Elsevier

The Lancet

Volume 377, Issue 9759, 1–7 January 2011, Pages 74-84
The Lancet

Seminar
Borderline personality disorder

https://doi.org/10.1016/S0140-6736(10)61422-5Get rights and content

Summary

Recent research findings have contributed to an improved understanding and treatment of borderline personality disorder. This disorder is characterised by severe functional impairments, a high risk of suicide, a negative effect on the course of depressive disorders, extensive use of treatment, and high costs to society. The course of this disorder is less stable than expected for personality disorders. The causes are not yet clear, but genetic factors and adverse life events seem to interact to lead to the disorder. Neurobiological research suggests that abnormalities in the frontolimbic networks are associated with many of the symptoms. Data for the effectiveness of pharmacotherapy vary and evidence is not yet robust. Specific forms of psychotherapy seem to be beneficial for at least some of the problems frequently reported in patients with borderline personality disorder. At present, there is no evidence to suggest that one specific form of psychotherapy is more effective than another. Further research is needed on the diagnosis, neurobiology, and treatment of borderline personality disorder.

Introduction

Borderline personality disorder is a common mental disorder associated with high rates of suicide, severe functional impairment, high rates of comorbid mental disorders, intensive use of treatment, and high costs to society.1, 2, 3, 4, 5 In recent years, research findings have contributed to an improved understanding and therapy of these difficult-to-treat patients. In this Seminar, we provide an up-to-date review of recent research on the diagnosis, epidemiology, course, causes, and treatment of borderline personality disorder in adults.

Section snippets

Epidemiology

In epidemiological studies of adults in the USA, prevalances for borderline personality disorder were between 0·5% and 5·9% in the general US population6, 7 with a median prevalence of 1·35 as assessed by Torgersen and colleagues.8 There is no evidence that borderline personality disorder is more common in women.7, 9 In clinical populations, borderline personality disorder is the most common personality disorder, with a prevalence of 10% of all psychiatric outpatients and between 15% and 25% of

Diagnosis

According to the current psychiatric classification system in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), borderline personality disorder is characterised by a pervasive pattern of instability in interpersonal relationships, identity, impulsivity, and affect (panel).12 For a diagnosis of borderline personality disorder, at least five of the nine criteria must be met. However, suicidal tendency or self-injury are the most useful indications for a

Course

Although more stable than major depressive disorder, borderline personality disorder seems to be less stable over time than expected for personality disorders.5, 16, 17 High rates of remission were reported in both short-term and long-term follow-up studies.16 The rate of remission does not seem to be affected by major depressive disorder. By contrast, the rate of remission of major depressive disorder does seem to be significantly reduced by co-occurring borderline personality disorder.18

Comorbidity

Borderline personality disorder is regularly associated with comorbid axis I and axis II disorders.5, 6, 7 84·5% of patients with borderline personality disorder met criteria for having one or more 12-month axis I disorders, and 73·9% met criteria for another lifetime axis II disorder.6, 7 Borderline personality disorder is most frequently associated with mood disorders, anxiety disorders, and disorders associated with substance misuse.5, 6, 7 With a lifetime prevalence of 39·2%, post-traumatic

Psychosocial factors in the development of borderline personality disorder

Patients with borderline personality disorder report many negative events (eg, trauma, neglect) during childhood32 and substantially more adverse events than do patients with other personality disorders.33 However, no close association between these experiences and the development of psychopathological changes in adulthood has been identified.34, 35 For this reason, an interaction between biological (eg, temperamental) and psychosocial factors (eg, adverse childhood events) will probably

Genetic factors and neurobiology

Evidence has emerged that genetic factors contribute to the development of borderline personality disorder;39, 40, 41 however, no specific genes have yet been clearly identified as causative. For dimensional representations of borderline personality disorder traits (ie, their quantitative intensity), a moderate heritability has been reported.40 In studies of twins, heritability scores for the full diagnosis were 0·65 to 0·75,42 consistent with heritability estimates for personality disorders in

Anatomical MRI findings

Although CT studies of the brain did not detect any morphological changes in patients with borderline personality disorder, reduced volume in the amygdala has been reported in some studies with structural MRI.54, 55 Excitotoxicity in the course of this disorder was discussed as a possible cause of reduced amygdala volume. Similar to these findings, no morphological changes in the amygdala were reported after the first appearance of symptoms in teenagers.56 Reduced hippocampal volumes,57 but no

Treatment

The American Psychiatric Association's practice guideline recommends psychotherapy as the main treatment of borderline personality disorder, with pharmacotherapy as an adjunctive component of treatment that targets state symptoms during periods of acute decompensation and trait vulnerabilities.28 This guideline is a set of evidence-based best practice recommendations. The pharmacotherapy algorithms are directed towards three clusters of symptoms: cognitive-perceptual symptoms (with

Future perspectives

Although much has been learned about borderline personality disorder in recent years, several questions remain. Despite conceptual coherence, borderline personality disorder seems to be a heterogeneous diagnostic category that is less stable and distinct over time than expected. These findings raise questions of both how to conceptualise this disorder and how to implement it in future versions of DSM as a form of personality pathology that is both enduring and distinct from other personality

Search strategy and selection criteria

We searched Medline, PsycINFO, and Current Contents from their start dates to Dec 31, 2009, with the database-specific search terms such as “borderline personality disorder”, “borderline personality”, or “borderline disorder”. The search was updated in Aug 30, 2010. We mainly selected publications from the past 5 years. Studies had to meet criteria of recent Cochrane reviews on borderline personality disorder;79, 107 for example, participants had to be aged 18 years or older, diagnosis of

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