Joel Paris, MD

Borderline personality disorder (BPD) is frequently seen in clinical practice. Over the past 2 decades, research on BPD has increased substantially, with concomitant specialized psychotherapies that have been proved to be effective. A number of pharmacological agents have also been investigated, but results have been mixed.

 is that only a minority have straightforward clinical presentations with no comorbidity. BPD typically coexists with depression, anxiety, and substance abuse. Symptoms of these conditions may lead the clinician to miss the diagnosis of personality disorder entirely.

Comorbidities in BPD reflect a connection with both internalizing and externalizing disorders and symptoms. This indicates that unlike many other disorders that are more strongly associated with either internalizing or externalizing symptoms, BPD is associated with domains of symptoms and categories of disorders. Studies have found a mean of 4.1 lifetime Axis I comorbidities and 1.9 lifetime Axis II comorbidities for patients with BPD.


Lifetime comorbidities in patients with BPD

: 96% of patients with BPD have a mood disorder during their life, and lifetime depression is reported at 71% to 83%.

 Anxiety disorders are also extremely common: 88% of patients have an anxiety disorder, 34% to 48% have panic disorder, and 47% to 56% have PTSD. Alcohol and substance abuse or dependence are reported by 50% to 65%; eating disorders affect 7% to 26% over a lifetime (

 Gender differences in these disorders are similar to what is seen in the general population: substance use disorders are more common comorbidities in males, and mood disorders and eating disorders are more common comorbidities in females.

Structured interviews, such as the Diagnostic Interview for Borderlines–Revised and the Structured Clinical Interview for DSM-IV, can confirm diagnoses of BPD and comorbid disorders.

 However self-report questionnaires designed for screening may inaccurately label patients who have BPD with another disorder. For example, the Mood Disorder Questionnaire often inaccurately identifies bipolar disorder in patients with BPD.

 Proposed changes in DSM-5 would not have solved this problem, since traits of negative affectivity, including anxiousness and depressivity, are associated with many other diagnoses. In the end, most of these comorbidities could be considered artifactual and BPD should often be considered as a primary diagnosis. The broader problem is that in DSM diagnoses, clear delineations between disorders or between traits and disorders are lacking.

Patients with BPD need treatment specific to the disorder, whatever comorbidities they have. There are now many specialized forms of psychotherapy for BPD backed up by clinical trials, particularly dialectical behavior therapy, mentalization-based treatment, and Systems Training for Emotional Predictability and Problem Solving, among others.

Many treatments for other psychiatric disorders, both psychotherapeutic and psychopharmacological, are less likely to be effective in BPD, and antidepressants in particular yield disappointing effects in treating MDD. In addition, if psychopharmacological treatment is provided and more than one clinician is involved, good communication between team members is essential. This applies to situations in which a prescribing physician and a therapist are treating the same patient and to situations in which there are multiple prescribing physicians, such as a mood disorders specialist and a substance use disorder specialist. Clear communication helps avoid splitting that can easily occur, especially when different treatment approaches are used at the same time.

Finally, be wary of providing too much treatment. There is no evidence in this population that more is better, and one of the guiding principles of treatment is to have patients build a life worth living. If life consists of frequent appointments with therapists and groups for several years, this may prevent patients from having activities outside of treatment and impede generalization of what they are learning in psychotherapy.

What new information does this article provide?


? This article summarizes the management of comorbidities in patients with borderline personality disorder (BPD). Despite advances in the treatment of BPD, management of comorbidities has been neglected: this article summarizes the literature and presents a framework for management of these difficult cases.

What are the implications for psychiatric practice?


? Patients with BPD are frequently encountered in clinical practice and most have multiple comorbidities. This article will help clinicians guide these patients to the most beneficial treatment options while avoiding unnecessary and ineffective treatments.

MDD is the most ubiquitous comorbidity in BPD. However, even patients who meet criteria for MDD may not benefit from antidepressants. The reasons for this are unclear, but some of the symptoms of MDD overlap with symptoms and associated features of BPD. For example, chronic dysphoria as seen in BPD is similar to sadness and worthlessness as experienced in MDD. Therefore, using treatments for MDD to target chronic dysphoria is less likely to be effective without additional treatment specific to BPD. In a study of 161 patients, of whom 42% had a current major depressive episode, improvement in BPD symptoms led to later improvement in major depressive symptoms, but the inverse was not true.

