Borderline personality disorder

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Borderline personality disorder (BPD) is identified as a personality disorder characterized by emotional dysregulation, extreme "black and white" thinking, and chaotic relationships.[1] The general profile of the disorder also includes a pervasive instability of mood, poor self-image, issues of identity, and disturbance in the sense of self. In extreme cases, periods of dissociation can also be demonstrated. [2]

Borderline personality disorder falls within the B cluster of personality disorders, along with Antisocial personality disorder, Histrionic personality disorder, and Narcissistic personality disorder. [2]

Disturbances experienced by those diagnosed as exhibiting the symptom profile for Borderline personality disorder have a wide-ranging and pervasive negative impact on many facets of the person's life, including employment, relationships at work, family life, and other social relationships. Co-occurrence of substance abuse and mood disorders, as well as para-suicidal and suicidal behavior, is common.

Epidemiology

Figures on the prevalence of BPD in the general population vary, ranging from approximately 1% to 2%. [3] [4] The diagnosis appears to be more common in women than in men, by a ration of as much as 3:1 according to the DSM-IV-TR. [5] [6]

Sufferers of BPD are also disproportionately represented in prison populations, with 23 percent of incarcerated men and 20 percent of incarcerated women are diagnosed with BPD. [7]

Diagnostic criteria

Note: The American Psychiatric Association, which publishes the Diagnostic and Statistical Manual of Mental Disorders, forbids the unauthorized reproduction of their diagnostic criteria. A narrative of the DSM-IV-TR criteria follows. Diagnosis is based on the self-reported experiences of the patient, as well as markers for the disorder observed by a psychiatrist, psychologist, or other qualified diagnostician through clinical assessment. This profile may be supported and/or corroborated by long term patterns of behavior as reported by family members, friends or co-workers. The list of criteria that must be met for diagnosis is outlined in the DSM-IV-TR.[2]

An initial assessment generally includes a comprehensive personal and family history, and may also include a physical examination by a physician. Although there are no physiological tests that confirm borderline personality disorder, medical tests may be employed to exclude any co-occurring medical conditions that may present with psychiatric symptoms. These include blood tests measuring TSH to exclude hypo- or hyperthyroidism, basic electrolytes and serum calcium to rule out a metabolic disturbance, full blood count including ESR to rule out a systemic infection or chronic disease, and serology to exclude syphilis or HIV infection; two commonly ordered investigations are EEG to exclude epilepsy, and a CT scan of the head to exclude brain lesions.

The World Health Organization's ICD-10 has a comparable diagnosis called Emotionally Unstable Personality Disorder - Borderline type (F60.31). This requires, in addition to the general criteria for personality disorder: disturbances in and uncertainty about self-image, aims, and internal preferences (including sexual); 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; and chronic feelings of emptiness.

The Chinese Society of Psychiatry's CCMD has a comparable diagnosis of Impulsive Personality Disorder. A patient diagnosed as having IPD must display "affective outbursts" and "marked impulsive behavior", plus at least three out of eight other symptoms. The construct has been described as a hybrid of the impulsive and borderline subtypes of the ICD's Emotionally Unstable Personality Disorder, and also incorporates six of the nine DSM BPD criteria.[8]

Differential diagnosis

Borderline personality disorder often co-occurs with mood disorders. Some features of borderline personality disorder may overlap with those of mood disorders, complicating the differential diagnostic assessment.[9][10][11]

Both diagnoses involve symptoms commonly known as "mood swings". In bipolar disorder, the term refers to the cyclic episodes of elevated and depressed mood generally lasting weeks or months. In the rapid cycling variant of bipolar disorder there are more than four episodes in a year, but even then the swings are more sustained than in borderline personality disorder. In borderline personality, the mood swings may arise and/or subside suddenly and dramatically and last for seconds, minutes, hours or days.

Bipolar depression is generally more pervasive with sleep and appetite disturbances, as well as a marked nonreactivity of mood, whereas mood with respect to borderline personality and co-occurring dysthymia remains markedly reactive and sleep disturbance not acute.[12]

The relationship between bipolar disorder and borderline personality disorder has been debated. Some hold that the latter represents a subthreshold form of affective disorder,[13][14] while others maintain the distinctness between the disorders, noting they often co-occur.[15][16]

Co-morbid diagnoses

Co-morbid conditions in BPD are common. When comparing individuals diagnosed with BPD to those diagnosed with other kinds of personality disorders, the former showed a higher rate of also meeting criteria for:[17]

