Borderline personality disorder

Borderline personality disorder
Specialty	Psychiatry, clinical psychology

Borderline Personality Disorder (BPD) is a psychiatric diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV Personality Disorders 301.83) that describes a prolonged disturbance of personality function characterized by depth and variability of moods. The disorder typically involves unusual levels of instability in mood; "black and white" thinking, or "splitting"; chaotic and unstable interpersonal relationships, 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. These disturbances can have a pervasive negative impact on many or all of the psychosocial facets of life. This includes difficulties maintaining relationships in work, home, and social settings. Attempted suicide and completed suicide are possible outcomes, especially without proper care and effective therapy. 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 psychotherapy, although medication and other approaches may also improve symptoms. 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.

As with other mental disorders, the causes of BPD are complex and unknown. One finding is a history of childhood trauma (possibly child sexual abuse), although researchers have suggested diverse possible causes, such as a genetic predisposition, neurobiological factors, environmental factors or brain abnormalities. The prevalence of BPD in the United States has been calculated as 1 to 3 percent of the adult population, with approximately 75% of those diagnosed being female, 25% male. It has been found to account for 20 percent of psychiatric hospitalizations. Common comorbid (co-occurring) conditions are other mental disorders such as substance abuse, depression and other mood disorders, and other personality disorders. BPD is one of four diagnoses classified as "cluster B" ("dramatic-erratic") personality disorders typified by disturbances in impulse control and emotional dysregulation, the others being narcissistic, histrionic, and antisocial personality disorders.

The term borderline, although it was used in this context as early as the 17th century, was employed by Adolph Stern in 1938 to describe a condition as being on the borderline between neurosis and psychosis. Because the term no longer reflects current thinking, there is an ongoing debate concerning whether this disorder should be renamed. There is related concern that the diagnosis stigmatizes people, usually women, and supports pejorative and discriminatory practices.

Persons suffering from borderline personality disorder and their families often feel the hardships are compounded due to lack of clear diagnoses, effective treatments and accurate information. At their request, the US House of Representatives unanimously declared the month of May as Borderline Personality Disorder Awareness Month (H. Res. 1005, 4/1/08), citing BPD’s "prevalence, enormous public health costs, and ... devastating toll on individuals, families, and communities."

History

Since the earliest record of medical history, the coexistence of intense, divergent moods within an individual has been recognized by such writers as Homer, 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 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. During the 1940s and 1950s a variety of other terms were also used for this group of patients, such as "ambulatory schizophrenia" (Zilboorg), "preschizophrenia" (Rapaport), "latent schizophrenia" (Federn), "pseudoneurotic schizophrenia" (Hoch and Polatin), "schizotypal disorder" (Rado), and "borderline state" (Knight).

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, the diagnosis was known as the hooker disorder, 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.

Diagnosis

Diagnosis is based on a clinical assessment 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 considered a relatively stable personality disorder and is used more generally to describe non-psychotic individuals who display emotional disregulation, splitting, and an unstable self image. 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. BPD has many similar characteristics to emotionally unstable personality disorder, subtype borderline; and complex post-traumatic stress disorder.

DSM-IV-TR criteria

The latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), the widely-used American Psychiatric Association guide for clinicians seeking to diagnose mental illnesses, defines Borderline Personality Disorder (BPD) as: "a pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by early adulthood and present in a variety of contexts." BPD is classed on "Axis II", as an underlying pervasive or personality condition, rather than "Axis I" for more circumscribed mental disorders. A DSM diagnosis of BPD requires any five out of nine listed criteria to be present for a significant period of time. There are thus 256 different combinations of symptoms that could result in a diagnosis, of which 136 have been found in practice in one study. The criteria are:

1. Frantic efforts to avoid real or imagined abandonment. [Not including suicidal or self-mutilating behavior covered in Criterion 5]
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., promiscuous sex, eating disorders, binge eating, substance abuse, reckless driving). [Again, not including suicidal or self-mutilating behavior covered in Criterion 5]
5. Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior such as cutting, interfering with the healing of scars (excoriation) or picking at oneself.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness, worthlessness.
8. Inappropriate anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation, delusions or severe dissociative symptoms

Comparable diagnoses

The World Health Organization's ICD-10 has a comparable diagnosis called Emotionally unstable personality disorder - Borderline type (F60.31). This requires the following, in addition to the general criteria for personality disorder: 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-harm; and chronic feelings of emptiness.

