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To examine how clinicians navigate providing treatment to Borderline Personality Disorder (BPD) in the context of the DSM 5, deinstitutionalization, and the biomedical model.

We conducted 39 interviews with mental health providers in the United States in a two-year period preceding and following the release of the DSM 5. Using Constructivist Grounded Theory, we analyzed the data for themes that emerged.

Clinicians faced pressures from insurance companies, the DSM categories, and their professional training to focus on biomedical treatments. These treatments, which emphasized pharmaceuticals and short courses of care, were ill-suited to BPD, which has a strong evidence base recommending long-term therapeutic interventions. We term this contradiction a “biomedical mismatch” and use Gidden’s concept of structuration to better understand how clinicians navigate the system of care. Providers ranged in their responses to the mismatch: some championed biomedicine, others were complicit, and a final group behaved as activists, challenging the paradigm. The sum of the strategies had downstream effects which included crisis reinstitutionalization and a discourse of untreatability. Ultimately, we discuss how social factors such as gender bias, stigma, and trauma are insufficiently represented in the biomedical model of care for BPD.

BPD fits poorly within the biomedical underpinnings of the current system. Accordingly, it illuminates the structuration of health care and where the rules of care break down. More precisely, deinstitutionalization was designed to remove patients from long courses of inpatient care. Many patients with BPD have failed to experience this outcome, with some patients now cycling through long courses of short-term crisis reinstitutionalization instead of having effective outpatient care over long periods. This unintended consequence of deinstitutionalization calls for a more biopsychosocial response to BPD.

This case study describes how threats to stab people, in a client with learning disabilities, may have been inadvertently reinforced during detention in a medium secure unit by over‐looking borderline personality traits. Formulating the case from the biopsychosocial model of borderline personality disorder (Linehan, 1993), the article illustrates how an invalidating environment provided by learning disability services may have interacted with underlying difficulties in emotion regulation to reinforce challenging behaviour. Explaining threats to stab purely in terms of learning disability accidentally invalidated the client's emotional distress, so the only way he could convey how he was feeling was by escalating challenging behaviour. Risk management procedures also strengthened the client's belief that he was a dangerous person, and reinforced the challenging behaviour by gaining interpersonal attention. The need for learning disability services to be aware of how personality features contribute to learning disability presentations and to formulate from an interactive perspective is highlighted.

The term borderline applied to personality dynamics was first introduced by Adolph Stern in 1938. This new term included a particular group of patients who, in an organizational blurring, remained in the limbo between neurosis and psychosis. To find a more assertive and holistic characterization of borderline personality disorder (BPD), the purpose of this paper is to explore borderline phenomenology, setting boundaries and discussing points of approach and divergence of this personality disorder comparing them specifically to bipolar affective disorder (BAD) and also explore the differences in their treatment and prognosis.

This paper is a review and synthesis of the extant literature, mapping out the similar and unique aspects of each pathology.

Although there are approximation parameters between BPD and BAD, the phenomenology and the course of both diseases appear to be different. Indeed, this paper seems to have some uncertainty about the sphere of each entity and the domain of comorbidity. Despite the overlapping rates found, it is the understanding that the consequences and strategies for managing comorbidity are underexplored.

As the association of both disorders can be difficult not only in terms of management and understanding of their consequences and implications but also in long-term negative perpetuation, this review has direct implications for clinicians so that they can understand the similarities and particularities of each entity, leading to a more correct psychopathological approach in these individuals.

Treatment satisfaction of different mental disorders is still poorly understood, but of high clinical interest. Inpatients of a general psychiatric care hospital were asked to fill out questionnaires on satisfaction and clinical variables at admission and discharge. On the basis of an exploratory approach, differences in treatment satisfaction among diagnostic groups were examined by means of one-way analysis of variance. Potential associated clinical and socio-demographic variables were studied using multi/univariate tests. Patients with personality disorders (n=18) showed a significantly lower treatment satisfaction (ZUF-8, Zurich Satisfaction Questionnaire) and a slightly lower improvement of symptoms (CGI, Clinical Global Impression) and global functioning (GAF, Global Assessment of Functioning scale) than that of other diagnostic groups (n=95). Satisfaction in patients with personality disorders correlated much stronger with the symptom improvement and slightly with the functioning level than in patients without personality disorders. Interestingly, in patients with personality disorders psychopharmacological treatment in general (present versus not present) was independent from satisfaction. This exploratory investigation suggests that a lower satisfaction of patients with personality disorders in a general psychiatric hospital is mainly based on a reduced improvement of the symptoms and of the global functioning level.

