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Borderline personality disorder has many clinical features, including relatively unrecognized sleep disturbances. Generally, sleep problems are not considered a primary characteristic of this condition, but research is beginning to identify specific patterns of sleep disruptions that are associated with the disorder.

 is characterized by substantial emotional instability, relationship strains, behavioral problems, and difficulties with self-image. It is disruptive for the person who has the disorder, as well as for other individuals in their lives. There is no effective or recommended pharmacological treatment for this chronic disorder. The clinical management, which consists of behavioral and cognitive therapies, is challenging.

 differ from the criteria for diagnosis of bipolar disorder, there are some similarities, and it can be difficult at times to differentiate the 2 conditions.

 Bipolar disorder is a psychiatric disorder characterized by fluctuations in mood and energy levels, often with features of 

 and depression. Borderline personality disorder and bipolar disorder can both profoundly interfere with an affected patient’s quality of life, and they both often cause mood instability, hopelessness, and other overlapping symptoms. Unlike borderline personality disorder, 

 is often treated with prescription medication, along with counseling and behavioral therapy. A 

 of either of these disorders can delay proper referral to a psychiatrist or behavioral specialist and delay the timely implementation of appropriate therapy.

Several studies have shown that patients who have borderline personality disorder experience substantial variability in their sleep times from night to night when compared with the general population. These trends have been documented by clinical history and questionaries, and objectively with actigraphy and polysomnogram studies.

 is a disruptive condition that causes fluctuations in sleep rhythms, with phase delay and misaligned rest-activity pattens. Patients who have circadian rhythm sleep disturbance can experience irregular sleep patterns, with inconsistency and unpredictability from day to day. This causes a lack of adequate sleep, as well as low energy and concentration during the day. This sleep disturbance has been associated with borderline personality disorder.

Furthermore, the severity of certain symptoms of borderline personality disorder has been shown to correlate with certain actigraphy patterns that demonstrate daytime and nighttime abnormalities that are consistent with circadian sleep disturbance. In one study, patients who carried a diagnosis of borderline personality disorder and who had high levels of impulsivity and mood instability showed substantial phase delayed daytime activity patterns, low inter daily stability, weak amplitude, and greater fragmentation of rest activity states over a study duration of 28 days.

 These patterns were not noted in the study participants who had a diagnosis of 

 or in the controls. Another study showed that patients with borderline personality disorder had delayed phase of nighttime rest patterns, delayed daytime activity onset, as well as delayed temperature phase, while controls and patients who had bipolar disorder did not exhibit these features.

While there appears to be a correlation between the severity of symptoms of borderline personality disorder and circadian rhythm dysfunction, the clinical implications have not been established, nor has any specific cause-and-effect relationship. Whether the emotional and behavioral aspects of borderline personality disorder affect circadian rhythm regulation, or the circadian rhythm dysregulation affects symptoms of borderline personality disorder is not clear. The distinct differences in circadian rhythm disturbance patterns between patients with borderline personality disorder and patients with bipolar disorder that has been replicated in several studies is interesting, especially given the similarities between the 2 conditions.

Circadian rhythm disturbance is objectively quantifiable, but difficult to treat, and these observations do not clearly provide direction for the treatment of borderline personality disorder. However, awareness and treatment of sleep disturbances are important aspects of patient management. Screening tests, including interviews and actigraphy, can identify 

 that patients might not have otherwise reported if they did not know those problems were abnormal. Patients who would benefit from appropriate therapy for their sleep disorder may experience an improved quality of life if treatment is implemented. Furthermore, the diagnostic signs can potentially provide an adjunct in the diagnostic process for patients when borderline personality disorder is considered in the differential diagnosis. Because borderline personality disorder lacks objective criteria, it is possible that some patients may feel empowered, heard, and understood when they are made aware of an objective feature of their condition. This may potentially improve compliance with treatment for some patients.

; clinical assistant professor, Case Western Reserve University School of Medicine, Division of Medical Education; and editor in chief emeritus of 

Self-report screening instruments differentiate bipolar disorder and borderline personality disorder.

The emerging circadian phenotype of borderline personality disorder: mechanisms, opportunities and future directions.

3. McGowan NM, Goodwin GM, Bilderbeck AC, Saunders KEA. 

Actigraphic patterns, impulsivity and mood instability in bipolar disorder, borderline personality disorder and healthy controls.

4. McGowan NM, Goodwin GM, Bilderbeck AC, Saunders KEA. 

Circadian rest-activity patterns in bipolar disorder and borderline personality disorder.

Sleep disturbances in borderline personality disorder are relatively unrecognized. 

Sleep Patterns in Borderline Personality Disorder 

There are 13 million adults with borderline personality disorder (BPD) in the United States and, of that number, 1.5 million are adolescents, Carl Fleisher, MD, told attendees of the 2021 Annual 

 World CME Conference. To best support them, there are 3 things you need to do, added Fleisher, assistant clinical professor of psychiatry at University of California Los Angeles Health.

