Jennifer Betts
University of Melbourne, Centre for youth mental health, Faculty Member
- Associate Professor Jennifer Betts, BA(Hons), D.Psych(Clinical), is the Program Manager of Personality Disorder Resea... moreAssociate Professor Jennifer Betts, BA(Hons), D.Psych(Clinical), is the Program Manager of Personality Disorder Research at Orygen & Centre for Youth Mental Health, University of Melbourne. She conducts innovative research that aims to improve the health and well-being of young people with personality disorder. A/Prof. Betts specialises in the implementation of randomised controlled trials evaluating psychosocial and pharmacological interventions for young people with personality disorder.edit
Introduction: This study aimed to analyze the real-time variability of suicidal ideation intensity and the relationship between real-time and retrospective reports of suicidal ideation made on the Beck Scale for Suicidal Ideation (BSS),... more
Introduction: This study aimed to analyze the real-time variability of suicidal ideation intensity and the relationship between real-time and retrospective reports of suicidal ideation made on the Beck Scale for Suicidal Ideation (BSS), among young people with borderline personality disorder (BPD).
Methods: Young people (15–25-year olds) with BPD (N = 46), recruited from two government-funded mental health services, rated the intensity of their suicidal ideation six times per day for 7 days before completing the BSS.
Results: For 70% of participants, suicidal ideation changed in intensity approximately five times across the week, both within and between days. BSS ratings were most highly correlated with the highest real-time ratings of suicidal ideation. However, this was not significantly different from the relationship between the BSS and both the average and most recent ratings. Median ratings of suicidal ideation intensity were higher on the BSS compared with an equivalent question asked in real time.
Conclusion: Findings suggest that young people with BPD experience high lev- els of fluctuation in their intensity of suicidal ideation across a week and that retrospective reports of suicidal ideation might be more reflective of the most intense experience of suicidal ideation across the week.
Methods: Young people (15–25-year olds) with BPD (N = 46), recruited from two government-funded mental health services, rated the intensity of their suicidal ideation six times per day for 7 days before completing the BSS.
Results: For 70% of participants, suicidal ideation changed in intensity approximately five times across the week, both within and between days. BSS ratings were most highly correlated with the highest real-time ratings of suicidal ideation. However, this was not significantly different from the relationship between the BSS and both the average and most recent ratings. Median ratings of suicidal ideation intensity were higher on the BSS compared with an equivalent question asked in real time.
Conclusion: Findings suggest that young people with BPD experience high lev- els of fluctuation in their intensity of suicidal ideation across a week and that retrospective reports of suicidal ideation might be more reflective of the most intense experience of suicidal ideation across the week.
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Background: One in five young people with first-episode psychosis (FEP) also presents with borderline personality disorder (BPD) features. Among people diagnosed with BPD, auditory verbal hallucinations occur in 29-50 % and delusions in... more
Background: One in five young people with first-episode psychosis (FEP) also presents with borderline personality disorder (BPD) features. Among people diagnosed with BPD, auditory verbal hallucinations occur in 29-50 % and delusions in 10-100 %. Co-occurrence of psychotic symptoms and BPD is associated with greater clinical severity and greater difficulty accessing evidence based FEP care. This study aimed to investigate psychotic symptoms and psychosocial functioning among young people presenting to an early intervention mental health service. Method: According to the presence or absence of either FEP or BPD, 141 participants, aged 15-25 years, were assigned to one of four groups: FEP, BPD, combined FEP + BPD, or clinical comparison (CC) participants with neither FEP nor BPD. Participants completed semi-structured diagnostic interviews and interviewer and self report measures of psychopathology and psychosocial functioning. Results: The FEP + BPD group had significantly more severe psychopathology and poorer psychosocial functioning than the FEP group on every measure, apart from intensity of hallucinations. Comparing the FEP or BPD groups, the BPD group had greater psychopathology, apart from intensity of psychotic symptoms, which was significantly greater in the FEP group. These two groups did not significantly differ in their overall psychosocial functioning. Compared with CC young people, both the FEP + BPD and BPD groups differed significantly on every measure, with medium to large effect sizes. Conclusions: Young people with co-occurring FEP and BPD experience more severe difficulties than young people with either diagnosis alone. This combination of psychosis and severe personality pathology has been longitudinally associated with poorer outcomes among adults and requires specific clinical attention.
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Research Interests: Psychology, Clinical Psychology, Nursing, Psychiatry, Violence, and 14 moreAnger, Personality Disorders, Borderline Personality Disorder, Young People, Medicine, Youth, Impulsivity, Crime, Data Linkage, Young Adults, Adolescents, Poison Control, Guidance and Counseling Intervention Programs, and Medicine and Health Sciences
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Objective: The impact of the wider social environment, such as neighbourhood characteristics, has not been examined in the development of borderline personality disorder. This study aimed to determine whether the treated incidence rate of... more
Objective: The impact of the wider social environment, such as neighbourhood characteristics, has not been examined in the development of borderline personality disorder. This study aimed to determine whether the treated incidence rate of full-threshold borderline personality disorder and sub-threshold borderline personality disorder, collectively termed borderline personality pathology, was associated with the specific neighbourhood characteristics of social deprivation and social fragmentation. Method: This study included young people, aged 15–24 years, who attended Orygen’s Helping Young People Early programme, a specialist early intervention service for young people with borderline personality pathology, from 1 August 2000–1 February 2008. Diagnoses were confirmed using the Structured Clinical Interview for DSM-IV Personality Disorders, and census data from 2006 were used to determine the at-risk population and to obtain measures of social deprivation and fragmentation. Results: The study included 282 young people, of these 78.0% ( n = 220) were female and the mean age was 18.3 years (SD = ±2.7). A total of 42.9% ( n = 121) met criteria for full-threshold borderline personality disorder, and 57.1% ( n = 161) had sub-threshold borderline personality disorder, defined as having three or four of the nine Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) borderline personality disorder criteria. There was more than a sixfold increase in the treated incidence rate of borderline personality pathology in the neighbourhoods of above average deprivation (Quartile 3) (incidence rate ratio = 6.45, 95% confidence interval: [4.62, 8.98], p < 0.001), and this was consistent in the borderline personality disorder sub-groups. This association was also present in the most socially deprived neighbourhood (Quartile 4) (incidence rate ratio = 1.63, 95% confidence interval: [1.10, 2.44]), however, only for those with sub-threshold borderline personality disorder. The treated incidence of borderline personality pathology increased incrementally with the level of social fragmentation (Quartile 3: incidence rate ratio = 1.93, 95% confidence interval: [1.37, 2.72], Quartile 4: incidence rate ratio = 2.38, 95% confidence interval: [1.77, 3.21]). Conclusion: Borderline personality pathology has a higher treated incidence in the more socially deprived and fragmented neighbourhoods. These findings have implications for funding and location of clinical services for young people with borderline personality pathology. Prospective, longitudinal studies should examine neighbourhood characteristics as potential aetiological factors for borderline personality pathology.
