Borderline Personality Disorder (BPD):Diagnosis and Management

Borderline Personality Disorder (BPD):Diagnosis and Management

• 1.    https://psychscenehub.com/psychinsights/bpd-diagnosis-management-strategies/ harsh@psychscene.com 150 min read Diagnosis and Management of Borderline Personality Disorder Posted on: September 29, 2024 Last Updated: November 8, 2024 Time to read: 74-100 minute(s) 465 This article covers the diagnosis and management of Borderline Personality Disorder (BPD), focusing on key diagnostic principles and evidence-based approaches to improve patient outcomes. This article follows the previous exploration of the historical evolution, diagnostic construct, and aetiological underpinnings of Borderline Personality Disorder (BPD). Through both neurobiological and psychodynamic lenses, we have discussed how genetic predispositions interact with environmental factors, such as early life stress and trauma, contributing to the multifaceted nature of BPD. We examined the neurobiological circuits and neurotransmitter systems implicated, particularly in affective and pain processing, and integrated these insights with psychodynamic perspectives to elucidate the internal conflicts, attachment disturbances, and maladaptive coping mechanisms characteristic of individuals with BPD.

• 2. Borderline Personality Disorder – Deconstructing the Diagnosis from a Neurobiological and Psychodynamic Lens In this article, we delve into the clinical diagnosis and management of BPD, addressing the ongoing debate about its validity as either a distinct disorder or part of a broader personality pathology spectrum. Despite this controversy, the societal impact of BPD is profound, with significant direct and indirect costs, particularly related to healthcare utilisation and social adaptation failures. [Hastrup et al, 2019]. By outlining key diagnostic principles, we aim to equip clinicians with tools to avoid common diagnostic pitfalls and ensure evidence-based management strategies that foster remission and improve patient outcomes. Misdiagnosis or inadequate treatment of BPD can lead to ineffective pharmacological interventions and perpetuate the cycle of emotional dysregulation and interpersonal difficulties that define the condition. Enhance Your Psychiatry Practice Join The Academy by Psych Scene and earn CME & CPD points from 100+ hours of expert-led psychiatry courses. Hub Pro Included ✅ DIAGNOSTIC UNCERTAINTY IN BPD The construct of Borderline Personality Disorder (BPD) is internally consistent and more homogeneous than often assumed; however, debates continue about its diagnostic validity and whether BPD is better represented by a categorical or dimensional approach. [Leichsenring et al., 2023] Read the evolution of the diagnostic construct. A significant aspect of this controversy revolves around the epistemic injustice individuals face with this diagnosis. There has been a decades-long outcry from survivor and patient groups who argue that the BPD construct affirms their worst fears, leading to iatrogenic care that retraumatises them. [Watts, 2024]

• 3. This outcry highlights the impact that diagnostic labels can have on those who receive them, often shaping their care in ways that perpetuate harm. On one hand, critics like Tyrer and Mulder contend that the term “Borderline” has outlived its utility. They argue that its continued use compromises the management and specific treatment of this group of conditions. They suggest that the label has become a major obstacle to understanding and no longer has a place in clinical practice. [Tyrer and Mulder, 2024] These same concerns apply to borderline personality disorder. It is like a large bubble wrap over all personality disorders, easily recognized on the surface but obscuring the disorders that lie beneath. An argument might be made that, while criticisms of the borderline personality disorder diagnosis are valid, the term is familiar to clinicians and could be seen as a synonym for moderate to severe personality pathology and lead to appropriate treatment with structured psychotherapy. We argue that the solution is to drop the borderline personality disorder diagnosis and replace it with a more transparent system of describing personality pathology. In conclusion, borderline personality disorder may best be seen as a transitional diagnosis which drew attention to patients suffering from moderate to severe personality disorders and encouraged structured psychotherapies to be tested. However, it has now emerged that the diagnosis is not related to specific personality traits, is overinclusive, and does not lead to specific treatments beyond structured clinical care. Its domineering presence in the field means that assessment and treatment of other personality pathology is discouraged, and the whole concept of personality dysfunction is stigmatized. It is time for borderline personality disorder to lie down and die. [Tyrer and Mulder, 2024] On the other hand, some underscore the importance of the diagnosis despite its challenges. The ICD-11 and DSM-5 Alternative Model for Personality Disorder have attempted to address this by recognising personality disorder as a unitary construct with varying levels of severity, with BPD largely synonymous with its most severe form.

• 4. Advocates for this perspective argue that adopting and rehabilitating the term “severe personality disorder,” along with ensuring early diagnosis, treatment, and parity of access to mental and general health systems, are crucial elements of reform. They argue that rather than seeking to rename personality disorder, it is essential to respect experiences of developmental adversity at any age and consider them within the context of an individual’s formulation of their presenting problems. Chanen (2021) argues that employing substitute diagnoses as a “Trojan horse” to encourage a more humane approach to individuals with BPD is both misleading and unlikely to succeed. He argues that the stigma associated with BPD will inevitably transfer to any new term, as it is the interpersonal dysfunction characteristic of the disorder that drives negative attitudes and behaviours among clinicians.[Chanen, 2021] Paris argues that the diagnosis of Borderline Personality Disorder (BPD) offers several advantages in clinical practice. While the diagnosis has its challenges, it remains a valuable tool for guiding treatment and educating patients and their families. [Paris, 2007] 1. It helps recognise complex psychopathology, accounting for the co-occurrence of affective, impulsive, and cognitive symptoms. 2. BPD’s characteristic course, with symptoms peaking in early adulthood and gradually improving by middle age, provides a useful framework for therapy. 3. Diagnosing BPD aids in predicting treatment response, as patients with BPD often respond inconsistently to antidepressants, highlighting the importance of reconsidering diagnosis and avoiding ineffective polypharmacy. 4. BPD diagnosis facilitates the referral to psychotherapy, which is often more effective than pharmacotherapy in managing BPD symptoms. Further debates centre on the classification of BPD as a distinct disorder. Some argue that there is insufficient solid scientific evidence to support BPD as a unified syndrome, with its diagnostic criteria showing a strong association with general personality pathology rather than a unique factor specific to BPD. [Tyrer, 2009] Some authors have advocated for a reformulation of Borderline Personality Disorder as a condition with a biological origin and a multifactorial presentation, although no effective biological treatment currently exists. [Jeyasingam, 2024]

• 5. Jeyasingam argues that maintaining this biological perspective is crucial, as it increases the chances of discovering future treatments while also recognising the significant progress made through psychotherapy. Continuing to explore BPD within this framework is seen as promising for advancing therapeutic approaches. [Jeyasingam, 2024] AKISKAL ON BPD Akiskal has raised important questions regarding the validity and stability of borderline personality disorder (BPD) as a distinct diagnostic category, particularly in light of its considerable overlap with subaffective disorders. He argues that the current use of BPD as an adjectival descriptor fails to capture a specific psychopathological syndrome, leading to an oversimplification of the condition. [Akiskal et al., 1985] While BPD is often characterised by affective dysregulation, Akiskal posits that it is unlikely nature would create entirely separate mechanisms of emotional instability for BPD and affective disorders. [Akiskal, 2004] The stability of BPD symptoms over time is also questioned, with studies indicating that while some symptoms may remain stable, others do not. However, the percentage of individuals retaining a BPD diagnosis after a two-year follow-up is comparable to other personality disorders, such as obsessive-compulsive and schizotypal personality disorders. This variability in symptom presentation raises questions about the reliability of BPD as a diagnostic entity and suggests that the operational construct of BPD may have been overstretched in its current form. [Akiskal, 2004] Borderline personality disorder is at best a confusing concept, and at worst, a countertransference diagnosis which robs the patient of the opportunity of much needed treatment. The BPD of contemporary psychiatry has been highjacked from the affective domain where it must be returned to make caring possible. No healer can sustain an indefinite therapeutic relationship with a disagreeable person; not even a loving mother can cope with such a daughter (or son) with equanimity, unless there is hope that such behaviour is the expression of an emotional storm, albeit protracted, which lends itself to rational

• 6. interventions – and that it will pass with as little destruction on its path as possible. Like affective disease, it is BPD which destroys the person – and not vice versa. To paraphrase what Michael Stone told me a quarter of a century earlier, BPD as a nosologic construct, like some of the patients it describes, will eventually self-destruct itself. This is certainly true of the DSM-IV construct. On the other hand, I am on record for having endorsed the Kernberg psychostructural approach as a more sensible conceptual and clinical framework for BPD patients – who could then be diagnosed on axis I (e.g., mood and anxiety disorders) and a new putative independent axis VI for psychodynamic formulation. Psychoanalytic understanding and descriptive nosology are complimentary to one another – they should not be collapsed into one another. The latter is the fatal mistake of those who gave birth to BPD on axis II. [Akiskal, 2004] Some researchers suggest that the significant overlap between BPD and general personality pathology, particularly the pervasive self and interpersonal dysfunction, indicates that BPD criteria may represent broader impairments in personality functioning rather than a distinct disorder. [Sharp & Wall 2021] This view aligns with Kernberg’s idea of borderline personality organization and fits within the dimensional models of personality disorders outlined in DSM-5 and ICD-11. [Kernberg, 1975] Within the ICD-11 system, BPD features are well-represented through a two-step diagnostic approach that first assigns a core personality disorder diagnosis based on self and interpersonal functioning, followed by specification via trait dimensions. [Bach & First, 2018]. Furthermore, the heterogeneity of the BPD diagnosis complicates research efforts focused on aetiology and treatment, as the requirement to meet five out of nine possible criteria allows for 256 different combinations that can lead to a BPD diagnosis. [Jeyasingam, 2024]

• 7. APPROACH TO THE DIAGNOSIS OF BPD Patients with Borderline Personality Disorder (BPD) often seek treatment during episodes of other mental health issues, such as depression, anxiety, trauma-related disorders, or substance use. [Leichsenring et al., 2023] They may also reach out following a suicide attempt, impulsive behaviour, or a significant personal crisis like a relationship breakdown or job loss. Diagnosing borderline personality disorder (BPD) through clinical interviews presents a significant challenge. [Gunderson et al., 2018] The potential for overgeneralisation is a common concern. Clinicians may extrapolate their observations from limited clinical encounters to broader life situations without adequate supporting evidence. This can lead to inaccuracies in diagnosis, either through overdiagnosis or underdiagnosis of BPD. Furthermore, clinicians might form a general impression of the patient’s personality during assessments, but such impressions are often insufficient to thoroughly evaluate the specific diagnostic criteria required for BPD. Consequently, clinical judgments may stray from strict criterion-based evaluations, resulting in diagnostic missteps. To address this, semi-structured and fully structured diagnostic interviews and self-report questionnaires have been developed. These tools are more reliable and valid than routine clinical assessments and are most effective when used together to ensure an accurate diagnosis of BPD. BPD can be initially suspected based on unstable identity, interpersonal relationships, and affect. Helpful screening questions for BPD may include: Do you often wonder who you really are? Do you sometimes feel that another person appears in you that does not fit you?

• 8. Do your feelings toward other people quickly change into opposite extremes (e.g., from love and admiration to hate and disappointment)? Do you often feel angry? Do you often feel empty? Have you been extremely moody? Have you ever deliberately hurt yourself (e.g., cut or burned yourself)? Assessing personality pathology can be particularly complex due to the intricate nature of self-perception. Individuals with personality-related concerns may not always have a clear or consistent awareness of their difficulties, especially when these challenges primarily emerge in the context of interpersonal relationships and daily functioning. Instead of relying solely on self-reported descriptions of personality traits, clinicians can gain valuable insights by observing patterns in how individuals describe their interactions, relational dynamics, and work-related behaviours. Clinicians may also rely on how individuals interact with them during interviews and may interview others close to the patient to gather additional perspectives. Common questions to evaluate personality include: [Gunderson et al., 2018] How would you describe yourself as a person? How do you think others would describe you? Who are the most important people in your life? How do you get along with them? KEY CONSIDERATIONS IN THE ASSESSMENT OF BORDERLINE PERSONALITY DISORDER (BPD) 1. Emotional Influence on the Clinician-Patient Relationship Assessing individuals with BPD often requires clinicians to navigate the emotional intensity that can emerge during evaluations. Common features include expressions of anger, neediness, demanding behaviour, and fluctuations in the way the clinician is perceived, alternating between idealisation and devaluation.

• 9. Awareness of these dynamics is essential, as they can influence the clinician’s judgment and the therapeutic alliance. Maintaining objectivity while acknowledging these emotional responses is crucial for a thorough and unbiased evaluation. 2. Pervasiveness across Contexts: A critical feature of BPD is the pervasiveness of its symptoms across multiple life contexts. Clinicians should gather detailed information about how patients perceive themselves and their interactions with others in various settings, including personal, social, and professional domains. [Leichsenring et al., 2024] BPD traits must be present in multiple contexts and exhibit a degree of inflexibility, meaning they persist despite evidence that they are maladaptive or inappropriate. This differentiates BPD from situational or transient emotional reactions, confirming the presence of a pervasive personality pathology. 3. Developmental Onset and Progression Personality disorders, including BPD, typically emerge during adolescence or early adulthood, often during periods of significant life transitions. A developmental approach is important in understanding the onset and evolution of BPD traits. Identifying the early appearance of symptoms and tracking their progression over time allows clinicians to differentiate BPD from other psychiatric conditions that may arise later in life. Understanding the developmental course of the disorder is crucial for contextualising the patient’s experiences and formulating appropriate interventions. 4. Change Over the Lifespan Although BPD has historically been considered a stable and enduring condition, recent longitudinal research suggests that it can show considerable improvement over time. Many individuals experience a reduction in symptom severity, challenging the traditional view of BPD as a lifelong disorder.

• 10. Clinicians should remain aware of the potential for positive change, incorporating this understanding into treatment planning and providing hope for recovery through appropriate interventions. 5. Comorbidity and Diagnostic Complexity Comorbidity is a hallmark of BPD, with individuals frequently presenting with co-occurring psychiatric conditions. The lifetime prevalence of mood disorders, such as major depressive disorder and bipolar disorder, ranges from 61% to 83% in individuals with BPD. Anxiety disorders are also highly prevalent, affecting up to 88% of individuals, and substance use disorders are present in approximately 78% of cases. [Leichsenring et al., 2024] Furthermore, BPD commonly coexists with other personality disorders, such as avoidant or dependent personality disorders. [Leichsenring et al., 2024] Distinguishing between the acute states of comorbid conditions and the stable traits of BPD is crucial for accurate diagnosis and treatment. 6. Diagnostic Assessment and Conveying the Diagnosis A comprehensive diagnostic assessment is a foundational aspect of BPD management. Clinicians should evaluate the full spectrum of symptoms and comorbidities, ensuring the diagnosis is communicated clearly to the patient. [Leichsenring et al., 2024] When conveying the diagnosis, it is essential to balance honesty with support, preparing the patient for potential challenges while fostering an attitude of acceptance and collaboration. Understanding and discussing the diagnosis transparently with the patient ensures they are well-informed and actively involved in their treatment. This empowers patients to engage with therapeutic interventions and fosters a more effective, collaborative treatment process.

• 11. 7. Distinguishing BPD from Bipolar Disorder A key clinical challenge lies in differentiating BPD from bipolar disorders, as both conditions share overlapping features, such as mood instability and impulsivity. A key point of contention is whether the fluctuating moods observed in BPD should be classified as an “ultra-rapid cycling” subtype of bipolar disorder, raising questions about the independence and interdependence of these two conditions within the broader spectrum of mood disorders. [Bayes et al., 2019]. The overlap in mood symptoms between BPD and BP disorders, including the debate over whether BPD’s fluctuating moods represent an “ultra-rapid cycling” subtype of BP, further complicates this diagnostic dilemma. However, unlike the episodic nature of bipolar disorder, where symptoms are separated by periods of remission, BPD is characterised by persistent and pervasive dysfunction in emotional regulation and interpersonal relationships. Click to enlarge. Downloadable with a Hub Pro subscription. This chronic, stable dysfunction is a distinguishing feature of BPD, underscoring the importance of longitudinal assessment in differentiating between these two conditions for accurate diagnosis and management.

• 12. Bayes et al. (2019) critically examined recent studies to clarify the clinical distinctions between bipolar II disorder and borderline personality disorder, aiming to refine their diagnostic boundaries. Click to enlarge. Downloadable with a Hub Pro subscription. The importance of accurately differentiating these conditions lies in their distinct treatment approaches: bipolar I and II disorders typically require pharmacotherapy, while BPD is best managed through psychotherapy, with medications playing a secondary role. In cases of co-occurrence, the treatment strategy must be carefully tailored, often prioritising the stabilization of the most severe condition first, which is usually bipolar disorder, to ensure the most effective outcomes for the patient. 8. Distinguishing CPTSD and BPD: Recent efforts to reconceptualise certain cases of Borderline Personality Disorder (BPD) within the framework of Complex Posttraumatic Stress Disorder (CPTSD) have gained attention. [Paris, 2023]. While there is a substantial overlap between BPD and CPTSD, particularly as defined in the ICD-11-both disorders involve significant challenges in affect regulation, self-concept,

• 13. and interpersonal relationships-empirical evidence suggests that these conditions can be distinctly differentiated. Paris and Ruffalo argue that CPTSD overlaps significantly with BPD, which already addresses key issues like aloneness, abandonment and and identity diffusion. They propose that BPD should remain a distinct diagnosis, as it includes critical aspects not fully captured by CPTSD. The introduction of CPTSD is controversial, as it may overshadow BPD, raising doubts about whether CPTSD is truly distinct or simply BPD with PTSD. [Ruffalo and Paris, 2024] CPTSD can be differentiated from BPD by specific symptoms and individual patient related patterns. [Karatzias et al., 2023] Differences: [Karatzias et al., 2023] Affect regulation: In CPTSD, affect regulation difficulties are typically ego-dystonic, stressor-specific, and variable over time. BPD is characterised by ego-syntonic affect regulation issues, which are more persistent and pervasive, aligning with the individual’s overall self-concept. Self-Percept: CPTSD generally maintain a consistently negative self-perception. BPD experience an unstable and often fluctuating sense of self. Relational difficulties CPTSD is characterised by consistent difficulties in trusting others and avoidance of intimacy or closeness. BPD is characterised by unstable or volatile patterns of interactions. Behavioural Patterns:

• 14. CPTSD is characterised by symptoms where impulsivity and suicidal/self-injurious behaviours may occur, but these are less frequent and not as prominent compared to other CPTSD symptoms. BPD is characterised by high rates of impulsivity, suicidal, and self-injurious behaviours, which are more common compared to CPTSD. Click to enlarge. Downloadable with a Hub Pro subscription. STANDARDISED INSTRUMENTS FOR DIAGNOSIS OF BPD Semi-structured clinical interviews or clinician-rated instruments: Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II) – All personality disorders. Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV) – All personality disorders. International Personality Disorders Examination (IPDE) – All personality disorders in DSM-IV and ICD-10. Structured Interview for DSM-IV Personality Disorders (SIDP-IV) – All personality disorders. Structured Clinical Interview for the DSM-5 Alternative Model for Personality Disorders Module III (SCID-5-AMPD) – BPD and five other personality disorders. Revised Diagnostic Interview for Borderlines (DIB-R) – BPD only.

