Borderline Personality Disorder (BPD)

Primer

Borderline Personality Disorder (BPD) is a personality disorder characterized by emotional dysregulation, a pattern of unstable interpersonal relationships and high impulsivity/recklessness. Patients can oscillate quickly between devaluing and idealizing relationships (commonly known as “splitting”). Other features include difficulty controlling anger, recurrent suicidal or self-harm behaviours, identity disturbance, and chronic feelings of emptiness.

Epidemiology
  • The population prevalence is estimated to be between 1.6 to 6%.
    • The prevalence in primary care settings is about 6%, and 10% in outpatient mental health clinics, and as high as 20% in psychiatric inpatients.[1]
    • The prevalence of BPD decreases in older age groups.
  • BPD is diagnosed predominantly in females (75%) and also present 3 times more commonly than men in treatment settings.[2]
Prognosis
  • The course of BPD is typically characterized by chronic instability in adolescence and early adulthood. Individuals can have serious affective instability, impulsivity (including self-harm and suicide attempts), and high levels of use of healthcare utilization.
  • BPD has a significant impact on an individual's social and occupational functioning, including recurrent job losses, educational failure, and separation or divorce are common.
  • Premature death from suicide can occur, especially in those with co-occurring depressive disorders or substance use disorders.
  • Naturalistic studies have shown that patients with BPD can have progressive improvement and remission.[3]
    • In one naturalistic study follow up after 10 years, 25% had full time employment and 40% were on disability benefits.[4]
    • By the fourth decade of life, half of the individuals no longer have a pattern of behavior that meets full criteria for BPD.
Comorbidity
Risk Factors
  • Physical and sexual abuse, neglect, hostile conflict, and early parental loss are risk factors
  • BPD is five times more common among first-degree biological relatives of those with diagnosed BPD
    • There are certain genes that also predispose individuals to BPD.[5]

Suicide

BPD is associated with significant morbidity, mortality and healthcare costs (due to repetitive self harm and admissions to hospital). There is a significant suicide rate of about 10%.[6] This is a source of significant distress for the patient, clinicians, and their community. Patients often have a chronic suicide risk that does not benefit from hospitalization. As a result, treating chronically suicidal patients requires balancing risks and require careful clinical judgment.[7]

History

The term “borderline” originated with the concept that this disorder was on the border between neurosis and psychosis, essentially “bordering” on schizophrenia. The name continues as a historical term, but it is most certainly not a psychotic disorder. BPD is a diagnostic label that is used to group common features seen in this clinical population. There is ongoing debate about changing the name itself to something more accurate and less stigmatizing, such as emotion regulation disorder. There are also proposals to change the future diagnostic criteria beyond the DSM-5.

Stigma and Misdiagnosis

  • Clinicians can be reluctant to make a diagnosis of BPD. One reason is that borderline personality is a complex syndrome with symptoms that resemble other primary psychiatric disorders such as depression, bipolar disorder, and psychosis.
    • Individuals with borderline personality disorder may be misdiagnosed as having one of these disorders, and have failed many medications over years, and not offered any evidence-based treatments for borderline personality such as dialectical behaviour therapy.
  • However, making a borderline diagnosis does more justice to patients than avoiding it, because it guides clinicians and patients towards the most effective treatments.[8]

DSM-5 Diagnostic Criteria

Criterion

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by at least 5 of the following:

  1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
  2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
  3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
  4. Impulsivity in at least two areas that are potentially self-damaging (e.g. - spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
  5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
  6. Affective instability due to a marked reactivity of mood (e.g. - intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
  7. Chronic feelings of emptiness.
  8. Inappropriate, intense anger or difficulty controlling anger (e.g. - frequent displays of temper, constant anger, recurrent physical fights).
  9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Mnemonic

The mnemonic IMPULSIVE can be used to remember the criteria for borderline personality disorder.

  • I - Impulsive: “Are you by nature an impulsive person? (e.g. - shop lifting, binging, gaming)”
  • M - Moodiness: “Do you find it difficult to control your emotions?”
  • P - Paranoia or dissociation under stress: “Do you ever feel you dissociate or feel things aren't real during stress (e.g. - zoning out, feeling like in a dream, or feeling the world around you isn't real)?”
  • U - Unstable self-image: “Do you feel that you have a poor sense of who you are and your identity?” “How would you describe yourself as a person?” “What are you interests?” “Ever have uncertainty about sexual orientation?” “What are your values as a person?”
  • L - Labile intense relationships: “Are your romantic relationships intense, where people can be amazing one moment but awful the next?”
  • S - Suicidal gestures: “Do you self-harm?”
  • I - Inappropriate anger: “Are you quick to anger?”
  • V - Vulnerability to abandonment: “Is it hard for you when people in your life leave you? Do you have a constant fear of being abandoned by others?”
  • E - Emptiness: “Do you frequently feel empty inside?” (Emptiness is a unique feeling in BPD - either you have it or you don't)

