|
| A) | depression and PTSD. | ||
| B) | neuroses and psychoses. | ||
| C) | neuroses and narcissism. | ||
| D) | psychoses and schizophrenia. |
Unlike most personality disorders that were first described in Europe, the term "borderline personality" was introduced by American psychoanalyst Adolph Stern in 1938 to describe a patient group who did not fully fit the characteristics of psychotic or neurotic patient groups, thus existing on the "borderline" between the two. This concept of BPD persisted into the 1950s and 1960s. The identification and labeling of patients as "borderline" first arose during the era when psychiatry was dominated by the psychoanalytic paradigm. The classification system for mental disorders was primitive and dichotomous, with classification tied to patient capacity for analysis. Patients considered analyzable, and thus treatable, were diagnosed with neuroses, while those considered not analyzable, and therefore untreatable, were deemed to have psychoses [6].
| A) | Homogeneity | ||
| B) | Heterogeneity | ||
| C) | Combining unstable symptoms and stable traits | ||
| D) | False dichotomy of Axis I and Axis II disorders |
The introduction of operationalized diagnoses for BPD and other disorders based on observable criteria in the 1980 DSM-III was considered a significant advancement in the field. However, the concept of and diagnostic criteria for BPD during and after the 2000 DSM-IV-TR became increasingly criticized on several grounds. For example, the description of BPD was non-specific. In the DSM III and the DSM-IV-TR, clinicians were instructed to diagnose BPD when five out of nine criteria were met. But, with this paradigm, individuals diagnosed with BPD could have as few as one criterion in common. This led to the same diagnosis given to patients with various criterion permutations, producing a heterogeneous patient group [11]. This issue is thought to have been largely resolved with the alternative DSM-5 criteria.
Research of BPD during the 13 years between the DSM-IV-TR and the DSM-5 clarified the understanding of BPD and prompted revisions to the diagnosis [4]. The greatest overall change between the DSM-IV and the DSM-5 has been the elimination of the multi-axial classification system, whereby BPD and other personality disorders were assigned a separate axis (Axis II). Several factors contributed to this change. The distinction between Axis I and Axis II disorders in earlier DSM editions received little empirical validation and increasingly became disputed in light of evolving research and clinical evidence. Personality disorders were traditionally conceptualized as the product of environmental factors, while Axis I disorders were viewed as having a biologic or organic cause. This dominant paradigm influenced the introduction of the multi-axial classification system in the DSM-III. While environmental stressors can contribute to personality disorder development, the same is also true with many Axis I disorders such as major depressive disorder (MDD) and PTSD. Also, BPD does not conform to traditional conceptions of personality disorders as ego-syntonic conditions; the symptoms of BPD are clearly ego-dystonic and lead patients to seek treatment for these symptoms [11,12]. Another criticism of DSM-IV-TR criteria was the combination of unstable, stress-induced symptoms and stable personality characteristics, also termed dimensional traits [13].
| A) | Environmental and biologic factors | ||
| B) | Affective instability and paranoid ideation | ||
| C) | Interpersonal relationship chaos and self-harm | ||
| D) | Impairments in personality functioning and pathologic personality traits |
In the 2010s, a new model for diagnosing personality disorders was presented to the DSM-5 Task Force, and it was strongly and unanimously approved. However, the American Psychiatric Association Board of Trustees voted to sustain the DSM-IV-TR diagnostic system for personality disorders, including unchanged criteria for BPD, in the main section of DSM-5 due to insufficient evidence to validate the new proposed model [14]. The proposed new model is maintained in the DSM-5 as an "alternative DSM-5 model for personality disorders," and professionals have reported good clinical utility. These proposed BPD criteria are organized into two sections: impairments in personality (self and interpersonal) functioning and pathologic personality traits [4]:
Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following areas:
Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism, chronic feelings of emptiness, and/or dissociative states under stress
Self-direction: Instability in goals, aspirations, values, or career plans
Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities
Intimacy: Intense, unstable, and con-flicted close relationships, marked by mistrust, neediness, and anxious pre-occupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal
Four or more of the following pathologic personality traits, at least one of which must be impulsivity, risk taking, or hostility:
Emotional lability (an aspect of negative affectivity): Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances
Anxiousness (an aspect of negative affectivity): Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control
Separation insecurity (an aspect of negative affectivity): Fears of rejection by—and/or separation from—significant others, associated with fears of excessive dependency and complete loss of autonomy
Depressivity (an aspect of negative affectivity): Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feeling of inferior self-worth; thoughts of suicide and suicidal behavior
Impulsivity (an aspect of disinhibition): Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress
Risk taking (an aspect of disinhibition): Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard for consequences; lack of concern for one's limitations and denial of the reality of personal danger
Hostility (an aspect of antagonism): Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults
| A) | much higher rates in men. | ||
| B) | higher rates in Asian women. | ||
| C) | comparable rates in women and men. | ||
| D) | lower rates in Native American men. |
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].
