A 26-year-old woman presents at the emergency care unit with severe hypoglycemia. She has been diagnosed as having type 1 diabetes at the age of 19 years and is on an intensive insulin regimen. During the previous 18 months, she was admitted to the emergency department 12 times because of hypoglycemia or hyperosmolar hyperglycemic state. The laboratory tests yielded highly increased hemoglobin A1c levels. The resident on duty spoke to her about her insulin regimen and her suboptimal adherence. In response, she immediately became furious and yelled at the resident. Afterward, she refused to talk to him again. The following morning, the senior physician talked with the patient and managed to establish a better contact with her. It became clear that the patient had dropped out of five previous psychotherapies already. She mentioned that “The therapists were all nonsense.” In addition, she was admitted to psychiatry 17 times because of suicide attempts and other crisis situations. She was repeatedly diagnosed as having borderline personality disorder (BPD). However, she had never received treatment that directly addressed borderline personality.
Upon admission, she understood that her health behavior and her frequent diabetes-related complications were probably associated with her impulsivity and personality problems. She agreed to see a psychiatrist, who admitted her to a specialized borderline personality unit in a nearby town. After 3 weeks of inpatient treatment, she was referred for individual psychotherapy. She managed to maintain a good therapeutic relationship with her therapist, and her diabetes complications disappeared in the subsequent 2 years. She started an apprenticeship as an accountant and engaged in a partnership that was much more stable than her earlier relationships.
BPD is a severe mental disorder that affects 0.7% to 3.5% of the general population (1–4). Impairment in the realms of regulation of emotions and impulses, identity, and interpersonal relationships cause major problems in social adaptation (5) and quality of life (6). Because of frequent self-harming behavior and suicide attempts (7), high medical and mental health service utilization (5,8), low compliance (9), and negative life-style and health-related behaviors (10), patients with BPD often experience considerable medical comorbidities (e.g., diabetes mellitus) and are seen frequently in all medical specialties. Patients with BPD are regarded to be “difficult,” those who challenge the health care provider’s interpersonal skills, those who are time-consuming and noncompliant, and those who drop out of treatment frequently (11).
The Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition; DSM-5) (12) contains two diagnostic approaches, a categorical one and a hybrid dimensional model consisting of personality functioning (PF) and personality traits. The primary approach of the DSM-5, section II, consists of general and specific criteria that both have to be fulfilled for the diagnosis of a personality disorder (PD). The former refer to the domains of the personality affected, inflexibility, distress, and chronicity of the condition. The specific diagnostic criteria of BPD are given in Figure 1.
The so-called Alternative DSM-5 Model for Personality Disorders (AMPD) (12, p. 761 ff.) contains as the first general diagnostic criterion, specifying an impairment in PF with specific patterns of impairment for the different specific PDs. Moreover, the AMPD comprises five PD trait domains with a certain number of facets each. The five domains are as follows: a) negative affectivity, b) detachment, c) antagonism, d) disinhibition, and e) psychoticism. From the impairment of PF and specific patterns of trait domains and facets, six individual PDs are defined, and in addition, a trait-specified description of every other combination of personality pathology can be composed. The description of BPD according to the AMPD is displayed in Figure 2.
The diagnosis of BPD is usually made clinically by experienced specialists; however, the use of psychological tests—questionnaires or structured interviews—is helpful to assure the diagnosis. Because the BPD diagnostic criteria for the categorical diagnosis have not been changed in DSM-5 (12), the instruments using Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (13) criteria can still be used. Because of their lack of reliability, questionnaires are not suited for making a diagnosis, but they can be used as screening tools. Well-established instruments are the Personality Disorder Questionnaire-4+ (14,15) or the Assessment of DSM-5 Personality Disorders (16). For the evaluation of changes in borderline symptoms, the Borderline Symptom List (17) has been developed. All three questionnaires can be obtained from the authors or downloaded free of charge on the internet. For the assessment of the new AMPD of the DSM-5, recently the Levels of Personality Functioning Self-Report (18) and the Personality Inventory for DSM-5 (19) have been published.
