The Diagnostic and Statistical Manual of Mental Disorders the fifth edition (1) describes Borderline personality disorder (BPD) as “a pervasive pattern of instability of interpersonal relationships, self-image, and marked impulsivity, beginning in early adulthood and present in a variety of contexts.” BPD is diagnosed in about 6% of primary care patients (2) and in community-based samples with a prevalence of 15–20% of patients in psychiatric hospitals and outpatient clinics (3).

Despite increased awareness, evidence suggests that a sizable proportion of individuals with BPD remain misdiagnosed, undiagnosed, and under-treated (4, 5). Studies show that persons meeting symptoms of BPD and seeking psychiatric treatment may be diagnosed and treated for Axis 1 comorbidity alone or are told that they have a disorder other than BPD, such as bipolar disorder (4).

The importance and relevance of disclosing the diagnosis is immense. One study found that when individuals diagnosed with BPD are educated about the disorder and given new coping strategies, the severity of symptoms decreases over 16 weeks (6).

There have been few studies investigating the extent to which psychiatrists disclose a diagnosis of BPD to their patients. A study examined how psychiatrists disclosed several psychiatric diagnoses and showed that there was a reluctance to disclose BPD compared to other conditions, such as bipolar, panic, and depressive disorders (7). A study by Clafferty and colleagues (8) compared disclosure practices across several diagnoses and found that 90–98% felt comfortable disclosing unipolar depression, bipolar disorder, anxiety disorder, and substance use disorders. However, only a minority (42%) revealed the diagnosis of personality disorder.

Studies on personality disorders have come a long way from justifying their existence in the Indian context (9) to disorders that are acknowledged to be causing significant morbidity (10). However, research into personality disorders in India is still at a nascent stage. In the International Pilot Study of Personality Disorders (IPSPD), the personality disorders frequently seen in the clinical sample in South India were schizotypal (19.1%) and borderline (14.7%) (11). To our knowledge, there are no studies on the diagnostic and management practices for BPD in India as yet.

This study aims to understand the BPD diagnostic and management practices and the practice of sharing diagnoses with patients and caregivers by psychiatrists in India, including the factors influencing this.

Demographic data was analyzed using descriptive statistics, including the mean with standard deviation (SD) for continuous variables and frequencies and percentages for categorical variables. The chi-square test was performed to determine the association between categorical variables and the outcome (e.g., sharing a diagnosis with persons: Yes vs. No groups). Continuous variables were compared across the groups using an independent t-test. Data was analyzed using STATA version 16.1 software (12).

A total of 302 participants completed the online survey. Six responses were excluded as the participants were not currently practicing in India.

Table 1 describes the demographic and clinical practice details of the participants.

The respondents had a mean age of 40.93 ± 10.56 with a slight male preponderance (54.7% male), with 13.97 ± 10.53 years being the mean duration of clinical practice. Only 6.1% were trainees, and the rest were all practicing psychiatrists. As seen in the figure (see supplementary material), many participants were from the states of Tamil Nadu, Karnataka, Kerala, and Maharashtra, which are in the southern half of India.

The commonest reasons reported by the participants for sharing the diagnosis with persons and families are for families to support persons better (255/296), explain the need for follow-up and long-term treatment (243/296), help persons understand what is happening to them (237), discuss management (227), and for medicolegal reasons (67).

The three most commonly cited reasons for psychiatrists not sharing diagnoses in descending order of frequency are uncertainty about diagnosis (119/296), worry about misuse of diagnosis by persons with BPD and families (80/296), and stigma (64/296).

Medications (86.1%) and psychological therapies (86.8%) are the most commonly used treatment options, followed by the respondents. Psychiatrists provide self-harm management (73.3%) and crisis management (70.9%). Inpatient treatment (27.7%) and referral to other practitioners (8.8%) are the other management practices adopted by the psychiatrists.

Psychiatrists have various options to choose from for therapies like supportive psychotherapy (n = 189; 63.9%), dialectical behavior therapy (DBT) (n = 177; 59.8%), cognitive behavior therapy (CBT) (n = 133; 44.9%), and family therapy (n = 126; 42.6%). Eclectic therapy (n = 87; 29.3%), mentalization based therapy (MBT) (n = 41; 13.9%) and psychodynamic psychotherapy (n = 41; 13.9%) are also available. Just under 50% of the participants (n = 143) reported that therapies were delivered by both themselves and the psychologists. Other respondents either delivered therapy themselves (n = 61; 20.6%) or referred to a psychologist (n = 85; 28.7%) for therapy.

The psychiatrists who completed the survey were more confident in diagnosing BPD compared to managing BPD, as shown in Table 3.

