Management
Psychotherapy is the primary
treatment for borderline personality disorder. Treatments should be based on the needs of the
individual, rather than upon the general diagnosis of BPD. Medications are
useful for treating comorbid disorders, such as depression and anxiety. Short-term hospitalization has not been found
to be more effective than community care for improving outcomes or long-term
prevention of suicidal behavior in those with BPD.
Psychotherapy
Long-term psychotherapy is currently
the treatment of choice for BPD. While
psychotherapy, in particular dialectical behavior therapy and psychodynamic
approaches, is effective, the effects are small.
More rigorous treatments are not
substantially better than less rigorous treatments. There are six such treatments available: dynamic deconstructive psychotherapy (DDP),
mentalization-based treatment (MBT), transference-focused psychotherapy,
dialectical behavior therapy (DBT), general psychiatric management, and schema-focused
therapy. While DBT is the therapy that
has been studied the most, all these treatments appear effective for treating
BPD, except for schema-focused therapy. Long-term therapy of any kind, including
schema-focused therapy, is better than no treatment, especially in reducing
urges to self-injure.
Transference focused therapy aims to
break away from absolute thinking. In this, it gets the people to articulate
their social interpretations and their emotions in order to turn their views
into less rigid categories. The therapist addresses the individual's feelings
and goes over situations, real or realistic, that could happen as well as how
to approach them.
Dialectical behavior therapy has
similar components to CBT, adding in practices such as meditation. In doing
this, it helps the individual with BPD gain skills to manage symptoms. These
skills include emotion regulation, mindfulness, and stress hardiness.
Cognitive behavioral therapy (CBT)
is also a type of psychotherapy used for treatment of BPD. This type of therapy
relies on changing people's behaviors and beliefs by identifying problems from
the disorder. CBT is known to reduce some anxiety and mood symptoms as well as
reduce suicidal thoughts and self-harming behaviors.
Mentalization-based therapy and
transference-focused psychotherapy are based on psychodynamic principles, and
dialectical behavior therapy is based on cognitive-behavioral principles and mindfulness. General psychiatric management combines the
core principles from each of these treatments, and it are considered easier to
learn and less intensive. Randomized
controlled trials have shown that DBT and MBT may be the most effective, and
the two share many similarities. Researchers are interested in developing
shorter versions of these therapies to increase accessibility, to relieve the
financial burden on patients, and to relieve the resource burden on treatment
providers.
Some research indicates that
mindfulness meditation may bring about favorable structural changes in the
brain, including changes in brain structures that are associated with BPD. Mindfulness-based interventions also appear to
bring about an improvement in symptoms characteristic of BPD, and some clients
who underwent mindfulness-based treatment no longer met a minimum of five of
the DSM-IV-TR diagnostic criteria for BPD.
Medications
A 2010 review by the Cochrane
collaboration found that no medications show promise for "the core BPD
symptoms of chronic feelings of emptiness, identity disturbance, and
abandonment." However, the authors found that some medications may impact
isolated symptoms associated with BPD or the symptoms of comorbid conditions. 2017 review examined evidence published since
the 2010 Cochrane review and found that "evidence of effectiveness of
medication for BPD remains very mixed and is still highly compromised by suboptimal
study design."
Of the typical antipsychotics studied
in relation to BPD, haloperidol may reduce anger and flupenthixol may reduce
the likelihood of suicidal behavior. Among the atypical antipsychotics, one
trial found that aripiprazole may reduce interpersonal problems and
impulsivity. Olanzapine, as well as
quetiapine, may decrease affective instability, anger, psychotic paranoid
symptoms, and anxiety, but a placebo had a greater benefit on suicidal ideation
than olanzapine did. The effect of ziprasidone was not significant.
Of the mood stabilizers studied, valproate
semi sodium may ameliorate depression, impulsivity, interpersonal problems, and
anger. Lamotrigine may reduce impulsivity and anger; topipiramate may
ameliorate interpersonal problems, impulsivity, anxiety, anger, and general
psychiatric pathology. The effect of carbamazepine was not significant. Of the
antidepressants, amitriptyline may reduce depression, but mianserin, fluoxetine,
fluvoxamine, and phenelzine, sulfate showed no effect. Omega-3 fatty acid may ameliorate suicidality
and improve depression. As of 2017, trials with these medications had not been
replicated and the effect of long-term use had not been assessed.
