Borderline personality disorder—as scientific understanding increases, improved clinical management needed

Even as researchers gain new insights into the neurobiology of borderline personality disorder (BPD), there's a pressing need to improve diagnosis and management of this devastating psychiatric condition. A scientific and clinical research update on BPD is presented in the September/October special issue of the Harvard Review of Psychiatry.

The special issue comprises seven papers, contributed by experts in the field, providing an integrated overview of research and clinical management of BPD. "We hope these articles will help clinicians understand their BPD patients, encourage more optimism about their treatability, and help set a stage from which the next generation of mental health professionals will be more willing to address the clinical and public health challenges they present," according to a guest editorial by Drs. Lois Choi-Kain and John Gunderson of the Adult Borderline Center and Training Institute at McLean Hospital, Belmont, Mass.

Borderline Personality Disorder—Research Advances, Emerging Clinical Approaches

Although the diagnostic criteria for BPD are well-accepted, it continues to be a misunderstood and sometimes neglected condition; many psychiatrists actively avoid making the diagnosis. Borderline personality disorder accounts for nearly 20 percent of psychiatric hospitalizations and outpatient clinic admissions, but only three percent of the research budget of the National Institute of Mental Health. (The NIMH provides information about BPD online at http://www.nimh.nih.gov/health/topics/borderline-personality-disorder)

The Guest Editors hope their special issue will contribute to overcoming the disparity between BPD's public health importance and the attention received by psychiatry. Highlights include:

• A research update on the neurobiology of BPD. Evidence suggests that chronic stress exposure may lead to changes in brain metabolism and structure, thus affecting the processing and integration of emotion and thought. This line of research might inform new approaches managing BPD—possibly including early intervention to curb the neurobiological responses to chronic stress.
• The urgent need for earlier intervention. A review highlights the risk factors, precursors, and early symptoms of BPD and mood disorders in adolescence and young adulthood. While the diagnosis of BPD may be difficult to make during this critical period, evaluation and services are urgently needed.
• The emergence of evidence-based approaches for BPD. While these approaches have raised hopes for providing better patient outcomes, they require a high degree of specialization and treatment resources. A stepped-care approach to treatment is proposed, using generalist approaches to milder and initial cases of BPD symptoms, progressing to more intensive, specialized care based on clinical needs.
• The critical issue of BPD in the psychiatric emergency department. This is a common and challenging situation in which care may be inconsistent or even harmful. A clinical vignette provides mental health professionals with knowledge and insights they can use as part of a "caring, informed, and practical" approach to helping BPD patients in crisis.

The special issue also addresses the critical issue of resident training—preparing the next generation of mental health professionals to integrate research evidence into more effective management for patients and families affected by BPD. Drs. Choi-Kain and Gunderson add, "For clinicians, educators, and researchers, we hope this issue clarifies an emerging basis for earlier intervention, generalist approaches to care for the widest population, and a more organized approach to allocating care for individuals with BPD."

Click here to read this special issue of the Harvard Review of Psychiatry.