key: cord-0777851-t7nn7ivs
authors: Vilaregut, Anna; Roca, Mariona; Ferrer, Marc; Pretel-Luque, Teresa; Calvo, Natàlia
title: Exploring the psychological impact of COVID-19 on adolescents with borderline personality disorder and their mothers: A focus group study
date: 2022-01-03
journal: Clin Child Psychol Psychiatry
DOI: 10.1177/13591045211058318
sha: ecd32076f8d337edde1044cab94c2656b0a2c613
doc_id: 777851
cord_uid: t7nn7ivs

The aim of this study was to explore the impact of the coronavirus pandemic on adolescents diagnosed with Borderline Personality Disorder (BPD) and their mothers. This exploratory study used a qualitative focus group approach. This study’s sample group consisted in nine participants: five adolescents diagnosed with BPD and their four mothers. Patients were recruited from a specialized BPD outpatient unit of a university hospital psychiatry department. The results are divided into two main areas, the first regarding the lockdown period and the second examining the period of gradual relaxation of lockdown restrictions. The results show that the adolescents had difficulties in the management of their interpersonal relationships, especially in striking a balance between individual and family space, as well as in communication, cohesion, and family dynamics. During the COVID lockdown, adolescents experienced a stabilization of psychopathological symptoms, but these symptoms worsened when the lockdown restrictions were lifted. Nevertheless, they reported having learned and implemented self-care strategies. The findings are discussed in terms of both individual and family impact, shedding light on some of the challenges precipitated by the COVID-19 pandemic.

In the context of the COVID-19 outbreak, the Spanish government declared a state of emergency and required citizens to remain physically isolated in their homes and to engage in social distancing. The unprecedented situation of state-regulated lockdown was defined in the country as home confinement. After 2 months, the remission of the first coronavirus wave caused the Spanish government to implement its plans to ease restrictions in a rapid series of phases.

In addition to the consequences of COVID-19 for the economy, society, and physical health, the pandemic also has dramatic mental health implications. A number of studies have also looked at the current pandemic, focusing on the psychological impact of lockdown on the general population. One systematic review and meta-analysis suggested that COVID-19 will have far-reaching psychological implications. The mental health effects of the pandemic found among the general Spanish population have not differed from those observed in international studies. During lockdown, people were likely to experience high levels of anxiety, display depressive symptoms, feel psychological distress, and report symptoms related to Post Traumatic Stress Disorder (PTSD) (González-Sanguino et al., 2020; Günther-Bel et al., 2020; Luo et al., 2020; Ozamiz-Etxebarria et al., 2020; Rodríguez-Rey et al., 2020) .

In addition to the severe and evident impact of COVID-19, it is necessary to highlight the alarming implications it has had in people with previous psychopathologies and the resulting burden that this has placed on the mental health system (Inchausti et al., 2020) . Undoubtedly, the pandemic has required the adaptation of psychotherapeutic interventions and care service delivery (Frías et al., 2020; Zhang et al., 2020) .

In particular, individuals suffering from Borderline Personality Disorder (BPD) are a highly vulnerable group due their comorbid pattern of internalizing and externalizing behaviors. They tend to have difficulties with emotional regulation, impulsivity, and self-destructive behaviors (American Psychiatric Association, 2013) . Indeed, BPD is currently most often conceptualized as a developmental disorder with onset in adolescence, a particularly vulnerable period given the dramatic changes in socio-emotional development. Hence, adolescents suffering from BPD may present a deterioration in clinical symptoms and increased suffering in the context of the pandemic and the accompanying uncertainty (Ventura Wurman et al., 2020; Yao et al., 2020) . Multiple factors have emerged during this situation both to increase the level of anxiety of people with this disorder and to impose possible constraints on their ability to seek or continue treatment. These anxieties interact with the typical symptomatology of BPD, generating the sort of emotional instability that can contribute to a clinical crisis and deterioration of symptoms (Choi, 2020) .

