Borderline personality disorder (BPD)

TYPE OF PSYCHOLOGY: Personality; psychopathology

Borderline personality disorder is characterized by a longstanding pattern of instability in mood and interpersonal relationships. It is the most prevalent personality disorder—modest estimations suggest 1.6 percent of the population of the United States is affected—and has been the focus of significant research.

Introduction

Borderline personality disorder (BPD) is a psychological condition characterized by oversensitivity, fear of abandonment, and chronic instability in mood and interpersonal relationships. BPD is classified in section III in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders: DSM-5-TR (2022), which implies that the disorder is the result of permanent traits (such as personality) and requires sustained treatment. The personality disorder did not appear until the manual’s third edition in 1980. The term “borderline” was used to refer to people who, it was believed, displayed behaviors that fell on the borderline between neurosis and psychosis. The term for the condition has remained despite it not describing the disorder very well. Over the years, the term has come to refer to a collection of symptoms that constitute an unstable personality structure and difficulty in regulating emotions.

According to the DSM-5, BPD is characterized by a longstanding pattern of instability in mood and relationships. To be classified as having borderline personality disorder, a patient must exhibit the following diagnostic criteria: impaired self-function (e.g., problem with self-image, chronic feelings of emptiness or worthlessness) or self-direction (e.g., unstable goals, aspirations, values, etc.), and diminished capacity for empathy or for intimacy (characterized by frequent, intense, unstable relationships with others; vacillating between devaluing and overidealizing significant people in his or her life; and efforts to avoid abandonment). People with BPD typically experience or exhibit frequent, extreme mood changes and disproportionate emotions; fears of rejection, separation, and paradoxically, excessive dependency; depressive feelings; suicidal thoughts and behavior; impulsivity and unnecessary risk taking; and hostility or irritability. BPD's characteristic intense fear of abandonment is commonly reflected in impulsive, damaging behavior, such as drug or alcohol abuse, promiscuity, binge eating, or overspending. Many people with BPD also engage in self-mutilating behaviors, such as self-inflicted cigarette burns or self-inflicted cutting or stabbing; although self-mutilation was formerly seen as inherent almost exclusively to those with BPD, the DSM-5 recognizes it as its own psychiatric problem independent of, albeit often coincidental with, BPD. People with BPD will often report that they self-mutilate because of these chronic feelings of emptiness in an effort to feel something. People with BPD frequently engage in conflict with others. Symptoms begin by early adulthood and tend to be persistent.

A number of studies conducted by the early 2020s found that roughly 1.6 of the US population had BPD, although other estimates placed its prevalence at 2 to 4 percent. Data published in 2019 and reported by the United States National Institutes of Health (NIH) suggested that as many as 10 percent of people with BPD die by suicide, although as many as 80 percent of people with BPD may exhibit suicidal behaviors.

Causes

A great deal of research has focused on the possible causes of BPD. Although legitimate causes are still the source of research, there are certain predetermined factors that make someone more susceptible to BPD. Often, mood disorders such as anxiety or depression coincide with BPD. Data published in 2023 by the NIH suggested that as many as 96 percent of those with BPD also meet the criteria for another mental health condition, including disorders related to mood, impulse control, and/or substance abuse. Other personality disorders, such as antisocial personality disorder (APSD), histrionic personality disorder (HPD), and narcissistic personality disorder (NPD), are also associated with the disorder. People with BPD, in their stressful states, also exhibit symptoms of and therefore be misdiagnosed with paranoid schizophrenia. While women have historically been diagnosed with BPD more often than men have, this has often been the result of confusion with other, coexisting psychiatric conditions in men. Many researchers have suggested that the prevalence of BPD is in fact equal across the gender spectrum. Research has not determined that race or education are predispositions for BPD. The diathesis-stress model examines how the effects of stress, combined with a diathesis, or genetic vulnerability to develop a psychological disorder, may instigate the development of BPD. The underlying personality traits of BPD, such as impulsivity and emotional instability, are inheritable. According to the diathesis-stress model, a person with these personality traits, combined with ineffective means of managing stress, may be at greater risk of developing BPD. Certain hereditary genes, such as those that lead to mood instability, could imply that the disorder is genetic. An irregular level of the neurotransmitter serotonin, which is linked to depression, has also been found in those with BPD. Other researchers have explored the role of the limbic system in people with BPD. The limbic system is the part of the brain associated with the regulation of emotional responses.

