An Introduction to Borderline Personality Disorder
Diagnosis, Origins, Course, And Treatment
by John G. Gunderson, MD
ACKNOWLEDGEMENTThis revision of earlier editions of A BPD Brief, which was co-authored with Cynthia Berkowitz, MD, uses invaluable input from Maureen Smith, LICSW and Brian Palmer, MD of McLean’s Borderline Center.
TABLE OF CONTENTS
An Explanation of the DSM-IV-TR Criteria
1. Abandonment Fears
2. Unstable Intense Relationships
3. Identity Disturbance
5. Suicidal or Self-injurious Behaviors
6. Affective (Emotional) Instability
9. Psychotic-like Perceptual Distortions
A. Inborn Biogenetic Temperaments
B. Psychological Factors
C. Social and Cultural FactorsThe Course of Borderline Personality Disorder
Suicidality and Self-Harm Behavior
Current Status of Treatment
D. Family Interventions
E. Group Therapies
Conclusion Resources and Publication and distribution
Borderline Personality Disorder Diagnosis
*DSM-IV-TR Diagnostic Criteria A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: Frantic efforts to avoid real or imagined abandonment.
A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
Identity disturbance: markedly and persistently unstable self-image or sense of self.
Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating).
Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
Chronic feelings of emptiness.
Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
Transient, stress-related paranoid ideation or severe dissociative symptoms.
* Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association Overview of the Borderline Personality Disorder DiagnosisEvery person has a personality: longstanding ways of perceiving, relating to, and thinking about the environment and oneself. However, when these traits are inflexible, maladaptive and cause significant functional impairment or subjective distress, they constitute a personality disorder.
There are 10 classified personality disorders and of those, Borderline Personality Disorder (BPD) is the most common, most complex, most studied, and certainly one of the most devastating, with up to 10% of those diagnosed committing suicide. BPD exists in approximately 2-4% of the general population; up to 20% of all psychiatric inpatients and 15% of all outpatients. Females predominate (about 75%) within psychiatric settings while males are more common in substance abuse or forensic settings.
As a result of clinical observations since the 1930’s and scientific studies done in the 1970’s, psychiatrists determined that people characterized by intense emotions, self-destructive acts, and stormy interpersonal relationships constituted a type of xe “personality disorder”personality disorder. The term “Borderline”xe “Borderline” was used because these patients were originally thought to exist as atypical (“borderline”) variants of other diagnoses and also because these patients tested the borders of whatever limits were set upon them. The diagnosis became “official” in 1980. While there has been much progress in the past 25 years in understanding and treating BPD, the diagnosis is underused. This owes mainly to the fact that BPD patients are difficult to treat and often evoke feelings of anger and frustration in the people trying to help. Such negative associations have caused many professionals to be unwilling to make the diagnosis. Many give precedence to co-occurring conditions such as depression, bipolar disorder, substance abuse, anxiety disorders and eating disorders. This problem has been aggravated by the lack of appropriate insurance coverage for the extended psychosocial treatments that BPD usually requires.
An Explanation of the DSM-IV TR Criteria
For a patient to be diagnosed with Borderline Personality Disorder, he or she must experience 5 out of the 9 criteria (see page 2) as set forth in the DSM-IV TR. Establishing the diagnosis is complicated by the fact that the presence of many of these criteria fluctuate. Here is a more detailed explanation of these symptoms:
Abandonment Fears. These fears should be distinguished from the more common and less severe phenomena of separation anxiety. The perception of impending separation or rejection, or the loss of external structure, can lead to profound changes in the BPD patient’s self-image, affect, cognition, and behavior. Individuals with BPD are interpersonally hypersensitive and may experience intense abandonment fears and inappropriate anger even when faced with criticisms or time-limited separations. These abandonment fears are related to an intolerance of being alone and a need to have other people with them. Frantic efforts to avoid abandonment may include impulsive actions such as self-injurious or suicidal behaviors. It was originally postulated that fear of abandonment developed as a result of failures in a child’s development during the rapprochement phase (from age one-and-a-half to two-and-a-half). However, empirical evidence has not borne this out.
