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Isabel Morales-Muñoz,1,2 Buse Beril Durdurak,1 Ayten Bilgin,3 Steven Marwaha,1,4 Catherine Winsper5 1Institute for Mental Health, School of Psychology, University of Birmingham, Birmingham, UK; 2Department of Public Health Solutions, Finnish Institute for Health and Welfare, Helsinki, Finland; 3School of Psychology, University of Kent, Canterbury, UK; 4The Barberry National Centre for Mental Health, Birmingham and Solihull Mental Health Trust, Birmingham, UK; 5Coventry and Warwickshire Partnership NHS Trust, Research and Innovation, Coventry, UKCorrespondence: Isabel Morales-MuñozInstitute for Mental Health, School of Psychology, University of Birmingham, 52 Pritchatts Road, Birmingham, B15 2TT, UKEmail I.Morales-Munoz@bham.ac.ukObjective: Recent research indicates that sleep problems in childhood precede the development of borderline personality disorder (BPD) symptoms, but the mechanisms by which sleep problems associate with BPD are still unknown. This narrative review aims to provide some potential explanations for how early sleep problems might associate with BPD.Methods: We used the biosocial developmental model of BPD as a framework to discuss how sleep problems may associate with BPD. Articles were identified via PubMed and Embase, and papers published between January 1991 and April 2021 were extracted. Authors made a series of literature searches using the following keywords: Sleep problems, Insomnia, Nightmares, Hypothalamic–Pituitary–Adrenal Axis (HPA), Prefrontal Cortex, Family Psychopathology, Disrupted Attachment, Child Maltreatment, Impulsivity, Emotion Regulation, Internalizing, Externalizing, Rumination, Childhood, Adolescence, Young people. The inclusion criteria were published in peer-reviewed journals; human studies or reviews; published in English. The exclusion criteria were commentaries; abstracts from conferences; studies with animal samples. A total of 96 articles were included for the purpose of this review.Results: The evidence from this review suggests that some biological factors and core features of BPD act as potential mechanisms mediating the associations between early sleep and subsequent BPD, while some family-related factors might constitute common risk factors for sleep problems and BPD.Conclusion: The biosocial developmental model of BPD provides a plausible characterization of how sleep disruption might lead to subsequent BPD. Further research on new developmental and early intervention approaches to understand how sleep in early stages associates with BPD could have significant clinical impact on these patients and could inform targeted therapeutic interventions.Keywords: sleep, borderline personality disorder, biosocial developmental model, childhood, adolescence, mechanisms

Background. Mobile mood-monitoring applications are increasingly used by mental health providers, widely advocated within research, and a potentially effective method to engage young people. However, little is known about their efficacy and usability in young populations. Method. A systematic review addressing three research questions focused on young people: (1) what are the psychometric properties of mobile mood-monitoring applications; (2) what is their usability; and (3) what are their positive and negative clinical impacts? Findings were synthesised narratively, study quality assessed and compared with evidence from adult studies. Results. We reviewed 25 articles. Studies on the psychometric properties of mobile mood-monitoring applications were sparse, but indicate questionable to excellent internal consistency, moderate concurrent validity and good usability. Participation rates ranged from 30% to 99% across studies, and appeared to be affected by methodological factors (e.g. payments) and individual characteristics (e.g. IQ score). Mobile mood-monitoring applications are positively perceived by youth, may reduce depressive symptoms by increasing emotional awareness, and could aid in the detection of mental health and substance use problems. There was very limited evidence on potential negative impacts. Conclusions. Evidence for the use of mood-monitoring applications in youth is promising but limited due to a lack of high-quality studies. Future work should explicate the effects of mobile mood-monitoring applications on effective selfregulation, clinical outcomes across disorders and young people's engagement with mental health services. Potential negative impacts in this population should also be investigated, as the adult literature suggests that application use could potentially increase negativity and depression symptoms. [ABSTRACT FROM AUTHOR]

Bed-sharing is a controversial but common parenting practice with claimed benefits for emotional and behavioral development. Using data from the UK Millennium Cohort Study ( N  = 16,599), this prospective study investigated whether bed-sharing at 9 months is associated with childhood internalizing and externalizing symptom trajectories. Children were grouped by their patterns of co-developing internalizing and externalizing symptoms from 3 to 11 years of age using a parallel process latent class growth analysis. There were no associations between bed-sharing at 9 months of age and internalizing and externalizing symptom trajectories across childhood. This finding suggests that bed-sharing at 9 months has no positive or negative influence on the development of internalizing and externalizing symptoms across childhood. Clinicians should inform parents that bed-sharing during the second half of the first year is unlikely to have an impact on the later emotional and behavioral development of the children.

