Clinical Practice Guidelines for Assessment and Management of Patients with Borderline Personality Disorder

INTRODUCTION

Delimitation of the topic and target group

This guideline uses the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnosis of “borderline personality disorder”.[1] The guideline is intended to be applied to specialised psychiatric and general/primary healthcare settings.

Personality disorders in the current classificatory systems

Research on personality disorders (PDs) has progressed significantly. Classificatory descriptions of PD have been changing from categorical to more acceptable dimensional ones. However, for this guideline, we have followed DSM-5, as most of the existing good quality evidence is based on DSM-5 or DSM-IV-TR criteria. Present-day scientific research primarily emphasizes the BPD categorical diagnosis and so does this guideline. International Classification of Diseases 10 (ICD-10) emotionally unstable PD: borderline type is similar to the DSM-5 borderline PD diagnosis [Table 1].[1,2] ICD-11 and DSM-5 describe personality disorders differently; in ICD-11, the equivalent to ‘borderline personality disorder’ would be the diagnosis of personality disorder (usually moderate or severe) with a specifier ‘borderline pattern.’

Table 1.

Diagnostic criteria/guidelines for borderline personality disorder

ICD-10 guidelines	DSM-5 criteria
F60.3 Emotionally unstable personality disorder	301.83 Borderline personality disorder
A personality disorder in which there is a marked tendency to act impulsively without consideration of the consequences, together with affective instability. The ability to plan ahead may be minimal, and outbursts of intense anger may often lead to violence or “behavioural explosions”; these are easily precipitated when impulsive acts are criticised or thwarted by others. Two variants of this personality disorder are specified, and both share this general theme of impulsiveness and lack of self-control.	Frantic attempts to avoid real or imagined rejection. Note Do not take into account suicidal behaviour or self-injury, etc., (criterion 5) Borderline and intense interpersonal relationships, characterised by alternating between extreme idealisation and belittling Identity disorder: significantly and continuously borderline self-image or experience of self Impulsivity in at least two areas of potential self-harm (e.g., spending,
F60.30 Impulsive type  The predominant characteristics are emotional instability and lack of impulse control. Outbursts of violence or threatening behaviour are common, particularly in response to criticism by others. Includes: explosive and aggressive personality (disorder). Excludes: dissocial personality disorder (F60.2) F60.31 Borderline type  Several of the characteristics of emotional instability are present; in addition, the patient’s own self-image, aims, and internal preferences (including sexual) are often unclear or disturbed. There are usually chronic feelings of emptiness. A liability to become involved in intense and borderline relationships may cause repeated emotional crises and may be associated with excessive efforts to avoid abandonment and a series of suicidal threats or acts of self-harm (although these may occur without obvious precipitants). Includes: borderline personality (disorder)	sex, use of substances, reckless driving, binge eating). Note do not consider self-destructive behaviour or self-injury, etc., (criterion 5) Repeated self-destructive behaviour, gestures or threats suggesting it, self-cutting etc. Affective instability due to significant mood reactivity (e.g., intense episodic dysphoria, irritability, or anxiety, usually lasting a few hours and rarely longer than a few days) Chronic feelings of emptiness Inappropriate, intense anger or difficulty controlling anger (e.g., frequent sudden or constant anger, frequent fighting) Transitory stress-related paranoid thinking or severe dissociative symptoms
ICD-11 Diagnostic requirements (https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f37291724)  Personality Disorder 6D10 Personality refers to an individual’s characteristic way of behaving, experiencing life, and perceiving and interpreting themselves, other people, events, and situations. Personality Disorder is a marked disturbance in personality functioning, which is nearly always associated with considerable personal and social disruption. The central manifestations of Personality Disorder are impairments in the functioning of aspects of the self (e.g., identity, self-worth, capacity for self-direction) and/or problems in interpersonal functioning (e.g., developing and maintaining close and mutually satisfying relationships, understanding others’ perspectives, managing conflict in relationships). Impairments in self-functioning and/or interpersonal functioning are manifested in maladaptive (e.g., inflexible or poorly regulated) patterns of cognition, emotional experience, emotional expression, and behaviour. The diagnostic requirements for Personality Disorder present a set of Essential Features, all of which must be present to diagnose a Personality Disorder. Once the diagnosis of a Personality Disorder has been established, it should be described in terms of its level of severity:  6D10.0 Mild Personality Disorder  6D10.1 Moderate Personality Disorder 6D10.2 Severe Personality Disorder A category relevant to this grouping is:  QE50.7 Personality Difficulty Personality Difficulty is not classified as a mental disorder, but rather is listed in the grouping of Problems associated with Interpersonal Interactions in the chapter on Factors Influencing Health Status or Contact with Health Services. Personality Difficulty refers to pronounced personality characteristics that may affect treatment or health services but do not rise to the level of severity to merit a diagnosis of Personality Disorder. Personality Disorder and Personality Difficulty can be further described using five trait domain specifiers. These trait domains describe the characteristics of the individual’s personality that are most prominent and that contribute to personality disturbance. As many as necessary to describe personality functioning should be applied. Trait domain specifiers that may be recorded include the following:  6D11.0 Negative Affectivity  6D11.1 Detachment  6D11.2 Dissociality  6D11.3 Disinhibition  6D11.4 Anankastia Clinicians may also wish to add an additional specifier for ‘Borderline pattern’:  6D11.5 Borderline pattern The Borderline pattern specifier has been included to enhance the clinical utility of the classification of Personality Disorders. Specifically, the use of this specifier may facilitate the identification of individuals who may respond to certain psychotherapeutic treatments. The Borderline pattern descriptor may be applied to individuals whose pattern of personality disturbance is characterised by: A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, as indicated by many of the following (https://www.bpdfoundation.org.au/diagnostic-criteria.php#ICD11):  Frantic efforts to avoid real or imagined abandonment  A pattern of borderline and intense interpersonal relationships  Identity disturbance manifested in markedly and persistently borderline self-image or sense of self  A tendency to act rashly in states of high negative affect, leading to potentially self-damaging behaviours  Recurrent episodes of self-harm  Emotional instability due to marked reactivity of mood
Chronic feelings of emptiness  Inappropriate, intense anger or difficulty controlling anger  Transient dissociative symptoms or psychotic-like features in situations of high affective arousal A complete description of a particular case of Personality Disorder includes the rating of the severity level and the assignment of the applicable trait domain specifiers (e.g., Mild Personality Disorder with Negative Affectivity and Anankastia; Severe Personality Disorder with Dissociality and Disinhibition.) The Borderline pattern specifier is considered optional but, if used, should ideally be used in combination with the trait domain specifiers (e.g., Moderate Personality Disorder with Negative Affectivity, Dissociality, and Disinhibition, Borderline pattern).

BASIC CONCEPTS

Personality and temperament

The term “Personality” encompasses a dynamic set of functions and traits. Personality can be described on four levels:

• Personality traits (e.g., temperament, Panel 1).

• Characteristic means of adaptation and individual goals.

• Narrative self (e.g., identity).

• Dynamics of interaction relationships.

Panel 1.

The five-factor model of the personality disorders

The five-factor model is the most widely studied temperament model, and the most systematic research data is available on it. Temperament traits corresponding to it have been described in many different cultures[12]

Five factors with subsections (and ICD-11 pathological equivalents#)

Extroversion/positive emotionality

Warmth, generosity, assertiveness, activity, excitement seeking, positive emotions

ICD-11 (pathological equivalent): Detachment

Neuroticism/negative emotionality

Anxiety, hostility, depression, self-consciousness, impulsivity, vulnerability

ICD-11 (equivalent): Negative affectivity

Openness to experiences

Imagination, aesthetics, feelings, action, ideas, values

ICD-11: No equivalent

Agreeableness

Trust, honesty, altruism, adaptability, modesty, tenderness

ICD-11 (pathological equivalent): Dissociality

Conscientiousness

Competence, orderliness, sense of duty, goal orientation, self-discipline, judgment

ICD-11 (pathological equivalent): Anankastia

^#The ICD-11 trait domain of Disinhibition would map partly into dissociality and (low) conscientiousness in the Five Factor model of personality

“Temperament” refers to individual, biologically based skills in regulating emotions that can be recognized already in infancy. DSM-5 defines personality traits as persistent ways of perceiving, relating to others, and understanding oneself and the environment.[1] Among the personality traits, (i) emotional stability, (ii) conscientiousness, and (iii) social dominance continue to increase until the age of 30–40 years.[3,4] Traits of healthy and disturbed personalities seem to form a continuum.

