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Sleep in Young People With Features of Borderline Personality

Disorder: A Scoping Review

Article in Journal of Personality Disorders · February 2022

DOI: 10.1521/pedi_2021_35_525

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 Journal of Personality Disorders, 36(1), 19–39, 2022
© 2022 The Guilford Press

SLEEP IN YOUNG PEOPLE WITH FEATURES

OF BORDERLINE PERSONALITY DISORDER:
A SCOPING REVIEW
Claire A. Jenkins, BSc, Katherine N. Thompson, PhD,
Christian L. Nicholas, PhD, and Andrew M. Chanen, MBBS, PhD

Sleep disturbance is commonly reported in young people with features of

borderline personality disorder (BPD). Examining sleep quality and sleep-
wake patterns in young people with features of BPD is essential to inform
the development of sleep-improvement interventions. A scoping review
was conducted according to the Joanna Briggs Institute methodology. The
objectives were to map the literature regarding sleep in young people with
features of BPD, highlight areas for further investigation, and provide
methodological recommendations for future research. Seven data sets
were included in the review. Young people with features of BPD had
poorer objective and subjective sleep quality, disturbed sleep architecture
(particularly rapid-eye-movement sleep), an increased vulnerability to
delayed sleep phase syndrome, and more nightmares and dream anxiety,
compared with healthy individuals. Future research should use both
objective and subjective sleep measures, include clinical comparison groups,
and focus specifically on young people with BPD.

Keywords: sleep, young people, BPD, scoping review, psychiatry

Borderline personality disorder (BPD) is a mental disorder characterized by

a pervasive pattern of instability in interpersonal relationships, an unstable
sense of self, intense and volatile emotions, and impulsive behaviors (Ameri-
can Psychiatric Association [APA], 2013; Gunderson et al., 2018). BPD typi-
cally has its clinical onset in young people aged 12 to 25 years (APA, 2013;
Chanen et al., 2017), and it is a leading cause of disability, morbidity, and
premature mortality (Chanen, Jovev, McCutcheon, et al., 2008; Winograd
et al., 2008). Sleep disturbances are among the most common complaints
of individuals with BPD (Hafizi, 2013) and are independently associated
with poor physical and mental health, reduced quality of life, and increased

From Melbourne School of Psychological Sciences, The University of Melbourne, Parkville, Victoria,
Australia (C. A. J., C. L. N.); Orygen, Parkville, Victoria, Australia (C. A. J., K. N. T., A. M. C.); Centre
for Youth Mental Health, The University of Melbourne, Parkville, Victoria, Australia (C. A. J., K. N. T.,
A. M. C.); and Institute for Breathing and Sleep, Heidelberg, Victoria, Australia (C. L. N.).
There are no known conflicts of interest to disclose.
Address correspondence to Prof. Andrew Chanen, Orygen, Locked Bag 10, Parkville, Victoria, 3052,
Australia. E-mail: andrew.chanen@orygen.org.au

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 20 JENKINS ET AL.

mortality risk (Adams et al., 2017; Morin & Jarrin, 2013). Despite these
findings, the sleep profile of young people with BPD has received relatively
little research attention.

SLEEP IN ADULTS WITH BPD

Sleep abnormalities have been described in adults with features of BPD, and
evidence suggests a bidirectional relationship between poor sleep and BPD
symptomatology. Features of BPD including impulsivity, emotion dysregu-
lation, and aggressive behaviors are associated with disturbed sleep and
an increased vulnerability to experiencing further sleep difficulties (Selby
& Joiner, 2009; Van Veen et al., 2017). Insomnia and other forms of sleep
disturbance also aggravate suicide and self-harm risk in individuals with
features of BPD, heighten emotional dysregulation, impede BPD recovery,
and further increase the likelihood of an individual developing a co-occurring
mood disorder (Plante et al., 2013a, 2013b; Winsper & Tang, 2014; Winsper
et al., 2017).
Sleep has been measured objectively (wrist actigraphy and polysomnog-
raphy) and subjectively (self-report measures) in adults with features of BPD.
Poor sleep quality has been displayed through longer sleep onset latencies,
shorter sleep duration, more frequent awakenings (reflecting sleep fragmenta-
tion and disturbed sleep continuity), increased wake after sleep onset (time
spent awake following sleep onset and before final awakening), and lower
sleep efficiency (time spent asleep in bed as a proportion of total time in
bed) relative to healthy individuals (for reviews, see Hafizi, 2013; Oltmanns
& Oltmanns, 2015; Winsper et al., 2017). Polysomnography data indicate
that individuals with features of BPD have disturbed sleep architecture (the
distribution of sleep stages and wakefulness across the night) compared with
healthy individuals. Specifically, BPD has been associated with shorter rapid-
eye-movement (REM) latency, increased REM density, longer REM duration,
and less slow-wave sleep (the deepest stage of non-REM sleep). Subjective
measures indicate that individuals with features of BPD consistently report
experiencing more nightmares (Lloyd et al., 1983; Selby et al., 2013) and
poorer sleep quality (Bromundt et al., 2013; Oltmanns & Oltmanns, 2015;
Sansone et al., 2010) than healthy individuals (Winsper et al., 2017).
Some previous studies included clinical comparison groups comprising
individuals with mental disorders other than BPD in order to elucidate the
specificity of any observed sleep disturbances. A comprehensive meta-analysis
of such studies found no significant differences for any objective sleep vari-
ables between clinical comparison and BPD groups (Winsper et al. 2017). This
meta-analysis did reveal that, despite some similarities, the sleep disturbances
observed in individuals with features of BPD cannot be solely attributed to
co-occurring depressive symptoms (Winsper et al., 2017).
The sleep disturbances outlined above reflect commonalities in research
findings. However, recent reviews have emphasized the need for additional
research due to significant heterogeneity in the literature to date. For example,

