#96222: Borderline Personality Disorder

The results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) study, the first large-scale, community study of personality disorders in the United States, were published in 2008. This study found the overall lifetime prevalence rate for BPD was 5.9% (18 million people), with similar rates in men (5.6%) and women (6.2%). The prevalence of BPD was higher in Native American men; younger adults who were separated, divorced, or widowed; and persons with lower levels of education and socioeconomic status. Those with lower BPD prevalence were Hispanic men and women and Asian women [1].

The NESARC data were subsequently analyzed using more conservative methods, which found a lifetime prevalence rate for BPD of 2.7% [2]. The findings of lower prevalence rates in earlier studies reflected self-report assessments for data collection and/or low response rates, and disparities between cross-sectional prevalence and lifetime prevalence reflect symptomatic recovery in some patients with BPD [16,17,18]. BPD prevalence is comparable to other major psychiatric disorders, such as schizophrenia or bipolar disorder, but lower than MDD or anxiety disorders [19,20].

In clinical settings, BPD prevalence is considerably higher than in the general population, and BPD is the most common personality disorder across all levels of care. BPD has a prevalence rates of 20% to 22% among psychiatric inpatients, 10% to 12% among psychiatric outpatients, 56% among emergency room patients admitted for suicidal behaviors, and 6% among primary care patients [18,21,22,23].

Persons with BPD and borderline symptoms are over-represented in civil, criminal, and child custody forensic settings, and individuals with BPD have an increased likelihood of legal system involvement as perpetrators and victims alike [24]. A study of 220 male and female offenders who recently entered prison found diagnosable BPD in 29.5% and the presence of at least one DSM-IV criterion for BPD in 93.2% [25]. This disparity between population and clinical prevalence indicates that many persons with BPD are undiagnosed and untreated [6].

Prospective longitudinal studies have identified environmental and parental factors that significantly contribute to BPD development. The number of BPD symptoms at 28 years of age has been found to be significantly and directly correlated with early attachment disorganization or maltreatment; maternal hostility, inconsistency, and/or over-involvement; aversive or hostile parental behavior; low parental affection; family disruption related to the father's presence; and family life stress. Maternal hostility and early life stress contributed independently to the prediction of BPD symptoms at 28 years of age [31,32]. Other studies identified additional factors associated with BPD development, including childhood physical abuse or neglect, sexual abuse, maladaptive parenting, maladaptive school experiences, and the demographic characteristics of low family socioeconomic status, family welfare support recipient status, and single-parent family status [33].

Childhood Sexual Abuse

During the 1980s, the findings that childhood sexual abuse was prevalent in histories of patients with BPD led to the theory of childhood trauma as a primary etiologic factor in BPD development. Further research confirmed that while childhood trauma was highly prevalent in BPD, childhood sexual abuse was not necessary or sufficient for BPD development and did not account for much of the variance in causation [18]. In inpatient and outpatient settings, 40% to 70% of patients with BPD report childhood sexual abuse. Although traumatic childhood experiences, including childhood sexual abuse, are strong risk factors for later developing BPD, fewer than 10% of those with a history of childhood sexual abuse develop BPD, effectively eliminating childhood sexual abuse as a primary cause [34,35,36].

Specific adolescent risk factors for adult BPD have been identified. Substance use disorders, especially alcohol, during adolescence are a significant factor. In addition, depression and/or disruptive behavior disorders in childhood or adolescence, including conduct disorder, oppositional defiant disorder, and attention deficit hyperactivity disorder, are predictive of adult-onset BPD. A history of repetitive, intentional self-harm in childhood or adolescence is more common in adults with BPD than the general population [37].

Persons with BPD have high lifetime rates of other psychiatric disorders, including bipolar disorder (10% to 20%), MDD (71% to 83%), substance use disorder (50% to 65%), panic disorder (34% to 48%), social phobia (23% to 47%), PTSD (47% to 56%), and eating disorders (7% to 26%). Co-occurring personality disorders are also common in BPD, including avoidant (43% to 47%), dependent (16% to 51%), obsessive-compulsive (18% to 26%), and paranoid (14% to 30%) personality disorders [12,38].

While several medical conditions are more common in patients with BPD than the overall population, exact figures on prevalence are difficult to find. One study suggests that individuals with BPD had a higher risk of almost all somatic comorbidities (e.g., diabetes, obesity, cardiovascular disease) and a worse prognosis than individuals with other personality disorders [39].

It is essential to note that BPD is no longer viewed as solely the result of parental or primary caregiver behaviors that shape passive, inert children. It is now recognized that innate temperament and behaviors in a child influence parental behaviors by passively evoking parental behaviors and by actively soliciting certain types of parental interactions [50,51]. This has been demonstrated in twin studies that found elicitation of maternal warmth was substantially controlled by child temperament [52].

A temperament that predisposes sensitivity to interpersonal stress contributes to the development of BPD. In these infants and children, heightened distress states may trigger fearful response in a vulnerable, depressed, anxious, ill, or traumatized caregiver, further diminishing his or her already compromised availability to the child. In particular, child traits of interpersonal hypersensitivity and stress reactivity evoke parental reactions of fearfulness or helplessness and withdrawal, which significantly affect the vulnerable child. Parents of a pre-BPD child are likely to exhibit adverse responses when confronted by increasing neediness or anger in the child, with child and parent factors both contributing to an escalating series of negative and difficult interactions that contribute to adult BPD [53].

Separation Distress and Ambivalent/Disorganized Attachment

Proneness to distress, particularly at separation, is a core feature of ambivalent and disorganized attachment patterns, the childhood counterparts of adult BPD attachment dysfunction. Infants with insecure attachments show greater distress-prone temperaments and irritability and are more likely to express the ambivalent form of attachment. Ambivalent infants engage in hyperactivation behaviors intended to elevate their visibility and increase engagement from an inconsistently attentive parent; these behaviors include clinging, anger, resistance to contact, and failure to soothe in the presence of their parents. Most ambivalently attached children also show the features of disorganized attachment, while a subgroup of infants with disorganized attachment exhibit the amplified distress and difficulty in soothing that is observed in ambivalent attachment. This latter infant subgroup has a heightened vulnerability for developing BPD. Thus, infants born with highly distress-prone temperaments and raised under non-optimal conditions of parental attention and interaction are at greater risk of evolving into ambivalent and/or disorganized attachment and BPD [54].

Disorganized Attachment

Disorganized attachment is the precursor to unresolved attachment, one of two attachment forms in BPD. Its expression mimics the relational style of adults with BPD and involves contradictory approach and avoidance with dissociative responses to caregivers. Roughly 15% of infants show disorganized attachment patterns by 1 year of age, which predicts controlling patterns of attachment relations by 3 to 6 years of age and behavior problems when entering school. Infant use of disorganized attachment strategies is heightened when raised in environments of low socioeconomic status (24%), parental psychopathology (30% to 60%), and infant maltreatment (60% to 70%). Higher cortisol stress responses are found in infants with disorganized versus organized attachment strategies, reflecting a genetic basis of the serotonergic abnormalities and high cortisol responses to separations found in adults with BPD [55,56].

Early psychoanalytic theorists identified problems with separation from caregivers as a developmental failure central to vulnerability for BPD, with insecure attachment and traumatic separation experiences the pathogenic factors that accounted for abandonment fears in BPD [57,58]. Subsequent empirical investigation confirmed the association between dysfunctional early caretaking experience (e.g., frequent separations, parental over- or underinvolvement) and BPD diagnosis [59,60]. These previous findings have been substantively enhanced and refined by more recent investigations, including the identification from multiple lines of evidence of specific caregiver contributions to childhood development of early attachment disturbance and interpersonal hypersensitivity.

Important contributions have come from reports by patients with BPD, who typically report experiencing very difficult primary attachment relationships in childhood. Common and recurrent themes include emotional neglect from both parents; parental invalidation of their thoughts and feelings; parents or primary caregivers who were emotionally withdrawn, who were inconsistent, who failed to protect them, or who were over-controlling; and early separation from their primary caregiver [61,62]. On the other hand, parents of patients with BPD often provide an account that is considerably less critical, and siblings of patients with BPD are commonly much better adjusted. The recollections by patients with BPD of their early family life should not be dismissed, but accepted with a degree of caution [53].

Caregiver Effects on Infant Attachments

Studies of twins have found that social adaptation in adulthood has a stronger association with infant attachment strategies toward their primary caregiver than toward other caregivers, and this finding is unchanged when the primary caregiver is not biologically related to the infant. Other research has shown that in 70% of cases, infant attachment pattern with the primary caregiver is highly correlated with caregiver attachment style before the infant was born. Attachment style is not heritable, and while caregiver behaviors do not sufficiently account for child attachments, they remain very important [55,63,64].

Parental Contributions to Disorganized Attachment

Disorganized responses of infants to parents are thought to indicate an approach-avoidance dilemma, or fear without solution, where the parent is both a source of fearful arousal and the only source of comfort from this arousal. Specific maternal responses to distress-prone infants engaging in the hyperactivation strategy have been identified. Referred to as aversive responses, these include withdrawal, fearful disorientation, role-reversal, negative-intrusion, and contradictory responses and bear great resemblance to the recollective accounts of adult patients with BPD [53,65].

The infant reacts to this dilemma with contradictory attachment responses that include crawling toward the mother while crying and then collapsing on the floor midway, or calling out to the door during separation and then retreating away from the door at reunion. These contradictory infant responses substantially mirror the contradictory need/fear components expressed in the prototypical interpersonal behaviors of adults with BPD, and multiple studies have validated the strength of this association [55,66].

Disrupted affective communication and emotional withdrawal in mothers with infants at 18 months of age have predicted the borderline personality traits of unstable relationships and self-harming behaviors in early adulthood, and disrupted maternal affective communication has been correlated with infant disorganization and maternal unresolved attachment [66,67]. These associations remain after controlling for abuse exposure and suggest that parent-child affective communication, independent of abuse history, may play an important and independent role in the development of adult BPD [53].

