Handbook of Psychiatric Measures

Purpose of review The International Classification of Diseases, 11th Edition (ICD-11) classifies personality disturbance according to levels of severity. This article reviews the literature on levels of personality functioning in relation to clinical management and treatment, and proposes how these findings apply to the ICD-11 classification of personality disorders. Recent findings Findings were primarily derived from studies using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) Level of Personality Functioning Scale (LPFS), Kernberg's Level of Personality Organization, and the general P-factor of personality disorder. Severity of personality dysfunction is related to treatment outcome, risk of dropout, therapeutic alliance, readiness for treatment, risk of harm to self or others, risk of dissociation and psychotic-like breaks, coherence in narrative identity, reflective functioning, and epistemic trust. Summary The overall level of personality disorder severity indicates risk of negative outcomes and may be used as decision tool for 'personalized medicine' and required treatment intensity (e.g., strength of alliance and the need for establishing epistemic trust). Beyond the ICD-11 guidelines for determining personality disorder severity, these implications also apply to practitioners using comparable frameworks such as the DSM-5 LPFS and Kernberg's Level of Personality Organization. Future research should focus on the interaction of severity with trait qualifiers in relation to clinical management.

How does level of personality functioning inform clinical management and treatment? Implications for ICD-11 classification of personality disorder severity.

Personality disorders (PDs) exert a great toll on health resources, and this is especially true for borderline personality disorder (BPD). As all PDs, BPD arises during adolescence or young adulthood. It is therefore important to detect the presence of this PD in its earlier stages in order to initiate appropriate treatment, thus ameliorating the prognosis of this condition. This review aims to highlight the issues associated with BPD diagnosis in order to promote its early detection and treatment. To do so, we conducted a search on PubMed database of current evidence regarding BPD early diagnosis, focusing on risk factors, which represent important conditions to assess during young patient evaluation, and on diagnostic tools that can help the clinician in the assessment process. Our findings show how several risk factors, both environmental and genetic/neurobiological, can contribute to the onset of BPD and help identify at-risk patients who need careful monitoring. They also highlight the importance of a careful clinical evaluation aided by psychometric tests. Overall, the evidence gathered confirms the complexity of BDP early detection and its crucial importance for the outcome of this condition.

Borderline Personality Disorder: Risk Factors and Early Detection.

Even though the borderline concept has historically been intertwined with psychosis, psychotic symptoms in people with borderline personality disorder (BPD) have long been marginalized as somehow not real, transient, or 'pseudo' in nature. Dispelling this myth, we summarize recent research indicating that (a) psychotic symptoms in general and auditory verbal hallucinations in particular in people with BPD show more similarities than differences with those symptoms in people with psychotic disorders, and (b) that the co-occurrence of BPD and psychotic symptoms is a marker of severe psychopathology and of risk for poor outcome (e.g. suicidality). We propose the period from puberty to the mid-20s, when both BPD and psychotic features usually emerge for the first time, constitutes a critical time window for early intervention to prevent the development of severe mental disorders in the future. Implications for the treatment of psychotic symptoms in BPD and future research directions in this field are discussed.

Psychotic symptoms in borderline personality disorder: developmental aspects.

Psychotic symptoms in BPD are not uncommon, and they are diverse and phenomenologically similar to those in schizophrenia spectrum disorders. Despite their prevalence in BPD patients, knowledge about the characteristics and severity of hallucinations is limited, especially in modalities other than auditory.This review summarises the causes, phenomenology, severity, and treatment options of hallucinations and other psychotic symptoms in BPD.The PubMed database was used with the following key terms: "borderline personality disorder" and 'hallucinations' and "psychotic symptoms". Articles were selected between January 1990 and May 2021. The primary keyword search yielded a total of 545 papers, of which 102 articles met the inclusion criteria and were fully screened. Papers from the primary source reference lists were also screened, assessed for eligibility, and then added to the primary documents where appropriate (n = 143). After the relevance assessment, 102 papers were included in the review. We included adult and adolescent studies to gather more recent reviews on this topic.Hallucinations are significantly prevalent in BPD, mainly auditory, similar to schizophrenia spectrum disorders. The relationship between hallucinations and depression, anxiety, suicidality, schizotypy, and loneliness in BPD has been discovered but requires more research. Studies for treatment options for hallucinations in BPD are lacking.Recognition of psychotic symptoms in patients with BPD as distinguished psychopathological phenomena instead of diminishing and overlooking them is essential in the clinical assessment and can be useful in predicting complications during treatment. More focused research in this area is needed. 

Hallucinations and Other Psychotic Symptoms in Patients with 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.

Avoiding Misdiagnosis When Auditory Verbal Hallucinations Are Present in Borderline Personality Disorder.

Background The availability of specialist psychotherapies for treating borderline personality disorder (BPD) is limited by costs associated with training, resourcing and treatment duration. Developing a programme that incorporates effective strategies from a range of evidence-based specialist treatments, concentrates their delivery and uses a group-based format will improve treatment access. Objective To assess the short-term clinical efficacy, acceptability and feasibility of a bespoke manualised programme for the treatment of BPD. This 10-week group-based outpatient programme was delivered 2 days per week in 4 hour sessions; participants received 80 hours of treatment in total. Methods Forty-three participants, many having severe BPD symptomatology, were assessed before and after the 10-week programme using a range of validated self-report questionnaires and a self-appraisal feedback form. The primary outcome measured was BPD symptom severity. Findings Statistically significant improvements were measured in BPD symptom severity, depression, trait anxiety, emotional regulation, general health, hopefulness, self-compassion and anger, several with moderate to large effect sizes. Many of these improvements remained at 4–6 months post treatment. More than 90% of surveyed participants expressed a moderate or high level of satisfaction with the programme. Conclusions This integrated treatment programme delivered in a highly concentrated format demonstrated short-term efficacy across many BPD-relevant endpoints; its acceptability was endorsed by most clients. Clinical implications Incorporation of key aspects of evidence-based treatment using a time-intensive group format could greatly enhance the capacity of mental health services to meet the needs of people who experience BPD within a population-based mental health service framework.

https://ebmh.bmj.com/content/ebmental/early/2021/01/04/ebmental-2020-300195.full.pdf

Ten-week Intensive Group Program (IGP) for borderline personality disorder: making the case for more accessible and affordable psychotherapy

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Avoiding Misdiagnosis When Auditory Verbal Hallucinations Are Present in Borderline Personality Disorder.

Ten-week Intensive Group Program (IGP) for borderline personality disorder: making the case for more accessible and affordable psychotherapy