Borderline personality features among individuals at clinical high risk for psychosis (CHR-P): A brief report.

AIM: This exploratory study reports on borderline symptomatology within a sample of individuals at clinical high risk for psychosis (CHR-P) through a validated, self-report instrument, the short version of the Borderline Symptom List (BSL-23). METHODS: The sample consisted of 44 help-seeking CHR-P youth (ages 14-29 years) who completed an initial evaluation at a specialized clinic for psychosis-risk. RESULTS: The mean BSL-23 score was 1.5 (SD = 1.0, range 0.1-4.0). Higher scores were strongly associated with greater reported depressive symptoms (r = 0.84, p < 0.001). Additionally, borderline symptoms associated with attenuated positive symptoms (r = 0.32, p = 0.034) and social anxiety (r = 0.34, p = 0.027). Borderline symptomatology was not associated with role or social functioning. CONCLUSIONS: This study is one of the first examinations of borderline symptomatology within a CHR-P sample through a validated self-report measure. Future research replicating these results is required to determine their robustness.

Comorbid early psychosis and borderline personality disorder: Conceptualizing clinical overlap, etiology, and treatment.

Despite substantial efforts aimed at the detection and intervention for early symptoms of mental illness, there is relatively limited research on the clinical overlap between borderline personality disorder (BPD) and early psychosis, for example, clinical high risk (CHR) for psychosis, in young people. We present a narrative review of the clinical overlap between BPD and psychosis spectrum symptoms. Both conditions have unstable temporal course, and both are marked by functional impairment, increased suicide risk, and higher rates of psychiatric inpatient services. We then review evidence-based treatments for psychosis and BPD, emphasizing treatments for early presentations of these symptoms and initial research considering treatments for the overlap. Psychotherapies with the strongest empirical support include cognitive behavioral models, with BPD showing limited response to adjunctive pharmacotherapy. We end by discussing specific recommendations for future research, including longitudinal studies to determine the predictors of the course of illness and the development of treatments to target comorbid BPD and CHR symptoms.

Evaluation of a Dialectical Behavior Therapy Psychiatry Residency Training Program.

OBJECTIVE: Dialectical behavior therapy (DBT) is a widely disseminated evidence-based treatment for patients with borderline personality disorder (BPD). This evaluation of a community psychiatry residency rotation compared a DBT training program to a standard care training program to determine the levels of confidence in treating patients with BPD, willingness to treat patients with BPD, and attitudes towards this patient population. METHODS: Participants were 57 psychiatry residents who completed a 3-month community psychiatry rotation in a DBT clinic (N = 33), or standard care clinic (N = 24) based in a partial hospitalization program in a community mental health center. A mixed method design was used to collect qualitative and quantitative data on participants' experiences working with BPD and patients at high-risk for suicide. Participants were asked several open-ended questions to determine what aspect of their community psychiatry rotation influenced their level of confidence in treating, and willingness to treat BPD, non-suicidal self-injurious behaviors, and suicidal behaviors. RESULTS: Compared to training in the standard care condition, the DBT condition demonstrated significantly higher rates of willingness to treat, and confidence in treating patients with BPD, and confidence in treating non-suicidal self-injury. There were no significant differences between the two conditions in the level of confidence in treating suicidal patients. Four themes emerged from a qualitative content analysis examining the benefits of the training program, including (1) exposure to high-risk patients, (2) team-based treatment structure, (3) formal didactic training, and (4) individual or group supervision. CONCLUSION: Participants receiving DBT training had more willingness to treat and confidence in treating patients with BPD compared to participants receiving training in the standard care clinic. Team-based structure of DBT and exposure to high-risk patients were two themes from the training that impacted these variables across both study arms, according to participant self-report. Internal validity of the study was limited by the lack of randomization and pre-post design. External validity of the study was strengthened due to the setting of a community mental health clinic and resident training program.

