The following articles have been selected because they are up to date, because they are on a topic of interest or because the authority of the paper is high. Always when reading it helps to ask a couple of questions:
Who is the author?
The more experience and learned an author is, the more we can expect their work to be of quality. Nonetheless, it pays to know a little more too. If the author is a psychiatrist, then they will have a different perspective to a psychologist: their training is different; their philosophical backgrounds are likely to be very different.
Is it published in a peer reviewed journal?
A peer reviewed paper has been submitted to the scrutiny of other experts in the area. They considered all aspects of the paper and whether it is valid and the research underlying the paper is rigorous. A peer reviewed paper has the highest authority.
The articles are loosely organised under the following headings:
The Victorian government has made early intervention a priority. It seems a logical response as long, of course, that treatment is readily available for those now well into adulthood.
2007 Prevention & early Intervention for borderline personality disorder by Andrew M Chanen, Louise K McCutcheon, Martina Jovev, Henry J Jackson and Patrick D McGorry. This paper written by Australians presents an argument for early intervention. While it is academic in tone and includes references a lay person would be challenged by, it is nonetheless easy to read.
2015 Clinical and Psychosocial Outcomes of Borderline Personality Disorder (BPD) in Childhood and Adolscence: A Systematic Review by Catherine Winsper. The paper considers BPD in young people in UK and supports the argument for early intervention. It divides young people into three groups: those who have a consisted BPD; those for whom it abates – but can come back; and those for whom BPD develops into other mental health problems. It says that those with BPD in childhood or adolescence have significant social, educational, work and financial impairment later in life.The paper looked at all the research in this area, it was not original research.
2016 Integrating Early Intervention for Borderline Personality Disorder and Mood Disorders by Andrew M Chanen, Michael Berk, Katherine Thompson. An Australian paper, it identifies ‘clinical staging’ for clinicians to use in the treatment process in order to apply appropriate and proportionate intervention strategies. It also addresses comorbidity with Bipolar and unipolar depression. This is an easy to read paper, considering it is an academic paper published.
It is important to open our minds to the wide world of BPD. Psychiatry and psychology have not always responded well to BPD and this has coloured the discourse over the years. Today we are beginning to understand the disorder much better. Our own personal experience of BPD is only one perspective; there are many different manifestations of the disorder…over 250 different ways for it to be present, and different levels of severity too.
2009 Borderline Personality Disorder The Nice Guideline on Treatment and Management National Clinical Practice Guideline Number 78, Commissioned by the National Institute for Health and Clinical Excellence, published by The British Psychological Society and The Royal College of Psychiatrists. The NICE Guideline on Treatment and Management of BPD is the official UK guidelines. It is designed for those who work in the mental health system, to guide them. It gives us insight into the different ways BPD is considered in the UK. It is interesting to compare it with our own Australian Guidelines.
2010 Report to Congress on Borderline Personality Disorder published by US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. This illuminating document was prepared by the US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA). The main difference between this document and official documents in Australia is the acceptance in USA at the highest levels of the research that identifies a prevalence of BPD as 5.9%. This is an easy to read overview of BPD.
There is a 40 – 60 % genetic predisposition to the development of BPD. The environment of the person with BPD is critical to the development of the disorder. When we take into account Marsha Linehan’s statement that a person with BPD is like an emotional burns victim because of their high sensitivity, we can appreciate the importance of family relationships. All this and more requires a sensitive understanding for the person with lived experience of BPD and their families.
2008 BPD's Interpersonal Hypersensitvity Phenotype: A Gene-Environment-Development Model by John G Gunderson and Karlen Lyons-Ruth. Published by the National Institute of Health. Gunderson and Lyons-Ruth of the USA explore the role of hypersensitivity in the development of the child and the subsequent interactions within the family. This gene-environment interactional theory helps explain the development of BPD. The work acknowledges that while a basic physiological disposition for BPD is accepted, the clinical theories focus on the aspect of a disturbed relationship underpinning their work. The study explores how hypersensitivity effects attachment.
2009 Borderline Personality Disorder: Ontogeny of a Diagnosis by John G Gunderson. The purpose of this paper is to describe the development of the diagnosis and in doing this it outlines how BPD has been seen from the pre 1970 position of an untreatable disorder, to 1990 when specific treatments were refined. Of interest is the reference to the study that found that treating patients as victims of abuse, usually made the condition worse highlighting that while childhood trauma (including sexual abuse) is related to BPD, “a history of such trauma is unnecessary…” and BPD “often develops without a history of significant trauma.”
