Personality Disorder Research Articles

How Do Personality Dysfunction and Maladaptive Personality Traits Predict Time to Premature Discontinuation of Pharmacological Treatment of ADHD?

Non-adherence to medication is common in the adult ADHD clinical group. The goal of this pre-registered study was to examine whether the DSM-5 Alternative Model of Personality Disorder (AMPD), generality personality dysfunction (LPFS-BF 2.0) or maladaptive personality traits (PID-5), can predict time to premature discontinuation of pharmacological treatment beyond other known factors. A sample of 284 adult patients with ADHD (60.6% female; Mage = 32.31 years) were investigated for medication adherence from 2018 to 2023, using time-to-event analytic methods. Of the sample, 54 were found to have discontinued treatment prematurely without consulting their physician. Interestingly this group was prescribed considerably lower doses before discontinuation than adhering patients. General personality dysfunction and maladaptive antagonistic personality traits are implicated in varying degrees, with the specific maladaptive personality facets Intimacy Avoidance and Deceitfulness (PID-5) significantly predicting time to premature discontinuation of ADHD medication beyond other known reasons for non-adherence. The broader implication is that the emerging personality pathology models hold promise to predict non-adherence in the adult ADHD population.

Supplemental Material for Mentalizing in Adolescence: Developmental Trends and Associations With Borderline Personality Disorder Features

Supplemental Material for Mentalizing in Adolescence: Developmental Trends and Associations With Borderline Personality Disorder Features

Who's Afraid of Murderous Rage? When Euthanasia Colludes with Self-Destructiveness.

The impact of intense countertransference affects in working with patients experiencing complex trauma can have a critical effect on decisions about euthanasia, especially when such decisions are made solely on the grounds of a psychiatric condition. These countertransference dynamics become particularly significant in the context of the rising number of euthanasia requests by psychiatric patients in the Netherlands. We contend that for a subgroup of patients with complex trauma, attachment trauma, and personality disorders, the label "treatment-resistant" may be applied prematurely and incorrectly. This may occur when highly complex transference-countertransference dynamics are not properly assessed, and tertiary treatment options like intensive short-term dynamic psychotherapy (ISTDP) are not considered, particularly in cases of chronic and severe childhood trauma leading to an unconscious reservoir of murderous rage that is directed at the self. A long-term therapeutic relationship can activate unconscious transferences, leading to the reenactment of previous attachment trauma. We propose that assessments for euthanasia must include a psychological analysis of the unconscious transference, enactment, and countertransference involved. This article presents a hypothetical case example to illustrate how a patient labeled as "treatment-resistant" can be supported through a psychodynamic formulation and proposes further pathways for clinical decision-making.

Risk of suicide and all-cause death in patients with mental disorders: a nationwide cohort study.

Mental disorders are associated with an increased risk of premature death, including suicide. This study aimed to examine the risk of suicide and all-cause death in patients with mental disorders after considering demographic, clinical, and lifestyle factors. Data from the National Health Insurance Sharing Service database and linked data from Statistics Korea were used. In total, 3,951,398 people aged ≥20 years were eligible for this study. Among the participants, 14 types of mental disorders were identified, and the subsequent incidences of suicide and all-cause death were monitored. The mean age of those with mental disorders and those without mental disorders was 56.5 (SD, 13.6) years and 46.6 (SD, 13.6) years, respectively. During an average follow-up period of 11.1 years (SD, 1.5), 249,830 participants died, of whom 12,290 died by suicide. Overall, the risk of suicide and all-cause death was higher in people with mental disorders than in controls. The risk of suicide was the highest among those with personality disorders, followed by those with bipolar disorder and schizophrenia spectrum disorder. The risk of all-cause death was the highest among those with intellectual disability, followed by those with schizophrenia spectrum disorder and alcohol use disorder. In conclusion, the risk of suicide and all-cause death increased among those with mental disorders, but there was substantial variation between the types of mental disorders for both suicide and all-cause death.

Investigating the associations between personality functioning, cognitive biases, and (non-)perceptive clinical high-risk symptoms of psychosis in the community.

