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Borderline Personality Disorder (BPD) is a major health problem in young people. Youth with BPD experience problems in social functioning and affect regulation resulting in social, occupational and health problems up to 20 years later. Eight percent of them die due to suicide. Youth with BPD criteria, such as self-harm, benefit from early detection and intervention which alters the life-course trajectory of the disorder, reducing long-term adverse consequences of BPD, such as poor psychosocial functioning and high morbidity and mortality [1]. Although effective treatments exist, they are difficult to access. No more than 6,5% of Dutch adolescents with BPD receive treatment for this disorder [2].


Youth with BPD are often referred for self-harm. 'Selfharm and suicidal behaviour' is the BPD criterion that is most frequently met in youth with BPD. Due to stigma, clinicians are often reluctant to assess self-harming youth, as a group at-risk for developing, or already suffering from, BPD who need effective treatment. This is a missed opportunity, as self-harm is not only a key symptom, but can also be considered one of the precursors for BPD [3], and is an important target for early intervention. Repetitive self-harm is associated with a variety of psychiatric disorders and outcomes, including affective disorders, risk of suicide and of personality disorders. As such self-harm in youth should be a major public health concern [4]. These different maladaptive outcomes of self-harm are in line with the maladaptive outcomes and high rates of comorbidity related to BPD. Adolescents with BPD are characterized by a blend of externalizing (eg, impulsive-aggressive behaviour, substance abuse) and internalizing (e.g., anxiety, depression) symptoms. This variety of psychopathology means that BPD can easily be confused with other psychiatric diagnoses, and a thorough understanding of differential diagnoses aids precision [3]. To improve diagnostic precision, assessment should not only include clinical (interview) assessment and self-report questionnaires, but also assessment of daily fluctuations in affect and social functioning, in order to be able to personalize interventions informed by the assessment.


This project aims to improve the emotional and social functioning of self-harming young people at risk for BPD and therefore to improve their future. Specifically, this project will test the effectiveness of a readily accessible, pre-treatment app-intervention

(Pre-Intervention Monitoring Affect and Relationships in Youth; 'PRIMARY', delivered through PsyMate) aimed at diminishing self-harming thoughts and behaviours in youth at risk for BPD by improving their affect regulation and social functioning. 'PRIMARY' is based on Safety planning, which is a a simple, evidence-based intervention for self-harm [39], which can be implemented early in care.


In this project, 180 help-seeking youth with recent self-harm will be invited into this study when they are on the waiting list for their first intake interview. Young people currently wait around 20 weeks for this intake interview, and in case of self-harm around 10 weeks, which is unacceptable for acute unwell individuals. For participants in this trial, the waiting period will be 6 weeks, during which participants will be allocated at random to (1) use the 'PRIMARY' app condition or (2) be placed on a 6-week waiting list condition. Both groups will have a two short questionnaire assessments at time of referral and 4 weeks after referral to assess their self-harming thoughts and behaviours, general psychopathology and quality of life. In addition, after their regular clinical intake assessment and provision of routine early intervention treatment, their progress within treatment will be monitored to investigate whether outcomes after 10, 25 and 52 weeks of early intervention.


The following research questions will be answered with this study:

1. Can a pre-treatment app-intervention ('PRIMARY') improve participants’ use of helpful/adaptive coping techniques, affect regulation and quality of relationships and decrease self-harming thoughts and behaviours in self-harming youth at-risk for BPD, before starting their regular assessment and early intervention for BPD (i.e. main effect of pre-treatment intervention)?

2. Can a pre-treatment app-intervention ('PRIMARY') improve treatment results in the regular early intervention in self-harming youth at risk for BPD (i.e. long-term effects of pre-treatment intervention 'PRIMARY')?

3. In the experimental condition: Can daily fluctuations in affect and social functioning predict self-harming thoughts and behaviours; and in addition detect the use of helpful/adaptive coping techniques strategies (both in affect regulation and psychosocial functioning) on a personal level in self-harming youth at risk for BPD?

4. In the experimental condition: How do youth and their professionals evaluate their use of 'PRIMARY'?


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