The (cost-)effectiveness of early intervention (MBT-early) versus standard protocolized treatment (CBT) for emerging borderline personality disorder in adolescents (the EARLY study): a study protocol for a randomized controlled trial.

BACKGROUND: Although clinical guidelines prioritize the treatment of depression and anxiety in young persons, there is accumulating evidence that the presence of symptoms of borderline personality disorder (BPD) is associated with the limited effectiveness of these standard treatments. These findings stress the need for interventions addressing early-stage BPD in young people with presenting symptoms of anxiety and depressive disorders. The aim of this study is to investigate the (cost-)effectiveness of an early intervention programme for BPD (MBT-early) compared to first-choice psychological treatment for depression and anxiety according to Dutch treatment guidelines (CBT), in adolescents with either depression, anxiety, or both, in combination with early-stage BPD. METHODS: This study is a multi-centre randomized controlled trial. A total of 132 adolescents, presenting with either depression, anxiety, or both and significant BPD features will be randomized to either MBT-early or CBT. The severity of BPD, symptoms of depression and anxiety, personality, social and academic functioning, and quality of life will be assessed at baseline, end of treatment, and at 12-, 18-, and 24-month follow-up, along with medical costs and costs of productivity losses for cost-effectiveness analyses. DISCUSSION: This study will provide an empirical evaluation of the potential surplus value of early intervention in young people for whom treatment oriented at common mental disorders like anxiety and depression may be insufficient given their underlying personality problems. TRIAL REGISTRATION: Netherlands Trial Register, NL9569. Registered on June 15, 2021.

A Multi-Method Study of Interpersonal Complementarity and Mentalization.

Research finds cross-sectional relationships between mentalizing impairments and maladaptive personality traits. The current study connects mentalizing impairments to dynamic interpersonal processes using a multi-method design. A sample of 218 participants completed the Movie for the Assessment of Social Cognition (MASC; Dziobek et al., 2006) to assess mentalizing ability. Subsequently, participants rated their agentic and communal behavior and their perception of interaction partners' agentic and communal behavior over 21-days. Mentalizing ability moderated the within-person relationship between behavior and perception for both agency and communion. Worse performance on the MASC was associated with weaker interpersonal complementarity, suggesting that mentalizing impairments lead to deviations from expected patterns of behavior and perception across interpersonal situations. These findings confirm the assumption of Contemporary Integrative Interpersonal Theory that mentalization impairments can disrupt normative interpersonal processes (Cain et al., 2024; Pincus & Hopwood, 2012).

Total Pain and Fear of Recurrence in Post-Treatment Cancer Patients: Serial Mediation of Psychological Flexibility and Mentalization and Gender Moderation.

Background: The research indicates that painful experiences can significantly affect the fear of cancer recurrence among cancer survivors, which is a distressing concern that influences both physiological and psychological recovery. This cross-sectional study aims to advance our comprehension of the associations between total pain and the fear of recurrence in post-treatment cancer patients by examining two potential mediators: psychological flexibility and mentalization. Methods: Three hundred and thirty-five participants (aged 22 to 88, 49.1% female) who had finished their cancer treatment completed self-report assessments of total pain, their fear of recurrence, psychological flexibility, and mentalization. Results: The serial mediation analysis showed that all dimensions of total pain were positively and indirectly related to the fear of recurrence through psychological flexibility and mentalization in serial. Additionally, gender was found to moderate these serial mediational effects. Conclusions: In line with the psychological flexibility model, personal capacities to face difficult internal/external problems and interpret one's behavior in motivational terms can counterbalance a patient's negative emotions and feelings related to the illness. Gender factors also determine the way in which post-treatment cancer patients manage potential future anxiety and fears.

Emotional impacts of racial discrimination on caregiver-child dyads: Can mentalizing-focused parenting groups buffer against racism-related stress?

