Borderline personality disorder (BPD), also known as emotionally unstable personality disorder - impulsive or borderline type or emotional intensity disorder, is a cluster-B personality disorder. The essential features include a pattern of impulsivity and instability of behaviors, interpersonal relationships, and self-image. The pattern is present by early adulthood and occurs across a variety of situations and contexts.[1]
Other symptoms usually include intense fears of abandonment, intense anger, and irritability, the reason for which others have difficulty understanding.[1][2] People with BPD often engage in idealization and devaluation of others, alternating between high positive regard and great disappointment. [3] Self-harm, suicidal behavior, and substance abuse are common.[4]
The disorder is recognized in the Diagnostic and Statistical Manual of Mental Disorders. Because a personality disorder is a pervasive, enduring, and inflexible pattern of maladaptive inner experiences and pathological behavior, there is a general reluctance to diagnose personality disorders before adolescence or early adulthood.[5] However, some emphasize that without early treatment the symptoms may worsen.[6]
There is an ongoing debate about the terminology of this disorder, especially the suitability of the word "borderline".[7][8]The ICD-10 manual refers to the disorder as Emotionally unstable personality disorder and has similar diagnostic criteria. In the DSM-5, the name of the disorder remains the same as in previous editions.
Signs and symptoms[edit]
Symptoms include:
- Splitting
- Chaos in relationships
- Markedly disturbed sense of identity
- Intense or uncontrollable emotional triggers
- Unstable interpersonal relationships and self-esteem
- Concerns about abandonment
- Self-damaging behavior
- Impulsivity
- Frequently accompanied by depression, anxiety, anger, substance abuse or rage
The most distinguishing symptoms of BPD are marked sensitivity to rejection, negative criticism, and thoughts and fears of possible abandonment.[9] Overall, the features of BPD include unusually intense sensitivity in relationships with others, difficulty regulating emotions, and impulsivity. Other symptoms may include feeling unsure of one's personal identity and values, having paranoid thoughts when feeling stressed, and severe dissociation.[9]
Emotions[edit]
People with BPD feel emotions more easily, more deeply, and longer than others do.[10][11] Emotions may repeatedly resurge and persist a long time.[11]Consequently, it may take longer than normal for people with BPD to return to a stable emotional baseline following an intense emotional experience.[12]
In Marsha Linehan's view, the sensitivity, intensity, and duration with which people with BPD feel emotions have both positive and negative effects.[12] People with BPD are often exceptionally enthusiastic, idealistic, joyful, and loving.[13] However, they may feel overwhelmed by negative emotions, experiencing intense griefinstead of sadness, shame and humiliation instead of mild embarrassment, rage instead of annoyance, and panic instead of nervousness.[13] People with BPD are especially sensitive to feelings of rejection, criticism, isolation, and perceived failure.[14] Before learning other coping mechanisms, their efforts to manage or escape from their intense negative emotions may lead to self-injury or suicidal behavior.[15] They are often aware of the intensity of their negative emotional reactions and, since they cannot regulate them, they shut them down entirely.[12] This can be harmful to people with BPD, since negative emotions alert people to the presence of a problematic situation and move them to address it.[12]
While people with BPD feel joy intensely, they are especially prone to dysphoria, or feelings of mental and emotional distress. Zanarini et al recognized four categories of dysphoria that are typical of this condition: extreme emotions, destructiveness or self-destructiveness, feeling fragmented or lacking identity, and feelings of victimization.[16] Within these categories, a BPD diagnosis is strongly associated with a combination of three specific states: feeling betrayed, "feeling like hurting myself", and feeling out of control.[16] Since there is great variety in the types of dysphoria experienced by people with BPD, the amplitude of the distress is a helpful indicator of borderline personality disorder.[16]
