Symptomatic Disorders in Adults and Adolescents With Borderline Personality Disorder

"When Standard Treatments Are Not Enough" - Showcasing Schema Therapy for the Treatment of Anorexia Nervosa and Borderline Personality Disorder

Whilst standard cognitive and behavioural treatments lead to clinical improvement for approximately half of the people with eating disorders, preliminary evidence indicates that complex comorbidity, including personality difficulties, insecure attachment patterns and Posttraumatic stress disorder, may hinder treatment engagement and outcomes. Such comorbidities tend to be associated with increased emotional dysregulation, rigidity of beliefs, and dissociation. Schema Therapy is a transdiagnostic approach that interweaves the treatment of current eating disorder symptomatology and comorbid presentations through addressing early maladaptive schemas linked to unmet attachment needs and traumas. The goals are to promote integration, coherence, and resilience of self, whilst reducing reliance on the eating disorder as a means of self-regulation and substitute identity. In this case example, we follow a 27-year-old woman with an eating disorder (Anorexia Nervosa) and comorbid personality disorder (Borderline Personality Disorder), illustrating how Schema Therapy can effectively treat both conditions by healing the underlying schemas. This case study highlights the ways in which the therapeutic 'limited reparenting' approach is used to interweave cognitive, experiential, and behavioural techniques that address clients' chronically unmet emotional needs, and the importance of enhancing the individual's Healthy Adult mode to facilitate self-regulation and the client's capacity to effectively manage their own psychological needs in the future.

Pharmacological interventions for co-occurring psychopathology in people with borderline personality disorder: secondary analysis of the Cochrane systematic review with meta-analyses

BACKGROUND

Medications are commonly used to treat co-occurring psychopathology in persons with borderline personality disorder (BPD).

AIMS

To systematically review and integrate the evidence of medications for treatment of co-occurring psychopathology in people with BPD, and explore the role of comorbidities.

METHOD

Building on the current Cochrane review of medications in BPD, an update literature search was done in March 2024. We followed the methods of this Cochrane review, but scrutinised all identified placebo-controlled trials post hoc for reporting of non BPD-specific ('co-occurring') psychopathology, and explored treatment effects in subgroups of samples with and without defined co-occurring disorders. GRADE ratings were done to assess the evidence certainty.

RESULTS

Twenty-two trials were available for quantitative analyses. For antipsychotics, we found very-low-certainty evidence (VLCE) of an effect on depressive symptoms (standardised mean difference (SMD) -0.22, P = 0.04), and low-certainty evidence (LCE) of an effect on psychotic-dissociative symptoms (SMD -0.28, P = 0.007). There was evidence of effects of anticonvulsants on depressive (SMD -0.44, P = 0.02; LCE) and anxious symptoms (SMD -1.11, P < 0.00001; VLCE). For antidepressants, no significant findings were observed (VLCE). Exploratory subgroup analyses indicated a greater effect of antipsychotics in samples including participants with co-occurring substance use disorders on psychotic-dissociative symptoms (P = 0.001).

CONCLUSIONS

Our findings, based on VLCE and LCE only, do not support the use of pharmacological interventions in people with BPD to target co-occurring psychopathology. Overall, the current evidence does not support differential treatment effects in persons with versus without defined comorbidities. Medications should be used cautiously to target co-occurring psychopathology.

General Psychiatric Management for Adolescents With Borderline Personality Disorder and Eating Disorders

Borderline personality disorder and eating disorders frequently co-occur among youths. These disorders emerge in adolescence, during the critical developmental period of building an independent sense of self and the capacity to relate to one's community. Because of core differences in the development and psychopathology of borderline personality disorder and eating disorders, adjustments are required when treating these disorders when they co-occur. Few established treatment approaches can address these disorders simultaneously. Evidence-based psychotherapies for borderline personality disorder, such as dialectical behavior therapy and mentalization-based treatment, have been adapted to accommodate the shared vulnerabilities and features of the two disorders. However, these approaches are specialized, intensive, and lengthy and are therefore poorly suited to implementation in general psychiatric or primary health care, where most frontline mental health care is provided. Generalist approaches can fill this public health gap, guiding nonspecialists in structuring informed clinical management for these impairing and sometimes fatal disorders. In this overview, the authors describe the adjustment of good (or general) psychiatric management (GPM) for adolescents with borderline personality disorder to incorporate the prevailing best practices for eating disorder treatment. The adjusted treatment relies on interventions most clinicians already use (diagnostic disclosure, psychoeducation, focusing on life outside treatment, managing patients' self-destructive behaviors, and conservative psychopharmacology with active management of comorbid conditions). Limitations of the adjusted treatment, as well as guidelines for referring patients to specialized and general medical treatments and for returning them to primary generalist psychiatric care, are discussed.

