Talking about borderline personality disorder, shaping care: The multiple doings of narratives.

This article focuses on the narratives that circulate about borderline personality disorder (BPD) in health-care settings in Australia and the effects such narratives can have on how people practice and seek out care. People with a BPD diagnosis frequently access health-care services, often encountering stigma and discrimination. Drawing on narrative theory, we critically unpack the circulation and capacities of BPD narratives and the ways they can often contribute to poor and troubling experiences. This article is based on qualitative interviews with people living with a BPD diagnosis, as well as health practitioners who work with people with a BPD diagnosis. Our findings identified insidious and powerful BPD narratives that circulate in health-care settings, particularly in short-term, acute, or non-specialist contexts, such as emergency departments and in-patient units. These narratives influenced the ways that participants both practiced and sought out care. To improve health service quality for people with a BPD diagnosis, or those experiencing mental distress, it is important to challenge the sociocultural-political norms and relations that can influence approaches to care and practice. Disrupting and reframing negative BPD narratives and raising awareness about the impact of stories that are told about BPD have the potential to generate social change.

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.

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.

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.

Emergency department utilisation by patients with a diagnosis of borderline personality disorder: An acute response to a chronic disorder.

OBJECTIVE: Patients with borderline personality disorder (BPD) are likely to attend the ED while experiencing crises and associated self-injury and suicidality. Our study describes the prevalence, features, and outcomes associated with ED presentations by patients diagnosed with BPD in Outer Eastern Melbourne, Australia. METHODS: A retrospective electronic audit of 157 364 ED attendances identified 700 unique BPD-related ED presentations between May 2015 and April 2016. For the purpose of comparison, 583 (81% female) of these 700 cases were matched with 'depression only' cases. ED re-presentation data were also extracted. RESULTS: The 583 matched BPD patients attended ED a total of 2807 times during the audit year compared with 1092 attendances for matched depression-only patients. BPD patients were more likely to: arrive by ambulance (50%); have comorbid substance abuse (44%); have a psychotic (15%) or bipolar disorder (17%); be under the care of a psychiatrist (31%); be case-managed (42%); and be admitted to an inpatient unit (21%). ED doctors saw 38% of BPD or depression patients within the recommended time according to their triage category. The majority (73%) of BPD patients attended ED more than once during the audit year (average 4.81 ± 6.63 times; range 2-78). CONCLUSION: Repeated ED attendance of a subset of patients diagnosed with BPD highlights both the severity of their presentation and the inadequacy of community mental health services for meeting their complex needs. Development of effective ED referral pathways with follow-up to engage patients in BPD-appropriate treatment will reduce the likelihood of crises and reliance on hospital EDs for acute episodic care.

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.

Discriminative stimulus properties of the 5-HT1A receptor biased agonists NLX-101 and F13714, in rats trained to discriminate 8-OH-DPAT from saline.

NLX-101 and F13714 are selective, full efficacy, biased agonists of the serotonin (5-HT1A) receptor. NLX-101 preferentially activates cortical postsynaptic 5-HT1A receptors, whereas F13714 preferentially activates raphe nuclei presynaptic 5-HT1A receptors. We compared NLX-101 and F13714 for their efficacy and potency to substitute for the discriminative cue produced by the prototypical, nonbiased 5-HT1A receptor agonist 8-OH-DPAT (racemate). Male and female Sprague-Dawley rats were trained to discriminate 8-OH-DPAT (0.1 mg/kg i.p., 20 min pretreatment) from saline using a classical two-lever drug-discrimination procedure. 8-OH-DPAT (0.01 and 0.05 mg/kg i.p.) dose-dependently substituted for the training dose, with about 50% responding on the 8-OH-DPAT-associated lever at 0.05 mg/kg. F13714 fully and very potently substituted for the training dose of 8-OH-DPAT from 0.018 mg/kg i.p., whereas NLX-101 only achieved full substitution at 0.5 mg/kg i.p., a dose which is known to also activate presynaptic 5-HT1A receptors. The 5-HT1A receptor partial agonist, buspirone, partially substituted (~80%) at 1 and 2 mg/kg i.p., doses which also decreased response rates. F13714 decreased response rates at 0.05 mg/kg. The selective 5-HT1A receptor antagonist WAY-100 635 (1 mg/kg s.c., 40 min pretreatment) elicited almost no responding on the 8-OH-DPAT-associated lever by itself, but blocked the discriminative stimulus effects produced by administration (20 min pretreatment) of 8-OH-DPAT (0.1 mg/kg), F13714 (0.025 mg/kg), NLX-101 (0.5 mg/kg) or buspirone (1 mg/kg). These data suggest that the discriminative cue produced by 0.1 mg/kg i.p. 8-OH-DPAT results from activation of presynaptic 5-HT1A receptors. They also further demonstrate the distinct profiles in behavioral models of 5-HT1A receptor-biased agonists.

Coroners' investigations of suicide in Australia: The hidden toll of borderline personality disorder.

