Borderline personality disorder

Borderline personality disorder (BPD) is defined within psychiatry and related fields as a disorder characterized primarily by emotional dysregulation, extreme "black and white" thinking in some areas, and turbulent relationships.

The name originated with the idea that individuals exhibiting this type of behavior were on the "borderline" between neurosis and psychosis. This idea has since fallen out of favor, 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 mental illness 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.

Origin of the term

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.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. Studies have also shown a strong correlation between childhood abuse and development of BPD. Zanarini, Gunderson, Marino, Schwartz, & Frankenburg. Childhood experiences of borderline patients. Comprehensive psychiatry, 1989; Jan-Feb;30(1):18-25.Brown GR, Anderson B. Psychiatric morbidity in adult inpatients with childhood histories of sexual and physical abuse. Am J Psychiatry, 1991; 148(1):55-61 There is a high rate of self-injury without suicidal intent, as well as a significant rate of suicide attempts and, in severe cases, successful suicides.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. The suicide rate is approximately 8-10%. ^*Patients often need extensive mental health services, and they account for 20 percent of psychiatric hospitalizations.Zanarini MC, Frankenburg FR. Treatment histories of borderline inpatients. Comprehensive Psychiatry, in press. It is recognized 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 individuals improve over time and are able to lead more stable and happy lives.

Controversy

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 term to be changed or done away with. Dyslimbia has been suggested by Dr. Leland Heller. ^*.

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:

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; 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.

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.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. 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 others 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, attention deficit disorder, 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.

Risk Factors

Patients with Borderline Personality Disorder are at very high risk of death by suicide. Excluding other co-morbid factors (i.e. such factors that add to the risk) patients with BPD have a risk of about 5-10% of death by suicide (about 500 to 1000 times more than the general population). The disorder is often poorly understood by psychiatrists and some psychiatrists simply refuse to accept BPD patients due to their instability (missed appointments, difficulty dealing with them). If a patient with BPD has co-morbid factors of substance abuse (alcohol or other drugs), the risk factor reaches an astounding 58% dying from suicide within five years. If a SSRI or a SNRI drug is prescribed to a patient with BPD without proper supervision and involvement of family caregivers, the risk factor has an added element that has recently been identified for the general patient population. While this group of psychotrophic drugs has been helpful for many patients, side effects, difficulty of withdrawal and risk factors of suicide are often poorly explained. Some physicians do not know how to make the distinction between side effects that are worsened by increase of dose and the symptoms that a patient is experiencing from the disorder. The paradigm of increasing the dose to address the worsening symptoms can be fatal to the patient if the symptoms are in fact a side effect of the drug.

Family members of patients who have been diagnosed should get clear information on the disorder from qualified medical practitioners so they can help their loved ones. Too many doctors, including psychiatrists, do not have a good understanding of this disorder and therefore are not competent to advise family members adequately. This disorder is not easy to understand as the behaviours of victims are very difficult to tolerate and are misunderstood. The question "Why are you doing this?" may remain unanswered or validated by distorted illogical thinking. There is a tendency for some doctors to prescribe tranquilizers such as the benzodiazepine group (includes diazepam (Valium) and lorazepam) for symptoms of anxiety or distress that BPD patients may have, but these drugs can increase impulsivity due to disinhibition and may add to the risk factor. Victims of this disorder may be very intelligent, loving people with strong personalities in terms of holding opinions and defending their ideas, but their self-image is damaged and they seek fulfilment sometimes in very bad environments.

Risk factors can be reduced by proper diagnosis and supportive care most often with involvement of family members. BPD victims need a strong supportive and loving security net of family and caregivers to get through this. Something as simple as validating love for the BPD victim in spite of behaviours can have a huge impact in reducing risk factors. This is not as easy as it sounds, but it is crucial.

The death of a victim of BPD (most often a young person) by their own hand due to inadequate diagnosis and care is a tragedy of incomprehensible proportions.

The risk impacts family members who may themselves become suicidal after the tragedy of loss of their loved one to suicide.

Treatment

Treatments for BPD have improved in recent years. 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. 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. This, however, is in dispute by some psychiatrists who caution against use of SSRI and SNRI drugs due to risk and side-effects. Medication must be carefully monitored with BPD patients as the ultimate risk is suicide, and this can potentially be the direct result of prescription drug mismanagement.

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.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 Antipsychotic drugs may also be used when there are distortions in thinking (e.g., paranoia).Siever LJ, Koenigsberg HW. The frustrating no-man's-land of borderline personality disorder. Cerebrum, The Dana Forum on Brain Science, 2000; 2(4). 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.Zanarini MC, Frankenburg. Pathways to the development of borderline personality disorder. Journal of Personality Disorders, 1997; 11(1): 93-104. Many others have an apparently hereditary form of the disease. Between 40% and 71% of BPD patients report having been sexually abused, usually by a non-caregiver.Zanarini MC. Childhood experiences associated with the development of borderline personality disorder. Psychiatric Clinics of North America, 2000; 23(1): 89-101.

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.Davidson RJ, Jackson DC, Kalin NH. Emotion, plasticity, context and regulation: perspectives from affective neuroscience. Psychological Bulletin, 2000; 126(6): 873-89. 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.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.

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

What is Borderline Personality Disorder?
Borderline Personality Disorder, Raising questions, finding answers from the NIMH website

The Doctors Lounge

Dialectical Behavior Therapy

Depiction of BPD in movies

External links

Footnotes

Personality disorders

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