Borderline personality disorder
Encyclopedia
Borderline personality disorder (BPD) is a personality disorder
described as a prolonged disturbance of personality function in a person (generally over the age of eighteen years, although it is also found in adolescents), characterized by depth and variability of moods.
The disorder typically involves unusual levels of instability in mood
; black and white thinking
, or splitting
; the disorder often manifests itself in idealization and devaluation
episodes, as well as chaotic and unstable interpersonal relationship
s, self-image, identity
, and behavior
; as well as a disturbance in the individual's sense of self. In extreme cases, this disturbance in the sense of self can lead to periods of dissociation
.
BPD splitting
includes a switch between idealizing and demonizing others. This, combined with mood disturbances, can undermine relationships with family, friends, and co-workers. BPD disturbances also may include self-harm
. Without treatment, symptoms may worsen, leading (in extreme cases) to suicide
attempts.
There is an ongoing debate among clinicians and patients worldwide about terminology and the use of the word borderline, and some have suggested that this disorder should be renamed. The ICD-10
manual has an alternative definition and terminology to this disorder, called Emotionally unstable personality disorder. There is related concern that the diagnosis of BPD stigmatizes
people and supports pejorative and discriminatory practices.
.
Studies suggest that individuals with BPD tend to experience frequent, strong and long-lasting states of aversive
tension, often triggered by perceived rejection, being alone or perceived failure. Individuals with BPD may show lability (changeability) between anger and anxiety or between depression
and anxiety and temperamental sensitivity to emotive stimuli.
The negative emotional states specific to BPD may be grouped into four categories: destructive or self-destructive feelings; extreme feelings in general; feelings of fragmentation or lack of identity; and feelings of victimization.
Individuals with BPD can be very sensitive to the way others treat them, reacting strongly to perceived criticism or hurtfulness. Their feelings about others often shift from positive to negative, generally after a disappointment or perceived threat of losing someone. Self-image can also change rapidly from extremely positive to extremely negative. Impulsive behaviors are common, including alcohol
or drug abuse
, unsafe sex, gambling and recklessness in general. Attachment studies have revealed a strong association between BPD and insecure attachment style
, the most characteristic types being "unresolved", "preoccupied", and "fearful". Evidence suggests that individuals with BPD, while being high in intimacy- or novelty-seeking, can be hyper-alert to signs of rejection or not being valued and tend toward insecure, avoidant or ambivalent, or fearfully preoccupied patterns in relationships. They tend to view the world as generally dangerous and malevolent.
Individuals with BPD are often described, including by some mental health
professionals (and in the DSM-IV), as deliberately manipulative or difficult, but analysis and findings generally trace behaviors to inner pain and turmoil, powerlessness and defensive reactions, or limited coping
and communication skills. There has been limited research on family members' understanding of borderline personality disorder and the extent of burden or negative emotion experienced or expressed by family members. However the effect of expressed emotion by family members may actually be opposite (paradox
ical) from the anticipated effect on individuals with such illnesses as depressive disorders and schizophrenia. For BPD such effect may be neutral or positive as opposed to negative, a counter-intuitive result.
Parents of individuals with BPD have been reported to show co-existing extremes of over-involvement and under-involvement. BPD has been linked to increased levels of chronic stress and conflict in romantic relationships, decreased satisfaction of romantic partners, abuse
and unwanted pregnancy
; these links may be general to personality disorder and subsyndromal problems.
Suicidal
or self-harm
ing behavior is one of the core diagnostic criteria in DSM IV-TR, and management of and recovery from this can be complex and challenging. The suicide rate is approximately 8 to 10 percent. Self-injury attempts are highly common among patients and may or may not be carried out with suicidal intent. BPD is often characterized by multiple low-lethality suicide attempts triggered by seemingly minor incidents, and less commonly by high-lethality attempts that are attributed to impulsiveness or comorbid clinical depression, with interpersonal stressors appearing to be particularly common triggers. Ongoing family interactions and associated vulnerabilities can lead to self-destructive behavior. Stressful life events related to sexual abuse have been found to be a particular trigger for suicide attempts by adolescents with a BPD diagnosis.
by a qualified mental health professional
. The assessment incorporates the patient's self-reported experiences as well as the clinician's observations. The resulting profile may be supported or corroborated by long-term patterns of behavior as reported by family members, friends or co-workers. The list of criteria that must be met for diagnosis is outlined in the DSM-IV-TR
.
Borderline personality disorder was once classified as a subset of schizophrenia
(describing patients with borderline schizophrenic tendencies). Today BPD is used more generally to describe individuals who display emotional dysregulation
and instability, with paranoid ideation or delusions being only one criterion (criterion #9) of a total of 9 criteria, of which 5, or more, must be present for this diagnosis.
Individuals with BPD are at high risk of developing other psychological disorders such as anxiety
and depression. Other symptoms of BPD, such as dissociation
, are frequently linked to severely traumatic childhood experiences, which some put forth as one of the many root causes of the borderline personality.
. Conceptual, as well as therapeutic, relief may be obtained through evidence that BPD is closely related to traumatic events during childhood and to post-traumatic stress disorder
(PTSD), about which much more is known.
Recovery can be faster with the help of family members and loved ones, however those involved must be trained for their assistance to have an effective impact. http://bpdfamily.com/tools/articles5.htm
, although medication and other approaches may also improve symptoms. Two forms of therapy in particular have been shown to be effective with BPD: Dialectical Behavioral Therapy
and Schema Therapy
. Both of these are influenced by Cognitive Behavioral therapy. While borderline personality disorder can manifest itself in children and teenagers, therapists are discouraged from diagnosing anyone before the age of 18, due to adolescence and a still-developing personality.
There are some instances when BPD can be evident and diagnosed before the age of 18. The DSM-IV states: "To diagnose a personality disorder in an individual under 18 years, the features must have been present for at least 1 year." In other words, it is possible to diagnose the disorder in children and adolescents, but a more conservative approach should be taken.
There is some evidence that BPD diagnosed in adolescence is predictive of the disease continuing into adulthood. It is possible that the diagnosis, if applicable, would be helpful in creating a more effective treatment plan for the child or teen.
fourth edition, DSM IV-TR, a widely used manual for diagnosing mental disorders, defines borderline personality disorder (in Axis II Cluster B) as:
It is a requirement of DSM-IV that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.
's ICD-10
defines a conceptually similar disorder to borderline personality disorder called Emotionally unstable personality disorder. It has two subtypes described below.
F60.30 Impulsive type
At least three of the following must be present, one of which must be (2):
It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.
F60.31 Borderline type
At least three of the symptoms mentioned in F60.30 Impulsive type must be present [see above], with at least two of the following in addition:
It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.
's CCMD has a comparable diagnosis of Impulsive Personality Disorder (IPD). A patient diagnosed as having IPD must display "affective outbursts" and "marked impulsive behavior," plus at least three out of eight other symptoms. The construct has been described as a hybrid of the impulsive and borderline subtypes of the ICD-10's Emotionally Unstable Personality Disorder, and also incorporates six of the nine DSM BPD criteria.
identified four subtypes of borderline. Any individual borderline person may exhibit none, one or more of the following:
Borderline personality disorder and mood disorder
s often appear concurrently. Some features of borderline personality disorder may overlap with those of mood disorders, complicating the differential diagnostic assessment.
Both diagnoses involve symptoms commonly known as "mood swing
s." In borderline personality disorder, the term refers to the marked lability and reactivity of mood defined as emotional dysregulation
. The behavior is typically in response to external psychosocial
and intrapsychic
stressors, and may arise or subside, or both, suddenly and dramatically and last for seconds, minutes, hours, days, weeks or months.
Bipolar depression is generally more pervasive with sleep and appetite disturbances, as well as a marked nonreactivity of mood, whereas mood with respect to borderline personality and co-occurring dysthymia remains markedly reactive and sleep disturbance not acute.
The relationship between bipolar disorder and borderline personality disorder has been debated. Some hold that the latter represents a subthreshold form of affective disorder, while others maintain the distinctness between the disorders, noting they often co-occur.
Some findings suggest that BPD may lie on a bipolar spectrum
, with a number of points of phenomenological and biological overlap between the affective lability criterion of borderline personality disorder and the extremely rapid cycling bipolar disorders. Some findings suggest that the DSM-IV BPD diagnosis mixes up two sets of unrelated items—an affective instability dimension related to Bipolar-II, and an impulsivity dimension not related to Bipolar-II.
It is important to emphasize that medical conditions which cause organic behavioral function may result in a clinical picture that mimics to some degree BPD. Hormonal dysfunction over a long period, or brain dysfunction (e.g. the encephalopathy caused by lyme disease
) can result in identity disturbance and mood lability, as can many other chronic medical conditions such as lupus
. These conditions may isolate the patient socially and emotionally, and/or cause limbic damage to the brain. However, this is not borderline personality disorder which results, but rather a reaction to the isolating circumstances caused by a medical condition and the possibly coincident struggles of the patient to control his or her mood given damage to the brain's limbic system. Heavy alcohol usage
over a long period itself can cause an encephalopathy which may cause limbic damage. Various frontal lobe syndromes can result in disinhibition and impulsive behavior.
Comorbid (co-occurring) conditions in BPD are common. When comparing individuals diagnosed with BPD to those diagnosed with other personality disorders, the former showed a higher rate of also meeting criteria for
There is evidence that suggests that BPD and post-traumatic stress disorder
(PTSD) are closely related. Evidence further suggests that BPD might result from a combination that can involve a traumatic
childhood, a vulnerable temperament and stressful maturational events during adolescence
or adulthood.
, especially child sexual abuse
, and development of BPD. Many individuals with BPD report to have had a history of abuse and neglect as young children. Patients with BPD have been found to be significantly more likely to report having been verbally, emotionally, physically or sexually abused by caregivers of either gender
. There has also been a high incidence of incest and loss of caregivers in early childhood for people with borderline personality disorder. They were also much more likely to report having caregivers (of both genders) deny the validity of their thoughts and feelings. They were also reported to have failed to provide needed protection, and neglected their child's physical care. Parents (of both sexes) were typically reported to have withdrawn from the child emotionally, and to have treated the child inconsistently. Additionally, women with BPD who reported a previous history of neglect by a female caregiver and abuse by a male caregiver were consequently at significantly higher risk for being sexually abused by a noncaregiver (not a parent). It has been suggested that children who experience chronic early maltreatment and attachment difficulties may go on to develop borderline personality disorder.
Otto Kernberg formulated a theory of borderline personality based on a premise of failure to develop in childhood. Writing in the psychoanalytic tradition, Kernberg argued that failure to achieve the developmental task of psychic clarification of self and other can result in an increased risk to develop varieties of psychosis, while failure to overcome splitting results in an increased risk to develop a borderline personality.
s. A major twin study found that if one identical twin met criteria for BPD, the other also met criteria in 35 percent of cases. People that have BPD influenced by genes usually have a close relative with the disorder.
