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Patient partnership and neuromodulation in mental health: A field worth cultivating

  • Jillian Mills,
  • Kamilia Soltani,
  • Olivier Roy and 
  • Lionel Cailhol

Résumé

Contexte/Originalité La collaboration entre les patients partenaires (PP), les cliniciens et les chercheurs connaît un essor considérable en santé mentale. Cette approche participative transforme progressivement les paradigmes de recherche en intégrant le savoir expérientiel des usagers à l’expertise scientifique, avec des impacts positifs multiples. Elle favorise l’adhésion aux projets de recherche, facilite la vulgarisation scientifique et contribue à réduire la stigmatisation associée aux troubles de santé mentale. De plus, elle contribue à la priorisation de cibles thérapeutiques par des interventions qui répondent aux besoins réels des patients.

La neuromodulation représente un domaine thérapeutique en pleine expansion offrant des perspectives pour dépasser les limites du système de santé actuel. Son efficacité démontrée dans diverses pathologies psychiatriques en fait un outil prometteur, mais peu connu du public et peu accessible pour plusieurs patients susceptibles d’en tirer des bénéfices. L’implication des PP dans ce secteur pourrait générer de nouvelles perspectives sur ces défis, justifiant une exploration actuellement absente de la littérature.

Objectif Cet article vise à explorer les rôles et retombées de l’implication des PP dans la recherche en neuromodulation en santé mentale, à partir des enjeux émergents de ce champ encore pionnier. Nous aborderons également les perspectives du PP et des chercheurs collaborant actuellement sur un projet d’application de stimulation transcrânienne par courant continu (STCC) à domicile, TENTADIS. Cette exploration des écrits et des expériences permettra d’identifier les différents rôles du patient partenaire, ainsi que les retombées de son implication dans le processus de coconstruction de la recherche en neuromodulation.

Méthode/Résultats attendus Perspective fondée sur une analyse réflexive des expériences de coconstruction au sein du projet TENTADIS, croisée avec les connaissances actuelles sur la recherche en neuromodulation en santé mentale et la recherche participative.

Impacts attendus (Discussion) Dans le cadre du projet de recherche TENTADIS, qui explore la STCC à domicile pour les patients avec un trouble de la personnalité limite, le PP participe activement à l’élaboration du protocole. Son savoir expérientiel enrichit la conception du projet, en tenant compte des contraintes pratiques, des attentes et des besoins des participants. Les impacts attendus incluent des avancées dans la compréhension des enjeux cliniques et patients liés à la neuromodulation, ainsi que l’identification des contributions spécifiques des PP dans ce secteur. Cette collaboration illustre comment la coconstruction pourrait réduire la barrière d’accès, améliorer l’acceptabilité des interventions et accélérer leur intégration dans le parcours de soins.

Mots-clés :

  • Neuromodulation,
  • savoir expérientiel,
  • stimulation transcrânienne à courant continu (STCC),
  • patient partenaire,
  • trouble de personnalité limite (TPL)

Abstract

Background/Originality Collaboration between patient partners (PPs), clinicians, and researchers is rapidly expanding in mental health care and research. This participatory approach, integrating patient experiential knowledge with scientific expertise is progressively transforming research paradigms with significant positive impacts. Patient engagement promotes adhesion to research projects, facilitates knowledge transfer, and contributes to reducing the stigma associated with mental illness. In addition, it helps advance therapeutic targets and interventions that better address patients’ real-world needs.

Neuromodulation is an emerging field with the potential to overcome many limitations of our current mental health systems. Its therapeutic efficacy has been demonstrated for various psychiatric conditions, yet it remains largely unknown to the public and inaccessible to many patients who could benefit from these otherwise promising interventions. The involvement of PPs in neuromodulation research and its impacts, currently undocumented in the scientific literature, would offer new and necessary perspectives on these challenges and warrants further investigation.

Objective This article explores the roles and impacts of PP engagement in mental health research involving neuromodulation, with a focus on the specific issues that affect its implementation. We also examine the perspectives of both the PP and the researchers currently collaborating on TENTADIS, a project investigating home-based transcranial direct current stimulation (tDCS) for individuals suffering from borderline personality disorder. Through an examination of the literature and experiential reflections, this paper identifies various roles that the patient partner can fill in the co-construction of neuromodulation research and the important effects of such partnerships.

Method/Expected Results This perspective article is based on a reflective analysis of co-construction experiences within the TENTADIS project, integrated with current literature on neuromodulation research and participatory approaches in mental health.

Expected Impacts (Discussion) Within the TENTADIS research project, the PP actively participates in protocol development, contributing experiential knowledge that highlights practical constraints, participant expectations, and patient needs, thus enriching project design. Expected outcomes include advances in understanding both clinical and patient-related issues associated with neuromodulation, and identification of the specific contributions PPs can make in this field. This collaboration illustrates how co-construction can reduce barriers to access, improve intervention acceptability, and accelerate the implementation of neuromodulation in mental health services.

Keywords:

  • neuromodulation,
  • experiential knowledge,
  • transcranial direct current stimulation (tDCS),
  • patient partner,
  • borderline personality disorder (BPD)
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by Lionel Cailhol 1,2,3,4,5,6,*ORCID,Kamilia Soltani 1,Cécilia Neige 5,6,Marine Mondino 5,6ORCID,Jérôme Brunelin 5,6ORCID andMartin Blay 7,8ORCID

Faculté de Médecine, Département de Psychiatrie et D’addictologie, Pavillon Roger-Gaudry, C.P. 6128, Succursale Centre-Ville, Montréal, QC H3T 1J4, Canada

2
Centre de Recherche de L’Institut Universitaire de Santé Mentale de Montréal, 7401 Rue Hochelaga, Montréal, QC H1N 3M5, Canada
3
CERVO Brain Research Center, 2301 Av. D’Estimauville, Québec City, QC G1E 1T2, Canada
4
CIUSSS de L’Est de L’île de Montréal, Montréal, QC H1A 1T5, Canada
5
PsyR2 Team, U1028 UMR5292, Centre de Recherche en Neurosciences de Lyon CRNL, CNRS, INSERM, Université Claude Bernard Lyon 1, 69500 Bron, France
6
PsyR2, Le Vinatier Psychiatrie Universitaire Lyon Métropole, 95 Boulevard Pinel, 69500 Bron, France
7
ADDIPSY, Santé Basque Développement Group, Addictology and Psychiatry Oupatient Center, 69007 Lyon, France
8
Centre de Recherche en Epidémiologie et Santé des Populations Team “DevPsy”, INSERM, UVSQ, Université Paris-Saclay, 94807 Villejuif, France
*
Author to whom correspondence should be addressed.
Brain Sci. 2025, 15(6), 547; https://doi.org/10.3390/brainsci15060547
Submission received: 8 May 2025 / Revised: 19 May 2025 / Accepted: 20 May 2025 / Published: 23 May 2025