• 15. Childhood Interview for DSM-IV Borderline Personality Disorder (CI-BPD) – BPD only, designed specifically for adolescents. Borderline Personality Disorder Severity Index-IV (BPDSI-IV) – BPD only, dimensional short-interval change measure with adolescent and parent versions. Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD) – BPD only, dimensional short-interval change measure. Structured interview for lay-person administration: Alcohol Use Disorder and Associated Disabilities Interview Schedule-5 (AUDADIS-5) – BPD, ASPD, and STPD, used in NESARC. Self-report instruments for diagnosis: Personality Diagnostic Questionnaire-4 (PDQ-4) – All personality disorders. Personality Assessment Inventory (PAI) – BPD and ASPD. Borderline Symptom List (BSL) – BPD. Five-Factor Borderline Inventory (FFBI) – BPD, based on the Five-Factor Model of personality traits. Self-report instruments to assess pathological personality traits: Schedule for Nonadaptive and Adaptive Personality-II (SNAP-II) – All personality disorders and traits. Dimensional Assessment of Personality Pathology–Basic Questionnaire (DAPP-BQ) – BPD and OPD traits. Minnesota Multiphasic Personality Inventory-2–Restructured Form (MMPI-2- RF) – Personality disorder traits. Personality Inventory for DSM-5 (PID-5) – BPD and OPD traits, based on the DSM-5 AMPD. Self-report instruments for screening: McLean Screening Instrument for BPD (MSI-BPD) – BPD, 10 items. Borderline Personality Questionnaire (BPQ) – BPD. Borderline Personality Features Scale for Children (BPFSC) – BPD, dimensional measure for children and adolescents, with child and parent versions.

• 16. Self-report instruments to assess impairment in personality functioning: Severity Indices of Personality Problems (SIPP-118) – Personality functioning. General Assessment of Personality Disorder (GAPD) – Personality functioning. Level of Personality Functioning Scale Self-Report (LPFS-SR) – Personality functioning, based on DSM-5 AMPD. MANAGEMENT OF BPD Management Principles in Borderline Personality Disorder (BPD) [Leichsenring et al., 2023], [Leichsenring et al., 2024], [Gunderson et al., 2018] 1. Diagnosis Disclosure and Patient Education The treatment of patients with borderline personality disorder (BPD) should commence with a clear disclosure of the diagnosis. It is essential to educate the patient about the nature of the disorder, its expected course, aetiological underpinnings, and available treatment options. This approach not only alleviates distress but also helps establish a therapeutic alliance between the patient and clinician. [Leichsenring et al., 2024] By providing accurate information, patients can gain a sense of control over their condition and better understand the role of treatment in managing BPD. Importantly, clinicians must emphasise that while effective therapies exist, the focus should be on learning self-care and that pharmacological treatments are largely adjunctive rather than curative. 2. Establishing Boundaries and Managing Expectations A fundamental component of managing BPD is the establishment of clear therapeutic boundaries. Setting boundaries around therapeutic expectations can prevent behaviours that may disrupt treatment, such as excessive demands or splitting behaviours where patients

• 17. perceive clinicians as “good” or “bad.” Consistency is particularly important in preventing splitting, which can undermine the therapeutic alliance. All clinicians involved in the patient’s care should adopt a unified approach to treatment, ensuring that patients receive coherent and consistent care throughout their therapeutic journey. Clinicians must balance boundary setting with maintaining empathy. For instance, patients with BPD may exhibit excessive demands for contact or treatment, and clinicians must avoid reinforcing such behaviours through their responses. Polypharmacy using multiple medications concurrently should be approached with caution, as it can complicate treatment without clear benefits. It is also crucial for clinicians to manage their responses to any provocative behaviour exhibited by patients. Emotional reactions from the clinician may exacerbate symptoms and hinder the therapeutic process. Instead, clinicians should maintain a calm and measured approach, focusing on long-term therapeutic goals rather than immediate emotional responses. 3. Building a Therapeutic Alliance A strong, productive patient-clinician relationship is at the heart of effective treatment for BPD. Clinicians must adopt an attitude of understanding, acceptance, and empathy. Setting realistic goals with the patient while communicating these goals fosters a shared understanding of the treatment process. Providing the patient a clear explanation of the disorder, its trajectory, and available treatment options can also improve adherence and motivation. Equally important is the need to offer realistic hope. While it is essential to instill a sense of hope, clinicians should avoid overpromising outcomes.

• 18. Unrealistic expectations can lead to disappointment, which may damage the therapeutic relationship. Instead, offering a balanced and evidence-based perspective on treatment can foster trust and optimism. 4. Avoiding Stigmatization in BPD Treatment Clinicians must actively work to challenge any stigmatising attitudes toward patients with BPD. Preconceptions, such as viewing these patients as intentionally difficult or resistant to treatment, can adversely affect the quality of care provided. Such attitudes undermine the clinician-patient relationship and erode the patient’s trust in the therapeutic process. Rather than focusing on behaviours as manipulative or problematic, it is more helpful to frame them as manifestations of the underlying disorder. By approaching BPD with empathy and a focus on treatment potential, clinicians can engage in more constructive management of these behaviours. 5. Collaboration and Consistency Among Clinicians In cases where multiple clinicians are involved in the care of a patient with BPD, it is crucial to ensure open communication and a consistent treatment approach. The phenomenon of “splitting”, where patients view one clinician as entirely “good” and another as “bad”, can disrupt the continuity of care. Therefore, all members of the treatment team must be aligned on the goals and methods of treatment, offering consistent messages and interventions to the patient. A unified treatment plan, where clinicians agree on boundaries, therapeutic goals, and intervention strategies, prevents splitting behaviours from undermining the therapeutic process and ensures that the patient receives cohesive care. 6. Recognising and Managing Countertransference Countertransference, emotional reactions from the clinician in response to the patient’s behaviour, is a common challenge in the treatment of BPD. Patients often struggle with

• 19. emotional and interpersonal regulation, which can provoke strong reactions from clinicians, such as feelings of powerlessness, frustration, or even anger. While countertransference can provide valuable insights into the patient’s internal experiences, it must be managed carefully to prevent it from interfering with treatment. Clinicians should aim to develop self-awareness and reflect on their emotional responses to use countertransference constructively. Understanding and processing these reactions can deepen the clinician’s empathy and offer a window into the patient’s emotional world, thus enhancing the therapeutic alliance. (See later) 7. Biographical Understanding and Patient History A thorough understanding of the patient’s biographical background, including any experiences of trauma or maltreatment, is essential for interpreting the strong emotional reactions often seen in patients with BPD. These emotional responses, such as anger, fear, or withdrawal, are often projections of past traumatic experiences rather than personal attacks on the clinician. By recognising these reactions as rooted in the patient’s history, clinicians can avoid taking them personally and respond in a way that is more therapeutic and less reactive. This understanding is essential in managing countertransference and fostering a supportive, empathic approach. FIRST-LINE MANAGEMENT OF BORDERLINE PERSONALITY DISORDER (BPD) 1. Psychotherapy as the Primary Treatment Psychotherapy is widely recognised as the first-line treatment for patients with borderline personality disorder (BPD) supported by extensive empirical evidence. [Gunderson et al., 2018], [Leichsenring et al., 2024] While pharmacotherapy can play an adjunctive role, its use should be reserved for specific situations, such as during acute crises or in the presence of comorbid conditions, and administered with caution.

• 20. Psychotherapy aims to foster long-term changes, while pharmacological treatments should be minimised and limited to the shortest duration necessary. Clinical guidelines advocate for sustained psychotherapeutic interventions, recommending that treatments extend beyond brief formats, typically lasting a minimum of three months, to ensure therapeutic efficacy. [Gunderson et al., 2018] Among the most effective and empirically validated therapies are dialectical behaviour therapy (DBT), mentalization-based therapy (MBT), transference-focused psychotherapy (TFP), and schema therapy (ST). In instances where specialised psychotherapeutic treatments such as DBT, MBT, TFP, or ST are unavailable within the clinical setting, referrals to mental health experts trained in these modalities are recommended. These specialised treatments have demonstrated significant benefits in reducing BPD symptoms, enhancing emotional regulation, and improving interpersonal functioning. [Leichsenring et al., 2024] Despite their proven effectiveness, the widespread implementation of these evidencebased therapies in routine clinical practice remains inconsistent, often due to limited access to trained professionals and resource constraints. In settings where specialised therapies are not readily available, clinicians may employ alternative approaches such as psychoeducation or crisis management to address immediate patient needs and provide foundational support until specialised care can be accessed. [Gunderson et al., 2018] Access to specialised care can significantly enhance treatment outcomes by providing patients with evidence-based interventions tailored to their specific needs. [Gunderson et al., 2018] 2. Prioritising Life-Threatening Behaviours In patients presenting with suicidal ideation or self-harm, these life-threatening behaviours must be addressed as a priority. Treatment plans should incorporate both verbal interventions and, if necessary, short-term pharmacotherapy to manage these behaviours.

• 21. The use of short-term medications may be considered to stabilise the patient during acute crises, but the primary focus remains on addressing the psychological underpinnings of self-harm and suicidality through therapy. Early identification and intervention are critical for preventing escalation and promoting safety. 3. Addressing Suicidality and Black-and-White Thinking The assessment and management of suicidality in BPD require careful evaluation of suicide risk factors, including the presence of a detailed plan, past attempts, and the availability of social support. The clinician should explore potential triggers for suicidal ideation, such as feelings of abandonment or loss, and work collaboratively with the patient to explore alternative solutions to their distress. Additionally, addressing the patient’s tendency toward black-and-white thinking, especially in response to perceived interpersonal rejection, can help reduce the intensity of suicidal thoughts. Encouraging the patient to develop more nuanced and integrated views of themselves and others can mitigate the extremity of their emotional responses. 4. Understanding and Managing Self-Harm Self-harm in BPD serves various functions, including regulating emotions, relieving feelings of emptiness or dissociation, or managing interpersonal relationships. [Gunderson et al., 2018] Clinicians should recognise these underlying functions to tailor interventions appropriately. In some cases, agreements between the patient and clinician regarding self-harm behaviours such as seeking medical attention for injuries before the next session can help manage the behaviour while preserving the therapeutic relationship. These agreements foster accountability and minimise harm without encouraging punitive responses. 5. Managing Comorbidities

• 22. BPD is often accompanied by comorbid psychiatric conditions, which can complicate the clinical presentation and treatment strategy. Disorders such as bipolar I disorder, severe substance use disorders, complex post-traumatic stress disorder (PTSD), and anorexia nervosa typically require prioritised treatment over BPD to ensure effective management. [Gunderson et al., 2018] Addressing these comorbid conditions is essential, as their remission can significantly enhance the overall treatment outcome for BPD. For instance, stabilising manic symptoms in bipolar I disorder before addressing BPD traits can lead to more effective and focused therapeutic interventions. Similarly, treating severe substance abuse or impulse control disorders can remove barriers to successful BPD treatment, allowing for more comprehensive and integrated care. Additionally, milder comorbidities may be managed concurrently with BPD treatment to support holistic patient recovery. [Gunderson et al., 2018] 6. Pharmacotherapy as an Adjunct to Psychotherapy While psychotherapy is the cornerstone of BPD treatment, pharmacotherapy may be indicated in certain circumstances, such as managing acute comorbid conditions or crises. However, pharmacotherapy should always be considered adjunctive to psychotherapy and used sparingly. When prescribed, it is recommended to limit medications to the minimum effective dose for the shortest duration possible, typically no longer than one week, unless otherwise necessary. This approach minimises the risk of overreliance on pharmacological treatments and focuses on developing the patients’ ability to manage their symptoms through therapeutic interventions. PSYCHOTHERAPY FOR BORDERLINE PERSONALITY DISORDER (BPD) Since the first randomised controlled trial (RCT) investigating the efficacy of psychotherapy for BPD in 1993, more than ten manualised psychotherapeutic interventions have been developed and rigorously evaluated. Core Therapies: 4 psychological interventions have been established as major evidencebased treatments (EBTs) for BPD:

• 23. 1. Dialectical Behavioural Therapy (DBT) 2. Mentalization-Based Treatment (MBT) 3. Schema-Focused Therapy (SFT) 4. Transference-Focused Psychotherapy (TFP) Another treatment approach for Borderline Personality Disorder (BPD) is Systems Training for Emotional Predictability and Problem Solving (STEPPS), a group-based intervention aimed at enhancing emotion regulation and behaviour management skills. STEPPS has been associated with reductions in BPD symptoms, improved quality of life, decreased depressive symptoms, and less negative affectivity. However, results have been mixed regarding its impact on impulsivity and suicidal behaviours. The program has been studied both as an add-on to ongoing treatments and as a standalone option with individual sessions. Despite its promise, high attrition rates complicate the generalisability of findings, and further research is required to establish more definitive conclusions. [Ekiz et al., 2023] Efficacy of Psychotherapy: Comparative studies have shown that psychotherapy generally yields significant clinical benefits over treatment-as-usual (TAU). A meta-analysis revealed that psychotherapy led to a standardised mean difference (SMD) of –0.52 in reducing symptom severity, highlighting its superior efficacy in reducing self-harm and suicide-related outcomes and improving overall psychosocial functioning. [Storebø et al., 2020] Although most studies support psychotherapy’s efficacy in controlled settings, evidence of its effectiveness under real-world clinical conditions remains limited, necessitating further research to determine its broader applicability. While the safety of psychotherapy is a paramount concern, current evidence does not suggest an increased risk of serious adverse events compared to TAU. Patients undergoing psychotherapy for BPD have not demonstrated higher rates of harm, further supporting the use of psychotherapy as a safe and effective intervention for BPD.

• 24. Specialised psychotherapies, including DBT, MBT, and schema therapy, consistently outperform more generic approaches, such as general psychiatric management, clientcentred therapy, and supervised team management, in clinical outcomes. [Setkowski et al., 2023] These specialised therapies have shown greater efficacy in reducing critical outcomes like suicidality, self-harm, depression, anxiety, and the need for hospitalisation or emergency room visits among BPD patients. However, in the adolescent population, the efficacy of psychotherapy for BPD remains less conclusive. [Storebø et al., 2020] A recent systematic review and meta-analysis of ten RCTs found that only a few demonstrated the superiority of psychotherapy over control conditions in adolescents with BPD or BPD features. [Jorgensen et al., 2021] Moreover, a Cochrane review concluded that while adolescent patients with BPD do benefit from psychotherapy, the magnitude of improvement is generally less pronounced compared to adult patients. To address the developmental differences between adolescents and adults, treatments such as DBT, TFP, and MBT have been adapted for younger patients. However, further research is needed to optimise these interventions and better understand their long-term impact on this population. [Storebø et al., 2020] SPECIFIC PSYCHOTHERAPEUTIC APPROACHES DIALECTICAL BEHAVIOUR THERAPY (DBT): Dialectical Behaviour Therapy (DBT) is rooted in the concept of dialectics, which refers to the coexistence of opposites. In DBT, individuals are taught two core strategies: acceptance, recognising the validity of their emotional experiences, and change, developing skills to manage emotions and improve behaviours. Grounded in cognitive-behavioural principles, DBT balances these seemingly contradictory approaches, providing a structured outpatient psychotherapy aimed at promoting emotional regulation and functional recovery.

• 25. It involves four components: [Leichsenring et al., 2024] 1. Individual Therapy: Exploration of parasuicidal behaviour Problem-solving behaviours, including short-term distress management techniques, are emphasised. Exploration of Therapy-interfering behaviours and behaviours impacting quality-oflife. Exploration and application of acquired behavioural skills Trauma history is addressed when the patient is ready (remembering the abuse, validation of memories, acknowledging emotions related to abuse, reducing self-‐ blame and stigmatisation, addressing denial and intrusive thoughts regarding abuse (e.g., by exposure techniques), and reducing polarisation or supporting a dialectical view of the self and the abuser). Consistent reinforcement of patient’s self-respect behaviours 2. Group Skills Training: Focuses on Core mindfulness Interpersonal effectiveness Emotion regulation Distress tolerance. Skills are reinforced through homework and diary cards. Weekly meetings for 2 hrs for a duration of approx. 6 months. Modules may be repeated, and the skills training group is recommended for at least one year. Core mindfulness: Core mindfulness in DBT is adapted from Eastern meditation practices. It aims to reduce impulsivity and emotion-driven behaviours by fostering presentmoment awareness.

• 26. Patients are taught to focus on one task at a time with a non-judgmental attitude, promoting full engagement in the present. This technique addresses the tendency to idealise or devalue oneself and others. Mindfulness also helps prevent rumination on the past and reduces anxiety about future events. Interpersonal effectiveness skills training Teaches patients how to ask for what they need and to say “no.” Focuses on managing interpersonal conflicts. Emotion regulation skills: Involves identifying and labeling emotions. Helps patients recognise obstacles to changing emotions, including parasuicidal behaviours. Guides patients to avoid vulnerable situations and increase positive emotional experiences. Teaches strategies for tolerating painful emotions. Distress tolerance skills: Includes self-soothing and distraction techniques. Aims to transform intolerable pain into tolerable suffering. 3. Telephone Coaching: Provides support during crises by encouraging non-abusive help-seeking behaviours. Minimises reinforcement for parasuicidal behaviours through an agreement: The patient must call the therapist before engaging in parasuicidal behaviour. The patient is not permitted to contact the therapist for 24 hours following a parasuicidal act, unless life-threatening injuries are present. 4. Team Consultations: Therapists participate in team consultations to maintain treatment fidelity and motivation.

• 27. Dialectical Behaviour Therapy (DBT) and other interventions that focus on improving affect regulation strategies might help to decrease this maladaptive top-down modulation, thereby reducing the reliance on self-injury for emotional regulation. MENTALIZATION-BASED TREATMENT (MBT): The failure to develop mentalisation, or reflective function, is a key aspect of BPD. This ability, which normally emerges in the context of healthy attachment relationships, allows individuals to understand their own and others’ mental states. Without it, BPD patients often equate their perceptions of others’ intentions with reality, leading to difficulties in considering alternative perspectives [Fonagy , 2000]. In BPD, there is often a reliance on automatic, affect-driven, and externally-focused mentalizing, which leads to an imbalance in how individuals process their own and others’ mental states. This imbalance results in non-mentalizing modes, such as psychic equivalence (where thoughts and feelings are perceived as reality), teleological thinking (where only observable actions are considered reflective of mental states), and the pretend mode (where mentalizing is detached from reality). These unprocessed emotional experiences (alien-self experiences) can lead to overwhelming emotions like anger or rejection, which are often externalised through maladaptive behaviours such as self-harm or substance abuse to cope. Mentalization-Based Therapy (MBT) aims to enhance patients’ capacity for mentalizing, particularly in the context of interpersonal relationships, where high levels of emotional arousal can disrupt this ability. MBT is primarily focused on addressing key issues in patients with Borderline Personality Disorder (BPD), including suicidality, self-harm, emotional dysregulation, and relational instability. Interventions include supportive techniques, clarification, and mentalizing the therapeutic relationship.

