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Characteristics and outcomes of individuals screening positive for borderline personality disorder on an adult inpatient psychiatry unit: a cross-sectional study
BMC Psychiatry volume 25, Article number: 452 (2025)
Abstract
Background
Outpatient psychotherapies are gold standard interventions for borderline personality disorder (BPD); however, in clinical reality, higher rates of psychiatric hospitalization and more severe symptoms, including suicidality and self-harm, occur for those with BPD compared to those with other psychiatric disorders in inpatient units.
Methods
This study aims to distinguish the clinical profile and outcomes of patients screening positive for a threshold of BPD traits in the inpatient psychiatric setting using the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD), from those who do not.
Results
Compared to those screening negative on the MSI-BPD (MSI-BPD-), those who screen positive (MSI-BPD +) are younger, more likely to be female, and more likely to report a range of health and psychosocial risk factors such as unstable housing, reduced educational attainment, physical health problems, past trauma, and problematic drug and alcohol use. MSI-BPD + patients report significantly higher severity of anxiety, depression, suicidality, self-harm, and global symptoms on admission than MSI-BPD- patients. In terms of response to inpatient care, they also self-report significantly greater improvements and higher proportions of reliable change on measures of anxiety, depression, and general psychiatric severity. At discharge, MSI-BPD + patients no longer report significantly higher suicidality but do report greater levels of thoughts of self-harm.
Conclusions
These findings suggest that patients with self-reported BPD symptoms experience acute symptom relief during short-term inpatient hospitalization, including for suicidality-related symptoms. Our study also demonstrates the feasibility of utilizing the MSI-BPD screening tool within a large adult inpatient psychiatric population to identify individuals likely to have BPD with distinct clinical profiles.
Background
Borderline personality disorder (BPD) exacts a significant personal and societal price [1, 2]. Characterized by self-destructive impulsivity, emotional dysregulation, interpersonal dysfunction, and identity disturbance [3], BPD is associated with worse mental, physical, and behavioral outcomes, including a higher incidence of co-occurring psychiatric illnesses, greater risk-taking behavior, and worse functional outcomes such as higher economic stress [4, 5]. Suicidal behavior is common among patients with BPD, resulting in an estimated 75% lifetime incidence of a suicide attempt among patients with BPD. Approximately 10% of patients with BPD complete suicide [6, 7]. Personality disorder-specific features such as frantic efforts to avoid abandonment, emptiness, and identity disturbance predict suicide attempts [8].
Due to its elevated suicide risk and complex pattern of comorbidity, BPD’s prevalence in psychiatric settings is disproportionately high, estimated at 12% in outpatient and 22% in inpatient psychiatric care settings [9]. Patients with BPD are more likely to be admitted for inpatient hospitalization than patients with other personality disorders [10, 11]. Additionally, patients with high utilization of inpatient psychiatric hospitalization are more likely to meet criteria for BPD diagnosis [12]. Despite high frequency contact with intensive psychiatric services, underdiagnosis is common for BPD. Many patients revolve through acute episodes of care without a formal diagnostic disclosure of BPD, which could organize more effective, longer-term treatment recommendations as well as expectations regarding treatment response to interventions such as medications [13,14,15]. A study of the prevalence of BPD among suicidal patients on an inpatient psychiatric unit reported that approximately half of all patients met criteria for BPD, yet 68% were undiagnosed [16]. Furthermore, this study reported that patients with BPD were distinguished by younger age, greater levels of depression and suicidality, more medications despite there being no medication approved by the Food and Drug Administration (FDA) for BPD, and three times greater likelihood of readmission to the unit than inpatients without BPD.
These facts illustrate a salient clinical paradox in the clinical management of BPD: inpatient hospitalization is not recommended as a definitive treatment for BPD, but is frequently employed, sometimes leading to reinforcement of repeated usage of this level of care without connection to optimal care. While the existing literature on inpatient hospitalization outcomes for BPD is limited [17], some research suggests that inpatient hospitalization yields more dramatic improvements on depression for patients screening positive for BPD than for those who do not [18]. National clinical guidelines recommend shorter hospitalizations for patients with BPD due to risk of regression [19,20,21]. Recent expert-led overviews on the clinical management of BPD advocate for inpatient hospitalizations to address crises related to suicide attempts, serious self-destructive high-risk behaviors, and uncontrolled aggression towards others [22]. More generalizable research is needed on the parameters of enhancing effective inpatient management of BPD.
