Borderline Personality Disorder: Practice Essentials, Background, Patho...

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Borderline Personality Disorder

Author: Roy H Lubit, MD, PhD; Chief Editor: Caroly Pataki, MD more...
Updated: Aug 04, 2014

Practice Essentials
Borderline personality disorder (BPD) is characterized by marked instability in
functioning, affect, mood, interpersonal relationships, and, at times, reality testing.
BPD is associated with significant morbidity due to common comorbid conditions,
including dysthymia, major depression, psychoactive substance abuse, and
psychotic disorders. Approximately 70-75% of patients with BPD have a history of at
least one deliberate act of self-harm, and the mean estimated rate of completed
suicides is 9%.[1, 2]

Signs and symptoms

Features that typically begin in adolescence or young adulthood in patients with
BPD include the following[3] :
Disturbances in experiencing oneself as unique, poor boundaries between
self and others, and poor emotion regulation.
An inability to soothe themselves adequately, resulting in excess emotional
reactions to stresses and frustrations; maladaptive attempts at self-soothing,
suicide threats, self-harm, and angry behavior
An unstable sense of self with poor ability for self-direction and impaired
ability to pursue meaningful short-term goals with satisfaction
Marked instability in functioning, affect, mood, interpersonal relationships,
and, at times, reality testing
Disturbances in empathy and intimacy
A pattern of impulsivity, risk taking, and poor self-image
See Presentation for more detail.

Diagnosis
In the American Psychiatric Associations Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5),[4] BPD is diagnosed on the basis of (1) a
pervasive pattern of instability of interpersonal relationships, self-image, and affects,
and (2) marked impulsivity beginning by early adulthood and present in a variety of
contexts, as indicated by at least five of the following:
Frantic efforts to avoid real or imagined abandonment; this does not include
suicidal or self-mutilating behavior covered in criterion 5
A pattern of unstable and intense interpersonal relationships characterized by
alternating between extremes of idealization and devaluation
Markedly and persistently unstable self-image or sense of self
Impulsivity in at least two areas that are potentially self-damaging (eg,
spending, sex, substance abuse, reckless driving, binge eating) [5] ; this does
not include suicidal or self-mutilating behavior covered in criterion 5
Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
Affective instability due to a marked reactivity of mood (eg, intense episodic
dysphoria, irritability, or anxiety usually lasting a few hours and only rarely
more than a few days)
Chronic feelings of emptiness
Inappropriate, intense anger or difficulty controlling anger (eg, frequent
displays of temper, constant anger, or recurrent physical fights)
Transient, stress-related paranoid ideation or severe dissociative symptoms
An alternative model described in DSM-5 for personality disorders includes essential
features for personality disorders, with specific features added to denote the specific
personality disorder. Essential features of personality disorders using this model
include: impairment in self-concept and interpersonal relationships, inflexible traits
causing impairment in personal and social situations, and pathological personality
traits. Pathological personality traits included in this model are Negative Affectivity,
Detachment, Antagonism, Disinhibition, and Psychoticism.
No laboratory tests are useful in identifying BPD. Some patients have abnormal
results on dexamethasone suppression testing and with abnormal thyrotropinreleasing hormone testing; however, these findings are also present in many
patients with depression. As with any thorough workup of a patient with a mood
disorder, fasting glucose and thyroid function studies are usually indicated.
Screening for substance abuse is often useful. Other laboratory tests are indicated,
depending on the clinical presentation.

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See Workup for more detail.