 This suggests that specific treatment for BPD may be an effective treatment for both disorders.

Consistent with this principle, studies of psychotherapy for patients with BPD have demonstrated reductions in self-reported depressive symptoms.

 While some pharmacotherapy trials have also demonstrated reductions in depressive symptoms, this finding is difficult to interpret.

In these studies, patients with comorbid MDD were excluded, so although the pharmacotherapeutic intervention led to a reduction in subsyndromal symptoms of depression, remission rates in patients with comorbid BPD and MDD could not be evaluated. Results from studies of the combination of medication and specialized psychotherapy have been mixed.

 This evidence generally supports the conclusion that treatment of BPD leads to improvement in depressive symptoms, and that psychotherapy plays a more important role than pharmacotherapy in the treatment of BPD with comorbid MDD.

If a patient with BPD has comorbid bipolar disorder type I, question whether there is a personality disorder at all; at least in some patients, intense affective lability or emotional dysregulation can produce similar symptoms. Comorbid bipolar disorder type II is a more complex problem, and it is a heterogeneous entity whose treatment remains controversial. Gunderson and colleagues

 found a comorbidity rate of 19% for bipolar disorder type II. Lower rates were reported by Paris and colleagues.

 The prevalence of this comorbidity depends on how strictly one defines hypomania. However, for the subset of patients in whom these comorbid disorders are clearly and accurately identified, mood stabilizers are required for the treatment of bipolar disorder and specialized psychotherapy is required for the treatment of BPD.

The course of anxiety disorders is similar to that of MDD comorbid with BPD. Good results have been shown with psychotherapies, which suggests that this comorbidity may also benefit primarily from a specialized psychotherapy designed for BPD.

 PTSD is a more complex problem, since its boundaries are not always clear. Some evidence suggests that trauma can worsen BPD, but it is important to remember that not all patients with BPD have histories of trauma and only a small minority of people who experience trauma develop BPD. However, evidence-based psychotherapies, such as dialectical behavior therapy (DBT), tend to focus on the present and short-term future, but in some cases, time-limited, evidence-based cognitive-behavioral therapy for PTSD may be useful.

The presence of a substance use disorder is particularly important and problematic. Some research suggests that the presence of a substance use disorder is associated with more severe BPD symptoms and a poorer prognosis over the intermediate term, but the prognostic importance of substance use disorders may attenuate over time.

 Treatment studies for BPD with comorbid substance use disorder suggest that successful psychotherapy can lead to reductions in both BPD symptoms and substance use.

 One study found added benefit from the use of a DBT-based smartphone application in reducing substance use urges.

Thirty-seven-year-old Nancy is being treated by a psychologist for long-standing depression and anxiety. She is referred for psychiatric assessment, and on the basis of a clinical interview augmented with a semi-structured interview, she receives a diagnosis of BPD. Current comorbidity includes MDD, panic disorder without agoraphobia, cannabis dependence, and alcohol abuse. In a collaborative decision, it is decided that Nancy would switch from her current therapy to a DBT program for BPD.

Antidepressant therapy is started but is of limited benefit. Over several months, BPD symptoms begin to resolve, which leads to a similar reduction in her anxiety and mood symptoms, but her alcohol use temporarily worsens. She is counseled to attend a substance use rehabilitation program concurrently with her DBT but feels unable to commit to that much treatment at one time. Her clinicians suggest that she take a temporary leave from psychotherapy until she completes substance use treatment. Once the rehabilitation program is finished, Nancy returns to the DBT program and shows significant treatment gains. After a year, she no longer meets criteria for BPD or any comorbidity.

When eating disorders are comorbid with BPD, rates of eating disorder decline over time, but change to another eating disorder, which is frequently eating disorder not otherwise specified. This suggests that these symptoms can be an impulsivity symptom of BPD. Little research has been done in the population of patients with both BPD and an eating disorder, and a preliminary study that used an adaptation of DBT had mixed results.

 If a patient has serious weight loss resulting from anorexia nervosa, this should be treated before undertaking therapy for BPD. In contrast, binging and purging behaviors can be targeted in the same way that self-harm or substance use are targeted in specialized psychotherapies for BPD.

