personality disorder research articles

• 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

American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. Washington, D.C: American Psychiatric Association; 2013.

Google Scholar  

Winsper C, Bilgin A, Thompson A, Marwaha S, Chanen AM, Singh SP, et al. The prevalence of personality disorders in the community: a global systematic review and meta-analysis. Br J Psychiatry. 2019;216:1–10.

Lewis KL, Fanaian M, Kotze B, Grenyer BFS. Mental health presentations to acute psychiatric services: 3-year study of prevalence and readmission risk for personality disorders compared with psychotic, affective, substance or other disorders. BJPsych Open. 2019;5:1–7.

Korzekwa MI, Dell PF, Links PS, Thabane L, Webb SP. Estimating the prevalence of borderline personality disorder in psychiatric outpatients using a two-phase procedure. Compr Psychiatry. 2008;49(4):380–6.

PubMed   Google Scholar  

Cristea IA, Gentili C, Cotet CD, Palomba D, Barbui C, Cuijpers P. Efficacy of psychotherapies for borderline personality disorder: a systematic review and meta-analysis. JAMA Psychiatry. 2017;74:319–28.

Morris C, Smith I, Alwin N. Is contact with adult mental health services helpful for individuals with a diagnosable BPD? A study of service users views in the UK. J Ment Health. 2014;23(5):251–5.

Bailey RC, Grenyer BFS. Supporting a person with personality disorder: a study of carer burden and well-being. J Personal Disord. 2014;28(6):796–809.

Bailey RC, Grenyer BFS. The relationship between expressed emotion and wellbeing for families and carers of a relative with borderline personality disorder. Personal Ment Health. 2015;9(1):21–32.

Dunne E, Rogers B. “It’s us that have to deal with it seven days a week”: Carers and borderline personality disorder. Community Ment Health J. 2013;49(6):643–8.

Grenyer BFS, Ng FY, Townsend ML, Rao S. Personality disorder: a mental health priority area. Aust N Z J Psychiatry. 2017;51(9):872–5.

Commonwealth of Australia. National standards for mental health services. 2010.

Mental Health Commission of Canada. Changing directions changing lives: The mental health strategy for Canada. 2012.

Jørgensen K, Rendtorff JD. Patient participation in mental health care - perspectives of healthcare professionals: an integrative review. Scand J Caring Sci. 2018;32(2):490–501.

Bee P, Brooks H, Fraser C, Lovell K. Professional perspectives on service user and carer involvement in mental health care planning: a qualitative study. Int J Nurs Stud. 2015;52(12):1834–45.

PubMed   PubMed Central   Google Scholar  

Milton AC, Mullan BA. A qualitative exploration of service users’ information needs and preferences when receiving a serious mental health diagnosis. Community Ment Health J. 2015;51(4):459–66.

Lammers J, Happell B. Mental health reforms and their impact on consumer and carer participation: a perspective from Victoria. Australia Issues Ment Health Nurs. 2004;25(3):261–76.

Stomski NJ, Morrison P. Participation in mental healthcare: a qualitative meta-synthesis. Int J Ment Heal Syst. 2017;11(1):67.

Redding A, Maguire N, Johnson G, Maguire T. What is the lived experience of being discharged from a psychiatric inpatient stay? Community Ment Health J. 2017;53(5):568–77.

Goodwin V, Happell B. Consumer and carer participation in mental health care: the carer’s perspective: part 1 - the importance of respect and collaboration. Issues Ment Health Nurs. 2007;28(6):607–23.

Goodwin V, Happell B. Consumer and carer participation in mental health care: the carer’s perspective: part 2—barriers to effective and genuine participation. Issues Ment Health Nurs. 2007;28(6):625–38.

Brennan A, Warren N, Peterson V, Hollander Y, Boscarato K, Lee S. Collaboration in crisis: Carer perspectives on police and mental health professional’s responses to mental health crises. Int J Ment Health Nurs. 2016;25(5):452–61.

Olasoji M, Maude P, McCauley K. Not sick enough: experiences of carers of people with mental illness negotiating care for their relatives with mental health services. J Psychiatr Ment Health Nurs. 2017;24(6):403–11.

CAS   PubMed   Google Scholar  

Lawn S, McMahon J. Experiences of care by Australians with a diagnosis of borderline personality disorder. J Psychiatr Ment Health Nurs. 2015;22(7):510–21.

CAS   PubMed   PubMed Central   Google Scholar  

Vandyk A, Bentz A, Bissonette S, Cater C. Why go to the emergency department? Perspectives from persons with borderline personality disorder. Int J Ment Health Nurs. 2019;28(3):757–65.

Lawn S, McMahon J. Experiences of family carers of people diagnosed with borderline personality disorder. J Psychiatr Ment Health Nurs. 2015;22(4):234–43.

Acres K, Loughhead M, Procter N. Carer perspectives of people diagnosed with borderline personality disorder: a scoping review of emergency care responses. Australas Emerg Care. 2019;22(1):34–41.

Lamont E, Dickens GL. Mental health services, care provision, and professional support for people diagnosed with borderline personality disorder: systematic review of service-user, family, and carer perspectives. J Ment Health. 2019:1–15.

Gillard S, Turner K, Neffgen M, Griggs I, Demetriou A. Doing research together: bringing down barriers through the ‘coproduction’ of personality disorder research. Ment Health Rev J. 2010;15(4):29–35.

Braun V, Clarke V, Hayfield N, Terry G. Thematic analysis. In: Liamputtong P, editor. Handbook of research methods in health social sciences. Singapore: Springer Singapore; 2019. p. 843–60.

Viera AJ, Garrett JM. Understanding interobserver agreement: the kappa statistic. Fam Med. 2005;37:360–3.

Buteau E, Dawkins K, Hoffman P. In their own words: improving services and hopefulness for families dealing with BPD. Soc Work Ment Health. 2008;6(1–2):203–14.

Horn N, Johnstone L, Brooke S. Some service user perspectives on the diagnosis of borderline personality disorder. J Ment Health. 2007;16(2):255–69.

Hackmann C, Wilson J, Perkins A, Zeilig H. Collaborative diagnosis between clinician and patient: why to do it and what to consider. BJPsych Adv. 2019;25(4):214–22.

Mortimer-Jones S, Morrison P, Munib A, Paolucci F, Neale S, Hellewell A, et al. Staff and client perspectives of the open Borders programme for people with borderline personality disorder. Int J Ment Health Nurs. 2019;28(4):971–9.

Sheehan L, Nieweglowski K, Corrigan P. The stigma of personality disorders. Curr Psychiatry Rep. 2016;18(1):1–7.

Day NJS, Hunt A, Cortis-Jones L, Grenyer BFS. Clinician attitudes towards borderline personality disorder: a 15-year comparison: attitudes toward borderline personality disorder. Personal Ment Health. 2018;12(4):309–20.

Bonnington O, Rose D. Exploring stigmatisation among people diagnosed with either bipolar disorder or borderline personality disorder: a critical realist analysis. Soc Sci Med. 2014;123:7–17.

Lamph G, Sampson M, Smith D, Williamson G, Guyers M. Can an interactive e-learning training package improve the understanding of personality disorder within mental health professionals? J Ment Health Train Educ Pract. 2018;13(2):124–34.

Welstead HJ, Patrick J, Russ TC, Cooney G, Mulvenna CM, Maclean C, et al. Mentalising skills in generic mental healthcare settings: can we make our day-to-day interactions more therapeutic? BJPsych Bull. 2018;42(3):102–8.

Gillard S, Gibson SL, Holley J, Lucock M. Developing a change model for peer worker interventions in mental health services: a qualitative research study. Epidemiol Psychiatr Sci. 2015;24(05):435–45.

Pallaveshi L, Balachandra K, Subramanian P, Rudnick A. Peer-led and professional-led group interventions for people with co-occurring disorders: a qualitative study. Community Ment Health J. 2014;50(4):388–94.

Ng FYY, Townsend ML, Miller CE, Jewell M, Grenyer BFS. The lived experience of recovery in borderline personality disorder: a qualitative study. Borderline Personal Disord Emot Dysregulation. 2019;6(1):1–9.

Tippin GK, Maranzan KA, Mountain MA. Client outcomes associated with interprofessional care in a community mental health outpatient program. Can J Commun Ment Health. 2016;35(3):83–96.

Haeyen S, van Hooren S, van der Veld WM, Hutschemaekers G. Promoting mental health versus reducing mental illness in art therapy with patients with personality disorders: a quantitative study. Arts Psychother. 2018;58:11–6.

Chanen AM, Thompson KN. Early intervention for personality disorder. Curr Opin Psychol. 2018;21:132–5.

Fitzpatrick S, Wagner AC, Monson CM. Optimizing borderline personality disorder treatment by incorporating significant others: a review and synthesis. Personal Disord Theory Res Treat. 2019;10(4):1–12.

CAS   Google Scholar  

Wonders L, Honey A, Hancock N. Family inclusion in mental health service planning and delivery: consumers’ perspectives. Community Ment Health J. 2019;55(2):318–30.

Landeweer E, Molewijk B, Hem MH, Pedersen R. Worlds apart? A scoping review addressing different stakeholder perspectives on barriers to family involvement in the care for persons with severe mental illness. BMC Health Serv Res. 2017;17(1):1–10.

Guest G, Bunce A, Johnson L. How many interviews are enough?: an experiment with data saturation and variability. Field Methods. 2006;18(1):59–82.

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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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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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• Orestis Kanter Bax , consultant psychiatrist in medical psychotherapy 1 2 ,
• Dimitrios Chartonas , consultant psychiatrist 2 3 ,
• Jennie Parker , independent lived experience researcher , KUF development lead 2 5 ,
• Spyridon Symniakou , GP partner 6 ,
• Tennyson Lee , consultant psychiatrist in medical psychotherapy , psychoanalyst , honorary senior lecturer 2 4 7 6 8
• 1 Basildon Complex Needs Psychotherapy and Personality Disorder Service, Essex Partnership University NHS Foundation Trust, UK
• 2 Centre for Understanding Personality (CUSP), London
• 3 Camden and Islington Personality Disorder Service, Camden and Islington NHS Foundation Trust
• 4 Deancross Personality Disorder Service, East London NHS Foundation Trust
• 5 Berkshire Healthcare NHS Foundation Trust
• 6 Blithdale Health Centre, Clinical Director East End Health Network
• 7 Institute of Psychoanalysis, British Psychoanalytical Society
• 8 Wolfson Institute, Queen Mary University of London
• Correspondence to O Kanter Bax orestis.kanter-bax{at}nhs.net

What you need to know

Personality disorders are a set of complex emotional difficulties. They are common, often unrecognised, and are associated with mental and physical health comorbidities and reduced life expectancy

Personality disorders are perceived as stigmatising diagnoses. Alternative terms have been proposed. New classification systems help in moving away from rigid use of categorical diagnoses

Assessment and management in primary care require a non-judgmental approach that builds trust through attentiveness, validation, openness, and consistency

Holistic care for people with personality disorders can be improved with reflective practice structures, staff training, collaboration, and team working

Sources and selection criteria

We searched Pubmed, Medline, Embase, the Cochrane Library, CINAHL, PsycINFO, AMED, British Nursing Index, HMIC, and Health Business Elite using the term “personality disorder”. Findings from randomised controlled trials (RCTs), systematic reviews, and meta-analyses were ranked as high in quality (see table 1 ) and we also used our own reference archives, books, and expert contacts to supplement the structured search.

Personality disorders describe a set of long standing complex emotional difficulties, which are common, highly stigmatised, and potentially disabling. They are frequently under-recognised and may run a long course when people lack access to appropriate treatment. Recent developments in evidence, guidelines, and policy have placed an emphasis on public awareness, de-stigmatisation, training professionals in generalist settings, improving access to specialist care, and improving physical health outcomes. 1 2 This article provides an overview of the latest information on the assessment and management of personality disorders in primary care, with an emphasis on borderline personality disorder (also referred to as emotionally unstable personality disorder).

What are personality disorders?

Personality disorders are pervasive and enduring, affecting the emotional, cognitive, and behavioural functioning of a person, expressed in relation to their self (eg, identity, self-evaluation, affect regulation, direction) and others (eg, intimacy, boundaries, sense of security in relationships). People with personality disorders may face difficulties with social functioning at work, with family, and with social life and leisure, and such difficulties may represent a significant deviation from what is expected for the individual’s developmental stage and culture. 3 No consensus exists on a single definition, research in the field is growing rapidly, and controversy surrounds the validity of existing conceptual frameworks. 4 Some people with lived experience and some clinicians question use of the term “personality disorder” altogether, and advocate for its replacement (for example, the term “complex emotional needs” has been proposed). 5

Negative attitudes and biases are still held about people who receive a diagnosis of personality disorder both in the general public 6 7 and among clinicians. 8 Longstanding misconceptions exist about the nature and “untreatability” of personality disorders, but evidence is growing for the efficacy of treatments for borderline personality disorder ( table 1 ) and emerging treatments for antisocial and narcissistic personality difficulties. 12 16

Evidence based treatment for borderline personality disorder 9 10 11

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What underlies personality disorders?