2015 Trauma and Mental Health 10 year mental health plan technical paper. Published by the Victorian Government. This paper was prepared for a 10 year mental health plan by the Victorian Govt and refers to the importance of trauma informed care. It highlights that 1 in 3 Australian women and 1 in 6 men will have experienced sexual abuse before the age of 16. Also, 1 in 5 women and 1 in 20 men have experienced sexual violence since the age of 15. Helpfully the definition of trauma is given and discussed.
These studies are the tip of the iceberg. The cost of not treating a person with BPD has massive effects of the person with lived experience, their families and the wider community. This cost is intergenerational also.
2010 Under the Radar Women with borderline personality disorder in prison by Matt Fossey and Georgia Black. Published by the Centre for Mental Health. The policy paper developed by the Centre for Mental Health in the UK explores the position of women in prison with mental health concerns including BPD, it quotes the 1998 study that found 20% of women in prison have BPD. This is a powerful document and a worthwhile read.
2012 Employment in Borderline Personality Disorder by Randy A Sansone and Lori A Sansone. Published in Innovations in Clinical Neuroscience. This complex study provides a powerful discussion of employment concerns with people with BPD. The study refers to the work done which indicates that people with BPD can have clinical improvements but that this is not necessarily reflected in obtaining employment or attending at school and even those who are employed may still not be self supporting.
2014 Inquiry into Social Inclusion and Victorians with Disability. Author Family and Community Development Committee. This document reports on the findings and recommendations of the Family and Community Development Committee of the Parliament of Victoria. It is an interesting document that explores what social inclusion means for people with a disability, how much social inclusion occurs and how to increase social inclusion through stimulating social capital. It was written with the understanding that the introduction of the NDIS would change how people with disabilities would be treated.
Gaining a diagnosis is a high priority for people with lived experience and their families. A diagnosis allows for people to learn and understand what has been happening to them.
2007 Why Psychiatrists are reluctant to diagnose Borderline Personality Disorder by Joel Paris. Published in the January edition of Psychiatry. The paper considers the interface between BPD and Depression, Bipolar and Psychosis. The co-morbidities that commonly exist with BPD are often a reason for clinicians to avoid diagnosis. In this easy to read paper, Dr Paris suggests that giving a diagnosis does more justice than not giving a diagnosis.
2009 Emotion Dysregulation as a core feature of Borderline Personality Disorder by Catherine R Glenn and E David Klonsky. Published in Journal of Personality Disorders. There has been considerable discussion to rename BPD as Emotional Regulation Disorder. In this article, the researchers argue that emotional dysregulation is a unique aspect of BPD separate to issues of negative emotionality including depression, anxiety and negative affect.
2010 Borderline Personality Disorder and the Misdiagnosis of Bipolar Disorder by Camilo J Ruggero, Mark Zimmerman, Iwona Chelminski and Diane Young. Published in National Institute of Health. BPD is often misdiagnosed as Bipolar Disorder. The research this article is based upon concludes that regardless of how a patient meets the criteria of BPD, that is, regardless which of the criteria are present, people with BPD are at an increased risk of being diagnosed with Bipolar Disorder.
2013 Revising the Borderline Diagnosis for DSM-V: An Alternative Proposal by John G Gunderson. Published in National Institute of Health. The Diagnostic Statistical Manual (DSM 5) is the authority for the definitions of mental illness that is commonly used in Australia. It is an American resource and it is regularly reviewed and updated. If we are to change the name of BPD, for example, it is the DSM that will do it. In 2013 the DSM was last updated. In spite of considerable discussion to update the diagnosis, it remained the same. Prior to this event, John Gunderson proposed a change to the diagnosis, suggesting the 4 sectors: Interpersonal Hypersensitivity, Emotional Dysregulation, Behavioural Dyscontrol and Disturbed Self. This article explains why.
2013 Disturbance of Self in Borderline Personality Personality Disorder: An Integrative Approach by Ross Michael Lafleur. Published by University of Wisconsin Milwaukee Digital Commons. The Disturbance of Self is a challenging concept to understand. This article was written towards the completion of a Masters in Psychology and looks at the literature available at the time and proposes an integrative approach to investigate the self in BPD. The paper provides a summary of the different psychological approaches to this concept in relation to BPD which provides an interesting perspective on the different schools of thought.
2014 Complex PTSD, affect dysregulation, and borderline personality disorder by Julian D Ford and Christine A Courtois. Published in BioMed Central. This paper explores the relationship between complex Post Traumatic Stress Disorder (cPTSD) and BPD and identifies that a core difference is the assumption that cPTSD is the result of exposure to traumatic stress. A detailed and dense discussion of the disorders concludes that there is considerable overlap but maintains there are two distinct disorders that require different treatments.