Validated assessment tools for detecting BPD are needed to study the effects of inpatient hospitalization for BPD in general psychiatric hospital services, where semi-structured interviews for diagnostic assessment are rarely feasible given the brevity of average lengths of stay combined with the resources such assessments would require. Low burden, widely relevant screening instruments are commonly used in large hospital services [23]. Several validated self-report tools have been developed to advance accurate diagnosis through efficient screening for BPD [24,25,26]. Of these, the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) is among the most frequently used [27, 28], in part because it simply utilizes the diagnostic features of BPD in the Diagnostic Statistical Manual (DSM-5) [3], which most clinicians will use to determine diagnosis in routine psychiatric care. To date, there has been limited research utilizing MSI-BPD in adult inpatient settings to characterize patients with and without BPD features. To our knowledge, only two studies have assessed the relationship of MSI-BPD to outcomes, namely suicide attempts and depression [18, 29], although a handful of additional studies have analyzed changes in symptoms during hospitalization among patients with any personality disorder [30,31,32,33]. Some of this literature indicates that patients with personality disorders have more severe symptoms at intake than other hospitalized patients [30, 32] and that their symptoms improve during hospitalization [18, 32]. In contrast, other evidence suggests that the extent of symptom improvement during hospitalization is reduced for patients with personality disorders relative to other patients [30, 31]. A more recent review [17] of crisis intervention for people with personality disorders concluded that the existing literature on acute hospitalization for people with personality disorders is small and does not yet provide sufficient evidence to conclude that this form of treatment is helpful or harmful. Four studies identified in this review found that patients’ symptoms improved over the course of inpatient hospitalization, and none found evidence of symptoms becoming worse.
There is a need for further study of the effects of inpatient hospitalization for BPD. This study aims to: 1) examine the feasibility and utility of MSI-BPD in identifying demographically and clinically distinct segments in a large adult inpatient population and 2) characterize the differing presentation and trajectory of a range of clinical outcomes among adult inpatients screening positive and negative for BPD. We hypothesized that, in alignment with the limited existing literature, patients screening positive for BPD would endorse higher severity on symptoms of depression, anxiety, suicidality, and self- harm, and we anticipated larger relative improvement in symptoms across a hospitalization [16, 18].
Methods
Subjects
Between September 2020 and February 2022, 1,034 adults who were admitted to a Division of Depression & Anxiety Disorders (DDAD) short-term inpatient unit at McLean Hospital participated in the Clinical Measurements Initiative (CMI) data collection process. Among the several specialized units at this free-standing psychiatric hospital, the short-term unit provides generalist care mostly for first episode and often undiagnosed individuals with mood and anxiety disorders without major psychotic features. The inpatient treatment reflects usual inpatient care that is not diagnostically specialized. Self-assessments were predominantly administered on electronic tablets (Apple iPads) or desktop computers using Research Electronic Database Capture (REDCap) in line with previous work describing the development and implementation of standardized patient-reported clinical measurements [33,34,35]. Acute mania, paranoia, and cognitive impairment per clinical staff report were exclusionary due to possible effects on self-reported symptoms.
Clinically eligible patients were approached to complete self-assessments within 48 h of admission and discharge by dedicated research staff. To best capture pre- and post-treatment states, assessments collected outside of 48 h of admission or discharge, typically due to clinical and operational limitations, were excluded (n = 191). Pre-treatment measures were collected on the first business day following the day of each patient’s admission; all discharge assessments were collected no earlier than one day prior to discharge, and no assessments included in this analysis were collected after discharge. Verbally administered assessments were also excluded (n = 6). Additionally, assessments collected on readmission (n = 84) were excluded from these analyses to avoid sampling error. Thus, the initial self-assessment completion of 753 individuals were included in these analyses. (See Fig. 1.)
This study and retrospective analysis of these data were classified as exempt and approved by the Mass General Brigham Institutional Review Board as a part of routine clinical quality assurance. This study was not pre-registered.
Measures
Demographics
Age, sex, gender, ethnicity, race, highest educational level, marital status, present and past housing history, and current employment were obtained by self-report on admission. History of psychiatric hospitalization, being currently the recipient of primary health care, and self-reported physical health status were additionally collected.
Borderline personality disorder
The McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) is a validated 10-item, true–false self-report assessment found to have good sensitivity (0.81) and specificity (0.85) in the original study of the measure [25]. The 10 items represent each of the 9 DSM-5 criteria, with the transient stress-induced paranoia and dissociation criteria being split between two questions on the MSI-BPD. Possible scores range from 0 to 10, with a score of 7 or above interpreted as highly suggestive of borderline personality disorder [25]. Those screening positive for BPD are referred to below as MSI-BPD +, and those screening negative for BPD are referred to below as MSI-BPD-. While the original study of MSI-BPD did not set a reference timeframe (e.g., past month, past year), in this study participants were asked to endorse items on the assessment based on the past week.
In line with previously published studies utilizing the MSI-BPD in acute psychiatric settings, we minimized construct overlap related to suicidality and self-harm for which many patients on this unit are admitted in crisis by removing the suicide and self-harm item from the MSI-BPD for certain analyses and setting a cutoff of 6 or higher for a positive screen [28, 36]. We refer to this as the modified MSI-BPD score.