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 SLEEP IN YOUNG PEOPLE WITH BPD FEATURES 21

some studies observed reductions in slow-wave sleep, while others observed

no significant differences (Hafizi, 2013; Oltmanns & Oltmanns, 2015; Win-
sper et al., 2017). It is likely that the inconsistent findings are, at least in part,
due to small sample sizes and methodological confounders, such as BPD
diagnosis method, sample characteristics (e.g., sex distribution, medication
use, co-occurring mental illnesses), and sleep assessment method (Oltmanns
& Oltmanns, 2015; Winsper et al., 2017). Methodological limitations have
received relatively little attention in previous reviews and have not been
consistently studied or highlighted. Extensive consideration of such factors
is required given the impact that methodological issues have on results and
their interpretation.

IMPORTANCE OF A DEVELOPMENTAL PERSPECTIVE

Existing literature has predominantly focused on adults with BPD, and there
is a specific dearth of research focusing on the sleep profile of young people
with features of BPD (Huýnh et al., 2016). To our knowledge, there are no
existing reviews, systematic or otherwise, and only a small number of primary
research papers in this field. There are three key reasons to study sleep distur-
bances separately in young people with features of BPD.
First, BPD is a developmental disorder (Tackett et al., 2009) that has
its peak incidence and prevalence during adolescence and early adulthood
(Chanen, Jovev, Djaja, et al., 2008). Implementing sleep interventions when
sleep disturbance or features of psychopathology first begin to present pro-
vides an optimal opportunity to prevent morbidity and promote recovery
(Brand & Kirov, 2011; Morin & Benca, 2012). As such, sleep-improvement
interventions are likely to be most beneficial when integrated with current
early interventions for BPD, thus requiring a specific focus on young people.
Second, sleep patterns predictably vary across the life span, with perhaps
the most dramatic changes occurring during adolescence and early adulthood
(Ohayon et al., 2004, 2017). This developmental period is associated with
a reduction in total sleep time, an independent reduction in the proportion
of slow-wave sleep, an increase in sleep-onset latency, and a phase delay in
sleep and rise times (Carskadon & Acebo, 2002; Hysing et al., 2013; Laberge
et al., 2001; Ohayon et al., 2004). These developmental changes, combined
with social factors such as early school start times and evening technology
use, contribute to a general lack of sleep in young people (Carskadon, 1990;
Carskadon et al., 2004; Gradisar et al., 2011; Lund et al., 2010; Matricciani
et al., 2012; Roberts et al., 2009). These normative developmental changes
also mean that research findings regarding sleep in adults with BPD might not
be readily generalized to a youth population. In addition, the commonality
of sleep disturbances and lack of sleep in healthy young people warrants a
specific focus on young people with BPD, given their heightened susceptibility
to experiencing sleep disturbance relative to adults.
Third, understanding and addressing sleep in young people with fea-
tures of BPD is crucial to minimize the negative consequences associated with

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 22 JENKINS ET AL.

poor sleep. Developmental changes to sleep have negative repercussions for

healthy young people, including increased daytime sleepiness and fatigue,
poor academic performance and attendance, physical health issues, increased
risk-taking behaviors, aggression, impulsivity, and mental health issues such as
mood disorders and emotional instability (Carskadon et al., 2004; Feinberg &
Campbell, 2010; Olds et al., 2010). Given that BPD is independently related
to these factors, it is not surprising that experiencing co-occurring BPD and
sleep disturbance is associated with even greater social and functional impair-
ment and poorer self-care than experiencing either one alone (Oltmanns &
Oltmanns, 2015; Selby, 2013; Winsper et al., 2017).
Recognition and management of sleep disturbance is therefore vital for
the health and well-being of young people with features of BPD. Improving
sleep quality might have widespread benefits across domains of symptomatic
and functional recovery, such as reduced suicidal risk, an improved ability to
manage stressful events, reduced fatigue, and increased positive affect (Selby,
2013). Moreover, improved sleep quality and fewer maladaptive sleep cogni-
tions are associated with recovery from BPD (Plante et al., 2013a). Develop-
ing sleep-improvement interventions unique to young people with features of
BPD might provide a valuable adjunct to current treatment protocols, many
of which fail to routinely assess and address sleep disturbances (Selby, 2013;
Simor & Horváth, 2013). Before effective, developmentally appropriate sleep-
improvement interventions can be developed, the characteristic sleep profile
of young people with features of BPD must be understood.

THE PRESENT SCOPING REVIEW

The aim of this scoping review was to identify and synthesize the literature
regarding sleep quality and sleep-wake patterns of young people with features
of BPD. The objectives were to map the current state of research, highlight
important areas for additional investigation, and provide methodological
recommendations for future studies. This review focused on the questions
of what, if any, sleep disturbances have been observed in young people with
features of BPD, and whether these disturbances are nonnormative. Investiga-
tion of sleep disturbance in relation to BPD illness course and comparing sleep
across age groups was beyond the scope of the present study.