Background: Enduring ethnic inequalities exist in mental healthcare. The COVID-19 pandemic has widened these., Aims: To explore stakeholder perspectives on how the COVID-19 pandemic has increased ethnic inequalities in mental healthcare., Method: A qualitative interview study of four areas in England with 34 patients, 15 carers and 39 mental health professionals from National Health Service (NHS) and community organisations (July 2021 to July 2022). Framework analysis was used to develop a logic model of inter-relationships between pre-pandemic barriers and COVID-19 impacts., Results: Impacts were largely similar across sites, with some small variations (e.g. positive service impacts of higher ethnic diversity in area 2). Pre-pandemic barriers at individual level included mistrust and thus avoidance of services and at a service level included the dominance of a monocultural model, leading to poor communication, disengagement and alienation. During the pandemic remote service delivery, closure of community organisations and media scapegoating exacerbated existing barriers by worsening alienation and communication barriers, fuelling prejudice and division, and increasing mistrust in services. Some minority ethnic patients reported positive developments, experiencing empowerment through self-determination and creative activities., Conclusions: During the COVID-19 pandemic some patients showed resilience and developed adaptations that could be nurtured by services. However, there has been a reduction in the availability of group-specific NHS and third-sector services in the community, exacerbating pre-existing barriers. As these developments are likely to have long-term consequences for minority ethnic groups' engagement with mental healthcare, they need to be addressed as a priority by the NHS and its partners.

Background: Long-standing ethnic inequalities in access and mental healthcare were worsened by the COVID-19 pandemic., Objectives: Stakeholders coproduced local and national implementation plans to improve mental healthcare for people from minority ethnic groups., Methods: Experience-based codesign conducted in four areas covered by National Health Service (NHS) mental health trusts: Coventry and Warwickshire, Greater Manchester, East London and Sheffield. Data were analysed using an interpretivist-constructivist approach, seeking validation from participants on their priority actions and implementation plans. Service users (n=29), carers (n=9) and health professionals (n=33) took part in interviews; focus groups (service users, n=15; carers, n=8; health professionals, n=24); and codesign workshops (service users, n=15; carers, n=5; health professionals, n=21) from July 2021 to July 2022., Findings: Each study site identified 2-3 local priority actions. Three were consistent across areas: (1) reaching out to communities and collaborating with third sector organisations; (2) diversifying the mental healthcare offer to provide culturally appropriate therapeutic approaches and (3) enabling open discussions about ethnicity, culture and racism. National priority actions included: (1) co-ordination of a national hub to bring about system level change and (2) recognition of the centrality of service users and communities in the design and provision of services., Conclusions: Stakeholder-led implementation plans highlight that substantial change is needed to increase equity in mental healthcare in England., Clinical Implications: Working with people with lived experience in leadership roles, and collaborations between NHS and community organisations will be essential. Future research avenues include comparison of the benefits of culturally specific versus generic therapeutic interventions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. Published by BMJ.)

Objective: Developing countries such as India face a major mental health care gap. Delayed or inadequate care can have a profound impact on treatment outcomes. We compared pathways to care in first episode psychosis (FEP) between North and South India to inform solutions to bridge the treatment gap., Methods: Cross-sectional observation study of 'untreated' FEP patients (n = 177) visiting a psychiatry department in two sites in India (AIIMS, New Delhi and SCARF, Chennai). We compared duration of untreated psychosis (DUP), first service encounters, illness attributions and socio-demographic factors between patients from North and South India. Correlates of DUP were explored using logistic regression analysis (DUP ≥ 6 months) and generalised linear models (DUP in weeks)., Results: Patients in North India had experienced longer DUP than patients in South India (β = 17.68, p < 0.05). The most common first encounter in North India was with a faith healer (45.7%), however, this contact was not significantly associated with longer DUP. Visiting a faith healer was the second most common first contact in South India (23.6%) and was significantly associated with longer DUP (Odds Ratio: 6.84; 95% Confidence Interval: 1.77, 26.49). Being in paid employment was significantly associated with shorter DUP across both sites., Conclusions: Implementing early intervention strategies in a diverse country like India requires careful attention to local population demographics; one size may not fit all. A collaborative relationship between faith healers and mental health professionals could help with educational initiatives and to provide more accessible care., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier B.V.)

This article presents an overview of the current literature on the course and outcomes of BPD. It begins with an overview of our changing understanding of BPD in terms of age of onset and prognosis over time. Recent research on clinical, functional and social recovery from BPD in youth and adult populations is then summarised. This is followed by an overview of contemporary prospective studies of adolescent BPD in community populations which seek to unravel complex pathways and the co-development of BPD symptoms and psychosocial problems. Studies of older populations are then described to shed light on how BPD manifests in middle to old age. The review concludes by bringing together these research strands to develop a picture of BPD across the lifespan and highlight areas for future research., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

