Borderline personality disorder (
BPD) (called
emotionally unstable personality disorder, borderline type in the
ICD-10) is a cluster-B
personality disorder whose essential features are a pattern of marked impulsivity and instability of
affects, interpersonal relationships, and
self image. The pattern is present by early adulthood and occurs across a variety of situations and contexts. Other symptoms may include intense fears of abandonment and intense
anger and irritability that others have difficulty understanding the
reason for.
People with BPD often engage in
idealization and devaluation of others, alternating between high positive regard and great disappointment.
Self-mutilation and
suicidal behavior are common.
This disorder is recognized by the
Diagnostic and Statistical Manual of Mental Disorders,
which specifies that it "begins by early adulthood". Because a
personality disorder is a pervasive, enduring and inflexible pattern of
maladaptive inner experience and pathological behavior, there is a
general reluctance to diagnose personality disorders before adolescence
or early adulthood. Some emphasize, however, that without early treatment, symptoms may worsen.
There is an ongoing debate about the
terminology of this disorder, especially the word "borderline".
The
ICD-10 manual refers to this disorder as
Emotionally unstable personality disorder and has similar diagnostic criteria. There is related concern that the diagnosis of BPD
stigmatizes people with BPD and supports discriminatory practices because it suggests that the personality of the individual is flawed. In the
DSM-5, the name of the disorder remains the same.
Signs and symptoms
The most distinguishing symptoms of BPD are being highly sensitive to
rejection and spending a lot of time thinking about and feeling afraid
of possible abandonment. Overall, the features of BPD include unusually intense sensitivity in
relationships with others, difficulty regulating emotions, and
impulsivity. Other symptoms can include feeling unsure of one's personal
identity and values, having paranoid thoughts when feeling stressed,
and severe
dissociation.
Emotions
People with BPD feel emotions more easily, more deeply, and for longer than others do. Emotions last longer in people with BPD.
Moreover, emotions in people with BPD might repeatedly re-fire, or
reinitiate, prolonging their emotional reactions even further.
Consequently, it can take a long time for people with BPD to return to a
stable emotional baseline following an intense emotional experience.
In
Marsha Linehan's
view, the sensitivity, intensity, and duration with which people with
BPD feel emotions have both positive and negative effects.
People with BPD are often exceptionally idealistic, joyful, and loving.
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. People with BPD are especially sensitive to feelings of rejection, isolation, and perceived failure.
Before learning other coping mechanisms, their efforts to manage or escape from their intense negative emotions can lead to
self-injury or suicidal behavior.
They are often aware of the intensity of their negative emotional
reactions and, since they cannot regulate them, shut them down entirely.
This can be harmful to people with BPD, as negative emotions alert
people to the presence of a problematic situation and move them to
address it.
While people with BPD 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 this condition:
extreme emotions; destructiveness or self-destructiveness; feeling
fragmented or lacking identity; and feelings of
victimization.
Within these categories, a BPD diagnosis is strongly associated with a
combination of three specific states: 1) feeling betrayed, 2) "feeling
like hurting myself", and 3) feeling completely out of control. Since there is great variety in the types of dysphoria experienced by
people with BPD, the amplitude of the distress is a helpful indicator of
borderline personality disorder.
In addition to intense emotions, people with BPD experience emotional
lability, or changeability. Although the term suggests rapid changes
between
depression and elation, the mood swings in people with this condition actually occur more frequently between anger and
anxiety, and between depression and anxiety.
Behavior
Impulsive behaviors are common, including:
substance or
alcohol abuse,
eating disorders,
unprotected sex or indiscriminate sex with multiple partners, reckless spending and
reckless driving. Treating "sex with multiple partners" as a symptom of mental illness is
controversial and might lead to a greater percentage of women receiving
a diagnosis of BPD, since having indiscriminate sex with multiple
partners contradicts the traditional female
gender role (see
Gender under
Controversies). Impulsive behaviors can also include quitting jobs or relationships, running away, shoplifting, and self-injury.
People with BPD act impulsively because it gives them immediate relief from their emotional pain.
However, in the long term, people with BPD suffer increased pain from the shame and guilt that follow such actions.
They can also suffer long-term consequences of hospitalization, incarceration, homelessness, and poverty.
A cycle often begins in which people with BPD feel emotional pain,
engage in impulsive behaviors to relieve that pain, feel shame and guilt
over their actions, feel emotional pain from the shame and guilt, and
then experience stronger urges to engage in impulsive behaviors to
relieve the new pain.