Personality disorder

Borderline personality disorder (BPD) is associated with a limited, rigid, or unstable experience of the established self and self-concept and difficulties in interpersonal relationships. Accentuated negative emotionality is a hallmark of borderline personality but the condition is also associated with acute symptoms.[1,5]

When managing BPD, it is important to remember that the diagnostic criteria for borderline personality describe a heterogeneous group of patients.[6] And also that the disease burden of PD patients is comparable to severe physical diseases.[7]

EPIDEMIOLOGY

Global prevalence

PD have been found at varying rates all over the world. The prevalence of PD (as per DSM-5) in the general population is about 6%. Cluster-B PD, which includes borderline, antisocial, histrionic, and narcissistic PD, have an overall global prevalence of 1.5%.[8] PD is clearly more common in young adulthood than later.[9,10] In high-quality European population studies, the prevalence of borderline personality was reported to be 0.7%.[11] As per estimates, BPDs occur in 6% of primary care patients but the proportion of identified cases is probably much lower.[12,13] Western studies suggest that almost 60% of people with BPD may be in contact with primary healthcare services during the year, usually due to somatic symptoms and illnesses. The prevalence is relatively higher among young adults, women, and people with little education and low income.[14] There is no research evidence of an increase in the prevalence of BPD.

Indian prevalence

Systemic studies from India and other developing countries assessing the prevalence of PD are lacking. Early studies (from the late 1980s) reported the prevalence of PD in the general population ranging from 0% to 2.8%, with a weighted mean prevalence of 0.6%. Male gender was significantly associated with PD.[15] Most epidemiological studies conducted in India have systematically under-reported the prevalence because of sampling bias and other methodological flaws. The prevalence of PD among treatment-seeking Indian populations (0.3%-1.6%) is lower than that of western data (25%-50%). However, this difference is likely due to under-recognition.[15] A retrospective chart review (1996–2006) among North Indian patients seeking treatment in psychiatric outpatient settings reported a prevalence of 1.07% for ICD-10 PDs. The most common PD documented in the study were anxious-avoidant and borderline.[16] The reported rates are higher in special populations such as individuals in conflict with the law (7.3%-33.3%), individuals with substance use disorder(s) (20%-55%), and those who had ever attempted suicide (47.8%-62.2%).[15] A recent study on patients (N = 100) visiting the emergency department of a private hospital in eastern India using translated scales to screen for ICD-10 diagnosis of PDs found 24% of participants met the cut-off criterion.[17]

RISK FACTORS

Childhood antecedents

BPD is thought to arise either from the interaction of predisposing factors or from the worsening of a childhood or adolescent psychiatric disorder. As per the so-called exposure model, BPD results from an interaction between predisposing factors. As per the so-called complication model, it is primarily the result of another psychiatric disorder. Support for both models has been found in longitudinal research because the age of onset and gender seem to lead to different developmental curves.[10] In girls, internalising symptoms in early adolescence, such as anxiety and depression, may predict BPD in late adolescence (complication model), while externalising symptoms, such as defiance and conduct symptoms in adolescence, may predict BPD in adulthood (exposure model).[18,19]

Predisposing factors

Factors that increase the risk of BPD are also associated with other psychiatric disorders and physical illnesses. The accumulation of several factors suggests a higher probability of a disorder. Hereditary factors are known to be associated with personality traits and BPD.[20] In some patients, the emergence of the disorder may be related to organic and neurocognitive factors, such as encephalitis (inflammation), epilepsy, learning disorders, and childhood attention deficit hyperactivity disorder. Risk factors during pregnancy, such as maternal smoking, medical complications, and complications during childbirth, seem to increase the risk of BPD.[21] Those suffering from BPD report more difficult, traumatic childhood experiences than healthy controls.[22] Anxiety sensitivity and aggressiveness or hostility related to the temperament trait of negative emotionality and severe emotional abuse are independently associated with the risk and severity of BPD. Heightened rejection sensitivity may be related to emotional neglect.[23,24] Sexual abuse as a single factor apparently increases the risk of BPD little or not at all.[25] There is conflicting evidence about the association between dissociation symptoms and traumatic anamnesis in BPD. Dissociation can manifest as forgetfulness, a feeling that the self (depersonalisation) or the world (derealisation) has become alien, or as short-term hallucinations. BPD is significantly but weakly related to accumulating parenting problems. The parent’s mental disorder and lower socioeconomic status may be background factors for abuse and emotional neglect. Prolonged separations from parents in the preschool years are linked to symptoms of BPD in adulthood.[24]

Abnormalities of brain function have been observed in neurophysiological studies (EEG and arousal response studies).[26] BPD is associated with disruption of the functioning of the serotonin system in the fronto-limbic areas of the brain.[27] Brain changes that occur in patients with BPD, such as a decrease in the volume of the hippocampus and amygdala, are possibly related to childhood maltreatment, the severity of the disorder, and comorbidity.[28]

PRIMARY PREVENTION

There has been no research on the primary prevention of BPD. A BPD exposes children to problems in parenting; so, good treatment of the disorder is likely to be promoted by good parenting. Parental guidance has a positive effect on the parenting patterns of at-risk families and children’s behaviour problems. A wide-ranging program including nutrition, education, and exercise implemented in kindergartens may reduce disruptive behaviour and psychotic symptoms in young adulthood. Parental guidance reduces behavioural disorders in children and may reduce the costs caused by the continuation of behavioural disorders later.[29]

CLINICAL FEATURES

Core features of BPD

The core features of BPD are marked affective dysregulation, marked disturbances in self-image, unpredictable interpersonal relationships, and marked impulsivity. A model by Sanislow et al., 2022[30] summarised the features of BPD into the following three dimensions:

1. Impaired relatedness–Chronic emptiness, unstable relationships with others, and identity disturbance.

2. Affective dysregulation–Affective lability, excessive anger, and violent efforts to avoid abandonment.

3. Behaviour dysregulation–Impulsivity, suicidality, and self-injurious behaviour.

Affective instability was shown to be the most sensitive and specific single manifestation of BPD in a sizeable psychiatric OPD sample evaluated using a semi-structured interview.[31] All symptoms of BPD are associated with psychosocial impairment and poor quality of life. Chronic feeling of emptiness was found to be associated with the highest morbidity, including suicidality.

Other important presenting features of BPD

Suicidality

Suicidal threats, gestures, and attempts are common manifestations of BPD. Data on rates of suicidal ideas, attempts, and suicide deaths have varied markedly. In retrospective studies, the rate of death by suicide is between 8% and 12% among individuals with BPD.[32] Years of suicide threats and self-injurious behaviour may precede a completed suicide and therefore predicting a suicide outcome may be difficult. All reported suicide ideations or attempts should be taken seriously in patients with BPD. Suicide risk assessment is described later. Chronic feelings of emptiness, impulsivity, negative affectivity, and poor psychosocial function are commonly replicated chronic risk factors of suicide. More acute risk factors for suicide attempts in BPD include recent depressive episode, substance intoxication, adverse life event, and recent loss.[33]

Interpersonal difficulties

Patients with BPD usually have volatile relationships, especially with persons in close association.[34] A phenomenon called “splitting” often characterises the stormy relationship patterns where a support person (friend or romantic partner) is viewed as “all good”, loving and ideal when the patient’s needs are met, and at other times the same support person may be viewed as “all bad”, mean, or cruel. A feeling of abandonment drives the behaviour of anger, clingy demands, depressed mood, hopelessness, and suicidal thoughts and acts when the support person leaves (or is unable to meet the patient’s needs), even if for a short period. This alternating pattern of view may shift very rapidly, often with episodes of crisis in between. Patients with BPD often interpret neutral events, words, or faces as “negative”. Thus, the patient is prone to misinterpret relatively minor disagreements or adverse events as a sign that the caretaker or the therapist wants to terminate the relationship. This inclination to “split” can impact the relationship with the therapist and the treatment outcome.

