Journal articles

Exploring the Pathways to Diagnosis for Men With Borderline Personality Disorder: A Qualitative Study

International Journal of Mental Health Nursing

J. H. Broadbear| M. G. Bhagwandas| S. Crowley| L. Cheney | S. Rao

3 September 2024

https://doi.org/10.1111/inm.13413

Short description:

Men with Borderline Personality Disorder (BPD) are less likely to receive a diagnosis and seek help. We have a limited understanding of the experiences of men with BPD and the journey they took to receive a diagnosis. We interviewed eight men with a BPD diagnosis. Key findings were that men with BPD often experience emotional invalidation when seeking mental health support, and General Practitioners play an important role in identifying BPD symptoms in men and making appropriate referrals.

ABSTRACT

Borderline personality disorder (BPD) is often perceived as being more common in females, since women are more likely to seek help and be diagnosed. However, epidemiological studies have reported no sex differences in community prevalence. The purpose of this study was to learn from the narrative journeys of men who have received a diagnosis of BPD. Eight men participated, mean age 45.9 years (range 27–73 years). Recruitment was through clinician referrals at the study site and via social media and website advertising. Participants consented to a 60–90-min semi-structured interview via an audio-visual digital platform. Audio recordings were transcribed and analysed using Interpretative Phenomenological Analysis (IPA). Three themes were identified: (i) The Emergence of Symptoms, (ii) Reaching Crisis Point and (iii) Receiving a Diagnosis. Participants reported many adverse experiences during childhood and adolescence. Early symptoms were often exacerbated by emotionally invalidating caregiving. Participants reported seeking mental health support only after reaching a crisis point, which often arose following an employment-related stressor. Participants typically initiated help-seeking by consulting a General Practitioner. Long delays were reported from initial help-seeking to being diagnosed with BPD; all expressed relief upon diagnosis. The findings highlight the deleterious consequences of emotional invalidation in participants' mental health and their capacity to access timely support. General Practitioners play a critical role in identifying probable symptoms of BPD in men and are the gateway to referral to psychiatrists and psychologists. It is vital that education is provided to assist their important work.

Exploring the Utility of Neurostimulation Therapies in the Treatment of Borderline Personality Disorder: A Systematic Literature Review

Journal of ECT

Michael Zou, Jillian Helen Broadbear, and Sathya Rao,

September 2023

https://doi.org/10.1097/yct.0000000000000916

Short description:

Electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS) are brain stimulation therapies that have been used for treatment in people with borderline personality disorder (BPD). This study reviewed the evidence relevant to this practice in this population. The few studies available suggest that TMS may be helpful in reducing BPD symptoms and depressive symptoms. While TMS shows early promise, more high-quality evidence is needed. Additionally, there is no clear evidence supporting the use of ECT for treating people with BPD; high quality research is needed.

Abstract

The use of electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS) in the treatment of people diagnosed with borderline personality disorder (BPD) highlights the need for systematic review of the evidence supporting this practice. A comprehensive literature search identified seven original clinical research studies investigating the use of brain stimulation therapies in people diagnosed with BPD. The lack of consistent study design, diagnostic methodology, treatment parameters, and outcome measures precluded analysis of aggregated study results. There were no ECT studies evaluating BPD symptom outcomes; however, studies of ECT in patients with comorbid BPD and depression suggested that depressive symptoms were less responsive to ECT compared with depression-only patients. The few studies available suggest that TMS may lead to clinically and statistically significant improvements in BPD symptoms and depressive symptoms. Similar overall improvements were reported despite the use of heterogeneous TMS treatment protocols, highlighting the importance of including a sham condition to investigate the contribution of the placebo effect to overall improvement. There is still no clear evidence supporting the use of ECT for treating people with BPD (with or without depression); therefore, the use of ECT in this population should be approached with caution. Although TMS shows early promise, the low numbers of participants in the few available studies suggest the urgent need for larger randomized controlled trials to provide an evidence base for this increasingly popular treatment.

Co-Occurring Autism Spectrum and Borderline Personality Disorder: An Emerging Clinical Challenge Seeking Informed Interventions

Harvard Review of Psychiatry

Lukas Cheney, Robert B Dudas, Jenna M Traynor, Josephine A Beatson, Sathya Rao, Lois W Choi-Kain

April 2023

https://doi.org/10.1097/hrp.0000000000000361

INITIAL CASE PRESENTATION/Short description

Brittany, a 21-year-old woman with borderline personality disorder (BPD), was referred to our specialist personality disorder service, with a presentation distinguished by high-lethality suicidal behaviors including ingestion of toxic substances and dangerous objects.

