borderline personality disorder case study paper

REVIEW article

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

• 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.

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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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Lived experiences of adults with borderline personality disorder: a qualitative systematic review protocol

McDonagh, Teresa 1 ; Higgins, Agnes 1 ; Archer, Jenny 2 ; Galavan, Eoin 3 ; Sheaf, Greg 4 ; Doyle, Louise 1,5

1 School of Nursing and Midwifery, Faculty of Health Sciences, Trinity College Dublin, The University of Dublin, Dublin, Ireland

2 The Open University, Milton Keynes, UK

3 School of Psychology, Faculty of Arts, Humanities and Social Sciences, Trinity College Dublin, The University of Dublin, Dublin, Ireland

4 The Library of Trinity College Dublin, Trinity College Dublin, The University of Dublin, Dublin, Ireland

5 The Trinity Centre for Practice and Healthcare Innovation: a Joanna Briggs Institute Affiliated Group

Correspondence: Teresa McDonagh, [email protected]

The authors declare no conflicts of interest.

Objective: 

The objectives of this review are: to explore the lived experiences of individuals with a diagnosis of borderline personality disorder (BPD) and to present recommendations for policy, practice, education and research.

Introduction: 

Borderline personality disorder is a mental disorder characterized by poor capacity to engage in effective relationships, intense and sudden mood changes, poor self-image and emotion regulation, significant impulsivity and severe functional impairment. Studies estimate the prevalence of BPD at 15% to 22% and identify a predominantly negative attitude among health professionals towards individuals with BPD. This review will examine the lived experiences of people with a diagnosis of BPD in order to better understand this condition.

Inclusion criteria: 

This review will include peer-reviewed qualitative studies on adults with a diagnosis of BPD in all settings and from any geographical location.

Methods: 

A three-step search strategy will be used. A search strategy has been developed for MEDLINE. A second search using all identified keywords and index terms will be conducted across MEDLINE, CINAHL, PsycINFO and Embase. Studies will be screened by title and abstract by two independent reviewers against the review inclusion criteria. The full text of selected citations will be assessed against the inclusion criteria and for methodological quality. Qualitative data will be extracted from included papers using a standardized data extraction tool. Qualitative research findings will be pooled using the meta-aggregation approach. The final synthesized findings will be graded according to the ConQual approach and presented in a Summary of Findings.

Systematic review registration number: 

PROSPERO CRD42019141098.

Introduction

The epidemiology of borderline personality disorder (BPD) has been studied in a variety of large-scale population-based surveys. 1 A national comorbidity survey (n = 5692) in the United States reported a prevalence of 1.4% for BPD. 2 A British study (n = 626) reported a lower population prevalence rate of approximately 0.7%. 3 Data from a large scale mental health survey (n = 5303) in the Netherlands 1 found that 3.8% of the study population experienced three to four symptoms of BPD and 1.1% experienced more than five symptoms, which the authors point out meets the criteria for a BPD diagnosis, according to Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). 4 However, the National Epidemiological Survey on Alcohol and Related Conditions, a US survey of more than 40,000 people conducted from 2000 to 2010, reported finding a higher lifetime prevalence of BPD of 5.9%. 5 Some consensus has therefore been reached that the population prevalence for BPD may be conservatively estimated at 1%. 1-3 Consistent with most epidemiological surveys, but not clinical studies, 1,6 the results demonstrated no significant difference in the prevalence of BPD between men and women. 5 This finding contradicts the DSM and other writings that assert that BPD occurs more commonly in women than in men by a ratio of 3:1. 1,4,6 From a feminist perspective, BPD is therefore considered to be a gendered diagnosis. 7,8 Higher rates of BPD diagnosis in women has been attributed to a number of factors, including assessment bias, increased treatment-seeking among women, sampling bias and sociocultural differences; however, these potential explanations require further research. 9-11

Studies estimate that the prevalence of BPD in people experiencing mental health problems and attending mental health outpatient clinics is 15% to 22%. 12,13 A 2008 two-phase cross-sectional study conducted in a Canadian general adult outpatient university clinic with 360 patients demonstrated a BPD prevalence rate of 22.6%. 12 A 2012 cross-sectional study conducted in two Shanghai psychiatric outpatient clinics (n = 3075) found the that prevalence of BPD among the psychiatric outpatients was 5.8%, with a prevalence of 3.5% among males and 7.5% among females. 13 The prevalence among outpatients in this Chinese study is notably lower than that reported in North America. The prevalence in mental health inpatient settings is further estimated to be in excess of 20%. 4,14,15

Borderline personality disorder was first introduced in the 1980s as a diagnostic category in the DSM-III. 15 Through the evolution of each version of the manual, the DSM maintains a narrow view from the medical model perspective on the problems experienced by people labeled as having BPD. The dominance of the medical model is much criticized and contested in mental health as an approach that is paternalistic, illness-focused and reductionist. 16 The medical model reduces human distress to a list of symptoms to be formulated into diagnosis without consideration of the “patient as a person.” Scott, 17 in questioning the medicalization of mental distress, decries the seemingly endemic diagnostic labeling in mental health. Remaining firmly entrenched in the medical model, the current manual DSM-5 18 demonstrates a particular understanding of BPD that continues to medicalize human distress. Similarly, within practice, many clinicians persist in labeling complex human experiences with features of emotional dysregulation, impulsivity and social-interpersonal difficulties, using the DSM-5 definition and nomenclature of BPD. This is also the terminology that appears most commonly in the literature. DSM-5 18 defines BPD as a “mental disorder” characterized by poor capacity to engage in effective relationships, intense and rapid changes in mood and affect, poor self-image and emotion regulation, significant levels of impulsivity and severe functional impairment. Within this framework, “symptoms” of BPD are said to normally emerge in adolescence or early adulthood. Symptom severity ranges from mildly impairing to severely disabling. 19 In a book that challenges the medical perspective, Gunn and Potter describe the nomenclature surrounding BPD, particularly that of the DSM, as that which “reduces this human struggle to a list of concrete symptoms.” 7 (p.112) The authors argue that this diminishes the individual concerned and results in complex human behaviors being examined out of context. Steffen 20 considers BPD from a humanistic standpoint and extols a holistic view of the individual as capable of self-actualization and growth in accordance with the Rogerian theory. 21 This view rejects clinical diagnosis as a means of labeling and pigeon-holing individuals into prescribed categories within a rigid system of classification.

The BPD label is particularly attributed to individuals who self-harm, especially women. 22 Consequently, individuals with a diagnosis of BPD frequently present in general hospital emergency departments for treatment following acts of self-harm, substance abuse and attempted suicide. 23-25 A meta-analysis of studies that examined gender differences in the prevalence of non-suicidal self-injury (NSSI) found that the rate of NSSI was slightly higher in women than in men. 26 A US study that examined the relationship between NSSI and borderline symptoms among college students found that participants who engaged in NSSI were more likely to be female χ 2 (1, N = 723) = 11.22, P < .001. 27 While those experiencing and living with any mental health diagnosis experience stigma, the term “surplus stigma” has been assigned to BPD. 28 Gunn and Potter describe BPD as “one of the most stigmatized and overused diagnoses in existence.” 7 (p.3) Some studies have explored the subjective experiences of stigma and discrimination endured by people with a diagnosis of BPD. One such study reveals that the experience can be separated into two categories: the stigma surrounding diagnosis and the BPD label, and the experience of stigma from within the healthcare context related to the negative attitudes of staff. 29 Further, Bonnington and Rose 29 describe the experiences of individuals with a diagnosis of BPD as being stereotyped, enduring psychological abuse and having their diagnosis withheld, resulting in exclusion from appropriate treatment.

People who experience significant mental distress that manifests as symptoms of emotional dysregulation and impulsivity often have a long history of complex trauma. Frequently, the distress that results from these traumatic experiences is subsequently categorized as BPD. Grant 30 emphasizes that the use of the term “distress” in this context does not mean “disease” or disorder” and discusses the need for a change of language to better conceptualize, research, understand and relieve “human misery.” People diagnosed with BPD report such distress as a form of intense emotional pain. 31 Such distress can impact on an individual's education, employment and social engagement leading to isolation, which in a circular manner, can exacerbate the individual's distress. 32 In addition, exclusion by society and health services has been the norm for people with a diagnosis of BPD for many years. 33-35 Yet national and international research studies, government policies and guidelines challenge the historical assumption that people with a diagnosis of personality disorders are untreatable. 31,36,37 Following a review of the literature, Biskin 38 concludes that BPD, once considered a lifelong medical condition, now carries a more positive prognosis. Mental health services worldwide have an obligation to provide appropriate services for quality care and management to improve outcomes for individuals with a diagnosis of BPD. 32,36,37

Health professionals have a critical role in working with individuals who have a diagnosis of BPD experiencing distress, whether in a hospital, forensic, outpatient clinic, primary healthcare or community setting. However, published literature reveals prevailing negative attitudes, lack of empathy, stigma, reluctance to engage and low levels of optimism for recovery among health professionals in relation to people with a BPD diagnosis. 39-41 In an Australian survey 39 on the experiences of emergency medicine and mental health clinicians (N = 140) working with BPD, many reported experiencing an “uncomfortable personal response” and feelings of frustration, anger and inadequacy when working with this cohort. Many participants believed people with a diagnosis of BPD to be more in control of their adverse behaviors such as self-harm than people with other psychiatric diagnoses.

In an Israeli study, 40 mental health clinicians (n = 710) from four professions (psychiatry, psychology, social work and nursing) completed two questionnaires, one measuring attitudes toward patients with a BPD diagnosis, and another measuring attitudes either toward patients with a BPD diagnosis, patients with major depressive disorder (MDD) diagnosis or patients with generalized anxiety disorder (GAD) diagnosis, using a short narrative. Nurses and psychiatrists encountered a greater number of patients with a BPD diagnosis and demonstrated more negative attitudes and lower levels of empathy toward these patients than the other two professions. Negative attitudes were positively correlated with caring for a higher numbers of patients with a BPD diagnosis. Nurses were most highly motivated to learn short-term methods for treating patients diagnosed with BPD and a lower percentage of psychiatrists demonstrated interest in improving their professional skills in treating this cohort.

An Irish study 41 that explored interactions and levels of empathy among psychiatric nurses (n = 17) found that overall the participants perceived people with a diagnosis of BPD in a negative way and found it difficult to deliver good quality care to this cohort. Studies from the consumer perspective reveal that individuals with a diagnosis of BPD commonly perceive health professionals as holding negative and stigmatizing attitudes and lacking in empathy. 42-43 Studies further indicate that prevailing negative attitudes of health practitioners and stigma act as barriers to people accessing services, resulting in exclusion of service users from care pathways. 44,45

Understanding the lived experience of people with a diagnosis of BPD, demonstrating empathy and the ability to relate to them in a humanistic way are key elements in the therapeutic relationship. Knowledge and understanding of that lived experience enables health professionals to promote individualized care and assist individuals experiencing mental distress to engage in personal reflection, thus leaning them towards self-care and mindful behavior change. 46 The evidence on negative attitudes among healthcare professionals and demonstrable lack of understanding and empathy for individuals with a diagnosis of BPD point to the need for further comprehensive research. This will be used to establish an evidence base from which improvements can be made, and services and health professionals developed to respond appropriately to the care needs of individuals with a diagnosis of BPD. This review will contribute to that evidence base.