Abstract

Background: Borderline Personality Disorder (BPD) is a severe psychiatric condition characterized by pervasive emotional dysregulation, impulsivity, and unstable interpersonal relationships. Affecting over 1% of the general population, BPD carries significant morbidity, frequent hospitalizations, and an increased risk of suicide. Although specialized psychotherapeutic approaches have shown efficacy, their impact is often constrained by availability, lengthy treatment durations, moderate effect sizes, and high dropout rates. Pharmacological treatments for BPD remain inadequate and are usually accompanied by adverse side effects. Objective: This narrative review seeks to explore the potential of transcranial direct current stimulation (tDCS) as a safe, cost-effective, and accessible neuromodulation intervention aimed at alleviating core BPD symptoms—namely, emotional dysregulation and impulsivity—while also addressing common comorbidities and opportunities for integration with existing therapeutic modalities. Methods: We conducted a narrative literature synthesis in accordance with the SANRA (Scale for the Assessment of Narrative Review Articles) guidelines. A PubMed/MEDLINE search was performed using keywords related to transcranial direct current stimulation (tDCS) and BPD, identifying five published randomized controlled trials on the topic. To provide a broader perspective, we also included studies from related fields examining mechanisms of action, safety and tolerability, cost-effectiveness, stimulation parameters, and clinical outcomes relevant to BPD. Results: Conventional tDCS protocols—typically involving 1–2 mA currents for 20–30 min—have demonstrated an excellent safety profile, resulting in only minimal and transient side effects without any risk of overdose or misuse, which is a key advantage for populations at high risk of suicidality. With moderately priced devices and the feasibility of home-based administration, tDCS provides a substantially more affordable alternative to both long-term pharmacotherapy and intensive psychotherapy. Neurobiologically, tDCS modulates the excitability of the dorsolateral and ventrolateral prefrontal cortex and enhances fronto-limbic connectivity, thereby strengthening top-down regulatory control over emotion and behavior. Pilot randomized controlled trials report moderate effect sizes for improvements in emotional regulation, inhibitory control, and rejection sensitivity, along with ancillary gains in executive functioning and reductions in depressive and substance-use symptoms when stimulating the left dorsolateral prefrontal cortex. Conclusions: tDCS stimulation emerges as a safe and scalable adjunctive treatment for BPD, leveraging targeted neuromodulation to address core features and common comorbidities like depression. However, variability in current protocols and the scarcity of well-powered randomized trials underscore the pressing need for standardized methodologies, longer-term follow-up, and individualized stimulation strategies to establish enduring clinical benefits.

 

1. Introduction

Borderline Personality Disorder (BPD) is a severe and complex psychiatric condition characterized by pervasive emotional dysregulation, impulsivity, and interpersonal dysfunction [1]. It affects more than 1% of the general population [2] and is associated with high rates of psychiatric comorbidities, particularly mood disorders, anxiety disorders, and substance use disorders [3]. Beyond its clinical features, BPD is among the most impairing psychiatric disorders, leading to significant functional impairment [4], frequent hospitalizations [5], and an elevated risk of suicide [6,7]. Individuals with BPD experience a mortality rate substantially higher than that of the general population, primarily due to suicide and related health complications [6,8]. Given its prevalence and severity, developing effective and accessible treatment strategies remains a critical challenge in psychiatry.
Specialized psychotherapy is currently the gold standard for BPD treatment [9,10,11]. Approaches such as Dialectical Behavior Therapy (DBT), Mentalization-Based Therapy (MBT), and Schema Therapy have demonstrated efficacy in reducing emotional instability, impulsive behaviors, and self-harm [12]. Despite their effectiveness, these treatments face considerable limitations. The demand for specialized therapy far exceeds the availability of trained clinicians, resulting in limited access to care and prolonged wait times [13]. Even when accessible, psychotherapy requires long-term engagement; while many patients benefit from these interventions, the effect sizes remain moderate [12], with improvements often occurring gradually over months or years. A further challenge is that individuals with BPD frequently struggle with treatment adherence [14], resulting in high dropout rates and diminished therapeutic benefits. In parallel, pharmacotherapy for BPD remains unsatisfactory. Although antidepressants, mood stabilizers, and antipsychotics are widely prescribed, no pharmacological treatment has been explicitly approved for BPD [15]. Available medications offer only partial symptom relief and frequently come with significant side effects, complicating treatment decisions. These challenges underscore the urgent need for innovative, alternative, or adjunctive approaches to improve treatment strategies and patient outcomes.
Neuromodulation has emerged as a promising avenue for psychiatric disorders, especially BPD, offering novel mechanisms to modulate brain activity and alleviate symptoms [16,17]. Transcranial direct current stimulation (tDCS) has gained attention among available techniques due to its safety, accessibility, and potential therapeutic effects. Notably, it is more cost-effective than repetitive transcranial magnetic stimulation (rTMS), and its potential for home-based administration makes it an attractive option for patients who face barriers to accessing traditional in-clinic treatments [18]. In the context of BPD, tDCS may be particularly relevant given its potential capacity to modulate neural networks implicated in emotion regulation and impulsivity. One of the most common hypotheses is the fronto-limbic hypothesis [19], positing that emotional dysregulation arises from heightened amygdala activity, reduced activation in prefrontal regions such as the dorsal anterior cingulate cortex, and weakened fronto-limbic connectivity [20,21], although the validity of this hypothesis remains debated by some authors [22]. By targeting these neural mechanisms, tDCS has the potential to address core symptoms of BPD in a biologically plausible and clinically meaningful manner.
In this context, this narrative review aims to explore the potential role of tDCS in the treatment of BPD. Specifically, it will examine the rationale for integrating tDCS into BPD care—focusing on its safety, affordability, and capacity to target key symptom domains such as emotional dysregulation and impulsivity—and will discuss optimal stimulation protocols (electrode placement, intensity, session duration, and frequency) as well as its potential to complement or enhance psychotherapy. We ask whether tDCS can safely, affordably, and effectively modulate core BPD features, and we hypothesize that (1) specific tDCS parameters (e.g., electrode montage and stimulation intensity) will differentially influence symptomatic targets, from core BPD symptoms to executive functions and common comorbidities, and (2) tDCS will provide additional benefits in terms of cost-effectiveness and synergistic gains when combined with psychotherapeutic interventions. Finally, we will address clinical applications and feasibility, evaluate tDCS as both a standalone and adjunctive treatment, highlight current gaps in the literature, and outline future research directions.

2. Materials and Methods

A comprehensive narrative review was conducted to synthesize preclinical and clinical evidence on tDCS for BPD. This narrative review was conducted in accordance with the guidelines of the SANRA (Scale for the Assessment of Narrative Review Articles), which outlines quality criteria for narrative reviews. The manuscript adheres to SANRA’s six domains: justification of the article’s importance, clear statement of objectives, description of the literature search, appropriate referencing, sound scientific reasoning, and proper presentation of data [23]. We searched PubMed/MEDLINE from database inception through 30 March 2025, using combinations of the keywords “borderline personality disorder”, “BPD”, “transcranial direct current stimulation”, “tDCS”, “neuromodulation”, “prefrontal”, “emotion regulation”, and “impulsivity.” No language restrictions were applied. Reference lists of included articles and pertinent review papers were hand-searched for additional studies. The review process was carried out in two steps. First, we focused on identifying RCTs investigating tDCS in individuals with BPD. Data extraction was conducted independently by two reviewers (MB, LC), based on a prior unpublished systematic review conducted by our team. Second, we performed targeted searches to complement this initial synthesis by including studies addressing (1) the efficacy of tDCS in treating common BPD comorbidities (identified through recent meta-analyses), (2) the safety profile of tDCS (via meta-analyses and clinical guidelines), and (3) cost-related aspects (medico-economic evaluations). Finally, we incorporated selected studies to enrich our understanding of the neurobiological mechanisms underlying tDCS and its potential synergies with psychotherapeutic interventions.
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Abstract

Background:

Borderline personality disorder (BPD) is frequently encountered in emergency departments. Acute emotional crises, suicidal behaviors, and severe interpersonal distress often precipitate care. Despite the high clinical burden and elevated suicide risk associated with this disorder, guidance for emergency decision-making remains fragmented and sometimes contradictory.