To kick off the discussion, Fleisher shared the case example of “Hannah,” a 16 year old girl who presents wondering if she has BPD after Googling her experience. Specifically, she has rapid mood swings, feels numb more often than sad, and cuts herself superficially several times a week. She has 1 friend and spends all of her time with that friend in fear the friend will desert her. She is interested in boys, but she avoids them. Hannah does not voice her needs to parents, teachers, or friend; instead, she goes along with whatever they want or like.

The first thing to do, therefore, is to make the diagnosis, Fleischer said. To do so, there are 9 criteria to consider, and sometimes it feels like they are all over the map. As such, the patient might not see the connections, so it is important to help draw them for patients. One way to do that, he explained, is to use a model of interpersonal hypersensitivity. Since we all want and need to be in relationships, and we are hypersensitive, we may have a fear of abandonment. From there, you can talk about the other symptoms.

 for rapid assessment of patients. It helps patients think things through, he explained. It also provides an opportunity for further discussion, as the clinician may have a different perspective than the patient does on a particular item.

Most patients are relieved when they finally receive a diagnosis, Fleischer said. He shared the following patient perspective: “It explained a lot of things and I felt an enormous sense of relief that there was an explanation for the way I was.”

The second thing is to refer to helpful resources, including psychoeducation, support, and treatment strategies, Fleisher said. He recommended a number of resources both for patients and their clinicians: the National Education Alliance for Borderline Personality Disorder, Mentalizing Initiative, the Anne Freud National Centre for Children and Families, and McLean’s Borderline Personality Disorder center.

In terms of treatments, there are 4 evidence-based psychotherapy modalities, Fleisher said. They include dialectical behavioral therapy, transference-focused psychotherapy, mentalizing-based therapy, and good psychiatric management, which is not an orientation but more of framework for clinicians. “It is also possible also that a plain old talk therapy is an adequate treatment for borderline personality disorder, especially if you have nothing else,” he told attendees.

It is also important to consider psychoeducation and family support, Fleischer added. He shared the results of a study looking at the impact of 6 weeks of psychoeducation on patients. The investigators found that symptoms reduced greatly—by about half—and stayed low for 2 months after the intervention protocol.

 Similarly, since caregivers and family members are under a lot of stress and strain, it is important to broaden the treatment lens and provide support to them, too.

Unfortunately, Fleischer noted there are no medications approved by the US Food and Drug Administration to specifically treat BPD. Likewise, there is no medication that is uniformly helpful. Too often, patients find themselves on multiple medications, he said, and polypharmacy poses a significant danger because of adverse effects, like weight gain associated with antipsychotics.

“We can do a whole hour-long talk on just medication for BPD, but the short of it would be: If you're going to use medication to treat one of the comorbid illnesses that BPD presents with, as opposed to this BPD itself, then you can try that,” Fleisher told attendees. “But if we're going to try to treat the symptoms of BPD itself like lability, paranoia, that sort of thing, then it may be that we want to consider a brief trial of medication to get people through a crisis.” After using the medications in a way that is helpful, it is important to consider taking it away, because we do not expect them to be helpful in the long-term and do not want to cause a problem of polypharmacy, he added.

The third thing to do is to monitor the effectiveness of the treatment, Fleischer said. Start with baseline measurements on the areas you and the patient want to address, be it self-harm, work performance, risky behaviors, and quality of life and relationships.

With these 3 things in mind, Fleisher concluded, clinicians can best support their patients with BPD. As he told attendees, “Borderline personality disorder is worth treating, and people with BPD are very rewarding to work with.”

1. Lester R, Prescott L, McCormack M, Sampson M; North West Boroughs Healthcare, NHS Foundation Trust. 

Service users' experiences of receiving a diagnosis of borderline personality disorder: A systematic review.

2. Ridolfi ME, Rossi R, Occhialini G, Gunderson JG. 

A Clinical Trial of a Psychoeducation Group Intervention for Patients With Borderline Personality Disorder

 2019;81(1):19m12753. Published 2019 Dec 31.

These 3 essential steps best support patients with borderline personality disorder, according to Carl Fleisher, MD. 

Borderline Personality Disorder: 3 Things You Need To Do for Patients

Tales From the Clinic: The Art of Psychiatry,

 we cover an intriguing case of dual substance use super-imposed on mood, anxiety, and trauma clinical picture. A significant challenge for this group of patients is the need for patient, methodical, consistent care to unravel the complex multifaceted triggers and perpetuating factors for continued maladaptive behaviors. The case description spans years of treatment and, while the details may seem sensational, they reflect the reality of what the addiction treatment clinic team encounters. In addition, there is much difficulty in hearing and processing patient accounts of trauma, which could lead to physician burnout.

“Ms Martin” is a 45-year-old female with bipolar disorder, generalized anxiety disorder, and suspected borderline personality disorder. She was transferred to the substance use disorders clinic by another psychiatrist after a diagnosis of opioid use disorder was obvious. At the time of her transfer, she was involved in prostitution to finance her roughly 25 tablets of acetaminophen and hydrocodone daily. Her opioid use disorder history had a protracted course, with her first exposure to prescription opioids at the age of 16 following a significant injury requiring surgical intervention. Her longest lifetime period of sobriety was 2 years.

