The Mediational Intervention for Sensitizing Caregivers: an evaluation of feasibility and acceptability among mothers with borderline personality disorder

Borderline personality disorder (BPD) is a complex psychiatric disorder most often diagnosed in women, many of whom are mothers. Research has demonstrated that the offspring of mothers with BPD have a greater risk of poor psychosocial outcomes than the children of mothers without BPD, and mothers with BPD often experience more stress and lower levels of satisfaction and competency than mothers without BPD. Therefore, supportive parenting interventions that focus on enhancing the caregiver-child relationship are important. The Mediational Intervention for Sensitizing Caregivers (MISC) holds promise for use with mothers with BPD as it incorporates principles of learning in addition to attachment. It focuses on concrete modifiable behaviors that enhance caregiver sensitivity and responsiveness, which may increase maternal feelings of competency and lower distress, while also encouraging positive child development. In the current chapter, we summarize what is known about mothers’ caregiving experiences with BPD and their children’s psychosocial outcomes. We review the research on caregiver-child interaction patterns in mothers with BPD and organize this literature according to MISC emotional and cognitive components. Finally, we review existing parenting interventions for this population and make suggestions of how MISC may address the weaknesses of these interventions. We end with a summary of ongoing work that aims to adapt MISC for mothers with BPD.

QuestionThis systematic review explores two questions: what parenting difficulties are experienced by mothers with borderline personality disorder (BPD); and what impact do these have on her children?Study selection and analysisStudies...

FC24-05 - Maternal transmission of borderline personality disorder (BPD): a prospective community-based cohort study

Accessible SummaryWhat is known on the subject?Internationally, stigma towards people with mental illness has reduced due to greater understanding, education and advocacy in the community, and more focus on recovery‐oriented care within practice guidelines.However, many people with a diagnosis of BPD continue to experience stigma and difficulty accessing health services. Contributing factors include lack of understanding of BPD and effective management by health professionals, stigma from the general population and within healthcare services, and financial and geographical barriers.Mental health nurses comprise a large part of the healthcare workforce responsible for the day‐to‐day care of people diagnosed with BPD.What the paper adds to existing knowledgeThis paper investigates how Australian consumer perspectives on BPD management have changed over time. Comments from a large survey, delivered to consumers in 2011 (N = 153) and 2017 (N = 424), were analysed for common themes.Themes were broadly related to NHMRC BPD Guidelines sections released in 2013. These data sets therefore present an opportunity to evaluate changes in consumer perspectives pre‐ and post‐Guideline release. Although no direct causal relationship can be drawn, analysing these changes can potentially assist with understanding the impact of the Guidelines in practice. No such analysis of the Australian Guidelines has been conducted to date in the existing literature.What are the implications for practice?Many people diagnosed with BPD continue to experience stigma, barriers to treatment and difficulty accessing appropriate services.Widespread practical implementation of the Guidelines was not apparent; however, improved general awareness and understanding of BPD from consumers and health professionals were evident. Improved education and practice across each and all aspects of the Guidelines are indicated.The Guidelines need review to ensure they are in‐line with current evidence‐based practice, as well as effective health professional education, support and funding to embed the revised Guidelines into practice.IntroductionInternationally, many individuals diagnosed with BPD continue to experience stigma within health care and are more likely to be viewed as manipulative and evoke negative responses from clinicians, compared with other mental health consumers.Aim/QuestionTo understand Australian consumer perspectives regarding BPD management, and how these have changed between 2011 and 2017. To comment on how NHMRC BPD Guidelines, released 2013, are faring in practice.MethodIndividuals who identified a BPD diagnosis completed a 75‐question survey, delivered online Australia‐wide, in 2011 (N = 153) and 2017 (N = 424), providing comparative data sets to evaluate changes in consumer perspective on BPD management.ResultsMany people diagnosed with BPD experience difficulties when seeking help, stigma within health services and barriers to treatment. Improved general awareness, communication and understanding of BPD from consumers and health professionals were evident.DiscussionConsumers demonstrated increased BPD‐literacy and help‐seeking behaviours in 2017, providing opportunity for health professionals to build stronger therapeutic relationships. Widespread practical implementation of the Guidelines does not appear to have been achieved. More health professional education, updated Guidelines, funding and strategies to embed these Guidelines into practice are needed.Implications for PracticeMental health nurses regularly provide care to people diagnosed with BPD; with practical education and support, they and other health professionals can improve their confidence in practice and provide better quality care to consumers.

