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Borderline personality disorder

Borderline personality disorder (BPD) is defined within psychiatry, and some other fields, as a disorder characterised primarily by emotional deregulation; extreme “black and white” thinking in some areas; and disrupted relationships.

The name originated with the idea that individuals exhibiting this type of behaviour were on the “borderline” between neurosis and psychosis. This idea has since fallen out of favour, but the name remains in use, as noted in the Diagnostic and Statistical Manual of Mental Disorders; the ICD-10 has an equivalent called Emotionally Unstable Personality Disorder, borderline type.

There is currently some discussion by the American Psychiatric Association about changing their name for the disorder to Emotional Dysregulatory Disorder, or Emotional Dysregulation Disorder in the next version of the DSM.

Psychiatrists and some other mental health professionals describe Borderline personality disorder as a serious disorder characterized by pervasive instability in mood, interpersonal relationships, self-image, identity, and behavior. This instability often disrupts family and work life, long-term planning, and the individual’s sense of self. The majority of those diagnosed with this disorder appear to have been individuals abused or traumatized during childhood.

Origins and objections to name

Originally thought to be at the “borderline” between psychosis and neurosis, people with BPD are now said to suffer from what has come to be called emotional dysregulation. While less well-known than schizophrenia or bipolar disorder (manic-depression), BPD is more common, affecting two percent of adults, mostly young women.(ref1)

In perhaps the majority of cases, the problems develop following abuse or trauma. There is a high rate of self-injury without suicidal intent, as well as a significant rate of suicide attempts and completed suicide in severe cases.(ref2) The suicide rate is approximately 8-10%. [1]Patients often need extensive mental health services, and they account for 20 percent of psychiatric hospitalizations.(ref3) It is recognised that they often receive poor service, however, in part due to lack of sympathy with or understanding of self-harm, impulsivity or so-called ‘non-compliance’. However, many improve over time and are able to lead more stable and happy lives.

Many who are labeled with ‘Borderline Personality Disorder’ feel it is unhelpful and stigmatizing as well as simply inaccurate, and there are many proposals for the name to be changed. [2] Dyslimbia has been suggested by Dr. Leland Heller. [3] “Emotional Regulation Disorder” and “Emotional Dysregulation Disorder” have been suggested by TARA, (Treatment and Research Advancement Association for Personality Disorders) as having “the most likely chance of being adopted by the American Psychiatric Association.”[4]

Others feel that the medical assumption of a distinct disorder is a problem, because the biopsychosocial issues involved are too complex to be categorised or treated as a single illness or disorder, which can also appear to locate problems within an individual rather than also within society.

DSM-IV-TR Diagnostic criteria

The DSM-IV-TR, a widely-used reference book for diagnosing mental disorders, defines borderline personality disorder as a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

  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, sex, substance abuse, reckless driving, binge eating; [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.

DSM-IV-TR, 301.83.

Mnemonic

A commonly used mnemonic to remember the features of the 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

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 hours, or at most a day.(ref4) These may be associated with episodes of self-injury (including cutting), impulsive aggression, and drug or alcohol abuse. Difficulties in cognition and sense of self can lead to frequent changes in long-term goals, career plans, jobs, friendships, 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. Ironically, it is the desperate clinging to other people that often serves as the very catalyst for conflict that drives them away.

People with BPD often have highly unstable patterns of social relationships. While they can develop intense but stormy attachments, their attitudes towards family, friends, and loved ones may suddenly shift from idealization (great admiration and love) to devaluation (intense anger and dislike). Thus, they may form an immediate attachment and trust for the other person, but when a separation or conflict occurs that others may see as slight, they can lose their sense of attachment and trust and may become withdrawn or angry. Even with family members, individuals with BPD can be highly sensitive to rejection, for example reacting with distress or anger to separations. These fears of abandonment may be related to difficulties feeling emotionally connected to important persons when they are physically absent, leaving the individual with BPD feeling lost and perhaps worthless. Suicidal attempts may occur along with anger at perceived abandonment and disappointments.

