Borderline Personality Disorder

Borderline personality disorder - Wikipedia, the free encyclopedia
http://en.wikipedia.org/wiki/Borderline_personality_disorder
Borderline personality disorder

From Wikipedia, the free encyclopedia
Borderline personality disorder (BPD) is a personality disorder described as a prolonged disturbance of personality function in a person (generally over the age of eighteen years, although it is also found in adolescents), characterized by depth and variability of moods.[n 1] The disorder typically involves unusual levels of instability in mood; blackand-white thinking, or splitting; the disorder often manifests itself in idealization and devaluation episodes, as well as chaotic and unstable interpersonal relationships, self-image, identity, and behavior; as well as a disturbance in the individual's sense of self. In extreme cases, this disturbance in the sense of self can lead to periods of dissociation.[1] Splitting in BPD includes a switch between idealizing and demonizing others. This, combined with mood disturbances, can undermine relationships with family, friends, and co-workers. BPD disturbances also may include self-harm.[2] Without treatment, symptoms may worsen, leading (in extreme cases) to suicide attempts.[n 2]
Borderline personality disorder

Classification and external resources ICD-10 F60.3 (http://apps.who.int /classifications/icd10/browse /2010/en#/F60.3) 301.83 (http://www.icd9data.com /getICD9Code.ashx?icd9=301.83)
ICD-9
MedlinePlus 000935 (http://www.nlm.nih.gov /medlineplus/ency/article /000935.htm) eMedicine article/913575 (http://emedicine.medscape.com /article/913575-overview) MeSH D001883 (http://www.nlm.nih.gov /cgi/mesh /2011/MB_cgi?field=uid& term=D001883)
There is an ongoing debate among clinicians and patients worldwide about terminology and the use of the word borderline,[3] and some have suggested that this disorder should be renamed.[4] The ICD-10 manual has an alternative definition and terminology to this disorder, called Emotionally unstable personality disorder. There is related concern that the diagnosis of BPD stigmatizes people and supports pejorative and discriminatory practices.[5]
Contents
1 Signs and symptoms 2 Diagnosis 2.1 Diagnostic and Statistical Manual 2.2 International Classification of Disease 2.3 Chinese Society of Psychiatry 2.4 Millon's subtypes 2.5 Family members 2.6 Adolescence 2.7 Differential diagnosis
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3 Causes 3.1 Childhood abuse 3.2 Other developmental factors 3.3 Genetics 3.4 Research on mediating and moderating factors 4 Management 4.1 Psychotherapy 4.2 Medications 4.3 Services 5 Prognosis 6 Epidemiology 7 History 8 Society and culture 8.1 Film and television 8.2 Literature 8.3 Awareness 8.4 Notable people 9 Controversies 9.1 Gender 9.2 Stigma 9.3 Terminology 10 Notes 11 References 12 Further reading 13 External links
Signs and symptoms

Borderline personality disorder is a diagnosis about which many articles and books have been written, yet about which little is known based on empirical research.[6] Studies suggest that individuals with BPD tend to experience frequent, strong and long-lasting states of aversive tension, often triggered by perceived rejection, being alone or perceived failure.[n 3] Individuals with BPD may show lability (changeability) between anger and anxiety or between depression and anxiety[7] and temperamental sensitivity to emotive stimuli.[8] The negative emotional states specific to BPD may be grouped into four categories: destructive or self-destructive feelings; extreme feelings in general; feelings of fragmentation or lack of identity; and feelings of victimization.[9] Individuals with BPD can be very sensitive to the way others treat them, reacting strongly to perceived criticism or hurtfulness. Their feelings about others often shift from positive to negative, generally after a disappointment or perceived threat of losing someone. Self-image can also change rapidly from extremely positive to extremely negative. Impulsive behaviors are common, including alcohol or drug abuse, unsafe sex, gambling and recklessness in general.[10]
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Attachment studies have revealed a strong association between BPD and insecure attachment style, the most characteristic types being "unresolved", "preoccupied", and "fearful".[11] Evidence suggests that individuals with BPD, while being high in intimacy- or novelty-seeking, can be hyper-alert[6] to signs of rejection or not being valued and tend toward insecure, avoidant or ambivalent, or fearfully preoccupied patterns in relationships.[12] They tend to view the world as generally dangerous and malevolent.[6] Individuals with BPD are often described, including by some mental health professionals (and in the DSM-IV),[13] as deliberately manipulative or difficult, but analysis and findings generally trace behaviors to inner pain and turmoil, powerlessness and defensive reactions, or limited coping and communication skills.