Her immediate environment was not conducive to recovery, as she lived in a trailer with a male roommate who had mutual acquaintances that provided pain pills. In addition, Ms Martin engaged in sexual activity with the roommate in exchange for opioids. As time progressed, the relationship became physically abusive; she left after her roommate tried to hit her with a vacuum cleaner when she “didn’t do a good job cleaning the trailer.” At the time, she had been in treatment for 1 year, was started in medication-assisted therapy (MAT), and had been prescribed buprenorphine. She moved into an apartment with her mother, which greatly reduced access to opioids. She responded very well to MAT, with an absence of significant relapses as evidenced by the drug screenings during her monthly visits.

Three years into treatment, Ms Martin met a new boyfriend. Her urine drug screen (UDS) resulted positive for amphetamine. He provided her with substances that boosted her energy and aided in weight loss. She was not fully aware of what she was taking, but she thought it might have been amphetamine since it came in a “large jar with many capsules.” Testing verified the presence of methamphetamine.

These results were shared with Ms Martin, to her genuine surprise, and she expressed earnest motivation to stop methamphetamine use. Unfortunately, over the next year, she eventually met criteria for stimulant (methamphetamine) use disorder. This paralleled toxic developments in her relationship. She described a continued strong sexual attachment to her partner, and she remained intimate with him despite knowledge that he was simultaneously sexually active with her mother. She later bashfully admitted engaging in group intercourse with her partner and mother. During intercourse she described her partner’s derogatory and sadistic tendencies, which she felt she “deserved.”

Eventually, she developed disgust toward him. This resulted in an internal conflict because while she described feeling revolted by him, she simultaneously experienced severe loneliness and feelings of abandonment when he did not give her attention. This fueled further methamphetamine use as she wanted to be “skinny and pretty.”

The ongoing sexual relationship between her partner and mother resulted in significant tension within the apartment they all shared. On multiple occasions, Ms Martin described anxiety that her partner and mother were colluding against her. Methamphetamine use may have intensified these feelings. Although at times she expressed a desire to leave, she felt she had nowhere to go. Her partner contributed to paying bills, which further complicated her situation.

For the next year, Ms Martin continued to express significant ambivalence about her relationship. She recognized how the situation placed a strain on her relationship with her mother, yet she simultaneously feared the rejection, abandonment, and loneliness that would result from a breakup. She described symptoms of anxiety and sadness when away from her partner, and he was using methamphetamine pills as a tool to control her. She compared her “love-hate” relationship with her significant other with that of her relationship with the methamphetamine pills.

In addition to work in building Ms Martin’s feelings of self-worth and autonomy, a motivational interviewing style was utilized to help her resolve some of her ambivalence toward the relationship. Although she voiced much more change talk to end the relationship, compared to sustain talk, she had difficulty committing to ending the relationship.

Due to the alarming rate of opioid overdoses secondary to fentanyl, clinicians and those struggling with substance use are becoming aware that the product purchased is not always as marketed. Anecdotal reports of increasing concomitant opioid and amphetamine use abound, but the condition is not well understood, nor systematically studied. In the case of this patient, confirmatory test showed methamphetamine, whereas she believed she was getting amphetamine or methylphenidate; she may have inadvertently gained access to a supply of methamphetamine.

Currently, there are no US Food and Drug Administration-approved treatments for methamphetamine use disorder. Some studies suggest the use of bupropion, naltrexone, and mirtazapine may have some limited efficacy in 

 In addition to treating Ms Martin’s SUD, the team addressed co-occurring mood and anxiety symptoms (she had witnessed her brother injured in a car accident). Her initial regimen included duloxetine and aripiprazole for depression, anxiety, and mood stabilization. Bupropion was not tried due to her concern of its risk of exacerbating her anxiety, and she declined mirtazapine due to its risk of weight gain because she already struggled with her body image. After Ms Martin expressed concerns that aripiprazole may be contributing to her weight gain, she was switched to cariprazine with the perceived potential benefit of weight-neutrality, since a desire for weight loss was a contributing factor to continued methamphetamine use. Another potential benefit of cariprazine includes preliminary interest in the D3 receptor affecting addictive behaviors.

Methylphenidate and lisdexamfetamine were other pharmacological therapies considered for treatment, given that Ms Martin has shown good response to replacement therapy such as buprenorphine. However, agonist substitution, while an excellent harm reduction approach, still faces stigma and resistance in clinical practice, especially for stimulant use.

According to the Centers for Disease Control, 40.4% of adults using methamphetamine within the last year also misused prescription opioids, and 16.9% used heroin between 2015 and 2018. In the United States there has been an increase in overdose deaths and hospital admissions involving 

 After limited availability of ephedrine and pseudoephedrine due to regulations, synthesis returned partially back to using phenyl-2-propanone (P2P).

 Due to increased purity and potency, there is concern that the P2P formulation may be contributing to addiction.

 This is something to keep in mind when treating a patient diagnosed with both opioid and stimulant use disorders. Unfortunately, there is no guideline as to whether MAT should be discontinued if a co-occurring substance use is still ongoing.

