Borderline personality disorder
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| Borderline personality disorder |
|ICD-10||F60.30 Impulsive type, F60.31 Borderline type|
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Synonyms and Keywords: BPD, unstable self-image, unstable relationships
Borderline Personality Disorder (BPD) is defined as a personality disorder primarily characterized by emotional dysregulation, extreme "black and white" thinking,"splitting", and chaotic relationships. The general profile of the disorder also typically includes a pervasive instability in mood, interpersonal relationships, self-image, identity, and behavior. Moreover, there may be a disturbance in the individual's sense of self. In extreme cases, this disturbance in the sense of self may lead to periods of dissociation. 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 the ability to hold down a job, maintain relationships at home, and interacting in social settings. Comorbidity is common; borderline personality disorder frequently occurs with substance use disorders and mood disorders. Attempted suicide and completed suicide are possible outcomes without proper care and effective therapy. The reference of "BPD" throughout this article refers to borderline personality disorder and not bipolar disorder.
- In the 1930s, there was a debate as to whether BPD should be renamed. The term "borderline" started among clinical use and originated from the idea (now out of favor) of some patients being on the "borderline" between neurosis and psychosis. As a deeper understanding of BPD began to emerge, the disorder could be classified and treated more efficiently once the disorder could be differentiated from neurotic behavior and psychotic behavior.
- In 1980, BPD only became an official Axis II (personality) diagnosis with the publication of DSM-III.
- Individuals who are labeled with "Borderline Personality Disorder" feel it is unhelpful and stigmatizing, as well as simply inaccurate, to support a name change. Criticisms have also come from a feminist perspective. It has also been claimed that, in some circles, "borderline" is used as a "garbage can" diagnosis for individuals who are hard to diagnose. This may be interpreted as meaning "nearly psychotic" despite a lack of empirical support for this conceptualization. It may also be used as a generic label for difficult clients or as an excuse for therapy going badly.
- Borderline personality disorder is characterized by three domains of dysfunction:
- Affect dysregulation
- Behavioral dyscontrol
- Interpersonal hypersensitivity
- Alternative suggestions for names include:
- 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."
- An emotional regulation disorder is a term favored by Dr. Marsha Linehan, pioneer of one of the most popular types of BPD therapy.
- Impulse disorder and 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.
- Mercurial disorder has been proposed by McLean Hospital's Dr. Mary Zanarini.
- 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, along with a common outcome of developmental or attachment trauma.
- Significantly, the above proposals, if adopted, will likely result in the recognition of BPD as a trauma- and/or mood-related disorder, and should move BPD from Axis II to Axis I in the next DSM (DSM-V, due in 2012).
- According to studies, a conceptual framework for future research in borderline personality disorder that is based on oxytocinergic modulation of the following biobehavioral mechanisms:
- In addition, preliminary data point to interactions between the oxytocin and cannabinoid system, with implications for pain processing.
- Borderline personality disorder should be differentiated from other disorders including:
Epidemiology and Demographics
- The prevalence of borderline personality disorder is 1600 to 5900 per 100,000 (1.6% to 5.9%) of the overall population. 
- The prevalence of any personality disorder was 9.1%, with borderline personality disorder being 1.4%.
- Researchers commonly believe that BPD results from a combination of a traumatic childhood, a vulnerable temperament, and stressful maturational events during adolescence or adulthood.
- Otto Kernberg formulated the theory of Borderline Personality based on a premise of failure to develop in childhood. There are, according to Kernberg, three developmental tasks an individual must accomplish:
- When one fails to accomplish a certain developmental task, this often corresponds with an increased risk of developing certain psychopathologies.
- Failing the first developmental task,psychic clarification of self and other, may result in an increased risk to develop varieties of psychosis.
- Not accomplishing the second task, overcoming splitting, may result in an increased risk to develop a borderline personality. 
|Childhood abuse, Trauma, or Negelct||
|Other Developmental Factors||
Natural History, Complications and Prognosis
- Studies suggest that individuals with BPD tend to experience frequent, strong and long-lasting states of aversive tension, often triggered by perceived rejection, being alone, or perceived failure.
- Individuals with BPD may show lability (changeability) between anger and anxiety or between depression and anxiety and temperamental sensitivity to emotional stimuli.
- The negative emotional states particularly associated with BPD have been grouped into four categories:
- Individuals with BPD can be very sensitive to the way others treat them, reacting strongly to perceived criticism or hurtfulness.
- Their feelings about others often shift from positive to negative, generally after a disappointment or perceived threat of losing someone.
- Self-image can also change rapidly from extremely positive to extremely negative.
- Impulsive behaviors are common, including alcohol or drug abuse, unsafe sex, gambling, and recklessness in general.
- Attachment studies suggest individuals with BPD while being high in intimacy- or novelty-seeking can be hyper-alert to signs of rejection or not being valued and tend towards insecure, ambivalent, preoccupied or fearful attitudes towards relationships.
- They tend to view the world generally as dangerous and malevolent, and themselves as powerless, vulnerable, unacceptable and unsure in self-identity.