Substance abuse is a common problem in BPD, whether due to impulsivity or as a coping mechanism, and 50% to 70% of psychiatric inpatients with BPD have been found to meet criteria for a substance use disorder.[18]

The Borderline Profile

The term "borderline" first appeared in clinical use during the 1930s, originating with the idea posited by Otto Kernberg that some patients fell on the "borderline" between neurosis and psychosis. BPD became an official Axis II diagnosis in 1980 with the publication of the DSM-III. [3] It has been noted that there is probably no other mental disorder about which so many articles and books have been written, yet about which so little is known based on empirical research.[19]

Studies suggest that individuals with BPD tend to experience frequent, strong and long-lasting states of aversive tension, often triggered by perceived rejection, being alone, or perceived failure.[20] Individuals with BPD may show lability (changeability) between anger and anxiety or between depression and anxiety[21] and temperamental sensitivity to emotive stimuli.[22]

The negative emotional states particularly associated with BPD have been grouped into four categories: extreme feelings in general; feelings of destructiveness or self-destructiveness; feelings of fragmentation or lack of identity; and feelings of victimization.[23]

Individuals with BPD can be very sensitive to the way others treat them, reacting strongly to perceived criticism or hurtfulness. Their feelings about others often shift from positive to negative, generally after a disappointment or perceived threat of losing someone. Self-image can also change rapidly from extremely positive to extremely negative. Impulsive behaviors are common, including alcohol or drug abuse, unsafe sex, gambling, and recklessness in general.[24] Attachment studies suggest individuals with BPD, while being high in intimacy- or novelty-seeking, can be hyper-alert[19] to signs of rejection or not being valued and tend towards insecure, ambivalent, preoccupied or fearful attitudes towards relationships.[25] They tend to view the world generally as dangerous and malevolent, and themselves as powerless, vulnerable, unacceptable and unsure in self-identity.[19]

Individuals with BPD are often described, including by some mental health professionals (and in the DSM-IV),[26] as deliberately manipulative or difficult, but analyses and findings generally trace behaviors to inner pain and turmoil, powerlessness and defensive reactions, or limited coping and communication skills.[27] [28] [29] There has been limited research on family members' understanding of borderline personality disorder and the extent of burden or negative emotion experienced or expressed by family members.[30] Parents of individuals with BPD have been reported to show co-existing extremes of over-involvement and under-involvement.[31] BPD has been linked to somewhat increased levels of chronic stress and conflict in romantic relationships, decreased satisfaction of romantic partners, abuse, and unwanted pregnancy; these links may largely be general to personality disorder and subsyndromal problems,[32] but such issues are commonly raised in support groups and published literature for partners of individuals with BPD.

Suicidal or self-harming behavior is one of the core diagnostic criteria in DSM IV-TR, and management of and recovery from this can be complex and challenging.[33] The suicide rate is approximately eight to ten percent.[34] The most recognized form of self-injury is automutilation (cutting the self), usually of the arms, but often other areas such as the legs, chest, belly, and face. Self-injury attempts are highly common among patients and may or may not be carried out with suicidal intent.[35][36] BPD is often characterized by multiple low lethality suicide attempts triggered by seemingly minor incidents, and less commonly by high lethality attempts that are attributed to impulsiveness or comorbid major depression, with interpersonal stressors appearing to be particularly common triggers.[37] Ongoing family interactions and associated vulnerabilities can lead to self-destructive behavior.[31] Stressful life events related to sexual abuse have been found to be a particular trigger for suicide attempts by adolescents with a BPD diagnosis.[38]

Etiology

BPD may result from a combination that can involve a traumatic childhood, a vulnerable temperament (possibly inherited), and stressful maturational events during adolescence or adulthood.[39][40]

An early theory, proposed by Otto Kernberg, is that Borderline Personality is based on a premise of failure to develop in childhood.[41] There are, according to Kernberg, 3 developmental tasks an individual must accomplish, and, when one fails to accomplish a certain developmental task, this often corresponds with an increased risk in developing certain psychopathologies. Failing the first developmental task of psychic clarification of self and other, can result in an increased risk to develop varieties of psychosis. Not accomplishing the second task, overcoming splitting, results in an increased risk to develop a borderline personality. [42]

More recentlly, a neurobehavioural theory proposes that emotional dysregulation, also called affective dysregulation, may be inherited and give a susceptibility to BPD.[1] This susceptibility may lead to manifesting BPD depending on adverse childhood experiences with the result resembling a chronic post-traumatic stress disorder[1].