Structured interviews are much more reliable for diagnosing PDs than self-report instruments. A well-established measure is the Structured Clinical Interview for DSM-5 Personality Disorders (20), which is regarded as a criterion standard for research purposes.
Prevalence and Costs
The point prevalence of BPD in the general population has been assessed in many studies with strong methodology; a number of large-scale surveys of the 21st century yielded between 0.7% and 3.5% (2–5,21–25). Although the consensus is that clinical BPD diagnoses are more common in women than in men (12, p. 666), evidence suggests that there are no marked sex differences in the prevalence of BPD in the community; female BPD patients are more prone to use mental health care services than male ones (2,3,24,25). Among primary care patients, BPD occurred in 6.4% (lifetime diagnosis) (26) and even 19% when diagnosed as having a questionnaire (27). In psychiatric outpatients, BPD occurs in 9.3% to 14.4% (28,29) and in 9% in psychiatric emergency services (30). Psychiatric inpatients are diagnosed as having BPD in 12% to 18% (31–33).
Between 60% and 80% of BPD patients attempt suicide during their lives (7,34); up to 10% die of suicide (7,31,35). Self-harming behavior occurs in 90% of the borderline patients during lifetime (7).
Patients with BPD show very high medical and mental health service use. Outpatient psychosocial treatment is used by 70% to 95% of all BPD patients during lifetime (3,36,37), the numbers of lifetime psychiatric inpatient treatment differ vastly and range from 13.4% in a British sample (38) up to 72% to 79% in patients from the United States (5,36,37). In the United States, more than 60% receive psychopharmacological medication during lifetime (5,36), with 40% taking more than three drugs at the same time (37). Reliable numbers regarding medical service use of BPD patients do not exist; however, it has been shown repeatedly that service use is increased compared with other psychiatric diagnostic groups (8,39) and with the general population (38,40). The increased service use and psychosocial impairment results in considerable direct and indirect costs. Several large-scale surveys yielded annual health care costs of €8508 in Germany (41) and total societal costs of €11,308 in Spain (42), €16,852 in the Netherlands (43), and €28,026 in Germany (44). In 1998, it was estimated that BPD patients generate 24% of the total costs of psychiatric inpatient treatment in Germany (45). Evidence-based psychotherapy has been determined to reduce annual costs by nearly €3000 in the Netherlands (46).
BPD goes along with severely impaired social and physical functioning (5,6,47–49), disability (4,25), and reduced quality of life (6). These impairments seem to be dependent on the presence of comorbid axis I disorders (3,38). However, it remains unclear whether functional impairment/disability is the consequence of comorbid axis I disorders or whether both functional impairment and axis I comorbidity are (independent) manifestations of a more severe underlying personality pathology. Interestingly, during the course of the disorder, symptoms tend to remit, but in many cases, impaired functioning persists, even after treatment (50). This is a relevant example that illustrates why DSM-5 has abandoned the multiaxial model that implied an (relative) independence of, for example, axes I and II. The new DSM-5 alternative model of PDs (Figure 2) refines this approach by diagnosing in a dimensional way instead of a categorical approach on different axes. Patients rather have one condition with personality and psychopathology in a highly individualized combination than a number of different and independent disorders.
Many studies have investigated the comorbidity of BPD. It has become clear that a “monomorbid BPD patient” is a relative rarity. Comorbidity of axis I disorders has been found in 84.5% (3), and that of axis II disorders has been found in 73.9% (25); the mean number of lifetime axis I diagnoses of BPD patients is 4.1; for axis II, it is 1.9 (51). Comorbid mood disorders occur in 50% to 60% of all BPD patients (4,25) with 93% lifetime diagnoses (52). Anxiety disorders (including posttraumatic stress disorder) have been found in 60% to 80% (25,53) with 88.4% lifetime diagnoses (52). The comorbidity of posttraumatic stress disorder is of particular importance in BPD patients because many have experienced maltreatment in childhood: it varies between 31.6% and 55.9% (25,51,52). Substance use disorders have been reported in slightly greater than 50% of BPD patients (25,51), with a lifetime rate of 64.1% (52). Eating disorders do also occur frequently in BPD patients; anorexia nervosa was found in 7% to 21%, and bulimia nervosa was found in 13% to 31% of all BPD patients (51,54,55). BPD has been found in 10% of somatization disorder patients (56,57); in 34.4% of BPD patients, comorbid somatization disorder was diagnosed (58).
