Borderline Personality Disorder Clinical Presentation

  • Author: Roy H Lubit, MD, PhD; Chief Editor: Caroly Pataki, MD   more...
 
Updated: Sep 2, 2011
 

History

  • In contrast to adult cases of borderline personality disorder (BPD), BPD in childhood has not been consistently and clearly categorized.
    • In the 1940s and 1950s, several researchers categorized this disorder in children in the realm of childhood psychoses or schizophrenia.[9, 10] Clinical observations included fluctuations in ego states, primitive regressions, disturbed interpersonal relationships, and severe anxiety.
    • Anna Freud described children with deep levels of regression, massive developmental arrests, withdrawal of libido from the object world and displacement onto the body or self, an inability to receive comfort from others, and numerous specific ego deficits.[11]
  • In 1982, Pine developed a working nosology of borderline syndromes in children.[12] These clinical subgroupings remain highly relevant, although the Diagnostic and Statistical Manual, 4th Edition, Text Revision (DSM-IV-TR) nomenclature was not modified to establish the diagnosis in patients younger than 18 years.[13]
    • Patients may have failures in developmental lines associated with major ego functions or central aspects of object relationships.
    • Patients may have an inability to adequately soothe themselves, with demonstrations of overemotionality and maladaptive attempts at self-soothing.
    • Patients may have an unstable sense of self that manifests as maladaptive attempts to fulfill their needs by means of suicide threats, self-harm, and angry behavior.
  • Borderline personality disorder has historically been considered to be on the border between psychosis and neurosis.
    • The disorder is characterized by marked instability in functioning, affect, mood, interpersonal relationships, and, at times, reality testing.
    • Patients with borderline personality disorder may manifest overwhelming anger when in a state of crisis.
    • Psychotic symptoms, when present, are short lived, circumscribed, or accompanied by good reality testing.
    • Individuals with personality disorders are frequently dissatisfied with their marked and sustained impairment in social, occupational, or academic functioning.
  • DSM-IV-TR diagnostic criteria for borderline personality disorder are (1) a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and (2) marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by at least 5 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 2 areas that are potentially self-damaging (eg, 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 (eg, 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 (eg, frequent displays of temper, constant anger, recurrent physical fights)
  9. Transient, stress-related paranoid ideation or severe dissociative symptoms

In a small study, 18 patients with BPD underwent a modified version of the Iowa Gambling Task while an electroencephalogram was recorded. The results indicated that patients with BPD are impaired in decision making, which might be related to a dysfunctional use of feedback information, as they did not learn to avoid harmful choices although they were aware of the negative consequences.[14]

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Physical

  • No consistent physical findings are specific to borderline personality disorder or borderline pathology in children.
  • Individuals may, however, have scars from self-cutting.
  • The diagnosis is based on clinical observations of behaviors and patient-reported symptoms.

The mental status examination should include the following:

  • General appearance and behavior: Grooming, height and weight, dress, any abnormal movements
  • Attitude toward interview including eye contact
  • Psychomotor activity
  • Range of affect
  • General mood and if it is appropriate to the situation
  • Speech: Rate, volume, prosody,
  • Thought process: Any sign of a thought disorder, thought blocking, flight of ideas, loose associations, or ideas of reference; tangentiality, goal focused
  • Thought content: Obsessions, suicidality, homicidality, paranoia
  • Hallucinations
  • Delusions
  • Orientation: Person, place, and time
  • Memory: Short- and long-term
  • Attention and concentration
  • Insight and judgment
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Causes

  • Most theories about the cause or pathogenesis of borderline personality disorder include the notion of a biologic predisposition[15] along with psychological and environmental factors. One theory posits that neurobiological development is affected by a combination of disruption of early attachments and subsequent trauma leading to hyper-responsiveness of the attachment system. During emotional arousal, images of self and object are affected and the individual begins to use primitive defense mechanisms.
  • A history of abuse is very common and Michael Stone has postulated that childhood abuse can lead to the development of borderline personality disorder.
  • Several researchers have proposed the existence of a constitutional incapacity to tolerate stress.
  • Kernberg has hypothesized that patients with borderline pathology have a constitutional inability to regulate their affect, which predisposes them to psychic disorganization or deterioration under early adverse environmental conditions.[2]
  • Persons with borderline personality disorder are at higher risk for Axis I syndromes, including depression, panic disorder, and agoraphobia. Studies commonly reveal that patients with BPD are anxious, dependent, and acutely sensitive to rejection and loss; these observations suggest that the condition might be specifically related to attachment bond regulation.
    • Mahler hypothesized that infants at risk are subjected to unpredictable and prolonged separation from their maternal figure during the separation-individuation process of development that occurs around age 18-36 months.[9] The unavailability of the maternal figure might make the child forever vulnerable to disorganization brought on by separation experiences.
    • Kernberg suggested that patients with BPD internalize early pathologic object relations.[2] The use of primitive defense mechanisms (which individuals without BPD outgrow during normal development) maintains these early pathologic object relations. Kernberg hypothesized that, in the early stages of development, the infant experiences the maternal figure in 2 contradictory ways: The first is the good mother, who provides for, loves, and remains close. The second is the hateful, depriving mother, who unpredictably punishes and abandons the child. The result is intense anxiety, which leads to the borderline defense of splitting.
    • Several researchers have proposed a hypothesis for borderline personality by using a family systems perspective.[16] In this view, the significant etiologic variables stem from the concepts of faulty family boundaries, the unpredictable proximity among family members, and the lack of an appropriate hierarchical structure.
  • Although the borderline condition in childhood is not necessarily a precursor to borderline personality disorder in adulthood, evidence suggests that both have strikingly similar risk factors, which might indicate a common etiology. These factors include family environments characterized by trauma, neglect, and/or separation; exposure to sexual and physical abuse; and serious parental psychopathology, such as substance abuse and antisocial personality disorder.
  • The pathogenesis of borderline personality is complex and probably multifactorial, as in the theory of Linehan et al, which states that borderline pathology results from the interaction of a biologic emotional vulnerability and a pervasively invalidating environment.[6, 7] More research involving developmental psychopathology, neurobiology, and family systems theory is necessary to explain how, when, and in what combination these various factors might pathologically affect development.
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Contributor Information and Disclosures
Author

Roy H Lubit, MD, PhD  Assistant Clinical Professor, Mount Sinai School of Medicine; Clinical Faculty, Department of Child Psychiatry, New York University School of Medicine; Private Practice

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Daniel Rauch, MD, FAAP  Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine

Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine

Disclosure: Baxter Honoraria Consulting

Chief Editor

Caroly Pataki, MD  Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Keck School of Medicine of the University of Southern California

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Elizabeth A Finley-Belgrad, MD and Joseph A Davies, MD to the development and writing of this article.

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