What is borderline personality disorder?

Borderline personality disorder (BPD) is a mental disorder that belongs to the group of mental illnesses called personality disorders. Therefore, like other personality disorders, it is characterized by a consistent pattern of thinking, feeling and interacting with others and with the world that tends to cause problems for the sufferer. Specifically, BPD tends to be associated with a pattern of unstable ways of seeing oneself, feeling, behaving, and relating to others that interferes with the individual's ability to function. Also, as with other personality disorders, the person is usually an adolescent or adult before they can be assessed as meeting meet full symptom criteria for BPD.

Historically, BPD has been thought to be a set of symptoms that include both mood problems (neuroses) and distortions of reality (psychosis), and therefore was thought to be on the borderline between mood problems and schizophrenia. However, it is now understood that while BPD may straddle those symptom complexes, it is more closely related to other personality disorders in terms of how it may develop and run in families. Contrary to what the medical community thought in the past, BPD is now understood to occur equally in men and women, rather than primarily in women. The frequency with which it occurs is also thought to be considerably higher than previously thought, affecting nearly 6% of adults over the course of a lifetime.

What other disorders often occur with BPD?

Men with BPD are more likely to also have a substance-use disorder and women are more likely to have eating disorders. In adolescents, BPD tends to co-occur with more anxious and odd personality disorders like schizotypal and passive aggressive personality disorder, respectively. Adults may be more likely to have antisocial personality disorder along with BPD. Interestingly, even people who have some symptoms (traits) of BPD but do not meet full diagnostic criteria for the disorder can experience both traits of that disorder and of narcissistic personality disorder.

Although there has been some controversy as to whether or not BPD is truly its own disorder or a variation of bipolar disorder, research supports the theory that BPD, like virtually every medical or mental-health disorder can appear (present) in nearly as many unique and complex ways as there are people who have it. In other words, some individuals with BPD will have that disorder alone, while others will have it in combination with bipolar or another mental disorder, and still others will appear to have BPD but really qualify for the diagnosis of bipolar disorder and visa versa.

BPD is not recognized worldwide. It is most closely diagnosed as emotionally unstable personality disorder in the International Classification of Disease, or ICD-10. Although countries like China and India recognize mental disorders that have some symptoms in common with BPD, its existence is not formally recognized.

What causes borderline personality disorder?

Although there is no specific cause for BPD, like most other mental disorders, it is understood to be the result of a combination of biological vulnerabilities, ways of thinking, and social stressors (biopsychosocial model). Biologically, individuals with BPD are more likely to have an overactive amygdala, the area of the brain that is understood to regulate emotions. Psychologically, BPD seems to make a person more vulnerable to difficulty managing their emotions, particularly impulsive aggression. Socially, this disorder predisposes sufferers to be more likely to excessively expect to be criticized or rejected and negatively personalize disinterest or inattention from others. In addition to these issues, people with BPD are more likely to have suffered from childhood abuse or neglect.

What are the risk factors for borderline personality disorder?

Although some research asserts that people with BPD seem to have areas of the brain that are more and less active compared to individuals who do not have the disorder, other research contradicts that. Therefore, specific patterns of brain functioning as they are currently studied and understood seem unreliable risk factors for BPD.

Although not alone in terms of risk, adults that come from families of origin where divorce, neglect, sexual abuse, substance abuse, or death occurred are at higher risk of developing BPD. Children also appear to be at risk for developing this disorder when they have a learning problem or certain temperaments. Adolescents who develop an alcohol-use disorder are also apparently at higher risk of developing BPD compared to those who do not.

What are the symptoms of borderline personality disorder?

