FACTORS AFFECTING CLINICIANS’ DECISIONS IN DIFFERENTIATING BORDERLINE

PERSONALITY DISORDER AND BIPOLAR DISORDER

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A Dissertation
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Submitted to the School of Graduate Studies and Research

in Partial Fulfillment of the

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Requirements for the Degree

Doctor of Psychology
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Kassandra Scioli

Indiana University of Pennsylvania

August 2021
 Indiana University of Pennsylvania
School of Graduate Studies and Research
Department of Psychology

We hereby approve the dissertation of

Kassandra Scioli

Candidate for the degree of Doctor of Psychology

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June 16, 2021 Signature on file
Derek R. Hatfield, Ph.D.
Professor of Psychology, Advisor
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June 16, 2021 Signature on file
Anthony Perillo, Ph.D.
Assistant Professor of Psychology
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June 16, 2021 Signature on file

Eric Rosenberger, Ph.D.
Professor of Psychology

ACCEPTED

Signature on file
Hilliary E. Creely, J.D., Ph.D.
Interim Dean
School of Graduate Studies and Research

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Title: Factors Affecting Clinicians’ Decisions in Differentiating Borderline Personality
Disorder and Bipolar Disorder

Author: Kassandra Scioli

Dissertation Chair: Dr. Derek R. Hatfield

Dissertation Committee Members: Dr. Anthony Perillo

Dr. Eric Rosenberger

Mental health professionals have difficulty distinguishing Borderline Personality

Disorder (BPD) and Bipolar Disorder due to overlapping clinical and etiological features. Such

difficulties may lead to misdiagnoses and inappropriate treatment recommendations; thus, it is

crucial to examine what factors impact clinicians’ decisions in distinguishing these disorders.

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This study intended to be one of the first to investigate whether the presence or absence of
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information, the anchoring heuristic, and overvaluing additional information compared to if that

information was presented initially affected participants’ diagnostic judgments between BPD and
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Bipolar Disorder in the context of affective instability and childhood trauma history.

Overall, 206 mental health professionals were randomly assigned to read one of four

versions of the affective instability (AI) case vignette and one of four versions of the childhood
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trauma (CT) case vignette. Both cases included BPD and Bipolar Disorder symptoms, and

differed in terms of the presentation of information about interpersonal difficulties in the context

of affective instability or childhood trauma history (i.e., absent, early, late, or additional

vignettes). Participants completed diagnostic tasks and a demographic questionnaire.

Results did not find that manipulating the presentation of the specified overlapping

features influenced the diagnosis of BPD and Bipolar Disorder for either case. Overall, the AI

case was generally seen as Bipolar Disorder, and the CT case as BPD. Qualitative analyses

revealed that factors outside of how information is presented influenced participants’ diagnostic

decisions. The findings suggest that clinicians consider interpersonal concerns when

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distinguishing these disorders; however, it may be that the specificity and content of the

interpersonal concerns are essential when mood symptoms are also present. Results also

indicated that although participants’ reported using information outside of childhood trauma

history, this information still influenced diagnostic judgments. Lastly, exploratory analyses

revealed certain demographic variables to impact participants’ diagnostic decisions. In the AI

case, Age, Gender, and Years of Clinical Experience affected diagnostic decisions. In the CT

case, Degree Obtained and Primary Theoretical Orientation influenced diagnostic decisions.

Considering these findings, implications for clinical practice and future research are discussed, as

well as the strengths and limitations of this study.

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 ACKNOWLEDGMENTS

To my dissertation chair, Dr. Derek Hatfield: Thank you for your guidance, support, and

mentorship not only through this dissertation process but over my graduate school experience as

well. I am grateful for your understanding and kindness in navigating the unforeseen challenges

over this last year. Your dedication to the IUP Clinical Psychology Doctoral Program is felt by

many. I wish you the best of luck on your next adventure. May the force be with you. To my

committee members, Dr. Anthony Perillo and Dr. Eric Rosenberger: I appreciate your

willingness to join my dissertation project. Thank you for your time and expertise. I am fortunate

to have been able to learn from and work with both of you during this project and in other

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clinical training experiences. To Jess: I am grateful to call you my best friend. Through the
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happy and challenging moments that graduate school and life have presented us with, I am

thankful that you were by my side. To my brother, family, and friends: Thank you for your
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constant check-ins. I have felt your love and support through this whole process. To my biggest

supporters, my parents, Lou and Josie Scioli: Your unconditional love, support, and endless

FaceTime calls mean more than you know. I am truly the luckiest to have you both in my life. It
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is a privilege to be your daughter. Finally, to Julia, Hunter, and Nonno: I dedicate this work to

your memories. I wish that I could share this with you. Since your passings last year, you all

have been deeply missed. I am forever grateful for the love, wisdom, and laughter you brought

into my life. I will cherish my memories of you three, always.

