example case study for borderline personality disorder

• Personality

The Borderline Personality: A Clinical Example

Alternately idealizing and devaluing leads to failure for borderlines..

Posted March 29, 2011

In Borderline Personality Disorder: Early Development I described how the young child must integrate multiple images (self and object representations) into a coherent, unitary, relatively consistent and stable sense of himself and the important people (objects) in his life. The person who suffers from Borderline Personality disorder has a greater than usual vulnerability to a regressive (re)splitting of his objects and himself when under stress . A clinical example follows:

Ms. S was an attractive, very bright young woman who entered into an intensive Psychotherapy to deal with issues related to her chronic insecurity and unhappiness and her tendency to get involved with unsuitable and disappointing men. Early on a pattern became apparent. She tended to heavily idealize new men she met, as long as they met certain threshold criteria (particularly in terms of their looks, intelligence , and job prospects.) For the first month or two of dating , the new relationship would be all I heard about in her sessions. Nothing else mattered in her life and all efforts to engage her in reflection about the man in question (about whom she often offered very early signs that all was not as rosy as she believed) were met with an angry accusation that I didn't want her to be happy. In fact, she would continue, this man was the answer to all her problems and I didn't want it to work out because if it did, she wouldn't need my help anymore and I wouldn't get her money!

[I might add that she was paying a very low fee at the time, and she knew, from previous therapy and from friends, that she was paying a very low fee.]

She would fantasize about marriage and their future together for several sessions and then, without any apparent warning, he would disappear from her sessions. Upon my inquiry, she would mention that she had stopped seeing him because he was a loser.

Her ability to explore what had happened was very limited for quite a while but eventually we were able to understand what typically happened.

After several iterations, the pattern repeated: my patient met the "perfect man."

He was extremely talented and very good looking; he was quite well known in his field. In addition, he was as excited by her as she was by him. She blandly mentioned that, though he (and she) were both in their 30s, he still lived with his mother. Further, until he met her (so he told her) he had only dated women younger than 21.

Either of these facts, on their own, would be sufficient to at least raise questions about whether this man had the requisite emotional health and maturity for a long term relationship. Furthermore, because I was quite aware of her tendency to use important others as "self objects" (ie, as means for stabilizing a positive sense of herself; see below) I had some reason to expect he had a similar level of self-pathology. In such cases, as soon as the important other disappoints, they lose their value as an external buttress for the damaged person's self-esteem . Such people, which includes but is not limited to Narcissistic and Borderline characters, tend to "split" objects into all-good and all-bad. When an all-good object fails them, the person's rage at the disappointment and sense of shame causes the object to shift to become all-bad. Usually the relationship ends at that point. (This is one of the difficulties in conducting therapy with such people; disappointments are inevitable in every human interaction and maintaining the therapy in the face of such reactions is a difficult technical problem.)

[A self-object is an idealized object which a person uses as a "perfect" mirror. The dynamic is as follows: if a "perfect" person loves me, then by reflection off of their image, I must be perfect, too. This is one way that Narcissists and Borderlines attempt to stabilize their sense of themselves and protect themselves from feeling defective and damaged.]

For the purposes of this discussion, the salient aspect is that once the inevitable disappointment occurred, a transformation in my patient's emotional life took place that was a marvel to witness. Not only was he a terrible disappointment and a loser but he had always been a terrible disappointment and a loser. She insisted she had always known that he was inappropriate ("how could someone who still lives with his mother at 35 be much of a man") but had chosen to overlook his shortcomings, knowing it wouldn't last, because she had enjoyed dating him, and psychologically needed him to be her perfect lover.

It is important to recognize that not only did the ex-boyfriend become, in the present and the past, a different person, but she experienced herself as a different person as well. She had been deeply in love, ready to make the move into marriage and family; an entire new aspect of her life was about to unfold. Her future husband was flawless and so was she. In fact, he needed to be imagined as perfect in order for her to feel that she was perfect. When he failed her (by dating an 18 year old while they were supposedly in love) the disappointment meant that if he remained perfect, she would have to accept that she was deeply flawed; otherwise why would he reject her? Her rage would not tolerate such an outcome (which would have led to a serious depression ) so she devalued him; he became worthless and she maintained her protective sense of herself as without flaws. In order to protect herself from knowing of her obviously flawed choice, she had to change her memory to "remember" that he had always been a poor choice.

It took many years of work before she was able to tolerate recognizing her own imperfections and she had to negotiate significant depression and rage to arrive at some comfort with a more accurate picture of herself, flaws and all.

In the next installment I plan on discussing some of the various treatment options at our disposal for helping people with Borderline Personality Disorder.

[A slightly different version of this, with some additional material, was originally posted at ShrinkWrapped in April, 2007 as Retrospective Falsification .]

Perry R. Branson, M.D., is a psychiatrist in New York.

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12 Borderline Personality Disorder

• Published: February 2013
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Chapter 12 covers Borderline Personality Disorder (BPD), and includes definition and history of the condition, description and background of dialectical behavior therapy (DBT) used to treatm BPD, background history of the patient, assessment strategy, case formulation and treatment approach, course of treatment, treatment transfer specific to this case, relapse prevention, avoiding common mistakes in therapy, and case conclusions.

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Borderline Personality Disorder: Case Study

Lukenotes, summer 2021.

Sr. Rita was angry and frustrated after being asked to step down from a third committee in two years. She was informed that she was being removed from the welcoming committee because she was not very friendly or hospitable and might deter potential members from joining the community. Sr. Rita huffed off in disbelief and worked to control her rising anger. She marched to mother superior’s office prepared to plead her case.

How did Sr. Rita get here? Why has she been removed from yet another committee?

Sr. Rita struggles with fear of rejection and abandonment and insecurity about not being good enough. She has a history of impulsivity, aggression, and self-injurious behavior. At age sixteen, after an intense argument with her best friend, Sr. Rita attempted suicide by ingesting a bottle of pills. She briefly engaged in therapy but did not believe there was anything she needed to work on.

Sr. Rita has been in religious life for 22 years. As a child, she did not consider pursuing a religious vocation. In college Sr. Rita joined a Catholic youth group, volunteered at the local monastery, and sought guidance from a family friend in a religious community. Immediately following college, she joined a community in the Midwest and started her religious journey. Sr. Rita is happy with her decision and shows her love for religious life by getting involved, planning activities for the community and neighborhood, and suggesting ways to improve community living.

Initially, Sr. Rita embraced the quiet time for prayer and found the structure and routine helpful. More recently, however, she balks at not being able to coordinate her own schedule and does not always participate in community activities. She does not enjoy sharing a kitchen or car with other sisters and often fails to adhere to established rules. Some community members are afraid of Sr. Rita and shared their concerns with the superior. Sr. Rita seems unaware of her impact on the other sisters and becomes irate when concerns are expressed about her behavior. She was encouraged to utilize additional support and reluctantly agreed to meet with a Saint Luke Institute therapist.

Sr. Rita felt scared, yet relieved, when she received the diagnosis of borderline personality disorder. The diagnosis helped explain years of chaotic behavior. Although therapy was challenging, every day Sr. Rita gained new insight and skills. Most notably, through her work at Saint Luke Institute, Sr. Rita finally opened up about her traumatic upbringing. Sr. Rita lost her father in a car accident when she was eight years old. Her mother battled depression and stopped taking care of Sr. Rita and her siblings. One day Sr. Rita’s mother dropped her siblings and she off at church and never came back to pick them up. Sr. Rita still remembers the feeling and the moment when she realized her mother was not coming back to get them.

Sr. Rita’s traumatic and unstable childhood shaped the way she navigated the world. She was sensitive to any hint of abandonment due to feeling discarded by both of her parents. She existed in a state of hypervigilance as a means of self-protection and shut down her feelings to avoid reliving the terrible experiences from growing up in the foster care system.

With the support of trauma therapy, group counseling, and psychoeducation workshops, Sr. Rita slowly recognized how much pain she carried around and masked all those years. She replaced unhealthy coping skills with mindfulness and distress tolerance skills and identified triggers to create a process for difficult moments. Sr. Rita still struggles with managing expectations and receiving feedback, but continues to work with her therapist to better understand her behavior. Sr. Rita also creates more balance in her life by exercising, setting boundaries, and building time in her schedule for self-care.

As Sr. Rita continues the therapy work and practices therapeutic tools, her style of relating to others will improve, she will respond instead of reacting, and she will have greater control over her thoughts and feelings. Every day Sr. Rita reminds herself that healing is a process and a lifelong journey.

For confidentiality, reasons, names, identifying data, and other details of treatment have been altered.

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5 Keys to Living With Borderline Personality Disorder

BPD can affect many aspects of your life, but there's hope

Amy Morin, LCSW, is a psychotherapist and international bestselling author. Her books, including "13 Things Mentally Strong People Don't Do," have been translated into more than 40 languages. Her TEDx talk,  "The Secret of Becoming Mentally Strong," is one of the most viewed talks of all time.

Image Source / Getty Images

• Understanding Symptoms
• Living With BPD
• How it Affects Your Life
• Recognizing Your Triggers
• Next in Borderline Personality Disorder Guide Borderline Personality Disorder in Teens

Living with borderline personality disorder (BPD) poses some challenges. Intense emotional pain and feelings of emptiness, desperation, anger, hopelessness, and loneliness are common. These symptoms can affect every part of your life. Despite the challenges, many people with BPD learn how to cope with the symptoms so they can live fulfilling lives.

At a Glance

Borderline personality disorder can affect many areas of your life, including relationships, work, and personal safety. You can make living with these symptoms more manageable by:

• Seeking help from an experienced mental health professional
• Having a safety plan in place
• Getting support from loved ones
• Caring for your physical and mental health
• Learning more about your condition

Let's explore some of the ways that you can cope, live, and thrive with BPD.

Understanding the Symptoms of BPD

Some of the key symptoms of borderline personality that may affect how you function in different areas of your life include:

• Intense mood swings
• Distorted, unstable self-image
• Idealizing or devaluing people
• Unstable relationships
• Impulsivity
• Chronic feelings of emptiness
• Inappropriate anger
• Attempts to avoid real or perceived abandonment
• Dissociation
• Self-harming or suicidal thinking

Living With BPD Symptoms

People with BPD do not have to resign themselves to a life of emotional pain. There are a number of things you can do to help you cope with the symptoms .

BPD is a very serious disorder. The intense experiences associated with BPD are not something that anyone should face alone. Fortunately, there are several effective treatments for BPD.

Treatments for BPD typically involve psychotherapy. Types of therapy that may be used include dialectical behavior therapy (DBT) , mentalization-based treatment (MBT) , and group therapy .

Medications may be prescribed to help treat specific symptoms of borderline personality disorder, such as mood swings and depression. BPD medications that may be prescribed are antidepressants, anti-anxiety drugs, mood stabilizers, and antipsychotics.

Finding a mental health professional you feel comfortable with and discussing your symptoms and treatment options is one of the most important steps you can take for your health.

Get Help Now

We've tried, tested, and written unbiased reviews of the best online therapy programs including Talkspace, BetterHelp, and ReGain. Find out which option is the best for you.

Borderline Personality Disorder Discussion Guide

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Have a Safety Plan

BPD causes very painful emotions and, as a result, it is not uncommon for mental health emergencies (for example, active suicidality) to arise. For this reason, it is critical for you to have a safety plan in place before a crisis happens.

If you are in danger of harming yourself or others, what will you do? Can you call 911? Is there a hospital nearby with an emergency room that you can go to? If you have a therapist, counselor, psychiatrist, or social worker, discuss this plan with them. 

If you are having suicidal thoughts, contact the  National Suicide Prevention Lifeline  at  988  for support and assistance from a trained counselor. If you or a loved one are in immediate danger, call 911.

For more mental health resources, see our  National Helpline Database .

Get Support

Having the support of your family, friends, or partner can be a big help. But, not everyone has someone to turn to when things get difficult. You may need to find ways to connect with others and to build a support network for yourself.

BPD is not an uncommon disorder; it occurs in about 1.4% of the population. That means that there are roughly 4 million people with BPD in the U.S. alone. Many of those people are looking for support, just like you.

Take Care of Yourself

It is important that people with BPD take good care of themselves. Healthy self-care can help reduce emotional pain, increase positive emotions, and reduce the emotional ups and downs you may experience.

Some of the most basic things like eating nutritious and regular meals, practicing good sleep hygiene, and getting regular exercise will help tremendously. Also, try to take time for relaxation and stress-reduction and schedule enjoyable activities into your daily life.  

When it comes to your mental health, knowledge is power. Educate yourself about the symptoms, causes, and treatments of BPD. Learn about ways to manage your symptoms. Share what you have learned with the people in your life who are affected by it.

Recognizing the Impact of BPD on Your Life

Part of living with borderline personality disorder is recognizing some of the ways that symptoms of the condition can impact your life. It can take a toll on your relationships and work, but symptoms can also physical health and safety. Being aware of these effects can help you better recognize the importance of treatment, support, and self-care.

Your Relationships and BPD

BPD can have a major impact on your relationships. In fact, having difficulties in relationships is one of the primary symptoms of BPD. People with BPD can have many arguments and conflicts with loved ones or a lot of relationships that repeatedly break up.

The way that you feel about your family, friends, or partner can change dramatically from day-to-day or hour-to-hour. These patterns can be very difficult both for the person with BPD and those who care about them.

Your Work and BPD

Work , school, or other productive pursuits can give us a sense of purpose in life. Unfortunately, BPD can interfere with your success at work or school.

Since BPD has such an impact on relationships, people with BPD may find themselves in trouble with co-workers, bosses, teachers, or other authority figures. The intense emotional changes may also impact work or school; you may have to be absent more often due to emotional concerns or hospitalization.

Some of the symptoms of BPD like  dissociation  can also interfere with concentration, which may make completing tasks very difficult.

Your Physical Health and BPD

Unfortunately, BPD can also have a major impact on your physical health. BPD is associated with a variety of conditions, including:

• Chronic pain disorders such as fibromyalgia and chronic fatigue syndrome
• Heart disease

BPD is also associated with less-than-healthy lifestyle choices such as smoking, alcohol use, and lack of regular exercise.

BPD and the Law

Some of the behaviors associated with BPD can lead to legal problems as well. The anger associated with it can lead to aggression (e.g., assaulting others, throwing objects, or acting out against others' personal property).

Impulsive behaviors, such as driving recklessly, misusing substances, shoplifting, or engaging in other illegal acts, can also lead to trouble.

Learn Your BPD Triggers

It can also be easier to live with borderline personality disorder if you learn to recognize and manage your triggers. BPD triggers are situations that set off symptoms. Common triggers for people with BPD include:

• Feelings of rejection or abandonment in relationships
• Memories of past traumas
• Being criticized
• The loss of a job or relationship
• Relationship conflicts
• Intrusive thoughts
• Isolation or boredom

Therapy is an essential part of learning how to manage these triggers. While you cannot control every single situation that might trigger your BPD symptoms, you can work on developing coping skills that will help you manage them more effectively.

Self-help strategies can also be beneficial. For example, you might try meditation apps to help you practice mindfulness techniques to build greater self-awareness and self-regulation skills. Finding ways to distract yourself when you're struggling with intense emotions can also be helpful.

Keep in Mind

It is important to remember that while the symptoms of borderline personality disorder can have serious effects on your life, the condition is highly treatable. Seeking help, adhering to your treatment plan, and getting support from your loved ones can make living with BPD much easier. Through therapy, you can work on new coping skills, such as changing negative thought patterns, improving interpersonal relationships , and better tolerating distress .

National Institute of Mental Health. Borderline personality disorder .

Choi-Kain LW, Finch EF, Masland SR, Jenkins JA, Unruh BT.  What works in the treatment of borderline personality disorder .  Curr Behav Neurosci Rep . 2017;4(1):21–30. doi:10.1007/s40473-017-0103-z

Choi-Kain LW, Finch EF, Masland SR, Jenkins JA, Unruh BT. What works in the treatment of borderline personality disorder . Curr Behav Neurosci Rep. 2017;4(1):21-30. doi:10.1007/s40473-017-0103-z

National Institute of Mental Health. Personality disorders .

Brüne M. Borderline personality disorder: Why 'fast and furious'? . Evol Med Public Health. 2016;2016(1):52-66. doi:10.1093/emph/eow002

Navarro-Gómez S, Frías Á, Palma C. Romantic relationships of people with borderline personality: A narrative review . Psychopathology . 2017;50(3):175-187. doi:10.1159/000474950

Elliott B, Konet RJ. The connections place: A job preparedness program for individuals with borderline personality disorder . Community Ment Health J. 2014;50(1):41-5. doi:10.1007/s10597-013-9601-y

Korzekwa MI, Dell PF, Pain C. Dissociation and borderline personality disorder: An update for clinicians . Curr Psychiatry Rep . 2009;11(1):82-8.

Cavicchioli M, Barone L, Fiore D, et al. Emotion regulation, physical diseases, and borderline personality disorders: conceptual and clinical considerations . Front Psychol . 2021;12:567671. doi:10.3389/fpsyg.2021.567671

Sansone RA, Sansone LA. Chronic pain syndromes and borderline personality . Innov Clin Neurosci . 2012;9(1):10-4.

Lee JS. Borderline personality disorder in the courtroom .  Psychiatr Psychol Law . 2020;28(2):206-217. doi:10.1080/13218719.2020.1767718

Miskewicz K, Fleeson W, Arnold EM, Law MK, Mneimne M, Furr RM. A contingency-oriented approach to understanding borderline personality disorder: Situational triggers and symptoms .  J Pers Disord . 2015;29(4):486-502. doi:10.1521/pedi.2015.29.4.486

By Kristalyn Salters-Pedneault, PhD  Kristalyn Salters-Pedneault, PhD, is a clinical psychologist and associate professor of psychology at Eastern Connecticut State University.

The Borderline Patient - A Case Study

What's it like living with Borderline Personality Disorder? Read therapy notes of female diagnosed with Borderline Personality Disorder, BPD.

• Watch the video on Therapy notes of a Borderline Patient  

Notes of first therapy session with T. Dal, female, 26, diagnosed with Borderline Personality Disorder (BPD)

Dal is an attractive young woman but seems to be unable to maintain a stable sense of self-worth and self-esteem. Her confidence in her ability to "hold on to men" is at a low ebb, having just parted ways with "the love of her life". In the last year alone she confesses to having had six "serious relationships".

Why did they end? "Irreconcilable differences". The commencement of each affair was "a dream come true" and the men were all and one "Prince Charming". But then she invariably found herself in the stormy throes of violent fights over seeming trifles. She tried to "hang on there", but the more she invested in the relationships, the more distant and "vicious" her partners became. Finally, they abandoned her, claiming that they are being "suffocated by her clinging and drama queen antics."

Is she truly a drama queen?

She shrugs and then becomes visibly irritated, her speech slurred and her posture almost violent:

"No one f***s with me. I stand my ground, you get my meaning?" She admits that she physically assaulted three of her last six paramours, hurled things at them, and, amidst uncontrollable rage attacks and temper tantrums, even threatened to kill them. What made her so angry? She can't remember now, but it must have been something really big because, by nature, she is calm and composed.

As she recounts these sad exploits, she alternates between boastful swagger and self-chastising, biting criticism of her own traits and conduct. Her affect swings wildly, in the confines of a single therapy session, between exuberant and fantastic optimism and unbridled gloom.

One minute she can conquer the world, careless and "free at last" ("It's their loss. I would have made the perfect wife had they known how to treat me right") - the next instant, she hyperventilates with unsuppressed anxiety, bordering on a panic attack ("I am not getting younger, you know - who would want me when I am forty and penniless?")

Dal likes to "live dangerously, on the edge." She does drugs occasionally - "not a habit, just for recreation", she assures me. She is a shopaholic and often finds herself mired in debts. She went through three personal bankruptcies in her short life and blames the credit card companies for doling out their wares "like so many pushers." She also binges on food, especially when she is stressed or depressed which seems to occur quite often.

She sought therapy because she is having intrusive thoughts about killing herself. Her suicidal ideation often manifests in minor acts of self-injury and self-mutilation (she shows me a pair of pale, patched wrists, more scratched than slashed). Prior to such self-destructive acts, she sometimes hears derisive and contemptuous voices but she know that "they are not real", just reactions to the stress of being the target of persecution and vilification by her former mates.

This article appears in my book, "Malignant Self Love - Narcissism Revisited"

next: Adolescent Narcissist ~ back to: Case Studies: Table of Contents

APA Reference Vaknin, S. (2009, October 1). The Borderline Patient - A Case Study, HealthyPlace. Retrieved on 2024, May 28 from https://www.healthyplace.com/personality-disorders/malignant-self-love/borderline-patient-a-case-study

Medically reviewed by Harry Croft, MD

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2024 HealthyPlace Inc. All Rights Reserved. Site last updated May 28, 2024

REVIEW article

Twenty years of research on borderline personality disorder: a scientometric analysis of hotspots, bursts, and research trends.

