Borderline Personality Disorder 

Updated: Nov 05, 2018
Author: Roy H Lubit, MD, PhD; Chief Editor: Caroly Pataki, MD 

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.

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

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.

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.

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.

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.

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:

  • MayoClinic.com, Borderline Personality Disorder

  • National Institute of Mental Health, Borderline Personality Disorder

 

Presentation

History

In contrast to borderline personality disorder (BPD) in adulthood, 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.[15, 23] 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, inability to receive comfort from others, and numerous specific ego deficits.[24]

In 1982, Pine developed a working nosology of borderline syndromes in children.[3] These clinical subgroupings remain highly relevant.

Patients with BPD may have failures in developmental lines associated with major ego functions or central aspects of object relationships. They are often unable to soothe themselves adequately, demonstrating overemotionality and maladaptive attempts at self-soothing. They also 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 has historically been considered to be on the border between psychosis and neurosis. The following findings are characteristic:

  • BPD 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

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

  • A pervasive pattern of instability of interpersonal relationships, self-image, and affects

  • Marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by the presence of at least 5 of 9 diagnostic criteria

In a small study, 18 patients with BPD underwent a modified version of the Iowa Gambling Task while an electroencephalogram (EEG) was recorded. The results indicated that patients with BPD are impaired with respect to decision-making. This impairment which might be related to a dysfunctional use of feedback information, in that the patients did not learn to avoid harmful choices even though they were aware of the negative consequences.[25]

Physical Examination

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

The mental status examination should include the following:

  • General appearance and behavior - Grooming, height and weight, dress, and 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, and prosody

  • Thought process - Any sign of a thought disorder, thought blocking, flight of ideas, loose associations, or ideas of reference; tangentiality; goal focus

  • Thought content - Obsessions, suicidality, homicidality, or paranoia

  • Hallucinations

  • Delusions

  • Orientation - Person, place, and time

  • Memory - Short- and long-term

  • Attention and concentration

  • Insight and judgment

 

DDx

Diagnostic Considerations

As many as one half of all patients with borderline personality disorder (BPD) may also meet the criteria for histrionic, antisocial, or schizotypal personality disorders. Chronic feelings of emptiness, impulsivity, self-mutilation, short-lived psychotic episodes, and manipulative suicide attempts help distinguish BPD from other personality disorders. The Gunderson Diagnostic Interview for Borderlines[26] and the Perry Borderline Personality Disorder Scale can be helpful structured tools in the diagnosis of BPD.

Andrulonis evaluated a population of 45 children (aged 5-12 years) who met the Diagnostic and Statistical Manual, Third Edition (DSM-III) , and Gunderson criteria for BPD.[21] The primary behaviors that differentiated these children from the control group were aggression and rage, attention-deficit/hyperactivity disorder (ADHD), excessive use of fantasy, impulsivity, and poor relationships.

Skodol et al examined data from 1996 participants in a national survey who initially had a diagnosis of major depression.[27] These participants were then reinterviewed 3 years later to determine the persistence and recurrence of the diagnosis. The study concluded that BPD robustly predicted persistence (a finding supported by subsequent studies). Thus, personality psychopathology, most notably BPD, should be assessed in patients with major depressive disorder and should be considered as part of prognosis and treatment.

Differential Diagnoses

 

Workup

Approach Considerations

No laboratory tests are useful in identifying borderline personality disorder (BPD). Some BPD patients have abnormal results with dexamethasone suppression testing and with 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. Other laboratory tests are indicated, depending on the clinical presentation.

No diagnostic imaging studies are specific for borderline disorders in adults or children. In one small study of 20 patients with BPD, 40% of patients had abnormal, diffuse, slow activity on electroencephalography (EEG).[13] Some patients with BPD have shortened rapid eye movement (REM) latency and sleep-continuity disturbances, but these findings are also found in a fair number of patients with depression.

Although psychological testing reveals and highlights clinical features, it does not increase diagnostic specificity. Most authors agree that patients with BPD demonstrate ordinary reasoning abilities on structured tests (eg, the Wechsler Adult Intelligence Scale [WAIS]). Abnormal processes are noted only on unstructured projective tests (eg, the Rorschach test). Projective testing highlights circumstantial reasoning and illogical and unrelated connections. In addition, responses of patients with BPD are often overwhelmingly negative.

