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Objective: To review the literature on the impact of gonadal hormones on features of borderline personality disorder. Background: Oestrogen flux and absolute sex hormone levels are known to be associated with various mood states in women. We investigated whether this was particularly relevant for borderline symptoms in women with or without borderline personality disorder (BPD). Methods: Systematic literature review. Discussion: There is some evidence that borderline symptoms are more severe during certain phases on the menstrual cycle in non-clinical samples of women. There is also a small evidence base that suggests that women with BPD show symptom exacerbation during the late luteal phase of their menstrual cycle. Conclusion: More work is required to establish the nature and mechanisms of interactions between gonadal hormones and symptom expression in BPD patients, and therapeutic endeavours need stringent empirical testing. [ABSTRACT FROM AUTHOR]

Borderline personality disorder (BPD) is frequently understood as a diagnosis applicable mainly to women, despite population studies suggesting similar prevalence between men and women. The scarce available information suggests that compared to women, men may face additional gender-related barriers to diagnosis and treatment when attempting to engage with support and treatment for BPD-related difficulties. The current study presents a qualitative in-depth exploration of the help-seeking and diagnosis experiences of four men with BPD. Using Interpretive Phenomenological Analysis, three themes were generated: (1) "There's just no help out there": barriers to treatment; (2) self-understanding and insight; and (3) the importance of emotional and psychological connection with health care professionals and close family and friends. Having a greater understanding of male-specific experiences of BPD could improve the helpseeking journeys of men with BPD through early identification, accurate and timely diagnosis, to relevant and effective treatment and support. [ABSTRACT FROM AUTHOR]

Objective: The prominence of suicidal ideation, suicide attempts and death by suicide among people diagnosed with Borderline Personality Disorder (BPD) underscores the importance of conducting relevant and informative risk assessment. The purpose of this study was to examine risk assessment protocols used in state public mental health services to assess whether and in what manner they include factors specific to suicidality/self-harm risk in people with BPD. Method: A qualitative evaluation of risk assessment protocols from nine of the thirteen (70%) of Victoria's public mental health was undertaken. Content analysis methodology was utilised to identify themes and compare these to recommendations for risk assessment of BPD as outlined in Australian clinical guidelines Results: The risk assessment protocols comprised suicide risk factors generally relevant to psychiatric disorders. Only one protocol incorporated BPD-specific risk assessment principles. Conclusions: Fully incorporating BPD-specific risk factors into mental health service risk assessment protocols will better inform service responses and potentially improve clinical outcomes for people with BPD whose presentation includes chronic suicidality and/or high lethality non-suicidal self-injury. Key Points: What is already known about this topic: Borderline Personality Disorder (BPD) is associated with frequent deliberate self-injury, chronic suicidal ideation, and suicidal behaviour. Specific clinical features of BPD such as chronic suicidality and impulsivity can reduce the applicability of more general psychiatric risk assessments and desensitise clinicians to high-risk situations. BPD-specific risk assessment training enables mental health professionals to differentiate between low versus high risk, chronic versus acute risk, and be alert to changes in the risk profile. What this topic adds: The majority of risk assessment protocols surveyed in public mental health services comprised suicide risk factors related to psychiatric disorders in general. Risk factors specific to chronic suicidality, deliberate self-injury, and changes in the pattern of risky behaviours in people with BPD are not systematically incorporated within public mental health risk assessment protocols. Incorporating existing evidence-based risk assessment protocols that incorporate factors specific to people with BPD may improve the consistency and accuracy with which suicide risk is assessed in public mental health services. [ABSTRACT FROM AUTHOR]

Borderline personality disorder (BPD) is a severe mental health condition marked by impairments in self and interpersonal functioning. Stigma from health staff may often result in a reluctance to diagnose, impacting recovery trajectories. Qualitative interviews were conducted with participants (N = 15; M Age = 36.4 years, SD = 7.5; 93.3% female) with lived experience of BPD exploring topics of illness onset, insight, experience of diagnosis and treatment. Qualitative responses were analysed within a co‐design framework with a member of the research team who identifies as having a lived experience of BPD. On average, participant symptoms emerged at 12.1 years of age (SD = 6.6 years, range 1.5–27), but diagnoses of BPD were delayed until 30.2 years (SD = 7.8 years, range 18–44) resulting in a 'diagnosis gap' of 18.1 years (SD = 9.6 years, range 3–30). Participant explanations for BPD emergence varied from biological, psychological and social factors. Benefits of diagnosis (e.g., fostering insight, aiding treatment planning and reducing isolation) were contrasted with challenges (e.g., stigma and treatment unavailability). Delay in diagnosis was common, and no participants reported receiving a diagnosis of BPD during their adolescence yet 85% felt they would have benefited from a diagnosis in adolescence. Only a quarter (27%) felt highly supported in the diagnostic process. An ideal four‐step diagnosis procedure was outlined based on recommendations from participants with a lived experience; this involved the following: (1) explain the process, (2) assess thoroughly, (3) explore how the features are active in everyday life and (4) link diagnosis to evidence‐based treatment planning. [ABSTRACT FROM AUTHOR]

Self-harm presents significant risk for individuals with borderline personality disorder (BPD). Both self-harm and BPD are associated with deficits in mindfulness and emotion dysregulation. Previous research suggests that thought suppression and emotional inexpressivity may underpin self-harm in people with BPD, suggesting potential links to self-harm functions common for those with BPD. More research is needed to strengthen our understanding of this relationship. This study examines how BPD symptoms, mindfulness, emotion dysregulation and self-harm functions are related. Australian community outpatients diagnosed with BPD (N = 110) completed measures of mindfulness, emotion dysregulation and self-harm functions. Serial mediation analyses were conducted to examine relationships between variables. BPD symptoms, chronic emptiness, mindfulness skills, describing and non-reacting, emotion dysregulation areas of emotion regulation strategies and poor emotional clarity were associated with recent self-harm. Various combinations of describing, strategies and clarity mediated the path between emptiness and self-harm functions more likely to be endorsed by individuals with a diagnosis of BPD. Describing was associated with all but anti-suicide function, while strategies was associated with all but anti-dissociation. The study highlights how individuals with BPD experiencing chronic emptiness may benefit from treatment targeting describing skills and adaptive emotion regulation strategies. [ABSTRACT FROM AUTHOR]

