BORDERLINE PERSONALITY DISORDER By Mark Zimmerman, MD, Rhode Island Hospital Content last modified May 2021 Borderline personality disorder is characterized by a generalized pattern of instability and hypersensitivity in interpersonal relationships, instability in self-image, extreme fluctuations in mood, and impulsivity. Diagnosis is by clinical criteria. Treatment is with psychotherapy and drugs. Patients with borderline personality disorder cannot tolerate being alone; they make frantic efforts to avoid abandonment and generate crises, such as suicide attempts, in such a way that they lead others to rescue and care for them. The reported prevalence of borderline personality disorders in the US varies. It is estimated that the average prevalence is 1.6%, but it can reach 5.9%. In patients treated during a psychiatric hospitalization for mental disorders, the prevalence is about 20%. About 75% of patients diagnosed with this disorder are women, but in the general US population, the male-to-female ratio is 1:1. Comorbidities are complex. Patients often have some other disorders, especially depression, anxiety disorders (eg, panic disorder), mood disorders, post-traumatic stress disorder, personality disorders, as well as eating disorders and drug use disorders.
Etiology of borderline personality disorder Stresses during early childhood can contribute to the development of borderline personality disorder. A childhood history of physical and sexual abuse, neglect, separation from caregivers, and/or loss of a parent is common among patients with borderline personality disorder. Certain people may have a genetic tendency to have pathological responses to environmental stress and borderline personality disorder clearly appears to have a hereditary component. First-degree relatives of patients with borderline personality disorder are 5 times more likely to have the disorder than the general population. Disturbances in the regulatory functions of the brain and neuropeptide systems may also contribute, but are not present in all patients with borderline personality disorder.
Signs and symptoms of borderline personality disorder When patients with borderline personality disorder feel that they are being abandoned or neglected, they feel intense fear or anger. For example, they may become panicked or furious when someone important to them is a few minutes late or cancels an appointment. They think this abandonment means they are bad. They fear abandonment in part because they don't want to be alone. These patients tend to change their point of view of other people abruptly and dramatically. They may idealize a potential caregiver or lover early in the relationship, demand that they spend a lot of time together and share everything. Suddenly, they may feel that the person doesn't care enough, and they become disillusioned; so they may despise or get angry with the person. This shift from idealization to devaluation reflects Manichean thinking (division and polarization of good and evil). Patients with borderline personality disorder can empathize with and care for a person, but only if they feel that that other person will be available to them whenever needed. Patients with this disorder have difficulty controlling their anger and often become inadequate and intensely angry. They may express their anger with biting sarcasm, bitterness, or irritated talk, often directed at the caregiver or lover for neglect or abandonment. After the outburst, they often feel shame and guilt, reinforcing their feelings that they are bad. Patients with borderline personality disorder can also abruptly and radically change their self-image, as shown by a sudden change in their goals, values, opinions, careers, or friends. They can be needy one minute and feel justifiably angry about being mistreated the next. Although they generally see themselves as evil, they sometimes feel that they do not exist at all—p. eg, when they don't have someone to care for them. They often feel empty inside.
Mood changes (eg, severe dysphoria, irritability, anxiety) usually last only a few hours and rarely last longer than a few days; they may reflect extreme sensitivity to interpersonal tensions in patients with borderline personality disorder. Patients with borderline personality disorder often sabotage themselves when they are about to reach a goal. For example, they might drop out of school just before graduation, or they might ruin a promising relationship. Impulsivity leading to self-harm is common. These patients may gamble, engage in unsafe sex, binge-eat, drive recklessly, abuse drugs, or spend too much. Suicidal behaviors, gestures and threats, and self-harm (eg, cutting yourself, burning yourself) are very common. Although many of these self-destructive acts are not intended to end life, the risk of suicide in these patients is 40 times greater than in the general population. Approximately 8 to 10% of these patients die by suicide. These self-destructive acts are usually triggered by rejection for possible abandonment or disappointment with a caregiver or lover. Patients may self-harm to compensate for their misbehavior, to reassert their ability to feel during a dissociative episode, or to divert attention from painful emotions. Dissociative episodes, thinking paranoid and sometimes psychotic-like symptoms (eg, hallucinations, ideas of reference) can be triggered by extreme stress, usually fear of abandonment, whether real or imagined. These symptoms are temporary and are not often severe enough to be considered a separate disorder. Symptoms subside in most patients; recurrence is low. However, functional status does not usually improve as much as symptoms. Diagnosis of borderline personality disorder · Clinical criteria (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5]) For the diagnosis of borderline personality disorder, patients must have · Persistent instability in relationships, self-image and emotions (emotional imbalance), as well as marked impulsivity. This pattern is characterized by ≥ 5 of the following: · Desperate efforts to avoid abandonment (real or imagined) · Intense and unstable relationships that alternate between idealizing and devaluation of the other person · Unstable self-image or sense of self · Impulsivity in ≥ 2 areas that can harm them (eg, unsafe sex, binge eating, reckless driving) · Repeated behaviors, gestures and/or threats of suicide or self-harm · Rapid changes in mood, typically lasting only a few hours and rarely more than a few days · Persistent feelings of emptiness · Inappropriately intense anger or problems controlling anger · Temporary paranoid thoughts or severe dissociative symptoms triggered by stress
