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Borderline personality disorder

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Borderline personality disorder
SpecialtyPsychiatry, clinical psychology Edit this on Wikidata
Personality disorders
Cluster A (odd)
Cluster B (dramatic)
Cluster C (anxious)
Not otherwise specified
Depressive
Others

Borderline personality disorder (BPD) (called emotionally unstable personality disorder, borderline type in the ICD-10) is a personality disorder characterized by unusual variability and depth of moods. These moods may secondarily affect cognition and interpersonal relationships.[n 1]

Other symptoms of BPD include impulsive behavior, intense and unstable interpersonal relationships, unstable self-image, and an unstable sense of self. An unstable sense of self can lead to periods of dissociation.[1] Borderline individuals often engage in idealization and devaluation of others, alternating between high positive regard and heavy disappointment or dislike. This behavior reflects a black-and-white thinking style, as well as the intensity with which borderline individuals feel emotions. Self-harm and suicidal behavior are common and may require inpatient psychiatric care.[2]

This disorder is only recognized by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) in individuals over the age of 18. However, symptoms of BPD can also be found in children and adolescents. Without treatment, symptoms may worsen, potentially leading to suicide attempts.[n 2]

There is an ongoing debate about the terminology of this disorder, especially the word "borderline."[3][4] The ICD-10 manual refers to this disorder as Emotionally unstable personality disorder and has similar diagnostic criteria. There is a related concern that the diagnosis of BPD stigmatizes borderline individuals and supports discriminatory practices.[5]

Signs and symptoms

The main features of BPD are impulsive behavior and instability of emotions, interpersonal relationships, and self-image.[1]

Behaviour

Emotional vulnerability

Borderline individuals feel emotions more easily, more deeply, and for longer than do others.[6] An emotion typically lasts for 12 seconds, but it can last up to 20 percent longer in borderline individuals.[7] Moreover, the emotions of people with BPD repeatedly re-fire, or reinitiate, prolonging their emotional reactions even further.[7] Once the emotion has stopped firing, it also takes longer in borderline individuals for its effects to subside.[8]

The sensitivity, intensity, and duration with which borderline individuals feel emotions have both positive and negative effects.[8] People with BPD are often exceptionally idealistic, joyful, and loving.[9] However, they can feel overwhelmed by negative emotions, experiencing intense grief instead of sadness, shame and humiliation instead of mild embarrassment, rage instead of annoyance, and panic instead of nervousness.[9] Individuals with BPD are especially sensitive to feelings of rejection, isolation, and perceived failure.[n 3] Before learning other coping mechanisms, borderline individuals' efforts to manage or escape from their intense negative emotions can lead to self-injury or suicidal behavior.[10] People with BPD are often aware of the intensity of their negative emotional reactions and, since they cannot regulate them, shut them down entirely.[8] This can be harmful to the borderline individual, as negative emotions alert people to the presence of a problematic situation and move them to address it.[8]

While borderline individuals also feel joy intensely, they are especially prone to dysphoria, or feelings of mental and emotional distress. Zanarini et al recognize four categories of dysphoria that are typical of BPD: extreme emotions; destructiveness or self-destructiveness; feeling fragmented or lacking identity; and feelings of victimization.[11] Within these categories, a BPD diagnosis was strongly associated with a combination of three specific states: 1) feeling betrayed, 2) "feeling like hurting myself", and 3) feeling completely out of control.[11] Since there is great variety in the types of dysphoria experienced by borderline individuals, the amplitude of the distress is a helpful indicator of borderline personality disorder.[11]

In addition to intense emotions, borderline individuals experience emotional lability, or changeability. Although the term suggests rapid changes between depression and elation, the mood swings of borderline individuals actually occur more frequently between anger and anxiety, and between depression and anxiety.[12]

Impulsivity

Impulsive behaviors are common, including: substance or alcohol abuse, eating disorders, unprotected or promiscuous sex, and reckless driving.[13] Labeling sex with multiple partners as "promiscuous" is controversial; see Gender under Controversies.

Interpersonal relationships

Individuals with BPD can be very sensitive to the way others treat them, feeling intense joy and gratitude at perceived expressions of kindness, and intense sadness or anger at perceived criticism or hurtfulness.[14] Their feelings about others often shift from positive to negative after a disappointment, a perceived threat of losing someone, or a perceived loss of esteem in the eyes of someone they value. This phenomenon, sometimes called splitting or black-and-white thinking, includes a shift from idealizing others (feeling great admiration and love) to devaluing them (feeling great anger or dislike).[15] Combined with mood disturbances, idealization and devaluation can undermine relationships with family, friends, and co-workers.[16] Self-image can also change rapidly from very positive to very negative.