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 TABLE OF CONTENTS

Chapter Page

1 INTRODUCTION .............................................................................................1

2 REVIEW OF RELATED LITERATURE .........................................................5

Borderline Personality Disorder ........................................................................5

Etiology .........................................................................................................6
Genetic Factors ........................................................................................6
Neurological Factors ................................................................................7
Environmental Factors .............................................................................8
Treatment ....................................................................................................10
Psychotherapy ........................................................................................10
Pharmacotherapy....................................................................................12
Bipolar I and II Disorder ..................................................................................13

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Bipolar I Disorder .......................................................................................13
Bipolar II Disorder ......................................................................................15
Etiology .......................................................................................................16
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Genetic Factors ......................................................................................16
Neurological Factors ..............................................................................17
Environmental Factors ...........................................................................18
Treatment ....................................................................................................19
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Pharmacotherapy....................................................................................20
Psychotherapy ........................................................................................20
Difficulty Distinguishing BPD and Bipolar Disorder ......................................22
The Bipolar Spectrum .................................................................................22
BPD Versus Bipolar Disorder: Clinical Features .......................................24
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Emotion Dysregulation/Affective Instability .........................................25

Impulsive Traits/Behaviors ....................................................................27
Suicidal Behavior/Gestures and Self-Mutilation ...................................29
Anger......................................................................................................30
Psychotic/Psychotic-Like Features ........................................................31
BPD Versus Bipolar Disorder: Etiology .....................................................32
Heritability .............................................................................................32
Childhood Trauma .................................................................................33
Summary .....................................................................................................34
Clinical Judgment and Decision-Making.........................................................36
Representative Heuristic .............................................................................37
Availability Heuristic ..................................................................................38
Anchoring and Adjustment Heuristic .........................................................39
Other Factors That Impact Clinical Judgment and Decision-Making ........47
Missing Information...............................................................................47
Waiting for Additional Information .......................................................49

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Chapter Page

Clinician Judgment and Decision-Making in the Differential Diagnosis

Between BPD and Bipolar Disorder ................................................................51
BPD Alone and Versus Other Disorders ....................................................53
Bipolar Disorder Alone and Versus Other Disorders .................................55
BPD Versus Bipolar Disorder.....................................................................58
Present Study ...................................................................................................59
Hypotheses ..................................................................................................62

3 METHODOLOGY ..........................................................................................65

Participants .......................................................................................................65
Materials ..........................................................................................................68
Vignettes .....................................................................................................68
Measures .....................................................................................................69
Diagnostic Questionnaire .......................................................................69

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Demographic Questionnaire ..................................................................69
Procedure ........................................................................................................69
Data Analysis ...................................................................................................72
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4 RESULTS ........................................................................................................73

Affective Instability Case ................................................................................73

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Diagnosis Assigned .....................................................................................73
Diagnostic Ratings ......................................................................................76
Exploratory Analyses ..................................................................................81
Demographic Variables .........................................................................81
Qualitative Data .....................................................................................85
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Childhood Trauma Case ..................................................................................87

Diagnosis Assigned .....................................................................................87
Diagnostic Ratings ......................................................................................90
Exploratory Analyses ..................................................................................95
Demographic Variables .........................................................................95
Qualitative Data .....................................................................................98

5 DISCUSSION ................................................................................................102

Diagnostic Judgment and Decision-Making ..................................................104

Overview of Primary Findings..................................................................104
Information Absent or Present ..................................................................106
Affective Instability Case ....................................................................106
Childhood Trauma Case ......................................................................110
The Anchoring Effect ...............................................................................112
Affective Instability Case ....................................................................113
Childhood Trauma Case ......................................................................115

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Chapter Page

Waiting for Additional Information ..........................................................116

Affective Instability Case ....................................................................117
Childhood Trauma Case ......................................................................118
Demographic Information .........................................................................120
Affective Instability Case ....................................................................120
Childhood Trauma Case ......................................................................121
Reasons for Diagnostic Decisions ............................................................125
Strengths and Limitations of Study.................................................................127
Summary and Conclusion ...............................................................................131

REFERENCES ................................................................................................................134

APPENDICES .................................................................................................................165

Appendix A – Criteria for Borderline Personality Disorder ..........................165

