INTRODUCTION Delimitation of the topic and target group This guideline uses the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnosis of “borderline personality disorder”.[1] The guideline is intended to be applied to specialised psychiatric and general/primary healthcare settings. Personality disorders in the current classificatory systems Research on personality disorders (PDs) has progressed significantly. Classificatory descriptions of PD have been changing from categorical to more acceptable dimensional ones. However, for this guideline, we have followed DSM-5, as most of the existing good quality evidence is based on DSM-5 or DSM-IV-TR criteria. Present-day scientific research primarily emphasizes the BPD categorical diagnosis and so does this guideline. International Classification of Diseases 10 (ICD-10) emotionally unstable PD: borderline type is similar to the DSM-5 borderline PD diagnosis [Table 1].[1,2] ICD-11 and DSM-5 describe personality disorders differently; in ICD-11, the equivalent to ‘borderline personality disorder’ would be the diagnosis of personality disorder (usually moderate or severe) with a specifier ‘borderline pattern.’Table 1: Diagnostic criteria/guidelines for borderline personality disorderBASIC CONCEPTS Personality and temperament The term “Personality” encompasses a dynamic set of functions and traits. Personality can be described on four levels: Personality traits (e.g., temperament, Panel 1). Characteristic means of adaptation and individual goals. Narrative self (e.g., identity). Dynamics of interaction relationships. Panel 1: The five-factor model of the personality disorders“Temperament” refers to individual, biologically based skills in regulating emotions that can be recognized already in infancy. DSM-5 defines personality traits as persistent ways of perceiving, relating to others, and understanding oneself and the environment.[1] Among the personality traits, (i) emotional stability, (ii) conscientiousness, and (iii) social dominance continue to increase until the age of 30–40 years.[3,4] Traits of healthy and disturbed personalities seem to form a continuum. Personality disorder Borderline personality disorder (BPD) is associated with a limited, rigid, or unstable experience of the established self and self-concept and difficulties in interpersonal relationships. Accentuated negative emotionality is a hallmark of borderline personality but the condition is also associated with acute symptoms.[1,5] When managing BPD, it is important to remember that the diagnostic criteria for borderline personality describe a heterogeneous group of patients.[6] And also that the disease burden of PD patients is comparable to severe physical diseases.[7] EPIDEMIOLOGY Global prevalence PD have been found at varying rates all over the world. The prevalence of PD (as per DSM-5) in the general population is about 6%. Cluster-B PD, which includes borderline, antisocial, histrionic, and narcissistic PD, have an overall global prevalence of 1.5%.[8] PD is clearly more common in young adulthood than later.[9,10] In high-quality European population studies, the prevalence of borderline personality was reported to be 0.7%.[11] As per estimates, BPDs occur in 6% of primary care patients but the proportion of identified cases is probably much lower.[12,13] Western studies suggest that almost 60% of people with BPD may be in contact with primary healthcare services during the year, usually due to somatic symptoms and illnesses. The prevalence is relatively higher among young adults, women, and people with little education and low income.[14] There is no research evidence of an increase in the prevalence of BPD. Indian prevalence Systemic studies from India and other developing countries assessing the prevalence of PD are lacking. Early studies (from the late 1980s) reported the prevalence of PD in the general population ranging from 0% to 2.8%, with a weighted mean prevalence of 0.6%. Male gender was significantly associated with PD.[15] Most epidemiological studies conducted in India have systematically under-reported the prevalence because of sampling bias and other methodological flaws. The prevalence of PD among treatment-seeking Indian populations (0.3%-1.6%) is lower than that of western data (25%-50%). However, this difference is likely due to under-recognition.[15] A retrospective chart review (1996–2006) among North Indian patients seeking treatment in psychiatric outpatient settings reported a prevalence of 1.07% for ICD-10 PDs. The most common PD documented in the study were anxious-avoidant and borderline.[16] The reported rates are higher in special populations such as individuals in conflict with the law (7.3%-33.3%), individuals with substance use disorder(s) (20%-55%), and those who had ever attempted suicide (47.8%-62.2%).[15] A recent study on patients (N = 100) visiting the emergency department of a private hospital in eastern India using translated scales to screen for ICD-10 diagnosis of PDs found 24% of participants met the cut-off criterion.