• 1 Department of Psychology, School of Humanities and Social Sciences, Anhui Agricultural University, Hefei, China
• 2 College of Computing & Informatics, Drexel University, Philadelphia, PA, United States
• 3 Department of Psychology, School of Education, China University of Geosciences, Wuhan, China
• 4 Department of Information Management, Anhui Vocational College of Police Officers, Hefei, China

Borderline personality disorder (BPD), a complex and severe psychiatric disorder, has become a topic of considerable interest to current researchers due to its high incidence and severity of consequences. There is a lack of a bibliometric analysis to visualize the history and developmental trends of researches in BPD. We retrieved 7919 relevant publications on the Web of Science platform and analyzed them using software CiteSpace (6.2.R4). The results showed that there has been an overall upward trend in research interest in BPD over the past two decades. Current research trends in BPD include neuroimaging, biological mechanisms, and cognitive, behavioral, and pathological studies. Recent trends have been identified as “prevention and early intervention”, “non-pharmacological treatment” and “pathogenesis”. The results are like a reference program that will help determine future research directions and priorities.

1 Introduction

Borderline personality disorder (BPD) is a complex and severe psychiatric disorder characterized by mood dysregulation, interpersonal instability, self-image disturbance, and markedly impulsive behavior (e.g., aggression, self-injury, suicide) ( 1 ). In addition, people with BPD may have chronic, frequent, random feelings of emptiness, fear, and so on. These symptoms often lead them to use unhealthy coping mechanisms in response to negative emotions, such as alcohol abuse ( 2 ). BPD has a long course, which makes treatment difficult and may have a negative impact on patients’ quality of life ( 3 ). Due to its clinical challenge, BPD is by far the most studied category of personality disorder ( 4 ). This disorder is present in 1−3% of the general population as well as in 10% of outpatients, 15−20% of inpatients, and 30−60% of patients with a diagnosed personality disorder, and has a suicide rate of up to 10% ( 5 , 6 ). Families of individuals with serious mental illness often experience distress, and those with relatives diagnosed with BPD tend to carry a heavier burden compared to other mental illnesses ( 7 , 8 ). As early as the 20th century, scholars began describing BPD and summarizing its symptoms. However, there was some debate regarding the precise definition of BPD.

In the past few decades, the research community has made remarkable progress in the study of BPD, equipping us with a wider range of perspectives and tools for understanding this intricate condition. However, numerous challenges still remain to be tackled by researchers. Diagnosing BPD is inherently challenging and often more difficult than anticipated. The symptoms of BPD are complex, diverse, and often overlap with those of other mental health conditions. For example, individuals with BPD may experience extreme mood swings similar to those observed in individuals with bipolar disorder ( 9 ); At the same time, they may also be entrenched in long-term depression, making it easy for doctors to initially misdiagnose them with depression ( 10 ). Because these symptoms overlap and interfere with each other, doctors often face the risk of misdiagnosing or overlooking the condition during initial diagnosis. Therefore, researchers are working to develop more accurate and comprehensive diagnostic tools and methods.

According to the “Neuro-behavioral Model” proposed by Lieb ( 1 ), the process of BPD formation is very complex and is determined by the interaction of several factors. The interaction between different factors can be complex and dynamic. Genetic factors and adverse childhood experiences may contribute to emotional disorders and impulsivity, leading to dysfunctional behaviors and inner conflicts. These, in turn, can reinforce emotional dysregulation and impulsivity, exacerbating the preexisting conditions. Genetic factors are an important factor in the development of BPD ( 11 ). Psychosocial factors, including adverse childhood experiences, have also been strongly associated with the development of BPD ( 12 ). Emotional instability and impulsive behavior are even more common in patients with BPD ( 13 ). The current study is based on the “Neuro-behavioral Model” and conducts a literature review of previous scientific research on BPD through bibliometric analysis to reorganize the influencing factors. Through large-sample data analysis, the association between BPD and other diseases is explored, which contributes to further refining this theory’s explanation of the common neurobiological mechanisms among various mental illnesses.

It is worth noting that with the development of BPD, some scholars have conducted bibliometrics studies on BPD to provide insights into this academic field. To date, the current study has identified two published bibliometric studies on the field: One is Ilaria M. A. Benzi and her colleagues’ 2020 metrological analysis of the literature in the field of BPD pathology for the period 1985−2020 ( 14 ). The other is a bibliometric analysis by Taylor Reis and his colleagues of the growth and development of research on personality disorders between 1980 and 2019 ( 15 ). Ilaria M. A. Benzi and her colleagues integrated and sorted out the research results of borderline personality pathology, and revealed the research results and development stages in this field through the method of network and cluster analysis. The results of the study clearly demonstrate that the United States and European countries are the main contributors, that institutional citations are more consistent, and that BPD research is well developed in psychiatry and psychology. At the same time, the development of research in borderline personality pathology is demonstrated from the initial development of the construct, through studies of treatment effects, to the results of longitudinal studies. Taylor Reis and his colleagues used a time series autoregressive moving average model to analyze publishing trends for different personality disorders to reveal their historical development patterns, and projected the number of publications for the period 2024 to 2029. The study finds a trend towards diversity in the research and development of personality disorders, with differences in publication rates for different types of personality disorders, and summarizes the reasons that influence these differences. This may ultimately determine which personality disorders will remain in future psychiatric classifications. These studies have provided valuable insights into the evolution of BPD, focusing primarily on its pathology or a broader personality disorder perspective. While basic bibliometric analyses of these studies have been conducted, there is a need for more in-depth investigations of specific trends in the evolution of BPD and a clearer delineation of emerging research foci. Therefore, in order to enhance the current study, this study extends the analysis to 2022 and utilizes a comprehensive structural variation analysis of the literature using scientometric methods. Building on previous bibliometric studies, we expect to provide new insights and additions to research in this area. At the same time, the research trends and hot topics in the field of BPD are further explored. In addition, several cocitation-based analyses are also carried out in order to better understand citation performance.

2.1 Objectives

One of our goals was to understand the current status and progress of researches on BPD, and to summarize the latest developments and research findings in BPD, such as new treatment methods and disease mechanisms. Through the intuitive presentation of knowledge graphs and other images or data, we aimed to provide clinical practice and research guidance for clinicians, researchers, and policymakers.

Our second goal was to help identify future research directions and priorities, and provide more scientific and systematic research guidance for researchers. For example, by identifying hotspots and associations in certain research areas, we can determine the fields and issues that require further investigations, thus providing clearer directions and focus for researches. Additionally, through bibliometric analysis, we can provide researchers with more targeted and practical research strategies and methods, improving research efficiency and the quality of research outcomes.

2.2 Search strategy and data collection

The selection of appropriate methods and tools in the process of analyzing research information is crucial. Web of Science (WOS) is a popular database for bibliometric analysis that includes numerous respectable and high-impact academic journals. In addition, data information, such as references and citations, is more extensive than other academic databases ( 16 ). Data collection took place on the date of May 10, 2023. The search strategy included the following: topic=“Neuro-behavioral Model” or “borderline characteristics” or “borderline etiology” or “borderline personality disorder”, database selected=WOS Core Collection, time span=2003−2022, index=Science Citation Index Expanded (SCI-EXPENDED) and Social Sciences Citation Index (SSCI). The “Neuro-behavioral Model” serves as a theoretical framework that is useful for explaining the development and pathophysiology of BPD; “borderline characteristics” can describe the related symptoms and features of BPD; “borderline etiology” helps to understand the factors that contribute to the development of BPD; “borderline personality disorder” is the most commonly used terms in relevant research. Using these as keywords in title searches can help researchers find researches related to BPD more accurately, facilitating deeper understanding of the characteristics, pathophysiology, etiology, and other aspects of BPD. In the current study, we focused only on two types of literature: articles and review articles, and limited the language to English. After removing all literature unrelated to BPD, a total of 7919 records met the criteria. They were exported in record and reference formats, and saved in plain text file format.

2.3 Data analysis and tools

Bibliometrics was first proposed by Alan Pritchard in 1969, as a method that combines data visualization to analyze publications statistically and quantitatively in specific fields and journals ( 17 ). Bibliometric analysis is a good way to analyze the trend of knowledge structure and research activities in scientific fields over time, and has been widely used in various fields since it was first used ( 18 ). Scientometrics is the application of bibliometrics in scientific fields, and it focuses on the quantitative characteristics and features of science and scientific researches ( 19 ). Compared to traditional literature review studies, visualized knowledge graphs can accurately identify key articles from many publications, comprehensively and systematically combing existing research in a field ( 20 ).

Currently, two important academic indicators are included in research. The impact factor (IF) is used as an indicator of a publication’s impact to assess the quality and importance of the publication ( 21 ). However, some researchers believe that IF has defects such as inaccuracy and misuse ( 22 ). Although many researchers have proposed to replace the impact factor with other indicators, IF is still one of the most effective ways to measure the impact of a journal ( 23 ). The IF published in the 2021 Journal Citation Reports were used. Another indicator is the H-index, which is an important measure of a scholar’s academic achievements. Some researchers consider it as a correction or supplement to the traditional IF ( 24 ).

All data were imported into CiteSpace (6.2.R4) and Scimago Graphica (1.0.30) for analysis. CiteSpace was used to obtain collaboration networks and impact networks. Scimago Graphica was used to construct a network graph of country collaboration. CiteSpace is a Java-based software developed in the context of scientometrics and data visualization ( 25 ). It combines scientific knowledge mapping with bibliometric analysis to determine the progress and current research frontiers in a particular field, as well as predict the development trends in that field ( 26 ). Scimago Graphica is a no-code tool. It can not only perform visualization analysis on communication data but also explore exploratory data ( 27 ). Currently, it is used for visual analysis of national cooperation relationships, displaying the geographic distribution of countries and publication trends.

3.1 Analysis of publication outputs, and growth trend prediction

Annual publications can provide an overview of the evolution of a research area and its progress ( 28 ). We retrieved 7919 articles from the WOS database on BPD between 2003 and 2022, including 6834 research articles and 1085 reviews ( Figure 1 ). As of the search date, these articles had received a total of 289,958 citations, equating to an average of 14,498 citations per year. Over the past two decades, the number of research articles published on BPD has shown a fluctuating upward trend. In addition, citations to these publications have increased significantly. A polynomial curve fit of the literature on BPD clearly indicates a strong correlation between the year of publication and the number of publications ( R 2 = 0.973). The number of research articles on BPD has indeed fluctuated and increased over the past two decades. This observation does, to some extent, indicate an upward trend, probably due to increasing interest in BPD. However, there are other factors to consider as well. For example, the accumulation of data or technological advances, government policies and corporate investment may also affect the direction of BPD research development.

Figure 1 Annual publications, citation counts, and the fitting equation for annual publications in BPD.

3.2 Analysis of co-citation references: clusters and timeline of research

Co-cited references, which are cited by multiple papers concurrently, are considered a crucial knowledge base in any given field ( 28 ). In the current study, CiteSpace clustering was utilized to identify common themes within BPD-related literature. Figure 2 presented a co-citation network of highly cited references between 2003 and 2022, comprising 1163 references. A time slice of 1 was used, with the g -index was set at k =25, which resulted in the identification of 14 clusters representing distinct research themes in BPD. The significant cluster structure is denoted by a modularity value ( Q value) of 0.7974, and the high confidence level in the clusters by an average profile value ( S value) of 0.9176.

Figure 2 Reference co-citation network with cluster visualization in BPD. Trend 1 clinical researches, sub-trend clinical characteristics includes clusters #1, #2, #4, #10, #12; biological mechanisms include clusters #3, #7; nursing treatments includes clusters #0, #8, #13. Trend 2 associations and complications includes clusters #5, #6, #9, #11, #14.

Cluster analysis is performed through CiteSpace. Related clusters are classified into the same trend based on the knowledge of related fields and whether the clusters show similar trends. At the same time, based on the analysis of time series, to identify the movement of one cluster to another. Based on the cluster map of co-cited references on BPD, several different research trends were identified. The first major research trend is clinical research on BPD, which in turn consists of three sub-trends: clinical characterization of BPD, biological mechanisms, and nursing treatment. Of the data obtained, the earliest research on the clinical characterization of BPD began in 1992 with cluster #12, “borderline personality disorder and suicidal behavior” ( S =0.979; 1992). Paul H. Soloff and his colleagues conducted a comparative study of suicide attempts between major depressives and patients with BPD. The aim of this study was to develop more effective intervention strategies for suicide prevention ( 29 ). This cluster was further developed in cluster #4, “nonsuicidal self-injury and suicide” ( S =0.96; 2004). Thomas A. Widiger and Timothy J. Trull proposed a more flexible dimension-based categorization model to overcome the previous drawbacks of personality disorder categorization ( 30 ). Next in cluster #10 “borderline personality disorder and impulsivity” ( S =0.93; 2000), Jim H. Patton and his colleagues revised the Barratt Impulsivity Scale to measure impulsivity to facilitate practical clinical research ( 31 ). Related research continues to evolve into cluster #1 “borderline personality disorder and emotions” ( S =0.87; 2007) and cluster #2 “borderline personality disorder and social cognition” ( S =0.911; 2009), researchers have focused on understanding the causal relationship between BPD traits and factors such as social environment, emotion regulation, and interpersonal evaluative bias, as well as their potential impact ( 32 , 33 ). In the sub-trend of biological mechanisms, two main clusters are involved: cluster #7 “borderline personality disorder and gene-environment interactions” ( S =0.871; 2002) and cluster #3 “borderline personality disorder and neuroimaging” ( S =0.938; 2007). In the related cluster, researchers have found a relationship between BPD and genetic and environmental factors ( 34 ). Researchers have also utilized various external techniques to explore the degree of correlation between the risk of developing BPD and its biological mechanisms, aiming to reveal the complex mechanisms that influence the emergence and development of BPD ( 35 ). In nursing treatment, cluster #8 “treatment of borderline personality disorder “ ( S =0.968; 2001), Silvio Bellino and his colleagues systematically analyzed the current publications on BPD pharmacotherapy research and summarized relevant clinical trials and findings ( 36 ). However, due to the complexity of BPD, there is still a lack of information on the exact efficacy of pharmacotherapy in BPD, and therefore pharmacotherapy remains an area of ongoing development and research. This trend continues to be developed in cluster #0 “borderline personality disorder treatment” ( S =0.887; 2006), which emphasizes the development of novel pharmacotherapies for BPD. Cluster #13 “borderline personality disorder care” ( S =0.997; 2013) mainly focuses on the comprehensive care of people with borderline personality disorder and the education of patients and families. The goal is to improve patients’ quality of life, reduce self-injury and suicidal behavior, and promote full recovery.

The second major research trend is association and comorbidity. This trend first began in cluster #9 “comorbidity and differentiation of disorders” ( S =0.946; 1999). Mary C Zanarini and his colleagues explored the comorbidity of BPD with other psychiatric disorders on Axis I ( 37 ). Cluster #14 “borderline personality disorder and psychosis” ( S =0.966; 2003) also explored symptoms associated with BPD ( 38 ). This trend continues, with researchers studying BPD research in cluster #11 “borderline personality disorder” ( S =0.935; 2004) and cluster #5 “borderline personality disorder research” ( S =0.881; 2007) ( 39 , 40 ). In addition, cluster #6 “borderline personality disorder in adolescents” ( S =0.894; 2011) points out that the focus of BPD research is increasingly shifting towards adolescents ( 41 ).

Figure 3 showed the time span and research process of the developmental evolution of these different research themes. The temporal view reveals the newest and most active clusters, namely #0 “dialectical behavior therapy”, #1 “daily life”, and #2 “social cognition”, which have been consistently researched for almost a decade. Cluster #0 “dialectical behavior therapy” has the largest number and the longest duration, lasting almost 10 years. Similarly, this article by Rebekah Bradley and Drew Westen on understanding the psychodynamic mechanisms of BPD from the perspective of developmental psychopathology has the largest node ( 34 ).

Figure 3 Reference co-citation network with timeline visualization in BPD.

3.3 Most cited papers

The top 10 highly cited papers on BPD research were presented in Table 1 . The most cited paper, by Marsha M. Linehan and colleagues, focus on the treatment of suicidal behavior in BPD ( 42 ). The transition between suicidal and non-suicidal self-injurious behavior in individuals with BPD has attracted researchers’s attention, mainly in cluster #4 “nonsuicidal self-injury and suicide” ( 52 ). The second is the experimental study by Josephine Giesen-Bloo and his colleagues on the psychotherapy of BPD ( 43 ). In cluster #0 “borderline personality disorder treatment” and Cluster #8 “treatment of borderline personality disorder”, researchers strive to find non-pharmacological approaches with comparable or enhanced therapeutic effects. This was followed by Sheila E. Crowell and her colleagues’ study of the biological developmental patterns of BPD ( 44 ). Research on the biological mechanisms and other contributing factors of BPD, including #7 “borderline personality disorder and gene-environment interactions” have been closely associated with the development of BPD ( 53 ).

Table 1 Top 10 cited references that published BPD researches.

3.4 Burst analysis and transformative papers

The “citation explosion” reflects the changing research focus of a field over time and indicates that certain literature has been frequently cited over time. Figure 4 showed the top 9 references with the highest citation intensity. The three papers with the greatest intensity of outbursts during the period 2003−2022 are: The first is the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders ( 54 ). In the second article, Vijay A. Mittal and Elaine F. Walker discuss key issues surrounding dyspraxia, tics, and psychosis that are likely to appear in an upcoming edition of the Diagnostic and Statistical Manual of Mental Disorders ( 39 ). In addition, Ioana A. Cristea and colleagues conducted a systematic review and meta-analysis to evaluate the effectiveness of psychotherapy for borderline personality disorder ( 55 ).

Figure 4 References with the strongest occurrence burst on BPD researches. Article titles correspond from top to bottom: Mittal VA et al. Diagnostic and Statistical Manuel of Mental Disorders; Linehan MM et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder; Giesen-Bloo J et al. Outpatient psychotherapy for borderline personality disorder: Randomized trial of schema-focused therapy vs transference-focused psychotherapy; Clarkin Jf et al. Evaluating three treatments for borderline personality disorder: A multiwave study; Grant BF et al. Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions; Leichsenring F et al. Borderline personality disorder; American Psychiatric Association, DSM-5 Task Force. Diagnostic and statistical manual of mental disorders: DSM-5™ (5th ed.); Cristea IA et al. Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis; Gunderson JG et al. Borderline personality disorder.

Structural variation analysis can be understood as a method of measuring and studying structural changes in the field, mainly reflecting the betweenness centrality and sigma of the references. The high centrality of the reference plays an important role in the connection between the preceding and following references and may help to identify critical points of transformation, or intellectual turning points. Sigma values, on the other hand, are used to measure the novelty of a study, combining a combination of citation burst and structural centrality ( 56 ). Table 2 listed the top 10 structural change references that can be considered as landmark studies connecting different clusters. The top three articles with high centrality are the studies conducted by Milton Z. Brown and his colleagues on the reasons for suicide attempts and non-suicidal self-injury in BPD women ( 57 ); the research by Nelson H. Donegan and his colleagues on the impact of amygdala on emotional dysregulation in BPD patients ( 59 ); and the fMRI study by Sabine C. Herpertz and her colleagues on abnormal amygdala function in BPD patients ( 61 ). In addition, publications with high sigma values are listed. They are Larry J. Siever and Kenneth L. Davis on psychobiological perspectives on personality disorders ( 58 ); Ludger Tebartz van Elst and his colleagues on abnormalities in frontolimbic brain functioning ( 60 ); and Marsha M. Linehan on therapeutic approaches in BPD research ( 62 ). These works are recognized as having transformative potential and may generate some new ideas.

Table 2 Top 7 betweenness centrality and stigma references.

3.5 Analysis of authors and co-authors

Figure 5 showed a map of the co-authorship network over the last two decades. In total, 10 different clusters are shown, each of which gathers co-authors around the same research topic. For example, the main co-authors of cluster #0 “remission” are Christian Schmahl, Martin Bohus, Sabine C. Herpertz, Timothy J. Trull and Stefan Roepke. More recently, the three authors with the greatest bursts of research have been Mary C. Zanarini, Erik Simonsen, and Carla Sharp. As shown in Table 3 , the three most published authors are Martin Bohus (145 publications; 1.83%; H-index=61), Mary C. Zanarini (144 publications; 1.82%; H-index=80) and Christian Schmahl (142 publications; 1.79%; H-index=54).

Figure 5 Top 10 clusters of coauthors in BPD (2003–2023). Selection Criteria: Top 10 per slice. Clusters labeled by keywords. The five authors with the highest number of publications in each cluster were labeled.

Table 3 Top 10 authors that published BPD researches.

3.6 Analysis of cooperation networks across countries

The top 10 countries in terms of number of publications in the BPD are added in Table 4 . With 3,440 published papers, or nearly 43% of all BPD research papers, the United States is the leading contributor to BPD research. This is followed by Germany (1196 publications; 15.10%) and the United Kingdom (1020 publications; 9.32%). Centrality refers to the degree of importance or centrality of a node in a network and is a measure of the importance of a node in a network ( 69 ). In Table 4 the United States is also has the highest centrality (0.43). Figure 6 shows the geographic collaboration network of countries in this field, with 83 countries contributing to BPD research, primarily from the United States and Europe.

Table 4 Top 10 countries that published BPD researches.

Figure 6 Map of the distribution of countries/regions engaged in BPD researches.

3.7 Analysis of the co-author’s institutions network

Table 5 listed the top 10 institutions ranked by the number of publications. The current study shows that Research Libraries Uk is the institution with the highest number of publications, with 766 publications (9.67%). The subsequent institutions are Harvard University and Ruprecht Karls University Heidelberg with 425 (5.37%) and 389 (4.91%) publications respectively. As can be seen from Table 4 , six of the top 10 institutions in terms of number of publications are from the United States. In part, this reflects the fact that the United States institutions are at the forefront of the BPD field and play a key role in it.