Interpersonal barriers to recovery from borderline personality disorder: A qualitative analysis of patient perspectives.

Social-environmental factors have been found to be an integral part in the recovery process for individuals with psychiatric disabilities. There are few studies that have obtained patient perspectives of how their social and treatment environments help facilitate or impede the recovery process. The following study examined the self-reported interpersonal barriers to recovery among a sample of individuals (N = 31) with borderline personality disorder who were receiving dialectical behaviour therapy. The goal of study was to identify self-reported problematic behaviour that interferes with recovery goals and identify types of family, friend and/or provider behaviours that increased the likelihood of patients engaging in these problematic behaviours. A content analysis yielded three themes of problematic behaviour, and how these behaviours were reinforced by others, including (1) avoidance behaviours, (2) encouragement of negative coping and (3) communication of low behavioural expectations. Implications for the impact of these patterns of reinforcement within behavioural health settings are discussed. Copyright © 2017 John Wiley & Sons, Ltd.

Suicide risk and associated demographic and clinical correlates among primary care patients with recent drug use.

BACKGROUND: There is an increased need to prepare primary care clinicians to effectively gauge the risk of suicidal behavior occurring within primary care patients who may abuse drugs, especially those served in safety-net settings. OBJECTIVES: The objectives of this paper were to explore suicide risk in a population of individuals endorsing recent drug use, and to describe patient demographic, medical, psychiatric, social, and substance use characteristics across different levels of suicide risk. METHODS: A total of 867 primary care patients with reported drug use in the previous 90 days were studied. Based upon their responses to two Addiction Severity Index questions, four suicide risk categories were constructed: (1) low risk; (2) moderate-low (suicidal ideation in the past 30 days); (3) moderate-high (history of a lifetime suicide attempt); and (4) high risk (history of a lifetime suicide attempt and suicidal ideation in the past 30 days). The association between suicide risk groups and demographic and clinical variables were assessed. RESULTS: A total of 40% of primary care patients endorsing recent drug use reported a lifetime suicide attempt. Compared to individuals in other suicide risk groups, individuals at high suicide risk had higher rates of substance use severity, recently used two or more substances, and were more likely to have a comorbid psychiatric condition. CONCLUSION: These findings indicate that the percentage of patients with suicide risk may be higher among patients with recent drug use. Primary care clinicians should be aware that they may be encountering patients with suicide risk among those with recent drug use.

Borderline Personality Disorder and High Utilization of Inpatient Psychiatric Hospitalization: Concordance Between Research and Clinical Diagnosis.

The goals of this study were to (1) assess prevalence rates of borderline personality disorder (BPD) in public mental health patients and (2) compare research assessment rates to clinical record rates in those with and without a history of high utilization of inpatient psychiatric hospitalization. One hundred and sixty participants randomly selected from county mental health centers were fully assessed. Among the non-high utilizers, 10% met criteria for BPD on research diagnosis, 4.5% on clinical record diagnosis, and 1.5% on both. Among high utilizers, 42% met criteria for BPD on research diagnosis, 19% on clinical record diagnosis, and 19% on both. For the non-high utilizers, the sensitivity of the clinical record diagnosis (compared to the gold standard of the research diagnosis) was 15% and the specificity was 97%. For the high utilizer group, the sensitivity of the clinical record diagnosis was 45% and specificity was 100% indicating that there was never an incorrect clinical diagnosis of BPD among the high utilizers. Thus, while the specificity of the clinical record was high, the sensitivity of the clinical record diagnosis was quite low, and the clinical record greatly underestimated the prevalence of BPD in this sample. Further, since effective outpatient treatment has been developed for these expensive high utilizers with BPD, the under-recognition of BPD has significant implications for the planning of outpatient mental health services in public sector settings.

Examining challenging behaviors of clients with borderline personality disorder.