In addition to the increasing levels of stress, the subjective loss of agency and control in the face of these circumstances experienced by people with BPD might generate greater difficulty in affective and emotional regulation, possibly triggering impulsive, and risky behavior (Pakpour & Griffiths, 2020; Shapiro et al., 2020; Ventura Wurman et al., 2020) . Furthermore, social distancing has created obstacles to interpersonal relationships and contributed to the feeling of social isolation (Frías et al., 2020) . This social atomization can also contribute to feelings of fear of abandonment and chronic emptiness (Choi, 2020; Ventura Wurman et al., 2020) . As a result of social distancing, group therapy could not be provided during lockdown. This had consequences for the therapeutic alliance and a negative impact on patients who had to abruptly stop attending sessions. This impact may have exacerbated self-harming behavior and escalated the use of emergency services by patients who lacked the necessary resources to continue with therapy online (Lakeman & Crighton, 2020) . Additionally, BPD patients' hypersensitivity to the stress triggered by the pandemic might have intensified their paranoid ideas, which in turn affected their social relations (Ventura Wurman et al., 2020) .

Nonetheless, it should be noted that some patients with BPD remained clinically unchanged throughout the pandemic (Frías et al., 2020) or reported a reduction in symptoms, specifically a decrease in feelings of shame or guilt, fear, and tension (Salamin et al., 2020) . The dissipation of the above-mentioned feelings may in turn have led to a decrease in binge eating behaviors and alcohol or drug abuse during lockdown. This improvement can be attributed to the decline in social and professional activities, accompanied by decreased exposure to interpersonal interactions. In other words, certain patients may have appeared more stable merely as the result of decreased social contact (Salamin et al., 2020; Ventura Wurman et al., 2020) . Hence, interpersonal relationships, especially family relations, are worthy of attention, as some studies suggest that family members of people with severe mental illness tend to experience high levels of burden Woody et al., 2019) . Research has also found that the families of individuals with severe mental illness tend to have dysfunctional family environments and problematic family interactions .Additionally, it has been argued that these families perceive their family environment and their family relationships more negatively (Gunderson & Lyoo, 1997) . Therefore, it is critical to collaborate with the family and to improve the parental relationship and in consequence adolescent's mental health symptoms (Brown, 2018) . For the patients, family relationships played a pivotal role during the pandemic, given that there was no guarantee of access to continued professional treatment. Studies have found evidence that supportive and reliable psychological attention to relatives can lead to a reduction in stress and vulnerability for patients, helping them to curb feeling of distrust and fear of abandonment, and to maintain their capacity for mentalization thanks to social contact (Choi, 2020; Ventura Wurman et al., 2020) .

Until now, most of the psychological literature on COVID-19 has largely focused on the pandemic's impact on individuals. However, some authors have also considered couple and family relationships. For instance, one study (Ayuso et al., 2020) observed the difficulties faced by families with children in balancing their work and family lives. Meanwhile, other researchers (Marchetti et al., 2020) showed that the unusually intense demands placed upon parents had sometimes produced parenting-related exhaustion. Anxiety and depression symptoms among parents were found to be associated with higher perceived stress (Brown et al., 2020) and with poorer marital, parental and co-parental functioning (Günther-Bel et al., 2020) . Parents of children with behavioral difficulties reported lower levels of satisfaction with their home environment (Fitzpatrick et al., 2021) .

As far as we are aware, this is the first study to explore the experiences of adolescents with BPD during the COVID-19 pandemic, and the impact on their families. This lack of research on this topic highlights the pertinence of further studies to increase the understanding of the internal and relational processes of BPD patients in the context of this extreme and unprecedented situation. Therefore, the main objective of the study is to explore, for the first time, the individual and family impact of the coronavirus pandemic. The study employs a qualitative research approach to assess the effects of COVID-19 on adolescents diagnosed with BPD and their parents.

For the purpose of this exploratory study, a focus group research method was selected. A qualitative research design was used to ascertain the perspectives and subjective experience of the COVID-19 lockdown's impact on BPD patients and their parents. To ensure the quality of the research, the guidance provided by Breen (2006) and Morgan and Krueger (1998) was followed.

