Perspective for people with borderline personality disorder
‘Raising awareness of the disorder is crucial since borderline personality disorder (BPD) still faces considerable stigma ’, says Anne Krause-Utz (Clinical Psychology) . Together with an international team of excellent scientists, Krause-Utz provides an update of current knowledge about this disorder, including treatment and guidance for new research. Publication in The Lancet on October 21, 2021.
Anne Krause-Utz: ‘For me it was a great honor to be invited to co-author this article with this excellent team of top international scientists. This group effort fueled me with new ideas and strengthened my passion for studying and treating this mental disorder.
This mental disorder places a high burden on patients, family members, and health care systems. Anne Krause-Utz. ‘Previously regarded as untreatable, many people still believe that it cannot be managed. However, several evidence-based treatments exist and around 60% of patients show diagnostic remission over an observation period of 5 to 14 years. Individuals with BPD often view themselves as inadequate, bad, guilty, disgusting and contemptible. They have the feeling that they are profoundly different and tend to isolate themselves. These experiences make it even harder for them to reach out for help. Therefore, it is important to reduce the stigma and provide psychoeducation, early interventions and appropriate treatment.’
Diving into data bases and guidelines
While much progress has been made in understanding and managing the disorder, the authors identified several unanswered questions which may guide further research. 'We searched relevant data bases (PubMed, PsycINFO, EMBASE) and the Cochrane Library for any entries relating to BPD. We also considered relevant evidence-based practice guidelines: i.e., the British NICE guidelines and the Australian NHMRC guidelines. Here, we focused on publications of the past five years (January 2015 to August 2020) but also included pivotal older publications if appropriate.'
BPD occurs in approximately 1-3% of adolescents and adults. The clinical presentation can be quite diverse, but it usually involves three core domains. Individuals with BPD have intense and rapidly changing emotions, which involves the tendency to act impulsively in stressful situations. They further experience unstable and inconsistent identity. Problems in interpersonal relations are the third core domain, which includes rejection sensitivity and trust issues. Behaviours such as repetitive self-harm, chronic suicidal thoughts, and aggressive outbursts can be understood as a maladaptive coping behavior to deal with these core problems. It is assumed that a complex interplay of vulnerability factors (e.g., emotional hypersensitivity) and developmental factors (e.g., traumatic stress) interferes with the normal development of emotion regulation, identity and interpersonal functioning.
Specialist treatment is not always accessible or affordable for patients, particularly those from lower socioeconomic status. 'We need more research into “stage-oriented treatment” with short, self-help–oriented programs for milder cases and lengthier complex therapies for more severe cases. So-called stepped care models may help to find appropriate support depending on clinical severity. Individuals in an early stage of the disorder may benefit from family psychoeducation or problem-solving skills, whereas those with persistent BPD symptoms and severe psychosocial impairment should receive intensive specialist psychosocial treatment.'
It is also crucial to involve family members of individuals with BPD since they experience considerable burden. Interventions for family members can help to alleviate the burden and to deal with emotions like shame, guilt or grief.
Early warning signals
Since symptoms of BPD typically onset in early adolescence around age 14, it is crucial to identify early warning signals and to provide early interventions, which may improve the course of the disorder. The validity and reliability of BPD diagnoses has been established for adolescents. Yet, members of this age group are still not regularly screened for BPD in routine clinical practice. Therefore, it is important to raise awareness for BPD in adolescence and to offer psychoeducation and treatment options.
Future research may also focus on the development of possible add/on inventions targeted at emotion regulation problems, existential loneliness, severe alienation, and identity confusion. Online E-health interventions may be a promising tool in this respect as they can be integrated in treatment or offered to people on the waiting-list.
Own diagnostic entity
Another outstanding question concerns the large overlap of BPD with the new International Classification of Diseases 11th Revision (ICD-11) diagnosis of complex Post-traumatic stress disorder (PTSD). Both share symptoms, such as emotion dysregulation, negative self-concept, and interpersonal problems. These symptoms may be the consequence of chronic stress and “complex trauma” (e.g., severe abuse and neglect in childhood, adolescence and adulthood). It is currently discussed whether BPD should be categorized as an own diagnostic entity or as a subcategory of disorders specifically associated with stress.