The burden of BPD on families is insufficiently understood. For families it is a traumatic experience for their loved one to have BPD. That a core element of BPD is ‘relational dysfunction’ indicates that there is an additional burden for family members. The genetic predisposition indicates that there may be family members also struggling with aspects of BPD themselves. When the mental health system abandons the person with BPD, the family is there to pick up the pieces. Sometimes the family rejects their loved one, sometimes the person with BPD rejects the family.
2006 SA Carers Charter Principals by Government of South Australia. This simple 2 page document spells out 7 Principles. Principle number 4 is: ‘Service providers work in partnership with carers.’ Although over 10 years old, the simplicity of this charter still informs us today.
2006 Family Guidelines, Multiple Family Group Program at McLean Hospital by John G Gunderson and Cynthia Berkowitz. Published by The New England Personality Disorder Association. The Family Guidelines are a good overall beginning for family members to begin to understand how best to support their loved ones with BPD. A worthwhile introduction to the subject.
2009 Carers and Supporting Recovery. A report commissioned by the Scottish Recovery Network. In Scotland research was done into what could help families support the recovery process. A small study, it highlighted the importance of ‘Carer Groups’ in this process. The conclusions of the study were that carers want to be more valued by mental health services, that they have the potential to assist the recovery process and that Carers Group are an important part of this process.
2012 Supporting people in care relationships in Victoria. Published by the State Government of Victoria. This 2 page documentrelates to The Victorian Carers Recognition Act of 2012. It is an interesting document that sets out the principles of the Act and who is affected by the act (state govt departments, local councils and organisations funded by government).
2014 Inquiry into Social Inclusion and Victorians with Disability. Published by Family and Community Development Committee, Parliament of Victoria. The state government’s Family and Community Development Committee produced this report in 2014 in light of the changes that would occur with the introduction of the NDIS. The report identifies a number of recommendations under 8 categories as a way to improve the social inclusion of those with disabilities.
2016 The economic value of informal mental health caring in Australia. Commissioned by Mind Australia. This informative report attempts to put a monetary value to the work of informal care by the ‘hidden’ workforce. The report identifies approximating 240,000 mental health carers in Australia in 2015, we would consider that a conservative figure indeed. The overall total replacement cost for informal care in 2015 was estimated at $14.3 billion.
All the resource is designed to add to the knowledge to improve the lives of those with lived experience of BPD, so in one sense all the research here is written for them. However, there are precise questions that directly affect people with lived experience, for example, how is their voice heard within the mental health system.
2012 Consumer participation in Victorian public mental health services. Published by the Victorian Department of Health. In 2009 the Victorian Government prepared an action plan to involve mental health services in participating with people with lived experience in the ‘Consumer Participation Standards’. We can see how the state government is encouraging involvement in the mental health system and how much is actually being achieved.
We have a vision of how a mental health system should be responsive to the needs of the community. There are some grand plans, but still we know that the amount of budget money directed towards mental health is sadly inadequate.
2006 Senate Report - Select Committee on Mental Health: A national approach to mental health - from crisis to community. Document printed by the Senate Pricing Unit, Parliament House, Canberra. This large (nearly 600 pages) report is a thorough review of the Mental Health System of Australia. Of particular interest to the BPD Community is the recommendations relating to the need for state government to introduce dual diagnosis facilities within Emergency Departments, that there be specialised inpatient facilities for people with dual diagnosis, specialised programs within community health facilities to treat conditions such as personality disorders, and more.
2016 Borderline Personality Disorder in the Emergency Department: Good Psychiatric Management by Victor Hong. Published in Harvard Review of Psychiatry. Although this is a US paper, it is entirely relevant to the Australian context. The difficulties for people with BPD to receive appropriate care and attention in Emergency Departments, is well understood in the BPD Community. This paper considers the use of Good Psychiatric Management as a method to reduce harm and improve care.
Sometimes controversial, sometime illuminating, the field of neuroscience is fascinating. There is much we can learn about BPD from this field of study. It was the understanding of the plasticity of the brain that brought us a glimmer of hope that we could understand, recovery is possible. MRIs and scans of the brains of people with BPD highlight the areas of the brain affected – the neural pathways from the amydala to the prefrontal cortex are limited which affects emotional regulation. We know that we can rebuild and strengthen neural pathways. And we know how hard that can be.
