Borderline Personality Disorder
by Anne Brown and Kristi Dodson, NARSAD Staff Writers

The concept of 'personality' presents many problems when diagnosing psychiatric disorders. Researchers often disagree about the boundaries between personality disorders and even the distinction between healthy and unhealthy personalities. On the whole, observing someone's personality is highly subjective. The concept of personality implies certain common features in what a person thinks, feels, and does over a period of time in changing situations. But the influence of these traits is difficult to distinguish from the influence of mental disorders, passionate emotional states, common responses to stress, and imposed or adopted social roles.

A host of theories surround the origin of Borderline Personality Disorder, yet none are supported with substantial empirical evidence. The symptoms of the disorder can be briefly summarized as instability in mood, thinking, behavior, personal relations, and self-image. Although people diagnosed with this disorder cannot bear to be alone and constantly demand attention, they are often difficult to work and live with. Chronically angry, quick to take offense, and easily depressed are just some of the traits that they exhibit. They also may make unreasonable demands on friends and family, engage in provocative behavior, throw tantrums, and make suicide threats. The individual suffering from BPD feels incomplete, lacking a solid core, who is at once entirely dependent on and attached to others, and then suddenly quite able to abruptly break away.

Epidemiology

Borderline personality disorder occurs in 2 to 3% of the general population and is the most common personality disorder in clinical settings. It appears to occur about three times more often in women than in men. BPD is also approximately five times more likely among first-degree relatives than in the general population.

The Role of Child Abuse

Some researchers believe BPD patients are suffering from Post-Traumatic Stress since many of their symptoms resemble those found in physically and sexually abused children and adults who have been diagnosed with Post-Traumatic Stress Disorder, a condition that results from an overwhelming assault on the mind and emotions. About 25% of patients with BPD are also given a diagnosis of PTSD. Research suggests that BPD patients have often been subjected to physical and sexual abuse.

Because of child abuse, some borderline patients may be so vulnerable that they overreact to events that would be insignificant to most people. Although borderline personality results from traumatic stress, not all studies have found an unusually high rate of child abuse. The present consensus is that child abuse may be important in some cases but is not a necessary cause of the borderline condition.

Causes

Many researchers in the field today believe that for severe mental illness, such as BPD, there first must be an inherited biological vulnerability-or a genetic susceptibility. "This vulnerability," reports Dr. Robert Trestman, a 1993 NARSAD Young Investigator, "may then either set the stage for a "second hit" (an environmental influence that triggers the expression of the disorder), or a time linked expression that develops regardless of the environment."

Family pedigree studies have suggested that people with BPD may be non-specifically predisposed to poor regulation of impulses and moods. Other preliminary studies suggest the disregulation may be related to a low threshold of excitability of the limbic system, and deficiencies in the central serotonin function may be linked to impulsive and hostile features associated to the disorder.

Most of the time, BPD, like schizophrenia and major depression, are caused by a combination of genetic risk and environmental circumstances. Some studies have found high rates of brain injury or developmental brain damage in these patients, especially in the frontal lobes and limbic region, where injury often results in impulsiveness, irritability, and emotional instability. But most research is retrospective, beginning in adulthood, thus limiting any definitive results.

Overall, available research supports the disorder's multifactorial origins. It appears to be the result of a variety of nonspecific predisposing neuro-biological, early developmental, and socializing factors.

Self-Destructiveness and Suicide: The role of Impulsivity in the BPD Sufferer

The self-destructiveness of the borderline patient can emerge in several ways, from self-mutilation to highly lethal behaviors. These dangerous behaviors are often "communicative gestures," conveying great distress, but lacking the intent to severely harm the self. However, BPD is one of the most lethal psychiatric disorders: completed suicide is a final outcome in 3% to 9.5% of patients with BPD, only slightly less than patients with depression, alcoholism or schizophrenia. Studies have shown that demographic, psychosocial and psychiatric risk factor for suicidal behavior among borderline populations include being older and having a higher level of education, and frequent childhood loss. Those at risk often also suffer from depressed moods, substance abuse disorders, bingeing and purging, driving recklessly, and self-mutilation.

The BPD patient's physical self-damaging actions, such as cutting, burning, and punching, are common, and are usually precipitated by threats of separation from others, by rejection, or by demands of parenting or intimacy. The acts may also occur during dissociated states, when self-mutilation may help the person feel real while also expiating feelings of badness. Self mutilation does not necessarily predict suicidal behavior, but it is a "severity" marker for the disorder. Those who self-mutilate are more likely to report genuine suicidal behaviors.

Many researchers prefer to measure the degree to which patients display BPD traits and where they fall on the continuum of psychiatric disorders since the diagnosis of BPD is not highly reliable. One of these traits is substance abuse, a common symp-tom of BPD. Probably more than half have a serious alcohol or drug problem at some time in their lives, and the rate of substance abuse is also high among parents, siblings, and children.

Impulsive Aggression: The Hallmark of BPD

Impulsivity fuels many of the self-destructive actions of BPD patients. Many doctors think that BPD is a disorder that should be placed on the spectrum of impulse control disorders. Impulse control disorders include conditions like Antisocial Personality Disorder, Intermittent Explosive Disorder, and Pathological Gambling. Researchers have found that the impulsive nature of patients with these disorders, including BPD, is a serotonergically mediated personality dimension which predisposes the patient to aggressive and suicidal behaviors under duress. Serotonin is involved in the inhibition of affect and behavior at the cortical function in the brain. Using functional brain imaging with positron tomography, (PET), Dr. Yoram Yovell, a 1995 NARSAD Young Investigator, has demonstrated that impulsive aggression is also associated with low activation of parts of the prefrontal cortex involved in the processing of emotional information and inhibition of activity. While the serotonin dysfunction and the prefrontal dysfunction in impulsive aggressive patients might be linked, their relationship has not been studied directly yet.

