is a psychiatrist and regional medical director with 

Elisabeth Netherton, MD 

Motherhood and the 4 Symptom Domains of Borderline Personality Disorder

Mothers with borderline personality disorder (BPD) often have experienced early-life trauma, especially attachment trauma. BPD is a clinical challenge for several reasons and is associated with treatment-refractory depression and anxiety.

 Limited symptom improvement is often seen with psychotropic medications.

 Effective psychotherapy, such as dialectical behavioral therapy, is intensive, often expensive, and frequently difficult to access.

BPD symptoms can directly limit patients’ ability to consistently engage in treatment. Additionally, BPD is associated with prominent safety concerns, with self-harm behaviors common and seen in around 50% of patients.

 Patients with BPD often struggle with safety-interfering behaviors like substance use.

 BPD is associated with a high rate of completed suicide, commonly cited at up to 10%.

 Although there are limited data about how BPD symptoms shift over the life span, we know that as a complete diagnostic entity, it has low prospective diagnostic stability, cited at 37% in 1 study across a study period of 18 years.

 Some theorize a burnout over time, in which symptoms may become less prevalent with age, with the largest change seen after age 44.

Some studies describe a more nuanced life span process, wherein affective lability, relationship challenges, and impairments in sense of self persist, but impulsivity improves over time.

 Overall, little is known about fluctuations in symptoms and diagnosis across the reproductive period and in relation to the experience of motherhood.

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Articles

Mothers with borderline personality disorder often have experienced early-life trauma. How can you help?

Mothers With Borderline Personality Disorder Often Experience Trauma

Women adapting to their new roles as mothers can struggle with substantial mental health challenges. 

, for example, is widely understood as the most common condition faced by mothers after delivery. However, mothers can face many other overlooked psychiatric challenges across pregnancy, the postpartum period, and motherhood. 

(BPD) is a common diagnosis among young women that is highly understudied in pregnancy and motherhood.

Prevalence of BPD in the general population may be as high as 5.9%, around 10% in psychiatric outpatient clinics, and around 20% among psychiatric inpatients.

; around 87% of those receiving diagnoses are female. It is also thought to be associated with a higher degree of disability in women.

 Average age upon diagnosis is 24.8 years. Delayed diagnosis is common, often happening after an average of 3.6 years of treatment.

“Motherhood” is a broad construct involving constant change: pregnancy, postpartum, infancy, toddlerhood, school-age children, teenager, empty-nesting. We can consider 4 main domains of symptoms within BPD: identity/sense of self, impulsivity, relationship difficulties, and affective instability.

In the United States, the mean age of women at first birth is 26.9 years, which closely corresponds to the average age of women upon BPD diagnosis.

 By age 44 years, 85% of women in the United States have had at least 1 biological child, with an average of 2.1 children per woman.

 Based on these data, women with BPD are statistically likely to become mothers.

. In women with BPD, symptom severity has been associated with teenage pregnancy, unplanned pregnancy, and multiple prenatal adverse events.

In one study, women with BPD who presented for delivery were more likely to have used 

 or other addictive substances during pregnancy.

 Women with BPD have shown overall low rates of adherence to prenatal care and overall high likelihood of experiencing pregnancy as traumatic.

Women with BPD have also been found to be at substantially higher risk of preterm delivery than women in a hospitalwide control group; their infants were more likely to have low Apgar scores.

 During the postpartum period, 23.1% of women seeking psychiatric inpatient admission to a mother-baby unit in Australia met criteria for BPD.

 Another 11.1% showed significant BPD features without meeting full diagnostic criteria.

There have been substantially higher rates of reports made to child protective services—and a high rate of substantiation for those reports—for women with BPD compared with women without BPD.

 Another study found that persistent high levels of 

 in the mother across the first year postpartum was associated with externalizing problems in children when measured at 2.5 years postpartum,

 but this link was entirely associated with the presence of BPD symptoms in the mother.