• 28. A critical goal of MBT is to foster epistemic trust, enabling patients to trust and apply the knowledge provided by others for their well-being, thereby facilitating their ability to engage positively with social and relational resources. 1. Managing anxiety and arousal is central, as high arousal leads to a loss of mentalizing, while low arousal results in overly abstract mentalizing detached from reality. 2. Interventions focus on restoring balanced mentalizing, countering the tendency in BPD patients to rely on automatic, affect-driven, and externally-focused mentalizing without integrating cognitive and emotional processes. 3. Therapists and patients are equal partners, working together to explore and understand interpersonal issues and how they relate to the patient’s symptoms. 4. The therapist prioritizes understanding the how of mental processes rather than focusing on the what or why. 5. Empathic emotional validation is a key feature to restore the patient’s sense of agency and comprehension of their experiences. Two empirically supported models of MBT for BPD include intensive outpatient MBT and day-hospitalisation MBT programs. MBT employs a range of interventions, including supportive strategies that normalize and regulate anxiety, fostering epistemic trust through marked mirroring to restore a sense of agency. Clarification and elaboration of subjective experiences are central, alongside techniques to restore basic mentalizing, such as “stop-and-rewind” and “stop-stand-andchallenge.” Interventions also focus on mentalizing the therapeutic relationship and generalizing insights from therapy to real-life interpersonal contexts. Phases of MBT: 1. Initial Phase: Involves psychoeducation through an MBT introductory group course. Develops case formulation collaboratively with the patient. Focuses on building a treatment alliance informed by the patient’s attachment history.

• 29. Emphasizes safety planning and the formulation of a mentalizing profile, identifying imbalances and triggers affecting mentalization. 2. Treatment Phase: Consisting of general and specific strategies General strategies: Stabilisation of risky behaviours. Supportive, empathic validation to regulate anxiety and re-activate mentalizing. Use of elaboration and clarification to enhance basic mentalizing, particularly for intense emotional states. Strong emphasis on interpersonal relationships and exploring alternative perspectives through relational mentalizing. Focus on repairing ruptures in the therapeutic alliance. Specific strategies: Management of impulsive behaviours by mentalizing triggering events. Activation of the attachment system in both group and individual therapy to develop basic mentalizing. Linking therapy experiences to daily life, with attention to social inclusion/exclusion and rejection. Improving mentalizing capacity under stress and recovering mentalizing after its loss. Mentalizing traumatic experiences when relevant. Final Phase: Reviews the therapy process, focusing on the ending experience for both the patient and therapist. Addresses BPD-specific concerns related to ending, such as fears of abandonment or rejection. Generalises stable mentalizing and social understanding. Considers how the patient can continue therapeutic progress post-therapy. TRANSFERENCE-FOCUSED PSYCHOTHERAPY (TFP):

• 30. Transference-Focused Psychotherapy (TFP) is based on psychoanalytic object relations theory, focusing on unconscious conflicts that emerge in the therapeutic relationship (transference). These conflicts are expressed through internalised object relations, where the self and others are represented in emotionally charged dyads. In therapy, these dynamics are enacted between the patient and therapist, mirroring unresolved conflicts from past relationships. The goal of TFP is to integrate split-off parts of the self, particularly disowned aggression, by addressing polarised views of self and others (idealisation and devaluation). This helps reduce psychological splitting, fostering a more cohesive identity and healthier relationships. Key Aspects of TFP: Transference Exploration: The therapist interprets the patient’s behaviours, linking them to unconscious conflicts and internalised object relations. Integration of Aggression: The focus is on helping patients recognise and integrate polarised emotions, especially anger, to achieve emotional regulation and identity cohesion. Psychoanalytic Techniques: 1. Interpretation: The therapist analyses verbal and nonverbal cues to uncover unconscious conflicts, often within transference. 2. Transference Analysis: This is the main tool for understanding how past object relations are re-enacted with the therapist. 3. Technical Neutrality: The therapist maintains an objective, non-engaging stance, providing insight without becoming part of the patient’s conflict. 4. Countertransference: The therapist uses their emotional responses to understand and interpret the patient’s unconscious dynamics without directly communicating them. (See Countertransference and management of countertransference later).

• 31. SCHEMA THERAPY (ST): Schema Therapy (ST) integrates cognitive-behavioural, psychodynamic, attachment, and emotion-focused approaches, addressing four key dysfunctional modes typically seen in individuals with Borderline Personality Disorder (BPD). These modes are the abandoned/abused child, the angry/impulsive child, the detached protector, and the punitive parent, with the presence of a healthy adult also being assumed. [Kellogg and Young, 2006] One of the primary goals of ST is to develop and strengthen the healthy adult mode, initially embodied by the therapist and later internalized by the patient during therapy. 1. Abandoned/Abused Child Mode: Characterised by feelings of isolation, being unloved, and a desperate need for a caretaker. This mode represents a core emotional state for BPD patients, often leading to frantic efforts to find a nurturing figure. 2. Angry/Impulsive Child Mode: Expresses rage over unmet emotional needs and perceived abandonment or mistreatment. Unfortunately, this outburst makes it less likely that the patient’s needs will be met. The punitive parent mode may activate, leading to self-punishing behaviours like self-harm. 3. Detached Protector Mode: The patient emotionally withdraws, feeling numb or empty. They may avoid relationships, become socially withdrawn, or seek distractions through fantasy or stimulation, which can hinder therapeutic progress. 4. Punitive Parent Mode: Involves the patient internalising an abusive parental figure, leading to feelings of worthlessness or evilness. This mode often results in self-punishing behaviours. The

• 32. therapist assists the patient in recognising and distancing themselves from this punitive inner voice. Therapeutic Process: Schema Therapy (ST) promotes change through four key processes: limited reparenting, emotion-focused work, cognitive restructuring, and behavioural pattern breaking. 1. Limited reparenting Offers a corrective emotional experience where therapists provide warmth, stability, and support to meet unmet childhood needs, while maintaining boundaries. Therapists may provide extra contact and transitional objects to address abandonment issues. 2. Emotion-focused techniques Involves imagery work, dialogues, and unsent letter writing. Therapists model the healthy adult role, helping patients confront past traumas and externalise punitive voices through techniques like Gestalt chair work. 3. Cognitive restructuring Educates patients on healthy emotional needs and reciprocal relationships, teaching them to express emotions appropriately and avoid black-and-white thinking. 4. Behavioural pattern breaking Helps patients apply therapy to real life through techniques like relaxation, assertiveness, and role-playing, addressing distorted expectations and changing maladaptive behaviours. Phases of Schema Therapy: [Young et al., 2003] 1. Bonding and emotional regulation:

• 33. The therapist establishes a safe, nurturing relationship that counters the abusive or punitive dynamics the patient experienced in childhood. The patient remains in the abandoned/abused child mode to internalize the therapist as a healthy parental figure. This phase allows the patient to express unmet needs and desires, while anger is managed in a controlled manner to avoid being counterproductive. The therapist engages in limited reparenting to fulfill the patient’s emotional needs. 2. Schema mode change: The therapist continues to nurture the abandoned/abused child mode, offering positive affirmations like calling the patient generous, empathetic, or creative. However, the punitive parent mode may resist these affirmations, and the detached protector mode may emerge as a defense mechanism, leading to emotional detachment. When this happens, the therapist helps the patient identify the costs and benefits of the detached protector mode, potentially adjusting therapy intensity or considering medication to manage overwhelming emotions. 3. Autonomy development: In the final phase, the focus shifts from reparenting within therapy to fostering independence outside sessions. The therapist and patient work on strengthening interpersonal relationships and developing a stable sense of identity, exploring how different modes interact in these areas to support the patient’s growth and self-understanding. PHARMACOTHERAPY Pharmacotherapy is generally not recommended for treating the core symptoms of BPD. Instead, it should be reserved for managing severe comorbid disorders such as major depression, severe anxiety, or transient psychotic symptoms. Medications should be used for the shortest possible duration and in crisis situations only. Comorbidities like major depressive disorder (MDD), anxiety disorders, and substance use disorders (SUDs) often necessitate pharmacological intervention, but the primary

• 34. focus should remain on BPD-specific psychotherapy. The National Institute for Health and Care Excellence (NICE) guidelines explicitly recommend against using psychotropic medications for the direct treatment of BPD symptoms. [NICE, 2009] Up to 96% of patients with BPD who seek treatment receive at least one psychotropic medication. Polypharmacy is particularly common, with approximately 19% of patients taking four or more psychotropic drugs concurrently. [Zanarini et al., 2015] A study of 457 individuals diagnosed with borderline personality disorder (BPD) revealed that nearly 80% of those without comorbid conditions were also undergoing pharmacological treatment. Specifically, 62.9% were prescribed antidepressants, 59.7% benzodiazepines, 22.6% mood stabilisers, and 27.4% antipsychotics, with 42% of patients receiving multiple medications simultaneously (polypharmacy). [Martín-Blanco et al., 2017] A systematic review assessing the efficacy of pharmacological treatments for co-occurring psychopathology in individuals with Borderline Personality Disorder (BPD) revealed that anticonvulsants had moderate to large effects on reducing depressive and anxiety symptoms, though the evidence is of very low certainty. [Pereira Ribeiro et al, 2024]. Antipsychotics demonstrated small effects on depressive and dissociative symptoms, with a more pronounced reduction in dissociative symptoms in individuals with co-occurring substance use disorders (SUDs). Overall, the findings provide limited support for pharmacological interventions in treating co-occurring symptoms in BPD, highlighting the need for caution given the low certainty of evidence. [Pereira Ribeiro et al, 2024]. Once initiated, patients with BPD often resist discontinuing medications, even when the target symptoms remain unchanged or worsen. This highlights the importance of cautious prescribing and ongoing evaluation of medication necessity. Despite the high prevalence of psychotropic drug use among BPD patients, no specific medication has been approved by the U.S. Food and Drug Administration (FDA) for the

• 35. treatment of BPD. The efficacy of existing psychotropic medications in treating core BPD symptoms remains inconsistent. EFFICACY OF PHARMACOTHERAPY FOR CORE SYMPTOMS OF BPD: A meta-analysis showed that overall, the evidence indicates that the efficacy of pharmacotherapies for the treatment of BPD is limited. [Gartlehner et al., 2021] Second-generation antipsychotics, anticonvulsants, and antidepressants were not able to consistently reduce the severity of BPD. Low-certainty evidence indicates that anticonvulsants can improve specific symptoms associated with BPD, such as anger, aggression, and affective lability, but the evidence is mostly limited to single studies. Second-generation antipsychotics had little effect on the severity of specific BPD symptoms, but they improved general psychiatric symptoms in patients with BPD. [Gartlehner et al., 2021] A nationwide database study showed that, treatment with benzodiazepines, antidepressants, antipsychotics, or mood stabilisers were not associated with a reduced risk of psychiatric rehospitalisation or hospitalisation owing to any cause or death in BPD. ADHD medications were the only pharmacological group associated with reduced risk of psychiatric rehospitalisation or hospitalisation owing to any cause or death among individuals with borderline personality disorder. [Lieslehto et al., 2023] MANAGEMENT OF ACUTE SYMPTOMS: Acute suicidality, severe agitation, dissociative states, and psychotic crises may require immediate pharmacological intervention. However, evidence from randomised controlled trials (RCTs) specifically addressing pharmacotherapy in BPD crises is lacking. [Gartlehner et al., 2021] Given the high comorbidity of BPD with substance use disorders, medications with dependence potential should be avoided.

• 36. In acute crises, sedative antihistamines (e.g., promethazine) or low-potency antipsychotics (e.g., quetiapine) may be used. Medications like Z-drugs (e.g., zolpidem) may be prescribed for severe insomnia but only for short-term use (no longer than four weeks) to avoid dependence. MANAGEMENT OF COMORBIDITIES IN BPD COMORBID MAJOR DEPRESSIVE DISORDER (MDD) IN BPD: Up to 80% of BPD patients experience at least one episode of MDD in their lifetime, and the presence of BPD often predicts more persistent and severe depressive episodes. [Pascual et al., 2023] BPD is often characterised by transient, stress-related depressive episodes (“microdepressions”), which may be mistaken for MDD in cross-sectional assessments. Characteristics of BPD micro-depressions to help differentiate from MDD : [Pascual et al., 2023] Usually precipitated by stress and interpersonal factors Transient, usually only lasting a few days Generally associated with non-suicidal self-harm or suicidal behaviour Often respond to psychotherapeutic crisis interventions, but limited clinical response to antidepressants In a cross-sectional assessment, the clinical features are often indistinguishable from MDD. First-Line Treatment: For mild to moderate MDD in BPD, psychotherapy should be prioritised. Pharmacotherapy may be considered in severe cases or when psychotherapy alone does not suffice. SSRIs (e.g., fluoxetine, sertraline) are often prescribed, but clinicians must be cautious due to the limited evidence of efficacy and potential risks in BPD.

• 37. Click to enlarge. Downloadable with a Hub Pro subscription. Mood Stabilisers: Mood stabilisers like valproate and lamotrigine have been explored as adjunctive treatments in BPD with MDD, but their efficacy remains uncertain. While some studies suggest benefits, large-scale trials have failed to consistently support their use in BPD. COMORBID ANXIETY DISORDERS IN BPD: Borderline Personality Disorder (BPD) frequently coexists with anxiety disorders, particularly panic disorder with agoraphobia, generalised anxiety disorder (GAD), and post-traumatic stress disorder (PTSD). Individuals with BPD are 14 times more likely to experience anxiety compared to the general population. Cognitive-behavioural therapy (CBT) is the most supported psychological treatment for anxiety in BPD. If psychotherapy is unavailable or inadequate, SSRIs and SNRIs are recommended as first-line pharmacotherapy. [Pascual et al., 2023]

• 38. Benzodiazepines, however, should be avoided due to their addictive potential and risk of increasing suicidal tendencies. In cases where SSRIs or SNRIs are ineffective, atypical antipsychotics or anticonvulsants can be considered, though not as first-line treatments, and polypharmacy should be minimised. Current guidelines do not recommend the use of medications like quetiapine, olanzapine, or gabapentin as a first line strategy. Pregabalin is an exception, which is recommended for GAD.[Pascual et al., 2023] Although guidelines advise against benzodiazepines due to addiction risk and increased suicidal behaviour, they are commonly prescribed in practice, often in response to anxiety comorbidities, patient requests for sedatives, or for managing acute anger in emergencies. [Pascual et al., 2023] COMORBID EATING DISORDERS (EDS) AND BPD: BPD is commonly comorbid with eating disorders, particularly bulimia nervosa (BN) and anorexia nervosa (AN). Approximately 28% of patients with BN and 25% of those with the binge-eating/purging subtype of AN have comorbid BPD. [Pascual et al., 2023] For patients with severe AN comorbid with BPD, clinical guidelines recommend following standard AN treatment protocols, including psychotherapy, nutritional management, and, in some cases, low-dose SSRIs or antipsychotics like olanzapine. In cases of less severe EDs, treatment should be coordinated with BPD-specific therapy. Medications such as SSRIs (e.g., fluoxetine), antipsychotics (e.g., quetiapine), and anticonvulsants may be used as adjuncts to psychotherapy, but with caution due to the potential impact on appetite and body weight. COMORBID SUBSTANCE USE DISORDERS (SUDS) AND BPD: BPD is associated with a high lifetime prevalence of SUDs (around 78%). The impulsivity and preference for short-term rewards typical of BPD increase the risk of developing SUDs.

• 39. The Neuroscience of Addiction – Application to Clinical Practice Alcohol Use Disorder – Evidence-Based Recommendations for Diagnosis and Pharmacotherapy Psychological therapy is the first-line treatment for SUDs in BPD. Specific interventions like Dialectical Behaviour Therapy adapted for SUD (DBT-SUD) and Dynamic Deconstructive Psychotherapy are effective in reducing dropout rates and improving treatment outcomes. In severe cases, pharmacological treatments for SUDs, such as disulfiram, naltrexone, and acamprosate, should be considered. Off-label use of anticonvulsants (e.g., pregabalin) or atypical antipsychotics may also be appropriate but should be prescribed cautiously. COMORBID ADHD AND BPD: Studies estimate a genetic overlap of approximately 60% between the two disorders, with ADHD patients having a 19.4-fold increased risk of developing BPD. [Ditrich et al., 2021] This genetic co-aggregation highlights a possible shared biological basis, though further research, particularly into gene-environment (GxE) interactions and epigenetics, is needed. [Weiner et al., 2019]

• 40. Click to enlarge. Downloadable with a Hub Pro subscription. Among people with attention-deficit/hyperactivity disorder, the lifetime rate of BPD was found to be 33.7%. [Bernardi et al., 2012] Childhood ADHD symptoms are significantly associated with an increased likelihood of BPD diagnosis in adulthood. [Weiner et al., 2019] There are four possible explanations for the frequent co-occurrence of ADHD and BPD [Weiner et al., 2019] 1. Attention-Deficit/Hyperactivity Disorder (ADHD) may function as a developmental antecedent to Borderline Personality Disorder (BPD). 2. ADHD and BPD may represent phenotypic variations of a shared underlying psychopathological mechanism rather than distinct clinical entities. 3. ADHD and BPD might be distinct nosological categories, yet they could share overlapping aetiological risk factors. 4. The presence of one disorder may confer an increased vulnerability to the subsequent development of the other. Additionally, some authors propose that severe ADHD may represent a subtype of BPD. [Ditrich et al., 2021]

• 41. Current treatment for comorbid ADHD and BPD relies on expert opinion rather than systematic evidence. Methylphenidate (MPH) may enhance decision-making in individuals with Borderline Personality Disorder (BPD), particularly when ADHD symptoms are more severe. [Gvirts et al., 2018] In a study, BPD-ADHD patients treated with MPH showed greater improvements in TraitState Anger, impulsivity, depression, and ADHD severity following a 4-week Dialectical Behavior Therapy (DBT) program compared to those not on stimulants. [Prada et al., 2015] This highlights the need to screen BPD patients for ADHD, as MPH treatment may improve outcomes. In a nationwide Swedish study (2006–2018), patients with Borderline Personality Disorder (BPD) were identified using national health registers. The study found that ADHD medications were the only pharmacological treatment associated with a reduced risk of psychiatric rehospitalisation, hospitalisation for any cause, or death. Other medications, such as benzodiazepines, antidepressants, antipsychotics, and mood stabilisers, did not demonstrate these benefits. [Lieslehto et al., 2023] COMORBID BPD AND PTSD: Comorbid borderline personality disorder (BPD) and post-traumatic stress disorder (PTSD) present a particularly severe and complex clinical challenge, characterised by heightened risks of suicide, increased healthcare utilisation, and significant psychosocial impairment. [Zeifman et al, 2021]. Despite the availability of treatment guidelines for each disorder independently, there is a notable lack of specific guidance for managing cases where BPD and PTSD co-occur. Epidemiological studies suggest that approximately 30% of individuals with BPD meet criteria for PTSD, while 25% of those with PTSD meet criteria for BPD, with even higher comorbidity rates observed within clinical BPD populations. [Zeifman et al, 2021].