As time goes on, impulsive behaviors can become an automatic response to emotional pain.
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.
The suicide rate among patients with BPD is 8 to 10 percent.
Self-injury is common, and can take place with or without suicidal intent.
The reported reasons for
non-suicidal self-injury (NSSI) differ from the reasons for suicide attempts. 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. In contrast, suicide attempts typically reflect a belief that others will be better off following the suicide. Both suicidal and non-suicidal self-injury are a response to feeling negative emotions.
Sexual abuse can be a particular trigger for suicidal behavior in adolescents with BPD tendencies.
Interpersonal relationships
People 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.
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).
Combined with mood disturbances, idealization and devaluation can undermine relationships with family, friends, and co-workers.
Self-image can also change rapidly from very positive to very negative.
While strongly desiring intimacy, people with BPD tend toward insecure, avoidant or ambivalent, or fearfully preoccupied
attachment patterns in relationships, and they often view the world as generally dangerous and malevolent. 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.
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.
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 people with BPD, particularly within the health
care system.
(See
Manipulative behavior and
Stigma under
Controversies.)
Sense of self
People with BPD have trouble seeing a clear picture of their
identity. In particular, they have a hard time knowing what they value
and enjoy. They are unsure about their long-term goals for relationships and jobs.
This difficulty with knowing who they are and what they value can cause
people with BPD to feel that they are empty and lost.
Cognitions
The intense emotions of people with BPD can make it difficult for
them to control the focus of their attention. In other words, it can be
difficult for them to concentrate.In addition, people with BPD might
dissociate, which can be thought of as an intense form of "zoning out". Dissociation often takes place in response to a painful event, or to a
"trigger" that causes someone to recall a painful event, and consists of
directing partial or full attention away from that event.
Although blocking out painful emotions provides relief from them, it
inhibits the natural experience of emotions, and decreases the ability
of people with BPD to function in their daily lives.
Sometimes it is possible to tell when someone with BPD is dissociating,
because their facial or vocal expressions might become flat or
expressionless, or they may appear to be very distracted; at other
times, dissociation might be barely noticeable.
Diagnosis
Diagnosis of borderline personality disorder is based on a clinical
assessment
by a qualified mental health professional. The assessment can include a
physical exam, laboratory tests to check for thyroid conditions and
levels of substance use, and a psychological evaluation. The
psychological evaluation includes asking the client about the beginning
and severity of symptoms, as well as other information about how
symptoms impact the client's quality of life. Issues of particular note
are suicidal ideations, experiences with self-harm, and thoughts about
harming others. Diagnosis is based both on the client's report of his or her symptoms and on the clinician's own observations.
The
DSM-IV-TR defines the main features of BPD as a pervasive pattern of instability in interpersonal relationships,
self image, and
affects, as well as markedly impulsive behavior. The
DSM-5 has the same diagnostic criteria as the DSM-IV-TR.
According to
Marsha Linehan,
many mental health professionals find it challenging to diagnose BPD
using the DSM criteria, since these criteria describe such a wide
variety of behaviors.
To address this issue, Linehan has grouped the symptoms of BPD under
five main areas of dysregulation: emotions, behavior, interpersonal
relationships, sense of self, and cognition.
Diagnostic and Statistical Manual
The
Diagnostic and Statistical Manual of Mental Disorders
fifth edition (DSM-5) has removed the multiaxial system. Consequently,
all disorders, including personality disorders, are listed in Section II
of the manual. Like the DSM-IV-TR, the DSM-5 states that a person must
meet 5 of 9 criteria to receive a diagnosis of borderline personality
disorder.
In addition, the DSM-5 proposes alternative diagnostic criteria for
Borderline personality disorder in section III, "Alternative DSM-5 Model
for Personality Disorders." These alternative criteria are based on
trait research and include specifying at least four of seven maladaptive
traits.
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.
- F60.30 Impulsive type
At least three of the following must be present, one of which must be (2):
- marked tendency to act unexpectedly and without consideration of the consequences;
- marked tendency to engage in quarrelsome behavior and to have
conflicts with others, especially when impulsive acts are thwarted or
criticized;
- liability to outbursts of anger or violence, with inability to control the resulting behavioral explosions;
- difficulty in maintaining any course of action that offers no immediate reward;
- 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:
- disturbances in and uncertainty about self-image, aims, and internal preferences;
- liability to become involved in intense and unstable relationships, often leading to emotional crisis;
- excessive efforts to avoid abandonment;
- recurrent threats or acts of self-harm;
- chronic feelings of emptiness.
