Becoming Trustworthy in Treating Patients With Borderline Personality Disorder.

No one doubts the importance of trust in psychotherapy, but few therapists think about the complexities of trusting relationships, and the trustworthiness that would justify trusting remains far from view. Fortunately, inasmuch as trusting and trustworthiness are inherently ethical concepts, contemporary philosophers have given trust the consideration it warrants. Integrating science and philosophy, the author reviews the broad scope and multifaceted nature of trust and trustworthiness, the social-cognitive development of trust, and the development of distrust in the context of borderline personality disorder. Without questioning therapists' character, the author makes the case for shifting the emphasis from the patient's distrust to the therapist's challenge to become trustworthy in the course of each treatment relationship and, more broadly, over the course of a professional career.

Contending With Polarization in the Expanding Scope of Psychotherapy.

The author queried 32 colleagues about their sense of polarization in the field of psychotherapy, using as an example the contrast between generalists (like himself) and specialists. This query was inspired by the proliferation of brands of psychotherapy coupled with the dominance of cognitive-behavioral therapies. His key conclusions: (a) tensions in the field are associated with a multitude of polarities and individual differences; (b) it is folly to reduce polarization to any single polarity; and (c) given the field's huge diversity, we are all specialists. While the author advocates greater integration of theories and methods, he also argues for expansion by including ethical thought into the scientific zeitgeist. He proposes skill in being human as a broad aspiration for therapists and patients.

Predicting depression outcomes throughout inpatient treatment using the general and specific personality disorder factors.

BACKGROUND: Clinical intuition suggests that personality disorders hinder the treatment of depression, but research findings are mixed. One reason for this might be the way in which current assessment measures conflate general aspects of personality disorders, such as overall severity, with specific aspects, such as stylistic tendencies. The goal of this study was to clarify the unique contributions of the general and specific aspects of personality disorders to depression outcomes. METHODS: Patients admitted to the Menninger Clinic, Houston, between 2012 and 2015 (N = 2352) were followed over a 6-8-week course of multimodal inpatient treatment. Personality disorder symptoms were assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th edition Axis II Personality Screening Questionnaire at admission, and depression severity was assessed using the Patient Health Questionnaire-9 every fortnight. General and specific personality disorder factors estimated with a confirmatory bifactor model were used to predict latent growth curves of depression scores in a structural equation model. RESULTS: The general factor predicted higher initial depression scores but not different rates of change. By contrast, the specific borderline factor predicted slower rates of decline in depression scores, while the specific antisocial factor predicted a U shaped pattern of change. CONCLUSIONS: Personality disorder symptoms are best represented by a general factor that reflects overall personality disorder severity, and specific factors that reflect unique personality styles. The general factor predicts overall depression severity while specific factors predict poorer prognosis which may be masked in prior studies that do not separate the two.

Personality trait domains predict psychiatric symptom and functional outcomes.

A review of high intensity, high dose mentalization-based inpatient psychiatric treatment indicated large effect-size reductions in symptoms of depression, anxiety, somatization, and improving emotion-regulation functioning (Allen et al., 2017). This study examined the impact of pathological personality traits has on baseline symptoms and functioning, as well as their impact on the longitudinal course in a large cohort of adult inpatient psychiatric sample (N = 804). The Personality Inventory for DSM-5 (PID-5; Krueger et al., 2012) was used to assess trait domains impact on longitudinal outcomes (anxiety, depression, somatic symptoms, and functional impairment) using hierarchical repeated measures modeling. Results indicate Negative Affectivity and Detachment were related to higher admission severity in all four outcome domains. Psychoticism was related to somatic symptoms, while Antagonism and Disinhibition were related to functional impairment. Paradoxically, when symptoms were plotted over 2-week intervals during hospitalization, patients with higher admission PID-5 trait scores exhibited greater improvement over time. The PID-5 appears to contribute to prediction of treatment outcome response above and beyond demographic and burden of illness. Importantly, the findings add to a growing body of literature indicating that impairments in personality traits do not preclude positive treatment response, particularly when treatments target pathological personality features. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Attachment Style Mediates the Relationship between Trauma and Somatic Distress among Individuals with Serious Mental Illness.