Physical Activity, Sleep and Eating in Young People With Borderline Personality Disorder

Previous research suggests a connection between borderline personality disorder (BPD) and somatic comorbidities, underscoring the importance of lifestyle and health-related behaviour (LHRB) in the emergence of BPD. We investigated LHRBs-physical activity, sleeping and overeating-among young people at different BPD stages compared to a matched community sample. Furthermore, we explored whether problematic LHRBs intensify in later BPD stages. Participants included 55 young people exhibiting BPD features from a specialized mental health care institution, matched with a community control group based on age, self-reported and education. A MANOVA assessed differences in physical activity, sleep disturbance, sleep-related impairment and emotional overeating between the BPD and control group. A second MANOVA explored these behaviours across BPD stages within the clinical group. Results revealed significantly higher levels of sleep-related problems among young people with BPD features compared to controls. However, no significant differences were found in physical activity or emotional overeating. Furthermore, problematic LHRBs did not show a significant association with BPD stage. These findings contribute to a better understanding of the relationship between BPD and problematic LHRBs, emphasizing the importance of early intervention targeting sleep-related problems in young people with BPD, alongside addressing other aspects of BPD and associated LHRBs.

The course of borderline personality disorder from adolescence to early adulthood: A 5-year follow-up study

BACKGROUND

Studies of the medium- to long-term clinical and functional course for treatment-seeking adolescents with borderline personality disorder (BPD) are lacking. This study aims to outline the psychopathological and functional status of participants, five years after being diagnosed with BPD during adolescence.

METHODS

Participants were originally enrolled in a randomized clinical trial that compared mentalization-based group treatment with treatment as usual for adolescents with BPD. Semi-structured interview assessments at five-year follow-up included the Schedules for Clinical Assessment in Neuropsychiatry and the Structured Clinical Interview for DSM-5 Personality Disorders. Attention deficit hyperactivity disorder (ADHD), alcohol, substance and tobacco use, posttraumatic stress disorder (PTSD), complex PTSD, and general functioning were assessed using self-report instruments.

RESULTS

97 of the original sample of 111 participants (87%) participated. They were aged 19-23 years. The most prevalent disorders were ADHD (59%), any personality disorder (47%) of which half continued to meet criteria for BPD (24%), anxiety disorders (37%), depressive disorders (32%), PTSD or complex PTSD (20%), schizophrenia (16%), and eating disorders (13%). Only 16% did not meet criteria for any mental disorder. Approximately half of the sample were in psychological and/or psychopharmacological treatment at the time of follow-up. Their general functioning remained impaired, with 36% not engaged in education, employment or training (NEET), which is nearly four times the rate of NEET in the same age group in the general population.

CONCLUSIONS

Although stability of the categorical BPD diagnosis is modest, adolescents meeting diagnostic criteria for BPD show a broad range of poor outcomes at five-year follow-up. BPD appears to be a marker of general maladjustment during adolescence and a harbinger of severe problems during the transition to young adulthood. Early intervention programs for adolescents diagnosed with BPD should focus upon a broad range of functional and psychopathological outcomes, especially social and vocational support, rather than the narrow BPD diagnosis.

Temperament, but not childhood trauma, distinguishes borderline personality disorder from bipolar disorder and ADHD

BACKGROUND

The aim of this study was to investigate if temperament and experience of childhood trauma differed between young psychiatric patients with borderline personality disorder (BPD), bipolar disorder (BD) and attention-deficit/hyperactivity disorder (ADHD).

METHODS

Diagnoses were based on the Structured Clinical Interview for DSM Axis I and Axis II. Temperament was assessed by the Temperament and Character Inventory (TCI) and childhood trauma by the Early Trauma Inventory-Self Report-Short Form (ETI-SR-SF). Temperament and childhood trauma were compared between the BPD group (n = 19) and the non-BPD group (BD/ADHD) (n = 95). Interactions between trauma and temperament were evaluated using a logistic regression model with a BPD diagnosis as outcome variable.

RESULTS

Participants in the BPD group showed higher novelty seeking (NS) and harm avoidance (HA). Traumatic experiences in childhood were common but the BPD group differed very little from the others in this regard. The interaction between temperament and trauma had low explanatory power for a BPD diagnosis in this sample.

CONCLUSION

Temperament might be useful to distinguish BPD when symptoms of impulsivity and affective instability are evaluated in psychiatric patients. The results from the interaction analysis support the multifactorial background to BPD.

Mental health disorders, functioning and health-related quality of life among extensively hospitalized patients due to severe self-harm - results from the Extreme Challenges project

Background

Severe self-harm leading to extensive hospitalization generates extreme challenges for patients, families, and health services. Controversies regarding diagnoses and health care often follow. Most evidence-based treatments targeting self-harm are designed for borderline personality disorder (BPD). However, current knowledge about mental health status among individuals with severe self-harm is limited.

Objectives

To investigate psychopathology among patients extensively hospitalized due to severe or frequent self-harming behaviors.

Method

A cross sectional study (period 2019-2021) targeting psychiatric inpatients (>18 years) with frequent (>5) or long (>4 weeks) admissions last year due to self-harm. The target sample (N = 42, from 12 hospitals across all Norwegian health regions) was compared to individuals admitted to outpatient personality disorder (PD) treatment within specialist mental health services in the same period (N = 389). Clinicians performed interviews on self-harm and psychopathology, supplemented by self-report.