Additional measures
As with previous work [33,34,35], additional self-report instruments were administered. The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) [37, 38], the Drug Abuse Screening Test (DAST-10) [39], and the Posttraumatic Stress Disorder (PTSD) Checklist for the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) (PCL-5) were administered at admission. The Generalized Anxiety Disorder 7-item scale (GAD-7) [40], the Quick Inventory of Depressive Symptomatology (QIDS) [41], and the Behavior and Symptom Identification Scale (BASIS-24®) were administered at admission and discharge. The suicidality item within the QIDS asks if the patient has “Thoughts of death or suicide”. Suicidality and self-harm questions within the BASIS-24 are “Think about ending your life?” and “Think about hurting yourself?”, respectively.
Statistical methods
Statistical analyses were performed with RStudio (RStudio Team, 2022), running R 4.2.1 for Windows [42]. All tests were two-tailed, and significance was defined as p < 0.05. Chi- squared tests and t-tests examined the bivariate associations between variables. Linear and logistic multivariate regressions were used to control for potential confounding. We constructed multiple linear regression models to estimate the effect on outcomes of interest (i.e., symptom severity on admission, symptom severity on discharge, and change in symptom severity from admission to discharge) associated with MSI-BPD status, first unadjusted, then adjusted for other clinical and demographic variables. We developed our model using purposeful selection of variables [43, 44]. We identified candidate covariates as variables with p < 0.05 on more than half of the univariate tests of each covariate against admission for the GAD-7, QIDS, and BASIS-24 and added these to our model. We retained only variables that were significant at an alpha level of 0.10 or were confounders (their removal changed any parameter estimate by ≥ 20%). The variables meeting these criteria were: sex, DAST-10, and PCL-5.
Changes from admission to discharge in the GAD-7, QIDS and BASIS-24 were assessed using the Reliable Change Index (RCI), a measure of the extent to which the change in an outcome for an individual is beyond what is attributable to measurement variability of the instrument [45, 46]. For the calculation of reliable change, we used the following Cronbach’s coefficient alphas: 0.92 for the GAD-7 [40], 0.69 for the QIDS [47], and 0.75 for the BASIS-24 [48].
We also considered the MSI-BPD score as a continuous measure, regressing it (crude and adjusted as above) against baseline QIDS score at admission, upon discharge, and the difference between them.
Results
Demographic characteristics
Out of 753 admitted patients who completed the self-assessment battery, 98% (n = 736) completed the MSI-BPD. Among these patients, 26.4% (n = 199) screened positive for BPD traits on the MSI-BPD and had a significantly higher average MSI-BPD score of 8.13 ± 1.06 compared to the negative group mean of 3.32 ± 1.92 (p < 0.001; See Table 1). Based on these averages, participants in the MSI-BPD + group self-report more than threshold level symptoms to meet diagnostic criteria for BPD < while those in the MSI-BPD- group do not. The 17 patients who did not complete the MSI-BPD were excluded from further analysis.
Individual items on the MSI-BPD were endorsed by a majority of the patients who screened positive (See Table 2). The mood-related features of BPD (e.g.,emptiness, mood dysregulation, and anger) were reported by a majority of participants in this acute care setting in the MSI-BPD + group. Diagnostically specific features such as identity disturbance (items 7 and 9) and instability of interpersonal relationships (items 1 and 10) were endorsed by over two-thirds of participants in the MSI-BPD + group.
In the sample, age at admission ranged from 17 to 79 years. MSI-BPD + patients were younger with a mean age of 29.5 ± 11.9 years relative to MSI-BPD- patients with a mean age of 34.8 ± 14.6 years (t = 4.98, df = 433.25, p < 0.001). A significantly higher proportion among MSI-BPD + patients were female by sex (56.3%) than among MSI-BPD- patients (χ2 = 4.49, df = 1, p = 0.04). MSI-BPD + patients had lower educational attainment relative to MSI-BPD- patients (χ2 = 8.46, df = 1, p = 0.004), and the difference remained significant when controlling for age (exp(β) = 0.62, p = 0.015). Patients screening positive for BPD were also more likely to have never been married than those screening negative (Fisher’s exact test, p = 0.007), but the difference was no longer significant after controlling for age (exp(β) = 0.88, p = 0.60). The MSI-BPD + group had lower rates of stable housing (Fisher’s exact test, p = 0.005). While MSI-BPD + patients reported similar rates of unemployment relative to MSI-BPD- patients, they were more likely to report part-time rather than full-time employment (χ2 = 10.18, df = 2, p = 0.006).
