What is a Borderline Personality Disorder 13
The borderline personality disorder in the psychosocial, psychotherapeutic and psychiatric care systems of Germany
In psychosocial, psychotherapeutic and psychiatric care, those affected with a borderline personality disorder are a common group of patients. Although several long-term studies suggest high remission rates for the disorder-specific symptoms, many of those affected with borderline personality disorder show impairments in the areas of psychosocial functioning, somatic health, and occupational and social integration, which mostly present themselves as secondary consequences of the disease and have a negative impact on life satisfaction and social participation. An essential factor in this development is the precarious care situation of those affected in the outpatient and complementary area. Most of the treatment takes place in the context of short-term inpatient crisis interventions. This makes it clear that so far it has not been possible to adequately care for this group in the out-of-hospital areas. As part of the contribution, a general overview of the epidemiology and health services research of borderline personality disorder is given. Based on the current knowledge, the authors draw attention to structural problems and interface problems in outpatient, complementary and inpatient areas and describe possible solutions for appropriate care.
People with borderline personality disorder belong to the group of heavy users of psychosocial, psychotherapeutic and psychiatric care. Although several follow-up studies found high remission rates for the disorder-specific symptoms many of those affected with a borderline personality disorder show impairments in the areas of psychosocial functioning, somatic health, work and social integration, which mostly present as secondary consequences of the disease and negatively affect life satisfaction and social participation. An essential factor in this development is the precarious care situation of those people in the outpatient and complementary area. The majority of the treatment takes place in the context of short-term inpatient crisis interventions. This makes it clear that it has been so far insufficient to provide this group with adequate care in the outpatients and complementary areas. The article provides a general overview of epidemiology and health services research for borderline personality disorder. Based on the current findings in health services research, the authors draw attention to structural problems and interface problems in the outpatient, complementary and inpatient areas and describe possible solutions for adequate care.
For a long time, borderline personality disorder (BPD) was a controversial disorder among experts. This diagnosis often represented a heterogeneous group of patients who could not be clearly classified in the classification at the time, but showed moderate to severe forms of mental disorders (cf. Stone 1979).
Early descriptions of BPD can be traced back to the 16th century in reports on hysterical patients (cf. Veith 1965, pp. 140 ff.). In 1883 the term Borderline For the first time by the American psychiatrist Hughes (orig. Borderland [German Grenzland]) to denote general conditions that move on the border between mental health and illness (Dulz 2011). The American psychoanalyst and psychiatrist Stern (1938) presented the first conceptual work on BPS that is still significant today. While BPD was mainly discussed as a subpsychotic disorder between the 1920s and 1950s and also as a subaffective disorder between the 1970s and 1980s, between the 1950s and 1980s there was a more precise elaboration of disorder-specific characteristics and conceptualization as a psychological entity ( Overview in Herpertz and Saß 2011). Finally, in 1980 the BPS was included as an independent personality disorder category in the third edition of the Diagnostic Statistical Manual (DSM) of mental disorders (APA 1980).
Even if there are currently still many controversial topics - e.g. B. about a close etiological connection between BPD and trauma-related disorders (Sack et al. 2011) or about the importance of psychotic symptoms in borderline symptomatology (Schroeder et al. 2013) - BPD is largely a recognized disorder among experts . Numerous research papers published in the last few decades have contributed to the understanding of this disorder. In addition, the treatment options improved through the introduction of evidence-based therapy methods such as B. transfer-focused psychotherapy (TFP) (Yeomans et al. 2017), mentalization-based psychotherapy (MBT) (Bateman and Fonagy 2008), dialectical behavioral psychotherapy (DBT) (Linehan 2008) or schema-focused psychotherapy (SFT) (Arntz and van Genderen 2010).
