Borderline Personality Disorder (2024)

Continuing Education Activity

Borderline personality disorder (BPD) is a mental health condition characterized by pervasive patterns of instability in mood, self-image, and interpersonal relationships, as well as marked impulsivity.Fear of abandonment and chronic feelings of emptiness further compound the complexity of this disorder. Individuals with BPD often experience intense and rapidly shifting emotions, have difficulty regulating their emotions, and engage in impulsive behavior, including recurrent self-harm and suicidality. BPDimpacts an individual's interpersonal and occupational functioning, and people with BPD are high utilizers of health care and are challenging to treat. Some develop transient psychotic symptoms.

This course discussion focuses on3 significant areas: the diagnosis of BPD, the pharmacologic and psychotherapeutic treatment of BPD, and the importance ofan interdisciplinary team in managingpatients with BPD. People with BPD may have comorbidities, such as mooddisorders, anxiety disorders, eating disorders, and substance use disorders, posing additional diagnostic and therapeutic challenges. This activity empowers healthcare professionals by equipping them withthe necessary knowledge and tools to provide optimal patient care for those individuals with BPD.

Objectives:

Applythe Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Text Revision(DSM-5-TR) diagnostic criteria for borderline personality disorder.
Evaluatetemperament and its clinical and diagnostic relevance to borderline personality disorder.
Assessthe clinical presentation of borderline personality disorder and its common mental status examination findings.
Collaborate with aninterdisciplinary team to improve care coordination in treating patients with borderline personality disorder.

Access free multiple choice questions on this topic.

Introduction

Borderline personality disorder (BPD) is a mental health condition characterized by pervasive patterns of instability in mood, self-image, and interpersonal relationships. People with BPDcommonly have distorted perceptions of themselves and others, leading to difficulties in maintaining stable and healthy relationships. Individuals with BPD experience intense and rapidly shifting emotions, have difficulty regulating their emotions, and engage in impulsive behaviors. Fear of abandonmentcan drive maladaptive behaviors, including impulsivity, self-harming behaviors, and suicidality. Individuals with BPD can suffer fromchronic feelings of emptiness. Mood disorders, anxiety disorders, eating disorders, posttraumatic stress disorder, other personality disorders, and substance use disorders can complicate BPD.[1]

The concept of BPD has evolved, and its history reflects changes in psychiatric understanding and diagnostic classifications. Hippocrates recorded early descriptions of intense, divergent moods.[2]What would later be recognized as BPD can be traced back to observations in the 1930s and 1940s. Psychiatrists such as Adolph Stern and Frieda Fromm-Reichmann made observations of patients who didn't neatly fit into existing diagnostic categories.In the 1950s, borderline conditions were often considered within the spectrum of schizophrenia. Psychiatrist Kurt Schneider used the term "borderline" to describe patients who were on the border between neurosis and psychosis.The term "borderline" gained more recognition in the 1960s and 1970s as psychiatrists and psychologists began to see a distinct group of patients with specific symptom patterns that didn't neatly fit into existing diagnostic categories.[3]Otto Kernberg and other psychoanalysts played a significant role in defining and describing borderline traits during this time.

The formal recognition ofBPD as a distinct diagnosis came with the publication of the third edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. This marked a significant shift from previous conceptualizations, providing specific criteria for diagnosis and contributing to increased research and understanding.Subsequent editions of the DSM, such as the DSM-IV in 1994 and DSM-5 in 2013, refined the diagnostic criteria for BPD. These revisions aimed to improve the reliability and validity of the diagnosis, addressing some of the controversies and criticisms associated with earlier editions.[4][3]

The current version of the DSM, the DSM-5-TR, divides personality disorders into Cluster A, Cluster B, and Cluster C. Each cluster encompasses a distinct set of personality disorders with commonalities regarding symptoms, behaviors, and underlying psychological patterns.[5]

Cluster Arefers to personality disorders with odd or eccentric characteristics. Theseinclude paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder. Individuals within this cluster often exhibit social withdrawal, peculiar or paranoid beliefs, and difficulties forming close relationships.

Cluster Bcomprisespersonality disorders with dramatic, emotional, or erratic behaviors.This cluster includes antisocial personality disorder, BPD, histrionic personality disorder, and narcissistic personality disorder.Individuals within this cluster often display impulsive actions, emotional instability, and challenges in maintaining stable relationships.

Cluster C consists of personality disorders with anxious and fearful characteristics. Theseinclude avoidant personality disorder, dependent personality disorder, and obsessive-compulsive personality disorder.Individuals within this cluster tend to experience significant anxiety, fear of abandonment, and an excessive need for control or perfectionism.