Affective instability

Rapid and distressing intense changes in the affective state is a common presenting complaint in BPD. Changes in the emotional states can vary between happiness, intense anger, anxiety, panic attacks, dysphoria, sadness, and crying spells with interposing periods of euthymia. These mood shifts can happen within the span of a few hours and are frequently cued by environmental stress (e.g., fear of abandonment). However, affective dysregulation in BPD can also happen without any identifiable external factor. All efforts should be made not to miss a comorbid cyclothymia or more severe mood disorder.

Impulsivity

Impulsive and potentially self-damaging behaviour are common in BPD, with minimal regard for possible negative consequences. Impulsivity can manifest in many forms: substance abuse, binge eating, engaging in unsafe sex, spending money irresponsibly, involvement in physical fights, and reckless driving. The loss of control in sudden decisions or acts may manifest in damaging ways, for example, suddenly quitting a job that the person needs or ending a relationship that has the potential to last, thereby sabotaging their own success. Impulsivity can also manifest with immature and regressive behaviour and often takes the form of sexually acting out. Although the patient may regret their behaviour afterwards and may even appreciate its potential dangerousness, they may find it difficult, if not impossible, to resist the urge to repeat the behaviour. From a management perspective, impulsivity should be manifested in at least two areas of life to be clinically significant.

Deficits in the cognitive functioning

Neuropsychologic functioning in patients with BPD is impaired in many domains. BPD patients perform significantly worse on tests of attention, cognitive flexibility, learning and memory, planning, processing speed, and visuospatial ability.[35]

Nonsuicidal self-injury (NSSI)

Patients with BPD may hurt themselves. Patients may typically recognise the activity as a compulsive act to calm down “inner tension.” It helps them to relieve stress and avoid suicidal thoughts or behaviours. NSSI is often associated with acute substance intoxication and recent rejections and may lead to frequent emergency visits. Although NSSI is often not driven by a wish to die, it is crucial to assess for suicidal ideas or intent.

Presentation of BPD in different age groups

Adolescence

Although features of personality disorder in adolescence usually ameliorate with age, severe PD symptoms in adolescence seem to predict adult PD. Features of PD can be observed in some cases as early as six years of age when they can remain stable for several years. BPD can be reliably diagnosed in adolescence. Clinically significant features of BPD occur in 10% of young people. Diverse mood symptoms often accompany the condition. By the age of 16 years, 1.3% of young people can be diagnosed as suffering from a BPD. The variation in the comorbidity of the disorders is similar to that in adult patients except for suicide attempts, which are more common in BPD in youth. For some patients, the criteria for diagnosis are only met in young adulthood. It is recommended that BPD should be diagnosed correctly in adolescence, as it enables the timely mobilisation of the necessary social and clinical support measures. The use of mental health services is as common in adolescents with BPD as in adults in western countries. Understandably systematic data from India are limited.

Old age

The prevalence of BPD in public healthcare patients aged more than 80 years has been estimated at 0.3%. The clinical assessment of personality disorders is complicated by changes in personality and cognitive functions with age: chronic depression, cognitive changes related to ageing, and behavioural changes related to organic brain and systemic diseases. Symptoms of frontal and temporal lobe degenerative disease may resemble symptoms of BPD.

Presentations of BPD in different clinical settings

Emergency department (ED)

An individual with BPD may present to the emergency department (ED) with deliberate self-harm (DSH), nonsuicidal self-injury (NSSI), panic attack, stress-induced dissociative/psychotic episode, or physical aggression leading to conflict with the law (thus brought to the hospital by police). While in the busy ED, it is challenging to ascertain a BPD diagnosis for several reasons (including heightened emotional response, poor rapport, biased answering, lack of reliable informant, need for more emergent physical healthcare, and legal proceedings). However, the liaising psychiatry team should provide the option of further psychiatric services utilisation for in-depth assessment and care, especially because these individuals need more structured mental healthcare. A reliable informant, if available, may help in informed decision-making and shared responsibility in the continuation of care. In case a patient visits ED repeatedly, the attending mental health professional may need to address the immediate psychosocial issue and establish rapport so that the patient follows up for more regular outpatient care.

Outpatient department (OPD)

Individuals with BPD may consider visiting OPD in acute crisis (suicidal ideas, acute stress reaction, dissociative episodes), marital/family relationship conflicts, comorbid psychiatric illness (depressive disorder, anxiety disorder, problematic substance use), or being asked by competent authority (school/college authority, employer, court of law). A thorough assessment of premorbid personality, preferably from different sources with careful evaluation of the pattern of emotional responses and behaviour, helps the clinician diagnose BPD. A structured assessment using a prevalidated tool may help the clinician to achieve a diagnosis of BPD with higher confidence.

Inpatient department (IPD)

A thorough personality assessment should be done in all the patients using psychiatric inpatient services considering the high burden of BPD (~20%) in this group of patients. This is even more relevant in patients with treatment resistance, poor adherence to pharmacological treatment, and multiple comorbidities. A comorbid diagnosis of BPD may help therapists make a more comprehensive management plan, including long-term therapeutic approaches, addressing the issues of future crisis management and improving the overall quality of life.

ASSESSMENT

Structured clinical assessment

Usually, a single unstructured interview is inadequate to make a diagnosis of personality disorders. Hence, in clinical diagnostics, it is good to use a structured interview (e.g., International Personality Disorder Examination [IPDE]–Hindi translation is available) or assessment scales (IPDE Screen, Personality Disorder Questionnaire–Version 4 [PDQ-4]) and supplement the findings with comprehensive clinical observations. Various semi-structured interviews and self-assessment methods have been developed for the diagnosis of personality disorders, which are presented in Table 2. Internationally, the Semistructured Clinical Interview for DSM personality disorders (SCID-II/SCID-5-PD) is most commonly used in clinical practice and research settings to increase the diagnostic accuracy of personality disorders. The information received from a third party (e.g., informants) does not necessarily increase the reliability of the diagnostic assessment.

Table 2.

Structured methods for diagnosing personality disorders and borderline personality

Method name and abbreviation	International Personality Disorder Examination (IPDE)	Structured Clinical Interview for DSM IV Personality Disorders (SCID-II)	Structured interview for DSM-IV Personality Disorders (SIDP-IV)	Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BDP)	Borderline Personality Disorder Severity Index (BPDSI)	Diagnostic Interview for Borderlines (Revised) (DIB-R)
Coverage of personality disorders	All	All	All	Specific	Specific	Specific
Criteria
DSM-IV/5	X	X	X	X		X
ICD-10	X
Psychometric properties
Internal consistency (Cronbach’s alpha)	-	0.53-0.94	-	0.85	0.82-0.93	0.87
Inter-rater reliability	0.71-0.92	0.48 to 0.98	0.32 to 1.00	0.66-0.97	0.92-0.93	0.55 to 0.94
Test-retest reliability	0.62 to 1.00	0.38-0.63	0.16-0.84	0.59-0.96	0.72 to 0.77	0.57-0.73
Sensitivity	0.94	0.12 to 1.00	0.39	-	0.92 to 0.95	0.81-0.96
Specificity	1.00	0.72-0.97	-	-	0.90 to 0.95	0.88-0.94
Items and use
Number of questions	157	120	160	-	70	125
Response time (min)	90-120	30-60	30-90	-	-	60
Research use (R) or clinical use (C)	R/C	R/C	R/C	R/C	R/C	R/C

There are several confounders in the diagnosis of personality disorder. Issues related to culture, ethnic background, age of onset of the disorder, gender, developmental changes in personality, and current psychiatric symptoms may impact the presentation of personality traits. In diagnostics, attention should be paid to the duration of the symptoms because, in personality disorders, the symptoms should be recognisable at the end of adolescence or young adulthood and should describe the patient’s functioning in the long term. When making a diagnosis, it is necessary to ensure that the general criteria for a personality disorder are met. When evaluating the diagnosis, each symptom criterion must be evaluated in the light of whether the feature is clearly pathological, long-term, and manifested in different contexts.

