Bordeline Personality Disorder, The Last Decade

Borderline Personality Disorder

The American Journal of Psychiatry has three articles on borderline personality disorder by some of the leading experts. Mostly about the development of the concept which is sumarized by Otto F. Kernberg and Robert Michels as:

…we have made tremendous strides in only a few decades, beginning with a theoretical concept in psychoanalysis that was ridiculed by most other psychiatrists, and progressing to a widely recognized clinical entity; from a pejorative label for disliked patients to a carefully defined diagnostic category; from the subject of almost no systematic study to one of the most intensively researched personality disorders—in terms of diagnosis, epidemiology, genetics, developmental psychology, biological correlates, pathophysiology, and treatment—and perhaps most important, from a hopeless prognosis to a hopeful one, and particularly one for which we have several evidence-based effective treatments.

The most progress is made in the last decades.

  • Borderline personality is a serious psychiatric disorder, with a prevalence of about 4% in the community, but as high as 20% in many clinical psychiatric populations
  • It is difficult to treat (both in the sense of responding poorly and as personally troubling to the therapist and the treatment team) and poorly understood
  • Borderline personality disorder has 68% heritability. This invalidated the theories about borderline personality disorder’s etiology that had focused exclusively on environmental causes. Also discussed in a recent blog post by Gene Expression. Is it a brain disease? Partly, these heritable risk factors, in turn, interfere with the normal attachment process during development, and this disruption can be magnified when there is inadequate parental support
  • Borderline personality disorder has an unexpectedly good course, 4% each year looses the diagnosis.
  • The guidelines for the treatment of borderline personality disorder retained a primary role for psychotherapy, but they emphasized the need to enroll patients as collaborators, the need for a primary (i.e., administratively responsible) clinician, and the value of psycho education, family involvement, and the use of an algorithm for medications
  • The “stress-vulnerability” model of disease is a useful guide to a biopsychosocial concept of borderline personality disorder patients

The authors conclude with the importance of training residents in treating these patients especially since psychotherapy has lost it’s attractiveness to teachers, residents and insurance companies. Skills needed in psychotherapy need a lot of training and supervision. I agree with one of their shocking statements about psychiatric curricula.

More remarkable is that borderline personality disorder still lacks a standing presence in psychiatric training curricula. Appropriate teaching—both academic and clinical—for residents is nonexistent in all but a few institutions.

NIMH information on Borderline Personality Disorder
Kernberg, O., & Michels, R. (2009). Borderline Personality Disorder American Journal of Psychiatry, 166 (5), 505-508 DOI: 10.1176/appi.ajp.2009.09020263
Oldham, J. (2009). Borderline Personality Disorder Comes of Age American Journal of Psychiatry, 166 (5), 509-511 DOI: 10.1176/appi.ajp.2009.09020262