Table 5 Top 10 institutions that published BPD researches.

3.8 Analysis of journals and cited journals

If the more papers are published in a particular journal and at the same time it has a high number of citations, then it can be considered that the journal is influential ( 70 ). The top 10 journals in the field of BPD in terms of number of publications are listed in Table 6 . Journal of Personality Disorders from the Netherlands published the most literature on BPD with 438 (5.53%; IF=3.367) publications. This was followed by two journals from the United States: Psychiatry Research and Personality Disorders Theory Research and Treatment , with 269 (3.40%, IF=11.225) and 232 (2.93%; IF=4.627) publications, respectively. Among the top 10 journals in terms of number of publications published, Psychiatry Research has the highest impact factor.

Table 6 Top 10 journals that published BPD researches.

3.9 Analysis of keywords and keywords co-occurrence

Keyword co-occurrence analysis can help researchers to understand the research hotspots in a certain field and the connection between different research topics. As shown in Figure 7 , all keywords can be categorized into 9 clusters: cluster #0 “diagnostic interview”, cluster #1 “diagnostic behavior therapy”, cluster #3 “social cognition”, cluster #4 “emotional regulation”, cluster #5 “substance use disorders “, cluster #6 “posttraumatic stress disorder”, cluster #7 “suicide” and cluster #8 “double blind”. These keywords have all been important themes in BPD research during the last 20 years.

Figure 7 The largest 9 clusters of co-occurring keywords. The top 5 most frequent keywords in each cluster are highlighted.

Keyword burst is used to identify keywords with a significant increase in the frequency of occurrence in a topic or domain, helping to identify emerging concepts, research hotspots or keyword evolutions in a specific domain ( 71 ). Figure 8 presented the top 32 keywords with the strongest citation bursts in BPD from 2003−2023. Significantly, the keywords “positron emission tomography” (29.63), “major depression” (27.93), and “partial hospitalization” (27.1) had the highest intensity of outbreaks.

Figure 8 Keywords with the strongest occurrence burst on BPD researches.

4 Discussion

4.1 application of the “neuro-behavioral model” to bpd research.

In this study, we chose specific search terms, particularly “Neuro-behavioral Model”, to efficiently collect and analyze BPD research literature related to this emerging framework. This choice of keyword helped narrow the research scope and ensure its relevance to our objectives. However, it may have excluded some studies using different terminology, thus limiting comprehensiveness. In addition, the ‘Neuro-behavioral Model’, as an interdisciplinary field, encompasses a wide range of connotations and extensions, which also poses challenges to our research. This undoubtedly adds to the complexity of the study, yet it enhances our understanding of the field’s diversity.

4.2 Summary of the main findings

This current study utilized CiteSpace and Scimago Graphic software to conduct a comprehensive bibliometric analysis of the research literature on BPD. The study presented the current status of research, research hotspots, and research frontiers in BPD over the past 20 years (2003–2022) through knowledge mapping. The scientific predictions of future trends in BPD provided by this study can guide researchers interested in this field. This study also uses bibliometrics analysis method to show the knowledge structure and research results in the field of BPD, as well as the scientific prediction of the future trend of BPD research.

4.3 Identification of research hotspots

Previous studies have indicated an increasing trend in the number of papers focused on BPD, with the field gradually expanding into various areas. The first major research trend involves clinical studies on BPD. This includes focusing on emotional recognition difficulties in BPD patients, as well as studying features related to suicide attempts and non-suicidal self-injury. Clinical recognition and confirmation of BPD remains low, mainly related to the lack of clarity of its biological mechanisms ( 72 ). The nursing environment for BPD patients plays an important role in the development of the condition, which has become a focus of research. Researchers are also exploring the expansion of treatment options from conventional medication to non-pharmacological approaches, particularly cognitive-behavioral therapy. Another major research trend involves the associations and complications of BPD, including a greater focus on the adolescent population to reduce the occurrence of BPD starting from adolescence. Additionally, many researchers are interested in the comorbidity of BPD with various clinical mental disorders.

4.4 Potential trends of future research on BPD

Based on the results of the above studies and the results of the research trends in the table of details of the co-citation network clusters in 2022 ( Table 7 ), several predictions are made for the future trends in the field of BPD. In Table 7 , there were some trends related to previous studies, including #1”dialectical behavior therapy”, #7 “dialectical behavior therapy” ( 73 ), #5 “mentalization” ( 74 ), and #9 “non-suicidal self-injury” ( 75 ). The persistence of these research trends is evidence that they have been a complex issue in this field and a focus of researchers. The recently emerged turning point paper provides a comprehensive assessment about BPD, offering practical information and treatment recommendations ( 76 ). New research is needed to improve standards and suggest more targeted and cost-effective treatments.

Table 7 The references co-citation network cluster detail (2022).

BPD symptoms in adolescents have been shown to respond to interventions with good results, so prevention and intervention for BPD is warranted ( 77 ). This trend can be observed in #3 “youth” ( 78 ). Mark F. Lenzenweger and Dante Cicchetti summarized the developmental psychopathology approach to BPD, one of the aims of which is to provide information for the prevention of BPD ( 79 ). Prevention and early intervention of BPD has been shown to provide many benefits, including reduced occurrence of secondary disorders, improved psychosocial functioning, and reduced risk of interpersonal conflict ( 80 ). However, there are differences between individuals, and different prevention goals are recommended for adolescents at risk for BPD. Therefore, prevention and early intervention for BPD has good prospects for the future.

The etiology of BPD is closely related to many factors, and its pathogenesis is often ignored by clinicians. The exploration of risk factors has been an important research direction in the study. Some studies have found that BPD is largely the product of traumatic childhood experiences, which may lead to negative psychological effects on children growing up ( 81 ). It has also been found that the severity of borderline symptoms in parents is positively associated with poor parenting practices ( 82 ). Future researches need to know more about the biological-behavioral processes of parents in order to provide targeted parenting support and create a good childhood environment.

Because pharmacotherapy is only indicated for comorbid conditions that require medication, psychotherapy has become one of the main approaches to treating BPD. The increasingly advanced performance and availability of contemporary mobile devices can help to take advantage of them more effectively in the context of optimizing the treatment of psychiatric disorders. The explosion of COVID-19 is forcing people to adapt to online rather than face-to-face offline treatment ( 83 ). The development of this new technology will effectively advance the treatment of patients with BPD. Although telemedicine has gained some level of acceptance by the general public, there are some challenges that have been reported, so further research on the broader utility of telemedicine is needed in the future.

4.5 The current study compares with a previous bibliometric review of BPD

As mentioned earlier, there have been previous bibliometric studies conducted by scholars in the field of BPD. This paper focuses more on BPD in personality disorders than the extensive study of personality disorders as a category by Taylor Reis et al. ( 15 ). The results of both studies show an increasing trend in the number of publications in the field of BPD, suggesting positive developments in the field. Taylor Reis et al. focused primarily on quantifying publications on personality disorders and did not delve into other specific aspects of BPD. Ilaria M.A. Benzi et al. focused on a bibliometric analysis of the pathology of BPD ( 14 ). They give three trends for the future development of BPD pathology: first, the growing importance of self-injurious behavior research; second, the association of attention deficit hyperactivity disorder with BPD and the influence of genetics and heritability on BPD; and third, the new focus on the overlap between fragile narcissism and BPD. The study in this paper also concludes that there are three future development directions for BPD: first, the prevention and early intervention of BPD; second, the non-pharmacological treatment of BPD; and third, research into the pathogenesis of BPD. Owing to variations in research backgrounds and data sources, the outcomes presented in the two studies diverge significantly. Nevertheless, both contributions hold merit in advancing the understanding of BPD. In addition to this, this paper also identifies trends in BPD over the past 20 years: the first trend is the clinical research of BPD, which is specifically subdivided into three sub-trends; the second trend is association and comorbidity. The identification of these trends is important for understanding the disorder, improving diagnosis and treatment, etc. Structural variant analysis also features prominently in the study. The impact of literature in terms of innovativeness is detected through in-depth mining and analysis of large amounts of literature data. This analysis is based on research in the area of scientific creativity, especially the role and impact of novel reorganizations in creative thinking. Structural variation analysis is precisely designed to find and reveal embodiments of such innovative thinking in scientific literature, enabling researchers to more intuitively grasp the dynamics and cutting-edge advances in the field of science.

5 Limitations

However, it must be admitted that our study has some limitations. The first is the limited nature of data resources. The data source for our study came from only one database, WOS. Second, the limitation of article type. Search criteria are limited to papers and reviews in SCI and SSCI databases. Third, the effect of language type. In the current study, only English-language literature could be included in the analysis, which may lead us to miss some important studies published in other languages. Fourth, limitations of research software. Although this study used well-established and specialized software, the results obtained by choosing different calculation methods may vary. Finally, the diversity of results interpretation. The results analyzed by the software are objective, but there is also some subjectivity in the interpretation and analysis of the research results. While we endeavor to be comprehensive and accurate in our research, the choice of search terms inevitably introduces certain limitations. Using “Neuro-behavioral Model” as the search term enhances the study’s relevance, but it may also cause us to miss significant studies in related areas. This limits the generalizability and replicability of our results. Furthermore, the inherent complexity and diversity of neurobehavioral models might introduce subjectivity and bias in our interpretation and application of the literature. Although we endeavored to reduce bias via multi-channel validation and cross-referencing, we cannot entirely eliminate its potential impact on our findings.

6 Conclusion

Overall, a comprehensive scientometrics analysis of BPD provides a comprehensive picture of the development of this field over the past 20 years. This in-depth examination not only reveals research trends, but also allows us to understand which areas are currently hot and points the way for future research efforts. In addition, this method provides us with a framework to evaluate the value of our own research results, which helps us to more precisely adjust the direction and strategy of research. More importantly, this in-depth analysis reveals the depth and breadth of BPD research, which undoubtedly provides valuable references for researchers to have a deeper understanding of BPD, and also provides a reference for us to set future research goals. In short, this scientometrics approach gives us a window into the full scope of BPD research and provides valuable guidance for future research.

Author contributions

YL: Data curation, Formal analysis, Investigation, Methodology, Software, Visualization, Writing – original draft, Writing – review & editing. CC: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. YZ: Validation, Visualization, Writing – review & editing. NZ: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. SL: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. SL is supported by the Outstanding Youth Program of Philosophy and Social Sciences in Anhui Province (2022AH030089) and the Starting Fund for Scientific Research of High-Level Talents at Anhui Agricultural University (rc432206).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: neuro-behavioral model, borderline personality disorder, BPD, bibliometric, Scimago Graphica

Citation: Liu Y, Chen C, Zhou Y, Zhang N and Liu S (2024) Twenty years of research on borderline personality disorder: a scientometric analysis of hotspots, bursts, and research trends. Front. Psychiatry 15:1361535. doi: 10.3389/fpsyt.2024.1361535

Received: 12 January 2024; Accepted: 19 February 2024; Published: 01 March 2024.

Reviewed by:

Copyright © 2024 Liu, Chen, Zhou, Zhang and Liu. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Shen Liu, [email protected] ; Chaomei Chen, [email protected] ; Na Zhang, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Borderline personality disorder in adolescence: the case for medium stay inpatient treatment

Affiliation.

• 1 Menninger Clinic and Baylor College of Medicine, Houston, USA. [email protected]
• PMID: 23507818
• DOI: 10.1097/01.pra.0000428563.86705.84

Background: The diagnosis of personality disorders in adolescents has been a topic of debate in recent years.

Method: This manuscript reviews the case of an adolescent girl admitted for a medium length combined inpatient and partial hospitalization program. This program has developed protocols to assess for Axis I and II pathology as well as various psychological processes. Comprehensive outcome measures were administered to the patient at discharge and follow-up.

Results/conclusions: Diagnosis of a personality disorder in adolescence appears to be associated with psychological processes usually identified in adults. Against the background of an emerging debate about the need to reform a culture of ultra-short inpatient care, this case study provides some support for more thorough assessment, diagnosis, and treatment of adolescents who appear to have comorbid Axis I and II disorders.

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• Borderline Personality Disorder* / psychology
• Borderline Personality Disorder* / therapy
• Depressive Disorder, Major* / complications
• Depressive Disorder, Major* / therapy
• Diagnostic and Statistical Manual of Mental Disorders
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What Is Borderline Personality Disorder (BPD)?

Complications

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Borderline personality disorder (BPD) is a mental health condition that causes long-term patterns of unstable moods, difficulty maintaining relationships, and turbulent emotions. Like other personality disorders, it affects how a person thinks, feels, and behaves, causing deviations from the typical norms of culture and society.

An estimated 1.4% of the adult population in the United States has borderline personality disorder, and about 75% of those diagnosed are people assigned female at birth. Assigned males may be equally affected by the condition, but they tend to be misdiagnosed with conditions like depression or PTSD .

BPD is classified under the category of cluster B personality disorders, which are disorders that cause constantly changing, dramatic, emotional thoughts or behaviors. Symptoms and traits include difficulty regulating emotions, poor self-image, and feelings of emptiness. These inner experiences, which typically begin in late adolescence or early adulthood, often result in impulsivity, chaotic relationships with others, and difficulty with daily functioning.

Types of BPD

Scientists over the years have been trying to understand more about borderline personality disorder. As a result, several studies have offered different ways of classifying this condition. One of the most well-known breakdowns of BPD was established by Theodore Millon, who identifies four primary types of BPD:

• Petulant BPD: People with this type of BPD have persistent, unpredictable mood swings and are often unable to maintain their relationships. They also have a sense of unworthiness and experience manipulative tendencies.
• Impulsive BPD: As the name may imply, this BPD subtype causes uncontrollable impulsivity, the tendency to be aggressive, and risky behaviors. People with this condition also yearn for instant satisfaction without considering the consequences.
• Discouraged BPD: People with discouraged BPD often hide their emotions and tend to keep their symptoms internal. They hardly express anger, even though they have intense mood swings and unstable self-identity. Compared to other subtypes of BPD, people with discouraged BPD tend to be less impulsive.
• Self-destructive BPD: This type of BPD often causes a sense of bitterness and self-hatred, a negative self-image, and suicidal thoughts . People who experience this type may also get involved in harmful and risky behaviors like overdosing, walking into traffic, and cutting themselves.

Looking for support?

If you are experiencing a crisis, or know someone who is, call or text the National Suicide Prevention Lifeline at 988 for free and confidential support 24/7. You can also visit SpeakingOfSuicide.com/resources for a list of additional resources or call the number below to reach the Substance Abuse and Mental Health Services Administration (SAMHSA) hotline.

Borderline Personality Disorder Symptoms and Traits

Borderline personality disorder can look different from person to person. If you or a loved one have BPD, you may exhibit these traits or experience the following symptoms :

• All-or-nothing mindset (thinking in extremes)
• Rapidly changing interests, values, and views of other people
• Impulsive or harmful behaviors such as substance use, unsafe sex, or excessive spending
• Intense emotions like rage, panic, shame, or deep sorrow
• Upsetting thoughts, such as feeling you are unworthy or a terrible person
• Irritability or anxiety
• Depressive moods or episodes
• Intense fear of rejection, being alone, or feeling abandoned
• Experiencing boredom or emptiness
• Abnormal episodes, such as hearing voices outside your head
• Feeling misunderstood
• Suicidal thoughts

The exact causes of BPD are not fully understood. However, health researchers believe the following factors may play significant roles in the development of this condition:

• Genetics: While research has not shown that any specific gene causes BPD, research suggests it has a strong genetic basis. Studies show that people who have a family history of BPD are more likely to develop this condition than people who do not have a relative with a personality disorder.  
• Environmental factors: Certain environmental factors are associated with BPD, such as fear and distress in childhood, trauma , and neglect or separation from parents.  
• Brain function and development: People with BPD may have variations or insufficiencies in brain neurotransmitters. Neurotransmitters are chemicals that allow brain cells to transmit signals to other parts of the body. One study that looked at brain scans of people with BPD also showed that many people had unusual activity in some parts of their brains or brains unusually small in size.

Borderline personality disorder can be challenging to diagnose as there are no specific tests that confirm someone has the condition. Symptoms of BPD can also look similar to other mental health conditions, which raises the risk of receiving a misdiagnosis. However, with the right education and proper assessment, some mental health providers can diagnose BPD correctly.

If you or a loved one are experiencing BPD symptoms, seeing a mental health provider can help learn more about the condition and get the support you need. During the diagnostic process, you can expect to receive a physical and psychological examination. Your healthcare provider will ask questions about your symptoms and how you react to certain experiences. They may also speak with your friends or family members to get more information about your feelings or behaviors.

To receive a diagnosis for BPD, you will also need to meet the criteria set by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Experiencing five or more of these symptoms determines a diagnosis:

• Desperate or strong efforts to avoid abandonment
• A pattern of emotional instability and intense interpersonal relationships
• Severe paranoid and dissociative symptoms
• Impulsive behavior that can be self-damaging, (e.g., reckless driving or substance use)
• Unstable self-image
• Constant feelings of emptiness
• Intense and inappropriate anger that is difficult to control
• Frequent mood swings that typically last a few hours and rarely more than a few days
• Suicidal thoughts or self-harming behaviors

Borderline Personality Disorder Treatments

If you have received a diagnosis of BPD, getting treatment from a mental health provider is critical for your care and overall quality of life. The primary treatment for this condition is psychotherapy. Your provider may recommend medications in conjunction with therapy to help alleviate some symptoms.

Psychotherapy

Psychotherapy, also called talk therapy, is the first line of treatment for borderline personality disorder. There are different types of psychotherapy healthcare providers adopt for treating BPD. Your mental health provider (whether that's a psychologist, social worker, or licensed therapist) may try one of the following techniques:

• Dialectical behavioral therapy (DBT): This type of therapy targets factors that cause a person with BPD to fall into a negative cycle and aims to break that cycle using one-on-one or group talks. It uses validation (accepting that your emotions are valid) and dialectics (openness to other ideas or opinions) to encourage positive behavioral changes.
• Mentalization-based therapy (MBT): People with BPD often have impaired mentalization (social cognition), and MBT can help address this. This type of therapy is beneficial for people dealing with interpersonal challenges and intense emotions by using a holistic approach to help them function better in regular social settings. 
• Transference-focused psychotherapy (TFP): This uses a client-therapist relationship to help change how people with BPD view themselves. Studies show that this treatment is effective in enhancing reflective thinking.
• Schema therapy: This is a cognitive therapy specifically designed for people with personality disorders. It helps transform faulty patterns that people with BPD develop about themselves and their relationships with others.

Medications

The Food and Drug Administration (FDA) has not approved any medication for treating borderline personality disorder, but certain medications may help manage BPD symptoms like depression , anxiety, and sleep disturbances. If your condition is causing other mental health symptoms, your provider may prescribe one or more of the following types of medications:  

• Mood stabilizers
• Antipsychotics
• Antidepressants
• Anxiolytics (anxiety medications)

Other Treatments

Your healthcare provider may also suggest other treatments alongside therapy and medication that can help reduce symptoms, improve overall well-being, and offer additional support. These may include:

• Art therapies, such as drama, music , and dance movement therapy
• Therapeutic communities (structured communities designed to help people improve their social skills)
• Psychoeducation (teaching people with BPD and their family members about the condition)
• Short-term inpatient hospitalization

There is no known way to prevent borderline personality disorder. Some older studies indicate that early interventions, such as detecting symptoms earlier and identifying appropriate risk factors may help people get an earlier diagnosis and receive treatment sooner.  

Treatments often improve BPD symptoms. When left untreated, it can increase the risk of developing other mental health conditions or behavioral concerns. These include:

• Substance use disorder
• Suicide attempts
• Difficulty maintaining relationships at work, home, or with friends

Living With BPD

It can be challenging to live with mental health conditions like BPD, especially as it can cause a feeling of not being understood. To improve your functioning abilities and help you manage the condition better, consider the following tips:

• Seeking appropriate medical attention and treatment
• Educating yourself more about your condition
• Working with your healthcare team on a treatment plan and sticking with the plan
• Identifying your triggers and avoiding them or creating strategies to deal with them better
• Avoiding the use of substances like alcohol and drugs, as they can worsen your symptoms or interact with your medications
• Writing in a journal or joining support groups to help express how you feel
• Trying stress management and relaxation techniques like deep breathing exercises and meditation

It’s also important to be patient with yourself during your treatment journey. With appropriate treatment and care, symptoms of BPD often improve. Improvement is often gradual, so sticking with your care plan is important.

If you're comfortable, consider telling your loved ones about your condition, your symptoms, and any challenges you're experiencing. This can help them understand how you feel and offer support.

Frequently Asked Questions

Borderline personality disorder and narcissistic personality disorder are the most common types.

People with BPD can experience intense and persistent symptoms that they have little to no control over. Having partners who are understanding, patient, empathetic, and supportive will go a long way toward helping them manage their condition better.  

While symptoms and experiences can vary from person to person, studies generally indicate an overall decrease in symptoms as people with BPD age. This may be because, over time, people learn to avoid their triggers, cope with their symptoms, or naturally grow out of them. Impulsive symptoms are also the most likely to decline as you get older.