Challenges encountered by psychiatrists when managing persons with BPD that affect their diagnostic and management practice included dysfunctional coping (72%), self-harm (69.6%), family conflicts (67.6%), countertransference (48%), and mistrust (42.9%). The other less reported challenges include idealization (23.6%), splitting staff (25%), devaluing people (29.4%), and trauma (26.4%).

To the best of our knowledge, this is the first study in India to explore the diagnostic and management practices of psychiatrists for BPD. While there are reservations about using online surveys (14), this was the best way to reach out to psychiatrists in different parts of the country, given the limitations of having a contact list for all the psychiatrists in the country in one place. Further restrictions were posed by the COVID-19 pandemic, rendering postal services unreliable for the study.

The clinical practice guidelines (15) advise using structured interviews or assessment scales to diagnose personality disorders. Our study shows that around one-third of psychiatrists use psychometric tests to diagnose, while the remaining rely on clinical history from the patient and their family. The guidelines also say that psychotherapeutic options should be at the center of the management of patients with BPD. Our survey shows that psychiatrists do use psychotherapeutic modalities themselves or practice collaboratively by referral to psychologists. Because most respondents were from an urban background, access to resources like psychologists might have been better. MBT and psychodynamic psychotherapy are reported to be used less commonly compared to other therapies like DBT. The lesser use of the above therapies might be due to the non-availability of certified professionals, lack of training, and cost and time involved in training and delivering the interventions. Uptake of therapies, even if available, might also have been a challenge.

The report of the use of medications in persons with BPD appears relatively high. The reasons for the higher use of medications will need to be explored through further studies to understand the reasons behind this. They could be addressed through specific training in BPD assessment and management.

While the clinicians appear to be very confident in diagnosing BPD, the confidence seems to be less in managing the disorder. The clinicians who participated in the study reported that their main training in BPD was during the psychiatry residency period. As postgraduate trainees report less adequate training and supervision in BPD (16), this might be why the confidence level in management could be lower in the study respondents.

The Clinical Practice Guidelines for Assessment and Management of Patients with BPD (15) also recommends that sharing a diagnosis is important for a therapeutic relationship and to support psychoeducation. With collaborative decision-making and a patient-participatory approach to treatment being recognized as necessary, the findings of our study indicate that psychiatrists in India are sharing diagnoses with their patients most of the time in keeping with the guidelines. Psychiatrists who are more confident in diagnosing and managing BPD and when they perceive the sharing to be helpful are more likely to share the diagnosis with patients. Clafferty et al. (8) found the rate of disclosure of personality disorder as a diagnosis was 42% as compared to 90-98% of other Axis 1 psychiatric illnesses. Studies done by McDonald-Scott in 1992 (7) reported that 55% of American psychiatrists and 16% of Japanese psychiatrists would inform patients of a BPD diagnosis. The disclosure rates in our study are similar to those of American psychiatrists (56.4%).

The significant reasons indicated as to why the diagnosis could not be shared were uncertainty about the diagnosis, stigma, and worry about misuse of the diagnosis by persons with BPD and their families. A survey of 134 psychiatrists conducted in the US (2) found that uncertainty about diagnostic validity and stigma were the two leading causes of not disclosing or documenting a diagnosis of BPD. A review of literature by Lequesne et al. (17) done in 2003 reported that uncertainty regarding the validity of the BPD diagnosis, the feeling that the diagnosis is too negative to divulge (stigma), and worries that such a diagnosis would have deleterious effects on the patient’s health and morale were major reasons for not disclosing the diagnosis. While the factors cited by psychiatrists in our study are not dissimilar to other studies, the unique factor of worry about misuse of diagnosis by families is reflective of the cultural aspects of medical care in India.

The surveyed psychiatrists are seeking increased emphasis on practical hands-on workshops aimed at the diagnosis and management of BPD in the future. Masland et al. (18) found that even a 1-day training event on general psychiatric management changed the attitude of clinicians towards BPD.

While many surveyed psychiatrists expressed a demand for specialized services to handle BPD cases, the small number of respondents necessitates further surveys among psychiatrists and psychiatric trainees to know if this need is widely felt.

This study contributes to the BPD research about Indian psychiatrist practices in diagnosis and management. The discrepancy in the confidence level of diagnosing and managing BPD can be bridged by conducting good quality practical hands-on workshops focussed on the management of BPD for trainees and practising psychiatrists. Practical workshops will ensure that psychiatrists are able to provide good quality care to persons with BPD. As the responses predominantly reflect practices in South India, further studies are required to determine whether patterns are similar in other parts of India. Future research should also explore patient perspectives on diagnosis and management practices.

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

SRF-CR/12/JUL-2021

All authors have contributed significantly to this work.

Obtained electronically from all participants.