Preliminary evaluation of psychometric properties of the Finnish Borderline Personality Disorder Severity Index: Oulu-BPD-Study

The hidden borderline patient: patients with borderline personality disorder who do not engage in recurrent suicidal or self-injurious behavior

BACKGROUND

Despite the significant psychosocial morbidity associated with borderline personality disorder (BPD), its underrecognition is a significant clinical problem. BPD is likely underdiagnosed, in part, because patients with BPD usually present with chief complaints associated with mood, anxiety, and substance use disorders. When patients with BPD do not exhibit self-harm behavior, we suspect that BPD is less likely to recognized. An important question is whether the absence of this criterion, which might attenuate the likelihood of recognizing and diagnosing the disorder, identifies a subgroup of patients with BPD who are 'less borderline' than patients with BPD who do not manifest this criterion.

METHODS

Psychiatric outpatients were evaluated with a semi-structured diagnostic interview for DSM-IV BPD, 390 of whom were diagnosed with BPD. We compared the demographic and clinical characteristics of patients with BPD who do and do not engage in repeated suicidal and self-harm behavior.

RESULTS

Approximately half of the patients with BPD did not meet the suicidality/self-injury diagnostic criterion for the disorder. There were no differences between the patients who did and did not meet this criterion in occupational impairment, likelihood of receiving disability payments, impairment in social functioning, level of educational achievement, comorbid psychiatric disorders, history of childhood trauma, or severity of depression, anxiety, or anger upon presentation for treatment.

CONCLUSIONS

Repeated self-injurious and suicidal behavior is not synonymous with BPD. It is critical for clinicians to be aware that the absence of repeated self-injury and suicide threats/gestures or attempts does not rule out the diagnosis of BPD.

Eating disorder behaviors as a form of non-suicidal self-injury

Nonsuicidal Self-Injury (NSSI), the purposeful harming of one's body tissue without suicidal intent. NSSI frequently co-occurs with other self-destructive forms of psychopathology, such as eating disorders (ED); however, it remains unclear if ED behaviors are used as a form of NSSI. This exploratory study examined the occurrence of Self-Injurious Disordered Eating Symptoms (SIDES), as well as differences in clinical correlates and treatment outcomes between NSSI patients with and without SIDES. Participants included 1,327 patients admitted for partial hospitalization or intensive outpatient treatment for NSSI (87.4% female; 75.3% Non-Hispanic White). Data were collected at admission and discharge as part of routine clinical outcome assessment. Results indicate that 29.5% of the sample engaged in SIDES, while most were not diagnosed with an ED. Patients that engaged in SIDES reported greater clinical severity at baseline, including greater general psychopathology, lower quality of life, and worse functional impairment, as well as more clinically severe NSSI (e.g., greater number of methods, higher urge to self-injure, greater intrapersonal functions). No differences in treatment outcomes were found. These findings suggest that some NSSI patients perceive ED behaviors as a form of NSSI and that SIDES may be a marker for a more severe clinical presentation.

Self-invalidation in borderline personality disorder: A content analysis of patients' verbalizations

OBJECTIVE

The ability to trust one's own perceptions is crucial for psychological well-being and growth. The relevance of its opposite, self-invalidation (SI), to the psychopathology of borderline personality disorder (BPD) is emphasized in many contemporary theories of evidence-based treatments for BPD. Empirical research on this topic remains scarce, however. This study aimed to describe manifestations of SI in individuals with BPD during a 40-session psychoeducational intervention based mainly on schema therapy.

METHOD

Transcripts of videotaped group sessions were analyzed inductively using qualitative content analysis.

RESULTS

SI emerged as a recurrent, ubiquitous phenomenon. The content analysis yielded three core categories of SI: (1) a self-critical and harsh attitude towards the self (subcategories reflected punitive internalizations that could engender fear-based inertia, self-erasing, submissive coping behavior, and temporal fluctuation in SI), (2) a deficient sense of normalcy, and self-doubt, and (3) self-stigma. We also found an association of SI with various dimensions of BPD, including difficulty in the identification of emotions, secondary emotional reactions such as guilt, shame, anger, and resentment, self-related and interpersonal problems, and suicidal urges.

CONCLUSIONS

SI is a detrimental cognitive-emotional process relevant to BPD that merits treatment. Efforts to reduce self-stigma, a pernicious aspect of SI, are imperative.

Understanding predictors of change in a day treatment setting for non-suicidal self-injury

OBJECTIVES

To examine change in non-suicidal self-injury (NSSI) frequency, quality of life, and functional impairment from admission to discharge in patients enrolled in partial hospitalization and intensive outpatient programmes (PHP/IOP) designed to treat NSSI. Demographic, clinical, and treatment-related predictors of changes were also examined.

DESIGN

Data were collected as part of routine clinical assessment procedures at admission and discharge from patients enrolled in a PHP/IOP programme designed to treat NSSI. The clinical assessment included measures examining quality of life, functional impairment, and NSSI behaviour.