While strongly desiring intimacy, borderline individuals tend toward insecure, avoidant or ambivalent, or fearfully preoccupied attachment patterns in relationships,[17] and they often view the world as generally dangerous and malevolent.[14] BPD is linked to increased levels of chronic stress and conflict in romantic relationships, decreased satisfaction of romantic partners, abuse and unwanted pregnancy. However, these factors appear to be linked to personality disorders in general.[18]

Manipulation to obtain nurturance is considered to be a common feature of BPD by many who treat the disorder, as well as by the DSM-IV.[19][20] However, some mental health professionals caution that an overemphasis on, and an overly broad definition of, "manipulation" can lead to misunderstanding and prejudicial treatment of borderline individuals, particularly within the health care system.[21] See Manipulative behavior and Stigma under Controversies.

Self-harm and suicidal behavior

Self-harming or suicidal behavior is one of the core diagnostic criteria in the DSM IV-TR. Management of and recovery from this behavior can be complex and challenging.[22] The suicide rate among BPD patients is 8 to 10 percent.[23][24]

Self-injury is common, and can take place with or without suicidal intent.[25][26] The reported reasons for non-suicidal self-injury (NSSI) differ from the reasons for suicide attempts.[10] Reasons for NSSI include expressing anger, self-punishment, generating normal feelings (often in response to dissociation), and distracting oneself from emotional pain or difficult circumstances.[10] In contrast, suicide attempts typically reflect a belief that others will be better off following the suicide.[10] Both suicidal and non-suicidal self-injury are a response to feeling negative emotions.[10]

Sexual abuse can be a particular trigger for suicidal behavior in adolescents with BPD tendencies.[27]

Diagnosis

Diagnosis is based on a clinical assessment by a qualified mental health professional. The assessment consists of the client's self-reported experiences as well as the clinician's observations. With permission from the client, the assessment may include interviews with friends or family members. The criteria for diagnosis are outlined in the DSM-IV-TR.[1] Five or more criteria must be present for diagnosis.

Diagnostic and Statistical Manual

The Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV-TR) defines borderline personality disorder (in Axis II Cluster B) as:[1][20]

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, as indicated by five (or more) of the following:
  1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-injuring 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., promiscuous sex, excessive spending, eating disorders, binge eating, substance abuse, reckless driving). Note: Do not include suicidal or self-injuring behavior covered in Criterion 5
  5. Recurrent suicidal behavior, gestures, threats or self-injuring behavior such as cutting, interfering with the healing of scars or picking at oneself (excoriation).
  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 anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
  9. Transient, stress-related paranoid ideation, delusions or severe dissociative symptoms

It is a requirement of DSM-IV that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

International Classification of Disease

The World Health Organization's ICD-10 defines a conceptually similar disorder to borderline personality disorder, called (F60.3) Emotionally unstable personality disorder. Its two subtypes are described below.[28]

F60.30 Impulsive type

At least three of the following must be present, one of which must be (2):

  1. marked tendency to act unexpectedly and without consideration of the consequences;
  2. marked tendency to engage in quarrelsome behavior and to have conflicts with others, especially when impulsive acts are thwarted or criticized;
  3. liability to outbursts of anger or violence, with inability to control the resulting behavioral explosions;
  4. difficulty in maintaining any course of action that offers no immediate reward;
  5. unstable and capricious (impulsive, whimsical) mood.
F60.31 Borderline type

At least three of the symptoms mentioned in F60.30 Impulsive type must be present [see above], with at least two of the following in addition:

  1. disturbances in and uncertainty about self-image, aims, and internal preferences;
  2. liability to become involved in intense and unstable relationships, often leading to emotional crisis;
  3. excessive efforts to avoid abandonment;
  4. recurrent threats or acts of self-harm;
  5. chronic feelings of emptiness.
  6. demonstrates impulsive behavior, e.g., speeding, substance abuse[29]

The ICD-10 also describes some general criteria that define what is considered a personality disorder.

Chinese Society of Psychiatry

The Chinese Society of Psychiatry's CCMD has a comparable diagnosis of Impulsive Personality Disorder (IPD). A person diagnosed with IPD must display "affective outbursts" and "marked impulsive behavior," plus at least three of eight other symptoms. IPD is considered to be a hybrid of the impulsive and borderline subtypes of the ICD-10's Emotionally Unstable Personality Disorder, and it includes six of the nine DSM-IV BPD criteria.[30]

Millon's subtypes

Theodore Millon, a psychologist noted for popular works on personality disorders, has unofficially proposed four subtypes of BPD.[n 4][n 5] He suggests that an individual diagnosed with BPD may exhibit none, one, or more of the following:

Family members

Family members of borderline individuals often feel confused and frustrated by unclear diagnoses, ineffective treatments, and inaccurate information. Theorists' efforts to equate BPD with post-traumatic stress disorder[31] (see Gender and Terminology), as well as findings that a majority of BPD individuals have experienced childhood trauma (see Childhood abuse), stigmatize family members by implying that they bear primary responsibility for this disorder, despite evidence of diverse causes (see Causes).