Objective: Individuals with mental illnesses severe enough to require psychiatric hospitalization often have significant trauma histories, have developed maladaptive attachment styles, and experience comorbid somatic distress. Gaining an understanding about the interaction of such factors may lead to prioritizing interventions that target factors that mediate the relationship between trauma and adverse somatic distress. Prior research has examined various mediation models, but results have been mixed and conducted only on outpatient samples.Method: Participants (47.7% female) in a large sample (N = 2702) with a mean age of 34.62 (SD = 14.7) were enrolled in a specialist inpatient program and completed self-report measures pertaining to demographics, attachment insecurity, lifetime trauma exposure, and somatic distress within 72 hours of admission. The dimensions of attachment insecurity (i.e., attachment anxiety and attachment avoidance) were tested as parallel mediators in the relationship between lifetime trauma exposure and somatic distress.Results: The mediation analyses revealed that attachment anxiety and avoidance partially mediated the relationship between lifetime trauma exposure and somatic distress.Conclusions: These results are the first to date to implicate both attachment anxiety and avoidance as mediators between trauma exposure and somatic distress in a high acuity sample. Although the results do not imply causality, they do call attention to social-cognitive factors related to somatic distress and highlight the importance of considering attachment styles as a possible contributor to comorbid physical symptoms in patients with trauma exposure.

Diagnostic accuracy of DSM-5 borderline personality disorder criteria: Toward an optimized criteria set.

OBJECTIVE: The polythetic system used by the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) for diagnosing borderline personality disorders (BPD) is far from optimal; however, accumulated research and clinical data are strong enough to warrant ongoing utilization. This study examined diagnostic efficiency of the nine DSM-IV BPD criteria, then explored the feasibility of an optimized criteria set in classifying BPD. METHODS: Adults (N=1,623) completed the Structured Clinical Interviews for DSM-IV Axis II Disorders resulting in a BPD group (n=352) and an inpatient psychiatric control group (PC) with no personality disorders (n=1,271). Receiver operator characteristics and diagnostic efficiency statistics were calculated to ascertain the relative diagnostic efficiency of each DSM-5 BPD criterion in classifying BPD cases. RESULTS: Affective instability (Criterion 6) evidenced the strongest capacity to differentiate the groups (AUC = .84, SE = .01, p < .0001). Abandonment fears (Criterion 1), unstable relationships (Criterion 2), identity disturbance (Criterion 3), impulsivity (Criterion 4), and chronic emptiness (Criterion 7) yielded good-to-moderate discrimination (AUC range = .75-.79). A composite index of these six criteria yielded excellent accuracy (AUC = .98, SE = .002, p < .0001), sensitivity (SN=.99), and specificity (SP=.90). CONCLUSIONS: The current findings add to evidence that affective instability is a useful gate criterion for screening, and the optimized criteria set evidences equivalent accuracy to the original 9 criteria, with a substantial reduction in estimated heterogeneity (from 256 combinations with the original set to 42 combinations with the optimized set).

Using the attachment network Q-sort for profiling one's attachment style with different attachment-figures.

Attachment instruments vary substantially in practicability of administration, employment of categorical versus dimensional scoring, quality of scales, and applicability to different attachment figures. The Attachment Network Q-sort (ANQ) is a self-report, quasi-qualitative instrument that discriminates relationship-specific attachment styles for multiple attachment figures. The current study assesses the properties of the ANQ in psychotherapy patients and in non-patient respondents, using mother, father and romantic partner as possible attachment figures. Analyzing the ANQ-data with latent class analysis, we found four types or classes of participants: a group with an overall secure profile, a group only insecure for father, a group only insecure for mother, and a group insecure for mother as well as father but not for partner (if available). These profiles proved to have good concurrent, discriminant and construct validity. We conclude that the ANQ is potentially a useful alternative clinical self-report instrument to assess combinations of attachment styles for a range of attachment figures such as parents and a romantic partner.

Lifetime and prospective associations among personality trait domains and suicide-related behaviors in patients with severe mental illness.

BACKGROUND: Despite extensive research and clinical efforts, the suicide rate in the United States continues to rise, driving the need for more research to identify latent factors that increase risk for suicide and to guide treatment decision-making. METHODS: The current study examined a large cohort (N = 1,219) of high-risk psychiatric inpatients to explore associations between personality traits and suicide-related variables measured retrospectively (lifetime history prior to hospital admission) and prospectively (at discharge and 12-month follow-up). RESULTS: Lifetime suicide-related behavior (SRB: combination of ideational severity, aborted, interrupted, actual attempts, and non-suicidal self-injury) was associated with age (younger), gender (female), and elevated scores on the Personality Inventory for DSM-5 (PID-5) negative affectivity, borderline trait composite score, and five-factor model traits of conscientiousness and neuroticism. Patients who manifested persistent suicidal ideation throughout a 6-8 week inpatient treatment (n = 162; 16.9%) tended to be younger, female, and to have elevated PID-5 borderline trait composite scores. Twelve-month post-discharge SRB was predicted by elevated PID-5 borderline trait composite scores. LIMITATIONS: Personality traits accounted for a small amount of variance in the overall model, thus limiting prediction based on individual traits. CONCLUSIONS: This large sample of high-risk inpatients with longitudinal outcomes provides a rare assessment of proximal personality traits in predicting lifetime SRB, persistent suicidal ideation observed during the course of a 6-8-week intensive inpatient treatment, and SRB outcomes within 12 months after discharge from hospitalization. Personality traits should be included in future attempts to create predictive algorithms that include relevant biological data (neuroimaging, genetic, microbiome).