The emergent recovery paradigm prioritises adaption to serious mental illness and a move towards personally meaningful goals. In this review, we combine a theory driven logic model approach with systematic review techniques to forward understanding of how recovery-oriented interventions can help service users in their personal recovery journey. We identified 309 studies meeting our inclusion criteria. Our logic model mapped out intervention typologies and their recovery outcomes, the mechanisms of action underpinning these links, and the contextual moderators of these mechanisms and outcomes. Interventions were associated with recovery outcomes (functional, existential and social) directly and through a sequence of processes, which were underpinned by four common mechanisms: 1) providing information and skills; 2) promoting a working alliance; 3) role modelling recovery; and 4) increasing choice. Moderators of these mechanisms were observed at the service user (e.g., motivation), mental health service (e.g., professional attitudes) and wider environmental (e.g., unemployment rates) level. Recovery-oriented interventions share common critical mechanisms, which can help propel service users towards recovery especially when delivered within pro-recovery and non-stigmatising contexts. Future studies should further examine ways to reduce (or remove) barriers preventing individuals with mental health problems from experiencing the same citizenship entitlements as everyone else., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objective: Despite considerable morbidity and functional losses associated with adolescent borderline personality disorder, little is known about psychopathological outcomes. This study examined associations between adolescent borderline personality disorder symptoms and subsequent depressive, psychotic and hypomanic symptoms., Methods: We used data from the Avon Longitudinal Study of Parents and Children. Participants were adolescents living in the community who had data for all longitudinal outcomes ( N  = 1758). We used logistic regression and path analysis to investigate associations between borderline personality disorder (five or more probable/definite symptoms) reported at age 11-12 years and depressive and psychotic symptoms reported at age 12 and 18, and lifetime hypomanic symptoms reported at age 22-23 years., Results: Adolescent borderline personality disorder symptoms were associated with psychotic symptoms (odds ratio: 2.36, confidence interval: [1.82, 3.06]), diagnosis of depression at age 18 years (odds ratio: 1.30, confidence interval: [1.03, 1.64]) and hypomanic symptoms (odds ratio: 2.89, confidence interval: [2.40, 3.48]) at 22-23 years. Path analysis controlling for associations between all outcomes indicated that borderline personality disorder symptoms were independently associated with depressive symptoms (β = 0.97, p  < 0.001) at 12 years and hypomanic (β = 0.58, p  < 0.01) symptoms at 22-23 years. Borderline personality disorder symptoms were also associated with psychotic symptoms at age 12 years (β = 0.58, p  < 0.01), which were linked (β = 0.34, p  < 0.01) to psychotic symptoms at age 18 years., Conclusion: Adolescents with borderline personality disorder symptoms are at future risk of psychotic and hypomanic symptoms, and a diagnosis of depression. Future risk is independent of associations between psychopathological outcomes, indicating that adolescent borderline personality disorder symptoms have multifinal outcomes. Increasing awareness of borderline personality disorder in early adolescence could facilitate timely secondary prevention of these symptoms subsequently, helping to prevent future psychopathology.

Background: Early regulatory problems (RPs) are associated with childhood internalising and externalising symptoms. Internalising and externalising symptoms, in turn, are associated with adolescent psychopathology (e.g. personality disorders, depression). We examined whether RPs are directly associated with adolescent psychopathology, or whether associations are indirect via childhood internalising and externalising symptoms., Methods: We used data from the Avon Longitudinal Study of Parents and Children. Mothers reported on their child's RPs at 6, 15-18 and 24-30 months, and internalising and externalising symptoms at 4, 7, 8 and 9.5 years. Adolescent psychotic, depression and BPD symptoms were assessed at 11-12 years. Children were grouped by their patterns of co-developing internalising and externalising symptoms using parallel process latent class growth analysis (PP-LCGA). Path analysis was used to examine direct and indirect associations from RPs to the three adolescent outcomes., Results: There were four groups of children with distinct patterns of co-developing internalising and externalising (INT/EXT) symptoms. Most children (53%) demonstrated low-moderate and stable levels of INT/EXT symptoms. A small proportion (7.7%) evidenced moderate and increasing INT and high stable EXT symptoms: this pattern was strongly predictive of adolescent psychopathology (e.g. depression at 11 years: unadjusted odds ratio = 5.62; 95% confidence intervals = 3.82, 8.27). The other two groups were differentially associated with adolescent outcomes (i.e. moderate-high increasing INT/moderate decreasing EXT predicted mother-reported depression at 12, while low stable INT/moderate-high stable EXT predicted child-reported depression at 11). In path analysis, RPs at each time-point were significantly indirectly associated with symptoms of BPD and child- and mother-reported depression symptoms via the most severe class of INT/EXT symptoms., Conclusions: Consistent with a cascade model of development, RPs are predictive of higher levels of co-developing INT/EXT symptoms, which in turn increase risk of adolescent psychopathology. Clinicians should be aware of, and treat, early RPs to prevent chronic psychopathology., (© 2019 Association for Child and Adolescent Mental Health.)

Background: Personality disorders are now internationally recognised as a mental health priority. Nevertheless, there are no systematic reviews examining the global prevalence of personality disorders., Aims: To calculate the worldwide prevalence of personality disorders and examine whether rates vary between high-income countries and low- and middle-income countries (LMICs)., Method: We systematically searched PsycINFO, MEDLINE, EMBASE and PubMed from January 1980 to May 2018 to identify articles reporting personality disorder prevalence rates in community populations (PROSPERO registration number: CRD42017065094)., Results: A total of 46 studies (from 21 different countries spanning 6 continents) satisfied inclusion criteria. The worldwide pooled prevalence of any personality disorder was 7.8% (95% CI 6.1-9.5). Rates were greater in high-income countries (9.6%, 95% CI 7.9-11.3%) compared with LMICs (4.3%, 95% CI 2.6-6.1%). In univariate meta-regressions, significant heterogeneity was partly attributable to study design (two-stage v. one-stage assessment), county income (high-income countries v. LMICs) and interview administration (clinician v. trained graduate). In multiple meta-regression analysis, study design remained a significant predictor of heterogeneity. Global rates of cluster A, B and C personality disorders were 3.8% (95% CI 3.2, 4.4%), 2.8% (1.6, 3.7%) and 5.0% (4.2, 5.9%)., Conclusions: Personality disorders are prevalent globally. Nevertheless, pooled prevalence rates should be interpreted with caution due to high levels of heterogeneity. More large-scale studies with standardised methodologies are now needed to increase our understanding of population needs and regional variations.

