LEARNING OBJECTIVES
After reading this article you will be able to:
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• understand the core clinical features and key aetiological factors of BPD
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• confidently diagnose BPD using a structured history-taking approach
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• recognise comorbid conditions when they occur and, where possible, distinguish BPD from disorders with shared clinical features.
Borderline personality disorder (BPD) is a contested diagnosis for a number of reasons: the phenotype is heterogeneous, there is extensive symptom overlap with other psychiatric diagnoses and debate about the validity of the BPD diagnosis in the literature. However, as a diagnostic construct, like many in psychiatry, it provides an important working concept for clinicians and a framework for organising clinical experience and treatment planning (Jablensky Reference Jablensky2016). BPD is the most widely researched personality disorder (Blashfield Reference Blashfield and Intoccia2000), which has informed the development of a treatment evidence base. Therefore, the diagnosis has pragmatic utility in supporting the identification of those who may respond to particular interventions. This is important since BPD is overrepresented in healthcare settings and individuals with a BPD diagnosis report significant difficulty accessing effective and consistent care and feeling understood by healthcare professionals (Lawn Reference Lawn and McMahon2015). Here we suggest an approach to performing a comprehensive clinical assessment to elicit core diagnostic features with a view to informing a holistic care plan.
Classification
The BPD diagnosis has long garnered controversy in terms of its conceptual and diagnostic validity. The diagnosis itself was created by expert committee without an empirical foundation, and research on its classification remains scant (Tyrer Reference Tyrer, Mulder and Kim2019). Despite this, it is argued that the diagnosis has clinical utility and has been an important driver of research and therapeutic developments.
Much debate and dissatisfaction hinges on the classification systems of personality disorder, in particular the question of categorical versus dimensional conceptualisation. It is argued that organising personality disorder into discrete subtypes generates high diagnostic covariation and within-diagnosis heterogeneity and that a dimensional model that considers personality disorder to exist along a continuum is preferable. This is true for BPD, where diagnosis by a categorical system is subject to particularly high heterogeneity (Hallquist Reference Hallquist and Pilkonis2012). It is argued that in psychiatry a categorical classification system does not define discrete disorder entities that are reliably delineated from other disorders (Hengartner Reference Hengartner and Lehmann2017). In this sense BPD ‘borders’ on a wide range of conditions and risks providing a catch-all diagnosis to explain a myriad of symptoms and problematic behaviours.
DSM-5 and ICD-10
DSM-5 defines the main features of BPD as a pervasive pattern of instability in interpersonal relationships, self-image and affect, in addition to marked impulsivity and self-injurious behaviour (Box 1) (American Psychiatric Association 2013). Although there is no stand-alone category of ‘borderline personality disorder’ in ICD-10 (World Health Organization 1992), ‘emotionally unstable personality disorder’, comprising the impulsive and borderline subtypes, is broadly equivalent.
Emotional:
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– Heightened emotional sensitivity
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– Impaired emotional regulation
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– Slow return to baseline from emotionally heightened state
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– Chronic feelings of emptiness
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– Difficulty controlling angry feelings
Interpersonal:
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– Abandonment fears
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– Relational instability
Behavioural:
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– Impulsive behaviours (for example, reckless spending, binge eating, substance misuse)
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– Self-harming
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– Suicidal behaviours
Cognitive:
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– Identity disturbance
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– Transient psychotic symptoms
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– Dissociative experiences
It was expected that the classification of personality disorders would undergo significant change during the revision process leading to DSM-5 to reflect the growing number of studies supporting a dimensional approach to diagnosis (Zachar Reference Zachar, Krueger and Kendler2016). To this end, a hybrid model of classification of personality disorder for DSM-5 containing categorical and dimensional elements was proposed. However, gaining consensus agreement proved elusive and the proposed model was rejected from the main body of DSM-5. The categorical personality disorder model represented in DSM-IV was retained in DSM-5 and the alternative hybrid model is printed in Section III (Emerging Measures and Models). In the alternative model, the essential criteria that define any personality disorder are both impairment in personality functioning and the presence of pathological personality traits. The hybrid methodology retains six personality disorder types: borderline personality disorder, obsessive–compulsive personality disorder, avoidant personality disorder, schizotypal personality disorder, antisocial personality disorder and narcissistic personality disorder.
ICD-11
In comparison, in ICD-11 (World Health Organization 2018) classification of personality disorders is dimensional and replaces categorical description. The focus is on the evaluation of a global impairment of personality functioning, classified according to degree of severity (personality difficulty, mild personality disorder, moderate personality disorder and severe personality disorder). The main determinants of severity include the degree of interpersonal dysfunction, the impact on social and occupational roles, cognitive and emotional experiences, and the risks of harm to self and others. In addition, the diagnosis may also be qualified with one or more prominent domain traits (negative affectivity, detachment, dissociality, disinhibition and anankastia). The trait qualifiers are available to describe the specific pattern of traits that contribute to the global personality dysfunction.