Experiences of consumers, carers and clinicians during borderline personality disorder presentations to the emergency department-An integrative review

Journal of Psychiatric and Mental Health Nursing

Joseph Miller, Elle Nguyen, Amanda Yu Hui Lam, Peter Brann, Stanley Innes, Paul Buntine, Jillian Broadbear, Judy Hope

18 December 2023

https://doi.org/10.1111/jpm.13009

Short description:

People with a borderline personality disorder (BPD) diagnosis or symptoms may experience emotional crises which necessitate use of the emergency department (ED). We reviewed research related to the experiences of consumers, carers and clinicians during BPD presentations in the ED. ED experiences related to BPD were mostly negative for consumers, carers and clinicians. Negative attitudes towards people with BPD were perceived as particularly harmful. ED models of care and staff education may be improved through co-design initiatives.

Abstract

Introduction: People with a borderline personality disorder (BPD) diagnosis or symptoms may experience emotional crises which necessitate use of the emergency department (ED). No existing reviews focus specifically on experiences of consumers, carers and clinicians in relation to ED presentations by people diagnosed with BPD.

Aim/question: The aim of this study was to synthesise knowledge on consumer, carer and clinician experiences of BPD in the ED.

Method: An integrative review methodology was chosen as it best captures the complexity of varied perspectives and emergent phenomena from diverse literature sources. EMBASE, CINAHL, PsycInfo and Medline were searched for papers published before 16 February 2022.

Results: Nine papers met the inclusion criteria (five qualitative, one quantitative, one mixed methods and two letters to the editor). Key themes were barriers to timely and adequate care, and stigmatising attitudes and practices towards people diagnosed with BPD. Negative attitudes were perceived to perpetuate harmful outcomes and further ED visits.

Discussion: Predominantly negative ED experiences were expressed by clinicians, consumers and carers. Further work is needed in ED models of care and staff education to improve the experience of care for consumers, carers and clinicians alike.

Implications for practice: Opportunities for change will exist through co-designed innovation, education, advocacy and leadership.

Mental health support for and telehealth use by Australians living with borderline personality disorder during the onset of the COVID-19 pandemic: A national study

Digital Health

Parvaneh Heidari, Jillian H Broadbear, Rita Brown, Nitin P Dharwadkar, and Sathya Rao

4 May 2023

https://doi.org/10.1177/20552076231169824

Short description:

During the COVID-19 pandemic, many people accessed mental health services through telehealth. We used a survey to ask people with borderline personality disorder (BPD) in Australia about their experience of using telehealth during the first year of the COVID-19 pandemic. More than 70% of participants used telehealth for receiving mental health services. Many participants found that telehealth somewhat benefited their mental health, however some challenges were that while using telehealth, some participants found it more difficult to control their impulses to self-harm, express self-harm and suicidal thoughts, control anger, and maintain treatment boundaries.

Abstract

Objective

To investigate mental health service use and telehealth experience of people living with BPD in Australia during the first year of the COVID-19 pandemic.

Methods

An online survey was used to collect data from people who self-identified with a diagnosis of BPD.

Results

One hundred and sixty-nine survey responses were included in the analysis. More than half of participants acknowledged receiving information from their health service about resources that they could use if they become distressed. More than 70% of participants used telehealth for receiving mental health services; the majority used telehealth to consult a psychologist or to obtain prescriptions. Telehealth sessions were conducted over the phone, via videoconferencing, or using a mix of the two. While using telehealth, some participants found it more difficult to control their impulses to self-harm, to express thoughts about self-harm and suicide, to control feelings of anger, and to establish and maintain agreed treatment boundaries. Thematic analysis of participants’ experiences of telehealth identified five main themes: Communication challenges, Technology challenges, Privacy concerns, Benefits of telehealth, and Personal preferences.

Conclusion

The study findings revealed a variety of positive and negative consumer experiences. While the majority of participants found telehealth somewhat benefitted their mental health, challenges were also reported which raise concerns about the broader utility and effectiveness of telehealth.

Seal, E., Flore, J., Kokanović, R., Borovic, T., Duff, C., Thomas S. D. M., Rao, S., Chanen, A. (2023). The emotional labour of peer work: Encountering stigma in mental healthcare spaces [Manuscript submitted for publication].

