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  • v.123(4); 2018 Dec

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Personality disorder: a disease in disguise

Lisa ekselius.

Department of Neuroscience, Psychiatry, Uppsala University, Sweden

Personality disorders (PDs) can be described as the manifestation of extreme personality traits that interfere with everyday life and contribute to significant suffering, functional limitations, or both. They are common and are frequently encountered in virtually all forms of health care. PDs are associated with an inferior quality of life (QoL), poor health, and premature mortality. The aetiology of PDs is complex and is influenced by genetic and environmental factors. The clinical expression varies between different PD types; the most common and core aspect is related to an inability to build and maintain healthy interpersonal relationships. This aspect has a negative impact on the interaction between health-care professionals and patients with a PD. From being discrete and categorical disease entities in previous classification systems, the current concept of PD, reflected in the newly proposed ICD-11, is a dimensional description based on the severity of the disturbed functioning rather than on the type of clinical presentation. Insight about the characteristics of PDs among medical practitioners is limited, which is partly because persons do not seek health care for their PD, but instead for other medical issues which are obscured by their underlying personality problems. What needs to be emphasized is that PDs affect both the clinical presentation of other medical problems, and the outcome of these, in a negative manner and that the integrated effects of having a PD are a shortened life expectancy. Accordingly, PDs need to be recognized in clinical practice to a greater extent than previously.


In everyday clinical practice persons who think, feel, behave, or relate to others differently than the average person are identified. This deviation from the norm is a central feature in all personality disorders (PDs). Although using slightly different formulations over the years, PDs are roughly characterized by ‘a pervasive pattern of thought, feeling and behaviour that characterize an individual’s unique lifestyle and mode of adaptation, which deviates markedly from the expectations of the individual’s culture’ ( 1 ). Such characteristics obviously create problems for those who bear them. PDs are likely to have an onset in adolescence or early adulthood, appear to be stable over time, and lead to impairment or distress ( 1 , 2 ).

This review, which is an overview on PDs and the core problems these ultimately lead to, is commenced with some background information about the concept of personality and on the attempts that have been made to understand and to describe different characteristics of personality, how these characteristics can be structured and understood, and about the deviations in normal personality that form the basis for the different types of PD. Above all, the paper focuses on problems met in primary and specialist health care. Such problems are common, and persons with PDs are known to be under-treated with respect to physical health ( 3 ) and are over-represented in the group categorized as the ‘difficult patient’ ( 4 , 5 ).

The present paper argues that all health-care professionals need basic knowledge about manifestations of different personality traits, above all in the form of manifest PDs, as we know that such pathology has a negative effect on the interaction between the patient and health-care professionals in terms of communication, clinical assessment, treatment, and outcome ( 6 ). The patients’ suffering is considerable, and generally they report a low QoL ( 7 , 8 ). Having a PD also infers a risk factor for premature mortality ( 9 , 10 ), which affects individuals and incurs a high cost to society ( 11 ).

A historic perspective of aberrant personalities

The large variation in the way individuals think, feel, and behave has been recognized throughout antiquity. The terms for these characteristics have been diverse. For instance, Confucius (551–479 BCE) used the combination of ‘blood and vital essence’. The Greek philosopher and naturalist Theophrastus (c. 371 to c. 287 BC) used the term ‘characters’, and in eighteenth-century France the Galenus–Hippocrates term ‘temperament’ was reinstituted. The term ‘personality’ has been used since the eighteenth century to label distinguishing qualities of a person ( 12 ).

Pathological personalities have also generated interest over the years. Since the fourth century BC, philosophers have been trying to understand what it is that makes ‘us’ what we are. Theophrastus, a scholar of Plato and Aristotle, was the first to publish a systematic description of the multifaceted nature of personality types ( 12 ). A few hundred years later, Aelius Galenus (130–200 AD) linked Hippocrates’ four humours to personality characteristics in his description of sanguine , phlegmatic , choleric , and melancholic temperaments. He proposed that each of these four body fluids held a combination of two properties split along two axes: temperature (hot/cold) and humidity (wet/dry). The humoral pathology system influenced the view among European doctors until the breakthrough of medical science in the nineteenth century.

In the early nineteenth century, Franz Joseph Gall (1758–1828), a German neuroanatomist, thought that some brain areas were associated with specific functions. He also thought that measurements of the skull represented differences in the individual’s personality ( 13 ).

Philippe Pinel (1745–1826), a French physician, was the first to include an aberrant personality in the nosology of psychiatry ( 14 ). Pinel introduced the term ‘ manie sans délire ’ (mania without delusion). During that time, the term ‘mania’ was employed to refer to states of agitation. Pinel described a few of his male patients who were disposed to bursts of irrational anger and impulsive violence in response to minor irritation. In the same intellectual environment Jean-Étienne Dominique Esquirol (1772–1840) introduced the concept monomanie raisonnante and the Englishman James Cowles Prichard (1786–1848) used the term moral insanity . These three physicians were obsessed by the practical question at that time whether psychiatry could explain abnormal behaviour in persons lacking acute psychiatric symptoms who had committed a violent crime ( 14 ).

During the late nineteenth and early twentieth century, several conceptual systems for normal and abnormal personalities emerged as the result of the work of European psychologists and psychiatrists (e.g. Ribot, Heymans, Lazursky, Schneider, and Sjöbring).

Théodule Ribot (1839–1916), a French psychologist, described normal and abnormal characters. He pointed out that a person’s character is stable from childhood into adult life. Ribot described three primary personality types: the sensitive, the active, and the apathetic, all three of which were divided into subtypes ( 15 ).

The Dutch scientist Gerard Heymans (1857–1930) applied empirical methods to the study of personality. He developed the Cube of Heymans, a description of a personality typology. He defined personality types in three dimensions: ‘activity level’, ‘emotionality’, and ‘primary versus secondary functioning’, with the last-mentioned dimension comparable to ‘extroversion/introversion’. These three dimensions are represented on the x -, y -, and z -axes of the Heymans cube, where all combinations of the three dimensions defined eight personality types ( 16 ).

The contributions of Aleksandr Lazursky (1874–1917), a Russian psychologist, were not widespread because most of his publications were in Russian and because of the political climate of the time. His major contribution was the description of the ‘endopsychic’ and ‘exopsychic’ aspects of personality. The endopsychic components represent the psychological functions (e.g. perception, memory, attention, thinking) that are mainly inborn; the exopsychic components are the consequence of the interaction with the outside world. The interplay between these two aspects of personality determines how a person functions in an integrated social context ( 17 ).

The German psychiatrist Kurt Schneider (1887–1967) focused on diagnostic issues that included concepts of ‘psychopathy’, which he had broadly equated to PDs. Based on his clinical views ( 18 ), he vaguely defined abnormal personality as a statistical deviation from the norm. He proposed 10 psychopathic personalities, all of which are very similar to those in the current classifications of PDs in the DSM-5 and ICD-10 ( 19 ).

Henrik Sjöbring (1879–1956), a Swedish psychiatrist, suggested four constitution factors of the personality: capacity (intelligence), validity (psychic energy), stability (balance in keynote), and solidity (firmness, tardiness, tenacity). By these variables, all persons can be categorized as either normal, super-, or sub-: e.g. subcapable (unintelligent), subvalid (lack of psychic energy), normosolid, superstable, and so on ( 20 ).

The first modern attempt to determine the structure of human personality was credited to the English scientist Sir Francis Galton (1882–1911). He used a lexical approach to the dimensions of personality based on the assumption that those personality characteristics important to a group of people will eventually be represented in their language ( 21 ). This work was continued by several others ( 22 ), and the lexical hypothesis constitutes the basis for how current approaches describe personality dimensions. It is also important to mention the work of the psychologists Raymond Bernard Cattell (1905–1998) ( 23 ) and Gordon Willard Allport (1897–1967) ( 24 ) who independently used advanced statistics (e.g. factor analysis) to discern dimensions of personality.

Modern concepts of personality disorder and personality

Before discussing this issue, it needs to be re-emphasized that the description of personalities is based purely on observations, or rather expressions, of the individual’s way to think, feel, behave, or relate. As a corollary, it follows that PDs are diagnoses based on symptoms described by the persons themselves, by persons in their surroundings, or are objectively observed in study situations. This circumstance accounts for why the validity and reliability of the current diagnostic instruments lack optimality ( 25 ).

Current knowledge on pathological personalities is primarily based on studies from four perspectives, all of which are necessary to create an in-depth template of what characterizes personality pathology.

The first perspective is the clinical picture, i.e. the integrated presentation of the clinical symptoms that are either expressed or witnessed. This perspective is what constitutes the basis for the clinical structured diagnosis according to classification systems. The second perspective entails a determination of underlying dysfunctional personality traits as well as dysfunctional limitations on capacity and functionality in the brain’s cognitive, emotional, and impulse control systems. The third perspective relates to the brain’s biological systems and their functions; this third perspective has highly benefited from the rapid development of brain imaging techniques ( 26 ). The fourth perspective denotes the underlying genetic contribution to the above-mentioned phenomena ( 27 ), which is currently approached in whole-genome association studies ( 28 ).

Not unexpectedly, studies have shown that the aetiology of personality pathology is complex. Overwhelming evidence supports the idea that an interaction between genetic and environmental factors is necessary for the development of human personality. The relation between the dimensions of normal personality and PD is not clear, however. Even if a PD has been viewed as an overexpression of personality traits to the extent that they lead to clinically significant distress or impairment, it has recently been demonstrated that a moderate-to-sizable proportion of the genetic influence underlying PD is not shared with the domain constructs of normative personality ( 29 ).

Based on the hypothesis that the domains of dysfunction in PDs are linked to specific neural circuits, neuroimaging techniques have been used over the past decade to examine the neural integrity of these circuits in personality-disordered individuals. Currently, the literature is flooded with information acquired through this approach. Most studies are done to explore borderline PD ( 30 ). In general, the studies have thus far demonstrated deviations in neuronal circuitry in areas previously found to be active in the symptomatology that characterizes the specific type of PD. Even if the results of such studies contribute to an understanding of underlying physiological processes, they are not yet ready to be used in clinical practice.

Several studies have examined the effects of being exposed to childhood adversities and the risk to develop PD. Just to mention one such study, we recently showed that exposure to cumulative childhood adversity was incrementally associated with a diagnosis of PD in young adulthood ( 31 ). Furthermore, childhood or adolescent psychiatric disorders have been suggested to trigger a chain of behaviours and responses that foster the more persistent psychopathology of a PD ( 32 , 33 ).

To determine the importance of genetic and environmental factors in early childhood in personality pathology the relationship between vulnerability to child abuse and antisocial personality patterns in adulthood was investigated ( 34 ). It was shown that individuals with a gene polymorphism that resulted in a low activity in monoamine oxidase A (MAOA) were more vulnerable to developing an antisocial personality pattern than those who had high activity in the MAOA gene, given that they had been exposed to child abuse. This gene–environment interaction has subsequently been confirmed ( 35 ). Moreover, a similar interaction for the effects of child maltreatment on antisocial behaviour has also been shown for other genes ( 36 , 37 ).

There is thus reason to consider genetic and environmental factors as interacting systems of crucial importance in the development of functional and dysfunctional personality traits.

Classification of personality disorders

The differences in the types of aberration in thought, feeling, and behaviour have been the basis for the classification of different PDs. The characteristics described by Galenus, and later by e.g. Pinel and Schneider, are very similar to contemporary classification systems. What today are referred to as PDs were earlier called ‘pathological personalities’ or ‘ persona pathologica ’ and were found under that heading in earlier versions of the ICD (up to ICD-8). These diagnoses were used rarely, in part because of their stigmatizing connotations.

Up to now, classification of PDs has been based on fulfilling a specified number of defined and ‘specific’ criteria for each PD, resulting in a categorical description; if a defined number of these criteria were met, a disorder was acknowledged, else not.

Over time, there has been an intraprofessional dispute on whether the classification of PDs should be based on the defined and specific characteristics or on the severity of the functional aberration. Historically, and currently, in the ICD-10 (which is from 1992) and in the current American DSM-5 ( 38 ) (from 2013) classification is based on types of symptom, i.e. characteristics of the clinical presentation, represented by the abovementioned ‘specific’ criteria for each PD. ICD-10 describes nine discrete and specific (as well as one unspecified) types of PD ( Table 1 ). The DSM-5 ( 38 ) identifies 10 PDs of similar structure. The DSM system has gone one step further in classification by grouping the different disorders in three clusters based on some overall common features. To illustrate, cluster A contains odd and eccentric personalities, cluster B includes dramatic, impulsive, emotional personalities, and cluster C fearful and anxious personalities.

Personality disorders in the ICD-10 ( 2 ).

A basic feature common for the different classification systems is that the aberration must be severe enough to cause a functional impairment in everyday life. This is the ‘general criterion’ for all PDs and overrides other perspectives. In other words, even the observance of very odd behaviour or feelings is not enough for a clinical diagnosis of a PD unless it can be ascertained that they lead to impairment or distress in everyday life.

Currently, there is somewhat of a paradigm shift in that more and more arguments speak for the relevance of a dimensional classification of PD based on the severity of symptoms rather than on the specific characteristics ( 19 ). Studies have, thus, shown that the conceptualization of PDs into discrete categories results in an insufficient description of the problem. Rather, it seems that within each discrete PD category the level of dysfunction is dimensional and dependent on the number of criteria fulfilled ( 39 ). Furthermore, only about half of all individuals with diagnosable PD fulfil criteria for a specific PD and are thus given a diagnosis of unspecified PD ( 40 ). In addition, the expression of different symptoms evolves continuously across the lifespan ( 41 ).

General description of personality disorders in ICD-11

The new ICD-11 classification system, which was released by WHO in June 2018 ( 42 ), means a radical change in the classification of PDs and will impact all aspects of health care, as well as influence the way PDs are seen ( 43 ). After 1–2 years of adaptive work, ICD-11 is expected to be operative internationally in 2020–2021. In ICD-11 PDs have been classified based on the perspectives mentioned above, i.e. according to the severity of suffering, and are divided into three severity groups: mild , moderate , or severe . The degree of severity is determined by the extent of problems in interpersonal relationships or the ability and willingness to perform expected social and occupational roles, or both (see Table 2 for a full description).

Personality disorders in the forthcoming ICD-11.

Excerpt from reference ( 41 ) with permission from WHO.

A new feature in ICD-11 is the introduction of the term ‘Personality Difficulty’, which refers to pronounced personality characteristics that may affect treatment or health services but do not rise to the level of severity to merit a diagnosis of PD.

Dimensions of personality disorders in ICD-11

ICD-11 has, thus, wiped out all type-specific categories of PD apart from the main one, the presence of PD itself. Instead, the type of clinical manifestation is added as a specific ‘post-coordination’ code describing the clinical characteristics in the form of six different personality domains. Factor analytic strategies have supported five domains, although clinical reasoning has suggested six domains ( 44–46 ). These six clinically derived personality domains do not fully correspond with the different specific PD types in the earlier ICD-10 ( Table 2 ).

The domain traits are not inherently pathological, but rather represent a profile of underlying personality structure ( 19 ). They apply equally to individuals without any PD and to those with severe disorder, but in PD they show where the focus of the disorder is apparent. In severe disorder, several domain traits are likely to be associated with the disorder ( 47 ). To describe personality functioning, as many domains as necessary can be applied.

The descriptions of the six different domain traits below are slightly and only linguistically modified from those in the original ICD-11.

Negative affectivity in personality disorder

The core aspect of negative affectivity is the tendency to experience a broad range of negative emotions. Common manifestations, not all of which may be present in everyone at a given time, include experiencing a variety of negative emotions with a frequency and intensity out of proportion to the situation: emotional lability and poor emotion regulation, negativistic attitudes, low self-esteem, low self-confidence, and mistrustfulness.

Patients fulfilling criteria for this disorder were classified as anxious/avoidant in previous classifications.

Detachment in personality disorder

The core aspect of the detachment domain is the tendency to maintain interpersonal (social detachment) and emotional distance (emotional detachment). Common manifestations, not all of which may be present in everyone at a given time, include social detachment (avoidance of social interactions, lack of friendships, and avoidance of intimacy) and emotional detachment (reserve, aloofness, and limited emotional expression and experience).

This disorder type is like the schizoid type of PD described in ICD-10.

Dissocial or antisocial personality disorder

Dissocial or antisocial PD is characterized by a gross disparity between behaviour and the prevailing social norms as well as by a callous unconcern for the feelings of others. Moreover, this type of PD can be described by a number of other attributes, including a gross and persistent attitude of irresponsibility and disregard for social norms, rules, and obligations; an incapacity to maintain enduring relationships, although having no difficulty in establishing them; very low tolerance to frustration and a low threshold for discharge of aggression, including violence; an incapacity to experience guilt or to profit from experience, particularly punishment; and finally, a marked proneness to blame others or to offer plausible rationalizations for the behaviour that has brought the person into conflict with society.

Persons with a dissocial PD often have an early criminal record and exhibit conduct problems in childhood or adolescence. The construct of a dissocial PD largely overlaps characteristics of the concept of psychopathy, which is not a term used to define a psychiatric disorder ( 48 ).

Disinhibition in personality disorder

The core aspect of disinhibition traits is the tendency to act rashly based on immediate external or internal stimuli (i.e. sensations, emotions, thoughts) without consideration of the consequences. Common manifestations—not all of which may be present in everyone at a given time—include impulsivity, distractibility, irresponsibility, recklessness, and lack of planning.

Patients fulfilling the criteria for this disorder in previous classifications were classified as histrionic, narcissistic, or borderline.

Anankastia in personality disorder

Anankastic PD (or obsessive-compulsive PD) is characterized by a narrow focus on orderliness and perfectionism and on right and wrong, although it also implies a need to control one’s own behaviour and the behaviour of others, as well as the need to control one’s environment to ensure conformity to these standards. Common manifestations, not all of which may be present in a given individual at a given time, can include conscientiousness (e.g. concern with social rules, obligations, and norms of right and wrong, scrupulous attention to detail, rigid, systematic, day-to-day routines, obsessiveness about hyper-scheduling, emphasis on organization, orderliness, and neatness) and emotional and behavioural constraint (e.g. rigid control over emotional expression, stubbornness and inflexibility, risk-avoidance, perseveration, and deliberativeness).

Borderline personality disorder

The criteria for this disorder are very similar to those for disinhibition. It was included in the new ICD-11 at a very late stage of the process ( 45 ). The classification may be applied to individuals whose pattern of personality disturbance is characterized by a pervasive pattern of instability of interpersonal relationships, self-image, and affects, as well as marked impulsivity, as indicated by many of the following behavioural patterns: frantic efforts to avoid real or imagined abandonment; a pattern of unstable and intense interpersonal relationships; identity disturbance, manifested in markedly and persistently unstable self-image or sense of self; a tendency to act rashly in states of high negative affect, leading to potentially self-damaging behaviours; recurrent episodes of self-harm; emotional instability due to marked reactivity of mood; chronic feelings of emptiness; inappropriate intense anger or difficulty controlling anger; and transient dissociative symptoms or psychotic-like features in situations of high affective arousal. The condition involves anxiety without an identifiable connection to concrete stimuli and, among other things, has been called ‘annihilation anxiety’, ‘pan-anxiety’, or ‘global anxiety’. The term ‘emptiness depression’ describes general feelings of despair and hopelessness with dominance of depressive thoughts.

Borderline PD (in ICD-10 ‘emotionally unstable PD’) is a dominating diagnosis in out- and inpatient psychiatric care ( 9 , 10 ). Clinical expressions are more evident in younger ages and tend to decrease with advancing age.

Borderline PD is associated with high mortality by suicide ( 9 , 10 , 49 ). There is also a high risk to die prematurely because of impulsive risk-taking, as well as succumbing to violence from others ( 9 , 10 ). Recurrent suicidal threats or attempts, when combined with fears of abandonment, are strongly indicative of the diagnosis ( 50 ). Even if these characteristics make borderline pattern PD easy to identify, the diagnosis is often overlooked. A key reason for this neglect is the perception that the overemotional, sometimes theatrical, and self-injurious behaviours are signs of wilfulness and manipulations rather than signs of an illness ( 51 ).

Borderline PD occasionally includes depressive and anxiety symptoms and mild irritability. In general, many persons with borderline PD describe recurrent occasions with panic anxiety, which may lead to suspicion of a primary panic disorder or generalized anxiety disorder. Likewise, experienced social discomfort and fears can arouse suspicion of primary social anxiety disorder. Finally, recent studies have suggested that attention deficit hyperactivity disorder (ADHD), bipolar disorder, and borderline PD have similar origins or share common pathological mechanisms ( 52 , 53 ).

Prevalence and longitudinal perspective

PDs are common in the general population. A recent overview ( 54 ), based on 13 studies conducted in the USA and Europe, reported prevalence figures varying from 3.9% to 15.5%. In the WHO World Mental Health Survey, carried out in 13 countries, the prevalence rate was 6.1% ( 55 ). The large variation in prevalence may be due to differences in sampling, diagnostic methods, and study settings. Furthermore, there may be differences in culture regarding significant personality pathology.

Persons in contact with the health-care system exhibit higher prevalence of PDs as compared with those not in contact. In fact, one-fourth of patients in primary care ( 56 ) and about half of those in psychiatric outpatient facilities fulfil the criteria for a PD ( 57 ).

PDs are equally common or more common in men ( 54 ) in the general population. In clinical settings, however, PDs are more often recognized in women, probably due to the higher rates of help-seeking behaviour in women ( 9 , 10 ).

Stability over time has long been a basic concept both in the description of personality and of PDs. Supporting this concept is the observation that there is rank-order stability over time in the expression of personality symptoms ( 58 ). On the other hand, an exaggeration in some personality traits over the life course and a decline in others have been observed ( 41 , 59 ). Furthermore, it has recently been shown that drugs affecting serotonin uptake can modulate personality traits ( 60 , 61 ). There is less support for the idea that a PD should be regarded as stable over time. Actually, modern research has shown that, although a maladaptive personality can be recognized early in life, it evolves continuously across the lifespan and is more plastic than previously believed ( 41 ). In addition, in the case of coexisting mental disorders, their contribution to the clinical picture will vary over time with the state of these disorders. In other words, even if personality traits are largely constant across time, there is a tendency that symptoms in persons with a PD change more over time than those without a PD. This change is often in the direction of improvement ( 62 , 63 ).

Diagnosis, differential diagnosis, and psychiatric comorbidity

Establishing a formal diagnosis of a PD is an issue for specialist psychiatry, where it must be regarded as a time-process function. The patient history must cover the life perspective to understand the current clinical landscape in context and against a background of the individual’s unique developmental history.

General and permanent problems in work, studies, and relationships are often primary and obvious observations. Difficulties in interpersonal relations are often visible already at the first patient encounter. Those difficulties justify a step-by-step deepening of the formal diagnostic work while initiating treatment efforts. Enhanced personal knowledge will also provide a more nuanced image of the patient’s problems as well as adaptive resources.

Accounts of the current problem and the patient’s current life situation are a natural starting point when collecting data on the clinical history of the patient. Special attention must be given to the risks of suicide and violence. The clinical history should be expanded in a piecemeal manner on appropriate occasions.