Ms Martin maintained abstinence from opioids while on MAT, but continued to use methamphetamine pills. The treatment team wondered if she was truly benefiting from the current level of care, and considered tapering off buprenorphine and referring her to a residential treatment program or a methadone clinic. However, Ms Martin did not have the financial resources for the latter and, in regards to the former, expressed anxiety and fear about being separated from her dog as well as the feeling of “being locked up.” Thus, her treatment team sought to maximize psychosocial support and psychotherapy interventions, but she had stopped going to group therapy and declined virtual therapy sessions.

With continued work, despite ongoing significant trauma, interpersonal conflict, financial instability, and continued methamphetamine use, Ms Martin increased engagement in treatment and is adherent with all medication management visits. The treatment team ultimately decided not to taper off the buprenorphine, given her gradual progress toward treatment goals was a product of a harm-reduction approach. She could have benefited from inpatient rehabilitation. However, reluctance to go into rehabilitation is common in patients with SUD. Additionally, most states do not allow involuntary inpatient SUD treatment as they do for involuntary psychiatric care, so patients have to suffer legal repercussion to be forced to attend court-ordered rehabilitation. Finally, many residential treatment programs may not be able to accommodate patients on MAT, as some are not yet comfortable with a harm-reduction approach or medical model of addictions treatment.

This case highlights several clinical and psychotherapeutic challenges that may arise in the treatment of substance use disorders. First, it is important to look for the presence of significant trauma in a patient with several barriers to care preventing access to psychotherapy, as there is a known link between a history of trauma and the development of 

 In this case, Ms Martin was a victim of physical, emotional, and sexual abuse. Unfortunately, there are limited standardized or manualized approaches to addressing trauma in patients with substance use disorders. When trauma informed therapy is available, access is often limited.

Similarly, another significant factor contributing to Ms Martin’s ambivalence about leaving the relationship was the codependency that existed with her partner.

Medication management visits typical to community psychiatry practice are likely not of sufficient length to address complex issues involving psychopharmacology and psychotherapy. Although the COVID-19 pandemic has accelerated the development of telepsychiatry, many patients do not have the technological means to make these visits and may not have private and safe living spaces where they can share sensitive information.

Additionally, drug use is perpetuated by perceived benefits, and cessation of use does not happen unless the patient appreciates the negative impact of substance use on their lives. When Ms Martin finally understood she was taking methamphetamine, it created an opportunity to see its use as a problem instead of an agent for cognitive enhancement/weight loss.

Methamphetamine is commonly used to improve sexual function. In fact, 

 has described methamphetamine as increasing sexual desire, pleasure, reducing the refractory period between intercourse, exacerbating impulsiveness, and impacting behavioral inhibition.

 In this case, it would be worth further exploring that idea, as the patient’s partner was supplying methamphetamine and requesting particular sexual demands.

A major challenge in the field continues to be the lack of available effective pharmacologic treatments for stimulant use disorders. Contingency management in combination with community reinforcement is a proven effective behavioral treatment for stimulant use disorders, as confirmed by 

 However, there are considerable barriers to implementing contingency management at this time, including public stigma and limited Medicaid support.

Lastly, in the context of treatment, it is often easy to feel patients are to blame for maladaptive, promiscuous, or risky behaviors. Countertransference feelings or bias may hinder patients getting expanded treatment options, especially if they display anger and hostility upon exploration of sensitive topics in session.

However, despite significant barriers to care, the presence of trauma, and ongoing struggles with stimulant use, patients demonstrate resilience and often continue to express desire for full recovery. Cognitive-behavioral therapy, relapse prevention, mindfulness, and psychodynamic therapies are all useful in treatment, but the level of complexity of patients with SUD often means a prolonged course of treatment with multiple modalities needed.

is a PGY-4 general psychiatry resident in the Menninger Department of Psychiatry & Behavioral Sciences at Baylor College of Medicine. He plans to pursue a fellowship in Addiction Psychiatry after graduation.

is an associate professor and addiction-boarded faculty at Harris Health System in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine. 

 is associate professor, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, and Ben Taub Adult Outpatient Services director, medical director, Stabilization, Treatment & Rehabilitation (STAR) Program for Psychosis. She also serves on

1. Colfax GN, Santos GM, Das M, et al Mirtazapine to reduce methamphetamine use: a randomized controlled trial. 

2. Elkashef AM, Rawson RA, Anderson AL, et al. Bupropion for the treatment of methamphetamine dependence. 

3. Trivedi MH, Walker R, Ling W, et al. Bupropion and naltrexone in methamphetamine use disorder. 

4. Jones CM, Underwood N, Compton W. Increases in methamphetamine use among heroin treatment admissions in the United States, 2008-2017. 

5. Maxwell JC, Brecht M-L. Methamphetamine: Here we go again? 

6. Dolatshahi B, Farhoudian A, Falahatdoost M, et al. A qualitative study of the relationship between methamphetamine abuse and sexual dysfunction in male substance abusers. 

7. Wiechelt SA, Straussner SLA. Introduction to the special issue: Examining the relationship between trauma and addiction. 

