A pilot randomized controlled study of a brief mentalizing enhancement intervention for borderline personality disorder

Since the 2001 publication of APA’s Practice Guideline for the Treatment of Patients With Borderline Personality Disorder (1), more studies have been published on borderline personality disorder (BPD) than on any other personality disorder (2, 3). New analyses of the validity of the DSMIV-TR criteria–defined construct of BPD have been published, new data on the prevalence of BPD are available, risk factors for and biological characteristics of BPD are being elucidated, and new studies on the treatment of BPD have been carried out. This guideline watch highlights the most important of these developments.

Relationship of Borderline Personality Disorder and Bipolar Disorder

Relationship of Borderline Personality Disorder and Bipolar Disorder

Understanding Emotion Regulation in Borderline Personality Disorder: Contributions of Neuroimaging

Of 50 patients with borderline personality disorder, 100% reported disturbed but nonpsychotic thought, 40% (N = 20) reported quasi-psychotic thought, and none reported true psychotic thought during the past 2 years; only 14% (N = 7) reported ever experiencing true psychotic thought. Disturbed and quasi-psychotic thought was significantly more common among these patients than among patients with other axis II disorders or schizophrenia and normal control subjects; however, true psychotic thought was significantly more common among schizophrenic patients. While disturbed thought was also common among axis II disorder and schizophrenic patients, quasi-psychotic thought was reported by only one of these subjects, suggesting that quasi-psychotic thought may be a marker for borderline personality disorder.

An Opioid Deficit in Borderline Personality Disorder: Self-Cutting, Substance Abuse, and Social Dysfunction

Pharmacologic treatments for borderline personality disorder.

In this article, it is aimed to review the efficacies of mood stabilizers and atypical antipsychotics, which are used commonly in psychopharmacological treatments of bipolar and borderline personality disorders. In this context, common phenomenology between borderline personality and bipolar disorders and differential features of clinical diagnosis will be reviewed in line with the literature. Both disorders can demonstrate common features in the diagnostic aspect, and can overlap phenomenologically. Concomitance rate of both disorders is quite high. In order to differentiate these two disorders from each other, quality of mood fluctuations, impulsivity types and linear progression of disorders should be carefully considered. There are various studies in mood stabilizer use, like lithium, carbamazepine, oxcarbazepine, sodium valproate and lamotrigine, in the treatment of borderline personality disorder. Moreover, there are also studies, which have revealed efficacies of risperidone, olanzapine and quetiapine as atypical antipsychotics. It is not easy to differentiate borderline personality disorder from the bipolar disorders. An intensively careful evaluation should be performed. This differentiation may be helpful also for the treatment. There are many studies about efficacy of valproate and lamotrigine in treatment of borderline personality disorder. However, findings related to other mood stabilizers are inadequate. Olanzapine and quetiapine are reported to be more effective among atypical antipsychotics. No drug is approved for the treatment of borderline personality disorder by the entitled authorities, yet. Psychotherapeutic approaches have preserved their significant places in treatment of borderline personality disorder. Moreover, symptom based approach is recommended in use of mood stabilizers and atypical antipsychotics.

Mentalization-Based Treatment for a Physician With Borderline Personality Disorder.

Disturbed Relationships as a Phenotype for Borderline Personality Disorder

This review of the descriptive literature on borderline patients indicates that accounts of such patients vary depending upon who is describing them, in what context, how the samples are selected, and what data are collected. The authors identify six features that provide a rational means for diagnosing borderline patients during an initial interview: the presence of intense affect, usually depressive or hostile; a history of impulsive behavior; a certain social adaptiveness; brief psychotic experiences; loose thinking in unstructured situations; and relationships that vacillate between transient superficiality and intense dependency. Reliable identification of these patients will permit better treatment planning and clinical research.