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COMMENT & RESPONSE In Reply We thank Allison and colleagues for their letter, comprising 5 key points. First, the authors suggest that the outcomes from the Monitoring Outcomes of Borderline Personality Disorder in Youth (MOBY) 1... more
COMMENT & RESPONSE In Reply We thank Allison and colleagues for their letter, comprising 5 key points. First, the authors suggest that the outcomes from the Monitoring Outcomes of Borderline Personality Disorder in Youth (MOBY) 1 study do not represent true treatment effects based on 1 comparison study. Our interpretation is based on 4 pieces of evidence: Headspace data on routine care for young people in Australia, 2 the natural history of the outcome variables, the rapid rate of change on symptom measures, and the consistency of our findings. We never sought to represent Headspace data as a clinical trial comparator. These are the best available data and are highly relevant despite limitations, such as the quality of diagnoses. These data were collected over a similar epoch (2013-2017); have a similar participant mean age (19.7 years), sex distribution (81% female), and geographical distribution (45% collected in the Australian state where MOBY was conducted); and had a similar mix of clinician disciplines. While the follow-up period for Headspace was the last occasion of service, for some participants this took place after 30 treatment sessions. Second, we disagree that not all groups received active treatment. This was a strength of the MOBY design compared with trials that have used treatment as usual as a comparator. The authors appear to be confusing dose (ie, that some participants attended few therapy sessions) with treatment activity. Third, the authors state that brief intervention does not alter the trajectory for severe personality disorder. The reference cited 3 includes brief treatments (2.5 months) and does not support the authors' assertion. Similar to the findings in this study, 3 the MOBY findings actually demonstrate changes in borderline personality disorder (BPD) severity and associated features, despite participants in the youth mental health service (YMHS) + befriending arm attending few sessions. There is no single trajectory of personality disorder. It is well established that the diagnostic features of BPD tend to attenuate over the MOBY time period, 4 but impairments in psychosocial functioning (which improved in MOBY) tend to remain poor and stable. 5 Fourth, Allison and colleagues claim the dose of treatment was unrelated to outcomes. The MOBY study did not investigate a dose-response relationship. The authors erroneously compare the Helping Young People Early (HYPE) service model + befriending with YMHS + befriending. MOBY was not designed to make this comparison. To date, the evidence regarding dose response in randomized clinical trials of psychosocial interventions for BPD has been contradictory. 3,6
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The study aimed to identify the relationships between patterns of non-suicidal self-injury (NSSI), their severity, and suicide attempts among 107 youth (aged 15-25 years) with borderline personality disorder (BPD). Two principal patterns... more
The study aimed to identify the relationships between patterns of non-suicidal self-injury (NSSI), their severity, and suicide attempts among 107 youth (aged 15-25 years) with borderline personality disorder (BPD). Two principal patterns were identified via a graphical representation of retrospectively reported 12-month histories of NSSI. These were habitual (NSSI occurring at regular intervals) and random patterns (NSSI inconsistently spaced). Habitual patterns of NSSI were associated with lower severity and fewer suicide attempts than random patterns. Within-person comparisons revealed a reduction in NSSI engaged within a habitual pattern and an increase in NSSI engaged within a random pattern in the month prior to a suicide attempt. Findings suggest that the accuracy of risk assessments among youth with BPD might be improved by identifying an individual's historical pattern of NSSI, as well as any relative increase in NSSI engaged within a random pattern or relative reduction in NSSI engaged within a habitual pattern.
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Objective: Caregivers of individuals with severe mental illness often experience significant negative experiences of care, which can be associated with higher levels of expressed emotion. Expressed emotion is potentially a modifiable... more
Objective: Caregivers of individuals with severe mental illness often experience significant negative experiences of care, which can be associated with higher levels of expressed emotion. Expressed emotion is potentially a modifiable target early in the course of illness, which might improve outcomes for caregivers and patients. However, expressed emotion and caregiver experiences in the early stages of disorders might be moderated by the type of severe mental illness. The aim was to determine whether experiences of the caregiver role and expressed emotion differ in caregivers of young people with first-episode psychosis versus young people with ‘first-presentation’ borderline personality disorder features. Method: Secondary analysis of baseline (pre-treatment) data from three clinical trials focused on improving caregiver outcomes for young people with first-episode psychosis and young people with borderline personality disorder features was conducted (ACTRN12616000968471, ACTRN12616000304437, ACTRN12618000616279). Caregivers completed self-report measures of experiences of the caregiver role and expressed emotion. Multivariate generalised linear models and moderation analyses were used to determine group differences. Results: Data were available for 265 caregivers. Higher levels of negative experiences and expressed emotion, and stronger correlations between negative experiences and expressed emotion domains, were found in caregivers of young people with borderline personality disorder than first-episode psychosis. Caregiver group (borderline personality disorder, first-episode psychosis) moderated the relationship between expressed emotion and caregiver experiences in the domains of need to provide backup and positive personal experiences. Conclusion: Caregivers of young people with borderline personality disorder experience higher levels of negative experiences related to their role and expressed emotion compared with caregivers of young people with first-episode psychosis. The mechanisms underpinning associations between caregiver experiences and expressed emotion differ between these two caregiver groups, indicating that different supports are needed. For borderline personality disorder caregivers, emotional over-involvement is associated with both negative and positive experiences, so a more detailed understanding of the nature of emotional over-involvement for each relationship is required to guide action.
