borderline personality disorder research paper

REVIEW article

Twenty years of research on borderline personality disorder: a scientometric analysis of hotspots, bursts, and research trends.

• 1 Department of Psychology, School of Humanities and Social Sciences, Anhui Agricultural University, Hefei, China
• 2 College of Computing & Informatics, Drexel University, Philadelphia, PA, United States
• 3 Department of Psychology, School of Education, China University of Geosciences, Wuhan, China
• 4 Department of Information Management, Anhui Vocational College of Police Officers, Hefei, China

Borderline personality disorder (BPD), a complex and severe psychiatric disorder, has become a topic of considerable interest to current researchers due to its high incidence and severity of consequences. There is a lack of a bibliometric analysis to visualize the history and developmental trends of researches in BPD. We retrieved 7919 relevant publications on the Web of Science platform and analyzed them using software CiteSpace (6.2.R4). The results showed that there has been an overall upward trend in research interest in BPD over the past two decades. Current research trends in BPD include neuroimaging, biological mechanisms, and cognitive, behavioral, and pathological studies. Recent trends have been identified as “prevention and early intervention”, “non-pharmacological treatment” and “pathogenesis”. The results are like a reference program that will help determine future research directions and priorities.

1 Introduction

Borderline personality disorder (BPD) is a complex and severe psychiatric disorder characterized by mood dysregulation, interpersonal instability, self-image disturbance, and markedly impulsive behavior (e.g., aggression, self-injury, suicide) ( 1 ). In addition, people with BPD may have chronic, frequent, random feelings of emptiness, fear, and so on. These symptoms often lead them to use unhealthy coping mechanisms in response to negative emotions, such as alcohol abuse ( 2 ). BPD has a long course, which makes treatment difficult and may have a negative impact on patients’ quality of life ( 3 ). Due to its clinical challenge, BPD is by far the most studied category of personality disorder ( 4 ). This disorder is present in 1−3% of the general population as well as in 10% of outpatients, 15−20% of inpatients, and 30−60% of patients with a diagnosed personality disorder, and has a suicide rate of up to 10% ( 5 , 6 ). Families of individuals with serious mental illness often experience distress, and those with relatives diagnosed with BPD tend to carry a heavier burden compared to other mental illnesses ( 7 , 8 ). As early as the 20th century, scholars began describing BPD and summarizing its symptoms. However, there was some debate regarding the precise definition of BPD.

In the past few decades, the research community has made remarkable progress in the study of BPD, equipping us with a wider range of perspectives and tools for understanding this intricate condition. However, numerous challenges still remain to be tackled by researchers. Diagnosing BPD is inherently challenging and often more difficult than anticipated. The symptoms of BPD are complex, diverse, and often overlap with those of other mental health conditions. For example, individuals with BPD may experience extreme mood swings similar to those observed in individuals with bipolar disorder ( 9 ); At the same time, they may also be entrenched in long-term depression, making it easy for doctors to initially misdiagnose them with depression ( 10 ). Because these symptoms overlap and interfere with each other, doctors often face the risk of misdiagnosing or overlooking the condition during initial diagnosis. Therefore, researchers are working to develop more accurate and comprehensive diagnostic tools and methods.

According to the “Neuro-behavioral Model” proposed by Lieb ( 1 ), the process of BPD formation is very complex and is determined by the interaction of several factors. The interaction between different factors can be complex and dynamic. Genetic factors and adverse childhood experiences may contribute to emotional disorders and impulsivity, leading to dysfunctional behaviors and inner conflicts. These, in turn, can reinforce emotional dysregulation and impulsivity, exacerbating the preexisting conditions. Genetic factors are an important factor in the development of BPD ( 11 ). Psychosocial factors, including adverse childhood experiences, have also been strongly associated with the development of BPD ( 12 ). Emotional instability and impulsive behavior are even more common in patients with BPD ( 13 ). The current study is based on the “Neuro-behavioral Model” and conducts a literature review of previous scientific research on BPD through bibliometric analysis to reorganize the influencing factors. Through large-sample data analysis, the association between BPD and other diseases is explored, which contributes to further refining this theory’s explanation of the common neurobiological mechanisms among various mental illnesses.

It is worth noting that with the development of BPD, some scholars have conducted bibliometrics studies on BPD to provide insights into this academic field. To date, the current study has identified two published bibliometric studies on the field: One is Ilaria M. A. Benzi and her colleagues’ 2020 metrological analysis of the literature in the field of BPD pathology for the period 1985−2020 ( 14 ). The other is a bibliometric analysis by Taylor Reis and his colleagues of the growth and development of research on personality disorders between 1980 and 2019 ( 15 ). Ilaria M. A. Benzi and her colleagues integrated and sorted out the research results of borderline personality pathology, and revealed the research results and development stages in this field through the method of network and cluster analysis. The results of the study clearly demonstrate that the United States and European countries are the main contributors, that institutional citations are more consistent, and that BPD research is well developed in psychiatry and psychology. At the same time, the development of research in borderline personality pathology is demonstrated from the initial development of the construct, through studies of treatment effects, to the results of longitudinal studies. Taylor Reis and his colleagues used a time series autoregressive moving average model to analyze publishing trends for different personality disorders to reveal their historical development patterns, and projected the number of publications for the period 2024 to 2029. The study finds a trend towards diversity in the research and development of personality disorders, with differences in publication rates for different types of personality disorders, and summarizes the reasons that influence these differences. This may ultimately determine which personality disorders will remain in future psychiatric classifications. These studies have provided valuable insights into the evolution of BPD, focusing primarily on its pathology or a broader personality disorder perspective. While basic bibliometric analyses of these studies have been conducted, there is a need for more in-depth investigations of specific trends in the evolution of BPD and a clearer delineation of emerging research foci. Therefore, in order to enhance the current study, this study extends the analysis to 2022 and utilizes a comprehensive structural variation analysis of the literature using scientometric methods. Building on previous bibliometric studies, we expect to provide new insights and additions to research in this area. At the same time, the research trends and hot topics in the field of BPD are further explored. In addition, several cocitation-based analyses are also carried out in order to better understand citation performance.

2.1 Objectives

One of our goals was to understand the current status and progress of researches on BPD, and to summarize the latest developments and research findings in BPD, such as new treatment methods and disease mechanisms. Through the intuitive presentation of knowledge graphs and other images or data, we aimed to provide clinical practice and research guidance for clinicians, researchers, and policymakers.

Our second goal was to help identify future research directions and priorities, and provide more scientific and systematic research guidance for researchers. For example, by identifying hotspots and associations in certain research areas, we can determine the fields and issues that require further investigations, thus providing clearer directions and focus for researches. Additionally, through bibliometric analysis, we can provide researchers with more targeted and practical research strategies and methods, improving research efficiency and the quality of research outcomes.

2.2 Search strategy and data collection

The selection of appropriate methods and tools in the process of analyzing research information is crucial. Web of Science (WOS) is a popular database for bibliometric analysis that includes numerous respectable and high-impact academic journals. In addition, data information, such as references and citations, is more extensive than other academic databases ( 16 ). Data collection took place on the date of May 10, 2023. The search strategy included the following: topic=“Neuro-behavioral Model” or “borderline characteristics” or “borderline etiology” or “borderline personality disorder”, database selected=WOS Core Collection, time span=2003−2022, index=Science Citation Index Expanded (SCI-EXPENDED) and Social Sciences Citation Index (SSCI). The “Neuro-behavioral Model” serves as a theoretical framework that is useful for explaining the development and pathophysiology of BPD; “borderline characteristics” can describe the related symptoms and features of BPD; “borderline etiology” helps to understand the factors that contribute to the development of BPD; “borderline personality disorder” is the most commonly used terms in relevant research. Using these as keywords in title searches can help researchers find researches related to BPD more accurately, facilitating deeper understanding of the characteristics, pathophysiology, etiology, and other aspects of BPD. In the current study, we focused only on two types of literature: articles and review articles, and limited the language to English. After removing all literature unrelated to BPD, a total of 7919 records met the criteria. They were exported in record and reference formats, and saved in plain text file format.

2.3 Data analysis and tools

Bibliometrics was first proposed by Alan Pritchard in 1969, as a method that combines data visualization to analyze publications statistically and quantitatively in specific fields and journals ( 17 ). Bibliometric analysis is a good way to analyze the trend of knowledge structure and research activities in scientific fields over time, and has been widely used in various fields since it was first used ( 18 ). Scientometrics is the application of bibliometrics in scientific fields, and it focuses on the quantitative characteristics and features of science and scientific researches ( 19 ). Compared to traditional literature review studies, visualized knowledge graphs can accurately identify key articles from many publications, comprehensively and systematically combing existing research in a field ( 20 ).

Currently, two important academic indicators are included in research. The impact factor (IF) is used as an indicator of a publication’s impact to assess the quality and importance of the publication ( 21 ). However, some researchers believe that IF has defects such as inaccuracy and misuse ( 22 ). Although many researchers have proposed to replace the impact factor with other indicators, IF is still one of the most effective ways to measure the impact of a journal ( 23 ). The IF published in the 2021 Journal Citation Reports were used. Another indicator is the H-index, which is an important measure of a scholar’s academic achievements. Some researchers consider it as a correction or supplement to the traditional IF ( 24 ).

All data were imported into CiteSpace (6.2.R4) and Scimago Graphica (1.0.30) for analysis. CiteSpace was used to obtain collaboration networks and impact networks. Scimago Graphica was used to construct a network graph of country collaboration. CiteSpace is a Java-based software developed in the context of scientometrics and data visualization ( 25 ). It combines scientific knowledge mapping with bibliometric analysis to determine the progress and current research frontiers in a particular field, as well as predict the development trends in that field ( 26 ). Scimago Graphica is a no-code tool. It can not only perform visualization analysis on communication data but also explore exploratory data ( 27 ). Currently, it is used for visual analysis of national cooperation relationships, displaying the geographic distribution of countries and publication trends.

3.1 Analysis of publication outputs, and growth trend prediction

Annual publications can provide an overview of the evolution of a research area and its progress ( 28 ). We retrieved 7919 articles from the WOS database on BPD between 2003 and 2022, including 6834 research articles and 1085 reviews ( Figure 1 ). As of the search date, these articles had received a total of 289,958 citations, equating to an average of 14,498 citations per year. Over the past two decades, the number of research articles published on BPD has shown a fluctuating upward trend. In addition, citations to these publications have increased significantly. A polynomial curve fit of the literature on BPD clearly indicates a strong correlation between the year of publication and the number of publications ( R 2 = 0.973). The number of research articles on BPD has indeed fluctuated and increased over the past two decades. This observation does, to some extent, indicate an upward trend, probably due to increasing interest in BPD. However, there are other factors to consider as well. For example, the accumulation of data or technological advances, government policies and corporate investment may also affect the direction of BPD research development.

Figure 1 Annual publications, citation counts, and the fitting equation for annual publications in BPD.

3.2 Analysis of co-citation references: clusters and timeline of research

Co-cited references, which are cited by multiple papers concurrently, are considered a crucial knowledge base in any given field ( 28 ). In the current study, CiteSpace clustering was utilized to identify common themes within BPD-related literature. Figure 2 presented a co-citation network of highly cited references between 2003 and 2022, comprising 1163 references. A time slice of 1 was used, with the g -index was set at k =25, which resulted in the identification of 14 clusters representing distinct research themes in BPD. The significant cluster structure is denoted by a modularity value ( Q value) of 0.7974, and the high confidence level in the clusters by an average profile value ( S value) of 0.9176.

Figure 2 Reference co-citation network with cluster visualization in BPD. Trend 1 clinical researches, sub-trend clinical characteristics includes clusters #1, #2, #4, #10, #12; biological mechanisms include clusters #3, #7; nursing treatments includes clusters #0, #8, #13. Trend 2 associations and complications includes clusters #5, #6, #9, #11, #14.

Cluster analysis is performed through CiteSpace. Related clusters are classified into the same trend based on the knowledge of related fields and whether the clusters show similar trends. At the same time, based on the analysis of time series, to identify the movement of one cluster to another. Based on the cluster map of co-cited references on BPD, several different research trends were identified. The first major research trend is clinical research on BPD, which in turn consists of three sub-trends: clinical characterization of BPD, biological mechanisms, and nursing treatment. Of the data obtained, the earliest research on the clinical characterization of BPD began in 1992 with cluster #12, “borderline personality disorder and suicidal behavior” ( S =0.979; 1992). Paul H. Soloff and his colleagues conducted a comparative study of suicide attempts between major depressives and patients with BPD. The aim of this study was to develop more effective intervention strategies for suicide prevention ( 29 ). This cluster was further developed in cluster #4, “nonsuicidal self-injury and suicide” ( S =0.96; 2004). Thomas A. Widiger and Timothy J. Trull proposed a more flexible dimension-based categorization model to overcome the previous drawbacks of personality disorder categorization ( 30 ). Next in cluster #10 “borderline personality disorder and impulsivity” ( S =0.93; 2000), Jim H. Patton and his colleagues revised the Barratt Impulsivity Scale to measure impulsivity to facilitate practical clinical research ( 31 ). Related research continues to evolve into cluster #1 “borderline personality disorder and emotions” ( S =0.87; 2007) and cluster #2 “borderline personality disorder and social cognition” ( S =0.911; 2009), researchers have focused on understanding the causal relationship between BPD traits and factors such as social environment, emotion regulation, and interpersonal evaluative bias, as well as their potential impact ( 32 , 33 ). In the sub-trend of biological mechanisms, two main clusters are involved: cluster #7 “borderline personality disorder and gene-environment interactions” ( S =0.871; 2002) and cluster #3 “borderline personality disorder and neuroimaging” ( S =0.938; 2007). In the related cluster, researchers have found a relationship between BPD and genetic and environmental factors ( 34 ). Researchers have also utilized various external techniques to explore the degree of correlation between the risk of developing BPD and its biological mechanisms, aiming to reveal the complex mechanisms that influence the emergence and development of BPD ( 35 ). In nursing treatment, cluster #8 “treatment of borderline personality disorder “ ( S =0.968; 2001), Silvio Bellino and his colleagues systematically analyzed the current publications on BPD pharmacotherapy research and summarized relevant clinical trials and findings ( 36 ). However, due to the complexity of BPD, there is still a lack of information on the exact efficacy of pharmacotherapy in BPD, and therefore pharmacotherapy remains an area of ongoing development and research. This trend continues to be developed in cluster #0 “borderline personality disorder treatment” ( S =0.887; 2006), which emphasizes the development of novel pharmacotherapies for BPD. Cluster #13 “borderline personality disorder care” ( S =0.997; 2013) mainly focuses on the comprehensive care of people with borderline personality disorder and the education of patients and families. The goal is to improve patients’ quality of life, reduce self-injury and suicidal behavior, and promote full recovery.

The second major research trend is association and comorbidity. This trend first began in cluster #9 “comorbidity and differentiation of disorders” ( S =0.946; 1999). Mary C Zanarini and his colleagues explored the comorbidity of BPD with other psychiatric disorders on Axis I ( 37 ). Cluster #14 “borderline personality disorder and psychosis” ( S =0.966; 2003) also explored symptoms associated with BPD ( 38 ). This trend continues, with researchers studying BPD research in cluster #11 “borderline personality disorder” ( S =0.935; 2004) and cluster #5 “borderline personality disorder research” ( S =0.881; 2007) ( 39 , 40 ). In addition, cluster #6 “borderline personality disorder in adolescents” ( S =0.894; 2011) points out that the focus of BPD research is increasingly shifting towards adolescents ( 41 ).

Figure 3 showed the time span and research process of the developmental evolution of these different research themes. The temporal view reveals the newest and most active clusters, namely #0 “dialectical behavior therapy”, #1 “daily life”, and #2 “social cognition”, which have been consistently researched for almost a decade. Cluster #0 “dialectical behavior therapy” has the largest number and the longest duration, lasting almost 10 years. Similarly, this article by Rebekah Bradley and Drew Westen on understanding the psychodynamic mechanisms of BPD from the perspective of developmental psychopathology has the largest node ( 34 ).

Figure 3 Reference co-citation network with timeline visualization in BPD.

3.3 Most cited papers

The top 10 highly cited papers on BPD research were presented in Table 1 . The most cited paper, by Marsha M. Linehan and colleagues, focus on the treatment of suicidal behavior in BPD ( 42 ). The transition between suicidal and non-suicidal self-injurious behavior in individuals with BPD has attracted researchers’s attention, mainly in cluster #4 “nonsuicidal self-injury and suicide” ( 52 ). The second is the experimental study by Josephine Giesen-Bloo and his colleagues on the psychotherapy of BPD ( 43 ). In cluster #0 “borderline personality disorder treatment” and Cluster #8 “treatment of borderline personality disorder”, researchers strive to find non-pharmacological approaches with comparable or enhanced therapeutic effects. This was followed by Sheila E. Crowell and her colleagues’ study of the biological developmental patterns of BPD ( 44 ). Research on the biological mechanisms and other contributing factors of BPD, including #7 “borderline personality disorder and gene-environment interactions” have been closely associated with the development of BPD ( 53 ).

Table 1 Top 10 cited references that published BPD researches.

3.4 Burst analysis and transformative papers

The “citation explosion” reflects the changing research focus of a field over time and indicates that certain literature has been frequently cited over time. Figure 4 showed the top 9 references with the highest citation intensity. The three papers with the greatest intensity of outbursts during the period 2003−2022 are: The first is the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders ( 54 ). In the second article, Vijay A. Mittal and Elaine F. Walker discuss key issues surrounding dyspraxia, tics, and psychosis that are likely to appear in an upcoming edition of the Diagnostic and Statistical Manual of Mental Disorders ( 39 ). In addition, Ioana A. Cristea and colleagues conducted a systematic review and meta-analysis to evaluate the effectiveness of psychotherapy for borderline personality disorder ( 55 ).

Figure 4 References with the strongest occurrence burst on BPD researches. Article titles correspond from top to bottom: Mittal VA et al. Diagnostic and Statistical Manuel of Mental Disorders; Linehan MM et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder; Giesen-Bloo J et al. Outpatient psychotherapy for borderline personality disorder: Randomized trial of schema-focused therapy vs transference-focused psychotherapy; Clarkin Jf et al. Evaluating three treatments for borderline personality disorder: A multiwave study; Grant BF et al. Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions; Leichsenring F et al. Borderline personality disorder; American Psychiatric Association, DSM-5 Task Force. Diagnostic and statistical manual of mental disorders: DSM-5™ (5th ed.); Cristea IA et al. Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis; Gunderson JG et al. Borderline personality disorder.

Structural variation analysis can be understood as a method of measuring and studying structural changes in the field, mainly reflecting the betweenness centrality and sigma of the references. The high centrality of the reference plays an important role in the connection between the preceding and following references and may help to identify critical points of transformation, or intellectual turning points. Sigma values, on the other hand, are used to measure the novelty of a study, combining a combination of citation burst and structural centrality ( 56 ). Table 2 listed the top 10 structural change references that can be considered as landmark studies connecting different clusters. The top three articles with high centrality are the studies conducted by Milton Z. Brown and his colleagues on the reasons for suicide attempts and non-suicidal self-injury in BPD women ( 57 ); the research by Nelson H. Donegan and his colleagues on the impact of amygdala on emotional dysregulation in BPD patients ( 59 ); and the fMRI study by Sabine C. Herpertz and her colleagues on abnormal amygdala function in BPD patients ( 61 ). In addition, publications with high sigma values are listed. They are Larry J. Siever and Kenneth L. Davis on psychobiological perspectives on personality disorders ( 58 ); Ludger Tebartz van Elst and his colleagues on abnormalities in frontolimbic brain functioning ( 60 ); and Marsha M. Linehan on therapeutic approaches in BPD research ( 62 ). These works are recognized as having transformative potential and may generate some new ideas.

Table 2 Top 7 betweenness centrality and stigma references.

3.5 Analysis of authors and co-authors

Figure 5 showed a map of the co-authorship network over the last two decades. In total, 10 different clusters are shown, each of which gathers co-authors around the same research topic. For example, the main co-authors of cluster #0 “remission” are Christian Schmahl, Martin Bohus, Sabine C. Herpertz, Timothy J. Trull and Stefan Roepke. More recently, the three authors with the greatest bursts of research have been Mary C. Zanarini, Erik Simonsen, and Carla Sharp. As shown in Table 3 , the three most published authors are Martin Bohus (145 publications; 1.83%; H-index=61), Mary C. Zanarini (144 publications; 1.82%; H-index=80) and Christian Schmahl (142 publications; 1.79%; H-index=54).

Figure 5 Top 10 clusters of coauthors in BPD (2003–2023). Selection Criteria: Top 10 per slice. Clusters labeled by keywords. The five authors with the highest number of publications in each cluster were labeled.

Table 3 Top 10 authors that published BPD researches.

3.6 Analysis of cooperation networks across countries

The top 10 countries in terms of number of publications in the BPD are added in Table 4 . With 3,440 published papers, or nearly 43% of all BPD research papers, the United States is the leading contributor to BPD research. This is followed by Germany (1196 publications; 15.10%) and the United Kingdom (1020 publications; 9.32%). Centrality refers to the degree of importance or centrality of a node in a network and is a measure of the importance of a node in a network ( 69 ). In Table 4 the United States is also has the highest centrality (0.43). Figure 6 shows the geographic collaboration network of countries in this field, with 83 countries contributing to BPD research, primarily from the United States and Europe.

Table 4 Top 10 countries that published BPD researches.

Figure 6 Map of the distribution of countries/regions engaged in BPD researches.

3.7 Analysis of the co-author’s institutions network

Table 5 listed the top 10 institutions ranked by the number of publications. The current study shows that Research Libraries Uk is the institution with the highest number of publications, with 766 publications (9.67%). The subsequent institutions are Harvard University and Ruprecht Karls University Heidelberg with 425 (5.37%) and 389 (4.91%) publications respectively. As can be seen from Table 4 , six of the top 10 institutions in terms of number of publications are from the United States. In part, this reflects the fact that the United States institutions are at the forefront of the BPD field and play a key role in it.

Table 5 Top 10 institutions that published BPD researches.

3.8 Analysis of journals and cited journals

If the more papers are published in a particular journal and at the same time it has a high number of citations, then it can be considered that the journal is influential ( 70 ). The top 10 journals in the field of BPD in terms of number of publications are listed in Table 6 . Journal of Personality Disorders from the Netherlands published the most literature on BPD with 438 (5.53%; IF=3.367) publications. This was followed by two journals from the United States: Psychiatry Research and Personality Disorders Theory Research and Treatment , with 269 (3.40%, IF=11.225) and 232 (2.93%; IF=4.627) publications, respectively. Among the top 10 journals in terms of number of publications published, Psychiatry Research has the highest impact factor.

Table 6 Top 10 journals that published BPD researches.

3.9 Analysis of keywords and keywords co-occurrence

Keyword co-occurrence analysis can help researchers to understand the research hotspots in a certain field and the connection between different research topics. As shown in Figure 7 , all keywords can be categorized into 9 clusters: cluster #0 “diagnostic interview”, cluster #1 “diagnostic behavior therapy”, cluster #3 “social cognition”, cluster #4 “emotional regulation”, cluster #5 “substance use disorders “, cluster #6 “posttraumatic stress disorder”, cluster #7 “suicide” and cluster #8 “double blind”. These keywords have all been important themes in BPD research during the last 20 years.

Figure 7 The largest 9 clusters of co-occurring keywords. The top 5 most frequent keywords in each cluster are highlighted.

Keyword burst is used to identify keywords with a significant increase in the frequency of occurrence in a topic or domain, helping to identify emerging concepts, research hotspots or keyword evolutions in a specific domain ( 71 ). Figure 8 presented the top 32 keywords with the strongest citation bursts in BPD from 2003−2023. Significantly, the keywords “positron emission tomography” (29.63), “major depression” (27.93), and “partial hospitalization” (27.1) had the highest intensity of outbreaks.

Figure 8 Keywords with the strongest occurrence burst on BPD researches.

4 Discussion

4.1 application of the “neuro-behavioral model” to bpd research.

In this study, we chose specific search terms, particularly “Neuro-behavioral Model”, to efficiently collect and analyze BPD research literature related to this emerging framework. This choice of keyword helped narrow the research scope and ensure its relevance to our objectives. However, it may have excluded some studies using different terminology, thus limiting comprehensiveness. In addition, the ‘Neuro-behavioral Model’, as an interdisciplinary field, encompasses a wide range of connotations and extensions, which also poses challenges to our research. This undoubtedly adds to the complexity of the study, yet it enhances our understanding of the field’s diversity.

4.2 Summary of the main findings

This current study utilized CiteSpace and Scimago Graphic software to conduct a comprehensive bibliometric analysis of the research literature on BPD. The study presented the current status of research, research hotspots, and research frontiers in BPD over the past 20 years (2003–2022) through knowledge mapping. The scientific predictions of future trends in BPD provided by this study can guide researchers interested in this field. This study also uses bibliometrics analysis method to show the knowledge structure and research results in the field of BPD, as well as the scientific prediction of the future trend of BPD research.

4.3 Identification of research hotspots

Previous studies have indicated an increasing trend in the number of papers focused on BPD, with the field gradually expanding into various areas. The first major research trend involves clinical studies on BPD. This includes focusing on emotional recognition difficulties in BPD patients, as well as studying features related to suicide attempts and non-suicidal self-injury. Clinical recognition and confirmation of BPD remains low, mainly related to the lack of clarity of its biological mechanisms ( 72 ). The nursing environment for BPD patients plays an important role in the development of the condition, which has become a focus of research. Researchers are also exploring the expansion of treatment options from conventional medication to non-pharmacological approaches, particularly cognitive-behavioral therapy. Another major research trend involves the associations and complications of BPD, including a greater focus on the adolescent population to reduce the occurrence of BPD starting from adolescence. Additionally, many researchers are interested in the comorbidity of BPD with various clinical mental disorders.

4.4 Potential trends of future research on BPD

Based on the results of the above studies and the results of the research trends in the table of details of the co-citation network clusters in 2022 ( Table 7 ), several predictions are made for the future trends in the field of BPD. In Table 7 , there were some trends related to previous studies, including #1”dialectical behavior therapy”, #7 “dialectical behavior therapy” ( 73 ), #5 “mentalization” ( 74 ), and #9 “non-suicidal self-injury” ( 75 ). The persistence of these research trends is evidence that they have been a complex issue in this field and a focus of researchers. The recently emerged turning point paper provides a comprehensive assessment about BPD, offering practical information and treatment recommendations ( 76 ). New research is needed to improve standards and suggest more targeted and cost-effective treatments.

Table 7 The references co-citation network cluster detail (2022).