The Chinese Society of Psychiatry'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.

Associated features

It has been noted that there is probably no other mental disorder about which so many articles and books have been written, yet about which so little is known based on empirical research.

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 particularly associated with BPD have been grouped into four categories: extreme feelings in general; feelings of destructiveness or self-destructiveness; 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 suggest 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 towards insecure, avoidant or ambivalent, or fearfully preoccupied patterns in relationships. They tend to view the world generally as dangerous and malevolent, and themselves as powerless, vulnerable, unacceptable and unsure in self-identity.

Individuals with BPD are often described, including by some mental health professionals (and in the DSM-IV), as deliberately manipulative or difficult, but analyses 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. Parents of individuals with BPD have been reported to show co-existing extremes of over-involvement and under-involvement. BPD has been linked to somewhat increased levels of chronic stress and conflict in romantic relationships, decreased satisfaction of romantic partners, abuse, and unwanted pregnancy; these links may largely be general to personality disorder and subsyndromal problems, but such issues are commonly raised in support groups and published literature for partners of individuals with BPD.

Suicidal or self-harming 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 eight to ten 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 major 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.

Differential diagnosis

Borderline personality disorder and mood disorders 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 swings". 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 or days.

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.

Comorbidity

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 depression and bipolar disorder)
• eating disorders (including anorexia nervosa and bulimia)
• and, to a lesser extent, somatoform disorders
• dissociative disorders; if all DSM criteria are met, it is recommended that the person should also be tested to have Dissociative Identity Disorder.

Substance abuse is a common problem in BPD, whether due to impulsivity or as a coping mechanism, and 50% to 70% 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.

Prevalence

Figures from surveys of the prevalence of diagnosable BPD in the general population vary, ranging from approximately one percent to two 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.

Etiology

At least one researcher believes that BPD results from a combination that can involve a traumatic childhood, a vulnerable temperament, and stressful maturational events during adolescence or adulthood.

Childhood abuse, neglect or separation

Numerous studies have shown a strong correlation between child abuse, especially child sexual abuse, and development of BPD. Many individuals with BPD report having had a history of abuse, neglect, or separation as young children. Patients with BPD have been found to be significantly more likely to report having been verbally, emotionally, physically, and sexually abused by caregivers of either gender. 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 the 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.

There is evidence for the central role of family in the development of BPD, including interactions that are negative and critical rather than supportive and empathic, with parental and family behaviors transacting with the child's own behaviors and emotional vulnerabilities, although no prospective studies have been conducted.

Genetics

An overview of the existing literature suggested that traits related to BPD are influenced by genes, but studies have had methodological problems and the links are not yet clear. A major twin study found that if one identical twin met criteria for BPD, the other also met criteria in 35 percent of cases.

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.

Neurofunction

Neurotransmitters implicated in BPD include serotonin, norepinephrine and acetylcholine (related to various emotions and moods); GABA, the brain's major inhibitory neurotransmitter (which can stabilize mood change); and glutamate, an excitatory neurotransmitter. Enhanced amygdala activation in BPD has been identified by some researchers as reflecting the intense and slowly subsiding emotions commonly observed in BPD in response to even low-level stressors. It is thought by some researchers the activation of both the amygdala and prefrontal cortical areas can reflect attempts to control intensive emotions during the recall of unresolved life events. Impulsivity or aggression, as sometimes seen in BPD, has been linked to alterations in serotonin function and specific brain regions in the cingulate and the medial and orbital prefrontal cortex by some researchers.