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This study aimed to investigate predictors of vocational disengagement (referred to as Not in Employment, Education, or Training [NEET]) in young people with borderline personality disorder (BPD). The sample comprised 112 outpatients with... more
This study aimed to investigate predictors of vocational disengagement (referred to as Not in Employment, Education, or Training [NEET]) in young people with borderline personality disorder (BPD). The sample comprised 112 outpatients with a BPD diagnosis, aged 15–25 years, who participated in a randomized controlled trial (ANZCTR12610000100099). The proportion of participants who were NEET (39.3%) at study entry did not improve after 18 months and NEET status frequently changed. Therefore, multinomial regression analyses were used to study three groups: Non-NEET, NEET, and Unstable NEET status. NEET status was predicted by not achieving expected age-appropriate educational milestones, greater instability in identity, and emptiness. Greater instability in interpersonal relationships and identity predicted Unstable NEET status. The findings suggest that specific vocational interventions, that also incorporate a focus on interpersonal functioning, emptiness, and identity disturbance, are needed to improve functioning in youth with BPD, especially when educational milestones are not achieved.
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Objective:The increasing focus on adolescent personality disorder has tended to ignore evidence of the developmental continuity of the period from puberty to young adulthood. This study aims to: (1) describe the characteristics of a... more
Objective:The increasing focus on adolescent personality disorder has tended to ignore evidence of the developmental continuity of the period from puberty to young adulthood. This study aims to: (1) describe the characteristics of a sample of young people with borderline personality disorder (BPD) who had no previous history of evidence-based treatment for the disorder and (2) compare their characteristics by participant age group.Methods:One hundred and thirty-nine young people (15 to 25 years) with BPD, newly enrolled in the Monitoring Outcomes of BPD in Youth randomized controlled trial, completed semi-structured interview and self-report measures assessing demographic, clinical, and functional characteristics. Younger (aged 15 to 17 years; n = 64) and older (aged 18 to 25 years; n = 75) participants were compared on these same variables using t-tests, chi-square tests, and logistic regression.Results:Young outpatients with BPD had extensive and severe psychopathology and were functioning poorly. Adolescents and young adults with BPD showed substantial similarities on 20 key aspects of their presentation. Significant between-groups differences were observed in household makeup, treatment history, antisocial personality disorder, emotion dysregulation, substance use, age of commencement and extent of self-harm, and achievement of age-appropriate educational milestones. Adolescent BPD group membership was predicted by family composition and self-harm, whereas young adult BPD group membership was predicted by not achieving age-appropriate milestones, vocational disengagement, and emotion dysregulation. The final model explained 54% of the variance and correctly classified 80.2% of the sample by age.Conclusions:Both adolescents and young adults with early stage BPD present with severe and often similar problems to one another, supporting developmental continuity across this age range. However, there are also meaningful differences in presentation, suggesting that pathways to care might differ by age and/or developmental stage. Detection and intervention for personality disorder should not be delayed until individuals reach 18 years of age.
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Objective: Preliminary evidence indicates that interventions designed to support family and friends (‘carers’) of young people with early-stage borderline personality disorder effectively improve carer outcomes. None of these... more
Objective: Preliminary evidence indicates that interventions designed to support family and friends (‘carers’) of young people with early-stage borderline personality disorder effectively improve carer outcomes. None of these interventions have been tested in a randomised controlled trial. Method: This clustered, partially nested, randomised controlled trial was conducted at Orygen, Melbourne, Australia. Carers of young people (aged 15–25 years) with borderline personality disorder features were randomly assigned as a unit in a 1:1 ratio, balanced for young person’s sex and age, to receive a 15-day intervention comprising: (1) the three-session, in-person, Making Sense of BPD (MS-BPD) multi-family group programme, plus two self-directed online psychoeducational modules (MS-BPD + Online, n = 38), or (2) the two self-directed online psychoeducational modules alone (Online, n = 41). The primary outcome was ‘negative experiences of care’, measured with the Experience of Caregiving Inventory, at the 7-week endpoint. Results: A total of 79 carers were randomised (pool of 281, 197 excluded, 94 declined) and 73 carers (51 females [69.9%], Mage = 43.8 years [standard deviation, SD = 12.9], MS-BPD + Online n = 35 [47.9%], Online n = 38 [52.1%]) provided follow-up data and were included in the intent-to-treat analysis. The intent-to-treat (and per protocol) analyses did not find any significant differences between the groups on the primary ( d = −0.32; 95% confidence interval = [−17.05, 3.97]) or secondary outcomes. Regardless of treatment group, caregivers improved significantly in their personality disorder knowledge. Conclusion: Delivering MS-BPD in conjunction with an online psychoeducational intervention was not found to provide additional benefit over and above access to an online intervention alone. In accordance with national guidelines, carer interventions should be routinely offered by youth mental health services as part of early intervention programmes for borderline personality disorder. Further research is warranted into which interventions work for whom, carers’ preferences for support and barriers to care.
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ObjectivesThere are no established tools to identify individuals at risk for developing bipolar disorder. We developed a set of ultra‐high‐risk criteria for bipolar disorder [bipolar at‐risk (BAR)]. The primary aim of the present study... more
ObjectivesThere are no established tools to identify individuals at risk for developing bipolar disorder. We developed a set of ultra‐high‐risk criteria for bipolar disorder [bipolar at‐risk (BAR)]. The primary aim of the present study was to determine the predictive validity of the BAR criteria.MethodsThis was a 12‐month prospective study that was conducted at Orygen Youth Health Clinical Program, a public mental health program for young people aged 15–24 years in metropolitan Melbourne, Australia. At intake, BAR screen‐positive individuals and a matched group of individuals who did not meet BAR criteria were observed over a period of 12 months. The BAR criteria include general criteria such as being in the peak age range for the onset of the disorder, as well as sub‐threshold mania, depression plus cyclothymic features, and depression plus genetic risk. Conversion to first‐episode mania/hypomania was defined by the presence of DSM‐IV manic symptoms for more than four days, in line with the DSM‐IV definition of hypomania/mania.ResultsA total of 559 help‐seeking patients were screened. Of the eligible participants, 59 (10.6%) met BAR criteria. Thirty‐five participants were included in the BAR group and 35 matched participants were selected to be in the control group. During the follow‐up, five BAR patients out of 35 (14.3%) converted to first‐episode hypomania/mania as opposed to none in the non‐BAR group [χ2(1) = 5.38, p = 0.020]. Four out of these five converters had a DSM‐IV diagnosis of bipolar I or bipolar II disorder.ConclusionsThese findings support the possibility of identification of persons prior to the onset of mania/hypomania. The proposed criteria need further evaluation in larger, prospective studies with longer follow‐up periods.
