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Borderline PD: Definition
In psychiatry, borderline personality disorder (BPD) is a personality disorder characterised by extreme "black and white" thinking, mood swings, emotional dysregulation, disrupted relationships and difficulty in functioning in a way society accepts as normal. The name comes from the DSM-IV-TR; the ICD-10 has an equivalent called Emotionally Unstable Personality Disorder, borderline type. Psychiatrists describe borderline personality disorder as a serious disorder characterized by pervasive instability in mood, interpersonal relationships, self-image and behavior. This instability often disrupts family and work life, long-term planning, and the individual's sense of self-identity.
Originally thought to be at the "borderline" between psychosis and neurosis, people with BPD actually suffer from what has come to be called emotional dysregulation. While less well-known than schizophrenia or bipolar disorder (manic-depression), BPD is more common, affecting two percent of adults, mostly young women. There is a high rate of self-injury without suicidal intent, as well as a significant rate of suicide attempts and completed suicide in severe cases. In some instances people with BPD kill themselves by accident in a case of self-injury that goes too far. Patients often need extensive mental health services, and they account for 20 percent of psychiatric hospitalizations. With help, however, many improve over time and are eventually able to lead productive lives.
The DSM-IV-TR, a widely used manual for diagnosing mental disorders, defines borderline personality disorder (see DSM cautionary statement) as a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
- frantic efforts to avoid real or imagined abandonment. (not including suicidal or self-mutilating behavior covered in Criterion 5)
- a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
- identity disturbance: markedly 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; [not including] suicidal or self-mutilating behavior covered in Criterion 5)
- recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
- affective instability due to a marked 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 ideation or severe dissociative symptoms
In the ICD-10 system, the equivalent disorder is Emotionally Unstable Personality Disorder (F60.3). The ICD-10 system has a slightly different categorization for personality disorders, as it does not use the DSM's 5-axis diagnosis system. Emotionally Unstable Personality Disorder has the following diagnostic criteria, which differs slightly from the DSM criteria above:
F60.30 Impulsive type
- The general criteria for personality disorder (F60) must be met. [see below]
- 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 quarrelsome behaviour and to conflicts with others, especially when impulsive acts are thwarted or criticized;
- liability to outbursts of anger or violence, with inability to control the resulting behavioural explosions;
- difficulty in maintaining any course of action that offers no immediate reward;
- unstable and capricious mood.
F60.31 Borderline type
- The general criteria for personality disorder (F60) must be met. [see below]
- At least three of the symptoms mentioned in criterion 2 for F60.30 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 (including sexual);
- liability to become involved in intense and unstable relationships, often leading to emotional crises;
- excessive efforts to avoid abandonment;
- recurrent threats or acts of self-harm;
- chronic feelings of emptiness.
F60 Disorders of adult personality and behavior
- There is evidence that the individual's characteristic and enduring patterns of inner experience and behavior as a whole deviate markedly from the culturally expected and accepted range (or "norm"). Such deviation must be manifest in more than one of the following areas:
- cognition (i.e. ways of perceiving and interpreting things, people, and events; forming attitudes and images of self and others);
- affectivity (range, intensity, and appropriateness of emotional arousal and response);
- control over impulses and gratification of needs;
- manner of relating to others and of handling interpersonal situations.
- The deviation must manifest itself pervasively as behaviour that is inflexible, maladaptive, or otherwise dysfunctional across a broad range of personal and social situations (i.e. not being limited to one specific "triggering" stimulus or situation).
- There is personal distress, or adverse impact on the social environment, or both, clearly attributable to the behavior referred to in criterion 2.
- There must be evidence that the deviation is stable and of long duration, having its onset in late childhood or adolescence.
- The deviation cannot be explained as a manifestation or consequence of other adult mental disorders, although episodic or chronic conditions from sections F00-F59 or F70-F79 of this classification may coexist with, or be superimposed upon, the deviation.
- Organic brain disease, injury, or dysfunction must be excluded as the possible cause of the deviation. (If an organic causation is demonstrable, category F07.- should be used.)