Research indicates that people with BPD report a history of one or more traumatic life events during childhood, such as physical or sexual abuse or neglect or separation from parents. Individuals who report sexual abuse, separation from or early loss of a parental figure, verbal and emotional abuse, and family chaos during childhood are more prone to developing BPD.

Treatment

Treatment for BPD is a challenging issue. The “cure” requires extended treatment and involves a significant change in behavior for the patient. People who have personality disorders such as BPD lack the insight that the dysfunction of their personality is the source of impairment. Many with BPD, therefore, may never seek treatment. When a person with BPD does seek treatment, it is usually for a reason other than their BPD. There is a high risk that the BPD patient will end treatment prematurely because of their difficulties with relationships and emotional functioning. When a person with BPD does engage in psychotherapy, the individual can be a challenge to a therapist—those with BPD can exhibit elements of the disorder in treatment, such as fear of abandonment or neediness.

American psychologist Marsha M. Linehan developed a treatment program called dialectical behavioral therapy, or DBT, to treat BPD patients. Dialectical behavioral therapy involves a combination of cognitive, behavioral, and Zen principles to develop a balance between acceptance and change. Dialectical behavioral therapy focuses on helping patients develop tools to solve problems, regulate their emotions, reframe suicidal or destructive behaviors, and become more mindful of themselves and others. Linehan’s therapy emphasizes the importance of the patient-therapist relationship in establishing progress. Linehan’s treatment model has gained widespread attention and has been implemented in treatment programs worldwide. Dialectical behavioral therapy can be used in both individual therapy and group therapy. Individual therapy using the dialectical behavioral therapy model focuses on six core areas: suicidal behaviors, behaviors that are counterproductive to the therapy process, behaviors that compromise the quality of life, the development of behavioral skills, post-traumatic stress behavior, and self-respecting behaviors. Individual therapy with the BPD patient can be very stressful. The therapist needs to set clear limits with the BPD patient and to be consistent in abiding by those limits, as these patients are characteristically manipulative and emotionally demanding.

Cognitive-behavioral therapies for BPD are grounded in the belief that these patients have distorted and self-defeating thinking patterns, or schemas, which include themes about abandonment, mistrust, low self-worth, and guilt. University of Pennsylvania psychiatrist Aaron T. Beck stated that dichotomous thinking (black-and-white thinking) is an essential problem among borderline patients and results in the extreme emotional responses that they display.

Other types of psychotherapy used for BPD treatment include mentalization-based therapy, which helps patients sort out thoughts as their own or others' and improve impulse control; schema therapy, which focuses on recognizing and modifying patterns of thought and behavior; and transference-focused psychotherapy, a psychodynamic approach in which the evolving client-therapist relationship serves as a model for the patient's other relationships.

Psychopharmacological therapy involves a combination of therapy and medication in treating BPD. Certain antidepressant medications (selective serotonin reuptake inhibitors, or SSRIs) have been effective in alleviating some of the symptoms of depression in BPD. Antianxiety and antipsychotic drugs have also been used in treatment.

Bibliography

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Insel, Thomas. "What's in a Name? The Outlook for Borderline Personality Disorder." National Institute of Mental Health. National Institutes of Health, US Dept. of Health and Human Services, 19 Apr. 2010. Web. 24 Feb. 2014.

Kreisman, Jerold J., and Hal Straus. I Hate You, Don’t Leave Me: Understanding the Borderline Personality. Rev. ed. New York: Penguin, 2010.

LeWine, Howard E. "Borderline Personality Disorder." Harvard Health Publishing, 20 Jan. 2023, www.health.harvard.edu/a‗to‗z/borderline-personality-disorder-a-to-z. Accessed 24 Jul. 2024.

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