Beyond psychosis prediction, clinical high-risk (CHR-P) symptoms show clinical relevance by their association with functional impairments and psychopathology, including personality pathology. Impaired personality functioning is prioritized in recent dimensional personality disorder models (DSM-5, ICD-11), yet underexplored in CHR-P, as are associations with cognitive biases, which early studies indicate as possibly linking CHR-P-symptoms and personality pathology. A community sample (N=444, 17-60years, 61.8% female) was assessed via clinical telephone interview and online questionnaires. Using zero-inflated Poisson models, we explored associations of personality functioning, cognitive biases, current psychopathology, and psychosocial functioning with likelihood and severity of overall CHR-P, as well as perceptive (per-) and non-perceptive (nonper-)CHR-P-symptoms distinctly. Higher nonper-CHR-P-symptom likelihood was associated with more impaired personality functioning and psychosocial functioning, while more severe cognitive biases were associated with higher CHR-P- and per-CHR-P-symptom likelihood, alongside higher CHR-P- and nonper-CHR-P-symptom severity. Further, more axis-I diagnoses were linked to higher CHR-P-, per-CHR-P-, and nonper-CHR-P-symptom likelihood, and younger age to higher CHR-P- and per-CHR-P-symptom severity, with CHR-P-symptom severity appearing higher in females. In an exploratory analysis, personality functioning elements identity and self-direction, and cognitive biases dichotomous thinking, emotional reasoning, and catastrophizing, respectively, showed multifaceted associations with nonper-CHR-P-symptom likelihood and overall CHR-P-symptom expression. Our study supports the association of CHR-P-symptoms with multiple mental health factors. Findings suggest intricate associations between personality functioning impairments and cognitive biases with CHR-P-symptom expression in non-help-seeking populations, possibly contributing to different per-CHR-P- and nonper-CHR-P-symptom expression patterns. Therefore, they should be targeted in future longitudinal studies, aiming at better understanding CHR-P-manifestations to inform preventive intervention.

Antisocial personality disorder:Failure to balance excitation/inhibition?

While healthy brain function relies on a dynamic but tightly regulated interaction between excitation (E) and inhibition (I), a spectrum of social cognition disorders, including antisocial behavior and antisocial personality disorder (ASPD), frequently ensuing from irregular neurodevelopment, may be associated with E/I imbalance and concomitant alterations in neural connectivity. Technological advances in the evaluation of structural and functional E/I balance proxies in clinical settings and in human cell culture models provide a general basis for identification of biomarkers providing a powerful concept for prevention and intervention across different dimensions of mental health and disease. In this perspective we outline a framework for research to characterize neurodevelopmental pathways to antisocial behavior and ASPD driven by (epi)genetic factors across life, and to identify molecular targets for preventing the detrimental effects of cognitive dysfunction and maladaptive social behavior, considering psychosocial experience; to validate signatures of E/I imbalance and altered myelination proxies as biomarkers of pathogenic neural circuitry mechanisms to determine etiological processes in the transition from mental health to antisocial behavior and ASPD and in the switch from prevention to treatment; to develop a neurobiologically-grounded integrative model of antisocial behavior and ASPD resultant of disrupted E/I balance, allowing to establish objective diagnoses and monitoring tools, to personalize prevention and therapeutic decisions, to predict treatment response, and thus counteract relapse; and finally, to promote transformation of dimensional disorder taxonomy and to enhance societal awareness and reception of the neurobiological basis of antisocial behavior and ASPD.

A systematic scoping review on exploring effective interventions for narcissistic personality disorder

A systematic scoping review on exploring effective interventions for narcissistic personality disorder

Personality Disorders: Current Conceptualizations and Challenges.

The personality disorders are said to be at the vanguard in the shift to a dimensional model of classification, as exemplified in the Alternative Model of Personality (AMPD) presented in Section III of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) for emerging models and in the 11th edition of the International Classification of Diseases (ICD-11). Considered herein are some limitations and challenges. For the DSM-5 AMPD trait model, these include problematic placements, inadequate coverage, perceived complexity, and lack of cutoff points. For the DSM-5 AMPD Level of Personality Functioning (LPF), they include the complexity, the questionable presumption that the LPF defines the core of personality disorder, the presumption that the LPF identifies what is unique to the personality disorders, and the premise that the LPF is distinct from the maladaptive traits. Limitations and challenges of the ICD-11 model are the absence of lower-order facet scales and the fact that only the level of severity is required. This review suggests that the trait of depressivity belongs with negative affectivity and suspicion belongs within antagonism, that maladaptive traits from all 10 poles of the five domains should be provided, and that cutoff points based on social-occupational impairment and/or distress should be provided. The review summarizes research that questions whether the LPF represents the core of personality disorder, identifies what is unique to the personality disorders, and is distinct from maladaptive traits. Finally, the review suggests that the ICD-11 should require the assessment of the traits and include facet scales.