Clinically, we see substantial symptom variability among women as they navigate motherhood, with some symptoms improving and others worsening. Although there is very little research addressing these symptom shifts directly, we can synthesize what we know from the literature and draw on clinical experience to examine how these symptoms are likely to change across the span of motherhood.

Personal identity is conceptualized through role commitments, a sense of inner agency, a world view that gives life meaning, and continuity across time. Motherhood has a profound impact on sense of self and can lead to a reevaluation of how autonomy, physical appearance, sexuality, and occupations influence these identities differently than they did prior to motherhood.

Shifts in how mothers understand themselves in relationship to others often begin with pregnancy.

 Socioculturally, intensive pressure is placed on mothers in Western societies to adopt “intensive parenting” practices that can squeeze out other important aspects of identity outside of motherhood.

 Cultural portrayals of motherhood emphasize fusion of a mother with her baby as the goal and the expectation.

In women with BPD, there are often clinical improvements in patients’ sense of self and a reduction in their experience of internal emptiness in their new role as mother. However, this initial stabilization is often brief. As children begin the process of individuation, mothers with BPD may experience it as a threat to their own sense of self, with subsequent heightened distress and symptomatology.

 There is also an increase in distress for these mothers as their grown children leave home, with substantial challenges in reestablishing a sense of self independent of the role they played as a mother caring for children living at home.

Impulsivity has a known negative impact on pregnancy. It is associated with a higher risk of unplanned pregnancy, risky sexual behaviors, and a risk for sexual victimization.

There is limited evidence that impulsivity increases during pregnancy and the postpartum period, although this notion is very understudied.

 Impulsivity in individuals with BPD commonly manifests in substance use disorders, with as many as 57% of individuals with BPD experiencing a 

 The negative impacts of substance use in pregnancy have been well documented.

Impulsivity is also associated with safety concerns, such as self-injurious behavior and risk for suicide.

 Impulsivity is also associated with eating, particularly binge eating, which can impact the health of women and their babies during pregnancy as well as body image during the postpartum period.

Evidence suggests that across the life span, impulsivity tends to become a less common symptom in BPD. However, certain kinds of impulsivity may increase during times of distress, and it is unclear how impulsivity changes in pregnancy and the postpartum period.

 For women in general, studies point to lower rates of self-harm during pregnancy.

The development of healthy relationships requires “theory of mind,” or the ability to understand our own internal state and that of others. Theory of mind includes cognitive and affective components, to understand others’ thoughts/beliefs and emotional states.

Connected regions of the brain that are active when we exercise this ability are referred to as the “theory of mind network.”

 Mothers make use of this ability, as they coregulate affect, when their baby is distressed and they mirror the baby’s distress to facilitate soothing.

During pregnancy, women experience changes in their brain architecture that likely strengthen their ability to care for and raise a child.

 These involve changes within the theory of mind network and have been shown to predict mother-baby attachment postpartum.

 These changes have the potential to impact women’s relationships with their larger community; their ability to draw support from their communities is associated with resilience to postpartum distress, whereas low support is a consistent risk factor in postpartum distress.

 Relationship distress, with increased conflict intensity, is common after the birth of children and women who lack support from a partner have a higher risk of developing and maintaining postpartum depression.

Relationships are particularly challenging for women with BPD. Adults with BPD have been shown to have significant deficits in theory of mind and often struggle to cooperate with others as a relationship progresses and to repair following a rupture in cooperation.

This makes women with BPD particularly vulnerable during the transition to motherhood and the postpartum period, when the ability to draw support from relationships is critical to maternal well-being. It also affects a mother’s ability to develop secure attachment with her baby, which is critical to child development. However, there is hope that the brain-based changes of motherhood might mitigate some of this risk or lend improvement in these areas.

Functional neuroimaging studies of patients with BPD have shown frontolimbic dysfunction that has a differential impact on negative emotionality and is consistent with clinical challenges around affective lability seen in adults with BPD.

