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.

Attachment Problems and Mentalizing Capacity Relate to Parent-Child Informant Discrepancies in Female Adolescents with Borderline Personality Disorder.

Parent-child informant discrepancies on psychopathology provide important knowledge on the parent-child relationship and the child's mental health, but mechanisms underlying parent-child informant discrepancies are largely unknown. Therefore, we investigated the relationship between attachment problems and mentalizing capacity and parent-child informant discrepancies on borderline personality disorder (BPD) severity, internalizing, and externalizing pathology in a clinical sample of 91 adolescent girls with BPD and their parents. Results showed that more attachment problems to parents and peers were related to adolescents reporting more severe BPD than parents. Adolescents who described more internalizing symptoms relative to parents, reported more parental attachment problems, but enhanced peer attachment, suggesting those adolescents who do not feel recognized by their parents might turn to their friends. When parents rated adolescents higher on externalizing behaviors, the adolescent reported more attachment problems to parents and lower mentalizing capacity, indicating that this sub-group of adolescents may reflect less about how their behavior affects others.

Short-Term versus Long-Term Mentalization-Based Therapy for Borderline Personality Disorder: A Randomized Clinical Trial (MBT-RCT).

INTRODUCTION: Borderline personality disorder (BPD) is a severe and prevalent psychiatric disorder. Mentalization-based therapy (MBT) is an evidence-based intervention for BPD, and several countries offer treatment programs for BPD lasting for years, which is resource demanding. No previous trial has compared short-term with long-term MBT. OBJECTIVE: The aim of the study was to assess the efficacy and safety of short-term versus long-term MBT for outpatients with BPD. METHODS: Adult outpatients (≥18 years) with subthreshold or diagnosed BPD were randomly assigned (1:1) to short-term MBT (5 months) or long-term MBT (14 months). The primary outcome was BPD symptoms assessed with the Zanarini Rating Scale for Borderline Personality Disorder. Secondary outcomes were functional impairment, quality of life, global functioning, and severe self-harm. All outcomes were primarily assessed at 16 months after randomization. This trial was prospectively registered at ClinicalTrials.gov, NCT03677037. RESULTS: Between October 4, 2018, and December 3, 2020, we randomly assigned 166 participants to short-term MBT (n = 84) or long-term MBT (n = 82). Regression analyses showed no evidence of a difference when assessing BPD symptoms (MD 0.99; 95% CI: -1.06 to 3.03; p = 0.341), level of functioning (MD 1.44; 95% CI: -1.43 to 4.32; p = 0.321), quality of life (MD -0.91; 95% CI: -4.62 to 2.79; p = 0.626), global functioning (MD -2.25; 95% CI: -6.70 to 2.20; p = 0.318), or severe self-harm (RR 1.37; 95% CI: 0.70-2.84; p = 0.335). More participants in the long-term MBT group had a serious adverse event compared with short-term MBT (RR 1.63; 95% CI: 0.94-3.07; p = 0.088), primarily driven by a difference in psychiatric hospitalizations (RR 2.03; 95% CI: 0.99-5.09; p = 0.056). CONCLUSION: Long-term MBT did not lead to lower levels of BPD symptoms, nor did it influence any of the secondary outcomes compared with short-term MBT.

Prevalence and incidence of personality disorders among children and adolescents in Danish mental health services: a nationwide register study.

A few epidemiological studies have examined personality disorders (PDs) among children and adolescents in secondary mental health services. This study aims to describe the prevalence and incidence of PDs among children and adolescents who have attended Danish child and adolescent psychiatric services (CAPS). Using register-based data, we studied all patients under the age of 18 years who were admitted to in- and outpatient CAPS (N = 115,121) in Denmark from 2007 to 2017. A total of 4952 patients were diagnosed with a PD during the study period. The mean prevalence was 859 patients per year, and the mean incidence was 274 patients per year, including an increased incidence and prevalence of borderline, anxious, and unspecified PDs over the decade. The number of patients diagnosed with PDs increased from 700 to 851 per year, but the proportion of patients with PDs compared to all psychiatric diagnoses decreased from 4.2% to 2.8% over the study period. The PD population had an older age (14.8 years vs. 11.3 years; p < 0.001), a higher likelihood of being female (74% vs. 44%; p < 0.001), and four times more contacts with the psychiatric emergency departments than other patients with a psychiatric diagnosis. Future studies should focus on (a) implementing further epidemiological studies in different countries; (b) tracking diagnostic practices to facilitate comparisons and provide feedback for training clinicians and raising awareness; and (c) estimating trajectories of PDs, including costs within the CAPS, to facilitate informed decision-making regarding the future organization and provision of services to these children, adolescents, and their families.