Implementing good diagnostics in general/primary healthcare is not simple. A proper assessment can be supported by a psychiatric consultation. Ways to deal with challenging patient behaviour are described in the “Clinical management” section and in Panel 2.

Panel 2.

Borderline personality disorder in general/primary healthcare

Tips for patient interaction

Familiarise yourself with the symptoms of the disorder and the common causes of inappropriate behaviour.

Treating a borderline personality disorder patient can be demanding, even for an experienced clinician. You should not set your goals too high.

There is no quick fix for non-life-threatening self-injurious behaviour. Hospitalisation may not always be beneficial.

Take the patient’s experiences seriously and understand that they have their own reasons for experiencing things the way they do. Name the feelings you think the patient has, such as rejection, anger, and shame, before focusing on the ‘facts’. Identify the real stress experienced by the patient.

Avoid being provoked by the patient’s disturbing behaviour.

Give the patient regular, time-limited appointments, and make exceptions for new onset illness.

Work within the limits you set at the beginning of the treatment and deviate from them only in an emergency.

Good treatment can only be based on an agreement on the possibility of open communication with other parties treating the patient.

Avoid polypharmacy and prescribing large quantities of potentially toxic drugs, for example, tricyclic antidepressants and benzodiazepines.

Avoid prescribing potentially addictive drugs such as benzodiazepines, sleeping pills, and pain relievers that affect the central nervous system.

Set limits on histrionic and pushy behaviour without judging the patient and their actions.

The patient is always responsible for his actions (if it is not due to psychosis)

Do not reward disruptive behaviour by giving increased attention, manage them by offering regular appointments that do not depend on the patient’s harmful activity.

Psychological assessment

BPD is often accompanied by neuropsychological changes, especially related to executive functions. A lower ability to regulate information may evoke negative emotions related to emotional volatility. Disturbances in executive control may increase self-injurious behaviour.

Tests used for personality assessment can provide additional information about the person’s ability to function and ways of processing information. A widely used method is the Rorschach inkblot test. Exner’s Comprehensive System helps in scoring and interpreting its results. The Rorschach inkblot test should not be used to diagnose BPD; it is mainly useful for assessing thinking, quality of object relationships, emotional instability, and suicidality.

Assessment of comorbidities

Other comorbid disorders occur in 70% of those suffering from BPD. BPD patients may have multiple psychiatric disorders at the same time. It is also associated with higher physical morbidity than the rest of the population, which further increases the risk of suicide attempts. Common psychiatric comorbidities with BPD and tools to assess these comorbidities have been described in Table 3.

Table 3.

Assessment of psychiatric comorbidities in BPD

Comorbid psychiatric conditions	Clinical presentations	Clinical instruments
Major Depressive Disorder (MDD)	Episodes of major depressive disorders (MDD) are not uncommon among individuals with BPD, especially during stress. Additional treatment of MDD is essential during the episode.	Hamilton Depression Rating Scale (HDRS)
Dysthymia	Persistent low-grade depressive symptoms with distress lasting for years (≥2 years) is a common finding in BPD.	Cornell Dysthymia Rating Scale (CDRS)
Anxiety and panic attacks	Acute anxiety attacks and panic attacks are common manifestations of BPD. Episodes of attacks are more pronounced at times of perceived abandonment or rejection.	Hamilton Anxiety Rating Scale (HAM-A)
Insomnia	Insomnia is frequent. Comorbid depression, anxiety or substance use may add to the dysfunctions related to BPD.	Pittsburgh Insomnia Rating Scale (PIRS)
Somatic symptom disorder (SSD)	Somatoform pain symptoms are often a significant cause of occupational dysfunction in individuals with BPD. Adequate pain management significantly improves the quality of life.	Patient Health Questionnaire-15 (PHQ-15)
Dissociative disorders	Stress-induced dissociative episodes are common. Comorbid substance use disorder or depressive episode imparts diagnostic and management difficulties. Dissociative identity disorders are amongst the most difficult to manage.	Dissociative Experiences Scale (DES)
Impulse control disorder (ICD)	Intense anger may lead to harm to self and others. An additional diagnosis of ICD may be provided when impulse control issues predominate the clinical picture and pose significant dysfunction.	Minnesota Impulse Disorders Interview (MIDI)
Substance use disorders	Comorbid substance use poses a significant burden on physical and psychological health. The risk of impulsive harm to self and others is higher during episodes of intoxication and withdrawal.	Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)
Brief psychotic episode	Stress-induced paranoid symptoms lasting for a few hours are common. Additional diagnosis of brief psychosis may be required when psychosis persists for more than one day.	Brief psychiatric rating scale (BPRS)
Posttraumatic stress disorder (PTSD)	Childhood physical and sexual abuses are common. A comorbid diagnosis of PTSD may be provided when presented independently. When symptoms of BPD emerge after significant, chronic or repetitive psychological traumas, a diagnosis of complex PTSD may be given.	PTSD symptoms scale (PSS)
Eating disorders (ED)	Bulimia and other eating disorders can be present as comorbid conditions with BPD. Body image disturbance is common in both anorexia and BPD. An additional diagnosis should be given when the diagnostic criteria for an independent eating disorder are met.	Eating Disorder Diagnostic Scale (EDDS)

Assessment of medicolegal aspects

Self-harm and physical or sexual abuse may lead to legal involvement in individuals with BPD. Comorbid dissocial traits and illicit substance use can also lead to conflicts with the law. Understanding the local and central legal standards on these aspects may be necessary while deciding the locus and modus of treatment. While underlying legal issues should not limit access to treatment, thorough record keeping and maintaining high standards of care is very important. All efforts should be made toward frequent monitoring and staff members should be well informed to avoid any abuse during patient care.

Assessment of functional capacity

Impaired functioning related to BPD is corrected more slowly than symptoms of BPD. The social functioning, physical health, and financial situation of a person suffering from BPD should be comprehensively evaluated when planning treatment and rehabilitation. Cognitive rehabilitation, psychoeducation, and dialectical behaviour therapy (DBT) may increase the functional capacity of a person suffering from BPD.

Assessment of Quality of life

Assessment of functioning and quality of life is important in planning the course of management. WHOQOL-BREF is a validated 26-item self-rated questionnaire to assess the quality of life objectively. The Hindi form of this scale is validated. While symptom remission and better emotional control are the initial focus of treatment, early social and occupational rehabilitation helps in recovery and improved quality of life.

Assessment of the ability to work (disability assessment)

Deterioration of functional ability is often accompanied by a decrease in ability to work. The ability to work may be most impaired in youth and early adulthood, when the transition to working life may be threatened. Vocational rehabilitation courses can improve working/life skills in adults, adults with disabilities, and young adults (aged 18-25 years). Such courses aim to increase life skills and support access to working life or education.

For young people, the risk of being marginalised is high both when transitioning to working life and at the beginning of working life, when employment relationships are often temporary. To prevent the development of marginalisation, possible periods of sick leave should generally be limited to acute periods with severe symptoms of concurrent psychiatric disorders. Referral to enhanced vocational rehabilitation or its assessment and, if necessary, psychiatric rehabilitation is appropriate for the same reason.

