Table 4.
Studies on BPD diagnosis.
| Diagnostic Criteria | ||||
|---|---|---|---|---|
| Study | Study Design | Sample | Trial Duration | Outcomes |
| Zimmerman et al., 2012 [131] | Cross-sectional study; clinical population | 3,200 psychiatric outpatients (1,976 with 0 or 1 DSM-IV criterion for BPD) | - | Low-severity levels of borderline personality disorder pathology can be determined reliably and have validity |
| Zimmerman et al., 2013 [132] | Cross-sectional study; clinical population | 3,069 psychiatric outpatients | - | Dimensional scoring of BPD more important for subthreshold levels of pathology, less critical once a patient meets the diagnostic threshold |
| Ellison et al., 2016 [133] | Cross-sectional study; clinical population | 1,870 adult psychiatric outpatients | - | BPD criteria of impulsivity, affective instability, emptiness and anger → dysfunction; emptiness → marker of impairment on all indices of psychosocial morbidity |
| Clinical assessment | ||||
| Study | Study design | Sample | Trial duration | Outcomes |
| Ramklint et al., 2003 [134] | Cross-sectional study; clinical population | 158 former inpatients (Mage = 30.5 years) | - | Identification + treatment of childhood psychiatric disorders → ↓ risk for development of an adult PD |
| Thatcher et al., 2005 [135] | Longitudinal study; community and clinical population | 355 adolescents with AUD and 169 adolescents without AUD aged 16 to 22 years | 6 years | AUD and other adolescent psychopathology can culminate in BPD symptomatology |
| Chanen et al., 2007 [136] | Cross-sectional study; clinical population | 177 psychiatric outpatients aged 15 to 18 years (46 with BPD, 88 with other PDs and 43 with no PDs) | - | BPD → psychopathology, general functioning, peer relationships, self-care and family and relationship functioning (> than Axis I disorders and other PDs) |
| Miller et al., 2008 [137] | Longitudinal study; community and clinical population | 96 adolescents with ADHD and 85 HCs, aged 16 to 26 years old | 3 years | Childhood ADHD → ↑ risk for PDs in late adolescence. |
| Belsky et al., 2012 [83] | Longitudinal cohort study; community population | 1,116 pairs of same-sex twins followed from birth through age 12 years | 12 years | BPD-related characteristics at age 12 years co-occurred with symptoms of conduct disorder, depression, anxiety and psychosis |
| Wolke et al., 2012 [89] | Longitudinal study; community population | 6,050 mothers and their children drawn from the Avon Longitudinal Study of Parents and Children (ALSPAC) | 11 years | Peer bullying and chronic victimization → ↑risk of BPD symptoms |
| Stepp et al., 2012 [138] | Longitudinal cohort study; community population | 1,233 girls drawn from the Pittsburgh Girls Study, aged 10 to 14 years | 4 years | ↑ levels of ADHD and ODD scores at age 8 → BPD symptoms at age 14 |
| Stepp et al., 2013 [52] | Longitudinal cohort study; community population | 1,709 students (14–18 years old), of which 360 had a history of a depressive disorder and 284 had a history of mood disorders, compared with 457 HC | 16 years | Maternal-child discord, maternal BPD, paternal SUD, + proband depression, SUD, and suicidality → later BPD symptoms |
| Ha et al., 2014 [20] | Cross-sectional study; clinical population | 335 adolescent inpatients (aged 12–17 years), 33% with BPD | - | Adolescent inpatients with BPD → ↑rates of psychiatric comorbidity |
| Stepp, Whalen et al., 2014 [43] | Longitudinal cohort study; community population | 2,451 girls aged 14 -17 drawn from the Pittsburgh Girls Study | 3 years | Child impulsivity and negative affectivity, as well as caregiver psychopathology, were related to parenting trajectories, while only child characteristics predicted BPD trajectories. |
| Conway et al., 2015 [66] | Longitudinal study; community population | 700 at-risk youths (15–20 years old) | 5 years | Maternal externalizing disorders + offspring internalizing disorders + family stressors + school-related stressors → BPD risk |
| Sharp et al., 2015 [109] | Longitudinal study; community population | 730 adolescents | 1 year | Experiential avoidance → BPD features + levels of borderline symptoms at 1-year follow-up |
| Krabbendam et al., 2015 [139] | Longitudinal study; community population | 229 detained adolescent females (mean age = 15.5 years) | 6 years | Post-traumatic stress, depressive symptoms and dissociation during detention → ↑ risk for BPD in adulthood |
| Bo et al., 2017 [140] | Cross-sectional study; clinical population | 109 adolescent patients with consecutive referrals to psychiatric clinic (45 with BPD, 64 CCs) | - | BPD group → ↓ mentalizing abilities + ↑ problematic attachments to parents and peers + ↑ self-reported levels of psychopathology |