Background: People living with borderline personality disorder (BPD) face high levels of prejudice and discrimination from both the community and medical professionals, but no measure of prejudice toward people living with BPD exists. Aims: The current study aimed to adapt an existing Prejudice toward People with Mental Illness (PPMI) scale and investigate the structure and nomological network of prejudice toward people with BPD. Methods: The original 28-item PPMI scale was adapted to create the Prejudice toward People with Borderline Personality Disorder (PPBPD) scale. The scale and related measures were completed by three samples: 217 medical or clinical psychology students, 303 psychology undergraduate students, and 314 adults from the general population. Results: The original four-factor structure of the PPMI was supported in the PPBPD scale. Reported prejudice toward people with BPD was more negative than prejudice toward people with mental illness in general. The association of the PPBPD scale with antecedents and consequences was assessed, including social dominance orientation, right-wing authoritarianism, ethnocentrism, personality traits, empathy, prior contact, and feelings toward other stigmatized groups and mental illnesses. Conclusions: This study provided evidence for the validity and psychometric properties of the PPBPD scale across three samples and investigated anticipated relationships with theoretically related antecedents and consequences. This research will help improve understanding of the expressions underlying prejudice toward people with BPD. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: Patients with borderline personality disorder (BPD) are likely to attend the ED while experiencing crises and associated self‐injury and suicidality. Our study describes the prevalence, features, and outcomes associated with ED presentations by patients diagnosed with BPD in Outer Eastern Melbourne, Australia. Methods: A retrospective electronic audit of 157 364 ED attendances identified 700 unique BPD‐related ED presentations between May 2015 and April 2016. For the purpose of comparison, 583 (81% female) of these 700 cases were matched with 'depression only' cases. ED re‐presentation data were also extracted. Results: The 583 matched BPD patients attended ED a total of 2807 times during the audit year compared with 1092 attendances for matched depression‐only patients. BPD patients were more likely to: arrive by ambulance (50%); have comorbid substance abuse (44%); have a psychotic (15%) or bipolar disorder (17%); be under the care of a psychiatrist (31%); be case‐managed (42%); and be admitted to an inpatient unit (21%). ED doctors saw 38% of BPD or depression patients within the recommended time according to their triage category. The majority (73%) of BPD patients attended ED more than once during the audit year (average 4.81 ± 6.63 times; range 2–78). Conclusion: Repeated ED attendance of a subset of patients diagnosed with BPD highlights both the severity of their presentation and the inadequacy of community mental health services for meeting their complex needs. Development of effective ED referral pathways with follow‐up to engage patients in BPD‐appropriate treatment will reduce the likelihood of crises and reliance on hospital EDs for acute episodic care. [ABSTRACT FROM AUTHOR]

Introduction: Early parenting services in Australia offer brief structured residential programs to address moderate to severe non‐psychotic mental health problems among women and unsettled infant/toddler behaviours. The aims were to (1) estimate the immediate and medium‐term impact of a five‐night psychoeducational residential early parenting program on postpartum depressive symptoms and (2) identify the factors associated with improvement or worsening of postpartum depressive symptoms after completing the program and six weeks post‐discharge. Methods: Audit of routinely collected medical record data from pre‐admission, pre‐discharge and post‐discharge assessments of a consecutive cohort of women admitted, with their infants/toddlers in a 15‐month period to Masada Private Hospital Early Parenting Centre. Data included structured questions assessing: demographic characteristics, access to family and social support, past and current mental health problems, reproductive and obstetric health, chronic health conditions, breastfeeding problems, coincidental major life events, health risk behaviours and infant/toddler feeding, sleeping and crying behaviours. Standardised instruments included the Partner Interaction after Birth Scale (PIBS), the MacLean Screening Instrument for Borderline Personality Disorder (MSI‐BPD), Modified Fatigue Assessment Scale (FAS) and selected items from the Karitane Parenting Confidence Scale. The primary outcomes were Edinburgh Postnatal Depression Scale scores at pre‐discharge and follow up assessments. Data were analysed using multinomial logistic regression models in which individual and psychosocial characteristics at pre‐admission were included as predictors of the likelihood of the changes of the outcomes from pre‐admission to pre‐discharge and follow up. Results: Complete data from 1220 of 1290 (95%) eligible women were available to assess pre‐admission to pre‐discharge and from 559 (45.8%) to assess pre‐discharge to six‐week follow‐up changes. The mean pre‐admission EPDS score was 11.7 (95% CI: 11.5; 12.0), pre‐discharge it was 7.1 (95% CI: 6.9; 7.4) and at six‐week follow up it was 5.7 (95% CI: 5.3; 6.1). We found that almost all women experienced a clinically meaningful and rapid improvement in depressive symptoms of at least this magnitude (reduction in mean EPDS scores of 4.6 points from pre‐admission to pre‐discharge (five nights) and a further reduction of 1.2 points pre‐discharge to follow up) (six weeks) and we identified an interpretable set of risk factors for symptoms that did not improve or worsened. The adverse outcomes were associated with having symptoms of borderline personality disorder, a partner experienced as lacking kindness and care, coincidental adverse events and having a child younger than six months. Conclusion: Residential early parenting programs, which take a psycho‐educational approach to strengthening caregiving skills, maximising agency, and reducing helplessness, have a rapid beneficial effect on women's postpartum depressive symptoms. These programs provide a valuable and effective component of comprehensive mental health services. Long‐term dialectical behaviour therapy is indicated for women with borderline personality disorder traits for whom early parenting programs alone are insufficient to improve depressive symptoms. [ABSTRACT FROM AUTHOR]

