A collection of postings on a range of issues is available on our website (www.mjacksongroup.ca). This month’s post is again from Ken Pope’s listserv, where he kindly provides daily summaries of current articles in the field.
JAMA includes an article: “Borderline Personality Disorder: A Review.”
The authors are Falk Leichsenring, DSc1,2; Nikolas Heim, MA, MSc3; Frank Leweke, MD1; Carsten Spitzer, MD2; Christiane Steinert, PhD1,3; Otto F. Kernberg, MD4.Here’s how it opens:
Borderline personality disorder (BPD) is characterized by alterations in self-image and interpersonal relationships marked by sudden shifts between extremes of idealization (extremely positive views about the self or others) and devaluation (extremely negative views about the self or others).1,2 People with BPD typically experience intense anxiety, irritability, or dysphoria as well as impulsive behavior with regard to spending, sexual activity, substance misuse, or binge eating.1 Borderline personality disorder affects approximately 0.7% to 2.7% of adults.3,4
This Review summarizes current evidence regarding the epidemiology, pathophysiology, diagnosis, and treatment of BPD in adults.
Here’s another excerpt:
Although BPD affects approximately 0.7% to 2.7% of adults in the general population,3,4 higher prevalence rates were reported in primary care (6%), patients using outpatient psychiatric services (11%-12%), and patients treated in psychiatric hospitals (22%).4,5 In a US community sample of 34 481 adults, 2.7% had been diagnosed with BPD in their lifetime. In this study, only slightly higher rates were observed in women compared with men (3% vs 2.4%),6 while among 3800 patients treated in a psychiatric outpatient setting, considerably higher rates of BPD were found in women compared with men (72% vs 28%).5 The age of onset varies, but symptoms are usually manifest in early adulthood.1 Borderline personality disorder is associated with severe social and vocational impairments, such as inability to hold a job, high rates of comorbid mental disorders and somatic diseases, more frequent use of outpatient and inpatient medical services, high rates of suicide, and high direct medical and indirect costs (eg, sick-leave days). These factors are more common in patients with BPD compared with patients with anxiety and depressive disorders, diabetes, epilepsy, or Parkinson disease.7–12 Only approximately 16% of people with BPD were reported to be married or living with a partner and only about 35% had good work or school performance.13 People with BPD had worse global social functioning than people with other personality disorders (avoidant and obsessive-compulsive personality disorders) and higher rates of comorbid major depressive disorder.14
More patients with BPD than patients with other personality disorders die by suicide. A 24-year prospective follow-up study including 290 patients with BPD and 72 patients with other personality disorders reported that 5.9% of patients with BPD died by suicide compared with 1.4% of patients with other personality disorders.12
Borderline personality disorder is associated with significantly higher prevalences of other mental disorders.16 In the US study of 34 481 community-dwelling adults, people with BPD had higher rates of the following mental disorders in their lifetime: mood disorders such as major depression or bipolar disorder (83%), anxiety disorders (85%), substance use disorders (78%), posttraumatic stress disorder (PTSD) (30%), and other personality disorders (53%).6
In the general population, including approximately 12% of individuals with personality disorders including BPD,19 lifetime prevalence rates of mood disorders, anxiety disorders, PTSD, substance use disorders, and personality disorders were 21%, 34%, 8%, 3%, and 12%, respectively.19-21
Of patients with BPD, approximately 10% had bipolar I disorder (depressive and manic episodes) and an additional 10% had bipolar II disorder (depressive and hypomanic episodes).22,23 Among people with attention-deficit/hyperactivity disorder, the lifetime rate of BPD was 37.7%.24
In older compared with younger patients with BPD, a shift in symptoms toward more depression, feelings of emptiness, and somatic problems has been described.25-27
As people with BPD become older, emotional dysregulation, unstable interpersonal relationships, anger, and attachment insecurity typically persist, whereas impulsivity and identity disturbances tend to decrease.25,26 In older people with BPD, self-harm may manifest as nonadherence to medications or misuse of medication.26
