Borderline personality disorder

Borderline personality disorder (BPD) is defined within psychiatry and related psychological fields as a disorder characterized primarily by emotional dysregulation, extreme "black and white" thinking, or "splitting" (believing that something is one of only two possible things, and ignoring any possible "in-betweens"), and turbulent relationships. It can also be described by mental health professionals as a serious mental illness characterized by pervasive instability in mood, interpersonal relationships, self-image, identity, and behavior, and a disturbance in the individual's sense of self.

The disturbances suffered by those with borderline personality disorder have a wide-ranging and pervasive negative impact on many or all of the psychosocial facets of life -- including employability and relationships in work, home and social settings.

Diagnosis

DSM criteria

The latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), the widely-used American Psychiatric Association guide for clinicians seeking to diagnose mental disorders, defines Borderline Personality Disorder ("B.P.D." or BPD) as: a pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by early adulthood and present in a variety of contexts.[1]. BPD is classed on "Axis II", as an underlying pervasive or personality condition, rather than "Axis I" for more circumscribed mental disorders. A diagnosis of BPD requires, according to the DSM, five or more of the following to be present for a significant period of time:

1. Frantic efforts to avoid real or imagined abandonment. [Not including suicidal or self-mutilating behavior covered in Criterion 5]
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, promiscuous sex, eating disorders, substance abuse, reckless driving, binge eating). [Again, not including suicidal or self-mutilating behavior covered in Criterion 5]
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

--- from the DSM-IV-TR, 301.83.

ICD criteria

The World Health Organization's ICD-10 has an equivalent diagnosis called Emotionally Unstable Personality Disorder - Borderline type (F60.31). This requires, in addition to the general criteria for personality disorder, disturbances in and uncertainty about self-image, aims, and internal preferences (including sexual); liability to become involved in intense and unstable relationships, often leading to emotional crisis; excessive efforts to avoid abandonment; recurrent threats or acts of self-harm; and chronic feelings of emptiness.

Signs and symptoms

While a patient with depression or bipolar disorder typically endures the same mood for weeks, a person with BPD may experience intense bouts of depression, anxiety, or anger that may last only minutes, hours, or at most a day.[2]

Self-destructive behavior which can cover a wide range of activities. The most well-known and most recognizable symptom of a borderline patient is automutilation (self-cutting), usually of the arms, but often other areas such as the legs, chest, belly, and face. Cutting may or may not be carried out with suicidal intent, even though both entail an increased chance of suicide and self-injury attempts are highly common among patients. [3][4]

Suicidal or self-harming behaviour is one of the core diagnostic criteria in DSM IV-TR, and management of this can be a complex and challenging issue.[5]

The suicide rate is approximately eight to ten percent. [6]

Mnemonic

A commonly used mnemonic to remember some features of borderline personality disorder is PRAISE:

• P - Paranoid ideas
• R - Relationship instability
• A - Angry outbursts, affective instability, abandonment fears
• I - Impulsive behaviour, identity disturbance
• S - Suicidal behaviour
• E - Emptiness

Differential diagnosis

Borderline personality disorder often co-occurs with mood disorders, and when criteria for both are met, both should be diagnosed. However, some features of borderline personality disorder may overlap with those of mood disorders, complicating the differential diagnostic assessment. [7][8][9]

Co-morbidity

Co-morbid (co-occurring) conditions in BPD are common. When comparing individuals diagnosed with BPD to those diagnosed with other kinds of personality disorders, the former showed a higher rate of also meeting criteria for:[10]

• anxiety disorders
• mood disorders (including clinical depression and bipolar disorder)
• eating disorders (including anorexia nervosa and bulimia)
• and, to a lesser extent, somatoform disorders

BPD has also been linked to substance abuse.[11]

BPD parents are more likely to have abusive and neglectful relationships with their spouse and especially their children.