Despite the historical division of personality disorders into clusters, there are limitations when approaching personality disorders in this manner, and it is not consistently validated in the literature.[6]

Etiology

The current hypothesis is that BPD is caused by an interaction between genetic factors and adverse childhood experiences affecting brain development via neuropeptides and hormones.[7] The relative importance of these factors is unclear.[8]

Genetic studies propose a hereditary component of personality disorders, including BPD. The estimated heritability of BPD is approximately 40%.[8]In a Swedish population, the familial association of BPD washighest for monozygotic twins, then dizygotic twins, then full siblings, then half-siblings.[9] A caveat is that twin studies may overestimate the genetic effect on personality disorders, astwins are generally raised in a shared family environment.[10]Meta-analyses have not supported the proposed association of BPD withthe serotonin transporter gene, the tryptophan hydroxylase 1 gene, or the serotonin 1B receptor gene,and there are no identified single-nucleotide variants associated with BPD.[8][11]

Multiple factors within social and family domains contribute to increased risk for BPD, although none are disorder-specific. Indices of broader social risk include low socioeconomic status, family adversity, maternal psychopathology, parental substance use, low warmth/harsh punishment, child abuse, neglect, and low cognitive function. Studies also show links between temperament factors and later BPD.[12][13]

BPD must be distinguished from personality traits arising fromother medical conditions. Conditions associated with personality changes include head trauma, cerebrovascular accident, CNS neoplasms, epilepsy, neurosyphilis, multiple sclerosis, endocrine disorders, heavy metal poisoning, and HIV-associated neurocognitive disorders.[14]

Psychoanalytic approaches to BPD focus on unconscious processes, early childhood experiences, and the influence of internal conflicts.[15]Psychoanalyst Wilhelm Reich introduced the concept of "character armor," referring to defense mechanisms individuals develop to alleviate cognitive conflict arising from internal impulses and interpersonal anxiety.[16]Defense mechanisms associated with BPD are projection, splitting, and acting out, which are related to insecure attachment.[17][18]The term "splitting" refers to the defense mechanism in which the patient cannot form a realistic view of another person. At any given time, the other person is viewed asentirely good orentirely bad. This inability to view others as having both positive and negative attributes impairs personal relationships. Otto Kernberg theorized that lack of integration in the early maternal relationship led to BPD.[19]Kernberg hypothesized that the infant experiences the maternal figure in a dichotomous framework: the loving and nurturing mother who provides for the child and the punishing, hateful mother who deprives the child. This contradiction causes intense anxiety and, if not integrated into a more moderate unitary concept, leads to splitting. Kernberg also points out that BPD is complex and warns of reductionist shortcuts in searching for etiology.[19]

Personality is a unique pattern of behaviors that an individual adopts in response toconstantly changing internal and external stimuli. It is a complex summation of biological, psychological, social, and developmental factors. Each personality is unique, even among those people grouped and labeled with a personality disorder. This uniqueness is broadly described as temperament, a heritable and innate psychobiological characteristic. Cloninger describes the4 dimensions of temperament as harm avoidance,novelty seeking,reward dependence, andpersistence, which are independently heritable.[20]Harm avoidanceinvolves a bias towards inhibiting behavior that would result in punishment or non-reward.[21]Individuals withBPD may have higher harm avoidance and fearful, anxiety-prone traits.[22][23]Novelty seeking is an inherent desire to initiate novel activities likely to produce a reward signal. Individuals with BPD tend to have a high amount of novelty-seeking behaviors.[22][23]Temperament is further shaped through life experiences such as trauma and socioeconomic conditions; these are adaptive etiological factors in personality development.[24][25]

Epidemiology

Nationwide epidemiologic studies estimate the prevalence ofBPD in the general population between 0.7% and 2.7%, with symptoms usually manifesting in early adulthood.[26][27][28]In primary care,the prevalence is 6%, and the rate is 11% to 12% in outpatient psychiatric clinics and 22% for psychiatric inpatients.[29]Although women have a slightly higher rate of BPD than men (3% versus 2.4%), in outpatient psychiatric settings, there are higher rates of BPD in women (78% versus 28%).[30][31][32]

Pathophysiology

Current neurobiological models of BPD link findings across neuroendocrinology, structural neuroimaging, and functional neuroimaging. Specific genes may be involved with disruptions in the hypothalamic-pituitary-adrenal axis consistent with stress-related changes and chronic elevation of cortisol, affecting emotional regulation and impulse control.[33] Neuroimaging studies haveidentified differences in the amygdala, hippocampus, and medial temporal lobes in patients with BPD, which may also be related to self-reported childhood trauma.

Top-down control abnormalities are seenin BPD, showingthat cortical activity to moderatethe amygdala (and other limbic areas) is impaired. Instead, behavior is driven from thebottom-up, meaning that amygdala activation is unmoderatedby higher-level cortical functions.[34]Studies also suggest that patients with BPDmay misattribute negative emotions (fear, anger, disgust) to neutral faces more than control patients despite having the perception of happy and upset faces equivalent to those groups.[35]On neuropsychological testing, patients withBPD have impaired cognitive flexibility and increased impulsivity. No correlation was found between BPD symptom severity and cognitive functions.[36][37]

History and Physical

The presentation of BPD is variable. Obtaining a thorough psychiatric history, medical history, social history, developmental history, and history of family dynamics is essential for diagnosis. The features of BPDmay start emerging in adolescence, and impulsive and dangerous behaviors may increase through early adulthood. The presence of affective instability identifies most patients with BPD, whodescribe fluctuating moods throughout the day depending on circ*mstances and interactions with others. This mood instability isdifferent than a depressive episode or manic episode, both of which have more consistent mood symptoms.[38]Individuals with BPD display wide emotional lability, including the potential to react strongly andbecomeangry, violent, or suicidal.