Research Interests: Depression, Bipolar Disorder, Australia, Adolescent, Humans, and 15 moreHypomania, Mania, Female, Male, Gender Differences, Follow Up, Clinical Neurology, Clinical Sciences, Bipolar Disorders, Age Factors, Disease Progression, Early Intervention In Psychiatry, Cyclothymia, Affective Disorder, and High risk
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This is the first study to explore interpersonal schemata in outpatient youths (age 15–25 years) with early-stage borderline personality disorder (BPD) and auditory verbal hallucinations (AVH). It also aimed to replicate, in a... more
This is the first study to explore interpersonal schemata in outpatient youths (age 15–25 years) with early-stage borderline personality disorder (BPD) and auditory verbal hallucinations (AVH). It also aimed to replicate, in a transdiagnostic youth sample, the finding from studies of adults with AVH that negative beliefs about the self and others lead to negative appraisals of voices, which in turn elicits depression. The following 3 groups were compared: youth with BPD+AVH (n = 23), youth with schizophrenia spectrum disorder (SZ) with AVH (SZ+AVH, n = 20), and youths with BPD who did not experience AVH (BPD no AVH, n = 23). The BPD+AVH group reported more negative and fewer positive self schemata than the SZ+AVH group. They also saw themselves as being more socially inferior to others than did the SZ+AVH group, but they did not differ in appraisals of self or others, compared with the BPD no AVH group. In youths with AVH (BPD+AVH, SZ+AVH combined), the indirect effect of beliefs about self or others, via negative appraisals of voices on depression, was not significant. Instead, a significant indirect effect of negative appraisals of voices on depression, via negative beliefs about self, was found. The experience of AVH during adolescence and young adulthood, when the identity is still being formed, might have a more profound effect on the developing self than during later adulthood, when the self is more stable and resilient. Negative self-appraisals might constitute a treatment target for early intervention for youths with distressing voices, including those with BPD.
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Concomitant substance misuse in adults with borderline personality disorder (BPD) is associated with a more severe course of illness and poorer outcomes. Previous research has found an association between the number of borderline... more
Concomitant substance misuse in adults with borderline personality disorder (BPD) is associated with a more severe course of illness and poorer outcomes. Previous research has found an association between the number of borderline personality features and substance misuse in community samples. This study examined the relationship between substance use and severity of BPD in youth presenting for the first time for treatment (first presentation) of BPD. Participants were 117 help-seeking youth aged 15-25 years (93 females; Mage = 19.0 years, SD = 2.8) with BPD. Hierarchical logistic regression was used to investigate whether the severity of BPD predicted substance use. After adjusting for demographic factors and concurrent mental state pathology, BPD independently predicted alcohol dependence, amphetamine use in the previous month, or use of 2 or more illicit substances in the previous month but not daily tobacco use or cannabis use in the previous month. BPD might increase the probability that an individual will engage in higher-risk behaviors, such as amphetamine and polysubstance use, or problematic alcohol use. These findings support the need for assessment of youth with BPD for alcohol, amphetamine, and polysubstance use along with the need for routine screening in drug and alcohol services for BPD features. (PsycINFO Database Record
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This study aimed to examine the lifetime risk of being the victim of criminal or violent offenses among young people with borderline personality disorder (BPD) features (1-9 DSM-IV criteria). Demographic and diagnostic data from 492... more
This study aimed to examine the lifetime risk of being the victim of criminal or violent offenses among young people with borderline personality disorder (BPD) features (1-9 DSM-IV criteria). Demographic and diagnostic data from 492 outpatients who attended a specialist public mental health service for 15- to 25-year-olds between January 1998 and March 2008 were linked with offending data from a state-wide police database, collected between March 1993 and June 2017, in order to establish victimization history. This included information on criminal offenses perpetrated against these young people and intervention orders implemented to protect them from being victimized by another person’s violent behavior. Logistic regression analyses, adjusted for sex and co-occurring mental state disorders, were conducted on n = 378 who had complete data (76.5% females). As hypothesized, BPD diagnosis and number of BPD criteria were both significantly associated with an increased risk of being the victim of a violent offense and the complainant of a family violence intervention order. Anger and impulsivity independently predicted a higher risk of being the victim of a violent offense, while unstable relationships, impulsivity, and affective instability independently predicted a higher risk of being the complainant of a family violence intervention order. No significant association was found between BPD and the risk of being the victim of a nonviolent offense. These findings indicate that young people with any BPD features (even below the DSM diagnostic threshold) are at increased risk for victimization by interpersonal violence. Moreover, this risk increases according to the number of BPD criteria. This issue needs to be addressed by prevention and early intervention programs (e.g., by working on self-assertion and interpersonal skills, taking into account the possible influence of previous traumatizing relationship experiences).
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Research Interests: Psychology, Clinical Psychology, Psychiatry, Early Intervention, Personality, and 13 moreBorderline Personality Disorder, Young People, Medicine, Distress, Carers, Youth, Young Adults, Psychoeducation, Psychological Intervention, Adolescents, Randomised Controlled Trial, Caregivers, and Randomized Controlled Trial
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This study aimed to investigate which factors contribute to poor functioning and poor quality of life in youth (aged 15–25 years) with borderline personality disorder (BPD), and whether the number of BPD criteria might be an independent... more
This study aimed to investigate which factors contribute to poor functioning and poor quality of life in youth (aged 15–25 years) with borderline personality disorder (BPD), and whether the number of BPD criteria might be an independent predictor of these outcomes. A sample of 499 help-seeking outpatient youth, aged 15–25 years, was assessed. Stepwise multiple regression analyses showed that the number of BPD criteria was the best predictor of poor functioning, followed by number of mental health visits in the past month, female sex, and a current diagnosis of depression. Current depression was the best predictor of Assessment of Quality of Life utility score, followed by the number of BPD criteria. These findings underscore the clinical significance of DSM-IV BPD features (even when subthreshold for a categorical diagnosis) in youth and their effects upon social and occupational functioning and quality of life early in the course of BPD.
