Study Points

Borderline Personality Disorder

Course #96221 - $60 • 15 Hours/Credits

  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
  1. The term "borderline" first arose to label patients with features in common with the two diagnostic entities it "bordered,"

    HISTORY OF BORDERLINE PERSONALITY DISORDER

    Unlike most personality disorders that were first described in Europe, the term "borderline personality" was introduced by American psychoanalyst Adolph Stern in 1938 to describe a patient group who did not fully fit the characteristics of psychotic or neurotic patient groups, thus existing on the "borderline" between the two. This concept of BPD persisted into the 1950s and 1960s. The identification and labeling of patients as "borderline" first arose during the era when psychiatry was dominated by the psychoanalytic paradigm. The classification system for mental disorders was primitive and dichotomous, with classification tied to patient capacity for analysis. Patients considered analyzable, and thus treatable, were diagnosed with neuroses, while those considered not analyzable, and therefore untreatable, were deemed to have psychoses [6].

    Click to Review
  2. The borderline personality disorder (BPD) concept and diagnostic criteria in the DSM-III and the DSM-IV were criticized on all of the following bases, EXCEPT:

    DIAGNOSTIC CRITERIA

    The introduction of operationalized diagnoses for BPD and other disorders based on observable criteria in the 1980 DSM-III was considered a significant advancement in the field. However, the concept of and diagnostic criteria for BPD during and after the 2000 DSM-IV-TR became increasingly criticized on several grounds. For example, the description of BPD was non-specific. In the DSM III and the DSM-IV-TR, clinicians were instructed to diagnose BPD when five out of nine criteria were met. But, with this paradigm, individuals diagnosed with BPD could have as few as one criterion in common. This led to the same diagnosis given to patients with various criterion permutations, producing a heterogeneous patient group [11]. This issue is thought to have been largely resolved with the alternative DSM-5 criteria.

    Research of BPD during the 13 years between the DSM-IV-TR and the DSM-5 clarified the understanding of BPD and prompted revisions to the diagnosis [4]. The greatest overall change between the DSM-IV and the DSM-5 has been the elimination of the multi-axial classification system, whereby BPD and other personality disorders were assigned a separate axis (Axis II). Several factors contributed to this change. The distinction between Axis I and Axis II disorders in earlier DSM editions received little empirical validation and increasingly became disputed in light of evolving research and clinical evidence. Personality disorders were traditionally conceptualized as the product of environmental factors, while Axis I disorders were viewed as having a biologic or organic cause. This dominant paradigm influenced the introduction of the multi-axial classification system in the DSM-III. While environmental stressors can contribute to personality disorder development, the same is also true with many Axis I disorders such as major depressive disorder (MDD) and PTSD. Also, BPD does not conform to traditional conceptions of personality disorders as ego-syntonic conditions; the symptoms of BPD are clearly ego-dystonic and lead patients to seek treatment for these symptoms [11,12]. Another criticism of DSM-IV-TR criteria was the combination of unstable, stress-induced symptoms and stable personality characteristics, also termed dimensional traits [13].

    Click to Review
  3. The proposed alternative diagnostic criteria for BPD in the DSM-5 are organized into what two sections?

    DIAGNOSTIC CRITERIA

    In the 2010s, a new model for diagnosing personality disorders was presented to the DSM-5 Task Force, and it was strongly and unanimously approved. However, the American Psychiatric Association Board of Trustees voted to sustain the DSM-IV-TR diagnostic system for personality disorders, including unchanged criteria for BPD, in the main section of DSM-5 due to insufficient evidence to validate the new proposed model [14]. The proposed new model is maintained in the DSM-5 as an "alternative DSM-5 model for personality disorders," and professionals have reported good clinical utility. These proposed BPD criteria are organized into two sections: impairments in personality (self and interpersonal) functioning and pathologic personality traits [4]:

    • Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following areas:

      • Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism, chronic feelings of emptiness, and/or dissociative states under stress

      • Self-direction: Instability in goals, aspirations, values, or career plans

      • Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities

      • Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal

    • Four or more of the following pathologic personality traits, at least one of which must be impulsivity, risk taking, or hostility:

      • Emotional lability (an aspect of negative affectivity): Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances

      • Anxiousness (an aspect of negative affectivity): Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control

      • Separation insecurity (an aspect of negative affectivity): Fears of rejection by—and/or separation from—significant others, associated with fears of excessive dependency and complete loss of autonomy

      • Depressivity (an aspect of negative affectivity): Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feeling of inferior self-worth; thoughts of suicide and suicidal behavior

      • Impulsivity (an aspect of disinhibition): Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress

      • Risk taking (an aspect of disinhibition): Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard for consequences; lack of concern for one's limitations and denial of the reality of personal danger

      • Hostility (an aspect of antagonism): Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults

    Click to Review
  4. The community prevalence of BPD indicates

    EPIDEMIOLOGY

    The results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) study, the first large-scale, community study of personality disorders in the United States, were published in 2008. This study found the overall lifetime prevalence rate for BPD was 5.9% (18 million people), with similar rates in men (5.6%) and women (6.2%). The prevalence of BPD was higher in Native American men; younger adults who were separated, divorced, or widowed; and persons with lower levels of education and socioeconomic status. Those with lower BPD prevalence were Hispanic men and women and Asian women [1].

