The course of borderline personality disorder from adolescence to early adulthood: A 5-year follow-up study.

BACKGROUND: Studies of the medium- to long-term clinical and functional course for treatment-seeking adolescents with borderline personality disorder (BPD) are lacking. This study aims to outline the psychopathological and functional status of participants, five years after being diagnosed with BPD during adolescence. METHODS: Participants were originally enrolled in a randomized clinical trial that compared mentalization-based group treatment with treatment as usual for adolescents with BPD. Semi-structured interview assessments at five-year follow-up included the Schedules for Clinical Assessment in Neuropsychiatry and the Structured Clinical Interview for DSM-5 Personality Disorders. Attention deficit hyperactivity disorder (ADHD), alcohol, substance and tobacco use, posttraumatic stress disorder (PTSD), complex PTSD, and general functioning were assessed using self-report instruments. RESULTS: 97 of the original sample of 111 participants (87%) participated. They were aged 19-23 years. The most prevalent disorders were ADHD (59%), any personality disorder (47%) of which half continued to meet criteria for BPD (24%), anxiety disorders (37%), depressive disorders (32%), PTSD or complex PTSD (20%), schizophrenia (16%), and eating disorders (13%). Only 16% did not meet criteria for any mental disorder. Approximately half of the sample were in psychological and/or psychopharmacological treatment at the time of follow-up. Their general functioning remained impaired, with 36% not engaged in education, employment or training (NEET), which is nearly four times the rate of NEET in the same age group in the general population. CONCLUSIONS: Although stability of the categorical BPD diagnosis is modest, adolescents meeting diagnostic criteria for BPD show a broad range of poor outcomes at five-year follow-up. BPD appears to be a marker of general maladjustment during adolescence and a harbinger of severe problems during the transition to young adulthood. Early intervention programs for adolescents diagnosed with BPD should focus upon a broad range of functional and psychopathological outcomes, especially social and vocational support, rather than the narrow BPD diagnosis.

Certified Nurse-Midwives in Rural Kansas Hospitals: A Survey of Senior Hospital Administrators.

INTRODUCTION: Little is known about the nurse-midwifery workforce in rural Kansas hospitals, despite Kansas facing a shortage of primary care physicians providing maternity care rurally. This study investigated the current number of hospitals with certified nurse-midwives (CNMs) with privileges to attend births in Kansas hospitals located in frontier, rural, and densely settled rural counties and anticipated trends in the size of the CNM workforce at hospitals over the next 5 years. METHODS: Electronic surveys were distributed to senior hospital administrators at 94 hospitals in rural Kansas from June to July 2019. The survey included both open and closed-ended questions related to scope of CNM privileges, collaborative agreements, and forecasted trends in the CNM workforce in rural Kansas. RESULTS: Fifty-six hospitals completed the survey. Only one hospital reported having CNM-attended births. Twenty-eight of 37 hospital administrators agreed CNMs should have collaborative agreements with physicians. Most respondents did not anticipate the number of CNMs with privileges to increase at their hospitals over the next 5 years. DISCUSSION: Future research should focus on understanding the factors limiting CNM expansion in rural Kansas, because CNMs represent an untapped, additional maternity care workforce for rural Kansas.

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

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

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

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

The mediating role of mentalizing capacity between parents and peer attachment and adolescent borderline personality disorder.

BACKGROUND: Insecure attachment is a precursor and correlate of borderline personality disorder. According to the mentalization-based theory of borderline personality disorder, the presence of insecure attachment derails the development of the capacity to mentalize, potentially resulting in borderline pathology. While one prior study found support for this notion in adolescents, it neglected a focus on peer attachment. Separation from primary caregivers and formation of stronger bonds to peers are key developmental achievements during adolescence and peer attachment warrants attention as a separate concept. FINDINGS: In a cross-sectional study, female outpatients (Mage 15.78=, SD = 1.04) who fulfilled DSM-5 criteria for BPD (N = 106) or met at least 4 BPD criteria (N = 4) completed self-reports on attachment to parents and peers, mentalizing capacity (reflective function) and borderline personality features. Our findings suggest that in a simple mediational model, mentalizing capacity mediated the relation between attachment to peers and borderline features. In the case of attachment to parents, the mediational model was not significant. CONCLUSIONS: The current study is the first to evaluate this mediational model with parent and peer attachment as separate concepts and the first to do so in a sample of adolescents who meet full or sub-threshold criteria for borderline personality disorder. Findings incrementally support that mentalizing capacity and attachment insecurity, also in relation to peers, are important concepts in theoretical approaches to the development of borderline personality disorder in adolescence. Clinical implications are discussed.

First empirical evaluation of outcomes for mentalization-based group therapy for adolescents with BPD.

Adolescent borderline personality disorder (BPD) is a devastating disorder, and it is essential to identify and treat the disorder in its early course. A total of 34 female Danish adolescents between 15 and 18 years old participated in 1 year of structured mentalization-based group therapy. Twenty-five adolescents completed the study, of which the majority (23) displayed improvement regarding borderline symptoms, depression, self-harm, peer-attachment, parent-attachment, mentalizing, and general psychopathology. Enhanced trust in peers and parents in combination with improved mentalizing capacity was associated with greater decline in borderline symptoms, thereby pointing to a candidate mechanism responsible for the efficacy of the treatment. The current study provides a promising rationale for the further development and evaluation of group-format mentalization-based treatment for adolescents with borderline traits. (PsycINFO Database Record

Mentalization-based treatment in groups for adolescents with borderline personality disorder (BPD) or subthreshold BPD versus treatment as usual (M-GAB): study protocol for a randomized controlled trial.

BACKGROUND: Evidence-based outpatient psychotherapeutic programs are first-line treatment of borderline personality disorder (BPD). Early and effective treatment of BPD is crucial to the prevention of its individual, psychosocial, and economic consequences. However, in spite of recent advantages in diagnosing adolescent BPD, there is a lack of cost-effective evidence-based treatment programs for adolescents. Mentalization-based treatment is an evidence-based program for BPD, originally developed for adults. AIMS/HYPOTHESES: We will investigate whether a specifically designed mentalization-based treatment in groups is an efficacious treatment for adolescents with BPD or subthreshold BPD compared to treatment as usual. The trial is a four-center, two-armed, parallel-group, assessor-blinded randomized clinical superiority trial. One hundred twelve patients aged 14 to 17 referred to Child and Adolescent Psychiatric Clinics in Region Zealand are randomized to 1 year of either mentalization-based treatment in groups or treatment as usual. Patients will be included if they meet at least four DSM-5 criteria for BPD. The primary outcome is self-reported borderline features at discharge. Secondary outcomes will include self-harm, depression, BPD criteria, externalizing and internalizing symptoms, and social functioning, together with parental reports on borderline features, externalizing and internalizing symptoms. Measures of attachment and mentalization will be included as mediational variables. Follow-up assessment will take place at 3 and 12 months after end of treatment. DISCUSSION: This is the first randomized controlled trial to test the efficacy of a group-based mentalization-based treatment for adolescents with BPD or subthreshold BPD. If the results confirm our hypothesis, this trial will add to the treatment options of cost-effective treatment of adolescent BPD. TRIAL REGISTRATION: Clinicaltrials.gov NCT02068326 , February 19, 2014.