Unstable, Intense Relationships. Individuals with BPD are frequently unable to see significant others (i.e., potential sources of care or protection) as other than idealized (if gratifying), or devalued (if not gratifying). This is often referred to as “black and white thinking,” and in psychological terms, reflects the construct of “splitting.” When anger initially intended toward a loved one is experienced as dangerous, it gets “split” off to preserve the loved one’s goodness. Relationship instability is thought to be a symptom of early insecure attachment characterized by both fearful distrust and needy dependency.
Identity Disturbance. The disorder of self which is specific to borderline patients is characterized by a distorted, unstable or weak self-image. Borderline patients often have values, habits, and attitudes which are dominated by whomever they are with. The interpersonal context in which these identity problems get magnified is thought to begin with not learning to identify one’s feeling states and the motives behind one’s behaviors.
Impulsivity. The impulsivity of the borderline individual is frequently self-damaging, in its effects if not in its intentions. This differs from impulsivity found in other disorders such as manic/hypomanic or antisocial disorders. Common forms of impulsive behavior for borderline patients are substance or alcohol abuse, bulimia, unprotected sex, promiscuity, and reckless driving.
Suicidal or Self-injurious Behaviors. Recurrent suicidal attempts, gestures, threats, or self-injurious behaviors are the hallmark of the borderline patient. The criterion is so prototypical of persons with BPD that the diagnosis rightly comes to mind whenever recurrent self-destructive behaviors are encountered. Self-destructive acts often start in early adolescence and are usually precipitated by threats of separation or rejection or by expectations that the BPD patient assume unwanted responsibilities. The presence of this pattern assists the diagnosis of concurrent BPD in patients whose presenting symptoms are depression or anxiety.
Affective (Emotional) Instability. Early clinical observers noted the intensity, volatility and range of the borderline patient’s emotions. It was originally proposed that borderline emotional instability involved the same problems of affective irregularity found in persons with mood disorders, particularly depression and bipolar disorder. It is now known that although individuals with BPD display marked affective instability (i.e., intense episodic depression, unrest, anger, panic, or despair), these mood changes usually last only a few hours, and that the underlying dysphoric mood is rarely relieved by periods of well-being or satisfaction. These episodes may reflect the individual’s extreme reactivity to stresses, particularly interpersonal ones and a neurobiologically-based inability to regulate emotions.
Emptiness. Chronic emptiness, described as a visceral feeling, usually felt in the abdomen or chest, plagues the borderline patient. It is not boredom, nor is it a feeling of existential anguish. This feeling state is associated with loneliness and neediness. Sometimes their experience is considered an emotional state and sometimes it is considered a state of deprivation.
Anger. The anger of the borderline patient may be due to temperamental excess (a genetic vulnerability) or a longstanding response to excessive frustration (an environmental cause). Whether the cause is genetic or environmental, many individuals with BPD report feeling angry much of the time, even when the anger is not expressed overtly. Anger is often elicited when an intimate or caregiver is seen as neglectful, withholding, uncaring, or abandoning. Expressions of anger are often followed by shame and contribute to a sense of being evil.
Psychotic-like Perpetual Distortions (Lapses in Reality Testing). Borderline patients can experience dissociation symptoms: feeling unreal or that the world is unreal. These symptoms are associated with other disorders, such as schizophrenia and Post Traumatic Stress Disorder (PTSD), but in those with BPD the symptoms generally are of short duration, at most, a few days, and often occur during situations of extreme stress. Borderline patients also can be unrealistically self-conscious, believing that others are critically looking at or talking about them. These lapses of reality in the BPD patient may also be distinguished from other pathologies in that generally the ability to correct their distortions of reality with feedback remains intact.
The borderline traits are usefully subdivided into four factors, each of which represents an underlying temperament (aka “phenotype”):
Interpersonal hypersensitivity (criteria 1, 2 and 7)
Affect (emotional) dysregulation (criteria 6, 8 and 7)
Behavioral dyscontrol (Impulsivity) (criteria 4 and 5)
Disturbed self (criteria 3 and 9)
The Origins of BPD
Borderline Personality Disorder, like all other major psychiatric disorders, is caused by a complex combination of genetic, social, and psychological factors. All modern theories now agree that multiple causes must interact with one another in order for the disorder to become manifest.