From a psychosomatic viewpoint, the comorbidity of BPD with somatic diseases is of particular importance. It is well known that BPD increases the risk of numerous medical (somatic) conditions considerably. Moreover, BPD can complicate the course of several diseases (59). This pattern can be attributed in part to the poor health-related behavior and life-style. BPD patients are known to smoke and consume alcohol and drugs, as well as abuse sleep and pain medication frequently. Moreover, they tend to show a lack of physical exercise (10,60). In addition, BPD goes along with a negative perception of health, which itself might impair health-related behaviors (61).
Patients with BPD show poor adherence to psychological and medical treatment recommendations (9,62), and they tend to engage in disruptive behaviors such as “yelling, screaming, verbally threatening, and refusing to talk with medical staff” (63), and sabotage their medical treatment (11,64), for example, by preventing wounds from healing (64–66). These behaviors can be regarded as self-injury equivalents (11). Factitious disorder represents the extreme manifestation of this behavior, that is, a clandestine self-injury that is presented as illness or accidental injury. These patients can cause severe problems and conflicts in health care providers and institutions and frequently end up in a fruitless power struggle with the caretakers. In the literature, it has been stated repeatedly that patients with factitious disorder often also have BPD (67–69); however, a recent review revealed contradictory results (70).
An overview of comorbidity studies of BPD with somatic diseases is given in Table 1. BPD is associated with cardiovascular, metabolic, and gastrointestinal diseases as well as pain conditions, venereal diseases and HIV, urinary incontinence, and sleep disturbance. Of particular interest are the increased prevalences of cardiovascular disease in general (15.3%), pain conditions like arthritis (17.2%–27.7%) and chronic pain in general (62.5%–80.3%), gastrointestinal (21.1%) and hepatic (3.1%) disease, and urinary incontinence (18.8%) and venereal disease (3.1%). However, one of the biggest surveys (71) showed that the increased risk of diabetes, stroke, and obesity in patients with BPD is no longer significant when rigidly controlled for sociodemographics (sex, age in years, race/ethnicity, education, marital status, and past year’s household income) and psychiatric comorbidity (any anxiety, mood, or substance use disorder, and any PD other than borderline). Thus, it can be assumed that there are complex correlations between different psychosomatic components rather than unidirectional causal relationships. Nevertheless, all in all, patients with BPD show more somatic illness than do patients without BPD.
BPD can be attributed to psychosocial and biological factors that interact in a complex way (88,89). More than 90% of the BPD patients are exposed to childhood maltreatment, abuse, and/or neglect (90,91). In a large prospective cohort study, low parental affection and aversive parental behavior in the early years of development have been shown to increase the risk of BPD in adulthood substantially (92). At the same time, a considerable heritability of 35% to 67% for BPD has been demonstrated in several studies, but so far, no direct role of genetic polymorphisms has been found (93). It is not BPD itself that is genetically determined but rather endophenotypes that predispose for the disorder, for example, impulsivity, aggression, affective dysregulation, or emotional information processing (94). These genetic vulnerabilities interact with environmental influences, and these interactions most probably shape biological abnormalities, neuropsychological impairment, and finally symptoms of BPD (93).
BPD goes along with a number of neurobiological alterations. First, specific changes in brain structure and brain function have been identified, and second, a number of neuroendocrine dysfunctions that exert influences on psychosomatic and somatic disorders occur. Neuroimaging studies have consistently revealed that BPD patients show an increased amygdala activity in combination with a decreased activity of dorsolateral prefrontal brain regions. These findings have been interpreted as neurobiological correlates of the emotional dysregulation in BPD (95,96).
