01 - Borderline personality disorder (BPD)

Borderline personality disorder (BPD)

The Maudsley® Prescribing Guidelines in Psychiatry, Fifteenth Edition. David M. Taylor, Thomas R. E. Barnes and Allan H. Young. © 2025 David M. Taylor. Published 2025 by John Wiley & Sons Ltd. Chapter 9 Borderline personality disorder (BPD) Borderline personality disorder (BPD) is common in psychiatric settings, affecting 2% of individuals living in the community,1 over 10% of community mental health patients and 20% of in-­patients.2 People diagnosed with BPD on average have higher prevalence of a wide range of other comorbid mental health conditions including mood disorders (both unipolar and bipolar affective disorder), anxiety disorders, eating disorders, post-­traumatic stress disorder (PTSD) and substance use disorders. Concurrent mental health conditions will affect successful treatment of BPD and should be treated prior to BPD, according to usual guidance for the particular condition, irrespective of any coexisting BPD diagnosis. More than 75% of people with BPD attempt suicide with ­2–­5% of patients dying from suicide.2,3 A high proportion of people with BPD are prescribed psychotropic drugs, often in polypharmacy regimens.4 A survey of prescribing practice in England found that over 90% of patients with BPD had been prescribed psychotropic medication, most commonly antidepressants or antipsychotics, particularly for affective instability.5 Individuals with BPD appear to be just as likely to be prescribed antipsychotics, antidepressants and mood stabilisers, whether or not they have a clear and documented comorbid diagnosis of schizophrenia, depression or bipolar disorder.4,5 This suggests that medicines are sometimes prescribed for the treatment of BPD per se (for which there is very limited support) rather than for specific comorbid conditions. No medicine is specifically licensed for the treatment of BPD, or indeed any aspect of BPD. Psychological treatments such as Dialectical Behaviour Therapy (DBT) have garnered much better ­evidence  –­ a Cochrane review noted 75 randomised controlled trials (RCTs) of psychological treatments in 20206 and a 2023  network meta-­analysis included 43 studies.7 Drug treatment of other psychiatric conditions