Parental Psychopathology

Psychopathology is highly prevalent in the parents of patients with BPD, although it is difficult to determine the exact prevalence due to limited studies. The prevalence of maternal BPD is 10% to 15%. These mothers are more insensitive to their infants at 2 months of age, and their children are likely to show disorganized attachments at 1 year of age. Also prevalent in parents of patients with BPD are substance abuse, depressive disorders, eating disorders, and antisocial or other personality disorders [68,69,70]. An estimated 30% are negative for psychiatric disorder history [53]. The prevalence of affective, impulsive, and interpersonal phenotypes is increased in families of patients with BPD, including findings that 50% of relatives have affective instability, 33% have impulsivity, and 28% have disturbed relationship styles comparable to their borderline offspring with BPD [68,71,72].

Given the high frequency of psychiatric illness and familiality of borderline phenotypes, many parents of pre-BPD children are highly probable for under-reactive or hypersensitive predisposition in their response to their infant's predisposed temperament of distress proneness and interpersonal hypersensitivity. Development of insecure attachment in children is predictive of parental insecure attachment style, and maternal mental illness has been found strongly associated with insecure, disorganized attachments in their children [65]. These findings are consistent with the pathogenic effect of parental psychopathology on their pre-BPD children.

The developmental pathways of BPD that evolve from early, disorganized attachment are complex, and the knowledge base is incomplete. However, some areas of research have been more thoroughly investigated, including controlling attachment strategies.

Controlling Attachment Strategies

Roughly 65% of children with disorganized attachment undergo a change between 18 months and 6 years of age, whereby attachment becomes organized around the goal of controlling interaction with the primary attachment figure. This is likely an adaptive response designed to increase dysfunctional parent involvement (i.e., alleviate parental inability to meet the child's comfort and security needs) [73]. After 18 months of age, dysfunctional parenting is more likely to be personalized in children with negative emotion as anger at the parent, which a hypersensitive parent may experience as personally rejecting. Controlling behaviors of these children toward their caregiver have been observed as young as 3 years of age [73].

The transition to controlling strategies involves two different forms. With controlling-punitive behavior, the child responds to attachment threats by attempts to control the parental relationship through hostile, coercive, or subtly humiliating behaviors. Controlling-caregiving behavior involves entertaining, organizing, directing, or giving approval to the parent. These two forms of controlling behavior are not mutually exclusive, and many children shift back and forth from devaluing, insulting comments to solicitous approval behavior toward the parent. The link between controlling parental strategies in preschool with teacher-reported behavior problems by 4 to 6 years of age is well-established, and controlling parental behaviors are associated with diagnosis of oppositional defiant disorder [55,65,73,74]. Prospective data are lacking, but adult patients with BPD frequently report caregiving or punitive controlling behaviors toward their parents in childhood [53,73,75].

In BPD, emotion sensitivity is thought to have a biologic origin with presence in early life. It involves heightened emotional reactivity to environmental stimuli and is primarily associated with negative mood states such as anger, fear, and sadness. This heightened emotional reactivity also involves the emotions of others. Emotion recognition studies in BPD show negativity bias in emotion recognition (i.e., negative emotions in others are over-identified) and poor accuracy in correctly identifying facial emotions [110,111].

BPD is strongly associated with high levels of negative affect on dimensions of intensity and reactivity. High negative affect in BPD is considered secondary to emotion sensitivity such that hyper-reactivity to environmental stimuli triggers rapid changes in mood [112]. In BPD, the essential features of negative affect are instability over time and rapid intensification with little warning. Comparisons of BPD with healthy controls found that subjects with BPD showed significantly greater instability on measures of emotional valence and distress, greater propensity for large decreases in positive mood, and a substantially greater proportion of rapid decreases in positive mood leading to negative mood states [108]. Compared with persons with MDD, subjects with BPD show significantly greater levels of variability in positive and negative affect; instability in hostility, fear, and sadness; and extreme changes in hostility [113].

Persons with BPD did not learn the skills necessary to regulate emotion as emotionally sensitive children experiencing heightened negative affect. As a result, they face great difficulty in controlling their emotions and timing its expression [108].

Ability to identify one's emotions is important for emotion regulation. Related to emotion awareness is capacity to distinguish among emotional states, termed emotional granularity. Persons with high emotional granularity can reliably and accurately differentiate emotional states (e.g., sadness from anger); those low in emotional granularity often describe emotional states in global terms, such as feeling good or feeling bad. Persons with BPD have shown deficient emotion awareness, low emotional granularity (as evidenced by poor emotional clarity and mood and emotion labeling), and greater affect polarity ("all-or-nothing" thinking) [114,115].

Poor distress tolerance, pervasive in BPD, is an artifact of deficient emotion regulation strategies, and both contribute to the development of BPD. Negative emotionality is the heritable tendency to experience negative affect and may be influenced by emotion sensitivity bias. Distress tolerance protects against developing BPD symptoms, to a much greater extent in persons with intense negative affect than with emotion hypersensitivity. Patients with BPD with poor distress tolerance and high levels of emotion hypersensitivity or intense negative affect are significantly more likely to exhibit impulsive and reckless behavior as maladaptive emotion regulation strategies [116].

Maladaptive behaviors to regulate emotion can lead to emotion dysregulation problems very obvious to others. If negative affect becomes sufficiently intense, the person will likely choose maladaptive over adaptive behaviors. While maladaptive behaviors can produce immediate reduction in negative affect and are simpler to employ than adaptive behaviors, they have negative consequences and can become ineffective with long-term use [117]. The maladaptive cognitive strategies of rumination and thought suppression, often used in BPD, actually increase negative affect in the long term [118,119]. Experiential avoidance is also common in BPD and is characterized by behaviors to escape unwanted experiences [120]. The impulsive, suicidal, and self-injurious behaviors common in BPD are behaviors specifically used to regulate affect [109].

The highly prevalent impulsive behaviors in BPD, such as disordered eating, impulsive buying, and drug use, serve to reduce negative affect. Psychometric studies strongly associate BPD with urgency/impulsive actions during negative mood (to alleviate negative affect) [121]. BPD uniquely clusters in high levels of affect instability, urgency, and absence of premeditation [122]. Neurobiology studies show altered ventromedial prefrontal cortex function with BPD, consistent with impulsivity in the context of negative affect [84]. Affective instability with identity disturbance and impulsivity has predicted suicidal behaviors; affective instability with childhood sexual abuse predicts suicide attempts [123].

Various forms of self-injurious behavior are common in patients with BPD, with a prevalence rate of 20% to 90%, with the most common being self-injury by cutting or burning. It is almost always reported to reduce feelings of negative emotion and help control mood [124,125]. Those with BPD report little or no pain during self-injurious behavior or during pain-induction tasks, an effect even more pronounced during distress [126]. Brain imaging has found a negative coupling between paralimbic and prefrontal brain regions in subjects with BPD, suggesting that prefrontal areas inhibit paralimbic regions following pain in this group [109,127].

Earlier studies following the course of psychopathology in adult patients with BPD after hospitalization reported minimal improvement and a corresponding negative prognosis. However, these studies possessed flaws in study design, and several more recent studies provide a more accurate depiction of the long-term course of BPD [18].

The McLean Study for Adult Development (MSAD) and the Collaborative Longitudinal Personality Disorder Study (CLPS) found dramatic and unexpectedly greater remission rates than anticipated of BPD psychopathology, as measured by decreases in BPD criteria and by an operationalized definition of remission [131,132]. Unexpectedly, patients with BPD who remitted were likely to remain remitted. In the CLPS, only 12% in remission relapsed [132]. Previous studies with shorter follow-up periods showed worse prognosis, perhaps because relapse rates are higher during the first few years of release from hospitalization [18].

Both studies examined the pattern of BPD symptom reduction. Four-year outcome data from the CLPS showed that certain criteria (e.g., self-harm) diminished more rapidly than other criteria (e.g., affective instability) [132]. Similar results were reported from the MSAD, in which impulsive characteristics and intense unstable relationships resolved earlier than loneliness/emptiness and intolerance of aloneness [131,133]. It appears from these findings that symptomatology of BPD can remit but that disturbances in core personality functioning persist substantially longer.

Findings related to the course of social adaptation in BPD natural history are more discouraging. The Global Assessment of Functioning scores (100 = optimal functioning) of subjects with BPD remained low (average: 65), with rates of disability support remaining stable. At 10-year follow-up, around 30% had full-time vocational activities and were married or had stable partnerships. However, the overall scores rose significantly on measures of self-satisfaction, recreation, and friends. A 16-year follow-up study reported that 60% of subjects had "recovered," defined by durable remission and sustained partnerships. This report gives a more hopeful perspective concerning sustained and substantive changes [18,131,132].

BPD is almost universally described as isolating by patients and their families, and this isolation also extends into the clinical setting. An interview of patients with BPD was conducted to better understand patient experience in receiving the diagnosis of BPD. Five themes emerged [141]:

Some patients reported a feeling of clarity, focus for the future, and a sense of control, as the BPD diagnosis provided something tangible they could grasp. Others felt out of control with the diagnosis due to a lack of understanding when providers were not forthcoming with information and not communicating any hope for recovery. Relief or distress after receiving the diagnosis was related to the extent that patients felt empowered with the knowledge and what they could do to recover. Unfortunately, the subjects consistently reported feeling that receiving the diagnosis was quickly followed by a withdrawal of services [141].

