Borderline Personality Disorder (Conclusion)

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.