Results

The target sample were young adults, mainly female, with considerable hospitalization and self-harming behaviors, both significantly more extensive than the comparison group. The majority in both groups reported self-harm onset <18 years. The target sample reported increasing severity of self-harm acts and suicidal intention over time. Both samples had high levels of childhood trauma, impaired personality functioning, and a majority fulfilled criteria for PD. In the target sample, comorbid depression, PTSD, anxiety disorders, and substance use occurred more frequently and in 50%, psychosis/dissociative disorder/autism spectrum disorder/ADHD was reported (outpatient comparison sample: 9%). 35% in the target sample screened over cut-off for possible intellectual disability. The target sample reported poor psychosocial functioning and health-related quality of life - greater impairment than the outpatient comparison sample.

Conclusion

The study reveals that severe self-harm inpatients have complex psychopathology and highlights the importance of individualized and thorough assessment among patients with severe and/or repetitive self-harm.

Dissociative experiences of adolescents with borderline personality disorder: description and prediction

AIMS

The first purpose of this study was to assess the severity of dissociative experiences reported by adolescent inpatients with borderline personality disorder (BPD). The second purpose was to compare the severity of their dissociative symptoms to those reported by a sample of adult inpatients with BPD. The third purpose of this study was to assess a range of clinically meaningful predictors of the severity of dissociation in adolescents and adults with BPD.

METHODS

The Dissociative Experiences Scale (DES) was administered to a total of 89 hospitalized girls and boys aged 13-17 with BPD and 290 adult inpatients with BPD. Predictors of the severity of dissociation in adolescents and adults with BPD were assessed using the Revised Childhood Experiences Questionnaire (a semi-structured interview), the NEO, and the SCID I.

RESULTS

Borderline adolescents and adults had non-significant differences on their overall DES scores and subscale scores. They also had a non-significant distribution of low, moderate, and high scores. In terms of multivariate predictors, neither temperament nor childhood adversity was a significant predictor of the severity of dissociative symptoms in adolescents. However, co-occurring eating disorders were found in multivariate analyses to be the only bivariate predictor to significantly predict this outcome. In adults with BPD, however, both the severity of childhood sexual abuse and co-occurring PTSD were significantly related to the severity of dissociative symptoms in multivariate analyses.

CONCLUSIONS

Taken together, the results of this study suggest that the severity of dissociation is not significantly different in adolescents and adults with BPD. However, the etiological factors differ substantially.

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.

Comorbidity and heterogeneity: Two challenges for personality pathology research

We critique the general state of methodological rigor in contemporary personality pathology research, focusing on challenges in study design, assessment, and data analysis resulting from two pervasive problems: comorbidity and heterogeneity. To inform our understanding of this literature, we examined every article published in the two main specialty journals for personality pathology research-Personality Disorders: Theory, Research, and Treatment and the Journal of Personality Disorders-in the 18-month period from January 2020 to June 2021 (a total of 23 issues and 197 articles). Our review of this database indicated that only three forms of personality pathology have generated substantial attention in the recent literature: borderline personality disorder (featured in 93 articles), psychopathy/antisocial personality disorder (39 articles), and narcissism/narcissistic personality disorder (28 articles), so we highlight them in our review. We discuss comorbidity-related problems that arise from group-based designs and recommend instead that researchers assess multiple forms of psychopathology as continuous dimensions. We offer separate recommendations for addressing heterogeneity in diagnosis- versus trait-based studies. For the former, we recommend that researchers (a) use measures that permit criterion-level analyses and (b) routinely report criterion-level results. For the latter, we emphasize the importance of examining specific traits when measures are known to be highly heterogeneous/multidimensional. Finally, we encourage researchers to work toward a truly comprehensive trait dimensional model of personality pathology. We suggest that this might include expanding the current alternative model of personality disorders to include additional content related to borderline features, psychopathy, and narcissism. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Inter-Rater Reliability of the Structured Interview of DSM-IV Personality (SIDP-IV) in an Adolescent Outpatient Population

Personality disorders (PDs) are a class of mental disorders which are associated with subjective distress, decreased quality of life and broad functional impairment. The presence of one or several PDs may also complicate the course and treatment of symptom disorders such as anxiety and depression. Accurate and reliable means of diagnosing personality disorders are thus crucial to ensuring efficient treatment planning and resource allocation, a fact which is widely acknowledged within the adult mental health field. In adolescents, on the other hand, the consensus view has been that the rapid and discontinuous processes of normal personality development render the construct of PD in adolescents clinically unhelpful and conceptually dubious. However, recent research has established the reliability and validity of the construct, heralding an increased interest in the field, with important conceptual and clinical implications. The present article presents reliability data for the Structured Interview of DSM-IV Personality (SIDP-IV) in an adolescent outpatient population. For this study, 25 interviews conducted by experienced clinicians were blindly re-scored based on sound recordings, which allowed for the calculation of intra-class correlation metrics. The intra-class correlation coefficient for categorical diagnosis of specific personality disorders was found to be 0.876 (95% CI 0.718-0.945); Cohen's kappa for presence/absence of personality diagnosis was found to be 0.896. The present study found excellent intra-rater reliability for the sample, which suggests that the SIDP-IV is a suitable instrument for assessing personality pathology in adolescent populations.