Objective:

This scoping review aimed to identify key elements informing emergency psychiatric assessment, disposition decisions, and acute management strategies for adults diagnosed with BPD. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines, four electronic databases were searched for studies published between January 1st, 2000, and December 31st, 2025, examining evaluation, orientation, or management of adults with BPD in emergency settings. Eligible studies were screened independently, and data were charted and synthesized thematically.

Results:

Twelve studies met inclusion criteria. Three interrelated domains emerged: structured suicide risk assessment contextualized within chronic vulnerability; preference for brief, goal-directed crisis hospitalization over prolonged inpatient admission; and cautious, symptom-targeted pharmacological use limited primarily to short-term management of acute agitation. Evidence consistently highlighted a paradox in which individuals with BPD often present with severe distress but are admitted less frequently than other psychiatric populations. Emerging clinical pathways emphasize voluntary short stays, rapid follow-up, and linkage to outpatient services to reduce recurrent emergency presentations and iatrogenic harm. Overall, pharmacotherapy plays an adjunctive rather than a central role in emergency care.

Conclusions:

Emergency encounters with individuals living with BPD represent critical inflection points in trajectories often marked by recurrent crises and suicide risk. Current evidence supports structured, formulation-based assessment, time-limited crisis stabilization, and integration with outpatient services, while underscoring significant gaps in high-quality research. Strengthening system-level pathways may enhance safety, continuity, and therapeutic engagement in this high-risk population.

1 Introduction

Borderline personality disorder (BPD) is characterized by pervasive instability in affect regulation, interpersonal relationships, and self-image, accompanied by marked impulsivity and recurrent self-destructive behaviors, including suicidal acts (). A core feature of the disorder is profound sensitivity to real or perceived abandonment, which often precipitates intense emotional dysregulation and maladaptive coping strategies. Individuals with BPD also frequently experience chronic feelings of emptiness, intense anxiety, and unstable self-perception, which may further contribute to crisis presentations and recurrent emergency service utilization. With an estimated lifetime prevalence of 1%-2% in the general population, BPD is a major public health concern (). Its high rates of psychiatric comorbidity (including mood, anxiety, substance use, and post-traumatic stress disorders as well as the frequency of self-injurious and suicidal behaviors, contribute to substantial functional impairment and recurrent utilization of emergency services (–).

Accordingly, personality disorders account for a significant proportion of psychiatric emergency consultations. Prevalence rates in psychiatric emergency departments have been reported as high as 26%, with BPD alone representing approximately 9% of visits (, ). The burden extends beyond psychiatric facilities: in general hospitals, BPD is identified in nearly 2% of all admissions, underscoring its cross-sector impact on healthcare systems ().

Emergency department (ED) presentations frequently result in either psychiatric hospitalization or referral to outpatient services. However, a striking paradox has emerged in the literature: although individuals with BPD presenting to emergency services often exhibit greater clinical severity compared to other psychiatric populations, they are less likely to be admitted to inpatient units (–). Multiple factors may contribute to this discrepancy. Emotional dysregulation and interpersonal volatility may complicate engagement during acute assessment. Structural stigma and therapeutic pessimism toward personality disorders may also influence clinical decision-making. Furthermore, clinical guidelines often emphasize outpatient psychotherapeutic management as the preferred intervention, but access to evidence-based ambulatory treatments is inconsistent or insufficient in many settings (, ).

This issue is particularly concerning, considering suicide risk data. An Australian study found that approximately one quarter of individuals with BPD who died by suicide had presented to an emergency department within the six weeks preceding their death (). Clinicians are therefore confronted with a complex and high-stakes dilemma: whether to proceed with hospitalization (an intervention associated in some reports with potential symptom aggravation and limited protective effect against suicide risk) or to discharge patients toward outpatient services whose availability and continuity of care may be uncertain (–). The ethical and clinical tensions are substantial, involving both the imperative to ensure patient safety and the responsibility to direct individuals toward interventions with demonstrated efficacy.

Through a scoping review, we sought to identify key elements to inform clinical decision-making during emergency psychiatric assessments of individuals diagnosed with BPD. Specifically, our objectives were: (1) to delineate factors relevant to hospitalization versus discharge decisions; (2) to clarify recommended care pathways following emergency evaluation; and (3) to synthesize available evidence regarding pharmacological interventions applicable to this population in acute settings.

2 Methods

2.1 Search strategies

This scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) (). A comprehensive and systematic search strategy was developed to identify empirical and review literature examining the evaluation, orientation, and management of patients diagnosed with BPD in emergency settings.

The electronic databases PubMed, Embase, PsycInfo, and CINAHL were searched to ensure multidisciplinary coverage of psychiatric, medical, psychological, and nursing literature. The search strategy combined controlled vocabulary terms (e.g., MeSH, Emtree) and free-text keywords to maximize sensitivity. Core search concepts included “personality disorder(s),” “borderline AND personality,” and “emergency.” Boolean operators were used to combine terms, and truncation and proximity operators were applied where appropriate to capture variations in terminology. The full search strategy for each database, including the syntax and applied limits, is provided in the Supplemental Materials.

The search covered publications from January 1, 2000, to December 31, 2025. This timeframe was selected to reflect contemporary conceptualizations of BPD, developments in emergency psychiatric practice, and evolving clinical guidelines regarding hospitalization and outpatient management. No restrictions were imposed at the search stage on study design to capture the breadth of available evidence relevant to clinical decision-making in emergency departments. The search strategy was developed collaboratively by MBB and MD, both experienced in psychiatric research methodology.

 

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Abstract

Introduction: 

Mentalization-based therapy (MBT) and dialectical behavior therapy (DBT) are effective treatments for cluster B personality disorders (PDs), but few studies have assessed their real-world clinical outcomes in routine practice outside a controlled trial setting.

Methods: 

Our descriptive naturalistic retrospective study evaluated 288 patients with cluster B PDs who predominantly had borderline PD referred to MBT or DBT.

Results: 

Observed changes in emergency department (ED) use and hospitalizations one year before and during the first year of therapy were described for patients with at least one relevant event, along with dropout rates. ED visit analyses concerned 104 patients, and hospitalization analyses concerned 30 patients. Across both treatment modalities, ED visits decreased from 119 in the year prior to treatment to 37 during the first year of treatment (p < .001 for both). Hospitalizations were observed to decrease for patients in MBT (p < .05), while no clear change was seen in the DBT group (p = .595). Drop-out rates during treatment were around 30% in both modalities.