| Koenig et al., 2017 [141] | Cross-sectional study; clinical and community population | 77 adolescent psychiatric inpatients and 50 detainees | - | Lifetime self-injury behavior among adolescent psychiatric inpatients and detainees is associated with similar patterns of psychopathology and BPD |
| Bornovalova et al., 2018 [137] | Longitudinal study; community population | 1,763 female twins aged 14 to 24 | 10 years | ↑ levels of BPD traits → earlier onset and faster escalation of AUD and DUD → ↓ normative decline in BPD traits |
| Structured diagnostic interviews and self-report questionnaires | ||||
| Study | Study design | Sample | Trial duration | Outcomes |
| Zanarini et al., 2000 [142] | Cross-sectional study; clinical population | 12 master’s or doctoral-level raters | - | Axis II disorders can be diagnosed reliably when using appropriate semi-structured interviews |
| Samuel et al., 2013 [143] | Longitudinal study; clinical population | 320 patients in the Collaborative Longitudinal Personality Disorders Study diagnosed with PDs by therapist, self-report and semi-structured interview at baseline | 5 years | Self-report questionnaire and semi-structured interview PD diagnoses → > predictive validity vs. PD diagnoses assigned by a treating clinician |
| Morey et al., 2016 [136] | Cross-sectional study; clinical population | 337 clinicians and their target patients | - | Clinical diagnoses of PDs diverge from the rules designated in the DSM |
| Zimmerman et al., 2017 [144] | Cross-sectional study; clinical population | 3674 psychiatric outpatients | - | Affective instability criterion: sensitivity of 92.8% (> than other 8 BPD criteria) + negative predictive value of 99% |
| Fung et al., 2020 [145] | Cross-sectional study; clinical population | 828 subjects with web-based diagnosis of BPD | - | The web-based BPD measure could discriminate between participants with and without BPD |
| Laboratory and instrumental assessment | ||||
| Study | Study design | Sample | Trial duration | Outcomes |
| Chanen et al., 2008 [146] | Cross-sectional study; clinical and community population | 20 BPD patients and 20 HCs | - | BPD patients → right-sided OFC grey-matter loss; no significant differences in amygdala or hippocampal volumes |
| Whittle et al., 2009 [147] | Cross-sectional study; clinical and community population | 15 female BPD patients and 15 female HCs | - | ↓ volume of the left ACC in BPD patients → parasuicidal behavior, impulsivity and fear of abandonment |
| Brunner et al., 2010 [148] | Cross-sectional study; clinical and community population | 60 female right-handed individuals (aged 14–18 years): 20 with BPD, 20 CCs and 20 HCs | - | Early morphological changes in BPD are located in the PFC: reduced gray matter in the DLPFC bilaterally and in the left orbitofrontal cortex OFC |
| Walterfang et al., 2010 [149] | Cross-sectional study; clinical and community population | 20 teenaged first-presentation BPD patients and 20 HCs | - | Gross neuroanatomical changes in the callosum are not present in teenagers with first-presentation BPD |
| Goodman et al., 2011 [73] | Cross-sectional study; clinical and community population | 13 adolescent inpatients with co-morbid BPD and MDD and 13 HCs | - | ↓ BA24 volume → ↑ number of suicide attempts and BPD symptom severity but not depressive symptoms |
| Doering et al., 2012 [150] | Cross-sectional study; clinical and community population | 17 female BPD patients and 17 female HCs | - | Deactivation in the anterior and posterior cortical midline structures → ↓ personality functioning + ↓ identity integration |
| New et al., 2013 [151] | Cross-sectional study; clinical and community population | 38 BPD patients (14 adolescents, 24 adults) and 32 HCs (13 adolescents, 19 adults) | - | In early onset BPD, the normal developmental “peak” in fractional anisotropy in ILF is not achieved → possible neural substrate for the OFC-amygdala disconnection in adults with BPD |
| Maier-Hein et al., 2014 [152] | Cross-sectional study; clinical and community population | 20 adolescent patients with BPD (aged 14–18 years), 20 HCs, and 20 CCs | - | In BPD, white-matter alterations in pathways involved in emotion regulation + parts of the heteromodal association cortex related to emotion recognition |
| Jovev et al., 2014 [107] | Cross-sectional study; community population | 153 healthy adolescents (Mage = 12.6 years) | - | Boys: ↑/↓ affiliation + hippocampal asymmetry → ↑ BPD symptoms; girls: ↓ effortful control + hippocampal asymmetry → ↑ BPD symptoms. |
| Richter et al., 2014 [153] | Cross-sectional study; clinical and community population | 60 right-handed female adolescents between 14 and 18 years of age (20 patients with BPD, 20 CCs and 20 HCs) | - | In BPD, differences in the right and left hippocampus and in the right amygdala + ↓volume in frontal and parietal regions |