Borderline PD: Description
While a patient with depression or bipolar disorder typically endures the same mood for weeks, a person with BPD may experience intense bouts of anger, depression and anxiety that may last only hours, or at most a day. These may be associated with episodes of impulsive aggression, self-injury including cutting, and drug or alcohol abuse. Distortions in cognition and sense of self can lead to frequent changes in long-term goals, career plans, jobs, friendships, and values. Sometimes people with BPD view themselves as fundamentally bad or unworthy. They may feel unfairly misunderstood or mistreated, bored, empty, and have little idea who they are. Such symptoms are most acute when people with BPD feel isolated and lacking in social support, and may result in frantic efforts to avoid being alone.
People with BPD often have highly unstable patterns of social relationships. While they can develop intense but stormy attachments, their attitudes towards family, friends, and loved ones may suddenly shift from idealization (great admiration and love) to devaluation (intense anger and dislike). Thus, they may form an immediate attachment and idealize the other person, but when a slight separation or conflict occurs, they switch unexpectedly to the other extreme and angrily accuse the other person of not caring for them at all. Even with family members, individuals with BPD are highly sensitive to rejection, reacting with anger and distress to such mild separations as a vacation, a business trip, or a sudden change in plans. These fears of abandonment seem to be related to difficulties feeling emotionally connected to important persons when they are physically absent, leaving the individual with BPD feeling lost and perhaps worthless. Suicide threats and attempts may occur along with anger at perceived abandonment and disappointments.
People with BPD exhibit other impulsive behaviors, such as manipulativeness, excessive spending, binge eating and risky sex. BPD often occurs together with other psychiatric problems, particularly bipolar disorder, depression, anxiety disorders, substance abuse, and other personality disorders.
Borderline PD: History of the disorder
- historical sources
- famous clinicans
Borderline PD: Epidemiology
- Borderline PD: Incidence
- Borderline PD: Prevalence
- Borderline PD: Morbidity
- Borderline PD: Mortality
- Borderline PD: Racial distribution
- Borderline PD: Age distribution
- Borderline PD: Sex distribution
Borderline PD: Risk factors
Borderline PD: Etiology
Borderline PD: Diagnosis & evaluation
- Borderline PD: Psychological tests
- Borderline PD: Assessment isssues
- Borderline PD: Evaluation protocols
Borderline PD: Treatment Treatments for BPD have improved in recent years. People with BPD, who are often distressed by at least some of their symptoms, typically undertake a series of empirical trials of drugs to see whether anything helps them, and may end up taking no drugs at all. Since about 1989, Prozac and other selective serotonin reuptake inhibitor antidepressants (SSRIs) have repeatedly been shown to improve the symptoms of BPD in some patients.
The book, Listening to Prozac describes some of these remarkable changes. In general, it takes a higher dose of an SSRI to treat BPD than depression. It also takes about three months to start seeing benefit, compared to two weeks for depression. The previous antidepressants, the tricyclics, were often unhelpful, and sometimes even worsened the symptoms. Increasing evidence implicates inadequate serotonergic neurotransmission as strongly related to impaired modulation of emotional and behavioral responses to everyday life, manifesting as "overreacting to everything." Even thinking is recruited by the intense (or underregulated) emotionality so that the world is perceived primitively in intense black-and-white terms.
Other pharmacological treatments are often prescribed for certain other specific target symptoms shown by the individual patient, especially for people with more than one psychiatric diagnosis. Mood stabilizers (lithium or certain antiepileptic drugs) may be helpful for explosive anger or if there is an admixture of bipolar disorder. Antipsychotic drugs may also be used when there are distortions in thinking (e.g. paranoia). Overall, medication has not been as effective for people who have only BPD (without any other mental illnesses) as it is in many other psychiatric disorders, leading many researchers to focus on non-chemical treatments, such as Dialectical Behavior Therapy, for "pure" BPD patients.
Dialectical Behavior Therapy
In 1991, a new psychosocial treatment termed Dialectical Behavior Therapy (DBT) was developed specifically to treat BPD, and this technique was the first to show any efficacy compared to a control group. Marsha Linehan, the developer of DBT, said in the early days that it took about a year to see substantial enduring improvement. Combining SSRIs and DBT (probably the standard treatment now) seems to give satisfying synergy and faster results.