• 42. This dual diagnosis is associated with greater symptom severity, higher rates of additional mental health comorbidities, and an increased healthcare burden compared to either disorder alone. Stage-based interventions, such as Dialectical Behavior Therapy for PTSD (DBT-PTSD) and Cognitive Processing Therapy (CPT), have shown promise in treating this dual diagnosis by addressing the full spectrum of core symptoms. [Kleindienst et al., 2021] Although current research indicates that trauma-focused treatments do not increase the risk of suicide or self-harm, further studies are needed to establish the safety and efficacy of these interventions for patients with BPD-PTSD. Post Traumatic Stress Disorder (PTSD) – A Primer on Neurobiology and Management Complex Post Traumatic Stress Disorder (cPTSD)- Impact of Childhood Trauma | Assessment and Management Principles COMORBID BPD AND PSYCHOSIS: Borderline Personality Disorder (BPD) is marked by emotional dysregulation and heightened sensitivity to stressors, with amygdala hyperreactivity and increased salience network activation, thus creating a vulnerability to psychotic-like experiences by exaggerating emotional responses to negative stimuli and social situations. [Denny et al., 2018] Early childhood trauma and adverse experiences can further sensitise neural circuits, particularly the amygdala, increasing susceptibility to subtle discrepancies in social interactions, which may manifest as fear, rumination, or even psychotic-like suspicion. [Millman et al., 2022] We covered the neurobiology of BPD here. Trauma-related dysregulation in emotional processing and autobiographical memory may contribute to the onset and maintenance of psychotic-like experiences, including intrusive imagery, dissociation, and paranoia. [Hardy, 2017] These experiences often manifest as two distinct types of intrusions: [Hardy, 2017]

• 43. 1. Trauma-related memory fragments 2. Anomalous experiences which may not be directly linked to trauma but emerge from dysregulated emotion regulation processes. Psychotic symptoms, especially auditory verbal hallucinations, have been frequently reported in BPD, with prevalence rates ranging from 26% to 54%. [Belohradova et al, 2022]. Psychotic symptoms in individuals with Borderline Personality Disorder (BPD) have often been dismissed as transient or ‘pseudo,’ but recent research challenges this view. Studies demonstrate that psychotic symptoms, particularly auditory verbal hallucinations, in BPD, show more similarities to those in primary psychotic disorders than previously acknowledged. [Cavelti, 2021] The co-occurrence of BPD and psychotic symptoms is linked to more severe psychopathology and worse outcomes, such as an increased risk of suicidality. Adolescence through the mid-20s, when both BPD and psychotic features typically emerge, represents a critical window for early intervention to mitigate the progression of severe mental disorders. [Cavelti, 2021] While auditory verbal hallucinations (AVHs) in Borderline Personality Disorder (BPD) are phenomenologically similar to those in schizophrenia and often meet the criteria for FirstRank Symptoms, they are more strongly associated with stress, dissociative experiences and childhood trauma. In contrast to schizophrenia, BPD generally lacks formal thought disorder, negative symptoms, and bizarre delusions, with affect remaining reactive and sociability usually intact. The relationship between childhood trauma, dissociation, and psychotic symptoms in BPD is well-documented. Dissociation, often linked to early emotional abuse, plays a crucial role in the development of psychotic symptoms, with auditory hallucinations being highly correlated with elevated dissociation. Stress-related psychotic reactivity is also common in BPD, with even minor

• 44. daily stressors eliciting pronounced psychotic responses, including paranoia and hallucinations. [Beatson et al., 2019] The Neuroscience of Dissociation – Clinical Application in Trauma Disorders Additionally, loneliness and social isolation have been identified as contributing factors to psychosis in BPD, potentially through mechanisms such as social deafferentation, which posits that social isolation may lead to the brain generating false social connections in the form of hallucinations. [Hoffman, 2008]. Treatment options for psychotic symptoms in Borderline Personality Disorder (BPD) remain limited, with few studies evaluating their efficacy. Antipsychotic medications have shown small to medium effects in alleviating cognitiveperceptual symptoms such as suspiciousness, paranoid thoughts, and hallucinations. Both typical and atypical antipsychotics appear to provide some benefit. Cognitive-behavioral therapy and non-invasive brain stimulation are also suggested as potential treatments, though more research is needed. Since loneliness contributes to hallucinations, improving social support and quality of life could be beneficial. [Belohradova et al, 2022].

• 45. Click to enlarge. Downloadable with a Hub Pro subscription. SELF-HARM IN BPD: Repetitive self-harming behaviours in Borderline Personality Disorder (BPD) may be conceptualised through an addictive model, where such behaviours are employed to alleviate psychological pain or distress. [Blasco-Fontecilla et al., 2016] This understanding has led to exploration of treatment strategies that target various neurobiological systems, including the opioid and dopaminergic pathways, as well as the hypothalamic-pituitary-adrenal (HPA) axis. Clinical trials involving opioid antagonists, such as naltrexone and buprenorphine, have shown promising results in reducing self-harming behaviours by blunting the rewarding effects typically associated with these actions. Recent findings indicate that ultra-low-dose buprenorphine may also reduce suicidal ideation in BPD patients. [Yovell et al., 2016] Naltrexone being a nonspecific competitive opiate antagonist has shown to be helpful in controlling self-injurious behavior (SIB) and dissociative symptoms in patients with BPD, however, further studiues are nedded to confirm its role. [Moghaddas et al., 2017] Click to enlarge. Downloadable with a Hub Pro subscription.

• 46. Furthermore, corticotropin-releasing factor (CRF) antagonists, such as antalarmin, are currently being investigated for their potential to modulate the HPA axis, which could help decrease stress sensitivity and mitigate self-harm behaviours. Lithium, widely recognised for its antisuicidal properties, may additionally possess antinociceptive effects, potentially lowering self-harm by alleviating psychological pain. However Lithium has not been specifically studied for this indication in BPD. Other agents that modulate glutamatergic transmission, gabapentin, lamotrigine, topiramate, acamprosate, memantine, modafinil, d-cycloserine, and N-acetylcysteine, have been proposed as possible candidates that may be useful in treatment of addiction to self-harming behaviours. Emptiness has been identified as a significant precipitating factor for ‘self-killing’; however, there has been little empirical research exploring the link between suicidal behaviours and emptiness. Cholinergic and serotonergic systems may be implicated in the experience of emptiness. [Blasco-Fontecilla et al., 2013] In one study, the administration of the acetylcholinesterase inhibitor physostigmine to individuals with personality disorders revealed that those with a depressive response were more likely to report feelings of emptiness. [Steinberg et al., 1997] This suggests that drugs with anticholinergic properties, such as tricyclic antidepressants or low-potency antipsychotics, could hold potential for treating emptiness. Despite its recognised impact, the relationship between emptiness and suicidal behaviour remains under-researched. [Blasco-Fontecilla et al., 2013] Since physical and psychological pain share common neural pathways, it raises the question of whether we can treat psychological pain with the same drugs used for physical pain, like headaches. [Meerwijk et al., 2013], [Ducasse et al., 2014] While opioid agonists are unsuitable due to risks like tolerance and dependence, nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen may offer potential. A study found that a 2-week course of acetaminophen reduced daily self-reported feelings of hurt compared to a placebo. [DeWall, 2011], [Dewall et al., 2010]

• 47. Ketamine has been shown to significantly reduce symptoms of depression, borderline personality disorder, suicidality, and anxiety in patients with treatment-resistant depression (TRD) and comorbid BPD. In a study, participants received four intravenous doses of ketamine (0.5-0.75mg/kg over 40 minutes) across two weeks, demonstrating its potential effectiveness in this population. [Danayan et al., 2023] Additionally, oxytocin, a social neuropeptide, is being explored for its role in mitigating selfharm behaviours, suggesting a promising area for further investigation. [Blasco-Fontecilla et al., 2016] MANAGEMENT OF BORDERLINE PSYCHODYNAMICS Countertransference Challenges: I feel used, manipulated, abused, and at the same time I feel responsible for her feelings of rejection and threats of suicide, or feel made to feel responsible for them because I don’t have time for her and don’t choose to be/ cannot be always available as a good object, nor as a standby part object. She has hooked me into thinking love and friendship will heal her, as if there were nothing wrong with her but rather it was all of the people in her life who were the problem. Then I come up with fatherly friendship, and her control begins. She tells me, in different ways, that I am different from the others. And just when I’m basking in “good objectivity,” she really begins to control me by telling me that I’m just like the rest, that I don’t care: “I see you looking at your watch. I know you want to leave. I know you have a life out there. It will be a long night. You don’t care. Nobody cares.” [Gabbard, 1993] Managing countertransference effectively is essential for successful psychotherapeutic treatment of patients with Borderline Personality Disorder (BPD). Due to the intensity of emotions and interpersonal dynamics inherent in BPD, therapists may often feel overwhelmed or challenged. Common countertransference reactions include feelings of being manipulated, walking on eggshells, or even being mistreated by the patient. These intense interactions can evoke polarised emotional responses, leading therapists to either over-identify with the patient and seek to protect them, or to distance themselves

• 48. emotionally. Recognising and managing these countertransference reactions is critical to maintaining therapeutic boundaries and fostering a productive therapeutic alliance with BPD patients. Bradley and Westen identified key transference and countertransference patterns in patients with Borderline Personality Disorder (BPD) through analyses of transference and countertransference questionnaires. Their findings revealed 10 prominent transference and countertransference patterns with the highest correlation with BPD. [Bradley and Westen, 2005] Transference reactions in descending order: 1. Difficulty dealing with separations (e.g., becomes upset or denies distress at times like vacations). 2. Flies into rages directed at the therapist. 3. Exhibits manipulative behaviours. 4. Is afraid of being abandoned by the therapist. 5. Vacillates between idealizing and devaluing the therapist. 6. Seeks excessive reassurance from the therapist. 7. Needs to feel special to the therapist, wanting to be more important than other patients. 8. Creates ongoing crises in therapy, causing continuous doubt about whether the therapeutic relationship will endure. 9. Worries that the therapist doesn’t like them. 10. Is frequently argumentative. Similarly, the analysis of countertransference responses highlighted the following items: 1. Feeling overwhelmed by the patient’s strong emotions. 2. Feeling overwhelmed by the patient’s needs. 3. Worrying about the patient more than other patients after sessions. 4. Feeling used or manipulated by the patient. 5. Feeling like you’re “walking on eggshells,” fearing the patient will explode, fall apart, or leave if the wrong thing is said.

• 49. 6. Feeling mistreated or abused by the patient. 7. Feeling frightened by the patient. 8. Feeling sad during sessions with the patient. 9. Feeling pushed to set very firm limits with the patient. 10. Feeling emotionally exhausted or drained after interactions. Countertransference reactions can be understood within specific domains, and recognising these reactions in the psychotherapy of borderline patients is essential. Rather than merely viewing them as interference in the therapeutic process, countertransference should be regarded as a valuable source of diagnostic and therapeutic insight, offering critical information to enhance treatment outcomes. [Gabbard, 1993] 1. Guilt feelings: “I’ve started questioning my treatment and feel guilty that I might have contributed to them worsening.” 2. Rescue fantasies: “I just want to take them out of this mess and make everything better.” “I feel the urge to go beyond my role to help them, as if I can be the one who saves them.” “Sometimes, I catch myself imagining scenarios where I completely change their life.” 3. Transgression of professional boundaries: “I find myself extending the session beyond the scheduled time.” “I’ve shared personal experiences that I wouldn’t normally disclose.” “I’ve considered deferring payment because I feel bad charging them.” “I know it’s crossing a line, but sometimes I feel an inappropriate level of closeness.” 4. Rage and hatred: “I feel an irrational anger towards them that I can’t shake.”

• 50. “It’s like their presence suffocates me, and I have to fight off this overwhelming irritation.” “Sometimes, I feel like they’re deliberately provoking me, and it makes me furious.” 5. Helplessness and worthlessness: “I feel completely incompetent, like nothing I do is right.” “Even the smallest mistake makes me feel like I’m entirely failing them.” “I start to doubt my skills, thinking maybe I’m just not good enough to help them.” 6. Anxiety and terror: “I feel a deep sense of dread before our sessions, almost like a looming threat.” “There’s a constant undercurrent of fear that something will go terribly wrong.” “Sometimes, I’m terrified of how they might react, and it leaves me feeling paralyzed.” My heart starts beating fast whenever I’ve got to see this patient.” PRINCIPLES OF MANAGING COUNTERTRANSFERENCE In managing countertransference with patients diagnosed with Borderline Personality Disorder (BPD), several key principles should be considered: 1. Recognition of push-pull dynamics: Patients with BPD often oscillate between extremes of idealisation and devaluation in their relationships, leading to emotional turbulence in the therapeutic alliance. Clinicians must be attuned to these dynamics and maintain a steady therapeutic stance. 2. Managing disorganised attachment patterns: Patients frequently re-enact disorganised attachment schemas within the therapeutic context, leading to countertransference responses characterised by confusion or ambivalence. A clear understanding of these patterns helps mitigate the therapist’s emotional reactions and maintains therapeutic effectiveness.

• 51. 3. Balancing confrontation with empathy: A successful therapeutic approach involves balancing the need to confront maladaptive behaviours (e.g., splitting, rage) with an empathic understanding of the patient’s emotional pain. This is crucial in addressing both the patient’s defensive mechanisms and their underlying vulnerabilities. 4. Navigating intense countertransference: BPD patients often elicit strong emotional reactions in their clinicians, including frustration, anger, or a desire to rescue. Therapists must be vigilant in recognising these emotions and avoiding enactment, maintaining a reflective and professional stance to support the patient’s treatment. 5. Understanding transference projections: Patients with BPD often project early attachment experiences onto the therapeutic relationship, resulting in rapid shifts between idealisation and devaluation of the therapist. Recognising and interpreting these transference projections is essential to maintaining therapeutic boundaries and advancing the patient’s understanding of their interpersonal patterns. In Transference-Focused Psychotherapy (TFP), managing transference and countertransference is central to treatment. Transference, where patients project unresolved relational patterns onto the therapist, is used to explore their distorted perceptions. By interpreting shifts between roles, such as victim and victimizer, therapists help patients gain awareness of these dynamics. Countertransference, or the therapist’s emotional reactions, is equally important. Recognising and reflecting on these responses helps therapists understand the patient’s inner world. This process allows for the integration of split self-perceptions, promoting emotional regulation and healthier relationships.

• 52. Treatment can’t be standardized. Much ingenuity is required, not only to adapt treatment to the individual patient, but to adapt it to his different ego states at any given time. Remember, the goal is not to uncover unconscious conflict, because that is not the problem. It is to firm up the defective ego. This requires an active therapist’s being a real person, an educator, a coach, lending the patient the benefit of one’s hopefully healthy ego. He assists the patient in seeing what role the patient does play and could play in life, and what he can become. He helps the patient recognize true feelings, especially the positive ones. He enhances the patient’s sense of self, giving appropriate feedback for small accomplishments. He helps the patient improve interpersonal skills and see the motives of people around him realistically. He is a model of humanness, in short, the patient’s ally in the real world.” [Moench, 1981] CONCLUSION Borderline Personality Disorder is a diagnosis that serves as a crucial construct. Yet, it is often misunderstood and misused, an irony that mirrors the internal conflict of splitting inherent to the disorder. The very nature of BPD’s diagnosis reflects the paradox of the condition it seeks to define. Understanding the complex interplay of emotional dysregulation, impulsivity, and interpersonal difficulties is key to developing effective interventions for BPD, which remains a significant challenge for mental health professionals. The recognition of BPD as a distinct and chronic condition rather than a transient state is critical for providing appropriate care and improving outcomes for individuals affected by this disorder. In the management of Borderline Personality Disorder (BPD), psychotherapy remains the cornerstone of treatment, with strong evidence supporting its efficacy as a first-line intervention.

• 53. While various psychotherapeutic approaches, such as Dialectical Behavior Therapy (DBT), Mentalization-Based Treatment (MBT), and Transference-Focused Psychotherapy (TFP), have shown positive outcomes, there is no conclusive evidence favouring one method over another. Despite these advances, high rates of non-response and relapse indicate a need for further refinement in therapeutic strategies. Pharmacotherapy, although reserved for severe comorbidities and crisis management, has yet to offer a targeted approach for the core symptoms of emotional dysregulation and interpersonal hypersensitivity characteristic of BPD. Therefore, future treatments must integrate psychotherapeutic and pharmacological interventions to address the enduring functional impairments and improve patients’ overall quality of life. Additionally, empowering patients with knowledge of their recovery potential can significantly elevate treatment expectations and outcomes. Get Serious About Psychiatry Learning Our courses offer practical knowledge and clinical expertise at exceptional value, plus CME & CPD points. References Leichsenring, F., Heim, N., Leweke, F., Spitzer, C., Steinert, C., & Kernberg, O. F. (2023). Borderline Personality Disorder: A Review. JAMA, 329(8), 670–679. Akiskal, H. S., Chen, S. E., Davis, G. C., Puzantian, V. R., Kashgarian, M., & Bolinger, J. M. (1985). Borderline: an adjective in search of a noun. The Journal of clinical psychiatry, 46(2), 41-48. Leichsenring, F., Fonagy, P., Heim, N., Kernberg, O. F., Leweke, F., Luyten, P., … & Steinert, C. (2024). Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies. World psychiatry, 23(1), 4-25.

• 54. Gunderson, J. G., Herpertz, S. C., Skodol, A. E., Torgersen, S., & Zanarini, M. C. (2018). Borderline personality disorder. Nature reviews disease primers, 4(1), 1-20. Karatzias, T., Bohus, M., Shevlin, M., Hyland, P., Bisson, J. I., Roberts, N. P., & Cloitre, M. (2023). Is it possible to differentiate ICD-11 complex PTSD from symptoms of borderline personality disorder?. World psychiatry : official journal of the World Psychiatric Association (WPA), 22(3), 484–486. Ekiz, E., Van Alphen, S. P., Ouwens, M. A., Van de Paar, J., & Videler, A. C. (2023). Systems Training for Emotional Predictability and Problem Solving for borderline personality disorder: A systematic review. Personality and mental health, 17(1), 20-39. Storebø, O. J., Stoffers-Winterling, J. M., Völlm, B. A., Kongerslev, M. T., Mattivi, J. T., Jørgensen, M. S., Faltinsen, E., Todorovac, A., Sales, C. P., Callesen, H. E., Lieb, K., & Simonsen, E. (2020). Psychological therapies for people with borderline personality disorder. The Cochrane database of systematic reviews, 5(5), CD012955. Setkowski, K., Palantza, C., van Ballegooijen, W., Gilissen, R., Oud, M., Cristea, I. A., … & Cuijpers, P. (2023). Which psychotherapy is most effective and acceptable in the treatment of adults with a (sub) clinical borderline personality disorder? A systematic review and network meta-analysis. Psychological Medicine, 53(8), 3261-3280. Jørgensen, M. S., Storebø, O. J., Stoffers-Winterling, J. M., Faltinsen, E., Todorovac, A., & Simonsen, E. (2021). Psychological therapies for adolescents with borderline personality disorder (BPD) or BPD features—A systematic review of randomized clinical trials with meta-analysis and Trial Sequential Analysis. PLoS One, 16(1), e0245331. Zanarini, M. C., Frankenburg, F. R., Bradford Reich, D., Harned, A. L., & Fitzmaurice, G. M. (2015). Rates of psychotropic medication use reported by borderline patients and axis II comparison subjects over 16 years of prospective follow-up. Journal of clinical psychopharmacology, 35(1), 63–67. Martín-Blanco, A., Ancochea, A., Soler, J., Elices, M., Carmona, C., & Pascual, J. C. (2017). Changes over the last 15 years in the psychopharmacological management of persons with borderline personality disorder. Acta psychiatrica Scandinavica, 136(3), 323– 331.

