In a small preliminary study published in the Journal of Personality Disorders last month, researchers investigated the efficacy of a treatment approach called the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders (UP) in addressing these comorbidities.6 The UP addresses the shared vulnerabilities by helping patients develop more acceptance toward their emotions. “The idea is that by developing more tolerance toward emotions, patients will rely less on the maladaptive avoidant coping strategies that backfire on them,” leading to reductions in rebound effects and negative emotions, Sauer-Zavala said.

In four of the five patients involved in the study, the approach led to significant reductions in symptoms of BPD, depression and anxiety, along with improvements in emotion regulation. While there is strong evidence for the efficacy of treatments like dialectical behavioral therapy in treating severe cases of BPD, there have not been many investigations into options for patients for whom intensive care is unnecessary. “This is where the UP could be a good fit,” noted Sauer-Zavala. “In summary, clinicians should not automatically assume that a BPD patient will be difficult to treat simply because of their diagnosis.”

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Dr Sulzer advocates a patient-centered approach that respects the patient and clearly communicates the BPD diagnosis while acknowledging its associated stigma. She encourages clinicians to consider the effects of their avoidance of patients with BPD.

“Where do they think these patients belong instead — what other social resources do we have in place to provide treatment?” she asks. “If there aren’t other systems in place, then I think clinicians need to consider the bigger picture consequences, intergenerational and otherwise, of not providing treatment when it is needed.”


  1. Sulzer SH. Does “difficult patient” status contribute to de facto demedicalization? The case of borderline personality disorder. Social Science & Medicine. 2015; 142:82-9.
  2. Saunders KEA, Bilderbeck AC, Price J, Goodwin GM. Distinguishing bipolar disorder from borderline personality disorder: A study of current clinical practice. European Psychiatry.  2015; 30(8): 965-74.
  3. Potvin A, Harris J, Gigot G. Improving patient-centered communication of the borderline personality disorder diagnosis. Journal of Mental Health; 2016.  25(1):5-9.
  4. Swenson CR, Choi-Kain LW. Mentalization and Dialectical Behavior Therapy. American Journal of Psychotherapy. 2015; 69(2):199-217.
  5. Kvarstein EH, Pedersen G, Urnes Ø, Hummelen B, Wilberg T, Karterud S. Changing from a traditional psychodynamic treatment programme to mentalization-based treatment for patients with borderline personality disorder–does it make a difference? Psychology and Psychotherapy. 2015; 88(1):71-86.
  6. Transdiagnostic Treatment of Borderline Personality Disorder and Comorbid Disorders: A Clinical Replication Series. Journal of Personality Disorders. 2016; 30(1):35-51.