Over the past four decades, many studies have been dedicated worldwide to examining the etiology, epidemiology, pathophysiology, costs, treatments and outcomes of this complex human condition. 47,48 The perspectives of people diagnosed with BPD have also been explored in the literature in respect of their lived experience of diagnosis, stigma and treatment. 49-51 A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews and the JBI Database of Systematic Reviews and Implementation Reports was conducted and no current or underway systematic reviews on the topic of the lived experiences of adults with a diagnosis of BPD were identified. A related review, as yet unpublished, was identified that explores experiences of stigma and discrimination in BPD. 52 This review is confined to examining the experience of stigma and/or discrimination experienced by individuals with a diagnosis of BPD or emotionally unstable personality disorder, including self-stigma. The principal outcomes are to understand to what extent individuals with the diagnosis experience stigma and discrimination and to establish the nature of those stigmatizing and discriminatory experiences endured by individuals diagnosed with BPD. A systematic review and meta-synthesis that examines the experiences of people diagnosed with BPD admitted to acute psychiatric inpatient wards has also recently been published. 53 In that review, the focus is specifically on “exploring the experiences of people with BPD in acute psychiatric wards.” 52 (p.2) The specific focus of this review is to explore the lived experience of individuals with a diagnosis of BPD, whether they have been hospitalized or not. This review differs in scope from the identified existing systematic reviews in that it is not solely concerned with the experiences of stigma and discrimination for individuals with a diagnosis of BPD but rather the broad spectrum of their lived experiences, and neither is the review confined to the inpatient setting but any setting in which the individuals lives. Studies included in the identified existing reviews may be included in the proposed review if they meet the inclusion criteria.

Human experience is necessarily at the core of qualitative research; however, the notion of “lived experience,” which comes from the German verb erleben meaning “to live through something,” has specific methodological significance. As Smith 54 explains, the term “lived experience” indicates an intention to explore directly the original and immediate meaning of phenomena in people's lives prior to any interpretation. In contemporary human scientific inquiry, exploring the “lived experience” aims to elicit critical insights into the meaning of phenomena in people's lives. 55 It is envisaged that in synthesizing the qualitative research that broadly explores the lived experiences of people with a diagnosis of BPD, this complex mental health problem may be better understood.

Review objectives

The aim of this systematic review is to synthesize available evidence on the lived experiences of adults with a diagnosis of BPD. The specific objectives of this review are:

• To explore the lived experiences of individuals with a diagnosis of BPD
• To present recommendations for policy, practice, education and research.

Inclusion criteria

Participants.

The review will consider studies where the data are obtained directly from adults (18 years of age and older) who are defined by the primary study authors as having a diagnosis of BPD.

Phenomenon of interest

The review will consider studies that examine the lived experiences of individuals with a diagnosis of BPD.

The context for this review is all settings, including, but not limited to, the home, primary health care, inpatient, outpatient, forensic and community mental health settings. The review will take an international perspective, aiming to capture all data relevant to the lived experiences of adults with a diagnosis of BPD. The review will consider publications from any geographical location (e.g. urban, rural and remote) in any country. Differences in culture and healthcare systems may be evident in some studies. 56

Types of studies

The current review will consider peer-reviewed studies published in English that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research. Mixed methods studies may be included where the qualitative element elicits rich descriptions and where there is a well described and recognized method of qualitative data analysis.

Exclusion criteria

Studies will be excluded where the reviewers find difficulty in extracting the qualitative data, for example, mixed methods studies where the qualitative data are not clearly separated out or studies with mixed participant groups where data on the experiences of individuals with a diagnosis of BPD cannot be separated out. Studies whose participants are younger than 18 years will be excluded. Studies that include participants both over and under the age of 18 years will be excluded if responses from the adult participants are not explicit in the findings. Conference abstracts, commentaries and opinion pieces will not be included. Studies whose participants are not attributed a diagnosis of BPD will be excluded.

The proposed systematic review will be conducted in accordance with the JBI methodology for systematic reviews of qualitative evidence. 57 This review has been registered in PROSPERO (CRD42019141098).

Search strategy

The search strategy aims to find published and unpublished studies that examine the phenomenon of interest. A three-step search strategy will be used in this review. An initial limited search of MEDLINE via PubMed will be undertaken, followed by an analysis of the text words contained in the title and abstract and the index words used to describe each article. A search strategy has been developed for MEDLINE (Appendix I). A second search using all identified keywords and index terms will then be conducted across all included databases. The reference list of all studies selected for critical appraisal will be screened for additional studies. Studies published in English from 1980 to the present will be included as BPD first appeared as a diagnostic entity in the DSM-III published in 1980. 15

Information sources

The databases to be searched include MEDLINE, CINAHL, PsycINFO and Embase. Initial keywords to be used in the search will be borderline personality disorder, experience, perspective, perceptions, qualitative research, phenomenology, grounded theory, ethnography, action research, feminist research and mixed methods. Sources of unpublished studies will include ProQuest Dissertations and Theses, and relevant government websites such as the National Institute of Mental Health (US), the National Health Service (UK) and RIAN (Ireland). Where necessary, authors of studies will be contacted for missing information, if possible, using the contact information provided in the article.

Study selection

Following the search, all identified citations will be collated and uploaded into EndNote X8.2 (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria of the review. Potentially relevant studies will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full text studies that do not meet the inclusion criteria will be recorded and reported in the systematic review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion, or with a third reviewer. The results of the search will be reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram. 58

Assessment of methodological quality

Each paper selected for retrieval will be assessed independently by two reviewers for methodological quality prior to inclusion in the review using the JBI Critical Appraisal Checklist for Qualitative Research. 57 Authors of papers will be contacted to request missing or additional data for clarification, where required. Any disagreements that arise between the two reviewers will be resolved through discussion or in consultation with a third reviewer. The results of critical appraisal will be reported in narrative form and in a table. All studies, regardless of the results of their methodological quality, will undergo data extraction and synthesis (where possible).

Data extraction

Qualitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI SUMARI. 57 The data extracted will include specific details about the populations, context, culture, geographical location, study methods and the phenomena of interest relevant to the review objective. The level of congruency between the findings and the supporting data will be graded for credibility using three levels: unequivocal, credible or unsupported. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.

Data synthesis

Qualitative research findings will, where possible, be pooled using JBI SUMARI with the meta-aggregation approach. 57 This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation through assembling the findings rated according to their quality and categorizing those findings based on similarity of meaning. These categories will then be subjected to meta-synthesis to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative form.

Assessing confidence in the findings

The final synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings. 59 The Summary of Findings includes the major elements of the review and details how the ConQual score is developed. Included in the Summary of Findings will be the title, population, phenomena of interest and context for the specific review. Each synthesized finding from the review will be presented along with the type of research informing it, a score for dependability and credibility, and the overall ConQual score.

Acknowledgments

Trinity College librarian, Jessica Eustace-Cook, for providing guidance on the development of the initial search strategy. This review is conducted as an element of a PhD for TMD.

Appendix I: Search Strategy for MEDLINE

Search run: 12-02-2018

Results retrieved: 574

• 1. MH “borderline personality disorder” OR TI (“borderline personality disorder∗” OR “emotionally unstable personality disorder∗”) OR AB (“borderline personality disorder ∗ ” OR “emotionally unstable personality disorder ∗ ”)
• 2. TI (attitude ∗ OR awareness OR belief ∗ OR comprehension OR experienc ∗ OR feel ∗ OR opinion ∗ OR perceiv ∗ OR perception ∗ OR perspective ∗ OR thought ∗ OR understanding OR value ∗ OR view ∗ ) OR AB (attitude ∗ OR awareness OR belief ∗ OR comprehension OR experienc ∗ OR feel ∗ OR opinion ∗ OR perceiv ∗ OR perception ∗ OR perspective ∗ OR thought ∗ OR understanding OR value ∗ OR view ∗ )
• 3. MH (“anecdotes as topic” OR “focus groups” OR “grounded theory” OR “hermeneutics” OR “interviews as topic” OR “narration” OR “nursing methodology research” OR “observational study as topic” OR “personal narratives as topic” OR “qualitative research” OR “tape recording” OR “video recording”) OR TI (“action research” OR “case stud ∗ ” OR “content analysis” OR descriptive OR ethnograph ∗ OR “exploratory stud ∗ ” OR “feminist research” OR “focus group ∗ ” OR “grounded theory” OR hermeneutic ∗ OR “interpretative analysis” OR interview ∗ OR “mixed design ∗ ” OR “mixed method ∗ ” OR “mixed model ∗ ” OR multimethod ∗ OR “multiple method ∗ ” OR narrative OR phenomenolog ∗ OR “qualitative research” OR “qualitative stud ∗ ” OR “thematic analysis” OR “thematic coding” OR triangulat ∗ ) OR AB (“action research” OR “case stud ∗ ” OR “content analysis” OR descriptive OR ethnograph ∗ OR “exploratory stud ∗ ” OR “feminist research” OR “focus group ∗ ” OR “grounded theory” OR hermeneutic ∗ OR “interpretative analysis” OR interview ∗ OR “mixed design ∗ ” OR “mixed method ∗ ” OR “mixed model ∗ ” OR multimethod ∗ OR “multiple method ∗ ” OR narrative OR phenomenolog ∗ OR “qualitative research” OR “qualitative stud ∗ ” OR “thematic analysis” OR “thematic coding” OR triangulat ∗ )
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Borderline personality disorder; meta-synthesis; emotional instability

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12 Borderline Personality Disorder

• Published: February 2013
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Chapter 12 covers Borderline Personality Disorder (BPD), and includes definition and history of the condition, description and background of dialectical behavior therapy (DBT) used to treatm BPD, background history of the patient, assessment strategy, case formulation and treatment approach, course of treatment, treatment transfer specific to this case, relapse prevention, avoiding common mistakes in therapy, and case conclusions.

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Borderline personality disorder “discouraged type”: a case report.

1. Introduction

2. case presentation, 3. discussion, 4. conclusions, author contributions, institutional review board statement, informed consent statement, conflicts of interest.

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Share and Cite

Duică, L.; Antonescu, E.; Totan, M.; Boța, G.; Silișteanu, S.C. Borderline Personality Disorder “Discouraged Type”: A Case Report. Medicina 2022 , 58 , 162. https://doi.org/10.3390/medicina58020162

Duică L, Antonescu E, Totan M, Boța G, Silișteanu SC. Borderline Personality Disorder “Discouraged Type”: A Case Report. Medicina . 2022; 58(2):162. https://doi.org/10.3390/medicina58020162

Duică, Lavinia, Elisabeta Antonescu, Maria Totan, Gabriela Boța, and Sînziana Călina Silișteanu. 2022. "Borderline Personality Disorder “Discouraged Type”: A Case Report" Medicina 58, no. 2: 162. https://doi.org/10.3390/medicina58020162

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• DOI: 10.3233/JVR-170874
• Corpus ID: 149105098

Work participation of individuals with borderline personality disorder: A multiple case study

• K. Dahl , N. Larivière , M. Corbière
• Published 2017
• Journal of Vocational Rehabilitation

13 Citations

Employment interventions to assist people who experience borderline personality disorder: a scoping review.

