Areas for Further Research
Methodological Issues
Our ability to draw clinically meaningful conclusions and conduct meta-analyses from research on BPD would be augmented by improvements in the design of studies. Specific steps that could be taken might include
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Improving the generalizability of study populations in terms of factors such as age, sex/gender, sexual orientation, race, ethnicity, culture, social determinants, presence of co-occurring conditions, illness severity, and risk of suicidal, aggressive, or self-harming behaviors.
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Enhancing study recruitment approaches and using a priori specification of analyses to obtain data on treatment effects in subgroups that have been underrepresented in prior research (e.g., inpatients; older individuals; individuals with multiple psychiatric or physical health conditions; individuals with severe and/or persistent illness; diverse samples of individuals in terms of sex/gender, sexual orientation, race, ethnicity, culture, neurodiversity, and social determinants).
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Developing approaches to data collection and transparent reporting of sociodemographic factors to facilitate pooling of data from multiple studies and to permit assessment of treatment effects in subgroups that have been underrepresented in previous research.
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Standardizing definitions for and collection of key data elements and outcome variables, insofar as possible.
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Incorporating individuals with lived experience into identification of data elements and outcome variables to ensure that research is assessing factors of importance to patients.
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Standardizing information, insofar as possible, on patient characteristics that are important to risk adjustment of outcomes (e.g., age at illness onset, illness duration and severity, presence of specific symptoms or symptom clusters, type and frequency of self-harming behaviors, co-occurring conditions).
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Collecting data on possible common mechanisms of psychotherapies (e.g., therapeutic alliance, therapist characteristics) in addition to elements that are hypothesized to relate to mechanisms of a specific psychotherapeutic approach.
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Reporting diagnostic information using both DSM-5-TR categorical diagnoses and the AMPD.
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Integrating dimensional measures of AMPD and symptom domains of BPD (e.g., impulsivity, affect dysregulation) into clinical trial design.
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Providing detailed information on processes used for random assignment and masking or blinding to treatment condition.
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Reporting data separately, insofar as possible, for each diagnostic group in studies that use transdiagnostic samples.
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Augmenting self-report observations with clinician interpretation of the self-report and with direct measurements of outcome, insofar as possible.
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Ensuring that sample sizes in clinical studies are estimated a priori and are adequate to achieve statistical power.
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Ensuring that studies report data in a consistent fashion, with pre-specification of outcomes of interest.
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When observations are missing, using appropriate data analytic approaches and performing sensitivity analyses, when indicated, to determine the effects of missing data.
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Identifying instruments for measuring BPD symptoms and features that are efficient, accurate, culturally sensitive, and validated in multiple languages for measuring key categorical and dimensional outcomes; fostering standardized and consistent use of such instruments across studies.
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Identifying standardized approaches for collecting information about factors that ultimately may be useful in individualizing treatment selection (e.g., biomarkers, family history, symptom history, treatment history, personality traits, self-harming behaviors).
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Ensuring that studies identify the magnitude of change in scale scores that would constitute a clinically meaningful difference.
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Increasing collection of data on patient-centered outcomes (e.g., quality of life, social functioning, physical health, recovery) and selecting these outcomes using input from individuals with lived experience.
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Developing consensus definitions of response and remission of BPD that can be applied consistently across studies.
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Developing approaches to understanding the diversity of elements and indicators of recovery using insights from individuals with lived experience.
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Providing detailed descriptions of the characteristics of active treatments, including treatment as usual, when they are used in a comparative effectiveness study.
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For studies of new treatments or adaptations of existing treatments, using standardized versions of active comparison treatments to permit consistency in comparing treatments for non-inferiority.
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For studies of new treatments or adaptations of existing treatments, conducting comparative effectiveness studies with more than a single existing treatment to allow broader conclusions to be drawn about the relative effectiveness of different interventions.