Unfortunately, the literature provides limited guidance on management of all cases of comorbidity. Careful diagnosis of BPD and comorbid disorders is the first step. Generally, the course of comorbidities is closely tied with the course of BPD, and thus improvements occur over time and specialized psychotherapy for BPD usually leads to improvements in comorbid disorders.

Most evidence indicates that symptoms of depression remit after specialized treatment for BPD, and the course of anxiety disorder is likely similar. Elements of substance use disorders and some eating disorders may be manifestations of impulsivity in BPD, which also would benefit from specialized DBT treatments, although the prognosis is more guarded in these cases. In general, specialized treatments for BPD are likely to improve both the symptoms of BPD and the comorbid disorders.

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Borderline personality disorder typically coexists with depression, anxiety, and substance abuse. Symptoms of these conditions may lead the clinician to miss the diagnosis of personality disorder entirely. Careful diagnosis of BPD and comorbid disorders is the first step.

Comorbidities in Borderline Personality Disorder

Suicidality is a defining feature of borderline personality disorder (BPD). It is also the feature that creates the most anxiety among those who treat patients with this disorder. It is rare to find patients with BPD who have never shown any suicidal behavior. As described in criterion 5 in DSM-IV-TR,

 these patients are characterized by "recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior." Suicidal ideas and threats are ubiquitous, and most patients make multiple suicide attempts.

 Suicidality in patients with BPD is chronic and can continue for extended periods (months to years).

 This feature helps distinguish patients with BPD from those with classic mood disorders, who are suicidal only when acutely depressed. While BPD often begins with repetitive suicide attempts starting in adolescence and continuing into young adulthood, these behaviors tend to remit over time.

 Suicidal thoughts vary in intensity over time, waxing when life is stressful and waning when it is not.

Suicidality in patients with BPD is associated with traits of affective instability. 

 Instead of continuous depression or mania, lasting for weeks to months, the rapid mood swings of BPD occur in response to life events.

 The unique quality of these symptoms is shown by the failure of mood in BPD to respond consistently to antidepressants.

 Suicidal actions are also associated with impulsive personality traits.

 reported a mean of 3 lifetime attempts in patients with BPD, and the frequency of attempts was related to levels of impulsivity.

Long-term naturalistic follow-up studies, with one exception,

 have shown that about 10% of patients with BPD eventually commit suicide and that about 90% do not.

 Although 2 recent prospective studies report suicide rates closer to 4%,

 these results may be limited to cohorts that were consistently compliant with treatment.

One of the most interesting findings that has emerged from long-term follow-up research in BPD is the age at which suicide completions occur. Threats and attempts peak early in the course of BPD, when patients are in their 20s, yet completion occurs much later. Thus, patients with BPD do not usually kill themselves at the time when they most alarm therapists, but later in development, usually if they fail to recover. In one follow-up study,

 the mean age of patients who completed suicide was 30, while in another,

 it was 37 (SD, ± 10). Clinicians should also keep in mind that since completions are rare relative to attempts, it is almost impossible to predict suicide in individual cases.

In BPD, the most typical suicidal behavior is an overdose of pills, occurring in an interpersonal context.

 These overdoses usually carry a message-sometimes for a lover and sometimes for a therapist. Patients with BPD also tend to cut their wrists repetitively, and/or carry out other actions to hurt themselves. 

 However, self-mutilation is not truly suicidal behavior. It typically consists of superficial cuts on the wrists and arms, and patients report that it functions to provide short-term regulation of intense dysphoric affects.

 Self-mutilation can come to resemble addictive behavior.

Suicidal ideas and actions in patients with BPD perform several functions.

 The first is providing a sense of control. If one cannot master one's life, one can at least choose to die or threaten to die. The second is offering a comforting option of escape from pain and suffering. The third is communicating distress. Patients with BPD do not expect to be readily heard by others, and often feel they need to demonstrate the depth of their suffering in a concrete fashion.

Borderline patients tend to be unpopular with therapists because their suicidality is frightening. Therapists may be concerned about the threat of litigation if a suicide should occur.

 However, in patients with BPD, suicidality "goes with the territory"

 and should be seen as another type of problem, in the same way as psychosis.