Prevalence

Figures from surveys of the prevalence of diagnosable BPD in the general population vary, ranging from approximately 1% to 2%[12][13]. The diagnosis appears to be several times more common in (especially young) women than in men, by as much as 3:1 according to the DSM-IV-TR[14] although the reasons for this are not clear.[15]

BPDs are disproportionately represented in prison populations: 23 per cent of incarcerated men and 20 per cent of incarcerated women are diagnosed with BPD. [16]

Terminology

There is a significant debate and controversy as to whether BPD should be renamed. The term "borderline" started in clinical use in the 1930s, originating in the idea (now out of favor) of some patients being on the "borderline" between neurosis and psychosis. BPD only became an official Axis II (personality) diagnosis in 1980 with the publication of DSM-III.[12]

Alternative suggestions for names include Emotional regulation disorder or Emotional dysregulation disorder. According to TARA, (Treatment and Research Advancement Association for Personality Disorders) this terminology has "the most likely chance of being adopted by the American Psychiatric Association." [17] Emotional regulation disorder is the term favored by Dr. Marsha Linehan, pioneer of one of the most popular types of BPD therapy. Impulse disorder or Interpersonal regulatory disorder are other valid alternatives, according to Dr. John Gunderson of McLean Hospital in the United States. Dyslimbia has been suggested by Dr. Leland Heller[18] and Mercurial disorder has been proposed by Harvard's Dr. Mary Zanarini.[19]

Another term advanced (for example by psychiatrist Carolyn Quadrio) is Post Traumatic Personality Disorganisation (PTPD), reflecting the condition's status as (often) both a form of chronic Post Traumatic Stress Disorder (PTSD) and Personality Disorder and a common outcome of developmental or attachment trauma.[20]

Many who are labeled with "Borderline Personality Disorder" feel it is unhelpful and stigmatizing as well as simply inaccurate, supporting and adding to calls for a name change.[21] Criticisms have also come from a feminist perspective.[22]

Etiology - causes and influences

Researchers commonly believe that BPD results from a combination that can involve individual genetic vulnerability and environmental stress, neglect or abuse as young children, and maturational events during adolescence or adulthood.

Role of childhood abuse, trauma or neglect

Numerous studies have shown a strong correlation between childhood abuse and development of BPD.[23][24][25][26]. Many (but not all) individuals with BPD report having had a history of abuse, neglect, or separation as young children.[27] Patients with BPD have been found to be significantly more likely to report having been verbally, emotionally, physically, and sexually abused by caretakers of either gender. They were also much more likely to report having caretakers (of both sexes) deny the validity of their thoughts and feelings. They were also reported to have failed to provide needed protection, and neglected their child's physical care. Parents (of both sexes) were typically reported to have withdrawn from the child emotionally, and to have treated the child inconsistently. Additionally, female borderlines who reported a previous history of neglect by a female caretaker and abuse by a male caretaker were consequently at significantly higher risk for being sexually abused by a noncaretaker (not a parent). [28] These are also the same risk factors for Reactive attachment disorder and it has been suggested that children who experience chronic early maltreatment and Reactive Attachment Disorder go on to develop a variety of personality disorders, including Borderline Personality Disorder. [29]

According to Joel Paris[30], "Some researchers, like Judith Herman, believe that BPD is a name given to a particular manifestation of post-traumatic stress disorder (PTSD): in Trauma and Recovery, she theorizes that when PTSD takes a form that emphasizes heavily its elements of identity and relationship disturbance, it gets called BPD; when the somatic (body) elements are emphasized, it gets called hysteria, and when the dissociative/deformation of consciousness elements are the focus, it gets called DID/MPD" (that is, dissociative identity disorder or multiple personality disorder).

Other developmental issues

Some studies suggest that BPD may not necessarily be a trauma-spectrum disorder and that it is biologically distinct from the post traumatic stress disorder that could be a precursor. None of the personality symptom clusters seem to be unrelated to specific abuses, but they may be related to more persistent aspects of interpersonal and family environments in childhood.[31]

It has also been suggested that BPD may be on a bipolar spectrum[32] so that the etiology may be fundamentally related to the development of mood instability.

Twin, sibling and other family studies indicate a partially heritable basis for impulsive aggression, but studies of serotonin-related genes to date have suggested only modest contributions to behavior.[31]

Neurofunction

Neurotransmitters implicated in BPD include serotonin, norepinephrine and acetylcholine (related to various emotions and moods); GABA, the brain's major inhibitory neurotransmitter (which can stablize mood change); and glutamate, an excitatory neurotransmitter.

Enhanced amygdala activation in BPD has been identified as reflecting the intense and slowly subsiding emotions commonly observed in BPD in response to even low-level stressors.[33] The activation of both the amygdala and prefrontal cortical areas can reflect attempts to control intensive emotions during the recall of unresolved life events[34] Impulsivity or aggression, as sometimes seen in BPD, has been linked to alterations in serotonin function and specific brain regions in the cingulate and the medial and orbital prefrontal cortex.[31]

Biosocial theory

Main article: Biosocial theory

Biosocial theory suggests that BPD may derive from the interaction between a biological dysfunction and an unfavorable social environment.

