Exploring the Utility of Neurostimulation Therapies in the Treatment of Borderline Personality Disorder: A Systematic Literature Review.

ABSTRACT: The use of electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS) in the treatment of people diagnosed with borderline personality disorder (BPD) highlights the need for systematic review of the evidence supporting this practice. A comprehensive literature search identified seven original clinical research studies investigating the use of brain stimulation therapies in people diagnosed with BPD. The lack of consistent study design, diagnostic methodology, treatment parameters, and outcome measures precluded analysis of aggregated study results. There were no ECT studies evaluating BPD symptom outcomes; however, studies of ECT in patients with comorbid BPD and depression suggested that depressive symptoms were less responsive to ECT compared with depression-only patients. The few studies available suggest that TMS may lead to clinically and statistically significant improvements in BPD symptoms and depressive symptoms. Similar overall improvements were reported despite the use of heterogeneous TMS treatment protocols, highlighting the importance of including a sham condition to investigate the contribution of the placebo effect to overall improvement. There is still no clear evidence supporting the use of ECT for treating people with BPD (with or without depression); therefore, the use of ECT in this population should be approached with caution. Although TMS shows early promise, the low numbers of participants in the few available studies suggest the urgent need for larger randomized controlled trials to provide an evidence base for this increasingly popular treatment.

Disjunction in the subjective and objective measurement of co-occurring depression in borderline personality disorder - Implications for diagnosis.

OBJECTIVE: Research and clinical experience suggest that people with borderline personality disorder (BPD) are more likely to report greater severity of depressive symptoms than is objectively measured by their clinician. The prominence of low mood in association with BPD can result in the treatment of depressive symptoms being prioritised over the diagnosis and treatment of BPD. METHOD: This study investigated the utility of validated clinician-administered and self-report depression rating scales during psychiatric assessment of 49 clients diagnosed with BPD. RESULTS: Considerable discrepancies emerged between client and clinician ratings of depression, with client-rated scales generating significantly higher depression scores. Both client-rated and clinician-rated depression scores were positively influenced by the severity of BPD symptoms. CONCLUSIONS: These findings raise questions about the interpretation of rating scales in clinical decision-making and highlight inherent uncertainty when diagnosing major depressive disorder in people who have borderline personality disorder. The accurate diagnosis of low mood has significant implications for the treatment and management of both disorders.

The impact of COVID-19 lockdown on the well-being of clients of a specialist personality disorder service.

OBJECTIVE: The aim of this study was to investigate the well-being of people with severe borderline personality disorder (BPD) during the first wave of COVID-19 social restrictions. METHOD: Clients of an outpatient specialist personality disorder clinic (n = 77) were invited to the study. An online survey was conducted including a range of open-ended questions exploring well-being and the Coronavirus Anxiety Scale (CAS) which assesses 'coronaphobia'. Qualitative data were analysed using inductive content analysis with NVivo software. CAS data were analysed descriptively using SPSS version 25. RESULTS: Thirty-six surveys were completed (48% response rate). Many participants experienced significant challenges to their overall well-being during lockdown although some reported improvements in psychosocial functioning. Three participants (8.3%) experienced clinically significant 'coronaphobia'. CONCLUSION: The self-reported physical and mental health of participants with BPD demonstrated resilience, suggesting that the capacity to maintain treatment via telehealth helped to mitigate many of the adverse aspects of social restrictions. This study was conducted during the first wave of social restrictions; subsequent studies will reveal longer-term effects of extended community lockdowns.

Development and Preliminary Evaluation of a Rapid Screening Tool for Detecting Borderline Personality Disorder in People Aged over 60 Years.

OBJECTIVES: Screening and diagnostic instruments for Borderline Personality Disorder (BPD) are not validated in people aged over 60. We report a pilot study examining the sensitivity and specificity of a de-novo screening instrument in older adults. METHODS: The BPD-OA screening tool incorporates DSM 5 and literature describing the expression of BPD in older adults. This study was conducted using a case control design. The Diagnostic Interview for Borderlines-Revised (DIB-R) and the McLean Screening Instrument for BPD (MSI-BPD) were used as comparators. Comprehensive assessment by psychiatric teams determined participants to be (i) BPD-positive (n = 22) or (ii) BPD-negative (gender matched; n = 21). RESULTS: The BPD-OA was the most sensitive instrument for discriminating older adult BPD from non-BPD participants (sensitivity = 0.82). No significant relationship was found between the BPD-OA score and age in BPD-diagnosed participants (r = -0.181, n = 21, p = .432). Participant age explained 3.2% of the variance in BPD-OA scores. Of the 21 BPD-negative participants, eight false positives experienced prominent mood disorders (specificity = 0.62). CONCLUSIONS: The BPD-OA screening tool is clearly superior to instruments validated for use in younger people. Further refinement and evaluation will enhance its sensitivity and specificity. CLINICAL IMPLICATIONS: Detection of BPD in older adult care settings will improve outcomes for patients, families, and staff through better understanding and appropriate management and treatment strategies.