BPD symptoms in adolescents have been shown to respond to interventions with good results, so prevention and intervention for BPD is warranted ( 77 ). This trend can be observed in #3 “youth” ( 78 ). Mark F. Lenzenweger and Dante Cicchetti summarized the developmental psychopathology approach to BPD, one of the aims of which is to provide information for the prevention of BPD ( 79 ). Prevention and early intervention of BPD has been shown to provide many benefits, including reduced occurrence of secondary disorders, improved psychosocial functioning, and reduced risk of interpersonal conflict ( 80 ). However, there are differences between individuals, and different prevention goals are recommended for adolescents at risk for BPD. Therefore, prevention and early intervention for BPD has good prospects for the future.

The etiology of BPD is closely related to many factors, and its pathogenesis is often ignored by clinicians. The exploration of risk factors has been an important research direction in the study. Some studies have found that BPD is largely the product of traumatic childhood experiences, which may lead to negative psychological effects on children growing up ( 81 ). It has also been found that the severity of borderline symptoms in parents is positively associated with poor parenting practices ( 82 ). Future researches need to know more about the biological-behavioral processes of parents in order to provide targeted parenting support and create a good childhood environment.

Because pharmacotherapy is only indicated for comorbid conditions that require medication, psychotherapy has become one of the main approaches to treating BPD. The increasingly advanced performance and availability of contemporary mobile devices can help to take advantage of them more effectively in the context of optimizing the treatment of psychiatric disorders. The explosion of COVID-19 is forcing people to adapt to online rather than face-to-face offline treatment ( 83 ). The development of this new technology will effectively advance the treatment of patients with BPD. Although telemedicine has gained some level of acceptance by the general public, there are some challenges that have been reported, so further research on the broader utility of telemedicine is needed in the future.

4.5 The current study compares with a previous bibliometric review of BPD

As mentioned earlier, there have been previous bibliometric studies conducted by scholars in the field of BPD. This paper focuses more on BPD in personality disorders than the extensive study of personality disorders as a category by Taylor Reis et al. ( 15 ). The results of both studies show an increasing trend in the number of publications in the field of BPD, suggesting positive developments in the field. Taylor Reis et al. focused primarily on quantifying publications on personality disorders and did not delve into other specific aspects of BPD. Ilaria M.A. Benzi et al. focused on a bibliometric analysis of the pathology of BPD ( 14 ). They give three trends for the future development of BPD pathology: first, the growing importance of self-injurious behavior research; second, the association of attention deficit hyperactivity disorder with BPD and the influence of genetics and heritability on BPD; and third, the new focus on the overlap between fragile narcissism and BPD. The study in this paper also concludes that there are three future development directions for BPD: first, the prevention and early intervention of BPD; second, the non-pharmacological treatment of BPD; and third, research into the pathogenesis of BPD. Owing to variations in research backgrounds and data sources, the outcomes presented in the two studies diverge significantly. Nevertheless, both contributions hold merit in advancing the understanding of BPD. In addition to this, this paper also identifies trends in BPD over the past 20 years: the first trend is the clinical research of BPD, which is specifically subdivided into three sub-trends; the second trend is association and comorbidity. The identification of these trends is important for understanding the disorder, improving diagnosis and treatment, etc. Structural variant analysis also features prominently in the study. The impact of literature in terms of innovativeness is detected through in-depth mining and analysis of large amounts of literature data. This analysis is based on research in the area of scientific creativity, especially the role and impact of novel reorganizations in creative thinking. Structural variation analysis is precisely designed to find and reveal embodiments of such innovative thinking in scientific literature, enabling researchers to more intuitively grasp the dynamics and cutting-edge advances in the field of science.

5 Limitations

However, it must be admitted that our study has some limitations. The first is the limited nature of data resources. The data source for our study came from only one database, WOS. Second, the limitation of article type. Search criteria are limited to papers and reviews in SCI and SSCI databases. Third, the effect of language type. In the current study, only English-language literature could be included in the analysis, which may lead us to miss some important studies published in other languages. Fourth, limitations of research software. Although this study used well-established and specialized software, the results obtained by choosing different calculation methods may vary. Finally, the diversity of results interpretation. The results analyzed by the software are objective, but there is also some subjectivity in the interpretation and analysis of the research results. While we endeavor to be comprehensive and accurate in our research, the choice of search terms inevitably introduces certain limitations. Using “Neuro-behavioral Model” as the search term enhances the study’s relevance, but it may also cause us to miss significant studies in related areas. This limits the generalizability and replicability of our results. Furthermore, the inherent complexity and diversity of neurobehavioral models might introduce subjectivity and bias in our interpretation and application of the literature. Although we endeavored to reduce bias via multi-channel validation and cross-referencing, we cannot entirely eliminate its potential impact on our findings.

6 Conclusion

Overall, a comprehensive scientometrics analysis of BPD provides a comprehensive picture of the development of this field over the past 20 years. This in-depth examination not only reveals research trends, but also allows us to understand which areas are currently hot and points the way for future research efforts. In addition, this method provides us with a framework to evaluate the value of our own research results, which helps us to more precisely adjust the direction and strategy of research. More importantly, this in-depth analysis reveals the depth and breadth of BPD research, which undoubtedly provides valuable references for researchers to have a deeper understanding of BPD, and also provides a reference for us to set future research goals. In short, this scientometrics approach gives us a window into the full scope of BPD research and provides valuable guidance for future research.

Author contributions

YL: Data curation, Formal analysis, Investigation, Methodology, Software, Visualization, Writing – original draft, Writing – review & editing. CC: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. YZ: Validation, Visualization, Writing – review & editing. NZ: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. SL: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. SL is supported by the Outstanding Youth Program of Philosophy and Social Sciences in Anhui Province (2022AH030089) and the Starting Fund for Scientific Research of High-Level Talents at Anhui Agricultural University (rc432206).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: neuro-behavioral model, borderline personality disorder, BPD, bibliometric, Scimago Graphica

Citation: Liu Y, Chen C, Zhou Y, Zhang N and Liu S (2024) Twenty years of research on borderline personality disorder: a scientometric analysis of hotspots, bursts, and research trends. Front. Psychiatry 15:1361535. doi: 10.3389/fpsyt.2024.1361535

Received: 12 January 2024; Accepted: 19 February 2024; Published: 01 March 2024.

Reviewed by:

Copyright © 2024 Liu, Chen, Zhou, Zhang and Liu. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Shen Liu, [email protected] ; Chaomei Chen, [email protected] ; Na Zhang, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

• Open access
• Published: 15 February 2023

Developmental predictors of young adult borderline personality disorder: a prospective, longitudinal study of females with and without childhood ADHD

• Sinclaire M. O’Grady 1 &
• Stephen P. Hinshaw 1 , 2  

BMC Psychiatry volume  23 , Article number:  106 ( 2023 ) Cite this article

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Research on the precursors of borderline personality disorder (BPD) reveals numerous child and adolescent risk factors, with impulsivity and trauma among the most salient. Yet few prospective longitudinal studies have examined pathways to BPD, particularly with inclusion of multiple risk domains.

We examined theory-informed predictors of young-adult BPD (a) diagnosis and (b) dimensional features from childhood and late adolescence via a diverse (47% non-white) sample of females with ( n  = 140) and without ( n  = 88) carefully diagnosed childhood attention-deficit hyperactivity disorder (ADHD).

After adjustment for key covariates, low levels of objectively measured executive functioning in childhood predicted young adult BPD diagnostic status, as did a cumulative history of childhood adverse experiences/trauma. Additionally, both childhood hyperactivity/impulsivity and childhood adverse experiences/trauma predicted young adult BPD dimensional features. Regarding late-adolescent predictors, no significant predictors emerged regarding BPD diagnosis, but internalizing and externalizing symptoms were each significant predictors of BPD dimensional features. Exploratory moderator analyses revealed that predictions to BPD dimensional features from low executive functioning were heightened in the presence of low socioeconomic status.

Conclusions

Given our sample size, caution is needed when drawing implications. Possible future directions include focus on preventive interventions in populations with enhanced risk for BPD, particularly those focused on improving executive functioning skills and reducing risk for trauma (and its manifestations). Replication is required, as are sensitive measures of early emotional invalidation and extensions to male samples.

Peer Review reports

Borderline personality disorder (BPD) is a persistent and highly impairing condition characterized by intense and pervasive dysregulation of emotion, behavior, and cognition, and a pattern of highly unstable interpersonal relationships [ 1 ]. Individuals with BPD are at extremely high risk for suicide: Up to 10% of individuals with BPD die by suicide each year, 50 times higher than the rate in the general population [ 2 , 3 ]. BPD is also associated with significant personal (i.e., severe psychosocial impairment) and economic/public health (i.e., high rates of underemployment and increased disability) consequences. In fact, although individuals with BPD comprise 1–2% of the general population [ 4 ], they have extremely high rates of health service use, representing up to 20% of individuals receiving inpatient psychiatric treatment and 10% receiving outpatient psychiatric care [ 5 ]. Evidence-based psychological treatments (e.g., Dialectical Behavior Therapy [DBT]) exist for BPD, with strong evidence for efficacy [ 6 ]. Yet they are resource-intensive, with limited availability of expert providers.

Given the high morbidity, mortality, and public health consequences of BPD, an urgent need exists to identify individuals at risk for its development. Relevant research is accumulating. A leading model is Linehan’s Biosocial Theory, which proposes that BPD emerges from transactions between (a) biological vulnerabilities linked with both impulsivity and emotional sensitivity and (b) specific environmental influences such as social invalidation, adversity, or trauma [ 1 , 7 ]. Across development, such combinations give rise to increasingly extreme emotional, behavioral, cognitive, and interpersonal dysregulation for vulnerable individuals. Although empirical research has generated numerous potential risk factors for BPD [ 8 , 9 ], relatively few studies have examined longitudinal pathways to BPD. Identification of such would help strengthen theoretical approaches to the development of BPD. In particular, few studies have examined childhood risk factors for BPD in prospective designs [ 10 ]. Indeed, a 2016 systematic review of risk factors for BPD revealed that risk factors were assessed mainly during early adolescence ( M age  = 13 years), highlighting the need for further investigation of childhood variables and processes [ 9 ]. Such studies could further inform leading theories [ 1 , 11 ] regarding heightened periods of risk (and areas for intervention). In the present investigation, we examine both child and late-adolescent risk factors for later BPD.

Developmental risk factors for BPD

Adhd symptoms.

Impulsivity is a key feature in both the development and presentation of BPD [ 1 ]. It is also a core symptom of attention-deficit hyperactivity disorder (ADHD). In fact, several studies have reported high comorbidity between BPD and ADHD [ 12 , 13 ]. In a large national study of 34,000 adults in the United States, among adults with ADHD the lifetime comorbidity with BPD was 33.7% [ 14 ]. Comorbid ADHD and BPD is a particularly impairing combination [ 12 ]. As for childhood ADHD in relation to adult BPD, most prior research has involved retrospective reports of symptoms. Here, 50–60% of adults with BPD endorsed high levels of ADHD symptoms in childhood [ 15 ]. Philipsen et al. [ 16 ] reported estimates of ADHD among adult women with BPD to be especially high during childhood (41.5%) as compared to adulthood (16.1%). Severity of childhood ADHD symptoms is also associated with higher frequency of personality disorder diagnoses, including BPD, by adulthood [ 17 ].

Hypothesized mechanisms linking ADHD and BPD focus on the interaction, across development, between early impulsivity (a highly heritable trait) and emotion dysregulation, the combination of which, in turn, is shaped by adverse socialization processes (e.g., maltreatment, family reinforcement of emotional lability) [ 11 ]. Proposed neurobiological mechanisms focus on dysfunction in the prefrontal cortex, which is also implicated in emotion regulatory capacities [ 11 , 18 ]. Essentially, early ADHD is hypothesized to confer risk for later BPD because of its associated behavioral dysregulation, promoting environmental reinforcement of maladaptive behaviors and often leading to a pervasive and difficult-to-treat cycle of dysregulation.

As noted above, however, few prospective studies have examined the link between childhood ADHD and later BPD. Notable exceptions (see [ 19 , 20 , 21 ]) reveal that childhood ADHD predicts personality disorders, including BPD, later in life. In a follow-up investigation of “hyperactive” children in young adulthood, Fischer et al. [ 22 ] found that 14% of hyperactive participants met criteria for BPD compared to 3% of their comparison group. Miller et al. [ 13 ] found that among a group with childhood ADHD, 13.5% were diagnosed with BPD in adolescence compared to 1.2% in their comparison group. Furthermore, in the Pittsburgh Girls Study, Stepp et al. [ 18 ] found that high levels of ADHD symptoms during childhood predicted BPD in adolescence (see also [ 23 ] for parallel findings in males). Using latent-class analysis, Thatcher et al. [ 24 ] found that the presence of ADHD symptoms in adolescents, along with substance use disorders, predicted more severe BPD symptoms at young-adult follow-up.

The majority of relevant research has focused on the categorical diagnosis of ADHD rather than the core ADHD dimensions of (a) hyperactivity/impulsivity and (b) inattention. Exceptions include Carlson et al. [ 25 ], who reported data from a prospective, longitudinal study. Teacher-rated severity of both attentional disturbance and behavioral instability (including impulsivity) at age 12 was predictive of adult BPD. This finding was recently replicated by Beeney et al. [ 8 ] in a prospective study of females. Here, parent- and child-reported severity of hyperactivity, impulsivity, and inattention at ages 14–15 predicted BPD at ages 16–18. In a prospective study in twins, maternal- and teacher-rated symptoms of impulsivity at age 5 were related to borderline symptoms at age 12 [ 26 ]. Finally, a recent national, prospective longitudinal study of twins in Sweden found that the association between childhood ADHD symptoms, assessed at age 9 or 12, and adult BPD was primarily driven by impulsivity as opposed to inattention or hyperactivity [ 27 ].

Some adult research has examined presentations (or “types”) of ADHD as related to BPD. Among adults with ADHD, one study reported a higher prevalence rate of comorbid BPD in the Combined presentation of ADHD (ADHD-C; 24%), for which hyperactivity/impulsivity and inattention are key components, compared to comorbid BPD and the Inattentive presentation (ADHD-I; 10%) [ 28 ]. Using latent class analysis with adult females, [ 29 ] found that one pathway to adult BPD emanated from a childhood profile with at least low/moderate levels of hyperactive/impulsive symptoms but low levels of inattentive symptoms.

Finally, considered either categorically or dimensionally, ADHD is clearly linked with increased risk for self-harm (a common feature of BPD), including suicidal behavior and nonsuicidal self-injury (NSSI) (see [ 30 ] for a recent review). Notably, females with ADHD, especially those with high levels of impulsivity as characterized by the ADHD-C presentation, are markedly at risk for attempted suicide and moderate-to-severe NSSI [ 31 ]. Mechanisms linking ADHD with later self-harm include internalizing and externalizing symptoms, as well as peer victimization and peer rejection [ 30 ]. Risk for suicidality is greatly increased when females with ADHD have histories of childhood maltreatment [ 32 ].

Executive functioning (EF)

EF includes goal-oriented cognitive processes such as planning, inhibition, organization, set shifting, working memory, and problem solving. EF deficits have frequently been linked to both ADHD and BPD. For a review of ADHD and EF see Brown [ 33 ]; for a review of BPD and EF, see Garcia-Villamisar et al. [ 34 ]. In general, individuals with BPD show greater EF deficits than typically developing controls [ 35 ]. Individuals with BPD have demonstrated EF deficits in the domains of planning [ 36 , 37 ], working memory [ 38 ], response inhibition and problem solving [ 39 ], and motor inhibition [ 40 ]. Additionally, a meta-analysis revealed that BPD samples with higher rates of comorbid psychopathology performed worse on EF tasks compared to samples with lower rates of comorbidity [ 41 ]. However, few prospective longitudinal studies have examined childhood EF as predictive of later BPD, with the notable exception of Belsky et al. [ 26 ], who found that a composite measure of EF deficits at age 5 was related to BPD symptoms at age 12. Longitudinal investigation of global measures of EF and relations to BPD are critically needed.

Early internalizing and externalizing symptoms

BPD is commonly comorbid with a variety of other psychological disorders, both internalizing and externalizing in nature [ 42 ]. In a systematic review of risk factors for BPD from longitudinal research, Stepp et al. [ 43 ] found that 16 of 19 studies examining internalizing and externalizing psychopathology yielded predictions to later BPD [ 9 ]. That is, dimensions of internalizing (depression) and externalizing (substance use disorder) behaviors in adolescence were associated with subsequent adult BPD symptoms. Indeed, existing literature theorizes that adolescence is a sensitive period for the development of personality disorders—and that personality disorders are preceded by internalizing and externalizing symptoms, not the other way around [ 44 ]. Additionally, some evidence indicates that internalizing and externalizing symptoms in childhood are also related to later BPD symptoms (Belsky et al., [ 26 ]; Geselowitz et al., [ 10 ] but see Burke [ 23 ] & Stepp, [ 18 ], for negative results). Hypothesized mechanisms include emotion dysregulation, which characterizes both internalizing and externalizing psychopathology [ 11 ]. In short, greater understanding of the contribution and developmental timing of internalizing and externalizing symptoms has the potential to inform early interventions to prevent the development of clinically significant BPD symptoms.

Adverse childhood experiences/trauma

Consistent with Linehan’s Biosocial Model, a large body of research has linked a history of environmental invalidation and adversity—and at its extreme, trauma—to the development of BPD [ 1 ]. A history of physical abuse, sexual abuse, and neglect in childhood has long been linked with BPD [ 9 ]. For key prospective longitudinal investigations, see Johnson et al. [ 45 ] and Widom et al. [ 46 ]. Having a parent with psychopathology (including depression and substance use problems) has consistently been found to be a family-related risk factor for BPD [ 9 , 43 ]. Empirical research on the role of parenting and parent–child transactions has been limited [ 47 ], even though key theories posit that transactions between a child’s biological sensitivity and adverse environments (including family factors and parenting) both lead to and maintain BPD symptomology [ 1 ] as well self-harmful behaviors in early adulthood [ 48 ]. High levels of parental depression and parental stress have been linked to BPD [ 49 ], as well as escalation of negative affect and behaviors in mother-daughter conflict situations [ 47 ]. In a prospective, longitudinal study of twins followed from age 5 to 12, children who were physically maltreated or exposed to high maternal negative expressed emotion developed high levels of BPD characteristics [ 26 ], replicating other prospective studies [ 25 , 50 , 51 ]. Still, at least one study revealed that maternal parenting stress in adolescence was not related to adolescent BPD symptom severity [ 52 ]. More research is needed related to transactions between parents and their offspring in terms of the development of BPD [ 53 ].

Present study and hypotheses

In sum, numerous risk factors for BPD have been posited, including ADHD symptom dimensions, low executive functioning, early internalizing and externalizing psychopathology, and childhood adversity and trauma. Yet with the clear exception of Beeney et al. [ 8 ], little research has examined such factors simultaneously, limiting current understanding of the independent or combined contributions of such variables. Also, many studies examine delimited developmental periods (e.g., childhood to adolescence, adolescence to young adulthood). Finally, there is a dearth of research examining the core ADHD dimensions of hyperactivity/impulsivity and inattention as related to risk for later BPD (for a review, see Beauchaine et al. [ 11 ]).

We leverage a sample of females with childhood-diagnosed ADHD and a matched comparison sample followed prospectively from childhood through young adulthood. Consistent with Linehan’s Biosocial Model, recent developmental models of females with ADHD [ 11 ], and extant literature, we hypothesize that both childhood and adolescent (a) hyperactivity/impulsivity and (b) adversity/trauma will emerge as significant risk factors for BPD after adjusting for demographic covariates as well as additional evidence-based risk factors. We also predict that, by late adolescence, internalizing and externalizing symptoms will be significant predictors of young adult BPD. An exploratory aim is to examine if childhood socioeconomic status (SES) moderates associations between predictors of interest and later BPD. We aim to add to the literature on developmental risk factors for BPD to inform existing models of BPD development and prevention approaches.

Procedure and participants

The current data were drawn from an ongoing prospective, longitudinal study of females with and without carefully diagnosed childhood ADHD (see Hinshaw, [ 54 ] for more complete details). This study was approved by the Committee for the Protection of Human Subjects (CPHS) at the University of California, Berkeley. Participants were initially recruited across a metropolitan area from schools, mental health centers, pediatric practices, and through advertisements to participate in research-based, 5-week summer day camps between 1997–1999. Some participants were recruited through the general population whereas others were recruited through the healthcare system. These programs were designed to be enrichment programs featuring classroom and outdoor environments for ecologically valid assessment, rather than intensive therapeutic interventions. All participants and their families underwent a rigorous, multi-step psychodiagnostic assessment process (see below), after which 140 girls with ADHD and 88 age- and ethnicity-matched comparison girls were selected to participate in the childhood program (Wave 1; M age  = 9.6 years, range = 6–12 years).

Following recruitment, all participants were screened for ADHD regardless of if they had already had a pre-established diagnosis. To establish a baseline diagnosis of ADHD, we used the parent-administered Diagnostic Interview Schedule for Children, 4 th ed. (DISC-IV) [ 55 ] and SNAP rating scale [ 52 ], Hinshaw, [ 54 ] for the diagnostic algorithm). Comparison girls could not meet diagnostic criteria for ADHD on either measure. Some comparison girls met criteria for internalizing disorders (3.4%) or disruptive behavior disorders (6.8%) at baseline, yet our goal was not to match ADHD participants on comorbid conditions but instead to obtain a representative comparison group. Exclusion criteria included intellectual disability, pervasive developmental disorders, psychosis, overt neurological disorder, lack of English spoken at home, and medical problems preventing summer camp participation. The final sample included 228 girls with ADHD-Combined presentation ( n  = 93) and ADHD-Inattentive presentation ( n  = 47), plus an age- and ethnicity-matched comparison sample ( n  = 88). Participants were ethnically diverse (53% White, 27% African American, 11% Latina, 9% Asian American), reflecting the composition of the San Francisco Bay Area in the 1990’s. Family income was slightly higher than the median local household income in the mid-1990s, yet income and educational attainment of families were highly variable, ranging from professional families to those receiving public assistance. On average, parents reported being married and living together (65.8%) at the baseline assessment.

Participants were then assessed 5 (Wave 2; M age  = 14.2 years, range = 11–18; 92% retention [data not included from this wave in the present study]), 10 (Wave 3; M age  = 19.6 years, range = 17–24 years; 95% retention), and 16 (Wave 4; M age  = 25.6 years, range = 21–29 years; 93% retention) years later. Data collection included multi-domain, multi-informant assessments, performed in our clinic for most individuals; when necessary, we performed telephone interviews or home visits. We obtained informed consent from all participants (for initial waves: all legal guardians for minors (if age was below 18 years) and parents; for later waves: all participants and parents). Participants received monetary compensation. For additional information see Hinshaw et al. [ 31 , 56 ], Owens et al. [ 57 ].

Predictor variables

Predictor variables were measured during the baseline assessment at Wave 1 (childhood), with repeated assessment of several key measures at Wave 3 (late adolescence), to incorporate risk factors in both developmental periods.

ADHD Symptom Severity: Swanson, Nolan, and Pelham rating scale, 4 th Ed. (SNAP-IV; Swanson, [ 58 ] ). We measured severity of both hyperactivity/impulsivity (SNAP-HI) and inattentive (SNAP-IA) symptoms using an average of parent- and teacher-report (childhood) or parent- and self-report (late adolescence) on a dimensionalized checklist of these two respective symptom domains (9 items for each) to obtain multi-informant composite scores (SNAP-HI: α = 0.950; SNAP-IA: α = 0.968). For example, items included “…this child is forgetful in daily activities” and “…this child blurts out answers to questions before the questions have been completed.” The severity of each symptom was scored 0 (not at all) to 3 (very much). Thus, scores of both hyperactivity/impulsivity and inattention symptoms ranged from 0–27, with higher scores indicating more severe symptomology. The SNAP-IV is a widely used scale of ADHD symptom severity in both research and clinical settings (e.g., MTA Cooperative Group, [ 59 ]). It has good internal consistency and test–retest reliability [ 60 ].

Executive Functioning: Rey Osterrieth Complex Figure (ROCF) [ 61 ]. We measured executive functioning using the ROCF, a laboratory-based cognitive task requesting that an individual copy and later recall a complex image composed of 64 segments. The ROCF measures multiple domains of executive functioning such as planning, inhibitory control, attention to detail, working memory, and organization. It is often considered a more “global” measure of executive functioning [ 62 ]. We analyzed the Copy condition of this task, during which participants are timed as they view the stimulus figure and draw the figure on a blank piece of paper. For scoring, we used the Error Proportion Score (EPS; the ratio of number of errors divided by the total number of segments drawn), a well-validated method of scoring the ROCF, indexing efficiency [ 63 ]. In previous research with this sample, only the Copy condition (versus Delayed Recall condition) differentiated girls with ADHD from our comparison sample at baseline. The ROCF EPS showed the largest effect size ( d  = 0.90) out of all other EF measures in our battery (Hinshaw et al., [ 64 ]; Sami et al., [ 63 ]). As well, childhood EPS predicts later academic and occupational functioning in comparison to other EF measures Miller et al., [ 62 ]).

Internalizing and Externalizing Symptoms: Child Behavior Checklist, Adult Self Report, and Adult Behavior Checklist (CBCL; ASR; ABCL) [ 65 , 66 ] . In childhood, we measured severity of internalizing (α = 0.89) and externalizing (α = 0.93) symptoms via parent-report on the Internalizing and Externalizing scales of the CBCL. In late adolescence, we averaged participant self-report on the Adult Self-Report (ASR) and parent-report on the Adult Behavior Checklist (ABCL) to obtain multi-informant composite scores. The ASR and ABCL are parallel versions of the CBCL for older individuals. We used T -scores ( M  = 50, SD  = 10) as dimensional symptom measures, with scores above 60 indicating elevated/at-risk and scores above 70 indicating clinically significant symptoms. For example, items included: “…. your child feels worthless or inferior” (internalizing) “…your child gets in many fights” (externalizing). The CBCL, ASR, and ABCL have good–excellent validity, test–retest reliability, and internal consistency [ 66 , 67 ].

Parent Psychopathology: Beck Depression Inventory (BDI-I; BDI-II) [ 68 , 69 ] . We measured depressive symptoms of the primary caregiver (typically the mother) using self-report on the BDI-I at Wave 1 and the BDI-II at Wave 3. Mothers rated each of the 21 items on a 4-point severity scale. For example, items included a choice between “1.) I do not feel sad. 2.) I feel sad. 3.) I am sad all the time and I can’t snap out of it. 4.) I am so sad or unhappy I can’t stand it.” Total possible scores could range from 0–63, with higher scores indicating greater severity of depression. The BDI is a widely used and extensively validated self-report measure of depression in adults [ 70 ].