- Individuals with BPD are often described, including by some mental health professionals (and in the DSM-IV), as deliberately manipulative or difficult, but analyses and findings generally trace behaviors to inner pain and turmoil, powerlessness and defensive reactions, or limited coping and communication skills.
- There has been limited research on family members' understanding of borderline personality disorder and the extent of burden or negative emotion experienced or expressed by family members. Parents of individuals with BPD have been reported to show co-existing extremes of over-involvement and under-involvement.
- BPD has been linked to somewhat increased levels of chronic stress and conflict in romantic relationships, decreased satisfaction of romantic partners, abuse, and unwanted pregnancy; these links may largely be general to personality disorder and subsyndromal problems, but such issues are commonly raised in support groups and published literature for partners of individuals with BPD.
- Suicidal or self-harming behavior is one of the core diagnostic criteria in DSM IV-TR. The management of and recovery from this can be complex and challenging. The suicide rate is approximately 8%-10%.
- The most recognized form of self-injury is auto-mutilation (cutting the self), usually of the arms, but often other areas such as the legs, chest, belly, and face. Self-injury attempts are highly common among patients and may or may not be carried out with suicidal intent.
- BPD is often characterized by multiple low lethality suicide attempts triggered by seemingly minor incidents, and less commonly by high lethality attempts that are attributed to impulsiveness or comorbid major depression, with interpersonal stressors appearing to be particularly common triggers.
- 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:
- Substance abuse is a common problem in BPD, whether due to impulsivity or as a coping mechanism. 50%-70% of psychiatric inpatients with BPD have been found to meet criteria for a substance use disorder.
- Poor prognostic factors include:
- Female gender
- Adolescence and early adulthood
- Identity problems
- Relatives with the same disease
- A diagnosis is based on self-reported experiences of patients, as well as markers for the disorder observed by a psychiatrist, psychologist, or another qualified diagnostician through clinical assessment. This profile may be supported and/or corroborated by long-term patterns of behavior as reported by family members, friends, or co-workers. The list of criteria that must be met for diagnosis is outlined in the DSM-IV-TR.
- An initial assessment generally includes a comprehensive personal and family history. It may also include a physical examination by a physician. Although there are no physiological tests that confirm borderline personality disorder, medical tests may be employed to exclude any co-occurring medical conditions that may present with psychiatric symptoms. These include:
- Blood tests measuring TSH to exclude hypo- or hyperthyroidism
- Basic electrolytes and serum calcium to rule out a metabolic disturbance
- Complete blood count including ESR to rule out a systemic infection or chronic disease
- Serology to exclude syphilis or HIV infection
- Two commonly ordered investigations are:
DSM-V Diagnostic Criteria for Borderline Personality Disorder
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:
- A commonly used mnemonic to remember some features of borderline personality disorder is PRAISE:
Emotionally Unstable Personality Disorder
- The World Health Organization's (WHO) ICD-10 has a comparable diagnosis called Emotionally Unstable Personality Disorder - Borderline type (F60.31). This requires, in addition to the general criteria for personality disorder:
- Disturbances among and uncertainty about self-image, aims, and internal preferences (including sexual).
- Liability to become involved in intense and unstable relationships, often leading to an emotional crisis.
- Excessive efforts to avoid abandonment; recurrent threats or acts of self-harm; and chronic feelings of emptiness.
- The Chinese Society of Psychiatry's (CCMD) has a comparable diagnosis of impulsive personality disorder. A patient diagnosed as having IPD must display "affective outbursts" and "marked impulsive behavior", plus at least three out of eight other symptoms. The construct has been described as a hybrid of the impulsive and borderline subtypes of the ICD's Emotionally Unstable Personality Disorder, and also incorporates six of the nine DSM BPD criteria.
- 1 Therapies
- 1.1 Psychotherapy
- Simple supportive therapy alone may enhance self-esteem and mobilize the existing strengths of individuals with BPD. Specific psychotherapies may involve sessions over several months or, as is particularly common for personality disorders, several years.
- Psychotherapy can often be conducted either with individuals or with groups. Group therapy can aid the learning and practice of interpersonal skills and self-awareness by individuals with BPD although drop-out rates may be problematic.
- 1.2 Dialectical Behavioral Therapy
- Dialectical behavior therapy is derived from cognitive-behavioral techniques (and can be seen as a form of CBT) 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.
- DBT can be based on a biosocial theory of personality functioning in which BPD is seen as a biological disorder of emotional regulation in a social environment experienced as invalidating by the borderline patient.
- 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. Although, whether it has additional efficacy in the overall treatment of BPD appears less clear. Training nurses in the use of DBT has been found to replace a therapeutic pessimism with a more optimistic understanding and outlook.
- 1.3 Schema Therapy
- Schema Therapy (also called Schema-Focused Therapy) is an integrative approach based on cognitive-behavioral or skills-based techniques along with object relations and gestalt approaches. It 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. Limited recent research suggests that it is significantly more effective than Transference-Focused Psychotherapy, with half of the individuals with borderline personality disorder assessed as having achieved full recovery after 4 years, with two-thirds showing clinically significant improvement. Another very small trial has also suggested efficacy.