The target population consisted of adolescents diagnosed with BPD and their parents. Purposive sampling was used, with potential participants recruited from a specialized BPD outpatient unit of a university hospital psychiatry department in Barcelona (Spain).

The inclusion criteria for the study were as follows: (a) families must have a child diagnosed with BPD; (b) families must be living together; and (c) patients must not have any offspring. Sample recruitment lasted 2 weeks, during which psychiatrists and psychologists from the outpatient psychiatry unit proposed patients who met the inclusion criteria to participate in the study. A total of nine patients and their family members were asked to participate. Four patients refused to participate due to time incompatibility or for other reasons unrelated to the object of the study. Five adolescents with BPD and four mothers ultimately agreed to take part and were included in the final sample.

Thus, the study featured nine participants, each of them placed in either the Patients Focus Group or the Family Focus Group. The family relations between the participating members were as follows: one mother with two daughters with BPD, two mothers with their respective daughters with BPD, one mother without her daughter with BPD, and one daughter with BPD without her mother.

Ethical approval for the study was granted by the Clinical Research Ethics Committee of the university hospital. The clinical professionals of the service explained the purpose of the study to the family members and told them that participation was voluntary. All participants gave the research team their informed consent both in the form of audio recordings and online, and participants' anonymity has been preserved throughout.

The research team included two clinicians who are experts in BPD from the Psychiatry department of a university hospital in Barcelona (Spain), and two academics specializing in family therapy.

We conducted two 90-minute online focus group sessions, one with adolescents diagnosed with BPD and the other with their mothers. Each focus group was conducted by a clinician and an academic belonging to the research team. The online focus group was conducted on June 29 using the Google Meet application. At the time, Spain had gradually ended the lockdown that had been imposed during the first wave of the pandemic. The discussion leaders used a semi-structured question guide that included questions about participants' perceived changes, difficulties and learning during the lockdown, and lockdown concerns, challenges, future needs and learning.

Audio recordings of the focus group were transcribed verbatim in a Word document and then entered into ATLAS.ti 8, a qualitative software analysis package, to facilitate data coding. Two authors acted as co-coders, and the emerging results were shared with the rest of the co-authors until full agreement was reached on the final thematic configuration. The transcripts compiled for the Patients Focus Group and the Family Focus Group were analyzed separately to identify themes unique to each group. Original responses were in Spanish and were translated into English for the purpose of this article.

Thematic analysis was used to identify and analyze repeated patterns of meaning within the textual data. This rigorous method used here consisted of the six-phase analytic procedure described by Braun and Clarke (2006) : (1) familiarizing oneself with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) naming and defining themes, and (6) producing the report. An interrater reliability of Κ = 0.83 was obtained between the assessments of the clinicians and family therapists. Discrepancies were resolved through discussion to obtain full agreement.

Patient Focus Group consisted of five female outpatients of 14-22 years of age (M = 18.6; SD = 2.8). Three of the members of the group were students, one was working, and one was unemployed. The patients were all already undergoing psychiatric and psychological treatment at the specialized BPD unit of the psychiatry department of a teaching hospital in Barcelona (Spain). All of them had been diagnosed as meeting the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) criteria for BPD using the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II; First et al., 1997) . They were also assessed via the Revised Diagnostic Interview for Borderlines (DIB-R; Barrachina et al., 2004) , and all recorded total scores for the instrument of 6 or higher. The participants scored higher on the subscales measuring Impulsive Behavior Patterns (M = 2.6, SD = .55) and Interpersonal Relationships (M = 2.4, SD = .55), and they scored lower on the Affect (M = 1 SD = .0) and Cognition scales (M = .6, SD = .55). Consult these scores in the appendix (cf. Table 1) .

Family Focus Group consisted of four mothers of 48-55 years of age (M = 50.25; SD = 3.96). Half of them were married and the other half divorced, and three of the mothers were working at the time of the study, while the fourth was unemployed.