- demonstrates impulsive behavior, e.g., speeding, substance abuse
The ICD-10 also describes some general criteria that define what is considered a
Personality disorder.
Millon's subtypes
Theodore Millon
has proposed four subtypes of BPD. He suggests that an individual
diagnosed with BPD may exhibit none, one, or more of the following:
| Subtype |
Features |
| Discouraged (including avoidant features) |
Pliant, submissive, loyal, humble; feels vulnerable and in constant
jeopardy; feels hopeless, depressed, helpless, and powerless. |
| Petulant (including negativistic features) |
Negativistic, impatient, restless, as well as stubborn defiant,
sullen, pessimistic, and resentful; easily slighted and quickly
disillusioned. |
| Impulsive (including histrionic or antisocial features) |
Capricious, superficial, flighty, distractible, frenetic, and
seductive; fearing loss, becomes agitated, and gloomy and irritable;
potentially suicidal. |
| Self-destructive (including depressive or masochistic features) |
Inward-turning, intropunitively angry; conforming, deferential, and
ingratiating behaviors have deteriorated; increasingly high-strung and
moody; possible suicide. |
Family members
People with BPD are prone to feeling angry at members of their family
and alienated by them. On their part, the families of people with BPD
often feel angry and helpless at the treatment they receive by their
loved ones. It is important for clinicians to be mindful of any strains
in the relationships between clients with BPD and their family members,
because family members often play a central role in providing social and
financial support.
A study in 2003 found that family members' experience of burden,
emotional distress, and hostility toward people with BPD were actually
worse when they had greater knowledge about BPD. These findings indicate a need to investigate the quality and accuracy of the information received by family members.
Parents of adults with BPD are often both over-involved and under-involved in family interactions.
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.
Adolescence
Onset of symptoms typically occurs during adolescence or young
adulthood, although symptoms suggestive of this disorder can sometimes
be observed in children. Symptoms among adolescents that predict the development of BPD in
adulthood include problems with body-image, extreme sensitivity to
rejection, behavioral problems, non-suicidal self-injury, attempts to
find exclusive relationships, and severe shame.
Many adolescents experience these symptoms without going on to develop
BPD, but those who experience them are 9 times as likely as their peers
to develop BPD. They are also more likely to develop other forms of
long-term social disabilities.
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.
A BPD diagnosis in adolescence might predict that the disorder will continue into adulthood.
Among adolescents who warrant a BPD diagnosis, there appears to be one
group in which the disorder remains stable over time, and another group
in which the individuals move in and out of the diagnosis.
Earlier diagnoses may be helpful in creating a more effective treatment plan for the adolescent.
Family therapy may be an essential component of treatment for adolescents with BPD.
Differential diagnosis and comorbidity
Lifetime
comorbid
(co-occurring) conditions are common in BPD. Compared to those
diagnosed with other personality disorders, people with BPD showed a
higher rate of also meeting criteria for
Comorbid Axis I disorders
A 2008 study found that at some point in their lives, 75 percent of
people with BPD meet criteria for mood disorders, especially major
depression and Bipolar I, and nearly 75 percent meet criteria for an
anxiety disorder.
Nearly 73 percent meet criteria for substance abuse or dependency, and about 40 percent for PTSD. It is noteworthy that less than half of the participants with BPD in
this study presented with PTSD, a prevalence similar to that reported in
an earlier study.
The finding that less than half of patients with BPD experience PTSD
during their lives challenges the theory that BPD and PTSD are the same
disorder.
Major gender differences exist in diagnoses for PTSD, substance abuse, and eating disorders.
A higher percentage of male patients with BPD meet criteria for
substance abuse and dependency, while a higher percentage of female
patients meet criteria for PTSD and eating disorders.
In two other studies, 38% of people with BPD met a diagnosis of ADHD
and 6 of 41 patients (15%) fulfilled criteria for an
autism spectrum disorder, a subgroup that had significantly more frequent suicide attempts.
The many, shifting Axis I disorders in people with BPD can sometimes
cause clinicians to miss the presence of the underlying personality
disorder. However, since a complex pattern of Axis I diagnoses has been
found to strongly predict the presence of BPD, clinicians can use the
feature of a complex pattern of comorbidity as a clue that BPD might be
present.
