By Adjunct Clinical Associate Professor Sathya Rao, Director, Spectrum, Personality Disorder Service for Victoria
Borderline Personality Disorder is a serious and a complex psychiatric illness. The prevalence of BPD in Australian community is around 1-4%. Therefore there are at least 240,000 Australians with significant BPD needing urgent care. With one in five psychiatric patients having BPD, it is common in mental health clinical practice, occurring in at least 10% of psychiatry outpatients and 20% of psychiatry inpatients. Within the primary care sector the prevalence rates are reported to be four fold higher than in the general community.
BPD usually emerges during adolescence (Chanen 2009). National Health and Medical Research Council (NHMRC) Guidelines for management of BPD (2012) suggests that BPD can be diagnosed from the age of 12. A recent report (Beatson et al 2016) has highlighted that BPD is also evident in older people who are more than 65 years of age. BPD impacts both men and women, although women are more often diagnosed with BPD in clinical settings.
People who experience BPD also have high levels of co-existing mental health problems (such as depression, PTSD, drug and alcohol use and eating disorders). People with BPD experience significant disability and have a poor quality of life. They are often unemployed. About 40% of people with BPD are reported to live in dysfunctional relationships. About 85% of people with BPD self-injure and 10% of people with BPD will die by suicide. Overall, people with BPD have high rates of mortality and morbidity. People with BPD as such have miserable and painful lives when their illness is active.
BPD causes significant distress to patients and their families and friends. Clinicians working with BPD also experience distress.
Unfortunately, BPD is also one of the most misunderstood and stigmatized of all psychiatric disorders. The Australian mental health workforce is poorly trained in the treatment of BPD and as a consequence regrettably the mental health workforces also tend to contribute to perpetuation of stigma and discrimination. BPD patients compete with other patients for mental health resources and are often left behind or excluded. Most BPD patients do not receive evidence based treatments.
In spite of the fact that the plight of people with BPD is quite confronting, we do not have a national strategy for addressing their unmet treatment needs. The NHMRC developed comprehensive and a world class clinical practice guidelines for BPD in 2012. However the implementation of the guidelines in the health sector has been minimal and disappointing.
On a positive note, plenty of good research has been done in the last two and a half decades in the field of BPD. The diagnosis of BPD is now well established. Brain mechanisms that are involved in the regulation of emotions in BPD are much better understood. It is now clear that BPD is an eminently treatable disorder and several effective evidence based psychotherapy treatments are available. It is also well documented that most persons with BPD achieve symptomatic recovery. Only a few people with BPD require lifelong treatment. A 16 year follow up study (Zanarini 2012) of BPD showed that up to 99% of patients achieved symptomatic remission for a 2 year period and 78% for an 8 year period. The study also reported a very low rate of relapse of BPD after achieving a period of symptom remission.
Unfortunately there are no medications to date that are helpful and specifically indicated or patented for BPD. However there are several well established evidence based effective psychological treatments for BPD.
Overall the therapeutic nihilism of the past has been replaced with hope and optimism, at least for those who work in specialist centres and amongst the scientific community.
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