Interventions for Family Members and Carers of Patients with Borderline Personality Disorder: A Systematic Review

Carers of patients with borderline personality disorder (BPD) experience high levels of distress. Several studies have been carried out on interventions designed to decrease their burden. However, the evidence from these studies has not been summarized. The objective of this work is to explore the clinical utility of interventions developed for family members of patients with BPD. A systematic review was conducted following the PRISMA guidelines (registration number CRD42018107318), including psychological interventions focused on relatives of patients with BPD. The following databases were used: PsycINFO, PubMed, EBSCOhost, and Web of Science. Two independent researchers reviewed the studies to determine whether the eligibility criteria were met. A total of 2,303 abstracts were identified. After duplicates had been removed, 1,746 studies were screened. Finally, 433 full‐text articles were reviewed, yielding 11 studies that satisfied the inclusion criteria. Results show that these interventions with different clinical formats and settings are effective. The quality of the included studies varies, and the empirical support for these programs is still preliminary. The results help to establish a general framework for interventions specifically developed for family members of patients with BPD, but additional efforts should be made to improve the methodological quality of this field of research and more solidly determine the utility of these interventions. Given the paucity of data so far, this information may open up new lines of research to improve the effectiveness of future programs for carers of patients with BPD and help to reduce their burden.     

Family connections: a program for relatives of persons with borderline personality disorder

This study assessed changes in family members who participated in Family Connections, a 12-week manualized education program for relatives of persons with borderline personality disorder (BPD). Family Connections, led by trained family members, is based on the strategies of standard Dialectical Behavior Therapy (DBT) and DBT for families. The program provides (a) current information and research on BPD, (b) coping skills, (c) family skills, and (d) opportunities to build a support network for family members. Forty-four participants representing 34 families completed the pre-, post-, and 6-month postbaseline self-report questionnaires. Analyses employing hierarchical linear modeling strategies showed significant reductions in grief and burden, and a significant increase in mastery from pre- to post-group assessment. Changes were maintained at 6 months post baseline.     

A comparative study of the impact of education vs. process groups for families of patients with affective disorders

This clinical project compares the relative impact of two types of multiple family groups on psychiatric inpatients and their families. Forty patients with a diagnosis of affective disorder, and their family members, were randomly assigned to a traditional multiple family group with a process orientation that emphasized support, destigmatization, and self-help about common problems; or to a psychoeducational multiple family group that emphasized the provision of information about the patient's illness and methods of coping with it effectively. Both groups, which met for four hours on a Saturday afternoon, were an integral part of an ongoing inpatient program specializing in the treatment of affective disorders. Pre- and post-measures were obtained regarding family and patient knowledge about affective disorders, level of personal distress, attitudes about the illness, and dyadic adjustment. In addition, both patients and family members were asked to rate their satisfaction with the group experience. A number of differences in knowledge, attitude and dyadic adjustment were found in the participants of both groups immediately following their respective group sessions, but there were only a few statistically significant differences between the two groups. Those who attended the psychoeducational session, however, reported significantly more satisfaction with the experience.     

Can negative attitudes toward patients with borderline personality disorder be changed? The effect of attending a STEPPS workshop

We sought to determine whether negative attitudes toward patients with borderline personality disorder (BPD) can be modified through education. Mental health clinicians attended a 1-day workshop on the Systems Training for Emotional Predictability and Problem Solving (STEPPS) group treatment program for BPD. A questionnaire to assess attitudes towards BPD was given to 271 clinicians before and after the workshop. Following the workshop, clinicians endorsed having significantly greater empathy toward patients with BPD, and having greater awareness of the distress and low self-esteem associated with the disorder. Significant improvement was seen in the clinicians' attitudes toward patients with BPD and their desire to work with them. Clinicians were significantly less likely to express dislike for BPD patients. They also reported feeling more competent in their ability to treat these patients. The study offers preliminary evidence that negative attitudes toward patients with BPD can be modified through education.     