• Highly Influenced
• 11 Excerpts

Course and predictors of social security disability insurance in patients with borderline personality disorder over 24 years of prospective follow-up

Daily living functioning in men with borderline personality disorders: a scoping review, individual placement and support effectiveness for personality disorders compared with other mental disorders: a retrospective study, the role of borderline personality disorder symptoms on absenteeism & work performance in the netherlands study of depression and anxiety (nesda), towards a fine-grained analysis of the link between borderline personality pathology and job burnout: investigating the association with work-family conflict, consumer, health professional and employment specialist experiences of an individual placement and support programme, personality testing and the americans with disabilities act: an applicant/employee perspective, experience of occupations among people living with a personality disorder, le 4ème congrès européen sur le trouble de personnalité limite et les troubles associés - vienne 2016, 41 references, women’s perceived work environment after stress-related rehabilitation: experiences from the redo project, recovery, as experienced by women with borderline personality disorder, supervisor competencies for supporting return to work: a mixed-methods study, prediction of time‐to‐attainment of recovery for borderline patients followed prospectively for 16 years, introduction to the special issue on individual placement and support., subjective cognitive complaints and functional disability in patients with borderline personality disorder and their nonaffected first-degree relatives, work accommodations and natural supports for maintaining employment., work outcomes and their predictors in the redesigning daily occupations (redo) rehabilitation programme for women with stress-related disorders., employment in borderline personality disorder., recovery in borderline personality disorder (bpd): a qualitative study of service users' perspectives, related papers.

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• Introduction
• Moral insanity in the 19th century: the rise of the hybrid and paradoxical profession
• Stern’s formal definition
• The development of borderline in the post-war period
• The Diagnostic and Statistical Manual III (1980): the appearance of borderline
• Post-Diagnostic and Statistical Manual: borderline hits the mainstream
• Conclusions
• Conflict of interest

Subjects and Keywords

Related content.

• Previous Article
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A history of borderline: disorder at the heart of psychiatry

This article suggests that to appreciate some of the conundrums that surround ‘borderline personality disorder’ (BPD), we need to understand more about its history and the contexts and cultures in which it arose, consolidated and proliferated. Previous work on the development of personality disorder diagnoses (Jones, 2016) points to their emergence and shape being determined by the interaction of a multiplicity of forces including the needs of distressed individuals and communities; the manoeuvring of professional groups seeking to provide solutions to that distress and the cultural, public and media representations and responses to those problems and the proposed solutions.

This single article can only begin to outline some of the key issues and will focus on the emergence of the diagnosis within the discourses of psychiatry. As we will see in the case of BPD, like other, so-called, disorders of personality, there are connections to major social changes; in particular to some of the anxieties raised by urbanisation and industrialisation and later processes of deindustrialisation and their impacts on people’s lives and identities.

The article argues that significant roots of the diagnosis can be traced back to major fault lines in the discipline of psychiatry and unresolved questions about its own borders. Is psychiatry a branch of the medical profession or is it a cross-disciplinary endeavour that centres the mind as an object of study and treatment, which cannot merely be located in the individual but is instead immanently connected to the social and cultural world?

This article suggests that to appreciate some of the conundrums that surround ‘borderline personality disorder’ (BPD), we need to understand more about its history and the contexts and cultures in which it arose, consolidated and proliferated. Previous work on the development of personality disorder diagnoses ( Jones, 2016 ) points to their emergence and shape being determined by the interaction of a multiplicity of forces including the needs of distressed individuals and communities; the manoeuvring of professional groups seeking to provide solutions to that distress and the cultural, public and media representations and responses to those problems and the proposed solutions.

The article is motivated by the idea that to appreciate some of the conundrums and puzzles that surround ‘borderline personality disorder’ (BPD), we need to understand more about its history and the contexts and cultures in which it arose, consolidated and proliferated. Previous work on the development of personality disorder diagnoses ( Jones, 2016 ) point to their emergence and shape being determined through iterative interaction of several forces:

• 1. The perception of distress, or problems, occurring at individual, community or social levels.
• 2. The manoeuvring of professional groups seeking to provide solutions to that distress or those problems.
• 3. The impact of cultural, public and media representations and responses to those problems and the proposed solutions.

While this single article can only begin to outline some of the key issues and will focus on the emergence of the diagnosis within the discourses of psychiatry, it needs to be held in mind that while the diagnosis is clearly the product of ‘psychiatry’, it is insufficient to simply focus on the appearance of the diagnosis within the textbooks and manuals of the profession. Its emergence has also to be understood within the various social and cultural contexts in which the diagnosis has arisen and been maintained. As we will see in the case of BPD, like other, so-called, disorders of personality, there are connections to major social changes; in particular to some of the anxieties raised by urbanisation and industrialisation and later processes of deindustrialisation and their impacts on people’s lives and identities.

Stories of the emergence of BPD usually attribute the formal recognition to the paper by the American psychoanalyst Adolf Stern ( 1938 ), and the substantial consolidation of the diagnosis to the appearance of BPD in the 3rd edition of the Diagnostic and Statistical Manual (DSM) published by the American Psychiatric Association in 1980. This article will suggest that there are complicated tales around these events and that the ‘problem’ with borderline is that it falls on territory that has been subject to considerable dispute within psychiatry. Borderline can only really be properly understood as what might be termed a transdisciplinary disorder that formed in the territory that is subject to substantial epistemological dispute.

The formal diagnosis emerged at a point in time and in places where there was explicit belief within the field of mental health and psychiatry that its endeavours were necessarily transdisciplinary in nature. The problem is that since then this transdisciplinary diagnosis has gone on to survive within disciplinary contexts that have little capacity to comprehend let alone respond to such a multidimensional ‘disorder’. Debate over the status of the ‘personality disorders’ runs to the heart of conflict over the nature of the subject matter of psychiatry, and BPD has come to be at the centre of the battle over where the boundaries of the discipline lie.

The article is divided into four chronologically ordered sections, each outlining the significance of a particular era. We begin at the birth of the formal profession of psychiatry in the early decades of the 19th century amidst the turbulence of industrialisation and urbanisation, when claims for new forms of ‘mental’ disorder were being made within the context of emergent modern European national states. These new forms of disorder were distinct from the insanity that was understood to involve a loss of reason (that would be understood to be visibly manifest [ Loughnan, 2012 ]) that had been understood for many centuries ( Walker, 1968 ). They were also distinct from forms of ‘unhappiness’ or ‘distress’ (such as melancholia, for example) that had both been recognised for centuries (for example, Burton, 1638 ).

These new disorders can be considered under the general heading of ‘moral insanity’ and were associated with antisociality, criminality and even violence, and were understood to exist, hidden away, within ‘the mind’ of the sufferer. The claim of expertise in the detection of such disorders was one of the central planks of the appeal made by the emerging profession of psychiatry. This proposal that ‘the mind’ should be at the heart of the psychiatric endeavour quickly became contested within the profession, and ‘borderline’ falls precisely on this disputed territory.

Second, this article surveys the emergence of the borderline diagnosis itself through the 1930s and into the post-Second World War period. It will be argued that the diagnosis, born formally at this point, needs to be understood as a transdisciplinary disorder. Like the earlier conceptions of moral insanity, it supposed a form of interiority, but one that was conceived within fields of enquiry that assumed an intimate connection between psychic states and the surrounding social world. Third, the article looks at the publication of BPD in DSM III in 1980. While doubtless a milestone in the establishment of the disorder, this official recognition glossed over underlying battles between different factions within psychiatry who understood the discipline in very different terms. One group were clinicians, strongly influenced by psychoanalytic ideas, who wanted to defend their expertise in the exploration of interiority and to provide treatment to those who attended their clinics. Ranged against this view were those who saw the job of psychiatry, as befitting of a branch of medicine, to observe symptoms and identify syndromes that could be associated with organic lesions. The resulting version of BPD that made it into DSM was recognisable in terms of symptomatology to the version that emerged in the 1930s but was largely shorn of the conceptualisation of BPD as a transdisciplinary disorder located both within the individual and within the environment. The fourth section looks at the explosion of BPD in the mainstream in the past few decades.

Up until the early decades of the 19th century the territory upon which new profession of psychiatry emerged ( Porter, 1987 ; 2002 ) could be understood as made up of two distinct areas. First, there were the various forms of unhappiness and distress (as the popularity of work such as Burton [ 1638 ], Mandeville [ 1711 ] and Cheyne [ 1733 ] can testify; and also see MacDonald [ 1981 ]). Second, there were also more overt and dramatic forms of insanity that rendered the sufferer without reason. This distinction has been largely carried through into the contrasting categories of neurosis and psychosis as they emerged through the first half of the 20th century ( Beer, 1996 ), such that Laplanche and Pontalis ( 1988 ) could dryly note that the former might indicate a visit to your doctor, while the latter more likely suggested accommodation in an asylum.

It is less well recognised that it was the ‘discovery’ of a set of disorders that do not fit into either category that was a crucial factor in the emergence of psychiatry as a formal professional body. It was the proposal of diagnoses such as ‘moral insanity’ in the early decades of the 19th century that staked out this third territory. The fundamental idea of ‘moral insanity’ (and the related diagnoses of the various monomanias and partial insanities) was that there were forms of insanity that could affect the mind of the sufferer in very particular ways that might impact on the emotions or morals of the individual, thus allowing for highly antisocial behaviour to occur. It was this conceptualisation that allowed the new profession to make claims for expertise in the criminal justice system to arbitrate on matters of insanity or criminal responsibility ( Goldstein, 1987 ; 1998 ; Jones, 2016 ). The diagnoses were used in the criminal justice system to defend those accused of serious crime, even when the defendant was evidently not suffering from obvious manifest forms of insanity that might have left them bereft of reason. These new forms of insanity were developed initially in French psychiatry through the notion of the ‘monomanias’ ( Esquirol, 1845 ; Goldstein, 1987 ); forms of insanity that might impact only on one very particular aspect of the mind and taking precise shapes such as kleptomanias and homicidal monomanias, for example (for example, Georget, 1826 ). At this point, they were distinctly psychological concepts, requiring professional expertise to detect them hidden away in the mind of the suffer often using what we now think of as a clinical interview ( Jones, 2017 ). With some success in the courtrooms around the middle of the 19th century (notably in Britain), this thinking was taken beyond the world of criminality, with the work of British medic James Cowle Prichard a landmark as he formally proposed the diagnosis of ‘moral insanity’ in the 1830s (for example, Prichard, 1835 ). He was interested in the more general antisocial tendencies that might be the consequence of this form of mental disorder. He argued that ‘moral insanity’ affected only the ‘feelings, temper, or habits’ of an individual, rendering them ‘incapable … of conducting himself with decency and propriety in the business of life’. Meanwhile their capacity to talk or reason was left intact ( Prichard, 1835 : 4).

As we will see, it is onto this ‘new’ territory that borderline was to be born some years later. The problem is that this is highly contested territory scarred by battle between those that would want the profession to be true to its medical roots and those that wanted to celebrate the hybridity of the profession ( Berrios, 2019 ). 1 The former assumed that disease resided in the organs of an individual and that treatments would ultimately need to intervene at the level of the body. The latter viewed the territory as encompassing ‘the mind’ which not only drew in the world of subjective experience but also raised many questions about where the borders of the mind might lie. Could the mind simply be considered as a function of the brain, or does it encompass the wider world of experiences that might include social and cultural matters?

For reasons discussed thoroughly elsewhere ( Jones, 2016 ; 2017 ), the organicist view of psychiatry triumphed from the middle of the 19th century, becoming entangled with eugenical thought whose catastrophic consequences became clear in the 1930s through the rise of Nazism. The clarity provided by this moral catastrophe strengthened those branches of psychiatry that were committed to social and psychological frameworks of understanding, and renewed interest in forms of ‘moral insanity’.

