CLINICAL APPLICATIONS

Borderline Personality Disorder in Patients With

Medical Illness: A Review of Assessment, Prevalence,
and Treatment Options
Stephan Doering, MD

ABSTRACT
Objective: Borderline personality disorder (BPD) occurs in 0.7% to 3.5% of the general population. Patients with BPD experience exces-
sive comorbidity of psychiatric and somatic diseases and are known to be high users of health care services. Because of a range of chal-
lenges related to adverse health behaviors and their interpersonal style, patients with BPD are often regarded as “difficult” to interact with
and treat optimally.
Methods: This narrative review focuses on epidemiological studies on BPD and its comorbidity with a specific focus on somatic illness.
Empirically validated treatments are summarized, and implementation of specific treatment models is discussed.
Results: The prevalence of BPD among psychiatric inpatients (9%–14%) and outpatients (12%–18%) is high; medical service use is very
frequent, annual societal costs vary between €11,000 and €28,000. BPD is associated with cardiovascular diseases and stroke, metabolic
disease including diabetes and obesity, gastrointestinal disease, arthritis and chronic pain, venereal diseases, and HIV infection as well as
sleep disorders. Psychotherapy is the treatment of choice for BPD. Several manualized treatments for BPD have been empirically validated,
including dialectical behavior therapy, transference-focused psychotherapy, mentalization-based therapy, and schema-focused therapy.
Conclusions: Health care could be substantially improved if all medical specialties would be familiar with BPD, its pathology, medical and
psychiatric comorbidities, complications, and treatment. In mental health care, several empirically validated treatments that are applicable
in a wide range of clinical settings are available.
Key words: borderline personality disorder, somatic illness, epidemiology, comorbidity, treatment, implementation.

CLINICAL CASE1
A 26-year-old woman presents at the emergency care unit with
severe hypoglycemia. She has been diagnosed as having type
1 diabetes at the age of 19 years and is on an intensive insulin reg-
imen. During the previous 18 months, she was admitted to the
emergency department 12 times because of hypoglycemia or
hyperosmolar hyperglycemic state. The laboratory tests yielded
highly increased hemoglobin A1c levels. The resident on duty
spoke to her about her insulin regimen and her suboptimal adher-
ence. In response, she immediately became furious and yelled at
the resident. Afterward, she refused to talk to him again. The fol-
lowing morning, the senior physician talked with the patient and
managed to establish a better contact with her. It became clear that
the patient had dropped out of five previous psychotherapies al-
ready. She mentioned that “The therapists were all nonsense.” In
addition, she was admitted to psychiatry 17 times because of
suicide attempts and other crisis situations. She was repeatedly
diagnosed as having borderline personality disorder (BPD).
However, she had never received treatment that directly addressed
borderline personality.
1
The case is not one individual real case but a merger of several similar
cases; thus, there is no threat to anonymity of an individual person.
Upon admission, she understood that her health behavior and
her frequent diabetes-related complications were probably associ-
ated with her impulsivity and personality problems. She agreed to
see a psychiatrist, who admitted her to a specialized borderline per-
sonality unit in a nearby town. After 3 weeks of inpatient treatment,
she was referred for individual psychotherapy. She managed to main-
tain a good therapeutic relationship with her therapist, and her diabetes
complications disappeared in the subsequent 2 years. She started
an apprenticeship as an accountant and engaged in a partnership
that was much more stable than her earlier relationships.
BPD is a severe mental disorder that affects 0.7% to 3.5% of
the general population (1–4). Impairment in the realms of regula-
tion of emotions and impulses, identity, and interpersonal relation-
ships cause major problems in social adaptation (5) and quality of
AMPD = Alternative DSM-5 Model for Personality Disorders,
BPD = borderline personality disorder, DBT = dialectical behavior
therapy, DSM-5 = Diagnostic and Statistical Manual of Mental Dis-
orders (Fifth Edition), GPM = good psychiatric management,
HPA = hypothalamic–pituitary–adrenal, MBT = mentalization-
based therapy, PD = personality disorder, PF = personality function-
ing, RCT = randomized controlled trial, SCM = structured clinical
management, SFT = schema-focused therapy, TFP = transference-
focused psychotherapy

