Borderline personality disorder
Borderline personality disorder (BPD) is a mental disorder characterized by disturbed and unstable interpersonal relationships and self-image, along with impulsive, reckless, and often self-destructive 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 the hallmark feature of borderline personality disorder. Because borderline patients set up such excessive and unrealistic expectations for others, they are inevitably disappointed when their expectations aren't 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 . It has also been used to describe the borderline states of consciousness these patients sometimes feel when they experience dissociative symptoms (a feeling of disconnection from oneself).
Causes and symptoms
Adults with borderline personalities often have a history of significant childhood traumas such as emotional, physical, and/or sexual abuse and parental neglect or loss. Feelings of inadequacy and self-loathing that arise from these situations may be key in developing the 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. Some studies suggests that this disorder is associated with mood or impulse control problems, others implicate malfunctioning neurotransmitters (the chemicals that send messages to nerve cells). The disorder has a genetic correlation since it occurs more commonly among first-degree relatives.
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 borderline disorder:
- frantic efforts to avoid real or perceived abandonment
- pattern of unstable and intense interpersonal relationships, characterized by alternating between idealization and devaluation ("love-hate" relationships)
- extreme, persistently unstable self-image and sense of self
- impulsive behavior in at least two areas (such as 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)
- unstable mood caused by brief but intense episodes of depression, irritability, or anxiety
- chronic feelings of emptiness
- inappropriate and intense anger, or difficulty controlling anger displayed through temper outbursts, physical fights, and/or sarcasm
- stress-related paranoia that passes fairly quickly and/or severe dissociative symptoms— feeling disconnected from one's self, as if one is an observer of one's own actions
Borderline personality disorder accounts for 30–60% of all personality disorders , and is present in approximately 2% of the general population. The disorder appears to affect women more frequently than men— as many as 75% of all diagnosed patients are female.
Borderline personality disorder typically first appears in early adulthood. 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.
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/hyperactivity disorder (ADHD), and other personality disorders. 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 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 due to 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 skill training, mood awareness and meditative exercises, and education on 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. Recent clinical studies indicate that naltrexone may be helpful in relieving physical discomfort related to dissociative episodes.
The disorder usually peaks in young adulthood and frequently stabilizes after age 30. Approximately 75–80% of borderline patients attempt or threaten suicide , and between 8–10% are successful. 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.
Prevention recommendations are scarce. The disorder may be genetic and not preventable. The only known prevention would be to ensure a safe and nurturing environment during childhood.
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Moskovitz, Richard A. Lost in the Mirror: An Inside Look at Borderline Personality Disorder. Dallas, TX: Taylor Publishing, 1996.
Tasman, Allan, Jerald Kay, and Jeffrey A. Lieberman, eds. Psychiatry. 1st ed. Philadelphia: W. B. Saunders Company, 1997.
Gurvits, I., H. Koenigsberg, L. Siever. "Neurotransmitter dysfunction in patients with borderline personality disorder." Psychiatric Clinics of North America 23, no. 1 (March 2000).
Soloff, P. "Psychopharmacology of borderline personality disorder." Psychiatric Clinics of North America 23, no. 1 (March 2000).
BPD Central, National Alliance for the Mentally Ill. 200 N. Glebe Road, Suite 1015, Arlington, VA 22203-3754. (800) 950-6264. Web site: <http://www.bpdcentral.com> .
Laith Farid Gulli M.D.
Linda Hesson, M.A., Psy. S., LLP, CAC
Michael Mooney, M.A., CAC, CCS