Many people diagnosed with or presenting with borderline personality disorder (BPD) attend the emergency department (ED) when in crisis, and are often referred to mental health nurses for further assessment, and to arrange appropriate follow-up (MHNs). Little is known about the knowledge, skills, confidence and competence of MHNs working with this group in these specialist roles. This study sought to describe the attitudes of MHNs working in EDs and crisis services towards people who present with symptoms characteristic of BPD and to explore their knowledge of the diagnostic criteria of BPD. A descriptive survey tool comprised of 23 questions was adapted from a previously used survey with clinicians in a mental health service in Australia. Fifty-four nurses who identified as MHNs and were currently employed in EDs or crisis settings completed the survey online. These MHNs were found to hold positive attitudes towards people with BPD including being optimistic about recovery and treatment. The experience and education of MHNs now employed in EDs may have contributed to positive attitudes and self-reported confidence relative to other nurses. Further research ought to focus on how MHNs assist people with a diagnosis of BPD who present in crisis meet immediate needs and facilitate access to effective ongoing care and treatment. [ABSTRACT FROM AUTHOR]

Borderline personality disorder (BPD) is associated with paradoxical trust behaviours, specifically a faster rate of trust growth in the face of trust violations. The current study set out to understand whether attachment style, self-protective beliefs, and feelings of rejection underpin this pattern. Young adults (N=234) played a 15-round trust game in which partner cooperation was varied to create three phases of trust: formation, dissolution, and restoration. Discontinuous growth modelling was employed to observe whether the effect of BPD trait count on trust levels and growth is moderated by fearful or preoccupied attachment style, self-protective beliefs, and feelings of rejection. Results suggest that the slower rate of trust formation associated with BPD trait count was accounted for by feelings of rejection or self-protective beliefs, both of which predicted a slower rate of trust growth. The faster rate of trust growth in response to trust violations associated with BPD trait count was no longer significant after self-protective beliefs were accounted for. Interventions targeting self-protective beliefs and feelings of rejection may address the trust-based interpersonal difficulties associated with BPD. [ABSTRACT FROM AUTHOR]

Objective: This paper describes and evaluates a high-fidelity Dialectical Behaviour Therapy (DBT) programme for youth (15–25 years). The project was undertaken as a partnership between public mental health services and a non-government organisation in regional Australia. DBT is an evidence-based treatment for Borderline Personality Disorder (BPD) but is rarely accessible within public mental health services. Method: Participants completed an Adverse Childhood Experiences (ACE) questionnaire, repeated measures of the Borderline Symptom List (BSL-23), supplementary behaviour questionnaire (BSL-Supp) and general well-being questionnaires. Hospital and emergency service use was examined for the year prior to referral to the programme and for the year following completion. The characteristics of those people who did not complete the programme were also described. Results: Borderline personality symptoms were correlated with the number of reported adverse childhood experiences. Participants who remained in the programme for at least twelve weeks had significant reductions in BSL-23 scores with several reporting no symptoms after completing the programme. Participants had high rates of hospital and emergency department use in the year before participation and significantly less use in the year following completion. Discussion: It is feasible to deliver a high fidelity DBT programme to youth in a regional centre in Australia and achieve reductions in symptoms and use of hospital and emergency services in a regional public mental health service. [ABSTRACT FROM AUTHOR]

Loneliness is related to mental and somatic health outcomes, including borderline personality disorder. Here, we analyze the sources of variation that are responsible for the relationship between borderline personality features (including four dimensions, affective instability, identity disturbance, negative relationships, self-harm and a total score) and loneliness. Using genetically informative data from two large nonclinical samples of adult twin pairs from Australia and the Netherlands (N = 11,329), we estimate the phenotypic, genetic and environmental correlations between self-reported borderline personality features and loneliness. Individual differences in borderline personality and loneliness were best explained by additive genetic factors with heritability estimates h2 = 41% for the borderline personality total score and h2 = 36% for loneliness, with the remaining variation explained by environmental influences that were not shared by twins from the same pair. Genetic and environmental factors influencing borderline personality (total score and four subscales separately) were also partial causes of loneliness. The correlation between loneliness and the borderline personality total score was rph = .51. The genetic correlation was estimated at rg = .64 and the environmental correlation at re = .40. Our study suggests common etiological factors in loneliness and borderline personality features. [ABSTRACT FROM AUTHOR]

Drug prescription and polypharmacy are commonly seen in the management of borderline personality disorder (BPD) in clinical practice, and the 'placebo effect of medications' in BPD patients is significant. However, it is to be noted that 'no drug' has a UK market authorisation or Food & Drug Administration approval in the USA for BPD. Here Dr Yadav reviews the guidelines. [ABSTRACT FROM AUTHOR]

Dialectical Behavioural Therapy (DBT) is an evidence-based treatment for borderline personality disorder and other problems associated with emotional dysregulation. It has traditionally been deployed as a face-to-face programme comprised of attendance at group skills training, individual therapy and phone coaching. Social distancing measures arising from the COVID-19 pandemic led to a cessation of therapeutic programmes in many places. This survey of DBT clinicians in a regional State mental health service in Australia explored the impact of the cessation of DBT programmes in the region and obstacles to engaging with people via online platforms. Clinicians have been able to engage in DBT informed care, but it was perceived that many people have experienced a clinical deterioration or have increased their use of crisis services, which is entirely appropriate, as group skills programmes have ceased. Movement to online platforms of delivery poses problems, as some people do not have the access to internet or privacy in their home environments to engage in online therapy. Ideally, clinicians need to be supported through education, supervision and coaching in the use of telehealth interventions. Social distancing requirements has enabled an opportunity to carefully consider how programmes can be adapted to enable the extension of these programmes to those who have traditionally been unable to access them. [ABSTRACT FROM AUTHOR]