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Background Self-harm in young people is a public health concern connected with severe mental health problems, such as personality pathology. Currently, there are no specific evidence-based interventions available for young people who... more
Background Self-harm in young people is a public health concern connected with severe mental health problems, such as personality pathology. Currently, there are no specific evidence-based interventions available for young people who self-harm. Therefore, we developed PRe-Intervention Monitoring of Affect and Relationships in Youth (PRIMARY), a smartphone-based intervention, co-designed by clinicians and young people with lived experience of mental ill-health. PRIMARY combines the Experience Sampling Method (ESM) with weekly report sessions. The study aims to examine the effectiveness of PRIMARY with regard to reducing self-harm, and improving emotion regulation and quality of relationships.
Methods This study is a multicenter, parallel groups, randomized controlled trial (RCT) comparing the PRIMARY intervention to a waiting list control group. PRIMARY comprises 28 consecutive days of questionnaires five times each day (i.e., ESM) and four weekly report sessions. Participants will comprise 180 young people referred for treatment
to the participating Dutch mental healthcare institutions and (1) are aged 12 to 25 years, and (2) engaged in ≥ 1 act of self-harm in the past year. Participants are randomly allocated to a study group after screening in a 1:1 ratio by an independent researcher using computer-generated randomization sequences with stratified block randomization
by age (12 to 15 years / 16 to 25 years). Staff will conduct assessments with all participants at baseline (Wave 1), after 28 days (Wave 2), and in a subsample after 10 weeks of subsequent specialized treatment (Wave 3). The primary outcomes are self-harm, emotion regulation, and quality of relationships. Secondary outcomes include patient
and clinician satisfaction. Exploratory analyses of ESM data will examine the relationship between emotions, social relationships, and self-harm.
Discussion The results of this trial will clarify whether an innovative smartphone-based intervention is effective for reducing self harm and improving emotion regulation and the quality of social relationships. It has the potential to fill a treatment gap of interventions specifically targeting self-harm. If proven effective, it would provide an accessible, easy-to-implement, low-cost intervention for young people. Furthermore, the ESM-data will allow detailed analyses into the processes underlying self-harm, which will contribute to theoretical knowledge regarding the behavior.
Methods This study is a multicenter, parallel groups, randomized controlled trial (RCT) comparing the PRIMARY intervention to a waiting list control group. PRIMARY comprises 28 consecutive days of questionnaires five times each day (i.e., ESM) and four weekly report sessions. Participants will comprise 180 young people referred for treatment
to the participating Dutch mental healthcare institutions and (1) are aged 12 to 25 years, and (2) engaged in ≥ 1 act of self-harm in the past year. Participants are randomly allocated to a study group after screening in a 1:1 ratio by an independent researcher using computer-generated randomization sequences with stratified block randomization
by age (12 to 15 years / 16 to 25 years). Staff will conduct assessments with all participants at baseline (Wave 1), after 28 days (Wave 2), and in a subsample after 10 weeks of subsequent specialized treatment (Wave 3). The primary outcomes are self-harm, emotion regulation, and quality of relationships. Secondary outcomes include patient
and clinician satisfaction. Exploratory analyses of ESM data will examine the relationship between emotions, social relationships, and self-harm.
Discussion The results of this trial will clarify whether an innovative smartphone-based intervention is effective for reducing self harm and improving emotion regulation and the quality of social relationships. It has the potential to fill a treatment gap of interventions specifically targeting self-harm. If proven effective, it would provide an accessible, easy-to-implement, low-cost intervention for young people. Furthermore, the ESM-data will allow detailed analyses into the processes underlying self-harm, which will contribute to theoretical knowledge regarding the behavior.
IMPORTANCE Predicting the onset of bipolar disorder (BD) could facilitate preventive treatments. Among risk measures, bipolar at-risk (BAR) criteria have shown promise in predicting onset of bipolar disorder in the first year in clinical... more
IMPORTANCE Predicting the onset of bipolar disorder (BD) could facilitate preventive treatments. Among risk measures, bipolar at-risk (BAR) criteria have shown promise in predicting onset of bipolar disorder in the first year in clinical cohorts; however, it is not known whether BAR criteria are associated with the onset of BD in the longer term. OBJECTIVE To assess the association of BAR criteria with onset of BD over 10 to 13 years follow-up. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study, completed between May 1, 2020, and November 7, 2022, included consenting people seeking help for nonpsychotic major mental health difficulties, including mood, personality, and substance use disorders, who were originally recruited at ages 15 to 25 years from a tertiary youth mental health setting in metropolitan
Objective: Preliminary evidence indicates that interventions designed to support family and friends (‘carers’) of young people with early-stage borderline personality disorder effectively improve carer outcomes. None of these... more
Objective: Preliminary evidence indicates that interventions designed to support family and friends (‘carers’) of young people with early-stage borderline personality disorder effectively improve carer outcomes. None of these interventions have been tested in a randomised controlled trial. Method: This clustered, partially nested, randomised controlled trial was conducted at Orygen, Melbourne, Australia. Carers of young people (aged 15–25 years) with borderline personality disorder features were randomly assigned as a unit in a 1:1 ratio, balanced for young person’s sex and age, to receive a 15-day intervention comprising: (1) the three-session, in-person, Making Sense of BPD (MS-BPD) multi-family group programme, plus two self-directed online psychoeducational modules (MS-BPD + Online, n = 38), or (2) the two self-directed online psychoeducational modules alone (Online, n = 41). The primary outcome was ‘negative experiences of care’, measured with the Experience of Caregiving Inven...
