Module 12: Personality Disorders

Case studies: personality disorders, learning objectives.

  • Identify personality disorders in case studies

Case Study: Latasha

Latasha was a 20-year-old college student who lived in the dorms on campus. Classmates described Latasha as absent-minded and geeky because she didn’t interact with others and rarely, if ever, engaged with classmates or professors in class. She usually raced back to her dorm as soon as classes were over. Latasha primarily stayed in her room, did not appear to have any friends, and had no interest in the events happening on campus. Latasha even asked for special permission to stay on campus when most students went home for Thanksgiving break.

Now let’s examine some fictional case studies.

Case Study: The Mad Hatter

The Mad Hatter, from Alice in Wonderland , appears to be living in a forest that is part of Alice’s dream. He appears to be in his mid-thirties, is Caucasian, and dresses vibrantly. The Mad Hatter climbs on a table, walks across it, and breaks plates and teacups along the way. He is rather protective of Alice; when the guards of the Queen of Hearts come, he hides Alice in a tea kettle. Upon making sure that Alice is safe, Mad Hatter puts her on his hat, after he had shrunk her, and takes her for a walk. While walking, he starts to talk about the Jabberwocky and becomes enraged when Alice tells him that she will not slay the Jabberwocky. Talking to Alice about why she needs to slay the Jabberwocky, the Mad Hatter becomes emotional and tells Alice that she has changed.

The Mad Hatter continues to go to lengths to protect Alice; he throws his hat with her on it across the field, so the Queen of Heart’s guards do not capture her. He lies to the Queen and indicates he has not seen Alice, although she is clearly sitting next to the Queen. He decides to charm the Queen, by telling her that he wants to make her a hat for her rather large head. Once the White Queen regained her land again, the Mad Hatter is happy.

Case Study: The Grinch

Clipart of the grinch.

The Grinch, who is a bitter and cave-dwelling creature, lives on the snowy Mount Crumpits, a high mountain north of Whoville. His age is undisclosed, but he looks to be in his 40s and does not have a job. He normally spends a lot of his time alone in his cave. He is often depressed and spends his time avoiding and hating the people of Whoville and their celebration of Christmas. He disregards the feelings of the people, knowingly steals and destroys their property, and finds pleasure in doing so. We do not know his family history, as he was abandoned as a child, but he was taken in by two ladies who raised him with a love for Christmas. He is green and fuzzy, so he stands out among the Whos, and he was often ridiculed for his looks in school. He does not maintain any social relationships with his friends and family. The only social companion the Grinch has is his dog, Max. The Grinch had no goal in his life except to stop Christmas from happening. There is no history of drug or alcohol use.

  • Modification, adaptation, and original content. Authored by : Julie Manley for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
  • Case Studies: The Grinch. Authored by : Dr. Caleb Lack and students at the University of Central Oklahoma and Arkansas Tech University. Located at : . License : CC BY-NC-SA: Attribution-NonCommercial-ShareAlike
  • The Mad Hatter. Authored by : Loren Javier. Located at : . License : CC BY-ND: Attribution-NoDerivatives
  • The Grinch. Located at : . License : CC0: No Rights Reserved

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CASE STUDY Mary (borderline personality disorder)

Case study details.

Mary is a 26-year-old African-American woman who presents with a history of non-suicidal self-injury, specifically cutting her arms and legs, since she was a teenager. She has made two suicide attempts by overdosing on prescribed medications, one as a teenager and one six months ago; she also reports chronic suicidal ideation, explaining that it gives her relief to think about suicide as a “way out.”

When she is stressed, Mary says that she often “zones out,” even in the middle of conversations or while at work. She states, “I don’t know who Mary really is,” and describes a longstanding pattern of changing her hobbies, style of clothing, and sometimes even her job based on who is in her social group. At times, she thinks that her partner is “the best thing that’s ever happened to me” and will impulsively buy him lavish gifts, send caring text messages, and the like; however, at other times she admits to thinking “I can’t stand him,” and will ignore or lash out at him, including yelling or throwing things. Immediately after doing so, she reports feeling regret and panic at the thought of him leaving her. Mary reports that before she began dating her current partner she sometimes engaged in sexual activity with multiple people per week, often with partners whom she did not know.

  • Concentration Difficulties
  • Emotion Dysregulation
  • Impulsivity
  • Mood Cycles
  • Risky Behaviors
  • Self-Injury
  • Suicidal thoughts

Diagnoses and Related Treatments

1. borderline personality disorder.

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A case study on a severe paranoid personality disorder client treated with metacognitive interpersonal therapy


  • 1 Center for Psychology and Health, Tages Charity, Florence, Italy.
  • 2 School of Human Health Sciences, University of Florence, Florence, Italy.
  • 3 Center for Metacognitive Interpersonal Therapy, Rome, Italy.
  • PMID: 34263957
  • DOI: 10.1002/jclp.23201

Paranoid personality disorder (PPD) is a severe condition, lacking specialized and empirically supported treatment. To provide the clinician with insights into how to treat this condition, we present a case study of a 61-year-old man with severe PPD who presented with ideas of persecution, emotionally charged hostility, and comorbid antisocial personality disorder. The client was treated with 6 months of Metacognitive Interpersonal Therapy, which included: creating a shared formulation of his paranoid attitudes; trying to change his inner self-image of self-as-inadequate and his interpersonal schemas where he saw the others as threatening. Guided imagery and rescripting techniques, coupled with behavioral experiments, were used to promote a change. At the end of the therapy the client reported a reliable change in general symptomatology and, specifically, in interpersonal sensitivity, hostility, and paranoid ideation; he could no longer be diagnosed as PPD and only some paranoid and antisocial characteristics remained.

Keywords: hostility; metacognition; paranoid ideation; paranoid personality disorder; suspiciousness.

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Case report: brief, intensive emdr therapy for borderline personality disorder: results of two case studies with one year follow-up.

\r\nLaurian Hafkemeijer*

  • 1 Department of Adult Psychiatry, GGZ Delfland, Delft, Netherlands
  • 2 Department of Personality Disorders, Parnassia Psychiatric Institute, The Hague, Netherlands
  • 3 Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam and VU University Amsterdam, Amsterdam, Netherlands
  • 4 Research Department PSYTREC, Bilthoven, Netherlands
  • 5 School of Health Sciences, Salford University, Manchester, United Kingdom
  • 6 Institute of Health and Society, University of Worcester, Worcester, United Kingdom
  • 7 School of Psychology, Queen’s University, Belfast, Ireland

Background: Exposure to adverse childhood events plays an important role in the development of borderline personality disorder (BPD). Emerging evidence suggests that trauma-focused therapy using eye movement desensitization and reprocessing (EMDR) can be beneficial for patients with BPD symptoms. To date, the effects of brief, intensive EMDR treatment for this target group have not been investigated in this population.

Objective: This study aimed to evaluate the effects of a brief and intensive trauma-focused therapy course using EMDR therapy in two patients diagnosed with BPD who did not fulfill the diagnostic criteria for post-traumatic stress disorder (PTSD). It was hypothesized that this approach would be associated with a decline in the core symptoms of BPD, and that this would have an enduring long-term effect on patients’ diagnostic status.

Method: Ten sessions of EMDR therapy were carried out across four consecutive treatment days, with the aim of processing patients’ core adverse childhood experiences. Both A-criterion-worthy memories (without intrusive reliving) and non-A-criterion-worthy memories that were considered responsible for the patients’ most prominent symptoms were targeted. The effects of EMDR therapy on trauma symptom severity and BPD diagnostic status (as established by the Structured Clinical Interview DSM-5) were determined. Additionally, the effects on psychological distress, quality of life, and difficulties in emotion regulation were determined at intake, post-treatment, and at 3-, 6-, and 12-months follow-up.

Results: Both patients showed a strong decline in psychological distress and difficulties in emotion regulation, and reported an improvement in their quality of life. At post-treatment, and at 3-, 6-, and 12-months follow-up they no longer met the DSM-5 criteria for BPD.

Conclusion: The findings of this small case study are in line with mounting evidence that a brief track of intensive trauma-focused therapy can result in long-term remission in patients with BPD. EMDR therapy seems to be a promising treatment approach for patients with BPD; however, the results need to be replicated in clinical trials.

1 Introduction

Borderline personality disorder (BPD) is characterized by a pattern of problematic interpersonal relationships, instability in affect regulation and impulse control, and recurring suicidal tendencies ( 1 ). International studies have shown that individuals fulfilling the diagnostic criteria for BPD display a high burden of disease and comorbidity ( 2 ), which is associated with reduced quality of life ( 3 ). The currently recommended first-line treatment options for BPD have proven to be extensive and costly ( 4 , 5 ) and show intensive use of mental health services ( 6 , 7 ). Effective interventions with a shorter duration are therefore a priority for this patient group.

Although post-traumatic stress disorder (PTSD) and BPD are classified differently, these mental health conditions often prove to be comorbid ( 8 ). Evidence suggests that 25–30% of individuals meeting the diagnostic criteria for PTSD also meet the diagnostic criteria for BPD ( 9 ). Conversely, at some point in their lives, 30–70% of individuals with a BPD diagnosis fulfill the diagnostic criteria for PTSD ( 9 , 10 ). More importantly, there is a strong similarity between the symptoms considered characteristic of BPD and the symptom clusters of what is termed Complex PTSD [i.e., emotional regulation difficulties, disturbances in relational capacities, and the presence of negative beliefs; ( 11 )], a mental health condition that has been found to be responsive to trauma-focused treatment ( 12 , 13 ).

However, to be classified with PTSD exposure to an A-criterion-worthy event is necessary, but memories of other types of adverse childhood events also seem to play an important role in the development of BPD. For example, one study showed that 97% of individuals diagnosed with BPD were exposed to at least one type of childhood trauma, including abuse and neglect [unpublished data from ( 14 )]. Also, Porter et al. ( 15 ) found that both emotional abuse (OR = 38.1) and neglect (OR = 17.7) were strongly associated with the presence of BPD.

Despite the strong association between exposure to childhood adverse events and symptom clusters that are considered characteristic of BPD ( 16 , 17 ), childhood adverse events have not yet been the primary target for BPD treatment. However, processing childhood memories could be a promising treatment approach for these individuals. The adaptive information processing (AIP) model, which is the theoretical framework of EMDR therapy, clarifies the impact of traumatic experiences on functioning and provides a rationale for utilizing EMDR in the treatment of BPD ( 18 ). This model is based on the premise that many forms of psychopathology, with PTSD being the most salient example, are the result of disruptive experiences (in the form of fearful images, dysfunctional cognitions, negative emotions, and physical sensations) that have occurred since the time of the event. For example, patterns of childhood maltreatment have been found to predict problems in emotion processing and regulation in emerging adulthood ( 19 ). Furthermore, trauma-focused psychotherapy has been proven to positively influence emotion regulation difficulties in individuals with severe PTSD who have been exposed to early childhood trauma ( 20 ). Given that emotion regulation problems are a core symptom of BPD, it seems reasonable that trauma-focused treatment would be a promising therapy for this patient group.

Indeed, evidence indicates that trauma-focused psychotherapies are effective in the treatment of PDs and BPD ( 21 – 24 ). To date, few studies have evaluated the impact of trauma-focused treatment on BPD symptoms and have demonstrated a significant decrease in borderline symptoms ( 25 ). Importantly, no increase in self-injurious behaviors, suicide attempts, or hospitalization was noted, whereas the mean weighted dropout rate during the PTSD treatment was low (17%). To this end, in particular EMDR therapy has proven to be a useful and effective treatment for patients with PD who do not fulfill the diagnostic criteria for PTSD ( 21 , 22 , 26 ). A randomized controlled study of 97 outpatients with PD as the main diagnosis, showed that psychological distress and personality dysfunction decreased significantly after only five sessions of EMDR therapy compared to wait list ( 22 ). Importantly, EMDR therapy proved to be not only effective for the debilitating effects of exposure to A-criterion-worthy events but also for the treatment of memories related to emotional abuse, neglect, and other distressing life events, such as divorce or severe physical illness ( 27 ).

In recent years, also brief and intensive trauma-focused treatment has been found to be a feasible and safe treatment approach for individuals with clinically elevated symptoms of BPD [e.g., ( 28 )]. For example, an uncontrolled outcome study among 45 patients diagnosed with both PTSD and BPD ( 23 ) found that BPD symptom severity decreased from pre- to post-treatment, and at 12-month follow-up, and 73% of the patients no longer met the criteria for BPD according to the SCID-5-P (Structured Clinical Interview for DSM-5) The 8-day treatment in this study consisted of a combination of Prolonged Exposure and EMDR therapy in an inpatient treatment setting. To date, intensive treatment with only EMDR therapy has not been explored in patients with BPD so far.

Therefore, in the present pilot study we offered 10 sessions of EMDR therapy lasting 90 min within four consecutive days to two people diagnosed with BPD, not fulfilling the diagnostic criteria for PTSD. Based on the findings of previous studies ( 22 , 23 , 26 , 28 ), we hypothesized that BPD symptoms would significantly decrease using an intensive track of EMDR therapy. In addition, we were interested in the extent to which the treatment would affect psychological distress, difficulties in emotion regulation, quality of life and patients’ diagnostic status 1 year after the termination of therapy.

2.1 Procedures

Both patients underwent an intake session in which the Clinician Administered PTSD Scale for DSM-5 [CAPS-5; ( 29 )] was administered to exclude a diagnosis of PTSD, whereas the SCID-5-P was used to determine the presence of PD. Although many of their symptoms seemed to be the result of traumatic experiences, neither fulfilled the diagnostic criteria for PTSD ( 30 ).

After being informed about EMDR therapy both patients gave their permission for participation and signed an informed consent form.

2.2 Measures

2.2.1 clinician-administered ptsd scale for dsm-5 (caps-5).

A Dutch translation of the CAPS-5 was used to measure the severity of PTSD symptoms ( 31 ). The CAPS-5 is a structured diagnostic instrument consisting of 20 questions. The severity of PTSD symptoms was scored on a scale of 0 to 4 (absent, mild, moderate, severe, and extreme, respectively), and the 20 questions together resulted in a total severity score. The other ten questions concerned the duration of PTSD symptoms, dissociative symptoms, and the negative effects of PTSD symptoms on different life domains (e.g., social contact and work/school) ( 32 ). The total CAPS-5 score demonstrates high internal consistency (α = 0.90) ( 29 ). All measurement moments are shown in Table 1 .

Table 1. Administration schedule of the questionnaires.

2.2.2 Structured clinical interview for DSM-5 personality disorders (SCID-5-P)

The SCID-P-5 is a structured clinical diagnostic interview used to determine whether someone meets the criteria for a personality disorder (PD) according to the DSM-5 ( 30 ). The Dutch translation of the SCID-P-5 contains 135 questions that are rated on a 3-point scale. Data on the reliability and validity of the Dutch SCID-5-P are not yet available, but they are expected to be equal to the previous version, which is the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) ( 33 ). All measurement moments are shown in Table 1 .

2.2.3 Childhood trauma questionnaire—Short form (CTQ-SF)

The CTQ-SF is a self-report questionnaire intended as a screening tool to detect maltreatment during childhood in both clinical and non-referred groups ( 34 , 35 ) and consists of five subscales. The subscales are physical and emotional neglect and physical, emotional, and sexual abuse. Respondents were asked to give a rating of between 1 and 5 on a five-point Likert scale for 25 statements about childhood trauma. This questionnaire also measures the severity of the exposure to childhood maltreatment (none, moderate, severe and extreme). The Dutch version of this questionnaire will be used with scales with good to excellent internal consistency (α = 0.89–0.95). Only the physical neglect scale has questionable internal consistency [α = 0.63; ( 35 )].

