Three years after the outbreak of COVID-19 pandemic, numerous epidemiological studies confirm its significant psychological impact. Recent meta-analyses with 50,000-70000 participants noted the increase in anxiety, depression and feelings of loneliness in the general population.¹ Patients with pre-existing mental disorders were a vulnerable group at high risk of deterioration.^1,2 As part of the measures to combat the pandemic, the operation of mental health services was reduced, the access to them became more difficult and the provision of supportive and psychotherapeutic interventions continued through telepsychiatry.²
Of particular interest is the study of the impact of the pandemic on patients with personality disorders (PD).³ These patients experience severe difficulties related to interpersonal relationships and identity, which lie at the basis of intense affective and behavioral manifestations.^4,5 Most studies on the impact of the pandemic on patients with personality pathology have focused on borderline personality disorder (BPD).⁶
Social distancing measures during the pandemic and increased sense of loneliness are serious aggravating factors for patients with BPD and may cause anxieties of abandonment and rejection, social withdrawal, and feelings of emptiness. Consequently, the patients' susceptibility to risky behaviors and substance use increases.^3,7 The anxieties caused by the condition, as well as the feeling of not being in control of the situation by the subject, may mobilize paranoid ideation in patients with BPD, which further exacerbates the difficulties in their interpersonal relationships.⁷ In a Nordic multicenter study of 1120 outpatients with PD during the first wave of the pandemic, results showed an increase in anxiety, depression, aggression, substance use, social isolation and a decrease in work activity, while the rates of suicidal behaviors remained the same.⁸ On the other hand, for some patients the restricted exposure to interpersonal triggers could lead to amelioration of symptoms.⁷
Several papers have studied the number of visits of patients with PD or patients with self-harm to hospital emergency departments during the pandemic.^6,9 In the studies that examined self-injury, the psychiatric diagnosis was not recorded, but they are mentioned here because the presence of self-harm is closely associated with PD.¹⁰ The number of emergency department visits of patients with PD or self-harm was found to be increased in some papers, decreased in others, and stable in others, compared to the previous year.^6,9 During the same period, however, both the distress of patients with PD and rates of self-harm thoughts in the general population increased.^3,6-8 The decreased number of emergency department visits could be the result of reduced access to services or amelioration of symptomatology due to decreased social contact or sufficient remote therapy through telepsychiatry. A critical issue that mental health services providing therapy to patients with PD had to encounter was the need to discontinue in person psychotherapy and continue by telephone or online. Patients with PD are particularly sensitive to therapeutic setting modifications and this was an aggravating factor.⁷ In several studies, discontinuation of in person psychotherapy for BPD patients was accompanied by worsening symptomatology, feelings of anxiety, sadness, and feelings of helplessness.^6,11 When it was not possible to continue sessions by telephone or online, there was an increase in the number of emergency department visits.^6,11 In contrast, continuation of sessions via tele-psychiatry was considered satisfactory by patients and in some cases their clinical picture, after the initial nuance, returned and maintained at previous level.^6,11 In the above studies, the discontinuation of sessions involved a period of 2-3 months. In a study conducted at the PD services of the First Psychiatric Department of the National and Kapodistrian University of Athens, at Eginition Hospital, at the start of the restriction measures, 51 BPD patients were attending group psychoanalytic psychotherapy sessions. The face-to-face sessions were discontinued and continued online for 4 months. During this time, no self-harm incidents, suicide attempts or hospitalizations occurred; 2 patients discontinued treatment. In crises, patients used telephone communication with therapists and no emergency department visits were recorded.¹²
In conclusion, the pandemic had a significant psychological impact on patients with PD. However, it should be emphasized that in cases where the therapeutic setting remained alive and the continuity of therapeutic collaboration was maintained, patients with PD, despite the severity of their pathology, showed good adaptation and were able to withstand the tensions caused by the pandemic.

Ioannis A. Malogiannis
Psychiatrist, Laboratory Teaching Staff
Head of the Specific Sector of Personality Disorders and of the Day Hospital, First Psychiatric Department, Medical School, National and Kapodistrian University of Athens, Eginition Hospital
Secretary of the Psychotherapy Section, Hellenic Psychiatric Association, Athens

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