During the diagnostic process, it often becomes clear that the patient presents with criteria for several disorders, both within and outside the PD spectrum. Such comorbidity is common ( 64 , 65 ); it is seen across the whole spectrum of PDs and other mental disorders and in general represents a broader pattern of symptoms as well as a more severe condition. This is reflected in the observation that the total number of fulfilled criteria for any PD is related to the observed dysfunction and to the reported QoL ( 54 ). Comorbidity between PDs and other mental disorders contributes significantly to functional impairment ( 64 ) while also increasing the risk of early mortality ( 9 , 10 ).

Because of this characteristic, it is not uncommon that the person who fulfils criteria for a diagnosis of PD will seek health care for another mental disorder, a fact that might be misleading during the diagnostic process. Not too infrequently, there are rapid onset depressive or anxiety states that motivate the care episode during which the coexisting problems related to a comorbid PD are apparent. A more pressing issue is comorbidity of a more enduring character. For example, a coexisting ADHD can obscure the clinical symptoms of borderline PD. Conversely, a severe and prolonged eating disorder may dominate over an underlying personality pathology.

When the symptomatic picture of PD is complex and partially overlapping between different diagnoses, it is seldom possible to distinguish between different underlying pathologies. The differential diagnostic procedure will therefore be more about evaluating the relative influence of the various demonstrable expressed symptoms on the severity of functioning.

To optimize diagnostic accuracy self-assessment tools, semi-structured interviews and personality inventories can be used. The SCID-II is such an interview support for personality diagnosis according to the DSM-IV and DSM-5 ( 66 ).

Personality disorders and health

The long-term negative effects of having a PD are significant ( 9 , 10 , 41 , 54 ). Furthermore, because a PD is often overlooked diagnostically, the potential risks for the bearer may go undetected. A certain proportion of those who fulfil the criteria for a diagnosis of PD will ultimately have psychiatric care, while almost everyone eventually comes in contact with primary care or specialized somatic care. Given that personality-related problems lead to varying degrees of lack of adaptivity in interaction with other people, there are often complications in the contacts with health care and social services.

Personality traits are well known to impact health-related QoL ( 8 ) and outcome in health care. The negative consequence of having a high degree of neuroticism has been extensively studied ( 67 ). The consequence of having a PD is, however, only well studied in psychiatric care, where a multitude of studies have shown that having a comorbid PD represents a more severe condition with a worse prognosis as stated above.

There has been less focus on somatic care. Still, it has been shown that having a PD is related to higher rates of pain, greater use of analgesics, and more primary care, taken together suggesting an increase in somatic morbidity ( 68 ). It has also been shown that the outcome of treatment for somatic ill health is usually worse in the presence of a PD ( 68 ). For instance, having a PD was found to increase the risk of stroke ( 69 ) and coronary artery disease ( 70 , 71 ). Furthermore, having any PD is strongly associated with severe occupational outcomes, including disability benefits, regardless of disability diagnosis ( 72–74 ).

The most studied PD in this respect is borderline PD. Persons with this PD tend to be impulsive, and where self-harm is common they have an increased tendency to seek health care ( 75 ). Borderline PD, however, is related to an increased risk for several health problems, and consequently for a greater consumption of health care ( 76–79 ).

Based on previous knowledge that individuals with a PD have a higher mortality rate and a shorter life expectancy compared with the general population ( 69 , 80–83 ), we recently assessed to what extent this was related to type of PD or cause of death ( 9 , 10 ). Data from nationwide Swedish hospital registers with a follow-up of 25 years were used. Overall, all-cause standardized mortality ratios (SMRs) were found to increase in all clusters of PDs for natural and unnatural causes of death. The overall SMR was 6.1 in women and 5.0 in men, figures in line with those previously reported for anorexia nervosa, with higher rates in cluster B and unspecified/other PDs. The increased mortality ratio was seen for all somatic causes of death, reflecting the impact of having a PD on somatic health and wellbeing. The SMR for suicide was as high as 34.5 in women and 16.0 in men for cluster B disorders. Somatic and psychiatric comorbidity increased SMRs further. This excess mortality was also observed for most patients diagnosed with PDs not severe enough to lead to hospitalization ( 9 ). This observation contradicts the idea that only those persons with a PD severe enough to motivate inpatient treatment are burdened by an increased risk in mortality. This has important practical implications in that most patients with clinical problems linked to a PD are only treated as outpatients. On the other hand, the risk of death in those only treated as outpatients was clearly less than in those who received inpatient care, supporting the view of a difference in clinical severity between these groups ( 47 ).

Aspects on handling and treatment

Given the impact of PDs on treatment outcomes in somatic and mental health care, a clinical pattern suggesting the existence of such a disorder should be identified in primary or somatic specialist care ( 84 ). Treatment is a concern for specialist psychiatry, however. A well-developed liaison psychiatry, a subspecialty of psychiatry, is particularly suitable.

Even if treatment modalities are not the topic of this survey, some basic principles must be addressed. Because PDs are deeply ingrained ways of thinking and behaving that evolved as the personality developed, they are considered difficult to treat. In recent years several studies have emerged that have, to some extent, changed this concept ( 85–88 ). In general, there are many challenges and no simple solution in the treatment of PDs. At the same time, because fundamental problems of PDs are related to interpersonal relations, a structured and stable relationship between the patient and the clinician is the basis for any successful approach. This ‘therapeutic alliance’ looms as the strongest predictor of successful outcome of any treatment attempt. The most difficult challenge for the clinician is to achieve this goal. In fact, the pre-existing quality of the patient’s relationships, rather than the type of PD, is the single factor that most affects the quality of this alliance ( 89 ). The strength of this alliance is crucial not only to obtain anamnestic information about the true history of the problems encountered but also to motivate and maintain adherence to treatment.

Although there is only a paucity of randomized controlled studies on the effect of psychotherapy in PD ( 90 ), the few studies published suggest that it should be the core treatment ( 91 ), leading to individual benefit and a reduction in care costs ( 92 ).

Currently, no pharmaceuticals are registered for use in PDs. Any attempt to apply a pharmacological approach is therefore an issue for the psychiatric specialist. Such an approach should aim to reduce or eliminate specific symptoms seen in other psychiatric disorders, where there is evidence that the drug in question is efficient. Irrespective of which drug is used, the clinical effect should be closely monitored.

The underlying hypothesis when attempting psychotropic pharmaceuticals in the treatment of PDs is the assumption that the features and attributes associated with the clinical expression are linked to biochemical abnormalities and thus can be regulated by psychotropic drugs. For most specific PDs, studies on the putative benefit of pharmaceuticals are lacking, and where studies have been done the results are at best modest ( 93 ). Despite this limitation, most psychiatrists can testify about patients with PDs who are prescribed many drugs, often over a long time, and without information about the expected or obtained benefit, or how the treatment was followed up. Such polypharmacy, particularly in combination with poor documentation, can put patients at risk of adverse drug events (side effects) and interactions. In other words, drugs should never be the first-line treatment but may be justified as a supplement to other treatment forms in specific situations.

PD frequently goes undetected, in the shade of other health problems or diseases. PD is a predictor of worse health, premature death, and more serious life issues. It constitutes a challenge to health-care professionals and, above all, a burden for the patient, the family, and society. PD involves deviations in cognition, affectivity, interpersonal functioning, and/or impulse control. Deepened knowledge requires intellectual approaches based on sociodemographic, as well as epidemiological and advanced genetic and imaging techniques.

There is a clinical shift from an earlier focus on the characteristics of discrete PD entities to an awareness of the common features of different PDs, the suffering of patients, and the many problems they face in interpersonal relationships and daily life. The new ICD-11 classification aims to improve the description of the severity of problems encountered by patients.

Knowledge of the clinical aspects of PDs in general health care, vigilance to symptoms of PD, and appropriate diagnosis are all essential for optimal support to affected patients.

Disclosure statement

No potential conflict of interest was reported by the authors.

Note on the contributor

Lisa Ekselius, MD, PhD, is a Full Professor of Psychiatry at Uppsala University and a Senior Consultant in Psychiatry at the Uppsala University Hospital. Her research is focused on issues related to personality and personality disorders. These include the epidemiology of personality disorders, but also the contribution of personality traits to the expression of somatic as well as psychiatric disorders, and to the vulnerability to recover from major body trauma.

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  • Dimitrios Chartonas , consultant psychiatrist 2 3 ,
  • Jennie Parker , independent lived experience researcher , KUF development lead 2 5 ,
  • Spyridon Symniakou , GP partner 6 ,
  • Tennyson Lee , consultant psychiatrist in medical psychotherapy , psychoanalyst , honorary senior lecturer 2 4 7 6 8
  • 1 Basildon Complex Needs Psychotherapy and Personality Disorder Service, Essex Partnership University NHS Foundation Trust, UK
  • 2 Centre for Understanding Personality (CUSP), London
  • 3 Camden and Islington Personality Disorder Service, Camden and Islington NHS Foundation Trust
  • 4 Deancross Personality Disorder Service, East London NHS Foundation Trust
  • 5 Berkshire Healthcare NHS Foundation Trust
  • 6 Blithdale Health Centre, Clinical Director East End Health Network
  • 7 Institute of Psychoanalysis, British Psychoanalytical Society
  • 8 Wolfson Institute, Queen Mary University of London
  • Correspondence to O Kanter Bax orestis.kanter-bax{at}nhs.net

What you need to know

Personality disorders are a set of complex emotional difficulties. They are common, often unrecognised, and are associated with mental and physical health comorbidities and reduced life expectancy

Personality disorders are perceived as stigmatising diagnoses. Alternative terms have been proposed. New classification systems help in moving away from rigid use of categorical diagnoses

Assessment and management in primary care require a non-judgmental approach that builds trust through attentiveness, validation, openness, and consistency

Holistic care for people with personality disorders can be improved with reflective practice structures, staff training, collaboration, and team working

Sources and selection criteria

We searched Pubmed, Medline, Embase, the Cochrane Library, CINAHL, PsycINFO, AMED, British Nursing Index, HMIC, and Health Business Elite using the term “personality disorder”. Findings from randomised controlled trials (RCTs), systematic reviews, and meta-analyses were ranked as high in quality (see table 1 ) and we also used our own reference archives, books, and expert contacts to supplement the structured search.

Personality disorders describe a set of long standing complex emotional difficulties, which are common, highly stigmatised, and potentially disabling. They are frequently under-recognised and may run a long course when people lack access to appropriate treatment. Recent developments in evidence, guidelines, and policy have placed an emphasis on public awareness, de-stigmatisation, training professionals in generalist settings, improving access to specialist care, and improving physical health outcomes. 1 2 This article provides an overview of the latest information on the assessment and management of personality disorders in primary care, with an emphasis on borderline personality disorder (also referred to as emotionally unstable personality disorder).

What are personality disorders?

Personality disorders are pervasive and enduring, affecting the emotional, cognitive, and behavioural functioning of a person, expressed in relation to their self (eg, identity, self-evaluation, affect regulation, direction) and others (eg, intimacy, boundaries, sense of security in relationships). People with personality disorders may face difficulties with social functioning at work, with family, and with social life and leisure, and such difficulties may represent a significant deviation from what is expected for the individual’s developmental stage and culture. 3 No consensus exists on a single definition, research in the field is growing rapidly, and controversy surrounds the validity of existing conceptual frameworks. 4 Some people with lived experience and some clinicians question use of the term “personality disorder” altogether, and advocate for its replacement (for example, the term “complex emotional needs” has been proposed). 5

Negative attitudes and biases are still held about people who receive a diagnosis of personality disorder both in the general public 6 7 and among clinicians. 8 Longstanding misconceptions exist about the nature and “untreatability” of personality disorders, but evidence is growing for the efficacy of treatments for borderline personality disorder ( table 1 ) and emerging treatments for antisocial and narcissistic personality difficulties. 12 16

Evidence based treatment for borderline personality disorder 9 10 11

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What underlies personality disorders?

As with other mental health conditions, genetic and environmental factors contribute to the development of personality disorders. The genetic link is still not well understood 17 18 and evidence on heritability is limited. 19 Genetic factors are thought to interact with the environment to lead to neurobiological changes. 20 Epigenetic effects of the environment on gene expression are also increasingly recognised. 21 Antenatal adversities (eg, increased stress in utero) 22 and adverse childhood experiences, 23 including physical, emotional, and sexual abuse, neglect, and parental mental illness, are associated with an increased risk of a diagnosis of personality disorder in adulthood. 24 In particular, a meta-analysis found that individuals with borderline personality disorder are 13.91 times more likely to report childhood adversity than non-clinical controls and 3.15 times more likely than other people with other psychiatric conditions. 25

Several theoretical models exist that can be clinically useful. Attachment theory provides a model for the understanding of how early disruptions in the infant-caregiver relationship may influence regulation of affect and development of the self. 26 Psychoanalytical object relations theory explains how early internal self and other (object) representations and “patterns” of relating are repeated in adulthood. 27 Adapted cognitive behavioural theory focuses on the effects of conditioning (eg, through invalidating environments) on emotional, cognitive, and behavioural patterns that develop in adulthood. Understanding the complex multi-causal pathways leading to a personality disorder diagnosis can reduce stigma. 28

How common are personality disorders, and who is affected?

Relatively little epidemiological research has been conducted in personality disorders, but estimates of prevalence suggest as many as one in 10 people in the general population has a personality disorder. 29 30 A 2000 study of 303 consecutive primary care attenders estimated that one in four met the criteria for a diagnosis. 31 Estimates of the prevalence in secondary mental healthcare are variable because of heterogeneity of samples, but two literature reviews reported that up to 52% of psychiatric outpatients and up to 70% of patients in inpatient and forensic settings met the criteria for personality disorders, 32 and 12% of patients in outpatient psychiatric clinics and 22% of patients in inpatient psychiatric clinics for borderline personality disorder. 33

Antisocial personality disorder is consistently more common in men than women. 34 There is possible measure or clinician bias in diagnosis of borderline personality disorder in lesbian, gay, and bisexual patients 35 and risk of symptom mislabelling in minority groups, differences in healthcare seeking behaviour between men and women, and mental health risks and barriers for LGBTQ+ populations. 36 Correlation exists between a diagnosis of personality disorder and low socioeconomic status, urbanicity, lower educational attainment, occupational difficulties, and marital discord. 34 Sparse evidence is available on ethnic variations. 37 Clinicians may find it helpful to expand their understanding of the impact of racial trauma 38 and barriers to accessing healthcare for people in black, Asian, and ethnic minority populations.

Prevalence in older populations is about 10%. 39 An underlying and undiagnosed personality disorder may become evident for the first time in older age if disruptions occur in a previously stable life (eg, new onset illness, loss of partner), which lead to decompensation. Differential diagnoses when making a new diagnosis of personality disorder in older people are important (eg, late onset or relapse of other mental or physical illness, including dementia, malignancy, or substance misuse). Evidence suggests a decline in diagnosis of borderline personality disorder with progression of age, indicating a natural improving course in this group. 40 41

How are personality disorders classified?

In ICD-11, 42 released by the World Health Organization in 2018, the clinician is invited to: a) identify the presence of a core problem in functioning of self and interpersonal relating; b) its level of severity (mild, moderate, severe); and c) its main traits : negative affectivity, detachment, dissociality, disinhibition, anankastia (ie, obsessive-compulsive traits), and whether a borderline pattern exists. This classification marked a radical shift away from the categorical classification adopted in ICD-10, DSM-IV, and DSM-5 ( table 2 ), 43 and it allows primary care clinicians to adopt a more pragmatic approach to recognising personality disorder: to look for a core problem, its functional impact and severity, and how this might present in the patient’s relationships and during clinical appointments. 44

Classification systems

DSM-5, which otherwise preserves the categorical approach of DSM-IV, attempts a “hybrid” approach between the categorical and dimensional models, by including an “alternative model” ( table 2 ).

For non-specialist clinicians, awareness of categorical dimensions might be useful, but finer differentiation may be left to the specialist.

How to approach suspected personality disorder

Establishing a specific working framework for the assessment and management of personality disorder can help to prevent exclusion, provide a safe and containing environment, and instil hope. General principles include an open, empathic, and non-judgmental attitude, attentive listening, active and genuine interest, and validation of the patient’s experience. Use a trauma informed approach, which recognises the high prevalence and complex impact of traumatic experiences in personality disorders. 45 46

Box 1 lists some helpful indicators for suspecting personality disorder. Clinicians may be able to incorporate these in their clinical encounters and use them to communicate their patient’s stories and needs to colleagues, while recognising that this list is not exhaustive.

Indicators for personality disorder in non-specialist settings

Strong indicators.

Negative affectivity and affective dysregulation (rapid mood changes, low mood, anxiety, anger, detachment)

Impulse dysregulation (risk taking behaviours, sexual promiscuity, alcohol and substance misuse)

Interpersonal problems: a) In “outside” life (eg, turbulent relationships, violence, dependence, avoidance, isolation); b) In the clinical encounter (eg, increased use of resources, recurrent crises, feeling stuck). In particular, turbulence and volatile relationships tend to be characteristic of borderline personality disorder difficulties

Strong emotional reactions in the clinician during the clinical encounter. Unusual departures from established clinical practice (eg, prescribing out of the ordinary, allocation of clinical time, working outside expertise)

Poor responses to evidence based treatments for other mental health conditions (anxiety, depression, post-traumatic stress disorder)

Additional indicators to look for

Cognitive-perceptual symptoms (rigid or bizarre ideas, antagonism, lack of trust, unusual dissociative or quasi-psychotic symptoms)

Evidence of self-injurious behaviours (scars, marks on skin), significant history of deliberate self-harm and suicidal behaviours

Medically unexplained symptoms 47 48

Parents of children presenting with evidence of deficits in the home environment (eg, neglect, abuse, social adversity, or trauma)

Early adversity and history of trauma (but do not adopt a mechanistic approach, assuming or excluding a diagnosis based on the presence or absence of adversity and trauma)

Childhood diagnosis of emotional disorder, disrupted behaviours, or conduct disorder

Longer initial appointments may be necessary and, where possible, having consistency rather than multiple involved clinicians. Allow time to build trust, tolerate any initial confusion, be open about the service limitations, and adopt an understanding and curious attitude if the person’s requests and demands seem excessive. Strong emotional reactions to patients (positive or negative), observation of unexpected dynamics at play in the doctor-patient interaction or within the team, or deviations from well established practices, may alert the clinician to unconscious repetitions of “patterns” of relating that may complicate the clinical encounter. 49 50

Anxiety, depression, sequelae of a recent trauma or life crisis, or requests relating to an existing diagnosis may in fact be indicators of a personality disorder. Aim to look beyond the apparent presenting symptom and try to understand the individual’s circumstances and their point of view. Simply put, it is essential to get to know a patient and their story. When you formulate their difficulties, try to cover the areas of: 1) sense of self; 2) interpersonal relating; 3) educational and vocational attainment; 4) risk assessment (self-harm and suicide, aggression and violence, risks to dependants and children, risk from others including domestic abuse); 5) hopes and expectations of clinical care. Involve families or carers when appropriate and, with the patient’s consent, seek information from other involved agencies.

Screening tools in primary care are of limited use, but the standardised assessment of personality scale is concise and may help in identifying a personality disorder. 51 Standardised tools can otherwise be used as indicated for mental health screening purposes. 52 Urine drug testing, neuro-imaging, and blood testing may be appropriate in specific cases to exclude other pathologies (eg, in addiction, older adults, and the perinatal period).

Management in primary care

Caring for people with personality disorders in primary care requires a person centred approach that promotes open dialogue and reduces stigma. The goal is not to provide a cure, or “fix” some underlying fault, but to engage in a curious and compassionate way with the person experiencing distress in their attempt to understand and manage their painful experience, even when their wishes and expectations may initially seem unclear or confusing ( box 2 ).

Patient and clinician perspectives on managing personality disorder in primary care

We asked two people to share their experiences of personality disorder. One is a practising GP in the NHS, the other a patient with experience of primary care services during their journey with personality disorder.

It takes a lot to recognise the need for additional support, and once this decision has been made, it can be the start of a very long and emotionally exhausting journey. For most, this starts with a visit to the GP, with the expectation of understanding and perhaps even some answers—medical or other. Someone who can listen without judgment, take the time to get to know us, and show compassion are just a few qualities that can save further distress or misunderstandings on either side. We may not know what we need, or how even to communicate (or comprehend) our thoughts and feelings in a 10 minute appointment. Prior experiences of rejection, abandonment, or attachment difficulties can make it really hard to put our trust in others, including healthcare professionals. Added to this, hidden past or current traumas hinder openness; building a trusting relationship is therefore key to progressing our journey.

We learn to view the world as an unsafe place, where we will not be believed, and that we are not worthy of care. Looking and sounding “OK,” we can come across as malingering—not a term I would choose, but one that fits my interpretation of the invalidating response received at times. All of these are experiences from my own journey over the past 25 years. On reflection, I did expect answers but didn’t really know the question. Part of this journey was through a maze of diagnoses and unhelpful treatments, both medical and psychological. Being referred to services that declined me due to my stigmatising diagnosis, falling between private sector care and the NHS, and repeated assessments or referrals became exhausting and frustrating. The one constant in this journey was my GP practice, perhaps the only place that cannot turn me away and hopefully does not judge based on a mental health label (which I might not even agree with). While I can now see that the remit of a GP is very broad, having someone in the practice that has the skills, time, and compassion to listen and support us in thinking what may be helpful can be invaluable and even life changing.

The question of how we, as a primary care team, can work with people experiencing relational and personality difficulties becomes an almost daily one. In a wider context, primary care unfortunately is becoming increasingly transactional and reactionary, a box ticking exercise, where the complexity of human interaction, continuity as a therapeutic ingredient, and empathy are being replaced by a conveyor belt-like service with e-consultations or orders, and expectations of next day-type delivery by exhausted and burnt out workers. Our commissioners are increasingly relying on numerical indicators to monitor the quantity and quality of our work.

One of the biggest difficulties my team and I face when interacting with a patient with personality disorder is the sense of isolation. Every interaction, especially with someone in need, can be challenging, more so if one has difficulties relating to a person. Lack of trust, breakdown of communication, complexity of presentation, suicidal risk, threatening or dismissive attitude, inconsistencies, lack of a descriptive or explanatory framework can all become barriers to effective clinical practice because they act as magnifying lenses to the difficulties all of us—clinical and non-clinical staff—may experience, and because of the complexity of human nature. This is when I feel most inadequate, full of stress, defensive, persecuted, confused, and hopeless, and this is an experience I share with my team members. But with a reflective space and effective communication between my team and colleagues and the wider mental health and care ecosystem, we can achieve miracles.

Structured management starts with working collaboratively with the person to produce a formulation and understanding of the nature of their difficulties. Consistency, clear communication, and clear boundaries are key. A “contract” between the patient and clinician that will guide their work together from the outset may be helpful 49 to provide clarity about the role and limitations of primary care, establishing clinician and patient responsibilities and modelling realistic expectations. 53

Box 3 outlines management principles, strategies, and techniques that can be used by generalist clinicians and teams.

