Borderline personality disorder (BPD) is a mental disorder that belongs to the group of mental illnesses called personality disorders. Therefore, like other personality disorders, it is characterized by a consistent pattern of thinking, feeling, and interacting with others and with the world that tends to cause significant problems for the sufferer.
Specifically, BPD tends to be associated with a pattern of unstable ways of seeing oneself, feeling, behaving, and relating to others that markedly interferes with the individual's ability to function. Also, as with other personality disorders, the person is usually an adolescent or adult before they can be assessed as meeting full symptom criteria for BPD.
Historically, BPD has been thought to be a set of symptoms that include both mood problems (neuroses) and distortions of reality (psychosis), and therefore was thought to be on the borderline between mood problems and schizophrenia. However, it is now understood that while the symptoms of BPD may straddle those symptom complexes, this illness is more closely related to other personality disorders in terms of how it may develop and occur within families.
Contrary to what the medical community thought in the past, BPD is now understood to occur equally in men and women in general, while primarily in women in groups of people who are receiving mental-health treatment (treatment populations). The frequency with which this disorder occurs is also thought to be considerably higher than previously thought, affecting nearly 6% of adults over the course of a lifetime.
As per the DSM (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Treatment Revision) definition, in order to qualify for the diagnosis of BPD, an individual must have at least five of the following symptoms:
- Unstable self-image, in that they may drastically and rapidly change in the way they perceive their own likes, dislikes, strengths, weaknesses, goals, and intrinsic value as a person.
- Unstable relationships, in that individuals with this disorder rapidly, drastically, and often frequently change from seeing another person as nearly perfect (idealizing) to seeing the other person as being virtually worthless (devaluing).
- Unstable emotions (affects), in that the sufferer experiences marked, rapid changes in feelings (for example, severe anger, joy, euphoria, anxiety, including panic attacks and depression) that are stress related, even if the stresses may be seen as minor or negligible to others.
- Desperate efforts to avoid being abandoned, whether the abandonment is real or imagined.
- Significant impulsivity, in that the person with BPD tends to act before thinking to the point that it is self-damaging (for example, sexual behaviors, spending habits, eating habits, driving behaviors, or in the use of substances).
- Recurring suicidal behaviors, threats, or attempts.
- Chronic feelings of emptiness.
- Inappropriate, intense anger or difficulty managing their anger when it occurs.
- Transient, stress-related paranoia or severe dissociation (lapses in memory).
Although there is no specific cause for BPD, like most other mental disorders, it is understood to be the result of a combination of biological vulnerabilities, ways of thinking, and social stressors (biopsychosocial model).
Biologically, individuals with BPD are more likely to have abnormalities in the size of the hippocampus, in the size and functioning of the amygdala, and in the functioning of the frontal lobes, which are the areas of the brain that are understood to regulate emotions and integrate thoughts with emotions.
Although some research asserts that people with BPD seem to have areas of the brain that are more and less active compared to individuals who do not have the disorder, other research contradicts that. Therefore, specific patterns of brain functioning, as they are currently studied and understood, seem unreliable predictors of BPD.
While it is not thought to be genetic, it can somewhat run in families. Psychologically, BPD seems to make a person more vulnerable to difficulty managing their emotions, particularly impulsive aggression. Socially, this disorder predisposes sufferers to be more likely to excessively expect to be criticized or rejected and negatively personalize disinterest or inattention from others.
Their social tendencies make for great difficulty in their relationships. In addition to these issues, people with BPD are more likely to have suffered from childhood abuse or neglect fulparenting.
Different forms of psychotherapy have been found to effectively treat BPD. Dialectical behavior therapy (DBT) is an approach to psychotherapy in which the therapist specifically addresses four areas that tend to be particularly problematic for individuals with BPD: self-image, impulsive behaviors, mood instability, and problems in relating to others.
To address those areas, treatment with DBT tries to build four major behavioral skill areas: mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness.
Talk therapy that focuses on helping the person understand how their thoughts and behaviors affect each other (cognitive behavioral therapy or CBT) has also been found to be effective treatment for BPD. Other psychotherapy approaches that have been used to address BPD include interpersonal psychotherapy (IPT) and psychoanalytic therapy.
IPT is an approach that focuses on how the person's symptoms are related to the problems that person has in relating to others. Psychoanalytic therapy, which seeks to help the individual understand and better manage his or her ways of defending against negative emotions, has been found to be effective in addressing BPD, especially when the therapist is more active or vocal than in traditional psychoanalytic treatment and when this approach is used in the context of current rather than past relationships.
On the positive side, some women who suffer from both BPD and bipolar disorder may experience a decrease in how irritable and angry they feel, as well as a decrease in how often and severely they become aggressive when treated with a mood stabilizer like Depakote. On the other hand, the use of medications in the treatment of symptoms in individuals with BPD may sometimes cause more harm than good.
For example, while people with BPD may experience suicidal behaviors no more often than other individuals with a severe mental illness, they often receive more medications and therefore suffer from more side effects. Also, given how frequently many sufferers of BPD experience suicidal feelings, great care is taken to avoid the medications that can be dangerous in overdose.
Partial hospitalization is an intervention that involves the individual with mental illness being in a hospital-like treatment center during the day but returning home each evening. In addition to providing a safe environment and frequent monitoring by mental-health professionals, partial hospitalization programs allow for more frequent mental-health interventions like professional assessments, psychotherapy medication treatment, as well as development of a treatment plan for after discharge from the facility.
While funding for a long-term stay in a partial hospitalization facility may be difficult, research shows that when it is provided using a psychoanalytic approach it may help the person with BPD enjoy a decrease in the severity of anxiety and depression, the frequency of suicide attempts and full hospitalizations, as well as developing improved relationships with others.
Contrary to earlier beliefs, BPD has been found to significantly improve in response to treatment with appropriate inpatient hospitalization. Loved ones of individuals with BPD might benefit from participation in a support group.