Borderline Personality Disorder

Overview

Borderline Personality Disorder is a personality disorder characterized by emotional instability and impulsivity in relationships, self-image, as well as emotions and mood. Individuals with Borderline Personality Disorder may have disproportionately intense reactions to certain triggers, and may also have a turbulent sense of self.

Symptoms often manifest in the form of overly idealizing attachment figures, as well as a fear of abandonment, and individuals may be preoccupied by feelings of impending rejection, neglect, or separation. Symptoms of the disorder can also lead to significant functional consequences that affect social, vocational or occupational lives, and can create considerable psychological distress resulting in suicide ideation and harm to oneself. 

While a female predominance is reported in clinical populations, there is no gender-based difference in the occurrence of the disorder in community samples. A higher prevalence can be observed in psychiatric clinical populations.

The interaction of genetic and environmental factors is implicated in the etiology of Borderline Personality Disorder, and there is emphasis on childhood adversity. There are often comorbidities, including depressive and anxiety disorders, disruptive disorders, substance use disorders, eating disorders, and posttraumatic stress disorder. Other personality disorders may also occur concomitantly. 

Treatment modalities for Borderline Personality Disorder are largely based in psychosocial intervention, with the development of various specific evidence-based therapies for symptom alleviation. Pharmacotherapy may also be effective for certain symptom domains. 

Signs and Symptoms

The signs and symptoms of Borderline Personality Disorder may include: 

1. Disproportionate fear of real or imagined abandonment 
2. Inappropriate or aggressive reactions to separation
3. Inappropriate or aggressive reactions to changes in plans
4. Unstable perceptions of self, relationships, and emotions
5. Impulsive reactions in order to avoid perceived threat of abandonment
6. Idealizing individuals such as caretakers or partners 
7. Demanding a lot of time together with idealized figures 
8. Quickly devaluing individuals and thinking they do not care enough about the individual 
9. Sudden changes in self including values, aspirations, sexual identity, etc.
10. Perceiving oneself as being evil or perceiving oneself as being nonexistent 
11. Impulsive and harmful habits such as gambling, binge eating, substance use, driving recklessly or engaging in unsafe sex
12. Suicidal tendencies and self-mutilation
13. Episodes of intense irritability or anxiety
14. Periods of anger, panic, or despair
15. Displaying extreme sarcasm, verbal abuse and outbursts, and bitterness
16. Dissociative symptoms
17. Undermining oneself on the cusp of goal-realization (such as dropping out of college right before graduating or sabotaging a good relationship) 
18. Symptoms resembling psychosis such as hallucinations or body-related distortions under stress

Risk Factors

In community samples, the prevalence of Borderline Personality Disorder appears to be equal among males and females. Contrasting to this, in clinical samples, a female predominance is noted. Compared to the general population, the prevalence of the disorder is significantly higher among psychiatric clinical populations. Symptom onset is likely to start between adolescence and early adulthood, though the retention of symptoms often continues into late adulthood as well.

The etiology of Borderline Personality Disorder may be looked at from a diathesis-stress perspective. Genetic factors are considered to increase sensitivity to environmental correlates. An interaction of genetic and biological factors with environmental trauma is implicated as a causative factor in the occurrence of the disorder. 

Borderline Personality Disorder is associated with considerable familial risk. Individuals with first-degree relatives who have Borderline Personality Disorder have a higher likelihood of developing the disorder. While this does not indicate an inheritance factor, it implies that certain genetic patterns are responsible for increasing susceptibility to the disorder.

Association studies have implicated the role of genes that are linked to the serotonergic and dopaminergic systems, as well as monoamine oxidase a genes, which are associated aggressive behavior and impulsivity, and the catechol-O-methyltransferase gene, which is responsible for breaking down dopamine. Neurodevelopmental and structural abnormalities with regards to neural circuitry that affects emotion regulation have also been implicated, as well as hormonal abnormalities in terms of dysfunction of the hypothalamic-pituitary-adrenal axis. 

Certain familial risks also are involved in inherited temperamental factors, which may increase sensitivity to and exacerbate the effect of adverse life experiences. 

One of the major factors operating in the etiology of Borderline Personality Disorder is childhood adversity. While childhood maltreatment is not a prerequisite while diagnosing the disorder, the effects of adverse experiences and trauma during childhood are considered to have a significant association with the development of Borderline Personality Disorder.

Factors such as physical abuse, sexual abuse and neglect, inconsistent parenting, over-involvement of the mother, aversive parental behaviors, as well as low emotionality on the part of the parents have been considered to increase the risk of the disorder. Separation of the child and the mother before five years of age is also considered to be a predisposing factor.

Certain trait factors, including high neuroticism and low agreeableness, conscientiousness, and openness to experience are observed among children who experience such events, and these traits can persist into adulthood, laying a foundation for the development of Borderline Personality Disorder. 

Psychopathology during childhood, or having underlying psychiatric conditions, can also increase the risk of Borderline Personality Disorder. Depressive, anxiety, substance use, and disruptive disorders may become predisposing factors. Other common comorbidities include eating disorders, posttraumatic stress disorder, and ADHD. 