METHODS

Paired t-tests were used to examine change in NSSI frequency, quality of life, and functional impairment. Reliable clinical change analyses were used to identify clinically significant change in quality of life and functional impairment. Multilevel mixed-effects regression was used to examine predictors of change for quality of life and functional impairment. Negative binomial regression was used to examine predictors of change for NSSI frequency.

RESULTS

From admission to discharge, NSSI frequency significantly decreased and quality of life and functional impairment evidenced clinically significant change. Age, race/ethnicity, and insurance type predicted change in functional impairment, while gender predicted change in quality of life. Urge to self-injure predicted change in NSSI frequency. Borderline symptoms predicted change across all outcome variables.

CONCLUSIONS

Patients who completed a day treatment programme for NSSI evidenced significant change in NSSI frequency, functional impairment, and quality of life at discharge; however, several demographic and clinical variables were associated with change.

PRACTITIONER POINTS

Patients who engage in NSSI show significant change from admission to discharge in a day treatment programme dedicated to the treatment of NSSI. Quality of life and functional impairment are important outcome variables to consider and evaluate in higher levels of care. It is important to consider demographic and clinical variables when creating a treatment plan for NSSI. Although BPD symptoms may be important to consider in day treatment for NSSI, interpersonal dysfunction, depressive symptoms, and mood lability may also affect change in symptoms.

"If you don't have a word for something, you may doubt whether it's even real" - how individuals with borderline personality disorder experience change

Objective: This study explored how psychological change was experienced and what treatment-related factors or events were perceived as supporting or hindering their process by individuals with borderline personality disorder. Methods: Eight BPD sufferers attended a 40-session psychoeducational group intervention at a community mental health care center. At intervention end, personal experience of meaningful change was explored in an in-depth interview and data were content-analyzed. Change in BPD symptoms was assessed by the Borderline Personality Disorder Severity Index IV interview. Results: The qualitative content analysis on subjectively perceived meaningful change yielded three core categories: (1) improved ability to observe and understand mental events, (2) decreased disconnection from emotions, emergence of new or adaptive emotional reactions and decrease in maladaptive ones, and (3) a new, more adaptive experience of self and agency. Accordingly, (1) learning and (2) normalizing emerged as the main categories of helpful treatment factors. In turn, treatment-related factors perceived as obstacles were: (1) aggression in the group, and (2) inflexibility. With respect to symptom change, four participants were considered clinically as remitted, and two showed a reliable change. Conclusions: Long-term psychoeducational group therapy seems to enhance mentalization / metacognitive functioning and promote self (or personality) integration in BPD patients.

Presence and Overlap of Bipolar Symptoms and Borderline Features during Major Depressive Episodes

BACKGROUND

Bipolar symptoms and borderline personality features occur in both unipolar and bipolar major depressive episodes (MDEs). We investigated their prevalence, severity, co-occurrence and overlap.

METHODS

We interviewed 124 psychiatric outpatients with MDE using the Structured Clinical Interview for DSM-IV-TR Axis I and II Disorders, the Borderline Personality Disorder Severity Index (BPDSI-IV), and about past (hypo)manic episodes, and stratified them according to the principal diagnosis into subcohorts of major depressive disorder (MDD, n = 50), bipolar disorder (BD, n = 43), and borderline personality disorder (BPD, n = 31). We quantified (hypo)manic symptoms using a novel semi-structured interview (MIXed symptoms during MDE, MIX-MDE) with good psychometric qualities.

RESULTS

The subcohorts did not differ in MDE severity. They differed significantly in some (hypo)manic symptoms being present on most days in 24% of MDD, 30% of BD, and 42% of BPD subcohort, but only 5% of the BD subcohort fulfilled the DSM-5 mixed features. The mean MIX-MDE scores were 5.7 (SD 4.0), 12.0 (8.2) and 10.5 (7.5), and BPDSI-IV scores 15.6 (7.0), 17.2 (6.2) and 26.9 (8.7), respectively (both p < 0.001). (Hypo)manic days and unspecific symptoms of distractibility and irritability inflated the correlation of observed (hypo)manic symptoms and borderline features.

LIMITATIONS

Moderate sample size, limited age variation (18-50 years); no previous validation of MIX-MDE.

CONCLUSIONS

Presence of some mixed and borderline features is common in MDEs, with overlap and diagnosis-specific differences. Unspecific symptoms of irritability and distractibility and the aggravating impact of hypomania on perceived BPD features blur the differential diagnosis.

The Italian Version of the Borderline Personality Disorder Severity Index IV: Psychometric Properties, Clinical Usefulness, and Possible Diagnostic Implications

Borderline personality disorder (BPD) has a core embodied in affective and behavioral dysregulations, impulsivity, and relational disturbance. Clinical presentation might be heterogeneous due to a combination of different symptoms listed in the DSM-5. Clinical diagnosis and assessment of the severity of manifestations might be improved through the administration of structured interviews such as the Borderline Personality Disorder Severity Index, 4th edition (BPDSI-IV). The psychometric properties of the Italian version of the BPDSI-IV were examined for the first time in 248 patients affected by BPD and 113 patients affected by bipolar disorder, proving to be a valid and accurate instrument with good internal consistency and high accuracy. The Italian version also demonstrates significant validity in the discrimination between these clinical groups (p < 5001).