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Appendix B – Criteria for Bipolar I Disorder ...............................................166
Appendix C – Criteria for Bipolar II Disorder ...............................................170
Appendix D – Case Vignette 1: Affective Instability x Interpersonal
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Content Absent ..............................................................................................173
Appendix E – Case Vignette 2: Affective Instability x Interpersonal
Content Absent + Additional Information .....................................................175
Appendix F – Case Vignette 3: Affective Instability x Interpersonal
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Content Early ..................................................................................................177
Appendix G – Case Vignette 4: Affective Instability x Interpersonal
Content Late ...................................................................................................179
Appendix H – Case Vignette 5: Childhood Trauma History Absent .............181
Appendix I – Case Vignette 6: Childhood Trauma History Absent +
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Additional Information ...................................................................................183

Appendix J – Case Vignette 7: Childhood Trauma History Early .................186
Appendix K – Case Vignette 8: Childhood Trauma History Late .................189
Appendix L – Diagnostic Questionnaire ........................................................191
Appendix M – Demographic Questionnaire ..................................................192
Appendix N – Recruitment Email via Qualtrics Email Distribution..............194
Appendix O – Recruitment Email With Open Access Link ..........................195
Appendix P – Informed Consent ....................................................................196
Appendix Q – Debriefing Form .....................................................................198

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 LIST OF TABLES

Table Page

1 Participant Demographic and Professional Information (N = 206) Mean

and Standard Deviation; Frequencies and Percentages ...........................................66

2 Diagnoses Assigned to the AI Case (N = 206) ........................................................73

3 Diagnoses Assigned to the AI Case by Randomly Assigned

Condition (N = 206) .................................................................................................74

4 Results of Chi-Square Analyses for AI Conditions .................................................75

5 BPD and Bipolar Disorder Diagnostic Ratings for AI Vignettes and

Manipulations: Means and Standard Deviations .....................................................76

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6 Effect of Independent Variables (Absent vs. Early vs. Late vs. Additional
Vignette) on Mean BPD Diagnostic Ratings in AI Case: Results of
One-Way ANOVA ..................................................................................................77
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7 Effect of Independent Variables (Absent vs. Early vs. Late vs. Additional
Vignette) on Mean Bipolar Disorder Diagnostic Ratings in AI Case:
Results of One-Way ANOVA .................................................................................77
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8 Effect of Presence of AIxIC (Present vs. Absent) and Whether AIxIC

Information was Provided Initially or Subsequently (Initial vs. Additional)
on Mean BPD Diagnostic Ratings: Results of One-Way ANOVA ........................78
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9 Effect of Presence of AIxIC (Present vs. Absent) and Whether AIxIC

Information was Provided Initially or Subsequently (Initial vs. Additional)
on Mean Bipolar Disorder Diagnostic Ratings: Results of One-Way ANOVA .....78

10 Effect of Vignette Condition (Absent vs. Early vs. Late vs. Additional) and
the Combined Early and Late Condition (Present or Initial) on BPD Versus
Bipolar Disorder Diagnostic Ratings in AI Case: Results of Paired T-Tests ..........79

11 Effect of Presence of AIxIC (Present vs. Absent), Placement of AIxIC

Information (Early vs. Late), and Whether AIxIC Information was Provided
Initially or Subsequently (Initial vs. Additional) on BPD Diagnostic Ratings:
Results of Independent T-Tests ...............................................................................80

12 Effect of Presence of AIxIC (Present vs. Absent), Placement of AIxIC

Information (Early vs. Late), and Whether AIxIC Information was Provided
Initially or Subsequently (Initial vs. Additional) on Bipolar Disorder
Diagnostic Ratings: Results of Independent T-Tests ..............................................80

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Table Page

13 Effect of Diagnosis Assigned Overall to the AI Case on BPD and

Bipolar Disorder Diagnostic Ratings: Results of Paired T-Tests ............................81

14 Diagnoses Assigned to AI Case by Age Group ......................................................82

15 Factors That Participants Reported Impacted Decision to Assign

Bipolar Disorder Diagnosis in AI Case (n = 152): Frequencies ..............................86

16 Factors That Participants Reported Impacted Decision to Assign BPD

Diagnosis in AI Case (n = 11): Frequencies............................................................87

17 Diagnoses Assigned to the CT Case (N = 206) .......................................................88

18 Diagnoses Assigned to the CT Case by Randomly Assigned

Condition (N = 206) ................................................................................................88

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19 Results of Chi-Square Analyses for CT Conditions ................................................89