‘Those others’: the emergence of borderline – the 1930s and the Second World War

While theorisation of ‘moral insanity’ in the 19th century laid the ground for the emergence of this ‘other’ category of mental disorder, which were to become known as ‘personality disorders’, it was not until the 1930s that the borderline diagnosis began to take shape. We can see the phrase ‘borderline’ beginning to be used in clinical literature (for example, Glover, 1932 ) and a formal description was published by Adolf Stern in 1938. It will be suggested here that the concept emerged through these periods of social crisis – the economic and social crises of the 1930s followed by the turmoil of war. The Second World War itself had considerable significance, as the full horror of the Holocaust revealed the twisted and dangerous logic of eugenics and pushed psychiatry away from the biological path it had been on for many decades. It was psychoanalysis that offered the most obvious alternative paradigm and it is here that borderline disorder begins to be conceptualised. As we will see, however, the concept fell within contested territory here as well.

The paper by psychoanalyst Adolph Stern, published in 1938, is often referred to as the first formal attempt to distinguish ‘borderline’ as a particular disorder. Stern reported gathering his data from the histories of his patients and his reflections on the experience of psychoanalytic therapy with them. Some of the features of the disorder that were to become established as characteristic of the diagnosis are here in Stern’s description. There are mentions of ‘hypersensitivity’, ‘deep rooted insecurity’, ‘dependent attitudes’ and ‘demands for pity, sympathy’, and the possibility of negative therapeutic reactions provoking ‘suicidal ideas’ or ‘suicidal attempts’ ( Stern, 1938 : 58–59). Besides this, there is no direct reference to self-harm, although Stern does claim that patients would ‘hurt themselves in their business, professional, social, in fact in all affective relations’ ( Stern, 1938 : 61).

Stern was a significant figure in the formative decades of American psychoanalysis, at various times being president of the American Psychoanalytic Institute and president of the New York Psychoanalytic Society ( Eisendorfer, 1959 ). His 1938 paper appears on the face of it to be light on theory, with only two authors referred to (Sigmund Freud and David M. Levy). 2 Nevertheless, it is apparent that Stern’s work can be located within what was becoming contested territory in psychoanalysis, with two prominent battles shaping the paper. These were, first, the significance of childhood trauma and abuse as salient causes of mental illness (and borderline issues in particular). Second, there was dispute over the intervention style: should the psychoanalyst actively provide emotional support to the patient rather than simply rely on the interpretive method of psychoanalysis? Both points came to be viewed as transgressive within orthodox psychoanalysis, and were both associated with the work of Sandor Ferenczi. This was the Hungarian psychoanalyst right at the heart of psychoanalytic endeavours, and a friend of Freud in the early years of psychoanalysis, until falling out of favour thanks to his views. Stern would have been very aware of Ferenczi’s work, notably attending the 6th Psychoanalytic Congress in The Hague in 1920 when Ferenczi was president of the International Society. Stern, attending as president of the American Psychoanalytic Society, was on the committee that approved the publication and adoption of the International Journal of Psychoanalysis founded by Ferenczi. At the same conference, Ferenczi presented a paper on the importance of the ‘active technique’ to work with some patients as an alternative to the blank screen of free-association (Ferenczi, 1980 [1920] ).

Stern declared that ‘at least 75%’ of his ‘borderline’ group had experienced at least one negative family factor in early childhood. Separation and divorce were described as commonly occurring before the age of seven. The mothers were described as ‘decidedly’ neurotic or psychotic types, who inflicted psychological injuries on their children as they lacked the ‘capacity for simple spontaneous affection’. Further, ‘actual cruelty, neglect and brutality’ were often found in the background operating ‘more or less constantly over many years from earliest childhood’ ( Stern, 1938 : 56). This latter theme was developed in a follow-up paper in 1945 that emphasised that it was not so much specific experiences of abuse that were the problem but that the ‘traumata were practically continuous’ such that ‘their environment was in itself traumatic’ ( Stern, 1945 : 190–191).

[I]t should be welcomed and responded to with whatever parental capacity the analyst has. Support, assurance, understanding, respect, consideration, and unflagging interest are all necessary. The assurance of being wanted, of belonging, helps materially to develop self-assurance and a strong ego structure. Since these are so lacking in the borderline group, they must be developed in and by the treatment. ( Stern, 1945 : 196)

Stern’s paper directly describes some of what were to be become regarded as the outward symptoms of borderline, but also what were to become enduring controversies concerning what might underlie such symptoms and what might provide help. Stern is aligned with Ferenczi’s plea both for ‘active therapy’ and the identification of the significance of environmental trauma. Both claims place him quite far from what had become psychoanalytic orthodoxy, which emphasised the significance of unconscious fantasy rather than actual abuse and the adherence to the classical technique.

Of course, although Stern’s paper appears as the first formal description, ideas of borderline conditions were already cropping up in clinical literature and elsewhere. The next section will consider the significance of an important example where the concept of borderline was being used in a way that was to prove influential. We see here how at least one version of the diagnosis was formed in circumstances far beyond the psychiatric clinic, encouraged by a highly cross-disciplinary understanding of the nature of mental distress.

There is little doubt that BPD has entered popular discourse thanks in considerable part to its inclusion in DSM III in 1980. This is the same edition that gave considerable boost to the use of the personality disorders by giving them their very own axis; inviting clinicians to assign their clients to a personality disorder alongside other conditions. This article will look at some of the debates that surrounded the inclusion of BPD in DSM a little closer, after exploring a little of the groundwork that led to some acceptance of the categories of personality disorder that took place in the pre-war years.

Borderliners: Winnicott, Hawkspur and the Institute for the Study of Delinquency

Andre Green (1977: 24) , at a conference organised to facilitate the entry of borderline into DSM III (discussed later), reviewed various theoretical approaches to the problem and then proclaimed Donald Winnicott as ‘the analyst of the borderline’. As Winnicott had not published explicitly on ‘borderline’, 3 the connection might not have been obvious. Winnicott had, however, described the ‘character disorders’ as ‘a third category … the in-betweens’ that he viewed as distinct from either the psychoneuroses or psychoses. He also echoed Stern’s earlier work in suggesting that these were ‘individuals who started well enough, but whose environment failed them at some point, or repeatedly, or over a long period of time’ ( Winnicott, 1984a : 235). However, Green’s justification for lauding Winnicott as the analyst of the borderline was deeper than this. It is important to understand that Winnicott’s stance was nurtured within the object relations school of psychoanalysis, that came to dominate psychoanalytic thought and practice in Britain and to a considerable extent in the United States and was widely acknowledged to have influenced those who had a strong hand in the entry of borderline into DSM. It is worth spending a little time understanding this perspective, and the way that it asks questions about the borders of the mind.

While it is only a certain amount of teleological hindsight that can identify ‘a school’ of object relations thinking, 4 at the core of the movement was a shift from early Freudian theory that supposed that human beings were only motivated towards relationships by the need to meet drives (whether of hunger, or of a sexual nature). Instead, it was assumed that individuals have a fundamental need to relate to others and this itself drives much human behaviour. Developmental processes are therefore embedded in social relationships. While, in keeping with the work of Melanie Klein, the mainstream world of psychoanalysis gave considerable emphasis to the fundamental importance of the relationship with the mother, there was significant scope for work that emphasised and theorised the significance of wider social and cultural relationships (notably in the work of Ian Sutie [ 1935 ] and John Macmurray [ 1939 ], for example).

The significant move here is that it became possible to question the idea that many forms of ‘psychopathology’ could be understood in terms of individual psychology, but were instead better understood as ‘relational’; existing in an intermediate territory between the internal world of the individual and the surrounding social world. It was Winnicott who was to become the best-known channel for this line of thought as he developed the idea of the importance of transitional phenomena and space (Winnicott, 1984b [1970] ). As Green (1977: 24) notes, this work emerged from a significant shift in Winnicott’s perspective away from the typical psychoanalytic focus on the intrapsychic towards the ‘interplay of the external and the internal’. The cause and radical nature of the shift in Winnicott’s thinking is perhaps not as well-known as it should be, but it is also very relevant to the question of ‘borderline’. Towards the end of his life Winnicott ( 1984b [1970] ) paid credit to the influence of the experience he had with working with children in the context of what was effectively an experiment in community living in the early 1940s. He had provided consultative support to a war-time children’s home that provided shelter for children, from troubled backgrounds, who were evacuated from the threat of bombing in London. Their behaviour and distress meant that they could not be accommodated in ordinary families and were instead billeted to institutional care. Once such home was organised by the Q-Camps committee who had run Hawkspur camp, an experimental intervention for young men between 1936 and 1941 who were considered at risk of falling into lives of delinquency ( Wills, 1941 ). There is no space to fully describe the principles of the camp here but suffice to say that it emerged from an eclectic mix of influences that included a commitment to community activism, an interest in the dynamics of democracy, belief in the benefits of a pioneering lifestyle that were all stimulated by the social and political changes wrought by economic depression, mass unemployment alongside some excitement at the democratic possibilities created by the emergence of full suffrage in 1928 ( Jones and Fees, 2024b ). Added to this was an interest in group processes and object relations psychoanalysis. The camp was directly supported by the Institute for the Study and Treatment of Delinquency (ISTD) (itself psychoanalytically informed but a highly cross-disciplinary organisation that went on to nurture the emergence of British criminology as well as the ‘Psychopathy Clinic’, that became the Portman Clinic). The Hawkspur work itself informed the development of group and community therapies that occurred in the post-war period ( Harrison, 2000 ).

It is also striking that Hawkspur was organised to provide a service for what the leading protagonist called ‘those others’, or ‘misfits’ who were not being served by mental health services as they existed at that point, often with challenging early experiences ( Franklin, 1971 ). The ISTD provided psychological assessments of the camp members, and we can see the language of character disorder and even ‘borderline’ itself being used ( Jones and Fees, 2024a ). For example, the psychiatrist Dennis Carrol at the ISTD described one of the very first admissions as ‘a borderline schizophrenic’ and that ‘his tendency to decide what is best for him and worry people to do it is characteristic of people in this state’. 5 More strikingly there is also evidence of this language of ‘borderliner’ being picked up the young men themselves. Indeed, the same young man wrote a letter after he had left referring himself as ‘a person who is called a “borderliner” by doctors and who is made continuously wretched by his ailment’. 6

Fuelled by the experiments in group and community therapies that aimed to work with this new client group there was considerable interest in treatment and policies aimed at the problem of psychopathy (that was at this point being used as a version of what was to become ‘antisocial personality disorder’) ( Ramon, 1986 ). In the UK psychopathy was to be an important part of the 1959 Mental Health Act, and the US witnessed a whole series of polices directed at the treatment of sexual psychopaths in the post-war period ( Swanson, 1960 ). It was this post-war period that saw the rise of the ‘personality disorders’.

The Diagnostic and Statistical Manual and ‘personality disorder’

The DSM itself arose from post-Second World War dissatisfaction with previous nosologies that appeared to only serve the needs of those who worked in the asylums (and dealt with cases of insanity) or those who worked with the neurotic and unhappy in private clinics ( Harper, 2020 ). The Second World War and mass mobilisation brought military psychiatry into contact with a wider array of the population, particularly those who had experienced trauma and whose difficulties might be characterised as struggling to fit in with the demands of military life ( APA, 1952 ). The significant ‘new’ category were the ‘personality disorders’ 7 that were described in terms that clearly occupied the territory opened up by the notion of ‘moral insanity’: ‘characterized by developmental defects or pathological trends in the personality structure, with minimal subjective anxiety, and little or no sense of distress. In most instances, the disorder is manifested by a lifelong pattern of action or behavior, rather than by mental or emotional symptoms’ ( APA, 1952 : 34).