2015 The Heart, the Brain, and the Regulation of Emotion by Sarah N Garfinkel, Jessica A Eccles and Hugo D Critchley. Published in JAMA Psychiatry, Vol 72, No.11, November 2015. This is an interesting review of a study using ECGs which shows that people with BPD have a higher heartbeat which is a predictor of symptoms of emotional instability. While those in remission, have a more normal heartbeat. The importance of being able to detect one’s own heartbeat is also called into question. The findings have an impact on the use of treatments to enhance emotional regulation and self awareness.
Prevalence is an issue that cuts to the core of the confusion regarding BPD. The challenges of the research done in this area are the different diagnostic tools used, and the size of the sample studied. BPD Community accepts the study of 2008 in USA based on the Wave 2 National Epidemiological on Alcohol and related disorders that gives an overall prevalence of 5.9%.
2008 Epidemiology of Personality Disorders by Mark F Lenzenweger. Published in Psychiatric Clinics of North America. This study looked at data from across the world and concluded the remarkably consistent result of a median prevalence for Personality Disorders at 10.56% and a mean prevalence of 11.39%.
2011 Report to Congress on Borderline Personality Disorder. Published by US Department of Health and Human Services. The USA Dept of Health and Human Services, Substance Abuse and Mental Health Services Administration, prepared this extensive report which gives an up to date overview of BPD in USA. It accepts the research of 2008 of a prevalence of 5.9% (5.6% for men and 6.2% for women). This is an easy to read and informative document.
2015 Classification, assessment, prevalence, and effect of personality disorder by Peter Tyrer, Geoffrey M Reed, and Mike J Crawford. Published www.thelancent.com Vol 385, February 21, 2015. Prepared for the World Health Organisation, this paper considers the international research on all Personality Disorders. It suggests a prevalence ranging from 4% to 15%, lowest in Europe and highest in North and South America. It discusses different aspects in relation to prevalence as well as other issues.
2016 Prevalence rates of borderline personality disorder symptoms: a study based on the Netherlands Mental Health Survey and Incidence Study-2 by Margreet ten ave, Roel Verheul, Ad Kaasenbrood, Saskia van Dorselaer, Marlous Tuithof, Marloes Kleinjan andRon De Graaf. Published in BioMed Central. This paper notes that although knowledge of BPD in the general community is increasing, research on prevalence is still lacking. The study, because it looked at BPD symptoms found that 25.2% had 1 - 2 symptoms, 3.8% had 3 – 4 symptoms and 1.1% had more than 5 symptoms. Symptom identification was based on the International Personality Disorder Examination. Of note was that even a relatively low number of symptoms was associated with comorbidity and functional disability.
BPD Community’s mission is to replace stigma and discrimination with hope and optimism. It is stigma and discrimination that prevents recovery, the source of our hope and optimism.
1988 Personality disorder: The patients psychiatrists dislike by Glyn Lewis and Louis Appleby. Published in British Journal of Psychiatry. This landmark paper based upon research concluded that to have a Personality Disorder is an enduring pejorative judgement rather than a clinical diagnosis. It is hoped we have come some way since this report, but old attitudes and habits are hard to break.
2006 Borderline Personality Disorder: Stigma, and Treatment Implications by Ron Aviram, Beth Brodsky, Barbara Stanley. Published in Harvard Review of Psychiatry. The authors of this paper make the point that the very behaviours that make it difficult to work with people with BPD contribute to the stigma of BPD. The result of this is a self fulfilling prophecyand a cycle of stigmatisation. This excellent paper considers this point and more.
2007 Why Psychiatrists are Reluctant to Diagnose Borderline Personality Disorder by Joel Paris. Published in Psychiatry (January). Dr Paris from Canada explores the issue of the relationships between BPD and Depression, Bipolar and Psychoses. He identifies that many psychiatrists may withhold a diagnosis in the belief that it is stigmatising. He proposes that the patients with the same symptoms under a different name will still be stigmatised against. He also considers that thinking the disorder is untreatable lends to discrimination. He also suggests that the challenges in diagnosing require clinical judgement and this contributes to withholding of diagnosis.
2012 Mental Illness in the news and the information media - A Critical Review by Jane Pirkis and Catherine Francis (April). This Australian study, searched for articles relating to mental illnesses but did not include Personality Disorders or BPD (or bipolar) in its search. Nonetheless it concluded that news and entertainment media often present a distorted and inaccurate picture of mental health and illness.
2015 Interventions Targeting Mental Health Self-Stigma: A Review and Comparison by Philip T. Yanos, Alicia Lucksted, Amy L. Drapalski, David Roe, and Paul Lysaker. Published in Psychiatric Rehabilitation Journal This review considers the effect of self stigma on people diagnosed with a mental illness. Self stigma is where the person concerned accepts and internalises the stigma they experience, believing it to be accurate.
