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According to previous research, borderline personality disorder (BPD) is associated with high cost-of-illness. However, there is still a shortage of cost-of-illness-studies assessing costs from a broad societal perspective, including direct and indirect costs. Further, there are considerable differences in the results among the existing studies. In the present study, 167 German men and women seeking specialized outpatient treatment for BPD were included. We assessed societal cost-of-illness bottom-up through structured face-to-face interviews and encompassed a wide range of cost components. All costs were calculated for the 2015 price level. Cost-of-illness amounted to € 31,130 per patient and year preceding disorder-specific outpatient treatment. € 17,044 (54.8%) were direct costs that were mostly related to hospital treatment. Indirect costs amounted to € 14,086 (45.2%). Within indirect costs, costs related to work disability were the most crucial cost driver. The present study underlines the tremendous economic burden of BPD. According to the present study, both the direct and indirect costs are of significant importance for the societal costs associated with BPD. Besides the need for more disorder-specific treatment facilities for men and women with BPD, we assume that education and employment are topics that should be specifically targeted and individually supported at an early stage of treatment.Trial Registration: German Clinical Trial Registration, DRKS00011534, Date of Registration: 11/01/2017, retrospectively registered.

Background Borderline Personality Disorder (BPD) is a severe and disabling condition. The Borderline Personality Disorder Checklist (BPDCL) was designed to specifically assess the subjective burden of a patient due to BPD symptoms. Various translations have been developed, but an assessment of the psychometric properties of these translations is needed. The aim was to examine the psychometric qualities of the BPDCL across different languages (i.e., Italian, Dutch, German, Spanish, English, and Greek). Methods Secondary data was used by reaching out to various researchers, who administered the BPDCL in previous studies. Five studies (N = 3199) conducted in Spain, Germany, Italy, the Netherlands, Australia, England, and Greece, were included in the current data set. The BPDCL was administered to BPD patients (N = 1131), Axis I disorder patients (N = 57), patients with other personality disorders (N = 225), and healthy controls (N = 1786). Item analyses and analyses assessing the known‐groups and convergent validity were performed to investigate the psychometric properties of the checklist. Results Each version of the BPDCL, differing in language, demonstrated high‐reliability coefficients (Cronbach's Alpha ranged from 0.93 to 0.96 and was 0.96 for the entire sample). The correlations between the BPDCL and other instruments, used in the studies, were weak to strong. Correlations greater than 0.55 were observed between the BPDCL and the scales BPDSI, SCL‐90 and the BSI. In addition, the BPDCL seems to differentiate well between diagnostic groups. BPD patients scored the highest, followed by patients with other personality disorders, who in turn scored higher than Axis I disorder patients and healthy controls. Conclusions In general, the BPDCL possesses good psychometric properties and seems to be an adequate self‐report instrument to measure the subjective burden of BPD patients.

Distress Tolerance Skills (DTS) are an important component of Dialectical Behavioral Therapy (DBT), a therapy method frequently used for treating patients with Borderline Personality Disorder (BPD). However, little is known about how DTS-training is experienced by individuals with BPD. The aim of this study was to explore BPD patients’ experiences with receiving DTS-training. Qualitative data were collected through semi-structured interviews with 24 individuals (87.5% females) with a primary diagnosis of BPD who received DTS-training in the context of 18 months of DBT treatment. Interview data were analyzed following the procedures of qualitative content analysis. Participants reported various effects of DTS including an immediate reduction of tension. Patients perceived DTS as a tool to cope with difficult interpersonal situations and emergencies and stated that this helped them to feel stable, safe and self-confident. Patients reported difficulties during the initial engagement, the learning process and the application of DTS as well as various facilitating factors. Implications of the findings for further research and for optimizing DTS-training in clinical practice are discussed.