Management principles, strategies, and techniques

General principles: open, empathic, and non-judgmental attitude; attentive listening; active and genuine interest; validation of the patient’s experience; positive regard that promotes hope; readiness to acknowledge own limitations and mistakes

Acknowledge the patient’s feelings and be aware of your own emotional responses

Be mindful of trauma and its impact on the patient’s life and help-seeking behaviours, and actively aim to avoid re-traumatisation

Be clear and transparent about procedures

Use person centred, co-produced, and mutually agreed treatment plans or “contracts”: negotiated agreements on how the patient and clinician will work with one another to frame the relationship, set goals, establish clear roles and expectations, and manage deviations from what has been agreed

Consider and discuss the use of emotion regulation, distress tolerance, and grounding techniques (muscle relaxation, breathing skills, self-soothing using one’s senses, silence, mindfulness and meditation, yoga postures, exercise)

• Use techniques aimed at improving mentalising during consultations (mentalising refers to the process by which we make sense of ourselves and others, in terms of subjective states and processes (thoughts, feelings, intentions) and impaired mentalising is a core feature of borderline personality disorder 53 )

Share an interview structure plan with the patient, slowing down a chaotic interview and “rewinding” to previously unresolved discussions

Identify and name the underlying emotion: this can help reduce the patient’s levels of anxiety and emotional arousal (anger, elation, sadness/despair, fear) during a consultation

Validate and reflect on the patient experience

Describe your own reflections on the discussion

Invite the patient to reflect from the third position: “What would you tell a friend in this situation?”

Use medications thoughtfully when necessary, and strive to rationalise unnecessary prescribing and polypharmacy; avoid prescribing or changing medications during crises

Encourage lifestyle changes and discuss sleep routines before considering the use of sleeping tablets

Be mindful of mental health comorbidities and treat accordingly, or seek specialist input when required (eg, mood and anxiety disorders, post-traumatic stress disorder, eating disorders, autism spectrum disorder, 54 attention deficit/hyperactivity disorder, intellectual disability 55 56 )

Address problematic alcohol and substances use

Be mindful of increased physical health morbidity, and consider physical health needs

Discuss social needs and encourage structured meaningful activity and social connectedness. Involvement of a primary care mental health practitioner, a social prescriber and peer coach, social care, and third sector organisations may be helpful when indicated

A shared sense of purpose and a culture of cooperation

Team cohesion and mutual support

Formalised regular supervision and reflective practice

Readiness to engage with difficult clinical situations and consider judgment or bias when identified in either colleagues or patients

A culture of reflection and adherence to agreed plans and strategies

Safety management

Establish clear pathways for safety and crisis management

Differentiate and identify an acute escalation in chronic risk and avoid complacency

Have shared safety management plans that are comprehensive and accessible

Encourage strategies to minimise harm in patients who self-harm

Adapting services to meet patients’ needs

Consider what adjustments in service delivery and staff training might improve patient care ( box 4 ). For some patients a long term and trusting relationship with a reliable GP who is genuinely interested may become key in their path to living a more fulfilling life. Chronic difficulties in clinical relationships can develop, however; unhelpful or entangled situations may arise, and this is not rare. Specialist advice or consultation 57 58 may help to resolve this, and reflection can lead to valuable learning from experience for the clinician. Avoid working in isolation, and consider ways to promote reflective spaces and staff wellbeing, to prevent burnout. 59

What can I put in place in my service?

Need specific services and adjustments.

Provide structure and consistency (allocate a named clinician)

Offer scheduled, regular appointments—do not adopt a reactive, crisis management practice

Consider longer appointments (20-30 minutes)

Consider planned telephone contacts with a named doctor

Have reliable and transparent crisis management plans and pathways

Offer bespoke training for first line clinical and reception staff

Put in place regular reflective practice groups across disciplines

Organise peer support, supervision, and clinical practice based meetings with mental health team specialists and/or a local psychiatrist

Establish reliable pathways of communication with local mental health specialists

Offer a tailored-to-need service to resolve complaints and conflict

Integrate a trauma informed approach into policies, procedures, and practices

Shared care, or blended primary and secondary team working, requires reliable communication pathways between all involved agencies. With permission from the patient, make transparent to involved services any treatment “contract” that has been agreed. Openly acknowledge, discuss, and reflect on any deviations from mutual agreements.

Managing safety

Non-suicidal self-injury (self-harm) is common in people with borderline personality disorder (65-80% of cases). 60 The risk of suicide is many times greater than in the general population, 33 with estimates suggesting that up to 10% of people with borderline personality disorder will die by suicide. 61 Plans for safety and crisis management are clinically indicated and actively researched. 62 People who have a personality disorder and are in crisis should access specific local protocols and pathways tailored to their needs. Document up-to-date assessments of the level of risk to self and others, and any safeguarding issues concerning the patient or dependants. Specialist or emergency psychiatry is appropriate for serious and escalating risk patterns.


Many people with a personality disorder take several drugs, despite an absence of evidence to support the use of any specific medication for the conditions. 63 64 Guidelines from the National Institute for Health and Care Excellence recommend treatment of comorbidities where present as indicated. 65 Recent research highlights the complex interpersonal dynamics that may influence prescribing, especially in patients with personality disorder. 66 67 Reactive prescribing without clear direction, especially during crises, may become a problem. When prescribing, either for physical or mental health, discuss in advance (and in a clear manner) goals, duration of treatment, target symptoms, and potential side effects. Seek informed consent, psychoeducation, and reflection on expectations. 68 69 Consider psychological aspects of resistance to treatment, poor adherence, and medication misuse, and be curious about the meaning of taking and prescribing medication. 70 71 72 If you prescribe without a clear clinical rationale, consider whether this is driven by your emotional reactions in your encounter with the patient. It may be practical to treat symptoms such as insomnia with short courses of medications. We advise specialist input if considering antipsychotic or mood stabilising medications.

When to refer and what to expect

Availability of specialist treatment may vary by region. Involvement of community psychiatry and/or specialist services for personality disorder is indicated for: a) diagnostic clarification; b) assessment of readiness for and choice of specialist treatment; c) case consultation regarding management difficulty and increased risk. Referral to non-specialist talking therapies services—in England through Improving Access to Psychological Therapies (IAPT)—may be appropriate for personality disorder of mild severity and when a full diagnosis is not met. These services may also be appropriate for cases in which focused psychological treatment of a comorbid mental health condition is indicated, if relevant training and resources are available in local provision, but IAPT services may not meet the patients’ needs otherwise. 73

The presence of a diagnosis does not in itself indicate psychological readiness for a specialist treatment programme. The specialist assessment can be demanding, and treatment is not always available or appropriate. In the UK, available specialist programmes are lengthy and require commitment, so that timing and competing priorities need to be considered in advance. Unstable living conditions, uncontrolled alcohol or substance misuse, severe eating disorder, serious risk of harm to self or others, and vulnerability to harm from others may need to be tackled first, with relevant specialist input if necessary (eg, addiction or eating disorder services, adult social services). Canvass patient views, preferences, and goals, based on any previous experience of psychological therapies, at an early stage. 74

Several evidence based treatments, mainly for borderline personality disorder, are available in secondary and tertiary care in the NHS ( table 1 ). No single modality stands out in terms of efficacy, 75 and sometimes multiple treatment attempts may be needed. Brief treatments (such as cognitive behavioural therapy) might not be helpful, and the choice and sequencing of treatments requires specialist involvement. 76

Contact other agencies (eg, probation services, social services, social support agencies for housing, occupation, and activities), as necessary, for support.

Education into practice

What training opportunities could be made available to staff to support their interactions with people who have a personality disorder?

Can you identify one specific barrier that people with a personality disorder may face when trying to access your service?

Useful resources (mainly UK based)

For clinicians.

National Institute for Health and Care Excellence. Personality disorders: borderline and antisocial: https://www.nice.org.uk/guidance/qs88 Updated June 2015.

World Health Organization, ICD-10 Classifications of mental and behavioural disorder: Clinical descriptions and diagnostic guidelines, World Health Organization, 1992: https://icd.who.int/browse10/2016/en

·World Health Organization, ICD-11 Classifications of mental and behavioural disorder: Clinical descriptions and diagnostic guidelines, World Health Organization, 2018: https://icd.who.int/browse11/l-m/en

Balint Society: https://balint.co.uk . Balint group membership provides a space to think about those encounters which leave professionals drained, puzzled, or stuck

Standardised Assessment of Personality—Abbreviated Scale (SAPAS): https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/standardised-assessment-of-personality-abbreviated-scale-sapas-preliminary-validation-of-a-brief-screen-for-personality-disorder/26FB730F35F54B952381AA9C662FF8C2

The Knowledge and Understanding Framework (KUF) national training programme: https://www.westlondon.nhs.uk/our-services/adult/mental-health-services/cassel-hospital/consultation-and-training-services and The National KUF Hub https://twitter.com/nationalkufhub

“Six levels of validation” interpersonal effectiveness skills resource: https://dbtselfhelp.com/dbt-skills-list/interpersonal-effectiveness/validation/

Safer care for patients with personality disorder. National confidential inquiry into suicide and homicide by people with mental illness, University of Manchester. 2018: https://documents.manchester.ac.uk/display.aspx?DocID=37564 Related educational videos “Safer care for patients given a diagnosis of personality disorder: a learning resource”: https://sites.manchester.ac.uk/ncish/resources/safer-care-for-patients-given-a-diagnosis-of-personality-disorder-a-learning-resource/

NHS England and NHS Improvement and the National Collaborating Centre for Mental Health, The Community Mental Health Framework for Adults and Older Adults, September 2019: https://www.england.nhs.uk/wp-content/uploads/2019/09/community-mental-health-framework-for-adults-and-older-adults.pdf

Office for Health Improvement & Disparities Guidance: Working definition of trauma-informed practice and resources: https://www.gov.uk/government/publications/working-definition-of-trauma-informed-practice/working-definition-of-trauma-informed-practice

For patients, families, and carers

For immediate help.

NHS 111 (option 2) can help if you have an urgent medical problem and you’re not sure what to do. Visit https://111.nhs.uk (for people aged 5 and over only) or call 111 (available 24 hours a day, 7 days a week)

With life threatening emergencies, call 999 or go to the nearest emergency department

The Samaritans are there to listen 24 hours a day. Call on 08457 90 90 90 or visit the website at https://www.samaritans.org .

SANEline is a national out-of-hours mental health helpline offering specialist emotional support, guidance, and information to anyone affected by mental illness, including family, friends, and carers. Available every day from 4.30 pm to 10.30 pm on 0300 304 7000: https://www.sane.org.uk/what_we_do/support/helpline

Most areas have a mental health crisis team available 24 hours a day; their contact details should be available via the local council or social services, or they can be contacted via hospital emergency departments.

Text SHOUT: a 24/7 UK based volunteer led text service for anyone in crisis. Developed by the Mental Health Innovations charity: https://www.giveusashout.org/

Other resources

MIND. Personality Disorders leaflet: https://www.mind.org.uk/information-support/types-of-mental-health-problems/personality-disorders/about-personality-disorders/

The National Education Alliance for Borderline Personality Disorder: https://www.borderlinepersonalitydisorder.com/consumer-recovery-resources/ A resource for families and people in recovery, education and training for professionals. (USA)

·The National Service user Network (NSUN) weekly bulletin offers a summary of involvement opportunities as well as policy updates: https://www.nsun.org.uk/

Mindfulness meditation—online resources that some may find helpful: https://www.freemindfulness.org/

Cognitive behavioural therapy based self-help resources and worksheets: https://www.getselfhelp.co.uk/

Dialectical behaviour therapy based self-help resources and worksheets: https://dbtselfhelp.com/

National self-harm network: https://www.nshn.co.uk/

Lifesigns: a user-led organisation working around self-injury: https://www.lifesigns.org.uk/

Rachel Reiland, Get Me Out Of Here: My recovery from borderline personality disorder, Hazelden Publishing, 2002.

Self-injury support: https://www.selfinjurysupport.org.uk/

Multimedia resources

Borderliner Notes: The BORDERLINE film interview Archive: https://www.youtube.com/borderlinernotes

Early Years Parenting Unit at the Anna Freud National Centre for Children and Families, Video Series: EYPU—What is “personality disorder”? https://www.youtube.com/watch?v=38EBpzJDodg What is meant by “good mentalisation”? https://www.youtube.com/watch?v=R5kFPpAMDF0

BBC, Radio I & IXtra Stories. Living with BPD: https://www.bbc.co.uk/programmes/p0700vh4/

BBC Radio 4. Narcissism: https://www.bbc.co.uk/programmes/p06y2j6v

Personality Disorder—subtitles. A film produced by the RCPsych Public Engagement Committee and Damn Fine Media: https://www.youtube.com/watch?v=OnwVTrZcn5s/

Adverse Childhood Experiences (ACEs), Public Health Network Cymru. A short film produced for Public Health Wales and Blackburn with Darwen Local Authority: https://www.youtube.com/watch?v=YiMjTzCnbNQ

RethinkBPD: In conversation: Talks on borderline personality disorder and recovery: https://rethinkbpd.org/

Ending exclusion: research and care for people with complex emotional needs #MHQT: A recording of panel discussion around NIHR mental health policy research unit activities: https://youtu.be/aQoQh66D6N4

Public Health Wales, Adverse Childhood Experience (ACE) and Adult Mental Well-Being Wales infograph. 2016: http://www.wales.nhs.uk/sitesplus/documents/888/embargoed%20final%20-%20ace%20%26%20mental%20well-being%20infograph%20e.pdf

Selected readings

Gask L, Evans M, Kessler D. Personality disorder. BMJ 2013;347:f5276

Schrift M, Personality disorders. BMJ Best Practice. 2019

RCPsych Position statement, services for people diagnosable with personality disorders. 2020

NIMHE Personality disorder: no longer a diagnosis of exclusion—policy implementation guidance for the development of services for people with personality disorder. 2003

NIMHE Breaking the cycle of rejection. The Personality Disorders Capabilities Framework. 2003

Bolton W, Lovell K, Morgan L, Wood H, Meeting the challenge, making a difference. Working effectively to support people with personality disorder in the Community. Project report, Department of Health, London. 2014. http://repository.tavistockandportman.ac.uk/864/1/Heather_Wood_-_MeetingTheChallenge.pdf

Mind, Centre for Mental Health, Royal College of Nursing, The British Association of Social Workers, Royal College of General Practitioners, The British Psychological Society, Anna Freud National Centre for Children and Families, Barnet, Enfield, and Haringey Mental Health NHS Trust. Shining lights in dark corners of people’s lives, The consensus statement for people with complex mental health difficulties who are diagnosed with a personality disorder. 2018: https://www.mind.org.uk/media/21163353/consensus-statement-final.pdf

How patients were involved in the creation of this article

JP, a co-author on this paper, has lived experience of personality disorder. Her insights were essential in giving it its final form. An anonymised patient perspective statement has also been included with consent from the author.

Contributors: OKB is the lead author and guarantor of the content of the paper. OKB designed the initial outline and OKB, DC, JP, SS and TL all contributed equally thereafter to writing the final version.

Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: none.

Further details of The BMJ policy on financial interests are here: https://www.bmj.com/about-bmj/resources-authors/forms-policies-and-checklists/declaration-competing-interests

Provenance and peer review : commissioned; externally peer reviewed.

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research paper topics on personality disorders

  • Research article
  • Open access
  • Published: 07 September 2020

Living with personality disorder and seeking mental health treatment: patients and family members reflect on their experiences

  • Karlen R. Barr 1 ,
  • Mahlie Jewell 2 ,
  • Michelle L. Townsend 1 &
  • Brin F. S. Grenyer 1  

Borderline Personality Disorder and Emotion Dysregulation volume  7 , Article number:  21 ( 2020 ) Cite this article

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Despite effective treatments for personality disorders being developed, consumers and carers often report negative experiences of mental health services, including challenges accessing these treatments.

This qualitative study used separate focus groups to compare the unique perspectives of consumer and carers, and to investigate how to improve services for individuals with personality disorders. Reflexive thematic analysis was used to analyze the data.

Both consumers and carers ( N  = 15) discussed the value of providing appropriate information to consumers when they are diagnosed with personality disorder. Consumers and carers described the importance of creating a safe environment for consumers when they present to the emergency department. Both groups discussed experiencing positive and negative treatment from mental health professionals, and suggested that professionals should be trained to understand personality disorder. Limited accessibility and quality of services, and offering peer support to consumers were also described by consumers and carers. Consumers and carers also had perspectives which were unique to their group. Consumers identified the importance of psychological treatment, having a strong therapeutic relationship with a mental health professional, and the benefit of long term psychotherapy with the same professional. Broadening the scope of psychotherapies including creative, animal-assisted, and physical therapies was recommended by consumers. Carers described the importance of assessing for personality disorder and intervening early. Involvement in the assessment, diagnosis, and intervention process was important to carers. The desire to be recognized and supported by mental health professionals was discussed by carers.


This research contributes to the concern that consumers with personality disorder and their carers experience stigma and low quality care within mental health services. In line with these findings, we recommend guidelines for health professionals who work with consumers with personality disorder.

Personality disorders are severe mental disorders characterized by disturbances in affect, identity, and relationships [ 1 ]. Approximately 7.8% of the population has a personality disorder [ 2 ], and people with personality disorders represent about 20% of emergency department and 25% of inpatient mental health admissions [ 3 ]. In mental health and primary care settings, borderline personality disorder (BPD) is the most common personality disorder [ 4 ]. Effective treatments for personality disorder exist, including dialectical behavior therapy (DBT) and psychodynamic therapies [ 5 ]. However, consumers with personality disorder often are not offered or are unable to access evidence-based therapies and thus have negative experiences when receiving mental health services [ 6 ]. In addition, carers supporting consumers with personality disorder often experience high levels of stress, grief, and mental health problems [ 7 , 8 ], and they can experience difficulties accessing appropriate services for themselves and the consumers they support [ 9 ]. Considering the perspectives of consumers and carers is recommended to improve mental health services [ 10 ], and is supported by government [ 11 , 12 ] and mental health professionals [ 13 , 14 ].

Experiences of mental health services have been studied from the perspectives of consumers with various mental illnesses and their carers. Consumers describe the importance of mental health professionals discussing diagnoses with consumers and carers, and providing hope and information regarding diagnosis [ 15 ]. Regarding treatment planning, consumers want to be involved in their treatment decisions [ 16 ], although they are often excluded from participating in decision making [ 17 ]. Further, consumers describe not being prepared for hospital discharge, not being involved in the decision to discharge, and not receiving adequate support following discharge [ 18 ]. Carers supporting consumers with a range of mental health problems express that they have little involvement in mental health services and little access to information on mental health services [ 16 ]. Many carers believe they should have access to information about consumers, and report that confidentiality prevents them from receiving information about the consumer they support. Carers describe wanting respectful treatment for themselves and consumers, and better communication from mental health professionals, including education about specific disorders [ 19 ]. Other barriers described by carers include poor communication between services, limited service accessibility, and receiving little information about consumer treatment plans [ 20 ]. Carers also experience inconsistent assistance from mental health professionals in response to consumer mental health crises [ 21 , 22 ].

Multiple studies have investigated the experiences of consumers with personality disorder regarding mental health services. Consumers with personality disorder often do not receive an explanation of their diagnosis [ 23 ], or experience stigmatizing language and insufficient evidence-based information about their diagnosis [ 6 ]. Consumers have also described negative responses from health professionals in the emergency department [ 24 ]. Other negative experiences include poor communication from professionals, and inappropriate treatment, such as not having concerns taken seriously [ 6 ]. Increasing psychological and emotional support is recommended by consumers with personality disorder [ 6 ], including being supported by health professionals who help them understand their feelings [ 23 ].

Perspectives of mental health services from carers supporting consumers with personality disorder have also been investigated. Carers often experience relationship difficulties with the consumers they support, and do not know where to find help [ 9 ]. The majority of carers want support for themselves but find carer support services are unavailable or difficult to access [ 9 , 25 ]. Carers can also experience difficulty supporting consumers to find mental health professionals and consistent services to provide support to consumers with personality disorder [ 9 ]. In addition, many carers describe not receiving an explanation of the consumer’s diagnosis and not being appropriately involved in treatment decisions [ 25 ]. Carers identified wanting more information about personality disorder and how to respond to crises, and express that they are often expected to make treatment decisions without having sufficient knowledge [ 26 ].

A systematic review of 38 studies examined the perspectives of consumers and carers regarding mental health services for individuals with BPD [ 27 ]. Across the studies, consumers described receiving limited information about the assessment process and BPD diagnosis, negative responses from mental health professionals in the emergency department or inpatient setting, limited information options for therapeutic interventions, and poor communication regarding the availability of services. Studies exploring the carer perspective found that carers wanted their supporting role and their difficulties to be recognized by mental health professionals, be provided more information regarding BPD diagnosis and treatment options, and information about how to effectively respond to the consumer they support. While consumers and carers shared some consistent views, differences in opinion were observed, such as carers focusing on the lack of support they received from professionals. Comparing the consumer and carer experiences was limited because only five studies were found regarding the carer perspective, and only one study included the perspectives of consumers and carers. Therefore, more information is required regarding similarities and differences of consumer and carer views. In addition, few of the included research studies were co-produced with consumers or carers, even though this is known to lead to questions and findings closer to what people with lived experience require [ 28 ].

Problems continue to be present in personality disorder services and programs and require input from consumers and carers regarding possible improvements. It is important to increase knowledge regarding the views of consumers and carers who support someone with personality disorder, to compare views of consumers and carers regarding services for individuals with personality disorder, and to co-produce research on consumer and carer perspectives. The purpose of this study was to bring together all these needs and gaps in the literature: to explore and compare the perspectives of consumers and carers regarding personality disorder services using a co-design approach aimed to inform the development of better services.


Participants were recruited using a flyer advertisement that was sent to consumer and carer support and advocacy groups, and services which support individuals with personality disorder. Participants were invited to participate if they were either a consumer with a lived experience of personality disorder or a carer or family member supporting someone with a personality disorder. The views of 15 individuals were obtained, a sample large enough for data saturation within a qualitative approach. Table  1 outlines the demographic characteristics of the participants.

Participants provided informed written consent prior to study participation, following study approval from the Institutional Review Board. Two focus group discussions occurred simultaneously; one with consumers and one with carers, as requested by the participants. Both focus groups were co-facilitated by 2 researchers with experience in personality disorders and group facilitation. The consumer focus group was co-facilitated by the consumer researcher. In addition, 1 mental health professional was present in each group to provide assistance to participants if they became distressed. Focus group questions were based on a guide that was co-designed by the authors. Some questions required participants to provide written answers or creative responses. Questions differed slightly for consumer and carer participants. Open-ended questions were followed with relevant follow-up questions as required. Questions explored the quality of care experienced at different services, including mental health services and emergency services, and how the practice of health professionals could improve. Questions included, “What have you found most helpful about the services you have been involved in?”, “Is there anything you wish clinicians and service leaders better understood about individuals living with personality disorder?” and “How can health professionals best support families and carers of individuals who have been recently diagnosed with personality disorder?” The discussions were audio recorded and transcribed. Focus group discussions occurred over a 90-min period. A $50 voucher was provided to participants as compensation for their time.

