Pathoetiology and pathophysiology of borderline personality: Role of prenatal factors, gut microbiome, mu- and kappa-opioid receptors in amygdala-PFC interactions.

The pathoetiology and pathophysiology of borderline personality disorder (BPD) have been relatively under-explored. Consequently, no targetted pharmaceutical treatments or preventative interventions are available. The current article reviews the available data on the biological underpinnings of BPD, highlighting a role for early developmental processes, including prenatal stress and maternal dysbiosis, in BPD pathoetiology. Such factors are proposed to drive alterations in the infant's gut microbiome, in turn modulating amygdala development and the amygdala's two-way interactions with other brain regions. Alterations in opioidergic activity, including variations in the ratio of the mu-and kappa-opioid receptors seem a significant aspect of BPD pathophysiology, contributing to its comorbidities with depression, anxiety, impulsivity and addiction. Stress and dysphoria are commonly experienced in people classed with BPD. A growing body of data, across a host of medical conditions, indicate that stress and mood dysregulation may be intimately associated with gut dysbiosis and increased gut permeability, coupled to heightened levels of oxidative stress and immune-inflammatory activity. It urgently requires investigation as to the relevance of such gut changes in the course of BPD symptomatology. Accumulating data indicates that BPD symptom exacerbations may be linked to cyclical variations in estrogen, in turn decreasing serotonin and local melatonin synthesis, and thereby overlapping with the pathophysiology of migraine and endometriosis, which also have a heightened association with BPD. Future research directions and treatment implications are indicated.

Mortality and Medical Comorbidity in the Severely Mentally Ill.

BACKGROUND: Mentally ill patients die on average 10 years earlier than the general population, largely due to general medical disorders. This study is the first to explore in a large German sample the prevalence, mortality, and medical comorbidity in pa- tients with severe mental illness (SMI). The patients were affected by borderline personality disorder (BPD), psychotic disorders, bipolar disorder, or severe unipolar depression. METHODS: Our database consists of billing data from all adults with statutory health insurance in Germany. Twelve-month administrative SMI prevalence and medical comorbidity were estimated using cross-sectional data from 2016 (age ≥ 18; N = 59 561 310). Two-year mortality was established longitudinally in a randomly selected subset of the billing data (most recent mortality information available for 2012 to 2014; 2012: n = 15 590 107). RESULTS: Severe unipolar depression had the highest prevalence (2.01%), followed by psychotic disorders (1.25%), BPD (0.34%), and bipolar disorder (0.29%). While the prevalence of malignant neoplasms showed moderate deviations from reference values [severe unipolar depression: OR = 1.30 (95% CI = 1.29; 1.31), BPD: OR = 1.11 (1.09; 1.14), psychotic dis- orders: OR = 0.90 (0.89; 0.90), bipolar disorder: OR = 1.07 (1.06; 1.09)], other disease groups (infectious, endocrine/nutritional/ metabolic, circulatory, respiratory) were substantially elevated in all categories of SMI. Mortality rates for psychotic disorders, BPD, bipolar disorder, and severe unipolar depression were increased (OR = 2.38 [95% CI=2.32; 2.44], 2.30 [2.08; 2.54], 1.52 [1.42; 1.62], and 1.40 [1.37; 1.44], respectively), with a loss of 2.6 to 12.3 years, depending on age, sex, and SMI. CONCLUSION: Mortality is substantially elevated in all SMI patients. The results underline the need to remove barriers to adequate general medical care, both on the patient and the provider side, to reduce excess mortality.

Predictors of short- and long-term recurrence of suicidal behavior in borderline personality disorder.

OBJECTIVE: To evaluate the incidence of suicidal outcomes and risk factors for short- and long-term recurrence of suicidal behavior (SB) among high-risk borderline personality disorder (BPD) patients during a 24-month prospective follow-up period. METHODS: A multicenter prospective cohort study was designed to compare data obtained from 136 patients admitted to the emergency department for current suicidal ideation (SI) or a recent suicide attempt (SA). Subjects were clinically evaluated and monitored for a new SA or suicide. RESULTS: The incidence of a new SA was 25.63 events/100 persons-year, and one patient died by suicide. Child sexual abuse (CSA) was the only significant predictor throughout the complete follow-up period. The absence of prior psychiatric treatment predicts the recurrence of SB in the first 6 months of follow-up. Patient age, poor psychosocial functioning before hospitalization, age at first SA, and having multiple suicide attempts increased risk of SB recurrence at the long-term period (24th months). In addition, there was an interaction between CSA and poor psychosocial functioning that increased risk of SB. CONCLUSION: The risk of recurrence was higher during the first 6 months. Risk factors at 6 and 24 months vary. These findings are important for implementing suicide strategies.

Suicidality in Borderline Personality Disorder.

Borderline personality disorder (BPD) is associated with suicidal behaviors and self-harm. Up to 10% of BPD patients will die by suicide. However, no research data support the effectiveness of suicide prevention in this disorder, and hospitalization has not been shown to be useful. The most evidence-based treatment methods for BPD are specifically designed psychotherapies.