Objectives: Borderline personality disorder is a complex mental disorder that is associated with a high degree of suffering for the individual. Dialectical behaviour therapy has been studied in the largest number of controlled trials for treatment of individuals with borderline personality disorder. The conversational model is a psychodynamic treatment also developed specifically for treatment of borderline personality disorder. We report on the outcomes of a randomised trial comparing dialectical behaviour therapy and conversational model for treatment of borderline personality disorder in a routine clinical setting. Method: Participants had a diagnosis of borderline personality disorder and a minimum of three suicidal and/or non-suicidal self-injurious episodes in the previous 12 months. Consenting individuals were randomised to either dialectical behaviour therapy or conversational model and contracted for 14 months of treatment (n = 162 commenced therapy). Dialectical behaviour therapy involved participants attending weekly individual therapy, weekly group skills training and having access to after-hours phone coaching. Conversational model involved twice weekly individual therapy. Assessments occurred at baseline, mid-treatment (7 months) and post-treatment (14 months). Assessments were conducted by a research assistant blind to treatment condition. Primary outcomes were change in suicidal and non-suicidal self-injurious episodes and severity of depression. We hypothesised that dialectical behaviour therapy would be more effective in reducing suicidal and non-suicidal self-injurious behaviour and that conversational model would be more effective in reducing depression. Results: Both treatments showed significant improvement over time across the 14 months duration of therapy in suicidal and non-suicidal self-injury and depression scores. There were no significant differences between treatment models in reduction of suicidal and non-suicidal self-injury. However, dialectical behaviour therapy was associated with significantly greater reductions in depression scores compared to conversational model. Conclusion: This research adds to the accumulating body of knowledge of psychotherapeutic treatment of borderline personality disorder and supports the use of both dialectical behaviour therapy and conversational model as effective treatments in routine clinical settings, with some additional benefits for dialectical behaviour therapy for persons with co-morbid depression. [ABSTRACT FROM AUTHOR]

Objective: Residential patients diagnosed with borderline personality disorder were evaluated to determine whether borderline personality disorder-focused psychotherapy reduced prescribing, personality disorder and co-morbid symptom severity.Method: Psychotropic prescriptions were measured at admission, discharge and 1 year later in 74 female participants with one or more personality disorder diagnosis and co-morbid mood disorders. Changes in pharmacotherapy were examined in the context of improvements in borderline personality disorder and/or co-morbid disorder symptom severity. Residential treatment included individual and group psychotherapy for borderline personality disorder. The Structured Clinical Interview for DSM-IV was used to confirm the borderline personality disorder diagnosis and associated co-morbid conditions. The Beck Depression Inventory was completed at each time point.Results: A significant reduction in the incidence and severity of self-rated depression as well as clinician assessed personality disorder, including borderline personality disorder, was accompanied by a reduction in prescription of psychoactive medications.Conclusions: Three to six months of intensive borderline personality disorder-specific psychotherapy showed lasting benefit with regard to symptom severity of personality disorders (borderline personality disorder in particular) as well as depressive symptoms. This improvement corresponded with a reduction in prescriptions for psychoactive medications, which is consistent with current thinking regarding treatment for borderline personality disorder. [ABSTRACT FROM AUTHOR]

Objective: To identify in the Australian context: (a) treatment and support services that are accessed by people living with borderline personality disorder (BPD) and their carers, (b) perceived benefits and challenges associated with these services, and (c) changes these individuals would like to see with regards to service provision and access. Method: This project involved semi‐structured qualitative interviews with 12 participants (75% female, M age = 39.9, SD = 11.7), nine with lived experience of BPD, three carers and two identifying with both roles. Additionally, two online focus groups were conducted via online peer support communities involving 11 participants in total. Interview transcripts and focus group text were analysed thematically. Results: Participants described mixed experiences across a range of treatment types, locations and intensities. Themes were: identity and discovery, (mis)communication, complexities of care, finding what works (for me), an uncertain future, and carer empowerment. Participants described community‐based psychotherapy as being critical for reducing symptoms of BPD and improving quality of life, but reported challenges at the macro and micro level with regards to costs, service access, clinician factors and client factors. Experiences were often not aligned with a recovery model of mental health. Conclusions: The current Australian mental health system is not designed to best meet the needs of people living with BPD, which remains highly stigmatised and misunderstood. Future research should consider how the system could be modified or restructured to better support recovery for these individuals and others with complex mental illness. [ABSTRACT FROM AUTHOR]

Although Recovery-oriented approaches to delivering mental health services are now promoted in health services across the globe, there is an ongoing need to adapt these approaches to meet the unique needs of consumers with a diagnosis of borderline personality disorder. The lived experience of borderline personality disorder includes emotional dysregulation, intense and unstable relationships, self-harming behaviours, fear of abandonment, and a limited capacity to cope with stress. These experiences present a range of challenges for those who deliver Recovery-oriented services and advocate the principles of empowerment and self-determination. This paper describes a novel crisis intervention program, “Open Borders,” which has been established to meet the unique needs of people with a borderline personality disorder diagnosis. Open Borders is a Recovery-oriented model that is run at a public, state-wide residential facility for mental health consumers in Western Australia, and offers alternative pathways to achieving mental health Recovery, including self-referral and short-term admission to a residential facility. The aims of the program are to break the cycle of hospital admission, reduce rates of self-harm, and support the complex Recovery journey of consumers with a diagnosis of borderline personality disorder. Open Borders provides an exemplar for other health service organisations seeking to establish Recovery-oriented crisis intervention alternatives. [ABSTRACT FROM PUBLISHER]

Objective: This study examines pregnancy and early infant outcomes of pregnant women with a clinical diagnosis of Borderline Personality Disorder presenting for obstetric services to a major metropolitan maternity hospital in Victoria, Australia.Method: A retrospective case review of pregnancy and early infant outcomes on 42 women who had been diagnosed with Borderline Personality Disorder via psychiatric assessment using DSM-IV-R criteria was undertaken. Outcomes were compared with a control group of 14,313 consisting of women and infants of non-affected women from the same hospital over the same period of time.Results: Women presenting for obstetric services with a clinical diagnosis of Borderline Personality Disorder experienced considerable psychosocial impairment. They anticipated birth as traumatic and frequently requested early delivery. High comorbidity with substance abuse was found and high rates of referral to child protective services. Mothers with Borderline Personality Disorder were significantly more likely to have negative birth outcomes such as lowered Apgar scores, prematurity and special care nursery referral when compared with controls.Conclusions: These findings offer preliminary evidence to be considered by clinicians in developing treatments and services for the perinatal care of women with Borderline Personality Disorder and their infants. Further research is required in order to develop evidence informed clinical guidelines for the management of women with Borderline Personality Disorder and their infants. [ABSTRACT FROM AUTHOR]