Parenting Stress Due To Dysfunctional Interactions: Parenting Stress Index-Short Form (PSI-SF) [ 71 ] . We measured stress-inducing dysfunctional parent–child interactions using the PSI-SF, a widely used self-report measure assessing stress experienced by parents related to their role as a parent. In particular, we used the 12-item Parental-Child Dysfunctional Interaction (PCDI) subscale which measures a parent’s perception of dysfunction in the parent–child relationship that contributes to the parent’s feelings of parental stress. Participants’ mothers rated each item on a scale from 1 (strongly agree) to 5 (strongly disagree). For example, items included: “My child does not like me or want to be close.” Higher scores indicated higher levels of maternal parenting stress. The PSI-SF has demonstrated good test-test reliability, internal consistency, and validity, with the reliability of the subscales ranging from 0.68 to 0.85 and the internal consistency ranging from 0.80 to 0.87 [ 72 , 73 ]. In our sample, the internal consistency (Cronbach’s alpha) of the Parental-Child Dysfunctional Interaction subscale at Wave 1 and Wave 3 were 0.88 and 0.93 respectively.

Cumulative childhood adversity: Adverse Childhood Experiences questionnaire (ACE) [ 74 ] . We measured cumulative experiences of childhood adversity via retrospective report by on the ACE questionnaire at Wave 4, which assesses experiences of childhood abuse, neglect, and household dysfunction during the first 18 years of life. ACE scores ranged from 0–10, with higher scores indicating experiences of multiple types of childhood adversity. For example, items included: “Did you often or very often feel that no one in your family loved you or thought you were important or special?” The ACE questionnaire is a commonly used measure to assess for the cumulative effect of multiple forms of childhood adversity [ 75 ], and has good reliability and validity [ 76 ]—including at least moderate test–retest reliability of retrospective reports [ 77 ].

Criterion variables

These were measured at Wave 4 (Young Adulthood).

Borderline Personality Disorder Diagnosis. A licensed clinical psychologist or a graduate student in clinical psychology, under close supervision, conducted a clinical interview with participants using the Structured Clinical Interview for DSM-IV-TR (SCID) [ 78 ] and the Borderline Personality Disorder (BPD) module of the SCID-II (SCID-II) [ 79 ]. The SCID-II is a semi-structured interview widely used in both research and clinical practice, with research indicating good to excellent inter-rater reliability [ 80 ]. A participant met criteria for a diagnosis of BPD if the clinician rated the participant at or above threshold on five of the nine symptom traits. A single dichotomous variable (0 or 1) reflected a BPD diagnosis.

Borderline Personality Disorder Dimensional Features. Because both diagnostic interview and self-report measures may yield optimal assessment of BPD [ 81 ], we also included a dimensional measure of BPD in order to assess and validate the categorical measure of BPD. For a large subset of the sample, a 15-item self-report scale was included, based on the BPD module of the Structured Clinical Interview for DSM-5 Axis II disorders (SCID-II) [ 82 ]. However, every participant did not complete this self-report measure, as it was added after data collection began. Additionally, some participants completed only interviews and did not return their packet of questionnaires including this measure. Each item of the measure is rated dichotomously (0 = No, 1 = Yes), so that the total possible score ranged from 0–15, with higher scores indicating more features of BPD. For example, items included: “Have you often become frantic when you thought that someone you really cared about was going to leave you?” This scale is consistent with DSM-5 BPD criteria, and has been used in several other studies, with satisfactory internal reliability (α = 0.81) [ 83 , 84 ].

To ascertain whether domains of impairment were related specifically to BPD status, we added covariates empirically associated with BPD and associated predictors: (1) SES—a composite measure of parent report of family income and maternal education in childhood; (2) parent report of child’s race/ethnicity in childhood; and (3) participant age in young adulthood.

Data analytic plan

Statistical analyses were performed with RStudio, version 1.2.1335. First, we computed descriptive statistics and zero-order correlations across potential predictors, background variables of interest, and young adult BPD (measured both categorically and dimensionally). Second, we conducted a series of (a) binary logistic regressions to test whether each theory-informed predictor independently predicted a young-adult diagnosis of BPD and (b) parallel linear regressions regarding dimensional features of BPD. We calculated effect sizes of Cohen’s d for the dichotomous criterion and R 2 for the dimensional measure. Given the many initial predictors, we deployed the stringent criterion that a predictor be retained for subsequent analyses only if it displayed a medium (or larger) effect size in relation to the respective categorical or dimensional measure of BPD. For Cohen’s d, we considered effect sizes ≧ 0.2 as small, ≧ 0.5 as medium, and ≧ 0.8 as large; for R 2 , we considered ≧ 0.02 as small, ≧ 0.13 as medium, and ≧ 0.26 as large (Cohen, 1988). Third, we tested whether predictors meeting this criterion continued to do so when adjusting for sociodemographic covariates (baseline SES, participant race/ethnicity, and participant age), using (a) binary logistic regressions or (b) linear regressions, respectively.

We added predictors maintaining significance into separate models by developmental period (Model 1 = childhood; Model 2 = late adolescence), Given the small subset with a BPD diagnosis, we used Firth’s penalized likelihood method in binary logistic regressions to minimize bias introduced by several independent variables [ 85 ]. For exploratory moderator analyses, we conceptualized a moderator as a baseline factor that might reveal differential predictor-criterion associations at different levels of the putative moderator [ 86 ]. Our moderator of interest included baseline (Wave 1) socioeconomic status. Understanding that such analyses are non-hypothesis-driven, we placed interaction terms of the putative predictor x SES moderator at the third step of each significant predictor regression model.

Descriptive analyses and correlations

A total of 19 participants met criteria for a diagnosis of BPD. Fourteen (74%) had received a childhood diagnosis of ADHD (χ 2 (3, N  = 199) = 1.1, p  = 0.3, OR : 1.31, CI: 0.79, 2.17), with a majority of them having received a childhood diagnosis of ADHD-C (58%).

Tables 1 , 2 , 3 and 4 present intercorrelations among key variables. Because maternal- and teacher-report of childhood hyperactivity/impulsivity (W1 SNAP-HI), inattention (W1 SNAP-IA), overt aggression (W1 CSBS), and relational aggression (W1 CSBS), plus maternal- and self-report of late adolescent hyperactivity/impulsivity (W3 SNAP-HI), inattention (W3 SNAP-IA), externalizing symptoms (W3 ASR/ABCL), and internalizing symptoms (W3 ASR/ABCL) were highly correlated, we averaged ratings across mother and teacher (childhood) and mother and self (early adulthood) to create a composite score for each domain.

For young-adult categorical BPD diagnoses, significant childhood point biserial correlates included hyperactivity/impulsivity (W1 SNAP-HI; r pb  = 0.17, p  < 0.05), low executive functioning (W1 ROCF; r pb  = 0.22, p  < 0.01), and a history of overall adversity (W4 ACEs; r pb  = 0.32, p  < 0.01) (see Table 1 ). Significant late-adolescent point biserial correlates included hyperactivity/impulsivity (W3 SNAP-HI; r pb  = 0.40, p  < 0.01), inattention (W3 SNAP-IA; r pb  = 0.38, p  < 0.01), externalizing symptoms (W3 ASR/ABCL; r pb  = 0.39, p  < 0.01), internalizing symptoms (W3 ASR/ABCL ; r pb  = 0.34, p  < 0.01), and maternal psychopathology (W3 BDI-II ( r pb  = 0.16, p  < 0.05) (see Table 2 ).

Regarding young-adult dimensionally scored features of BPD, childhood hyperactivity/impulsivity (W1 SNAP-HI; r  = 0.43, p  < 0.01), childhood inattention (W1 SNAP-IA; r  = 0.29, p  < 0.01), low executive functioning (W1 ROCF; r  = 0.25, p  < 0.01), externalizing symptoms (W1 CBCL; r  = 0.36, p  < 0.01), internalizing symptoms (W1 CBCL; r  = 0.24, p  < 0.01), overt aggression (W1 CSBS; r  = 0.38, p  < 0.01), relational aggression (W1 CSBS; r  = 0.32, p  < 0.01), negative peer nominations (W1 Peer Report; r  = 0.35, p  < 0.01), and a cumulative history of childhood adversity (W4 ACEs; r  = 0.47, p  < 0.01) were significant correlates. Late adolescent hyperactivity/impulsivity (W3 SNAP-HI; r  = 0.52, p  < 0.01), inattention (W3 SNAP-IA; r  = 0.43, p  < 0.01), low executive functioning (W3 ROCF;; r  = 0.20, p  < 0.05), externalizing symptoms (W3 ASR/ABCL; r  = 0.63, p  < 0.01), internalizing symptoms (W3 ASR/ABCL ; r  = 0.57, p  < 0.01), maternal psychopathology (W3 BDI-II; r  = 0.25, p  < 0.01), and maternal parenting stress due to dysfunctional interactions (W3 PSI-PCDI; r  = 0.23, p  < 0.05) were all significantly correlated with young adult BPD features (Table 4 ).

Predictors of young adult BPD diagnosis

In the binary logistic regressions with Firth’s penalized likelihood method, conducted to assess independent predictors of the dichotomous outcome of meeting (vs. not meeting) diagnostic criteria for BPD in young adulthood, we initially tested whether each predictor of interest was significantly associated with BPD, followed by inclusion of (a) covariates and (b) other significant predictor variables according to developmental period (Table 5 ).

Among childhood predictors, hyperactivity/impulsivity ( p  < 0.05; d  = 0.58) and low executive functioning ( p  < 0.01; d  = 0.76) each predicted BPD diagnostic status in young adulthood, but only low executive functioning maintained significance after adjusting for covariates ( p  < 0.05). As well, the childhood ACE score was a significant predictor, even with adjustment for covariates ( p  < 0.001; d  = 1.14). Regarding for late-adolescent predictors, hyperactivity/impulsivity ( p  < 0.001; d  = 1.45), inattention ( p  < 0.001; d  = 1.36), externalizing ( p  < 0.001; d  = 1.41), and internalizing ( p  < 0.001; d  = 1.23) symptoms each predicted young adult BPD, adjusting for covariates. Maternal psychopathology did not survive inclusion of covariates ( p  = 0.093).

Finally, we entered all predictors with a medium or larger effect size (Cohen’s d ≧ 0.5) that had maintained significance after inclusion of covariates into models divided by developmental period. In childhood, low executive functioning ( p  = 0.012) and the ACE score maintained significance ( p  = 0.003). In the late-adolescent predictor model, only inattentive symptoms maintained marginal significance ( p  = 0.059), but hyperactivity/impulsivity ( p  > 0.05), internalizing symptoms ( p  > 0.05), and externalizing symptoms ( p  > 0.05) did not.

Predictors: Young adult dimensional BPD features

Via linear regressions, childhood hyperactivity/impulsivity ( p  < 0.001; R 2  = 0.182), inattention ( p  < 0.001; R 2  = 0.079), low executive functioning ( p  = 0.004; R 2  = 0.054), externalizing symptoms ( p  < 0.001; R 2  = 0.121), internalizing symptoms ( p  = 0.004; R 2  = 0.051), overt aggression ( p  < 0.001; R 2  = 0.137), relational aggression ( p  < 0.001; R 2  = 0.094), negative peer nominations ( p  < 0.001; R 2  = 0.114), and maternal psychopathology ( p  = 0.045; R 2  = 0.020) independently predicted young-adult features of BPD. Of these, only childhood hyperactivity/impulsivity ( p  < 0.001), inattention ( p  < 0.001), externalizing symptoms ( p  < 0.001), internalizing symptoms ( p  < 0.05), overt aggression ( p  < 0.001), relational aggression ( p  < 0.001), and negative peer nominations ( p  < 0.001) maintained significance after adjusting for covariates. Maternal parenting stress due to dysfunctional interactions became significant after adjusting for covariates ( p  < 0.05). The ACE score significantly predicted young adult BPD features ( p  < 0.001; R 2  = 0.213), even after adjusting for covariates ( p  < 0.001).

For late-adolescent predictors, hyperactivity/impulsivity ( p  < 0.001; R 2  = 0.265), inattention ( p  < 0.001; R 2  = 0.177), low executive functioning ( p  < 0.05; R 2  = 0.033), externalizing symptoms ( p  < 0.001; R 2  = 0.398), internalizing symptoms ( p  < 0.001; R 2  = 0.317), maternal psychopathology ( p  < 0.01; R 2  = 0.053), and maternal parenting stress due to dysfunctional interactions ( p  < 0.05; R 2  = 0.043) each independently predicted features of BPD in young adulthood. Of these, hyperactivity/impulsivity ( p  < 0.001), inattention ( p  < 0.001), externalizing symptoms ( p  < 0.001), internalizing symptoms ( p  < 0.001), maternal psychopathology ( p  < 0.05), and maternal parenting stress due to dysfunctional interactions ( p  < 0.01) maintained significance after adjusting for covariates. Low executive functioning did not.

Finally, we entered predictors with a medium (or above) effect size ( R 2 ≧ 0.13)—that had maintained significance after inclusion of covariates—into separate models by developmental period. In childhood, only childhood hyperactivity/impulsivity ( p  < 0.01) and the ACE score maintained significance ( p  < 0.001), but overt aggression did not ( p  > 0.05). As for late-adolescent predictors, only externalizing ( p  < 0.001) and internalizing symptoms ( p  < 0.01) maintained significance—but not hyperactivity/impulsivity ( p  > 0.05) or inattention ( p  > 0.05).

Exploratory moderator analyses

Regarding categorical young adult BPD diagnosis, no predictor x moderator interactions emerged as statistically significant. For young adult dimensional BPD features, only an interaction between (a) low childhood executive functioning (predictor) and (b) low childhood socioeconomic status (moderator) (W1 SES; Δ R 2  = 0.022, p  < 0.05) emerged as statistically significant. Here, it was the combination of low executive functioning and low baseline SES that predicted higher levels of BPD dimensional features.

Leveraging a well-characterized longitudinal female sample with and without carefully diagnosed childhood ADHD, we examined theory-informed predictors of young adult BPD—considered both categorically and dimensionally—from childhood and late-adolescent timespans. Although we emphasize caution regarding interpretation of findings due to our small sample size, this investigation extends research from our laboratory on developmental predictors of self-harm behaviors [ 87 ] to include borderline personality disorder as a criterion measure. We note that individuals with BPD—a condition characterized by intense and pervasive dysregulation of emotion, behavior, cognition, and relationships—may or may not engage in self-harm.

First, regarding our categorical measure of BPD, using binary logistic regressions with correction for small sample size, we found that—as hypothesized—a cumulative history of childhood adversity, as measured by the ACE score, predicted BPD diagnosis. Low EF in childhood was also a significant predictor, even after adjusting for ACE scores and demographic covariates. Regarding late-adolescent predictors, hyperactivity/impulsivity, inattention, internalizing, and externalizing symptoms each independently predicted young adult BPD diagnosis after adjusting for covariates, but maternal depression did not. In stringent analyses accounting for all independently significant late adolescent predictors, only symptoms of inattention were independently (albeit marginally) related to young adult BPD diagnosis.

Second, with respect to our dimensional measure of BPD features, we found—consistent with hypotheses—that both childhood hyperactivity/impulsivity and a cumulative history of childhood adversity from the ACE score predicted young adult BPD features, with adjustment for covariates. Furthermore, childhood inattention, externalizing symptoms, internalizing symptoms, overt aggression, relational aggression, negative peer nominations, and maternal parenting stress due to dysfunctional interactions also independently predicted young adult BPD features after adjusting for covariates. Yet in the final model, including all childhood predictors with a medium (or larger) effect size that had survived covariates, only childhood hyperactivity/impulsivity and the ACE score maintained significance. As for late-adolescent predictors of the dimensional outcome, hyperactivity/impulsivity, inattention, externalizing symptoms, internalizing symptoms, maternal psychopathology, and maternal parenting stress due to dysfunctional interactions maintained significance after adjusting for covariates, but low executive functioning did not. In the final analysis, adding all surviving predictors in the same model, only late-adolescent externalizing and internalizing symptoms maintained significance. Finally, as for exploratory moderator analyses, we found an interaction between low childhood executive functioning and low socioeconomic status at baseline was significant, suggesting that socioeconomic disadvantage may compound the predictive effects of low executive functioning with respect to later BPD dimensional scores.

Overall, the child and adolescent predictors of later BPD are largely consistent with those from previous investigations [ 8 , 10 , 18 , 25 , 26 , 43 ], emerging here from a carefully controlled prospective investigation. Regarding ADHD symptoms, almost 75% of women who met criteria for BPD in young adulthood had diagnoses of childhood ADHD, most often characterized by high levels of impulsivity (ADHD-C). This finding is consistent with both cross-sectional and longitudinal research, as well as theoretical models of the developmental course of individuals with high levels of early impulsivity, related to BPD as an end-point [ 11 ].

For ADHD dimensions, our findings add to the limited number of studies examining hyperactive, impulsive, and inattentive symptoms and their severity across development, especially beginning in childhood [ 8 , 25 , 26 , 27 ]. That hyperactivity/impulsivity in childhood and adolescence did not significantly predict later categorical BPD diagnosis was unexpected and may relate to our small sample size. Yet regarding our dimensional measure, when adjusting for covariates and other predictors, hyperactivity/impulsivity in childhood did significantly predict later BPD features. This finding is consistent with the only two other known studies to our knowledge that have examined prospective associations between childhood impulsivity and later BPD [ 26 , 27 ]. Two studies have found prospective prediction from both adolescent hyperactivity/impulsivity and inattention to later BPD [ 8 , 25 ]—along this line, note our marginally significant prediction of categorical BPD from late-adolescent inattentive symptoms: In both Carlson et al. [ 25 ] and a recent machine learning study of 128 variables related to risk for BPD, inattention in adolescence emerged as an important predictor [ 8 ]. Each dimension of ADHD appears to play an important role in the development of BPD symptoms.

The finding linking low EF in childhood to young adult BPD diagnosis is also consistent with previous (yet limited) research. In the only known prospective longitudinal study to date examining childhood EF as predictive of later BPD, a composite measure of EF at age 5 predicted BPD symptoms at age 12 [ 26 ]. When we examined low childhood EF and BPD dimensional features, our findings were not significant. Still, moderator analyses revealed that girls with both low EF and low socioeconomic status were at especially risk for high levels of BPD features. Perhaps difficulties in low EF are related to high or clinically significant BPD in the context of socioeconomic disadvantage.

Regarding internalizing and externalizing symptoms, we found that high levels of each were related to later BPD features after adjusting for other important predictors—but not when we measured BPD categorically. Furthermore, multiple forms of aggression in childhood including both overt and relational aggression, plus negative peer nominations, predicted young adult BPD features, but these findings did not maintain significance in the presence of other important predictors. Thus, symptoms of aggression and peer preference are important in childhood as risk factors for later BPD, yet other factors—childhood hyperactivity/impulsivity and trauma-remain statistically superior. Indeed, there was substantial overlap in our measures of aggression, negative peer nomination, hyperactivity/impulsivity, and broadband externalizing symptoms. Overall, our key findings replicate those from Stepp et al. [ 43 ], who showed that adolescent internalizing and externalizing symptoms predict adult BPD (for additional research, see Belsky et al., [ 26 ]; and Geselowitz et al., [ 10 ]). Adolescence appears to be a particularly sensitive period during which vulnerability for the development of severe and pervasive dysregulation across the lifespan may be realized [ 44 ].

Although maternal psychopathology—plus both child and late-adolescent maternal parenting stress due to dysfunctional interactions—were each independently associated with young adult BPD features after adjusting for covariates, their effect sizes were small. Any implications require replication. Findings from other research indicate that parental invalidation and negative parenting practices may well be stronger predictors [ 53 ].

Consistent with a large body of research linking a history of childhood adversity/trauma with later BPD [ 88 ], we found that a cumulative history of childhood adversity, measured by the ACE scale, was a crucial predictor of both young-adult BPD diagnosis and dimensional features. This measure of cumulative history of childhood adversity is retrospective—and may therefore be better characterized as a subjective experience of childhood trauma rather than objective experiences of childhood trauma. These findings are consistent recent data finding that risk of psychopathology is high among individuals with subjective reports of childhood maltreatment regardless of whether these experiences were validated by objective measures [ 89 ]. As well, the ACE measure we used constitutes the gold standard in the field.

Our results support theories that transactions between dispositional and environmental factors over time can lead to a cycle of dysregulation of emotion, behavior, and cognition as well as difficult interpersonal relationships [ 1 , 11 ]. Indeed, findings support Linehan’s Biosocial Theory plus recent developmental models of females with ADHD [ 11 ]. That is, behaviorally expressed impulsivity may be a risk factor for a range of outcomes, including BPD. As development progresses, children with trait impulsivity may experience childhood trauma—linked with, for example, intergenerational trauma, maladaptive parenting practices (especially in relation to the child’s impulsive behavior), and/or parents’ own behavioral impulsivity—which may then transactionally escalate the development of BPD. The original impulsivity may, via heterotypic continuity, come to be expressed as a combination of internalizing and externalizing dimensions, leading to BPD [ 11 , 90 ]—a suggestion requiring further empirical investigation. Future research should include prospective temporal assessment of these domains, as well as other environmental mediators (e.g., peer relationship influences, substance use) and valid measures of behavioral parental invalidation, to assess multi-factor etiological influences.

Clinical implications

Although our sample size is too small to draw definitive clinical recommendations, we provide several ideas for possible clinical and public health implications, emphasizing caution in interpretation of results related to study limitations (see below for more detail in this regard). First, findings highlight the longstanding effects of early experiences of adversity and trauma. Prevention of these childhood experiences, especially through public health initiatives, cannot be overemphasized. Second, our results reveal the importance including global EF deficits in childhood as indicators of risk for BPD, in addition to the focus on childhood impulsivity. These findings have implications for guiding early clinical assessment and intervention (e.g., through early EF skills training) to prevent later BPD. In short, we highlight the need for interventions before the adolescent period, which appears to be an especially sensitive time of risk [ 11 ].

Children with histories of adversity/trauma and/or deficits in EF could receive interventions targeting emotion dysregulation, a mechanism linked to the development of BPD, such as Dialectical Behavior Therapy for Children (DBT-C) [ 91 ], Parent–Child Interaction Therapy (PCIT) [ 92 ], or creative combinations of these therapies [ 93 ]. Widespread assessment of early risk factors to identify individuals at risk remains a challenge. We also recommend that evidence-based treatments for severe emotion dysregulation (i.e., DBT) include remediation of EF deficits.

Limitations and future directions

Our study has several important limitations. First, our sample size is small for the categorical BPD variable, with only 19 females meeting diagnostic criteria for BPD in young adulthood, clearly limiting statistical power. Note that we used Firth’s penalized likelihood method to statistically account for our small sample [ 94 ]. Furthermore, only a subset of our sample completed the self-report dimensional BPD measure. We emphasize the need for replication and cautious interpretation of findings. Second, we did not have symptom-level data available for our categorical measure of BPD, preventing us from evaluating clinician-assessed dimensions of BPD symptoms. Future research would benefit from examining dimensional severity of BPD symptoms, as well as specific traits, some of which have recently been linked to increased risk for a suicide attempt [ 95 ]. Third, several measures—including those of BPD features, cumulative trauma history, and ADHD (in part) were self-reported—and may thus be subject to bias. Fourth, we were not able to peform mediator analyses and therefore cannot add to the literature on potential “driving” mechanisms between childhood and adulthood (e.g., emotion dysregulation). Fifth, we did not separate predictor symptom domains of hyperactivity vs. impulsivity, as psychometrics are superior when using the full 9-item Hyperactivity/Impulsivity scale. As well, this measure is more consistent with the DSM’s layout of symptoms. Although we support the separation of theses symptoms in future research—see the excellent national analysis by Tiger et al. [ 27 ]—we elected to include the full 9-item scale. Sixth, our measure of externalizing symptoms in late adolescence (ASR, ABCL) included measures of aggression, but given our multiple testing, we did not examine aggression per se during this developmental window. Future research would benefit from examining aggressive symptoms across development, given empirical research and theory linking high levels aggression and peer problems with later BPD [ 11 , 18 ]. Seventh, there is controversy over whether the Rey-Osterrieth Complex Figure Test captures meaningful variance in executive functioning [ 96 ]. It could be that this measure is a better index of visual-motor integration and overall neuropsychological functioning than of executive functioning [ 97 , 98 ]. Future research should investigate different domains of neuropsychological functioning and BPD development. Eighth, there is definitional overlap between ADHD and BPD, given that both are characterized by impulsivity, which could account for some of the present results. Finally, a key limitation is the timing of our BPD measure—we measured BPD only during young adulthood, but some participants may already have met criteria for BPD in adolescence.

Still, key strengths include a carefully diagnosed, ethnically and socioeconomically diverse sample of females; emphasis on multi-domain and multi-informant measures; high sample retention; and a prospective (and ongoing) longitudinal design. Moreover, we included stringent use of covariates and statistical penalization. Finally, we examined multiple domains of risk for BPD simultaneously and included several measures of BPD symptomology.

The current findings add to existing research on developmental pathways to BPD, especially among females with ADHD. Future directions should include replication, further examination of dimensions of both ADHD and EF, and distinct types of traumatic life events across development [ 99 ] as related to later BPD. Sensitive measures of early emotional invalidation are also necessary [ 53 ].

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Adverse childhood experiences scale

Attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder, combined presentation

Attention-deficit/hyperactivity disorder, inattentive presentation

Beck depression inventory

• Borderline personality disorder

Child behavior checklist

Children’s social behavior scale

Executive functioning

Hyperactivity/impulsivity

Inattention

Nonsuicidal self-injury

Parenting stress index

Parent–child dysfunctional interactions

Rey osterrieth complex figure task

Structured clinical interview for DSM disorders

Swanson, Nolan, and Pelham questionnaire

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Acknowledgements

We express gratitude to the young women who have participated in our ongoing investigation, and their families, as well as the members of the Hinshaw lab both past and present who have made this research possible.

Preparation of this research was supported by Grant R01 MH45064 from the National Institute of Mental Health.

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S.M.O. played a lead role in conceptualization and data curation, formal analysis, writing of original draft, and writing of review and editing. S. P. H. played lead role in the original study design, methodology, data collection, as well as supervision of S. M. O., and an equal contribution in the conceptualization, drafting, and critical revision of this work and writing. All authors read and approved the final manuscript.

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S. M. O. is a psychology doctoral student at the University of California, Berkeley studying developmental pathways to self-harm, with emphasis on trait impulsivity, childhood maltreatment, emotion dysregulation, and suicide. S. P. H. is a Distinguished Professor of Psychology at the University of California, Berkeley, and Professor of Psychiatry and Behavioral Sciences at the University of California, San Francisco. He investigates developmental psychopathology and mental illness stigma.