Caregiving for Patients in Vegetative and Minimally Conscious States: Perceived Burden as a Mediator in Caregivers’ Expression of Needs and Symptoms of Depression and Anxiety

Involvement of family members is crucial to provide daily informal caring to patients in vegetative state and minimally conscious state. Previous studies showed that perceived burden is a risk factor for informal caregivers as it increases psychophysical distress. This research further investigated the relationship between these factors and aimed at providing a model that thoroughly describes this mechanism of functioning. In the frame of a national survey on people with disorders of consciousness, 487 informal caregivers of children and adult patients in vegetative and minimally conscious state were administered measures of depression, anxiety, caregiver needs, and family strain. Regression models proposed by Baron and Kenny and the Sobel test were adopted to investigate the relationship between depressive and anxiety symptoms, perceived burden and needs expressed. Our study shows that the relation between those symptoms and needs is mediated by burden, where higher burden accentuates and lower burden mitigates the needs expressed by caregivers. Our findings demonstrate that psychosocial components of the burden perceived by caregivers of patients with disorders of consciousness play a key role in shaping those caregivers’ needs, especially their needs for information and communication. We recommend implementation of comprehensive steps to meet the needs of these caregivers, steps that incorporate improved economic and public health programs, social support, and use of psychological interventions to ameliorate caregivers’ psychological distress and decrease their burden.     

Social networks in borderline personality disorder

The interpersonal dysfunction that characterizes borderline personality disorder (BPD) has generally been studied using broad global measures, leading to a lack of precision. We report on a novel methodology using social network analysis (SNA) to quantify interactions with others in the patient's social world. We assessed the social networks of 22 clinical patients, diagnosed with either BPD (N = 11) or no personality disorder (No PD; N = 11). The social networks of patients with BPD contained a greater number of former romantic partners, and a greater number of relationships that had been terminated. Mixed model analyses found that the No PD group reported higher levels of positive relationships (e.g., trust, social support) with more central members of their social networks, whereas the BPD group did not discriminate among members of their networks. Results suggest deficits in social cognition for positive relations, but not for negative relations such as interpersonal conflict.     

Age-related differences in individual DSM criteria for borderline personality disorder

This study examined age-related effects of individual DSM criteria for borderline personality disorder (BPD) and symptoms of depression and anxiety in three groups: patients diagnosed with BPD, another personality disorder, or no personality disorder. The goal was to determine if distinctive age effects emerged within the BPD group. This mixed clinical and community sample (N = 380) ranged from 20-50 years old. Each participant was assessed for symptoms of axis I and II psychopathology. We found significant interactions for personality disorder group x age for the suicidal behavior and impulsivity criteria that reflected distinctive changes in the BPD group. The BPD group reported significantly more anxious and depressive symptoms. However, no main effect for age or personality disorder x age interaction emerged with symptoms. These results demonstrate that older individuals with BPD report less impulsivity and fewer suicidal behaviors, although symptoms of distress persist.     

Parental burden associated with borderline personality disorder in female offspring

To identify aspects of parental burden associated with borderline personality disorder (BPD), an anonymous internet survey linked to BPD support websites was developed for parents to complete on their BPD offspring and unaffected siblings. The questions cover aspects of the child's life from pregnancy through young adulthood, and query about the impact of the child's BPD on six domains of the parent's life, including physical and emotional health, marriage, job, standard of living, social life, and career trajectory. Additionally, financial burden was assessed with questions pertaining to insurance and out-of pocket costs associated with the BPD disorder. BPD offspring were identified by meeting diagnostic criteria embedded within the survey and having been given a diagnosis of BPD by a professional at some point in their life. We report on 233 female offspring meeting strict criteria for BPD. Parents of daughters with BPD endorsed varying levels of impact on the six domains comprising burden with the largest impact on emotional health which was impacted in over 88% of the respondents. Over 50% of parents endorsed four or greater of the six burden items. Particular aspects of the offspring's BPD symptom profile correlated with intensity of parental burden included including problems in adolescence with acting out behavior (p < .000), property destruction (.003), delusional symptoms (.007), and hallucinatory symptoms (.008). A subgroup of respondents provided data on specific financial expenses. The average and median out-of-pocket expense was $60,087, and $10,000. Insurance costs totaled an average of $108,251 with a mean of $20,000. The average cost per year after diagnosis was $14,606 out-of-pocket and $45,573 billed to insurance. The median cost per year after diagnosis was $3,667 out-of-pocket, and $12,500 billed to insurance. After adjusting for household income, a female proband who had been raped incurred roughly $40,000 more in BPD-related costs, while a diagnosis of conduct disorder led to about $50,000 in additional costs. Parents of female offspring with BPD experience burden in multiple domains of their life and many have incurred substantial financial expense. Increasing awareness of co-morbid conditions in the BPD proband that significantly increase parental burden may be indicators for the provision of increased family support.     