The results of the two focus groups are shown separately and also divided into two main areas. The first, regarding the lockdown period, analyzed three major thematic areas: Changes, Difficulties, and Lessons Learned. The second, examining the period of gradual relaxation of lockdown restrictions, focused on the four topics of Concerns, Challenges, Needs, and Lessons Learned. Every major theme was divided and analyzed according to the following units of analysis: Individual and Family. The themes and the categories that emerged within them are shown in the figures below. Due to the length of the discussions, some representative quotations have been selected to illustrate the findings and ground them in examples. Full text quotations can be consulted in the appendix (cf. Table 2 , 3, 4 and 5). Total score (0-10) 7/10 6/10 5/10 8/10 8/10 Affect (0-2 ) 1 1 1 1 1 Cognition scale (0-2 ) 1 0 0 1 1 Impulsive behavior pattern (0-3 ) 3 2 2 3 3 Interpersonal relationships (0-3 ) 2 2 2 3 3

Lockdown period: changes, difficulties, and lessons learned according to patients

As Figure 1 illustrates, patients tended to report experiencing changes during the lockdown period in connection with self-care behaviors. Some of them recounted engaging in efforts and activities to improve their psychological and emotional wellbeing, but some said they felt a lack of motivation to care for themselves. Some of the participants reported having been able to adapt well to the difficult new circumstances, while others said that the change in living conditions under the pandemic had left them feeling anxious or depressed. In terms of mood and personal dynamics, some participants said they had felt calmer during the lockdown because they did not feel social pressure to leave their homes and did not have the means to compare their lives with those of their peers:

"I felt more relaxed since everyone else was just as stuck as I was".

Others, however, felt anxious because they were unable to leave the house and socialize with their friends, or they presented depressive symptomatology: What I've seen with my daughter, strangely, has been an improvement. She is usually very socially isolated. She is often shut away in her room, and she disconnects from others most of the day. During the lockdown, though, she has been aware that everyone else was in the same situation, and for her it has been something of a relief. Given everything, she hasn't had such a bad time. She has had an excuse, in that she knew everyone else was in the same situation as her 

We came to agreements (…) and we got along well 2 Balance between personal and family space

It was critical both that everyone could have their own space and that there were certain things that the three of us could share 2 "I was sleeping all day long, or with my cell phone, that is, I did nothing, because I was unwell".

In terms of their families, the patients observed changes in family communication in the form of increased arguments resulting from being confined together. Some, however, reported improvements in family dynamics.

"With my family things went really well because they didn't bring in any negativity from outside since we were all locked in together".

The patients tended to highlight certain individual difficulties associated with lockdown. For example, they reported frustrations connected to addictive behaviors (such as not being able to smoke), social relations (the impossibility of seeing friends or partners), and academic or workrelated concerns. They also reported some broader issues affecting the family as a whole. For instance, they cited problematic family dynamics emerging from spending a prolonged period of time with the same people, as well as difficulties in finding a balance between personal and family space:

"My family like to be physically close to one another, and they don't understand that I need my space".

The patients reported having learned some lessons related to individual time management: 

People also need their space and a little bit of quiet, and they don't have to see me every day. This especially happens with my boyfriend, because I want to see him a lot, and he gets overwhelmed, and that's hard for me. Because the fact that he doesn't want to see me every day doesn't mean that he doesn't love me… 1 Self-care I have learned that I have to love and respect myself and my body. I have to love myself mentally and stop regretting things, like crying. We can't depend on others to be happy. The only person who will always be there is you yourself, and I depended a lot on my mother and my friends to be happy I have learned that we can't depend on others to be happy. The only person who will always be there is you yourself, and I depended a lot on my mother and my friends to be happy 7 Self-esteem My self-esteem was really low, because of the stress, the anxiety and everything. I've had a lot of problems with food, and this makes me feel worse, and it turns into a vicious cycle 3

Realizing that I don't always need to be… well, I would like to always be around people, but it's also good for me to be on my own, to have my own space, to get bored, to think, to not always be clinging to others 1 Some also reported having embraced healthier attitudes when it comes to self-care, expressing an awareness of the importance of personal space: "In the end, I've learned that I like to be on my own. That was the problem, pressure".

