Borderline Personality Disorder
Raising questions, finding answers
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 worthless. 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 impulsivity, 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
1 Swartz 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.
2 Soloff 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.
3 Gardner DL, Cowdry RW. Suicidal and parasuicidal behavior in
borderline personality disorder. Psychiatric Clinics of North
America, 1985; 8(2): 389-403.
4 Zanarini MC, Frankenburg FR. Treatment histories of borderline
inpatients. Comprehensive Psychiatry, in press.
5 Zanarini 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.
6 Koerner K, Linehan MM. Research on dialectical behavior therapy
for patients with borderline personality disorder. Psychiatric
Clinics of North America, 2000; 23(1): 151-67.
7 Siever LJ, Koenigsberg HW. The frustrating no-mans-land of
borderline personality disorder. Cerebrum, The Dana Forum on
Brain Science, 2000; 2(4).
8 Zanarini MC, Frankenburg. Pathways to the development of
borderline personality disorder. Journal of Personality
Disorders, 1997; 11(1): 93-104.
9 Zanarini MC. Childhood experiences associated with the
development of borderline personality disorder. Psychiatric
Clinics of North America, 2000; 23(1): 89-101.
10 Davidson RJ, Jackson DC, Kalin NH. Emotion, plasticity, context
and regulation: perspectives from affective neuroscience.
Psychological Bulletin, 2000; 126(6): 873-89.
11 Davidson 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: National Institute of Mental Health, Publication No.01-4928