Borderline personality disorder and aggressive behavior: A study based on the DSM-5 alternative model.

INTRODUCTION: Unplanned reactive aggressive acts are a clinical feature of particular interest in patients with borderline personality disorder (BPD). The early identification of personality traits correlated to aggressive behavior is certainly desirable in BDP populations. This study analyzes a clinical sample of 122 adult outpatients with BPD referred to Adult Mental Health Services of the Department of Mental Health of Bologna, in Italy. METHODS: The study examines the relationship with personality facets of the DSM-5 alternative model for personality disorders (AMPD), Personality Inventory for DSM (PID-5), with respect to the four main components of aggression measured by the Aggression Questionnaire (AQ): hostility, anger, verbal and physical aggression. Using robust regression models, the relationships between PID-5 facets and domains and the aggression components under consideration were identified. RESULTS: Verbal and physical aggression in our sample of BPD outpatients is mainly associated to PID-5 antagonism domain. Physically aggressive behavior is also related to callousness facet. CONCLUSIONS: The traits most consistently associated with aggression were the domain of Antagonism and the facet of Hostility. The study findings highlight the need for clinicians working with individuals with BPD to pay particular attention to traits of hostility, callousness, and hostility to understand aggression.

Aggressive behavior and self-harm in Borderline Personality Disorder: The role of impulsivity and emotion dysregulation in a sample of outpatients.

Impulsivity has often been related to aggressive and self-mutilative behavior in Borderline Personality Disorder (BPD). Many authors focused on the key role of emotion dysregulation in explaining vulnerability to dysfunctional behavior in BPD in addition to trait impulsivity. Furthermore, recent works have shed light on a gap in empirical research concerning the specific mechanisms by which a lack of affective regulation produces aggression proneness. The purpose of the study was to investigate the role of impulsivity and emotion dysregulation in determining vulnerability to aggression and deliberate self-harm in a sample of BPD outpatients. Enrolled patients with BPD (N =79) completed a comprehensive assessment for personality disorder symptoms, trait impulsivity, emotional dysregulation, aggressive and self - mutilative behavior. Trait impulsivity significantly predicted both aggressive and self-mutilative proneness. Furthermore, emotion dysregulation was found significantly to account for the vulnerability to aggression and self-injury, in addition to the variance explained by impulsivity. In conclusion, these findings support evidence that emotion dysregulation plays an important role in increasing the risk of dysfunctional behavior in impulsive BPD individuals.

[The family of a patient with borderline personality disorder: burden of illness and interventions for caregivers]. / La famiglia del paziente con disturbo borderline di personalità: carico della malattia e interventi destinati ai caregiver.

AIM: The scientific literature focused on factors involved in the onset of borderline personality disorder (BPD) has given a central role to the families of these patients. The role of the family in understanding the disorder has gradually changed thanks to research that investigated the interaction of several factors in the development of this psychopathology. Recently, scientific literature on DBP has allowed to consider parents as no longer "responsible" for the development of the disorder, but as directly involved in interpersonal problems of patients and therefore a potential "ally" in the management of crisis. The aim of this study is to describe and quantify the family burden of BPD patients and browse specific interventions for the family of these patients. METHODS: PubMed and PsycINFO have been used for review with the following keywords: "borderline personality disorder", "family", "psychopathology", "burden", "psychoeducation", "caregiver", "caretaker". RESULTS: Studies on family burden of BPD patients are still few. Research shows that the family burden of BPD patients is comparable with that of families of patients with schizophrenia. Clinical trials of interventions for caregivers of patients with BPD show that specific strategies can reduce the family burden and improve their self-efficacy. DISCUSSION: Scientific literature highlights the relevance of problems of families with a BPD member and the importance of involving them in the treatment of these patients.

Moderators of remission with interpersonal counselling or drug treatment in primary care patients with depression: randomised controlled trial.

BACKGROUND: Despite depressive disorders being very common there has been little research to guide primary care physicians on the choice of treatment for patients with mild to moderate depression. AIMS: To evaluate the efficacy of interpersonal counselling compared with selective serotonin reuptake inhibitors (SSRIs), in primary care attenders with major depression and to identify moderators of treatment outcome. METHOD: A randomised controlled trial in nine centres (DEPICS, Australian New Zealand Clinical Trials Registry number: ACTRN12608000479303). The primary outcome was remission of the depressive episode (defined as a Hamilton Rating Scale for Depression score ≤7 at 2 months). Daily functioning was assessed using the Work and Social Adjustment Scale. Logistic regression models were used to identify moderators of treatment outcome. RESULTS: The percentage of patients who achieved remission at 2 months was significantly higher in the interpersonal counselling group compared with the SSRI group (58.7% v. 45.1%, P = 0.021). Five moderators of treatment outcome were found: depression severity, functional impairment, anxiety comorbidity, previous depressive episodes and smoking habit. CONCLUSIONS: We identified some patient characteristics predicting a differential outcome with pharmacological and psychological interventions. Should our results be confirmed in future studies, these characteristics will help clinicians to define criteria for first-line treatment of depression targeted to patients' characteristics.

Depression in primary care: interpersonal counseling vs selective serotonin reuptake inhibitors. The DEPICS Study. A multicenter randomized controlled trial. Rationale and design.