[17] RISK FACTORS Childhood antecedents BPD is thought to arise either from the interaction of predisposing factors or from the worsening of a childhood or adolescent psychiatric disorder. As per the so-called exposure model, BPD results from an interaction between predisposing factors. As per the so-called complication model, it is primarily the result of another psychiatric disorder. Support for both models has been found in longitudinal research because the age of onset and gender seem to lead to different developmental curves.[10] In girls, internalising symptoms in early adolescence, such as anxiety and depression, may predict BPD in late adolescence (complication model), while externalising symptoms, such as defiance and conduct symptoms in adolescence, may predict BPD in adulthood (exposure model).[18,19] Predisposing factors Factors that increase the risk of BPD are also associated with other psychiatric disorders and physical illnesses. The accumulation of several factors suggests a higher probability of a disorder. Hereditary factors are known to be associated with personality traits and BPD.[20] In some patients, the emergence of the disorder may be related to organic and neurocognitive factors, such as encephalitis (inflammation), epilepsy, learning disorders, and childhood attention deficit hyperactivity disorder. Risk factors during pregnancy, such as maternal smoking, medical complications, and complications during childbirth, seem to increase the risk of BPD.[21] Those suffering from BPD report more difficult, traumatic childhood experiences than healthy controls.[22] Anxiety sensitivity and aggressiveness or hostility related to the temperament trait of negative emotionality and severe emotional abuse are independently associated with the risk and severity of BPD. Heightened rejection sensitivity may be related to emotional neglect.[23,24] Sexual abuse as a single factor apparently increases the risk of BPD little or not at all.[25] There is conflicting evidence about the association between dissociation symptoms and traumatic anamnesis in BPD. Dissociation can manifest as forgetfulness, a feeling that the self (depersonalisation) or the world (derealisation) has become alien, or as short-term hallucinations. BPD is significantly but weakly related to accumulating parenting problems. The parent’s mental disorder and lower socioeconomic status may be background factors for abuse and emotional neglect. Prolonged separations from parents in the preschool years are linked to symptoms of BPD in adulthood.[24] Abnormalities of brain function have been observed in neurophysiological studies (EEG and arousal response studies).[26] BPD is associated with disruption of the functioning of the serotonin system in the fronto-limbic areas of the brain.[27] Brain changes that occur in patients with BPD, such as a decrease in the volume of the hippocampus and amygdala, are possibly related to childhood maltreatment, the severity of the disorder, and comorbidity.[28] PRIMARY PREVENTION There has been no research on the primary prevention of BPD. A BPD exposes children to problems in parenting; so, good treatment of the disorder is likely to be promoted by good parenting. Parental guidance has a positive effect on the parenting patterns of at-risk families and children’s behaviour problems. A wide-ranging program including nutrition, education, and exercise implemented in kindergartens may reduce disruptive behaviour and psychotic symptoms in young adulthood. Parental guidance reduces behavioural disorders in children and may reduce the costs caused by the continuation of behavioural disorders later.[29] CLINICAL FEATURES Core features of BPD The core features of BPD are marked affective dysregulation, marked disturbances in self-image, unpredictable interpersonal relationships, and marked impulsivity. A model by Sanislow et al., 2022[30] summarised the features of BPD into the following three dimensions: Impaired relatedness–Chronic emptiness, unstable relationships with others, and identity disturbance. Affective dysregulation–Affective lability, excessive anger, and violent efforts to avoid abandonment. Behaviour dysregulation–Impulsivity, suicidality, and self-injurious behaviour. Affective instability was shown to be the most sensitive and specific single manifestation of BPD in a sizeable psychiatric OPD sample evaluated using a semi-structured interview.[31] All symptoms of BPD are associated with psychosocial impairment and poor quality of life. Chronic feeling of emptiness was found to be associated with the highest morbidity, including suicidality. Other important presenting features of BPD Suicidality Suicidal threats, gestures, and attempts are common manifestations of BPD. Data on rates of suicidal ideas, attempts, and suicide deaths have varied markedly. In retrospective studies, the rate of death by suicide is between 8% and 12% among individuals with BPD.