The theme of rejection in the clinical setting is reported throughout the literature. A primary contributor may be the diagnosis itself. Many clinicians believe that treating the personality of a patient is impossible, resulting in persons with BPD receiving mental health care only during a crisis for exacerbated symptoms instead of ongoing treatment that addresses the full dimension of the disorder. Use of mental health services during crises is time-limited and brief, and the absence of lasting benefit from the short duration of therapy reinforces professional views that BPD is untreatable, which strengthens the associated stigma. Many patients diagnosed with BPD report feeling stigmatized during contacts with the mental health system, with staff assuming the patient is difficult, manipulative, and attention seeking. Many also report feeling blamed for their condition when the greatest message they seek is one of legitimacy and basic acceptance [8,142]. The results of one systematic review indicate that there is a substantial difference in a patient's understanding and interpretation of a BPD diagnosis, depending on whether the diagnosis is well- or poorly delivered [143]. The way in which a diagnosis of BPD is shared by the clinician with the patient shapes the patient's hope for recovery and subsequent use of healthcare services. Families often feel just as blamed by clinicians for their loved one's illness, and despite the growing body of evidence of substantial heritable and innate contribution to the development of BPD, there remains an unwavering view by some professionals that someone is culpable for a person's BPD [8,142]. The misconception of BPD as solely the result of environmental stressors such as childhood abuse and trauma had been so persistent and salient that some therapists have used "recovered memory therapies" in treating BPD [12,144].

A positive development in the United States has been the increased attention on and consideration of the perspective gained from those with psychiatric diagnoses and their families. Although not yet universally embraced or valued by mental health systems and professionals, many have come to appreciate the importance of their input when applied to treatment and service design, delivery, and evaluation. Greater attention to the voices of those living with BPD can help inform delivery of new methods of person-centered care [145]. A byproduct has been the redefined relationships between mental health consumers/family members and professionals and the reduction in discrimination and bias [8,146].

The single greatest obstacle for people with BPD is overcoming pervasive misconceptions regarding the nature, causes, diagnosis, and treatment of the disorder. At the individual patient level, clinician knowledge of contributory environmental factors can offer important insight and guide treatment decisions, but it should not be the sole or even the primary determinant in treatment selection. Approaching the patient with BPD as someone afflicted with a brain disorder that requires fixing obscures the important experiential factors of the patient, such as his or her attachment of meaning and importance to past events. As stated, person-centered care has received increased attention as an element of overall healthcare reform and is essential in fostering recovery for BPD [145]. A person-centered approach also interrupts the life-long pattern in which patient perception of experiences, and of self, has been defined and labeled by others. Providers should understand that even destructive behavior has meaning and represents communication by the only means the patient has. The most effective interventions are compassionate, reinforcing of patient dignity, and grounded by shared respect. While patients may require different approaches at different points in recovery, the most important approach at any stage is to view them as humans who need a compassionate relationship that embodies hope and healing [8,143].

Healthcare providers can create a more comfortable environment for a patient of another culture by acknowledging the impact of culture and cultural differences on physical and mental health. Symptom presentation is influenced by cultural factors, and this should be taken into account during the assessment process.

As noted, diagnosis of BPD can lead to rejection by the mental health system, resulting in clinician reluctance in making a diagnosis associated with stigma [152]. There can also be a general reluctance by patients and their families to explore the psychological origins and conflicts related to personality disorders, and this may encourage a diagnosis of MDD or bipolar disorder because a "chemical imbalance" can represent a preferable and more palatable diagnostic conclusion [153]. Structural stigma involves societal-level conditions, cultural norms, and organizational policies that inhibit the opportunities, resources, and well-being of people living with BPD [154]. Structural stigma involves societal-level conditions, cultural norms, and organizational policies that inhibit the opportunities, resources, and well-being of people living with BPD [154].

In psychiatry, the dominant emphasis on pharmacotherapy and focus on symptoms contrasts with the greater complexity of a biopsychosocial approach. Implementing the latter is more complicated, but neglecting to do so can lead to delivery of unnecessary treatment of marginal benefit, postponement of necessary treatment, problematic side effects or unanticipated treatment harms, and potentially tragic outcomes [139].

Many of the former Axis I diagnostic entities, such as anxiety, bipolar, and mood disorders, are more familiar to healthcare professionals, while making an accurate personality disorder diagnosis requires more experience. Clinicians attempting to diagnose the patient with BPD may also tend to aim for a straightforward diagnosis. Simpler constructs, such as MDD, also lead to treatment options with greater clinician familiarity (e.g., pharmacotherapy) [155]. Evidence-based treatments for BPD are more complex, and many require training, skill, and patient involvement. They are also delivered over extended periods, with recommended times of one year for dialectical behavioral therapy and transference-focused psychotherapy, 18 months for mentalization-based therapy, and three years for schema therapy [156,157,158,159]. Although criticized for their cost and duration, the alternative can be a protracted series of acute treatments that may help the patient survive from crisis to crisis, but without durable long-term benefit [139].

Some insurance companies have had a policy of refusing reimbursement for care for a diagnosed personality disorder, often on the grounds that personality disorders are not conditions of medical necessity. This lack of coverage adds practical problems to the burden of suffering [139].

In the BPD domain of maladaptive and dysregulated interpersonal functioning, the fearful, highly reactive component combines abandonment fears, rejection sensitivity, and intolerance of aloneness to represent the most distinctive and pathogenic component of interpersonal pathology. This is termed the interpersonal hypersensitivity phenotype [53]. A strong genetic basis has been found for this phenotype [76].

The interpersonal hypersensitivity phenotype carries great clinical significance, as dysphoric negative emotional states and the absence of adaptive modulatory ability frequently lead to dissociation and self-injurious behaviors in response to interpersonal events such as rejection or aloneness. Patients with BPD are also hypersensitive to expressions of feeling they perceive in other's faces, with particular sensitivity and physiologic reactions to angry faces. Data from long-term studies show that symptom remission in patients with BPD is very often a response to positive interpersonal events—the characteristically negative emotional responses to interpersonal interactions convert to positive responses [53]. In these remitted patients, relapse is almost always the result of a negative event or outcome in a romantic relationship [53].

Several studies of adult subjects with BPD have found a greater than 90% prevalence of insecure attachment, with the preoccupied type of insecure attachment somewhat higher in prevalence than the unresolved type. The preoccupied type appears in the needy quality of attachments, and the insecure type captures the fearful and contradictory qualities. Hostile-helpless attachments have also shown high prevalence in BPD. With this attachment type, representations of attachment figures are perceived as hostile, untrustworthy, or abdicating of a parental role [73,103]. These features of BPD have in common a highly negative meaning attached to real or imagined interpersonal slights or insults, especially in the context of important attachment relationships, and represent a core psychological vulnerability in patients with BPD [53].

Abandonment fears may be confused with separation fears, and patients with BPD also frequently have intense separation anxiety concerning attachment figures. The self-image, affect, cognition, and behavior of the person with BPD can abruptly and profoundly change when he or she perceives an imminent separation, rejection, or loss of external structure. Interpersonal hypersensitivity can result in intense abandonment fears and inappropriate anger, triggered even when confronted by criticism or with a time-limited separation. Abandonment fears stem from an intolerance of being alone and a need to have other people with them, and frantic, impulsive actions to avoid abandonment can include self-injurious or suicidal behaviors [3].

Related to chronic emptiness is the tendency to become overly attached to others and to desperately fear abandonment. This also relates to issues of trust and mistrust, an aspect of BPD that often manifests in family relations and confers an important rationale for family education and intervention. Family members find the intense attachment and fear of abandonment difficult to understand and stressful to deal with and are often perplexed as to why their repeated reassurances of love and devotion have little effect on the fears of these patients [139].

Chronic emptiness is described as a visceral feeling that is usually felt in the abdomen or chest and plagues the patient with BPD. It is not a feeling of boredom or existential anguish, but a feeling state associated with loneliness and neediness. Some have considered this experience an emotional state, while others describe it as a state of deprivation [3]. A sense of emptiness is often reported by patients with BPD as the very core element of their self-identity. It can be the most painful aspect of the disorder for some and can lead to drug use, promiscuity, or cutting in the effort to fill the void [139].

The characteristics of BPD self-identity, unique to the disorder, involve a distorted, unstable, or weak self-image that is reflected by sudden changes in goals, beliefs, vocational aspirations, and sexual identity. The absence of a clear, coherent sense of self leads to frequent and painful problems stemming from one's values, goals, likes, and dislikes being undefined. This often results in the person with BPD adopting and assimilating the values, habits, and attitudes of whomever they frequently associate. The inability to identify one's feeling states and motives behind one's behaviors (mentalization) are thought to account for the amplification of these identity disturbances in the interpersonal context [15].

Aggressive urges become problematic in persons who are unable to integrate aggression into their overall personality structure, usually reflecting modulatory failure by higher cortical structures. Many individuals with BPD report feeling angry much of the time, even when anger is not overtly expressed. Anger is often triggered when perceiving an intimate or caregiver as neglectful, withholding, uncaring, or abandoning. Expressions of anger may be followed by shame and contribute to a sense of being "evil" [3]. In some patients with BPD, innate temperament and environment interact to create an extreme loading of aggressive affect. The distinction between higher and lower level patients with BPD and excessive anger was one of several factors that predicted poor prognosis in a naturalistic longitudinal study of 500 patients with BPD. Factors predicting negative outcome include [139,151]:

Anger and aggression are likely to appear in any attachment relationship when abandonment is perceived, but most of all in the intimate relationships of persons with BPD. Perception of emotional distance or physical separation, coupled with intense fear of abandonment and loneliness, can provoke intense anger or rage. Studies of men and lesbians with BPD in treatment for domestic violence have found identical emotional and behavioral processes surrounding anger and violence toward intimate partners. For these patients, violence is used as a strategy to prevent abandonment by maintaining the connection to a partner through coercion and/or fear [166].

Little research has been published on the prevalence of intimate partner violence and BPD in non-clinical populations or in women in general or comparing gender-specific rates. One study was conducted to explore the relationship between intimate partner aggression and borderline personality using the questionnaire responses of 14,154 college students in 67 colleges worldwide (19 in the United States) [166]. In this study, borderline personality referred to borderline personality organization, defined as similar but less severe core features of BPD, including emotional and behavioral dysregulation, disturbance in identity and self, and interpersonal hypersensitivity [167]. The prevalence of borderline personality was 11% to 15%, a rate three to four times greater than BPD. Borderline personality was used as a surrogate for BPD and was assessed by respondent answers to questions derived from DSM-IV-TR criteria for BPD [166]. The past-year rates of intimate partner aggression were generally greater for women, with the exception of sexual aggression (Table 1). These results are remarkable by virtue of the sample size and the extension of behavioral characteristics in clinical populations to community populations. Importantly, the results challenge long-held assumptions of gender differences in the expression of interpersonal intimate aggression. These findings also provide cross-cultural validity for the construct of borderline personality characteristics [166].