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Objective: The impact of the wider social environment, such as neighbourhood characteristics, has not been examined in the development of borderline personality disorder. This study aimed to determine whether the treated incidence rate of... more
Objective: The impact of the wider social environment, such as neighbourhood characteristics, has not been examined in the development of borderline personality disorder. This study aimed to determine whether the treated incidence rate of full-threshold borderline personality disorder and sub-threshold borderline personality disorder, collectively termed borderline personality pathology, was associated with the specific neighbourhood characteristics of social deprivation and social fragmentation. Method: This study included young people, aged 15–24 years, who attended Orygen’s Helping Young People Early programme, a specialist early intervention service for young people with borderline personality pathology, from 1 August 2000–1 February 2008. Diagnoses were confirmed using the Structured Clinical Interview for DSM-IV Personality Disorders, and census data from 2006 were used to determine the at-risk population and to obtain measures of social deprivation and fragmentation. Results:...
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Objective: The impact of the wider social environment, such as neighbourhood characteristics, has not been examined in the development of borderline personality disorder. This study aimed to determine whether the treated incidence rate of... more
Objective: The impact of the wider social environment, such as neighbourhood characteristics, has not been examined in the development of borderline personality disorder. This study aimed to determine whether the treated incidence rate of full-threshold borderline personality disorder and sub-threshold borderline personality disorder, collectively termed borderline personality pathology, was associated with the specific neighbourhood characteristics of social deprivation and social fragmentation. Method: This study included young people, aged 15-24 years, who attended Orygen's Helping Young People Early programme, a specialist early intervention service for young people with borderline personality pathology, from 1 August 2000-1 February 2008. Diagnoses were confirmed using the Structured Clinical Interview for DSM-IV Personality Disorders, and census data from 2006 were used to determine the at-risk population and to obtain measures of social deprivation and fragmentation. Results: The study included 282 young people, of these 78.0% (n = 220) were female and the mean age was 18.3 years (SD = ±2.7). A total of 42.9% (n = 121) met criteria for full-threshold borderline personality disorder, and 57.1% (n = 161) had sub-threshold borderline personality disorder, defined as having three or four of the nine Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) borderline personality disorder criteria. There was more than a sixfold increase in the treated incidence rate of borderline personality pathology in the neighbourhoods of above average deprivation (Quartile 3) (incidence rate ratio = 6.45, 95% confidence interval: [4.62, 8.98], p < 0.001), and this was consistent in the borderline personality disorder subgroups. This association was also present in the most socially deprived neighbourhood (Quartile 4) (incidence rate ratio = 1.63, 95% confidence interval: [1.10, 2.44]), however, only for those with sub-threshold borderline personality disorder. The treated incidence of borderline personality pathology increased incrementally with the level of social fragmentation (Quartile 3: incidence rate ratio = 1.93, 95% confidence interval: [1.37, 2.72], Quartile 4: incidence rate ratio = 2.38, 95% confidence interval: [1.77, 3.21]). Conclusion: Borderline personality pathology has a higher treated incidence in the more socially deprived and fragmented neighbourhoods. These findings have implications for funding and location of clinical services for young people
Background State and trait dissociation are associated with borderline personality disorder (BPD) severity and severity of commonly co-occurring mental health symptoms. Although these distinct constructs do not consistently co-occur in... more
Background State and trait dissociation are associated with borderline personality disorder (BPD) severity and severity of commonly co-occurring mental health symptoms. Although these distinct constructs do not consistently co-occur in experimental settings, they are frequently reported as the same construct, namely dissociation. This study aimed to investigate the co-occurrence of state and trait dissociation among young people with BPD and to examine whether state or trait dissociation were associated with symptom severity in this population. Methods State dissociation was induced using a stressful behavioural task in a clinical sample of 55 young people (aged 15–25 years) with three or more BPD features. Diagnoses, state and trait dissociation, BPD severity and severity of posttraumatic stress disorder (PTSD), depressive, and stress symptoms were assessed by self-report or research interview. Results A chi-square test of independence showed a strong association between state and ...
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This study aimed to investigate predictors of vocational disengagement (referred to as Not in Employment, Education, or Training [NEET]) in young people with borderline personality disorder (BPD). The sample comprised 112 outpatients with... more
This study aimed to investigate predictors of vocational disengagement (referred to as Not in Employment, Education, or Training [NEET]) in young people with borderline personality disorder (BPD). The sample comprised 112 outpatients with a BPD diagnosis, aged 15–25 years, who participated in a randomized controlled trial (ANZCTR12610000100099). The proportion of participants who were NEET (39.3%) at study entry did not improve after 18 months and NEET status frequently changed. Therefore, multinomial regression analyses were used to study three groups: Non-NEET, NEET, and Unstable NEET status. NEET status was predicted by not achieving expected age-appropriate educational milestones, greater instability in identity, and emptiness. Greater instability in interpersonal relationships and identity predicted Unstable NEET status. The findings suggest that specific vocational interventions, that also incorporate a focus on interpersonal functioning, emptiness, and identity disturbance, a...
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Objective: Caregivers of individuals with severe mental illness often experience significant negative experiences of care, which can be associated with higher levels of expressed emotion. Expressed emotion is potentially a modifiable... more
Objective: Caregivers of individuals with severe mental illness often experience significant negative experiences of care, which can be associated with higher levels of expressed emotion. Expressed emotion is potentially a modifiable target early in the course of illness, which might improve outcomes for caregivers and patients. However, expressed emotion and caregiver experiences in the early stages of disorders might be moderated by the type of severe mental illness. The aim was to determine whether experiences of the caregiver role and expressed emotion differ in caregivers of young people with first-episode psychosis versus young people with ‘first-presentation’ borderline personality disorder features. Method: Secondary analysis of baseline (pre-treatment) data from three clinical trials focused on improving caregiver outcomes for young people with first-episode psychosis and young people with borderline personality disorder features was conducted (ACTRN12616000968471, ACTRN126...
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BackgroundFamily and friends (‘carers’) of adults with borderline personality disorder (BPD) and carers of young people with other serious illnesses experience significant adversity but research on the experiences of caring for a young... more
BackgroundFamily and friends (‘carers’) of adults with borderline personality disorder (BPD) and carers of young people with other serious illnesses experience significant adversity but research on the experiences of caring for a young person with BPD features is sparse. This study aimed to: (i) describe the experiences of carers of young people with BPD features; (ii) compare them with published data assessing carers of young people with other serious illnesses and with adults from the general population.MethodsEighty-two carers (M age = 44.74, SD = 12.86) of 54 outpatient young people (M age = 18.76, SD = 3.02) who met 3 to 9 DSM-IV BPD criteria completed self-report measures on distress, experiences of caregiving, coping, and expressed emotion. Independent-samples t-tests were employed to compare scores with those reported by convenience comparison groups of general population adults or carers of young people with eating disorders, cancer, or psychosis.ResultsCarers of young peop...