Data analysis

The data were analyzed using reflexive thematic analysis, which conceptualizes themes as patterns based in meaning [ 29 ]. First, the transcripts were read and re-read and brief notes were made to obtain familiarization with the data. Next, participant statements were coded into nodes through the software NVivo 11. Nodes were created using an inductive orientation to gather statements with similar meanings. Themes were constructed based on the nodes, and were revised as needed to reflect the lived experience of participants. One researcher independently coded the data, which was informed by regular discussions with the research team. The consumer researcher was part of the research team throughout all phases and provided active input into the themes developed. Inter-rater reliability was obtained by all team members arriving at a consensus for the coding. In addition, an independent researcher coded a portion of data to allow us another view on agreement - with Cohen’s kappa coefficient for inter-rater reliability being κ = 0.75, which indicates a relatively high level of agreement [ 30 ].

Consumer perspectives

In this section, the views that were gathered from the consumer focus group are presented.

Theme 1: challenges and successes finding a mental health professional who understands personality disorder

Consumers described how medical and psychiatric registrars often do not have the experience and knowledge base to provide treatment or information to people with personality disorders. Difficulties in finding a mental health professional who has training in and understands personality disorders were described by several participants. “In my long hard, long lived history as a consumer, with an illness, I have been referred and searched high and low for private psychologists who would have knowledge of this particular ill – normality, this illness, and you know, there’s very few out there who are familiar enough with it.” Consumers described various instances when mental health professionals used stigmatizing language, which had a major negative influence on their well-being. “[After multiple stigmatizing comments] I felt so completely let down and failed by the public system. Like my life didn’t matter, like I didn’t matter.”

Several consumers described positive experiences with mental health professionals who specialize in treating personality disorders. Consumers explained the importance of finding a mental health professional that they can connect with, who complements their specific needs. A trial and error process of finding a suitable mental health professional was described , “They’re not always going to be – the right one is not always going to be the first one you get. There’s a lot of trial and error.” Participants valued mental health professionals who were clear about how long they could work with them, admitted to making mistakes, kept them accountable to their goals, and persevered in contacting consumers. “I didn’t turn up three times and she kept calling me. And she kept saying to me, ‘If you won’t come see me, let me send you to someone else.’”

The importance of mental health professionals being specifically trained to work with people with personality disorders was discussed. “They (mental health professionals) should all be, you know, trained to work with people who have BPD. They should understand it.” Communicating with consumer advocates was recommended for mental health professionals to improve their understanding of personality disorders. Consumers discussed how they wanted mental health professionals to understand that people with personality disorders can recover.

Theme 2: the need to improve the assessment and diagnosis process

While some participants reported that they did not respond well to the diagnosis initially, others readily embraced the diagnosis. “I liked my diagnosis. I was, like, yes. I know what it is.” Consumers frequently described being given a diagnosis of personality disorder without any explanation or further information about symptoms, or how being provided with this information would help. One participant described receiving a diagnosis following a quick assessment, without receiving an explanation. “I spoke to her (the psychologist) for, maybe, 60 to 90 minutes, and then she diagnosed me with borderline personality disorder… no one gave me any, sort of, information or anything. I was just stuck with this diagnosis and I knew nothing about it.” Consumers described the potential helpfulness of receiving appropriate treatment options when a diagnosis is given, including referral to specialist clinicians. Factsheets that provide information about personality disorders, including symptoms and treatment options, were suggested to be given to consumers at diagnosis. “I’d like a fact sheet that you could – you know. An actual, just, you – you know, this is your diagnosis, these are the symptoms you have with it, here is the available treatment options, here is what happens through with these treatment options.” Consumers described the importance of health professionals assessing for co-occurring mental health or physical health issues.

Theme 3: the need to improve communication between mental health professionals to ensure continuity of care

Consumers described how improved communication between mental health professionals regarding diagnosis, treatment, and hospital discharge is needed . “Then they referred me to the dietician who never came, and that was it, and then they just discharged me.” Participants described disappointment when mental health professionals did not respond to recommendations made by a consumer’s private psychologist, particularly when consumers are experiencing a crisis. “In spite of my psychologist writing a detailed letter with all of my symptoms, the fact that she’s known me for so long, and that she’s sufficiently worried about my safety at this point in time, they were still willing to try and send me back home.” Professionals listening to the advice of a consumer’s psychologist can help consumers feel cared for and help them trust professionals and the mental health system. “She (my psychologist) tried to visit me a couple of times in locked wards and was not allowed in, um, and – and, um, would have been really helpful if she could have just spoken to them and said, ‘Hey, here’s what works for [the person I support],’ but they wouldn’t listen to her.” In addition, it was recommended that professionals share their resources with one another, such as fact sheets, so that consumers can receive the information they require.

The importance of continuity of care was discussed by many participants. “He (psychiatry registrar) says to me, ‘What are you here for?’ And I say, ‘Well, did you read the notes from my last appointment here?’ He said, ‘No. Tell me all about yourself.’” The capacity of a mental health professional to see a consumer for more than a few months may relieve a consumer from the difficulty of repeatedly sharing their past experiences. When a referral to another mental health professional occurs, it may be helpful to provide information on the consumer to assist continuity of care, if consent from consumers is provided. “There hadn’t been any change over from the previous therapist, so we had to start all over again and tell the story for the umpteenth time.” When referring a consumer to another service, professionals could provide some crisis skills training to help consumers while they are in between services. Following up with information that is communicated to consumers was also described as important. “I had a lot of problems with their continuity of service, in, ‘We’ll call you tomorrow,’ and then three days later you get a call back.”

Theme 4: increasing feelings of safety when consumers are experiencing a crisis

Consumers described how first responders often communicated effectively with them and helped them to feel safe and comfortable. “I feel more safe having police and ambos come to my house than I would have an acute care worker come to my house.” However, inappropriate verbal and physical interactions from first responders were also discussed. Consumers described how identifying with the LGBTIQA+ community can result in negative or poor treatment from some first responders.

Some consumers described how acute care units and emergency departments did not provide a safe environment. Consumers described receiving negative judgments from mental health professionals during crises, including being ignored, shamed, denied services or being told that they are “not trying hard enough.” Simple changes to service environments such as allowing curtains to be drawn or receiving positive communication from mental health professionals were described to increase comfort. “They allow you to have the curtains on, so you can calm yourself down.”

Limitations of inpatient wards and emergency departments were described, such as being locked up and alone. Therefore, alternative safe places were suggested for consumers to go to when experiencing distress, such as cafes, respite homes, or rehabilitation centres. “I can’t be alone because I’m not safe enough to be alone, but I don’t need the acute care centres. I just don’t even need to be talking to someone, but I just need to not be alone.”

Theme 5: providing expanded treatment options and increasing service accessibility

Consumers described various ways that treatments and services could be improved. Some consumers discussed the power of art therapy and creative therapies, animal-assisted therapy, nature therapy, and physical therapy. “I found a sexual assault nurse who actually got balloons and filled them with, um, like, paint, and just gave me, like, darts, basketball shooters, the room was just splattered everywhere. It was so colourful that it was a distraction… I find sometimes just having a psychologist isn’t good enough, you need that art therapy; you need the physical therapy.” Several consumers described how peer support could aid them, including providing support groups and safe places where people with lived experience can connect. Consumers also described the helpfulness of 24-h phone lines. One consumer described the usefulness of e-therapy. “He (my psychologist) was prepared to do some sessions remotely by video-conference. You know, so, we were just about to go into the UK at the time, and then it – I didn’t have to break my therapy.” One consumer discussed the benefit of support being provided to carers. “The support group that my mum has been going to… before she’d often just get upset or angry or - whereas now she just seems to be a lot better at knowing what to do without making it worse, kind of thing. So, it’s good.”

Consumers discussed the limited availability of mental health services for personality disorders. Some barriers to accessing mental health services included homelessness, location, and finances . “I wish clinicians understood how cost-prohibitive consistent treatment is for low-income patients.” Non-government organizations were acknowledged by some participants as providing better care compared to government organizations.

Carer perspectives

In this section, five themes from discussions in the carer focus group are presented.

Theme 1: the importance of carer involvement in early assessment and intervention

Carers described how they wanted to be involved during assessment, diagnosis and intervention. Receiving a diagnosis for the person they support was described as taking a lengthy amount of time. “ My biggest issue was getting the diagnosis. Yeah. That took 10 years. Yeah. And the hardest part was that how quick they seem to have – have wanted to keep sending her home.” Frustration was expressed by carers about how mental health professionals often mislabelled a consumer’s difficulties as anxiety, depression, or ‘normal’ behaviours, before later giving a diagnosis of personality disorder. Carers described working hard to find a mental health professional who would provide an assessment or diagnosis for the person they support, particularly during adolescence. “It took yeah, begging and pleading and we are not taking her home until we spoke to a psychiatrist, to tell them our side, and then we got a diagnosis.” After diagnosis, carers emphasized the importance of mental health professionals explaining a personality disorder diagnosis to consumers and carers. The importance of early diagnosis and assessment was highlighted by many carers, such as when a person first experiences a crisis. “ They hit their absolute lowest before there’s a click or a diagnosis into what’s going on, in comparison to trying to seek help for many years, when you can already see many traits .”

Carers discussed the importance of communicating their perspective of the person they support to inform decisions made by mental health professionals, such as diagnosis. Involving carers as soon as possible was recommended, such as during the consumer’s first crisis. Several participants suggested involving carers in treatment helps them to understand what the person they support is learning and experiencing. Confidentiality was described as a barrier to carers being involved in assessment and treatment. “There is no communication, because of this confidentiality. And I think that could be the worst enemy, basically, standing in the way of the family therapy.”

Theme 2: improving responses and follow-up when consumers present in crisis

Mixed feedback was received from carers in relation to the responses from police and ambulance responders. Some negative interactions were described, including physical force by police rather than a dialogue approach. “In one case, the police came and basically… he was thrown on to the floor, you know, with policemen with the guns. It was so traumatic, instead of first having a dialogue approach.” However, many carers described compassionate treatment from police and ambulance responders towards consumers and carers, which was sometimes experienced as comparably better than treatment provided by other mental health professionals during crises. “The first responders are much more caring for carers, family members and explaining what they’re doing, and in their compassionate treatment.”

Carers discussed how consumers can experience difficulties at the emergency department when there are physical health assessments and long wait times for mental health problems. Several carers discussed how separating mental health problems and physical health problems in the emergency department may result in better care. Providing a safe place within the emergency department “that people can go to in a crisis to calm down and self-soothe” was also recommended.

Carers described how consumers were often sent home from the emergency department without appropriate support. “We went to emergency and were sent home with nothing in our first instant… [the person I support] was just sent home to me, with no explanation of anything .” Following discharge from emergency departments or inpatient services, carers recommended that mental health professionals inform consumers and carers about the treatment that was provided and treatment options for the future. Carers proposed that communication between mental health professionals and carers about a consumer’s hospital discharge can help protect the safety of consumers and others. Several carers described not receiving information from mental health professionals unless it was requested by the carer. “Even when [the person I support] was sent home from hospital two times, she was never sent home with anything… Not unless you ask for it.”

Theme 3: increasing mental health professionals’ understanding of personality disorders and improving communication

Carers described the harms of mental health professionals using inappropriate and stigmatizing language when communicating with consumers and carers. The use of recovery-oriented, strengths-based language was desired by carers, such as expressing an understanding of the difficult experiences faced by carers and consumers. Mental health professionals who provided explanations about mental health problems which can be understood by consumers and carers were valued. “I think if they actually remember that this is the first time someone’s hearing it, they actually may be forthcoming with more information.”

Many carers discussed improving training and awareness of personality disorders for health professionals. “If the training is proper – with the GPs, with the doctors, psychiatrists, psychologists, nurses, we have the system right. It’s a matter of just the right education.” Carers described how mental health professionals need to be aware of support that is available and to explain treatment options. Carers also wanted guidance from mental health professionals on how they can best support consumers. “We (carers) need to know what we can do to help them. We want to understand how they feel and why they act/behave the way they do. Please help us to ensure they get the best care and the treatment they need to recover.”

Carers discussed the value of mental health professionals communicating with one another, including providing referral information. When mental health professionals liaise, it can provide a more holistic picture of a person’s difficulties, including physical and psychological symptoms. “[The person I support] has a lot of physical symptoms that I think are a result of her mental state. But I’m not sure. So, they sent her off for all these tests… but there’s no – no one’s like, pulling it all together. The GPs should be, but they don’t.”

Theme 4: improving accessibility and quality of services for consumers

Several carers described limited availability and quality of services within the mental health system, including the public and private healthcare system. “She’s had stays in private hospitals as well. And to be honest, not a lot better. I mean, it’s much nicer place. But I don’t know that the level of care is much better, really, considering how much you pay for it.” The small amount of psychological sessions provided by the public healthcare system was described by carers as insufficient. The proximity of services was also described negatively, including consumers having long commutes to receive treatment. Long wait times to receive treatment were also discussed. “She was on four waitlists in the city at private clinics. One down here in this region. Couldn’t get her in. Christmas Eve, they rang and said, ‘Oh, we’ve got a bed in the city.’ So October, November, December, she was on 24-hour watch. Because I couldn’t get her in anywhere.”

Carers also recommended personalizing therapy for specific consumers, including offering support in nature. Several carers described the helpfulness of DBT. “She (the person I support) ended up being put through a DBT group… that has by far been one of the best things for our entire family.” Carers described how offering employment assistance and peer support groups for consumers may be beneficial.

Theme 5: improving support for carers

Carers described feeling overwhelmed and stressed by caring for a person with personality disorder and suggested carer respite as a valuable form of support. One carer described feeling hopeless after multiple attempts to find a treatment that would work for the person they support. Financial and work difficulties due to time commitments supporting someone with personality disorder were also described. “The Government needs to know is the financial strain on families… with needing weekly psychologist, regular psychiatrist, not being able to get to work, because you get called home all the time.”

Carers discussed the importance of mental health professionals understanding the difficulties experienced by carers. Carers described receiving little support for themselves from mental health professionals. Mental health professionals asking a carer ‘how are you?’ was described as a positive first step. “I had one registered nurse, who was special… who actually asked me how I was. And that was probably year six of the journey. And until then, not a soul had ever asked me how I was.” Other options for providing support to carers were discussed, including a 24-h phone line, peer support groups, counselling for carers, and promoting self-care. Providing educational resources to carers was recommended, such as having brochures in hospital waiting rooms, offering educational groups, and providing links to online information. Several carers recommended increasing public awareness and understanding of personality disorders through education, which may help others in the general community understand the experiences of consumers and carers.

A comparison of the consumer and carer themes can be found in Table  2 . Both consumers and carers described disturbing stigma and prejudice, but also receiving some exemplar care from some professionals. Broadening support options for both consumers and carers was a priority.

This study explored and compared experiences of personality disorder services from the perspectives of consumers and carers. Consumers and carers described a number of negative and positive experiences with mental health services and provided recommendations on how services could improve.

Both consumers and carers discussed the importance of receiving appropriate information when a person is diagnosed with personality disorder, which is consistent with previous research [ 6 , 23 , 31 , 32 ]. Taking a collaborative stance in working with consumers during the assessment and diagnosis process was identified as a way to reduce stigmatization and empower consumers to engage in treatment [ 33 ]. Safety when in crisis was a major concern, both interpersonally (e.g. through promoting compassionate communication) and physically (e.g. avoiding rough handling by authorities, having safe rooms within emergency settings). Consumers also described creating safe places separate from the emergency department, such as voluntary residential or drop-in programs. Previous research indicates that residential programs may be a beneficial alternative to the emergency department for consumers with BPD [ 34 ]. Investigating the carer perspective of alternative safe places and respite options could also be important.

Both positive and negative experiences with mental health professionals and first responders were described by consumers and carers. The literature suggests that stigmatization and discrimination of personality disorder in mental health services continues to be prominent [ 35 ], although professional attitudes toward personality disorder have improved over time [ 36 ]. During crises, consumers and carers expressed receiving better treatment from first responders, compared to mental health professionals, which may mean that mental health professionals have more stigma of personality disorder compared to first responders [ 37 ]. Both groups suggested improving mental health professionals’ knowledge and understanding regarding personality disorders. Research has shown that training can improve mental health professionals’ understanding and attitudes [ 38 , 39 ]. Increasing the accessibility and awareness of training may be required. Providing training to first responders and increasing public awareness of personality disorder may also help reduce stigma and discrimination [ 35 ].

Consumers and carers described the potential benefit of offering peer support to consumers. Peer support can help consumers with various mental health problems by providing shared experiences which offer validation and hope [ 40 , 41 ]. Increasing the number of peer workers and peer support groups for consumers with personality disorder may be valuable. In addition, both carers and consumers described difficulty accessing personality disorder services. Increasing availability of services and making services more affordable may benefit consumers and carers.

From the consumer perspective, importance was given to the therapeutic relationship with mental health professionals, including finding a clinician they can connect with who specializes in personality disorder. This finding is unsurprising given that a strong therapeutic alliance can facilitate recovery [ 42 ]. Consumers described how mental health professionals, such as medical registrars, often did not have sufficient knowledge and experience to support them, and they requested people with experience who had specialized knowledge of personality disorders. Ensuring registrars who work with consumers with personality disorder have appropriate knowledge prior to in-person interactions and are supported by a specialist mental health professional may be helpful. Regarding referrals, health professionals should increase their awareness of personality disorder treatments available in their area, and offer consumers a range of possible mental health professionals that can support them.

Consumers also discussed the importance of continuity of care, including being able to work long term with a mental health professional. Therefore, it is important for mental health professionals to clarify how long they can work with consumers and to provide appropriate support when a consumer is transitioning from one professional to another. In addition, mental health professionals should communicate with one another to ensure they have all necessary information to support a consumer with personality disorder. Collaboration amongst mental health professionals involved in a consumer’s treatment is associated with improved consumer outcomes [ 43 ]. Further, consumers described the importance of private psychologists being able to communicate with other professionals involved in their care during a crisis. With a consumer’s consent, emergency department and inpatient services should collaborate with a consumer’s primary mental health professional, such as a private psychologist.

Expanded therapy options, such as art and animal-assisted therapy, were also recommended by consumers. Previous research has shown that art therapy can help increase well-being and decrease symptoms in consumers with a personality disorder [ 44 ]. Increasing accessibility and affordability of creative therapies and other approaches is recommended to improve referrals and options for consumers.

For carers, importance was placed on early assessment and intervention, which is supported by evidence and treatment guidelines [ 10 , 45 ]. However, consumers did not discuss early intervention, although they have previously described delays in receiving a diagnosis [ 42 ]. Carers also focussed on being involved in the assessment and treatment of the consumers they support, although consumers did not mention this. While carer involvement in assessment and intervention is important to carers and may help them support consumers [ 46 ], the perspective of consumers should be considered because not all consumers endorse family or friend involvement in their care [ 47 , 48 ]. In addition, carers focussed on improving support for carers, including having mental health professionals checking in on carers. However, consumers can have negative experiences of mental health professionals providing support to their carers [ 47 ]. Therefore, professionals may need to find a balance when providing support to consumers and carers. For example, a professional might provide carers with referral information to a psychological education or carer peer support group after consulting with the consumer and clearly explaining the reason for providing support to carers. Alternatively, carers may seek their own supports through mental health professionals and support groups. Table  3 provides a summary guideline of recommendations for health professionals arising from this research.

Limitations and future research

Although data saturation occurred in the analysis of qualitative interviews, the small sample size used in the study may be a limitation as other views may not have been represented [ 49 ]. We did not investigate further the treatment history, specific diagnoses of the consumers, amount of carer engagement with services, or cultural background of participants, meaning it was difficult to estimate to what extent our sample were representative of the broader consumer and carer population. Statements spontaneously reported by consumers and carers did reflect in detail findings from previous studies supporting that our sample was comparative to others in the literature. Further, the sample was predominately female, and the perspectives of male consumers and carers were limited, and it would be important to increase their participation in future research. Consumers and carers were not always asked the same questions, making it difficult to compare their experiences in some topic areas. The groups were ran as semi-structured focus groups and the facilitators followed a guide, but were all responsive to the participants in the focus group and what they wanted to focus on. For example, consumers were not asked about carer involvement in assessment and treatment. Despite the limitations, the findings provide important information to improve services for individuals living with personality disorder and their carers. Future research could explore safe environments for consumers experiencing crisis, and expanded treatment options for personality disorders, including art therapy and peer support. In addition, there is a need to broaden our understanding of the variety and nature of consumer views of having carers involved in their assessment and treatment.

The current study explored and compared mental health service experiences from the perspectives of consumers with personality disorder and carers. The findings add to the ongoing concern about the stigma, prejudice and poor provision of services for people with personality disorder, despite some examples of high quality work being delivered. In addition, the findings highlight similarities and differences in consumer and carer perspectives. Based on the findings, a number of guidelines are provided to inform the practice of health professionals who support consumers with personality disorder.

Availability of data and materials

Data from the current study will not be made available, as participants did not consent for their transcripts to be publicly released. Extracts of participant responses have been made available within the manuscript.


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Charlotte van Schie for inter-rater reliability, and consumers and carers who participated in this study.

NSW Mental Health Commission Lived Experience Framework Implementation Grant, and NSW Ministry of Health support to the Project Air Strategy for Personality Disorders. The funders had no role in the design, recruitment, collection, interpretation, or writing of the study.

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Borderline personality disorder: associations with psychiatric disorders, somatic illnesses, trauma, and adverse behaviors

  • Ashley E. Tate   ORCID: orcid.org/0000-0002-4523-6960 1 ,
  • Hanna Sahlin   ORCID: orcid.org/0000-0002-6353-024X 2 ,
  • Shengxin Liu 1 ,
  • Yi Lu   ORCID: orcid.org/0000-0001-9933-3654 1 ,
  • Sebastian Lundström 3 , 4 ,
  • Henrik Larsson 1 , 5 ,
  • Paul Lichtenstein   ORCID: orcid.org/0000-0003-3037-5287 1 &
  • Ralf Kuja-Halkola 1  

Molecular Psychiatry volume  27 ,  pages 2514–2521 ( 2022 ) Cite this article

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Psychiatric disorders

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In one of the largest, most comprehensive studies on borderline personality disorder (BPD) to date, this article places into context associations between this diagnosis and (1) 16 different psychiatric disorders, (2) eight somatic illnesses, and (3) six trauma and adverse behaviors, e.g., violent crime victimization and self-harm. Second, it examines the sex differences in individuals with BPD and their siblings. A total of 1,969,839 Swedish individuals were identified from national registers. Cumulative incidence with 95% confidence intervals (CI) was evaluated after 5 years of follow-up from BPD diagnosis and compared with a matched cohort. Associations were estimated as hazard ratios (HR) with 95% CIs from Cox regression. 12,175 individuals were diagnosed with BPD (85.3% female). Individuals diagnosed with BPD had higher cumulative incidences and HRs for nearly all analyzed indicators, especially psychiatric disorders. Anxiety disorders were most common (cumulative incidence 95% CI 33.13% [31.48–34.73]). Other notable findings from Cox regressions include psychotic disorders (HR 95% CI 24.48 [23.14–25.90]), epilepsy (3.38 [3.08–3.70]), violent crime victimization (7.65 [7.25–8.06]), and self-harm (17.72 [17.27–18.19]). HRs in males and females with BPD had overlapping CIs for nearly all indicators. This indicates that a BPD diagnosis is a marker of vulnerability for negative events and poor physical and mental health similarly for both males and females. Having a sibling with BPD was associated with an increased risk for psychiatric disorders, trauma, and adverse behaviors but not somatic disorders. Clinical implications include the need for increased support for patients with BPD navigating the health care system.