Discussion: 

These patterns descriptively suggest that both therapies are associated with reduced service use during treatment in clinical practice. Future research should investigate which patient- and system-level characteristics can guide patients and clinicians toward the most suitable treatment for everyone, and whether these observed patterns persist beyond the treatment period.

1 Introduction

Cluster B personality disorders (PDs) (borderline, narcissistic, antisocial, and histrionic) represent around 13% of the clinical psychiatric population and roughly 2.5% to 3% of the general population (1, 2). Within this group, borderline personality disorder (BPD) is the most prevalent diagnosis in clinical settings. Cluster B PDs are not only common in both general and clinical populations, but they are also associated with a significantly reduced life expectancy, by approximately 9 years for women and 13 years for men at age 20, primarily due to elevated suicide rates and comorbid physical illnesses (1). People with cluster B PDs are also high health care service users: in one year, 78% of them have consulted a family physician, 62% of them visited a psychiatrist, 44% were admitted into the emergency room, and 22% were hospitalized (1). This vital health care use translates into high treatment costs, ranging from $15,000 USD to $50,000 USD per patient every year (3, 4).

Furthermore, many studies have shown that PDs are often comorbid, particularly with borderline personality disorder (BPD) (2, 5). While studying BPD in isolation through randomized controlled trials helps optimize sample homogeneity and design targeted psychotherapeutic interventions, clinicians in real-world settings must frequently manage significant comorbidity, especially among Cluster B PDs. Furthermore, patients with comorbid PDs tend to have a poorer prognosis and are less likely to achieve complete symptomatic remission (6). Therefore, given the high mortality rates, healthcare service utilization, and unfavorable prognosis for patients with comorbid cluster B PDs, it is essential to study this population as a whole.

Mentalization-based therapy (MBT) and dialectical behavior therapy (DBT) are two evidence-based treatments designed for individuals with borderline PD (7, 8). MBT is grounded in psychodynamic theory and attachment theory, with a specific focus on mentalization (9). DBT is a type of cognitive-behavioral therapy that integrates Eastern mindfulness practices to enhance a person’s ability to regulate distress, accept experiences, and manage interpersonal emotions (10). While meta-analyses have established that these treatments have a moderate effect size (Setkowski et al., 2023), their implementation in real-world clinical settings presents several challenges. Patient populations are more heterogeneous, comorbidities are frequent, and therapists differ in their level of experience and training, especially in managing the clinical complexity of Cluster B PDs. Thus, although their efficacy is well established—and even explored in real-world settings for patients with borderline PD (11)—their efficiency in a broader PD population remains underexplored. Similarly, beyond the documented efficacy of specialized psychotherapies in research settings, treatment dropout has been the subject of numerous studies for borderline PDs (12). However, none have specifically focused on the population of individuals with Cluster B PDs.

In this retrospective, naturalistic study, we examine the outcomes of MBT and DBT as delivered in routine clinical practice for adult patients with predominantly BPD along with other Cluster B PDs. Specifically, we aim to describe pre-post differences of these treatments in a real-world setting by analyzing two key clinical indicators during the first year of therapy: the number of emergency department (ED) visits and psychiatric hospitalizations. These ‘hard outcomes’ are frequently used in the literature to evaluate clinical trajectories, with reductions typically reflecting a more favorable prognosis (11, 13, 14). Additionally, we investigate treatment completion rates by comparing dropout rates before and after the start of therapy. Given the naturalistic design, absence of a control group, and lack of a priori hypotheses, all findings are interpreted as associative and exploratory rather than as evidence of treatment effects or comparative effectiveness.

2 Methods

2.1 Study design and participants

This retrospective, naturalistic, and descriptive study was conducted in a real-world, clinical outpatient setting. We examined adults who have been referred to MBT or DBT from general psychiatrists or the ED after being admitted to the “Service des troubles relationnels et de la personnalité”, which is an outpatient clinic at the Institut Universitaire en Santé Mentale de Montréal, in Quebec, Canada, between January 1st, 2015, and December 31st, 2019. Most participants were diagnosed with at least one cluster B PD as their primary diagnosis. In some cases, patients with a PD not otherwise specified (NOS) or PD traits as their primary diagnosis were also admitted if it caused them significant distress or daily life dysfunction. The study’s population consisted of 363 participants, among whom 75 had dropped out before entering treatment modalities and were excluded from further analysis. The final treatment cohort consisted of 288 patients, which was used for descriptive analyses of treatment dropout following initiation. Analyses of emergency department visits and hospitalizations were further restricted to subgroups of patients who presented with at least each respective event in the observation period. All patient data were extracted from the DATA Bank, which includes all voluntary patients admitted to the outpatient clinic. Both the data bank and this specific study were reviewed and approved by the Research Ethics Board of the CIUSSS de l’Est-de-l’Île-de-Montréal., with which the Institut Universitaire en Santé Mentale de Montréal is affiliated, and the procedures followed were by the Helsinki Declaration as revised in 2013. Written informed consent for the use of clinical data was obtained from patients at admission, and the ethics board waived the requirement for additional consent specific to this retrospective analysis.

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Objective: This scoping review aims to synthesize the current literature on peer support interventions for individuals with BPD, focusing on their benefits, risks, and implementation challenges.

Methods: Following the Joanna Briggs Institute (JBI) methodology and PRISMA-ScR guidelines, a comprehensive search was conducted across six databases (Medline, PsycINFO, EMBASE, Cochrane Library, CINAHL, and Google Scholar) and grey literature sources. The inclusion criteria were defined using the Population–Concept–Context (PCC) framework. Eleven studies published between 2019 and 2025 were included. Data extraction focused on study design, participant characteristics, intervention content and structure, outcomes, and implementation challenges.

Results: Peer support interventions varied from structured and manualized programs to flexible and community-based formats. Reported benefits included improved emotion regulation, reduced isolation, enhanced empowerment, and increased hope. Peer workers also reported personal growth and a strengthened sense of purpose. However, challenges such as emotional exhaustion, role ambiguity, inadequate supervision, and limited engagement in online settings were frequently noted. Only a few studies included quantitative measures of symptom change, and methodological heterogeneity limited cross-study comparisons.

Conclusions: Peer support interventions show promising psychosocial benefits for individuals with BPD, particularly in domains related to relational connectedness, emotional coping, and subjective recovery. However, evidence remains limited by a lack of standardized models and rigorous evaluation. Future studies should employ mixed-method and controlled designs to better assess clinical outcomes and ensure safe, effective, and sustainable peer-led programs for this population.