The roles of impulsivity, comorbid ADHD, and borderline personality disorder in patients with bulimia nervosa

BackgroundBulimia nervosa (BN) is a serious mental illness with impulsivity as a cardinal symptom. Impulsivity contributes to various other, often comorbid, mental disorders, such as attention deficit/hyperactivity disorder (ADHD) and borderline personality disorder (BPD). The aim of this study was to explore comorbidities of BN with ADHD and BPD as well as the contribution of impulsivity as an underlying trait linking these disorders.MethodsHundred and fifteen females with BN and 98 healthy matched controls (HC) (age range between 16 and 48 years) were assessed regarding adult and childhood-ADHD, personality disorders and impulsivity.ResultsPatients with BN were more impulsive (p < 0.001) and more often fulfilled criteria of childhood/adulthood ADHD (p < 0.001) than HC, and criteria of BPD than expected in the general population. Childhood-ADHD (p = 0.009) and BPD (p = 0.017) both were significant positive predictors for impulsivity scores found in patients with BN.ConclusionComorbidity with ADHD and BPD often is prevalent in BN and associated with an increase in impulsivity, the latter being a relevant transdiagnostic trait. It might be beneficial to explore impulsivity as well as comorbidities in the clinical care of patients with BN.Level of evidence IIIEvidence obtained from well-designed cohort or case–control analytic studies.

Identity Pathology and Emptiness as Novel Predictors of Suicidal Ideation.

We examined whether identity pathology was indirectly associated with future SI via emptiness, and tested impulsivity and emotion dysregulation as moderators. Participants (N = 251) completed baseline questionnaires assessing SI, borderline personality disorder symptoms, emotion dysregulation, and impulsivity, and SI 2 months later. Identity pathology was indirectly associated with future SI via emptiness, controlling for baseline SI (β = 0.15, Bootstrap 95% CI = [0.06, 0.24]). There was a two-way interaction between emptiness and both poor use of emotion regulation strategies (β = 0.06, p < 0.001) and impulsive lack of premeditation (β = 0.09, p = 0.03) predicting SI. Those with greater identity pathology were more likely to experience emptiness, which was in turn associated with future SI. Participants who felt empty were also more likely to experience SI when they also reported an inability to use emotion regulation strategies and a tendency to act without considering the consequences. We provide preliminary support for an untested risk pathway for SI, highlighting the need to further study these important experiences.

Evaluation of the personality disorder positive outcomes programme (PDPOP) in general practice.

GPs and primary care services have been identified as crucial to the care of people with personality disorder. Individuals living with personality disorder frequently face stigma and difficulties when accessing healthcare. Primary care staff often describe feeling demoralised, incompetent, hurt or angry after difficult interactions with patients. To evaluate the effect of PDPOP training delivered to 10 GP practices in 2022-23. PDPOP is a co-produced training course aimed at all staff within GP surgeries to help teams, including administrative, reception and clinical staff, to feel confident and skilled when interacting with patients who may have personality disorder. The New World Kirkpatrick Model was used to evaluate the training, through questionnaires pre- training, post-training, at follow-up, and semi-structured interviews. Evaluation found that practice teams were highly satisfied with PDPOP training and found it relevant, engaging and useful. Results demonstrated that staff felt more confident and skilled when interacting with patients who may have personality disorder through use of the training's core concepts. Increased confidence in managing distress, crisis and participant's own emotions, was associated with reduced impact on staff at interview. Practices also demonstrated action taken post-training to reduce dependency on primary care services. By including lived-experience trainers and introducing core concepts, PDPOP has demonstrated a sustained positive impact on primary care teams. Further expansion of this type of training may help to increase the confidence of healthcare staff in delivering care to patients with personality disorder and similar complex emotional needs.

Pareto in Prison.