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BPD and Bipolar Disorder Diagnostic Ratings for CT Vignettes and
Manipulations: Means and Standard Deviations .....................................................90

21 Effect of Independent Variables (Absent vs. Early vs. Late vs. Additional
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Vignette) on Mean BPD Diagnostic Ratings in CT Case: Results of
One-Way ANOVA ..................................................................................................91

22 Effect of Independent Variables (Absent vs. Early vs. Late vs. Additional
Vignette) on Mean Bipolar Disorder Diagnostic Ratings in CT Case:
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Results of One-Way ANOVA .................................................................................91

23 Effect of Presence of CT (Present vs. Absent) and Whether CT Information

was Provided Initially or Subsequently (Initial vs. Additional) on Mean BPD
Diagnostic Ratings: Results of One-Way ANOVA ................................................92

24 Effect of Presence of CT (Present vs. Absent) and Whether CT Information

was Provided Initially or Subsequently (Initial vs. Additional) on Mean
Bipolar Disorder Diagnostic Ratings: Results of One-Way ANOVA ....................92

25 Effect of Vignette Condition (Absent vs. Early vs. Late vs. Additional) and
the Combined Early and Late Condition (Present or Initial) on BPD Versus
Bipolar Disorder Diagnostic Ratings in CT Case: Results of Paired T-Tests .........93

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Table Page

26 Effect of Presence of CT (Present vs. Absent), Placement of CT Information

(Early vs. Late), and Whether CT Information was Provided Initially or
Subsequently (Initial vs. Additional) on BPD Diagnostic Ratings: Results of
Independent T-Tests ................................................................................................94

27 Effect of Presence of CT (Present vs. Absent), Placement of CT Information

(Early vs. Late), and Whether CT Information was Provided Initially or
Subsequently (Initial vs. Additional) on Bipolar Disorder Diagnostic
Ratings: Results of Independent T-Tests.................................................................94

28 Effect of Diagnosis Assigned Overall to the CT Case on BPD and

Bipolar Disorder Diagnostic Ratings: Results of Paired T-Tests ............................95

29 Factors That Participants Reported Impacted Decision to Assign BPD

Diagnosis in CT Case (n = 76): Frequencies ...........................................................99

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30 Factors That Participants Reported Impacted Decision to Assign Bipolar
Disorder Diagnosis in CT Case (n = 34): Frequencies ..........................................101
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 LIST OF FIGURES

Figure Page

1 Scatter Plot of Years of Clinical Experience by Diagnostic Ratings for

Bipolar Disorder With Fit Line in AI Case: Simple Linear Regression..................83

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 CHAPTER 1

INTRODUCTION

Borderline Personality Disorder (BPD) is characterized by a pattern of intense and

unstable relationships, affects, and impulsivity, starting from adolescence or young adulthood

(American Psychiatric Association [APA], 2013). Patients with BPD often experience internal

struggles (i.e., lack of identity, fears of abandonment, affect instability), which can lead to

dysfunction in many domains, and suicidal behavior.

Bipolar Disorder is a mood disorder characterized by periods of elation and low mood

(i.e., mania, hypomania, and/or depression) (APA, 2013). Bipolar Disorder is comprised of

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subcategories; the focus in this study was Bipolar I Disorder (BDI) and Bipolar II Disorder
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(BDII). BDI must include a manic episode. A manic episode may include abnormally elevated,

expansive, or irritable mood, and increased energy or goal-directed behavior over a week. Only a
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manic episode is required for a diagnosis of BDI, however hypomanic or major depressive

episodes may occur. BDII must include a hypomanic and major depressive episode. A

hypomanic episode is similar to a manic episode, but the time required for symptoms to be
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present is four days. A major depressive episode is characterized by symptoms including

depressed mood, loss of pleasure, body weight or sleep changes, and suicidal ideation or

behavior.

Many researchers argue that overlap in both clinical features and etiology make

differentiating these two disorders challenging, particularly under time constraints (e.g., Bayes &

Parker, 2017; Magill, 2004; Paris et al., 2007; Saunders et al., 2015; Zimmerman & Morgan,

2013). Some have even argued that BPD should be conceptualized on a Bipolar Disorder

spectrum (Akiskal et al., 1985; Deltito et al., 2001; Perugi et al., 2003; Smith et al., 2004).