• 55. Gartlehner, G., Crotty, K., Kennedy, S., Edlund, M. J., Ali, R., Siddiqui, M., Fortman, R., Wines, R., Persad, E., & Viswanathan, M. (2021). Pharmacological Treatments for Borderline Personality Disorder: A Systematic Review and Meta-Analysis. CNS drugs, 35(10), 1053–1067. Lieslehto, J., Tiihonen, J., Lähteenvuo, M., Mittendorfer-Rutz, E., Tanskanen, A., & Taipale, H. (2023). Association of pharmacological treatments and real-world outcomes in borderline personality disorder. Acta psychiatrica Scandinavica, 147(6), 603–613. Bernardi, S., Faraone, S. V., Cortese, S., Kerridge, B. T., Pallanti, S., Wang, S., & Blanco, C. (2012). The lifetime impact of attention deficit hyperactivity disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Psychological medicine, 42(4), 875–887. Gvirts, H. Z., Lewis, Y. D., Dvora, S., Feffer, K., Nitzan, U., Carmel, Z., Levkovitz, Y., & Maoz, H. (2018). The effect of methylphenidate on decision making in patients with borderline personality disorder and attention-deficit/hyperactivity disorder. International clinical psychopharmacology, 33(4), 233–237. Prada, P., Nicastro, R., Zimmermann, J., Hasler, R., Aubry, J. M., & Perroud, N. (2015). Addition of methylphenidate to intensive dialectical behaviour therapy for patients suffering from comorbid borderline personality disorder and ADHD: a naturalistic study. Attention deficit and hyperactivity disorders, 7(3), 199–209. Zeifman, R. J., Landy, M. S., Liebman, R. E., Fitzpatrick, S., & Monson, C. M. (2021). Optimizing treatment for comorbid borderline personality disorder and posttraumatic stress disorder: A systematic review of psychotherapeutic approaches and treatment efficacy. Clinical Psychology Review, 86, 102030 Denny, B. T., Fan, J., Fels, S., Galitzer, H., Schiller, D., & Koenigsberg, H. W. (2018). Sensitization of the neural salience network to repeated emotional stimuli following initial habituation in patients with borderline personality disorder. American Journal of Psychiatry, 175(7), 657-664. Millman, Z. B., Schiffman, J., Gold, J. M., Akouri-Shan, L., Demro, C., Fitzgerald, J., … & Waltz, J. A. (2022). Linking salience signaling with early adversity and affective distress in

• 56. individuals at clinical high risk for psychosis: results from an event-related fMRI Study. Schizophrenia Bulletin Open, 3(1), sgac039. Blasco-Fontecilla, H., Fernández-Fernández, R., Colino, L., Fajardo, L., Perteguer-Barrio, R., & de Leon, J. (2016). The Addictive Model of Self-Harming (Non-suicidal and Suicidal) Behavior. Frontiers in psychiatry, 7, 8. Yovell, Y., Bar, G., Mashiah, M., Baruch, Y., Briskman, I., Asherov, J., Lotan, A., Rigbi, A., & Panksepp, J. (2016). Ultra-Low-Dose Buprenorphine as a Time-Limited Treatment for Severe Suicidal Ideation: A Randomized Controlled Trial. The American journal of psychiatry, 173(5), 491–498. Steinberg, B. J., Trestman, R., Mitropoulou, V., Serby, M., Silverman, J., Coccaro, E., Weston, S., de Vegvar, M., & Siever, L. J. (1997). Depressive response to physostigmine challenge in borderline personality disorder patients. Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology, 17(4), 264–273. Blasco-Fontecilla, H., de León-Martínez, V., Delgado-Gomez, D., Giner, L., Guillaume, S., & Courtet, P. (2013). Emptiness and suicidal behavior: an exploratory review. Suicidol Online, 4(4), 21-32. Dewall, C. N., Macdonald, G., Webster, G. D., Masten, C. L., Baumeister, R. F., Powell, C., Combs, D., Schurtz, D. R., Stillman, T. F., Tice, D. M., & Eisenberger, N. I. (2010). Acetaminophen reduces social pain: behavioral and neural evidence. Psychological science, 21(7), 931–937. Danayan, K., Chisamore, N., Rodrigues, N. B., Vincenzo, J. D. D., Meshkat, S., Doyle, Z., Mansur, R., Phan, L., Fancy, F., Chau, E., Tabassum, A., Kratiuk, K., Arekapudi, A., Teopiz, K. M., McIntyre, R. S., & Rosenblat, J. D. (2023). Real world effectiveness of repeated ketamine infusions for treatment-resistant depression with comorbid borderline personality disorder. Psychiatry research, 323, 115133. Borderline Personality Disorder : A Comprehensive Approach to Diagnosis and Management harsh@psychscene.com

• 57. September 29, 2024 5:29 pm No Comments Achieve clinical excellence in Adult ADHD Join Academy by Psych Scene and get instant access to interactive, cutting-edge courses on ADHD. Over 40 hours of learning that earn CME/CE/CPD points. DIAGNOSTIC UNCERTAINTY IN BPD content The construct of Borderline Personality Disorder (BPD) is internally consistent and more homogeneous than often assumed; however, debates continue about its diagnostic validity and whether BPD is better represented by a categorical or dimensional approach. [Leichsenring et al., 2023] Read the evolution of the diagnostic construct. A significant aspect of this controversy revolves around the epistemic injustice individuals face with this diagnosis. There has been a decades-long outcry from survivor and patient groups who argue that the BPD construct affirms their worst fears, leading to iatrogenic care that retraumatises them. [Watts, 2024] This outcry highlights the impact that diagnostic labels can have on those who receive them, often shaping their care in ways that perpetuate harm. On one hand, critics like Tyrer and Mulder contend that the term "Borderline" has outlived its utility. They argue that its continued use compromises the management and specific treatment of this group of conditions. They suggest that the label has become a major obstacle to understanding and no longer has a place in clinical practice. [Tyrer and Mulder, 2024] AKISKAL ON BPD content Akiskal has raised important questions regarding the validity and stability of borderline personality disorder (BPD) as a distinct diagnostic category, particularly in light of its considerable overlap with subaffective disorders. He argues that the current use of BPD as an adjectival descriptor fails to capture a specific psychopathological syndrome, leading to an oversimplification of the condition. [Akiskal et al., 1985] While BPD is often characterised by affective dysregulation, Akiskal posits that it is unlikely nature would create entirely separate mechanisms of emotional instability for BPD and affective disorders. [Akiskal, 2004] The stability of BPD symptoms over time is also questioned,

• 58. with studies indicating that while some symptoms may remain stable, others do not. However, the percentage of individuals retaining a BPD diagnosis after a two-year followup is comparable to other personality disorders, such as obsessive-compulsive and schizotypal personality disorders. This variability in symptom presentation raises questions about the reliability of BPD as a diagnostic entity and suggests that the operational construct of BPD may have been overstretched in its current form. [Akiskal, 2004] APPROACH TO THE DIAGNOSIS OF BPD content Patients with Borderline Personality Disorder (BPD) often seek treatment during episodes of other mental health issues, such as depression, anxiety, trauma-related disorders, or substance use. [Leichsenring et al., 2023] They may also reach out following a suicide attempt, impulsive behaviour, or a significant personal crisis like a relationship breakdown or job loss. Diagnosing borderline personality disorder (BPD) through clinical interviews presents a significant challenge. [Gunderson et al., 2018] The potential for overgeneralisation is a common concern. Clinicians may extrapolate their observations from limited clinical encounters to broader life situations without adequate supporting evidence. This can lead to inaccuracies in diagnosis, either through overdiagnosis or underdiagnosis of BPD. Furthermore, clinicians might form a general impression of the patient’s personality during assessments, but such impressions are often insufficient to thoroughly evaluate the specific diagnostic criteria required for BPD. Consequently, clinical judgments may stray from strict criterion-based evaluations, resulting in diagnostic missteps. To address this, semi-structured and fully structured diagnostic interviews and self-report questionnaires have been developed. These tools are more reliable and valid than routine clinical assessments and are most effective when used together to ensure an accurate diagnosis of BPD. BPD can be initially suspected based on unstable identity, interpersonal relationships, and affect. Helpful screening questions for BPD may include: Do you often wonder who you really are? Do you sometimes feel that another person appears in you that does not fit you? Do your feelings toward other people quickly change into opposite extremes (e.g., from love and admiration to hate and disappointment)? Do you often feel angry? Do you often feel empty?

• 59. Have you been extremely moody? Have you ever deliberately hurt yourself (e.g., cut or burned yourself)? Assessing personality pathology can be particularly complex due to the intricate nature of self-perception. Individuals with personality-related concerns may not always have a clear or consistent awareness of their difficulties, especially when these challenges primarily emerge in the context of interpersonal relationships and daily functioning. Instead of relying solely on self-reported descriptions of personality traits, clinicians can gain valuable insights by observing patterns in how individuals describe their interactions, relational dynamics, and work-related behaviours. Clinicians may also rely on how individuals interact with them during interviews and may interview others close to the patient to gather additional perspectives. Common questions to evaluate personality include: [Gunderson et al., 2018] How would you describe yourself as a person? How do you think others would describe you? Who are the most important people in your life? How do you get along with them? KEY CONSIDERATIONS IN THE ASSESSMENT OF BORDERLINE PERSONALITY DISORDER (BPD) content 1. Emotional Influence on the Clinician-Patient Relationship Assessing individuals with BPD often requires clinicians to navigate the emotional intensity that can emerge during evaluations. Common features include expressions of anger, neediness, demanding behaviour, and fluctuations in the way the clinician is perceived, alternating between idealisation and devaluation. Awareness of these dynamics is essential, as they can influence the clinician’s judgment and the therapeutic alliance. Maintaining objectivity while acknowledging these emotional responses is crucial for a thorough and unbiased evaluation. 2. Pervasiveness across Contexts: A critical feature of BPD is the pervasiveness of its symptoms across multiple life contexts. Clinicians should gather detailed information about how patients perceive themselves and their interactions with others in various settings, including personal, social, and professional domains. [Leichsenring et al., 2024] BPD traits must be present in multiple contexts and exhibit a degree of inflexibility, meaning they persist despite evidence that they are maladaptive or inappropriate. This differentiates BPD from situational or transient emotional reactions,

• 60. confirming the presence of a pervasive personality pathology. 3. Developmental Onset and Progression Personality disorders, including BPD, typically emerge during adolescence or early adulthood, often during periods of significant life transitions. A developmental approach is important in understanding the onset and evolution of BPD traits. Identifying the early appearance of symptoms and tracking their progression over time allows clinicians to differentiate BPD from other psychiatric conditions that may arise later in life. Understanding the developmental course of the disorder is crucial for contextualising the patient's experiences and formulating appropriate interventions. 4. Change Over the Lifespan Although BPD has historically been considered a stable and enduring condition, recent longitudinal research suggests that it can show considerable improvement over time. Many individuals experience a reduction in symptom severity, challenging the traditional view of BPD as a lifelong disorder. Clinicians should remain aware of the potential for positive change, incorporating this understanding into treatment planning and providing hope for recovery through appropriate interventions. 5. Comorbidity and Diagnostic Complexity Comorbidity is a hallmark of BPD, with individuals frequently presenting with co-occurring psychiatric conditions. The lifetime prevalence of mood disorders, such as major depressive disorder and bipolar disorder, ranges from 61% to 83% in individuals with BPD. Anxiety disorders are also highly prevalent, affecting up to 88% of individuals, and substance use disorders are present in approximately 78% of cases. [Leichsenring et al., 2024] Furthermore, BPD commonly coexists with other personality disorders, such as avoidant or dependent personality disorders. [Leichsenring et al., 2024] Distinguishing between the acute states of comorbid conditions and the stable traits of BPD is crucial for accurate diagnosis and treatment. 6. Diagnostic Assessment and Conveying the Diagnosis A comprehensive diagnostic assessment is a foundational aspect of BPD management. Clinicians should evaluate the full spectrum of symptoms and comorbidities, ensuring the diagnosis is communicated clearly to the patient. [Leichsenring et al., 2024] When conveying the diagnosis, it is essential to balance honesty with support, preparing the patient for potential challenges while fostering an attitude of acceptance and collaboration. Understanding and discussing the diagnosis transparently with the patient ensures they are well-informed and actively involved in their treatment. This empowers patients to engage with therapeutic interventions and fosters a more effective, collaborative treatment process. 7. Distinguishing BPD from Bipolar Disorder A key clinical challenge lies in differentiating BPD from bipolar disorders, as both conditions share overlapping features, such as mood instability and impulsivity. A key point of contention is whether the fluctuating moods

• 61. observed in BPD should be classified as an "ultra-rapid cycling" subtype of bipolar disorder, raising questions about the independence and interdependence of these two conditions within the broader spectrum of mood disorders. [Bayes et al., 2019]. The overlap in mood symptoms between BPD and BP disorders, including the debate over whether BPD's fluctuating moods represent an "ultra-rapid cycling" subtype of BP, further complicates this diagnostic dilemma. However, unlike the episodic nature of bipolar disorder, where symptoms are separated by periods of remission, BPD is characterised by persistent and pervasive dysfunction in emotional regulation and interpersonal relationships. This chronic, stable dysfunction is a distinguishing feature of BPD, underscoring the importance of longitudinal assessment in differentiating between these two conditions for accurate diagnosis and management. Bayes et al. (2019) critically examined recent studies to clarify the clinical distinctions between bipolar II disorder and borderline personality disorder, aiming to refine their diagnostic boundaries.

• 62. The importance of accurately differentiating these conditions lies in their distinct treatment approaches: bipolar I and II disorders typically require pharmacotherapy, while BPD is best managed through psychotherapy, with medications playing a secondary role. In cases of co-occurrence, the treatment strategy must be carefully tailored, often prioritising the stabilization of the most severe condition first, which is usually bipolar disorder, to ensure the most effective outcomes for the patient. 8. Distinguishing CPTSD and BPD: Recent efforts to reconceptualise certain cases of Borderline Personality Disorder (BPD) within the framework of Complex Posttraumatic Stress Disorder (CPTSD) have gained attention. [Paris, 2023]. While there is a substantial overlap between BPD and CPTSD, particularly as defined in the ICD-11-both disorders involve significant challenges in affect regulation, self-concept, and interpersonal relationships-empirical evidence suggests that these conditions can be distinctly differentiated. Paris and Ruffalo argue that CPTSD overlaps significantly with BPD, which already addresses key issues like aloneness, abandonment and and identity diffusion. They propose that BPD should remain a distinct diagnosis, as it includes critical aspects not fully captured by CPTSD. The introduction of CPTSD is controversial, as it may overshadow BPD, raising doubts about whether CPTSD is truly distinct or simply BPD with PTSD. [Ruffalo and Paris, 2024] CPTSD can be differentiated from BPD by specific symptoms and individual patient related patterns. [Karatzias et al., 2023] Differences: [Karatzias et al., 2023] Affect regulation: In CPTSD, affect regulation difficulties are typically ego-dystonic, stressor-specific, and variable over time.

• 63. BPD is characterised by ego-syntonic affect regulation issues, which are more persistent and pervasive, aligning with the individual's overall self-concept. Self-Percept: CPTSD generally maintain a consistently negative self-perception. BPD experience an unstable and often fluctuating sense of self. Relational difficulties CPTSD is characterised by consistent difficulties in trusting others and avoidance of intimacy or closeness. BPD is characterised by unstable or volatile patterns of interactions. Behavioural Patterns: CPTSD is characterised by symptoms where impulsivity and suicidal/self-injurious behaviours may occur, but these are less frequent and not as prominent compared to other CPTSD symptoms. BPD is characterised by high rates of impulsivity, suicidal, and self-injurious behaviours, which are more common compared to CPTSD. STANDARDISED INSTRUMENTS FOR DIAGNOSIS OF BPD

• 64. content Semi-structured clinical interviews or clinician-rated instruments: Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II) – All personality disorders. Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV) – All personality disorders. International Personality Disorders Examination (IPDE) – All personality disorders in DSM-IV and ICD-10. Structured Interview for DSM-IV Personality Disorders (SIDP-IV) – All personality disorders. Structured Clinical Interview for the DSM-5 Alternative Model for Personality Disorders Module III (SCID-5-AMPD) – BPD and five other personality disorders. Revised Diagnostic Interview for Borderlines (DIB-R) – BPD only. Childhood Interview for DSM-IV Borderline Personality Disorder (CI-BPD) – BPD only, designed specifically for adolescents. Borderline Personality Disorder Severity Index-IV (BPDSI-IV) – BPD only, dimensional short-interval change measure with adolescent and parent versions. Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD) – BPD only, dimensional short-interval change measure. Structured interview for lay-person administration: Alcohol Use Disorder and Associated Disabilities Interview Schedule-5 (AUDADIS-5) – BPD, ASPD, and STPD, used in NESARC. Self-report instruments for diagnosis: Personality Diagnostic Questionnaire-4 (PDQ-4) – All personality disorders. Personality Assessment Inventory (PAI) – BPD and ASPD. Borderline Symptom List (BSL) – BPD. Five-Factor Borderline Inventory (FFBI) – BPD, based on the Five-Factor Model of personality traits. Self-report instruments to assess pathological personality traits:

• 65. Schedule for Nonadaptive and Adaptive Personality-II (SNAP-II) – All personality disorders and traits. Dimensional Assessment of Personality Pathology–Basic Questionnaire (DAPP-BQ) – BPD and OPD traits. Minnesota Multiphasic Personality Inventory-2–Restructured Form (MMPI-2- RF) – Personality disorder traits. Personality Inventory for DSM-5 (PID-5) – BPD and OPD traits, based on the DSM-5 AMPD. Self-report instruments for screening: McLean Screening Instrument for BPD (MSI-BPD) – BPD, 10 items. Borderline Personality Questionnaire (BPQ) – BPD. Borderline Personality Features Scale for Children (BPFSC) – BPD, dimensional measure for children and adolescents, with child and parent versions. Self-report instruments to assess impairment in personality functioning: Severity Indices of Personality Problems (SIPP-118) – Personality functioning. General Assessment of Personality Disorder (GAPD) – Personality functioning. Level of Personality Functioning Scale Self-Report (LPFS-SR) – Personality functioning, based on DSM-5 AMPD. MANAGEMENT OF BPD content Management Principles in Borderline Personality Disorder (BPD) [Leichsenring et al., 2023], [Leichsenring et al., 2024], [Gunderson et al., 2018] 1. Diagnosis Disclosure and Patient Education The treatment of patients with borderline personality disorder (BPD) should commence with a clear disclosure of the diagnosis. It is essential to educate the patient about the nature of the disorder, its expected course, aetiological underpinnings, and available treatment options. This approach not only alleviates distress but also helps establish a therapeutic alliance between the patient and clinician. [Leichsenring et al., 2024] By providing accurate information, patients can gain a sense of control over their condition and better understand the role of treatment in managing BPD. Importantly, clinicians must emphasise that while effective therapies exist,