Women with BPD struggle more with mood shifts in response to hormone fluctuations; that is, changes in ovarian hormone levels have been associated with fluctuations in negative emotionality and impulsivity in women with BPD. Fluctuations in hormone levels also characterize pregnancy and parturition, which may indicate that there is an increased risk in women with BPD for mood changes and symptom exacerbation during this period compared with women without BPD.

BPD traits vary individually over time and core traits of BPD can carry additional risk for distress as women transition to motherhood and parent young children. Additional research is needed to further understand the model of pathology for women with BPD as they enter motherhood and to determine strategies that can lead to resilience and health for mothers and their families.

 is a psychiatrist and regional medical director with

is director of women’s mental health at Houston Methodist Hospital in Texas.

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Borderline personality disorder is a common diagnosis among young women that is highly understudied in pregnancy and motherhood. Learn more here. 

The mental health provider shortage could not be happening at a worse time. It was already a problem that has been decades in the making, but the 

In 2020, 38% of adults in the United States reported symptoms of anxiety or depression, up from just 11% in 2019.

 Emergency departments have seen more individuals seek treatment for suicide attempts, drug overdoses, 

The demand for mental health care may be rising, but the supply of providers has been lagging for years. Back in 2013, a deficit of more than 6000 psychiatrists was projected for 2025, representing 12% of the workforce.

 Today, that estimate has been pushed to more than 7500.

 And it is not just happening in the mental health field: More than 15,000 primary care and 11,000 dental health providers are needed to 

For mental health providers, there are more reasons for the shortage than solutions. Certainly, increased awareness and better screening have boosted people’s confidence to seek treatment. There are internal reasons: recruitment challenges, an aging workforce, and provider 

. There are also external forces: a biased insurance reimbursement system and lingering stigma around psychiatry and mental health.

Solving the provider shortage is no easy task. But without real solutions, the ones who lose out are the patients we serve, especially those who are minorities, live in rural areas, or come from low-income areas. In providing solutions, psychiatry needs to be a leader in making bold decisions, leveling the playing field, and shaping the future of mental health.

We know that our patients are differentially impacted by this shortage. While one-third of all Americans lack adequate access to mental health care, this tends to be much higher in rural and partially rural areas of the country.

 In Wyoming and Utah, for example, 96.4% and 83.3% of the population live in provider shortage areas, respectively, compared to 0.4% in New Jersey and 4% in Massachusetts.

Part of the problem with provider coverage is that psychiatrists in the United States tend to congregate in the northeast and along the west coast. Delaware, for example, needs only 15 mental health providers to cover its gap in care, while Texas needs 638.

A patient’s choice of psychiatrist is highly personal—maybe more so than other types of physicians. For example, women with histories of sexual trauma often prefer to meet with female psychiatrists. The severity of shortages in many areas of the country prevents patients from exercising their ability to choose the right provider for them, directly impacting their care experience.

Patients are also challenged by long wait times for treatment. Those who do get an outpatient appointment often have to wait several months. During this wait, many are lost to treatment or resort to seeking care in emergency rooms. In 2016, 1 in 5 adults reported that they were suffering from mental illness, yet less than 50% of them received treatment.

 In 2017, the average wait time to receive emergency psychiatric care was 23 hours.

Psychiatrists also face challenges from the shortage, including pressure to fit more patients into their tight clinic schedules. Many psychiatrists find their appointments becoming shorter to accommodate more patients. But this only prevents in-depth clinical assessment, 

collaboration with treatment team members

, and consultation with primary care providers we rely on.

With shorter appointments, there is a greater chance of overprescribing antipsychotics and other medications. It takes a great deal more time to educate patients about the need to subtract medications than it does to add new ones. Additionally, the length between prescription refills may be extended beyond a provider’s ability to monitor responses and side effects.

Stretched too thin, these scenarios set the stage for 

. Physicians in general have high rates of burnout, with 45.8% of physicians reporting at least 1 symptom.

 Psychiatrists experience a unique kind of stress, as they “use themselves as tools” to treat patients. This can be exacerbated by long hours, managing suicidal or homicidal patients, and poor work-life balance.