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Overlap in clinical features of impulsivity (e.g., Ghaemi et al., 2014; Paris et al., 2007), affective

instability (e.g., Akiskal et al., 1985; Bayes et al., 2016b; Henry et al., 2001), suicidal behavior or

gestures (APA, 2013; Joyce et al., 2010), anger (Renaud et al., 2012), and psychotic features

(e.g., Bassett, 2012; Bassett et al., 2017) are observed, causing confusion in the differential

diagnostic process. Regarding etiological factors, childhood trauma is primarily associated with

BPD, yet it is prevalent in Bipolar Disorder and can lead to severe consequences. Furthermore,

Bipolar Disorder is considered more heritable than BPD, though BPD has been shown to be

heritable as well. Affective instability and childhood trauma history were of interest in the

present study.

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Rates of misdiagnoses between BPD and Bipolar Disorder suggest that clinicians do
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indeed have difficulty distinguishing these disorders (Deltito et al., 2001; Ruggero et al., 2010;

Zimmerman et al., 2010). Such findings are problematic due to the differences in treatment
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recommendations for each disorder. BPD is primarily treated through psychotherapy (APA,

2001) and Bipolar Disorder through pharmacotherapy (Youngstrom et al., 2011). A misdiagnosis

can lead to patients receiving ineffective treatment, which can impact functioning, symptom
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relief, and cause patients to become confused, frustrated, and disheartened with their recovery

(e.g., Bayes & Parker, 2020; da Costa et al., 2019; Fiorentini et al., 2020).

Research has found that many factors impact clinicians’ judgments and decision-making.

Among these factors are heuristics (i.e., mental shortcuts that people use when solving problems

and making quick judgments), including the anchoring heuristic (Simon, 1990; Tversky &

Kahneman, 1974). The anchoring heuristic occurs when individuals place disproportionate

weight on the information presented initially and fail to adjust their judgments when new

information is presented (Tversky & Kahneman, 1974). This effect has been found to occur in

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clinical contexts (e.g., Friedlander & Stockman, 1983; Mumma & Wilson, 1995; Richards &

Wierzbicki, 1990). Clinicians have also been found to make different judgments in situations

where a piece of information is absent versus if this information was present (e.g., Cataldo,

2018). Therefore, simply withholding a piece of information can alter a judgment made. Finally,

people make different decisions when they have all the information initially versus when they

start with partial information and then gain the remainder (e.g., Bastardi & Shafir, 1998;

Redelmeier et al., 2001). In these specific instances, it is posited that people assign more value to

the additional information, and they make decisions in line with this additional information.

Research has examined how heuristics and other factors impact BPD and Bipolar

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Disorder diagnoses independently or with other disorders (e.g., Bruchmüller & Meyer, 2009;
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Cataldo, 2018; Eubanks-Carter & Goldfried, 2006; Lacy, 2014; Meyer & Meyer, 2009). Non-

systematic studies have provided suggestions on what information can differentiate BPD and
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Bipolar Disorder (e.g., Hatchett, 2010; Johnson et al., 2010; Kernberg & Yeomans, 2013; Parker,

2011). To the researchers’ knowledge, no systematic research has examined whether the

presence or absence of information, the anchoring heuristic, and overvaluing information not
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gathered initially impact the differential diagnostic process of BPD and Bipolar Disorder. Thus,

the current study examined whether these factors impact clinicians’ judgments in the context of

the two abovementioned shared features (i.e., affective instability and childhood trauma).

Researchers have identified a need to understand how clinicians make diagnostic

decisions (Bruchmüller & Meyer, 2009; Meyer & Meyer, 2009). Moreover, Saunders et al.

(2015) suggest that current clinical practice in differentiating BPD and Bipolar Disorder is, at

this time, inadequate. Due to insufficient diagnostic practices and the significant implications of

misdiagnoses between BPD and Bipolar Disorder, there is a need to understand clinicians’

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decision-making processes in this diagnostic dilemma. The investigators hoped that the present

study would shed light on current clinical practices in differentiating BPD and Bipolar Disorder

so that accurate diagnoses can be attained. With accurate diagnostic practices, the likelihood that

patients will be matched with appropriate and effective treatment will increase.