Inquiring about the patient's relationships with family, friends, and romantic partners can help diagnose patients with suspected BPD. Splitting is common, viewing others as "all good" or "all bad" from moment to moment. Individuals with BPD can become dependent on others but also have dramatic shifts in their feelings when feeling abandoned or disregarded.[39]Men with BPD are more impaired, impulsive, and aggressive than women with BPD and may be at higher risk of dying by suicide.[40]People with BPD describe chronic feelings of "emptiness" related tohopelessness, loneliness, and isolation.[41]Maladaptive coping is inherent in the diagnosis of BPD. It can present as substance use, impulsive spending, high-risk sexual behavior, binge eating, reckless driving, self-harm, or self-sabotaging behaviors. Body modification byexcessive piercings, tattoos, or scarification can represent identity diffusion and low self-concept clarity and may be connected to BPD.[42]

Self-harming behavior can be either nonsuicidal self-harm or suicidal behavior (with the intent to die). Nonsuicidal self-harm can be expressed by deliberate cutting among women and hitting one's own body in men. Suicide methods include hanging oneself, shooting oneself, jumping off a tall structure, substance overdose, and refusing fluids and food. Nonsuicidal self-harm and suicidal behavior are interrelated, and self-harming behavior is a risk factor for future suicide. Any self-harming behavior should be carefully assessed for intent to die.[43][44]Suicidal behaviors tend to remit over time, but suicidality may continue when BPD symptoms are untreated or severe or if the patient is poorly functioning. Another risk factor for suicide is comorbid major depressive disorder.[45]

The mental status examination is crucial in assessing individuals for BPD. The specific elements and findings of the examination can vary depending on each case of BPD. Assessment of patients should include the following:

Appearance: Individuals with BPD may have excessive tattoos, piercings, or scarification. The patient should be assessed for scars from cutting.[42]
Behavior: Splitting behavior may be present, and the clinician should be sensitive to this dynamic. Patients with BPD may be angry, antagonistic, or violent.
Affect: Patients with BPD may present with constricted, dysphoric, or angry affect.
Thought content: Assess for thoughts of self-harm, suicidality, or thoughts of harming others. Transient psychosis may be present.
Thought process: Individuals with BPD are usually clear and coherent but may dissociate at times.
Cognition:Individuals with BPD are usually cognitively intact and oriented to person, place, and date.
Insight:Typically, individuals with BPD have a poor understanding of how their behaviors are related to their feelings, dysregulated emotions, and interpersonal difficulties.
Judgment and impulse control: Poor judgment and poor impulse control are common in patients with BPD.

Evaluation

Diagnosis ofBPD is based on the longitudinal observation of a patient's behaviors to assess functioning over time. The symptoms of a personality disorder may overlap with symptoms observed during acute psychiatric conditions such as mood disorders. If possible, personality disorders should be diagnosed when other psychiatric conditions are quiescent.[46] BPD can also significantly contribute to the exacerbation of another psychiatric illness and lead to hospitalization.[47]

Clinicians often develop a psychological reaction to patients with BPD, which is known as "countertransference." This occurs due to the nature of the encounters, as patients may be difficult, aggressive, self-harming, or suicidal.[48] Clinicians must recognize signs of countertransference, which may negatively affect patient care.[49] When clinicians feel frustrated with patients who may be suffering from a personality disorder, it is helpful to use those feelings as an evaluation tool to guide diagnosis and treatment.[50][51]

Evidence-based assessment of BPD can include a self-report inventory, such as the 10-item, true-false McLean Screening Instrument for BPD. A score of 7 or more yields both good sensitivity and specificity for diagnosing BPD. The Zanarini rating scale is another common tool used to screen for BPD.[52]

Treatment / Management

The first-line treatmentforBPD is psychotherapy.[56][57]BPD-tailored therapies are effective for patients with BPDcompared to treatment as usual. In clinical trials, psychotherapy improved psychosocial functioning, reduced the severity of BPD symptoms, and may reduce self-harm and depression. The efficacy of psychotherapy for adolescents is not known due to the lack of high-quality studies.[7]

Mentalization-based treatment (MBT) is a complex attachment-based psychological therapy program that helps patients with BPD regulateemotions by increasing their mentalizing capacity and reflective functioning. Patients can then understand and recognize their feelings and the feelings they evoke in others. MBT combines individual therapy and group therapy.[7]

Dialectical behavioral therapy (DBT) is a highly structured psychological therapy that combines mindfulness practices with concrete interpersonal and emotion regulation skills based on cognitive behavioral therapy. DBT aims to change behavior and enable the patient to tolerate distressing feelings by skill-building in emotion regulation, mindfulness, and interpersonal behavior. DBT combines individual therapy, group therapy, and weekly team consultations for the therapists.[7]

Transference-focused psychotherapy (TFP) uses the patient-therapist relationship to develop the patient's awareness of problematic interpersonal dynamics. The therapist uses clarification, confrontation, and transference interpretation within the relationship between the patient and the therapist.[7]

