The New Era of Borderline Personality Disorder Care

Lois Choi-Kain, MD, MEd, sees personality disorder care, and psychiatry as whole, moving into a new era. While her forerunners in the space—including John G. Gunderson, MD, whose namesake is carried in her institution’s name at McLean Hospital—established borderline personality disorder (BPD) as an identifiable and treatable mental illness, she and her colleagues now want to indoctrinate it as a staple of health care focus.

In the second segment of an interview with HCPLive during the American Psychiatric Association (APA) 2022 Annual Meeting in New Orleans last week, Choi-Kain, director of the Gunderson Personality Disorders Institute at McLean, discussed the need to modernize BPD care—starting first with treatment durations.

“I don’t know if I want to do a treatment that’s a year long for myself, because it takes a lot of time and navigation to fit everything in,” Choi-Kain said. “We have to get more realistic of what we’re asking of clinicians and patients.”

As such, a trend in BPD research has sought to compare efficacy of shorter-duration treatment regimens versus standard-care long-term regimens. Choi-Kain also discussed wanting to assure future BPD care is guided and directed toward informed and patient-beneficial outcomes.

“Don’t try to manage their suicidality with repeated hospitalizations if you can do something different,” Choi-Kain said. “Don’t give them polypharmacy if it’s not guided. Give them reasonable expectations for what those medications could do.”

She also highlighted efforts into making treatments more scalable, as well as the somewhat controversial subject of “dimensionalizing diagnoses” of BPD, noting the high rate of psychiatric comorbidity in affected patients. Understanding the interplay of other personality disorders is key.

“On the one hand, it’s taken 4 decades to legitimize borderline personality disorder as a distinct, discreet disorder that has its own course, biological markers and treatments,” Choi-Kain said. “But on the other hand, BDP is rarely the lone diagnosis a patient has.”

Lastly, Choi-Kain discussed the “burden of microeconomics” on BPD treatment, in which supply of available therapies does not meet the demand. The social determinants of access to care are highly impactful on clinical outcomes, and she and her colleagues need more scalable treatments available on the basis of consistent efficacy markers.

“I think by treating all these disorders in a very general way, by just making the diagnosis and using common sense to manage it, I think it will demystify and de-stigmatize all of these disorders,” she said.