The Latest Information on BPD

From the meetings of the American Psychiatric Association.

Posted May 19, 2012

Since the month of May has been officially designated by Congress as Borderline Personality Disorder Month, it is most appropriate that BPD is a prominent topic at the annual May meetings of the American Psychiatric Association. Some of the latest research was presented on a variety of areas.

DIAGNOSIS

After some delays, it is now all but certain that DSM V will be published in May, 2013, with a number of differences from DSM IV. It is proposed that personality disorders now be removed from Axis II designation, and be described more prominently on Axis I, alongside all other prominent psychiatric diagnoses. Four of the current ten labels will be discarded, leaving borderline, narcissistic, antisocial, avoidant, obsessive-compulsive, and schizotypal personality disorders as the remaining fully described diagnoses.

Proposed defining criteria will attempt to describe a more dimensional description of the disorder. Instead of a list of criteria, a minimum of which must be present to fulfill the diagnosis, the degree of borderline-ishness will be described, matching the patient to a stereotype description.

TREATMENT

Although studies indicate that BPD patients are often treated with multiple medications, medicine is only minimally ameliorative, and psychotherapy is still the cornerstone of treatment. Dialectical Behavioral Therapy (DBT) is the most studied therapy, and the treatment most closely associated with BPD, but at this year’s APA emphasis was on other psychotherapy approaches. Mentalization Behavioral Therapy (MBT) is an approach gaining more interest.

However, many experts believe that these and other highly specialized therapies can be reserved for more resistant symptoms. Instead, the initial approach to therapy should be Good Psychiatric Management. GPM is defined as weekly supportive case management, involving education about BPD, management of (preferably minimal) medications, and potential involvement of family and significant others. Emphasis is on social and vocational rehabilitation. Understanding disruptive behavior, developing corrective experiences of trust (starting with the therapist), and assuming personal responsibility are stressed. This approach is very similar to our SET-UP (Support, Empathy, Truth--Understanding, Perseverance) techniques explicated in our books, I Hate You, Don’t Leave Me, and Sometimes I Act Crazy.

PROGNOSIS

It is now becoming clear that most borderlines get better. Indeed, the long-term prognosis of remission of many symptoms is better in BPD than in major depression and bipolar disorder, though not as good as improvement in other personality disorders. Although improvement is common over time, even without treatment, relapses are also frequent. Most BPD patients usually have other accompanying diagnoses, especially depression and bipolar disorder. When BPD symptoms improve, the other disorders diminish in intensity. However, when the co-occurring disorders improve, BPD symptoms may not.

As we develop better ways to define, treat, and, especially, understand patients with BPD, we will improve the ability to relieve the suffering inherent in this illness.