    Click to Review
  5. Although there is no exact age of onset established for BPD, data extrapolation suggest

    EPIDEMIOLOGY

    In general, prevalence studies of BPD have found that prevalence in women is three times higher than in men in clinical settings, with similar gender prevalence in community settings [17,27,28]. Although epidemiologic studies have not formally assessed age of onset of BPD, data extrapolation from onset of self-harm (the most predictive symptom of BPD) suggests the onset of BPD occurs before 12 years of age in 32.8% of patients, begins between 13 and 17 years of age in 30.2%, and at 18 years of age or older in 37% [29,30]. The association of higher BPD prevalence with lower education, income, and socioeconomic class suggests these adversity factors predispose to developing BPD, although this association is likely bidirectional; BPD symptoms may contribute to poor educational achievement, lower income, and social class [18,27].

    Click to Review
  6. Which of the following sociodemographic factors is NOT associated with higher BPD prevalence?

    EPIDEMIOLOGY

    In general, prevalence studies of BPD have found that prevalence in women is three times higher than in men in clinical settings, with similar gender prevalence in community settings [17,27,28]. Although epidemiologic studies have not formally assessed age of onset of BPD, data extrapolation from onset of self-harm (the most predictive symptom of BPD) suggests the onset of BPD occurs before 12 years of age in 32.8% of patients, begins between 13 and 17 years of age in 30.2%, and at 18 years of age or older in 37% [29,30]. The association of higher BPD prevalence with lower education, income, and socioeconomic class suggests these adversity factors predispose to developing BPD, although this association is likely bidirectional; BPD symptoms may contribute to poor educational achievement, lower income, and social class [18,27].

    Click to Review
  7. The lifetime prevalence of major depressive disorder (MDD) in BPD is

    EPIDEMIOLOGY

    Persons with BPD have high lifetime rates of other psychiatric disorders, including bipolar disorder (10% to 20%), MDD (71% to 83%), substance use disorder (50% to 65%), panic disorder (34% to 48%), social phobia (23% to 47%), PTSD (47% to 56%), and eating disorders (7% to 26%). Co-occurring personality disorders are also common in BPD, including avoidant (43% to 47%), dependent (16% to 51%), obsessive-compulsive (18% to 26%), and paranoid (14% to 30%) personality disorders [12,41].

    Click to Review
  8. Medical conditions with higher prevalence in BPD include all of the following, EXCEPT:

    EPIDEMIOLOGY

    While several medical conditions are more common in patients with BPD than the overall population, exact figures on prevalence are difficult to find. Higher lifetime rates of diabetes, cardiovascular disease, sexually transmitted infection, and functional somatic symptoms appear in persons with BPD [42].

    Click to Review
  9. Which of the following statements concerning BPD pathogenesis is TRUE?

    PATHOGENESIS AND PATHOPHYSIOLOGY

    It is essential to note that BPD is no longer viewed as solely the result of parental or primary caregiver behaviors that shape passive, inert children. It is now recognized that innate temperament and behaviors in a child influence parental behaviors by passively evoking parental behaviors and by actively soliciting certain types of parental interactions [57,58]. This has been demonstrated in twin studies that found elicitation of maternal warmth was substantially controlled by child temperament [59].

    A temperament that predisposes sensitivity to interpersonal stress contributes to the development of BPD. In these infants and children, heightened distress states may trigger fearful response in a vulnerable, depressed, anxious, ill, or traumatized caregiver, further diminishing his or her already compromised availability to the child. In particular, child traits of interpersonal hypersensitivity and stress reactivity evoke parental reactions of fearfulness or helplessness and withdrawal, which significantly affect the vulnerable child. Parents of a pre-BPD child are likely to exhibit adverse responses when confronted by increasing neediness or anger in the child, with child and parent factors both contributing to an escalating series of negative and difficult interactions that contribute to adult BPD [60].

    Click to Review
  10. Infants with ambivalent attachment use which behaviors to engage the inconsistently attentive parent?

    PATHOGENESIS AND PATHOPHYSIOLOGY

    Proneness to distress, particularly at separation, is a core feature of ambivalent and disorganized attachment patterns, the childhood counterparts of adult BPD attachment dysfunction. Infants with insecure attachments show greater distress-prone temperaments and irritability and are more likely to express the ambivalent form of attachment. Ambivalent infants engage in hyperactivation behaviors intended to elevate their visibility and increase engagement from an inconsistently attentive parent; these behaviors include clinging, anger, resistance to contact, and failure to soothe in the presence of their parents. Most ambivalently attached children also show the features of disorganized attachment, while a subgroup of infants with disorganized attachment exhibit the amplified distress and difficulty in soothing that is observed in ambivalent attachment. This latter infant subgroup has a heightened vulnerability for developing BPD. Thus, infants born with highly distress-prone temperaments and raised under non-optimal conditions of parental attention and interaction are at greater risk of evolving into ambivalent and/or disorganized attachment and BPD [63].