Twin, sibling and other family studies indicate a partially heritable basis for impulsive aggression, but studies of serotonin
-related genes to date have suggested only modest contributions to behavior.
Other research has examined whether the negative affectivity
associated with BPD—that is, the tendency to often feel anger, contempt, guilt, nervousness, and other negative feelings—can be helped by the technique of thought suppression
, or consciously trying not to think certain thoughts. The results of this study found that thought suppression mediated the relationship between negative affectivity and BPD symptoms. While negative affectivity significantly predicted BPD symptoms, this relationship was greatly reduced when thought suppression was introduced into the model. Thus, the relationship of negative affectivity to BPD symptoms is mediated by thought suppression.
Ayduk, et al., found that rejection sensitivity and executive control
are predictors of BPD symptoms; in other words, people who are highly apt to feel rejected, and/or who have poor control of their emotions and behavior, are more likely to develop BPD. Another factor the authors studied, namely a child's ability to tolerate delayed gratification at age 4, did not appear to predict later development of BPD.
Parker, Boldero and Bell examined another facet of BPD, which is instability of the sense of self. Their findings indicated that Self-Discrepancy--the sense of failing to match one's own ideals—was strongly correlated to BPD. Self-complexity
, or being aware of one's own mental patterns, was not. Among those high in self-complexity, the relationship between AI self-discrepancy magnitudes and BPD features was lower than among those with less self-complexity. Actual-ought self-discrepancy relationship with BPD features was not significantly moderated by self-complexity.
forms the foundation of treatment for borderline personality disorder with medications playing a lesser role. Treatments should be based on individual case presentation, rather than upon the diagnosis of BPD with co-morbid conditions determining medications use, if any. Hospitalization has not been found to improve outcomes or prevent suicide over community care in those with BPD.
treatments (mentalization-based, and transference-focused
) and two cognitive-behavioral treatments (dialectical behavioral, and schema-focused
) – were the subject of a 2009 review that found that each therapy reduced the severity of the disorder or some elements of it, especially physical self-harm. A 2010 review found that the highest quality evidence from clinical trials of psychotherapeutic interventions supports dialectical behavior therapy and mentalization-based therapy. A special problem of psychotherapy with borderline patients is intense projection
. It requires the psychotherapist to be flexible in considering negative attributions by the patient rather than quickly interpreting the projection.
found that the total severity of BPD is not significantly affected by any drug. No drugs show promise for "the core BPD symptoms of chronic feelings of emptiness, identity disturbance and abandonment." However, the authors found that some drugs may impact certain associated symptoms or the symptoms of comorbid conditions.
Of the typical antipsychotic
s studied in relation to BPD, haloperidol
may reduce anger, and flupenthixol may reduce the likelihood of suicidal behavior. Among the atypical antipsychotic
s, aripiprazole
may reduce interpersonal problems, impulsivity, anger, psychotic paranoid symptoms, depression, anxiety, and general psychiatric pathology; olanzapine
may decrease affective instability, anger, psychotic paranoid symptoms, and anxiety, but placebo
had a greater ameliorative impact on suicidal ideation than olanzapine did; and ziprasidone
treatment demonstrated no significant therapeutic affect. Of the mood stabilizers studied, valproate semisodium
may ameliorate depression and interpersonal problems, and it may reduce anger; lamotrigine
may reduce impulsivity and anger, topiramate
may ameliorate interpersonal problems, impulsivity, anxiety, anger and general psychiatric pathology, but carbamazepine
treatment demonstrated no significant effect. Among the antidepressant
s, amitriptyline
may reduce depression, but mianserin
, fluoxetine
, fluvoxamine
and phenelzine
sulfate showed no effect. Omega-3 fatty acid
may ameliorate suicidality and improve depression. The review warned that most trials have not been replicated, so the evidence is not strong, and the effect of long-term use has not been assessed.
Because of the weakness of the evidence and the potential for serious side effects from some drug therapies, the UK National Institute for Health and Clinical Excellence
(NICE) 2009 clinical guideline for the treatment and management of BPD recommends: "Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder" but "drug treatment may be considered in the overall treatment of comorbid conditions," and suggests "review of the treatment of people with borderline personality disorder who do not have a diagnosed comorbid mental or physical illness and who are currently being prescribed drugs, with the aim of reducing and stopping unnecessary drug treatment."
states that recent advancements have led to treatments reaching an 86% remission rate 10 years after treatment.
Particular difficulties have been observed in the relationship between care providers and individuals diagnosed with BPD. A majority of psychiatric staff report finding individuals with BPD moderately to extremely difficult to work with, and more difficult than other client groups. Some clients feel a diagnosis is helpful, allowing them to understand they are not alone, and to connect with others who have BPD and who have developed helpful coping mechanisms. On the other hand, some with the diagnosis of BPD have reported that the term "BPD" felt like a pejorative
label
rather than a helpful diagnosis, that self-destructive behaviour was incorrectly perceived as manipulative, and that they had limited access to care. Attempts are made to improve public and staff attitudes.
of BPD in the general population ranges from 1 to 2 percent. The diagnosis appears to be several times more common in (especially young) women than in men, by as much as 3:1, according to the DSM-IV-TR, although the reasons for this are not clear.
The prevalence of BPD in the United States has been calculated as 1 percent to 3 percent of the adult population, with approximately 75 percent of those diagnosed being female. It has been found to account for 20 percent of psychiatric hospitalizations.
, Hippocrates
and Aretaeus
, the last describing the vacillating presence of impulsive anger, melancholia and mania within a single person. After medieval suppression of the concept, it was revived by Swiss physician Théophile Bonet in 1684, who, using the term folie maniaco-mélancolique, noted the erratic and unstable moods with periodic highs and lows that rarely followed a regular course. His observations were followed by those of other writers who noted the same pattern, including writers such as the American psychiatrist C. Hughes in 1884 and J.C. Rosse in 1890, who described "borderline insanity". Kraepelin
, in 1921, identified an "excitable personality" that closely parallels the borderline features outlined in the current concept of borderline.
Adolf Stern wrote the first significant psychoanalytic work to use the term "borderline" in 1938, referring to a group of patients with what was thought to be a mild form of schizophrenia
, on the borderline between neurosis
and psychosis
. For the next decade the term was in popular and colloquial use, a loosely conceived designation mostly used by theorists of the psychoanalytic and biological schools of thought. Increasingly, theorists who focused on the operation of social forces were recognized as well.
The 1960s and 1970s saw a shift from thinking of the borderline syndrome as borderline schizophrenia to thinking of it as a borderline affective disorder (mood disorder
), on the fringes of manic depression
, cyclothymia
and dysthymia. In DSM-II, stressing the affective components, it was called cyclothymic personality (affective personality). In parallel to this evolution of the term "borderline" to refer to a distinct category of disorder, psychoanalysts such as Otto Kernberg were using it to refer to a broad spectrum
of issues, describing an intermediate level of personality organization between neurotic and psychotic processes.
Standardized criteria were developed to distinguish BPD from affective disorders and other Axis I disorders, and BPD became a personality disorder diagnosis in 1980 with the publication of DSM-III
. The diagnosis was formulated predominantly in terms of mood and behavior, distinguished from sub-syndromal schizophrenia which was termed "Schizotypal personality disorder
". The final terminology in use by the DSM today was decided by the DSM-IV Axis II Work Group of the American Psychiatric Association.
and Fatal Attraction
are two examples, as is the memoir Girl, Interrupted
by Susanna Kaysen
(and the movie
based on it, with Winona Ryder
as Kaysen). Each of these films suggests the emotional instability of the disorder; however, the first two cases show a person more aggressive to others than to herself, which in fact is less typical. The 1992 film Single White Female
suggests different aspects of the disorder: the character Hedy suffers from a markedly disturbed sense of identity and, as with the last two films, abandonment leads to drastic measures.
The character of Anakin Skywalker/Darth Vader
in the Star Wars
films has been "diagnosed" as having BPD. Psychiatrists Eric Bui and Rachel Rodgers have argued that the character meets six of the nine diagnostic criteria; Bui also found Anakin a useful example to explain BPD to medical students. In particular, Bui points to the character's abandonment issues, uncertainty over his identity and violent dissociative episodes. Other films attempting to depict characters with the disorder include The Crush, Malicious, Interiors
, Notes On a Scandal
, The Cable Guy
and Cracks
. The film Borderline
, based on the book of the same name by Marie-Sissi Labrèche, attempts to explore BPD through its main character, Kiki.
.
In Lois McMaster Bujold
's science fiction novel Komarr, Tien Vorsoisson has BPD; his disorder drives a large part of the story.
declared the month of May as Borderline Personality Disorder Awareness Month.
was diagnosed with BPD.
Author Susanna Kaysen
was diagnosed with BPD, during her time at McLean Hospital
. Her memoir Girl, Interrupted
chronicles her time at the hospital. The memoir was later adapted into a film starring Winona Ryder
as Susanna.
in childhood. One feminist critique suggests that BPD is a stigmatizing diagnosis that can sometimes evoke negative responses from health care providers, and additionally, that women who have survived sexual abuse in childhood are therefore sometimes re-traumatized by any such abusive mental health service.
Some feminist writers have suggested it would be better to give these women the diagnosis of a post-traumatic disorder as this would acknowledge their abuse, but others have argued that the use of the PTSD diagnosis merely medicalizes abuse rather than addressing the root causes in society. Women may be more likely to receive a personality disorder diagnosis if they reject the female role by being hostile, successful or sexually active; alternatively if a woman presents with psychiatric symptoms but does not conform to a traditional passive sick role
, she may be labelled as a "difficult" patient and given the stigmatizing diagnosis of BPD.
" are often used, and may become a self-fulfilling prophecy as the clinician's negative response triggers further self-destructive behaviour. In psychoanalytic theory, this stigmatization may be thought to reflect countertransference
(when a therapist projects their own feelings on to a client), as people with BPD are prone to use defense mechanisms such as splitting
and projective identification
. Thus the diagnosis "often says more about the clinician's negative reaction to the patient than it does about the patient ... as an expression of counter transference hate, borderline explains away the breakdown in empathy
between the therapist and the patient and becomes an institutional epithet in the guise of pseudoscientific jargon" (Aronson, p 217).
This inadvertent counter transference can give rise to inappropriate clinical responses including excessive use of medication, inappropriate mothering and punitive use of limit setting and interpretation. People with BPD are seen as among the most challenging groups of patients, requiring a high degree of skill and training in the psychiatrists, therapists and nurses involved in their treatment. While some clinicians agree with the diagnosis under the name "borderline personality disorder", some would like the name to be changed. One critique says that some who are labeled
"Borderline Personality Disorder" feel this name is unhelpful, stigmatizing, and/or inaccurate.
The Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigns to change the name and designation of BPD in DSM-5
. The paper How Advocacy is Bringing BPD into the Light reports that "the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma...".
disorder. Impulse disorder and interpersonal regulatory disorder are other valid alternatives, according to John Gunderson of McLean Hospital
in the United States. Another term (for example, by psychiatrist Carolyn Quadrio) is post traumatic personality disorganization (PTPD), reflecting the condition's status as (often) both a form of chronic post traumatic stress disorder (PTSD) and a personality disorder
in the belief that it is a common outcome of developmental or attachment trauma. Some people do not report any kind of traumatic event.
Personality disorder
Personality disorders, formerly referred to as character disorders, are a class of personality types and behaviors. Personality disorders are noted on Axis II of the Diagnostic and Statistical Manual of Mental Disorders or DSM-IV-TR of the American Psychiatric Association.Personality disorders are...
described as a prolonged disturbance of personality function in a person (generally over the age of eighteen years, although it is also found in adolescents), characterized by depth and variability of moods.
The disorder typically involves unusual levels of instability in mood
Mood (psychology)
A mood is a relatively long lasting emotional state. Moods differ from emotions in that they are less specific, less intense, and less likely to be triggered by a particular stimulus or event....
; black and white thinking
False dilemma
A false dilemma is a type of logical fallacy that involves a situation in which only two alternatives are considered, when in fact there are additional options...
, or splitting
Splitting (psychology)
Splitting may mean two things: splitting of the mind, and splitting of mental concepts . The latter is thinking purely in extremes Splitting (also called all-or-nothing thinking in cognitive distortion) may mean two things: splitting of the mind, and splitting of mental concepts (or black and...
; the disorder often manifests itself in idealization and devaluation
Idealization and devaluation
In psychoanalytic theory, when an individual is unable to integrate difficult feelings, specific defenses are mobilized to overcome what the individual perceives as an unbearable situation. The defense that helps in this process is called splitting. Splitting is the tendency to view events or...
episodes, as well as chaotic and unstable interpersonal relationship
Interpersonal relationship
An interpersonal relationship is an association between two or more people that may range from fleeting to enduring. This association may be based on limerence, love, solidarity, regular business interactions, or some other type of social commitment. Interpersonal relationships are formed in the...
s, self-image, identity
Identity (social science)
Identity is a term used to describe a person's conception and expression of their individuality or group affiliations . The term is used more specifically in psychology and sociology, and is given a great deal of attention in social psychology...
, and behavior
Human behavior
Human behavior refers to the range of behaviors exhibited by humans and which are influenced by culture, attitudes, emotions, values, ethics, authority, rapport, hypnosis, persuasion, coercion and/or genetics....
; as well as a disturbance in the individual's sense of self. In extreme cases, this disturbance in the sense of self can lead to periods of dissociation
Dissociation
Dissociation is an altered state of consciousness characterized by partial or complete disruption of the normal integration of a person’s normal conscious or psychological functioning. Dissociation is most commonly experienced as a subjective perception of one's consciousness being detached from...
.
BPD splitting
Splitting (psychology)
Splitting may mean two things: splitting of the mind, and splitting of mental concepts . The latter is thinking purely in extremes Splitting (also called all-or-nothing thinking in cognitive distortion) may mean two things: splitting of the mind, and splitting of mental concepts (or black and...
includes a switch between idealizing and demonizing others. This, combined with mood disturbances, can undermine relationships with family, friends, and co-workers. BPD disturbances also may include self-harm
Self-harm
Self-harm or deliberate self-harm includes self-injury and self-poisoning and is defined as the intentional, direct injuring of body tissue most often done without suicidal intentions. These terms are used in the more recent literature in an attempt to reach a more neutral terminology...
. Without treatment, symptoms may worsen, leading (in extreme cases) to suicide
Suicide
Suicide is the act of intentionally causing one's own death. Suicide is often committed out of despair or attributed to some underlying mental disorder, such as depression, bipolar disorder, schizophrenia, alcoholism, or drug abuse...
attempts.
There is an ongoing debate among clinicians and patients worldwide about terminology and the use of the word borderline, and some have suggested that this disorder should be renamed. The ICD-10
ICD-10
The International Statistical Classification of Diseases and Related Health Problems, 10th Revision is a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases, as maintained by the...
manual has an alternative definition and terminology to this disorder, called Emotionally unstable personality disorder. There is related concern that the diagnosis of BPD stigmatizes
Social stigma
Social stigma is the severe disapproval of or discontent with a person on the grounds of characteristics that distinguish them from other members of a society.Almost all stigma is based on a person differing from social or cultural norms...
people and supports pejorative and discriminatory practices.
Signs and symptoms
Borderline personality disorder is a diagnosis about which many articles and books have been written, yet about which little is known based on empirical researchEmpiricism
Empiricism is a theory of knowledge that asserts that knowledge comes only or primarily via sensory experience. One of several views of epistemology, the study of human knowledge, along with rationalism, idealism and historicism, empiricism emphasizes the role of experience and evidence,...
.
Studies suggest that individuals with BPD tend to experience frequent, strong and long-lasting states of aversive
Aversives
In psychology, aversives are unpleasant stimuli that induce changes in behavior through punishment; by applying an aversive immediately following a behavior, the likelihood of the behavior occurring in the future is reduced. Aversives can vary from being slightly unpleasant or irritating to...
tension, often triggered by perceived rejection, being alone or perceived failure. Individuals with BPD may show lability (changeability) between anger and anxiety or between depression
Depression (mood)
Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behaviour, feelings and physical well-being. Depressed people may feel sad, anxious, empty, hopeless, helpless, worthless, guilty, irritable, or restless...
and anxiety and temperamental sensitivity to emotive stimuli.
The negative emotional states specific to BPD may be grouped into four categories: destructive or self-destructive feelings; extreme feelings in general; feelings of fragmentation or lack of identity; and feelings of victimization.
Individuals with BPD can be very sensitive to the way others treat them, reacting strongly to perceived criticism or hurtfulness. Their feelings about others often shift from positive to negative, generally after a disappointment or perceived threat of losing someone. Self-image can also change rapidly from extremely positive to extremely negative. Impulsive behaviors are common, including alcohol
Alcoholism
Alcoholism is a broad term for problems with alcohol, and is generally used to mean compulsive and uncontrolled consumption of alcoholic beverages, usually to the detriment of the drinker's health, personal relationships, and social standing...
or drug abuse
Drug abuse
Substance abuse, also known as drug abuse, refers to a maladaptive pattern of use of a substance that is not considered dependent. The term "drug abuse" does not exclude dependency, but is otherwise used in a similar manner in nonmedical contexts...
, unsafe sex, gambling and recklessness in general. Attachment studies have revealed a strong association between BPD and insecure attachment style
Attachment theory
Attachment theory describes the dynamics of long-term relationships between humans. Its most important tenet is that an infant needs to develop a relationship with at least one primary caregiver for social and emotional development to occur normally. Attachment theory is an interdisciplinary study...
, the most characteristic types being "unresolved", "preoccupied", and "fearful". Evidence suggests that individuals with BPD, while being high in intimacy- or novelty-seeking, can be hyper-alert to signs of rejection or not being valued and tend toward insecure, avoidant or ambivalent, or fearfully preoccupied patterns in relationships. They tend to view the world as generally dangerous and malevolent.
Individuals with BPD are often described, including by some mental health
Mental health
Mental health describes either a level of cognitive or emotional well-being or an absence of a mental disorder. From perspectives of the discipline of positive psychology or holism mental health may include an individual's ability to enjoy life and procure a balance between life activities and...
professionals (and in the DSM-IV), as deliberately manipulative or difficult, but analysis and findings generally trace behaviors to inner pain and turmoil, powerlessness and defensive reactions, or limited coping
Coping (psychology)
Coping has been defined in psychological terms by Susan Folkman and Richard Lazarus as "constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing" or "exceeding the resources of the person".Coping is thus expending...
and communication skills. There has been limited research on family members' understanding of borderline personality disorder and the extent of burden or negative emotion experienced or expressed by family members. However the effect of expressed emotion by family members may actually be opposite (paradox
Paradox
Similar to Circular reasoning, A paradox is a seemingly true statement or group of statements that lead to a contradiction or a situation which seems to defy logic or intuition...
ical) from the anticipated effect on individuals with such illnesses as depressive disorders and schizophrenia. For BPD such effect may be neutral or positive as opposed to negative, a counter-intuitive result.
Parents of individuals with BPD have been reported to show co-existing extremes of over-involvement and under-involvement. BPD has been linked to increased levels of chronic stress and conflict in romantic relationships, decreased satisfaction of romantic partners, abuse
Domestic violence
Domestic violence, also known as domestic abuse, spousal abuse, battering, family violence, and intimate partner violence , is broadly defined as a pattern of abusive behaviors by one or both partners in an intimate relationship such as marriage, dating, family, or cohabitation...
and unwanted pregnancy
Pregnancy
Pregnancy refers to the fertilization and development of one or more offspring, known as a fetus or embryo, in a woman's uterus. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets...
; these links may be general to personality disorder and subsyndromal problems.
Suicidal
Suicide
Suicide is the act of intentionally causing one's own death. Suicide is often committed out of despair or attributed to some underlying mental disorder, such as depression, bipolar disorder, schizophrenia, alcoholism, or drug abuse...
or self-harm
Self-harm
Self-harm or deliberate self-harm includes self-injury and self-poisoning and is defined as the intentional, direct injuring of body tissue most often done without suicidal intentions. These terms are used in the more recent literature in an attempt to reach a more neutral terminology...
ing behavior is one of the core diagnostic criteria in DSM IV-TR, and management of and recovery from this can be complex and challenging. The suicide rate is approximately 8 to 10 percent. Self-injury attempts are highly common among patients and may or may not be carried out with suicidal intent. BPD is often characterized by multiple low-lethality suicide attempts triggered by seemingly minor incidents, and less commonly by high-lethality attempts that are attributed to impulsiveness or comorbid clinical depression, with interpersonal stressors appearing to be particularly common triggers. Ongoing family interactions and associated vulnerabilities can lead to self-destructive behavior. Stressful life events related to sexual abuse have been found to be a particular trigger for suicide attempts by adolescents with a BPD diagnosis.
Diagnosis
Diagnosis is based on a clinical assessmentPsychiatric assessment
A psychiatric assessment, or psychological screening, is a process of way of gathering information about a person within a psychiatric service, with the purpose of making a diagnosis. The assessment is usually the first stage of a treatment process, but psychiatric assessments may also be used for...
by a qualified mental health professional
Mental health professional
A mental health professional is a health care practitioner who offers services for the purpose of improving an individual's mental health or to treat mental illness. This broad category includes psychiatrists, clinical psychologists, clinical social workers, psychiatric nurses, mental health...
. The assessment incorporates the patient's self-reported experiences as well as the clinician's observations. The resulting profile may be supported or corroborated by long-term patterns of behavior as reported by family members, friends or co-workers. The list of criteria that must be met for diagnosis is outlined in the DSM-IV-TR
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
.
Borderline personality disorder was once classified as a subset of schizophrenia
Schizophrenia
Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social...