 Unmanaged, this stress can drive psychiatrists to feel the need to rescue patients, to feel like failures if treatment is not effective, to feel powerless against illness, or to fear becoming ill themselves.

Psychiatry is a challenging profession that still suffers from 

. It is often viewed negatively by other medical professionals and seen as remote from other forms of medicine—an unscientific specialty lacking in glamour or prestige. That many medical students’ exposure to psychiatry is limited to emergency medicine and inpatient psychiatric hospitals further exacerbates this stigma. It is a view that continues to challenge recruitment efforts during medical school.

After World War II, 7% to 10% of medical students chose psychiatry as their specialty.

 But the closures of state-run psychiatric hospitals and the sidelining of care for the seriously mentally ill took a toll. By the 1970s, this rate fell by half and has fluctuated between 3% and 5.5% ever since.

Upon matriculation, only about 1.6% of medical students choose psychiatry as their specialty.

 By the time they graduate, however, this grows to about 4.1%.

 Put another way, close to 80% of future psychiatrists did not go into medical school seeking that specialty. Somewhere along the way, however, they were inspired to make this their life’s work, underscoring the importance of reaching students during medical school.

Encouragingly, we do see these numbers improving. Ten years ago, only about 4% of medical students chose to specialize in psychiatry. In 2020, however, that rose to 6.5%, an increase greater than all other medical specialties.

 Part of this is likely due to a growing awareness that physical and mental health have a symbiotic relationship. It may also be due to a rising interest in neuroscience. While the number of practicing psychiatrists declined by 10% between 2003 and 2013, neurologists increased by more than 15%.

Students are often pulled to psychiatry for deeply personal reasons. Perhaps they witnessed a family member suffer from mental illness. Perhaps their interest was piqued by a previous degree in psychology, an inspiring teacher, or an exceptional clinical placement. While it is reassuring to see medical students have that “lightbulb” moment, there is an opportunity to encourage more students to enter medical school because of the power of psychiatry.

We also know that earning potential is a powerful motivator for medical students, but psychiatry simply does not pay as much as other specialties. Psychiatrists make an average of $275,000 a year, compared to plastic surgeons at the high end of the spectrum earning $526,000 and pediatricians on the low end earning $221,000.

 Reasons for this vary, but if you follow the money, it inevitably leads to insurance companies and how they reimburse psychiatric and other mental health services.

 has long dragged its feet on adequately covering mental health care. Patients are 3 to 6 times more likely to receive out-of-network mental health care providers and facilities than other medical and surgical services.

 Reimbursement policies for health insurance companies can be so daunting that 40% of psychiatrists in 2017 operated cash-only private practices, second only to dermatologists.

Historically, insurance companies tend to favor physical health care needs over mental health. Although it is unthinkable for anyone to suffer long from a broken ankle, individuals with serious mental illnesses often have to wait months for treatment. 

 companies work additional legal loopholes by requiring patients to meet a high bar of criteria to qualify for treatment. Often, this means only patients who are very ill qualify for care coverage.

There are additional disparities in how payors reimburse medical services. In 2014, for example, an in-network office reimbursement was $66 for a psychiatrist, compared to $76 for other medical office visits.

 Because of this gap, providers may forego participating in an insurance network because they can charge more out-of-network.

While federal and state parity laws seek to balance coverage, insurance companies often skirt this requirement by shrinking provider networks. As a result, patients wait longer to receive treatment and have fewer options when selecting a provider. Those who do have in-network options often have to wade through outdated insurance databases or “ghost networks” filled with providers who do not even take insurance, had disconnected numbers, or had died.

As a result, many patients either give up on seeking treatment or pay a higher cost to see out-of-network providers. Additionally, the gap has widened between what insurers will cover for in-network psychotherapy and out-of-network costs for these services. This widening gap, which also includes patient cost-sharing, can be partially attributed to the provider shortage.

