The research, led by Katharina T. E. Morken of Haukeland University Hospital and the University of Bergen, together with colleagues at Oslo University Hospital, drew on data from the Network of Personality Disorders in Norway, a quality register covering specialised treatment units across the country. In total, 742 patients with personality disorders were followed during treatment delivered between 2017 and 2022. The scale and design of the study matter: rather than a snapshot of a single clinic, the investigators tracked patients repeatedly over time across many treatment centres, allowing them to separate changes within individual patients from stable differences between them.

At baseline, every participant underwent structured diagnostic interviews. Personality disorders were assessed with the Structured Clinical Interview for DSM-5 Personality Disorders, while other mental disorders were captured using the Mini International Neuropsychiatric Interview. Substance use was measured with the first three items of the Drug Use Disorders Identification Test and the three-item consumption version of the Alcohol Use Disorders Identification Test. Crucially, these substance use measures were repeated at six-month intervals throughout treatment, so the researchers could observe how fluctuations in a patient’s own drinking and drug use related to fluctuations in the quality of their therapeutic relationships.

The therapeutic alliance itself was measured from the patient’s perspective using two well-established instruments. For individual therapy, patients completed the Working Alliance Inventory Short Form, which breaks the alliance down into three components: the emotional bond between patient and therapist, agreement on the tasks of therapy, and agreement on its goals. For group therapy, patients completed the Group Questionnaire, which captures not only bond, work, and goal agreement but also the deeper sense of mutuality and collaboration within the group. These alliance ratings were also collected every six months, producing a dense longitudinal dataset.

To analyse this structure, the team used three-level hierarchical linear mixed models, a statistical framework designed for nested data. Repeated alliance assessments were nested within patients, and patients were nested within treatment centres. This approach allowed the investigators to ask a precise question: when a given patient reports higher substance use than their own typical level, does their alliance rating drop? This within-person design is statistically powerful because each patient serves as their own control, filtering out stable traits that might otherwise confound the association.

The headline result concerns group therapy. After accounting for time of assessment, personality disorder diagnosis, other mental disorders, gender, age, and treatment context, the researchers found a significant negative relationship between within-person increases in substance use and the work dimension of the Group Questionnaire. In plain terms, when patients used more drugs than their own average, they reported poorer mutuality in the collaborative work of their therapy groups. This is a specific and clinically meaningful finding: the work component of group alliance reflects how well members engage together in the shared task of treatment, and it is precisely this collaborative core that appears vulnerable to substance use.

Perhaps more striking is what the study did not find. There were no significant associations between substance use and total alliance scores in either group or individual treatment, and no significant links to the emotional bond in either setting. Trends emerged suggesting a negative association between substance use and agreement on tasks and goals in individual therapy, but these did not reach statistical significance. Alcohol consumption, measured by the AUDIT-C, showed no significant associations with any alliance measure. The damaging signal, in other words, was confined to drug use and to one specific facet of the group alliance.

The authors are candid about the implications of this pattern. The negative impact of comorbid substance use on the therapeutic alliance appears to be more limited than previous literature had suggested. Instead, they argue, the preponderance of alliance-related difficulties in patients with personality disorders may reflect the influence of the personality disorder itself, or other patient-level factors that have not yet been characterised. This reframing is important. If clinicians assume that substance use is the primary obstacle to alliance formation in this population, they may misattribute difficulties that actually stem from the interpersonal and emotional features of the personality disorder, such as mistrust, fear of abandonment, or unstable self-image.

For treatment planning, the study points toward pragmatism and responsiveness. The clinical significance statements accompanying the paper emphasise that a sensitive, responsive collaboration between patient and therapist may be critical when tailoring treatment for patients with combined personality disorder and substance use conditions. Because the observed effect was specific to group work and to the mutuality of collaboration, group-based programmes—the backbone of much specialised personality disorder treatment, including mentalization-based approaches delivered at several of the participating units—may need to monitor substance use actively and adjust group interventions when a patient’s use escalates. Rather than excluding these patients from group treatment, the findings suggest vigilance and flexibility.

Methodologically, the study also demonstrates the value of longitudinal, multi-level designs in psychotherapy research. Cross-sectional studies can show that patients with substance use disorders report weaker alliances, but they cannot determine whether substance use drives the alliance or whether some third factor explains both. By modelling repeated measurements within patients across eighteen treatment units, the Norwegian team could isolate the dynamic contribution of substance use with unusual clarity. The remaining uncertainty lies in the association between substance use and alliance being weaker than hypothesised, and in the possibility that missing data or unmeasured patient characteristics still shape the picture. Even so, the central message stands: in specialised personality disorder treatment, comorbid drug use specifically undermines the collaborative work of group therapy, while the broader alliance appears more resilient than feared—a finding that should reassure clinicians and sharpen their attention to the group setting where the vulnerability is real.