The main point to keep in mind is not to apply management strategies designed for acute suicidality to chronic suicidality.

 Active interventions designed to prevent suicide have a tendency to be counterproductive in patients with BPD because they reinforce the very behaviors they are designed to treat.

 Most BPD experts have advised therapists to tolerate suicidality and focus on the problems that cause it. Kernberg

 recommends that therapists inform patients and their families that they cannot take responsibility for, or ultimately prevent, completed suicide; and Maltsberger

 argues that one must accept a calculated risk to effectively treat patients with BPD.

Many believe that, if possible, hospitalization should be avoided. Linehan

 sees hospitalization as interfering with effective treatment and is only willing to tolerate an overnight hospital stay. Livesley

 advises keeping hospitalization to a rarity. Dawson and MacMillan

 suggest that hospitalization should almost never be used for patients with BPD. Gunderson,

 while not excluding admission, tries to avoid it by informing patients that it will not be helpful. The American Psychiatric Association guideline for the treatment of borderline personality disorder represent a committee consensus and take a different point of view.

 The guideline (page 8) states, "When the patient's safety is judged to be a serious risk, hospitalization may be indicated." Yet there is no evidence that such interventions actually increase safety or reduce mortality. Moreover, when suicidality is chronic, hospitalization tends to become recurrent.

 Thus while hospital admission may provide temporary relief, most patients continue to have suicidal ideas after discharge. Hospitalization can also be harmful when recurrent admissions disrupt the patient's life.

 There is a good evidence-based alternative. Clinical trials of outpatient treatment support its use for patients with BPD in crisis.

 Day hospitals have the advantages of intensive treatment by an experienced team without the disadvantages of a full inpatient admission.

Most patients with BPD are managed as outpatients with psychotherapy.

 It is also common to use pharmacotherapy as an adjunct to reduce impulsivity, 14 but there is no evidence that drugs can prevent suicide. The key to effective psychotherapy in BPD may be to address the life issues that make patients consider ending their lives rather than making an endless cycle of attempts to prevent suicide.

 Dialectical behavior therapy (DBT) is an effective method for reducing levels of parasuicidal behavior.

 DBT uses specific strategies to manage suicidality: therapists conduct a behavioral analysis in which they validate the distress behind suicidal ideas, identify the problems leading to that distress, and work to develop alternative solutions to these problems. Instead of reinforcing suicidality through increased therapist contact (a common problem in other therapies), DBT offers brief coaching through telephone contact when patients communicate thoughts but provides negative reinforcement (temporary loss of sessions) of suicidal actions. Recently, several other promising forms of therapy, including mentalization- based treatment, transferencefocused therapy, and schema therapy have undergone clinical trials.

 Suicidality in BPD remits when patients attain meaningful work and establish a network of relationships.

 The long-term follow-up studies reviewed above show that most recovered patients are working, about half achieve some kind of stable relationship, and about a quarter raise children, although formal research has not determined whether the offspring of patients with BPD are also at risk.

The management of suicidality in patients with BPD is anxiety provoking. Yet fear need not paralyze therapists or lead them to avoid these patients. Research suggests that most people with BPD get better with time, and that patients in crisis are not at high risk for suicide completion. The focus of therapy should be on problem solving and improved functioning, with the ultimate goal of supporting reasons for living.

 Dr Paris is a professor in the department of psychiatry at McGill University and a researcher at the Institute of Community and Family Psychiatry of the Sir Mortimer B. Davis- Jewish General Hospital in Montreal, Quebec. He reports that he has no conflicts of interest concerning the subject matter of this article.

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Brown MZ, Comtois KA, Linehan MM. Reasons for    suicide attempts and nonsuicidal self-injury in women    with borderline personality disorder. J Abnorm    Psychol. 2002;111:198-202.  

Soloff PH, Lynch KG, Kelly TM, et al. Characteristics    of suicide attempts of patients with major depressive    episode and borderline personality disorder: a    comparative study. Am J Psychiatry. 2000;157:601-    608. 

Suicidality in patients with borderline personality disorder is chronic. It is important to distinguish these patients from those with classic mood disorders, who are suicidal only when acutely depressed.

Author | Joel Paris, MD

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