Because of weak evidence and the
potential for serious side effects from some of these medications, the UK
National Institute for Health and Clinical Excellence (NICE) 2009 clinical
guideline for the treatment and management of BPD recommends, "Drug
treatment should not be used specifically for borderline personality disorder
or for the individual symptoms or behavior associated with the disorder."
However, "drug treatment may be considered in the overall treatment of
comorbid conditions". They suggest a "review of the treatment of
people with borderline personality disorder who do not have a diagnosed
comorbid mental or physical illness and who are currently being prescribed
drugs, with the aim of reducing and stopping unnecessary drug treatment".
Services
There is a significant difference
between the number of those who would benefit from treatment and the number of
those who are treated. The so-called "treatment gap" is a function of
the disinclination of the afflicted to submit for treatment, an underdiagnosing
of the disorder by healthcare providers, and the limited availability and
access to state-of-the-art treatments. Nonetheless, individuals with BPD accounted
for about 20 percent of psychiatric hospitalizations in one survey. The majority of individuals with BPD who are
in treatment continue to use outpatient treatment in a sustained manner for
several years, but the number using the more restrictive and costly forms of
treatment, such as inpatient admission, declines with time.
Experience of services varies. Assessing suicide risk can be a challenge for
clinicians, and patients themselves tend to underestimate the lethality of
self-injurious behaviors. People with BPD typically have a chronically elevated
risk of suicide much above that of the general population and a history of
multiple attempts when in crisis. Approximately half the individuals who commit
suicide meet criteria for a personality disorder. Borderline personality
disorder remains the most commonly associated personality disorder with
suicide.
After a patient suffering from BPD
died, The National Health Service (NHS) in England was criticized by a coroner
in 2014 for the lack of commissioned services to support those with BPD.
Evidence was given that 45% of female patients had BPD and there was no
provision or priority for therapeutic psychological services. At the time,
there were 60 specialized inpatient beds in England, all of them located in
London or the northeast region.
Prognosis
With treatment, the majority of
people with BPD can find relief from distressing symptoms and achieve remission,
defined as a consistent relief from symptoms for at least two years. A longitudinal study tracking the symptoms of
people with BPD found that 34.5% achieved remission within two years from the
beginning of the study. Within four years, 49.4% had achieved remission, and
within six years, 68.6% had achieved remission. By the end of the study, 73.5%
of participants were found to be in remission. Moreover, of those who achieved recovery from
symptoms, only 5.9% experienced recurrences. A later study found that ten years
from baseline (during a hospitalization), 86% of patients had sustained a
stable recovery from symptoms.
Patient personality can play an
important role during the therapeutic process, leading to better clinical
outcomes. Recent research has shown that BPD patients undergoing dialectical
behavior therapy (DBT) exhibit better clinical outcomes correlated with higher
levels of the trait of agreeableness in the patient, compared to patients
either low in agreeableness or not being treated with DBT. This association was
mediated through the strength of a working alliance between patient and
therapist; that is, more agreeable patients developed stronger working
alliances with their therapists, which in turn, led to better clinical outcomes.
In addition to recovering from
distressing symptoms, people with BPD also achieve high levels of psychosocial functioning.
A longitudinal study tracking the social and work abilities of participants
with BPD found that six years after diagnosis, 56% of participants had good
function in work and social environments, compared to 26% of participants when
they were first diagnosed. Vocational achievement was generally more limited,
even compared to those with other personality disorders. However, those whose symptoms
had remitted were significantly more likely to have good relationships with a
romantic partner and at least one parent, good performance at work and school,
a sustained work and school history, and good psychosocial functioning overall.
Epidemiology
The prevalence of BPD was initially
estimated to be 1 to 2 percent of the general population and to occur three
times more often in women than in men. However, the lifetime prevalence of BPD in a
2008 study was found to be 5.9% of the general population, occurring in 5.6% of
men and 6.2% of women. The difference in
rates between men and women in this study was not found to be statistically
significant.
Borderline personality disorder is
estimated to contribute to 20 percent of psychiatric hospitalizations and to
occur among 10 percent of outpatients.
29.5 percent of new inmates in the
U.S. state of Iowa fit a diagnosis of borderline personality disorder in 2007,
and the overall prevalence of BPD in the U.S. prison population is thought to
be 17 percent. These high numbers may be
related to the high frequency of substance abuse and substance use disorders among
people with BPD, which is estimated at 38 percent.
