Borderline Personality Disorder: Updates in a Postpandemic World
Abstract
Basic Facts: Definitions, Epidemiology, Longitudinal Course
Variable or assessment | Measure or population |
---|---|
Epidemiology % in adults (% in adolescents) (14, 15, 23, 32) | |
General population | 2.7% (1%–3%) |
Psychiatric inpatients | 20%–25% (33%–49%) |
Psychiatric outpatients | 8%–18% (11%–22%) |
Emergency room visits with suicidal ideation | 56% (88%) |
Suicidal behavior (3, 5, 16) | |
Average number of attempts | 3 |
Suicide | 3%–10% (50×greater than among general population) |
Proportion of all suicides with borderline personality disorder | 18% of all suicides; 33% of all youth suicides |
Cost to society (10, 33) | |
Indirect costs of lost productivity (Europe) | $12,484–$50,000 |
Risk for disability with borderline personality symptoms<19 | 15-fold |
Risk for unemployment with borderline personality symptoms<19 | 22-fold |
Psychosocial functioning (24–37) | |
Functional impairment and changes in symptom levels | Good premorbid function provides positive prognosis; remission predicts good functioning |
Poorer interpersonal functioning | Improvement in close relationships occurs with reduction in borderline personality disorder symptoms |
Assessments | |
Semi-structured interviews or clinician rated | |
Structured Clinical Interview for DSM-5 Personality Disorders | All personality disorders |
Diagnostic Interview for DSM-IV Personality Disorders | All personality disorders |
International Personality Disorders Examination | All personality disorders in DSM-IV and ICD-10 |
Revised Diagnostic Interview for Borderlines | Borderline personality disorder only |
Diagnostic self-reports | |
Personality Diagnostic Questionnaire-4 | All personality disorders |
Personality Assessment Inventory | All personality disorders |
Borderline Symptom List | Borderline personality disorder only |
Five-Factor Borderline Inventory | Borderline personality disorder only |
Screening self-reports for borderline personality disorder | |
McLean Screening Instrument for borderline personality disorder | |
Borderline Personality Questionnaire | |
Zanarini Rating Scale for BPD | |
Dimensional personality functioning assessment | |
Personality Inventory for DSM-5 | Personality traits |
Level of Personality Functioning Scale Self-Report | Personality functioning |
Controversies: Dimensional Versus Categorical Diagnosis
Psychiatric disorder | Odds ratio (controlled for sociodemographic characteristics) | 99% CI | Odds ratio (unadjusted) | 99% CI |
---|---|---|---|---|
Any substance use disorder | 3.2* | 2.73–3.97 | 4.50 | 3.57–5.71 |
Any drug use disorder | 4.0* | 3.30–4.72 | 5.78 | 4.67–7.14 |
Any anxiety disorder | 7.7* | 6.51–9.19 | 14.29* | 10.87–18.87 |
Any mood disorder | 9.1* | 7.71–10.78 | 14.93* | 11.63–19.61 |
Major depressive disorder | 2.5* | 2.07–2.90 | 11.76* | 9.35–14.93 |
Dysthymia | 3.2* | 2.51–4.16 | 8.33* | 6.62–10.53 |
Bipolar I | 9.9* | 8.11–12.01 | 16.39* | 13.33–20.41 |
Bipolar II | 4.3* | 3.00–6.03 | 3.70* | 2.71–5.05 |
Any other personality disorder | 12.5* | 10.54–14.86 | 15.87* | 12.82–19.61 |
Paranoid | 5.8* | 4.69–7.25 | 12.20* | 8.93–16.39 |
Schizoid | 4.5* | 3.55–5.76 | 14.29* | 8.40–24.39 |
Schizotypala | 26.5* | 21.53–32.68 | 111.11* | 66.67–200.00 |
Antisocial | 3.5* | 2.71–4.40 | 6.33* | 4.76–8.40 |
Histrionic | 6.5* | 4.90–8.52 | 14.49* | 6.85–31.25 |
Narcissistic | 14.5* | 12.12–17.42 | 55.56* | 40.00–83.33 |
Avoidant | 7.2* | 5.45–9.56 | 11.63* | 7.87–17.24 |
Dependent | 8.2* | 4.65–14.46 | 20.41* | 9.71–41.67 |
Obsessive-compulsive | 3.7 | 3.06–4.52 | 7.75* | 5.65–10.64 |
Variable | ICD-11 | DSM-5 AMPD | HiTOP |
---|---|---|---|
Components of global personality disorder severity | Global severity: self- and interpersonal functioning, risk of harm to self and/or others | Criterion A: self- and interpersonal functioning | Superspectra: general psychopathology severity (p factor) |
Specific and/or stylistic trait domains | Trait qualifiers: negative affectivity, detachment, dissociality, disinhibition, anankastia | Criterion B trait domains: negative affectivity, detachment, antagonism, disinhibition, psychoticism | Spectra: internalizing, detachment, antagonistic externalizing, disinhibited externalizing, thought disorder, somatoform (provisional) |
Neuroimaging Advances
The Frontolimbic Hypothesis: Shared or Distinct Neurobiological Disruptions?