Background Borderline Personality Disorder (BPD) is a severe mental illness that is associated with low quality of life, low psychosocial functioning, and high societal costs. Treatments for BPD have improved in the last decades. Dialectical behavior therapy (DBT) and Schema therapy (ST) have demonstrated efficacy in reducing BPD symptoms and costs. However, research has not compared these two treatment approaches. In addition, there is a lack of ‘real world studies’ that replicate positive findings in regular mental healthcare settings. Thus, the PROgrams for Borderline Personality Disorder (PRO*BPD) study will compare the (cost-) effectiveness of DBT and ST in structured outpatient treatment programs in the routine clinical setting of an outpatient clinic. Methods/Design We aim to recruit 160 BPD patients, who will be randomly assigned to either DBT or ST. In both conditions, patients receive one group therapy and one individual therapy session/week for a maximum of 18 months. Both treatment programs have similar frameworks, which guarantee clinical equipoise. The primary outcome is a reduction of BPD-symptoms. Also, the costs related to BPD are assessed and an economic evaluation is performed from a societal perspective. Secondary outcomes examine other measures of BPD-typical and general psychopathology, comorbidity, quality of life, psychosocial functioning and participation. Data are collected prior to the beginning therapy and every six months until the end of therapy, as well as at six months, one year and two years of follow-up after the end of therapy. Finally, we conduct a qualitative study to understand patients’ experiences with the two methods. Discussion The PRO*BPD study is the first randomized trial to compare the (cost-) effectiveness of DBT and ST. By examining the clinical effectiveness of a broad spectrum of outcome parameters, conducting an economic evaluation and assessing patients’ experiences, this study will significantly advance our knowledge on psychotherapy for BPD and will provide insight into the treatment approaches that should be offered to different BPD patients from clinical, economic and stakeholder’s perspectives. Trial registration German Clinical Trial Register, DRKS00011534 , Date of registration: 11/01/2017, retrospectively registered.

Background: Childhood maltreatment and difficulties in emotion regulation are common in patients with Borderline Personality Disorder (BPD) and Depressive Disorders (DD). Objective: This study examines differences between patients with BPD and patients with DD, regarding childhood maltreatment and difficulties in emotion regulation as well as the mediating effect of different aspects of emotion regulation deficits on the association between childhood maltreatment and BPD-symptoms. Method: A total of 305 participants, 177 with BPD and 128 with DD completed an assessment including the Childhood Trauma Questionnaire (CTQ), the Emotion Regulation Scale (DERS), the Brief Symptom Inventory (BSI), and the Structured Clinical Interview for DSM-IV (SCID). Data was analyzed using multiple analyses of variances and mediation analyses. Results: Patients with BPD reported more childhood maltreatment and more difficulties in emotion regulation than patients with DD. When general symptom severity, age, and gender were included in the analysis as covariates only group differences regarding 'impulse control difficulties' (F(1,299) = 38.97, p < .001, η p 2 = .115), 'limited access to emotion regulation strategies' (F(1,299) = 4.66, p = .032, η p 2 = .015), and 'lack of emotional clarity' (F(1,299) = 9.38, p = .002, η p 2 = .030) remained statistically significant. A mediation analysis, including above-mentioned covariates, indicated an association between emotional abuse and BPD-symptoms, which was mediated by difficulties in emotion regulation (indirect effect B = .012, 95% CI [.001; .031], R 2 = .429). Subscale analyses revealed 'impulse control difficulties' as the aspect of difficulties in emotion regulation that has the greatest impact on this association (B = .021, 95% CI [.003; .045]). Conclusions: Patients with BPD display more childhood maltreatment and difficulties in emotion regulation than patients with DD. Difficulties in emotion regulation, especially difficulties in impulse control, seem to play an important role in the association between childhood emotional abuse and BPD-symptoms. Patients with BPD report more childhood maltreatment and more emotion regulation difficulties than patients with DD and difficulties in emotion regulation, specifically impulse control, play an important role in the association between childhood emotional abuse and BPD symptoms.