Victimisation is a traumatic experience linked to development of Borderline personality disorder (BPD). However, there is limited research investigating the developmental journey prior to BPD diagnosis. School environments offer an opportunity for BPD prevention and early intervention. A survey with 19 Australian family carers of people with BPD asked what they noticed during the person’s infancy, childhood and adolescence, and their experiences of seeking help during that time. Sensitivity was most noticeable during infancy; difficulty making friends, school refusal/truancy and being bullied were prominent concerns once the child was at school; and concerns about anger, moodiness and impulsivity were the strongest prompts to seek help during adolescence, though doctor or teacher recommendation to do so was uncommon. BPD family carers’ experiences suggest that improved focus on addressing bullying and communication is needed. [ABSTRACT FROM PUBLISHER]

Accessible summary Borderline personality disorder (BPD) is a complex and challenging mental health condition for the person and service providers who support them., This paper reports on the results of a survey of 153 people with a diagnosis of BPD about their experiences of attempting to receive support in managing this mental health condition. It provides their perceptions of a range of experiences not reported in the existing literature, including general practitioner roles, urban and rural differences, public and private hospital differences, and comparison of usefulness of support across multiple support types., People with a diagnosis of BPD continue to experience significant discrimination when attempting to get their needs met within both public and private health services. Further education for nurses and other health professionals is indicated to address pervasive negative attitudes towards people with a diagnosis of BPD., Abstract There is limited understanding of the experience of seeking and receiving treatment and care by people with a diagnosis of borderline personality disorder ( BPD), their perceptions of barriers to care and the quality of services they receive. This study aimed to explore these experiences from the perspective of Australians with this diagnosis. An invitation to participate in an online survey was distributed across multiple consumer and carer organizations and mental health services, by the Private Mental Health Consumer Carer Network ( Australia) in 2011. Responses from 153 people with a diagnosis of BPD showed that they experience significant challenges and discrimination when attempting to get their needs met within both public and private health services, including general practice. Seeking help from hospital emergency departments during crises was particularly challenging. Metropolitan and rural differences, and gender differences, were also apparent. Community supports were perceived as inadequate to meet their needs. This study provides data on a range of experiences not reported in existing literature, including general practitioner roles, urban and rural differences, public and private hospital differences, and comparison of usefulness of support across multiple support types. Its findings can help inform better training for health professionals and better care for this population. [ABSTRACT FROM AUTHOR]

Accessible summary Borderline personality disorder (BPD) is a complex and challenging mental health condition for the person and family carers who support them., This paper reports on the results of a survey of 121 family carers of people diagnosed with BPD about their experiences of being carers, their attempts to seek help for the person diagnosed with BPD and their own carer needs. It provides the first detailed account across these domains., Family carers of people diagnosed with BPD experience significant exclusion and discrimination when attempting to interact with generalist health and mental health services. Further education for all health professionals is indicated, particularly general practitioners who likely come into contact with BPD carers. All health professionals need to improve their skills and attitudes in working with people diagnosed with BPD, and also their skills and attitudes in working with BPD carers. Carers of people diagnosed with BPD may need specialist carer support that addresses their distinct information, education and support needs., Abstract There is limited understanding of the experience of family carers of people diagnosed with borderline personality disorder ( BPD). This study aimed to explore their experiences of being carers, their attempts to seek help for the person diagnosed with BPD and their own carer needs. An invitation to participate in an online survey was distributed to carers across multiple consumer and carer organizations and mental health services, by the Private Mental Health Consumer Carer Network ( Australia) in 2011. Responses from 121 carers showed that they experience significant challenges and discrimination when attempting to engage with and seek support from health services. Comparison with consumers' experiences (reported elsewhere) showed that these carers have a clear understanding of the discrimination faced by people with this diagnosis, largely because they also experience exclusion and discrimination. Community carer support services were perceived as inadequate. General practitioners were an important source of support; however, they and other service providers need more education and training to support attitudinal change to address discrimination, recognize carers' needs and provide more effective support. This study provides the first detailed account of BPD carers' experiences across a broad range of support needs and interactions with community support and health services. [ABSTRACT FROM AUTHOR]

Objective: To consider the use of the diagnostic category 'complex posttraumatic stress disorder' (c-PTSD) as detailed in the forthcoming ICD-11 classification system as a less stigmatising, more clinically useful term, instead of the current DSM-5 defined condition of 'borderline personality disorder' (BPD).Conclusions: Trauma, in its broadest definition, plays a key role in the development of both c-PTSD and BPD. Given this current lack of differentiation between these conditions, and the high stigma faced by people with BPD, it seems reasonable to consider using the diagnostic term 'complex posttraumatic stress disorder' to decrease stigma and provide a trauma-informed approach for BPD patients. [ABSTRACT FROM AUTHOR]

Aims To examine the genetic overlap between borderline personality features ( BPF) and substance use disorders ( SUDs) and the extent to which variation in personality traits contributes to this covariance. Design Genetic structural equation modelling was used to partition the variance in and covariance between personality traits, BPF and SUDs into additive genetic, shared and individual-specific environmental factors. Setting All participants were registered with the Australian Twin Registry. Participants A total of 3127 Australian adult twins participated in the study. Measurements Diagnoses of DSM-IV alcohol and cannabis abuse/dependence ( AAD; CAD) and nicotine dependence ( ND) were derived via computer-assisted telephone interview. BPF and five-factor model personality traits were derived via self-report questionnaires. Findings Personality traits, BPF and substance use disorders were partially influenced by genetic factors with heritability estimates ranging from 0.38 (neuroticism; 95% confidence interval: 0.30-0.45) to 0.78 ( CAD; 95% confidence interval: 0.67-0.86). Genetic and individual-specific environmental correlations between BPF and SUDs ranged from 0.33 to 0.56 (95% CI = 0.19-0.74) and 0.19-0.32 (95% CI = 0.06-0.43), respectively. Overall, there was substantial support for genetic influences that were specific to AAD, ND and CAD (30.76-68.60%). Finally, genetic variation in personality traits was responsible for 11.46% (extraversion for CAD) to 59.30% (neuroticism for AAD) of the correlation between BPF and SUDs. Conclusions Both genetic and individual-specific environmental factors contribute to comorbidity between borderline personality features and substance use disorders. A substantial proportion of this comorbidity can be attributed to variation in normal personality traits, particularly neuroticism. [ABSTRACT FROM AUTHOR]