| A) | onset is between 13 and 17 years of age in 67%. | ||
| B) | age of onset is between 12 and 19 years of age in 75%. | ||
| C) | onset occurs after 18 years of age in roughly 75% of persons. | ||
| D) | onset in roughly 33% of persons occurs at or before 12 years of age. |
In general, prevalence studies of BPD have found that prevalence in women is three times higher than in men in clinical settings, with similar gender prevalence in community settings [17,26,27]. Although epidemiologic studies have not formally assessed age of onset of BPD, data extrapolation from onset of self-harm (the most predictive symptom of BPD) suggests the onset of BPD occurs before 12 years of age in 32.8% of patients, begins between 13 and 17 years of age in 30.2%, and at 18 years of age or older in 37% [28,29]. The association of higher BPD prevalence with lower education, income, and socioeconomic class suggests these adversity factors predispose to developing BPD, although this association is likely bidirectional; BPD symptoms may contribute to poor educational achievement, lower income, and social class [18,26].
| A) | Lower income | ||
| B) | Lower education | ||
| C) | Lower socioeconomic class | ||
| D) | Urban childhood setting |
In general, prevalence studies of BPD have found that prevalence in women is three times higher than in men in clinical settings, with similar gender prevalence in community settings [17,26,27]. Although epidemiologic studies have not formally assessed age of onset of BPD, data extrapolation from onset of self-harm (the most predictive symptom of BPD) suggests the onset of BPD occurs before 12 years of age in 32.8% of patients, begins between 13 and 17 years of age in 30.2%, and at 18 years of age or older in 37% [28,29]. The association of higher BPD prevalence with lower education, income, and socioeconomic class suggests these adversity factors predispose to developing BPD, although this association is likely bidirectional; BPD symptoms may contribute to poor educational achievement, lower income, and social class [18,26].
| A) | 34% to 48%. | ||
| B) | 47% to 56%. | ||
| C) | 50% to 65%. | ||
| D) | 71% to 83%. |
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].
| A) | Diabetes | ||
| B) | Alzheimer disease | ||
| C) | Cardiovascular disease | ||
| D) | Sexually transmitted infection |
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].
| A) | Childhood abuse and trauma play a large role. | ||
| B) | Innate infant/child temperament plays a substantive role. | ||
| C) | Harsh early environment has similar adverse effects on all infants/children. | ||
| D) | Adverse parental behaviors are the single most significant contributing factor. |
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].
| A) | Withdrawal | ||
| B) | Hyperactivation | ||
| C) | Approach/avoidance | ||
| D) | Controlling/caregiving |
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].
| A) | 1% to 5%. | ||
| B) | 10% to 15%. | ||
| C) | 25% to 30%. | ||
| D) | 50% to 60%. |
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].