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O’Grady, S.M., Hinshaw, S.P. Developmental predictors of young adult borderline personality disorder: a prospective, longitudinal study of females with and without childhood ADHD. BMC Psychiatry 23 , 106 (2023). https://doi.org/10.1186/s12888-023-04515-3

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Borderline personality disorder: associations with psychiatric disorders, somatic illnesses, trauma, and adverse behaviors

• Ashley E. Tate   ORCID: orcid.org/0000-0002-4523-6960 1 ,
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Psychiatric disorders

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In one of the largest, most comprehensive studies on borderline personality disorder (BPD) to date, this article places into context associations between this diagnosis and (1) 16 different psychiatric disorders, (2) eight somatic illnesses, and (3) six trauma and adverse behaviors, e.g., violent crime victimization and self-harm. Second, it examines the sex differences in individuals with BPD and their siblings. A total of 1,969,839 Swedish individuals were identified from national registers. Cumulative incidence with 95% confidence intervals (CI) was evaluated after 5 years of follow-up from BPD diagnosis and compared with a matched cohort. Associations were estimated as hazard ratios (HR) with 95% CIs from Cox regression. 12,175 individuals were diagnosed with BPD (85.3% female). Individuals diagnosed with BPD had higher cumulative incidences and HRs for nearly all analyzed indicators, especially psychiatric disorders. Anxiety disorders were most common (cumulative incidence 95% CI 33.13% [31.48–34.73]). Other notable findings from Cox regressions include psychotic disorders (HR 95% CI 24.48 [23.14–25.90]), epilepsy (3.38 [3.08–3.70]), violent crime victimization (7.65 [7.25–8.06]), and self-harm (17.72 [17.27–18.19]). HRs in males and females with BPD had overlapping CIs for nearly all indicators. This indicates that a BPD diagnosis is a marker of vulnerability for negative events and poor physical and mental health similarly for both males and females. Having a sibling with BPD was associated with an increased risk for psychiatric disorders, trauma, and adverse behaviors but not somatic disorders. Clinical implications include the need for increased support for patients with BPD navigating the health care system.

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Introduction.

Borderline Personality Disorder (BPD; Diagnostic and Statistical Manual of Mental Disorders [DSM] terminology), or Emotionally Unstable Personality Disorder (International Classification of Diseases [ICD] terminology), is a serious psychiatric disorder estimated to affect 1.7% of the worldwide population [ 1 ]. The core features of this diagnosis include: unstable interpersonal relationships, recurring self-harm, and emotional dysregulation [ 2 ].

Receiving a BPD diagnosis has been repeatedly associated with a high degree of psychiatric and somatic comorbidities, traumatic events, and criminal behavior [ 3 , 4 , 5 ]. These results have shaped the clinical perception and research directions of BPD, however specific estimates across psychiatric disorders, somatic illnesses, trauma, and adverse behavior have never been comprehensively presented in one study. Moreover, the majority of past studies were limited to smaller clinical samples or cross-sectional community samples, which did not allow for unselected samples nor longitudinal data. Additional longitudinal trait-based epidemiological studies have examined BPD symptoms in twins, however, few participants reached the full diagnostic criteria and thus may not be reflective of individuals with severe BPD symptoms [ 6 , 7 ]. Therefore, it is of interest to examine these estimates in a representative and well-powered population-based study in order to provide the context for a BPD diagnosis and reframe misconceptions.

Psychiatric comorbidities are the rule rather than the exception in patients with BPD. A Swedish national study reported that 95.7% of individuals with a BPD diagnosis had a comorbid psychiatric diagnosis [ 8 ]. Mood disorders, post-traumatic stress disorder (PTSD), impulsive disorders, and bipolar disorders are commonly associated with BPD symptoms and diagnosis [ 9 , 10 , 11 ]. Precise estimates for these comorbidities are lacking, especially for rare and serious disorders, e.g., psychotic disorders [ 12 ].

Somatic illnesses

Individuals with BPD use health care services at a higher rate than those with other personality disorders, and even elevated BPD symptoms are associated with receiving disability [ 13 , 14 ]. BPD has been linked to poor somatic health, such as obesity, diabetes, gastrointestinal disease, cardiovascular disease, hypertension, chronic pain, and sexually transmitted infections [ 3 , 15 ]. It is likely that somatic illnesses associated with BPD have been overlooked in smaller studies, for example, infertility [ 16 , 17 ]. Moreover, patients often perceive the severity of their illness worse than reports based on medical records, highlighting the importance of objective measurement [ 18 ].

Trauma and adverse behaviors

Up to 90% of patients with BPD are estimated to have a history of childhood trauma [ 1 ]. BPD has been linked to an increased risk for sexual abuse victimization in adulthood [ 19 ] and physical trauma resulting from accidents [ 3 ]. However, the association between BPD and other trauma types, e.g., death of a family member, is unclear. The relationship between trauma and BPD is theorized to be bidirectional, although the evidence for this is conflicting [ 20 ]. Similar to somatic reports, capturing objective measures of trauma would prevent biases that may arise from self-reports [ 21 ].

The association between violent crime and a BPD diagnosis is well documented, however less literature exists on nonviolent offenses [ 22 ]. It is unclear which nonviolent offenses are predominant in patients with BPD, although it is likely borne from impulsive actions. As recurrent self-harm is a core feature of BPD [ 2 ], we expect the rate of self-harm requiring medical attention to be higher than the general population. However, a precise estimate from a population sample is unknown.

Sex differences

BPD is predominately diagnosed in females, although evidence suggests that this is largely the result of a diagnostic bias [ 23 ]. Moreover, gender differences have been found for symptom expression and comorbidities [ 22 ]. Males have a higher prevalence of substance use disorders and antisocial personality disorder and exhibit symptoms related to aggression; while females show increased rates of risky behavior and an increased prevalence of comorbid mood disorders, eating disorders, and PTSD [ 22 , 24 ]. Males are typically underrepresented in BPD studies, thus potential differences in outcomes and precursors of BPD is of particular importance. Given a diagnostic bias, males would need greater symptom severity in order to be diagnosed, leading to a difference in symptom severity between the sexes. With this, we hypothesize elevated rates across most categories for males with BPD compared to their female counterparts.

Further, this raises etiological questions about the differences between the sexes. With our hypothesis that males with BPD will have more severe symptomatology, we postulate that individuals with a brother diagnosed with BPD will have higher rates of diagnoses and adverse outcomes across all domains compared to those with a sister with a BPD diagnosis, similar to the so-called female protective effect in autism, with the sexes reversed [ 25 ].

Present study

The primary aim of this study was to describe the extent of the association for individuals with BPD and (1) psychiatric disorders, (2) somatic illnesses, and (3) trauma and adverse behaviors in a Swedish nationwide sample. As sensitivity analyses, we examined the temporal order of these associations, sex-specific differences for individuals, and those with siblings diagnosed with BPD.

Materials and methods

Study population.

The study population included individuals born in Sweden between January 1st, 1973 and December 31st, 1993 with a personal identity number and a biological mother identifiable in the register (2,177,075). We excluded individuals with a congenital malformation (113,566), those who died before age 18 (6972), and/or emigrated before age 18 (62,664). Thus, 1,969,839 individuals were included in our study.

Data sources

Swedish personal identity numbers were used to link multiple Swedish registers in order to identify the cohort and create the analyzed variables, termed here as “indicators” (Table  1 ) [ 26 , 27 , 28 , 29 , 30 ]. The National Patient Register (NPR) contains administrative data from in-patient and specialist outpatient care (but not primary care) with diagnosis made by licensed medical doctors. The diagnoses have been externally validated by reviewing a random subset of patient’s medical records with comparison to the received diagnostic code. The positive predictive value of the psychiatric and somatic diagnoses in the register is high; out of the investigated medical records 80% or more retained the stated diagnostic code upon review [ 29 ]. Physical trauma requiring medical attention was found to have an acceptable positive predictive value of 74% [ 30 , 31 ].

BPD diagnosis was defined by receiving an Emotionally Unstable Personality Disorder diagnosis in the NPR (ICD 10th revision: F60.3) by psychiatrists in in- or outpatient psychiatric clinics. In one validation study, structured interviews had been used in 36% of examined personality disorders (including other personality disorders than BPD), as identified from medical charts. However, the positive predictive value, i.e., proportion of diagnoses validated upon review, for the 26 BPD-diagnoses investigated was high regardless if structured interviews had been used or not, between 77% (based on DSM-criteria) and 100% (based on ICD-criteria); inter-rater agreement was between 85% (ICD-criteria) and 100% (DSM-criteria) [ 32 ]. Another validation study based on 70 medical charts with a BPD-diagnosis, and reported a positive predictive value of 81%, with an inter-rater agreement of 93% [ 33 ].

The indicators in our study were selected based on an existing data linkage, which contains a subset of all ICD-codes (Supplementary Table  1 ). Indicators were placed into three groups: psychiatric disorders, somatic illnesses, and trauma and adverse behaviors (Supplementary Tables  2 – 4 ). As a sensitivity analysis, we analyzed the three most common subcategories for umbrella indicators with many subtypes, e.g., autoimmune disorders. Adverse behaviors included violent/nonviolent crime and self-harm. Trauma included accidents requiring medical attention, violent crime victimization requiring medical attention, death of a close family member, and childhood neighborhood quality.

We only considered time of the first observed event for all indicators, except for childhood poverty and neighborhood quality.

The study was approved by the Regional Ethics Committee in Stockholm, Sweden (Dnr 2013/862 31/5). As our study participants were non-identifiable, no informed consent was needed by Swedish law.

Statistical analysis

Cumulative incidence.

First, we estimated cumulative incidence for those with and without a BPD diagnosis in order to quantify the associations between BPD and the indicators on an absolute scale. Each patient with BPD was matched with ten individuals not diagnosed with BPD on birth year and sex. Follow up for individuals with BPD began at the date of the first observed BPD diagnosis and continued until the end of follow-up, December 31, 2013, this date was also used for their matched non-exposed individuals. We calculated 5-year cumulative incidence, interpreted as the probability of the event occurring within 5 years, while accounting for censoring. We used Kaplan-Meier estimation to estimate the cumulative incidence as 1 minus the survival function.

Associations between BPD diagnosis and the indicators

To quantify the association between BPD and our indicators, hazard ratios (HR) with 95% confidence intervals (CI) were obtained using sex-stratified Cox regression. Age was used as an underlying time score and we adjusted for birth cohort (1973–1977, 1978–1982, 1983–1987, and 1988–1993). BPD diagnosis was treated as a binary, time-constant, exposure regardless of when the diagnosis occurred. We followed each individual from birth or the start of ICD-9, January 1, 1987, until the first instance of either death, emigration, indicator occurrence, or end of follow-up. We did not account for competing risks, since standard methods introduce changes in the association dependent on whether the exposure is associated with the competing outcome [ 34 ].

We adjusted the analysis for multiple testing according to Benjamini–Hochberg method, with an alpha of 0.05, we obtained a false discovery rate p value threshold of 8.34 · 10 −58 for the main analysis and 0.04 for secondary analyses [ 35 ].

Secondary analyses

Sex-separated and sibling analysis.

To evaluate potential differences between males and females diagnosed with BPD, we repeated the cumulative incidence-, association-, and time-varying analyses by analyzing males and females separately. To investigate potential etiological differences, we repeated the association analyses among men and women separately, split by exposure being having a full sister or having a full brother with a BPD diagnosis.

Time-varying sensitivity analyses

By not considering timing of exposure in our main analysis, we assumed that individuals were exposed since birth although the BPD diagnosis occurred at a later age. This means that we were “borrowing information from the future”, an approach that may introduce bias. Therefore, we repeated all Cox regression analyses comparing the indicators before or after a BPD diagnosis to treat exposures as time-varying. Risk factor analyses considered the indicators to be exposures prior to a BPD diagnosis, while outcome analyses considered indicators as an outcome following a BPD diagnosis.

SAS was used for data management and all subsequent analysis was done in R using the survival package [ 36 ].

Descriptive statistics

The cohort consisted of 1,969,839 individuals (48.8% female) with 12,175 individuals with BPD (85.3% female; 0.6% of sample) (Table  2 ; absolute values Supplementary Tables  5 – 7 ). Total follow-up time was 32,637,932 person-years, calculated from the first possible time of BPD diagnosis, i.e., from its introduction in 1997, and onward. The diagnosis was evenly distributed between birth year cohorts, and the total cohort had a mean age of 29.69 years at the end of follow-up.

Cumulative incidences

The 5-year cumulative incidence showed increased incidences in individuals with BPD compared to the matched control sample for all indicators, except intellectual disability (Fig.  1 ; Supplementary Figs.  1 – 7 ). The largest cumulative incidences were for anxiety disorders (Cumulative incidence [95% CI]; BPD 33.13% [31.48–34.73%]; not BPD (NBPD) 3.17% [2.98–3.79%]), major depressive disorder (BPD 25.65% [24.11–27.16%]; NBPD 3.04% [2.85–3.24%]) personality disorders (BPD 21.33% [20.26–22.39%]; NBPD 0.36% [0.31–0.41%]), accidents requiring medical attention (BPD 21.50% [20.13–22.64%]; NBPD 10.91% [10.60–11.21%]), and attention-deficit hyperactive disorder (BPD 14.62% [13.75–15.48%]; NBPD 0.81% [0.74–0.88%]). Intellectual disability had zero first event occurrences after date of BPD-diagnosis for both exposed and unexposed.

The cumulative incidence of each of the main indicators broken down by subgroups.

Associations between BPD diagnosis and indicators

All HRs for BPD and the indicators included in our main analysis were statistically significant, i.e., larger than 1, after correcting for multiple testing, except for intellectual disability and infertility in females (Fig.  2 ). The majority of the indicators under the umbrella categories were also statistically significantly larger than 1 (Supplementary Figs.  8 and 9 ).

*Statistically significant after correcting for multiple testing using the Benjamini-Hochberg method, resulting in a p value threshold of 8.34 · 10 −58 .

Psychiatric disorders had the highest HRs across all analyses. The highest HRs were personality disorders not including BPD (HR [95% CI] 67.06 [64.66–69.54]), bipolar disorders (28.18 [27.04–29.36]), and PTSD (25.61 [24.25–27.04]). Psychotic disorders were also elevated (24.48 [23.14–25.90]).

The largest HRs for the association between BPD and somatic illnesses were for epilepsy (3.38 [3.08–3.70]), obesity (2.8 [2.63–2.98]), and diabetes (2.61 [2.32–2.93]).

Traumatic events and adverse behaviors

The strongest association regarding traumatic events was violent crime victimization (7.45 [7.13–7.78]). Death of a close family member also had a positive association (1.58 [1.52–1.64]). Self-harm had the highest hazard ratios of adverse behaviors (17.72 [17.27–18.19]). Committing a violent crime (7.65 [7.26–8.06]) had a stronger association than nonviolent crimes (4.20 [4.06–4.34]). Impulsive nonviolent crimes, i.e., property damage (6.66 [6.05–7.33]), had a stronger association than planned crime, possessing fake identification (1.94 [1.19–3.17]). Although they were analyzed as risk factors by definition, the HRs for poverty in childhood (1.93 [1.86–2.00]) and childhood neighborhood quality (1.52 [1.47–1.59]) were positively associated with BPD diagnosis (Supplementary Fig.  10 and Supplementary Table  5 ).

Females with BPD had higher cumulative incidences compared to males with BPD in nearly all somatic disorders, e.g., obesity (male 1.80 [0.97–2.62]; female 5.29 [4.68–5.90]); while the inverse was true for adverse behaviors and traumas, e.g., committing a violent crime (male 10.27 [8.14–12.35]; female 2.44 [2.06–2.83]). However, the CIs frequently overlapped between the sexes (Supplementary Figs.  11 – 23 ). HRs were largely uniform (Supplementary Fig.  24 ). Males had higher HRs for bipolar disorder (male 36.31 [32.62–40.41]; female 27.11 [25.93–28.33]), PTSD (male 34.99 [29.54–41.44], female 24.72 [23.35–26.18]) and affective disorders (male 31.42 [27.63–35.72]; female 21.32 [20.13–22.59]). Somatic disorders were mostly uniform across sex. Committing a violent crime was relatively more elevated in females (male 6.90 [6.38–7.46]; female 8.25 [7.68–8.86]). Additionally, being a victim of a violent crime requiring medical attention had a higher HR in females (male 5.05 [4.56–5.58]; female 8.58 [8.17–9.01]).

Individuals with siblings diagnosed with BPD had increased rates of indicators, however, many CIs contained 1, especially within somatic disorders (Supplementary Tables  9 – 11 ). Individuals with brothers diagnosed with BPD had higher HRs than those with sisters who were diagnosed in 87 out of 123 indicators. Psychiatric disorders had the strongest association, e.g., PTSD (males with brothers diagnosed with BPD (BBPD) 6.76 [3.74–12.24], males with sisters diagnosed with BPD (SBPD) 2.62 [1.78–3.87], females with BBPD 4.09 [2.72–6.16], females with SBPD 3.62 [3.02–4.35]).

Broadly, the magnitude of HRs for each indicator stayed relatively consistent when treating indicators as a risk factor prior to, or as an outcome following, a BPD diagnosis (Supplementary Tables  8 , 12 – 13 and Supplementary Figs.  10 , 25 , and 26 . Some notable exceptions were personality disorders (HR [95% CI] risk factor for subsequent BPD diagnosis 71.50 [68.36–74.78]; outcome following a BPD diagnosis 43.77 [41.40–46.28]), bipolar disorders (risk 35.94 [34.16–37.82]; outcome 17.27 [16.12–18.51), and psychotic disorders (risk 25.82 [24.19–27.56]; outcome 17.96 [16.23–19.87]) which had higher HRs leading up to a BPD diagnosis, and epilepsy (risk 2.89 [2.59–3.22]; outcome 5.36 [4.53–6.34]) that had a higher HR following a BPD diagnosis.

In this population-based study, which included 12,175 individuals with BPD in a total sample of 1,969,839 Swedes, we found that BPD was associated with an increased risk for psychiatric comorbidities, somatic illnesses, traumatic events, and adverse behaviors. Our findings replicate previously known associations and identify unknown or understudied associations, e.g., epilepsy, infertility, and death of close family members. Moreover, this work extends findings to include both sexes and their siblings.

BPD was strongly associated with all psychiatric disorders except intellectual disability. We found a robust association between BPD and all other personality disorders, mood disorders, eating disorders, PTSD, and substance use disorders. Certain findings need additional vigilance from clinicians and researchers, e.g., the strong association with psychotic disorders. This finding follows the historical implication of the term borderline, coined to indicate that the patients were on the borderline between psychosis and neurosis [ 37 ]. Psychotic experiences are often treated as transient symptoms according to DSM guidelines, although symptoms are often perpetual [ 12 ]. Our finding highlights the importance of carefully assessing psychotic symptoms in BPD, and indicates that psychotic disorders are indeed overrepresented in individuals with BPD [ 38 ].

Individuals with BPD had a higher risk of almost all somatic comorbidities in the main analysis except for female infertility. A Danish study also found a positive association between somatic disorders and combined personality disorders, however, their estimates were smaller than our results [ 39 ]. This could suggest that a BPD diagnosis has a worse prognosis than other personality disorders. In line with the literature, epilepsy and metabolic-related comorbidities, such as type 2 diabetes and obesity, had the strongest associations [ 10 ]. Previous studies have indicated a relationship between epilepsy and BPD, and here we show a clear association [ 40 ].

Individuals with BPD were at a higher risk of all traumatic events both before and after receiving their diagnosis. Namely, individuals with BPD were at a higher risk of seeking medical care due to violent crime victimization, especially sexual assault, which had the strongest association. This supports the expansive literature linking sexual assault and a BPD diagnosis [ 19 ]. Second, there was a positive association between BPD and the death of a close family member, which has only been reported in studies involving the death of a parent in childhood [ 41 ]. Third, our study identified an underreported positive link between childhood poverty and poor neighborhood quality and subsequent BPD diagnosis [ 42 ]. Although the CIs overlapped, sex-separated analysis found that males had higher rates of traumatic events, except for sexual assault, fitting within previous literature on BPD symptoms and trauma [ 43 ].

The consistent time-varying results provide evidence for the theory of a close, cyclical relationship between trauma and BPD [ 1 , 20 ]. Our sibling analysis found evidence to support an overlap in genetic and/or environmental etiology between traumatic events and BPD diagnosis, previously theorized to be present [ 44 ].

As expected, BPD individuals had higher instances of adverse behaviors: self-harm, violent and nonviolent crime. In line with previous findings, the most common criminal behaviors were aggressive in nature, such as making violent threats and assault [ 2 , 4 ]. Additionally, our study identified that impulsive nonviolent crimes such as property damage or petty theft are more common than planned crimes, e.g., having fake identification.

Sex differences and time-varying findings

The HRs were largely uniform across sexes, even though the absolute proportions, i.e., cumulative incidences, sometimes differed substantially. This suggests that this disorder confers similar increase in rates of comorbidities between males and females. A diagnostic bias between the sexes could result in an inflated estimate for males with BPD, as males who receive the correct diagnosis might have a more severe symptom presentation.

Individuals with a sibling with BPD had higher rates of psychiatric disorders, trauma, and adverse behaviors but not somatic disorders. HRs were higher in individuals with a brother diagnosed with BPD compared to those with a sister diagnosed for the majority of indicators. Families with a male diagnosed with BPD appear to have a more severe phenotype and vulnerability to psychiatric disorders [ 45 ]. However, this must be interpreted with caution as the CIs overlapped for having a brother or sister diagnosed with BPD. Follow-up on these associations is needed.

As the associations for the time-varying analyses were largely consistent with the main analysis, ignoring time of BPD diagnosis did not introduce bias that invalidated our inferences.

Strengths, weaknesses

In the largest and most detailed BPD study to date, we were able to capture all Sweden-born individuals with BPD with prospective follow-up using national records. This considerable sample size allowed us to thoroughly examine a variety of understudied variables in a representative sample.

However, this study comes with caveats. First, although the NPR and BPD diagnostic codes are well-validated, the extent to which these comorbidities may be misdiagnosed is unclear [ 29 , 32 , 33 ]. However, one may argue that diagnoses, if not correctly diagnosed, may reflect levels of symptom presentation even if the full criteria of diagnosis is not met. Further, the prevalence of a BPD diagnosis in our sample (0.6%) is conservative compared to the projected median estimate of 1.7% [ 1 ]. This likely indicates that many individuals who meet the criteria for a BPD diagnosis remain undiagnosed. And, as a BPD diagnosis generally takes multiple, intensive clinical interviews, it is likely that we are capturing individuals with more severe BPD symptoms.

Next, we were only able to identify the instances of the indicators identifiable in the register, this means the true estimate of these incidences may be higher in under-reported or less severe cases. Some individuals with BPD may be less willing to seek certain types of medical care due to distrust or stigmatization from the health care system, which may attenuate our results [ 46 ]. Additionally, trauma is both an objective and deeply subjective experience; and we are unable to capture the subjective experience [ 21 ]. Finally, symptoms of BPD, like all psychiatric disorders, are continuously distributed across the population rather than a binary diagnosis. We are unable to examine specific BPD symptoms which limits the information gained from this study.

Future directions for research

This study identifies many avenues for needed research. The comorbidities between BPD and psychotic disorders should be examined further. Moreover, the association with death of a close family member opens the question of the heritability of premature mortality in families [ 47 ]. Also, studies should examine these associations in other severe psychiatric disorders, such as bipolar disorder, to determine what associations are specific to BPD rather than general to severe psychiatric disorders [ 48 , 49 ]. Finally, further research should carefully expand on any causal assumptions about the nature of BPD.

Clinical implications

Our results indicate individuals with BPD frequently use health care services for a variety of psychiatric and somatic conditions. Unfortunately, despite their needs, the interpersonal difficulties and stigma surrounding individuals with BPD can be challenging for clinicians, which often results in poor care or premature ending of treatment [ 46 , 50 ]. Thus, there is a clear need for support and advocates for individuals with BPD navigating the health care system. Clinicians should be aware of these difficulties within the health care system and offer adapted health education or referrals, e.g., a dietitian to prevent type 2 diabetes. Additionally, implementing already developed anti-stigmatization methods could help improve the doctor–patient relationship [ 50 , 51 ].

Conclusions

BPD was associated with nearly all of the more than 30 indicators of psychiatric disorders, somatic illnesses, trauma, and adverse behavior. The associations were consistent across sex and temporality. This paper can serve as an atlas for associations within the aforementioned categories, many of which have previously been un- or under-reported, and can lead the way towards further causal and etiological research. Critically, the clinical implications indicate that increased support is needed for patients surrounding health care visits. It is hopeful that this provides the groundwork towards an understanding and increased awareness for this patient group.

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Tate has received funding from the European Union’s Horizon 2020 Research and Innovation Program under the Marie Sklodowska-Curie CAPICE Project grant agreement number 721567. ( https://www.capice-project.eu/ ) Lu is in part supported by a 2018 NARSAD Young Investigator Grant from the Brain & Behaviour Research Foundation and US NIMH (R01 MH123724). Open access funding provided by Karolinska Institute.

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Ashley E. Tate, Shengxin Liu, Yi Lu, Henrik Larsson, Paul Lichtenstein & Ralf Kuja-Halkola

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AET, RK-H, and HS conceptualized the study. AET completed the analysis and wrote the manuscript. SL, YL, SL, PL, HS, RK-H provided feedback on the conceptualization and manuscript.

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Tate, A.E., Sahlin, H., Liu, S. et al. Borderline personality disorder: associations with psychiatric disorders, somatic illnesses, trauma, and adverse behaviors. Mol Psychiatry 27 , 2514–2521 (2022). https://doi.org/10.1038/s41380-022-01503-z

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Article Contents

Introduction, behavioral ecology, traits associated with bpd following a fast lh strategy, are there features of bpd following a slow lhs, neuroimaging, comorbidity, acknowledgement.

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Borderline Personality Disorder: Why ‘fast and furious’?

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Martin Brüne, Borderline Personality Disorder: Why ‘fast and furious’?, Evolution, Medicine, and Public Health , Volume 2016, Issue 1, January 2016, Pages 52–66, https://doi.org/10.1093/emph/eow002

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The term ‘Borderline Personality Disorder’ (BPD) refers to a psychiatric syndrome that is characterized by emotion dysregulation, impulsivity, risk-taking behavior, irritability, feelings of emptiness, self-injury and fear of abandonment, as well as unstable interpersonal relationships. BPD is not only common in psychiatric populations but also more prevalent in the general community than previously thought, and thus represents an important public health issue. In contrast to most psychiatric disorders, some symptoms associated with BPD may improve over time, even without therapy, though impaired social functioning and interpersonal disturbances in close relationships often persist. Another counterintuitive and insufficiently resolved question is why depressive symptoms and risk-taking behaviors can occur simultaneously in the same individual. Moreover, there is an ongoing debate about the nosological position of BPD, which impacts on research regarding sex differences in clinical presentation and patterns of comorbidity.

In this review, it is argued that many features of BPD may be conceptualized within an evolutionary framework, namely behavioral ecology. According to Life History Theory, BPD reflects a pathological extreme or distortion of a behavioral ‘strategy’ which unconsciously aims at immediate exploitation of resources, both interpersonal and material, based on predictions shaped by early developmental experiences. Such a view is consistent with standard medical conceptualizations of BPD, but goes beyond classic ‘deficit’-oriented models, which may have profound implications for therapeutic approaches.