Unfortunately, impulsivity plays a key role in self-mutilation, unstable relationships, violence, and in completed suicides. Studies have revealed that having both a current depressive episode and BPD dramatically increases the chance of suicidal behavior than does having a depressive episode alone. What this means is that depression alone usually does not result in self-destructive behavior unless there is the element of impulsivity and aggression, which are traits of BPD. However, depressed patients need not be diagnosed with BPD to exhibit impulsivity and aggression. These traits increase the risk of suicide in psychiatric illness. It just so happens that the seat of these personality traits is found in BPD.

Depression and BPD

Unstable and extreme moods are the connection between borderline personality and affective disorders. As many as 60% of these patients have had episodes of major depression, and the rate of depression in their families is high. They often complain that they are bored, their life is empty, or they do not know who they are. However, in many ways they differ greatly than those who are chronically depressed. Their moods are much more susceptible to change in response to external events, and their depression is qualitatively different, with less guilt, appetite loss, and lethargy, but more loneliness, emptiness, and boredom. They do not generally respond well to antidepressant drugs.

Treatment

Despite an estimated 20% of psychiatric patients having BPD, there are no strong guidelines for treatment. Controlled research on the treatment of personality disorder is difficult: personality is often very difficult to change, and patients may regard attempts to change it as brainwashing or punishments.

Medications

There is little controlled research on the pharmacological treatment of BPD. However, Dr. Rebecca Dulit, a 1996 NARSAD Young Investigator from Cornell University, has studied some promising leads. She reports that preliminary results from several studies suggest that "a certain class of antidepressants, selective serotonin reuptake inhibitors (SSRI), may reduce the depressive and impulsive symptoms of BPD." Dr. Dulit is also studying a psychosocial treatment called Dialectic Behavior Therapy (DBT), developed by Marsha Linehan, Ph.D. DBT combines intensive individual psychotherapy and group work to develop emotional and interpersonal skills. The new skills emphasize change and acceptance of the patient as they are, and acceptance of the moment as it is. Dr. Dulit is currently researching how the combined use of DBT and SSRI may provide a new approach to conducting system-atic medication trials in BPD and possibly lead to the development of a synergistic state-of- the-art treatment for BPD.

The therapeutic effect of SSRIs is due to their antidepressant effect, and more importantly, their enhancement of serotonin activity. The serotonin system impacts aggression and impulsive and self-destructive behavior. Improved serotonin function can diminish rage and mood changes, producing a state of mild indifference to self-criticism and self-doubt. SSRI's alone may be insufficient for some borderline patients, but because of their safety they are usually the first class of drugs to be tried.

Biological studies show inadequate regulation of serotonin, dopamine, and other neurotransmitters in patients with BPD. Monoamine oxidase (MAO) inhibitors, which prevent the breakdown of norepinephrine and other neurotransmitters, appear to be moderately helpful for patients experiencing rejection-sensitive dysphoria (excessive sensitivity to real or imagined rejection).

Several controlled studies indicate that low doses of antipsychotics may help alleviate sustained symptoms of obsessive thoughts, physical complaints, and to dissociative experiences. In the short term, neuroleptics are effective at reducing the tendency to misinterpret what others say, and the projection of rage onto others. The newer atypical antipsychotic drug, clozapine, may help control self-inflicted injury and other abusive behavior in seriously disturbed patients. A study done with patients exhibiting severe self-mutilation and/or violence showed statistically significant reductions in incidents of self-mutilation, seclusion, and injuries to staff and peers after treatment with clozapine.

Therapy

Generally, one starts treatment planning for BPD inclusively, to combine individual psychotherapy, groups and family therapy, and pharmacotherapy, as determined by the particular symptoms of the specific patient. Usually, psychotherapists attempt to modify personality traits in order to change some aspect of the patient's behavior. Many authorities disagree on how to treat the illness, but it is widely accepted that classical psychoanalysis is not effective because BPD patients cannot tolerate a psychoanalyst's silence and apparent neutrality, and often develop psychotic delusions as a result, which can be dangerous to both patient and psychotherapist. The most common treatment is individual psychotherapy (supportive or interpretive) conducted several times a week, lasting from several months to several years.

Supportive psychotherapy invol-ves a professional who helps the patient deal with immediate problems, but devotes little or no time to interpret the patient's fantasies or past experiences. The therapist makes suggestions, gives advice, or may even directly intervene in the patient's life. Supportive therapy is most helpful for preventing emotional crises, and is needed when the patient's emotional life is out of balance.

Interpretive therapy involves a more profound search for the causes and meanings of the patient's behavior. This process requires the patient to establish a relationship with the therapist as a real person in the effort to replace distorted relationships caused by inadequate and immature ego defenses, such as splitting, devaluation, projection and denial. Some therapists try to provide the comfort and affection that the borderline patient may have lacked as a child, although this approach can lead to dangerously intense transference reactions. Other therapists choose to confront these patients directly with the nature and motives of their behavior and set rules for them in the effort to prevent self-destructive behavior.

Once rules have been established and the risk of self-destructive behavior reduced, the patient is able to talk more about the relationship with the therapist and make use of childhood memories and interpretations. It is then the therapist's duty to identify, address, and modify these defenses.

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