Borderline Personality Disorder
Borderline Personality Disorder
Borderline Personality Disorder
Borderline personality disorder (BPD) is a mental disorder characterized by disturbed and unstable interpersonal relationships and self-image, along with impulsive behavior, unstable mood, and suicidal behavior.
Individuals with BPD have a history of unstable interpersonal relationships. They have difficulty interpreting reality and view significant people in their lives as either completely flawless or extremely unfair and uncaring (a phenomenon known as “splitting”). These alternating feelings of idealization and devaluation are one major feature of borderline personality disorder. Because borderline patients set up such excessive and unrealistic expectations for others, they are inevitably disappointed when their expectations are not realized.
The term “borderline” was originally used by psychologist Adolf Stern in the 1930s to describe patients whose condition bordered somewhere between psychosis and neurosis, although today, the term “borderline” used in this sense is considered a misnomer. The term is better applicable today in describing the borderline states of consciousness these patients sometimes feel when they experience dissociative symptoms (a feeling of disconnection from oneself). The syndrome itself is considered a complex disorder, rather than one lying on a border between psychosis and neurosis.
In about 24% of cases, there is a history of childhood sex abuse, and in about one-third of cases, there is a history of severe abuse of some kind. Thus, abuse is considered a risk factor, but it is an environmental contributor thought to interact with a genetic basis. Twin studies have suggested that at least some features of this disorder are highly heritable. Mood instability and impulsivity are about 50% heritable, and studies of BPD specifically suggest a similar level of heritability. The root biological cause may be disruptions in signaling pathways involving serotonin, a nerve signaling molecule, but more studies are necessary to confirm the biological basis.
The feelings of inadequacy and self-loathing that arise from situations of abuse or neglect may contribute to the development of a borderline personality. It has also been theorized that these patients try to compensate for the care they were denied in childhood through the idealized demands they now make on themselves and on others as adults.
The handbook used by mental health professionals to diagnose mental disorders is the Diagnostic and Statistical Manual of Mental Disorders (DSM). The 2000 edition of this manual (fourth edition, text revised) is known as the DSM-IV-TR. Published by the American Psychiatric Association, the DSM contains diagnostic criteria, research findings, and treatment information for mental disorders. It is the primary reference for mental health professionals in the United States. BPD was first listed as a disorder in the third edition DSM-III, which was published in 1980, and has been revised in subsequent editions.
The DSM-IV-TR requires that at least five of the following criteria (or symptoms) be present in an individual for a diagnosis of BPD, although some researchers suggest that criteria from each of three dimensions (groupings) should actually be met:
DIMENSION: AFFECTIVE (MOOD-RELATED) SYMPTOMS
- Unstable mood caused by brief but intense episodes of depression, irritability, or anxiety. These episodes are generally much briefer than the highs and lows of bipolar disorder. The strongest tendency is to outbursts of anger. The level of mood instability can be a strong predictor of whether or not suicide will be attempted.
- Chronic feelings of emptiness.
- Inappropriate and intense anger, or difficulty controlling anger displayed through temper outbursts, physical fights, and/or sarcasm.
DIMENSION: IMPULSIVE SYMPTOMS
- Impulsive behavior in at least two areas (e.g., spending, sex, substance abuse, reckless driving, binge eating).
- Recurrent suicidal behavior, gestures, or threats, or recurring acts of self-mutilation (such as cutting or burning oneself). This behavior results from the combination of impulsivity and rapidly and intensely changeable mood.
- Pattern of unstable and intense interpersonal relationships, characterized by alternating between idealization and devaluation (“love-hate” relationships).
DIMENSION: INTERPERSONAL SYMPTOMS
- Extreme, persistently unstable self-image and sense of self.
- Frantic efforts to avoid real or perceived abandonment.
In addition, there is a cognitive criterion for diagnosis that includes stress-related paranoia that passes fairly quickly and/or severe dissociative symptoms—feeling disconnected from oneself, as if one is an observer of one’s own actions; sometimes occurs with flashbacks. One study found that about 40% of patients with BPD reported having semipsychotic thoughts. The rate in another study was 27% of patients. A different study also found that the presence of psychotic symptoms can be a predictor of self-harm in patients who have personality disorders.
Some patients with BPD are mistakenly diagnosed with bipolar disorder or with schizophrenia. BPD can be distinguished from bipolar disorder based on the brevity of the extreme mood swings, which typically last only hours, rather than days or weeks. In spite of the fact that auditory hallucinations can occur in people with BPD, it is distinguished from schizophrenia because the patient with BPD knows the hallucinations are not real, whereas the patient with schizophrenia does not.