The goal of schema therapy (ST) is the development of ahealthy adult. ST addresses4 dysfunctional life schemas characteristic of BPD: the abandoned/abused child, the angry/impulsive child, the detached protector, and the punitive parent. Cognitive-behavioral, psychodynamic, attachment, and emotion-focused approaches characterize ST.[7]

There is no evidence that pharmacotherapy is efficacious for BPD core symptoms, yet contrary to guidelines, up to 96% of patients with BPD receive at least1 psychotropic medication, and polypharmacy is common.[58] No medications are FDA-approved for the treatment of BPD.[56]Medications such as serotonin reuptake inhibitors (SRIs), mood stabilizers, and antipsychotic medications show limited effectiveness in trials aimed at the control of transient symptoms of anxiety, sleep disturbance, depression, or agitation.[59]Pharmacotherapy is only recommended for the treatment of comorbid disorders such as severe depression or anxiety, transient psychotic symptoms, severe agitation, or aggressive behavior.[7]

Polypharmacy can be associated with iatrogenic harm and contribute to functional impairment. Consider reducing patients' high-risk polypharmacy regimens when determining the risks and benefits of a treatment regimen.[60]

Self-injurious behavior, boundary issues, suicidality, and substance use present challenges in the treatment of patients with BPD.

Patients with BPDdo not typically require hospitalization; however, inpatient care may be necessary in certain situations as follows:

Overt suicidal ideation with imminent risk of high lethality behavior
Intense negative thoughts, agitation, or transient psychosis
Rapid escalation in the severity of self-harm
Exacerbationof comorbid psychiatric disorders or substance use disorders

Differential Diagnosis

BPD often co-occurs with depressive or bipolar disorders, which should be diagnosed if the criteria for those disorders are met. Exacerbations of BPD can mimic mood disorders, so the diagnosis of BPD should only be made based on documented long-standing patterns of behavior.

Both separation anxiety and BPD are characterized by fear of abandonment, but problems with impulsivity, identity, and interpersonal functioning are needed to diagnose BPD.

Personality disorders have overlapping features and can be confused with BPD. It is essential to distinguish BPD by its characteristic features. If an individual meets the criteria for more than1 personality disorder, the other personality disorders can be diagnosed.

Dissociative identity disorder is characterized by2 or more personality states that are each distinct and with an enduring pattern of behavior. In BPD, there are problems with identity and self-image, but these are transient, unstable, and fluctuate.

Persistent substance use can lead to symptoms that mimic BPD.

BPD must be distinguished from personality traits arising from another medical condition. Conditions associated with personality changes include head trauma, cerebrovascular accident, CNS neoplasms, epilepsy, neurosyphilis, multiple sclerosis, endocrine disorders, heavy metal poisoning, and HIV-associated neurocognitive disorders.[14]

Pertinent Studies and Ongoing Trials

There are significant limitations to existing models for describing personality disorders, including BPD. The "cluster" system is commonly used due to its implementation in the DSM. Similar patterns of behavior areclassified into syndromes known as personality disorders; however, the uniqueness of each person remains a problem for the diagnosis and research into each specific personality disorder as patterns overlap and diverge.[6]

Experts in personality disorders suggest switching to a dimensional model of personality. Dimensional models generally describe temperament, utilization of defense mechanisms, and pathological personality traits to diagnose personality disorders.[61]

The DSM-5-TR Alternative Dimensional Model for Diagnosing BPD preserves continuity with the categorical diagnostic model witha hybrid dimensional-categorical model that defines personality disorders in terms of personality functioning and pathological traits. This approach also acknowledges that individuals do not usually present with symptoms of just1 personality disorder.

The paradigm will likely shift further towards a dimensional model as research informs evolving clinical guidelines about diagnosis and treatment. In addition, high-quality head-to-head trials of the major forms of psychotherapy and studies of the nature of mechanisms of change are needed.

Prognosis

Patients with BPD have a fair prognosis, and studies demonstrate that BPD psychopathology improves more than generally expected but that psychosocial functioning often remains impaired. Systematic meta-analysis with 5- to 15-year follow-up periods showed mean remission rates of 60%.[62]

Despite high rates of remission and low rates of relapse, patients with BPD have severe and persistent impairment in functional and social recovery. This is consistent with the theory that with stable supports and avoidance of interpersonal stressors, patients with BPD remit clinically. Patients with persistent BPD were more likely to have had inpatient treatment and had more comorbid borderline psychopathology.[63][64][65]

Complications

Patients with BPD have a higher rate of suicide (5.9%) than patients with other personality disorders (1.4%). In1 study, more than 75% of patients with BPD had suicide attempts.[7][66]Other complications of BPD include comorbid medical conditions such as obesity, diabetes, gastrointestinal disease, cardiovascular disease, hypertension, chronic pain, and sexually transmitted diseases. There is a strong association between BPD andall other personality disorders, mood disorders, eating disorders, posttraumatic stress disorder, and substance use disorders. People with BPD have a poorer life expectancy than others and struggle to negotiate the health care system.[7][67][68]