Differentiating bipolar disorder from borderline personality disorder: Diagnostic accuracy of the difficulty in emotion regulation scale and personality inventory for DSM-5.

BACKGROUND: Confusion abounds when differentiating the diagnoses of bipolar disorder (BD) from borderline personality disorder (BPD). This study explored the relative clinical utility of affective instability and self-report personality trait measures for accurate identification of BD and BPD. METHODS: Receiver operator characteristics and diagnostic efficiency statistics were calculated to ascertain the relative diagnostic efficiency of self-report measures. Inpatients with research-confirmed diagnoses of BD (n = 341) or BPD (n = 381) completed the Difficulty in Emotion Regulation Scale (DERS) and Personality Inventory for DSM-5 (PID-5). RESULTS: The total score for DERS evidenced relatively poor accuracy for differentiating the disorders (AUC = 0.72, SE = 0.02, p < .0001), while subscales of affective instability measures yielded fair discrimination (AUC range = 0.70-0.59). The PID-5 BPD algorithm (consisting of emotional lability, anxiousness, separation insecurity, hostility, depressivity, impulsivity, and risk taking) evidenced moderate-to-excellent accuracy (AUC = 0.83, SE = 0.04, p < .0001) with a good balance of specificity (SP = 0.79) and sensitivity (SN = 0.77). CONCLUSION: Findings support the use of the PID-5 algorithm for differentiating BD from BPD. Furthermore, findings support the accuracy of the DSM-5 alternative model Criteria B trait constellation for differentiating these two disorders with overlapping features.

A naturalistic longitudinal study of extended inpatient treatment for adults with borderline personality disorder: An examination of treatment response, remission and deterioration.

BACKGROUND: Experts express reluctance to hospitalize patients with borderline personality disorder (BPD) for more than a few days, arguing that extended inpatient care leads to deterioration and adverse events. To date, there is no empirical support for these assertions. AIMS: The current study examined the assumption of iatrogenic effects among BPD adults. METHODS: Clinically significant and reliable change in symptoms, functional capacities, and adverse events were quantified for both inpatients with BPD (n = 245) and a well-matched inpatient reference (n = 220) sample. Latent growth curve (LGC) models were used to evaluate moderators of the trajectory of PHQ-9 depression scores over the course of hospitalization. RESULTS: Large effect size improvements were observed in depression, anxiety, suicidal ideation and functional disability among patients with BPD (Cohen's d ≥ 1.0) and those in the reference sample (Cohen's d ≥ .80). Clinical deterioration and adverse events were rare (occurring in no more than 1.1% of BPD and reference patients on any outcome) with no difference across patient cohorts. BPD diagnosis failed to influence the trajectory of continuous depression severity. Rather, trait emotion dysregulation was associated with initial depression severity. CONCLUSIONS: Twenty-five years ago it was assumed that adults with BPD could not benefit from psychiatric treatment. Today there are a number of effective evidence-based outpatient treatments for BPD, but beliefs about extended inpatient treatment have changed little. Current results indicate that extended inpatient treatment can result in significant and clinically meaningful symptomatic and functional improvement in BPD patients without iatrogenic effects.

Clinical utility of the DSM-5 alternative model for borderline personality disorder: Differential diagnostic accuracy of the BFI, SCID-II-PQ, and PID-5.

