Laboratory test availability and user fees in routine HIV care: a global analysis in 42 countries.

Borderline personality disorder (BPD) is a severe mental health condition characterized by identity problems, instability of interpersonal relationships and emotion dysregulation (). BPD affect 2%–3% of adolescents in the community, 11%–22% of adolescents attending outpatient mental health services, and up to 33% in inpatient adolescent services (). As these rates were derived from different studies, they may not generalize uniformly across countries. As adolescence represents a developmental window that is particularly critical for expansion of the social brain (), as well as the emergence of personality pathology, vulnerabilities in attachment security (characterized by avoidant or ambivalent patterns of relating) and impairments in reflective functioning (defined as the capacity to understand one's own and others' behavior in terms of underlying mental states) can be associated with core features of BPD (). Identifying specific pathways in this age group may inform early detection strategies and guide preventive or early interventions. Evidence from studies in adults, suggests that insecure attachment is associated with BPD, while a recent study in adult women identified mentalizing as a key mechanism linking insecure attachment to Borderline Personality Traits (BPTs) (, ). Recent evidence also suggests that BPTs typically become observable in adolescence, and elevated BPTs in adolescence show meaningful continuity and are associated with an increased likelihood of borderline pathology in adulthood (, ). Most existing studies focus either on attachment or on reflective functioning, or they examine adult populations where personality organization is more crystalized compared to adolescence (). Theoretical and conceptual models for the development of personality pathology propose that personality disorder develops against the backdrop of an insecure early caregiving environment, which in turn, impedes social-cognitive development (, ). Specifically, secure attachment relationships are thought to facilitate the development of mentalizing (or reflective functioning), thereby reducing vulnerability to maladaptive personality functioning. We therefore aimed to evaluate the strength of relationship between attachment insecurity and BPTs; in addition, we aimed to test the hypothesis that reflective functioning explains significant variance in the association between insecure attachment (avoidant and ambivalent) and BPTs in early adolescence. Focusing on attachment is crucial since although BPTs become more readily observable during adolescence, prospective findings suggest that relevant vulnerabilities, including early adversity and low maternal support may be detectable from the preschool years ().