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 CHAPTER 2

REVIEW OF RELATED LITERATURE

Borderline Personality Disorder

Borderline Personality Disorder (BPD) affects 1.6% to 5.9% of the general population,

and 75% of those diagnosed with the disorder are female (APA, 2013). However, findings from

community-based studies indicate that the prevalence of BPD is similar across genders

(Lenzenweger et al., 2007; Tomko et al., 2014). Data suggests that 10% of the population

diagnosed with BPD seek outpatient treatment, whereas 20% experience inpatient treatment

(APA, 2013). A pattern of unstable interpersonal relationships, self-image, affect, and increased

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impulsivity that begins by early adulthood and occurs in multiple domains of the individual’s life
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characterizes BPD. This pattern is observed in various cultural settings around the world (APA,

2013). According to the Diagnostic and Statistical Manual of Mental Disorders (DSM), 5th
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edition, criteria for BPD include: efforts to avoid real or imagined abandonment; unstable and

intense interpersonal relationships characterized by extreme idealization and devaluation;

disturbances in self-image; impulsivity that can be self-damaging (e.g., spending money,

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promiscuity, substance abuse, etc.); recurrent suicidal behavior, gestures or threats, or self-

mutilating behavior; affective instability as a result of mood reactivity; chronic feelings of

emptiness; exhibiting anger; and stress-related paranoia or dissociation (APA, 2013). A

diagnosis of BPD requires the individual to exhibit five or more of the above criteria (see

Appendix A).

The course of BPD is variable. Symptom impairment and suicide risk are highest in

young adulthood and generally decrease as the individual ages, mainly when therapeutic

interventions are implemented (APA, 2013). BPD is associated with premature death,

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particularly among those with co-occurring depressive or substance use disorders; 10% of those

who meet criteria for BPD eventually commit suicide (APA, 2013). However, studies generally

find that few individuals relapse and many experience symptom remission (APA, 2013;

Gunderson et al., 2003; Zanarini et al., 2006; Zanarini et al., 2012). Individuals diagnosed with

BPD may demonstrate a pattern of undermining their abilities across various domains. This

pattern, in conjunction with symptoms of impulsivity, self-destructive behavior, and emotion

dysregulation, can negatively impact their education, career, and interpersonal success.

Many individuals diagnosed with BPD seek treatment to address co-occurring mental

health disorders. BPD has been found to co-occur with Bipolar Disorders (Fornaro et al., 2016;

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Frías et al., 2016; McDermid et al., 2015; Zimmerman & Morgan, 2013), Major Depressive
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Disorder (MDD) (McGlashan et al., 2000; Zanarini et al., 1998; Zimmerman & Mattia, 1999),

anxiety-related disorders (Zanarini et al., 1998), Attention Deficit Hyperactive Disorder (ADHD)
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(Asherson et al., 2014), and Posttraumatic Stress Disorder (PTSD) (APA, 2013). When

examining gender differences, males diagnosed with BPD are likely to have co-occurring

substance use disorder(s) and Antisocial Personality Disorder; whereas, females are more likely
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to have co-occurring eating-, mood-, anxiety-, or trauma-related disorders (Sansone & Sansone,

2011).

Etiology

Genetic Factors

Methodological variability across studies limits our understanding of accurate heritability

rates of BPD (Gunderson et al., 2018; Hooley et al., 2012). Twin studies estimate heritability

rates to be between 0.40 to 0.70 (Distel et al., 2008; Torgersen et al., 2000). Results of Torgersen

et al. (2000)’s study attributed 69% of the variance in BPD symptoms to additive genetic effects,

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and 31% to non-shared environmental effects. Distel et al. (2008) expanded on Torgersen et al.’s

(2000) research, examining the genetic and environmental contributions to BPD in non-clinical

samples, across three countries (i.e., Netherlands, Belgium, and Australia). The results attributed

42% of the variance in BPD symptoms to additive genetic effects, and 58% of the variance to

non-shared environmental effects (Distel et al., 2008). BPD is approximately five times more

prevalent among first-degree biological relatives with BPD (APA, 2013). Research has studied

the strong heritability of traits associated with BPD, including neuroticism, negative

emotionality, and impulsivity (Nigg & Goldsmith, 1994).

Some genes that control neurotransmitters, including serotonin (associated with emotion

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regulation, impulsivity, and aggression), and dopamine (associated with emotion regulation,
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impulsivity, and aggression) are linked to BPD (see Hooley et al., 2012 and Lis et al., 2007 for

reviews). However, no evidence suggests that these genes are specific to BPD as they are
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implicated in other disorders (i.e., Bipolar Disorders, Schizophrenia, MDD). Researchers have

highlighted the growing interest in the role epigenetics, the study of heritable changes in gene

expression that are unrelated to changes in the DNA sequence itself, may play in BPD, with a
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particular interest in how childhood maltreatment alters gene expression (e.g., Crowell et al.,

2009; Hooley et al., 2012; Gunderson et al., 2018; Nia et al., 2018; Winsper, 2018).