2.2.4 Life events checklist for the DSM-5 (LEC-5)

The Dutch translation of the LEC-5 has been used ( 32 ). This self-report questionnaire estimates exposure to potentially traumatic life-events ( 36 ). The LEC-5 distinguishes 17 potentially traumatic experiences (e.g., physical violence and natural disasters) as well as the type of exposure to a potentially traumatic event [1 = it happened to me, 2 = I witnessed it, 3 = I have taken note of it, 4 = in the context of work, 5 = I am not sure, 6 = does not apply to me; ( 31 )]. The LEC was administered at baseline. Although the Dutch version has not yet been evaluated, agreement for the original scale is substantial (κ = 0.61) ( 36 ).

2.2.5 Mental health quality of life (MHQoL) questionnaire

The MHQoL is a standardized, self-report questionnaire that measures quality of life. This questionnaire was developed for people with mental health problems ( 37 ) and consists of eight questions. The first seven questions represent seven different domains of mental health (e.g., self-image, relationships, and mood). Patients rated their degree of satisfaction with these domains on a four-point Likert Scale. The seven questions combined gave a total score. On the eight questions, the patients were asked to fill out a visual analog scale about their general psychological wellbeing (0, the worst you can imagine; 10, the best you can imagine). The MHQoL was administered on days 1 (pre-treatment), 4 (post-treatment), at 3-month follow-up, at 6-month follow-up and 12-month follow-up. Internal consistency of the Dutch version has proven to be high for the total score (α = 0.85) ( 37 ). All measurement moments are shown in Table 1 .

2.2.6 Difficulties in emotion regulation scale (DERS)

The DERS is a self-report questionnaire that measures difficulties in emotion regulation ( 38 ). Respondents are requested to indicate the frequency of 36 emotion regulation statements on a five-point Likert scale. The questionnaire consists of six subscales: lack of emotional clarity, lack of emotional awareness, impulsivity, non-acceptance of emotional responses, limited access to emotion regulation strategies and difficulties engaging in goal-directed behavior. Whereas the English DERS has demonstrated excellent internal consistency in a BPD sample ( a = 0.94) ( 38 ), the subscales of the Dutch version have shown good internal consistencies in an adolescent sample [average a = 0.81; ( 39 )]. All measurement moments are shown in Table 1 .

2.2.7 Outcome questionnaire (OQ-45)

The OQ-45 is a self-report questionnaire ( 40 ) that measures different domains of psychosocial functioning, such as symptom distress, interpersonal relations and social role ( 41 ). The Dutch version of the OQ-45 contains 45 items that are scored on a five-point Likert scale (never, rarely, sometimes, often, almost, and always). The OQ-45 has demonstrated excellent internal consistency for the total score in clinical samples (α = 0.93), but questionable internal consistency for the specific social role subscale (α = 0.69) ( 41 ). All measurement moments are shown in Table 1 .

2.3 Treatment

Eye movement desensitization and reprocessing therapy is a standardized eight-phased trauma-focused therapy. It consists of dosed attention directed at a disturbing memory while simultaneously engaging in another concurrent (dual attention) task ( 18 , 42 ). The EMDR therapy in this study was performed according to the guidelines of Shapiro ( 18 ) and the Dutch version of the EMDR standard protocol ( 43 ). In the present study EMDR was applied in that patients were requested to imagine the most disturbing part of a traumatic event while taxing their working memory capacity by visually following the therapist’s finger movements or other working memory-demanding elements to maximize working memory load ( 44 ). The EMDR therapists were experienced therapists who were certified as an EMDR Europe practitioner (LM) or trainer (AdJ) according to the guidelines of the EMDR Europe Association (EMDREA).

2.4 Participants

Two patients diagnosed with BPD were recruited through a call on the world’s largest professional network on the Internet, “LinkedIn.” Patients could participate if they had BPD as a primary diagnosis according to the DSM-5 criteria and the ability to speak and understand Dutch or English. Exclusion criteria were the presence of a PTSD diagnosis and acute current suicidal intention. The first two people who volunteered and fulfilled the criteria for inclusion were enrolled as study participants. The names mentioned in this case study are fictitious. In addition, essential background and personal details of both patients were changed to ensure anonymity and make recognition impossible.

Amy, a single woman of 42 years old, reported emotional neglect with multiple memories of situations in which she did not feel heard or seen and extreme emotional abuse, of which the latter had the greatest impact on her daily life. Table 2 shows the results of the Life Events Checklist for the DSM-V (LEC-5), which provides a representation of Amy’s adverse life events. For example, she had witnessed several events of physical violence and had been exposed to multiple accidents; such as a pressure cooker exploding on her face and her hair catching fire when she was young.

Table 2. Life Events Checklist for DSM-5 (LEC-5).

On admission, Amy was not in therapy; however, she reported an extensive treatment history, including different psychotherapies and hospitalizations. She suffered from suspicious thoughts and feelings, and often felt that she was not good enough. In romantic relationships and friendships, she felt worthless. Furthermore, she tended to be submissive to others in their relationships. Amy met the following criteria for BPD according to the SCID-5-P; a pattern of instability in interpersonal relationships, frantic effort to avoid abandonment, persistently unstable self-image, affect lability, chronic feelings of emptiness and paranoid ideas or dissociative ideations caused by stress.

Kate is a 31-year-old woman, born in Somalia during war. She grew up in an unsafe family situation including physical and verbal violence. Table 2 provides an overview of Kate’s adverse life events. She reported multiple events that met the A-criteria for PTSD ( 30 ). During childhood, she was sexually and physically abused by a nephew, and as an adult she was exposed to sexual abuse multiple times. Kate also had been the witness of many war crimes, and as a refugee she almost drowned. Despite these traumas she did not exhibit any PTSD symptoms. With the aid of the CAPS-5, it became clear that Kate did not experience any feelings when she talked about the horrible events she had been exposed to. She described two people: “Kate before the war and after the war.” She suffered the most from the physical abuse by her nephew when she was 7 years old. Furthermore, she had a history of extreme emotional abuse, physical abuse, sexual abuse, and emotional neglect during childhood.

Kate’s most prominent symptoms were a low self-esteem and fear of losing loved ones. She indicated that it was difficult for her to open up to someone, and emotionally connect with others. Based on the administration of the SCID-5-P, Kate met the following criteria for BPD: a pattern of instability in interpersonal relationships, frantic effort to avoid abandonment, impulsivity, persistently unstable self-image, affect lability, a chronic feeling of emptiness and an intense, inadequate feeling of anger that is hard to control. Kate indicated that she had had schema focused treatment for 3 years prior to admission into this study and completed a track of cognitive behavioral therapy.

2.5 Case conceptualization

In the first session, a case conceptualization was performed by two experienced EMDR therapists. This was based on a trauma-focused approach, followed by a symptom-focused approach. First, memories of traumatic events fulfilling the A criterion for PTSD were identified (intrusive memories prior to non-intrusive memories). All the memories were placed in a hierarchy based on their subjective units of disturbance (SUD). Second, the most pronounced and distressing symptoms were inventoried, after which the memories (of childhood adverse events) that gave rise to or worsened these symptoms were identified and ordered and structured along a timeline. Then, these memories were placed in a hierarchy based on their subjective units of disturbance (SUD). The case conceptualization was based on the principle that memories with the highest SUD would be treated first.

3.1 Course of treatment

Amy did not report any intrusive memories. However, several non-intrusive memories of A-criterion events were selected, such as a severe physical assault on her sister that she witnessed, and another violent incident. During the case conceptualization session, Amy mentioned experiencing distrust, self-sacrifice, and a negative self-image as her main symptoms. One specific memory that seemed to significantly influence her low self-esteem was an event in which her mother expressed that she had never wanted children. Most of Amy’s memories were related to emotional neglect. Notably, these memories evoked a high level of emotional distress and had high SUD ratings. She had not realized the extent of the impact these memories had on her before.

As Amy progressed through the desensitization phase and various memories were successfully processed, she began to understand more clearly the influence of traumatic events on her self-perception and worldview. Consequently, she began to believe that there was nothing inherently wrong with her. This new perspective has led to increased self-compassion and a reduction in self-criticism. Additionally, during the therapy sessions, she learned to view others, including her mother, with greater empathy. She gradually recognized the deficiencies her mother had experienced, which prevented her from receiving attention and care for Amy.

During the desensitization phase of the sessions, Amy noticed occasional suspicion toward the therapists. By allowing this feeling to be present in the session, acknowledging it briefly, and continuing with the EMDR therapy, the intensity of this feeling diminished. She realized that it was primarily a response to escalating tension, something she also recognized in her daily life. Cognitive interweaves ( 18 ), which are short, open-ended questions aimed at providing functional and supportive information during a session, proved to be helpful for Amy to gain a different perspective and take better care of herself. For example, when asked, “What would you like to do for that little girl now?” Amy would respond, “I would give her a hug and tell her that she matters.” The SUD scores decreased rapidly and the sessions consistently ended in a positive manner. Amy increasingly felt a sense of self-worth, and began to feel stronger.

The Flashforward technique ( 45 ) was used to prepare Amy for a future confrontation with her mother, a situation she had been avoiding and felt a great deal of anxiety about. Her catastrophic thought was that her mother would reject her. Once the overall disturbance related to this catastrophic fantasy significantly decreased, Amy became fully convinced that she could handle this confrontation and that it was necessary to break free from her avoidance behavior and establish a new, healthier relationship with her mother.

Kate reported numerous memories that met the A-criterion for PTSD, including war crimes in Somalia, memories of being a victim of both physical and sexual abuse from a young age, and the situation where she nearly drowned while attempting to flee from Somalia. Initially, she was reluctant to face the latter situation and preferred to consider it a “funny scenario in a Hollywood film.” However, when the memory was intensified by asking Kate to create a mental image of the possibility of drowning and formulating the negative cognition “I am powerless,” she reported disturbance and a high SUD level associated with the image. During the sessions, she could feel and re-experience the danger of the situation, and expressed a desire to escape, but the cognitive interweave “Are you safe now?” helped her continue the therapy. Whereas Kate previously described herself as “a Kate before and a Kate after the war,” she increasingly realized that all the significant events had been part of who she was before EMDR treatment.

The memories related to her primary complaints were also addressed. One significant symptom cluster was Kate’s low self-esteem, which was identified during the case conceptualization session as having originated in her early childhood, where girls were considered less valuable than boys in her culture. Memories from various situations were processed. However, despite the high working memory load, Kate often blamed her younger self and found it difficult to view the events from a different perspective. For instance, she remained convinced that the rape she experienced at the age of seven was her own fault. Kate frequently experienced “looping” (this happens when a patient is stuck on negative thoughts or beliefs) during the EMDR therapy sessions. Cognitive interweaves were also helpful for Kate in accessing new information, enabling her to realize that the young girl was not to blame but should have been protected by others. This allowed her to look at herself with more compassion and feel anger toward the perpetrators. Kate’s negative self-image was further reinforced by memories of events that she was bullied as a child. These memories were also processed. Additionally, she gained insight into how hard she had always worked to seek approval from others and to compensate for her negative self-image. By the end of the treatment, Kate recognized herself primarily as “a fighter,” “brave,” and “worthy,” and she truly felt that she no longer needed to be ashamed of her past.

3.2 Change in psychological distress, quality of life, and emotion regulation difficulties

At the start of therapy both patients scored much higher than 56 on the OQ-45, the cutoff score between the normal and patient populations ( 46 ). During the 4 days of intensive EMDR therapy both patients reported a decrease in psychological distress and dysfunctioning as measured using the total score of the OQ-45 (see Table 3 ). Three months after the treatment, Amy reported a low level of psychological distress. The total Kate score increased from three to 12 months of follow-up.

Table 3. Course of psychological distress (OQ-45), difficulties in emotion regulation (DERS) and quality of life (MHQoL) over the measurement moments.

At baseline Amy reported an average score and Kate had a much lower quality of life as indexed by the MHQoL than the general population. From baseline to post-treatment, both patients showed an increase in their quality of life followed by a decrease. From the 6-month follow-up until the 12-month follow-up, both patients reported an increase in quality of life.

Both patients showed a decrease in difficulty with emotion regulation over time ( Table 3 ). The greatest decrease in difficulty was observed during the trajectory of EMDR therapy. These improvements were maintained in all follow-up measurements.

3.3 Change in PTSD symptom severity and diagnostic status

At baseline, Amy showed symptoms of PTSD, but did not fulfill the diagnostic criteria for PTSD. At 3-month follow-up PTSD symptoms strongly decreased. Additionally, at six follow-up measurements, a further decline in these symptoms was observed. Amy indicated experiencing more peace in her life, as well as the opportunity “to do and see exactly what I am, and to really take control again, where I did not feel this way before.”

After EMDR therapy Amy no longer required further treatment. Kate reported no PTSD symptoms at baseline. However, at the 3-month follow-up, the patient fulfilled the diagnostic criteria for PTSD. After continuation of EMDR therapy by an independent psychologist, PTSD symptoms started to decrease again. At the 6-month follow-up, the patient no longer fulfilled the diagnostic criteria for PTSD. Figure 1 shows the mean CAPS scores at different measurement points. After the course of intensive EMDR therapy, Kate continued schema-focused therapy delivered by her psychologist. From post-treatment to the first follow-up measurement at 3 months she received six sessions of schema-focused therapy and three sessions of imaginary re-scripting. From the 3-months follow-up to the 6-months follow-up she received five sessions of schema-focused therapy and five sessions of EMDR therapy, and from the 6- to 12 months follow-up this treatment was continued.

Figure 1. Means of CAPS-scores over time. * CAPS, clinician-administered PTSD Scale for DSM-5; T0: baseline measurement.

3.4 Change in BPD symptom severity and diagnostic status

At post-treatment, and at all follow-up measurement moments, neither of the patients met the DSM-5 criteria of BPD according to the SCID-5-P (see Figure 2 ).

Figure 2. Mean SCID-5-P scores of BPD over time at pre-treatment (T0), 3-month follow-up, 6-month follow-up and 12-month follow-up. * BPD, borderline personality disorder; SCID-5-P, structured clinical interview for DSM-5; * SCID-5-P, structured clinical interview For DSM-5 personality disorder.

4 Discussion

Longitudinal studies have demonstrated the tremendous impact of adverse childhood experiences on the development of a wide variety of mental health conditions, including PDs ( 47 , 48 ). However, to date, only a few studies have evaluated the effects of trauma-focused treatment on the symptoms of mental health conditions. In this study, two patients received 10 sessions of EMDR therapy for four consecutive days, focused on reprocessing the memories seemingly involved in the persistence of their main symptoms of their pathology. The results showed a strong decline in psychological distress, difficulties in emotion regulation, and improvement in the patients’ quality of life. At the 3-, 6-, and 12-months follow-up measurements neither patient fulfilled the diagnostic criteria for BPD.

The results of the present study are consistent with those of earlier case studies of patients diagnosed with BPD ( 21 , 26 ). The results are also in line with two uncontrolled studies among patients with PTSD and comorbid BPD ( 23 , 49 ), and a study among individuals diagnosed with BPD without the presence of PTSD ( 22 ). Furthermore, consistent with two previous studies, the effects on BPD symptoms ( 28 ), as well as BPD diagnostic status ( 23 ), could be maintained 1 year after therapy.