History
Devaluation in Edvard Munch's Salome
(1903). Idealization and devaluation of others in personal relations is a
common trait in BPD. The painter Edvard Munch depicted his new friend, the
violinist Eva Mudocci, in both ways within days. First as "a woman seen by
a man in love", then as "a bloodthirsty and cannibalistic
Salome”. In modern times, Munch has been
diagnosed as having had BPD.
The coexistence of intense,
divergent moods within an individual was recognized by Homer, Hippocrates, and
Aretaeus, the latter describing the vacillating presence of impulsive anger,
melancholia, and mania within a single person. The concept was revived by Swiss
physician Théophile Bonet in 1684 who, using the term folie
maniaco-mélancolique, described the phenomenon of unstable moods that
followed an unpredictable course. Other writers noted the same pattern,
including the American psychiatrist Charles H. Hughes in 1884 and J.C. Rosse in
1890, who called the disorder "borderline insanity". In 1921, Kraepelin identified an
"excitable personality" that closely parallels the borderline
features outlined in the current concept of BPD.
The first significant psychoanalytic
work to use the term "borderline" was written by Adolf Stern in 1938.
It described a group of patients
suffering from what he thought to be a mild form of schizophrenia, on the borderline
between neurosis and psychosis.
The 1960s and 1970s saw a shift from
thinking of the condition as borderline schizophrenia to thinking of it as a
borderline affective disorder (mood disorder), on the fringes of bipolar
disorder, cyclothymia, and dysthymia. In the DSM-II, stressing the intensity
and variability of moods, it was called cyclothymic personality (affective
personality). While the term
"borderline" was evolving to refer to a distinct category of
disorder, psychoanalysts such as Otto Kernberg were using it to refer to a
broad spectrum of issues, describing an intermediate level of personality
organization between neurosis and psychosis.
After standardized criteria were
developed to distinguish it from mood disorders and other Axis I disorders, BPD
became a personality disorder diagnosis in 1980 with the publication of the DSM-III. The diagnosis was distinguished from
sub-syndromal schizophrenia, which was termed "Schizotypal personality
disorder”. The DSM-IV Axis II Work Group of the American
Psychiatric Association finally decided on the name "borderline
personality disorder", which is still in use by the DSM-5 today. However, the term "borderline" has
been described as uniquely inadequate for describing the symptoms
characteristic of this disorder.
Etymology
Earlier versions of the DSM, prior
to the multiaxial diagnosis system, classified most people with mental health
problems into two categories, the psychotics and the neurotics. Clinicians
noted a certain class of neurotics who, when in crisis, appeared to straddle
the borderline into psychosis. The term stuck and evolved into the personality
disorder diagnosis of today.
Controversies
Credibility
and validity of testimony
The credibility of individuals with
personality disorders has been questioned at least since the 1960s. Two concerns are the incidence of dissociation
episodes among people with BPD and the belief that lying is a key component of
this condition.
Dissociation
Researchers disagree about whether
dissociation, or a sense of detachment from emotions and physical experiences,
impacts the ability of people with BPD to recall the specifics of past events.
A 1999 study reported that the specificity of autobiographical memory was
decreased in BPD patients. The
researchers found that decreased ability to recall specifics was correlated
with patients' levels of dissociation.
Lying
as a feature
Some theorists argue that patients
with BPD often lie. However, others
write that they have rarely seen lying among patients with BPD in clinical
practice.
The belief that lying is a
distinguishing characteristic of BPD can impact the quality of care that people
with this diagnosis receive in the legal and healthcare systems.
Gender
Since BPD can be a stigmatizing diagnosis
even within the mental health community, some survivors of childhood abuse who
are diagnosed with BPD are re-traumatized by the negative responses they
receive from healthcare providers. One
camp argues that it would be better to diagnose these men or women with
post-traumatic stress disorder, as this would acknowledge the impact of abuse
on their behavior. Critics of the PTSD diagnosis argue that it medicalizes
abuse rather than addressing the root causes in society. Regardless, a diagnosis of PTSD does not
encompass all aspects of the disorder
Joel Paris states that "In the
clinic ... Up to 80% of patients are women. That may not be true in the
community." He offers the following
explanations regarding these gender discrepancies:
The most probable explanation for
gender differences in clinical samples is that women are more likely to develop
the kind of symptoms that bring patients in for treatment. Twice as many women
as men in the community suffer from depression (Weissman & Klerman, 1985).