[14][15][n 4] There has been limited research on family members' understanding of borderline personality disorder and the extent of burden or negative emotion experienced or expressed by family members.[16] However the effect of expressed emotion by family members may actually be opposite (paradoxical) from the anticipated effect on individuals with such illnesses as depressive disorders and schizophrenia. For BPD such effect may be neutral or positive as opposed to negative, a counter-intuitive result.[17] Parents of individuals with BPD have been reported to show co-existing extremes of over-involvement and under-involvement.[18] BPD has been linked to increased levels of chronic stress and conflict in romantic relationships, decreased satisfaction of romantic partners, abuse and unwanted pregnancy; these links may be general to personality disorder and subsyndromal problems.[19] Suicidal or self-harming behavior is one of the core diagnostic criteria in DSM IV-TR, and management of and recovery from this can be complex and challenging.[20] The suicide rate is approximately 8 to 10 percent.[21] Self-injury attempts are highly common among patients and may or may not be carried out with suicidal intent.[22][23] BPD is often characterized by multiple low-lethality suicide attempts triggered by seemingly minor incidents, and less commonly by high-lethality attempts that are attributed to impulsiveness or comorbid clinical depression, with interpersonal stressors appearing to be particularly common triggers.[24] Ongoing family interactions and associated vulnerabilities can lead to self-destructive behavior.[18] Stressful life events related to sexual abuse have been found to be a particular trigger for suicide attempts by adolescents with a BPD diagnosis.[25]
Diagnosis
Diagnosis is based on a clinical assessment by a qualified mental health professional. The assessment incorporates the patient's self-reported experiences as well as the clinician's observations. The resulting profile may be supported or corroborated by long-term patterns of behavior as reported by family members, friends or co-workers. The list of criteria that must be met for diagnosis is outlined in the DSM-IV-TR.[1] Borderline personality disorder was once classified as a subset of schizophrenia (describing patients with borderline schizophrenic tendencies). Today BPD is used more generally to describe individuals who display emotional dysregulation and instability, with paranoid ideation or delusions being only one criterion (criterion #9) of a total of 9 criteria, of which 5, or more, must be present for this diagnosis.
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Diagnostic and Statistical Manual

The Diagnostic and Statistical Manual of Mental Disorders fourth edition, DSM IV-TR, a widely used manual for diagnosing mental disorders, defines borderline personality disorder (in Axis II Cluster B) as:[1][13] A pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as 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-injuring 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., promiscuous sex, eating disorders, binge eating, substance abuse, reckless driving). Note: Do not include suicidal or self-injuring behavior covered in Criterion 5 5. Recurrent suicidal behavior, gestures, threats or self-injuring behavior such as cutting, interfering with the healing of scars (excoriation) or picking at oneself. 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 anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). 9. Transient, stress-related paranoid ideation, delusions or severe dissociative symptoms It is a requirement of DSM-IV that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.
International Classification of Disease

The World Health Organization's ICD-10 defines a conceptually similar disorder to borderline personality disorder called (F60.3 (http://apps.who.int/classifications/icd10/browse/2010/en# /F60.3) ) Emotionally unstable personality disorder. It has two subtypes described below.[26] F60.30 Impulsive type At least three of the following must be present, one of which must be (2): 1. marked tendency to act unexpectedly and without consideration of the consequences; 2. marked tendency to quarrelsome behaviour and to conflicts with others, especially when impulsive acts are thwarted or criticized; 3. liability to outbursts of anger or violence, with inability to control the resulting behavioural explosions; 4. difficulty in maintaining any course of action that offers no immediate reward; 5. unstable and capricious mood.
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F60.31 Borderline type At least three of the symptoms mentioned in F60.30 Impulsive type must be present [see above], with at least two of the following in addition: 1. disturbances in and uncertainty about self-image, aims, and internal preferences (including sexual); 2. liability to become involved in intense and unstable relationships, often leading to emotional crisis; 3. excessive efforts to avoid abandonment; 4. recurrent threats or acts of self-harm; 5. chronic feelings of emptiness. The ICD-10 also describes some general criteria that define what is considered a personality disorder.