Mediators and moderators

While research has examined variables that predict the development of borderline personality disorder (BPD), researchers have only recently begun to examine the variables that mediate and moderate the relationships between these variables and the development of the disorder. A mediator is a variable that effects how the relationship occurs. Mediation is said to be present when both the predictor variable and the mediating variable are significantly correlated with the dependent variable, and when the relationship between the predictor variable and the outcome variable is significantly reduced when controlling for the mediating variable .A moderating variable by contrast specifies the conditions under which a given outcome will occur. Moderation is said to occur when there is an interaction effect between the predicting variable and the moderating variable on the dependent variable . More specifically, the effect of the predicting variable is different depending on the level of the moderating variable.

Research has found that there are statistically significant relationships between BPD symptoms and both sexual and physical abuse. Other factors including family environment variables also contribute to the development of the disorder . Bradley et al. found that both child sexual abuse (CSA) and childhood physical abuse and BPD symptoms were significantly related, and both CSA and childhood physical abuse were significantly related to family environment. When family environment and childhood physical abuse were entered simultaneously into a regression equation, family environment was related to BPD symptoms and childhood physical abuse was related to BPD symptoms, although the relationship between BPD symptoms and childhood physical abuse was reduced. Therefore, CSA and childhood physical abuse both directly influence the development of BPD symptoms directly and are mediated by family environment .

Other research has examined the relationship between negative affectivity, thought suppression, and BPD symptoms. The results of the mediational models in this study found that thought suppression mediated the relationship between negative affectivity and BPD symptoms . While negative affectivity significantly predicted BPD symptoms after controlling for CSA, 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. (2008) found and interaction between rejection sensitivity and executive control in the prediction of BPD symptoms. This study found that BPD features were positively associated with rejection sensitivity (RS) and neuroticism and negatively associated with emotional control (EC). Their statistical analysis indicated that among those low in EC, RS was positively related to BPD features and among those high in RS, EC was negatively associated with BPD. By contrast among those high in EC, RS was not significantly related to BP features, and among those low in RS, EC was not related to BPD features. In Study 2, BPD features were positively correlated to RS and negatively correlated with executive control. Additionally, the authors found that delay gratification times at age 4 had no significant relationship with BPD features at the time of the current study. Again, as in Study 1, the RS x EC interaction was significant. Among those low in EC, RS was positively related to BPD features, while among those high in EC, the effect of RS was reduced to marginal significance. Moreover, among those high in RS, EC was negatively associated with BPD features, but among those low in RS, EC was unrelated to BPD features.

Parker, Boldero, and Bell (2006) study indicated that both AI and AO self-discrepancy magnitudes were strongly correlated to each other and to BPD features. Self-complexity was not significantly related to any of the other factors. 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.

BPD is complex and several factors have an impact on whether or not clinical features of BPD are present. None of the prediction factors above are sufficient to be the in the development of BPD features. Increased knowledge into the development of the disorder may elucidate both ways of preventing symptom aggravation and may aide in the development of new treatment strategies. Future research should integrate the knowledge gained from these areas and study these variables simultaneously. Studies in which these variables are simultaneously examined would provide greater specificity in the relationships between the variables. These articles taken together not only increase our knowledge of what factors and variables lead to the development of BPD features and BPD itself but also, when taken together, indicate future lines of research yet to be studied.

Treatment

The mainstay of treatment is various forms of psychotherapy, although medication and other approaches may also improve symptoms.

Psychotherapy

There has traditionally been skepticism about the psychological treatment of personality disorders, but several specific types of psychotherapy for BPD have developed in recent years. The limited studies to date do not allow confident claims of effectiveness but do suggest that people with a diagnosis of BPD can benefit on at least some outcome measures. Supportive therapy alone may enhance self-esteem and mobilize the existing strengths of individuals with BPD. Specific psychotherapies may involve sessions over several months or, as is particularly common for personality disorders, several years. Psychotherapy can often be conducted either with individuals or with groups. Group therapy can aid the learning and practice of interpersonal skills and self-awareness by individuals with BPD although drop-out rates may be problematic.

Dialectical behavioral therapy

University of Washington psychology professor, Marsha Linehan, is credited for developing the first empirically supported standard treatment for BPD, termed dialectical behavioral therapy (DBT). DBT grew dramatically in popularity among mental health professionals following the publication of Linehan’s treatment manuals for DBT in 1993. DBT was originally developed as an intervention for patients who meet criteria for BPD and particularly those who are highly suicidal.