Micropsychosis

  • The term micropsychotic episodes is a historical term originating from the 1970s, when borderline personality was still being defined and thought of as being on the schizophrenia spectrum – the “borderline” between psychosis and neurosis.[9]
    • At the time, patients with BPD were felt to have brief “psychotic” episodes that included paranoia, dissociation, and auditory hallucinations.
  • Nowadays, this term continues to be used in a clinical context to describe these symptoms in a non-psychotic individual. Micropsychotic episodes may occur during periods of high stress for individuals with BPD.
  • It is important to note that the term micropsychosis is not a formal terminology in the DSM, nor in the diagnostic criteria.[10]

Screening

  • Affective instability (i.e. - difficulty with emotional regulation) is most frequently occurring symptom in BPD. A single screening question, “Are you quick to react with anxiety/anger?” has a sensitivity of 94% and negative predictive value >95%.[11]

Pathophysiology

  • The exact etiology of BPD is currently unknown.
  • The development of borderline personality is thought to be due an underlying sensitive temperament in the individual, plus an invalidating environment. Abuse and neglect is ubiquitous in the borderline population (>90%).
  • A tripartite model of the development of BPD has been suggested by Zanarini (1997), which involves: (1) a traumatic childhood (i.e. - adverse childhood events), (2) a vulnerable (hyperbolic/sensitive) temperament, and (3) a triggering event(s).[12]
    • This model suggests that borderline patients have a unique pathway to the development is a result of these three core elements.
  • However, traumatic (physical/sexual/emotional) abuse alone does not cause BPD; there can be other factors that lead to the development of BPD.
Functional Neuroimaging
  • In neuroimaging findings, individuals with BPD have higher neural activity in the insular cortex (which correlates with individuals who experience who experience emotions more intensely) and the cingulate gyrus.[13]
  • Individuals with BPD also show less activation in prefrontal brain areas involved in cognitive control, which is impacted under conditions of negative emotions.[14]

Differential Diagnosis

  • Identity problems
    • BPD should be distinguished from an identity problem, which is reserved for identity concerns related to a developmental phase (e.g. - adolescence) and does not qualify as a mental disorder.
  • Depressive and bipolar disorders
    • BPD can co-occur with depressive or bipolar disorders, and when criteria for both are met, both may be diagnosed. However, since cross-sectional symptoms of BPD can also resemble an episode of depressive or bipolar disorder, the diagnosis of BPD should only be given if there is a well-documented pattern of behaviour with an early onset and a long standing course prior to the mood episode.
    • Individuals with bipolar disorder are more likely to have a family history of bipolar illness, whereas self-harm and past sexual abuse are more likely in borderline personality disorder.[15]
  • Histrionic personality disorder
    • Although histrionic personality disorder is also characterized by attention seeking, manipulative behavior, and rapidly shifting emotions, BPD differs in that there is self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness and loneliness.
  • Schizotypal personality disorder
    • Paranoid ideas or illusions can be present in both BPD and schizotypal personality disorder. However, these symptoms are more transient, interpersonal, and responsive to external restructuring in BPD.
  • Antisocial personality disorder (ASPD)
    • Although ASPD and BPD are both characterized by manipulative behavior, individuals with ASPD manipulate others to gain profit, power, or for material gratification. In BPD, this is directed more toward gaining the concern of other individuals or caretakers.
  • Paranoid personality disorder and narcissistic personality disorder
    • Stable self-image, lack of destructiveness behaviours, relatively less impulsivity, and lack of abandonment fears distinguishes these personality disorders from BPD. BPD, paranoid personality disorder, and narcissistic personality disorder all share the common feature of angry reaction to minor stimuli.
  • Dependent personality disorder
    • Both dependent personality disorder and BPD are characterized by fear of abandonment. However, in BPD, the individual reacts to abandonment with feelings of emotional emptiness, rage, and demands, whereas in dependent personality disorder, the individual reacts with submissiveness. BPD can further be distinguished from dependent personality disorder by the typical pattern of unstable and intense relationships.
  • Personality change due to another medical condition
    • BPD must be differentiated from personality change due to another medical condition (e.g. - traumatic brain injury), in which the traits that emerge are attributable to the effects of another medical condition on the central nervous system.
  • Substance use disorders
    • BPD must also be distinguished from symptoms that may develop in association with persistent substance use.