- 1.4 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.
- 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.
- 1.5 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 over-involved families are often actively struggling with a dependency issue by denial or by anger towards their parents.
- Interest in the use of psychoeducation and skills training approaches for families with borderline members is growing.
- 1.6 Psychoanalysis
- Traditional psychoanalysis has become less commonly used than in the past, both in general and in regard to BPD. This intervention has been linked to an exacerbation of BPD symptoms although there is also evidence of the effectiveness of certain techniques in the context of partial hospitalization.
- 1.7 Transference Focused Psychotherapy
- 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 organization). Unlike in the case of traditional psychoanalysis, the therapist plays a very active role in TFP. In the 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, and that TFP in comparison to Dialectical Behavior Therapy and supportive therapy results in increased reflective functioning (the ability to realistically think about how others think) and a more secure attachment style. Furthermore, TFP has been shown to be as effective as DBT in the improvement of suicidal behavior, and has been more effective than DBT in alleviating anger and in reducing verbal or direct assaultive behavior. Limited research suggests that TFP appears to be less effective than schema-focused therapy while being more effective than no treatment.
- 1.8 Cognitive Analytic Therapy
- 1.1 Psychotherapy
- 2 Medication
- 2.1 Antidepressants
- Selective serotonin reuptake inhibitor (SSRI) antidepressants have been shown in randomized controlled trials to improve the attendant symptoms of anxiety and depression, such as anger and hostility, associated with BPD in some patients.
- Dosage: According to Listening to Prozac, it takes a higher dose of an SSRI to treat mood disorders associated with BPD than depression alone. It also takes about three months for benefit to appear, compared to the three to six weeks for depression.
- 2.2 Antipsychotics
- The newer atypical antipsychotics are claimed to have an improved adverse effect profile than the typical antipsychotics. Antipsychotics are also sometimes used to treat distortions in thinking or false perceptions. Use of antipsychotics has varied, from intermittent, for a brief psychotic or dissociative episode, to more general, particularly atypical antipsychotics, for both those diagnosed with bipolar disorder (BiP), as well as those diagnosed with a borderline personality disorder (BPD).
- Long-term use of antipsychotics is particularly controversial. There are numerous adverse effects with the older medications, notably Tardive dyskinesia (TDK). Atypical antipsychotics are also known for often causing considerable weight gain, with associated health complications.
- Dosage: 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.
- 2.1 Antidepressants
- 3 Mental Health Services and Recovery
- 3.1 Combining Pharmacotherapy and Psychotherapy
- In practice, psychotherapy and medication may often be combined but there is limited data on clinical practice. Efficacy studies often assess the effectiveness of interventions when added to 'treatment as usual' (TAU), which may involve general psychiatric services, supportive counseling, 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, showed significantly more improvement on some measures related to BPD, compared to those undergoing DBT and taking a placebo pill, 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.
- 3.2 Difficulties in Therapy
- There can be unique challenges in the treatment of BPD, eg. hospital care. In psychotherapy, a client may be unusually sensitive to rejection and abandonment and may react negatively (e.g., by harming themselves or withdrawing from treatment) if they sense this. In addition, clinicians may emotionally distance themselves from individuals with BPD for self-protection or due to the stigma associated with the diagnosis, leading to a self-fulfilling prophecy and a cycle of stigmatization to which both patient and therapist may contribute to.
- Some psychotherapies, for example, DBT, were developed partially 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. Comorbid disorders, particularly substance use disorders, can complicate attempts to achieve remission.
- 3.3 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. Some individuals may forego them or not benefit (enough) from them. It has been argued that diagnostic categorization can have limited utility in directing therapeutic work in this area and that, in some cases, it is only with reference to past and current relationships that "borderline" behavior can be understood as partly adaptive and how people can best be helped.
- 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, employment - helping feelings of competence (e.g. self-efficacy), having a social role and being valued by others, boosting self-esteem.
- 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, particularly in Europe, although their usage has declined many have specialized in the treatment of severe personality disorder.
- Psychiatric rehabilitation services aimed at helping people with mental health problems to reduce psychosocial disability, engage in meaningful activities and avoid stigma and social exclusion of people who suffer from BPD. There are also many mutual-support or co-counseling groups run by and for individuals with BPD. A goal may be full recovery rather than reliance on services.
- Data indicates that substantial percentages of people diagnosed with BPD can achieve remission even within a year or two. A longitudinal study found that six years after being diagnosed with BPD, 56% showed good psychosocial function compared to the 26% at baseline. Although vocational achievement was more limited even compared to those with other personality disorders, those whose symptoms had remitted were significantly more likely to have a good relationship with a spouse/partner, at least one parent, good work/school performance, a sustained work/school history, good global functioning, and good psychosocial functioning.
- 3.1 Combining Pharmacotherapy and Psychotherapy
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- Emotional dysregulation
- Post-traumatic stress disorder (PTSD)
- Complex post-traumatic stress disorder (C-PTSD)
- Dialectical behavior therapy
- Bipolar disorder
- DSM-IV Codes#Personality Disorders
- Structured Clinical Interview for DSM-IV
- Dissociative disorders