In light of the clinical importance of understanding co-morbidity within offender populations, the purpose of this paper is to examine the prevalence and comorbidities of clinical disorder (Axis I) and personality disorder (Axis II) within a sample of high risk, male offenders located in a high secure, prison-based personality disorder treatment service.

The study utilised clinical assessment data for both Axis I diagnoses (Structured Clinical Interview for DSM-IV) and Axis II diagnoses (International Personality Disorder Examination) of 115 personality disordered offenders who met the criteria for the treatment service between 2004 and 2015.

Co-morbidity between Axis I and Axis II diagnoses was high, with 81 per cent of the sample having co-morbid personality disorder and clinical disorder diagnosis. The most prevalent Axis I disorder was substance misuse, and Axis II was antisocial, borderline, and paranoid personality disorder. Following χ² analysis, Cluster A personality disorder demonstrated co-morbidity with both mood disorder and schizophrenia/other psychotic disorder. Paranoid, schizoid, narcissistic, and avoidant personality disorder demonstrated a level of co-morbidity with Axis I disorders. There was no association found between the clinical disorders of substance use and anxiety with any personality disorder within this sample.

In part these results suggest that certain Axis II disorders may increase the risk of lifetime Axis I disorders.

The findings of no co-morbidity between the clinical disorders of substance use and anxiety with any personality disorder within sample are inconsistent to previous findings.

The purpose of this paper is to examine the associations among psychopathic and borderline traits, intimate partner violence (IPV) and sensitivity to facial affect. The authors hypothesized that IPV men high in psychopathic traits would exhibit reduced sensitivity to expressions of distress specifically (fear + sadness), while IPV men high in borderline traits would show heightened sensitivity to facial affect more generally.

A community sample of 79 IPV men in heterosexual relationships were exposed to slides of facial affect displays while psychophysiological reactions were recorded. Sensitivity to facial affect was operationalized as accuracy in recognizing and skin conductance responses (SCR) while viewing discrete facial expressions.

Borderline personality disorder (BPD) features were positively related to accuracy in labeling fear and surprise while primary psychopathy (Factor 1) was negatively related to accuracy in labeling disgust. Borderline traits were positively associated with SCR while primary psychopathy was negatively associated with SCR while viewing slides of facial affect. Secondary psychopathy (Factor 2) follows the same physiological patterns of BPD traits but the correlates are weaker. Results suggest that IPV men high in traits of primary psychopathy show hypoarousal whereas those high borderline features show hyperarousal to facial emotions.

Limitations include a small sample of heterosexual violent community couples. Women’s IPV was not analyzed. Findings suggest that BPD and primary psychopathy traits are diametrically opposite in SCR, making them powerful comparison groups for psychophysiological studies. Findings challenge Blair’s (1995) model of a specific deficit in processing distress cues for individuals high in psychopathic traits. Rather results suggest that IPV men high in traits of primary psychopathy show more pervasive hypoarousal to facial emotion. The hyperarousal of men high in BPD traits across facial expressions supports Linehan’s (1993) emotional vulnerability model of borderline personality disorder.

Differences in psychophysiological responding to emotions may be clinically relevant in the motivations for violence perpetration. The hypoarousal associated with primary psychopathy may facilitate the perpetration of proactive violence. The hyperarousal associated with BPD and secondary psychopathy may be fundamental in the perpetration of reactive violence. Treatment matching by IPV perpetrators’ personality traits may improve the efficacy of battering intervention programs. Perpetrators high in borderline personality features may benefit from emotional regulation therapies, such as Dialectical Behavior Therapy. IPV men high in traits of primary psychopathy may benefit from affective empathy and validation training.

Currently, battering intervention programs show little efficacy in reducing intimate partner recidivism. Experimental psychopathology studies such as this one may inform advocates seeking to develop new, tailored treatment packages for partner violence offenders with different personality disorder traits.

Many treatment providers assume that men who batter women have deficits in empathy and emotional intelligence. However, this study suggests that rather than global deficits, deficits depend on personality traits. The current study is the first to assess psychophysiological reactivity in response to facial affect displays among IPV perpetrators. Examining SCR responding to photos of facial affect may be used in future studies of affect sensitivity.

The purpose of this paper is to describe the evolution of the field of personality disorder since the publication of “Personality disorder: no longer a diagnosis of exclusion” in 2003.

A review of both the academic literature contained within relevant databases alongside manual searches of policy literature and guidance from the key stakeholders was undertaken.