[32] Years of suicide threats and self-injurious behaviour may precede a completed suicide and therefore predicting a suicide outcome may be difficult. All reported suicide ideations or attempts should be taken seriously in patients with BPD. Suicide risk assessment is described later. Chronic feelings of emptiness, impulsivity, negative affectivity, and poor psychosocial function are commonly replicated chronic risk factors of suicide. More acute risk factors for suicide attempts in BPD include recent depressive episode, substance intoxication, adverse life event, and recent loss.[33] Interpersonal difficulties Patients with BPD usually have volatile relationships, especially with persons in close association.[34] A phenomenon called “splitting” often characterises the stormy relationship patterns where a support person (friend or romantic partner) is viewed as “all good”, loving and ideal when the patient’s needs are met, and at other times the same support person may be viewed as “all bad”, mean, or cruel. A feeling of abandonment drives the behaviour of anger, clingy demands, depressed mood, hopelessness, and suicidal thoughts and acts when the support person leaves (or is unable to meet the patient’s needs), even if for a short period. This alternating pattern of view may shift very rapidly, often with episodes of crisis in between. Patients with BPD often interpret neutral events, words, or faces as “negative”. Thus, the patient is prone to misinterpret relatively minor disagreements or adverse events as a sign that the caretaker or the therapist wants to terminate the relationship. This inclination to “split” can impact the relationship with the therapist and the treatment outcome. Affective instability Rapid and distressing intense changes in the affective state is a common presenting complaint in BPD. Changes in the emotional states can vary between happiness, intense anger, anxiety, panic attacks, dysphoria, sadness, and crying spells with interposing periods of euthymia. These mood shifts can happen within the span of a few hours and are frequently cued by environmental stress (e.g., fear of abandonment). However, affective dysregulation in BPD can also happen without any identifiable external factor. All efforts should be made not to miss a comorbid cyclothymia or more severe mood disorder. Impulsivity Impulsive and potentially self-damaging behaviour are common in BPD, with minimal regard for possible negative consequences. Impulsivity can manifest in many forms: substance abuse, binge eating, engaging in unsafe sex, spending money irresponsibly, involvement in physical fights, and reckless driving. The loss of control in sudden decisions or acts may manifest in damaging ways, for example, suddenly quitting a job that the person needs or ending a relationship that has the potential to last, thereby sabotaging their own success. Impulsivity can also manifest with immature and regressive behaviour and often takes the form of sexually acting out. Although the patient may regret their behaviour afterwards and may even appreciate its potential dangerousness, they may find it difficult, if not impossible, to resist the urge to repeat the behaviour. From a management perspective, impulsivity should be manifested in at least two areas of life to be clinically significant. Deficits in the cognitive functioning Neuropsychologic functioning in patients with BPD is impaired in many domains. BPD patients perform significantly worse on tests of attention, cognitive flexibility, learning and memory, planning, processing speed, and visuospatial ability.[35] Nonsuicidal self-injury (NSSI) Patients with BPD may hurt themselves. Patients may typically recognise the activity as a compulsive act to calm down “inner tension.” It helps them to relieve stress and avoid suicidal thoughts or behaviours. NSSI is often associated with acute substance intoxication and recent rejections and may lead to frequent emergency visits. Although NSSI is often not driven by a wish to die, it is crucial to assess for suicidal ideas or intent. Presentation of BPD in different age groups Adolescence Although features of personality disorder in adolescence usually ameliorate with age, severe PD symptoms in adolescence seem to predict adult PD. Features of PD can be observed in some cases as early as six years of age when they can remain stable for several years. BPD can be reliably diagnosed in adolescence. Clinically significant features of BPD occur in 10% of young people. Diverse mood symptoms often accompany the condition. By the age of 16 years, 1.3% of young people can be diagnosed as suffering from a BPD. The variation in the comorbidity of the disorders is similar to that in adult patients except for suicide attempts, which are more common in BPD in youth. For some patients, the criteria for diagnosis are only met in young adulthood. It is recommended that BPD should be diagnosed correctly