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Borderline Personality Disorder (BPD; Diagnostic and Statistical Manual of Mental Disorders [DSM] terminology), or Emotionally Unstable Personality Disorder (International Classification of Diseases [ICD] terminology), is a serious psychiatric disorder estimated to affect 1.7% of the worldwide population [ 1 ]. The core features of this diagnosis include: unstable interpersonal relationships, recurring self-harm, and emotional dysregulation [ 2 ].

Receiving a BPD diagnosis has been repeatedly associated with a high degree of psychiatric and somatic comorbidities, traumatic events, and criminal behavior [ 3 , 4 , 5 ]. These results have shaped the clinical perception and research directions of BPD, however specific estimates across psychiatric disorders, somatic illnesses, trauma, and adverse behavior have never been comprehensively presented in one study. Moreover, the majority of past studies were limited to smaller clinical samples or cross-sectional community samples, which did not allow for unselected samples nor longitudinal data. Additional longitudinal trait-based epidemiological studies have examined BPD symptoms in twins, however, few participants reached the full diagnostic criteria and thus may not be reflective of individuals with severe BPD symptoms [ 6 , 7 ]. Therefore, it is of interest to examine these estimates in a representative and well-powered population-based study in order to provide the context for a BPD diagnosis and reframe misconceptions.

Psychiatric comorbidities are the rule rather than the exception in patients with BPD. A Swedish national study reported that 95.7% of individuals with a BPD diagnosis had a comorbid psychiatric diagnosis [ 8 ]. Mood disorders, post-traumatic stress disorder (PTSD), impulsive disorders, and bipolar disorders are commonly associated with BPD symptoms and diagnosis [ 9 , 10 , 11 ]. Precise estimates for these comorbidities are lacking, especially for rare and serious disorders, e.g., psychotic disorders [ 12 ].

Somatic illnesses

Individuals with BPD use health care services at a higher rate than those with other personality disorders, and even elevated BPD symptoms are associated with receiving disability [ 13 , 14 ]. BPD has been linked to poor somatic health, such as obesity, diabetes, gastrointestinal disease, cardiovascular disease, hypertension, chronic pain, and sexually transmitted infections [ 3 , 15 ]. It is likely that somatic illnesses associated with BPD have been overlooked in smaller studies, for example, infertility [ 16 , 17 ]. Moreover, patients often perceive the severity of their illness worse than reports based on medical records, highlighting the importance of objective measurement [ 18 ].

Trauma and adverse behaviors

Up to 90% of patients with BPD are estimated to have a history of childhood trauma [ 1 ]. BPD has been linked to an increased risk for sexual abuse victimization in adulthood [ 19 ] and physical trauma resulting from accidents [ 3 ]. However, the association between BPD and other trauma types, e.g., death of a family member, is unclear. The relationship between trauma and BPD is theorized to be bidirectional, although the evidence for this is conflicting [ 20 ]. Similar to somatic reports, capturing objective measures of trauma would prevent biases that may arise from self-reports [ 21 ].

The association between violent crime and a BPD diagnosis is well documented, however less literature exists on nonviolent offenses [ 22 ]. It is unclear which nonviolent offenses are predominant in patients with BPD, although it is likely borne from impulsive actions. As recurrent self-harm is a core feature of BPD [ 2 ], we expect the rate of self-harm requiring medical attention to be higher than the general population. However, a precise estimate from a population sample is unknown.

Sex differences

BPD is predominately diagnosed in females, although evidence suggests that this is largely the result of a diagnostic bias [ 23 ]. Moreover, gender differences have been found for symptom expression and comorbidities [ 22 ]. Males have a higher prevalence of substance use disorders and antisocial personality disorder and exhibit symptoms related to aggression; while females show increased rates of risky behavior and an increased prevalence of comorbid mood disorders, eating disorders, and PTSD [ 22 , 24 ]. Males are typically underrepresented in BPD studies, thus potential differences in outcomes and precursors of BPD is of particular importance. Given a diagnostic bias, males would need greater symptom severity in order to be diagnosed, leading to a difference in symptom severity between the sexes. With this, we hypothesize elevated rates across most categories for males with BPD compared to their female counterparts.

Further, this raises etiological questions about the differences between the sexes. With our hypothesis that males with BPD will have more severe symptomatology, we postulate that individuals with a brother diagnosed with BPD will have higher rates of diagnoses and adverse outcomes across all domains compared to those with a sister with a BPD diagnosis, similar to the so-called female protective effect in autism, with the sexes reversed [ 25 ].

Present study

The primary aim of this study was to describe the extent of the association for individuals with BPD and (1) psychiatric disorders, (2) somatic illnesses, and (3) trauma and adverse behaviors in a Swedish nationwide sample. As sensitivity analyses, we examined the temporal order of these associations, sex-specific differences for individuals, and those with siblings diagnosed with BPD.

Materials and methods

Study population.

The study population included individuals born in Sweden between January 1st, 1973 and December 31st, 1993 with a personal identity number and a biological mother identifiable in the register (2,177,075). We excluded individuals with a congenital malformation (113,566), those who died before age 18 (6972), and/or emigrated before age 18 (62,664). Thus, 1,969,839 individuals were included in our study.

Data sources

Swedish personal identity numbers were used to link multiple Swedish registers in order to identify the cohort and create the analyzed variables, termed here as “indicators” (Table  1 ) [ 26 , 27 , 28 , 29 , 30 ]. The National Patient Register (NPR) contains administrative data from in-patient and specialist outpatient care (but not primary care) with diagnosis made by licensed medical doctors. The diagnoses have been externally validated by reviewing a random subset of patient’s medical records with comparison to the received diagnostic code. The positive predictive value of the psychiatric and somatic diagnoses in the register is high; out of the investigated medical records 80% or more retained the stated diagnostic code upon review [ 29 ]. Physical trauma requiring medical attention was found to have an acceptable positive predictive value of 74% [ 30 , 31 ].

BPD diagnosis was defined by receiving an Emotionally Unstable Personality Disorder diagnosis in the NPR (ICD 10th revision: F60.3) by psychiatrists in in- or outpatient psychiatric clinics. In one validation study, structured interviews had been used in 36% of examined personality disorders (including other personality disorders than BPD), as identified from medical charts. However, the positive predictive value, i.e., proportion of diagnoses validated upon review, for the 26 BPD-diagnoses investigated was high regardless if structured interviews had been used or not, between 77% (based on DSM-criteria) and 100% (based on ICD-criteria); inter-rater agreement was between 85% (ICD-criteria) and 100% (DSM-criteria) [ 32 ]. Another validation study based on 70 medical charts with a BPD-diagnosis, and reported a positive predictive value of 81%, with an inter-rater agreement of 93% [ 33 ].

The indicators in our study were selected based on an existing data linkage, which contains a subset of all ICD-codes (Supplementary Table  1 ). Indicators were placed into three groups: psychiatric disorders, somatic illnesses, and trauma and adverse behaviors (Supplementary Tables  2 – 4 ). As a sensitivity analysis, we analyzed the three most common subcategories for umbrella indicators with many subtypes, e.g., autoimmune disorders. Adverse behaviors included violent/nonviolent crime and self-harm. Trauma included accidents requiring medical attention, violent crime victimization requiring medical attention, death of a close family member, and childhood neighborhood quality.

We only considered time of the first observed event for all indicators, except for childhood poverty and neighborhood quality.

The study was approved by the Regional Ethics Committee in Stockholm, Sweden (Dnr 2013/862 31/5). As our study participants were non-identifiable, no informed consent was needed by Swedish law.

Statistical analysis

Cumulative incidence.

First, we estimated cumulative incidence for those with and without a BPD diagnosis in order to quantify the associations between BPD and the indicators on an absolute scale. Each patient with BPD was matched with ten individuals not diagnosed with BPD on birth year and sex. Follow up for individuals with BPD began at the date of the first observed BPD diagnosis and continued until the end of follow-up, December 31, 2013, this date was also used for their matched non-exposed individuals. We calculated 5-year cumulative incidence, interpreted as the probability of the event occurring within 5 years, while accounting for censoring. We used Kaplan-Meier estimation to estimate the cumulative incidence as 1 minus the survival function.

Associations between BPD diagnosis and the indicators

To quantify the association between BPD and our indicators, hazard ratios (HR) with 95% confidence intervals (CI) were obtained using sex-stratified Cox regression. Age was used as an underlying time score and we adjusted for birth cohort (1973–1977, 1978–1982, 1983–1987, and 1988–1993). BPD diagnosis was treated as a binary, time-constant, exposure regardless of when the diagnosis occurred. We followed each individual from birth or the start of ICD-9, January 1, 1987, until the first instance of either death, emigration, indicator occurrence, or end of follow-up. We did not account for competing risks, since standard methods introduce changes in the association dependent on whether the exposure is associated with the competing outcome [ 34 ].

We adjusted the analysis for multiple testing according to Benjamini–Hochberg method, with an alpha of 0.05, we obtained a false discovery rate p value threshold of 8.34 · 10 −58 for the main analysis and 0.04 for secondary analyses [ 35 ].

Secondary analyses

Sex-separated and sibling analysis.

To evaluate potential differences between males and females diagnosed with BPD, we repeated the cumulative incidence-, association-, and time-varying analyses by analyzing males and females separately. To investigate potential etiological differences, we repeated the association analyses among men and women separately, split by exposure being having a full sister or having a full brother with a BPD diagnosis.

Time-varying sensitivity analyses

By not considering timing of exposure in our main analysis, we assumed that individuals were exposed since birth although the BPD diagnosis occurred at a later age. This means that we were “borrowing information from the future”, an approach that may introduce bias. Therefore, we repeated all Cox regression analyses comparing the indicators before or after a BPD diagnosis to treat exposures as time-varying. Risk factor analyses considered the indicators to be exposures prior to a BPD diagnosis, while outcome analyses considered indicators as an outcome following a BPD diagnosis.

SAS was used for data management and all subsequent analysis was done in R using the survival package [ 36 ].

Descriptive statistics

The cohort consisted of 1,969,839 individuals (48.8% female) with 12,175 individuals with BPD (85.3% female; 0.6% of sample) (Table  2 ; absolute values Supplementary Tables  5 – 7 ). Total follow-up time was 32,637,932 person-years, calculated from the first possible time of BPD diagnosis, i.e., from its introduction in 1997, and onward. The diagnosis was evenly distributed between birth year cohorts, and the total cohort had a mean age of 29.69 years at the end of follow-up.

Cumulative incidences

The 5-year cumulative incidence showed increased incidences in individuals with BPD compared to the matched control sample for all indicators, except intellectual disability (Fig.  1 ; Supplementary Figs.  1 – 7 ). The largest cumulative incidences were for anxiety disorders (Cumulative incidence [95% CI]; BPD 33.13% [31.48–34.73%]; not BPD (NBPD) 3.17% [2.98–3.79%]), major depressive disorder (BPD 25.65% [24.11–27.16%]; NBPD 3.04% [2.85–3.24%]) personality disorders (BPD 21.33% [20.26–22.39%]; NBPD 0.36% [0.31–0.41%]), accidents requiring medical attention (BPD 21.50% [20.13–22.64%]; NBPD 10.91% [10.60–11.21%]), and attention-deficit hyperactive disorder (BPD 14.62% [13.75–15.48%]; NBPD 0.81% [0.74–0.88%]). Intellectual disability had zero first event occurrences after date of BPD-diagnosis for both exposed and unexposed.

figure 1

The cumulative incidence of each of the main indicators broken down by subgroups.

Associations between BPD diagnosis and indicators

All HRs for BPD and the indicators included in our main analysis were statistically significant, i.e., larger than 1, after correcting for multiple testing, except for intellectual disability and infertility in females (Fig.  2 ). The majority of the indicators under the umbrella categories were also statistically significantly larger than 1 (Supplementary Figs.  8 and 9 ).

figure 2

*Statistically significant after correcting for multiple testing using the Benjamini-Hochberg method, resulting in a p value threshold of 8.34 · 10 −58 .

Psychiatric disorders had the highest HRs across all analyses. The highest HRs were personality disorders not including BPD (HR [95% CI] 67.06 [64.66–69.54]), bipolar disorders (28.18 [27.04–29.36]), and PTSD (25.61 [24.25–27.04]). Psychotic disorders were also elevated (24.48 [23.14–25.90]).

The largest HRs for the association between BPD and somatic illnesses were for epilepsy (3.38 [3.08–3.70]), obesity (2.8 [2.63–2.98]), and diabetes (2.61 [2.32–2.93]).

Traumatic events and adverse behaviors

The strongest association regarding traumatic events was violent crime victimization (7.45 [7.13–7.78]). Death of a close family member also had a positive association (1.58 [1.52–1.64]). Self-harm had the highest hazard ratios of adverse behaviors (17.72 [17.27–18.19]). Committing a violent crime (7.65 [7.26–8.06]) had a stronger association than nonviolent crimes (4.20 [4.06–4.34]). Impulsive nonviolent crimes, i.e., property damage (6.66 [6.05–7.33]), had a stronger association than planned crime, possessing fake identification (1.94 [1.19–3.17]). Although they were analyzed as risk factors by definition, the HRs for poverty in childhood (1.93 [1.86–2.00]) and childhood neighborhood quality (1.52 [1.47–1.59]) were positively associated with BPD diagnosis (Supplementary Fig.  10 and Supplementary Table  5 ).

Females with BPD had higher cumulative incidences compared to males with BPD in nearly all somatic disorders, e.g., obesity (male 1.80 [0.97–2.62]; female 5.29 [4.68–5.90]); while the inverse was true for adverse behaviors and traumas, e.g., committing a violent crime (male 10.27 [8.14–12.35]; female 2.44 [2.06–2.83]). However, the CIs frequently overlapped between the sexes (Supplementary Figs.  11 – 23 ). HRs were largely uniform (Supplementary Fig.  24 ). Males had higher HRs for bipolar disorder (male 36.31 [32.62–40.41]; female 27.11 [25.93–28.33]), PTSD (male 34.99 [29.54–41.44], female 24.72 [23.35–26.18]) and affective disorders (male 31.42 [27.63–35.72]; female 21.32 [20.13–22.59]). Somatic disorders were mostly uniform across sex. Committing a violent crime was relatively more elevated in females (male 6.90 [6.38–7.46]; female 8.25 [7.68–8.86]). Additionally, being a victim of a violent crime requiring medical attention had a higher HR in females (male 5.05 [4.56–5.58]; female 8.58 [8.17–9.01]).

Individuals with siblings diagnosed with BPD had increased rates of indicators, however, many CIs contained 1, especially within somatic disorders (Supplementary Tables  9 – 11 ). Individuals with brothers diagnosed with BPD had higher HRs than those with sisters who were diagnosed in 87 out of 123 indicators. Psychiatric disorders had the strongest association, e.g., PTSD (males with brothers diagnosed with BPD (BBPD) 6.76 [3.74–12.24], males with sisters diagnosed with BPD (SBPD) 2.62 [1.78–3.87], females with BBPD 4.09 [2.72–6.16], females with SBPD 3.62 [3.02–4.35]).

Broadly, the magnitude of HRs for each indicator stayed relatively consistent when treating indicators as a risk factor prior to, or as an outcome following, a BPD diagnosis (Supplementary Tables  8 , 12 – 13 and Supplementary Figs.  10 , 25 , and 26 . Some notable exceptions were personality disorders (HR [95% CI] risk factor for subsequent BPD diagnosis 71.50 [68.36–74.78]; outcome following a BPD diagnosis 43.77 [41.40–46.28]), bipolar disorders (risk 35.94 [34.16–37.82]; outcome 17.27 [16.12–18.51), and psychotic disorders (risk 25.82 [24.19–27.56]; outcome 17.96 [16.23–19.87]) which had higher HRs leading up to a BPD diagnosis, and epilepsy (risk 2.89 [2.59–3.22]; outcome 5.36 [4.53–6.34]) that had a higher HR following a BPD diagnosis.

In this population-based study, which included 12,175 individuals with BPD in a total sample of 1,969,839 Swedes, we found that BPD was associated with an increased risk for psychiatric comorbidities, somatic illnesses, traumatic events, and adverse behaviors. Our findings replicate previously known associations and identify unknown or understudied associations, e.g., epilepsy, infertility, and death of close family members. Moreover, this work extends findings to include both sexes and their siblings.

BPD was strongly associated with all psychiatric disorders except intellectual disability. We found a robust association between BPD and all other personality disorders, mood disorders, eating disorders, PTSD, and substance use disorders. Certain findings need additional vigilance from clinicians and researchers, e.g., the strong association with psychotic disorders. This finding follows the historical implication of the term borderline, coined to indicate that the patients were on the borderline between psychosis and neurosis [ 37 ]. Psychotic experiences are often treated as transient symptoms according to DSM guidelines, although symptoms are often perpetual [ 12 ]. Our finding highlights the importance of carefully assessing psychotic symptoms in BPD, and indicates that psychotic disorders are indeed overrepresented in individuals with BPD [ 38 ].

Individuals with BPD had a higher risk of almost all somatic comorbidities in the main analysis except for female infertility. A Danish study also found a positive association between somatic disorders and combined personality disorders, however, their estimates were smaller than our results [ 39 ]. This could suggest that a BPD diagnosis has a worse prognosis than other personality disorders. In line with the literature, epilepsy and metabolic-related comorbidities, such as type 2 diabetes and obesity, had the strongest associations [ 10 ]. Previous studies have indicated a relationship between epilepsy and BPD, and here we show a clear association [ 40 ].

Individuals with BPD were at a higher risk of all traumatic events both before and after receiving their diagnosis. Namely, individuals with BPD were at a higher risk of seeking medical care due to violent crime victimization, especially sexual assault, which had the strongest association. This supports the expansive literature linking sexual assault and a BPD diagnosis [ 19 ]. Second, there was a positive association between BPD and the death of a close family member, which has only been reported in studies involving the death of a parent in childhood [ 41 ]. Third, our study identified an underreported positive link between childhood poverty and poor neighborhood quality and subsequent BPD diagnosis [ 42 ]. Although the CIs overlapped, sex-separated analysis found that males had higher rates of traumatic events, except for sexual assault, fitting within previous literature on BPD symptoms and trauma [ 43 ].

The consistent time-varying results provide evidence for the theory of a close, cyclical relationship between trauma and BPD [ 1 , 20 ]. Our sibling analysis found evidence to support an overlap in genetic and/or environmental etiology between traumatic events and BPD diagnosis, previously theorized to be present [ 44 ].

As expected, BPD individuals had higher instances of adverse behaviors: self-harm, violent and nonviolent crime. In line with previous findings, the most common criminal behaviors were aggressive in nature, such as making violent threats and assault [ 2 , 4 ]. Additionally, our study identified that impulsive nonviolent crimes such as property damage or petty theft are more common than planned crimes, e.g., having fake identification.

Sex differences and time-varying findings

The HRs were largely uniform across sexes, even though the absolute proportions, i.e., cumulative incidences, sometimes differed substantially. This suggests that this disorder confers similar increase in rates of comorbidities between males and females. A diagnostic bias between the sexes could result in an inflated estimate for males with BPD, as males who receive the correct diagnosis might have a more severe symptom presentation.

Individuals with a sibling with BPD had higher rates of psychiatric disorders, trauma, and adverse behaviors but not somatic disorders. HRs were higher in individuals with a brother diagnosed with BPD compared to those with a sister diagnosed for the majority of indicators. Families with a male diagnosed with BPD appear to have a more severe phenotype and vulnerability to psychiatric disorders [ 45 ]. However, this must be interpreted with caution as the CIs overlapped for having a brother or sister diagnosed with BPD. Follow-up on these associations is needed.

As the associations for the time-varying analyses were largely consistent with the main analysis, ignoring time of BPD diagnosis did not introduce bias that invalidated our inferences.

Strengths, weaknesses

In the largest and most detailed BPD study to date, we were able to capture all Sweden-born individuals with BPD with prospective follow-up using national records. This considerable sample size allowed us to thoroughly examine a variety of understudied variables in a representative sample.

However, this study comes with caveats. First, although the NPR and BPD diagnostic codes are well-validated, the extent to which these comorbidities may be misdiagnosed is unclear [ 29 , 32 , 33 ]. However, one may argue that diagnoses, if not correctly diagnosed, may reflect levels of symptom presentation even if the full criteria of diagnosis is not met. Further, the prevalence of a BPD diagnosis in our sample (0.6%) is conservative compared to the projected median estimate of 1.7% [ 1 ]. This likely indicates that many individuals who meet the criteria for a BPD diagnosis remain undiagnosed. And, as a BPD diagnosis generally takes multiple, intensive clinical interviews, it is likely that we are capturing individuals with more severe BPD symptoms.

Next, we were only able to identify the instances of the indicators identifiable in the register, this means the true estimate of these incidences may be higher in under-reported or less severe cases. Some individuals with BPD may be less willing to seek certain types of medical care due to distrust or stigmatization from the health care system, which may attenuate our results [ 46 ]. Additionally, trauma is both an objective and deeply subjective experience; and we are unable to capture the subjective experience [ 21 ]. Finally, symptoms of BPD, like all psychiatric disorders, are continuously distributed across the population rather than a binary diagnosis. We are unable to examine specific BPD symptoms which limits the information gained from this study.

Future directions for research

This study identifies many avenues for needed research. The comorbidities between BPD and psychotic disorders should be examined further. Moreover, the association with death of a close family member opens the question of the heritability of premature mortality in families [ 47 ]. Also, studies should examine these associations in other severe psychiatric disorders, such as bipolar disorder, to determine what associations are specific to BPD rather than general to severe psychiatric disorders [ 48 , 49 ]. Finally, further research should carefully expand on any causal assumptions about the nature of BPD.

Clinical implications

Our results indicate individuals with BPD frequently use health care services for a variety of psychiatric and somatic conditions. Unfortunately, despite their needs, the interpersonal difficulties and stigma surrounding individuals with BPD can be challenging for clinicians, which often results in poor care or premature ending of treatment [ 46 , 50 ]. Thus, there is a clear need for support and advocates for individuals with BPD navigating the health care system. Clinicians should be aware of these difficulties within the health care system and offer adapted health education or referrals, e.g., a dietitian to prevent type 2 diabetes. Additionally, implementing already developed anti-stigmatization methods could help improve the doctor–patient relationship [ 50 , 51 ].


BPD was associated with nearly all of the more than 30 indicators of psychiatric disorders, somatic illnesses, trauma, and adverse behavior. The associations were consistent across sex and temporality. This paper can serve as an atlas for associations within the aforementioned categories, many of which have previously been un- or under-reported, and can lead the way towards further causal and etiological research. Critically, the clinical implications indicate that increased support is needed for patients surrounding health care visits. It is hopeful that this provides the groundwork towards an understanding and increased awareness for this patient group.