If the patient has previously been able to work despite their disorder, it can be considered that their work disability is not solely due to BPD. Medical reports related to the patient’s ability to work must describe carefully:

• Symptoms

• Life course

• Diagnosis

• Ability to work and function in real situations

• Treatment attempts and their results

• Educational and work history

• Vocational rehabilitation plan

SPECIFIC ISSUES IN ASSESSMENT

Risk assessment

Assessment of the risk of harm to self/others is one of the most critical factors when formulating a management plan for BPD. A thorough history from the patient, relevant other informants and medical/legal records, followed by a detailed mental state examination, is crucial. When a patient’s thought is inaccessible and behaviour is unpredictable, appropriate precautions should be taken. Brief hospitalisation can be advised in such cases for further observations.

Factors indicating high suicide risk:

• High lethality of attempt

• Suicide intent

• Active planning

• Depressive cognition

• History of suicide attempts

• Recent loss

• Poor psychosocial support

Factors indicating a high risk for harm to others:

• Prior harm to or threatening behaviours toward dependent children

• Poor self-control on dangerous impulses

• Active homicidal thoughts

• Poor insight

Considerations for the Indian context

Presentation, interpretation, and treatment options for BPD may vary significantly depending on the culture. Although systematic data from India on the cultural effect on personality organisation and presentation are sparse, some points may be highlighted. Understanding and representation of self in the Indian context present as interdependent self with fluid and flexible interpersonal bonds.[36] Indian large and often joint families experience allow for frequent arguments/fights with minimal/no fear of abandonment, in stark difference to the western values of individualism and independence. Indian family constructs are tolerant of dependent or even manipulative acts (somatic complaints, provocative actions, misleading messages, and self-destructive acts), which are not considered particularly deviant unless they cause significant dysfunction in other areas of life or to the significant others. Cultural acceptance of psychosomatic expressions of distress also curtails the need for strong emotional responses during crises or interpersonal difficulties.

DIFFERENTIAL DIAGNOSIS

Disorders that are important for differential diagnosis of BPD are described in Table 4:

Table 4.

Differential diagnosis of the borderline personality disorder

Differential diagnosis	Description
Depression and dysthymia	Similar in their sense of emptiness and loneliness and the risk of suicide, BPD patients are convinced that they are self-sufficient, despite being dependent on others (it is particularly evident in the state of mania) while depressed people are aware of their need for help, but are usually capable of being completely autonomous. Sudden anger characteristics are rare in depression; although there are symptoms in common, in true depression a sense of mistrust with resignation prevails, in the borderline, this mistrust is accompanied by anger It is also necessary to distinguish the isolated reactive depressive episode from the maladaptive behavioural nature that underlies the depressive episode.
Bipolar disorder	“Bipolarity” differs from “borderline personality disorder” mainly due to the degree of pervasiveness in the subject’s psychic sphere. In the BPD, the oscillation is frequent, and the cycles are short, they last a few days or a few hours. The overhang is usually reactive to something that has to do with the perception of rejection by the other. Minimal signs of disinterest rather than alleged frustrations or losses are magnified and dramatised. In bipolar disorder, the oscillations are more discontinuous and lasting and can occur unexpectedly, regardless of the external situation.
Post-traumatic stress disorder	Both have anxiety, fear, and anger, but in posttraumatic stress disorder, the trauma that caused it is evident and often recent, even if it may develop in the BPD.
Somatoform disorder	In BPD, there is no real simulation of all the symptoms of a pathology but mainly an altered emotional state. Somatic symptoms are commonly manifested in BPD.
Histrionic PD	Both BPD and Histrionic PD want attention. The individual with histrionic PD seeks companionship and often appears happy in appearance, puts in place a seductive and sociable appearance. The individual with borderline PD shows his anger and frustration.
Narcissistic PD	Both are very sensitive to criticism, but the narcissist has a fixed sense of his superiority (grandiose self) that the borderline does not have stably.
Antisocial PD	Borderline antisocial behaviours (transgressing the rules, lying, manipulating) can occur, but the patient never loses the sense of guilt or the ability to feel remorse, while the BPD can repress them, but they are always very present.
Schizotypal PD	Both BPD and Schizotypal PD present with cognitive distortions, behavioural eccentricities and semi-psychotic symptoms during crises (e.g., delusions, paranoia, derealisation, depersonalisations and dissociations). The symptoms of schizotypal PD are deeper, often with unusual perceptual experiences, bordering on schizophrenia, unlike BPD. BPD and Schizotypal PD have in common - unstable emotionality (rapidly fluctuating mood) and the fear of social and personal rejection. However, the individual with BPD can look a lot like schizotypal, especially if it has comorbidities with psychotic or obsessive symptoms.

PROGNOSIS

Remission is common in BPD and, once achieved, is usually stable.[37] More than half of the patients suffering from BPD no longer meet the diagnostic criteria for the disorder after five years. Likewise, depressive symptoms are alleviated and functional capacity recovers clinically significantly in a few years. Among the signs, the fastest to relieve are self-destructiveness and identity diffusion. Impulsivity and fluctuations in emotional life are relieved more gradually with increasing age. As personality instability eases, mood and anxiety disorders also decrease, but do so more slowly. Depression slows down recovery from BPD. Comorbid PDs have also been found to be alleviated in patients with BPD during a six-year follow-up.[38]

The treatment results seem to be poor when people suffering from BPD have a lifestyle predisposing them to chronic diseases and high utilisation of health services. Even at the age of more than 50 years, the features of BPD may cause failures in relationships. Key prognostic factors are summarised in Table 5.

Table 5.

Factors predicting the outcome of the treatment of borderline personality during a 10-year follow-up period

Factors explaining recovery	HR=hazard ratio
Faster recovery
The severity of perceived violence	HR 0.94, P<0.03
No sexual abuse	HR 1.48, P=0.006
Childhood intellectual ability	HR 1.03, P<0.05
No PTSD symptoms	HR 1.56, P=0.002
No concurrent cluster C personality disorder	HR 1.84, P<0.001
No previous hospitalisations	HR 1.68, P=0.001
The parents do not have a mood disorder	HR 1.38, P<0.03
The parents do not have a substance abuse disorder	HR 1.84, P<0.001
Good professional development	HR 1.68, P<0.001
Temperament
Agreeableness	HR 1.04, P<0.001
Conscientiousness	HR 1.03, P<0.001
Extroversion	HR 1.04, P<0.001
Slower recovery
Temperament
Negative emotionality	HR 0.96, P<0.001
Severity of neglect	HR 0.98, P<0.002
The severity of the abuse	HR 0.96, P<0.002

MANAGEMENT

Central to the treatment of someone suffering from BPD is psychotherapeutic methods. They can be combined with other forms of treatment. The therapeutic relationship and the effectiveness of the therapy may be jeopardised if shame is not recognised in the therapeutic relationship and in the patient’s most central emotional experiences. As per patients’ reports, recovery is facilitated when the care provider offers security, respect, trust, and understanding while guiding toward change by being appropriately active and using specific strategies. At the beginning of the treatment, the therapist should:

• Carry out a wide-ranging risk assessment,

• Define crisis management options,

• Work on the details of the treatment in coordination with the patient, and

• Avoid communication that increases stigma or negatively judges the patient.

Treatment utilisation

It may be helpful to understand the treatment of borderline personality as per the well-known phase model of substance use treatment:

• In the precontemplation phase, there is a lack of awareness of the need for change.

• In the contemplation phase, the advantages and disadvantages of the change seem equal.

• In the preparation phase, the person suffering from the disorder has understood the need for change and tells others about it.

• In the action phase, the person suffering from the disorder is committed to their treatment and works for change.

Typical features in the treatment of those suffering from borderline personality are:

• Abundant and short-term use of different treatment services and forms (Emergency services, primary/general healthcare, specialist mental healthcare, complementary/alternative help).