in adolescence, as it enables the timely mobilisation of the necessary social and clinical support measures. The use of mental health services is as common in adolescents with BPD as in adults in western countries. Understandably systematic data from India are limited. Old age The prevalence of BPD in public healthcare patients aged more than 80 years has been estimated at 0.3%. The clinical assessment of personality disorders is complicated by changes in personality and cognitive functions with age: chronic depression, cognitive changes related to ageing, and behavioural changes related to organic brain and systemic diseases. Symptoms of frontal and temporal lobe degenerative disease may resemble symptoms of BPD. Presentations of BPD in different clinical settings Emergency department (ED) An individual with BPD may present to the emergency department (ED) with deliberate self-harm (DSH), nonsuicidal self-injury (NSSI), panic attack, stress-induced dissociative/psychotic episode, or physical aggression leading to conflict with the law (thus brought to the hospital by police). While in the busy ED, it is challenging to ascertain a BPD diagnosis for several reasons (including heightened emotional response, poor rapport, biased answering, lack of reliable informant, need for more emergent physical healthcare, and legal proceedings). However, the liaising psychiatry team should provide the option of further psychiatric services utilisation for in-depth assessment and care, especially because these individuals need more structured mental healthcare. A reliable informant, if available, may help in informed decision-making and shared responsibility in the continuation of care. In case a patient visits ED repeatedly, the attending mental health professional may need to address the immediate psychosocial issue and establish rapport so that the patient follows up for more regular outpatient care. Outpatient department (OPD) Individuals with BPD may consider visiting OPD in acute crisis (suicidal ideas, acute stress reaction, dissociative episodes), marital/family relationship conflicts, comorbid psychiatric illness (depressive disorder, anxiety disorder, problematic substance use), or being asked by competent authority (school/college authority, employer, court of law). A thorough assessment of premorbid personality, preferably from different sources with careful evaluation of the pattern of emotional responses and behaviour, helps the clinician diagnose BPD. A structured assessment using a prevalidated tool may help the clinician to achieve a diagnosis of BPD with higher confidence. Inpatient department (IPD) A thorough personality assessment should be done in all the patients using psychiatric inpatient services considering the high burden of BPD (~20%) in this group of patients. This is even more relevant in patients with treatment resistance, poor adherence to pharmacological treatment, and multiple comorbidities. A comorbid diagnosis of BPD may help therapists make a more comprehensive management plan, including long-term therapeutic approaches, addressing the issues of future crisis management and improving the overall quality of life. ASSESSMENT Structured clinical assessment Usually, a single unstructured interview is inadequate to make a diagnosis of personality disorders. Hence, in clinical diagnostics, it is good to use a structured interview (e.g., International Personality Disorder Examination [IPDE]–Hindi translation is available) or assessment scales (IPDE Screen, Personality Disorder Questionnaire–Version 4 [PDQ-4]) and supplement the findings with comprehensive clinical observations. Various semi-structured interviews and self-assessment methods have been developed for the diagnosis of personality disorders, which are presented in Table 2. Internationally, the Semistructured Clinical Interview for DSM personality disorders (SCID-II/SCID-5-PD) is most commonly used in clinical practice and research settings to increase the diagnostic accuracy of personality disorders. The information received from a third party (e.g., informants) does not necessarily increase the reliability of the diagnostic assessment.Table 2: Structured methods for diagnosing personality disorders and borderline personalityThere are several confounders in the diagnosis of personality disorder. Issues related to culture, ethnic background, age of onset of the disorder, gender, developmental changes in personality, and current psychiatric symptoms may impact the presentation of personality traits. In diagnostics, attention should be paid to the duration of the symptoms because, in personality disorders, the symptoms should be recognisable at the end of adolescence or young adulthood and should describe the patient’s functioning in the long term. When making a diagnosis, it is necessary to ensure that the general criteria for a personality disorder are met. When evaluating the diagnosis, each symptom criterion must be evaluated in