A study in 2003 found that family members' experience of burden, emotional distress, and hostility toward borderline individuals were actually worse when they had greater knowledge about BPD.[32] These findings indicate a need to investigate the quality and accuracy of the information received by family members.[32]

Parents of adults with BPD are often both over-involved and under-involved in family interactions.[33] In romantic relationships, BPD is linked to increased levels of chronic stress and conflict, decreased satisfaction of romantic partners, abuse, and unwanted pregnancy. However, these links may apply to personality disorders in general.[18]

Adolescence

Onset of symptoms typically occurs during adolescence or young adulthood, although symptoms can sometimes be observed in children. Clinicians are discouraged from diagnosing anyone with BPD before the age of 18, due to adolescence and a still-developing personality. However, BPD can sometimes be diagnosed before age 18, in which case the features must have been present and consistent for at least 1 year.[1]

A BPD diagnosis in adolescence might predict that the disorder will continue into adulthood. Earlier diagnoses may be helpful in creating a more effective treatment plan for the child or teen.[1][34]

Differential diagnosis and comorbidity

Comorbid (co-occurring) conditions are common in BPD. Compared to those diagnosed with other personality disorders, borderline individuals showed a higher rate of also meeting criteria for[35]

A 1998 study found that over 90 percent of borderline individuals meet criteria for mood disorders (especially major depression), over 80 percent for an anxiety disorder, and about 10 percent for somatoform disorders.[35] Gender differences existed in diagnoses for PTSD, alcohol and substance abuse, and eating disorders. A higher percentage of male patients with BPD met criteria for alcohol and substance abuse/dependency, while a higher percentage of female patients met criteria for PTSD, social anxiety, and eating disorders.[35][36]

Gender differences in Axis I comorbid diagnosis
Approximate values, 1998[35]

Axis I diagnosis Male Female
Mood disorders 90 % 90 %
Anxiety disorders (including PTSD) 80 % 80 %
PTSD 35 % 61 %
Alcohol abuse/dependence 74 % 46 %
Overall substance abuse/dependence 65 % 41 %
Anorexia nervosa _7 % 25 %
Bulimia nervosa 10 % 30 %
Eating disorder otherwise not specified (mostly binging or purging) 11 % 30 %
Somatoform disorders 10 % 10 %
Psychotic disorders _1 % _1 %

Mood disorders

Borderline personality disorder and mood disorders, such as major depressive disorder and bipolar disorders, are often comorbid.[16] Some features of borderline personality disorder may resemble those of mood disorders, complicating the diagnosis.[37][38][39]

Symptoms known as "mood swings" are common in both BPD and bipolar disorders. In borderline personality disorder, the term refers to marked intensity and variability of mood[citation needed], typically in response to external psychosocial and intrapsychic stressors. Changes in mood, and changes in intensity, may occur abruptly and last for minutes, hours, days, or weeks.[40] At face value, there can appear to be overlap between the affective lability of BPD and the rapid mood cycling of bipolar disorders.[41][42] However, bipolar disorders generally involve higher levels of sleep and appetite disturbance, as well as a marked non-reactivity of mood, whereas BPD involves a marked reactivity of mood and severe sleep disturbance is rare.[43]

While BPD was once considered to be a mild form of bipolar disorders,[44][45] or to exist on the bipolar spectrum, this would require that the underlying mechanism causing these symptoms be the same for both conditions. Differences in phenomenology, family history, longitudinal course, and responses to treatment indicate that this is not the case.[46]

Benazzi et al suggest that the DSM-IV BPD diagnosis combines two unrelated characteristics: an affective instability dimension related to Bipolar-II, and an impulsivity dimension not related to Bipolar-II.[47]

Premenstrual dysphoric disorder

Premenstrual dysphoric disorder occurs in 3-8 percent of women. Symptoms begin 5–11 days before a woman's period and cease a few days after it begins.[48] Symptoms include: marked mood swings, irritability, depressed mood, feeling hopeless or suicidal, a subjective sense of being overwhelmed or out of control, anxiety, binge eating, difficulty concentrating, and substantial impairment of interpersonal relationships.[49][50] PMDD typically begins in patients' early twenties, but many women wait until their early 30's to seek treatment.[49] The timing and duration of symptoms is a major distinguishing characteristic between BPD and PMDD, as the symptoms of PMDD only take place during the luteal phase of a woman's menstrual cycle,[49] whereas BPD symptoms occur persistently at all stages of the menstrual cycle. In addition, the symptoms of PMDD do not include impulsivity.

Alcohol or substance abuse

Prolonged alcohol abuse can cause behavior resembling BPD.