 

1 Introduction

Borderline personality disorder (BPD) is characterized by emotional instability, tumultuous interpersonal relationships, marked impulsivity, intense fear of abandonment, and self-destructive behaviors (1). These symptoms can significantly disrupt daily functioning and diminish quality of life (2). Individuals living with BPD often struggle to maintain consistent relationships (3), manage daily responsibilities and regulate their emotions effectively (4, 5). These challenges can lead to considerable difficulties in various aspects of life, including their personal, social, and professional spheres, ultimately reducing their overall sense of fulfillment and well-being (6). Additionally, individuals with BPD are at increased risk for premature death, primarily due to elevated suicide rates and high burden of physical health complications (7, 8). BPD is estimated to affect approximately 1.9% of the general population (9) but accounts for 15–28% of patients in psychiatric settings, including clinics and hospitals, as well as a significant number of individuals seeking psychological support in general healthcare facilities (10).

1.1 Challenges in accessing and retaining effective treatment for BPD

Clinical guidelines generally recommend psychotherapy as the first-line treatment for BPD, with Dialectical Behavior Therapy (DBT) often highlighted, despite no consensus regarding the superiority of any psychological intervention (11). However, access to adequate treatment for BPD remains limited in most countries because of significant shortage of qualified professionals, insufficient funding and ongoing stigmatization of this population within the healthcare system (12–14). As a result, many individuals are left without access to the recommended care, as the demand for these services far exceeds the available supply (13). Individuals with BPD frequently report dissatisfaction with the services they receive, citing a significant disparity between their needs and the care provided, while also facing critical stigmatization (15). Although DBT and other psychotherapies are recognized as the most effective treatments, meta-analyses have shown only moderate effect sizes in reducing BPD symptoms with psychotherapy (16). Additionally, a meta-analysis indicates that the dropout rate for outpatient psychotherapies is 28.2% (17), highlighting the challenges of retaining patients in these therapeutic programs.

 

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CBT-I in Adults Suffering from Cluster B Personality Disorder and Insomnia: A Feasibility Study (INSOPERSO Study)

Résumé

Introduction

L’insomnie est hautement prévalente parmi les personnes vivant avec un trouble de la personnalité du groupe B (TPB). La thérapie cognitivo-comportementale de l’insomnie (TCC-I) est le traitement le plus recommandé pour l’insomnie persistante, mais aucune étude ne s’est penchée sur l’administration de cette modalité chez les patients avec un TPB. Cette étude vise à évaluer la faisabilité d’un programme de TCC-I pour cette patientèle.

Méthode

Il s’agit d’une étude pilote à devis mixte sans groupe contrôle. Vingt-deux participants souffrant d’insomnie et de TPB ont été recrutés au sein d’un programme spécialisé pour les troubles de la personnalité et ont suivi ce programme de TCC-I conçu spécifiquement pour cette patientèle. Les mesures quantitatives incluaient le taux de recrutement et de rétention ainsi que des questionnaires autorapportés évaluant l’insomnie et des comorbidités qui y sont associées. Les données qualitatives ont été recueillies par une discussion de groupe focalisée et des entrevues semi-structurées effectuées post-traitement.

Résultats

Vingt-deux participants ont été recrutés sur un objectif initial de vingt-quatre. Quatorze participants ont abandonné en cours de traitement pour un taux de rétention de 45 %. Une diminution significative de l’insomnie, de la dépression et de l’anxiété a été observée entre l’inclusion et trois mois après la fin de la thérapie. Par ailleurs, six grands thèmes ont été relevés, lors des entrevues qualitatives, auprès des quatre participants : le contenu, le fonctionnement, le thérapeute, la formule de groupe, l’effet de la thérapie et les facteurs influençant la motivation.

Conclusion

La présente étude pilote a permis d’établir qu’un protocole de TCC-I en groupe de courte durée pour cette clientèle est faisable, mais partiellement acceptable. Par ailleurs, les résultats préliminaires concernant l’évolution clinique sont prometteurs et concordent avec les données probantes existantes. Des améliorations méthodologiques sont prévues pour les recherches subséquentes, notamment l’intégration d’un groupe contrôle afin de renforcer la validité interne des conclusions.

Abstract

Introduction

Insomnia is highly prevalent among individuals with Group B personality disorders (GBPD). Cognitive-behavioral therapy for insomnia (CBT-I) is the most recommended treatment for chronic insomnia; however, no study has examined this approach in patients with GBPD. This study aimed to assess the feasibility of a CBT-I program for this patient population, focusing on acceptability, gathering preliminary measures of effectiveness, and collecting participant experiences to enhance treatment.

Method

This pilot study employs a mixed methods design without a control group. Twenty-two adult participants diagnosed with GBPD and experiencing insomnia were recruited from a specialized program for personality disorders. The four-session CBT-I program was specifically designed for patients with GBPD to enhance treatment retention and therapeutic response. Quantitative measures included recruitment and retention rates and self-administered questionnaires assessing insomnia and comorbidities, collected before, during and three months after treatment. Per protocol and intention-to-treat analyses were conducted on data from these questionnaires. Qualitative data were gathered through group discussions and semi-structured interviews, and the qualitative data were analyzed using thematic content analysis.

Results

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Comparison of social and clinical characteristics according to sex among individuals with cluster B personality disorder

Résumé

Introduction

Dans le domaine des troubles de la personnalité (TP) du groupe B, les études ont surtout porté sur le TP limite/borderline (TPL), incluant principalement les femmes. De plus, les études incluant divers TP du groupe B ont comparé quelques caractéristiques cliniques entre des hommes et des femmes, en particulier les symptômes, sans tenir compte de composantes sociales.

Objectifs

Cette étude visait à comparer les caractéristiques sociales et cliniques de femmes et d’hommes présentant un TP du groupe B, à partir d’une base de données d’un service dédié aux personnes vivant avec un TP.

Méthodes

Les variables cliniques examinées étaient : la gravité de la psychopathologie selon les intervenants et les symptômes perçus des TP. Ces dernières ont été mesurées avec des outils validés et entrées dans la base de données du service. Les variables sociales incluaient par exemple, le statut conjugal et le réseau social. Ces caractéristiques ont été colligées systématiquement à l’entrée des personnes dans le service. De plus, les buts de thérapie, faisant partie de l’évaluation initiale ont été comparés de manière qualitative.

Résultats

Sur le plan social, il n’y avait pas de différence statistiquement significative entre les hommes (n = 103) et les femmes (n = 283) concernant le statut conjugal, la scolarité, la source de revenus et le nombre de loisirs. Les hommes avaient un réseau social plus limité que les femmes (p < 0,001). Selon le Borderline Personality Questionnaire (BPQ), plus de femmes ont obtenu la cote du diagnostic de TPL que les hommes (p < 0,001). L’analyse des dimensions du BPQ a montré que les femmes avaient plus de symptômes dissociatifs (p = 0,04). Aussi, la proportion de femmes ayant consommé des substances dans le dernier mois était significativement plus élevée (p = 0,04). Concernant les thèmes des buts au préalable de la thérapie, ce qui était le plus fréquent chez les femmes était d’améliorer la relation avec soi et les autres. Chez les hommes, les buts touchaient surtout la relation avec les symptômes et les activités de la vie courante (ex., trouver un emploi, reprise d’habitudes de vie saines).

Conclusion

Cette étude poursuit la réflexion sur la prise en compte du sexe et du genre dans l’offre des services pour les personnes vivant avec un TP du groupe B. Même s’il y a plusieurs similitudes entre les hommes et les femmes, certaines différences sur le plan social soutiennent l’ajout d’interventions ciblant entre autres les habitudes de vie pour les hommes.