A recent study gave hints on a cortical malfunction of the processing of bodily signals in BPD (97) patients that might foster the development of a number of somatic diseases due to an increased awareness of bodily changes. These probably take place in concert with neuroendocrine alterations, such as increased sympathetic activation and decreased parasympathetic deactivation under laboratory stress (98). Changes in hypothalamic-pituitary-adrenal (HPA) axis dysfunction have been reported in terms of increased salivary cortisol levels, increased total cortisol in response to awakening, increased total daily cortisol levels, and more nonsuppressors of cortisol in the low-dose dexamethasone suppression test (99). Because an association of methylation of the glucocorticoid receptor gene, childhood maltreatment, and clinical severity of BPD has been detected (100), a biopsychosocial genes–trauma–HPA axis interaction has been hypothesized (101). However, recently, it was shown that alterations of the HPA axis occur as a response to early maltreatment rather than as a consequence of comorbid BPD pathology (101,102). A few studies demonstrated increased testosterone levels in saliva after awakening (103) and in hair (104), as well as reduced plasma oxytocin in BPD women (105). The latter particularly occurs in BPD patients with unresolved (disorganized) attachment representations (106). Finally, differences between BPD patients and healthy controls have been found with regard to the μ-opioid receptor concentrations and the endogenous opioid system activation in response to negative emotional stimuli (107). It was hypothesized that BPD in itself represents a dysregulation of the endogenous opioid system (108); however, until now, this remains speculative (102).
Empirically Validated Treatments
Treatment guidelines from the United States (109), the United Kingdom (110), and Germany (111) consentaneously mention psychotherapy as the treatment of choice for BPD. Moreover, the guidelines state that there is no pharmacological treatment of BPD itself; if drugs are given, they should aim at comorbid disorders and/or target symptoms such as severe impulsivity, anxiety, severe restlessness, or sleep disturbance (109–111). Recent reviews concluded that second-generation antipsychotics (e.g., lower-dose quetiapine), mood stabilizers, and dietary supplementation by omega-3 fatty acids may yield some beneficial effects on selected symptoms of BPD but will not change the personality. They might particularly be indicated when no evidence-based psychotherapy is available. Selective serotonin reuptake inhibitors have not been shown to be effective in BPD (112,113).
Four disorder-specific manualized psychotherapies have demonstrated their efficacy in randomized controlled trials (RCTs) (114): dialectical behavior therapy (DBT) (115), transference-focused psychotherapy (TFP) (116), mentalization-based therapy (MBT) (117), and schema-focused therapy (SFT) (118). DBT has been developed specifically as a treatment for the reduction of suicidal and self-harming behavior by applying skills training and specific cognitive behavioral techniques for the enhancement of emotion regulation (115). Compared with the other treatments, it has been investigated in the largest number of open trials and RCTs. A meta-analysis revealed moderate global effects and particularly moderate effect sizes for the reduction of suicidal and self-injurious behaviors (119). In an uncontrolled German study, a reduction of 50% of total societal costs was achieved in those 70% of patients who could be followed up 1 year after 12 months of DBT (44). TFP is a psychodynamic treatment that focuses on PF, particularly the integration of the self (identity) and quality of interpersonal relationships (116). It demonstrated its efficacy in a number of uncontrolled studies and two RCTs(120,121); particularly PF, mentalization, and attachment representations have been improved significantly (121–124). MBT also is a psychodynamic treatment that is usually delivered as a combination of individual and group therapy; it specifically aims at mentalization, that is, the ability to understand one’s own and others motives, feelings, and behaviors (117). MBT has been shown to be effective in a variety of uncontrolled studies and two RCTs; one took place in a day care unit setting with a considerable follow-up period of 8 years (125,126), the second one was an outpatient treatment study (127). Both yielded highly significant effects on general psychopathology, self-harming behavior, suicidality, and social functioning. SFT aims at the change of specific dysfunctional schema modes in BPD, that is, internal images of early relationship experiences such as mistrust/abuse, defectiveness/shame, angry child, impulsive child, by using behavioral, cognitive, and experimental techniques. SFT represents a cognitive behavioral treatment that has incorporated some aspects of psychodynamic theory and focuses primarily on relationship experiences in the present and past (118). SFT was found to effectively reduce general psychopathology, borderline symptoms, and quality of life in uncontrolled trails as well as in two RCTs; one used individual outpatient treatment (128), and the other one used outpatient group therapy (129).