Causes

As with other mental disorders, the causes of BPD are complex and not fully understood.[4] Evidence suggests that BPD and post-traumatic stress disorder (PTSD) are closely related.[31] However, research also suggests diverse possible causes of BPD, including a history of childhood trauma,[51] brain abnormalities, genetic predisposition, neurobiological factors, and environmental factors.[4][52]

Brain abnormalities

Hippocampus

The hippocampus is smaller in people with BPD. This trait is shared by individuals with post-traumatic stress disorder. However, only in BPD are both the hippocampus and the amygdala smaller.[53]

Amygdala

The amygdala is smaller and more active in people with BPD.[53] Decreased amygdala volume has also been found in people with obsessive-compulsive disorder.[54] One study has found unusually strong activity in borderline individuals’ left amygdalas when experiencing and viewing displays of negative emotions.[55] As the amygdala is a major structure involved in generating negative emotions, this might explain the unusual strength and longevity of fear, sadness, anger, and shame experienced by borderline individuals, as well as their heightened sensitivity to displays of these emotions in others.[53]

Prefrontal cortex

The prefrontal cortex is less active in people with BPD, especially when recalling memories of abandonment.[56] This relative inactivity occurs in the right anterior cingulate (areas 24 and 32).[56] Given its role in regulating emotional arousal, the relative inactivity of the prefrontal cortex might explain the difficulties borderline individuals experience in regulating their emotions and responses to stress.[57]

Hypothalamic-pituitary-adrenal axis

The hypothalamic-pituitary-adrenal axis (HPA axis) regulates cortisol production, which is released in response to stress. Cortisol production is elevated in people with BPD, indicating a hyperactive HPA axis in these individuals.[58] This causes them to experience a greater biological stress response, which might explain their greater vulnerability to irritability.[59] Since traumatic events can increase cortisol production and HPA axis activity, borderline individuals' unusual activity in the HPA axis may be related to the traumatic childhood and maturational events that correlate with BPD.[59] Conversely, by heightening their sensitivity to stressful events, borderlines' increased cortisol production may predispose them to experience stressful childhood and maturational events as traumatic.

Increased cortisol production is also associated with suicidal behavior.[60]

Childhood abuse

There is a strong correlation between child abuse, especially child sexual abuse, and development of BPD.[51][61][62][63][64] Many individuals with BPD report a history of abuse and neglect as young children.[65] Patients with BPD have been found to be significantly more likely to report having been verbally, emotionally, physically or sexually abused by caregivers of either gender. They also report a high incidence of incest and loss of caregivers in early childhood.[66]

Individuals with BPD were also likely to report having caregivers of both sexes deny the validity of their thoughts and feelings. Caregivers were also reported to have failed to provide needed protection and to have 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.[66]

Additionally, women with BPD who reported a previous history of neglect by a female caregiver and abuse by a male caregiver were consequently at significantly higher risk of reporting sexual abuse by a non-caregiver.[66] It has been suggested that children who experience chronic early maltreatment and attachment difficulties may go on to develop borderline personality disorder.[67]

Genetics

The heritability of BPD is estimated to be .65.[68] That is, 65 percent of the variability in symptoms among different individuals with BPD can be explained by genetic differences; note that this is different from saying that 65 percent of BPD is caused by genes. Twin studies may overestimate the effect of genes on variability in personality disorders due to the complicating factor of a shared family environment.[69]

Twin, sibling and other family studies indicate partial heritability for impulsive aggression, but studies of serotonin-related genes have suggested only modest contributions to behavior.[70]

Neurobiological factors

Estrogen

Individual differences in women’s estrogen cycles may be related to the expression of BPD symptoms in female patients.[71] A 2003 study found that women’s BPD symptoms were predicted by changes in estrogen levels throughout their menstrual cycles, an effect that remained significant when the results were controlled for a general increase in negative affect.[72]

When women who were already experiencing high levels of BPD symptoms began using estrogen-based oral contraceptives, their BPD symptoms worsened significantly.[72]

Non-traumatic developmental factors

The intensity and reactivity of a person's negative affectivity, or tendency to feel negative emotions, predicts BPD symptoms more strongly than does childhood sexual abuse.[73] This finding, differences in brain structure (see Brain abnormalities), and the fact that some patients with BPD do not report a traumatic history,[74] suggest that BPD is distinct from the post-traumatic stress disorder that frequently accompanies it. Thus researchers examine developmental causes in addition to childhood trauma.

Writing in the psychoanalytic tradition, Otto Kernberg argues that a child's failure to achieve the developmental task of psychic clarification of self and other and failure to overcome splitting might increase the risk of developing a borderline personality.[75]

A child's ability to tolerate delayed gratification at age 4 does not predict later development of BPD.[76]

Mediating and moderating factors

Executive function

High executive function appears to mediate the relationship between rejection sensitivity and BPD symptoms, potentially reducing or protecting against BPD symptoms.[77]

Family environment

Family environment mediates the effect of child sexual abuse on the development of BPD. An unstable family environment predicts the development of the disorder, while a stable family environment may buffer against it.[78]