Abstract

Introduction

In the field of Cluster B personality disorders (PDs), studies have primarily focused on borderline personality disorder (BPD), predominantly including women. Moreover, studies comparing various Cluster B PDs have examined some clinical features between men and women, particularly symptoms, without considering social characteristics.

Objectives

This study aims to compare the social and clinical characteristics of women and men with Cluster B PDs, using a database from a specialized service for persons with a PD.

Methods

Clinical variables examined included the severity of psychopathology as assessed by clinicians and perceived PD symptoms. These were measured using validated tools and entered into the service’s database. Social variables included for example marital status and social network, and were systematically collected upon entry into the service. Additionally, therapy goals, part of the initial assessment, were qualitatively compared.

Results

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Impact of a French-speaking, international, and online training on personality disorder

Résumé

Contexte

Alors que la prévalence du Trouble de la Personnalité Limite (TPL) est élevée et qu’il est caractérisé par une importante sévérité, les personnes atteintes rencontrent souvent des obstacles à l’accès à des soins efficaces en raison de la stigmatisation dans les services de santé. Les formations sur le sujet jouent un rôle crucial pour améliorer la compétence des intervenants et changer leur regard sur les personnes vivant avec le TPL. Dans ce contexte, une équipe de professeurs a développé une formation en ligne autonome intégrant des témoignages de patients partenaires.

Objectifs

Évaluer la satisfaction des participants à cette formation, ainsi que l’impact sur différents domaines (perception et compréhension du TPL, impact sur leur pratique).

Matériels et méthodes

Étude transversale utilisant deux sondages auprès de l’ensemble des étudiants inscrits à un cours en ligne de janvier à septembre 2023. Outre une description des résultats des deux échantillons, nous avons réalisé une approche qualitative des réponses des participants aux questions ouvertes.

Résultats

En plus d’une importante satisfaction, nous avons retrouvé une augmentation du confort des apprenants avec les patients vivant avec un TPL après avoir suivi le cours en ligne. Les réponses qualitatives ont mis en évidence l’intégration de nouvelles approches thérapeutiques, une meilleure compréhension du TPL, une confiance accrue dans la prise en charge des patients, des changements concrets dans la pratique clinique, ainsi qu’une amélioration de la gestion des émotions.

Discussion et conclusion

Les participants au cours ont intégré plusieurs compétences, et la formation aurait amélioré la perception des personnes vivant avec un TPL chez les cliniciens, renforçant la compréhension, réduisant les préjugés, et favorisant une meilleure gestion émotionnelle. L’étude s’inscrit dans la littérature sur la pédagogie médicale en ligne. Bien qu’efficaces, elles doivent être considérées comme des stratégies complémentaires aux approches en présence.

Abstract

Context

While the prevalence of Borderline Personality Disorder (BPD) is high and it is characterized by significant severity, individuals affected often encounter obstacles to accessing effective care due to stigma in healthcare services. Training on the subject plays a crucial role in improving the competence of caregivers and changing their perception of individuals living with BPD. In this context, a team of professors developed an autonomous online training integrating testimonials from patient partners.

Objectives

To evaluate the satisfaction of participants in this training, as well as its impact on various domains (perception and understanding of BPD, impact on their practice).

Materials and methods

A cross-sectional study was conducted using two surveys among all students enrolled in an online course from January to September 2023. The first survey, conducted after the course, was gradually administered before the allocation of training credits, while the second, anonymous survey was distributed via the student forum, accessible to all enrolled students in September 2023, regardless of their stage of course completion. Sample 1, consisting of 32 respondents predominantly female (F/H ratio = 3.3), mainly comprised physicians (42.8%) working in a hospital setting (39.0%) and frequently exposed to individuals living with BPD. Sample 2, with 44 respondents, mainly included participants who had partially completed the course (61.4%) and had not participated in synchronous sessions (70.4%), with no data on socio-demographic characteristics.

Results

Sample 1, mainly composed of physicians working in hospital settings and frequently exposed to patients with BPD, reported an increase in their comfort with these patients after completing the online course, with high satisfaction both for the online format and the course length. Qualitative responses highlighted the integration of new therapeutic approaches, a better understanding of BPD, increased confidence in patient care, concrete changes in clinical practice, as well as improved emotional management and counter transference. Improvement suggestions included more in-depth content on comorbidities and therapies, aspects related to professional practice and external management, as well as particular attention to prevention and pharmacology. As for Sample 2, respondents’ satisfaction was high, emphasizing the expertise of the trainers, the variety of educational materials, the relevance and updating of the content, as well as the flexibility and accessibility of the course. Areas for improvement included lack of diversity of viewpoints, length and density of content, lack of associated resources and the ability to download course materials, as well as issues with audiovisual quality and use of sophisticated terms.

Discussion and conclusion

Participants have integrated several skills, and the training appears to have improved clinicians’ perception of individuals living with BPD, enhancing understanding, reducing biases and resistance, and promoting better emotional management. While the strengths of the training have been identified, improvements are needed, including greater diversity of perspectives and more effective management of content length and density. The study aligns with the literature on online medical education. Although online training can be effective, it should not completely replace traditional training and should be viewed as supplementary strategies. The study results are limited by a low response rate, but suggest that online training on BPD is feasible and effective, with implications for enhancing future courses and the need for further research to assess its impact on participants’ knowledge.
 
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Abstract

 

Methods: This open-label study recruited adults with BPD who were not undergoing psychotherapy. Participants completed informational psychoeducation sessions, followed by 10 daily sessions of 20-minute tDCS over 2 weeks. Stimulation involved a continuous 2-mA current with the anode over the left DLPFC and the cathode over the right DLPFC. During each session, participants simultaneously engaged in online cognitive training using the Lumosity app (aspredicted.org no. 206 001).

Results: We included 29 participants. We noted significant improvements in cognitive functions, including the Towers of London task (Cohen d = −0.38 to −0.78), the Corsi Block-Tapping direct and total scores (d = −0.41 and −0.42, respectively), and the Stroop Interference and Alternance tests (d = 0.80 and 0.94, respectively). Emotional dysregulation showed a substantial reduction (d = 0.44), while impulsivity did not change significantly. Symptoms of BPD decreased (d = 0.69), while general functioning (d = 0.33) and the internal component of BPD functioning improved (d = −0.51).

Limitations: Although these preliminary findings are encouraging, further controlled studies are necessary to validate the efficacy and long-term effect of the intervention.

Conclusion: This combined approach appears to be well tolerated and produced promising short-term improvements in cognitive performance, BPD symptoms, and overall functioning. The results underscore the relevance of the left DLPFC in developing neuropsychologically integrative interventions for BPD.