Borderline Personality Disorder (BPD) is associated with a high risk of death by suicide. Our study describes a population-based analysis of Coroners' investigations of suicides where there was evidence of a BPD diagnosis. We utilised the Victorian Suicide Register to identify suicides occurring between 2009 and 2013 where evidence of a BPD diagnosis was recorded. Of the 2870 suicides during this period, 181 (6.3%) had a BPD diagnosis recorded. Evidence of other diagnosed personality disorders was recorded in an additional 14 (0.5%) suicides and BPD was suspected in another 72 (2.5%) suicides. Information coded in the 181 diagnosed BPD suicides was compared with the 2689 suicides without a BPD diagnosis. Compared to the 'no BPD suicide group', the 'BPD suicide group' was younger, comprised a smaller proportion of women, had greater diagnostic complexity, a higher proportion of death by drug overdose, and a higher proportion of social and contextual stressors. 99% of people with a BPD diagnosis who died from suicide had contact with emergency and mental health services within 12 months of death; 88% sought help from these services within 6 weeks of death. These findings demonstrate the magnitude of this most severe outcome of mental illness, confirming that BPD belongs in the same category as schizophrenia, bipolar disorder and depressive disorder with respect to suicide representation. The help-seeking behaviours evident in almost all cases highlight a critical window of opportunity for providing timely support and treatment to help avert future deaths.

Developments in diagnosis and treatment of people with borderline personality disorder.

PURPOSE OF REVIEW: Borderline personality disorder (BPD) attracts significant attention from clinicians and researchers alike. Despite increased recognition and willingness to diagnose BPD, most effective treatment approaches remain inaccessible to most. We consider recent developments in the diagnosis and treatment of BPD. RECENT FINDINGS: A literature search of EMBASE and PsychINFO, using the search terms 'borderline personality disorder,' 'diagnosis' and 'treatment' for publications since October 2018, yielded over 300 articles and reviews. The literature highlights the increasing awareness of the diagnostic complexity of BPD as well as the emerging significance of 'common factors' and stepped care approaches for managing and treating the disorder. SUMMARY: Clinical practice is evolving to embrace more holistic diagnostic approaches, generalist treatment frameworks and stepped-care models that can be tailored to fit individual needs and service resources. The new frontiers in this field include expansion of timely treatment options, improved knowledge regarding the expression and management of BPD in men, adolescents and the elderly, and bridging cultural divides to create a worldwide population approach.

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.

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.

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.

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.

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.

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.

Risky drug use and effects on sleep quality and daytime sleepiness.

OBJECTIVE: Sleep problems are commonly reported following alcohol and cannabis abuse, but our understanding of sleep in non-clinical drug using populations is limited. The present study examined the sleep characteristics of alcohol and cannabis users recruited from the wider community. METHODS: Two hundred forty-eight self-identified alcohol and/or cannabis users (131 women and 117 men) with a mean age of 26.41 years completed an online study that was advertised via online forums, print media and flyers. As part of the study, participants completed validated sleep scales assessing sleep quality (Pittsburgh Sleep Quality Index) and excessive daytime sleepiness (Epworth Sleepiness Scale) in addition to validated drug scales assessing alcohol (Alcohol Use Disorders Identification Test) and cannabis (Marijuana Screening Inventory) use. RESULTS: Problems with sleep quality were more commonly reported than were complaints of excessive daytime sleepiness. Clinically significant poor sleep quality was associated with comorbid problem alcohol and cannabis use. Women reporting problem alcohol and cannabis use had poorer sleep outcomes than men. CONCLUSIONS: Social drug users who report risky alcohol and cannabis use also report poor sleep. Poor sleep quality likely exacerbates any drug-associated problems in non-clinical populations.

Long-Term Antihyperalgesic and Opioid-Sparing Effects of 5-Day Ketamine and Morphine Infusion ("Burst Ketamine") in Diabetic Neuropathic Rats.

BACKGROUND: "Burst ketamine" (BK) is the long-term infusion of subanesthetic ketamine in combination with an opioid. It is used clinically with mixed success to provide long-term pain relief and improve opioid response in patients. BK has not been simulated preclinically, therefore, its effectiveness was investigated in an animal model of neuropathic pain--streptozotocin-induced diabetic neuropathy. METHODS: Diabetic neuropathic rats were randomized to receive a subcutaneous infusion of ketamine 20 mg/kg/day plus morphine 20 mg/kg/day (BK), either drug alone at the same dose, or sham treatment. Drugs were administered continuously over 5 days via osmotic minipump. Antihyperalgesic effects and antinociceptive responsiveness to morphine (0.625-10 mg/kg, i.p.) were assessed at 2, 4, 6, and 12 weeks post-treatment using paw withdrawal latency (PWL) from noxious heat (thermal hyperalgesia) and mechanical touch (tactile allodynia). RESULTS: Antihyperalgesic effects with significant increases in PWL from noxious heat occurred following BK and ketamine-only infusion, persisting 12 and 4 weeks, respectively. Opioid-sparing effects from noxious heat with increased sensitivity to morphine analgesia also occurred for 6 weeks after BK and 2 weeks after ketamine treatment; acute treatment with the maximum nonsedating dose of morphine (5 mg/kg) produced an antinociceptive effect in these two groups, but not in sham-treated rats. In morphine-only infusion rats, hyperalgesia and opioid insensitivity were both increased. CONCLUSIONS: This is the first preclinical study to use a model of neuropathic pain to demonstrate the utility of the BK procedure for delivering a long-lasting reduction in hyperalgesia and improved antinociceptive responsiveness to opioids.