eMedicine Specialties > Psychiatry > Adult

Borderline Personality Disorder

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
Coauthor(s): Elizabeth A Finley-Belgrad, MD, Clinical Assistant Professor, Department of Psychiatry, Northeastern Ohio Universities College of Medicine
Contributor Information and Disclosures

Updated: Apr 1, 2008

Introduction

Background

Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself. They are exhibited in a wide range of important social and personal contexts. When these traits are significantly maladaptive and cause serious functional impairment or subjective distress, they constitute a personality disorder. The manifestations of personality disorders are often recognized by adolescence and continue throughout most of adult life.

Personality disorders are not formally diagnosed in patients younger than 18 years because of the ongoing developmental changes. However, if the disturbance is pervasive and if the criteria are fully and persistently met and are not limited to a developmental stage, diagnosing borderline personality disorder (BPD) in children and adolescents is appropriate.

BPD has historically been considered to be on the border between psychosis and neurosis. It is characterized by marked instability in functioning, affect, mood, interpersonal relationships, and, at times, reality testing. In 1942, Deutsch described a group of patients who lacked a consistent sense of identity and source of inner direction.1 She created the term "as-if personalities" because the patients completely identified with those upon whom they were dependent. In 1975, Kernberg conceptualized BPD to describe a group of patients with particular primitive defense mechanisms and pathologic internalized object relations (eg, splitting, projective identification).2

Borderline pathology in children refers to a syndrome characterized by a combination of externalizing symptoms (disruptive behavioral problems), internalizing symptoms (mood and anxiety symptoms), and cognitive symptoms. Follow-up studies of these children show that they have a tendency to develop a wide range of personality disorders, not specifically BPD. Further research in this area is imperative, not only to elucidate etiology, but also to allow for the earliest possible intervention.

Pathophysiology

Some studies have suggested that patients with BPD might have increased rates of soft neurologic signs,3 as well as learning disorders, attention deficit hyperactivity disorder, and abnormal EEG findings.4 Reports also indicate that adults with BPD have increased impulsivity, cognitive inflexibility, and poor self-monitoring and perseveration, which may be indicators of frontal lobe dysfunction.

As with most psychiatric disorders, the etiology of BPD is likely to include several factors, including an organic predisposition as well as psychosocial and environmental factors.

Some researchers postulate the presence of an underlying affective instability to which the individual responds with maladaptive behaviors.

Frequency

United States

To the authors' knowledge, no definitive prevalence studies have been performed; however, BPD is reported to be present in 1-2% of the general population. In a study performed by Clarkin et al in 1983, approximately 11% of psychiatric outpatients and 19% of inpatients met the criteria for BPD.5

Mortality/Morbidity

  • Premature death among patients with BPD may be due to the increased risk of suicide in this population. Approximately 70-75% of patients with BPD have a history of at least one deliberate act of self-harm. According to Linehan et al, the mean estimated rate of completed suicides 9%.6,7
  • BPD is associated with significant morbidity due to common comorbid conditions, including dysthymia, major depression, psychoactive substance abuse, and psychotic disorders. In a 1999 study of 409 patients, Zimmerman and Mattia demonstrated that patients with BPD were twice as likely to receive a diagnosis of 3 or more current axis-I disorders and that they were nearly 4 times as likely to have a diagnosis of 4 or more axis-I disorders than those without BPD.8 These included mood disorders, anxiety, substance abuse, eating disorders, and somatoform disorders.
  • Morbidity in this population includes failure in social relationships, developmental delay, and occupational impairment. Health care costs in patients with borderline pathology are enormous, and treatment dropout rates are extraordinarily high.

Race

No evidence suggests a relationship between race and the diagnosis of BPD or borderline disorders of childhood.

Sex

Virtually every study of BPD has revealed that the diagnosis is more common in females than in males; the female-to-male ratios are as high as 4:1.

Age

Symptoms of BPD are usually present by late adolescence, but the diagnosis has been made in children. The initial diagnosis of this disorder is rarely made in patients older than 40 years.

Clinical

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, (DSM-IV) 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.
  • BPD is considered to have a condition 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 BPD 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.

Physical

  • No consistent physical findings are specific to BPD or borderline pathology in children.
  • The diagnosis is based on clinical observations of behaviors and patient-reported symptoms.

Causes

  • Most theories about the cause or pathogenesis of BPD include the notion of a biologic predisposition14 along with psychological and environmental factors.
  • 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 BPD 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.15 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 BPD 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.

More on Borderline Personality Disorder

Overview: Borderline Personality Disorder
Differential Diagnoses & Workup: Borderline Personality Disorder
Treatment & Medication: Borderline Personality Disorder
Follow-up: Borderline Personality Disorder
References
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Further Reading

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Keywords

BPD, borderline personality, borderline personality disorder, borderline disorder, multiple complex developmental disorder, borderline disorder of childhood, borderline syndrome, schizophrenia, as-if personalities, pseudoneurotic schizophrenia, disorder of character, personality traits, psychiatric disorder, learning disabilities, attention deficit disorder, abnormal electroencephalograms, increased impulsivity

cognitive inflexibility, poor self-monitoring, poor perseveration, frontal lobe dysfunction, neurodevelopmental delays, unusual central nervous system sensitivities, increased risk of suicide, dysthymia, major depression, psychoactive substance abuse, psychotic disorders, mood disorders, anxiety, substance abuse, eating disorders, somatoform disorders, fluctuations in ego states, primitive regressions, disturbed interpersonal relationships, axis-I syndromes, panic disorder, agoraphobia, sexual abuse, physical abuse, parental psychopathology, antisocial personality disorder

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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.

Coauthor(s)

Elizabeth A Finley-Belgrad, MD, Clinical Assistant Professor, Department of Psychiatry, Northeastern Ohio Universities College of Medicine
Elizabeth A Finley-Belgrad, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry
Disclosure: Nothing to disclose.

Medical Editor

Carol Diane Berkowitz, MD, Executive Vice Chair, Department of Pediatrics, Professor, Harbor-University of California at Los Angeles Medical Center
Carol Diane Berkowitz, MD is a member of the following medical societies: Alpha Omega Alpha, Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, American Medical Association, American Pediatric Society, and North American Society for Pediatric and Adolescent Gynecology
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

CME Editor

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

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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