8. Colfax G, Shoptaw S. The methamphetamine epidemic: Implications for HIV prevention and treatment. 

9. De Crescenzo F, Ciabattini M, D’Alò GL, et al. Comparative efficacy and acceptability of psychosocial interventions for individuals with cocaine and amphetamine addiction: A systematic review and network meta-analysis. 

10. McMahan VM, Kingston S, Newman A, et al. Interest in reducing methamphetamine and opioid use among syringe services program participants in Washington State. 

A patient presents with multiple substance use disorders super-imposed on mood and anxiety disorders. Where does a clinician even begin?

I Had to Use

A. Hyperactivity of the amygdala and prefontal cortex is characteristic of patients with BPD.

B. Increased acetylcholine activity in the hippocampus and neocortex accounts for impulsive aggression in patients with BPD.

C. Treatment of BPD with oxytocin increases hypermentalization by decreasing activity in the prefrontal cortex. 

D. Use of emotion regulation strategies taught in DBT correlates with decreased activity in the amygdala.

E. fMRI studies show that affective, cognitive, behavioral, and interpersonal difficulties are inherited rather than BPD itself.

What do functional magnetic resonance neuroimaging findings reveal about the neurobiology of borderline personality disorder? Take the quiz and learn more.

Mini Quiz: Neurobiology of Borderline Personality Disorder

For the answer, please see the next page >

Clinicians often see patients with personality disorders as treatment resistant-and, in some cases, untreatable. While it is true that patients with personality disorders may be challenging to treat, they are treatable.

Borderline Personality Disorder: Treatment Resistance Reconsidered

Do personality disorders get a bad rap? Take the quiz and learn more.

Mini Quiz: Borderline Personality Disorder

The concept of treatment resistance deserves reconsideration. Originally formulated in psychoanalytic terms, resistance in treatment referred to the inevitable ways patients unconsciously express their psychology in terms of defense mechanisms and transference enactment. This form of resistance provides a window into the patient’s problems; therefore, it is a major focus of the inquiry and intervention. Modern psychiatry defines treatment resistance as a lack of response to adequate treatment. Both conceptualizations locate treatment resistance within the patient, rather than as a product of limited, underdeveloped, and ineffective treatments. As a result, the term “treatment resistant” can fuel views of patients as “oppositional” and recalcitrant, instead of expectably symptomatic.

Trait Stages of Diagnosis for Borderline Personality Disorder

Treatment resistance is highly prevalent across most psychiatric disorders-even in common diagnoses generally associated with positive outcomes, such as depression. There are many more obstacles to effective treatment (

) than the patient’s psychological resistance alone. Identification of specific factors that diminish treatment response may provide more useful points of intervention than the label of treatment resistance.

Comorbid disorders contribute to poor treatment response. Treatment guidelines are often based on a false assumption that patients present with single disorders that respond to specific evidence-based treatments. Regardless of increasing attention to problems of comorbidity, guidelines for combining and prioritizing the treatment of different diagnoses remain largely underdeveloped.

Comorbid personality disorders complicate treatment. Over 50% of patients in specialized psychiatric settings have personality disorders.

 These patients are more likely to face social adversity, suffer from complex comorbidities, and drop out of treatment or not adhere to medication regimens-all of which contribute to an increased risk of a lack of response to treatment. The presence of a personality disorder, particularly borderline, predicts persistence of anxiety and substance use disorders as well as poorer outcomes in depressive disorders. Moreover, 13% of those who complete suicide have personality disorders.

Clinicians often see patients with personality disorders as treatment resistant-and, in some cases, untreatable.

 While it is true that patients with personality disorders may be challenging to treat, they are treatable. The self-defeating coping skills and difficulty with relationships that are central to personality disorders make a productive treatment alliance difficult to sustain. Clinicians prototypically react with feelings of frustration, disengagement, incompetence, confusion, helplessness, and even rage.

 The identification of these countertransference reactions can facilitate the diagnosis of personality disorders but can overwhelm and disturb clinicians, leading them to avoid diagnosis and personalize problems as a product of either the patient’s immutable character or the clinician’s limitations.

Our progress in understanding and treating borderline personality disorder (BPD) illustrates the benefits of centralizing the personality disorder diagnosis in care management. For over half a century, patients with BPD were identified by their negative therapeutic reactions, that is, worsening with what was thought to be otherwise appropriate treatment. While pessimism and stigma about the disorder remain, our notion of BPD’s prognosis has radically improved with research.

A major longitudinal study of BPD and other personality disorders with 16 years of follow-up showed that virtually all subjects with BPD achieve sustained remission for at least 2 years, and 78% sustain remission for 8 years. Recovery, that is attending work or school and sustaining at least one meaningful relationship, occurred for 60% of patients for 2 years, and was maintained in 40% over 8 years.

 This evidence suggests that the majority of individuals with BPD (and other personality disorders) can achieve remission and most can recover some sustained functioning, which challenges the notion that patients themselves resist treatment.

Research findings also demonstrate that BPD responds to a variety of treatments. Several specialized psychotherapies formulated for BPD-dialectical behavior therapy (DBT), mentalization-based treatment (MBT), schema-focused psychotherapy, and transference-focused psychotherapy (TFP)-reduce self-injury, suicide attempts, and hospitalizations.