Self-complexity

Self-complexity, or considering one’s self to have many different characteristics, appears to moderate the relationship between Actual-Ideal self-discrepancy and the development of BPD symptoms. That is, for individuals who believe that their actual characteristics do not match the characteristics that they hope to acquire, high self-complexity reduces the impact of their conflicted self-image on BPD symptoms. However, self-complexity does not moderate the relationship between Actual-Ought self-discrepancy and the development of BPD symptoms. That is, for individuals who believe that their actual characteristics do not match the characteristics that they should already have, high self-complexity does not reduce the impact of their conflicted self-image on BPD symptoms. The protective role of self-complexity in Actual-Ideal self-discrepancy, but not in Actual-Ought self-discrepancy, suggests that the impact of conflicted or unstable self-image in BPD depends on whether the individual views her self in terms of characteristics that she hopes to acquire, or in terms of characteristics that she should already have.[79]

Thought suppression

A 2005 study found that thought suppression, or conscious attempts to avoid thinking certain thoughts, mediates the relationship between emotional vulnerability and BPD symptoms.[80] A later study found that the relationship between emotional vulnerability and BPD symptoms is not necessarily mediated by thought suppression. However, this study did find that thought suppression mediates the relationship between an invalidating environment and BPD symptoms.[81]

Management

Main article: Management of borderline personality disorder

Psychotherapy is the primary treatment for borderline personality disorder.[82] Treatments should be based on the needs of the individual, rather than upon the general diagnosis of BPD. Medications are useful for treating comorbid disorders, such as depression and anxiety.[83] Short-term hospitalization has not been found to be more effective than community care for improving outcomes or long-term prevention of suicidal behavior in those with BPD.[84]

Psychotherapy

Long-term psychotherapy is currently the treatment of choice for BPD.[85] There are four such treatments available: mentalization-based treatment (MBT), transference-focused psychotherapy, dialectical behavior therapy (DBT), and schema-focused therapy. Mentalization-based therapy and transference-focused psychotherapy are based on psychodynamic principles, and dialectical behavior therapy and schema-focused therapy are based on cognitive-behavioral principles.[85] All four have been found to reduce some symptoms of BPD, especially self-injury, indicating that long-term therapy of some kind is better than no treatment.[85] Randomized controlled trials have shown that DBT and MBT are the most effective.[86][87] As of July 2006, DBT was found to have the most empirical support,[86] but DBT and MBT share many similarities.[87] Researchers are interested in developing shorter versions of these therapies to increase accessibility, to relieve the financial burden on patients, and to relieve the resource burden on treatment providers.[85][87]

A special problem of psychotherapy with borderline patients is intense projection. It requires the psychotherapist to be flexible in considering negative attributions by the patient rather than quickly interpreting the projection.[88]

Medications

A 2010 review by the Cochrane collaboration found that no medications show promise for "the core BPD symptoms of chronic feelings of emptiness, identity disturbance and abandonment." However, the authors found that some medications may impact isolated symptoms associated with BPD or the symptoms of comorbid conditions.[89]

Of the typical antipsychotics studied in relation to BPD, haloperidol may reduce anger, and flupenthixol may reduce the likelihood of suicidal behavior. Among the atypical antipsychotics, aripiprazole may reduce interpersonal problems, impulsivity, anger, psychotic paranoid symptoms, depression, anxiety, and general psychiatric pathology. Olanzapine may decrease affective instability, anger, psychotic paranoid symptoms, and anxiety, but a placebo had a greater ameliorative impact on suicidal ideation than olanzapine did. The effect of Ziprasidone was not significant.[89]

Of the mood stabilizers studied, valproate semisodium may ameliorate depression, interpersonal problems, and anger. Lamotrigine may reduce impulsivity and anger; topiramate may ameliorate interpersonal problems, impulsivity, anxiety, anger and general psychiatric pathology. The effect of carbamazepine was not significant effect. Of the antidepressants, amitriptyline may reduce depression, but mianserin, fluoxetine, fluvoxamine and phenelzine sulfate showed no effect. Omega-3 fatty acid may ameliorate suicidality and improve depression. As of 2010, trials with these medications had not been replicated, and the effect of long-term use had not been assessed.[89]

Because of weak evidence and the potential for serious side effects from some of these medications, the UK National Institute for Health and Clinical Excellence (NICE) 2009 clinical guideline for the treatment and management of BPD recommends: "Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder." However, "drug treatment may be considered in the overall treatment of comorbid conditions." They suggest a "review of the treatment of people with borderline personality disorder who do not have a diagnosed comorbid mental or physical illness and who are currently being prescribed drugs, with the aim of reducing and stopping unnecessary drug treatment."[90]

Services

Individuals with BPD sometimes use mental health services extensively. They accounted for about 20 percent of psychiatric hospitalizations in one survey.[91] 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.[92] Experience of services varies.[93] Assessing suicide risk can be a challenge for mental health services (and patients themselves tend to underestimate the lethality of self-injurious behaviours) with typically a chronically elevated risk of suicide much above that of the general population and a history of multiple attempts when in crisis.[94] Approximately half the individuals who commit suicide meet criteria for a personality disorder. Borderline personality disorder remains the most commonly associated personality disorder with suicide.[95]