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Ensuring that studies of new treatments, technologies, delivery system modifications, or clinical decision support systems include specific attention to health equity in implementation methods.
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Developing mechanisms such as registries for systematic collection of information on program outcomes as a complement to collecting clinical trial data.
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Incorporating approaches to study recruitment and treatment implementation to reduce the impact of placebo effects on study outcomes.
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Improving systematic collection of information on harms, including in studies of psychotherapies.
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Ensuring that studies assess longer-term treatment (e.g., at least 1 year) as well as long-term follow-up assessments (e.g., 3–5 years) to identify possible long-term harms and patterns of relapse after treatment completion.
Research Topics
Prevention, Screening, and Assessment
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Identify risk factors for development of BPD that could be used in defining subgroups of adolescents or adults who warrant prospective screening or could benefit from preventive interventions.
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Determine whether patient characteristics and symptoms can be used to identify adolescents or adults who would benefit from early intervention to prevent onset of BPD.
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Determine whether specific approaches to prevention (e.g., in high-risk adolescents) are associated with benefits on patient-oriented outcomes.
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Determine whether identification of BPD using targeted screening is associated with benefits on patient-oriented outcomes in adolescents and adults.
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Determine circumstances in which the AMPD is more useful than a categorical diagnosis of BPD or in which a categorical diagnosis of BPD is more useful than the AMPD.
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Determine whether additional screening, assessment, or longitudinal rating scales need to be developed for BPD to ensure that their scores have reliability and can be interpreted as measures of a specific construct or outcome among a broad range of ages, genders, cultures, languages, symptom patterns, settings, treatment approaches, and diagnostic models (e.g., categorical, alternative model).
Treatment Planning
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Determine ways to optimize short- and long-term patient outcomes in adolescents and adults, including recovery, using factors and approaches such as
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Early identification and intervention
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“Stepped-care” or clinical staging approaches that start with less intensive treatment and shift to more intensive interventions, as needed, to achieve recovery
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Telehealth (individual, group, and family)
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Setting specific interventions (e.g., emergency, inpatient, long-term care)
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Large-scale data analytics and predictive algorithms
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Self-help and guided self-help approaches, including groups, manual-based approaches, or computer-based programs (including Web-based, phone applications, chatbots, and other modalities)
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Family/caregiver interventions, including support groups and psychoeducation
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Involving certified peer support specialists as part of the multidisciplinary team
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Modifying treatment to improve physical health and address co-occurring health conditions, including substance-related and addictive disorders and other psychiatric disorders
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Modifying treatment to address significant symptoms such as suicidal ideas and behaviors, NSSI, aggressive behavior, anger, mood lability, or anxiety
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Modifying treatment to address attachment-related issues or traumatic experiences, including adverse childhood experiences
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Modifying treatment to address development-related issues in adolescents and emerging adults
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Developing new treatments to target key aspects of personality in BPD.
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Identify clinical indicators, biomarkers, and other factors that can help in individualizing treatment selection, frequency, and duration to achieve optimal patient outcomes in adolescents and adults.
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Identify clinical indicators, biomarkers, and other factors that can help in determining an optimal sequence of treatments, if an initial therapeutic modality is not associated with response or recovery.
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Identify approaches to individualizing treatment selection and delivery to optimize outcomes for individuals of different ages, developmental stages, sexes, genders, races, ethnicities, and cultural groups, among other individual facets.
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Obtain additional evidence in adolescents and adults on the optimal duration and frequency of treatments in relation to the severity of patient symptoms and other clinical variables.
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Obtain additional evidence in adolescents and adults on novel or existing psychotherapies (e.g., interpersonal psychotherapy, acceptance and commitment therapy, DDP) in the treatment of BPD.
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Obtain additional evidence in adolescents and adults on novel or existing psychotherapies in patients with common co-occurring disorders (e.g., PTSD, SUD, depression).