Linehan's dialectical behavior therapy method is based on negotiation between therapist and patient. The dialectic referred to in the treatment's name is of the therapist's acceptance and validation of the patient as she is, on the one hand, while the same time insisting on the need for change. The idea is to give the patient tools he/she never acquired as a child, typically to control and deal with his/her emotions. Some patients, when asked after several years of treatment, why they have stopped inflicting self-injury, answer "I picture myself sitting with my psychotherapist, and we talk about why I want to injure myself."
Schema and Mode Therapy
It should be noted that a promising new treatment for Borderline Personality Disorder and other characterological difficulties is a variant of Schema Therapy as devised by Jeffrey Young in the 1990's. The new form of tresatment is referred to as 'Mode Therapy'.
Young attributed the development of many characterological difficulties to the formation of Early Maladaptive Schemas (EMS). Schema Therapy involves the careful examination and understanding of these maladaptive themes with patients. However, his work with Borderline patients suggests that most of them have experienced all or nearly all of the 18 Maladpative Schemas that have so far been identified within the model. This makes Schema Therapy ungainly for these patients.
Mode Therapy focusses on the 'states' that a patient presents in the 'Here and Now'. The technique essentially involves the limited reparenting of the patient to help them to grow and develop emotionally towards a healthy adult state.
Although the causes of BPD are uncertain, both environmental and genetic factors are thought to play a role in predisposing patients to BPD symptoms and traits, possibly through the final common pathway of reduced central serotonergic neurotransmission. Studies show that many (but not all) individuals with BPD report a history of abuse, neglect, or separation as young children. Many others have an apparently hereditary form of the disease. Forty to 71 percent of BPD patients report having been sexually abused, usually by a non-caregiver. Others have impeccably innocuous histories.
Researchers believe that BPD results from a combination of individual genetic vulnerability, and environmental stress, neglect or abuse as young children, and maturational events that trigger the onset of the disorder during adolescence or adulthood.
Adults with BPD are also considerably more likely to be the victim of violence, including rape and other crimes. This may result from both harmful environments as well as impulsivity and poor judgment in choosing partners and lifestyles. An additional factor is that borderlines, with their irrational outbursts of anger and tendency to launch into accusatory rants at loved ones, can push even the most passive people over the edge. This often results in the borderline becoming the victim of violence, particularly in domestic situations. Their anger, impulsivity, and poor judgment may also explain why people with BPD are more likely than average to be arrested for and convicted of crimes ranging from petty theft to murder.
National Institute of Mental Health-funded neuroscience research is revealing brain mechanisms underlying the impulsivity, mood instability, aggression, anger, and negative emotion seen in BPD. Studies suggest that people predisposed to impulsive aggression have impaired regulation of the neural circuits that modulate emotion. The amygdala, a small almond-shaped structure deep inside the brain, is an important component of the circuit that regulates negative emotion. In response to signals from other brain centers indicating a perceived threat, it marshals fear and arousal. This might be more pronounced under the influence of stress and/or drugs like alcohol. Areas in the front of the brain (pre-frontal area) act to dampen the activity of this circuit. Recent brain imaging studies show that individual differences in the ability to activate regions of the prefrontal cerebral cortex thought to be involved in inhibitory activity predict the ability to suppress negative emotion.
Serotonin, norepinephrine and acetylcholine are among the chemical messengers in these circuits that play a role in the regulation of emotions, including sadness, anger, anxiety and irritability. Drugs that enhance brain serotonin function sometimes improve emotional symptoms in BPD. Likewise, mood-stabilizing drugs that are known to enhance the activity of GABA, the brain's major inhibitory neurotransmitter, may help people who experience BPD-like mood swings. Such brain-based vulnerabilities can be managed with help from behavioral interventions and medications, much like people manage susceptibility to diabetes or high blood pressure through both medication and lifestyle changes.