Confidence of psychiatry trainees in meeting the needs of borderline personality disorder in comparison with schizophrenia.

OBJECTIVE: Borderline personality disorder (BPD) and schizophrenia are both serious and chronic mental health conditions of similar prevalence. This study was designed to assess trainees' confidence in the assessment, management and treatment of BPD in comparison with schizophrenia. METHODS: A survey was used to assess psychiatry trainees' confidence and experience of training with regard to managing BPD and schizophrenia. RESULTS: Eighty-two psychiatry trainees completed the survey. Overall, confidence scores of respondents with respect to BPD were significantly lower in comparison with schizophrenia. Trainees reported a preference for working with patients with schizophrenia compared with BPD. Respondents reported receiving less adequate supervision and training in the assessment, management and treatment of BPD than for schizophrenia. CONCLUSIONS: The results suggest an urgent need to enhance training and supervision in skills related to the diagnosis, management and treatment of BPD, with a greater focus on psychotherapy to improve trainee psychiatrists' confidence in working with people diagnosed with BPD.

Avoiding Misdiagnosis When Auditory Verbal Hallucinations Are Present in Borderline Personality Disorder.

Misdiagnosis is common for patients with a primary diagnosis of borderline personality disorder (BPD) who experience auditory verbal hallucinations (AVHs). AVHs in BPD are associated with severe BPD and high levels of suicidality. Wrongly treating these patients as though they are suffering from schizophrenia or other primary psychotic disorder and not treating BPD can cause significant iatrogenic damage. We outline a specific pattern of symptoms and phenomenology that will assist diagnostic accuracy in these cases. A focused review identified the following characteristic pattern: AVHs in BPD cannot be distinguished phenomenologically from AVH in schizophrenia, often meet the criteria for First-Rank Symptoms (FRSs), are highly stress related, and are strongly associated with dissociative experiences and childhood trauma. Formal thought disorder is uncommon, negative symptoms are usually absent, bizarre delusions are absent, affect remains reactive, and sociability is usually retained. Diagnostic accuracy can be improved by examining the overall clinical presentation and is essential to improving the prognosis for these patients.

Borderline personality disorder and depressive disorder.

OBJECTIVE: Borderline personality disorder (BPD) is frequently accompanied by low mood, the features of which may satisfy the diagnostic criteria for major depressive disorder (MDD). Treatment of depressive symptoms in the absence of BPD-appropriate treatment is less effective and may cause iatrogenic harm. This paper briefly reviews the co-occurrence of BPD and depressive disorder and suggests ways of differentiating these disorders and optimising treatment within the Australian Mental Health context. CONCLUSIONS: Depressive symptoms are present in the majority of people with BPD. To address the difficulty differentiating clinically distinct MDD from depressive symptoms that are integral to BPD psychopathology, it is suggested that depressive symptoms arising from a primary diagnosis of BPD (i) may exhibit transience and be stress reactive, (ii) lack a robust clinical response to antidepressant medication and/or electroconvulsive treatment and (iii) are responsive to BPD-appropriate psychotherapy.

Reviewing the clinical significance of 'fear of abandonment' in borderline personality disorder.

OBJECTIVES:: To review and highlight the clinical significance of the symptom 'fear of abandonment' in borderline personality disorder (BPD). METHODS:: A systematic search of the literature was conducted using MEDLINE and PubMed, employing search terms including 'fear of abandonment', 'borderline personality disorder' and 'rejection'. The most relevant English-language articles and books were selected for this review. RESULTS:: Fear of abandonment is widely recognised as a core symptom in BPD; a biopsychosocial explanation for the occurrence of the symptom is presented. While fear of abandonment may differ in its clinical presentation, it has a significant impact on therapeutic engagement, suicidal behaviour and non-suicidal self-injury, clinical management and prognosis. Most evidence based psychotherapies for BPD address the phenomenon of fear of abandonment; however, the lack of specifically targeted treatment interventions is disproportionate to its prominence and clinical significance. CONCLUSIONS:: Given its defining role in BPD, we recommend fear of abandonment as an important subject of future research and a specific therapy target.