Mentalizing mediates the relationship between psychopathy and premeditated criminal offending in schizophrenia: a 6-year follow-up study.

PURPOSE: Research has shown that schizophrenia augments the risk for criminal behaviour and variables both defining- and related to schizophrenia, increase criminal offending. Premeditated criminal offending is considered a severe form of criminal offending, however, very little is known about what predicts future premeditated criminal offending in schizophrenia. METHOD AND MATERIALS: In this 6-year follow-up study we explored which factors underlie future premeditated criminal behaviour in a sample of patients diagnosed with schizophrenia (N = 116). We also investigated if a specific mentalizing profile underlie part of the variance of premeditated criminal offending. RESULTS: Results showed that psychopathy underlie future premeditated crime in schizophrenia, and that a specific mentalizing profile, comprised of a dysfunctional emotional and intact cognitive mentalizing profile in relation to others, mediated parts of the relation between psychopathy and premeditated criminal offending. Finally, our results indicated that patients with schizophrenia with a specific mentalizing profile (see above) engaged in premeditated criminal behaviour earlier during the 6-year follow-up period compared to patients with other mentalizing profiles. CONCLUSIONS: Our findings suggest that mentalization should carefully be inspected in patients with schizophrenia in relation to future premeditated offending.

Mentalizing in Adolescents With and Without Prominent Borderline Features: Validation of the Reflective Functioning Questionnaire for Youths (RFQY) and an Investigation of the Factor Structure of Hypo- and Hypermentalizing.

The Reflective Functioning Questionnaire for Youths (RFQY) is a self-report measure of reflective functioning (RF) also referred to as mentalizing. Lower levels of RF are characteristic of a wide range of mental disorders and are especially relevant in the assessment of personality pathology. The goal of the current study is to examine the psychometric properties of a Danish translation of the RFQY and to corroborate previous research on the measure's ability to differentiate between adolescents with and without borderline personality disorder (BPD) features. 889 adolescents were administered the RFQY and divided into three subsamples: a community sample (n = 644), a clinical non-personality disorder sample (n = 64), and a BPD sample (n = 181). Construct validity was examined through bivariate correlations between RFQY and a dimensional assessment of borderline personality features. Analysis of variance (ANOVA) supported the utility of the RFQY to discriminate between adolescents with and without BPD features. Moreover, a two-factor structure based on previous research of the adult version of the RFQ was examined. A series of exploratory and confirmatory factor analyses yielded a two-factor structure corroborating previous research. Implications for prevention, assessment, and treatment are discussed along with methodological limitations and suggestions for future research.

Maladaptive personality traits may link childhood trauma history to current internalizing symptoms.

Research supports a strong relationship between childhood maltreatment and internalizing psychopathology (e.g., anxiety and depression), and features of personality are assumed to explain some of this relationship. In this study, we proposed a model in which maladaptive traits mediate the effect of childhood trauma history on internalizing symptoms in adult individuals. A mixed sample (N = 462) composed of 142 psychiatric patients and 320 community-dwelling individuals completed the Childhood Trauma Questionnaire (CTQ), the Personality Inventory for DSM-5 (PID-5), and the Symptom Checklist (SCL-27) for internalizing psychopathology. The effect of childhood traumas explained 34% of the variance in internalizing symptoms while controlling for the influence of age and gender. The traits accounted for 78% of this effect, which was predominantly exerted through the domains of Negative Affectivity, Detachment, and Psychoticism, and specifically through the facets of Depressivity, Suspiciousness, Anxiousness, Perceptual Dysregulation, and Distractibility. This finding provides preliminary support for the proposed model indicating that the aforementioned maladaptive trait domains potentially function as mediating links by which childhood traumas are translated into internalizing symptoms in adulthood. However, these findings must be interpreted with caution due to the cross-sectional and retrospective mono-method design of this study. Clinical implications are discussed in relation to transdiagnostic treatment and the potential value of specifying trait domain specifiers in ICD-11 and DSM-5 models of personality disorders.

Schizotypy and psychopathic tendencies interactively improve misattribution of affect in boys with conduct problems.

