Psychiatric Annals

Guest Editorial Free

Is Borderline Personality Disorder Serious Enough to Be Called Serious Mental Illness?

Asim A. Shah, MD

Historically, the term “serious mental illness” (SMI) invariably referred to the following diagnoses: bipolar disorder, schizophrenia, and severe depression; these conditions have a particular level of severity and are well studied and discussed. In this issue of Psychiatric Annals, we explore the background of various definitions of SMI and how borderline personality disorder (BPD) should be classified as an SMI based on the definition from the National Institute of Mental Health. Also, we explore how BPD can develop into an SMI that would make early diagnosis and treatment imperative.

BPD is among the most common challenges seen in mental health care; it affects 1 in 5 psychiatric outpatients.1 Although the condition usually emerges between puberty and young adulthood, diagnosis and treatment is often delayed until late in the course of the illness, leading to more significant functional impairment and limiting treatment efficacy.2 BPD is now understood to be a unitary construct across the lifespan with a rise in pathology in the pubertal period that subsequently wanes from early adulthood onwards, partly due to maturation and socialization.3 Furthermore, it is now known that disruptive behavior, attention disturbances, and emotional dysregulation in childhood conditions such as attention-deficit/hyperactivity disorder, oppositional defiant disorder, substance use disorder, self-injury, anxiety, and depression can all be precursors to an emerging diagnosis of BPD.4 Beginning with childhood and early adolescence, patients with current or emerging BPD present many distressing symptoms that fit the criteria of SMI. These include frequent and persistent depression (with suicidal ideation and attempts), stressful peer interactions, intense negative affect and aggression (especially in girls) and auditory hallucinations that are indistinguishable from patients with schizophrenia.5 BPD is more common in women in clinical settings.6 This difference was attributed to the fact that more women seek treatment as compared to men.7 However, according to an epidemiological survey, the lifetime prevalence between men and women was about the same in community settings.7,8 The prevalence of BPD may decrease in older patients.6

Because of symptom overlap, differentiating biploar disorder (BD) from BPD poses a diagnostic challenge for mental health providers. However, given that the treatment for each of the disorders varies, with the most efficacious treatment for BD being pharmacological and for BPD psychotherapeutic, accurate diagnosis is pivotal for optimal prognosis. To help aid in diagnosis, providers may begin with a brief screening. For BPD, the McLean Screening Instrument for BPD has been found to be specific and sensitive to identify BPD at a cut-off score of 7.9 There are no FDA-approved medications for BPD; however, there is evidence for symptom alleviation with certain agents. Furthermore, BPD requires high utilization of treatment services, causing high direct and indirect costs.10

In my view, BPD should be considered as an SMI according to the definition from the Center of Mental Health and Services. BPD affects the social, interpersonal, and medical trajectories of people who are affected. Addressing the stigma and countertransference issue associated with this condition is imperative in early detection and for appropriate referral and treatment, which are necessary to improve engagement with the health care system and to improve outcomes.


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  6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013: 663–565.
  7. Grant BF, Chou SP, Goldstein RB, et al. Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder. J Clin Psychiatry. 2008;69(4):533–545. doi:10.4088/jcp.v69n0404 [CrossRef] PMID:18426259
  8. Kaess M, Brunner R, Chanen A. Borderline personality disorder in adolescence. Pediatrics. 2014;134:782–793. doi:10.1542/peds.2013-3677 [CrossRef] PMID: 25246626
  9. Zanarini MC, Vujanovic AA, Parachini EA, Boulanger JL, Frankenburg FR, Hennen J. A screening measure for BPD: the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD). J Pers Disord. 2013;17:568–573. doi:10.1521/pedi.17.6.568.25355 [CrossRef]
  10. Wunsch E, Kliem S, Kröger C. Population-based cost-offset estimation for the treatment of borderline personality disorder: projected costs in a currently running, ideal health system. Behav Res Ther. 2014;60:1–7. doi:10.1016/j.brat.2014.06.002 [CrossRef] PMID:25014129
Asim A. Shah, MD

Asim A. Shah, MD, is a Professor and the Executive Vice Chair, Menninger Department of Psychiatry and Behavioral Sciences; and a Professor, Department of Community and Family Medicine, Baylor College of Medicine.

Address correspondence to Asim A. Shah, MD, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Room 2.125, Neuropsychiatric Center, 1502 Taub Loop, Houston, TX 77030; email:

Disclosure: The author has no relevant financial relationships to disclose.


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