Subject of Research: The effect of comorbid substance use on therapeutic alliance in specialised personality disorder treatment

Article Title: The impact of comorbid substance use on individual and group therapeutic alliance in specialised personality disorder treatment: a longitudinal multi-site study

Article References: Morken, K. T. E., Molde, H., Bergwitz, A., Hummelen, B., Pedersen, G., & Kvarstein, E. H. (2026). The impact of comorbid substance use on individual and group therapeutic alliance in specialised personality disorder treatment: a longitudinal multi-site study. BMC Psychiatry. https://doi.org/10.1186/s12888-026-08707-5

Image Credits: AI Generated

DOI: 10.1186/s12888-026-08707-5

Keywords: therapeutic alliance, personality disorder, substance use disorder, group therapy, group cohesion, hierarchical linear models, longitudinal study, Working Alliance Inventory, Group Questionnaire, mental health, psychotherapy, comorbidity

The research team, led by María Vicenta Lucas and Marc Peraire of the Consorcio Hospitalario Provincial de Castellón together with colleagues from Universidad Cardenal Herrera-CEU, carried out a pre-experimental, longitudinal, prospective study over eleven months in the hospital’s Short-Term Hospitalisation Unit. Rather than simulating crises in a laboratory, they observed the ward as it actually functioned, recording every verbal de-escalation performed by nursing staff. In total, the team analyzed 714 de-escalation episodes involving 165 patients, a cohort in which 58.8 percent were male and the average age was 37.64 years. For each episode, the researchers documented the patient’s level of psychomotor agitation, the intervention the nurse chose, and a battery of clinical and sociodemographic variables using purpose-built ad hoc scales.

Psychomotor agitation is a state of excessive motor and verbal activity driven by inner tension, and it is among the most dangerous situations in acute psychiatric care, both for patients and for staff. When verbal strategies fail, clinicians may resort to coercive measures, including mechanical restraint or chemical restraint delivered orally or intramuscularly. International frameworks, including the Convention on the Rights of Persons with Disabilities, have pushed hospitals worldwide to minimize such measures, making de-escalation not just a clinical preference but an ethical and legal imperative. Yet the decision of when and how to intervene verbally has traditionally rested on individual nurse experience rather than on systematic evidence about which patients are at highest risk.

The statistical analysis revealed striking patterns. Female sex was associated with requiring more verbal de-escalation interventions, with a regression coefficient of 6.34 and a p-value below 0.001, indicating an association that is very unlikely to be due to chance. Patients with affective disorders, such as depression or bipolar disorder, also required more de-escalation attempts, with a coefficient of 1.59, and substance use emerged as the strongest driver of all, with a coefficient of 7.08. In practical terms, this means that a patient admitted with an affective disorder compounded by active substance use, or a woman experiencing acute agitation, is likely to demand substantially more verbal engagement from nursing staff over the course of a hospitalization.

Timing mattered as much as frequency. Female sex was associated with de-escalation episodes occurring later in the admission, with a coefficient of 6.05, while personality disorder and substance use were associated with earlier crises, with coefficients of −8.01 and −3.61 respectively, the latter reaching statistical significance at p = 0.005. This temporal signature carries real operational value for ward management. A patient with a personality disorder or active substance use may need heightened observation and preventive engagement from the very first hours of admission, whereas a female patient’s risk window may open later, suggesting that vigilance should be sustained and adjusted throughout the stay rather than front-loaded.

The study also quantified the risk of escalation to chemical restraint, and here the diagnostic picture diverged sharply. Patients with personality disorders showed a higher likelihood of requiring oral chemical restraint, with an odds ratio of 1.66 and p = 0.026, and a substantially higher likelihood of requiring intramuscular restraint, with an odds ratio of 2.87 and p = 0.016. Intramuscular administration is typically reserved for the most severe agitation, when a patient cannot or will not accept oral medication, so an odds ratio approaching three marks personality disorder as a red flag for the most coercive end of the intervention spectrum. Conversely, patients with affective disorders were less likely to need oral chemical restraint, with an odds ratio of 0.81 and p = 0.001, suggesting that verbal strategies alone are often sufficient for this group.

These results matter because they translate directly into individualized care plans. If a nurse receiving a new admission knows that a particular profile, for instance a patient with a dual diagnosis of mental illness and substance use, is statistically associated with early and frequent agitation, the care team can prioritize rapport-building, environmental adjustments, and early verbal engagement rather than waiting for a crisis. The authors argue that identifying characteristics associated with psychomotor agitation based on sex, diagnosis, and substance use may help prevent or reduce agitation episodes and support nursing staff in designing personalized de-escalation interventions for different patient profiles. In an era when psychiatric units face chronic staffing pressure, such risk stratification offers a way to allocate the scarcest resource, skilled nursing attention, where it will do the most good.