Prognosis

Data indicate that people with BPD often make good progress. Around a third (depending on criteria used) of people diagnosed with BPD achieve remission within a year or two.[96] A longitudinal study found that, six years after being diagnosed with BPD, 56% had good psychosocial functioning compared to 26% at baseline. While vocational achievement was generally 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 and at least one parent, good work/school performance, a sustained work/school history, good global functioning and good psychosocial functioning.[97]

Another study found that ten years from baseline (during a hospitalization), 86% of patients had sustained remission of symptoms, with around half achieving recovery defined as being free of symptoms and achieving certain levels of both social and vocational functioning.[98]

Particular difficulties have been observed in the relationship between some care providers and some individuals diagnosed with BPD. A majority of psychiatric staff report finding individuals with BPD moderately to extremely difficult to work with, and more difficult than other client groups.[99] Some clients feel a diagnosis is helpful, allowing them to understand they are not alone, and to connect with others who have BPD and who have developed helpful coping mechanisms. On the other hand, some 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 incorrectly perceived as manipulative, and that they had limited access to care.[100] Attempts are made to improve public and staff attitudes.[101][102]

Epidemiology

The prevalence of BPD in the general population ranges from 1 to 2 percent.[96][103] 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,[1] although the reasons for this are not clear.[104]

The prevalence of BPD in the United States has been calculated as 1 percent to 3 percent of the adult population,[4] with approximately 75 percent of those diagnosed being female.[105] It has been found to account for 20 percent of psychiatric hospitalizations.[citation needed]

A 2007 study found that 29.5 percent of new inmates in Iowa fit a diagnosis of borderline personality disorder.[106] The National Education Alliance for Borderline Personality Disorder (NEABPD) reports an overall prevalence of 17 percent in the U.S. prison population.[107] These high numbers may be related to the high frequency of substance abuse and substance use disorders among borderline individuals, which the NEABPD reports to be 38 percent.[107]

History

The coexistence of intense, divergent moods within an individual was recognized by Homer, Hippocrates and Aretaeus, the last describing the vacillating presence of impulsive anger, melancholia and mania within a single person. The concept was revived by Swiss physician Théophile Bonet in 1684 who, using the term folie maniaco-mélancolique,[n 6] described the phenomenon of unstable moods that followed an unpredictable course. Other writers noted the same pattern, including the American psychiatrist C. Hughes in 1884 and J.C. Rosse in 1890, who called the disorder "borderline insanity".[108] In 1921, Kraepelin identified an "excitable personality" that closely parallels the borderline features outlined in the current concept of BPD.[n 1]

The first significant psychoanalytic work to use the term "borderline" was written by Adolf Stern in 1938.[109] It described a group of patients suffering from what he thought to be a mild form of schizophrenia, on the borderline between neurosis and psychosis.

The 1960s and 1970s saw a shift from thinking of the condition as borderline schizophrenia to thinking of it as a borderline affective disorder (mood disorder), on the fringes of Bipolar disorder, cyclothymia and dysthymia. In the DSM-II, stressing the intensity and variability of moods, it was called cyclothymic personality (affective personality).[1] While the term "borderline" was evolving to refer to a distinct category of disorder, psychoanalysts such as Otto Kernberg were using it to refer to a broad spectrum of issues, describing an intermediate level of personality organization[n 1] between neurosis and psychosis.[110]

After standardized criteria were developed[111] to distinguish it from mood disorders and other Axis I disorders, BPD became a personality disorder diagnosis in 1980 with the publication of the DSM-III.[96] The diagnosis was distinguished from sub-syndromal schizophrenia, which was termed "Schizotypal personality disorder".[110] The DSM-IV Axis II Work Group of the American Psychiatric Association finally decided on the name "borderline personality disorder," which is still in use by the DSM-IV today.[n 7] However, the term "borderline" has been described as uniquely inadequate for describing the symptoms characteristic of this disorder.[112]

Controversies

Credibility and validity of testimony

The credibility of individuals with personality disorders has been questioned at least since the 1960’s.[113] Two concerns are borderline individuals' dissociative episodes and the belief that lying is a key component of this condition.

Dissociation

Researchers disagree about whether dissociation, or a sense of detachment from emotions and physical experiences, impacts borderline individuals' ability to recall the specifics of past events. A 1999 study reported that the specificity of autobiographical memory was decreased in BPD patients.[114] The researchers found that decreased ability to recall specifics was correlated with patients' levels of dissociation.[114] However, a larger study in 2010 found that people with BPD and without depression had more specific autobiographical memory than did people without BPD and with depression. The presence of depression (though not its severity) was the main factor related to a decreased ability to recall the specifics of past events. This decreased ability was found to be unrelated to dissociation and other symptoms of BPD,[115] thus supporting the reliability of the testimony of borderline individuals.