An exploration of self-compassion and self-criticism in the context of personal recovery from borderline personality disorder.

OBJECTIVES:: A lack of compassion for oneself, or harsh self-criticism, is associated with a range of psychiatric disorders including borderline personality disorder (BPD). Personal recovery in the context of a mental illness such as BPD involves building a life that is subjectively meaningful and satisfying. Limited self-compassion or harsh self-criticism may be an impediment to recovery from BPD. The association between self-compassion and recovery and self- criticism and recovery were examined. METHOD:: Nineteen individuals diagnosed with BPD completed the Neff Self-Compassion Scale, the Forms of Self-Criticising/Attacking and Self-Reassuring Scale and the Recovery Assessment Scale at a single time point. RESULTS:: There was a strong positive correlation between self-compassion and recovery ( r = 0.75) and a strong negative correlation ( rho = -0.67) between self- criticism and recovery. CONCLUSIONS:: Although preliminary in nature, these results suggest the importance of fostering self-compassion and working to address self-criticism within clinical interventions supporting recovery from BPD.

What is the clinical significance of chronic emptiness in borderline personality disorder?

OBJECTIVE: The objective of this study was to review the clinical significance of the experience of chronic emptiness in borderline personality disorder (BPD). METHODS: A systematic search of the literature was conducted using MEDLINE and PubMed, employing search terms including 'emptiness', 'personality disorder' and 'borderline personality disorder'. The most relevant English-language articles and books were selected for this review. RESULTS: Published literature and clinical experience suggest that chronic emptiness represents a substantial component of the symptom burden experienced by people with BPD, contributes to functional impairment and may distinguish BPD from other disorders such as major depressive disorder. CONCLUSIONS: Further research will elucidate the significance of chronic emptiness with regard to diagnosis, prognosis and treatment of BPD.

Personality disorder: A mental health priority area.

Personality disorders have received limited recognition as a public health priority, despite the publication of treatment guidelines and reviews showing effective treatments are available. Inclusive approaches to understanding and servicing personality disorder are required that integrate different service providers. This viewpoint paper identifies pertinent issues surrounding early intervention, treatment needs, consumer and carer experiences, and the need for accurate and representative data collection in personality disorder as starting points in mental health care reform.

Evaluation of a novel risk assessment method for self-harm associated with Borderline Personality Disorder.

OBJECTIVES: Borderline personality disorder (BPD) is associated with frequent self-harm and suicidal behaviours. This study compared physician-assessed self-harm risk and intervention choice according to a (i) standard risk assessment and (ii) BPD-specific risk assessment methods. METHODS: Forty-five junior and senior mental health physicians were assigned to standard or BPD-specific risk training groups. The assessment utilized a BPD case vignette containing four scenarios describing high/low lethality self-harm and chronic/new patterns of self-harm behaviour. Participants chose from among four interventions, each corresponding to a risk category. RESULTS: Standard and BPD-specific groups were alike in their assessment of self-harm risk. Divergence occurred on intervention choice for assessments of low lethality, chronic risk ( p<.01) and high lethality, chronic risk ( p<.005). Overall, psychiatrists were more likely than their junior colleagues to correctly assess risk and management options. CONCLUSIONS: Although standard and BPD-specific methods are well aligned for assessing self harm-associated risk, BPD-specific training raised awareness of BPD-appropriate interventions, particularly in the context of chronic patterns of self-harm behaviour. Wider dissemination of BPD-specific risk training may enhance the confidence of mental health clinicians in identifying the nature of self-harm risk as well as the most clinically appropriate interventions for clients with BPD.

Missed diagnosis: The emerging crisis of borderline personality disorder in older people.