Mood disorders
Borderline personality disorder and
mood disorders, such as major depressive disorder and bipolar disorders, are often comorbid.
Some characteristics of BPD are similar to those of mood disorders, which can complicate the diagnosis. It is especially common for people to be misdiagnosed with bipolar
disorder when they have borderline personality disorder, or vice versa.
For someone with bipolar disorder, behavior suggestive of BPD might
appear while the client is experiencing an episode of major depression
or
mania, only to disappear once the client's mood has stabilized.
For this reason, it is ideal to wait until the client's mood has stabilized before attempting to make a diagnosis.
At face value, the affective lability of BPD and the rapid mood cycling of bipolar disorders can seem very similar. It can be difficult even for experienced clinicians, if they are
unfamiliar with BPD, to differentiate between the mood swings of these
two conditions.
However, there are some clear differences.
First, the mood swings of BPD and bipolar disorder have different
durations. In some people with bipolar disorder, episodes of depression
or mania last for at least two weeks at a time, which is much longer
than moods last in people with BPD. Even among those who experience bipolar disorder with more rapid mood
shifts, their moods usually last for days, while the moods of people
with BPD can change in minutes or hours.
So while euphoria and impulsivity in someone with BPD might resemble a
manic episode, the experience would be too brief for a manic episode.
Second, the moods of bipolar disorder do not respond to changes in
the environment, while the moods of BPD do respond to changes in the
environment.That is, a positive event could not lift the depressed mood caused by
bipolar disorder, but a positive event could potentially lift the
depressed mood of someone with BPD. Similarly, a negative event could
not dampen the
euphoria caused by bipolar disorder, but a negative event could dampen the euphoria of someone with borderline personality disorder.
Third, people with BPD usually experience euphoria without the racing thoughts and decreased need for sleep that are typical of
hypomania.
Bipolar disorders generally involve high levels of sleep and appetite
disturbance, but severe sleep disturbance is rarely seen among the
symptoms of BPD.
Due to the similarity of the two conditions, BPD was once considered to be a mild form of
bipolar disorder, or to exist on the bipolar spectrum. However, 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.
Researchers have found "only a modest association" between bipolar
disorder and borderline personality disorder, with "a strong spectrum
relationship with [BPD and] bipolar disorder extremely unlikely."
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.
Premenstrual dysphoric disorder
Premenstrual dysphoric disorder (PMDD) 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.
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. PMDD typically begins in patients' early twenties, but many women wait until their early 30's to seek treatment. 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,
whereas BPD symptoms occur persistently at all stages of the menstrual
cycle. In addition, the symptoms of PMDD do not include impulsivity.
Comorbid Axis II disorders
Percentage of people with BPD and a lifetime comorbid Axis II diagnosis, 2008
| Axis II diagnosis |
Overall ( % ) |
Male ( % ) |
Female ( % ) |
| Any Cluster A |
50.4 |
49.5 |
51.1 |
| Paranoid |
21.3 |
16.5 |
25.4 |
| Schizoid |
12.4 |
11.1 |
13.5 |
| Schizotypal |
36.7 |
38.9 |
34.9 |
| Any Other Cluster B |
49.2 |
57.8 |
42.1 |
| Antisocial |
13.7 |
19.4 |
_9.0 |
| Histrionic |
10.3 |
10.3 |
10.3 |
| Narcissistic |
38.9 |
47.0 |
32.2 |
| Any Cluster C |
29.9 |
27.0 |
32.3 |
| Avoidant |
13.4 |
10.8 |
15.6 |
| Dependent |
_3.1 |
_2.6 |
_3.5 |
| Obsessive-compulsive |
22.7 |
21.7 |
23.6 |
Comorbid personality disorders are highly common among people
diagnosed with BPD. A 2008 study found that at some point in their
lives, 73.9 percent of people with BPD meet criteria for a second Axis
II disorder.
Cluster A disorders, which include
paranoid,
schizoid, and
schizotypal, are the most common, with a prevalence of 50.4 percent in people with BPD.
The second most common are another Cluster B disorder, which include
antisocial,
histrionic, and
narcissistic.
These have an overall prevalence of 49.2 percent in people with BPD,
with narcissistic being the most common, at 38.9 percent; antisocial the
second most common, at 13.7 percent; and histrionic the least common,
at 10.3 percent.