In contrast, there is a preponderance of men meeting criteria for substance
abuse and psychopathy (Robins & Regier, 1991), and males with these
disorders do not necessarily present in the mental health system. Men and women
with similar psychological problems may express distress differently. Men tend
to drink more and carry out more crimes. Women tend to turn their anger on themselves;
leading to depression as well as the cutting and overdosing that characterize
BPD. Thus, anti-social personality disorder (ASPD) and borderline personality
disorders might derive from similar underlying pathology but present with
symptoms strongly influenced by gender (Paris, 1997a; Looper & Paris,
2000).
We have even more specific evidence that men with BPD may not seek help. In a
study of completed suicides among people aged 18 to 35 years (Lesage et al.,
1994), 30% of the suicides involved individuals with BPD (as confirmed by
psychological autopsy, in which symptoms were assessed by interviews with
family members). Most of the suicide completers were men, and very few were in
treatment. Similar findings emerged from a later study conducted by our own
research group (McGirr, Paris, Lesage, Renaud, & Turecki, 2007).
In short, men are less likely to
seek or accept appropriate treatment, more likely to be treated for symptoms of
BPD such as substance abuse rather than BPD itself (the symptoms of BPD and
ASPD possibly deriving from a similar underlying aetiology), possibly more
likely to wind up in the correctional system due to criminal behavior, and possibly
more likely to commit suicide prior to diagnosis.
Among men diagnosed with BPD there
is also evidence of a higher suicide rate: "men are more than twice as
likely as women—18 percent versus 8 percent"—to die by suicide.
There are also sex differences in
borderline personality disorders. Men
with BPD are more likely to abuse substances, have explosive temper, high
levels of novelty seeking and have anti-social, narcissistic,
passive-aggressive or sadistic personality traits. Women with BPD are more likely to have eating
disorders, mood disorders, anxiety and post-traumatic stress.
Manipulative
behavior
Manipulative behavior to obtain
nurturance is considered by the DSM-IV-TR and many mental health professionals
to be a defining characteristic of borderline personality disorder. However, Marsha Linehan notes that doing so
relies upon the assumption that people with BPD who communicate intense pain,
or who engage in self-harm and suicidal behavior, do so with the intention of
influencing the behavior of others. The
impact of such behavior on others—often an intense emotional reaction in
concerned friends, family members, and therapists—is thus assumed to have been
the person's intention.
However, their frequent expressions
of intense pain, self-harming, or suicidal behavior may instead represent a
method of mood regulation or an escape mechanism from situations that feel
unbearable.
Stigma
The features of BPD include
emotional instability; intense, unstable interpersonal relationships; a need
for intimacy; and a fear of rejection. As a result, people with BPD often evoke
intense emotions in those around them. Pejorative terms to describe people with
BPD, such as "difficult", "treatment resistant",
"manipulative", "demanding", and "attention-seeking",
are often used and may become a self-fulfilling prophecy, as the negative
treatment of these individuals triggers further self-destructive behavior.
Physical
violence
The stigma surrounding borderline
personality disorder includes the belief that people with BPD are prone to
violence toward others. While movies and
visual media often sensationalize people with BPD by portraying them as
violent, the majority of researchers agree that people with BPD are unlikely to
physically harm others. Although people
with BPD often struggle with experiences of intense anger, a defining
characteristic of BPD is that they direct it inward toward themselves. One of the key differences between BPD and antisocial
personality disorder (ASPD) is that people with BPD tend to internalize anger
by hurting themselves, while people with ASPD tend to externalize it by hurting
others.
In addition, adults with BPD have
often experienced abuse in childhood; so many people with BPD adopt a
"no-tolerance" policy toward expressions of anger of any kind. Their extreme aversion to violence can cause
many people with BPD to overcompensate and experience difficulties being
assertive and expressing their needs. This is one way in which people with BPD
choose to harm themselves over potentially causing harm to others. Another way in which people with BPD avoid
expressing their anger through violence is by causing physical damage to them,
such as engaging in non-suicidal self-injury.
Mental
health care providers
People with BPD are considered to be
among the most challenging groups of patients to work with in therapy,
requiring a high level of skill and training for the psychiatrists, therapists
and nurses involved in their treatment. A majority of psychiatric staff report finding
individuals with BPD moderately to extremely difficult to work with and more
difficult than other client groups. Efforts are ongoing to improve public and
staff attitudes toward people with BPD.