The Pareto principle is based on the concept that roughly 80% of outcomes are generated by 20% of inputs, efforts, or contributors within a group. Using a national sample of U.S. prison inmates, we examined various percentile rankings of self-reported institutional misconduct to determine how much disorder is created behind bars by the most prolific offenders. Findings revealed that, regardless of sex, the top 20% of inmates were responsible for approximately 90% of all rule violations and write-ups received. These general patterns remained similar even after adjusting infractions for time served in prison. Further analyses indicated that membership within these high-rate groups was often significantly predicted by those who were younger, black, had more extensive criminal histories, committed violent crimes, resided in state facilities, anticipated being released, used drugs prior to their arrest, were diagnosed with a personality disorder or ADHD, and exhibited worse negative affect. Some sex-specific effects were also observed. The disproportionate impact these chronic offenders have on the prison environment is detrimental to all individuals who live and work around them. Future research should investigate specific types of misconduct, distinct time intervals of incarceration, and facility effects such as management style, security levels, or offender composition.

Psychiatric diagnoses of professional musicians: Results of an outpatient service specializing in musicians’ health

Professional musicians are often confronted with multiple profession-related stressors, which may be associated with an increased risk of mental strain, but empirical evidence focusing on clinical samples of musicians is limited. The aim of this study was to examine clinically confirmed mental disorders and personality accentuations in musicians attending a musician-specific outpatient service, to better understand how occupational and person-related stressors may impact their mental health. We performed a cross-sectional secondary data analysis of diagnoses and sociodemographic data of 678 professional musicians (including music students) that were routinely collected in the outpatient clinic. Of the 678 patients, 110 (16.2%) received a tentative psychiatric diagnosis, and 46 presented themselves to the psychiatric outpatient clinic for extensive diagnostics (using ICD-10 and SKID-II). In these 46 musicians, depression (39%) and music performance anxiety (26%) were the most frequent diagnoses, followed by adjustment disorders (13%) and somatoform disorders (11%). Twenty-eight percent of the sample fulfilled the criteria of either a personality disorder or accentuation. The frequency rates emphasize the importance of targeting the mental health of professional musicians with preventive and therapeutic measures. Further research with larger sample sizes is needed to validate and extend our findings and develop individual preventive measures.

Timing of risk factors, prodromal features, and comorbidities of dementia from a large health claims case–control study

BackgroundMany risk factors for dementia have been identified, but the timing of risk is less well understood. Here, we analyzed risk factors in a case–control study covering 10 years before an incident dementia diagnosis.MethodsWe designed a case–control study using insurance claims of outpatient consultations of patients with German statutory health insurance between January 1, 2012, and December 31, 2022. We included patients with an incident diagnosis of dementia and controls without a diagnosis of dementia matched 1:2 for age, sex, region, and earliest year of outpatient encounter. We selected exposures based on previous systematic reviews, case–control and cohort studies reporting on risk factors, comorbidities, and prodromal features of dementia. We calculated the prevalence of risk factors in cases and controls and odds ratios for each year before the index date, along with Bonferroni-corrected confidence intervals, using conditional logistic regression.ResultsWe identified a total of 1,686,759 patients with incident dementia (mean (SD) age, 82.15 (6.90) years; 61.70% female) and 3,373,518 matched controls (mean (SD) age, 82.15 (6.90) years; 61.70% female). Study participants were followed up for a mean (SD) of 6.6 (2.3) years. Of the 63 risk factors and prodromal features examined, 56 were associated with an increased risk of dementia in all years during the 10th and the 1st year before the index date. These included established risk factors, such as depression, hypertension, hearing impairment, nicotine and alcohol abuse, obesity, hypercholesterolaemia, traumatic brain injury, and diabetes. The greatest risk, with odds ratios greater than 2.5, was conferred by delirium, memory impairment, mental retardation, personality and behavioral disorders, sensory disorders, schizophrenia, and psychosis. Cancer was associated with a reduced risk of dementia.ConclusionsThis large case–control study confirmed established risk factors of dementia. In addition, the study identified non-specific diagnoses that showed a steep increase in risk close to the index date, such as psychosis, conduct disorder, and other sensory disorders. Consideration of these diagnoses, which may represent prodromal features rather than risk factors for dementia, may help to identify people with dementia in routine care.