"DBT is based on a biosocial theory of personality functioning in which BPD is seen as a biological disorder of emotional regulation. The disorder is characterized by heightened sensitivity to emotion, increased emotional intensity and a slow return to emotional baseline. Characteristic behaviors and emotional experiences associated with BPD theoretically result from the expression of this biological dysfunction in a social environment experienced as invalidating by the borderline patient." [35]

Treatment

Psychotherapy

There has traditionally been skepticism about the psychological treatment of personality disorders, but several specific types of psychotherapy for BPD have developed in recent years. The limited studies to date do not allow confident claims of effectiveness but do suggest that people with a diagnosis of BPD can benefit on at least some outcome measures[36]. Psychotherapy may be individual or group-based, and may involve sessions over several months or, particularly for personality disorders, several years.

Dialectical behavioral therapy

In the 1990s, a new psychosocial treatment termed dialectical behavioral therapy (DBT) became established in the treatment of BPD, having originally developed as an intervention for patients with suicidal behavior.[37]

Dialectical behavior therapy is derived from cognitive-behavioral techniques but emphasizes an exchange and negotiation between therapist and client, between the rational and the emotional, and between acceptance and change (hence dialectic). Treatment targets are agreed upon, with self-harm issues taking priority. The learning of new skills is a core component - including mindfulness, interpersonal effectiveness (e.g. assertiveness and social skills), coping adaptively with distress and crises; and identifying and regulating emotional reactions.

Dialectical behavioral therapy has been found to significantly reduce self-injury and suicidal behavior in individuals with BPD, beyond the effect of usual or expert treatment, and to be better accepted by clients[38][39] although whether it has additional efficacy in the overall treatment of BPD appears less clear.[36] Training nurses in DBT has been found to replace a therapeutic pessimism with a more optimistic understanding and outlook[40]

Schema Therapy

Schema Therapy (also called Schema-Focused Therapy) is based on cognitive-behavioral or skills-based techniques but also directly targets deeper aspects of emotion, personality and schemas (fundamental ways of categorizing and reacting to the world). The treatment also focuses on the relationship with the therapist (including a process of "limited re-parenting"), daily life outside of therapy, and traumatic childhood experiences. It was developed by Jeffrey Young and became established in the 1990s. Recent research suggests that it is significantly more effective than Transference Focused Psychotherapy, with half of individuals with borderline personality disorder assessed as having achieved full recovery after 4 years, with two thirds showing clinically significant improvement[41][42]. Another very small trial has also suggested efficacy[43]

Cognitive behavioral therapy

Cognitive Behavioral Therapy (CBT) is the most widely used and established psychological treatment for mental disorders, but has appeared less successful in BPD, due partly to difficulties in developing a therapeutic relationship and treatment adherence. Approaches such as DBT and Schema-focused therapy developed partly as an attempt to expand and add to traditional CBT, which uses a limited number of sessions to target specific maladaptive patterns of thought, perception and behavior. A recent study did find a number of sustained benefits of CBT, in addition to treatment as usual, after an average of 16 sessions over one year.[44]

Eye Movement Desensitization and Reprocessing (EMDR) is a treatment for PTSD, a condition closely associated to BPD in many cases. It is similar to CBT, and seen by some as a type of CBT, but also includes unique techniques intended to facilitate full emotional processing and coming to terms with traumatic memories.

Group Therapy

Group Therapy is often helpful in learning and practicing new interpersonal skills and increasing awareness of problematic interpersonal traits and behaviors. Group therapy, usually with concurrent individual therapy, appears to be useful for borderline patients. [45]

Marital or Family Therapy

Marital Therapy can be helpful in stabilizing the marital relationship and in reducing marital conflict and stress that can worsen BPD symptoms. Family Therapy or Family Psychoeducation can help educate family members regarding BPD, improve family communication and problem solving, and provide support to family members in dealing with their loved one's illness.

Two patterns of family involvement can help clinicians plan family interventions: overinvolvement and neglect. Borderline patients who are from overinvolved families are often actively struggling with a dependency issue by denial or by anger at their parents.