The methodological design deserves attention. As a pre-experimental study, it captures real-world associations without the randomization of a controlled trial, and the researchers themselves frame it as a description of actual clinical experience rather than proof of causation. The ad hoc scales used to record agitation levels and interventions were developed specifically for this setting, and data collection was anonymous, with the protocol approved by the hospital’s Ethics Committee for Drug Research in July 2023 and all participants providing informed consent before discharge. The eleven-month window and the substantial number of de-escalation episodes lend the findings ecological validity that laboratory studies of de-escalation training often lack, though the single-site design means the specific coefficients may vary in hospitals with different patient mixes.

The broader context is a field in transition. De-escalation research has historically focused on training programs and organizational policies, with comparatively little work mapping patient-level predictors of who will need verbal intervention, how much, and when. By quantifying these associations with regression coefficients and odds ratios, the Castellón team has provided a template that other units could replicate, potentially building a body of evidence that turns de-escalation from an art learned through apprenticeship into a data-informed practice. The finding that substance use dominates both the frequency and the early timing of agitation episodes is particularly relevant given rising rates of dual disorders in acute psychiatric admissions across Europe.

For patients, the stakes of this line of research are profound. Every episode of agitation that is defused with words rather than injections or restraint is an episode experienced without the trauma, physical risk, and erosion of trust that coercion can bring. For nurses, the study validates verbal de-escalation as an essential, measurable clinical skill and offers a statistical scaffold for clinical judgment. As the authors conclude, verbal de-escalation is an essential nursing skill required during acute psychiatric hospitalisation, and knowing which patients are most likely to need it, and when, may be the difference between a crisis averted and a crisis managed. The next step will be testing whether care plans built on these risk profiles actually reduce restraint rates, a trial that could change how psychiatric wards around the world greet their most vulnerable admissions.

Subject of Research: Predictors of psychomotor agitation and verbal de-escalation needs in acute psychiatric inpatient care

Article Title: Identification of characteristics associated with psychomotor agitation for individualised nursing interventions in acute psychiatric care settings: a real world experience

Article References: Identification of characteristics associated with psychomotor agitation for individualised nursing interventions in acute psychiatric care settings: a real world experience. (n.d.). https://doi.org/10.1186/s12912-026-05429-7

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05429-7

Keywords: psychomotor agitation, verbal de-escalation, psychiatric nursing, chemical restraint, personality disorder, affective disorder, substance use, dual disorders, acute psychiatric care, individualized interventions, BMC Nursing, Spain

The review, led by Léonie Richardson of the Division of Psychiatry at University College London and the University of Glasgow, together with colleagues including Sarah Ikhtabi, Eiluned Pearce, Alexandra Pitman and Sonia Johnson, set out to map a landscape that has remained surprisingly under-described. Despite decades of clinical observation that people diagnosed with ‘personality disorder’ struggle to form and maintain social connections, the precise structural characteristics of their social networks—their size, diversity, composition, and the frequency of contact within them—had never been systematically synthesised. The team searched four major electronic databases, PsycINFO, Embase, Web of Science and Medline, from their inception to April 2025, capturing quantitative studies that compared people with the diagnosis against other clinical groups and against the general population.

Methodologically, the review followed established standards for evidence synthesis. Each study was appraised using the Joanna Briggs Institute critical appraisal tools, which examine sources of bias in study design, sampling and measurement. The certainty of the body of evidence was then graded using the GRADE approach—Grading of Recommendation, Assessment, Development and Evaluation—which rates confidence in findings from ‘high’ down to ‘very low’ depending on factors such as risk of bias, inconsistency, indirectness and imprecision. That rigour matters here, because the headline certainty rating the authors assigned to their findings was ‘very low’, a caveat that shapes how the results should be interpreted and underscores how much high-quality research remains to be done.

The 29 included studies were dominated by cross-sectional designs, the kind of snapshot research that measures a group at a single point in time, and most were conducted in the United States. This matters for interpretation. Cross-sectional studies can reveal associations but cannot establish whether social isolation precedes the diagnosis, follows from it, or arises from shared underlying causes. The geographic concentration in the US raises further questions about how findings might generalise to countries with different healthcare systems, welfare arrangements and cultural expectations around friendship and family obligation. Nevertheless, the consistency of certain patterns across studies gives the synthesis its weight.

