BPD is a common disorder associated with significant functional impairment, high treatment use, and societal costs. Its classification—categorical or dimensional—remains debated, and further research is needed on risk factors, neurobiology, and the role of social and neurocognition.Conclusions from the Article:
Conclusions
BPD is a common mental disorder, associated with considerable functional impairment, intensive treatment utilization, and high societal costs. The construct of BPD is internally consistent and more homogeneous than often assumed 262 . However, it is still controversial whether BPD is better represented by a categorical or dimensional approach 19 . Future research is required to clarify this issue. This is also true for the elucidation of the risk factors, the neurobiological underpinnings, and the role of social cognition and neurocognition in the disorder.
With regard to treatment of BPD, pharmacotherapy is presently only recommended for severe and discrete comorbid mental disorders and for the short‐term treatment of crises. Psychotherapy has proven to be efficacious in BPD 17 and is recommended as first‐line treatment 22 . With regard to the different types of psychotherapy, there is presently no reliable evidence that one method is superior to others 17 , 216 . Some differences in efficacy that were recently reported are based on a few trials 216 . As a limitation, rates of non‐response and relapse are relatively large 23 . Thus, psychotherapy needs to be further improved.
Future studies of psychotherapy in BPD are recommended to focus on patients at risk of non‐response and on improving long‐term effects, as well as on reducing self‐harm behavior and suicidal ideation 263 . Taking the high dropout rate into account 234 , an‐other focus should be on patients prematurely terminating treatments. By studying dropouts, researchers can learn which aspects of a treatment are experienced by patients as not beneficial or even harmful, and in which way treatments may be improved. Thus, patients who drop out of a treatment can provide important information 264 .
As another limitation, the quality of psychotherapy studies was found to be modest 17 , 216 . Further high‐quality studies are required, in both adults and adolescents. Taking the shift from categorical to dimensional concepts into account 20 , research on psychotherapy of BPD (and of personality disorders in general) needs to take dimensional outcome measures (e.g., Level of Personality Functioning Scale 27 ), as well as personality traits, into account. Treatment research on dimensionally defined (severe) personality disorders is required 265 .
In addition, high‐quality head‐to‐head comparisons of the major forms of psychotherapy with a sufficient statistical power, adequate treatment implementation, and control of bias and researcher allegiance are needed. Such trials may also examine presumed mechanisms of change. For these head‐to‐head comparisons, proponents of each approach need to be included on an equal basis (adversarial collaboration) 266 . Funding organizations are encouraged to support these comparative trials, since large samples may be required to detect small but clinically significant differences, implying considerable study costs. As the differences in efficacy between the major psychotherapeutic approaches do not seem to be substantial at the group level 17 , 216 , identifying what works for whom seems to be a promising strategy. Individual participant data meta‐analysis may be helpful in this regard 216 .
Leichsenring F, Fonagy P, Heim N, Kernberg OF, Leweke F, Luyten P, Salzer S, Spitzer C, Steinert C. Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies. World Psychiatry. 2024 Feb;23(1):4-25. doi: 10.1002/wps.21156. PMID: 38214629; PMCID: PMC10786009.