• 66. the focus should be on learning self-care and that pharmacological treatments are largely adjunctive rather than curative. 2. Establishing Boundaries and Managing Expectations A fundamental component of managing BPD is the establishment of clear therapeutic boundaries. Setting boundaries around therapeutic expectations can prevent behaviours that may disrupt treatment, such as excessive demands or splitting behaviours where patients perceive clinicians as “good” or “bad.” Consistency is particularly important in preventing splitting, which can undermine the therapeutic alliance. All clinicians involved in the patient's care should adopt a unified approach to treatment, ensuring that patients receive coherent and consistent care throughout their therapeutic journey. Clinicians must balance boundary setting with maintaining empathy. For instance, patients with BPD may exhibit excessive demands for contact or treatment, and clinicians must avoid reinforcing such behaviours through their responses. Polypharmacy using multiple medications concurrently should be approached with caution, as it can complicate treatment without clear benefits. It is also crucial for clinicians to manage their responses to any provocative behaviour exhibited by patients. Emotional reactions from the clinician may exacerbate symptoms and hinder the therapeutic process. Instead, clinicians should maintain a calm and measured approach, focusing on long-term therapeutic goals rather than immediate emotional responses. 3. Building a Therapeutic Alliance A strong, productive patientclinician relationship is at the heart of effective treatment for BPD. Clinicians must adopt an attitude of understanding, acceptance, and empathy. Setting realistic goals with the patient while communicating these goals fosters a shared understanding of the treatment process. Providing the patient a clear explanation of the disorder, its trajectory, and available treatment options can also improve adherence and motivation. Equally important is the need to offer realistic hope. While it is essential to instill a sense of hope, clinicians should avoid overpromising outcomes. Unrealistic expectations can lead to disappointment, which may damage the therapeutic relationship. Instead, offering a balanced and evidence-based perspective on treatment can foster trust and optimism. 4. Avoiding Stigmatization in BPD Treatment Clinicians must actively work to challenge any stigmatising attitudes toward patients with BPD. Preconceptions, such as viewing these patients as intentionally difficult or resistant to treatment, can adversely affect the quality of care provided. Such attitudes undermine the clinician-patient relationship and erode the patient’s trust in the therapeutic process. Rather than focusing on behaviours as manipulative or problematic, it is more helpful to frame them as manifestations of the underlying disorder. By approaching BPD with empathy and a focus on treatment potential, clinicians can engage in more constructive management of these behaviours. 5.

• 67. Collaboration and Consistency Among Clinicians In cases where multiple clinicians are involved in the care of a patient with BPD, it is crucial to ensure open communication and a consistent treatment approach. The phenomenon of "splitting", where patients view one clinician as entirely "good" and another as "bad", can disrupt the continuity of care. Therefore, all members of the treatment team must be aligned on the goals and methods of treatment, offering consistent messages and interventions to the patient. A unified treatment plan, where clinicians agree on boundaries, therapeutic goals, and intervention strategies, prevents splitting behaviours from undermining the therapeutic process and ensures that the patient receives cohesive care. 6. Recognising and Managing Countertransference Countertransference, emotional reactions from the clinician in response to the patient’s behaviour, is a common challenge in the treatment of BPD. Patients often struggle with emotional and interpersonal regulation, which can provoke strong reactions from clinicians, such as feelings of powerlessness, frustration, or even anger. While countertransference can provide valuable insights into the patient’s internal experiences, it must be managed carefully to prevent it from interfering with treatment. Clinicians should aim to develop self-awareness and reflect on their emotional responses to use countertransference constructively. Understanding and processing these reactions can deepen the clinician’s empathy and offer a window into the patient’s emotional world, thus enhancing the therapeutic alliance. (See later) 7. Biographical Understanding and Patient History A thorough understanding of the patient’s biographical background, including any experiences of trauma or maltreatment, is essential for interpreting the strong emotional reactions often seen in patients with BPD. These emotional responses, such as anger, fear, or withdrawal, are often projections of past traumatic experiences rather than personal attacks on the clinician. By recognising these reactions as rooted in the patient’s history, clinicians can avoid taking them personally and respond in a way that is more therapeutic and less reactive. This understanding is essential in managing countertransference and fostering a supportive, empathic approach. FIRST-LINE MANAGEMENT OF BORDERLINE PERSONALITY DISORDER (BPD) content 1. Psychotherapy as the Primary Treatment Psychotherapy is widely recognised as the first-line treatment for patients with borderline personality disorder (BPD) supported by extensive empirical evidence. [Gunderson et al., 2018], [Leichsenring et al., 2024] While pharmacotherapy can play an adjunctive role, its use should be reserved for specific situations, such as during acute crises or in the presence of comorbid

• 68. conditions, and administered with caution. Psychotherapy aims to foster long-term changes, while pharmacological treatments should be minimised and limited to the shortest duration necessary. Clinical guidelines advocate for sustained psychotherapeutic interventions, recommending that treatments extend beyond brief formats, typically lasting a minimum of three months, to ensure therapeutic efficacy. [Gunderson et al., 2018] Among the most effective and empirically validated therapies are dialectical behaviour therapy (DBT), mentalization-based therapy (MBT), transference-focused psychotherapy (TFP), and schema therapy (ST). In instances where specialised psychotherapeutic treatments such as DBT, MBT, TFP, or ST are unavailable within the clinical setting, referrals to mental health experts trained in these modalities are recommended. These specialised treatments have demonstrated significant benefits in reducing BPD symptoms, enhancing emotional regulation, and improving interpersonal functioning. [Leichsenring et al., 2024] Despite their proven effectiveness, the widespread implementation of these evidence-based therapies in routine clinical practice remains inconsistent, often due to limited access to trained professionals and resource constraints. In settings where specialised therapies are not readily available, clinicians may employ alternative approaches such as psychoeducation or crisis management to address immediate patient needs and provide foundational support until specialised care can be accessed. [Gunderson et al., 2018] Access to specialised care can significantly enhance treatment outcomes by providing patients with evidence-based interventions tailored to their specific needs. [Gunderson et al., 2018] 2. Prioritising Life-Threatening Behaviours In patients presenting with suicidal ideation or self-harm, these life-threatening behaviours must be addressed as a priority. Treatment plans should incorporate both verbal interventions and, if necessary, short-term pharmacotherapy to manage these behaviours. The use of shortterm medications may be considered to stabilise the patient during acute crises, but the primary focus remains on addressing the psychological underpinnings of self-harm and suicidality through therapy. Early identification and intervention are critical for preventing escalation and promoting safety. 3. Addressing Suicidality and Black-and-White Thinking The assessment and management of suicidality in BPD require careful evaluation of suicide risk factors, including the presence of a detailed plan, past attempts, and the availability of social support. The clinician should explore potential triggers for suicidal ideation, such as feelings of abandonment or loss, and work collaboratively with the patient to explore alternative solutions to their distress. Additionally, addressing the patient’s tendency toward black-and-white thinking, especially in response to perceived interpersonal rejection, can help reduce the intensity of suicidal thoughts. Encouraging the

• 69. patient to develop more nuanced and integrated views of themselves and others can mitigate the extremity of their emotional responses. 4. Understanding and Managing Self-Harm Self-harm in BPD serves various functions, including regulating emotions, relieving feelings of emptiness or dissociation, or managing interpersonal relationships. [Gunderson et al., 2018] Clinicians should recognise these underlying functions to tailor interventions appropriately. In some cases, agreements between the patient and clinician regarding self-harm behaviours such as seeking medical attention for injuries before the next session can help manage the behaviour while preserving the therapeutic relationship. These agreements foster accountability and minimise harm without encouraging punitive responses. 5. Managing Comorbidities BPD is often accompanied by comorbid psychiatric conditions, which can complicate the clinical presentation and treatment strategy. Disorders such as bipolar I disorder, severe substance use disorders, complex post-traumatic stress disorder (PTSD), and anorexia nervosa typically require prioritised treatment over BPD to ensure effective management. [Gunderson et al., 2018] Addressing these comorbid conditions is essential, as their remission can significantly enhance the overall treatment outcome for BPD. For instance, stabilising manic symptoms in bipolar I disorder before addressing BPD traits can lead to more effective and focused therapeutic interventions. Similarly, treating severe substance abuse or impulse control disorders can remove barriers to successful BPD treatment, allowing for more comprehensive and integrated care. Additionally, milder comorbidities may be managed concurrently with BPD treatment to support holistic patient recovery. [Gunderson et al., 2018] 6. Pharmacotherapy as an Adjunct to Psychotherapy While psychotherapy is the cornerstone of BPD treatment, pharmacotherapy may be indicated in certain circumstances, such as managing acute comorbid conditions or crises. However, pharmacotherapy should always be considered adjunctive to psychotherapy and used sparingly. When prescribed, it is recommended to limit medications to the minimum effective dose for the shortest duration possible, typically no longer than one week, unless otherwise necessary. This approach minimises the risk of overreliance on pharmacological treatments and focuses on developing the patients' ability to manage their symptoms through therapeutic interventions. PSYCHOTHERAPY FOR BORDERLINE PERSONALITY DISORDER (BPD) content Since the first randomised controlled trial (RCT) investigating the efficacy of psychotherapy for BPD in 1993, more than ten manualised psychotherapeutic

• 70. interventions have been developed and rigorously evaluated. Core Therapies: 4 psychological interventions have been established as major evidence-based treatments (EBTs) for BPD: 1. Dialectical Behavioural Therapy (DBT) 2. Mentalization-Based Treatment (MBT) 3. Schema-Focused Therapy (SFT) 4. Transference-Focused Psychotherapy (TFP) Another treatment approach for Borderline Personality Disorder (BPD) is Systems Training for Emotional Predictability and Problem Solving (STEPPS), a group-based intervention aimed at enhancing emotion regulation and behaviour management skills. STEPPS has been associated with reductions in BPD symptoms, improved quality of life, decreased depressive symptoms, and less negative affectivity. However, results have been mixed regarding its impact on impulsivity and suicidal behaviours. The program has been studied both as an add-on to ongoing treatments and as a stand-alone option with individual sessions. Despite its promise, high attrition rates complicate the generalisability of findings, and further research is required to establish more definitive conclusions. [Ekiz et al., 2023] Efficacy of Psychotherapy: Comparative studies have shown that psychotherapy generally yields significant clinical benefits over treatment-as-usual (TAU). A meta-analysis revealed that psychotherapy led to a standardised mean difference (SMD) of –0.52 in reducing symptom severity, highlighting its superior efficacy in reducing self-harm and suicide-related outcomes and improving overall psychosocial functioning. [Storebø et al., 2020] Although most studies support psychotherapy's efficacy in controlled settings, evidence of its effectiveness under real-world clinical conditions remains limited, necessitating further research to determine its broader applicability. While the safety of psychotherapy is a paramount concern, current evidence does not suggest an increased risk of serious adverse events compared to TAU. Patients undergoing psychotherapy for BPD have not demonstrated higher rates of harm, further supporting the use of psychotherapy as a safe and effective intervention for BPD. Specialised psychotherapies, including DBT, MBT, and schema therapy, consistently outperform more generic approaches, such as general psychiatric management, client-centred therapy, and supervised team management, in clinical outcomes. [Setkowski et al., 2023] These specialised therapies have shown greater efficacy in reducing critical outcomes like suicidality, self-harm, depression, anxiety, and the need for hospitalisation or emergency room visits among BPD patients. However, in the adolescent population, the efficacy of

• 71. psychotherapy for BPD remains less conclusive. [Storebø et al., 2020] A recent systematic review and meta-analysis of ten RCTs found that only a few demonstrated the superiority of psychotherapy over control conditions in adolescents with BPD or BPD features. [Jorgensen et al., 2021] Moreover, a Cochrane review concluded that while adolescent patients with BPD do benefit from psychotherapy, the magnitude of improvement is generally less pronounced compared to adult patients. To address the developmental differences between adolescents and adults, treatments such as DBT, TFP, and MBT have been adapted for younger patients. However, further research is needed to optimise these interventions and better understand their long-term impact on this population. [Storebø et al., 2020] SPECIFIC PSYCHOTHERAPEUTIC APPROACHES content DIALECTICAL BEHAVIOUR THERAPY (DBT): Dialectical Behaviour Therapy (DBT) is rooted in the concept of dialectics, which refers to the coexistence of opposites. In DBT, individuals are taught two core strategies: acceptance, recognising the validity of their emotional experiences, and change, developing skills to manage emotions and improve behaviours. Grounded in cognitivebehavioural principles, DBT balances these seemingly contradictory approaches, providing a structured outpatient psychotherapy aimed at promoting emotional regulation and functional recovery. It involves four components: [Leichsenring et al., 2024] 1. Individual Therapy: Exploration of parasuicidal behaviour Problem-solving behaviours, including short-term distress management techniques, are emphasised. Exploration of Therapy-interfering behaviours and behaviours impacting quality-oflife. Exploration and application of acquired behavioural skills Trauma history is addressed when the patient is ready (remembering the abuse, validation of memories, acknowledging emotions related to abuse, reducing self-‐ blame and stigmatisation, addressing denial and intrusive thoughts regarding abuse

• 72. (e.g., by exposure techniques), and reducing polarisation or supporting a dialectical view of the self and the abuser). Consistent reinforcement of patient’s self-respect behaviours 2. Group Skills Training: Focuses on Core mindfulness Interpersonal effectiveness Emotion regulation Distress tolerance. Skills are reinforced through homework and diary cards. Weekly meetings for 2 hrs for a duration of approx. 6 months. Modules may be repeated, and the skills training group is recommended for at least one year. Core mindfulness: Core mindfulness in DBT is adapted from Eastern meditation practices. It aims to reduce impulsivity and emotion-driven behaviours by fostering presentmoment awareness. Patients are taught to focus on one task at a time with a non-judgmental attitude, promoting full engagement in the present. This technique addresses the tendency to idealise or devalue oneself and others. Mindfulness also helps prevent rumination on the past and reduces anxiety about future events. Interpersonal effectiveness skills training Teaches patients how to ask for what they need and to say "no." Focuses on managing interpersonal conflicts. Emotion regulation skills: Involves identifying and labeling emotions. Helps patients recognise obstacles to changing emotions, including parasuicidal behaviours. Guides patients to avoid vulnerable situations and increase positive emotional experiences. Teaches strategies for tolerating painful emotions.

• 73. Distress tolerance skills: Includes self-soothing and distraction techniques. Aims to transform intolerable pain into tolerable suffering. 3. Telephone Coaching: Provides support during crises by encouraging non-abusive help-seeking behaviours. Minimises reinforcement for parasuicidal behaviours through an agreement: The patient must call the therapist before engaging in parasuicidal behaviour. The patient is not permitted to contact the therapist for 24 hours following a parasuicidal act, unless life-threatening injuries are present. 4. Team Consultations: Therapists participate in team consultations to maintain treatment fidelity and motivation. Dialectical Behaviour Therapy (DBT) and other interventions that focus on improving affect regulation strategies might help to decrease this maladaptive top-down modulation, thereby reducing the reliance on self-injury for emotional regulation. MENTALIZATION-BASED TREATMENT (MBT): The failure to develop mentalisation, or reflective function, is a key aspect of BPD. This ability, which normally emerges in the context of healthy attachment relationships, allows individuals to understand their own and others' mental states. Without it, BPD patients often equate their perceptions of others' intentions with reality, leading to difficulties in considering alternative perspectives [Fonagy , 2000]. In BPD, there is often a reliance on automatic, affect-driven, and externally-focused mentalizing, which leads to an imbalance in how individuals process their own and others' mental states. This imbalance results in non-mentalizing modes, such as psychic equivalence (where thoughts and feelings are perceived as reality), teleological thinking (where only observable actions are considered reflective of mental states), and the pretend mode (where mentalizing is detached from reality). These unprocessed emotional experiences (alien-self experiences) can lead to overwhelming emotions like anger or rejection, which are often externalised through maladaptive behaviours such as self-harm or substance abuse to cope. Mentalization-

• 74. Based Therapy (MBT) aims to enhance patients' capacity for mentalizing, particularly in the context of interpersonal relationships, where high levels of emotional arousal can disrupt this ability. MBT is primarily focused on addressing key issues in patients with Borderline Personality Disorder (BPD), including suicidality, self-harm, emotional dysregulation, and relational instability. Interventions include supportive techniques, clarification, and mentalizing the therapeutic relationship. A critical goal of MBT is to foster epistemic trust, enabling patients to trust and apply the knowledge provided by others for their well-being, thereby facilitating their ability to engage positively with social and relational resources. 1. Managing anxiety and arousal is central, as high arousal leads to a loss of mentalizing, while low arousal results in overly abstract mentalizing detached from reality. 2. Interventions focus on restoring balanced mentalizing, countering the tendency in BPD patients to rely on automatic, affect-driven, and externally-focused mentalizing without integrating cognitive and emotional processes. 3. Therapists and patients are equal partners, working together to explore and understand interpersonal issues and how they relate to the patient’s symptoms. 4. The therapist prioritizes understanding the how of mental processes rather than focusing on the what or why. 5. Empathic emotional validation is a key feature to restore the patient’s sense of agency and comprehension of their experiences. Two empirically supported models of MBT for BPD include intensive outpatient MBT and day-hospitalisation MBT programs. MBT employs a range of interventions, including supportive strategies that normalize and regulate anxiety, fostering epistemic trust through marked mirroring to restore a sense of agency. Clarification and elaboration of subjective experiences are central, alongside techniques to restore basic mentalizing, such as "stopand-rewind" and "stop-stand-and-challenge." Interventions also focus on mentalizing the therapeutic relationship and generalizing insights from therapy to real-life interpersonal contexts. Phases of MBT: 1. Initial Phase: Involves psychoeducation through an MBT introductory group course. Develops case formulation collaboratively with the patient. Focuses on building a treatment alliance informed by the patient’s attachment history.

