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Chapter: Essentials of Psychiatry: Personality Disorders

Borderline Personality Disorder

Borderline personality disorder (BPD) is a pervasive pattern of impulsivity and instability in interpersonal relationships and self-image .

Borderline Personality Disorder




Borderline personality disorder (BPD) is a pervasive pattern of impulsivity and instability in interpersonal relationships and self-image (American Psychiatric Association, 2000). A broad domain of general personality functioning is neuroticism or emotional instability. characterized by facets of angry hostility, anxiousness, depressiveness, impulsivity and vulnerability; BPD is essentially the most extreme and highly maladaptive variant of emotional instability. This disorder is indicated by the presence of five or more of the nine diagnostic criteria presented in the DSM-IV-TR criteria for BPD.


Etiology and Pathology


There are studies to indicate that BPD may breed true but most research has suggested an association with mood and impulse dyscontrol disorders. There is also consistent empirical support for a childhood history of physical and/or sexual abuse, as well as parental conflict, loss and neglect. It appears that past traumatic events are important in many if not most cases of BPD, contrib-uting to the overlap and association with post traumatic stress and dissociative disorders but the nature and age at which these events have occurred will vary. BPD may involve the interaction of a genetic disposition towards dyscontrol of mood and impulses (i.e., emotionally unstable temperament), with a cumulative and evolving series of intensely pathogenic relationships.


There are numerous theories regarding the pathogenic mechanisms of BPD, most concern issues regarding abandon-ment, separation, and/or exploitative abuse, which is one of the reasons that frantic efforts to avoid abandonment is the first item in the DSM-IV-TR diagnostic criterion set. Persons with BPD have quite intense, disturbed, and/or abusive relationships with the significant persons of their past, including their parents, contributing to the development of malevolent perceptions and expectations of others. These expectations, along with an impair-ment in the ability to regulate affect and impulses may contribute to the perpetuation of intense, angry and unstable relationships. Neurochemical dysregulation is evident in persons with BPD but it is unclear whether this dysregulation is a result, cause, or cor-relate of prior interpersonal traumas.


Assessment and Differential Diagnosis


All of the DSM-IV assessment instruments described earlier include the assessment of BPD. However, an instrument that is focused on the assessment of BPD is the Diagnostic Interview for Borderlines-Revised (DIB-R; Zanarini et al., 1989). The DIB-R provides a more thorough assessment of components of BPD (e.g., impulsivity, affective dysregulation and cognitive–perceptual aberrations) than is provided by more general DSM-IV-TR per-sonality disorder semi-structured interviews, but psychiatrists might find it impractical to devote up to 2 hours to assess one particular personality disorder, especially when it is likely that other maladaptive personality traits not covered by the DIB-R are also likely to be present.


Most persons with BPD develop mood disorders and it is at times difficult to differentiate BPD from a mood disorder if the assessment is confined to the current symptomatology. A diagnosis of BPD requires that the borderline symptomatology be evident since adolescence, which should differentiate BPD from a mood disorder in all cases other than a chronic mood disorder. If there is a chronic mood disorder, then the additional features of transient, stress-related paranoid ideation, dissociative experi-ences, impulsivity and anger dyscontrol that are evident in BPD should be emphasized in the diagnosis (Gunderson, 2001).


Epidemiology and Comorbidity


Approximately 1 to 2% of the general population would meet the DSM-IV criteria for BPD. BPD is the most prevalent personality disorder within maximum clinical settings. Approximately 15% of all inpatients (51% of inpatients with a personality disorder) and 8% of all outpatients (27% of outpatients with a personality disorder) have a borderline personality disorder. Approximately 75% of persons with BPD will be female. Persons with BPD meet DSM-IV-TR criteria for at least one Axis I disorder. The range of potential Axis I comorbid psychopathology includes mood (major depressive disorder), anxiety (post traumatic stress dis-order), eating (bulimia nervosa), substance (alcohol dependence), dissociative (dissociative identity disorder), and psychotic (brief psychotic) disorders (Gunderson, 2001). Persons with BPD also meet DSM-IV-TR criteria for at least one other personality dis-order, particularly histrionic, dependent, antisocial, schizotypal, or passive–aggressive. Researchers and clinicians have at times responded to this extensive cooccurrence by imposing a diag-nostic hierarchy whereby other disorders are not diagnosed in the presence of BPD because BPD is generally the most severely dysfunctional disorder (Gunderson et al., 2000). A potential limitation of this approach is that it resolves the complexity of personality by largely ignoring it. This approach may fail to rec-ognize the presence of maladaptive personality traits that could be important for understanding a patient’s dysfunctions and for developing an optimal treatment plan.