There are currently no empirically supported interventions to target parenting among mothers who have Borderline Personality Disorder (BPD). The current study uses Consensus Qualitative Research (CQR) methodology to: I) learn about mothers' experiences of parenting with BPD, and II) identify treatment modifications to Dialectical Behavior Therapy (DBT) as suggested by mothers with BPD who are currently engaged in DBT skills training. Twenty-three mothers were recruited from intensive outpatient and partial hospitalization programs that teach DBT skills. A total of 9 focus groups that met one time were conducted asking women a series of questions regarding their experiences of parenting with BPD and how they would modify DBT to address parenting issues. Using the CQR approach, we coded domains and categories that were discussed by mothers in the focus groups. Coding revealed that mothers with BPD wished parenting was integrated more in their current DBT skills groups. In addition, one of the most prominent themes to emerge was that parenting is particularly stressful to mothers with BPD and is associated with guilt, uncertainty, and worry. Finally, mothers offered many ideas for how to integrate parenting-focused interventions into DBT. The CQR method revealed gaps in current treatment for mothers with BPD and provided useful ideas for how to modify DBT to target parenting and integrate these modifications into other approaches for treating mothers with BPD.

Children of mothers with borderline personality disorder (BPD) should be considered a high-risk group given the wide array of poor psychosocial outcomes that have been found in these children. This article describes the parenting strategies that might explain the transmission of vulnerability from mothers with BPD to their offspring, from infancy through adolescence. We conclude that oscillations between extreme forms of hostile control and passive aloofness in their interactions with their children may be unique to mothers with BPD. We provide an overview of interventions that are currently recommended for mothers and family members with BPD, namely attachment therapy and psychoeducational approaches. On the basis of an integration of the empirical findings on parenting and child outcomes, as well as from the review of current approaches to intervention, we conclude with recommendations for treatment targets. We argue that mothers with BPD need psychoeducation regarding child development and recommended parenting practices and skills for providing consistent warmth and monitoring, including mindfulness-based parenting strategies.

Comments on an article Children of mothers with borderline personality disorder: Identifying parenting behaviors as potential targets for intervention by Stepp, Whalen, Pilkonis, Hipwell, and Levine (see record 2011-05873-001). Despite both a limited empirical literature and the muddy problem of borderline personality disorder (BPD) classification, the authors have significantly clarified the risk factors relevant to children of mothers with BPD and have outlined important and reasonable skill-based interventions likely to mitigate these risks. Not only have they sensibly connected the dots among the extant studies (which included very different samples, ages of children, criterion behaviors, etc.), they have identified the few key points of agreement across studies and translated these into a blueprint for early intervention. This commentary (a) further elaborates on some of the parameters of BPD that make risk assessment for children of mothers with BPD complicated, including both diagnostic heterogeneity and myriad other problems that reduce the specificity of BPD as a classification tool for these purposes and (b) identifies direct, indirect, and general mechanisms of transmission of difficulties from a mother (or parent or caregiver) with BPD to her child.

