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. 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. Yet, with help, many
improve over time and are eventually able to lead productive lives.
Symptoms of BPD
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. 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.
Treatment of BPD
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. 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.
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. Forty to 71 percent of BPD
patients report having been sexually abused, usually by a non-caregiver.
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 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 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.
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.
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.
Borderline Personality Disorder
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