    Click to Review
  11. The prevalence of BPD in mothers of patients with BPD is

    PATHOGENESIS AND PATHOPHYSIOLOGY

    Psychopathology is highly prevalent in the parents of patients with BPD, although it is difficult to determine the exact prevalence due to limited studies. The prevalence of maternal BPD is 10% to 15%. These mothers are more insensitive to their infants at 2 months of age, and their children are likely to show disorganized attachments at 1 year of age. Also prevalent in parents of patients with BPD are substance abuse, depressive disorders, eating disorders, and antisocial or other personality disorders [22,80,81]. An estimated 30% are negative for psychiatric disorder history [60]. The prevalence of affective, impulsive, and interpersonal phenotypes is increased in families of patients with BPD, including findings that 50% of relatives have affective instability, 33% have impulsivity, and 28% have disturbed relationship styles comparable to their borderline offspring with BPD [22,82,83].

    Click to Review
  12. The concordance hazard ratio of BPD is highest among which types of siblings?

    PATHOGENESIS AND PATHOPHYSIOLOGY

    A genetic basis of BPD was identified in several family studies that found family loading for the disorder and significantly higher prevalence of BPD in first-degree relatives of patients with BPD than in the general population [81]. Research from a 2019 total population study estimated aggregation and hereditability among family members, which showed a pattern of decreased familial association with genetic relatedness [47]. The concordance hazard ratio of BPD was 11.5 for monozygotic twins and 7.4 for dizygotic twins [47]. Among full siblings, the hazard ratio indicated a 4.7 times greater risk of BPD, compared with maternal half-siblings (2.1 times) and paternal half-siblings (1.3 times). Cousin relations were also part of the study, and it was found that the hazard ratio was 1.7 for cousins whose parents were full siblings, 1.1 for cousins whose parents were maternal half-siblings, and 1.9 for cousins whose parents were paternal half-siblings. Heritability has been found to range from 44% to 60%, with individual specific environmental factors accounting for the remaining variance. This extent of genetic influence exceeds that of anxiety disorders and depression, but is less than that of bipolar affective disorder or schizophrenia [18,47,95].

    Click to Review
  13. All of the following areas of the brain are believed to be involved in mediating emotion regulation, EXCEPT:

    PATHOGENESIS AND PATHOPHYSIOLOGY

    Emotion regulation is mediated by frontolimbic brain regions that include, among other structures, the amygdala, hippocampus, hypothalamus, dorsolateral and right dorsomedial prefrontal cortex, orbital frontal cortex, anterior cingulate cortex, and insula [121]. These and other structures are interconnected by function and structure and are recruited to modulate subcortical responses to emotional stimuli and inhibit behavioral impulses [122]. Dysfunction of this circuitry contributes to emotion dysregulation. Emotion regulation is best understood as an individual and interpersonal process that begins with early attachment and continues to later peer and romantic relationships. Early attachment and interpersonal relationships distribute the effort of emotion regulation through co-regulation [123].

    Click to Review
  14. Emotion sensitivity in BPD

    PATHOGENESIS AND PATHOPHYSIOLOGY

    In BPD, emotion sensitivity is thought to have a biologic origin with presence in early life. It involves heightened emotional reactivity to environmental stimuli and is primarily associated with negative mood states such as anger, fear, and sadness. This heightened emotional reactivity also involves the emotions of others. Emotion recognition studies in BPD show negativity bias in emotion recognition (i.e., negative emotions in others are over-identified) and poor accuracy in correctly identifying facial emotions [137,138].

    Click to Review
  15. Maladaptive emotion regulation strategies

    PATHOGENESIS AND PATHOPHYSIOLOGY

    Maladaptive behaviors to regulate emotion can lead to emotion dysregulation problems very obvious to others. If negative affect becomes sufficiently intense, the person will likely choose maladaptive over adaptive behaviors. While maladaptive behaviors can produce immediate reduction in negative affect and are simpler to employ than adaptive behaviors, they have negative consequences and can become ineffective with long-term use [148]. The maladaptive cognitive strategies of rumination and thought suppression, often used in BPD, actually increase negative affect in the long term [149,150]. Experiential avoidance is also common in BPD and is characterized by behaviors to escape unwanted experiences [151]. The impulsive, suicidal, and self-injurious behaviors common in BPD are behaviors specifically used to regulate affect [136].