METHOD

The small number of studies identified and the wide variability in study design,
methodology, and sample characteristics did not permit examination by quan-
titative or meta-analytic techniques. Thus, a scoping review was deemed the
most appropriate method for the present article. Scoping reviews are particu-
larly useful in mapping the available evidence and identifying evidence gaps
in the existing literature, particularly in areas of emerging research or with
heterogeneous sources (Levac et al., 2010; Peters et al., 2015). This scoping

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 SLEEP IN YOUNG PEOPLE WITH BPD FEATURES 23

review was conducted in accordance with the Joanna Briggs Institute Review-
ers’ Manual (Peters et al., 2015).

INCLUSION CRITERIA
The inclusion criteria for this review are described in this section.

Participants. Articles must have included participants aged 12–25 years. This
period is distinct and developmentally coherent (Chanen et al., 2020) and is
consistent with definitions of the World Health Organization and the Inter-
national Association of Youth Mental Health. All articles about participants
with a mean sample age between 12 and 25 years (inclusive) were selected,
regardless of the age range. This mean-age approach for inclusion has been
used in other youth mental health review reports (Hayes et al., 2018) and is
intended to optimize inclusivity in the current study given the limited number
of articles in this field.

Concept. Articles needed to include at least one measure of sleep (e.g., self-
report questionnaire, clinical interview, actigraphy, polysomnography) and
at least one measure of BPD (e.g., structured clinical interview, self-report
questionnaire). Dimensional measures of BPD features were included given the
clinical significance and psychosocial morbidity associated with subthreshold
BPD (Thompson et al., 2019; Zimmerman et al., 2012).

Context. No restrictions on context (inpatient, outpatient, community), sex,

or geographical location of study were set.

Other Restrictions. Articles in a peer-reviewed journal and gray literature

(e.g., conference abstracts, theses) published in the English language were
included. Gray literature identified using the search strategy was included
given the limited number of articles in this field. No date restrictions were set.

SEARCH STRATEGY AND IDENTIFICATION

OF RELEVANT STUDIES
The literature for this review was collated from a comprehensive search con-
ducted in November 2019 on the PsycINFO, EMBASE, Web of Science and
PubMED databases using the following search terms: (sleep* or insomnia
or wakeful* or waking or drows* or REM or awaken or hypersomnia or
circadian* or actigraph* or EEG* or polysomnograph*) AND (borderline
personality disorder* or BPD) AND (adolescen* or teen* or young adult* or
young person* or youth).
The reference lists of relevant identified articles were also scanned for
additional studies. Identified articles were manually screened for full-text
review following inspection of titles and abstracts. Studies were identified by
the first author (C.J.). Given the limited number of relevant studies and the

G5047_525.indd 23 1/27/2022 10:07:02 AM

 24 JENKINS ET AL.

clarity provided by the inclusion criteria, interrater reliability was not deemed
necessary for this scoping review.

RESULTS

The search yielded 120 unique results. Of these, 99 were excluded for not meet-
ing concept inclusion criteria and a further 13 were excluded for not meeting
the participant inclusion criteria outlined above. The remaining eight articles
were selected for inclusion in the current scoping review (see Figure 1). Note
that two of these articles used the same data set (Battaglia et al., 1993, 1999),
resulting in the inclusion of seven unique data sets. Details of the included
articles are presented in Table 1. The data sets varied widely in sleep assess-
ment method, with one using polysomnography, one using actigraphy, two
using subjective reports, one using clinical interview, one using both clinical
interview and subjective reports, and one using both polysomnography and
subjective reports. Of the two data sets that used a combination of subjec-
tive and objective measures, neither study conducted a comparison between
measures.

FIGURE 1. Preferred Reporting Items for Systematic and Meta-Analyses (PRISMA;

Moher et al., 2010) flow diagram.

G5047_525.indd 24 1/27/2022 10:07:02 AM

G5047_525.indd 25
Author (year) Country Female
Battaglia et al. (1993) Italy
(Study 1)
Battaglia et al. (1999)
(Study 2 – used same
data set as Study 1)
Claridge et al. (1998) Canada
1/27/2022 10:07:02 AM
TABLE 1. Summary of Studies Investigating Sleep in Young People With Features of BPD
Co-occurring
BPD Assessment
Sample Size % Mental Illnesses and Key Findings
Tool
Age (SD) in years Sample Source Sleep Measure(s) Medication Use
BPD: 10 (60% F) BPD: 25.4 (4.5) Psychiatric inpatient Polysomnography Excluded: lifetime history Clinical interview: Study 1: Sleep quality: Individuals
HC: 10 (60% F) HC: 24.9 (3.5) (first admission to continuously of schizophrenia, Structured Interview with features of BPD had increased
that hospital) monitored for depression, mania, for DSM-III-R sleep onset latency (Mann-Whitney
Range: 19-34 years
48 hrs (2 days, 2 cyclothymia or Personality (SIDP-R) = 2.3, p ≤ .02), greater wake after
nights) dysthymia, or drug/ sleep onset (Mann-Whitney = 3.1,
Self-Report:
alcohol abuse in the past Personality p ≤ .02), more awakenings (Mann-
6 months. Diagnostic Whitney = 2.1, p ≤ .04), and lower
Lifetime diagnoses: Questionnaire sleep efficiency (t(18) = 4.49,
drug abuse (50%), (PDQ-R) p ≤ .0001). Sleep architecture:
somatization disorder Individuals with features of BPD
(20%), alcohol abuse had more stage N1 sleep
(20%), brief reactive (t(18) = 2.79, p ≤ .01), and shorter
psychosis (20%), and REM latency (t(18) = 3.37,
panic disorder (10%). p ≤ .003).
Co-occurring personality Study 2: Individuals with features
disorders (PD): Histrionic of BPD displayed increased REM
PD (50%), Dependent density in the first REM episode of
PD (30%), Narcissistic the sleep period relative to controls
PD (20%), Paranoid PD (t = 2.83, p = .01 first night;
(10%). t = 3.36, p = .003 second night).
2-week “pharmacological
washout” while living
in clinic
Study 1: 60 Study 1: 20.4 Studies 1 and 2: Nightmare Distress Not stated Self-Report: Study 1: Positive correlation between
Study 2: 66 Study 2: 21.5 students in Oxford (ND) Scale; Dream Borderline features of BPD and nightmare
Study 3: community and Nightmare Personality Scale distress (r = .42, p < .001). BPD
Study 3: 203 Study 3: 21.2
sample Enquiry (DANTE) (STB) features were a strong predictor
100% F (across all Range: 18-30 years of nightmare distress, even after
studies) (across all studies) controlling for neglect and sexual
abuse (p = .03).
Study 2: Positive correlation between
BPD features and adult (r = .31,
p < .01), but not childhood,
nightmare content.
Study 3: Positive correlation between
nightmare distress and BPD features
(r = .49, p < .001).
(continued)

