GAP Initiative (Early Diagnosis)

Prevention and early intervention for borderline personality
disorder: a novel public health priority

The article was published in World Psychiatry 16:2 – June 2017 (215-216) – click here to download the article in PDF format.

There is now a broad evidence-based consensus that borderline
personality disorder (BPD) is a reliable, valid, common and
treatable mental disorder1. The adverse personal, social and economic
consequences of BPD are severe. They include persistent
functional disability2, high family and carer burden3, incomplete
education with fewer qualifications and disproportionately high
unemployment4, physical ill health5, greater burden of mental
disorders, recurrent self-harm, and a suicide rate of around 8%1.
The high economic costs of BPD (estimated to be e16,852 per
patient per annum in the Netherlands) are attributable to high
direct treatment costs and high indirect costs, chiefly workrelated
disability1. BPD is a stronger predictor of being on disability
support than either depressive or anxiety disorders6.

Although BPD usually has its onset in the period between
puberty and emerging adulthood (young people)7, delay in the
diagnosis and treatment is the norm, and discrimination against
people with BPD is widespread. Specific treatment is
usually only offered late in the course of the disorder, to relatively
few individuals, and often in the form of inaccessible,
highly specialized and expensive services4. Accumulating evidence
indicates that such “late intervention” often reinforces
functional impairment, disability and therapeutic nihilism.

The proliferation of knowledge about BPD in adolescents
and emerging adults (“youth”) over the past two decades8,9
has provided a firm basis for establishing early diagnosis and
treatment (“early intervention”) for BPD and for subthreshold
borderline personality pathology7. Several salient issues arise
from this literature. First, personality disorder begins in childhood
and adolescence, and can be diagnosed in young people.
Second, DSM-5 BPD is as valid and reliable a diagnosis in
adolescence as it is in adulthood, based on similarity in prevalence,
phenomenology, stability and risk factors, marked separation
of course and outcome from other disorders, and efficacy
of disorder-specific treatment. Third, BPD is common among
young people: the estimated prevalence is 1-3% in the community,
rising to 11-22% in outpatients, and 33-49% in inpatients
7,8. Fourth, when BPD is compared with other mental
disorders, it is among the leading causes of disability-adjusted
life years (DALYs) in young people9. BPD is also a substantial
financial burden for the families of young people, with estimated
average costs per annum in the US of $14,606 out-ofpocket,
plus $45,573 billed to insurance10. Fifth, the “first
wave” of evidence-based treatments has demonstrated that
structured treatments for BPD in young people are effective4.
Finally, the weight of empirical evidence has led the DSM-5
and the UK and Australian national treatment guidelines to
“legitimize” the diagnosis of BPD prior to age 18.

The Global Alliance for Prevention and Early Intervention
for BPD had its origins at a meeting convened under the auspices
of the National Education Alliance for BPD in New York
in May 2014. The Alliance calls for action through a set of scientifically
based clinical, research and social policy strategies
and recommendations.

Clinical priorities include: a) early intervention (i.e., diagnosis
and treatment of BPD when an individual first meets DSM-5 criteria
for the disorder, regardless of his/her age) should be a routine
part of child and youth mental health practice; b) training of
mental health professionals in evidence-based early interventions
should be prioritized; c) indicated prevention (preventing
the onset of new “cases” by targeting individuals showing subthreshold
features of BPD) currently represents the best starting
point toward developing a comprehensive prevention strategy
for BPD; d) early identification should be encouraged through
workforce development strategies (knowledge about BPD as a
severe mental disorder affecting young people should be disseminated
among trainees and clinicians in the child and youth
mental health professions; programs should address clinician=centred
discomfort with the label, mistaken beliefs, and prejudicial
and discriminatory attitudes and behaviour); e) the diagnosis
of BPD should not be delayed (non-diagnosis of BPD is discriminatory
because it denies individuals the opportunity to make
informed and evidence-based treatment decisions, and excludes
BPD from health care planning, policy and service implementation,
ultimately harming the young people’s prospects); f) misleading
terms, or the intentional use of substitute diagnoses,
should be discouraged (when sub-threshold BPD is present,
terms such as “BPD features” or “borderline pathology” are preferred);
g) family and friends should be actively involved as collaborators
in prevention and early intervention (typically, family
and friends are the “front line” for young people with BPD, and
their central role should be recognized and supported).