National Alliance on Mental Health. Borderline personality disorder

American Psychiatric Association. What are personality disorders?

MedlinePlus. Personality disorders

Duică L, Antonescu E, Totan M, Boța G, Silișteanu SC. Borderline personality disorder "discouraged type": A case report . Medicina (Kaunas). 2022;58(2):162. doi:10.3390/medicina58020162

Goodman M, Tomas IA, Temes CM, Fitzmaurice GM, Aguirre BA, Zanarini MC. Suicide attempts and self-injurious behaviors in adolescent and adult patients with borderline personality disorder . Personal Ment Health . 2017;11(3):157-163. doi:10.1002/pmh.1375

Chapman J, Jamil RT, Fleisher C. Borderline personality disorder . In: StatPearls . StatPearls Publishing; 2023

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Ansari D, Lakkimsetti M, Olaleye KT, et al. Genetic Influences on Outcomes of Psychotherapy in Borderline Personality Disorder: A Narrative Review of Implications for Personalized Treatment . Cureus . 2023;15(8):e43702. doi:10.7759/cureus.43702

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Office on Women's Health. Borderline personality disorder .

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• Published: 17 May 2024

Comparison of 8-vs-12 weeks, adapted dialectical behavioral therapy (DBT) for borderline personality disorder in routine psychiatric inpatient treatment—A naturalistic study

• Milenko Kujovic 1 ,
• Daniel Benz 1 ,
• Mathias Riesbeck 1 ,
• Devin Mollamehmetoglu 1 ,
• Julia Becker-Sadzio 2 ,
• Zsofia Margittai 1 ,
• Christian Bahr 1 &
• Eva Meisenzahl 1  

Scientific Reports volume  14 , Article number:  11264 ( 2024 ) Cite this article

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Dialectical behavior therapy (DBT) is widely acknowledged as an effective treatment for individuals with borderline personality disorder (BPD). However, the optimal treatment duration within DBT remains a topic of investigation. This retrospective, naturalistic non-randomized study aimed to compare the efficacy of 8 week and 12 week DBT interventions with equivalent content, focusing on the change of BPD-specific symptomatology as the primary outcome and depressive symptoms as the secondary outcome. Overall, 175 patients who participated in DBT and received either 8 week or 12 week intervention were included in the analysis. Routine inpatient treatment was adapted from standard DBT with the modules: skill training, interpersonal skills, dealing with feelings, and mindfulness. Measurements were taken at baseline, mid-point, and endpoint. The borderline symptom list-23 (BSL-23) was used for the assessment of borderline-specific symptoms, while the Beck depression inventory-II (BDI-II) was used for the assessment of depressive symptoms. Statistical analysis was conducted using linear mixed models. Effect sizes were calculated for both measures. The results of the analysis indicated an improvement in both groups over time. Effect sizes were d  = 1.29 for BSL-23 and d  = 1.79 for BDI-II in the 8 week group, and d  = 1.16 for BSL-23 and d  = 1.58 for BDI-II in the 12 week group. However, there were no differences in the change of BPD-specific symptoms or the severity of depressive symptoms between the 8 week and 12 week treatment duration groups. Based on these findings, shorter treatment durations, like 8 weeks, could be a viable alternative, offering comparable therapeutic benefits, potential cost reduction, and improved accessibility. However, further research is needed to explore factors influencing treatment outcomes and evaluate the long-term effects of different treatment durations in DBT for BPD.

Trial registration: drks.de (DRKS00030939) registered 19/12/2022.

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Introduction.

Dialectical behavioral therapy (DBT) was originally developed to treat chronically suicidal patients by Marsha Linehan 1 and is regarded as the first choice evidence-based treatment for borderline personality disorder (BPD 2 ). BPD is a severe mental illness 3 and describes a pattern of emotional, behavioral, cognitive, and interpersonal dysregulation leading to marked distress as well as impairments in social and occupational functioning 1 , 4 . Furthermore, BPD is characterized by self-harming behaviour, an increased risk of suicide 5 and high rates of axis-I comorbidities, with mood disorders being the most prevalent 6 . In addition, high comorbidities are shown for eating disorders, substance abuse, post-traumatic stress disorder, and personality disorders 7 . While recent long-term studies show that remission of symptoms was sustained over time in almost one half of the affected individuals, social integration was significantly worse 7 . According to population-based studies, the prevalence of BPD ranges from 0.7 to 4.5% 8 , with a lifetime prevalence of 5.9% 9 . This suggests that in Germany, there are an estimated 500,000 to 1,000,000 individuals affected by this condition 10 , 11 , 12 . Besides, BPD patients show a high prevalence among psychiatric (in-)patients 4 .

Furthermore, the outpatient and inpatient care situation for BPD in Germany can be considered insufficient 10 . Thus, an estimated 700 inpatient places are available 11 and therapists in inpatient and outpatient care are often not specifically trained or may even refuse treatment in some cases 10 . Furthermore, Iliakis et al. 13 estimated a ratio of 1:1102 of specialized, certified therapists in relation to the annual number of BPD patients to be treated. Beyond the individual burden caused by BPD, the economic burden by means of high mental health care costs—mainly driven by repetitive hospital stays 3 , 14 , 15 —is immense. Direct and indirect costs are estimated to result in numbers of up to € 40.000 per case and year depending on factors included and approach 3 . Accordingly, there is a need for specialized hospitals to conduct the complex management of chronic diseases as well as to provide the necessary resources.

According to several treatment guidelines for BPD, psychotherapy is considered first-line therapy 16 , 17 . Considering the German guideline for BPD 16 , DBT shows the best evidence and is recommended particularly when the treatment’s primary outcome is the reduction of severe self-harming behaviors (including suicidal behaviors). Furthermore, manualized disorder-specific psychotherapy programs such as DBT, mentalization-based psychotherapy (MBT) 18 and schema therapy 19 have been found to be effective 20 . Also, Bohus 7 stated that disorder-specific treatment in the case of BPD in comparison to unspecific treatment seems to lead to further improvements, e.g. lower suicide rates. DBT is a modularized, individual and group-based skills training consisting of four key elements: mindfulness, distress tolerance, emotion regulation and interpersonal competence 1 . Additionally, DBT has since been advanced to include other important components, such as self-esteem, as BPD is often associated with dysfunctional self-concepts 21 . The efficacy of DBT for BPD has been proven in several randomized controlled trials with different designs 22 , 23 . These findings are supported by recent systematic reviews and meta-analysis showing that DBT is effective in reducing BPD specific symptoms and superior compared to treatment-as-usual (e.g., 23 , 24 ). According to Snoek et al. 25 , DBT offers a more favorable cost-effectiveness as compared to cognitive behavioral therapy (CBT) or other treatments, such as weekly individual therapy or psychoeducational groups.

While many studies have investigated the efficacy of psychotherapeutic treatments, only a few have focused on the general framework or organizational conditions of psychotherapeutic treatment (such as the duration of treatment, or inpatient vs. outpatient setting) and their effectiveness 26 . Knowledge about the influence of these contextual factors on therapy outcomes is still somewhat limited. Originally, DBT was developed as an outpatient treatment as hospitalization might decrease patients’ ability to learn effective coping strategies for their daily lives 1 . According to Van Swearingen and Lothes 27 , the standard version of DBT within outpatient settings should require approximately 1 year. However, BPD patients often require more intensive care and show a high prevalence in inpatient settings 4 . In addition, Bloom et al. 28 argue that the outpatient setting cannot adequately be provided for all BPD patients as well as that outpatient treatment staff might be feeling overwhelmed when dealing with BPD. Consequently, DBT was adapted for inpatient settings 29 .

One of the first studies to examine DBT in the inpatient setting was performed by Bohus et al. 30 , who adapted this type of DBT program by Swenson et al. 31 for the inpatient setting in Europe. The treatment lasts about 3 months 30 . Yet, inpatient treatment programs for BPD show variation in the duration and content 28 . Compared to the 1 year DBT originally scheduled by Linehan 1 , abbreviated inpatient and outpatient implementations of DBT were studied with different variations of duration, ranging from very short 5 day intensive group-based DBT-skills training to longer-term 6 month programs 26 , 32 . Despite heterogeneity in the duration of inpatient treatment programs a survey by Richter et al. 11 found that among 42 German hospitals and day clinics about half of the clinics set the treatment duration a priori to 12 weeks. Furthermore, Bloom et al. 28 found the modal duration of inpatient DBT to be 3 months. Consequently, it can be assumed that 3 months (12 weeks) is the most common duration of inpatient DBT in Germany and can be seen as the standard duration in the inpatient setting.

Based on studies examining the effects of duration of DBT treatments in the inpatient setting, research has also suggested that even short versions of DBT could be (equally) effective in reducing BPD-specific symptoms. A study conducted in a German hospital found small to medium effect sizes regarding the reduction of BPD symptoms within a treatment duration between 8 and 12 weeks 33 . This is also one of the few naturalistic studies that has been conducted within routine care 26 . Other studies have shown different beneficial effects for shorter treatment durations. For instance, 25% of patients seemed to refrain from self-harm within the first week of therapy 34 . Additionally, Probst et al. 35 showed that a 5 weeks inpatient DBT therapy showed a significant reduction in BPD specific symptoms and improved emotion regulation. In addition, results indicate that symptom and functional improvement for shortened therapies were stable at 5 year follow-ups with annual measurements and readmission rates remained low after treatment completion 26 , 27 . Regarding other setting conditions, recent research suggests that DBT-inpatients may benefit more than outpatients regarding self-esteem, distress, and quality of life 26 .

Although the evidence base is somewhat sparse and further research is urgently needed, it suggests that shorter (inpatient) DBT may be as effective as a longer treatment. Moreover, shorter treatment duration is associated with potentially different advantages like reduced dropout rates 26 or reduced health care and societal costs. A recent meta-analysis found that dropout rates in psychotherapies for BPD are generally high, ranging between 20 to 30% 36 . According to Iliakis et al. 36 main reasons for dropping out were treatment dissatisfaction, exclusion from treatment, insufficient motivation, as well as life events or changes in life situation. Likewise, Iliakis et al. 36 suggest that abbreviated treatment programs could have an impact on patient motivation and satisfaction, thereby increasing adherence and commitment to therapy as well as reducing dropout rates. Furthermore, a shortened treatment duration enables an earlier treatment completion and should lead to a greater benefit for BPD-patients in general as more patients could participate in disorder-specific treatments within the same period and facility 26 . Also beneficial is an earlier treatment response, e. g. faster reduction of self-harming behavior and earlier return to ‘real life’ leading to (earlier) occupational as well as leisurely activities.

Aims of the study

Consequently, we argue that an adequate adjustment of ‘standard’ DBT in terms of shortened treatment duration of 8 weeks compared to 12 weeks within inpatient setting might deliver significant benefits for patients with BPD while maintaining the efficacy of (longer) DBT-programs. Accordingly, we hypothesize that a shortened 8 week DBT is comparable regarding efficacy to the standard 12 week program (both with equal content) in routine clinical psychiatric inpatient treatment. The primary outcome of the study was the change in BPD-specific symptoms, while the secondary outcome was the change in depressive symptoms.

The study was conducted between August 2019 and September 2021 at a specialized ward for patients with BPD at the LVR-clinics Dusseldorf, department of psychiatry and psychotherapy at the Heinrich–Heine-university, Dusseldorf. Each potential patient receives a pre-admission interview prior to acceptance. After admission within routine clinical treatment, patients with BPD were offered a DBT program as obligatory to continue inpatient treatment. Generally, the treatment plan was scheduled for 8 weeks. From August 2020 to March 2021 an adaptation was implemented to offer an extension of four more weeks (i.e. 12 weeks in total) to patients showing high commitment and motivation to deepen and improve knowledge and coping skills. The decision to extend was made during the sixth week by the clinical assessment of the treatment team. This applied to patients who were engaged and participated effectively in the program. Accordingly, patients who extended the treatment up to 12 weeks had the opportunity to repeat and practice. Nevertheless, beyond time and treatment session extension, there were no differences regarding contents or skills training provided. The difference in treatment duration resulted in two separate samples of patients who received the same DBT treatment, but were treated for either 8 or 12 weeks. For all patients, the routine clinical treatment also comprises occupational therapy, sports/physical activity therapy, music therapy, and psychiatric care including psychotropic drug treatment, which should be administered as low as possible. All data were collected within the routine treatment and analyzed post hoc. Assessments included in the analyses considered baseline (prior treatment), midpoint (after 4 or 6 weeks respectively) and after treatment (week 8 or 12 respectively). Due to the routine care setting, both treatment conditions were provided by the same personnel. Initial assessments including diagnosis were blind to treatment condition, as group allocation took place in the sixth week of DBT-treatment at the earliest. Assessments after week 8 were not blind to treatment condition, however assessors i.e. patients (due to self-assessment instruments) as well as treating personnel were unaware of the hypothesis. Adherence (of therapists) to (DBT-) manual was not assessed. All participants have given informed consent to anonymized analyses as the standard procedure associated with inpatient treatment. Before retrospective data collection, an ethics vote was requested from the Medical Faculty Ethics Committee of Heinrich Heine University, Dusseldorf, which was approved on 1 February 2022 (reference number: 2021-1693). All methods were performed in accordance with the relevant guidelines and regulations.

Inclusion/exclusion criteria and sample

All patients with a diagnosis of BPD according to DSM-5 criteria 37 , which was assured by SCID-II (meeting at least five criteria on the BPD scale 38 ,) and additionally confirmed by means of a clinical diagnosis according to ICD-10 39 were included in the trial and analyses. Also, diagnosis of depression and further mental disorders were confirmed using Diagnostisches Kurzinterview bei psychischen Störungen (mini-DIPS OA 40 ,). Trained clinicians that were either psychotherapists or psychotherapists in training conducted the diagnostic process. Training in SCID-II assessments are part of the routine clinical management at our facility, however no formal reliability checks were conducted. Furthermore, patients had to be at least 18 years old, commencing DBT treatment and having at least baseline assessment in the borderline symptom checklist 23 (BSL-23 41 ;). In the study, all comorbidities were allowed except for disorders within the schizophrenia spectrum and addiction disorders, which were considered exclusion criteria. Overall, 175 patients participated, 153 patients under an 8 weeks treatment condition and 22 patients under 12 week condition.

Primary outcome: BSL-23

The BSL is a self-rating instrument for assessing typical symptoms associated with the BPD 41 . The items address both diagnostic criteria, such as affective instability and self-harming behavior, as well as borderline-typical empirical findings regarding self-criticism, trust issues, emotional vulnerability, and feelings of shame, loneliness, and helplessness 42 . The BSL is available in long and short versions. The long version consists of 95 items while the short version assesses the symptoms with only 23 items. The BSL-23 is used for measuring the borderline specific symptoms 1 week prior to the assessment 41 . Participants’ ratings are given on a Likert scale from 0 (not at all) to 4 (very strong). BSL-23 has proven to have sufficient psychometric properties regarding validity and reliability 41 . In the present study, the standardized percentile rank of the test was analyzed.

Secondary outcome: BDI-II

The revised Beck depression inventory (BDI-II) is a self-report questionnaire designed to measure the severity of depression in individuals 43 . The BDI-II consists of 21 items where individuals can rate the severity of their symptoms on a scale from 0 to 3, whereas higher scores indicate more severe depression. The BDI-II has high internal consistency as well as good validity 44 .

DBT treatment

The offered modularized DBT program according to Linehan’s manual adapted for inpatient treatment in Germany by Bohus and Wolf–Arehult 45 , contains the modules: skill training, interpersonal skills, dealing with feelings, and mindfulness. The self-esteem module is not provided. The typical treatment comprises the following obligatory components: each patient receives individual psychotherapeutic sessions (1–2 per week), DBT-based skills training (group: 2 per week), mindfulness-based group therapy (1 per week), psychoeducation about DBT and BPD (1 per week), and “tools” group (consolidation of elements taught in DBT such as emotion analysis, 1 per week). The program was designed for 8 weeks, accordingly all patients were provided with the opportunity to complete the four modules offered. Patients in the 12 week group were not provided with more content in the program, but were able to use the additional time to repeat the content. To ensure adherence to the DBT manual, all staff members in direct patient contact from various professional backgrounds, including medical personnel, psychotherapists, nursing staff, occupational therapists, and others, underwent training in all modules (basis- and skills-modules) provided by the Dachverband DBT e.V. Certified personnel from the DBT association conducted these training sessions consisting of six modules of a total of 96 h of instruction.

Statistical analysis

Routine data was analyzed post hoc. Group differences (8 vs. 12 weeks) in primary (BSL-23) and secondary (BDI-II) endpoints were analyzed by linear mixed models repeated measurement with group, time (baseline, mid- and endpoint) and group*time-interaction as fixed effects and patient as random effect to deal adequately with missing values (intention-to-treat analyses). In addition, baseline scores (BSL-23 or BDI-II respectively) were included as covariates. To control for potential ‘historical’ effects (prior March 2021, 8 week and 12 week DBT was offered, after March 2021 only 8 weeks DBT; thus, after March 2021 n = 52 patients, i.e. 34% of all 153 patients with 8 weeks-DBT, were treated for 8 weeks whereas no patient for 12 weeks) all analyses were also conducted regarding a three-group comparison (8 weeks pre March 21 vs. 8 weeks post March 21 vs. 12 weeks). Effect sizes were calculated using the estimated means of the linear mixed model including baseline as covariate divided by the pooled standard deviation of both groups at baseline. To test for pre-treatment differences, Chi-square-tests were conducted for categorical measures and t -tests (two-group comparisons) or ANOVAs (three-group comparisons) for metric measures. In addition, the potential confounding effect of group differences in routine treatment with psychotropic drugs was analyzed regarding the kind of drugs, amount of drugs in ‘days applied’ and percentage of hospital days with drugs (the patients of the 12 week group had naturally a significantly longer hospital stay, thus the percentage was calculated). Due to the computer based documentation system of the hospital, drug dose could not be assessed. Given the naturalistic and retrospective design of the study and especially the evolving divergent group sample sizes (n = 153 for 8 week vs. n = 22 for 12 week DBT) statistical requirements to examine a more appropriate non-inferiority hypothesis (especially balanced groups for sound parameter estimates) were unfortunately not given. All analyses were conducted using IBM SPSS statistics version 29.

Descriptives

The mean age of the participants in the 8 week program was 28.3 ( SD  = 8.6), whereas participants in the 12 weeks program were on average 24.7 ( SD  = 7.1) years old. This difference was significant, t (173) = 1.9, p  = 0.036. Regarding sex proportions both samples showed no significant differences, Χ 2 (1) = 0.54, p  = 0.58. The proportion of females in the 8 week group was 79.7% and 86.4% in the 12 weeks condition. While the cumulative days of inpatient treatment in the 8 weeks group averaged 55.6 days ( SD  = 12.5), individuals in the 12 week group spent an average of 75.5 days ( SD  = 12.2) in the hospital. Accordingly, the 12 week group showed a discrepancy in terms of the intended average duration. Table 1 shows the observed means of BSL-23 and BDI-II as well as their standard deviations for both groups regarding all three measurement points. At baseline, BSL-23 and BDI-II were not significantly different between treatment groups ( p  = 0.33 and 0.12 respectively). In addition, comorbidity with (other) mental disorders according to ICD-10 diagnosis was not significantly different between groups (see Table S1 in supplement).

Mixed linear models analysis

Bsl-23: primary outcome.

In this study, we used mixed linear models to compare two groups (8 weeks vs. 12 weeks DBT) with respect to changes in BSL-23 as the primary outcome. Table 2 shows the estimated mean percentile ranks for BSL-23 comparing 8 weeks against the 12 weeks treatment. Figure  1 depicts the observed and estimated mean percentile ranks for all three measurement time points comparing 8 weeks with 12 weeks of DBT. As Fig.  2 shows there is a decline in borderline specific symptoms over time, this main effect was significant, F (1, 120.11) = 19.45, p  < 0.001. Therefore, borderline specific symptoms reduced significantly over time in both groups. The main effect of the group was not significant, F (1, 161.43) = 0.04, p  = 0.85, as well as the interaction of group and time, F (1, 120.09) = 2.66, p  = 0.11. Accordingly, groups showed no differences regarding BSL-23 at any time nor in reduction over time. With respect to single time comparisons, only the comparison of mid to end was not significant for twelve weeks, p  = 0.29. Likewise, the three-group-comparison (8 weeks pre March 21 vs. 8 weeks post March 21 vs. 12 weeks) yielded comparable results.

Observed and estimated percentile ranks regarding the BSL-23 for both groups on all assessment time points: Base, mid (after 4 weeks for 8 weeks treatment and after 6 weeks for 12 weeks treatment) and end (after 8 weeks for 8 weeks treatment and after 12 weeks for 12 weeks treatment).

Observed and estimated sum scores for BDI-II for both groups over time; ‘Mid’ = after 4 weeks for 8 weeks treatment and after 6 weeks for 12 weeks treatment; ‘End’ = after 8 weeks for 8 weeks treatment and after 12 weeks for 12 weeks treatment.