The term Borderline Personality Disorder (BPD) refers to a psychiatric condition that is characterized by unstable interpersonal relationships, fear of abandonment, difficulties in emotion regulation, feelings of emptiness, chronic dysphoria or depression, as well as impulsivity and heightened risk-taking behaviors. Paranoid ideation and dissociative states are also transient features of the syndrome ( Table 1 ). Moreover, many patients with BPD show recurring self-injurious or suicidal behavior [ 1 ]. BPD has a lifetime prevalence of about 6%. It is much more common in clinical settings, thus rendering BPD highly relevant for health care providers and public health in general [ 2 ].

Descriptive diagnostic criteria of Borderline Personality Disorder according to the DSM-5

A diagnosis is based on the presence of at least five of the following signs or symptoms

Etiological models of BPD suggest that the development of ‘mistrustful inner working models’ based on insecure attachment predisposes to perceiving others as untrustworthy and rejecting [ 3–5 ]. Causal factors in this development include childhood trauma such as emotional neglect or physical and sexual abuse, though associating BPD with traumatic events alone is an oversimplification [ 6–8 ]. The contribution of genetics to BPD is inconclusive, but heritability of BPD seems to be significant [ 9 , 10 ]. Taken together, the experience of early adversity, particularly the emotional unresponsiveness of attachment figures, trauma or abuse, coins an individual’s expectations with regard to future resource availability, including the quality of interpersonal relationships in terms of others’ reliability and trustworthiness [ 5 ].

BPD is often a comorbid condition of other psychiatric disorders (formerly conceptualized as axis-I disorders according to DSM-IV), foremost depression, other personality disorders, and there seems to be syndromal overlap and/or comorbidity with bipolar disorder (BD), attention deficit/hyperactivity disorder (ADHD) and posttraumatic stress disorder (PTSD) [ 2 , 11–14 ].

In keeping with traditional medical conceptualizations, many scholars see BPD as a clinical syndrome with identifiable brain lesions or defects, mainly affecting fronto-limbic connections, which account for patients’ emotional dysregulation, impulsivity and inability to cope with interpersonal distress [e.g. 15]. Such views are incompatible, however, with observations suggesting that interpersonal difficulties of individuals with BPD are largely absent outside emotionally challenging situations, and that over time many patients experience a substantial reduction in self-mutilating behavior and impulsivity, though full recovery is rare and interpersonal difficulties and emotional instability are more pervasive [ 16 ]. In fact, most psychiatric conditions worsen with increasing age, so, why should BPD be an exception? Another counter-intuitive issue pertaining to BPD is that risk-taking behavior and depression co-occur in the same condition, whereby people with depression are usually risk-averse, rather than risk-prone, the latter being a typical feature of BPD [ 17 ]. Finally, there is controversy about sex differences in prevalence and clinical presentation of BPD, much of which remains unresolved, possibly due to conceptual diversity [ 18–20 ].

In consideration of these conceptual inconsistencies, the present article seeks to shed a different light on BPD. It is proposed that some features of BPD can be better understood in a frame of reference taking into account insights from behavioral ecology. Accordingly, cognition, emotions and behaviors typical of BPD may become meaningful and comprehensive, sometimes even logical, when imagining a world that is dangerous and unpredictable, where a ‘fast and furious’ lifestyle may appear appropriate. Such a view does not contend that BPD is adaptive per se . Instead, it is suggested that individual signs and symptoms associated with BPD can be meaningfully integrated in a life history perspective, and that sub-threshold or ‘diluted’ phenotypes of BPD may well pay off reproductively (i.e. being adaptive in the biological sense), though perhaps at the expense of well-being and mental health. With regard to clinical implications, it is claimed that a behavioral ecological perspective may also shift focus in relation to psychotherapeutic goals away from fighting signs and symptoms (i.e. ‘dis-ease’) to views that aim at reframing an individual’s life history strategy in more functional ways by means of improving patients’ insight into and acceptance of the inter-relatedness of early life experiences with the pursuit of current bio-social goals.

Behavioral Ecology focuses on the variation in behavior between as well as within species and its contingency on environmental conditions. An important behavioral ecological concept, termed Life History Theory (LHT), concerns an organism’s differential allocation of resources to physical growth and reproduction. Put another way, there is a trade-off between an organism’s capacity to invest energy in somatic growth, as opposed to investment of energy in reproductive activity, resulting in different life history strategies (LHS) shaped by natural selection. Accordingly, growth rate, age and body size at sexual maturation, number and size of offspring, mortality rate, longevity, etc. are biological traits modeled by environmental contingencies [ 21 ].

The concept of LHT was originally applied to differences between species, with growing evidence for within-species differences in LHS [ 22 ]. That is, ecological (environmental) conditions (interacting with genetic factors) determine whether an individual adopts a ‘faster’ or ‘slower’ LHS, whereby current and future resource availability is estimated by observable cues or predicted based on prior experience acquired in early developmental stages [ 23 ]. Critical aspects involved in ‘decisions’ over faster or slower LHS concern the timing of biological maturation, current versus future reproduction, quality versus quantity of offspring, and quality versus quantity of parental care in offspring and mating [ 24 , 25 ].

A wealth of research has shown that the principles of LHT apply to humans in the same way as to any other organism [ 24 ]. It is necessary to point out, however, that terms such as ‘strategy’ or ‘decision-making’ do not imply conscious reflection or intentional action. The timing of biological maturation, sexual activity and intensity of care for offspring is regulated by sex hormones, the stress response system and neuropeptides [ 26–28 ]. In a more general vein, however, LHS have also profound ramifications for the shaping of interpersonal behavior including cooperation, reciprocity, aggression and pair-bonding, as well as for neurocognitive domains, such as risk-taking, executive functioning and inhibitory control [ 25 ]. According to the ‘Adaptive Calibration Model’ individual differences in stress-regulation, as a function of complex gene–environment interaction, may translate into different adaptive strategies, which may shift one’s somatic development and psychological mechanisms toward a ‘faster’ or ‘slower’ LHS [ 25 , 27 ].

In support of theories about LHS, abundant research suggests that differences in early environmental conditions shape an individual’s LHS in predictable ways [ 29 ]. Central to this is the observation that the quality of parenting profoundly influences the way children develop ‘inner working models’ which in turn serve as a guideline for predicting future resource availability [ 3 ]. That is, children who grow up in an emotionally safe and stable familial environment learn to see the world as a safe place, in which stable relationships with trustworthy others (family, peers, partners) indicate the availability of social and material resources in the future. Accordingly, from the perspective of attachment theory, securely attached individuals tend to pursue slower LHS, that is, they tend to mature later, delay reproduction, are generally risk averse, and form stable long-term intimate relationships with partners. Such individuals are also cooperative, empathetic, display low levels of interpersonal aggression, and have good inhibitory control over impulses. In terms of personality traits, they score high on conscientiousness and agreeableness. In contrast, children who are exposed to environmental cues such as harsh parenting, violence or other sources of danger are more likely to develop an inner working model suggesting that future resource availability is unpredictable, thereby shifting LHS toward faster development, including earlier biological maturation, sexual activity and earlier reproduction [ 24 , 29 ]. A faster LHS is more often associated with insecure attachment patterns, increased delay discounting, greater impulsivity, larger numbers of sexual partners, lack of reciprocity, reduced inhibitory control, increased risk-taking behavior and less parental effort. Moreover, several personality traits may also be linked to differential LHS, whereby conscientiousness and agreeableness may be the most relevant in this regard, whereas others such as extraversion, openness and neuroticism may be more ambiguous indicators of a particular LHS ( Table 2 ) [ 30 , 31 ].

Prediction from LHT with regard to cognitive, emotional development, interpersonal behavior and physiology (modified after Del Giudice [ 25 ])

Supportive evidence for Borderline Personality Disorder as a ‘fast’ Life History Strategy (LHS).

In line with LHT models of socialization, and consistent with the Adaptive Calibration Model, the experience of early adversity, particularly emotional unresponsiveness of attachment figures, trauma, abuse, coins an individual’s expectations with regard to future resource availability in terms of interpersonal relationships, i.e. trustworthiness, reciprocity and empathetic concern, suggesting that individuals would tend to maximize short-term benefits from interpersonal relationships, that is pursue a fast LHS [ 27 , 29 , 32 ].

Accordingly, the idea that BPD is typical of a ‘fast’ LHS has face value, because several diagnostic criteria such heightened impulsivity, emotional dysregulation and risk-taking behavior already point in that direction, as well as the prevalence of adverse experiences during childhood. In extension to this, LHT would predict that people with BPD may show signs of high stress responsivity (which may be a distinguishing feature from antisocial personality traits or disorder, where a more unemotional reactivity pattern is typical), a lack of trusting relationships, unstable romantic relationships, high number of short-term sexual relationships as well as increased vigilance toward partners’ faithfulness, early biological maturation, and poor investment in own offspring [ 33 ]. Moreover, symptom patterns were expected to differ between men and women, with male patients showing more externalizing features and females showing more internalizing behaviors [ 29 ]. Furthermore, comorbid conditions of BPD should feature among those syndromes associated with a ‘faster’ LHS, including ADHD, perhaps except the inattentive type of ADHD, BD, substance abuse and bulimia nervosa (BN) [ 25 ].

Neuropsychology

One key feature of BPD concerns patients’ difficulties in regulating their emotions in appropriate ways, which may account for several symptoms including idealization and derogation of others, impulsivity and risk-taking behavior. These signs and symptoms can be conceptualized as behavioral expression of high stress responsivity. According to the Adaptive Calibration Model high stress responsivity promotes a fast LHS in dangerous and unpredictable contexts, whereby it increases vigilance to threat and down-regulates one’s sensitivity to social feedback [ 27 , 34 ]. Consistent with this hypothesis, several studies have shown alterations of the hypothalamic–pituitary–adrenal stress axis in BPD, which correlate with symptom severity and a history of childhood trauma [ 35 ]. In fact, early adversity in general has been found to be associated with persistent changes of stress responsivity, possibly via epigenetic mechanisms [ 36 ]. Along similar lines, research into emotion perception suggests that patients with BPD display heightened vigilance or avoidance reactions to negative emotions such as fear and anger [ 37 , 38 ]. At the same time, patients with BPD are often ‘alexithymic’, that is, they have difficulties in reflecting upon own and others’ emotions, whereby alexithymia in BPD has been found to be related to stress intolerance and impulsivity [ 39 ]. This apparent ‘empathy paradox’ however is plausible considering LHS emerging from early adversity [ 40 ]. Linehan has argued that patients with BPD may be hypersensitive to emotional cues that potentially signal rejection or abandonment [ 41 ]. Such biased emotion perception impacts on social interaction, if it interacts with difficulties in emotion regulation arising from overactivation of the attachment system [ 5 ]. Overactivation of the attachment system leads to a functional down-regulation of mentalizing abilities, partly, as a means of self-protection against continuing traumatization by an abusive caregiver [ 5 ]. Accordingly, hypersensitivity toward negative emotions may further contribute to distorted views of others, such that others are generally perceived as untrustworthy [ 42 , 43 ]. In turn, seeing others as untrustworthy and uncooperative may enhance one’s own (unconscious) opportunistic attitude toward short-term exploitation of resources [ 44 ].

This view is also compatible with research showing enhanced impulsivity and delay discounting in patients with BPD. In fact, if one’s inner working model suggests poor resource availability in the future (compatible with a fast LHS), immediate resource acquisition is a logical consequence. In line with predictions, empirical evidence suggests that patients with BPD are poor in impulse control and in tolerating delay of gratification, that is they prefer immediate (lower) gains over (higher) future monetary gratification [ 45 ].

Personality traits and interpersonal behavior

Research involving theories of temperament and personality development suggests that a fast LHS would be associated with high scores on novelty seeking, low scores on cooperativeness and harm avoidance, and low scores on agreeableness and conscientiousness, whereby high scores on the latter two dimensions were more characteristic of slow LHS [ 25 , 31 , 46 ]. In addition, the exploitation of others is typical of Machiavellian personality traits [ 47 ].

Consistent with this hypothesis, one study reported higher scores on novelty seeking and lower scores on cooperativeness in BPD patients compared with nonclinical and clinical controls [ 48 ]. In another study, BPD patient scored higher on Machiavellianism than controls [ 49 ]. These findings are consistent with the hypothesis of a fast LHS in BPD. Our own research group has utilized neuroeconomic games and responsivity of patients to the intranasal administration of a single dose of oxytocin (OT) to study LH-relevant behavior in BPD. For example, in a study using a Dictator Game version, in which participants had the option to punish observed unfairness occurring during an interaction of two characters, we found differences in personality traits between BPD patients and controls, which had diametrically opposite impact on participant’s motivation to engage in third-party punishment. In line with predictions regarding the association of personality traits with a fast LHS, patients with BPD scored higher than controls on Machiavellianism, and lower on agreeableness and conscientiousness. Most interestingly, in BPD third-party punishment correlated Machiavellianism (and with neuroticism), and inversely with agreeableness (as a measure of empathetic concern for others), which was the reverse in nonclinical controls. This finding is consistent with the interpretation that patients with BPD seemed to pathologically identify with the disadvantaged person in the Dictator Game, whereby antisocial traits motivated patients to punish unfair behavior, rather than empathic concern for others [ 50 ].

In a similar vein, research into interpersonal trust and cooperation has revealed that individuals with BPD have difficulties in maintaining and re-establishing reciprocal trusting relationships. For example, King-Casas et al. used a so-called trust game (TG), where one player (the investor) is endowed with a sum of money units (MUs), of which he or she can ‘invest’ a proportion of his choice in another player (the trustee) [ 51 ]. The trustee then decides how much he or she is willing to return to the investor (as a measure of reciprocality and cooperation). Mistrustful investors are less likely to spend a substantial share, because they would expect an insignificant return by the trustee. Conversely, mistrustful trustees unlikely reciprocate, if the TG is played iteratively with the same investor, because they probably expect the investor to defect over time. BPD patients, as trustees, initially returned as many MUs as controls. However, contrary to controls, patients’ willingness to reciprocate diminished over successive rounds. Moreover, when the investor’s behavior was experimentally manipulated such that the trustee was frustrated by the lack of the other player’s cooperation, psychologically healthy subjects could be coaxed back into cooperation by overly generous investments, whereas BPD patients did not respond to cajoling [ 51 ]. In further support of a fast LHS associated with BPD, Unoka et al. found that BPD subjects, in the role of an investor in a TG, transferred fewer MUs than patients with depression and healthy controls, depending on symptom severity such as stress-related paranoia and difficulties in interpersonal relations, as well as with a lack of confidence in the trustee (i.e. reduced trust) [ 52 ]. Likewise, another study reported that patients with BPD, as investors, adjusted their investment in that they transferred fewer MU to unfair trustees while ignoring—unlike nonclinical controls—the trustee’s neutral or negative facial expression [ 53 ]. These findings are therefore compatible with the view that BPD patients act in quite opportunistic ways and disregard emotional signals of others that might guide one’s decision of whether or not to cooperate with others.

Another feature, often considered pathognomonic for BPD, is self-injurious behavior. Self-harm may occur in BPD in situations in which patients feel detached from their social environment or have activated their attachment system in the fear of being abandoned. While self-injury can be seen as the expression of the inability to differentiate inner experience from reality, an evolutionary view suggests that self-harm can also be a strong signal addressed at perceived attachment figures, including therapists [ 5 ]. In humans, parental care for offspring is extremely expanded, such that a threat posed by offspring to terminate one’s life is a menace to the biological fitness of the parents themselves. Put another way, self-imposed threat to the physical existence by offspring is perhaps the strongest signal on the side of the offspring to increase parental care and nurturance, and this may well be transferred to therapeutic relationships [ 54 ].

Sexuality and mating

According to Del Giudice et al. ’s Adaptive Calibration Model, a fast LHS would predictably be associated with increased risk-taking, earlier sexual intercourse and larger numbers of sexual partners. In addition, biological maturation is expected to be accelerated [ 24 , 27 , 29 ]. Indeed, a large population-based study revealed that early age at first sexual intercourse predicted lifetime number of sexual partners and future risk-taking behavior in general [ 55 ]. With regard to BPD, several studies have found that women with BPD engage earlier in sexual intercourse and have more sexual partners than nonborderline women [ 33 , 56 , 57 ]. In addition, BPD women experience more often partner violence, date rape and sexual coercion [ 56 ]. Moreover, comorbid substance abuse puts BPD subjects at risk for unprotected casual sex, sexually transmitted diseases and commercial sex work [ 58 , 59 ]. Symptom severity of BPD is furthermore associated with teenage pregnancy, unplanned pregnancies and live births, but not number of abortions [ 60 ]. According to a recent survey in over 100 in-patients with BPD, a majority reported significantly more sexual partners in the past 12 months than healthy controls, BPD subjects also expected to have more sexual partners in the near future than controls, and they reported a greater willingness to engage in risky health behaviors, but not financial risks (Brüne M, Edel M-A, Decker C, Schojai M., unpublished work). In further support of the idea that BPD reflects a fast LHS, individuals with BPD are more likely to experience breakups of relationships [ 61 ], even though individuals with borderline features engage more in costly mate retention tactics, whereby monopolization of time, emotional manipulation, commitment manipulation, violence against rivals, submission and debasement, and verbal possession signals are more frequently observed in men, whereas jealousy induction, derogation of competitors and derogation of the mate are more prevalent in women [ 62 ]. This is compatible with a fast LHS, because these mate retention tactics are more likely to work effectively in the short term, but less so in the long run. This may be so, because they are costly to the pursuer, and aversive to one’s mate, which may, in fact, increase the likelihood of a breakup [ 63 ].

In contrast to the idea that BPD reflects a fast LHS, there is no evidence so far for an earlier somatic maturation such as age at menarche in BPD [ 33 , 57 ]. This poses a serious drawback on the theoretical conceptualization of BPD as a pathological variation of a fast LHS. Research in nonclinical youths suggests, however, that younger age at menarche in girls is associated with increased risk for psychopathology [ 64 , 65 ]. For example, early maturing girls exhibit higher levels of internalizing stress and aggression, particularly those who have experienced emotional numbing in response to peer stress [ 66 ]. Precocious menarche also seems to nongenetically impact on the development of conduct disorder in girls [ 67 ]. Taken together, these studies suggest that earlier sexual maturation in girls is associated with sub-threshold BPD or at least with important ‘core’ features of BPD.

A fast LHS would not only be compatible with high mating effort, it would also be associated with low parental effort. In fact, invalidating parenting may be one mechanism involved in the transgenerational transmission of BPD personality traits [ 41 ]. In line with the hypothesis of a fast LHS in BPD, mothers with BPD seem to display critical and intrusive behaviors, as well as role confusion (i.e. fear of being abandoned by own offspring) and frightened or frightening behaviors. This oscillation between over-involvement and withdrawal as well as between hostility and coldness seems to be characteristic of mothers with BPD [ 68 ]. Our own observation in an in-patient sample of patient with BPD seems to corroborate this conclusion. We found that a relatively large number of patients with BPD came from a family background in which the biological father was absent, or multiple consecutive stepfathers had been present during childhood and adolescence of the affected individual. Moreover, several patients have half-siblings from relationships of their mothers with multiple partners. Likewise, we observed among in-patients with BPD that a substantial number of women have been forced to give their children into foster care or under the auspices of youth welfare services (Brüne et al. , unpublished work), which, from an evolutionary perspective makes sense in light of the assumption of a fast LHS.

Even though the overall pattern of behavior in BPD, as well as the underlying cognitive and emotional processes, implies a fast LHS, some traits associated with the syndrome are rather suggestive of a slow LHS. These could, in part, reflect compensatory mechanisms for behaviors at the fast end of the continuum. In fact, BPD is not a stable condition, and it could well be that ‘slowing’ (rather than ‘slow’) features emerge secondary to negative experiences following the pursuit of a fast LHS. As Del Giudice points out, while risky strategies may yield large gains in case of success, they also impose considerable costs in case of failure. For example, a defensive strategy in BPD could serve the purpose to avoid abandonment, which could explain why BPD patients score high on ‘harm avoidance’ [ 25 , 46 , 48 ]. However, as shown above, this does not seem to apply to sexual harm [ 55–60 ].

Another feature, typically found in individuals with BPD, is the tendency of patients to denigrate themselves, which may be expressed by feelings of emptiness or self-disgust. In fact, disgust seems to be a relevant factor involved in patients’ self-concepts, whereby the degree of disgust is often linked to the severity of traumatizing experiences [ 69 ]. High sensitivity to disgust interferes with a fast LHS, particularly in relation to sexual behavior. Conversely, insensitivity to disgust may bare the risk of contracting sexually transmitted diseases [ 25 ]. Following this line of reasoning, the presence of disgust could be an indicator of a slowing LHS, even though it seems relevant to distinguish between pathogen, moral and sexual disgust, whereby the latter two correlate with conscientiousness and agreeableness in nonclinical subjects, which is implausible in the case of BPD, because conscientiousness and agreeableness are usually low in BPD [ 70 ].

Abundant evidence suggests that childhood maltreatment is associated with reductions in volume of limbic areas and the corpus callosum, and that impulsivity in BPD is associated with alterations in blood flow in frontal cortical regions [ 71–74 ]. While this review cannot summarize all relevant neuroimaging findings in BPD, an important issue with regard to the interpretation of neuroimaging data concerns the view suggesting that alterations in brain metabolism or structure do not necessarily reflect defective functioning. According to Teicher et al. , early environmental stress, e.g. in the form of childhood neglect or abuse, is possibly not simply toxic to the brain, thus interfering with (normal) brain development [ 73 ]. Instead, ‘exposure to significant stressors during a sensitive developmental period causes the brain to develop along a stress-responsive pathway’, thereby eliciting ‘a cascade of stress responses that organizes the brain to develop along a specific pathway selected to facilitate reproductive success and survival in a world of deprivation and strife’ [ 73 ]. This fundamentally different view of structural and functional brain imaging findings is in full accordance with the Adaptive Calibration Model according to which early experiences not only shape the psychological development of inner working models and how individuals adapt their LHS according to their predictions of future resource availability, but also that early experiences leave a mark on how the hardware (i.e. the brain) supports the operation of one’s individual software (i.e. inner working model) [ 27 ]. In the case of BPD, this suggests that alterations in limbic structure may actually support a fast LHS.

A recent review concluded that despite evidence for heritability of around 40% of BPD, the search for candidate genes involved in BPD has been disappointing, which could relate to the ‘tendency to look for genetic effects on disease rather than genetic effects on vulnerability to environmental causes of disease’ [ 9 ]. Generally speaking, research into psychiatric genetics has largely focused on the diathesis-stress model, according to which subjects are vulnerable to develop a disorder if carrying a genetic variant that meets some sort of adversity or negative life event [ 75 ]. Conversely, some genetic variation may protect against the development of a disorder even in the presence of severe adversity [ 76 ]. The diathesis stress model can, however, not explain why so many ‘vulnerability genes’ have undergone recent positive selection in human evolution. This is contradictory in itself, because it is implausible to assume that natural selection has favored allelic variants, which increase vulnerability to adversity [ 77 ]. Instead, this strongly suggests that these genes exert hitherto undetected or overlooked beneficial effects with regard to reproductive fitness (which is not necessarily the same as ‘good for health’) [ 24 ]. Accordingly it has been argued that a particular genetic variation that predisposes to pathology if associated with early adversity can have beneficial effects when environmental contingencies are developmentally more supportive [ 78 , 79 ]. This suggests that it is more accurate to speak of differential susceptibility or plasticity conferred by genetic variation—i.e. responsivity to both positive and negative conditions—rather than focusing one-sidedly on vulnerability, whereby plasticity genes can have additive effects, that is the susceptibility to the environment may increase with the number of plasticity alleles [ 80 , 81 ]. It is therefore plausible to assume that the same genetic polymorphism can be linked to a ‘faster’ or ‘slower’ LHS, depending on the quality of early environments.

A look into genes involved in OT turnover may exemplify this view. Genes coding for the oxytocin receptor (OXTR), genes coding for OT and genes that indirectly contribute to OT expression such as CD38 have been linked to social cognition and interaction including quality of marital relationships, as well as childhood problems, which renders them interesting candidates for research in BPD [ 82–85 ]. Moreover, imaging genetic studies suggest that polymorphic variation of the OXTR gene is associated with structural and functional differences in limbic structures, which are known to contribute to emotion regulation, a key dysfunction in BPD [ 86 ].

Indirect evidence from studies in nonclinical samples linking the OXTR with childhood adversity, insecure attachment and emotion dysregulation indicate that the OXTR may also play a role in BPD or subthreshold phenotypes. From an LHT perspective, one would expect that one allele would convey plasticity, whereby the association with early adversity would more likely lead to a fast LHS, and association with supportive environments would produce a slow LHS. The phenotype associated with the other allele would be unresponsive to environmental influence. In partial support of this idea, gene–environment interaction between childhood maltreatment and both emotional dysregulation and attachment style that was moderated by polymorphic variation of the OXTR gene, whereby homozygous G-carriers of the single nucleotide polymorphism (SNP) rs53576 showed more pronounced emotional dysregulation and disorganized attachment patterns when exposed to childhood trauma compared with A/G or A/A allele carriers [ 87 ]. In contrast, parental emotional warmth and family stability compensated, in part, for the effects of traumatic experiences on mood and resilience in carriers of at least one G allele [ 88 ]. Along similar lines, individuals who experienced childhood maltreatment were susceptible to developing depression when carrying at least one G allele, whereas A/A carriers were less responsive to early adversity [ 89 ].

Conversely, a recent study reported a diametrically opposite finding, whereby A-allele carriers of the same SNP had high levels of BPD symptoms when raised by depressed mothers and low levels when grown up in families with nondepressed mothers. GG homozygotes were unresponsive to early rearing conditions, suggesting that the SNP rs53576 of the OXTR gene could confer ‘differential susceptibility’ to environmental contingencies [ 90 ]. In keeping with differential susceptibility models, another study reported that girls were at greater risk of developing BPD symptoms when carrying at least on A allele of the SNP rs53576 and when experiencing childhood maltreatment, whereas maltreated boys were more vulnerable to developing BPD symptoms when being homozygous for the G/G allele [ 91 ]. The opposite genotypes were unresponsive to family environment in both sexes. Notably, among boys the G/G carriers were less likely to show BPD symptoms when growing up in nonmaltreating family environments with no comparable effect in female A/A carriers, which led the authors to suggest that differential susceptibility occurs solely in boys [ 91 ].

