We searched MEDLINE for articles with the main search term “borderline personality disorder”. We chose articles relevant to the topics epidemiology, diagnosis, pathophysiology, psychotherapy, and pharmacotherapy, with special emphasis on randomised controlled trials.
SeminarBorderline personality disorder
Section snippets
Epidemiology
In epidemiological studies of adults, the weighted prevalence of borderline personality disorder ranges from 0·7% in Norway to 1·8% in the USA.1, 2 Additionally, findings from these studies showed that the disorder was more common in women than in men (about 70% and 30%, respectively), indicating the sex difference that is typical in treated-patients.3 In a community-based sample of children and adolescents, the prevalence of borderline personality disorder was 11% at age 9–19 years and 7·8% at
Diagnosis
The panel lists the nine diagnostic and statistical manual of mental disorders (DSM) IV criteria for borderline personality disorder—which in the international classification of diseases 10th revision is a subtype of emotionally unstable personality disorders. Here, we have organised these criteria into four sectors of psychopathology because patients who manifest symptoms in all four areas simultaneously can be successfully discriminated from those with other forms of personality disorder.9
The
Causal factors
The cause of borderline personality disorder is complex with several factors, which interact in various ways wtih each other (figure). Genetic factors and adverse childhood experiences might cause emotional dysregulation and impulsivity leading to dysfunctional behaviours and psychosocial conflicts and deficits, which again might reinforce emotional dysregulation and impulsivity.22 Data for the role of genetic factors are sparse. In one twin study, based on DSM-IV criteria, concordance rates
Neurobiological findings
The neurobiological factors of borderline personality disorder, such as impulsivity and affect dysregulation, are poorly understood. In view of the heterogeneity of the disorder, workers have investigated distinct subgroups in search of different endophenotypes.21, 22, 38 Furthermore, sex seems to have an important role in the neurobiology of this disorder. Several researchers have recorded substantial39, 40, 41 differences between male and female patients with respect to serotonergic function.
Treatment
Over their lifetime, 97% of patients with borderline personality disorder presenting for treatment in the USA receive outpatient care from an average of six therapists;57, 58 95% receive individual therapy, 56% group therapy, 42% family or couples psychotherapy, 37% day treatment, 72% psychiatric hospitalisation, and 24% treatment in a halfway house. 9–40% of frequent users of inpatient psychiatric services are diagnosed with the disorder.3, 59, 60, 61, 62
Analyses of outcomes measured 2–3 years
Psychosocial interventions
Very few randomised controlled trials have assessed psychosocial interventions for borderline personality disorder, especially compared with the number of trials for other psychiatric disorders. Over the past 10 years, however, two structured psychotherapeutic programmes have emerged as effective interventions for this disorder. Both treatments target the highly dysfunctional and out-of-control patient. Of the two, a variation of cognitive behavioural therapy—dialectical behaviour therapy
Pharmacotherapy
High proportions of patients with this disorder are continuously taking medication, and rates of intensive polypharmacy are not uncommon and do not decline with time.88 Results of placebo-controlled trials (table 2)89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100 suggest that pharmacotherapy for borderline personality disorder could be used to target certain aspects, such as cognitive-perceptual symptoms, emotional dysregulation, or impulsive-behavioural dyscontrol.101, 102 In many patients,
Course and prognosis
Research suggests that borderline personality disorder, or at least some of its symptoms, begins in the late latency period of childhood but that treatment is typically not sought until late adolescence.6 The disorder has a better prognosis than other serious mental illnesses, such as bipolar disorder.117, 118 In two large-scale prospective studies of the course of borderline personality disorder, symptoms have been noted to be less stable than previously recognised.116, 119 After 6 years'
Future prospects
Much still needs to be learned about borderline personality disorder. If the prodromal condition or the actual disorder first manifests itself in childhood or adolescence, early intervention and prevention strategies need to be developed. Irrespective of when the disorder first develops, current treatments are suboptimum, and better and more cost-effective treatments are needed. Until now, the most broadly effective treatments are the psychosocial interventions, especially DBT, which not only
Search Strategy and Selection Criteria
References (126)
- et al.
Treatment histories of borderline inpatients
Compr Psychiatry
(2001) - et al.
Experience of aversive tension and dissociation in female patients with borderline personality disorder: a controlled study
J Psychiatr Res
(2001) - et al.
Axis I diagnostic comorbidity and borderline personality disorder
Compr Psychiatry
(1999) - et al.
Axis II comorbidity of borderline personality disorder
Compr Psychiatry
(1998) - et al.
The borderline diagnosis I: psychopathology, comorbidity, and personality structure
Biol Psychiatry
(2002) - et al.