Heidari, P., Broadbear, J. H., Brown, R., Dharwadkar, N. P., & Rao, S. (2023). Mental health support for and telehealth use by Australians living with borderline personality disorder during the onset of the COVID-19 pandemic: A national study. Digital Health, 9. https://doi.org/10.1177/20552076231169824

Cheney, L., Dudas, R. B., Traynor, J. M., Beatson, J. A., Rao, S., & Choi-Kain, L. W. (2023). Co-occurring autism spectrum and borderline personality disorder: An emerging clinical challenge seeking informed interventions. Harvard Review of Psychiatry, 31(2), 83-91. https://doi.org/10.1097/HRP.0000000000000361

Zou, M., Broadbear, J. H., & Rao, S. (2023). Exploring the utility of neurostimulation therapies in the treatment of borderline personality disorder: A systematic literature review. The Journal of ECT, 1090-1097. https://doi.org/10.1097/YCT.0000000000000916

Jo, R., Broadbear, J. H., Hope, J., & Rao, S. (2023). Late manifestation of borderline personality disorder: Characterization of an under‐recognized phenomenon. Personality and Mental Health, 17(2), 165-175. https://doi.org/10.1002/pmh.1571

Nolan, J., Mildred, H., Broadbear, J. H., Knight, T., & Rao, S. (2023). Are there underlying differences between sexually diverse and non-sexually diverse people diagnosed with borderline personality disorder? Psychology & Sexuality, 14(2), 371-382. https://doi.org/10.1080/19419899.2022.2137057

Broadbear, J. H., Rotella, J. A., Lorenze, D., & Rao, S. (2022). Emergency department utilisation by patients with a diagnosis of borderline personality disorder: An acute response to a chronic disorder. Emergency Medicine Australasia, 34(5), 731-737. https://doi.org/10.1111/1742-6723.13970

Broadbear, J. H., Beatson, J. A., Moss, F., Jayaram, H., George, K., Planinic, A., Rodrigo, K., & Rao, S. (2022). Development and preliminary evaluation of a rapid screening tool for detecting borderline personality disorder in people aged over 60 Years. Clinical Gerontologist, 1-11. https://doi.org/10.1080/07317115.2022.2123727

Merrett, Z., Castle, D. J., Thomas, N., Toh, W. L., Beatson, J., Broadbear, J., Rao, S., & Rossell, S. L. (2022). Comparison of the phenomenology of hallucination and delusion characteristics in people diagnosed with borderline personality disorder and schizophrenia. Journal of Personality Disorders, 36(4), 413-430. https://doi.org/10.1521/pedi.2022.36.4.413

Cheney, L., Broadbear, J. H., & Rao, S. (2022). Disjunction in the subjective and objective measurement of co-occurring depression in borderline personality disorder: Implications for diagnosis. Australasian Psychiatry, 30(4), 481-485. https://doi.org/10.1177/10398562211065296

Brown, R., Heidari, P., Taylor, K., Veltkamp, J., Broadbear, J. H., & Rao, S. (2022). Assessment of peer-conceptualised, written and led single-session group interventions for carers supporting a person with borderline personality disorder. Advances in Mental Health, 20(2), 134-145. https://doi.org/10.1080/18387357.2021.2020139

Heidari, P., Broadbear, J. H., Cheney, L., Dharwadkar, N. P., & Rao, S. (2022). The impact of COVID-19 lockdown on the well-being of clients of a specialist personality disorder service. Australasian Psychiatry, 30(2), 235-238. https://doi.org/10.1177/10398562211057078

Heidari, P., Broadbear, J., Cheney, L., Dharwadkar, N. P., & Rao, S. (2022). The impact of COVID-19 lockdown on the well-being of mental healthcare providers working in a specialist clinic for personality disorder. Australian Psychologist, 57(1), 21-27. https://doi.org/10.1080/00050067.2021.1990735

Nithianandan, M., Heidari, P., Broadbear, J., & Rao, S. (2021). Confidence of psychiatry trainees in meeting the needs of borderline personality disorder in comparison with schizophrenia. Australasian Psychiatry, 29(6), 690-694. https://doi.org/10.1177/1039856221992650

Broadbear, J. H., Heidari, P., Dharwadkar, N. P., Cheney, L., & Rao, S. (2021). Telehealth psychotherapy for severe personality disorder during COVID-19: Experience of Australian clinicians. Global Journal of Health Science, 13(12), 61. https://doi.org/10.5539/gjhs.v13n12p61