In summary, these findings, though in part contradictory, suggest that variation of the OXTR gene is involved in individual differences in susceptibility to adversity and hence, the development of BPD symptoms. However, OT is certainly not the only, and most likely not the most important neuromodulator involved in the regulation of stress responsivity and LHS. In any event, it may nevertheless be helpful to consider the view that genetic polymorphisms involved in a psychiatric condition may not simply confer vulnerability, but possibly act in protective ways depending on early environment [ 24 , 92 ]. As regards BPD, it is currently unclear whether individuals being at risk of developing the condition carry a larger than average number of plasticity alleles, which in combination with early adversity produce a BPD phenotype. Future genetic studies should address this question more explicitly.

The spectrum of comorbid disorders associated with BPD is mixed, with ADHD being suggestive of a fast LHS, whereas the case for PTSD and depression is more complex. Studies suggest that comorbidity rates of these disorders with BPD are considerable [ 93 , 94 ]. ADHD is associated with increased impulsivity, novelty-seeking and other externalizing features indicative of a fast LHS [ 95 ]. PTSD seems to feature the extremes of variation of defense mechanisms akin to arrested flight, submission, freezing and dissociation [ 96 , 97 ]. Both PTSD and depression can be situated at both ends of the fast-slow LHS spectrum. As for the fast end, hypervigilance and highly reactive stress regulating mechanisms can have adaptive properties in dangerous environments (i.e. promoting a fast LHS), yet they may also bare the risk of dysfunction. Accordingly, PTSD and depression could be a costly consequence of a failure of stress regulation. Consistent with this interpretation, depression is more likely to occur in fast maturers, somatic symptoms associated with depression are linked with early adversity and depression in adolescence often co-occurs with externalizing behaviors, and generally with lower agreeableness, conscientiousness and poor inhibitory control [ 25 ]. Along similar lines, Belsky et al. have argued that internalizing problems—which are typical for many women with BPD—may ultimately serve to lower metabolism, increase body fat and thus initiate menarche earlier [ 29 ]. It is equally plausible, however, to assign low mood a role in slow LHS, because it may shield an individual from pursuing unattainable goals and help avoid risks. With regard to BPD, either explanation may apply, that is depression could be the cost for failure of a high-risk (fast) strategy, or a self-protective mechanism in the sense of down-regulating strategic action to cope with stress caused by a fast LH pattern.

Along similar lines, eating disorders may reside at both ends of the continuum of LHS, based on the relevance of sexual competition for mates. Accordingly, a slow LHS would promote females to desire a thinner body than what men perceive sexually most attractive, which in turn, would increase the woman’s value as a long-term mate [ 25 ]. Consequently, slow LHS should be more characteristic of anorexia nervosa (AN) than BN [ 98 ]. Consistent with this hypothesis, BN is associated with earlier sexual maturation and activity; patients with BN also show more externalizing behaviors than patients with AN. In accordance, BPD seems to be more often associated with BN than AN [ 99 ]. However, more evenly distributed comorbidity rates have been reported in other studies, e.g. [ 100 ].

Seen through the lens of Behavioral Ecology, there is abundant evidence in support of the idea that BPD reflects a pathological variant of a fast LHS [ 33 ]. In addition, insights from research into the neuropsychology, personality traits, interpersonal behavior, neuroimaging findings and genetics of BPD corroborate this view. While there is still controversy over differences in prevalence rates of BPD in men and women, there is overwhelming evidence for the prediction from LHT suggesting that men show more aggressive and noncompliant behavior (akin to antisocial personality traits), whereas women more often show signs of internalizing behavior, including signs of depression and anxiety [ 101 , 102 ]. Accordingly, male BPD is more often characterized by explosive temperamental features and higher levels of novelty seeking compared with female BPD [ 103 ]. With regard to personality, antisocial traits or full-blown antisocial personality disorder is more common among men with BPD. In addition, men with BPD have more often than women comorbid substance use disorders. By comparison, women with BPD are more often diagnosed with comorbid eating disorders, depression and anxiety, and PTSDs, all of which is consistent with predictions from LHT [ 11 , 104 ].

Why is all this interesting in regard of public health issues? First, the behavioral ecological view on BPD may have important ramifications for the psychiatric treatment of this condition. For one, neuroimaging studies of BPD may be worth reconsidering. In contrast to the traditional ‘medical’ perspective suggesting that deviations from a statistical norm represent ‘deficits’ (i.e. brain damage), neuroimaging findings in BPD may, in fact, reflect complex adaptations to early adversity and thus serve stress-regulation purposes, which may be functional in dangerous and unpredictable environments, but dysfunctional in safer environments [ 73 ]. So, in keeping with the Adaptive Calibration Model, a therapeutic stance could entail acknowledging that a patient’s personal history has impacted on his or her stress regulating mechanisms which include brain circuits involved in threat evaluation and prediction of future resource availability [ 105 ]. This attitude is fundamentally different to a more fatalistic ‘brain damage’ perspective. Of note, studies have shown that anatomical ‘abnormalities’ found in patients with a history of childhood adversity are reversible upon psychotherapy, suggesting that functional or structural brain variation is not necessarily impervious to modification [ 106 ].

Along similar lines, LHT suggests that the one-sided view on psychiatric genetics (vulnerability concept) should, in part, be replaced by one that considers genetic variations as expression of plasticity ‘for better or worse’, depending on the interaction of genes with the environment [ 81 , 107 ]. This is a crucial point, because the same allelic variation can promote a slow or a fast LHS, depending on early environmental contingencies, thus acting at both ends of the LHS spectrum [ 27 ]. This view may have profound implications for the understanding of BPD, because BPD patients may actually be among the genetically most plastic individuals who, due to early adversity, have developed dysfunctional interpersonal strategies [ 108 ].

Another example for how interpretation can influence therapeutic perspectives comes from studies in BPD using neuroeconomic paradigms. Commenting on King-Casas et al. ’s TG study, Kishida et al. noted ‘borderline personality disorder confers a ‘diminished capacity’ to represent expectations for social partners, and as a consequence individuals with BPD ‘cannot take corrective action’ (social control signal) that might serve to re-establish cooperative interaction’ (this author’s italics) [ 51 , 109 ]. An alternative interpretation of the same finding that is in line with LHT suggests that, rather than reflecting a cognitive deficit, it is the motivational structure of patients with BPD that lead them not to take corrective action by reinstalling cooperation. That is, individuals whose inner working models suggest that others are untrustworthy may not be ‘motivated’ to respond to attempts to entice them back into a cooperative relationship [ 44 ].

As regards psychotherapy in general, existing treatments for BPD patients that have proved to be effective—dialectic behavioral therapy, transference-focused therapy, mentalization-based treatment, as well as newer developments including metacognitive interpersonal therapy and compassion-focused therapy (CFT)—have barely taken into account evolutionary aspects, with the exception of CFT [ 110 , 111 ]. However, potential implications from LHT have entirely been disregarded so far. This review contends that it could help patients change interpersonal attitudes and expectations, as well as their ‘real-life’ behavior, if they gained insight into the inappropriateness of their current behavior considering present-day environmental conditions. Put another way, a ‘fast and furious’ LHS may make sense in unpredictable and dangerous conditions, but less so in relatively safe and reliable circumstances. Of course, this cannot simply be ‘taught’, but worked-through over time in insight-oriented psychotherapeutic approaches [ 53 ]. As Fonagy put it, ‘we are likely to see behavioral organizations that we currently term personality disorders as age-specific adaptations to biopsychosocial pressures, which are best treated by developmentally specific interventions’ [ 112 ].

The behavioral ecological approach has several limitations in explanatory power. One is that BPD is a fairly heterogeneous syndrome. Given that five out of nine diagnostic criteria are necessary for a diagnosis, it also follows that two randomly picked patients with BPD may overlap in only one symptom [ 113 ]. Accordingly, the LH model presented here may not fit all phenotypic variations of BPD. (An alternative would be to develop a novel taxonomy of psychiatric disorders solely based on predictions from LHT, but such a re-launch ‘from scratch’ would disregard that diagnostic systems such as the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) have evolved just like ‘memes’, and so has medical education. Thus, it would put evolutionary approaches to psychiatric conditions at risk of not being seriously considered by clinicians at all.) Moreover, human behavior is extraordinarily malleable and plastic, such that signs and symptoms change over time. In the case of BPD, features most indicative of a fast LHS such as risk-taking behavior, impulsivity and self-mutilation decline in severity with increasing age [ 114 ]. This is also predictable from LHT, because LHS that aim at maximizing reproductive success early in life become less relevant with increasing age, and should be negligibly present beyond the reproductive lifespan, i.e. in post-menopausal women.

From an LH perspective, future research should aim at collecting quantitative data about survival, reproduction and gene replication in large clinical samples. These data should include a detailed description of the various behavioral phenotypes according to LHT criteria (beyond DSM diagnoses) and individuals’ early and current environmental conditions.

Although no such data exist to date, a large study of fecundity in different psychiatric disorders found that those conditions that qualify best as ‘fast’ LHS [ 95 ], including BD, substance abuse (and in part, depression) are not associated with reduced fecundity (or even better than average fecundity), while those that may follow a ‘slow’ LHS (e.g. autism) are associated with reduced fecundity [ 115 ]. To answer the question whether or not ‘subthreshold’ or ‘diluted’ phenotypes are associated with reproductive advantages or disadvantages, there is a need for epidemiological studies in large nonclinical samples that are well characterized according to character and personality dimensions.

Related to this, a final point of interest for public health concerns how psychiatric diagnoses are made. An LH perspective suggests that the decision over ‘disorder’ versus ‘no disorder’ is not a matter of unconditional veracity, but highly dependent on contextual including cultural factors [ 95 ]. Potential implications for psychiatric nosology cannot be exhaustively discussed here, however, as the case of BPD may illustrate, the functional analysis of ‘problem behavior’ in an evolutionary perspective may come to different conclusions compared with views from social science perspectives [ 29 ]. An LH approach to psychiatric conditions does not imply that disorders are, in general, adaptive. On the contrary, it is explicitly contended that BPD is not an adaptive condition. However, sub-threshold phenotypical trait expression may be adaptive in specific (here, unpredictable) circumstances, especially when considering that ‘adaptive’ in a biological sense does not entail well-being or physical and mental health [ 116 ].

‘Dis-order’ arises from the inappropriateness of cognitions, emotions and behavior in a given environmental context. This can leave long-lasting or even permanent marks on the central nervous system and the way interpersonal processes are ‘embodied’. Psychiatry needs to take on the challenge to not emphasize boundaries between ‘disease’ and ‘normalcy’, particularly in light of waxing and waning weights assigned to the ‘bio’, the ‘psycho’ and the ‘social’ aspects of psychiatric conditions, whereby evolutionary approaches may be helpful to integrate these aspects into a more coherent framework for psychiatric conditions.

I am indebted to Marco Del Giudice for his helpful comments on an earlier draft of this manuscript.

Conflict of interest : None declared.

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• borderline personality disorder
• comorbidity
• depressive disorders
• interpersonal relations
• irritable mood
• mental disorders
• self-injurious behavior
• sex characteristics
• social adjustment
• public health medicine
• risk-taking behavior
• impulsivity
• conceptualization

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• Research article
• Open access
• Published: 07 September 2020

Living with personality disorder and seeking mental health treatment: patients and family members reflect on their experiences

• Karlen R. Barr 1 ,
• Mahlie Jewell 2 ,
• Michelle L. Townsend 1 &
• Brin F. S. Grenyer 1  

Borderline Personality Disorder and Emotion Dysregulation volume  7 , Article number:  21 ( 2020 ) Cite this article

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Despite effective treatments for personality disorders being developed, consumers and carers often report negative experiences of mental health services, including challenges accessing these treatments.

This qualitative study used separate focus groups to compare the unique perspectives of consumer and carers, and to investigate how to improve services for individuals with personality disorders. Reflexive thematic analysis was used to analyze the data.

Both consumers and carers ( N  = 15) discussed the value of providing appropriate information to consumers when they are diagnosed with personality disorder. Consumers and carers described the importance of creating a safe environment for consumers when they present to the emergency department. Both groups discussed experiencing positive and negative treatment from mental health professionals, and suggested that professionals should be trained to understand personality disorder. Limited accessibility and quality of services, and offering peer support to consumers were also described by consumers and carers. Consumers and carers also had perspectives which were unique to their group. Consumers identified the importance of psychological treatment, having a strong therapeutic relationship with a mental health professional, and the benefit of long term psychotherapy with the same professional. Broadening the scope of psychotherapies including creative, animal-assisted, and physical therapies was recommended by consumers. Carers described the importance of assessing for personality disorder and intervening early. Involvement in the assessment, diagnosis, and intervention process was important to carers. The desire to be recognized and supported by mental health professionals was discussed by carers.

Conclusions

This research contributes to the concern that consumers with personality disorder and their carers experience stigma and low quality care within mental health services. In line with these findings, we recommend guidelines for health professionals who work with consumers with personality disorder.

Personality disorders are severe mental disorders characterized by disturbances in affect, identity, and relationships [ 1 ]. Approximately 7.8% of the population has a personality disorder [ 2 ], and people with personality disorders represent about 20% of emergency department and 25% of inpatient mental health admissions [ 3 ]. In mental health and primary care settings, borderline personality disorder (BPD) is the most common personality disorder [ 4 ]. Effective treatments for personality disorder exist, including dialectical behavior therapy (DBT) and psychodynamic therapies [ 5 ]. However, consumers with personality disorder often are not offered or are unable to access evidence-based therapies and thus have negative experiences when receiving mental health services [ 6 ]. In addition, carers supporting consumers with personality disorder often experience high levels of stress, grief, and mental health problems [ 7 , 8 ], and they can experience difficulties accessing appropriate services for themselves and the consumers they support [ 9 ]. Considering the perspectives of consumers and carers is recommended to improve mental health services [ 10 ], and is supported by government [ 11 , 12 ] and mental health professionals [ 13 , 14 ].

Experiences of mental health services have been studied from the perspectives of consumers with various mental illnesses and their carers. Consumers describe the importance of mental health professionals discussing diagnoses with consumers and carers, and providing hope and information regarding diagnosis [ 15 ]. Regarding treatment planning, consumers want to be involved in their treatment decisions [ 16 ], although they are often excluded from participating in decision making [ 17 ]. Further, consumers describe not being prepared for hospital discharge, not being involved in the decision to discharge, and not receiving adequate support following discharge [ 18 ]. Carers supporting consumers with a range of mental health problems express that they have little involvement in mental health services and little access to information on mental health services [ 16 ]. Many carers believe they should have access to information about consumers, and report that confidentiality prevents them from receiving information about the consumer they support. Carers describe wanting respectful treatment for themselves and consumers, and better communication from mental health professionals, including education about specific disorders [ 19 ]. Other barriers described by carers include poor communication between services, limited service accessibility, and receiving little information about consumer treatment plans [ 20 ]. Carers also experience inconsistent assistance from mental health professionals in response to consumer mental health crises [ 21 , 22 ].

Multiple studies have investigated the experiences of consumers with personality disorder regarding mental health services. Consumers with personality disorder often do not receive an explanation of their diagnosis [ 23 ], or experience stigmatizing language and insufficient evidence-based information about their diagnosis [ 6 ]. Consumers have also described negative responses from health professionals in the emergency department [ 24 ]. Other negative experiences include poor communication from professionals, and inappropriate treatment, such as not having concerns taken seriously [ 6 ]. Increasing psychological and emotional support is recommended by consumers with personality disorder [ 6 ], including being supported by health professionals who help them understand their feelings [ 23 ].

Perspectives of mental health services from carers supporting consumers with personality disorder have also been investigated. Carers often experience relationship difficulties with the consumers they support, and do not know where to find help [ 9 ]. The majority of carers want support for themselves but find carer support services are unavailable or difficult to access [ 9 , 25 ]. Carers can also experience difficulty supporting consumers to find mental health professionals and consistent services to provide support to consumers with personality disorder [ 9 ]. In addition, many carers describe not receiving an explanation of the consumer’s diagnosis and not being appropriately involved in treatment decisions [ 25 ]. Carers identified wanting more information about personality disorder and how to respond to crises, and express that they are often expected to make treatment decisions without having sufficient knowledge [ 26 ].

A systematic review of 38 studies examined the perspectives of consumers and carers regarding mental health services for individuals with BPD [ 27 ]. Across the studies, consumers described receiving limited information about the assessment process and BPD diagnosis, negative responses from mental health professionals in the emergency department or inpatient setting, limited information options for therapeutic interventions, and poor communication regarding the availability of services. Studies exploring the carer perspective found that carers wanted their supporting role and their difficulties to be recognized by mental health professionals, be provided more information regarding BPD diagnosis and treatment options, and information about how to effectively respond to the consumer they support. While consumers and carers shared some consistent views, differences in opinion were observed, such as carers focusing on the lack of support they received from professionals. Comparing the consumer and carer experiences was limited because only five studies were found regarding the carer perspective, and only one study included the perspectives of consumers and carers. Therefore, more information is required regarding similarities and differences of consumer and carer views. In addition, few of the included research studies were co-produced with consumers or carers, even though this is known to lead to questions and findings closer to what people with lived experience require [ 28 ].

Problems continue to be present in personality disorder services and programs and require input from consumers and carers regarding possible improvements. It is important to increase knowledge regarding the views of consumers and carers who support someone with personality disorder, to compare views of consumers and carers regarding services for individuals with personality disorder, and to co-produce research on consumer and carer perspectives. The purpose of this study was to bring together all these needs and gaps in the literature: to explore and compare the perspectives of consumers and carers regarding personality disorder services using a co-design approach aimed to inform the development of better services.

Participants

Participants were recruited using a flyer advertisement that was sent to consumer and carer support and advocacy groups, and services which support individuals with personality disorder. Participants were invited to participate if they were either a consumer with a lived experience of personality disorder or a carer or family member supporting someone with a personality disorder. The views of 15 individuals were obtained, a sample large enough for data saturation within a qualitative approach. Table  1 outlines the demographic characteristics of the participants.

Participants provided informed written consent prior to study participation, following study approval from the Institutional Review Board. Two focus group discussions occurred simultaneously; one with consumers and one with carers, as requested by the participants. Both focus groups were co-facilitated by 2 researchers with experience in personality disorders and group facilitation. The consumer focus group was co-facilitated by the consumer researcher. In addition, 1 mental health professional was present in each group to provide assistance to participants if they became distressed. Focus group questions were based on a guide that was co-designed by the authors. Some questions required participants to provide written answers or creative responses. Questions differed slightly for consumer and carer participants. Open-ended questions were followed with relevant follow-up questions as required. Questions explored the quality of care experienced at different services, including mental health services and emergency services, and how the practice of health professionals could improve. Questions included, “What have you found most helpful about the services you have been involved in?”, “Is there anything you wish clinicians and service leaders better understood about individuals living with personality disorder?” and “How can health professionals best support families and carers of individuals who have been recently diagnosed with personality disorder?” The discussions were audio recorded and transcribed. Focus group discussions occurred over a 90-min period. A $50 voucher was provided to participants as compensation for their time.

Data analysis

The data were analyzed using reflexive thematic analysis, which conceptualizes themes as patterns based in meaning [ 29 ]. First, the transcripts were read and re-read and brief notes were made to obtain familiarization with the data. Next, participant statements were coded into nodes through the software NVivo 11. Nodes were created using an inductive orientation to gather statements with similar meanings. Themes were constructed based on the nodes, and were revised as needed to reflect the lived experience of participants. One researcher independently coded the data, which was informed by regular discussions with the research team. The consumer researcher was part of the research team throughout all phases and provided active input into the themes developed. Inter-rater reliability was obtained by all team members arriving at a consensus for the coding. In addition, an independent researcher coded a portion of data to allow us another view on agreement - with Cohen’s kappa coefficient for inter-rater reliability being κ = 0.75, which indicates a relatively high level of agreement [ 30 ].

Consumer perspectives

In this section, the views that were gathered from the consumer focus group are presented.

Theme 1: challenges and successes finding a mental health professional who understands personality disorder

Consumers described how medical and psychiatric registrars often do not have the experience and knowledge base to provide treatment or information to people with personality disorders. Difficulties in finding a mental health professional who has training in and understands personality disorders were described by several participants. “In my long hard, long lived history as a consumer, with an illness, I have been referred and searched high and low for private psychologists who would have knowledge of this particular ill – normality, this illness, and you know, there’s very few out there who are familiar enough with it.” Consumers described various instances when mental health professionals used stigmatizing language, which had a major negative influence on their well-being. “[After multiple stigmatizing comments] I felt so completely let down and failed by the public system. Like my life didn’t matter, like I didn’t matter.”

Several consumers described positive experiences with mental health professionals who specialize in treating personality disorders. Consumers explained the importance of finding a mental health professional that they can connect with, who complements their specific needs. A trial and error process of finding a suitable mental health professional was described , “They’re not always going to be – the right one is not always going to be the first one you get. There’s a lot of trial and error.” Participants valued mental health professionals who were clear about how long they could work with them, admitted to making mistakes, kept them accountable to their goals, and persevered in contacting consumers. “I didn’t turn up three times and she kept calling me. And she kept saying to me, ‘If you won’t come see me, let me send you to someone else.’”

The importance of mental health professionals being specifically trained to work with people with personality disorders was discussed. “They (mental health professionals) should all be, you know, trained to work with people who have BPD. They should understand it.” Communicating with consumer advocates was recommended for mental health professionals to improve their understanding of personality disorders. Consumers discussed how they wanted mental health professionals to understand that people with personality disorders can recover.

Theme 2: the need to improve the assessment and diagnosis process

While some participants reported that they did not respond well to the diagnosis initially, others readily embraced the diagnosis. “I liked my diagnosis. I was, like, yes. I know what it is.” Consumers frequently described being given a diagnosis of personality disorder without any explanation or further information about symptoms, or how being provided with this information would help. One participant described receiving a diagnosis following a quick assessment, without receiving an explanation. “I spoke to her (the psychologist) for, maybe, 60 to 90 minutes, and then she diagnosed me with borderline personality disorder… no one gave me any, sort of, information or anything. I was just stuck with this diagnosis and I knew nothing about it.” Consumers described the potential helpfulness of receiving appropriate treatment options when a diagnosis is given, including referral to specialist clinicians. Factsheets that provide information about personality disorders, including symptoms and treatment options, were suggested to be given to consumers at diagnosis. “I’d like a fact sheet that you could – you know. An actual, just, you – you know, this is your diagnosis, these are the symptoms you have with it, here is the available treatment options, here is what happens through with these treatment options.” Consumers described the importance of health professionals assessing for co-occurring mental health or physical health issues.

Theme 3: the need to improve communication between mental health professionals to ensure continuity of care

Consumers described how improved communication between mental health professionals regarding diagnosis, treatment, and hospital discharge is needed . “Then they referred me to the dietician who never came, and that was it, and then they just discharged me.” Participants described disappointment when mental health professionals did not respond to recommendations made by a consumer’s private psychologist, particularly when consumers are experiencing a crisis. “In spite of my psychologist writing a detailed letter with all of my symptoms, the fact that she’s known me for so long, and that she’s sufficiently worried about my safety at this point in time, they were still willing to try and send me back home.” Professionals listening to the advice of a consumer’s psychologist can help consumers feel cared for and help them trust professionals and the mental health system. “She (my psychologist) tried to visit me a couple of times in locked wards and was not allowed in, um, and – and, um, would have been really helpful if she could have just spoken to them and said, ‘Hey, here’s what works for [the person I support],’ but they wouldn’t listen to her.” In addition, it was recommended that professionals share their resources with one another, such as fact sheets, so that consumers can receive the information they require.

The importance of continuity of care was discussed by many participants. “He (psychiatry registrar) says to me, ‘What are you here for?’ And I say, ‘Well, did you read the notes from my last appointment here?’ He said, ‘No. Tell me all about yourself.’” The capacity of a mental health professional to see a consumer for more than a few months may relieve a consumer from the difficulty of repeatedly sharing their past experiences. When a referral to another mental health professional occurs, it may be helpful to provide information on the consumer to assist continuity of care, if consent from consumers is provided. “There hadn’t been any change over from the previous therapist, so we had to start all over again and tell the story for the umpteenth time.” When referring a consumer to another service, professionals could provide some crisis skills training to help consumers while they are in between services. Following up with information that is communicated to consumers was also described as important. “I had a lot of problems with their continuity of service, in, ‘We’ll call you tomorrow,’ and then three days later you get a call back.”

Theme 4: increasing feelings of safety when consumers are experiencing a crisis

Consumers described how first responders often communicated effectively with them and helped them to feel safe and comfortable. “I feel more safe having police and ambos come to my house than I would have an acute care worker come to my house.” However, inappropriate verbal and physical interactions from first responders were also discussed. Consumers described how identifying with the LGBTIQA+ community can result in negative or poor treatment from some first responders.

Some consumers described how acute care units and emergency departments did not provide a safe environment. Consumers described receiving negative judgments from mental health professionals during crises, including being ignored, shamed, denied services or being told that they are “not trying hard enough.” Simple changes to service environments such as allowing curtains to be drawn or receiving positive communication from mental health professionals were described to increase comfort. “They allow you to have the curtains on, so you can calm yourself down.”

Limitations of inpatient wards and emergency departments were described, such as being locked up and alone. Therefore, alternative safe places were suggested for consumers to go to when experiencing distress, such as cafes, respite homes, or rehabilitation centres. “I can’t be alone because I’m not safe enough to be alone, but I don’t need the acute care centres. I just don’t even need to be talking to someone, but I just need to not be alone.”

Theme 5: providing expanded treatment options and increasing service accessibility

Consumers described various ways that treatments and services could be improved. Some consumers discussed the power of art therapy and creative therapies, animal-assisted therapy, nature therapy, and physical therapy. “I found a sexual assault nurse who actually got balloons and filled them with, um, like, paint, and just gave me, like, darts, basketball shooters, the room was just splattered everywhere. It was so colourful that it was a distraction… I find sometimes just having a psychologist isn’t good enough, you need that art therapy; you need the physical therapy.” Several consumers described how peer support could aid them, including providing support groups and safe places where people with lived experience can connect. Consumers also described the helpfulness of 24-h phone lines. One consumer described the usefulness of e-therapy. “He (my psychologist) was prepared to do some sessions remotely by video-conference. You know, so, we were just about to go into the UK at the time, and then it – I didn’t have to break my therapy.” One consumer discussed the benefit of support being provided to carers. “The support group that my mum has been going to… before she’d often just get upset or angry or - whereas now she just seems to be a lot better at knowing what to do without making it worse, kind of thing. So, it’s good.”

Consumers discussed the limited availability of mental health services for personality disorders. Some barriers to accessing mental health services included homelessness, location, and finances . “I wish clinicians understood how cost-prohibitive consistent treatment is for low-income patients.” Non-government organizations were acknowledged by some participants as providing better care compared to government organizations.

Carer perspectives

In this section, five themes from discussions in the carer focus group are presented.

