Introduction

Once thought to be untreatable, borderline personality disorder (BPD) has been legitimized as a valid psychiatric diagnosis with both biological and environmental risk factors, unique longitudinal course marked by high rates of remission and lower rates of recovery, and responsiveness to multiple evidence-based treatments (EBTs) specifically tailored to its core features [1]. Most of these EBTs are intensive, long-term and require extensive training for clinicians. However, meta-analytic studies indicate that duration and intensity do not determine outcome [2]. The specialization and demands of these treatments on both clinicians and patients limit their scalability and contribute to a grave access to care problem [3]. While investigators are testing briefer variants of these treatments that may broaden access over time [4, 5], more resources for clinicians and patients are urgently needed to initiate proper care plans to stabilize patients in acute crises and initiate diagnostically guided care plans efficiently.

Multiple high quality meta-analytic studies have evaluated the efficacy of treatments for BPD that have been subjected to randomized controlled trials [2, 6–8]. The most consistent finding is that psychotherapies designed expressly to treat the problems of BPD result in greater improvements than those that are not diagnostically specific, such as treatment as usual (TAU) and cognitive behavioral therapy (CBT). A common feature of effective treatments is psychoeducation about the disorder, its symptoms, and attention to a core mechanism the treatment proposes to address. This psychoeducational process not only provides much needed information for patients to understand their illness and the problems for which their treatments are prescribed, but also structures the therapeutic alliance, roles, and tasks moving forward. For a disorder distinguished by its unstable relationship vulnerabilities, this structure stabilizes a working framework in the context of expectable interpersonal and behavioral challenges.

Psychoeducation has also been proven as an effective stand-alone intervention. Zanarini and Frankenburg published the results of a trial of psychoeducation involving a sample of 50 women with BPD, randomized to either attend a one day, in-person psychoeducational workshop about BPD or a waitlist control condition. Participants in the workshop condition reported significantly greater reductions in impulsivity and storminess of close relationships than participants in the waitlist condition [9]. Zanarini et al. later assessed the efficacy of a self-guided online psychoeducational program in a randomized control trial of 80 adult women with BPD and found that women in the treatment condition had a significantly greater reduction in all five sectors of borderline symptomatology studied (affective, cognitive, impulsivity, interpersonal, and over-all) [10]. In a study conducted in a community-based outpatient setting, a psychoeducational group conducted over six sessions was tested against a waitlist control condition. Participants of the psychoeducation group had significantly greater reductions in affective, interpersonal, and cognitive symptoms, with almost half the group achieving a greater than 50% reduction in BPD symptoms compared to 3% of the waitlist [11].

Psychoeducational interventions provide a cost-effective first step of care [9]. Training professionals or even non-professional staff to administer interventions of any kind requires resources and skilled human resources. Video prescriptions, which are used across psychiatry and medicine in the routine care of patients [12–15], may eliminate this burdensome requirement for training and clinical face time by enabling clinicians to provide links that patients can access on their own time, watch in the comfort of their chosen surrounding, and review if needed at their leisure. This study aims to extend the existing research on psychoeducation by testing the safety, feasibility, and preliminary efficacy of a suite of short online psychoeducational videos developed by a clinical expert and delivered in a way that directly converses with patients. The control condition videos, produced at the same institution, are matched in length and frequency to the BPD videos and cover mental health topics not specific to BPD. To assess treatment effects and mechanisms, this protocol also includes a comprehensive battery of online assessments, including neuropsychological testing, ecological momentary assessment (EMA), and traditional self-report measures. While the online digital assessments do not utilize gold standard interview-based measures diagnostic of BPD, they employ a valid diagnostic self-report instrument. The absence of a skilled assessor replicates the real-world circumstances of most clinicians who may utilize this digital resource to add an outcomes-based evaluation to the general psychiatric management they provide in their settings.

Online assessments may also serve as an auxiliary intervention in and of itself. Both the regular and daily assessments promote improved self-awareness, which has been shown to be impaired in adults with BPD [16]. While there has been limited research regarding feedback on neuropsychological assessments, numerous published case studies have reported the benefits of feedback, which also increases self-awareness and allows support to be focused on areas of more severe impairment, while enhancing areas of higher ability [17–21]. Feedback on symptom dynamics in a case study increased insight and openness to treatment [22]. Feedback on progress in treatment has been examined as well with promising results for reducing depressive symptoms and improving outcomes [23, 24]. In addition, one non-randomized trial found that receiving feedback on neuropsychological assessment improved patient outcomes on metrics including quality of life and personal mastery [25]. By providing individualized feedback on baseline and longitudinal trends or changes in symptoms and neurocognitive performance, standardized interventions can be tailored so that the patient and clinicians treating them make decisions based on personalized unique data.

