Borderline Personality Disorder: Raising questions, finding answers
What is Borderline Personality Disorder?
Borderline personality disorder (BPD) is a serious mental illness characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior. It is a diagnosis given to individuals who display several or all of the following behavioral symptoms:
Fear of being abandoned or left alone
Having unstable relationships that alternate between love and hate for another
Having an unstable self-image or no identity
Engaging in impulsive behaviors (gambling, spending, shoplifting, sex, substance abuse, binge eating)
Making suicidal threats, gestures, attempt, and/or engaging in self-injurious behaviors (cutting)
Having intense mood swings and emotional overreactions
Having feelings of emptiness
Experiencing intense and inappropriate anger and having trouble controlling anger
Being paranoid or losing a sense of reality
These behaviors and the related instability often disrupt family and work life, long-term planning, and the individual's sense of self-identity. Interpersonal relationships and the quality of life are poor because of the constant "drama" and emotional turmoil.
Originally thought to be at the "borderline" of psychosis, people with BPD suffer from a disorder of emotional regulation. While less well known than schizophrenia or bipolar disorder (manic-depressive illness), BPD is more common, affecting 2 percent of adults. Although women are more likely than men to receive a BPD diagnosis, men also suffer from this disorder and it is not clear why they are often misdiagnosed.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.
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.
Description of 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 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.
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.
The goal of DBT is to help individuals with BPD create a HIGHER QUALITY OF LIFE. This is done through therapeutic techniques that include mindfulness, cognitive restructuring, and psycho-education designed to teach new skills designed to:
Eliminate suicidal and other life-threatening behaviors like cutting or self mutilation.
Correct distorted thinking patterns that result in depression, anxiety, eating disorders, problems with relationships, family. or work.
Improve attention and the ability to be present and aware (mindfulness).
Improve interpersonal relationships.
Achieve emotional balance by understanding emotional triggers.
Increase discomfort threshold and learn to tolerate emotional pain.
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
The outlook depends on how severe the condition is and whether the person is willing to accept help. Motivation and perseverance are the key to recovery. With long-term talk therapy, the person will often gradually improve.
Call your health care provider if you or your child has symptoms of borderline personality disorder. It is especially important to seek help right away if you or your child is having thoughts of suicide.
Recent Research Findings
Causes, incidence, and risk factors
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 Risk factors for BPD include:
Abandonment in childhood or adolescence
Disrupted family life
Poor communication in the family
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 judgment in choosing partners and lifestyles. NIMH-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 amygdale, 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, depending on the severity and symptoms, medications, much like people manage susceptibility to diabetes or high blood pressure.
Additional Information Online:
American Psychiatric Association. (2009). www.HealthyMinds.org
Anxiety Disorders Association of America. www.adaa.org
National Institute of Mental Health. (2009, March 30). Anxiety disorders. Retrieved June 16, 2009, from http://www.nimh.nih.gov/health/publications/anxiety-disorders/complete-index.shtml
National Mental Health Organization. (2009). Fact sheet: Anxiety disorders. Retrieved June 16, 2009, from http://www.mentalhealthamerica.net/go/information/get-info/anxiety-disorders
Burns, D. (1999). The feeling good handbook. Penguin: New York, NY
Forsyth, J. P. (2008). The mindfulness and acceptance workbook for anxiety: A guide to breaking free from anxiety, phobias, and worry using acceptance and commitment therapy. New Harbinger Publications.
Greenberger, D. (1995). Mind over mood: Change how you feel by changing the way you think. Guilford Press: New York, NY
The information on this page is provided for informational purposes only and does not replace in any way a formal medical or psychiatric evaluation or suggest a diagnosis. If you suspect you may be experiencing any symptoms we would recommend you seek an evaluation by a psychiatrist or mental health professional. All therapy should begin with seeking any medical reasons for the presenting problem.
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