As with other mental health conditions, genetic and environmental factors contribute to the development of personality disorders. The genetic link is still not well understood 17 18 and evidence on heritability is limited. 19 Genetic factors are thought to interact with the environment to lead to neurobiological changes. 20 Epigenetic effects of the environment on gene expression are also increasingly recognised. 21 Antenatal adversities (eg, increased stress in utero) 22 and adverse childhood experiences, 23 including physical, emotional, and sexual abuse, neglect, and parental mental illness, are associated with an increased risk of a diagnosis of personality disorder in adulthood. 24 In particular, a meta-analysis found that individuals with borderline personality disorder are 13.91 times more likely to report childhood adversity than non-clinical controls and 3.15 times more likely than other people with other psychiatric conditions. 25

Several theoretical models exist that can be clinically useful. Attachment theory provides a model for the understanding of how early disruptions in the infant-caregiver relationship may influence regulation of affect and development of the self. 26 Psychoanalytical object relations theory explains how early internal self and other (object) representations and “patterns” of relating are repeated in adulthood. 27 Adapted cognitive behavioural theory focuses on the effects of conditioning (eg, through invalidating environments) on emotional, cognitive, and behavioural patterns that develop in adulthood. Understanding the complex multi-causal pathways leading to a personality disorder diagnosis can reduce stigma. 28

How common are personality disorders, and who is affected?

Relatively little epidemiological research has been conducted in personality disorders, but estimates of prevalence suggest as many as one in 10 people in the general population has a personality disorder. 29 30 A 2000 study of 303 consecutive primary care attenders estimated that one in four met the criteria for a diagnosis. 31 Estimates of the prevalence in secondary mental healthcare are variable because of heterogeneity of samples, but two literature reviews reported that up to 52% of psychiatric outpatients and up to 70% of patients in inpatient and forensic settings met the criteria for personality disorders, 32 and 12% of patients in outpatient psychiatric clinics and 22% of patients in inpatient psychiatric clinics for borderline personality disorder. 33

Antisocial personality disorder is consistently more common in men than women. 34 There is possible measure or clinician bias in diagnosis of borderline personality disorder in lesbian, gay, and bisexual patients 35 and risk of symptom mislabelling in minority groups, differences in healthcare seeking behaviour between men and women, and mental health risks and barriers for LGBTQ+ populations. 36 Correlation exists between a diagnosis of personality disorder and low socioeconomic status, urbanicity, lower educational attainment, occupational difficulties, and marital discord. 34 Sparse evidence is available on ethnic variations. 37 Clinicians may find it helpful to expand their understanding of the impact of racial trauma 38 and barriers to accessing healthcare for people in black, Asian, and ethnic minority populations.

Prevalence in older populations is about 10%. 39 An underlying and undiagnosed personality disorder may become evident for the first time in older age if disruptions occur in a previously stable life (eg, new onset illness, loss of partner), which lead to decompensation. Differential diagnoses when making a new diagnosis of personality disorder in older people are important (eg, late onset or relapse of other mental or physical illness, including dementia, malignancy, or substance misuse). Evidence suggests a decline in diagnosis of borderline personality disorder with progression of age, indicating a natural improving course in this group. 40 41

How are personality disorders classified?

In ICD-11, 42 released by the World Health Organization in 2018, the clinician is invited to: a) identify the presence of a core problem in functioning of self and interpersonal relating; b) its level of severity (mild, moderate, severe); and c) its main traits : negative affectivity, detachment, dissociality, disinhibition, anankastia (ie, obsessive-compulsive traits), and whether a borderline pattern exists. This classification marked a radical shift away from the categorical classification adopted in ICD-10, DSM-IV, and DSM-5 ( table 2 ), 43 and it allows primary care clinicians to adopt a more pragmatic approach to recognising personality disorder: to look for a core problem, its functional impact and severity, and how this might present in the patient’s relationships and during clinical appointments. 44

Classification systems

DSM-5, which otherwise preserves the categorical approach of DSM-IV, attempts a “hybrid” approach between the categorical and dimensional models, by including an “alternative model” ( table 2 ).

For non-specialist clinicians, awareness of categorical dimensions might be useful, but finer differentiation may be left to the specialist.

How to approach suspected personality disorder

Establishing a specific working framework for the assessment and management of personality disorder can help to prevent exclusion, provide a safe and containing environment, and instil hope. General principles include an open, empathic, and non-judgmental attitude, attentive listening, active and genuine interest, and validation of the patient’s experience. Use a trauma informed approach, which recognises the high prevalence and complex impact of traumatic experiences in personality disorders. 45 46

Box 1 lists some helpful indicators for suspecting personality disorder. Clinicians may be able to incorporate these in their clinical encounters and use them to communicate their patient’s stories and needs to colleagues, while recognising that this list is not exhaustive.

Indicators for personality disorder in non-specialist settings

Strong indicators.

Negative affectivity and affective dysregulation (rapid mood changes, low mood, anxiety, anger, detachment)

Impulse dysregulation (risk taking behaviours, sexual promiscuity, alcohol and substance misuse)

Interpersonal problems: a) In “outside” life (eg, turbulent relationships, violence, dependence, avoidance, isolation); b) In the clinical encounter (eg, increased use of resources, recurrent crises, feeling stuck). In particular, turbulence and volatile relationships tend to be characteristic of borderline personality disorder difficulties

Strong emotional reactions in the clinician during the clinical encounter. Unusual departures from established clinical practice (eg, prescribing out of the ordinary, allocation of clinical time, working outside expertise)

Poor responses to evidence based treatments for other mental health conditions (anxiety, depression, post-traumatic stress disorder)

Additional indicators to look for

Cognitive-perceptual symptoms (rigid or bizarre ideas, antagonism, lack of trust, unusual dissociative or quasi-psychotic symptoms)

Evidence of self-injurious behaviours (scars, marks on skin), significant history of deliberate self-harm and suicidal behaviours

Medically unexplained symptoms 47 48

Parents of children presenting with evidence of deficits in the home environment (eg, neglect, abuse, social adversity, or trauma)

Early adversity and history of trauma (but do not adopt a mechanistic approach, assuming or excluding a diagnosis based on the presence or absence of adversity and trauma)

Childhood diagnosis of emotional disorder, disrupted behaviours, or conduct disorder

Longer initial appointments may be necessary and, where possible, having consistency rather than multiple involved clinicians. Allow time to build trust, tolerate any initial confusion, be open about the service limitations, and adopt an understanding and curious attitude if the person’s requests and demands seem excessive. Strong emotional reactions to patients (positive or negative), observation of unexpected dynamics at play in the doctor-patient interaction or within the team, or deviations from well established practices, may alert the clinician to unconscious repetitions of “patterns” of relating that may complicate the clinical encounter. 49 50

Anxiety, depression, sequelae of a recent trauma or life crisis, or requests relating to an existing diagnosis may in fact be indicators of a personality disorder. Aim to look beyond the apparent presenting symptom and try to understand the individual’s circumstances and their point of view. Simply put, it is essential to get to know a patient and their story. When you formulate their difficulties, try to cover the areas of: 1) sense of self; 2) interpersonal relating; 3) educational and vocational attainment; 4) risk assessment (self-harm and suicide, aggression and violence, risks to dependants and children, risk from others including domestic abuse); 5) hopes and expectations of clinical care. Involve families or carers when appropriate and, with the patient’s consent, seek information from other involved agencies.

Screening tools in primary care are of limited use, but the standardised assessment of personality scale is concise and may help in identifying a personality disorder. 51 Standardised tools can otherwise be used as indicated for mental health screening purposes. 52 Urine drug testing, neuro-imaging, and blood testing may be appropriate in specific cases to exclude other pathologies (eg, in addiction, older adults, and the perinatal period).

Management in primary care

Caring for people with personality disorders in primary care requires a person centred approach that promotes open dialogue and reduces stigma. The goal is not to provide a cure, or “fix” some underlying fault, but to engage in a curious and compassionate way with the person experiencing distress in their attempt to understand and manage their painful experience, even when their wishes and expectations may initially seem unclear or confusing ( box 2 ).

Patient and clinician perspectives on managing personality disorder in primary care

We asked two people to share their experiences of personality disorder. One is a practising GP in the NHS, the other a patient with experience of primary care services during their journey with personality disorder.

It takes a lot to recognise the need for additional support, and once this decision has been made, it can be the start of a very long and emotionally exhausting journey. For most, this starts with a visit to the GP, with the expectation of understanding and perhaps even some answers—medical or other. Someone who can listen without judgment, take the time to get to know us, and show compassion are just a few qualities that can save further distress or misunderstandings on either side. We may not know what we need, or how even to communicate (or comprehend) our thoughts and feelings in a 10 minute appointment. Prior experiences of rejection, abandonment, or attachment difficulties can make it really hard to put our trust in others, including healthcare professionals. Added to this, hidden past or current traumas hinder openness; building a trusting relationship is therefore key to progressing our journey.

We learn to view the world as an unsafe place, where we will not be believed, and that we are not worthy of care. Looking and sounding “OK,” we can come across as malingering—not a term I would choose, but one that fits my interpretation of the invalidating response received at times. All of these are experiences from my own journey over the past 25 years. On reflection, I did expect answers but didn’t really know the question. Part of this journey was through a maze of diagnoses and unhelpful treatments, both medical and psychological. Being referred to services that declined me due to my stigmatising diagnosis, falling between private sector care and the NHS, and repeated assessments or referrals became exhausting and frustrating. The one constant in this journey was my GP practice, perhaps the only place that cannot turn me away and hopefully does not judge based on a mental health label (which I might not even agree with). While I can now see that the remit of a GP is very broad, having someone in the practice that has the skills, time, and compassion to listen and support us in thinking what may be helpful can be invaluable and even life changing.

The question of how we, as a primary care team, can work with people experiencing relational and personality difficulties becomes an almost daily one. In a wider context, primary care unfortunately is becoming increasingly transactional and reactionary, a box ticking exercise, where the complexity of human interaction, continuity as a therapeutic ingredient, and empathy are being replaced by a conveyor belt-like service with e-consultations or orders, and expectations of next day-type delivery by exhausted and burnt out workers. Our commissioners are increasingly relying on numerical indicators to monitor the quantity and quality of our work.

One of the biggest difficulties my team and I face when interacting with a patient with personality disorder is the sense of isolation. Every interaction, especially with someone in need, can be challenging, more so if one has difficulties relating to a person. Lack of trust, breakdown of communication, complexity of presentation, suicidal risk, threatening or dismissive attitude, inconsistencies, lack of a descriptive or explanatory framework can all become barriers to effective clinical practice because they act as magnifying lenses to the difficulties all of us—clinical and non-clinical staff—may experience, and because of the complexity of human nature. This is when I feel most inadequate, full of stress, defensive, persecuted, confused, and hopeless, and this is an experience I share with my team members. But with a reflective space and effective communication between my team and colleagues and the wider mental health and care ecosystem, we can achieve miracles.

Structured management starts with working collaboratively with the person to produce a formulation and understanding of the nature of their difficulties. Consistency, clear communication, and clear boundaries are key. A “contract” between the patient and clinician that will guide their work together from the outset may be helpful 49 to provide clarity about the role and limitations of primary care, establishing clinician and patient responsibilities and modelling realistic expectations. 53

Box 3 outlines management principles, strategies, and techniques that can be used by generalist clinicians and teams.

Management principles, strategies, and techniques

General principles: open, empathic, and non-judgmental attitude; attentive listening; active and genuine interest; validation of the patient’s experience; positive regard that promotes hope; readiness to acknowledge own limitations and mistakes

Acknowledge the patient’s feelings and be aware of your own emotional responses

Be mindful of trauma and its impact on the patient’s life and help-seeking behaviours, and actively aim to avoid re-traumatisation

Be clear and transparent about procedures

Use person centred, co-produced, and mutually agreed treatment plans or “contracts”: negotiated agreements on how the patient and clinician will work with one another to frame the relationship, set goals, establish clear roles and expectations, and manage deviations from what has been agreed

Consider and discuss the use of emotion regulation, distress tolerance, and grounding techniques (muscle relaxation, breathing skills, self-soothing using one’s senses, silence, mindfulness and meditation, yoga postures, exercise)

• Use techniques aimed at improving mentalising during consultations (mentalising refers to the process by which we make sense of ourselves and others, in terms of subjective states and processes (thoughts, feelings, intentions) and impaired mentalising is a core feature of borderline personality disorder 53 )

Share an interview structure plan with the patient, slowing down a chaotic interview and “rewinding” to previously unresolved discussions

Identify and name the underlying emotion: this can help reduce the patient’s levels of anxiety and emotional arousal (anger, elation, sadness/despair, fear) during a consultation

Validate and reflect on the patient experience

Describe your own reflections on the discussion

Invite the patient to reflect from the third position: “What would you tell a friend in this situation?”