Chinese Society of Psychiatry

The Chinese Society of Psychiatry's CCMD has a comparable diagnosis of Impulsive Personality Disorder (IPD). A patient diagnosed as having IPD must display "affective outbursts" and "marked impulsive behavior," plus at least three out of eight other symptoms. The construct has been described as a hybrid of the impulsive and borderline subtypes of the ICD-10's Emotionally Unstable Personality Disorder, and also incorporates six of the nine DSM BPD criteria.[27]
Millon's subtypes
Theodore Millon, a psychologist noted for popular works on personality disorders, has unofficially proposed four subtypes of borderline.[n 5][n 6] He suggests an individual diagnosed with BPD may exhibit none, one or more of the following: Discouraged borderline including avoidant, depressive or dependent features Impulsive borderline including histrionic or antisocial features Petulant borderline including negativistic (passive-aggressive) features Self-destructive borderline including depressive or masochistic features
Family members
It is common for those with borderline personality disorder and their families to feel their problems compounded by a lack of clear diagnoses, effective treatments, and accurate information. This is true especially because of evidence that this disorder originates in the families of those with it[18] and has a lot to do with psychosocial and environmental factors (Axis IV), rather than belonging strictly in the personality disorders and mental retardation section (Axis II) of the DSM-IV construct. Conceptual, as well as therapeutic, relief may be obtained through evidence that BPD is closely related to traumatic events during childhood and to post-traumatic stress disorder (PTSD), about which much more is known.[28] Recovery can be faster with the help of family members and loved ones, however those involved must be trained for their assistance to have an effective impact. [1] (http://bpdfamily.com/tools/articles5.htm)
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Adolescence
Onset of symptoms typically occurs during adolescence or young adulthood. While borderline personality disorder can manifest itself in children and teenagers, therapists are discouraged from diagnosing anyone before the age of 18, due to adolescence and a still-developing personality. There are some instances when BPD can be evident and diagnosed before the age of 18. The DSM-IV states: "To diagnose a personality disorder in an individual under 18 years, the features must have been present for at least 1 year." In other words, it is possible to diagnose the disorder in children and adolescents, but a more conservative approach should be taken. There is some evidence that BPD diagnosed in adolescence is predictive of the disorder continuing into adulthood. It is possible that the diagnosis, if applicable, would be helpful in creating a more effective treatment plan for the child or teen.[1][29]
Differential diagnosis
Comorbid (co-occurring) conditions are common in BPD. When comparing individuals diagnosed with BPD to those diagnosed with other personality disorders, the former showed a higher rate of also meeting criteria for[30] anxiety disorders mood disorders (including clinical depression and bipolar disorder) eating disorders (including anorexia nervosa and bulimia) and, to a lesser extent, somatoform or factitious disorders dissociative disorders Substance abuse is a common problem in BPD, whether due to impulsivity or as a coping mechanism, and 50 percent to 70 percent of psychiatric inpatients with BPD have been found to meet criteria for a substance use disorder, especially alcohol dependence or abuse which is often combined with the abuse of other drugs.[31] Borderline personality disorder and mood disorders often appear concurrently.[2] Some features of borderline personality disorder may overlap with those of mood disorders, complicating the differential diagnostic assessment.[32][33][34] Both diagnoses involve symptoms commonly known as "mood swings." In borderline personality disorder, the term refers to the marked lability and reactivity of mood defined as emotional dysregulation.[citation needed] The behavior is typically in response to external psychosocial and intrapsychic stressors, and may arise or subside, or both, suddenly and dramatically and last for seconds, minutes, hours, days, weeks or months.[35] Bipolar depression is generally more pervasive with sleep and appetite disturbances, as well as a marked nonreactivity of mood, whereas mood with respect to borderline personality and co-occurring dysthymia remains markedly reactive and sleep disturbance not acute.[36] Some hold that BPD represents a subthreshold form of affective disorder,[37][38] while others maintain the categorical distinction between the disorders while noting they often co-occur. [39][40] Some findings suggest BPD lies on a bipolar spectrum, with a number of points of phenomenological and biological overlap between the affective lability criterion of borderline personality disorder and the extremely rapid cycling bipolar disorders.[41][42] Other findings suggest that the DSM-IV BPD diagnosis mixes up two sets of unrelated itemsan affective
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instability dimension related to Bipolar-II, and an impulsivity dimension not related to BipolarII.[43] General medical conditions can cause behavioral dysfunction resulting in a clinical picture that may resemble to some degree BPD. This may include hormonal dysfunction over a long period, and brain dysfunction (e.g. the encephalopathy caused by lyme disease).[citation needed] These conditions may isolate the patient socially and emotionally, and/or cause limbic damage to the brain. However, it is not BPD that results, but rather a reaction to the isolating circumstances caused by a medical condition and the possibly coincident struggles of the patient to control his or her mood given damage to the brain's limbic system. Heavy alcohol usage over a long period itself can cause an encephalopathy which may cause limbic damage, and various frontal lobe syndromes can also result in disinhibition and impulsive behavior resembling BPD.[citation needed]
