Borderline Personality Disorder

Updated: May 18, 2016
  • Author: Roy H Lubit, MD, PhD; Chief Editor: Caroly Pataki, MD  more...
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Overview

Practice Essentials

Borderline personality disorder (BPD) is characterized by marked instability in functioning, affect, mood, interpersonal relationships, and, at times, reality testing. BPD is associated with significant morbidity due to common comorbid conditions, including dysthymia, major depression, psychoactive substance abuse, and psychotic disorders. Approximately 70-75% of patients with BPD have a history of at least one deliberate act of self-harm, and the mean estimated rate of completed suicides is 9%. [1, 2]

Signs and symptoms

Features that typically begin in adolescence or young adulthood in patients with BPD include the following [3] :

  • Disturbances in experiencing oneself as unique, poor boundaries between self and others, and poor emotion regulation.
  • An inability to soothe themselves adequately, resulting in excess emotional reactions to stresses and frustrations; maladaptive attempts at self-soothing, suicide threats, self-harm, and angry behavior
  • An unstable sense of self with poor ability for self-direction and impaired ability to pursue meaningful short-term goals with satisfaction
  • Marked instability in functioning, affect, mood, interpersonal relationships, and, at times, reality testing
  • Disturbances in empathy and intimacy
  • A pattern of impulsivity, risk taking, and poor self-image

See Presentation for more detail.

Diagnosis

In the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), [4] BPD is diagnosed on the basis of (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 five of the following:

  • Frantic efforts to avoid real or imagined abandonment; this does not include 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
  • Markedly and persistently unstable self-image or sense of self
  • Impulsivity in at least two areas that are potentially self-damaging (eg, spending, sex, substance abuse, reckless driving, binge eating) [5] ; this does not include 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 (eg, 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 (eg, frequent displays of temper, constant anger, or recurrent physical fights)
  • Transient, stress-related paranoid ideation or severe dissociative symptoms

An alternative model described in DSM-5 for personality disorders includes essential features for personality disorders, with specific features added to denote the specific personality disorder. Essential features of personality disorders using this model include: impairment in self-concept and interpersonal relationships, inflexible traits causing impairment in personal and social situations, and pathological personality traits. Pathological personality traits included in this model are Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism.

No laboratory tests are useful in identifying BPD. Some patients have abnormal results on dexamethasone suppression testing and with abnormal thyrotropin-releasing hormone testing; however, these findings are also present in many patients with depression. As with any thorough workup of a patient with a mood disorder, fasting glucose and thyroid function studies are usually indicated. Screening for substance abuse is often useful. Other laboratory tests are indicated, depending on the clinical presentation.

See Workup for more detail.

Management

Historically, treatment of patients with BPD has been difficult. Therapy for BPD is as follows:

  • Dialectic behavior therapy (DBT), a modification of standard cognitive-behavioral techniques, [6] is currently the only data-supported treatment for BPD
  • For children and adolescents with BPD traits, family-oriented interventions appear to provide superior benefits
  • Most children and adolescents with traits of BPD appear to benefit from structured day programs with strong behavioral management components [7]
  • Psychotherapy is often difficult because of regression, overwhelming affect, and impulsive behavior
  • Hospitalization may be necessary because of suicidal or other self-injurious behavior

Pharmacologic treatment may be necessary for impulsivity, affective instability, and psychosis. Medications are at times useful. See the following:

  • Selective serotonin reuptake inhibitors (SSRIs) are greatly preferred to the other classes of antidepressants; they can reduce impulsivity and aggression; they are less dangerous in overdose than many other psychoactive drugs; care must be taken that they do not lead to suicidality, however
  • Low-dose neuroleptics (eg, risperidone) are effective in the short term for control of transient psychotic symptoms and can decrease general agitation
  • Treatment with the opiate receptor antagonist naltrexone may reduce the duration and intensity of dissociative symptoms in a small number of patients with BPD [8]
  • Patients with BPD tend to have strong placebo responses to medication; thus, impressive short-term improvement might occur and unexpectedly fade
  • Patients with BPD commonly take overdoses of their prescribed medication; thus, tricyclic antidepressants, lithium, and other mood stabilizers must be prescribed with great caution and as part of an ongoing therapeutic relationship
  • Benzodiazepines, although helpful with anxiety, create risks of increased impulsivity and dependency

See Treatment and Medication for more detail.

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Background

Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself. When they are exhibited in a wide range of important social and personal contexts 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.

Historically, BPD has been seen as lying on the border between psychosis and neurosis. It is characterized by marked instability in functioning, affect, mood, interpersonal relationships, and, at times, reality testing. Of patients with BPD about 20-50% report psychotic symptoms. [9]

In 1942, Deutsch described a group of patients who lacked a consistent sense of identity and source of inner direction. [10] She created the term “as-if personalities” because the patients completely identified with those upon whom they were dependent, changing their identifications and sense of self as their relationships changed. In 1975, Kernberg conceptualized BPD to describe a group of patients with particular primitive defense mechanisms and pathologic internalized object relations (splitting and projective identification). [11]

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, with no strong specific tendency toward BPD. Further research in this area is needed to elucidate the etiology and facilitate early intervention.