Borderline personality disorder accounts for 30-60% of all personality disorders and is present in approximately 1% of the general population, a frequency similar to that of schizophrenia. The disorder appears to affect women more frequently than men; as many as 80% of all patients receiving therapy are female, but this sex bias is not as obvious in samples from community populations. The characteristic of suicidality (thinking about or attempting suicide) is less prominent in traditional societies that experience little cultural change from one generation to the next, but is increasing in modern societies and in societies experiencing rapid change.
Borderline personality disorder typically first appears in early adulthood, with the usual age of onset around 18 years. Although the disorder may occur in adolescence, it may be difficult to diagnose, since borderline symptoms such as impulsive and experimental behaviors, insecurity, and mood swings are common—even developmentally appropriate—occurrences at this age.
Assessment is based first on determination of whether or not the person meets at least five of the nine DSM-IV-TR criteria. The next step typically involves completion of a personality assessment, which involves interviewing the patient, but also can involve querying family members or friends, with the patient’s agreement. Last, the symptoms of BPD that suggest the diagnosis must have been present consistently over time.
Borderline symptoms may also be the result of chronic substance abuse and/or medical conditions (specifically, disorders of the central nervous system). These should be ruled out before making the diagnosis of borderline personality disorder.
BPD commonly occurs with mood disorders (i.e., depression and anxiety), post-traumatic stress disorder (PTSD), eating disorders, attention deficit/hyper-activity disorder (ADHD), and other personality disorders. Another accompanying comorbidity may be substance use disorder. It has also been suggested by some researchers that borderline personality disorder is not a true pathological condition in and of itself, but rather a number of overlapping personality disorders; it is, however, commonly recognized as a separate and distinct disorder by the American Psychiatric Association and by most mental health professionals. It is diagnosed by interviewing the patient and matching symptoms to the DSM-IV-TR criteria. Supplementary testing may also be necessary.
Individuals with borderline personality disorder seek psychiatric help and hospitalization at a much higher rate than people with other personality disorders, probably because of their fear of abandonment and their need to seek idealized interpersonal relationships. These patients represent the highest percentage of diagnosed personality disorders (up to 60%).
Providing effective therapy for the borderline personality patient is a necessary, but difficult, challenge. The therapist-patient relationship is subject to the same inappropriate and unrealistic demands that borderline personalities place on all their significant interpersonal relationships. They are chronic “treatment seekers” who become easily frustrated with their therapist if they feel they are not receiving adequate attention or empathy, and symptomatic anger, impulsivity, and self-destructive behavior can impede the therapist-patient relationship. However, their fear of abandonment and of ending the therapy relationship may actually cause them to discontinue treatment as soon as progress is made.
Psychotherapy, typically in the form of cognitive-behavioral therapy, is usually the treatment of choice for borderline personalities. Dialectical behavior therapy (DBT), a cognitive-behavioral technique, has emerged as an effective therapy for borderline personalities with suicidal tendencies. The treatment focuses on giving the borderline patient self-confidence and coping tools for life outside of treatment through a combination of social skills training, mood-awareness and meditative exercises, and education about the disorder. Group therapy is also an option for some borderline patients, although some may feel threatened by the idea of “sharing” a therapist with others.
Medication is not considered a first-line treatment choice but may be useful in treating some symptoms of the disorder and/or the mood disorders that have been diagnosed in conjunction with BPD. Some patients with BPD may find themselves taking several different medications, each designed to address one of the main manifestations of BPD, but there are no data from clinical trials supporting such a regimen.
The disorder usually peaks in young adulthood and frequently stabilizes after age 30. In 75% of cases, normal function will have returned by age 35 to 40, and in 90% of cases, function will be normal by age 50. Unfortunately, the remaining 10% fall into the group of patients who die as a result of suicide. Approximately 75-80% of borderline patients attempt or threaten suicide, and between 8-10% are successful. Managing this highly prevalent suicidality is one of the greatest therapeutic challenges in BPD. The behavior peaks usually when the patient is in the mid-20s, but most of the completed suicides actually occur among patients older than 30 years, usually in patients who have experienced no recovery after many treatment attempts. If the borderline patient suffers from depressive disorder, the risk of suicide is much higher. For this reason, swift diagnosis and appropriate interventions are critical. Self-harming behaviors are generally not considered to be attempted suicide but instead to serve as a relief from an extreme emotional state.
Prevention recommendations are scarce. Given the genetic basis of the disorder, current technologies do not allow preventions targeting that aspect of its etiology. The only known prevention would be to ensure a safe and nurturing environment during childhood.
See alsoDissociation/Dissociative disorders.
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Glebe Road, Suite 1015, Arlington, VA 22203-3754. Telephone: (800) 950-6264. Web site: <http://www.bpdcentral.com>.
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Laith Farid Gulli, MD
Linda Hesson, MA, Psy.S., L.L.P., C.A.C.
Micheal Mooney, MA., C.A.C, C.C.S.
Emily Jane Willingham, PhD