Psychopathic tendencies are associated with difficulties in affective theory of mind (ToM), that is, in recognizing others affective mental states. In clinical and non-clinical adult samples, it has been shown that where psychopathic tendencies co-occur with schizophrenia spectrum disorders, the impairing effects of psychopathic tendencies on ToM are attenuated. These effects are yet to be examined in adolescents. We examined if the impairing effect of psychopathic tendencies on affective ToM was attenuated with increasing severity of schizotypal personality disorder (PD) in a sample of 80 incarcerated adolescent boys. We showed that the impairing effect of psychopathic tendencies on the recognition of neutral mental states, but not positive or negative mental states, was evident when the relative severity of schizotypal PD was low. However, with higher scores on both measures, we observed better performance in judging neutral mental states. The preservation of affective ToM in adolescents who show elevations in psychopathic tendencies and schizotypal PD may enable them to manipulate and extort their victims for personal gain. Our results emphasize the need to consider comorbidity in clinical case formulation when working with adolescents with conduct problems and psychopathic tendencies. More broadly, our results also suggest that the pattern of social cognitive abilities associated with co-occurring psychopathology does not always conform to an often-theorized double-dose of deficit hypothesis.

Mentalization-based treatment in groups for adolescents with Borderline Personality Disorder: 3- and 12-month follow-up of a randomized controlled trial.

Mentalization-based treatment in groups (MBT-G) has never been tested in adolescents with Borderline Personality Disorder (BPD) in a randomized controlled trial. The current study aimed to test the long-term effectiveness of MBT-G in an adolescent sample with BPD or BPD features (≥ 4 DSM-5 BPD criteria). Hundred and eleven patients with BPD (n = 106) or BPD features (n = 5) were randomized to either (1) a 1-year modified MBT-G program comprising three MBT introductory sessions, five individual case formulation sessions, 37 weekly MBT group sessions, and six MBT-Parent sessions, or (2) treatment as usual (TAU), defined as at least 12 individual monthly treatment sessions with follow-up assessments at 3 and 12 months post treatment. The primary outcome was the score on the Borderline Personality Features Scale for Children (BPFS-C), and secondary outcomes included clinician-rated BPD symptoms and global level of functioning as well as self-reported self-harm, depression, externalizing and internalizing symptoms, and caregiver reports. There were no statistically significant differences between MBT-G and TAU on the primary outcome measure or any of the secondary outcomes. Both groups showed improvement on the majority of clinical and social outcomes at both follow-up points, although remission rates were modest with just 35% in MBT-G and 39% in TAU 2 years after inclusion into the study. MBT-G was not superior to TAU in improving borderline features in adolescents. Although improvement was observed equally in both interventions over time, the patients continued to exhibit prominent BPD features, general psychopathology and decreased functioning in the follow-up period, which points to a need for more research and better understanding of effective components in early intervention programs. The ClinicalTrials.gov identifier is NCT02068326.

Awakening to recognize the detrimental effects of social avoidance and the possibility of healing through reconnection.

BACKGROUND: Loneliness and social avoidance are widespread and serious mental health problems. People experiencing loneliness or social avoidance have difficulties maintaining ordinary life activities and often experience profound suffering. How do we as clinicians deal with or help people out of loneliness and social avoidance? AIMS: In this paper, we introduce the issue on loneliness and social avoidance. We do so by first defining loneliness and social avoidance and outlining the impact on mental health issues of these phenomena. Next, we introduce the six papers central to the special issue along with some thoughts on how to understand therapy and treatment of social avoidance. DISCUSSION: We discuss new directions and how to move beyond more conventional therapeutic approaches to these problems.

What is behind the closed door? A case illustration of working with social isolation in adolescents using Adaptive Mentalization-Based Integrative Treatment (AMBIT).

BACKGROUND: In this paper, we outline our approach to dealing with complex social isolation by presenting a network treatment approach named Adaptive Mentalization-Based Integrative Treatment (AMBIT). METHOD: We describe the AMBIT approach, what elements it consists of, and we explain how we employed this method in the case of a 17-year-old boy referred to our child and adolescent psychiatric clinic, who isolated himself from the world. RESULTS: We emphasize in which ways the specific network approach pertinent to the AMBIT approach was helpful in this complex case. Furthermore, we describe and reveal our insecurities and doubts related to our interventions and the general treatment process and point to why the AMBIT network approach and the interventions were crucial in this case. DISCUSSION: We argue that the boy could not have been helped out of his social isolation within the conventional child and adolescent psychiatric system without engaging and establishing an integrated professional network from many sectors.

Predictors of dropout among adolescents with borderline personality disorder attending mentalization-based group treatment.