Use medications thoughtfully when necessary, and strive to rationalise unnecessary prescribing and polypharmacy; avoid prescribing or changing medications during crises

Encourage lifestyle changes and discuss sleep routines before considering the use of sleeping tablets

Be mindful of mental health comorbidities and treat accordingly, or seek specialist input when required (eg, mood and anxiety disorders, post-traumatic stress disorder, eating disorders, autism spectrum disorder, 54 attention deficit/hyperactivity disorder, intellectual disability 55 56 )

Address problematic alcohol and substances use

Be mindful of increased physical health morbidity, and consider physical health needs

Discuss social needs and encourage structured meaningful activity and social connectedness. Involvement of a primary care mental health practitioner, a social prescriber and peer coach, social care, and third sector organisations may be helpful when indicated

A shared sense of purpose and a culture of cooperation

Team cohesion and mutual support

Formalised regular supervision and reflective practice

Readiness to engage with difficult clinical situations and consider judgment or bias when identified in either colleagues or patients

A culture of reflection and adherence to agreed plans and strategies

Safety management

Establish clear pathways for safety and crisis management

Differentiate and identify an acute escalation in chronic risk and avoid complacency

Have shared safety management plans that are comprehensive and accessible

Encourage strategies to minimise harm in patients who self-harm

Adapting services to meet patients’ needs

Consider what adjustments in service delivery and staff training might improve patient care ( box 4 ). For some patients a long term and trusting relationship with a reliable GP who is genuinely interested may become key in their path to living a more fulfilling life. Chronic difficulties in clinical relationships can develop, however; unhelpful or entangled situations may arise, and this is not rare. Specialist advice or consultation 57 58 may help to resolve this, and reflection can lead to valuable learning from experience for the clinician. Avoid working in isolation, and consider ways to promote reflective spaces and staff wellbeing, to prevent burnout. 59

What can I put in place in my service?

Need specific services and adjustments.

Provide structure and consistency (allocate a named clinician)

Offer scheduled, regular appointments—do not adopt a reactive, crisis management practice

Consider longer appointments (20-30 minutes)

Consider planned telephone contacts with a named doctor

Have reliable and transparent crisis management plans and pathways

Offer bespoke training for first line clinical and reception staff

Put in place regular reflective practice groups across disciplines

Organise peer support, supervision, and clinical practice based meetings with mental health team specialists and/or a local psychiatrist

Establish reliable pathways of communication with local mental health specialists

Offer a tailored-to-need service to resolve complaints and conflict

Integrate a trauma informed approach into policies, procedures, and practices

Shared care, or blended primary and secondary team working, requires reliable communication pathways between all involved agencies. With permission from the patient, make transparent to involved services any treatment “contract” that has been agreed. Openly acknowledge, discuss, and reflect on any deviations from mutual agreements.

Managing safety

Non-suicidal self-injury (self-harm) is common in people with borderline personality disorder (65-80% of cases). 60 The risk of suicide is many times greater than in the general population, 33 with estimates suggesting that up to 10% of people with borderline personality disorder will die by suicide. 61 Plans for safety and crisis management are clinically indicated and actively researched. 62 People who have a personality disorder and are in crisis should access specific local protocols and pathways tailored to their needs. Document up-to-date assessments of the level of risk to self and others, and any safeguarding issues concerning the patient or dependants. Specialist or emergency psychiatry is appropriate for serious and escalating risk patterns.

Medications

Many people with a personality disorder take several drugs, despite an absence of evidence to support the use of any specific medication for the conditions. 63 64 Guidelines from the National Institute for Health and Care Excellence recommend treatment of comorbidities where present as indicated. 65 Recent research highlights the complex interpersonal dynamics that may influence prescribing, especially in patients with personality disorder. 66 67 Reactive prescribing without clear direction, especially during crises, may become a problem. When prescribing, either for physical or mental health, discuss in advance (and in a clear manner) goals, duration of treatment, target symptoms, and potential side effects. Seek informed consent, psychoeducation, and reflection on expectations. 68 69 Consider psychological aspects of resistance to treatment, poor adherence, and medication misuse, and be curious about the meaning of taking and prescribing medication. 70 71 72 If you prescribe without a clear clinical rationale, consider whether this is driven by your emotional reactions in your encounter with the patient. It may be practical to treat symptoms such as insomnia with short courses of medications. We advise specialist input if considering antipsychotic or mood stabilising medications.

When to refer and what to expect

Availability of specialist treatment may vary by region. Involvement of community psychiatry and/or specialist services for personality disorder is indicated for: a) diagnostic clarification; b) assessment of readiness for and choice of specialist treatment; c) case consultation regarding management difficulty and increased risk. Referral to non-specialist talking therapies services—in England through Improving Access to Psychological Therapies (IAPT)—may be appropriate for personality disorder of mild severity and when a full diagnosis is not met. These services may also be appropriate for cases in which focused psychological treatment of a comorbid mental health condition is indicated, if relevant training and resources are available in local provision, but IAPT services may not meet the patients’ needs otherwise. 73

The presence of a diagnosis does not in itself indicate psychological readiness for a specialist treatment programme. The specialist assessment can be demanding, and treatment is not always available or appropriate. In the UK, available specialist programmes are lengthy and require commitment, so that timing and competing priorities need to be considered in advance. Unstable living conditions, uncontrolled alcohol or substance misuse, severe eating disorder, serious risk of harm to self or others, and vulnerability to harm from others may need to be tackled first, with relevant specialist input if necessary (eg, addiction or eating disorder services, adult social services). Canvass patient views, preferences, and goals, based on any previous experience of psychological therapies, at an early stage. 74

Several evidence based treatments, mainly for borderline personality disorder, are available in secondary and tertiary care in the NHS ( table 1 ). No single modality stands out in terms of efficacy, 75 and sometimes multiple treatment attempts may be needed. Brief treatments (such as cognitive behavioural therapy) might not be helpful, and the choice and sequencing of treatments requires specialist involvement. 76

Contact other agencies (eg, probation services, social services, social support agencies for housing, occupation, and activities), as necessary, for support.

Education into practice

What training opportunities could be made available to staff to support their interactions with people who have a personality disorder?

Can you identify one specific barrier that people with a personality disorder may face when trying to access your service?

Useful resources (mainly UK based)

For clinicians.

National Institute for Health and Care Excellence. Personality disorders: borderline and antisocial: https://www.nice.org.uk/guidance/qs88 Updated June 2015.

World Health Organization, ICD-10 Classifications of mental and behavioural disorder: Clinical descriptions and diagnostic guidelines, World Health Organization, 1992: https://icd.who.int/browse10/2016/en

·World Health Organization, ICD-11 Classifications of mental and behavioural disorder: Clinical descriptions and diagnostic guidelines, World Health Organization, 2018: https://icd.who.int/browse11/l-m/en

Balint Society: https://balint.co.uk . Balint group membership provides a space to think about those encounters which leave professionals drained, puzzled, or stuck

Standardised Assessment of Personality—Abbreviated Scale (SAPAS): https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/standardised-assessment-of-personality-abbreviated-scale-sapas-preliminary-validation-of-a-brief-screen-for-personality-disorder/26FB730F35F54B952381AA9C662FF8C2

The Knowledge and Understanding Framework (KUF) national training programme: https://www.westlondon.nhs.uk/our-services/adult/mental-health-services/cassel-hospital/consultation-and-training-services and The National KUF Hub https://twitter.com/nationalkufhub

“Six levels of validation” interpersonal effectiveness skills resource: https://dbtselfhelp.com/dbt-skills-list/interpersonal-effectiveness/validation/

Safer care for patients with personality disorder. National confidential inquiry into suicide and homicide by people with mental illness, University of Manchester. 2018: https://documents.manchester.ac.uk/display.aspx?DocID=37564 Related educational videos “Safer care for patients given a diagnosis of personality disorder: a learning resource”: https://sites.manchester.ac.uk/ncish/resources/safer-care-for-patients-given-a-diagnosis-of-personality-disorder-a-learning-resource/

NHS England and NHS Improvement and the National Collaborating Centre for Mental Health, The Community Mental Health Framework for Adults and Older Adults, September 2019: https://www.england.nhs.uk/wp-content/uploads/2019/09/community-mental-health-framework-for-adults-and-older-adults.pdf

Office for Health Improvement & Disparities Guidance: Working definition of trauma-informed practice and resources: https://www.gov.uk/government/publications/working-definition-of-trauma-informed-practice/working-definition-of-trauma-informed-practice

For patients, families, and carers

For immediate help.

NHS 111 (option 2) can help if you have an urgent medical problem and you’re not sure what to do. Visit https://111.nhs.uk (for people aged 5 and over only) or call 111 (available 24 hours a day, 7 days a week)

With life threatening emergencies, call 999 or go to the nearest emergency department

The Samaritans are there to listen 24 hours a day. Call on 08457 90 90 90 or visit the website at https://www.samaritans.org .

SANEline is a national out-of-hours mental health helpline offering specialist emotional support, guidance, and information to anyone affected by mental illness, including family, friends, and carers. Available every day from 4.30 pm to 10.30 pm on 0300 304 7000: https://www.sane.org.uk/what_we_do/support/helpline

Most areas have a mental health crisis team available 24 hours a day; their contact details should be available via the local council or social services, or they can be contacted via hospital emergency departments.

Text SHOUT: a 24/7 UK based volunteer led text service for anyone in crisis. Developed by the Mental Health Innovations charity: https://www.giveusashout.org/

Other resources

MIND. Personality Disorders leaflet: https://www.mind.org.uk/information-support/types-of-mental-health-problems/personality-disorders/about-personality-disorders/

The National Education Alliance for Borderline Personality Disorder: https://www.borderlinepersonalitydisorder.com/consumer-recovery-resources/ A resource for families and people in recovery, education and training for professionals. (USA)

·The National Service user Network (NSUN) weekly bulletin offers a summary of involvement opportunities as well as policy updates: https://www.nsun.org.uk/

Mindfulness meditation—online resources that some may find helpful: https://www.freemindfulness.org/

Cognitive behavioural therapy based self-help resources and worksheets: https://www.getselfhelp.co.uk/

Dialectical behaviour therapy based self-help resources and worksheets: https://dbtselfhelp.com/

National self-harm network: https://www.nshn.co.uk/

Lifesigns: a user-led organisation working around self-injury: https://www.lifesigns.org.uk/

Rachel Reiland, Get Me Out Of Here: My recovery from borderline personality disorder, Hazelden Publishing, 2002.

Self-injury support: https://www.selfinjurysupport.org.uk/

Multimedia resources

Borderliner Notes: The BORDERLINE film interview Archive: https://www.youtube.com/borderlinernotes

Early Years Parenting Unit at the Anna Freud National Centre for Children and Families, Video Series: EYPU—What is “personality disorder”? https://www.youtube.com/watch?v=38EBpzJDodg What is meant by “good mentalisation”? https://www.youtube.com/watch?v=R5kFPpAMDF0

BBC, Radio I & IXtra Stories. Living with BPD: https://www.bbc.co.uk/programmes/p0700vh4/

BBC Radio 4. Narcissism: https://www.bbc.co.uk/programmes/p06y2j6v

Personality Disorder—subtitles. A film produced by the RCPsych Public Engagement Committee and Damn Fine Media: https://www.youtube.com/watch?v=OnwVTrZcn5s/

Adverse Childhood Experiences (ACEs), Public Health Network Cymru. A short film produced for Public Health Wales and Blackburn with Darwen Local Authority: https://www.youtube.com/watch?v=YiMjTzCnbNQ

RethinkBPD: In conversation: Talks on borderline personality disorder and recovery: https://rethinkbpd.org/

Ending exclusion: research and care for people with complex emotional needs #MHQT: A recording of panel discussion around NIHR mental health policy research unit activities: https://youtu.be/aQoQh66D6N4

Public Health Wales, Adverse Childhood Experience (ACE) and Adult Mental Well-Being Wales infograph. 2016: http://www.wales.nhs.uk/sitesplus/documents/888/embargoed%20final%20-%20ace%20%26%20mental%20well-being%20infograph%20e.pdf

Selected readings

Gask L, Evans M, Kessler D. Personality disorder. BMJ 2013;347:f5276

Schrift M, Personality disorders. BMJ Best Practice. 2019

RCPsych Position statement, services for people diagnosable with personality disorders. 2020

NIMHE Personality disorder: no longer a diagnosis of exclusion—policy implementation guidance for the development of services for people with personality disorder. 2003

NIMHE Breaking the cycle of rejection. The Personality Disorders Capabilities Framework. 2003

Bolton W, Lovell K, Morgan L, Wood H, Meeting the challenge, making a difference. Working effectively to support people with personality disorder in the Community. Project report, Department of Health, London. 2014. http://repository.tavistockandportman.ac.uk/864/1/Heather_Wood_-_MeetingTheChallenge.pdf

Mind, Centre for Mental Health, Royal College of Nursing, The British Association of Social Workers, Royal College of General Practitioners, The British Psychological Society, Anna Freud National Centre for Children and Families, Barnet, Enfield, and Haringey Mental Health NHS Trust. Shining lights in dark corners of people’s lives, The consensus statement for people with complex mental health difficulties who are diagnosed with a personality disorder. 2018: https://www.mind.org.uk/media/21163353/consensus-statement-final.pdf

How patients were involved in the creation of this article

JP, a co-author on this paper, has lived experience of personality disorder. Her insights were essential in giving it its final form. An anonymised patient perspective statement has also been included with consent from the author.

Contributors: OKB is the lead author and guarantor of the content of the paper. OKB designed the initial outline and OKB, DC, JP, SS and TL all contributed equally thereafter to writing the final version.

Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: none.

Further details of The BMJ policy on financial interests are here: https://www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/declaration-competing-interests

Provenance and peer review : commissioned; externally peer reviewed.

• Hoffman P ,
• Global Alliance for Prevention and Early Intervention for Borderline Personality Disorder
• American Psychiatric Association
• ↵ Livesley J. Handbook of personality disorders. Second Edition: Theory, research and treatment. Guilford Publications, 2018.
• Sheridan Rains L ,
• Sheehan L ,
• Nieweglowski K ,
• Chartonas D ,
• Kyratsous M ,
• Dracass S ,
• Stoffers JM ,
• Choi-Kain LW ,
• Masland SR ,
• Jenkins JA ,
• Bateman A ,
• O’Connell J ,
• Lorenzini N ,
• Gardner T ,
• Simsek-Duran F ,
• McCormick B ,
• Attwood G ,
• Miloseska K ,
• Diamond D ,
• Yeomans F ,
• Martín-Blanco A ,
• Moffitt TE ,
• Reichborn-Kjennerud T
• Gescher DM ,
• Hillemacher T ,
• Frieling H ,
• Brannigan R ,
• Tanskanen A ,
• Huttunen MO ,
• Battle CL ,
• Johnson DM ,
• Palmier-Claus J ,
• Branitsky A ,
• Mansell W ,
• Warwick H ,
• Johnson BN ,
• Clouthier TL ,
• Caligor E ,
• Hörz-Sagstetter S ,
• Volkert J ,
• Gablonski TC ,
• Torgersen S ,
• Kringlen E ,
• Jenkins R ,
• Blizard R ,
• Beckwith H ,
• Ellison WD ,
• Rosenstein LK ,
• Morgan TA ,
• Zimmerman M
• Roberts A ,
• Rodriguez-Seijas C ,
• Semlyen J ,
• McGilloway A ,
• Nicolas G ,
• Abrams RC ,
• Horowitz SV
• Álvarez-Tomás I ,
• Guilera G ,
• Zanarini MC ,
• Frankenburg FR ,
• ↵ World Health Organization. International statistical classification of diseases and related health problems (11th Revision). 2018. https://icd.who.int/browse11/l-m/en
• van der Kolk BA
• Stubley J ,
• ↵ Royal College of General Practitioners and the Royal College of Psychiatrists, CR152, The management of patients with physical and psychological problems in primary care: a practical guide, Report of a joint working group of the, January ref incomplete??? 2009.
• Hatcher S ,
• Walters P ,
• Thornicroft G ,
• ↵ Schrift M, Personality disorders. BMJ Best Practice. 2019.
• Bateman AW ,
• Lovejoy C ,
• Cassidy S ,
• Allison C ,
• Baron-Cohen S
• Carrington A ,
• Herbert A ,
• British Medical Association, Caring for the Mental Health of the Medical Workforce
• Cornelius J ,
• Borschmann R ,
• Barrett B ,
• Hellier JM ,
• Crawford MJ ,
• Bhatti SF ,
• Stoffers-Winterling JM ,
• Storebø OJ ,
• Pereira Ribeiro J ,
• ↵ National Institute for Health and Care Excellence. Personality disorders: borderline and antisocial. https://www.nice.org.uk/guidance/qs88 2015.
• Martean L ,
• Konstantinidou H
• ↵ Francois D, Roth SD, Klingman D. The efficacy of pharmacotherapy for borderline personality disorder: a review of the available randomized controlled trials. Psychiatric Ann 2015;45:431-7.
• Gabbard G ,
• Weinberg E ,
• Konstantinidou H ,
• Rogalski D ,
• Goddard E ,
• Wingrove J ,
• Roughley M ,
• Maguire A ,
• Cristea IA ,
• Gentili C ,
• Palomba D ,
• Albert EB ,
• Gunderson JG

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• Published: 18 March 2022

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

• Ashley E. Tate   ORCID: orcid.org/0000-0002-4523-6960 1 ,
• Hanna Sahlin   ORCID: orcid.org/0000-0002-6353-024X 2 ,
• Shengxin Liu 1 ,
• Yi Lu   ORCID: orcid.org/0000-0001-9933-3654 1 ,
• Sebastian Lundström 3 , 4 ,
• Henrik Larsson 1 , 5 ,
• Paul Lichtenstein   ORCID: orcid.org/0000-0003-3037-5287 1 &
• Ralf Kuja-Halkola 1  

Molecular Psychiatry volume  27 ,  pages 2514–2521 ( 2022 ) Cite this article

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• Bipolar disorder

Psychiatric disorders

• Schizophrenia

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.

Gunderson JG, Herpertz SC, Skodol AE, Torgersen S, Zanarini MC. Borderline personality disorder. Nat Rev Dis Prim. 2018;4:1–20.

Google Scholar  

APA. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Association Publication; 2013.

Frankenburg FR, Zanarini MC. The association between borderline personality disorder and chronic medical illnesses, poor health-related lifestyle choices, and costly forms of health care utilization. J Clin Psychiatry . 2004.

Arola R, Antila H, Riipinen P, Hakko H, Riala K, Kantojärvi L. Borderline personality disorder associates with violent criminality in women: a population based follow-up study of adolescent psychiatric inpatients in Northern Finland. Forensic Sci Int. 2016;266:389–95.

Article   PubMed   Google Scholar  

Zanarini MC, Frankenburg FR, Hennen J, Reich DB, Silk KR. Axis I comorbidity in patients with borderline personality disorder: 6-year follow-up and prediction of time to remission. Am J Psychiatry. 2004;161:2108–14.

Czajkowski N, Aggen SH, Krueger RF, Kendler KS, Neale MC, Knudsen GP, et al. A twin study of normative personality and DSM-IV personality disorder criterion counts: evidence for separate genetic influences. Am J Psychiatry. 2018;175:649–56.

Article   PubMed   PubMed Central   Google Scholar  

Torgersen S, Czajkowski N, Jacobson K, Reichborn-Kjennerud T, Røysamb E, Neale M, et al. Dimensional representations of DSM-IV cluster B personality disorders in a population-based sample of Norwegian twins: a multivariate study. Psychol Med. 2008;38:1617–25.

Article   CAS   PubMed   Google Scholar  

Skoglund C, Tiger A, Rück C, Petrovic P, Asherson P, Hellner C, et al. Familial risk and heritability of diagnosed borderline personality disorder: a register study of the Swedish population. Mol. Psychiatry. 2019:1–10.

Zapolski TC, Settles RE, Cyders MA, Smith GT. Borderline personality disorder, bulimia nervosa, antisocial personality disorder, ADHD, substance use: common threads, common treatment needs, and the nature of impulsivity. Independent . Practitioner. 2010;30:20.

Tomko RL, Trull TJ, Wood PK, Sher KJ. Characteristics of borderline personality disorder in a community sample: comorbidity, treatment utilization, and general functioning. J Personal Disord. 2014;28:734–50.

Article   Google Scholar  

Welander-Vatn A, Ystrom E, Tambs K, Neale M, Kendler K, Reichborn-Kjennerud T, et al. The relationship between anxiety disorders and dimensional representations of DSM-IV personality disorders: a co-twin control study. J Affect Disord. 2016;190:349–56.

Barnow S, Arens EA, Sieswerda S, Dinu-Biringer R, Spitzer C, Lang S. Borderline personality disorder and psychosis: a review. Curr Psychiatry Rep. 2010;12:186–95.

Doering S. Borderline personality disorder in patients with medical illness: a review of assessment, prevalence, and treatment options. Psychosom Med. 2019;81:584–94.

Østby KA, Czajkowski N, Knudsen GP, Ystrom E, Gjerde LC, Kendler KS, et al. Personality disorders are important risk factors for disability pensioning. Soc Psychiatry Psychiatr Epidemiol. 2014;49:2003–11.

El-Gabalawy R, Katz LY, Sareen J. Comorbidity and associated severity of borderline personality disorder and physical health conditions in a nationally representative sample. Psychosom Med. 2010;72:641–7.

Sharma TR. Polycystic ovarian syndrome and borderline personality disorder: 3 case reports and scientific review of literature. J Psychiatry. 2015;18:1–4.

De Genna NM, Feske U, Larkby C, Angiolieri T, Gold MAPregnancies. abortions, and births among women with and without borderline personality disorder. Women’s Health Issues. 2012;22:e371–e377.

Sansone RA, Sansone LA. Borderline personality: a primary care context. Psychiatry. 2004;1:19.

PubMed   PubMed Central   Google Scholar  

de Aquino Ferreira LF, Pereira FHQ, Benevides AMLN, Melo MCA. Borderline personality disorder and sexual abuse: a systematic review. Psychiatry Res. 2018;262:70–77.

Conway CC, Boudreaux M, Oltmanns TF. Dynamic associations between borderline personality disorder and stressful life events over five years in older adults. Personal Disord: Theory Res Treat. 2018;9:521.

Baldwin JR, Degli Esposti M. Triangulating evidence on the role of perceived versus objective experiences of childhood adversity in psychopathology. JCPP Adv. 2021;1:e12010.

Sansone RA, Sansone LA. Gender patterns in borderline personality disorder. Innov Clin Neurosci. 2011;8:16.

Grant BF, Chou SP, Goldstein RB, Huang B, Stinson FS, Saha TD, 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. J Clin Psychiatry. 2008;69:533.

Barnow S, Herpertz SC, Spitzer C, Stopsack M, Preuss UW, Grabe HJ, et al. Temperament and character in patients with borderline personality disorder taking gender and comorbidity into account. Psychopathology. 2007;40:369–78.

Robinson EB, Lichtenstein P, Anckarsäter H, Happé F, Ronald A. Examining and interpreting the female protective effect against autistic behavior. Proc Natl Acad Sci. 2013;110:5258–62.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Källén B, Källén K. The Swedish Medical Birth Register—a summary of content and quality. 2003.

Careja R, Bevelander P. Using population registers for migration and integration research: examples from Denmark and Sweden. Comp Migr Stud. 2018;6:19.

Brooke HL, Talbäck M, Hörnblad J, Johansson LA, Ludvigsson JF, Druid H, et al. The Swedish cause of death register. Eur J Epidemiol. 2017;32:765–73.

Ludvigsson JF, Andersson E, Ekbom A, Feychting M, Kim J-L, Reuterwall C, et al. External review and validation of the Swedish national inpatient register. BMC Public Health. 2011;11:450.

Ludvigsson JF, Svedberg P, Olén O, Bruze G, Neovius M. The longitudinal integrated database for health insurance and labour market studies (LISA) and its use in medical research. Eur J Epidemiol. 2019;344:1–15.

Tampe U, Frank S, Weiss RJ, Jansson K-Å. Diagnosis of open tibial fracture showed high positive predictive value in the Swedish National Patient Register. Clin Epidemiol. 2020;12:1113.

Kouppis E, Ekselius L. Validity of the personality disorder diagnosis in the Swedish National Patient Register. Acta Psychiatr Scand. 2020;141:432–8.

Kuja-Halkola R, Juto KL, Skoglund C, Rück C, Mataix-Cols D, Pérez-Vigil A, et al. Do borderline personality disorder and attention-deficit/hyperactivity disorder co-aggregate in families? A population-based study of 2 million Swedes. Mol Psychiatry. 2018:261:1–9.

Bhaskaran K, Rachet B, Evans S, Smeeth L. Re: Helene Hartvedt Grytli, Morten Wang Fagerland, Sophie D. Fosså, Kristin Austlid Taskén. Association between use of β-blockers and prostate cancer-specific survival: a cohort study of 3561 prostate cancer patients with high-risk or metastatic disease. Beta-Blockers and Prostate Cancer Survival-Interpretation of Competing Risks Models. Eur Urol. 2022;64:e86–e87. https://doi.org/10.1016/j.eururo.2013.01.007 .

Article   CAS   Google Scholar  

Benjamini Y, Hochberg Y. Controlling the false discovery rate: a practical and powerful approach to multiple testing. J R Stat Soc: Ser B (Methodol). 1995;57:289–300.

Therneau T. A package for survival analysis in R. R package version 3.2-3. Computer software] Rochester, MN: Mayo Clinic. https://CRAN.R-project.org/package=survival . 2020.

Slotema CW, Daalman K, Blom JD, Diederen KM, Hoek HW, Sommer I. Auditory verbal hallucinations in patients with borderline personality disorder are similar to those in schizophrenia. Psychological Med. 2012;42:1873.

Strålin P, Hetta J. First episode psychosis: register-based study of comorbid psychiatric disorders and medications before and after. Eur Arch Psychiatry Clin Neurosci. 2020;271:303–13.

Momen NC, Plana-Ripoll O, Agerbo E, Benros ME, Børglum AD, Christensen MK, et al. Association between mental disorders and subsequent medical conditions. N Engl J Med. 2020;382:1721–31.

Lanska DJ. The Klüver-Bucy syndrome. Neurologic-psychiatric syndromes in focus—Part I . 41. Karger Publishers; 2018. p. 77–89.

Weaver TL, Clum GA. Early family environments and traumatic experiences associated with borderline personality disorder. J Consulting Clin Psychol. 1993;61:1068.