As children, persons with BPD are likely to have been emotionally unstable, impulsive and angry or hostile. Their chaotic impulsiv-ity and intense affectivity may contribute to involvement within rebellious groups as a child or adolescent, along with a variety of Axis I disorders, including eating, substance use and mood dis-orders. BPD is often diagnosed in children and adolescents but considerable caution should be used when doing so as some of the symptoms of BPD (e.g., identity disturbance and unstable rela-tionships) could be confused with a normal adolescent rebellion or identity crisis. As adults, persons with BPD may require numerous hospitalizations due to their affect and impulse dyscontrol, psy-chotic-like and dissociative symptomatology and risk of suicide. Minor problems quickly become crises as the intensity of affect and impulsivity result in disastrous decisions. They are at a high risk for developing depressive, substance-related, bulimic and post traumatic stress disorders. The potential for suicide increases with comorbid mood and substance-related disorder. Approximately 3 to 10% commit suicide by the age of 30 years. Relationships tend to be very unstable and explosive and employment history is poor. Affectivity and impulsivity, however, may begin to diminish as the person reaches the age of 30 years, or earlier if the person becomes involved with a supportive and patient sexual partner. Some, however, may obtain stability by abandoning the effort to obtain a relationship, opting instead for a lonelier but less volatile life. The mellowing of the symptomatology, however, can be eas-ily disrupted by the occurrence of a severe stressor (e.g., divorce by or death of a significant other) that results in a brief psychotic, dissociative, or mood disorder episode.




Persons with BPD often develop intense, dependent, hostile, un-stable and manipulative relationships with their therapists as they do with their peers. At one time they might be very compliant, responsive and even idealizing, but later angry, accusatory and devaluing. Their tendency to be manipulatively as well as impul-sively self-destructive is often very stressful and difficult to treat (Stone, 2000).


Persons with BPD are often highly motivated for treatment. Psychotherapeutic approaches tend to be both supportive and ex-ploratory. Therapists should provide a safe, secure environment in which anger can be expressed and actively addressed without destroying the therapeutic relationship. The historical roots of current bitterness, anger and depression within past familial rela-tionships should eventually be explored, but immediate, current issues and conflicts must also be explicitly addressed. Suicidal behavior should be confronted and contained, by hospitalization when necessary. Patients with BPD can be very difficult to treat because the focus of the patient’s love and wrath will often be shifted toward the therapist, and the treatment may itself become the patient’s latest unstable, intense relationship. Immediate and ongoing consultation with colleagues is often necessary, as it is not unusual for therapists to be unaware of the extent to which they are developing or expressing feelings of anger, attraction, annoyance, or intolerance toward their borderline patient.


A particular form of cognitive–behavioral therapy, dialecti-cal behavior therapy, has been shown empirically to be effective in the treatment of BPD (Linehan, 2000). Part of the strategy entailskeeping patients focused initially on the priorities of reducing sui-cidal threats and gestures, behaviors that can disrupt or resist treat-ment, and behaviors that affect the immediate quality of life (e.g., bulimia, substance abuse, or unemployment). Once these goals are achieved, the focus can then shift to a mastery of new coping skills, management of reactions to stress and other individualized goals. Individual therapy is augmented by skills-training groups that may be highly structured (e.g., comparable to a classroom format). Patients are taught skills for coping with identity diffu-sion, tolerating distress, improving interpersonal relationships, controlling emotions and resolving interpersonal crises. Patients are given homework assignments to practice these skills that are further addressed and reinforced within individual sessions. Neg-ative affect is also addressed through a mindful meditation that contributes to an acceptance and tolerance of past abusive experi-ences and current stress. The dialectical component of the therapy is that “the dialectical therapist helps the patient achieve synthesis of oppositions, rather than focusing on verifying either side of an oppositional argument”. An illustrative list of dialectical strategies is presented in Table 62.3.


DBT, however, also includes more general principles of treatment that are important to emphasize in all forms of therapy for BPD (Linehan, 1993; Stone, 1993, 2000), some of which are presented in Table 62.4. For example, exasperated therapists may unjustly experience and even accuse borderline patients of being unmotivated or unwilling to work. It is important to appreciate that they do want to improve and are doing the best that they can. One should not make the therapy personal, but instead identify the sources of the inhibition or interference to their motivation to change. One should take seriously their complaints that their lives are indeed unbearable but not absolve them of their responsibility to solve their own problems. They are unlikely to change simply through a passive reception of insight, nurturance, support and



medication. They will need to work actively on changing their lives. Therapists will often be tempted to rescue their patients, particularly when they are within a crisis. However, it is precisely at such times that there will be the best opportunity to develop and learn new coping strategies. Failures can occur, and it is a fail-ure of the therapy that should be conscientiously and effectively addressed by the therapist. Finally, therapists need honestly to recognize their own limitations. All therapists have their own flaws and limits and patients with BPD invariably strain and overwhelm these limits. Therapists need to be open and recep-tive to outside support, advice and criticism.


Pharmacologic treatment of patients with BPD is varied, as it depends primarily on the predominant Axis I symptomatology. Persons with BPD can display a wide variety of Axis I symptoms, including anxiety, depression, hallucinations, delusions and dis-sociations. It is important in their pharmacologic treatment not to be unduly influenced by transient symptoms or by symptoms that are readily addressed through exploratory or supportive tech-niques. On the other hand, it is equally important to be flexible in the use of medications and not to be unduly resistant to their use. Relying solely upon one’s own psychotherapeutic skills can be unnecessary and even irresponsible.


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