The Emerging Circadian Phenotype of Borderline Personality Disorder: Mechanisms, Opportunities and Future Directions

Dialectical Behavior and Social Rhythm Therapy for Comorbid Bipolar Disorder and Borderline Personality Disorder

Bipolar disorder and borderline personality disorder commonly co-occur. Each disorder is associated with substantial morbidity and mortality, which are worsened by co-occurrence of the disorders. Emotional dysregulation, suicidality, and disrupted circadian rhythm are key aspects of psychopathology associated with both conditions. A novel psychotherapy combining elements of two evidence-based treatments (i.e., dialectical behavior therapy [DBT] for borderline personality disorder and social rhythm therapy [SRT] for bipolar disorder) is described. Unlike either treatment alone, the new therapy, called dialectical behavior and social rhythm therapy (DBSRT), targets all three disease-relevant processes and therefore may represent a promising new approach to treatment for individuals with these two conditions. DBSRT may also have utility for individuals with overlapping characteristics of bipolar disorder and borderline personality disorder or for those whose illness manifestation includes a mix of bipolar and borderline personality disorder traits. Strategies associated with DBSRT are described, and a brief case vignette illustrates its application.

Interventions to improve the sleep quality of adults with personality disorder: A systematic review

Poor quality sleep is common for people who have a diagnosis of personality disorder (PD). Core cognitive and behavioral features of PD may cause and perpetuate poor sleep, but to date, no review has collated the evidence on the efficacy of interventions to improve sleep quality for people with PD. Structured searches for interventional studies among adults with PD and reporting validated measures of sleep quality were conducted up to November 2022 in multiple databases. Single-case reports were excluded. Study quality was assessed with standardized risk of bias tools. Unreported data was sought systematically from authors. This review was pre-registered with an international prospective register of systematic reviews (PROSPERO) (CRD42021282105). Of the 3503 identified studies, nine met inclusion criteria, representing a range of psychological, pharmaceutical, and other interventions and outcome measures. Meta-analytic methods were not feasible because of the serious risk of bias in all studies, and results were therefore synthesized narratively. There is limited and low-quality evidence of the effects of a variety of interventions to improve the sleep quality of people living with PD. Further research might consider specifically including people diagnosed with PD in trials of sleep interventions and using sleep outcome measures in trials of established PD treatments.

Sleep Quality After Quetiapine Augmentation in Patients With Treatment-Resistant Depression and Personality Disorders

PURPOSE/BACKGROUND

Quetiapine is a first-line augmenting agent for treatment-resistant depression (TRD) and is used off-label in insomnia. Quetiapine and its active metabolite norquetiapine act mostly on 5-HT2A, 5-HT2C, H1, and D2 as antagonists and on 5-HT1A as partial agonists. Patients with TRD often have comorbid personality disorder (PD), and evidence suggests an association between sleep disturbance and recovery among patients with PD. Here, we aimed to evaluate the effects of quetiapine on sleep in TRD patients with and without PD (PD+/PD-).

METHODS/PROCEDURES

We reviewed health records of 38 patients with TRD (20 TRD/PD+) who had been treated with a pharmacotherapy regimen including quetiapine. Clinical outcomes were determined by comparing changes in sleep items of the Hamilton Depression Rating Scale at the beginning (T0) and after 3 months of an unchanged treatment (T3).

FINDINGS/RESULTS

Patients with TRD/PD+ and TRD/PD- taking quetiapine showed significant improvement in sleep items from T0 to T3 (P < 0.001, ηp2 ≥ 0.19). There was a significant personality × time interaction for sleep-maintenance insomnia (P = 0.006, ηp2 = 0.23), with TRD/PD+ showing a greater improvement at T3 compared with TRD/PD- (P = 0.01). While exploring other sleep items, no personality × time interaction was found. In the TRD/PD- group, improvement in sleep items was associated with an overall improvement in depressive symptoms (r = 0.55, P = 0.02).

IMPLICATIONS/CONCLUSIONS

Quetiapine induced greater improvements in sleep-maintenance insomnia among TRD/PD+ patients than TRD/PD-. These findings suggest quetiapine could have a therapeutic role for insomnia in PD underscoring a distinct underlying neurobiological mechanism of sleep disturbance in people living with PD.