    Click to Review
  16. All of the following factors contribute to delays in accurate diagnosis of BPD, EXCEPT:

    BARRIERS TO CARE

    Recurrent suicidal threats or actions in response to fears of abandonment are by themselves strongly indicative of a BPD diagnosis. However, BPD remains underdiagnosed, and often misdiagnosed, in large part because the characteristic recurrent crises, emotional volatility, and self-injurious behavior are perceived as willful manipulative choices rather than expressions of illness [49,62,77]. A substantial gap exists between the education and practice of mental health care, and the current educational system for mental health professionals does not pay adequate attention to BPD or other personality disorders. One study found an average 10-year time gap between initial presentation for treatment and accurate diagnosis of BPD [178]. With this time delay comes unnecessary suffering, wasted treatment efforts, and, with a 10% mortality rate from suicide in patients with BPD, tragic and potentially preventable fatality [171,179]. Several factors contribute to delays in accurate diagnosis of BPD, including stigma, reliance on pharmacologic treatments, desire for a clear-cut diagnosis, and costs.

    Click to Review
  17. All of the following statements regarding the appropriate age of BPD diagnosis are TRUE, EXCEPT:

    ASSESSMENT AND DIAGNOSIS

    The DSM-IV-TR explicitly stated to exercise great caution when diagnosing BPD in patients younger than 18 years of age, largely from the belief that personality and behavioral patterns during adolescence are predominantly transient. In other words, adolescents may "outgrow" borderline symptoms, so diagnosing them before 18 years of age is premature [187,188]. However, more recent research on BPD and personality development indicates that an adolescent diagnosis of BPD is valid, and ignoring BPD as a possible disorder in adolescents may hamper effective clinical intervention [189]. The typical onset of self-harm before 12 years of age suggests an important window to screen and provide early intervention for these children and their families [30].

    Click to Review
  18. Abnormal personality traits in BPD have been attributed to four factors. Which of the following is NOT one of these factors?

    ASSESSMENT AND DIAGNOSIS

    The new proposed diagnostic criteria for BPD in the DSM-5 are reliable and replicable and reflect the observable manifestation of dysregulated interpersonal, behavioral, identity, and cognitive domains [136]. However, the symptom criteria do not fully capture the foundational basis of the psychopathology. Abnormal personality traits in BPD have been attributed to four factors, with each factor representing an underlying temperament or phenotype:

    • Interpersonal hypersensitivity

    • Affect (emotional) dysregulation

    • Behavioral dyscontrol (impulsivity)

    • Disturbed self

    Click to Review
  19. In regards to intimate partner violence in persons with BPD, research suggests

    ASSESSMENT AND DIAGNOSIS

    RATES OF INTIMATE PARTNER VIOLENCE PERPETRATED BY MEN AND WOMEN WITH BPD

    Type of AggressionMenWomen
    AnySevereAnySevere
    Physical aggression23.9%8.0%31.0%11.3%
    Psychologic aggression65.7%20.9%75.3%25.3%
    Sexual aggression29.3%2.2%21.2%1.5%
    Click to Review
  20. In the initial assessment and diagnostic interview of persons with suspected BPD, a suggested approach is

    ASSESSMENT AND DIAGNOSIS

    The reliability of the diagnostic assessment for personality disorder has been considerably improved by the introduction of standardized interview schedules. There are two structured interview techniques widely used for diagnosing personality disorder with high specificity and reliability: the Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD) and the International Classification of Diseases, 10th Revision International Personality Disorder Examination (IPDE-ICD-10) [67,75,77]. The SCID-5-PD aligns with DSM-5 criteria for personality disorders diagnosis, while the IPDE-ICD-10 aligns with diagnostic criteria using the ICD-10 and DSM-IV-TR [67,75,77], One issue, common to many of the instruments, is the excessive length of time required for administration, with the interview for either method taking approximately one to three hours, depending on experience and skill level of the interviewing clinician [75,77]. A patient questionnaire is also available that can be completed in approximately 20 to 30 minutes, and will lessen the time of the interview. It should be noted that despite strengths such as reliability and direct correlation with DSM criteria, structured interviews and questionnaires may not fully capture the complexity and dynamics of patient mental health status. The diagnosis of BPD is most easily established by asking patients whether they believe the criteria for the disorder fits them and by listening to patients describe interpersonal interactions. Patients with BPD may be more likely to accept the assessment process by participating in the diagnosis. As discussed, patients and their families often find it helpful to be informed of the diagnosis and are relieved to learn that others share similar symptoms for which there are effective treatments [49].

    Click to Review
  21. Bipolar II disorder can be differentiated from BPD by all of the following, EXCEPT:

    ASSESSMENT AND DIAGNOSIS

    Distinguishing BPD from bipolar disorder, and especially bipolar disorder II, can present a diagnostic dilemma due to the shared, overlapping symptoms. Both disorders have in common a substantial risk of suicide or suicide attempt, impulsivity, and inappropriate anger. However, symptoms that differentiate BPD include self-mutilation, self-injurious behavior without suicidal intent, and a frequent history of childhood abuse. Insecure attachments, reflected by intense abandonment fears, are hallmarks of BPD and uncommon in bipolar disorder. Patients with BPD have higher levels of impulsivity, hostility, and acute suicidal threats relative to those with bipolar disorder. Careful history taking usually elicits a differing time course of mood lability. Patients with BPD are extremely sensitive to rejection and do not have episodes of mania. Mood lability is often triggered by interpersonal sensitivity; mood lability in bipolar disorder tends to be autonomous and persistent [49,161,203].