G5047_525.indd 26
Dagan et al. (1998) Israel
Grove et al. (2017) USA
Huỳnh et al. (2016) Canada
1/27/2022 10:07:02 AM
TABLE 1. (Continued)
63 (11 with BPD) 17.36 (1.99) Psychiatric Sleep–wake habits Of the 5 patients with Diagnosed on Adolescents diagnosed with
48% F Range: 13-23 years inpatients structured interview comorbid BPD and admission to the personality disorders had a
(interviews DSPS, 4 had no hospital by senior significantly higher probability of
conducted 4-6 comorbidities. psychiatrists also experiencing delayed sleep
weeks after Current medications according to DSM-IV phase syndrome (DSPS) (p < .05).
admission) (n): Zuclopenthixol criteria Adolescents with DSPS were
decanoatea (1), more likely to have only an Axis
Chlorpromazinea (1), II diagnosis, and were more likely
Promethazine (1) to be diagnosed with a mental
disorder characterized by affective
lability, including BPD (p < .001).
Half (50%) of adolescent patients
with DSPS had BPD odds ratio =
7.67; 95% CI [1.70, 34.48]). *This
information was provided through
personal communication with Prof.
Dagan, February 22, 2019.
Sample 1: 293 23 (not stated) Students Pittsburgh Sleep Not stated Self-Report: The Significant correlations (r = .14-.45)
(65% F) (undergraduate, Quality Index Borderline Symptom between total BPD features and
Sample 2: 188 University of (PSQI) List (short form; all 12 facets of BPD with global
(63% F) Utah ) BSL-23) subjective sleep quality. Although
associations between sleep quality
variables were consistent across
all BPD features, the strongest
correlation was with symptoms
relating to emotional dysregulation.
BPD: 18 (83% F) BPD: 16.0 (1.1) Psychiatric Actigraphy (9 Excluded: current co- Clinical interview: BPD vs. HC: No differences on
Bipolar: 6 (67% F) Bipolar: 16.7 (1.0) outpatients, days, including 2 occurring depression, BPD diagnosis schedule-present days. On
Riviére-des- weekends); sleep sleep disorders, current confirmed by schedule-free days, adolescents
HC: 20 (65% F) HC: 14.7 (1.0)
Prairies Hospital diary psychotic features or treating psychiatrist with features of BPD spent more
Range: 12-17 years current diagnosis of and assessed using time in bed (p = .026, d = 0.86),
bipolar disorder (in BPD Diagnostic Interview spent more time asleep (p = .030,
group). for Borderlines d = 0.64) and woke up later (1 hr
Co-occurring disorders, n Revised (DIB-R); on average; p = .0004, d = 0.93)
last 12 months (n lifetime): Abbreviated compared to healthy control
major depressive disorder: Diagnostic Interview adolescents. Adolescents with
6 (12), dysthymic disorder: for Borderlines features of BPD woke up over 1 hr
2 (2), separation anxiety (Ab-DIB) to rule out later compared to healthy controls
disorder: 0 (3), panic BPD in HCs across schedule-present and
disorder: 3 (5), specific schedule-absent days (p = .005,
phobia: 2 (2), social d = 0.93). Total sleep time and rise
phobia: 2 (2), generalized time were more variable between
anxiety disorder: 2 (2), nights in adolescents with BPD
posttraumatic stress features (p = .007, d = 3.79).
disorder: 1 (1), obsessive- BPD vs. bipolar: On schedule-
compulsive disorder: 2 (2), present days, adolescents with
attention-deficit/ features of BPD spent more time
awake in bed than adolescents with
bipolar features ( p = .01, d = 1.44).
G5047_525.indd 27
Saleh et al. (2018) Egypt
NOTE: conference
abstract only
1/27/2022 10:07:02 AM
hyperactivity disorder 0
(1), oppositional defiant
disorder-conduct disorder
8 (12), alcohol/substance
use related disorders 1 (4).
Current medications (n):
antidepressants
(Fluoxetine: 2,
Mirtazapine: 2,
Venlafaxine: 1),
Norepinephrine reuptake
inhibitors (Atomexetine: 1)
Atypical antipsychotics
(Olanzapine: 1,
Quetiapine: 4,
Risperidone: 1)
Psychostimulants
(Dextroamphetamine: 1,
Methylphenidate: 2),
Others (Propranolol: 1)
BPD: 30 (100% F) Not reported University Pittsburgh Not reported Clinical interview: Subjective: Adolescents with features
HC: 30 (100% F) psychiatric Sleep Quality Structured Clinical of BPD subjectively reported poorer
hospital patients Index (PSQI); Interview according sleep quality than healthy controls
(unclear if Polysomnography to DSM‐IV (SCID‐I (p < .001).
inpatient or (one night) & II); Self-Report: Objective: Adolescents with BPD
outpatient) Borderline features displayed altered REM
Personality sleep, including higher REM
Questionnaire percentage (p < .001), shorter REM
(BPQ) latency (p < .001), higher REM
density (p < .001), and higher
number of REM periods in the first
half of the night (p = .000). REM
sleep changes were not associated
with BPD severity (as measured
by BPQ).
(continued)
G5047_525.indd 28
Semiz et al. (2008) Turkey
Note. HC = healthy controls; BPD = borderline personality disorder; NS = nonsignificant.
TABLE 1. (Continued)
BPD: 88 (46% F) BPD: 21.7 (3.6) Psychiatric inpatient Clinician-rated Excluded: current co- Clinical interview: Sleep quality: patients with BPD
HC: 100 (43% F) HC: 22.3 (3.9) questionnaire to occurring Axis II disorder, Structured Clinical features reported poorer sleep
assess Nightmare and psychotic disorder, Interview for DSM- quality than healthy controls.
Range 18-34 Disorder (DSM-IV mood disorder, or PTSD III-R Personality Reported longer sleep latency,
years criteria). Pittsburgh during the past 12 Disorders shorter sleep duration, lower
Sleep Quality Index months. habitual sleep efficiency, more sleep
(PSQI) Van Dream Free of substances and disturbances, higher use of sleeping
Anxiety Scale psychotropic medications medication, and a higher daytime
(VDAS) for at least 4 weeks dysfunction (all ps < .001). Most
(95.5%) of those with BPD features
reported to be “poor sleepers”
(PSQI > 5) compared to 12% of
controls.
Nightmare disorder and dream
anxiety: Individuals with features of
BPD reported higher levels of dream
anxiety (p < .001) and experienced
more nightmares ( p < .001) than
controls. Individuals with nightmare
disorder also displayed greater BPD
psychopathology.