(describing patients with borderline schizophrenic tendencies). Today BPD is used more generally to describe individuals who display emotional dysregulation
Emotional dysregulation
Emotional dysregulation is a term used in the mental health community to refer to an emotional response that is poorly modulated, and does not fall within the conventionally accepted range of emotive response...
and instability, with paranoid ideation or delusions being only one criterion (criterion #9) of a total of 9 criteria, of which 5, or more, must be present for this diagnosis.
Individuals with BPD are at high risk of developing other psychological disorders such as anxiety
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
and depression. Other symptoms of BPD, such as dissociation
Dissociation
Dissociation is an altered state of consciousness characterized by partial or complete disruption of the normal integration of a person’s normal conscious or psychological functioning. Dissociation is most commonly experienced as a subjective perception of one's consciousness being detached from...
, are frequently linked to severely traumatic childhood experiences, which some put forth as one of the many root causes of the borderline personality.
Family members
It is common for those with borderline personality disorder and their families to feel their problems compounded by a lack of clear diagnoses, effective treatments, and accurate information. This is true especially because of evidence that this disorder originates in the families of those with it and has a lot to do with psychosocial and environmental factors (Axis IV), rather than belonging strictly in the personality disorders and mental retardation section (Axis II) of the DSM-IV constructConstruct (philosophy of science)
A construct in the philosophy of science is an ideal object, where the existence of the thing may be said to depend upon a subject's mind. This, as opposed to a "real" object, where existence does not seem to depend on the existence of a mind....
. Conceptual, as well as therapeutic, relief may be obtained through evidence that BPD is closely related to traumatic events during childhood and to post-traumatic stress disorder
Post-traumatic stress disorder
Posttraumaticstress disorder is a severe anxiety disorder that can develop after exposure to any event that results in psychological trauma. This event may involve the threat of death to oneself or to someone else, or to one's own or someone else's physical, sexual, or psychological integrity,...
(PTSD), about which much more is known.
Recovery can be faster with the help of family members and loved ones, however those involved must be trained for their assistance to have an effective impact. http://bpdfamily.com/tools/articles5.htm
Adolescence
Onset of symptoms typically occurs during adolescence or young adulthood. Symptoms may persist for several years, but the majority of symptoms lessen in severity over time, with some individuals fully recovering. The mainstay of treatment is various forms of psychotherapyPsychotherapy
Psychotherapy is a general term referring to any form of therapeutic interaction or treatment contracted between a trained professional and a client or patient; family, couple or group...
, although medication and other approaches may also improve symptoms. Two forms of therapy in particular have been shown to be effective with BPD: Dialectical Behavioral Therapy
Dialectical behavioral therapy
Dialectical behavior therapy is a system of therapy originally developed by Marsha M. Linehan, a psychology researcher at the University of Washington, to treat people with borderline personality disorder...
and Schema Therapy
Schema Therapy
Schema Therapy was developed by Dr. Jeffrey E. Young for use in treatment of personality disorders and chronic Axis I disorders, such as when patients fail to respond or relapse after having been through other therapies...
. Both of these are influenced by Cognitive Behavioral therapy. While borderline personality disorder can manifest itself in children and teenagers, therapists are discouraged from diagnosing anyone before the age of 18, due to adolescence and a still-developing personality.
There are some instances when BPD can be evident and diagnosed before the age of 18. The DSM-IV states: "To diagnose a personality disorder in an individual under 18 years, the features must have been present for at least 1 year." In other words, it is possible to diagnose the disorder in children and adolescents, but a more conservative approach should be taken.
There is some evidence that BPD diagnosed in adolescence is predictive of the disease continuing into adulthood. It is possible that the diagnosis, if applicable, would be helpful in creating a more effective treatment plan for the child or teen.
Diagnostic and Statistical Manual
The Diagnostic and Statistical Manual of Mental DisordersDiagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
fourth edition, DSM IV-TR, a widely used manual for diagnosing mental disorders, defines borderline personality disorder (in Axis II Cluster B) as:
- A pervasive pattern of instability of interpersonal relationshipInterpersonal relationshipAn interpersonal relationship is an association between two or more people that may range from fleeting to enduring. This association may be based on limerence, love, solidarity, regular business interactions, or some other type of social commitment. Interpersonal relationships are formed in the...
s, self-image and affectAffect (psychology)Affect refers to the experience of feeling or emotion. Affect is a key part of the process of an organism's interaction with stimuli. The word also refers sometimes to affect display, which is "a facial, vocal, or gestural behavior that serves as an indicator of affect" .The affective domain...
s, as well as marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
-
- Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-injuring behavior covered in Criterion 5
- A pattern of unstable and intense interpersonal relationshipInterpersonal relationshipAn interpersonal relationship is an association between two or more people that may range from fleeting to enduring. This association may be based on limerence, love, solidarity, regular business interactions, or some other type of social commitment. Interpersonal relationships are formed in the...
s characterized by alternating between extremes of idealization and devaluationIdealization and devaluationIn psychoanalytic theory, when an individual is unable to integrate difficult feelings, specific defenses are mobilized to overcome what the individual perceives as an unbearable situation. The defense that helps in this process is called splitting. Splitting is the tendency to view events or...
. - IdentityIdentity (social science)Identity is a term used to describe a person's conception and expression of their individuality or group affiliations . The term is used more specifically in psychology and sociology, and is given a great deal of attention in social psychology...
disturbance: markedly and persistently unstable self-image or sense of self. - ImpulsivityImpulsivityImpulsivity is a personality trait characterized by the inclination of an individual to initiate behavior without adequate forethought as to the consequences of their actions, acting on the spur of the moment. Eysenck and Eysenck related impulsivity to risk-taking, lack of planning, and making up...
in at least two areas that are potentially self-damaging (e.g., promiscuous sex, eating disorderEating disorderEating disorders refer to a group of conditions defined by abnormal eating habits that may involve either insufficient or excessive food intake to the detriment of an individual's physical and mental health. Bulimia nervosa, anorexia nervosa, and binge eating disorder are the most common specific...
s, binge eatingBinge eatingBinge eating is a pattern of disordered eating which consists of episodes of uncontrollable eating. It is sometimes as a symptom of binge eating disorder. During such binges, a person rapidly consumes an excessive amount of food...
, substance abuseSubstance abuseA substance-related disorder is an umbrella term used to describe several different conditions associated with several different substances .A substance related disorder is a condition in which an individual uses or abuses a...
, reckless drivingReckless drivingReckless driving is a major moving traffic violation. As a legal term, it is used within the United States. This offence has been abolished in the United Kingdom and replaced...
). Note: Do not include suicidal or self-injuring behavior covered in Criterion 5 - Recurrent suicidal behaviorSuicideSuicide is the act of intentionally causing one's own death. Suicide is often committed out of despair or attributed to some underlying mental disorder, such as depression, bipolar disorder, schizophrenia, alcoholism, or drug abuse...
, gestures, threats or self-injuring behavior such as cutting, interfering with the healing of scars (excoriation) or picking at oneself. - AffectiveAffect (psychology)Affect refers to the experience of feeling or emotion. Affect is a key part of the process of an organism's interaction with stimuli. The word also refers sometimes to affect display, which is "a facial, vocal, or gestural behavior that serves as an indicator of affect" .The affective domain...
instability due to a marked reactivity of moodMood (psychology)A mood is a relatively long lasting emotional state. Moods differ from emotions in that they are less specific, less intense, and less likely to be triggered by a particular stimulus or event....
(e.g., intense episodic dysphoriaDysphoriaDysphoria is medically recognized as a mental and emotional condition in which a person experiences intense feelings of depression, discontent and indifference to the world around them.Mood disorders can induce dysphoria, often with a heightened risk of suicide, especially in...
, irritability or anxietyAnxietyAnxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
usually lasting a few hours and only rarely more than a few days). - Chronic feelings of emptinessEmptinessEmptiness as a human condition is a sense of generalized boredom, social alienation and apathy. Feelings of emptiness often accompany dysthymia, depression, loneliness, despair, or other mental/emotional disorders such as borderline personality disorder...
- Inappropriate angerAngerAnger is an automatic response to ill treatment. It is the way a person indicates he or she will not tolerate certain types of behaviour. It is a feedback mechanism in which an unpleasant stimulus is met with an unpleasant response....
or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). - Transient, stressStress (medicine)Stress is a term in psychology and biology, borrowed from physics and engineering and first used in the biological context in the 1930s, which has in more recent decades become commonly used in popular parlance...
-related paranoidParanoiaParanoia [] is a thought process believed to be heavily influenced by anxiety or fear, often to the point of irrationality and delusion. Paranoid thinking typically includes persecutory beliefs, or beliefs of conspiracy concerning a perceived threat towards oneself...
ideation, delusionDelusionA delusion is a false belief held with absolute conviction despite superior evidence. Unlike hallucinations, delusions are always pathological...
s or severe dissociativeDissociationDissociation is an altered state of consciousness characterized by partial or complete disruption of the normal integration of a person’s normal conscious or psychological functioning. Dissociation is most commonly experienced as a subjective perception of one's consciousness being detached from...
symptoms
It is a requirement of DSM-IV that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.
International Classification of Disease
The World Health OrganizationWorld Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...
's ICD-10
ICD-10
The International Statistical Classification of Diseases and Related Health Problems, 10th Revision is a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases, as maintained by the...
defines a conceptually similar disorder to borderline personality disorder called Emotionally unstable personality disorder. It has two subtypes described below.
F60.30 Impulsive type
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 quarrelsome behaviour and to conflicts with others, especially when impulsive acts are thwarted or criticized;
- liability to outbursts of angerAngerAnger is an automatic response to ill treatment. It is the way a person indicates he or she will not tolerate certain types of behaviour. It is a feedback mechanism in which an unpleasant stimulus is met with an unpleasant response....
or violence, with inability to control the resulting behavioural explosions; - difficulty in maintaining any course of action that offers no immediate reward;
- unstable and capricious mood.
It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.
F60.31 Borderline type
At least three of the symptoms mentioned in F60.30 Impulsive type must be present [see above], with at least two of the following in addition:
- disturbances in and uncertainty about self-image, aims, and internal preferences (including sexual);
- liability to become involved in intense and unstable relationships, often leading to emotional crisis;
- excessive efforts to avoid abandonment;
- recurrent threats or acts of self-harmSelf-harmSelf-harm or deliberate self-harm includes self-injury and self-poisoning and is defined as the intentional, direct injuring of body tissue most often done without suicidal intentions. These terms are used in the more recent literature in an attempt to reach a more neutral terminology...
; - chronic feelings of emptiness.
It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.
Chinese Society of Psychiatry
The Chinese Society of PsychiatryChinese Society of Psychiatry
The Chinese Society of Psychiatry is the largest organization for psychiatrists in China. It publishes the Chinese Classification of Mental Disorders...
's CCMD has a comparable diagnosis of Impulsive Personality Disorder (IPD). A patient diagnosed as having IPD must display "affective outbursts" and "marked impulsive behavior," plus at least three out of eight other symptoms. The construct has been described as a hybrid of the impulsive and borderline subtypes of the ICD-10's Emotionally Unstable Personality Disorder, and also incorporates six of the nine DSM BPD criteria.
