Borderline Personality Disorder (BPD)

Borderline Personality Disorder (BPD) is a long-lasting and complex mental health ailment that is associated with considerable social and vocational impairments and greater use of medical services. BPD has affective, impulsive, interpersonal, and cognitive distortion symptoms. BPD patients have a pervasive pattern of instability in interpersonal relationships, self-image and affects, and marked impulsivity. This disorder is associated with highly polymorphic symptoms and signs. 

Borderline personality disorder affects approximately 0.7% to 2.7% of adults. considerably higher rates of BPD were found in women compared with men. (nearly 75% of people diagnosed with BPD are women).  BPD is caused by a complex combination of genetic, social, and psychological factors.

The researchers have found structural brain abnormalities in borderline personality disorder. BPD has been linked to the amygdala and limbic systems of the brain, the centers that control emotion and, particularly, rage, fear, and impulsive automatic reactions. Studies have shown that the hippocampus and amygdala may be as much as 16% smaller in people with BPD.  Positron emission tomography (PET) scans have generally shown that people with BPD show hypometabolism of glucose in their prefrontal cortex and limbic system.

The term borderline personality disorder was coined in 1938 by Adolph Stern, a psychoanalyst who viewed the symptoms of BPD as being on the borderline between psychosis and neurosis. He noticed significant mood-related symptoms including masochistic behavior and psychic rigidity, indicating a protective mechanism against any perceived changes in the environment or within the individual.

Individuals with BPD show deficits across a number of domains of adaptive personality functioning. From a psychodynamic perspective, a hallmark of BPD is a lack of integration of self-representations.  Kernberg (1975) proposed that borderline phenomena follow from a failure to integrate representations of good and bad aspects of the self and others. According to Masterson (1976), borderline dynamics develop in a relationship with a caregiver who has her own tremendous difficulties with separation and emotion regulation.

Borderline personality disorder (BPD) can cause a wide range of symptoms. BPD is characterized by unstable behavior, unstable emotions, unstable relationships, and awareness problems. Borderline Personality Disorder causes disturbances of personal identity, and they view things in extremes. People with BPT have difficulty managing their emotions and often they have a loss of emotional control with anger issues, especially self-loathing.

They experience intense mood swings and volatile interpersonal relationships, and it can swing from extreme closeness to extreme dislike. Their relationships are chaotic and unstable. They have difficulty developing and sustaining trusting relationships. They have turbulent, erratic, and intense relationships. They make quick decisions and act impulsively and recklessly. They are affected by distorted and unstable self-image, unstable sense of self with chronic feelings of emptiness, and feelings of existential anguish. They experience a painful sense of incoherence. Some have stress-related paranoia. They live with constant emotional pain with psychosocial impairment.

People with BPD engage in self-destructive behavior or self-sabotage with dramatic and erratic behaviors. Cognitive distortion aka black-and-white thinking often seen in BPD. They view situations, people, and even self-perception in extreme, all-or-nothing terms. Behavioral minimization (having no accountability for actions or behaviors) can be identified in them.

An extreme fear of abandonment is a common symptom of BPD. They have an intense fear of abandonment with a sense of instability and insecurity. They experience a profound attachment insecurity with poor attachment interactions. They try to avoid real or imagined abandonment.  This fear can lead to the need for frequent reassurance and can lead to unhealthy attachments. They become, codependent or sometimes sabotage their relationships. When they feel that they are about to be abandoned, they typically become fearful and angry. The intensity of their reaction reflects their sensitivity to rejection. 

Guilt and shame play a major role in their lives.  Sometimes they are impacted by temporary paranoid thoughts. Transient, stress-related paranoid ideation is common among the patients. Moreover, they have impulsivity, disrupted interpersonal interactions (splitting behaviors of family, friends, and coworkers), low distress tolerance, emotional dysregulation, high emotional sensitivity, highly variable moods, poor boundaries between self and others, impairment in self-concept, sudden shifts in identity, alterations in self-image, maladaptive attempts at self-soothing, sexual promiscuity, chronic boredom, poor ability for self-direction, inappropriate, intense anger and depressive symptoms.

Borderline personality disorder (BPD) is associated with suicidal behaviors and self-harm and has a mean of three-lifetime suicide attempts. Up to 10% of BPD patients will die by suicide. Self-punishing and self-mutilation behaviors are common among the BPD patients. Self-harm behaviors (non-suicidal self-injury) usually present as superficial cuts to the wrists and arms.  Often, they threaten to harm themselves for manipulative purposes.

People with BPD lack insight into their disruptive behavior and thought patterns. They have an inability to move on from or process their emotions. Some of the patients have dissociative symptoms. (about 40%–50% of patients with the disorder have brief periods of psychotic symptoms or dissociation).

The Karpman drama triangle is evident in BPD. The triangle consists of the persecutor, the rescuer, and the victim. It indicates a destructive pattern of social behavior. They have an impaired ability to pursue meaningful short-term goals with satisfaction.

Some experts view BPD symptoms as a way to cope with childhood trauma. The prevalence of traumatic life events such as abuse and abandonment in childhood is high among those with borderline personality disorder. Up to 70% of people with BPD have experienced childhood trauma. In addition, borderline personality disorder runs in families. It’s estimated that 1.4% of the adult U.S. population experiences BPD.   

Common co-morbid psychiatric conditions associated with borderline personality disorder include depression, bipolar disorder, anxiety disorder, sleep disorder, and substance abuse.

Unfortunately, people living with BPD are often stigmatized and avoided by treatment providers. Often the patients sabotage the treatment interventions. Emotional manipulation is also a common factor. Furthermore, they tend to attack the therapist or make allegations against the service provider.

The central elements of treatment are psychoeducation, self-management, improved stress tolerance and awareness, emotion management, and training in social competence. Social rehabilitation can be the most important therapeutic measure. Traditional “talk” therapies have little success in Borderline Personality Disorder (BPD) and Dialectical Behavioral Therapy (DBT), schema-focused therapy (SFT) has proven more effective.  

Dialectical Behavioral Therapy (DBT) components are interpersonal (communication), distress tolerance, emotional regulation, and mindfulness. DBT provides more awareness of the current moment. Psychodynamic psychotherapy is one of the accepted treatments for BPD. Cognitive behavioral therapy (CBT) focuses on assisting the patient to see difficult experiences, interactions, or relationships more clearly. CBT helps to identify and change core beliefs and behaviors that come from inaccurate perceptions and problems interacting with others.

Many of the specialized psychotherapies help patients with BPD, but long-term functional recovery is difficult. Early identification of patients with BPD and early intervention may allow these patients to resume a healthier trajectory. However, remission is more common as people reach the middle years of life.

Written and compiled by Ruwan M Jayatunge M.D.