 

Treatment

Approach Considerations

The treatment of BPD is largely based on psychotherapeutic interventions, however, patients with BPD may also present with symptoms, such as anxiety, depression, transient psychosis that can be managed with medication. Patients with borderline personality disorder (BPD) are often impulsive thereby increasing their risk of overdoses of their prescribed medication. Antidepressants, lithium, and other mood stabilizers must be prescribed with caution and monitored carefully as part of an ongoing therapeutic relationship. Because of their relative safety, selective serotonin reuptake inhibitors (SSRIs) are the agents of choice for treating symptoms of anxiety and depression. Antipsychotic medication treatment may become necessary to manage psychotic symptoms, albeit their use is associated with potential adverse effects (eg, tardive dyskinesia or neuroleptic malignant syndrome).

Suicidal behavior may be a chronic problem. Although patients with BPD often threaten suicide due to poor emotion regulation and poor frustration tolerance, a clinician must never ignore suicide threats or attempts. In children and adolescents, any suicidal ideation or attempt should be treated with a thorough psychiatric evaluation and appropriate inpatient hospitalization to ensure the patient’s safety.

Because of the boundary issues in patients with BPD, boundaries must be strictly observed. These patients are particularly likely to be seductive, test boundaries, and even to make false allegations.

If BPD or borderline disorder of childhood is suspected, a child psychiatrist or other appropriately trained mental health professional should be consulted.

Indications for Hospitalization

Inpatient care is generally not indicated, unless the goals of treatment are well defined. However, some individuals with BPD need to be hospitalized as a result of suicidal or other self-injurious behavior. The hospital stay should be as short as possible; all but the briefest hospitalizations are likely to lead to regression.

Many individuals have chronic suicidal ideation. In such cases, therapists are placed in a difficult position. They must weigh the following factors:

  • The intensity of the individual’s thoughts

  • The risk that the individual will do something impulsive

  • The safety net the person has in the community

  • The likelihood that the patient will call before doing anything

  • The likelihood that the suicide attempt will prove fatal if the patient does take action to hurt himself or herself

The therapist’s willingness to be constantly available by phone and to make frequent calls to monitor the patient and provide support can affect the level of safety. Some therapists find it necessary to hospitalize their BPD patients when they go on vacation because the risk of self-injurious behavior is so high. Major depressive disorder and poor social adjustment increase the risk of a suicide attempt.

Psychotherapy

Psychotherapy, such as Dialectical Behavior therapy (DBT) is often a first line approach for BPD and has been shown to be useful and effective despite the challenges of patent regression, overwhelming affect, and impulsive behavior.

Kernberg, historically, prior to the development of DBT believed that psychoanalytic therapy was the most effective approach, however currently this type of treatment is not considered the first line of intervention.[11] The goal of this type of therapy is to resolve pathologic internalized representations of interpersonal relationships. The therapist requires adequate support systems, including access to prolonged hospitalization, which might be necessary.

A second view regarding psychotherapy for BPD is that the regressive transference resulting from analytically oriented treatment is often detrimental to the patient. According to proponents of this view, a supportive, reality-oriented approach in which the goal of therapy is a gradual social adjustment in the framework of a realistic therapeutic relationship is more beneficial.

A third view is that experiences are more likely to benefit the patient than explanations are. Thus, the therapist remains calm, without anxiety or anger, while remaining emotionally available. In this setting, the patient can learn to tolerate the hateful and destructive feelings that arise because of transference and, eventually, to replace them with more constructive and positive reactions. The patient also internalizes a calm, soothing supportive object.

Dialectic behavior therapy (DBT) is a modification of standard cognitive-behavioral techniques designed specifically for the treatment of BPD.[6, 28] Currently, DBT is the only data-supported therapy for BPD. Although DBT was developed as an outpatient program, it has been modified for use in hospital settings and among more diverse populations. Its focus is on teaching patients the following 4 skills:

  • Mindfulness (attention to one’s experience)

  • Interpersonal effectiveness (predominantly assertiveness)

  • Emotional regulation

  • Distress tolerance without impulsivity

In randomized clinical trials, DBT was more effective than usual treatment in reducing suicidal and self-injurious behaviors, treatment dropout, hospitalizations, and self-reports of anger and anxious ruminations.[1, 2, 29] Increased rates of global adjustment were observed after 1 year of treatment, and these gains were maintained over the subsequent year.

