Borderline Personality Disorder

The main feature of borderline personality disorder (BPD) is a pervasive pattern of instability in interpersonal relationships, self-image, and emotions. People with borderline personality disorder are also usually very impulsive.

This disorder occurs in most by early adulthood. The unstable pattern of interacting with others has persisted for years and is usually closely related to the person’s self-image and early social interactions. The pattern is present in a variety of settings (e.g., not just at work or home) and often is accompanied by a similar lability (fluctuating back and forth, sometimes in a quick manner) in a person’s emotions and feelings. Relationships and the person’s emotion may often be characterized as being shallow.

Borderline Personality Disorder (BPD)
Borderline Personality Disorder (BPD)

A person with this disorder will also often exhibit impulsive behaviors and have a majority of the following symptoms:

  • Frantic efforts to avoid real or imagined abandonment
  • A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
  • Identity disturbance, such as a significant and persistently unstable self-image or sense of self
  • Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)
  • Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
  • Emotional instability due to significant reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
  • Chronic feelings of emptiness
  • Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
  • Transient, stress-related paranoid thoughts or severe dissociative symptoms

As with all personality disorders, the person must be at least 18 years old before they can be diagnosed with it.

Borderline personality disorder symptoms vary from person to person and women are more likely to have this disorder than men. Common symptoms of the disorder include the following:

Borderline Personality Disorder (BPD)
Borderline Personality Disorder (BPD)
  • Having an unstable or dysfunctional self-image or a distorted sense of self (how one feels about one’s self)
  • Feelings of isolation, boredom, and emptiness
  • Difficulty feeling empathy for others
  • A history of unstable relationships that can change drastically from intense love and idealization to intense hate
  • A persistent fear of abandonment and rejection, including extreme emotional reactions to real and even perceived abandonment
  • Intense, highly changeable moods that can last for several days or for just a few hours
  • Strong feelings of anxiety, worry, and depression
  • Impulsive, risky, self-destructive and dangerous behaviors, including reckless driving, drug or alcohol abuse and having unsafe sex
  • Hostility
  • Unstable career plans, goals and aspirations

The borderline personality disorder is more prevalent in females (75 percent of diagnoses made are in females). It is thought that borderline personality disorder affects approximately 2 percent of the general population.

Like most personality disorders, borderline personality disorder typically will decrease in intensity with age, with many people experiencing few of the most extreme symptoms by the time they are in the 40s or 50s.

Details about Borderline Personality Disorder Symptoms

Frantic efforts to avoid real or imagined abandonment.

The perception of impending separation or rejection, or the loss of external structure, can lead to profound changes in self-image, emotion, thinking, and behavior. Someone with the borderline personality disorder will be very sensitive to things happening around them in their environment. They experience intense abandonment fears and inappropriate anger, even when faced with a realistic separation or when there are unavoidable changes in plans. For instance, becoming very angry with someone for being a few minutes late or having to cancel a lunch date. People with a borderline personality disorder may believe that this abandonment implies that they are “bad.” These abandonment fears are related to an intolerance of being alone and a need to have other people with them. Their frantic efforts to avoid abandonment may include impulsive actions such as self-mutilating or suicidal behaviors.

Borderline Personality Disorder (BPD)
Borderline Personality Disorder (BPD)

Unstable and intense relationships.

People with the borderline personality disorder may idealize potential caregivers or lovers at the first or second meeting, demand to spend a lot of time together, and share the most intimate details early in a relationship. However, they may switch quickly from idealizing other people to devaluing them, feeling that the other person does not care enough, does not give enough, is not “there” enough. These individuals can empathize with and nurture other people, but only with the expectation that the other person will “be there” in return to meet their own needs on demand. These individuals are prone to sudden and dramatic shifts in their view of others, who may alternately be seen as beneficient supports or as cruelly punitive. Such shifts other reflect disillusionment with a caregiver whose nurturing qualities had been idealized or whose rejection or abandonment is expected.

Identity disturbance.

There are sudden and dramatic shifts in self-image, characterized by shifting goals, values, and vocational aspirations. There may be sudden changes in opinions and plans about career, sexual identity, values and types of friends. These individuals may suddenly change from the role of a needy supplicant for help to a righteous avenger of past mistreatment. Although they usually have a self-image that is based on being bad or evil, individuals with the borderline personality disorder may at times have feelings that they do not exist at all. Such experiences usually occur in situations in which the individual feels a lack of a meaningful relationship, nurturing and support. These individuals may show worse performance in unstructured work or school situations.