Splitting is the psychological construct describing the subconscious process that compartmentalizes bad, toxic, and/or terrifying representations of self and other from the good, rewarding, positive, and comforting representations [3]. This aspect of BPD is difficult for others, especially family members, to understand. A reality basis is rare; instead, patient perceptions are filtered by internal images of self and others that are exaggerated, distorted, and superimposed on relationships with others and on themselves [139].

Expression in Relationships with Others

As discussed, a distinctive characteristic of patients with BPD is a hypersensitivity to rejection and fearful preoccupation with anticipated abandonment. While these patients feel their lives are meaningless unless they feel connected to someone they believe truly "cares," their perception of "caring" usually imposes unrealistic expectations of availability and validation from the attachment figure. Within such relationships, an initial idealization can rapidly shift to devaluation when rejection is perceived. The near-universal inability of persons with BPD to perceive attachment objects in terms other than idealized (if gratifying) or devalued (if not gratifying) plays a large contribution to the stormy, chaotic, and unstable relationships of these persons. It is considered a symptom of early insecure attachment characterized by both fearful distrust and needy dependency [3].

Expression in Relation to Self

In addition to this external "splitting," patients with BPD experience internal splitting. This typically involves vacillation between the viewing of self as a good person who has been mistreated, with anger the dominant emotion, and self as a bad person whose life is without value, with self-destructive or suicidal behavior the dominant expression. Splitting is also reflected in black-and-white or all-or-nothing dichotomous thinking [43,53].

Patients with BPD can experience dissociation symptoms, whereby the feeling and perception of self and/or environment has an unreal quality. These symptoms often occur during situations of extreme stress. These patients can also be unrealistically self-conscious, believing that others are critically looking at or talking about them. These lapses of reality in the patient with BPD are distinct from other pathologies because, with proper feedback, they are usually able to correct their distortions of reality [3].

Impulsivity in patients with BPD is frequently self-damaging in effect, if not by intent, and differs from the impulsivity found in other disorders, such as bipolar or antisocial personality disorder. As discussed, impulsive behavior is usually driven by the need to escape intolerable negative affect. Common forms of impulsive behavior include substance or alcohol abuse, bulimia, unprotected sexual promiscuity, and reckless driving [3,139].

Recurrent suicidal attempts, gestures, threats, or self-injurious behaviors are a hallmark of BPD, and this behavior is so prototypical with BPD that in the absence of other patient background information, recurrent self-destructive behaviors indicate a high probability of BPD. Self-harming acts often start in early adolescence or younger. Self-injurious behaviors or suicidal gestures are usually precipitated by interpersonal stressors, such as threats of separation or rejection, or by misinterpretation of emotion or communication in others as meaning that abandonment is imminent. When present, this clinical feature can greatly assist in the differential diagnosis in patients with dominant features of depression or anxiety [3].

Early clinical observers noted the intensity, volatility, and range of emotions in patients with BPD, all of which contributed to the belief that emotional instability in BPD involved a variant of affective irregularity in affective and bipolar disorders. It is now known that although individuals with BPD display marked affective instability, these mood changes usually last only a few hours and the underlying dysphoric mood is rarely relieved by periods of well-being or satisfaction. These episodes may reflect extreme reactivity of the patient to stress, particularly interpersonal stress, and a neurobiologically mediated inability to regulate emotions [3].

Description of BPD symptomatology in peer-reviewed published research is often lacking in dimension. The following passage captures the gravity of the experience when a person struggles daily with the symptoms of BPD [165]:

The differential diagnostic issues surrounding BPD have changed over time. The original question of whether BPD was an atypical form of schizophrenia was dismissed with findings of the modest overlap in phenomenology and absence of familial or genetic connection. However, a novel case-control genome-wide study of BPD and comorbid conditions demonstrated a genetic overlap of BPD and other mental disorders, especially with bipolar disorder, and to a lesser degree with MDD and schizophrenia [171]. More research is needed to further explore the potential genetic overlap and association between the conditions.

The question of whether BPD represents an atypical form of affective disorder has proven more difficult to dispel, one reason being that most patients with BPD have lifetime MDD and present with complaints of severe dysphoria. Interpersonal and behavioral characteristics differentiate BPD from MDD, and unlike MDD, depressive episodes in BPD are characterized by emptiness, shame, and a long-standing negative self-image [18,43].

Major Depressive Episode

Patients with a major depressive episode show significant retardation in thought processes and psychomotor behavior and severe depression of mood ranging from profound sadness to the total unavailability of any subjective sense of feeling, with a sense of total freezing of all emotional experience in the most severe cases. The content of thought processes are severely self-demeaning and self-accusatory, rather than focused on blaming and accusing others. Possibly present in severe MDD are guilt feelings, ranging from intense exaggeration of real or perceived deficits or faults to extreme and delusional self-devaluations and self-accusations. This combination of behavior slowing, lowering in mood, and self-devaluation spanning a period of weeks to months, with consistent daily symptom fluctuations of feeling worse in mornings with mood improving gradually every evening, characterizes a typical major depressive episode [153].

Patients with MDD or BPD commonly report feeling chronically hopeless and helpless, and while this indicates depressive despondency, further questioning of what the patient feels hopeless about and helpless over will evoke in patients with BPD a response with accusations and rage against others, with affect more angry than depressed. This dominance of rageful reactions while professing total self-devaluating depression is characteristic of personality disorders and should call into question the assumption of MDD. Patients with MDD withdraw from social contacts and may worsen when premature efforts are made to encourage them to socialize. Depressive reactions in personality disorders are usually less severe, can shift abruptly from one day to the next or from one hour to the next, and are positively or negatively influenced by the immediate social environment. These are characteristic of a personality disorder with a characterologic depression (termed dysthymic disorder), not a major depressive episode [153].

Evaluation of Baseline Personality Structure

Patients with BPD may experience severe dysthymic reactions with frequent symptoms of depression but absent the intensity, consistency, and duration found in MDD episodes. These patients typically have a history of chronic minor depressive episodes or dysthymic reactions over many years without significant periods of remission. While they report having been depressed all of their lives, these symptomatic features require differentiation from the characterologic depressive personality [153].

Around 30% of patients with MDD develop chronic, treatment-refractory depression that shows a remarkable lack of response to pharmacologic interventions [172]. Some may significantly improve for several weeks with electroconvulsive therapy and then revert to chronic depression. Correct diagnosis is especially important in these patients, because some with refractory depression may have a characterologic depression that would benefit from appropriate psychotherapy, especially given that co-occurring BPD significantly reduces treatment response to therapy for MDD [153].

Environmental Triggers Preceding a Depressive Episode

Typically, in characterologic depressive reactions, environmental conditions may trigger depressive reactions, and while often remarkably minor, the patient pays undue attention to the symbolic value of the triggering event. MDD usually lacks this disproportionate reaction to environment as a primary episode trigger [153].

The more severe the psychic and neurovegetative symptoms, the more likely there is a major depression. Conversely, the more predominant the personality disposition and environmental triggers, the more likely there is a dysthymic disorder (characterologic depression). Some patients present a "double depression," with an acute episode of MDD in the context of a chronic characterologic depression. These cases require, first, the treatment of the episode of MDD. Only after the resolution of this episode by pharmacologic and/or other treatments will a complete and accurate diagnosis, prognosis, and treatment plan for the characterologically based dysthymic disorder become feasible [153].

Self-Destructive Behaviors in MDD and BPD

Issues common to MDD and BPD include suicidal tendencies and parasuicidal behavior. Acute or chronic parasuicidal behavior, such as repeated cutting or burning (particularly under conditions of intense emotional agitation, temper tantrums, or acute frustrations), typically reflects BPD. This can seem to happen "out of the blue" and correspond to an outburst of temper without the background of symptoms of MDD [153].

In contrast, suicide attempts in patients with MDD require careful diagnostic assessment of the conditions under which suicidal behavior occurred. The types of suicidality generally found in patients with BPD can most often be treated with outpatient psychotherapy. However, suicide attempts in patients with MDD have severe prognostic implications, require immediate, systematic pharmacologic treatment, and may require hospitalization; patients unresponsive to other treatments may require electroconvulsive treatment [153].

Distinguishing BPD from bipolar disorder, and especially bipolar disorder II, can present a diagnostic dilemma due to the shared, overlapping symptoms. Both disorders have in common a substantial risk of suicide or suicide attempt, impulsivity, and inappropriate anger. However, symptoms that differentiate BPD include self-mutilation, self-injurious behavior without suicidal intent, and a frequent history of childhood abuse. Insecure attachments, reflected by intense abandonment fears, are hallmarks of BPD and uncommon in bipolar disorder. Patients with BPD have higher levels of impulsivity, hostility, and acute suicidal threats relative to those with bipolar disorder. Careful history taking usually elicits a differing time course of mood lability. Patients with BPD are extremely sensitive to rejection and do not have episodes of mania. Mood lability is often triggered by interpersonal sensitivity; mood lability in bipolar disorder tends to be autonomous and persistent [43,129,173].

The most frequent diagnostic error is confusing the chronic emotional instability and affect storms of patients with BPD with true hypomanic or manic behavior. This differentiation is easier with bipolar I, while the assumption of hypomanic behavior can form the basis for a bipolar II diagnosis. The diagnosis of bipolar disorder requires at least one episode of a manic (bipolar I) or hypomanic (bipolar II) episode. Accurate assessment of such an episode is essential and is done by patiently ascertaining whether the patient has one or several periods of three to four days (or longer) of dominant and unusually euphoric, angry, or irritated mood, with a sense of heightened energy, affective dyscontrol, little need to sleep, hyperactivity, and unusual behavior that contrasts with the patient norm. The behavior can involve inappropriate sexual exposure or behavior, gross recklessness with money or other properties, socially inappropriate approaches to others, and possibly elevated sexual drive along with overall expansiveness of mood and behavior. A full manic episode often involves loss of reality testing, grossly inappropriate social behavior with patient unawareness of the behavioral deviation, and possibly hallucinations or delusions that can lead to intervention by others [153].