Remarkably, until now, almost all studies on the treatment of individuals with BPD included patients who were also classified as having PTSD ( 25 ). However, the majority of individuals with a PD do not meet the diagnostic criteria for PTSD, because the adverse childhood events they had been exposed to do not meet the A-criterion of the PTSD classification in accordance with the DSM-5, or they do not report sensory-based intrusive images of these events ( 30 , 50 , 51 ), such as Kate and Amy. To this end, it is important to note that EMDR therapy has been found to be also effective in patients with a PD focused on non-A-criteria worthy memories, such as those involving emotional abuse, neglect, and other distressing life events ( 27 ) similar to the two patients in the present case study. Interestingly, one of the two patients (Kate) no longer met the diagnostic criteria for BPD 3 months after treatment, but unexpectedly met those for PTSD. One possible explanation for this could be that Kate acquired strong survival strategies to regulate her emotions growing up in the war. Probably because of this, it proved difficult for Kate to allow her to experience emotions when the therapist asked her about the memory of fleeing the war. Kate was, in fact, a person with an overregulated affect, who was not easily overwhelmed with tears, who avoided feelings, and who was well capable to suppress and avoid emerging re-experiences. It is quite possible that this form (“overregulation of distress”) was the reason why she did not fulfill the criteria for PTSD at baseline ( 11 ). In short, it is conceivable that Kate’s treatment led to a reversal of the inhibition of previously overregulated emotions that gradually made the memories more accessible. The second treatment with EMDR therapy resulted in PTSD remission.

This study has several limitations. First, like any case study, it offers little basis for generalizing results to other clinical groups and contexts or for making predictions about future developments. Additionally, recruitment through social media could have attracted patients with mild problems; however, the questionnaire scores were within the clinical range. Conversely, to the best of our knowledge, this is the first case study to examine the effects of brief, intensive trauma-focused treatment using EMDR therapy in patients with BPD without PTSD. Only one earlier study ( 52 ) reported the effects of 20 weekly sessions of therapy in a 33-year-old female with BPD. She showed improvement in symptoms of borderline personality disorder, dissociative symptoms, depression and anxiety symptoms, which were maintained for 3 months after treatment. However, in this study a phase-based treatment approach was used, which started with a stabilizing phase using Resource Development and Installation (RDI) that lasted four sessions, followed by a trauma processing phase, and a “personality rehabilitation phase.” In our study the therapists immediately started with trauma processing in the first treatment session, treating the most disturbing memory first. Second, both self-report measurements and clinical interviews at several measurement points (at baseline, 3-, 6-, and 12-month follow-ups) were conducted, providing both a subjective and objective evaluation of the long-term therapeutic effects. Third, given the promising results, this study adds to the support of Shapiro’s Adaptive Information Processing (AIP) model, thereby underlining the importance of a trauma-focused approach to the treatment of patients with BPD and providing hope for further improvement of treatment outcomes for this and other diagnostic groups.

In conclusion, the findings of these case studies support the notion that reprocessing meaningful memories that are believed to underlie patients’ present symptoms within a brief time period of only 4 days not only improves PTSD symptoms but also core symptoms of BPD and may even result in long-lasting remission of BPD. Thus, replication in larger samples and clinical trials is required. To this end, we are currently awaiting the results of a randomized controlled outcome study on the effectiveness of EMDR therapy in a large group of people with a wide range of personality disorders ( 53 ), with and without PTSD.

Data availability statement

The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Ethics statement

Ethical approval was not required for the studies involving humans because the treatment was performed in accordance with the regulations for research as stated in the Declaration of Helsinki and the Dutch Medical Research on Humans Act ( 54 ) concerning scientific research. The measures that were used were standard routine outcome measurements and the same as those of our TEMPO study [( 53 ); approved by the Medical Ethics Committee nr MEC-2020-0583]. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author contributions

LH: Conceptualization, Data curation, Investigation, Project administration, Visualization, Writing – original draft, Writing – review and editing. KS: Writing – review and editing. AdJ: Conceptualization, Project administration, Writing – original draft, Writing – review and editing. NdH: Visualization, Writing – review and editing.

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Conflict of interest

AdJ reports personal fees from teaching activities, personal fees from books about trauma and its treatment (e.g., EMDR therapy), outside the submitted work; and has been a board member of the Dutch EMDR Association, and the EMDR Europe Association.

The remaining 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 : EMDR, borderline personality disorder, trauma, neglect, case studies, abuse

Citation: Hafkemeijer L, Slotema K, de Haard N and de Jongh A (2023) Case report: Brief, intensive EMDR therapy for borderline personality disorder: results of two case studies with one year follow-up. Front. Psychiatry 14:1283145. doi: 10.3389/fpsyt.2023.1283145

Received: 25 August 2023; Accepted: 26 October 2023; Published: 15 December 2023.

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Copyright © 2023 Hafkemeijer, Slotema, de Haard and de Jongh. 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: Laurian Hafkemeijer, [email protected]

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case study personality disorder

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Working with a patient with personality disorder: a case report and reflection on my experience.

Published online by Cambridge University Press:  20 June 2022

Emotionally unstable personality disorder (EUPD) accounts for up to 20% of diagnoses in the inpatient psychiatry population. The assessment, diagnosis, and treatment of any personality disorder may be challenging, and its classification remains debatable. Here I will describe a case of a dual diagnosis of EUPD and schizotypal personality disorder. Through the case report I will also reflect on my first experience of working with a patient with personality disorder, as a Psychiatry Foundation Fellowship doctor with little previous exposure to the psychiatry specialty.

The patient was a female in her thirties, previously diagnosed with EUPD, who had not benefitted from a number of psychological treatments. She had a history of suicidal behaviour and previous admissions but presented differently this time. She had short hair that was dyed in a vivid colour, was paranoid that she was being spied upon from an alternative universe and had suicidal plans to join the alternative universe. She also had auditory and visual hallucinations. On exploration it became apparent that she had similar episodes in the past, each lasting no more than a day. An additional diagnosis of schizotypal personality disorder was made, and she responded well to risperidone. Unfortunately, she was transferred to another ward for bed management reasons, whereupon the diagnosis reverted to EUPD and antipsychotics were stopped.

This case highlights how in mixed personality disorders, features of one personality disorder may be more predominant than another at different times. It also contradicts the notion that people with schizotypal personality disorder rarely present to mental health services. The inconsistency of diagnosis and lack of continuity of care caused immense distress to the patient, prolonging the acute episode. This highlights the importance of a good formulation in order to tailor care for the patient.

As a newly qualified doctor, working with patients with personality disorders was a meaningful experience. Through ward rounds and the seemingly trivial conversations along the corridor, I thought about the effect of transference and countertransference for the first time, which is applicable to any interpersonal interaction. I witnessed the harm caused by the lack of continuity of care. I reflected on the intricate balance between the advantage of establishing a diagnosis for the patient, and the drawback of the diagnosis leading to labelling. It made me face the stereotypes I held and allowed me to learn about the patient as an individual.

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  • Research article
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The lived experience of recovery in borderline personality disorder: a qualitative study

  • Fiona Y. Y. Ng   ORCID: 1 , 2 ,
  • Michelle L. Townsend 2 , 3 ,
  • Caitlin E. Miller 2 , 3 ,
  • Mahlie Jewell 4 &
  • Brin F. S. Grenyer 2 , 3  

Borderline Personality Disorder and Emotion Dysregulation volume  6 , Article number:  10 ( 2019 ) Cite this article

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The concept of recovery in borderline personality disorder (BPD) is not well defined. Whilst clinical approaches emphasise symptom reduction and functioning, consumers advocate for a holistic approach. The consumer perspective on recovery and comparisons of individuals at varying stages have been minimally explored.

Fourteen narratives of a community sample of adult women with a self-reported diagnosis of BPD, were analysed using qualitative interpretative phenomenological analysis to understand recovery experiences. Individuals were at opposite ends of the recovery continuum (seven recovered and seven not recovered).

Recovery in BPD occurred across three stages and involved four processes. Stages included; 1) being stuck, 2) diagnosis, and 3) improving experience. Processes included; 1) hope, 2) active engagement in the recovery journey, 3) engagement with treatment services, and 4) engaging in meaningful activities and relationships. Differences between individuals in the recovered and not recovered group were prevalent in the improving experience stage.

Recovery in BPD is a non-linear, ongoing process, facilitated by the interaction between stages and processes. Whilst clinical aspects are targets of specialist interventions, greater emphasis on fostering individual motivation, hope, engagement in relationships, activities, and treatment, may be required within clinical practice for a holistic recovery approach.

Recovery in borderline personality disorder (BPD) has predominantly been viewed in the context of symptom improvement and no longer meeting diagnostic criteria. Longitudinal studies have demonstrated that symptom remission is a common occurrence, with remission rates ranging between 33 and 99% [ 1 ]. Personal recovery however, adopts a holistic stance and views recovery as a process rather than a fixed outcome [ 2 , 3 ]. Conceptual frameworks of personal recovery have synthesised the stages across the transtheoretical model of change, and processes into the CHIME framework (connectedness, hope, identity, meaning and empowerment) [ 4 ]. The application of personal recovery to individuals with BPD requires further exploration [ 5 ].

Qualitative studies examining the experience of individuals with personality disorder describe recovery as involving the reconciliation of self and other representations, fostered through interpersonal relationships and integration within the community [ 6 , 7 ]. These views were similarly identified by Castillo and colleagues [ 8 ] who described recovery as a hierarchical process, starting from the development of healthy attachment patterns, progressing to a state of transitional recovery. This process encompassed stages including, the sense of belonging, and development of hope, goals, identity and roles [ 8 ]. These stages were similar to the personal goals by Katsakou and colleagues [ 2 ], which included aspects associated with regulating emotions and other symptoms. These findings were further confirmed in a study of treatment goals of individuals seeking treatment for BPD, where goals were identified to extend beyond the reduction of symptoms and included improving relationships, developing a sense a self and improving one’s sense of wellbeing [ 9 ]. Whilst these findings indicate the treatment targets of manualised interventions may be narrow, there are innate difficulties in understanding recovery in personality disorders [ 7 ], given the similarities between clinical phenomenology and domains of personal recovery. The current changes to the conceptualisation of personality disorder from a categorical to dimensional approach, focusing upon individual traits, severity, and functioning, provides an opportunity to more fully integrate individual perspectives into treatment [ 10 ].

The perspectives of individuals accessing specialist treatment have been well represented within the literature. While important, a broader approach to include individuals who do not access specialist services, such as who have difficulty accessing services or no longer require services may provide a more representative view. This coincides with calls to further understanding the experiences of people who are at the opposite ends of recovery [ 11 ]. Therefore, this study aims to understand the experience and conceptualisation of recovery in individuals with BPD who are at varying stages of the recovery process. Comparisons between individuals in the recovered and not recovered groups were made to illustrate differences.

Participants and inclusion

Individuals were initially recruited to take part in an online survey, via mental health organisations and social media, adapting methods used by previous studies of experience in personality disorder [ 12 ]. The study’s inclusion criteria was based on the recognition in the wider literature that recovery may occur across stages and is fluctuating in nature (Andresen et al., 2003). A longitudinal study of individuals with schizophrenia identified that half the sample did not progress past the first stage (‘overwhelmed by the disability’), and no individuals attained the final stage of recovery (‘living beyond the disability’) within the two-year follow-up period [ 11 ]. Findings from a study examining recovery in BPD similarly identified the final stage (‘recovered’) to be more uncertain [ 2 ]. Therefore, the perspectives of individuals at the extreme ends may be important to understand in order to capture what the recovery spectrum in BPD may entail.

Following completion of an online survey, researchers grouped individuals into one of four groups identified by recovery and diagnostic status. Recovery status was obtained through asking individuals to define recovery in BPD and identification with their personal definition. Diagnostic status was determined through the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) [ 13 ]. The MSI-BPD is a 10-item self-report screening measure, where a score of 7 or greater indicates the high likelihood of meeting DSM-5 criteria for BPD. The MSI-BPD has good psychometric properties with high sensitivity (0.81), specificity (0.85) and reliability (alpha = 0.74) [ 13 ]. The narratives of individuals who self-identified with being recovered and no longer met criteria for BPD (recovered group), and individuals who did not self-identify with being recovered and met criteria for BPD (not recovered group) were included in the study. Individuals were further matched on age, gender, and treatment history. Narratives were included into the study until thematic saturation was reached. This resulted in the inclusion of 14 individual narratives ( n  = 7 recovered group and n = 7 not recovered group). The study was approved by the University of Wollongong Social Sciences Human Research Ethics Committee (HE16/215) and all individuals provided informed consent.

Data analysis

Semi-structured interviews following a topic guide were conducted. The guide provided general prompts for the interviewer and was refined following consultation with a consumer advisory committee (Additional file  1 ). The interviewer asked individuals to describe their first experiences with BPD, current life, views of recovery, and experience of treatment and supports. Interviews were audio recorded, transcribed verbatim and entered into NVivo 11 for data analysis.

Interpretive phenomenological analysis (IPA) was used as the overarching methodology to understand individuals’ experience and the ascribed meaning associated with the recovery journey in BPD [ 14 ]. Smaller sample sizes are recommended to gain in-depth understanding [ 14 ]. An inductive approach outlined by Smith and colleagues [ 14 ] was used to understand the emergent themes and the relationship between themes. Firstly, researchers immersed themselves in the narrative by reading transcripts, whilst free coding to gain an overarching understanding of the data. Secondly, free codes were coded into emergent themes summarising excerpts of individual’s narratives. Emergent themes were then clustered into superordinate themes to describe individuals’ experiences. This process was supported by discussions by the research team, where discrepancies between the team were resolved via consensus. Two transcripts, which represented over 10% of the data were coded by two independent raters (FN and CM) (inter-rater reliability = 91%). The remaining data was independently coded by one researcher (FN). The names of individuals have been de-identified to their participant number for confidentiality purposes. Individuals in the recovered group are denoted with ‘R’ and those who are not recovered are denoted with ‘NR’. Once the coding was determined by the researchers, the findings were discussed with a member of the consumer advisory committee, whose feedback was integrated to strengthen the paper (MJ).

A total of 171 individuals provided contact details for follow-up from the online survey, where 108 individuals were contacted. Thirty-nine individuals completed the telephone interview. Using the study’s inclusion criteria, 14 individual narratives (7 recovered and 7 not recovered) were included in the study. All individuals in this study were female with an average age of 33.36 years (SD = 10.26). The majority of individuals were from Australasia, with one individual from the Middle East. There were no significant differences on socio-demographic characteristics between the two groups. Comparison of socio-demographic characteristics of individuals are provided in Table  1 .

Stages of recovery in borderline personality disorder

Recovery in BPD occurred across three core stages, including; 1) being stuck, 2) diagnosis, and 3) improving experience. Differences between individuals in the recovered and not recovered groups were observed in the final stage of recovery continuum. The movement between stages fluctuated, therefore narratives were discussed from a current or retrospective stance. A graphical representation of the stages and processes of recovery in BPD is depicted in Fig.  1 .

figure 1

Stages and processes of recovery in borderline personality disorder

Being stuck

This stage was characteristic of all individuals when first experiencing symptoms of BPD. Individuals did not have a clear conceptualisation of their experiences and described ‘being stuck’ as a state of ‘floundering, getting bounced in and out of hospital… I was lacking in therapy and not really engaging in services’ (JTR191-R). An individual’s emotional intensity was identified to impact upon daily living and was noted to extend beyond the realms of normal experience, where ‘emotions are so raw and powerful, they drove everything. I had no insight whatsoever into what I was doing. I didn’t know who I was, what I was doing or why. I reacted to everything in an unhealthy way’ (JTR280-R). Reports of maladaptive coping strategies such as self-harm or repeated suicide attempts were prevalent at this stage.