Back to table of contents Previous article Next article LettersFull AccessAdvance Directives: Another Gap in Services for People With Borderline Personality DisorderEvan A. Iliakis, B.A., Lois W. Choi-Kain, M.D., M.Ed.Evan A. IliakisSearch for more papers by this author, B.A., Lois W. Choi-KainSearch for more papers by this author, M.D., M.Ed.Published Online:1 May 2020https://doi.org/10.1176/appi.ps.71504AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail IN REPLY: Manigsaca and colleagues (1) make a case for psychiatric advance directives (PADs) to be used alongside other evidence-based treatments for borderline personality disorder to improve treatment outcomes. An increasing number of countries and states in the United States are beginning to make explicit legal provisions for PADs (2) as a way for service users to make their treatment preferences known if they are not competent to make treatment decisions in a mental health crisis.Crisis planning is an important element of both specialist and generalist evidence-based treatments for borderline personality disorder. Crisis plans are developed by the primary treater in collaboration with the patient and others involved in a support system to provide a predictable set of procedures and options that could help in a crisis. Crisis planning can prevent harmful treatment interventions in the care of borderline personality disorder, such as unnecessary hospitalizations, derailed treatments, and reactive prescribing (resulting in psychiatric polypharmacy). It also helps guide further treatment and disposition planning in the emergency room or inpatient setting. In other words, crisis planning is a low-resource way to ensure that service users are receiving emergency care in line with evidence-based guidelines for the treatment of borderline personality disorder.Manigsaca and colleagues highlight the effectiveness of PADs for use with schizophrenia and bipolar disorder, in which acute psychotic or manic episodes threaten competence. Like schizophrenia and bipolar disorder, borderline personality disorder is a serious mental illness associated with high health care costs and levels of disability (3). But unlike psychosis and mania, acute symptoms in borderline personality disorder are more transient. For example, affective shifts in borderline personality disorder are more frequent, short-lived, and interpersonally mediated than those of bipolar disorder (4). This symptom profile sets borderline personality disorder apart from other serious mental illnesses, with symptoms that impair competence more transiently rather than chronically.This difference is important in making treatment recommendations for borderline personality disorder. Management of bipolar disorder and schizophrenia relies on medications to stabilize acute symptoms of mania or psychosis. However, the U.S. Food and Drug Administration has approved no medications for borderline personality disorder. Its evidence-based treatments are psychotherapies that depend more heavily on the activity of the patient to make changes in ways of thinking, managing emotions, and behaving. While we agree with Manigsaca and colleagues that crisis planning is important in the treatment of borderline personality disorder, we argue that it should ideally happen in conjunction with an approach that emphasizes and builds the competence of the patient.References1 Manigsaca A, Glue P, O’Brien A: Advance directives: another gap in services for people with borderline personality disorder. Psychiatr Serv 2020; 71:528–529Abstract, Google Scholar2 Scholten M, Gieselmann A, Gather J, et al.: Psychiatric advance directives under the Convention on the Rights of Persons with Disabilities: why advance instructions should be able to override current preferences. Front Psychiatry 2019; 10:631Crossref, Medline, Google Scholar3 van Asselt AD, Dirksen CD, Arntz A, et al.: The cost of borderline personality disorder: societal cost of illness in BPD-patients. Eur Psychiatry 2007; 22:354–361Crossref, Medline, Google Scholar4 Reich DB, Zanarini MC, Hopwood CJ, et al.: Comparison of affective instability in borderline personality disorder and bipolar disorder using a self-report measure. Pers Ment Health 2014; 8:143–150Crossref, Medline, Google Scholar FiguresReferencesCited byDetailsCited byNone Volume 71Issue 5 May 01, 2020Pages 529-530 Metrics PDF download History Published online 1 May 2020 Published in print 1 May 2020