These gains remain 3 years after the beginning of treatment.

Although the results are positive for long-term treatment effectiveness for BPD, difficulty in learning and implementing these psychotherapies because of their specialization and intensity renders them largely unavailable to most patients and clinicians.

 The difficulty in providing or referring patients to effective care is therefore a major factor in treatment resistance and challenges to treating BPD.

A recent meta-analysis of evidence-based psychotherapies for BPD suggests that structure and focus on BPD-related problems such as self-harm and suicidality, rather than intensity, determine outcomes.

 The small-to-medium effect sizes related to the efficacy of evidence-based therapies disappear in studies where the control treatment is structured. Intensity (ie, duration and exposure) did not appear to influence outcomes. This meta-analysis did not show significant differences between DBT and psychodynamic approaches (which included MBT and TFP). It also reported that cognitive behavioral therapy performed no better than control conditions, which indicates that structured treatment alone is not sufficient; the treatment needs to focus on BPD. These findings suggest that evidenced-based treatments might be simplified and still retain effectiveness by maintaining structure and specificity for BPD patients.

The findings from 2 large outpatient trials of DBT and MBT support the idea that less intensive but structured, informed, and systematic care of BPD patients can be effective. General Psychiatric Management (GPM)10 and Structured Clinical Management

 were compared with outpatient DBT and MBT, respectively. Both specialized and generalist approaches yielded similar decreases in suicidality and non-suicidal self-injury and improvements in interpersonal functioning and quality of life.

 While further research is needed, these findings suggest that treatment resistance can be overcome with informed and structured care. We propose the following strategies.

Good care for BPD begins with a diagnosis. Many clinicians avoid telling patients, particularly adolescents, that they have a personality disorder. But the BPD diagnosis can be made reliably before the age of 18, and early intervention is needed for better outcomes.

 When the diagnosis is made objectively and optimistically, patients typically feel less alienated and alone, as well as more hopeful. Sitting down with a patient to review the diagnostic criteria for BPD is an opportunity for clinicians and patients to think together about how each criterion can be applied to challenges the patient faces.

It is important to inform patients that social and vocational recovery is more difficult to achieve than symptom remission alone. These challenges and their course of treatment can be delivered in a clinical management approach that is not primarily psychotherapeutic. An essential part of this is to explain that difficulties in the clinical relationship are to be expected. This allows both patient and clinician to manage these disruptions, rather than react in overly personalized or pejorative ways.

The clarification of treatment goals and expectations, as well as predictions about therapeutic challenges, functions primarily to educate the patient. Psychoeducation alone can reduce symptoms of interpersonal instability and impulsivity.

 With a shared understanding of how interpersonal and emotional sensitivities connect to self-destructive tendencies (ie, self-harm or suicide attempts), the patient and clinician can communicate and collaborate around symptom management in a consistent way.

Evidence-based treatments for BPD stabilize high-intensity interchanges between self-destructive patients and their clinicians by providing an established framework for managing self-destructive behaviors. Good clinical management of any psychiatric diagnosis guides mental health professionals to establish a plan that patients can use when they have urges to hurt themselves at the beginning of treatment. When self-destructive problems arise, patients then have resources mapped out so that independent management can increasingly replace reflexive reliance on hospitalization or paging. According to GPM, clinicians can actively evaluate suicide risk by weighing risk factors (eg, prior attempts, access to means, dangerousness of plans, assessment of intent, substance use, and depression) against protective factors (eg, social supports, capacity to use skills and entertain alternatives). After these episodes, clinicians and patients can analyze what is working in the safety plan and what needs modification.

Chain analyses, reviews of the various events and internal reactions leading to self-destructive urges, are used in many evidence-based treatments for BPD.

 The chain analysis helps clinicians and patients to better understand what has happened and revise safety plans accordingly. With a shared system of managing safety and a shared expectation that reducing suicidality and self-harm is a focus of treatment, more treatment collaboration rather than resistance occurs.

BPD rarely presents without major comorbidity. Most patients with BPD also suffer from depression and anxiety disorders, and many have problems with substance use, eating, and other personality disorders. However, useful and scientifically informed guidelines for prioritizing focus on BPD over other comorbidities are provided in GPM (

 These guidelines encourage clinicians to prioritize BPD over its most common comorbidities of depression, panic disorder, generalized anxiety, and other personality disorders, because these comorbidities are less likely to remit if BPD symptoms do not improve. Moreover, randomized controlled trials of existing evidence-based treatments for BPD report concomitant reductions in depression and anxiety during and after treatment.

Other comorbidities, such as substance dependence, anorexia, and mania, must be prioritized over BPD treatments, because these disorders interfere with the learning required in BPD treatment. New evidence indicates that BPD and PTSD can be treated effectively at the same time. PTSD symptoms may even improve with the treatment of BPD alone.

