Borderline Personality Disorder 

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

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.

Historically, borderline personality disorder 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. 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 borderline personality disorder 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 borderline personality disorder. Further research in this area is imperative, not only to elucidate etiology, but also to allow for the earliest possible intervention.

Case study

Susan was 28 years old. She experienced a troubled childhood, including her father dying when she was 4 and her mother marrying a man who brought great tension into the house and eventually sexually abused her. Since she was a child, her reactions to events had always been very strong. As a child, people found her difficult. Her mother eventually got rid of the abusive stepfather and provided structure. Susan was able to do well in school and even get through college by going to a small very supportive school with lots of structure. Once out in the work environment, however, she ran into problems. Colleagues and employers did not like her moodiness and the ease with which she could fly off the handle. She also was inappropriately seductive at times.

Her greatest difficulties occurred in her relationships. Fairly attractive, she did not have trouble attracting men. However, relationships rapidly became stormy and self destructive. She would rapidly become clingy. She could go into a rage if her boyfriend was not fully available to her. When her most recent boyfriend went to visit his parents without her she became so distraught that she found a man at a bar and spent the weekend with him. The first night she met a man, she would be sure he was the life of her life and perfect. She would throw herself into the relationship, idealize him, share every bit of her history and self, only to become rapidly disillusioned by him.

At times this woman would feel she did not exist and would cut her arms in dissociative episodes. She could never tolerate being alone with herself. Without structure and activities she would feel bored, empty, and almost desperately throw herself into some risky activity.

Since finishing college she had considered various career paths. She started law school and dropped out, worked for a magazine for awhile and quit, and joined the Peace Corps. Stationed in a far off land with little contact with her mother or friends she developed paranoid thoughts and had to be brought back home. Susan's thoughts about herself and others vacillated markedly. Sometimes she would feel rage at her mother for not protecting her. Other times she would idealize her for standing by her and helping her. Her image of herself also vacillated from seeing herself as a loser who would never survive in the world to seeing herself as a heroic survivor.

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Pathophysiology

Some studies have suggested that patients with borderline personality disorder 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 borderline personality disorder 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 borderline personality disorder 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.

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Epidemiology

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 borderline personality disorder.[5]

Mortality/Morbidity

  • Premature death among patients with borderline personality disorder 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]
  • Borderline personality disorder 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 borderline personality disorder 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 borderline personality disorder 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 borderline personality disorder 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. 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 committed suicide and are no longer part of the population.

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Proceed to Clinical Presentation
 
 
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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