There are, however, known risk factors for the development of BPD. The risk factors include those present at birth, called temperaments; experiences occurring in childhood; and sustained environmental influences.
A. Inborn Biogenetic Temperaments
The degree in which Borderline Personality Disorder is caused by inborn factors, called the “level of heritability” is estimated to be 52-68%. This is about the same as for bipolar disorder. What is believed to be inherited are the biogenetic dispositions, i.e., temperaments, (or, as noted above, phenotypes), for Affective Dysregulation, Impulsivity, and Interpersonal Hypersensitivity. For children with these inborn dispositions, environmental factors can then significantly delimit or exacerbate them into adult BPD. But, in addition, some more BPD-specific disposition is inherited that glues these phenotypes together.
Many studies have shown that disorders of emotional regulation, interpersonal hypersensitivity, or impulsivity are disproportionately higher in relatives of BPD patients. The affect/emotion temperament predisposes individuals to being easily upset, angry, depressed, and anxious. The impulsivity temperament predisposes individuals to act without thinking of the consequences, or even to purposefully seek dangerous activities. The interpersonal hypersensitivity temperament probably starts with extreme sensitivity to separations or rejections. Another theory has proposed that patients with BPD are born with excessive aggression which is genetically based (as opposed to being environmental in origin). A child born with a cheerful, warm, placid or passive temperament would be unlikely to develop BPD.
Normal neurological function is needed for such complex tasks as impulse control, regulation of emotions, and perception of social cues. Studies of BPD patients have identified an increased incidence of neurological dysfunctions, often subtle that are discernible on close examination. The largest portion of the brain is the cerebrum, where information is interpreted coming in from the senses, and from which conscious thoughts and planned behavior emanate. Preliminary studies have found that individuals with BPD have a diminished response to emotionally intense stimulation in the planning/organizing areas of the cerebrum and that the lower levels of brain activity may promote impulsive behavior. The limbic system, located at the center of the brain, is sometimes thought of as “the emotional brain”, and consists of the amygdala, hippocampus, thalamus, hypothalamus and parts of the brain stem. There is evidence that in response to emotional arousal, the amygdale is particularly active in persons with BPD.
B. Psychological Factors
Like most other mental illnesses, Borderline Personality Disorder does not appear to originate during a specific, discrete phase of development. Recent studies have suggested that pre-borderline children fail to learn accurate ways to identify feelings or to accurately attribute motives in themselves and others (often called failures of “mentalization”). Such children fail to develop basic mental capacities that constitute a stable sense of self and make themselves or others understandable or predictable. One important theory has emphasized the critical role of an invalidating environment. This occurs when a child is led to believe that his or her feelings, thoughts and perceptions are not real or do not matter.
About 70% of people with BPD report a history of physical and/or sexual abuse. Childhood traumas may contribute to symptoms such as alienation, the desperate search for protective relationships, and the eruption of intense feeling that characterize BPD. Still, since relatively few people who are physically or sexually abused develop the borderline disorder (or any other psychiatric disorder) it is essential to consider temperamental disposition. Since BPD can develop without such experiences, these traumas are not sufficient or enough by themselves to explain the illness. Still, sexual or other abuse can be the “ultimate” invalidating environment. Indeed, when the abuser is a caretaker, the child may need to engage in splitting (denying feelings of hatred and revulsion in order to preserve the idea of being loved). Approximately 30% of people with BPD have experienced early parental loss or prolonged separation from their parents, experiences believed to contribute to the borderline patient’s fears of abandonment. People with BPD frequently report feeling neglected during their childhood. Sometimes the sources for this sense of neglect are not obvious and might be due to a sense of not being sufficiently understood. Patients often report feeling alienated or disconnected from their families. Often they attribute the difficulties in communication to their parents. However, the BPD individual’s impaired ability to describe and communicate feelings or needs, or resistance to self-disclosure may be a significant cause of the feelings of neglect and alienation.
C. Social and Cultural Factors
Evidence shows that borderline personality is found in about 2-4% of the population. There may be societal and cultural factors which contribute to variations in its prevalence. A society which is fast-paced; highly mobile, and where family situations may be unstable due to divorce, economic factors or other pressures on the caregivers, may encourage development of this disorder.