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Obtain evidence on emerging therapeutic approaches such as psychedelic- or MDMA-assisted psychotherapy, which may facilitate the psychotherapeutic process by generating greater openness and self-compassion.
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Obtain additional evidence in adolescents and adults on novel or existing pharmacotherapies in the treatment of BPD.
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Obtain additional evidence in adolescents and adults on novel or existing neurostimulation therapies, such as TMS, in the treatment of BPD.
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Conduct additional studies on the comparative effectiveness of psychotherapies and other interventions to treat BPD in adolescents and adults.
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Identify and standardize several effective psychotherapies for BPD in adults and adolescents that can then be used in a consistent fashion as an active comparator in comparative effectiveness studies.
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Conduct additional RCTs of treatment in adolescents and emerging adults.
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Identify optimal approaches to providing multidisciplinary team–based care of BPD in adolescents and adults with quantification of staff training and supervision requirements, cost-effectiveness, and program sustainability.
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Determine the circumstances in which “bundled” treatment programs are appropriate to use in adolescents and adults with BPD, including the elements of these programs that enhance patient outcomes.
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Identify clinical considerations in assessment and monitoring as well as optimal approaches to providing treatment to individuals with BPD who wish to become pregnant, are pregnant, or are breastfeeding.
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Determine which factors can be used in selecting an optimal treatment setting for adolescents and adults with BPD.
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Determine optimal monitoring frequencies and approaches to detect treatment-related benefits and adverse effects for adolescents and adults with BPD.
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Develop approaches to care that reduce relapse and avoid discontinuities in care for adolescents and adults with BPD.
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Identify the treatment elements and approaches that are viewed as most and least helpful by adolescents and adults who have responded to treatment of BPD.
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Identify differences in the characteristics of patients who seek or receive treatment with psychotherapy, pharmacotherapy, or both.
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Identify methods that will allow information from mobile technologies, wearable technology, and large-scale data analytics to inform assessment, treatment, and future research.
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Identify approaches to redesigning workflows and models of care delivery to improve the use of best practices and reduce inequities in the care of adolescents and adults with BPD.
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Determine the ways in which health system factors and treatment delivery characteristics influence patient outcomes for adolescents and adults with BPD.
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Develop approaches to the dissemination of training in effective psychotherapies.
Ethical Issues in BPD Assessment and Treatment
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Determine approaches for including individuals with lived experience in informing research goals, designs, methodologies, and interpretation, among other roles.
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Determine approaches for including family members or other caregivers of individuals with BPD in informing research goals, designs, methodologies, and interpretation, among other roles.
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Determine the optimal approaches to assess capacity to accept or decline treatment in patients with BPD.
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Determine optimal approaches (e.g., verbal communications, electronic information sharing via patient portals or open notes) for involving family in treatment while also protecting the privacy and confidentiality of adolescents and emerging adults.
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Identify ways in which social media influences BPD symptoms and treatment engagement in adolescents and adults.
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Determine whether specific policy recommendations, regulatory requirements, or adjustments to social media algorithms can reduce the deleterious effects of social media in adolescents and adults who have BPD.
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Identify ways in which risk factors, prevention, assessment, treatment, and outcomes of individuals with BPD are affected by internalized stigma and by biases and discrimination of society and health care professionals related to factors such as BPD and co-occurring diagnoses, physical health symptoms or conditions, age, sex/gender, sexual orientation, race, ethnicity, culture, and social determinants.
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Identify effective approaches to reducing and eliminating health disparities due to bias and discrimination in the assessment and treatment of adolescents and adults with BPD.
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Determine whether specific policy recommendations, regulatory requirements, or health care service delivery interventions can reduce disparities in access to care based on factors such as age, sex/gender, sexual orientation, race, ethnicity, culture, and social determinants as well as insurance status and geographical location.
Information & Authors
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The American Psychiatric Association Practice Guideline for the Treatment of Patients With Borderline Personality Disorder
November 2024
©American Psychiatric Association Publishing
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