Determining whether BPD is present involves evaluating the nature of interpersonal and significant relationships. Patients with pure bipolar disorder lack severe pathology of object relations in periods of normal functioning; even patients with chronic bipolar disorder with manic and major depressive episodes maintain the capacity for depth and stability in their relationships and for assessing themselves and significant others appropriately [174]. This contrasts with the pronounced and pervasive emotional immaturity; the absence of affective stability and significant and mature relations with others; chronic instability in work or profession, love relations, and self-assessment; and identity diffusion with lack of an integrated concept of self that typifies BPD [153]. However, roughly 19% of patients with BPD are comorbid with bipolar disorder. These patients show severe, chronic affective instability together with clear hypomanic episodes [136,171].

The dramatic expansion in concept and diagnosis of bipolar "spectrum" disorders has contributed to patients with BPD receiving this misdiagnosis. The evidence that mood stabilizers provide modest benefit to some patients with BPD will probably continue to encourage undue reliance on medication treatments [18].

The high prevalence of childhood trauma in patients with BPD first reported in the 1980s led to a movement in the 1990s that argued BPD was not an entity unto itself, but a misunderstood form of PTSD [175]. However, the literature indicates that only one-third of the BPD population has a history of severe and extended abuse and only 20% of individuals with a history of serious abuse go on to have serious psychopathology as adults [176].

Potential confusion between BPD and PTSD also arises from repeated findings that ongoing, chronic sexual, physical, or psychological traumatization, particularly in early childhood, constitutes an important etiologic factor in the development of a severe personality disorder, particularly BPD [153]. Additionally, there is a syndrome of severe early trauma leading to sequelae including a BPD-like syndrome, called complex PTSD, whereby trauma is the central concern and requires therapeutic priority. These patients experience great difficulty in trust and cognitive processing, rendering BPD treatments ineffective. However, as discussed, trauma in most patients with BPD is superimposed on a genetically determined pre-existing sensitivity, and although these patients experience psychophysiologic difficulty in processing trauma and communicating about these adverse events, as adults they benefit from therapies for BPD. Thus, patients with BPD, unlike those with PTSD, respond to treatments that focus on feelings and not trauma and challenge them to take control of their lives [18].

The typical symptoms of PTSD arise within the first six months after a traumatic event and may last up to two or three years following the event. Symptoms include insomnia, irritability, angry outbursts, difficulty concentrating, hypervigilance, exaggerated startle response, and intensive reliving of the trauma in the form of nightmares, "flashbacks," and repeated memories of the trauma. The development of further symptoms many years after the actual, real, or assumed trauma, including somatization symptoms, dissociative symptoms, emotional lability, impulsivity, self-destructive behavior, and, particularly, chronic interpersonal difficulties with manifestations of emotional immaturity, is indicative of a structured personality disorder, which may derive from trauma or a combination of personality disposition and traumatic experiences [153].

Treatment of PTSD requires a psychotherapeutic approach that facilitates the controlled reliving and working through of the traumatic experience in the context of a safe and secure therapeutic relationship. In contrast, when traumatic experiences are at the origin of a personality disorder, the conflicts triggered by the trauma usually take the form of an unconscious identification with the traumatic relationship—that is, an unconscious identification with both victim and perpetrator of the trauma. This differentiation is important from a therapeutic standpoint. In the transference-focused psychotherapy of patients with BPD, they have to be helped to acquire conscious awareness of this double identification and resolve it in the course of transference analysis. This represents a very different psychotherapeutic approach than that required for the treatment of PTSD [153,177].

In contrast to patients with BPD who present different aspects of their internal world from one moment to the next, patients with narcissistic personality disorder mask the fragmentation and weakness of their identity under a brittle and fragile grandiose self that they present to the world and to themselves [153]. Patients with a severe narcissistic personality disorder may present symptoms strikingly similar to those of patients with BPD, including general impulsivity, chaos in relations with significant others, severe breakdown in their capacity for work and emotional intimacy, and parasuicidal and self-mutilating behavior. These patients are also prone to antisocial behavior, which requires the differential diagnosis among different types of narcissistic pathology with different levels of antisocial features [153].

Important differential features include the patient with narcissistic personality disorder's difficulty accepting any dependent relationship, their severe lack of investment in relations with significant others except in exploitative or parasitic relationships, and an aloofness that contrasts with the highly ambivalent yet clinging and dependent relationships of patients with BPD. Patients with narcissistic personality disorder can show extreme fluctuations between feelings of inferiority and failure and corresponding depressive reactions and an inordinate sense of superiority and grandiosity reflected by contemptuous and dismissive behavior toward others, including therapists. Patients with BPD may alternate their relationship between clinging dependency/idealization and angry rejection and dismissal, but do not show the chronically contemptuous and dismissive attitude of narcissistic patients. Resulting from these characteristics, patients with narcissistic personality disorder are usually isolated socially, even if they are externally part of a social network. They lose their friends and do not maintain relationships over an extended period of time, and their objective loneliness contrasts with the complicated, contradictory, yet enmeshed relationships of patients with BPD [153].

Antisocial behavior may be a complicating symptom of BPD, but it may be more central in lower levels of narcissistic personality disorder; it is always a negative prognostic factor. This is particularly true for antisocial personality disorder and for the syndrome of malignant narcissism, the most severe form of the narcissistic personality characterized by ego-syntonic aggression, paranoia, and antisocial traits. These are important differential diagnostic considerations when the clinical picture appears to be, at first sight, a BPD. They should be considered in the differential diagnosis of all patients within this spectrum of pathology who present with chronic antisocial behaviors [153].

Multimodal treatment, the use of two or more treatment modalities, has been affirmed by several lines of evidence as effective in the treatment of BPD. Different modalities of treatment can complement and augment the benefits of each other. The inclusion of multiple providers in a treatment team elevates the level of mutual support. The use of multiple modalities and providers allow the patient with BPD to express anger and disappointment without leaving treatment [18,192].

Group therapies are either led by professionals who select enrollment or by peers as self-help groups of people who assemble to discuss common issues. Both are effective in BPD.

Dialectical behavioral therapy skills training groups resemble classrooms in structure, with focus, direction, and homework between sessions provided by the group leader. Mentalization-based therapy groups assist in recognizing misattributions and how one's actions affect others. Patients with BPD may resist interpersonal or psychodynamic groups in order to avoid the required expression of strong feelings or personal disclosures; this is why such groups are beneficial. All professional-led groups can significantly enhance the treatment course by allowing patients with BPD to learn from persons with similar life experiences [3].

Patients with BPD may also join self-help groups addressing specific problems, such as Alcoholics Anonymous, Overeaters Anonymous, or Survivors of Incest. These and other self-help groups can provide a network of supportive peers that is beneficial as an adjunct to treatment, but they should not be used as a sole intervention [3].

Elements of group therapies designed for BPD include [184]:

Group therapy for BPD can help in developing the following skills [184]:

Most providers working with patients with BPD will at some point need to determine the appropriate level of care for patients in crisis (Table 2). This decision should be made balancing the important principle of keeping treatment at the least restrictive level of care while maintaining patient safety. In other words, it is necessary to maintain sufficient structure to keep the patient safe but enough exposure to problems to maintain engagement in working toward treatment targets. Higher levels of care will provide safety and crises containment, but unnecessary placement in a higher level of care in response to dramatically expressed distress is an over-reaction that will reinforce the recurrence of crises and avoidance. Conversely, placement in an inappropriately low level of care will likely result in the patient spiraling into panic and desperation, an escalation of impulsive behaviors, and halting of treatment progress. The optimal level of care is based on clinical judgment and experience, because research guidance in this area is not of sufficient quality [3,18].

Hospitalization

For patients with BPD, hospitalization is usually restricted to the management of crises (including, but not limited to, situations in which patient safety is precarious) and is short in duration. Hospitals provide a safe place where the patient has an opportunity to gain distance and perspective on a particular crisis and where professionals can assess the patient's psychological and social problems and resources. It is not uncommon for medication changes to take place in the context of a hospital stay, so professionals can monitor the impact of new medications in a controlled environment [3].

However, hospital admission carries liabilities unique to patients with BPD. The American Psychiatric Association's recommendation of hospitalization whenever patients with BPD are suicidal has been criticized by experts for several reasons [193]. Patients can internalize the invalidating message of their inability to get through a crisis without hospitalization. Progress in therapy can be rendered impossible by repeated hospitalization, as this becomes the learned coping strategy for distress. Hospitalization also prevents addressing the interpersonal problem that triggered the crisis in the first place and can reinforce pathologic behaviors and make the patient worse [194].

The most dangerous features of BPD are self-harming behaviors and suicide risk. Suicidal ideation (i.e., ruminating and fantasizing about suicide) is pervasive in the BPD population [3]. Up to 10% of persons with BPD complete suicide, a rate 50 times greater than in the general population. More than 70% of those with BPD attempt suicide at least once, and patients with BPD attempt suicide an average of 3.3 times in their life [195]. Suicide attempts in BPD tend to peak when patients are in their 20s and 30s, although suicidality can occur in any age group [8].

This led researchers to investigate whether a high lethality subtype of BPD could be identified. One study found that patients at highest risk for suicide had greater illness severity, vocational failures, and estrangement from family and friends. Low lethality subjects had better overall psychosocial functioning but more negativism, lifetime substance abuse, and histrionic and/or narcissistic personality disorder comorbidity. Suicide attempts of this latter group may reflect dramatic "communicative gestures," which show little change in medical lethality with repeat attempts [196]. Long-term longitudinal data have identified factors with greatest prediction of suicide attempt: diagnosis of MDD, substance use disorder, or PTSD; non-suicidal self-harm behavior; sexual assault as an adult; caretaker death from completed suicide; affective instability; and more severe dissociation. Prediction of suicide attempts in patients with BPD is complex and involves assessment of co-occurring psychiatric disorders, prominent BPD symptoms (i.e., self-harm, affective reactivity, and dissociation), adult adversity, and family history of completed suicide [197].