Management
Historically, treatment of patients with BPD has been difficult. Therapy for BPD is as
follows:
Dialectic behavior therapy (DBT), a modification of standard cognitivebehavioral techniques, [6] is currently the only data-supported treatment for
BPD
For children and adolescents with BPD traits, family-oriented interventions
appear to provide superior benefits
Most children and adolescents with traits of BPD appear to benefit from
structured day programs with strong behavioral management components [7]
Psychotherapy is often difficult because of regression, overwhelming affect,
and impulsive behavior
Hospitalization may be necessary because of suicidal or other self-injurious
behavior
Pharmacologic treatment may be necessary for impulsivity, affective instability, and
psychosis. Medications are at times useful. See the following:
Selective serotonin reuptake inhibitors (SSRIs) are greatly preferred to the
other classes of antidepressants; they can reduce impulsivity and aggression;
they are less dangerous in overdose than many other psychoactive drugs;
care must be taken that they do not lead to suicidality, however
Low-dose neuroleptics (eg, risperidone) are effective in the short term for
control of transient psychotic symptoms and can decrease general agitation
Treatment with the opiate receptor antagonist naltrexone may reduce the
duration and intensity of dissociative symptoms in a small number of patients
with BPD [8]
Patients with BPD tend to have strong placebo responses to medication;
thus, impressive short-term improvement might occur and unexpectedly fade
Patients with BPD commonly take overdoses of their prescribed medication;
thus, tricyclic antidepressants, lithium, and other mood stabilizers must be
prescribed with great caution and as part of an ongoing therapeutic
relationship
Benzodiazepines, although helpful with anxiety, create risks of increased
impulsivity and dependency
See Treatment and Medication for more detail.

Background
Personality traits are enduring patterns of perceiving, relating to, and thinking about
the environment and oneself. When they are exhibited in a wide range of important
social and personal contexts and cause serious functional impairment or subjective
distress, they constitute a personality disorder. The manifestations of personality
disorders are often recognized by adolescence and continue throughout most of
adult life.
Personality disorders are not formally diagnosed in patients younger than 18 years,
because of the ongoing developmental changes. However, if the disturbance is
pervasive and if the criteria are fully and persistently met and are not limited to a
developmental stage, diagnosing borderline personality disorder (BPD) in children
and adolescents is appropriate.
Historically, BPD has been seen as lying on the border between psychosis and
neurosis. It is characterized by marked instability in functioning, affect, mood,
interpersonal relationships, and, at times, reality testing.
In 1942, Deutsch described a group of patients who lacked a consistent sense of
identity and source of inner direction.[9] She created the term as-if personalities
because the patients completely identified with those upon whom they were
dependent, changing their identifications and sense of self as their relationships
changed. In 1975, Kernberg conceptualized BPD to describe a group of patients
with particular primitive defense mechanisms and pathologic internalized object
relations (splitting and projective identification).[10]
Borderline pathology in children refers to a syndrome characterized by a
combination of externalizing symptoms (disruptive behavioral problems),
internalizing symptoms (mood and anxiety symptoms), and cognitive symptoms.
Follow-up studies of these children show that they have a tendency to develop a
wide range of personality disorders, with no strong specific tendency toward BPD.
Further research in this area is needed to elucidate the etiology and facilitate early
intervention.

Diagnostic criteria (DSM-5)

According to the American Psychiatric Associations Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5),[4] BPD is diagnosed on the basis
of (1) a pervasive pattern of instability of interpersonal relationships, self-image, and

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affects, and (2) marked impulsivity beginning by early adulthood and present in a
variety of contexts, as indicated by at least 5 of the following:
Frantic efforts to avoid real or imagined abandonment; this does not include
suicidal or self-mutilating behavior covered in criterion 5
A pattern of unstable and intense interpersonal relationships characterized by
alternating between extremes of idealization and devaluation
Identity disturbance - Markedly and persistently unstable self-image or sense
of self
Impulsivity in at least 2 areas that are potentially self-damaging (eg,
spending, sex, substance abuse, reckless driving, or binge eating); this does
not include suicidal or self-mutilating behavior covered in criterion 5
Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
Affective instability due to a marked reactivity of mood (eg, intense episodic
dysphoria, irritability, or anxiety usually lasting a few hours and only rarely
more than a few days)
Chronic feelings of emptiness
Inappropriate, intense anger or difficulty controlling anger (eg, frequent
displays of temper, constant anger, or recurrent physical fights)
Transient, stress-related paranoid ideation or severe dissociative symptoms

Pathophysiology
Some studies have suggested that patients with BPD might have increased rates of
soft neurologic signs,[11] as well as learning disorders, attention-deficit/hyperactivity
disorder (ADHD), and abnormal electroencephalographic (EEG) findings.[12] Reports
also indicate that adults with BPD have increased impulsivity, cognitive inflexibility,
and poor self-monitoring and perseveration, which may be indicators of frontal lobe
dysfunction.
The pathogenesis of BPD, like those of most psychiatric disorders, is likely to
include an organic predisposition as well as psychosocial and environmental factors.
Some researchers postulate the presence of an underlying affective instability to
which the individual responds with maladaptive behaviors.