Millon's subtypes
Theodore MillonTheodore Millon
Theodore Millon is an American psychologist known for his work on personality disorders.-Biography:Millon was born in 1928, the only child of immigrant Jewish parents from Lithuania and Poland. His 19th-century ancestors came from the town of Valozhyn, then a part of the Russian Empire...
identified four subtypes of borderline. Any individual borderline person may exhibit none, one or more of the following:
- Discouraged borderline — including avoidantAvoidant personality disorderAvoidant personality disorder is a personality disorder recognized in the Diagnostic and Statistical Manual of Mental Disorders handbook in a person characterized by a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of...
, depressive or dependentDependent personality disorderDependent personality disorder , formerly known as asthenic personality disorder, is a personality disorder that is characterized by a pervasive psychological dependence on other people...
features - Impulsive borderline — including histrionicHistrionic personality disorderHistrionic personality disorder is defined by the American Psychiatric Association as a personality disorder characterized by a pattern of excessive emotionality and attention-seeking, including an excessive need for approval and inappropriately seductive behavior, usually beginning in early...
or antisocialAntisocial personality disorderAntisocial personality disorder is described by the American Psychiatric Association's Diagnostic and Statistical Manual, fourth edition , as an Axis II personality disorder characterized by "...a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood...
features - Petulant borderline — including negativistic (passive-aggressive) features
- Self-destructive borderline — including depressive or masochisticSelf-defeating personality disorderSelf-defeating personality disorder is a personality disorder that was never formally admitted into the Diagnostic and Statistical Manual of Mental Disorders . It was discussed in an appendix of the manual's revised third edition...
features
Differential diagnosis
Common comorbid (co-occurring) conditions are mental disorders such as substance abuse, depression and other mood and personality disorders.Borderline personality disorder and mood disorder
Mood disorder
Mood disorder is the term designating a group of diagnoses in the Diagnostic and Statistical Manual of Mental Disorders classification system where a disturbance in the person's mood is hypothesized to be the main underlying feature...
s often appear concurrently. Some features of borderline personality disorder may overlap with those of mood disorders, complicating the differential diagnostic assessment.
Both diagnoses involve symptoms commonly known as "mood swing
Mood swing
-Associated disorders:Mood swings are commonly associated with mood disorders including bipolar disorder and depression. In patients with cases of bipolar disorder, the patient experiences serious mood swings that last for days or even weeks...
s." In borderline personality disorder, the term refers to the marked lability and reactivity of mood defined as emotional dysregulation
Emotional dysregulation
Emotional dysregulation is a term used in the mental health community to refer to an emotional response that is poorly modulated, and does not fall within the conventionally accepted range of emotive response...
. The behavior is typically in response to external psychosocial
Psychosocial
For a concept to be psychosocial means it relates to one's psychological development in, and interaction with, a social environment. The individual needs not be fully aware of this relationship with his or her environment. It was first commonly used by psychologist Erik Erikson in his stages of...
and intrapsychic
Intrapsychic
Intrapsychic is a psychological term referring to internal psychological processes of the individual. These processes can be positive , negative or neutral....
stressors, and may arise or subside, or both, suddenly and dramatically and last for seconds, minutes, hours, days, weeks or months.
Bipolar depression is generally more pervasive with sleep and appetite disturbances, as well as a marked nonreactivity of mood, whereas mood with respect to borderline personality and co-occurring dysthymia remains markedly reactive and sleep disturbance not acute.
The relationship between bipolar disorder and borderline personality disorder has been debated. Some hold that the latter represents a subthreshold form of affective disorder, while others maintain the distinctness between the disorders, noting they often co-occur.
Some findings suggest that BPD may lie on a bipolar spectrum
Bipolar spectrum
The bipolar spectrum refers to a category of mood disorders that feature abnormally elevated or depressed mood. These disorders range from bipolar I disorder, featuring full-blown manic episodes, to cyclothymia, featuring less prominent hypomanic episodes, to "subsyndromal" conditions where only...
, with a number of points of phenomenological and biological overlap between the affective lability criterion of borderline personality disorder and the extremely rapid cycling bipolar disorders. Some findings suggest that the DSM-IV BPD diagnosis mixes up two sets of unrelated items—an affective instability dimension related to Bipolar-II, and an impulsivity dimension not related to Bipolar-II.
It is important to emphasize that medical conditions which cause organic behavioral function may result in a clinical picture that mimics to some degree BPD. Hormonal dysfunction over a long period, or brain dysfunction (e.g. the encephalopathy caused by lyme disease
Lyme disease
Lyme disease, or Lyme borreliosis, is an emerging infectious disease caused by at least three species of bacteria belonging to the genus Borrelia. Borrelia burgdorferi sensu stricto is the main cause of Lyme disease in the United States, whereas Borrelia afzelii and Borrelia garinii cause most...
) can result in identity disturbance and mood lability, as can many other chronic medical conditions such as lupus
Lupus
Lupus most commonly refers to the disease systemic lupus erythematosus.Lupus may also refer to:-Medicine:* Lupus erythematosus, a chronic autoimmune disease with several different forms...
. These conditions may isolate the patient socially and emotionally, and/or cause limbic damage to the brain. However, this is not borderline personality disorder which results, but rather a reaction to the isolating circumstances caused by a medical condition and the possibly coincident struggles of the patient to control his or her mood given damage to the brain's limbic system. Heavy alcohol usage
Alcohol abuse
Alcohol abuse, as described in the DSM-IV, is a psychiatric diagnosis describing the recurring use of alcoholic beverages despite negative consequences. Alcohol abuse eventually progresses to alcoholism, a condition in which an individual becomes dependent on alcoholic beverages in order to avoid...
over a long period itself can cause an encephalopathy which may cause limbic damage. Various frontal lobe syndromes can result in disinhibition and impulsive behavior.
Comorbid (co-occurring) conditions in BPD are common. When comparing individuals diagnosed with BPD to those diagnosed with other personality disorders, the former showed a higher rate of also meeting criteria for
- anxiety disorders
- mood disorders (including clinical depressionClinical depressionMajor depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
and bipolar disorderBipolar disorderBipolar disorder or bipolar affective disorder, historically known as manic–depressive disorder, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or...
) - eating disorders (including anorexia nervosaAnorexia nervosaAnorexia nervosa is an eating disorder characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight. Although commonly called "anorexia", that term on its own denotes any symptomatic loss of appetite and is not strictly accurate...
and bulimia) - and, to a lesser extent, somatoformSomatoform disorderIn psychology, a somatoform disorder is a mental disorder characterized by physical symptoms that suggest physical illness or injury - symptoms that cannot be explained fully by a general medical condition, direct effect of a substance, or attributable to another mental disorder . The symptoms that...
or factitious disorderFactitious disorderFactitious disorders are conditions in which a person acts as if he or she has an illness by deliberately producing, feigning, or exaggerating symptoms. Factitious disorder by proxy is a condition in which a person deliberately produces, feigns, or exaggerates symptoms in a person who is in their...
s - dissociative disordersDissociative disordersDissociative disorders are defined as conditions that involve disruptions or breakdowns of memory, awareness, identity and/or perception. See also dissociation. People with dissociative disorders are able to escape from reality involuntarily...
- Substance abuseSubstance abuseA substance-related disorder is an umbrella term used to describe several different conditions associated with several different substances .A substance related disorder is a condition in which an individual uses or abuses a...
is a common problem in BPD, whether due to impulsivity or as a coping mechanism, and 50 percent to 70 percent of psychiatric inpatients with BPD have been found to meet criteria for a substance use disorder, especially alcohol dependence or abuse which is often combined with the abuse of other drugs.
Causes
As with other mental disorders, the causes of BPD are complex and not fully understood. One finding is a history of childhood trauma, abuse or neglect, although researchers have suggested diverse possible causes, such as a genetic predisposition, neurobiological factors, environmental factors, or brain abnormalities.There is evidence that suggests that BPD and post-traumatic stress disorder
Post-traumatic stress disorder
Posttraumaticstress disorder is a severe anxiety disorder that can develop after exposure to any event that results in psychological trauma. This event may involve the threat of death to oneself or to someone else, or to one's own or someone else's physical, sexual, or psychological integrity,...
(PTSD) are closely related. Evidence further suggests that BPD might result from a combination that can involve a traumatic
Psychological trauma
Psychological trauma is a type of damage to the psyche that occurs as a result of a traumatic event...
childhood, a vulnerable temperament and stressful maturational events during adolescence
Adolescence
Adolescence is a transitional stage of physical and mental human development generally occurring between puberty and legal adulthood , but largely characterized as beginning and ending with the teenage stage...
or adulthood.
Childhood abuse
Numerous studies have shown a strong correlation between child abuseChild abuse
Child abuse is the physical, sexual, emotional mistreatment, or neglect of a child. In the United States, the Centers for Disease Control and Prevention and the Department of Children And Families define child maltreatment as any act or series of acts of commission or omission by a parent or...
, especially child sexual abuse
Child sexual abuse
Child sexual abuse is a form of child abuse in which an adult or older adolescent uses a child for sexual stimulation. Forms of child sexual abuse include asking or pressuring a child to engage in sexual activities , indecent exposure with intent to gratify their own sexual desires or to...
, and development of BPD. Many individuals with BPD report to have had a history of abuse and neglect as young children. Patients with BPD have been found to be significantly more likely to report having been verbally, emotionally, physically or sexually abused by caregivers of either gender
Gender
Gender is a range of characteristics used to distinguish between males and females, particularly in the cases of men and women and the masculine and feminine attributes assigned to them. Depending on the context, the discriminating characteristics vary from sex to social role to gender identity...
. There has also been a high incidence of incest and loss of caregivers in early childhood for people with borderline personality disorder. They were also much more likely to report having caregivers (of both genders) deny the validity of their thoughts and feelings. They were also reported to have failed to provide needed protection, and neglected their child's physical care. Parents (of both sexes) were typically reported to have withdrawn from the child emotionally, and to have treated the child inconsistently. Additionally, women with BPD who reported a previous history of neglect by a female caregiver and abuse by a male caregiver were consequently at significantly higher risk for being sexually abused by a noncaregiver (not a parent). It has been suggested that children who experience chronic early maltreatment and attachment difficulties may go on to develop borderline personality disorder.
Other developmental factors
Some studies suggest that BPD may not necessarily be a trauma-spectrum disorder and that it is biologically distinct from the post-traumatic stress disorder that could be a precursor. The personality symptom clusters seem to be related to specific abuses, but they may be related to more persistent aspects of interpersonal and family environments in childhood.Otto Kernberg formulated a theory of borderline personality based on a premise of failure to develop in childhood. Writing in the psychoanalytic tradition, Kernberg argued that failure to achieve the developmental task of psychic clarification of self and other can result in an increased risk to develop varieties of psychosis, while failure to overcome splitting results in an increased risk to develop a borderline personality.