From the Department of Psychoanalysis and Psychotherapy, Medical University of Vienna, Vienna, Austria.
Address correspondence to Stephan Doering, MD, Department of Psychoanalysis and Psychotherapy, Medical University of Vienna, Waehringer
Guertel 18-20, 1090 Vienna, Austria. E-mail: stephan.doering@meduniwien.ac.at
Received for publication September 1, 2018; revision received May 1, 2019.
DOI: 10.1097/PSY.0000000000000724
Copyright © 2019 by the American Psychosomatic Society

Psychosomatic Medicine, V 81 • 584-594 584 September 2019

Copyright © 2019 by the American Psychosomatic Society. Unauthorized reproduction of this article is prohibited.

life (6). Because of frequent self-harming behavior and suicide
attempts (7), high medical and mental health service utilization
(5,8), low compliance (9), and negative life-style and health-
related behaviors (10), patients with BPD often experience con-
siderable medical comorbidities (e.g., diabetes mellitus) and are
seen frequently in all medical specialties. Patients with BPD are
regarded to be “difficult,” those who challenge the health care
provider’s interpersonal skills, those who are time-consuming
and noncompliant, and those who drop out of treatment fre-
quently (11).
DIAGNOSIS
The Diagnostic and Statistical Manual of Mental Disorders (Fifth
Edition; DSM-5) (12) contains two diagnostic approaches, a cate-
gorical one and a hybrid dimensional model consisting of person-
ality functioning (PF) and personality traits. The primary approach
of the DSM-5, section II, consists of general and specific criteria
that both have to be fulfilled for the diagnosis of a personality dis-
order (PD). The former refer to the domains of the personality af-
fected, inflexibility, distress, and chronicity of the condition. The
specific diagnostic criteria of BPD are given in Figure 1.
The so-called Alternative DSM-5 Model for Personality Disorders
(AMPD) (12, p. 761 ff.) contains as the first general diagnostic
criterion, specifying an impairment in PF with specific patterns of
impairment for the different specific PDs. Moreover, the AMPD
comprises five PD trait domains with a certain number of facets
each. The five domains are as follows: a) negative affectivity,
b) detachment, c) antagonism, d) disinhibition, and e) psychoticism.
From the impairment of PF and specific patterns of trait domains
and facets, six individual PDs are defined, and in addition, a trait-
specified description of every other combination of personality
pathology can be composed. The description of BPD according to
the AMPD is displayed in Figure 2.
FIGURE 1. Diagnostic criteria of BPD according to DSM-5, section II, page 663 (12).
Psychosomatic Medicine, V 81 • 584-594
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BPD and Somatic Disorder
The diagnosis of BPD is usually made clinically by experi-
enced specialists; however, the use of psychological tests—
questionnaires or structured interviews—is helpful to assure the
diagnosis. Because the BPD diagnostic criteria for the categorical
diagnosis have not been changed in DSM-5 (12), the instruments
using Diagnostic and Statistical Manual of Mental Disorders
(Fourth Edition) (13) criteria can still be used. Because of their
lack of reliability, questionnaires are not suited for making a diag-
nosis, but they can be used as screening tools. Well-established in-
struments are the Personality Disorder Questionnaire-4+ (14,15)
or the Assessment of DSM-5 Personality Disorders (16). For the
evaluation of changes in borderline symptoms, the Borderline
Symptom List (17) has been developed. All three questionnaires
can be obtained from the authors or downloaded free of charge