OBJECTIVE: Clinical experience suggests a growing prevalence of borderline personality disorder in aged residential care and psychiatric facilities with attendant difficulties in their management. This paper reviews the literature concerning the prevalence, phenomenology and diagnosis of borderline personality disorder in old age. The aim is to elucidate the phenomenological differences in old age and thus improve identification of the disorder. METHODS: A systematic search was conducted using MEDLINE, PubMed, EMBASE and PsycINFO databases, employing the search terms including 'personality disorder', 'borderline personality disorder', 'aged care', 'gerontology', 'geriatric psychiatry' and 'life span'. The search included articles in English involving participants 65+ years. Long-term prospective studies of borderline personality disorder, long-term follow-up studies and studies involving older adults from 50+ years were also examined. RESULTS: There is a paucity of literature on borderline personality disorder in the elderly. No diagnostic or rating instruments have been developed for borderline personality disorder in the elderly. The phenomenology of borderline personality disorder in the aged population differs in several respects from that seen in younger adults, causing some of the difficulties in reaching a diagnosis. Escalations of symptoms and maladaptive behaviours usually occur when the diagnosis of borderline personality disorder is either not made or delayed. Improved identification of borderline personality disorder in older patients, together with staff education concerning the phenomenology, aetiology and management of these patients, is urgently needed. CONCLUSION: Diagnostic instruments for borderline personality disorder in the elderly need to be developed. In the interim, suggestions are offered concerning patient symptoms and behaviours that could trigger psychiatric assessment and advice concerning management. A screening tool is proposed to assist in the timely diagnosis of borderline personality disorder in older people. Timely identification of these patients is needed so that they can receive the skilled help, understanding and treatment needed to alleviate suffering in the twilight of their lives.

Evaluation of changes in prescription medication use after a residential treatment programme for borderline personality disorder.

OBJECTIVE: Residential patients diagnosed with borderline personality disorder were evaluated to determine whether borderline personality disorder-focused psychotherapy reduced prescribing, personality disorder and co-morbid symptom severity. METHOD: Psychotropic prescriptions were measured at admission, discharge and 1 year later in 74 female participants with one or more personality disorder diagnosis and co-morbid mood disorders. Changes in pharmacotherapy were examined in the context of improvements in borderline personality disorder and/or co-morbid disorder symptom severity. Residential treatment included individual and group psychotherapy for borderline personality disorder. The Structured Clinical Interview for DSM-IV was used to confirm the borderline personality disorder diagnosis and associated co-morbid conditions. The Beck Depression Inventory was completed at each time point. RESULTS: A significant reduction in the incidence and severity of self-rated depression as well as clinician assessed personality disorder, including borderline personality disorder, was accompanied by a reduction in prescription of psychoactive medications. CONCLUSIONS: Three to six months of intensive borderline personality disorder-specific psychotherapy showed lasting benefit with regard to symptom severity of personality disorders (borderline personality disorder in particular) as well as depressive symptoms. This improvement corresponded with a reduction in prescriptions for psychoactive medications, which is consistent with current thinking regarding treatment for borderline personality disorder.

Mentalization-based intervention to recurrent acute presentations and self-harm in a community mental health service setting.

OBJECTIVES: A proof-of-concept study over an 18-month period to determine whether a mentalization-based intervention (MBI) in a metropolitan community mental health service, when added to a recovery-based model of care, would be of clinical benefit to borderline personality disorder (BPD) consumers with a history of recurrent, deliberate self-harm. The feasibility of implementing the intervention, and factors that could improve its implementation, will be evaluated. METHODS: Three-monthly focus groups with participating community mental health service case managers (N = 8) assessed the implementation and the impact of an MBI added to a recovery model of care and the way the clinicians worked with consumers with BPD and recurrent, deliberate self-harm in this context. RESULTS: Qualitative analysis revealed compatibility of the MBI with a recovery-based case management approach for the above group of consumers, albeit with operational barriers. CONCLUSIONS: MBI with consumers with BPD appears to be compatible with recovery-focused psychiatric case management and was accepted by consumers. The case managers perceived that no harm was rendered in terms of deliberate self-harm and acute service utilization. The MBI led to a sense of improved therapeutic alliance in case managers working with consumers.

Psychotherapy for borderline personality disorder.

OBJECTIVE: This paper aims to provide a succinct overview of the factors common to empirically validated psychotherapies for borderline personality disorder (BPD), including the treatment structure required. CONCLUSION: Individual psychotherapy remains the cornerstone of treatment for BPD. Factors common to empirically validated modalities of therapeutic treatment have been identified. These need to be provided within an individualised and structured treatment framework. Improved outcome of treatment for BPD can then be achieved.

The emotional labour of peer work: encountering stigma in mental healthcare spaces.