Etiology
Most theories about the cause or pathogenesis of BPD include the notion of a
biologic predisposition[13] along with psychological and environmental factors. One
theory posits that neurobiologic development is affected by a combination of
disruption of early attachments and subsequent trauma leading to
hyperresponsiveness of the attachment system. During emotional arousal, images
of self and object are affected, and the individual begins to use primitive defense
mechanisms.
A history of abuse is very common, and Michael Stone has postulated that childhood
abuse can lead to the development of BPD. Several researchers have proposed the
existence of a constitutional incapacity to tolerate stress. Kernberg has hypothesized
that patients with borderline pathology have a constitutional inability to regulate their
affect, which predisposes them to psychic disorganization or deterioration under
early adverse environmental conditions.[10]
Persons with BPD are at higher risk for depression, panic disorder, and
agoraphobia. Studies commonly reveal that patients with BPD are anxious,
dependent, and acutely sensitive to rejection and loss; these observations suggest
that the condition might be specifically related to attachment bond regulation.
Mahler hypothesized unpredictable and prolonged separation from their maternal
figure during the separation-individuation process of development (18 and 36
months) places children at risk.[14] The unavailability of the maternal figure might
make the child forever vulnerable to disorganization brought on by separation
experiences.
Kernberg suggested that patients with BPD internalize early pathologic object
relations.[10] The use of primitive defense mechanisms (which individuals without
BPD outgrow during normal development) maintains these early pathologic object
relations. Kernberg hypothesized that in the early stages of development, the infant
experiences the maternal figure in 2 contradictory ways, as follows:
The good mother, who provides for, loves, and remains close to the child
The hateful, depriving mother, who unpredictably punishes and abandons the
child
These contradictory experiences result in intense anxiety, which leads to the
borderline defense of splitting. In splitting, an individual is unable to combine positive
and negative feelings about another individual into a realistic picture of the other
person, and stable feelings about the other person, that can withstand normal life
frustrations and disappointments. As a result, the individual rapidly shifts between
having very positive to very negative feelings about others.
Several researchers have proposed an etiology for borderline personality that
derives from a family systems perspective.[15] In this view, the significant etiologic

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variables stem from the concepts of faulty family boundaries, the unpredictable
proximity among family members, and the lack of an appropriate hierarchical
structure.
Although the borderline condition in childhood is not necessarily a precursor to BPD
in adulthood, evidence suggests that both have strikingly similar risk factors, which
might indicate a common etiology. These factors include family environments
characterized by trauma, neglect, and/or separation; exposure to sexual and
physical abuse; and serious parental psychopathology, such as substance abuse
and antisocial personality disorder.
The theory developed by Linehan et al states that borderline pathology results from
the interaction between a biologic emotional vulnerability and a pervasively
invalidating environment.[1, 2] More research involving developmental
psychopathology, neurobiology, and family systems theory is necessary to explain
how, when, and in what combinations these various factors might exert a pathologic
effect on development.

Epidemiology
United States statistics
To the authors knowledge, no definitive prevalence studies have been performed;
however, BPD is reported to be present in 1-2% of the general population. In a study
performed by Clarkin et al in 1983, approximately 11% of psychiatric outpatients and
19% of inpatients met the criteria for BPD.[16]

Age-, sex-, and race-related demographics

Symptoms of BPD are usually present by late adolescence, but the diagnosis has
been made in children. The initial diagnosis is rarely made in patients older than 40
years. The incidence of the disorder tends to decrease after age 40 years, partly
because personality disorders often decrease with age and partly because some
who have the disorder commit suicide and thus are no longer part of the population.
Virtually every study of borderline personality disorder has revealed that the
diagnosis is more common in females than in males; the female-to-male ratios are
as high as 4:1.[17] No evidence suggests a relationship between race and the
diagnosis of BPD or borderline disorders of childhood.

