What are the criteria and treatment options for borderline personality disorder?

Diagnostic Criteria for Borderline Personality Disorder

Borderline personality disorder requires at least five specific characteristics from a pervasive pattern of instability in interpersonal relationships, self-image, and affects, with marked impulsivity beginning by early adulthood. 1, 2

Core Diagnostic Features

The American Academy of Child and Adolescent Psychiatry defines BPD by instability across three main domains 1:

• Interpersonal relationships: Unstable relationships that alternate between idealization and devaluation, with intense fears of abandonment 1, 3
• Self-image: Identity disturbance with varying self-concept oscillating between grandiosity and worthlessness 1, 3
• Emotional regulation: Rapid mood swings, intense irritability, difficulty controlling anger, and chronic feelings of emptiness 1, 3

Specific Diagnostic Criteria

The diagnosis requires documentation of at least five of these characteristic patterns 2:

• Repeated suicide attempts and non-lethal self-injury 2, 3
• Pervasive impulsivity in self-damaging behaviors (excessive spending, impulsive sexual activity, reckless driving, substance abuse) 1, 2, 3
• Unstable and intense interpersonal relationships 2, 3
• Affective instability with rapid mood shifts 2, 3
• Inappropriate, intense anger or difficulty controlling anger 1
• Transient stress-related paranoid ideation or severe dissociative symptoms 2, 4
• Chronic feelings of emptiness 1, 4
• Frantic efforts to avoid real or imagined abandonment 3

Assessment Methodology

Use structured or semi-structured interviews conducted by mental health specialists, not self-report questionnaires, because lack of insight is a core feature of personality disorders. 2, 3

The assessment must include 2, 3:

• Information from multiple sources using developmentally sensitive techniques 2, 3
• Confirmation from multiple informants due to impaired patient insight 3
• Systematic evaluation of informant discrepancies 2
• Timeline of symptoms including age at onset, predominant early symptoms, relationship to life events, and progression over time 3
• Special attention to suicidality during mental state examination 3

Behavioral clues during assessment provide important diagnostic information, including intense emotional reactions, splitting (viewing others as all good or all bad), and testing boundaries. 3

Severity Classification

The ICD-11 framework differentiates BPD by severity: mild, moderate, and severe, with optional specification of maladaptive personality traits including negative affectivity, detachment, dissociality, disinhibition, anankastia, and borderline pattern 5, 2

Common Diagnostic Pitfalls

• Patients may be reluctant to disclose symptoms due to fear, embarrassment, or stigma 3
• Clinicians may dismiss borderline personality traits as normal developmental concerns in adolescents 3
• Lack of insight is especially prominent in BPD compared to primary psychiatric disorders 3
• Patients often cannot accurately self-report their symptoms 3

Differential Diagnosis

BPD differs from bipolar disorder by the more chaotic and reactive nature of mood instability, rather than the episodic mood changes seen in bipolar disorder. 1

Relationships in BPD are more tumultuous and chaotic compared to the socially isolated and awkward relationships seen in schizophrenia 1

Comorbidity Assessment

Evaluate for common co-occurring disorders 3:

• Depressive disorders 4
• Anxiety disorders (including social anxiety disorder) 3, 4
• Substance use disorders 4
• Post-traumatic stress disorder 4
• Attention-deficit/hyperactivity disorder 4
• Obsessive-compulsive disorder 3
• Eating disorders (particularly bulimia nervosa) 4

Treatment Approaches for Borderline Personality Disorder

Dialectical behavior therapy (DBT) is the treatment of choice for BPD, with the primary goal of reducing suicidality. 2

First-Line Treatment: Evidence-Based Psychotherapy

Psychotherapy is the treatment of choice for BPD, with various approaches showing efficacy in randomized controlled trials, though no single approach has proved superior to others. 2, 4

Dialectical Behavior Therapy (DBT)

DBT involves four core modules delivered over 12-22 weekly sessions 2:

• Core mindfulness skills 2
• Interpersonal effectiveness skills 2
• Distress tolerance 2
• Emotion regulation skills 2

The treatment structure includes 2:

• Weekly individual therapy sessions
• Skills training groups
• Telephone consultations for crisis management
• Patient consultation groups

Other Evidence-Based Psychotherapies

Additional approaches with empirical support include 4:

• Mentalization-based therapy 4
• Transference-focused therapy 4
• Schema-focused therapy 4

Compared to treatment as usual, psychotherapy has proved more efficacious with effect sizes between 0.50 and 0.65 regarding core BPD symptom severity, though almost half of patients do not respond sufficiently. 4

Pharmacological Treatment

No psychoactive medication consistently improves the core features of BPD; pharmacotherapy should target specific comorbid conditions rather than core personality disorder symptoms. 2

Target-Specific Medication Approach

The three psychopathological dimensions for pharmacotherapy are 6:

• Affective dysregulation: SSRIs are the preferred first-line choice for comorbid anxiety disorders or major depression, though maintain realistic expectations regarding impact on core BPD symptoms 2, 6
• Impulsive-behavioral dyscontrol: Mood stabilizers (valproate semisodium, lithium, carbamazepine, lamotrigine) show promise for controlling mood instability and impulsivity 6
• Cognitive-perceptual symptoms: Atypical antipsychotics may improve impulsivity, anger, and hostility, though evidence is limited 6

Avoid benzodiazepines; use low-potency antipsychotics or off-label sedative antihistamines for short-term acute crisis management instead. 2

Crisis Management

Implement crisis response planning with clear warning signs and coping strategies for 2:

• Suicidal behavior or ideation 2
• Extreme anxiety 2
• Psychotic episodes 2

Risk Assessment and Monitoring

Approximately half of young people with BPD report self-harm, and BPD is considered a particularly high-risk psychiatric disorder for suicide. 2

Key areas of ongoing risk assessment include 2:

• Self-harm (which may be related to low mood, emotional dysregulation, or attempts to change physical appearance) 2
• Suicidality (BPD has high morbidity and mortality with significant suicide risk) 2
• Unsafe cosmetic procedures (approximately half of young people with BPD desire cosmetic procedures, with poor psychological outcomes) 2

Prognosis

BPD is associated with 2:

• High morbidity and mortality 2
• Considerable functional impairment 2
• Intensive treatment utilization 2
• High societal costs 2
• Premature mortality risk 2

Early diagnosis and treatment of BPD can reduce individual suffering and societal costs. 4