Developments in Diagnosis and Treatment of People With Borderline Personality Disorder

Sathya Rao; Parvaneh Heidari; Jillian H. Broadbear


Curr Opin Psychiatry. 2020;33(5):441-446. 

In This Article

Cooccurring and Overlapping Psychiatric Disorders

The recognition of significant comorbidity and symptomatic/etiologic overlap with trauma-related and affective disorders has improved over the past decade.[13] Frequent overlap with other psychiatric disorders can make BPD difficult to delineate and diagnose accurately, resulting in unnecessary polypharmacy and inadequate psychotherapeutic treatment of BPD. Recent studies assist with differentiating BPD from other psychiatric disorders. With respect to BPD and bipolar disorder, Reich et al.[14] propose that basal amygdala-frontal functional connectivity may distinguish BPD from bipolar II; Perez Arribas et al.[15] differentiated these diagnoses by studying the evolving interrelationships between different elements of mood. Bayes et al.[16] differentiated BPD from bipolar subgroups using factors including depression, developmental trauma, borderline personality scores, self-harm and suicide attempts. With respect to diagnostic criteria, 'abandonment fears' and 'identity disturbance' have the best specificity for differentiating bipolar from BPD.[17] Fowler et al.[18] found that the Personality Inventory for DSM-5 is a more sensitive self-report measure for differentiating BPD from bipolar compared with the difficulty in Emotion Regulation Scale. Although these studies offer some clues, clinicians may continue to have difficulties differentiating BPD from bipolar disorders.

A trauma history accompanied by trauma-related psychiatric symptoms is very common in BPD; childhood adversity is 14 times more likely than in nonclinical populations.[19] Posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) share symptoms with BPD including emotional dysregulation, impulsivity and unstable interpersonal relationships.[20] Similarities in the treatment of BPD and PTSD suggest that treating PTSD might improve outcomes in people with cooccurring BPD, decreasing self-harm and severe BPD symptoms.[21] Metaanalysis of brain imaging studies in people with BPD and PTSD showed decreased activation in the left and right precuneus when compared with controls; conversely activation in the anterior cingulate/paracingulate gyri and left superior frontal gyrus was reduced in PTSD and increased in BPD,[22] suggesting neurological similarities and differences. However, with the introduction of CPTSD as a diagnostic category within ICD-11, clinicians may need to choose between diagnoses when BPD is associated with childhood trauma, despite similarities in their presentations and treatment needs. It is notable that Bohus and Priebe[23] have developed a treatment approach, dialectic behavioural treatment (DBT)-PTSD, which simultaneously targets BPD and PTSD.

Attention deficit hyperactivity disorder is also difficult to differentiate from BPD. Although they share symptoms including impulsivity, interpersonal impairment and emotional dysregulation, adults with BPD have more severe emotion dysregulation and less severe impulsivity.[24]

Auditory verbal hallucinations (AVH) are a shared feature of BPD and psychotic disorders such as schizophrenia. In a review of factors that may distinguish these diagnoses, Beatson et al.[25] concluded that people with BPD who experience AVH do not experience flat or blunted affect and have AVH content that is mostly negative, often comprising elements of childhood trauma.