Emotionally unstable personality In such cases the individual reacts with excitability and ineffectiveness when confronted by minor stress. His judgment may be undependable under stress, and his relationship to other people is continuously fraught with fluctuating emotional attitudes, because of strong and poorly controlled hostility, guilt, and anxiety. This term is synonymous with the former term ‘psychopathic personality with emotional instability’. ( APA, 1952 : 36)

The use of the male gender here, of course, is consistent with writing conventions in a society that saw masculinity as the norm. It is fair to say, however, that there is no reason to think this was a diagnosis aimed at women at this point. Meanwhile, the language of ‘hostility, guilt and anxiety’ is indicative of the influence of psychoanalysis, although there is no particular reference to Stern’s description, nor to the idea of being close to ‘psychosis’.

The second edition of DSM ( APA, 1968 ) represented a shift to a more ‘psychological’ approach and the influence of psychoanalysis is clearer. According to the appendix the equivalent of ‘emotionally unstable’ is now ‘hysterical personality disorder’, which was described as ‘characterized by excitability, emotional instability, over-reactivity, and self-dramatization. This self-dramatization is always attention-seeking and often seductive, whether or not the patient is aware of its purpose. These personalities are also immature, self-centered, often vain, and usually dependent on others’ ( APA, 1968 : 43: 301.5). The linguistic assumption of male gender has now disappeared and, given the historical association of the term hysterical with femininity, this now seems to be a gendered diagnosis. There is brief mention of ‘borderline schizophrenia’ ( APA, 1968 : p34) but there is still no notable entity of borderline even at this point. The entry of borderline was to take place in 1980, and was one of the most controversial topics dealt with by the committee dealing with the new edition.

Published in 1980, DSM III is widely recognised as representing a remarkable shift in psychiatric nosology ( Kutchins and Kirk, 1997 ). It is considerably longer, consisting of almost 500 pages and 265 diagnoses, compared to DSM II of around 130 pages and 182 diagnoses. Planning for DSM III began only five years after the publication of DSM II ( Decker, 2013 ). As the APA acknowledged, there was an urgency driven by a sense that psychiatry faced crisis, besieged by an array of critics ( Mayes and Horwitz, 2005 ). One wing of the attack took a broadly sociological stance that viewed the concepts of psychiatry as mere social constructions designed to oppress and coerce those whose behaviour and thoughts did not fit the expectations of rational Western modernity, or who otherwise railed against the observed injustices or negative experiences of the average patient. This view was consistent with the various counter-cultural movements of the 1960s that questioned conventional institutions and their assumptions. Surveyed under this harsh light, psychiatry was not just failing to ameliorate the misery of mental suffering, it was often one of the causes. The other major attack came from a very different angle; from those who saw psychiatry as failing to carry out its promise to become a full and proper branch of medicine. To them its concepts were already too woolly, based on clinical intuition and deductive logic (that at this point was often following well-trodden psychoanalytic theoretical tropes). Scrutinised under the microscope of conventional medicine, psychiatry was systematically failing to identify syndromes and pin their aetiology down into identifiable lesions within the organs of the body ( Kutchins and Kirk, 1997 ).

This battle was to be played out most explicitly over the terrain of the personality disorders. Decker ( 2013 ) describes Robert Spitzer, appointed to lead the transformation of DSM, as ‘pre-occupied’ from the outset with this ‘contentious’ and ‘mine strewn grouping’ that exemplified the battle between researchers and clinicians ( Decker, 2013 : 196). As a psychoanalyst and quantitatively minded researcher he was well placed to bridge between the researchers who loathed these seemingly amorphous categories, and the clinicians who found the diagnoses usefully described forms of distress that they encountered in their clinics.

The positivistic minded researchers styled themselves as ‘neo-Kraepelins’ after Emil Kraepelin, the influential German psychiatrist who pushed hard for psychiatric diagnoses to be more objectively tied to symptom manifestations that were assumed to represent underlying lesions of the nervous system ( Kendler et al, 2009 ). While this group were generally sceptical about the concepts of personality disorder, they could accept the idea that there were disorders that were not fully manifest versions of more identifiable mental illnesses (such as schizophrenia). In this view the concept of borderline could be understood to be referring to a disorder that was merely on the borderline with psychosis, and not an entity in its own right.

The shape of the immediate battle that led to the inclusion of BPD can be seen in a major conference on borderline that was hosted by the Menninger Clinic in Topeca in March 1976 (leading to a collection of papers edited by Peter Hartocollis [ 1977 ]). Andre Green’s paper that emphasised the significance of Winnicott was given at this conference and has already been discussed. While the nature of the host venue ensured that the interests of clinicians were well represented, it brought protagonists from both sides of the divide together. Kafka ( 1981 ) later observed that despite ‘some genuine attempts at communication’, there was huge distance between the philosophical approaches taken by the groups and ‘massive resistances’ were mobilised against venturing into shared terrain. The clinicians were generally followers of psychoanalytic theory and those that had direct influence on DSM such as Otto Kernberg ( 1977 ) and Donald Rinsley ( 1977 ) both gave papers at the conference and pressed for a version of object relations theorisation. Researchers and medical psychiatric perspectives were represented by papers that promoted psychometrics ( Singer, 1977 ), described links to ‘borderline schizophrenia’ ( Gunderson, 1977 ) and proposed the familial links between schizophrenia and borderline ( Goldstein and Jones, 1977 ).

Despite scepticism from the positivist perspectives, Spitzer appeared to acquiesce to the clinicians and favoured the inclusion of borderline as a particular entity. As part of a strategy for clearing the way for this, he, and researchers Jean Endicott and Miriam Gibbon, published a technical paper in the Archives of General Psychiatry on the eve of the publication of DSM III ( Spitzer et al, 1979 ). They reported on their efforts to tease out the two different ways that the concept of borderline could be understood. Was ‘borderline’ best construed as a specific clinical entity as favoured by the clinicians or as simply as a word that signalled a milder form of another diagnosis such as schizophrenia (using the term schizotypal)? Spitzer et al ( 1979 ) operationalised a set of criteria for both versions and tested both on a sample of patients. 8 They argued that their findings provided evidence for both forms of disorder – schizotypal and borderline. Throughout the paper, however, the authors emphasised their negative feelings about the term borderline and their hope to replace it with ‘unstable personality disorder’ (similar to that previously used in DSM I). They acknowledged, however, that the clinicians they consulted would ‘never abandon the term “borderline”’ as it better described what they saw as a rather stable condition. Spitzer conceded on the term ‘borderline’, and the argument that BPD should be recognised as a distinct clinical entity was won. At the point of publication there were three clusters of personality disorder. BPD was found in cluster B, alongside narcissistic, hysterical and antisocial personality disorders. The categories of borderline, narcissistic and hysterical all have obvious connections to psychoanalysis and an underlying theoretical link to all four is provided by Kernberg’s notion of borderline organisation (Kernberg, 1985 [1975] ), itself rooted in object relations psychoanalysis ( Klein and Tribich, 1981 ). However, the DSM process meant that this version of borderline bore little relationship to the more complex, cross-disciplinary disorder that was construed as existing in a form of transitional space (to use Winnicott’s language) between the world of individual psychology and the social world. Instead, the chosen criteria focused on observable behaviour and thus this squeezed out the knotty problems concerning where the boundaries of the mind might be judged to lie, let alone how ‘it’ might be observed and measured. Of the eight criteria, five clearly emphasise the location of the pathology within an individual (impulsivity/unpredictability, inappropriate anger, affective instability, physically self-damaging acts, chronic feelings of emptiness or boredom), while three are perhaps a little more suggestive of the significance of social dynamics: identity disturbance, unstable and intense interpersonal relationships, and an intolerance of being alone ( APA, 1980 : 321). Just over a single page of the manual is devoted to BPD, in contrast to the four pages devoted to ‘antisocial personality disorder’. There is little sense here of just how significant this diagnosis was to become in the following decades.

The inclusion of BPD as a specific clinical entity in DSM might have looked like a victory for the clinicians and psychoanalysis. However, the avowedly positivistic stance and the reliance on simple descriptions of behaviours meant that in many ways this was a major defeat. The diagnosis was shorn of its connections with the exploration of interiority, and certainly with the idea that it might be a disorder existing within a transitional space that existed neither solely within the borders of the individual, nor simply within the social world. The DSM definition is an individualised diagnosis, with little trace of the transdisciplinary understanding of borderline that was apparent in the work of Hawkspur, and that of Winnicott. Neither is the more sympathetic account of Stern and his emphasis on the significance of environmental damage apparent here either.

DSM III was in its own terms a considerable success. It became the accepted textbook in US psychiatry and then more globally. Medical students were taught to learn and use its criteria, academic and professional journals expected authors to refer to it ( Mayes and Horwitz, 2005 ). As Mayes and Horwitz (2005: 264) argued, ‘the historic shift from a psychosocial to a symptom-based view of mental health was complete’. A few years after the publication of DSM III, Morton Reiser, responsible for training psychiatrists in the United States, worried that psychiatry was ‘losing the mind’ ( Reiser, 1988 ), as the trainees he was coming across were ‘astoundingly unpsychological’. They used DSM III to diagnose and decide on the ‘pharmacotherapy’, at which point ‘meaningful communication stopped’ and so did the ‘curiosity about the patient as a person’, with no interest in their mental life and experiences ( Reiser, 1988 : 151).

Post- Diagnostic and Statistical Manual : borderline hits the mainstream

Almost 50 years after becoming a recognisable syndrome among psychoanalytically orientated clinicians, the concept of ‘borderline’ made it into the third edition of DSM. It survived subsequent revisions of DSM and was still present in DSM 5 despite a concerted campaign to remove the distinct categories of personality disorder. Indeed, borderline received further recognition in the 11th edition of the International Classification of Diseases (ICD) produced by the World Health Organization in 2019. BPD had been removed from ICD 10 (1990), to be replaced by Emotionally Unstable Personality Disorder (EUPD) – the diagnosis that appeared in the very first edition of DSM in 1952. EUPD itself was then removed in ICD 11 as the manual steered towards a dimensional approach to PD that distinguished according to the severity of symptoms (mild, moderate or severe) rather than categories. The general description emphasised disturbances of affect and identity, as well as difficulties in interpersonal relationships characterised by persistent conflict alongside patterns of withdrawal and dependency. Nevertheless, the term borderline actually reappeared as it was used to describe a ‘Borderline Pattern (ICD-11)’, that strongly echoes and reinforces the DSM version of BPD. 9

It is also fair to say that BPD has not only survived in the diagnostic manuals, it has positively flourished in the outside world becoming a common facet of everyday discourse ( Cariola, 2017 ). A number of studies have found that only the BPD and Antisocial Personality Disorder (ASPD) diagnoses are used very much at all in practice and have become the PD diagnoses ( Newton-Howes et al, 2021 ).