Back to table of contents Previous article Next article Professional NewsFull AccessCenter Connects People With Resources on BPDEve BenderEve BenderSearch for more papers by this authorPublished Online:15 Apr 2005https://doi.org/10.1176/pn.40.8.00400008People with borderline personality disorder and their families have at their disposal a wellspring of information about the causes, course, and treatment of the disorder through the Borderline Personality Disorder Resource Center (BPDRC).Family members of people with borderline personality disorder established the center in late 2003 using private donations.The resource center, which is affiliated with and located adjacent to the New York-Presbyterian Hospital–Westchester Division in White Plains, N.Y., also functions as a source of referrals for people seeking treatment for borderline personality disorder around the country.“Through the resource center, we have been able to assist the many patients who call us for help in locating the best treatment available to them in their communities,” said the center's clinical director, Otto Kernberg, M.D., in an interview with Psychiatric News.The center's referral database includes about 250 referral sources for those seeking treatment for borderline personality disorder. These include inpatient programs, outpatient programs, residential treatment centers, and individual practitioners.The Borderline Personality Disorder Resource Center provides an abundance of information for people with borderline personality disorder and for their families.In addition, the resource center houses a library of books on many aspects of borderline personality disorder, ranging from etiology and treatment to personal accounts written by people with the disorder.Kernberg, who is also director of New York-Presbyterian Hospital's Personality Disorders Institute, pointed out that a large number of people with borderline personality disorder are misdiagnosed and therefore do not receive appropriate treatment.Once they do receive the right diagnosis and treatment, they can achieve some level of stability and enjoy meaningful lives, he added.Psychotherapeutic approaches that have been helpful to people with borderline personality disorder include dialectic-behavioral therapy, transference-focused psychotherapy (developed by Kernberg), cognitive-behavioral therapy, psychodynamic psychotherapy, and supportive psychotherapy.According to information listed on the BPDRC Web site, pharmacological treatments “are often prescribed based on specific target symptoms” experienced by the patient. For instance, antidepressant drugs and mood stabilizers may alleviate depressed and/or labile mood, and antipsychotic drugs are used when thought distortion or anxiety is present.Lithium is “sometimes helpful” and “may make it possible to use lower doses of other drugs,” the Web site notes.Kernberg emphasized that “while we have become much better at treating patients with borderline personality disorder in recent years, that doesn't mean we are able to help everyone at all times.”He also pointed out that the center does not endorse one type of therapy over another.According to Eliza Whoriskey, M.A., administrative manager of the BPDRC, more than half of the calls coming into the center are from patients or family members looking for referrals to an expert in their area.Since the center opened, Whoriskey said, there have been approximately 900 calls from patients, 720 calls from family members of patients, and 180 calls from mental health professionals seeking information about borderline personality disorder.Whoriskey said she sometimes relies on the clinical expertise of Kernberg and his staff at the Personality Disorders Institute to field phone inquiries.Inquiries can also be made in person or via e-mail, but the vast majority of inquiries come through the center's toll-free number, according to Whoriskey. She will be staffing a booth about the center at APA's 2005 annual meeting next month in Atlanta.In addition to disseminating up-to-date information to the public, the center has plans to award those who have demonstrated outstanding achievement in borderline personality disorder clinical work or research.The awardee will receive $5,000, a plaque, and a presentation dinner in his or her honor.More information about the Borderline Personality Disorder Resource Center and its first annual Award for Distinguished Achievement is posted online at<www.bpdresourcecenter.org>.▪ ISSUES NewArchived

Borderline personality disorder (BPD) and schizophrenia are both serious and chronic mental health conditions of similar prevalence. This study was designed to assess trainees' confidence in the assessment, management and treatment of BPD in comparison with schizophrenia. A survey was used to assess psychiatry trainees' confidence and experience of training with regard to managing BPD and schizophrenia. Eighty-two psychiatry trainees completed the survey. Overall, confidence scores of respondents with respect to BPD were significantly lower in comparison with schizophrenia. Trainees reported a preference for working with patients with schizophrenia compared with BPD. Respondents reported receiving less adequate supervision and training in the assessment, management and treatment of BPD than for schizophrenia. The results suggest an urgent need to enhance training and supervision in skills related to the diagnosis, management and treatment of BPD, with a greater focus on psychotherapy to improve trainee psychiatrists' confidence in working with people diagnosed with BPD.