Dialectical behaviour therapy (DBT) is an effective treatment for borderline personality disorder and other problems underpinned by difficulties with emotional regulation. The main components of DBT are skills training groups and individual therapy. The COVID‐19 outbreak forced a rapid adaptation to online delivery, which largely mirrored face‐to‐face programmes using videoconferencing technology. This study aimed to elicit and describe the experiences and learning of therapists involved in providing high‐fidelity DBT programmes via the Australian DBT Institute, which established an online delivery platform called DBT Assist™ prior to the COVID‐19 pandemic. The report conforms with the consolidated criteria for reporting qualitative research (COREQ). Seven therapists were interviewed. Data were transcribed and analysed thematically. Delivering skills training online, either exclusively or in hybrid form (with face‐to‐face individual therapy), was acceptable and even preferable to therapists and clients. It was considered safe, the programme was associated with few non‐completers, and it improved the accessibility of DBT to those who might otherwise not be able to engage in a face‐to‐face programme. Skills training utilized a 'flipped‐learning' approach which improved the efficiency of online delivery. Other unique and helpful features of the online programme were described. The best outcomes associated with online DBT are likely to be achieved through careful adaptation to the online environment in accord with the principles of DBT rather than mirroring face‐to‐face processes. Further research is required to determine the efficacy of online therapy relative to face‐to‐face, and who might be best suited to different modes of delivery. [ABSTRACT FROM AUTHOR]

Purpose Recovery is an important concept within mental healthcare policy. There is a growing expectation that clinicians adopt approaches that align with the recovery principles, despite significant disagreements about what recovery-oriented interventions might look like in practice. It is also unclear how recovery may be relevant to personality disorder. This paper aims to discuss these issues.Design/methodology/approach In total, 16 clinicians were interviewed at two mental health services in Melbourne, Australia. These clinicians had specialist training and experience in the treatment of borderline personality disorder (BPD) and provided insight regarding the meaning and relevance of the recovery paradigm in the context of BPD. Thematic analysis within a grounded theory approach was used to understand key themes identified from the interview data.Findings Thematic analysis suggested that clinicians understand recovery in three distinct ways: as moving towards a satisfying and meaningful life, as different ways of relating to oneself and as remission of symptoms and improved psychosocial functioning. Clinicians also identified ways in which recovery-related interventions in current use were problematic for individuals diagnosed with BPD. Different approaches that may better support recovery were discussed. This study suggests that practices supporting recovery in BPD may need to be tailored to individuals with BPD, with a focus on cultivating agency while acknowledging the creative nature of recovery.Originality/value Clinicians are in a strong position to observe recovery. Their insights suggest key refinements that will enhance the ways in which recovery in BPD is conceptualized and can be promoted. [ABSTRACT FROM AUTHOR]

Intimate partner cyberstalking refers to the monitoring and controlling of an intimate partner through technologies. Unlike the cyberstalking of strangers, less is known about the motives and perpetration of intimate partner cyberstalking. In this study, we explore how vulnerable narcissism, secondary psychopathy, and borderline traits (i.e., the "Vulnerable Dark Triad") and rejection sensitivity relate to the perpetration of intimate partner cyberstalking. Participants (N = 278; 58 percent women) were recruited through social media and completed an anonymous online questionnaire. Positive correlations were observed between vulnerable narcissism, secondary psychopathy, borderline traits, rejection sensitivity, and intimate partner cyberstalking. Borderline traits moderated the relationship between participant sex (men and women) and intimate partner cyberstalking, and women with high borderline traits were most likely to cyberstalk intimate partners. Lastly, there was a significant indirect effect of vulnerable narcissism on intimate partner cyberstalking through rejection sensitivity. These findings highlight the importance of relational insecurity and rejection sensitivity in intimate partner cyberstalking and provide useful directions for future research exploring cyberstalking behaviors in intimate relationships. [ABSTRACT FROM AUTHOR]

A diagnosis of Borderline Personality Disorder (BPD) can significantly affect access to services. Two Australian approaches to addressing this crucial social justice issue are compared: Project AIR (Affect Integration and Recovery), exemplifying changes within the existing psychiatric paradigm; and Adults Surviving Child Abuse's Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery. Changes within the existing paradigm do not address stigma and fragmented services that create barriers to service. By comparison, the Guidelines represent a trauma informed perspective that recognises underlying complex trauma for most with the BPD diagnosis. Implications for services are discussed. [ABSTRACT FROM AUTHOR]

Borderline personality disorder (BPD), the focus of this issue of I Australasian Psychiatry i , has had a chequered history in psychiatry. Several other treatments were then developed for BPD and empirically validated as effective, including dialectical behavioural treatment, mentalization-based treatment, schema-based psychotherapy and transference-focused psychotherapy.[2]. [Extracted from the article]

Indigenous participants who had been given the label Borderline Personality Disorder were engaged in informal interviewins in order to find out more about the contextual factors underlying the symptoms of their diagnosis. Five participants were interviewed at great length about their experiences of identity, their personal histories, and their understanding of their mental illness. A number of themes emerged from the interviews, including identity, racism, family issues, the feeling of walking in two worlds, and experiences of alternative care during childhood. Aspects of personal and collective trauma related to their symptoms and diagnosis were also examined. Finally, knowledge and personal experience of BPD and its symptoms, as well as experiences of mental health services, emerged as strong themes. Table 1 compares the nine DSM-IV symptoms with alternative interpretations based on historical and social contexts reported by participants. We conclude that practitioners need to explore a greater range of contexts for any symptoms, and that rather than thinking of individuals in terms of having a 'borderline personality,' we suggest rethinking of them in terms of having had 'borderline socializing environments.' [ABSTRACT FROM AUTHOR]

This study investigated social perspective coordination (SPC) in youth (15-24-year-olds) with first-presentation borderline personality disorder (BPD). SPC is defined as the capacity to differentiate and integrate the perspective of the self with the perspectives of others (Selman, Beardslee, Schultz, Krupa, & Podorefsky, 1986). Two groups: patients with full or sub-syndromal BPD ( n == 30) and patients with major depressive disorder (MDD; n == 30) completed measures of SPC derived from the interpersonal negotiation strategies (INS) model (Selman et al., 1986). Compared with the MDD group, the BPD group responded to all vignettes with significantly lower SPC scores and SPC was a significant predictor of BPD status over and above self-reported, personality factors (Neuroticism and Agreeableness), attachment disturbance and functional impairment. These findings suggest that disturbances in social cognition are an important characteristic of individuals with BPD pathology. These difficulties extended beyond attachment contexts and were not limited to situations involving BPD-related themes of abandonment, deprivations or mistrust/abuse. [ABSTRACT FROM AUTHOR]

