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
SeminarBorderline 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
References (144)
- et al.
The borderline diagnosis I: psychopathology, comorbidity, and personality structure
Biol Psychiatry
(2002) - et al.
Borderline personality disorder
Lancet
(2004) - et al.
Personality disorders in the National Comorbidity Survey Replication
Biol Psychiatry
(2007) - et al.
Five year follow-up comparison of borderline and schizophrenic patients
Compr Psychiatry
(1977) - et al.
The interface between borderline personality disorder and bipolar spectrum disorders
Compr Psychiatry
(2007) - et al.
The 5-HTTLPR polymorphism modulates the association of serious life events (SLE) and impulsivity in patients with borderline personality disorder
J Psychiatr Res
(2009) - et al.
The borderline diagnosis III: identifying endophenotypes for genetic studies
Biol Psychiatry
(2002) - et al.
The borderline diagnosis II: biology, genetics, and clinical course
Biol Psychiatry
(2002) - et al.
Association between serotonin transporter gene and borderline personality disorder
J Psychiatr Res
(2006) - et al.
Failure to detect an association between the serotonin transporter gene and borderline personality disorder
J Psychiatr Res
(2008)
Serotonin genes and gene-gene interactions in borderline personality disorder in a matched case-control study
Prog Neuropsychopharmacol Biol Psychiatry
Magnetic resonance imaging of hippocampal and amygdala volume in women with childhood abuse and borderline personality disorder
Psychiatry Res
Orbitofrontal, amygdala and hippocampal volumes in teenagers with first-presentation borderline personality disorder
Psychiatry Res
Magnetic resonance imaging (MRI) measurement of hippocampal volume in posttraumatic stress disorder: a meta-analysis
J Affect Disord
Magnetic resonance imaging-based measurement of hippocampal volume in postttraumatic stress disorder related to childhood physical and sexual abuse—a preliminary report
Biol Psychiatry
Orbitofrontal, amygdala and hippocampal volumes in teenagers with first-presentation borderline personality disorder
Psychiatry Res
Frontolimbic structural changes in borderline personality disorder
J Psychiatr Res
Pituitary volume in teenagers with first-presentation borderline personality disorder
Psychiatry Res
An MRI study of pituitary volume and parasuicidal behavior in teenagers with first-presentation borderline personality disorder
Psychiatry Res
Pituitary volume predicts future transition to psychosis in individuals at ultra-high risk of developing psychosis
Biol Psychiatry
Reduced size and abnormal asymmetry of parietal cortex in women with borderline personality disorder
Biol Psychiatry
Size abnormalities of the superior parietal cortices are related to dissociation in borderline personality disorder
Psychiatry Res
Reduced prefrontal and orbitofrontal gray matter in female adolescents with borderline personality disorder: is it disorder specific?
Neuroimage
Positron emission tomography in female patients with borderline personality disorder
J Psychiatr Res
Laboratory induced aggression: a positron emission tomography study of aggressive individuals with borderline personality disorder
Biol Psychiatry
Neural correlates of emotion processing in borderline personality disorder
Psychiatry Res
Fronto-limbic dysfunction in response to facial emotion in borderline personality disorder: an event-related fMRI study
Psychiatry Res
Neural correlates of the use of psychological distancing to regulate responses to negative social cues: a study of patients with borderline personality disorder
Biol Psychiatry
Evidence of abnormal amygdala functioning in borderline personality disorder: a functional MRI study
Biol Psychiatry
Posttraumatic stress disorder and fMRI activation patterns of traumatic memory in patients with borderline personality disorder
Biol Psychiatry
Amygdala deactivation as a neural correlate of pain processing in patients with borderline personality disorder and co-occurrent posttraumatic stress disorder
Biol Psychiatry
A trial of carbamazepine in borderline personality disorder
Eur Neuropsychopharmacol
Treatment utilization by patients with personality disorders
Am J Psychiatry
Borderline personality disorder and suicidality
Am J Psychiatry
The Collaborative Longitudinal Personality Disorders Study (CLPS): overview and implications
J Pers Disord
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
The prevalence of personality disorders in a community sample
Arch Gen Psychiatry
Epidemiology
Borderline personality disorder: ontogeny of a diagnosis
Am J Psychiatry
Borderline personality disorder in primary care
Arch Intern Med
Diagnostic and Statistical Manual of Mental Disorders
Diagnostic efficiency of DSM-IV criteria for borderline personality disorder: an evaluation in Hispanic men and women with substance use disorders
J Consult Clin Psychol
Longitudinal diagnostic efficiency of DSM-IV criteria for borderline personality disorder: a 2-year prospective study
Can J Psychiatry
Confirmatory factor analysis of DSM-IV criteria for borderline personality disorder: findings from the collaborative longitudinal personality disorders study
Am J Psychiatry
Prediction of the 10-year course of borderline personality disorder
Am J Psychiatry
Plausibility and possible determinants of sudden “remissions” in borderline patients
Psychiatry
Major depressive disorder and borderline personality disorder revisited: longitudinal interactions
J Clin Psychiatry
The subsyndromal phenomenology of borderline personality disorder: a 10-year follow-up study
Am J Psychiatry
Ten-year stability and latent structure of the DSM-IV schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders
J Abnorm Psychol
The longitudinal relationship of personality traits and disorders
J Abnorm Psychol
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