The idea that BPD could be understood in behavioural terms was strongly promoted by one of the most influential treatment models that emerged in the late 1980s called Dialectic Behaviour Therapy (for example, Linehan, 1987 ). This has been driven mainly by Marsha Linehan’s work that has construed BPD in what she has termed a ‘biosocial’ model, which appears to very deliberately exclude the psychological realm. Issues of self-harm and parasuicidal behaviours are foregrounded as BPD is understood as a disorder that is characterised chiefly by emotional dysregulation which is understood in terms of a biological pre-disposition that leads to a range of behaviours that are viewed as ultimately self-damaging and self-defeating. The social dimension of the disorder is not entirely excluded but attention is focused on the failure of the developmental environment to adequately ‘train’ the individual to regulate their emotions. This can occur through lack of attention and support, so that ‘often they learn that extreme emotional displays are necessary to provoke a helpful environmental response’ (Linehan, 1997: P265).

BPD and ASPD have become the diagnoses of personality disorder. The personality disorders themselves have been at the centre of heated debate about the nature of mental illness and distress. Part of the problem with borderline is that it lies on a significant fault line within the discipline of psychiatry. On one side of this line are those forces that have sought to establish a discipline that is unambiguously a part of the now established field of medicine. This entails the privileging of positivist scientific methods to identify diseases that can be associated with lesions and disorders within the organs of the body. On the other side are those forces that have sought to locate ‘the mind’ as a central concern of the discipline. While this allows for a wider array of human experience to be drawn into the analytic frame, it also provokes many unresolved questions; to what extent is it possible to draw boundaries around the individual mind or instead is it necessary to draw elements of not only the corporeal but also of the social and cultural worlds into this analysis? The inclusion of the subjective world of experience and its relationship to culture as a historical and shifting phenomenon is deeply challenging for those who want to see psychiatry joining the epistemic ranks of the natural sciences.

As reviewed in this article, it was diagnoses associated with the idea of moral insanity that initially put the exploration of the mind within the modern psychiatric project. This controversial territory has played a key role in the development and growth of psychiatry. In the post-Second World War period it was the personality disorders that were responsible for considerable growth in the expanse and reach of the psychiatric realm. Since its inclusion in DSM in 1980, the borderline diagnosis has grown enormously and is now well established in Western culture, well beyond the clinic.

The reference to ‘borders’ is perhaps no mere oddity but does perhaps explain something of the longevity of the diagnosis as it hints at the marginalisation of individuals who are viewed as, or experience themselves as, on the edge or outside of the norm. The reference to borders perhaps also refers to questions about the boundaries of the discipline of psychiatry and where they lie. This article has only been able to touch upon the wider social and cultural issues that have also driven the ‘popularity’ of the diagnosis. There is little doubt that the emergence of psychiatry itself was fuelled at least in part by feelings of anxiety about social change in the 19th century. The emergence of borderline itself occurred in the middle of the 20th century; initially in 1930s Britain, which was being transformed by social change and industrial decline, fear of what would become of young men left under-employed and disconnected. This association with young men at that point is noteworthy. The diagnosis became more associated with women in the latter decades of that century. There was no borderline in DSM II (1968) but there was hysterical personality – a diagnosis clearly highly gendered. It is notable that hysterical survived as a separate category even when borderline made its appearance in DSM III where it perhaps operates as the sister diagnosis to ‘anti-social personality disorder’ that was very much associated with men.

The big question that needs far more exploration is why did borderline explode in popularity in the latter decades of the 20th century? Christopher Lasch (1979) suggested that it was post-industrial American culture that led to the emergence of a culture of narcissism and it is noteworthy that he based his analysis on an understanding of Kernberg’s theorisation of borderline personality organisation.

Meanwhile, borderline remains a tortured and paradoxical diagnosis – it falls into territory that has been key to the emergence and the popular spread of psychiatry as a profession – ushering many contemporary forms of human misery within the psychiatric ambit. But this territory remains highly contested with many within the profession regarding it as alien territory that does not belong within the boundaries of a properly medicalised discipline.

Berrios ( 2019 : 111), for example, suggested that at birth, the project of psychiatry was a hybrid that drew on fragments of ‘philosophy, history, psychology, rhetoric, the nascent sociology and the neurosciences’.

Levywas another New York psychiatrist who theorised that emotional deprivation or ‘affect hunger’ was deeply damaging to child development ( Levy, 1937 ).

He did explicitly discuss ‘borderline’ cases in his correspondence, for example, to Robert Rodman in 1969 ( Rodman, 1987 ).

The work of a group who largely worked in Britain that included Melanie Klein, Donald Fairburn and Donald Winnicott came to be viewed as at the forefront of object relations ideas.

Letter from Carrol, ISTD, to Frankling, 1 February 1936, Planned Environment Therapy Archives: https://mulberrybush.org.uk/mb3/archives/ SA/Q1/HM 31.131.5.

Letter from Walker to Mr Thompson – Solicitors Jermyn Street, 29 August 1936, Planned Environment Therapy Archives: https://mulberrybush.org.uk/mb3/archives/ SA/Q1/HM 31.131.5.

It is noteworthy that the more obvious language of ‘psychopathy’ was not adopted at this point. This is despite the popular success of the term following Cleckley’s work (however ironic this is, as Cleckley himself was critical of the term). It is likely that the APA were concerned to avoid association to the eugenical work on ‘psychopathy’ in the previous decades ( Breggin, 1993 ) and the by then discredited policy initiatives aimed at the control of ‘sexual psychopaths’ ( Lave, 2009 ).

The sampled ‘borderline group’ used in the study was 68 per cent female, showing gender was significant at this point – although not exclusive.

A ‘pervasive pattern of instability of interpersonal relationships, self-image, and affects’ and marked with impulsivity in a number of areas, including ‘frantic efforts, efforts to avoid real or imagined abandonment’, ‘self-damaging’ and rash behaviour, ‘self-harm’, ‘chronic feelings of emptiness, inappropriate intense anger’. There is also some nod to the idea that this was a disorder close to the border with psychosis with reference to ‘[t]ransient dissociative symptoms or psychotic-like features in situations of high affective arousal’ (ICD11: 2019 ).

This was partly supported by a grant from the British Academy/Leverhulme SG152275.

The author declares that there is no conflict of interest.

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Borderline Personality Disorder: Case Study

Lukenotes, summer 2021.

Sr. Rita was angry and frustrated after being asked to step down from a third committee in two years. She was informed that she was being removed from the welcoming committee because she was not very friendly or hospitable and might deter potential members from joining the community. Sr. Rita huffed off in disbelief and worked to control her rising anger. She marched to mother superior’s office prepared to plead her case.

How did Sr. Rita get here? Why has she been removed from yet another committee?

Sr. Rita struggles with fear of rejection and abandonment and insecurity about not being good enough. She has a history of impulsivity, aggression, and self-injurious behavior. At age sixteen, after an intense argument with her best friend, Sr. Rita attempted suicide by ingesting a bottle of pills. She briefly engaged in therapy but did not believe there was anything she needed to work on.

Sr. Rita has been in religious life for 22 years. As a child, she did not consider pursuing a religious vocation. In college Sr. Rita joined a Catholic youth group, volunteered at the local monastery, and sought guidance from a family friend in a religious community. Immediately following college, she joined a community in the Midwest and started her religious journey. Sr. Rita is happy with her decision and shows her love for religious life by getting involved, planning activities for the community and neighborhood, and suggesting ways to improve community living.

Initially, Sr. Rita embraced the quiet time for prayer and found the structure and routine helpful. More recently, however, she balks at not being able to coordinate her own schedule and does not always participate in community activities. She does not enjoy sharing a kitchen or car with other sisters and often fails to adhere to established rules. Some community members are afraid of Sr. Rita and shared their concerns with the superior. Sr. Rita seems unaware of her impact on the other sisters and becomes irate when concerns are expressed about her behavior. She was encouraged to utilize additional support and reluctantly agreed to meet with a Saint Luke Institute therapist.

Sr. Rita felt scared, yet relieved, when she received the diagnosis of borderline personality disorder. The diagnosis helped explain years of chaotic behavior. Although therapy was challenging, every day Sr. Rita gained new insight and skills. Most notably, through her work at Saint Luke Institute, Sr. Rita finally opened up about her traumatic upbringing. Sr. Rita lost her father in a car accident when she was eight years old. Her mother battled depression and stopped taking care of Sr. Rita and her siblings. One day Sr. Rita’s mother dropped her siblings and she off at church and never came back to pick them up. Sr. Rita still remembers the feeling and the moment when she realized her mother was not coming back to get them.

Sr. Rita’s traumatic and unstable childhood shaped the way she navigated the world. She was sensitive to any hint of abandonment due to feeling discarded by both of her parents. She existed in a state of hypervigilance as a means of self-protection and shut down her feelings to avoid reliving the terrible experiences from growing up in the foster care system.

With the support of trauma therapy, group counseling, and psychoeducation workshops, Sr. Rita slowly recognized how much pain she carried around and masked all those years. She replaced unhealthy coping skills with mindfulness and distress tolerance skills and identified triggers to create a process for difficult moments. Sr. Rita still struggles with managing expectations and receiving feedback, but continues to work with her therapist to better understand her behavior. Sr. Rita also creates more balance in her life by exercising, setting boundaries, and building time in her schedule for self-care.

As Sr. Rita continues the therapy work and practices therapeutic tools, her style of relating to others will improve, she will respond instead of reacting, and she will have greater control over her thoughts and feelings. Every day Sr. Rita reminds herself that healing is a process and a lifelong journey.

For confidentiality, reasons, names, identifying data, and other details of treatment have been altered.

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Improving Research Practice for Studying Borderline Personality Disorder: Lessons From the Clinic

Khushwant dhaliwal.

1 Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA

Ayala Danzig

Sarah k. fineberg, short abstract.

Borderline personality disorder is an often misunderstood and underdiagnosed mental illness characterized in part by affective lability. Clinicians’ unique understanding of the disorder has allowed them to develop disorder-specific approaches to treatment. In this review, we highlight how borderline personality disorder research can benefit from greater engagement with key disorder-specific features, including symptom variability and interpersonal sensitivity. In addition, we propose that research which employs interactive tasks will be more reflective of the kinds of volatility found in the real-life situations. Finally, we discuss how mixed-methodology can serve as a way for recovery-oriented research to practice the very ideals and recommendations it suggests. We use a patient case to contextualize each section. As interest in borderline personality disorder continues to grow, an intentional emphasis on a person-centered, recovery-focused, and disorder-specific approach to research is needed.

Introduction

There has been increased interest in the biological mechanisms of borderline personality disorder (BPD) over the past decade and also increased recognition of its significant co-morbidity and symptomatic/etiologic overlap with trauma-related and affective disorders. Major not for profit mental health funding organizations (e.g., Brain and Behavior Research Foundation, American Foundation for Suicide Prevention) have increased focus on BPD, and community and scientific advocates have lobbied the National Institutes of Health to consider BPD as a serious mental illness. As neuroscience and cognitive psychology projects work to define the paths to BPD onset, maintenance, and recovery, it will be important for projects to define outcome measures with an eye to disorder-specific features.