Despite the positive developments, borderline patients still belong to a group that does not benefit sufficiently from the psychiatric, psychotherapeutic and psychosocial care systems. In the context of the article, the authors summarize the current state of research on epidemiology, the long-term course and health care research and refer to structural problems and interface problems in psychosocial, psychotherapeutic and psychiatric care. In doing so, they are based on the structures of the German health system. They then describe possible solutions for appropriate care for those affected with BPS.
Epidemiology and long-term course of borderline personality disorder
Population-based studies found a frequency between 0.7 and 4.5% for BPS (overview by Fiedler 2018). According to a recent review, the average prevalence is 1.6% (ibid.). Based on this prevalence rate, with a population of around 68 million people between the ages of 18 and 60, around 1 million people in Germany may be ill with BPD (Federal Statistical Office 2017). The main socio-demographic characteristics include younger average age (mean 25), type of living living alone and lower level of education (Cramer et al. 2008). The gender distribution is relatively even in the population.
In addition, several research studies show that in addition to BPD, those affected often have additional disorders such as substance and alcohol abuse disorders, depression, anxiety disorders, eating disorders, trauma-related disorders or personality disorders (Frias and Palma 2014; Samuels et al. 2002). In addition, compared to the general population, those affected report somatic symptoms and complaints (e.g. headaches, migraines, back pain) more often than average (Heath et al. 2018). All this information suggests that BPD is often associated with complex health problems in addition to the actual symptoms.
With regard to the long-term course, the Collaborative Longitudinal Disorders Study first comprehensive knowledge of various personality disorders (Grilo et al. 2000). A total of 668 patients who were in inpatient treatment on the reporting date took part in the study. The sample consisted of the diagnoses schizotypic personality disorder (13%), anxiety-avoidant personality disorder (26%), obsessive-compulsive personality disorder (23%) and BPD (26%). Patients with major depression (14%) were included as a control group. With BPS, the results showed a cumulative remission rate (decrease in existing diagnostic criteria) of over 90% over the entire 10-year study period (Gunderson et al. 2011). Those affected also showed improvements over time in terms of their general level of functioning. However, the average increase in the values in the BPS group of 53 to 57 was rather small compared to the other groups (personality disorders 62–64, major depression 61–69).
In contrast to Collaborative Longitudinal Personality Disorders Study examined the McLean Study of Adult Development only the long-term course of the BPS. The focus of the study was on 290 borderline patients admitted to the hospital and 72 patients with other psychiatric diagnoses (Zanarini et al. 2005). In the meantime, the data obtained from the study go back to a period of more than 16 years with a response rate of 87% (Zanarini et al. 2012). While the borderline patients showed a cumulative remission rate (complete decrease in criteria) of 35% after two years, it was 88% in the control group. However, the remission rates in the borderline group increased significantly over the study period. After 4 years the cumulative remission rate was 55%, after 8 years 88%, after 12 years 95% and after 16 years 99% (ibid.). The psychosocial functional level also improved over the entire study period (2 years 14%, 8 years 43%, 12 years 50%, 16 years 60%). However, these rates were significantly lower than in the control group (2 years 51%, 8 years 67%, 12 years, 85%, 16 years 85%). In both groups, however, the level of psychosocial functioning was significantly below the values of the remission rates over the entire study period.
More recent long-term studies also suggest a high level of remission in BPS. A working group from Spain determined a remission rate of 55% over a 10-year period with a total of 64 patients (response rate 64%) (Alvarez-Tomás et al. 2017). In Germany, a working group found a remission of 81% in 60 borderline patients (response rate 87%) over a study period of 12 to 18 years (Zeitler et al. 2018).