In order to qualify for the diagnosis of BPD, an individual must have at least five of the following symptoms:

• Unstable self-image, in that they may drastically and rapidly change in the way they perceive their own likes, dislikes, strengths, weaknesses, goals, and intrinsic value as a person



• Unstable relationships, in that individuals with this disorder rapidly, drastically, and often frequently change from seeing another person as nearly perfect (idealizing) to seeing the other person as being virtually worthless (devaluing)



• Unstable emotions (affects), in that the sufferer experiences marked, rapid changes in feelings (for example, anger, joy, euphoria, anxiety, and depression) that are stress related, even if the stresses may be seen as minor or negligible to others



• Desperate efforts to avoid being abandoned, whether the abandonment is real or imagined



• Significant impulsivity, in that the person with BPD tends to act before thinking to the point that it is self-damaging (for example, sexual behaviors, spending habits, eating habits, driving behaviors, or in the use of substances)



• Recurring suicidal behaviors, threats, or attempts



• Chronic feelings of emptiness



• Inappropriate, intense anger or difficulty managing their anger when it occurs



• Transient, stress-related paranoia or severe dissociation (lapses in memory)

How is borderline personality disorder diagnosed?

There is no specific definitive test, like a blood test, that can accurately assess that a person has BPD. Therefore, practitioners conduct a mental-health interview that looks for the presence of the symptoms previously described. As with any mental-health assessment, the practitioner will usually work toward ruling out other mental disorders. The professional will also try to ensure that the individual is not suffering from a medical problem that may cause emotional symptoms. The mental-health practitioner will therefore often inquire about when the person has most recently had a physical examination, comprehensive blood testing, and any other tests that a medical professional deems necessary to ensure that the individual is not suffering from a medical condition instead of or in addition to emotional symptoms. Due to the use of a mental-health interview in making the diagnosis and the fact that this disorder can be quite resistant to treatment, it is of great importance that the practitioner know to conduct a thorough assessment lest the person be incorrectly assessed as having BPD when he or she does not.

How is borderline personality disorder treated?

Different forms of psychotherapy have been found to effectively treat BPD. Dialectical behavior therapy (DBT) is an approach to psychotherapy in which the therapist specifically addresses four areas that tend to be particularly problematic for individuals with BPD: self-image, impulsive behaviors, mood instability, and problems in relating to others. To address those areas, DBT tries to build four major behavioral skill areas: mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness. Talk therapy that focuses on helping the person understand how their thoughts and behaviors affect each other (cognitive behavioral therapy) has also been found to be effective treatment for BPD. Other psychotherapy approaches that have been used to address BPD include interpersonal psychotherapy (IPT) and psychoanalytic therapy. ITP is an approach that focuses on how the person's symptoms are related to the problems that person has in relating to others. Psychoanalytic therapy, which seeks to help the individual understand and better manage his or her ways of defending against negative emotions, has been found to be effective in addressing BPD, especially when the therapist is more active or vocal than in traditional psychoanalytic treatment and is used in the context of current rather than past relationships.

The use of psychiatric medications, like antidepressants (for example, fluoxetine [Prozac], sertraline [Zoloft], citalopram [Celexa], escitalopram [Lexapro], or trazodone [Desyrel]), mood stabilizers (for example, divalproex sodium [Depakote], carbamazepine [Tegretol], or lamotrigine [Lamictal]) or antipsychotics (for example, olanzapine [Zyprexa], risperidone [Risperdal], aripiprazole [Abilify], or paliperidone [Invega]) may be useful in addressing some of the symptoms of BPD but do not manage the illness in its entirety. On the positive side, some women who suffer from both BPD and bipolar disorder may experience a decrease in how irritable and angry they feel, as well as a decrease in how often and severely they become aggressive when treated with a mood stabilizer like Depakote. On the other hand, the use of medications in the treatment of symptoms in individuals with BPD may sometimes cause more harm than good. For example, while people with BPD may experience suicidal behaviors no more often than other individuals with a severe mental illness, they often receive more medications and therefore suffer from more side effects. Also, given how frequently many sufferers of BPD experience suicidal feelings, great care is taken to avoid the medications that can be dangerous in overdose.