Lying as a feature of BPD

Some theorists argue that patients with BPD often lie.[116] However, others write that they have rarely seen lying among borderline patients in clinical practice.[116] Regardless, lying is not one of the diagnostic criteria for BPD.

The mistaken belief that lying is a distinguishing characteristic of BPD can impact the quality of care that borderline individuals receive in the legal and healthcare systems. For instance, Jean Goodwin relates an anecdote of a patient with multiple personality disorder, now called dissociative identity disorder, who suffered from pelvic pain due to traumatic events in her childhood.[117] Due to their disbelief in her accounts of these events, physicians diagnosed her with borderline personality disorder, reflecting a belief that lying is a key feature of BPD. Based upon her BPD diagnosis, the physicians then disregarded the patient's assertion that she was allergic to adhesive tape. The patient was in fact allergic to adhesive tape, which later caused complications in the surgery to relieve her pelvic pain.[117]

Gender

Feminist critics question why women are three times more likely to be diagnosed with BPD than men, while other stigmatizing diagnoses, such as antisocial personality disorder, are diagnosed three times as often in men.[118][119][n 8]

One explanation is that some of the diagnostic criteria of BPD uphold stereotypes about women. For example, the criteria of "a pattern of unstable personal relationships, unstable self-image, and instability of mood," can all be linked to the stereotype that women are "neither decisive nor constant".[120] Women may be more likely to receive a personality disorder diagnosis if they reject the traditional female role by being assertive, successful, or sexually active.[121] If a woman presents with psychiatric symptoms but does not conform to a traditional, passive sick role, she may be labelled as a "difficult" patient and given a BPD diagnosis.[121]

Since BPD is a stigmatizing diagnosis even within the mental health community (see Stigma), some feminists argue that survivors of childhood sexual abuse who are diagnosed with BPD are thus re-traumatized by the negative responses they receive from healthcare providers.[122] One camp argues that it would be better to diagnose these women with post-traumatic stress disorder, as this would acknowledge the impact of abuse on their behavior. Critics of the PTSD diagnosis argue that it medicalizes abuse rather than addressing the root causes in society.[123] Regardless, a diagnosis of PTSD does not encompass all aspects of the disorder (see Brain abnormalities and Terminology).

Manipulative behavior

Manipulative behavior to obtain nurturance is considered by the DSM-IV-TR and many mental health professionals to be a defining characteristic of borderline personality disorder.[124] However, Marsha Linehan notes that doing so relies upon the assumption that borderline individuals who communicate intense pain, or who engage in self-harm and suicidal behavior, do so with the intention of influencing the behavior of others.[125] The impact of such behavior on others – often an intense emotional reaction in concerned friends, family members, and therapists – is thus assumed to have been the borderline patient’s intention.[125]

However, since borderline patients lack the ability to successfully manage painful emotions and interpersonal challenges, their frequent expressions of intense pain, self-harming, or suicidal behavior may instead represent a method of mood regulation or an escape mechanism from situations that feel unbearable.[126] Linehan notes that if, for example, one were to withhold pain medication from burn victims and cancer patients, leaving them unable to regulate their severe pain, they would also exhibit “attention-seeking” and self-destructive behavior in order to cope.[127]

Stigma

The features of BPD include emotional instability, intense unstable interpersonal relationships, a need for intimacy, and a fear of rejection. As a result, people with BPD often evoke intense emotions in those around them. Pejorative terms to describe borderline individuals, such as “difficult,” “treatment resistant,” “manipulative,” “demanding” and “attention seeking," are often used, and may become a self-fulfilling prophecy as the negative treatment of these individuals triggers further self-destructive behaviour.[128]

In psychoanalytic theory, this stigmatization may be thought to reflect countertransference (when a therapist projects their own feelings on to a client). Thus a diagnosis of BPD "often says more about the clinician's negative reaction to the patient than it does about the patient" and "explains away the breakdown in empathy between the therapist and the patient and becomes an institutional epithet in the guise of pseudoscientific jargon".[110] This inadvertent countertransference can give rise to inappropriate clinical responses, including excessive use of medication, inappropriate mothering, and punitive use of limit setting and interpretation.[129]

People with BPD are considered to be among the most challenging groups of patients, requiring a high level of skill and training in the psychiatrists, therapists and nurses involved in their treatment.[130] Mental health professionals frequently refuse to provide services to those who have received a BPD diagnosis.[131]

Terminology

Because of the above concerns, and because of a move away from the original theoretical basis for the term (see history), there is ongoing debate about renaming Borderline Personality Disorder. While some clinicians agree with the current name, others argue that it should be changed,[132] since many who are labeled with "Borderline Personality Disorder" find the name unhelpful, stigmatizing, or inaccurate.[132] The Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) is campaigning to change the name and designation of BPD in the forthcoming DSM-5.[133] The paper How Advocacy is Bringing BPD into the Light[134] reports that "the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma."