All studies indicate that BPD is not a chronic mental disorder, at least on the symptom level. The disorder usually begins in adolescence. This is where the first symptoms such as impulsiveness, identity problems and affective instability appear, which can also occur in healthy adolescents in the context of the adolescence crisis and manifest in early adulthood through symptoms of affective dysregulation, impulsivity, suicidality and maladaptive interpersonal behavior to a pronounced disorder (cf.Arens et al. 2013). In middle and later adulthood there is a noticeable remission, especially with the acute symptoms that are often associated with inpatient admissions (e.g. impulsiveness, self-injurious behavior, suicidality, psychotic decompensation, substance abuse) (Gunderson et al. 2011; Zanarini et al. 2003). On the other hand, symptoms such as affective instability, intense anger, feelings of emptiness, depression and fear of being alone are among the symptoms with a slower remission period (see Alvarez-Tomás et al. 2017; Gunderson et al. 2011; Zanarini et al. 2003) . The positive predictors include a younger age at the start of initial treatment, a good level of education and low use of inpatient assistance in the past (cf. Gunderson et al. 2011; Paris 2002b).
The role of psychotherapy is controversially discussed in this context because the direct influence of psychotherapeutic interventions on the level of remission is difficult to demonstrate in the studies, many of the patients have different therapy experiences over the course of the study and the remission rates are also high in the studies with random samples without psychotherapeutic care fail (see Paris and Zweig-Frank 2001). It can therefore be assumed that there is a natural remission in BPD, which is accelerated and additionally promoted by psychotherapy (Paris 2020).
Despite the high remission rates, those affected with BPD show low values in the areas of psychosocial functional level in the follow-up studies. Less than half of the patients in the McLean Study of Adult Development showed improvements after 10 years (Zanarini et al. 2012). It can be assumed that secondary consequences of illness (e.g. somatic health, incapacity for work, social disintegration) - which have a negative effect on life satisfaction and social participation - play an important role.
Suicidality and attempted suicide
With regard to suicidality, the follow-up studies suggest a prevalence of 3 to 13% (Alvarez-Tomás et al. 2017; Soloff and Chiappetta 2019; Zanarini et al. 2012). The average age of suicides is between 30 and 37 years (Paris 2002a; Soloff and Chiappetta 2019). The frequency of suicide attempts is significantly higher in BPD at 70 to 80% (Soloff and Chiappetta 2019; Teismann et al. 2016). On average, those affected report three suicide attempts in their lives. Compared to other mental disorders, the number of suicide attempts is clearly overrepresented in BPD (Yen et al. 2003). The following factors for an increased suicide risk could be identified in follow-up studies: Male gender, long medical history with ineffective treatment experiences, hopelessness, age between 30 and 37 years, substance abuse, impulsiveness, comorbid depression, frequent inpatient admissions in the past, previous suicide attempts, lack of connection to Outpatient therapeutic forms of treatment, living alone, low social integration, lower income and lower level of psychosocial functioning (see Pérez et al. 2014; Soloff and Chiappetta 2017, 2019). Here it becomes clear that especially those affected with a long-term course of the disease, ineffective treatment experiences, comorbid disorders and severe psychosocial problems such as social disintegration or incapacity for work are exposed to a high risk of suicide.
The supply situation for borderline personality disorder
Prevalence in clinical samples
In general, BPD is one of the most common personality disorders in psychosocial, psychiatric and psychotherapeutic care (Grilo et al. 1998; Loranger et al. 1994; Ranger et al. 2004; Zimmerman et al. 2005). A review by Ellison et al. (2018), the proportion of those affected with BPD can be estimated at 12% in the extra-inpatient psychiatric care offers and at 22% in the inpatient psychiatric offers. With a gender ratio of 70 to 30%, the proportion of women in this area is significantly higher (overview in Paris 2002a). It is assumed that BPD is more often characterized by externalizing symptoms (e.g. impulsiveness, aggressiveness, antisocial behavior) in male patients and is associated with high levels of characteristics of an antisocial personality disorder or substance abuse disorder, which means that male patients are more likely to be affected are to be found in the forensic setting or in prison (Barnow et al. 2007; Paris 2020). However, general gender-specific differences in help-seeking behavior can also explain the unevenly distributed sex ratio of BPD in clinical samples.
