Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies

Summary & key facts

This paper is a long review of what we know about borderline personality disorder, or BPD. It explains how BPD is diagnosed, what the main symptoms are, what may cause it, and what treatments seem to help. The review says BPD causes big problems in life, often starts after difficult childhood experiences combined with genetic risk, and that talking therapies are the best-proven treatment. Medicines do not clearly help the core features. The authors say more research is still needed.

Key facts:

• Borderline personality disorder first appeared as a diagnosis in 1980, and its main defining features have stayed mostly the same since then.
• BPD is marked by unstable self-image, unstable close relationships, strong mood swings, impulsive acts, intense anger, feeling empty, fear of being abandoned, and sometimes brief paranoid or dissociative episodes.
• People with BPD have a high risk of self-harm and suicide, and the disorder often causes serious problems at work, school, and in relationships.
• In the general adult population, lifetime BPD has been reported in about 0.7% to 2.7% of people; it is found in about 12% of psychiatric outpatients and about 22% of psychiatric inpatients.
• BPD often occurs with other mental health problems, including depression, anxiety and post-traumatic stress, attention problems like ADHD, substance use problems, bipolar disorder, and eating disorders such as bulimia.
• Research suggests that BPD most likely comes from a mix of genetic vulnerability and harmful or stressful experiences in childhood, though the exact brain changes behind the disorder are still unclear.
• Psychotherapy (talk therapy) is the main treatment. Several types of therapy have been shown to work in careful studies, including dialectical behavior therapy, mentalization-based therapy, transference-focused therapy, and schema therapy.
• Compared to usual care, psychotherapy produces a moderate improvement in core BPD symptoms. The measured effects are roughly in the middle range used by researchers, but about half of people still do not get enough benefit from current therapies.
• There is no consistent evidence that any medication reliably improves the core features of BPD. Medicines may still be useful for short periods to treat very severe anxiety, depression, or psychotic-like symptoms that occur alongside BPD.
• The authors say early diagnosis and treatment can help reduce suffering and costs, but they also call for more high-quality studies in both teenagers and adults.

Abstract

Borderline personality disorder (BPD) was introduced in the DSM-III in 1980. From the DSM-III to the DSM-5, no major changes have occurred in its defining criteria. The disorder is characterized by instability of self-image, interpersonal relationships and affects. Further symptoms include impulsivity, intense anger, feelings of emptiness, strong abandonment fears, suicidal or self-mutilation behavior, and transient stress-related paranoid ideation or severe dissociative symptoms. There is evidence that BPD can be reliably diagnosed and differentiated from other mental disorders by semi-structured interviews. The disorder is associated with considerable functional impairment, intensive treatment utilization, and high societal costs. The risk of self-mutilation and suicide is high. In the general adult population, the lifetime prevalence of BPD has been reported to be from 0.7 to 2.7%, while its prevalence is about 12% in outpatient and 22% in inpatient psychiatric services. BPD is significantly associated with other mental disorders, including depressive disorders, substance use disorders, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, bipolar disorder, bulimia nervosa, and other personality disorders. There is convincing evidence to suggest that the interaction between genetic factors and adverse childhood experiences plays a central role in the etiology of BPD. In spite of considerable research, the neurobiological underpinnings of the disorder remain to be clarified. Psychotherapy is the treatment of choice for BPD. Various approaches have been empirically supported in randomized controlled trials, including dialectical behavior therapy, mentalization-based therapy, transference-focused therapy, and schema therapy. No approach has proved to be superior to others. Compared to treatment as usual, psychotherapy has proved to be more efficacious, with effect sizes between 0.50 and 0.65 with regard to core BPD symptom severity. However, almost half of the patients do not respond sufficiently to psychotherapy, and further research in this area is warranted. It is not clear whether some patients may benefit more from one psychotherapeutic approach than from others. No evidence is available consistently showing that any psychoactive medication is efficacious for the core features of BPD. For discrete and severe comorbid anxiety or depressive symptoms or psychotic-like features, pharmacotherapy may be useful. Early diagnosis and treatment of BPD can reduce individual suffering and societal costs. However, more high-quality studies are required, in both adolescents and adults. This review provides a comprehensive update of the BPD diagnosis and clinical characterization, risk factors, neurobiology, cognition, and management. It also discusses the current controversies concerning the disorder, and highlights the areas in which further research is needed.

Topics

Bipolar Disorder and Treatment Personality Disorders and Psychopathology Suicide and Self-Harm Studies

Categories

Clinical Psychology Psychology Social Sciences

Tags

Anxiety Bipolar disorder Borderline personality disorder Clinical psychology Environmental health Hypomania Impulsivity Mania Medicine Mood Panic disorder Poison control Population Psychiatry Psychology Suicidal ideation Suicide prevention

Conditions & symptoms

ADHD Anxiety Depression Eating Disorder Panic disorder and phobias PTSD Substance abuse disorder Anxiety or worry Difficulty focusing Feeling disconnected from others Sadness or low mood