Gec, D., Broadbear, J. H., Bourton, D., & Rao, S. (2021). Ten-week Intensive Group Program (IGP) for borderline personality disorder: Making the case for more accessible and affordable psychotherapy. BMJ Mental Health, 24(1), e1. https://doi.org/10.1136/ebmental-2020-300195

Dharwadkar, N. P., Broadbear, J. H., Heidari, P., Cheney, L., & Rao, S. (2021). Psychotherapy via Telehealth during the COVID-19 Pandemic in Australia–Experience of Clients with a Diagnosis of Borderline Personality Disorder. Global Journal of Health Science, 14(1), 29-35. https://doi.org/10.5539/gjhs.v14n1p29

Broadbear, J. H., Dwyer, J., Bugeja, L., & Rao, S. (2020). Coroners’ investigations of suicide in Australia: The hidden toll of borderline personality disorder. Journal of Psychiatric Research, 129, 241-249. https://doi.org/10.1016/j.jpsychires.2020.07.007

Rao, S., Heidari, P., & Broadbear, J. H. (2020). Developments in diagnosis and treatment of people with borderline personality disorder. Current Opinion in Psychiatry, 33(5), 441-446. https://doi.org/10.1097/yco.0000000000000625

Broadbear, J. H., & Rao, S., (2020). Designing a study to evaluate a clinical training program: Training clinicians to assess ongoing risk in people with borderline personality disorder. In Sage Research Methods Cases: Medicine and Health. SAGE Publications. https://doi.org/10.4135/9781529740882

Donald, F., Lawrence, K. A., Broadbear, J. H., & Rao, S. (2019). An exploration of self-compassion and self-criticism in the context of personal recovery from borderline personality disorder. Australasian Psychiatry : Bulletin of the Royal Australian and New Zealand College of Psychiatrists, 27(1), 56–59. https://doi.org/10.1177/1039856218797418

Donald, F., Arunogiri, S., & Lubman, D. I. (2019). Substance use and borderline personality disorder: fostering hope in the face of complexity. Australasian Psychiatry : Bulletin of the Royal Australian and New Zealand College of Psychiatrists, 27(6), 569–572. https://doi.org/10.1177/1039856219875061

Palihawadana, V., Broadbear, J. H., & Rao, S. (2019). Reviewing the clinical significance of ‘fear of abandonment’ in borderline personality disorder. Australasian Psychiatry : Bulletin of the Royal Australian and New Zealand College of Psychiatrists, 27(1), 60–63. https://doi.org/10.1177/1039856218810154

Beatson, J. A., Broadbear, J. H., Duncan, C., Bourton, D., & Rao, S. (2019). Avoiding misdiagnosis when auditory verbal hallucinations are present in borderline personality disorder. The Journal of Nervous and Mental Disease, 207(12), 1048-1055. http://dx.doi.org/10.1097/NMD.0000000000001073

Rao, S., & Broadbear, J. (2019). Borderline personality disorder and depressive disorder. Australasian Psychiatry : Bulletin of the Royal Australian and New Zealand College of Psychiatrists, 27(6), 573–577. https://doi.org/10.1177/1039856219878643

Rao, S. (2019). Borderline personality disorder–a misunderstood disorder. Sri Lanka J Psychiatry, 10, 1-3. https://doi.org/10.4038/sljpsyc.v10i2.8217

2018

Elsner, D., Broadbear, J. H., & Rao, S. (2018). What is the clinical significance of chronic emptiness in borderline personality disorder? Australasian Psychiatry : Bulletin of the Royal Australian and New Zealand College of Psychiatrists, 26(1), 88–91. https://doi.org/10.1177/1039856217734674

2017

Grenyer, B. F., Ng, F. Y., Townsend, M. L., & Rao, S. (2017). Personality disorder: A mental health priority area. Australian and New Zealand Journal of Psychiatry, 51(9), 872–875. https://doi.org/10.1177/0004867417717798

Rao, S., Broadbear, J. H., Thompson, K., Correia, A., Preston, M., Katz, P., & Trett, R. (2017). Evaluation of a novel risk assessment method for self-harm associated with Borderline Personality Disorder. Australasian Psychiatry : Bulletin of the Royal Australian and New Zealand College of Psychiatrists, 25(5), 460–465. https://doi.org/10.1177/1039856217707390

