The latest article in our Clinical Practice series, Borderline Personality Disorder, reviews the characteristic features of borderline personality disorder, evidence to indicate genetic and environmental factors in pathogenesis, and effective treatment strategies.
BPD is present in about 6% of primary care patients and persons in community-based samples and in 15 to 20% of patients in psychiatric hospitals and outpatient clinics. In clinical settings, about 75% of persons with the disorder are women, although this percentage is lower in community-based samples.
• How can BPD be recognized?
Recurrent suicidal threats or acts in combination with fears of abandonment are by themselves strongly indicative of the diagnosis. The most distinctive characteristics of patients with BPD are their hypersensitivity to rejection and their fearful preoccupation with expected abandonment.
• What is the prognosis for patients with BPD?
While BPD has long been considered a chronic and largely untreatable disorder, more recent data indicate a high remission rate (about 45% by 2 years and 85% by 10 years), as defined by meeting fewer than two criteria for at least 12 months, and a low relapse rate (about 15%). In other respects, however, the prognosis remains discouraging. The suicide rate is about 8 to 10%, with a particularly high proportion of young women. Moreover, even after remission, most patients with BPD have severe functional impairment, with only about 25% of patients with full-time employment and about 40% receiving disability payments after 10 years.
Table 1. Criteria for the Diagnosis of Borderline Personality Disorder.
Morning Report Questions
Q: What is the primary method for treating BPD?
A: Psychotherapy is the primary method for treating BPD. Randomized trials involving patients with BPD support the efficacy of several forms of psychotherapy. The best studied of these methods is dialectical behavior therapy.
Q: Is there a role for pharmacotherapy for patients with BPD?
A: Selective serotonin-reuptake inhibitors and other antidepressants are frequently prescribed to patients with BPD, but in randomized trials such drugs have little if any benefit over placebo. In such trials, benefits for patients with BPD have been shown for atypical antipsychotic agents (e.g., olanzapine) and mood stabilizers (e.g., lamotrigine), particularly for reducing impulsivity and aggression. However, these effects are typically modest, and side effects are common.