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Real-World Issues and Treatment Implications
Borderline personality disorder (BPD) is frequently seen in clinical practice. Over the past 2 decades, research on BPD has increased substantially, with concomitant specialized psychotherapies that have been proved to be effective. A number of pharmacological agents have also been investigated, but results have been mixed.1
One of the enduring challenges in treating patients with BPD is that only a minority have straightforward clinical presentations with no comorbidity. BPD typically coexists with depression, anxiety, and substance abuse. Symptoms of these conditions may lead the clinician to miss the diagnosis of personality disorder entirely.
Comorbidities in BPD reflect a connection with both internalizing and externalizing disorders and symptoms. This indicates that unlike many other disorders that are more strongly associated with either internalizing or externalizing symptoms, BPD is associated with domains of symptoms and categories of disorders. Studies have found a mean of 4.1 lifetime Axis I comorbidities and 1.9 lifetime Axis II comorbidities for patients with BPD.2
Diagnosis
Mood disorders prevail with Axis I comorbidities: 96% of patients with BPD have a mood disorder during their life, and lifetime depression is reported at 71% to 83%.2,3 Anxiety disorders are also extremely common: 88% of patients have an anxiety disorder, 34% to 48% have panic disorder, and 47% to 56% have PTSD. Alcohol and substance abuse or dependence are reported by 50% to 65%; eating disorders affect 7% to 26% over a lifetime (Table).2,3 Gender differences in these disorders are similar to what is seen in the general population: substance use disorders are more common comorbidities in males, and mood disorders and eating disorders are more common comorbidities in females.
Structured interviews, such as the Diagnostic Interview for Borderlines- Revised and the Structured Clinical Interview for DSM-IV, can confirm diagnoses of BPD and comorbid disorders.4,5 However selfreport questionnaires designed for screening may inaccurately label patients who have BPD with another disorder. For example, the Mood Disorder Questionnaire often inaccurately identifies bipolar disorder in patients with BPD.6 Proposed changes in DSM-5 would not have solved this problem, since traits of negative affectivity, including anxiousness and depressivity, are associated with many other diagnoses. In the end, most of these comorbidities could be considered artifactual and BPD should often be considered as...