1/27/2022 10:07:02 AM
 SLEEP IN YOUNG PEOPLE WITH BPD FEATURES 29

SAMPLE CHARACTERISTICS
Data were collected in a range of populations and age groups. One data set
included an undergraduate student sample, one included both a student and
a community sample, three included an inpatient sample, and one included
an outpatient sample (note: a conference abstract included by Saleh et al.,
2018, is unclear as to whether the hospital sample consisted of inpatients
or outpatients). One data set included adolescents and young adults (13–23
years), two included adolescents (12–17 years and unspecified age range),
and four included adults with features of BPD (18–30 years, 18–34 years,
19–34 years, and unspecified age range [“undergraduates”]) but were deemed
appropriate for the current review because the average age fell within inclu-
sion criteria (12–25 years). All authors of articles with unspecified age ranges
or ranges that exceeded 25 years were contacted to determine the age range
and proportion of participants aged between 12 and 25 years; however, no
further details were provided by any authors.
Three data sets did not include BPD-specific samples (Claridge et al.,
1998; Dagan et al., 1998; Grove et al., 2017). Instead, samples consisted
of undergraduate students, young adults in the community, and adolescent
inpatients more generally. Data specific to adolescents with features of BPD
were obtained upon request from the authors of the adolescent inpatient study
(Dagan et al., 1998). Data sets that utilized community and student samples
were of adequate size (n = 60–293); however, most studies with BPD-specific
samples had relatively small sample sizes, as shown in Table 1.
Inconsistencies were identified in how studies considered medications,
co-occurring mental illnesses, and criteria for healthy comparison groups.
Three data sets partially adjusted for co-occurring mental illnesses by excluding
individuals with current or lifetime histories of other mental disorders
(Battaglia et al., 1993, 1999; Huýnh et al., 2016; Semiz et al., 2008;; see
Table 1 for more details). Two data sets adjusted for medication use through
a pharmacological washout period (Battaglia et al., 1993, 1999; Semiz et al.,
2008). Two other data sets clearly stated the medication use of participants
(Dagan et al., 1998; Huýnh et al., 2016), and the remaining three data sets
did not report on medications (Claridge et al., 1998; Grove et al., 2017; Saleh
et al., 2018). Of data sets that included a healthy comparison group, two did
not describe the criteria for inclusion or exclusion in this group, aside from
stating that individuals were matched for age and sex (Saleh et al., 2018; Semiz
et al., 2008). As such, it remains unclear whether individuals included in these
healthy comparison groups were screened for BPD, other mental illnesses, or
sleep disturbances. Two other data sets, however, did provide clear descriptions
of exclusion criteria and the specific measures used to assess each criterion
(Battaglia et al., 1993, 1999; Huýnh et al., 2016).

