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Borderline Personaility Disorder

Borderline Personality Disorder

Borderline Personaility Disorder

Borderline personality disorder is often a devastating mental health condition, both for the people who have it and for those around them. 

Understanding Borderline Personality Disorder

Borderline personality disorder (BPD) is a disorder characterized primarily by emotional dysregulation, extreme "black and white" thinking (believing that something is one of only two possible things, and ignoring any possible "in-betweens"), and turbulent relationships. It is also characterized by pervasive instability in mood, interpersonal relationships, self-image, identity, and behavior, and a disturbance in the individual's sense of self.

People diagnosed with borderline personality disorder live in a world of inner and outer turmoil. They have difficulty regulating their emotions and are often in a state of upheaval. They have distorted images of themselves, often feeling worthless and fundamentally bad or damaged.  And while they yearn for loving relationships, people with borderline personality disorder typically find that their anger, impulsivity, stormy attachments and frequent mood swings push others away.  The disturbances suffered by those with borderline personality disorder have a wide-ranging and pervasive negative impact on many or all of the psychosocial facets of life, including employability and relationships in work, home and social settings. Furthermore, borderline personality disorder may be marginalized by society due to their moods and behaviors.

People with borderline personality disorder have unstable relationships, highly reactive and intense moods, and impulsive behavior. Sometimes they harm themselves (for example, cutting or burning) as a form of self-punishment or to combat a numb feeling. At those times, suicide is not the goal although persons with borderline personality disorder have a high suicide rate.

Diagnosis of Borderline Personality Disorder

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), the widely-used American Psychiatric Association guide for clinicians seeking to diagnose mental disorders, 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.

Signs and Symptoms of Borderline Personality Disorder

While a patient with depression or bipolar disorder typically endures the same mood for weeks, a person with borderline personality disorder may experience intense bouts of depression, anxiety, or anger that may last only minutes, hours, or at most a day. These may be associated with episodes of self-injury, impulsive aggression, and drug abuse or alcohol abuse. Difficulties in cognition and sense of self can lead to frequent changes in long-term goals, career plans, jobs, gender identity, sexual orientation, friendships, and values.  Sometimes people with borderline personality disorder 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 borderline personality disorder feel isolated and lacking in social support, and may result in frantic efforts to avoid being alone.

People with borderline personality disorder 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 trust for the other person, but when a separation or conflict occurs that others may see as slight (e.g., a minor argument), they can lose their sense of attachment and trust and may become withdrawn or angry.

People with borderline personality disorder have a deep fear of abandonment. This can occur with family members, health professionals and friends, as well as partners.  They compete for social acceptance, are terrified of rejection and often feel lonely even in the context of an intimate relationship. Therefore, it is more difficult for them to manage the normal ups and downs of a romantic partnership. Impulsive, self-destructive behavior may be an attempt to ward off rising anxiety related to the fear of being left alone.  Suicide attempts or self-injury may occur along with anger at perceived abandonment and disappointments.

As a consequence of difficulties with emotional regulation and maintaining some social boundaries, people with borderline personality disorder can sometimes make rapid and seemingly deep connections with others, marked by unrealistically high levels of mutual admiration.  They can also feel overwhelmed by others, or be taken advantage of.  Due to the inherent instability of such relationships, and unresolved issues for the person with borderline personality disorder (particularly in matters of trust and self-worth), they are prone to react strongly to apparent slights and reverse their over-positive view. This can be experienced by others as unexpected hostility or betrayal, and can also be confusing and painful for the person with borderline personality disorder.

People with borderline personality disorder exhibit other impulsive behaviors, such as excessive spendinggambling, binge eating and risky sex. Borderline personality disorder often occurs together with other mental health problems, particularly bipolar disorder, depression, anxiety disorders, substance abuse, and other personality disorders.  The depression which accompanies this disorder can cause much suffering and can lead to serious suicide attempts.