In addition to intense emotions, people with BPD experience emotional lability, or changeability. Although the term suggests rapid changes between depression and elation, the mood swings in people with this condition actually occur more frequently between anger and anxiety and between depression and anxiety.[17]
Behavior[edit]
Impulsive behavior is common, including substance or alcohol abuse, eating disorders, unprotected sex or indiscriminate sex with multiple partners, reckless spending, and reckless driving.[18] Impulsive behavior may also include leaving jobs or relationships, running away, and self-injury.[19]
People with BPD act impulsively because it gives them immediate relief from their emotional pain.[19] However, in the long term, people with BPD suffer increased pain from the shame and guilt that follow such actions.[19] A cycle often begins in which people with BPD feel emotional pain, engage in impulsive behavior to relieve that pain, feel shame and guilt over their actions, feel emotional pain from the shame and guilt, and then experience stronger urges to engage in impulsive behavior to relieve the new pain.[19] As time goes on, impulsive behavior may become an automatic response to emotional pain.[19]
Self-harm and suicide[edit]
Self-harming or suicidal behavior is one of the core diagnostic criteria in the DSM IV-TR. Management of and recovery from this behavior can be complex and challenging.[20] The lifetime risk of suicide among people with BPD is between 3% and 10%.[9][21] There is evidence that men diagnosed with BPD are approximately twice as likely to commit suicide as women diagnosed with BPD.[22] There is also evidence that a considerable percentage of men who commit suicide may have undiagnosed BPD.[23]
Self-injury is common and may take place with or without suicidal intent.[24][25] The reported reasons for non-suicidal self-injury (NSSI) differ from the reasons for suicide attempts.[15] Reasons for NSSI include expressing anger, self-punishment, generating normal feelings (often in response to dissociation), and distracting oneself from emotional pain or difficult circumstances.[15] In contrast, suicide attempts typically reflect a belief that others will be better off following the suicide.[15]Both suicidal and non-suicidal self-injury are a response to feeling negative emotions.[15]
Sexual abuse can be a particular trigger for suicidal behavior in adolescents with BPD tendencies.[26][quantify]
Interpersonal relationships[edit]
People with BPD can be very sensitive to the way others treat them, feeling intense joy and gratitude at perceived expressions of kindness, and intense sadness or anger at perceived criticism or hurtfulness.[27] Their feelings about others often shift from positive to negative after a disappointment, a perceived threat of losing someone, or a perceived loss of esteem in the eyes of someone they value. This phenomenon, sometimes called splitting or black-and-white thinking, includes a shift from idealizing others (feeling admiration and love) to devaluing them (feeling anger or dislike).[28] Combined with mood disturbances, idealization and devaluation can undermine relationships with family, friends, and co-workers.[29] Self-image can also change rapidly from positive to negative.
While strongly desiring intimacy, people with BPD tend toward insecure, avoidant or ambivalent, or fearfully preoccupied attachment patterns in relationships,[30] and they often view the world as dangerous and malevolent.[27] BPD is linked to increased levels of chronic stress and conflict in romantic relationships, decreased satisfaction of romantic partners, abuse, and unwanted pregnancy. However, these factors appear to be linked to personality disorders in general.[31]
Manipulation to obtain nurturance is considered to be a common feature of BPD by many who treat the disorder, as well as by the DSM-IV.[32][33] However, somemental health professionals caution that an overemphasis on, and an overly broad definition of, manipulation can lead to misunderstanding and prejudicial treatment of people with BPD within the health care system.[34] (See Manipulative behavior and Stigma under Controversies.)