BACKGROUND: Depression is a frequently observed and disabling condition in primary care, mainly treated by Primary Care Physicians with antidepressant drugs. Psychological interventions are recommended as first-line treatment by the most authoritative international guidelines but few evidences are available on their efficacy and effectiveness for mild depression. METHODS/DESIGN: This multi-center randomized controlled trial was conducted in 9 Italian centres with the aim to compare the efficacy of Inter-Personal Counseling, a brief structured psychological intervention, to that of Selective Serotonin Reuptake Inhibitors. Patients with depressive symptoms referred by Primary Care Physicians to psychiatric consultation-liaison services were eligible for the study if they met the DSM-IV criteria for major depression, had a score ≥ 13 on the 21-item Hamilton Depression Rating Scale, and were at their first or second depressive episode. The primary outcome was remission of depressive symptoms at 2-months, defined as a HDRS score ≤ 7. Secondary outcome measures were improvement in global functioning and recurrence of depressive symptoms at 12-months. Patients who did not respond to Inter-Personal Counseling or Selective Serotonin Reuptake Inhibitors at 2-months received augmentation with the other treatment. DISCUSSION: This trial addresses some of the shortcomings of existing trials targeting major depression in primary care by evaluating the comparative efficacy of a brief psychological intervention that could be easily disseminated, by including a sample of patients with mild/moderate depression and by using different outcome measures. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12608000479303.

Recognition and treatment of depression in primary care: effect of patients' presentation and frequency of consultation.

OBJECTIVE: Primary care physicians (PCPs) are expected to recognize depression and appropriately prescribe antidepressants. This article investigated the single and combined effects of different patient presentations and frequency of visits on detection and antidepressant use. METHODS: Data came from an Italian nationwide survey on depressive disorders in primary care, involving 191 PCPs and 1910 attenders. Two hundred fifty patients suffering from major or subthreshold depression were compared in relation to their presentation (psychological, physical, and pain) and frequency of visits (low and high). RESULTS: Recognition of depression significantly varied according to both presentation and frequency of visits. When compared to patients with psychological complaints, the odds ratios for nonrecognition of depression were higher for patients presenting with physical symptoms [2.3; 95% confidence interval (CI)=1.1-5.3] and with pain (4.1; 95% CI=1.6-9.9). Subjects who rarely attended the practice were 2.3 times less likely to receive a diagnosis of depression, compared with those having a high frequency of visits (95% CI=1.2-4.6). Similarly, patients presenting with physical symptoms or with pain and those with a low frequency of visits were rarely treated with antidepressants. The combination of physical or pain presentation with low frequency of visits further increased the risk for nonrecognition, which was sixfold that of the reference category. CONCLUSIONS: Some subgroups of depressed patients still run a high risk of having their depression unrecognized by the PCP. Screening for depression among patients presenting with pain might be useful in order to improve recognition and management.

Psychological interventions for major depression in primary care: a meta-analytic review of randomized controlled trials.

OBJECTIVE: Various studies have tested psychological therapies in the treatment of depression in primary care. Yet, concerns over their clinical effectiveness, as compared to usual general practitioner (GP) care or treatment with antidepressants, have been raised. The present meta-analysis was aimed at assessing currently available evidence on the topic. METHOD: A systematic search of electronic databases identified 10 randomized controlled trials comparing psychological forms of intervention with either usual GP care or antidepressant medication for major depression. Meta-analytical procedures were used to examine the impact of psychological intervention in primary care on depression, as compared to usual GP care and antidepressant treatment. RESULTS: The main analyses showed greater effectiveness of psychological intervention over usual GP care in both the short term [standardized mean difference (SMD)=-0.42, 95% confidence interval (CI)=-0.59 to -0.26, n=408] and long term (SMD=-0.30, 95% CI=-0.45 to -0.14, n=433). The heterogeneity test was not significant in the short term at the P<.05 level (df=5, P=.57, I(2)=0%), but it was significant in the long term (df=5, P=.004, I(2)=70.9%). The comparison between psychological forms of intervention and antidepressant medication yielded no effectiveness differences, for either the short term or the long term. CONCLUSIONS: Psychological forms of intervention are significantly linked to clinical improvement in depressive symptomatology and may be useful for supplementing usual GP care.

Models of collaboration between general practice and mental health services in Italy

Background and objectives: Anxiety and Depressive disorders represent an important public health problem, which involves not only the mental health services, but the General Practice as well. This paper examines models of Collaboration between General Practice and Community Mental Health Services developed in Italy. Methods: Different Consultation –Liaison activities are presented. For every Collaboration model advantages and disadvantage are discussed. Results: The structured Consultation Liaison Service is based on supplying diagnostic consultation and therapeutic interventions in support of General Practitioners (GPs). The service could be based in either a Community Mental Health Centre (CMHC) or externally. Diagnostic evaluation can be followed by brief and focal therapeutic interventions, in support of the GP's therapeutic plan. The spontaneous collaboration in small centres are frequent in rural areas where the contained dimensions of the services and the direct acquaintance between psychiatrists and GPs encourage the personalization of the collaboration. The model of Liaison and Group-Training focuses on direct contact between consultant and GPs. In the course of regular meetings, the consultant gives the GPs supervision and education, and they can discuss the therapeutic plans for patients requiring specialist intervention. Conclusion: The empiric classification presented should be considered an attempt to represent a complex reality. Every service, in fact, carries out activities that are necessarily wider than abstract typologies and that overlap with other models’ activities (AU)

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