Causes and Influences of Borderline Personality Disorder

Personality disorders probably are caused by both environmental and biological factors. Researchers commonly believe that borderline personality disorder results from a combination that can involve individual genetic vulnerability and environmental stress, neglect or abuse as young children, and maturational events during adolescence or adulthood.

While less well known than schizophrenia or bipolar disorder (manic-depressive illness), borderline personality disorder is more common, affecting about 2% of the population in the United States (with some estimates running as high as 10-14%).  Three times as many women as men are diagnosed with borderline personality disorder.  The increased frequency of borderline disorders among women may be related to genetic or hormonal influences, but it could also be a consequence of the greater incidence of incestuous experiences during their childhood. This is believed to occur ten times more often in women than in men, with estimates running to up to one-fourth of all women. This chronic or periodic victimization and sometimes brutalization can later result in impaired relationships and mistrust of men and excessive preoccupation with sexuality, sexual promiscuity and sexual addiction, sexual inhibitions, deep-seated depression and a seriously damaged self-image.

Numerous studies have shown a strong correlation between childhood abuse and development of borderline personality disorder.  Many individuals with borderline personality disorder report having had a history of abuse, neglect, or separation as young children.  Parents (of both sexes) were typically reported to have withdrawn from the child emotionally, and to have treated the child inconsistently. Additionally, females with borderline personality disorder who have reported a previous history of neglect by a female caretaker and abuse by a male caretaker were consequently at significantly higher risk for being sexually abused by a non caretaker (not a parent).

Experts also have suggested that people with borderline personality disorder may have inherited difficulties regulating their anxiety or moods. They may be more vulnerable to loss or more sensitive to stress.  Some studies of twins and families suggest that personality disorders may be inherited.

Some research shows changes in certain areas of the brain involved in emotion regulation, impulsivity and aggression. In addition, certain brain chemicals that help regulate mood, such as serotonin, may not function properly.

Treatment of Borderline Personality Disorder

While there has traditionally been skepticism about the psychological treatment of personality disorders, several specific types of psychotherapy for borderline personality disorder have developed in recent years and psychotherapy now appears to be a key part of the treatment of borderline personality disorder.  Psychotherapy may be individual or group-based, and may involve sessions over several months or, particularly for personality disorders, even several years.

There can be unique challenges in the treatment of borderline personality disorder.  In regard to psychotherapy, borderline personality disorder is associated with fear of abandonment and acting out of fear, and a client may attempt to reject a therapist before the possibility that the therapist rejects them. Those who exhibit sensitivity and turbulence in their relationships may also replicate them with their therapist too. The problems in this disorder are related to the person's habitual ways of relating to others and coping with obstacles. People with this disorder tend either to idealize the therapist or to become frustrated easily. They have exaggerated reactions to disappointment. Therefore, it may be difficult for them to sustain a relationship with a mental health professional. This disorder tests the skill of therapists, who have to use a combination of techniques to be effective.

Cognitive Behavioral Therapy (CBT) is the most widely used and established psychological treatment for mental disorders, but has appeared less successful in borderline personality disorder, due partly to difficulties in developing a therapeutic relationship and treatment adherence.   Within the past 15 years, a new psychosocial treatment termed dialectical behavior therapy (DBT) was developed specifically to treat borderline personality disorder, and this technique has looked promising in treatment studies.  Dialectical behavior therapy is derived from cognitive-behavioral therapy techniques but emphasizes an exchange and negotiation between therapist and client, between the rational and the emotional, and between acceptance and change (hence dialectic). Treatment targets are agreed upon, with self-harm issues taking priority.

As with psychotherapy approaches, there is no single medication that is clearly helpful in treating borderline personality disorder. Instead, medication is usually used to treat symptoms as they emerge.  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.  In practice, psychotherapy and medication are often combined.

Additional Information

For more information about borderline personality disorder or other mental health problems, please click on the linked websites listed below.

 Borderline Personality Disorder Central
 NIHM on borderline personality disorder

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