Deterrence and Patient Education

The treatment of BPD is contingent upon developing and maintaining a therapeutic alliance in the face of the impaired interpersonal relationshipsthat complicate engagement between clinician and patient. Patients with BPD may have unstable emotional states, be highly demanding, act out, and push the limits of the relationship. Needy patients can strain treatment relationship boundaries. Patients can be engaged by seeking relationships and may respond to warmth and support. Therapists canoffer reassurance that the environment is safe and supportive, and encourage patientsto describetheir symptoms and communicate psychosocial stressors. Clinicians should aim to understand and address the specific concerns and challenges the patient with BPD faces, particularly when the patient is not in acute distress or crisis. Patients can be encouraged to utilize support networks through their remaining social relationships and group involvement.[69]

Pearls and Other Issues

Key insights and strategies to navigate the complexities of BPD, optimizing patient care and treatment outcomes include the following:

Patients with BPD can be challenging to treat due to splitting dynamics, and it is important to maintain boundaries in the provider-patient relationship.
Suicidality and self-harm behaviors should be regularly assessed and addressed, coordinating with emergency services as needed. Safety plans should be implemented.
Psychotherapy is the treatment of choice with mentalization-based treatment (MBT), dialectical behavioral therapy (DBT), transference-focused psychotherapy (TFP), and schema therapy (ST) having evidence of efficacy.
There are no psychopharmacologic treatments shown to be helpful in the routine treatment of BPD, and polypharmacy should be avoided.
Comorbid conditions such as depression, anxiety, substance abuse, and eating disorders, which can complicate BPD management, should be recognized and addressed.

Enhancing Healthcare Team Outcomes

Patients with BPD are high utilizers of health care. Early identification and management of patients with BPD is imperative in reducing morbidity and mortality. Caring for patients with BPD requires a collaborative approach among healthcare professionals to ensure patient-centered care and improve overall outcomes. Psychiatrists,advanced carepractitioners, emergency medicine physicians, primary care physicians, nurses, pharmacists, and other health professionals involved in caring for patients with BPD should possess essential clinical skills and knowledge to accurately diagnose and manage BPD. This includes expertise in recognizing the varied clinical presentations and understanding the nuances of diagnosis. Team approaches that include social work, vocational rehabilitation, and recreational therapy improve outcomes in BPD.

A strategic approach should useevidence-based strategies to optimize treatment plans and minimizeadverse effects. Ethical considerations must guide decision-making, ensuring informed consent and respecting patient autonomy in treatment choices. Each healthcare professional must be aware of their responsibilities and contribute their unique expertise to the patient's care plan, fostering a multidisciplinary approach and avoiding splitting. Effective interprofessional communication is paramount, allowing seamless information exchange and collaborative decision-making among the team members. Care coordination plays a pivotal role in ensuring that the patient's journey from diagnosis to treatment and follow-up is well-managed, minimizing errors and enhancing patient safety. By embracing these principles of skill, strategy, ethics, responsibilities, interprofessional communication, and care coordination, healthcare professionals can deliver patient-centered care, ultimately improving patient outcomes and enhancing team performance in the management of patients affected by BPD.

