Characterising Sleep in Young People with Borderline Personality Disorder
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2021
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Melbourne Authors
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Melbourne School of Psychological Sciences
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PhD thesis
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Open Access
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© 2021 Claire Anne Jenkins
Abstract
Background. Borderline personality disorder (BPD) features typically have their
clinical onset during adolescence and early adulthood, coinciding with normative developmental changes to sleep quality and sleep-wake patterns. Sleep disturbances are commonly reported by individuals with BPD features and are independently associated with a range of adverse outcomes. Yet, few studies have investigated sleep in young people with BPD.
Aims. This thesis consists of five studies. Study 1 was a scoping review that mapped the existing literature, highlighted areas for further investigation, and provided methodological recommendations for future research. Study 2 assessed inter-device reliability between two actigraphs (Actiwatch-2 and GENEActiv). This was an essential methodological step in this research program because it allowed actigraphy-derived sleep parameters to be reliably compared across BPD and clinical comparison groups, despite different actigraphs having been used. Studies 3-5 addressed the overarching aim of this thesis: to characterise sleep in young people with BPD features. This involved investigating whether subjective and objective (actigraphy) sleep patterns were non-normative and/or specific to BPD (Study 3), exploring the mechanisms underlying sleep disturbance (Study 4), and assessing the feasibility of using polysomnography in this population and providing pilot data (Study 5).
Method. Participants in studies 3 and 4 were 96 young people aged 15-25 years (M = 20.02, SD = 2.62). This included 40 with 3 or more BPD features, 38 healthy individuals, and 18 young people seeking help for non-BPD psychopathology. Sleep was assessed subjectively (self- report questionnaires) and objectively (10 days wrist actigraphy). In study 5, a subset of participants (7 with BPD features, 6 healthy individuals) completed overnight polysomnography monitoring.
Results. Young people with BPD features reported poorer sleep quality, more severe insomnia and later chronotype than healthy and clinical comparison groups. Impulse control difficulties, limited access to emotion regulation strategies and anxiety indirectly affected the relationship between BPD features and subjective sleep disturbances. Actigraphy data revealed that young people with BPD features had irregular sleep timing, later rise times, greater time in bed, and longer sleep durations compared with healthy young people. Additionally, individuals with BPD features displayed superior sleep quality (greater sleep efficiency, less wake after sleep onset) and slept longer than the clinical comparison group. Anxiety and lack of emotional awareness indirectly affected the association between BPD features and actigraphy-assessed bedtime variability and longer time in bed, respectively. The feasibility of in-home and sleep laboratory-based polysomnography were both demonstrated. Pilot polysomnography data indicated that individuals with BPD features had fewer arousals from sleep than healthy young people, but displayed an otherwise comparable sleep profile.
Conclusion. Young people with BPD features reported sleep disturbances beyond the normative changes found during this developmental period and beyond those reported by young people seeking help for non-BPD psychopathology. Although a subjective-objective sleep discrepancy was revealed, subjective sleep disturbances alone reflect sleep-related distress and thus warrant clinical attention. Sleep-improvement interventions should be investigated as possible beneficial adjuncts to current early interventions for young people with BPD features to improve subjective sleep, quality of life, and potentially promote broader symptomatic and functional recovery.
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Keywords
Sleep, Borderline personality disorder, BPD, Psychiatry, Young people, Adolescents, Insomnia