Genetic factors and adverse childhood experiences may interact to influence brain development through altered hormones and neuropeptides, increasing the risk of BPD.7,37-40 Adverse childhood experiences may modulate gene expression and lead to stable personality traits.7,38,41 Borderline personality disorder is more common in people with a family history of BPD.7,42 For example, a population-based Swedish study including 1 851 755 participants, of whom 11 665 (0.6%) had a diagnosis of BPD according to the ICD-10, estimated heritability of BPD at 46%; the remaining 54% of variance was explained by nonshared environmental factors.43 The hazard ratio was highest in identical twins (11.5; 95% CI, 1.6-83.3). The risk of receiving a BPD diagnosis was increased 4.7-fold for full siblings.43 However, no single-nucleotide variants have been identified for BPD.44 Adverse childhood experiences including physical, sexual, or emotional abuse and neglect are more common in people with BPD.16,45,46 However, not all people diagnosed with BPD have a history of adverse childhood experiences.45 An empirically supported model of the neurobiology of BPD does not exist, as meta-analyses on neuroendocrinological processes47-49 and brain functioning50,51 found only a few differences in these variables among people with BPD compared with healthy controls. The most consistent finding was hyperactivity of the amygdala,50,51 but its role remains unclear.52
Patients with BPD should be informed of their diagnosis, the expected course of the disorder, etiology, and treatment options.54 Clinicians should set clear boundaries, avoid responding to provocative behavior, avoid polypharmacotherapy, and facilitate open communication and agreement on a consistent approach with all treating clinicians to prevent a situation in which some clinicians are regarded as “good” and others as “bad” (Table 1).54,55,67 The patient should be informed that effective methods of psychotherapy exist and that medications are appropriate only for treating discrete comorbid mental disorders or in situations of crisis, such as suicidal behavior, extreme anxiety, or psychotic episodes. This education of patients facilitates an alliance between patients and clinicians and may encourage patients to take part in psychotherapy.7 Typical crises in BPD consist of suicidal behavior or ideation, extreme anxiety, psychotic episodes, or other extreme behavior likely to endanger the patient or others, usually caused by interpersonal problems such as real or imagined abandonment or by shifts from idealization to devaluation. Life-threatening behaviors (eg, suicidal, self-mutilating, or high-risk behaviors, as well as attacks against others) should be identified and promptly treated (see Pharmacotherapy section and Table 1). With regard to comorbid mental disorders, experts suggest that comorbid bipolar I disorder, early-onset complex PTSD, severe substance misuse, and anorexia should be treated before BPD, since these disorders need to be well controlled before BPD can be treated successfully.7 In contrast, for patients who have comorbid depressive disorder, panic disorder, adult-onset PTSD, intermittent substance use disorder, or bulimia, treating BPD should take priority since these disorders will likely improve once BPD is controlled. In a randomized trial of 68 family members of patients with BPD, group psychoeducation about the disorder along with self-care and peer support skills reduced the emotional stress associated with BPD in family members compared with a wait-list control condition.68 If specialized methods of psychotherapy are not available, experienced mental health professionals may apply psychoeducation (informing a patient about the disorder and its treatments) or manage acute crises using pharmacotherapy and clinical management as described in the Pharmacotherapy section.69 Benefit for this generalist model of treating patients with BPD has emerged from several randomized clinical trials.70-72 This type of care can be carried out by experienced clinicians without training in the specialized methods of psychotherapy discussed below.69
Although the 2001 American Psychiatric Association practice guidelines for BPD recommended antidepressants such as fluoxetine, sertraline, or venlafaxine; mood stabilizers such as lithium carbonate, carbamazepine, or valproate; antipsychotics such as haloperidol; monoamine oxidase inhibitors such as phenelzine or tranylcypromine; or benzodiazepines such as alprazolam or clonazepam for affective dysregulation and impulsive behavior dyscontrol, new evidence has accumulated since these guidelines were published.73