Cohen P, Chen H, Gordon K, Johnson J, Brook J, Kasen S. Socioeconomic background and the developmental course of schizotypal and borderline personality disorder symptoms. Dev Psychopathol. 2008;20:633–50.

Amstadter AB, Aggen SH, Knudsen GP, Reichborn-Kjennerud T, Kendler KS. Potentially traumatic event exposure, posttraumatic stress disorder, and Axis I and II comorbidity in a population-based study of Norwegian young adults. Soc Psychiatry Psychiatr Epidemiol. 2013;48:215–23.

White CN, Conway CC, Oltmanns TF. Stress and personality disorders. The Oxford handbook of stress and mental health 2019 : 183.

Neale MC, Røysamb E, Jacobson K. Multivariate genetic analysis of sex limitation and G × E interaction. Twin Res Hum Genet. 2006;9:481–9.

Hall K, Moran P. Borderline personality disorder: an update for neurologists. Pract Neurol. 2019;19:483–91.

Temes CM, Frankenburg FR, Fitzmaurice GM, Zanarini MC. Deaths by suicide and other causes among patients with borderline personality disorder and personality-disordered comparison subjects over 24 years of prospective follow-up. J Clin Psychiatry. 2019;80:0–0.

Caspi A, Houts RM, Belsky DW, Goldman-Mellor SJ, Harrington H, Israel S, et al. The p factor: one general psychopathology factor in the structure of psychiatric disorders? Clin Psychol Sci. 2014;2:119–37.

Kjær JN, Biskin R, Vestergaard C, Munk-Jørgensen P. All-cause mortality of hospital-treated borderline personality disorder: a nationwide cohort study. J Personal Disord. 2020;34:723–35.

Healthcare Management Forum. Mental illness-related stigma in healthcare: barriers to access and care and evidence-based solutions. Healthc Manage Forum 2017. SAGE Publications Sage CA: Los Angeles, CA.

Knaak S, Szeto AC, Fitch K, Modgill G, Patten S. Stigma towards borderline personality disorder: effectiveness and generalizability of an anti-stigma program for healthcare providers using a pre-post randomized design. Borderline Personal Disord Emot Dysregul. 2015;2:1–8.

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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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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.

1. Lieb K, Zanarini MC, Schmahl C, Linehan MM, Bohus M. Borderline personality disorder. Lancet (2004) 364:453–61. doi: 10.1016/S0140-6736(04)16770-6

PubMed Abstract | CrossRef Full Text | Google Scholar

2. Chugani CD, Byrd AL, Pedersen SL, Chung T, Hipwell AE, Stepp SD. Affective and sensation-seeking pathways linking borderline personality disorder symptoms and alcohol-related problems in young women. J Pers Disord . (2020) 34:420–31. doi: 10.1521/pedi_2018_32_389

3. Bagge CL, Stepp SD, Trull TJ. Borderline personality disorder features and utilization of treatment over two years. J Pers Disord . (2005) 19:420–39. doi: 10.1521/pedi.2005.19.4.420

4. Paris J. Suicidality in borderline personality disorder. Medicina . (2019) 55:223. doi: 10.3390/medicina55060223

5. Lenzenweger MF, Lane MC, Loranger AW, Kessler RC. DSM-IV personality disorders in the National Comorbidity Survey Replication. Biol Psychiatry . (2007) 62:553–64. doi: 10.1016/j.biopsych.2006.09.019

6. Skodol AE, Gunderson JG, Pfohl B, Widiger TA, Livesley WJ, Siever LJ. The borderline diagnosis I: Psychopathology, comorbidity, and personality structure. Biol Psychiatry . (2002) 51:936–50. doi: 10.1016/s0006-3223(02)01324-0

7. Bailey RC, Grenyer BF. Burden and support needs of carers of persons with borderline personality disorder: A systematic review. Harvard Rev Psychiatry . (2013) 21:248–58. doi: 10.1097/HRP.0b013e3182a75c2c

CrossRef Full Text | Google Scholar

8. Weimand BM, Hedelin B, Sällström C, Hall-Lord M-L. Burden and health in relatives of persons with severe mental illness: A Norwegian cross-sectional study. Issues Ment Health Nursing . (2010) 31:804–15. doi: 10.3109/01612840.2010.520819

9. Saccaro LF, Schilliger Z, Dayer A, Perroud N, Piguet C. Inflammation, anxiety, and stress in bipolar disorder and borderline personality disorder: A narrative review. Neurosci Biobehav Rev . (2021) 127:184−192. doi: 10.1016/j.neubiorev.2021.04.017

10. Dixon-Gordon KL, Laws H. Emotional variability and inertia in daily life: Links to borderline personality and depressive symptoms. J Pers Disord . (2021) 35:162−171. doi: 10.1521/pedi_2021_35_504

11. Torgersen S. Genetics of patients with borderline personality disorder. Psychiatr Clinics North A . (2000) 23:1–9. doi: 10.1016/S0193-953X(05)70139-8

12. Quenneville AF, Kalogeropoulou E, Küng AL, Hasler R, Nicastro R, Prada P, et al. Childhood maltreatment, anxiety disorders and outcome in borderline personality disorder. Psychiatry Res . (2020) 284:112688. doi: 10.1016/j.psychres.2019.112688

13. Antoine SM, Fredborg BK, Streiner D, Guimond T, Dixon-Gordon KL, Chapman AL, et al. Subgroups of borderline personality disorder: A latent class analysis. Psychiatry Res . (2023) 323:115131. doi: 10.1016/j.psychres.2023.115131

14. Benzi IMA, Di Pierro R, De Carli P, Cristea IA, Cipresso P. All the faces of research on borderline personality pathology: Drawing future trajectories through a network and cluster analysis of the literature. J Evidence-Based Psychotherapies . (2020) 20:3–30. doi: 10.24193/jebp.2020.2.9

15. Reis T, Gekker M, Land MGP, Mendlowicz MV, Berger W, Luz MP, et al. The growth and development of research on personality disorders: A bibliometric study. Pers Ment Health . (2022) 16:290–9. doi: 10.1002/pmh.1540

16. Singh VK, Singh P, Karmakar M, Leta J, Mayr P. The journal coverage of Web of Science, Scopus and Dimensions: A comparative analysis. Scientometrics . (2021) 126:5113–42. doi: 10.1007/s11192-021-03948-5

17. Pritchard A. Statistical bibliography or bibliometrics. J Documentation . (1969) 25:348.

Google Scholar

18. Price DJ. Networks of scientific papers. Science . (1965) 149:510–5. doi: 10.1126/science.149.3683.510

19. Sabe M, Chen C, Perez N, Solmi M, Mucci A, Galderisi S, et al. Thirty years of research on negative symptoms of schizophrenia: A scientometric analysis of hotspots, bursts, and research trends. Neurosci Biobehav Rev . (2023) 144:104979. doi: 10.1016/j.neubiorev.2022.104979

20. Shen Z, Ji W, Yu S, Cheng G, Yuan Q, Han Z, et al. Mapping the knowledge of traffic collision reconstruction: A scientometric analysis in CiteSpace, VOSviewer, and SciMAT. Sci Justice . (2023) 63:19–37. doi: 10.1016/j.scijus.2022.10.005

21. Wu H, Wang Y, Tong L, Yan H, Sun Z. Global research trends of ferroptosis: A rapidly evolving field with enormous potential. Front Cell Dev Biol . (2021) 9:646311. doi: 10.3389/fcell.2021.646311

22. Brody S. Impact factor: Imperfect but not yet replaceable. Scientometrics . (2013) 96:255–7. doi: 10.1007/s11192-012-0863-x

23. Kaldas M, Michael S, Hanna J, Yousef GM. Journal impact factor: A bumpy ride in an open space. J Invest Med . (2020) 68:83–7. doi: 10.1136/jim-2019-001009

24. Schubert A, Glänzel W. A systematic analysis of Hirsch-type indices for journals. J Informetrics . (2007) 1:179–84. doi: 10.1016/j.joi.2006.12.002

25. Chen C. CiteSpace II: Detecting and visualizing emerging trends and transient patterns in scientific literature. J Am Soc Inf Sci Technol . (2006) 57:359–77. doi: 10.1002/asi.20317

26. Cheng K, Guo Q, Shen Z. Bibliometric analysis of global research on cancer photodynamic therapy: Focus on nano-related research. Front Pharmacol . (2022) 13:927219. doi: 10.3389/fphar.2022.927219

27. Hassan-Montero Y, De-Moya-Anegón F, Guerrero-Bote VP. SCImago Graphica: A new tool for exploring and visually communicating data. Profesional la Información . (2022) 31:e310502. doi: 10.3145/EPI

28. Wang Y, Li D, Jia Z, Hui J, Xin Q, Zhou Q, et al. A bibliometric analysis of research on the links between gut microbiota and atherosclerosis. Front Cardiovasc Med . (2022) 9:941607. doi: 10.3389/fcvm.2022.941607

29. Soloff PH, Lynch KG, Kelly TM, Malone KM, Mann JJ. Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: a comparative study. Am J Psychiatry . (2000) 157:601–8. doi: 10.1176/appi.ajp.157.4.601

30. Widiger TA, Trull TJ. Plate tectonics in the classification of personality disorder: shifting to a dimensional model. Am Psychol . (2007) 62:71–83. doi: 10.1037/0003-066X.62.2.71

31. Patton JH, Stanford MS, Barratt ES. Factor structure of the Barratt impulsiveness scale. J Clin Psychol . (1995) 51:768–74. doi: 10.1002/1097-4679(199511)51:6<768::aid-jclp2270510607>3.0.co;2-1

32. Bartow S, Stopsack M, Grabe HJ, Meinke C, Spitzer C, Kronmüller K, et al. Interpersonal evaluation bias in borderline personality disorder. Behav Res Ther . (20092009) 47:359–65. doi: 10.1016/j.brat.2009.02.003

33. Cheavens JS, Rosenthal MZ, Daughters SB, Nowak J, Kosson D, Lynch TR, et al. An analogue investigation of the relationships among perceived parental criticism, negative affect, and borderline personality disorder features: The role of thought suppression. Behav Res Ther . (2005) 43:257–68. doi: 10.1016/j.brat.2004.01.006

34. Bradley R, Westen D. The psychodynamics of borderline personality disorder: a view from developmental psychopathology. Dev Psychopathol . (2005) 17:927–57. doi: 10.1017/s0954579405050443

35. Tzourio-Mazoyer N, Landeau B, Papathanassiou D, Crivello F, Etard O, Delcroix N, et al. Automated anatomical labeling of activations in SPM using a macroscopic anatomical parcellation of the MNI MRI single-subject brain. NeuroImage . (2002) 15:273–89. doi: 10.1006/nimg.2001.0978

36. Bellino S, Rinaldi C, Bozzatello P, Bogetto F. Pharmacotherapy of borderline personality disorder: a systematic review for publication purpose. Curr Medicinal Chem . (2011) 18:3322–9. doi: 10.2174/092986711796504682

37. Zanarini MC, Frankenburg FR, Dubo ED, Sickel AE, Trikha A, Levin A. Axis I comorbidity of borderline personality disorder. Am J Psychiatry . (1998) 155:1733–9. doi: 10.1176/ajp.155.12.1733

38. Yee L, Korner AJ, McSwiggan S, Meares RA, Stevenson J. Persistent hallucinosis in borderline personality disorder. Compr Psychiatry . (2005) 46:147–54. doi: 10.1016/j.comppsych.2004.07.032

39. Mittal VA, Walker EF. Diagnostic and statistical manual of mental disorders. Psychiatry Res . (2011) 189:158–9. doi: 10.1016/j.psychres.2011.06.006

40. Torgersen S, Kringlen E, Cramer V. The prevalence of personality disorders in a community sample. Arch Gen Psychiatry . (2001) 58:590–6. doi: 10.1001/archpsyc.58.6.590

41. Crick NR, Murray-Close D, Woods K. Borderline personality features in childhood: A short-term longitudinal study. Dev Psychopathol . (2005) 17:1051–70. doi: 10.1017/S0954579405050492

42. Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, 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. Arch Gen Psychiatry . (2006) 63:757–66. doi: 10.1001/archpsyc.63.7.757

43. Giesen-Bloo J, van Dyck R, Spinhoven P, van Tilburg W, Dirksen C, van Asselt T, et al. Outpatient psychotherapy for borderline personality disorder: Randomized trial of schema-focused therapy vs transference-focused psychotherapy. Arch Gen Psychiatry . (2006) 63:649–58. doi: 10.1001/archpsyc.63.6.649

44. Crowell SE, Beauchaine TP, Linehan MM. A biosocial developmental model of borderline personality: Elaborating and extending Linehan's theory. psychol Bulletin . (2009) 135:495–510. doi: 10.1037/a0015616

45. Leichsenring F, Leibing E, Kruse J, New AS, Leweke F. Borderline personality disorder. Lancet (2011) 377(9759):74–84. doi: 10.1016/S0140-6736(10)61422-5

46. Whiteside SP, Lynam DR, Miller JD, Reynolds SK. Validation of the UPPS impulsive behaviour scale: A four-factor model of impulsivity. Eur J Pers (2005) 19(7):559–74. doi: 10.1002/per.556

47. Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF. Evaluating three treatments for borderline personality disorder: A multiwave study. Am J Psychiatry (2007) 164(6):922–8. doi: 10.1176/ajp.2007.164.6.922

48. Bateman A, Fonagy P. Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Am J Psychiatry (2009) 166(12):1355–64. doi: 10.1176/appi.ajp.2009.09040539

49. Fonagy P, Luyten P. A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder. Dev Psychopathol (2009) 21(4):1355–81. doi: 10.1017/S0954579409990198

50. Levy KN, Meehan KB, Kelly KM, Reynoso JS, Weber M, Clarkin JF, et al. Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder. J Consulting Clin Psychol (2006) 74(6):1027–40. doi: 10.1037/0022-006X.74.6.1027

51. Carr DS, Francis A. Childhood familial environment, maltreatment and borderline personality disorder symptoms in a non-clinical sample: A cognitive behavioural perspective. Clin Psychol (2009) 13(1):28–37. doi: 10.1080/13284200802680476

52. Selby EA, Kranzler A, Fehling KB, Panza E. Nonsuicidal self-injury disorder: The path to diagnostic validity and final obstacles. Clin Psychol Review . (2015) 38:79–91. doi: 10.1016/j.cpr.2015.03.003

53. Skoglund C, Tiger A, Rück C, Petrovic P, Asherson P, Hellner C, et al. Familial risk and heritability of diagnosed borderline personality disorder: A register study of the Swedish population. Mol Psychiatry . (2021) 26:999–1008. doi: 10.1038/s41380-019-0442-0

54. American Psychiatric Association, DSM-5 Task Force. Diagnostic and statistical manual of mental disorders: DSM-5™ . 5th ed. Washington: American Psychiatric Publishing, Inc., (2013). doi: 10.1176/appi.books.9780890425596

55. Cristea IA, Gentili C, Cotet CD, Palomba D, Barbui C, Cuijpers P. Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis. JAMA Psychiatry . (2017) 74:319–28. doi: 10.1001/jamapsychiatry.2016.4287

56. Chen C. Predictive effects of structural variation on citation counts. J Am Soc Inf Sci Technol . (2012) 63:431–49. doi: 10.1002/asi.21694

57. Brown MZ, Comtois KA, Linehan MM. Reasons for suicide attempts and non-suicidal self-injury in women with borderline personality disorder. J Abnormal Psychol . (2002) 111:198–202. doi: 10.1037//0021-843x.111.1.198

58. Siever LJ, Davis KL. A psychobiological perspective on the personality disorders. Am J Psychiatry . (1991) 148:1647–58. doi: 10.1176/ajp.148.12.1647

59. Donegan NH, Sanislow CA, Blumberg HP. Amygdala hyperreactivity in borderline personality disorder: Implications for emotional dysregulation. Biol Psychiatry . (2003) 54:1284–93. doi: 10.1016/S0006-3223(03)00636-X

60. Tebartz van Elst L, Hesslinger B, Thiel T, Geiger E, Haegele K, Lemieux L, et al. Frontolimbic brain abnormalities in patients with borderline personality disorder: A volumetric magnetic resonance imaging study. Biol Psychiatry . (2003) 54:163–71. doi: 10.1016/s0006-3223(02)01743-2

61. Herpertz SC, Dietrich TM, Wenning B, Krings T, Erberich SG, Willmes K, et al. Evidence of abnormal amygdala functioning in borderline personality disorder: A functional MRI study. Biol Psychiatry . (2001) 50:292–8. doi: 10.1016/S0006-3223(01)01075-7

62. Linehan MM. Cognitive-behavioral treatment of borderline personality disorder . New York: Guilford Press (1993).

63. Black DW, Blum N, Pfohl B, Hale N. Suicidal behavior in borderline personality disorder: Prevalence, risk factors, prediction, and prevention. J Pers Disord (2004) 18(3):226–39. doi: 10.1521/pedi.18.3.226.35445

64. Brambilla P, Soloff PH, Sala M, Nicoletti MA, Keshavan MS, Soares JC. Anatomical MRI study of borderline personality disorder patients. Psychiatry Res (2004) 131(2):125–33. doi: 10.1016/j.pscychresns.2004.04.003

65. Stiglmayr CE, Grathwol T, Linehan MM, Ihorst G, Fahrenberg J, Bohus M. Aversive tension in patients with borderline personality disorder: A computer-based controlled field study. Acta Psychiatrica Scandinavica (2005) 111(5):372–9. doi: 10.1111/j.1600-0447.2004.00466.x

66. Silbersweig D, Clarkin JF, Goldstein M, Kernberg OF, Tuescher O, Levy KN, et al. Failure of frontolimbic inhibitory function in the context of negative emotion in borderline personality disorder. Am J Psychiatry (2007) 164(12):18321841. doi: 10.1176/appi.ajp.2007.06010126

67. Bohus M, Haaf B, Stiglmayr C, Pohl U, Böhme R, Linehan M. Evaluation of inpatient dialectical-behavioral therapy for borderline personality disorder–a prospective study. Behav Res Ther (2000) 38(9):875887. doi: 10.1016/s0005-7967(99)00103-5

68. Rossouw TI, Fonagy P. Mentalization-based treatment for self-harm in adolescents: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry (2012) 51(12):13041313. doi: 10.1016/j.jaac.2012.09.018

69. Zhang S, Wang S, Liu R. A bibliometric analysis of research trends of artificial intelligence in the treatment of autistic spectrum disorders. Front Psychiatry . (2022) 13:967074. doi: 10.3389/fpsyt.2022.967074

70. Dzikowski P. A bibliometric analysis of born global firms. J Business Res . (2018) 85:281–94. doi: 10.1016/j.jbusres.2017.12.054

71. Chen C, Ibekwe-SanJuan F, Hou J. The structure and dynamics of cocitation clusters: A multiple-perspective cocitation analysis. J Am Soc Inf Sci Technol . (2010) 61:1386–409. doi: 10.1002/asi.21309

72. Gunderson JG, Herpertz SC, Skodol AE, Torgersen S, Zanarini MC. Borderline personality disorder. Nat Rev Dis Primers . (2018) 4:18029. doi: 10.1038/nrdp.2018.29

73. Tan MYL, McConnell B, Barlas J. Application of Dialectical Behaviour Therapy in treating common psychiatric disorders: Study protocol for a scoping review. BMJ Open . (2002) 12:e058565. doi: 10.1136/bmjopen–2021–058565

74. Quevedo Y, Booij L, Herrera L, Hernández C, Jiménez JP. Potential epigenetic mechanisms in psychotherapy: A pilot study on DNA methylation and mentalization change in borderline personality disorder. Front Hum Neurosci . (2022) 16:955005. doi: 10.3389/fnhum.2022.955005

75. Uhlmann C, Tschöke S, Steinert T, Schmid P. Can you see and hear how bad I feel right now? Self–injury and suicidal communication in borderline personality disorder-A secondary analysis. Psychiatrische Praxis . (2022) 49:329–33. doi: 10.1055/a–1820–0438

76. Bohus M, Stoffers-Winterling J, Sharp C, Krause-Utz A, Schmahl C, Lieb K. Borderline personality disorder. Lancet (2022) 398:1528–40. doi: 10.1016/S0140–6736(21)00476–1

77. Schuppert HM, Giesen-Bloo J, van Gemert TG, Wiersema HM, Minderaa RB, Emmelkamp PMG, et al. Effectiveness of an emotion regulation group training for adolescents—A randomized controlled pilot study. Clin Psychol Psychother . (2009) 16:467–78. doi: 10.1002/cpp.637

78. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, text revision . 4th ed. Washington: American Psychiatric Association (2000).

79. Lenzenweger MF, Cicchetti D. Toward a developmental psychopathology approach to borderline personality disorder. Dev Psychopathol . (2005) 17:893–8. doi: 10.1017/S095457940505042X

80. Chanen AM, Jovev M, McCutcheon LK, Jackson HJ, McGorry PD. Borderline personality disorder in young people and the prospects for prevention and early intervention. Curr Psychiatry Rev . (2008) 4:48–57. doi: 10.2174/157340008783743820

81. Pohl S, Steuwe C, Mainz V, Driessen M, Beblo T. Borderline personality disorder and childhood trauma: Exploring the buffering role of self-compassion and self-esteem. J Clin Psychol . (2021) 77:837–45. doi: 10.1002/jclp.23070

82. Bartsch DR, Roberts R, Proeve M. Relationships between parental borderline symptom severity, empathy, parenting styles and child psychopathology. Clin Psychol . (2022) 26:211–21. doi: 10.1080/13284207.2022.2031947

83. Lakeman R, Hurley J, Campbell K, Hererra C, Leggett A, Tranter R, et al. High fidelity dialectical behaviour therapy online: Learning from experienced practitioners. Int J Ment Health Nursing . (20222022) 31:1405–16. doi: 10.1111/inm.13039

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.

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Research Article

Treatment of personality disorder using a whole of service stepped care approach: A cluster randomized controlled trial

Roles Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Illawarra Health and Medical Research Institute and School of Psychology, University of Wollongong, Wollongong, New South Wales, Australia

Roles Data curation, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

Roles Methodology, Project administration, Resources, Writing – review & editing

Affiliation Illawarra Health and Medical Research Institute and School of Nursing, University of Wollongong, Wollongong, New South Wales, Australia

Roles Conceptualization, Funding acquisition, Methodology, Project administration, Resources, Supervision, Writing – review & editing

Affiliation NSW Ministry of Health, Sydney, New South Wales, Australia

• Brin F. S. Grenyer, 
• Kate L. Lewis, 
• Mahnaz Fanaian, 

• Published: November 6, 2018
• https://doi.org/10.1371/journal.pone.0206472
• Reader Comments

Background and objectives

People with personality disorders are prevalent in emergency and inpatient mental health services. We examined whether implementing a stepped care model of psychological therapy reduces demand on hospital units by people with personality disorder, in a cluster randomized controlled trial.

A total of 642 inpatients (average age 36.8, 50.5% female) with a primary ICD-10 personality disorder were recruited during 18 months baseline, then monitored during an 18 month active trial phase. In the active trial phase two equivalent sites were randomised to either treatment as usual (TAU), or a whole of service intervention that diverted people away from hospital and into stepped care psychological therapy clinics. The study design was cost neutral, with no additional staff or resources deployed between sites. A linear mixed models analysis evaluated outcomes.

As predicted, demand on hospital services reduced significantly in the intervention compared to TAU site. The intervention site evidenced shorter bed days, from an average of 13.46 days at baseline to 4.28 days per admission, and patients were 1.3 times less likely to re-present to the emergency department compared to TAU. Direct cost savings for implementing the approach was estimated at USD$2,720 per patient per year. Limitations included not directly comparing individual symptom changes.

Conclusions

Using a whole of service stepped care model of treatment for personality disorder significantly reduced demand on hospital services.

Citation: Grenyer BFS, Lewis KL, Fanaian M, Kotze B (2018) Treatment of personality disorder using a whole of service stepped care approach: A cluster randomized controlled trial. PLoS ONE 13(11): e0206472. https://doi.org/10.1371/journal.pone.0206472

Editor: Jacobus P. van Wouwe, TNO, NETHERLANDS

Received: July 17, 2018; Accepted: October 9, 2018; Published: November 6, 2018

Copyright: © 2018 Grenyer et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data is owned by a third party (NSW Ministry of Health) and contains potentially identifying and sensitive information. The authors are under contractual legal restriction not to release this data. Applications to access the data may be sent to NSW Ministry of Health, Locked Mail Bag 961 North Sydney 2059, Australia. Email: Julia Smailes [email protected] . Others would be expected to be able to access these data in the same manner as the authors, as we did not have any special access privileges that others would not have.

Funding: This study is part of a larger project funded by New South Wales Ministry of Health (to Professor Brin F.S. Grenyer). The funding body provided the authors with the data, however had no role in the design, data analysis, or preparation of the manuscript. The funding body gave approval for the manuscript to be published.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Personality disorder prevalence in the community has consistently found to be 6% [ 1 ] and it is estimated that 40–50% of psychiatric inpatients have a personality disorder, with borderline personality disorder (BPD) the most prominent [ 2 ]. In relation to BPD specifically, it is estimated over 30% of persons treated in an inpatient mental health facility and over 20% of psychiatric outpatients have the diagnosis ([ 2 – 4 ], see [ 5 ] for a review).

Presentations of people with personality disorder to emergency or inpatient hospitals are well known to include features of significant emotional crisis, with or without a self-harm injury, or suicidal threats or attempts [ 6 , 7 ]. The treatment as usual (TAU) clinical response usually involves crisis management or short-term admission for safety and de-escalation of distress, with referral to longer-term community based services [ 8 – 11 ]. A broad range of longer term psychological therapies are effective, particularly for BPD [ 12 – 14 ]. However the capacity of community mental health services and private services to offer such evidence-based treatments can be limited due to their cost and duration, typically involving at least one year of treatment, and often involving multiple sessions per week [ 15 ]. Without specialised psychological therapy programs, this patient group typically experience long waiting times for appropriate therapy, and recurrent crisis-prone behaviour and non-continuous engagement with a diverse range of therapy and other treatment options that are not optimal (ie. long-term inpatient care or off-label pharmacotherapy) [ 16 ]. Due to this and the nature of their interpersonal deficits, people with personality disorders may further escalate help-seeking behaviours, putting further strain on acute and emergency services, which may also cause ambivalence towards help provided and induce challenges for the treatment provider [ 17 ].