The Course of Borderline Personality Disorder
Borderline Personality Disorder usually manifests itself in early adulthood, but symptoms of it (e.g., self-harm) can be found in early adolescence. As individuals with BPD age, their symptoms and/or the severity of the illness usually diminish. Indeed, about 40-50% of borderline patients remit within two years and this rate rises to 85% by 10 years. Unlike most other major psychiatric disorders, those who do remit from BPD don’t usually relapse! Studies of the course of BPD have indicated that the first five years of treatment are usually the most crisis-ridden. A series of intense, unstable relationships that end angrily with subsequent self-destructive or suicidal behaviors are characteristic. Although such crises may persist for years, a decrease in the frequency and seriousness of self-destructive behaviors and suicidal ideation and acts and a decline in both the number of hospitalizations and days in hospital are early indications of improvement. Whereas about 60% of hospitalized BPD patients are readmitted in the first six months, this rate declines to about 35% in the eighteen months to two-year period following an initial hospitalization. In general, psychiatric care utilization gradually diminishes and increasingly involves briefer, less intensive interventions.
Improvements in social functioning proceed more slowly and less completely than do the symptom remissions. Only about 25% of the patients diagnosed with BPD eventually achieve relative stability through close relationships or successful work. Many more have lives that include only limited vocational success and become more avoidant of close relationships. While stabilization is common, and life satisfaction is usually improved, the persisting impairment of social role functioning of the patients is often disappointing.
Suicidality and Self-Harm Behavior
The most dangerous and fear-inducing features of Borderline Personality Disorder are the self-harm behavior and potential for suicide. While 8-10% of the individuals with Borderline Personality Disorder commit suicide, suicidal ideation (thinking and fantasizing about suicide) is pervasive in the borderline population. Deliberate self-harm behaviors (sometimes referred to as parasuicidal acts) are a common feature of BPD, occurring in approximately 75% of patients having the diagnosis and in an even higher percentage for those who have been hospitalized. These behaviors can result in physical scarring, and even disabling physical handicaps. Self-harm behavior takes many forms. Patients with BPD often will self-injure without suicidal intent. Most often, the self-injury involves cutting, but can involve burning, hitting, head banging, and hair pulling. Some self-destructive acts are unintentional, or at least are not perceived by the patient as self-destructive, such as unprotected sex, driving under the influence, or binging and purging. Tattoos or pornography with retrospective shame are new variations of this.
The motivations for self-injurious behaviors are complex, vary from individual to individual, and may serve different purposes at different times. About 40% of self-harming acts done by borderline patients occur during dissociative experiences, times when numbness and emptiness prevail. For these patients self-injury may be the only way to experience feelings at all. Patients report that causing themselves physical pain generates relief which temporarily alleviates excruciating psychic pain. Sometimes people with BPD make suicide attempts when they feel alone and unloved, or when life feels so excruciatingly painful as to feel unbearable. There may be a vaguely conceived plan to be rescued, which represents an attempt to relieve the intolerable feelings of being alone by establishing some connection with others. There may even be a neurochemical basis for some self-harming acts – the physical act may result in a release of certain chemicals (endorphins) which inhibit, at least temporarily, the inner turmoil. Self-destructive behaviors can become addictive, and one of the initial and primary components of treatment is to break this cycle.
In addition to substance abuse, major depression can contribute to the risk of suicide. Approximately 50% of people with BPD are experiencing an episode of major depression when they seek treatment, and about 80% have had a major depressive episode in their lifetimes. When depression coexists with the inability to tolerate intense emotion, the urge to act impulsively is exacerbated. It is imperative that treaters evaluate the patient’s mood carefully, appreciate the severity of the patient’s unhappiness, but also recognize that antidepressant medications usually have only modest effects.
Family members are, understandably, tormented by the threat and/or carrying out of such acts. Reactions, naturally, vary widely, from wanting to protect the patient, to anger at the perceived attention-demanding aspects of the behavior. The risk of suicide incites fear, anger, and helplessness. It is imperative, however, that family members do not assume the primary burden to ensure the patient’s safety. Whenever there is a perceived threat of harm, or the patient has already engaged in self-harm, a professional should be contacted.
