Borderline Personality Disorder

What Is It?

Borderline personality disorder is characterized by poor self-image, great difficulty coping with loneliness and feeling empty. People with this disorder have unstable relationships, highly reactive and intense moods, and impulsive behavior. They are more likely to attempt or commit suicide. 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.

When stressed, people with borderline personality disorder may develop psychoticlike symptoms. They experience a distortion of perception or belief rather than a distinct break with reality. Especially in close relationships, they tend to misinterpret or amplify what other people feel about them. For example, they may assume persecutory or hateful feelings when a friend or family member may be only mildly annoyed or angry.

Personality disorders probably are caused by both environmental and biological factors. Some researchers have suggested that borderline personality disorder springs from an abusive or neglectful childhood. A significant number of people with this disorder report a history of abuse in childhood.

Experts also have suggested that people with this disorder may have inherited difficulties regulating their anxiety or moods. They may be more vulnerable to loss or more sensitive to stress. Scientists have begun to see how people with borderline personality disorder are biologically different from people without this disorder. In some of these people, specific brain regions show alterations in size and function. Researchers have also discovered change in hormone levels and the immune system.

People with borderline personality disorder have a deep fear of abandonment. 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.

The flip side of the fear is the hope that a relationship will be completely soothing. These people may idealize a family member, romantic partner or friend, then become enraged when an inevitable disappointment occurs. They might hold that person responsible for the pain they feel and devalue the relationship.

It is quite common for people with borderline personality disorder to also have a mood disorder, eating disorder or substance abuse problem. The person may turn to alcohol or drugs to escape from painful, uncontrollable emotions. There is no clear line between a personality style and a disorder. Personality patterns are considered to be a disorder when they impair a person's functioning and cause stress.

Three times as many women as men are diagnosed with borderline personality disorder. It occurs in about 2% of the population in the United States.

Symptoms

It is normal to feel vulnerable, so most people have experienced some of the symptoms on this list. The diagnosis of borderline personality disorder is made only when someone has had many of these symptoms to a severe degree, over a long period.

• Unstable, intense and difficult relationships
• Poor self-image
• Self-destructive, impulsive behavior
• Suicidal threats or attempts
• Self-mutilation
• Extreme mood reactions, including intense, inappropriate anger
• Feeling empty or alone
• Fear of abandonment
• Short-lived psychoticlike distortions of perception or belief, especially under stress

Diagnosis

The diagnosis is made on the basis of a person's history, usually by a mental health professional. There are no laboratory tests to determine whether someone has a personality disorder. Since there is often an overlap with mood disorder or substance abuse, these possibilities should be considered in anyone who has the symptoms of borderline personality disorder.

Expected Duration

All personality disorders are lifelong patterns.

Prevention

There is no way to prevent borderline personality disorder.

Treatment

Psychotherapy is a key part of the treatment of borderline personality disorder.

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.

It's not enough for a person with this disorder to learn coping strategies on an intellectual level. The person has to learn how to tolerate the emotional discomfort that is common in relationships and to manage their intense emotions more successfully.

A form of treatment called dialectical behavior therapy (DBT) tries to take the special problems of borderline personality disorder into account, using a combination of psychotherapy techniques, education, and both individual and group psychotherapy to support the patient's progress.

At first, treatment aims at helping the person endure feeling isolated, depressed or anxious without resorting to self-destructive behavior. To accomplish this, hospitalization sometimes is necessary.

Outside the hospital, a person with borderline personality disorder may need additional support, such as day-treatment programs, residential treatment, or group, couples or family therapy.

There have been relatively few controlled studies of psychotherapy for borderline personality disorder. Since the problems in this disorder vary widely, the researchers tend to study a few factors at a time. In some studies, DBT has reduced the frequency of self-harm and the intensity of suicidal thinking. It has also been shown to reduce the intensity of symptoms of depression or anxiety. In a study of psychoanalytically oriented psychotherapy conducted in a partial hospital, patients receiving this type of treatment needed less psychotropic medication, had lower anxiety and depression scores, and had better social adjustment.

As with psychotherapy, there is no single medication that is clearly helpful in borderline personality disorder. Instead, medication is usually used to treat symptoms as they emerge. Antidepressants, such as the selective serotonin reuptake inhibitors (SSRIs) can be used for depression and anxiety. There is also some evidence that this group of drugs reduce anger. SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil) and citalopram (Celexa). Sometimes, a mood stabilizer is added or used by itself. These include lithium (Lithobid and other brand names), divalproex sodium (Depakote) or topiramate (Topamax). Antipsychotic medication, such as risperidone (Risperdal) or olanzapine (Zyprexa), may be tried if the person's thinking is distorted.

People with borderline personality disorder are more likely than average to commit suicide. They should discuss self-destructive impulses with their health care professionals and make specific plans for what to do to get help when these thoughts or impulses arise.

When To Call a Professional

Because personality styles tend to become more entrenched with age, it is best to seek treatment as soon as significant distress or poor functioning is noticed.

Prognosis

The course of this illness varies and depends on the severity of the symptoms; the amount of stress; the availability of support; the degree of functional impairment; the extent of self-destructive or suicidal behavior; and the presence of other psychiatric disorders, such as depression or substance abuse. It also depends on the person's ability to stay in treatment. Some people are quite resolute and courageous about their treatment and are able to bear deep disappointment, even though it may be very difficult. Others, however, find themselves in a cycle of seeking help, then feeling rejected and rejecting the help.

Also, because this disorder is difficult to treat, some people find themselves poorly matched with a clinician, and the treatment turns out to be ineffective. As in the person's life, it is difficult for him or her to distinguish between real and exaggerated disappointment in a treatment setting. Many researchers are now more optimistic about the long-term outcomes in borderline personality disorder. With persistence, many people with this disorder eventually can resolve painful problems and have fewer symptoms, which ultimately leads to more comfortable relationships and satisfying life achievements.

Additional Info

American Foundation for Suicide Prevention

120 Wall St.

22nd Floor

New York, NY 10005

Phone: 212-363-3500

Toll-Free: 1-888-333-2377

Fax: 212-363-6237

Email: inquiry@afsp.org

http://www.afsp.org/index-1.htm

American Psychiatric Association

1000 Wilson Blvd.

Suite 1825

Arlington, VA 22209-3901

Phone: 703-907-7300

Toll-Free: 1-888-357-7924

Email: apa@psych.org

Web site: http://www.psych.org/Public information site: http://www.healthyminds.org/

American Psychological Association

750 First St., NE

Washington, DC 20002-4242

Phone: 202-336-5510

Toll-Free: 1-800-374-2721

TTY: 202-336-6123

http://www.apa.org/

National Alliance for the Mentally Ill

Colonial Place Three

2107 Wilson Blvd.

Suite 300

Arlington, VA 22201-3042

Phone: 703-524-7600

Toll-Free: 1-800-950-6264

TTY: 703-516-7227

Fax: 703-524-9094

http://www.nami.org/

National Institute of Mental Health

Office of Communications

6001 Executive Blvd.

Room 8184, MSC 9663

Bethesda, MD 20892-9663

Phone: 301-443-4513

Toll-Free: 1-866-615-6464

TTY: 301-443-8431

Fax: 301-443-4279

Email: nimhinfo@nih.gov

http://www.nimh.nih.gov/