The initial proposal by the ICD-11 Personality Disorders Working Group (Tyrer Reference Tyrer, Crawford and Mulder2011) was met with concerns, particularly regarding the failure to include BPD in the classification and the consequent implications for research, therapy and access to treatment. It was intended that the characteristics associated with BPD could be found across the domains of negative affectivity, disinhibition and dissociality, rendering the need for the borderline label obsolete. However, this rationale was not accepted and, in response to these concerns, the option of applying a ‘borderline pattern descriptor’ was introduced (akin to the ICD-10 description of emotionally unstable personality disorder) but only after severity levels have been determined (Tyrer Reference Tyrer, Mulder and Kim2019). It is suggested that the classification of severity may inform prognosis and intensity of treatment, and trait qualifiers that reflect clinical features and dynamics of personality functioning may support the choice and nature of treatment (Bach Reference Bach and First2018). The ICD-11 classification may support rational clinical decision-making for people with BPD where treatment intensity is determined by illness severity (Irwin Reference Irwin and Malhi2019).
Prognosis
Prognosis of BPD should be considered optimistically in light of contemporary research evidence – several long-term outcome studies demonstrate high levels of remission. For example, 88% of people with BPD achieved remission over the course of a 10-year follow-up study (Zanarini Reference Zanarini, Frankenburg and Hennen2006). This study also identified a number of factors that were found to predict earlier time to remission, such as younger age, absence of childhood sexual abuse, no family history of substance use disorder and temperamental characteristics of low neuroticism and high agreeableness.
The assessment interview
If approached with interest and curiosity, the assessment process affords an opportunity to initiate the development of a therapeutic alliance with the patient. The clinician can maintain clear boundaries at the outset by explaining their role and the purpose and timeframe of the assessment. Adopting a warm and optimistic stance is important, particularly if the patient is anxious about the assessment and its potential outcome. The assessment may necessitate more than one session and should include a careful review of the available medical records to avoid premature arrival at an inaccurate diagnosis.
Screening tools
Personality assessment can be time-consuming so a brief screen for identification of people who might warrant further detailed assessment for personality disorder may be particularly valuable for the clinician. Self-report instruments are likely to overestimate prevalence rates of personality disorder (Zimmerman Reference Zimmerman and Coryell1990) so a clinician-rated scale may be preferable (see ‘Assessment tools’ below).
Screening for personality disorder
The Standardised Assessment of Personality – Abbreviated Scale (SAPAS) is an eight-item screening interview for personality disorder in general rather than for specific personality disorders. It consists of eight questions, corresponding to a descriptive statement about the person. Possible scores range from 0 to 8. A score of 3 or more is sensitive and specific as a measure of the presence of a personality disorder according to the Structured Clinical Interview for the DSM-IV Axis II Personality Disorders (SCID-II) (Moran Reference Moran, Leese and Lee2003).
Screening for BPD
The McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) is a ten-item, true/false self-report screening measure for BPD (Zanarini Reference Zanarini, Vujanovic and Parachini2003a). Each endorsed item is scored 1 point on a scale that ranges from 0 to 10. A cut-off score of 7 or more on the measure’s ten items yields both good sensitivity and specificity for the diagnosis of BPD as defined by DSM-IV.
Assessment tools
Structured interviews
There are several diagnostic interviews available for the reliable and valid assessment of BPD (Carcone Reference Carcone, Tokarz and Ruocco2015). Formulating a reliable diagnosis of personality disorder can be challenging and formal personality assessment tools may be used as an adjunct to clinical interview.
The SCID-II (First Reference First, Spitzer and Gibbon1995) is a clinician-administered interview for the assessment of personality disorders according to DSM. The interview begins with an overview of the patient’s patterns of behaviour and typical relationships. There is an optional screening questionnaire, which asks the patient to review items linked to each of the DSM-5 personality disorder criteria. The clinician then administers interview items that correspond to those endorsed on the screening questionnaire. Each item is scored as 1 (absent), 2 (subthreshold) or 3 (threshold). If a threshold is reached on a sufficient number of items, the category of personality disorder is deemed to be present.
The Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV) is a semi-structured interview consisting of 108 items pertaining to the past 2 years of the patient’s life (Zanarini Reference Zanarini, Frankenburg and Sickel1996). It assesses the ten DSM-IV personality disorders, along with passive–aggressive and depressive personality disorders. Each disorder is rated on a scale of 0 (absent) to 2 (present): if the totalled score exceeds the threshold for a particular disorder the clinician can diagnose that disorder (Furnham Reference Furnham, Milner and Akhtar2014).
