HealthJuly 29, 2022

Borderline personality disorder: Screening, diagnosing, and treating patients

When it comes to borderline personality disorder (BPD), two facts should concern clinicians in psychiatry and general practice.

The first is that roughly 3 in 4 BPD patients attempt suicide or otherwise engage in self-harm. The second is that BPD is often overlooked and undiagnosed in clinical practice. 

These concerns underscore the need for more education around diagnosing borderline personality disorder, as well as optimization of available treatments. Recently, one expert explored those topics and more in a 34-minute audio lecture, now available on-demand for CME credit from AudioDigest®.

Delivered by Donald W. Black, MD, Professor of Psychiatry at the University of Iowa Roy J. and Lucille A. Carver College of Medicine, the session “Update on Borderline Personality Disorder” covers the latest research informing BPD diagnostic criteria, screening, and treatment.

Check out the summary below, and then stream or download the full lecture at 

Understanding personality disorders 

Up to 2% of the general population has BPD, and those rates increase in different settings. Up to 10%, 20%, and 30% of psychiatric outpatient, psychiatric inpatient, and incarcerated populations respectively experience this condition. 

Unlike similar disorders, BPD can start off with a higher risk of self-harm and impulsivity before lessening over time. Onset typically begins in a person’s 20s, and attenuation may happen in their 40s, 50s, and 60s. Women are most likely to be affected, and all patients tend to have psychiatric comorbidities such as major depression. 

While the cause of BPD is not fully understood, risk factors may stem from both genetics and environmental factors: The condition is likely inherited, but childhood neglect and abuse can also play a role.

Recognizing borderline personality disorder symptoms 

Given the epidemiology of BPD, experts consider the diagnostic criteria to be polythetic — meaning that instead of requiring a single identifying symptom, a mix of BPD symptoms can qualify for diagnosis. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) provides nine symptomatic criteria, with at least five needed for a diagnosis. These include: 

  1. Inappropriate anger 
  2. Feelings of emptiness 
  3. Rapid mood instability 
  4. Stress-related paranoia and disassociation 
  5. Identity disturbance 
  6. Recurrent suicidal behavior 
  7. Impulsivity, such as in spending or eating 
  8. Fear of abandonment 
  9. Unstable relationships 

Screening and assessing BPD symptoms 

Because symptoms can make a person seem unlikable and dangerous, patients may not be receiving the care they need. According to one study conducted by Dr. Black, 37% of healthcare professionals admitted to avoiding care for BPD patients. 

Clinicians can overcome these barriers by more diligently screening and assessing patients. One option is the Zanarini Rating Scale, which asks patients how problematic certain symptoms have been over a period of time, such as the past week. 

Another option is to distribute a self-rating questionnaire that patients can fill out in the waiting room. This assessment would ask patients to scale their symptoms, such as whether a trusted person has become untrustworthy, from 1 to 5.  

No matter which screening method you use, also look for other psychiatric conditions, such as depression or posttraumatic stress disorder (PTSD). Awareness of these comorbidities can inform treatment. 

Optimizing psychotherapy and pharmacotherapy for BPD patients

Depending on the patient’s readiness and willingness to try them, treatments can include a balance of psychotherapy and pharmacotherapy options.  

Lifestyle changes such as nutritional support and physical activity are also important. Given misinformation surrounding BPD, patients should be taught more about their condition, a portion of care Dr. Black calls “bibliotherapy.” He lists some suggested books in his lecture. 

Improving clinicians’ familiarity with BPD 

Borderline personality disorder can be dangerous but remains underdiagnosed. Clinicians can help overcome the stigmas by evaluating more patients for DSM-5 criteria. While every case is different, patients may benefit from a mix of approaches across psychology and pharmacotherapy — as long as they’re willing to try them.  

Catch more of this critical topic and explore others in psychiatry, general practice, family medicine, and internal medicine.

Listen to Dr. Black’s full AudioDigest® lecture for the latest updates on Borderline Personality Disorder and read more about Dr. Black's lecture.


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