How is Borderline Personality Disorder Diagnosed

Personality disorders such as borderline personality disorder are typically diagnosed by a trained mental health professional, such as a psychologist or psychiatrist. Family physicians and general practitioners are generally not trained or well-equipped to make this type of psychological diagnosis. So while you can initially consult a family physician about this problem, they should refer you to a mental health professional for diagnosis and treatment. There are no laboratory, blood or genetic tests that are used to diagnose the borderline personality disorder.

Many people with the borderline personality disorder don’t seek out treatment. People with personality disorders, in general, do not often seek out treatment until the disorder starts to significantly interfere or otherwise impact a person’s life. This most often happens when a person’s coping resources are stretched too thin to deal with stress or other life events.

A diagnosis of borderline personality disorder is made by a mental health professional comparing your symptoms and life history with those listed here. They will make a determination whether your symptoms meet the criteria necessary for a personality disorder diagnosis.

Borderline Personality Disorder (BPD)
Borderline Personality Disorder (BPD)

Tests and Diagnosis

A licensed mental health professional—such as a psychiatrist, psychologist, or clinical social worker—experienced in diagnosing and treating mental disorders can diagnose borderline personality disorder by:

  • Completing a thorough interview, including a discussion about symptoms
  • Performing a careful and thorough medical exam, which can help rule out other possible causes of symptoms
  • Asking about family medical histories, including any history of mental illness

Borderline personality disorder often occurs with other mental illnesses. Co-occurring disorders can make it harder to diagnose and treat borderline personality disorder, especially if symptoms of other illnesses overlap with the symptoms of borderline personality disorder. For example, a person with the borderline personality disorder may be more likely to also experience symptoms of depression, bipolar disorder, anxiety disorders, substance use disorders, or eating disorders.

The World Health organizations define a disorder that is conceptually similar to the borderline personality disorder, called Emotionally unstable personality disorder. Its two subtypes are described below.

Borderline Personality Disorder (BPD)
Borderline Personality Disorder (BPD)

Impulsive type

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

  • 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 the 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.

Borderline type

At least three of the symptoms mentioned in Impulsive type must be present, 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 in a car or substance abuse

Causes of Borderline Personality Disorder

Researchers today don’t know what causes borderline personality disorder. There are many theories, however, about the possible causes of borderline personality disorder. Most professionals subscribe to a biopsychosocial model of causation – that is, the causes of are likely due to biological and genetic factors, social factors (such as how a person interacts in their early development with their family and friends and other children), and psychological factors (the individual’s personality and temperament, shaped by their environment and learned coping skills to deal with stress). This suggests that no single factor is responsible – rather, it is the complex and likely intertwined nature of all three factors that are important. If a person has this personality disorder, research suggests that there is a slightly increased risk for this disorder to be “passed down” to their children.

Research on the causes and risk factors for BPD is still in its early stages. However, scientists generally agree that genetic and environmental influences are likely to be involved.

Borderline Personality Disorder (BPD)
Borderline Personality Disorder (BPD)

Certain events during childhood may also play a role in the development of the disorder, such as those involving emotional, physical and sexual abuse. Loss, neglect, and bullying may also contribute. The current theory is that some people are more likely to develop BPD due to their biology or genetics and harmful childhood experiences can further increase the risk.

Following are the Causes of Borderline Personality Disorder

Genetics

The heritability of BPD has been estimated at 40%. That is, 40 percent of the variability in liability underlying BPD in the population can be explained by genetic differences. Twin studies may overestimate the effect of genes on variability in personality disorders due to the complicating factor of a shared family environment. Nonetheless, the researchers of this study concluded that personality disorders “seem to be more strongly influenced by genetic effects than almost any axis I disorder [e.g., bipolar disorder, depression, eating disorders], and more than most broad personality dimensions.” Moreover, the study found that BPD was estimated to be the third most-heritable personality disorder out of the 10 personality disorders reviewed. 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

A number of neuroimaging studies in Borderline Personality Disorder have reported findings of reductions in regions of the brain involved in the regulation of stress responses and emotion, affecting the hippocampus, the orbitofrontal cortex, and the amygdala, amongst other areas. A smaller number of studies have used magnetic resonance spectroscopy to explore changes in the concentrations of neuro-metabolites in certain brain regions of BPD patients, looking specifically at neuro-metabolites such as N-acetylaspartate, creatine, glutamate-related compounds, and choline-containing compounds.

Few Brain Abnormalities are listed below that results in Borderline Personality Disorder

  • Hippocampus
  • Amygdala
  • Prefrontal cortex
  • Hypothalamic-pituitary-adrenal axis

Increased cortisol production is also associated with an increased risk of suicidal behavior.