The complexities of the borderline patient: how much more complex when considering physical health?

OBJECTIVE: Borderline Personality Disorder is associated with a substantially reduced life expectancy, mostly due to physical health conditions that are life-shortening. This clinical review highlights pertinent risk issues for such conditions in Borderline Personality Disorder and suggests ways in which clinicians might address these. METHODS: Selective literature review. RESULTS: People with Borderline Personality Disorder have a reduced life expectancy of some 20 years, attributable largely to physical health maladies, notably cardiovascular. Risk factors include obesity, sedentary lifestyle, poor diet and smoking. Added to these are other physical health problems, including poor sexual health, self-harm, substance use and blood-borne viruses. Chronic pain and opioid and benzodiazepine use are also common in people with Borderline Personality Disorder. Some psychiatric medications commonly used in people with Borderline Personality Disorder - notably certain antipsychotic agents - can add to the metabolic burden. Barriers to care include self-stigma and erratic adherence to medical care, as well as stigma on the part of clinicians, who often do not screen or provide adequate care for the physical health problems suffered by people with Borderline Personality Disorder. CONCLUSIONS: Clinicians need to be aware of the physical health problems in people with Borderline Personality Disorder and ensure appropriate screening and interventions, both preventative and therapeutic, are offered routinely.

Deaths by Suicide and Other Causes Among Patients With Borderline Personality Disorder and Personality-Disordered Comparison Subjects Over 24 Years of Prospective Follow-Up.

OBJECTIVE: This study has 4 aims. The first is to determine rates of mortality due to suicide and other causes for patients with borderline personality disorder (BPD) and personality-disordered comparison subjects over 24 years of prospective follow-up. The second and third aims are to determine the best predictors of time-to-suicide and time-to-premature death (not due to suicide) in patients with BPD. A final aim is to determine whether mortality rates are impacted by recovery status. METHODS: A total of 290 adult inpatients meeting rigorous Revised Diagnostic Interview for Borderlines and DSM-III-R criteria for BPD and 72 personality-disordered comparison subjects were recruited during inpatient admission at McLean Hospital between June 1992 and December 1995. Participants were followed and reassessed every 2 years, with data collection now entering its 26th year. Participant deaths were tracked over time. RESULTS: A total of 5.9% of borderline patients and 1.4% of comparison subjects died by suicide. Additionally, 14.0% of borderline patients and 5.5% of comparison subjects died by non-suicide causes. Among borderline patients, number of prior hospitalizations significantly predicted completed suicide (HR = 1.62, P = .037). Sociodemographic factors, physical health indicators, and psychiatric history significantly predicted premature death (not due to suicide) in bivariate analyses (all P values < .05). In multivariate analyses, male sex (HR = 3.56, P = .003) and more prior psychiatric hospitalizations (HR = 2.93, P < .001) significantly predicted premature death. Most borderline patients who died either by suicide (87.5%) or non-suicide-related causes (88%) were not recovered before death. CONCLUSIONS: Taken together, these findings suggest that individuals with BPD are at elevated risk of premature death. Patients who did not achieve recovery were at a disproportionately higher risk of early death than recovered patients.

Trastorno límite de la personalidad y conductas autolíticas / Borderline personality disorder and self-harming behaviors

En este artículo se rastrean los factores de riesgo de suicidio en pacientes con diagnóstico de trastorno límite de la personalidad y se propone un abordaje de diagnóstico exhaustivo. Se realizó una búsqueda bibliográfica en PubMed (desde 2007) con las palabras clave (en inglés) «trastorno límite de la personalidad», «suicidio» y «conductas autolíticas». A partir de los resultados, se elaboraron las siguientes conclusiones: 1) las conductas autolesivas no autolíticas se diferencian de los intentos letales de suicidio en pronóstico y en rasgos de personalidad; 2) hay resultados contradictorios, probablemente porque el trastorno límite de la personalidad es una categoría heterogénea; y 3) el riesgo global de suicidio consumado en estos pacientes es elevado y los actuales criterios diagnósticos (DSM-IV-TR) son insuficientes para capturar los indicadores de riesgo asociados (afección comórbida, entorno y rasgos de personalidad). Finalmente se propone una exploración topográfica de la personalidad, que incluye aspectos relevantes no capturados por el DSM-IV(AU)

This review explores suicide risk factors in patients diagnosed with borderline personality disorder and proposes a comprehensive diagnostic assessment. A literature search in PubMed (since 2007) was performed, with the following key word search: "borderline personality disorder", "suicide", and "self-harming behaviour". With the selected articles, the following conclusions were drawn up: 1) self harming behaviors are different to lethal suicide attempts in terms of prognosis and personality traits; 2) there are controversial results, probably explained by the fact that borderline personality disorder is an heterogeneous category; and 3) the global risk of completed suicide in these patients is high and the current diagnostic criteria (DSM-IV-TR) do not take into account the associated risk factors (comorbidities, environment, personality traits). Lastly, a topographic assessment of personality, including those aspects not present in the DSM, is proposed(AU)

In-patient suicide--a 13-year assessment.

