The borderline personality disorder (BPD) is a personality disorder characterized by having turbulent lives, moods and unstable personal relationships, and have a low self – esteem.
BPD occurs most often in early adulthood. The unsustainable pattern of interaction with others persists for years and is usually related to the person’s self-image.
This pattern of behavior is present in several areas of life: home, work and social life. These people are very sensitive to environmental circumstances. The perception of rejection or separation from another person can lead to profound changes in thoughts, behaviors, affection and self-image.
They experience deep fears of abandonment and inappropriate hatred, even when faced with temporary separations or when there are inevitable changes in plans. These fears of abandonment are related to an intolerance to being alone and a need to have other people with them.
A person with BPD will often display impulsive behaviors and will have most of the following symptoms:
- Frenzied efforts to avoid real or imagined abandonment.
- An unsustainable and intense pattern of personal relationships characterized by the extremes of idealization and devaluation.
- Alteration of identity, such as an unstable self-image.
- Impulsiveness in at least two areas that are potentially harmful to yourself: spending, sex, substance abuse, binge eating, reckless driving.
- Recurrent suicidal behavior, gestures, threats, or self-harm.
- Emotional instability.
- Chronic feelings of emptiness.
- Intense and inappropriate anger or difficulty controlling anger; constant anger, fights.
- Stress-related paranoid thoughts.
- Frenzied efforts to avoid real or imagined abandonment.
- The perception of impending separation or rejection can lead to profound changes in self-image, emotions, thoughts, and behaviors.
- A person with BPD will be very sensitive to what is happening in their environment and will experience intense fears of abandonment or rejection, even when the separation is temporary.
People with BPD feel emotions more deeply, longer, and more easily than other people. These emotions can appear repeatedly and persist for a long time, making it more difficult for people with BPD to return to a normalized state.
People with BPD are often enthusiastic and idealistic. However, they may be overwhelmed by negative emotions, experiencing intense sadness, shame, or humiliation.
They are especially sensitive to feelings of rejection, criticism, or perceived failure. Before learning other coping strategies, your efforts to control negative emotions can lead to self-harm or suicidal behaviors.
In addition to feeling intense emotions, people with BPD experience great emotional swings, changes between anger and anxiety or between depression and anxiety being common.
Intense and unsustainable personal relationships
People with BPD can idealize their loved ones, demand to spend a lot of time with them, and often share intimate details in the early stages of relationships.
However, they can quickly go from idealization to devaluation, feeling that other people don’t care enough or don’t give enough.
These people can empathize with and contribute to others, but only with the expectation that they will “be there.” They are prone to sudden changes in the perception of others, seeing them as good supporters or as cruel punishers.
This phenomenon is called black and white thinking, and it includes the shift from idealizing others to devaluing them.
Alteration of identity
There are sudden changes in self-image; change of vocational goals, values and aspirations. There may be changes in opinions or plans about career, sexual identity, values or types of friends.
Although they normally have a self-image of being bad, people with BPD can sometimes have feelings of not existing at all. These experiences usually occur in situations where the person feels a lack of affection and support.
The intense emotions experienced by people with BPD can make it difficult for them to control their focus of attention or concentrate.
In fact, these people tend to dissociate in response to experiencing a painful event; the mind redirects attention away from the event, supposedly to ward off intense emotions.
Although this tendency to block out strong emotions can give temporary relief, it can also have the side effect of reducing the experience of normal emotions.
It can sometimes be told when a person with BPD dissociates, because their vocal or facial expressions become flat, or they seem distracted. At other times, the dissociation is hardly noticeable.
Self harm or suicide
Self-harm or suicidal behavior is one of the DSM IV diagnostic criteria. Treating this behavior can be complex.
There is evidence that men diagnosed with BPD are twice as likely to commit suicide as women. There is also evidence that a considerable percentage of men who commit suicide could have been diagnosed with BPD.
Self-harm is common and can occur with or without suicide attempts. Reasons for self-harm include: expressing hatred, self-punishment, and distraction from emotional pain or difficult circumstances.
In contrast, suicide attempts reflect a belief that others will be better off after suicide. Both self-harm and suicidal behavior represent a response to negative emotions.
Evidence suggests that BPD and post-traumatic stress disorder may be related in some way. Currently it is believed that the cause of this disorder is biopsychosocial; Biological, psychological and social factors come into play.
Borderline personality disorder (BPD) is related to mood disorders and is more common in families with the problem. The heritability of BPD is estimated to be 65%.