The least common are Cluster C disorders, which include
avoidant,
dependent, and
obsessive-compulsive, and have a prevalence of 29.9 percent in people with BPD.
The percentages for specific comorbid Axis II disorders can be found in the table below.
Causes
As is also the case with other mental disorders, the causes of BPD are complex and not fully understood.
Evidence suggests that BPD and
post-traumatic stress disorder (
PTSD) are closely related.
However, research also suggests diverse possible causes of BPD, including a history of childhood trauma,
brain abnormalities, genetic predisposition, neurobiological factors, and environmental factors.
Genetics
The
heritability of BPD is estimated to be 65%. 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.
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.
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.
Amygdala
The
amygdala is smaller and more active in people with BPD.
Decreased amygdala volume has also been found in people with
obsessive-compulsive disorder.
One study has found unusually strong activity in the left amygdalas of
people with BPD when they experience and view displays of negative
emotions.
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 people with BPD, as well as
their heightened sensitivity to displays of these emotions in others.
[ Prefrontal cortex
The
prefrontal cortex is less active in people with BPD, especially when recalling memories of abandonment.
This relative inactivity occurs in the right
anterior cingulate (areas
24 and
32).
Given its role in regulating emotional arousal, the relative inactivity
of the prefrontal cortex might explain the difficulties people with BPD
experience in regulating their emotions and responses to stress.
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.This causes them to experience a greater biological stress response, which might explain their greater vulnerability to
irritability.
Since traumatic events can increase cortisol production and HPA axis
activity, the unusual activity in the HPA axis of people with BPD may be
related to the traumatic childhood and maturational events that
correlate with this condition. Conversely, by heightening their sensitivity to stressful events,
increased cortisol production may predispose those with BPD to
experience stressful childhood and maturational events as traumatic.
Increased cortisol production is also associated with suicidal behavior.
Neurobiological factors
Estrogen
Individual differences in women's
estrogen cycles may be related to the expression of BPD symptoms in female patients. 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.
Symptoms experienced due to disturbed levels of estrogen are often
misdiagnosed as BPD, like extreme mood swings and depression. As
endometriosis is an estrogen responsive disease, severe PMS and PMDD
symptoms are observed, that are both physical and psychological in
nature. Hormone-responsive mood disorders also known as reproductive
depression are seen to cease only after menopause or hysterectomy.
Psychotic episodes treated with estrogen in women with BPD show
considerable improvement but must not be prescribed to those with
endometriosis as it worsens their endocrine condition. Mood stabilizing
drugs used for bipolar disorder do not help patients with disturbed
estrogen levels. A correct diagnosis between endocrine disorder and
psychiatric disorder must be made.
Adverse childhood experiences
There is a strong correlation between child abuse, especially child sexual abuse, and development of BPD.
Many individuals with BPD report a history of abuse and neglect as young children.
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.
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.
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. It has been suggested that children who experience chronic early maltreatment and
attachment difficulties may go on to develop borderline personality disorder.
Other 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.
This finding, differences in brain structure (see
Brain abnormalities), and the fact that some patients with BPD do not report a traumatic history,
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.
A child's ability to tolerate delayed gratification at age 4 does not predict later development of BPD.
Mediating and moderating factors
Executive function
While high
rejection sensitivity is associated with stronger symptoms of borderline personality disorder,
executive function appears to
mediate the relationship between rejection sensitivity and BPD symptoms.
That is, a group of
cognitive processes that include planning,
working memory,
attention, and problem-solving might be the mechanism through which
rejection sensitivity impacts BPD symptoms. A 2008 study found that the
relationship between a person's rejection sensitivity and BPD symptoms
was stronger when executive function was lower, and that the
relationship was weaker when executive function was higher.This suggests that high executive function might help protect people with high rejection sensitivity against symptoms of BPD.
A 2012 study found that problems in working memory might contribute to greater impulsivity in people with BPD.
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.
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 self in terms of characteristics that she hopes to
acquire, or in terms of characteristics that she should already have.
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.
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.
Management
Psychotherapy is the primary treatment for borderline personality disorder.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.
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.
Psychotherapy
Long-term psychotherapy is currently the treatment of choice for BPD.
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. 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. Randomized controlled trials have shown that DBT and MBT are the most effective. As of July 2006, DBT was found to have the most empirical support, but DBT and MBT share many similarities.