on the internet. For the assessment of the new AMPD of the
DSM-5, recently the Levels of Personality Functioning Self-
Report (18) and the Personality Inventory for DSM-5 (19) have
been published.
Structured interviews are much more reliable for diagnosing
PDs than self-report instruments. A well-established measure is
the Structured Clinical Interview for DSM-5 Personality Disorders
(20), which is regarded as a criterion standard for research purposes.
EPIDEMIOLOGY
Prevalence and Costs
The point prevalence of BPD in the general population has been
assessed in many studies with strong methodology; a number of
large-scale surveys of the 21st century yielded between 0.7%
and 3.5% (2–5,21–25). Although the consensus is that clinical
BPD diagnoses are more common in women than in men
(12, p. 666), evidence suggests that there are no marked sex
differences in the prevalence of BPD in the community; female
585 September 2019
 CLINICAL APPLICATIONS
FIGURE 2. Proposed diagnostic criteria for BPD according to DSM-5, section III, page 766–67 (12).
BPD patients are more prone to use mental health care services
than male ones (2,3,24,25). Among primary care patients, BPD
occurred in 6.4% (lifetime diagnosis) (26) and even 19% when
diagnosed as having a questionnaire (27). In psychiatric outpatients,
BPD occurs in 9.3% to 14.4% (28,29) and in 9% in psychiatric
emergency services (30). Psychiatric inpatients are diagnosed as
having BPD in 12% to 18% (31–33).
Between 60% and 80% of BPD patients attempt suicide dur-
ing their lives (7,34); up to 10% die of suicide (7,31,35). Self-
harming behavior occurs in 90% of the borderline patients during
lifetime (7).
Patients with BPD show very high medical and mental health
service use. Outpatient psychosocial treatment is used by 70% to
95% of all BPD patients during lifetime (3,36,37), the numbers
of lifetime psychiatric inpatient treatment differ vastly and range
from 13.4% in a British sample (38) up to 72% to 79% in patients
from the United States (5,36,37). In the United States, more than
60% receive psychopharmacological medication during lifetime
(5,36), with 40% taking more than three drugs at the same time
(37). Reliable numbers regarding medical service use of BPD pa-
tients do not exist; however, it has been shown repeatedly that
Psychosomatic Medicine, V 81 • 584-594
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service use is increased compared with other psychiatric diagnos-
tic groups (8,39) and with the general population (38,40). The in-
creased service use and psychosocial impairment results in
considerable direct and indirect costs. Several large-scale surveys
yielded annual health care costs of €8508 in Germany (41) and to-
tal societal costs of €11,308 in Spain (42), €16,852 in the
Netherlands (43), and €28,026 in Germany (44). In 1998, it was
estimated that BPD patients generate 24% of the total costs of psy-
chiatric inpatient treatment in Germany (45). Evidence-based psy-
chotherapy has been determined to reduce annual costs by nearly
€3000 in the Netherlands (46).
BPD goes along with severely impaired social and physical
functioning (5,6,47–49), disability (4,25), and reduced quality of
life (6). These impairments seem to be dependent on the presence
of comorbid axis I disorders (3,38). However, it remains unclear
whether functional impairment/disability is the consequence of co-
morbid axis I disorders or whether both functional impairment and
axis I comorbidity are (independent) manifestations of a more se-
vere underlying personality pathology. Interestingly, during the
course of the disorder, symptoms tend to remit, but in many cases,
impaired functioning persists, even after treatment (50). This is a
586 September 2019