Comparing Effectiveness of Treatments for Borderline Personality Disorder in Communal Mental Health Care: The Oulu BPD Study

The implementation of effective psychotherapies in community mental health care is challenging. This study aimed to create a well-structured and easily applicable treatment model for patients with severe borderline personality disorder (BPD). We integrated a schema therapy based psycho-educational group into an available individual therapy. Two groups were formed: (1) community treatment by experts (CTBE) patients (n = 24) receiving new treatment and (2) treatment as usual (TAU) patients (n = 47). Changes in symptoms were measured by Borderline Personality Disorder Severity Index-IV interview and quality of life by the 15D health-related quality of life questionnaire. After 1 year the CTBE patients showed a significant reduction in a wider range of BPD symptoms and better quality of life than TAU patients. The results of this study are encouraging. A well-structured treatment model was successfully implemented into community mental health care with improved patient adherence to treatment and superior treatment outcomes compared to TAU patients.

Association of parasuicidal behaviour to early maladaptive schemas and schema modes in patients with BPD: The Oulu BPD study

The present study aimed to examine which early maladaptive schemas (EMSs) and schema modes emerged in parasuicidal and non-parasuicidal patients with BPD participating in the Oulu BPD study. The patients' EMSs were assessed using the Young Schema Questionnaire, and schema modes using the Young Atkinson Mode Inventory. Sixty patients with BPD responded to both the schema and schema mode questionnaires; of these, 46 (76.7%) fulfilled the criteria for parasuicidality. In BPD patients with parasuicidality, the EMSs of emotional deprivation, abandonment/instability, mistrust/abuse and social isolation were the most prevalent, and the schema modes of vulnerable child, angry child, detached protector and compliant surrender were prominent. In patients without parasuicidality, the schema modes of healthy adult and happy child were the most prevalent. Significant correlations were observed between the schema modes of detached protector, vulnerable child, punitive parent and angry child and almost every EMS in BPD patients with parasuicidality. Our preliminary findings suggest that associations between certain EMSs and schema modes to parasuicidality in BPD patients may provide valuable information when planning and implementing their treatment.

Prediction of treatment discontinuation and recovery from Borderline Personality Disorder: Results from an RCT comparing Schema Therapy and Transference Focused Psychotherapy

Knowing what predicts discontinuation or success of psychotherapies for Borderline Personality Disorder (BPD) is important to improve treatments. Many variables have been reported in the literature, but replication is needed and investigating what therapy process underlies the findings is necessary to understand why variables predict outcome. Using data of an RCT comparing Schema Therapy and Transference Focused Psychotherapy as treatments for BPD, variables derived from the literature were tested as predictors of discontinuation and treatment success. Participants were 86 adult outpatients (80 women, mean age 30.5 years) with a primary diagnosis of BPD who had on average received 3 previous treatment modalities. First, single predictors were tested with logistic regression, controlling for treatment type (and medication use in case of treatment success). Next, with multivariate backward logistic regression essential predictors were detected. Baseline hostility and childhood physical abuse predicted treatment discontinuation. Baseline subjective burden of dissociation predicted a smaller chance of recovery. A second study demonstrated that in-session dissociation, assessed from session audiotapes, mediated the observed effects of baseline dissociation on recovery, indicating that dissociation during sessions interferes with treatment effectiveness. The results suggest that specifically addressing high hostility, childhood abuse, and in-session dissociation might reduce dropout and lack of effectiveness of treatment.

Changes in schemas of patients with severe borderline personality disorder: the Oulu BPD study

Borderline personality disorder (BPD) is a relatively common and severe psychiatric disorder that can impair quality of life in many ways. The aim of this study was to determine whether a combined treatment model for BPD patients, utilising major principles from schema-focused therapy (SFT) and dialectical behavioral therapy (DBT), could be more effective in relieving early maladaptive schemas of BPD patients, compared to treatment as usual (TAU). This study is a part of the Oulu BPD study conducted at mental health care services run by Oulu city social and health care services. The study is a multisite, randomized controlled trial conducted over a one year period, involving two groups of patients with severe BPD: (1) Community Treatment By Experts (CTBE) patients (n = 18) receiving the combined treatment model, and 2) TAU patients (n = 27). The patients' schemas were assessed using the Young Schema Questionnaire (YSQ-L3a) before and after one year of treatment. The results reveal that CTBE patients who attended the combined treatment model showed a statistically significant reduction in eight out of 18 early maladaptive schemas, while patients receiving treatment as usual did not demonstrate any significant changes in schemas. The cognitive therapeutic treatment model can be applied for clinical use in public mental health settings using existing professionals, and appears to produce positive changes in patients with BPD.