Borderline Personality Disorder
Borderline personality disorder (BPD) is a serious mental illness characterized
by pervasive instability in moods, interpersonal relationships, self-image,
and behavior. This instability often disrupts family and work life, long-term
planning, and the individual's sense of self-identity. Originally thought to
be at the "borderline" of psychosis, people with BPD suffer from a
disorder of emotion regulation. While less well known than schizophrenia or
bipolar disorder (manic-depressive illness), BPD is more common, affecting 2
percent of adults, mostly young women.1
There is a high rate of self-injury without suicide intent, as well as a significant rate of suicide attempts and completed suicide in severe cases.2,3 Patients often need extensive mental health services, and account for 20 percent of psychiatric hospitalizations.4 Yet, with help, many improve over time and are eventually able to lead productive lives.
Symptoms
While a person with depression or bipolar disorder typically endures the same
mood for weeks, a person with BPD may experience intense bouts of anger, depression
and anxiety that may last only hours, or at most a day.5 These may be associated
with episodes of impulsive aggression, self-injury, and drug or alcohol abuse.
Distortions in cognition and sense of self can lead to frequent changes in long-term
goals, career plans, jobs, friendships, gender identity, and values. Sometimes
people with BPD view themselves as fundamentally bad, or unworthy. They may
feel unfairly misunderstood or mistreated, bored, empty, and have little idea
who they are. Such symptoms are most acute when people with BPD feel isolated
and lacking in social support, and may result in frantic efforts to avoid being
alone.
People with BPD often have highly unstable patterns of social relationships.
While they can develop intense but stormy attachments, their attitudes towards
family, friends, and loved ones may suddenly shift from idealization (great
admiration and love) to devaluation (intense anger and dislike). Thus, they
may form an immediate attachment and idealize the other person, but when a slight
separation or conflict occurs, they switch unexpectedly to the other extreme
and angrily accuse the other person of not caring for them at all. Even with
family members, individuals with BPD are highly sensitive to rejection, reacting
with anger and distress to such mild separations as a vacation, a business trip,
or a sudden change in plans. These fears of abandonment seem to be related to
difficulties feeling emotionally connected to important persons when they are
physically absent, leaving the individual with BPD feeling lost and perhaps
worthlessness. Suicide threats and attempts may occur along with anger at perceived
abandonment and disappointments.
People with BPD exhibit other impulsive behaviors, such as excessive spending,
binge eating and risky sex. BPD often occurs together with other psychiatric
problems, particularly bipolar disorder, depression, anxiety disorders, substance
abuse, and other personality disorders.
Treatment
Treatments for BPD have improved in recent years. Group and individual psychotherapy
are at least partially effective for many patients. Within the past 15 years,
a new psychosocial treatment termed dialectical behavior therapy (DBT) was developed
specifically to treat BPD, and this technique has looked promising in treatment
studies.6 Pharmacological treatments are often prescribed based on specific
target symptoms shown by the individual patient. Antidepressant drugs and mood
stabilizers may be helpful for depressed and/or labile mood. Antipsychotic drugs
may also be used when there are distortions in thinking.7
Recent Research Findings
Although the cause of BPD is unknown, both environmental and genetic factors
are thought to play a role in predisposing patients to BPD symptoms and traits.
Studies show that many, but not all individuals with BPD report a history of
abuse, neglect, or separation as young children.8 Forty to 71 percent of BPD
patients report having been sexually abused, usually by a non-caregiver.9 Researchers
believe that BPD results from a combination of individual vulnerability to environmental
stress, neglect or abuse as young children, and a series of events that trigger
the onset of the disorder as young adults. Adults with BPD are also considerably
more likely to be the victim of violence, including rape and other crimes. This
may result from both harmful environments as well as impulsivity and poor judgement
in choosing partners and lifestyles.