Alternative suggestions for names include emotional regulation disorder or emotional dysregulation disorder. Impulse disorder and interpersonal regulatory disorder are other valid alternatives, according to John Gunderson of McLean Hospital in the United States.[135] Another term suggested by psychiatrist Carolyn Quadrio is post traumatic personality disorganization (PTPD), reflecting the condition's status as (often) both a form of chronic post traumatic stress disorder (PTSD) as well as a personality disorder.[64] However, although many with BPD do have traumatic histories, some do not report any kind of traumatic event, which suggests that BPD is not necessarily a trauma spectrum disorder.[136]

Society and culture

Film and television

Several films portraying characters either explicitly diagnosed or with traits strongly suggestive of mental illness have been the subject of discussion by certain psychiatrists and film experts. The films Play Misty for Me[137] and Fatal Attraction are two examples,[138] as is the memoir Girl, Interrupted by Susanna Kaysen (and the movie based on it, with Winona Ryder as Kaysen). Each of these films suggests the emotional instability of the disorder; however, the first two cases show a person more aggressive to others than to herself, which is less typical of the disorder.[139] The 1992 film Single White Female suggests different aspects of the disorder: the character Hedy suffers from a markedly disturbed sense of identity and, as with the first two films, abandonment leads to drastic measures.[140]

The character of Anakin Skywalker/Darth Vader in the Star Wars films has been "diagnosed" as having BPD. Psychiatrists Eric Bui and Rachel Rodgers have argued that the character meets six of the nine diagnostic criteria; Bui also found Anakin a useful example to explain BPD to medical students. In particular, Bui points to the character's abandonment issues, uncertainty over his identity, and dissociative episodes.[141] Other films attempting to depict characters with the disorder include The Crush, Mad Love, Malicious, Interiors, Notes On a Scandal, The Cable Guy, Mr. Nobody, Closer, and Cracks.[138] The film Borderline, based on the book of the same name by Marie-Sissi Labrèche, attempts to explore BPD through its main character, Kiki.

Literature

The Buddha and the Borderline: My Recovery from Borderline Personality Disorder through Dialectical Behavior Therapy, Buddhism, and Online Dating is a memoir by Kiera Van Gelder.

Girl, Interrupted is a memoir by American author Susanna Kaysen, relating her experiences as a young woman in a psychiatric hospital in the 1960s after being diagnosed with borderline personality disorder.

Out of Here: My Recovery from Borderline Personality Disorder is a memoir by author Rachel Reiland, relating her treatment and recovery from borderline personality disorder.[142]

Songs of Three Islands, by Millicent Monks, is a memoir speculating about the impact of BPD upon the Carnegie family. Readers have criticized it for presenting a biased and stigmatizing view of BPD.[143]

Awareness

In early 2008, the United States House of Representatives declared the month of May as Borderline Personality Disorder Awareness Month.[144][145]

Notable people

Notable people with comorbid diagnoses

In addition to antisocial personality disorder (ASPD), the individuals below have also been diagnosed with BPD. However, while the symptoms of ASPD include “a pervasive pattern of disregard for and violation of the rights of others,” [152] this characteristic is not included in the diagnosis of BPD. In contrast, BPD is characterized by hypersensitivity to emotions of both the self and of others, a passive style of solving interpersonal conflict, and learned helplessness.[153]

Notes

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References

Further reading

  • Bockian, Neil R. et al. New Hope for People with Borderline Personality Disorder: Your Friendly, Authoritative Guide to the Latest in Traditional and Complementary Solutions ISBN 978-0-7615-2572-1
  • Chapman, Alex & Gratz, Kim The Borderline Personality Disorder Survival Guide (2007)
  • Jensen, Joy A. Putting The Pieces Together: A Practical Guide to Recovery from Borderline Personality Disorder ISBN 978-0-9667037-6-4
  • Kreger, Randi The Essential Family Guide to Borderline Personality Disorder: New Tools and Techniques to Stop Walking on Eggshells (2008)
  • Kreisman, Jerold J. and Strauss, Hal. I Hate You, Don't Leave Me: Understanding the Borderline Personality (HPBooks, 1989) ISBN 0895866595
  • Manning, Shari. Loving Someone with Borderline Personality Disorder (2011)
  • Linehan, Marsha M., Skills training manual for treating borderline personality disorder New York ; London : Guilford Press, (1993.) ISBN 978-0-89862-034-4
  • Mason, Paul T. & Kreger, Randi Stop Walking on Eggshells: Taking Your Life Back When Someone You Care About Has Borderline Personality Disorder (1998)
  • Moskovitz, Richard A. Lost in the Mirror: An Inside Look at Borderline Personality Disorder (2001) ISBN 978-0-87833-266-3
  • Petrovic, Nick. The 3D Society (2004)
  • Reiland, Rachel. Get Me Out Of Here: My Recovery from Borderline Personality Disorder (2004) ISBN 978-1-59285-099-0

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