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Back to Psychiatry Diseases
Borderline personality disorder (BPD)
In psychiatry, borderline personality disorder (BPD) is a personality
disorder characterised by extreme 'black and white' thinking, mood
swings, disrupted relationships and difficulty in functioning in a way
society accepts as normal.
Psychiatrists describe borderline personality disorder as 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-depression), BPD is more common, affecting 2 percent of
adults, mostly young women. There is a high rate of self-injury without
suicidal intent, as well as a significant rate of suicide attempts and
completed suicide in severe cases. Patients often need extensive mental
health services, and account for 20 percent of psychiatric
hospitalizations. 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. These may be associated with episodes of impulsive aggression,
self-injury including cutting, 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.
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Treatment
Treatments for BPD have improved in recent years. Group and individual
psychotherapy are at least partially effective for many patients. In
1991, a new psychosocial treatment termed dialectical behavior therapy (DBT)
was developed specifically to treat BPD, and this technique has looked
promising in treatment studies. 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.
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. Forty to 71 percent of BPD patients report having been
sexually abused, usually by a non-caregiver. 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.
National Institute of Mental Health-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. 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.
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.
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.
Effects on family members
An interesting area of research relating to BPD is the study of the
effects of the disorder on other family members and significant others
in the lives of those with traits of borderline personality disorder.
These people refer to themselves as NonBPs. Living with someone with BPD
traits is often disorienting and difficult. NonBPs require support from
the mental health community as they help those with the disorder while
maintaining strength in their own view of reality.
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