IntroductionBrain-derived neurotrophic factor (BDNF) has been associated with both emotionally unstable personality disorder (EUPD) and suicidal behavior. No study has yet investigated BDNF-associated epigenetic alterations in severely impaired EUPD and suicidal patients.ObjectivesThe main goal of the present study was to investigate whether epigenetic dysregulation in BDNF, CRP, IL-1, IL-2 and IL-6 were associated with EUPD and severity of suicidal behavior.MethodsThe discovery cohort consisted of 97 women with emotionally unstable personality disorder (EUPD) with at least two serious suicide attempts (SA) and 32 healthy women. The genome-wide methylation pattern was measured by the Illumina EPIC BeadChip and analyzed by robust linear regression models to investigate mean BDNF methylation levels in a targeted analysis conditioned upon severity of suicide attempt. The validation cohort consisted of 60 female suicide attempters, stratified into low- (n=45)and high-risk groups (n=15) based on degree of intent-to-die and lethality of suicide attempt method, and occurrence of death-by-suicide at follow-up.ResultsMean BDNF methylation levels exhibited hypermethylation in relation to EUPD(p=0.0343, percentage mean group difference ~3.8%). Similarly, this locus was confirmed as hypermethylated in an independent cohort of women with severe suicidal behavior (p=0.0469). Results were independent of age and BMI.ConclusionsThis study elicits emerging evidence of epigenetic dysregulation of BDNF in relation to phenotypes known to increase risk of suicide (lethality of suicide-attempt method and presence of EUPD diagnosis with history of recent SA). Further studies investigating epigenetic and genetic effects of BDNF on severe suicidal behavior and EUPD are needed to elucidate the role of epigenetic regulatory mechanisms and neurotrophic factors in relation to suicide risk.Disclosure of InterestNone Declared

Brain-derived neurotrophic factor (BDNF) has previously been associated with the pathogenesis of both emotionally unstable personality disorder (EUPD) and suicidal behavior. No study has yet investigated BDNF-associated epigenetic alterations in a group of severely impaired EUPD and suicidal patients. The discovery cohort consisted of 97 women with emotionally unstable personality disorder (EUPD) with at least two serious suicide attempts (SAs) and 32 healthy female controls. The genome-wide methylation pattern was measured by the Illumina EPIC BeadChip and analyzed by robust linear regression models to investigate mean BDNF methylation levels in a targeted analysis conditioned upon severity of suicide attempt. The validation cohort encompassed 60 female suicide attempters, stratified into low- (n = 45) and high-risk groups (n = 15) based on degree of intent-to-die and lethality of SA method, and occurrence of death-by-suicide at follow-up. Mean BDNF methylation levels exhibited increased methylation in relation to EUPD (p = 0.0159, percentage mean group difference ~3.8%). Similarly, this locus was confirmed as higher-methylated in an independent cohort of females with severe suicidal behavior (p = 0.0300). Results were independent of age and BMI. This is the first study to reveal emerging evidence of epigenetic dysregulation of BDNF with dependence on features known to confer increased risk of suicide deaths (lethality of suicide-attempt method and presence of EUPD diagnosis with history of recent SAs). Further studies investigating epigenetic and genetic effects of BDNF on severe suicidal behavior and EUPD are needed to further elucidate the role of epigenetic regulatory mechanisms and neurotrophic factors in relation to suicide and EUPD, and hold potential to result in novel treatment methods.

BackgroundBorderline personality disorder (BPD) is associated with unemployment and impaired functioning. However, a comprehensive understanding of barriers and facilitators to employment from a multidisciplinary perspective is currently lacking. Therefore, the aim of this qualitative study was to explore barriers and facilitators in gaining and maintaining employment in BPD from the perspectives of patients, mental health practitioners (MHPs) and insurance physicians (IPs).MethodsFifteen semi-structured interviews were conducted in patients with BPD and two focus groups were carried out among MHPs (n = 7) and IPs (n = 6) following a thematic content analysis approach.ResultsAll participants described barriers and facilitators relating to three overall themes: characteristics of BPD, stigma, and support to employment. Barriers to employment mainly related to characteristics of BPD, such as low self-image, difficulty posing personal boundaries, difficulty regulating emotions, and lack of structure. MHPs and IPs additionally mentioned externalization and overestimation of competencies on the part of patients. Enhancing emotion regulation and self-reflection by successful treatment was suggested as a facilitator to enhance employment. Increasing collaboration between mental health and vocational rehabilitation services, and increasing knowledge about BPD, were suggested to increase sustainable employment and decrease stigma.ConclusionsThe present findings revealed that both facilitators and barriers are important in gaining and maintaining employment in BPD in which diminishing symptoms, examining stigma and increasing support to employment are key. As a next step, supported employment strategies that follow patient preferences and integrate employment and mental health services, should be studied in the context of BPD.