Genetics
An overview of the existing literature suggested that traits related to BPD are influenced by geneGene
A gene is a molecular unit of heredity of a living organism. It is a name given to some stretches of DNA and RNA that code for a type of protein or for an RNA chain that has a function in the organism. Living beings depend on genes, as they specify all proteins and functional RNA chains...
s. A major twin study found that if one identical twin met criteria for BPD, the other also met criteria in 35 percent of cases. People that have BPD influenced by genes usually have a close relative with the disorder.
Twin, sibling and other family studies indicate a partially heritable basis for impulsive aggression, but studies of serotonin
Serotonin
Serotonin or 5-hydroxytryptamine is a monoamine neurotransmitter. Biochemically derived from tryptophan, serotonin is primarily found in the gastrointestinal tract, platelets, and in the central nervous system of animals including humans...
-related genes to date have suggested only modest contributions to behavior.
Research on mediating and moderating factors
Research suggests that, rather than having a single cause, BPD may develop as a result of a number of different factors. Research has found that both physical and sexual abuse appear to be factors in developing BPD symptoms. Other factors including family environment also contribute to the development of the disorder. Bradley et al. found that both child sexual abuse (CSA) and childhood physical abuse both directly influence the development of BPD symptoms directly and are mediated by family environment.Other research has examined whether the negative affectivity
Negative affectivity
Negative Affect is a general dimension of subjective distress and unpleasurable engagement that subsumes a variety of aversive mood states, including anger, contempt, disgust, guilt, fear, and nervousness...
associated with BPD—that is, the tendency to often feel anger, contempt, guilt, nervousness, and other negative feelings—can be helped by the technique of thought suppression
Thought suppression
Thought suppression is the process of deliberately trying to stop thinking about certain thoughts . It is often associated with obsessive–compulsive disorder, in which a sufferer will repeatedly attempt to prevent or "neutralize" intrusive distressing thoughts centered around one or more obsessions...
, or consciously trying not to think certain thoughts. The results of this study found that thought suppression mediated the relationship between negative affectivity and BPD symptoms. While negative affectivity significantly predicted BPD symptoms, this relationship was greatly reduced when thought suppression was introduced into the model. Thus, the relationship of negative affectivity to BPD symptoms is mediated by thought suppression.
Ayduk, et al., found that rejection sensitivity and executive control
Executive functions
The executive system is a theorized cognitive system in psychology that controls and manages other cognitive processes. It is responsible for processes that are sometimes referred to as the executive function, executive functions, supervisory attentional system, or cognitive control...
are predictors of BPD symptoms; in other words, people who are highly apt to feel rejected, and/or who have poor control of their emotions and behavior, are more likely to develop BPD. Another factor the authors studied, namely a child's ability to tolerate delayed gratification at age 4, did not appear to predict later development of BPD.
Parker, Boldero and Bell examined another facet of BPD, which is instability of the sense of self. Their findings indicated that Self-Discrepancy--the sense of failing to match one's own ideals—was strongly correlated to BPD. Self-complexity
Self-complexity
Self-complexity is a term that refers to a person’s perceived knowledge of himself or herself, based upon the number of distinct cognitive structures, or self-aspects, they believe themselves to possess...
, or being aware of one's own mental patterns, was not. Among those high in self-complexity, the relationship between AI self-discrepancy magnitudes and BPD features was lower than among those with less self-complexity. Actual-ought self-discrepancy relationship with BPD features was not significantly moderated by self-complexity.
Management
PsychotherapyPsychotherapy
Psychotherapy is a general term referring to any form of therapeutic interaction or treatment contracted between a trained professional and a client or patient; family, couple or group...
forms the foundation of treatment for borderline personality disorder with medications playing a lesser role. Treatments should be based on individual case presentation, rather than upon the diagnosis of BPD with co-morbid conditions determining medications use, if any. Hospitalization has not been found to improve outcomes or prevent suicide over community care in those with BPD.
Psychotherapy
Four comprehensive psychosocial interventions for BPD – two psychodynamicPsychodynamics
Psychodynamics is the theory and systematic study of the psychological forces that underlie human behavior, especially the dynamic relations between conscious motivation and unconscious motivation...
treatments (mentalization-based, and transference-focused
Transference focused psychotherapy
Transference Focused Psychotherapy , is a highly structured, twice-weekly modified psychodynamic treatment based on Otto Kernberg’s object relations model of borderline personality disorder...
) and two cognitive-behavioral treatments (dialectical behavioral, and schema-focused
Schema Therapy
Schema Therapy was developed by Dr. Jeffrey E. Young for use in treatment of personality disorders and chronic Axis I disorders, such as when patients fail to respond or relapse after having been through other therapies...
) – were the subject of a 2009 review that found that each therapy reduced the severity of the disorder or some elements of it, especially physical self-harm. A 2010 review found that the highest quality evidence from clinical trials of psychotherapeutic interventions supports dialectical behavior therapy and mentalization-based therapy. A special problem of psychotherapy with borderline patients is intense projection
Psychological projection
Psychological projection or projection bias is a psychological defense mechanism where a person subconsciously denies his or her own attributes, thoughts, and emotions, which are then ascribed to the outside world, usually to other people...
. It requires the psychotherapist to be flexible in considering negative attributions by the patient rather than quickly interpreting the projection.
Medications
A 2010 review by the Cochrane collaborationCochrane Collaboration
The Cochrane Collaboration is a group of over 28,000 volunteers in more than 100 countries who review the effects of health care interventions tested in biomedical randomized controlled trials. A few more recent reviews have also studied the results of non-randomized, observational studies...
found that the total severity of BPD is not significantly affected by any drug. No drugs show promise for "the core BPD symptoms of chronic feelings of emptiness, identity disturbance and abandonment." However, the authors found that some drugs may impact certain associated symptoms or the symptoms of comorbid conditions.
Of the typical antipsychotic
Typical antipsychotic
Typical antipsychotics are a class of antipsychotic drugs first developed in the 1950s and used to treat psychosis...
s studied in relation to BPD, haloperidol
Haloperidol
Haloperidol is a typical antipsychotic. It is in the butyrophenone class of antipsychotic medications and has pharmacological effects similar to the phenothiazines....
may reduce anger, and flupenthixol may reduce the likelihood of suicidal behavior. Among the atypical antipsychotic
Atypical antipsychotic
The atypical antipsychotics are a group of antipsychotic tranquilizing drugs used to treat psychiatric conditions. Some atypical antipsychotics are FDA approved for use in the treatment of schizophrenia...
s, aripiprazole
Aripiprazole
Aripiprazole is an atypical antipsychotic and antidepressant used in the treatment of schizophrenia, bipolar disorder, and clinical depression...
may reduce interpersonal problems, impulsivity, anger, psychotic paranoid symptoms, depression, anxiety, and general psychiatric pathology; olanzapine
Olanzapine
Olanzapine is an atypical antipsychotic, approved by the FDA for the treatment of schizophrenia and bipolar disorder...
may decrease affective instability, anger, psychotic paranoid symptoms, and anxiety, but placebo
Placebo
A placebo is a simulated or otherwise medically ineffectual treatment for a disease or other medical condition intended to deceive the recipient...
had a greater ameliorative impact on suicidal ideation than olanzapine did; and ziprasidone
Ziprasidone
Ziprasidone was the fifth atypical antipsychotic to gain FDA approval . In the United States, Ziprasidone is Food and Drug Administration approved for the treatment of schizophrenia, and the intramuscular injection form of ziprasidone is approved for acute agitation in schizophrenic patients...
treatment demonstrated no significant therapeutic affect. Of the mood stabilizers studied, valproate semisodium
Valproate semisodium
Valproate semisodium or divalproex sodium consists of a compound of sodium valproate and valproic acid in a 1:1 molar relationship in an enteric coated form. It is used in the United Kingdom, Canada, and United States for the treatment of the manic episodes of bipolar disorder...
may ameliorate depression and interpersonal problems, and it may reduce anger; lamotrigine
Lamotrigine
Lamotrigine, marketed in the US and most of Europe as Lamictal by GlaxoSmithKline, is an anticonvulsant drug used in the treatment of epilepsy and bipolar disorder. It is also used as an adjunct in treating depression, though this is considered off-label usage...
may reduce impulsivity and anger, topiramate
Topiramate
Topiramate is an anticonvulsant drug. It was originally produced by Ortho-McNeil Neurologics and Noramco, Inc., both divisions of the Johnson & Johnson Corporation. This medication was discovered in 1979 by Bruce E. Maryanoff and Joseph F. Gardocki during their research work at McNeil...
may ameliorate interpersonal problems, impulsivity, anxiety, anger and general psychiatric pathology, but carbamazepine
Carbamazepine
Carbamazepine is an anticonvulsant and mood-stabilizing drug used primarily in the treatment of epilepsy and bipolar disorder, as well as trigeminal neuralgia...
treatment demonstrated no significant effect. Among the antidepressant
Antidepressant
An antidepressant is a psychiatric medication used to alleviate mood disorders, such as major depression and dysthymia and anxiety disorders such as social anxiety disorder. According to Gelder, Mayou &*Geddes people with a depressive illness will experience a therapeutic effect to their mood;...
s, amitriptyline
Amitriptyline
Amitriptyline is a tricyclic antidepressant . It is the most widely used TCA and has at least equal efficacy against depression as the newer class of SSRIs...
may reduce depression, but mianserin
Mianserin
Mianserin is a psychoactive drug of the tetracyclic antidepressant chemical class which is classified as a noradrenergic and specific serotonergic antidepressant and has antidepressant, anxiolytic, hypnotic, antiemetic, orexigenic, and antihistamine effects...
, fluoxetine
Fluoxetine
Fluoxetine is an antidepressant of the selective serotonin reuptake inhibitor class. It is manufactured and marketed by Eli Lilly and Company...
, fluvoxamine
Fluvoxamine
Fluvoxamine is an antidepressant which functions as a selective serotonin reuptake inhibitor . Fluvoxamine was first approved by the U.S. Food and Drug Administration in 1993 for the treatment of obsessive compulsive disorder . Fluvoxamine CR is approved to treat social anxiety disorder...
and phenelzine
Phenelzine
Phenelzine is a non-selective and irreversible monoamine oxidase inhibitor of the hydrazine class which is used as an antidepressant and anxiolytic...
sulfate showed no effect. Omega-3 fatty acid
Omega-3 fatty acid
N−3 fatty acids are essential unsaturated fatty acids with a double bond starting after the third carbon atom from the end of the carbon chain....
may ameliorate suicidality and improve depression. The review warned that most trials have not been replicated, so the evidence is not strong, and the effect of long-term use has not been assessed.
Because of the weakness of the evidence and the potential for serious side effects from some drug therapies, the UK National Institute for Health and Clinical Excellence
National Institute for Health and Clinical Excellence
The National Institute for Health and Clinical Excellence is a special health authority of the English National Health Service , serving both English NHS and the Welsh NHS...