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BackgroundWomen's crisis houses have been developed in the UK as a less stigmatising and less institutional alternative to traditional psychiatric wards.AimsTo examine the effectiveness and cost-effectiveness of women's crisis... more
BackgroundWomen's crisis houses have been developed in the UK as a less stigmatising and less institutional alternative to traditional psychiatric wards.AimsTo examine the effectiveness and cost-effectiveness of women's crisis houses by first examining the feasibility of a pilot patient-preference randomised controlled trial (PP–RCT) design (ISRCTN20804014).MethodWe used a PP–RCT study design to investigate women presenting in crisis needing informal admission. The four study arms were the patient preference arms of women's crisis house or hospital admission, and randomised arms of women's crisis house or hospital admission.ResultsForty-one women entered the randomised arms of the trial (crisis house n = 19, wards n = 22) and 61 entered the patient-preference arms (crisis house n = 37, ward n = 24). There was no significant difference in outcomes (symptoms, functioning, perceived coercion, stigma, unmet needs or quality of life) or costs for any of the groups (random...
Research Interests: Psychiatry, Quality of life, Medicine, England, Humans, and 15 moreHospitalization, Female, Psychological Intervention, Patient Satisfaction, Patient Preference, Cost effectiveness, Mental Disorders, Clinical Sciences, Adult, Cost Benefit Analysis, Preference, Pilot Projects, Acute Disease, Psychology and Cognitive Sciences, and Medical and Health Sciences
Objective: The increasing focus on adolescent personality disorder has tended to ignore evidence of the developmental continuity of the period from puberty to young adulthood. This study aims to: (1) describe the characteristics of a... more
Objective: The increasing focus on adolescent personality disorder has tended to ignore evidence of the developmental continuity of the period from puberty to young adulthood. This study aims to: (1) describe the characteristics of a sample of young people with borderline personality disorder (BPD) who had no previous history of evidence-based treatment for the disorder and (2) compare their characteristics by participant age group. Methods: One hundred and thirty-nine young people (15 to 25 years) with BPD, newly enrolled in the Monitoring Outcomes of BPD in Youth randomized controlled trial, completed semi-structured interview and self-report measures assessing demographic, clinical, and functional characteristics. Younger (aged 15 to 17 years; n = 64) and older (aged 18 to 25 years; n = 75) participants were compared on these same variables using t-tests, chi-square tests, and logistic regression. Results: Young outpatients with BPD had extensive and severe psychopathology and we...
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COMMENT & RESPONSE In Reply We thank Allison and colleagues for their letter, comprising 5 key points. First, the authors suggest that the outcomes from the Monitoring Outcomes of Borderline Personality Disorder in Youth (MOBY) 1 study do... more
COMMENT & RESPONSE In Reply We thank Allison and colleagues for their letter, comprising 5 key points. First, the authors suggest that the outcomes from the Monitoring Outcomes of Borderline Personality Disorder in Youth (MOBY) 1 study do not represent true treatment effects based on 1 comparison study. Our interpretation is based on 4 pieces of evidence: Headspace data on routine care for young people in Australia, 2 the natural history of the outcome variables, the rapid rate of change on symptom measures, and the consistency of our findings. We never sought to represent Headspace data as a clinical trial comparator. These are the best available data and are highly relevant despite limitations, such as the quality of diagnoses. These data were collected over a similar epoch (2013-2017); have a similar participant mean age (19.7 years), sex distribution (81% female), and geographical distribution (45% collected in the Australian state where MOBY was conducted); and had a similar mix of clinician disciplines. While the follow-up period for Headspace was the last occasion of service, for some participants this took place after 30 treatment sessions. Second, we disagree that not all groups received active treatment. This was a strength of the MOBY design compared with trials that have used treatment as usual as a comparator. The authors appear to be confusing dose (ie, that some participants attended few therapy sessions) with treatment activity. Third, the authors state that brief intervention does not alter the trajectory for severe personality disorder. The reference cited 3 includes brief treatments (2.5 months) and does not support the authors' assertion. Similar to the findings in this study, 3 the MOBY findings actually demonstrate changes in borderline personality disorder (BPD) severity and associated features, despite participants in the youth mental health service (YMHS) + befriending arm attending few sessions. There is no single trajectory of personality disorder. It is well established that the diagnostic features of BPD tend to attenuate over the MOBY time period, 4 but impairments in psychosocial functioning (which improved in MOBY) tend to remain poor and stable. 5 Fourth, Allison and colleagues claim the dose of treatment was unrelated to outcomes. The MOBY study did not investigate a dose-response relationship. The authors erroneously compare the Helping Young People Early (HYPE) service model + befriending with YMHS + befriending. MOBY was not designed to make this comparison. To date, the evidence regarding dose response in randomized clinical trials of psychosocial interventions for BPD has been contradictory. 3,6
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Objective: Caregivers of individuals with severe mental illness often experience significant negative experiences of care, which can be associated with higher levels of expressed emotion. Expressed emotion is potentially a modifiable... more
Objective: Caregivers of individuals with severe mental illness often experience significant negative experiences of care, which can be associated with higher levels of expressed emotion. Expressed emotion is potentially a modifiable target early in the course of illness, which might improve outcomes for caregivers and patients. However, expressed emotion and caregiver experiences in the early stages of disorders might be moderated by the type of severe mental illness. The aim was to determine whether experiences of the caregiver role and expressed emotion differ in caregivers of young people with first-episode psychosis versus young people with 'first-presentation' borderline personality disorder features. Method: Secondary analysis of baseline (pre-treatment) data from three clinical trials focused on improving caregiver outcomes for young people with first-episode psychosis and young people with borderline personality disorder features was conducted (ACTRN12616000968471, ACTRN12616000304437, ACTRN12618000616279). Caregivers completed self-report measures of experiences of the caregiver role and expressed emotion. Multivariate generalised linear models and moderation analyses were used to determine group differences. Results: Data were available for 265 caregivers. Higher levels of negative experiences and expressed emotion, and stronger correlations between negative experiences and expressed emotion domains, were found in caregivers of young people with borderline personality disorder than first-episode psychosis. Caregiver group (borderline personality disorder, first-episode psychosis) moderated the relationship between expressed emotion and caregiver experiences in the domains of need to provide backup and positive personal experiences.