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Tate has received funding from the European Union’s Horizon 2020 Research and Innovation Program under the Marie Sklodowska-Curie CAPICE Project grant agreement number 721567. ( https://www.capice-project.eu/ ) Lu is in part supported by a 2018 NARSAD Young Investigator Grant from the Brain & Behaviour Research Foundation and US NIMH (R01 MH123724). Open access funding provided by Karolinska Institute.

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AET, RK-H, and HS conceptualized the study. AET completed the analysis and wrote the manuscript. SL, YL, SL, PL, HS, RK-H provided feedback on the conceptualization and manuscript.

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Tate, A.E., Sahlin, H., Liu, S. et al. Borderline personality disorder: associations with psychiatric disorders, somatic illnesses, trauma, and adverse behaviors. Mol Psychiatry 27 , 2514–2521 (2022). https://doi.org/10.1038/s41380-022-01503-z

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Psychology Questions About Personality

Personality Psychology Research Topics

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

research paper topics on personality disorders

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List of Personality Topics

  • Before You Begin
  • Starting Your Research

Personality is a popular subject in psychology, so it's no surprise that this broad area is rife with fascinating research topics. There are many psychology questions about personality that can be a great topic for a paper, or just help you get to know others a little better.

Are you looking for a great topic for a paper , presentation, or experiment for your personality psychology class? Here are just a few ideas that might help kick-start your imagination.

At a Glance

If you are writing a paper, doing an experiment, or just curious about why people do the things they do, exploring some different psychology questions about personality can be a great place to start. Topics you might choose to explore include different personality traits, personality tests, and how different aspects of personality influence behavior.

Possible Topics for Personality Psychology Research

The type of psychology questions about personality that you might want to explore depend on what you are interested in and what you want to know. Some topics you might opt to explore include:

Personality Traits

  • How do personality traits relate to creativity? Are people with certain traits more or less creative? For your project, you might try administering scales measuring temperament and creativity to a group of participants.
  • Are certain personality traits linked to prosocial behaviors ? Consider how traits such as kindness, generosity, and empathy might be associated with altruism and heroism .
  • How does Type A behavior influence success in school? Are people who exhibit Type A characteristics more likely to succeed?
  • Is there a connection between a person's personality type and the kind of art they like? For example, are extroverts more drawn to brighter colors or art that depicts people vs. abstract, non-representational art?
  • Do people tend to choose pets based on their personality types? How do the personalities of dog owners compare to those of cat owners?

Personality Tests

  • How do personality assessments compare? Consider comparing common assessments such as the Myers-Briggs Temperament Indicator , the Keirsey Temperament Sorter, and the 16PF Questionnaire.
  • How reliable are personality test results? If you give someone the same test weeks later, will their results be the same?

Family and Relationships

  • Do people tend to marry individuals with similar personalities? Do people who marry partners with personalities similar to their own have more satisfying relationships?
  • What impact does birth order have on personality? Are first-born children more responsible, and are last-borns less responsible?

Personality and Behaviors

  • Is there a connection between personality types and musical tastes ? Do people who share certain personality traits prefer the same types of music?
  • Are people who participate in athletics more likely to have certain personality characteristics? Compare the personality types of athletes versus non-athletes.
  • Are individuals with high self-esteem more competitive than those with low self-esteem? Do those with high self-esteem perform better than those who have lower self-esteem?
  • Is there a correlation between personality type and the tendency to cheat on exams? Are people low in conscientiousness more likely to cheat? Are extroverts or introverts more liable to cheat?
  • How do personality factors influence a person's use of social media? For example, are people high in certain traits more likely to use Facebook, Instagram, and Twitter? Are individuals who use social media frequently more or less extroverted?

You can also come up with questions about your own about different topics in personality psychology. Some that you might explore include:

  • Big 5 personality traits
  • The id, ego, and superego
  • Psychosocial development
  • Hierarchy of needs
  • Myers-Briggs Type Indicator
  • Personality disorders

What to Do Before You Begin Your Research

Once you find a suitable research topic, you might be tempted just to dive right in and get started. However, there are a few important steps you need to take first.

Most importantly, be sure to run your topic idea past your instructor. This is particularly important if you are planning to conduct an actual experiment with human participants.

In most cases, you will need to gain your instructor's permission and possibly submit your plan to your school's human subjects committee to gain approval.

How to Get Started With Your Research

Whether you are doing an experiment, writing a paper , or developing a presentation, background research should always be your next step.

Consider what research already exists on the topic. Look into what other researchers have discovered. By spending some time reviewing the existing literature, you will be better able to develop your topic further.

What This Means For You

Asking psychology questions about personality can help you figure out what you want to research or write about. It can also be a way to think about your own personality or the characteristics of other people. If you're stumped for an idea, consider talking to your instructor or think about some questions you've had about people in your own life.

Atherton OE, Chung JM, Harris K, et al. Why has personality psychology played an outsized role in the credibility revolution ?  Personal Sci . 2021;2:e6001. doi:10.5964/ps.6001

American Psychological Association. Frequently asked questions about institutional review boards .

Leite DFB, Padilha MAS, Cecatti JG. Approaching literature review for academic purposes: The Literature Review Checklist .  Clinics (Sao Paulo) . 2019;74:e1403. doi:10.6061/clinics/2019/e1403

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."



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  • Lars Mehlum 7 ,
  • Babette Renneberg 8 &
  • Johannes Zimmermann 9  

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Purpose of Review

Individuals with personality disorders are frequently seen in mental health settings. Their symptoms typically reflect a high level of suffering and burden of disease, with potentially harmful societal consequences, including costs related to absenteeism at work, high use of health services, ineffective or harmful parenting, substance use, suicidal and non-suicidal self-harming behavior, and aggressiveness with legal consequences. Psychotherapy is currently the first-line treatment for patients with personality disorders, but the study of psychotherapy in the domain of personality disorders faces specific challenges.

Recent Findings

Challenges include knowing what works for whom, identifying which putative mechanisms of change explain therapeutic effects, and including the social interaction context of patients with a personality disorder. By following a dimensional approach, psychotherapy research on personality disorders may serve as a model for the development and study of innovative psychotherapeutic interventions.

We recommend developing the following: (a) an evidence base to make treatment decisions based on individual features; (b) a data-driven approach to predictors, moderators, and mechanisms of change in psychotherapy; (c) methods for studying the interaction between social context and psychotherapy.

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Personality disorders (PDs) may be understood as pervasive, inflexible, and enduring patterns of experience or behavior that deviate markedly from common expectations, causing significant disturbances in self- and interpersonal functioning. Symptoms associated with PDs reflect a high level of suffering and burden of disease. As a consequence, high costs related to absenteeism at work, high use of health services, ineffective or harmful parenting, substance use, suicidal and non-suicidal self-harming behavior, and aggressiveness with legal consequences are reported. In the absence of effective PD-specific psychopharmacological treatments, psychotherapy remains the first-line treatment [ 1 , 2 ••]. However, despite meta-analytic evidence demonstrating the probable efficacy (and effectiveness) of psychotherapy for PDs, key questions remain unanswered. To date, the majority of psychotherapy studies for patients presenting with PDs have either focused on (a) internally controlled comparative trials between two or more treatments (i.e., bonafide vs treatment as usual) and (b) pre- and post-comparisons of treatments as they are offered in the community. While valuable, such classical designs only partially address the pressing challenges the field of PDs currently faces. While the evidence base for psychotherapy is good for the average case, a significant portion of patients has a poor response to treatment [ 1 , 2 ••]. A limitation of the current evidence base for psychotherapy for PDs is that it is largely restricted to patients with borderline personality disorder (BPD), but neglects the array of other personality pathology [ 1 ]. Also, it remains insufficiently clear what type of treatment works for what type of patients and this knowledge would enable clinicians to make differentiated treatment recommendations for individual patients [ 3 ]. There is a rudimentary knowledge base on the mechanisms of change in psychotherapy for patients with PDs, as well as an insufficient inclusion of social contextual factors for explaining recovery in PDs. It is necessary to address these challenges to further the development and dissemination of effective treatment methods and support the adequate treatment of large patient populations across the globe.

Consolidating evidence in this field will also need to rest on convincing study replications, which require stronger national and international collaborations between psychotherapy researchers. Researchers in Europe have formed a collaborative alliance to address the need for accelerating research on and dissemination of PD-specific treatments on this continent [ 4 ]. The scientific society under which the collaborative alliance is formed organizes training seminars for early career psychotherapy researchers interested in PDs to promote high-quality research in more European countries and offers workshop conferences for clinicians to accelerate the dissemination of evidence-based treatments in underserved regions. Finally, the alliance organizes research congresses and offers members and affiliates opportunities to develop their research collaboration on specific topics through an increasing number of thematic sections. Hopefully, such alliances will lead to a more systematic development of the research base needed to deliver affordable treatments in a sustainable and equitable way to the people who need them.

This paper, written by an expert group from this alliance, elaborates on the following three pressing challenges to psychotherapy research for PDs: (a) how can psychotherapy research determine what works for whom and thus make individualized treatment recommendations based on evidence? (b) How can psychotherapy research contribute to the knowledge of how and why change in PDs occurs? (c) How can psychotherapy research take into account the social (i.e., interpersonal) context of the treatment of PDs? A brief conclusion follows with recommendations for researchers on methodological approaches that may ultimately improve the impact of psychotherapeutic interventions for PDs.

Developing an Evidence Base to Make Differentiated Recommendations on What Works for Whom

Typically, the efficacy of a particular treatment package is investigated using randomized controlled trials (RCTs), in which patients are randomly assigned to a treatment condition and a control condition. To date, treatment trials have largely been able to demonstrate the overall effectiveness of interventions in relatively heterogeneous clinical samples. However, only a few studies have collected samples large enough to allow for the analysis of subgroups or treatment moderators [ 5 ••]. Such analyses are needed to give us more precise information on who is benefiting the most from the treatments. Tailoring or optimizing treatments to individual patients’ needs is recommended in most treatment guidelines for people with PD [ 6 ], but to do so, we need more detailed and reliable knowledge. In order to determine what works for whom, we need evidence-based models that (a) describe psychopathology reliably and validly and (b) assess change due to psychotherapy by taking into account individual trajectories. Dimensional conceptions of PDs may help for both points. Consequences related to using dimensional conceptions concern (a) the selection of patients on the basis of inclusion and exclusion criteria, (b) the measurement of outcome variables, and (c) the statistical analysis of the results. Dimensional conceptions of PDs represent unique opportunities for addressing these current and future challenges.

When defining a treatment trial target population, a major problem with a categorical diagnostic approach is the issue of co-occurring disorders, i.e., that the individuals who meet the criteria for a particular disorder often also meet the criteria for other disorders. For example, approximately 74% of individuals diagnosed with BPD also meet the criteria for another PD [ 7 ], and about 85% of these individuals fulfill the criteria for another mental disorder [ 8 ]. As Hopwood et al. (2020, p. 3)[ 9 ] noted, in such a situation, “the researcher either has to select a patient population that is so specific as to be rare in actual practice (if the selection criterion is meeting a single diagnosis and no others) or so diverse that the interpretability of findings is imprecise (if multiple diagnoses are allowed).” In research on psychotherapy for BPD, the latter is probably true, as patients with co-occurring disorders are usually not excluded (with a few exceptions, such as comorbid psychotic disorder, bipolar disorder, and substance use [ 2 ••]). Considering the observation that the diagnosis of BPD itself encompasses heterogeneous symptoms, the implication is that the study results refer to a group of individuals with potentially very different problems. This makes it more difficult—although not impossible—to demonstrate the effectiveness of specific interventions or mechanisms of change at a group level. To address this problem, one approach is to accept the substantial heterogeneity of individual problems and base common treatment principles of the intervention on the severity of the problems and functional impairments [ 10 – 12 ]. The inclusion criterion would then not be a specific PD diagnosis but instead on a specific severity spectrum (e.g., severe PD according to ICD-11). An alternative possibility is to select patients based on the nature of their problematic traits [ 12 – 14 ]. Especially for mild or moderate PD’s according to ICD-11, it seems realistic to find patients who only fulfil the criteria for a certain trait domain but not for other trait domains. In more homogeneous groups of patients, it might be more feasible to demonstrate the efficacy of specific interventions or mechanisms of change.

A second problem with using a categorical understanding of mental disorders is that it frequently leads to the use of outcome measures that use arbitrary thresholds to classify individuals as recovered or remitted. For example, in research on BPD, a person who met four criteria over a period of time would be considered “remitted,” but a person who met five criteria would not [ 15 ]. This dichotomization loses important information about fine-grained differences in severity. In fact, Markon et al. [ 16 ] demonstrated that this reduces reliability by an average of 15% and validity by 37%, which in turn has unfavourable impact on the power of RCTs to detect treatment effects. To address this problem, the characterization of patients can include a map of the individual’s disorder-specific symptomatology and a broad multidimensional profile, because a dimensional understanding of disorders “makes no a priori assumptions about the level of the hierarchy at which a treatment might have its effects” ([ 9 ], p. 11). In this way, one could empirically determine which interventions have broad effects at the level of the general factor of PD and which are more likely to lead to specific changes in individual symptoms or facets.

Third, regarding statistical modeling, a categorical understanding of mental disorders typically leads to comparisons of the proportion of patients recovered or remitted between treatment conditions using statistical methods at the group level. This is problematic in two respects: on the one hand, it ignores the fact that outcome measurement is not perfect and is subject to measurement error; on the other hand, this way only the average effect of the treatment is estimated and the heterogeneity of individual treatment effects remains undetected. To address this problem, a dimensional definition of PD can facilitate the use of statistical models with latent variables to evaluate the effect of psychotherapy. Consequently, measurement error in individual indicators is explicitly accounted for and treatment effects can be estimated without measurement error. Provided that the relevant baseline covariates are included in the model and the sample is large enough, this approach allows for an estimate of the average treatment effect as well as an evaluation of the extent to which individual treatment effects depend on the specific characteristics of the person [ 17 ]. To some extent, specific studies in the recent meta-analysis by Storebø et al. [ 2 ••] tackled this problem for the diagnosis of BPD, although a broader approach is needed. A dimensional understanding of PD has the potential to achieve an evidence-based personalization of therapeutic interventions.

The notion of the functional domain (e.g., aggressiveness; [ 18 ••]) is a particularly fruitful avenue for re-conceptualizing PD and is related to dimensional models. Studies targeting functional domains advance psychotherapy research in several ways. A functional domain may be conceptualized as (a) an outcome criterion that complements symptom relief or (b) a variable that predicts change or moderates treatment effects, and (c) a mechanism of change in treatments. Importantly, change in functional domains may be observable on psychological and neurobiological levels [ 19 , 20 ]. More research is needed to learn whether the dimensional constructs defining PDs may parallel specific functional domains ([ 21 ], e.g., reward responsiveness and valuation, and their relationship with the disinhibition trait domain [ 22 ]). Such re-conceptualization of PDs may have an impact on treatment content [ 14 ], length [ 23 ], and format of delivery [ 24 ].

Developing an Evidence Base that Explains Why and How Psychotherapy Leads to Change

A pressing issue in psychotherapy research is the explanation of why and how psychotherapy leads to change in outcomes and, thus, the development of an evidence base that supports conceptualizations of mechanisms of change in psychotherapy. The study of mechanisms of change helps to advance an integrated model of change, which focuses less on theory-specific mechanisms and more on providing therapists with the knowledge they need to foster common mechanisms of change in a person-specific way [ 25 ].

A central mechanism of change in therapies for PDs may be building, maintaining, and repairing the therapeutic alliance. The therapeutic alliance, commonly defined as the patient and therapist’s agreement on therapy goals, collaboration on therapy tasks, and affective bond of trust and respect [ 26 ], is widely recognized as a crucial component of psychotherapy that bears a robust association with outcome across patient populations, including patients with PD diagnoses [ 27 ]. Many have noted the challenges of building and maintaining strong alliances with patients whose disorders are in part defined as disorders of interpersonal functioning (e.g., [ 28 ]). Hence, research on difficulties in the alliance, also known as alliance ruptures, is particularly relevant for therapy with patients with personality pathology. Studies have found that therapy with patients with PD diagnoses is marked by more alliance ruptures [ 29 , 30 ] and ruptures of greater intensity [ 31 ] than comparison conditions of patients who do not have PD diagnoses.

Ruptures present challenges for treatment, as they mark moments of poor patient-therapist collaboration and, if left unrepaired, predict premature dropout and poor treatment outcome; at the same time, rupture repair is associated with good treatment outcome, and this association is not moderated by patient PD diagnosis [ 32 ]. Repairing an alliance rupture can provide a valuable corrective experience for patients who may be accustomed to experiencing criticism, rejection, or abandonment in their interpersonal relationships [ 33 ].

Other theorized mechanisms of change in treatments of PDs include improvement in emotion regulation (i.e., emotion awareness and transformation), coping skills, and changes in reflective capacities (i.e., mentalization, theory of mind). Research provides preliminary support for these three additional classes of mechanisms of change [ 34 ••, 35 ]. Several studies show that improvements in various facets of emotion regulation, including access to, awareness of, and experience of emotions, may be active ingredients of effective psychotherapy for patients with PDs (for review and discussions, [ 36 ••]) [ 11 , 37 ]. Evidence suggests that the enhancement of specific mental activities, mentalizing, meta-cognitive and reflective capacities and schema modes may explain the psychotherapeutic change for PDs [ 34 ••]. Accumulating evidence also demonstrates that the enhancement of coping skills and improvements in mindfulness, especially a nonjudgmental stance, may constitute mechanisms of change [ 38 •].

Most studies on mechanisms of psychotherapeutic change have attempted to validate specific theory-driven mechanisms; few studies have addressed the question of whether theorized treatment-specific mechanisms may be common across diverse approaches. A recent study by Euler et al. [ 39 ] explored whether a theorized non-treatment-specific mechanism of change in dialectical-behavior therapy (DBT)—change in defense mechanisms—explained the effects of DBT skills training for BPD. Improvements in overall defensive functioning were greater for those randomized to 20 weeks of DBT skills compared to those randomized to treatment as usual. The results indicate that a theorized treatment-specific mechanism (i.e., defensive functioning that is central to psychodynamic psychotherapy) may be a transtheoretical mechanism of psychotherapeutic action.

Most research to date has been based on simple correlational designs. There is a need for research that examines more complex temporal relationships between variables, as this may point to more specific treatment targets. A study by Kramer et al. [ 40 ] addressed this question by exploring the temporal relationship between clients’ behavioral coping and outcome. Based on a sample of 57 participants with BPD enrolled in 10 sessions of either good psychiatric management (GPM) or GPM combined with motive-oriented relationship (MOTR), the results showed that decreases in in-session behavioral coping between sessions 1 and 5 mediated outcomes measured between sessions 5 and 10, suggesting that preceding changes in coping may explain subsequent symptom change in brief therapy.

In designing studies on mechanisms of psychotherapeutic change, researchers should consider the inclusion of multiple process measures as well as adopt carefully planned temporal designs to allow for the exploration of the temporal relationship between variables [ 41 ••, 42 ••]. No studies to date involve the experimental manipulation of mechanisms, which limits causal conclusions [ 43 , 44 ]. As the field moves forward, such studies are needed.

A final challenge when developing an evidence base on how and why psychotherapy produces its effects concerns the study of neurobiological correlates of mechanisms of change. Rather than broad treatment programs, future psychotherapies for patients with PDs may consist of treatment modules that target specific active ingredients in change [ 45 ]. To identify these active ingredients, psychologically informed neuroscience may provide a coherent framework to better understand the neuronal correlates that underlie changes in distinct psychological processes, such as cognition and emotion, motives, competencies, or habits. These different facets of the mind are rooted in various basic brain systems that may need to be specifically targeted and changed. Neuroscientific knowledge could thus be important for selecting targeted interventions since specific techniques affect different brain systems [ 46 ].

Several neuroimaging studies have investigated neuronal correlates of mechanisms of psychotherapy-induced change in emotion (or affective) dysregulation, one of the core functional impairments in BPD [ 47 ]. For instance, a study by Schmitt et al. [ 48 ] focused on the effects of DBT on improving reappraisal, the most efficient affect regulation strategy in daily life. The experiment asked participants to reduce their negative affective responses by reappraising the meaning of aversive social cues. Comparing patients who showed a treatment-response to DBT to nonresponders as well as a BPD control group who did not receive DBT, DBT responders exhibited reduced neural activities in the right amygdala, the rostral and dorsal anterior cingulate cortex, and in the orbitofrontal and dorsolateral prefrontal cortex after treatment. In addition, responders showed increased connectivity within the limbic-prefrontal network. Notably, the pre/post reduction of insula activity among DBT patients correlated with a reduction in affect dysregulation, suggesting a relationship between clinical improvement and lower insular activity as a core region of the salience system.

Threat hypersensitivity is a major explanatory construct of reactive aggression in BPD. In a recent randomized controlled trial [ 49 ••], researchers investigated whether a mechanism-based anti-aggression group psychotherapy (MAAP) with interventions that specifically target threat hypersensitivity was superior to a nonspecific supportive group psychotherapy (NSSP). Results indicated a better clinical outcome and reduced amygdala activity in response to facial emotions after MAAP, whereas amygdala activity was increased after NSSP. Furthermore, MAAP, but not NSSP, was followed by increased functional connectivity between the amygdala and dorsomedial prefrontal cortex from pre- to post-treatment [ 20 ].

Neuroscientific methods have helped to increase our understanding of how psychotherapy works. However, so far, experimental paradigms are rather removed from real life or real psychotherapy. More ecologically valid paradigms are therefore needed, which also vary the context in which symptoms are likely to occur. In the long run, neuroscience needs to include methods that can be transferred to the natural context. Furthermore, multimodal imaging has to date provided information on group effects rather than single subjects, and a more patient-centered approach may facilitate efforts to personalize treatment.

Developing an Evidence Base on How Change Due to Psychotherapy is Embedded in a Social Interaction Context

In this final section, we consider how behavior change is influenced by the social interaction context. Family and friends of individuals with PD are often burdened by the interpersonal problems inherent to personality pathology [ 50 ]. Research on social functioning will enhance knowledge of these interpersonal dysfunctions and processes. However, a major challenge for research on social factors and interpersonal dysfunction is the sheer number of aspects that have been shown to be associated with the development and course of mental disorders as well as their complex interplay [ 51 ]. General factors include socioeconomic status, working and living conditions, informal and formal social supports, social network, social integration, as well as the quality of interpersonal relationships in vocational and personal life.

Focusing on social transactions in relationships, expectations, and first impressions of interactions with strangers were examined in participants with BPD [ 52 ]. Results show that compared to control groups, patients with BPD form more negative first impressions of others and are at the same time perceived more negatively by others. These processes might lead to reduced approach behavior and less positive reciprocal interactions on both sides, thereby contributing to conflictual relationships in patients with BPD [ 52 ]. Miano et al. [ 53 ] examined interactional behavior in romantic relationships and pointed to the intertwined problems of emotion regulation and interpersonal conflicts. A specific challenge in successfully treating mental disorders is the social context, including interpersonal patterns that are transmitted over generations. In order to break the cycle of transmission, it has to be considered if patients with children need help with parenting [ 54 , 55 ]. An ongoing study is evaluating parenting training for mothers with BPD and their children [ 56 , 57 •]. An example of studying such social factors is the examination of the quality of youth welfare services provided to families of parents with a diagnosis of BPD.