Causes
As with other mental disorders, the causes of BPD are complex and not fully understood.[4] One finding is a history of childhood trauma, abuse or neglect,[44] although researchers have suggested diverse possible causes, such as a genetic predisposition, neurobiological factors, environmental factors, or brain abnormalities.[4] There is evidence that suggests that BPD and post-traumatic stress disorder (PTSD) are closely related.[28] Evidence further suggests that BPD might result from a combination that can involve a traumatic childhood, a vulnerable temperament and stressful maturational events during adolescence or adulthood.[45]
Childhood abuse
Numerous studies have shown a strong correlation between child abuse, especially child sexual abuse, and development of BPD.[44][46][47][48][49] Many individuals with BPD report to have had a history of abuse and neglect as young children.[50] Patients with BPD have been found to be significantly more likely to report having been verbally, emotionally, physically or sexually abused by caregivers of either gender. There has also been a high incidence of incest and loss of caregivers in early childhood for people with borderline personality disorder. They were also much more likely to report having caregivers (of both genders) deny the validity of their thoughts and feelings. They were also reported to have failed to provide needed protection, and neglected their child's physical care. Parents (of both sexes) were typically reported to have withdrawn from the child emotionally, and to have treated the child inconsistently. Additionally, women with BPD who reported a previous history of neglect by a female caregiver and abuse by a male caregiver were consequently at significantly higher risk for being sexually abused by a noncaregiver (not a parent).[51] It has been suggested that children who experience chronic early maltreatment and attachment difficulties may go on to develop borderline personality disorder.[52]
Other developmental factors

Some findings suggest that BPD is not necessarily a trauma-spectrum disorder, and may be biologically distinct from the post-traumatic stress disorder that could be a precursor to it. The
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personality symptom clusters seem to be related to specific abuses, but they may also be related to more persistent aspects of interpersonal and family environments in childhood.[53] Otto Kernberg formulated a theory of borderline personality based on a premise of failure to develop in childhood. Writing in the psychoanalytic tradition, Kernberg argued that failure to achieve the developmental task of psychic clarification of self and other can result in an increased risk to develop varieties of psychosis, while failure to overcome splitting results in an increased risk to develop a borderline personality.[54]
Genetics
An overview of the existing literature suggested that traits related to BPD are influenced by genes.[55] A major twin study found that if one identical twin met criteria for BPD, the other also met criteria in 35 percent of cases. People that have BPD influenced by genes usually have a close relative with the disorder.[56] Twin, sibling and other family studies indicate a partially heritable basis for impulsive aggression, but studies of serotonin-related genes to date have suggested only modest contributions to behavior.[53]
Research on mediating and moderating factors

Research suggests that, rather than having a single cause, BPD may develop as a result of a number of different factors. Research has found that both physical and sexual abuse appear to be factors in developing BPD symptoms. Other factors including family environment also contribute to the development of the disorder.[57] Bradley et al.[57] found that both child sexual abuse (CSA) and childhood physical abuse both directly influence the development of BPD symptoms directly and are mediated by family environment.[57] Other research has examined whether the negative affectivity associated with BPDthat is, the tendency to often feel anger, contempt, guilt, nervousness, and other negative feelingscan be helped by the technique of thought suppression, or consciously trying not to think certain thoughts. The results of this study found that thought suppression mediated the relationship between negative affectivity and BPD symptoms.[58] While negative affectivity significantly predicted BPD symptoms, this relationship was greatly reduced when thought suppression was introduced into the model. Thus, the relationship of negative affectivity to BPD symptoms is mediated by thought suppression. Ayduk, et al., found that rejection sensitivity and executive control are predictors of BPD symptoms; in other words, people who are highly apt to feel rejected, and/or who have poor control of their emotions and behavior, are more likely to develop BPD. Another factor the authors studied, namely a child's ability to tolerate delayed gratification at age 4, did not appear to predict later development of BPD.[59] Parker, Boldero and Bell examined another facet of BPD, which is instability of the sense of self. Their findings indicated that Self-Discrepancy--the sense of failing to match one's own idealswas strongly correlated to BPD. Self-complexity, or being aware of one's own mental patterns, was not. Among those high in self-complexity, the relationship between AI