Impulsivity in Borderline Personality Disorder (BPD) has been defined as rapid and unplanned action. However, a preference for immediate gratification and discounting of delayed rewards might better account for the impulsive behaviors that appear to regulate emotional distress in BPD. To investigate this, a delay discounting task was administered to 30 outpatients diagnosed with BPD and 28 healthy community controls (all aged 15-24) before and after a mood induction. Trait impulsivity was measured with the Barratt Impulsiveness Scale. The results showed that the BPD group had a greater preference for immediate gratification and higher rate of discounting the delayed reward than the control group. Although the mood induction resulted in increased feelings of rejection and anger in all participants, and the rate of delay discounting changed significantly in the control group, the rate of discounting did not change for the BPD group. There was no evidence of rapid decision-making in the BPD group as response times were similar between the two groups during both trials. Finally, greater general impulsiveness and nonplanning impulsiveness were associated with greater rates of discounting in the BPD group. Together these findings suggest that BPD is characterized by a preference for immediate gratification and tendency to discount longer-term rewards. This characteristic appears to exist independent of feelings of rejection and anger, rather than being reactive to this, and to be related to trait impulsivity. [ABSTRACT FROM AUTHOR]

There is a paucity of research literature regarding Indigenous people diagnosed with Borderline Personality Disorder (BPD). This review focuses on analyzing the contextual issues arising from such a diagnosis, particularly when applied to Indigenous Australians, and on the social and historical contexts which might facilitate a more accurate interpretation of the symptoms of BPD. The literature on historical and social contexts of Indigenous Australians was reviewed, with particular emphasis on alternative views of self and of collective trauma likely impacting upon the diagnoses. Table 1 compares the DSM-IV discussion of the nine symptoms with alternative contextual interpretations. This review serves as a starting point for finding more positive and effective ways of working with people who present with BPD symptoms, and providing more detailed and more culturally appropriate contexts in which to view individuals. [ABSTRACT FROM AUTHOR]

ABSTRACT Contemporary theories of borderline personality disorder (BPD) have detailed the functional importance of emotional invalidation in meaningful relationships as an aetiological and perpetuating factor of its core disturbances. The purpose of our study was to test aspects of Linehan's (1993) biosocial and Fruzzetti (1996) and Fruzzetti, Shenk, and Hoffman's (2005) validation/invalidation family interactions transactional theories in a community sample of 186 participants. Results indicated that a multi-mediational path model of invalidation in meaningful relationships, emotion dysregulation, poor distress tolerance and BPD symptoms provided a perfect fit to the data and accounted for a substantial amount of variance in BPD (38%). The results provided support for these complimentary theories of BPD, which hold promise for clinical applications and future research. Copyright © 2013 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

With the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders ( DSM-5) scheduled for publication in 2013, researchers continue to debate the optimal classification of borderline personality disorder (BPD). Much of the discussion has focused on the relative merits of dimensional versus categorical classification schemes for BPD. Advances in statistical technologies have made it possible to adjudicate between continuous and categorical models of BPD using quantitative methods, yet no prior studies have attempted such a comparison. The current study directly compares the fit of dimensional, categorical, and hybrid models of BPD in a large community sample ( N = 700) of young adults at risk for psychopathology due to elevated rates of maternal depression. BPD symptoms were assessed using the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). Latent class, latent trait, and factor mixture models of SCID-II symptoms were estimated, and a latent trait model provided superior fit to the data, supporting a dimensional conceptualization of borderline pathology. The nosological implications of these results are discussed with respect to a 'hybrid' model of BPD diagnosis currently under consideration for DSM-5. [ABSTRACT FROM AUTHOR]

The experience of rejection or abandonment in Borderline Personality Disorder (BPD) can lead to profound changes in affect. Yet, the intensity, duration, and type of mood changes that occur in response to rejection remain unclear. This study examined the effect of ostracism upon mood in 30 outpatient youth diagnosed with BPD and 22 healthy community control participants (aged 15-24). Cyberball, a virtual balltoss game, was used to simulate ostracism and 13 mood states were recorded before, immediately after, and 15 minutes after the game. The results showed that while ostracism induced changes in anger, rejection, surprise, suspicion, and joy, there were no differences in the pattern of emotional responding and regulation between the two groups. The BPD group consistently rated their mood as more intense across all 13 mood states and across time compared with the control group. These findings suggest that, compared to healthy individuals, those youth with BPD experience negative emotions as more intense and that in mild cases of interpersonal rejection, their emotional responding and regulation are similar to their healthy peers. [ABSTRACT FROM AUTHOR]

The patient population of borderline personality disorder (BPD) is heterogeneous; many different combinations of BPD symptoms can lead to a BPD diagnosis. We investigated to what extent the covariance among four main components of BPD is explained by shared genetic and environmental factors. Using an extended twin design, multivariate genetic models were applied to the scales of the PAI-BOR, a self-report questionnaire tapping four main features of BPD (affective instability, identity problems, negative relationships, and self-harm). Data on the four BPD scales were available for 5,533 twins and 1,202 siblings from the Netherlands, Belgium, and Australia. The correlations among the scales ranged from 0.23 to 0.50 and were best explained by a genetic common pathway model. This model specifies that genes and environment influence the covariance between four main features of BPD in qualitatively similar ways, through a single latent factor representing the BPD construct. the heritability of the latent BPD factor was 51% and the remainder of its variance was explained by unique environmental influences. For each BPD scale, except self-harm, around 50% of its variance was explained by the latent BPD factor. The remaining variance for each of the four scales was explained by genetic (4% for affective instability to 20% for self-harm) and environmental (38% for negative relationships to 67% for self-harm) factors that were specific to each scale. [ABSTRACT FROM AUTHOR]

