A growing body of scientific research has identified the underlying causes of so-called borderline personality disorder (BPD), but the vexing mental health condition remains a “neglected” illness that is misunderstood and misdiagnosed by many psychiatrists.
That’s the upshot of a landmark new report published in a special edition of the Harvard Review of Psychiatry that identifies “a pressing need to improve diagnosis and management of this devastating psychiatric condition.”
BPD strikes up to 6 percent of the U.S. population — 14 million Americans — and accounts for one in five psychiatric medical facility admissions, according to federal health statistics. That's nearly five times as many Americans as those diagnosed with Alzheimer's disease.
“Although the diagnostic criteria for BPD are well-accepted, it continues to be a misunderstood and sometimes neglected condition; many psychiatrists actively avoid making the diagnosis,” the report’s authors conclude.
“Borderline personality disorder accounts for nearly 20 percent of psychiatric hospitalizations and outpatient clinic admissions, but only three percent of the research budget of the National Institute of Mental Health.”
Among the special report’s findings:
Stress reduction can help. Chronic stress can lead to changes in brain metabolism and structure, and affect the processing and integration of emotions and thoughts in people with BPD. Therapies that ease stress — meditation, yoga, biofeedback, or cognitive behavioral approaches — have been shown to help.
Earlier intervention is necessary. Knowing the risk factors, precursors, and early symptoms of BPD and mood disorders in adolescence and young adulthood (before age 25) can help doctors, patients, and loved ones identify those at risk for BPD and that can lead to effective treatment and management.
More BPD research needed. While CBT and other therapies can help combat the disorder, more resources and training are needed to identify new and better treatments and help clinicians better understand how to diagnose and treat BPD.
ER care must improve. Better standard emergency care for BPD patients who are in crisis is necessary. Training mental health professionals so they have deeper knowledge and insights into BPD is needed so patients are treated with a "caring, informed, and practical" approach.
In an editorial accompanying the special Harvard report, Drs. Lois Choi-Kain and John Gunderson — of the Adult Borderline Center and Training Institute at McLean Hospital, Belmont, Mass. — said doctor training is “critical” to addressing the challenges of treating BPD.
"For clinicians, educators, and researchers, we hope this issue clarifies an emerging basis for earlier intervention, generalist approaches to care for the widest population, and a more organized approach to allocating care for individuals with BPD," they said.
"We hope these articles will help clinicians understand their BPD patients, encourage more optimism about their treatability, and help set a stage from which the next generation of mental health professionals will be more willing to address the clinical and public health challenges they present."
According to the National Institute of Mental Health:
- BPD symptoms include wide instability in moods, behavior, self-image, and functioning. These experiences often result in impulsive actions and a pattern of intense and unstable relationships with family, friends, and loved ones, often swinging from extreme closeness and love to extreme dislike or hate.
- A person with BPD may experience intense episodes of uncontrollable anger, depression, and anxiety that may last from only a few hours to days or longer.
- People with some forms of BDP may blame others or external factors for their problems, which can add to relationship conflicts and may keep them from seeking therapy to help them manage their condition.
- People with BPD may experience extreme mood swings and can display uncertainty about who they are. As a result, their interests and values can change rapidly.
- Some people with BPD also have high rates of co-occurring mental disorders, such as mood disorders, anxiety disorders, and eating disorders, along with substance abuse, self-harm, suicidal thinking and behaviors.
- 80 percent of people with BPD display suicidal behaviors, including suicide attempts, cutting themselves, burning themselves, and other self-destructive acts.
- Some with BPD have desperate fears of real or imagined abandonment, a distorted and unstable self-image or sense of self, chronic feelings of emptiness, stress-related paranoid thoughts, and severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body, or losing touch with reality.
Mental health experts note that ordinary or minor events can trigger extreme symptoms — particularly rage — in people with BPD.
A licensed mental health professional — such as a psychiatrist, psychologist, or clinical social worker — can diagnose BPD based on a thorough interview and a comprehensive medical exam and decide on best treatments. (Research funded by NIMH is underway to look for ways to improve diagnosis of and treatments for BPD).
Studies suggest that genetic, neurological, social, and environmental factors (including childhood trauma or abuse) may be involved in the development of BPD.
A variety of treatments — some relatively new — have been proven to help people with BPD experience fewer or less severe symptoms and an improved quality of life.
Among them:
Psychotherapy (or “talk therapy”) is the main treatment for BPD. Therapists often switch from one type of psychotherapy to another, mix techniques from different therapies, or use a combination of psychotherapies, based on a patient’s needs.
Cognitive behavioral therapy (CBT) helps people identify and change core beliefs and/or behaviors that underlie inaccurate perceptions of themselves and others and problems interacting with others.
Dialectical behavior therapy (DBT) utilizes the concept of mindfulness, or being aware of and attentive to the current situation and moods, and teaches skills to control and change intense emotions, reduce self-destructive behaviors, and improve relationships.
Schema-focused therapy combines elements of CBT and psychotherapy to refocus the ways people view themselves and improve self-image, interactions with others, and cope with problems or stress.
STEPPS, short for Systems Training for Emotional Predictability and Problem Solving, is a type of group therapy that aims to educate family members, significant others, and health care professionals about BPD and gives them guidance on how to interact consistently with the person with the disorder.
Medications to treat specific symptoms, such as mood swings, depression, or other disorders that may occur with BPD, can be helpful in managing the condition.
Experts note that BPD is a serious condition requiring treatment. The NIMH offers the following checklist:
- If you believe you may have BPD, talk to a doctor about treatment options; try to maintain a stable schedule of meals and sleep times; engage in mild activity or exercise to reduce stress; set realistic goals for yourself; spend time with people you trust; don’t drink alcohol or use illicit drugs – they will likely make things worse.
- If you are thinking about suicide, tell someone who can help right away. Call a mental health professional or go to the nearest hospital emergency room.
- If a loved one is considering suicide, try to get your loved one to seek immediate help from a doctor or the nearest hospital ER, or call 911.
- If you or a loved one are in crisis, call the toll-free National Suicide Prevention Lifeline at 1-800-273-TALK (8255), available 24 hours a day, 7 days a week.
For more information on BPD, read the full Harvard Review of Psychiatry online or visit the NIMH Website.