Negative experiences from childhood and adolescence, such as bullying or abuse, was reported to affect an individual’s perception about self and others. For example ‘BPD can be rooted in childhood trauma… I was taught it was always my fault as a child. Being in a relationship now with the same thing happen, my brain will assume, it is my fault’ (JTR051 – NR). The enduring nature was also noted in interpersonal difficulties, such that ‘even at six years old, I had that instable personality… Not having any kind of self-worth and switching from one friend to another depending on what my needs were and how that person was feeling…’ (JTR239 – R).

Unsuccessful attempts at seeking help for mental health concerns was also characteristic during this stage. Misdiagnosis of other mental health concerns, such as depression, anxiety and bipolar disorder, were a common experience. Individuals reported these diagnoses did not encapsulate the severity of their experience, as ‘it felt much worse but they told me my problems are mild and not an issue’ (JTR051 – NR). The knowledge of health professionals and the ability to access effective treatments were viewed to be crucial for an individual to move on from the ‘being stuck’ phase.

Receiving a diagnosis of BPD was identified to be a turning point in assisting individuals to conceptualise their experiences and emotional intensity. Diagnosis provided individuals a narrative ‘to describe what was going on, that I wasn’t alone and other people had experienced this as well’ (JTR011 – R), giving individuals a sense of validation and relief, which assisted with progression in the recovery journey. The impact of delayed or mis-diagnosis was highlighted in the length of time taken to receive a diagnosis of BPD, as diagnosis assisted some individuals to gain access to evidence based treatment for BPD. Non-acceptance or disinterest in the diagnosis was reported by a minority of individuals, ‘I didn’t accept the borderline diagnosis. I wasn’t interested and no one was interested in talking to me about it… but I understood what bipolar was and thought that did seem to fit’ (JTR239 – R). Some participants highlighted the immediate need for information about BPD to contextualise the diagnosis, as ‘the worst thing is when people are not given any information when they are diagnosed with BPD.’ (JTR280 – R). Whilst knowledge was predominately acquired from engagement with health services, some individuals identified their own efforts to gain knowledge, ‘I did a lot of reading once I got the diagnosis. It really made sense’ (JTR011 – R). However, the prevalence of stigma and discrimination associated with the diagnosis of BPD promoted negative experiences, where ‘I’ve had some really traumatic experiences as a result of having the diagnosis… I no longer seek help if I’m in crisis, because I know that I’ll get treated badly and be more stressed than if I didn’t do anything...I feel like I don’t trust the system’ (JTR051 – NR).

Improving experience

Developing greater awareness of emotions and of self and others was described as a core stage and influencer of recovery. Three domains were associated with this stage including 1) Developing Greater Awareness of Emotions and Thoughts, 2) Strengthening Sense of Self, and 3) Understanding the Perspectives of Others. These domains were not mutually exclusive, yet the progression made in this stage differed between individuals.

Individual’s conceptualisation of recovery indicated that there was skepticism surrounding the amelioration of symptoms. Recovery was considered an ongoing journey with elements of survival, resilience and self-management. For example, ‘it can be managed… I don’t think the symptoms will ever 100% disappear forever. They’ll always be there to some degree in the background. I hope I get to a point where it doesn’t impact on your life in a negative way’ (JTR051 – NR). This was echoed by individuals who identified with being recovered as, ‘I got to a point where I realised that all that suffering made me much stronger. I have more insight because I had to do the work to recover’ (JTR280 – R).

Developing greater awareness of emotions and thoughts

The identification of emotions and thoughts was considered a starting point in fostering understanding of oneself and the use of coping strategies, such that ‘I was beginning to develop more awareness of my emotions, but not so much control. Just the ability to not be blindsided by them’ (JTR459 – NR). However, the identification of emotions did not preclude individuals to distress, where ‘I don’t necessarily act on my thoughts anymore. My first reaction to something will be ‘I should self-harm’, but even though I’m not actually physically doing it, having my thoughts consumed by it is distressing’ (JTR083 – NR).

Strengthening sense of self

All individuals acknowledged that developing one’s sense of self was a central component of the recovery journey. Individuals who identified with being recovered provided greater details of the nuances of developing a stronger sense of self. This was conceptualised as a process of reframing how one understands or perceives oneself. This process was noted to commence in conjunction with developing skills to recognise and tolerate emotions.

Individual narratives discussed the lack of identity stemming from first experiences of BPD and their sense of self being constructed upon symptom experience and identification with the BPD diagnosis. For example; ‘Sometimes I feel like my whole identity has been based around my trauma… and when you suddenly start being able to react differently to things, I kind of felt like a lot of my identity was disappearing, because I no longer feel as intense’ (JTR051 – NR). Stigma arising from interactions with others had the potential to reinforce negative self-perceptions, such that ‘I was very reluctant to actually disclose to people [my diagnosis] up until only really a few years ago, because I disclosed previously without thinking about it and then experienced unpleasant responses.’ (JTR011 – R).

Being aware of individual patterns and triggers provided opportunities to ‘always challenge myself to become better. Instead of avoiding things like I used to, I think about how I can do it until I’m not stressed out by it anymore’ (JTR233 – R). This allowed for skill practice but also a subsequent sense of agency. Difficulties moving away from the illness identity was articulated by a minority of individuals in the recovered group. Despite progress made in identifying emotions and skill usage, individuals noted that ‘my therapist had been telling me that I was recovered and I didn’t meet criteria, but I didn’t believe her. I think it was because I lacked an identity. I still don’t understand what identity is… I held onto that diagnosis for such a long time, that was who I was’ (JTR239 – R). The fear associated with developing a greater sense of self exacerbated this as ‘what if I use the skills and do what I need to do to achieve recovery and I still hate myself?’ (JTR280 – R).

Understanding the perspectives of others

This theme was discussed by a minority of individuals in the recovered group. Individuals described this as a process of reflecting beyond one’s own subjective experience to include the capacity of others and the relational context. The impact of being able to understand the perspectives of others in reconciling relationships was highlighted in an individual’s response, where ‘I got to experience the pain that I inflicted on my mother, by projecting all my self-loathing onto her. My mum had her own weaknesses… but I was too caught up in my own narcissistic injuries before to conceptualise how much pain I’d caused her.’ (JTR191 – R). This was similarly discussed by another individual, where the perspectives of others allowed for the calibration of her own perceptions of self. For example ‘My husband always saw my potential and knew what I’m capable of, but I didn’t see that at the time. I just thought he was ridiculous and was making fun of me, but I now know what he means’ (JTR072 – R).

Processes of recovery in borderline personality disorder

Four recovery processes in BPD were identified from individual’s narratives; 1) active engagement in the recovery process, 2) hope, 3) treatment and, 4) meaningful activities and relationships. These processes could be overlapping and facilitate or hinder the recovery journey. Some differences between individuals in the recovered and not recovered groups were identified. These recovery processes contributed to the movement through the recovery stages and the growth within individuals.

Active engagement in the recovery process

The desire and willingness to engage in the recovery process was crucial for progress in recovery to be made. Yet these observations were often made from a retrospective standpoint, when individuals had already accepted their diagnosis and take ‘responsibility to learn the skills and do it yourself, you’re going to get to a finite point, where it’s all going to be ok’ (JTR011 – R). Motivational differences between individuals in the recovered and not recovered groups were identified, such that individuals in the recovered group placed emphasis on intrinsic factors, whilst individuals in the not recovered group emphasised extrinsic factors. A minority of individuals identified that the mindset in which they approached treatment may impact on willingness to active engage in recovery such that a change-oriented mindset was necessary. ‘I was in treatment but I thought why I was sitting there listening to other people talk about their issues. I thought this isn’t my problem and I felt so angry, I didn’t see the point, so I dropped out.’ (JTR239 – R).

Hope was an overarching concept, permeated when experiences positively contrasted to individual perceptions or their worldview. Recovery was considered unexpected and promoted a new outlook which was not previously considered by some individuals. States of hopelessness particularly observed during the early stages was prevalent in all individuals, such that ‘I didn’t have any kind of hope. I didn’t have anything to hold onto…’ (JTR239 – R). Hope could be generated through vocational and relational engagement and the subsequent sense of agency gained from the use of skills or reflection on progress. For some individuals in the not recovered group, the maintenance of hope was associated with the ability to get treatment, ‘I had a wonderful psychologist who I got along really well with. But at the moment it’s hard to keep my eye on the prize, per se ’ (JTR459 - NR).

Hope played a role in the maintenance of motivation, as it contributed to gains in self-belief and the reduction of self-doubt. ‘That sense of just knowing the emotions will end, this isn’t a permanent thing... I used to feel like it was just never going to end’ (JTR239 – R). The shift in perspective had a compounding effect on individuals and their clinicians, as ‘…I suppose I wouldn’t expect it (recovery). I mean my clinicians were surprised by my recovery’ (JTR151 – R).

Engagement with treatment services

Seeking treatment was identified by all individuals as a key component in the recovery process, where effective treatment aligned with individual goals provided a sense of hope and the development of skills. Whilst these provided individuals a sense that ‘this could be working. Maybe things will be ok’ (JTR061 – NR), services and treatments were described as mixed and fragmented. All individuals described at least one negative experience, where difficulties accessing treatment hindered progress on recovery. Individuals described greater difficulties when at the start of the recovery continuum.

Incongruent relationships through a lack of therapeutic alliance between clinician and individual also contributed to a lack of progress made in recovery, such that ‘I don’t think I progressed much with them (clinician) because we didn’t fit well’ (JTR051 – NR). This contrasted to the progress made with clinicians who promoted collaborative and trustworthy relationships, as these fostered stronger relationships, as ‘she would make an appointment with me and I wouldn’t turn up. She didn’t get angry… she just kept trying and waited until I was ready’ (JTR233 – R).

Engaging in meaningful activities and relationships

Engaging in meaningful activities and relationships was described as providing a sense of belonging and connectedness, the opportunity to practice new skills, reflect upon one’s emotional reactions and sense of self. Although individual differences influenced what was considered meaningful, these commonly included employment, education, and relationships with friends, family, significant others and clinicians. Benefits such as the independence gained from being employed and the sense of ‘affirmation and sense of purpose’ (JTR011-R) was discussed.

For some individuals during the early experiences of BPD, their experience of symptoms precluded their participation in activities such that when ‘when I was a student and before I started working full-time, it was much harder and my symptoms were more pronounced. I had a lot more difficulty’ (JTR011-R). This also extended into the relational domain, where some individuals avoided relationships in fear of the negative effects on symptoms, such that ‘I haven’t had a relationship for the last seven months, it’s easier when you don’t have one… I’m really scared of actually going into a relationship again, because when that goes bad, I’m going to go bad.’ (JTR018 – NR).

All individuals acknowledged the role activities and relationships had for self-exploration and reflection. For example, meditation was described by one individual as ‘a laboratory that helps you sit with yourself and watch how the emotions just rise and fall away’ (JTR191 – R). Whilst others identified differences in self in differing contexts, for example ‘At work I would be fine, but I can be a complete mess outside of work. I can organise 10 other people but then my brain just switches. As soon as I don’t have something to focus on, I focus on myself, which is bad.’ (JTR018 – NR). Noticing differences in oneself provided opportunities to gain greater insight into oneself.

The present study aimed to gain a holistic understanding of recovery in individuals with lived experience of BPD at either end of the recovery continuum. Overall, recovery was characterised by an interaction between the stages and processes. The identification of recovery in BPD as an ongoing journey is reflective of current literature on personal recovery in mental health [ 2 , 15 ].

The stages of recovery identified in the present study align with the broad recovery stages mapped by Leamy and colleagues [ 4 ]. However, stages identified were framed by individuals in a clinical manner. Domains associated with improving experience were reflective of core psychopathology in BPD [ 16 ]. This mimics the tasks identified in other qualitative studies examining recovery in personality disorder [ 2 , 6 , 7 ]. Therefore, the developed framework may be reflective of recovery within the context of treatment. Individuals in this study on average had 10 years of treatment, therefore the importance of treatment as part of recovery is not without standing. Yet, the literature proposes that there are multiple routes to recovery, including engagement in non-traditional mental health services [ 3 ], The possibility of individual recovery through the use of other supports, such as peer workers or recovery colleges, could be further investigated within the context of personality disorder. Despite this, only the perspectives of women were included as part of the study. The perspectives of men could be a focus for future research.

As individuals were required to have a diagnosis of BPD to take part in the study, the being stuck and diagnosis stages were universally described. Diagnosis played a role in shifting the trajectory of experience and provide opportunity to formulate meaning and promote hope. However, the gap between an individual’s perceived age of onset and age of diagnosis in this sample was approximately 15 years. This may be representative of a knowledge gap in health professionals and the need to upskill clinicians in working with people with personality disorder or stigma which may prevent timely diagnosis [ 7 , 17 , 18 ]. This compounds with the desire of individuals for information about BPD at diagnosis.

Differences between the recovered and not recovered groups were most pronounced in the improving experience stage. The narratives of individuals in the recovered group articulated experiences of understanding self and others, compared to individuals in the not recovered group who discussed working towards improving awareness of emotions and thoughts. Whilst growth is exemplified as a stage in other models of personal recovery, often involving self-management of symptoms [ 19 ], narratives in this study indicate that the process of growth began through gaining awareness of emotions.

Strengthening the sense of self was identified to be a domain central to growth. There are differences between what is currently conceptualised as identity in the personal recovery literature, which proposes that individuals reformulate their sense of self [ 20 , 21 ], suggesting that individuals have some sense of self, prior to their first experiences of mental health concerns. In this study, individuals describe a lack of identity from first experiences of BPD. Adopting an illness identity has been associated with less favourable outcomes [ 22 ], whilst the movement away from illness identity is supported by the current personal recovery literature [ 4 ]. The emphasis on diagnosis in the current findings suggests that acceptance of the illness is required to a degree to progress in recovery in BPD. Over-identification however, can also lead to stagnation in recovery. Greater understanding of illness identity in BPD is required and is particularly salient given identity disturbances is core to the disorder. Identifying internal narratives may be a starting point in promoting motivation and willingness to engage in the recovery journey.

Engaging in relationships and meaningful activities is known to be a priority for individuals with BPD [ 1 ]. Interestingly, the proportion of individuals engaged in paid employment and in a relationship did not significantly differ, despite individuals being at either end of the recovery continuum. This indicates that recovery status may have an influence on the quality of the relationship or the amount of work engaged in. Existing longitudinal studies have identified that approximately 50% of individuals experience ‘good recovery’ following 10 years of follow-up, indicating that individuals have experienced concurrent remission from BPD and have full time vocational engagement [ 23 , 24 ]. In the present study, less than half of the individuals in the recovered group were engaged in a relationship or in paid work, indicating that the current sample may have a more severe presentation and experience greater psychosocial difficulties compared participants in existing longitudinal studies. Differences between the treatment context in individuals in the current sample and longitudinal studies such as The McLean Study of Adult Development [ 24 ] are worth noting. Individuals in the McLean study were more functional and therefore likely to be employed than those in the current sample. This may be due to differences in capacity to pay for and access care, with the McLean sample being mainly health insured patients compared with our sample that were more reliant on stretched public services for care.