Black and Latinx caregivers face high risk for parenting stress and racism-related stress due to experiences of racial discrimination (RD). This study aimed to explore the associations between RD, parenting stress, and psychological distress in caregiver-child dyads, as well as the impact of a mentalizing-focused group intervention on caregivers' experiences of RD distress. Ethnoracially minoritized caregivers of children aged 5-17 years old participated in a non-randomized clinical trial (N = 70). They received either a 12-session mentalizing-focused group parenting intervention or treatment-as-usual in outpatient psychiatry. We assessed self-reported frequency and distress related to RD, parenting stress, and psychological distress at baseline (T1) and post-intervention (T2). Caregiver- and self-reported child psychological distress were also measured. The results showed that greater RD frequency and greater RD distress separately predicted higher overall parenting stress and parental role-related distress. Greater RD distress was linked to increased psychological distress in caregivers. Similarly, greater RD frequency and distress among caregivers were associated with higher caregiver-reported, but not self-reported, child psychological distress. No significant changes in RD distress were observed between T1 and T2 for either of the treatment groups. These findings highlight the exacerbating role of RD on parenting stress and psychological distress among ethnoracially minoritized caregivers and their children.

Antisocial personality disorder and therapeutic pessimism - how can mentalization-based treatment contribute to an increased therapeutic optimism among health professionals?

Antisocial personality disorder (ASPD) is associated with therapeutic pessimism among health professionals. Several variables are associated with obstacles in therapist's willingness to treat ASPD. Variables that are relevant are (i) confusion associated with the term ASPD, (ii) characteristics of the disorder, (iii) attitudes, experiences, and knowledge clinicians possess, and (iv) insufficient management of countertransference. We assume that therapeutic pessimism is related to the lack of evidence-based, effective treatment for individuals with ASPD. This is problematic because ASPD is associated with large socio-economic costs and considerable suffering for the individual and the society. Mentalization-based treatment (MBT) was developed in treating borderline personality disorder (BPD) and is now considered an effective treatment for this group. Mentalization is defined as the process by which individuals make sense of themselves and others in terms of subjective states and mental processes. This ability affects an individual's psychological functioning, mental health, self-organization, and interpersonal relationships. The overall goal of MBT is to strengthen the individual's mentalizing abilities and facilitate more adaptive handling of problematic, internal states. Recently, a version of MBT tailored for individuals with ASPD (MBT-ASPD) has been developed. The purpose of this review is to investigate how MBT-ASPD relates to the major obstacles that contribute to the therapeutic pessimism toward this group. Despite a limited evidence base, preliminary studies indicate promising results for MBT-ASPD. More research is still required, this review suggests MBT-ASPD can contribute to increased therapeutic optimism and demonstrate specific characteristics of MBT-ASPD that contribute to management of therapeutic pessimism.

Understanding and Breaking the Intergenerational Cycle of Abuse in Families Enrolled in Routine Mental Health and Welfare Services by Investigating the Feasibility and Effectiveness of a Mentalization-Based Early Intervention Program (UBICA-II Study): Study Protocol for a Non-Randomized, Open-Label, Single-Arm Feasibility Study.

Although home visiting programs have generally shown small overall effects on the prevention of child maltreatment, at-risk families with severe strain do not seem to benefit sufficiently from this support. A crucial factor for success seems to be the quality of the service system. The aim of the current study is to evaluate the effects of mentalization-based team supervision on the already existing welfare service of a German early prevention program (EPP). This will be a non-randomized, open-label, single-arm feasibility study. The EPP staff will be trained according to the mentalization-based team approach (MB-TA) and regularly receive MFT supervision by a trained and experienced child and adolescent psychiatrist. A minimum of eighty-four families with defined risk factors with children below 24 months of age and pregnant women in the third trimester will be included. Assessments will take place at T0 (after inclusion in the study), at T1 (after family care ends, as an intermediate assessment,) and at T2 (as a follow-up). We hypothesize that the risk of maltreatment can be reduced by strengthening the skills and capacities of the primary care system. This will be evaluated at the end of the follow-up period by comparing the Parental Stress Index (PSI) scores of all participants pre- and postintervention. Stress levels and mentalization abilities will be assessed as feasibility endpoints for the participating EPP teams.