Model supported | Citation | Sample | Method | Analysis or aims | Summary | Implications |
---|---|---|---|---|---|---|
Dimensional neurobiological model | Baranger et al., 2020 (62) | N=1,398 scans from the Duke Neurogenetics Study and Human Connectome Project | Structural MRI | 152 structural metrics examined (e.g., cortical thickness, cortical surface area, subcortical volumes) | Borderline traits not associated with any of 152 structural metrics investigated | Traits that are specific to borderline pathology are not associated with brain structure |
Degasperi et al., 2021 (63) | 52 studies N=1,104 borderline personality disorder and 1,100 control participants | Task-based fMRI (any task) | Activation likelihood estimation meta-analysis | No clusters of significant convergence or differences identified during the performance of any task; when analyses were restricted to emotion processing tasks; two significant clusters of greater activation, in borderline personality disorder vs. controls, in amygdalate and ACC | Borderline-specific pathology is not associated broadly with brain function during fMRI task performance | |
Traynor et al., 2021 (64) | N=45 borderline personality disorder and 29 control participants | Resting-state fMRI | Connectivity analysis | Limbic system connectivity strength in borderline personality disorder significantly associated with severity of impairments in dimensional self- and interpersonal functioning (DSM-5 AMPD criterion A); typology-specific measure of borderline personality disorder symptom severity not significantly associated with any resting-state connectivity patterns | Limbic system disruptions are related to dimensional psychopathology impairments and are not borderline personality disorder–specific | |
van Zutphen et al., 2017 (65); van Zutphen et al., 2020 (66) | N=51 borderline personality disorder, 26 cluster C, and 44 nonpatient control participants | Task-based fMRI (emotion processing task and affective inhibitory control task) | Activation analysis | Insula and TPJ hyperactivation during emotion processing in borderline personality disorder vs. other groups; hyperactivation in FEF and IPL during inhibition of negative vs. neutral stimuli, in borderline personality disorder vs. other groups; activation differences showed significant linear trend related to diagnostic severity vs. category | Differences in brain activation may be related more to the severity of psychopathology vs. diagnostic category | |
Kebets et al., 2021 (67) | 166 females with borderline personality disorder, bipolar disorder, or ADHD | Resting-state fMRI | Partial least squares analysis of resting-state signal variability | Frontolimbic network signal variability associated with emotion dysregulation across disorders; severity of emotion dysregulation accounted for 74% of shared variance in frontolimbic signal; depression and mania severity not associated with frontolimbic signal | Emotion dysregulation-related frontolimbic function is shared across disorders and not specific to borderline personality disorder | |
Bilek et al., 2019 (68) | N=120 borderline personality disorder vs. 115 control participants | Task-based fMRI (threat processing task) | Activation analysis | Significant reduction in amygdala habituation to threat processing in borderline personality disorder vs. controls; effect unrelated to borderline personality disorder symptom severity or category but significantly associated with severity of childhood adversity | Abnormalities in brain activation during threat processing may be related more to severity of early adversity vs. categorical borderline personality diagnosis | |
Metz et al., 2019 (69) | N=18 borderline personality disorder, 20 PTSD, 40 control participants | Task-based fMRI | RCT of autobiographical memory (AM) retrieval after administration of 10 mg of hydrocortisone or placebo | No between-group differences in neural activation during AM retrieval after hydrocortisone or placebo; hydrocortisone effects on amPFC, vlPFC, PCC, angular gyrus, and cerebellum positively correlated with childhood trauma questionnaire scores | Hydrocortisone-induced neural activation during AM retrieval is related to childhood trauma (vs. borderline personality disorder diagnosis) | |