the light of whether the feature is clearly pathological, long-term, and manifested in different contexts. Implementing good diagnostics in general/primary healthcare is not simple. A proper assessment can be supported by a psychiatric consultation. Ways to deal with challenging patient behaviour are described in the “Clinical management” section and in Panel 2.Panel 2: Borderline personality disorder in general/primary healthcarePsychological assessment BPD is often accompanied by neuropsychological changes, especially related to executive functions. A lower ability to regulate information may evoke negative emotions related to emotional volatility. Disturbances in executive control may increase self-injurious behaviour. Tests used for personality assessment can provide additional information about the person’s ability to function and ways of processing information. A widely used method is the Rorschach inkblot test. Exner’s Comprehensive System helps in scoring and interpreting its results. The Rorschach inkblot test should not be used to diagnose BPD; it is mainly useful for assessing thinking, quality of object relationships, emotional instability, and suicidality. Assessment of comorbidities Other comorbid disorders occur in 70% of those suffering from BPD. BPD patients may have multiple psychiatric disorders at the same time. It is also associated with higher physical morbidity than the rest of the population, which further increases the risk of suicide attempts. Common psychiatric comorbidities with BPD and tools to assess these comorbidities have been described in Table 3.Table 3: Assessment of psychiatric comorbidities in BPDAssessment of medicolegal aspects Self-harm and physical or sexual abuse may lead to legal involvement in individuals with BPD. Comorbid dissocial traits and illicit substance use can also lead to conflicts with the law. Understanding the local and central legal standards on these aspects may be necessary while deciding the locus and modus of treatment. While underlying legal issues should not limit access to treatment, thorough record keeping and maintaining high standards of care is very important. All efforts should be made toward frequent monitoring and staff members should be well informed to avoid any abuse during patient care. Assessment of functional capacity Impaired functioning related to BPD is corrected more slowly than symptoms of BPD. The social functioning, physical health, and financial situation of a person suffering from BPD should be comprehensively evaluated when planning treatment and rehabilitation. Cognitive rehabilitation, psychoeducation, and dialectical behaviour therapy (DBT) may increase the functional capacity of a person suffering from BPD. Assessment of Quality of life Assessment of functioning and quality of life is important in planning the course of management. WHOQOL-BREF is a validated 26-item self-rated questionnaire to assess the quality of life objectively. The Hindi form of this scale is validated. While symptom remission and better emotional control are the initial focus of treatment, early social and occupational rehabilitation helps in recovery and improved quality of life. Assessment of the ability to work (disability assessment) Deterioration of functional ability is often accompanied by a decrease in ability to work. The ability to work may be most impaired in youth and early adulthood, when the transition to working life may be threatened. Vocational rehabilitation courses can improve working/life skills in adults, adults with disabilities, and young adults (aged 18-25 years). Such courses aim to increase life skills and support access to working life or education. For young people, the risk of being marginalised is high both when transitioning to working life and at the beginning of working life, when employment relationships are often temporary. To prevent the development of marginalisation, possible periods of sick leave should generally be limited to acute periods with severe symptoms of concurrent psychiatric disorders. Referral to enhanced vocational rehabilitation or its assessment and, if necessary, psychiatric rehabilitation is appropriate for the same reason. If the patient has previously been able to work despite their disorder, it can be considered that their work disability is not solely due to BPD. Medical reports related to the patient’s ability to work must describe carefully: Symptoms Life course Diagnosis Ability to work and function in real situations Treatment attempts and their results Educational and work history Vocational rehabilitation plan SPECIFIC ISSUES IN ASSESSMENT Risk assessment Assessment of the risk of harm to self/others is one of the most critical factors when formulating a management plan for BPD. A thorough history from the patient, relevant other informants and medical/legal records, followed by a detailed mental state examination, is crucial. When a patient’s thought is inaccessible and