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self-discrepancy magnitudes and BPD features was lower than among those with less self-complexity. Actual-ought self-discrepancy relationship with BPD features was not significantly moderated by self-complexity.[60]
Management
Main article: Management of borderline personality disorder Psychotherapy forms the foundation of treatment for borderline personality disorder with medications playing a lesser role.[61] Treatments should be based on individual case presentation, rather than upon the diagnosis of BPD with co-morbid conditions determining medications use, if any.[62] Hospitalization has not been found to improve outcomes or prevent suicide over community care in those with BPD.[63]
Psychotherapy
Four comprehensive psychosocial interventions for BPD two psychodynamic treatments (mentalization-based, and transference-focused) and two cognitive-behavioral treatments (dialectical behavioral, and schema-focused) were the subject of a 2009 review that found that each therapy reduced the severity of the disorder or some elements of it, especially physical self-harm.[64] A 2010 review found that the highest quality evidence from clinical trials of psychotherapeutic interventions supports dialectical behavior therapy and mentalization-based therapy.[65] A special problem of psychotherapy with borderline patients is intense projection. It requires the psychotherapist to be flexible in considering negative attributions by the patient rather than quickly interpreting the projection.[66]
Medications
A 2010 review by the Cochrane collaboration found that the total severity of BPD is not significantly affected by any drug. No drugs show promise for "the core BPD symptoms of chronic feelings of emptiness, identity disturbance and abandonment." However, the authors found that some drugs may impact certain associated symptoms or the symptoms of comorbid conditions.[67] Of the typical antipsychotics studied in relation to BPD, haloperidol may reduce anger, and flupenthixol may reduce the likelihood of suicidal behavior. Among the atypical antipsychotics, aripiprazole may reduce interpersonal problems, impulsivity, anger, psychotic paranoid symptoms, depression, anxiety, and general psychiatric pathology; olanzapine may decrease affective instability, anger, psychotic paranoid symptoms, and anxiety, but placebo had a greater ameliorative impact on suicidal ideation than olanzapine did; and ziprasidone treatment demonstrated no significant therapeutic affect. Of the mood stabilizers studied, valproate semisodium may ameliorate depression and interpersonal problems, and it may reduce anger; lamotrigine may reduce impulsivity and anger, topiramate may ameliorate interpersonal problems, impulsivity, anxiety, anger and general psychiatric pathology, but carbamazepine treatment demonstrated no significant effect. Among the antidepressants, amitriptyline may reduce depression, but mianserin, fluoxetine, fluvoxamine and phenelzine sulfate showed no effect. Omega-3 fatty acid may ameliorate suicidality and improve depression. The review warned that most trials have not been replicated, so the evidence is not strong, and the effect of
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long-term use has not been assessed.[67] Because of the weakness of the evidence and the potential for serious side effects from some drug therapies, the UK National Institute for Health and Clinical Excellence (NICE) 2009 clinical guideline for the treatment and management of BPD recommends: "Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder" but "drug treatment may be considered in the overall treatment of comorbid conditions," and suggests "review of the treatment of people with borderline personality disorder who do not have a diagnosed comorbid mental or physical illness and who are currently being prescribed drugs, with the aim of reducing and stopping unnecessary drug treatment."[68]
Services
Individuals with BPD sometimes use mental health services extensively. They accounted for about 20 percent of psychiatric hospitalizations in one survey.[69] The majority of BPD patients continue to use outpatient treatment in a sustained manner for several years, but the number using the more restrictive and costly forms of treatment, such as inpatient admission, declines with time.[70] Experience of services varies.[71] Assessing suicide risk can be a challenge for mental health services (and patients themselves tend to underestimate the lethality of self-injurious behaviours) with typically a chronically elevated risk of suicide much above that of the general population and a history of multiple attempts when in crisis.[72]
Prognosis
Data indicate that people with BPD often make good progress. Around a third (depending on criteria used) of people diagnosed with BPD achieve remission within a year or two.[73] A longitudinal study found that, six years after being diagnosed with BPD, 56% had good psychosocial functioning compared to 26% at baseline. While vocational achievement was generally more limited even compared to those with other personality disorders, those whose symptoms had remitted were significantly more likely to have a good relationship with a spouse/partner and at least one parent, good work/school performance, a sustained work/school history, good global functioning and good psychosocial functioning.[74] Another study found that ten years from baseline (during a hospitalization), 86% of patients had sustained remission of symptoms, with around half achieving recovery defined as being free of symptoms and achieving certain levels of both social and vocational functioning.