Borderline personality disorder

In psychiatry, borderline personality disorder (BPD) is a personality disorder characterised by extreme 'black and white' thinking, mood swings, emotional reasoning, disrupted relationships and difficulty in functioning in a way society accepts as normal.

The name comes from the DSM-IV-TR; the ICD-10 in Europe has an equivalent called Emotionally Unstable Personality Disorder. Psychiatrists describe borderline personality disorder as a serious mental illness characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior. This instability often disrupts family and work life, long-term planning, and the individual's sense of self-identity.

Originally thought to be at the "borderline" between psychosis and neurosis, people with BPD suffer from a disorder of emotion regulation. While less well-known than schizophrenia or bipolar disorder (manic-depression), BPD is more common, affecting two percent of adults, mostly young women. 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. In some instances people with BPD kill themselves by accident in a case of self-injury that goes too far. Patients often need extensive mental health services, and they account for 20 percent of psychiatric hospitalizations. With help, however, many will improve over time and are eventually able to lead productive lives.

Contents

1 Diagnostic criteria (DSM-IV-TR)

2 Symptoms

3 Treatment

3.1 Dialectical Behavior Therapy

4 Recent research findings

5 Future progress

6 Effects on family members

Diagnostic criteria (DSM-IV-TR)

The DSM-IV-TR, a widely used manual for diagnosing mental disorders, defines borderline personality disorder (see DSM cautionary statement) 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:

frantic efforts to avoid real or imagined abandonment. (not including suicidal or self-mutilating behavior covered in Criterion 5)
a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
identity disturbance: markedly and persistently unstable self-image or sense of self
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)
recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
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)
chronic feelings of emptiness
inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
transient, stress-related paranoid ideation or severe dissociative symptoms

Symptoms

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. These may be associated with episodes of impulsive aggression, self-injury including cutting, 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.

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 idealize the other person, but when a slight separation or conflict occurs, they switch unexpectedly to the other extreme and angrily accuse the other person of not caring for them at all. Even with family members, individuals with BPD are highly sensitive to rejection, reacting with anger and distress to such mild separations as a vacation, a business trip, or a sudden change in plans. These fears of abandonment seem to 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. Suicide threats and 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, and other personality disorders.

Treatment

Treatments for BPD have improved in recent years. Since about 1989, Prozac and other selective serotonin reuptake inhibitor antidepressants (SSRIs) have repeatedly been shown to remarkably improve the symptoms of BPD. 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 to start seeing benefit, compared to 2 weeks for depression. The previous antidepressants, the tricyclics, were not often helpful, and often worsened the symptoms. Increasing evidence implicates inadequate serotonergic neurotransmission as the central cause of the impaired modulation of emotional and behavioral responses to everyday life, manifesting as "overreacting to everything.". Even thinking is recruited by the intense (that is, underregulated) emotionality so that the world is perceived primitively, in intense black and white terms, as if by a three year-old.

Other pharmacological treatments are often prescribed for certain other specific target symptoms shown by the individual patient. Mood stabilizers (lithium or certain antiepileptic drugs) may be helpful for explosive anger or if there is an admixture of bipolar disorder. Antipsychotic drugs may also be used when there are distortions in thinking (e.g. paranoia). Group and individual psychotherapy are at least partially effective for many patients.

Dialectical Behavior Therapy

In 1991, a new psychosocial treatment termed Dialectical Behavior 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 method is based on negotiation between therapist and patient. The dialectic referred to in the treatment's name is of the therapist's acceptance and validation of the patient as he or she is, on the one hand, whilst at the same time insisting on the need for change. The idea is to give the patient tools he never acquired as a child, typically to control and deal with his emotions. Some patients, when asked after several years of treatment, why they have stopped inflicting self-injury, answer "I picture myself sitting with my psychotherapist, and we talk about why I want to injure myself."

Recent research findings

Although the cause of BPD is unknown, 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. 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. Others have impeccably innocuous histories. Researchers believe that BPD results from a combination of individual vulnerability, say inherited low serotonergic neurotranmission, and environmental stress, neglect or abuse as young children which has also been shown to lower serotonergic neurotranmission, and maturational events that trigger the onset of the disorder as teenagers or young adults. Adults with BPD are also considerably more likely to be the victim of violence, including rape and other crimes. This may result from both harmful environments as well as impulsivity and poor judgment in choosing partners and lifestyles.

National Institute of Mental Health-funded neuroscience research is revealing brain mechanisms underlying the impulsively, 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. 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.

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 can be managed with help from behavioral interventions and medications, much like people manage susceptibility to diabetes or high blood pressure.

Future progress

Studies that translate basic findings about the neural basis of temperament, mood regulation and cognition into clinically relevant insights which bear directly on BPD represent a growing area of research supported by the National Institute of Mental Health (NIMH) in the USA. 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 in BPD on brain hormones. 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 pinpoint specific environmental factors and personality traits that predict a more favorable outcome. The Institute is also collaborating with a private foundation to help attract new researchers to develop a better understanding and better treatment for BPD.

Effects on family members

An interesting area of research relating to BPD is the study of the effects of the disorder on other family members and significant others in the lives of those with traits of borderline personality disorder. These people refer to themselves as NonBPs. Living with someone with BPD traits is often disorienting and difficult. NonBPs require support from the mental health community as they help those with the disorder while maintaining strength in their own view of reality.

Related books

"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
Stop Walking on Eggshells: Taking Your Life Back When Someone You Care About Has Borderline Personality Disorder by Paul T. Mason, M.S., and Randy Kreger ISBN 157224108X
The Stop Walking on Eggshells Workbook: Practical Strategies for Living With Someone Who Has Borderline Personality Disorder by Randi Kreger, James Paul Shirley ISBN 1572242760 [for NonBPs]
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