Self-esteem in patients with borderline and avoidant personality disorders

This study compared self-esteem in patients with avoidant personality disorder (APD) and borderline personality disorder (BPD). Patients diagnosed with one or more personality disorders answered the questionnaire Index of Self Esteem as part of a comprehensive evaluation within the setting of a treatment trial. Our hypotheses were that (1) both patients with APD and patients with BPD would report low levels of self-esteem, (2) patients with APD would report lower self-esteem than patients with BPD. We further expected that (3) patients with higher levels of depression would report lower levels of self-esteem, but that (4) both borderline and avoidant personality pathology would contribute to explained variance in self-esteem beyond what would be accounted for by depression. All of our hypotheses were supported. The results from our study showed a significant difference in self-esteem level between the two personality disorders, patients with APD reporting lower self-esteem than patients with BPD. Subjects with both disorders were measured to have self-esteem levels within the range that presumes clinical problems. Self-esteem represents an important quality of subjective experience of the self, and the study of self-esteem in PDs can offer new and important knowledge of PDs as self-pathology.     

Social uncertainty and interdependence: A study of resource allocation decisions in groups

Social uncertainty about the behavior of others with whom one is interdependent for rewards is hypothesized to encourage self-interested behavior and inhibit behavioral commitment to the group. This paper examines the roles of uncertainty, expectations, and feedback about other group members' contributions to the group in interdependent decision making. In the absence of feedback, resources tend to be divided between individual and group interests. Resource allocations to the group are found to increase significantly if group members receive feedback about other members' allocations, particularly if that feedback is at the individual level, not an aggregated group level. However, the effects of feedback presence and type are eliminated when group members state their expectations about other members' future contributions to the group. Implications for expectancy value theories of motivation and commitment to groups in organizations are discussed.     

The epigenesis of the family system as a context for individual development

In this article, the concept introduced by Lyman Wynne, that the individual develops epigenetically within the family system, is discussed and validated with data from a study of the characteristics and relationships of 27 women with borderline personality disorder and their parents. Each stage of the epigenetic process is impaired in one way or another, adversely affecting subsequent stages. Early impairment of attachment-care-giving processes is at least partly attributable to a lack of empathic parenting; effective communication is married by family members' inability to experience or express feelings (alexithymia); this, in turn, makes it difficult to engage in joint family problem solving. Mutuality between family members does not occur in such a context, and there is an absence of intimacy between family members. These are often abusive family systems, with multiple abuse and intrafamilial sexual abuse more specifically directed at the daughter with BPD. The symptoms of the daughter can be understood systemically, as representing both predispositional characteristics and reactions to the family system. It is suggested that the epigenetic paradigm could be used to characterize the specific failure of developmental processes in many different disorders.     

The initiation and development of a group for relatives of patients with chronic emotional disorders

This paper describes the initiation and development of an educational discussion group for relatives of patients with chronic emotional problems and the process by which it became transformed into a group combining a self-help, modified therapy model with a primary focus on the members' interaction with their patientrelatives. The group offered the opportunity to ventilate pent up emotions in a supportive, reality-oriented context and provided information and education about the nature of emotional disorders. Generally this helped family members to effect positive changes in their interactions with their patient-relatives; to accept with greater understanding their relatives' illness; and to better evaluate the quality of treatment their relatives were receiving. The group chose this model over an educational model or traditional psychotherapy model or multifamily model, all of which were phases of this process. The positive results are supported by recent reports in the literature of similar groups.Formerly on the staff of The New Britain General Hospital Mental Health Clinic.     

Combat veterans' symptoms of PTSD and partners' distress: the role of partners' perceptions of veterans' deployment experiences

Romantic partners of combat veterans with posttraumatic stress disorder (PTSD) report elevated relationship and psychological distress. One recent study suggests that this association may be weaker when partners perceive that veterans experienced higher levels of traumatic deployment events, but such results have not yet been replicated. We replicated and extended these findings in a sample of 206 National Guard service members who deployed overseas since 2001 and their partners. We used multivariate structural equation models to explore whether partners' perceptions of service members' deployment experiences moderated the associations of severity of service members' overall PTSD and specific PTSD clusters with partners' psychological and relationship distress. The significant association of overall PTSD symptom severity with partners' distress was not moderated by partners' perceptions. When examining PTSD symptoms at the cluster level, only the numbing/withdrawal cluster was significantly associated with distress. However, this association was moderated by partners' perceptions of service members' deployment experiences, such that the associations weakened as these perceptions increased. These results are in line with research indicating that the avoidance cluster of PTSD symptoms is particularly detrimental for partners of those with PTSD. Furthermore, they indicate that such symptoms are associated with less distress in partners who perceive that service members experienced high levels of potentially traumatic deployment events. Such perceptions may be linked with external attributions for symptoms, which suggests that psychoeducation regarding the causes of PTSD and the totality of PTSD symptoms may be useful in intervening with such partners.     