People with BPD exhibit other impulsive behaviors, such as excessive spending, binge eating and risky sex. BPD often occurs together with other psychiatric problems, particularly bipolar disorder, depression, anxiety disorders, substance abuse, eating disorders and other personality disorders.

As a consequence of difficulties with emotional regulation and maintaining some social boundaries, people with BPD can sometimes make rapid and seemingly deep connections with others, marked by unrealistically high levels of mutual admiration. When very open and in need of reassurance and love, they can sometimes overwhelm others with praise, attention and intimacy. They can also feel overwhelmed by others or be taken advantage of. Due to the inherent instability of such relationships, and unresolved issues for the person with BPD, particularly in matters of trust and self-worth, they are prone to react strongly to apparent slights and reverse their over-positive view. This can be experienced by others as unexpected hostility or betrayal, and can also be confusing and painful for the person with BPD.

Treatment

Treatments for BPD have improved in recent years. (ref5) People with BPD, who are often distressed by at least some of their symptoms, typically undertake a series of empirical trials of drugs to see whether anything helps them, and may end up taking no drugs at all. Since about 1989, Prozac and other selective serotonin reuptake inhibitor (SSRI) antidepressants have repeatedly been shown to improve the symptoms of BPD in some patients.

The book Listening to Prozac describes some of these remarkable changes. In general, 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, and sometimes even worsened the symptoms. Increasing evidence implicates inadequate serotonergic neurotransmission as strongly related to impaired modulation of emotional and behavioral responses to everyday life, manifesting as “overreacting to everything”. Even thinking is recruited by the intense (or underregulated) emotionality so that the world is perceived primitively in intense black-and-white terms.

Other pharmacological treatments are often prescribed for certain other specific target symptoms shown by the individual patient, especially for people with more than one psychiatric diagnosis. Mood stabilizers (lithium or certain antiepileptic drugs) may be helpful for explosive anger, impulsivity, or if there is an admixture of bipolar disorder.(ref6) Antipsychotic drugs may also be used when there are distortions in thinking (e.g., paranoia).(ref7) Overall, medication has not been as effective for people who have only BPD (without any other mental illnesses) as it has been in many other psychiatric disorders, leading many researchers to focus on non-chemical treatments, such as Dialectical Behavior Therapy, for “pure” BPD patients.

Cognitive and behaviorally oriented group and individual psychotherapy are effective for many patients. Traditional psychoanalysis is usually avoided, because it has been known to exacerbate BPD symptoms.

Another relatively recent and exciting development is a variation on Jeffrey Young’s ‘Schema Therapy’, entitled ‘Mode Therapy’. Details can be obtained from his book.

Dialectical Behavioral Therapy

In 1991, a new psychosocial treatment termed Dialectical Behavioral Therapy (DBT) was developed specifically to treat BPD, and this technique was the first to show any efficacy compared to a control group. Marsha Linehan, the developer of DBT, said in the early days that it took about a year to see substantial enduring improvement. Combining SSRIs and DBT (probably the standard treatment now) seems to give satisfying synergy and faster results.

Linehan’s dialectical behavior therapy is based on negotiation between therapist and patient. The dialectic described in the treatment’s name is of the therapists’ acceptance and validation of patients as they are, combined with the insistence on the need for change. The idea is to give patients tools that they never acquired as children, typically to control and handle their emotions. Some patients, when asked after several years of treatment, why they have stopped inflicting self-injury, give answers to the effect of “I picture myself sitting with my psychotherapist, and we talk about why I want to injure myself.”

