Borderline Personality Disorder

Updates on Borderline Personality Disorder by Dr. Donald W. Black


“Borderline Personality Disorder.”

At the mere mention of these three words, more than a few healthcare providers in general and mental health professions, in particular, are inclined to answer with a few choice words of their own, often including:

“No thank you.”

In his insightful 35-minute lecture recorded exclusively for AudioDigest, Donald W. Black, MD, Professor Emeritus of Psychiatry, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City dives deeper into this concerning phenomenon.

“Many BPD patients are seen as unlikeable, untreatable, or even dangerous,” says Dr. Black in his talk, entitled The Diagnosis and Management of Borderline Personality Disorder. “There’s also a great deal of stigma surrounding the diagnosis—not just among patients, but among clinicians as well.”

Dr. Black himself details a previous 2011 paper he wrote on the matter to further illustrate his point—backed by strong data points.

“The 2011 paper was based on interviews with over 700 mental health clinicians,” recalls Dr. Black. “This included psychiatrists, psychologies, social workers, nurses, residents—and 47 percent said they’d prefer to avoid caring for BPD patients.

“I submit that most of us would look at that statistic and say it’s unacceptable. We certainly wouldn’t find that acceptable in the case of a schizophrenic patient population, bipolar patients, or depressed patients. So this is something that we have to overcome as a profession.”

In the powerful and highly trained mind of Dr. Black himself, there’s one predominant reason for this currently “unacceptable” situation when it comes to the treatment (or lack thereof) of patients living with Borderline Personality Disorder.

“I think what it comes down to is clinician discomfort with the concept of BPD,” surmises Dr. Black. “I like to make the point that ignoring BPD will not make it go away.”

When you consider that this mental illness affects between two and four million Americans, these words from Dr. Black become even more sobering.

Listen to Dr. Black discuss the diagnosis and management of borderline personality disorder ⟶

A Deeper Dive into the BPD Mind…

After listening intently to and learning from Dr. Black’s expert psychiatry lecture, physicians, clinicians, and other engaged healthcare professionals will be better positioned to both diagnose and manage Borderline Personality Disorder (BPD). Particular benefits will be realized in the following areas:

  • Understanding and explaining the criteria for BPD as shown in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition)
  • Screening and assessing patients presenting with BPD
  • Optimizing the use of psychotherapy and pharmacotherapy in the treatment of BPD

Dr. Black’s fascinating lecture also delves into some illuminating case studies, or as he refers to them, “clinical vignettes” from his distinguished career. The lecture is also fully-accredited for CME, qualifying for up to 1.25 AMA PRA Category 1 Credits™ for three years from its original publication on Sept. 7, 2021. The AudioDigest Foundation is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians—as well as by the American Nurses Credentialing Center (ANCC) Commission on Accreditation as a provider of continuing nursing education.

BPD in DSM-V: What’s in a Name, Exactly?

The Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5 or DSM-V for short) was updated in 2013 and currently serves as the go-to taxonomic and diagnostic tool published by the American Psychiatric Association (APA). The DSM-V identifies and outlines 157 distinct mental disorders—including symptoms, criteria, risk factors, culture and gender-related features, and other vital diagnostic information.

According to the DSM-V section on BPD, the disease is characterized by “persistently unstable relationships and self-image.” The affected individual displays high impulsivity, with an onset of such erratic behavior in early adulthood. In order to be clinically diagnosed with BPD, an individual has to meet at least five of the nine diagnostic criteria. These nine distinct criteria are classified into four categories—affective symptoms (i.e. inappropriate anger, feelings of emptiness); cognitive symptoms (stress-related paranoia, unstable sense of self); behavioral symptoms (self-harm, impulsivity); and interpersonal symptoms (abandonment fears, unstable relationships).

“According to DSM-V, the person must have five or more of the nine symptoms to qualify for BPD diagnosis,” says Dr. Black, who notes a 2002 study by Charles A. Sanislow, Ph.D. et al that calculated 151 possible combinations of symptoms to satisfy this BPD diagnosis requirement. “There are no required symptoms. It’s a polythetic approach to diagnosis.”

As Dr. Black goes on to vividly illustrate, BPD and its resultant symptoms still somehow manage to go widely (and sometimes wildly) overlooked during clinical assessment by today’s clinicians—often due to a lack of precise questions available to ask of patients. This powerful lecture by Dr. Black goes a long way towards better equipping healthcare professionals with effective questions and other assessment tools.