relevant example that illustrates why DSM-5 has abandoned the
multiaxial model that implied an (relative) independence of, for
example, axes I and II. The new DSM-5 alternative model of
PDs (Figure 2) refines this approach by diagnosing in a dimen-
sional way instead of a categorical approach on different axes.
Patients rather have one condition with personality and psycho-
pathology in a highly individualized combination than a num-
ber of different and independent disorders.
Comorbidity—Psychiatric Disorders
Many studies have investigated the comorbidity of BPD. It has be-
come clear that a “monomorbid BPD patient” is a relative rarity.
Comorbidity of axis I disorders has been found in 84.5% (3),
and that of axis II disorders has been found in 73.9% (25); the
mean number of lifetime axis I diagnoses of BPD patients is 4.1;
for axis II, it is 1.9 (51). Comorbid mood disorders occur in 50%
to 60% of all BPD patients (4,25) with 93% lifetime diagnoses
(52). Anxiety disorders (including posttraumatic stress disorder)
have been found in 60% to 80% (25,53) with 88.4% lifetime diag-
noses (52). The comorbidity of posttraumatic stress disorder is of
particular importance in BPD patients because many have experi-
enced maltreatment in childhood: it varies between 31.6% and
55.9% (25,51,52). Substance use disorders have been reported in
slightly greater than 50% of BPD patients (25,51), with a lifetime
rate of 64.1% (52). Eating disorders do also occur frequently in
BPD patients; anorexia nervosa was found in 7% to 21%, and bu-
limia nervosa was found in 13% to 31% of all BPD patients
(51,54,55). BPD has been found in 10% of somatization disorder
patients (56,57); in 34.4% of BPD patients, comorbid somatization
disorder was diagnosed (58).
Comorbidity—Somatic Illness
From a psychosomatic viewpoint, the comorbidity of BPD with
somatic diseases is of particular importance. It is well known that
BPD increases the risk of numerous medical (somatic) conditions
considerably. Moreover, BPD can complicate the course of several
diseases (59). This pattern can be attributed in part to the poor
health-related behavior and life-style. BPD patients are known to
smoke and consume alcohol and drugs, as well as abuse sleep
and pain medication frequently. Moreover, they tend to show a
lack of physical exercise (10,60). In addition, BPD goes along
with a negative perception of health, which itself might impair
health-related behaviors (61).
Patients with BPD show poor adherence to psychological and
medical treatment recommendations (9,62), and they tend to en-
gage in disruptive behaviors such as “yelling, screaming, verbally
threatening, and refusing to talk with medical staff” (63), and sab-
otage their medical treatment (11,64), for example, by preventing
wounds from healing (64–66). These behaviors can be regarded
as self-injury equivalents (11). Factitious disorder represents the
extreme manifestation of this behavior, that is, a clandestine
self-injury that is presented as illness or accidental injury. These
patients can cause severe problems and conflicts in health care
providers and institutions and frequently end up in a fruitless
power struggle with the caretakers. In the literature, it has been
stated repeatedly that patients with factitious disorder often also
have BPD (67–69); however, a recent review revealed contra-
dictory results (70).
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BPD and Somatic Disorder
An overview of comorbidity studies of BPD with somatic dis-
eases is given in Table 1. BPD is associated with cardiovascular,
metabolic, and gastrointestinal diseases as well as pain conditions,
venereal diseases and HIV, urinary incontinence, and sleep dis-
turbance. Of particular interest are the increased prevalences of
cardiovascular disease in general (15.3%), pain conditions like
arthritis (17.2%–27.7%) and chronic pain in general (62.5%–
80.3%), gastrointestinal (21.1%) and hepatic (3.1%) disease,
and urinary incontinence (18.8%) and venereal disease (3.1%).
However, one of the biggest surveys (71) showed that the in-
creased risk of diabetes, stroke, and obesity in patients with
BPD is no longer significant when rigidly controlled for socio-
demographics (sex, age in years, race/ethnicity, education, marital
status, and past year’s household income) and psychiatric comor-
bidity (any anxiety, mood, or substance use disorder, and any
PD other than borderline). Thus, it can be assumed that there are
complex correlations between different psychosomatic compo-
nents rather than unidirectional causal relationships. Nevertheless,
all in all, patients with BPD show more somatic illness than do pa-
tients without BPD.
ETIOLOGY
BPD can be attributed to psychosocial and biological factors that
interact in a complex way (88,89). More than 90% of the BPD pa-
tients are exposed to childhood maltreatment, abuse, and/or ne-
glect (90,91). In a large prospective cohort study, low parental
affection and aversive parental behavior in the early years of devel-
opment have been shown to increase the risk of BPD in adulthood
substantially (92). At the same time, a considerable heritability of
35% to 67% for BPD has been demonstrated in several studies, but
so far, no direct role of genetic polymorphisms has been found
(93). It is not BPD itself that is genetically determined but rather
endophenotypes that predispose for the disorder, for example, im-
pulsivity, aggression, affective dysregulation, or emotional infor-
mation processing (94). These genetic vulnerabilities interact
with environmental influences, and these interactions most proba-
bly shape biological abnormalities, neuropsychological impair-
ment, and finally symptoms of BPD (93).
BPD goes along with a number of neurobiological alterations.
First, specific changes in brain structure and brain function have
been identified, and second, a number of neuroendocrine dysfunc-
tions that exert influences on psychosomatic and somatic disorders
occur. Neuroimaging studies have consistently revealed that BPD
patients show an increased amygdala activity in combination with
a decreased activity of dorsolateral prefrontal brain regions. These
findings have been interpreted as neurobiological correlates of the
emotional dysregulation in BPD (95,96).
A recent study gave hints on a cortical malfunction of the pro-
cessing of bodily signals in BPD (97) patients that might foster the
development of a number of somatic diseases due to an increased
awareness of bodily changes. These probably take place in concert
with neuroendocrine alterations, such as increased sympathetic ac-
tivation and decreased parasympathetic deactivation under labora-
tory stress (98). Changes in hypothalamic-pituitary-adrenal (HPA)
axis dysfunction have been reported in terms of increased salivary
cortisol levels, increased total cortisol in response to awakening,
increased total daily cortisol levels, and more nonsuppressors of
cortisol in the low-dose dexamethasone suppression test (99).
587 September 2019
 TABLE 1. Relationship of Borderline Personality Disorder and Somatic Illness