It is known that providing specialist long-term evidence-based approaches for the treatment of BPD have significant cost benefits compared to usual treatment [ 18 ]. However, as places in specialist long term approaches are often limited by long wait-lists, alternative pathways into suitable care need to be explored and developed that are have rapid access after crisis. Stepped care models are usually described as 'doing more with less' in that they aim to ensure the needs of the patient is balanced by the resources available [ 15 ]. Personality disorder has high prevalence, and there is significant variability in the prognosis and outcome between people with the diagnosis. Given this, Paris [ 19 ] suggests that a stepped care approach to personality disorder may be beneficial as not all patients with personality disorder need long-term care. Laporte et al [ 20 ] showed that a 12 week short term treatment can be as effective as a 24 month longer-term treatment for most but not all patients, reinforcing the benefits of stepped care approaches in the treatment of personality disorder.

This study describes and evaluates a new model designed to add a stepped model of psychological therapy in between usual crisis care and longer term treatment in the community [ 21 ]. The concept of rapid follow up interventions has been described elsewhere but mostly in the context of reducing suicide risk [ 22 ]. Initial pilot work on a similar brief intervention model was published [ 23 ] and the approach for personality disorders used here was manualised [ 24 ], and this study evaluates its impact on hospital service use.

The approach used here [ 21 ] was informed by key recommendations of Project Air Clinical Practice Guidelines and National Health and Medical Research Council Clinical Practice Guidelines (NHMRC; [ 25 ]) for BPD [ 13 ]. The operationalization of the model involves a combination of senior management and clinical leadership, training and support, and the redesign of existing service models to enhance clinical pathways to suit individual consumer need, without the need for additional resources or staff. Core to the strategy is the provision of psychological therapy, involving rapid referral to the stepped care brief intervention clinic following a crisis presentation, in order to divert from inpatient units and emergency departments ( Table 1 ), improve the trajectory of care through the health service, and maximise use of evidence based psychological therapy approaches. Central to the provision of the stepped care model is the role of clinical staff in coordinating the flow of consumers into the brief intervention clinic, then on to engagement with appropriate longer term psychological therapy in the community.

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https://doi.org/10.1371/journal.pone.0206472.t001

With collaboration and assistance from senior management, the stepped care model was implemented in one site, referred to here as the intervention site. Two comparable geographic hospital sites within the service were given an equal opportunity to be selected as the intervention site. It was anticipated the intervention would enable a more ‘personality disorders inclusive service’ whereby systems are established to provide more effective management of patients with personality disorder in crisis. We expected that this in turn would ultimately reduce the demand by people with personality disorders on mental health inpatient hospital units and emergency departments.

Setting and location

This trial was carried out at one health service in New South Wales Australia. Two separate hospital sites within the same service were randomly allocated as intervention or TAU site. At the time of the study, both sites were comparable in that they were similar in size (in staffing, beds) and both had hospital mental health units servicing patients of varying acuity along with associated community outpatient services available. The two sites were separated by natural geography and landforms including a national park, meaning they operated relatively independently and the communities they served did not generally travel between sites. The primary outcomes reported here did not involve explicit written consent procedures. De-identified data was provided to the researchers for occasions of service during the initial implementation period (April 2011 to September 2012), and a baseline comparative study period (January 2009 to February 2011). The study was approved by the institutional review board in February 2011. Approval for access to electronic medical record history was also granted by the Health Services Research Governance Committees and Records Managers. The authors confirm that all ongoing and related trials for this intervention are registered. The trial was part of a state-wide health service funded initiative and the decision to evaluate this empirically was made early in the project. The protocol described in the trial registration (ACTRN12612000843853 http://www.anzctr.org.au ) and study protocol accompanying this study ( S1 File ) is accurate and true to initial planned implementation.

Randomisation

This study is a cluster randomised controlled trial [ 26 , 27 ]. The two sites both implemented TAU for the first 18 months, meaning the intervention was delayed. This baseline phase recruited all inpatients with a diagnosis of personality disorder meeting study criteria. Then after 18 months baseline, the two sites were randomly allocated to either intervention or treatment as usual using computer sequence randomisation, and the effects were evaluated for a further 18 months by way of follow-up monitoring of the recruited participants use of health services. Management and staff from the intervention site were not blind to the condition allocated as they implemented the stepped care model.

Standard care

The treatment as usual (TAU) was 36 months of standard care, involving usual medical care and community treatment by health care professionals, with the usual variation in services on a case-by-case basis. In this setting, it was not unusual for waitlists for long term treatment programs (e.g. Dialectical Behaviour Therapy) to be in excess of 12 months. If patients were not already engaged in treatment prior to hospital admission, they were either referred to community mental health, whereby they may have been put on a long waitlist, or referred to a community physician or private clinician, whereby participation and follow-up rates are unknown. The main difference between standard care and the intervention was that standard care had an absence of any planned stepped care approach with no brief intervention clinics available.

Intervention

Active intervention was stepped care psychological therapy, using a whole of service guidelines based approach using an integrative relational model [ 21 ], as informed by key recommendations of the NHMRC and Project Air Clinical Practice Guidelines [ 13 ]. Psychological clinics for rapid follow-up were established at the intervention site. The model allowed the service to triage patients into brief and longer psychological therapies based on their need and readiness for intervention ( Table 1 ). The stepped care brief intervention clinic was manualised [ 24 ], comprising one month of weekly contact. Three 50 minute sessions were with the patient, focussed on here-and-now structured psychological treatment, crisis management, safety and care planning, and provision of psychotherapy to reduce symptoms and improve psychosocial functioning. An additional session (usually between session 2 and 3) involved connection with the partner, family member(s) or other carers (usually without the patient present), to provide psychoeducation about the disorder and to facilitate positive recovery support [ 28 ]. The stepped care clinics were placed in the community mental health setting, but administratively linked to the acute crisis teams, meaning presentations to the service (e.g. emergency department, mental health inpatient units, crisis telephone line) could be identified and triaged to receive an appointment in the clinic within 0–36 hours of presentation, once any acute suicidal risk had been stabilised. The brief intervention was developed as a standard service delivered in community mental health structures by existing mental health care clinicians working in these settings. The intervention was delivered following release from hospital or the emergency department, thus any care provided in the hospital setting followed standard procedures. For community clinicians delivering the intervention, caseloads shifted from mainly long-term case management, to brief and longer treatments in a stepped care approach as described.

Further information about the brief intervention clinic, key principles, and referral criteria are available in the published manual that describes specific session outlines and supporting resources (including care plans) [ 24 ]. Following the brief intervention, patients were provided options for further community treatment by health care professionals, as available in TAU standard care. The stepped care approach allowed a responsive service to the presenting difficulties, and gave clinicians a better understanding of the patients problems and level of additional treatment required.

Implementation of the model

Initially, implementation of the model involved a process of gaining support and assistance from senior management as well as clinical leaders within the different structures to aid in the redesign or services, to ‘champion’ the model, and to encourage relevant staff to participate in training. During the active 18 month phase, clinicians in the intervention site also had access to a series of resources including guidelines [ 29 ] and patient directed fact sheets, videos and other clinical resources to aid in treatment provided (all manuals, guidelines and resources are available at www.projectairstrategy.org ). The dissemination and implementation of the model was cost neutral, using existing resources and staff.

The Project Air Strategy clinical guidelines [ 13 , 29 ] describe the pathway of a consumer through the health service, from assessment and care planning, brief and longer-term therapies, and the role of inpatient and community care. They also discuss involving families and carers, as well as systemic issues for services. Staff within the services participated in specifically designed training with the aim of enhancing confidence, knowledge, and skills, and to educate on systemic changes and referral pathways. Because the intervention was implemented as a whole of service approach, participation in the training was strongly encouraged and supported by senior management and clinical leaders. Basic personality disorder training (2 hours) was delivered to 80% of all mental health clinicians working within the intervention site, and subsequent specialised training (one day) was developed and delivered to target specific aspects of working with people who have a personality disorder (e.g. stepped care psychological treatment model). Almost half (48%) of mental health clinicians within the service attended at least one full day training. The model delivered through training emphasises a compassionate, hopeful, less stigmatised response to patients with personality disorder, and also emphasises the importance of rapid implementation of structured psychological approaches following crisis. Topics in the basic level training covered engagement, assessment of urgent needs, establishment of systems of safety, orientation to services, education and support, and the development of a care plan. Subsequent full day training sessions targeted core assessment skills and more intensive application of evidence-based intervention for personality disorders treatment including the stepped model of care [ 21 ]. Specific resources used to accompany the training are also publicly available ( www.projectairstrategy.org ).

Measures and inclusion criteria

All patients with mental health presentations to the hospital inpatient unit or emergency department were routinely diagnosed using a structured, trained protocol [ 30 ]. Patients were included if they (a) were aged 12 or over; (2) had at least one inpatient admission within the 18 months baseline, prior to the randomisation, and (3) had a primary diagnosis of personality disorder based on ICD-10 [ 31 ]. Administratively, these were provided based on the Australian Refined Diagnosis Related Groups model (AR-DRG; [ 32 ]) of consumer classification, whereby episodes of care are categorised and measured for the Australian Classification of Health Interventions [ 33 ]. Whole of service data for every mental health admission or emergency presentation for the 36-month study period was obtained. Data provided to the researchers was de-identified and included admission and discharge dates, demographic and diagnostic information. Same patient separations were identified using unique anonymous identifiers, grouped in chronological order and classified as either ‘baseline’ or ‘active’. The primary outcomes reported here did not involve a written consent procedure as de-identified anonymous data only was provided to researchers. The number of and length of inpatient stays and the number of emergency department presentations were the primary outcomes.

Statistical analysis

Electronic medical record data was used to generate specific active phase and baseline indicators and used to evaluate the impact of the intervention on mental health inpatient hospital services. Specifically, we were interested in the (i) number of bed days in the inpatient unit during each phase, for each site, and (ii) number of admissions to the inpatient unit during each phase, for each site. The dataset also allowed analysis of emergency department presentations for the sample studied.

Each admission was classified as baseline or active according to the admission date, and subsequently totals were generated for the number of days spent in the inpatient unit, and number of inpatient unit admissions for the baseline and active phases. A linear mixed models approach (SPSS-21) was used to analyse the data. Specifically, a mixed models analysis was performed for each outcome variable, with covariance structure for residuals specified as ante-dependent (first order). Any pre-intervention differences on dependent variables were controlled for using this method [ 34 ]. The model was also run including gender as a covariate to determine whether any baseline gender differences had impact on the outcomes. Eleven cases were identified as extreme cases and removed from the data prior to analysis. These cases either had an extreme number of stays within the study period, or one long-term stay (300 or more days) where they were admitted within the last month of the baseline phase, and that extended through the active phase.

Cost analysis

Cost of an inpatient bed day in a government hospital was AU$842 (see [ 35 ], Table 4.2, p. 116), equivalent to USD$881 at the time of completion of the study (AU/USD exchange $1.0464: [ 36 ]). Using this, differences in inpatient costs from baseline phase of intervention to post intervention were compared between the active intervention and control site. Cost savings to hospitals following the implementation of the stepped care approach were calculated based on the data in this study, and subsequently annualised to give the estimated yearly impact, per patient of implementing the stepped care guidelines based approach described in this paper.

Of a total 3167 patients who had been admitted to an inpatient mental health facility during the baseline phase in the intervention and TAU sites, 653 (20.6%) had a primary diagnosis of personality disorder for at least one of their stays. Participants were not included in the analysis if they were not given a primary diagnosis of personality disorder during one of their stays. Following random allocation of sites to the treatment model, 338 patients (51.8%) patients were studied who received treatment at the intervention site, and 315 (48.2%) were studied who received treatment at the TAU site. Following the removal of extreme cases (n = 11), 335 patients comprised the intervention group (52.2%) and 307 (47.8%) the TAU group ( Fig 1 ). Patients were aged 14 through 90 years (M = 36.85, SD = 13.11). The mean age did not differ between intervention (M = 36.60, SD = 12.48) and TAU site (M = 37.12, SD = 13.78), however the proportion of females from the intervention site (46.0%) was significantly lower than the TAU site (55.4%; χ 2 = 5.668, p = .017). See Table 2 .

https://doi.org/10.1371/journal.pone.0206472.g001

https://doi.org/10.1371/journal.pone.0206472.t002

For total bed days, a significant main effect for time was found ( F (1,640) = 37.732, p = .000). However, when considered together, there was a significant interaction between time and study site ( F (1,640) = 4.301, p = .038). Patients from the intervention site showed a significantly larger reduction in time spent in hospital in the active phase than those from the TAU, as shown in Fig 2 . There were no differences between groups in total numbers of inpatient admissions across the study period ( Table 3 ). These findings remained after controlling for gender differences between the sites.

https://doi.org/10.1371/journal.pone.0206472.g002

https://doi.org/10.1371/journal.pone.0206472.t003

Of the patients studied, 453 had an emergency department presentation within the study period also (101 from the intervention site, and 342 from the TAU site). Using this sub-sample, we found patients from the intervention site were more 1.28 times more likely (CI = 1.17–1.40, χ 2 = 19.980, p = .000) to have a reduction in ED presentations than patients from the TAU site. Specifically, 90.1% of those from the intervention site had fewer emergency department presentations, compared to only 67.5% of those from the TAU site.