2016 Borderline Personality Disorder, Stigma and Young People. Published by Orygen, The National Centre of Excellence in Youth Mental Health. Orygen (an Australian Mental Health provider for young people) published this paper. It particularly addresses the issues of gaining a diagnosis. The paper suggests that a tendency not to diagnose BPD in young people reinforces the stereotype of BPD as an enduring illness from which people have little chance of recovery.
2016 The Stigma of Personality Disorders by Lindsay Sheehan, Katherine Nieweglowski and Patrick Corrigan. Sheehan defines stigma to arrive at four forms of stigma: public stigma, provider stigma, self stigma and structural stigma in relation to Personality Disorders. He concludes that the erroneous belief that Personality Disorders are not treatable underlies provider stigma and that structural stigma especially in relation to funding for these disorders, needs to be addressed.
2014 Functions of non-suicidal self-injury in adolescents and young adults with Borderline Personality Disorder symptoms by Naomi Sadeh, Esme A. Londahl-Shaller, Auran Piatigorsky, Samantha Fordwood, Barbara K. Stuart, Dale E. McNiel, E. David Klonsky, Elizabeth M. Ozer, Alison M. Yaeger. Published in Psychiatry Research. This study considers non-suicidal self-harm in adolescents in general and in those with BPD and is able to identify that people with BPD self- harm for different reasons than the general self-harming adolescent. A person with BPD will tend to self-harm as a way to help regulate their emotions and to ‘punish’ themselves, the non BPD self-harm is related to bond with peers and the assert autonomy) Understanding this difference can inform treatment choices.
2013 A BPD Teaching Supplement for the Clinical Community by Frank Yeomans. this supplement to a training program on BPD. He begins with a discussion on the importance of an accurate diagnosis making the point that there is an average of a 10 yr delay in receiving a diagnosis following the initial presentation, leading to unnecessary suffering and wasted efforts.
There are 8 successful treatment types supported by meta data research and 4 supported by research. Of these Dialectical Behaviour Therapy (DBT) is the oldest therapy and possibly the most researched. Marsha Linehan developed this treatment and offers training and accreditation for qualified therapists. Mentalisation is a therapy often practised here in Australia. Schema therapy is also available, as is ‘General Psychiatric Management’. Two more recent therapies are ACT (Acceptance and Commitment Therapy) and Cognitive Analytical Therapy (CAT). The Australian National Guidelines for the Clinical Management of BPD has a good section explaining the different therapeutic approaches.
It is worth noting that there is no known medication that helps with BPD, although there is medication for anxiety and depression and other mental illnesses that might affect a person with BPD.
2005 Attachment and Borderline Personality Disorder by Peter Fonagy. Published in Journal of the American Psychoanalytic Association. Peter Fonagy is an authority in Mentalisation treatment. In this article he explores the effect of early trauma based on fear of the caregiver which may inhibit the development of healthy attachment relationships.
2009 Mindfulness without meditation by Russ Harris. Published in HCPJ (October). This article by Australian Russ Harris explores ACT (Acceptance and Commitment Therapy). He explains that the aim of ACT is to accept what is outside your personal control and commit to taking action that enriches your life. ACT is about mindfulness within the context of values and committed action.
2013 A BPD Teaching Supplement for the Clinical Community by Frank Yeomans. This undated but extensive booklet Assoc Prof Frank Yeomans of Cornell University, USA was written after 2013 and is therefore reasonably up to date. It is an analysis of a book called Remnants of a Life on Paper, using it to teach clinicians about how to effectively treat BPD. It is easy to read too
2013 Mindfulness Practice, Rumination and Clinical Outcome in Mindfulness-Based Treatments by Lance L. Hawley, Danielle Schwartz, Peter J. Bieling, Julie Irving, Kathleen Corcoran, Norman A. S. Farb, Adam K. Anderson, Zindel V. Segal. Published in Springer Science+Business Media New York. The authors of this Canadian study identified that formal Mindfulness practice decreased ruination which in turn alleviated symptoms, however informal Mindfulness practice did not show the same results.
2017 Borderline Personality Disorder Psychological Treatment: An Integrative Review by Beverly Reeves-Dudley. Published in Elsevier. In this dense research, Gunderson categorises the therapy types as either psychodynamic or dialectical treatments. He also offers two models of treatment for consideration. He suggests the philosophical foundation for care that is the Tidal model of mental health recovery which has 10 essential values. He concludes that this study is limited to psychological aspects to treatments and suggests that more ‘inductive research’ is important.