OBJECTIVE: To describe the suicide rates of psychiatric in-patients in the canton of Zurich for the period 1992-2004, and to determine putative risk factors. METHOD: The data were derived from the psychiatric case register of the canton Zurich. The analyses were based on person-years calculations and standardised mortality ratios. Additional information was assessed via case records. RESULTS: During the 13-year period the standardised mortality ratio was 48.9. The risk of suicide was particularly high in patients with personality and affective disorders. Most suicides occurred during regular leave periods, despite the fact that clinical assessment had indicated there was no suicide risk for the patient. CONCLUSION: The suicide risk of in-patients is distinctly higher than in the general population. A better assessment of suicide risk before regular leave periods could lead to a decrease of suicides in in-patient settings, as well as a more rigorous treatment of borderline cases, and of affective and psychotic symptoms.

An examination of DSM-IV borderline personality disorder symptoms and risk for death by suicide: a psychological autopsy study.

OBJECTIVE: To clarify whether certain Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), borderline personality disorder (BPD) symptoms are more prevalent among people who die by suicide, and thereby better predict suicide risk. METHOD: A psychological autopsy method with best informants was used to investigate DSM-IV BPD symptoms and suicide risk among people who died by suicide and met criteria for BPD (n = 62), and BPD control subjects (n = 35). RESULTS: BPD symptoms in people who died by suicide were less likely to include affective instability and paranoid ideation-dissociative symptoms. The negative association between paranoid ideation-dissociative symptoms and suicide was independent of all other BPD symptoms, Cluster B comorbidity, and alcohol dependence. CONCLUSIONS: We found that discrete DSM-IV BPD symptoms differentiate people with BPD who die by suicide and those who do not. People with BPD who go on to die by suicide appear to constitute a specific subgroup of those who meet criteria for BPD, characterized by different general clinical presentation, but also by different characteristics within BPD.

Psychosocial functioning of borderline patients and axis II comparison subjects followed prospectively for six years.

The purpose of this study was to determine the course of the psychosocial functioning of patients with borderline personality disorder (BPD) over 6 years of prospective follow-up. The psychosocial functioning of 290 patients meeting both DIB-R and DSM-III-R criteria for BPD and 72 patients meeting DSM-III-R criteria for another Axis II disorder (and neither criteria set for BPD) was assessed at baseline using a semistructured interview of demonstrated reliability. Over 94% of surviving patients were reinterviewed about their psychosocial functioning blind to all previously collected information at three distinct follow-up waves: 2-, 4-, and 6-year follow-up. The psychosocial functioning of borderline patients improved substantially over time, with the percentage meeting criteria for good overall psychosocial functioning increasing from 26% at baseline to 56% during the third wave of follow-up. Despite this improvement, borderline patients functioned significantly more poorly than Axis II comparison subjects, particularly in the area of vocational achievement. However, a more detailed examination revealed that borderline patients who had experienced a symptomatic remission during the course of the study functioned significantly better both socially and vocationally than never-remitted borderline patients. More specifically, they were significantly more likely to have a good relationship with a spouse/partner and at least one parent, good work/school performance, a sustained work/school history, a GAF score of 61 or higher (43% vs. 0% 6 years after their index admission), and to have good overall psychosocial functioning (66% vs. 27% at 6 year follow-up). Taken together, the results of this study suggest that psychosocial improvement is both common among borderline patients and strongly related to their symptomatic status.

Reported suicidal behavior and current suicidal ideation in a psychiatric outpatient clinic.

One thousand consecutive intakes at an outpatient psychiatric clinic were screened for past suicide attempts and present suicidal ideation and diagnosed using DSM-III-R criteria. A full range of thoughts about death and suicide were prevalent in all diagnostic groups. Over one-third of patients with major depression and borderline personality disorder had actual plans to kill themselves, and over two-thirds of patients with borderline personality disorder had made one or more suicide attempts.

Witnessed suicides.

Suicides that take place in the presence of others have not been the topic of systematic scientific inquiry. The so-called witnessed suicides account for a small percentage of all suicides but offer a unique view into the dynamics of self-destructive behavior. An epidemiologic and forensic description of 50 witnessed suicides drawn from a 15-year series of over 1,000 cases is presented. A taxonomy is developed based on the role played by the witness and related to previous work on self-destructive behavior and its motivation. Brief vignettes are used to illustrate some of the interpersonal dynamics associated with these deaths.

Self-destructive behavior in children and adolescents.

This overview of suicidal behavior of children and adolescents covers aspects of epidemiology and risk factors. The risk factors can be classified as early developmental experiences, expression of affects, and current environmental situations. These risk factors include depression, aggression, parental suicidal behavior, family losses, and family violence and depression.