BACKGROUND: With the publication of DSM 5 alternative model for personality disorders it is critical to assess the components of the model against evidence-based models such as the five factor model and the DSM-IV-TR categorical model. This study explored the relative clinical utility of these models in screening for borderline personality disorder (BPD). METHODS: Receiver operator characteristics and diagnostic efficiency statistics were calculated for three personality measures to ascertain the relative diagnostic efficiency of each measure. A total of 1653 adult inpatients at a specialist psychiatric hospital completed SCID-II interviews. Sample 1 (n=653) completed the SCID-II interviews, SCID-II Questionnaire (SCID-II-PQ) and the Big Five Inventory (BFI), while Sample 2 (n=1,000) completed the SCID-II interviews, Personality Inventory for DSM5 (PID-5) and the BFI. RESULTS: BFI measure evidenced moderate accuracy for two composites: High Neuroticism+ low agreeableness composite (AUC=0.72, SE=0.01, p<0.001) and High Neuroticism+ Low+Low Conscientiousness (AUC=0.73, SE=0.01, p<0.0001). The SCID-II-PQ evidenced moderate-to-excellent accuracy (AUC=0.86, SE=0.02, p<0.0001) with a good balance of specificity (SP=0.80) and sensitivity (SN=0.78). The PID-5 BPD algorithm (consisting of elevated emotional lability, anxiousness, separation insecurity, hostility, depressivity, impulsivity, and risk taking) evidenced moderate-to-excellent accuracy (AUC=0.87, SE=0.01, p<0.0001) with a good balance of specificity (SP=0.76) and sensitivity (SN=0.81). CONCLUSIONS: Findings generally support the use of SCID-II-PQ and PID-5 BPD algorithm for screening purposes. Furthermore, findings support the accuracy of the DSM 5 alternative model Criteria B trait constellation for diagnosing BPD. Limitations of the study include the single inpatient setting and use of two discrete samples to assess PID-5 and SCID-II-PQ.

Patient-reported Outcomes in Practice: Clinicians' Perspectives From an Inpatient Psychiatric Setting.

The use of patient-reported outcomes (PROs) has become increasingly common. They have been used to assess quality of care and to support policy decisions, but the evidence concerning their utility to improve patient outcomes is inconsistent. A better understanding of clinicians' experience with PROs has the potential to improve their effectiveness. This exploratory, quantitative, and qualitative study investigated the perspectives of clinicians (N=70) from multiple disciplines (psychiatrists, psychologists, social workers, and psychiatric nurses) on the utility of PROs in an inpatient psychiatric setting. During scheduled, monthly, discipline-specific administrative meetings, clinicians in attendance completed a 1-time, 5-item survey. The highest rated item related to the frequency of reviewing outcomes reports; this item was rated higher than all other items (mean±SD, 4.5±1.5), which 37.5% of the participants in the overall sample stated they "always" did. The lowest rated item related to the frequency of conveying the results of the outcomes reports to patients (3.3±1.9), which 20% of participants reported "always" doing; this item was rated lower than all other items (P<0.03). Qualitative analyses were based on 30 comments from 22 clinicians, which resulted in the emergence of 6 themes. The 2 themes that received the highest number of comments related to: (1) the sensitivity and specificity of measures across the PROs platform and (2) the value of the reports in directly influencing treatment decisions. Clinicians' relatively favorable perspective of PROs in practice in this study may be related to the assessment-oriented culture at the study institution. Nonetheless, many barriers to the routine use of PROs exist. Addressing clinician concerns has the potential to improve utilization of this facet of good clinical care.

An Open Effectiveness Trial of a Multimodal Inpatient Treatment for Depression and Anxiety Among Adults With Serious Mental Illness.

OBJECTIVE: This prospective open effectiveness trial examined symptom change trajectories and rates of remission from depression and anxiety in an intensive multimodal inpatient treatment for adults with serious mental illness (SMI). Patient baseline characteristics were examined as mediators/moderators of treatment response. METHODS: Adult inpatients with SMI (N = 994) completed an average of 39 days of inpatient treatment. Latent growth curve (LGC) methods were used to model symptom trajectories, estimating expected remission based on individual patterns of change observed across the sample. RESULTS: Absolute reductions in symptoms were substantial, with large effect size improvements for both depression (d = 1.21, 95% CI [1.13, 1.29]) and anxiety (d = 1.13, 95% CI [1.05, 1.21]). For those presenting with elevated depressive symptoms (Patient Health Questionnaire-Depression ≥ 5.0; 87.5% of the sample), 46.9% evidenced remission from admission to discharge. Among patients presenting with significant anxiety (Patient Health Questionnaire-Generalized Anxiety Disorder Screener ≥ 5.0; 84.5% of the sample), 50.0% evidenced remission from admission to discharge. Mediation analyses revealed that depression and anxiety severity decreased more rapidly with increasing age and initial levels of experiential avoidance. CONCLUSIONS: Rates of remission of depression and anxiety were greater than anticipated in this large cohort of adult SMI inpatients and may be related to intensity and length of hospitalization.