Background: Affective instability (AI) is transdiagnostic, and associated with suicidality and healthcare use. It has rarely been compared between diagnoses or to controls. We investigated: whether AI differs between clinical cases and controls and between diagnoses; how different AI components are correlated; and whether AI is associated with functioning in clinical cases., Methods: Cases (N = 69) from psychiatric services had a diagnosis of borderline personality disorder, bipolar disorder, major depression or psychosis and were compared to primary care controls (N = 25). Participants completed the affective lability scale (ALS), affective intensity measure (AIM), affective control scale (ACS), scored mood fluctuation rate and the WHO-DAS., Results: There was a significant difference in affective lability between cases and controls and across diagnostic groups (p < 0.001). Compared to controls, cases showed lower affective control (p < 0.05). There were no differences in affective intensity between cases and controls or between diagnostic groups, or in mood fluctuation rate between groups. ALS score (p < 0.001), and total number of medications (p < 0.046), were associated with functioning, independent of diagnosis., Limitations: The sample size was modest. Cases were not in an acute illness episode and this could bias estimates of group difference towards the null., Conclusion: Individuals with mental disorder demonstrate higher levels of affective lability and lower affect control than those without mental disorder. In contrast affective intensity may not be useful in demarcating abnormal affective experience. Independent of diagnosis, affective instability, as measured by affect lability, adversely impacts day-to-day functioning. It could be an important target for clinical intervention., (Copyright © 2018. Published by Elsevier B.V.)

Background: Cannabis use in young people is common and associated with psychiatric disorders. However, the prospective link between cannabis use and bipolar disorder symptoms has rarely been investigated. The study hypothesis was that adolescent cannabis use is associated with hypomania in early adulthood via several potential etiological pathways., Methods: Data were used from the Avon Longitudinal Study of Parents and Children, a UK birth cohort study. The prospective link between cannabis use at age 17 and hypomania at age 22-23 years was tested using regression analysis, adjusted for gender, early environmental risk factors, alcohol and drug use, and depression and psychotic symptoms at age 18 years. Path analysis examined direct and indirect effects of the link and whether gender, childhood family adversity, or childhood abuse are associated with hypomania via an increased risk of cannabis use., Results: Data were available on 3370 participants. Cannabis use at least 2-3 times weekly was associated with later hypomania (OR = 2.21, 95% CI = 1.49-3.28) after adjustment. There was a dose-response relationship (any use vs weekly). Cannabis use mediated the association of both childhood sexual abuse and hypomania, and male gender and hypomania. The cannabis use-hypomania link was not mediated by depression or psychotic symptoms., Conclusions: Adolescent cannabis use may be an independent risk factor for future hypomania, and the nature of the association suggests a potential causal link. Cannabis use mediates the link between childhood abuse and future hypomania. As such it might be a useful target for indicated prevention of hypomania.

Background: Understanding the relative risks of maintenance treatment versus discontinuation of antipsychotics following remission in first episode psychosis (FEP) is an important area of practice., Method: A systematic review and meta-analysis. Prospective experimental studies including a parallel control group were identified to compare maintenance antipsychotic treatment with total discontinuation or medication discontinuation strategies following remission in FEP., Results: Seven studies were included. Relapse rates were higher in the discontinuation group (53%; 95% CIs: 39%, 68%; N = 290) compared with maintenance treatment group (19%; 95% CIs: 0.05%, 37%; N = 230). In subgroup analyses, risk difference of relapse was lower in studies with a longer follow-up period, a targeted discontinuation strategy, a higher relapse threshold, a larger sample size, and samples with patients excluded for drug or alcohol dependency. Insufficient studies included psychosocial functioning outcomes for a meta-analysis., Conclusions: There is a higher risk of relapse for those who undergo total or targeted discontinuation strategies compared with maintenance antipsychotics in FEP samples. The effect size is moderate and the risk difference is lower in trials of targeted discontinuation strategies., Declaration of Interest: A.T. has received honoraria and support from Janssen-Cilag and Otsuka Pharmaceuticals for meetings and has been has been an investigator on unrestricted investigator-initiated trials funded by AstraZeneca and Janssen-Cilag. He has also previously held a Pfizer Neurosciences Research Grant. S.M. has received sponsorship from Otsuka and Lundbeck to attend an academic congress and owns shares in GlaxoSmithKline and AstraZeneca. J.H. has attended meetings supported by Sunovion Pharmaceuticals.