| A) | Full siblings | ||
| B) | Dizygotic twins | ||
| C) | Monozygotic twins | ||
| D) | Maternal half-siblings |
A genetic basis of BPD was identified in several family studies that found family loading for the disorder and significantly higher prevalence of BPD in first-degree relatives of patients with BPD than in the general population [70]. Research from a 2019 total population study estimated aggregation and hereditability among family members, which showed a pattern of decreased familial association with genetic relatedness [76]. The concordance hazard ratio of BPD was 11.5 for monozygotic twins and 7.4 for dizygotic twins [76]. Among full siblings, the hazard ratio indicated a 4.7 times greater risk of BPD, compared with maternal half-siblings (2.1 times) and paternal half-siblings (1.3 times). Cousin relations were also part of the study, and it was found that the hazard ratio was 1.7 for cousins whose parents were full siblings, 1.1 for cousins whose parents were maternal half-siblings, and 1.9 for cousins whose parents were paternal half-siblings. Heritability has been found to range from 44% to 60%, with individual specific environmental factors accounting for the remaining variance. This extent of genetic influence exceeds that of anxiety disorders and depression but is less than that of bipolar affective disorder or schizophrenia [18,76,77].
| A) | Cerebellum | ||
| B) | Hypothalamus | ||
| C) | Prefrontal cortex | ||
| D) | Anterior cingulate cortex |
Emotion regulation is mediated by frontolimbic brain regions that include, among other structures, the amygdala, hippocampus, hypothalamus, dorsolateral and right dorsomedial prefrontal cortex, orbital frontal cortex, anterior cingulate cortex, and insula [100]. These and other structures are interconnected by function and structure and are recruited to modulate subcortical responses to emotional stimuli and inhibit behavioral impulses [101]. Dysfunction of this circuitry contributes to emotion dysregulation. Emotion regulation is best understood as an individual and interpersonal process that begins with early attachment and continues to later peer and romantic relationships. Early attachment and interpersonal relationships distribute the effort of emotion regulation through co-regulation [102].
| A) | involves stunted emotional reactivity. | ||
| B) | is thought to have an environmental origin. | ||
| C) | is primarily associated with positive mood states. | ||
| D) | results in poor accuracy in correctly identifying facial emotions. |
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].
| A) | can increase negative affect. | ||
| B) | include experiential avoidance. | ||
| C) | are chosen over adaptive behaviors with sufficient negative affect. | ||
| D) | All of the above |
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].
| A) | Costs | ||
| B) | Stigma | ||
| C) | Reliance on psychotherapy | ||
| D) | Desire for a clear-cut diagnosis |
Recurrent suicidal threats or actions in response to fears of abandonment are by themselves strongly indicative of a BPD diagnosis. However, BPD remains underdiagnosed, and often misdiagnosed, in large part because the characteristic recurrent crises, emotional volatility, and self-injurious behavior are perceived as willful manipulative choices rather than expressions of illness [43,147,148]. A substantial gap exists between the education and practice of mental health care, and the current educational system for mental health professionals does not pay adequate attention to BPD or other personality disorders. Training health practitioners in BPD-related educational interventions can enhance positive attitudes and change practice toward people with BPD [149].
| A) | BPD cannot be diagnosed in persons younger than 18 years of age. | ||
| B) | Personality development research supports adolescent BPD validity. | ||
| C) | Diagnosing adolescent BPD affords intervention to alter disease course. | ||
| D) | Characteristic BPD traits (e.g., self-harm) can emerge by 12 years of age. |
The DSM-IV-TR explicitly stated to exercise great caution when diagnosing BPD in patients younger than 18 years of age, largely from the belief that personality and behavioral patterns during adolescence are predominantly transient. In other words, adolescents may "outgrow" borderline symptoms, so diagnosing them before 18 years of age is premature [160,161]. However, more recent research on BPD and personality development indicates that an adolescent diagnosis of BPD is valid, and ignoring BPD as a possible disorder in adolescents may hamper effective clinical intervention [162]. The typical onset of self-harm before 12 years of age suggests an important window to screen and provide early intervention for these children and their families [29].
