Updating Diagnostics, Attitudes, and Treatments Surrounding Borderline Personality Disorder

There is an urgent need to improve diagnostic abilities and management of borderline personality disorder, despite significant breakthroughs.

Recent findings published in the Harvard Review of Psychiatry included seven papers that took to key areas of concern regarding borderline personality disorder.

"We hope these articles will help clinicians understand their borderline personality disorder patients, encourage more optimism about their treatability, and help set a stage from which the next generation of mental health professionals will be more willing to address the clinical and public health challenges they present," said Drs. Lois Choi-Kain and John Gunderson of the Adult Borderline Center and Training Institute at McLean Hospital, Belmont, Mass. in a guest editorial.

The primary highlights of their findings included:

1. Updating the neurobiological terms of borderline personality disorders: Researchers systematically searched published literature about borderline personality disorder and presented an integrated model, which specified interactions among brain regions, hormones, and other factors are involved in emotion and cognition. Additionally, they postulated the role of the amygdala should be expanded when considering borderline personality disorder in reference to a person's goals and motivations.

2. Stressing the need for earlier interventions in patients with borderline personality disorder: While there are frequent crossovers between borderline and mood related personality disorders, both deserve earlier interventions. The researchers said that although the risks for misdiagnoses are present at earlier stages, "clinical staging" might be the most pragmatic diagnostic tool to guide prevention and early interventions. “Regardless of whether an individual crosses such an arbitrary threshold for caseness, a significant proportion of individuals will develop clinically important and persistent functional, vocational, and interpersonal impairment and disability,” the authors concluded.

3. Using evidence based treatments and how to implement them: There are plenty of specialized treatments designed for borderline personality disorder patients that have been successful in controlled trials, the researchers acknowledge. They add that these treatments provide hope, but said that clinicians are typically unable to offer them. The authors evaluated four major evidence based treatments for borderline personality disorder — dialectical behavioral therapy, mentalization-based treatment, transference-focused psychotherapy, and General Psychiatric Management – and determined that a stepped care approach is beneficial, beginning with milder symptoms and progressing to more intensive and specialized care based on the patients' individual needs.

4. Treating borderline personality disorder in the psychiatric emergency department: Stigma surrounding borderline personality disorder patients in the psychiatric emergency department are prevalent, including among hospital staff, even when these patients are advised to utilize such facilities. The study authors noted that attitudes would improve with more education and training about how to understand, approach, and treat these patients in that setting. Some of the principles that could improve interactions the researchers explored included psychoeducation, the reinforcement of the connection between symptoms and interpersonal stressors, and employment of an active, authentic therapeutic stance.

"For clinicians, educators, and researchers, we hope this issue clarifies an emerging basis for earlier intervention, generalist approaches to care for the widest population, and a more organized approach to allocating care for individuals with borderline personality disorder," the study authors concluded.

The study is titled, “Emerging Topics in the Treatment of Borderline Personality Disorder.”

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