Borderline Personality Disorder

Borderline personality disorder (BPD) is a serious mental illness characterized by unstable moods, interpersonal relationships, self-image, and behavior. This instability disrupts family and work life, long-term planning, and the patient's sense of identity. Patients are commonly suicidal and have a reputation for being very difficult to treat. It is thought that they suffer from a disorder of emotional regulation.

While less well-known than schizophrenia or Bipolar Disorder|bipolar disorder (manic-depressive illness), BPD is the most common personality disorder, affecting about 1.4% percent of the population.^[1] It affects women more often than men.^[2] It is also the most serious personality disorder. Due in part to their frequent suicidal behaviors, patients often need extensive mental health services, and account for 20% of psychiatric hospitalizations.^[1]

Yet, with help, and particularly with early intervention as the disorder begins to emerge in adolescence, some improve over time and are eventually able to lead productive lives.

Signs and Symptoms

People who are diagnosed with BPD have at least five of the following symptoms, as listed in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. A borderline patient may:

• Make frantic efforts to avoid real or imagined abandonment.
• Have a pattern of difficult relationships caused by alternating between extremes of intense admiration and hatred of others.
• Have an unstable self-image or be unsure of his or her own identity.
• Act impulsively in ways that are self-damaging, such as extravagant spending, frequent and unprotected sex with many partners, substance abuse, binge eating, or reckless driving.
• Have recurring suicidal thoughts, make repeated suicide attempts, or cause self-injury through mutilation, such as cutting or burning him- or herself.
• Have frequent emotional overreactions or intense mood swings, including feeling depressed, irritable, or anxious. These mood swings usually only last a few hours at a time. In rare cases, they may last a day or two.
• Have long-term feelings of emptiness.
• Have inappropriate, fierce anger or problems controlling anger. The person may often display temper tantrums or get into physical fights.
• Have temporary episodes of feeling suspicious of others without reason (paranoia) or losing a sense of reality.

Not everyone who has five or more of these symptoms is diagnosed with borderline personality disorder. For a person to be diagnosed with any personality disorder, the symptoms must be severe and must go on long enough to cause significant emotional distress or problems functioning in relationships or at work.^[2]

While a person with depression or bipolar disorder typically endures the same mood for weeks, a person with BPD may experience intense bouts of anger, depression, and anxiety that may last only hours, or at most a day. ^[3] These may be associated with episodes of impulsive aggression, self-injury, and drug or alcohol abuse. Distortions in cognition and sense of self can lead to frequent changes in long-term goals, career plans, jobs, friendships, gender identity, and values. Sometimes people with BPD view themselves as fundamentally bad or unworthy. They may feel unfairly misunderstood or mistreated, bored, empty, and have little idea who they are. Such symptoms are most acute when people with BPD feel isolated and lacking in social support, and may result in frantic efforts to avoid being alone.

BPD patients may feel that their own emotional states depend to an unusual degree upon what other people do, so they often behave in what can appear to be a manipulative way toward others in an attempt to control those emotions.^[4]

BPD often occurs together with other psychiatric problems, particularly bipolar disorder,^[5] depression, anxiety disorders, substance abuse, and other personality disorders.

Causes and Risk Factors

Personality forms during childhood. It is shaped by both inherited tendencies and experiences during childhood. Some factors related to personality development can increase the risk of developing BPD. These include:

• Hereditary predisposition. Risk of being affected by BPD seems to be worse if a close family member—a mother, father or sibling—has BPD or another serious psychiatric disorder.^[6] Certain types of genes, such as those that control serotonin, may predispose people to develop borderline traits. ^[7]

• Childhood abuse. Many people with the disorder report being sexually or physically abused during childhood.^[8]

• Neglect. Some people with the disorder describe severe deprivation, neglect and abandonment during childhood.

Studies show that many, but not all individuals with BPD report a history of abuse, neglect, or separation as children.^[9] Researchers believe that BPD results from a combination of individual vulnerability to environmental stress, neglect or abuse as young children, and a series of events that trigger the onset of the disorder as young adults. Adults with BPD are also considerably more likely to be the victims of violence, including rape and other crimes.^[10] This may result from both harmful environments as well as impulsivity and poor judgement in choosing partners and lifestyles.

Diagnosis

Patients are diagnosed with BPD if they have at least five of the characteristics listed by the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV), and if the traits cause them considerable impairment and distress. See "Symptoms" for a list of these traits. At present there are no tests available; the diagnosis depends upon the mental health provider.

Treatment

Treatment for BPD has improved in recent years with the adoption of techniques specifically aimed at people with this disorder.