n n n Prevalence
(Patients (Specific Heath (General Odds Ratio/Relative (%) of Somatic Condition
Somatic Illness Relationship With BPD) Condition) Community Sample) Risk Ratio in BPD Patients Reference
Hypertension Increased the risk of arteriosclerosis or hypertension in 2231 34,653 1.86 28.2 (71)
BPD patients
Nonremitted BPD patients have an increased risk of 200 2.78 12.5 (60)
CLINICAL APPLICATIONS

having hypertension compared with remitted BPD patients.

Psychosomatic Medicine, V 81 • 584-594

Arteriosclerosis Woman with BPD have significantly greater intima-media 47 — — (72)
thickness than do healthy women.
Cardiovascular Increased the risk of cardiovascular disease in BPD patients 2231 34,653 2.78 15.3 (71)
disease BPD/BPD traits increase risk of cardiovascular disease. 244 1.32 — (73)
BPD increases risk of ischemic heart disease. 111 8580 7.2 3.0 (74)
BPD features increase risk of heart disease. 1051 2.22 — (75)
6.8% of BPD comorbidity in heart failure patients 404 — — (76)
Stroke Increased the risk of stroke in BPD patients 2231 34,653 13.8 1.1 (71)

588
BPD increases risk of stroke. 111 8580 8.5 1.2 (74)
Diabetes Increased the risk of diabetes in BPD patients 2231 34,653 1.55 9.3 (71)
Nonremitted BPD patients have an increased risk of 200 8.31 10.9 (60)
having diabetes compared with remitted BPD patients.
Obesity Increased the risk of obesity in BPD patients 2231 34,653 1.29 33.6 (71)
Nonremitted BPD patients have an increased risk of 200 1.52 40.6 (60)
having obesity compared with remitted BPD patients.
BPD features increase risk of obesity. 1051 2.92 — (75)
Metabolic syndrome Increased rate of metabolic syndrome in BPD patients 135 1194 — 23.3 (77)
Gastrointestinal Increased the risk of gastrointestinal disease in BPD patients 2231 34,653 2.31 12.1 (71)
disease
Hepatic disease Increased the risk of hepatic disease in BPD patients 2231 34,653 4.49 3.1 (71)
Arthritis Increased the risk of arthritis in BPD patients 2231 34,653 2.38 27.7 (71)
Nonremitted BPD patients have an increased risk of 200 2.29 17.2 (60)
having arthritis compared with remitted BPD patients.
BPD features increase risk of arthritis. 1051 2.64 — (75)

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September 2019
 Chronic pain Nonremitted BPD patients have an increased risk of having 200 1.62 62.5 (60)
chronic back pain compared with remitted BPD patients.
BPD patients are more likely to experience pain 290 — 80.3 (78)
than nonborderline patients
Number of BPD diagnostic criteria correlates significantly 15 576 — — (6)
with bodily pain.
BPD in 25.6% of chronic pain patients 43 — — (79)
Pain patients have significantly higher levels of BPD 5692 — — (80)
symptoms than do pain-free subjects.
15% of BPD among chronic low back pain patients 200 — — (81)
BPD features predict pain severity in chronic pain patients. 147 — — (82)
Migraine patients with comorbid BPD have a more sever 50 — — (83)
course of migraine.

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Urinary incontinence Nonremitted BPD patients have an increased risk of having 200 3.21 18.8 (60)
urinary incontinence compared with remitted BPD patients.
Polycystic ovary Review: significantly increased serum androgen levels — — (84)
syndrome and incidence of polycystic ovaries
Venereal disease Increased the risk of venereal disease in BPD patients 2231 34,653 3.40 3.1 (71)
HIV BPD increases risk of HIV infection. 70 34,653 4.01 — (85)
HIV-positive patients are more likely to have BPD. 553 28,817 2.10 — (86)
Sleep Meta-analysis: significantly decreased objective sleep continuity — — (87)