The estimated mean cost per patient from the intervention site reduced from $11858 (SD $23451) during the pre-intervention phase to $3774 (SD = $11356) during the post-intervention phase. The estimated cost per patient from the control site also reduced from $11439 (SD $20950) to $7435 (SD $26309). Compared to the control site, total estimated mean cost saving following implementation of the intervention is USD$4080 per patient, equating to an estimated annual saving of USD$2720 per patient.

This paper describes an integrated whole of service approach to the management of personality disorders within mental health settings, and evaluates the pilot implementation in a local health district in New South Wales, Australia. A stepped care guidelines based approach [ 21 ] was designed to be integrated and adapted into existing mental health systems with collaboration and support from senior management, clinical leaders and clinicians. This study reports on the pilot roll out of the model in a health district, implemented over a period of 18 months, with comparison to a comparable site within the same health district. Data from the active intervention phase is compared with baseline data from the 18 months prior to the implementation of the intervention.

Core to the model is the provision of stepped care services and referral to suitable pathways, diverting patients from inpatient units and emergency departments, when it is not helpful. Evaluation of the stepped care approach, compared with treatment as usual showed presentations to Emergency Departments significantly reduced by 22%, and the number of days spent in the inpatient unit significantly reduced from an average of 13.46 days to 4.28 days–a significantly larger reduction than the TAU site (12.98 to 8.44 days). As a consequence, the mean cost saving for implementing personality disorder psychological treatment is estimated to be USD $2,720 per patient per year in this sample. This estimate, although only measuring the cost impact of inpatient stays, is consistent with global benchmarks outlined in a comprehensive economic evaluation review study [ 18 ], which reports an annual cost saving for psychological treatment for BPD specifically of USD $2988 per patient in total healthcare costs. Meuldijk and colleagues conclude that effectively implemented evidence based treatments for BPD demonstrate significant cost savings, and this is supported in the current evaluation of a stepped care approach.

Interestingly, we did observe a smaller reduction in hospital admissions in the TAU site also. Anecdotally, around the time of this study, and with the publication of national and international guidelines [ 25 , 37 ], preference for treatment and management in the community over inpatient hospital admissions was gaining momentum. Hence, it is likely these results reflect a genuine and gradual shift in attitudes about personality disorder at the time of this study [ 38 ]. The greater improvement in the study site suggests the implementation of an intervention including emphasis on stepped care in the community and whole of service development supported and extended this shift in the field.

Limitations and future research

This study is the first of its kind to evaluate the implementation of a stepped care model on demand for hospital services. Despite this, this study has limitations. Although the redesigning of services and staff training were limited to the intervention site only, given the size and complexity of the local health districts studied, we were unable to control conversations and distribution of resources between staff working at each site, and staff transfers between sites. Additionally, this study used anonymous data from health service records. This made it difficult to determine the exact drivers of difference between the groups, although the study had high ecological validity as service changes were made directly by clinicians.

In this study, we had access to hospital medical records. Unfortunately this access did not extend to community settings, whereby the stepped care intervention was delivered. Therefore, we were not able to evaluate the number of people referred to the stepped care intervention, nor the participation rate. The stepped care intervention however was part of a service level change, and it was expected that all patients deemed suitable for the clinic were referred to the service for an appointment. Future research is recommended to study of referral and participation rates, as well as analyses of individual patient outcomes.

Future studies might also consider the impact of a whole of service stepped care approach on different personality disorder traits or subtypes. It is possible that service impact could differ depending on severity, traits and subtype of personality disorder [ 39 ]. Similarly, it should be noted that in this study we observed substantial variation in patient age. Further study of age and its impact on frequency and duration of hospital days would allow further insight into the patterns of hospital use by people with personality disorder.

The generalizability of these findings, and applicability to other settings would depend on the practices, services available, and staff within the setting in which it is implemented. Attempts at replication of this study would have to consider the contextual factors of the site, and tailor the implementation strategy to suit. Anecdotally, the setting in this study was a typical Australian mental health service, however the generalisability of these findings to international settings is unclear. Research would benefit by implementation of the model in other settings, locally and internationally. Similarly, impact of the stepped care approach needs to be studied further at the individual level in the short and long-term.

People with personality disorders comprise a significant proportion of those presenting to emergency and inpatient mental health units [ 3 , 40 ]. They can be costly to health systems [ 18 ]. Psychological treatment is effective for reducing symptoms [ 14 ]. This study demonstrates that the implementation and integration of a stepped care model [ 21 ] of brief psychological clinics, using existing resources, supported and championed by senior management and clinical leaders, can result in cost savings by reduced demand on inpatient and emergency hospital services.

Supporting information

S1 file. trial protocol..

https://doi.org/10.1371/journal.pone.0206472.s001

S2 File. CONSORT checklist.

https://doi.org/10.1371/journal.pone.0206472.s002

Acknowledgments

The authors would like to acknowledge support from the NSW Ministry of Health, the clinicians undertaking the structured interviews and those participating in the stepped care brief intervention clinics. The authors would also like to acknowledge the Medical Records Managers for providing the data.

• View Article
• PubMed/NCBI
• Google Scholar
• 9. National Institute for Mental Health in England. Personality disorder: No longer a diagnosis of exclusion. Policy implementation guidance for the development of services for people with personality disorders. London: NIMHE, 2003.
• 24. Project Air Strategy for Personality Disorders. Brief intervention manual for personality disorders. Wollongong: University of Wollongong, Illawarra Health and Medical Research Institute; 2015.
• 25. National Health and Medical Research Council. Clinical practice guideline for the management of borderline personality disorder. Melbourne: NHMRC; 2012.
• 29. Project Air Strategy for Personality Disorders. Treatment guidelines for personality disorders. 2nd ed: NSW Health and Illawarra Health and Medical Research Institute; 2015. https://doi.org/10.1037/per0000091
• 30. New South Wales Department of Health. Your guide to MH-OAT: Clinicians’ reference guide to NSW Mental Health Outcomes and Assessment Tools. Sydney, NSW: NSW Department of Health; 2001.
• 31. World Health Organisation. International statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). Geneva: WHO; 1992.
• 32. Australian Institute of Health and Welfare. Australian refined diagnosis-related groups (AR-DRG) data cubes: Australian Government; 2014 [1 Mar 2017]. Available from: http://www.aihw.gov.au/hospitals-data/ar-drg-data-cubes/ .
• 33. National Centre for Classification in Health. The Australian Classification of Health Interventions—Seventh Edition. Sydney: NCCH, Faculty of Health Sciences, The University of Sydney; 2010.
• 35. Department of Health and Ageing. National Mental Health Report 2013: Tracking progress of mental health reform in Australia, 1993–2011. Canberra: Commonwealth of Australia; 2013.
• 36. Reserve Bank of Australia. Exchange Rates—Daily—2010 to 2013: Reserve Bank of Australia; 2018 [17th April 2018]. Available from: https://www.rba.gov.au/statistics/historical-data.html
• 37. National Institute for Health & Clinical Excellence. Borderline personality disorder: Treatment and management. Leicester and London: National Collaborating Centre for Mental Health 2009.

Borderline Personality Disorder

The latest theory on borderline personality disorder, new research uses logic to understand people with borderline disorder..

Posted April 27, 2024 | Reviewed by Lybi Ma

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• Theories of borderline personality disorder focus on early emotional experiences as the cause of splitting.
• A new approach uses statistical modeling to see what factors influence the tendency toward splitting.
• People with this disorder can use their experiences to help overcome splitting and achieve integration.

When you think of someone with borderline personality disorder , it’s likely that you imagine their tendency to let their emotions veer out of control, become overly intrusive, and alternate between loving and hating the same individual, or what’s known as “splitting.”

Perhaps you have an in-law who you know has this diagnosis, and as much as you would like to show understanding and empathy, it’s difficult when they decide to make you the target of the hate side of the splitting equation. If only you could figure out what’s behind these stormy changes of heart, perhaps you could get along better, if not become a trusted source of help. New research uses a logical analysis to provide some clues.

The Logic of Splitting in Borderline Personality Disorder

According to the University of College London’s Giles Story and colleagues (2024), traditional theories of this disorder regard splitting as an offshoot of unhealthy early emotional development, in which “an infant structures its experience by discriminating between positive and negative affect… [leading to] disconnected states of extreme satisfaction and frustration.” (p. 750) In ordinary development, individuals learn to bring these two states into balance as the bonds with their caregivers become stable and enduring, regardless of whether their needs are satisfied or frustrated. In BPD, though, this integration fails to occur, and individuals come to acquire split representations not just of other people, but of themselves.

Tracing the development of these “object relations” approaches to BPD, Story and colleagues maintain that these approaches miss the mark by considering only emotional aspects of splitting and not potential cognitive ones. Instead, the UCL authors propose a framework of probabilistic inference. Perhaps people with BPD form the wrong conclusions when they try to establish the causes of other people’s behaviors.

Everyone engages in this type of speculation, whether BPD or not. Even a simple act such as someone smiling at you could have you wonder what’s behind their apparent good intentions. Did you do something they liked, which would be a “situational” cause, or are they just people who tend to smile (“dispositional” cause)? You might then go on to observe their future behavior which would allow you to settle the question.

There are many possible variants of the situational versus dispositional attributional process. If you like someone, you’ll be more inclined to view good behavior as dispositional. If someone generally behaves a certain way and then suddenly shows the opposite behavior, it must be situational. For the most part, these reasoning processes are rational, allowing individuals to test “hypotheses” about why others behave as they do. In BPD, all-or-nothing reasoning sets in, in which people tend to view the causes of other people’s behavior in overly simplistic, all-or-nothing ways.

A Statistical Modeling Approach to Splitting

In ordinary experience, Story and colleagues propose, people go through statistical thinking known as “Bayesian,” in which they change the probabilities of a person’s behavior reflecting dispositional factors based on behaviors as they unfold over time. The first time you see a stranger smile, you have no idea whether they are nice, or not. However, as you see them continuing to smile regardless of what’s happening around them, the odds increasingly shift in favor of a dispositional attribution. If people with BPD can’t make that calculation, they’ll judge someone’s personality based on a snap judgment that won’t change over time. Splitting, in this view, becomes “a distorted causal inference.” They don’t, as the authors propose, update a “person prior” (p. 757). Once nice, always nice, and vice versa. The “split priors,” in which people are all bad or all good become “impervious to learning." (p. 762)

The UCL authors ran statistical models on data from a prior study of participants with BPD and non-BPD controls given the simulated task of judging the moral character of “Person A” toward “Person B.” Ordinarily if you were making such a judgment with no “prior person,” you would have to wait to see what Person A actually did in a given situation and then update your judgments. By running a model against the actual data from participants as they judged whether Person A was a good or a bad “agent,” Story and colleagues could determine whether the groups differed in their ability to draw Bayesian inferences.

Not only did the findings confirm the predictions of differences in attributional processes between BPD and non-BPD groups, but the authors were also able to run a model to show how the tendency to engage in splitting could potentially be modified. Part of the problem in making attributions in general is that sometimes the external context in which people act isn’t all that clear-cut. The lack of clarity only feeds into the tendency of people with BPD to draw conclusions based on their initial impressions of others. However, by creating a model in which precise information is available about Person A’s behavior, attributions based on splitting diminish and a more integrated, and realistic, set of judgments can emerge.

Turning Statistical Modeling into Intervention

The job of intervention is to help “split priors” to be updated by data from experience, using the processes described through the Bayesian modeling. Consider the example provided by the authors. A person with BPD might jump to the conclusion that if someone they’re supposed to meet is late, this proves that “they hate me.” Intervention can help the individual take extra external information into account (such as heavy traffic). Training the individual to be more sensitive to situational factors would reduce the tendency to make judgments based not on what people do, but on how they imagine people to be (all good or all bad).

In general, it is a good idea to let the evidence influence your judgments of people, but for individuals who tend to block out the data from experience, this type of intervention could help the person with BPD become more attuned to what the people around them are actually doing. Additionally, based on the Bayesian model, in which your judgments about probability should shift depending on prior outcomes, training people to monitor their conclusions about people over time would help individuals integrate positive and negative judgments rather than shift toward one or the other.

To sum up, whatever early experiences shape the individual with BPD are less important, in this approach, than the logic of the decisions the individual makes in the here and now. Giving people with this disorder the power and knowledge to observe themselves over time can help build the fulfillment that comes from an integrated view of the people in their lives.

Story, G. W., Smith, R., Moutoussis, M., Berwian, I. M., Nolte, T., Bilek, E., Siegel, J. Z., & Dolan, R. J. (2024). A social inference model of idealization and devaluation. Psychological Review , 131 (3), 749-780. https://doi.org/10.1037/rev0000430

Susan Krauss Whitbourne, Ph.D. , is a Professor Emerita of Psychological and Brain Sciences at the University of Massachusetts Amherst. Her latest book is The Search for Fulfillment.

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