Dialectical behavior therapy draws its principles from behavioral science (including cognitive-behavioral techniques), dialectical philosophy, and Zen practice. The treatment emphasizes balancing acceptance and change (hence dialectic), with the overall goal of helping patients not just survive but build a life worth living. Treatment is delivered in four stages, with self-harm and other life-threatening issues taking priority. In the second stage, patients are encouraged to experience the painful emotions that they have been avoiding. Stage three addresses problems of living such as career and marital problems. Finally, stage four focuses on helping clients feel complete and reducing feelings of emptiness and boredom.

DBT encompasses four modes of therapy, the first being traditional individual therapy between a single therapist and client. The second mode of therapy is skills training; the learning of new skills is a core component of DBT, including mindfulness, interpersonal effectiveness (e.g. assertiveness and social skills), coping adaptively with distress and crises; and identifying and regulating emotional reactions.

The third mode of therapy used is skills generalization, which focuses on helping clients integrate the skills taught in DBT into real-life situations. This usually involves coaching in the form of telephone contact outside of normal therapy hours. The calls are usually brief interactions focused on helping clients apply specific skills to circumstances they are experiencing. The fourth mode of therapy is the use of a consultation team designed to support the therapists. These teams have several important functions including reducing therapist burnout, providing therapy for the therapists, improving empathy for clients, and providing ongoing consultations for client difficulties.

The goal of all the treatment approaches used in DBT is to reduce the ineffective action tendencies that are linked to dysregulated emotions. DBT is based on a biosocial theory of personality functioning in which the core problem is seen as the breakdown of the patient’s cognitive, behavioral, and emotion regulation systems when experiencing intense emotions. The etiology of BPD is seen as a biological predisposition towards emotional dysregulation combined with a perceived invalidating social environment.

DBT can be based on a biosocial theory of personality functioning in which BPD is seen as a biological disorder of emotional regulation in a social environment experienced as invalidating by the borderline patient.

Several random controlled trials (RCTs) comparing DBT to other forms of treatment have favored the use of DBT to treat borderline patients. Specifically, DBT has been found to significantly reduce self-injury, suicidal behavior, impulsivity, self-rated anger, and the use of crisis services among borderline patients. These reductions have been found even when controlling for other treatment factors such as therapist experience, affordability of treatment, gender of therapist, and the number of hours spent in individual therapy. However, the additional efficacy in the overall treatment of BPD is less clear; future research is needed to isolate the specific components of DBT that are most effective in treating BPD. Furthermore, little research has examined the efficacy of DBT in treating male and minority patients with BPD. Training nurses in the use of DBT has been found to replace a therapeutic pessimism with a more optimistic understanding and outlook.

Schema therapy

Schema therapy (also called schema-focused therapy) is an integrative approach based on cognitive-behavioral or skills-based techniques along with object relations and gestalt approaches. It directly targets deeper aspects of emotion, personality and schemas (fundamental ways of categorizing and reacting to the world). The treatment also focuses on the relationship with the therapist (including a process of "limited re-parenting"), daily life outside of therapy, and traumatic childhood experiences. It was developed by Jeffrey Young and became established in the 1990s. Limited recent research suggests that it is significantly more effective than transference-focused psychotherapy, with half of individuals with borderline personality disorder assessed as having achieved full recovery after four years, with two thirds showing clinically significant improvement. Another very small trial has also suggested efficacy.

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is the most widely used and established psychological treatment for mental disorders, but has appeared less successful in BPD, due partly to difficulties in developing a therapeutic relationship and treatment adherence. Approaches such as DBT and Schema-focused therapy developed partly as an attempt to expand and add to traditional CBT, which uses a limited number of sessions to target specific maladaptive patterns of thought, perception and behavior. A recent study did find a number of sustained benefits of CBT, in addition to treatment as usual, after an average of 16 sessions over one year.

Marital or family therapy

Marital therapy can be helpful in stabilizing the marital relationship and in reducing marital conflict and stress that can worsen BPD symptoms. Family therapy or family psychoeducation can help educate family members regarding BPD, improve family communication and problem solving, and provide support to family members in dealing with their loved one's illness.

