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Clinical considerations for evidence-based treatment of borderline personality disorder (BPD) are outlined in the context of the best available evidence, discussed with reference to BPD traits currently identified in the upcoming Diagnostic and Statistical Manual of Mental Disorders - 5 (DSM-5) revision. The DSM-5 will highlight refractory affective, interpersonal, and identity symptoms in BPD as potential treatment targets. In addition to providing a framework for clinical decision-making, future research strategies will also focus on neurotransmitter systems of greater relevance to understanding overall personality functioning.Although only a few randomized controlled trials of psychopharmacological treatments for BPD have been published recently, several meta-analyses and systematic reviews converge on the consensus effectiveness of lamotrigine, topiramate, valproate, aripiprazole, olanzapine, and omega-3 fatty acid supplementation. Stronger evidence exists for treating disinhibition and antagonism than negative affectivity, particularly interpersonal facets of such traits. In addition, basic research suggests a future role for modifying glutamatergic, opioid, and oxytocinergic neurotransmitter systems to treat BPD.Clinicians should utilize omega-3, anticonvulsants, and atypical antipsychotic agents in treating specific DSM-5 BPD traits, notably disinhibition, antagonism, and some aspects of negative affectivity. Future research will focus on normalizing opioid and oxytocin dysregulation, as an adjunct to evidence-based psychotherapy, in an effort to improve interpersonal functioning.

Over the past 60 years, the Diagnostic and Statistical Manual of Mental Disorders (DSM) has evolved from early efforts to collect statistical information to a modern compendium of mental disorders that can be reliably diagnosed, but have not been validated. Throughout this history, DSM architects have struggled with the seemingly fundamental, but complex question of how to define a mental disorder. Current proposals indicate that a spectrum model of mental illness will be embraced in DSM-5, prompting renewed concern and debate about pathologizing normal existence. While a spectrum view of mental illness may reflect biologic reality and help pave the path towards validated models of psychiatric disorder, diagnostic expansion does have important practical implications and could give rise to problems in clinical work and society at large, including the further sanctioning of a shift from psychiatric treatment to neuroenhancement. Debates about what should or should not be considered a mental illness in DSM-5 are likely to remain unresolved and, in the future, must be framed according to contextual utility. Diagnosis and thresholds of pathology are ultimately value-based so that careful analysis and perhaps even different definitions of disorder may be required to guide decision-making in research, clinical work, and public policy.

Borderline personality disorder is the most widely researched single personality disorder, and much research activity continues. This review covers empirical literature on diagnosis, classification and treatment of borderline personality disorder published during 2006 and 2007. Several of the issues that concern borderline personality disorder also concern personality disorders in general, and so the review is broadened in the diagnostic section to include the latter.Integration of categorical and dimensional approaches to personality disorders is actively being sought for inclusion in the next revision of the psychiatric classifications. Although there are few new studies on pharmacotherapy for borderline personality disorder, many new findings on psychotherapy have been reported. They indicate that a variety of treatment modalities can influence borderline personality disorder, but the role of spontaneous improvement over time and established prognostic factors have not received sufficient attention. New modalities of psychotherapy have been tested by less stringent designs.Research into classification, diagnosis and psychotherapy of borderline personality disorder is flourishing, but research activity in pharmacotherapy is limited.

Objective: To assess 5-year mental disorder recognition rates and determine the natural history of mental disorders in primary care. Methods: A prospective cohort of adults presenting to a primary care walk-in clinic with a physical symptom were evaluated at baseline (n = 500) and at 5 years (n = 387) for mental disorders with the Primary Care Evaluation of Mental Disorders (PRIME-MD). Additional measures included functional status (Medical Outcomes Study SF-6; MOS-SF6), Patient Health Questionnaire-15, Satisfaction (Rand-9), unmet expectations, and symptom outcome. Patients self-reported whether their disorder was diagnosed or treated at the 5-year follow-up. Results: At baseline, 29% of patients had a mental disorder (major depression: 8.4%, minor depression 10.4%, Panic disorder 1.4%, generalized anxiety disorder 2%, anxiety not otherwise specified (NOS) 11.4%); of these patients, 26% had more than one mental disorder. Over 5 years, 33% were recognized. Threshold disorders were more likely to be recognized (major depression 56%, panic 100%, generalized anxiety disorder 88%) than subthreshold disorders (minor depression 20%, anxiety NOS 25%). Correlates of recognition included having a threshold or multiple disorders; recognition was associated with greater likelihood of persistence. Most patients with subthreshold disorders at baseline had no disorder at 5 years and few progressed to threshold disorders (minor to major depression 12%, anxiety NOS to generalized anxiety or panic 8%). Conclusions: Mental disorders are common and their recognition and treatment remain low. Subthreshold disorders have a better prognosis. Patients with threshold or multiple disorders, worse functioning or persistence of their disorder were more likely to be diagnosed.