• Difficulty adhering to treatment agreements can complicate the treatment of both mental and physical illnesses.

• Difficulty establishing a long-term psychotherapeutic treatment contact: the patient usually attends psychotherapy only for a short time and ends up using the services of many different therapists.

Clinical risk factors for discontinuation of psychotherapy include (1) high aggression and impulsivity, (2) high comorbidity with other mental disorders, and (3) high lifetime suicide attempts.

Symptoms of BPD are often connected to somatic problems and increased use of health services. In western countries, almost half of the BPD patients in general/primary care may be without appropriate psychiatric treatment and the need for treatment may not be noticed. The situation is likely to be worse in India. Patients with BPD who are being treated in general/primary healthcare often use a lot of general/primary healthcare services, are often in contact with doctors by phone between appointments, and take several different medications at the same time. When BPD is treated in general/primary care, it is beneficial to offer regular office visits (regardless of the physical health status) to avoid frequent and impulsive use of services. The patient’s anxiety is relieved by the knowledge that the doctor will not leave him without support. It is appropriate for the primary/general health services to be in contact with the many entities that provide the BPD patient social and healthcare services because of their multiple needs, for example, people suffering from BPD in general/primary care have remarkably frequent childhood trauma experiences.

Assessment of the need for treatment

When assessing the need for treatment, attention must be paid to current and long-term symptoms:

• For planning consistent, patient-friendly, and systematic treatment.

• To provide a long-term care relationship.

• For intermittent, symptomatic treatment, which may be sufficient for those with milder symptoms.

The following must be taken into account when assessing the patient’s risk

• Acute and chronic suicidality.

• Suicide plans.

• Previous plans and attempts.

• Factors that potentially threaten the care relationship.

• Impulsivity and substance use.

• Degree of distress and hopelessness.

• The ability to perceive alternatives.

• The ability to experience and receive care.

Telling the diagnosis

The diagnosis should be told to the patient to promote their autonomy and support patient education and cooperation. It is necessary to provide the patient with information about what a borderline personality means, what is supposed to cause it, and the current understanding of effective treatment. Telling the diagnosis and psychoeducation have been found to affect the therapeutic relationship positively. Psychoeducation may alleviate symptoms of BPD.

Psychotherapies

Randomised controlled studies on sufficiently large samples and diagnostically specified naturalistic follow-up studies on the effectiveness of psychotherapies for borderline personality are available.[39] In all psychotherapy studies, the patients have received drug treatments at the same time. A summary of psychotherapy methods studied in controlled settings is presented in Table 6.

Table 6.

Psychotherapy methods that have been studied in a randomised and controlled manner. Source: Koivisto M. 2020

	Dialectical Behaviour Therapy (Marsha Linehan)	Mentalisation Therapy (Anthony Bateman & Peter Fonagy)	Schema Therapy (Jeffrey Young)	Transference- focused therapy (Otto Kernberg, John Clark, and Frank Yeomans)	STEPPS (Systems Training for Emotional Predictability and Problem Solving) (Nancee Blum and Donald Black)	A group aimed at accepting emotions (Kim Gratz)	Good general psychiatric management (John Gunderson)
Background theories	Emotion theory Dialectical philosophy Mindfulness Cognitive behavioural therapy Biosocial theory	Psychodynamic theory of development Attachment theory Object relations theory Cognitive theory	Cognitive-behavioural theory Attachment theory Constructivist theory Object relations theory Character psychotherapy (Gestalt)	Object relations theory	Cognitive-behavioural theory Schema therapy System theory	Acceptance and commitment therapy Dialectical behaviour therapy	Attachment theory Psychodynamic and behavioural theory “Common sense”
A core understanding of borderline personality disorder	Emotion regulation disorder	Background insecure (often unstructured) attachment relationship with lower ability to mentalise, especially in attachment contexts and in association with strong emotional experiences	Failure to meet the child’s basic emotional needs and respond to them	Object imagery dominated by the use of splitting as a defence mechanism	Disorder of emotional intensity and regulation	Difficulty regulating emotions	Interpersonal hypersensitivity Interpersonal attachment problems
Key therapy goals	Learn to validate self and then others Learn new coping ability for possible difficult situations Working towards personal life goals	Promoting and maintaining mentalisation in as many contexts as possible Recognising feelings and expressing them appropriately to others Taking personal responsibility and interacting with others	Learn to recognise, accept and express basic emotional needs Recognising schemas and modes, understanding their development and gradual correction of schemas Survival modes gradually become redundant Reducing the power and influence of harmful authority modes Strengthening wise adult mode	Integration of loosely integrated part-object relationships and gradual transition to the world of intact and stable human relationships	Increasing self-understanding Identifying early maladaptive schemas and other emotional and behavioural triggers Learning emotion regulation and other skills Connecting the patient to the network	Promoting acceptance and adaptive regulation of emotions Learning skills that facilitate awareness, understanding and acceptance of emotions Inhibition of affective behaviour but not emotion	Therapist acts as a centre of gravity In handling the patient’s real-life interaction relationships In problematic attachment patterns In regulating emotions, especially in interactions In supporting functioning and work ability
Treatment implementation	Individual psychotherapy (once a week) Group skills coaching (once a week) The possibility of telephone consultation between meetings Consultation among the team of therapists The duration of treatment is one to three years	Day hospital model: Individual psychotherapy (once a week) Group psychotherapy (thrice a week) Optional: creative therapy groups Community meeting (every week) Monitoring of drug treatment (monthly) Duration of treatment: one and a half to three years Outpatient model: Individual psychotherapy (once a week) Group therapy (once a week) Telephone support in case of crises Monitoring of drug treatment Duration of treatment: one and a half years Can also be offered in hospital conditions	Individual psychotherapy (once or twice a week) Duration of individual psychotherapy: in studies, one and a half to four years, ideally as long as the patient needs Also developed group therapy to be offered alongside other treatment: 30 sessions	Individual psychotherapy (twice a week) Duration of treatment: one to four years in studies	Psychoeducational group: 20 sessions (weekly) Alongside the existing treatment	Educational group: 14 sessions (weekly)	Regular contact with a psychiatrist or psychologist (weekly) Psychoeducation about emotional instability for the patient and family Case management Family get-togethers It can be combined with various group treatments Medical treatment, if necessary Duration of treatment: ideally as long as the patient needs

Access to psychotherapy as per effective methods is limited in India and it is necessary to improve the coverage of training/education of mental health professionals. The psychotherapist must have experience in the treatment of people suffering from BPD or receive close supervision as support. About a third of those receiving psychotherapy have been found to have only a mild PD,[40] suggesting a need for better prioritisation of services.

Psychotherapy for BPD

Psychotherapies of limited duration are useful in the treatment of PDs. A person suffering from PD may also benefit from group psychotherapies.

DBT reduces difficulties in regulating emotions, impulsivity, and feelings of emptiness. It also reduces hostility and self-injurious acts (including suicide attempts) in women with BPD better than treatment as usual. In addition, DBT reduces substance use in women with BPD who have a comorbid substance dependence. The treatment result of DBT in reducing symptoms of instability, suicide attempts, and self-harming acts is apparently just as good, even if the patient has concurrent posttraumatic stress syndrome. Even short-term (20 weeks) DBT, in which only group skills training is implemented, is effective for typical symptoms of BPD and reduces the number of self-harming acts.[41]

Cognitive-behavioural therapy (CBT) is more effective than treatment as usual.[42,43] CBT may be more effective than treatment as usual in reducing post-traumatic stress symptoms in patients with BPD. Short-term interventions derived from CBT may also be equally effective.

Schema-focused psychotherapy apparently reduces, at least in women, the severity of BPD and the anxiety and depressive symptoms associated with it and improves the quality of life.