Psychotherapy

Psychotherapy is the core treatment for BPD. Dialectical behavior therapy (DBT) was developed specifically to treat the disorder by clinical psychologist Martha Linehan in the early 1990s.^[11] Generally conducted through individual, group and phone counseling, DBT uses a skills-based approach to teach people how to regulate their emotions, tolerate distress and improve relationships. Dialectical behavior therapy appears to be effective, although the number of people in scientific studies is still few,^[12] and its cost-effectiveness still isn't clear.^[13]

Cognitive behavioral therapy, a highly effective treatment for many other mental health problems, does not appear to be particularly helpful for people with BPD.^[14]

Medications

Medications can't cure BPD, but they can help associated problems, such as depression, impulsivity and anxiety. Medications may include antidepressants, antipsychotic and antianxiety medications. There is no single drug of choice; each patient's medication should be tailored to his or or needs.^[15][16]

Hospitalization

At times, people with BPD may need more intense treatment in a psychiatric hospital or clinic. Hospitalization can also keep them safe from self-injury. Because treatment can be intense and long term, people face the best chance for success when they find mental health providers who have experience treating BPD.

Holistic and alternative treatments

One study has examined the role of omega-3 fatty acids in treating BPD.^[17] The authors concluded that the treatment was safe and effective, but the study has been criticized as drawing unwarranted conclusions from its data. The critics concluded there was no evidence that omega-3 fatty acids helped treat borderline symptoms.^[18]

Research

Research is revealing brain mechanisms underlying the impulsivity, mood instability, aggression, anger, and negative emotion seen in BPD. Studies suggest that people predisposed to impulsive aggression have impaired regulation of the neural circuits that modulate emotion. The amygdala, a small almond-shaped structure deep inside the brain, is an important component of the circuit that regulates negative emotion. In response to signals from other brain centers indicating a perceived threat, it marshals fear and arousal. This might be more pronounced under the influence of drugs like alcohol, or stress. Areas in the front of the brain (pre-frontal area) act to dampen the activity of this circuit. A recent study using magnetic resonance imaging of the brains of BPD patients found that the hippocampus, and possibly the amygdala, in these patients is smaller than in healthy people.^[19]

Serotonin, norepinephrine and acetylcholine are among the chemical messengers in these circuits that play a role in the regulation of emotions, including sadness, anger, anxiety, and irritability. Drugs that enhance brain serotonin function may improve emotional symptoms in BPD. Likewise, mood-stabilizing drugs that are known to enhance the activity of GABA, the brain's major inhibitory neurotransmitter, may help people who experience BPD-like mood swings. Such brain-based vulnerabilities may one day be managed with help from therapy and medications, in the same way that people manage susceptibility to diabetes or high blood pressure.^[4]

Studies that translate basic findings about the neural basis of temperament, mood regulation, and thought into insights about BPD represent a growing area of research. Research is also underway to test the efficacy of combining medications with behavioral treatments like DBT. Research is also looking at the effect of childhood abuse and other stress in BPD on brain hormones. Data from the first long-term study of BPD, which began in the early 1990s, is expected to reveal how treatment affects the course of the illness. It will also pinpoint specific environmental factors and personality traits that predict a better outcome.

Debate

Borderline personality disorder was named in the context of the prevailing psychiatry theories of the 1930s, but today's better understanding of the disorder, along with an advocacy movement, has led to debate] about what would be a more informative and less stigmatic name. Suggestions have included dyslimbia, referring to the limbic system of the brain, and emotional dysregulation disorder, among others.

History

Borderline personality was described and named in 1938 by psychiatrist Adolph Stern.^[20] He chose the term because these patients seemed to be on a borderline between psychosis and neurosis. Although that view of the problem has been superseded by knowledge about childhood traumas and genetic susceptibilities, the name remains.

Interesting Facts

In the film "Fatal Attraction," Glenn Close's character shows BPD-like behaviors. According to one alumna, J. Blair, M.D., a Yale Medical School psychiatry class has used the film to illustrate the disorder.

Notable Experts

• McLean Center for the Treatment of Borderline Personality Disorder, Boston, Massachusetts, USA; a Harvard Medical School affiliate.
  • Director, John G. Gunderson, MD
• Behavorial Research and Therapy Clinics, University of Washington, Seattle, Washington, USA.
  • Director (and pioneer of dialectical behavior therapy, the most popular form of BPD therapy), Marsha Linehan, PhD

