Psych · General adult psychiatry — personality disorders
Borderline personality disorder
Also known as BPD · Emotionally unstable personality disorder · Borderline pattern personality disorder · Cluster B personality disorder · Emotion dysregulation disorder
Exam-exhaustive fellowship reference on borderline personality disorder — DSM-5-TR and ICD-11 nosology; epidemiology and suicide risk; biosocial and mentalization models; differentials including bipolar, trauma, ADHD and organic change; crisis and risk formulation; DBT, MBT, schema therapy, TFP and structured clinical management; limited pharmacotherapy with Cochrane and LABILE evidence; longitudinal recovery. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Acute suicidal intent, plan, or high-lethality attempt — medical stabilisation first, means restriction, same-day senior review, least-restrictive safe setting
- New late-onset personality change with cognitive, neurological or systemic red flags — investigate organic disease before locking a BPD label
- Severe agitation with risk to others, intimate partner violence, or child safeguarding concerns — escalate safety response and legal duties
- Chronic polypharmacy without review dates (benzodiazepines, multiple antipsychotics) — iatrogenic harm is an examiner trap
- Missed bipolar mania/hypomania, PTSD, substance intoxication/withdrawal, or major depression with psychosis while calling everything 'BPD'
- Staff splitting and inconsistent team responses — re-establish a single agreed crisis plan and consultation structure
Meet the patient
A 22-year-old arrives at the ED at 2am, her third visit this year. She took an impulsive overdose two hours after her partner ended the relationship. She is loud, then tearful, then furious at the triage nurse. The overnight note reads: "just borderline, attention-seeking."[18][19]
Two questions decide your fellowship station. First: what does "attention-seeking" miss tonight? Second: which treatment — named, with trials — actually changes this trajectory? This topic is the answer to both.[16][17][19]
References20ShowHide
- [1]Linehan MM, Armstrong HE, Suarez A, Allmon D, et al. Cognitive-behavioral treatment of chronically parasuicidal borderline patients Arch Gen Psychiatry, 1991.PMID 1845222
- [2]Linehan MM, Comtois KA, Murray AM, Brown MZ, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder Arch Gen Psychiatry, 2006.PMID 16818865
- [3]Linehan MM, Korslund KE, Harned MS, Gallop RJ, et al. Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: a randomized clinical trial and component analysis JAMA Psychiatry, 2015.PMID 25806661
- [4]McMain SF, Links PS, Gnam WH, Guimond T, et al. A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder Am J Psychiatry, 2009.PMID 19755574
- [5]Bateman A, Fonagy P Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder Am J Psychiatry, 2009.PMID 19833787
- [6]Bateman A, Fonagy P 8-year follow-up of patients treated for borderline personality disorder: mentalization-based treatment versus treatment as usual Am J Psychiatry, 2008.PMID 18347003
- [7]Giesen-Bloo J, van Dyck R, Spinhoven P, van Tilburg W, et al. Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy Arch Gen Psychiatry, 2006.PMID 16754838
- [8]Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF Evaluating three treatments for borderline personality disorder: a multiwave study Am J Psychiatry, 2007.PMID 17541052
- [9]Cristea IA, Gentili C, Cotet CD, Palomba D, et al. Efficacy of Psychotherapies for Borderline Personality Disorder: A Systematic Review and Meta-analysis JAMA Psychiatry, 2017.PMID 28249086
- [10]Storebø OJ, Stoffers-Winterling JM, Völlm BA, Kongerslev MT, et al. Psychological therapies for people with borderline personality disorder Cochrane Database Syst Rev, 2020.PMID 32368793
- [11]Lieb K, Völlm B, Rücker G, Timmer A, et al. Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials Br J Psychiatry, 2010.PMID 20044651
- [12]Stoffers-Winterling JM, Storebø OJ, Pereira Ribeiro J, Kongerslev MT, et al. Pharmacological interventions for people with borderline personality disorder Cochrane Database Syst Rev, 2022.PMID 36375174
- [13]Kendall T, Burbeck R, Bateman A Pharmacotherapy for borderline personality disorder: NICE guideline Br J Psychiatry, 2010.PMID 20118465
- [14]Crawford MJ, Sanatinia R, Barrett B, Cunningham G, et al. The Clinical Effectiveness and Cost-Effectiveness of Lamotrigine in Borderline Personality Disorder: A Randomized Placebo-Controlled Trial Am J Psychiatry, 2018.PMID 29621901
- [15]Grant BF, Chou SP, Goldstein RB, Huang B, et al. Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions J Clin Psychiatry, 2008.PMID 18426259
- [16]Gunderson JG, Stout RL, McGlashan TH, Shea MT, et al. Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorders study Arch Gen Psychiatry, 2011.PMID 21464343
- [17]Zanarini MC, Frankenburg FR, Hennen J, Reich DB, et al. The McLean Study of Adult Development (MSAD): overview and implications of the first six years of prospective follow-up J Pers Disord, 2005.PMID 16274279
- [18]Lieb K, Zanarini MC, Schmahl C, Linehan MM, et al. Borderline personality disorder Lancet, 2004.PMID 15288745
- [19]Bohus M, Stoffers-Winterling J, Sharp C, Krause-Utz A, et al. Borderline personality disorder Lancet, 2021.PMID 34688371
- [20]Gunderson JG, Herpertz SC, Skodol AE, Torgersen S, et al. Borderline personality disorder Nat Rev Dis Primers, 2018.PMID 29795363