Screening and Assessing the BPD Patient

One such powerful and accurate assessment tool is the Zanarini Rating Scale for BPD. The test, named after McLean Hospital Laboratory for the Study of Adult Development Director Mary C. Zanarini, EdD, is administered as a 10-item, validated, clinician-based diagnostic interview conducted with a patient who is presenting with BPD symptoms. It assesses the severity of and changes within those symptoms for the presenting patient. A score of 8 or higher indicates a diagnosis of Borderline Personality Disorder.

Dr. Black is a big believer in the Zanarini Rating Scale.

“There’s a number of questions that are easily pulled from this instrument that will help identify patients with BPD,” states Dr. Black. “I’ve given this scale hundreds of times and I’ve incorporated all these questions into my memory bank. I encourage residents and students I work with to at least incorporate some of those questions.”

Dr. Black also suggests becoming familiar with a self-rating, 15-question tool (with a 1-5 rating system for each question-and-answer) that is also used to effectively diagnose BPD in patients. Dr. Black played a role in the development of this self-rating tool at the University of Iowa.

“If you plot that scale that you calculate and watch that from visit to visit, you can see the patient worsening or the patient improving,” explains Dr. Black. “As patients enter and receive treatment, they tend to get better. But their improvement isn’t a straight line—it goes up and down.”

BPD Treatment: Optimizing Psychotherapy and Pharmacotherapy

When it comes to effective treatment and management of BPD and the at-times seriously daunting symptoms and resultant behaviors stemming from the condition, a number of options are available to patients and clinicians today.

Contemporary BPD treatment options include psychological treatments (both individual and group psychotherapy), pharmacotherapy, and lifestyle operations. Dr. Black notes that the clinician should assess the patient, taking into account his or her individual treatment preferences. The overall consideration should include psychiatric comorbidity to identify depression, anxiety, substance abuse, PTSD, stage of illness, and overall psychosocial situation.

Evidence-based psychotherapy programs remain a mainstay of treatment of patients with BPD. These programs typically include both group and individual therapy modalities and sessions. Cognitive therapy, mentalization-based therapy, schema-focused therapy, and dialectical behavior therapy are all often part of the treatment program for BPD patients.

Dr. Black notes that randomized controlled trials (RCTs) demonstrate that various therapy modalities are equally effective for improving BPD symptoms—including serious behavioral manifestations such as wild mood swings and self-harm. He also makes it clear that BPD patients must first be psychologically ready to engage in a program, with dialectical behavior therapy serving as the most common treatment program.

“Patients should be referred to an evidence-based psychotherapy program,” says Dr. Black. “While the developers of programs all tend to claim that their program is superior to others, the evidence suggests otherwise—and suggests that all programs produce a benefit. When programs are tested head-to-head, these programs appear to be equivalent.”

On the matter of pharmacotherapy, Dr. Black notes that while many BPD patients do show mild improvement with the use of certain drugs, they do not respond definitively to any of them. While medication is widely prescribed for such patients (with some studies showing a prescription rate of more than 90 percent), no drug is currently approved by the Food and Drug Administration (FDA) for the treatment of BPD.

“The antidepressant (approach) simply doesn’t work that well, for reasons we really haven’t been able to pin down,” explains Dr. Black.

Benzodiazepines also haven’t proven effective in treating Borderline Personality Disorder, and have actually posed problems for BPD patients over the years. Dr. Black cites a 1988 study that actively recommended avoidance of benzodiazepines, which can cause disinhibition and promote acting out among patients who are taking them. There’s also the serious matter of benzodiazepines posing a risk for patients who have co-morbid substance use disorders.

On the whole, Dr. Black advises it’s wisest to “target the comorbidities and/or preponderant symptoms when using pharmacotherapy.” He also cites a 2010 study sponsored by Cochrane that suggests benefits from second-generation antipsychotics and mood stabilizers (along with Omega-3 fatty acids)—but not from first-generation antipsychotics and antidepressants.

Dr. Black also addresses a 2009 study from the National Institute for Health and Care Excellence that states while medication can effectively treat depression, anxiety, hostility, and impulsivity, it cannot alter the “fundamental nature of BPD.”

On the topic of lifestyle changes, Dr. Black suggests and highlights the use of appropriate nutrition and diet to address and limit obesity; a surge in physical activity, especially for physically inactive patients; appropriate sleep and leisure activities; self-education on BPD and our overall understanding of the condition; and compliance with treatment for any existing physical disorders.

Learn More and Discover AudioDigest Gold

If you’ve derived value from Dr. Black’s lecture, we encourage you to also download Top 5 CME Lectures in Psychiatry. Key insights on vital topics such as sleep and sleep disorders, medical marijuana, dementia, and suicide risk, and physician liability.

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