Research priorities are as follows: a) prevention and early
intervention for BPD must be integrated with similar efforts
for other severe mental disorders, such as mood and psychotic
disorders, acknowledging the “equifinal” and “multifinal” pathways
for the development of psychopathology; b) building a
knowledge base for a health care system response to prevention
and early intervention for BPD can take two approaches (for
indicated prevention and early intervention, a critical task is to
identify risk factors for the persistence or worsening of problems,
rather than the “onset” or incidence of disorder per se; or treatment
development can be based upon causal mechanisms that
underlie risk, such as environmental adversities); c) novel, lowcost
preventive interventions that can be widely disseminated
should be developed and evaluated (such interventions will need
to be developmentally appropriate, and stage/phase specific,
incorporating stepped care service models); d) education and
skill development programs for families with a young person
with BPD are a key priority for treatment research; e) research
needs to fully quantify the educational, vocational and social
outcomes for young people with BPD; f) further development
and validation of brief and “user-friendly” assessment tools is
needed to promote the systematic use of standardized evaluation
in research and clinical settings; g) detailed health economic
data are needed to support prevention and early intervention
programs for BPD and should be included in all clinical trials; h)
research identifying methods to improve access to evidencebased
treatments and reduce treatment dropout is a priority (this
should include novel locations and formats for delivery of treatments,
such as in schools, out-of-home care, or youth forensic
settings).

Social and policy priorities include the following: a) BPD
needs to be recognized as a severe mental disorder at all levels
of the health system; b) evidence-based policy is needed to
address BPD from primary through to specialist care, with the
aim of building a health care system response to prevention
and early intervention with young people and those who care
for them as its focus, and including young people and families
as partners in the design of such systems; c) discriminatory
practices in health care systems must be eliminated, especially
regarding BPD as a “diagnosis of exclusion” from services and
refusing health insurance coverage for people with BPD.

Andrew M. Chanen¹, Carla Sharp², Perry Hoffman³ and the Global
Alliance for Prevention and Early Intervention for Borderline
Personality Disorder.

  1. Orygen, National Centre of Excellence in Youth Mental Health & Centre for Youth Mental Health, University of Melbourne, Melbourne, Australia;
  2. University of Houston, Houston, TX, USA;
  3. National Education Alliance for Borderline Personality Disorder, USA

A. Chanen and C. Sharp are joint first authors of this letter. The Global Alliance for Prevention and Early Intervention for Borderline Personality Disorder includes: B. Aguirre, G. Andersen, R. Barkauskiene, A. Bateman, E. Bleiberg, M. Bohus, R. Brunner, A. Chanen, L. Courey, S. Crowell, F. de Fruyt, M.-P. De Valdivia, M. Debban!e, B. De Clercq, K. Ensink, D. Flynn, P. Fonagy, A. Fossati, A. Fruzetti, L. Gervinskaite-Paulaitiene, M. Goodman, K. Goth, K. Gratz, J. Gunderson, K. Hall, S.B. Hansen, S. Herpertz, H. Herrman, C. Hessels, P. Hoffman, J. Hutsebaut, M. Jacobsen, M. Kaess, C. Kaplan, C. Kempinsky, R. Kissell, M. Kongerslev, B. Krueger, P. Luyten, K. Lyons-Ruth, J. Mazza, L. McCutcheon, P. McGorry, L. Mehlum, A. Miller, C. Mirapeix, A. New, J. Oldham, J. Paris, J. Rathus, M.E. Ridolfi, T. Rossouw, S. Schl€uter-M€uller, C. Schmahl, K. Schmeck, C. Sharp, R. Shiner, E. Simonsen, M. Speranza, B. Stanley, S. Stepp, J. Tackett, Ø. Urnes, R. Verheul, M. Wells, C. Winsper, S. Yen, M. Zanarini; the International Society for the Study of Personality Disorders, the European Society for the Study of Personality Disorders, the North American Society for the Study of Personality Disorders, the National Education Alliance for Borderline Personality Disorder USA, the National Education Alliance for Borderline Personality Disorder Australia, the National Education Alliance for Borderline Personality Disorder Israel, the National Education Alliance for Borderline Personality Disorder Italy, and the Sashbear Foundation.

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6. Ostby KA, Czajkowski N, Knudsen GP et al. Soc Psychiatry Psychiatr Epidemiol
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8. Sharp C, Fonagy P. J Child Psychol Psychiatry 2015;56:1266-88.
9. The Public Health Group. The Victorian burden of disease study. Melbourne: Victorian Government Department of Human Services, 2005.
10. Goodman M, Patil U, Triebwasser J et al. J Person Disord 2011;25:59-74.
DOI:10.1002/wps.20429