A number of laws have worked to close the gaps in coverage. Passed in 2008, the Mental Health Parity and Addiction Equity Act (MHPAEA) required insurance companies to reimburse mental health conditions in a manner similar to other medical conditions. This law sought to patch previous legislation that allowed limits on facilities and treatment visits as well as higher copays for outpatient mental health visits. The law also expanded coverage to include 

The Affordable Care Act of 2010 went a step further by requiring all insurance plans to provide coverage for mental health and substance use treatment, listing these among 10 essential health benefits. In December 2020, Congress enacted new provisions requiring payors to provide comparative analyses showing its compliance with MHPAEA.

Some states are passing separate legislation designed to provide further protection for consumers. In 2021, California joined 6 other states including Texas, Maryland, and Colorado in requiring insurance companies to reduce wait times to see a mental health provider to just 10 days. Insurance companies have pushed back. They blame the provider shortage for longer wait times and say it is unfair to put the onus on insurance companies to solve it.

Addressing psychiatry’s provider shortage requires a multifaceted approach that involves multiple stakeholders that include providers, trade associations, patient advocates, insurers, and federal and state governments.

Prioritizing recruitment; mentoring; and longer, hands-on training residencies is vital in giving students ample opportunity to explore psychiatry. Expanding these opportunities into rural areas may also encourage students to remain in these areas after graduation. Additional training and recruitment of 

, clinical pharmacists, and physician assistants can also provide a foundation of support to provide greater care for patients.

 holds enormous potential for giving access to hard-to-reach patients, especially those living in rural areas. During the pandemic, federal and state governments eased hundreds of restrictions to allow patients access to telehealth care via video-conferencing services.

 However, these are temporary measures. Because each state differs in how it legislates and regulates the practice of medicine and telehealth, there are limits to how far these services can extend. Suggestions on how to strike a healthy compromise include making it easier for providers to obtain out-of-state licenses, allowing states to recognize licenses from other states, and allowing clinicians to apply for a national license along with their state license.

 It is becoming increasingly clear that mental health and physical health are linked. Through a 

, psychiatrists serve as team leaders in a primary care setting where the holistic needs of patients are taken into account and treated collectively. This is especially effective with patients who are suffering from cooccurring medical and behavioral health conditions.

Eventually, psychiatry’s success lies in its ability to partner with other medical specialties. We need to capitalize on the growing understanding that, ultimately, mental health is physical health. By working to blend behavioral health and psychiatry into primary care, we can forge a powerful partnership and nurture this symbiotic relationship.

Insurance reimbursement system improvement: 

The fact that 40% of psychiatrists do not accept insurance highlights the growing gap between the cost of services and reimbursement amounts.

 This requires diligence on the part of providers to continue to negotiate fair market rates. Innovative prospective payment systems can be used as a more reliable cost-based methodology to set rates. This can be useful when Medicare is involved, as it can protect practices from limiting access to psychiatric services to avoid a net loss.

While federal regulations guide the big picture, there is room to improve legislative consistency across the states. For example, HIPAA regards patient confidentiality regulations equally among psychiatry and general medicine. But states can apply their own, more restrictive measures to create a firewall and limit collaboration between behavioral health and primary care providers.

Solving the provider shortage is not easy, as it requires action on a number of fronts. The COVID-19 pandemic particularly highlights these shortfalls and promises to make a big problem potentially worse. It is a problem that starts in medical school, progresses through stigma and insurance barriers, and ends with progressively older providers retiring without replacement. We must continue to broaden access to providers through telehealth and other means while recognizing they can only see a finite number of patients.

By demanding that reimbursements adequately cover the cost of services, promoting the importance of mental health, and partnering with primary care providers, we can spread our reach and encourage collaboration to reach and affect total wellness within patients.

1. Barna M. Mental health workforce taxed during COVID-19 pandemic: worker shortage hinders access. 

The pandemic amplifies a growing crisis that requires a multifaceted approach.

Elisabeth Netherton, MD

Articles

Mothers With Borderline Personality Disorder Often Experience Trauma

Motherhood and the 4 Symptom Domains of Borderline Personality Disorder

Bridging the Provider Gap

A Teacher and Mother