(NICE) 2009 clinical guideline for the treatment and management of BPD recommends: "Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder" but "drug treatment may be considered in the overall treatment of comorbid conditions," and suggests "review of the treatment of people with borderline personality disorder who do not have a diagnosed comorbid mental or physical illness and who are currently being prescribed drugs, with the aim of reducing and stopping unnecessary drug treatment."
Services
Individuals with BPD sometimes use mental health services extensively. They accounted for about 20 percent of psychiatric hospitalizations in one survey. The majority of BPD patients continue to use outpatient treatment in a sustained manner for several years, but the number using the more restrictive and costly forms of treatment, such as inpatient admission, declines with time. Experience of services varies. Assessing suicide risk can be a challenge for mental health services (and patients themselves tend to underestimate the lethality of self-injurious behaviours) with typically a chronically elevated risk of suicide much above that of the general population and a history of multiple attempts when in crisis.Prognosis
The American Psychiatric AssociationAmerican Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
states that recent advancements have led to treatments reaching an 86% remission rate 10 years after treatment.
Particular difficulties have been observed in the relationship between care providers and individuals diagnosed with BPD. A majority of psychiatric staff report finding individuals with BPD moderately to extremely difficult to work with, and more difficult than other client groups. Some clients feel a diagnosis is helpful, allowing them to understand they are not alone, and to connect with others who have BPD and who have developed helpful coping mechanisms. On the other hand, some with the diagnosis of BPD have reported that the term "BPD" felt like a pejorative
Pejorative
Pejoratives , including name slurs, are words or grammatical forms that connote negativity and express contempt or distaste. A term can be regarded as pejorative in some social groups but not in others, e.g., hacker is a term used for computer criminals as well as quick and clever computer experts...
label
Labeling theory
Labeling theory is closely related to interactionist and social construction theories. Labeling theory was developed by sociologists during the 1960's. Howard Saul Becker's book entitled Outsiders was extremely influential in the development of this theory and its rise to popularity...
rather than a helpful diagnosis, that self-destructive behaviour was incorrectly perceived as manipulative, and that they had limited access to care. Attempts are made to improve public and staff attitudes.
Epidemiology
The prevalencePrevalence
In epidemiology, the prevalence of a health-related state in a statistical population is defined as the total number of cases of the risk factor in the population at a given time, or the total number of cases in the population, divided by the number of individuals in the population...
of BPD in the general population ranges from 1 to 2 percent. The diagnosis appears to be several times more common in (especially young) women than in men, by as much as 3:1, according to the DSM-IV-TR, although the reasons for this are not clear.
The prevalence of BPD in the United States has been calculated as 1 percent to 3 percent of the adult population, with approximately 75 percent of those diagnosed being female. It has been found to account for 20 percent of psychiatric hospitalizations.
History
Since the earliest record of medical history, the coexistence of intense, divergent moods within an individual has been recognized by such writers as HomerHomer
In the Western classical tradition Homer , is the author of the Iliad and the Odyssey, and is revered as the greatest ancient Greek epic poet. These epics lie at the beginning of the Western canon of literature, and have had an enormous influence on the history of literature.When he lived is...
, Hippocrates
Hippocrates
Hippocrates of Cos or Hippokrates of Kos was an ancient Greek physician of the Age of Pericles , and is considered one of the most outstanding figures in the history of medicine...
and Aretaeus
Aretaeus of Cappadocia
Aretaeus , is one of the most celebrated of the ancient Greek physicians, of whose life, however, few particulars are known. There is some uncertainty regarding both his age and country, but it seems probable that he practised in the 1st century CE, during the reign of Nero or Vespasian...
, the last describing the vacillating presence of impulsive anger, melancholia and mania within a single person. After medieval suppression of the concept, it was revived by Swiss physician Théophile Bonet in 1684, who, using the term folie maniaco-mélancolique, noted the erratic and unstable moods with periodic highs and lows that rarely followed a regular course. His observations were followed by those of other writers who noted the same pattern, including writers such as the American psychiatrist C. Hughes in 1884 and J.C. Rosse in 1890, who described "borderline insanity". Kraepelin
Emil Kraepelin
Emil Kraepelin was a German psychiatrist. H.J. Eysenck's Encyclopedia of Psychology identifies him as the founder of modern scientific psychiatry, as well as of psychopharmacology and psychiatric genetics. Kraepelin believed the chief origin of psychiatric disease to be biological and genetic...
, in 1921, identified an "excitable personality" that closely parallels the borderline features outlined in the current concept of borderline.
Adolf Stern wrote the first significant psychoanalytic work to use the term "borderline" in 1938, referring to a group of patients with what was thought to be a mild form of schizophrenia
Schizophrenia
Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social...
, on the borderline between neurosis
Neurosis
Neurosis is a class of functional mental disorders involving distress but neither delusions nor hallucinations, whereby behavior is not outside socially acceptable norms. It is also known as psychoneurosis or neurotic disorder, and thus those suffering from it are said to be neurotic...
and psychosis
Psychosis
Psychosis means abnormal condition of the mind, and is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality"...
. For the next decade the term was in popular and colloquial use, a loosely conceived designation mostly used by theorists of the psychoanalytic and biological schools of thought. Increasingly, theorists who focused on the operation of social forces were recognized as well.
The 1960s and 1970s saw a shift from thinking of the borderline syndrome as borderline schizophrenia to thinking of it as a borderline affective disorder (mood disorder
Mood disorder
Mood disorder is the term designating a group of diagnoses in the Diagnostic and Statistical Manual of Mental Disorders classification system where a disturbance in the person's mood is hypothesized to be the main underlying feature...
), on the fringes of manic depression
Bipolar disorder
Bipolar disorder or bipolar affective disorder, historically known as manic–depressive disorder, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or...
, cyclothymia
Cyclothymia
Cyclothymia is a mood and mental disorder in the bipolar spectrum that causes both hypomanic and depressive episodes. It is defined medically within the bipolar spectrum and consists of recurrent disturbances between sudden hypomania and dysthymic episodes. The diagnosis of cyclothymic disorder is...
and dysthymia. In DSM-II, stressing the affective components, it was called cyclothymic personality (affective personality). In parallel to this evolution of the term "borderline" to refer to a distinct category of disorder, psychoanalysts such as Otto Kernberg were using it to refer to a broad spectrum
Spectrum disorder
A spectrum in psychiatry is a range of linked conditions, such that there is "not a unitary disorder but rather a syndrome composed of subgroups". The subgroups may be linked together by clinical appearance or by shared underlying causation...
of issues, describing an intermediate level of personality organization between neurotic and psychotic processes.
Standardized criteria were developed to distinguish BPD from affective disorders and other Axis I disorders, and BPD became a personality disorder diagnosis in 1980 with the publication of DSM-III
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
. The diagnosis was formulated predominantly in terms of mood and behavior, distinguished from sub-syndromal schizophrenia which was termed "Schizotypal personality disorder
Schizotypal personality disorder
Schizotypal personality disorder, or simply schizotypal disorder, is a personality disorder that is characterized by a need for social isolation, anxiety in social situations, odd behavior and thinking, and often unconventional beliefs.-Genetic:...
". The final terminology in use by the DSM today was decided by the DSM-IV Axis II Work Group of the American Psychiatric Association.
Film and television
Several films portraying characters either explicitly diagnosed or with traits strongly suggestive of mental illness have been the subject of discussion by certain psychiatrists and film experts. The films Play Misty for MePlay Misty for Me
Play Misty for Me is a 1971 American psychological thriller film, directed by and starring Clint Eastwood, in his directorial debut. Jessica Walter and Donna Mills co-star. The original music score was composed by Dee Barton.-Plot:...
and Fatal Attraction
Fatal Attraction
Fatal Attraction is a 1987 American thriller blended with horror, directed by Adrian Lyne and stars Michael Douglas, Glenn Close and Anne Archer. The film centers around a married man who has a weekend affair with a woman who refuses to allow it to end, resulting in emotional blackmail, stalking...
are two examples, as is the memoir Girl, Interrupted
Girl, Interrupted
Girl, Interrupted is a best-selling 1993 memoir by American author Susanna Kaysen, relating her experiences as a young woman in a psychiatric hospital in the 1960s after being diagnosed with borderline personality disorder...
by Susanna Kaysen
Susanna Kaysen
-Life:Susanna Kaysen was born and raised in Cambridge, Massachusetts. She is the daughter of economist Carl Kaysen, a professor at MIT and former advisor to President John F. Kennedy, and his wife Annette Neutra Kaysen. Kaysen has one sister and is divorced...
(and the movie
Girl, Interrupted (film)
Girl, Interrupted is a 1999 drama film about a teenager's 18-month stay at a mental institution, starring Winona Ryder, Brittany Murphy, Angelina Jolie, Whoopi Goldberg and Vanessa Redgrave, with Jolie winning an Academy Award for her performance....
based on it, with Winona Ryder
Winona Ryder
Winona Ryder is an American actress. She made her film debut in the 1986 film Lucas. Ryder's first significant role came in Tim Burton's Beetlejuice as a goth teenager, which won her critical and commercial recognition...
as Kaysen). Each of these films suggests the emotional instability of the disorder; however, the first two cases show a person more aggressive to others than to herself, which in fact is less typical. The 1992 film Single White Female
Single White Female
Single White Female is a 1992 American erotic thriller based on John Lutz's novel SWF Seeks Same. The film stars Bridget Fonda and Jennifer Jason Leigh and is directed by Barbet Schroeder.-Plot:...
suggests different aspects of the disorder: the character Hedy suffers from a markedly disturbed sense of identity and, as with the last two films, abandonment leads to drastic measures.
The character of Anakin Skywalker/Darth Vader
Darth Vader
Darth Vader is a central character in the Star Wars saga, appearing as one of the main antagonists in the original trilogy and as the main protagonist in the prequel trilogy....
in the Star Wars
Star Wars
Star Wars is an American epic space opera film series created by George Lucas. The first film in the series was originally released on May 25, 1977, under the title Star Wars, by 20th Century Fox, and became a worldwide pop culture phenomenon, followed by two sequels, released at three-year...
films has been "diagnosed" as having BPD. Psychiatrists Eric Bui and Rachel Rodgers have argued that the character meets six of the nine diagnostic criteria; Bui also found Anakin a useful example to explain BPD to medical students. In particular, Bui points to the character's abandonment issues, uncertainty over his identity and violent dissociative episodes. Other films attempting to depict characters with the disorder include The Crush, Malicious, Interiors
Interiors
Interiors is a 1978 drama film written and directed by Woody Allen. Featured performers are Kristin Griffith, Mary Beth Hurt, Richard Jordan, Diane Keaton, E. G. Marshall, Geraldine Page, Maureen Stapleton and Sam Waterston....
, Notes On a Scandal
Notes on a Scandal (film)
Notes on a Scandal is a 2006 British psychological thriller film, adapted from the 2003 novel of the same name by Zoë Heller. The screenplay was written by Patrick Marber and the film was directed by Richard Eyre. Many parts of the film were shot in Islington Arts and Media School...