Neurological Factors

Many brain regions are implicated in BPD. Research reviews indicate that the amygdala,

hippocampus, and frontal cortex may play central roles in the deficits associated with BPD (e.g.,

Gunderson et al., 2018; Hooley et al., 2012; Leichsenring et al., 2011; Lis et al., 2007; Visintin et

al., 2016). Neuroimaging studies have found decreased amygdala and hippocampus volume in

those diagnosed with BPD (Driessen et al., 2000; Nunes et al., 2009; Weniger et al., 2009).

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Neuroimaging studies consistently find increased amygdala activation in individuals with BPD

compared to controls (Leichsenring et al., 2011; Lis et al., 2007). The amygdala and

hippocampus are essential to consider in the context of BPD. Both of these regions are part of the

limbic system and play an important role in the processing of emotions and aggression. The

dorsolateral prefrontal cortex (DLPFC), orbitofrontal cortex (OFC), and anterior cingulate gyrus

(ACC) are all found in the frontal cortex (van Elst et al., 2003). Reductions in OFC volume have

been found in BPD populations compared to controls, which is significant since the OFC has

been linked to impulsivity (van Elst et al., 2003). van Elst et al. (2003) also found reduced ACC

volumes compared to controls. ACC volume reduction is associated with self-harm behavior,

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impulsivity, and maladaptive interpersonal cognitions in BPD (Whittle et al., 2009). Lastly,
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increased activity in the prefrontal cortex and ACC have been associated with deficits in social

cognition (Ruocco et al., 2010). Frontal cortex brain regions are associated with processes that
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help one understand the mental state of themselves and others. Thus, abnormal activity in these

structures can lead to the intra- and interpersonal deficits observed in BPD (Gunderson et al.,

2018).
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Environmental Factors

Many individuals diagnosed with BPD report a history of childhood trauma (e.g.,

physical, sexual, and emotional abuse, neglect, viewing violence, separation from parents).

Approximately 60% to 80% of individuals diagnosed with BPD report experiencing any form of

childhood abuse, rates that are higher than other disorders, including mood and other personality

disorders (e.g., Bandelow et al., 2005; Herman et al., 1989; Ogata et al., 1990; Zanarini, 2000;

Zanarini et al., 1989). These experiences increase one’s risk of developing BPD, but they are not

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a prerequisite. For example, Bandelow et al. (2005) compared rates of trauma in patients with

BPD and controls, 6.1% of the BPD patient group reported never experiencing a traumatic event.

Rates of specific abuse reported by those with BPD differ. Paris et al. (1994), Zweig-

Frank et al. (1994), and Zanarini et al. (1997) were some of the first researchers to study multiple

forms of childhood trauma in BPD. Sexual abuse was the primary focus of previous research.

Paris et al. (1994) assessed childhood trauma rates in adult females diagnosed with BPD and

Zweig-Frank et al. (1994) assessed these rates in adult males diagnosed with BPD. In both

studies, the researchers compared the experimental group to adults diagnosed with other

personality disorders. Paris et al. (1994) found that females diagnosed with BPD reported

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significantly higher instances of sexual abuse (71% versus 46%), physical abuse (73% versus
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53%), and a lack of maternal affection than the female control group. Males with BPD reported

significantly higher instances of sexual abuse (48% versus 25%) compared to the male control
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group (Zweig-Frank et al., 1994). Additionally, males in the BPD group reported prolonged

separation or loss with their caregiver and more parental control (Zweig-Frank et al., 1994).

Zanarini et al. (1997) compared the trauma experiences of those diagnosed with BPD
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versus other personality disorders. Of the participants with BPD, 91% to 92% reported

experiencing childhood trauma (i.e., general abuse and neglect), and 62% reported experiencing

childhood sexual abuse compared to 32% of the controls.

More recently, de Aquino Ferreira et al. (2018) conducted a comprehensive review of

sexual abuse history in BPD. The review found a range from 16% to 85% of those diagnosed

with BPD reported sexual abuse histories. Patients with BPD reported higher rates of sexual

abuse compared to those diagnosed with other personality disorders. Results from their review

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also suggested strong associations between sexual abuse history and BPD symptoms, including

increased suicidal behavior, dissociation, psychosocial impairment, and PTSD-related symptoms.

Treatment

The American Psychiatric Association’s practice guidelines suggest that psychotherapy

should be the primary treatment of BPD (APA, 2001). They advise pharmacotherapy to be used

as an adjunct to address periods of extreme decompensation and specific traits (i.e., affective,

cognitive-perceptual, and impulsivity traits).