Childhood abuse, trauma or neglect

Numerous studies have shown a strong correlation between childhood abuse and development of BPD.[43][44][45][46] Most (60%) patients with BPD self-report childhood sexual abuse[44], which is higher than the rate of 25% reported by adults from the general population[47]. Many individuals with BPD report having had a history of abuse, neglect, or separation as young children.[39] Patients with BPD have been found to be significantly more likely to report having been verbally, emotionally, physically, and sexually abused by caretakers of either gender. They were also much more likely to report having caretakers (of both genders) deny the validity of their thoughts and feelings. They were also reported to have failed to provide needed protection, and 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 caretaker and abuse by a male caretaker were consequently at significantly higher risk for being sexually abused by a noncaretaker (not a parent).[48]These are also the same risk factors for reactive attachment disorder and it has been suggested that children who experience chronic early maltreatment and Reactive Attachment Disorder go on to develop a variety of personality disorders, including Borderline Personality Disorder.[49] Many of these children are violent[50] and aggressive[51] and as adults are at risk of developing a variety of psychological problems[52] such as borderline personality disorder.[49]

According to Joel Paris,[53] "Some researchers, like Judith Herman, believe that BPD is a name given to a particular manifestation of post-traumatic stress disorder (PTSD): in Trauma and Recovery, she theorizes that when PTSD takes a form that emphasizes heavily its elements of identity and relationship disturbance, it gets called BPD; when the somatic (body) elements are emphasized, it gets called hysteria, and when the dissociative/deformation of consciousness elements are the focus, it gets called DID/MPD" (dissociative identity disorder or multiple personality disorder).

Other developmental factors

Some studies suggest that BPD may not necessarily be a trauma-spectrum disorder and that it is biologically distinct from the post traumatic stress disorder that could be a precursor. The personality symptom clusters seem to be related to specific abuses, but they may be related to more persistent aspects of interpersonal and family environments in childhood.[54]

There is evidence for the central role of family in the development of BPD, including interactions that are negative and critical rather than supportive and empathic, with parental and family behaviors transacting with the child's own behaviors and emotional vulnerabilities.[55]

Some findings suggest that BPD may lie on a bipolar spectrum, with a number of points of phenomenological and biological overlap between the affective lability criterion of borderline personality disorder and the extremely rapid cycling bipolar disorders.[56][57] Some findings suggest that the DSM-IV BPD diagnosis mixes up two sets of unrelated items—an affective instability dimension related to Bipolar-II, and an impulsivity dimension not related to Bipolar-II.[58]

Genetics

An overview of the existing literature suggested that traits related to BPD are influenced by genes, and since personality is generally quite heritable then BPD should also be, but studies have had methodological problems and the links are not yet clear.[59] A major twin study found that if one identical twin met criteria for BPD, the other also met criteria in around a third (35%) of cases, whereas the concordance rate in dizygotic twin pairs was 7% in monozygotic, yielding an inheritance of 0.69.[60]

Twin, sibling and other family studies indicate a partially heritable basis for impulsive aggression, but studies of serotonin-related genes to date have suggested only modest contributions to behavior.[54]

Neurological considerations

Neurotransmitters implicated in BPD include serotonin, norepinephrine and acetylcholine (related to various emotions and moods); GABA, the brain's major inhibitory neurotransmitter (which can stabilize mood change); and glutamate, an excitatory neurotransmitter.

Enhanced amygdala activation in BPD has been identified as reflecting the intense and slowly subsiding emotions commonly observed in BPD in response to even low-level stressors. The activation of both the amygdala and prefrontal cortical areas can reflect attempts to control intensive emotions during the recall of unresolved life events.[61] Impulsivity or aggression, as sometimes seen in BPD, has been linked to alterations in serotonin function and specific brain regions in the cingulate and the medial and orbital prefrontal cortex.[54]

Treatment

Various psychotherapies for patients with BPD have been studied in randomized controlled trials including dialectical behavior therapy[62][63], mentalization based treatment[64][65], schema-focused therapy[66], Dynamic Deconstructive Psychotherapy (DDP)[67], and transference-focused psychotherapy[68]

The choice of treatment may depend on symptoms.[69]

Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a treatment for family members of patients and augmented psychotherapy in a randomized controlled trial.[70]

Prognosis

One half of patients achieve recovery (defined as remission of symptoms and having good social and vocational functioning for two years) according to a cohort study.[71]

See also

References

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Personality disorders
Cluster A (Odd): Schizotypal | Schizoid | Paranoid
Cluster B (Dramatic): Antisocial | Borderline | Histrionic | Narcissistic
Cluster C (Anxious): Dependent | Obsessive-Compulsive | Avoidant