SUBJECTIVE SLEEP QUALITY IN YOUNG PEOPLE

WITH FEATURES OF BPD
Young people with features of BPD (adolescents, undergraduate students, and
inpatients aged 18–34 years) reported significantly poorer sleep quality (as

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 30 JENKINS ET AL.

measured by the Pittsburgh Sleep Quality Index; PSQI) than healthy individuals
(Grove et al., 2017; Saleh et al., 2018; Semiz et al., 2008). This included reports
of longer sleep-onset latency, shorter sleep duration, lower sleep efficiency, higher
sleep disturbance, greater use of sleep medication, and greater daytime dysfunc-
tion. Of those with features of BPD, 95.5% were subjectively “poor sleepers”
(PSQI score >5), compared with only 12% of healthy individuals (Semiz et al.,
2008). Poor subjective sleep quality was associated with total BPD symptoms, as
well as with all 12 facets of BPD (r = .14–.45), and was most strongly associated
with facets relating to emotional dysregulation (Grove et al., 2017).

NIGHTMARES
Positive correlations (r = .42–.49, p < .001) were observed between scores
on a self-report BPD measure (the borderline personality scale [STB] of the
Schizotypal Traits Questionnaire; Claridge & Broks, 1984) and nightmare
distress in both undergraduate and community samples of individuals aged
18–34 years (Claridge et al., 1998). STB scores also strongly predicted night-
mare distress and remained a strong predictor after adjusting for sexual abuse
or neglect. Similarly, 18- to 34-year-old inpatients with BPD features reported
experiencing significantly more nightmares and dream anxiety than healthy
individuals (Semiz et al., 2008). Specifically, individuals with features of BPD
reported experiencing difficulty returning to sleep after waking up from a
nightmare, and a fear of falling asleep due to anticipating a nightmare. Indi-
viduals with co-occurring BPD features and nightmare disorder (characterized
by repeated dysphoric and well-remembered dreams involving efforts to avoid
threats to survival, security, or physical integrity; APA, 2013) displayed greater
psychopathology across a number of clinical characteristics compared to indi-
viduals with BPD features without nightmare disorder (Semiz et al., 2008).

DELAYED SLEEP PHASE SYNDROME

Delayed sleep phase syndrome is a circadian rhythm sleep-wake disorder
characterized by delayed sleep onset and wake times and an inability to fall
asleep or wake up at a desired or conventionally acceptable earlier time (APA,
2013). Psychiatric inpatients aged 13–23 years with features of BPD were
more susceptible to experiencing delayed sleep phase syndrome compared with
same-age inpatients with other mental disorders, such that 50% of those with
delayed sleep phase syndrome also had BPD features. (Dagan et al., 1998).

OBJECTIVE SLEEP QUALITY AND ARCHITECTURE

Actigraphy. One study used actigraphy to assess sleep-wake patterns and
sleep quality in adolescents aged 12–17 years with features of BPD (Huýnh
et al., 2016). As is typical of actigraphy studies in this age group, data were
separated into schedule-present (school/work) and schedule-absent (weekend/
free) days. On schedule-present days, no significant differences were observed
between BPD and healthy groups for any sleep variables. On schedule-absent
days, however, adolescents with BPD features displayed significantly later rise

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 SLEEP IN YOUNG PEOPLE WITH BPD FEATURES 31

times, longer time in bed, and increased sleep duration (by 1 hour on average)
compared to healthy individuals, despite no group differences in bedtime. In
addition, adolescents with features of BPD displayed greater interdaily vari-
ability in sleep duration and rise time across the week. Combined data from
schedule-present and schedule-absent days indicated that adolescents with
features of BPD displayed significantly later rise times (by 1 hour on average)
than healthy individuals. No significant differences were found between adoles-
cents with BPD and healthy groups for sleep-onset latency, sleep efficiency, or
final awakening (defined as the “interval between the end of the sleep interval
and the end of the rest interval”) for schedule-present days, schedule-absent
days, or combined data. Notably, this was the only study in the present review
to include a clinical comparison group, comprising adolescents with bipolar
disorder. Across all sleep variables, the only significant difference between BPD
and bipolar groups was that those with BPD features spent more time awake
in bed on schedule-present days, which is one indicator of poorer sleep quality.

Polysomnography. Battaglia and colleagues (1993, 1999) used polysomnography

to assess sleep quality and sleep architecture in individuals aged 19–34. Indi-
viduals with features of BPD had poorer sleep quality than healthy individuals,
displaying longer sleep onset latencies, increased wake after sleep onset, more
awakenings, lower sleep efficiencies, and higher percentages of stage N1 sleep
(the lightest stage of NREM sleep). Perhaps the most notable finding was that
of disturbed REM sleep architecture. This included shorter REM latency and
increased REM density during the first REM episode in the BPD group, with no
group differences in overall REM density across the night or in the number of
REM episodes. Because participants in this study had no history of depression,
the authors argued that these REM sleep abnormalities might indicate liability
to a depressive disorder prior to the onset of depressive symptoms. A recently
published conference abstract (Saleh et al., 2018) also highlighted interesting
REM sleep architecture differences in adolescent females, including greater REM
percentage, shorter REM latency, higher REM density, and more REM periods in
the first half of the night. Interestingly, these REM abnormalities did not appear
to be associated with BPD severity (Saleh et al., 2018). Taken together, these
REM disturbances are consistent with research on adults with BPD and might
be a crucial early intervention target because there is an association between
high REM density and later suicide attempts both in individuals with BPD and
in those with depression (Battaglia et al., 1999).