References

1. ↑ ^{1.0 1.1} Chanen AM, McCutcheon LK, Jovev M, Jackson HJ, McGorry PD. Prevention and early intervention for borderline personality disorder. Med J Aust. 2007 Oct 1;187(7 Suppl):S18-21. Abstract | Full Text
2. ↑ ^{2.0 2.1} American Psychiatric Association (2000). Personality disorders. In Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text rev., pp. 706–710. Washington, DC: American Psychiatric Association.
3. ↑ Zanarini MC, Frankenburg FR, DeLuca CJ, Hennen J, Khera GS, Gunderson JG. The pain of being borderline: dysphoric states specific to borderline personality disorder. Harvard Review of Psychiatry. 1998; 6(4): 201-7. Abstract
4. ↑ ^{4.0 4.1} Siever LJ, Koenigsberg HW. The frustrating no-man's-land of borderline personality disorder. Cerebrum, The Dana Forum on Brain Science. 2000; 2(4). Full Text
5. ↑ Gunderson JG, Weinberg I, Daversa MT et al. Descriptive and longitudinal observations on the relationship of borderline personality disorder and bipolar disorder. Am J Psychiatry. 2006 Jul;163(7):1173-8. Erratum in: Am J Psychiatry. 2006 Oct;163(10):1843. Abstract | Full Text
6. ↑ White CN, Gunderson JG, Zanarini MC, Hudson JI. Family studies of borderline personality disorder: a review. Harv Rev Psychiatry. 2003 Jan-Feb;11(1):8-19. Abstract
7. ↑ Lyons-Ruth K, Holmes BM, Sasvari-Szekely M, Ronai Z, Nemoda Z, Pauls D. Serotonin transporter polymorphism and borderline or antisocial traits among low-income young adults. Psychiatr Genet. 2007 Dec;17(6):339-43. Abstract | Full Text
8. ↑ Zanarini MC, Yong L, Frankenburg FR et al. Severity of reported childhood sexual abuse and its relationship to severity of borderline psychopathology and psychosocial impairment among borderline inpatients. J Nerv Ment Dis. 2002 Jun;190(6):381-7. Abstract
9. ↑ Zanarini MC, Frankenburg FR, Reich DB et al. Biparental failure in the childhood experiences of borderline patients. J Personal Disord. 2000 Fall;14(3):264-73. Abstract
10. ↑ Zanarini MC, Frankenburg FR, Reich DB, Marino MF, Haynes MC, Gunderson JG. Violence in the lives of adult borderline patients. J Nerv Ment Dis. 1999 Feb;187(2):65-71. Abstract
11. ↑ Blennerhassett RC, O'Raghallaigh JW. Dialectical behaviour therapy in the treatment of borderline personality disorder. Br J Psychiatry. 2005 Apr;186:278-80. Abstract | Full Text
12. ↑ Binks CA, Fenton M, McCarthy L, Lee T, Adams CE, Duggan C. Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews. 2006. Issue 1. Art. No.: CD005652. Abstract | Summary
13. ↑ Brazier J, Tumur I, Holmes M et al. Psychological therapies including dialectical behaviour therapy for borderline personality disorder: a systematic review and preliminary economic evaluation. Health Technol Assess. 2006 Sep;10(35):iii, ix-xii, 1-117. Abstract | Full Text
14. ↑ Palmer S, Davidson K, Tyrer P et al. The cost-effectiveness of cognitive behavior therapy for borderline personality disorder: results from the BOSCOT trial. J Personal Disord. 2006 Oct;20(5):466-81. Abstract | Full Text
15. ↑ Soloff PH. Is there any drug treatment of choice for the borderline patient? Acta Psychiatr Scand Suppl. 1994;379:50-5.
16. ↑ Hirschfeld RM. Pharmacotherapy of borderline personality disorder. J Clin Psychiatry. 1997;58 Suppl 14:48-52; discussion 53. Abstract
17. ↑ Zanarini MC, Frankenburg FR. Omega-3 Fatty acid treatment of women with borderline personality disorder: a double-blind, placebo-controlled pilot study. Am J Psychiatry. 2003 Jan;160(1):167-9. Abstract | Full Text
18. ↑ Ross BM, Seguin J, Sieswerda LE. Omega-3 fatty acids as treatments for mental illness: which disorder and which fatty acid? Lipids Health Dis. 2007 Sep 18;6:21. Abstract | Full Text
19. ↑ Driessen M, Herrmann J, Stahl K et al. Magnetic resonance imaging volumes of the hippocampus and the amygdala in women with borderline personality disorder and early traumatization. Arch Gen Psychiatry. 2000 Dec;57(12):1115-22. Abstract | Full Text
20. ↑ Stern A. Psychoanalytic investigation of and therapy in the borderline group of neuroses. Psychoanal Q. 1938;7:467-489.

External Links

The frustrating no-man's-land of borderline personality disorder, by Harold W. Koenigsberg and Larry J. Siever. Cerebrum, The Dana Forum on Brain Science. October 1, 2000.

BPD Central Information and Support

American Association for Marriage and Family Therapy

Borderline Personality Disorder Research Foundation

Borderline Personality Disorder Resource Center at New York-Presbyterian Hospital-Weill Cornell Medical College

National Education Alliance for Borderline Personality Disorder

Treatment and Research Advancements Association for Personality Disorder

National Alliance on Mental Illness: A national nonprofit educational and advocacy organization for BPD

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