Psychotherapy is regarded as the first-line treatment for people with borderline personality disorder. In recent years, several disorder-specific interventions have been developed. This is an update of a review published in the Cochrane Database of Systematic Reviews in 2006. To assess the effects of psychological interventions for borderline personality disorder (BPD). We searched the following databases: CENTRAL 2010(3), MEDLINE (1950 to October 2010), EMBASE (1980 to 2010, week 39), ASSIA (1987 to November 2010), BIOSIS (1985 to October 2010), CINAHL (1982 to October 2010), Dissertation Abstracts International (31 January 2011), National Criminal Justice Reference Service Abstracts (15 October 2010), PsycINFO (1872 to October Week 1 2010), Science Citation Index (1970 to 10 October 2010), Social Science Citation Index (1970 to 10 October 2010), Sociological Abstracts (1963 to October 2010), ZETOC (15 October 2010) and the metaRegister of Controlled Trials (15 October 2010). In addition, we searched Dissertation Abstracts International in January 2011 and ICTRP in August 2011. Randomised studies with samples of patients with BPD comparing a specific psychotherapeutic intervention against a control intervention without any specific mode of action or against a comparative specific psychotherapeutic intervention. Outcomes included overall BPD severity, BPD symptoms (DSM-IV criteria), psychopathology associated with but not specific to BPD, attrition and adverse effects. Two review authors independently selected studies, assessed the risk of bias in the studies and extracted data. Twenty-eight studies involving a total of 1804 participants with BPD were included. Interventions were classified as comprehensive psychotherapies if they included individual psychotherapy as a substantial part of the treatment programme, or as non-comprehensive if they did not.Among comprehensive psychotherapies, dialectical behaviour therapy (DBT), mentalisation-based treatment in a partial hospitalisation setting (MBT-PH), outpatient MBT (MBT-out), transference-focused therapy (TFP), cognitive behavioural therapy (CBT), dynamic deconstructive psychotherapy (DDP), interpersonal psychotherapy (IPT) and interpersonal therapy for BPD (IPT-BPD) were tested against a control condition. Direct comparisons of comprehensive psychotherapies included DBT versus client-centered therapy (CCT); schema-focused therapy (SFT) versus TFP; SFT versus SFT plus telephone availability of therapist in case of crisis (SFT+TA); cognitive therapy (CT) versus CCT, and CT versus IPT.Non-comprehensive psychotherapeutic interventions comprised DBT-group skills training only (DBT-ST), emotion regulation group therapy (ERG), schema-focused group therapy (SFT-G), systems training for emotional predictability and problem solving for borderline personality disorder (STEPPS), STEPPS plus individual therapy (STEPPS+IT), manual-assisted cognitive treatment (MACT) and psychoeducation (PE). The only direct comparison of an non-comprehensive psychotherapeutic intervention against another was MACT versus MACT plus therapeutic assessment (MACT+). Inpatient treatment was examined in one study where DBT for PTSD (DBT-PTSD) was compared with a waiting list control. No trials were identified for cognitive analytical therapy (CAT).Data were sparse for individual interventions, and allowed for meta-analytic pooling only for DBT compared with treatment as usual (TAU) for four outcomes. There were moderate to large statistically significant effects indicating a beneficial effect of DBT over TAU for anger (n = 46, two RCTs; standardised mean difference (SMD) -0.83, 95% confidence interval (CI) -1.43 to -0.22; I(2) = 0%), parasuicidality (n = 110, three RCTs; SMD -0.54, 95% CI -0.92 to -0.16; I(2) = 0%) and mental health (n = 74, two RCTs; SMD 0.65, 95% CI 0.07 to 1.24 I(2) = 30%). There was no indication of statistical superiority of DBT over TAU in terms of keeping participants in treatment (n = 252, five RCTs; risk ratio 1.25, 95% CI 0.54 to 2.92).All remaining findings were based on single study estimates of effect. Statistically significant between-group differences for comparisons of psychotherapies against controls were observed for BPD core pathology and associated psychopathology for the following interventions: DBT, DBT-PTSD, MBT-PH, MBT-out, TFP and IPT-BPD. IPT was only indicated as being effective in the treatment of associated depression. No statistically significant effects were found for CBT and DDP interventions on either outcome, with the effect sizes moderate for DDP and small for CBT. For comparisons between different comprehensive psychotherapies, statistically significant superiority was demonstrated for DBT over CCT (core and associated pathology) and SFT over TFP (BPD severity and treatment retention). There were also encouraging results for each of the non-comprehensive psychotherapeutic interventions investigated in terms of both core and associated pathology.No data were available for adverse effects of any psychotherapy. There are indications of beneficial effects for both comprehensive psychotherapies as well as non-comprehensive psychotherapeutic interventions for BPD core pathology and associated general psychopathology. DBT has been studied most intensely, followed by MBT, TFP, SFT and STEPPS. However, none of the treatments has a very robust evidence base, and there are some concerns regarding the quality of individual studies. Overall, the findings support a substantial role for psychotherapy in the treatment of people with BPD but clearly indicate a need for replicatory studies.