Diagnosis

In the context of Borderline Personality Disorder, there is a multiplicity of factors that may lead individuals to professional treatment. Episodes of comorbid disorders, most likely depressive or anxiety symptoms as well as substance use disorders, may influence an individual’s decision to seek professional help.

Problems in the context of interpersonal relationships or occupational setbacks may also be a relevant factor. Lastly, individuals may be required to seek professional help consequently after an attempt to take one’s life, or as a consequence of other actions motivated by self-destruction tendencies. 

Clinical interviews are usually the initial stage of the diagnostic process. Clinicians may make the use of unstructured, semi-structured, or structured interviews that make the use of appropriately framed questions to determine whether the individual fits into the diagnostic criteria put forth for Borderline Personality Disorder.

The Structured Clinical Interview for DSM-IV, the Axis II Disorders (SCID-II), the Structured Interview for DSM-IV Personality Disorders (SIDP-IV), the Revised Diagnostic Interview for Borderlines (DIB-R), and the Childhood Interview for DSM-IV Borderline Personality Disorder (CI-BPD) are some available interviews. Self-report tools may also be administered. 

The DSM-5 provides the following criteria for the diagnosis of Borderline Personality Disorder: 

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:

1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. 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).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Treatment

There have been considerable developments in psychosocial treatments for Borderline Personality Disorder. 

Various forms of Evidence-Based Therapy (EBT) treatments have proven to be considerably effective in the management of Borderline Personality Disorder. One of the mainstays of management interventions is Dialectical Behavioral Therapy, which is based on a combination of reasoning and validation used to facilitate the acquisition of skills and shaping of behavior.

By instilling skills such as mindfulness, DBT allows individuals to deal with stress effectively, manage relationships, and regulate emotions. This can be effective in addressing emotional sensitivity and affect components of symptoms. 

Mentalization-Based Treatment (MBT) is another form of intervention for Borderline Personality Disorder, the focal point of which is the individual’s ability to imagine interpersonal relationships from the point of view of the self and others. MBT strategies encourage patients to look at interpersonal situations in a more grounded way, and use the process of mentalizing to think through a more flexible view. 

Transference-Focused Psychotherapy (TFP) provides a deeper look into interpersonal dynamics and how they may influence stress and emotional states. Interpersonal dynamics of the patient are observed through their interactions with the therapist, and are then assessed in order to work through the negatives and understand their impact on emotionality and relationships. Importance is given to coherence and balance. 

Schema-Focused Therapy (SFT) puts together cognitive, behavioral, and experiential techniques focused on individualistic experiences in order to create change. Through a process of ‘limited re-parenting’, the therapy works on changing negative patterns of thinking, feeling and behaving and instead coming up with healthy ways to replace them. 

General Psychiatric Management and Structured Clinical Management may also be effective as forms of less intensive intervention. 

While no medication specifically targets Borderline Personality Disorder, certain psychopharmacological intervention has proven to aid the improvement of various dimensions of Borderline Personality Disorders symptoms.

Antipsychotics, including haloperidol, and olanzapine, as well as anticonvulsants, including lamotrigine, divalproex and topiramate, have shown to improve emotional regulation issues. Aripiprazole, an antipsychotic, as well as lamotrigine and topiramate improved behavioral control problems and impulsivity, and aripiprazole and olanzapine were effective in improving cognitive-perceptual symptoms. 

A combination of psychosocial and pharmacological intervention may show higher efficacy. Comorbidities must also be taken into consideration and effectively treated.  

Differential Diagnosis

1. Depressive and bipolar disorders: Borderline personality disorder often co-occurs with depressive or bipolar disorders, when criteria for both are met, both may be diagnosed.

2. Other personality disorders: Other personality disorders may be confused with borderline personality disorder because they have common features. It is therefore important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to borderline personality disorder, all can be diagnosed. Histrionic personality, paranoid personality disorder, narcissistic personality disorder, antisocial personality disorder and dependent personality disorder have various symptoms common to borderline personality disorder. But the cause, duration and nature help differentiate them.

3. Personality changes due to another medical condition: Borderline personality disorder must be distinguished from personality change due to another medical condition that affects the central nervous system.

4. Substance use disorders: Borderline personality disorder must also be distinguished from behaviour that develops due to substance use.

5. Identity problems: Borderline personality disorder should be distinguished from an identity problem, which is reserved for identity concerns related to a developmental phase (e.g., adolescence) and does not qualify as a mental disorder.

Specialist

Individuals may approach healthcare settings upon experiencing symptoms of comorbid disorders such as depressive or anxiety disorder. Psychiatrists and clinical psychologists may be involved in initial assessment procedures. On the basis of the intervention in question, therapists and practitioners with adequate training may be involved in the management of Borderline Personality Disorder. 

In Conclusion

There is no permanent treatment for Borderline Personality Disorder, but therapy and counseling help in reducing the symptoms of the individual. This condition mainly affects the emotional balance of the affected person. 

It is difficult to maintain a sound social, personal, and professional life when emotions are consistently imbalanced.

Thus, it is advised to get therapy and professional help at an early stage of diagnosis and reduce repetitive episodes of depression, anxiety, and stress. The symptoms can arise at an early age and can affect many areas of life such as school, work, social activities, and image of self. 

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