Length of stay
The mean length of stay was not statistically different between MSI-BPD + (13.4 ± 16.1 days) and MSI-BPD- (12.2 ± 14.5) patients (t = −0.84, df = 262, p = 0.40). Median length of stay for both groups was eight days (range 0–131 days). Patients staying 1.5 standard deviations or more above the mean length of stay were considered length of stay outliers (LOS outliers). The average stay for LOS outliers (n = 21) was 56.9 ± 25.5 days, significantly higher than non-outliers whose average stay was 9.46 ± 6.93 days (t = −11.15, df = 35.36, p < 0.001). Between length of stay outliers and non-outliers, there was no statistical difference in the percentage of patients screening positive on the MSI-BPD (χ2 = 0.01, df = 1, p = 0.95). LOS outliers did not report significantly different change in symptom severity from admission to discharge than non-outliers (GAD-7: t = −0.03, df = 37.24, p = 0.97; QIDS: t = 0.80, df = 38.93, p = 0.43; BASIS-24: t = −0.58, df = 37.51, p = 0.57; QIDS Suicidality: t = 0.15, df = 42.40, p = 0.88; BASIS-24 Suicidality: t = 0.31, df = 33.57, p = 0.76; BASIS-24 Self-harm: t = −1.16, df = 37.07, p = 0.25); however, LOS outliers were significantly less likely to endorse the MSI-BPD items related to other impulsivity (t = 2.65, df = 41.56, p = 0.01) and extreme moodiness (t = 2.11, df = 37.24, p = 0.04).
Clinical measures at admission
Among the MSI-BPD + group, the mean score on the MSI-BPD was 8.13 ± 1.06, and among the MSI-BPD- group, the mean score was 3.32 ± 1.92 (t = −43.06, df = 628.76, p < 0.001). Thirty-one percent of patients in the MSI-BPD + group reported having been hospitalized in the past six months, significantly higher than patients in the MSI-BPD- group (22.7%) (χ2 = 4.41, df = 1, p = 0.04), and they reported worse physical health (χ2 = 30.08, df = 4, p < 0.001). MSI-BPD + patients also reported higher likelihood to meet DSM-5 criteria for PTSD (χ2 = 52.73, df = 1, p < 0.001), higher likelihood of problematic drug use (χ2 = 35.16, df = 2, p < 0.001), and higher likelihood of hazardous or harmful drinking (χ2 = 8.33, df = 2, p = 0.02).
At admission, the MSI-BPD + group scored significantly higher on anxiety, depression, and global symptoms (GAD-7: t = −12.08, df = 502.73, p < 0.001; QIDS: t = −10.69, df = 438.32, p < 0.001; BASIS-24: t = −15.78, df = 389.23, p < 0.001). The differences for all three measures remained significant when controlling for sex and positive screens for substance use and meeting DSM-5 criteria for PTSD (GAD-7: adjusted R2 = 0.22, p < 0.001; QIDS: adjusted R2 = 0.26, p < 0.001; BASIS-24: adjusted R2 = 0.42, p < 0.001).
Suicidality at admission was higher among MSI-BPD + patients both in the QIDS (χ2 = 34.84, df = 3, p < 0.001) and the BASIS-24 (χ2 = 68.09, df = 4, p < 0.001). MSI-BPD + patients endorsed thoughts of self-harm on the BASIS-24 at higher rates than MSI-BPD- patients (χ2 p < 0.001). For all measures of suicidality and self-harm, the differences remained significant when using the modified MSI-BPD score and controlling for sex and positive screens for substance use and meeting DSM-5 criteria for PTSD (adjusted R2 = 0.08, p < 0.001; adjusted R2 = 0.15, p < 0.001; adjusted R2 = 0.13, p < 0.001, respectively).
Considered as a continuous variable, the MSI-BPD score was statistically significantly associated with a higher baseline QIDS score (crude model α = 10.64 [p < 0.0001], β*MSI-BPD = 1.05 [p < 0.0001], R2 = 0.27; adjusted model α = 11.59 [p < 0.0001], β*MSI-BPD = 0.99 [p < 0.0001], β*sex = −1.68 [p < 0.0001], R2 = 0.28).
Clinical measures at discharge
At discharge, patients in the MSI-BPD + group still had significantly higher anxiety, depression, and global symptom scores relative to the MSI-BPD- group (GAD-7: t = −3.63, df = 264.38, p < 0.001; QIDS: t =—3.15, df = 257.66, p = 0.002; BASIS-24: t = −6.03, df = 243.19, p < 0.001); however, the differences in the GAD-7, QIDS, and BASIS-24 scores at discharge were no longer significant when controlling for scores at admission (adjusted R2 = 0.19, p = 0.93; adjusted R2 = 0.16, p = 0.07; adjusted R2 = 0.26, p = 0.65; See Fig. 2).
Symptom Severity at Admission and Discharge by MSI-BPD Screening Status. Plots indicate average score at admission and discharge with the bars representing the MSI-BPD + and MSI-BPD with error bars for standard error. MSI-BPD, McLean Screening Instrument for Borderline Personality Disorder; MSI-BPD +, respondents who endorsed 7 or more items on the MSI-BPD; MSI-BPD-, respondents who endorsed 6 or fewer items on the MSI-BPD
MSI-BPD + patients no longer had a significant difference in scores on the QIDS measure of suicidality at discharge relative to MSI-BPD- patients (Fisher’s exact test, p = 0.23), even when using the modified MSI-BPD score (Fisher’s exact test, p = 0.14; see Figs. 3 and 4). As seen in Fig. 4, of the 154 MSI-BPD + patients who completed the QIDS suicidality measure at both admission and discharge, 55% (n = 85) reported one of the two most severe levels of suicidality at admission, but only 13% (n = 20) did so at discharge. At discharge, 67% (n = 103) of MSI-BPD + patients reported no suicidality on the QIDS measure. At discharge, only two patients (1.3%) reported having thoughts of death or suicide several times a day.