This article focuses on the workplace experiences of peer workers with a diagnosis of borderline personality disorder (BPD) in mental healthcare settings in Australia. Our article is located at the intersection of political, social, cultural, and legislative forces that have fostered the development of peer work as a paid profession. We draw on the concept of stigma to analyse findings from qualitative interviews with peer workers conducted in [state], Australia. By examining peer work in the broader context of lifeworlds of BPD, we address the interplay of work and professional identity, and the experience of a profoundly stigmatised diagnosis at this intersection.Our findings demonstrate the physical and emotional effects of stigma and how it produces boundaries and inequalities between peer workers and other health practitioners. These boundaries are reinforced by invisible markers that delineate what is expected, 'normal' and deemed professional in the workplace. Moreover, these same medico-socio-political relations help shape peer workers' identities and experiences. The development of peer workforces in mental healthcare service delivery is a prominent area of reform in Australia and internationally. Our research highlights the urgency of efforts to transform current socio-cultural-political relations that inhibit peer workers in their roles and impact workplace experiences.

Depression and borderline personality disorder.

Borderline personality disorder (BPD) is a serious mental illness characterised by dysregulation of emotions and impulses, an unstable sense of self, and difficulties in interpersonal relationships, often accompanied by suicidal and self-harming behaviour. Major depressive disorder (MDD) commonly co-occurs with BPD. Patients with BPD often present with depressive symptoms. It can be difficult to distinguish between BPD and MDD, especially when the two disorders co-occur. Research is needed to clarify the commonalities and differences between BPD and MDD, and BPD and rapid-cycling bipolar disorder. When MDD and BPD co-occur, both conditions should be treated concurrently. MDD co-occurring with BPD does not respond as well to antidepressant medication as MDD in the absence of BPD. MDD is not a significant predictor of outcome for BPD, but BPD is a significant predictor of outcome for MDD. Treatment of BPD with specific psychotherapies tends to result in remission of co-occurring MDD. Empirically validated psychotherapies for BPD share common features that are applicable in all treatment settings where patients with BPD are likely to present, including primary care. Methodologically sound research is required to examine the effectiveness of medications for treatment of MDD co-occurring with BPD.

Late manifestation of borderline personality disorder: Characterization of an under-recognized phenomenon.

Although uncommon, borderline personality disorder (BPD) may manifest for the first time later in life. A retrospective clinical file audit was used to identify the clinical manifestation of BPD for the first time at or above the age of 30, and to examine whether particular clinical and psychosocial factors may be associated with a later-in-life manifestation of BPD. Twenty-three cases of late manifestation BPD were identified. People with late manifestation of BPD had similar risk factors and vulnerabilities, including childhood trauma, to the broader BPD population. They were distinguished by having higher levels of education, employment, and long-term intimate relationships. Interpersonal problems, loss of employment and reminders of past sexual trauma were key precipitating factors. The findings underscore the legitimacy of a late-manifestation diagnosis of BPD by demonstrating that BPD does not present exclusively during adolescence and early adulthood. BPD may present for the first time in later life in response to loss of protective factors or triggering of past trauma. This understanding may reduce misdiagnosis or delayed diagnosis, prescription of inappropriate treatments or delays in receiving BPD-appropriate treatments.

Mental health support for and telehealth use by Australians living with borderline personality disorder during the onset of the COVID-19 pandemic: A national study.

Objective: To investigate mental health service use and telehealth experience of people living with BPD in Australia during the first year of the COVID-19 pandemic. Methods: An online survey was used to collect data from people who self-identified with a diagnosis of BPD. Results: One hundred and sixty-nine survey responses were included in the analysis. More than half of participants acknowledged receiving information from their health service about resources that they could use if they become distressed. More than 70% of participants used telehealth for receiving mental health services; the majority used telehealth to consult a psychologist or to obtain prescriptions. Telehealth sessions were conducted over the phone, via videoconferencing, or using a mix of the two. While using telehealth, some participants found it more difficult to control their impulses to self-harm, to express thoughts about self-harm and suicide, to control feelings of anger, and to establish and maintain agreed treatment boundaries. Thematic analysis of participants' experiences of telehealth identified five main themes: Communication challenges, Technology challenges, Privacy concerns, Benefits of telehealth, and Personal preferences. Conclusion: The study findings revealed a variety of positive and negative consumer experiences. While the majority of participants found telehealth somewhat benefitted their mental health, challenges were also reported which raise concerns about the broader utility and effectiveness of telehealth.