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ORLANDO, FL — Borderline personality disorder, a disorder that is often misunderstood by the general public,1 also raises questions for psychiatrists. Some of these questions include: What is the best way to narrow down who should be assessed for borderline personality disorder? Should I tell my patients their diagnosis, or will it scare them away from returning to therapy? How realistic is their potential for recovery? What is the best course for treatment, especially regarding pharmacotherapy?
In his presentation at US Psych Congress 2018, Mark Zimmerman, MD, from Brown University, Providence, Rhode Island, discusses his research on these questions and advises psychiatrists on how to best handle these scenarios.
Question 1: Who Should Be Assessed for Borderline Personality Disorder?
Screening is recommended in the following conditions:2
- Bipolar disorder
- Post-traumatic stress disorder (PTSD)
- Major depressive disorder
- Panic disorder
Screening is not recommended in:
- Dysthymic disorder
- Generalized anxiety disorder
- Adjustment disorder
However, Dr Zimmerman delved deeper into the question of screening and diagnosis: Can “gate criteria,” or criteria with high sensitivity and high negative predictive value, be used to determine who should be screened for borderline personality disorder?
Criteria of borderline personality disorder
- Avoidance of abandonment
- Unstable relationships
- Identity disturbance
- Affective instability
- Stress-induced paranoia/dissociation
Results of an analysis conducted by Dr Zimmerman and colleagues found that of the 9 criteria for borderline personality disorder, affective instability was the best predictor of borderline personality disorder and should most likely be used as the gate criterion for screening.2
Structured Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Personality Questions
Questions to ask patients include:
1. Has anyone ever told you that your moods seem to change a great deal?
If yes, what did they say?
2. Do you often have days where your mood changes a great deal, days when you shift back and forth from feeling like your usual self to feeling angry or depressed or anxious?
If yes, how intense are your mood swings? How often does this happen in a typical week? How long do the moods last?
Question 2: Should I tell patients their diagnosis of borderline personality disorder?
Many psychiatrists are hesitant to tell their patients their diagnosis of borderline personality disorder for fear that they will react negatively.3
To examine whether patients with borderline personality disorder are less satisfied or more upset with their initial evaluation than patients without borderline personality disorder, Dr Zimmerman and colleagues conducted the MIDAS project, evaluating 1093 patients at the Rhode Island Hospital partial hospital program.3
Using the Clinically Useful Patient Satisfaction Scale (CUPSS), the researchers found almost no difference between how patients with borderline personality disorder reacted to their diagnosis compared with patients without borderline personality disorder. (Mean scores differed by two-tenths of a point, or less, on the 5-point scale.)
A total of 74.9% of patients with borderline personality disorder were extremely satisfied with their initial evaluation compared with 75.1% of patients without borderline personality disorder (x2 =.003; ns), and 76.0% of patients with borderline personality disorder said they strongly agreed that their diagnosis was explained in a clear way compared with 80.6% of patients without borderline personality disorder (x2 = 1.87; ns). Patients with borderline personality disorder were also as likely to believe that their physicians understood their problems.
“Patients with borderline personality disorder do not differ from other patients in their satisfaction with the initial evaluation,” Dr Zimmerman stated. “Clinicians should approach the diagnosis of borderline personality disorder in the same way that they make other psychiatric diagnoses.”
Question 3: What is the prognosis for patients with borderline personality disorder?
Although borderline personality disorder was first believed to be a severe, chronic, and untreatable disorder with poor prognosis,4 “seminal long-term retrospective studies…largely completed…from 1985 to 1995, indicated that…many patients get better, thereby challenging the widely held view of [borderline personality disorder] as an unremittingly chronic condition. Still, the methodological and design limitations that characterized this prior literature diminished its impact, and a firmly entrenched pessimism about the prognosis of patients with [borderline personality disorder] has persisted.”5
However, there is now more current literature examining the prognosis of patients with borderline personality disorder. Dr Zimmerman highlighted 2 studies conducted in 2010: the McLean Study of Adult Development (MSAD) and the Collaborative Longitudinal Personality Disorders Study (CLPS).5,6
On the basis of results of these 2 studies, Dr Zimmerman noted that:
- The longitudinal course of borderline personality disorder is heterogeneous.
- The rate of remission partially depends on how remission is defined.
- There is cause for optimism: the vast majority of patients remitted symptomatically.
- Functional remission was less likely than symptomatic remission; however, many patients with borderline personality disorder achieve satisfactory to good functional remission during a 10-year follow-up.
There is therefore cause for optimism in the prognosis of patients with borderline personality disorder, contrary to past beliefs about the disorder.
Question 4: What is the best course for treatment in borderline personality disorder, including pharmacotherapy?