Insecure Minds through the Looking Glass: The Mediating Role of Mentalization in the Relationships between Adult Attachment Styles and Problematic Social Media Use.

Research shows that insecure attachment styles and failures in mentalizing are associated with increased problematic social media use (PSMU). This study aimed to investigate the mediating role of failures in mentalizing in the relationships between attachment styles and PSMU within a large sample of individuals from the community. The study involved the participation of 3600 adult volunteers (2312 females, 64.2%) aged between 18 and 60 years old (M = 29.92; SD = 10.68). Participants completed measures to assess socio-demographics, adult attachment styles, mentalization, and PSMU. Findings showed that secure and dismissing attachment styles predicted reduced levels of PSMU, and that preoccupied and fearful attachment styles predicted increased levels of PSMU. The relationships between adult attachment styles and PSMU were mediated by failures in mentalizing. Thus, individuals with preoccupied and fearful attachment styles may excessively resort to social media as a means of coping with unprocessed mental states. Clinical interventions that focus on improving mentalizing abilities and promoting the adoption of appropriate self-regulation strategies might reduce maladaptive engagement in social media.

Maternal and paternal insightfulness and reaction to the diagnosis in families of preschoolers with Autism spectrum disorder: associations with observed parental sensitivity and inter-parent interaction.

Sensitivity among parents of children with Autism Spectrum Disorder (ASD) is based on parental insightfulness and on resolution regarding the child's diagnosis. This has been supported in studies of mothers, and we examined whether the same is true regarding fathers. Also, we asked whether parents' Insightfulness and Resolution tap general mentalization and therefore also be expressed in parent-parent interactions. Eighty preschooler boys with ASD and both of their parents participated. As expected, fathers who were more insightful and mothers who were more resolved were more sensitive. Contrary to expectations, no associations were found between fathers' resolution and mothers' insightfulness and their sensitivity. Associations were found between parental insightfulness and resolution and positive parent-parent interaction. The findings are the first to demonstrate the insightfulness-sensitivity link among fathers of children with ASD. Also, they suggest that both insightfulness and resolution involve general mentalization that is evident both in parent-child and parent-parent interactions.

War: Mentalization and Totalitarian State of Mind.

For most residents of Europe, war is a new experience in which they find themselves both as witnesses and participants. In this paper the war in Ukraine serves as an illustration and case example. Like any unfamiliar experience, war elicits profound emotional responses which can be so overwhelming that an individual may be unable to fully process them and to create mental representations of the reality of war. When the psyche becomes entrapped in an unprocessed state, without the capacity to derive meaning from it, this results in the "fossilization" of the psyche akin to what McGinley and Segal describes as a totalitarian state of mind. Subjectivity and individual differences come under collective or personal attack, or both. This state of being prioritizes the needs of the collective psyche over the individual psyche. The image of Gorgon Medusa, who transformed living people into "fossilized" ones, is presented as a metaphor of total identification with the collective dimension. In contrast, the psyche can reveal a creative approach to resolving war-induced trauma. This is depicted in the concept of the Alchemical Stone and its creation, which symbolizes a harmonious connection between the external and internal realms, the subjective and objective experiences, and the real and the imaginal dimension.