The Narcissistic Messiah: Personality Disorder, Sun Myung Moon, and its Legacy in the Unification Church

In recent years, several scholars have been re-examining the lives of numerous sect and cult leaders through the lens of current psychiatric personality disorders and mental health classifications. Narcissism is a frequently applied disorder used to evaluate the behaviors, attitudes, and beliefs of these leaders, but no one has yet used this personality disorder to examine the life of Sun Myung Moon (founder of the Unification Church) and its significance for a multitude of connected organizations. Using analyses of Moon’s talks and speeches in conjunction with other primary documents from the Unification Church itself (along with court materials and accounts from former members), we argue that Moon likely suffered from narcissistic personality disorder, which (paradoxically) helps to explain much of the devotion that members felt toward him during his life (and now after his death). Moon’s probable narcissism also helps to explain some of the group’s theology and practices that have continued posthumously. Keywords: Sun Myung Moon, Unification Church, narcissism, Hak Ja Han Moon, sexual predation

The progress in the field of clinical staging for mental disorders within the last decade: an updated systematic review

IntroductionClinical staging aims to refine psychiatric diagnosis by describing mental disorders on a continuum of disorder progression, with the pragmatic goal of improved treatment planning and outcome prediction. The first systematic review on this topic, published a decade ago, included 78 papers, and identified separate staging models for schizophrenia, unipolar depression, bipolar disorder, panic disorder, substance use disorder, anorexia, and bulimia nervosa. The current review updates this review by including new proposals for staging models and by systematically reviewing research based upon full or partial staging models since 2012.MethodsPsycINFO, MEDLINE, EMBASE, and the Cochrane databases were systematically searched from 2012 to June 2023. The original review’s eligibility criteria were used and extended with newly introduced categories of DSM-5 mental disorders, along with mental disorders for which a progressive course might be expected. Included papers: a) contained a complete or partial staging model, or b) focused upon clinical features that might be associated with stages, or c) focused upon treatment research associated with specific stages.ResultsSeventy-one publications met the inclusion criteria. They described staging models for schizophrenia and related psychoses (21 papers), bipolar (20), depressive (4), anxiety (2), obsessive-compulsive (3), trauma related (4), eating (3), personality disorders (2), and ‘transdiagnostic’ staging models (13).DiscussionThere is a steady but slow increase in interest in clinical staging and evidence for the validity of staging remains scarce. Staging models might need to be better tailored to the complexities of mental disorders to improve their clinical utility.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/, identifier CRD42021291703.

Understanding the Traumatic Narcissism Theory and its Clinical Utility

This paper sets forth the Traumatic Narcissism Theory and will define and clarify the following terms: traumatic narcissism; narcissistic abuse; the traumatizing narcissist; the traumatizing narcissist’s relational system of subjugation. The Traumatic Narcissism Theory is intended for the treatment of victims of narcissistic abuse, distinguishing it from other psychoanalytic theories intended for the treatment of pathological narcissism and individuals diagnosed with Narcissistic Personality Disorder. This paper identifies eight specific abusive behaviors deployed by the traumatizing narcissist that are subjugating and traumatizing. Keywords: Traumatic Narcissism Theory; traumatizing narcissist; narcissistic abuse; the traumatizing narcissist’s relational system of subjugation

Associations between childhood trauma and epistemic trust, attachment, mentalizing, and symptoms of borderline personality disorder.

Introduction The construct of epistemic trust (ET) has gained wide acceptance and support in the field, although there is little empirical evidence to substantiate the theoretical assumed model. Studies of the assessment of ET were conducted in community samples only and the mediating role of attachment and mentalizing in addition to ET was not investigated. This study examines the theoretical assumed relationships between ET and attachment and mentalizing as well as the mediating role of attachment, mentalizing and ET in the association between childhood adversity and borderline personality disorder (BPD) in a heterogeneous sample containing also patients. Methods The associations between ET and attachment, mentalizing, childhood maltreatment and BPD were explored in a sample of 245 participants, including subjects from the community as well as patients diagnosed with anxiety and personality disorders from two clinical samples. Multiple mediation analysis was performed to explore the mediating role of attachment (ECR-R), mentalizing (RFQ) and ET within the relationship between childhood trauma (CTQ-SF) and BPD (MSI-BPD). Results Strong relationships between ET and attachment and mentalizing were found indicating that lower degrees of ET are associated with insecure attachment and lower reflective functioning. Attachment, mentalizing, and ET together accounted for 75% of the mediation between childhood adversity and BPD. Hypomentalizing and anxious attachment accounted for the largest share of the mediation. Conclusion Our findings provide preliminary evidence for the theoretical supposed model of ET and suggest relevance of ET in the mediation between childhood adversity and PDs, although the role of ET seems smaller than assumed by recent theories.

