Borderline Personality Disorder
EPIDEMIOLOGY
Borderline is a very common condition, affecting ~5M U.S. adults.
1.5 - 3% of the U.S. population has BPD at any given time, with 5.9% of U.S. adults experiencing BPD at some point in their lives.
Interestingly, in the largest epidemiologic studies, 6% of individuals endorsed at least 5 of 9 BPD symptoms, but 50% of those individuals didn’t experience substantial functional impairment. That means over 1 in 20 people align with this personality type but only 1/2 of those individuals are clinically diagnosable (and therefore likely to seek treatment).
In other words — you can have a borderline personality type and still function well (or well enough) in the world. These traits may still cause significant difficulties (particularly in relationships) that don’t rise to the level of a clinical disorder. You just need those Ferrari driving skills to handle interpersonal hypersensitivity and avoid the difficulties or roadblocks it may create.
Clinical Settings
Borderline is even more common in clinical settings, and frequently misdiagnosed. ~20% of the inpatient and outpatient clinical population experience BPD. In inpatient and emergency room settings, 50% of those with suicidal thinking will meet criteria for this disorder — and unfortunately most of those people will be misdiagnosed.
Most doctors are very hesitant to give a diagnosis of BPD, even if they believe its appropriate to the patient. In one study, 57% of psychiatrists chose not to disclose a BPD diagnosis to their patients, and 37% did not document the diagnosis in their patient’s medical charts — citing stigma and uncertainty regarding the diagnosis as rationale. In another study, only 9% of health practitioners reported fully disclosing a BPD diagnosis to their patients. Even if this is done with good intention, it certainly makes it even more challenging for patients with this disorder and their families to effectively understand their challenges and navigate to appropriate care.
URGENCY
Borderline is definitionally a life threatening condition.
One of the nine diagnostic criteria is suicide and self harm behavior.
On average, someone with BPD will attempt suicide 3x over the course of their life, with a 3-10% risk of suicide. 75% of BPD patients engage in some form of non-suicidal self-harm.
A recent study found that, out of all observed risk factors, identity disturbance, chronic feelings of emptiness, and frantic efforts to avoid abandonment — three features that are not diagnostic of any disorder other than BPD — were most predictive of suicide attempts, further highlighting the critical nature of properly identifying and treating the condition.
BUT THERE’S HOPE
Disease Course
Symptom remission rates for BPD (meaning a patient no longer meets 5 out of 9 diagnostic criteria) are quite high:
~25% in 1 year
~50% in 2 years
~85% in 10 years
Once remitted, relapse isn’t common — at only a ~15% rate.
Treatability
There are multiple validated forms of treatment for BPD, and most patients experience significant symptom improvement with these treatments. The most common therapies include:
Dialectical Behavioral Therapy (DBT)
Good Psychiatric Management (GPM)
Mentalization Based Therapy (MBT)
Transference Focused Psychotherapy (TFP)
However, symptom improvement doesn’t necessarily mean that the patient is living a full and happy life. Only a fraction of patients achieve stable marriage or full time employment within 10 years.