[75] Particular difficulties have been observed in the relationship between some care providers and some individuals diagnosed with BPD. A majority of psychiatric staff report finding individuals with BPD moderately to extremely difficult to work with, and more difficult than other client groups.[76] Some clients feel a diagnosis is helpful, allowing them to understand they are not alone, and to connect with others who have BPD and who have developed helpful coping mechanisms. On the other hand, some with the diagnosis of BPD have reported that the term "BPD" felt like a pejorative label rather than a helpful diagnosis, that self-destructive behaviour was incorrectly perceived as manipulative, and that they had limited access to care.[77] Attempts are made to improve public and staff attitudes.[78][79]
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Epidemiology
The prevalence of BPD in the general population ranges from 1 to 2 percent.[73][80] The diagnosis appears to be several times more common in (especially young) women than in men, by as much as 3:1, according to the DSM-IV-TR,[1] although the reasons for this are not clear.[81] The prevalence of BPD in the United States has been calculated as 1 percent to 3 percent of the adult population,[4] with approximately 75 percent of those diagnosed being female.[82] It has been found to account for 20 percent of psychiatric hospitalizations.[citation needed]
History
Since the earliest record of medical history, the coexistence of intense, divergent moods within an individual has been recognized by such writers as Homer, Hippocrates and Aretaeus, the last describing the vacillating presence of impulsive anger, melancholia and mania within a single person. After medieval suppression of the concept, it was revived by Swiss physician Thophile Bonet in 1684, who, using the term folie maniaco-mlancolique,[n 7] noted the erratic and unstable moods with periodic highs and lows that rarely followed a regular course. His observations were followed by those of other writers who noted the same pattern, including writers such as the American psychiatrist C. Hughes in 1884 and J.C. Rosse in 1890, who described "borderline insanity"[citation needed]. Kraepelin, in 1921, identified an "excitable personality" that closely parallels the borderline features outlined in the current concept of borderline.[n 1] Adolf Stern wrote the first significant psychoanalytic work to use the term "borderline" in 1938,[83] referring to a group of patients with what was thought to be a mild form of schizophrenia, on the borderline between neurosis and psychosis. For the next decade the term was in popular and colloquial use, a loosely conceived designation mostly used by theorists of the psychoanalytic and biological schools of thought[citation needed]. Increasingly, theorists who focused on the operation of social forces were recognized as well. The 1960s and 1970s saw a shift from thinking of the borderline syndrome as borderline schizophrenia to thinking of it as a borderline affective disorder (mood disorder), on the fringes of manic depression, cyclothymia and dysthymia. In DSM-II, stressing the affective components, it was called cyclothymic personality (affective personality).[1] In parallel to this evolution of the term "borderline" to refer to a distinct category of disorder, psychoanalysts such as Otto Kernberg were using it to refer to a broad spectrum of issues, describing an intermediate level of personality organization[n 1] between neurotic and psychotic processes.[84] Standardized criteria were developed[85] to distinguish BPD from affective disorders and other Axis I disorders, and BPD became a personality disorder diagnosis in 1980 with the publication of DSM-III.[73] The diagnosis was formulated predominantly in terms of mood and behavior, distinguished from sub-syndromal schizophrenia which was termed "Schizotypal personality disorder".[84] The final terminology in use by the DSM today was decided by the DSM-IV Axis II Work Group of the American Psychiatric Association.[n 8]
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Society and culture

Film and television
Several films portraying characters either explicitly diagnosed or with traits strongly suggestive of mental illness have been the subject of discussion by certain psychiatrists and film experts. The films Play Misty for Me[86] and Fatal Attraction are two examples,[87] as is the memoir Girl, Interrupted by Susanna Kaysen (and the movie based on it, with Winona Ryder as Kaysen). Each of these films suggests the emotional instability of the disorder; however, the first two cases show a person more aggressive to others than to herself, which in fact is less typical.[88] The 1992 film Single White Female suggests different aspects of the disorder: the character Hedy suffers from a markedly disturbed sense of identity and, as with the last two films, abandonment leads to drastic measures.[89] The character of Anakin Skywalker/Darth Vader in the Star Wars films has been "diagnosed" as having BPD. Psychiatrists Eric Bui and Rachel Rodgers have argued that the character meets six of the nine diagnostic criteria; Bui also found Anakin a useful example to explain BPD to medical students. In particular, Bui points to the character's abandonment issues, uncertainty over his identity and violent dissociative episodes.[90] Other films attempting to depict characters with the disorder include The Crush, Malicious, Interiors, Notes On a Scandal, The Cable Guy and Cracks.[87] The film Borderline, based on the book of the same name by Marie-Sissi Labrche, attempts to explore BPD through its main character, Kiki.