behaviour is unpredictable, appropriate precautions should be taken. Brief hospitalisation can be advised in such cases for further observations. Factors indicating high suicide risk: High lethality of attempt Suicide intent Active planning Depressive cognition History of suicide attempts Recent loss Poor psychosocial support Factors indicating a high risk for harm to others: Prior harm to or threatening behaviours toward dependent children Poor self-control on dangerous impulses Active homicidal thoughts Poor insight Considerations for the Indian context Presentation, interpretation, and treatment options for BPD may vary significantly depending on the culture. Although systematic data from India on the cultural effect on personality organisation and presentation are sparse, some points may be highlighted. Understanding and representation of self in the Indian context present as interdependent self with fluid and flexible interpersonal bonds.[36] Indian large and often joint families experience allow for frequent arguments/fights with minimal/no fear of abandonment, in stark difference to the western values of individualism and independence. Indian family constructs are tolerant of dependent or even manipulative acts (somatic complaints, provocative actions, misleading messages, and self-destructive acts), which are not considered particularly deviant unless they cause significant dysfunction in other areas of life or to the significant others. Cultural acceptance of psychosomatic expressions of distress also curtails the need for strong emotional responses during crises or interpersonal difficulties. DIFFERENTIAL DIAGNOSIS Disorders that are important for differential diagnosis of BPD are described in Table 4:Table 4: Differential diagnosis of the borderline personality disorderPROGNOSIS Remission is common in BPD and, once achieved, is usually stable.[37] More than half of the patients suffering from BPD no longer meet the diagnostic criteria for the disorder after five years. Likewise, depressive symptoms are alleviated and functional capacity recovers clinically significantly in a few years. Among the signs, the fastest to relieve are self-destructiveness and identity diffusion. Impulsivity and fluctuations in emotional life are relieved more gradually with increasing age. As personality instability eases, mood and anxiety disorders also decrease, but do so more slowly. Depression slows down recovery from BPD. Comorbid PDs have also been found to be alleviated in patients with BPD during a six-year follow-up.[38] The treatment results seem to be poor when people suffering from BPD have a lifestyle predisposing them to chronic diseases and high utilisation of health services. Even at the age of more than 50 years, the features of BPD may cause failures in relationships. Key prognostic factors are summarised in Table 5.Table 5: Factors predicting the outcome of the treatment of borderline personality during a 10-year follow-up periodMANAGEMENT Central to the treatment of someone suffering from BPD is psychotherapeutic methods. They can be combined with other forms of treatment. The therapeutic relationship and the effectiveness of the therapy may be jeopardised if shame is not recognised in the therapeutic relationship and in the patient’s most central emotional experiences. As per patients’ reports, recovery is facilitated when the care provider offers security, respect, trust, and understanding while guiding toward change by being appropriately active and using specific strategies. At the beginning of the treatment, the therapist should: Carry out a wide-ranging risk assessment, Define crisis management options, Work on the details of the treatment in coordination with the patient, and Avoid communication that increases stigma or negatively judges the patient. Treatment utilisation It may be helpful to understand the treatment of borderline personality as per the well-known phase model of substance use treatment: In the precontemplation phase, there is a lack of awareness of the need for change. In the contemplation phase, the advantages and disadvantages of the change seem equal. In the preparation phase, the person suffering from the disorder has understood the need for change and tells others about it. In the action phase, the person suffering from the disorder is committed to their treatment and works for change. Typical features in the treatment of those suffering from borderline personality are: Abundant and short-term use of different treatment services and forms (Emergency services, primary/general healthcare, specialist mental healthcare, complementary/alternative help). Difficulty adhering to treatment agreements can complicate the treatment of both mental and physical illnesses. Difficulty establishing a long-term psychotherapeutic treatment contact: the patient usually attends psychotherapy only for a short time and ends up using the service
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