In the family sphere, the patients said they had had some insights in relation to family connections (1) and family dynamics (2) and the need to find a balance among these factors (3):

"I realized that all of us in the family have some internal problems, but that not all of us are aware of them" (1). Lockdown period: changes, difficulties, and lessons learned according to BPD patients' mothers Figure 2 shows the changes observed by the mothers during the lockdown period. Some of the most commonly experienced changes had to do with their degree of adaptability. On the positive or functional side, some mothers reported that they had not felt afraid during the lockdown. The dysfunctional changes, meanwhile, included feelings of anxiety and sadness. The mothers in the study also expressed satisfaction with the changes in their personal time management thanks to the opportunity to work from home. Most of the family changes they identified were related to their daughters diagnosed with BPD, and they observed improvements in family communication (1) and stronger emotional connections (2):

"In my case, we were able to have more time to talk" (1).

"My daughter and I have been able to understand each other better" (2).

They also perceived improvements in their daughters' clinical symptoms:

"What I've seen with my daughter, strangely, has been an improvement. She is usually very socially isolated. She is often shut away in her room, and she disconnects from others most of the day. During the lockdown, though, she has been aware that everyone else was in the same situation, and for her it has been something of a relief. Given everything, she hasn't had such a bad time. She has had an excuse, in that she knew everyone else was in the same situation as her". In terms of individual problems, they highlighted the difficulties they had in adapting their everyday routines. The most common family issues were connected to communication, as arguments became more frequent. They also reported problems related to family structure.

"Timetables [were a problem]. We had to make a schedule for when they had to help around the house, because everything was out of control. Everyone was going to bed whenever they wanted, getting up whenever they wanted…".

In broad terms, the mothers reported having gained insights in relation to the attitudes they had assumed in the face of the lockdown and the ability to adapt to the situation.

"I have learned to be more patient, to enjoy whatever was happening in order to benefit everyone".

The lessons learned in terms of family relations were often connected to the degree of cohesion between mothers and patients. They also reported success in striking a balance between family and personal space and in establishing healthy family dynamics by coming to agreements about shared responsibilities.

"It was critical both that everyone could have their own space and that there were certain things that the three of us could share".

Relaxation of lockdown restrictions: concerns, challenges, needs, and lessons learned, according to patients During the period of gradual relaxation of lockdown restrictions, as Figure 3 makes clear, the patients expressed concern and fear of a new lockdown and the possible consequences for their professional and academic lives. They also reported feeling concerned about their social relations. Some expressed fear of social exposure (1), while others were worried about social isolation (2).

"Since I haven't been very well during the lockdown, now that it's ending I want to go out and do lots of things" (1).

"I was worried about going out again, because I don't usually like to go out much. I would rather stay home and do things on my own" (2).

Their family-related concerns were mostly connected to the health and the professional situations of their relatives. They also reported worries about family communication, family dynamics (1) and family connections (2):

"My mother doesn't want me to do so many things, because it's not good for me. This causes conflicts, because I want to do things, and they don't give me permission, but I do them anyway. Then we start to fight and there is tension" (1).

"I'm worried about how my parents are going to feel now that the lockdown is ending" (2).

In terms of individual challenges, the patients highlighted the need to adapt once again to the new situation, to focus on their studies and to care for themselves.

"My challenge is to get better and feel better about myself in order to be healthy".

The family-related challenges were mostly connected to communication and relationship dynamics.

"I think that I'm really the challenge in my house. I know it's hard for them to deal with me, and now I'm in a phase where it's especially hard. And I know they try, but they don't manage to do it". Discussing future treatment, the patients expressed an interest in integrated psychological and psychiatric care. Specifically, they expressed a desire to attend both individual and group therapy sessions. The latter approach, they said, would allow them to identify with others and feel supported by their peers (1); they also observed a need for family therapy to resolve issues within the family (2).

"I think group therapy would be pretty good for me, because learning about others' problems and seeing that I'm not alone could help me" (1).

"I think I need family therapy with my family. I'm sure about this, because the situation is unsustainable" (2).

Finally, in terms of lessons and insights, they reported having gained self-control strategies (1), an appreciation for the importance of self-care (2), and greater awareness of their self-esteem problems (3): "When I'm unhappy and I feel like I want to self-harm, I meditate or do yoga" (1).