• 75. Emphasizes safety planning and the formulation of a mentalizing profile, identifying imbalances and triggers affecting mentalization. 2. Treatment Phase: Consisting of general and specific strategies General strategies: Stabilisation of risky behaviours. Supportive, empathic validation to regulate anxiety and re-activate mentalizing. Use of elaboration and clarification to enhance basic mentalizing, particularly for intense emotional states. Strong emphasis on interpersonal relationships and exploring alternative perspectives through relational mentalizing. Focus on repairing ruptures in the therapeutic alliance. Specific strategies: Management of impulsive behaviours by mentalizing triggering events. Activation of the attachment system in both group and individual therapy to develop basic mentalizing. Linking therapy experiences to daily life, with attention to social inclusion/exclusion and rejection. Improving mentalizing capacity under stress and recovering mentalizing after its loss. Mentalizing traumatic experiences when relevant. Final Phase: Reviews the therapy process, focusing on the ending experience for both the patient and therapist. Addresses BPD-specific concerns related to ending, such as fears of abandonment or rejection. Generalises stable mentalizing and social understanding. Considers how the patient can continue therapeutic progress post-therapy. TRANSFERENCE-FOCUSED PSYCHOTHERAPY (TFP):

• 76. Transference-Focused Psychotherapy (TFP) is based on psychoanalytic object relations theory, focusing on unconscious conflicts that emerge in the therapeutic relationship (transference). These conflicts are expressed through internalised object relations, where the self and others are represented in emotionally charged dyads. In therapy, these dynamics are enacted between the patient and therapist, mirroring unresolved conflicts from past relationships. The goal of TFP is to integrate split-off parts of the self, particularly disowned aggression, by addressing polarised views of self and others (idealisation and devaluation). This helps reduce psychological splitting, fostering a more cohesive identity and healthier relationships. Key Aspects of TFP: Transference Exploration: The therapist interprets the patient's behaviours, linking them to unconscious conflicts and internalised object relations. Integration of Aggression: The focus is on helping patients recognise and integrate polarised emotions, especially anger, to achieve emotional regulation and identity cohesion. Psychoanalytic Techniques: 1. Interpretation: The therapist analyses verbal and nonverbal cues to uncover unconscious conflicts, often within transference. 2. Transference Analysis: This is the main tool for understanding how past object relations are re-enacted with the therapist. 3. Technical Neutrality: The therapist maintains an objective, non-engaging stance, providing insight without becoming part of the patient’s conflict. 4. Countertransference: The therapist uses their emotional responses to understand and interpret the patient’s unconscious dynamics without directly communicating them. (See Countertransference and management of countertransference later). SCHEMA THERAPY (ST): Schema Therapy (ST) integrates cognitive-behavioural, psychodynamic, attachment, and emotion-focused approaches, addressing four key dysfunctional modes typically seen in individuals with Borderline Personality Disorder (BPD). These modes are the

• 77. abandoned/abused child, the angry/impulsive child, the detached protector, and the punitive parent, with the presence of a healthy adult also being assumed. [Kellogg and Young, 2006] One of the primary goals of ST is to develop and strengthen the healthy adult mode, initially embodied by the therapist and later internalized by the patient during therapy. 1. Abandoned/Abused Child Mode: Characterised by feelings of isolation, being unloved, and a desperate need for a caretaker. This mode represents a core emotional state for BPD patients, often leading to frantic efforts to find a nurturing figure. 2. Angry/Impulsive Child Mode: Expresses rage over unmet emotional needs and perceived abandonment or mistreatment. Unfortunately, this outburst makes it less likely that the patient’s needs will be met. The punitive parent mode may activate, leading to self-punishing behaviours like self-harm. 3. Detached Protector Mode: The patient emotionally withdraws, feeling numb or empty. They may avoid relationships, become socially withdrawn, or seek distractions through fantasy or stimulation, which can hinder therapeutic progress. 4. Punitive Parent Mode: Involves the patient internalising an abusive parental figure, leading to feelings of worthlessness or evilness. This mode often results in self-punishing behaviours. The therapist assists the patient in recognising and distancing themselves from this punitive inner voice. Therapeutic Process: Schema Therapy (ST) promotes change through four key processes: limited reparenting, emotion-focused work, cognitive restructuring, and behavioural pattern breaking. 1. Limited reparenting Offers a corrective emotional experience where therapists provide warmth, stability, and support to meet unmet childhood needs, while maintaining boundaries. Therapists may provide extra contact and transitional objects to address abandonment issues. 2. Emotion-focused techniques

• 78. Involves imagery work, dialogues, and unsent letter writing. Therapists model the healthy adult role, helping patients confront past traumas and externalise punitive voices through techniques like Gestalt chair work. 3. Cognitive restructuring Educates patients on healthy emotional needs and reciprocal relationships, teaching them to express emotions appropriately and avoid black-and-white thinking. 4. Behavioural pattern breaking Helps patients apply therapy to real life through techniques like relaxation, assertiveness, and role-playing, addressing distorted expectations and changing maladaptive behaviours. Phases of Schema Therapy: [Young et al., 2003] 1. Bonding and emotional regulation: The therapist establishes a safe, nurturing relationship that counters the abusive or punitive dynamics the patient experienced in childhood. The patient remains in the abandoned/abused child mode to internalize the therapist as a healthy parental figure. This phase allows the patient to express unmet needs and desires, while anger is managed in a controlled manner to avoid being counterproductive. The therapist engages in limited reparenting to fulfill the patient's emotional needs. 2. Schema mode change: The therapist continues to nurture the abandoned/abused child mode, offering positive affirmations like calling the patient generous, empathetic, or creative. However, the punitive parent mode may resist these affirmations, and the detached protector mode may emerge as a defense mechanism, leading to emotional detachment. When this happens, the therapist helps the patient identify the costs and benefits of the detached protector mode, potentially adjusting therapy intensity or considering medication to manage overwhelming emotions.

• 79. 3. Autonomy development: In the final phase, the focus shifts from reparenting within therapy to fostering independence outside sessions. The therapist and patient work on strengthening interpersonal relationships and developing a stable sense of identity, exploring how different modes interact in these areas to support the patient’s growth and self-understanding. PHARMACOTHERAPY content Pharmacotherapy is generally not recommended for treating the core symptoms of BPD. Instead, it should be reserved for managing severe comorbid disorders such as major depression, severe anxiety, or transient psychotic symptoms. Medications should be used for the shortest possible duration and in crisis situations only. Comorbidities like major depressive disorder (MDD), anxiety disorders, and substance use disorders (SUDs) often necessitate pharmacological intervention, but the primary focus should remain on BPD-specific psychotherapy. The National Institute for Health and Care Excellence (NICE) guidelines explicitly recommend against using psychotropic medications for the direct treatment of BPD symptoms. [NICE, 2009] Up to 96% of patients with BPD who seek treatment receive at least one psychotropic medication. Polypharmacy is particularly common, with approximately 19% of patients taking four or more psychotropic drugs concurrently. [Zanarini et al., 2015] A study of 457 individuals diagnosed with borderline personality disorder (BPD) revealed that nearly 80% of those without comorbid conditions were also undergoing pharmacological treatment. Specifically, 62.9% were prescribed antidepressants, 59.7% benzodiazepines, 22.6% mood stabilisers, and 27.4% antipsychotics, with 42% of patients receiving multiple medications simultaneously (polypharmacy). [Martín-Blanco et al., 2017] A systematic review assessing the efficacy of pharmacological treatments for co-occurring psychopathology in individuals with Borderline Personality Disorder (BPD) revealed that anticonvulsants had moderate to large effects on reducing depressive and anxiety symptoms, though the evidence is of very low certainty. [Pereira Ribeiro et al, 2024]. Antipsychotics demonstrated small effects on depressive and dissociative symptoms, with a more pronounced reduction in dissociative symptoms in individuals with co-occurring substance use disorders (SUDs). Overall, the findings provide limited support for pharmacological interventions in treating

• 80. co-occurring symptoms in BPD, highlighting the need for caution given the low certainty of evidence. [Pereira Ribeiro et al, 2024]. Once initiated, patients with BPD often resist discontinuing medications, even when the target symptoms remain unchanged or worsen. This highlights the importance of cautious prescribing and ongoing evaluation of medication necessity. Despite the high prevalence of psychotropic drug use among BPD patients, no specific medication has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of BPD. The efficacy of existing psychotropic medications in treating core BPD symptoms remains inconsistent. EFFICACY OF PHARMACOTHERAPY FOR CORE SYMPTOMS OF BPD: A meta-analysis showed that overall, the evidence indicates that the efficacy of pharmacotherapies for the treatment of BPD is limited. [Gartlehner et al., 2021] Second-generation antipsychotics, anticonvulsants, and antidepressants were not able to consistently reduce the severity of BPD. Low-certainty evidence indicates that anticonvulsants can improve specific symptoms associated with BPD, such as anger, aggression, and affective lability, but the evidence is mostly limited to single studies. Second-generation antipsychotics had little effect on the severity of specific BPD symptoms, but they improved general psychiatric symptoms in patients with BPD. [Gartlehner et al., 2021] A nationwide database study showed that, treatment with benzodiazepines, antidepressants, antipsychotics, or mood stabilisers were not associated with a reduced risk of psychiatric rehospitalisation or hospitalisation owing to any cause or death in BPD. ADHD medications were the only pharmacological group associated with reduced risk of psychiatric rehospitalisation or hospitalisation owing to any cause or death among individuals with borderline personality disorder. [Lieslehto et al., 2023] MANAGEMENT OF ACUTE SYMPTOMS: Acute suicidality, severe agitation, dissociative states, and psychotic crises may require immediate pharmacological intervention. However, evidence from randomised controlled trials (RCTs) specifically addressing pharmacotherapy in BPD crises is lacking. [Gartlehner et al., 2021] Given the high comorbidity of BPD with substance use disorders, medications with dependence potential should be avoided. In acute crises, sedative antihistamines (e.g., promethazine) or low-potency antipsychotics (e.g., quetiapine) may be used. Medications like Z-drugs (e.g., zolpidem) may be prescribed for severe insomnia but only for short-term use (no longer than four weeks) to avoid dependence. MANAGEMENT OF COMORBIDITIES IN BPD

• 81. content COMORBID MAJOR DEPRESSIVE DISORDER (MDD) IN BPD: Up to 80% of BPD patients experience at least one episode of MDD in their lifetime, and the presence of BPD often predicts more persistent and severe depressive episodes. [Pascual et al., 2023] BPD is often characterised by transient, stress-related depressive episodes ("microdepressions"), which may be mistaken for MDD in cross-sectional assessments. Characteristics of BPD micro-depressions to help differentiate from MDD : [Pascual et al., 2023] Usually precipitated by stress and interpersonal factors Transient, usually only lasting a few days Generally associated with non-suicidal self-harm or suicidal behaviour Often respond to psychotherapeutic crisis interventions, but limited clinical response to antidepressants In a cross-sectional assessment, the clinical features are often indistinguishable from MDD. First-Line Treatment: For mild to moderate MDD in BPD, psychotherapy should be prioritised. Pharmacotherapy may be considered in severe cases or when psychotherapy alone does not suffice. SSRIs (e.g., fluoxetine, sertraline) are often prescribed, but clinicians must be cautious due to the limited evidence of efficacy and potential risks in BPD.

• 82. Mood Stabilisers: Mood stabilisers like valproate and lamotrigine have been explored as adjunctive treatments in BPD with MDD, but their efficacy remains uncertain. While some studies suggest benefits, large-scale trials have failed to consistently support their use in BPD. COMORBID ANXIETY DISORDERS IN BPD: Borderline Personality Disorder (BPD) frequently coexists with anxiety disorders, particularly panic disorder with agoraphobia, generalised anxiety disorder (GAD), and post-traumatic stress disorder (PTSD). Individuals with BPD are 14 times more likely to experience anxiety compared to the general population. Cognitive-behavioural therapy (CBT) is the most supported psychological treatment for anxiety in BPD. If psychotherapy is unavailable or inadequate, SSRIs and SNRIs are recommended as first-line pharmacotherapy. [Pascual et al., 2023] Benzodiazepines, however, should be avoided due to their addictive potential and risk of increasing suicidal tendencies. In cases where SSRIs or SNRIs are ineffective, atypical antipsychotics or anticonvulsants can be considered, though not as first-line treatments, and polypharmacy should be minimised. Current guidelines do not recommend the use of medications like quetiapine, olanzapine, or gabapentin as a first line strategy. Pregabalin is an exception, which is recommended for GAD.[Pascual et al., 2023] Although guidelines advise against benzodiazepines due to addiction risk and increased suicidal behaviour, they are commonly prescribed in practice, often in response to anxiety comorbidities, patient requests for sedatives, or for managing acute anger in emergencies. [Pascual et al., 2023] COMORBID EATING DISORDERS (EDS) AND BPD: BPD is commonly comorbid with eating disorders, particularly bulimia nervosa (BN) and anorexia nervosa (AN). Approximately 28% of patients with BN and 25% of those with the bingeeating/purging subtype of AN have comorbid BPD. [Pascual et al., 2023] For patients with severe AN comorbid with BPD, clinical guidelines recommend following standard AN treatment protocols, including psychotherapy, nutritional management, and, in some cases, low-dose SSRIs or antipsychotics like olanzapine. In cases of less severe EDs, treatment should be coordinated with BPD-specific therapy. Medications such as SSRIs (e.g., fluoxetine), antipsychotics (e.g., quetiapine), and anticonvulsants may be used as adjuncts to psychotherapy, but with caution due to the potential impact on appetite and body weight. COMORBID SUBSTANCE USE DISORDERS (SUDS) AND BPD: BPD is associated with a high lifetime prevalence of SUDs (around 78%). The impulsivity and preference for short-term rewards typical of BPD increase the risk of developing SUDs. The Neuroscience of Addiction – Application to Clinical Practice Alcohol Use Disorder – Evidence-Based Recommendations for Diagnosis and Pharmacotherapy Psychological therapy is the first-line treatment for SUDs in BPD. Specific interventions like Dialectical

• 83. Behaviour Therapy adapted for SUD (DBT-SUD) and Dynamic Deconstructive Psychotherapy are effective in reducing dropout rates and improving treatment outcomes. In severe cases, pharmacological treatments for SUDs, such as disulfiram, naltrexone, and acamprosate, should be considered. Off-label use of anticonvulsants (e.g., pregabalin) or atypical antipsychotics may also be appropriate but should be prescribed cautiously. COMORBID ADHD AND BPD: Studies estimate a genetic overlap of approximately 60% between the two disorders, with ADHD patients having a 19.4-fold increased risk of developing BPD. [Ditrich et al., 2021] This genetic co-aggregation highlights a possible shared biological basis, though further research, particularly into gene-environment (GxE) interactions and epigenetics, is needed. [Weiner et al., 2019] Among people with attention-deficit/hyperactivity disorder, the lifetime rate of BPD was found to be 33.7%. [Bernardi et al., 2012] Childhood ADHD symptoms are significantly associated with an increased likelihood of BPD diagnosis in adulthood. [Weiner et al., 2019] There are four possible explanations for the frequent co-occurrence of ADHD and BPD [Weiner et al., 2019] 1. Attention-Deficit/Hyperactivity Disorder (ADHD) may function as a developmental antecedent to Borderline Personality Disorder (BPD). 2. ADHD and BPD may represent phenotypic variations of a shared underlying psychopathological mechanism rather than distinct clinical entities.

• 84. 3. ADHD and BPD might be distinct nosological categories, yet they could share overlapping aetiological risk factors. 4. The presence of one disorder may confer an increased vulnerability to the subsequent development of the other. Additionally, some authors propose that severe ADHD may represent a subtype of BPD. [Ditrich et al., 2021] Current treatment for comorbid ADHD and BPD relies on expert opinion rather than systematic evidence. Methylphenidate (MPH) may enhance decisionmaking in individuals with Borderline Personality Disorder (BPD), particularly when ADHD symptoms are more severe. [Gvirts et al., 2018] In a study, BPD-ADHD patients treated with MPH showed greater improvements in Trait-State Anger, impulsivity, depression, and ADHD severity following a 4-week Dialectical Behavior Therapy (DBT) program compared to those not on stimulants. [Prada et al., 2015] This highlights the need to screen BPD patients for ADHD, as MPH treatment may improve outcomes. In a nationwide Swedish study (2006–2018), patients with Borderline Personality Disorder (BPD) were identified using national health registers. The study found that ADHD medications were the only pharmacological treatment associated with a reduced risk of psychiatric rehospitalisation, hospitalisation for any cause, or death. Other medications, such as benzodiazepines, antidepressants, antipsychotics, and mood stabilisers, did not demonstrate these benefits. [Lieslehto et al., 2023] COMORBID BPD AND PTSD: Comorbid borderline personality disorder (BPD) and post-traumatic stress disorder (PTSD) present a particularly severe and complex clinical challenge, characterised by heightened risks of suicide, increased healthcare utilisation, and significant psychosocial impairment. [Zeifman et al, 2021]. Despite the availability of treatment guidelines for each disorder independently, there is a notable lack of specific guidance for managing cases where BPD and PTSD co-occur. Epidemiological studies suggest that approximately 30% of individuals with BPD meet criteria for PTSD, while 25% of those with PTSD meet criteria for BPD, with even higher comorbidity rates observed within clinical BPD populations. [Zeifman et al, 2021]. This dual diagnosis is associated with greater symptom severity, higher rates of additional mental health comorbidities, and an increased healthcare burden compared to either disorder alone. Stage-based interventions, such as Dialectical Behavior Therapy for PTSD (DBT-PTSD) and Cognitive Processing Therapy (CPT), have shown promise in treating this dual diagnosis by addressing the full spectrum of core symptoms. [Kleindienst et al., 2021] Although current research indicates that trauma-focused treatments do not increase the risk of suicide or self-harm, further studies are needed to establish the safety and

• 85. efficacy of these interventions for patients with BPD-PTSD. Post Traumatic Stress Disorder (PTSD) – A Primer on Neurobiology and Management Complex Post Traumatic Stress Disorder (cPTSD)- Impact of Childhood Trauma | Assessment and Management Principles COMORBID BPD AND PSYCHOSIS: Borderline Personality Disorder (BPD) is marked by emotional dysregulation and heightened sensitivity to stressors, with amygdala hyperreactivity and increased salience network activation, thus creating a vulnerability to psychotic-like experiences by exaggerating emotional responses to negative stimuli and social situations. [Denny et al., 2018] Early childhood trauma and adverse experiences can further sensitise neural circuits, particularly the amygdala, increasing susceptibility to subtle discrepancies in social interactions, which may manifest as fear, rumination, or even psychotic-like suspicion. [Millman et al., 2022] We covered the neurobiology of BPD here. Trauma-related dysregulation in emotional processing and autobiographical memory may contribute to the onset and maintenance of psychotic-like experiences, including intrusive imagery, dissociation, and paranoia. [Hardy, 2017] These experiences often manifest as two distinct types of intrusions: [Hardy, 2017] 1. Trauma-related memory fragments 2. Anomalous experiences which may not be directly linked to trauma but emerge from dysregulated emotion regulation processes. Psychotic symptoms, especially auditory verbal hallucinations, have been frequently reported in BPD, with prevalence rates ranging from 26% to 54%. [Belohradova et al, 2022]. Psychotic symptoms in individuals with Borderline Personality Disorder (BPD) have often been dismissed as transient or 'pseudo,' but recent research challenges this view. Studies demonstrate that psychotic symptoms, particularly auditory verbal hallucinations, in BPD, show more similarities to those in primary psychotic disorders than previously acknowledged. [Cavelti, 2021] The co-occurrence of BPD and psychotic symptoms is linked to more severe psychopathology and worse outcomes, such as an increased risk of suicidality. Adolescence through the mid-20s, when both BPD and psychotic features typically emerge, represents a critical window for early intervention to mitigate the progression of severe mental disorders. [Cavelti, 2021] While auditory verbal hallucinations (AVHs) in Borderline Personality Disorder (BPD) are phenomenologically similar to those in schizophrenia and often meet the criteria for First-Rank Symptoms, they are more strongly associated with stress, dissociative experiences and childhood trauma. In contrast to schizophrenia, BPD generally lacks formal thought disorder, negative symptoms, and bizarre delusions, with affect remaining reactive and sociability