Sense of self[edit]
People with BPD tend to have trouble seeing a clear picture of their identity. In particular, they tend to have difficulty knowing what they value, believe, prefer, and enjoy.[35] They are often unsure about their long-term goals for relationships and jobs. This difficulty with knowing who they are and what they value can cause people with BPD to experience feeling "empty" and "lost".[35]
Cognitions[edit]
The often intense emotions experienced by people with BPD can make it difficult for them to control the focus of their attention—to concentrate.[35] In addition, people with BPD may tend to dissociate, which can be thought of as an intense form of "zoning out".[36] Dissociation often occurs in response to experiencing a painful event (or experiencing something that triggers the memory of a painful event). It involves the mind automatically redirecting attention away from that event, presumably to protect against experiencing intense emotion and unwanted behavioral impulses that such emotion might otherwise trigger.[36] Although the mind's habit of blocking out intense painful emotions may provide temporary relief, it can also have the unwanted side effect of blocking or blunting the experience of ordinary emotions, reducing the access of people with BPD to the information contained in those emotions, which helps guide effective decision-making in daily life.[36] Sometimes, it is possible for another person to tell when someone with BPD is dissociating, because their facial or vocal expressions may become flat or expressionless, or they may appear to be distracted; at other times, dissociation may be barely noticeable.[36]
Causes[edit]
As is the case with other mental disorders, the causes of BPD are complex and not fully agreed upon.[8] Evidence suggests that BPD and post-traumatic stress disorder (PTSD) may be related in some way.[37] Most researchers agree that a history of childhood trauma can be a contributing factor,[38] but less attention has historically been paid to investigating the causal roles played by congenital brain abnormalities, genetics, neurobiological factors, and environmental factors other than trauma.[8][39] Social factors include how people interact in their early development with their family, friends, and other children.[40] Psychological factors include the individual's personality and temperament, shaped by his or her environment and learned coping skills that deal with stress.[40] These different factors together suggest that there are multiple factors that may contribute to the disorder.
Genetics[edit]
The heritability of BPD is estimated to be 65%.[41] That is, 65 percent of the variability in liability underlying BPD in the population can be explained by genetic differences. (Note that this is different from saying that 65 percent of BPD is "caused" by genes.) Twin studies may overestimate the effect of genes on variability in personality disorders due to the complicating factor of a shared family environment.[42]
Twin, sibling, and other family studies indicate partial heritability for impulsive aggression, but studies of serotonin-related genes have suggested only modest contributions to behavior.[43]
Families with twins in the Netherlands were participants of an ongoing study by Trull and colleagues, in which 711 pairs of siblings and 561 parents were examined to identify the location of genetic traits that influenced the development of BPD.[44] Research collaborators found that genetic material on chromosome nine was linked to BPD features.[44] Studies conclude that 42 percent of variation in BPD features was attributable to genetic influences and 58 percent was attributable to environmental influences.[44]
Genes currently under investigation include the 7-repeat polymorphism of the dopamine D4 receptor (DRD4), which has been linked to disorganized attachment, whilst the combined effect of the 7-repeat polymorphism and the 10/10 dopamine transporter (DAT) genotype has been linked to abnormalities in inhibitory control, both noted features of BPD.[45]
Brain abnormalities[edit]
A number of neuroimaging studies in BPD have reported findings of reductions in regions of the brain involved in the regulation of stress responses and emotion, affecting the hippocampus, the orbitofrontal cortex, and the amygdala, amongst other areas.[45] A smaller number of studies have used magnetic resonance spectroscopy to explore changes in the concentrations of neurometabolites in certain brain regions of BPD patients, looking specifically at neurometabolites such as N-acetylaspartate, creatine, glutamate-related compounds, and choline-containing compounds.[45]
Hippocampus[edit]
The hippocampus tends to be smaller in people with BPD, as it is in people with post-traumatic stress disorder (PTSD). However, in BPD, unlike PTSD, theamygdala also tends to be smaller.[46]
Amygdala[edit]
The amygdalas are smaller and more active in people with BPD.[46] Decreased amygdala volume has also been found in people with obsessive-compulsive disorder.[47] One study has found unusually strong activity in the left amygdalas of people with BPD when they experience and view displays of negative emotions.[48] Since the amygdalas generate all emotions (including "negative" ones), this unusually strong activity may explain the unusual strength and longevity of fear, sadness, anger, and shame experienced by people with BPD, as well as their heightened sensitivity to displays of these emotions in others.[46]
Prefrontal cortex[edit]
The prefrontal cortex tends to be less active in people with BPD, especially when recalling memories of abandonment.[49] This relative inactivity occurs in the rightanterior cingulate (areas 24 and 32).[49] Given its role in regulating emotional arousal, the relative inactivity of the prefrontal cortex might explain the difficulties people with BPD experience in regulating their emotions and responses to stress.[50]
Hypothalamic-pituitary-adrenal axis[edit]
The hypothalamic-pituitary-adrenal axis (HPA axis) regulates cortisol production, which is released in response to stress. Cortisol production tends to be elevated in people with BPD, indicating a hyperactive HPA axis in these individuals.[51] This causes them to experience a greater biological stress response, which might explain their greater vulnerability to irritability.[52] Since traumatic events can increase cortisol production and HPA axis activity, one possibility is that the prevalence of higher than average activity in the HPA axis of people with BPD may simply be a reflection of the higher than average prevalence of traumatic childhood and maturational events among people with BPD.[52] Another possibility is that, by heightening their sensitivity to stressful events, increased cortisol production may predispose those with BPD to experience stressful childhood and maturational events as traumatic.