The broad recruitment strategy adopted by the study allowed for individuals to be recruited from more than one treatment service or service catchment, allowing for a wider range of views and experiences to be included in the study. However, consistent with previous research, the study adopted a retrospective approach. Difficulties in comparing individuals were encountered by researchers, as recovery is not a static process. For example, individuals in the not recovered group may have previously experienced periods in which they considered themselves as recovered and could draw on these experiences. The narratives of individuals may be subjected to some level of response bias given the significant gap between individual’s age of onset, diagnosis and current age. The use of prospective longitudinal research to map recovery to obtain real time accounts may be a direction for future research. The adoption of blind data collection and analysis process may also reduce the likelihood of researcher bias.

This study identified stages and processes associated with recovery in BPD through the perspectives of individuals with lived experience. The findings extend existing knowledge by contrasting the experiences of individuals at either ends of the recovery continuum. The inclusion of individuals in the recovered group, provides a stronger indication of what the full recovery spectrum may constitute. The findings however, represents recovery in the context of treatment. Therefore, it is difficult to extend these findings to individuals who seek support for BPD outside of traditional treatment services. To incorporate a more holistic approach to recovery in clinical practice, it is recommended that a greater focus on individual motivation, treatment engagement, relationships and hope is needed.

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The authors would like to acknowledge the individuals with lived experience who took part in the study.

FYYN was supported by an Australian Government Research Training Scholarship. BFSG receives funding from the NSW Ministry of Health for Project Air Strategy. The funders had no role in the design, recruitment, collection, interpretation or writing of the manuscript.

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Data from the current study will not be made available, as participants did not consent for their transcripts to be publically released. Extracts of participant responses have been made available within the manuscript.

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School of Health Sciences, Institute of Mental Health, University of Nottingham, Nottingham, UK

Fiona Y. Y. Ng

School of Psychology, University of Wollongong, Wollongong, Australia

Fiona Y. Y. Ng, Michelle L. Townsend, Caitlin E. Miller & Brin F. S. Grenyer

Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, Australia

Michelle L. Townsend, Caitlin E. Miller & Brin F. S. Grenyer

Project Air Strategy Consumer and Carer Advisory Committee, Wollongong, Australia

Mahlie Jewell

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FYYN designed the study, recruited participants, conducted all interview participants, conducted the formal data analysis, and wrote the first draft of the manuscript. MLT contributed to the interpretation of the results. CM was the secondary coder for qualitative data analysis. MJ contributed to the interpretation of the results. BFSG contributed to the design of the study and interpretation of the results. All authors read and approved the final version of the manuscript.

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Correspondence to Fiona Y. Y. Ng .

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Ng, F.Y.Y., Townsend, M.L., Miller, C.E. et al. The lived experience of recovery in borderline personality disorder: a qualitative study. bord personal disord emot dysregul 6 , 10 (2019).

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  • Borderline personality disorder
  • Lived experience
  • Qualitative

Borderline Personality Disorder and Emotion Dysregulation

ISSN: 2051-6673

case study personality disorder

  • Introduction
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A, The clock paradigm consists of decision and feedback phases. During the decision phase, a dot revolves 360° around a central stimulus over the course of 4 seconds. Participants press a button to stop the revolution and receive a probabilistic outcome. During the feedback phase, participants are informed about the number of points they won on this trial, with 0 points representing reward omission. Rewards are drawn from 1 of 2 monotonically time-varying contingencies in which expected values of choices either increase (increasing expected value [IEV]) or decrease (decreasing expected value [DEV]) with prolonged wait. Reward probabilities and magnitude varied independently (eFigure 1 in Supplement 1 ). B, Evolution of participants’ response times (RT) and RT swings by contingency in the borderline personality disorder (BPD) and major depressive disorder (MDD) samples. Plotted data are smoothed using a generalized additive model (GAM) in the ggplot2 package of R version 3.4.4 (R Foundation). In subplots on the right, the smoothing used natural splines from the splines package in R version 4.3.2, with a basis of 5 knots. The shaded area around the lines represents 95% CIs. Participants learned to respond later in the IEV compared to the DEV condition and RT swings generally decreased later in learning (especially in IEV). To ascertain that time courses were not distorted by smoothing, trial-averaged data are presented in eFigures 2 and 3 in Supplement 1 . The difference between DEV and IEV at trial 1 is due to the alternation of IEV and DEV conditions, which change every 40 trials of the task.

A, The Strategic Exploration/Exploitation of Temporal Instrumental Contingencies (SCEPTIC) reinforcement learning model shows basis function representation. Top: participant responds at 1 second and wins 110 points. Bottom left: the 1-dimensional space of the task is tiled with Gaussian-shaped learning elements with staggered receptive fields. Bottom right: the reward at 1 second updates expected values (weights) of nearby basis elements. Color indicates the location of the basis function within the interval. Darker colors indicate earlier responses, and lighter colors indicate later responses. B, Entropy dynamics of the information-compressing reinforcement learning (RL) model. Early in learning, entropy is high because all locations have similar values. The figure shows example value distribution early in learning, first within the circular visual space of the task and then projected linearly onto the abscissa. Later in learning, entropy decreased as the most attractive option dominated. Traditional RL is contrasted with information-compressing RL. Information compression (arrows) reduces the entropy of the value distribution. In contrast to traditional RL with long-term value persistence, information-compressing RL learns and forgets faster. Information compression is an emerging property of the algorithm, resulting from both the decay of unchosen options and value updates of the chosen location. In contrast, entropy change in the traditional RL model depends only on the latter. Entropy was defined as Shannon entropy of the normalized vector of element weights (gray bars). C, Random-effects bayesian model comparison of SCEPTIC model variants. Dots represent the estimated model frequency (ie, the proportion of participants for whom a given model provided the best fit to the data). The shade matches that of the same models in panel B. Uncertainty-sensitive RL is the SCEPTIC model variant where choice was influenced by both uncertainty and reward value to embody the alternative hypothesis that uncertainty modulates exploration. Information-compressing RL was used in the study as it performed better than traditional or uncertainty-sensitive RL. Diagnostic groups exhibited a similar pattern of model fits to the full sample. BOR indicates bayesian omnibus risk; EP, exceedance probability.

Estimates from multilevel linear regression models predicting trial-level responses. See eTables 4, 18, 19, and 22 in Supplement 1 , respectively, for full outputs of these models. A, Response time (RT) swings following reward vs omission by group in the borderline personality disorder (BPD) sample. Smaller numbers indicate larger RT swings and vice versa. Individuals with high-lethality (HL) suicide attempts had lower levels of win-stay/lose-shift behavior (ie, the tendency to repeat rewarded options and shift away from unrewarded options). Whereas individuals with HL suicide attempts were less likely to shift behavior after a previously unrewarded action (smaller lose-shift), individuals with low-lethality (LL) suicide attempts were less likely to stick with the previously rewarded actions (smaller win-stay). B, Entropy dynamics by group during the clock task in the BPD sample. The ordinate depicts Shannon entropy of normalized element weights (illustrated in Figure 2 ), with higher values reflecting a greater number of competing options. Individuals with HL suicide attempts discovered fewer options than other groups, as evidenced by a lack of value entropy expansion in that group. C, Response time swings following reward vs omission as in panel A, replication in the major depressive disorder (MDD) sample. D, Response time swings following reward vs omission on the clock task and prospective suicidal ideation during ecological momentary assessment in individuals with BPD. Lower levels of win-stay/lose-shift (especially after reward omission) were associated with more frequent suicidal ideation in daily life. AU indicates arbitrary units; HC, healthy control individuals; NON, individuals without lifetime history of suicide attempts; SI, suicidal ideation.

eTable 1. Demographic and clinical characterization of the BPD sample

eTable 2. Demographic and clinical characterization of the MDD sample

eTable 3. Model fits by diagnostic groups

eTable 4. BPD sample: Exploration and exploitation on the Clock task

eTable 5. BPD sample sensitivity analysis: Levels of depressive symptoms (excluding healthy controls)

eTable 6. BPD sample sensitivity analysis: Suicide attempt recency

eTable 7. BPD sample sensitivity analysis: Impulsivity

eTable 8. BPD sample sensitivity analysis: Medication exposure to antidepressants (excluding healthy controls)

eTable 9. BPD sample sensitivity analysis: Medication exposure to opioids (excluding healthy controls)

eTable 10. BPD sample sensitivity analysis: Medication exposure to sedatives or hypnotics (excluding healthy controls)

eTable 11. BPD sample sensitivity analysis: Medication exposure to antipsychotics (excluding healthy controls)

eTable 12. BPD sample sensitivity analysis: Estimated premorbid IQ

eTable 13. BPD sample sensitivity analysis: Executive function

eTable 14. BPD sample sensitivity analysis: Effects of working memory

eTable 15. BPD sample sensitivity analysis controlling for individual random slopes of RT lag

eTable 16. BPD sample sensitivity analysis controlling for individual random slopes of RT vmax

eTable 17. BPD sample sensitivity analysis controlling for individual random slopes of reward (reward lag)

eTable 18. BPD sample: model without RT vmax:Group:trial interaction as a covariate

eTable 19. BPD sample: Information dynamics reflective of option competition

eTable 20. MDD sample: Exploration and exploitation on the Clock task

eTable 21. BPD sample: model without reward lag:RT lag interaction as a covariate

eTable 22. BPD EMA subsample: Exploration and exploitation on the Clock task predicting the frequency of prospective daily suicidal ideation

eTable 23. BPD EMA subsample sensitivity analysis: Excluding 2 relatively extreme values on daily suicidal ideation measure

eTable 24. BPD EMA subsample sensitivity analysis: SA recency

eTable 25. BPD EMA subsample sensitivity analysis: Controlling for average levels of negative internalizing affect in daily life

eTable 26. BPD EMA subsample sensitivity analysis: Controlling for average levels of externalizing affect in daily life

eTable 27. BPD EMA subsample sensitivity analysis: Controlling for average levels of impulsive affect in daily life

eFigure 1. Reward magnitude and probability across time-varying contingencies

eFigure 2. Behavioral manipulation checks by group (generalized additive model)

eFigure 3. Behavioral manipulation checks (raw data, trial averages across groups)

eFigure 4. Behavioral manipulation checks (raw data, trial averages by group)

eFigure 5. Posterior predictive checks

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Tsypes A , Hallquist MN , Ianni A , Kaurin A , Wright AGC , Dombrovski AY. Exploration-Exploitation and Suicidal Behavior in Borderline Personality Disorder and Depression. JAMA Psychiatry. Published online July 10, 2024. doi:10.1001/jamapsychiatry.2024.1796

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Exploration-Exploitation and Suicidal Behavior in Borderline Personality Disorder and Depression

  • 1 Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
  • 2 Department of Psychology and Neuroscience, University of North Carolina, Chapel Hill
  • 3 Department of Psychology, University of Wuppertal, Wuppertal, Germany
  • 4 Department of Psychology, University of Michigan, Ann Arbor
  • 5 Eisenberg Family Depression Center, University of Michigan, Ann Arbor

Question   Is the inability to explore multiple alternatives and take advantage of the best options associated with suicidal behavior?

Findings   In 2 case-control studies of adults with borderline personality disorder and depression, inability to fully explore available options was associated with medically serious suicide attempts. In an ambulatory study, this pattern predicted suicidal ideation.

Meaning   The findings suggest that the inability to explore a full range of solutions in a state of suicidal crisis may prevent one from discovering alternatives to attempting suicide; exploring novel ways to cope may help individuals build their safety plans.

Importance   Clinical theory and behavioral studies suggest that people experiencing suicidal crisis are often unable to find constructive solutions or incorporate useful information into their decisions, resulting in premature convergence on suicide and neglect of better alternatives. However, prior studies of suicidal behavior have not formally examined how individuals resolve the tradeoffs between exploiting familiar options and exploring potentially superior alternatives.

Objective   To investigate exploration and exploitation in suicidal behavior from the formal perspective of reinforcement learning.

Design, Setting, and Participants   Two case-control behavioral studies of exploration-exploitation of a large 1-dimensional continuous space and a 21-day prospective ambulatory study of suicidal ideation were conducted between April 2016 and March 2022. Participants were recruited from inpatient psychiatric units, outpatient clinics, and the community in Pittsburgh, Pennsylvania, and underwent laboratory and ambulatory assessments. Adults diagnosed with borderline personality disorder (BPD) and midlife and late-life major depressive disorder (MDD) were included, with each sample including demographically equated groups with a history of high-lethality suicide attempts, low-lethality suicide attempts, individuals with BPD or MDD but no suicide attempts, and control individuals without psychiatric disorders. The MDD sample also included a subgroup with serious suicidal ideation.

Main Outcomes and Measures   Behavioral (model-free and model-derived) indices of exploration and exploitation, suicide attempt lethality (Beck Lethality Scale), and prospectively assessed suicidal ideation.

Results   The BPD group included 171 adults (mean [SD] age, 30.55 [9.13] years; 135 [79%] female). The MDD group included 143 adults (mean [SD] age, 62.03 [6.82] years; 81 [57%] female). Across the BPD (χ 2 3  = 50.68; P  < .001) and MDD (χ 2 4  = 36.34; P  < .001) samples, individuals with high-lethality suicide attempts discovered fewer options than other groups as they were unable to shift away from unrewarded options. In contrast, those with low-lethality attempts were prone to excessive behavioral shifts after rewarded and unrewarded actions. No differences were seen in strategic early exploration or in exploitation. Among 84 participants with BPD in the ambulatory study, 56 reported suicidal ideation. Underexploration also predicted incident suicidal ideation (χ 2 1  = 30.16; P  < .001), validating the case-control results prospectively. The findings were robust to confounds, including medication exposure, affective state, and behavioral heterogeneity.

Conclusions and Relevance   The findings suggest that narrow exploration and inability to abandon inferior options are associated with serious suicidal behavior and chronic suicidal thoughts. By contrast, individuals in this study who engaged in low-lethality suicidal behavior displayed a low threshold for taking potentially disadvantageous actions.

People who survive suicide attempts usually come to regret their choice of suicide attempt over constructive alternatives, 1 suggesting that this choice is often an error of decision-making. Individuals who use substances or gamble in real life 2 , 3 and do not make optimal value-based choices or effectively learn from rewards and punishments in the laboratory 4 - 12 may be more vulnerable to suicidal behavior. However, our understanding of decision-making in a state of suicidal crisis is limited by the reliance on simple decision tasks used in case-control studies that leave out critical real-life demands. In a crisis, decisions are often made during a complex sensorimotor interaction, as one may take a phone call, read an upsetting message, walk, look around, and even begin to implement a suicidal plan. There is usually real or perceived time pressure, and a vast number of options may become available and vanish dynamically. Imagine a person experiencing unbearable distress who may consider drinking alcohol, taking an overdose, going for a walk while practicing a coping skill, or calling a friend. Drinking and overdose are always there, while the availability and worth of alternatives can change: the friend may not answer the call after a work shift starts, and a walk may bring no relief once the afternoon heat sets in. Many alternatives may remain, but it is hard to consider which ones would work when experiencing a sense of crisis.

Clinical theories describe the suicidal crisis as a myopic, passive, and constricted cognitive state—one of tunnel vision. 13 - 15 While clinical accounts yield few predictions about neurobehavioral mechanisms, reinforcement learning 16 - 19 provides a useful theoretical framework for understanding decision-making. Dynamic decision-making involves a continuous competition between available actions, 20 - 22 and adaptive behavior depends on resolving this competition. 23 Reinforcement learning frames option competition as a dilemma between exploiting options thought to be best and exploring potentially superior alternatives. 24 In this explore-exploit framework, we can view cognitive constriction as a narrow and ineffective exploration, yielding a subset of suboptimal choices. Returning to our example, one may end up drinking alcohol or even attempting suicide, having not explored constructive solutions when they were available and useful.