Introduction

Borderline personality disorder (BPD) is a mental disorder that exhibits instability in several domains, such as relationships, emotions, and self-perception.1 This disorder is also characterized by substantial impulsivity.1 Its prevalence is estimated at 1%–2% within the general population and around 15%–28% among patients with psychiatric conditions.2–4 Clinical research has advanced considerably in the symptomatic treatment of BPD, primarily through psychotherapy.5 However, although these treatments show moderate effect sizes in reducing symptoms, their overall influence on psychosocial functioning is generally regarded as limited.5,6

One possible explanation for this limited improvement is that these treatments primarily focus on emotions, relational patterns, and dysfunctional cognitive schemas without particularly targeting neuropsychological impairments.7 Although these factors are connected to psychosocial functioning, they may not fully account for it.7 Compared with the general population, people with BPD exhibit substantial neuropsychological impairments across multiple domains, particularly in cognitive flexibility, inhibition, and executive control.8 A meta-analysis by D’Iorio and colleagues8 found moderate-to-strong effect sizes in areas like executive functioning, working memory, decision-making, and sustained attention. Processing speed and visuospatial abilities showed smaller deficits, while memory — primarily verbal and spatial — exhibited significant levels of impairment.9–11 A meta-analysis by Ruocco and colleagues11 and a systematic review by McClure and colleagues12 both found that patients with BPD also experience notable difficulties in planning.13 These neuropsychological impairments are associated with daily functional challenges.8,14

Numerous studies have highlighted specific brain regions or networks that support these neuropsychological functions. 15 In BPD, neurobiological anomalies are linked to symptoms and cognitive dysfunctions, particularly corticolimbic alterations.16,17 Therefore, a central aspect of the neurobiological explanation for BPD involves functional and structural alterations of the dorsolateral prefrontal cortex (DLPFC), which plays a critical role in impulse control, cognitive functions, and emotional regulation.18,19 Findings about the lateralization of the DLPFC are yet to be specific to 1 side.18,19 The left DLPFC has been directly implicated in several studies specific to BPD, although the results are somewhat contradictory.18,20,21 Hypoactivation of the left DLPFC in BPD has been observed during reward-based tasks, reflecting a potential dysfunction in processing motivational salience or future-oriented behaviour, which contributes to impulsivity and difficulty in decision-making.18 This reduced activation impairs the DLPFC’s ability to modulate limbic and subcortical activity, which is essential for controlling impulsive behaviour.17,20–22 Interestingly, the left DLPFC may show heightened activation during tasks involving negative emotional stimuli and behavioural inhibition (e.g., aggression regulation), suggesting an overengaged cognitive control system in emotionally charged contexts, further complicating emotional regulation.18,20,21 Another study reported that people with BPD exhibit reduced bilateral DLPFC activation during negative emotion processing, suggesting a reduced capacity for cognitive control and the use of emotion regulation strategies, which are key features of the disorder’s cognitive dysfunction.18,23 In contrast, healthy individuals show more functionally distinct lateralization in the DLPFC, with the left DLPFC consistently engaged in working memory, stimulus interference control, planning, and proactive control, often without right DLPFC involvement, while the right DLPFC is associated with behavioural inhibition and impulse control during reactive tasks such as go/no-go or stop-signal paradigms.18,23,24

These findings have paved the way for new therapeutic approaches like neuromodulation. In the past decade, these methods have emerged to treat various mental health conditions.25 Notably, many neuromodulation studies in BPD have targeted the left DLPFC, particularly in protocols aiming to enhance regulatory capacities and cognitive functions.25 This focus highlights the potential functional relevance of the left DLPFC in treatment-oriented approaches. Among all these techniques, transcranial direct current stimulation (tDCS) is the most cost-efficient and logistically simple to administer, with the added advantage of potential for supervised home use.26 It applies a low electrical current to the scalp to modulate neuronal excitability and enhance cognitive functions.26,27 It has shown effectiveness for several mental illnesses, including major depressive disorder, anxiety disorders, obsessive–compulsive disorder, and bipolar disorder.26

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Abstract

Background/Objectives: Borderline Personality Disorder (BPD) involves emotional dysregulation, interpersonal instability and impulsivity. Although treatments have advanced, evaluating the latest innovations remains essential. This rapid review aimed to (1) identify and classify recent therapeutic innovations for BPD, (2) assess their effects on clinical and functional outcomes, and (3) highlight research gaps to inform future priorities. Methods: Employing a rapid review design, we searched PubMed/MEDLINE, PsycINFO, and Embase for publications from 1 January 2019 to 28 March 2025. Eligible studies addressed adult or adolescent BPD populations and novel interventions—psychotherapies, pharmacological agents, digital tools, and neuromodulation. Two independent reviewers conducted screening, full-text review, and data extraction using a standardised form. Results: Sixty-nine studies—predominantly from Europe and North America—were included. Psychotherapeutic programmes dominated, ranging from entirely novel models to adaptations of established treatments (for example, extended or modified Dialectical Behavior Therapy). Pharmacological research offered fresh insights, particularly into ketamine, while holistic approaches such as adventure therapy and digital interventions also emerged. Most investigations centred on symptom reduction; far fewer examined psychosocial functioning, mortality, or social inclusion. Conclusions: Recent innovations show promise in BPD treatment but underserve the needs of mortality and societal-level outcomes. Future research should adopt inclusive, equity-focused agendas that align with patient-centred and recovery-oriented goals, supported by a coordinated, integrated research strategy.