Specific measures of BPD
The Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD) is a clinician-administered rating scale that was designed to measure changes in borderline symptomatology overtime (Zanarini Reference Zanarini2003b). The scale features nine symptom items based on each of the DSM-IV criteria for BPD, grouped in four sectors reflecting the core areas of psychopathology: affective, cognitive, impulsive and interpersonal. Each symptom item is rated on a 5-point scale representing the frequency and severity of psychopathology. There are three affective symptoms in the ZAN-BPD: inappropriate anger/frequent angry acts, chronic feelings of emptiness, and mood instability. There are two cognitive symptoms: stress-related paranoia/dissociation and severe identity disturbance. The two impulsive symptoms include self-mutilative/suicidal efforts and at least two other forms of impulsivity. The interpersonal dimension includes intense, unstable relationships and frantic efforts to avoid abandonment. The four sector scores sum to provide a total score of borderline psychopathology.
Gender differences
Women with BPD have greater overall symptomology than men (Silberschmidt Reference Silberschmidt, Lee and Zanarini2015) and appear to exhibit an ‘internalising’ clinical picture manifested by higher rates of histrionic personality disorder, post-traumatic stress disorder (PTSD), other anxiety disorders, somatoform, affective and eating disorders (McCormick Reference McCormick, Blum and Hansel2007). Men tend to present with an ‘externalising’ picture, with higher rates of substance use disorders, antisocial personality disorder, narcissistic personality disorder and schizotypal personality disorder.
Physical assessment
Mental disorder is associated with an unhealthy lifestyle, social disadvantage, difficulties accessing medical healthcare and unwanted physical effects of psychotropic medication, and people with personality disorders in particular struggle to obtain adequate healthcare and have greater unmet treatment needs (Hayward Reference Hayward, Slade and Moran2006). A body of evidence is emerging that asserts that people at risk for personality disorders in the general population are at significantly increased risk for poor physical health. Therefore, careful screening and treatment of physical health conditions among people with BPD is warranted.
Recognising and using the countertransference
Working with patients with BPD can evoke strong feelings in the clinician and it is of diagnostic utility to attend to these emotions while working with the patient, i.e. recognising countertransference. The patient may interact with the clinician in ways that reflect repetitive patterns of relating to significant others (Colli Reference Colli, Tunzilli and Dimaggio2014), yielding clues as to how they interact within their relationships. In personality disorder, countertransference responses occur in predictable patterns, which are useful in understanding the patient’s patterns of relating to others (Betan Reference Betan, Heim and Zittel Conklin2005). Patients with BPD tend to arouse more negative responses, with clinicians reporting feeling inadequate, anxious and apprehensive about failing to help the patient and guilt when their patient is in distress. Immature defence mechanisms such as splitting and projective identification are strongly associated with borderline psychopathology (Zanarini Reference Zanarini, Frankenburg and Fitzmaurice2013). Splitting is a primitive defence mechanism in which there is a failure to integrate the positive and negative aspects of the self and others into a cohesive whole. Other people may be compartmentalised into ‘all good’ or ‘all bad’ groups and the patient may hold alternating contradictory representations of themselves. Projective identification involves an unconscious disavowal of aspects of oneself while simultaneously attributing these disavowed aspects to another. In the clinical encounter, such disavowed attributes from the patient can be induced in the clinician so that the clinician as a recipient of the projection identifies with the emotions induced in them, which can lead to a belief that the projected attributes originate from the clinician rather than the patient (Schlapobersky Reference Schlapobersky2016). Therefore, it may be clinically helpful to reflect on one’s countertransference experience as part of the assessment process as a source of information about the patient.
Giving a diagnosis
Clinicians may be concerned that disclosure of the diagnosis of BPD may engender pessimism in the patient and may not wish to ascribe a diagnostic ‘label’ that may be perceived as pejorative (Lequesne Reference Lequesne and Hersh2004). However, not sharing the diagnosis of BPD disadvantages patients by denying the potential relief that a diagnosis unifying their various symptoms may bring and limiting the therapeutic options available to them if the presence of a diagnosis is a treatment requirement. It is important to explain the diagnosis of BPD in a clear, understandable manner, all the while maintaining a sense of hopefulness for change and recovery. Therefore, sharing a diagnosis of BPD is an opportunity for psychoeducation about both the diagnosis and treatment options, which can help the patient to make informed decisions about their care (National Institute for Health and Care Excellence 2009). It facilitates the development of a shared understanding of the patient’s difficulties and a common language to discuss symptoms. It can be helpful to use examples from the person’s experience to illustrate features of the diagnosis, with a view to making the diagnosis personally relevant and meaningful. The patient should be afforded the opportunity to ask questions and to seek clarification on what has been discussed. Helpful online resources for patients and significant others are available from the Royal College of Psychiatrists and reputable mental health websites such as MIND.
Conclusions
Borderline personality disorder is a common, serious and clinically heterogeneous disorder, although the prognosis should be considered optimistically. Particular attention should be paid to assessing for psychiatric comorbidity, as BPD is highly comorbid with other mental disorders and its presence typically confers a worse prognosis. Careful clinical assessment should promote understanding of the patient’s emotional, behavioural, relational and occupational needs, in addition to informing assessment of risk and physical health status among people with this disorder.