BDI-II: secondary outcome

Also for the secondary outcome regarding the BDI-II a linear mixed model was conducted. Table 3 shows the estimated means and 95% confidence intervals for BDI-II for 8 weeks and 12 weeks treatment groups. As can be seen in Fig.  2 BDI-II scores significantly improved over time, F (1, 121.06) = 31.42, p  < 0.001. Likewise, as for BSL-23, there was no significant main effect of the group on BDI-II, F (1, 161.39) = 0.08, p  = 0.78, and no significant interaction of group and time, F (1, 121.02) = 1.30, p  = 0.26. Regarding single comparisons, all specific time effects were highly significant ( p  < 0.001) except for mid to end for the 12 weeks group, p  = 0.040. Regarding the three-group-comparison (8 weeks pre March 21 vs. 8 weeks post March 21 vs. 12 weeks), besides a significant time-effect ( p  < 0.001) and a non-significant group*time-interaction ( p  = 0.32), a significant group-effect ( p  = 0.006) evolved. However, as post-hoc comparisons indicate, the groups of ‘8 weeks pre March 21’ shows a significantly higher BDI-II reduction as compared to the ‘8 weeks post March 21’ at mid- as well as the endpoint, but both groups were not significantly different from the ‘12 weeks’ group (see Fig. S1 in the supplement).

Effect sizes

Effect sizes for overall symptom reduction were calculated for both BSL-23 and BDI-II values. Figure  3 shows the effect sizes for the BSL-23 and Fig.  4 for BDI-II. As can be seen the overall effect size of treatment on BSL-23 and BDI-II were high (reduction greater than one standard deviation of baseline scores) for the 8 week and 12 week group. Nevertheless, 95% CIs indicate that there were no significant differences between 8 and 12 weeks. Regarding the three-group-comparison (8 weeks pre March 21 vs. 8 weeks post March 21 vs. 12 weeks), 95% CIs likewise indicate a (significant) higher effect for the group ‘8 weeks pre March 21’ compared to the ‘8 weeks post March 21’ in BDI-II reduction, but again, both groups were not significantly different from the ’12 weeks’ group (see Fig. S2 in the supplement).

Effect sizes and 95% CIs from the beginning of the treatment to the end of the treatment separately for 8- and 12 weeks groups for BSL-23.

Effect sizes and 95% CIs from the beginning of the treatment to the end of the treatment separately for 8- and 12 weeks groups for BDI-II.

Psychotropic drugs

Analyses regarding group differences in treatment with psychotropic drugs within the treatment phase (see Table S2 in supplement) revealed only slight, however significant differences in treatment with mood stabilizers and sleeping drugs. Whereas the proportions of patients with such drugs was not significantly different, the mean percentage of days with such drugs (related to total treatment duration) differs (mood stabilizer: M / SD  = 4.1%/8.6 for 8 weeks group and 0.1%/0.4 for 12 weeks group, p  < 0.001; sleeping drugs: 3.3%/12.2 for 8 weeks group and 0.1%/0.3 for 12 weeks, p  < 0.001). Regarding treatment with antidepressants, antipsychotics, benzodiazepines or other psychotropic drugs (predominantly stimulants for ADHD treatment) no significant differences evolved.

The current retrospective, naturalistic study examined the efficacy of an 8 weeks DBT inpatient treatment in comparison to a 12 weeks DBT treatment within routine care. We found no differences regarding the reduction in borderline specific symptoms as well as the severity of depressive symptoms between both groups. Furthermore, both treatment groups showed high effect sizes regarding BPD-specific symptoms as well as depressive symptoms. Therefore, we conclude that an 8 week treatment was as effective as a longer 12 weeks treatment.

The fact that we found no difference between the two groups is even more surprising given a possible selection bias for the 12 weeks group as the patients were marked as highly motivated and were therefore given the opportunity to deepen their DBT knowledge and skills for another 4 weeks. One possible explication was given by Seow et al. 26 , who found no difference between a (very) short intensive DBT skills program of 5 days and a 12 weeks DBT treatment. Based on the good-enough level model 46 , 47 , it is argued that treatment is a mutual process between patients and practitioners, whereby therapy completes in case of sufficient improvement 26 . A lower dose regarding overall treatment length could lead to a higher effort, commitment and adherence to achieve a symptom reduction in a shorter period of time 26 . Thus, this would be a possible explanation, as in the current study the decision to extend to 12 weeks was made already in the sixth week of the treatment.

The overall reduction of borderline specific and depressive symptoms in inpatient settings using DBT is in line with Bloom et al. 28 , who suggested that inpatient DBT could facilitate the treatment of BPD. Moreover, a shorter DBT implementation than the most commonly used 12 week duration in the inpatient setting was equally effective in reducing borderline-specific symptoms. In comparison to the literature, the estimated effect sizes in the current studies were larger. Probst et al. 35 found effect sizes between d  = 0.38 and d  = 0.47 for intention to treat analysis and completers using the BSL-23 while conducting a 5 week inpatient DBT treatment. Also, Probst et al. 35 compared their effect sizes with effects reported in previous studies. Those effect sizes varied between d  = 0.13 and d  = 1.40 35 . In addition, Seow et al. 26 also had lower BSL-23 values in the inpatient setting, as well as Herzog et al. 33 found smaller effect sizes for BSL-95. One possible reason could be that severity of borderline specific symptoms was higher as the observed mean percentage ranks were M  = 56.8 for 8 weeks and M  = 62.5 for 12 weeks treatment, compared to a mean percentage rank of M  = 43 which corresponds to the mean raw score of 1.9 found by Probst et al. 35 . Furthermore, we had a longer treatment duration than Probst et al. 35 ; 5 weeks. Due to our results, a significant symptom reduction also evolved between week 4 and week 8. Nevertheless, as stated above, a longer duration must not always contribute to efficacy as we did not find higher effect sizes for the 12 weeks treatment and found higher effect sizes compared to Bohus et al. 48 although we had a shorter treatment duration.

Although we found that even shorter 8 weeks of treatment showed a significant reduction in BPD symptoms, several studies have shown that there is variation in the duration and even content of inpatient DBT treatments 3 , 26 , 28 . While 12 weeks was the most common duration of therapy, our results might indicate, that it does not seem necessary to use this duration. Especially since patients are out of their daily routine for a quarter of a year, making it more difficult to pursue their goals in real life and thus prevent social and functional decline. This would be consistent with the argument to establish DBT therapy primarily in the outpatient setting 1 , although this is not always feasible 28 . For this reason, there is a need to focus on what duration of therapy is appropriate and to strike a balance between costs and benefits. On the one hand, both health care and individual including the social costs of the therapy have to be considered, on the other hand, the short and long-term efficacy of the therapy has to be in focus. In this regard, treatment adherence and dropout rates are essential factors contributing to efficacy. Several different results show that shorter treatment duration contributes to better adherence and lower discontinuation rates 36 , 49 . As psychiatric therapy shifts to an individually adapted treatment (e.g. 33 , 50 ,), the duration of treatment might be considered also a variable parameter regarding personalization. Given the fundamental changes for diagnosis of personality disorders in ICD-11 which will the future (obligatory) diagnosis system in German health care, the severity categorization might also be a relevant parameter 51 . In addition, predictive models might be used to make personalized recommendations regarding the optimal therapy 33 . Therefore, the optimal treatment duration length should be considered when designing further treatment programs. Due to our results, 8 weeks of treatment seems (highly) effective, however, should be further evaluated in a larger prospective and randomized study with a longer observational period (e.g. 1–2 years) and long-term data.

Limitations

However, consistent with Bloom et al. 28 , results remain difficult to compare as studies to date have contrasted different implementations of DBT in the inpatient setting. The implementation (especially duration and content) has not been compared in a standardized way so far. In the future, a more standardized comparison would be recommended.

One major limitation is that our study was not a randomized controlled trial comparing 8 weeks versus 12 weeks. Also, the current study lacks a control group like treatment-as-usual. Therefore, internal validity is limited. In addition, the 12 week treatment group sample was small ( n  = 22), therefore, conclusions are limited. Likewise, as the group allocation was not randomized a selection bias must be assumed regarding the 12 week period, as it was administered to particularly motivated patients. With respect to the observational design and routine data collected, another limitation arises; as described, there might be unaware influencing factors with respect to the therapy program during the period examined. Accordingly, an additional comparison was conducted controlling for time dependent influences, and the findings are presented in the supplement. Astonishingly, we found some differences in the reduction of depressive symptoms in the three-group comparison, however only between the 8 week treatment prior vs. post March 2021. Since no differences in DBT or drug treatment as well as setting structure took place, we assume that this might be an effect of the COVID-19 pandemic in Germany leading to a (further) increase especially in depressive symptoms and psychiatric patients 52 .

Also, we found minor differences regarding treatment with psychotropic drugs between the 8 week and 12 week conditions. Treatment with sleeping drugs and mood stabilizers was slightly more often in the 8 weeks group however in an overall low amount (below 5% of days in hospital) and no differences in antidepressants and antipsychotics occurred. Thus, we do not assume that this has affected results.

Furthermore, the present study had a retrospective focus whereas a prospective design should also be pursued in future studies to ensure the treatment success of abbreviated inpatient DBT programs. This could also be used to conduct cost-sensitivity analysis.

In our retrospective, naturalistic study we showed that an 8 weeks DBT inpatient treatment yielded a significant reduction in BPD symptoms as well as depressive symptoms. No significant differences to a 12 weeks program with equivalent content were found. Accordingly, abbreviated treatments could have a positive effect on costs and benefits compared to the common implementation of 12 week therapy programs. In particular, treatment programs with shorter duration give the opportunity to treat more patients overall in a consecutive time period. This might contribute to better patient-centered care for patients with BPD.

Data availability

Aggregated data (e.g. for meta-analysis) will be available from the corresponding author.

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A complex systems perspective on chronic aggression and self-injury: case study of a woman with mild intellectual disability and borderline personality disorder

• Daan H. G. Hulsmans 1 , 2 ,
• Roy Otten 1 ,
• Evelien A. P. Poelen 1 , 2 ,
• Annemarie van Vonderen 2 ,
• Serena Daalmans 1 ,
• Fred Hasselman 1 ,
• Merlijn Olthof 1 , 3 &
• Anna Lichtwarck-Aschoff 3  

BMC Psychiatry volume  24 , Article number:  378 ( 2024 ) Cite this article

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Challenging behaviors like aggression and self-injury are dangerous for clients and staff in residential care. These behaviors are not well understood and therefore often labeled as “complex”. Yet it remains vague what this supposed complexity entails at the individual level. This case-study used a three-step mixed-methods analytical strategy, inspired by complex systems theory. First, we construed a holistic summary of relevant factors in her daily life. Second, we described her challenging behavioral trajectory by identifying stable phases. Third, instability and extraordinary events in her environment were evaluated as potential change-inducing mechanisms between different phases.

Case presentation

A woman, living at a residential facility, diagnosed with mild intellectual disability and borderline personality disorder, who shows a chronic pattern of aggressive and self-injurious incidents. She used ecological momentary assessments to self-rate challenging behaviors daily for 560 days.

Conclusions

A qualitative summary of caretaker records revealed many internal and environmental factors relevant to her daily life. Her clinician narrowed these down to 11 staff hypothesized risk- and protective factors, such as reliving trauma, experiencing pain, receiving medical care or compliments. Coercive measures increased the chance of challenging behavior the day after and psychological therapy sessions decreased the chance of self-injury the day after. The majority of contemporaneous and lagged associations between these 11 factors and self-reported challenging behaviors were non-significant, indicating that challenging behaviors are not governed by mono-causal if-then relations, speaking to its complex nature. Despite this complexity there were patterns in the temporal ordering of incidents. Aggression and self-injury occurred on respectively 13% and 50% of the 560 days. On this timeline 11 distinct stable phases were identified that alternated between four unique states: high levels of aggression and self-injury, average aggression and self-injury, low aggression and self-injury, and low aggression with high self-injury. Eight out of ten transitions between phases were triggered by extraordinary events in her environment, or preceded by increased fluctuations in her self-ratings, or a combination of these two. Desirable patterns emerged more often and were less easily malleable, indicating that when she experiences bad times, keeping in mind that better times lie ahead is hopeful and realistic.

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In residential care for individuals with an intellectual disability, challenging behavior is an often used umbrella term for repeatedly engaging in dangerous or threatening behaviors. These can be outer-directed, like aggression towards people or damaging property, and inner-directed, such as self-injurious behavior [ 1 , 2 ]. The latter is defined as inflicting deliberate damage on- or destruction of one’s own body tissue with or without suicidal intent, for example by skin cutting, burning, scratching, or ingesting inedible objects [ 3 ]. For staff, these behaviors are hard to grasp and sometimes difficult to anticipate. Managing incidents afterwards with freedom restricting measures, such as seclusion or fixation, remains an unwanted and increasingly unaccepted common-practice that is harmful to clients and increases staff stress and turnover [ 4 , 5 ]. Staff typically describe challenging behaviors as a way the individual communicates unmet “complex needs” [ 6 ]. Although group-level research reveals many biological, psychological and social correlates of challenging behavior [ 2 , 7 , 8 ], it remains vague what this often-used adjective “complex” means at the individual level. Research focused on the individual rather than on the group can efficiently advance our understanding of complex phenomena [ 9 ]. Therefore, this study provides a unique exploration of patterns of chronic aggressive and self-injurious behaviors in one woman with a mild intellectual disability (MID) and borderline personality disorder (BPD), day-by-day over the course of 560 days.

The overall goal is to obtain an in-depth understanding of when and why challenging behaviors occur, using an analytical strategy inspired by complex systems theory (cf [ 10 ]). This complex systems lens differs from the dominant biomedical perspective on psychopathology. That is, from a complex systems perspective psychiatric disorders are not understood as latent entities that cause symptoms through (relatively static) hard-wired biological mechanisms, but as dynamic patterns of behaviors, emotions and cognitions that are formed over time [ 11 , 12 ]. Complex systems principles have guided individual-specific explorations of dynamics in high-risk young adults [ 13 ], people with depression [ 14 , 15 , 16 ] and dissociative identity disorder [ 17 , 18 ]. While these studies all used quantitative timeseries analyses to describe the dynamics, qualitative methods are just as well-suited within a complex systems framework. Central to complex systems theory is a holistic approach to understand the person in their environment [ 12 ] and qualitative methods can provide a rich account thereof [ 19 ]. The current study therefore offers a holistic and dynamic exploration of a woman with MID and BPD, by employing a mixed-methods strategy with three overarching aims. In the following sections we introduce these three aims step-by-step, with more detailed theoretical background.

Summarizing daily life

The first step is to qualitatively summarize the complex nature of challenging behavior. From a complex systems perspective, any person is considered a complex system, not just individuals with challenging behavior [ 12 ]. It is complex because there is no root cause for the way a person (i.e., system as a whole) feels, thinks, or behaves at certain moments in time. Emotions, thoughts or behaviors emerge from continuous and interdependent exchanges between the system’s internal state and its environment [ 20 ]. Complex systems are everchanging, which is why an integrative understanding requires a detailed description of the interplay between the system’s and context elements over a longer period of time. It is therefore necessary to sample personal experiences and contextual influences frequently over time, for example by making use of ecological momentary assessment (EMA). EMA is a method in which someone frequently self-reports on current or very recent behaviors and experiences over time (typically via mobile-phone) [ 21 ]. The method is well-established in samples with BPD, but although feasible [ 22 ] not often used in MID research. In earlier work involving clients with BPD, momentary self-injury was associated with daily ruminations or heightened negative affect [ 23 ]. Other EMA studies found the intensity of anger associated with daily reports of aggression [ 24 ]. Such internal experiences (i.e., related to thoughts, emotions, or other behaviors) are the primary focus of most EMA research, but there are few studies that explicitly investigate contextual influences and changes [ 23 ]. This is remarkable, because theory indicates that (challenging) behaviors are not only internally driven but are to a large extend elicited by environmental factors [ 12 ]. For instance, self-injury, is known to occur more frequently when experiencing interpersonal stress [ 25 ]. However, internal factors and the environment differs between persons [ 26 , 27 ]. Whereas one person’s self-injury may be triggered by an argument with parents, someone else’s work pressure may trigger it. To obtain a holistic summary of the person-environment interplay, we first explore person-specific internal states and environmental factors qualitatively.

Describing change over time

The second step is to zoom out, quantitatively exploring how these factors are ordered in time on the participant’s 560-day timeline. EMA research typically employs multiple daily self-ratings for 1–3 weeks, but individual accounts of challenging behaviors over longer timeframes are scarce. Some studies used not daily but weekly caretaker-reports of challenging behavioral incidents. These showed that, during a period of 41 weeks, staff of 33 inpatients with MID reported in total 210 aggressive- and 104 self-injurious incidents [ 28 , 29 ]. Interestingly, 4 of those 33 inpatients were responsible for over half of the 210 aggressive incidents, while a staggering 85% of the 104 self-injurious incidents were from only 2 clients. Few individuals thus account for many incidents, but little is known about the day-to-day temporal patterns of such chronic challenging behaviors over the course of weeks or months.

When a person is tracked over longer periods of time, one can detected phases in which certain behaviors are relatively stable. A single-case study using EMA of a person with a major depressive disorder over almost eight months (239 days) [ 15 ] found two distinct phases. The first four months were characterized by consistent low self-reported depressive symptoms. On the 127th day this abruptly changed, marking the start of a four-month period characterized by consistently high depressive symptoms. From a complex systems perspective, these two stable phases (before and after day 127) are called attractors [ 30 ]. That is, the dynamics of the person (i.e., person-environment system) are attracted towards a specific behavioral pattern that remains relatively stable over time (e.g., a depressive phase in this example). Importantly, stability does not speak to the desirableness of the patterns, but only to the consistency of change over time. For example, consistently never self-harming, consistently being aggressive once-per-week on Tuesdays, or consistently self-harming on weekends are all examples of stable patterns. Following complex systems theory, stable patterns of challenging behaviors can thus be understood as attractors [ 11 , 12 ]. Our second research question is how challenging behaviors are ordered on the participant’s 560-day timeline? This is done by identifying if there are different attractor states (e.g. time-periods with relatively few vs. many challenging behaviors) and explicate ways in which these time-periods are (dis)similar from one another in terms of internal states (e.g., experienced emotions) and environmental influences (e.g., social interactions).

Change-mechanisms

In the third and last step we zoom in again by exploring transition-points: moments that ‘kickstart’ abrupt change towards a new attractor (cf. day 127 in [ 15 ]). Complex systems theory posits two general mechanisms for the change from one attractor to another that are relevant in the context of this study.

First, instability-induced change (also called bifurcation-induced change [ 31 ]) is the mechanism in which an existing attractor destabilizes, thereby forcing the system to reach a new attractor. In Fig.  1 , someone’s current state (e.g., frequently self-injuring) is visualized as a ball, located in a basin which reflects the attractor. The two basins reflect two example attractors: a pattern of few self-injuring behaviors and a pattern of frequent self-injuring behaviors. The basin’s depth metaphorically represents the strength of the attractor state. Stronger attractors are harder to change and therefore everyday events typically do not trigger enduring change. Figure  1 A shows instability-induced change, in which an existing attractor destabilizes to the extent that there is no valley left to contain the ball, making the ball roll towards a new valley [ 11 , 12 , 32 ]. Note that during instability, the ball can move more ‘freely’ through the valley (as it is less steep), leading to increasingly variable behavior. Measures of temporal complexity and variability can therefore pick up on instability [ 33 , 34 ].

Second, event-induced (also called noise-induced [ 31 ]) change is when an extraordinary event (e.g., unexpectedly being fired from work) ‘pushes’ the ball towards a different attractor, without the existing attractor losing its stability first (Fig.  1 B). One would not expect instability as an early warning signal for the transition in this event-induced change, while one would expect the presence of an extraordinary event [ 12 , 31 ]. This makes it possible to empirically differentiate instability-induced and event-induced changes. The third aim of this study was therefore to evaluate which, if any, of these two change-mechanism(s) potentially underlie transitions between attractors.

Conceptualization of two potential change-mechanisms according to complex systems theory. Possible attractors are visually conceptualized as a landscape with basins. In this example, the left basin reflects a desirable attractor (few self-injury) and right one an undesirable attractor (frequent self-injury). The ball reflects a person’s state at one point in time while arrows below the ball symbolize interactions between person and environment in daily life. The top panel ( A ) reflects a mechanism in which we can observe instability over time. During instability the attractor loses strength, visualized as the basin becoming more shallow. When this happens, interactions between person and environment, however casual or extraordinary, lead to a transition towards another attractor. The bottom panel’s mechanism ( B ) reflects a mechanism in which the attractor itself does not lose strength. Therefore this will not be marked by instability. Everyday events will not be enough to reach a transition. Instead it takes extraordinarily strong environment-person interaction to ‘force’ this change

The participant is a woman in her 30s, diagnosed with MID and BPD. For over a decade, she has lived in a 24-hour residential care facility specialized for people with MID and severe behavioral problems. Her daily routine typically consists of working in the house (e.g., cooking, cleaning), she likes to take walks, and enjoys playing board games. For several days a week she goes to an activity center where she works creatively (e.g., draw paintings, make music), alone or together with others. This provides important structure in her daily routine. Staff is available 24 − 7 to support her. Even seemingly regular tasks, such as arriving in time for appointments, may be perceived as onerous. Staff are therefore reminded to compliment her regularly, even with seemingly trivial accomplishments. She best thrives when she experiences support that is clear and structured, because that makes her feel calm and secure.