The borderline individual may plead to keep communications or behaviors secret, but safety must be the priority. The patient, treaters, and family cannot work together effectively without candor, and the threat or occurrence of self-destructive acts cannot be kept secret. This is for the benefit of all concerned. Family members/friends do not have the capacity to live with the specter of these behaviors in their lives, and patients will not progress in their treatment until these behaviors are eliminated.
Once safety concerns have been addressed, through the intervention of professionals, family members/friends can play an important role in diminishing the likelihood of recurring self-destructive threats by simply being present and listening to their loved one, without criticism, rejection or disapproval.
BPD individuals often misuse alcohol or drugs (both prescribed and illegal). This may diminish social anxiety, distance them from painful ruminations, or minimize the intensity of their negative emotions. Often alcohol or drugs have disinhibiting affects that encourage self-injury and suicide attempts as well as other self-endangering behaviors.
Current Status of Treatment
In the past few decades, treatment for Borderline Personality Disorder has changed radically, and, in turn, the prognosis for improvement and/or recovery has significantly improved.
One of the preliminary questions confronting families/friends is how and when to place confidence in those responsible for treating the patient. Generally speaking, the more clinical experience the treater(s) have working with borderline patients, the better. In the event that several professionals are involved in the care of a borderline individual, it will be important that they are compatible in their approaches and are communicating with one another. Support by family members of treatment is equally important.
Hospitalization in the care of borderline patients is usually restricted to the management of crises (including, but not limited to, situations where the individual’s safety is precarious). Hospitals provide a safe place where the patient has an opportunity to gain distance and perspective on a particular crisis and where professionals can assess the patient’s psychological and social problems and resources. It is not uncommon for medication changes to take place in the context of a hospital stay, where professionals can monitor the impact of new medications in a controlled environment. Hospitalizations are usually short in duration.
Psychotherapy is the cornerstone of most treatments of borderline patients. Although development of a secure attachment to the therapist is generally essential for the psychotherapy to have useful effects, this does not occur easily with the borderline patient, given his or her intense needs and fears about relationships.
Moreover, many therapists are apprehensive about working with borderline patients. The symptomology of the borderline patient can be as difficult for professionals as it is for family members. The treater may assume the role of protective caretaker, and then experience feelings of anger and fear when the patient engages in dangerous and maladaptive behaviors. Even very able, motivated therapists are sometimes abruptly terminated by borderline patients. Often, however, though experienced as a failure, these brief therapies turn out to have served a valuable role in helping the patient through an otherwise insurmountable situation and in making the patient more amenable to subsequent therapists.
The standard recommendation for individual psychotherapy involves one to two visits a week with an experienced clinician for a period of one to six years. Good therapists need to be active and maintain consistent expectations of change and patient participation. Essential to successful therapy for a borderline patient is the development of feelings of trust and closeness with the therapist (which may have been missing from the patient’s life to that point) with the expectation that this would enhance the ability of the patient to have relationships of this nature with others. Validation, including being listened to, helps individuals develop recognition and acceptance of their self as unique and worthy.
Multiple forms of psychotherapy have been shown by research to be effective. All of them decrease self-harm, suicidality, and use of hospitals, emergency rooms, and medications. The best known and most widely practiced of the empirically validated therapies is Dialectical Behavior Therapy (DBT). It combines individual and group therapy modalities and is directed at teaching the borderline patient skills to regulate intense emotional states and to diminish self-destructive behaviors. DBT includes the concept of mindfulness, including self-awareness and balancing cognitive and emotional states, resulting in “wise mind.” DBT also emphasizes regulating emotions; distress tolerance skills and effective interpersonal skills. This therapy’s proactive, problem-solving approach readily engages borderline patients who are motivated to change.
Two of the effective therapies for BPD are psychodynamic (aka psychoanalytic). Transference focused psychotherapy (TFP) is a twice-weekly individual psychotherapy that emphasizes the interpretation of the meaning for the patient’s behaviors within relationships, most notably the relationship with the therapist. TFP also emphasizes the importance of experiences of anger. Mentalization based therapy (MBT) combines individual and group therapy. It emphasizes learning to recognize one’s own mental states (feelings/attitudes) and those of others as ways of explaining behaviors. This capability is called mentalizing, and is a capacity that all effective therapies try to enhance.