| A) | Narcissism | ||
| B) | Disturbed self | ||
| C) | Interpersonal hypersensitivity | ||
| D) | Behavioral dyscontrol (impulsivity) |
The new proposed diagnostic criteria for BPD in the DSM-5 are reliable and replicable and reflect the observable manifestation of dysregulated interpersonal, behavioral, identity, and cognitive domains [109]. However, the symptom criteria do not fully capture the foundational basis of the psychopathology. Abnormal personality traits in BPD have been attributed to four factors, with each factor representing an underlying temperament or phenotype:
Interpersonal hypersensitivity
Affect (emotional) dysregulation
Behavioral dyscontrol (impulsivity)
Disturbed self
| A) | women with BPD are more often victims of physical aggression than men. | ||
| B) | men more often perpetrate psychological and physical violence than women. | ||
| C) | women more often perpetrate psychological and physical violence than men. | ||
| D) | women more often perpetrate psychological violence, while men more often perpetrate physical violence. |
| A) | adhering to a standardized formula approach for assessment. | ||
| B) | enlisting patient involvement by asking if each criteria fits them. | ||
| C) | using the "gold standard" assessment instrument in all evaluations. | ||
| D) | attempting to obtain full patient history in first contact, even with patient distress. |
The reliability of the diagnostic assessment for personality disorder has been considerably improved by the introduction of standardized interview schedules. There are two structured interview techniques widely used for diagnosing personality disorder with high specificity and reliability: the Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD) and the International Classification of Diseases, 10th Revision International Personality Disorder Examination (IPDE-ICD-10) [148,168,169]. The SCID-5-PD aligns with DSM-5 criteria for personality disorders diagnosis, while the IPDE-ICD-10 aligns with diagnostic criteria using the ICD-10 and DSM-IV-TR [148,168,169], One issue, common to many of the instruments, is the excessive length of time required for administration, with the interview for either method taking approximately one to three hours, depending on experience and skill level of the interviewing clinician [148,169]. A patient questionnaire is also available that can be completed in approximately 20 to 30 minutes, and will lessen the time of the interview. It should be noted that despite strengths such as reliability and direct correlation with DSM criteria, structured interviews and questionnaires may not fully capture the complexity and dynamics of patient mental health status. The diagnosis of BPD is most easily established by asking patients whether they believe the criteria for the disorder fits them and by listening to patients describe interpersonal interactions. Patients with BPD may be more likely to accept the assessment process by participating in the diagnosis. As discussed, patients and their families often find it helpful to be informed of the diagnosis and are relieved to learn that others share similar symptoms for which there are effective treatments [43].
| A) | Excessive inappropriate anger | ||
| B) | Capacity for relationship stability | ||
| C) | Appropriate appraisal of self and others | ||
| D) | Autonomous and persistent mood lability |
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].
| A) | impulsivity. | ||
| B) | severely chaotic intimate relationships. | ||
| C) | self-harming and self-mutilating behavior. | ||
| D) | persistently contemptuous and dismissive behavior toward therapist. |
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].
| A) | Therapist passivity | ||
| B) | Therapist neutrality | ||
| C) | Therapist interpretation of negative motivations | ||
| D) | All the above |
Kernberg stated that the adverse reactions to therapy that were highly commonplace in patients with BPD resulted from unconscious guilt (as an element of masochistic character structures), unconscious envy that underlies patient need to destroy what is received from their therapist, and unconscious identification with a primitive and sadistic object that underlies patient need to destroy the therapist as a good object [182]. Patient failure to improve with psychoanalytic therapy was solely attributed to pathologic motivations in the patient with BPD [6]. Improvements were rare exceptions rather than the rule. Although unknown at the time, in many patients with BPD traditional psychoanalytic therapy promoted symptom exacerbation from unintended toxic interaction between therapist approach and core BPD psychopathology [184]. Specifically, therapist neutrality encouraged patient projection and fueled abandonment fears, and therapist passivity promoted patient fears of disinterest and neglect. Therapist interpretations of negative motivations were experienced by patients as blaming and invalidating.