Review Questions

References

1.: Biskin RS. The Lifetime Course of Borderline Personality Disorder. Can J Psychiatry. 2015 Jul;60(7):303-8. [PMC free article: PMC4500179] [PubMed: 26175388]
2.: Sedivec V. [Mental disorders in the writings of Hippocrates]. Cesk Psychiatr. 1989 Aug;85(4):270-3. [PubMed: 2680117]
3.: Bateman A, Fonagy P. Mentalization based treatment for borderline personality disorder. World Psychiatry. 2010 Feb;9(1):11-5. [PMC free article: PMC2816926] [PubMed: 20148147]
4.: Hörz-Sagstetter S, Ohse L, Kampe L. Three Dimensional Approaches to Personality Disorders: a Review on Personality Functioning, Personality Structure, and Personality Organization. Curr Psychiatry Rep. 2021 Jun 28;23(7):45. [PMC free article: PMC8238706] [PubMed: 34181116]
5.: Hopwood CJ, Thomas KM, Markon KE, Wright AG, Krueger RF. DSM-5 personality traits and DSM-IV personality disorders. J Abnorm Psychol. 2012 May;121(2):424-32. [PMC free article: PMC3909514] [PubMed: 22250660]
6.: Tackett JL, Silberschmidt AL, Krueger RF, Sponheim SR. A dimensional model of personality disorder: incorporating DSM Cluster A characteristics. J Abnorm Psychol. 2008 May;117(2):454-9. [PubMed: 18489222]
7.: Leichsenring F, Fonagy P, Heim N, Kernberg OF, Leweke F, Luyten P, Salzer S, Spitzer C, Steinert C. Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and currentcontroversies. World Psychiatry. 2024 Feb;23(1):4-25. [PMC free article: PMC10786009] [PubMed: 38214629]
8.: Amad A, Ramoz N, Thomas P, Jardri R, Gorwood P. Genetics of borderline personality disorder: systematic review and proposal of an integrative model. Neurosci Biobehav Rev. 2014 Mar;40:6-19. [PubMed: 24456942]
9.: Skoglund C, Tiger A, Rück C, Petrovic P, Asherson P, Hellner C, Mataix-Cols D, Kuja-Halkola R. Familial risk and heritability of diagnosed borderline personality disorder: a register study of the Swedish population. Mol Psychiatry. 2021 Mar;26(3):999-1008. [PMC free article: PMC7910208] [PubMed: 31160693]
10.: Torgersen S. Genetics of patients with borderline personality disorder. Psychiatr Clin North Am. 2000 Mar;23(1):1-9. [PubMed: 10729927]
11.: Sanchez-Roige S, Gray JC, MacKillop J, Chen CH, Palmer AA. The genetics of human personality. Genes Brain Behav. 2018 Mar;17(3):e12439. [PMC free article: PMC7012279] [PubMed: 29152902]
12.: Stepp SD, Lazarus SA, Byrd AL. A systematic review of risk factors prospectively associated with borderline personality disorder: Taking stock and moving forward. Personal Disord. 2016 Oct;7(4):316-323. [PMC free article: PMC5055059] [PubMed: 27709988]
13.: Bozzatello P, Rocca P, Baldassarri L, Bosia M, Bellino S. The Role of Trauma in Early Onset Borderline Personality Disorder: A Biopsychosocial Perspective. Front Psychiatry. 2021;12:721361. [PMC free article: PMC8495240] [PubMed: 34630181]
14.: Leppla I, Fishman D, Kalra I, Oldham MA. Clinical Approach to Personality Change Due toAnother Medical Condition. J Acad Consult Liaison Psychiatry. 2021 Jan-Feb;62(1):14-21. [PubMed: 33190792]
15.: Scarpa A, Raine A. Psychophysiology of anger and violent behavior. Psychiatr Clin North Am. 1997 Jun;20(2):375-94. [PubMed: 9196920]
16.: Nielsen DA, Goldman D, Virkkunen M, Tokola R, Rawlings R, Linnoila M. Suicidality and 5-hydroxyindoleacetic acid concentration associated with a tryptophan hydroxylase polymorphism. Arch Gen Psychiatry. 1994 Jan;51(1):34-8. [PubMed: 7506517]
17.: Tanzilli A, Di Giuseppe M, Giovanardi G, Boldrini T, Caviglia G, Conversano C, Lingiardi V. Mentalization, attachment, and defense mechanisms: a Psychodynamic Diagnostic Manual-2-oriented empirical investigation. Res Psychother. 2021 Mar 31;24(1):531. [PMC free article: PMC8082535] [PubMed: 33937117]
18.: Zanarini MC, Weingeroff JL, Frankenburg FR. Defense mechanisms associated with borderline personality disorder. J Pers Disord. 2009 Apr;23(2):113-21. [PMC free article: PMC3203733] [PubMed: 19379090]
19.: Kernberg OF, Michels R. Borderline personality disorder. Am J Psychiatry. 2009 May;166(5):505-8. [PubMed: 19411373]
20.: Cloninger CR, Svrakic DM, Przybeck TR. A psychobiological model of temperament and character. Arch Gen Psychiatry. 1993 Dec;50(12):975-90. [PubMed: 8250684]
21.: Wan L, Zha R, Ren J, Li Y, Zhao Q, Zuo H, Zhang X. Brain morphology, harm avoidance, and the severity of excessive internet use. Hum Brain Mapp. 2022 Jul;43(10):3176-3183. [PMC free article: PMC9188967] [PubMed: 35332975]
22.: Kouros I, Holmberg H, Ekselius L, Ramklint M. Temperament, but not childhood trauma, distinguishes borderline personality disorder from bipolar disorder and ADHD. Nord J Psychiatry. 2024 Jan;78(1):79-86. [PubMed: 37870069]
23.: Réale D, Reader SM, Sol D, McDougall PT, Dingemanse NJ. Integrating animal temperament within ecology and evolution. Biol Rev Camb Philos Soc. 2007 May;82(2):291-318. [PubMed: 17437562]