Theme 1: the importance of carer involvement in early assessment and intervention

Carers described how they wanted to be involved during assessment, diagnosis and intervention. Receiving a diagnosis for the person they support was described as taking a lengthy amount of time. “ My biggest issue was getting the diagnosis. Yeah. That took 10 years. Yeah. And the hardest part was that how quick they seem to have – have wanted to keep sending her home.” Frustration was expressed by carers about how mental health professionals often mislabelled a consumer’s difficulties as anxiety, depression, or ‘normal’ behaviours, before later giving a diagnosis of personality disorder. Carers described working hard to find a mental health professional who would provide an assessment or diagnosis for the person they support, particularly during adolescence. “It took yeah, begging and pleading and we are not taking her home until we spoke to a psychiatrist, to tell them our side, and then we got a diagnosis.” After diagnosis, carers emphasized the importance of mental health professionals explaining a personality disorder diagnosis to consumers and carers. The importance of early diagnosis and assessment was highlighted by many carers, such as when a person first experiences a crisis. “ They hit their absolute lowest before there’s a click or a diagnosis into what’s going on, in comparison to trying to seek help for many years, when you can already see many traits .”

Carers discussed the importance of communicating their perspective of the person they support to inform decisions made by mental health professionals, such as diagnosis. Involving carers as soon as possible was recommended, such as during the consumer’s first crisis. Several participants suggested involving carers in treatment helps them to understand what the person they support is learning and experiencing. Confidentiality was described as a barrier to carers being involved in assessment and treatment. “There is no communication, because of this confidentiality. And I think that could be the worst enemy, basically, standing in the way of the family therapy.”

Theme 2: improving responses and follow-up when consumers present in crisis

Mixed feedback was received from carers in relation to the responses from police and ambulance responders. Some negative interactions were described, including physical force by police rather than a dialogue approach. “In one case, the police came and basically… he was thrown on to the floor, you know, with policemen with the guns. It was so traumatic, instead of first having a dialogue approach.” However, many carers described compassionate treatment from police and ambulance responders towards consumers and carers, which was sometimes experienced as comparably better than treatment provided by other mental health professionals during crises. “The first responders are much more caring for carers, family members and explaining what they’re doing, and in their compassionate treatment.”

Carers discussed how consumers can experience difficulties at the emergency department when there are physical health assessments and long wait times for mental health problems. Several carers discussed how separating mental health problems and physical health problems in the emergency department may result in better care. Providing a safe place within the emergency department “that people can go to in a crisis to calm down and self-soothe” was also recommended.

Carers described how consumers were often sent home from the emergency department without appropriate support. “We went to emergency and were sent home with nothing in our first instant… [the person I support] was just sent home to me, with no explanation of anything .” Following discharge from emergency departments or inpatient services, carers recommended that mental health professionals inform consumers and carers about the treatment that was provided and treatment options for the future. Carers proposed that communication between mental health professionals and carers about a consumer’s hospital discharge can help protect the safety of consumers and others. Several carers described not receiving information from mental health professionals unless it was requested by the carer. “Even when [the person I support] was sent home from hospital two times, she was never sent home with anything… Not unless you ask for it.”

Theme 3: increasing mental health professionals’ understanding of personality disorders and improving communication

Carers described the harms of mental health professionals using inappropriate and stigmatizing language when communicating with consumers and carers. The use of recovery-oriented, strengths-based language was desired by carers, such as expressing an understanding of the difficult experiences faced by carers and consumers. Mental health professionals who provided explanations about mental health problems which can be understood by consumers and carers were valued. “I think if they actually remember that this is the first time someone’s hearing it, they actually may be forthcoming with more information.”

Many carers discussed improving training and awareness of personality disorders for health professionals. “If the training is proper – with the GPs, with the doctors, psychiatrists, psychologists, nurses, we have the system right. It’s a matter of just the right education.” Carers described how mental health professionals need to be aware of support that is available and to explain treatment options. Carers also wanted guidance from mental health professionals on how they can best support consumers. “We (carers) need to know what we can do to help them. We want to understand how they feel and why they act/behave the way they do. Please help us to ensure they get the best care and the treatment they need to recover.”

Carers discussed the value of mental health professionals communicating with one another, including providing referral information. When mental health professionals liaise, it can provide a more holistic picture of a person’s difficulties, including physical and psychological symptoms. “[The person I support] has a lot of physical symptoms that I think are a result of her mental state. But I’m not sure. So, they sent her off for all these tests… but there’s no – no one’s like, pulling it all together. The GPs should be, but they don’t.”

Theme 4: improving accessibility and quality of services for consumers

Several carers described limited availability and quality of services within the mental health system, including the public and private healthcare system. “She’s had stays in private hospitals as well. And to be honest, not a lot better. I mean, it’s much nicer place. But I don’t know that the level of care is much better, really, considering how much you pay for it.” The small amount of psychological sessions provided by the public healthcare system was described by carers as insufficient. The proximity of services was also described negatively, including consumers having long commutes to receive treatment. Long wait times to receive treatment were also discussed. “She was on four waitlists in the city at private clinics. One down here in this region. Couldn’t get her in. Christmas Eve, they rang and said, ‘Oh, we’ve got a bed in the city.’ So October, November, December, she was on 24-hour watch. Because I couldn’t get her in anywhere.”

Carers also recommended personalizing therapy for specific consumers, including offering support in nature. Several carers described the helpfulness of DBT. “She (the person I support) ended up being put through a DBT group… that has by far been one of the best things for our entire family.” Carers described how offering employment assistance and peer support groups for consumers may be beneficial.

Theme 5: improving support for carers

Carers described feeling overwhelmed and stressed by caring for a person with personality disorder and suggested carer respite as a valuable form of support. One carer described feeling hopeless after multiple attempts to find a treatment that would work for the person they support. Financial and work difficulties due to time commitments supporting someone with personality disorder were also described. “The Government needs to know is the financial strain on families… with needing weekly psychologist, regular psychiatrist, not being able to get to work, because you get called home all the time.”

Carers discussed the importance of mental health professionals understanding the difficulties experienced by carers. Carers described receiving little support for themselves from mental health professionals. Mental health professionals asking a carer ‘how are you?’ was described as a positive first step. “I had one registered nurse, who was special… who actually asked me how I was. And that was probably year six of the journey. And until then, not a soul had ever asked me how I was.” Other options for providing support to carers were discussed, including a 24-h phone line, peer support groups, counselling for carers, and promoting self-care. Providing educational resources to carers was recommended, such as having brochures in hospital waiting rooms, offering educational groups, and providing links to online information. Several carers recommended increasing public awareness and understanding of personality disorders through education, which may help others in the general community understand the experiences of consumers and carers.

A comparison of the consumer and carer themes can be found in Table  2 . Both consumers and carers described disturbing stigma and prejudice, but also receiving some exemplar care from some professionals. Broadening support options for both consumers and carers was a priority.

This study explored and compared experiences of personality disorder services from the perspectives of consumers and carers. Consumers and carers described a number of negative and positive experiences with mental health services and provided recommendations on how services could improve.

Both consumers and carers discussed the importance of receiving appropriate information when a person is diagnosed with personality disorder, which is consistent with previous research [ 6 , 23 , 31 , 32 ]. Taking a collaborative stance in working with consumers during the assessment and diagnosis process was identified as a way to reduce stigmatization and empower consumers to engage in treatment [ 33 ]. Safety when in crisis was a major concern, both interpersonally (e.g. through promoting compassionate communication) and physically (e.g. avoiding rough handling by authorities, having safe rooms within emergency settings). Consumers also described creating safe places separate from the emergency department, such as voluntary residential or drop-in programs. Previous research indicates that residential programs may be a beneficial alternative to the emergency department for consumers with BPD [ 34 ]. Investigating the carer perspective of alternative safe places and respite options could also be important.

Both positive and negative experiences with mental health professionals and first responders were described by consumers and carers. The literature suggests that stigmatization and discrimination of personality disorder in mental health services continues to be prominent [ 35 ], although professional attitudes toward personality disorder have improved over time [ 36 ]. During crises, consumers and carers expressed receiving better treatment from first responders, compared to mental health professionals, which may mean that mental health professionals have more stigma of personality disorder compared to first responders [ 37 ]. Both groups suggested improving mental health professionals’ knowledge and understanding regarding personality disorders. Research has shown that training can improve mental health professionals’ understanding and attitudes [ 38 , 39 ]. Increasing the accessibility and awareness of training may be required. Providing training to first responders and increasing public awareness of personality disorder may also help reduce stigma and discrimination [ 35 ].

Consumers and carers described the potential benefit of offering peer support to consumers. Peer support can help consumers with various mental health problems by providing shared experiences which offer validation and hope [ 40 , 41 ]. Increasing the number of peer workers and peer support groups for consumers with personality disorder may be valuable. In addition, both carers and consumers described difficulty accessing personality disorder services. Increasing availability of services and making services more affordable may benefit consumers and carers.

From the consumer perspective, importance was given to the therapeutic relationship with mental health professionals, including finding a clinician they can connect with who specializes in personality disorder. This finding is unsurprising given that a strong therapeutic alliance can facilitate recovery [ 42 ]. Consumers described how mental health professionals, such as medical registrars, often did not have sufficient knowledge and experience to support them, and they requested people with experience who had specialized knowledge of personality disorders. Ensuring registrars who work with consumers with personality disorder have appropriate knowledge prior to in-person interactions and are supported by a specialist mental health professional may be helpful. Regarding referrals, health professionals should increase their awareness of personality disorder treatments available in their area, and offer consumers a range of possible mental health professionals that can support them.

Consumers also discussed the importance of continuity of care, including being able to work long term with a mental health professional. Therefore, it is important for mental health professionals to clarify how long they can work with consumers and to provide appropriate support when a consumer is transitioning from one professional to another. In addition, mental health professionals should communicate with one another to ensure they have all necessary information to support a consumer with personality disorder. Collaboration amongst mental health professionals involved in a consumer’s treatment is associated with improved consumer outcomes [ 43 ]. Further, consumers described the importance of private psychologists being able to communicate with other professionals involved in their care during a crisis. With a consumer’s consent, emergency department and inpatient services should collaborate with a consumer’s primary mental health professional, such as a private psychologist.

Expanded therapy options, such as art and animal-assisted therapy, were also recommended by consumers. Previous research has shown that art therapy can help increase well-being and decrease symptoms in consumers with a personality disorder [ 44 ]. Increasing accessibility and affordability of creative therapies and other approaches is recommended to improve referrals and options for consumers.

For carers, importance was placed on early assessment and intervention, which is supported by evidence and treatment guidelines [ 10 , 45 ]. However, consumers did not discuss early intervention, although they have previously described delays in receiving a diagnosis [ 42 ]. Carers also focussed on being involved in the assessment and treatment of the consumers they support, although consumers did not mention this. While carer involvement in assessment and intervention is important to carers and may help them support consumers [ 46 ], the perspective of consumers should be considered because not all consumers endorse family or friend involvement in their care [ 47 , 48 ]. In addition, carers focussed on improving support for carers, including having mental health professionals checking in on carers. However, consumers can have negative experiences of mental health professionals providing support to their carers [ 47 ]. Therefore, professionals may need to find a balance when providing support to consumers and carers. For example, a professional might provide carers with referral information to a psychological education or carer peer support group after consulting with the consumer and clearly explaining the reason for providing support to carers. Alternatively, carers may seek their own supports through mental health professionals and support groups. Table  3 provides a summary guideline of recommendations for health professionals arising from this research.

Limitations and future research

Although data saturation occurred in the analysis of qualitative interviews, the small sample size used in the study may be a limitation as other views may not have been represented [ 49 ]. We did not investigate further the treatment history, specific diagnoses of the consumers, amount of carer engagement with services, or cultural background of participants, meaning it was difficult to estimate to what extent our sample were representative of the broader consumer and carer population. Statements spontaneously reported by consumers and carers did reflect in detail findings from previous studies supporting that our sample was comparative to others in the literature. Further, the sample was predominately female, and the perspectives of male consumers and carers were limited, and it would be important to increase their participation in future research. Consumers and carers were not always asked the same questions, making it difficult to compare their experiences in some topic areas. The groups were ran as semi-structured focus groups and the facilitators followed a guide, but were all responsive to the participants in the focus group and what they wanted to focus on. For example, consumers were not asked about carer involvement in assessment and treatment. Despite the limitations, the findings provide important information to improve services for individuals living with personality disorder and their carers. Future research could explore safe environments for consumers experiencing crisis, and expanded treatment options for personality disorders, including art therapy and peer support. In addition, there is a need to broaden our understanding of the variety and nature of consumer views of having carers involved in their assessment and treatment.

The current study explored and compared mental health service experiences from the perspectives of consumers with personality disorder and carers. The findings add to the ongoing concern about the stigma, prejudice and poor provision of services for people with personality disorder, despite some examples of high quality work being delivered. In addition, the findings highlight similarities and differences in consumer and carer perspectives. Based on the findings, a number of guidelines are provided to inform the practice of health professionals who support consumers with personality disorder.

Availability of data and materials

Data from the current study will not be made available, as participants did not consent for their transcripts to be publicly released. Extracts of participant responses have been made available within the manuscript.

Abbreviations

Borderline personality disorder

Dialectical behavior therapy

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Acknowledgements

Charlotte van Schie for inter-rater reliability, and consumers and carers who participated in this study.

NSW Mental Health Commission Lived Experience Framework Implementation Grant, and NSW Ministry of Health support to the Project Air Strategy for Personality Disorders. The funders had no role in the design, recruitment, collection, interpretation, or writing of the study.

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KRB - study design, participant recruitment, data collection, data analysis, and writing- original draft. MJ and MLT- study design, participant recruitment, data collection, data analysis, and writing- review and editing. BFSG - study design, data collection, and writing- review and editing. All authors read and approved the final version of the manuscript.

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Barr, K.R., Jewell, M., Townsend, M.L. et al. Living with personality disorder and seeking mental health treatment: patients and family members reflect on their experiences. bord personal disord emot dysregul 7 , 21 (2020). https://doi.org/10.1186/s40479-020-00136-4

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• Personality disorder
• Lived experience
• Qualitative
• Mental health services

Borderline Personality Disorder and Emotion Dysregulation

ISSN: 2051-6673

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The Impact of a One-Day Workshop on Good Psychiatric Management for Adolescent (GPM-A) Borderline Personality Disorder

• In Brief Report
• Published: 23 May 2024

Cite this article

• Craigan Usher   ORCID: orcid.org/0000-0002-4055-9015 1 ,
• Ilana Freeman 1 ,
• Dalton Wesemann 1 ,
• Elisa Ross 1 ,
• Carl Fleisher 2 &
• Lois Choi-Kain 3  

Despite evidence validating the diagnosis of borderline personality disorder (BPD) in youth, specifically showing persistence of BPD symptoms and morbidity similar to adults, there is reluctance to diagnose this in teens. Further, there is a belief among many trainees and academic child and adolescent psychiatrists (CAPs) that only specialty programs are effective, leading to treatment delays. This study charts the impact of a full-day workshop offered to an entire academic CAP department.

A Good Psychiatric Management for Adolescent (GPM-A) Borderline Personality Disorder in-person workshop was offered to department members. Participants were asked to complete a pre-survey, an immediate post-training survey, and a survey at 6 months post-training. Utilizing a Qualtrics questionnaire, both linear mixed-effect models and paired t -tests were used to estimate the immediate and sustained effects of the training.

Thirty-two participants completed the workshop, with 31 answering the pre-survey, 27 the post-training survey, and 23 the 6-month follow-up survey. Immediately after the training and 6 months later, participants demonstrated statistically significant ( p  < .05) improvements in willingness to disclose the diagnosis of BPD, a reduced negative attitude around BPD, and an enhanced sense of confidence in addressing the needs of adolescents with BPD.

Conclusions

GPM-A training can make a positive impact on groups of clinicians who work with youth who meet criteria for BPD, specifically reducing stigma, encouraging trainees and faculty members to make the diagnosis more readily, and helping them feel more competent in addressing the treatment needs of adolescents with BPD.

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Data Availability

Data is available by contacting corresponding author.

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Lois Choi-Kain is co-editor of the Handbook of Good Psychiatric Management for Adolescent Borderline Personality Disorder and receives royalties from American Psychiatric Association Publishing. Dr. Choi-Kain is a consultant to three companies: Boehringer-Ingelheim, Tetricus, and Optum Healthcare. She is also a paid board member of Silver Hill Hospital and the American Psychiatric Association DSM Revision Committee for Personality Disorders, and contributes to the American Psychiatric Association Guidelines for BPD treatment.

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Usher, C., Freeman, I., Wesemann, D. et al. The Impact of a One-Day Workshop on Good Psychiatric Management for Adolescent (GPM-A) Borderline Personality Disorder. Acad Psychiatry (2024). https://doi.org/10.1007/s40596-024-01984-w

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What is borderline personality disorder?

Posted: November 29, 2023 | Last updated: April 5, 2024

Borderline personality disorder (BPD) is a little-known and little-understood mental illness that is rarely discussed. When it is mentioned in the media, the representations only serve to further stigmatize an already highly-stigmatized condition. It is fueling the false narrative that people with BPD are all master manipulators who crave attention and are cruel to others. Click through this gallery to find out what border personality disorder really is, and how it can be treated.

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Borderline personality disorder

Borderline personality disorder is one of the 10 personality disorders currently recognized in the DSM (the official diagnostic manual used by medical professionals for the treatment of mental illness).

BPD is one of the Cluster B conditions, which also include antisocial personality disorder, histrionic personality disorder, and narcissistic personality disorder. These disorders are all characterized by intense or unusual emotions that are difficult to regulate.

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Emotional dysregulation

For those with BPD, emotional regulation is the main challenge they face. The illness causes them to experience intense emotions and sudden mood swings. This can result in impulsive behavior, intense and unstable relationships, and frequent changes in self-image.

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It tends to affect women slightly more often than men and is more likely to occur in those who have a family history of the illness. Research is still in the early stages, but it’s believed that both genetic and social factors contribute to the manifestation of BPD.

Family link

According to the National Education Alliance for Borderline Personality Disorder, the illness is five times more likely to occur in those who have a close family member with the condition, such as a parent or sibling.

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Childhood trauma

The environmental factor is also significant. Many people who suffer from BPD have experienced childhood trauma such as abuse or abandonment. Others were sensitive children who grew up in an unstable environment where they felt invalidated by those around them.

There is also research to suggest that people with BPD have structural and functional differences in their brains, particularly in the areas that contribute to impulsive behavior and emotional regulation.

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Heightened emotions

Those who have BPD are often high functioning in many areas of their lives. It’s usually their personal lives where they may struggle and experience instability. They feel extreme emotions that might be triggered by an event that seems minor to others, and it’s much harder for them to return to their “emotional baseline” afterward.

Four groups of symptoms

The symptoms of borderline personality disorder can be grouped into four different areas. The first is emotional instability, or emotional dysregulation, which we've already outlined. The second group of symptoms are associated with distorted perception, meaning a disconnection from reality.

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The third group of symptoms involve impulsive behavior, which can often be self-destructive. The final group is characterized by unstable relationships. The symptoms of a personality disorder can range from mild to severe. They usually start to emerge in adolescence or early adulthood.

When it comes to many mental illnesses, the average person could scan the list of symptoms and say “oh my God, I have that!” Most symptoms merely describe normal parts of human life, such as feeling tired or anxious, fearing rejection, or struggling with low self-esteem.

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Abandonment

One of the main symptoms people with BPD experience is a fear of abandonment and rejection. They are intensely worried that even their closest friends and family will leave them, and will go to great lengths to avoid this nightmare scenario.

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Relationships

People with BPD usually have a history of unstable relationships. They can be prone to drastic changes in the way they see their partners or friends, one day idealizing them and hating them the next. This negative switch is usually triggered by a feeling of insecurity that makes them think the other person is cruel and doesn’t care about them.

Self-image and identity are difficult to pin down for someone with BPD. They sometimes feel like they’re a terrible person, other times they might feel like they don’t exist. There are frequent shifts in core values, life goals, and relationships.

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Considering how difficult it is for someone with BPD to feel secure in their relationships and their own identity, the things that usually anchor us and make us feel connected, it’s no surprise that they experience intense feelings of loneliness. This can also manifest as a feeling of emptiness.

Disconnection from reality

In moments of severe stress, someone with BPD might become paranoid and even lose touch with reality for a period of a few minutes or a few hours. Psychosis can occur in extreme cases.

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Mood swings

Persistent mood swings are another common symptom of BPD. Sudden changes in mood can last for hours or days, and may come with pleasant or unpleasant emotions, such as joy, excitement, shame, anxiety, or sadness.

One particularly problematic emotion of people with BPD is anger. They can have strong emotional reactions to issues that might seem small to someone else. Once they feel intense anger, it takes much longer for it to fade than it does for others. People with severe BPD who haven’t learned the skills to regulate their emotions may even end up in physical fights.

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Impulsive behavior

Impulsive behavior is also common, particularly when it has a self-destructive outcome. Examples might include excessive spending, unsafe sex, gambling, suddenly quitting a good job, or ending a healthy relationship. Those for whom impulsive behavior is particularly problematic are more likely to engage in substance abuse.

Dissociation

People with BPD may sometimes feel disconnected from their bodies, their thoughts, or their identities. This “out of body” sensation makes the world feel less real.

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Someone struggling with BPD is at a higher risk of harming themselves when things are particularly difficult. They may hurt themselves by cutting or burning, threaten to take their own lives, and even make an attempt to do so. This is one of the reasons it’s so important for them to seek help with their condition and improve their quality of life.

Treatment and outlook

Many of these symptoms sound scary, and they can be, but there is huge variation in how BPD can manifest itself in each person. Some people will experience much milder symptoms and are high functioning, while others may need inpatient treatment at some point. It’s thought that symptoms of BPD are more intense in youth and naturally lessen in middle age.

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Borderline personality disorder can be a scary diagnosis because it’s a highly stigmatized condition that’s widely misunderstood, but it is treatable. There are therapies and medications that can massively improve the symptoms and help patients live happy, fulfilling lives.

The main type of therapy used to treat BPD is called dialectical behavioral therapy, or DBT. It’s a talk therapy that helps people with BPD understand and accept their emotions, as well as giving them the skills to manage them.

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There isn’t one specific medication that is used to treat all cases of BPD. For some, anti-depressants or mood stabilizers may be used to help with anxiety, depression, and mood swings. For those who suffer particularly from paranoia and disorganized thinking, anti-psychotics are an option.

Another important element for recovery from BPD is support from family and/or friends. It’s extremely helpful if loved ones understand the condition and also have the tools to deal with difficult situations that may arise. There are many support groups and educational resources available.

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Borderline personality disorder is still highly stigmatized, partly because even healthcare professionals didn’t understand the condition until recently. There’s a misconception that people who suffer from it are dramatic, manipulative, and attention-seeking.

This misunderstanding is extremely detrimental as it can make those with the condition feel hopeless and wary of seeking help or confiding in others. It’s important to find support from a clinician with a deep and up-to-date understanding of the condition, to avoid misdiagnosis or mistreatment.

There is hope

Thankfully, we live in a time where mental illness is being destigmatized and we as a society are recognizing that no one goes through life without being touched by it.

Sources: (Mayo Clinic) (NIMH) (National Education Alliance for Borderline Personality Disorder) (Verywell Mind)

See also: Overcoming the stigma surrounding psychiatric medication

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What Works in the Treatment of Borderline Personality Disorder

Lois w. choi-kain.

1 Harvard Medical School, McLean Hospital, 115 Mill St., Mail Stop 312, Belmont, MA 02478 USA

Ellen F. Finch

Sara r. masland, james a. jenkins.

2 Massachusetts General Hospital, McLean Hospital, Belmont, MA 02478 USA

Brandon T. Unruh

Purpose of the review.

This review summarizes advances in treatments for adults with borderline personality disorder (BPD) in the last 5 years.

Recent Findings

Evidence-based advances in the treatment of BPD include a delineation of generalist models of care in contrast to specialist treatments, identification of essential effective elements of dialectical behavioral therapy (DBT), and the adaptation of DBT treatment to manage post-traumatic stress disorder (PTSD) and BPD. Studies on pharmacological interventions remain limited and have not provided evidence that any specific medications can provide stand-alone treatment.

The research on treatment in BPD is leading to a distillation of intensive packages of treatment to be more broadly and practically implemented in most treatment environments through generalist care models and pared down forms of intensive treatments (e.g., informed case management plus DBT skills training groups). Evidence-based integrations of DBT and exposure therapy for PTSD provide support for changing practices to simultaneously treat PTSD and BPD.

Introduction

Once thought to be an untreatable condition, borderline personality disorder (BPD) is now effectively treated by a growing number of evidence based psychotherapeutic treatments. Twenty-five years ago, Marsha Linehan published the first randomized control trial (RCT) for dialectical behavioral therapy (DBT), which yielded more significant reduction in the disorder’s most challenging features—parasuicidal behavior, inpatient psychiatric stays, and treatment drop out—than treatment as usual (TAU). Since then, over 13 manualized psychotherapies for BPD have been tested. Five major treatments—DBT, mentalization-based treatment (MBT) [ 1 ], schema-focused therapy (SFT) [ 2 ], transference-focused psychotherapy (TFP) [ 3 ], and systems training for emotional predictability and problem solving (STEPPS) [ 4 ]—have been established as evidence based treatments (EBTs) for BPD [ 5 ]. In contrast, trials testing psychopharmacologic treatments have not yielded consistent results [ 6 , 7 ]; therefore, to date no medication has an official indication for BPD [ 8 •]. This review will summarize major findings of what works in treatments for BPD, with a special emphasis on developments in the last 5 years.

The Cochrane review of psychological therapies for borderline personality disorder, which analyzed 28 studies published until 2011, is among the most significant additions to the literature on treatments for BPD in the last 5 years [ 5 ]. The major randomized controlled studies can be characterized in four major waves (Table ​ (Table1). 1 ). The first wave of studies compared specialized therapies for BPD to TAU. In this first wave of studies, DBT and MBT were established as EBTs [ 1 , 9 – 11 ]. Additionally, a short-term group therapy, STEPPS, was added to TAU and found to be more effective than TAU alone in reducing symptoms of BPD, negative mood states, and impulsivity while increasing functioning [ 4 ].

Major waves of RCTs for BPD treatment

Responding to criticisms that treatments lead by experts had an obvious advantage to TAU, investigators in subsequent trials in the second wave compared specialized BPD treatments, such as DBT and TFP, to treatment by expert therapists in the community, known for their willingness and interest in patients with BPD [ 21 , 22 ]. DBT again showed higher reduction in suicidal behavior and self-injury, inpatient hospitalization, and treatment drop out than treatment by other experts in the community [ 21 ]. Similarly, in the trial comparing TFP to treatment by community experts, TFP yielded greater improvements in not only suicide attempts, inpatient hospitalization, and treatment drop out, but also in borderline symptoms, psychosocial functioning, and personality functioning [ 22 ]. Treatment by experts was as effective as specialty treatments in reducing depressive symptoms, and in the DBT trial, treatment by experts was effective in reducing suicidality, but not to the degree achieved in DBT [ 21 , 22 ].