Before she lived in the care facility, during her childhood and teenage years, she experienced traumatic events that undoubtedly contributed to challenges she faces nowadays. She often perceives her life as a struggle, some days more than others. She mostly communicates her struggles calmly to others, but sometimes her tensions become explicit to her environment when she self-injures or is physically aggressive. According to her care professionals, her overall well-being is poorer on days when she shows these behaviors. Her care professionals have several hypotheses about factors contributing to her challenging behaviors. One is that she does not trust herself to be alone. The self-injuring and aggressive incidents are, at least sometimes, perceived as a call for reassuring attention from staff. Another hypothesis is that her challenging behaviors are a maladaptive emotion-regulation strategy. Unpleasant emotions can (sometimes unexpectedly) accumulate very rapidly. Over time, she has learned that she can immediately achieve short-term relief from this overwhelming emotional experience by self-injuring. Alternatively, difficulties regulating negative emotions are also considered a cause of aggressive behaviors. After self-injurious or aggressive incidents, staff need to ensure the participant’s and others’ safety, sometimes by imposing freedom restricting measures such as seclusion or fixation. Such drastic measures are resented by staff and the participant alike. She is highly motivated to change her challenging behavioral patterns, and therefore follows dialectical behavior therapy that aims to increase her emotion regulatory abilities [ 35 ].

Procedure and measures

As part of dialectical behavior therapy, the participant completed daily self-registrations via a mobile phone application. Hence, these EMA data were initially not collected for research purposes. The participant and her clinician formulated the application’s daily EMA questions together. Emotions, behaviors and cognitions with maximum relevance to her treatment goals and daily life were translated into questions that the app prompted automatically on her phone at 7:00 PM. Seven of those questions could be answered on a slider with six answer options that ranged between “not feeling at all” and “an intense feeling”. These questions inquired to what extend she (1) felt happy, (2) felt scared, (3) felt sad, (4) felt angry, (5) had the urge to self-injure, (6) thought of death, and (7) had the urge to be aggressive, on that particular day. She also self-rated with either a “yes” or “no” whether she, on that day, (8) had self-injured and (9) had been physically aggressive. The participant followed dialectical behavior therapy from mid-2019 until mid-2021, which consisted of weekly group sessions with other clients, one-on-one sessions with a therapist and 24-hour telephone consultation. During these individual sessions, therapist and participant discussed recent self-injurious and aggressive incidents registered in the diary. The participant continued to complete her self-ratings on a daily basis, even when therapy was paused due to Covid-19 restrictions. This was not because she was told to – she felt that she benefitted from daily self-reflections in the app. In total, she completed her diaries for a period of 560 days and was rewarded with a gift card for her long-term dedication.

Informed consent was obtained from the participant and her legal guardian to (1) present and analyze the aforementioned daily diary entries and (2) to access the records (i.e., electronic client files) to perform supplementary qualitative analyses about therapeutical context and care professional’s perspective on her functioning. This electronic health system is a routine procedure in which care professionals describe multiple times per day, the provided care, implemented measures and any relevant daily events concerning the participant. The records of the 560-day self-rating period were retrieved and any information that could be traced back (names of persons, cities, organizations, locations) were replaced by codes such ‘Person A’ or ‘City B’. Her clinical team (clinician and closest care professionals) approved aforementioned procedures beforehand. The Ethical Committee Social Sciences of Radboud University and the Ethics committee of the care organization judged that the research was conducted in accordance with the Declaration of Helsinki.

Visualization of our three-step-approach to this case-study

We employed a mixed-methods triangulation design study with both qualitative and quantitative data [ 36 ]. The study had a three-step approach based on complex systems theory (Fig.  2 ). First, we obtained a comprehensive summary of the participant’s daily life through qualitative analyses of the daily caretaker records. These qualitative findings were then quantified, to then be integrated with quantitative daily self-reports. Secondly, we described the trajectory of her self-reported challenging behaviors by identifying transition-points and characterizing the different attractor states. Thirdly, we evaluated transition between attractor states in terms of (in)stability and extraordinary events (cf. Figure  1 ).

Analytical strategy

The first step was to qualitatively analyze the anonymized daily records in accordance with the phased approach of thematic analysis [ 19 ]. This thematic analysis was conducted by the first author together with four Master’s students in Pedagogical Sciences, all under the supervision of a researcher with ample experience in qualitative methods. A thematic analysis is an inductive method whereby the coders collaboratively construct themes and patterns from the text in an iterative process that contains six phases: data familiarization, generating initial codes, searching for themes, reviewing themes, defining themes, and producing the research report. In each of these phases, the coders frequently came together to discuss and interpret the records. All five coders first familiarized themselves with the data by reading the whole daily records text file, which consisted of > 300,000 words. Together the coders then practiced the initial coding. The text file was then divided into five roughly equally large chunks of daily records text. Each coder then generated initial codes on his/her own text. The coding was done using MAXQDA 2022 [ 37 ]. During the initial code generating phase, coders came together thrice to compare each other’s initial coding wording and interpretation of the text. These iterative consensus-building sessions lead to the construction of a preliminary overview of candidate subthemes and themes (i.e., codes that were interpreted as reflecting the same higher-order construct). During this collaborative, inductive process, the wording and structure of these (sub)themes were refined into one thematic overview that contained a theme- and subtheme-structure that captured themes based on the whole dataset. This procedure fosters a shared understanding among all coders, resulting in a consensus over the overarching thematic structure (thematic map). From this jointly construed thematic map, every coder then coded the records once more from scratch. That finally resulted in a MAXQDA file with fragments of coded text on a specific day. These qualitative data were then quantified to a dataset containing only binary variables with a (sub)theme coding present (1) or not present (0) per day.

The researcher then met with the participant’s clinician, who has known her for over a decade, to discuss the thematic overview and underlying codes. The goal of this meeting with the clinician was to (1) ascertain the appropriateness of challenging behaviors as the most indicatory variables to summarize the system’s overall state, and (2) identify the most relevant (sub)themes for explaining the frequency of challenging behavioral incidents at any given period.

Describing change trajectory

The subsequent steps were quantitative analyses – all performed in RStudio-2022.02.2–458 [ 38 ] which runs on R software version 4.2.0 [ 39 ]. To evaluate concurrent validity of self-ratings, we performed χ 2 tests between self-ratings and informant-reported (daily records) accounts of days with self-injury and physical aggression. Kazdin [ 40 ] recommends evaluating single-case timelines by combining visual inspections of graphed timeseries with statistical analyses. We therefore visualized the two self-report timeseries (physical aggression and self-injury) using functionality from ggplot2 [ 41 ].

Next, we pinpointed transitions in the physical aggression and self-injury timeseries on the 560-day timeline. This transition-point detection was done with the ts_levels function from package casnet [ 42 ], which uses recursive partitioning [ 43 ] to classify segments (or phases) on a timeseries with a relatively stable mean. We did this for the physical aggression and self-injury variables. Because these two variables are binary (0 = behavior did not occur on that day; 1 = behavior occurred on that day), mean levels effectively reflected the proportion of days with incidents within a phase. In the ts_levels function the minimum duration of one phase was set to seven days, comprising a whole weekly routine, and controlling for day-of-the-week effects. The absolute change criterion was set to 25%, meaning that each identified transition reflected at least a 25% increase or decrease compared to the mean of the preceding phase (cf [ 44 , 45 ]). Based on suggestions by Kazdin [ 40 ], we searched for transitions by visually inspecting a graph of the raw binary timeseries and a plot of the levels identified using the ts_levels function [ 42 ].

After pinpointing transitions, we characterized the different attractor states in terms of what makes them (dis)similar from one another on the 560-day timeline. We calculated – per phase and across the whole 560-day timeline – the mean frequency of self-rated challenging behaviors (i.e., mean days with challenging behaviors) and the mean frequencies of (sub)themes that the participant’s clinician hypothesized to be explanatory. Furthermore, we examined – per phase and across the whole 560-day timeline – whether these clinically relevant (sub)themes were associated with challenging behaviors. That is, Fisher’s exact tests evaluated whether a reported challenging behavior occurred (beyond chance) on the same days as reports of staff-hypothesized risk- or protective factors. Additionally, we performed Fisher’s exact tests to evaluate the relation between staff-hypothesized risk- or protective factors from one day until the next (lag-1 association). Due to the number of repeated bivariate associations we evaluated significance at p  < 0.01.

For the third and last step we analyzed temporal instability and pinpointed extraordinary events, to obtain insight into potential change-mechanisms (i.e., either instability-induced, event-induced or both). The (in)stability of daily self-ratings was analyzed with dynamic complexity [ 46 ] as implemented in R-package casnet [ 42 ]. Dynamic complexity is comprised of a multiplication between distribution measure D, which reflects the distribution uniformity of data-points within the range of the used scale, and fluctuation measure F, which indicates the strength and number of fluctuations within the timeseries. As such, it is more robust to non-stationarity and periodicity than alternative measures such as variance (cf [ 33 , 46 ]). Because dynamic complexity cannot handle missing data, we first employed Kalman smoothing with the na_kalman function [ 47 ] to impute missing data-points using a structural model fitted by maximum likelihood. Dynamic complexity can only be computed for ordinal or continuous timeseries [ 46 ], hence dynamic complexity could not be computed for the binary variables aggressive and self-injury incidents. Instead, dynamic complexity was calculated on the most relevant six-point scale items: “urge for aggression” and “urge for self-injury”, each within a seven-day backwards overlapping window. This window shifts gradually along the timeseries without changing in width, such that dynamic complexity is first calculated for each item between day 1 and day 7, then between day 2 and day 8, and so on. With this 7-day window we again control for day-of-the-week effects. The windowed dynamic complexity was visualized on a timeline per item. A one-tailed z test (α = 0.05) was applied on each dynamic complexity timeline to determine at which time-windows there was significant instability (i.e., high dynamic complexity). We chose to perform a one-tailed significance test because we wanted to examine the occurrence of high dynamic complexity values (not low values), exceeding the threshold of the average dynamic complexity (cf [ 17 , 18 , 33 ]). We ultimately described, per identified transition, whether it was preceded or accompanied by significant instability and/or an extraordinary event. These extraordinary events were codes categorized into subthemes during the thematic analysis procedure. That is, after the coders had familiarized themselves with the data, generated and discussed initial codes they reached consensus about which events reflected everyday events and which events were extraordinary across the 560 day period. In the absence of instability, an extraordinary event occurring the week prior to a transition was considered an potential indicator of an event-induced mechanism (cf. Figure  1 ). Change was potentially instability induced when the dynamic complexity of aggression and/or self-injury was significantly high the week before or during change, without an extraordinary event the week prior. In the presence of both instability and an extraordinary event, we conclude change was potentially event- and instability-induced.

To first obtain a comprehensive summary of her daily life we conducted a thematic analysis of the care taker’s records. The analysis resulted in a thematic map consisting of six themes and sixteen subthemes. The six themes were the received care, daily activities not related to care, positivity, physical complaints, emotional tensions, and challenging behavior. These themes reflect categorizations that are interrelated. We visualized (sub)themes and their interrelations in Fig.  3 .

Thematic map, generated from the thematic analysis, showing (sub)themes and the links between them

Anything positive reported in the daily records was coded under the theme positivity . This pertained to events that were extraordinary positive for her on the 560 days. Positive social contact was a subtheme that reflected more casual positive interactions with care professionals, family or friends. The subtheme general positivity included any mention of positive affect. This could be sense of humor, making a relaxed impression, having a good day, or positive dialogue with care professional. For example the mention “ client played boardgames after the barbecue and visibly enjoyed herself ” indicates that positivity occurred during descriptions of the issue of the day, which are subdivided under two themes: received care and daily schedule. The latter involved her daily schedule unrelated to medical or psychological treatment, which could be either at the facility (e.g., doing the household or taking a walk) or social activities away from the facility (e.g., board games at activity center). Received care related to any actions from care professionals, which could be either in the form of security measures (e.g., checking her room for potential objects used for self-injury or secluding the participant), dialogue with care professionals (e.g., talking about what is on her mind, complimenting the participant), medical care (e.g., treatment of wounds at care facility or hospitalization), or psychological therapy sessions (dialectical behavior therapy and psychomotor therapy).

Challenging behavior was a theme with three subthemes: verbal aggression, physical aggression, and self-injury. The latter two were also self-reported on a daily basis by the participant. Daily record accounts of challenging behavior related to emotional and/or physical discomfort, for example “ client cut herself with a broken piece of plate, she says she wanted to experience different pain than the pain in her stomach ”. The theme physical complaints related to either feeling sick (e.g., nauseated) or mentions of the participant communicating experiencing physical pain. Both could be a cause and consequence of challenging behavior. For example, self-injury caused wounds, which lead to inflammation, which naturally come with pain or sickness such as fever. Self-injury through re-opening existing wounds was the most frequently reported self-injurious form, which exacerbated physical complaints. That required her receiving (extra) care. Related to both challenging behaviors and physical complaints were emotional tensions – a broad theme that comprised of three subthemes. Records describing extraordinary negative events (e.g., losing her pet), social tensions (e.g., quarrels with staff or family) and general descriptions of negative affect (e.g., feeling irritated, fearful, frustrated, or insecure). Emotional tensions could be triggered during any daily activity and could be both cause and consequence of physical complaints. For example “ client is working on a painting. When we adjust schedule to playing a boardgame she becomes angry” . Moreover, it could result in receiving extra care (e.g., support from staff when in distress) or was the consequence of dissatisfaction with received care (e.g., anger after imposed security measure). Challenging behavior always came with some form of emotional tension.

To better interpret the thematic map, the researcher then asked the participant’s clinician whether the participant knows better and worse times and what typically indicates to staff whether her overall well-being is high or low. Before having seen the results, she confirmed that the frequency of self-injurious and physically aggressive incidents is most telling about her overall well-being. This indicates challenging behaviors summarize her overall state. From the (sub)themes generated in the thematic analysis, the clinician then identified 11 staff-hypothesized risk- and protective factors for her challenging behaviors. These factors were either specific codes or broader (sub)themes: reliving past trauma, hallucinating, negative affect, receiving medical care, receiving compliments, the imposing of freedom restricting measures, experiences of physical pain and sickness, receiving psychological therapy, tensions with her family, and positive social interactions. These variables were used for subsequent analyses.

The participant completed the daily survey 494 times during the 560 days (88%). Physical aggressive incidents were self-reported on 65 days (13%), while self-injury was self-reported on 247 days (50%). Staff reported aggressive and self-injurious incidents on respectively 75 days (16%) and 164 days (33%). A χ 2 test indicated agreement between self- and informant ratings. That is, counts of observed matches between self- and informant ratings of these challenging behaviors (i.e., both reporting daily presence or absence of behavior) was significantly higher than the expected count for self-injury, χ 2 (1, N  = 494) = 91.56, p  < 0.001, and for aggression, χ 2 (1, N  = 494) = 12.76, p  < 0.001. As both challenging behaviors can occur without being noticed by staff (e.g., when on leave), we analyze self-reported challenging behavioral dynamics.

Binary timeseries of self-reported physical aggression and self-injurious behavior during 560 days and changes in its mean frequency. X-axes show number of days. Panel A shows raw challenging behavioral timelines. Gray cells are days that the participant did not complete her diary. In panel B, the lines reflect mean-level changes in raw diary timelines, detected by recursive partitioning algorithm. Colors reflect identified challenging behavioral attractor states (see text for details). The same color means a qualitatively similar attractor. Identified transition-points between attractors are thus the days (on x-axis) when the color changes

Figure  4 A illustrates the raw binary timeseries of self-reported physical aggression and self-injury for 560 days. The recursive partitioning algorithm [ 42 ] first detected mean-frequency changes in raw diary timelines (4A) – the outcome of which is visualized with dashed and solid lines in Fig.  4 B. After visual inspection of the binary timeseries (4A) and their mean-levels (lines in 4B), we found 10 transitions that mark that end of an old- and start of a new attractor (colors in 4B). When the mean-level changes detected by recursive partitioning (up or downward trend in lines 4B) of the two challenging behaviors occurred in the same direction within close proximity to one another (i.e., within 14 days), we marked it as transition that starts or ends a challenging behavioral phase. For example, on day 86 for self-injury a 30% drop was detected by recursive partitioning and on day 91 aggression dropped by 28%. Here we marked day 91 as the transition, as it marked the end of a phase with frequent challenging behavior. Similarly, when self-injury and aggression increased on respectively day 446 and 452, we marked 446 as the transition for a start with frequent challenging behaviors. One exception was made, based on a clear difference in absolute change: on day 46 the proportion of aggressive incidents increased with 25%, while 11 days later the proportion in self-injurious incidents increased by 60%. Hence, only day 57 was marked as a transition. Two detected mean-changes were not marked as transitions: the increase of self-injury on day 122 and the decrease in aggressive incidents on day 257. The latter (day 257) was not marked as an attractor change, because of the large number of missing values that followed this transition (see gray band in Fig.  4 A). Day 122 was not marked after visual inspection of the self-injurious incidents timeseries (Fig.  4 A) we noted that (1) the upward trend may have started sooner (possibly day 110) and (2) this upward trend did not seem significant as the frequency of self-injuries– relative to the entire timeline – was already high between day 57 and day 146.

Table  1 summarizes, for each phase, the mean frequency (i.e., percentage of days) that both challenging behaviors were self-reported in the diaries. Furthermore, we calculated the mean frequency per phase for each of the 11 staff-hypothesized risk- and protective factors (see Supplementary Material 1 ). To obtain insight into what makes phases (dis)similar from each other in terms of these risk- and protective factors, we compared the mean frequency of them within each phase to the 560-day mean of that factor. We considered a phase-mean salient if it was above or below 1 SD relative to that factor’s 560-day mean. For example, salient about phase 1 (day 1 to 56) was that familial tensions occurred on 18% of days, which was relatively often, given that it is > 1 SD relative to the 560-day mean of 5%. Although Table  1 shows that the 11 frequencies of staff-hypothesized risk- and protective factors differ between phases, we find no unequivocal bivariate if-then explanation (e.g., if a phase has familial tensions, then high aggression) for either of the challenging behavioral frequencies.

In addition to describing average frequencies across phases, we also analyzed bivariate associations at the within-day level (contemporaneous) and across days (lag-1). That is, whether challenging behaviors and reports of staff-hypothesized risk- and protective factors co-occurred on the same day and from day-to-day. Fisher’s exact test revealed that, across the entire 560-day timeline, freedom restricting measures were more often applied on days with aggression (OR = 5.27, 95%CI [2.82, 9.78]) or self-injury (OR = 2.72, 95%CI [1.56, 4.89]). Across the 560-day period, there were no bivariate contemporaneous associations between challenging behaviors and reliving trauma, hallucinating, receiving medical care, compliments or psychological therapy, having pain, sickness, experiencing negative affect or familial tensions, or positive interactions. On days after an implemented freedom restricting measure, our participant was more likely to engage in aggressive (OR = 4.80, 95%CI [2.58, 8.86]) and/or self-injurious behavior (OR = 1.97, 95%CI [1.67, 3.39]). On days after a psychological therapy session (DBT or psychomotor therapy) she was less likely to engage in self-injurious behavior (OR = 0.36, 95%CI [0.15, 0.79]). To explore these associations within phases (and possible differences between phases), we repeated the same Fisher’s tests per phase, on both the contemporaneously and lagged timescale (484 tests; 11 themes × 2 behaviors × 11 phases × 2 timescales). The only significant associations that hold within certain phases evolve around freedom restricting measures, indicating that these measures were more likely to occur on the same day as aggression in phase 5, before days with self-injury in phase 7 and before days with aggression in phase 11. All other contemporaneous and lag-1 associations between challenging behaviors and the 11 variables that the clinician hypothesized to be explanatory, were non-significant (evaluated at p  < 0.01 due to multiple testing).

Combined graph of the participant’s self-reported challenging behavioral patterns, transition-points, dynamic complexity, and extraordinary events. Panel A shows the raw data of self-reported physical aggression and self-injury. Gray cells are missing data. Panel B and C reflect the dynamic complexity of both challenging behaviors. High values reflect unstable patterns, whereas low dynamic complexity reflects stability during the 7 prior days. The horizontal red lines mark the significance threshold for each variable; dynamic complexity values above the lines indicate statistical significance (α = 0.05). Orange, yellow, blue, and green background colors are attractor states. Panel D and E reflect pinpointed positive and negative extraordinary events that were identified as such in the daily records

Figure  5 shows the occurrence of challenging behaviors (panel A), the (in)stability of self-reported patterns in urges for challenging behaviors (panel B and C), and extraordinary events (panel D and E) on the 560-day timeline Footnote 1 . Each point on the graphs in panel B and C reflects how unstable (i.e., irregular and erratic) the fluctuations of self-rated urges for challenging behaviors were in the previous 7 days. Low values indicate stable patterns, whereas high dynamic complexity values are indicative of temporal instability. Everyday events are extremely plentiful, making them impractical to pinpoint on a timeline. Extraordinary events, however, were derived from thematic analysis results. We considered two subthemes: positive events and negative events (see themes positivity and emotional tensions in Fig.  3 ), as they reflected impactful events that were extraordinary across the 560-day timeline.