Clinicians recognize expressive language disturbances in borderline personality disorder (BPD) as a feature attenuating psychiatric history-taking. Neuroimaging studies demonstrate activation of key differentiating neural networks characterizing a traumatic memory system in BPD patients. Yet there are few BPD studies evaluating expressive language disturbances in response to emotionally salient, clinically relevant stimuli and no controlled studies. The aim was to examine expressive language disturbances in response to a clinically relevant emotional stimulus, the Adult Attachment Interview (AAI). Twenty BPD participants and 20 age-, sex-, and education-matched controls were administered the AAI. Verbatim transcripts were analyzed by four computerized measures designed to evaluate various linguistic components of speech (i.e., overall expressive language impairment, lexical complexity, syntactic complexity, and semantic complexity). BPD participants evidenced significantly greater levels of overall expressive language impairment and reduced syntactic and lexical complexity, but not semantic complexity scores. Detailed linguistic profiles demonstrated specific deficits linked to BPD. [ABSTRACT FROM AUTHOR]

Developmental scientists describe the role confusion that can occur for adolescents as they are forming a personal identity. Clinical psychologists describe low self-worth, lack of self-clarity, feelings of emptiness, and dissociation as the key elements of identity disturbance, and they link these to borderline personality disorder. In this study, the authors aimed to work at the juncture of these approaches by considering interrelations between four elements of identity disturbance, typical identity formation processes reflective of identity commitment and confusion, and borderline features. Australian youth (N = 505, 63% female and aged 12–20 years) recruited from clinical and community settings reported on identity commitment, exploration and reconsideration, four elements of identity disturbance, and borderline features. Identity confusion (especially reconsideration) and disturbance were associated with elevated borderline symptoms. Emptiness stood out as the strongest correlate of borderline symptoms. Youth reporting greater emptiness were nearly twice as likely to report a high borderline symptom profile. [ABSTRACT FROM AUTHOR]

Objective: This exploratory study was conducted in Australia and New Zealand and examined the impact of two types of education programs (cognitive-behavioral and psychoanalytic) on clinicians' attitude toward deliberate self-harm behaviors in borderline personality disorder and toward working with patients with this disorder. Methods: The Attitudes Towards Deliberate Self-Harm Questionnaire was used to assess the attitudes of mental health and emergency medicine clinicians (N=65) before and after attending an education program and at the six-month follow-up. Results: Compared with participants in the control group (N=22), participants in the cognitive-behavioral program (N= 18) showed significant improvement in attitudes immediately after attending the program (p=.02), as did participants in the psychoanalytic education program (N=25) (p<.01). However, the six-month follow-up revealed that only the psychoanalytic education group maintained significant changes in attitude (p<.05). Conclusions: Results are discussed in terms of the use of relatively brief educational interventions in facilitating enduring attitude change toward working with patients with borderline personality disorder. [ABSTRACT FROM AUTHOR]

Presents a case study on the use of a multimodal therapy approach to the treatment of borderline personality disorder in a patient who resided in a forensic psychiatry unit in Australia. Subject characteristics; Medication phase; Multimodal phase; Support phase.

Objective: To determine the efficacy, safety and acceptability as well as the patient demographics of three newly developed emergency department–embedded Psychiatric Assessment and Planning Units located in Metropolitan Melbourne at Austin, Peninsula and Eastern Health Services. Methods: The evaluation reviewed a 12-month period of service activity from 1 September 2017 to 31 August 2018, when all three Psychiatric Assessment and Planning Units services were operational. A 12-month period from 1 September 2014 to 31 August 2015 was compared as the pre-Psychiatric Assessment and Planning Units period. Mixed qualitative and quantitative methods were used. This included semi-structured interviews of 30 Psychiatric Assessment and Planning Units patients and 30 emergency department staff (10 of each for all 3 sites), patient survey, statistical analysis of Client Management Interface data for the emergency department and related Psychiatric Assessment and Planning Units as well as audit of RISKMAN registers. Results: There were 365 Austin, 567 Eastern and 791 Peninsula Psychiatric Assessment and Planning Units admissions. Psychiatric Assessment and Planning Units were generally well accepted by patients and emergency department staff, relatively safe, operating within the Key Performance Indicators with mixed effect on emergency department flow. Austin emergency department processing times improved post-Psychiatric Assessment and Planning Units (4 hours 57 minutes to 4 hours 19 minutes; p < 0.001) while deteriorating at Eastern and Peninsula. Adjustment Disorder and Depression and Borderline Personality Disorder were the most common admission diagnoses. While the Psychiatric Assessment and Planning Units had mixed utility on emergency department processing times, they appear to serve a demographic not previously accommodated in traditional emergency department psychiatry models. Conclusion: The emergency department–embedded Psychiatric Assessment and Planning Unit model of care appears effective on some measures, safe and acceptable to patients and staff. The Psychiatric Assessment and Planning Units seem to service a group not previously accommodated in traditional emergency psychiatry models. [ABSTRACT FROM AUTHOR]

Deficits regulating emotions are a core process underlying both substance use and mental health disorders. Research has focused on identifying one-to-one associations between individual emotion regulation (ER) strategies and mental health symptoms. Consequently, little is known about how patterns of ER relate to a broad range of psychopathology, in treatment seeking young people. Latent class analysis was used to examine patterns of ER strategies and their relationship with symptoms of depression, anxiety, eating disorders, substance use and borderline personality disorder, in a sample of young treatment seekers. Participants were young people (N = 306, M = 20.8 years) accessing youth advocacy and support or mental health services in Australia. Participants recalled an emotionally-arousing event experienced when on their own and indicated their use of 14 possible ER responses in an online questionnaire. Symptoms of mental health and substance use were measured. The LCA identified three distinct classes of ER responses: Ruminators/avoiders (n = 76), active regulators (n = 81), and low regulators (n = 129). The ruminators/avoiders endorsed the most severe symptom picture across all disorders except alcohol use. Within this cohort, distinct patterns of ER responding had unique relationships with symptoms of psychopathology. The deleterious impact of heightened maladaptive ER strategies (rumination and avoidance) in the absence of adaptive strategies was highlighted. [ABSTRACT FROM AUTHOR]