Background: Premature termination from treatment or dropout is prevalent among patients with borderline personality disorder (BPD). To our knowledge, no studies have examined which factors predisposes dropout from therapy among adolescents with BPD. The current study examined sociodemographic, clinical and psychological predictors of dropout among adolescents who attended a one-year treatment program with mentalization-based group treatment (MBT-G).Methods: Participants were 89 female adolescent patients aged 14-18 years who attended MBT-G in a Danish child and adolescent psychiatric service and 56 matched controls who received non-manualized individual sessions (treatment as usual). Forty (45%) dropped out and 49 (55%) completed treatment in MBT-G. Pretreatment predictors included (1) sociodemographic variables such as age, schooling, relationship status and after-school job, (2) clinical measures of self-reported adolescent borderline personality features, depression, self-harm, internalizing and externalizing symptoms, and (3) psychological measures on self-reported reflective functioning (i.e., mentalizing) and attachment to peers and parents.Results: Binary logistic regression analyses revealed that lower reflective functioning was the only significant predictor of dropout in MBT-G. No sociodemographic or clinical variables predicted dropout. No significant predictors of dropout were identified among participants who received treatment as usual.Conclusions: Adolescents with BPD who report low reflective functioning are at increased risk of dropping out of MBT-G treatment but not treatment as usual. These findings highlight that clinicians need to consider level of reflective functioning among adolescents with BPD in MBT or in group therapy and adapt psychotherapy to the needs of the patient in order to reduce dropout.

Mentalization-based treatment in groups for adolescents with borderline personality disorder: a randomized controlled trial.

BACKGROUND: Borderline personality disorder (BPD) typically onsets in adolescence and predicts later functional disability in adulthood. Highly structured evidence-based psychotherapeutic programs, including mentalization-based treatment (MBT), are first choice treatment. The efficacy of MBT for BPD has mainly been tested with adults, and no RCT has examined the effectiveness of MBT in groups (MBT-G) for adolescent BPD. METHOD: A total of 112 adolescents (111 females) with BPD (106) or BPD symptoms ≥4 DSM-5 criteria (5) referred to child and adolescent psychiatric outpatient clinics were randomized to a 1-year MBT-G, consisting of three introductory, psychoeducative sessions, 37 weekly group sessions, five individual case formulation sessions, and six group sessions for caregivers, or treatment as usual (TAU) with at least 12 monthly individual sessions. The primary outcome was the score on the borderline personality features scale for children (BPFS-C); secondary outcomes included self-harm, depression, externalizing and internalizing symptoms (all self-report), caregiver reports, social functioning, and borderline symptoms rated by blinded clinicians. Outcome assessments were made at baseline, after 10, 20, and 30 weeks, and at end of treatment (EOT). The ClinicalTrials.gov identifier is NCT02068326. RESULTS: At EOT, the primary outcome was 71.3 (SD = 15.0) in the MBT-G group and 71.3 (SD = 15.2) in the TAU group (adjusted mean difference 0.4 BPFS-C units in favor of MBT-G, 95% confidence interval -6.3 to 7.1, p = .91). No significant group differences were found in the secondary outcomes. 29% in both groups remitted. 29% of the MBT group completed less than half of the sessions compared with 7% of the control group. CONCLUSIONS: There is no indication for superiority of either therapy method. The low remission rate points to the importance of continued research into early intervention. Specifically, retention problems need to be addressed.

Psychopathy in a forensic sample - the factor structure of the PCL:SV in a Danish forensic sample.

The research literature reveals an ongoing debate regarding the most appropriate conceptualization of psychopathic personality disorder. Specifically, it is discussed to what degree antisocial behavior is part of the conceptualization of the psychopathy construct and what constitutes the best factor model of the Psychopathy Checklist scales. The aim of the present study is to consider the underlying factor structure of the PCL:SV (Psychopathy Checklist Screening Version) in a Danish sample as well as considering the role of antisocial behavior in the psychopathy construct. Data from a Danish forensic patient sample (N = 225) was used and item response theory (IRT), aonfirmatory factor analyses (CFA) and structural equations model (SEM) analyses were carried out. Overall, the findings suggest appropriate item and model fit for the PCL:SV as well as superiority of the three-factor model over the four-factor model. The results are discussed in relation to the broader concept of personality disorder as well as clinical practice in regards to violence risk assessments and treatment of psychopathy.

Does Affective Theory of Mind Contribute to Proactive Aggression in Boys with Conduct Problems and Psychopathic Tendencies?

Adolescent psychopathic tendencies are associated with phenotypic increases in proactive aggression. However, the extent to which an understanding of others' affective mental states, or affective theory of mind (ToM), contributes to proactive aggression remains unknown. We examined how performance on a well-known test of affective ToM, based on cropped images of the eye region, contributes to reactive and proactive types of aggression in a mixed ethnicity sample of 80 incarcerated adolescent boys. A hierarchical regression model showed that affective ToM predicted proactive aggression over and above the influence of clinically rated psychopathic tendencies. Importantly, affective ToM was unrelated to reactive aggression. Our results suggest that being able to recognize others' affective mental states may be an important factor in aggressing against others for personal gain. These findings have implications for interventions designed to enhance ToM in youth with conduct problems.