No class of psychoactive medication has been consistently effective in treating BPD in randomized clinical trials, and therefore no medications have been approved by the US Food and Drug Administration or licensed for use in BPD in the UK.7,74–76 For these reasons, the UK National Institute for Health and Care Excellence (NICE) guideline does not recommend pharmacotherapy to treat any core symptom of BPD (eg, marked emotional instability, transient stress-related paranoid ideation).61,62 This is consistent with reviews of functional magnetic resonance imaging studies showing that pharmacotherapy does not induce changes in brain activity or brain connectivity,77 whereas psychotherapy appears to alter neural activities and connectivity of regions subserving executive control and emotion regulation.78 The NICE guideline recommends pharmacotherapy in BPD only for discrete and severe comorbid disorders such as severe depressive disorders, including suicidal ideation or severe anxiety disorders. For these types of comorbid disorders in BPD, selective serotonin reuptake inhibitors such as escitalopram, sertraline, or fluoxetine may be used. Antipsychotic drugs are not recommended by the NICE guideline for medium- or long-term treatment of BPD. For specific recommendations regarding the treatment of comorbid conditions in BPD, NICE recommends consulting the NICE clinical guidelines for the respective disorders. Few randomized clinical trials have focused on BPD with distinct comorbidities.76 Most randomized clinical trials of pharmacotherapy excluded patients with comorbid major depressive disorder, bipolar disorder, psychotic disorders, or substance-related disorders, limiting available evidence for patients with BPD and these comorbidities.76For the management of crises in BPD as defined above, NICE recommends verbal intervention (eg, trying to understand a crisis from a patient’s view) (Table 1) and short-term pharmacotherapy using a single drug, with the minimum effective dose or prescribing fewer tablets more frequently if there is a risk of overdose.61For treatment of acute crises in BPD, sedative antihistamines (eg, promethazine) or low-potency antipsychotics (eg, quetiapine), but not benzodiazepines (eg, diazepam, lorazepam), may be used as part of an overall treatment plan agreed on by all participating clinical practitioners (Table 2).62 The duration of pharmacological treatment should be agreed on with the patient and is not recommended for longer than 1 week.61,62Sedative antihistamines such as promethazine, however, are not licensed in either the US or in the UK for BPD; therefore, informed consent should be obtained and documented.61 This includes informing patients that promethazine is associated with abuse80 and should be used with caution in a disorder in which patients have higher rates of substance abuse. For insomnia in BPD, general advice about sleep hygiene without medication prescription is recommended. For short-term management of insomnia, “Z-drugs” (eg, zolpidem or eszopiclone) may be prescribed.61 Due to concerns about dependency, use of Z-drugs is recommended only for severe insomnia, with the lowest dose possible and for no longer than 4 weeks.81
Short-term symptoms of depression or anxiety that are part of BPD emotional instability and that can be related to specific triggering situations such as interpersonal problems should not be misinterpreted as comorbid disorders and should be treated solely with psychotherapy.
Psychotherapy is first-line treatment for BPD and should be recommended to all patients with BPD.7,61,82Several meta-analyses of randomized clinical trials have shown that psychotherapy is associated with benefit for patients with BPD (Table 3). A Cochrane series of meta-analyses that included a total of 75 randomized clinical trials with 4507 patients provided evidence regarding efficacious therapies for BPD.60 For example, in a meta-analysis of 22 randomized clinical trials with 1244 patients comparing psychotherapy with usual care, psychotherapy was associated with significant improvement in symptom severity compared with usual care, with a medium effect size (standardized mean difference [SMD], −0.52) (Table 3).60 This effect size exceeded the minimum clinically relevant difference for BPD symptom severity (SMD, 0.43) and represented a clinically relevant reduction.60 Psychotherapy was not associated with higher rates of adverse effects compared with usual care (risk ratio, 0.86; 95% CI, 0.14-5.09; P = .86 [4 trials; n = 571]).60 Several types of psychotherapy for BPD exist (eTable in the Supplement). A subgroup analysis from the Cochrane meta-analysis60 compared dialectical behavior therapy, psychodynamic therapy, cognitive behavior therapy, and eclectic therapy in data from 17 randomized clinical