Use of assistance
Compared to other disorders, those affected with BPD have an above-average use of psychotherapeutic, medical or psychiatric treatments. Here z. B. the Collaborative Longitudinal Personality Disorders Study show that borderline patients in the last 12 months had high user values in areas such as: outpatient psychotherapy (85%), drug therapy (69%), consultations from emergency rooms (31%) and inpatient admissions (31%) (Bender et al . 2006). In the McLean Study of Adult Development higher values were also determined in the past compared to a control group (KG). The variables tested included individual psychotherapy (BPS 96% vs. KG 86%), group therapy (BP 36% vs. KG 18%), family therapy (BP 38% vs. KG 29%), self-help groups (BP 51% vs. KG 32%), day clinic (BPS 42% vs. KG 19%), inpatient treatment (BPS 37% vs. KG 10%), inpatient psychiatric treatment (BPS 79% vs. KG 50%), drug therapy (BPS 84%) vs. KG 61%) and other unspecified forms of hospitalization (BP 60% vs. KG 21%) (Zanarini et al. 2001).
Even in the long-term, the frequency of use decreases only slowly despite a reduction in symptoms (Bender et al. 2006; Hörz et al. 2010). Particularly those affected with a high degree of suicidality, comorbid anxiety disorders, psychotic symptoms and with experiences of sexual abuse or violence in childhood show an increased level of utilization (cf. Coid et al. 2009; Comtois et al. 2003; Hull et al. 1996, Zanarini et al. 2001). However, these predictors mainly relate to the use of inpatient psychiatric aids.
Treatment and illness costs
In recent years, several European studies have been able to determine data on the direct (direct resource consumption resulting from the treatment and its consequences) and indirect (all production losses due to occupational disability or premature death that can be attributed to the disease) disease costs caused by BPD (Review in Wagner et al. 2013). In the Netherlands, Van Asselt et al. (2007) annual costs of € 21,120 per patient. Of this, 50% were indirect costs. Around 12% were caused by inpatient and day-care treatment and a further 10% by outpatient treatment. In Great Britain, Bateman and Fonagy (2003) calculated direct costs of € 38,771 per patient. In contrast, the working group around Palmer et al. (2006) for Great Britain the direct costs are around € 16,779. A working group from Denmark found € 40,411 per patient (Hastrup et al. 2019). Of this, 60% of the total costs were indirect costs. For Germany, Wagner et al. (2013) in the Berlin borderline care study per patient annual costs of € 28,026, whereby the direct costs (approx. € 17,976) outweighed the indirect costs (approx. € 8988). 50% of the costs were attributable to inpatient and day-care treatment and 25% to the consequences of disability. Based on these figures, Stiglmayr and Gunia (2017) estimate the treatment costs of BPS in Germany at € 5 billion per year (€ 7.5 billion including indirect costs). These costs are only exceeded by patients with schizophrenia or multiple sclerosis and make up a considerable proportion of the total costs for inpatient care for mentally ill people (Wagner et al. 2013). The most important causes include frequent inpatient stays as a result of crises and admissions, disability of those affected and a lack of out-of-hospital care.
Consequences for the supply in Germany
The available studies make it clear that those affected with BPD belong to a group of patients with complex and multiple problem areas and have a need for various therapeutic, psychosocial and medical aids. In addition to the borderline problem, the majority of those affected are severely impaired in the areas of health, education, professional situation and social relationships, which significantly worsens the quality of life. Especially in Germany, whose care system is characterized by a high degree of fragmentation, mentally ill people with complex needs often benefit only insufficiently (cf. Giertz and Große 2020).
Cross-sectoral networking and flexible alignment of the individual support offers is therefore necessary for adequate care of those affected with BPS so that in a crisis situation they do not have to fall back on the complex range of cost-intensive inpatient offers. Interventions to network the individual support measures, which primarily aim to promote existing social resources (Giertz and Aderhold in this issue) as well as outreach therapeutic forms of treatment that enable complex treatment measures in crisis situations and thus a more effective implementation of individual coping strategies (Schindler et al. In this booklet), can make a contribution to improving the care situation of those affected.