Prognosis
Short-term follow-up studies indicate that BPD is a chronic condition, though many
patients improve over time. In a 1998 prospective follow-up study, Links et al
reported that almost 50% of their former inpatients with BPD continued to meet
diagnostic criteria at 7 years.[18] Furthermore, these patients have significantly more
comorbid personality psychopathology; this finding supported the assertion that the
level of pathology at the initial assessment primarily predicts the level of borderline
psychopathology.
The long-term outcome is variable. The initial diagnosis of BPD is rarely made in
patients older than 40 years. Children with borderline pathology tend to develop a
wide range of personality disorders, not necessarily BPD. Andrulonis has suggested
that BPD traits in girls are more likely to evolve toward affective disorders, whereas
BPD traits in boys evolve toward episodic dyscontrol syndromes and substance
abuse.[19]
Premature death among patients with BPD may be due to the increased risk of
suicide in this population. Approximately 70-75% of patients with BPD have a history
of at least 1 deliberate act of self-harm. According to Linehan et al, the mean
estimated rate of completed suicides is 9%.[1, 2]
BPD is associated with significant morbidity. The individuals relationships are
generally unstable. Marked changes in feelings about people, high levels of anger,
and impulsivity compromise social and work activities. There are high rates of
depression and substance abuse. Psychosis occasionally occurs. In a study of 409
patients, Zimmerman et al found that in comparison with patients who did not have
BPD, patients with BPD were twice as likely to receive a diagnosis of 3 or more
current axis-I disorders (eg, mood disorders, anxiety, substance abuse, eating
disorders, or somatoform disorders) and nearly 4 times as likely to have a diagnosis
of 4 or more such disorders.[20]
Morbidity in this population includes failure in social relationships, developmental
delay, and occupational impairment. Healthcare costs in patients with borderline
pathology are enormous, and treatment dropout rates are high.

Patient Education
Patients with BPD should be helped to understand that their feelings, though very
intense, will change if they can wait and pause. These individuals will feel great
despair and want to hurt themselves; they will feel great anger and want to hurt

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others; they will feel terrible emptiness and want to jump into a risky activity to deal
with it. Helping them learn that the feelings will not last and that there are things they
can do to soothe themselves is highly therapeutic.
Similarly, patients need to learn about their tendency first to overidealize and then to
devalue people. Helping them establish an understanding of their feelings can
encourage them to learn how not to act out on feelings in self-destructive ways.
Patients should also be taught that their mood fluctuations and excessive reactions
will ease as they get older. They need to learn social skills and how people normally
function in relationships without letting their feelings carry them away.
Education of family members is also crucial. Family members can easily become
burned out, and without their support, the patient is likely to become far more
unstable. Family members should be helped to understand that the patient is not
consciously manipulating them but is experiencing overpowering emotions in
response to events that overwhelm his or her judgment. Family members should be
made aware of the chronic abandonment fears of individuals with BPD and should
try to avoid inadvertently stirring up those fears.
For patient education resources, see the Mental Health Center, as well as
Schizophrenia. The following Web sites may also be helpful:
MayoClinic.com, Borderline Personality Disorder
National Institute of Mental Health, Borderline Personality Disorder
Clinical Presentation

Contributor Information and Disclosures

Author
Roy H Lubit, MD, PhD Private Practice
Roy H Lubit, MD, PhD is a member of the following medical societies: American Academy of Child and
Adolescent Psychiatry
Disclosure: Nothing to disclose.
Chief Editor
Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of
California, Los Angeles, David Geffen School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent
Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility
Disclosure: Nothing to disclose.
Acknowledgements
Elizabeth A Finley-Belgrad, MD Clinical Assistant Professor, Department of Psychiatry, Northeastern Ohio
Universities College of Medicine
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of
Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.

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