Borderline Personality
Disorder
Raising Questions, Finding Answers
A brief overview
that focuses on the symptoms,
treatments, and research findings.
(2001)
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
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NIH Publication No.
01-4928