Pour la plupart des habitants de l'Europe, la guerre est une nouvelle expérience dans laquelle ils se retrouvent à la fois témoins et participants. Dans cet article, la guerre en Ukraine sert d'illustration et de cas exemplaire. Comme toute expérience qui sort de l'ordinaire, la guerre suscite des réactions émotionnelles profondes qui peuvent être si accablantes qu'un individu peut se trouver incapable de les traiter pleinement et de créer des représentations mentales de la réalité de la guerre. Lorsque la psyché se retrouve piégée dans un état qu'elle ne peut pas traiter, sans la capacité d'en tirer un sens, il en résulte une « fossilisation ¼ de la psyché, semblable à ce que McGinley et Segal a décrit comme un état d'esprit totalitaire. La subjectivité et les différences individuelles font l'objet d'attaques collectives ou personnelles, ou des deux. Cet état d'être donne la priorité aux besoins de la psyché collective plutôt qu'à la psyché individuelle. L'image de la Gorgone Méduse, qui a transformé des êtres vivants en êtres «fossilisés¼, est présentée comme une métaphore de l'identification totale à la dimension collective. En revanche, la psyché peut révéler une approche créative pour résoudre les traumatismes induits par la guerre. Ceci est représenté par le concept de la Pierre Alchimique et de sa création, qui symbolise un lien harmonieux entre les royaumes extérieur et intérieur, les expériences subjectives et objectives, et les dimensions réelles et imaginales.

Para la mayoría de los habitantes de Europa, la guerra es una experiencia nueva en la que se encuentran tanto como testigos y como participantes. En este artículo, la guerra en Ucrania sirve como ilustración y ejemplo de caso. Como cualquier experiencia desconocida, la guerra provoca profundas respuestas emocionales que pueden ser tan abrumadoras que un individuo puede ser incapaz de procesarlas completamente y de crear representaciones mentales de la realidad de la guerra. Cuando la psique queda atrapada en un estado, sin posibilidad de elaborar y sin la capacidad para hallarle un sentido, se produce una "fosilización" de la psique similar a lo que McGinley Segal describe como un estado mental Totalitario. La subjetividad y las diferencias individuales son objeto de ataques colectivos o personales, o ambos. Este estado de ánimo prioriza las necesidades de la psique colectiva sobre la individual. La imagen de la Gorgona Medusa, que transformó a las personas vivas en "fosilizadas", se presenta como una metáfora de la identificación total con la dimensión colectiva. Por el contrario, la psique puede revelar un enfoque creativo para resolver el trauma inducido por la guerra. Esto se representa en el concepto de la Piedra Alquímica y su creación, que simboliza una conexión armoniosa entre los reinos externo e interno, las experiencias subjetivas y objetivas, y las dimensiones real e imaginal.

Theory of mind in chronic migraine with medication overuse assessed with the MASC.

Theory of Mind (ToM) is the ability to infer one's own and others' mental states. Growing research indicates that ToM is impaired in Chronic Migraine with Medication Overuse (CM + MO). However, the research in this field has been conducted using static scenario-based tasks, often failing to test mentalization in everyday situations and measuring only performance accuracy. We filled this gap by administering the Movie for the Assessment of Social Cognition (MASC) to subjects with CM + MO compared to episodic migraine (EM). This test allows us to assess both affective and cognitive ToM and which, in addition to being accurate, also analyzes the type of error in attribution of mental states, distinguishing between hypo-mentalization and hyper-mentalization. Thirty patients suffering from CM + MO and 42 from EM were enrolled. Results showed that CM + MO patients were less accurate in mental state attribution than EM. In addition, compared to EM, CM + MO individuals were more impaired in the affective ToM dimensions and committed more errors of hypo-mentalization. In conclusion, the application of MASC in patients with CM + MO allowed for the detection of an alteration in their ability to correctly draw conclusions about other people's mental states. This latter contributes critically to appropriate social reactions and also, possibly, to satisfactory social interactions.

Attachment and mentalization among survivors of sexual abuse: A questionnaire survey.

Knowledge of the long-term consequences of child sexual abuse (CSA) is crucial to further develop preventive strategies and treatment programs. The aim of this study is to investigate attachment and mentalizing ability in people who have experienced CSA. Attachment style, measured with the Experiences in Close Relationships-Relationship Structures Questionnaire (ECR-RS), and mentalization, measured with the Reflective Functioning Questionnaire (RFQ), were examined through a quantitative questionnaire survey in a sample of 49 individuals who had experienced CSA, and a control group of 612 with no history of CSA. The CSA group was, to a greater extent, identified with insecure attachment style. In addition, participants with insecure attachment were more likely to use hypomentalizing compared to individuals identified with a secure attachment. No significant association was found between attachment style and the relationship between the victim and the offender or the length of traumatic episodes.