589
and architecture as well as increased self-reported
sleep problems

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BPD and Somatic Disorder

September 2019
 CLINICAL APPLICATIONS
Because an association of methylation of the glucocorticoid recep-
tor gene, childhood maltreatment, and clinical severity of BPD has
been detected (100), a biopsychosocial genes–trauma–HPA axis
interaction has been hypothesized (101). However, recently, it
was shown that alterations of the HPA axis occur as a response
to early maltreatment rather than as a consequence of comorbid
BPD pathology (101,102). A few studies demonstrated increased
testosterone levels in saliva after awakening (103) and in hair
(104), as well as reduced plasma oxytocin in BPD women (105).
The latter particularly occurs in BPD patients with unresolved (dis-
organized) attachment representations (106). Finally, differences
between BPD patients and healthy controls have been found with
regard to the μ-opioid receptor concentrations and the endogenous
opioid system activation in response to negative emotional stimuli
(107). It was hypothesized that BPD in itself represents a dysreg-
ulation of the endogenous opioid system (108); however, until
now, this remains speculative (102).
TREATMENT
Empirically Validated Treatments
Treatment guidelines from the United States (109), the United
Kingdom (110), and Germany (111) consentaneously mention
psychotherapy as the treatment of choice for BPD. Moreover, the
guidelines state that there is no pharmacological treatment of
BPD itself; if drugs are given, they should aim at comorbid disor-
ders and/or target symptoms such as severe impulsivity, anxiety,
severe restlessness, or sleep disturbance (109–111). Recent reviews
concluded that second-generation antipsychotics (e.g., lower-
dose quetiapine), mood stabilizers, and dietary supplementation
by omega-3 fatty acids may yield some beneficial effects on se-
lected symptoms of BPD but will not change the personality.
They might particularly be indicated when no evidence-based
psychotherapy is available. Selective serotonin reuptake inhibi-
tors have not been shown to be effective in BPD (112,113).
Four disorder-specific manualized psychotherapies have dem-
onstrated their efficacy in randomized controlled trials (RCTs)
(114): dialectical behavior therapy (DBT) (115), transference-
focused psychotherapy (TFP) (116), mentalization-based therapy
(MBT) (117), and schema-focused therapy (SFT) (118). DBT
has been developed specifically as a treatment for the reduction
of suicidal and self-harming behavior by applying skills training
and specific cognitive behavioral techniques for the enhancement
of emotion regulation (115). Compared with the other treatments,
it has been investigated in the largest number of open trials and
RCTs. A meta-analysis revealed moderate global effects and par-
ticularly moderate effect sizes for the reduction of suicidal and
self-injurious behaviors (119). In an uncontrolled German study,
a reduction of 50% of total societal costs was achieved in those
70% of patients who could be followed up 1 year after 12 months
of DBT (44). TFP is a psychodynamic treatment that focuses on
PF, particularly the integration of the self (identity) and quality
of interpersonal relationships (116). It demonstrated its efficacy
in a number of uncontrolled studies and two RCTs(120,121); par-
ticularly PF, mentalization, and attachment representations have
been improved significantly (121–124). MBT also is a psychody-
namic treatment that is usually delivered as a combination of indi-
vidual and group therapy; it specifically aims at mentalization, that
Psychosomatic Medicine, V 81 • 584-594
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is, the ability to understand one’s own and others motives, feelings,
and behaviors (117). MBT has been shown to be effective in a va-
riety of uncontrolled studies and two RCTs; one took place in a
day care unit setting with a considerable follow-up period of
8 years (125,126), the second one was an outpatient treatment
study (127). Both yielded highly significant effects on general psy-
chopathology, self-harming behavior, suicidality, and social func-
tioning. SFT aims at the change of specific dysfunctional schema
modes in BPD, that is, internal images of early relationship expe-
riences such as mistrust/abuse, defectiveness/shame, angry child,
impulsive child, by using behavioral, cognitive, and experimental
techniques. SFT represents a cognitive behavioral treatment that
has incorporated some aspects of psychodynamic theory and fo-
cuses primarily on relationship experiences in the present and past
(118). SFT was found to effectively reduce general psychopathol-
ogy, borderline symptoms, and quality of life in uncontrolled trails
as well as in two RCTs; one used individual outpatient treatment
(128), and the other one used outpatient group therapy (129).
In addition to the four manualized and empirically validated
stand-alone treatments, the Systems Training for Emotional Pre-
dictability and Problem Solving is an add-on manualized group
treatment program that has shown to be effective in BPD when
combined with other forms of therapy (130,131). Recently, new
treatments have been developed to be applied specifically in
BPD as a basic psychiatric care. These treatments, good psychiat-
ric management (GPM) (132) and structured clinical management
(SCM) (133), are also manualized treatments that integrate basic
attitudes and techniques from effective psychotherapies to be used
in general mental health care by professionals without extended
training. Preliminary evidence hints at an effectiveness of both
treatments: SCM showed to be equally effective than MBT in ma-
jor outcome variables of an RCT (127); GPM was compared with
DBT in an RCT, and no significant differences between both
groups were found in all primary and secondary outcomes
(134,135). However, although easier to learn, these programs
premise an experienced and interpersonally skilled clinician
as well as a regular and structured setting with weekly contacts
for 12 to 18 months or longer.
Although there is no doubt that psychotherapies are effective in
BPD and can even change central aspects of the personality, evi-
dence on the biobehavioral underpinnings of these changes is
sparse. Three functional magnetic resonance imaging studies re-
vealed that 12-week inpatient DBT resulted in specific changes
in neuronal activity in DBT responders toward a more normal
functioning (136–138). One study investigated changes in neuro-
nal functioning before and after TFP and also yielded significant
changes (139). These studies provide evidence for an influence
of psychotherapy on brain function that tends to change toward
normalized functioning. However, until now, there is no convinc-
ing theoretical model on how neuronal changes, psychotherapy,
and behavioral changes interact and determine each other.
Implementation of Treatment Models
All of the four empirically validated BPD psychotherapies are
taught in curricula in many countries. Networks or international
societies exist and can easily be found on the internet or by ap-
proaching the authors of the manuals and efficacy studies. Usually,
a training curriculum consists of a manageable amount of
590 September 2019

