Diagnostic Criteria
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
3. identity disturbance: markedly and persistently unstable self-image or sense of self
4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
6. affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)
7. chronic feelings of emptiness
8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
9. transient, stress-related paranoid ideation or severe dissociative symptoms
Borderline Personality Disorder
BPD is characterized by impulsivity & by instability in mood, self-image, & personal relationships. It is fairly common & is diagnosed more often in females than males.
Symptoms-
Individuals with BPD have several of the following symptoms:
+ 1. Marked mood swings with periods of intense depression, irritability &/or anxiety lasting a few hours to a few days.
+ 2. Inappropriate, intense, or uncontrolled anger.
+ 3. Impulsiveness in spending, sex, substance use, shoplifting, reckless driving, or binge eating.
+ 4. Recurring suicidal threats or self-injurious behavior.
+ 5. Unstable, intense personal relationships with extreme, black & white views of people & experiences, sometimes alternating between “all good” idealization & “all bad” devaluation.
+ 6. Marked persistent uncertainty about self-image, long term goals, friendships, values.
+ 7. Chronic boredom or feelings of emptiness.
+ 8. Frantic efforts to avoid abandonment, either real or imagined.
A person with a borderline personality disorder often experiences a repetitive pattern of disorganization and instability in self-image, mood, behavior and close personal relationships. This can cause significant distress or impairment in friendships and work. A person with this disorder can often be bright and intelligent, and appear warm, friendly and competent. They sometimes can maintain this appearance for a number of years until their defense structure crumbles, usually around a stressful situation like the breakup of a romantic relationship or the death of a parent.
Symptoms
Relationships with others are intense but stormy and unstable with marked shifts of feelings and difficulties in maintaining intimate, close connections. The person may manipulate others and often has difficulty with trusting others. There is also emotional instability with marked and frequent shifts to an empty lonely depression or to irritability and anxiety. There may be unpredictable and impulsive behavior which might include excessive spending, promiscuity, gambling, drug or alcohol abuse, shoplifting, overeating or physically self-damaging actions such as suicide gestures. The person may show inappropriate and intense anger or rage with temper tantrums, constant brooding and resentment, feelings of deprivation, and a loss of control or fear of loss of control over angry feelings. There are also identity disturbances with confusion and uncertainty about self-identity, sexuality, life goals and values, career choices, friendships. There is a deep-seated feeling that one is flawed, defective, damaged or bad in some way, with a tendency to go to extremes in thinking, feeling or behavior. Under extreme stress or in severe cases there can be brief psychotic episodes with loss of contact with reality or bizarre behavior or symptoms. Even in less severe instances, there is often significant disruption of relationships and work performance. The depression which accompanies this disorder can cause much suffering and can lead to serious suicide attempts.
Etiology
It is a common disorder with estimates running as high as 10-14% of the general population. The frequency in women is two to three times greater than men. This may be related to genetic or hormonal influences. An association between this disorder and severe cases of premenstrual tension has been postulated. Women commonly suffer from depression more often than men. The increased frequency of borderline disorders among women may also be a consequence of the greater incidence of incestuous experiences during their childhood. This is believed to occur ten times more often in women than in men, with estimates running to up to one-fourth of all women. This chronic or periodic victimization and sometimes brutalization can later result in impaired relationships and mistrust of men and excessive preoccupation with sexuality, sexual promiscuity, inhibitions, deep-seated depression and a seriously damaged self-image. There may be an innate predisposition to this disorder in some people. Because of this there may ensue subsequent failures in development in the relationship between mother and infant particularly during the separation and identity-forming phases of childhood.
Treatment
Treatment includes psychotherapy which allows the patient to talk about both present difficulties and past experiences in the presence of an empathetic, accepting and non-judgemental therapist. The therapy needs to be structured, consistent and regular, with the patient encouraged to talk about his or her feelings rather than to discharge them in his or her usual self-defeating ways. Sometimes medications such as antidepressants, lithium carbonate, or antipsychotic medication are useful for certain patients or during certain times in the treatment of individual patients. Treatment of any alcohol or drug abuse problems is often mandatory if the therapy is to be able to continue. Brief hospitalization may sometimes be necessary during acutely stressful episodes or if suicide or other self-destructive behavior threatens to erupt. Hospitalization may provide a a temporary removal from external stress. Outpatient treatment is usually difficult and long-term – sometimes over a number of years. The goals of treatment could include increased self-awareness with greater impulse control and increased stability of relationships. A positive result would be in one’s increased tolerance of anxiety. Therapy should help to alleviate psychotic or mood-disturbance symptoms and generally integrate the whole personality. With this increased awareness and capacity for self-observation and introspection, it is hoped the patient will be able to change the rigid patterns tragically set earlier in life and prevent the pattern from repeating itself in the next generational cycle.
