What predicts psychosocial functioning in borderline personality disorder? Investigating the association with reflective functioning.

OBJECTIVES: The aim of this study was to investigate factors associated with functioning in participants with and without borderline personality disorder (BPD). In particular, we were interested whether mentalizing and related social cognitive capacities, as factors of internal functioning, are important in predicting psychosocial functioning, in addition to other psychopathological and sociodemographic factors. METHOD: This is a cross-sectional study with N = 53 right-handed females with and without BPD, without significant differences in age, IQ, and socioeconomic status, who completed semi-structured diagnostic and self-report measures of social cognition. Mentalizing was assessed using the Reflective Functioning Scale based on transcribed Adult Attachment Interviews. A regularized regression with the elastic net penalty was deployed to investigate whether mentalizing and social cognition predict psychosocial functioning. RESULTS: Borderline personality disorder symptom severity, sexual abuse trauma, and social and socio-economic factors ranked as the most important variables in predicting psychosocial functioning, while reflective functioning (RF) was somewhat less important in the prediction, social cognitive functioning and sociodemographic variables were least important. CONCLUSIONS: Borderline personality disorder symptom severity was most important in determining functional impairment, alongside trauma related to sexual abuse as well as social and socio-economic factors. These findings verify that BPD symptoms themselves most robustly predict functional impairment, followed by history of sexual abuse, then contextual factors (e.g. housing, financial, physical health), and then RF. These results lend marginal support to the conceptualization that mentalizing may enhance psychosocial functioning by facilitating social learning, but emphasize symptom reduction and stabilization of life context as key intervention targets.

Validation of computerized reflective function: A replication study.

Objective: The Reflective Function (RF) Scale is the original validated measure of mentalizing, applied to Adult Attachment Interview (AAI) transcripts. This study aimed to replicate the preliminary validation of Computerized RF (CRF), a computerized text analysis measure of RF.Methods: 49 women with borderline personality disorder (BPD; n = 20) and without (n = 29) completed diagnostic interviews and the AAI. AAIs were scored by certified coders using the RF Scale, and by computerized text analysis software using CRF dictionaries.Results: CRF significantly correlated with RF. The frequency of High CRF words had moderate-to-strong correlations with RF in the total sample (rs = .47), BPD group (rs = .61), and non-BPD group (rs = .41). Adding the frequency of Low CRF words to create a proportion of High and Low CRF words, and applying CRF to AAIs trimmed to include only items that "demand" RF, both produced significant, but not stronger, correlations with RF.Conclusion: CRF is an efficient alternative to the RF Scale that can estimate mentalization. Near average levels, neither RF nor CRF significantly differentiated between groups, indicating mentalizing deficits may not always be present, detectable, or defining in BPD samples. While more research is needed, CRF is a valid assessment of RF when codable text is available.

Smartphone applications targeting borderline personality disorder symptoms: a systematic review and meta-analysis.