Suicidality and Self-Harm Symptom Severity at Admission and Discharge by Modified MSI-BPD Screening Status. Plots indicate average score at admission and discharge for each group with error bars for standard error. MSI-BPD, McLean Screening Instrument for Borderline Personality Disorder; MSI-BPD + (excl. suicide/self-harm), respondents who endorsed 6 or more items on the MSI-BPD, excluding the item related to suicide and self-harm; MSI-BPD- (excl. suicide/self-harm), respondents who endorsed 5 or fewer items on the MSI-BPD, excluding the item related to suicide and self-harm
Change in Suicidality on QIDS among MSI-BPD + Patients. Alluvial plot of the relative frequency of different levels of suicidal ideation reported in the MSI-BPD + group at admission and discharge. Four outlined sections represent the four levels on the suicidality scale at each timepoint. Colors represent reported level at baseline. The vast majority of patients who endorsed the highest level of suicidal ideation at admission improved by at least one category by discharge. Most improved by two or more categories
MSI-BPD + patients did endorse significantly higher suicidality (Fisher’s exact test, p = 0.02) and self-harm (Fisher’s exact test, p < 0.001) on the respective items in the BASIS-24, including when using the modified MSI-BPD score (Fisher’s exact test, p = 0.03; Fisher’s exact test, p = 0.001).
Across the six clinical outcome measures, patients screening positive on the MSI-BPD showed significantly higher improvement on all measures (p < 0.001 for all) during hospitalization, but no significant effect remained after controlling for scores at admission for each measure (GAD-7: adjusted R2 = 0.37, p = 0.93; QIDS: adjusted R2 = 0.34, p = 0.57; BASIS-24: adjusted R2 = 0.37, p = 0.65; QIDS Suicidality: adjusted R2 = 0.54, p = 0.07; BASIS-24 Suicidality: adjusted R2 = 0.70, p = 0.17; BASIS-24 Self-harm: adjusted R2 = 0.55, p = 0.59). There was not a significant interaction between baseline symptom severity and MSI-BPD screening for any of the symptom measures examined.
Considered as a continuous variable, after covariate adjustment, the MSI-BPD score was associated with neither discharge QIDS score (crude model α = 6.77 [p < 0.0001], β*MSI-BPD = 0.41 [p < 0.0001], R2 = 0.05; adjusted model α = 3.31 [p < 0.0001], β*MSI-BPD = −0.05 [p = 0.58], β*baseline QIDS = 0.48 [p < 0.0001], β*sex = −1.72 [p < 0.0001], R2 = 0.26) nor QIDS score difference (crude model α = −4.08 [p < 0.0001], β*MSI-BPD = −0.60 [p < 0.0001], R2 = 0.09; adjusted model α = 3.31 [p < 0.0001], β*MSI-BPD = −0.05 [p = 0.58], β*baseline QIDS = −0.59 [p < 0.0001], β*sex = −1.72 [p < 0.0001], R2 = 0.35).
Using the reliable change index (RCI), the standard error of the difference was 2.34 for the GAD- 7, 4.39 for the QIDS, and 10.11 for the BASIS-24. Based on these values, 82.1% of MSI-BPD + patients experienced reliable change in the GAD-7, 53.5% in the QIDS, and 53.9% in the BASIS-24. Furthermore, MSI-BPD + patients had significantly higher percentage of patients reporting reliable change than MSI- BPD- patients across all three measures, with MSI-BPD + patients being 2.9 times more likely to report reliable change on the GAD-7 than MSI-BPD- patients, 2.6 times more likely on the QIDS, and 3.3 times more likely on the BASIS-24. (See Table 3.)
Missing data
The subgroups did not differ across age; sex/gender; ethnicity; marital status; self-rated health; history of recent hospitalization; MSI-BPD and PCL-5 screeners; baseline GAD-7, QIDS, and BASIS-24 scores; degree of suicidality and self-harm; or alcohol or substance use.