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.
From a psychodynamic perspective, a special problem of psychotherapy with people with BPD is intense
projection.
It requires the psychotherapist to be flexible in considering negative
attributions by the patient rather than quickly interpreting the
projection.
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.
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.
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. 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.
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
behavior 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."
Services
Individuals with BPD sometimes use mental health services
extensively. They accounted for about 20 percent of psychiatric
hospitalizations in one survey.
The majority of patients with BPD 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. Experience of services varies. Assessing suicide risk can be a challenge for clinicians, and patients
themselves tend to underestimate the lethality of self-injurious
behaviors. People with BPD typically have a chronically elevated risk of
suicide much above that of the general population and a history of
multiple attempts when in crisis. 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.
Prognosis
With treatment, the majority of people with BPD can find relief from
distressing symptoms and achieve remission, defined as a consistent
relief from symptoms for at least two years.
A
longitudinal study
tracking the symptoms of people with BPD found that 34.5% achieved
remission within two years from the beginning of the study. Within four
years, 49.4% had achieved remission, and within six years, 68.6% had
achieved remission. By the end of the study, 73.5% of participants were
found to be in remission. Moreover, of those who achieved recovery from symptoms, only 5.9%
experienced recurrences. A later study found that ten years from
baseline (during a hospitalization), 86% of patients had sustained and
stable recovery from symptoms.
Thus contrary to popular belief, recovery from BPD is not only
possible but common, even for those with the most severe symptoms. However, it is important to note that these high rates of relief from
distressing symptoms have only been observed among those who receive
treatment of some kind.
Patient personality can play an important role during the therapeutic
process, leading to better clinical outcomes. Recent research has shown
that BPD patients with higher levels of trait agreeableness undergoing
Dialectical Behavior Therapy (DBT) exhibited better clinical outcomes
than other patients either low in Agreeableness or not being treated
with DBT. This association was mediated through the strength of a
working alliance between patient and therapist; that is, more Agreeable
patients developed stronger working alliances with their therapists
which in turn led to better clinical outcomes.
In addition to recovering from distressing symptoms, people with BPD also achieve high levels of
psychosocial
functioning. A longitudinal study tracking the social and work
abilities of participants with BPD found that six years after diagnosis,
56% of participants had good function in work and social environments,
compared to 26% of participants when they were first diagnosed.
Vocational achievement was generally more limited, even compared to
those with other personality disorders. However, those whose symptoms
had remitted were significantly more likely to have good relationships
with a romantic partner and at least one parent, good performance at
work and school, a sustained work and school history, and good
psychosocial functioning overall.
Epidemiology
The
prevalence of BPD was initially estimated to be 1 to 2 percent of the general population
and to occur three times more often in women than in men.
However, the lifetime prevalence of BPD in a 2008 study was found to be
5.9% of the general population, occurring in 5.6% of men and 6.2% of
women.The difference in rates between men and women in this study was not found to be
statistically significant.
Borderline personality disorder is estimated to contribute to 20
percent of psychiatric hospitalizations, and to occur among 10 percent
of outpatients.
In Iowa, 29.5 percent of new inmates in Iowa fit a diagnosis of borderline personality disorder in 2007, and the overall prevalence of BPD in the U.S. prison population is thought to be 17 percent. These high numbers may be related to the high frequency of
substance abuse and
substance use disorders among people with BPD, which is estimated at 38 percent.
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, 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". In 1921,
Kraepelin identified an "excitable personality" that closely parallels the borderline features outlined in the current concept of BPD.
The first significant psychoanalytic work to use the term "borderline" was written by Adolf Stern in 1938. 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). 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
between neurosis and psychosis.
After standardized criteria were developed
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.
The diagnosis was distinguished from sub-syndromal schizophrenia, which was termed "
Schizotypal personality disorder".
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. However, the term "borderline" has been described as uniquely
inadequate for describing the symptoms characteristic of this disorder.
Controversies
Credibility and validity of testimony
The credibility of individuals with personality disorders has been questioned at least since the 1960s. Two concerns are the incidence of
dissociative episodes among people with BPD, 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 the ability of people with BPD to recall the specifics of past
events. A 1999 study reported that the specificity of
autobiographical memory was decreased in BPD patients. The researchers found that decreased ability to recall specifics was correlated with patients' levels of dissociation. 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,
thus supporting the reliability of the testimony of people with BPD.