Partial hospitalization is an intervention that involves the individual with mental illness being in a hospital-like environment during the day but returning home each evening. In addition to providing a safe environment and frequent monitoring by mental-health professionals, partial hospitalization programs allow for more frequent mental-health interventions like professional assessments, psychotherapy, and medication treatment. While funding for a long-term stay in a partial hospitalization may be difficult, research shows that when it is provided using a psychoanalytic approach it may help the person with BPD enjoy a decrease in the severity of anxiety and depression, the frequency of suicide attempts and full hospitalizations, as well as developing improved relationships with others. Contrary to earlier beliefs, BPD has been found to significantly improve in response to treatment with appropriate inpatient hospitalization.

What are the complications of borderline personality disorder?

The presence of BPD can often influence, usually worsening, the course of another mental condition with which it occurs. For example, it tends to change the symptoms of posttraumatic stress disorder and to worsen depression.

Individuals with BPD are at risk for self-mutilation, as well as for attempting or completing suicide. While both self-mutilating and suicidal behaviors seem to be associated with alleviating negative feelings, it is thought that self-mutilating behaviors are more an expression of anger, punishing oneself, distracting oneself, and eliciting more normal feelings. In contrast, suicide attempts are thought to be more often associated with feeling survivors will be better off for their death. People who engage in self-mutilation are more likely to commit suicide compared to those who do not self-mutilate.

Although most individuals with a mental disorder do not engage in violent behavior, those who suffer from BPD have a somewhat increased risk for such behaviors. That risk is also increased for individuals who suffer from antisocial personality disorder, have previous history of violent behavior, frequent use of sedative medications, or experience several changes in their psychiatric medications in general.

What is the prognosis of people with borderline personality disorder?

Overall, how well or poorly people with BPD progress over time seems to be influenced by how severe the disorder is at the time that treatment starts, the state of the individual's current personal relationships, as well as whether or not the sufferer has a history of being abused as a child. Simultaneously suffering from depression, other emotional problems, or a low level of conscientiousness has been found to be associated with a greater likelihood of symptoms of BPD to return (relapse). Conversely, having steady employment or school status once symptoms of BPD subside (remit) tends to protect BPD sufferers from experiencing a future relapse.

Where to can I get more information on borderline personality disorder?

Borderline Personality Disorder Research Foundation
340 West 12th Street
New York, NY 10014
Phone: 212-421-5244
Fax: 212-421-5243
Email: BPDRF.USA@Verizon.net
Web site: http://www.borderlineresearch.org

Borderline Personality Disorder Resource Center
New York Presbyterian Hospital -- Westchester Division
21 Bloomingdale Road
White Plains, NY 10605
Phone: 1-888-694-2273
Email: info@bpdresourcecenter.org
Web site: http://www.bpdresourcecenter.org/index.htm

Borderline Personality Disorder Resources.net
Web site: http://www.bpdresources.net

Borderline Personality Disorder Today
Web site: http://www.borderlinepersonalitytoday.com

National Alliance on Mental Illness (NAMI)
Colonial Place Three
2107 Wilson Boulevard Suite 300
Arlington, VA 22201-3042
Phone: 1-800-950-NAMI 1-800-950-6264 hotline for help with depression
703-524-7600
Fax: 703-524-9094
TDD: 703-516-7227
Email: info@nami.org
Web site: http://www.nami.org

National Education Alliance for BPD
PO Box 974
Rye, New York 10580
Web site: http://www.neabpd.org

National Institute of Mental Health (NIMH)
6001 Executive Boulevard
Room 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: 1-866-615-6464 toll-free
301-443-4513
Fax: 301-443-4279
TDD: 1-866-415-8051 toll-free
Email: nimhinfo@nih.gov
Web site: http://www.nimh.nih.gov