Background: Mothers with borderline personality disorder (BPD) often show altered emotional availability toward their own child and heightened stress vulnerability. The aims of the present study were (1) to examine total cortisol output in saliva during mother-child interaction in mothers with BPD and their children and (2) to test whether maternal nonhostility as a subscale of emotional availability mediates the relationship between maternal BPD and child total cortisol output. Methods: We investigated 16 mothers with BPD and 30 healthy control mothers (HC) and 29 children of mothers with BPD and 33 children of HC mothers. Children were between 5 and 12 years old. Salivary cortisol was collected prior to and twice after an episode of a 21-min standardized play situation between mother and child. Nonhostility was rated using the emotional availability scales. Analyses of covariance were computed to test for group differences in total cortisol output (measured with area under the curve with respect to ground). Pearson’s correlation was calculated to test the association between maternal and child total cortisol output. To test the second question, a mediation analysis according to Preacher and Hayes was conducted. Results: Mothers with BPD and their children had lower total cortisol output. Maternal and child total cortisol output was significantly correlated. Contrary to our hypothesis, maternal nonhostility did not mediate the relationship between BPD and child total cortisol output. Conclusion: Results imply that the hormonal stress activity of mothers with BPD and their children is altered, which may reflect modified stress regulation and stress vulnerability in mother and child and may impact on mother-child interaction. The finding of a positive association between mother’s and child total cortisol output could indicate an intergenerational transmission of these alterations.

Borderline Personality Disorder (BPD) is a condition characterised by significant social and occupational impairment and high rates of suicide. In high income countries, mental health professionals carry negative attitudes towards patients with BPD, find it difficult to work with patients with BPD, and even avoid seeing these patients. Negative attitudes and stigma can cause patients to fear mistreatment by health care providers and create additional barriers to care. Patients’ self-stigma and illness understanding BPD also affects treatment engagement and outcomes; better knowledge about mental illness predicts intentions to seek care. The perspectives of mental health clinicians and patients on BPD have not been researched in the Pakistani setting and likely differ from other settings due to economic, cultural, and health care system differences. Our study aims to understand the attitudes of mental health clinicians towards patients with BPD in Pakistan using a self-report survey. We also aim to explore explanatory models of illness in individuals with BPD and their family members/carers using a Short Explanatory Model Interview (SEMI). The results of this study are important as we know attitudes and illness understanding greatly impact care. Results of this study will help guide BPD-specific training for mental health clinicians who care for patients with BPD and help inform approaches to interventions for patients with BPD in Pakistan.

Parental invalidation is central to etiological models of borderline personality disorder (BPD). Previous studies relied on retrospective accounts or laboratory observations to examine these associations. There is a dearth of research assessing these constructs in daily life, and limited studies have tested the effect of parental invalidation on BPD symptoms during early adolescence, when BPD onsets. The current study took a dynamic approach to assess parents' validating and invalidating behavior and its effect on youths' BPD symptom expression in daily life, while accounting for parent-perceived helpfulness of these behaviors and youth-perceived support. A psychiatric sample of 162 early adolescents (age range = 10-14 years; 47% female) and their parent completed a four-day ecological momentary assessment study. Parents reported on the use of validating and invalidating (e.g. punishing and ignoring) behaviors during parent-child conflict, as well as perceived helpfulness of these behaviors. Youth reported on their BPD symptoms and perceived parental support. Multilevel models were used to test the between- and within-person effects of parents' validating and invalidating behaviors, parent-perceived helpfulness and youth-perceived support, and their interaction on youth's momentary expression of BPD symptoms. At the between-person level, invalidating behaviors, specifically punishing behaviors, were related to greater BPD symptoms in daily life, while ignoring behaviors were associated with fewer BPD symptoms. Youth-perceived support predicted fewer BPD symptoms. Results underscore the importance of parental invalidation for the expression of BPD symptoms in daily life and also highlight the importance of youth's subjective experience of parental support. Findings are discussed in terms of etiological and intervention models that emphasize a dyadic framework.

Emotion dysregulation mediates the effect of borderline personality disorder on child psychopathology.

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