Research on how social context impacts response to the treatment of PD poses specific methodological challenges. First, the assessment of social context variables should typically not be restricted to self-report methods, including observer raters of the individual’s behaviors. There is a need for longitudinal studies and the necessity of complex designs helping to disentangle the transactional nature of the social context. Examples of such complex designs are round robin or half-block designs, in which groups of participants make repeated assessments as they interact [ 58 ]. Based on the complex dyadic data thus obtained, researchers can analyze the perceptions, affective experiences, and interpersonal behaviors of individuals with PDs, as well as the reactions these individuals evoke in others [ 59 ]. In this regard, intensive longitudinal designs that take into account the social context of the individual (e.g., electronically activated recorder; EAR; [ 60 ]), as well as just-in-time adaptive interventions (JITAI [ 61 ]), may prove valuable.

In order to improve the course of recovery from PDs, more research on the social context and social transaction is needed. Research may inform psychotherapists’ efforts to improve tailored interventions [ 52 , 53 ]. Additionally, we also need more studies investigating the impact of living conditions and patient-related outcomes in everyday life. Outcomes listed in the International Classification of Functioning, Disability, and Health (ICF) should be included in research studies. The importance of educating significant others about helpful ways of interacting has been pointed out, but systematic studies addressing the benefits are lacking. A related aspect is to increase public participation by including patients and relatives in the research. Examples include providing psychoeducation for families and carers of patients with PDs [ 62 , 63 ]. Co-designing research that is both rigorous and inclusive is critical [ 48 ]. The development of interventions to improve social integration and social functioning will help patients and may at the same time serve as a preventive measure for their offspring. Relatedly, recent advances have highlighted the necessity of embedding psychotherapeutic interventions into specific cultural contexts, including minority status and gender [ 64 ].

Conclusions and Research Recommendations

Evidence-based treatments for PD are effective under certain circumstances, which have started to be elucidated, and more research is needed. In order to address the pressing issues in the domain of psychotherapy for PDs, we discussed the need to refer to a dimensional classification which may increase the precision of outcome studies and help to develop knowledge on what works for whom. In order to advance the understanding of psychotherapy for PDs, we discussed the study of mechanisms of change from an integrative viewpoint and proposed novel designs addressing the limitations of earlier studies, including the essential assessment of biological correlates. In order to take a broad picture of recovery in the context of psychotherapy for PDs, we argued that researchers should include social context variables, including variables pertaining to a social transaction, in an informed and balanced way.

This paper highlights challenges in the field of psychotherapy research for PDs and recommends solutions. Our proposed solutions recommend moving beyond classical comparator designs toward research that accounts for the complexity of PDs, the processes of change in psychotherapy, and the social context within which psychotherapeutic change takes place. This requires moving away from group-based comparisons toward more fine-grained comparisons of change, which may become increasingly relevant to the individual.

In conclusion, we put forward three main recommendations for psychotherapy researchers. First, in order to assist with making treatment decisions, we recommend that researchers develop an evidence base that is informed by individual responses. Second, in order to explain the effects of treatments, we recommend that researchers develop a data-driven approach to predictors, moderators, and mechanisms of change. Third, in order to get a broad picture of change in psychotherapy, we recommend that researchers study recovery in PDs by taking into account the social context, including social transactions.

In the future, in order to build such valid and robust knowledge related to either of these recommendations, researchers need to rigorously build on earlier existing studies and systematically broaden the evidence base. Solid and broadly valid knowledge is not necessarily built within a separate therapy approach (i.e., dialectical-behavior therapy or mentalization-based therapy) but should increasingly adopt a theory-integrative focus that aims at using concepts pertaining to a multitude of theories, clinical practices, and contexts. Preregistration, registered reports, and replication studies are becoming the norm in basic science [ 65 ] but remain rare in research on PDs [ 66 ], yet they are extremely important when it comes to building such solid and robust knowledge for the future. Outcome research may also increasingly use more advanced designs, such as the Sequential Multiple Assignment Randomized Trial (“SMART”; [ 67 ]). More research should aim at refining and consolidating conclusions from earlier studies.

In the future, in order to take into account the critical idiosyncratic characterizations of patients with PDs, it is useful to consider methods based on intensive longitudinal designs [ 68 , 69 ], idiographic network analysis [ 70 ], and the development of case formulation methodologies [ 42 ••]. Such approaches should be implemented more rigorously in the future [ 71 – 73 ]. Only relying on nomothetic variables may overlook the more fine-grained idiographic dynamics and meaning structures that are increasingly accessible to quantitative assessment tools. Linking these manifestations to dimensional constructs of PDs [ 74 ], as well as to their neurobiological underpinnings, remain challenges ahead.

In the future, psychotherapy research for PDs may need to address clinically pressing questions even more. Among these is the necessity for large dissemination of evidence-based treatments for PDs, in order to make sure that those who need the treatment receive it. Psychotherapies for PDs tend to be lengthy (1 to 3 years) and intensive (several sessions per week) and rely heavily on access to highly skilled therapists. Even wealthy countries lack a supply of therapists skilled in evidence-based PD-specific treatments that can adequately meet public health demands [ 75 ]. Several attempts have been made to solve these challenges [ 23 , 76 ], for example, by developing brief or simplified therapeutic approaches for PDs, as recently reviewed by Dixon-Gordon et al. [ 77 ]. Along these lines, several studies have examined whether DBT skills training of varying duration could be delivered as a stand-alone intervention while still retaining sufficient improvement in important treatment targets, such as reductions in suicidal and self-injurious behaviors. It appears that for an online version of such skills training—with unclear adherence to DBT principles—researchers reported an increase in the risk of self-harming behavior in at-risk adults [ 78 ], while in sufficiently adherent DBT protocols for patients with PDs and other pathologies, the DBT skills components have repeatedly been associated with a reduction in suicidal and para-suicidal behaviors and other relevant outcomes [ 77 ].

In order to address our research recommendations, it is important, but insufficient, to learn about the efficacy of a structured and complex package of intervention; there are clinically critical situations for which therapists need evidence-based and appropriate responses and where many therapy manuals may fall short of providing guidance. An example may be efforts to train therapists to identify alliance ruptures and address them using strategies such as therapeutic meta-communication [ 79 ]. A study found that introducing alliance-focused training to therapists working with patients with PDs facilitated decreases in negative interpersonal behaviors such as therapists blaming or controlling and patients submitting, and increases in positive behaviors such as therapists affirming and both patients and therapists expressing their inner experience [ 80 ]. Again, more research targeting specific functional domains when they emerge as problematic in a specific therapy process may be studied using “if-then” algorithms (i.e., “if the client does this, then the therapist should respond like that”).

To conclude, in the future, even more so than in the past given, the multi-faceted challenges the field faces, collaboration between researchers will be key. We advocate for international, multi-disciplinary, theory-integrative, and broad collaborations which aim at rigorously refining and consolidating of knowledge into robust models. Scientific societies may play a key role in this task. In the domain of PDs, several scientific societies, such as the European Society for the Study of Personality Disorders (ESSPD), play an important role in the creation of research networks of collaboration across Europe [ 4 ]. We hope that such initiatives may contribute to address some of the challenges described in the current synthesis.

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The editors would like to thank Dr. Sebastian Simonsen for taking the time to review this manuscript.

Open access funding provided by University of Lausanne. The present paper is the product of two consecutive editions (2019; 2021) of the European Society for the Study of Personality Disorders Summer School for early career researchers, which took place in Crêt-Bérard, Switzerland, with the support of the Department of Psychiatry, University of Lausanne (Switzerland), and the financial support of the Swiss Academy for Medical Sciences (2019 edition) and the Swiss National Science Foundation (2021 edition, IZSEZ0_198813/1).

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REVIEW article

Twenty years of research on borderline personality disorder: a scientometric analysis of hotspots, bursts, and research trends.

Yuanli Liu

  • 1 Department of Psychology, School of Humanities and Social Sciences, Anhui Agricultural University, Hefei, China
  • 2 College of Computing & Informatics, Drexel University, Philadelphia, PA, United States
  • 3 Department of Psychology, School of Education, China University of Geosciences, Wuhan, China
  • 4 Department of Information Management, Anhui Vocational College of Police Officers, Hefei, China

Borderline personality disorder (BPD), a complex and severe psychiatric disorder, has become a topic of considerable interest to current researchers due to its high incidence and severity of consequences. There is a lack of a bibliometric analysis to visualize the history and developmental trends of researches in BPD. We retrieved 7919 relevant publications on the Web of Science platform and analyzed them using software CiteSpace (6.2.R4). The results showed that there has been an overall upward trend in research interest in BPD over the past two decades. Current research trends in BPD include neuroimaging, biological mechanisms, and cognitive, behavioral, and pathological studies. Recent trends have been identified as “prevention and early intervention”, “non-pharmacological treatment” and “pathogenesis”. The results are like a reference program that will help determine future research directions and priorities.

1 Introduction

Borderline personality disorder (BPD) is a complex and severe psychiatric disorder characterized by mood dysregulation, interpersonal instability, self-image disturbance, and markedly impulsive behavior (e.g., aggression, self-injury, suicide) ( 1 ). In addition, people with BPD may have chronic, frequent, random feelings of emptiness, fear, and so on. These symptoms often lead them to use unhealthy coping mechanisms in response to negative emotions, such as alcohol abuse ( 2 ). BPD has a long course, which makes treatment difficult and may have a negative impact on patients’ quality of life ( 3 ). Due to its clinical challenge, BPD is by far the most studied category of personality disorder ( 4 ). This disorder is present in 1−3% of the general population as well as in 10% of outpatients, 15−20% of inpatients, and 30−60% of patients with a diagnosed personality disorder, and has a suicide rate of up to 10% ( 5 , 6 ). Families of individuals with serious mental illness often experience distress, and those with relatives diagnosed with BPD tend to carry a heavier burden compared to other mental illnesses ( 7 , 8 ). As early as the 20th century, scholars began describing BPD and summarizing its symptoms. However, there was some debate regarding the precise definition of BPD.

In the past few decades, the research community has made remarkable progress in the study of BPD, equipping us with a wider range of perspectives and tools for understanding this intricate condition. However, numerous challenges still remain to be tackled by researchers. Diagnosing BPD is inherently challenging and often more difficult than anticipated. The symptoms of BPD are complex, diverse, and often overlap with those of other mental health conditions. For example, individuals with BPD may experience extreme mood swings similar to those observed in individuals with bipolar disorder ( 9 ); At the same time, they may also be entrenched in long-term depression, making it easy for doctors to initially misdiagnose them with depression ( 10 ). Because these symptoms overlap and interfere with each other, doctors often face the risk of misdiagnosing or overlooking the condition during initial diagnosis. Therefore, researchers are working to develop more accurate and comprehensive diagnostic tools and methods.

According to the “Neuro-behavioral Model” proposed by Lieb ( 1 ), the process of BPD formation is very complex and is determined by the interaction of several factors. The interaction between different factors can be complex and dynamic. Genetic factors and adverse childhood experiences may contribute to emotional disorders and impulsivity, leading to dysfunctional behaviors and inner conflicts. These, in turn, can reinforce emotional dysregulation and impulsivity, exacerbating the preexisting conditions. Genetic factors are an important factor in the development of BPD ( 11 ). Psychosocial factors, including adverse childhood experiences, have also been strongly associated with the development of BPD ( 12 ). Emotional instability and impulsive behavior are even more common in patients with BPD ( 13 ). The current study is based on the “Neuro-behavioral Model” and conducts a literature review of previous scientific research on BPD through bibliometric analysis to reorganize the influencing factors. Through large-sample data analysis, the association between BPD and other diseases is explored, which contributes to further refining this theory’s explanation of the common neurobiological mechanisms among various mental illnesses.

It is worth noting that with the development of BPD, some scholars have conducted bibliometrics studies on BPD to provide insights into this academic field. To date, the current study has identified two published bibliometric studies on the field: One is Ilaria M. A. Benzi and her colleagues’ 2020 metrological analysis of the literature in the field of BPD pathology for the period 1985−2020 ( 14 ). The other is a bibliometric analysis by Taylor Reis and his colleagues of the growth and development of research on personality disorders between 1980 and 2019 ( 15 ). Ilaria M. A. Benzi and her colleagues integrated and sorted out the research results of borderline personality pathology, and revealed the research results and development stages in this field through the method of network and cluster analysis. The results of the study clearly demonstrate that the United States and European countries are the main contributors, that institutional citations are more consistent, and that BPD research is well developed in psychiatry and psychology. At the same time, the development of research in borderline personality pathology is demonstrated from the initial development of the construct, through studies of treatment effects, to the results of longitudinal studies. Taylor Reis and his colleagues used a time series autoregressive moving average model to analyze publishing trends for different personality disorders to reveal their historical development patterns, and projected the number of publications for the period 2024 to 2029. The study finds a trend towards diversity in the research and development of personality disorders, with differences in publication rates for different types of personality disorders, and summarizes the reasons that influence these differences. This may ultimately determine which personality disorders will remain in future psychiatric classifications. These studies have provided valuable insights into the evolution of BPD, focusing primarily on its pathology or a broader personality disorder perspective. While basic bibliometric analyses of these studies have been conducted, there is a need for more in-depth investigations of specific trends in the evolution of BPD and a clearer delineation of emerging research foci. Therefore, in order to enhance the current study, this study extends the analysis to 2022 and utilizes a comprehensive structural variation analysis of the literature using scientometric methods. Building on previous bibliometric studies, we expect to provide new insights and additions to research in this area. At the same time, the research trends and hot topics in the field of BPD are further explored. In addition, several cocitation-based analyses are also carried out in order to better understand citation performance.

2.1 Objectives

One of our goals was to understand the current status and progress of researches on BPD, and to summarize the latest developments and research findings in BPD, such as new treatment methods and disease mechanisms. Through the intuitive presentation of knowledge graphs and other images or data, we aimed to provide clinical practice and research guidance for clinicians, researchers, and policymakers.

Our second goal was to help identify future research directions and priorities, and provide more scientific and systematic research guidance for researchers. For example, by identifying hotspots and associations in certain research areas, we can determine the fields and issues that require further investigations, thus providing clearer directions and focus for researches. Additionally, through bibliometric analysis, we can provide researchers with more targeted and practical research strategies and methods, improving research efficiency and the quality of research outcomes.

2.2 Search strategy and data collection

The selection of appropriate methods and tools in the process of analyzing research information is crucial. Web of Science (WOS) is a popular database for bibliometric analysis that includes numerous respectable and high-impact academic journals. In addition, data information, such as references and citations, is more extensive than other academic databases ( 16 ). Data collection took place on the date of May 10, 2023. The search strategy included the following: topic=“Neuro-behavioral Model” or “borderline characteristics” or “borderline etiology” or “borderline personality disorder”, database selected=WOS Core Collection, time span=2003−2022, index=Science Citation Index Expanded (SCI-EXPENDED) and Social Sciences Citation Index (SSCI). The “Neuro-behavioral Model” serves as a theoretical framework that is useful for explaining the development and pathophysiology of BPD; “borderline characteristics” can describe the related symptoms and features of BPD; “borderline etiology” helps to understand the factors that contribute to the development of BPD; “borderline personality disorder” is the most commonly used terms in relevant research. Using these as keywords in title searches can help researchers find researches related to BPD more accurately, facilitating deeper understanding of the characteristics, pathophysiology, etiology, and other aspects of BPD. In the current study, we focused only on two types of literature: articles and review articles, and limited the language to English. After removing all literature unrelated to BPD, a total of 7919 records met the criteria. They were exported in record and reference formats, and saved in plain text file format.

2.3 Data analysis and tools

Bibliometrics was first proposed by Alan Pritchard in 1969, as a method that combines data visualization to analyze publications statistically and quantitatively in specific fields and journals ( 17 ). Bibliometric analysis is a good way to analyze the trend of knowledge structure and research activities in scientific fields over time, and has been widely used in various fields since it was first used ( 18 ). Scientometrics is the application of bibliometrics in scientific fields, and it focuses on the quantitative characteristics and features of science and scientific researches ( 19 ). Compared to traditional literature review studies, visualized knowledge graphs can accurately identify key articles from many publications, comprehensively and systematically combing existing research in a field ( 20 ).

Currently, two important academic indicators are included in research. The impact factor (IF) is used as an indicator of a publication’s impact to assess the quality and importance of the publication ( 21 ). However, some researchers believe that IF has defects such as inaccuracy and misuse ( 22 ). Although many researchers have proposed to replace the impact factor with other indicators, IF is still one of the most effective ways to measure the impact of a journal ( 23 ). The IF published in the 2021 Journal Citation Reports were used. Another indicator is the H-index, which is an important measure of a scholar’s academic achievements. Some researchers consider it as a correction or supplement to the traditional IF ( 24 ).

All data were imported into CiteSpace (6.2.R4) and Scimago Graphica (1.0.30) for analysis. CiteSpace was used to obtain collaboration networks and impact networks. Scimago Graphica was used to construct a network graph of country collaboration. CiteSpace is a Java-based software developed in the context of scientometrics and data visualization ( 25 ). It combines scientific knowledge mapping with bibliometric analysis to determine the progress and current research frontiers in a particular field, as well as predict the development trends in that field ( 26 ). Scimago Graphica is a no-code tool. It can not only perform visualization analysis on communication data but also explore exploratory data ( 27 ). Currently, it is used for visual analysis of national cooperation relationships, displaying the geographic distribution of countries and publication trends.

3.1 Analysis of publication outputs, and growth trend prediction

Annual publications can provide an overview of the evolution of a research area and its progress ( 28 ). We retrieved 7919 articles from the WOS database on BPD between 2003 and 2022, including 6834 research articles and 1085 reviews ( Figure 1 ). As of the search date, these articles had received a total of 289,958 citations, equating to an average of 14,498 citations per year. Over the past two decades, the number of research articles published on BPD has shown a fluctuating upward trend. In addition, citations to these publications have increased significantly. A polynomial curve fit of the literature on BPD clearly indicates a strong correlation between the year of publication and the number of publications ( R 2 = 0.973). The number of research articles on BPD has indeed fluctuated and increased over the past two decades. This observation does, to some extent, indicate an upward trend, probably due to increasing interest in BPD. However, there are other factors to consider as well. For example, the accumulation of data or technological advances, government policies and corporate investment may also affect the direction of BPD research development.


Figure 1 Annual publications, citation counts, and the fitting equation for annual publications in BPD.

3.2 Analysis of co-citation references: clusters and timeline of research

Co-cited references, which are cited by multiple papers concurrently, are considered a crucial knowledge base in any given field ( 28 ). In the current study, CiteSpace clustering was utilized to identify common themes within BPD-related literature. Figure 2 presented a co-citation network of highly cited references between 2003 and 2022, comprising 1163 references. A time slice of 1 was used, with the g -index was set at k =25, which resulted in the identification of 14 clusters representing distinct research themes in BPD. The significant cluster structure is denoted by a modularity value ( Q value) of 0.7974, and the high confidence level in the clusters by an average profile value ( S value) of 0.9176.


Figure 2 Reference co-citation network with cluster visualization in BPD. Trend 1 clinical researches, sub-trend clinical characteristics includes clusters #1, #2, #4, #10, #12; biological mechanisms include clusters #3, #7; nursing treatments includes clusters #0, #8, #13. Trend 2 associations and complications includes clusters #5, #6, #9, #11, #14.

Cluster analysis is performed through CiteSpace. Related clusters are classified into the same trend based on the knowledge of related fields and whether the clusters show similar trends. At the same time, based on the analysis of time series, to identify the movement of one cluster to another. Based on the cluster map of co-cited references on BPD, several different research trends were identified. The first major research trend is clinical research on BPD, which in turn consists of three sub-trends: clinical characterization of BPD, biological mechanisms, and nursing treatment. Of the data obtained, the earliest research on the clinical characterization of BPD began in 1992 with cluster #12, “borderline personality disorder and suicidal behavior” ( S =0.979; 1992). Paul H. Soloff and his colleagues conducted a comparative study of suicide attempts between major depressives and patients with BPD. The aim of this study was to develop more effective intervention strategies for suicide prevention ( 29 ). This cluster was further developed in cluster #4, “nonsuicidal self-injury and suicide” ( S =0.96; 2004). Thomas A. Widiger and Timothy J. Trull proposed a more flexible dimension-based categorization model to overcome the previous drawbacks of personality disorder categorization ( 30 ). Next in cluster #10 “borderline personality disorder and impulsivity” ( S =0.93; 2000), Jim H. Patton and his colleagues revised the Barratt Impulsivity Scale to measure impulsivity to facilitate practical clinical research ( 31 ). Related research continues to evolve into cluster #1 “borderline personality disorder and emotions” ( S =0.87; 2007) and cluster #2 “borderline personality disorder and social cognition” ( S =0.911; 2009), researchers have focused on understanding the causal relationship between BPD traits and factors such as social environment, emotion regulation, and interpersonal evaluative bias, as well as their potential impact ( 32 , 33 ). In the sub-trend of biological mechanisms, two main clusters are involved: cluster #7 “borderline personality disorder and gene-environment interactions” ( S =0.871; 2002) and cluster #3 “borderline personality disorder and neuroimaging” ( S =0.938; 2007). In the related cluster, researchers have found a relationship between BPD and genetic and environmental factors ( 34 ). Researchers have also utilized various external techniques to explore the degree of correlation between the risk of developing BPD and its biological mechanisms, aiming to reveal the complex mechanisms that influence the emergence and development of BPD ( 35 ). In nursing treatment, cluster #8 “treatment of borderline personality disorder “ ( S =0.968; 2001), Silvio Bellino and his colleagues systematically analyzed the current publications on BPD pharmacotherapy research and summarized relevant clinical trials and findings ( 36 ). However, due to the complexity of BPD, there is still a lack of information on the exact efficacy of pharmacotherapy in BPD, and therefore pharmacotherapy remains an area of ongoing development and research. This trend continues to be developed in cluster #0 “borderline personality disorder treatment” ( S =0.887; 2006), which emphasizes the development of novel pharmacotherapies for BPD. Cluster #13 “borderline personality disorder care” ( S =0.997; 2013) mainly focuses on the comprehensive care of people with borderline personality disorder and the education of patients and families. The goal is to improve patients’ quality of life, reduce self-injury and suicidal behavior, and promote full recovery.

The second major research trend is association and comorbidity. This trend first began in cluster #9 “comorbidity and differentiation of disorders” ( S =0.946; 1999). Mary C Zanarini and his colleagues explored the comorbidity of BPD with other psychiatric disorders on Axis I ( 37 ). Cluster #14 “borderline personality disorder and psychosis” ( S =0.966; 2003) also explored symptoms associated with BPD ( 38 ). This trend continues, with researchers studying BPD research in cluster #11 “borderline personality disorder” ( S =0.935; 2004) and cluster #5 “borderline personality disorder research” ( S =0.881; 2007) ( 39 , 40 ). In addition, cluster #6 “borderline personality disorder in adolescents” ( S =0.894; 2011) points out that the focus of BPD research is increasingly shifting towards adolescents ( 41 ).