Borderline Personality Disorder At A Glance

• Borderline personality disorder is a personality disorder characterized by consistently problematic ways of thinking, feeling, and interacting.
• BPD is associated with unstable self-image, feelings, behaving, and relating to others.
• BPD affects 6% of adults, men as often as women.
• Antisocial personality disorder in adults, substance abuse problems in men, eating disorders in women, and anxious and odd personality disorders in adolescents tend to co-occur with BPD.
• There has been some controversy about whether or not BPD is its own disorder or a variation of bipolar disorder, but in many countries, there is more agreement on the existence of BPD.
• Like most other mental disorders, it is understood to be the result of a combination of biological vulnerabilities, ways of thinking, and social stressors (biopsychosocial model).
• BPD sufferers are more likely to have a learning problem or certain temperaments as children, or to come from families of origin where divorce, neglect, sexual abuse, substance abuse, or death occurred.
• In order to be diagnosed with BPD, the sufferer must experience at least five of the following symptoms: unstable self-image, relationships or emotions, severe impulsivity, repeated suicidal behaviors or threats, chronic feelings of emptiness, inappropriate anger, trouble managing anger, or transient paranoia or dissociation.
• As with other mental disorders, there is no specific definitive test, like a blood test, to diagnose BPD. Therefore, practitioners conduct a mental-health interview that looks for the presence of the symptoms previously described and usually explore the person's history for any medical problem that may show symptoms of the disorder.
• Psychotherapy approaches that have been helpful in treating BPD include dialectical behavior therapy, cognitive behavioral therapy, interpersonal therapy, and psychoanalytic psychotherapy.
• The use of psychiatric medications like antidepressants, mood stabilizers, and antipsychotics may be useful in addressing some of the symptoms of BPD but do not manage the illness in its entirety.
• Partial hospitalization can help treat BPD by providing frequent supervision and assessment in a safe environment, while allowing the sufferer to go home each evening.
• The presence of BPD tends to worsen the symptoms of other mental illnesses and increase the risk for self-mutilation, as well as for attempting or completing suicide.
• People with BPD are at somewhat higher risk for engaging in violent behavior. That risk is further increased when the individual with BPD also is suffering from antisocial personality disorder, has a previous history of violent behavior, frequently uses sedative medications, or experiences several changes in their psychiatric medications.
• How well or poorly people with BPD progress over time seems to be influenced by the severity of the symptoms, the individual's current personal relationships, as well as whether or not the sufferer has a history of being abused as a child.
• Steady employment or school status once symptoms of BPD subside (remit) tends to protect BPD sufferers from experiencing a future relapse.

References:

Axelrod, S.R., Morgan, C.A., Southwick, S.M. Symptoms of posttraumatic stress disorder and borderline personality disorder in veterans of operation desert storm. American Journal of Psychiatry 162 Feb. 2005: 270-275.

Bateman, A., Fonagy, P. Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: An 18-month follow-up. Focus 4 Spring 2006: 244-252.

Becker, D.F., Grilo, C.M., Edell, W.E., et al. Comorbidity of borderline personality disorder with other personality disorders in hospitalized adolescents and adults. American Journal of Psychiatry 157 Dec. 2000: 2011-2016.

Brown, M.Z., Comtois, K.A., Linehan, M.M. Reasons for suicide attempts and nonsuicidal self-injury in women with borderline personality disorder. Journal of Abnormal Psychology 111.1 Feb. 2002: 198-202.

Brunton, J.N., Lacey, J.H., Waller, G.D. Narcissism and eating characteristics in young nonclinical women. The Journal of Nervous and Mental Disease 193.2 Feb. 2005: 140-143.

Dolan, B., Warren, F., Norton, K. Change in borderline symptoms one year after therapeutic community treatment for severe personality disorder. The British Journal of Psychiatry 171 (1997): 274-279.

Frankenburg, F.R., Zanarini, M.C. Divalproex sodium treatment of women with borderline personality disorder and bipolar II disorder: a double-blind placebo-controlled pilot study. Journal of Clinical Psychiatry 63.5 May 2002: 442-446.

Giesen-Bloo, J., van Dyck, R., Spinhoven, P., et al. Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs. transference-focused psychotherapy. Archives of General Psychiatry 63 (2006: 649-658.

Grant, B.F., Chou, S.P., Goldstein, R.B., et al. Prevalence, correlates, disability and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry 69.4 Apr. 2008: 533-545.