• 86. usually intact. The relationship between childhood trauma, dissociation, and psychotic symptoms in BPD is well-documented. Dissociation, often linked to early emotional abuse, plays a crucial role in the development of psychotic symptoms, with auditory hallucinations being highly correlated with elevated dissociation. Stress-related psychotic reactivity is also common in BPD, with even minor daily stressors eliciting pronounced psychotic responses, including paranoia and hallucinations. [Beatson et al., 2019] The Neuroscience of Dissociation – Clinical Application in Trauma Disorders Additionally, loneliness and social isolation have been identified as contributing factors to psychosis in BPD, potentially through mechanisms such as social deafferentation, which posits that social isolation may lead to the brain generating false social connections in the form of hallucinations. [Hoffman, 2008]. Treatment options for psychotic symptoms in Borderline Personality Disorder (BPD) remain limited, with few studies evaluating their efficacy. Antipsychotic medications have shown small to medium effects in alleviating cognitiveperceptual symptoms such as suspiciousness, paranoid thoughts, and hallucinations. Both typical and atypical antipsychotics appear to provide some benefit. Cognitivebehavioral therapy and non-invasive brain stimulation are also suggested as potential treatments, though more research is needed. Since loneliness contributes to hallucinations, improving social support and quality of life could be beneficial. [Belohradova et al, 2022]. SELF-HARM IN BPD: Repetitive self-harming behaviours in Borderline Personality Disorder (BPD) may be conceptualised through an addictive model, where such

• 87. behaviours are employed to alleviate psychological pain or distress. [Blasco-Fontecilla et al., 2016] This understanding has led to exploration of treatment strategies that target various neurobiological systems, including the opioid and dopaminergic pathways, as well as the hypothalamic-pituitary-adrenal (HPA) axis. Clinical trials involving opioid antagonists, such as naltrexone and buprenorphine, have shown promising results in reducing self-harming behaviours by blunting the rewarding effects typically associated with these actions. Recent findings indicate that ultra-low-dose buprenorphine may also reduce suicidal ideation in BPD patients. [Yovell et al., 2016] Naltrexone being a nonspecific competitive opiate antagonist has shown to be helpful in controlling selfinjurious behavior (SIB) and dissociative symptoms in patients with BPD, however, further studiues are nedded to confirm its role. [Moghaddas et al., 2017] Furthermore, corticotropin-releasing factor (CRF) antagonists, such as antalarmin, are currently being investigated for their potential to modulate the HPA axis, which could help decrease stress sensitivity and mitigate self-harm behaviours. Lithium, widely recognised for its antisuicidal properties, may additionally possess antinociceptive effects, potentially lowering self-harm by alleviating psychological pain. However Lithium has not been specifically studied for this indication in BPD. Other agents that modulate glutamatergic transmission, gabapentin, lamotrigine, topiramate, acamprosate, memantine, modafinil, dcycloserine, and N-acetylcysteine, have been proposed as possible candidates that may be useful in treatment of addiction to self-harming behaviours. Emptiness has been identified as a significant precipitating factor for 'self-killing'; however, there has been little

• 88. empirical research exploring the link between suicidal behaviours and emptiness. Cholinergic and serotonergic systems may be implicated in the experience of emptiness. [Blasco-Fontecilla et al., 2013] In one study, the administration of the acetylcholinesterase inhibitor physostigmine to individuals with personality disorders revealed that those with a depressive response were more likely to report feelings of emptiness. [Steinberg et al., 1997] This suggests that drugs with anticholinergic properties, such as tricyclic antidepressants or low-potency antipsychotics, could hold potential for treating emptiness. Despite its recognised impact, the relationship between emptiness and suicidal behaviour remains under-researched. [Blasco-Fontecilla et al., 2013] Since physical and psychological pain share common neural pathways, it raises the question of whether we can treat psychological pain with the same drugs used for physical pain, like headaches. [Meerwijk et al., 2013], [Ducasse et al., 2014] While opioid agonists are unsuitable due to risks like tolerance and dependence, non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen may offer potential. A study found that a 2-week course of acetaminophen reduced daily self-reported feelings of hurt compared to a placebo. [DeWall, 2011], [Dewall et al., 2010] Ketamine has been shown to significantly reduce symptoms of depression, borderline personality disorder, suicidality, and anxiety in patients with treatment-resistant depression (TRD) and comorbid BPD. In a study, participants received four intravenous doses of ketamine (0.5-0.75mg/kg over 40 minutes) across two weeks, demonstrating its potential effectiveness in this population. [Danayan et al., 2023] Additionally, oxytocin, a social neuropeptide, is being explored for its role in mitigating self-harm behaviours, suggesting a promising area for further investigation. [Blasco-Fontecilla et al., 2016] MANAGEMENT OF BORDERLINE PSYCHODYNAMICS content Countertransference Challenges: PRINCIPLES OF MANAGING COUNTERTRANSFERENCE content In managing countertransference with patients diagnosed with Borderline Personality Disorder (BPD), several key principles should be considered: 1. Recognition of push-pull dynamics: Patients with BPD often oscillate between extremes of idealisation and devaluation in their relationships, leading to emotional turbulence in the therapeutic alliance.

• 89. Clinicians must be attuned to these dynamics and maintain a steady therapeutic stance. 2. Managing disorganised attachment patterns: Patients frequently re-enact disorganised attachment schemas within the therapeutic context, leading to countertransference responses characterised by confusion or ambivalence. A clear understanding of these patterns helps mitigate the therapist’s emotional reactions and maintains therapeutic effectiveness. 3. Balancing confrontation with empathy: A successful therapeutic approach involves balancing the need to confront maladaptive behaviours (e.g., splitting, rage) with an empathic understanding of the patient’s emotional pain. This is crucial in addressing both the patient’s defensive mechanisms and their underlying vulnerabilities. 4. Navigating intense countertransference: BPD patients often elicit strong emotional reactions in their clinicians, including frustration, anger, or a desire to rescue. Therapists must be vigilant in recognising these emotions and avoiding enactment, maintaining a reflective and professional stance to support the patient’s treatment. 5. Understanding transference projections: Patients with BPD often project early attachment experiences onto the therapeutic relationship, resulting in rapid shifts between idealisation and devaluation of the therapist. Recognising and interpreting these transference projections is essential to maintaining therapeutic boundaries and advancing the patient’s understanding of their interpersonal patterns. In Transference-Focused Psychotherapy (TFP), managing transference and countertransference is central to treatment. Transference, where patients project unresolved relational patterns onto the therapist, is used to explore their distorted

• 90. perceptions. By interpreting shifts between roles, such as victim and victimizer, therapists help patients gain awareness of these dynamics. Countertransference, or the therapist’s emotional reactions, is equally important. Recognising and reflecting on these responses helps therapists understand the patient’s inner world. This process allows for the integration of split self-perceptions, promoting emotional regulation and healthier relationships. CONCLUSION content Borderline Personality Disorder is a diagnosis that serves as a crucial construct. Yet, it is often misunderstood and misused, an irony that mirrors the internal conflict of splitting inherent to the disorder. The very nature of BPD's diagnosis reflects the paradox of the condition it seeks to define. Understanding the complex interplay of emotional dysregulation, impulsivity, and interpersonal difficulties is key to developing effective interventions for BPD, which remains a significant challenge for mental health professionals. The recognition of BPD as a distinct and chronic condition rather than a transient state is critical for providing appropriate care and improving outcomes for individuals affected by this disorder. In the management of Borderline Personality Disorder (BPD), psychotherapy remains the cornerstone of treatment, with strong evidence supporting its efficacy as a first-line intervention. While various psychotherapeutic approaches, such as Dialectical Behavior Therapy (DBT), Mentalization-Based Treatment (MBT), and Transference-Focused Psychotherapy (TFP), have shown positive outcomes, there is no conclusive evidence favouring one method over another. Despite these advances, high rates of non-response and relapse indicate a need for further refinement in therapeutic strategies. Pharmacotherapy, although reserved for severe comorbidities and crisis management, has yet to offer a targeted approach for the core symptoms of emotional dysregulation and interpersonal hypersensitivity characteristic of BPD. Therefore, future treatments must integrate psychotherapeutic and pharmacological interventions to address the enduring functional impairments and improve patients' overall quality of life. Additionally, empowering patients with knowledge of their recovery potential can significantly elevate treatment expectations and outcomes. Get serious about psychiatry learning

• 91. Join Academy by Psych Scene to access over 40 hours of in-depth, high-quality psychiatry courses that earn CPD points/CME credits. References Leichsenring, F., Heim, N., Leweke, F., Spitzer, C., Steinert, C., & Kernberg, O. F. (2023). Borderline Personality Disorder: A Review. JAMA, 329(8), 670–679. Akiskal, H. S., Chen, S. E., Davis, G. C., Puzantian, V. R., Kashgarian, M., & Bolinger, J. M. (1985). Borderline: an adjective in search of a noun. The Journal of clinical psychiatry, 46(2), 41-48. Leichsenring, F., Fonagy, P., Heim, N., Kernberg, O. F., Leweke, F., Luyten, P., … & Steinert, C. (2024). Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies. World psychiatry, 23(1), 4-25. Gunderson, J. G., Herpertz, S. C., Skodol, A. E., Torgersen, S., & Zanarini, M. C. (2018). Borderline personality disorder. Nature reviews disease primers, 4(1), 1-20. Karatzias, T., Bohus, M., Shevlin, M., Hyland, P., Bisson, J. I., Roberts, N. P., & Cloitre, M. (2023). Is it possible to differentiate ICD-11 complex PTSD from symptoms of borderline personality disorder?. World psychiatry : official journal of the World Psychiatric Association (WPA), 22(3), 484–486. Ekiz, E., Van Alphen, S. P., Ouwens, M. A., Van de Paar, J., & Videler, A. C. (2023). Systems Training for Emotional Predictability and Problem Solving for borderline personality disorder: A systematic review. Personality and mental health, 17(1), 20-39. Storebø, O. J., Stoffers-Winterling, J. M., Völlm, B. A., Kongerslev, M. T., Mattivi, J. T., Jørgensen, M. S., Faltinsen, E., Todorovac, A., Sales, C. P., Callesen, H. E., Lieb, K., & Simonsen, E. (2020). Psychological therapies for people with borderline personality disorder. The Cochrane database of systematic reviews, 5(5), CD012955. Setkowski, K., Palantza, C., van Ballegooijen, W., Gilissen, R., Oud, M., Cristea, I. A., … & Cuijpers, P. (2023). Which psychotherapy is most effective and acceptable in the

• 92. treatment of adults with a (sub) clinical borderline personality disorder? A systematic review and network meta-analysis. Psychological Medicine, 53(8), 3261-3280. Jørgensen, M. S., Storebø, O. J., Stoffers-Winterling, J. M., Faltinsen, E., Todorovac, A., & Simonsen, E. (2021). Psychological therapies for adolescents with borderline personality disorder (BPD) or BPD features—A systematic review of randomized clinical trials with meta-analysis and Trial Sequential Analysis. PLoS One, 16(1), e0245331. Zanarini, M. C., Frankenburg, F. R., Bradford Reich, D., Harned, A. L., & Fitzmaurice, G. M. (2015). Rates of psychotropic medication use reported by borderline patients and axis II comparison subjects over 16 years of prospective follow-up. Journal of clinical psychopharmacology, 35(1), 63–67. Martín-Blanco, A., Ancochea, A., Soler, J., Elices, M., Carmona, C., & Pascual, J. C. (2017). Changes over the last 15 years in the psychopharmacological management of persons with borderline personality disorder. Acta psychiatrica Scandinavica, 136(3), 323– 331. Gartlehner, G., Crotty, K., Kennedy, S., Edlund, M. J., Ali, R., Siddiqui, M., Fortman, R., Wines, R., Persad, E., & Viswanathan, M. (2021). Pharmacological Treatments for Borderline Personality Disorder: A Systematic Review and Meta-Analysis. CNS drugs, 35(10), 1053–1067. Lieslehto, J., Tiihonen, J., Lähteenvuo, M., Mittendorfer-Rutz, E., Tanskanen, A., & Taipale, H. (2023). Association of pharmacological treatments and real-world outcomes in borderline personality disorder. Acta psychiatrica Scandinavica, 147(6), 603–613. Bernardi, S., Faraone, S. V., Cortese, S., Kerridge, B. T., Pallanti, S., Wang, S., & Blanco, C. (2012). The lifetime impact of attention deficit hyperactivity disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Psychological medicine, 42(4), 875–887. Gvirts, H. Z., Lewis, Y. D., Dvora, S., Feffer, K., Nitzan, U., Carmel, Z., Levkovitz, Y., & Maoz, H. (2018). The effect of methylphenidate on decision making in patients with borderline personality disorder and attention-deficit/hyperactivity disorder. International clinical psychopharmacology, 33(4), 233–237.

• 93. Prada, P., Nicastro, R., Zimmermann, J., Hasler, R., Aubry, J. M., & Perroud, N. (2015). Addition of methylphenidate to intensive dialectical behaviour therapy for patients suffering from comorbid borderline personality disorder and ADHD: a naturalistic study. Attention deficit and hyperactivity disorders, 7(3), 199–209. Zeifman, R. J., Landy, M. S., Liebman, R. E., Fitzpatrick, S., & Monson, C. M. (2021). Optimizing treatment for comorbid borderline personality disorder and posttraumatic stress disorder: A systematic review of psychotherapeutic approaches and treatment efficacy. Clinical Psychology Review, 86, 102030 Denny, B. T., Fan, J., Fels, S., Galitzer, H., Schiller, D., & Koenigsberg, H. W. (2018). Sensitization of the neural salience network to repeated emotional stimuli following initial habituation in patients with borderline personality disorder. American Journal of Psychiatry, 175(7), 657-664. Millman, Z. B., Schiffman, J., Gold, J. M., Akouri-Shan, L., Demro, C., Fitzgerald, J., … & Waltz, J. A. (2022). Linking salience signaling with early adversity and affective distress in individuals at clinical high risk for psychosis: results from an event-related fMRI Study. Schizophrenia Bulletin Open, 3(1), sgac039. Blasco-Fontecilla, H., Fernández-Fernández, R., Colino, L., Fajardo, L., Perteguer-Barrio, R., & de Leon, J. (2016). The Addictive Model of Self-Harming (Non-suicidal and Suicidal) Behavior. Frontiers in psychiatry, 7, 8. Yovell, Y., Bar, G., Mashiah, M., Baruch, Y., Briskman, I., Asherov, J., Lotan, A., Rigbi, A., & Panksepp, J. (2016). Ultra-Low-Dose Buprenorphine as a Time-Limited Treatment for Severe Suicidal Ideation: A Randomized Controlled Trial. The American journal of psychiatry, 173(5), 491–498. Steinberg, B. J., Trestman, R., Mitropoulou, V., Serby, M., Silverman, J., Coccaro, E., Weston, S., de Vegvar, M., & Siever, L. J. (1997). Depressive response to physostigmine challenge in borderline personality disorder patients. Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology, 17(4), 264–273. Blasco-Fontecilla, H., de León-Martínez, V., Delgado-Gomez, D., Giner, L., Guillaume, S., & Courtet, P. (2013). Emptiness and suicidal behavior: an exploratory review. Suicidol

• 94. Online, 4(4), 21-32. Dewall, C. N., Macdonald, G., Webster, G. D., Masten, C. L., Baumeister, R. F., Powell, C., Combs, D., Schurtz, D. R., Stillman, T. F., Tice, D. M., & Eisenberger, N. I. (2010). Acetaminophen reduces social pain: behavioral and neural evidence. Psychological science, 21(7), 931–937. Danayan, K., Chisamore, N., Rodrigues, N. B., Vincenzo, J. D. D., Meshkat, S., Doyle, Z., Mansur, R., Phan, L., Fancy, F., Chau, E., Tabassum, A., Kratiuk, K., Arekapudi, A., Teopiz, K. M., McIntyre, R. S., & Rosenblat, J. D. (2023). Real world effectiveness of repeated ketamine infusions for treatment-resistant depression with comorbid borderline personality disorder. Psychiatry research, 323, 115133. Dr. Sanil Rege is a Consultant Psychiatrist and founder of Psych Scene and Vita Healthcare. He currently practices on the Mornington Peninsula.

• 95. Dr Sanil Rege

• 96. MBBS, MRCPsych, FRANZCP Dr. Sanil Rege is a Consultant Psychiatrist and founder of Psych Scene and Vita Healthcare. He has dual psychiatry qualifications from the United Kingdom and Australia. He currently practices on the Mornington Peninsula. His focus on combining psychiatry with principles of entrepreneurship has uniquely enabled him to not only contribute to the academic world through his several publications but also add value to the real world by establishing two successful enterprises in a short span of 6 years. He was appointed Associate Professor of Psychiatry at a prestigious Australian University at the age of 32 but left the role to focus on his passion of entrepreneurship in psychiatry. Psych Scene was co-founded to enhance psychiatry education, and Vita Healthcare was to provide the highest quality mental health care to the public. He is passionate about learning from multiple disciplines (Medicine, Psychiatry, Neurosciences, Accounting, Entrepreneurship, Finance and Psychology) with the aim of adding value to the world. By taking on multiple roles of a clinician, entrepreneur, father, educator, investor and MBA student, he recognises that personal development is a journey that needs to touch others lives for the better. He lives by the motto “All the knowledge in the world is not found in one academic discipline” and driven by curiosity. Dr. Sanil Rege is a Fellow of the Royal Australian and New Zealand College of Psychiatrists and Member of the Royal College of Psychiatrists (UK). He has practiced Psychiatry in the United Kingdom and throughout Australia. He has experience in the assessment and management of a broad range of psychiatric disorders, including psychosis, depression, anxiety, post-traumatic stress disorders, personality disorders, neuropsychiatric presentations and consultation-liaison psychiatry. Read More Download this article

• 97. As a Pro user you can download this article in a PDF format. After clicking, please wait for your PDF to download Download this article As a Pro user you can download this article in a PDF format. Download Hub’s materials for your personal use Get our articles as PDFs, download article images, and enjoy an ad-free experience for only $99/year. Generated with Reader Mode