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Summary

Criteria listed in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition; DSM-5): borderline personality disorder (BPD) is characterized by persistently unstable relationships and self-image; individual has high impulsivity with onset in early adulthood; out of the 9 diagnostic criteria, ≥5 are needed to be diagnosed with BPD; these are classified into 4 categories; affective symptoms — include inappropriate anger, feelings of emptiness, and mood instability; cognitive symptoms — stress-related paranoia and dissociation, identity disturbance (an unstable sense of self); behavioral symptoms — most concerning symptoms for psychiatrists; there is recurrent suicidal behavior and/or self-harm, and impulsivity (eg, inappropriate spending, eating); interpersonal symptoms — the most characteristic symptoms of BPD; include abandonment fears and unstable relationships; using polythetic approach to diagnosis, 151 combinations of symptoms are possible (according to Sanislow et al [2002])

Diagnosis: BPD often overlooked during clinical assessment by clinicians because of lack of precise questions; possibly related to clinician discomfort with the concept of BPD; many patients are seen as unlikable, untreatable, or even dangerous; there is also stigma surrounding the diagnosis, among patients and clinicians; according to speaker’s 2011 study, 47% of health care professionals admit to avoiding caring for BPD patients

Zanarini Rating Scale for BPD: includes 9 questions corresponding to symptoms listed in the DSM-5; a time range for the symptom is chosen (typically the previous week); answers are scaled from 0 (symptom absent) to 4 (very problematic); the patient answers such questions as “Have you found your mood has suddenly changed”, “Have you been unsure of who you are or what you are really like”, “Have you had episodes when you feel spaced out or numb”; mood instability and identity disturbance are likely the most important topics for screening

Self-rating scale: patient questionnaire includes 15 questions and scaling from 1 to 5; topics include fear of abandonment, and believing a trusted person has become untrustworthy; scores can change with each visit

Importance of diagnosis: BPD is associated with increased morbidity and mortality, increased health care use, and poor response to medication for, eg, comorbid depression; some individuals need specialized psychological care; this includes the Systems Training for Emotional Predictability and Problem Solving (STEPS) program or dialectical behavior therapy; this should be used only after a complete diagnosis

Epidemiology: prevalence is 1% to 2% in the community, ≈6% in primary care settings, 10% in psychiatric outpatients, 20% in psychiatric inpatients, and ≈30% in prison populations (according to one study), including male and female offenders; thus it affects 2 to 4 million people in the United States; most patients are female (70% vs 30%); this has been confirmed in studies; psychiatric comorbidities include major depression; may be chronic but typically recurrent; others include substance use disorders, posttraumatic stress disorder (PTSD), social phobia, panic disorder, eating disorders, and bipolar disorder (10%-20% meet criteria)

Onset and course: onset in late teens or early 20s; mood instability may extend back to childhood; higher severity seen earlier; over time, the disorder attenuates and is easier to manage; BPD improves even over relatively short periods of time; according to longitudinal study and 6-yr follow up by Zanarini et al (2003), emotional disturbances persisted in most patients but patients were improved and 75% of patients no longer met threshold for diagnosis; this means individuals in their 40s, 50s, and 60s are likely less impulsive, with lower risk for self-harm or suicidal behaviors (eg, overdosing on medication); ≈73% of patients with BPD attempt suicide and ≈75% engage in deliberate self-harm

Risk factors: heritability is ≈0.6; childhood neglect and physical and sexual abuse are included; the disorder likely results from a combination of genetics and environment; brain imaging findings show limbic excitability in the amygdala and insula and sluggish control mechanisms, especially in the dorsolateral prefrontal cortex

Treatment options: includes psychological treatments (individual and group psychotherapy), pharmacotherapy, and lifestyle alterations; clinician should assess patient (including their treatment preferences); consideration should include psychiatric comorbidity to identify depression, anxiety, substance abuse, PTSD, stage of illness, and psychosocial situation; consider accessibility of treatment

Evidence-based psychotherapy programs: mainstay of treatment; it includes group and individual therapy (eg, dialectical behavior therapy, mentalization-based therapy), and adjunctive programs (eg, STEPS program); does not replace treatment; individual programs include cognitive therapy, schema-focused therapy, transference-focused psychotherapy, and general psychiatric management; according to randomized controlled trials (RCTs), therapies are equally effective for improvements of symptoms, including self-harm, mood regulation, and health care use; STEPS is the shortest (5 mo); Schema-focused therapy is the longest (3 yr); patients must be psychologically ready to engage in a program; decision also depends on program availability; dialectical behavior therapy is the most common; recommended to begin with a less intensive program (eg, STEPS) before using a comprehensive program

Pharmacotherapy: according to Paris (1994), it was viewed as disappointing and unsatisfactory, and patients show mild improvement with many drugs, but do not respond definitively to any; medication is widely prescribed for patients, but none are approved for BPD by the Food and Drug Administration; but, eg, an antidepressant for comorbid depression may be approved; studies show ≥90% of patients are prescribed medications (eg, antipsychotics, antidepressants, anticonvulsants, benzodiazepines, lithium carbonate); ≥3 medications were used in 54% of cases, according to a 2015 study involving a European database

Treatment guidelines for pharmacotherapy: Cochrane review (2010) — suggests benefit from second-generation antipsychotics, mood stabilizers, and omega-3 fatty acids, but not first-generation antipsychotics and antidepressants; further studies are needed; National Institute for Health and Care Excellence (2009) — stated that medication treats depression, anxiety, hostility, and impulsivity, but does not alter fundamental nature of BPD

Evidence for pharmacotherapy: RCTs published since 2006 are positive for aripiprazole, quetiapine, showed mixed results for olanzapine and lamotrigine, and negative for divalproex and naltrexone; benzodiazepines should be avoided because they might cause disinhibition and promote acting out; a 1988 study also recommended avoidance of benzodiazepines

Guidelines for pharmacotherapy: suggest to target the comorbidities and/or preponderant symptoms when using pharmacotherapy, eg, antidepressants for depression, mood stabilizers (eg, lithium carbonate) or second-generation antipsychotic for bipolar disorder; use antipsychotic for impulsive behavior; use aripiprazole and quetiapine to target the entire syndrome; avoid tricyclic antidepressants and monoamine oxidase (MAO) inhibitors because of risk for overdose (can be given to older patients); avoid benzodiazepines because of risk for an overlap in patients with substance use disorders; research suggests antipsychotics may be approved therapy in next 5 to 10 yr

Lifestyle changes: include appropriate nutrition and diet for obesity; encourage physical activity; patients tend to be inactive; encourage appropriate sleep and leisure activities; encourage compliance with treatment for patients’ physical disorders; encourage reading books to understand the illness