Anxious-Withdrawal and Sleep Problems during Adolescence: The Moderating Role of Peer Difficulties

Anxious-withdrawal is a well-established individual risk factor for psychosocial difficulties during adolescence. It is unknown, however, whether it also places youth at increased risk for physical health problems, such as sleep difficulties. This study examines the concurrent and prospective associations between anxious-withdrawal and six types of sleep difficulties (i.e., sleeping too much, sleeping too little, talking/walking in sleep, being overtired, nightmares, and general trouble sleeping). We further evaluate whether these associations differ for adolescents who are high versus low in exclusion and victimization. The participants were 395 adolescents (Mage = 13.61 years; 35% ethnic minority) who completed peer nominations of anxious-withdrawal, exclusion, and victimization at Time 1 (T1). Their mothers completed reports of sleep difficulties at T1 and at Time 2 (T2). Path analyses revealed unique associations between anxious-withdrawal and several types of sleep difficulties (e.g., sleeping too much) at T1. Analyses also revealed a significant interaction effect between T1 anxious-withdrawal and exclusion/victimization such that anxious-withdrawal was prospectively associated with trouble sleeping only for those young adolescents who are highly excluded/victimized. Our findings are the first to link anxious-withdrawal to a physical health outcome in adolescence and point to the need for future research to not only examine anxious-withdrawal and physical health but also to include assessments of peer difficulties.

Accelerated epigenetic aging in women with emotionally unstable personality disorder and a history of suicide attempts

Emotional unstable personality disorder (EUPD; previously borderline personality disorder, BPD) is associated with excess natural-cause mortality, comorbid medical conditions, poor health habits and stress related epigenomic alterations. Previous studies demonstrated that GrimAge - a state-of-the-art epigenetic age (EA) estimator - strongly predicts mortality risk and physiological dysregulation. Herein, we utilize the GrimAge algorithm to investigate whether women with EUPD and a history of recent suicide attempts exhibit EA acceleration (EAA) in comparison to healthy controls. Genome-wide methylation patterns were measured using the Illumina Infinum Methylation Epic BeadChip in whole blood from 97 EUPD patients and 32 healthy controls. The control group was significantly older (p < 0.0001) and reported lesser exposure to violent behavior in both youth and adulthood (p < 0.0001). Groups were otherwise comparable regarding gender, BMI, or tobacco usage (p > 0.05). EA estimator DNAmGrimAge exceeded chronological age by 8.8 and 2.3 years in the EUPD and control group, respectively. Similarly, EAA marker AgeAccelGrim was substantially higher in EUPD subjects when compared to controls, in both univariate and multivariate analyzes (p < 0.00001). Tobacco usage conferred substantial within-group effects on the EA-chronological age difference, i.e., 10.74 years (SD = 4.19) compared to 6.00 years (SD = 3.10) in the non-user EUPD group (p < 0.00001). Notably, past alcohol and substance abuse, use of psychotropic medications, global assessment of functioning, self-reported exposure to violent behavior in youth and adulthood, later completed suicide (N = 8) and age at first suicide attempt did not predict EAA in the EUPD group (p > 0.05). These results underscore the importance of addressing medical health conditions along with low-cost preventative interventions aimed at improving somatic health outcomes in EUPD, such as efforts to support cessation of tobacco use. The independency of GrimAge to other EA algorithms in this group of severely impaired EUPD patients, suggest it may have unique characteristics to evaluate risk of adverse health outcomes in context of psychiatric disorders.

Bright light therapy for mental and behavioral illness: A systematic umbrella review

Bright light therapy (BLT) is a promising non-pharmacological treatment for a range of psychiatric conditions. The goal of this review was to provide a comprehensive overview of the efficacy of BLT across mental and behavioral illnesses. Using systematic umbrella review methodology, we searched Ovid MEDLINE, Embase, PsycInfo, Web of Science, and Google Scholar for systematic reviews of randomized controlled trials (RCTs) evaluating BLT for any mental or behavioral illness from the date of inception until March 2021. Review quality was assessed using the AMSTAR 2 tool and summary efficacy data were extracted from recent reviews. Of 792 unique records, 67 systematic reviews were included which targeted a range of disorders related to mood, neurocognition, sleep, and eating. Recent meta-analyses targeting seasonal or non-seasonal depression found that BLT outperformed light-related control conditions. Reviews of other disorders identified few RCTs and generally did not support the efficacy of BLT for various outcomes. Overall, the extant literature supports the efficacy of BLT for seasonal and non-seasonal depression, although higher quality systematic reviews are needed to increase confidence in these findings. There was no specific funding for this review, and it was preregistered on Prospero (ID: CRD42021240751).

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.