"I have learned that I have to love and respect myself and my body. I have to love myself mentally and stop regretting things, like crying. We can't depend on others to be happy. The only person who will always be there is you yourself, and I depended a lot on my mother and my friends to be happy" (2).

"My self-esteem was really low, because of the stress, the anxiety and everything. I've had a lot of problems with food, and this makes me feel worse, and it turns into a vicious cycle" (3).

They also reported having learned to establish greater stability in their social relations and said they had gained both greater awareness of their emotional bonds with others (1) and the ability to value moments and spaces in which they could be alone (2):

"People also need their space and a little bit of quiet, and they don't have to see me every day. This especially happens with my boyfriend, because I want to see him a lot, and he gets overwhelmed, and that's hard for me. Because the fact that he doesn't want to see me every day doesn't mean that he doesn't love me…" (1).

"Realizing that I don't always need to be… well, I would like to always be around people, but it's also good for me to be on my own, to have my own space, to get bored, to think, to not always be clinging to others" (2).

Relaxation of lockdown restrictions: concerns, challenges, needs, and lessons learned, according to mothers of BPD patients Figure 4 shows that, as the lockdown was eased, the mothers were concerned about future uncertainty and about the pace with which the restrictions were being lifted. Their family-related concerns were connected to relationship dynamics and the potential that their daughters with BPD would experience clinical setbacks. "The other day she self-harmed, which she didn't do during the lockdown".

In terms of individual challenges, the patients' mothers identified the desire to make it through the pandemic and to advance at work. They highlighted their daughters' need to meet academic challenges.

The mothers stressed the need for group therapy, because of the opportunities it affords for sharing (1), learning (2), and mutual support (3):

"There should be groups, even if they just meet occasionally, for family members, to help us handle this, to let us be with families who are going through the same thing as us. I think this could help us, even if it was just once every two months" (1). "There's really a lack of information and support. I don't mean for the kids, but for the parents" (2).

"The chance to talk and help other people, and if I have a problem to have them listen to me, to know that I can count on them, might help everyone" (3).

They also expressed a need for individual psychological treatment to better their understanding (1) and adaptive abilities (2), and to learn to accept their current situations (3):

"I need them to tell me how to act or what's happening to her, because I don't understand it" (1).

"Everything in my life depends on the attitude or the progress of my daughter" (2).

"As a mother, you blame yourself. Where did I go wrong?" (3).

Meanwhile, they highlighted the need for greater social awareness and a lessening of the stigma surrounding mental health problems, as well as a desire for more mental health resources, especially specialized BPD units. Additionally, they expressed an interest in access to group therapy for their daughters.

"I think she needs group therapy to identify with others, with boys and girls like her".

In terms of insights, they reported learning the importance of maintaining a positive attitude (1) and that they had become more aware of the consequences and perception of the disorder (2):

"We have to be strong and very, very positive. Because if not, we'll be at each other's throats. When I talk to the psychologist, I say that I'm all in, and it's true" (1).

"It's a disease, and that's all there is to it. You realize that she's not a spoiled brat, she's not impolite, she's not selfish" (2)

This research was intended as a first attempt at an exploration of the experiences of adolescents with BPD and their mothers during the first wave of the COVID-19 pandemic and through the resulting lockdown and its easing, using an exploratory approach examining both participants as individuals and their relationships. This study offers an overview of the experiences of these adolescents and their mothers during the pandemic, and it allows us to delve into a range of individual and family factors. This includes both factors that protected against or mitigated the negative effects of the pandemic and others that contributed additional stress or difficulties to the participants' efforts to cope with the unexpected situation that arose in the context of COVID-19.

When discussing their families as a whole, both mothers and daughters stressed the importance of effectively managing relationships in the context of shared family life, a need which became more evident than ever to them during the lockdown. They agreed that certain difficulties had emerged or become more apparent, especially when it came to distinguishing individual and family space and issues of communication, cohesion, and family dynamics. Nonetheless, they underlined the highly positive consequences for all members of the family system of striking the right balance in the management of a range of relationship issues. These findings highlight the importance of being attentive to family relationships and to offer support to family members of patients with the disorder (Brown, 2018) .