These empirically informed guidelines mitigate the chaos and reactivity that challenge clinicians in their management of multiple comorbidities by providing an organizational framework. Improving BPD by enhancing coping and inter­personal functioning is likely to increase self-regulation and the sustainability of supportive relationships, while decreasing stressors. Informed management of comorbidities with BPD can reduce treatment resistance, with a focus on a central and treatable source of vulnerability and dysfunction.

Conservative prescribing of pharmacological and somatic therapies

No medication is FDA-approved for the treatment of BPD. Few randomized controlled trials have tested pharmacological treatments for BPD, and their results are inconclusive. European guidelines from the National Institute for Clinical Excellence state that existing evidence is insufficient to support any prescribing of medications, except for the treatment of diagnosable comorbidities. American Psychiatric Association guidelines, informed by meta-analysis of the small number of existing pharmacology studies, advocate for judicious use of mood stabilizers and antipsychotics for BPD symptoms related to affective instability, impulsivity, and cognitive perceptual symptoms.

Antidepressants show minimal benefit in the treatment of core BPD features. Similarly, BPD patients respond to ECT inconsistently, with lower degrees of antidepressant response and higher rates of relapse compared with patients without personality pathology.

 These psychopharmacological and somatic therapies for BPD patients should be used judiciously to target the symptoms of true comorbidities, rather than features of BPD. Conservative prescribing can reduce the burden of polypharmacy and exposure to an increasing number of treatments that are unlikely to achieve the desired results.

The concept of treatment resistance deserves reconsideration, especially in the case of BPD. While the treatment of BPD is challenging and potentially complex, the notion that it is treatment resistant is contradicted by longitudinal and treatment research that indicates high rates of remission over time, moderate rates of recovery, and significant response to structured treatments tailored to symptoms. Furthermore, exposure to adequate care is not the norm, since intensive evidence-based treatments for BPD are not easily learned or implemented. Structured generalist approaches, such as GPM, offer tips such as psychoeducation, systematic and informed management of self-destructive tendencies and comorbidities, and conservative use of pharmacological and somatic treatments. BPD may render comorbid disorders less responsive to therapy, but this may be an argument that treating BPD helps stabilize the expectable challenges and thereby reduces treatment resistance overall.

Dr. Choi-Kain is Director, Adult Borderline Center and Training Institute and McLean Gunderson Residence at McLean Hospital in Belmont, MA, as well as Assistant Professor of Psychiatry at Harvard Medical School in Boston; Mr. Glasserman and Ms. Finch are research assistants, McLean Hospital, Harvard Medical School.

The authors report no conflicts of interest concerning the subject matter of this article.

 Zimmerman M, Chelminski I, Young D. The frequency of personality disorders in psychiatric patients. 

 World Health Organization. Figures and Facts about Suicide; 1999. 

http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/

 Tyrer P, Reed GM, Crawford MJ. Classification, assessment, prevalence, and effect of personality disorder. 

 Colli A, Tanzilli A, Dimaggio G, Lingiardi V. Patient personality and therapist response: an empirical investigation. 

 Zanarini MC, Frankenburg FR, Reich DB, Fitzmaurice G. Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and axis II comparison subjects: a 16-year prospective follow-up study. 

 Stoffers-Winterling JM, VÃ¶llm BA, RÃ¼cker G, et al. Psychological therapies for people with borderline personality disorder. 

 McMain SF, Guimond T, Streiner DL, et al. Dialectical behavior therapy compared with general psychiatric management for borderline personality disorder: clinical outcomes and functioning over a 2-year follow-up. 

 Choi-Kain LW, Albert EB, Gunderson JG. Evidence-based treatments for borderline personality disorder: implementation, integration, and stepped care. 

 Cristea IA, Gentili C, Cotet CD, et al. Efficacy of psychotherapies for borderline personality disorder: a systematic review and meta-analysis. 

Handbook of Good Psychiatric Management for Borderline Personality Disorder

. Washington, DC: American Psychiatric Publishing; 2014.

Borderline Personality Disorder: An Evidence-Based Guide for Generalist Mental Health Professionals

. Oxford University Press: New York; 2013.

 Chanen AM, McCutcheon L. Prevention and early intervention for borderline personality disorder: current status and recent evidence. 

 Zanarini MC, Frankenburg FR. A preliminary, randomized trial of psychoeducation for women with borderline personality disorder. 

 Harned MS, Chapman AL, Dexter-Mazza ET, et al. Treating co-occurring Axis I disorders in recurrently suicidal women with borderline personality disorder: a 2-year randomized trial of dialectical behavior therapy versus community treatment by experts. 

 Rasmussen KG. Do patients with personality disorders respond differentially to electroconvulsive therapy? A review of the literature and consideration of conceptual issues. 

While treatment of bipolar disorder challenging , the notion that it is treatment resistant is contradicted by longitudinal and treatment research that indicates high rates of remission over time, moderate rates of recovery, and significant response to structured treatments tailored to symptoms.

The authors describe an alternative model for BPD diagnosis that is dimensional in nature and requires fulfillment of 4 of 7 personality traits.