To understand how people who are vulnerable to suicide resolve option competition under time pressure, we investigated the exploration-exploitation of a continuous space where a large number of options become available and vanish dynamically. We used the clock task 25 ( Figure 1 A), where movement through a 1-dimensional environment is signaled by a dot rotating around a circle and rewards, and the distance between consecutive choices provides a straightforward measure of exploration. To assess exploitation, we used a previously validated computational model that explores and exploits efficiently in a resource-rational manner. 26 During learning, when one chooses among discrete options, it is hard to infer that a given choice is exploratory without computational modeling. By contrast, shifts to far-away locations of a continuous space, particularly when unexplained by reward history, are likely to reflect exploration. Much exploration on the clock task results from shifting away immediately after unrewarded responses. Humans and other mammals consistently display these so-called win-stay/lose-shift responses alongside reinforcement learning. 27 - 30 Critically, smaller win-stay/lose-shift responses were associated with attempted suicide in our earlier armed bandit studies of late-life depression. 8 Here, we aimed to understand whether this impairment—and ostensibly the inability to find solutions in a suicidal crisis—may reflect deficits in exploration (including by shifting far away from unrewarded options) or in exploitation based on longer-term learned values. 4 - 12

Surveying diverse forms of suicidal behavior maximally representative of death by suicide, we examined exploration-exploitation in people with borderline personality disorder (BPD) and late-life depression who had made high-lethality vs low-lethality suicide attempts. Whereas BPD is characterized by affective instability, rash decisions, and recurrent suicidal thoughts and behaviors, 31 , 32 suicidal acts in individuals with late-life depression are less frequent but more determined and lethal. 33 - 35 Finally, to validate our case-control findings prospectively, we examined whether behavioral exploration/exploitation predicted incident suicidal thoughts assessed via ecological momentary assessment. We hypothesized that high-lethality suicide attempts and incident suicidal thoughts would be associated with underexploration, particularly following unrewarded choices, and with inability to exploit.

Participants ( Table 1 ; eTables 1 and 2 in Supplement 1 ) included 171 adults with BPD and 143 adults with major depressive disorder (MDD). We contrasted individuals with high-lethality suicide attempts with those with low-lethality attempts, patients with no history of suicide attempts, and psychiatrically healthy control individuals. To identify deficits specific to attempted rather than merely contemplated suicide, we included a group with suicidal ideation with a plan but no attempt history in the MDD sample only. See the eMethods in Supplement 1 for full clinical and psychological characterization of the samples. This study followed the Enhancing the Quality and Transparency of Health Research ( EQUATOR ) reporting guideline. The institutional review board of the University of Pittsburgh approved the study procedures. Written informed consent was obtained before participation.

Participants completed a 21-day ecological momentary assessment protocol (6 surveys per day) within predefined time windows. Suicidal ideation was assessed with 2 dichotomous items (1 = yes, 0 = no 36 , 37 ) from the Columbia Suicide Severity Rating Scale 38 : “Have you wished you were dead or wished you could go to sleep and not wake up?” and “Have you actually had any thoughts of killing yourself?” We averaged across the instances of endorsements of suicidal ideation over the duration of the ecological momentary assessment protocol to get an index of frequency.

All participants explored and exploited a 1-dimensional continuous space on the clock task 25 ( Figure 1 ; eMethods and eFigures 1-4 in Supplement 1 ) over the course of 240 trials. During the decision phase, a green dot revolved 360° around a central stimulus. Participants were informed that the timing of their response controlled the number of points they could win and that not responding during a single revolution (4 seconds in the BPD sample and 5 seconds in the MDD sample) would leave them with no points on that trial. They pressed a button to stop the revolution and received probabilistic feedback controlled by 2 difficult contingencies, such that expected values of choices either increased or decreased along the interval. Reward probabilities and magnitude varied independently. Contingencies reversed every 40 trials and, to rule out the effects of novelty on task behavior, the MDD participants were not signaled about these changes.

Computational modeling is illustrated in Figure 2 and the eMethods, eTable 3, and eFigure 5 in Supplement 1 . Our goal was to identify the highest-value region of the space, which a successful agent would be exploiting on any given trial, given each participant’s sampling and reinforcement history using reinforcement learning. Thus, we fitted our previously validated (across environments and levels of analysis 26 , 39 , 40 ) Strategic Exploration/Exploitation of Temporal Instrumental Contingencies (SCEPTIC) model to participants’ choices. SCEPTIC reduces the potentially infinite continuous options to a handful of discrete actions, using learning elements with staggered receptive fields implemented as gaussian temporal basis functions. 39 To explore and exploit efficiently, while reducing memory load, SCEPTIC selectively maintains the values of preferred actions and allows the nonpreferred alternatives to decay. To improve precision, model parameters were estimated by an empirical bayesian procedure using the variational bayesian approach, 41 regularizing individual estimates by the group posterior.

Measures of exploration and exploitation are detailed in Table 2 and the eMethods in Supplement 1 . As in our previous studies, 26 , 39 we examined individual differences in exploration and exploitation in multilevel linear regression models predicting trial-by-trial response times (RTs) implemented in the lme4 package of R version (R Foundation), accounting for random intercepts for each participant and run and, in sensitivity analyses, participant-level random slopes of behavioral variables. Missed responses and RTs less than 200 ms were excluded (BPD sample: 341 of 41 040 trials [0.83%]; MDD sample: 517 of 34 320 trials [1.51%]).

Participants’ tendency to explore was measured by the decreased effect of RT in the previous trial (RT[t-1]) on RT in the current trial (RT[t]), conceptually corresponding to the tendency to alternate between early and late parts of the interval (RT swings) and primarily reflecting random rather than uncertainty-directed exploration. 39 Its interaction with reward quantified the tendency to shift away from unrewarded choices, while the interaction with trial specifically tested adaptive early exploration. These large RT swings of 1 to 2 seconds far exceed the threshold of sensorimotor precision. Participants’ ability to exploit was captured by the effect of RT with the highest expected value, as predicted by the SCEPTIC model (RT[Vmax]), on their choices. The RT(Vmax) × trial interaction tested the transition from earlier exploration to later exploitation.

Results for exploration in the BPD sample (mean [SD] age, 30.55 [9.13] years; 135 [79%] female and 36 [21%] male) are shown in Figure 3 A and eTable 4 in Supplement 1 . Levels of exploration differed across groups (group × RT[t-1]: χ 2 3  = 50.68; P  < .001). Follow-up analyses revealed smaller RT swings (lower exploration) in individuals with BPD and high-lethality suicide attempts vs those with BPD and low-lethality suicide attempts ( t 39,350  = −4.32; P  < .001) even after accounting for the effects of reward described below. Further, both individuals with BPD and low-lethality attempts ( t 39,340  = −7.01; P  < .001) and those with BPD and no suicide attempts ( t 39,310  = −2.63; P  = .008) had larger RT swings compared to control individuals. Thus, we observed a striking heterogeneity among individuals with suicidal behavior, with relatively low exploration in individuals with BPD and high-lethality suicide attempts and relatively high exploration in those with BPD and low-lethality suicide attempts. We found no selective impairment in early exploration above and beyond these differences.

Much exploration on the clock task depends on RT swings away from unrewarded choices (lose-shifts). 39 Our analysis found a group × reward × RT[t-1] interaction (χ 2 3  = 20.03; P  < .001). Follow-up analyses revealed diminished win-stay/lose-shift responses in individuals with BPD and high-lethality suicide attempts vs all other groups (BPD with low-lethality attempts: t 38,950  = 2.81; P  = .004; those with BPD and no suicide attempts: t 39,020  = 2.64; P  = .008; control individuals: t 38,960  = 4.46; P  < .001). Qualitatively, while all BPD groups, particularly those with low-lethality attempts, displayed smaller win-stays; those with BPD and high-lethality attempts displayed smaller lose-shifts, particularly vs those with BPD and low-lethality attempts, but also vs those with BPD and no suicide attempts. Group differences persisted after controlling for the levels of depressive symptoms, suicide attempt recency (although recency predicted smaller lose-shifts), impulsivity, medication exposure, estimated premorbid IQ, and executive function (eTables 5-13 in Supplement 1 ). Smaller lose-shifts among individuals with BPD and high-lethality attempts could also be due to a working memory deficit; however, this alternative explanation was also ruled out (eTable 14 in Supplement 1 ). Group differences were not explained by individual heterogeneity of behavioral effects, as indicated by sensitivity analyses including random slopes of behavioral variables (eTables 15-17 in Supplement 1 ), or by suppressor effects (eTable 18 in Supplement 1 ).

To ascertain whether individuals with BPD and high-lethality suicide attempts indeed underexplored the option space, we used the SCEPTIC model to examine information dynamics reflective of option competition, finding that individuals with BPD and high-lethality attempts discovered fewer options than other groups ( Figure 3 B; eTable 19 in Supplement 1 ).

Results for exploration in the MDD sample (mean [SD] age, 62.03 [6.82] years; 81 [57%] female and 62 [43%] male) are shown in Figure 3 C and eTable 20 in Supplement 1 . Levels of exploration differed across groups (group × RT[t-1]: χ 2 4  = 36.34; P  < .001). As in the BPD sample, follow-up analyses revealed smaller RT swings in individuals with MDD and high-lethality suicide attempts vs those with MDD and low-lethality suicide attempts ( t 33,170  = −5.12; P  < .001), as well as vs those with MDD and suicidal ideation but no attempt ( t 33,170  = −2.13; P  = .03) and control individuals ( t 33,170  = −2.20; P  = .03). We found no group differences in early exploration specifically.

As in the BPD sample, group differences in exploration were further qualified by reward (group × reward × RT[t-1]: χ 2 4  = 13.66; P  = .008). Individuals with MDD and high-lethality suicide attempts had diminished win-stay/lose-shift responses compared to individuals with MDD and no suicide attempts ( t 33,160  = 2.33; P  = .02) and those with MDD and low-lethality suicide attempts ( t 33,170  = 3.48; P  < .001). Again, relative to other groups, whereas individuals with MDD and high-lethality suicide attempts displayed smaller lose-shifts, those with MDD and low-lethality attempts exhibited greater lose-shifts.

Results for exploitation in the BPD sample are shown in eTable 4 in Supplement 1 . After accounting for the effects of the last reward described above, omnibus tests showed no overall group differences in exploitation; however, individuals with BPD and high-lethality suicide attempts displayed higher levels of exploitation vs control individuals ( t 34,980  = −2.31; P  = .02) but not vs other groups (| t | ≤ 1.16). Since partialing out the effects of last reward (reward × RT[t-1]) from effects of long-term reinforcement (RT[Vmax]) constitutes overcontrolling, we tested a model (eTable 21 in Supplement 1 ) omitting the reward × RT[t-1] term, finding that levels of overall exploitation differed across groups (group × RT[Vmax]: χ 2 3  = 9.20; P  = .03): individuals with BPD and high-lethality suicide attempts exhibited higher exploitation vs control individuals ( t 36,510  = −2.70; P  = .007) but not vs other groups.

Results for exploitation in the MDD sample are shown in eTable 20 in Supplement 1 . We found no group differences in exploitation.

Results pertaining to suicidal thoughts are illustrated in Figure 3 D and eTable 22 in Supplement 1 . Eighty-four individuals with BPD completed the 21-day ecological momentary assessment study, with 56 of these reporting suicidal thoughts (present on average 7% of days; median [range], 2% [0%-94%]), enabling us to examine the associations between exploration-exploitation on the clock task and prospectively assessed suicidal thinking in daily life.

Prospective suicidal ideation was associated with the same pattern of lower exploration (χ 2 1  = 30.16; P  < .001) and smaller lose-shifts (χ 2 1  = 11.31; P  = .001) as individuals with high-lethality suicide attempts ( Figure 3 A, B, and C). No selective association was observed with early vs late exploration. Results remained qualitatively unchanged when excluding 2 participants with extreme frequencies of suicidal ideation (40% and 94% days) or controlling for suicide attempt recency or affective predictors of suicidal ideation (negative internalizing, externalizing, and impulsive affect during ecological momentary assessment) (eTables 23-27 in Supplement 1 ).

The behavioral experiments in this case-control study, augmented with reinforcement-learning modeling, found associations between serious suicidal behavior in both borderline personality disorder and late-life depression and an inability to shift away from unrewarded choices resulting in the underexploration of a continuous option space. This narrow, inflexible behavior prospectively predicted daily suicidal ideation. By contrast, low-lethality suicidal behavior in both individuals with BPD and depression was associated with excessive shifts after rewarded as well as unrewarded actions. These associations were not explained by plausible confounds, including medication exposure, depressive symptoms, premorbid IQ, executive function, behavioral heterogeneity, and affective predictors of suicidal ideation.

Earlier studies using armed bandits found associations between high-lethality suicidal behavior in mid- and late-life depression and deficits in learning and behavioral adaptation. 8 , 42 Supporting these associations, the present findings reveal that, given a choice among many uncertain options under time pressure, individuals at the highest risk explore only a limited subset, sticking with unrewarded choices. To our knowledge, this behavioral pattern has not been described in psychopathology research; it diverges from the performance of patients with schizophrenia, for example, on the same task. 43 It is equally distinct from win-shift behavior on bandit tasks we previously observed in individuals who attempted suicide, 8 potentially indicating multiple deficits with additive or similar effects on suicide risk. What neurocomputational deficits may underlie an inability to shift away from unrewarded choices? In rodents, lose-shift behavior depends on the lateral striatum, 29 , 44 a sensorimotor region approximately homologous to the primate dorsolateral putamen. In contrast, win-stay rodent behavior depends on the ventromedial striatum 44 and lateral habenula. 45 Interestingly, however, human lose-shift responding increases under cognitive load, suggesting that frontoparietal control may suppress automatic, striatum-mediated lose-shifts. 46 During exploration and learning in continuous spaces, dynamic maps of competing options are found in frontoparietal circuits, specifically the dorsal stream and caudal posterior parietal cortex . 40 , 47 One intriguing possibility is that inappropriately rigid or exaggerated frontoparietal responses to option competition suppress adaptive lose-shift behavior in people who are prone to serious suicidal behavior. Conversely, excessive lose-shifts in individuals with low-lethality suicide attempts may be related to a disrupted encoding of the longer-term reinforcement history we previously described in attempted suicide. 4 , 7

Our observations resonate with clinical notions of cognitive constriction and tunnel vision and provide a fine-grained behavioral and computational account of the suicide diathesis. Curiously, although the present study was not designed to distinguish between traitlike and statelike deficits, exploratory analyses of suicide attempt recency (eTables 5 and 22 in Supplement 1 ) suggest that decreased lose-shift responding may be a state-modulated trait. At the same time, our results highlight the role of trait impairments in decision capacity, which can facilitate serious suicidal behavior in a crisis, consistent with the view of suicide as an unintentional decision where the demands of a crisis exceeded one’s decision-making capacity. 16 , 48 Specifically, individuals prone to underexploration are more likely to select an often-used (or considered) solution in a crisis in lieu of adaptively exploring potentially better alternatives. In psychotherapy, exploring solutions one had never tried before may be a useful skill to learn and practice both at an emotional baseline and when distressed.

