404) were summarized into 44 global statements. The most frequent global statements were worries about the burden on other family members (70.0%), poor cooperation with clinical centers and other institutions (60.0%), financial burden (56.7%), worry about the patient's future (53.3%), and dissatisfaction with the patient's treatment and rehabilitation (53.3%). Linear regression and regression tree analysis identified predictors for more burdened caregivers. Caregivers of patients with personality disorders experience a variety of burdens, some disorder specific. Yet these caregivers often receive little attention or support.

Factors associated with caregiver psychological distress in chronic schizophrenia

BACKGROUND AND AIMS

Caregivers of patients with schizophrenia experience increased levels of psychological distress. This study investigated the impact of caring for patients with chronic schizophrenia on the mental health status of the caregivers and described the relationship between various socio-demographic and clinical characteristics and caregiving psychological distress.

METHODS

The study was carried out at the Psychiatric Hospital of Athens. The Symptom Check List Revised (SCL-90-R) was administered to 87 caregivers of chronic schizophrenia patients and 90 healthy controls. The Positive and Negative Syndrome Scale (PANSS) was administered to schizophrenia patients in order to assess illness severity.

RESULTS

The group of caregivers scored higher on the majority of symptom dimensions of the SCL-90-R than the control group. Clinical features of schizophrenia, i.e. duration of illness and PANSS positive and negative symptoms significantly predicted caregiving psychological distress. Caregivers' and patients' socio-demographic characteristics were not associated with caregivers' distress, with the exception of caregivers' sex: female caregivers experienced significantly higher levels of psychological distress than males.

CONCLUSIONS

The study suggests that clinical features of schizophrenia influence distress levels in caregivers of patients with chronic schizophrenia. The stronger predictors of distress appear to be female caregiver's gender, duration of illness as well as positive and negative symptomatology.

Wie psychisch belastet fühlen sich Jugendliche mit selbstverletzendem Verhalten?

In den letzten Jahren wurden zahlreiche Prävalenzstudien zum selbstverletzenden Verhalten bei Heranwachsenden in unterschiedlichen Ländern veröffentlicht. Aus der Schweiz liegen jedoch keine belastbaren Zahlen vor. Kritisch ist bei der Vielzahl der Studien anzumerken, dass sich diese oft auf ein „einfaches“ Feststellen der Prävalenz beschränken und kaum Hinweise für eine effektive Frühintervention geben. Im Rahmen einer epidemiologischen Fragebogenuntersuchung im Kanton Basel-Stadt wurden 447 Schüler (M = 14.95 Jahre, SD = 0.74, 52 % männlich) untersucht. Neben der Erfassung der Form und Art der Selbstverletzung wurde auch die psychische Belastung der Schüler erfasst. Es sollte überprüft werden, wie viele Selbstverletzer sich im Screening für psychische Störungen (SPS-J) als psychisch belastet beschreiben. 61 (13.6 %) Jugendliche gaben an, sich bereits mindestens einmal selbstverletzt zu haben. 29 (6.4 %) haben sich im letzten Monat selbst verletzt, 4 davon häufiger als viermal. Die Ergebnisse bestätigten die hohen Prävalenzraten für selbstverletzendes Verhalten. Interessant ist, dass Selbstverletzer im Schnitt zwar wesentlich höhere Werte im SPS-J erzielten, sich aber bei weitem nicht alle als psychisch auffällig beschrieben (18 von 61 selbstverletzenden Jugendlichen erzielten unauffällige Werte). Für eine effektivere Identifikation sollten daher Fragen zum selbstverletzenden Verhalten in psychopathologische Screeningfragebögen integriert werden, um diese Symptomatik adäquat abbilden zu können. Die Ergebnisse und die hohen Prävalenzen legen nahe, dass verschiedene Subgruppen von Selbstverletzern existieren, die passgenaue Hilfen für ihre Symptomatik benötigen.

A life tiptoeing: being a significant other to persons with borderline personality disorder

AIM

The aim of this study was to describe significant others' experiences of living close to a person with borderline personality disorder and their experience of encounter with psychiatric care.

METHODS

Data were collected by free-text questionnaires and group interviews and were analyzed by qualitative content analysis.

RESULTS AND CONCLUSION

The results revealed four categories: a life tiptoeing; powerlessness, guilt, and lifelong grief; feeling left out and abandoned; and lost trust. The first two categories describe the experience of living close to a person with BPD, and the last two categories describe encounter with psychiatric care.

Parental burden associated with borderline personality disorder in female offspring

To identify aspects of parental burden associated with borderline personality disorder (BPD), an anonymous internet survey linked to BPD support websites was developed for parents to complete on their BPD offspring and unaffected siblings. The questions cover aspects of the child's life from pregnancy through young adulthood, and query about the impact of the child's BPD on six domains of the parent's life, including physical and emotional health, marriage, job, standard of living, social life, and career trajectory. Additionally, financial burden was assessed with questions pertaining to insurance and out-of pocket costs associated with the BPD disorder. BPD offspring were identified by meeting diagnostic criteria embedded within the survey and having been given a diagnosis of BPD by a professional at some point in their life. We report on 233 female offspring meeting strict criteria for BPD. Parents of daughters with BPD endorsed varying levels of impact on the six domains comprising burden with the largest impact on emotional health which was impacted in over 88% of the respondents. Over 50% of parents endorsed four or greater of the six burden items. Particular aspects of the offspring's BPD symptom profile correlated with intensity of parental burden included including problems in adolescence with acting out behavior (p < .000), property destruction (.003), delusional symptoms (.007), and hallucinatory symptoms (.008). A subgroup of respondents provided data on specific financial expenses. The average and median out-of-pocket expense was $60,087, and $10,000. Insurance costs totaled an average of $108,251 with a mean of $20,000. The average cost per year after diagnosis was $14,606 out-of-pocket and $45,573 billed to insurance. The median cost per year after diagnosis was $3,667 out-of-pocket, and $12,500 billed to insurance. After adjusting for household income, a female proband who had been raped incurred roughly $40,000 more in BPD-related costs, while a diagnosis of conduct disorder led to about $50,000 in additional costs. Parents of female offspring with BPD experience burden in multiple domains of their life and many have incurred substantial financial expense. Increasing awareness of co-morbid conditions in the BPD proband that significantly increase parental burden may be indicators for the provision of increased family support.

Borderline personality disorder and couple dysfunctions

The central characteristics of borderline personality disorder (BPD) are bound to be associated with the development and maintenance of couple dysfunction. Although seven of the nine diagnostic criteria of BPD in the DSM-IV-TR refer directly to interpersonal functioning, very few empiric studies have addressed the exact nature of the relationship between BPD and couple functioning. This article examines recent studies describing couple outcomes--union formation and durability, partner choice, relationship satisfaction, intimate violence, attachment security, and sexual functioning--associated with BPD. The relationship between couple dynamics (including partner personality characteristics) and BPD symptomatology is probably bidirectional or reciprocal. The review concludes with an exploration of diagnostic and treatment implications.