theoretical training and treatment for a patient under regular super-
vision; in general, a basic psychotherapeutic training or at least a
license as psychiatrist or clinical psychologist is a prerequisite.
The general psychiatric care models (GPM and SCM) are easier
to learn, but it should be taken into consideration that a consider-
able experience as a mental health professional is essential and a
setting allowing for regular appointments (as mentioned previ-
ously) is indispensable. Individual psychotherapists or psychia-
trists can participate in training courses at regional institutes or
attend introductory workshops at the conferences of the Interna-
tional Society for the Study of Personality Disorders (www.
isspd.com), the North American Society for the Study of Personal-
ity Disorders (www.nasspd.org), or the European Society for the
Study of Personality Disorders (www.esspd.eu), among others.
All treatments can also be implemented by in-house trainings at in-
stitutions or clinical departments. Certified teachers and supervi-
sors will be available to come to the sites for theoretical training
and supervision; the latter is also provided online by many super-
visors. MBT has been primarily developed as a day care unit treat-
ment, and DBT and TFP have also been evaluated as inpatient
treatments (140,141). For institutional teams in inpatient or day
care units, a comprehensive training of the whole team is recom-
mended to be able to develop a joint understanding and concept
of intervention in the treatment for BPD patients; regular external
supervision is indispensable.
CONCLUSIONS
BPD—like many other psychiatric disorders—can be regarded as
a psychosomatic illness. Genetic disposition, early environmental
stress, epigenetic makeup, neurobiological and neuroendocrine
changes, and early relationship experiences interact with each
other and lead to BPD pathology. Comorbidities of psychiatric
and also of medical illnesses are frequent. Personality problems
on the level of life-style and health behavior as well as the often
troublesome interpersonal interactions with health professionals
cause and/or facilitate highly complicated courses of somatic ill-
nesses and their treatment. Health care professionals of any spe-
cialty should be aware of the challenging relationship with
patients having BPD; being familiar with the pathology and its
complications may be productive in adapting an interactive style
that will benefit the therapeutic relationship. Awareness of avail-
able treatment resources and referral processes will promote both
mental and medical health care. Health care professionals dealing
with BPD patients would benefit from striving to learn one of the
empirically validated treatment options, and teams and institutions
should be aware of evidence-based treatments for BPD and make
these treatments available to patients with BPD.
Source of Funding and Conflicts of Interest: No financial or
other support was received by the author for preparing this man-
uscript. The author is a therapist and a supervisor of transference-
focused psychotherapy.
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