Some traits – such as impulsivity – can be inherited, although environmental influences also matter.
One psychosocial influence is the possible contribution of early trauma to BPD, such as sexual and physical abuse. In 1994, researchers Wagner and Linehan found in an investigation with women with BPD, that 76% reported having suffered child sexual abuse.
In another 1997 study by Zanarini, 91% of people with BPD reported abuse and 92% inattention before the age of 18.
A number of neuroimaging studies in people with BPD have found reductions in brain regions related to the regulation of stress and emotion responses: hippocampus , orbitofrontal cortex, and amgidala, among other areas.
It is usually smaller in people with BPD, as well as in people with post-traumatic stress disorder.
However, in BPD, unlike in PTSD, the amygdala also tends to be smaller.
The amygdala is more active and smaller in someone with BPD, which has also been found in people with obsessive compulsive disorder.
It tends to be less active in people with BPD, especially when recalling experiences of neglect.
The hypothalamic-pituitary-adrenal axis regulates the production of cortisol, a stress-related hormone. Cortisol production tends to be elevated in people with BPD, indicating hyperactivity on the HPA axis.
This causes them to experience a greater biological response to stress, which may explain their greater vulnerability to irritability.
Increased cortisol production is also associated with an increased risk of suicidal behavior.
A 2003 study found that the symptoms of women with BPD were predicted by changes in estrogen levels through menstrual cycles.
New research published in 2013 by Dr. Anthony Ruocco of the University of Toronto has highlighted two patterns of brain activity that may be underlying the characteristic emotional instability of this disorder:
- Increased activity has been described in the brain circuits responsible for negative emotional experiences.
- Reducing the activation of brain circuits that normally regulate or suppress these negative emotions.
These two neural networks are dysfunctional in the frontal limbic regions, although the specific regions vary widely between individuals.
Diagnostic criteria according to DSM-IV
A general pattern of instability in interpersonal relationships, self-image and effectiveness, and marked impulsivity, beginning in early adulthood and occurring in various contexts, as indicated by five (or more) of the following items:
- Frenzied efforts to avoid real or imagined abandonment. Note: do not include suicidal or self-mutilating behaviors that are included in criterion 5.
- A pattern of unstable and intense interpersonal relationships characterized by the alternative between the extremes of idealization and devaluation.
- Alteration of identity: self-image or sense of self marked and persistently unstable.
- Impulsiveness in at least two areas, which is potentially harmful to yourself (eg spending, sex, substance abuse, reckless driving, binge eating). Note: do not include suicidal or self-mutilating behaviors that are included in criterion 5.
- Recurring suicidal behaviors, attempts or threats, or self-mutilating behaviors.
- Affective instability due to marked reactivity of mood (for example episodes of severe dysphoria, irritability or anxiety, which usually last a few hours and rarely a few days).
- Chronic feelings of emptiness.
- Inappropriate and intense anger or difficulties controlling anger (for example, frequent displays of temper, constant anger, recurring physical fights).
- Transient paranoid ideation related to stress or severe dissociative symptoms.
Diagnostic criteria according to ICD-10
The CIEO-10 of the World Health Organization defines a disorder that is conceptually similar to the limit personality disorder, called disorder of emotional instability of personality. Its two subtypes are described below.
At least three of the following must be present, one of which must be (2):
- marked tendency to act unexpectedly and without consideration of the consequences;
- marked tendency to engage in quarrelsome behavior and conflict with others, especially when impulsive acts are criticized or frustrated;
- tendency to fall into outbursts of violence or anger, without the ability to control the outcome of the explosions;
- difficulty in maintaining any course of action that does not offer immediate reward;
- unstable and capricious mood.
At least three of the symptoms mentioned in the impulsive type must be present, with at least two of the following:
- uncertainty about one’s image;
- tendency to get involved in intense and unstable relationships, often leading to emotional crises;
- excessive efforts to avoid abandonment;
- recurring threats or acts of self-harm;
- chronic feelings of emptiness;
- demonstrates impulsive behavior, eg, speeding or substance abuse.
There are comorbid (co-occurring) conditions that are common in BPD. Compared with other personality disorders, people with BPD showed a higher rate meeting criteria for:
- Mood disorders, including major depression and bipolar disorder.
- Anxiety disorders, including panic disorder, social phobia, and post-traumatic stress disorder.
- Other personality disorders.
- Substance abuse.
- Eating disorders, including anorexia nervosa and bulimia.