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The increasing focus on adolescent personality disorder has tended to ignore evidence of the developmental continuity of the period from puberty to young adulthood. This study aims to: (1) describe the characteristics of a sample of young... more
The increasing focus on adolescent personality disorder has tended to ignore evidence of the developmental continuity of the period from puberty to young adulthood. This study aims to: (1) describe the characteristics of a sample of young people with borderline personality disorder (BPD) who had no previous history of evidence-based treatment for the disorder and (2) compare their characteristics by participant age group. Methods: One hundred and thirty-nine young people (15 to 25 years) with BPD, newly enrolled in the Monitoring Outcomes of BPD in Youth randomized controlled trial, completed semi-structured interview and self-report measures assessing demographic, clinical, and functional characteristics. Younger (aged 15 to 17 years; n ¼ 64) and older (aged 18 to 25 years; n ¼ 75) participants were compared on these same variables using t-tests, chi-square tests, and logistic regression. Results: Young outpatients with BPD had extensive and severe psychopathology and were functioning poorly. Adolescents and young adults with BPD showed substantial similarities on 20 key aspects of their presentation. Significant between-groups differences were observed in household makeup, treatment history, antisocial personality disorder, emotion dysregulation, substance use, age of commencement and extent of self-harm, and achievement of age-appropriate educational milestones. Adolescent BPD group membership was predicted by family composition and self-harm, whereas young adult BPD group
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IMPORTANCE Clinical trials have neither focused on early intervention for psychosocial impairment nor on the contribution of components of borderline personality disorder (BPD) treatment beyond individual psychotherapy. OBJECTIVE To... more
IMPORTANCE Clinical trials have neither focused on early intervention for psychosocial impairment nor on the contribution of components of borderline personality disorder (BPD) treatment beyond individual psychotherapy. OBJECTIVE To evaluate the effectiveness of 3 early interventions for BPD of differing complexity. DESIGN, SETTINGS, AND PARTICIPANTS This single-blinded randomized clinical trial recruited young people between March 17, 2011, and September 30, 2015, into parallel groups. The study took place at 2 government-funded mental health services for young people in Melbourne, Australia. Inclusion criteria were age 15 to 25 years (inclusive), recent DSM-IV-TR BPD diagnosis, and never receiving evidence-based BPD treatment. A total of 139 participants were randomized (pool of 876; 70 declined, 667 excluded), balanced for sex, age, and depressive symptomatology. Data analysis completed May 2020. INTERVENTIONS (1) The Helping Young People Early (HYPE) dedicated BPD service model for young people, combined with weekly cognitive analytic therapy (CAT); (2) HYPE combined with a weekly befriending psychotherapy control condition; and (3) a general youth mental health service (YMHS) model, combined with befriending. Therefore, the 3 treatment arms were HYPE + CAT, HYPE + befriending, and YMHS + befriending. Participants were randomly assigned both to 1 treatment arm (in a 1:1:1 ratio) and to a clinician. MAIN OUTCOMES AND MEASURES Psychosocial functioning, measured with the Inventory of Interpersonal Problems Circumplex Version and the Social Adjustment Scale Self-report. RESULTS One hundred twenty-eight participants (104 [81.3%] were female; mean [SD] age, 19.1 [2.8] years; HYPE + CAT: 40 [31.3%]; HYPE + befriending: 45 [35.2%]; YMHS + befriending: 43 [33.6%]) who provided postbaseline data were included in the intent-to-treat analysis. Regardless of group, from baseline to 12 months, there was a mean of 19.3% to 23.8% improvement in the primary outcomes and 40.7% to 52.7% for all secondary outcomes, except severity of substance use and client satisfaction. The latter remained high across all time points. Planned comparisons (YMHS + befriending vs HYPE; HYPE + CAT vs befriending) showed that neither the service model nor the psychotherapy intervention was associated with a superior rate of change in psychosocial functioning by the 12-month primary end point. The HYPE service model was superior to YMHS + befriending for treatment attendance (median [IQR], 22 [19] vs 3 [16] contacts; median duration, 200 [139.5] vs 94 [125] days) and treatment completion (44 of 92 [47.8%] vs 9 of 47 [19.2%]). HYPE + CAT was superior to befriending for treatment attendance (median [IQR], 12 [16.5] vs 3 [9.8] sessions) and treatment completion (24 of 46 [52.2%] vs 29 of 93 [31.2%]). CONCLUSIONS AND RELEVANCE In this randomized clinical trial of 3 interventions for young people with BPD, effective early intervention was not reliant on availability of specialist psychotherapy but did require youth-oriented clinical case management and psychiatric care. A dedicated early intervention BPD service model (HYPE), with or without individual psychotherapy, achieved greater treatment attendance and completion, making it more likely to meet service user, family, and community expectations of care.
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This study aimed to investigate predictors of vocational disengagement (referred to as Not in Employment, Education, or Training [NEET]) in young people with borderline personality disorder (BPD). The sample comprised 112 outpatients with... more
This study aimed to investigate predictors of vocational disengagement (referred to as Not in Employment, Education, or Training [NEET]) in young people with borderline personality disorder (BPD). The sample comprised 112 outpatients with a BPD diagnosis, aged 15-25 years, who participated in a randomized controlled trial (ANZCTR12610000100099). The proportion of participants who were NEET (39.3%) at study entry did not improve after 18 months and NEET status frequently changed. Therefore, multinomial regression analyses were used to study three groups: Non-NEET, NEET, and Unstable NEET status. NEET status was predicted by not achieving expected age-appropriate educational milestones, greater instability in identity, and emptiness. Greater instability in interpersonal relationships and identity predicted Unstable NEET status. The findings suggest that specific vocational interventions, that also incorporate a focus on interpersonal functioning, emptiness, and identity disturbance, are needed to improve functioning in youth with BPD, especially when educational milestones are not achieved.