Gunderson, J.G., Daversa, M.T., Grilo, C.M., McGlashan, T.H., et al. Predictors of 2-year outcome for patients with borderline personality disorder. American Journal of Psychiatry 163 May 2006: 822-826.

Harman, M.J. Children at-risk for borderline personality disorder. Journal of Contemporary Psychotherapy 34.3 Sept. 2004: 279-290.

Lis, E., Greenfield, B., Henry, M., Guile, J.M., Dougherty, G. Neuroimaging and genetics of borderline personality disorder: a review. Journal of Psychiatry and Neuroscience 32.3 May 2007: 162-173.

Makela, E.H., Moeller, K.E., Fullen, J.E., Gunel, E. Medication utilization patterns and methods of suicidality in borderline personality disorder. The Annals of Pharmacotherapy 40.1 (2006): 49-52.

Miller, A.L., Wyman, S.E., Huppert, J.D., et al. Analysis of behavioral skills utilized by suicidal adolescents receiving dialectical behavior therapy. Cognitive and Behavioral Practice 7.2 (2000): 183-187.

Nath, S., Patra, D.K., Biswas, S., Mallick, A.K., Bandyopadhyay, G.K., Ghosh, S. Comparative study of personality disorder associated with deliberate self harm in two different age groups (15-24 years and 45-74 years). Indian J Psychiatry 50 (2008): 177-80.

Oldham, J.M. Borderline personality disorder: an overview. Psychiatric Times 21.8 July 2004.

Oldham, J.M. Borderline personality disorder comes of age. American Journal of Psychiatry 166 May 2009: 509-511.

Oumaya, M., Friedman, S., Pham, A., et al. Borderline personality disorder, self-mutilation and suicide: literature review. Encephale 34.5 Oct 2008: 452-458.

Quigley, B.D. Diagnostic Relapse in Borderline Personality Disorder: risk and protective factors. 2003 August Doctoral dissertation, Texas A & M University. http://handle.tamu.edu/1969.1/1237.

Rohde, P., Lewinsohn, P.M., Kahler, C.W., Seeley, J.R., Brown, R.A. Natural course of alcohol use disorders from adolescence to young adulthood. Psychiatry 40.1 Jan. 2001: 83-90.

Soliman, A.E., Reza, H. Risk factors and correlates of violence among acutely ill adult psychiatric inpatients. Psychiatric Services 52 Jan. 2001: 75-80.

Soloff, P.H., Lynch, K.G., Kelly, T.M., Malone, K.M., Mann, J.J. Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: a comparative study. American Journal of Psychiatry 157 Apr. 2000: 601-608.

Stone, M.H. Relationship of borderline personality disorder and bipolar disorder. American Journal of Psychiatry 163 July 2006: 1126-1128.

van Asselt, A.D.I., Dirksen, C.D., Arntz, A., et al. Out-patient psychotherapy for borderline personality disorder: cost-effectiveness of schema-focused therapy v. transference-focused psychotherapy. The British Journal of Psychiatry 192 (2008): 450-457.

Winston, A.P. Recent developments in borderline personality disorder. Advances in Psychiatric Treatment 6 (2000): 211-217.

World Health Organization. Tenth revision of the international classification of disease, chapter V(F): mental and behavior disorders. Diagnosis criteria for research. Geneva: World Health Organization; 1993: 162-163.

Zanarini, M.C., Frankenburg, F.R., Dubo, E.D., et al. Axis I comorbidity of borderline personality disorder. American Journal of Psychiatry 155.12 Dec. 1998: 1733-1739.

Zanarini, M.C., Williams, A.A., Lewis, R.E., et al. Reported pathological childhood experiences associated with the development of borderline personality disorder. American Journal of Psychiatry 154 (1997): 1101-1106.

Zhong, J., Leung, F. Should borderline personality disorder be included in the fourth edition of the Chinese classification of mental disorders? Chinese Medical Journal 120.1 (2007): 77-82.

Last Editorial Review: 9/21/2009

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