Cognitive dysfunction, social behavior disorder, cerebellar ataxia, and atypical brain FDG-PET presentation in spinocerebellar ataxia 17: a case report.

BACKGROUND: Spinocerebellar ataxia 17 (SCA17) is a rare autosomal dominant form of inherited ataxia, caused by heterozygous trinucleotide repeat expansions encoding glutamine in the TATA box-binding protein (TBP) gene. CASE DESCRIPTION: We describe the clinical history, neuropsychological, and neuroimaging findings of a 42-year-old patient who presented for medical attention showing prevalent behavioral and cognitive problems along with progressively worsening gait disturbances. The patient's family history indicated the presence of SCA17 in the maternal lineage. Genetic analysis confirmed a heterozygous 52-CAG pathological expansion repeat in TBP (normal interval, 25-40 CAG. Brain 18-fluorodeoxyglucose positron emission tomography (FDG-PET) showed bilateral hypometabolism in the sensorimotor cortex, with a slight predominance on the right, as well as in the striatal nuclei and thalamic hypermetabolism, a finding similar to what is observed in Huntington's disease. The patient also underwent neuropsychological evaluation, which revealed mild cognitive impairment and difficulties in social interaction and understanding other's emotions (Faux Pas Test and Reading the Mind in the Eyes Test). CONCLUSION: Our report emphasizes the importance of considering SCA17 as a possible diagnosis in patients with a prevalent progressive cognitive and behavioral disorders, even with a pattern of FDG-PET hypometabolism not primarily indicative of this disease.

Emotional arousal and reflective functioning among parents participating in attachment-based family therapy for LGBTQ+ young adults and their nonaccepting parents.

OBJECTIVE: Parents' rejection of their LGBTQ + young adults can have a negative impact on their young adult's psychological welfare, and on the young adult-parent relationship. Parents' ability to reflect on their child's pain and unmet needs is thought to evoke empathy and compassion, and reduce rejection. Empirical and clinical evidence suggest that parents' level of reflective functioning (RF) is impacted by their level of emotional arousal (EA). This study examined the association between parents' EA and RF within the context of attachment-based family therapy for nonaccepting parents and their LGBTQ+ young adults. METHODS: 43 therapy sessions drawn from six different cases were coded for parental RF and EA, based on 30-second segments. This generated a total of 343 observations for analyses. RESULTS: Hierarchal linear modeling revealed that parents' level of RF was a function of their concomitant EA, with moderate levels of arousal predicting the highest RF levels. CONCLUSION: Moderate EA may facilitate optimal parental reflective functioning. With nonaccepting parents, who typically present for treatment with high levels of maladaptive fear and shame, therapists would do well to assess their level of arousal and, when indicated, employ downregulating interventions before inviting them to reflect on their young adult's experience and needs.

Attachment styles and associated psychosocial factors in patients at ultra-high risk for psychosis: A systematic review.

BACKGROUND: Patients with an ultra-high risk of psychosis (UHR) are more likely to transition to psychosis. Attachment style has also been associated with psychosis and other symptoms. AIMS: To review attachment styles in UHR patients and to analyze related psychosocial factors. Ours is the first systematic review of attachment in this population. METHOD: We performed a systematic review of attachment and related psychosocial factors in UHR patients following the PRISMA methodology. RESULTS: We identified five studies. The results revealed high rates of insecure attachment in this population (more than 80%). The UHR sample presented high levels of depression, anxiety, social anxiety, emotional reactivity, trauma, and poor mentalization. Premorbid social adjustment was a predictor of improvement in disorganization and negative symptoms. The rate of transition to psychosis was 10%. Attachment patterns accounted for 16.8% of the variance. This vulnerability for psychosis was also associated with poor mentalization. CONCLUSION: Early detection of patients with UHR and insecure attachment is crucial, since early intervention to address symptoms, mentalization, and attachment is feasible and may lead to an improvement in the remaining associated psychosocial related factors (secure style: better global functioning and less affective and anxious symptoms). PROSPERO ID440957.