NIMH-funded neuroscience research is revealing brain mechanisms underlying
the impulsively, mood instability, aggression, anger, and negative emotion seen
in BPD. Studies suggest that people predisposed to impulsive aggression have
impaired regulation of the neural circuits that modulate emotion.10 The amygdala,
a small almond-shaped structure deep inside the brain, is an important component
of the circuit that regulates negative emotion. In response to signals from
other brain centers indicating a perceived threat, it marshals fear and arousal.
This might be more pronounced under the influence of drugs like alcohol, or
stress. Areas in the front of the brain (pre-frontal area) act to dampen the
activity of this circuit. Recent brain imaging studies show that individual
differences in the ability to activate regions of the prefrontal cerebral cortex
thought to be involved in inhibitory activity predict the ability to suppress
negative emotion.11
Serotonin, norepinephrine and acetylcholine are among the chemical messengers
in these circuits that play a role in the regulation of emotions, including
sadness, anger, anxiety and irritability. Drugs that enhance brain serotonin
function may improve emotional symptoms in BPD. Likewise, mood-stabilizing drugs
that are known to enhance the activity of GABA, the brain's major inhibitory
neurotransmitter, may help people who experience BPD-like mood swings. Such
brain-based vulnerabilities can be managed with help from behavioral interventions
and medications, much like people manage susceptibility to diabetes or high
blood pressure.7
Future Progress
Studies that translate basic findings about the neural basis of temperament,
mood regulation and cognition into clinically relevant insights—which bear
directly on BPD—represent a growing area of NIMH-supported research. Research
is also underway to test the efficacy of combining medications with behavioral
treatments like DBT, and gauging the effect of childhood abuse and other stress
in BPD on brain hormones. Data from the first prospective, longitudinal study
of BPD, which began in the early 1990s, is expected to reveal how treatment
affects the course of the illness. It will also pinpoint specific environmental
factors and personality traits that predict a more favorable outcome. The Institute
is also collaborating with a private foundation to help attract new researchers
to develop a better understanding and better treatment for BPD.
References
1Swartz M, Blazer D, George L, Winfield I. Estimating the prevalence of borderline
personality disorder in the community. Journal of Personality Disorders, 1990;
4(3): 257-72.
2Soloff PH, Lis JA, Kelly T, Cornelius J, Ulrich R. Self-mutilation and suicidal
behavior in borderline personality disorder. Journal of Personality Disorders,
1994; 8(4): 257-67.
3Gardner DL, Cowdry RW. Suicidal and parasuicidal behavior in borderline personality
disorder. Psychiatric Clinics of North America, 1985; 8(2): 389-403.
4Zanarini MC, Frankenburg FR. Treatment histories of borderline inpatients.
Comprehensive Psychiatry, in press.
5Zanarini MC, Frankenburg FR, DeLuca CJ, Hennen J, Khera GS, Gunderson JG.
The pain of being borderline: dysphoric states specific to borderline personality
disorder. Harvard Review of Psychiatry, 1998; 6(4): 201-7.
6Koerner K, Linehan MM. Research on dialectical behavior therapy for patients
with borderline personality disorder. Psychiatric Clinics of North America,
2000; 23(1): 151-67.
7Siever LJ, Koenigsberg HW. The frustrating no-mans-land of borderline personality
disorder. Cerebrum, The Dana Forum on Brain Science, 2000; 2(4).
8Zanarini MC, Frankenburg. Pathways to the development of borderline personality
disorder. Journal of Personality Disorders, 1997; 11(1): 93-104.
9Zanarini MC. Childhood experiences associated with the development of borderline
personality disorder. Psychiatric Clinics of North America, 2000; 23(1): 89-101.
10Davidson RJ, Jackson DC, Kalin NH. Emotion, plasticity, context and regulation:
perspectives from affective neuroscience. Psychological Bulletin, 2000; 126(6):
873-89.
11Davidson RJ, Putnam KM, Larson CL. Dysfunction in the neural circuitry of
emotion regulation - a possible prelude to violence. Science, 2000; 289(5479):
591-4.
Source: NIH Publication No. 01-4928
Updated: January 01, 2001
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