    Click to Review
  22. Narcissistic personality disorder can be differentiated from BPD by the presence of

    ASSESSMENT AND DIAGNOSIS

    In contrast to patients with BPD who present different aspects of their internal world from one moment to the next, patients with narcissistic personality disorder mask the fragmentation and weakness of their identity under a brittle and fragile grandiose self that they present to the world and to themselves [181]. Patients with a severe narcissistic personality disorder may present symptoms strikingly similar to those of patients with BPD, including general impulsivity, chaos in relations with significant others, severe breakdown in their capacity for work and emotional intimacy, and parasuicidal and self-mutilating behavior. These patients are also prone to antisocial behavior, which requires the differential diagnosis among different types of narcissistic pathology with different levels of antisocial features [181].

    Important differential features include the patient with narcissistic personality disorder's difficulty accepting any dependent relationship, their severe lack of investment in relations with significant others except in exploitative or parasitic relationships, and an aloofness that contrasts with the highly ambivalent yet clinging and dependent relationships of patients with BPD. Patients with narcissistic personality disorder can show extreme fluctuations between feelings of inferiority and failure and corresponding depressive reactions and an inordinate sense of superiority and grandiosity reflected by contemptuous and dismissive behavior toward others, including therapists. Patients with BPD may alternate their relationship between clinging dependency/idealization and angry rejection and dismissal, but do not show the chronically contemptuous and dismissive attitude of narcissistic patients. Resulting from these characteristics, patients with narcissistic personality disorder are usually isolated socially, even if they are externally part of a social network. They lose their friends and do not maintain relationships over an extended period of time, and their objective loneliness contrasts with the complicated, contradictory, yet enmeshed relationships of patients with BPD [181].

    Click to Review
  23. Which approach in traditional psychoanalytic psychiatry tends to exacerbate BPD patient pathology?

    GENERAL TREATMENT CONSIDERATIONS

    Kernberg stated that the adverse reactions to therapy that were highly commonplace in patients with BPD resulted from unconscious guilt (as an element of masochistic character structures), unconscious envy that underlies patient need to destroy what is received from their therapist, and unconscious identification with a primitive and sadistic object that underlies patient need to destroy the therapist as a good object [212]. Patient failure to improve with psychoanalytic therapy was solely attributed to pathologic motivations in the patient with BPD [6]. Improvements were rare exceptions rather than the rule. Although unknown at the time, in many patients with BPD traditional psychoanalytic therapy promoted symptom exacerbation from unintended toxic interaction between therapist approach and core BPD psychopathology [214]. Specifically, therapist neutrality encouraged patient projection and fueled abandonment fears, and therapist passivity promoted patient fears of disinterest and neglect. Therapist interpretations of negative motivations were experienced by patients as blaming and invalidating.

    Click to Review
  24. All of the following are TRUE of hospitalizing patients with BPD, EXCEPT:

    GENERAL TREATMENT CONSIDERATIONS

    For patients with BPD, hospitalization is usually restricted to the management of crises (including, but not limited to, situations in which patient safety is precarious) and is short in duration. Hospitals provide a safe place where the patient has an opportunity to gain distance and perspective on a particular crisis and where professionals can assess the patient's psychologic and social problems and resources. It is not uncommon for medication changes to take place in the context of a hospital stay, so professionals can monitor the impact of new medications in a controlled environment [3].

    However, hospital admission carries liabilities unique to patients with BPD. The American Psychiatric Association's recommendation of hospitalization whenever patients with BPD are suicidal has been criticized by experts for several reasons [86,223]. Patients can internalize the invalidating message of their inability to get through a crisis without hospitalization. Progress in therapy can be rendered impossible by repeated hospitalization, as this becomes the learned coping strategy for distress. Hospitalization also prevents addressing the interpersonal problem that triggered the crisis in the first place and can reinforce pathologic behaviors and make the patient worse [225].

    Click to Review
  25. All of the following statements regarding completed suicides in patients with BPD are TRUE, EXCEPT:

    GENERAL TREATMENT CONSIDERATIONS

    The most dangerous features of BPD are self-harming behaviors and suicide risk. Suicidal ideation (i.e., ruminating and fantasizing about suicide) is pervasive in the BPD population [3]. Up to 10% of persons with BPD complete suicide, a rate 50 times greater than in the general population. More than 70% of those with BPD attempt suicide at least once, and patients with BPD attempt suicide an average of 3.3 times in their life [86,226]. Suicide attempts in BPD tend to peak when patients are in their 20s and 30s, although suicidality can occur in any age group [8].