Discussion
The first goal of this study was to demonstrate the practical implementation of the MSI- BPD screening instrument to identify a higher risk, more clinically severe cohort in adult inpatient settings, which have been shown to have high prevalence of BPD. Our study included a total of 753 participants on general psychiatric inpatient units in a tertiary care hospital in a routine quality assurance assessment, among whom 199 or 24.6% screened positive for BPD with a mean score of 8.13 ± 1.06 of 10 items representing the nine BPD criteria in the DSM-5, compared to the negative group mean of 3.32 ± 1.92 (p < 0.001). This percentage of potential BPD patients is concordant with reported prevalence rates of 20–25% with BPD in general inpatient psychiatric populations [9]. The sociodemographic features, and clinical profile of patients who screened positive were similar to those reported in samples of rigorously diagnosed patients with BPD, including being more likely to be younger and female, as well as more likely to report a range of risk factors, such as housing and employment instability and worse physical health [4, 5, 11, 16, 49, 50]. Those screening positive for BPD also were more likely to have problematic use of alcohol and drugs. These patients, who are identifiable by BPD screening tools which simply assess for DSM-5 criteria, are in general at greater risk for both internalizing and externalizing disorders. MSI-BPD + patients in our sample were also more likely than MSI-BPD- patients to meet diagnostic criteria for PTSD. More generally, our findings also converge with an ample literature that the pattern of co-occurring psychiatric conditions is higher for this group and needs clinical attention [51,52,53,54]. These BPD + individuals are at greater risk for both stress sensitive disorders and stressful life situations [55] that often require a wrap-around combination of psychiatric evaluation, case management, and social services interventions which is often available in inpatient units, but rarely accessible in ambulatory care packaged with evidence-based therapies for BPD.
Existing research suggests that semi-structured interviews are not necessarily superior in identifying individuals with BPD to self-report, but rather that each approach has different merits [56]. Our study underlines the adequacy of using simple self-reported measures in a large hospital system during brief admissions to investigate the characteristics and responsiveness of patients of different clinical profiles to this highly intensive, expensive, and yet more immediately accessible treatment option, which in general, far exceeds the supply of evidence-based psychotherapies for BPD which are in very limited supply [57]. No data was collected on the rate of usage of this quality assurance data in the diagnostic review and disclosure by the psychiatrists or other clinical professionals managing the care of these individuals in these analyses. However, the clinical profiles reported suggests that the MSI-BPD potentially identifies patients to clinical care teams who have already endorsed threshold level DSM-5 criteria for diagnosing BPD on this self-reported screening measure. A formal clinical diagnosis, which does not require semi-structured or validated diagnostic scales in American national practice guidelines [58], can be made by clinical professionals after review of the MSI-BPD data collected by this routine pragmatic assessment.
The second goal of the current study was to inform treatment in inpatient settings by describing how MSI-BPD + patients differ from others in terms of admitting presentation and clinical trajectory on a wider range of clinical outcomes than exists in current literature. Consistent with our hypothesis and existing literature [16, 59], patients screening positive on the MSI-BPD endorsed significantly greater symptom severity at admission than the MSI-BPD- group across all six clinical measures of anxiety, depression, global symptoms, suicidality, and self-harm. MSI-BPD + patients had significantly higher improvement in scores on all six clinical measures than MSI-BPD- patients. A majority of individuals screening positive for BPD were significantly more likely to achieve reliable change on measures of anxiety, depression, and global symptoms than patients whose screen was not reaching criteria for BPD, in part due to higher absolute symptom severity at admission and thus greater opportunity for symptom improvement. Significant improvement in BPD symptomatology over a short period is consistent with literature demonstrating the feasibility of short-term “remission” of symptoms among BPD patients without subsequent relapse [60].
A longstanding belief that inpatient hospitalization is iatrogenic is likely informed by isolated experiences of negative therapeutic interactions when lengthy hospitalizations were more common [20, 61] and evidence-based treatments for BPD had not yet been proliferated. In response to this, conventional wisdom took hold that it was best to avoid hospitalization [21]. DBT specifically instructs therapists to be available outside of sessions around the clock to provide coaching measures to help people with BPD stay out of the hospital and reduce avoidance of stressful situations that trigger symptoms [62]. However, more recent clinical advisement recognizes the high utilization of inpatient psychiatric admission and provide guidance on use of brief hospitalizations [22]. Our current findings converge with other studies that report that those with BPD symptoms show improvement on measures of anxiety, depression, self-harm, suicidality, and global symptoms [17]. Furthermore, our finding that those who screened positive for BPD were no more likely than other patients to be outliers in terms of length of stay also provides some data to counterbalance clinical wisdom that associates patients with BPD with lengthy and iatrogenic stays [63].
False beliefs regarding positive versus negative outcomes for patients with BPD may be a result of the tendency of the need-fear dilemmas, emotional storms, and acute self-destructive behaviors characteristic of BPD to cause strong emotional reactions in staff and therefore be unusually salient in the memories of inpatient clinicians. Surveys of clinical staff on inpatient units consistently reveal pervasive negative attitudes towards patients with BPD [64,65,66], including endorsement of negative emotional reactions such as anger and resentment [63, 66]. However, these challenging cases are the exception and not the norm for those with BPD. These results confirm that people with higher BPD symptoms do benefit within the parameters of general inpatient psychiatric treatment within a comparable length of stay in a tertiary care setting. Whether or not these results can generalize to other units is unclear, and further study should investigate what protocols within inpatient hospitalizations are more effective in management of individuals with higher BPD symptoms as opposed to treatment as usual. The disposition from inpatient units with appropriate outpatient follow up for BPD may diminish the likelihood of repeated hospitalizations, but further research is needed to formally evaluate the effects of successful referral to BPD focused follow up on repeated admissions.