Social cognition in women with borderline personality disorder based on an exhaustive analysis of the Movie for Assessment of Social Cognition (MASC) categories.

A significant number of borderline personality disorder (BPD) symptoms are manifested in the interpersonal context. This can be explained by the difficulties in attributing the mental states of oneself and others, which constitutes social cognition. Errors in social cognition are interrelated with the affective, cognitive, impulsive, and interpersonal areas of the person with BPD. The aims of this study was to analyze social cognition in women with BPD compared with a control group and to analyze social cognition in BPD based on BPD symptoms and its severity. To assess social cognition, we used a full range of social cognition categories provided by the Movie for the Assessment of Social Cognition (MASC): correct theory of mind (ToM); attribution of mental states (thoughts, emotions, or intentions); errors of mentalization; types of ToM; and attribution of mental states through perceptive or cognitive cues and through hot or cold emotions. The MASC has high ecological validity and has been validated in Spanish. The sample comprised 79 women, including 47 women with BPD and 32 healthy women. Worse social cognition performance was observed in women with BPD. More severe borderline symptoms were related to worse functioning in the correct ToM and to errors of no mentalization. Involvement of the cognitive area in borderline symptoms was associated with worse functioning in correct ToM and worse social cognition in cognitive areas as well as with hypermentalization. This is the first study that uses all the MASC categories and considers BPD heterogeneity and its severity to study social cognition.

Capacity of Generative AI to Interpret Human Emotions From Visual and Textual Data: Pilot Evaluation Study.

BACKGROUND: Mentalization, which is integral to human cognitive processes, pertains to the interpretation of one's own and others' mental states, including emotions, beliefs, and intentions. With the advent of artificial intelligence (AI) and the prominence of large language models in mental health applications, questions persist about their aptitude in emotional comprehension. The prior iteration of the large language model from OpenAI, ChatGPT-3.5, demonstrated an advanced capacity to interpret emotions from textual data, surpassing human benchmarks. Given the introduction of ChatGPT-4, with its enhanced visual processing capabilities, and considering Google Bard's existing visual functionalities, a rigorous assessment of their proficiency in visual mentalizing is warranted. OBJECTIVE: The aim of the research was to critically evaluate the capabilities of ChatGPT-4 and Google Bard with regard to their competence in discerning visual mentalizing indicators as contrasted with their textual-based mentalizing abilities. METHODS: The Reading the Mind in the Eyes Test developed by Baron-Cohen and colleagues was used to assess the models' proficiency in interpreting visual emotional indicators. Simultaneously, the Levels of Emotional Awareness Scale was used to evaluate the large language models' aptitude in textual mentalizing. Collating data from both tests provided a holistic view of the mentalizing capabilities of ChatGPT-4 and Bard. RESULTS: ChatGPT-4, displaying a pronounced ability in emotion recognition, secured scores of 26 and 27 in 2 distinct evaluations, significantly deviating from a random response paradigm (P<.001). These scores align with established benchmarks from the broader human demographic. Notably, ChatGPT-4 exhibited consistent responses, with no discernible biases pertaining to the sex of the model or the nature of the emotion. In contrast, Google Bard's performance aligned with random response patterns, securing scores of 10 and 12 and rendering further detailed analysis redundant. In the domain of textual analysis, both ChatGPT and Bard surpassed established benchmarks from the general population, with their performances being remarkably congruent. CONCLUSIONS: ChatGPT-4 proved its efficacy in the domain of visual mentalizing, aligning closely with human performance standards. Although both models displayed commendable acumen in textual emotion interpretation, Bard's capabilities in visual emotion interpretation necessitate further scrutiny and potential refinement. This study stresses the criticality of ethical AI development for emotional recognition, highlighting the need for inclusive data, collaboration with patients and mental health experts, and stringent governmental oversight to ensure transparency and protect patient privacy.