Literature
The memoir Songs of Three Islands by Millicent Monks is a meditation on how BPD affects several generations of the wealthy Carnegie family. In Lois McMaster Bujold's science fiction novel Komarr, Tien Vorsoisson has BPD; his disorder drives a large part of the story.[91]
Awareness
In early 2008, the United States House of Representatives declared the month of May as Borderline Personality Disorder Awareness Month.[92][93]
Notable people
NFL Player Brandon Marshall was diagnosed with BPD.[94] Author Susanna Kaysen was diagnosed with BPD, during her time at McLean Hospital. Her memoir Girl, Interrupted chronicles her time at the hospital. The memoir was later adapted into a film starring Winona Ryder as Susanna. Psychologist and founder of Dialectical Behavioral Therapy, Marsha Linehan, has recently spoken out [95] about her past as an individual who suffered and still struggles with BPD.
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Controversies
Gender
The diagnosis of BPD has been criticized from a feminist perspective.[96] This is because some of the diagnostic criteria/symptoms of the disorder uphold common gender stereotypes about women. For example, the criteria of "a pattern of unstable personal relationships, unstable self-image, and instability of mood," can all be linked to the stereotype that women are "neither decisive nor constant".[97] The question has also been raised of why women are three times more likely to be diagnosed with BPD than men.[n 9] Some think that people with BPD commonly have a history of sexual abuse in childhood.[98] One feminist critique suggests that BPD is a stigmatizing diagnosis that can sometimes evoke negative responses from health care providers, and additionally, that women who have survived sexual abuse in childhood are therefore sometimes re-traumatized by any such abusive mental health service.[99] Some feminist writers have suggested it would be better to give these women the diagnosis of a post-traumatic disorder as this would acknowledge their abuse, but others have argued that the use of the PTSD diagnosis merely medicalizes abuse rather than addressing the root causes in society.[100] Women may be more likely to receive a personality disorder diagnosis if they reject the female role by being hostile, successful or sexually active; alternatively if a woman presents with psychiatric symptoms but does not conform to a traditional passive sick role, she may be labelled as a "difficult" patient and given the stigmatizing diagnosis of BPD.[101]
Stigma
The features of BPD include emotional instability, intense unstable interpersonal relationships, a need for relatedness and a fear of rejection. As a result, people with BPD often evoke intense emotions in those around them. Pejorative terms to describe persons with BPD such as difficult, treatment resistant, manipulative, demanding and attention seeking" are often used, and may become a self-fulfilling prophecy as the clinician's negative response triggers further self-destructive behaviour.[102] In psychoanalytic theory, this stigmatization may be thought to reflect countertransference (when a therapist projects their own feelings on to a client), as people with BPD are prone to use defense mechanisms such as splitting and projective identification. Thus the diagnosis "often says more about the clinician's negative reaction to the patient than it does about the patient ... as an expression of counter transference hate, borderline explains away the breakdown in empathy between the therapist and the patient and becomes an institutional epithet in the guise of pseudoscientific jargon" (Aronson, p 217).[84] This inadvertent counter transference can give rise to inappropriate clinical responses including excessive use of medication, inappropriate mothering and punitive use of limit setting and interpretation.[103] People with BPD are seen as among the most challenging groups of patients, requiring a high degree of skill and training in the psychiatrists, therapists and nurses involved in their treatment.[104] While some clinicians agree with the diagnosis under the name "borderline personality disorder", some would like the name to be changed.[105] One critique says that some who are labeled "Borderline Personality Disorder" feel this name is unhelpful, stigmatizing, and/or inaccurate.[105]
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The Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigns to change the name and designation of BPD in DSM-5.[106] The paper How Advocacy is Bringing BPD into the Light[107] reports that "the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma...".