Table  2 summarizes what happens one week before each of the 10 transition-points. There were four transitions towards an attractor with more frequent challenging behavior than before. These undesirable transitions were all either instability-induced, environment-induced or a combination of both (Table  2 ). Day 221, for example, was likely an event-induced change, given that there was no instability, but the first Covid-19 lockdown likely led to this undesirable change. Social contact with friends and family – as well as support from staff – were drastically reduced while in lockdown, disrupting her everyday routine increasing her need for aggression and self-injury as an outlet. There were also six desirable changes. One such example was that the week before she finished her tattoo (extraordinary event on day 413) was instable, possibly due to prospect of this exhilarating moment, marked the start of a new phase with few challenging behaviors. However, the relation between transitions, instability and extraordinary events was not entirely clear-cut, as two desirable transition-points (day 147 and 286) occurred during stable periods and without any notable events. Figure  5 further shows that extraordinary events occurred during stability, but without a transition (e.g., starting her tattoo on day 350). Even an extraordinary event in combination with instability was no guarantee for a transition (e.g., on day 367 a fight in the family occurred during a highly unstable week without a transition). In summary, although instability seemed to increase the chance of transitions – especially in combination with an extraordinary event – our findings do not imply that instability and extraordinary events are incontrovertible warning signals that always explain meaningful change on the participant’s 560-day timeline.

Discussion and conclusions

The current study provides a unique exploration of day-by-day aggressive and self-injurious patterns in one woman with a MID and BPD. Applying a three-step-approach inspired by complex systems theory, we aimed for an in-depth understanding of her challenging behaviors over the course of 560 days. Summarizing her daily life was the first step, revealing that a large set of internal and environmental factors relevant to her daily life. The clinician narrowed this large set down to 11 staff hypothesized risk- and protective factors: freedom restrictive measures, reliving trauma, hallucinating, experiencing pain, sickness, negative affect, familial tensions, positive interactions, receiving medical care, compliments or psychological therapy. Overall, freedom restricting measures were more likely to occur on the same day as challenging behaviors, which is not surprising. It is striking, however, that self-injury and/or aggression were more likely to occur the day after a coercive measure by staff, indicating that although these measures may be effective to suppress certain behaviors in the moment, they have detrimental effects on the longer run [ 4 , 5 ]. Furthermore, we found that on the day after a psychological therapy session (DBT or psychomotor therapy) she was less likely to self-injure. These results imply that downscaling of freedom restricting measures and upscaling of psychological therapy (where possible) is warranted. All other bivariate associations between hypothesized risk- and protective factors with both challenging behaviors – explored phase-by-phase and day-by-day – were non-significant, indicating that challenging behaviors are not governed by mono-causal if-then explanations (e.g., if phase has many familial tensions, then high aggression or if day with hallucination, then self-injury). The multitude of bivariate null-results speaks to the complex nature of these behaviors at the case-level [ 2 , 6 , 7 , 8 ].

In the second step, we described the trajectory of challenging behaviors over time. We identified 11 distinct, relatively stable phases within the 560-days timeline. These 11 phases could be narrowed down to four qualitatively different attractor states: high levels of self-injury and aggression (2 phases), average levels of self-injury and aggression (5 phases), low levels of self-injury and aggression (3 phases), or high levels self-injury with low levels of aggression (1 phase). The mean frequency of the 11 staff-hypothesized risk- and protective factors varied by phase: no two phases were similar (Table  1 ).

In the third step we focused on (the week before) transitions between attractors, exploring potential change-inducing mechanisms (Fig.  1 ). Our findings suggest that the mechanism of two transitions remained unknown, two were event-induced, two were instability-induced and four could be environment- and/or instability-induced (Table  2 ). Six transitions were thus potentially instability-induced, which is in line with empirical evidence for instability as an early warning signal for upcoming transitions [ 17 , 33 , 34 ]. Nevertheless, extraordinary events and/or instability did not unequivocally imply a transition, as both instability and extraordinary events occurred without transitions afterwards (Fig.  5 ). The two unknown mechanisms were both for desirable transitions, which could mean that relatively minor events in daily life apparently were enough to elicit positive change. One possible explanation would be that her desirable attractor is stronger than the undesirable one. That is, we could perceive her undesirable basin (Fig.  1 ) to be shallower, making this state easier malleable relatively minor everyday events. Future research could explore this further with recently developed analytical methods that quantify the stability of an attractor state [ 48 ].

There were three notable limitations to this study. First, results from a case-study are obviously not generalizable. Repeating (and finetuning) our three-step-approach on different cases, will reveal the extent to which of our findings are person-specific or generalizable across cases. This will ultimately increase our understanding of challenging behaviors and consequently enable optimized care. Second, our thematic analysis was based on care professionals’ daily records. Registering relevant events in the electronic health records is a routine practice in the residential care setting – done with the intention to document the client’s case file and keep colleagues up to date. Hence, care professionals received no instructions as to how extensive or comprehensive their reports should be. This meant that when a specific code was not identified from the records on a specific day, it may either have not been observed by care professional(s) or simply not been registered. Seemingly trivial happenings, such as giving complements will likely have occurred more often than that the coders coded in the records. Third, despite a-priori anonymization of the records, it was evident that the records included reports of many different (approximately > 30 different) care professionals. The richness of the described daily events likely partially depended on who reported and how much time that person had. Fourth, our three-step procedure was subject to many researcher’s degrees of freedom. The 11 staff-hypothesized (sub)themes that the participant’s clinician selected out of the thematic map, for example, remained a personal choice. Furthermore, the criterion we used to evaluate a threshold for instability (one tailed z-test at p  < 0.05) is based on convention (cf [ 16 , 18 , 33 ]), but ultimately still a choice. On the other hand, there are no established guidelines available for a complex systems guided case study.

This study also had strengths. First, by shedding light on events in the environmental that may ‘push’ the system into another state, our study adds to the (complex systems) psychological literature that has so far predominantly focused on instability preceding transitions [ 24 , 33 , 34 , 45 ]. Qualitative analyses of case records allowed us to distinguish everyday- from extraordinary events. Because this distinction was informant-based and not self-reported, it is possible that meaningful events were missed (here or in any step of our analysis). Future qualitative or mixed-methods research should further explore the nature of events that the individual perceives to ‘kickstart’ transitions. A second strength is that our research gives a helicopter view of day-by-day processes across several months. The majority of EMA research in BPD studies within-day fluctuations. For our participant behavior did not only fluctuate within-days, also across time-periods of multiple weeks or months. This may inspire EMA research in BPD to consider further exploring fluctuations on slower timescales. Nevertheless, within-day processes remain relevant. Complex systems, after all, are characterized by interacting processes across many timescales [ 12 , 49 ]. In our case, unobserved instability at shorter timescales (e.g., hour-to-hour) could have induced our (un)observed transitions. After all, within-day affective instability is a well-documented correlate of challenging behaviors in BPD [ 23 , 24 ]. The case records did provide within-day detail, but because we eventually quantified these into dichotomous codes per day (present vs. absent), the richness of within-day information was lost. Future research should zoom further into what happens within the day of (or days before) a transition. Statistical process control charts [ 50 ] could then be used to detect whether significant rises in tensions predict challenging during the day.

The participant selection in this study was solely based on convenience sampling, that is, she was the only one in DBT who adhered to the diaries this consistently for this long. The uniqueness of the already collected diary data, both in terms of the chronicity of her challenging behavior [ 28 , 29 ] and her devoted compliance to the diaries, was the reason she and her legal guardians were asked for this study. Whether or not these study procedures can be replicated in different cases depends on how well the implemented diary procedure elicits an intrinsic motivation to stay compliant. There were certain participant- and study characteristics that contributed to her uniquely long-term compliance, which are lessons for scientists or practitioners who wish to collect similar data. First, the diaries were an integral part of her DBT program – for which she was already highly motivated. Second, the diaries items were constructed in collaboration with the participant, and thus tailored to her experience world. A personalized approach to EMA in practice, by integrating it in therapy and individualizing item-selection, is an opportunity for increasing participant involvement and compliance [ 22 , 51 ]. Third, for compliance it may have been helpful that the participant has lived in residential care since childhood. This institutionalization – at least with our participant – contributed to the responsibility she felt to follow through on prescribed activities in her care plan. Completing the diaries became part of her daily routine structure. It is likely that this played a part in her continued compliance to the diaries, even when the Covid pandemic made DBT impossible. Nevertheless, further research into factors that enhance or hamper EMA compliance is necessary.

Importantly, personalized daily diary monitoring – and therefore this study’s three-step analytical procedure – is already certainly feasible for other individuals [ 22 ]. Replicating this design is therefore encouraged. Complex systems theoretical principles have already guided mainly quantitative timeseries analytical inquiries in different clinical case studies with less measurements (e.g., 91 [ 17 ] or 138 [ 18 ]) and more measurements (e.g., 1.476 [ 15 ]). Based on these studies [ 15 , 17 , 18 ] we would we expect that altering between different phases over time is a finding that is likely to replicate. However, other clients without such chronic challenging behavior and without such an institutionalized background would likely show very different patterns. That is, dynamic patterns with qualitatively different – and potentially less strong – attractor states. At this point, it remains speculation how this case study’s findings relate to other clients. The surge of EMA applications in clinical settings during the past years suggests that large n  = 1 datasets may become more commonly available. Replicating our three-step method would allow for between-person comparisons, shedding light on how (a)typical the nature of our participant’s attractor states and number of change-points was, compared to others (e.g., people with BPD and/or in residential MID care).

The study altogether illustrates the added value of in-depth case-study research [ 9 ] and the utility of complex systems principles to guide such an inquiry. Our three-step approach adheres to recent calls for holistic and dynamic accounts of challenging behaviors in BPD [ 52 ]. Over time, few (if any) if-then relationships could be said to possibly explain the participant’s challenging behavior, substantiating it as a complex phenomenon that is difficult to grasp. Our results thus make explicit why care professionals describe to these behaviors as “complex” [ 6 ]. Nevertheless, in-depth idiographic science can help disentangle this complexity, generating new insights relevant for practice. Zooming out revealed different phases of challenging behaviors. For staff it is good to recognize available attractors and adjust care accordingly. With our participant it illustrated that she – just as anyone – has both ups and downs. Her desirable attractors actually emerged more often than desirable ones (three periods of low aggression and self-injury vs. two periods with high aggression and self-injury). Moreover, her desirable patterns were less easily malleable than undesirable ones. For the participant, this means that when things are down, keeping in mind better times are ahead is as hopeful as it is realistic. Repeating this idiographic design on other persons with chronic challenging behavioral patterns may therefore nuance the bad reputation they may have at the care facility.

Data availability

R scripts are publicly available from https://doi.org/10.17605/OSF.IO/XRMHU . Preprocessed data are available upon reasonable request via https://doi.org/10.17026/SS/VOXYE9 . Requests can be made for research purposes only.

In Fig.  5 we present the dynamic complexity of the most relevant two variables for these challenging behaviors. For completeness sake, we present raw data of all seven self-rated variables and their (average) dynamic complexity in Supplementary Material 2 . Visualizations of the 11 staff-hypothesized risk- and protective factors, in combination with challenging behaviors and instability are accessible through https://hulsmans.shinyapps.io/themes/ .

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Acknowledgements

We are most thankful to the participant for her long adherence to the daily diaries, and for allowing us to use the data to make this research report. Another big thanks goes out to her clinician for the discussing the thematic analysis results with us. We also thank her legal guardian for proofreading this manuscript. Lastly, we wish to thank Masters students Sophia Politis, Jynthe van Dongen, Fenne van Mil and Maud Wouters for their help with the thematic analysis.

DH, RO and EP were supported by funding from the Netherlands Organisation for Health Research and Development (ZonMw); Grant Number 555002014. ALA and MO were supported by a NWO VIDI grant, Grant No. VI.Vidi.191.178.

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Daan H. G. Hulsmans, Evelien A. P. Poelen & Annemarie van Vonderen

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DH: formulated the research plans and questions, designed and performed qualitative and quantitative analyses, interpreted the results, wrote the initial manuscript draft, and revised the manuscript. RO: formulated the research plans and questions, project supervision, interpreted the results, and revised the manuscript. EP: formulated the research plans and questions, project supervision, interpreted the results, and revised the manuscript. AvV: formulated the research plans and questions, interpreted the results, and revised the manuscript. SD: helped design and perform qualitative data analysis, interpreted the results, and revised the manuscript. MO: helped design quantitative analyses, interpreted the results, and revised the manuscript. FH: helped design and perform quantitative analyses, interpreted the results, and revised the manuscript. A-LA: formulated the research plans and questions, helped design quantitative analyses, project supervision, interpreted the results, and was a major contributor in revising the manuscript. All authors approved the final version of the manuscript.

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Informed consent was obtained from the participant and her legal guardian to analyze the daily diaries and daily records and write this case-report. Her clinical team (clinician and closest care professionals) were consulted and approved study procedures. The Ethics Committee Social Sciences of Radboud University and the Ethics committee of the care organization were consulted prior to conducting this study. Due to the use of already existing data, the need for formal approval was waived. Both committees judged that our procedures were conducted in accordance with the Declaration of Helsinki.

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Hulsmans, D.H.G., Otten, R., Poelen, E.A.P. et al. A complex systems perspective on chronic aggression and self-injury: case study of a woman with mild intellectual disability and borderline personality disorder. BMC Psychiatry 24 , 378 (2024). https://doi.org/10.1186/s12888-024-05836-7

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17 Startling Truths About Borderline Personality Disorder No One Ever Explained to You

Posted: May 22, 2024 | Last updated: May 22, 2024

Being around some­one with borderline pe­rsonality disorder (BPD) is like riding a wild roller coaster – emotions can change rapidly and drastically. One minute­, they’re blissfully happy, the ne­xt, deeply sad. 

Here are 17 key insights about this puzzling condition that causes such turbulent e­motions and behaviors.

Ups and Downs Galore

For those with Borderline Personality Disorder (BPD), fe­elings are super inte­nse and changeable. Highs are super high, and lows are rock bottom. Regulating e­motions is an everyday struggle.

Black or White­ Thinking

People with BPD tend to se­e things as black or white, all good or all bad. This “splitting” exte­nds to how they view others. Someone idolized one day may be­ demonized the ne­xt. Maintaining stable relationships is a major challenge­.

Fear of Being Abandoned

A core­ fear for many with BPD is being abandoned by love­d ones. Past rejections (real or perceived) fue­l this fear. Some cling tightly, while othe­rs push people away to avoid anticipated hurt.

Not having a solid se­nse of self is common with BPD. They may fe­el empty and unsure of the­ir identity. This unstable self-image­ contributes to impulsive choices and rocky re­lationships.

Impulse Control Issues

Acting rashly without considering conse­quences is a BPD hallmark. From splurging reckle­ssly to risky behaviors, impulsivity can seriously disrupt someone­’s life.

Mood Swings on Steroids

Do you sometime­s feel like your e­motions are a rollercoaster? That’s typical for those­ with Borderline Personality Disorde­r (BPD). They may swiftly switch betwee­n happiness, sadness, and fury. Basic eve­nts can trigger these sudde­n mood swings, making everyday life unpre­dictable.

Walking on Eggshells

Being around some­one with BPD can feel like­ walking on eggshells. You neve­r know what might set them off. One wrong word or action could unle­ash a torrent of emotions, leading to argume­nts and misunderstandings. It’s a constant balancing act for loved ones.

The­ Battle Within

Imagine having a constant war raging inside you. That’s what life­ is like for those with BPD. They struggle­ with overwhelming inner turmoil, and it’s an exhausting battle­ to keep their e­motions in check.

Support Systems Matter

Having a strong support syste­m is vital for those with BPD. Friends, family, and mental he­alth professionals can provide the unde­rstanding and empathy they despe­rately need. It’s a lifeline during their emotional storms.

The­ Stigma of BPD

Despite how common it is, BPD is often misunde­rstood and stigmatized. This leads to shame and re­luctance to seek he­lp. Educating others and raising awareness is ke­y to debunking myths and ensuring those with BPD ge­t the support they nee­d.

The Power of Validation

Individuals with BPD really be­nefit from validation. It helps them fe­el recognized and appre­ciated in their struggles. Acknowle­dging their emotions and expe­riences can affirm the re­ality of their feelings, foste­ring a sense of unity.

Finding Balance in Relationships

For folks with BPD, maintaining strong ties might be­ challenging, yet it’s certainly not impossible­. Drawing boundaries, communicating effective­ly, and self-care can aid in nurturing robust and stable re­lationships.

Coping with Emotional Triggers

Understanding and de­aling with emotional triggers is vital for those suffe­ring from BPD to control their intense e­motions. Staying aware, applying grounding strategies, and e­mploying self-soothing techniques can alleviate the e­motional chaos.

Building Emotional Resilience

People­ with BPD need to build solid mental stre­ngth. It assists them in handling their emotional swings. Maste­ring helpful coping methods and acquiring self-aware­ness aids them in recove­ring from challenges.

Celebrating Progress, Not Perfection

Improving from BPD is a journey fille­d with obstacles and achieveme­nts. Noticing even small amounts of progress and practicing self-compassion is vital for individuals with BPD to keep moving forward.

Breaking Stigma

By sharing their stories and raising awareness, individuals with BPD can help break the stigma surrounding the condition. Opening up about their struggles can empower others and encourage compassion and understanding.

Embracing Hope and He­­aling

Dealing with Borderline­ Pe­rsonality Disorder (BPD) can definitely be­ tough. But there’s hope, you know? With the­ right kind of help, therapy, and coping skills, people­ with BPD can learn to handle those e­motional ups and downs better. They can have­ more stability and resilience­ in their lives.

Working Towards Peace

It’s true that unde­rstanding BPD can feel challe­nging. But by raising awareness, gaining understanding, and having a strong support syste­m, people with BPD can find effe­ctive ways to manage their e­motions and live fulfilling lives. By taking the­ time to understand this condition, they can de­velop tools to embrace life’s journey with greater confidence and inner peace­.

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Improving Research Practice for Studying Borderline Personality Disorder: Lessons From the Clinic

Khushwant dhaliwal.

1 Department of Psychiatry, Yale School of Medicine, Yale University, New Haven, CT, USA

Ayala Danzig

Sarah k. fineberg, short abstract.

Borderline personality disorder is an often misunderstood and underdiagnosed mental illness characterized in part by affective lability. Clinicians’ unique understanding of the disorder has allowed them to develop disorder-specific approaches to treatment. In this review, we highlight how borderline personality disorder research can benefit from greater engagement with key disorder-specific features, including symptom variability and interpersonal sensitivity. In addition, we propose that research which employs interactive tasks will be more reflective of the kinds of volatility found in the real-life situations. Finally, we discuss how mixed-methodology can serve as a way for recovery-oriented research to practice the very ideals and recommendations it suggests. We use a patient case to contextualize each section. As interest in borderline personality disorder continues to grow, an intentional emphasis on a person-centered, recovery-focused, and disorder-specific approach to research is needed.

Introduction

There has been increased interest in the biological mechanisms of borderline personality disorder (BPD) over the past decade and also increased recognition of its significant co-morbidity and symptomatic/etiologic overlap with trauma-related and affective disorders. Major not for profit mental health funding organizations (e.g., Brain and Behavior Research Foundation, American Foundation for Suicide Prevention) have increased focus on BPD, and community and scientific advocates have lobbied the National Institutes of Health to consider BPD as a serious mental illness. As neuroscience and cognitive psychology projects work to define the paths to BPD onset, maintenance, and recovery, it will be important for projects to define outcome measures with an eye to disorder-specific features.

BPD is a mental illness that occurs frequently in the community. Estimates of prevalence over time have been 0.5%–6% 1 ; a recent meta-analysis estimated worldwide prevalence at 1.8%, though heterogeneity across studies was quite high and frequency was higher in high-income than in low-income areas. 2 Frequency is even higher in mental health clinics (10%–20%). 3 , 4 BPD is associated with significant morbidity and mortality, 5 including markedly increased risk of suicide. 6 – 8 People with BPD experience both affective lability (the most sensitive single-item criterion 9 ) and chronic mood symptoms. 10 Interpersonal problems are prominent with fears of abandonment, alternating idealization and devaluation, dependence and/or counter-dependence, and stormy relationships. 11 , 12 Chronic suicidal ideation and behavior are common symptoms and can co-occur with impulsive suicidal statements that serve interpersonal functions (e.g., to communicate overwhelming emotions or to keep a social partner engaged). In addition to interpersonal instability, moment-to-moment shifts can also occur in one’s sense of self. Symptoms can also include impulsivity, anger (felt and/or displayed), dissociation, and quasi-psychotic experiences (e.g., transient hallucinations, ideas of reference, and paranoia).

The specific challenges faced by people with BPD have led clinicians to work out disorder-specific approaches in order to increase treatment-related benefits. 12 , 13 For example, psychoanalytically-inspired treaters have adapted their techniques to include more eye contact and more concrete, active interventions, leaving less room for the people in their care to feel confused about interpersonal cues and overwhelmed by experiences of abandonment and threat (transference-focused psychotherapy 14 and mentalization-based treatment 15 ). Behavioral clinicians and supportive therapists working with people with BPD have shifted toward focus on psychoeducation, especially about the intensity and variability of emotion and behavior (dialectical behavior therapy 16 and good psychiatric management 17 ).

