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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PH, Lis JA, Kelly T, Cornelius J, Ulrich
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DL, Cowdry RW. Suicidal and parasuicidal
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Psychiatric Clinics of North America, 1985;
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MC, Frankenburg FR. Treatment histories
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RJ, Jackson DC, Kalin NH. Emotion, plasticity,
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RJ, Putnam KM, Larson CL. Dysfunction in
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NIH Publication No. 01-4928