It has been questioned whether phenomena such as passive death wish, suicidal thoughts, and more vs less medically serious suicidal acts belong to a single severity continuum and whether underlying risk factors differ only quantitatively or also qualitatively. 49 , 50 Consistent behavioral differences between individuals with high-lethality and low-lethality suicide attempts controvert the continuum model, pointing instead to qualitatively distinct behavioral pathways. One is generally skeptical of studies where the performance of distinct clinical groups falls on both sides of healthy control individuals, since this pattern often reflects merely unexplained interindividual heterogeneity. However, here, the behavioral divergence between individuals with high-lethality vs low-lethality suicide attempts was replicated across different clinical populations and was robust to statistical controls for individual heterogeneity and plausible confounds. Furthermore, the behavioral distinctiveness of high-lethality suicide attempts from other forms of suicidal behavior and ideation has been observed in several previous studies across clinical populations and samples, 4 , 5 , 7 , 8 , 11 suggesting that this divergence is systematic. Thus, it is likely that qualitatively distinct behavioral pathways lead to high-lethality suicide attempts and, by extension, many suicide deaths vs lower-lethality suicide attempts. While the first pathway is marked by narrow and inflexible choices, the second is characterized by excessive behavioral plasticity in response to failures, which may correspond to a lower threshold for engaging in potentially disadvantageous and specifically suicidal behavior. Additionally, maximum attempt lethality—a hard outcome (relative to one’s level of intent or planning)—must be considered a key dimension of past suicidal behavior in both research and practice.

Contrary to expectations, we found no evidence that people prone to suicide are unable to exploit the best of previously sampled options, with the caveat that the individuals at the highest risk were choosing from a more limited set than other participants. If anything, there was some evidence of overexploitation in the borderline personality disorder sample, with no group differences in the depression sample. Considering prior evidence associating suicidal behavior with disadvantageous value-based choices, 5 , 11 , 51 our findings suggest that such behavior may instead reflect an admixture of overly rigid and erratic behavioral patterns, challenging the notion of simple insensitivity to long-term value.

The case-control design of our study limits causal inferences, a limitation partly offset by prospective validation. Future studies will also need to differentiate strategic from stochastic exploration and examine how affective states shape the set of options under consideration, particularly following adverse outcomes, and test formal accounts of affective meta-reasoning during learning and decision-making. 16 , 52

In summary, divergent behavioral signatures of high-lethality vs low-lethality suicide attempts likely expose distinct neurocognitive pathways. This underscores the need for a broader taxonomy of clinically relevant individual differences in human decision-making.

Accepted for Publication: April 25, 2024.

Published Online: July 10, 2024. doi:10.1001/jamapsychiatry.2024.1796

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Tsypes A et al. JAMA Psychiatry .

Corresponding Author: Aliona Tsypes, PhD, Department of Psychiatry, University of Pittsburgh School of Medicine, 100 N Bellefield Ave, BT 748, Pittsburgh, PA 15213 ( [email protected] ).

Author Contributions: Drs Tsypes and Dombrovski had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design : Tsypes, Hallquist, Wright, Dombrovski.

Acquisition, analysis, or interpretation of data : All authors.

Drafting of the manuscript : Tsypes, Kaurin, Dombrovski.

Critical review of the manuscript for important intellectual content : All authors.

Statistical analysis : All authors.

Obtained funding : Hallquist, Wright, Dombrovski.

Administrative, technical, or material support : Dombrovski.

Supervision : Dombrovski.

Conflict of Interest Disclosures: Dr Wright reported grants from the National Institutes of Health during the conduct of the study. No other disclosures were reported.

Funding/Support: This research was supported by grants from the National Institute of Mental Health (K23MH130664, R01MH048463, R01MH100095, R01MH119399, and T32MH018269), the University of Pittsburgh’s Clinical and Translational Science Institute, which is funded by the National Institutes of Health (NIH) Clinical and Translational Science Award (CTSA) program (UL1TR001857). The CTSA program is led by the NIH’s National Center for Advancing Translational Sciences.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

Additional Contributions: We thank Mandy Collier, BS; Michelle Perry, BA, BS; Tanya Shah, BA; Shreya Sheth, MA; Nathan Stimmel, MA; and Laura Taglioni, BA, for their contributions to data collection. We thank Morgan Buerke, MA; Jiazhou Chen, BA; BS; Bea Langer, BS; and Andrew Papale, PhD, for their contributions to data management. At the time of the study, all of these contributors were employed full-time by our team at the University of Pittsburgh. No additional compensation was provided beyond regular salary.

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Special Report: Antisocial Personality Disorder—The Patient in Need Often Overlooked

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Psychiatric and medical comorbidity of aspd, genetic, neurobiological, and environmental causes, gene-environment interplay in antisocial personality disorder, psychosocial factors, treatment guidance.

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  • Donald W. Black
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Case Report: Anomalous Experience in a Dissociative Identity and Borderline Personality Disorder

Hugo andré de lima martins.

1 Unidade do Cérebro, Surubim, Brazil

Valdenilson Ribeiro Ribas

2 Instituto do Cérebro de Pernambuco, Jaboatão dos Guararapes, Brazil

Ketlin Helenise dos Santos Ribas

Luciano da fonseca lins.

3 Universidade de Pernambuco (UPE), Garanhuns, Brazil

Alessandra Ghinato Mainieri

4 Federal University of Rio Grande do Sul, Porto Alegre, Brazil

Associated Data

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.


Dissociative identity disorder, formerly called multiple personality disorder, is a rupture of identity characterized by the presence of two or more distinct personality states, described in some cultures as an experience of possession.

The case of a 30-year-old woman with dissociative identity disorder and borderline personality disorder associated with a previous history of anomalous experience was reported.

Case Report

A 30-year-old woman who fulfilled the DSM-5 criteria for dissociative identity disorder and borderline personality disorder reported the presence of unusual sensory experiences (clairvoyance, premonitory dreams, clairaudience) since she was 5 years old. The patient told that for 12 months she presented episodes in which a “second self” took charge of her actions: she would then speak with a male voice, become aggressive, and require several people to contain her desire for destruction. After 3 months of religious follow-up, and accepting her unusual experiences and trance possessions as normal and natural, she had significant improvement.

When approaching DID and BPD patients, it is necessary to observe the anomalous phenomena (in the light of) closer to their cultural and religious contexts, to promote better results in the treatment of their disorders, which has not been explored in the treatment guide.

Pierre Janet was the first to describe, in 1889, dissociation as disaggregation of the unity of experience at the mental level ( 1 ). Dissociative identity disorder (DID) is characterized by two or more distinct identities or dissociated personalities.

Dissociation is characterized by a disturbance in integrated dimensions of the mind such as consciousness, attention, memory, and perception of the environment. This dispersion of the sense of self-oneness causes deterioration of chronological, biographical, and perceptive unity ( 1 – 4 ).

Dissociative disorders seem to arise because of the transaction between genetic factors, which determine an individual's biological vulnerability and environmental condition ( 5 ). Among the latter, the socio-cognitive model highlights the importance of social-cultural self-oneness as the cause of deterioration of chronological, biographical, and perceptive unity ( 1 , 2 , 4 ), while the trauma model, which has received more support and was studied more, underlies the role of traumatic life experiences ( 6 , 7 ). Very recently, aligned with the transdiagnostic model, it was proposed that dissociation can be understood as failures of normally adaptive systems and functions ( 8 ).

Some theorists believe that the alleged personalities would be an attempt to defend the weakened ego from childhood trauma or abuse that occurs in more than 80% of cases of DID ( 1 , 4 ). In such cases, dissociation acts as a self-hypnotic defense mechanism that provides conditions for the individual to cope with trauma ( 1 , 9 – 11 ). Other researchers, more skeptical, think that DID is not a real condition, but a disorder produced by doctors or cultural influence in highly hypnotizable and “suggestible” patients ( 12 ). These are the two main lines of thought about the etiology of DID, although the latter seems to have less empirical support.

Symptoms of dissociation are present in a variety of mental disorders such as DID and post-traumatic stress disorder (PTSD) ( 13 ). Borderline personality disorder (BPD) is a very serious psychiatric condition characterized by severe affective instability and impulsivity, associated with problems in self-image and interpersonal relationships ( 1 ). Transient, stress-related severe dissociative symptoms” serve as a criterion for borderline personality disorder ( 14 ). Most patients with BPD present episodes of identity confusion, derealization, depersonalization, and dissociative amnesia ( 4 ).

‘Anomalous Experiences' (AE) is a term proposed to designate unusual experiences which are considered ‘outside the ordinary explanations' (hallucinations, synesthesia, and experiences interpreted as telepathic, paranormal, among others), without assuming psychopathological implications. These phenomena are reported in all cultures and in all times of humanity, which were the object of study of official science in the late nineteenth and early twentieth centuries, but which only in recent years have returned as interesting areas in the academic field. Some examples of AE are clairvoyance, premonitions, xenoglossia, and mediumistic incorporations ( 15 – 17 ). In general, authors make a distinction between those who present AE, which represents a form of non-pathological dissociation, from those who fulfill criteria for DID which causes discomfort and suffering ( 18 ).

We report a case of DID associated with BPD that draws attention to the presence of AE, such as clairvoyance, premonitory dreams, and clairaudience, from 5 years of age, preceding the onset of possession-type dissociative identity crises in more than two decades. The patient gave informed consent for this case report and the study was approved by the ethical committee with number 3,605,351. There was no funding for this research.

Clinical Case

A 30-year-old woman presented with a history of repeated episodes of identity disturbance characterized by a marked change in behavior, aggression, psychomotor agitation, and voice change (from female to male voice). The episodes started in March 2018 and lasted from 10 min to 6 h, at an average frequency of 3 times a week.

The patient generally had a partial or total recollection of events. She was ashamed of the people who witnessed the episodes because she felt ridiculed. She could not avoid possession, which happened in places like churches, at the school where she worked as a teacher, at home, and at the doctor's office. Since the beginning of the condition, she had been showing moderate social isolation, because the community where she lives believed that she was possessed by an evil entity. She had several days of absenteeism at work due to crises and failed several medical treatments.

She often attended masses of the Catholic Church, where these occurrences were not well regarded. After one almost uncontrollable crisis, the patient broke the pews of the church during the service. The priest decided to submit her to a ritual of exorcism, which consisted of prayers, holy water, and crucifix presentation. During the session, the patient attacked eight people, including the priest, who had his clothes torn.

The treatment was abandoned, as the patient's family was embarrassed by the amount of stuff broken and people injured during the “possession” state, besides not obtaining satisfactory results, which diminished the interest in continuing this procedure.

She did not intend any kind of secondary gain with that disorder and, most of the time, she would get physically exhausted along with the trance: at the start, she would get overly strong and, up to the end, she would be very weak. Practitioners of her religion (Catholic) were not used to dealing with these manifestations. As time went by, the trance episodes increased in frequency and intensity and she felt more isolated at work and in her social relationships. Concomitantly with those religious sessions, the patient went through several unsuccessful psychiatric treatments over a year. Our service was then referred to the patient by another colleague.

At the initial consultation, she was quite frightened, as she had several embarrassing situations and was profoundly affected by the fact that she had no control over her body. Personal background: She denies a history of abuse or neglect. She said that at the age of 5, she was in the recovery room of a tonsillectomy surgery when she had a vision of a spiritual entity, dressed in light clothes, who told her about the importance of ethical and moral behavior in life.

She reported the vision to her family, but it was not taken seriously, and they mocked her. The most striking case was that of a repetitive dream with an unknown middle-aged man, whom she met after a few months at a horse farm.

She had other similar dreams between the ages of 5 and 11. When she was 10 years old, she was awakened in the middle of the night by an entity who stated to be her grandfather, who had died 2 years before. She wrote a letter dictated by her deceased grandfather to her father regarding personal matters that were completely unknown to her. The signature showed some resemblance to her grandfather's. The next day, her parents read the letter and said they were sure it was the devil's work and tore the entire manuscript. In her early teens, she had the feeling that a spiritual entity intended to have sex against her will. She was very bothered by the feeling that someone was running his hands all over her body, including her private parts. She did not talk to others about these feelings, because she was afraid someone might think she was “crazy.” After starting her sexual life, she had an invisible and unusual sensory experience as rape-like provoked by supposed bad spiritual beings. These sensations were so threatening that they led her to frequent suicidal thoughts. The patient reports that the episodes were completely unwanted and aroused a feeling of despair, with an intense resemblance to reality.

She made several suicide attempts through lethal methods such as hanging, drowning, moving motorcar, and electric shock, always being driven by a male voice that guided her. At several moments, she completely lost her mind and body control during the episodes and assumed that an external entity commanded her. The patient consulted several specialists, who gave various diagnoses such as depression, anxiety disorder, schizophrenia, and panic disorder. She took nortriptyline 75 mg daily for 6 months, fluoxetine 40 mg daily for 4 months, escitalopram 20 mg daily for 3 months, risperidone 6 mg daily for 4 months, quetiapine 600 mg at night for 4 months, some of them in combination in the last year, with no clinical improvement. She did not have any therapeutic benefits from these drugs, although she experienced all the side effects. In this case, there was probably a good adherence to pharmacological treatment, although it is not been proven by measuring the plasma level of the substances.

Among the symptoms, the patient said that she heard voices, saw figures, often dreamed of deceased people, thought randomly about things that came to happen after a while, believed to write automatically and unconsciously, driven by a force external to her thinking. She complained of many very rapid mood swings, fear of abandonment, and an intense feeling of emptiness.

The patient was born by transpelvian delivery and had normal neuropsychomotor development. She had a tonsillectomy at 5 years of age. She never attended psychological counseling. The patient denied a history of childhood abuse or neglect. The patient spent her childhood and adolescence in a situation of low socioeconomic level. Her mother had behavioral problems but never went through any kind of treatment. There is no information on family health and AE history.

In the mental state examination, the patient did not present alterations except for a very anxious mood. The structure of thought was completely normal. The physical and neurological examination revealed no abnormalities. The patient obtained 45 points in the Beck anxiety inventory (BAI) and 45 on the dissociative experiences scale (DES). Lab Tests, Brain MRI, and 3 repetitive EEGs were normal.

The patient fulfilled all criteria for diagnosis of dissociative identity disorder according to DSM-V: characterized by two or more distinct personality states (also called alter egos or self-states or identities). There is also an inability to recall daily events, important personal information, and/or traumatic or stressful events, all of which typically would not normally be lost with normal forgetting. The symptoms caused social and professional harm, were not part of a context accepted by religious practice, and were not due to a physiological effect of substances or other medical conditions.

The patient refused psychotherapy for economic reasons and decided to attend Spiritism, which accepts communication among the living and the dead as part of its doctrinal framework. Spiritism started initially in France as a spiritualistic movement developed in the 19th century, and nowadays it has spread around the world. In Brazil, it is the third-largest religion and its practices strongly emphasize controlled psychotic and dissociative experiences called mediumship. Mediumistic practices are not reimbursed but are considered charitable voluntary work ( 19 , 20 ).

After 3 months in the new religious order, where her dissociative manifestations were naturally accepted, without the interpretation that it would be the result of the influence of the supreme evil, the patient had marked improvement in anxiety symptoms, reducing the BAI score to 26, becoming able to speak spontaneously about her crises and very rarely presented the picture outside the appropriate religious context. People sometimes refer to fear in participating in Spiritism meetings due to the lack of proper information about the safety of the procedure. The patient denied any concern about it, although she kept discretion about her treatment for people outside its context, due to the fear of suffering prejudice. She also returned to her social and occupational activities.