Few studies have examined effects of challenging behaviors of clients with borderline personality disorder (BPD) on psychotherapy outcomes. Dialectical behavior therapy (DBT) is an evidence-based treatment designed to treat chronic suicidality, self-directed violence (SDV), and emotion dysregulation, while targeting challenging behaviors. DBT has been shown to be effective with clients with BPD. We evaluated whether therapist reported challenging behaviors, such as high volume phone contacts or violating the therapist's limits, during DBT would be associated with dropping out of DBT, severity and frequency of SDV, emotion regulation deficits, psychological symptom severity and client's and therapist's satisfaction of treatment. The current study examined challenging behaviors reported by therapists in a sample of 63 psychiatrically disabled outpatient DBT clients diagnosed with BPD (73% women, average age 37 years). More frequent phone contacts were associated with a decrease in dropout and psychological symptoms, and an increase in client and therapist satisfaction. More avoidance/disengagement behavior was associated with more than twice the risk of SDV and a decrease in therapist satisfaction. Findings suggest that the phone coaching might serve to maximize client satisfaction and reduce the likelihood of dropout.

Comparing the motivational interviewing integrity in two prevalent models of brief intervention service delivery for primary care settings.

This quasi experimental study compared the motivational interviewing (MI) integrity in two prevalent brief intervention (BI) service delivery models for drug abuse. Routine primary care providers (RCPs) and non-routine care providers (NRCPs) performed BIs using an MI style within the same medical setting, patient population, and Screening, Brief Intervention, and Referral for Treatment (SBIRT) protocol. Interventionists (9 RCPs and 6 NRCPs) underwent similar MI training and performed a total of 423 audiorecorded BIs. We compared the MI integrity scores for all audio recorded sessions from these two SBIRT models for up to 40 months post MI training. Both groups met the lower standard (beginning proficiency in MI) on 4 of 5 MI integrity scores, but NRCPs met more of the higher standards (competency in MI) than RCPs. There may be limitations with regards to MI fidelity when using RCPs to conduct BIs in some primary care settings. Further experimental investigation is warranted to replicate this finding and identify casual factors of observed differences in MI fidelity.

Barriers and solutions to implementing dialectical behavior therapy in a public behavioral health system.

Dialectical behavior therapy (DBT) is an evidence-based treatment that is considered to be the standard of care in treating individuals with BPD, however there have been few published studies to identify the challenges and solutions for implementing DBT in community-based settings. The current study identified the barriers and solutions within a system-wide roll-out of DBT within a large, urban public health system encompassing both mental health and substance abuse treatment settings. Qualitative interviews were conducted with 19 clinicians receiving DBT training over a period of 13 months. A content analysis revealed three themes that were identified as challenges to the DBT implementation process including program development and recruitment of patients, a lack of administrative support or organizational investment in DBT, and time commitment of DBT. In order to transfer DBT into a public behavioral health system, investment from both clinic- and system-level administrators is required. Strategies to prevent drift, such as incorporating a train-the-trainer model, are discussed.

Dialectical behavior therapy training to reduce clinical burnout in a public behavioral health system.

There is a risk of experiencing clinical burnout among therapists providing treatment to clients with borderline personality disorder (BPD), a complex, costly and difficult-to-treat psychiatric disorder. Dialectical behavior therapy (DBT) is an evidence-based treatment of BPD that has been widely disseminated. There is only one published study that has examined pre and post scores of burnout among clinicians who receive training in DBT, and none that have taken place within a public behavioral health system in the United States where resources for community-based agencies are limited and demands are high. The current study examined the rates of burnout among therapists treating clients with BPD within a large, urban public behavioral health system. The study included a sample of nine clinicians and showed significantly decreased scores of burnout after participants attended a series of DBT trainings over a period of 13 months. There were several key limitations to internal validity including the lack of a control group. Similar evaluations of training outcomes are needed to address the widespread occurrence of burnout among community-based clinicians providing treatment to clients with BPD in order to enhance the quality of patient care.