Acceptance, Safety, and Effect Sizes in Online Dialectical Behavior Therapy for Borderline Personality Disorder: Interventional Pilot Study.

The potential of telehealth psychotherapy (ie, the online delivery of treatment via a video web-based platform) is gaining increased attention. However, there is skepticism about its acceptance, safety, and efficacy for patients with high emotional and behavioral dysregulation. This study aims to provide initial effect size estimates of symptom change from pre- to post treatment, and the acceptance and safety of telehealth dialectical behavior therapy (DBT) for individuals diagnosed with borderline personality disorder (BPD). A total of 39 individuals meeting the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition]) criteria for BPD received 1 year of outpatient telehealth DBT at 3 sites in Germany and Canada. Effect size estimates were assessed using pre-post measures of BPD symptoms, dissociation, and quality of life. Safety was evaluated by analyzing suicide attempts and self-harm. Additionally, acceptance and feasibility, satisfaction with treatment, useability of the telehealth format, and the quality of the therapeutic alliance were assessed from both therapists' and patients' perspectives. All analyses were conducted on both the intention-to-treat (ITT) and according-to-protocol (ATP) samples. Analyses showed significant and large pre-post effect sizes for BPD symptoms (d=1.13 in the ITT sample and d=1.44 in the ATP sample; P<.001) and for quality of life (d=0.65 in the ITT sample and d=1.24 in the ATP sample). Dissociative symptoms showed small to nonsignificant reductions. Self-harm behaviors decreased significantly from 80% to 28% of all patients showing at least 1 self-harm behavior in the last 10 weeks (risk ratio 0.35). A high dropout rate of 38% was observed. One low-lethality suicide attempt was reported. Acceptance, feasibility, and satisfaction measures were high, although therapists reported only moderate useability of the telehealth format. Telehealth DBT for BPD showed large pre-post effect sizes for BPD symptoms and quality of life. While the telehealth format appeared feasible and well-accepted, the dropout rate was relatively high. Future research should compare the efficacy of telehealth DBT with in-person formats in randomized controlled trials. Overall, telehealth DBT might offer a potentially effective alternative treatment option, enhancing treatment accessibility. However, strategies for decreasing drop-out should be considered. German Clinical Trials Register DRKS00027824; https://drks.de/search/en/trial/DRKS00027824.

Effects on impulsivity and delay discounting of intermittent theta burst stimulation add-on to dialectical behavioral therapy in borderline personality disorder: a randomized, sham-controlled pilot trial

BackgroundDialectical behavioral therapy (DBT) and repetitive transcranial magnetic stimulation (rTMS) are both effective in treating borderline personality disorder (BPD). Impulsivity and impaired decision-making are prominent features of BPD, and therapeutic interventions targeting these symptoms could lead to significant improvements.Objective/HypothesisWe hypothesized that intermittent theta burst stimulation (iTBS), a modified rTMS protocol that targets the left dorsolateral prefrontal cortex, would enhance the therapeutic effects of DBT, leading to greater improvements in impulsivity and decision-making compared with sham stimulation.MethodsWe performed a single-blind, randomized, sham-controlled pilot study to evaluate the efficacy of iTBS as an add-on to an 8-week DBT program for BPD in a routine inpatient setting. A total of 53 BPD patients were randomly assigned to receive either iTBS (n = 25) or sham stimulation (n = 28) during weeks 4 to 8 of DBT, and 36 patients met the inclusion criteria for the present analysis (≥ 16 of 20 iTBS/sham sessions and assessment of delay discounting). The study endpoints were the Barratt Impulsiveness Scale-15 for impulsivity and the Monetary Choice Questionnaire for decision-making/delay discounting.ResultsA mixed model repeated measures analysis with a 2 × 2 factorial between-subjects design showed a significant overall improvement over time in impulsivity but not in decision-making/delay discounting. No significant differences were found between iTBS and sham, although post hoc tests revealed significant changes in impulsivity in the iTBS group (meandiff = -4.7, p = .001, Cohen’s d = 0.68) but not in the sham group (meandiff = -2.1, p = .077, d = 0.31).ConclusionsiTBS may offer long-term benefits as an add-on treatment to DBT for impulsivity in BPD, suggesting the need for further investigation in larger-scale studies.Trial registrationRegistered at drks.de (no. DRKS00020413) on January 13, 2020.