When a patient presents with episodes of depression, irritability, and emotional lability (especially tears and anger, with rapid changes), might he or she have borderline personality disorder (BPD)? Or could it be rapid cycling bipolar disorder (BD)? Although there are other possibilities, such as substance use, differentiating these 2 common conditions can be extremely difficult. DSM criteria have a roughly 90% overlap. Only

features are clearly present in one and absent in the other-namely, abandonment fear and chronic emptiness.

 as well as others have argued that borderlinity is just another version of bipolarity or at least that the “broadening of the bipolar diagnosis to include a spectrum of poorly defined conditions has added to the plausibility of this idea.”

 In refutation of this notion, data that demonstrate a clear difference between the 2 conditions-involving interpersonal trust-have 

The social psychology research tool called 

 Briefly: imagine that 2 criminals are caught simultaneously. If both cooperate with one another and tell the same false story, each can get off with a light sentence. But if one finks on the other (dubbed “Defect”), he gets off scot-free while the other takes the rap. However, if both defect, both are punished. This has been modeled in a game of cooperation. If both player and partner cooperate, each earns 40 pence. If both defect, each earns only 20 pence. But if one defects while the other cooperates, the defector earns 70 pence and the cooperator, nothing: he is punished for cooperating with a defector, whose score is actually better than could be achieved through mutual cooperation.

If such a game is played between 2 partners, just once, the best strategy is to defect: it limits losses. But if the game is played repeatedly, the best strategy in most circumstances is called “tit-for-tat”: play cooperation first and then follow the move of your partner. If he cooperates, do likewise. When he defects, also do likewise and continue thus until he plays cooperate-then follow that move as well.

The result is a test of willingness to cooperate. When euthymic bipolar patients played (ostensibly with another person, though the actual partner was a computer), they made choices very like control patients, choosing to cooperate almost 75% of the time. But patients with BPD cooperated only about 50% of the time (analysis of variance difference,

This is not a clinical tool: first of all, separation between the 2 groups was far from 100%. Second, iterative games of Prisoner’s Dilemma are not easily administered, even by computer. The point of this research is that an objectively measurable difference between BD and BPD was evident. Conclusions: (1) these 2 conditions are not variations within a species-they are different (though perhaps related) animals; and (2) the difference observed mirrors what we see clinically, namely an impairment in relationship.

Some might regard this as another instance in which social psychology goes to great lengths to prove an accepted observation (as remarked 

*: “. . . for more than 20 years I have been searching for one fact . . . discovered in a psychological laboratory which did not repeat what we already knew”5). But given the degree of controversy about the bipolar/borderline distinction, this finding seems worth passing along.

When one sits down with a patient and within 5 minutes is aware of something odd going on-excessive praise or an unwarranted devaluation or simply a sort of “latching on”-these feelings are data. Something is amiss in the social exchange. For example, you play Cooperate, he plays Defect, even after several overtures. In this context, your clinical hunch has been supported: BD may or may not be present, but the probability of borderlinity has gone up.

Thanks to our esteemed Samaritan Health Services librarian Ken Willer for access to articles like this.*

This article was originally posted on 4/12/2016 and has since been updated.

Dr Phelps is Director of the Mood Disorders Program at Samaritan Mental Health in Corvallis, OR. He is the Bipolar Disorder Section Editor for 

 Phelps J. Bipolar Disorder and “Borderline Personality Disorder.” Updated 2013. 

http://psycheducation.org/diagnosis/bipolar-disorder-and-borderline-personality-disorder/

 Deltito J, Martin L, Riefkohl J, et al. 

Do patients with borderline personality disorder belong to the bipolar spectrum?

Borderline personality disorder, but not euthymic bipolar disorder, is associated with a failure to sustain reciprocal cooperative behaviour: implications for spectrum models of mood disorders

https://en.wikipedia.org/wiki/Prisoner%27s_dilemma

 Fite W. The human soul and the scientific prepossession. 

http://www.unz.org/Pub/AtlanticMonthly-1918dec-00796

The Prisoner’s Dilemma reveals a clear distinction between the 2 conditions.

Borderline or Bipolar: Objective Data Support a Difference

Here's what's new in personality disorders: DBT treatment, DSM-5 criteria, borderline personality disorder, narcissistic personalities, and mentalization-based treatments.

The World of Personality Disorders in 6 Clinical Reports

Clarification of the molecular and biological underpinnings of borderline personality disorder (BPD) is imperative for a more thorough understanding of the disorder, one that anchors our quest for effective treatment. This article provides a brief overview of the neurobiology of BPD. Anatomical structures are reviewed as well as genetic and epigenetic factors that contribute to the pathophysiology and, potentially, to the treatment of this disorder.

Over the past decade, much of the literature concerning the biological basis of BPD has shifted to direct visualization of brain structure and function using neuroimaging. Most of the findings pertain to brain regions involved in emotional processing, such as the amygdala, insula, posterior cingulate cortex, hippocampus, anterior cingulate cortex, and prefrontal regulatory regions (

). These include the orbital frontal cortex, dorsal lateral prefrontal cortex, and ventral lateral prefrontal cortex.

There is more to BPD than meets the eye. A complex interaction exists between environmental, anatomical, functional, genetic, and epigenetic factors. 

Borderline Personality