Increased cortisol production is also associated with an increased risk of suicidal behavior.[53]
Neurobiological factors[edit]
Estrogen[edit]
Individual differences in women's estrogen cycles may be related to the expression of BPD symptoms in female patients.[54] A 2003 study found that women's BPD symptoms were predicted by changes in estrogen levels throughout their menstrual cycles, an effect that remained significant when the results were controlled for a general increase in negative affect.[55]
Symptoms experienced due to disturbed levels of estrogen are often misdiagnosed as BPD, like extreme mood swings and depression. As endometriosis is an estrogen responsive disease, severe PMS and PMDD symptoms are observed, that are both physical and psychological in nature. Hormone-responsive mood disorders also known as reproductive depression are seen to cease only after menopause or hysterectomy. Psychotic episodes treated with estrogen in women with BPD show considerable improvement but must not be prescribed to those with endometriosis as it worsens their endocrine condition. Mood-stabilizing drugs used for bipolar disorder do not help patients with disturbed estrogen levels. A correct diagnosis between an endocrine disorder and a psychiatric disorder must be made.[citation needed]
Developmental factors[edit]
Childhood trauma[edit]
There is a strong correlation between child abuse, especially child sexual abuse, and development of BPD.[38][56][57][58][59] Many individuals with BPD report a history of abuse and neglect as young children.[60] 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. They also report a high incidence of incest and loss of caregivers in early childhood.[61]
Individuals with BPD were also likely to report having caregivers of both sexes deny the validity of their thoughts and feelings. Caregivers were also reported to have failed to provide needed protection and to have 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.[61] Additionally, women with BPD who reported a previous history of neglect by a female caregiver and abuse by a male caregiver were significantly more likely to experience sexual abuse by a non-caregiver.[61]
It has been suggested that children who experience chronic early maltreatment and attachment difficulties may go on to develop borderline personality disorder.[62]
However, none of these studies provide evidence that childhood trauma necessarily causes or contributes to causing BPD. Rather, both the trauma and the BPD could be caused by a third factor.[citation needed] For example, it could be that many caregivers who tend to expose children to traumatic experiences do so partly because of their own heritable personality disorders, the genetic predisposition for which they may pass on to their children, who develop BPD as a result of that predisposition and other factors, and not as a result of prior mistreatment.[63]
Writing in the psychoanalytic tradition, Otto Kernberg argues that a child's failure to achieve the developmental task of psychic clarification of self and other and failure to overcome splitting might increase the risk of developing a borderline personality.[64]
A child's inability to tolerate delayed gratification at age 4 does not predict later development of BPD.[65]
Neurological patterns[edit]
The intensity and reactivity of a person's negative affectivity, or tendency to feel negative emotions, predicts BPD symptoms more strongly than does childhood sexual abuse.[66] This finding, differences in brain structure (see Brain abnormalities), and the fact that some patients with BPD do not report a traumatic history,[67]suggest that BPD is distinct from the post-traumatic stress disorder, which frequently accompanies it. Thus, researchers examine developmental causes in addition to childhood trauma.