Figure 3 showed the time span and research process of the developmental evolution of these different research themes. The temporal view reveals the newest and most active clusters, namely #0 “dialectical behavior therapy”, #1 “daily life”, and #2 “social cognition”, which have been consistently researched for almost a decade. Cluster #0 “dialectical behavior therapy” has the largest number and the longest duration, lasting almost 10 years. Similarly, this article by Rebekah Bradley and Drew Westen on understanding the psychodynamic mechanisms of BPD from the perspective of developmental psychopathology has the largest node ( 34 ).


Figure 3 Reference co-citation network with timeline visualization in BPD.

3.3 Most cited papers

The top 10 highly cited papers on BPD research were presented in Table 1 . The most cited paper, by Marsha M. Linehan and colleagues, focus on the treatment of suicidal behavior in BPD ( 42 ). The transition between suicidal and non-suicidal self-injurious behavior in individuals with BPD has attracted researchers’s attention, mainly in cluster #4 “nonsuicidal self-injury and suicide” ( 52 ). The second is the experimental study by Josephine Giesen-Bloo and his colleagues on the psychotherapy of BPD ( 43 ). In cluster #0 “borderline personality disorder treatment” and Cluster #8 “treatment of borderline personality disorder”, researchers strive to find non-pharmacological approaches with comparable or enhanced therapeutic effects. This was followed by Sheila E. Crowell and her colleagues’ study of the biological developmental patterns of BPD ( 44 ). Research on the biological mechanisms and other contributing factors of BPD, including #7 “borderline personality disorder and gene-environment interactions” have been closely associated with the development of BPD ( 53 ).


Table 1 Top 10 cited references that published BPD researches.

3.4 Burst analysis and transformative papers

The “citation explosion” reflects the changing research focus of a field over time and indicates that certain literature has been frequently cited over time. Figure 4 showed the top 9 references with the highest citation intensity. The three papers with the greatest intensity of outbursts during the period 2003−2022 are: The first is the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders ( 54 ). In the second article, Vijay A. Mittal and Elaine F. Walker discuss key issues surrounding dyspraxia, tics, and psychosis that are likely to appear in an upcoming edition of the Diagnostic and Statistical Manual of Mental Disorders ( 39 ). In addition, Ioana A. Cristea and colleagues conducted a systematic review and meta-analysis to evaluate the effectiveness of psychotherapy for borderline personality disorder ( 55 ).


Figure 4 References with the strongest occurrence burst on BPD researches. Article titles correspond from top to bottom: Mittal VA et al. Diagnostic and Statistical Manuel of Mental Disorders; Linehan MM et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder; Giesen-Bloo J et al. Outpatient psychotherapy for borderline personality disorder: Randomized trial of schema-focused therapy vs transference-focused psychotherapy; Clarkin Jf et al. Evaluating three treatments for borderline personality disorder: A multiwave study; Grant BF et al. Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions; Leichsenring F et al. Borderline personality disorder; American Psychiatric Association, DSM-5 Task Force. Diagnostic and statistical manual of mental disorders: DSM-5™ (5th ed.); Cristea IA et al. Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis; Gunderson JG et al. Borderline personality disorder.

Structural variation analysis can be understood as a method of measuring and studying structural changes in the field, mainly reflecting the betweenness centrality and sigma of the references. The high centrality of the reference plays an important role in the connection between the preceding and following references and may help to identify critical points of transformation, or intellectual turning points. Sigma values, on the other hand, are used to measure the novelty of a study, combining a combination of citation burst and structural centrality ( 56 ). Table 2 listed the top 10 structural change references that can be considered as landmark studies connecting different clusters. The top three articles with high centrality are the studies conducted by Milton Z. Brown and his colleagues on the reasons for suicide attempts and non-suicidal self-injury in BPD women ( 57 ); the research by Nelson H. Donegan and his colleagues on the impact of amygdala on emotional dysregulation in BPD patients ( 59 ); and the fMRI study by Sabine C. Herpertz and her colleagues on abnormal amygdala function in BPD patients ( 61 ). In addition, publications with high sigma values are listed. They are Larry J. Siever and Kenneth L. Davis on psychobiological perspectives on personality disorders ( 58 ); Ludger Tebartz van Elst and his colleagues on abnormalities in frontolimbic brain functioning ( 60 ); and Marsha M. Linehan on therapeutic approaches in BPD research ( 62 ). These works are recognized as having transformative potential and may generate some new ideas.


Table 2 Top 7 betweenness centrality and stigma references.

3.5 Analysis of authors and co-authors

Figure 5 showed a map of the co-authorship network over the last two decades. In total, 10 different clusters are shown, each of which gathers co-authors around the same research topic. For example, the main co-authors of cluster #0 “remission” are Christian Schmahl, Martin Bohus, Sabine C. Herpertz, Timothy J. Trull and Stefan Roepke. More recently, the three authors with the greatest bursts of research have been Mary C. Zanarini, Erik Simonsen, and Carla Sharp. As shown in Table 3 , the three most published authors are Martin Bohus (145 publications; 1.83%; H-index=61), Mary C. Zanarini (144 publications; 1.82%; H-index=80) and Christian Schmahl (142 publications; 1.79%; H-index=54).


Figure 5 Top 10 clusters of coauthors in BPD (2003–2023). Selection Criteria: Top 10 per slice. Clusters labeled by keywords. The five authors with the highest number of publications in each cluster were labeled.


Table 3 Top 10 authors that published BPD researches.

3.6 Analysis of cooperation networks across countries

The top 10 countries in terms of number of publications in the BPD are added in Table 4 . With 3,440 published papers, or nearly 43% of all BPD research papers, the United States is the leading contributor to BPD research. This is followed by Germany (1196 publications; 15.10%) and the United Kingdom (1020 publications; 9.32%). Centrality refers to the degree of importance or centrality of a node in a network and is a measure of the importance of a node in a network ( 69 ). In Table 4 the United States is also has the highest centrality (0.43). Figure 6 shows the geographic collaboration network of countries in this field, with 83 countries contributing to BPD research, primarily from the United States and Europe.


Table 4 Top 10 countries that published BPD researches.


Figure 6 Map of the distribution of countries/regions engaged in BPD researches.

3.7 Analysis of the co-author’s institutions network

Table 5 listed the top 10 institutions ranked by the number of publications. The current study shows that Research Libraries Uk is the institution with the highest number of publications, with 766 publications (9.67%). The subsequent institutions are Harvard University and Ruprecht Karls University Heidelberg with 425 (5.37%) and 389 (4.91%) publications respectively. As can be seen from Table 4 , six of the top 10 institutions in terms of number of publications are from the United States. In part, this reflects the fact that the United States institutions are at the forefront of the BPD field and play a key role in it.


Table 5 Top 10 institutions that published BPD researches.

3.8 Analysis of journals and cited journals

If the more papers are published in a particular journal and at the same time it has a high number of citations, then it can be considered that the journal is influential ( 70 ). The top 10 journals in the field of BPD in terms of number of publications are listed in Table 6 . Journal of Personality Disorders from the Netherlands published the most literature on BPD with 438 (5.53%; IF=3.367) publications. This was followed by two journals from the United States: Psychiatry Research and Personality Disorders Theory Research and Treatment , with 269 (3.40%, IF=11.225) and 232 (2.93%; IF=4.627) publications, respectively. Among the top 10 journals in terms of number of publications published, Psychiatry Research has the highest impact factor.


Table 6 Top 10 journals that published BPD researches.

3.9 Analysis of keywords and keywords co-occurrence

Keyword co-occurrence analysis can help researchers to understand the research hotspots in a certain field and the connection between different research topics. As shown in Figure 7 , all keywords can be categorized into 9 clusters: cluster #0 “diagnostic interview”, cluster #1 “diagnostic behavior therapy”, cluster #3 “social cognition”, cluster #4 “emotional regulation”, cluster #5 “substance use disorders “, cluster #6 “posttraumatic stress disorder”, cluster #7 “suicide” and cluster #8 “double blind”. These keywords have all been important themes in BPD research during the last 20 years.


Figure 7 The largest 9 clusters of co-occurring keywords. The top 5 most frequent keywords in each cluster are highlighted.

Keyword burst is used to identify keywords with a significant increase in the frequency of occurrence in a topic or domain, helping to identify emerging concepts, research hotspots or keyword evolutions in a specific domain ( 71 ). Figure 8 presented the top 32 keywords with the strongest citation bursts in BPD from 2003−2023. Significantly, the keywords “positron emission tomography” (29.63), “major depression” (27.93), and “partial hospitalization” (27.1) had the highest intensity of outbreaks.


Figure 8 Keywords with the strongest occurrence burst on BPD researches.

4 Discussion

4.1 application of the “neuro-behavioral model” to bpd research.

In this study, we chose specific search terms, particularly “Neuro-behavioral Model”, to efficiently collect and analyze BPD research literature related to this emerging framework. This choice of keyword helped narrow the research scope and ensure its relevance to our objectives. However, it may have excluded some studies using different terminology, thus limiting comprehensiveness. In addition, the ‘Neuro-behavioral Model’, as an interdisciplinary field, encompasses a wide range of connotations and extensions, which also poses challenges to our research. This undoubtedly adds to the complexity of the study, yet it enhances our understanding of the field’s diversity.

4.2 Summary of the main findings

This current study utilized CiteSpace and Scimago Graphic software to conduct a comprehensive bibliometric analysis of the research literature on BPD. The study presented the current status of research, research hotspots, and research frontiers in BPD over the past 20 years (2003–2022) through knowledge mapping. The scientific predictions of future trends in BPD provided by this study can guide researchers interested in this field. This study also uses bibliometrics analysis method to show the knowledge structure and research results in the field of BPD, as well as the scientific prediction of the future trend of BPD research.

4.3 Identification of research hotspots

Previous studies have indicated an increasing trend in the number of papers focused on BPD, with the field gradually expanding into various areas. The first major research trend involves clinical studies on BPD. This includes focusing on emotional recognition difficulties in BPD patients, as well as studying features related to suicide attempts and non-suicidal self-injury. Clinical recognition and confirmation of BPD remains low, mainly related to the lack of clarity of its biological mechanisms ( 72 ). The nursing environment for BPD patients plays an important role in the development of the condition, which has become a focus of research. Researchers are also exploring the expansion of treatment options from conventional medication to non-pharmacological approaches, particularly cognitive-behavioral therapy. Another major research trend involves the associations and complications of BPD, including a greater focus on the adolescent population to reduce the occurrence of BPD starting from adolescence. Additionally, many researchers are interested in the comorbidity of BPD with various clinical mental disorders.

4.4 Potential trends of future research on BPD

Based on the results of the above studies and the results of the research trends in the table of details of the co-citation network clusters in 2022 ( Table 7 ), several predictions are made for the future trends in the field of BPD. In Table 7 , there were some trends related to previous studies, including #1”dialectical behavior therapy”, #7 “dialectical behavior therapy” ( 73 ), #5 “mentalization” ( 74 ), and #9 “non-suicidal self-injury” ( 75 ). The persistence of these research trends is evidence that they have been a complex issue in this field and a focus of researchers. The recently emerged turning point paper provides a comprehensive assessment about BPD, offering practical information and treatment recommendations ( 76 ). New research is needed to improve standards and suggest more targeted and cost-effective treatments.


Table 7 The references co-citation network cluster detail (2022).

BPD symptoms in adolescents have been shown to respond to interventions with good results, so prevention and intervention for BPD is warranted ( 77 ). This trend can be observed in #3 “youth” ( 78 ). Mark F. Lenzenweger and Dante Cicchetti summarized the developmental psychopathology approach to BPD, one of the aims of which is to provide information for the prevention of BPD ( 79 ). Prevention and early intervention of BPD has been shown to provide many benefits, including reduced occurrence of secondary disorders, improved psychosocial functioning, and reduced risk of interpersonal conflict ( 80 ). However, there are differences between individuals, and different prevention goals are recommended for adolescents at risk for BPD. Therefore, prevention and early intervention for BPD has good prospects for the future.

The etiology of BPD is closely related to many factors, and its pathogenesis is often ignored by clinicians. The exploration of risk factors has been an important research direction in the study. Some studies have found that BPD is largely the product of traumatic childhood experiences, which may lead to negative psychological effects on children growing up ( 81 ). It has also been found that the severity of borderline symptoms in parents is positively associated with poor parenting practices ( 82 ). Future researches need to know more about the biological-behavioral processes of parents in order to provide targeted parenting support and create a good childhood environment.

Because pharmacotherapy is only indicated for comorbid conditions that require medication, psychotherapy has become one of the main approaches to treating BPD. The increasingly advanced performance and availability of contemporary mobile devices can help to take advantage of them more effectively in the context of optimizing the treatment of psychiatric disorders. The explosion of COVID-19 is forcing people to adapt to online rather than face-to-face offline treatment ( 83 ). The development of this new technology will effectively advance the treatment of patients with BPD. Although telemedicine has gained some level of acceptance by the general public, there are some challenges that have been reported, so further research on the broader utility of telemedicine is needed in the future.

4.5 The current study compares with a previous bibliometric review of BPD

As mentioned earlier, there have been previous bibliometric studies conducted by scholars in the field of BPD. This paper focuses more on BPD in personality disorders than the extensive study of personality disorders as a category by Taylor Reis et al. ( 15 ). The results of both studies show an increasing trend in the number of publications in the field of BPD, suggesting positive developments in the field. Taylor Reis et al. focused primarily on quantifying publications on personality disorders and did not delve into other specific aspects of BPD. Ilaria M.A. Benzi et al. focused on a bibliometric analysis of the pathology of BPD ( 14 ). They give three trends for the future development of BPD pathology: first, the growing importance of self-injurious behavior research; second, the association of attention deficit hyperactivity disorder with BPD and the influence of genetics and heritability on BPD; and third, the new focus on the overlap between fragile narcissism and BPD. The study in this paper also concludes that there are three future development directions for BPD: first, the prevention and early intervention of BPD; second, the non-pharmacological treatment of BPD; and third, research into the pathogenesis of BPD. Owing to variations in research backgrounds and data sources, the outcomes presented in the two studies diverge significantly. Nevertheless, both contributions hold merit in advancing the understanding of BPD. In addition to this, this paper also identifies trends in BPD over the past 20 years: the first trend is the clinical research of BPD, which is specifically subdivided into three sub-trends; the second trend is association and comorbidity. The identification of these trends is important for understanding the disorder, improving diagnosis and treatment, etc. Structural variant analysis also features prominently in the study. The impact of literature in terms of innovativeness is detected through in-depth mining and analysis of large amounts of literature data. This analysis is based on research in the area of scientific creativity, especially the role and impact of novel reorganizations in creative thinking. Structural variation analysis is precisely designed to find and reveal embodiments of such innovative thinking in scientific literature, enabling researchers to more intuitively grasp the dynamics and cutting-edge advances in the field of science.

5 Limitations

However, it must be admitted that our study has some limitations. The first is the limited nature of data resources. The data source for our study came from only one database, WOS. Second, the limitation of article type. Search criteria are limited to papers and reviews in SCI and SSCI databases. Third, the effect of language type. In the current study, only English-language literature could be included in the analysis, which may lead us to miss some important studies published in other languages. Fourth, limitations of research software. Although this study used well-established and specialized software, the results obtained by choosing different calculation methods may vary. Finally, the diversity of results interpretation. The results analyzed by the software are objective, but there is also some subjectivity in the interpretation and analysis of the research results. While we endeavor to be comprehensive and accurate in our research, the choice of search terms inevitably introduces certain limitations. Using “Neuro-behavioral Model” as the search term enhances the study’s relevance, but it may also cause us to miss significant studies in related areas. This limits the generalizability and replicability of our results. Furthermore, the inherent complexity and diversity of neurobehavioral models might introduce subjectivity and bias in our interpretation and application of the literature. Although we endeavored to reduce bias via multi-channel validation and cross-referencing, we cannot entirely eliminate its potential impact on our findings.

6 Conclusion

Overall, a comprehensive scientometrics analysis of BPD provides a comprehensive picture of the development of this field over the past 20 years. This in-depth examination not only reveals research trends, but also allows us to understand which areas are currently hot and points the way for future research efforts. In addition, this method provides us with a framework to evaluate the value of our own research results, which helps us to more precisely adjust the direction and strategy of research. More importantly, this in-depth analysis reveals the depth and breadth of BPD research, which undoubtedly provides valuable references for researchers to have a deeper understanding of BPD, and also provides a reference for us to set future research goals. In short, this scientometrics approach gives us a window into the full scope of BPD research and provides valuable guidance for future research.

Author contributions

YL: Data curation, Formal analysis, Investigation, Methodology, Software, Visualization, Writing – original draft, Writing – review & editing. CC: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. YZ: Validation, Visualization, Writing – review & editing. NZ: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. SL: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. SL is supported by the Outstanding Youth Program of Philosophy and Social Sciences in Anhui Province (2022AH030089) and the Starting Fund for Scientific Research of High-Level Talents at Anhui Agricultural University (rc432206).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: neuro-behavioral model, borderline personality disorder, BPD, bibliometric, Scimago Graphica

Citation: Liu Y, Chen C, Zhou Y, Zhang N and Liu S (2024) Twenty years of research on borderline personality disorder: a scientometric analysis of hotspots, bursts, and research trends. Front. Psychiatry 15:1361535. doi: 10.3389/fpsyt.2024.1361535

Received: 12 January 2024; Accepted: 19 February 2024; Published: 01 March 2024.

Reviewed by:

Copyright © 2024 Liu, Chen, Zhou, Zhang and Liu. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Shen Liu, [email protected] ; Chaomei Chen, [email protected] ; Na Zhang, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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New treatment could reverse hair loss caused by an autoimmune skin disease

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A colorized microscopic view shows the cone-shaped microneedles laid on out a grid, in yellow, on a purple surface.

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A colorized microscopic view shows the cone-shaped microneedles laid on out a grid, in yellow, on a purple surface.

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Researchers at MIT, Brigham and Women’s Hospital, and Harvard Medical School have developed a potential new treatment for alopecia areata, an autoimmune disorder that causes hair loss and affects people of all ages, including children.

For most patients with this type of hair loss, there is no effective treatment. The team developed a microneedle patch that can be painlessly applied to the scalp and releases drugs that help to rebalance the immune response at the site, halting the autoimmune attack.

In a study of mice, the researchers found that this treatment allowed hair to regrow and dramatically reduced inflammation at the treatment site, while avoiding systemic immune effects elsewhere in the body. This strategy could also be adapted to treat other autoimmune skin diseases such as vitiligo, atopic dermatitis, and psoriasis, the researchers say.

“This innovative approach marks a paradigm shift. Rather than suppressing the immune system, we’re now focusing on regulating it precisely at the site of antigen encounter to generate immune tolerance,” says Natalie Artzi, a principal research scientist in MIT’s Institute for Medical Engineering and Science, an associate professor of medicine at Harvard Medical School and Brigham and Women’s Hospital, and an associate faculty member at the Wyss Institute of Harvard University.

Artzi and Jamil R. Azzi, an associate professor of medicine at Harvard Medical School and Brigham and Women’s Hospital, are the senior authors of the new study , which appears in the journal Advanced Materials . Nour Younis, a Brigham and Women’s postdoc, and Nuria Puigmal, a Brigham and Women’s postdoc and former MIT research affiliate, are the lead authors of the paper.

The researchers are now working on launching a company to further develop the technology, led by Puigmal, who was recently awarded a Harvard Business School Blavatnik Fellowship.

Direct delivery

Alopecia areata, which affects more than 6 million Americans, occurs when the body’s own T cells attack hair follicles, leading the hair to fall out. The only treatment available to most patients — injections of immunosuppressant steroids into the scalp — is painful and patients often can’t tolerate it.

Some patients with alopecia areata and other autoimmune skin diseases can also be treated with immunosuppressant drugs that are given orally, but these drugs lead to widespread suppression of the immune system, which can have adverse side effects.

“This approach silences the entire immune system, offering relief from inflammation symptoms but leading to frequent recurrences. Moreover, it increases susceptibility to infections, cardiovascular diseases, and cancer,” Artzi says.

A few years ago, at a working group meeting in Washington, Artzi happened to be seated next to Azzi (the seating was alphabetical), an immunologist and transplant physican who was seeking new ways to deliver drugs directly to the skin to treat skin-related diseases.

Their conversation led to a new collaboration, and the two labs joined forces to work on a microneedle patch to deliver drugs to the skin. In 2021, they reported that such a patch can be used to prevent rejection following skin transplant. In the new study, they began applying this approach to autoimmune skin disorders.

“The skin is the only organ in our body that we can see and touch, and yet when it comes to drug delivery to the skin, we revert to systemic administration. We saw great potential in utilizing the microneedle patch to reprogram the immune system locally,” Azzi says.

The microneedle patches used in this study are made from hyaluronic acid crosslinked with polyethylene glycol (PEG), both of which are biocompatible and commonly used in medical applications. With this delivery method, drugs can pass through the tough outer layer of the epidermis, which can’t be penetrated by creams applied to the skin.

“This polymer formulation allows us to create highly durable needles capable of effectively penetrating the skin. Additionally, it gives us the flexibility to incorporate any desired drug,” Artzi says. For this study, the researchers loaded the patches with a combination of the cytokines IL-2 and CCL-22. Together, these immune molecules help to recruit regulatory T cells, which proliferate and help to tamp down inflammation. These cells also help the immune system learn to recognize that hair follicles are not foreign antigens, so that it will stop attacking them.

Hair regrowth

The researchers found that mice treated with this patch every other day for three weeks had many more regulatory T cells present at the site, along with a reduction in inflammation. Hair was able to regrow at those sites, and this growth was maintained for several weeks after the treatment ended. In these mice, there were no changes in the levels of regulatory T cells in the spleen or lymph nodes, suggesting that the treatment affected only the site where the patch was applied.

In another set of experiments, the researchers grafted human skin onto mice with a humanized immune system. In these mice, the microneedle treatment also induced proliferation of regulatory T cells and a reduction in inflammation.

The researchers designed the microneedle patches so that after releasing their drug payload, they can also collect samples that could be used to monitor the progress of the treatment. Hyaluronic acid causes the needles to swell about tenfold after entering the skin, which allows them to absorb interstitial fluid containing biomolecules and immune cells from the skin.

Following patch removal, researchers can analyze samples to measure levels of regulatory T cells and inflammation markers. This could prove valuable for monitoring future patients who may undergo this treatment.

The researchers now plan to further develop this approach for treating alopecia, and to expand into other autoimmune skin diseases.

The research was funded by the Ignite Fund and Shark Tank Fund awards from the Department of Medicine at Brigham and Women’s Hospital.

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MIT researchers have developed microneedle patches that are capable of restoring hair growth in alopecia areata patients, reports Ernie Mundell for HealthDay . The team’s approach includes a, “patch containing myriad microneedles that is applied to the scalp,” writes Mundell. “It releases drugs to reset the immune system so it stops attacking follicles.” 

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