Also, symptoms must have happened in early adulthood, but can also occur during adolescence. Differential diagnosis Most of the time, borderline personality disorder is misdiagnosed as · Bipolar disorder: This disorder is also characterized by wide variations in mood and behavior. However, in borderline personality disorder, mood and behavior change rapidly in response to stressors, especially interpersonal ones, whereas in bipolar disorder, mood is more sustained and less reactive, and people often have significant changes in energy and activity. Other personality disorders share similar manifestations. · Histrionic Personality Disorder or Narcissistic Personality Disorder: Patients with either of these disorders are attention-seeking and manipulative, but those with borderline personality disorder also consider themselves bad and feel empty. Some patients meet criteria for antisocial personality disorders. The differential diagnosis of borderline personality disorder also encompasses
· Depressive Disorders and Anxiety Disorders: These disorders can be distinguished from borderline, or borderline, personality disorder by the negative self-image, instability of attachments, and sensitivity to rejection, which are prominent features of borderline personality disorder and are often absent in patients with a mood or anxiety disorder. · Chemical dependency disorders · Post-traumatic stress disorder Many disorders that are part of the differential diagnosis of borderline personality disorder coexist. Treatment of borderline personality disorder · Psychotherapy · Drugs The general treatment of borderline personality disorder is the same as for all personality disorders. Identifying and treating coexisting disorders is important for the effective treatment of borderline personality disorder. Psychotherapy The main treatment for borderline personality disorder is psychotherapy. Many psychotherapeutic interventions are effective in reducing suicidal behavior, improving depression and improving function in patients with this disorder. Cognitive-behavioral therapy focuses on emotional dysregulation and a lack of social skills. This encompasses: · Dialectical behavior therapy (a combination of individual and group sessions with therapists acting as behavioral counselors available on demand day and night) · Training Systems for Emotional Predictability and Problem Solving (STEPPS)
STEPPS is done in weekly group sessions for 20 weeks. Patients acquire skills to manage their emotions, question their negative expectations, and take better care of themselves. They learn to set goals, avoid illegal substances, and improve their eating, sleeping, and exercise habits. Patients are invited to build a support network of friends, family and healthcare professionals who are willing to help in a crisis. Other interventions focus on disturbances in the way patients emotionally experience themselves and others. These interventions include: Mindfulness refers to people's ability to reflect on and understand their own moods and the moods of others. Mentalization is considered to be learned through a secure bond with the caregiver. Mindfulness-based treatment helps patients do the following: · Effectively regulate your emotions (eg, calm down when upset). · Understand how they contribute to your problems and difficulties with others. · Reflect and understand the minds of others. Thus, she helps them to relate to others with empathy and compassion. Transference-focused psychotherapy focuses on the interaction between patient and therapist. The therapist asks questions and helps patients think about their reactions in such a way that they can examine their distorted, exaggerated, and unrealistic images of self during the session. The current moment (eg, how patients relate to the therapist) is emphasized rather than the past. For example, when a shy, silent patient suddenly becomes hostile and argumentative, the therapist may ask if the patient has noticed a change in feelings and then ask the patient to think about how he experienced the therapist and the self when things changed. The aim is:
· Allow patients to develop a more stable and realistic sense of themselves and others · Relating to others in a healthy way through transference with the therapist Schema-focused therapy is an integrative therapy that combines cognitive behavioral therapy, attachment theory, psychodynamic concepts, and emotion-focused therapies. It focuses on lifelong maladaptive patterns of thinking, feeling, behaving, and coping (called schemas), affective change techniques, and the therapeutic relationship, with limited reparenting. Limited reparenting represents the establishment of a secure bond between patient and therapist (within professional boundaries), allowing the therapist to help the patient experience what the patient lost during childhood that led to maladaptive behavior. The goal of therapy focusing on this schema is to help patients change their patterns. Therapy has 3 stages: · Assessment: identification of schemas · Awareness: recognizing schemas as they operate in daily life · Behavioral change: replacing negative thoughts, feelings and behaviors with healthier ones. Some of these interventions are specialized and require specialized training and supervision. But some interventions do not require it; one of these interventions, which is designed for the general practitioner, is · General (or good) psychiatric management Good psychiatric treatment includes individual therapy once a week, psychoeducation about borderline personality disorder, setting treatment goals and expectations, and sometimes drugs. It focuses on the patient's reactions to interpersonal stressors in everyday life. Supportive psychotherapy is also helpful. The objective is to establish an emotional, encouraging and supportive relationship with the patient and thus help him to develop healthy defense mechanisms, especially in interpersonal relationships.
drugs Drugs work best when used sparingly and systematically for specific symptoms. Selective serotonin reuptake inhibitors (SSRIs) are generally well tolerated; the probability of a lethal overdose is minimal. But SSRIs are only marginally effective for depression and anxiety in patients with borderline personality disorder. The following drugs may be effective in relieving symptoms of borderline personality disorder: · Mood stabilizers: for depression, anxiety, mood lability and impulsivity ·Atypical (2nd generation) antipsychotics: for anxiety, anger, mood instability, and cognitive symptoms, including transient, stress-related cognitive distortions (eg, paranoid thoughts, Manichean thinking, severe cognitive disorganization) Benzodiazepines and stimulants are not recommended because of the risks of addiction, overdose, disinhibition, and misuse. Additional Information The following English resource may be helpful. Please note that The Handbook is not responsible for the content of this resource.
·Gunderson JG, Herpertz SC, Skodol AE, et al: Borderline personality disorder. Nat Rev Dis Primers 4: 18029, 2018. 1oi:10.1038/nrdp.2018.29
Comments