The field of Borderline Personality Disorder (BPD) research is rapidly expanding, improving our understanding of contributing factors, comorbidities, prognosis, evidence-based treatments, biological signposts, and changes in symptom expression across the life span. Longitudinal studies have provided robust evidence of remission and recovery, greatly improving the outlook for people with BPD, their families, and the medical and community services that support them.
Over the past 20 years perceptions relating to BPD have changed considerably. Originally perceived as a serious, untreatable disorder with a poor prognosis, it is now widely accepted that BPD has a hopeful prognosis. Key to this is early diagnosis and access to evidence-based psychotherapy.
Implementing effective treatment services remains a challenge worldwide, as psychotherapy is expensive, and the diagnosis is often difficult to make. Diagnosis and treatment may also be delayed due to complications arising from co-occurring disorders, which are common in people with BPD. The persistence of stigma associated with having a BPD diagnosis may also impede access to appropriate treatment.
Conservative estimates suggest that BPD affects at least one to two per cent of people in our community. Untreated BPD is often associated with life-long distress and disability, with ongoing social dysfunction that affects families, and reduces engagement with education and career opportunities. BPD has similar prevalence to bipolar disorder and schizophrenia; as many as 10 per cent of people with BPD will take their own lives. Despite these startling numbers, health services are often inadequately resourced, and may struggle to identify and treat people with BPD.
We present here a selection of thought-provoking and foundational papers from around the world. While not exhaustive, these highlight some of the major advances and challenges facing BPD research and treatment today.
Longitudinal studies of recovery from BPD
Zanarini MC, Frankenburg FR, Reich DB, Wedig MM, Conkey LC, Fitzmaurice GM. Prediction of time-to-attainment of recovery for borderline patients followed prospectively for 16 years Acta Psychiatr Scand. 2014 Sep; 130(3):205-13. doi: 10.1111/acps.12255.
Ng FY, Bourke ME, Grenyer BF. Recovery from Borderline Personality Disorder: A Systematic Review of the Perspectives of Consumers, Clinicians, Family and Carers. PLoS One.2016 Aug 9;11(8):e0160515. doi: 10.1371/journal.pone.0160515.
Stone MH. Long-Term Course of Borderline Personality Disorder, Psychodyn Psychiatry. Fall 2016;44(3):449-74. doi: 10.1521/pdps.2016.44.3.449.
Suicide and self-harm papers
Paris J. Half in love with easeful death: the meaning of chronic suicidality in borderline personality disorder, Harv Rev Psychiatry.2004 Jan-Feb;12(1):42-8.
Calati R, Courtet P, Is psychotherapy effective for reducing suicide attempt and non-suicidal self-injury rates? Meta-analysis and meta-regression of literature data, J Psychiatr Res. 2016 Aug; 79:8-20. doi: 10.1016/j.jpsychires.2016.04.003.
Stigma in relation to diagnosis of BPD
Grambal A, Prasko J, Kamaradova D, Latalova K, Holubova M, Marackova M, Ociskova M, Slepecky M. Self-stigma in borderline personality disorder — cross-sectional comparison with schizophrenia spectrum disorder, major depressive disorder, and anxiety disorders, Neuropsychiatr Dis Treat.2016 Sep 22;12:2439-2448.
Lam DC, Poplavskaya EV, Salkovskis PM, Hogg LI, Panting H, An experimental Investigation of the Impact of Personality Disorder Diagnosis on Clinicians: Can We See Past the Borderline?, Behav Cogn Psychother.2016 May; 44(3):361-73. doi: 10.1017/S1352465815000351.
Key papers highlighting the evidence-based BPD treatments
Bateman A, O’Connell J, Lorenzini N, Gardner T, Fonagy P, A randomised controlled trial of mentalization-based treatment versus structured clinical management for patients with comorbid borderline personality disorder and antisocial personality disorder, BMC Psychiatry. 2016 Aug 30;16:304. doi: 10.1186/s12888-016-1000-9
Mary C. Zanarini, Psychotherapy of Borderline Personality Disorder, Acta Psychiatr Scand. 2009 Nov; 120(5): doi:10.1111/j.1600-0447.2009.01448.x.
Giesen-Bloo J, van Dyck R, Spinhoven P, van Tilburg W, Dirksen C, van Asselt T, Kremers I, Nadort M, Arntz A., Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy, Arch Gen Psychiatry. 2006 Jun;63(6):649-58.
Recent reviews of the ‘common factors’ treatment hypothesis
Merced M, The Beginning Psychotherapist and Borderline Personality Disorder: Basic Treatment Principles and Clinical Foci, Am J Psychother. 2015;69(3):241-68.
Sledge W, Plakun EM, Bauer S, Brodsky B, Caligor E, Clemens NA, Deen S, Kay J, Lazar S, Mellman LA, Myers M, Oldham J, Yeomans F, Psychotherapy for suicidal patients with borderline personality disorder: an expert consensus review of common factors across five therapies, Borderline Personal Disord Emot Dysregul. 2014 Nov 11;1:16. doi: 10.1186/2051-6673-1-16.
Fonagy P, Luyten P, Bateman A, Treating Borderline Personality Disorder With Psychotherapy: Where Do We Go From Here?, JAMA Psychiatry 2017 Mar 1. doi: 10.1001/jamapsychiatry.2016.4302. [Epub ahead of print]
Spectrum has an active research program and we welcome contact from mental health workers to discuss and participate in studies that are designed to clarify aetiology and diagnosis, investigate treatment efficacy, and highlight training needs to improve services for people diagnosed with BPD, and those who support them.
If you would like to discuss our current research activities and your research interests, please phone (03) 8833 3050 or email Spectrum.Research@easternhealth.org.au.