Lying as a feature of BPD
Some theorists argue that patients with BPD often lie. However, others write that they have rarely seen lying among patients with BPD in clinical practice. 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 people with this diagnosis
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. 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.
Gender
Feminists 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.
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". 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.
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.
Since BPD is a stigmatizing diagnosis even within the mental health community (see
Stigma),
some survivors of childhood sexual abuse who are diagnosed with BPD are
thus re-traumatized by the negative responses they receive from
healthcare providers.
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.
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. However,
Marsha Linehan
notes that doing so relies upon the assumption that people with BPD who
communicate intense pain, or who engage in self-harm and suicidal
behavior, do so with the intention of influencing the behavior of
others. 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 person's intention.
However, since people with BPD 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. 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.
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 people with BPD, 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 behavior.
Physical violence
The stigma surrounding borderline personality disorder includes the
belief that people with BPD are prone to violence toward others.
While movies and visual media often sensationalize people with BPD by
portraying them as violent, the majority of researchers agree that
people with BPD are unlikely to physically harm others. Although people with BPD often struggle with experiences of intense
anger, a defining characteristic of BPD is that they direct it inward
toward themselves.
One of the key differences between BPD and
antisocial personality disorder
(ASPD) is that people with BPD tend to internalize anger by hurting
themselves, while people with ASPD tend to externalize it by hurting
others. In addition, adults with BPD have often experienced abuse in childhood,
so many people with BPD adopt a "no-tolerance" policy toward
expressions of anger of any kind.
Their extreme aversion to violence can cause many people with BPD to
overcompensate and experience difficulties being assertive and
expressing their needs.
This is one way in which people with BPD choose to harm themselves over potentially causing harm to others. Another way in which people with BPD avoid expressing their anger
through violence is by causing physical damage to themselves, such as
engaging in non-suicidal self injury.
Mental healthcare providers
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. A majority of psychiatric staff report finding individuals with BPD
moderately to extremely difficult to work with, and more difficult than
other client groups.
Efforts are ongoing to improve public and staff attitudes toward people with BPD.
In psychoanalytic theory, the
stigmatization among mental healthcare providers 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".
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.
Some clients feel the diagnosis is helpful, allowing them to
understand that they are not alone and to connect with others with BPD
who have developed helpful coping mechanisms. However, others experience
the term "Borderline Personality Disorder" as a
pejorative label
rather than an informative diagnosis. They report concerns that their
self-destructive behavior is incorrectly perceived as manipulative, and
that the stigma surrounding this disorder limits their access to
healthcare. Indeed, mental health professionals frequently refuse to provide services to those who have received a BPD diagnosis.
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,
since many who are
labelled with "Borderline Personality Disorder" find the name unhelpful, stigmatizing, or inaccurate.
Valerie Porr, president of Treatment and Research Advancement
Association for Personality Disorders states 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. 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. 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.
The Treatment and Research Advancements National Association for
Personality Disorders (TARA-APD) campaigned unsuccessfully to change the
name and designation of BPD in
DSM-5,
published in May 2013, in which the name Borderline personality
disorder remains unchanged and it is not considered a Trauma- and
stressor-related disorder.
Society and culture
Film and television
There are several films portraying characters either explicitly diagnosed or with traits suggestive of BPD. The films
Play Misty for Me and
Fatal Attraction are two examples, as is the movie
Girl, Interrupted, based on the
memoir by
Susanna Kaysen, with
Winona Ryder
playing 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.
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.
Psychiatrists Eric Bui and Rachel Rodgers argue that the character of
Anakin Skywalker/Darth Vader in the
Star Wars
films 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. 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 and
Cracks.
Unfortunately, dramatic portrayals of people with BPD in movies and
other forms of visual media contribute to the stigma surrounding
borderline personality disorder, especially the myth that people with
BPD are violent toward others.
The majority of researchers agree that in reality, people with BPD are very unlikely to harm others. See
The myth of violence under
Stigma.
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.
Get Me 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.
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.
In
Lois McMaster Bujold's science fiction novel
Komarr,
Tien Vorsoisson has BPD, per the author; his disorder drives a large part of the story.
Kreisman, Jerold J MD, I Hate You—Don't Leave Me: Understanding the Borderline Personality
Awareness
In early 2008, the
United States House of Representatives declared the month of May as Borderline Personality Disorder Awareness Month.