For Germany it can be stated that the care situation of those affected in the outpatient and complementary area is particularly precarious. Most of the treatment takes place in the context of short-term inpatient crisis interventions (cf. Wagner et al. 2013). Continuous outpatient psychotherapy is only used by a small proportion, which may be related to the fact that many outpatient psychotherapists consider the treatment of BPD to be difficult due to suicidality, self-aggressive behavior or behavior. In a survey in Munich, around 21% of psychotherapists reported that they generally did not treat borderline patients and another 51% stated that they did not have sufficient capacities available (Jobst et al. 2010). For those affected, this results in a therapeutic undersupply. In addition, 86% of the therapists surveyed did not have any training that was not specific to the disorder, which increases the risk of treatment discontinuation. This therapeutic undersupply is also supported by an international study on the implementation of specific treatment methods and care approaches for BPD. For Germany, based on epidemiological data, data from the World Health Organization and international professional associations, as well as data from training and accreditation centers, the working group calculated a ratio between therapists trained for specific disorders (e.g. psychologists, psychiatrists, social workers) and the annual number of patients to be treated a BPS of 1 to 1102 (Iliakis et al. 2019). In addition to the expansion of outpatient, disorder-specific capacities, the establishment of therapeutic networks can help reduce the burden on the individual outpatient therapists, enable continuous treatment and reduce the risk of treatment discontinuation (see Margreiter in this issue; Stiglmayr in this issue ).
Many people affected by BPS often take advantage of psychosocial care offers such as assisted living, outpatient care offers, crisis services or advice centers. To date, there are no disorder-specific supply concepts in this supply sector (cf. Dammann 2007). This, too, can lead to an increase in psychosocial functional impairments, chronification and inpatient crisis interventions. According to a qualitative study in this area, disorder-specific approaches and a differentiated view of the individual symptoms of those affected appear to be necessary for the creation of sustainable professional relationship work, on the basis of which design skills can develop (Gahleitner et al. 2020). In addition, the implementation of, for example, behavioral and cognitive therapeutic or other therapeutic interventions in this area can support those affected in the mediation and implementation of coping strategies in everyday life in order to promote recovery processes and reduce the frequent use of inpatient crisis interventions (Rahn in this issue ).
Another area concerns preventive support measures to counteract the long-term consequences of BPD. The age at which BPD is diagnosed is often in adolescence and manifests itself in early adulthood (cf. Gunderson et al. 2011; Zanarini et al. 2003). Early detection and early therapeutic measures in the youth sector can preventatively contribute to reducing long-term consequences such as dropping out of training, tendencies towards becoming chronic, stigmatization and social disintegration (Paris 2020). The majority of those affected are also unable to work, which on the one hand results in high indirect illness costs and on the other hand also impairs participation in society. Here, too, alternative care models such as Supportet Employment provide an opportunity to integrate those affected into the general labor market through supportive employment (cf. Richter et al. 2019).
Overall, the findings on the care situation of those affected with BPS in Germany suggest that, in addition to the expansion of therapeutic capacities and disorder-specific psychosocial offers in the outpatient and complementary area, stronger and more flexible networking between the inpatient and outpatient areas is necessary in order to deal with the complex To respond to the need for help of those affected and to counteract chronification processes, secondary consequences of illness and impairments of social and professional participation. Initial approaches can be found in Germany through the establishment of therapeutic networks in various large cities (see Stiglmayr in this issue), the implementation of integrated care for those affected with BPS in Hamburg (see Schindler et al. In this issue), the implementation of the open dialogue in community psychiatric care (see Giertz and Aderhold in this booklet) or the introduction of STEPPS skills training in various psychiatric clinics and providers of integration assistance (see Rahn in this booklet).
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