In the treatment of children with BPD traits, family-oriented interventions appear to be both more beneficial to the patient and less likely to further undermine parental self-esteem. Many studies of these children highlight the importance of early acquisition of self-control for predicting a good developmental outcome. In 1982, Hanson et al demonstrated that most children and adolescents with BPD traits appear to benefit from structured day programs with strong behavioral management components.[7]

Historically, treatment of patients with BPD has been difficult. In any treatment approach, the therapist must combine elements of conflict resolution and social learning to minimize and limit aggression and impulsivity. Consultants must be readily available, and the therapist must have access to appropriate hospitalization for periods of severe regression and heightened suicidal risk.

However, the therapist must also limit inpatient treatment whenever possible, both because of the increased costs and because of the inherent difficulties with inpatient treatment of this population (including possible severe regression after admission and destructive countertransference enactments when staff training or supervision is less than ideal). Several authors have reported that offering a truly appropriate and adequate course of treatment costs substantially less than using crisis interventions when required.

Pharmacologic Therapy

Patients with BPD tend to have strong placebo responses to medication; thus, impressive short-term improvement might occur but then fade unexpectedly. Impulsivity, affective instability, and psychosis are the significant manifestations of borderline pathology that might necessitate pharmacologic treatment.

SSRIs are strongly preferred to the other classes of antidepressants. Benzodiazepines are contraindicated because they reduce inhibitions and are therefore likely to increase impulsivity; furthermore, patients with BPD are prone to sedative addiction. Risperidone and naltrexone may be considered.

Selective serotonin reuptake inhibitors

When used at high doses, SSRIs appear to reduce impulsivity and aggression; however, their antidepressant effects are less impressive than those of other drugs. An important advantage of SSRIs is their relative safety; this is especially important because patients with BPD commonly take overdoses of their prescribed medication. The use of TCAs, lithium, and other mood stabilizers is usually not indicated without specific relevant symptoms and a strong, ongoing therapeutic relationship.

Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with TCAs. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered in the treatment of a child or adolescent with a mood disorder.

Special concerns in children

Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory stating that most SSRIs are not suitable for use by persons younger than 18 years for treatment of “depressive illness.” After review, this agency decided that the risks that SSRI therapy poses to pediatric patients outweigh the benefits, except in the case of fluoxetine, which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in children being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.

However, a study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declined rather than rose with the use of antidepressants. To date, this is the largest study to have addressed this issue.[30]

The evidence currently available does suggest that obsessive-compulsive disorder (OCD) and other anxiety disorders treated with SSRIs are associated with an increased risk of suicide.

Other agents

Low-dose neuroleptics are effective in the short term for control of transient psychotic symptoms, as well as agitation. Antipsychotic agents have long been used to control impulsivity and aggression in patients with BPD, though SSRIs are preferred because of their more benign adverse effect profile. If the use of an antipsychotic agent is necessary, butyrophenones should be avoided in favor of atypical agents such as risperidone.[31, 32, 33]

In 1999, Bohus et al reported a significant reduction in the duration and intensity of dissociative symptoms in a small number of patients with BPD during treatment with naltrexone, an opiate receptor antagonist.[8] Evidence suggests that alterations of the endogenous opiate systems contribute to dissociative symptoms in patients with BPD. In a case report, naltrexone appeared to decrease self-injurious behavior in a 3-year-old boy.[34]

Long-Term Monitoring

Patients usually require long-term psychotherapy with an appropriate therapist in an individual setting, a group setting, or both.

Both the time to attainment of recovery from BPD and the stability of recovery vary from patient to patient. In a study involving 290 inpatients with BPD, 93% attained a remission of symptoms lasting at least 2 years, 86% attained a remission lasting at least 4 years, and 50% achieved recovery.[35] Recovery from BPD seems difficult for many patients to attain; however, once it is attained, it can be relatively stable over time.