This article presents an overview of current knowledge regarding the aetiology of Borderline Personality Disorder (BPD). It begins with a brief synopsis of early research and theory, and discusses how changing conceptualisations of BPD have impacted on our aetiological knowledge. Contemporary theories are described and presented within a developmental psychopathology framework. Deficient co-regulation and social communication in infancy are purported to underpin emotional dysregulation and social cognition deficits across development. These mechanisms are further potentiated by maladaptive social experiences in a series of positive feedback loops. Prospective research provides preliminary evidence for the reciprocal (or mediating) effects of maladaptive experiences and childhood dysregulation. Moving forward, cohort studies may incorporate neurobiological assessments to examine the biological systems underpinning phenotypic (e.g., impulsivity, disturbed relatedness) covariation., (Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.)

Background: Developmental theories for the aetiology of Borderline Personality Disorder (BPD) suggest that both individual features (e.g., childhood dysregulated behaviour) and negative environmental experiences (e.g., maladaptive parenting, peer victimisation) may lead to the development of BPD symptoms during adolescence. Few prospective studies have examined potential aetiological pathways involving these two factors., Method: We addressed this gap in the literature using data from the Avon Longitudinal Study of Parents and Children (ALSPAC). We assessed mother-reported childhood dysregulated behaviour at 4, 7 and 8 years using the Strengths and Difficulties Questionnaire (SDQ); maladaptive parenting (maternal hitting, punishment, and hostility) at 8 to 9 years; and bully victimisation (child and mother report) at 8, 9 and 10 years. BPD symptoms were assessed at 11 years using the UK Childhood Interview for DSM-IV BPD. Control variables included adolescent depression (assessed with the Short Moods and Feelings Questionnaire-SMFQ) and psychotic symptoms (assessed with the Psychosis-Like Symptoms Interview-PLIKS) at 11 to 14 years, and mother's exposure to family adversity during pregnancy (assessed with the Family Adversity Scale-FAI)., Results: In unadjusted logistic regression analyses, childhood dysregulated behaviour and all environmental risk factors (i.e., family adversity, maladaptive parenting, and bully victimisation) were significantly associated with BPD symptoms at 11 years. Within structural equation modelling controlling for all associations simultaneously, family adversity and male sex significantly predicted dysregulated behaviour across childhood, while bully victimisation significantly predicted BPD, depression, and psychotic symptoms. Children displaying dysregulated behaviour across childhood were significantly more likely to experience maladaptive parenting (β = 0.075, p  < 0.001) and bully victimisation (β = 0.327, p  < 0.001). Further, there was a significant indirect association between childhood dysregulated behaviour and BPD symptoms via an increased risk of bullying (β = 0.097, p  < 0.001). While significant indirect associations between dysregulated behaviour, bully victimisation and depression (β = 0.063, p  < 0.001) and psychotic (β = 0.074, p  < 0.001) outcomes were also observed, the indirect association was significantly stronger for the BPD outcome (BPD - depression = 0.034, p  < 0.01; BPD - psychotic symptoms = 0.023, p  < 0.01)., Conclusions: Childhood dysregulated behaviour is associated with BPD in early adolescence via an increased risk of bully victimisation. This suggests that childhood dysregulation may influence the risk of bully victimisation, which in turn influences the development of BPD. Effective interventions should target dysregulated behaviour early on to reduce exposure to environmental risks and the subsequent development of BPD.

Aim: To delineate the sleep profile of Borderline Personality Disorder (BPD)., Method: A meta-analysis to synthesise findings on the objective and subjective sleep characteristics of BPD., Results: We identified 32 studies published between 1980 and December 2015. Meta-analysis indicated significant differences between BPD and healthy control groups across objective sleep continuity (sleep onset latency, total sleep time, sleep efficiency) and architecture (rapid eye movement latency/density, slow wave sleep) measures, and self-reported sleep problems (nightmares, sleep quality). Findings were independent of depression (in clinical and community populations), and concomitant psychotropic medication use. There were few significant differences between BPD and clinical (majority depressed) control groups., Conclusion: BPD is associated with comparable sleep disturbances to those observed in depression. These disturbances are not solely attributable to comorbid depression. Given growing evidence that sleep disturbance may exacerbate emotional dysregulation and suicide risk, treatments for BPD should explicitly address sleep problems. Future studies should utilise prospective designs to ascertain whether (and in which circumstances) sleep problems predate or follow the onset of the disorder., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Sleep disorders, such as insomnia and nightmares, are commonly associated with Borderline Personality Disorder (BPD) in adulthood. Whether nightmares and sleep-onset and maintenance problems predate BPD symptoms earlier in development is unknown. We addressed this gap in the literature using data from the Avon Longitudinal Study of Parents and Children (ALSPAC). Participants included 6050 adolescents (51.4 % female) who completed the UK Childhood Interview for DSM-IV BPD at 11 to 12 years of age. Nightmares and sleep onset and maintenance problems were prospectively assessed via mother report when children were 2.5, 3.5, 4.8 and 6.8 years of age. Psychopathological (i.e., emotional temperament; psychiatric diagnoses; and emotional and behavioural problems) and psychosocial (i.e., abuse, maladaptive parenting, and family adversity) confounders were assessed via mother report. In logistic regressions, persistent nightmares (i.e., regular nightmares at 3 or more time-points) were significantly associated with BPD symptoms following adjustment for sleep onset and maintenance problems and all confounders (Adjusted Odds Ratio = 1.62; 95 % Confidence Interval = 1.12 to 2.32). Persistent sleep onset and maintenance problems were not significantly associated with BPD symptoms. In path analysis controlling for all associations between confounders, persistent nightmares independently predicted BPD symptoms (Probit co-efficient [β] = 0.08, p = 0.013). Emotional and behavioural problems significantly mediated the association between nightmares and BPD (β =0.016, p < 0.001), while nightmares significantly mediated associations between emotional temperament (β = 0.001, p = 0.018), abuse (β = 0.015, p = 0.018), maladaptive parenting (β = 0.002, p = 0.021) and subsequent BPD. These findings tentatively support that childhood nightmares may potentially increase the risk of BPD symptoms in early adolescence via a number of aetiological pathways. If replicated, the current findings could have important implications for early intervention, and assist clinicians in the identification of children at risk of developing BPD., Competing Interests: S.T.L., C.W, N.K.Y.T & D.W report no conflict of interest.