Psychotherapy

Evidence-based psychological treatments used for BPD include Dialectical Behavior

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Therapy (DBT), Transference-Focused Psychotherapy (TFP), Schema-Focused Therapy (SFT),
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and Mentalization-Based Treatment (MBT) (Division 12, 2016).

DBT (see Linehan, 1993 for a review) is a specific form of cognitive-behavior

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psychotherapy that adds dialectical philosophy (i.e., acceptance and change) and mindfulness

practice. The overarching goals of DBT are to modify behavior through acceptance and change

and to manage emotions. DBT is very comprehensive; it includes individual therapy, skills
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training, phone consultation, and a therapist consultation team.

Currently, DBT has the most empirical support compared to other treatments for BPD.

DBT has shown to be effective in reducing suicide attempts, hospitalizations, suicidal ideation,

self-injurious acts, and improving expression of anger and behavioral avoidance across a variety

of settings (i.e., inpatient, outpatient) compared to community treatments (e.g., Bohus et al.,

2004; Linehan et al., 1991; Linehan et al., 2006; Neacsiu et al., 2014). Research has found DBT

skills training alone to be associated with greater improvements in depression, anger, and

anxiety, lower drop-out rates, increased reports of skill use, and decreased suicide attempts (e.g.,

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Neacsiu et al., 2010; Soler et al., 2009). Phone consultation is a unique feature of DBT. Linehan

et al. (1991) found no differences between the number of phone calls therapists received in a

DBT condition versus a treatment-as-usual condition, but phone calls in the latter condition were

correlated with suicidal behavior. Linehan et al. (1991) suggested that these results demonstrate

DBT’s ability to reduce the contingency between patients’ suicidal behavior and phone calls

made to the therapist.

TFP is a highly structured psychodynamic treatment that aims to integrate affect states

and self-representations to achieve identity integration (see Levy et al., 2006 for a review). TFP

involves setting a treatment frame through a therapist-patient contract that outlines the

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responsibilities of both parties, understanding countertransference (i.e., the therapist’s reactions
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to the patient), and engaging the patient in understanding the dynamics occurring between them

and the therapist (Yeomans et al., 2013). Research has found TFP to be associated with fewer
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suicide attempts, alleviating BPD symptoms (i.e., impulsivity, irritability, verbal and direct

assault), increased psychosocial functioning, and decreased suicidal behavior (Clarkin et al.,

2007; Doering et al., 2010).

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SFT for BPD focuses on reorganizing the inner structure of the individual via cognitive-

behavioral, attachment, psychodynamic, and emotion-focused principles (see Kellogg & Young,

2006 for a review). Research has found SFT to be associated with improvements in functioning,

including reductions in impulsivity, self-injurious behavior, self-hatred, loneliness, and feelings

of emptiness (Farrell et al., 2006).

Finally, MBT aims to help patients with BPD learn how to accurately understand the

thoughts and emotions of themselves and others, especially in times of distress (see Bateman &

Fonagy, 2010 for a review). MBT has been found to aid in treating BPD symptoms, reduce

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 hospitalization admissions, increase social functioning, and reduce self-harm behavior and

suicidal behavior in various settings over an extended period of time compared to other

interventions (Bateman & Fonagy, 1999; Bateman & Fonagy, 2001; Bateman & Fonagy, 2008;

Bateman & Fonagy, 2009).

Pharmacotherapy

The use of medication in the treatment of BPD is common. To highlight this practice,

Zanarini et al. (2015) examined pharmacotherapy use among BPD inpatients and an axis II

inpatient control group over a 16-year follow-up study. Compared to the control group, patients

with BPD were significantly more likely to be prescribed antidepressants, anxiolytics,

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antipsychotics, and mood stabilizers. Patients with BPD reported substantial antidepressant use
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(79.7% reported use at baseline and 58.4% at 16 years follow-up); followed by anxiolytic (46.6%

versus 26%), antipsychotic (38.6% versus 28.1%), and finally mood stabilizers (35 % versus
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29%).

A study conducted in Europe by Bridler et al. (2015) examined pharmacotherapy use in

hospitalized patients with BPD. Eighty percent of patients with BPD were prescribed at least two
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psychotropic drugs, and 54% were prescribed three or more. Antipsychotic and/or antidepressant

use made up 70% of medication used among these participants.

Although it is evident that medication use is common, at this time, there are no US FDA

approved medications in the treatment of BPD (Gunderson et al., 2018). Instead, medication is

most often used to treat depressive, anxiety, and cognitive-perceptual symptoms that accompany

a presentation of BPD. This off-label use of medications stems from the known effects of these

medications in the treatment of other psychiatric disorders. For example, antidepressants may be

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