| Beeney et al., 2016 [154] | Cross-sectional study; clinical and community population | 8 right-handed females (17 with BPD, 21 HCs) aged 18–60. | - | In BPD, ↓ maintenance of self and other representations + ↑ activation in medial PFC, temporal parietal junction, regions of the frontal pole, precuneus and middle temporal gyrus (areas crucial for social cognition) |
| Bozzatello et al., 2019 [155] | Cross-sectional study; clinical and community population | 24 BPD patients and 24 HCs | - | Inefficient attempt to reconstruct a coherent narrative of life events → hyperactivity in ACC and DLPFC in BPD patients |
| Pop-Jordanova et al., 2019 [156] | Cross-sectional study; clinical and community population | 10 BPD patients (5 males and 5 females, mean age 20.4 years), 10 HCs (6 males and 4 females, mean age 24.2 years). | - | EEG characteristics in BPD without statistical differences, except in low bands (delta and theta) → lower frequencies and coherence |
| Arikan et al., 2019 [157] | Cross-sectional study; clinical and community population | 111 subjects (11 HCs, 25 BPD, 75 BD) | - | No significant differences in EEG characteristics between the two clinical groups |
| Differential diagnosis and comorbidities | ||||
| Study | Study design | Sample | Trial duration | Outcomes |
| Orbach et al., 2003 [158] | Cross-sectional study; clinical and community population | 32 suicidal inpatients (14 males, 18 females), 29 non-suicidal inpatients (11 males, 18 females), aged 25–60; 98 HCs (75 females and 23 males), aged 19–39 | - | Intense mental pain related to loss of life meaning and suicide |
| Gunderson et al., 2004 [159] | Longitudinal study; clinical population | 161 BPD patients, with and without co-occurring MDD | 3 years | Rate of remissions of BPD → not affected by co-occurring MDD; rate of MDD remissions → ↓ by co-occurring BPD |
| Eaton et al., 2011 [160] | Cross-sectional study; community population | 34,653 civilian, non-institutionalized individuals aged ≥18 years | - | Complex patterns of co-morbidity in BPD → connections to other disorders (latent internalizing and externalizing dimensions) |
| Hasin et al., 2011 [161] | Longitudinal study; clinical population | 1172 subjects with alcohol dependence, 454 with cannabis use disorder and 4017 with nicotine dependence, drawn from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) | 3 years | ASPD, BPD and STPD associated with persistent alcohol, cannabis and nicotine use disorders |
| Skodol et al., 2011 [162] | Longitudinal study; community population | 1,996 participants in a national survey | 3 years | APD, HPD, PPD, SPD, STPD and especially BPD → ↑ risk for MDD persistence |
| Gunderson et al., 2014 [163] | Longitudinal study; clinical population | 223 BPD patients with co-occurring MDD (n = 161), bipolar I disorder (n = 34) and bipolar II disorder (n = 28) | 10 years | BPD and MDD strongly related: ↑ time to remission and ↑ time to relapse; BPD and BD largely independent disorders, except BD II → ↑ BPD’s time to remission |
| Keuroghlian et al., 2015 [164] | Longitudinal study; clinical population | 164 BPD patients with co-occurring GAD (n = 42), panic disorder with agoraphobia (n = 39), panic disorder without agoraphobia (n = 36), social phobia (n = 48), OCD (n = 36) and PTSD (n = 88) | 10 years | BPD negatively affects the course of GAD, social phobia and PTSD; anxiety disorders have little effect on BPD course |
| Boritz et al., 2016 [165] | Randomized controlled trial | 180 BPD patients | 3 years | BPD + PTSD → ↑ levels of global psychological distress |
BPD, borderline personality disorder, PDs, personality disorders, ASPD, antisocial personality disorder, NPD, narcissistic personality disorder, HPD, histrionic personality disorder, PPD, paranoid personality disorder, STPD, schizotypal personality disorder, SPD, schizoid personality disorder, APD, avoidant personality disorder, MDD, major depressive disorder, BD, bipolar disorder, SUD, substance use disorder, AUD, alcohol use disorder, DUD, drug use disorder, ADHD, attention deficit-hyperactivity disorder, ODD, oppositional defiant disorder, GAD, generalized anxiety disorder, OCD, obsessive-compulsive disorder, PTSD, posttraumatic stress disorder, cPTSD, complex posttraumatic stress disorder, DSM, Diagnostic and Statistical Manual of Mental Disorders, HC, healthy controls, CC, clinical controls, PFC, pre-frontal cortex, OFC, orbito-frontal cortex, ACC, anterior cingulate cortex, DLPFC, dorsolateral pre-frontal cortex, BA24, Brodmann area, ILF, inferior longitudinal fasciculus.