Contemporary theories for the aetiology of borderline personality disorder (BPD) take a lifespan approach asserting that inborn biological predisposition is potentiated across development by environmental risk factors. In this review, we present and critically evaluate evidence on the neurobiology of BPD in childhood and adolescence, compare this evidence to the adult literature, and contextualise within a neurodevelopmental framework. A systematic review was conducted to identify studies examining the neurobiological (i.e. genetic, structural neuroimaging, neurophysiological, and neuropsychological) correlates of BPD symptoms in children and adolescents aged 19 years or under. We identified, quality assessed, and narratively summarised 34 studies published between 1980 and June 2016. Similar to findings in adult populations, twin studies indicated moderate to high levels of heritability of BPD, and there was some evidence for gene-environment interactions. Also consistent with adult reports is that some adolescents with BPD demonstrated structural (grey and white matter) alterations in frontolimbic regions and neuropsychological abnormalities (i.e. reduced executive function and disturbances in social cognition). These findings suggest that neurobiological abnormalities observed in adult BPD may not solely be the consequence of chronic morbidity or prolonged medication use. They also provide tentative support for neurodevelopmental theories of BPD by demonstrating that neurobiological markers may be observed from childhood onwards and interact with environmental factors to increase risk of BPD in young populations. Prospective studies with a range of repeated measures are now required to elucidate the temporal unfurling of neurobiological features and further delineate the complex pathways to BPD.

Background: Recently, school mobility was identified as a risk factor for psychotic symptoms in early adolescence. The extent to which this risk continues into late adolescence and the trajectories via which this risk manifests remain unexplored., Methods: Psychotic symptoms in 4,720 adolescents aged 18 were ascertained by trained psychologists using the Psychosis-Like Symptoms Interview. Mothers reported on sociodemographic factors (i.e., family adversity, ethnicity and urbanicity) from pregnancy to 4 years; child's involvement in bullying at age 6-7 years; residential mobility at 11 years and school mobility at 11-12 years. Young people reported on their friendships at 8 years, and antisocial behaviour and cannabis use at 15 years., Results: School mobility across childhood significantly predicted psychotic symptoms at 18 years (adjusted odds ratio = 2.15; 95% confidence intervals = 1.06, 4.40). Within path analysis, school mobility (β = .183, p = .035), involvement in bullying (β = .133, p = .013), antisocial behaviour (β = .052, p = .004), cannabis use (β = .254, p = .020) and female sex (β = .420, p < .001) significantly predicted psychotic symptoms. Residential mobility (β = .375, p < .001), involvement in bullying (β = .120, p = .022) and poor friendships (β = .038, p = .014) significantly predicted school mobility. Residential mobility indirectly increased the risk of psychotic symptoms via school mobility (β = .069, p = .041)., Conclusions: Children who move schools often are more likely to have experienced peer problems. School mobility, in turn, appears to be a robust marker for psychotic symptoms in late adolescence. Clinicians and teachers should consider school mobility as an important risk indicator for both peer problems and psychopathology., (© 2016 Association for Child and Adolescent Mental Health.)