Thus, it is important to keep in mind the heavy burden carried by family members of people with severe mental illness (Woody et al., 2019) . Indeed, in this study both the patients themselves and their mothers were highly aware of the need to expand the care options for BPD patients. This was emphasized by the fact that participants mentioned that they would appreciate greater access to group therapy, as well as other therapy modalities, such as family therapy.

We might have expected BPD patients in particular to experience a dramatic deterioration in terms of their individual psychological symptoms in the context of the health crisis and the accompanying lockdown restrictions. However, our findings show that patients with the disorder likely reacted to the situation in much the same way as the population as a whole, reporting symptoms of anxiety and depression, as well as high levels of stress (Choi, 2020; Lakeman & Crighton, 2020; Pakpour & Griffiths, 2020; Shapiro et al., 2020; Yao et al., 2020) and difficulties with social relations as a result of social isolation (Frías et al., 2020) . In fact, our exploratory study corroborates previous studies (Frías et al., 2020; Salamin et al., 2020) as during lockdown most of the patients' psychopathological symptoms seem to be stable. This might be due to a reduction of some demands of daily life, with fewer occasions to cope with stressful situations and manage interpersonal relations (Frías et al., 2020; Salamin et al., 2020; Ventura Wurman et al., 2020) .

Nonetheless, this apparent stability or clinical improvement did not remain intact when lockdown restrictions began to be lifted. Specifically, the patients in this phase experienced difficulties in managing their interpersonal relationships, the focus of some of their most severe clinical problems. In spite of these obstacles, the patients indicated that they had succeeded in activating certain adaptive resources and personal abilities in the face of the pandemic.

Finally, the perceived psychological impact on the mothers is largely comparable to the effects that have been found by studies examining the population at large. Specifically, they reported increases in stress and symptoms of depression and anxiety (González-Sanguino et al., 2020; Günther-Bel et al., 2020; Luo et al., 2020; Ozamiz-Etxebarria et al., 2020; Rodríguez-Rey et al., 2020) .

This study was exploratory in nature, but we believe that future research could benefit from the inclusion of fathers in the focus groups, rather than just mothers, as fathers may have perceived some individual or relational aspects differently from mothers. It would also have been desirable to incorporate the perceptions of male patients in order to examine any possible differences considering the gender perspective, although the inclusion of male patients with BPD is a common limitation in research and clinical practice. Furthermore, we believe it would have been beneficial to assess patients with differing levels of clinical severity, as the ability for psychosocial functioning might have played a role in their experiences of lockdown and the lifting of restrictions. Finally, given that the present situation is highly dynamic and uncertain, we think that valuable additional conclusions might be gleaned from a longitudinal study to explore the progress of the participants over time.

In conclusion, the first wave of the COVID-19 pandemic has provided new evidence regarding the difficulties experienced by adolescents with a diagnosis of BPD. This study's results seem to suggest that during the lockdown period the patients did not perceive lockdown as a negative experience, as they reported feeling as if they were in an artificial situation in which they felt constrained. On the other hand, in the period of gradual relaxation of lockdown restrictions, the difficulties associated with the disorder reappeared, due to the fact that participants once again had to face the demands of life (e.g., making decisions and managing interpersonal relationships).

This concern might explain the patients' request for group therapy treatment and family therapy, as well as their mothers' interest in support groups to allow them to share their experiences with others in similar situations. Hence, we believe it would be important and beneficial to the scientific community to carry out further studies that consider the relationship and family factors affecting patients diagnosed with BPD.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the State Research Agency of the Government of Spain for the aid to R + D + i grant number PSI 2017-83146-R.

Anna Vilaregut  https://orcid.org/0000-0001-8284-2954

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Review of services to inform clinical frameworks for adolescents and young adults with severe, persistent and complex mental illness

Patients with mental health disorders in the COVID-19 epidemic

Recommended psychological crisis intervention response to the 2019 novel coronavirus pneumonia outbreak in China: A model of West China Hospital