Interest in the use of psychoeducation and skills training approaches for families with borderline members is growing. [45]

Psychoanalysis

Traditional or neo-Freudian psychoanalysis has become less commonly used than in the past, both in general and in regard to BPD. These interventions have been linked to an exacerbation of BPD symptoms[46] although there is also evidence of effectiveness of certain techniques in the context of partial hospitalization.[47]

Transference Focused Psychotherapy (TFP) is a form of psychoanalytic therapy dating to the 1960s, rooted in the conceptions of Otto Kernberg on BPD and its underlying structure (borderline personality organisation). In session the therapist works on the relationship between the patient and the therapist. The therapist will try to explore and clarify aspects of this relationship so the underlying object relations dyads become clear. Some limited research on TFP suggests it may reduce some symptoms of BPD by affecting certain underlying processes[48] although it appears to be less effective than schema-focused therapy and is more effective than no treatment.[41]

Medication

A number of medications are used and researched for the treatment of BPD. The evidence base is limited[49]

Antidepressants

Selective serotonin reuptake inhibitor (SSRI) antidepressants have been shown in randomized controlled trials to improve the symptoms of BPD in some patients, such as anger and hostility.[49] According to Listening to Prozac, it takes a higher dose of an SSRI to treat BPD than depression. It also takes about three months for benefit to appear, compared to two weeks for depression. The previous antidepressants, the tricyclics, were often unhelpful; side-effects generally difficult to tolerate and the drugs are often lethal in overdose.

Antipsychotics

The newer atypical antipsychotics are claimed to have an improved adverse effect profile than the typical antipsychotics. Antipsychotics may also be used to treat distortions in thinking or perceptions.[50] Usage of antipsychotics has varied, from intermittent use for a brief psychotic or dissociative episode to more general use, particularly the atypicals, for both those with bipolar disorder (BP) and with borderline personality disorder (BPD).

One meta-analysis of 14 prior studies has suggested that several atypical antipsychotics, including olanzapine, clozapine, quetiapine and risperidone, may help BPD patients with psychotic-like, impulsive or suicidal symptoms [51]

Long term use of antipsychotics is particularly controversial. There are numerous adverse effects, notably Tardive dyskinesia (TDK)[52]. Atypical antipsychotics are also known for often causing considerable weight gain, with associated health complications[53]

Mental health services and recovery

Individuals with BPD sometimes need extensive mental health services, and have been found to account for around 20% of psychiatric hospitalizations.[54] The majority of BPD patients continue to use outpatient treatment in a sustained manner for several years, but the number using the more restrictive and costly forms of treatment, such as inpatient admission, declines with time.[55] Experience of services varies[56].

Particular difficulties have been observed in the relationship between care providers and individuals diagnosed with BPD. A majority of psychiatric staff report finding individuals with BPD moderately to extremely difficult to "deal" with, and more difficult than other client groups.[57] On the other hand, those with the diagnosis of BPD have reported that the term "BPD" felt like a pejorative label rather than a helpful diagnosis, that self destructive behaviour was wrongly perceived as manipulative, and that they had limited access to care.[58] Attempts are made to improve public and staff attitudes[59][60]

Combining pharmacotherapy and psychotherapy

In practice, psychotherapy and medication are often combined. Studies often assess the effectiveness of interventions when added to 'treatment as usual' (TAU), which may involve general psychiatric services, supportive counselling, medication and psychotherapy.

One small study, which excluded individuals with a comorbid Axis 1 disorder, has indicated that outpatients undergoing Dialectical Behavioral Therapy and taking the antipsychotic Olanzapine show significantly more improvement on some measures related to BPD, compared to those undergoing DBT and taking a placebo pill,[61] although they also experienced weight gain and raised cholesterol. Another small study found that patients who had undergone DBT and then took fluoxetine (Prozac) showed no significant improvements, whereas those who underwent DBT and then took a placebo pill did show significant improvements[62].

Difficulties in therapy

There can be unique challenges in the treatment of BPD, including in inpatient settings[63] In regard to psychotherapy, borderline personality disorder is associated with fear of abandonment and acting out of fear, and a client may attempt to reject a therapist before the possibility that the therapist rejects them. Those who exhibit sensitivity and turbulence in their relationships may also replicate them with their therapist too. Some psychotherapies, for example DBT, developed partly to overcome problems with interpersonal sensitivity and maintaining a therapeutic relationship. Adherence to medication regimes is also a problem, due in part to adverse effects, with drop-out rates of between 50% and 88% in medication trials[64]

Other strategies

Psychotherapies and medications form a part of the overall context of mental health services and psychosocial needs related to BPD. The evidence base is limited for both, and some individuals may forego them or not benefit (enough) from them. Numerous other strategies may be used, including alternative medicine techniques (see List of branches of alternative medicine), exercise and physical fitness, including team sports; occupational therapy techniques, including creative arts; having structure and routine to the days, particularly through employment - helping feelings of competence (e.g. self-efficacy), having a social role and being valued by others, boosting self-esteem.