BPD is a mental illness that occurs frequently in the community. Estimates of prevalence over time have been 0.5%–6% 1 ; a recent meta-analysis estimated worldwide prevalence at 1.8%, though heterogeneity across studies was quite high and frequency was higher in high-income than in low-income areas. 2 Frequency is even higher in mental health clinics (10%–20%). 3 , 4 BPD is associated with significant morbidity and mortality, 5 including markedly increased risk of suicide. 6 – 8 People with BPD experience both affective lability (the most sensitive single-item criterion 9 ) and chronic mood symptoms. 10 Interpersonal problems are prominent with fears of abandonment, alternating idealization and devaluation, dependence and/or counter-dependence, and stormy relationships. 11 , 12 Chronic suicidal ideation and behavior are common symptoms and can co-occur with impulsive suicidal statements that serve interpersonal functions (e.g., to communicate overwhelming emotions or to keep a social partner engaged). In addition to interpersonal instability, moment-to-moment shifts can also occur in one’s sense of self. Symptoms can also include impulsivity, anger (felt and/or displayed), dissociation, and quasi-psychotic experiences (e.g., transient hallucinations, ideas of reference, and paranoia).

The specific challenges faced by people with BPD have led clinicians to work out disorder-specific approaches in order to increase treatment-related benefits. 12 , 13 For example, psychoanalytically-inspired treaters have adapted their techniques to include more eye contact and more concrete, active interventions, leaving less room for the people in their care to feel confused about interpersonal cues and overwhelmed by experiences of abandonment and threat (transference-focused psychotherapy 14 and mentalization-based treatment 15 ). Behavioral clinicians and supportive therapists working with people with BPD have shifted toward focus on psychoeducation, especially about the intensity and variability of emotion and behavior (dialectical behavior therapy 16 and good psychiatric management 17 ).

We suggest here that research in BPD can also benefit from increased attention to disorder-specific features. These considerations will be relevant to researchers focused on BPD, as well as to those focused on populations with significant BPD pathology, including post-traumatic stress disorder (PTSD), substance use disorders, and transdiagnostic groups with high impulsivity and/or affective lability.

We begin by introducing a case, which is a composition of patients we have encountered in our clinical work. We suggest several specific approaches (summarized in Table 1 ), including engaging symptom variance in outcome measurement (see Symptom Variability section), increasing interactive approaches in studies of social cognition (see Need for Interactive Tasks section), paying particular attention to the interpersonal aspects of research interactions (see Interpersonal Sensitivity section), and considering recovery-focused outcome measures (see Recovery-Focused Methodology section). Each approach is contextualized with respect to the presented case example.

Ideas for improving clinical research with BPD and related populations.

BPD: borderline personality disorder; EMA: ecologic momentary assessment. Note: *This case is based on a series of adults with BPD with whom we have worked. It does not reflect the specific experiences of any particular individual.

Nora* is a 24-year-old single woman with three children. She has a history of BPD, one prior episode of postpartum depression, and hypertension. She presents for outpatient psychiatric treatment due to intense depression and anxiety with frequent thoughts about suicide as well as episodic anger. She is distressed that so many bad things keep happening to her and feels that her mental illness causes her to act in ways that are out of character. Nora’s sister is in outpatient treatment for schizophrenia with good benefit from medications, and Nora is hopeful that she can find a medication to help her just as much. Over the past several years, Nora had been prescribed antidepressant, mood stabilizing, and antipsychotic medications, and while she initially felt some benefit from each one, the benefits were short-lived.

Nora had recently done well without individual treatment while enrolled in an intensely supportive parenting program outside of the clinic. She returns now, shortly after the conclusion of that program. She is distressed by her frequent conflicts in romantic relationships, with her family, and at work when she has a job. The tipping point came when she got into a physical fight in public which led to arrest. Her probation officer encouraged her to return to treatment after she said that extended time on parole might lead her to kill herself.

While initially hesitant to commit to meeting at regular intervals for psychotherapy, Nora did agree to start with two assessment sessions. She was eager for the therapist to explain her diagnosis to friends and family and to help her work toward solving problems.

How BPD Research Can Better Engage BPD-Specific Features

Symptom variability.

Nora’s therapist initially assessed anxiety and depressive symptoms with self-report scales, which query average mood over one to two weeks. Her therapist found that this approach was not sensitive to the intense mood fluctuations Nora experienced on a day to day basis. While her anxiety and depression were chronic, Nora described “suddenly flying off the handle” or “blacking out with anxiety” when her children misbehaved or her boyfriend was not responsive. By contrast, she often felt and behaved calmly in the hours leading up to these incidents. Nora’s social experience was also rapidly shifting. For example, at one session, she reported that during an argument, she had pinched her boyfriend’s arm hard enough to leave a bruise. She was furious, feeling that he is constantly disrespectful and that she would break off the relationship. In the following session, she spoke of him in markedly different terms, describing him as supportive, loving, and a source of stability and comfort. Nora said that her mood changes were unpredictable and inexplicable. Nora and her therapist began to name mood fluctuations as a specific treatment target. Now, simple statements like “I see that things are up and down again” are used to re-focus from the emotions in the moment to the larger pattern of mood and relational variance.

Clinical research projects often define outcomes as mean value or mean change from baseline. This approach makes sense for disorders with symptoms that are relatively steady over time and across contexts. However, in BPD, symptom variability is a core feature of the disorder; fluctuations are expected in multiple symptom domains. Therefore, research outcome measures need to assess symptoms over enough time, across enough contexts, and with enough repeated observations to capture both the extremes of symptom intensity and the frequency of change. 18 Measuring variance as an outcome itself has been done in BPD to good effect, 19 though this approach has thus far been infrequent in the literature.

Symptom fluctuations in BPD are thought to intensify in the context of stress, especially interpersonal stress. 12 Current symptoms and behavior can be placed in context by assessing for recent stressors and measuring current levels of arousal (self-reported and physiologic). Guided imagery has become an important technique in the addiction field to evoke personally relevant stressors in the laboratory. 20 These personalized narratives have also been used to test the neurobiologic correlates of self-injurious urges in BPD 21 and of paroxetine-associated symptom reduction in PTSD. 22

In order to understand variability, it will be important to use outcome measurement tools that are sensitive to change. Research will benefit from increased granularity of data generated by frequent and even passive sampling. For example, ecologic momentary assessment (EMA) can facilitate tracking of emotions and urges throughout the day. 23 , 24 One study used EMA to demonstrate a correlation between suicidal ideation and affective instability in people with BPD. 25 Another provided real-world support for the hypothesis that non-suicidal self-injury contributed to short-term affect stabilization in people with BPD. 26 Furthermore, EMA has been used for the analysis of event-triggered data. For example, one study analyzed real-time responses of people with BPD to conversations, allowing for the close inspection of the effects of proximal social interaction on perceived rejection and mood. 27 Passive tracking of smartphone use can offer a great deal of information about real-world social experience with very little participant burden (e.g., text and call frequency, number of individuals contacted, sound features of phone calls, and lexical analyses of content). 28 , 29

Need for Interactive Tasks

Nora experienced frequent and extreme shifts in her feelings about people, and these were often triggered during interactions, or as she later reviewed the interactions in her mind. Making use of the therapist–patient relationship, especially in-the-moment interactions was critical to helping Nora apply the techniques and understandings she developed in the sessions to her outside life. On one occasion, Nora arrived to a session feeling flustered and insulted by a comment a friend had made about her new hairstyle, though her friend had insisted it was intended as a compliment. Together, she and her therapist discussed interpersonal sensitivity, misreading of social cues, and examples of when this was happening in the interactions between the two of them. Nora was then able to articulate that she often mistook her therapist’s concern for anger. They began to explicitly discuss the way each interprets the other’s words, gestures, and facial expressions to make sense of emotion and intention.

A great deal of work has examined responses of people with BPD to non-interactive social cues, such as pictures of faces, yielding important information about such processes as attention, response to negative facial expressions, and value judgments (reviewed in Schulze et al. 30 and Bertsch et al. 31 ). Recent studies have begun to extend this work with experiments in interactive social contexts: this approach will be needed to elucidate the interaction-dependent symptoms that are so prominent in BPD. 32 – 34 Two interesting examples of interactive social work are translation of paradigms between rodent and human models and computational modeling approaches to describing social decisions.

Some research in this area has leveraged direct translation to or from animal models. For example, researchers interested in understanding the substrates of social anxiety in human psychopathology translated the rodent “open field” paradigm to a human scale (football field) and social context (open air market) and used GPS technology to trace naturalistic paths of research participants through these venues. 35 To better describe the neurobiology of BPD, two groups have set out to develop animal models of the biology of social exclusion. One of these is in process 36 ; the other has been able to recapitulate several key features of the disorder (including diminished inter-individual trust). 37

Formal modeling of decisions and learning in interactive behavioral tasks has also yielded advances in our understanding of social dysfunction in BPD. For example, King-Casas et al. published a paper in 2008 describing neuroeconomic behavior in BPD. 38 In a computer-based “Trust Game,” they found that people with BPD failed to cooperate with a partner toward a shared goal, and when the partner “defected,” they failed to “coax” the partner back to play. This appeared to fit canonical clinical perspectives: that people with BPD are mistrustful and antagonistic in interactions, perhaps due to poor emotion regulation or high interpersonal sensitivity. However, the application of a formal computational model to these data allowed the scientists to test more specific propositions about mechanism. 39 Data from this model allow us to arbitrate between two very different mechanisms of poor cooperation: a model of ignorance (failing to notice cues from a partner that signal social discord) and a model of antagonism (expecting conflict and being on the offense). The modeling results suggest that people with BPD are much more likely to be ignorant of partner irritability than are control participants. These data also fit with recent data from our group showing that people with BPD are less responsive than controls to rapidly changing reward probabilities in a reinforcement learning task. 40 This finding held for both social and non-social cues, suggesting that the social interactive symptoms in BPD may be explained by a more general difficulty in learning from a changing environment. 40

These two selected examples are far from an exhaustive examination of the approaches to social interactive work, in general or even in BPD, but serve to illustrate the value of innovation.

Interpersonal Sensitivity

When Nora was presented with standardized measures such as the Patient Health Questionnaire (PHQ-9) or Generalized Anxiety Disorder 7-item scale (GAD-7) she would consistently check the boxes that indicated maximum symptoms of depression and anxiety. Not having the capacity to express her feelings verbally, Nora seemed to feel this was the most effective way to express the intensity of her suffering. She also worried that if she did not appear ill enough she might not receive the treatment and help that she craved.

Interpersonal hypersensitivity is a key feature of BPD. As occurred in the case above, the exquisite responsiveness of people with BPD to perceived social cues may lead to biased responses both in the clinic and in research settings. Participants with BPD may be quite focused on the imagined consequences of their responses in the minds of study staff. Participants may be sensitive to how their responses affect study inclusion versus exclusion decisions, which can be perceived as a social validation or rejection. Also, in follow-up visits, a participant with intense psychological distress may be reluctant to say that some symptoms have improved for fear that she will be misunderstood to mean that everything is now okay. She may also be reluctant to say that things have worsened, as she wishes to please the study staff and continue to feel warmly included in the study cohort.

Attention to the quality of interactions that occur between research staff and research participants may help to decrease bias in reported symptoms. Participants may adhere to study procedures more closely due to perceived warmth in the laboratory experience. However, for completion of study outcome measures, it may be helpful to think explicitly about how to reduce response bias that could arise from both positive and negative experiences with study staff. It has been demonstrated that, in clinical settings, therapist-offered validating comments can decrease self-reported negative affect. 41 This is consistent with the core principles of dialectical behavior therapy and may suggest a relevant technique for clinical researchers working with people who have BPD. 16 One approach, therefore, may be to demonstrate interest in all experiences, positive or negative, and/or to separate neutral study raters from the warmer support staff in the lab. Another approach may be to speak very explicitly to participants about the value we see in all responses and how much we value their time, effort, and accuracy, thereby shifting perceived social success from content to process. Social interventions by study staff, such as validating statements to participants, time spent with participants, and inter-session contacts between staff and participants, should be carefully considered and potentially quantified.