    This led researchers to investigate whether a high lethality subtype of BPD could be identified. One study found that patients at highest risk for suicide had greater illness severity, vocational failures, and estrangement from family and friends. Low lethality subjects had better overall psychosocial functioning but more negativism, lifetime substance abuse, and histrionic and/or narcissistic personality disorder comorbidity. Suicide attempts of this latter group may reflect dramatic "communicative gestures," which show little change in medical lethality with repeat attempts [227]. Long-term longitudinal data have identified factors with greatest prediction of suicide attempt: diagnosis of MDD, substance use disorder, or PTSD; non-suicidal self-harm behavior; sexual assault as an adult; caretaker death from completed suicide; affective instability; and more severe dissociation. Prediction of suicide attempts in patients with BPD is complex and involves assessment of co-occurring psychiatric disorders, prominent BPD symptoms (i.e., self-harm, affective reactivity, and dissociation), adult adversity, and family history of completed suicide [228].

    Click to Review
  26. In assessing suicide risk in a patient with BPD, higher risk is suggested when the patient is in which state?

    GENERAL TREATMENT CONSIDERATIONS

    Many clinicians have found concepts from dynamic deconstructive psychotherapy useful in understanding affective instability and suicide risk in patients with BPD [239]. This model frames the emotionally labile reactions to the environment as a switch between different states of being, or pseudo-personalities, such that patients can alternately present as helpless and childlike (helpless victim state), angry and self-righteous (angry victim state), or depressed and suicidal (guilty perpetrator state). These states reflect different sets of polarized and poorly integrated attributions of self and others, and not strategies of manipulation [235].

    Click to Review
  27. Which of the following is NOT one of the components of dialectical behavioral therapy?

    PSYCHOSOCIAL THERAPIES

    Dialectical behavioral therapy is based on the theoretical principle that maladaptive behaviors, including self-injury, are attempts to manage intense overwhelming affect of biosocial origin. Dialectical behavioral therapy incorporates the two key elements of a behavioral, problem-solving approach blended with acceptance-based strategies, with an emphasis on dialectical processes. This therapy approach emphasizes balancing behavioral change, problem-solving, and emotional regulation with validation, mindfulness, and acceptance of patients. Therapists follow a detailed procedural manual [22,87]. The term "dialectical" refers to the philosophical principle of opposite truths, such that constructs can be opposing yet true at the same time. A core dialectic in this therapy is accepting patients where they are in the moment and working to help them change [225]. The five components of dialectical behavioral therapy are [87,225]:

    • Capability enhancement (skills training)

    • Motivational enhancement (individual behavioral treatment plans)

    • Generalization (access to therapist outside clinical setting, homework, inclusion of family in treatment)

    • Structuring the environment (emphasis on reinforcing adaptive behaviors)

    • Capability and motivational enhancement of therapists (therapist team consultation group)

    Click to Review
  28. Which of the following statements regarding mentalization in BPD treatment is FALSE?

    PSYCHOSOCIAL THERAPIES

    Mentalization-based therapy is a psychodynamic approach based on attachment and cognitive theory. Mentalization refers to the ability to accurately imagine the mental states of others, a normal developmental milestone attained by stable early attachment relationships. Patients with BPD are thought to have deficits in mentalization resulting from problematic early attachments. The core features of BPD are thought to reflect this failure to develop mentalizing ability and the resultant profound disorganization of self-structure [225,248].

    The objective of mentalization-based therapy is to increase patient curiosity about their feelings and thoughts and to develop skills in identifying feelings and thoughts in themselves and others in the context of attachment relationships. By developing mentalizing skills and the capacity to understand their mental states and those of others in attachment contexts, patients are able to address problems with affect, impulse control, and interpersonal functioning, and reduce triggers for self-harm and suicidal behavior. Mentalization-based therapy is delivered in weekly individual and group therapy sessions [88,249].

    Click to Review
  29. A core pathologic BPD trait addressed in transference-focused psychotherapy is

    PSYCHOSOCIAL THERAPIES

    Transference-focused psychotherapy is based on Kernberg's conceptualization of the core problem of BPD—excessive early aggression led the young child to split positive and negative images of him/herself and his or her mother [250]. The pre-borderline child is unable to merge positive and negative images and corresponding affects to attain a more realistic and ambivalent view of self and others. The primary goal of transference-focused psychotherapy is to reduce symptomatology and self-destructive behavior by modifying representations of self and others as enacted in the transference relationship. Clarifications, confrontations, and transference interpretations are the primary techniques of this twice-weekly psychotherapy [88,248].

    Click to Review
  30. Which of the following therapy approaches has the greatest efficacy for BPD?

    PSYCHOSOCIAL THERAPIES

    While dialectical behavioral therapy, mentalization-based therapy, transference-focused psychotherapy, and interpersonal psychotherapy modified for BPD have all shown substantial benefit, no single therapy approach has emerged with greatest efficacy, which suggests that clinicians should offer the therapy modality that best matches their training, theoretical orientation, and preferences [42,252]. This point is underscored by repeated findings that treatment outcomes in patients with BPD is particularly influenced by the individual therapist [42].