| A) | Medication changes may take place in the context of a hospital stay. | ||
| B) | Hospitalization is essential for long-term stability and is underused. | ||
| C) | Hospitalization can interfere with the learning of healthy coping skills. | ||
| D) | The American Psychiatric Association has recommended hospitalizing patients with BPD whenever suicidal. |
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].
| A) | Roughly 10% of patients with BPD commit suicide. | ||
| B) | Risk is elevated by co-occurring psychiatric disorders. | ||
| C) | Poor vocational and relationship function are risk factors. | ||
| D) | Suicide is least likely to be attempted earlier in the course of illness, when patients are in their 20s and 30s. |
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].
| A) | Angry victim state | ||
| B) | Helpless victim state | ||
| C) | Guilty perpetrator state | ||
| D) | Helpless perpetrator state |
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].
| A) | Generalization | ||
| B) | Psychoeducation | ||
| C) | Capability enhancement | ||
| D) | Motivational enhancement |
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]:
Capability enhancement (skills training)
Motivational enhancement (individual behavioral treatment plans)
Generalization (access to therapist outside clinical setting, homework, inclusion of family in treatment)
Structuring the environment (emphasis on reinforcing adaptive behaviors)
Capability and motivational enhancement of therapists (therapist team consultation group)
| A) | It is a normal developmental milestone. | ||
| B) | It requires stable early attachment relationships. | ||
| C) | It refers to subconscious "switching" between different states of mind. | ||
| D) | It refers to ability to imagine and perceive thoughts/feelings in self/others. |
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].
| A) | splitting. | ||
| B) | impulse dyscontrol. | ||
| C) | emotion dysregulation. | ||
| D) | projective identification. |
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].
| A) | Mentalization-based therapy | ||
| B) | Transference-focused psychotherapy | ||
| C) | Interpersonal psychotherapy modified for BPD | ||
| D) | No single therapy approach has emerged with greatest efficacy. |
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].
| A) | To help resolve treatment-defeating behavior | ||
| B) | To eliminate the need for any other treatment | ||
| C) | To help motivate the patient to change their behavior | ||
| D) | To help avoid the pathologic personality traits of the patient |
Two approaches for the primary care setting are motivational interviewing and problem solving. These are not treatment approaches per se, but instead are concrete, problem-focused tools that allow the clinician to improve the outcomes of patients with BPD while navigating some of the problematic behaviors and attitudes driven by the personality traits of BPD. Both were developed to address the very legitimate provider concerns over emotional endurance and job satisfaction when managing patients with BPD. When treating patients with BPD, clinicians should also consider a collaboratively developed crisis and safety plan and should use an overall approach of active listening, mindfulness, and strengthening patients' connections to their most important values [216,232,233].
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].
| A) | Polypharmacy is not more effective than monotherapy. | ||
| B) | In many cases, drug therapy can be the primary or sole treatment. | ||
| C) | Drug therapy has not shown efficacy in treating core BPD features. | ||
| D) | Drug therapy can be effective in reducing a narrow range of symptoms. |
Medications may effectively reduce a single or narrow range of targeted symptoms in BPD but have not yet shown convincing efficacy in addressing the core features (i.e., frantic efforts to avoid abandonment, emptiness, identity disturbance, and dissociation). Medication is considered adjunctive to psychotherapy, and prescribing psychotropic medication can help build a positive alliance with the patient with BPD. The selection and prescribing of medication for BPD is more complicated than in patients with other psychiatric conditions [18,236]. For example, patients with BPD are often highly perceptive to physiologic stimuli and medication side effects. Several strategies can be used to help optimize pharmacotherapy response and minimize interference from BPD pathology [18,184]:
Emphasize the need for collaboration.
Set realistic expectations that medications are unlikely to produce BPD symptom remission and that therapeutic effects may be difficult to assess.
Involve the patient to help identify therapeutic targets, improve compliance, ensure safety, weigh possible benefits against drawbacks from side effects.