Treatment

Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) has the most robust evidence for the treatment of borderline personality disorder. DBT skills groups also have good evidence, but there is actually no data on one-on-one DBT interventions and techniques. DBT is not a panacea, and needs to be used appropriately. Remember, DBT is not the gold standard despite this frequent refrain.[16] There is no evidence that DBT is necessarily superior to other active, BPD-specific treatments (especially when compared to any long-term therapy that has some structure).[17][18] It is also important to recognize that patients with BPD can also improve without treatment.

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Other Evidence-Based Psychotherapies

  • Transference Focused Therapy (TFP)[19]
  • Mentalization Based Therapy (MBT)[20]
  • Schema Focused Therapy (SFT)[21][22]
  • Good Psychiatric Management[23]

Hospitalization

  • While hospital admissions may provide temporary relief, there is no research evidence that shows hospitalizations actually increase safety or even reduce mortality in BPD.[24][25]
  • In fact, hospitalization can even be counterproductive or harmful. When there is chronic, unmodifiable suicidality, hospitalization can become recurrent and disruptive to the patient's life.[26]
  • However, this does not mean that individuals with BPD are never admitted to hospital. After a comprehensive safety and suicide risk assessment has been done, the clinician ultimately must make the decision on whether there are acute risk factors that would be modifiable with a hospital admission.

Medication

Antipsychotics Should Not Be Used Long-Term!

The UK's National Institute for Health and Care Excellence (NICE) guidelines specifically recommend that antipsychotics should not be used for the medium- and long-term treatment of borderline personality disorder.
  • Pharmacotherapy should never be (and is not) the first-line treatment for borderline personality disorder!
  • Clinicians should always use medications for BPD with caution, and remind themselves it should be for short-term symptom relief.
  • Current literature suggest that mood stabilizers and second-generation antipsychotics may be effective for treating a number of core symptoms. Pharmacotherapy should therefore be targeted at specific symptoms, with a review on whether or not medications are actually helping with the symptoms. [27]
  • Unfortunately, there continues to be worldwide overuse of prescription medications for BPD.[28] Medications (if prescribed at all) must be prescribed thoughtfully!

Expert recommendations for specific symptom treatment (Cochrane Review 2010)

Symptom Cluster Effective Treatment
Interpersonal Pathology Aripiprazole, valproate, topiramate
Affective Dysregulation Topiramate, lamotrigine*,[29] valproate, haloperidol, aripiprazole, olanzapine
Impulsive-behavioural dyscontrol Topiramate, lamotrigine*, flupentixol, aripiprazole, omega-3 fatty acid
Cognitive-perceptual Aripiprazole, olanzapine
* = Newest evidence is suggesting limited efficacy

Guidelines

Personality Disorder Guidelines

Guideline Location Year PDF Website
World Federation of Societies of Biological Psychiatry (WFSBP) International 2009 - Link

Borderline Personality Disorder Guidelines

Guideline Location Year PDF Website
Canadian Medical Association Journal (CMAJ) Canada 2012 - Link
National Institute for Health and Care Excellence (NICE) UK 2009 - Link
American Psychiatric Association (APA) USA 2001, 2005 - • Guideline (2001)
• Guideline Watch (2005)
• Quick Reference

Resources

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Articles
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References

1) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
2) Grant, B. F., Chou, S. P., Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T. D., ... & Ruan, W. J. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. The Journal of clinical psychiatry, 69(4), 533.
3) Zanarini, M. C., Frankenburg, F. R., Hennen, J., Reich, D. B., & Silk, K. R. (2005). The McLean Study of Adult Development (MSAD): overview and implications of the first six years of prospective follow-up. Journal of personality disorders, 19(5), 505-523
4) Gunderson, J. G., Stout, R. L., McGlashan, T. H., Shea, M. T., Morey, L. C., Grilo, C. M., ... & Skodol, A. E. (2011). Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorders study. Archives of general psychiatry, 68(8), 827-837.
5) Gunderson, J. G., Zanarini, M. C., Choi-Kain, L. W., Mitchell, K. S., Jang, K. L., & Hudson, J. I. (2011). Family study of borderline personality disorder and its sectors of psychopathology. Archives of General Psychiatry, 68(7), 753-762.
6) Paris, J. (2019). Suicidality in borderline personality disorder. Medicina, 55(6), 223.
7) Paris, J. (2006). Managing suicidality in patients with borderline personality disorder. Psychiatric Times, 23(8), 34-34.
8) Paris J. Why Psychiatrists are Reluctant to Diagnose: Borderline Personality Disorder. Psychiatry (Edgmont). 2007;4(1):35-39.
9) Zanarini, M. C., Gunderson, J. G., & Frankenburg, F. R. (1990). Cognitive features of borderline personality disorder. The American journal of psychiatry.
10) Paris, J. (2007). Why psychiatrists are reluctant to diagnose: borderline personality disorder. Psychiatry (Edgmont), 4(1), 35.
11) Zimmerman, M., Chelminski, I., Dalrymple, K., & Rosenstein, L. (2017). Principal diagnoses in psychiatric outpatients with borderline personality disorder: Implications for screening recommendations. Annals of Clinical Psychiatry, 29(1), 54-60.
12) Zanarini, M. C., & Frankenburg, F. R. (1997). Pathways to the development of borderline personality disorder. Journal of personality disorders, 11(1), 93-104.
13) Schulze, L., Schmahl, C., & Niedtfeld, I. (2016). Neural correlates of disturbed emotion processing in borderline personality disorder: a multimodal meta-analysis. Biological psychiatry, 79(2), 97-106.
14) Silbersweig, D., Clarkin, J. F., Goldstein, M., Kernberg, O. F., Tuescher, O., Levy, K. N., ... & Epstein, J. (2007). Failure of frontolimbic inhibitory function in the context of negative emotion in borderline personality disorder. American Journal of Psychiatry, 164(12), 1832-1841.
15) Ghaemi, S. N., Dalley, S., Catania, C., & Barroilhet, S. (2014). Bipolar or borderline: a clinical overview. Acta Psychiatrica Scandinavica, 130(2), 99-108.
16) Choi-Kain, L. W., Albert, E. B., & Gunderson, J. G. (2016). Evidence-based treatments for borderline personality disorder: Implementation, integration, and stepped care. Harvard Review of Psychiatry, 24(5), 342-356.
17) Choi-Kain, L. W., Finch, E. F., Masland, S. R., Jenkins, J. A., & Unruh, B. T. (2017). What works in the treatment of borderline personality disorder. Current behavioral neuroscience reports, 4(1), 21-30.
18) Choi-Kain, L. W., Albert, E. B., & Gunderson, J. G. (2016). Evidence-based treatments for borderline personality disorder: Implementation, integration, and stepped care. Harvard Review of Psychiatry, 24(5), 342-356.
19) Giesen-Bloo, J., Van Dyck, R., Spinhoven, P., Van Tilburg, W., Dirksen, C., Van Asselt, T., ... & Arntz, A. (2006). Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy. Archives of general psychiatry, 63(6), 649-658.
20) Vogt, K. S., & Norman, P. (2019). Is mentalization‐based therapy effective in treating the symptoms of borderline personality disorder? A systematic review. Psychology and Psychotherapy: Theory, Research and Practice, 92(4), 441-464.
21) Giesen-Bloo, J., Van Dyck, R., Spinhoven, P., Van Tilburg, W., Dirksen, C., Van Asselt, T., ... & Arntz, A. (2006). Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy. Archives of general psychiatry, 63(6), 649-658.
22) van Asselt, A. D., Dirksen, C. D., Arntz, A., Giesen-Bloo, J. H., van Dyck, R., Spinhoven, P., ... & Severens, J. L. (2008). Out-patient psychotherapy for borderline personality disorder: cost-effectiveness of schema-focused therapy v. transference-focused psychotherapy. The British Journal of Psychiatry, 192(6), 450-457.
23) Gunderson, J. G. (2014). Handbook of good psychiatric management for borderline personality disorder. American Psychiatric Pub.
24) Paris, J. (2004). Is hospitalization useful for suicidal patients with borderline personality disorder?. Journal of personality disorders, 18(3: Special issue), 240-247.
25) Biskin, R. S., & Paris, J. (2012). Management of borderline personality disorder. Cmaj, 184(17), 1897-1902.
26) Biskin, R. S., & Paris, J. (2012). Management of borderline personality disorder. Canadian Medical Association Journal, 184(17), 1897-1902.
27) Lieb, K., Völlm, B., Rücker, G., Timmer, A., & Stoffers, J. M. (2010). Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials. The British Journal of Psychiatry, 196(1), 4-12.
28) Martín‐Blanco, A., Ancochea, A., Soler, J., Elices, M., Carmona, C., & Pascual, J. C. (2017). Changes over the last 15 years in the psychopharmacological management of persons with borderline personality disorder. Acta Psychiatrica Scandinavica, 136(3), 323-331.
29) Crawford, M. J., Sanatinia, R., Barrett, B., Cunningham, G., Dale, O., Ganguli, P., ... & Montgomery, A. (2018). Lamotrigine for people with borderline personality disorder: a RCT.