The relationship between trauma-related negative cognitions and post-traumatic stress disorder (PTSD) symptoms has been studied frequently. Several studies found a mediating effect of trauma-related negative cognitions on symptom reduction in studies on different psychotherapeutic treatments, however, this relationship has never been studied in imagery rescripting (ImRs) or eye movement desensitization and reprocessing (EMDR). To analyse the role of trauma-related negative cognitions in the treatment of PTSD due to childhood trauma with EMDR and ImRs. = 155 patients with PTSD due to childhood trauma aged between 18 and 65 (  = 38.54) participated in a randomized clinical trial and were treated with either EMDR or ImRs in Australia, Germany, and the Netherlands between October 2014 and June 2019. We analysed the relationship between PTSD symptoms (Clinician-administered PTSD Scale for DSM-5, CAPS-5 and Impact of Event Scale revised; IES-R, completed twice for index trauma and for all other traumas) and trauma-related negative cognitions (Post-Traumatic Cognitions Inventory, PTCI) using Granger Causality analyses with linear mixed models on person-centered variables. Assessments were conducted pre-treatment, post-treatment (12 sessions in 6 weeks), eight weeks post-treatment, and one year after the pre-treatment assessment. Changes in negative cognitions (PTCI) preceded changes in PTSD symptoms (unidirectional) as measured by the CAPS and the IES-R for index trauma. For the IES-R related to all other traumas, a unidirectional relationship was found in which changes in PTSD symptoms preceded changes in negative cognitions. No moderating effect of treatment was found. On the level of PTCI subscales only changes in cognitions about oneself preceeded changes in PTSD symptoms. The results support the idea of a general role of trauma-related negative cognitions in the treatment of PTSD. The analyses should be replicated with a higher frequency of assessments.

Background The network theory of mental disorders asserts the pivotal role of feedback loops in psychopathology. We investigated intra-individual dynamics and potential feedback loops in psychological networks and their association with long-term outcomes. Methods At the beginning of the COVID-19 pandemic, data from a population-based cohort ( N  = 2029) were collected every three days for six months on well-being, worries, fatigue, sleep quality, social integration, and activity. Subgrouping—Group Iterative Multiple Model Estimation -was used to estimate networks of time-series data on the individual, subgroup, and group levels. Subgroup networks were compared and associations of subgroup membership with sociodemographic and health status variables at baseline and outcomes at follow-up were examined. Results Despite the large heterogeneity between individuals, a potential feedback loop involving sleep quality, fatigue and well-being was identified. Furthermore, two subgroups were identified, whereby the edges of the potential feedback loop were more present in Subgroup 1 than in Subgroup 2. Membership to Subgroup 1 was associated with lower education and fewer people aged over 60 in their household at baseline as well as poorer well-being, more worries, and more frequent and earlier COVID-19 diagnoses at follow-up. Conclusions The identified feedback loop might indeed represent a vicious cycle and thus contribute to the development of psychopathology. However, limitations such as the limited measurement density made it difficult to find temporal associations and call for a cautious interpretation of results.

eHealth programs have been found to be effective in treating many psychological conditions. Regarding Borderline Personality Disorder (BPD), few programs have been tested; nevertheless, results are promising. The therapeutic alliance is an important factor predicting treatment outcome in BPD. However, we do not know yet to what extent BPD patients form a therapeutic alliance with an eHealth tool and how this relationship differs from the relationship with their human therapist. This study aims to address this question using priovi, an interactive schema therapy-based eHealth tool for BPD. Semi-structured interviews were conducted to explore how patients perceived the therapeutic alliance with priovi and its differences compared to the alliance with their human therapist (N = 9). Interview data were analyzed following the procedures of qualitative content analysis. Additionally, the Working Alliance Inventory (WAI-SR) was administered in two versions (regarding the human therapist and priovi, N = 16) every three months during the treatment phase of one year. Results indicate that patients were able to form a good therapeutic relationship with priovi, but it differed from the relationship to their human therapist. Important categories were “priovi is helpful, supportive and always there” and “priovi is less flexible”. WAI ratings for the task subscale were high in both relationships but significantly higher in WAItherapist compared to WAIpriovi in two measurements (nine-months measurement: t = 2.76, df = 15, p = 0.015; twelve-months measurement: t = 3.44, df = 15, p = 0.004). These results indicate that BPD patients can form a functioning alliance with an eHealth program and that eHealth programs may be especially useful for psychoeducation and cognitive exercises.