An experimental investigation of emotion dysregulation in borderline personality disorder

Despite the prominent role of emotion dysregulation in theoretical accounts of borderline personality disorder (BPD), few studies have examined emotion dysregulation in BPD. This study extends extant research by providing an experimental investigation of emotion dysregulation among outpatients with BPD. Specifically, this study modified an experimental measure of distress tolerance to examine differences between outpatients with BPD (n = 17) and those without a personality disorder (n = 18) in 2 aspects of emotion dysregulation: (a) the unwillingness to experience emotional distress in order to pursue goal-directed behavior and (b) the inability to engage in goal-directed behavior when distressed. As hypothesized, BPD participants were less willing to experience distress in order to pursue goal-directed behavior. However, BPD participants did not evidence greater difficulties engaging in goal-directed behavior when distressed. Results highlight directions for future research and suggest that particular aspects of emotion dysregulation may be more or less relevant to BPD.     

Children At-Risk for Borderline Personality Disorder

Adult patients who have been diagnosed with borderline personality disorder (BPD) have provided valuable information about events and family dynamics that are frequently associated with BPD. Clinicians who work with children are frequently aware of family or individual characteristics that may put a child at risk for developing BPD. Such situations frequently involve attachment issues with the child's caregivers and can include sexual abuse, divorce, alcoholism/substance use, illness/ death, and neglect. Child characteristics such as learning difficulties and temperament may also predict BPD. Yet, many children are resilient and seemingly unaffected by these events or situations, especially when early intervention may prevent development of BPD.     

Borderline personality and obsessive-compulsive symptoms

Diagnostic criteria for borderline personality disorder (BPD) are diverse, covering a broad range of symptoms. One criterion, self-mutilation, is a behavioral excess that may be considered a predictor of other psychopathological states. The present study sought to determine the extent to which two groups of BPD patients, those who mutilate and those who do not, differed on measures of general psychopathology, depression, anxiety, and obsessive-compulsive symptoms. Results indicate that the only source of significant variation was the level of obsessive-compulsive symptoms, with mutilators exhibiting greater symptomatology. The findings from this study support the idea that self-mutilation is a more severe form of psychopathology relative to the rest of the BPD population. These results are interpreted based on the affect regulation model of self-mutilation, and contrasted with contemporary models of impulse control in relation to obsessive-compulsive disorder.     

Helping patients by involving their families

Patients and their family members may become highly interdependent as patients near the end of life. To best help these patients, healthcare providers can try to become a member of the patient/family team. By becoming a member, careproviders can improve patients' and family members' access to medical information, more effectively offer advice, and assure patients and family members that they can still choose to do what they think is best.     

Race-Related Differences in the Experiences of Family Members of Persons with Mental Illness Participating in the NAMI Family to Family Education Program

Families play an important role in the lives of individuals with mental illness. Coping with the strain of shifting roles and multiple challenges of caregiving can have a huge impact. Limited information exists regarding race-related differences in families’ caregiving experiences, their abilities to cope with the mental illness of a loved one, or their interactions with mental health service systems. This study examined race-related differences in the experiences of adults seeking to participate in the National Alliance on Mental Illness Family-to-Family Education Program due to mental illness of a loved one. Participants were 293 White and 107 African American family members who completed measures of problem- and emotion-focused coping, knowledge about mental illness, subjective illness burden, psychological distress, and family functioning. Multiple regression analyses were used to determine race-related differences. African American caregivers reported higher levels of negative caregiving experiences, less knowledge of mental illness, and higher levels of both problem-solving coping and emotion-focused coping, than White caregivers. Mental health programs serving African American families should consider targeting specific strategies to address caregiving challenges, support their use of existing coping mechanisms and support networks, and increase their knowledge of mental illness.     

Family Members' Retrospective Perceptions of Intrafamilial Relationships

Parents and daughters in 21 families of women with borderline personality disorder (BPD), 23 women with restricting anorexia nervosa (AN), and 25 women without clinical histories (NC) responded to the Parental Bonding Instrument (PBI) and the Beavers Self-Report Family Inventory (SFI). On the PBI, BPD daughters' perceptions differed from both their parents' whereas AN daughters' perceptions differed from their mothers'. On the SFI, both groups reported less family health than their parents. On both instruments, nonclinical daughters' perceptions were congruent with the parents'. These findings have implications for researchers and therapists for integrating and utilizing the varying perceptions of family members.