There is growing interest in whether the parenting strategies and offspring outcomes of mothers with borderline personality disorder (BPD) differ from those of mothers without BPD. We searched PsychINFO, PubMed, EMBASE, Web of Science, Scopus and ASSIA databases for studies examining parenting skills and attitudes among mothers with BPD/BPD symptoms and/or offspring outcomes. PRISMA reporting guidelines were followed. Of 10,067 abstracts screened, 101 full-text articles were retrieved and 33 met pre-determined criteria for qualitative synthesis. Overall, studies suggest that mothers with BPD/BPD symptoms are more likely to engage in maladaptive interactions with their offspring characterised by insensitive, overprotective, and hostile parenting compared to mothers without BPD/BPD symptoms. Adverse offspring outcomes include BPD symptoms, internalising (including depression) and externalising problems, insecure attachment patterns, and emotional dysregulation. Findings suggest that vulnerability from mother to offspring may be partly transmitted via maladaptive parenting and maternal emotional dysfunction. Conclusions were limited by study heterogeneity in methodology and construct definitions, as well as a paucity of clinical comparison groups. Prospective studies of mothers with BPD and their offspring from pregnancy onwards may further elucidate mechanisms of transmission and identify resilience factors across development. Parenting behaviour awareness, improving attachment behaviours and emotional regulation strategies may be important intervention targets., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Controversy surrounds the diagnosis of Borderline Personality Disorder (BPD) in youth. This meta-analysis summarised evidence regarding the aetiological and psychopathological validity of youth BPD (the extent to which youth and adult BPD share common risk factors and psychopathology). We identified 61 studies satisfying predetermined inclusion criteria. Statistically significant pooled associations with youth (19 years of age and under) BPD were observed for sexual abuse (all youth: odds ratio=4.88; 95% confidence interval=3.30, 7.21; children: OR=3.97; 95% CI=1.51, 10.41; adolescents: OR=5.41; 95% CI=3.43, 8.53); physical abuse (all youth: 2.79 [2.03, 3.84]; children: 2.86 [1.98, 4.13]; adolescents: 2.60 [1.38, 4.90]); maternal hostility/verbal abuse (all youth: 3.28 [2.67, 4.03]; children: 3.15 [2.55, 3.88]; adolescents: 4.71 [1.77, 12.53]); and neglect (all youth: 3.40 [2.27, 5.11]; children: 2.87 [1.73, 4.73]; adolescents: 4.87 [2.24, 10.59]). Several psychopathological features were also associated with youth BPD, including comorbid mood (3.21 [2.13, 4.83]), anxiety (2.30 [1.44, 3.70]) and substance use (2.92 [1.60, 5.31]) disorders; self-harm (2.81 [1.61, 4.90]); suicide ideation (all youth: 2.02 [1.23, 3.32]; children: 6.00 [1.81, 19.84]; adolescents: 1.75 [1.20; 2.54]) and suicide attempt (2.10 [1.21, 3.66]). Results demonstrate that adult and youth BPD share common aetiological and psychopathological correlates. This offers some support for the diagnostic validity of youth BPD and indicates the need for clinical recognition in this age group., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Studies demonstrate ethnic variations in pathways to care during first episode psychosis (FEP). There are no extant studies, however, that have statistically examined the influence of culturally mediated illness attributions on these variations., Methods: We conducted an observational study of 123 (45 White; 35 Black; 43 Asian) patients recruited over a two-year period from an Early Intervention Service (EIS) in Birmingham, UK. Sociodemographic factors (age; sex; education; country of birth; religious practice; marital status; living alone), duration of untreated psychosis (DUP), service contacts (general practitioner; emergency services; faith-based; compulsory detention; criminal justice) and illness attributions ("individual;" "natural;" "social;" "supernatural;" "no attribution") were assessed., Results: Ethnic groups did not differ in DUP (p = 0.86). Asian patients were more likely to report supernatural illness attributions in comparison to White (Odds Ratio: 4.02; 95 % Confidence Intervals: 1.52, 10.62) and Black (OR: 3.48; 95 % CI: 1.25, 9.67) patients. In logistic regressions controlling for confounders and illness attributions, Black (OR: 14.00; 95 % CI: 1.30, 151.11) and Asian (OR: 13.29; 95 % CI: 1.26, 140.47) patients were more likely to consult faith-based institutions than White patients. Black patients were more likely to be compulsorily detained than White patients (OR: 4.56; 95 % CI: 1.40, 14.85)., Conclusion: Illness attributions and sociodemographic confounders do not fully explain the ethnic tendency to seek out faith-based institutions. While Asian and Black patients are more likely to seek help from faith-based organisations, this does not appear to lead to a delay in contact with mental health services.

Despite both having some shared features, evidence linking psychosis and adult attention deficit hyperactivity disorder (ADHD) is sparse and inconsistent. Hypotheses tested were (1) adult ADHD symptoms are associated with auditory hallucinations, paranoid ideation and psychosis (2) links between ADHD symptoms and psychosis are mediated by prescribed ADHD medications, use of illicit drugs, and dysphoric mood. The Adult Psychiatric Morbidity Survey 2007 (N=7403) provided data for regression and multiple mediation analyses. ADHD symptoms were coded from the ADHD Self-Report Scale (ASRS). Higher ASRS total score was significantly associated with psychosis, paranoid ideation and auditory hallucinations despite controlling for socio-demographic variables, verbal IQ, autism spectrum disorder traits, childhood conduct problems, hypomanic and dysphoric mood. An ASRS score indicating probable ADHD diagnosis was also significantly associated with psychosis. The link between higher ADHD symptoms and psychosis, paranoia and auditory hallucinations was significantly mediated by dysphoric mood, but not by use of amphetamine, cocaine or cannabis. In conclusion, higher levels of adult ADHD symptoms and psychosis are linked and dysphoric mood may form part of the mechanism. Our analyses contradict the traditional clinical view that the main explanation for people with ADHD symptoms developing psychosis is illicit drugs., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: Mood instability levels are high in depression, but temporal precedence and potential mechanisms are unknown. Hypotheses tested were as follows: (1) mood instability is associated with depression cross-sectionally, (2) mood instability predicts new onset and maintenance of depression prospectively and (3) the mood instability and depression link are mediated by sleep problems, alcohol abuse and life events., Method: Data from the National Psychiatric Morbidity Survey 2000 at baseline (N = 8580) and 18-month follow-up (N = 2413) were used. Regression modeling controlling for socio-demographic factors, anxiety and hypomanic mood was conducted. Multiple mediational analyses were used to test our conceptual path model., Results: Mood instability was associated with depression cross-sectionally (odds ratio: 5.28; 95% confidence interval: [3.67, 7.59]; p < 0.001) and predicted depression inception (odds ratio: 2.43; 95% confidence interval: [1.03-5.76]; p = 0.042) after controlling for important confounders. Mood instability did not predict maintenance of depression. Sleep difficulties and severe problems with close friends and family significantly mediated the link between mood instability and new onset depression (23.05% and 6.19% of the link, respectively). Alcohol abuse and divorce were not important mediators in the model., Conclusion: Mood instability is a precursor of a depressive episode, predicting its onset. Difficulties in sleep are a significant part of the pathway. Interventions targeting mood instability and sleep problems have the potential to reduce the risk of depression., (© The Royal Australian and New Zealand College of Psychiatrists 2015.)