A separate study found that a 10-year course of BPD is associated with high rates of remission, low rates of relapse, and severe social functioning impairment, which is persistent.[36]

 

Medication

Medication Summary

In the treatment of borderline personality disorder (BPD), selective serotonin reuptake inhibitors (SSRIs) are greatly preferred to the other classes of antidepressants. Benzodiazepines are contraindicated in this population because they reduce inhibitions and are therefore likely to increase impulsivity. Antipsychotic agents and opiate receptor antagonists may also be considered.

Selective Serotonin Reuptake Inhibitors (SSRIs)

Class Summary

SSRIs are chemically unrelated to the tricyclic, tetracyclic, and other available antidepressants. They inhibit neuronal reuptake of serotonin in the central nervous system (CNS) and may have a weak effect on neuronal reuptake of norepinephrine and dopamine. SSRIs are also used to treat anxiety, phobias, and obsessive-compulsive disorder (OCD).

At high dosages, SSRIs appear to reduce impulsivity and aggression; however, their antidepressant effects are less impressive than those of other drugs. Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants.

Fluoxetine (Prozac)

Fluoxetine selectively inhibits presynaptic serotonin reuptake, with minimal or no effect on norepinephrine or dopamine uptake. It was the first available SSRI and remains the prototype. Of all the SSRIs, it has the longest half-life (72 hours). Commonly reported adverse effects (eg, general insomnia, agitation, and gastrointestinal [GI] disturbance) are generally well tolerated, and discontinuance by the patient is rare.

The dosage should be increased only if improvement is not evident. A trial of 6-8 weeks may be required before resistance is inferred. Higher dosages are generally more effective in BPD. Fluoxetine is approved by the US Food and Drug Administration (FDA) for treatment of depression and OCD in children and adolescents.

Sertraline (Zoloft)

Sertraline has a shorter half-life (25 hours) and fewer reported adverse effects than fluoxetine. It does not increase plasma levels of other psychotropic medications to the same extent that fluoxetine does. The most commonly reported adverse effects are generally well tolerated; discontinuance by the patient is rare. Sertraline is FDA-approved for OCD in children older than 6 years and for posttraumatic stress disorder (PTSD) in adults. An oral liquid concentrate is available.

Paroxetine (Paxil, Pexeva)

Paroxetine is a potent selective inhibitor of neuronal serotonin reuptake. It also has a weak effect on norepinephrine and dopamine neuronal reuptake.

Escitalopram (Lexapro)

This agent is an SSRI and an S-enantiomer of citalopram that is used for the treatment of depression. Escitalopram enhances serotonin activity because of selective reuptake inhibition at the neuronal membrane. Its mechanism of action is thought to be the potentiation of serotonergic activity in the central nervous system (CNS) through the inhibition of CNS neuronal reuptake of serotonin. The onset of depression relief may occur after 1-2 weeks, which is faster than the relief obtained from other antidepressants.

Fluvoxamine (Luvox CR)

Fluvoxamine is a potent selective inhibitor of neuronal serotonin reuptake. It does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors and thus has fewer adverse effects than TCAs do. In the treatment of BDD, higher doses than those used for depression generally are needed. Fluvoxamine is FDA-approved for children with OCD.

Antipsychotics

Class Summary

Low-dose neuroleptics are effective in the short term for control of transient psychotic symptoms. Antipsychotics have long been used to control impulsivity and aggression in patients with BPD, although SSRIs are preferred because of their more benign adverse effect profile.

Low-dose neuroleptics are effective in the short term for control of transient psychotic symptoms. Antipsychotics have long been used to control impulsivity and aggression in patients with BPD, although SSRIs are preferred because of their more benign adverse effect profile.

Risperidone (Risperdal)

Risperidone binds to dopamine D2 receptors with an affinity 20 times lower than its affinity for the serotonin 5-HT2 receptor. It improves negative symptoms of psychoses and reduces the incidence of extrapyramidal adverse effects. Risperidone is FDA-approved for several indications in pediatric patients: schizophrenia in adolescents (13-17 years), bipolar mania in children and adolescents (10-17 years), and irritability associated with autistic disorder in children (5-16 years). It is available as an oral solution.