Two patterns of family involvement can help clinicians plan family interventions: overinvolvement and neglect. Borderline patients who are from overinvolved families are often actively struggling with a dependency issue by denial or by anger at their parents.

Interest in the use of psychoeducation and skills training approaches for families with borderline members is growing.

Psychoanalysis

The term dates back to 1884. It was C. Hugues who first spoke about subjects oscillating throughout their whole life between the limits of insanity and normality. A. Stern brings back the term in 1938 to describe a " hypersentimentality of the subjects, their defensive rigidity and their little self-respect." It is psychoanalysis that the term "borderline" was developed to define an "oedipian intermédaire organization". Edward Glover (psychoanalyst) for example spoke about "transitional states" (1932). Addictions are real states borderline in the sense that they are one foot in the psychoses and the other one in the neurosis. (...). It have their root in the paranoid states and, occasionally in the dominant melancolic state. He had established a plan which placed very clearly the place of the borderline in touch with the other disorders. Since, the works of Otto Kernberg, the French Jean Bergeret developed the concept which adapted itself to the modern psychoanalysis. It is in the apparition of the DSM 4 that the term took two orientations: psychiatric one behavioral and the other, included in a psychoanalytical psychopathology. According to this split, the diagnosis takes on, or a character objectivizing with ascendancy of symptoms to be eradicated or it indicates a particular type of patients of psychoanalysts to treat in modalities different from those typical cures,, .

Transference-focused psychotherapy

Further information: Otto F. Kernberg § Transference-Focused Psychotherapy

Transference-focused psychotherapy (TFP) is a form of psychoanalytic therapy dating to the 1960s, rooted in the conceptions of Otto Kernberg on BPD and its underlying structure (borderline personality organization). Unlike in the case of traditional psychoanalysis, the therapist plays a very active role in TFP. In session the therapist works on the relationship between the patient and the therapist. The therapist will try to explore and clarify aspects of this relationship so the underlying object relations dyads become clear. Some limited research on TFP suggests it may reduce some symptoms of BPD by affecting certain underlying processes, and that TFP in comparison to dialectical behavioral therapy and supportive therapy results in increased reflective functioning (the ability to realistically think about how others think) and a more secure attachment style. Furthermore, TFP has been shown to be as effective as DBT in improvement of suicidal behavior, and has been more effective than DBT in alleviating anger and in reducing verbal or direct assaultive behavior. Limited research suggests that TFP appears to be less effective than schema-focused therapy, while being more effective than no treatment.

Cognitive analytic therapy

Cognitive analytic therapy (CAT) combines cognitive and psychoanalytic approaches and has been adapted for use with individuals with BPD with mixed results.

Mentalization based treatment

Mentalization based treatment, developed by Peter Fonagy and Antony Bateman, rests on the assumption that people with BPD have a disturbance of attachment due to problems in the early childhood parent-child relationship. Fonagy and Bateman hypothesize that inadequate parental mirroring and attunement in early childhood lead to a deficit in mentalization, "the capacity to think about mental states as separate from, yet potentially causing actions", in other words the capacity to intuitively understand the thoughts, intentions and motivations of others, and the connections between one's own thoughts, feelings and actions. Mentalization failure is thought to underlie BPD patients' problems with impulse control, mood instability and difficulties sustaining intimate relationships. Mentalization based treatment aims to develop patients' self-regulation capacity through a psychodynamically informed multi-modal treatment program which incorporates group psychotherapy and individual psychotherapy in a therapeutic community, partial hospitalization or out-patient context. In a randomized controlled trial, a group of BPD patients received 18 months of intensive partial-hospitalization MBT followed by 18 months of group psychotherapy, and were followed up over five years. The treatment group showed significant benefits aross a range of measures including number of suicide attempts, reduced time in hospital, and reduced use of medication.