We suggest here that research in BPD can also benefit from increased attention to disorder-specific features. These considerations will be relevant to researchers focused on BPD, as well as to those focused on populations with significant BPD pathology, including post-traumatic stress disorder (PTSD), substance use disorders, and transdiagnostic groups with high impulsivity and/or affective lability.

We begin by introducing a case, which is a composition of patients we have encountered in our clinical work. We suggest several specific approaches (summarized in Table 1 ), including engaging symptom variance in outcome measurement (see Symptom Variability section), increasing interactive approaches in studies of social cognition (see Need for Interactive Tasks section), paying particular attention to the interpersonal aspects of research interactions (see Interpersonal Sensitivity section), and considering recovery-focused outcome measures (see Recovery-Focused Methodology section). Each approach is contextualized with respect to the presented case example.

Ideas for improving clinical research with BPD and related populations.

BPD: borderline personality disorder; EMA: ecologic momentary assessment. Note: *This case is based on a series of adults with BPD with whom we have worked. It does not reflect the specific experiences of any particular individual.

Nora* is a 24-year-old single woman with three children. She has a history of BPD, one prior episode of postpartum depression, and hypertension. She presents for outpatient psychiatric treatment due to intense depression and anxiety with frequent thoughts about suicide as well as episodic anger. She is distressed that so many bad things keep happening to her and feels that her mental illness causes her to act in ways that are out of character. Nora’s sister is in outpatient treatment for schizophrenia with good benefit from medications, and Nora is hopeful that she can find a medication to help her just as much. Over the past several years, Nora had been prescribed antidepressant, mood stabilizing, and antipsychotic medications, and while she initially felt some benefit from each one, the benefits were short-lived.

Nora had recently done well without individual treatment while enrolled in an intensely supportive parenting program outside of the clinic. She returns now, shortly after the conclusion of that program. She is distressed by her frequent conflicts in romantic relationships, with her family, and at work when she has a job. The tipping point came when she got into a physical fight in public which led to arrest. Her probation officer encouraged her to return to treatment after she said that extended time on parole might lead her to kill herself.

While initially hesitant to commit to meeting at regular intervals for psychotherapy, Nora did agree to start with two assessment sessions. She was eager for the therapist to explain her diagnosis to friends and family and to help her work toward solving problems.

How BPD Research Can Better Engage BPD-Specific Features

Symptom variability.

Nora’s therapist initially assessed anxiety and depressive symptoms with self-report scales, which query average mood over one to two weeks. Her therapist found that this approach was not sensitive to the intense mood fluctuations Nora experienced on a day to day basis. While her anxiety and depression were chronic, Nora described “suddenly flying off the handle” or “blacking out with anxiety” when her children misbehaved or her boyfriend was not responsive. By contrast, she often felt and behaved calmly in the hours leading up to these incidents. Nora’s social experience was also rapidly shifting. For example, at one session, she reported that during an argument, she had pinched her boyfriend’s arm hard enough to leave a bruise. She was furious, feeling that he is constantly disrespectful and that she would break off the relationship. In the following session, she spoke of him in markedly different terms, describing him as supportive, loving, and a source of stability and comfort. Nora said that her mood changes were unpredictable and inexplicable. Nora and her therapist began to name mood fluctuations as a specific treatment target. Now, simple statements like “I see that things are up and down again” are used to re-focus from the emotions in the moment to the larger pattern of mood and relational variance.

Clinical research projects often define outcomes as mean value or mean change from baseline. This approach makes sense for disorders with symptoms that are relatively steady over time and across contexts. However, in BPD, symptom variability is a core feature of the disorder; fluctuations are expected in multiple symptom domains. Therefore, research outcome measures need to assess symptoms over enough time, across enough contexts, and with enough repeated observations to capture both the extremes of symptom intensity and the frequency of change. 18 Measuring variance as an outcome itself has been done in BPD to good effect, 19 though this approach has thus far been infrequent in the literature.

Symptom fluctuations in BPD are thought to intensify in the context of stress, especially interpersonal stress. 12 Current symptoms and behavior can be placed in context by assessing for recent stressors and measuring current levels of arousal (self-reported and physiologic). Guided imagery has become an important technique in the addiction field to evoke personally relevant stressors in the laboratory. 20 These personalized narratives have also been used to test the neurobiologic correlates of self-injurious urges in BPD 21 and of paroxetine-associated symptom reduction in PTSD. 22

In order to understand variability, it will be important to use outcome measurement tools that are sensitive to change. Research will benefit from increased granularity of data generated by frequent and even passive sampling. For example, ecologic momentary assessment (EMA) can facilitate tracking of emotions and urges throughout the day. 23 , 24 One study used EMA to demonstrate a correlation between suicidal ideation and affective instability in people with BPD. 25 Another provided real-world support for the hypothesis that non-suicidal self-injury contributed to short-term affect stabilization in people with BPD. 26 Furthermore, EMA has been used for the analysis of event-triggered data. For example, one study analyzed real-time responses of people with BPD to conversations, allowing for the close inspection of the effects of proximal social interaction on perceived rejection and mood. 27 Passive tracking of smartphone use can offer a great deal of information about real-world social experience with very little participant burden (e.g., text and call frequency, number of individuals contacted, sound features of phone calls, and lexical analyses of content). 28 , 29

Need for Interactive Tasks

Nora experienced frequent and extreme shifts in her feelings about people, and these were often triggered during interactions, or as she later reviewed the interactions in her mind. Making use of the therapist–patient relationship, especially in-the-moment interactions was critical to helping Nora apply the techniques and understandings she developed in the sessions to her outside life. On one occasion, Nora arrived to a session feeling flustered and insulted by a comment a friend had made about her new hairstyle, though her friend had insisted it was intended as a compliment. Together, she and her therapist discussed interpersonal sensitivity, misreading of social cues, and examples of when this was happening in the interactions between the two of them. Nora was then able to articulate that she often mistook her therapist’s concern for anger. They began to explicitly discuss the way each interprets the other’s words, gestures, and facial expressions to make sense of emotion and intention.

A great deal of work has examined responses of people with BPD to non-interactive social cues, such as pictures of faces, yielding important information about such processes as attention, response to negative facial expressions, and value judgments (reviewed in Schulze et al. 30 and Bertsch et al. 31 ). Recent studies have begun to extend this work with experiments in interactive social contexts: this approach will be needed to elucidate the interaction-dependent symptoms that are so prominent in BPD. 32 – 34 Two interesting examples of interactive social work are translation of paradigms between rodent and human models and computational modeling approaches to describing social decisions.

Some research in this area has leveraged direct translation to or from animal models. For example, researchers interested in understanding the substrates of social anxiety in human psychopathology translated the rodent “open field” paradigm to a human scale (football field) and social context (open air market) and used GPS technology to trace naturalistic paths of research participants through these venues. 35 To better describe the neurobiology of BPD, two groups have set out to develop animal models of the biology of social exclusion. One of these is in process 36 ; the other has been able to recapitulate several key features of the disorder (including diminished inter-individual trust). 37

Formal modeling of decisions and learning in interactive behavioral tasks has also yielded advances in our understanding of social dysfunction in BPD. For example, King-Casas et al. published a paper in 2008 describing neuroeconomic behavior in BPD. 38 In a computer-based “Trust Game,” they found that people with BPD failed to cooperate with a partner toward a shared goal, and when the partner “defected,” they failed to “coax” the partner back to play. This appeared to fit canonical clinical perspectives: that people with BPD are mistrustful and antagonistic in interactions, perhaps due to poor emotion regulation or high interpersonal sensitivity. However, the application of a formal computational model to these data allowed the scientists to test more specific propositions about mechanism. 39 Data from this model allow us to arbitrate between two very different mechanisms of poor cooperation: a model of ignorance (failing to notice cues from a partner that signal social discord) and a model of antagonism (expecting conflict and being on the offense). The modeling results suggest that people with BPD are much more likely to be ignorant of partner irritability than are control participants. These data also fit with recent data from our group showing that people with BPD are less responsive than controls to rapidly changing reward probabilities in a reinforcement learning task. 40 This finding held for both social and non-social cues, suggesting that the social interactive symptoms in BPD may be explained by a more general difficulty in learning from a changing environment. 40

These two selected examples are far from an exhaustive examination of the approaches to social interactive work, in general or even in BPD, but serve to illustrate the value of innovation.

Interpersonal Sensitivity

When Nora was presented with standardized measures such as the Patient Health Questionnaire (PHQ-9) or Generalized Anxiety Disorder 7-item scale (GAD-7) she would consistently check the boxes that indicated maximum symptoms of depression and anxiety. Not having the capacity to express her feelings verbally, Nora seemed to feel this was the most effective way to express the intensity of her suffering. She also worried that if she did not appear ill enough she might not receive the treatment and help that she craved.

Interpersonal hypersensitivity is a key feature of BPD. As occurred in the case above, the exquisite responsiveness of people with BPD to perceived social cues may lead to biased responses both in the clinic and in research settings. Participants with BPD may be quite focused on the imagined consequences of their responses in the minds of study staff. Participants may be sensitive to how their responses affect study inclusion versus exclusion decisions, which can be perceived as a social validation or rejection. Also, in follow-up visits, a participant with intense psychological distress may be reluctant to say that some symptoms have improved for fear that she will be misunderstood to mean that everything is now okay. She may also be reluctant to say that things have worsened, as she wishes to please the study staff and continue to feel warmly included in the study cohort.

Attention to the quality of interactions that occur between research staff and research participants may help to decrease bias in reported symptoms. Participants may adhere to study procedures more closely due to perceived warmth in the laboratory experience. However, for completion of study outcome measures, it may be helpful to think explicitly about how to reduce response bias that could arise from both positive and negative experiences with study staff. It has been demonstrated that, in clinical settings, therapist-offered validating comments can decrease self-reported negative affect. 41 This is consistent with the core principles of dialectical behavior therapy and may suggest a relevant technique for clinical researchers working with people who have BPD. 16 One approach, therefore, may be to demonstrate interest in all experiences, positive or negative, and/or to separate neutral study raters from the warmer support staff in the lab. Another approach may be to speak very explicitly to participants about the value we see in all responses and how much we value their time, effort, and accuracy, thereby shifting perceived social success from content to process. Social interventions by study staff, such as validating statements to participants, time spent with participants, and inter-session contacts between staff and participants, should be carefully considered and potentially quantified.

Lush et al. have recently explored conscious and unconscious biases in research responses, such as social desirability, demand characteristics, and hypnotizability, and they have examined the implications of these biases for psychological experiments. 42 They coin the term “phenomenological control” to describe the involuntary responses that people have in order to align their experiences in psychological tasks with their prior expectations of experience. For example, in the rubber hand illusion, people with a greater degree of phenomenological control are more susceptible to the illusion that the rubber hand is part of their body. The illusion allows experience to fit with the prior expectation that what you see and what you feel should align. And indeed, people with BPD, who are highly influenced by social cues, have increased susceptibility even to the canonically less illusion-inducing asynchronous condition of the rubber hand illusion task. 43 Therefore, the hypothesis put forth by Lush et al. that direct measurement of hypnotizability may help to control for the contribution of high phenomenological control in participant responses may also have particular relevance for research in people with BPD. Hypnotizability and other quantified traits may be helpful to assess and understand biased response.

Thus, it is important for BPD researchers to engage in a continual careful consideration of the ways in which the interpersonal hypersensitivity discussed and observed in clinical settings can manifest in measurement of research outcomes.

Recovery-Focused Methodology

Setting goals in treatment were initially a big challenge for Nora. She identified wanting to feel less depressed and less anxious but could only imagine this being accomplished with medication. Here too, orienting around her symptoms was limiting as it reinforced her sense of not having agency in her life. It also unrealistically set the expectation that medication could be the main treatment for her illness. Shifting focus from reduction of symptoms to the dialectical behavior therapy-inspired idea of a “life worth living” enabled Nora to set goals that included finding employment and improving her self-care with exercise and dietary changes. Even as Nora’s mood fluctuations continued, she could see progress and feel good about actions she took to improve her life.

Over the past two decades, many mental health clinicians have shifted their frameworks of practice to include recovery as a philosophy on an individual and collective scale. 44 – 46 Davidson et al. have described recovery-oriented care as “a set of guiding principles for mental health care and services in support of the person’s own long-term recovery efforts.” 47 This recovery-orientation often manifests in clinical work as a prioritization of life goals that are meaningful to the person, identification of barriers to achieving those goals (potentially including clinical symptoms), and individual strengths. Increased focus on recovery-oriented practice promotes growth beyond traditional clinical goals. Meaningful changes for individuals may include psychosocial growth (e.g., in personal relationships or forging new social connections), economic progress (e.g., employment and/or financial independence), and lifestyle improvements (e.g., increased occupational engagement that may begin with volunteering or part-time work in areas of personal interest). 48

Although the recovery model has shown promise and relevance in the clinical setting 49 – 52 and was adopted by the United States' President's New Freedom Commission on Mental Health in 2003, 53 identifying research outcomes that reflect recovery principles has been a slower process. This may reflect an apparent conflict between the clinical research focus on group-level analysis and the recovery focus on the individual. Although understanding person-centered outcomes is especially important in a clinical encounter, the practice of recovery-relevant methodology and use of meaningful outcome measures is equally important in BPD research. The literature which informs clinical practice should exemplify the very theoretical ideals and practical recommendations it proposes: research can and should adopt a recovery-orientation. Consideration of best methodological practices is especially relevant right now in BPD research given that explicit engagement with recovery-oriented ideas in our field is in its early stages. 54 , 55

From the perspective of methodology, qualitative interview-based practices offer new insights into recovery. Although few studies have directly focused on recovery in BPD, one recent report indicates that narrative accounts are more sensitive to residual BPD symptoms as compared to quantitative reports of improvement. 55 This longitudinal study at the University of Pittsburgh prospectively followed individuals with BPD for 2 to 31 years (mean 9.94 years, biannual assessments). Among participants with high scores on a measure of baseline function (Global Assessment Scale (GAS) score), 71.8% achieved diagnostic remission. However, the remaining 28.2% also went on to achieve good psychosocial outcomes even without diagnostic remission. Conversely, among participants with lower baseline GAS scores, 35.5% achieved diagnostic remission despite poor psychosocial outcomes. The authors sought to understand the gap between diagnostic remission and psychosocial recovery using qualitative interviews. These interviews found that those who achieved diagnostic remission often struggled with depression and anxiety and had difficulty in maintaining employment and good interpersonal relationships. For those participants who achieved diagnostic remission, residual BPD symptoms increased the occurrence of co-morbid psychiatric disorders, economic dependence, and poor-quality relationships. This work adds a new level of understanding to previously reported results describing the time-course and relationships of remission and recovery in BPD. 56 , 57

Recent qualitative studies indicate that definitions of recovery are multidimensional and may not align with providers’ definitions. One study found that people receiving services in two recovery-oriented programs of the National Health Service in the UK believed that interpersonal support outside of the clinical team, employment, and everyday activities such as walking and reading books were critical for recovery. 58 Another qualitative study found that conceptualizing seemingly small steps to recovery as valuable progress was key to cultivating the self-compassion necessary for BPD recovery. 59 In addition, another interview-based study found that participants with BPD indicated that there was a mismatch between the focus of their treatment, especially in structured group therapy programs such as dialectical behavior therapy, and their personal recovery aspirations, which included such varied goals as dealing with eating problems and managing traumatic experiences from their pasts. 60 However, the qualitative interviews with people staying in inpatient units made evident that patient definitions of recovery are strongly influenced by their providers’ focus on the biomedical model. For example, participants saw factors such as medication adherence as key to demonstrating to their psychiatrists that they were ready for discharge and on a path to recovery. Many clinicians will relate to the difficulty convincing “experienced” patients that we are at all interested in hearing about life beyond whether a person took her medication and if she feels suicidal.

Considering such promising qualitative research on recovery, qualitative methodology may seem to be the way forward. This view is supported by evidence that the process of completing the traditional clinical-trial approach of self-report measures may not be empowering mental health recovery. In one study, participants were interviewed about their experience of completing a set of self-report symptom scales. 61 Although participants refused external help from the researcher in reading aloud and explaining the items while completing the self-report measures, they noted afterwards that they had difficulty understanding the professional and unclear language in the measures and that they were frustrated by the process. When conducting research with people experiencing mental health issues, and especially for people with BPD who can experience high levels of shame, 62 , 63 researchers would do well to structure participant experience to avoid disempowering people on their journey to recovery.

At the same time, qualitative research is not without its own shortcomings. In their research, Stuart et al. found that overly optimistic views of recovery in qualitative research may homogenize individuals’ journeys. 64 Also, these views may place unintentional blame on participants when interviewers shy away from asking participants about the difficulties in their recovery journey, perhaps suggesting that having difficulties is unique to the person being interviewed, and not a common part of the bumpy recovery road. 64 Thus, mixed-methodology that seeks to marry “subjective” narrative qualitative measures with “objective” quantitative validated domain-specific survey-based measures may be the best approach for researching symptom outcomes not only in BPD but also in mental illness more broadly. 65 , 66

In addition to the unique benefits of using mixed-methods to define recovery through research, mixed-methodology may also be useful in other aspects of recovery-oriented research. Multiple groups have now argued that a mixed-methods approach also be used at the development and validation stages for novel tools measuring recovery as an outcome. 67 – 69 Keetharuth et al. were able to develop a new recovery survey assessing quality of life titled the Recovery Quality of Life (ReQoL), after using mixed-methods to understand key evidence from both patients and clinicians. 67 Their final ReQoL measure assesses themes including activity, belonging and relationships, hope, self-perception, well-being, and choice, control, and autonomy. Mixed methods studies like this one indicate that, as recovery-oriented research evolves, new guidelines for quantitative surveys and qualitative interview questions should incorporate individual-defined goals. That is to say, scales or interviews should seek to understand a participant’s progress toward their personally defined goals. Myers et al. used the “meaningful day” construct as a person-centered outcome to understand the recovery of people receiving services at the Opening Doors to Recovery program in Georgia over the course of a year. 65 Notably, the authors of this paper reflected on how the use of mixed-methods allowed them to discern non-overlapping aspects of personalized recovery.

As research follows clinical care in increasing in recovery orientation, the practices of research methodology must also evolve to reflect these changing definitions. Mixed-methodology is one example of how this change be facilitated. We suggest that studies could also include recovery-relevant measures (such as individual strengths) as variables in analyses, and that outcome measures that report on quality of life and life satisfaction can help to increase focus on variables other than those of the traditional medical model (e.g., symptoms, treatment adherence, and emergency visits).

Summary and Future Directions

In this paper, we have argued that the clinical approach to BPD has insights to offer to research practice. In particular, we suggest that researchers increase attention to symptom variance, interactive context, interpersonal sensitivity, and recovery-based research practices and outcome measures. Although in some settings, symptom-focused and recovery-oriented approaches may be seen as orthogonal, we see them as complementary in thinking about clinical and research best practices.

We imagine that future work can extend these ideas by considering the experience and structure of the research enterprise on both an individual and group level. On an individual level, researchers may be able to learn from recovery-oriented clinical practices to understand how it feels to be a patient-participant, including feeling empowered or, by contrast, disheartened. This issue speaks to ethical and clinical concerns about research practice and also to practical concerns around the accuracy of research data. We want to ensure that participants with BPD feel able to report accurately on their difficult and rapidly shifting experiences.

We also see potential for extending this proposal in light of ideas on structural competency and systems-level viewpoints. A rich and growing body of work initiated and developed by Metzl and Hansen 70 among others urges increased focus on the ways that institutional systems, cultures, and histories influence clinical outcomes and people’s experiences in therapeutic and research settings. System- and group-level frameworks for conceptualizing pathology in BPD will be important additions to the focus we have urged here on individual-level factors. For BPD in particular, stigma prevents people from seeking care and providers from offering appropriate diagnosis and treatment. 71 – 73 This is particularly true for men, as there is a misconception that BPD is significantly more frequent in women despite data to the contrary, 74 and therefore clinicians may focus on the more-prominent anger symptoms in men. 75

Researchers increasingly include people with lived experience of BPD on advisory councils and even in day-to-day lab work. Collaborative engagement with stakeholders can serve as an example to mental health researchers on the ways in which research can be a positive experience for research participants and can significantly increase researcher appreciation of the nuances of living with the condition. Inclusion of people with lived experiences on research teams will also bring novel and rich perspectives to data analysis and interpretation.

In sum, engagement with clinical knowledge about BPD can help shift researchers toward better engagement of research participants with BPD and BPD-related disorders, and the collection of more accurate clinical research data. Best practices can include a wide range of methods to fit research questions, but these practices are united by their consideration of the specific symptomatology of BPD.

Acknowledgements

We are very grateful to our clinical and research participants for all we learn from them as we work together on these complicated concerns. We would like to thank Paula Tusiani-Eng and Jillian Papa for recent conversations on the meaning and implications of recovery in BPD. We also thank Rebecca Miller and Eli Neustadter for comments on manuscript drafts.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Cohen Public Service Fellowship (to K. D.), by American Foundation for Suicide Prevention Young Investigator Grant No. YIG-1-045-16 (to S. K. F.), and by the Department of Mental Health and Addiction Services, State of Connecticut. This publication does not express the views of the Department of Mental Health and Addiction Services or the State of Connecticut. The views and opinions expressed are those of the authors.

Sarah K. Fineberg https://orcid.org/0000-0001-6024-6721