Few inpatient psychiatric interventions have been tested for any disorder. And while discrete psychotherapeutic interventions are testable in units in which nationalized health care systems pay for treatment [67], to our knowledge no codified inpatient protocols have been tested in the United States. Acute crises can precipitate inpatient admissions for people with many different diagnoses, and very few health care contexts can definitively provide treatments for more longstanding disorders such as BPD (e.g. autism) [68]. Expert guidance on acute management of BPD-related crises outline three main tasks: 1) stabilization of self-endangering behaviors including attention to general risk factors including substance use, insomnia, and social stressors; 2) diagnosis and psychoeducation regarding BPD and related co-occurring disorders; 3) encouragement to increasing short term support therapeutically [22].
Good psychiatric management (GPM) [69, 70] provides a model to address these tasks combined with usual standards of inpatient care in a structured fashion tailored to the specific needs of care for BPD. Treatments proven effective for BPD have in common a reliance on structure to mitigate the interpersonal instability, emotional reactivity, and behavioral dyscontrol at hand relevant to the diagnosis. Notions about the untreatability of BPD patients, particularly in inpatient settings, have been developed from the general experience that those with BPD are uniquely harmed by unstructured milieu treatment. The understanding that structure is “neither invasive nor neglectful––it is impersonal” is helpful in creating a predictable environment for staff, patients, and their family members. GPM emphasizes generic tools for creating structure by providing 1) diagnostic assessment and collaborative review of criterion, 2) psychoeducation about the prevalence, core mechanisms of emotional dysregulation and interpersonal hypersensitivity, pattern of co-occurring disorders, and effective treatment including lack of evidence that medication resolves BPD; 3) goal setting for hospitalization, 4) recognition and adaptation to community norms and rules; and 5) accountability within the treatment [71]. GPM encourages clinicians to continue to rely on care as usual in an inpatient ward including clarification of events and life stressors leading to hospitalization, development of a plan to begin addressing or more effectively coping with stressors, and aftercare planning which would ideally connect patients to informed BPD care, whether specialist or generalist. Given the fact that people with BPD are more likely to experience recurrent hospitalization [16, 72], the identification and diagnosis they can receive on inpatient units with the case management usually available provides a critical opportunity to connect patients with more definitive care. Inpatient hospitalization is not the definitive or indicated treatment for any disorder, but rather aimed for crisis stabilization which can occur for any psychiatric condition. While inpatient hospitalization can be iatrogenic if implemented in the absence of other diagnostically appropriate care, avoidance of this clinical resource does not seem feasible, so adaptation to render inpatient care more effective for those with BPD is needed. Diagnostic identification in a general or nonspecialized psychiatric inpatient program is critical to determining effective dispositions to outpatient treatment plans designed to definitively treat BPD and its usual co-occurring conditions such as substance use and post-traumatic stress disorders.
Limitations of the current study must be acknowledged. As highlighted through our terminology of MSI-BPD + and MSI-BPD- patients, we used MSI-BPD as a screening tool and did not conduct follow-up diagnostic interviews to affirmatively diagnose BPD. In the initial study of the MSI-BPD, the screening tool was found to have high sensitivity (0.81) and specificity (0.85) [25], and a review and meta-analysis found similar sensitivity (0.80) though lower specificity (0.66) [73]. As noted in Zimmerman’s recent critique of a study from our group similarly using MSI-BPD as a screening tool without clinical diagnosis [74, 75], positive predictive value is an important indicator of the reliability of screening instruments. This suggests that the MSI-BPD cannot replace clinical diagnosis, which was not assessed in these data. However, our findings indicate that the MSI-BPD may be a useful real-world screening instrument to support diagnosis and treatment. The most recent American Psychiatric Association Practice Guideline for treatment of BPD [58] suggests flexibly assessing the presence and severity of all DSM criteria for BPD. The MSI-BPD’s close adherence to DSM criteria make it a useful starting point for understanding problems in personality functioning to inform either a formal diagnostic evaluation or a BPD-informed treatment approach in the case of subthreshold but meaningful BPD-related impairments. The presumption that semi-structured interview approaches to diagnosing BPD which are the gold standard in research is also the gold standard in clinical practice might drastically reduce the likelihood of diagnostic identification and disclosure. Clinical diagnosis only requires assessment of DSM-5 criteria, which comprise the focused items in the MSI-BPD. Additionally, while the original study of the MSI-BPD asked about symptoms without a set timeframe, the MSI-BPD was administered in this study with a reference timeframe of the past week, which may contribute to higher correlation with other symptoms of acute distress. Furthermore, this study utilized only admission and discharge scores for a single hospitalization and thus does not establish the durability of the improvements in symptoms among MSI-BPD + patients, which offers a valuable avenue for future research as recovery from BPD has been found to be unstable [76]. All outcome measures studied utilized self-assessments rather than clinician assessments of patient symptomatology, though the findings on depression align with existing literature utilizing clinician ratings [18]. Missingness in self-reports was also a limitation, with length of stay and PCL-5 screening status, both used as covariates, having 18.2% and 26.7% missingness, respectively. That the study sample is drawn from a well-resourced, standalone academic psychiatric hospital may limit generalizability. Nonetheless, its findings are consistent with and reinforce the evidence base inferred from settings different from ours.