- Attention deficit disorder and hyperactivity.
- Somatoform disorder.
- Dissociative disorders.
The diagnosis of BPD should not be made during an untreated mood disorder, unless the medical history supports the presence of a personality disorder.
Psychologist Theodore Millon has proposed four subtypes of BPD:
- Discouraged (including avoidance characteristics): submissive, loyal, humble, vulnerable, desperate, depressed, powerless, and powerless.
- Petulant (including negativistic characteristics): negative, impatient, restless, defiant, pessimistic, resentful, stubborn. quickly disappointed.
- Impulsive (including histrionic or antisocial characteristics): whimsical, superficial, frivolous, distracted, frantic, irritable, potentially suicidal.
- Self-destructive (including depressive or masochistic characteristics).
Psychotherapy is the first line of treatment for borderline personality disorder.
Treatments should be based on the individual, rather than the general diagnosis of BPD. Medication is helpful in treating comorbid disorders like anxiety and depression.
Cognitive behavioral therapy
Although cognitive behavioral therapy is used in mental disorders, it has been shown to be less effective in BPD, due to the difficulty in developing a therapeutic relationship and committing to treatment.
Dialectical Behavioral Therapy
It is derived from cognitive-behavioral techniques and focuses on the exchange and negotiation between the therapist and the patient.
The therapy goals are agreed, prioritizing the problem of self-harm, the learning of new competences, social skills, adaptive control of anxiety and the regulation of emotional reactions.
Schematic focal cognitive therapy
It is based on cognitive-behavioral techniques and skills acquisition techniques.
It focuses on deep aspects of emotion, personality, schemas, in the relationship with the therapist, in traumatic experiences of childhood and in daily life.
It is a brief therapy that aims to provide an effective and accessible treatment, combining cognitive and psychoanalytic approaches.
It is based on the assumption that people with BPD have an attachment distortion due to problems in parent-child relationships in childhood.
It is intended to develop the self-regulation of patients through psychodynamic group therapy and individual psychotherapy in the therapeutic community, partial or outpatient hospitalization.
Couples, marital or family therapy
Couples or family therapy can be effective in stabilizing relationships, reducing conflict and stress.
The family is psychoeducated and communication within the family improves, fostering problem solving within the family and supporting family members.
Some drugs may have an impact on isolated symptoms associated with BPD or the symptoms of other comorbid conditions (co-occurring).
- Of the typical antipsychotics studied, haloperidol can reduce anger and flupenthixol can reduce the likelihood of suicidal behavior.
- Of the atypical antipsychotics, aripiprazole can reduce interpersonal problems, anger, impulsivity, paranoid symptoms, anxiety, and general psychiatric pathology.
- Olanzapine can reduce emotional instability, hatred, paranoid symptoms, and anxiety.
- Selective serotonin reuptake inhibitor (SSRI) antidepressants have been shown in randomized controlled trials to improve comorbid symptoms of anxiety and depression.
- Studies have been conducted to evaluate the use of some anticonvulsants in the treatment of the symptoms of BPD. Among them, Topiramate and Oxcarbazepine as well as opiate receptor antagonists such as naltrexone to treat dissociative symptoms or clonidine, an antihypertensive with the same purpose.
Due to the weak evidence and potential side effects of some of these medications, the UK Institute for Health and Clinical Excellence (NICE) recommends:
Drug treatment should not be treated specifically for BPD or for the individual symptoms or behaviors associated with the disorder. However, “drug treatment could be considered in the general treatment of comorbid conditions.”
With proper treatment, most people with BPD can lessen the symptoms associated with the disorder.
Recovery from BPD is common, even for people who have more severe symptoms. However, recovery only occurs in people who receive some kind of treatment.
The patient’s personality can play an important role in recovery. In addition to recovery from symptoms, people with BPD also achieve better psychosocial functioning.
In a 2008 study it was found that the prevalence in the general population is 5.9%, occurring in 5.6% of men and 6.2% of women.
It is estimated that BPD contributes to 20% of psychiatric hospitalizations.
- American Psychiatric Association 2013, p. 645
- American Psychiatric Association 2013, pp. 646–9
- Linehan et al. 2006, pp. 757–66
- Johnson, R. Skip (July 26, 2014). “Treatment of Borderline Personality Disorder.” BPDFamily.com. Retrieved August 5, 2014.
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- Oldham, John M. (July 2004). “Borderline Personality Disorder: An Overview”. Psychiatric Times XXI (8).