Medication

A number of medications are used in conjunction with BPD treatments, although the evidence base is limited. As BPD has been traditionally considered a primarily psychosocial condition, medication is intended to treat co-morbid symptoms, such as anxiety and depression, rather than BPD itself. All known medications for BPD have had the unpleasant side effects of involuntary projectile diarrhea and constant steady gas discharge which can often last for days at a time. It is for this reason that these medications are not recommended, as they may create circumstances which can often add to the difficulty of those with BPD to be fully functional members of society.

Antidepressants

Selective serotonin reuptake inhibitor (SSRI) antidepressants have been shown in randomized controlled trials to improve the attendant symptoms of anxiety and depression, such as anger and hostility, associated with BPD in some patients. According to Listening to Prozac, it takes a higher dose of an SSRI to treat mood disorders associated with BPD than depression alone. It also takes about three months for benefit to appear, compared to the three to six weeks for depression.

Antipsychotics

The newer atypical antipsychotics are claimed to have an improved adverse effect profile than the typical antipsychotics. Antipsychotics are also sometimes used to treat distortions in thinking or false perceptions. Use of antipsychotics is generally short-term.

One meta-analysis of two randomly controlled trials, four non-controlled open-label studies and eight case reports has suggested that several atypical antipsychotics, including olanzapine, clozapine, quetiapine and risperidone, may help BPD patients with psychotic-like, impulsive or suicidal symptoms. However, there are numerous adverse effects of antipsychotics, notably Tardive dyskinesia (TD). Atypical antipsychotics are known for often causing considerable weight gain, with associated health complications.

Services and recovery

Individuals with BPD sometimes use mental health services extensively. People with this diagnosis accounted for around 20% 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.

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 "deal" with, and more difficult than other client groups. On the other hand, those 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 correctly perceived as manipulative, and that they had limited access to care. Attempts are made to improve public and staff attitudes.

Combining pharmacotherapy and psychotherapy

In practice, psychotherapy and medication may often be combined but there are limited data on clinical practice. Efficacy studies often assess the effectiveness of interventions when added to 'treatment as usual' (TAU), which may involve general psychiatric services, supportive counselling, medication and psychotherapy.

One small study, which excluded individuals with a comorbid Axis 1 disorder, has indicated that outpatients undergoing Dialectical Behavioral Therapy and taking the antipsychotic Olanzapine show significantly more improvement on some measures related to BPD, compared to those undergoing DBT and taking a placebo pill, although they also experienced weight gain and raised cholesterol. Another small study found that patients who had undergone DBT and then took fluoxetine (Prozac) showed no significant improvements, whereas those who underwent DBT and then took a placebo pill did show significant improvements.

Difficulties in therapy

There can be unique challenges in the treatment of BPD, for example hospital care. In psychotherapy, a client may be unusually sensitive to rejection and abandonment and may react negatively (e.g., by harming themselves or withdrawing from treatment) if they sense this. In addition, clinicians may emotionally distance themselves from individuals with BPD for self-protection or due to the stigma associated with the diagnosis, leading to a self-fulfilling prophecy and a cycle of stigmatization to which both patient and therapist can contribute.

Some psychotherapies, for example DBT, were developed partly to overcome problems with interpersonal sensitivity and maintaining a therapeutic relationship. Adherence to medication regimens is also a problem, due in part to adverse effects, with drop-out rates of between 50 percent and 88 percent in medication trials. Comorbid disorders, particularly substance use disorders, can complicate attempts to achieve remission.

Other strategies

Psychotherapies and medications form a part of the overall context of mental health services and psychosocial needs related to BPD. The evidence base is limited for both, and some individuals may forego them or not benefit (enough) from them. It has been argued that diagnostic categorisation can have limited utility in directing therapeutic work in this area, and that in some cases it is only with reference to past and current relationships that "borderline" behavior can be understood as partly adaptive and how people can best be helped.

Numerous other strategies may be used, including alternative medicine techniques (see List of branches of alternative medicine), exercise and physical fitness, including team sports; occupational therapy techniques, including creative arts; having structure and routine to the days, particularly through employment - helping feelings of competence (e.g. self-efficacy), having a social role and being valued by others, boosting self-esteem.

Group-based psychological services encourage clients to socialize and participate in both solitary and group activities. These may be in day centers. Therapeutic communities are an example of this, particularly in Europe, although their usage has declined many have specialised in the treatment of severe personality disorder.