Conclusion
The results of this study may offer valuable clinical guidance on screening and treating patients with BPD traits on adult inpatient psychiatry units. We found the MSI-BPD was a useful tool for identifying differentiable sub-groups that align with expected BPD symptomatology among the broader inpatient population. The MSI-BPD identified a subsample of individuals within inpatient units with similar clinical and sociodemographic features such as more severe baseline depression and anxiety, as well as higher likelihood of substance use disorder, PTSD, and social or economic stressors, as formally diagnosed individuals with BPD. These findings further suggest that patients who screen positive for BPD experience even greater absolute improvement and reliable change in depression, anxiety, and psychiatric severity through short-term inpatient hospitalization than those screening negative, including on measures of suicidality and self-harm. Outliers in long length of stay showed no association with screening positive for BPD, challenging the myth that those who are chronically hospitalized in general psychiatric units have this disorder. Future research is needed to validate the use of self-report screenings to identify people with a BPD diagnosis by more formal research standards. The same applies to the self-reported measures used to assess anxiety, depression, suicidality, self-harm, and global symptomatology assessed in this study. Efforts to formally diagnose those likely to have BPD in inpatient settings and connect them to outpatient care tailored for BPD may result in lower rates of re-hospitalization, when use of more extensive and specialized diagnostic tools is not likely globally feasible in a non-specialized inpatient unit such as the one on which these data were collected. Further development of structured inpatient protocols for managing BPD, as well as determining available and appropriate aftercare, and their effects on longer term outcomes including repeated hospitalization requires further study.
Data availability
The data comprise protected health information and were accessible to the authors under an IRB-exempt record review protocol and are therefore not available for data sharing with external investigators.
Abbreviations
- BPD:
-
Borderline Personality Disorder
- MSI-BPD:
-
McLean Screening Instrument for Borderline Personality Disorder
- FDA:
-
Food and Drug Administration
- MDD:
-
Major Depressive Disorder
- DDAD:
-
Division of Depression & Anxiety Disorders
- CMI:
-
Clinical Measurements Initiative
- AUDIT-C:
-
Alcohol Use Disorders Identification Test-Consumption:
- DAST-10:
-
Drug Abuse Screening Test
- PTSD:
-
Posttraumatic Stress Disorder
- PCL-5:
-
Posttraumatic Stress Disorder Checklist
- DSM-5:
-
Diagnostic and Statistical Manual of Mental Disorders Fifth Edition
- GAD-7:
-
Generalized Anxiety Disorder 7-item scale
- QIDS:
-
Quick Inventory of Depressive Symptomatology
- BASIS-24:
-
Behavior and Symptom Identification Scale
- LOS:
-
Length of Stay
- GPM:
-
Good Psychiatric Management
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Not applicable. This study and retrospective analysis of these data were classified as consent- exempt and approved by the Mass General Brigham Institutional Review Board.
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JC, LD, SW, SL, FRV, SG, EG, JE, KR, and AY contributed to the conception and design of the work. JC, LD, SW, SL, and AY contributed to the collection and analysis of data. JC, SM, LCK, and AY contributed to the drafting and revision of the manuscript. All authors have read and approved the final manuscript.
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Data were collected as part of McLean Hospital’s Clinical Measurements Initiative (CMI) data collection process. The methods used for data collection and analysis data adhered to the Declaration of Helsinki. Specifically, this study and retrospective analysis of these data were classified as consent- exempt and approved by the Mass General Brigham Institutional Review Board (IRB).
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Not applicable. This study and retrospective analysis of these data were classified as consent- exempt and approved by the Mass General Brigham Institutional Review Board.
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Dr. Ressler reports having performed scientific consultation for Bioxcel, Bionomics, Acer, and Jazz Pharmaceuticals. He serves on Scientific Advisory Boards for Sage Therapeutics, Boehringer Ingelheim, and the Brain Research Foundation, and he has received sponsored research support from Brainsway and Alto Neuroscience. None of these roles are related to the current publication. Dr. Choi-Kain receives royalties from American Psychiatric Association Publishing for royalites on Good Psychiatric Management books, as well as consulting fees from Tetricus. No other authors have disclosures to report.
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Chen, J.J., Mermin, S.A., Duffy, L.A. et al. Characteristics and outcomes of individuals screening positive for borderline personality disorder on an adult inpatient psychiatry unit: a cross-sectional study. BMC Psychiatry 25, 452 (2025). https://doi.org/10.1186/s12888-025-06928-8
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DOI: https://doi.org/10.1186/s12888-025-06928-8