Mentalisation therapy is effective in the treatment of BPD and mentalisation therapy implemented in outpatient care is as effective as mentalisation therapy implemented in day hospital treatment. In a study conducted in Great Britain, mentalisation therapy was found to be effective even in patients with several comorbid PDs. Mentalisation therapy is effective even in young people.[44]

Transference-focused psychotherapy is effective in patients suffering from BPD. Systematically implemented supportive group therapy that includes psychoeducation and is based on a psychodynamic model may also be effective. Transference-focused psychotherapy, supportive psychotherapy, and DBT may be equally effective in treating depression and anxiety symptoms and improving functioning in people with BPD.[45]

The STEPPS program (Systems Training for Emotional Predictability and Problem Solving) implemented in an outpatient setting, in addition to the existing conventional psychiatric treatment, apparently has a large effect on the symptoms and functional capacity of BPD.[46] A 14-week emotion regulation group aimed at understanding and accepting emotions, implemented alongside the patient’s existing outpatient treatment, seems useful in the treatment of women suffering from intentional self-harm and BPD or its features. Young people suffering from BPD may also benefit from emotion regulation coaching.

Experts disagree about the usefulness of long-term and intensive (e.g., inpatient) psychotherapy in the treatment of patients with BPD. In a small naturalistic group comparison study, it was found that a therapy designed for BPD and based on a manual (DBT and dynamic-deconstructive psychotherapy) was more effective than conventional psychotherapy.[47]

When considering long-term psychotherapy, it is necessary to make an accurate diagnosis and pay attention to the patient’s (i) ability to build relationships, (ii) severity of self-esteem vulnerability, (iii) impulsivity, and (iv) antisociality. Problems on these dimensions may indicate a risk of complications when using therapy other than that designed for treating BPD.

DBT is the recommended form of therapy in the early stages of the disorder. Hospital treatments are frequent if the symptoms are severe, especially if self-harming behaviour is frequent.[48]

Family therapy

Educational and skill-oriented family interventions offered in groups may improve family functioning and the relatives’ wellbeing. Counselling families can lighten the burden on relatives and alleviate potential conflicts between the patient and relatives and between relatives and care providers. The most common family problems are communication difficulties, dealing with hostile reactions, and fear of the patient’s suicide. Key principles and features of family psychoeducation[49] are:

• Provision of information about treatment and prognosis and the verification of understanding of the information provided.

• Reduction of expressed emotions (expression of anger and criticism within the family).

• Increasing the ability of family members to take each other’s experiences seriously and considering them valid from the individual’s perspective.

Family intervention should usually be started at the beginning of the treatment.

Drug and neuromodulation treatments

In some patients, antipsychotics reduce hostility, suspiciousness, affect dysregulation, cognitive and perceptual distortions, psychotic symptoms, and intentional self-harm related to BPD.[50]

The mood stabilisers valproate, carbamazepine, lamotrigine, and topiramate may reduce the impulsivity and aggressiveness associated with BPD in some patients. Valproate should be used in women of childbearing age or pregnant women only if other treatments are not effective or appropriate. Oxcarbazepine may also be a useful alternative.

Selective serotonin reuptake inhibitors may reduce the difficulty of impulse control and emotion regulation associated with BPD in some patients [Table 7].[40,51-54]

Table 7.

Psychotropic medications for the treatment of personality disorders

Drugs used in PD	Doses (mg/day)	Indications in PD	Level of evidence	Strength of recommendations
Escitalopram	5-20	Impulsivity, anger, affective instability, depression, self-harm, and anxiety symptoms	Level II	Strong
Sertraline	50-200	Same as escitalopram (maybe better tolerated by some individuals)	Level II	Strong
Mirtazapine	7.5-45	Depression, anxiety, and somatic symptoms	Level IV	Weak
Lamotrigine	25-275	Affective instability, impulsivity, anger, and aggression	Level II	Weak
Topiramate	100-250	Aggression and somatic symptoms (e.g., headache)	Level II	Weak
Divalproex	250-1500	Impulsivity, anger, aggression, and substance use	Level II	Weak
Olanzapine	2.5-20	Inappropriate anger, impulsivity, paranoid ideation, and dissociative symptoms (side effects may lead to poor adherence to treatment in higher doses)	Level I	Strong
Aripiprazole	5-30	Anger, depression, anxiety, and self-harm	Level II	Weak
Risperidone	0.5-8	Anger, cognitive inflexibility, paranoid ideation, and affective instability	Level II	Weak
Quetiapine	25-600	Sleep disturbance, cognitive inflexibility, paranoid ideation, and affective instability	Level II	Weak

PD, Personality disorder; RCT, Randomised controlled trial; SUD, Substance use disorder. [Level of evidence] Level I: Large RCTs with clear-cut results; Level II: Small RCTs with unclear results; Level III: Cohort and case-control studies; Level IV: Historical cohort or case-control studies; Level V: Case series, studies with no control. [Strength of recommendations] Strong: Indicates confidence that the benefits of the intervention clearly outweigh harms; Weak: Indicates uncertainty (i.e., the balance of benefits and harms is difficult to judge or either the benefits or the harms are unclear)

Benzodiazepines are not a recommended drug treatment for the symptoms of BPD. There is no high-quality treatment research available on their use in the treatment of BPD. Once started, stopping the use of benzodiazepines is very difficult for patients with cluster BPDs including BPD; hence, the development of benzodiazepine dependence is a significant risk in BPD. Benzodiazepine may also increase impulsive behaviour. Alternatives to benzodiazepines may include buspirone and pregabalin, which have been shown to be effective in treating generalised anxiety disorder and are nonaddictive. However, their use has not been studied in the treatment of borderline personality. Pregabalin enhances the effect of narcotics, so it is not suitable for drug-dependent patients due to the risk of abuse. In some patients, intranasal oxytocin may relieve the anxiety associated with borderline personality in social situations but the treatment results so far are contradictory, and oxytocin is not yet in general clinical use in the treatment of borderline personality.

The results of a few small studies suggest that omega-3 fatty acids may alleviate symptoms associated with borderline personality. Supervised disulfiram treatment can be helpful in the treatment of alcohol dependence in patients with a borderline personality disorder.

Electroconvulsive therapy does not alleviate symptoms of BPD. However, BPD is not a contraindication to electroconvulsive therapy for depression. Repetitive transcranial magnetic stimulation may relieve anxiety related to BPD in some patients, but to date, it is an experimental treatment for this indication.

The effort to alleviate the different psychiatric symptoms of BPD may lead to inappropriate polypharmacy. When planning drug treatment, one must consider the increased risk of suicide with drugs and the risk of impulsive suicide attempts, susceptibility to drug dependence, substance use and self-will in the implementation of drug treatment, and the patient’s other illnesses.

Hospital treatment

The planning of treatment requires an integrated service package. A short crisis intervention in the emergency department, combined with subsequent specialised outpatient treatment, can reduce the need for psychiatric hospital treatment in the follow-up of an acutely suicidal borderline personality patient. A crisis treatment plan designed and agreed together with the patient guarantees the durability of the treatment relationship but does not seem to increase the effectiveness of the treatment.

Issues needing round-the-clock hospital care include:

• Acute serious suicidal risk;

• Psychotic symptoms that are not controlled in outpatient care;

• Severe dissociation symptoms, accompanied by significant impairment of functional capacity;

• Severe mood disorder; and

• Uncontrolled substance use in a patient with severe symptoms.

Standard, reliable, and comprehensive research evidence on the results of round-the-clock hospital care is not available. Due to the risk of deterioration of the clinical condition and especially an increase in self-harming activity, the treatment period must be as structured as possible, as additional support and experience of the predictability of the environment can improve the patient’s wellbeing. Sending a patient to an unstructured program may do more harm than good when the patient has made a mild suicide attempt related to chronic suicidality. In the context of hospital treatment, it is appropriate to determine the patient’s wishes for his treatment and the priority of the treatment methods and to jointly agree on a plan for the continuation. Stormy emotionality may arouse difficult emotional reactions in treatment units. Managing them is important to reduce risks.