24.: Svrakic DM, Cloninger RC. Epigenetic perspective on behavior development, personality, and personality disorders. Psychiatr Danub. 2010 Jun;22(2):153-66. [PubMed: 20562740]
25.: Gescher DM, Kahl KG, Hillemacher T, Frieling H, Kuhn J, Frodl T. Epigenetics in Personality Disorders: Today's Insights. Front Psychiatry. 2018;9:579. [PMC free article: PMC6252387] [PubMed: 30510522]
26.: Clarkin JF, Widiger TA, Frances A, Hurt SW, Gilmore M. Prototypic typology and the borderline personality disorder. J Abnorm Psychol. 1983 Aug;92(3):263-75. [PubMed: 6619404]
27.: Nasiri H, Abedi A, Ebrahimi A, Ameli SS, Samouei R. Personality profile of women affected with borderline personality disorder. Mater Sociomed. 2013;25(1):60-3. [PMC free article: PMC3655790] [PubMed: 23687463]
28.: Eaton NR, Greene AL. Personality disorders: community prevalence and socio-demographic correlates. Curr Opin Psychol. 2018 Jun;21:28-32. [PubMed: 28961462]
29.: Ellison WD, Rosenstein LK, Morgan TA, Zimmerman M. Community and Clinical Epidemiology of Borderline Personality Disorder. Psychiatr Clin North Am. 2018 Dec;41(4):561-573. [PubMed: 30447724]
30.: Zimmerman M, Becker L. The hidden borderline patient: patients with borderline personality disorder who do not engage in recurrent suicidal or self-injurious behavior. Psychol Med. 2023 Aug;53(11):5177-5184. [PubMed: 35903008]
31.: Lenzenweger MF, Lane MC, Loranger AW, Kessler RC. DSM-IV personality disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007 Sep 15;62(6):553-64. [PMC free article: PMC2044500] [PubMed: 17217923]
32.: Grant BF, Chou SP, Goldstein RB, Huang B, Stinson FS, Saha TD, Smith SM, Dawson DA, Pulay AJ, Pickering RP, Ruan WJ. Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2008 Apr;69(4):533-45. [PMC free article: PMC2676679] [PubMed: 18426259]
33.: Ruocco AC, Carcone D. A Neurobiological Model of Borderline Personality Disorder: Systematic and Integrative Review. Harv Rev Psychiatry. 2016 Sep-Oct;24(5):311-29. [PubMed: 27603741]
34.: Kulacaoglu F, Kose S. Borderline Personality Disorder (BPD): In the Midst of Vulnerability, Chaos, and Awe. Brain Sci. 2018 Nov 18;8(11) [PMC free article: PMC6266914] [PubMed: 30453675]
35.: Law MK, Fleeson W, Arnold EM, Furr RM. Using Negative Emotions to Trace the Experience of Borderline Personality Pathology: Interconnected Relationships Revealed in an Experience Sampling Study. J Pers Disord. 2016 Feb;30(1):52-70. [PMC free article: PMC4547903] [PubMed: 25710731]
36.: Aslan IH, Grant JE, Chamberlain SR. Cognition in adults with borderline personality disorder. CNS Spectr. 2023 Dec;28(6):674-679. [PubMed: 36924168]
37.: Baird AA, Veague HB, Rabbitt CE. Developmental precipitants of borderline personality disorder. Dev Psychopathol. 2005 Fall;17(4):1031-49. [PubMed: 16613429]
38.: Zimmerman M, Multach MD, Dalrymple K, Chelminski I. Clinically useful screen for borderline personality disorder in psychiatric out-patients. Br J Psychiatry. 2017 Feb;210(2):165-166. [PubMed: 27908898]
39.: Ruocco AC. The neuropsychology of borderline personality disorder: a meta-analysis and review. Psychiatry Res. 2005 Dec 15;137(3):191-202. [PubMed: 16297985]
40.: Sher L, Rutter SB, New AS, Siever LJ, Hazlett EA. Gender differences and similarities in aggression, suicidal behaviour, and psychiatric comorbidity in borderline personality disorder. Acta Psychiatr Scand. 2019 Feb;139(2):145-153. [PubMed: 30353921]
41.: Klonsky ED. What is emptiness? Clarifying the 7th criterion for borderline personality disorder. J Pers Disord. 2008 Aug;22(4):418-26. [PubMed: 18684053]
42.: Vizgaitis AL, Lenzenweger MF. Pierced identities: Body modification, borderline personality features, identity, and self-concept disturbances. Personal Disord. 2019 Mar;10(2):154-162. [PubMed: 30113185]
43.: Reichl C, Kaess M. Self-harm in the context of borderline personality disorder. Curr Opin Psychol. 2021 Feb;37:139-144. [PubMed: 33548678]
44.: Paris J. Suicidality in Borderline Personality Disorder. Medicina (Kaunas). 2019 May 28;55(6) [PMC free article: PMC6632023] [PubMed: 31142033]
45.: Soloff PH, Chiappetta L. 10-Year Outcome of Suicidal Behavior in Borderline Personality Disorder. J Pers Disord. 2019 Feb;33(1):82-100. [PMC free article: PMC9237746] [PubMed: 29469667]
46.: Clark LA. Assessment and diagnosis of personality disorder: perennial issues and an emerging reconceptualization. Annu Rev Psychol. 2007;58:227-57. [PubMed: 16903806]
47.: Campbell K, Clarke KA, Massey D, Lakeman R. Borderline Personality Disorder: To diagnose or not to diagnose? That is the question. Int J Ment Health Nurs. 2020 Oct;29(5):972-981. [PubMed: 32426937]
48.: Sansone RA, Sansone LA. Responses of mental health clinicians to patients with borderline personality disorder. Innov Clin Neurosci. 2013 May;10(5-6):39-43. [PMC free article: PMC3719460] [PubMed: 23882440]
49.: Parth K, Datz F, Seidman C, Löffler-Stastka H. Transference and countertransference: A review. Bull Menninger Clin. 2017 Spring;81(2):167-211. [PubMed: 28609147]