In addition to the four manualized and empirically validated stand-alone treatments, the Systems Training for Emotional Predictability and Problem Solving is an add-on manualized group treatment program that has shown to be effective in BPD when combined with other forms of therapy (130,131). Recently, new treatments have been developed to be applied specifically in BPD as a basic psychiatric care. These treatments, good psychiatric management (GPM) (132) and structured clinical management (SCM) (133), are also manualized treatments that integrate basic attitudes and techniques from effective psychotherapies to be used in general mental health care by professionals without extended training. Preliminary evidence hints at an effectiveness of both treatments: SCM showed to be equally effective than MBT in major outcome variables of an RCT (127); GPM was compared with DBT in an RCT, and no significant differences between both groups were found in all primary and secondary outcomes (134,135). However, although easier to learn, these programs premise an experienced and interpersonally skilled clinician as well as a regular and structured setting with weekly contacts for 12 to 18 months or longer.
Although there is no doubt that psychotherapies are effective in BPD and can even change central aspects of the personality, evidence on the biobehavioral underpinnings of these changes is sparse. Three functional magnetic resonance imaging studies revealed that 12-week inpatient DBT resulted in specific changes in neuronal activity in DBT responders toward a more normal functioning (136–138). One study investigated changes in neuronal functioning before and after TFP and also yielded significant changes (139). These studies provide evidence for an influence of psychotherapy on brain function that tends to change toward normalized functioning. However, until now, there is no convincing theoretical model on how neuronal changes, psychotherapy, and behavioral changes interact and determine each other.
Implementation of Treatment Models
All of the four empirically validated BPD psychotherapies are taught in curricula in many countries. Networks or international societies exist and can easily be found on the internet or by approaching the authors of the manuals and efficacy studies. Usually, a training curriculum consists of a manageable amount of theoretical training and treatment for a patient under regular supervision; in general, a basic psychotherapeutic training or at least a license as psychiatrist or clinical psychologist is a prerequisite. The general psychiatric care models (GPM and SCM) are easier to learn, but it should be taken into consideration that a considerable experience as a mental health professional is essential and a setting allowing for regular appointments (as mentioned previously) is indispensable. Individual psychotherapists or psychiatrists can participate in training courses at regional institutes or attend introductory workshops at the conferences of the International Society for the Study of Personality Disorders (www.isspd.com), the North American Society for the Study of Personality Disorders (www.nasspd.org), or the European Society for the Study of Personality Disorders (www.esspd.eu), among others. All treatments can also be implemented by in-house trainings at institutions or clinical departments. Certified teachers and supervisors will be available to come to the sites for theoretical training and supervision; the latter is also provided online by many supervisors. MBT has been primarily developed as a day care unit treatment, and DBT and TFP have also been evaluated as inpatient treatments (140,141). For institutional teams in inpatient or day care units, a comprehensive training of the whole team is recommended to be able to develop a joint understanding and concept of intervention in the treatment for BPD patients; regular external supervision is indispensable.
BPD—like many other psychiatric disorders—can be regarded as a psychosomatic illness. Genetic disposition, early environmental stress, epigenetic makeup, neurobiological and neuroendocrine changes, and early relationship experiences interact with each other and lead to BPD pathology. Comorbidities of psychiatric and also of medical illnesses are frequent. Personality problems on the level of life-style and health behavior as well as the often troublesome interpersonal interactions with health professionals cause and/or facilitate highly complicated courses of somatic illnesses and their treatment. Health care professionals of any specialty should be aware of the challenging relationship with patients having BPD; being familiar with the pathology and its complications may be productive in adapting an interactive style that will benefit the therapeutic relationship. Awareness of available treatment resources and referral processes will promote both mental and medical health care. Health care professionals dealing with BPD patients would benefit from striving to learn one of the empirically validated treatment options, and teams and institutions should be aware of evidence-based treatments for BPD and make these treatments available to patients with BPD.
Source of Funding and Conflicts of Interest: No financial or other support was received by the author for preparing this manuscript. The author is a therapist and a supervisor of transference-focused psychotherapy.
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1The case is not one individual real case but a merger of several similar cases; thus, there is no threat to anonymity of an individual person.