trials and 1045 patients. There were no significant differences between these treatments for the outcome of symptom severity or psychosocial functioning (P = .88). Dialectical behavior therapy, a form of cognitive behavior therapy specifically developed for treatment of BPD, focuses on increasing a patient’s motivation to engage in treatment and problem-solving strategies, and uses group skills training to help regulate emotions and interpersonal relationships and telephone coaching in times of crises between regular sessions (eTable in the Supplement). Compared with usual care, dialectical behavior therapy was associated with a medium between-group effect size (SMD) of −0.60 for improving BPD severity (Table 3) and small between-group effect sizes for self-harm (SMD, −0.28) and psychosocial functioning (SMD, −0.36), with low to moderate heterogeneity (I2 = 42%, 0%, and 31%, respectively).60Psychodynamic therapy proved to be efficacious in treatment of BPD as well.83 Psychodynamic therapy includes a family of psychotherapeutic approaches that focus on identification of recurring patterns of behavior related to the self and others, including the therapeutic relationship, expression of emotion, exploration of defensive (avoidance) patterns, and discussion of past experiences that have an effect on a patient’s present experiences.85Specific forms of psychodynamic therapy have been developed that tailor treatment specifically to BPD, such as transference-focused psychotherapy and mentalization-based therapy (eTable in the Supplement). In a meta-analysis that included 16 randomized clinical trials and 1081 participants, psychodynamic therapy was associated with medium between-group effect sizes compared with usual care (Table 3) for the outcomes of core BPD symptoms (SMD, −0.65), suicide-related outcomes (SMD, −0.67), and psychosocial functioning (SMD, −0.57), with low or moderate heterogeneity (I2 = 15%, 40%, and 60%, respectively) (John R. Keefe, written communication of data for comparison of psychodynamic therapy with usual care for the meta-analysis by Barber et al,83 November 3, 2021).
An observational study of 290 patients with BPD reported that over a 10-year period, 50% recovered, defined as symptomatic remission and good social and vocational functioning over a 2-year period.89 Among the patients who recovered, 34% lost their recovery and 30% had a recurrence of BPD symptoms and diagnosis after a 2-year long remission.89 (In these studies, recovery was defined as symptomatic recovery in combination with excellent social and vocational functioning over 2 years. Recurrence was defined as recurrence of classic BPD symptoms.) In contrast, 93% of BPD patients attained remission from BPD lasting 2 years and 86% attained remission lasting 4 years.89
Excellent recovery, defined as remission of BPD or other personality disorders and good social and full-time vocational functioning, occurred in 39% of patients with BPD compared with 73% of patients with other personality disorders.90 However, most individuals with BPD in these longitudinal studies received pharmacotherapy or psychotherapy. Therefore, these remission rates may be better than the natural history of untreated BPD over time and might be related to these therapies.91
Here’s how the article concludes:
Borderline personality disorder affects approximately 0.7% to 2.7% of adults and is associated with functional impairment and greater use of medical services. Psychotherapy with dialectical behavior therapy and psychodynamic therapy are first-line therapies for BPD, while psychoactive medications do not improve the primary symptoms of BPD.
REPRINTS & OTHER CORRESPONDENCE:
Falk Leichsenring, DSc, Department of Psychosomatics and Psychotherapy, University of Giessen, Ludwigstrasse 76, 35392 Giessen, Germany (email@example.com).
Ken Pope, Nayeli Y. Chavez-Dueñas, Hector Y. Adames, Janet L. Sonne, and Beverly A. Greene
Hector Y. Adames, Nayeli Y. Chavez-Dueñas, Melba J.T. Vasquez, & Ken Pope:
Ken Pope, Melba J.T. Vasquez, Nayeli Y. Chavez-Dueñas, & Hector Y. Adames:
“Yes, the newspapers were right: snow was general all over Ireland. It was falling softly upon the Bog of Allen and, further westwards, softly falling into the dark mutinous Shannon waves. It was falling too upon every part of the lonely churchyard where Michael Furey lay buried. It lay thickly drifted on the crooked crosses and headstones, on the spears of the little gate, on the barren thorns. His soul swooned slowly as he heard the snow falling faintly through the universe and faintly falling, like the descent of their last end, upon all the living and the dead.”
—James Joyce, “The Dead” (1914)