Schaub et al., 2021 (70) | N=313 with borderline personality disorder, cocaine use disorder, opioid use disorder, major depressive disorder, schizophrenia, or first-episode psychosis | Structural MRI | Examined associations between anhedonia and gray matter volume | Negative associations found between volumes of left putamen and bilateral cerebellum with anhedonia scores across disorders | Clinical problems, such as anhedonia, have shared neurobiological substrates across borderline personality disorder and other disorders | |
Neukel et al., 2021 (71) | N=45 borderline personality disorder and 25 control participants | Task-based fMRI (emotion processing task) | Activation analysis | Abnormal precuneus activation during emotion processing of neutral and fearful stimuli in borderline personality disorder related to severity of impairments in self- and interpersonal functioning (DSM-5 AMPD criterion A) | Abnormalities in emotion-related brain activation may be related more to severity of psychopathology vs. diagnostic category | |
Cremers et al., 2021 (72) | N=51 borderline personality disorder, 26 cluster C, and 44 nonpatient control participants | Task-based fMRI (emotion regulation task) | Support vector machine classification of borderline personality disorder | Unable to classify borderline personality disorder with high accuracy by using brain activation during emotion regulation; 55% classification accuracy was not statistically significant under permutation model | Brain activation during emotion regulation cannot be used to distinguish individuals with borderline personality disorder from those without the disorder | |
Hybrid dimensional-categorical neurobiological model | Yu et al., 2019 (73) | 13 borderline personality disorder studies (N=395 borderline personality disorder and 415 control participants) and 47 bipolar disorder studies (N=2,111 bipolar disorder and 3,261 control participants) | Structural MRI | Meta-analysis of gray matter volume and density in borderline personality disorder vs. bipolar disorder | Shared: decreased gray matter volume and density in right medial OFC; specific to borderline personality disorder: decreased gray matter volume and density in amygdala and right parahippocampal gyrus; specific to bipolar disorder: decreased gray matter volume and density in right insula and thalamus and increased volume and density in right putamen (and putamen volume correlated with young mania rating scale scores) | Borderline personality disorder and bipolar disorder have both shared and distinct neural substrates |
Lou et al., 2021 (74) | 15 borderline personality disorder datasets (N=442 borderline personality disorder and 441 control participants) and 11 PTSD datasets (N=214 PTSD and 258 control participants) | Structural MRI | Meta-analysis of gray matter volume in borderline personality disorder vs. PTSD | Shared: gray matter volume reductions in orbitofrontal gyrus and anterior cingulate cortex; specific to borderline personality disorder: gray matter volume increases in PCC/precuneus; specific to PTSD: gray matter volume decreases in amygdala and hippocampus | Borderline personality disorder and PTSD have both shared and distinct neural substrates | |
De la Peña-Arteaga et al., 2021 (75) | N=19 borderline personality disorder, 20 major depressive disorder, and 19 control participants | Task-based fMRI (cognitive reappraisal task) | Activation analysis | Shared: decreased vlPFC activation during cognitive reappraisal; specific to major depressive disorder: overall prefrontal hypoactivation; specific to borderline personality disorder: abnormalities attributed to connectivity disruptions between vlPFC and temporal regions | Borderline personality disorder and major depressive disorder both have shared and distinct neural substrates |
Interpersonal Hypersensitivity, Negative Affectivity, and the Default Mode Network (DMN)
Biomarkers of Aggression and Hostility in Borderline Personality Disorder
Self-Harm in Borderline Personality Disorder and Biomarkers of Psychotherapy Outcomes
Treatment
Psychotherapy
Pharmacology and Novel Brain-Based Therapeutics
Conclusions
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