Studies of completed suicide in BPD found that duration of the "suicidal process," spanning from the first unequivocal suicidal communication by verbal threat to first suicide attempt and ultimately to death, may be as brief as 30 months or as long as 10 years. Suicide completion in BPD tends to occur relatively late in the course of the illness. In a 27-year follow-up study, the average age of those who completed suicide was 37 years. Younger patients with BPD tended to make frequent low-lethality attempts as communicative gestures, while older patients completed suicide after years of illness [198,199,200].

Approximately 50% of people with BPD experience an episode of major depression when they seek treatment, and about 80% have a lifetime prevalence of a major depressive episode. When depression coexists with an inability to tolerate intense emotion (as seen with BPD), the urge to act impulsively is exacerbated. It is imperative that providers carefully evaluate patient mood and appreciate the severity of the patient's unhappiness, but also recognize that antidepressant medications usually have only modest effects.

Patients with BPD often abuse alcohol or prescribed/illicit drugs for the short-term benefit of diminished social anxiety, distance from painful ruminations, or diminished intensity of negative emotions. While drug or alcohol use to achieve these effects can be viewed as self-medication, this use of substances is problematic because the disinhibiting effect from many substances elevates the risk of self-injury, suicide attempts, and other self-endangering behaviors [3].

As discussed, the propensity of patients with BPD to attempt suicide can often be intensely stressful for providers caring for them. As these patients are prone to feeling rejected and then reacting with rage, the manner in which they endanger their lives can be intended to inflict emotional agony on the provider(s) the patient perceives as uncaring or rejecting. As an example, a case was described in which a patient was discharged from an inpatient unit, walked to her car, and ingested all of her prescribed medications. She then called the inpatient ward, told staff she had just overdosed on all her medications, but would not reveal where she or her car were. In this case, the patient was found by hospital personnel in time to intervene and save her life [5].

Intentional self-harm behaviors (also termed parasuicidal acts or non-suicidal self-harm) are a common feature of BPD, occurring in 75% of those with the diagnosis and in an even higher percentage of those who have been hospitalized. Physical scarring and potentially disabling physical handicaps can result from this behavior [3].

Self-harm behavior assumes many forms, and patients with BPD often self-injure without suicidal intent. Most self-injury involves cutting, but it can also involve burning, hitting, head banging, or hair pulling. Some self-destructive behaviors are not perceived by patients as self-harming; among these are unprotected promiscuous sex, driving under the influence, and binging and purging [3]. Non-suicidal self-harm can also occur during hospitalization and may be expressed by treatment-sabotaging behavior. In one study, 63% of psychiatric inpatients who exhibited medically self-sabotaging behaviors had BPD. Behaviors and motivation included purposely avoiding needed medical treatment and/or prescribed medication(s) to hurt oneself; gravitating toward a dangerous situation hoping to be physically hurt; and damaging oneself on purpose to seek medical treatment [201].

Motivations for non-suicidal self-harm differ between individuals and within individuals across situations. As many as 40% of non-suicidal self-harm acts occur during dissociative periods, when numbness and emptiness dominate; as discussed, the most common motive for non-suicidal self-harm is to temporarily alleviate numbness or excruciating emotional pain. Suicide attempts are sometimes made when feeling alone and unloved or when life feels too painful to endure. Suicide attempts can occur with a vaguely conceived plan to be rescued, indicating a motive that relief from intolerable feelings of aloneness will occur when connection with others is established with "discovery" of the patient [3].

Clinicians can become constantly fearful of the suicide potential of patients with BPD, and managing this risk is of the utmost importance to maintain client safety. Intentional self-harm, impulsive behaviors with potentially self-destructive consequences (e.g., driving under the influence), and recurrent suicidal threats are probably the most difficult and stressful aspects of BPD for providers [8]. The patient with BPD may plead with his or her provider to keep communications or behaviors secret, but safety must be the priority. The patient, providers, and family cannot work together effectively without candor, and self-destructive threats or acts should never be kept secret for the benefit of all concerned. Family members/friends do not have the capacity to live with the specter of self-destructive behaviors in their lives, and patients will not progress in their treatment until these behaviors are eliminated [3].

Providers may find it difficult to distinguish between suicidal and non-suicidal self-harm, complicating selection of the safest and least restrictive intervention to implement. Some patients with non-suicidal self-harm may require hospitalization if the non-suicidal self-harm behavior is life-threatening. Providers may underestimate the severity of intent in chronically suicidal patients and forego the decision to hospitalize; alternatively, a decision to hospitalize may adversely impact a therapeutic relationship if the patient disagrees with the need for hospitalization [129].

Distinguishing suicidal from non-suicidal self-harm can be assisted by asking the patient about his or her intention. If suicidal intent is confirmed, patient safety is the priority. This may require hospitalization and usually necessitates contact with the patient's family members, often despite the patient's protests. In cases in which suicidal intent is denied, self-harming behaviors or threats may be effectively managed by concerned attention from family/friends and the provider and by establishing a plan for crisis management. In clinical trials of various types of psychotherapy, emergency department visits have been used as needed in such situations, but alternative distress-coping strategies, such as telephone or e-mail contact or use of an Alcoholics Anonymous sponsor, should be encouraged. With repeated or escalating self-destructive behavior, a mental health professional with BPD experience should be involved in patient care [43].

Assessment of self-harm or suicidal behavior should be ongoing, with differing focus as dictated by patient status or clinical setting (Table 3). As noted, patients with BPD are often serious about suicide and have a high lifetime risk of completed suicide. Many overdoses later show ambivalent suicide intent, and episodes of non-suicidal self-harm are predictors of suicide risk and future suicide attempts. Suicide attempt or non-suicidal self-harm seldom reflects conscious attention-seeking behavior. However, some patients may use this as a motive in order to try to minimize the seriousness of their intent. Patients with BPD can also make suicide threats to lengthen their hospital stays. One study of 100 female inpatients with BPD found that subjects commonly expressed suicidal ideation or made suicidal gestures or threats around the time of discharge [202,203].

Because patients with BPD are known as extensive users of healthcare services, with multiple presentations for crises, self-harm, or suicidal threats, healthcare providers can become desensitized and doubtful over the seriousness of patient intent and may feel manipulated [205]. Affective instability is the BPD feature with greatest association to attempted suicide. The affect, mood, and behavior of patients with BPD can rapidly change, as when shifting from very depressed and suicidal to angry and entitled, leaving the provider feeling frustrated and baffled [208].

Self-destructive behavior with suicidal intent may be planned or impulsive in persons with BPD. Some patients with BPD use threats of suicide to communicate distress to their provider or other people with whom they feel a close attachment. With a trusting therapeutic relationship established, patients with persistent suicidal thoughts may disclose risk factors that require intervention, such as stockpiling medication intended for overdose [40].

Many clinicians have found concepts from dynamic deconstructive psychotherapy useful in understanding affective instability and suicide risk in patients with BPD [209]. This model frames the emotionally labile reactions to the environment as a switch between different states of being, or pseudo-personalities, such that patients can alternately present as helpless and childlike (helpless victim state), angry and self-righteous (angry victim state), or depressed and suicidal (guilty perpetrator state). These states reflect different sets of polarized and poorly integrated attributions of self and others, and not strategies of manipulation [205].

In the angry victim state, patients see themselves as heroic victims, do not accept responsibility for failures, and blame others for their setbacks and problems. They feel justified in their actions and behaviors, including anger, manipulation, or violence. The angry victim state protects the patient from feelings of shame or humiliation and is triggered by interpersonal stimuli. In this state, patients are at low risk for suicide because they externalize the source of their problems [205].

Patients with BPD in the guilty perpetrator state are at significantly elevated risk for suicide [210]. Patients assume complete responsibility for every setback or misfortune, view their lives as an unending series of failures and bad decisions, and feel ugly, worthless, and evil. The guilty perpetrator state preserves an idealized image of others by devaluing oneself and is often triggered by perceived rejection, abandonment, separation anxiety, or any situation that prompts ambivalence toward major attachment figures [205].

Circumstances that intensify attachment wishes and fears can induce or amplify states of being and rapidity of switching. These can include abusive relationships, prolonged hospital stays, or poor patient-therapist boundaries, such as physical touch, multiple contacts per week, or extended sessions. These conditions can result in the patient with BPD regressing and becoming moody and childlike, grossly over-reacting to slight provocation, and rapidly shifting between states of being [205].

Most importantly, clinicians should know their ambivalence and conflict over whether or not they should take the suicidal behavior and threats of a patient with BPD seriously actually mirrors the same internal conflict within the patient. This inner conflict involves whether or not their illness is legitimate or whether they are fully to blame for all their problems, attention-seeking, or simply needing to "clean up their act." As the patient takes one side of the inner conflict or changes from one side to another, he or she can rapidly switch states as blame is switched from self to others. Determining immediate risk of self-harm is informed by assessing the patient for current state of being, recent stressors, alcohol misuse, and support system integrity [205].

Dialectical Behavioral Therapy

Dialectical behavioral therapy is based on the theoretical principle that maladaptive behaviors, including self-injury, are attempts to manage intense overwhelming affect of biosocial origin. Dialectical behavioral therapy incorporates the two key elements of a behavioral, problem-solving approach blended with acceptance-based strategies, with an emphasis on dialectical processes. This therapy approach emphasizes balancing behavioral change, problem-solving, and emotional regulation with validation, mindfulness, and acceptance of patients. Therapists follow a detailed procedural manual [68,213]. The term "dialectical" refers to the philosophical principle of opposite truths, such that constructs can be opposing yet true at the same time. A core dialectic in this therapy is accepting patients where they are in the moment and working to help them change [194]. The five components of dialectical behavioral therapy are [194,213]:

The Department of Veterans Affairs recommends that dialectical behavioral therapy may be considered for patients with BPD and recent self-directed violence.