The borderline diagnosis II: biology, genetics, and clinical course
Biol Psychiatry
(2002) - et al.
A twin study of personality disorders
Compr Psychiatry
(2000) - et al.
Childhood experiences of borderline patients
Compr Psychiatry
(1989) - et al.
Psychological risk factors for borderline personality disorder in female patients
Compr Psychiatry
(1994) - et al.
The borderline diagnosis III: identifying endophenotypes for genetic studies
Biol Psychiatry
(2002)
Impulsivity, gender, and response to fenfluramine challenge in borderline personality disorder
Psychiatry Res
Brain glucose metabolism in borderline personality disorder
J Psychiatr Res
Impulsivity and prefrontal hypometabolism in borderline personality disorder
Psychiatry Res
Positron emission tomography in female patients with borderline personality disorder
J Psychiatr Res
A fenfluramine-activated FDG-PET study of borderline personality disorder
Biol Psychiatry
A brain MRI study in subjects with borderline personality disorder
J Affect Disord
Frontolimbic brain abnormalities in patients with borderline personality disorder: a volumetric magnetic resonance imaging study
Biol Psychiatry
Neural correlates of memories of abandonment in women with and without borderline personality disorder
Biol Psychiatry
A positron emission tomography study of memories of childhood abuse in borderline personality disorder
Biol Psychiatry
Evidence of abnormal amygdala functioning in borderline personality disorder: a functional MRI study
Biol Psychiatry
Amygdala hyperreactivity in borderline personality disorder: implications for emotional dysregulation
Biol Psychiatry
Magnetic resonance imaging of hippocampal and amygdala volume in women with childhood abuse and borderline personality disorder
Psychiatry Res
Hyperresponsiveness of hypothalamic-pituitary-adrenal axis to combined dexamethasone/corticotropin-releasing hormone challenge in female borderline personality disorder subjects with a history of sustained childhood abuse
Biol Psychiatry
Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder
Drug Alcohol Depend
Naturalistic evaluation of dialectical behavior therapy-oriented treatment for borderline personality disorder
Cognit Behav Practice
Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder
Behav Ther
Dialectical behavior therapy of borderline patients with and without substance use problems: implementation and long-term effects
Addict Behav
DBT with an inpatient forensic population: the CMHIP forensic model
Cognit Behav Practice
Evaluation of inpatient dialectical-behavioral therapy for borderline personality disorder: a prospective study
Behav Res Ther
Effectiveness of inpatient dialectical behavioral therapy for borderline personality disorder: a controlled trial
Behav Res Ther
A trial of carbamazepine in borderline personality disorder
Eur Neuropsychopharmacol
The prevalence of personality disorders in a community sample
Arch Gen Psychiatry
Estimating the prevalence of borderline personality disorder in the community
J Personal Disord
Epidemiology of borderline personality disorder
Hosp Comm Psychiatry
Functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder
Am J Psychiatry
Practice guideline for the treatment of patients with borderline personality disorder—introduction
Am J Psychiatry
Treatment utilization by patients with personality disorders
Am J Psychiatry
Prevalence and stability of the DSM-III-R personality disorders in a community-based survey of adolescents
Am J Psychiatry
Discriminating borderline personality disorder from other axis II disorders
Am J Psychiatry
The pain of being borderline: dysphoric states specific to borderline personality disorder
Harv Rev Psychiatry
Characterizing affective instability in borderline personality disorder
Am J Psychiatry
Cognitive features of borderline personality disorder
Am J Psychiatry
An empirical study of psychosis in borderline personality disorder
Am J Psychiatry
Comorbidity of axis I and axis II disorders
Am J Psychiatry
Axis I comorbidity of borderline personality disorder
Am J Psychiatry
The Collaborative Longitudinal Personality Disorders Study: baseline axis I/II and II/II diagnostic co-occurrence
Acta Psychiatr Scand
Diagnosing personality disorders: a review of issues and research models
Arch Gen Psychiatry
Phenotypic and genetic structure of traits delineating personality disorder
Arch Gen Psychiatry
Reported pathological childhood experiences associated with the development of borderline personality disorder
Am J Psychiatry
Characteristics of borderline personality disorder: a Canadian study
Can J Psychiatry
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Group interpersonal psychotherapy (IPT-G) for borderline personality disorder: A randomized controlled study
2023, Journal of Psychiatric ResearchResting-state functional magnetic resonance imaging alterations in borderline personality disorder: A systematic review
2023, Journal of Affective DisordersReadiness and Personality Disorders: Considering Patients' Readiness for Change and Our System's Readiness for Patients
2024, Harvard Review of Psychiatry