Neurobiological factors

Individual differences in women’s estrogen cycles may be related to the expression of BPD symptoms in female patients.

Developmental factors

  • Childhood trauma
  • Neurological patterns

Mediating and moderating factors

  • Executive function
  • Family environment
  • Self-complexity
  • Thought suppression

Risk Factors for Borderline Personality Disorder

The cause of borderline personality disorder is not yet clear, but research suggests that genetics, brain structure and function, and environmental, cultural, and social factors play a role, or may increase the risk for developing the borderline personality disorder.

  • Family History. People who have a close family member, such as a parent or sibling with the disorder may be at higher risk of developing the borderline personality disorder.
  • Brain Factors. Studies show that people with the borderline personality disorder can have structural and functional changes in the brain especially in the areas that control impulses and emotional regulation. But is it not clear whether these changes are risk factors for the disorder, or caused by the disorder.
  • Environmental, Cultural, and Social Factors. Many people with borderline personality disorder report experiencing traumatic life events, such as abuse, abandonment, or adversity during childhood. Others may have been exposed to unstable, invalidating relationships, and hostile conflicts.

Although these factors may increase a person’s risk, it does not mean that the person will develop a borderline personality disorder. Likewise, there may be people without these risk factors who will develop borderline personality disorder in their lifetime.

Subtypes of Borderline personality disorder

Discouraged borderline (including avoidant or dependent personality features)

  • Pliant, submissive, loyal, humble;
  • feels vulnerable and in constant jeopardy;
  • feels hopeless, depressed, helpless, and powerless.

Petulant borderline (including negativistic features)

  • Negativistic, impatient, restless, as well as stubborn, defiant, sullen, pessimistic, and resentful; easily feels “slighted” and quickly disillusioned.

Impulsive borderline (including histrionic or antisocial features)

  • Capricious, superficial, flighty, distractible, frenetic, and seductive;
  • hearing loss, the individual becomes agitated;
  • gloomy and irritable, and potentially suicidal.

Self-destructive borderline (including depressive or masochistic and self-defeating features)

  • Inward-turning, intropunitively (self-punishing) angry;
  • conforming, deferential, and ingratiating behaviors have deteriorated; increasingly high-strung and moody; possible suicide.

Differential diagnosis of Borderline personality disorder

Lifetime conditions are common in BPD. Compared to those diagnosed with other personality disorders, people with BPD Symptoms showed a higher rate of also meeting criteria for following conditions

  • mood disorders, including major depression and bipolar disorder
  • anxiety disorders, including panic disorder, social anxiety disorder, and post-traumatic stress disorder (PTSD)
  • other personality disorders, including schizotypal, antisocial and dependent personality disorder
  • substance abuse
  • eating disorders, including anorexia nervosa and bulimia
  • the attention deficit hyperactivity disorder
  • somatic symptom disorder (formerly known as a somatoform disorder, this is a category of mental disorder included in a number of diagnostic schemes of mental illness)
  • dissociative disorders
Borderline Personality Disorder (BPD)
Borderline Personality Disorder (BPD)

Treatment of Borderline personality disorder

The recommended treatment for borderline personality disorder includes psychotherapy, medications, and group, peer, and family support. Group and individual psychotherapy have been shown to be effective forms of treatment for many patients.

Psychotherapy

Long-term psychotherapy is currently the treatment of choice for BPD. While psychotherapy, in particular, dialectical behavior therapy and psychodynamic approaches, is effective, the effects are small.

Two examples of psychotherapies used to treat borderline personality disorder include:

  • Dialectical Behavior Therapy (DBT): This type of therapy was developed for individuals with borderline personality disorder. DBT uses concepts of mindfulness and acceptance or being aware of and attentive to the current situation and emotional state. DBT also teaches skills that can help:
    • Control intense emotions
    • Reduce self-destructive behaviors
    • Improve relationships
  • Cognitive Behavioral Therapy (CBT): This type of therapy can help people with borderline personality disorder identify and change core beliefs and behaviors that underlie inaccurate perceptions of themselves and others, and problems interacting with others. CBT may help reduce a range of mood and anxiety symptoms and reduce the number of suicidal or self-harming behaviors.
Borderline Personality Disorder (BPD)
Borderline Personality Disorder (BPD)

Medications

typical antipsychotics studied in relation to BPD, haloperidol may reduce anger and flupenthixol may reduce the likelihood of suicidal behavior. Among the atypical antipsychotics, one trial found that aripiprazole may reduce interpersonal problems and impulsivity. 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.

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. The omega-3 fatty acid may ameliorate suicidality and improve depression. As of 2017, trials with these medications had not been replicated and the effect of long-term use had not been assessed.

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