Causes-
The causes of BPD are unclear, although psychological & biological factors may be involved. Originally thought to “border on” schizophrenia, BPD now appears to be more related to serious depressive illness. In some cases, neurological or attention deficit disorders play a role. Biological problems may cause mood instability & lack of impulse control, which in turn may contribute to troubled relationships. Difficulties in psychological development during childhood, perhaps associated with neglect, abuse, or inconsistent parenting, may create identity & personality problems. More research is needed to clarify the biolological &/or psychological factors causing BPD.
Treatments
-A combination of psychotherapy & medication appears to provide the best results for treatment of BPD. Medications can be useful in reducing anxiety, depression, & disruptive impulses. Relief of such symptoms may help the individual deal with harmful patterns of thinking & interacting that disrupt daily activities. However, medications do not correct ingrained character difficulties. Long-term outpatient psychotherapy & group therapy (if the individual is carefully matched to the group) can be helpful. Short-term hospitalization may be necessary during times of extreme stress, impulsive behavior, or substance abuse. While some individuals respond dramatically, more often treatment is difficult & long term. Symptoms of the disorders are not easily changed & often interfere with therapy. Periods of improvement may alternate with periods of worsening. Fortunately, over time, most individuals achieve a significant reduction in symptoms & improve functioning.
Co-existing Disorders-
Other disorders may also be present. Determining whether other psychiatric disorders may be involved is critical. BPD may be accompanied by serious depressive illness (including bipolar disorder), eating disorders, & alcohol or drug abuse. About 50% of people with BPD experience episodes of serious depression. At these times, the “usual” depression becomes more intense & steady, & sleep & appetite disturbances may occur or worsen. These symptoms, & the other disorders mentioned above, may require specific treatment. A neurological evaluation may be necessary for some individuals. Medications-Antidepressants, anticonvulsants, & short-term use of neuroleptics are common for BPD. Decisions about medication use should be made cooperatively between the individual & the therapist. Issues to be considered include the person’s willingness to take the medication as prescribed, & the possible benefits, risks, & side effects of the meds, particularly the risk of overdose. Dr. Allen Frances, Payne Whitney, 525 E. 68, NYC 10021, 472-5909
Drug treatments for Borderline Personality Disorder
By Carl Salzman, M.D. Professor of Psychiatry at Harvard Medical School
Borderline personality is a disorder with a variety of symptoms that can be briefly summarized as instability in mood, thinking, behavior, personal relations, and self-image. Borderline patients are moody, self-destructive, and sometimes subject to transient disorders of thinking. They suffer greatly and inflict much suffering on others. In its milder forms, borderline personality may be a type of mood disorder; the more severe forms may result from sexual and physical abuse. Often patients have never had a reliable emotional attachment to their parents.
Biological studies show inadequate regulation of serotonin, dopamine, and other neurotransmitters in patients with borderline personality. Monoamine oxidase (MAO) inhibitors, antidepressants that prevent the breakdown of norepinephrine and other neurotransmitters, have proved moderately helpful for borderline patients with rejection-sensitive dysphoria–excessive sensitivity to real or imaged rejection. But MAO inhibitors cause weight gain and sexual problems and can be lethal when taken in combination with stimulants or with foods containing the substance tyramine. Neuroleptics (antipsychotic drugs) in low doses are useful short term to reduce thinking disturbances, especially the tendency to misinterpret what others say and project hostility and rage onto others. The newer atypical neuroleptic drug clozapine may also help to control self-inflected injury and other abusive behavior in the most seriously disturbed patients.
A major breakthrough in the treatment of mild to moderate cases of borderline personality has been the introduction of selective serotonin reuptake inhibitors (SSRIs): fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil). Some have claimed that these drugs can actually change a patient’s personality. Although that is not likely to occur, SSRIs are useful in reducing anger, impulsiveness, and mood instability.
This therapeutic effect is due not only to their antidepressant activity but, more specifically to their enhancement of serotonin transmission. The serotonin system influences aggression and impulsive and self-destructive behavior. Enhanced serotonin function may improve the personal relationships of borderline patients by diminishing rage and mood changes and therefore producing a state of mild indifference to self-criticism and self-doubt. The therapeutic alliance is one of the relationships improved by SSRIs, and the resulting enhancement of the psychotherapeutic process is often striking. SSRIs are also used to treat obsessive-compulsive disorder, and there is evidence that they reduce obsessive ruminations in borderline patients. Yet to be seen is whether newer serotonin-enhancing antidepres-sants such as venlafaxine and nefa-zodone will be as effective.
SSRIs alone may be insufficient for some borderline patients, at least in the early stages of treatment. These patients may also need benzodiazepines for anxiety, restlessness, and sleeplessness. Care must be taken in prescribing these drugs, because borderline patients are more likely than others to overuse or misuse them. Borderline patients whose moods swing rapidly from depression or rage to elation may be helped by the addition of a mood stabilizer such as lithium, valproate, or carbamazepine. Very low doses of neuroleptics (anti-psychotic drugs) may reduce distortions of reality and communications. (Sept. 96, Harvard Mental Health Letter)