Psychiatric rehabilitation services aimed at helping people with mental health problems, to reduce psychosocial disability, engage in meaningful activities, and avoid stigma and social exclusion may be of value to people who suffer from BPD. There are also many mutual-support or co-counseling groups run by and for individuals with BPD. Services, or individual goals, are increasingly based on a recovery model that supports and emphasizes an individual's personal journey and potential.

Data indicate that the diagnosis of BPD is more variable over time than the DSM implies. Substantial percentages (for example around a third, depending on criteria) of people diagnosed with BPD achieve remission within a year or two. A longitudinal study found that, six years after being diagnosed with BPD, 56% showed good psychosocial functioning, compared to 26% at baseline. Although vocational achievement was more limited even compared to those with other personality disorders, those whose symptoms had remitted were significantly more likely to have a good relationship with a spouse/partner and at least one parent, good work/school performance, a sustained work/school history, good global functioning and good psychosocial functioning.

Controversies

Gender

The concept of BPD has been criticised from a feminist perspective. and the question has been raised of why BPD is diagnosed somewhat more commonly in women than in men. Some think that people with BPD commonly have a history of sexual abuse in childhood, and since girls are much more commonly sexually abused than boys, it is inevitable that BPD would be more common in women. BPD is a stigmatizing diagnosis which evokes negative responses from health care providers (see below), so it is suggested that women who have survived sexual abuse in childhood are in this way re-traumatized by abusive mental health services. Some feminist writers have suggested that 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. Clinicians respond differentially to men and women presenting with the same symptoms, for example women presenting with angry, promiscuous behaviour are likely to be diagnosed with BPD, whereas men presenting with identical symptoms will be diagnosed with Antisocial personality disorder. 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.

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 such as “difficult”, “treatment resistant,” “manipulative,” “demanding,” and “attention seeking" 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 defence 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 countertransference 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 countertransference 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. People labeled with "Borderline Personality Disorder" also often feel it is unhelpful and stigmatizing as well as simply inaccurate, supporting and adding to calls for a name change.

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 dysregulation disorder. According to TARA, (Treatment and Research Advancement Association for Personality Disorders) this terminology has "the most likely chance of being adopted by the American Psychiatric Association." Emotional regulation disorder is the term favored by Marsha Linehan, pioneer of one of the most popular types of BPD therapy. Impulse disorder and Interpersonal regulatory disorder are other valid alternatives, according to John Gunderson of McLean Hospital in the United States. Dyslimbia has been suggested by Leland Heller and Mercurial disorder has been proposed by McLean Hospital's Mary Zanarini. Another term advanced (for example by psychiatrist Carolyn Quadrio) is Post Traumatic Personality Disorganisation (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.

Sociological and cultural aspects

Cultural references

Several films have portrayed characters either explicitly diagnosed or with traits strongly suggestive of the diagnosis which have been the subject of discussion by psychiatrists and film experts alike. The films Play Misty for Me and Fatal Attraction are two cited examples, as well as the book and movie Girl, Interrupted; all highlight the emotional instability of the disorder and the frantic attempts to avoid abandonment. However, each case shows a person more aggressive to others than to herself; the latter is a more usual outcome in these situations. The 1992 film Single White Female highlights different aspects of the disorder, as the character Hedy, suffering from a markedly disturbed sense of identity, adopts wholesale the attributes of her flatmate. A chronic emptiness is implied and, as with the last two films, abandonment leads to drastic measures. Other films cited as depicting prominent characters with the disorder include The Crush, Malicious, Interiors, Presumed Innocent, and The Hand That Rocks the Cradle.

On stage, BPD was a central theme of Joe Penhall's 2000 play Blue/Orange in which two psychiatrists do battle over the future treatment of a patient suffering from the condition.

See also

• Emotional dysregulation
• Post-traumatic stress disorder (PTSD)
• Complex post-traumatic stress disorder (C-PTSD)
• Bipolar disorder
• DSM-IV Codes#Personality Disorders
• Structured Clinical Interview for DSM-IV
• Dissociative disorders

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