Newer research published in January 2013 from Dr. Anthony Ruocco at the University of Toronto has highlighted two patterns of brain activity that may underlie the dysregulation of emotion indicated in this disorder: There has been described, increased activity in the brain circuits responsible for the experience of heightened negative emotions, coupled with reduced activation of the brain circuits that normally regulate or suppress these generated negative emotions. These two neural networks are seen to be dysfunctionally operative in the frontolimbic regions, but the specific regions vary widely in individuals, which calls for the analysis of more neuroimaging studies. Also, differing from earlier studies, sufferers of BPD showed less activation in the amygdala in situations of increased negative emotionality than the control group. Dr. John Krystal, Editor of Biological Psychiatry, added that, "This new report adds to the impression that people with borderline personality disorder are 'set-up' by their brains to have stormy emotional lives, although not necessarily unhappy or unproductive lives".[68]
Mediating and moderating factors[edit]
Executive function[edit]
While high rejection sensitivity is associated with stronger symptoms of borderline personality disorder, executive function appears to mediate the relationship between rejection sensitivity and BPD symptoms.[65] That is, a group of cognitive processes that include planning, working memory, attention, and problem-solving might be the mechanism through which rejection sensitivity impacts BPD symptoms. A 2008 study found that the relationship between a person's rejection sensitivity and BPD symptoms was stronger when executive function was lower and that the relationship was weaker when executive function was higher.[65] This suggests that high executive function might help protect people with high rejection sensitivity against symptoms of BPD.[65]
A 2012 study found that problems in working memory might contribute to greater impulsivity in people with BPD.[69]
Family environment[edit]
Family environment mediates the effect of child sexual abuse on the development of BPD. An unstable family environment predicts the development of the disorder, while a stable family environment predicts a lower risk. One possible explanation is that a stable environment buffers against its development.[70]
Self-complexity[edit]
Self-complexity, or considering one's self to have many different characteristics, appears to moderate the relationship between Actual-Ideal self-discrepancy and the development of BPD symptoms. That is, for individuals who believe that their actual characteristics do not match the characteristics that they hope to acquire, high self-complexity reduces the impact of their conflicted self-image on BPD symptoms. However, self-complexity does not moderate the relationship between Actual-Ought self-discrepancy and the development of BPD symptoms. That is, for individuals who believe that their actual characteristics do not match the characteristics that they should already have, high self-complexity does not reduce the impact of their conflicted self-image on BPD symptoms. The protective role of self-complexity in Actual-Ideal self-discrepancy, but not in Actual-Ought self-discrepancy, suggests that the impact of conflicted or unstable self-image in BPD depends on whether the individual views self in terms of characteristics that they hope to acquire, or in terms of characteristics that they should already have acquired.[71]
Thought suppression[edit]
A 2005 study found that thought suppression, or conscious attempts to avoid thinking certain thoughts, mediates the relationship between emotional vulnerabilityand BPD symptoms.[66] A later study found that the relationship between emotional vulnerability and BPD symptoms is not necessarily mediated by thought suppression. However, this study did find that thought suppression mediates the relationship between an invalidating environment and BPD symptoms.[72]
Diagnosis[edit]
Diagnosis of borderline personality disorder is based on a clinical assessment by a qualified mental health professional. The best method is to present the criteria of the disorder to patients and to ask them if they feel that these characteristics accurately describe them.[9] Actively involving patients with BPD in determining their diagnosis can help them become more willing to accept it.[9] Although some clinicians prefer not to tell patients with BPD what their diagnosis is, either from concern about the stigma attached to this condition or because BPD used to be considered untreatable, it is usually helpful for patients with BPD to know their diagnosis.[9]This helps them know that others have had similar experiences and can point them toward effective treatments.[9]
In general, the psychological evaluation includes asking the patient about the beginning and severity of symptoms, as well as other questions about how symptoms impact the patient's quality of life. Issues of particular note are suicidal ideations, experiences with self-harm, and thoughts about harming others.[73] Diagnosis is based both on the patient's report of his or her symptoms and on the clinician's own observations.[73] Additional tests for BPD can include a physical exam and laboratory tests to rule out other possible triggers for symptoms, such as thyroid conditions or substance abuse.[73]
Diagnostic and Statistical Manual[edit]
The Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) has removed the multiaxial system. Consequently, all disorders, including personality disorders, are listed in Section II of the manual. A person must meet 5 of 9 criteria to receive a diagnosis of borderline personality disorder.[74] The DSM-5