Diagnostic criteria (DSM-5)

According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), [4] BPD is diagnosed on the basis of (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:

  • Frantic efforts to avoid real or imagined abandonment; this does not include 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 2 areas that are potentially self-damaging (eg, spending, sex, substance abuse, reckless driving, or binge eating); this does not include 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 (eg, 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 (eg, frequent displays of temper, constant anger, or recurrent physical fights)
  • Transient, stress-related paranoid ideation or severe dissociative symptoms
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Pathophysiology

Some studies have suggested that patients with BPD might have increased rates of soft neurologic signs, [12] as well as learning disorders, attention-deficit/hyperactivity disorder (ADHD), and abnormal electroencephalographic (EEG) findings. [13] 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.

The pathogenesis of BPD, like those of most psychiatric disorders, is likely to include 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.

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Etiology

Most theories about the cause or pathogenesis of BPD include the notion of a biologic predisposition [14] along with psychological and environmental factors. One theory posits that neurobiologic development is affected by a combination of disruption of early attachments and subsequent trauma leading to hyperresponsiveness 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 BPD. 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. [11]

Persons with BPD are at higher risk for 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 unpredictable and prolonged separation from their maternal figure during the separation-individuation process of development (18 and 36 months) places children at risk. [15] 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. [11] 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, as follows:

  • The good mother, who provides for, loves, and remains close to the child
  • The hateful, depriving mother, who unpredictably punishes and abandons the child

These contradictory experiences result in intense anxiety, which leads to the borderline defense of splitting. In splitting, an individual is unable to combine positive and negative feelings about another individual into a realistic picture of the other person, and stable feelings about the other person, that can withstand normal life frustrations and disappointments. As a result, the individual rapidly shifts between having very positive to very negative feelings about others.

Several researchers have proposed an etiology for borderline personality that derives from 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 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 theory developed by Linehan et al states that borderline pathology results from the interaction between a biologic emotional vulnerability and a pervasively invalidating environment. [1, 2] More research involving developmental psychopathology, neurobiology, and family systems theory is necessary to explain how, when, and in what combinations these various factors might exert a pathologic effect on development.

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Epidemiology

United States statistics

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. [17]

Age-, sex-, and race-related demographics

Symptoms of BPD are usually present by late adolescence, but the diagnosis has been made in children. The initial diagnosis is rarely made in patients older than 40 years. The incidence of the disorder tends to decrease after age 40 years, partly because personality disorders often decrease with age and partly because some who have the disorder commit suicide and thus are no longer part of the population.

Virtually every study of borderline personality disorder has revealed that the diagnosis is more common in females than in males; [18] the female-to-male ratios are as high as 4:1. [19] No evidence suggests a relationship between race and the diagnosis of BPD or borderline disorders of childhood.

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Prognosis

Short-term follow-up studies indicate that BPD is a chronic condition, though many patients improve over time. In a 1998 prospective follow-up study, Links et al reported that almost 50% of their former inpatients with BPD continued to meet diagnostic criteria at 7 years. [20] Furthermore, these patients have significantly more comorbid personality psychopathology; this finding supported the assertion that the level of pathology at the initial assessment primarily predicts the level of borderline psychopathology.

The long-term outcome is variable. The initial diagnosis of BPD is rarely made in patients older than 40 years. Children with borderline pathology tend to develop a wide range of personality disorders, not necessarily BPD. Andrulonis has suggested that BPD traits in girls are more likely to evolve toward affective disorders, whereas BPD traits in boys evolve toward episodic dyscontrol syndromes and substance abuse. [21]

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 1 deliberate act of self-harm. According to Linehan et al, the mean estimated rate of completed suicides is 9%. [1, 2]

BPD is associated with significant morbidity. The individual’s relationships are generally unstable. Marked changes in feelings about people, high levels of anger, and impulsivity compromise social and work activities. There are high rates of depression and substance abuse. Psychosis occasionally occurs. In a study of 409 patients, Zimmerman et al found that in comparison with patients who did not have BPD, patients with BPD were twice as likely to receive a diagnosis of 3 or more current axis-I disorders (eg, mood disorders, anxiety, substance abuse, eating disorders, or somatoform disorders) and nearly 4 times as likely to have a diagnosis of 4 or more such disorders. [22]

Morbidity in this population includes failure in social relationships, developmental delay, and occupational impairment. Healthcare costs in patients with borderline pathology are enormous, and treatment dropout rates are high.

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Patient Education

Patients with BPD should be helped to understand that their feelings, though very intense, will change if they can wait and pause. These individuals will feel great despair and want to hurt themselves; they will feel great anger and want to hurt others; they will feel terrible emptiness and want to jump into a risky activity to deal with it. Helping them learn that the feelings will not last and that there are things they can do to soothe themselves is highly therapeutic.

Similarly, patients need to learn about their tendency first to overidealize and then to devalue people. Helping them establish an understanding of their feelings can encourage them to learn how not to act out on feelings in self-destructive ways. Patients should also be taught that their mood fluctuations and excessive reactions will ease as they get older. They need to learn social skills and how people normally function in relationships without letting their feelings carry them away.

Education of family members is also crucial. Family members can easily become burned out, and without their support, the patient is likely to become far more unstable. Family members should be helped to understand that the patient is not consciously manipulating them but is experiencing overpowering emotions in response to events that overwhelm his or her judgment. Family members should be made aware of the chronic abandonment fears of individuals with BPD and should try to avoid inadvertently stirring up those fears.

For patient education resources, see the Mental Health Center, as well as Schizophrenia. The following Web sites may also be helpful:

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