Recent research findings

Although the causes of BPD are uncertain, both environmental and genetic factors are thought to play a role in predisposing patients to BPD symptoms and traits, possibly through the final common pathway of reduced central serotonergic neurotransmission. Studies show that many (but not all) individuals with BPD report a history of abuse, neglect, or separation as young children.(ref8) Many others have an apparently hereditary form of the disease. Forty to 71 percent of BPD patients report having been sexually abused, usually by a non-caregiver.(ref9)

Researchers believe that BPD results from a combination of individual genetic vulnerability, and environmental stress, neglect or abuse as young children, and maturational events that trigger the onset of the disorder during adolescence or adulthood.

Adults with BPD are also considerably more likely to be the victim of violence, including rape and other crimes. This may be the result of vulnerabilities resulting from BPD (e.g., willingness to tolerate unsafe environments to avoid abandonment, tendency to form intense relationships) as well as impulsivity and poor judgment in choosing partners and lifestyles. Anger, impulsivity, and poor judgment may also explain why people with BPD are more likely than average to be arrested for and convicted of crimes ranging from petty theft to murder.

Neuroscience research examines brain mechanisms possibly 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.(ref10) 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 stress and/or drugs like alcohol. Areas in the front of the brain (pre-frontal area) act to dampen the activity of this circuit. Recent brain imaging studies show that individual differences in the ability to activate regions of the prefrontal cerebral cortex thought to be involved in inhibitory activity predict the ability to suppress negative emotion.(ref11)

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 sometimes 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.

Future progress

Studies that translate basic findings about the neural basis of temperament, mood regulation and cognition into clinically relevant insights which bear on BPD represent a growing area of research. Research is also underway to test the efficacy of combining medications with behavioral treatments like DBT, and gauging the effect of childhood abuse and other stress. Data from the first prospective, longitudinal study of BPD, which began in the early 1990s, is expected to reveal how treatment affects the course of the illness. It will also hopefully pinpoint specific environmental factors and personality traits that predict a more favorable outcome.

The NonBP, or counter-Borderline

NonBP is a non-clinical term originally coined by Kreger & Mason in the book Stop Walking on Eggshells (ISBN 157224108X) in the mid-1990’s. It has since come into widespread, and popular usage. The term describes individuals who are in a consistent, and sometimes significant, relationship with a person exhibiting a Borderline character, aspects of Complex Post Traumatic Stress Disorder (C-PTSD), or a formally diagnosed Borderline personality disorder. These people can be friends, spouses, lovers, offspring, co-workers, and extended family members, among others.

While “NonBP” is a colloquial expression, and not a clinically defined condition or syndrome, the idea parallels that of the “roles” that people often take on in alcoholic families, or abusive relationships. It is also consistent with the idea of “roles” described in co-dependent relationships, such as “enabler”, “counter-dependent”, and/or “agent”. Part of the value of this type of informal terminology is that it helps describe the manner in which others potentially behave when in relationship to a person whose social skills are inadequate, in what ever way that presents itself.

When talking about the Borderline relationship, the “Non-reactive NonBP” is considered to be a person who interacts with the Borderline character, while not being drawn into, or engaging, the chaos of the disorder. The “Reactive NonBP”, however, both interacts with the Borderline character, and engages the Borderline behavior. This often throws the person off-center, and promotes a kind of parallel emotional dysregulation within them. The “Reactive” relationship style breaks down into two distinct sub-styles; transpersonal, or the “trans-Borderline”, and counterpersonal, or the “counter-Borderline”.

The “trans-Borderline” is an individual who engages the Borderline character, and is drawn only to the chaos of the disorder itself. Rather than being directly affected, s/he is more apt to stay focused on “cleaning up” after the Borderline personality. This is something akin to the “caretaker/enabler” role found in alcoholic relationships. In both cases, this person is characteristically co-dependent, or set up to be co-dependent in that relationship. S/he acts as enabler, or agent, or both.

The “counter-Borderline”, on the other hand, not only reacts to and integrates the Borderline style, but reflects it, as well. This individual is the most negatively affected by his/her relationship to the Borderline personality. Very often, this person will begin to behave in a manner very similar to a person with a Borderline personality. This type of relationship is very treacherous and, when talking about chaotic relationships with Borderline personalities, this is the sort of situation to which most people are referring. This type of relationship often leaves the NonBP questioning his/her own sanity, and the “emotional hangover” of such a relationship can take a considerable amount of time from which to recover.