, The Cable Guy
The Cable Guy
The Cable Guy is a 1996 black comedy film, directed by Ben Stiller, and starring Jim Carrey and Matthew Broderick. The film also features Leslie Mann, Jack Black, and Owen Wilson...
and Cracks
Cracks (film)
Cracks is an independent drama film starring Eva Green, Juno Temple, María Valverde, and Imogen Poots, which was released theatrically in the UK and Ireland on December 4, 2009...
. The film Borderline
Borderline (2008 film)
Borderline is a 2008 Canadian film directed by Lyne Charlebois and co-written with Marie-Sissi Labrèche, based on her novels Borderline and La Brèche...
, based on the book of the same name by Marie-Sissi Labrèche, attempts to explore BPD through its main character, Kiki.
Literature
The memoir Songs of Three Islands by Millicent Monks is a meditation on how BPD affects several generations of the wealthy Carnegie familyAndrew Carnegie
Andrew Carnegie was a Scottish-American industrialist, businessman, and entrepreneur who led the enormous expansion of the American steel industry in the late 19th century...
.
In Lois McMaster Bujold
Lois McMaster Bujold
Lois McMaster Bujold is an American author of science fiction and fantasy works. Bujold is one of the most acclaimed writers in her field, having won the prestigious Hugo Award for best novel four times, matching Robert A. Heinlein's record. Her novella The Mountains of Mourning won both the Hugo...
's science fiction novel Komarr, Tien Vorsoisson has BPD; his disorder drives a large part of the story.
Awareness
In early 2008, the United States House of RepresentativesUnited States House of Representatives
The United States House of Representatives is one of the two Houses of the United States Congress, the bicameral legislature which also includes the Senate.The composition and powers of the House are established in Article One of the Constitution...
declared the month of May as Borderline Personality Disorder Awareness Month.
Notable people
NFL Player Brandon MarshallBrandon Marshall
-2006:Before the regular season even began, Marshall suffered a slight tear to his PCL in a pre-season game against the Detroit Lions. Although the injury sidelined him for a couple of weeks, he was able to return and play 15 games during the regular season. Marshall had a total of 20 catches, 309...
was diagnosed with BPD.
Author Susanna Kaysen
Susanna Kaysen
-Life:Susanna Kaysen was born and raised in Cambridge, Massachusetts. She is the daughter of economist Carl Kaysen, a professor at MIT and former advisor to President John F. Kennedy, and his wife Annette Neutra Kaysen. Kaysen has one sister and is divorced...
was diagnosed with BPD, during her time at McLean Hospital
McLean Hospital
McLean Hospital is a psychiatric hospital in Belmont, Massachusetts.It is noted for its clinical staff expertise and ground-breaking neuroscience research...
. Her memoir Girl, Interrupted
Girl, Interrupted
Girl, Interrupted is a best-selling 1993 memoir by American author Susanna Kaysen, relating her experiences as a young woman in a psychiatric hospital in the 1960s after being diagnosed with borderline personality disorder...
chronicles her time at the hospital. The memoir was later adapted into a film starring Winona Ryder
Winona Ryder
Winona Ryder is an American actress. She made her film debut in the 1986 film Lucas. Ryder's first significant role came in Tim Burton's Beetlejuice as a goth teenager, which won her critical and commercial recognition...
as Susanna.
Gender
The diagnosis of BPD has been criticized from a feminist perspective. This is because some of the diagnostic criteria/symptoms of the disorder uphold common gender stereotypes about women. For example, the criteria of "a pattern of unstable personal relationships, unstable self-image, and instability of mood," can all be linked to the stereotype that women are "neither decisive nor constant". The question has also been raised of why women are three times more likely to be diagnosed with BPD than men. Some think that people with BPD commonly have a history of sexual abuseSexual abuse
Sexual abuse, also referred to as molestation, is the forcing of undesired sexual behavior by one person upon another. When that force is immediate, of short duration, or infrequent, it is called sexual assault. The offender is referred to as a sexual abuser or molester...
in childhood. One feminist critique suggests that BPD is a stigmatizing diagnosis that can sometimes evoke negative responses from health care providers, and additionally, that women who have survived sexual abuse in childhood are therefore sometimes re-traumatized by any such abusive mental health service.
Some feminist writers have suggested it would be better to give these women the diagnosis of a post-traumatic disorder as this would acknowledge their abuse, but others have argued that the use of the PTSD diagnosis merely medicalizes abuse rather than addressing the root causes in society. Women may be more likely to receive a personality disorder diagnosis if they reject the female role by being hostile, successful or sexually active; alternatively if a woman presents with psychiatric symptoms but does not conform to a traditional passive sick role
Sick role
Sick role is a term used in medical sociology concerning the social aspects of falling ill and the privileges and obligations that accompany it. It is a concept created by American sociologist Talcott Parsons in 1951.-Concept:...
, she may be labelled as a "difficult" patient and given the stigmatizing diagnosis of BPD.
Stigma
The features of BPD include emotional instability, intense unstable interpersonal relationships, a need for relatedness and a fear of rejection. As a result, people with BPD often evoke intense emotions in those around them. Pejorative terms to describe persons with BPD such as “difficult,” “treatment resistant,” “manipulative,” “demanding” and “attention seekingAttention seeking
Enjoying the attention of others is quite socially acceptable. In some instances, however, the need for attention can lead to difficulties. The term attention seeking is generally reserved for such situations where excessive and "inappropriate attention seeking" is seen.-Styles:The following...
" are often used, and may become a self-fulfilling prophecy as the clinician's negative response triggers further self-destructive behaviour. In psychoanalytic theory, this stigmatization may be thought to reflect countertransference
Countertransference
Countertransferenceis defined as redirection of a psychotherapist's feelings toward a client—or, more generally, as a therapist's emotional entanglement with a client.-Early formulations:...
(when a therapist projects their own feelings on to a client), as people with BPD are prone to use defense mechanisms such as splitting
Splitting (psychology)
Splitting may mean two things: splitting of the mind, and splitting of mental concepts . The latter is thinking purely in extremes Splitting (also called all-or-nothing thinking in cognitive distortion) may mean two things: splitting of the mind, and splitting of mental concepts (or black and...
and projective identification
Projective identification
Projective Identification is 'a term first used by Melanie Klein to describe a process whereby parts of the ego are thought of as forced into another person who is then expected to become identified with whatever has been projected'....
. Thus the diagnosis "often says more about the clinician's negative reaction to the patient than it does about the patient ... as an expression of counter transference hate, borderline explains away the breakdown in empathy
Empathy
Empathy is the capacity to recognize and, to some extent, share feelings that are being experienced by another sapient or semi-sapient being. Someone may need to have a certain amount of empathy before they are able to feel compassion. The English word was coined in 1909 by E.B...
between the therapist and the patient and becomes an institutional epithet in the guise of pseudoscientific jargon" (Aronson, p 217).
This inadvertent counter transference can give rise to inappropriate clinical responses including excessive use of medication, inappropriate mothering and punitive use of limit setting and interpretation. People with BPD are seen as among the most challenging groups of patients, requiring a high degree of skill and training in the psychiatrists, therapists and nurses involved in their treatment. While some clinicians agree with the diagnosis under the name "borderline personality disorder", some would like the name to be changed. One critique says that some who are labeled
Labeling theory
Labeling theory is closely related to interactionist and social construction theories. Labeling theory was developed by sociologists during the 1960's. Howard Saul Becker's book entitled Outsiders was extremely influential in the development of this theory and its rise to popularity...
"Borderline Personality Disorder" feel this name is unhelpful, stigmatizing, and/or inaccurate.
The Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigns to change the name and designation of BPD in DSM-5
DSM-5
The next edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders , commonly called DSM-5 , is currently in consultation, planning and preparation...
. The paper How Advocacy is Bringing BPD into the Light reports that "the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma...".
Terminology
Because of the above concerns, and because of a move away from the original theoretical basis for the term (see history), there is ongoing debate about renaming BPD. Alternative suggestions for names include emotional regulation disorder or emotional dysregulationEmotional dysregulation
Emotional dysregulation is a term used in the mental health community to refer to an emotional response that is poorly modulated, and does not fall within the conventionally accepted range of emotive response...
disorder. Impulse disorder and interpersonal regulatory disorder are other valid alternatives, according to John Gunderson of McLean Hospital
McLean Hospital
McLean Hospital is a psychiatric hospital in Belmont, Massachusetts.It is noted for its clinical staff expertise and ground-breaking neuroscience research...
in the United States. Another term (for example, by psychiatrist Carolyn Quadrio) is post traumatic personality disorganization (PTPD), reflecting the condition's status as (often) both a form of chronic post traumatic stress disorder (PTSD) and a personality disorder
Personality disorder
Personality disorders, formerly referred to as character disorders, are a class of personality types and behaviors. Personality disorders are noted on Axis II of the Diagnostic and Statistical Manual of Mental Disorders or DSM-IV-TR of the American Psychiatric Association.Personality disorders are...
in the belief that it is a common outcome of developmental or attachment trauma. Some people do not report any kind of traumatic event.
Further reading
- Bockian, Neil R. et al. New Hope for People with Borderline Personality Disorder: Your Friendly, Authoritative Guide to the Latest in Traditional and Complementary Solutions ISBN 978-0-7615-2572-1
- Chapman, Alex & Gratz, Kim The Borderline Personality Disorder Survival Guide (2007)
- Jensen, Joy A. Putting The Pieces Together: A Practical Guide to Recovery from Borderline Personality Disorder ISBN 978-0-9667037-6-4
- Kreger, Randi The Essential Family Guide to Borderline Personality Disorder: New Tools and Techniques to Stop Walking on Eggshells (2008)
- Kreisman, Jerold J. and Strauss, Hal. I Hate You, Don't Leave Me: Understanding the Borderline Personality (1991) ISBN 978-0-380-71305-9
- Linehan, Marsha M.Marsha M. LinehanMarsha M. Linehan is an American psychologist and author. Linehan is a Professor of Psychology, Adjunct Professor of Psychiatry and BehavioralSciences at the University of Washington and Director of the Behavioral Research and TherapyClinics...
, Skills training manual for treating borderline personality disorder New York ; London : Guilford Press, (1993.) ISBN 978-0-89862-034-4 - Mason, Paul T. & Kreger, Randi Stop Walking on Eggshells: Taking Your Life Back When Someone You Care About Has Borderline Personality Disorder (1998)
- Moskovitz, Richard A. Lost in the Mirror: An Inside Look at Borderline Personality Disorder (2001) ISBN 978-0-87833-266-3
- Petrovic, Nick. The 3D Society (2004)
- Reiland, Rachel. Get Me Out Of Here: My Recovery from Borderline Personality Disorder (2004) ISBN 978-1-59285-099-0
- Oakley, Barbara. Evil Genes (2008) PROMETHEUS BOOKS ISBN 978-1591026655