General Psychiatric Management (GPM) is a once-weekly therapy that can include prescribing medications and family interventions as needed. The therapy tries to create a “containing environment” within which patients can learn to trust and feel. This therapy requires clinical experience, but is the least theory-bound and easiest to learn of the empirically validated therapies.
Selective serotonin reuptake inhibitors and other antidepressants have frequently been prescribed to patients with BPD, but they are only modestly useful. Randomized controlled trials now suggest that atypical antipsychotics or mood stabilizers may be better choices. These studies also show that no type of medication is consistently or dramatically effective. Benzodiazepines are the one class of medications shown to make patients worse, though even here, there are exceptions. Thus medications should be initiated with the full understanding by the borderline patient that they have an adjunctive role to psychotherapy in treatment. In practice, prescribing medications may help to facilitate a positive alliance by concretely demonstrating the physician’s wish to help the borderline patient feel better; but unrealistic expectations of the benefits of medication can undermine work on self-improvement.
Common concerns when prescribing medication to these patients include risks of overdosing and non-compliance, but experience suggests that medications can be used with much reduced risk as long as a patient is regularly seeing and communicating with his or her provider. Another common problem in practice is polypharmacy, which may occur when patients want to continue or add medications despite a lack of demonstrable benefit; eighty percent of borderline patients are taking three or more medications. Consequences include side effects such as obesity (especially with antipsychotic agents) and associated problems such as hypertension and diabetes.When the benefit of a medication is unclear, patients should be urged to discontinue it before initiating a new one.
Parents and spouses often bear a significant burden. They usually feel misjudged and unfairly criticized when the person with BPD blames them for their suffering. Suffice it to say, that for both the borderline patient, and those who love them, living with this disorder is challenging. Family members are usually grateful to be educated about the borderline diagnosis, the likely prognosis, reasonable expectations from treatment, and how they can contribute. Such interventions often improve communication, decrease alienation, and relieve family burdens.
Conjoint sessions with parents and the BPD offspring should be offered both the borderline patient and their parents need to be motivated to participate, to have established an ability to communicate with words (rather than actions) and to willing listen to each other.
Group therapies include those led by professionals, with selected membership, and self-help groups, comprised of people who gather together to discuss common problems. Both are effective treatments.
DBT skills groups are often like classrooms with much focus and direction offered by the group leader and with homework between sessions. MBT groups offer a form for recognizing misattributions and how one affects others. Borderline patients may be resistant to interpersonal or psychodynamic groups which require the expression of strong feelings or the need for personal disclosures. However, such forums may be useful for these very reasons. Moreover, such groups offer an opportunity for borderline patients to learn from persons with similar life experiences, which, in conjunction with the other modalities discussed here, can significantly enhance the treatment course.
Many borderline patients will find it more acceptable to join self-help groups, such as AA, and other groups that are directed to problems such as eating disorders or that have purely supportive functions, such as Survivors of Incest. Such self-help groups that provide a network of supportive peers can be useful ad an adjunct to treatment, but should not be relied on as the sole source of support.
Despite its prevalence in clinical settings and its enormous public health costs, borderline personality disorder has only recently begun to command the attention it requires. This is evident in the emergence of parental advocacy/education/support groups, in the identification of BPD as a priority by the National Institute of Mental Health (NIMH) and by the National Alliance on Mental Illness (NAMI) in 2006. In 2009, the US Congress passed a resolution calling for more awareness of this disorder and more investment into its research and treatment. To date this has not occurred.
Our understanding of the disorder itself is in the process of dramatic change. Where its etiology was once thought to be exclusively environmental, we now know it is heavily genetic. Where it was thought to be a highly chronic, resistant-to-change disorder, we now know it has a remarkably good prognosis. Finally, where once it was thought to require heroic commitments to undertake BPD treatment, we now have a variety of interventions specifically designed for BPD, which can have significant and enduring benefits.
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Publication and distribution of A BPD Brief is made possible by the support of the following organizations: The New England Personality Disorder Association (NEPDA)
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