The clearest contrast emerged between people diagnosed with ‘personality disorder’ and the general population. Eleven studies, encompassing 1,348 participants, found that the diagnosed group had reduced social contact and smaller, less diverse social networks than people without mental health conditions. Network diversity is a particularly telling metric in social neuroscience: a healthy network typically includes a mix of family, friends, colleagues and acquaintances, each serving different emotional and practical functions. A network shrunk to a few contacts, or dominated by a single category such as immediate family or professional carers, is more fragile and offers less buffering against stress. The review suggests this kind of structural thinning is a real feature of life for many people carrying the diagnosis.

Yet there was a striking exception buried in the data. Three studies, including 1,349 participants, found that people diagnosed specifically with ‘avoidant personality disorder’ showed no differences from the general population in these network measures. The finding is counterintuitive on its face—avoidance is the defining feature of that diagnosis—but it may reflect how social networks are measured, or the possibility that people with avoidant patterns maintain a small but stable set of connections rather than the broader, more volatile networks seen in other presentations. It is also possible that the pooled samples in those three studies were drawn differently, and the authors themselves note this subgroup finding as an area requiring careful further investigation rather than a settled conclusion.

When the comparison shifted to other clinical groups, the picture changed again. Eight studies, covering 892 participants, indicated that people diagnosed with ‘personality disorder’ show similar degrees of social isolation and comparable network characteristics to people with other mental health conditions. This is arguably the review’s most consequential finding for clinical practice and public discourse. Social isolation is not a signature of ‘personality disorder’ alone; it is a common companion of serious mental ill health more broadly. That framing matters because the ‘personality disorder’ label has historically carried heavy stigma, with social difficulties often attributed to the individual’s character or interpersonal style rather than recognised as a shared consequence of mental illness, poverty, exclusion and the disruptions that conditions impose on education, employment and relationships.

A further thread of evidence came from four studies, with 695 participants and mixed quality ratings, which found that people with the diagnosis reported fewer friendships and fewer supportive relationships than both general population samples and other clinical groups. Supportive relationships—the people one can turn to in crisis, confide in, or rely on for practical help—are among the strongest known predictors of recovery and physical health. Their scarcity in this group suggests that even where the sheer number of social contacts resembles that of other patient populations, the felt quality of those connections may be diminished. The review’s authors argue that future quantitative and qualitative research should focus on identifying the barriers that prevent people with the diagnosis from developing and maintaining meaningful, satisfying relationships, including friendships and intimate partnerships, and on how those barriers can be overcome.

Why does this matter beyond the clinic? Loneliness and social isolation have emerged over the past decade as major public health concerns, with associations to cardiovascular disease, cognitive decline and premature mortality that rival well-known behavioural risk factors. If people diagnosed with ‘personality disorder’ experience structural network deficits—fewer contacts, less diversity, less support—then any treatment plan that addresses symptoms while ignoring the social architecture of the person’s life is treating only half the problem. The review was explicitly motivated by this gap: the authors aimed to synthesise the quantitative literature in order to inform intervention strategies targeting the specific social needs of this group. Social network analysis, once the preserve of sociology, is increasingly seen as a clinical instrument, and this review supplies the baseline measurements that intervention designers have lacked.

The limitations are as instructive as the findings. With GRADE certainty rated ‘very low’, the synthesis is best understood as a well-mapped starting point rather than a definitive verdict. The reliance on cross-sectional data, the dominance of US samples, and the heterogeneity of measures used to define isolation and network size all constrain what can be concluded. The review also excluded qualitative work, meaning the lived experience of isolation—how it feels, how it develops, how people cope—remains outside its scope, though the authors call for qualitative research to complement the numbers. Funded in part through the UK’s Loneliness and Social Isolation in Mental Health Research Network, supported by UK Research and Innovation and the National Institute for Health and Care Research, the study signals a growing institutional commitment to treating social connection as a core outcome in mental health care. What the review establishes beyond reasonable doubt is that the deficit is real, measurable, and shared across diagnostic boundaries—and that understanding why, and how to reverse it, is now one of the most pressing questions in social psychiatry.

Subject of Research: Social isolation and social network characteristics in people diagnosed with personality disorder

Article Title: Objective social isolation and social network characteristics of people who have received a diagnosis of ‘personality disorder’: a systematic review of quantitative studies

Article References: Richardson, L., Ikhtabi, S., Liguori, A., Wang, Y., Pearce, E., Lee, C. Y., Pitman, A., & Johnson, S. (2026). Objective social isolation and social network characteristics of people who have received a diagnosis of ‘personality disorder’: a systematic review of quantitative studies. BMC Psychiatry. https://doi.org/10.1186/s12888-026-08662-1

Image Credits: AI Generated

DOI: 10.1186/s12888-026-08662-1

Keywords: personality disorder, social isolation, social networks, systematic review, loneliness, mental health, psychiatry, friendships, GRADE, BMC Psychiatry, social support, avoidant personality disorder