The quest for tailored treatments: a meta-discussion of six social cognitive therapies.

In this commentary on the 6 articles comprising this In Session issue on metacognition and mentalizing in the psychotherapeutic treatment of severe mental disorders, we strive to contextualize and bring together salient issues reflected in these articles. In the foreground of our discussion is the point that the commonalities of these and related social cognitive treatments far outweigh their differences. We attempt to pinpoint some of the more specific tailored treatment elements described by the authors and relate these to empirical findings and theoretical and practical problems. Among the key issues addressed in this commentary are conceptual fallacies, therapist transparency, personality disorder and self-harm in adolescence, therapeutic alliance, and a metacognitive-informed group psychotherapy practice for patients with avoidant personality disorder or alexithymia.

Mentalizing mediates the relationship between psychopathy and type of aggression in schizophrenia.

Convincing evidence demonstrates that psychopathy is associated with premeditated aggression. However, studies have failed to explain why this association exists and whether socio-cognitive functions, such as mentalizing, could explain the relation. This cross-sectional study investigates, in 108 patients with schizophrenia, the association of psychopathy and mentalizing abilities with premeditated and impulsive aggression and probes the nature of their influence on these specific aggression patterns. Patients' engagement in premeditated aggression was associated with diminishing mentalizing and increasing psychopathic tendencies. Moreover, mediation analyses reveal that the ability to attribute mental states to others mediates the relation between psychopathy and type of aggression. This mediation is facilitated by a specific mentalizing profile characterized by the presence of intact cognitive and deficient emotional mentalizing capacities. This study is the first to report a mediating effect of mentalizing on the relationship between psychopathy and type of aggression in schizophrenia. Implications of these results are discussed.

The role of co-morbid personality pathology in predicting self-reported aggression in patients with schizophrenia.

BACKGROUND: Personality pathology affects behavioral patterns in patients with schizophrenia notwithstanding psychotic symptomatology. An investigation of the role of co-morbid personality pathology in the occurrence of aggression in schizophrenia is explored using both categorical and dimensional approaches to personality pathology. METHODS: In a cross-sectional study we evaluate, in 97 patients diagnosed with schizophrenia, the effect of personality pathology on the occurrence of aggression in schizophrenia using both a categorical approach, as described in DSM-IV-TR Axis II, and a dimensional approach, as operationalized in the Dimensional Assessment of Personality Pathology-Basic Questionnaire (DAPP-BQ). We also employ mediation analyses to explore the extent to which dimensions within the DAPP mediate the relationship between co-morbid personality disorders and aggression. RESULTS: Personality pathology accounts for aggression in schizophrenia. Both the categorical and the dimensional approaches equally well account for the occurrence of aggression, with each model accounting for 60% of the variance. Interestingly, the mediation analysis reveals that the association between categorically defined personality pathology and aggression is substantially mediated by the higher-order-trait dissocial behavior of the DAPP-BQ, accounting for 50.6 % of the total effect size. CONCLUSION: Personality pathology can be a significant predictor of aggression in patients with schizophrenia. While both the categorical and the dimensional trait models of personality disorders equally explain the aggression data, much of the relationship between the categorically defined personality disorders and the occurrence of aggression in schizophrenia can be explained by the presence of dissocial behavior as operationalized in the DAPP-BQ dimensional model.

Subtypes of aggression in patients with schizophrenia: the role of personality disorders.

BACKGROUND: Research has repeatedly demonstrated that schizophrenia has a small but significant association with violence. It is further recognised that a subgroup of people with such links also have personality disorders, but the extent to which type of violence or aggression varies according to subgroup is less clear. AIM: This study aimed to investigate, among co-morbid cases, if the number or type of personality disorders predicts type of aggression. METHODS: In a cross-sectional study, 108 patients with schizophrenia were assessed for personality disorder, Axis-I diagnosis, verbal IQ, social functioning and type of aggression. RESULTS: Logistic regression revealed that the more personality disorders identified (Cluster B personality disorders compared with Clusters A and C) and anti-social personality disorder compared with other Cluster B disorders significantly predicted premeditated aggression. CONCLUSIONS: These findings suggest that detailed personality assessment should be a routine part of comprehensive assessment of patients with schizophrenia. Improved knowledge of the presence and type of personality disorders may help detect and manage the risk of some types of aggression.

Personality Disorder and Adolescents-Still Living on a Shoestring?

Personality disorder (PD) has been and continues to be a controversial mental disorder to discuss with young people under the age of 18 [...].