Discovering the impact of psychotherapeutic hospital treatment for adults with serious mental illness.

The authors summarize findings from a multiyear research project designed primarily to investigate outcomes of intensive, psychotherapeutic hospital treatment lasting several weeks. Patients are assessed with well-established measures at admission, and their progress is reassessed biweekly up to discharge. A follow-up component was added recently to track outcomes for 1 year after discharge. All inpatient assessments are integrated with clinical care by providing individual results for each time point to the patient and the treatment team. In addition to reporting findings from inpatient treatment, the authors summarize what has been learned about the measures and methodology as well as what the assessments have revealed about psychopathology in these patients. More recently, the outcomes project has included a neuroscience initiative with findings from neuroimaging, genetics, and the microbiome; initial findings are also summarized. The authors conclude with a discussion of their understanding of the basis of the effectiveness of this increasingly rare form of inpatient treatment.

A Novel Approach to Identifying a Neuroimaging Biomarker for Patients With Serious Mental Illness.

Serious mental illness (SMI) is disabling, and current interventions are ineffective for many. This exploratory study sought to demonstrate the feasibility of applying topological data analysis (TDA) to resting-state functional connectivity data obtained from a heterogeneous sample of 235 adult inpatients to identify a biomarker of treatment response. TDA identified two groups based on connectivity between the prefrontal cortex and striatal regions: patients admitted with greater functional connectivity between these regions evidenced less improvement from admission to discharge than patients with lesser connectivity between them. TDA identified a potential biomarker of an attenuated treatment response among inpatients with SMI. Insofar as the observed pattern of resting-state functional connectivity collected early during treatment is replicable, this potential biomarker may indicate the need to modify standard of care for a small, albeit meaningful, percentage of patients.

A controlled comparison trial of the Collaborative Assessment and Management of Suicidality (CAMS) in an inpatient setting: Outcomes at discharge and six-month follow-up.

This controlled comparison trial evaluated a suicide-specific intervention, the Collaborative Assessment and Management of Suicidality (CAMS), in an extended-stay psychiatric inpatient setting. Multiple outcomes were examined for 104 patients, half of whom received individual therapy from therapists trained in CAMS. The comparison group was selected from a larger pool through Propensity Score Matching to ensure comparability on age, sex, treatment program, number of prior suicide attempts, and severity of suicidal ideation. Results showed that a) all patients improved significantly across a wide range of measures, including depression, suicidal ideation, functional disability, and well-being; b) these gains were durable over a 6-month post-discharge period; and c) patients treated by a CAMS-trained individual therapist improved significantly more from admission to discharge across all measures. Differences between CAMS and non-CAMS patients were no longer statistically significant at 6-month follow-up, although statistical power was compromised due to attrition. Although replication studies are needed, these findings suggest that interventions specifically tailored for suicidal patients may have advantages compared to usual, intensive inpatient treatment, perhaps by addressing psychological vulnerabilities specific to the population. The lack of significant differences at follow-up suggest that post-treatment contact may be needed to maintain advantages associated with this and similar interventions.

Incremental validity of the PID-5 in relation to the five factor model and traditional polythetic personality criteria of the DSM-5.

BACKGROUND: This study assessed the incremental validity of the Personality Inventory for DSM-5 (PID-5) beyond the impact of demographic, burden of illness, five-factor model of personality, and DSM-5 personality disorder criteria with respect to associations with admission psychiatric symptoms and functional disability. METHODS: Psychiatric inpatients (N = 927) were administered the Big Five Inventory, PID-5, and personality disorder criteria counts. Prior treatment utilization, as well as baseline depression, anxiety, emotion regulation, and functional disability were administered within two days of the personality measures. Hierarchical regression models were used to explore the association of personality functioning with symptom functioning, emotion regulation and disability. RESULTS: Neuroticism was associated with all symptom measures, providing further support for its relevance in clinical populations. Personality trait domains (negative affect, detachment, and psychoticism) from the PID-5 demonstrated incremental validity in predicting baseline symptom and disability functioning over and above demographic, burden of illness, and psychiatric comorbidity and five-factor model (FFM) personality traits. CONCLUSIONS: Dimensional measures of personality functioning were consistently associated with baseline symptom functioning, supporting the relevance of personality functioning as it relates to psychiatric symptoms. The PID-5 uniquely contributed to the prediction of baseline symptom functioning, thus providing incremental validity over gold-standard personality trait measures.