Materials and methods

Design

This study will follow a sequential multiple randomization trial design with two points of randomization: 1) BPD psychoeducational vs. control videos, and 2) feedback vs. no feedback (Fig 1). This yields three participant groups: (1) BPD-related videos x neuropsychological and reported symptom feedback, (2) BPD-related videos x no feedback, (3) control videos x no feedback. At the first randomization point, randomization will be weighted such that two-thirds of participants enter the BPD-related video arm, and one-third enter the control video arm. At the second randomization point, the participants will be split evenly between the feedback vs. no-feedback conditions. At both randomization points, we will use computer generated block randomization to balance BPD symptom severity and gender. After randomization, participant will be allocated by IDs to the appropriate group by the study research assistant(s). Participants and the statistician will be blind to the assignments.

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Fig 1. Schedule of enrolment, interventions, and assessments.

-t1 = Timepoint A (baseline); t1 = Timepoint B; t2 = Timepoint C; tx = Timepoint D.

https://doi.org/10.1371/journal.pone.0294331.g001

Interventions

Psychoeducation.

Two steps of interventions will be employed in this study: psychoeducational videos and feedback on self-reported symptom and trait features, daily EMA, and cognitive task performance. The psychoeducational videos have been filmed for the purpose of this study and feature the principal investigator, an expert in BPD treatment. The videos were shown to three people with lived experience and a family advocate for their perspectives in the development phase. Each of the ten videos is approximately 4–10 minutes long, and covers the following topics: (1) symptoms of BPD, (2) the interpersonal hypersensitivity model of BPD, (3) basic facts about BPD, (4) the long term course of BPD, (5) co-occurring disorders, (6) key principles for recovery, (7) common factors across treatments for BPD, (8) pharmacotherapy for BPD, (9) available psychotherapeutic treatment options for BPD, (10) review of top 10 tips to guide recovery. One video will be delivered to participants in the BPD-related video condition every business day (Mon-Fri) over the course of two weeks.

The videos that will be sent to the participants in the control video condition are matched in length and frequency to the BPD-related videos. The control videos cover aspects of mental and physical health that are not related to BPD, such as diet and exercise, self-compassion, depression, and healthy sleep habits. The suite of control videos was curated from the McLean webinar series, publicly available on the McLean Hospital website for consumers. Links to the control videos can be found in S2 File.

Participants who wish to withdraw their participation in the study may do so at any time and should inform study staff. They will be compensated for the portion of the study they complete.

Neuropsychological and reported symptom feedback.

Participants across all three arms of the study will complete full-length cognitive tests at four different timepoints: baseline (day 1), time 2 (day 15), time 3 (day 30), and follow-up (day 60). The full-length cognitive tests include: the Gradual Onset Continuous Performance Test (GradCPT) [26], the multiracial version of the Reading the Mind in the Eyes Task (RMET) [26], the Belmont Emotion Sensitivity Test (BEST) [26], the Forward and Backward Digit Span Tests (DST) [27], and the Digit Symbol Matching Test (DSMT) [26]. Additionally, participants will complete 1-minute versions of the CPT and the DSMT daily for 30 days. See the Measures section for more information on each test. Participants who are randomized into the feedback condition will receive an email in the time period between time 2 and time 3 of the study including the results from their cognitive tests and their self-reported BPD symptoms (Fig 2).

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Fig 2. Study schema.

In the Study Schema, “A” corresponds to Baseline, “B” to Time 2, “C” to Time 3, and “D” to Follow-up.

https://doi.org/10.1371/journal.pone.0294331.g002

Measures

Self-reports.

Table 1 outlines the protocol’s schedule of assessments. The primary outcome is BPD symptom severity, which will be measured with the Borderline Symptom List 23 (BSL-23) [28]. The BSL-23 is a brief version of the original BSL, which consisted of 95 descriptions of symptoms common in individuals with BPD [28]. The measure has high internal consistency, is strongly correlated with the original BSL, consistently differentiates between individuals with and without BPD, and is sensitive to symptomatic change [28].

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Table 1. Schedule of assessments.

https://doi.org/10.1371/journal.pone.0294331.t001

The secondary outcome is depressive symptom severity, which will be measured with the Patient Health Questionnaire (PHQ-9) [29]. The PHQ-9 assesses each of the 9 DSM-5 criteria for a major depressive disorder (MD) on a Likert scale from 0 = not at all to 3 = nearly every day. The measure has high internal consistency, differentiates consistently between individuals with and without MDD, has high test-retest reliability, and its criterion validity was established in conjunction with interviews conducted my mental health professionals [29].

Additional self-report measures that will be included in this study are the Three-Item Loneliness Scale (LS-3) [30], the San Diego Wisdom Scale (SD-WISE) [31], and the Level of Personality Functioning Scale-Brief (LPFS-B) [32]. The LPFS assesses criterion A’s domains of self and interpersonal functioning, comprising a measure of general personality pathology and impairment [29]. The three aforementioned scales are all psychometrically validated with acceptable internal reliability and construct validity [30–32]. The Client Satisfaction Questionnaire (CSQ-8) [33] will also be included as an acceptability questionnaire, including questions about satisfaction and whether the intervention has helped them deal more effectively with their problems.