References

Further reading

  • “Putting The Pieces Together: A Practical Guide to Recovery from Borderline Personality Disorder” by Joy A. Jensen ISBN 0966703766
  • I Hate You, Don’t Leave Me: Understanding the Borderline Personality by Jerold J. Kreisman, M.D., and Hal Strauss ISBN 0380713055
  • New Hope for People with Borderline Personality Disorder: Your Friendly, Authoritative Guide to the Latest in Traditional and Complementary Solutions by Neil R. Bockian, et al ISBN 0761525726
  • Lost in the Mirror: An Inside Look at Borderline Personality Disorder by Richard A. Moskovitz M.D. ISBN 0878332669
  • The Angry Heart: Overcoming Borderline and Addictive Disorders: An Interactive Self-Help Guide by Joseph Santoro, Ph.D., and Ronald Cohen, Ph.D. ISBN 1572240806
  • Understanding the Borderline Mother: Helping Her Children Transcend the Intense, Unpredictable, and Volatile Relationship by Christine Ann Lawson ISBN 0765703319
  • Cognitive-Behavioral Treatment of Borderline Personality Disorder Dr. Marsha M. Linehan (1993) ISBN 0898621836
  • Borderline Personality Disorder: A Clinical Guide Dr. John G. Gunderson (2001) ISBN 8870787966
  • How I Stayed Alive When My Brain Was Trying to Kill Me: One Person’s Guide to Suicide Prevention Susan Rose Blauner (2003) ISBN 0060936215

Depiction of BPD in movies

External links

Footnotes

  • (ref1) Swartz M, Blazer D, George L, Winfield I. Estimating the prevalence of borderline personality disorder in the community. Journal of Personality Disorders, 1990; 4(3): 257-72.
  • (ref2) Soloff PH, Lis JA, Kelly T, Cornelius J, Ulrich R. Self-mutilation and suicidal behavior in borderline personality disorder. Journal of Personality Disorders, 1994; 8(4): 257-67. & Gardner DL, Cowdry RW. Suicidal and parasuicidal behavior in borderline personality disorder. Psychiatric Clinics of North America, 1985; 8(2): 389-403.
  • (ref3) Zanarini MC, Frankenburg FR. Treatment histories of borderline inpatients. Comprehensive Psychiatry, in press.
  • (ref4) 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.
  • (ref5) Koerner K, Linehan MM. Research on dialectical behavior therapy for patients with borderline personality disorder. Psychiatric Clinics of North America, 2000; 23(1): 151-67.
  • (ref6) Hollander E, et al. Impact of trait impulsivity and state aggression on divalproex versus placebo response in borderline personality disorder. Am J Psychiatry. 2005 Mar;162(3):621-4
  • (ref7) Siever LJ, Koenigsberg HW. The frustrating no-man’s-land of borderline personality disorder. Cerebrum, The Dana Forum on Brain Science, 2000; 2(4).
  • (ref8) Zanarini MC, Frankenburg. Pathways to the development of borderline personality disorder. Journal of Personality Disorders, 1997; 11(1): 93-104.
  • (ref9) Zanarini MC. Childhood experiences associated with the development of borderline personality disorder. Psychiatric Clinics of North America, 2000; 23(1): 89-101.
  • (ref10) Davidson RJ, Jackson DC, Kalin NH. Emotion, plasticity, context and regulation: perspectives from affective neuroscience. Psychological Bulletin, 2000; 126(6): 873-89.
  • (ref11) Davidson RJ, Putnam KM, Larson CL. Dysfunction in the neural circuitry of emotion regulation – a possible prelude to violence. Science, 2000; 289(5479): 591-4.

Adapted for T-VOX from Wikipedia by Jennifer Kirk