When BPD was first described, its symptoms were thought to border on what were then the two main categories of psychiatric problems: psychotic illnesses and neurotic disorders.
Both the concept of BPD and the diagnostic classification of psychiatric disorders have evolved since then.
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) removed neurosis as a diagnostic category, and authors working on the next edition have proposed changes that would further distance BPD from psychotic disorders such as schizophrenia.
Because BPD is a particularly severe form of personality disorder, those affected often make up a relatively large proportion of patients in mental health treatment.
• It affects 1% to 2% of American adults, but approximately 10% of psychiatric outpatients and 15% to 20% of inpatient psychiatric patients.
• Between 69% and 80% of BPD patients have suicidal behavior (including suicide attempts and life-threatening actions), and up to 9% of BPD patients die by suicide.
For many years, childhood adversity and abuse, particularly sexual abuse, were considered major risk factors for developing BPD.
Some studies reported that 81% to 91% of BPD patients had experienced abuse as children.
But other researchers have argued that risk is not the same as causation and that some of the earlier studies may have been subject to recall bias, especially when patients were consulted years later.
The current thinking about BPD is that it develops due to the interaction of multiple factors, such as trauma in children who are temperamentally or genetically vulnerable. Family and twin studies suggest that BPD is 69% heritable, meaning that genes account for the majority of susceptibility to developing this disorder.
Studies conducted by researchers at the University of Washington have concluded that dialectical behavior therapy is effective in reducing self-mutilation and suicide attempts, as well as the number of days spent in psychiatric hospitals.
In a study involving 101 women with BPD who had attempted suicide at least twice in the past five years, researchers randomly assigned half to treatment with dialectical behavior therapy and the other half to treatment by medical experts (defined as experienced and associated with prestigious institutions). ) Both interventions lasted one year.
The researchers found that patients who underwent dialectical behavior therapy were half as likely as others to attempt suicide and were less likely to self-mutilate or be hospitalized.
Therapists focus on building the therapeutic relationship and use techniques such as guided imagery, assertiveness training, and role-playing to help the patient cope with daily experiences and past traumatic events. Essential psychological schemes have restructured the help the manifestations of fear. Therapy must continue for at least two years to be effective.
In a randomized, controlled study involving 86 patients, researchers at the Academic Hospital Maastricht in the Netherlands compared schema-focused therapy with transference-focused psychotherapy.
The patients underwent therapy twice a week for three years. Both treatments relieved BPD symptoms and improved patients’ quality of life and psychological functioning.
In general, however, schema-focused therapy was more likely to lead to recovery.
At the end of the study, 46% of patients assigned to schema-focused therapy (20 of 44) had recovered (as defined by a clinical instrument that assesses BPD symptoms), compared with 24% of those assigned to transference-focused therapy (10 of 42).
One long-term study reported that mentalizing-based treatment reduced the use of antipsychotics and the number of suicide attempts, and increased the chance of recovery five years after completing treatment.
Because the researchers conducted their initial research in a partial hospital setting, they conducted a separate study in an outpatient setting.
In an 18-month study, they randomly assigned 134 patients with BPD to mentalizing-based treatment or structured clinical treatment (consisting of case management, supportive counseling, and problem-solving sessions).
Although patients in both interventions improved significantly (measured by a decrease in suicide attempts, hospitalizations, and other crisis events), those assigned to mentalization-based treatment improved substantially more than those who received structured clinical treatment.