The third wave of studies staged head-to-head trials between specialist treatments (i.e., TFP vs. DBT [ 3 ]; SFT vs. TFP [ 2 ]). The evidence suggested a variety of systematic and well-informed manualized psychotherapies were effective at treating BPD and little was to be gained at horseracing to determine the superiority of any of them [ 27 ]. Clarkin’s TFP trial straddles both the third and fourth wave of studies [ 3 ]. It incorporated a systematic, manualized supportive therapy as a third comparison treatment to TFP and DBT. All three treatments, which were systematic and supervised, yielded improvements in depression, anxiety, and functioning [ 3 ]. While the supportive therapy arm failed to match reductions in suicidality yielded by both DBT and TFP, it proved effective enough to be an alternative to treating BPD patients in the absence of DBT and TFP treatments.

The other fourth wave of studies compared specialist therapies to systematic and well-informed generalist approaches to managing BPD. These studies aimed to show that the core ingredients to the specialist treatments provided increased gains in treatment, apart from the well organized and well-informed aspects of the clinical approach [ 3 ]. Unexpectedly, these enhanced, structured, and well-informed generalist treatment approaches performed as well in most ways to their already established specialized counterparts. Structured clinical management (SCM) [ 25 , 28 ] and general psychiatric management (GPM) [ 8 •, 24 ] emerged to provide less specialized means of managing BPD in the general patient population. Additionally, supportive therapy, when delivered in a systematic way [ 3 ] or by experienced clinicians in a group format [ 26 ], proved comparable in outcomes to TFP and MBT. When clinicians treating a general caseload of patients cannot often commit the time and expense to training for the gold standard specialist treatments for BPD [ 29 ], SCM, GPM, and supportive therapy offer practical, less intensive, “good enough” treatment options.

While generalist approaches to BPD could widen access to evidence-based care, research dismantling differing aspects of effective, but complex and intensive treatments, can clarify their essential elements. Linehan and colleagues published a dismantling study of DBT, illustrating that a simplified version of DBT, involving skills training group combined with weekly case management was effective in treating problems of self-harm, suicidality, and use of hospitalization [ 30 •]. Generalist care, with the addition of targeted short-term adjunctive interventions in group formats or aimed at suicidality [ 4 , 18 , 31 ] may complement supportive or generalist approaches to yield good outcomes, with the investment of fewer clinical resources.

Investigators have also adapted the established evidence based treatments for BPD to manage the usual complex co-morbidities of BPD including substance use disorders substance use disorders (SUDs) [ 32 ], eating disorders (EDs) [ 33 ], and post-traumatic stress disorder (PTSD) [ 34 ]. BPD patients who present with acutely symptomatic co-morbidities of these types are often challenging to manage with strictly BPD oriented treatments [ 35 ]. Conversely, in SUD and ED treatments, individuals with co-morbid BPD may also present with problems that are difficult to manage in those treatment environments. Efforts to target BPD with its co-morbid disorders simultaneously have been developed and studies of their feasibility and effectiveness have been published in the last 5 years [ 15 •, 32 , 33 , 36 , 37 , 38 ].

The remainder of this review will describe the prevailing evidence-based psychotherapies for BPD, the newer generalist management approaches for BPD, dismantling studies of evidence-based treatments (EBTs) for BPD, adaptations of EBTs for complex co-morbidities, and the current state of knowledge on psychopharmacologic interventions for BPD. This overview will demonstrate trends to paring down treatments to what essentially works for BPD, that most clinical settings can consider implementing as a more clear and feasible standard of care.

Specialized Evidence-Based Treatments (EBTs) for BPD

Dialectical behavioral therapy (dbt).

The most well-known, well researched, and widely available EBT for BPD is DBT [ 39 , 40 ]. Informed by clinical experience with suicidal personality disordered patients who did not improve with standard cognitive behavioral therapy intervention, Linehan developed DBT by incorporating the concept of dialectics and the strategy of validation into a treatment focused on skills acquisition and behavioral shaping. DBT formulates the problems of BPD as a result of the transaction between individuals born with high emotional sensitivity and “invalidating environments” that is, people or systems (i.e., families, schools, treatment settings, workplaces) that cannot perceive, understand, and respond effectively to their vulnerabilities.

DBT proposes that individuals with BPD can become more effective in managing their sensitivities and interactions with others through acquisition of skills that enhance mindfulness and enable them to better tolerate distress, regulate their emotions, and manage relationships. The full empirically validated package of DBT includes 1 h of weekly individual therapy, a 2-h group skills training session, out-of-session paging, and consultation team for the therapist. The intensity and structure of DBT, which is organized in an explicit, comprehensive set of manuals with instruction to therapists as well as hundreds of skills worksheets, provides an instant foundation for practitioners of any discipline or level of experience. DBT is designed for teams of clinicians and is among the most time intensive modalities for patients and clinicians. Its major mechanism of change occurs via acquisition and generalization of skills to be more emotionally regulated, mindful, and effective in the face of individual sensitivities.

Mentalization-Based Treatment (MBT)

Mentalization refers to the complex capacity human beings develop to imagine the thoughts and feelings in one’s own and other’s minds to understand interpersonal interactions [ 41 ]. Therein lies its mechanism of change. MBT proposes that BPD symptoms arise when a patient stops mentalizing, leading patients to operate from pathologically certainty about other’s motives, the disconnection from grounding influence of reality, and a desperate need for proof of feelings through action. Attachment interactions become hyperactivated, feeding into distress and difficulty coping, rather than providing safety and security, rendering the therapeutic process with BPD difficult.

MBT aims to stabilize the problems of BPD by strengthening the patient’s capacity to mentalize under the stress of attachment activation [ 41 ]. MBT therapists adopt a stance of curiosity, and “not knowing” in order to encourage patients to assess their emotional and interpersonal situation through a more grounded, flexible, and benevolent lens. Prioritizing the maintenance of mentalizing, MBT therapists support patients to think through hyperactivated states themselves, rather than providing prepackaged or intellectualized explanations, insights, or skills. Outpatient MBT involves 50 min of weekly individual therapy, 75 min of group therapy, and a reflecting team meeting which serves to support clinical team members in their mentalization in the process of treatment [ 25 ]. Developed within the National Health Services (NHS) in the United Kingdom, MBT provides a tenable model for treating personality disordered patients settings where patients and clinicians face scarce resources.

Transference-Focused Psychotherapy (TFP)

Based on the conceptualization of borderline personality organization introduced by Otto Kernberg in the 1960s, transference-focused psychotherapy (TFP) is a manualized, psychoanalytically oriented psychotherapy. Kernberg defined identity diffusion, primitive defense mechanisms (e.g., splitting), unstable reality testing, internally and externally expressed aggression, and conflicted internal working models of relationships as key features of personality disorders at borderline level of organization [ 42 ].

TFP’s focus is the problematic interpersonal dynamics in the patient’s life and their resultant intense emotional states. The patient’s inherent interpersonal dynamic emerge in interactions with the therapist in the transference, and are jointly examined to resolve the splits between good and bad that drive instabilities in affect and relationships. Like MBT, TFP’s mechanism of change occurs through helping patients achieve more balanced, integrated, and coherent ways of thinking about oneself and others. TFP involves two weekly individual therapy sessions, without group therapy. Clinicians in TFP are encouraged to receive supervision. TFP is more compatible with treatments by individual clinicians, not working in teams.

Schema-Focused Therapy (SFT)

Schema-focused therapy (SFT) is an integrative cognitive therapy focused on generating structural changes to a patient’s personality. In twice weekly individual therapy sessions, the clinician uses a variety of behavioral, cognitive, and experiential techniques that focus on the therapeutic relationship, daily life outside therapy, and past traumatic experiences. Unlike the more neutral stances of other therapies, SFT encourages an attachment between therapist and client, a process described as “limited re-parenting”. Therapy focuses on four schema modes of BPD: detached protector, punitive parent, abandoned/abused child, and angry/impulsive child. Its mechanism of change occurs through changing negative patterns of thinking, feeling, and behaving and developing healthier alternatives to replace them so that these dysfunctional schemas no longer control a patient’s life.

Generalist Approaches to BPD

General psychiatric management (gpm).

Given the limitations of treatment models that require significant training and significant clinic resources, there is a need to develop, test, and disseminate less intensive treatments. One of these new EBTs is general psychiatric management (GPM) [ 8 •].

GPM is based on a case management model, where interventions rely on common sense and are learned easily by generalist clinicians. Inherent in the case management approach is a focus on the patient’s life outside of therapy. GPM prioritizes the attainment of stable vocational functioning over romantic relationships, as well as improvement in social functioning over specific symptom improvement. Diagnostic disclosure with a discussion of the disorder’s symptoms should be the first step in psychoeducation for patients and their families, followed by information about the disorder’s etiology and positive prognosis. This frames a discussion of treatment frequency and duration—treatment is only provided if it is helping the patient progress based on articulated goals. GPM rarely involves more than one weekly individual appointment. The treatment is multimodal in nature and provides guidance for psychopharmacological interventions, as well as the provision of group and family therapy and coordination across providers. Its mechanism of change is to facilitate the natural course of the disorder’s improvement with specific attention to promoting functioning in endeavors outside of treatment.

What may be most specific to GPM is its central focus on an interpersonal hypersensitivity model of BPD [ 43 ]. In this model, the symptoms of BPD are understood as resulting from an emotional cascade that begins with an interpersonal stressor (e.g., separation, criticism). The therapist actively hypothesizes that any emotion dysregulation, impulsive or self-harming behavior, or hospitalization has resulted from an interpersonal problem, and works with the patient to better understand his or her sensitivities and responses.

In a randomized trial of GPM versus DBT, McMain et al. [ 24 ] found that patients in both treatments showed significant and comparable improvement across a variety of clinical outcomes measures after 1 year. Results were consistent at 2-year follow-up [ 44 ]. Furthermore, this trial later demonstrated that of patients with high Axis 1 co-morbidity, those assigned to GPM had significantly lower dropout rates than their DBT counterparts [ 45 ]. Moreover, there is evidence that attending a 1-day GPM workshop improves clinicians’ attitudes about treating BPD. For example, clinicians report feeling more hopeful, competent, and open to treat BPD [ 46 ]. These findings are particularly important given that BPD is a disorder for which significant stigma may introduce barriers to successful treatment. The success of treatment dissemination depends in large part on whether clinicians are willing to use treatments and feel competent to do so.

Structured Clinical Management (SCM)

Structured clinical management (SCM) was developed in the UK, similar to GPM, reflects “best general psychiatric treatment” that is feasible for use by “generalist mental health clinicians” with minimal additional training [ 47 , p. 57]. It was developed based on “expert consensus” about what general practices work best for treating BPD, and has been tested primarily in the context of RCTs evaluating the effectiveness of MBT [ 25 ]. Compared to patients who received MBT, those who received SCM showed substantial improvements across an array of clinical outcomes. Patients receiving MBT improved somewhat more quickly and continued to show greater benefit than SCM at 18-month follow-ups. However, those who received SCM were as well at 6 months as those in the MBT group, and showed faster reductions in self-harm.

Like GPM, SCM provides a structured framework for approaching treatment for BPD (see Table ​ Table2 2 for comparisons). This framework is guided by a number of generalist principles and is meant to make treatment understandable and predictable for patients. There is an emphasis on sharing the borderline diagnosis with patients, psychoeducation, alliance building that is based both on contractual (e.g., goal agreement) and relational factors (e.g., trust, reliability, liking), encouragement of family involvement, limited reliance on psychopharmacological intervention, some guidance on managing co-morbid conditions, and explicit safety planning. Both GPM and SCM recommend intersession contact be used sparingly. However, SCM takes a more cautious approach, advocating for “vigorously supporting the patient on the telephone if necessary” [ 47 , p. 69], vehemently pursuing clients who have not come to treatment, and a willingness to meet them at home or elsewhere when safety risk is elevated. This may have more to do with differences in the legal climate of the UK versus the USA than with beliefs about the utility of intersession contact. Also, SCM includes specifically articulated weekly group therapy. Group therapy is open on a rolling basis for patients and includes psychoeducation and a framework focused on problem solving.

Comparison of GPM and SCM

SCM has considerable similarity to GPM in terms of training requirements, structure, and general principles. However, descriptions of therapeutic techniques employed in SCM suggest that in some respects, it may appear more similar to MBT than GPM in practice. GPM is less psychotherapeutically oriented than other evidence-based treatments for BPD [ 29 ]. The general therapeutic stance includes responsivity, appropriate self-disclosure, flexibility, and pragmatism. The nonspecific techniques and therapeutic stance employed in SCM are generally rooted in psychodynamic principles consistent with MBT. These include authenticity and openness, the adoption of a “not knowing” stance, a focus on misunderstandings in the relationship, and generation of curiosity about belief and intentions.

Dismantling Studies

Now that several evidence-based treatments for BPD have been tested, their most essential ingredients can be discerned from dismantling studies. A major advance in the last 5 years for understanding what works in BPD treatment comes from Linehan’s dismantling study of DBT. DBT in its standard form involves an intensive package of weekly individual therapy, weekly two and a half hour skills training group, 1-h consultation team for the therapist, and paging for skills coaching available between sessions. Linehan and colleagues compared this full, or “standard DBT” package to DBT individual therapy (DBT-I) without DBT skills training group as well as DBT skills training group (DBT-S) without skills coaching [ 30 •]. All packages of DBT demonstrated significant improvements in suicidality and reduction in use of crisis services. While standard DBT showed greater improvement in frequency of self-harm, anxiety, and depression than the DBT-I condition, it did not show significant gains over DBT-S despite the significant difference in total hours of treatment (average 55.3 h in standard DBT versus 31.7 h in DBT-S). Linehan’s component analysis advances an imperative to distill the specialized and resource intensive EBTs for BPD to its most basic effective parts for the broadest, most resource efficient implementation.

Other Brief Cost-Effective Options

Systems training for emotional predictability and problem solving (stepps).

Designed to supplement ongoing treatments such as medication, individual therapy, and case management, systems training for emotional predictability and problem solving (STEPPS) consists of cognitive behavioral elements, skills training, and a systems component. The STEPPS program includes 20 weeks of 2-h seminar-like group sessions. Two co-facilitators lead the sessions by following detailed lesson plans that cover three main components of STEPPS. The first component, psychoeducation, focuses on reframing BPD as an “emotional intensity disorder,” correcting misconceptions about BPD, and helping participants gain an awareness of the schemas that drive their behaviors. The second, emotion management skills trainings, teaches skills to better manage the effects of BPD including distancing, communicating, and problem management. The third, behavior management skills training, covers goal setting, healthy eating, sleep, and exercise habits, self-harm avoidance, and interpersonal effectiveness. Participants are responsible for course materials and homework. The skills-based group sessions are supplemented by a single 2-h psychoeducation and skills training session for families which accounts for the systems component of STEPPS. While STEPPS is not designed to be a stand-alone treatment, a limited body of research indicates that STEPPS’ manualized, supplemental group sessions may enhance concurrent BPD treatments.

More recently, a series of studies conducted by Black and colleagues [ 48 ] explored the effectiveness of STEPPS for BPD patients with co-morbid antisocial personality disorder (ASPD) in both university and correctional settings. The findings indicate that subjects with co-morbid ASPD experienced similar or greater improvement in BPD symptoms, impulsiveness, and global symptoms than their non-ASPD counterparts and that STEPPS treatment is effective. These preliminary findings suggest that STEPPS has potential for treating a uniquely difficult to treat population: offenders with co-morbid BPD and ASPD.

Treatments for BPD and Major Co-morbidities

BPD’s usual complex pattern of co-morbidity [ 49 , 50 ] is another challenging factor in its clinical management. While depression is its most common co-morbidity, co-occurring with BPD in the majority of cases [ 50 ], evidence from RCTs presented here suggest it responds to specialist and generalist approaches, and tends to improve when BPD improves [ 51 ]. Other common co-morbidities such as substance use disorders (SUDS) [ 32 ], eating disorders (EDs) [ 33 ], and post-traumatic stress disorder (PTSD) [ 34 ] have been shown to lead to poorer treatment outcomes in some trials. While some evidence exists that these co-occurring disorders respond to DBT [ 35 ], MBT [ 52 ], and GPM [ 53 ], the combination of self-harm or suicidality with active substance dependence or eating disorder often makes these patients ineligible for specific treatment programs in clinical practice. The application and adaptation of some of the EBTs reviewed here have begun to elucidate direction in the simultaneous management of these challenging co-morbidities.

Substance Use Disorders (SUDs)

Two reviews of interventions for co-occurring BPD and SUDs were published in the last 5 years [ 32 , 38 ]. These reviews indicate that DBT, in standard form as well as adapted in combination with opiate agonist medication, resulted in greater improvement of SUD, than either opiate agonist medication alone or treatment by community experts [ 35 , 54 ]. In addition, dynamic deconstructive psychotherapy (DDP) [ 55 ], a manualized psychodynamic treatment for BPD and alcohol use disorders aimed at integrating and verbalizing emotional experiences as well as enhancing interpersonal identity and interactions through greater differentiation of self and other, showed greater improvements in BPD and alcohol use problems than TAU [ 20 ].

Eating Disorders

A limited number of studies have suggested that some individuals with co-morbid EDs and BPD will respond to standard DBT treatment [ 35 , 56 ]. One study adapted DBT for EDs in a 3-month inpatient treatment, with improvement in both bulimia nervosa (BN) and anorexia nervosa (AN), resulting in remission rates higher than reported for standard DBT from other studies [ 33 ]. The impact of this modified form of DBT was more robust for BN than AN. MBT has been adapted to treat the combination of BPD and ED [ 37 ], but results of this trial are yet to be published.

Post-Traumatic Stress Disorder (PTSD)

Of the three complicating co-morbidities for BPD presented here, the clearest progress in treatment in the last 5 years has developed for treatment of BPD and PTSD. While BPD patients commonly have co-occurring PTSD (approximately 30% in community samples and 50% in clinical samples) [ 36 ], guidelines for treating both simultaneously did not exist until recently. Common practice prior to these studies assumed BPD would need attention first, and then PTSD work would follow. Standard PTSD protocols have been contraindicated in the context of active self-harm or suicidality [ 57 ]. Two different DBT research groups have published positive trials on adaptations of DBT for co-morbid PTSD, one adding exposure protocols to standard DBT [ 15 •, 36 ] and the other modifying standard DBT to address severe PTSD symptoms at the outset of treatment [ 28 ]. The first of these trials [ 15 •] focused on PTSD associated with the most complex and severe forms of trauma, for example childhood sexual abuse, in a 3-month residentially based treatment, reporting significant reductions in PTSD-related symptoms when compared to TAU (waitlist). This distilled adaptation to DBT focuses on exposure with anti-dissociation skills, emotional regulation regarding shame and guilt, and acceptance on the trauma and the feelings a patient has surrounding it. The second trial [ 36 ] compared standard DBT to DBT plus a DBT prolonged exposure protocol (DBT-PE), conducted in an outpatient setting over 12 months. This second smaller study demonstrated the superiority in the enhanced DBT-PE treatment in terms of reduction of PTSD-related symptom as well as suicidality and self-injury. These two trials suggest co-morbid PTSD and BPD can be concurrently treated with DBT and exposure protocols effectively. Bohus’s trial was a larger study involving 29 patients in a naturalistic treatment setting and a waitlist comparison group of 29 patients. It employed a pared down and concentrated version of DBT without a need to prioritize attention to self-harming behaviors, or to wait for a reduction in suicidality or self-harm to start the treatment. Harned’s trial was small, with ten of 17 DBT-PE patients completing the treatment, compared to five of nine completing standard DBT as its comparison group. The results of these trials suggest changing notions that these two disorders cannot be treated concurrently, or that significant stabilization need to occur prior to initiating PTSD focused work. Further research is needed to replicate these results.

Pharmacology

Compared with the growing evidence base for effective psychological treatments, pharmacologic treatments for BPD remain less well-studied. To date, no medication has been approved by the FDA for BPD or proven to definitively manage its cardinal symptoms, interpersonal impairments, and functional difficulties. Clinical applicability of the available evidence is hampered by a limited number of studies, small sample sizes, non-overlapping batteries of outcome measures, brief observation periods, and exclusion of co-morbidities in a population for whom both psychiatric and medical co-morbidity are the rule rather than an exception.

Studies of prescribing practices indicate little conformity with the existing humble evidence-base. BPD patients are commonly subject to psychotropic polypharmacy, more likely to receive all classes of psychotropics, except TCAs and MAOIs [ 58 ]. After 16 years of prospective follow-up, 18.6 and 6.9% of BPD patients report taking four or more and five or more psychotropic medications, respectively [ 59 ]. In the same cohort over 14 years of follow-up, nearly one-third consistently used PRN medication despite the absence of any evidence-based protocols for prescribing PRNs for BPD [ 60 ]. The wish to be helpful and perceived “pressure to do something” for patients presenting in acute distress reporting unrelenting agitation, anxiety, and insomnia may account for the tendency to prescribe outside of evidence-based parameters.

In an attempt to offer sensible clinical roadmaps, practice guidelines have been proposed by regulatory organizations and thought leaders. The American Psychiatric Association (APA) guidelines proposed a symptom-targeted approach using specific medication classes to treat specific BPD symptom domains [ 61 ]. Their recommendations include the use of SSRIs for symptoms of affective dysregulation and impulsivity, and low-dose atypical antipsychotics for “cognitive-perceptual” symptoms such as transient stress-induced paranoia and dissociation. These guidelines have been criticized for being based on an artificial construct of the psychobiology of personality disorders, an overreliance on reconstructions of retrospective data, and the lack of adequately powered RCTs to inform their recommendations [ 62 ].

In contrast, the UK-based National Institute for Clinical Excellence (NICE) guidelines revised in 2015 conclude from its review of available RCTs that the evidence is not robust enough to inform any prescribing practices, citing the study limitations discussed above [ 63 ]. NICE recommends against using any medications for BPD or specific associated symptoms, but suggests they should be used for true co-morbidities and hesitantly allows their short-term use during acute crisis.

Subsequent meta-analyses have extended the “symptom domain” model that informed the APA guidelines to extrapolate across variable outcome measurements between individual studies. The Cochrane review meta-analysis found that although differences between drugs were not statistically different and effects were modest at best, improvement was seen in all symptom domains of BPD with psychopharmacological treatment [ 7 ]. Affective dysregulation was found to improve with haloperidol, aripiprazole, olanzapine, lamotrigine, divalproex, and topiramate, with no significant differences between these medications or classes. Behavioral dyscontrol/impulsivity improved with aripiprazole, topiramate, and lamotrigine. Cognitive-perceptual symptoms improved with aripiprazole and olanzapine. Interestingly, no SSRIs were found to improve any domain of symptoms and no medications alleviated certain core BPD symptoms, including avoidance of abandonment, chronic feelings of emptiness, identity disturbance, and dissociation. A second meta-analysis by Ingenhoven et al. identified a larger effect size for mood stabilizers on the treatment of behavioral dyscontrol-impulsive behaviors and anger and a more pronounced effect on global functioning, especially for lamotrigine and topiramate [ 64 ].

Of the psychotherapeutic approaches reviewed here, only GPM and SCM incorporates specific psychopharmacological guidelines, which combine elements of NICE and APA guidelines [ 8 •]. Principled, yet flexible approaches to prescribing attempts to strike a balance between the evidence-based perspective that medications appear at best adjunctive while also being potentially harmful and the clinical wisdom that medication may be cautiously used in a symptom-targeted manner to promote engagement in psychotherapy. Prescribers are encouraged to avoid reactive prescribing and deliver psychoeducation about suggested medications which includes appropriate uncertainty about expected benefits.

GPM offers a specific algorithm to help prescribers limit harm and maximize potential benefit from medications. In this algorithm, no medications are prescribed for patients who do not request them and are not in distress. SSRIs are prescribed for either bona fide co-morbid major depressive episode or for patients who may have mild distress and request a medication. For behavioral dyscontrol/impulsivity and anger, either a mood stabilizer or antipsychotic can be prescribed, but risks must be discussed. For those with cognitive-perceptual disturbance, low-dose antipsychotics are recommended. In keeping with NICE guidelines, GPM promotes discontinuing medications if ineffective, avoiding polypharmacy, and time-limiting use.

Existing guidelines for pharmacotherapy in BPD do not reflect consensus but rather a chorus of distinct voices with a few overlapping refrains. One shared aim is the minimization of harms by prioritizing psychotherapy whenever possible, avoiding polypharmacy, adding medications and tapering those lacking clear efficacy in a stepwise fashion, promoting patients’ collaboration through psychoeducation and joint monitoring of risks and benefits, and considering the usefulness of prescribing in view of effects on the therapeutic relationship. Finally, benzodiazepines and benzodiazepine-like substances should be avoided out of concern for promoting dependence, abuse, and behavioral disinhibition.

Prior to 2011, a number of highly specialized psychotherapies, (e.g., DBT, MBT, TFP, and SFT) entered the clinical scene as effective EBTs for BPD. The proliferation of these intensive EBTs turned the tide of prevailing notions that BPD was an untreatable condition. However, while effective treatments became more available, the intensity of EBTs for BPD suggested that BPD could best be treated by specialists. More recently, structured generalist management approaches such as GPM and SCM, have also been proven to work for patients with BPD. A dismantling study of DBT has offered evidence that a more pared down version of DBT, with skills training group and case management is nearly as effective as standard resource intensive packages of DBT.

Now less intensive forms of effective treatment for BPD are more available, providing hope that the general standard of care for these complex patients can be improved. Some proposals for determining which patients should received generalist care versus specialized care have recommended that patients with either greater personality dysfunction (i.e., greater numbers of personality disorder diagnoses) [ 52 ] or lack of response to generalist models of care [ 29 ] be allocated to a higher more intensive EBT. In contrast to psychotherapy trials, pharmacology trials suggest medications are adjunctive at best, and best minimized except in the treatment of co-morbidities.

Lastly, the BPD treatment research has paid increasing attention to co-morbidities such as SUDs, EDs, and PTSD. While evidence is accumulating for treatment studies in this area, clear advances in adapting DBT to treatment for PTSD has been made in the last 5 years. Now, exposure protocols for treating PTSD have been incorporated into DBT to help patients with both BPD and PTSD symptoms. Further research on adaptations of treatment for patients with more complex co-morbidities is still needed.

Acknowledgements

This work was generously funded by donors to the BPD challenge grant for expanding care to underserved patients.

Compliance with Ethical Standards

Conflict of interest.

Dr. Lois W. Choi-Kain declares book royalties from Springer, outside of the submitted work. Ellen F. Finch, Dr. Sara R. Masland, Dr. James A. Jenkins, and Dr. Brandon T. Unruh declare that they have no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

This article is part of the Topical Collection on Personality and Impulse Control Disorders

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