BACKGROUND: Smartphone applications could improve symptoms of borderline personality disorder (BPD) in a scalable and resource-efficient manner in the context limited access to specialized care. OBJECTIVE: This systematic review and meta-analysis aims to evaluate the effectiveness of applications designed as treatment interventions for adults with symptoms such as anger, suicidality, or self-harm that commonly occur in BPD. DATA SOURCES: Search terms for BPD symptoms, smartphone applications, and treatment interventions were combined on PubMed, MEDLINE, and PsycINFO from database inception to December 2019. STUDY SELECTION: Controlled and uncontrolled studies of smartphone interventions for adult participants with symptoms such as anger, suicidality, or self-harm that commonly occur in BPD were included. STUDY APPRAISAL AND SYNTHESIS METHODS: Comprehensive Meta-Analysis v3 was used to compute between-groups effect sizes in controlled designs. The primary outcome was BPD-related symptoms such as anger, suicidality, and impulsivity; and the secondary outcome was general psychopathology. An average dropout rate across interventions was computed. Study quality, target audiences, therapeutic approach and targets, effectiveness, intended use, usability metrics, availability on market, and downloads were assessed qualitatively from the papers and through internet search. RESULTS: Twelve studies of 10 applications were included, reporting data from 408 participants. Between-groups meta-analyses of RCTs revealed no significant effect of smartphone applications above and beyond in-person treatments or a waitlist on BPD symptoms (Hedges' g = - 0.066, 95% CI [-.257, .125]), nor on general psychopathology (Hedges' g = 0.305, 95% CI [- 0.14, 0.75]). Across the 12 trials, dropout rates ranged from 0 to 56.7% (M = 22.5, 95% CI [0.15, 0.46]). A majority of interventions studied targeted emotion dysregulation and behavioral dyscontrol symptoms. Half of the applications are commercially available. CONCLUSIONS: The effects of smartphone interventions on symptoms of BPD are unclear and there is currently a lack of evidence for their effectiveness. More research is needed to build on these preliminary findings in BPD to investigate both positive and adverse effects of smartphone applications and identify the role these technologies may provide in expanding mental healthcare resources.

A meta-analysis of treatment as usual for borderline personality disorder.

In the era of evidence-based medicine, "treatment as usual" (TAU) for borderline personality disorder (BPD) is often considered ineffective or even iatrogenic. To evaluate the effects of TAU, this meta-analysis examined published data from the TAU arms of randomized controlled trials of manualized psychotherapies for BPD. Studies were selected through a comprehensive bibliographic search. A total of 16 studies met inclusion criteria. Comprehensive Meta-analysis V3 software was used for computing and pooling effect sizes. For the primary outcome category of BPD symptoms, Hedges' g showed a small-to-moderate improvement for patients in TAU conditions (11 studies; g = 0.371; 95% confidence intervals [CI: 0.246, 0.495]). Secondary outcomes included general psychopathology, global functioning, and self-harm/suicidality. Hedges' g indicated small improvements in general psychopathology (14 studies; g = 0.119; 95% CI [0.025, 0.214]) and global functioning (10 studies; g = 0.254; 95% CI [0.123, 0.384]). No significant effect was found for changes in self-harm/suicidality (four studies; g = 0.003; 95% CI [-0.193, 0.199]). These findings question the notion that TAU for BPD is inherently iatrogenic. Thus, in the absence of specialized treatment for BPD, standard available care may be a practical option. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Treatment of Borderline Personality Disorder: Is Supply Adequate to Meet Public Health Needs?

OBJECTIVES: This study aimed to assess the supply of and demand for treatment of borderline personality disorder (BPD) to inform current standards of care and training in the context of available resources worldwide. METHODS: The total supply of mental health professionals and mental health professionals certified in specialist evidence-based treatments for BPD was estimated for 22 countries by using data from publicly available sources and training programs. BPD prevalence and treatment-seeking rates were drawn from large-scale national epidemiological studies. Ratios of treatment-seeking patients to available providers were computed to assess whether current systems are able to meet demand. Training and certification requirements were summarized. RESULTS: The ratio of treatment-seeking patients with BPD to mental health professionals (irrespective of professionals' interest or training in treating BPD) ranged from approximately 4:1 in Australia, the Netherlands, and Norway to 192:1 in Singapore. The ratio of treatment-seeking patients to clinicians certified in providing evidence-based care ranged from 49:1 in Norway to 148,215:1 in Mexico. Certification requirements differed by treatment and by country. CONCLUSIONS: Shortages of both providers available to treat BPD and providers certified in specialist treatments of BPD exist in most of the 22 countries studied. In well-resourced countries, training clinicians to provide generalist or abbreviated treatments for BPD, in addition to specialist treatments, could help address the current implementation gap. More resource-efficient alternatives must be considered in countries with insufficient staff to implement even generalist treatments. Consideration of realistic allocation of care may shape future guidelines and standards of BPD treatments, beyond intensive evidence-based psychotherapies.