Do not prescribe prophylactically, only with patient request or when severely distressed. When requested but patient is not severely distressed, pharmacotherapy may still be considered to help establish an alliance. In these cases, be cautious and prescribe selective serotonin reuptake inhibitors, because despite modest benefits, they carry a low lethality risk in overdose.
If a patient is severely distressed but declines medication, encourage but do not push.
Use judgment in assessing medication benefit, because patients with BPD may value or devalue medications as a proxy for their perception of the prescriber relationship. Patients' decisions regarding medication may be based on fear of being controlled, not feeling cared for, or expectation of being cured.
Establish a policy that if medication response is absent, initiation of an alternate medication is contingent on full taper of the first medication (or cross-taper in severely distressed patients).
Stress the necessity for responsible usage to evaluate effectiveness.
When pharmacotherapy is used to help manage a BPD crisis, the medication should be withdrawn after the crisis has been resolved. The treatment course, dose, planned duration, and review intervals should be documented and communicated to other prescribers involved in the patient's care.
| A) | Identity disturbance | ||
| B) | Chronic feeling of emptiness | ||
| C) | Abandonment fear and hypersensitivity | ||
| D) | No drug agent has been found effective in improving core BPD symptoms. |
Among the more rigorously designed clinical trials of drug therapy for BPD, no drug agent has been found effective in improving the core features of abandonment fears and hypersensitivity, chronic feelings of emptiness, identity disturbance, or dissociation. This may be due to outcome assessments lacking the ability to detect change in these symptoms or because these core BPD symptoms are not treatable with currently available drug therapies [237].
| A) | Loxapine | ||
| B) | Ziprasidone | ||
| C) | Haloperidol | ||
| D) | Aripiprazole |
Second-generation atypical antipsychotics are more frequently prescribed for BPD, because they possess greater tolerability and show a broader therapeutic range due to their serotonergic and noradrenergic activity. Broadly, atypical antipsychotics are efficacious in reducing impulsive aggression, mood instability, anxiety, anger, impulsivity, and cognitive symptoms. Olanzapine and aripiprazole have accounted for a sizeable proportion of positive clinical trial results and have shown significantly improved affective instability, impulsivity, psychosis, and interpersonal dysfunction [222,235,238].
Aripiprazole has the added benefit of a long half-life and favorable metabolic profile, making administration easier and possibly increasing adherence and therapeutic benefit. As a partial agonist at D2 and 5-HT1A receptors and an antagonist at 5-HT2A receptors, aripiprazole may possess greater efficacy in reducing the impulsivity and aggression associated with BPD [244,245]. Despite a similar mechanistic profile, ziprasidone has not shown benefit in BPD [246].
| A) | cause behavioral inhibition. | ||
| B) | carry no risk of addiction and overdose. | ||
| C) | are helpful in long-term control of panic and anxiety. | ||
| D) | can interfere with learning and skills development from BPD therapy. |
Use of benzodiazepines has not received empirical support and is generally contraindicated for patients with BPD due to the risks of behavioral disinhibition, addiction, and overdose [184]. Benzodiazepines also impose the risks of inhibiting learning and interfering with skills acquirement [206]. Tricyclic antidepressants also pose a high risk of toxicity in overdose, including death due to fatal arrhythmia, and are generally avoided [257].
| A) | family psychoeducation of BPD benefits patient and family. | ||
| B) | family members can be highly distressed from living with the BPD patient. | ||
| C) | families benefit from learning the skills to address difficult patient dynamics. | ||
| D) | All of the above |
There is broad awareness that families of patients with BPD should, in most cases, be involved in the therapeutic process. One reason is that destructive family dynamics can greatly contribute to treatment drop-out by patients with BPD. In addition, families typically experience significant distress from living with and trying to cope with the problems of the patient with BPD. Regardless of the role family played in life adversity of the patient with BPD, they can become entangled in dysfunctional relationships with the patient that impede treatment. Family intervention can include providing psychoeducation concerning BPD and its origin, course, and treatment; teaching family members problem-solving skills to address difficult patient dynamics and provide the patient with validation; and transmit other communication skills to address the emotional reactivity of the relative with BPD [258,259,260].