The patient reported dreams that seemed very real to her. Some authors have correlated dissociative symptoms with sleep disorders ( 21 ), even highlighting the role of the latter as a cause of dissociation ( 22 – 25 ). For instance, sleep improvement reduces dissociative symptoms ( 26 ). When sleep and dream systems are impaired, the memory process during (REM) sleep becomes unregulated and it may as well induce dissociative symptoms ( 24 ).

The reported case shows a patient with unusual and premonitory dreams in her childhood, which seem to be related to a current psychopathological condition. A very interesting study evaluated the frequency of dream recall and the experience of unusual dreams, longitudinally, in children of both genders, aged between 10 and 11 years, for 2 years, with an initial assessment and after 12 and 24 months. The tendency to have unusual dreams, such as repetitive dreams, remembering dreams over a long period, or dreams that cannot be understood, was associated with internalizing and externalizing behavioral problems reported by the adolescents' parents ( 27 ).

A particular type of dreaming is designated by the term lucid dreaming in which the dreamer is aware of dreaming ( 28 , 29 ). Furthermore, in this condition, control (the capacity to change the dream events) and dissociation represent the other criteria ( 30 ). In this report, the patient had no control over the dream plot and perceived it as real and unpleasant. Lucidity in dreaming has been linked with positive rather than negative emotions ( 24 ), but when the person has no control over the dream, which seems to be more common, lucid dreaming is associated with psychopathological distress and several types of symptoms ( 31 ).

There were not remarkable events that might be considered very traumatic in the patient's childhood and adolescence. The possibility of abuse and neglect was extensively researched and no evidence was found. It has been widely documented in specialized literature that in most cases of DID there is a serious and traumatic event during the patient's life, which might justify the onset of dissociative symptoms ( 12 , 32 , 33 ). Otherwise, minor traumas, such as surgery at age 5 with hallucination, associated with an invalidating attitude from the family who mocked her, could lead to the DID.

The patient heard commanding voices ordering her to commit suicide, which resulted in several attempts. Auditory hallucinations present in epileptic seizures are generally elementary, characterized by repetitive and simple sounds ( 4 ). She also fulfilled the criteria for borderline personality disorder as an unstable sense of self; chronic feeling of emptiness; inappropriate and intense anger; history of recurrent suicidal behavior; and severe dissociative symptoms, which justify the absence of effectiveness in pharmacological treatment.

Recently, some researchers have studied the accuracy of the information contained in a letter supposedly dictated by a deceased person to the influential Brazilian “medium” Chico Xavier, encountering highly specific hits ( 34 ). The patient's letter was torn and could not be evaluated. Otherwise, the automatic writing may be explained by dissociative absorption and imaginative involvement, which is not necessarily pathological and is characterized by a tendency to become immersed in a stimulus while neglecting to attend to one's surroundings ( 35 ). As a quite common dissociative process, automatic writing may be characterized by a diminished sense of agency ( 36 ) and it can alternatively explain why someone assigns the authorship of the letter to someone else.

Since childhood, the patient had AE, such as clairvoyance and premonitions, which were never studied with attention, probably because this is an unknown field to the lay public and poorly explored by the scientific community. Although AE, in general, occurs in people with no mental disorders, the present case pointed to the possibility of overlapped events like AE and psychopathologic alterations as the patient underwent various suicide attempts during her life and it is in general associated with a mental disorder. There has been recently a new tendency to make AE an object of study in the natural sciences again ( 16 , 37 ).

The patient was refractory to various drug therapy regimens, which are widely cited in the literature related to the dissociative identity disorder ( 10 ). Unfortunately, there was no opportunity to perform psychotherapy to integrate identities, because the patient lacked the financial resources to do so.

A very interesting fact was the clinical improvement of the patient, evidenced by both the mental state examination and the use of a psychometric instrument (BAI) after being welcomed into a religious community (Spiritism) that accepted possession as part of its doctrinal structure. According to the DSM-5, one of the criteria for diagnosing DID is that it does not belong to a widely accepted religious or cultural practice ( 38 ).

In low- and middle-income countries, psychotic experiences are present at least occasionally in more than 90% of the people. There is an assumption that these experiences are more culturally accepted in these countries, which justifies the numbers. For these individuals, lower distress is predicted by spiritual appraisals and better social support from family and friends ( 39 ). Possibly, this approach influenced the favorable outcome in this case report.

This study explored the importance of cultural and religious contexts, and consequently, their interference in the evolution of patients with anomalous experiences and dissociative disorder, and explored the relationship between anomalous experience and dissociative disorder, expanding the explanatory possibilities for this disorder.

The main strength of this report is showing an alternative way to manage the complex DID. The limitation is related to the type of study (case report) and to the possibility that the patient improved by accepting her AE as natural, which could, in theory, happen in supportive psychotherapy.

Although it should be acknowledged that parts of some cases of DID have traumatic etiological factors, the present case reflects the positive association between the event and the trajectory of the dissociation that changed once she found a social or religious group that accepted her possession crises as a natural event, providing a positive framework not just for the present symptoms, but also a possible explanation to the different events that she had all along her life.

Data Availability Statement

Ethics statement.

The studies involving human participants were reviewed and approved by Federal University of Pernambuco. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual for the publication of any potentially identifiable images or data included in this article.

Author Contributions

HM contributed substantially to the design of the study: he was responsible for the acquisition of data (articles) for the work and for the critical review of the work and also participated in the writing of the introduction, in the critical review of the case report, and in preparing the abstract. VR was responsible for the choices of scientific articles related to the study, participated with substantial contributions to the design of the study, and in discussions about interpretations of the chosen articles and also as a corresponding author. KR contributed to the writing of the case report, participated in discussions on the choices and interpretations of the chosen scientific articles and submission to the ethics and research committee. LL participated in the discussions and interpretations of the scientific articles related to the study and in the critical review. AM participated in all discussions related to data and the study phenomenon, agreed to be responsible for all aspects of the work, and ensuring that issues related to the accuracy or integrity of any part of the work are investigated. All authors contributed to the article and approved the submitted version.

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.

The Paranoid Patient - A Case Study

What's it like living with Paranoid Personality Disorder (PPD)? Take a look at these therapy session notes for insight into PPD.

Notes of first therapy session with Dale G., male, 46, diagnosed with Paranoid Personality Disorder (PPD)

Dale's first enquiry is whether I am in any way associated either with the government or with his former employer. He doesn't seem reassured by my negative response. He eyes me skeptically and insists that I inform him if things change and I do become entangled with his persecutors. Why do I treat him pro bono? He suspects some ulterior motives behind my altruism and inexplicable generosity. I explain to him that I donate 25 hours a month to the community. "It's good for your image, gives you access to local bigwigs, I bet." - he retorts, accusingly. He refuses to allow me to tape record our conversation.

I set some boundaries by reminding him that the therapy session is about him, not me. He nods sagely: it's all part of an intricate scheme to "subdue" him and place him "under firm control". Why would "they" want to do that? Because he knows too much, having exposed fraud, lies, and deceit in the highest places. He has done all this from his position as a sanitary worker at the municipality? - I inquire. He is visibly offended: "There are more secrets in people's trash than in the CIA!" - he exclaims - "You think that your academic degree makes you more clever than I am or somehow superior to me?"

I remind him that therapy was more or less forced on him by his long-suffering wife. Is she one of "them"? He snickers. Well? "Yes," - he rages - "they got to her, too. She used to be on my side." His phones are tapped, his mail intercepted and inspected, there was a mysterious fire in his apartment only days after he complained against a senior law enforcement officer. Wasn't it the antiquated television set that burst into flames? "If you care to believe such nonsense." - he eyes me with pity.

When was the last time he went out with friends? He has to think hard to come up with an answer: "Four years ago." Why so long? Is he a recluse by nature? Not at all, he is actually gregarious. So, why the social isolation? Part of his defense. You never know when something you have said in company will be used against you. His so-called friends have been asking him too many intrusive questions lately. They insisted on meeting in new venues at odd times and he got suspicious.

So, what is he doing all alone at home? He laughs bitterly: "Won't they love to know my next moves!" He isn't going to give them the pleasure of evincing his strategy. All he is willing to say is that "they" will pay dearly for having underestimated him and for having turned his life "into a long nightmare in hell". Who are "they"? His superiors at the sanitary department. They reassigned him to a dangerous part of town, working night shifts, effectively demoting him from team foreman to "common janitor". He will never forgive them. But wasn't this a temporary arrangement owing to manpower shortages? "That's what they said at the time"- he admits reluctantly.

At the end of the session he insists on inspecting my phone jacks and the under-surfaces of my desk. "You can never be too careful." - he half apologizes.

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

next: The Psychopathic Patient ~ back t o: Case Studies: Table of Contents

APA Reference Vaknin, S. (2009, October 1). The Paranoid Patient - A Case Study, HealthyPlace. Retrieved on 2024, July 20 from

Medically reviewed by Harry Croft, MD

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A Case Study about Severe Borderline Personality Disorder.

  • August 2020

Ekata Deb at Christ University, Bangalore

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Suzanne Degges-White Ph.D.

Misdiagnosed: BPD or Autism Spectrum Disorder (ASD)?

If you’re a woman, your asd is more likely to be misdiagnosed as bpd..

Posted July 12, 2024 | Reviewed by Monica Vilhauer

  • What Is Autism?
  • Find counselling to help with autism
  • Women are less likely to be accurately diagnosed with ASD.
  • Females are more adept at masking their ASD symptoms.
  • Misdiagnosed ASD can lead to harmful interventions based on a BPD diagnosis.

After a recent blog that I posted regarding Borderline Personality Disorder (BPD) and the common obstacles to treatment, I received an email from a reader. In this email, it was noted that being misdiagnosed with BPD rather than with their actual diagnosis, Autism Spectrum Disorder (ASD), led to years of misguided and damaging treatment for a disorder they did not have. In the past several years, increasing attention has been given to the symptom overlap between these two distinct disorders and reasons why the misdiagnosis of women is more likely to occur.

Are There Shared Symptoms Between BPD and ASD?

The primary challenge for those diagnosed with ASD revolves around social communication. It is a neurodevelopmental disorder that has been identified as occurring at three levels of severity that reflect increasing difficulty in successful social connection (Dell’Osso et al., 2023). Emotional dysregulation is also a common trait among those diagnosed with ASD which can lead to outbursts and flares of temper when frustrated or angry or it may lead to withdrawal from others and the presence of depressive symptoms. This may be related to their heightened sensory sensitivity or the intensity at which they experience their emotions. Another potentially confounding symptom is engagement in repetitive behavior that includes self-harming activities, such as suicidality , cutting, hair pulling, or hand hitting (Blanchard et al., 2021). In fact, people diagnosed with ASD have a likelihood of self-harm and suicidality three times higher than the general population.

With BPD, emotional regulation can also be extremely challenging as individuals diagnosed with BPD frequently exhibit extreme mood swings and anger outbursts. A person with BPD also typically has extreme fears of abandonment and the tendency to misread innocuous comments or facial expressions as signs of disapproval, rejection, or insult by others. Impulsiveness is another trait common to the BPD diagnosis and this impulsiveness can lead to self-harming behaviors. Around 60-70% of individuals with BPD attempt suicide during their lives and 10% die of suicide (Goodman et al., 2012).

Who Is More Likely to Be Misdiagnosed?

Women are less likely to be accurately diagnosed with ASD during their childhoods, adolescence , or adulthood and are often misdiagnosed with BPD or other disorders before they receive an ASD diagnosis. One possible explanation is that young girls learn early about the importance of “fitting in” and getting along with others (Dell’Osso, 2023). This focus on social interaction may encourage them to camouflage their autism symptoms so that they don’t stand out. Overall, males with ASD have poorer social skills and more social difficulties than their female peers. Another surprising reason that diagnoses of ASD may be missed is that the restrictive interests that are common to those with ASD may include a focus on food and diet . This focus mirrors Anorexia nervosa symptoms, which are more frequently exhibited by females, and that may be the diagnosis that is made with ASD going undetected. Females also tend to have higher linguistic skills than males and are more easily able to express their thoughts and feelings, which may delay accurate diagnosis.

What Symptoms Lead to the BPD Misdiagnosis?

One of the symptoms that is most likely to lead to a misdiagnosis is self-harm, so clinicians should also explore the motivation for self-harm expressed by the client (Powell et al., 2024). This behavior may be used as a coping method by those with ASD to mitigate unease regarding sensory issues, change, or uncertainty; with individuals with BPD, it is more likely to be motivated by issues related to their relationships. Further, when individuals with ASD spend time alone, this may be experienced as pleasurable, whereas those with BPD often experience fears of abandonment when they are alone. There are also similarities in these two groups’ ability to experience empathy or understand another’s perspective. In addition, the emotional dysregulation that is expressed by females with ASD can be mistaken for BPD as can the lack of quality friendships.

When an Accurate ASD Diagnosis Is Delayed

One of the most significant problems in making an inaccurate diagnosis is that the treatment for BPD is inappropriate for those with ASD and vice versa. For those with BPD, psychotherapeutic treatment is beneficial, as it provides support for developing healthy relationships, awareness of and changing of one’s thoughts and behaviors, and emotional stability . A standard treatment protocol for managing BPD is Dialectical Behavior Therapy (DBT), which is designed to help clients regulate their emotions and enhance their social and interpersonal skills. DBT is not designed for those with ASD, and the real needs of these clients go unmet. Medication prescribed to treat symptoms of BPD can be deleterious to someone with ASD. The stigma of a BPD diagnosis has also been noted as a harmful by-product of an incorrect diagnosis of ASD.

ASD treatment goals tend to revolve around improved communication, sensory integration , and functioning effectively in daily life. A behavior-focused approach is used rather than a psychotherapeutic approach, although Cognitive Behavioral Therapy (CBT) might be appropriate for some issues. Medication isn’t prescribed for ASD, although co-occurring disorders might require medication.

Being misdiagnosed results in delayed treatment for the individual’s actual diagnosis and this lack of congruence between treatment and symptoms can lead to increased withdrawal from others and blaming oneself for not “getting better” when the treatment doesn’t match the diagnosis. Traumatization can result when those with ASD are required to follow protocols that do not take into account the ways in which ASD manifests and the sensory sensitivities associated with it. If you are concerned that you might have been misdiagnosed, seek out another practitioner for a second opinion. Being given the right diagnosis can change the course of one's life for the better.

To find a therapist, visit the Psychology Today Therapy Directory .

Blanchard, A., Chihuri, S., DiGuiseppi, C. G., & Li, G. (2021). Risk of self-harm in children and adults with autism spectrum disorder: a systematic review and meta-analysis. JAMA network open , 4 (10), e2130272-e2130272.

Dell’Osso, L., Cremone, I. M., Nardi, B., Tognini, V., Castellani, L., Perrone, P., ... & Carpita, B. (2023). Comorbidity and Overlaps between Autism Spectrum and Borderline Personality Disorder: State of the Art. Brain sciences , 13 (6), 862.

Goodman, M., Roiff, T., Oakes, A. H., & Paris, J. (2012). Suicidal risk and management in borderline personality disorder. Current Psychiatry , 14 ( 1 ), 79–85.

Powell, T., Parker, J., Kitson, H., & Rogalewski, M. (2024). “It Was Like the Final Piece in the Puzzle for Me”: A Qualitative Study on the Experiences of Autistic Women Initially Diagnosed with Borderline Personality Disorder. Autism in Adulthood .

Suzanne Degges-White Ph.D.

Suzanne Degges-White, Ph.D. , is a licensed counselor and professor at Northern Illinois University.

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