In psychoanalytic theory, the stigmatization
among mental health care providers may be thought to reflect countertransference
(when a therapist projects his or her own feelings on to a client). Thus, a
diagnosis of BPD "often says more about the clinician's negative reaction
to the patient than it does about the patient" and "explains away the
breakdown in empathy between the therapist and the patient and becomes an
institutional epithet in the guise of pseudoscientific jargon". This inadvertent countertransference can give
rise to inappropriate clinical responses, including excessive use of
medication, inappropriate mothering, and punitive use of limit setting and
interpretation.
Some clients feel the diagnosis is
helpful, allowing them to understand that they are not alone and to connect
with others with BPD who has developed helpful coping mechanisms. However,
others experience the term “borderline personality disorder” as a pejorative
label rather than an informative diagnosis. They report concerns that their
self-destructive behavior is incorrectly perceived as manipulative and that the
stigma surrounding this disorder limits their access to health care. Indeed, mental health professionals frequently
refuse to provide services to those who have received a BPD diagnosis.
Terminology
Because of concerns around stigma,
and because of a move away from the original theoretical basis for the term, there
is ongoing debate about renaming borderline personality disorder. While some
clinicians agree with the current name, others argue that it should be changed,
since many who are labelled with borderline personality disorder find the name
unhelpful, stigmatizing, or inaccurate. Valerie Porr, president of Treatment and
Research Advancement Association for Personality Disorders states that
"the name BPD is confusing, imparts no relevant or descriptive
information, and reinforces existing stigma."
Alternative suggestions for names
include emotional regulation disorder or emotional dysregulation disorder. Impulse disorder
and interpersonal regulatory disorder are other valid alternatives,
according to John G. Gunderson of McLean Hospital in the United States. Another term suggested by psychiatrist Carolyn
Quadrio is post traumatic personality disorganization (PTPD), reflecting
the condition's status as (often) both a form of chronic post-traumatic stress
disorder (PTSD) as well as a personality disorder. However, although many with BPD do have
traumatic histories, some do not report any kind of traumatic event, which
suggests that BPD is not necessarily a trauma spectrum disorder.
The Treatment and Research
Advancements National Association for Personality Disorders (TARA-APD)
campaigned unsuccessfully to change the name and designation of BPD in DSM-5,
published in May 2013, in which the name "borderline personality
disorder" remains unchanged and it is not considered a trauma- and
stressor-related disorder.
Society
and culture
Fiction
Films and television shows have
portrayed characters either explicitly diagnosed with or exhibiting traits
suggestive of BPD. These may be misleading if they are thought to depict this
disorder accurately. The majority of
researchers agree that in reality, people with BPD are very unlikely to harm
others.
Robert O. Friedel has suggested that
the behavior of Theresa Dunn, the leading character of Looking for Mr. Goodbar (1975) is consistent with a diagnosis of
borderline personality disorder.
The films Play Misty for Me (1971) and Girl,
Interrupted (1999, based on the eponymous memoir) both suggest the
emotional instability of the disorder. The film Single
White Female (1992), like the first example, also suggests characteristics,
some of which are actually atypical of the disorder: the character Hedy had
markedly disturbed sense of identity and reacts drastically to abandonment. In a review of the film Shame (2011) for the British journal The Art of Psychiatry,
another psychiatrist, Abby Seltzer, praises Carey Mulligan's portrayal of a
character with the disorder even though it is never mentioned onscreen.
Films attempting to depict
characters with the disorder include A
Thin Line Between Love and Hate (1996), Filth
(2013), Fatal Attraction (1987), The Crush (1993), Mad Love (1995), Malicious
(1995), Interiors (1978), The Cable Guy (1996), Mr. Nobody (2009), Moksha (2001), Cracks (2009),
Welcome Me (2014). Psychiatrists Eric Bui and Rachel Rodgers
argue that the Anakin Skywalker/Darth Vader character in the Star Wars films meets six of the nine
diagnostic criteria; Bui also found Anakin a useful example to explain BPD to
medical students. In particular, Bui points to the character's abandonment
issues, uncertainty over his identity, and dissociative episodes.
On television, The CW show Crazy Ex-Girlfriend portrays a main
character with borderline personality disorder and Emma Stone’s character in the
Netflix miniseries Maniac is
diagnosed with the disorder. Additionally, incestuous twins Cersei and
Jaime Lannister, in George R. R. Martin's A Song of Ice and Fire series and its
television adaptation, Game of Thrones,
have traits of borderline and narcissistic personality disorders.
Awareness
In early 2008, the United Stated
House of Representatives declared the month of May Borderline Personality
Disorder Awareness Month.