Participants will also report their mental health treatment history on a self-report measure that was adapted from the Background Information Schedule for this study [34], report hospitalizations that have occurred since the last data collection time-point, and complete an assessment of their level of knowledge about BPD and its treatment developed by the study team.

Ecological momentary assessment.

In the first 30 days of the study, all participants will respond to a daily EMA survey containing questions about the participant’s immediate surroundings and functioning, as well as their emotional, interpersonal, and behavioral reactions to recent stressful or supportive social interactions. Each EMA survey will be accompanied by a 1-minute version of the CPT and the DSMT. The survey will be sent to the participants at a randomly generated time between 9:00am and 9:00pm and will take approximately 5–6 minutes.

Cognitive tests.

In the GradCPT, participants are instructed to press a button when a city scene is displayed on the screen, and to refrain from pressing a button when a mountain scene is displayed. The images fade from one into the other, with no pause between trials. City scenes appear in 80–90% of trials, and mountain scenes in only 10–20% of trials. This task measures sustained attention, response inhibition, and cognitive control [26, 27].

In the DST, participants are asked to recall lists of digits in the same (forward condition) or reverse (backward condition) order that they were originally presented, and an individual’s scores on the forward and backward conditions represents the length of the longest list of digits they were able to accurately recall and type at least once. Scores in the forward condition can indicate attention/concentration ability, while scores in the backward condition can indicate working memory [35].

In the BEST, participants choose which of two faces presented on the screen is more emotional for three different affect conditions: anger, fear, and happiness. All three affect conditions assess social communication ability (i.e., ability to receive social communication from facial expressions) and ability to understand mental states. The anger and fear conditions also measure potential threat, while the happiness condition measures positive valence [26].

In the RMET, participants are shown images of only the eye-region of different faces and asked to select one of four emotion words on the screen to describe the face’s emotional expression. This task assesses social communication ability (i.e., ability to receive social communication from facial expressions) [26].

In the DSMT, participants are asked to use a symbol-number key shown on screen to match as many symbols and numbers as possible in 90 seconds. This test measures cognitive processing speed and visual short-term memory [26].

Discussion

This pilot study aims to preliminarily assess safety, feasibility, and preliminary efficacy of online psychoeducation and assessment with individualized feedback which primary care providers and generalist mental health clinicians might be able to prescribe for patients upon diagnostic disclosure before uptake or enrollment in further treatment. Many patients and clinicians are unable to access BPD-specific care due to a lack of availability in their locale, stigma, or prohibitive costs in treatments not automatically covered by insurance [3]. Similarly, many primary care physicians (PCPs), psychopharmacology prescribers, emergency room clinicians, or generalist mental health clinicians are unable to provide referrals to gold standard treatment for their patients with BPD. Instead of relying on a time and resource intensive process of training clinicians and staff to provide psychoeducation and relevant assessments for optimizing care, this set of digital interventions provides an opportunity to systematize a readily available system of meeting needs in the current climate of pervasive shortages of mental health services to meet demands.

Delivering the psychoeducation asynchronously through videos sent directly to participants may have some advantages over both in-person teaching and website-based programs. The asynchronous nature of the intervention avoids two significant sources of variability in treatment response: the therapist themself and the therapist’s role in the alliance [41, 42]. This may be particularly helpful to individuals with BPD, who are hypersensitive in interpersonal relationships and interactions [43]. Providing videos directly to patients via a daily email or text message may motivate or remind participants to continue with the intervention, rather than relying on the participant to self-direct to a specific webpage. It also adds a low level of direct communication, which may increase participant buy-in, especially if they may be prone to avoid social contact out of shame, paranoia, mistrust, or logistical barriers such as work, childcare, or travel barriers to treatment access. By creating widely accessible, user-friendly digital resources such as these, and testing their efficacy, we may be able to broadly augment existing care with a specialized BPD framework that can augment usual good clinical care available in most settings.

This study will produce preliminary data to support future, larger scale research on psychoeducational video prescriptions as a scalable intervention to reduce BPD symptomatology. This study will also contribute to existing research on neuropsychological and reported symptom feedback as an intervention.

Supporting information

Acknowledgments

We would like to express our gratitude to our funding sources the Brain & Behavior Research Foundation, Families for BPD Research, and the Eric Dorris Translational Research Award for providing this opportunity to study this approach to broadening access to care. We also thank Kerry Ressler M.D. Ph.D. for his mentorship in our “blue sky” idea for our NARSAD Young Investigator grant which made this effort possible. Lastly, we thank Rebbie Ratner and her team in filming and producing our psychoeducational video series.