Donald, F., Duff, C., Lawrence, K., Broadbear, J., & Rao, S. (2017). Clinician perspectives on recovery and borderline personality disorder. The Journal of Mental Health Training, Education, and Practice, 12(3), 199–209. https://doi.org/10.1108/JMHTEP-09-2016-0044

Donald, F., Duff, C., Broadbear, J., Rao, S., & Lawrence, K. (2017). Consumer perspectives on personal recovery and borderline personality disorder. The Journal of Mental Health Training, Education, and Practice, 12(6), 350–359. https://doi.org/10.1108/JMHTEP-09-2016-0043

Beatson, J., Broadbear, J. H., Lubrnan, D. I., & Rao, S. (2017). Hallucinations in BPD: more prevalent than community sample study suggests? British Journal of Psychiatry, 211(4), 250–251. https://doi.org/10.1192/bjp.211.4.250b

2016

Beatson, J., Broadbear, J. H., Sivakumaran, H., George, K., Kotler, E., Moss, F., & Rao, S. (2016). Missed diagnosis: The emerging crisis of borderline personality disorder in older people. Australian & New Zealand Journal of Psychiatry, 50(12), 1139–1145. https://doi.org/10.1177/0004867416640100

Broadbear, J. H., Nesci, J., Thomas, R., Thompson, K., Beatson, J., & Rao, S. (2016). Evaluation of changes in prescription medication use after a residential treatment programme for borderline personality disorder. Australasian Psychiatry: Bulletin of the Royal Australian and New Zealand College of Psychiatrists, 24(6), 583–588. https://doi.org/10.1177/1039856216654391

2015

Bosanac, P., Hamilton, B., Beatson, J., Trett, R., Rao, S., Mancuso, S., & Castle, D. (2015). Mentalization-based intervention to recurrent acute presentations and self-harm in a community mental health service setting. Australasian Psychiatry : Bulletin of the Royal Australian and New Zealand College of Psychiatrists, 23(3), 277–281. https://doi.org/10.1177/1039856215586148

Broadbear, J., & Rao, S. (2015). Psychotherapy for Borderline Personality Disorder Reduces the Need for Prescription Medication. European Psychiatry, 30, 1528–1528. https://doi.org/10.1016/S0924-9338(15)31181-0

2014

Beatson, J., & Rao, S. (2014). Psychotherapy for borderline personality disorder. Australasian Psychiatry : Bulletin of the Royal Australian and New Zealand College of Psychiatrists, 22(6), 529–532. https://doi.org/10.1177/1039856214555531

2013

Thompson, K., Mashhood, A., Nesci, J., & Rao, S. (2013). Where should the borders of psychiatry training be? The need for more emphasis on borderline personality disorder. Australasian Psychiatry : Bulletin of the Royal Australian and New Zealand College of Psychiatrists, 21(2), 183–184. https://doi.org/10.1177/1039856212469847

2012

Beatson, J. A., & Rao, S. (2012). Depression and borderline personality disorder. Medical Journal of Australia, 197(11–12), 620–621. https://doi.org/10.5694/mja12.11646

Morton, J., Snowdon, S., Gopold, M., & Guymer, E. (2012). Acceptance and Commitment Therapy Group Treatment for Symptoms of Borderline Personality Disorder: A Public Sector Pilot Study. Cognitive and Behavioral Practice, 19(4), 527–544. https://doi.org/10.1016/j.cbpra.2012.03.005

2011

Lubman, D. I., Hall, K., Pennay, A., & Rao, S. (2011). Managing Borderline Personality Disorder and Substance Use: An Integrated Approach. Australian Family Physician, 40(6), 376–381. https://www.racgp.org.au/getattachment/27ed2be7-e385-4f70-bd4e-23fff178bc02/Managing-borderline-personality-disorder-and-subst.aspx

2010

Hulbert, C., & Thomas, R. (2010). Predicting self-injury in BPD: An investigation of the experiential avoidance model. Journal of Personality Disorders, 24(5), 651–663. https://doi.org/10.1521/pedi.2010.24.5.651

2008

Giffin, J. (2008). Family Experience of Borderline Personality Disorder. Australian and New Zealand Journal of Family Therapy, 29(3), 133–138. https://doi.org/10.1375/anft.29.3.133

2007

Hulbert, C., & Thomas, R. (2007). Public Sector Group Treatment for Severe Personality Disorder: A 12-month follow-up Study. Australasian Psychiatry : Bulletin of the Royal Australian and New Zealand College of Psychiatrists, 15(3), 226–231. https://doi.org/10.1080/10398560701317101