Olanzapine (Zyprexa)

Olanzapine may inhibit the effects of serotonin, muscarine, and dopamine.

Quetiapine (Seroquel)

Quetiapine may act by antagonizing the effects of dopamine and serotonin. Its efficacy is similar to that of risperidone and olanzapine. This agent causes fewer dose-dependent adverse effects and less concern regarding weight gain.

Opiate Receptor Antagonists

Class Summary

In small studies and case reports, opiate receptor antagonists have been reported to reduce the duration and intensity of dissociative symptoms in patients with BPD and to decrease self-injurious behavior. Evidence suggests that alterations of the endogenous opiate systems contribute to dissociative symptoms in patients with BPD.

Naltrexone (ReVia, Vivitrol)

Naltrexone is a cyclopropyl derivative of oxymorphone that acts as a competitive antagonist at opioid receptors.

 

Questions & Answers

Overview

How is borderline personality disorder (BPD) characterized?

What are the signs and symptoms of borderline personality disorder (BPD)?

What are the DSM-5 diagnostic criteria for borderline personality disorder (BPD)?

Which lab tests are performed in the workup of borderline personality disorder (BPD)?

How is borderline personality disorder (BPD) treated?

What is the role of medications in the treatment of borderline personality disorder (BPD)?

What is borderline personality disorder (BPD)?

How is borderline personality disorder (BPD) diagnosed?

What is the pathophysiology of borderline personality disorder (BPD)?

What causes borderline personality disorder (BPD)?

What is the role of family systems in the etiology of borderline personality disorder (BPD)?

What is the prevalence of borderline personality disorder (BPD) in the US?

Which patient groups have the highest prevalence of borderline personality disorder (BPD)?

What is the prognosis of borderline personality disorder (BPD)?

What is included in the patient education about borderline personality disorder (BPD)?

Where are patient education resources found for borderline personality disorder (BPD)?

Presentation

Which clinical history findings are characteristic of borderline personality disorder (BPD)?

What is the basis for diagnosis for borderline personality disorder (BPD)?

What is the role of a mental status exam in the diagnosis of borderline personality disorder (BPD)?

DDX

How is borderline personality disorder (BPD) differentiated from other personality disorders?

How is borderline personality disorder (BPD) diagnosed in children?

How does borderline personality disorder (BPD) affect the prognosis of major depression?

What are the differential diagnoses for Borderline Personality Disorder?

Workup

What is the role of lab testing in the workup of borderline personality disorder (BPD)?

What is the role of imaging studies in the workup of borderline personality disorder (BPD)?

What is the role of psychological testing in the workup of borderline personality disorder (BPD)?

Treatment

When are medications indicated in the treatment of borderline personality disorder (BPD)?

How are suicidal ideation and behaviors treated in borderline personality disorder (BPD)?

When is inpatient care indicated for the treatment of borderline personality disorder (BPD)?

What is the role of psychotherapy in the treatment of borderline personality disorder (BPD)?

What is the role of dialectic behavior therapy (DBT) in the treatment of borderline personality disorder (BPD)?

How is borderline personality disorder (BPD) treated in children?

What are the components of borderline personality disorder (BPD) treatment?

How does the placebo effect affect the treatment for borderline personality disorder (BPD)?

What is the role of SSRIs in the treatment of borderline personality disorder (BPD)?

What precautions should be taken when prescribing medications for the treatment of borderline personality disorder (BPD) in children?

What is the role of neuroleptics in the treatment of borderline personality disorder (BPD)?

What is the role of naltrexone in the treatment of borderline personality disorder (BPD)?

What is included in the long-term monitoring of borderline personality disorder (BPD)?

Medications

What is the preferred medication for the treatment of borderline personality disorder (BPD)?

Which medications in the drug class Opiate Receptor Antagonists are used in the treatment of Borderline Personality Disorder?

Which medications in the drug class Antipsychotics are used in the treatment of Borderline Personality Disorder?

Which medications in the drug class Selective Serotonin Reuptake Inhibitors (SSRIs) are used in the treatment of Borderline Personality Disorder?