    Click to Review
  31. Motivational interviewing is used by primary care providers for patients with BPD for all of the following reasons, EXCEPT:

    PSYCHOSOCIAL THERAPIES

    Two approaches for the primary care setting are motivational interviewing and problem solving. These are not treatment approaches per se, but instead are concrete, problem-focused tools that allow the clinician to improve the outcomes of patients with BPD while navigating some of the problematic behaviors and attitudes driven by the personality traits of BPD. Both were developed to address the very legitimate provider concerns over emotional endurance and job satisfaction when managing patients with BPD. When treating patients with BPD, clinicians should also consider a collaboratively developed crisis and safety plan and should use an overall approach of active listening, mindfulness, and strengthening patients' connections to their most important values [242,244,246].

    One of the biggest challenges in the successful treatment of patients with BPD and other personality disorders is the patient's tendency for irregular treatment attendance, disengagement and premature discontinuation of treatment, and resistance to help and intervention. Motivational interviewing has shown promise in assisting the provider to motivate patients with BPD to engage in therapy and effect positive change (Table 6) [230,244].

    Click to Review
  32. Which of the following is FALSE concerning pharmacotherapy for BPD?

    PHARMACOTHERAPY

    Medications may effectively reduce a single or narrow range of targeted symptoms in BPD but have not yet shown convincing efficacy in addressing the core features (i.e., frantic efforts to avoid abandonment, emptiness, identity disturbance, and dissociation). Medication is considered adjunctive to psychotherapy, and prescribing psychotropic medication can help build a positive alliance with the patient with BPD. The selection and prescribing of medication for BPD is more complicated than in patients with other psychiatric conditions [18,199]. For example, patients with BPD are often highly perceptive to physiologic stimuli and medication side effects. Several strategies can be used to help optimize pharmacotherapy response and minimize interference from BPD pathology [18,42,214]:

    • Emphasize the need for collaboration.

    • Set realistic expectations that medications are unlikely to produce BPD symptom remission and that therapeutic effects may be difficult to assess.

    • Involve the patient to help identify therapeutic targets, improve compliance, ensure safety, weigh possible benefits against drawbacks from side effects.

    • Do not prescribe prophylactically, only with patient request or when severely distressed. When requested but patient is not severely distressed, pharmacotherapy may still be considered to help establish an alliance. In these cases, be cautious and prescribe selective serotonin reuptake inhibitors, because despite modest benefits, they carry a low lethality risk in overdose.

    • If a patient is severely distressed but declines medication, encourage but do not push.

    • Use judgment in assessing medication benefit, because patients with BPD may value or devalue medications as a proxy for their perception of the prescriber relationship. Patients' decisions regarding medication may be based on fear of being controlled, not feeling cared for, or expectation of being cured.

    • Establish a policy that if medication response is absent, initiation of an alternate medication is contingent on full taper of the first medication (or cross-taper in severely distressed patients).

    • Stress the necessity for responsible usage to evaluate effectiveness.

    • When pharmacotherapy is used to help manage a BPD crisis, the medication should be withdrawn after the crisis has been resolved. The treatment course,dose, planned duration, and review intervals should be documented and communicated to other prescribers involved in the patient's care.

    Polypharmacy is associated with multiple side effects and has not shown improved efficacy over monotherapy. In fact, the number of prescribed medications is inversely related to improvement. Minimal attention has been given to medication effects on interpersonal relationships.

    Click to Review
  33. Which type of symptom in BPD may be more responsive to drug therapy?

    PHARMACOTHERAPY

    Among the more rigorously designed clinical trials of drug therapy for BPD, no drug agent has been found effective in improving the core features of abandonment fears and hypersensitivity, chronic feelings of emptiness, identity disturbance, or dissociation. This may be due to outcome assessments lacking the ability to detect change in these symptoms or because these core BPD symptoms are not treatable with currently available drug therapies [196].

    Click to Review
  34. Which atypical antipsychotic drug has shown some evidence of benefit in BPD?

    PHARMACOTHERAPY

    Second-generation atypical antipsychotics are more frequently prescribed for BPD, because they possess greater tolerability and show a broader therapeutic range due to their serotonergic and noradrenergic activity. Broadly, atypical antipsychotics are efficacious in reducing impulsive aggression, mood instability, anxiety, anger, impulsivity, and cognitive symptoms. Olanzapine and aripiprazole have accounted for a sizeable proportion of positive clinical trial results and have shown significantly improved affective instability, impulsivity, psychosis, and interpersonal dysfunction [197,201,251].

    Aripiprazole has the added benefit of a long half-life and favorable metabolic profile, making administration easier and possibly increasing adherence and therapeutic benefit. As a partial agonist at D2 and 5-HT1A receptors and an antagonist at 5-HT2A receptors, aripiprazole may possess greater efficacy in reducing the impulsivity and aggression associated with BPD [141,142]. Despite a similar mechanistic profile, ziprasidone has not shown benefit in BPD [139].