(https://www.healthquality.va.gov/guidelines/MH/srb Last Accessed: March 21, 2023)

Level of Evidence: I (At least one properly done randomized controlled trial)

Dialectical behavioral therapy involves weekly individual sessions, skills-training group sessions, telephone consultation available at all times with a therapist, and team consultation meetings. Therapeutic targets are ranked in hierarchical order, with life-threatening behaviors addressed first, followed by therapy-interfering behaviors, and then behaviors that interfere with quality of life [194].

Specific strategies used by dialectical behavioral therapists include alternating between acceptance and change strategies, adding intuitive knowing to emotional experience and logical analysis, playing the role of devil's advocate, exploring novel and alternate points of view, turning problems into assets, and introducing and exploring a middle path [214].

Cognitive and Cognitive-Behavioral Therapy

CBT is a structured psychological treatment that helps the patient identify maladaptive beliefs and thoughts, connect these beliefs to their feelings and behaviors, and replace maladaptive beliefs and thoughts with adaptive ones. CBT was originally developed for treating depression and anxiety disorders. In patients with depression or anxiety, CBT is generally focused on present situations. In patients with BPD, CBT is modified to address the contribution of previous experiences in the development of core beliefs (termed "schemas"), the structure of therapy and problems that can disrupt the therapeutic relationship, shifting problems and goals, losing focus on therapy objectives, losing structure, and homework non-compliance [40,213].

CBT for BPD is usually delivered in weekly 30- to 90-minute sessions over 9 to 36 months. Patients are given homework between sessions, and some clinics or practices have therapists available by telephone outside clinic visits [40].

Systems Training for Emotional Predictability and Problem Solving

Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a manualized, CBT-based skills development package intended to supplement primary BPD therapy. The components of STEPPS include BPD psychoeducation, emotion management skills training, and behavior management skills training. It includes a two-hour session for family members and significant others, including members of the treatment team, to introduce them to the concepts and skills enabling them to provide support and reinforcement to the patient. STEPPS is delivered in 20 two-hour weekly group meetings led by two co-therapists, with each session addressing a specific emotion or behavior management skill. Throughout the 20 weeks, patients are instructed to monitor their thoughts, feelings, and behaviors to facilitate the recognition and monitoring of changes in the intensity and frequency of emotional episodes [40,202,215].

Cognitive Analytic Therapy

Cognitive analytic therapy is an integrative and relational approach combining CBT with attention to the therapeutic relationship as the vehicle of change. The aim of cognitive analytic therapy is to help the patient understand how problematic, harsh, and punitive relationship patterns with self and others have been learned and continue to be re-enacted. Cognitive analytic therapy uses the methods of narrative and diagrammatic reformulation. These are used to describe the recurrent patterns of relating with others by helping patients understand their experience of "switching" between different states of mind in response to unmanageable feelings or unmet needs. BPD is viewed as representing a form of severe and pervasive damage to self, largely due to complex developmental trauma and deprivation. This leads to a tendency to dissociate into different "self-states," with resultant highly distressing impairment of self-reflective capacity and sense of identity, impaired executive function, and disturbed interpersonal relations. Therapy aims to provide a reparative relational experience and to provide patients with the motivation, skills, and opportunities to learn new patterns of relating to oneself and others [40,216].

Dynamic Deconstructive Psychotherapy

Dynamic deconstructive psychotherapy is a 12- to 18-month, manual-driven treatment for adults with BPD that combines elements of translational neuroscience, object relations theory, and deconstruction philosophy to help patients heal from a negative self-image and maladaptive processing of emotionally charged experiences. Neuroscience research suggests the complex behavior problems of patients with BPD result from deactivation of brain regions responsible for verbalizing emotional experiences, attaining a sense of self, and differentiating self from other; instead, the activated brain regions contribute to hyperarousal and impulsivity [217].

Dynamic deconstructive psychotherapy helps patients connect with their experiences in order to develop authentic and fulfilling connections with others. During the weekly, one-hour sessions, patients discuss recent interpersonal experiences, label their emotions, and reflect on their experiences in increasingly complex and realistic ways to begin the process of self-acceptance. An important clinician skill is learning to recognize, understand, and use the intense emotional reactions elicited by patients with BPD to foster patient recovery, avoid burnout, and provide novel experiences in the client-therapist relationship that support individuation and challenge basic assumptions of themselves and others harbored by the patient [217].

Mentalization-Based Therapy

Mentalization-based therapy is a psychodynamic approach based on attachment and cognitive theory. Mentalization refers to the ability to accurately imagine the mental states of others, a normal developmental milestone attained by stable early attachment relationships. Patients with BPD are thought to have deficits in mentalization resulting from problematic early attachments. The core features of BPD are thought to reflect this failure to develop mentalizing ability and the resultant profound disorganization of self-structure [194,218].

The objective of mentalization-based therapy is to increase patient curiosity about their feelings and thoughts and to develop skills in identifying feelings and thoughts in themselves and others in the context of attachment relationships. By developing mentalizing skills and the capacity to understand their mental states and those of others in attachment contexts, patients are able to address problems with affect, impulse control, and interpersonal functioning, and reduce triggers for self-harm and suicidal behavior. Mentalization-based therapy is delivered in weekly individual and group therapy sessions [219,220].

Schema-Focused Psychotherapy

Schemas are pervasive patterns of thinking, feeling, and behaving, and schema-focused psychotherapy is based on the theory that patients with BPD acquire four dysfunctional schemas in early life that maintain their psychopathology and impairment: the detached protector, the punitive parent, the abused/abandoned child, and the angry/impulsive child. These schemas are maintained by inflexible processes that prevent new learning, termed schema maintenance, schema avoidance, and schema compensation. Schema-focused psychotherapy strives to facilitate affective engagement and re-learning, and this may involve elements of re-parenting. Approaches include a range of behavioral, cognitive, and experiential methods that focus on the therapeutic relationship, daily life outside therapy, and past experiences (including trauma, if relevant). Patients explore the role these core beliefs played in helping them adapt to early environmental adversity and to question whether they remain appropriate for helping adaptation to their current circumstances. Recovery in schema-focused psychotherapy occurs when dysfunctional schemas no longer control the patient's life. Schema-focused psychotherapy is usually provided in biweekly 50-minute sessions [40,218,219].

Transference-Focused Psychotherapy

Transference-focused psychotherapy is based on Kernberg's conceptualization of the core problem of BPD—excessive early aggression led the young child to split positive and negative images of him/herself and his or her mother [221]. The pre-borderline child is unable to merge positive and negative images and corresponding affects to attain a more realistic and ambivalent view of self and others. The primary goal of transference-focused psychotherapy is to reduce symptomatology and self-destructive behavior by modifying representations of self and others as enacted in the transference relationship. Clarifications, confrontations, and transference interpretations are the primary techniques of this twice-weekly psychotherapy [218,219].

Psychodynamic Interpersonal Therapy

Interpersonal therapy is a structured, time-limited supportive therapy first developed for patients with major depression. With this approach, the clinician addresses interpersonal sensitivity, role transitions, interpersonal disputes, or losses and links these to changes in mood [40]. Psychodynamic interpersonal therapy is a manualized therapy for BPD in which the clinician establishes a therapeutic atmosphere that facilitates "connectedness" between the patient and therapist to develop a shared language for feelings. This serves to amplify expression of the patient's personal and inner world during conversation, increasing the opportunity for clinicians to identify traumatic memories that surface and help patients with their integration into the system of self. These disjunctions appear as negative affect, linear thinking, orientation toward events and the outer world, changes in the self-state, and the development of transference [40].

Psychodynamic/Psychoanalytic Psychotherapy

Psychodynamic/psychoanalytic psychotherapy emphasizes the role of unconscious conflict within the context of internal representations of self and others. Relationship problems are replicated in the therapeutic relationship through transference and are interpreted by the clinician. Psychodynamic/psychoanalytic psychotherapy diverges from the traditional approach of psychoanalysis that encouraged therapist neutrality to form a "blank screen" onto which the patient projected inner conflicts and wishes. Instead, with psychodynamic/psychoanalytic psychotherapy, the therapist provides greater structure and is more active with patients [40].

Several therapies developed for patients with BPD have been evaluated in clinical trials, and the efficacy of these approaches was compared in a review of literature published before 2011 [222]. This analysis found that dialectical behavioral therapy was superior to treatment as usual on outcomes of anger, parasuicidality, and overall mental health, and comparable on treatment retention [222,223].

Compared with the outcomes of patients randomized to control therapy, patients receiving several therapies developed for BPD showed significantly greater improvements in core BPD pathology and associated psychopathology. These included dialectical behavioral therapy; dialectical behavioral therapy adapted for patients with BPD plus PTSD; mentalization-based treatment in a partial hospitalization or outpatient setting; transference-focused psychotherapy; and interpersonal psychotherapy modified for BPD. Standard interpersonal psychotherapy was effective in reducing associated depression only. CBT and deconstructive dynamic psychotherapy did not show significant benefit on BPD core pathology or associated psychopathology outcomes. Dialectical behavioral therapy was more effective in improving core and associated psychopathology than patient-centered therapy, and schema-focused therapy was more effective than transference-focused psychotherapy on measures of BPD severity and treatment retention [222,223]. A 2014 study suggests dialectical behavioral therapy uniquely benefits patients with BPD by improving expressions of anger and experiential avoidance and that improvement in overall negative emotion comes from non-specific factors common to specialist and generalist therapies [224].

While dialectical behavioral therapy, mentalization-based therapy, transference-focused psychotherapy, and interpersonal psychotherapy modified for BPD have all shown substantial benefit, no single therapy approach has emerged with greatest efficacy, which suggests that clinicians should offer the therapy modality that best matches their training, theoretical orientation, and preferences [223]. This point is underscored by repeated findings that treatment outcomes in patients with BPD is particularly influenced by the individual therapist [40].