Background: Whilst cannabis use appears to be a causal risk factor for the development of schizophrenia-related psychosis, associations with mania remain relatively unknown. This review aimed to examine the impact of cannabis use on the incidence of manic symptoms and on their occurrence in those with pre-existing bipolar disorder., Methods: A systematic review of the scientific literature using the PRISMA guidelines. PsychINFO, Cochrane, Scopus, Embase and MEDLINE databases were searched for prospective studies., Results: Six articles met inclusion criteria. These sampled 2391 individuals who had experienced mania symptoms. The mean length of follow up was 3.9 years. Studies support an association between cannabis use and the exacerbation of manic symptoms in those with previously diagnosed bipolar disorder. Furthermore, a meta-analysis of two studies suggests that cannabis use is associated with an approximately 3-fold (Odds Ratio: 2.97; 95% CI: 1.80-4.90) increased risk for the new onset of manic symptoms., Limitations: We were only able to identify a small number of studies of variable quality, thus our conclusions remain preliminary., Conclusions: Our findings whilst tentative, suggest that cannabis use may worsen the occurrence of manic symptoms in those diagnosed with bipolar disorder, and may also act as a causal risk factor in the incidence of manic symptoms. This underscores the importance of discouraging cannabis use among youth and those with bipolar disorder to help prevent chronic psychiatric morbidity. More high quality prospective studies are required to fully elucidate how cannabis use may contribute to the development of mania over time., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Objective: Social adversity and urban upbringing increase the risk of psychosis. We tested the hypothesis that these risks may be partly attributable to school mobility and examined the potential pathways linking school mobility to psychotic-like symptoms., Method: A community sample of 6,448 mothers and their children born between 1991 and 1992 were assessed for psychosocial adversities (i.e., ethnicity, urbanicity, family adversity) from birth to 2 years, school and residential mobility up to 9 years, and peer difficulties (i.e., bullying involvement and friendship difficulties) at 10 years. Psychotic-like symptoms were assessed at age 12 years using the Psychosis-like Symptoms Interview (PLIKSi)., Results: In regression analyses, school mobility was significantly associated with definite psychotic-like symptoms (odds ratio [OR] =1.60; 95% CI =1.07-2.38) after controlling for all confounders. Within path analyses, school mobility (probit coefficient [β] = 0.108; p = .039), involvement in bullying (β = 0.241; p < .001), urbanicity (β = 0.342; p = .016), and family adversity (β = 0.034; p < .001) were all independently associated with definite psychotic-like symptoms. School mobility was indirectly associated with definite psychotic-like symptoms via involvement in bullying (β = 0.018; p = .034)., Conclusions: School mobility is associated with increased risk of psychotic-like symptoms, both directly and indirectly. The findings highlight the potential benefit of strategies to help mobile students to establish themselves within new school environments to reduce peer difficulties and to diminish the risk of psychotic-like symptoms. Awareness of mobile students as a possible high-risk population, and routine inquiry regarding school changes and bullying experiences, may be advisable in mental health care settings., (Crown Copyright © 2014. Published by Elsevier Inc. All rights reserved.)

Insomnia can be lethal, increasing the risk of suicide and accidental death by overdose. In this review we present a synthesis of the literature investigating the insomnia-suicide link and the psychological mechanisms underpinning the association. Specifically, we review the findings of prospective epidemiological studies demonstrating the insomnia-suicide link in adult and adolescent community populations. Robust associations between insomnia and suicide are observed in clinically depressed and anxious populations, and there are indications across a number of cross-sectional and longitudinal studies that these linkages are attributable to a disrupted sleep pattern, dysfunctional beliefs about sleep and nightmares, independent of depression and anxiety symptoms. Borderline personality disorder (BPD) and chronic pain (CP) are highlighted as high-risk subgroups given the elevated rates of insomnia and suicidality in both conditions. Aside from the influence of comorbid depression and anxiety symptoms, emerging evidence has identified impulsivity and emotional dysregulation as possible mechanisms driving the insomnia-suicide link in BPD, and catastrophizing and the sense of defeat/entrapment as potential cognitive pathways through which insomnia aggravates suicidality in CP. Screening for, and interventions that tackle, insomnia and these associated psychological mechanisms, offer a novel avenue for reducing suicidality across a range of clinical and non-clinical populations.