The academic and policy literature concentrates on treating borderline and antisocial personality disorders. It seems unlikely that evidence will resolutely support any one treatment modality over another. Criticism has arisen that comparison between modalities misses inter and intra patient heterogeneity and the measurement of intervention has become conflated with overall service design and the need for robust care pathways. Apparent inconsistency in service availability remains, despite a wealth of evidence demonstrating the availability of cost-effective interventions and the significant inequality of social and health outcomes for this population.

The inclusion of heterogeneous sources required pragmatic compromises in methodological rigour.

This paper charts the recent developments in the field with a wealth of wide-ranging evidence and robust guidance from institutions such as NICE. The policy literature has supported the findings of this evidence but current clinical practice and what patients and carers can expect from services remains at odds. This paper lays bare the disparity between what we know and what is being delivered. The authors argue for the need for greater research into current practice to inform the setting of minimum standards for the treatment of personality disorder.

GGzE, a mental health care organisation in the south Netherlands, implemented treatment for patients with severe personality disorders and substance use: clinical case management (CCM). CCM is a special healthcare facility for patients whose needs do not match other existing treatment designs. These patients are characterised by unproductive or disturbed relationships and multiple crises that deregulate clinical practice and impede recovery. In the CCM team, patients are treated with the theoretical concepts of relationship management, interpersonal reconstructive therapy, Livesley's stage‐wise treatment and integrated dual disorder treatment (IDDT). These theoretical models and methods used within CCM have been described extensively, though there has been no clinical study about its effect within GGzE so far. Professionals working within the CCM team report that behaviour such as acting out is reduced after about one year of treatment, with less interventions from other caretakers or police involvement. To substantiate these claims, a single group pre‐test and posttest was conducted to find out whether these patients really experience changes in physical and psychological problems, as well as changes in their personality disorder.The sample consists of patients who started treatment between 2004 and 2009 (pre measurement T=0), (n = 21). At T=0, patients completed the Symptom Checklist (SCL‐90) and Personality Characteristics Questionnaire (Vragenlijst Kenmerken Persoonlijkheid, VKP). The outcomes are compared with the results of the same questionnaires that were completed by patients in 2010 (post measurement T=1). The outcomes of the SCL‐90 show significant changes for fear, depression, hostility, distrust and interpersonal sensitivity, as well as the total score of psychoneurosis. The VKP shows significant changes for general personality disorder, schizoid personality disorder and borderline personality disorder. More research is needed to find stronger evidence of treatment effects of CCM, using a bigger sample, a control group and more outcome measurements that also include the drug use of patients.

National Institute for Clinical and Health Excellence guidelines (2009) state that low intensity psychological interventions should not be used for borderline personality disorder. However, an emerging body of evidence suggests brief interventions such as psychoeducation may be relevant for those presenting with borderline personality difficulties. The purpose of this study is to evaluate the benefit of learning about thinking, emotions and relationships (LATER), a co-produced psychoeducation programme for borderline personality difficulties in a community-based setting.

Participants (n = 125) self-referred to LATER, a group-based psychoeducation programme delivered at the [NHS Trust] Recovery College. Participants were assessed pre- and post-intervention using the tailor-made psychological education group evaluation scale, the borderline evaluation of severity over time and work and social adjustment scale. Paired t-tests were conducted on pre- and post-scores, and effect sizes were calculated.

After LATER, participants reported a significant decrease in negative thoughts and feelings, destructive behaviours and overall borderline symptom severity, but no significant increase in positive behaviours. Significant decreases were found in areas of work and social impairment. Participants’ overall understanding of personality difficulties significantly improved. Effect sizes were small to moderate.

Limitations of the study include the lack of a control group, adjustment for confounders and follow-up. Replication with a more robust methodology is needed.

This study contributes to the evidence for the usefulness of brief interventions for personality difficulties, particularly in the context of a stepped model of care and adds to the research on co-production.

This paper aims to assess highly toxic personality disorders in leaders, implications for organizations, and methods for assessment and intervention.

Action research was used, including a thick description case study narrative and application of the DSM IV‐TR.

Personality disorders are a source of a highly toxic and dysfunctional organizational behavior; borderline personality disorder in a leader may serve as a systemic contaminant for an organization.

A qualitative, case study approach may not lend itself to replication or quantification; usage of the DSM IV‐TR requires clinical training in counseling psychology; the growing incidence of personality disorders in leadership warrants cognizance, ability to assess, the creation of early detection systems and methods of intervention.

Through the narrative of a case study researchers and practitioners can obtain a glimpse into the day‐to‐day operations and nuances of a highly toxic leader and how it impacts an organization; interventions and solutions are provided.

This paper calls attention to highly toxic leadership and organizational dysfunction by investigating borderline personality disorder as a prototype.