DISCUSSION

This scoping review demonstrated that young people with features of BPD
experience substantial subjective and objective sleep disturbances. Young
people with features of BPD were found to consistently report poorer sleep
quality, more nightmares, and higher levels of nightmare distress and dream
anxiety compared to same-age healthy individuals. Reports of poorer sleep
quality included subjectively longer sleep-onset latencies, lower sleep efficien-
cies, greater sleep disturbance, greater use of sleep medication, and higher levels

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 32 JENKINS ET AL.

of daytime dysfunction. In addition, young people with features of BPD were

found to be more susceptible to delayed sleep phase syndrome compared with
other young psychiatric inpatients. Actigraphy data indicated that, relative to
healthy individuals, young people with BPD features had significantly later
rise times (by 1 hour on average) across the week, spent more time in bed,
had longer total sleep times (by 1 hour on average) on schedule-absent days,
and displayed greater variability in total sleep time and rise time.
Consistent with the subjective findings, polysomnography data indicated
that young people with BPD features experienced poorer sleep quality than
healthy individuals, which was displayed through longer sleep-onset latencies,
increased wake after sleep onset, more awakenings, and lower sleep efficiencies.
Observed sleep architecture changes included a higher percentage of stage N1
sleep and, most notably, REM sleep disturbances. Specifically, BPD features
were associated with a higher percentage of REM across the night, shorter
REM latency, higher REM density (particularly in the first REM episode), and
a greater number of REM periods in the first half of the night.
Overall, the findings of this review suggest that young people with fea-
tures of BPD have sleep-wake patterns, sleep architecture, and sleep quality
that differ from same-age healthy individuals. Given that only one study
included a clinical comparison group, no clear inferences can be made about
the specificity of these sleep disturbances to BPD. The findings were largely
consistent with previous reviews and meta-analyses of adults with features of
BPD, observing poorer subjective and objective sleep quality, more nightmares,
increased stage N1 sleep, reduced REM latency and increased REM density
compared with healthy adults (Oltmanns & Oltmanns, 2015; Winsper et al.,
2017). While the findings are similar to those identified in previous reviews,
the current study extended existing research by focusing specifically on young
people with features of BPD. This scoping review was essential to highlight
the particular dearth of research with young people and to draw attention to
the importance of conducting further research with this population.
Understanding and addressing sleep in this population is vital due to
the extensive negative repercussions of experiencing such sleep disturbances.
Delayed sleep phase syndrome and poor sleep quality are both associated with
adverse outcomes for young people, including poor academic performance
(Pagel et al., 2007; Saxvig et al., 2012; Sivertsen, Glozier, et al., 2015), greater
attentional difficulties, and school absences (Gradisar et al., 2011). Sleep dis-
turbance and delayed sleep phase syndrome have also been associated with
poorer psychological functioning, including lower resilience and higher levels
of depression, anxiety, anger, emotional instability, and drug and alcohol use
(Crowley et al., 2007; Roberts et al., 2002; Sivertsen, Harvey, et al., 2015).
Nightmares, increased REM density in the first REM episode, increased REM
sleep across the night, and sleep disturbance in general have all been associated
with increased suicidality and future suicide attempts (Battaglia et al., 1999;
Sabo et al., 1991; Singareddy & Balon, 2001; Sjöström et al., 2007). Given
that BPD is independently associated with functional impairment, co-occurring
mental illnesses, and high rates of suicide (Chanen et al., 2007, 2017; Gunder-
son, 2011; Kaess et al., 2013; Pompili et al., 2005; Speranza et al., 2011), it is
possible that sleep disturbance plays a role in the development, maintenance,

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 SLEEP IN YOUNG PEOPLE WITH BPD FEATURES 33

or exacerbation of such factors in this already high-risk population. While

replication of existing findings is needed, the evidence presented in this review
suggests that tailored sleep-improvement interventions might be beneficial for
young people with features of BPD to promote overall functioning and well-
being in addition to improving sleep quality.

LIMITATIONS OF CURRENT RESEARCH

AND FUTURE DIRECTIONS
The paucity of research in this area clearly warrants additional attention. This
review has identified a number of limitations of the existing literature and
established methodological recommendations for future research.

Sample Characteristics. Medication use and co-occurring mental illnesses are

normative and ubiquitous among young people with BPD (Chanen et al., 2007;
Oltmanns & Oltmanns, 2015; Winsper et al., 2017). While some studies in
this review included a pharmacological washout period (Battaglia et al., 1993,
1999; Semiz et al., 2008) or provided detailed medication information (Dagan
et al., 1998; Huýnh et al., 2016), others failed to report on medication use
(Claridge et al., 1998; Grove et al., 2017; Saleh et al., 2018). Pharmacologi-
cal washouts are effective in eliminating the impact of medication on sleep.
However, they are not always feasible, are often unethical, and can result in
atypical, unrepresentative samples of young people with features of BPD.
Future studies should aim to provide detailed information regarding medica-
tion use of all participants to allow informed interpretation of the results.
Similarly, some studies in this review provided clear exclusion criteria and
information regarding co-occurring mental illnesses (Battaglia et al. 1993,
1999; Huýnh et al. 2016; Semiz et al. 2008), whereas other studies remained
unclear as to whether individuals in healthy and/or BPD groups were screened
for BPD, other mental illnesses, or sleep disorders (Grove et al., 2017; Saleh
et al., 2018; Semiz et al., 2008). Screening across all groups is crucial given
the considerable population prevalence rates for personality disorder of up to
9.6%, with sleep disturbances being even more common (Petrov et al., 2014;
Winsper et al., 2020). Medication use and co-occurring mental illnesses both
have the potential to bias results and interpretation, and providing clear details
of these factors increases clarity and accuracy when interpreting, comparing,
and synthesizing findings across studies.
To better conceptualize the sleep profile of young people with BPD,
research must focus specifically on this population. Of the seven data sets
included in this review, four had an average sample age that fell within review
criteria (mean age 12–25 years) but did not exclusively focus on young peo-
ple. Although the sleep patterns observed in the current review were largely
consistent with sleep patterns observed in adults with BPD (Oltmanns &
Oltmanns, 2015; Winsper et al., 2017), the paucity of literature and lack of
focus on young people in a number of studies preclude conclusions regarding
differences in sleep profiles across age groups. Developmental differences in
sleep quality and architecture across the life span (Ohayon et al., 2004, 2017)
highlight the need for future studies to focus specifically on young people