The Effect of Alexithymia, Attention, and Pain Characteristics on Mentalizing Abilities Among Adults With Chronic Pain.

Introduction: Impaired mentalizing abilities are found among persons with chronic pain, yet it is still unknown why. The current study focuses on mentalizing abilities and how these could be affected by different pain factors, alexithymia traits, and other aspects of psychological functioning (depression, anxiety, attention) in persons experiencing chronic pain.Methods: 71 participants (80.3% female; mean age 56.1 (SD = 13.1)) with subjectively reported chronic pain conditions participated in the study. Mentalizing abilities were assessed using an objective assessment of the Frith-Happé animations test. Alexithymia was measured using Toronto Alexithymia Scale. Subjectively reported data on various pain characteristics and other related psychological factors (depression, anxiety, attention) were collected. Bivariate linear regression analyses were used to identify variables that had statistically significant relationships with Frith-Happé test scores as dependent variables, which were then used to build multivariate models.Results: Mentalization task scores had no significant associations with alexithymia. However, in bivariate models, greater Frith-Happé animations categorisation score was associated with higher attention task scores (ßs = .332, p = .005), higher education (ßs = .317, p = .007), and lower level of depressiveness (ßs = -.234, p = .049). Greater animations feelings scores were associated with less severe pain intensity (ßs = -.322, p = .006), younger age (ßs = -.399, p = .001), and better attention (ßs = .383, p = .001). In multivariate analysis models predicting both animations categorisation and feelings scores, attention was found to be the only statistically significant factor (respectively, ßs = .257, p = .029 and ßs = .264, p = .035).Conclusions: No significant correlations were found between mentalizing abilities and alexithymic features in persons with chronic pain. Disruptions of attention was the most significant factor leading to lower mentalizing abilities in persons with chronic pain.

Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies.

Borderline personality disorder (BPD) was introduced in the DSM-III in 1980. From the DSM-III to the DSM-5, no major changes have occurred in its defining criteria. The disorder is characterized by instability of self-image, interpersonal relationships and affects. Further symptoms include impulsivity, intense anger, feelings of emptiness, strong abandonment fears, suicidal or self-mutilation behavior, and transient stress-related paranoid ideation or severe dissociative symptoms. There is evidence that BPD can be reliably diagnosed and differentiated from other mental disorders by semi-structured interviews. The disorder is associated with considerable functional impairment, intensive treatment utilization, and high societal costs. The risk of self-mutilation and suicide is high. In the general adult population, the lifetime prevalence of BPD has been reported to be from 0.7 to 2.7%, while its prevalence is about 12% in outpatient and 22% in inpatient psychiatric services. BPD is significantly associated with other mental disorders, including depressive disorders, substance use disorders, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, bipolar disorder, bulimia nervosa, and other personality disorders. There is convincing evidence to suggest that the interaction between genetic factors and adverse childhood experiences plays a central role in the etiology of BPD. In spite of considerable research, the neurobiological underpinnings of the disorder remain to be clarified. Psychotherapy is the treatment of choice for BPD. Various approaches have been empirically supported in randomized controlled trials, including dialectical behavior therapy, mentalization-based therapy, transference-focused therapy, and schema therapy. No approach has proved to be superior to others. Compared to treatment as usual, psychotherapy has proved to be more efficacious, with effect sizes between 0.50 and 0.65 with regard to core BPD symptom severity. However, almost half of the patients do not respond sufficiently to psychotherapy, and further research in this area is warranted. It is not clear whether some patients may benefit more from one psychotherapeutic approach than from others. No evidence is available consistently showing that any psychoactive medication is efficacious for the core features of BPD. For discrete and severe comorbid anxiety or depressive symptoms or psychotic-like features, pharmacotherapy may be useful. Early diagnosis and treatment of BPD can reduce individual suffering and societal costs. However, more high-quality studies are required, in both adolescents and adults. This review provides a comprehensive update of the BPD diagnosis and clinical characterization, risk factors, neurobiology, cognition, and management. It also discusses the current controversies concerning the disorder, and highlights the areas in which further research is needed.