Lush et al. have recently explored conscious and unconscious biases in research responses, such as social desirability, demand characteristics, and hypnotizability, and they have examined the implications of these biases for psychological experiments. 42 They coin the term “phenomenological control” to describe the involuntary responses that people have in order to align their experiences in psychological tasks with their prior expectations of experience. For example, in the rubber hand illusion, people with a greater degree of phenomenological control are more susceptible to the illusion that the rubber hand is part of their body. The illusion allows experience to fit with the prior expectation that what you see and what you feel should align. And indeed, people with BPD, who are highly influenced by social cues, have increased susceptibility even to the canonically less illusion-inducing asynchronous condition of the rubber hand illusion task. 43 Therefore, the hypothesis put forth by Lush et al. that direct measurement of hypnotizability may help to control for the contribution of high phenomenological control in participant responses may also have particular relevance for research in people with BPD. Hypnotizability and other quantified traits may be helpful to assess and understand biased response.

Thus, it is important for BPD researchers to engage in a continual careful consideration of the ways in which the interpersonal hypersensitivity discussed and observed in clinical settings can manifest in measurement of research outcomes.

Recovery-Focused Methodology

Setting goals in treatment were initially a big challenge for Nora. She identified wanting to feel less depressed and less anxious but could only imagine this being accomplished with medication. Here too, orienting around her symptoms was limiting as it reinforced her sense of not having agency in her life. It also unrealistically set the expectation that medication could be the main treatment for her illness. Shifting focus from reduction of symptoms to the dialectical behavior therapy-inspired idea of a “life worth living” enabled Nora to set goals that included finding employment and improving her self-care with exercise and dietary changes. Even as Nora’s mood fluctuations continued, she could see progress and feel good about actions she took to improve her life.

Over the past two decades, many mental health clinicians have shifted their frameworks of practice to include recovery as a philosophy on an individual and collective scale. 44 – 46 Davidson et al. have described recovery-oriented care as “a set of guiding principles for mental health care and services in support of the person’s own long-term recovery efforts.” 47 This recovery-orientation often manifests in clinical work as a prioritization of life goals that are meaningful to the person, identification of barriers to achieving those goals (potentially including clinical symptoms), and individual strengths. Increased focus on recovery-oriented practice promotes growth beyond traditional clinical goals. Meaningful changes for individuals may include psychosocial growth (e.g., in personal relationships or forging new social connections), economic progress (e.g., employment and/or financial independence), and lifestyle improvements (e.g., increased occupational engagement that may begin with volunteering or part-time work in areas of personal interest). 48

Although the recovery model has shown promise and relevance in the clinical setting 49 – 52 and was adopted by the United States' President's New Freedom Commission on Mental Health in 2003, 53 identifying research outcomes that reflect recovery principles has been a slower process. This may reflect an apparent conflict between the clinical research focus on group-level analysis and the recovery focus on the individual. Although understanding person-centered outcomes is especially important in a clinical encounter, the practice of recovery-relevant methodology and use of meaningful outcome measures is equally important in BPD research. The literature which informs clinical practice should exemplify the very theoretical ideals and practical recommendations it proposes: research can and should adopt a recovery-orientation. Consideration of best methodological practices is especially relevant right now in BPD research given that explicit engagement with recovery-oriented ideas in our field is in its early stages. 54 , 55

From the perspective of methodology, qualitative interview-based practices offer new insights into recovery. Although few studies have directly focused on recovery in BPD, one recent report indicates that narrative accounts are more sensitive to residual BPD symptoms as compared to quantitative reports of improvement. 55 This longitudinal study at the University of Pittsburgh prospectively followed individuals with BPD for 2 to 31 years (mean 9.94 years, biannual assessments). Among participants with high scores on a measure of baseline function (Global Assessment Scale (GAS) score), 71.8% achieved diagnostic remission. However, the remaining 28.2% also went on to achieve good psychosocial outcomes even without diagnostic remission. Conversely, among participants with lower baseline GAS scores, 35.5% achieved diagnostic remission despite poor psychosocial outcomes. The authors sought to understand the gap between diagnostic remission and psychosocial recovery using qualitative interviews. These interviews found that those who achieved diagnostic remission often struggled with depression and anxiety and had difficulty in maintaining employment and good interpersonal relationships. For those participants who achieved diagnostic remission, residual BPD symptoms increased the occurrence of co-morbid psychiatric disorders, economic dependence, and poor-quality relationships. This work adds a new level of understanding to previously reported results describing the time-course and relationships of remission and recovery in BPD. 56 , 57

Recent qualitative studies indicate that definitions of recovery are multidimensional and may not align with providers’ definitions. One study found that people receiving services in two recovery-oriented programs of the National Health Service in the UK believed that interpersonal support outside of the clinical team, employment, and everyday activities such as walking and reading books were critical for recovery. 58 Another qualitative study found that conceptualizing seemingly small steps to recovery as valuable progress was key to cultivating the self-compassion necessary for BPD recovery. 59 In addition, another interview-based study found that participants with BPD indicated that there was a mismatch between the focus of their treatment, especially in structured group therapy programs such as dialectical behavior therapy, and their personal recovery aspirations, which included such varied goals as dealing with eating problems and managing traumatic experiences from their pasts. 60 However, the qualitative interviews with people staying in inpatient units made evident that patient definitions of recovery are strongly influenced by their providers’ focus on the biomedical model. For example, participants saw factors such as medication adherence as key to demonstrating to their psychiatrists that they were ready for discharge and on a path to recovery. Many clinicians will relate to the difficulty convincing “experienced” patients that we are at all interested in hearing about life beyond whether a person took her medication and if she feels suicidal.

Considering such promising qualitative research on recovery, qualitative methodology may seem to be the way forward. This view is supported by evidence that the process of completing the traditional clinical-trial approach of self-report measures may not be empowering mental health recovery. In one study, participants were interviewed about their experience of completing a set of self-report symptom scales. 61 Although participants refused external help from the researcher in reading aloud and explaining the items while completing the self-report measures, they noted afterwards that they had difficulty understanding the professional and unclear language in the measures and that they were frustrated by the process. When conducting research with people experiencing mental health issues, and especially for people with BPD who can experience high levels of shame, 62 , 63 researchers would do well to structure participant experience to avoid disempowering people on their journey to recovery.

At the same time, qualitative research is not without its own shortcomings. In their research, Stuart et al. found that overly optimistic views of recovery in qualitative research may homogenize individuals’ journeys. 64 Also, these views may place unintentional blame on participants when interviewers shy away from asking participants about the difficulties in their recovery journey, perhaps suggesting that having difficulties is unique to the person being interviewed, and not a common part of the bumpy recovery road. 64 Thus, mixed-methodology that seeks to marry “subjective” narrative qualitative measures with “objective” quantitative validated domain-specific survey-based measures may be the best approach for researching symptom outcomes not only in BPD but also in mental illness more broadly. 65 , 66

In addition to the unique benefits of using mixed-methods to define recovery through research, mixed-methodology may also be useful in other aspects of recovery-oriented research. Multiple groups have now argued that a mixed-methods approach also be used at the development and validation stages for novel tools measuring recovery as an outcome. 67 – 69 Keetharuth et al. were able to develop a new recovery survey assessing quality of life titled the Recovery Quality of Life (ReQoL), after using mixed-methods to understand key evidence from both patients and clinicians. 67 Their final ReQoL measure assesses themes including activity, belonging and relationships, hope, self-perception, well-being, and choice, control, and autonomy. Mixed methods studies like this one indicate that, as recovery-oriented research evolves, new guidelines for quantitative surveys and qualitative interview questions should incorporate individual-defined goals. That is to say, scales or interviews should seek to understand a participant’s progress toward their personally defined goals. Myers et al. used the “meaningful day” construct as a person-centered outcome to understand the recovery of people receiving services at the Opening Doors to Recovery program in Georgia over the course of a year. 65 Notably, the authors of this paper reflected on how the use of mixed-methods allowed them to discern non-overlapping aspects of personalized recovery.

As research follows clinical care in increasing in recovery orientation, the practices of research methodology must also evolve to reflect these changing definitions. Mixed-methodology is one example of how this change be facilitated. We suggest that studies could also include recovery-relevant measures (such as individual strengths) as variables in analyses, and that outcome measures that report on quality of life and life satisfaction can help to increase focus on variables other than those of the traditional medical model (e.g., symptoms, treatment adherence, and emergency visits).

Summary and Future Directions

In this paper, we have argued that the clinical approach to BPD has insights to offer to research practice. In particular, we suggest that researchers increase attention to symptom variance, interactive context, interpersonal sensitivity, and recovery-based research practices and outcome measures. Although in some settings, symptom-focused and recovery-oriented approaches may be seen as orthogonal, we see them as complementary in thinking about clinical and research best practices.

We imagine that future work can extend these ideas by considering the experience and structure of the research enterprise on both an individual and group level. On an individual level, researchers may be able to learn from recovery-oriented clinical practices to understand how it feels to be a patient-participant, including feeling empowered or, by contrast, disheartened. This issue speaks to ethical and clinical concerns about research practice and also to practical concerns around the accuracy of research data. We want to ensure that participants with BPD feel able to report accurately on their difficult and rapidly shifting experiences.

We also see potential for extending this proposal in light of ideas on structural competency and systems-level viewpoints. A rich and growing body of work initiated and developed by Metzl and Hansen 70 among others urges increased focus on the ways that institutional systems, cultures, and histories influence clinical outcomes and people’s experiences in therapeutic and research settings. System- and group-level frameworks for conceptualizing pathology in BPD will be important additions to the focus we have urged here on individual-level factors. For BPD in particular, stigma prevents people from seeking care and providers from offering appropriate diagnosis and treatment. 71 – 73 This is particularly true for men, as there is a misconception that BPD is significantly more frequent in women despite data to the contrary, 74 and therefore clinicians may focus on the more-prominent anger symptoms in men. 75

Researchers increasingly include people with lived experience of BPD on advisory councils and even in day-to-day lab work. Collaborative engagement with stakeholders can serve as an example to mental health researchers on the ways in which research can be a positive experience for research participants and can significantly increase researcher appreciation of the nuances of living with the condition. Inclusion of people with lived experiences on research teams will also bring novel and rich perspectives to data analysis and interpretation.

In sum, engagement with clinical knowledge about BPD can help shift researchers toward better engagement of research participants with BPD and BPD-related disorders, and the collection of more accurate clinical research data. Best practices can include a wide range of methods to fit research questions, but these practices are united by their consideration of the specific symptomatology of BPD.

Acknowledgements

We are very grateful to our clinical and research participants for all we learn from them as we work together on these complicated concerns. We would like to thank Paula Tusiani-Eng and Jillian Papa for recent conversations on the meaning and implications of recovery in BPD. We also thank Rebecca Miller and Eli Neustadter for comments on manuscript drafts.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Cohen Public Service Fellowship (to K. D.), by American Foundation for Suicide Prevention Young Investigator Grant No. YIG-1-045-16 (to S. K. F.), and by the Department of Mental Health and Addiction Services, State of Connecticut. This publication does not express the views of the Department of Mental Health and Addiction Services or the State of Connecticut. The views and opinions expressed are those of the authors.

Sarah K. Fineberg https://orcid.org/0000-0001-6024-6721