    Click to Review
  35. When used in the treatment of patients with BPD, benzodiazepines

    PHARMACOTHERAPY

    Use of benzodiazepines has not received empirical support and is generally contraindicated for patients with BPD due to the risks of behavioral disinhibition, addiction, and overdose. Benzodiazepines also impose the risks of inhibiting learning and interfering with skills acquirement [236]. Tricyclic antidepressants also pose a high risk of toxicity in overdose, including death due to fatal arrhythmia, and are generally avoided [104].

    Click to Review
  36. Family members of patients with BPD should be engaged in treatment because

    ADDRESSING THE FAMILY

    There is broad awareness that families of patients with BPD should, in most cases, be involved in the therapeutic process. One reason is that destructive family dynamics can greatly contribute to treatment drop-out by patients with BPD. In addition, families typically experience significant distress from living with and trying to cope with the problems of the patient with BPD. Regardless of the role family played in life adversity of the patient with BPD, they can become entangled in dysfunctional relationships with the patient that impede treatment. Family intervention can include providing psychoeducation concerning BPD and its origin, course, and treatment; teaching family members problem-solving skills to address difficult patient dynamics and provide the patient with validation; and transmit other communication skills to address the emotional reactivity of the relative with BPD [97,98,102].

    Click to Review
  37. In the treatment of BPD and comorbid MDD,

    TREATMENT OF COMORBIDITIES

    Although MDD is virtually ubiquitous as a comorbidity in BPD and despite some overlap between MDD and BPD symptoms (such as chronic dysphoria in BPD and sadness and worthlessness in MDD), patients meeting full criteria may not benefit from antidepressants. The reasons for reduced antidepressant response remain unclear. Clinical trials have found that in patients with BPD and a co-occurring major depressive episode, improvement in BPD symptoms resulted in later improvements in major depressive symptoms, but the reverse was not found. In addition, patients with BPD receiving psychotherapy have shown reductions in self-reported depressive symptoms. Thus, specific treatment that targets BPD may be effective treatment for both disorders [41,202,251].

    Although some pharmacotherapy trials have found reductions in comorbid depressive symptoms, these results are difficult to interpret, as most of the studies excluded patients with comorbid MDD. Furthermore, while the interventions led to reductions in subsyndromal depression symptoms, remission rates in patients with comorbid BPD and MDD were not evaluated. Studies combining medication and specialized psychotherapy have shown mixed results, generally supporting the conclusion that treatment of BPD leads to improvement in depressive symptoms. Psychotherapy is generally more important than pharmacotherapy in positive treatment outcomes of BPD and comorbid MDD [41,251].

    Click to Review
  38. Which of the following statements regarding BPD and PTSD is TRUE?

    TREATMENT OF COMORBIDITIES

    Comorbid PTSD is a more complex problem. It is important that BPD is not treated as a variant of PTSD. Evidence-based psychotherapies for BPD, such as dialectical behavioral therapy, tend to focus on the present and short-term future, and these alone are not helpful for PTSD. In some cases, time-limited, evidence-based CBT for PTSD has been useful [41].

    Click to Review
  39. In the treatment of BPD and comorbid eating disorder,

    TREATMENT OF COMORBIDITIES

    When eating disorders are comorbid with BPD, rates of the eating disorder tend to decline over time, although change to another eating disorder may also occur. This suggests that eating disorder symptoms reflect the core impulsivity of BPD. Patients who exhibit serious weight loss from anorexia nervosa require treatment for the eating disorder before starting BPD therapy. Binging and purging behaviors can be addressed by the same treatment approaches used to reduce self-harming behaviors in specialized psychotherapies for BPD [41,94].

    Click to Review
  40. Long-term follow-up studies of BPD prognosis have found

    PATIENT PROGNOSIS

    However, the course of BPD rarely, if ever, shows a simple linear improvement. The frequent alternation between progress and setback is emotionally draining for everyone involved. Long-term studies of the course of BPD found the first five years of treatment are typically the most crisis-ridden. A series of intense, unstable relationships that end angrily, with subsequent self-destructive or suicidal behaviors, are characteristic. Although such a pattern may persist for years, decreasing frequency and seriousness of self-destructive behaviors, decreased suicidal ideation and acts, and declining frequency and duration of hospitalization are early indicators of improvement. Following hospitalization, roughly 60% of patients with BPD are readmitted in the first 6 months; this declines to 35% 18 to 24 months after initial hospitalization. In aggregate, utilization of psychiatric care gradually diminishes over time to involve briefer, less intensive interventions [3].

    Interpersonal and social functioning are much slower to improve, and improvements are usually smaller in magnitude than with other BPD symptoms. Approximately 25% of patients with BPD eventually achieve stable relationships or successful vocational adjustment. Many more show limited vocational success and become more avoidant of close relationships. While many patients attain symptom stabilization and improved life satisfaction, impairment of social role functioning is highly persistent and often disappointing [3].

    Click to Review

  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.