| A) | MDD should be the initial focus of treatment. | ||
| B) | comorbid MDD lowers response to BPD therapy. | ||
| C) | patients are less likely to show antidepressant response. | ||
| D) | pharmacotherapy is generally more important than psychotherapy in positive treatment outcomes. |
Although MDD is virtually ubiquitous as a comorbidity in BPD and despite some overlap between MDD and BPD symptoms (such as chronic dysphoria in BPD and sadness and worthlessness in MDD), patients meeting full criteria may not benefit from antidepressants. The reasons for reduced antidepressant response remain unclear. Clinical trials have found that in patients with BPD and a co-occurring major depressive episode, improvement in BPD symptoms resulted in later improvements in major depressive symptoms, but the reverse was not found. In addition, patients with BPD receiving psychotherapy have shown reductions in self-reported depressive symptoms. Thus, specific treatment that targets BPD may be effective treatment for both disorders [38,222,263].
Although some pharmacotherapy trials have found reductions in comorbid depressive symptoms, these results are difficult to interpret, as most of the studies excluded patients with comorbid MDD. Furthermore, while the interventions led to reductions in subsyndromal depression symptoms, remission rates in patients with comorbid BPD and MDD were not evaluated. Studies combining medication and specialized psychotherapy have shown mixed results, generally supporting the conclusion that treatment of BPD leads to improvement in depressive symptoms. Psychotherapy is generally more important than pharmacotherapy in positive treatment outcomes of BPD and comorbid MDD [38,222].
| A) | Dialectical behavior therapy is a highly beneficial therapy for PTSD. | ||
| B) | With trauma highly prevalent in both, BPD can be treated as a PTSD variant. | ||
| C) | With high patient response to the same therapies, BPD can be treated as PTSD. | ||
| D) | None of the above |
Comorbid PTSD is a more complex problem. It is important that BPD is not treated as a variant of PTSD. Evidence-based psychotherapies for BPD, such as dialectical behavioral therapy, tend to focus on the present and short-term future, and these alone are not helpful for PTSD. In some cases, time-limited, evidence-based CBT for PTSD has been useful [38].
| A) | bulimia should be treated before BPD. | ||
| B) | anorexia often improves when therapy focuses on BPD. | ||
| C) | eating disorders do not improve over time with therapy for BPD. | ||
| D) | binging and purging behaviors can be addressed with specialized psychotherapies for BPD. |
When eating disorders are comorbid with BPD, rates of the eating disorder tend to decline over time, although change to another eating disorder may also occur. This suggests that eating disorder symptoms reflect the core impulsivity of BPD. Patients who exhibit serious weight loss from anorexia nervosa require treatment for the eating disorder before starting BPD therapy. Binging and purging behaviors can be addressed by the same treatment approaches used to reduce self-harming behaviors in specialized psychotherapies for BPD [38,266].
| A) | full symptom remission is rare. | ||
| B) | self-destructive behaviors are the core feature most resistant to change. | ||
| C) | the 8 to 10 years following first hospitalization is the most crisis-ridden. | ||
| D) | interpersonal dysfunction is a core feature most resistant to improvement. |
However, the course of BPD rarely, if ever, shows a simple linear improvement. The frequent alternation between progress and setback is emotionally draining for everyone involved. Long-term studies of the course of BPD found the first five years of treatment are typically the most crisis-ridden. A series of intense, unstable relationships that end angrily, with subsequent self-destructive or suicidal behaviors, are characteristic. Although such a pattern may persist for years, decreasing frequency and seriousness of self-destructive behaviors, decreased suicidal ideation and acts, and declining frequency and duration of hospitalization are early indicators of improvement. Following hospitalization, roughly 60% of patients with BPD are readmitted in the first 6 months; this declines to 35% 18 to 24 months after initial hospitalization. In aggregate, utilization of psychiatric care gradually diminishes over time to involve briefer, less intensive interventions [3].