Quitline nurses' experiences in providing telephone-based smoking cessation help to mental health patients: A mixed methods study.

WHAT IS KNOWN ON THE SUBJECT?: Quitlines are known to be effective in helping people quit smoking, including those with mental health conditions. It is particularly important to address smoking in this population as the prevalence of smoking ranges from 40% to 75%. However, professionals working in quitlines often face barriers due to their limited training and resources to effectively support these smokers quit, especially if they are not mental health professionals. Therefore, training programmes should be developed to enhance their knowledge and skills in providing smoking cessation support to this vulnerable population. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The '061 QUIT-MENTAL study' evaluated the efficacy of a proactive telephone-based intervention for smoking cessation among smokers with severe mental health disorders. Conducted through a quitline service in Catalonia, Spain, the study focused on training non-mental health specialized nurses and other health professionals to provide evidence-based interventions for promoting smoking cessation among individuals with mental health disorders. The objective of this study is to assess the changes in nurses' knowledge and readiness to treat smokers with mental health conditions, while also capturing their insights and perceptions regarding the facilitators and barriers to providing smoking cessation interventions. The training and insights of the nurses were integral to conducting this research and providing valuable information for the future sustainability of such interventions. This is particularly important as quitlines hold the potential to offer cessation support to these patients at the community level. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: While the training programme was successful in improving non-mental health specialized nurses' knowledge and motivation skills to help patients with mental health disorders quit smoking, they encountered obstacles in delivering this intervention over the phone. These difficulties were mainly due to challenges in reaching participants and delivering the intervention as detailed in the protocol. The study highlights the need of reducing barriers for providers in attending to these patients, particularly if they are non-mental health specialized professionals. By minimizing the stigmatization associated with caring for mentally ill individuals and promoting coordination with specialists, innovative approaches may be introduced to alleviate the burden of tobacco-related diseases among this population. ABSTRACT: Introduction The viewpoint of those who implement a programme for the first time is crucial for understanding its impact and ensuring its long-term viability. The 061 QUIT-MENTAL study was a pragmatic randomized controlled trial evaluating a proactive telephone-based intervention addressed to mental health patients conducted by non-psychiatric specialized nurses. Aim We assessed nurses' knowledge of smoking cessation interventions addressed to this population before and after receiving training and their insights after delivering the intervention. Method Mixed methods study: (1) Pre-post evaluation to assess self-reported knowledge, self-efficacy and opinions about smoking cessation. (2) In-depth interviews with key nurses to ascertain their perceptions regarding the impact of the training received in delivering the study intervention. Results The training enhanced nurses' knowledge of psychological and pharmacological resources to aid these patients, as well as their ability to increase their motivation to quit. However, nurses reported difficulties in delivering population-based interventions to individuals with mental health disorders. These challenges primarily arose from participants being hard to reach, exhibiting low motivation to quit, struggling to comprehend instructions or follow recommendations, and nurses feeling unsure about their capacity to assist individuals with mental illnesses in quitting, despite the training they received. Discussion Despite the training and protocol designed to facilitate the delivery of the intervention, nurses faced difficulties in providing population-based interventions to individuals with mental health disorders. Implications for Practice Future quitline programmes aimed at the population with mental health disorders should strive to reduce barriers for providers in attending to these patients, particularly if they are non-mental health specialized professionals. By minimizing the stigmatization associated with caring for mentally ill individuals and promoting coordination with specialists, innovative approaches may be introduced to alleviate the burden of tobacco-related diseases among this population.