Psychiatric rehabilitation services seek to help people with mental health problems, including BPD, to reduce psychosocial disability, engage in meaningful activities, and avoid stigma and social exclusion.

Group-based psychological services encourage clients to socialize and participate in both solitary and group activities. These may be in day centers. Therapeutic communities are an example of this, originating in psychoanalytic approaches. Once involving 24/7 inpatient services, concerns have been raised about how cost-effective or evidence-based they are, and their usage has decreased, but many have specialised in the treatment of BPD.

There are also many mutual-support or co-counseling groups run by and for individuals with BPD.

Data indicate that substantial percentages of people diagnosed with BPD can achieve remission even within a year or two.[12]

A goal may be full psychosocial recovery rather than just being maintained on a medication or being reliant on services.

Footnotes

Bibliography

• Mechanisms of change in mentalization-based treatment of BPD. J Clin Psychol. 2006 Apr;62(4):411-30. Fonagy P, Bateman AW.
• A developmental approach to mentalizing communities: I. A model for social change. Twemlow SW, Fonagy P, Sacco F. Bulletin of the Menninger Clinic [NLM - MEDLINE]. Fall 2005. Vol. 69, Iss. 4; p. 265
• Mentalization-based treatment of BPD. J Personal Disord. 2004 Feb;18(1):36-51. Bateman AW, Fonagy P.
• Psychotherapy for Borderline Personality: Focusing on Object Relations Mardi J Horowitz. The American Journal of Psychiatry. Washington: May 2006. Vol. 163, Iss. 5; p. 944 (2 pages)
• Mental representations, interpersonal functioning and childhood trauma in personality disorders by Vinocur, Danielle, Ph.D., Long Island University, The Brooklyn Center, 2005, 187 pages; AAT 3195364
• Borderline personality features: Instability of self-esteem and affect. Journal of Social & Clinical Psychology. Vol 25(6) Jun 2006, 668-687. PsycINFO Zeigler-Hill, Virgil; Abraham, Jennifer.
• Risky Assessments: Participant Suicidality and Distress Associated with Research Assessments in a Treatment Study of Suicidal Behavior Sarah K Reynolds, Noam Lindenboim, Katherine Anne Comtois, Angela Murray, Marsha M Linehan. Suicide & Life - Threatening Behavior. New York: Feb 2006. Vol. 36, Iss. 1; p. 19 (16 pages)
• Interpersonal Outcome of Cognitive Behavioral Treatment for Chronically Suicidal Borderline Patients Marsha M Linehan, Darren A Tutek, Heidi L Heard, Hubert E Armstrong. The American Journal of Psychiatry. Washington: Dec 1994. Vol. 151, Iss. 12; p. 1771 (6 pages)

See also

• Child abuse
• Emotion
• Emotional dysregulation
• Post-traumatic stress disorder (PTSD)
• Complex post-traumatic stress disorder (C-PTSD)
• Dialectical behavior therapy
• Bipolar disorder -- a.k.a. manic-depression
• Reactive attachment disorder

External links

• BPD Resource Center
• PDF Borderline Personality Disorder, Raising questions, finding answers from the NIMH website
• BPD Information page at The Doctors' Lounge
• TARA an organization devoted to teaching families effective ways to help their loved ones and to advancing treatment methods
• Mental Health Matters - Borderline Personality Disorder
• BPD synopsis - MentalHealth.com
• Too Late for Kate - Borderline Personality Disorder Video Documentary with interviews from Psychiatrists and BPD sufferers
• BPDWorld - Live Online Support and Telephone Help Line

This article is licensed under the GNU Free Documentation License. It uses material from the Wikipedia article "Borderline personality disorder".

Bibliographic details for "Borderline personality disorder"

• Page name: Borderline personality disorder
• Author: Wikipedia contributors
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• Permanent link: http://en.wikipedia.org/w/index.php?title=Borderline_personality_disorder&oldid=109899585
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