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 34 JENKINS ET AL.

to ensure that data accurately reflect the sleep profile of this developmental
group and to determine whether sleep patterns differ across young people
and adults with features of BPD. A number of studies in the present review
assessed BPD features in community or student populations, rather than focus-
ing specifically on individuals diagnosed with BPD. This again reduces the
applicability of findings to BPD-specific populations and prevents exploration
of the relationship between specific features of BPD, BPD severity, and sleep
disturbance. Future research should aim to utilize BPD-specific samples and
validated, structured clinical interviews to determine diagnosis and severity.
Larger sample sizes are also warranted in future research to increase general-
izability and statistical power, given that some nonsignificant findings in the
current review were attributed to small sample sizes (Huýnh et al., 2016).
Directing research efforts to focus on large, youth- and BPD-specific samples
will inform developmentally tailored, specialized sleep-improvement interven-
tions unique to the needs of this population.

Sleep Assessment Method. There was wide variation in methodology across

studies considered in the current review. Each sleep assessment method was
utilized in only one or two studies and the focus of each study varied substan-
tially (e.g., nightmares, sleep quality, delayed sleep phase syndrome), limiting
the ability to assess agreement or inconsistencies across studies. Furthermore,
no studies used a combination of sleep assessment methods. This is a key rec-
ommendation for future research for three reasons. First, it allows the unique
benefits of each sleep assessment method to be fully realized. Subjective reports
provide valuable insights into an individual’s experience of sleep and level of
sleep-related distress (Carney et al., 2012), while polysomnography provides
detailed information regarding sleep architecture and qualitative electroen-
cephalogram disturbances, and actigraphy is beneficial in collecting naturalistic
data over extended time periods and encourages exploration of intra-individual
sleep variability (Ancoli-Israel et al., 2003; Johnson et al., 2007). Investigating
intra-individual sleep variability affords particular insights about young people
because atypical sleep-wake patterns, such as weekend-weekday discrepancies,
are extremely common in this developmental group (Bei et al., 2016; Carskadon
& Acebo, 2002). Second, using a combination of sleep assessment methods
provides valuable insights for intervention development, given that subjective
and objective sleep disturbances require different interventions (Vgontzas et al.
2013). Third, it allows comparisons to be made across subjective and objec-
tive measures. Such comparisons are particularly warranted in this population
because subjective-objective discrepancies have been observed in adults with
BPD (Bastien et al., 2008; Hafizi, 2013; Philipsen et al., 2005; Stanley & Wilson,
2006). Future studies should use a combination of sleep assessment methods to
obtain a more holistic understanding of the sleep profile of young people with
features of BPD and to adequately guide intervention development.

THE VALUE OF A CLINICAL COMPARISON GROUP

The current review demonstrates a lack of comparative literature about young
people with features of BPD compared to young people with other mental

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 SLEEP IN YOUNG PEOPLE WITH BPD FEATURES 35

illnesses. Only one study in the present review included a clinical comparison
group, comprising adolescents with bipolar disorder (Huýnh et al., 2016).
While it is important to determine whether sleep in young people with BPD is
nonnormative, it is equally vital to explore the specificity of any observed sleep
disturbances to BPD, which can only be achieved through the inclusion of a
clinical comparison group. Sleep disturbances are ubiquitous among individu-
als with mental illnesses (Benca et al., 1992; Harvey, 2009), and research in
adults demonstrates similarities between the sleep profiles of those with BPD
and those with depression (Hafizi, 2013; Winsper et al., 2017). The dearth of
literature comparing sleep in young people with features of BPD with other
clinical groups means that it remains unclear which, if any, sleep disturbances
are uniquely associated with BPD features and which are associated with psy-
chopathology per se or help-seeking more generally. Determining the specificity
of sleep disturbances in young people with features of BPD is a key area for
future research and will provide valuable insights to inform sleep-improvement
interventions that meet the specific needs of this population.

CONCLUSION
There is some evidence that young people with features of BPD have poor
objective and subjective sleep quality, disturbed sleep architecture, increased
vulnerability to delayed sleep phase syndrome, and more nightmares and
dream anxiety compared to healthy individuals. Additional research is
required to elucidate these findings, explore the specificity of the observed
sleep disturbances, and compare different sleep assessment methods. Rec-
ommendations for future studies are to utilize a combination of objective
and subjective methods, include clinical comparison groups, provide clear
details of sample characteristics (medications, other mental illnesses, inclu-
sion/exclusion criteria) for all groups, and focus specifically on young people
with BPD. Further investigation in this field will help to clarify the charac-
teristic sleep profile of young people with features of BPD, which, in turn,
will guide the development of uniquely tailored sleep-improvement inter-
ventions. Such interventions might be particularly valuable for young peo-
ple because the flexibility and malleability of BPD traits in this population
makes this group a key target for early intervention and provides an optimal
opportunity for symptomatic recovery, functional recovery, and an improved
life course trajectory (Chanen & McCutcheon, 2013; Kaess et al., 2014).

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