- outcome studies
- Borderline PD: Treatment protocols
- Borderline PD: Treatment considerations
- Borderline PD: Evidenced based treatment
- Borderline PD: Theory based treatment
- Borderline PD: Team working considerations
- Borderline PD: Followup
Studies that translate basic findings about the neural basis of temperament, mood regulation and cognition into clinically relevant insights which bear directly on BPD represent a growing area of research supported by the National Institute of Mental Health (NIMH) in the USA. Research is also underway to test the efficacy of combining medications with behavioral treatments like DBT, and gauging the effect of childhood abuse and other stress in BPD on brain hormones. Data from the first prospective, longitudinal study of BPD, which began in the early 1990s, is expected to reveal how treatment affects the course of the illness. It will also pinpoint specific environmental factors and personality traits that predict a more favorable outcome. The Institute is also collaborating with a private foundation to help attract new researchers to develop a better understanding and better treatment for BPD.
Borderline PD: For people with this difficulty
- Borderline PD: Service user: How to get help
- Borderline PD: Service user: Self help materials
- Borderline PD: Service user: Useful reading
- Borderline PD: Service user: Useful websites
- Borderline PD: Service user: User feedback on treatment of this condition
Borderline PD: For their carers
Effects on family members, significant others, and friends
An interesting area of research relating to BPD is the study of the effects of the disorder on other family members and significant others in the lives of those with traits of borderline personality disorder. These people refer to themselves as NonBPs. Living with or being in a relationship with someone that has BPD traits is disorienting and difficult; at worst, the toll of being in such a relationship on the NonBP's emotional and mental well-being can cause significant long-term problems for the NonBP. Some NonBP's report symptoms of PTSD or depression. NonBPs also commonly find it difficult to end a relationship with a person that exhibits BPD traits. Due to their fear of abandonment, a person with BPD may go to extremes in order to prevent the NonBP from leaving. NonBPs typically require support from the mental health community or other healthy, positive people and organizations if they choose to stay in a relationship with someone that exhibits BPD traits.
- Borderline PD: Carer: How to get help
- Borderline PD: Carer: Useful reading
- Borderline PD: Carer: Useful websites
Instructions_for_archiving_academic_and_professional_materials Borderline PD: Academic support materials
- Borderline PD: Academic: Lecture slides
- Borderline PD: Academic: Lecture notes
- Borderline PD: Academic: Lecture handouts
- Borderline PD: Academic: Multimedia materials
- Borderline PD: Academic: Other academic support materials
- Borderline PD: Academic: Anonymous fictional case studies for training
Borderline PD: For the practitioner
- BPD Recovery - focusing on healthy, happy living; support, resources, info, education, etc.
- BPD Family - education and emotional support for family, and relationship partners of those with borderline personality disorder - 27,000 members
- Borderline Personality Disorder
- A Page full of useful links about BPD
- BPD Central - borderline personality disorders - books, cds, info, support, resources, links
- Borderline Personality Disorder Sanctuary - books, education, communities
- Borderline Personality Disorder
- Yellow Brick Road Tour - Support for Partners & Friends
- BPD411 - support for the NonBP
- Dialectical Behavioral Therapy
- Dialectical Behaviour Therapy
- Dialectical Behavior Therapy
- National Institute of Mental Health (NIMH) Home Page
- Mental Health Matters: Borderline Personality Disorder
- Psych Forums: Borderline Personality Forum
- Helen's World of BPD Resources: 1000s of links & info for friends/family/sufferers
- Borderlands: A Survivor's Tale (Guide for partners of BPD sufferers)
- Mechanisms of BPD - Articles written by an individual with BPD for the benefit of treatment teams, families, friends and people with BPD .
|Personality disorder | Psychopathy|
|Cluster A (Odd) - Schizotypal, Schizoid, Paranoid|
|Cluster B (Dramatic) - Antisocial, Borderline, Histrionic, Narcissistic|
|Cluster C (Anxious) - Dependent, Obsessive-Compulsive, Avoidant|
|Personality disorder not otherwise specified|
|Assessing Personality Disorder|
|MCMI | MMPI | Functional assessment|
|Treating Personality Disorder|
|DBT | CBT | Psychotherapy |Mindfulness-based Cognitive Therapy|
|Prominent workers in Personality Disorder|
| Millon | Linehan