1. Introduction

Borderline Personality Disorder (BPD) is a severe and complex psychiatric condition characterised by pervasive instability in emotional regulation, interpersonal relationships, self-image, and impulse control. Individuals with BPD frequently experience intense affective lability, chronic feelings of emptiness, identity disturbance, and recurrent suicidal behaviour or self-injury [1]. Since the seminal study of Linehan [2], substantial progress has been made in the therapeutic management of BPD. A large body of evidence has supported the efficacy of structured psychotherapies [3], and new modalities—both psychological and biological—are continuously emerging. Our understanding of the underlying mechanisms of BPD, its clinical heterogeneity, and the impact on everyday functioning has significantly deepened [4,5]. This growing body of knowledge is now shedding lig on specific therapeutic targets [4,6,7]—mortality, symptoms, psychosocial functioning, and social inclusion—which will be explored in the following section, alongside emerging personalised interventions.
Among all treatment priorities, life expectancy stands out as the most fundamental. While death is an inherent part of life, the stark inequalities in life expectancy between individuals with BPD and the general population are both striking and unacceptable [8,9,10]. Reducing this gap is imperative because, without life, no other therapeutic goal retains its meaning. Historically, efforts to extend life expectancy have focused primarily on lowering suicide, which remains the most prominent cause of excess mortality in individuals with BPD compared to the general population [9,11]. Consequently, suicide prevention has become a central focus of numerous therapeutic interventions. While several treatments have demonstrated effects on suicidal ideation, self-injurious behaviour, and suicide attempts [3,12], it is important to recognise that no intervention to date has shown a definitive impact on reducing suicide mortality itself. Moreover, a critical but often overlooked reality is that most individuals with BPD ultimately die from physical health conditions—many of which are both preventable and more prevalent in this population than in the general population (e.g., cardiovascular disease, substance-related disorders, metabolic syndrome) [8,9].
Beyond its potential to mitigate mortality risks associated with both BPD and comorbid conditions, symptom reduction also addresses the core reasons individuals seek psychiatric care, making it a critical therapeutic priority. Treating BPD involves alleviating the emotional distress and functional impairments associated with core BPD symptoms, along with those stemming from common comorbidities. Over the past decades, most clinical studies have focused on reducing BPD symptomatology as the primary treatment target [3,13]. However, there is a growing recognition that comorbid conditions—such as depression, anxiety, PTSD, substance use disorders, ADHD and eating disorders—are not only highly prevalent in individuals with BPD [14], but also significantly influence clinical outcomes, including relapse [15], quality of life [16], and suicide risk [17,18]. Acknowledging the central role of comorbidities underscores the importance of considering their reduction and management as essential therapeutic outcomes.
The third level of treatment targets broader, person-centred outcomes such as quality of life, sense of purpose, functional recovery, and social integration. For many individuals with BPD, the pursuit of a fulfilling life—encompassing gratifying relationships, stable employment, meaningful activities and projects, and a coherent life narrative—remains a significant challenge [19] and a goal [20]. While symptomatic remission is often achievable, complete recovery, defined by both clinical and functional remission, is far less common [21]. Despite their importance, these outcomes have traditionally been treated as secondary endpoints in clinical research, often overshadowed by symptom reduction and safety measures. This raises important questions about treatment development and evaluation priorities: Are we aiming for mere symptom control or for the possibility of functioning optimally in everyday activities and thriving in a meaningful life? Addressing this gap calls for a shift toward long-term, holistic goals that reflect patients lived experiences and aspirations.
A fourth level of treatment targets operates at the interpersonal and societal level, reflecting the bidirectional relationship between individuals with BPD and their social environment. It is well established that early relational trauma—particularly during childhood and adolescence—plays a central role in the development of BPD [22]. Later in life, social stigma, especially within healthcare systems, can further exacerbate suffering and reinforce exclusion [23]. Conversely, BPD significantly affects others. As a disorder fundamentally rooted in interpersonal dysfunction, BPD can place considerable strain on families [24], partners, children [25], friends, and professional networks. At a broader level, the disorder poses challenges to healthcare systems and society, contributing to high rates of service use, emotional burden on caregivers, and workplace difficulties [26]. Acknowledging and addressing this social dimension is essential. Therapeutic innovations must not only aim to support the individual but also repair and strengthen social bonds, reduce stigma, and consider systemic impacts, ultimately fostering healthier relational ecosystems around the person with BPD.
While research continues to provide growing evidence on how best to treat individuals with BPD, efforts often remain fragmented. Each study pursues its own path, focusing on specific aspects of the disorder without contributing to a unified understanding. Despite the clinical and societal burden of BPD, research funding remains limited [27], and there is currently no coordinated strategy or collective roadmap to address the four central domains of treatment outcomes: premature mortality, symptom reduction, psychosocial functioning, and societal impact. This fragmentation also impacts clinical care [28]. People with BPD and their families consistently express a desire for high-quality, professional healthcare that is rooted in respect, compassion, and meaningful therapeutic relationships [29]. This rapid review examines whether current therapeutic innovations truly reflect and respond to the full complexity of BPD.
The objectives of this rapid review were threefold. First, to systematically identify and classify recent therapeutic innovations for BPD, including novel psychotherapies, pharmacological treatments, digital tools, and neuromodulation techniques, published between 2019 and 2025. Second, to evaluate how these interventions address key clinical and functional outcome domains, such as mortality (e.g., suicide prevention and reduction in physical health-related mortality), symptomatology (targeting core BPD symptoms and common comorbidities), psychosocial functioning (including recovery, quality of life, and global remission), and societal impact (such as stigma reduction, interpersonal relationships, and occupational functioning). Third, this review aimed to identify persisting research gaps and misalignments between current innovation trends and pressing therapeutic needs, to inform future research priorities and promote a more socially responsive and outcome-relevant research agenda.

2. Materials and Methods

2.1. Rapid Review Methodology

This study employed a rapid review approach, defined as a form of knowledge synthesis that accelerates the systematic review process by streamlining or omitting specific steps to deliver evidence in a resource- and time-efficient manner. As outlined by the Cochrane Rapid Reviews Methods Group [30], rapid reviews are beneficial when timely evidence is needed for urgent or high-priority decision-making. In this specific case, our goal was to provide our research community with timely insights so they could identify any potential gaps in the protocol and address them as needed. Methodological adaptations may include narrowing eligibility criteria, limiting the number of databases searched, simplifying screening and data extraction processes, and using single-reviewer approaches with verification.

2.2. Eligibility Criteria

  • Inclusion Criteria
    ○
    Population: Adults or adolescents diagnosed with BPD (DSM-5, ICD-10/11, or equivalent standardised diagnostic criteria).
    ○
    Intervention: Any intervention deemed innovative (mutual agreement at selection based on treatment development knowledge), including but not limited to novel pharmacological agents, new psychotherapeutic modalities, digital interventions, neuromodulation techniques, or microbiome-based approaches.
    ○
    Publications dated between 1 January 2019 and 28 March 2025.
    ○
    Original empirical studies of the following designs: randomised controlled trials (RCTs), quasi-experimental studies, feasibility or pilot studies, and prospective or retrospective observational cohorts.
    ○
    Language: Full-text articles published in English or French.
  • Exclusion Criteria
    ○
    Mixed-diagnosis populations without separate BPD results.
    ○
    Paediatric samples (<12 years).
    ○
    Non–peer-reviewed material (e.g., protocols, abstracts, editorials, letters, opinion pieces).
    ○
    Reviews without original data.
    ○
    Studies of other personality disorders without separate BPD analyses.

2.3. Search Strategy

An expert in mental health literature searching (MD) conducted comprehensive electronic searches across three databases: PubMed/MEDLINE, PsycINFO, and Embase. The goal was to identify all studies of innovative interventions for BPD published between 2019 and March 2025.
  • Keyword Development (Supplementary Materials)
    –
    Borderline personality disorder: Descriptors: “Borderline Personality Disorder” [Mesh] or keywords (titles abstracts): Borderline personality(ies), Borderline state(s)
    –
    Studies: Descriptors: “Clinical Study” [Publication Type] or keywords (titles abstracts): Clinical trial(s), Clinical study(ies), Randomised-control trial(s), Observational study(ies)
  • Search Documentation and Management
All search results were imported into Covidence, where duplicate records across databases were automatically identified and eliminated. A master list of unique citations was maintained, with each entry annotated based on its database of origin.

2.4. Study Selection

Two reviewers (SS and LC) independently screened all titles and abstracts for potential inclusion. Each reviewer applied the predefined eligibility criteria. Conflicts at the title/abstract stage were resolved by consensus. Studies that passed title/abstract screening underwent a full-text review by SS and LC. During full-text review, reasons for exclusion (e.g., incorrect population, out-of-scope interventions such as non-innovative treatments, non-empirical studies) were documented in a standardised exclusion log. The overall selection process is illustrated in a PRISMA flow diagram (Figure 1).
Brainsci 15 00827 g001
Figure 1. PRISMA flow-chart.

2.5. Data Extraction

A standardised data extraction form was developed in Covidence. A first extraction was performed using ChatGPT 04-mini (prompt in Supplementary Materials), and then manually verified (LC).
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