Sleep in Young People With Features of Borderline Personality Disorder: A Scoping Review

A theoretical perspective on the role of sleep in borderline personality disorder: From causative factor to treatment target

Sleep plays a crucial role in emotion regulation. Disturbed sleep is therefore increasingly seen as a potential causal factor for the development and maintenance of affective psychiatric disorders. This may hold especially for borderline personality disorder (BPD), a core emotion dysregulation disorder. Although BPD is strongly associated with sleep disturbances such as insomnia, nightmares and circadian dysrhythmia, research into the role of sleep in BPD remains sparse. In this narrative review, we outline a putative vicious cycle of reciprocal exacerbation of disturbed sleep and emotion dysregulation in BPD, that sheds light on BPD pathophysiology and opens up new avenues for sleep-based treatments. We discuss emotional dysregulation as the base of BPD as well as the observed sleep disturbances in BPD. Based on existing theories of sleep's role in emotion regulation and memory, we then propose several behavioral and neurobiological pathways by which inherent sleep disturbances in BPD may hamper adaptive overnight emotional processing. This likely results in sustained emotional states and associated sleep-disruptive behavior, which in turn negatively impact sleep. We end by proposing a sleep-based research agenda for BPD to further detail the causative role of disturbed sleep in BPD and test the effectiveness of novel sleep-based treatment strategies.

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.

Imagery rehearsal therapy for the treatment of nightmares in individuals with borderline personality disorder - A pilot study

Insomnia and nightmares are present in up to 45 % of individuals with borderline personality disorder (BPD) and can contribute to challenges with emotion regulation, low sleep quality, dream anxiety, increased arousal and self-control. Despite their prevalence, nightmares are usually not addressed in classical BPD treatment. Imagery rehearsal therapy (IRT) is considered first in line treatment for nightmares, however, there are no studies to date that investigate its effects in individuals with BPD. Here we investigated a) whether IRT can be used to treat nightmares in individuals with BPD and b) whether there is an additional benefit of the intervention on symptoms associated with BPD. In a between-subjects design, 22 individuals with BPD completed eight sessions of group-IRT as an add-on to their inpatient treatment and were compared to 22 gender and age matched control participants regarding nightmares, trauma, depression and anxiety symptoms. Nightmare symptoms improved significantly during the intervention as indicated by subjective ratings. Moreover, participants in the IRT group showed a more pronounced decrease in intrusions, hyperarousal and anxiety compared to the control group. This pilot study gives a first glimpse into the feasibility and benefits of imagery rehearsal therapy in individuals with BPD. Our findings suggest that IRT may not only help treat nightmare symptoms but also reduce anxiety and trauma symptoms in BPD. Future studies should include randomized controlled trials of IRT in individuals with BPD with larger sample sizes and polysomnography in both groups.

Chronotype, sleep quality, impulsivity and aggression in patients with borderline personality disorder and healthy controls

Impulsivity, aggression, and suicide are the major clinical symptoms of borderline personality disorder (BPD). Although previous studies indicated poor sleep quality and its relationship with clinical symptoms in patients with BPD, chronotype, an important sleep parameter, was not investigated in these patients. This study aimed to analyze chronotype and its relationship with clinical symptoms in patients with BPD. Participants in this study consisted of 68 BPD patients and 65 healthy controls. Subjective sleep characteristics, impulsivity, aggression, suicide probability, and chronotype were assessed using the Pittsburgh Sleep Quality Index (PSQI), Barratt Impulsivity Scale, Buss-Perry Aggression Scale (BPAQ), Suicide Probability Scale, and Morningness - Eveningness Questionnaire, respectively. PSQI total and subscale scores subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, and daytime drowsiness were significantly higher in the BPD group (p < 0.001). There was a positive correlation between the PSQI total score and the BPAQ total score (r = 0.268, p = 0.027). The rate of evening type was significantly higher in the control group (p = 0.004). Suicide attempts and the subscale of suicide probability hopelessness, suicidal ideation, and negative self-evaluation scores were significantly higher in evening type BPD patients. (p = 0.017, p = 0.009, p = 0.001, p = 0.047). Sleep quality is associated with aggression, and the eveningness chronotype is associated with suicide. It may be useful to focus on sleep problems in treating BPD patients.

Potential mechanisms underlying sleep disturbance in young people with borderline personality disorder features: an exploratory study

BACKGROUND

Sleep disturbance is common among young people (15-25 years) with features of borderline personality disorder (BPD). However, the mechanisms underlying sleep disturbance in BPD remain unknown. Understanding these underlying processes is essential to guide the development of sleep-improvement interventions and to optimise their efficacy through identifying beneficial treatment targets. This exploratory study aimed to investigate potential underlying mechanisms to inform future hypotheses, research development, and provide insight into potential treatment targets to improve sleep in young people with BPD. This study explored the indirect roles of emotion regulation difficulties, depression, anxiety and stress in the relationship between BPD features and sleep disturbance in young people.

METHODS

Sleep was measured subjectively (self-report questionnaires) and objectively (10 days wrist actigraphy) in 40 young people with BPD features and 38 healthy young people. Participants also completed the Difficulties in Emotion Regulation Scale and the Depression, Anxiety and Stress Scale.

RESULTS

Mediation analyses revealed that impulse control difficulties, limited emotion regulation strategies and anxiety indirectly affected the relationship between group (BPD vs. healthy) and subjective sleep disturbance in young people. Lack of emotional awareness and anxiety contributed to associations between group and objectively longer time in bed and bedtime variability, respectively.

CONCLUSIONS

These preliminary findings suggest that targeting emotional dysregulation (impulse control, strategies, emotional awareness) and anxiety might be beneficial for improving sleep in this population.

Subjective and objective sleep in young people with borderline personality disorder features

Characterising sleep in young people (aged 15-25 years) with borderline personality disorder (BPD) features is crucial given the association between BPD features and sleep disturbance, negative consequences of poor sleep, and normative developmental sleep changes that occur in this age group. The present study aimed to characterise the sleep profile of young people with BPD to determine whether this profile is non-normative and specific to BPD. Participants were 96 young people (40 with BPD features, 38 healthy individuals, and 18 young people seeking help for mental health difficulties without BPD). Sleep was measured subjectively (self-report questionnaires) and objectively (10 days of actigraphy). Young people with BPD features reported poorer subjective sleep quality, greater insomnia symptoms and later chronotype than same-age healthy and clinical comparison groups. Young people with BPD features also displayed irregular sleep timing, later rise times, greater time in bed and longer sleep durations than healthy young people. Those with BPD features had superior sleep quality (greater sleep efficiency, less wake after sleep onset) and longer sleep durations than the clinical comparison group. Sleep profiles were similar across young people with BPD features with and without co-occurring depression. Overall, the findings revealed a subjective-objective sleep discrepancy and suggest that sleep-improvement interventions might be beneficial to improve subjective sleep in young people with BPD features.