Importantly, the highly structured comparator treatments used in many of the randomized controlled trials have also been found effective. This evidence of comparable benefit from tailored specialized therapies and structured control group therapies is thought to reflect core elements that are common to both groups of psychological treatment [225].

The findings of comparable positive patient outcomes between specialized therapies and generalist therapies in clinical trials are believed to reflect common shared features (Table 4), which makes intuitive sense as both groups of therapy were tailored for the clinical needs of patients with BPD. While these common factors are elements of all evidence-based treatments effective for patients with BPD, generalist treatments are not meant to replace specialist treatments. At this point, the respective roles of specialist and generalist approaches are not clear, but further research may find the majority of BPD can be successfully treated with generalist treatment, with a subgroup needing specialist treatment [226]. Implicit with generalist treatment is recognition that patients not showing improvement require referral to mental health providers with specialized training.

Structured Clinical Management

Structured clinical management is based on a counseling model that resembles supportive therapy, with the addition of case management, advocacy support, problem solving, a crisis plan, medication review, and assertive follow-up if the patient begins missing appointments. Medication is used as an adjunct, when clinically indicated. Structured clinical management is provided by non-specialist clinicians, usually as weekly individual and group therapy sessions [226].

A comparison of mentalization-based therapy with structured clinical management found substantial improvements with both treatments across a range of clinical outcome measures. Mentalization-based therapy achieved steeper and somewhat larger effect sizes after 18 months, but structured clinical management was equally effective over the initial 6 months and patients receiving structured clinical management showed faster reduction in self-harming behaviors [220].

Good Clinical Care

Good clinical care is a CBT-informed approach that incorporates a problem-solving paradigm as the core treatment intervention and stresses the importance of effective organizational structure. Psychologists trained in CBT provide therapy and case management. Patients are discussed in a weekly team meeting, with each team including a psychiatrist. A therapy session is typically offered once per week, which is flexible if patients need an additional contact, up to a maximum of 24 therapy sessions over six months. Case management is also flexibly provided, with clinical trials averaging around three management sessions for every therapy session. This underscores the point that effective intervention involves more than formal psychotherapy [160,226]. A study that randomized adolescents with BPD or BPD traits to cognitive analytic therapy or good clinical care found that subjects in both groups showed significant improvements across a range of clinical outcome measures, with little difference in benefit between therapies [160,227].

Supportive Psychotherapy

Supportive psychotherapy places an emphasis on establishing and maintaining a comfortable, relaxed therapy relationship, with minimal use of interpretation. The focus of supportive psychotherapy is to offer emotional support and advice on current problems encountered by the patient. Transference is followed and managed by the therapist, while interpretation is intentionally avoided. The mechanism of change with supportive psychotherapy is thought to involve the client identifying with the consistent attitudes of benevolence, interest, kindness, and nonjudgmental acceptance by the therapist. Sessions are provided weekly and supplemented with additional sessions as needed [226,228].

The outcomes of patients with BPD receiving dialectical behavioral therapy, transference-focused psychotherapy, or supportive psychotherapy were compared after one year of treatment. Patients in all three groups demonstrated significant improvements across a range of clinical measures, with outcomes from all three treatments reported as generally equivalent [213,229]. Patients assigned to supportive psychotherapy received one scheduled session per week plus additional sessions if needed, while patients in the two specialist treatments received two scheduled sessions per week, a clear cost-savings advantage [74,226].

General Psychiatric Management

General psychiatric management is a psychodynamically informed approach that includes case management and symptom-targeted adjunctive medication. The psychodynamic approach stresses that disturbed early attachments are a primary deficit in BPD [192]. General psychiatric management was developed to provide professionals involved in the care of patients with BPD with the basic knowledge necessary to manage this patient group without the need for intensive advanced training. General psychiatric management includes four basic elements [139,230]:

During the initial phases, the targets of therapeutic focus and improvement or resolution of symptoms follow a sequential pattern (Table 5).

One study randomized subjects with severe BPD to one year of dialectical behavioral therapy or general psychiatric management [231]. The study found that general psychiatric management and dialectical behavioral therapy both led to significant and comparable improvements across a broad of clinical outcome measures, which persisted at two-year follow-up. With general psychiatric management, 66% of providers were psychiatrists [226].

One of the biggest challenges in the successful treatment of patients with BPD and other personality disorders is the patient's tendency for irregular treatment attendance, disengagement and premature discontinuation of treatment, and resistance to help and intervention. Motivational interviewing has shown promise in assisting the provider to motivate patients with BPD to engage in therapy and effect positive change (Table 6) [200,232].

Patients with BPD typically possess poor judgment, poor problem solving, and an inability to tolerate distress. They can react to a crisis with behaviors strongly motivated to reduce the overwhelming distress they experience—typically impulsive, manipulative, or self-harming behaviors. This behavioral response creates a subsequent crisis, prompting a maladaptive response, and a vicious cycle is created. Patients may also respond to stress or a crisis with regressive behavior or by shutting down [234].

The problem-solving technique can be used to intervene in patients with BPD to assist them in identifying a more adaptive solution to the current problem and empowering them to change the maladaptive behavior (Table 7). Problem solving is performed by implementing the following steps [234]:

Omega-3 fatty acids have received increasing recognition for their benefit in mood stabilization. One study of omega-3 ethyl-eicosapentaenoic acid supplementation in patients with moderate-to-severe BPD found efficacy in decreasing aggression and affective symptoms [47].

A trial of patients with comorbid PTSD and BPD found some benefit with clonidine, an α-adrenergic agonist, but this effect was limited to alleviation of PTSD symptoms [253].

Preliminary trials of opioid antagonists have shown limited and inconsistent benefit in patients with BPD. A placebo-controlled trial of naltrexone failed to demonstrate significant improvement in dissociative symptoms [254,255].

A 2022 systematic review was undertaken to update an earlier review of pharmacologic interventions for people with BPD [256]. The 2022 review included 46 trials and more than 2,700 participants. Medications reviewed included antipsychotics, antidepressants, and mood stabilizers. Compared with placebo, no medication had a significant effect on BPD symptom severity, self-harm, suicide-related outcomes, or psychosocial functioning. There was low-certainty evidence that antipsychotics may slightly reduce interpersonal problems and that mood stabilizers may result in a reduction in this outcome. Antidepressants had little to no effect on interpersonal problems [256].

Involving the family allows access to valuable input regarding patient history and clinical presentation. It also provides the opportunity for family education on the nature of BPD and a realistic understanding of treatment options and long-term course [139].

Therapist discussion of BPD and referral to informational resources are critical during the evaluation phase. The therapist should know that a better-informed family usually translates into greater help and added treatment benefit for the patient [139]. Families often blame themselves for their relative's BPD, and psychoeducation helps the family understand the complex nature of BPD and avoid assigning blame, regardless of patient perception or accusation.

Psychoeducation includes describing the disorder, expected symptoms of the illness and how best to respond, and information on the biology and psychology of the illness and how these interact. Positive but realistic expectations for treatment should be conveyed. Specialized treatments now show a track record of long-term improvement, but given the 10% fatality rate from suicide, the family should have a guarded optimism and patience with their relative while he or she participates in the treatment process. This realistic appraisal can help families better prepare for the process ahead.

Discussing the role of the family in the patient's life is essential because, despite their best intentions, some families sabotage progress (e.g., by providing financial support without guidelines). The provider can help the family understand to what extent support is realistic and how to balance patient support with patient empowerment for eventual autonomy.

Parameters for patient communication should be established during initial treatment. While patient communication to the therapist is confidential (except with potentially life-threatening content), the family can access the therapist to communicate concerns the patient may not disclose [139]. The nature of family communication should be tailored to patient need, such as the option for family to call the therapist with concerns or structuring the communication to include a monthly family meeting. In most cases, it is prudent to ask the patient to sign a consent form for release of information between therapist and family.

As the communication system is discussed and developed, encourage the patient and family to communicate as openly as possible with each other. When the therapist becomes the conduit of information between patient and family, this is a misuse of therapy.

Addressing family as the secondary client affirms the importance of assessing family needs as an aspect of care that engages the entire family system. The clinician can inform and support the family in gaining coping strategies for their distress and confusion resulting from chronic exposure to their relative's BPD symptoms [139]. For patients with severe BPD symptoms, the negative emotional impact on family members is best addressed by referral to family therapy. In family therapy, all parties participate to resolve communication problems and other family system stressors.

Family members can also be referred to additional support, such as that provided by the Treatment and Research Advancements for Borderline Personality Disorder (TARA) and the NEA-BPD Family Connections System models. The TARA model uses family psychoeducation (including an in-depth understanding of BPD) and elements of treatment approaches that can be applied to family communication. The NEA-BPD model uses the principles of dialectical behavioral therapy to help families better understand BPD and incorporate dialectical behavioral concepts into their communication with the patient.

A good general resource for families is the BPD Resource Center website (https://www.nyp.org/bpdresourcecenter). This website includes access to trained specialists who can address questions, give information, and provide linkage to additional resources. It also allows communication with others who have also experienced the stress of living with a family member with BPD.

All parties should understand the course of BPD treatment can be intense and may occasionally be very difficult. Periods of greatest difficulty may be triggered by external events and for reasons that are unclear at the moment. It is essential for the provider, patient, and family to continue working together during the most difficult periods with honest communication [139].

Providers working with the BPD population should have the ability to "weather the storm" of intense displays of patient affect without over-reacting or retreating. By "containing" intense patient affects, the provider shows the patient and family that these discharges of emotion can be experienced, reflected on, and mastered. If the patient's condition worsens during treatment, the provider should obtain outside consultation with an expert to determine if another approach could be more helpful. In most cases, the best provider strategy during symptom exacerbation is to continue working with the patient and family using the same therapy modality.

Medication is often part of the broader treatment plan. In some cases, the patient with BPD requires a medication choice that carries greater toxicity or lethality risk with overdose. Family members should be fully informed about medications, including the specific target symptoms, anticipated symptom changes from the medication, potential side effects, and actions to take in case of emergency [139].