Diagnostic instruments for borderline personality disorder in the elderly need to be developed. In the interim, suggestions are offered concerning patient symptoms and behaviours that could trigger psychiatric assessment and advice concerning management. A screening tool is proposed to assist in the timely diagnosis of borderline personality disorder in older people. Timely identification of these patients is needed so that they can receive the skilled help, understanding and treatment needed to alleviate suffering in the twilight of their lives.

orderline personality disorder (BPD) is a serious mental illness characterised by dysregulation of emotions and impulses, an unstable and inconsistent sense of self and of others in close relationships, and marked difficulties in interpersonal relationships, often accompanied by suicidal and selfharming behaviour.The instability of emotions and predominance of negative affect that characterise BPD often lead to problems determining whether the patient has major depression co-occurring with BPD, or whether the depressive symptoms are part and parcel of the BPD itself. In this article, we aim to assist clinicians facing this situation to make an accurate diagnosis.To prepare the article, we searched PsychInfo and MEDLINE databases for articles published between 2000 and 2012 relating to BPD co-occurring with major depression, other depressive disorders, or bipolar disorder. Review articles and those involving randomised controlled trials of treatment were particularly sought. Book chapters relevant to the search criteria were also examined. The diagnostic problemMajor depressive disorder (MDD) commonly co-occurs with BPD. The lifetime prevalence of major depression in the course of BPD was 83% in one large study, 1 which accords with other research and clinical experience.Patients with BPD often present to clinicians with depressive symptoms. As the symptoms of depression and BPD overlap significantly, it can be challenging to make an accurate diagnosis of a major depressive illness when the disorders co-occur. Accurate diagnosis is essential because each disorder requires treatment in its own right. It is important to note that rating scales of depression, whether patient-or clinician-rated, are less helpful for assessing the severity of depressive symptoms when BPD is present. 2 BPD is not a variant of affective disorderGiven the prominent overlap of symptoms between BPD and affective disorders, it has been suggested that BPD is a variant of affective disorder -either depressive disorder or bipolar disorder. 3,4 However, the consensus of expert opinion is that BPD is not a variant of either MDD or bipolar disorder, 5-12 although overlap of symptoms of both disorders can occur with BPD.The most significant evidence that BPD is not a variant of depressive disorder is that treatment of depression does not result in remission of BPD symptoms. An important longitudinal study found that effective treatment of BPD tends to result in remission of depression, and antidepressants often show only modest benefit for depressive disorders that co-occur with BPD. 6 A 2010 review of phenotype, endophenotype and genotype comparisons between BPD and MDD found that BPD differs from MDD in symptomatology, prognosis, heritability, patterns of brain region involvement, neurohormonal indices and sleep architecture. 7 Some biological processes overlapped, including amygdala hyperreactivity, volume changes in the anterior cingulate cortex, and deficient serotonin function. The authors noted that definitive clarification of the commonalit...

Hallucinations and delusions in borderline personality disorder (BPD) are understudied. The authors explore the phenomenology of multisensory hallucinations and delusions in individuals with BPD and compare them to those in individuals with schizophrenia spectrum disorders (SSD). Clinical psychopathology was also explored. Eighty-nine adults participated and were categorized into four groups: BPD with voices, BPD without voices, SSD with high BPD traits, and SSD with low BPD traits. Among individuals with BPD, 81% reported visual and tactile hallucinations, 75% reported olfactory hallucinations, and 94% experienced delusions. When comparing BPD with and without voices, there were no significant differences in nonpsychotic psychopathology. Slight differences were found when hallucinations in BPD were compared with hallucinations in SSD, but overall the experiences were similar across diagnoses. The BPD group also reported significantly higher rates of paranoia/suspiciousness and delusions of guilt than the SSD group. Multisensory hallucinations and delusions occur in BPD and should be explored when treating people with BPD.

Summary Borderline personality disorder (BPD) is a serious mental illness characterised by dysregulation of emotions and impulses, an unstable sense of self, and difficulties in interpersonal relationships, often accompanied by suicidal and self‐harming behaviour. Major depressive disorder (MDD) commonly co‐occurs with BPD. Patients with BPD often present with depressive symptoms. It can be difficult to distinguish between BPD and MDD, especially when the two disorders co‐occur. Research is needed to clarify the commonalities and differences between BPD and MDD, and BPD and rapid‐cycling bipolar disorder. When MDD and BPD co‐occur, both conditions should be treated concurrently. MDD co‐occurring with BPD does not respond as well to antidepressant medication as MDD in the absence of BPD. MDD is not a significant predictor of outcome for BPD, but BPD is a significant predictor of outcome for MDD. Treatment of BPD with specific psychotherapies tends to result in remission of co‐occurring MDD. Empirically validated psychotherapies for BPD share common features that are applicable in all treatment settings where patients with BPD are likely to present, including primary care. Methodologically sound research is required to examine the effectiveness of medications for treatment of MDD co‐occurring with BPD.

There is a patient group predisposed to depression on the basis of adverse early life experience. In these cases, the neurobiology of attachment offers a means of integrating findings concerning sensitization of the HPA axis in infancy, the effects of early life experience on brain development, and predisposition to depression and other psychiatric disorders. These findings have important implications for the development of interventions aimed at prevention and treatment for this patient group.