Dr Zimmerman noted that if patients ask for medication, they should first be referred to therapy.1
Types of therapy for borderline personality disorder include:7
- DBT: Dialectical behavior therapy
- MBT: Mentalization-based therapy
- TFP: Transference-focused psychotherapy
- SFT: Schema-focused therapy
- GPM: Good psychiatric management
- STEPPS: Systems training for emotional predictability and problem solving
Dr Zimmerman also highlighted a study demonstrating recent progress in psychotherapy for borderline personality disorder, including the potential to develop treatments for comorbid post-traumatic stress disorder and borderline personality disorder, and the emergence of generalist therapies.7
One limitation of research in this area is that little attention is given to improving functional outcome; almost all research focuses on improving symptoms.1
Almost all patients with borderline personality disorder are treated with a variety of psychotropic medication, with polypharmacy being the rule rather than the exception. However, Dr Zimmerman noted that no medication has been approved for treating borderline personality disorder anywhere in the world.8
Official treatment guidelines for borderline personality disorder include:
American Psychiatry Association (APA):9
- Psychotherapy is the first-line treatment
- Symptom-specific medication treatment is recommended:
- Selective serotonin reuptake inhibitors for affective dysregulation or impulsivity
- Mood stabilizers for impulsivity
- Antipsychotics for cognitive-perceptual symptoms
NICE (National Institute of Clinical Excellence):10
- Psychotherapy is first-line treatment
- Do not recommend medication for symptoms of borderline personality disorder
- Do recommend medication for comorbid conditions
Closing Advice to Clinicians
Dr Zimmerman concluded his presentation with guidelines for a practical approach to diagnosing and treating borderline personality disorder.1 These include:
- Screen for the diagnosis.
- Tell patients if you make the diagnosis.
- Educate patients about the diagnosis (and prognosis).
- Don’t let patients define themselves by their disorder.
- Be collaborative: provide a safe and nonjudgmental environment.
- Set limits.
- Don’t be rigid.
- Be willing to be wrong when you have made a mistake, and don’t be afraid to apologize.
- Think long-term for the patient and their risk for mortality. There is a good chance that the patient will do better in a decade; prognosis is good.
- Refer patients for therapy, even if they ask for medication — and possibly require it.
- Be an island of stability and predictability, so patients can count on their physician.
- Set expectations regarding medication: There is no magic pill!
- Understand the down sides of prescribing medication. Discuss the side effects of medication with the patient.
- Keep in mind that improvement may be a result of the placebo effect.
- Try to avoid medicating during crises; wait 1 to 2 days. It is better to instead increase the frequency of visits.
- Try to avoid polypharmacy (or poly, polypharmacy). Switching medications is recommended, rather than augmenting.
- Try to achieve adequate duration and dosage.
- Involve the family.
- Focus on functioning and symptom management, rather than symptom elimination.
- Promote acceptance. Focus on functional improvement and coping skills with patients.
- Promote a healthy lifestyle including sleep, eating, and exercise habits.
- Talk to colleagues about your frustrations and concerns.
- Zimmerman M. Update on borderline personality disorder: what every clinician needs to know. Presented at: US Psych Congress 2018; October 25-28, 2018; Orlando, FL.
- Zimmerman M, Multach MD, Dalrymple K, Chelminski I, et al. Clinically useful screen for borderline personality disorder in psychiatric out-patients. J Clin Psychiatry. 2017;210(2):165-166.
- Zimmerman M, et al. Does diagnosing a patient with borderline personality disorder negatively impact patient satisfaction with the initial diagnostic evaluation? Ann Clin Psychiatry. 2018;30(3):215-219.
- Alvarez-Tomás I, Soler J, Bados, et al. Long-term course of borderline personality disorder: A prospective 10-year follow-up study. J Pers Disord. 2017;31(5):590-805.
- Gunderson JG, et al. Ten-year course of borderline personality disorder: psychopathology and function from the collaborative longitudinal personality disorders study. Arch Gen Psychiatry. 2011;68(8):827-837.
- Zanarini MC Frankenburg FR, Reich DB, Fitzmaurice G. Time to attainment of recovery from borderline personality disorder and stability of recovery: A 10-year prospective follow-up study. Am J Psychiatry. 2010;167(6):663-667.
- Links PS, Shah R, Eynan R. Psychotherapy for borderline personality disorder: Progress and remaining challenges. Curr Psychiatry Rep. 2017;19(3):16.
- Starcevic V, Janca A. Pharmacotherapy of borderline personality disorder: replacing confusion with prudent pragmatism. Curr Opin Psychiatry. 2018;31(1):69-73.
- American Psychiatry Association Work Group on Borderline Personality Disorder. Practice guideline for the treatment of patients with borderline personality disorder. October 2001. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bpd.pdf. Accessed October 26, 2018.
- National Institute of Clinical Excellence. Borderline personality disorder: recognition and management. January 2009. https://www.nice.org.uk/guidance/cg78/resources/borderline-personality-disorder-recognition-and-management-pdf-975635141317. Accessed October 26, 2018.