Very intensive inpatient treatment based on evidence-based psychotherapies for borderline personality, provided by staff trained in that treatment model, may be helpful. In the treatment of borderline personality, mentalisation therapy implemented in day hospital conditions is effective. Characteristics of effective day hospital care are:

• Flexible, structured care;

• Consideration of compliance with treatment;

• A clear goal;

• A consistent and shared understanding of BPD; and

• Integration into the rest of the care package.

Clinical management of borderline personality

The following principles are central to the clinical management of BPD:

• The treatment has a clear framework.

• The work has jointly agreed goals and targets.

• The therapist is active.

• Emotions are at the center of work.

• The quality of the relationship is constantly monitored.

Mindfulness may lay the foundation for the ability to recognise and name emotions and regulate them. Ways to modify behaviour in managing symptoms include, for example, shifting attention elsewhere and using substitute activities. The patient can direct his attention to pleasant or everyday activities. Compensatory activities refer to less dangerous means of affect regulation compared to suicidal, impulsive, or otherwise harmful behaviour. Among other things, intense physical activity or the use of cold sensations have been recommended in this context. For example, the patient can submerge his hands up to the forearms in cold water or hold an ice cube in his hand. Relaxation, positive mental imagery, and reminder cards or a diary can also be used to manage symptoms. Behavioural therapeutic methods can produce the first experiences that it is possible to regulate emotional states.

Some patients may continue the harmful and addictive use of medicines. In this case, an attempt can be made to ensure appropriate treatment, for example, by notifying the pharmacy (with the patient’s agreement).

Clinical management of crises, dissociations, and anger

Increasing distress (escalating dysphoria) means an expanding, intense, and often panic-like feeling of discomfort, which is often accompanied by impulsivity, such as self-destruction, cognitive fragmentation, and dissociation. The patient’s emotional experiences should be taken seriously so that instead of the content of the crisis, the focus is on the patient’s feelings and a clear understanding of his/her current situation and experiences. In a crisis, patients hope more for sensitive listening, genuine interest, and presence than for a concrete answer to the problem in question. Patients perceive the assessment of interpersonal motives and cognitive reformulation before the formation of a good cooperative relationship as belittling. A strong increase in external control, criticism, or a counter-assertive style must be avoided, as they seem to increase the risk of worsening the crisis.

A flexible and warm attitude that takes the patient’s experiences seriously is considered important in the treatment of dissociative states and difficulties in regulating emotions. The soothing speech of the person caring for the patient can bring relief when the patient’s emotional arousal or cognitive fragmentation increases or s/he begins to suffer from dissociation. When dissociation symptoms have already appeared, the patient can be reassured, for example, by telling them that the symptom is very unpleasant but temporary. Many patients need coping mechanisms to manage their dissociative symptoms before they are able to discuss their traumatic experiences.

In anger management, the patient is first allowed to vent his anger, after which he can be asked to describe his anger in more detail. When the anger has levelled off, the goal is to examine the emotional experience and its expression realistically together with the patient in such a way as to avoid a punitive attitude and rejection of the patient’s experience. Only when the emotional state has calmed down is it possible to examine the patient’s own possible contribution to the problems.

Pain-reducing medical treatment can be used if necessary.

REHABILITATION

A multiprofessional assessment of the need for rehabilitation is appropriate in association with the monitoring of psychiatric treatment. The patient may benefit from psychiatric rehabilitation if their ability to function is severely impaired over a long term (e.g., prolonged sick leave, long-term employment difficulties) or if s/he has deficits in psychological functioning, such as the inability to organise his/her own life and plan for the future. The patient’s need for neuropsychological rehabilitation must be assessed, especially when s/he has specific learning or other neuropsychological deficits.

Working life skills can also be improved with vocational rehabilitation. Group-based course activity, for example, adaptation training, may be suitable for youth with disabilities. People suffering from mental health disorders in working life can apply for disability benefits.

ORGANISATION OF CARE SERVICES

The systematic planning of the treatment of borderline personality requires the establishment of special clinical teams to ensure sufficient competence and effective continuing professional education of team members and other healthcare professionals. The main responsibility for diagnosis, treatment, and integration of treatments belongs to the psychiatric outpatient unit, which works in close cooperation with the psychiatric hospital department, general/primary healthcare, substance abuse treatment, the social sector, and the providers of psychotherapy services. The treatment of a person suffering from a borderline personality should be organised and carried out as far as possible in outpatient care and, in the case of hospital treatment, in day hospital conditions.

The primary task of general/primary healthcare is to screen patients and refer them to specialised medical care. Preparing for crisis situations is the cornerstone of treatment. However, where applicable, treatment can be arranged in general/primary healthcare.

The coordination of the patient’s overall care is facilitated by naming a responsible person or clinical team. The service supervisor is responsible for monitoring the implementation of the treatment plan and, if necessary, gives other operational units advice to support treatment measures or decisions.

Health and substance abuse services must be coordinated flexibly and by promoting the possibility of smooth consultation. The patient benefits more from the treatment if both substance abuse disorder and psychiatric disorder are treated in the same unit.

Patients may simultaneously use various social welfare services, such as child protection support measures and income support. Cooperation with different actors can be promoted in network meetings, which are especially necessary for the treatment of patients at risk of exclusion.

General/Primary healthcare

Psychiatric consultation

The possibility of psychiatric consultations can increase the general/primary care physician’s ability to assess the patient’s need for treatment. It is necessary to organise adequate opportunities for regular consultations. It is often appropriate to conduct consultations on a long-term basis. Regular consulting activities can also serve as a form of continuing education. Psychiatric consultation is especially relevant when:

• The patient uses a lot of health or social care services;

• The patient does not commit to the treatment of his physical illness;

• The symptomatology is difficult to control, but the patient does not want hospital treatment;

• The need for involuntary care is assessed as required by law;

• The symptomatology presents a differential diagnostic problem; and

• The treatment given by the general practitioner has not produced a sufficient result.

Care in general/primary health setting

Most people with personality disorders use general/primary healthcare services like the rest of the population. People who have personality disorders almost invariably come to treatment because of a physical illness or their symptoms, other mental disorders, or a difficult life situation. BPD may lead to problems with adherence to medical treatment.

Regarding the treatment of other disorders/diseases, it is generally necessary to follow the criteria set for them. The general/primary care doctor should have at their disposal, consultation, and/or supervision of specialised medical care that is required by the situation and can be implemented quickly enough, especially in threatening situations. A personality disorder may require more specific psychotherapeutic and drug treatment carried out in a mental health specialist care when the patient has

• Long-term and recurring problems,

• Difficulties that are not limited only to crisis situations,

• A threat of loss of functional capacity,

• A threat of loss of ability to work or study,

• Low motivation for treatment, and

• Less ability to commit to treatment.

Patients suffering from hypochondriasis, somatisation symptoms, or many somatic diseases should primarily be treated in general/primary care. When a person suffering from a borderline personality uses a lot of general/primary care services, a general/primary care doctor should (i) actively consult specialised psychiatric care; (ii) establish a confidential, contractual treatment relationship with the patient (it is good to set motivation for treatment as the first goal because it may be very difficult for the patient to enter into a regular treatment relationship and comply with agreements); (iii) prepare a treatment plan as per the patient’s needs; and (iv) assess and, if necessary, intervene in the patient’s risky behaviour, such as suicidality.

The patient’s risk behaviour is addressed by expressing concern about the patient’s functioning, by offering the opportunity to talk about burdensome matters in calm conditions, and by openly asking what kind of help the patient expects during the critical phase. After the critical phase, the patient’s condition should be actively monitored and the patient should be explained that the attending physician is not always available and that there are alternative care providers from whom help is available during emergency hours.

The attending physician should be aware that the patient evokes strong emotional reactions in care providers, which may be difficult for the doctor to tolerate and may complicate the patient’s treatment. S/he should cooperate with specialised psychiatric care and, if necessary, substance abuse services.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.