Purpose of review To describe the prevalence and specific management of severe and complex personality disorders in community mental health services and similar settings. Recent findings Conflicting reports exist in the literature but the consensus of evidence suggests that more complex personality disorder (more so than simple personality disorder) impairs response to treatment of most psychiatric disorders and complicates their management. Poor adherence to treatment may be one of the mechanisms underlying this. Summary Increasing evidence now suggests that more complex and severe personality disorders have a negative impact on the outcome of most psychiatric disorders. Some indications, however, are there to show that pharmacological treatments may not handicap the outcome of pharmacological treatment as much as other types of intervention and may be selectively chosen in this group. Severe personality disorder needs to be identified early in community services as by anticipating and adjusting to its effects it is likely to improve treatment plans and prognosis.

In recent years a considerable number of publications has appeared on various aspects of Internet interventions for mental health care. The purpose of the present article is to review the current scientific status of Internet interventions for the treatment of mental disorders.Randomized controlled studies on the use Internet interventions for the treatment of mental disorders are still scarce. Most studies in the field have been on Internet interventions for the treatment of depressive disorders and anxiety disorders, using cognitive behavioural therapy. In addition, a few studies have been published on the use of Internet interventions in the treatment of substance use disorders (smoking, problem drinking), insomnia and tinnitus.Recent studies provide provisional evidence that Internet interventions may be a promising tool for the treatment of some mental disorders.

Purpose of reviewThis article reviews the problem of ‘boundaries’ in psychopathology and its conceptualization in the diagnostic classification of psychiatric disorders.Recent findingsA modest number of publications in 2004–2005 contribute concepts, methods and data relevant to several aspects of th

Interest in the possibility of successful interventions for personality disorders has increased during the past 2 years, mainly because of heightened awareness of the diagnosis. In particular, efficacy of treatments for borderline personality disorder has improved, with good evidence for the superiority of focused day hospital psychotherapy compared with standard care, and somewhat less convincing evidence for the value of sodium valproate in this condition. Other reports also suggest that both psychosocial and pharmacological treatments are both likely to have a significant role to play in the treatment of all personality disorders, and for the first time these modalities are being properly evaluated in good research studies. The view that personality disorders are untreatable can now be challenged with serious evidence.

Although personality disorders are often regarded as “untreatable” by third-party payers, there is actually a growing empirical literature suggesting that Axis II conditions may be eminently treatable by psychotherapy. This literature is critically reviewed, the implications for length of treatment are discussed, and cost-effectiveness issues are examined.

The authors review the assessment of comorbid mental and substance-use disorders and provide practical guidelines to inform the clinician's diagnostic decisions. They describe how to differentiate between intoxication and withdrawal syndromes and substanceinduced and primary disorders as defined in DSM-FV and present different viewpoints about how comorbid, substance-induced, primary, and secondary disorders can be defined. They discuss the types of psychiatric symptoms that may be associated with different substances (both substances of abuse and prescribed medications), focusing on mood, anxiety, and psychotic disorders. How to assess personality disorders in the context of substance use is also reviewed. Finally, the authors provide examples of questions the clinician can use during the patient evaluation to facilitate diagnostic decision making. (JPract Psychiatry Behav Health 1996;5:272-282)

This report investigates the way in which the presence of a personality disorder (PD) in probands affects the frequency of psychiatric disorders in relatives. Four proband groups--panic, panic plus a PD, major depression, and depression plus a PD--were given the Family History-Research Diagnostic Criteria and the Family History for DSM-III Anxiety and Personality Disorders. Information was gathered on 730 first-degree relatives. Panic patients with a PD had higher incidences of panic and panic plus a PD in relatives. There was increased depression in relatives of probands with either depression or a PD. Alcoholism appeared highest in relatives of probands who had combined depression and a PD.

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