50.: Knaak S, Mantler E, Szeto A. Mental illness-related stigma in healthcare: Barriers to access and care and evidence-based solutions. Healthc Manage Forum. 2017 Mar;30(2):111-116. [PMC free article: PMC5347358] [PubMed: 28929889]
51.: Bodner E, Cohen-Fridel S, Mashiah M, Segal M, Grinshpoon A, Fischel T, Iancu I. The attitudes of psychiatric hospital staff toward hospitalization and treatment of patients with borderline personality disorder. BMC Psychiatry. 2015 Jan 22;15:2. [PMC free article: PMC4307152] [PubMed: 25609479]
52.: Zanarini MC, Weingeroff JL, Frankenburg FR, Fitzmaurice GM. Development of the self-report version of the Zanarini Rating Scale for Borderline Personality Disorder. Personal Ment Health. 2015 Nov;9(4):243-9. [PMC free article: PMC4609276] [PubMed: 26174588]
53.: Widiger TA, Hines A, Crego C. Evidence-Based Assessment of Personality Disorder. Assessment. 2024 Jan;31(1):191-198. [PubMed: 37231676]
54.: Dao TK, Prevatt F, Horne HL. Differentiating psychotic patients from nonpsychotic patients with the MMPI-2 and Rorschach. J Pers Assess. 2008 Jan;90(1):93-101. [PubMed: 18444100]
55.: Sellbom M, Ben-Porath YS, Lilienfeld SO, Patrick CJ, Graham JR. Assessing psychopathic personality traits with the MMPI-2. J Pers Assess. 2005 Dec;85(3):334-43. [PubMed: 16318573]
56.: Choi-Kain LW, Finch EF, Masland SR, Jenkins JA, Unruh BT. What Works in the Treatment of Borderline Personality Disorder. Curr Behav Neurosci Rep. 2017;4(1):21-30. [PMC free article: PMC5340835] [PubMed: 28331780]
57.: Storebø OJ, Stoffers-Winterling JM, Völlm BA, Kongerslev MT, Mattivi JT, Jørgensen MS, Faltinsen E, Todorovac A, Sales CP, Callesen HE, Lieb K, Simonsen E. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev. 2020 May 04;5(5):CD012955. [PMC free article: PMC7199382] [PubMed: 32368793]
58.: Bridler R, Häberle A, Müller ST, Cattapan K, Grohmann R, Toto S, Kasper S, Greil W. Psychopharmacological treatment of 2195 in-patients with borderline personality disorder: A comparison with other psychiatric disorders. Eur Neuropsychopharmacol. 2015 Jun;25(6):763-72. [PubMed: 25907249]
59.: Parker JD, Naeem A. Pharmacologic Treatment of Borderline Personality Disorder. Am Fam Physician. 2019 Mar 01;99(5):Online. [PubMed: 30811158]
60.: Madan A, Oldham JM, Gonzalez S, Fowler JC. Reducing Adverse Polypharmacy in Patients With Borderline Personality Disorder: An Empirical Case Study. Prim Care Companion CNS Disord. 2015;17(4) [PMC free article: PMC4664564] [PubMed: 26693036]
61.: Trull TJ, Widiger TA. Dimensional models of personality: the five-factor model and the DSM-5. Dialogues Clin Neurosci. 2013 Jun;15(2):135-46. [PMC free article: PMC3811085] [PubMed: 24174888]
62.: Winsper C. Borderline personality disorder: course and outcomes across the lifespan. Curr Opin Psychol. 2021 Feb;37:94-97. [PubMed: 33091693]
63.: Gunderson JG, Stout RL, McGlashan TH, Shea MT, Morey LC, Grilo CM, Zanarini MC, Yen S, Markowitz JC, Sanislow C, Ansell E, Pinto A, Skodol AE. Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorders study. Arch Gen Psychiatry. 2011 Aug;68(8):827-37. [PMC free article: PMC3158489] [PubMed: 21464343]
64.: Links PS, Heslegrave R, van Reekum R. Prospective follow-up study of borderline personality disorder: prognosis, prediction of outcome, and Axis II comorbidity. Can J Psychiatry. 1998 Apr;43(3):265-70. [PubMed: 9561315]
65.: Zimmerman M, Mattia JI. Axis I diagnostic comorbidity and borderline personality disorder. Compr Psychiatry. 1999 Jul-Aug;40(4):245-52. [PubMed: 10428182]
66.: Black DW, Blum N, Pfohl B, Hale N. Suicidal behavior in borderline personality disorder: prevalence, risk factors, prediction, and prevention. J Pers Disord. 2004 Jun;18(3):226-39. [PubMed: 15237043]
67.: Tate AE, Sahlin H, Liu S, Lu Y, Lundström S, Larsson H, Lichtenstein P, Kuja-Halkola R. Borderline personality disorder: associations with psychiatric disorders, somatic illnesses, trauma, and adverse behaviors. Mol Psychiatry. 2022 May;27(5):2514-2521. [PMC free article: PMC9135625] [PubMed: 35304564]
68.: Parmar A, Kaloiya G. Comorbidity of Personality Disorder among Substance Use Disorder Patients: A Narrative Review. Indian J Psychol Med. 2018 Nov-Dec;40(6):517-527. [PMC free article: PMC6241194] [PubMed: 30533947]
69.: Bender DS. The therapeutic alliance in the treatment of personality disorders. J Psychiatr Pract. 2005 Mar;11(2):73-87. [PubMed: 15803042]

: Disclosure: Jennifer Chapman declares no relevant financial relationships with ineligible companies.
: Disclosure: Radia Jamil declares no relevant financial relationships with ineligible companies.
: Disclosure: Carl Fleisher declares no relevant financial relationships with ineligible companies.
: Disclosure: Tyler Torrico declares no relevant financial relationships with ineligible companies.