Terminology
Because of the above concerns, and because of a move away from the original theoretical basis for the term (see history), there is ongoing debate about renaming BPD. Alternative suggestions for names include emotional regulation disorder or emotional dysregulation disorder. Impulse disorder and interpersonal regulatory disorder are other valid alternatives, according to John Gunderson of McLean Hospital in the United States.[108] Another term (for example, by psychiatrist Carolyn Quadrio) is post traumatic personality disorganization (PTPD), reflecting the condition's status as (often) both a form of chronic post traumatic stress disorder (PTSD) and a personality disorder in the belief that it is a common outcome of developmental or attachment trauma.[49] Some people do not report any kind of traumatic event.[n 10]
Notes
1. ^ a b c d e f Borderline personality disorder (http://www.behavenet.com/capsules/disorders /borderlinepd.htm) - Diagnostic and Statistical Manual of Mental Disorders Fourth edition Text Revision (DSM-IV-TR) American Psychiatric Association (2000) 2. ^ a b Robinson, David J. (2005). Disordered Personalities. Rapid Psychler Press. pp. 255310. ISBN 1-894328-09-4. 3. ^ "Borderline Personality Disorder: Proposal to include a supplementary name in the DSM-IV text revision" (http://www.borderlinepersonalitytoday.com /main/name_change.htm) . Borderline Personality Today. http://www.borderlinepersonalitytoday.com /main/name_change.htm . Retrieved 8 February 2010. 4. ^ a b c d "Borderline personality disorder" (http://www.mayoclinic.com/health/borderlinepersonality-disorder/DS00442/DSECTION=3) . MayoClinic.com. http://www.mayoclinic.com/health/borderlinepersonality-disorder/DS00442/DSECTION=3 . Retrieved 15 May 2008. 5. ^ "New Theses about the Borderline Personality" (http://wilhelm-griesingerinstitut.de/veroeffentlichungen /borderline,engl.html) . wilhelm-griesingerinstitut.de. http://wilhelm-griesinger14 of 24
institut.de/veroeffentlichungen /borderline,engl.html . Retrieved 31 January 2009. 6. ^ a b c Arntz A (September 2005). "Introduction to special issue: cognition and emotion in borderline personality disorder". Behav Ther Exp Psychiatry 36 (3): 16772. doi:10.1016/j.jbtep.2005.06.001 (http://dx.doi.org /10.1016%2Fj.jbtep.2005.06.001) . PMID 16018875 (http://www.ncbi.nlm.nih.gov /pubmed/16018875) . 7. ^ Koenigsberg HW, Harvey PD, Mitropoulou V, et al. (May 2002). "Characterizing affective instability in borderline personality disorder" (http://ajp.psychiatryonline.org /cgi/pmidlookup?view=long&pmid=11986132) . Am J Psychiatry 159 (5): 7848. doi:10.1176/appi.ajp.159.5.784 (http://dx.doi.org /10.1176%2Fappi.ajp.159.5.784) . PMID 11986132 (http://www.ncbi.nlm.nih.gov /pubmed/11986132) . http://ajp.psychiatryonline.org /cgi/pmidlookup?view=long&pmid=11986132 . 8. ^ Meyer B, Ajchenbrenner M, Bowles DP (December 2005). "Sensory sensitivity, attachment experiences, and rejection responses among adults with borderline and
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Borderline personality disorder - PubMed Health
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001931/
Repeated crises and acts of self-injury, such as wrist cutting or overdosing
Signs and tests

Like other personality disorders, BPD is diagnosed based on a psychological evaluation and the history and severity of the symptoms.
Treatment
Many types of individual talk therapy, such as dialectical behavioral therapy (DBT), can successfully treat BPD. In addition, group therapy can help change self-destructive behaviors. In some cases, medications can help level mood swings and treat depression or other disorders that may occur with this condition.
Expectations (prognosis)
The outlook depends on how severe the condition is and whether the person is willing to accept help. With long-term talk therapy, the person will often gradually improve.
Complications
Depression Drug abuse Problems with work, family, and social relationships Suicide attempts and actual suicide
Calling your health care provider

Call your health care provider if you or your child has symptoms of borderline personality disorder. It is especially important to seek help right away if you or your child is having thoughts of suicide.
References
1. Blais MA, Smallwood P, Groves JE, Rivas-Vazquez RA. Personality and personality disorders. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier;2008:chap 39.
Review Date: 11/15/2010. Reviewed by: Linda Vorvick, MD, Medical Director, MEDEX Northwest Division of Physician Assistant Studies, University of Washington School of Medicine; and David B. Merrill, MD, Assistant Clinical Professor of Psychiatry, Department of Psychiatry, Columbia University Medical Center, New York, NY. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
A.D.A.M., Disclaimer A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch). The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only they do not constitute endorsementscof those other sites. 19972011 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited. Copyright 2011, A.D.A.M., Inc.
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Borderline Personality Disorder Symptoms, Causes, Treatment...

How is borderline personality disorder diagnosed?
http://www.medicinenet.com/borderline_personality_disorder/...
There is no specific definitive test, like a blood test, that can accurately assess that a person has BPD. People who are concerned that they may suffer from BPD might explore the possibility by taking a self-test, either an online or printable test. To determine the presence of this disorder, practitioners conduct a mentalhealth interview that looks for the presence of the symptoms, also called diagnostic criteria, previously described. As with any mentalhealth assessment, the practitioner will usually work toward ruling out other mental disorders, including mood problems like depression, anxiety disorders including anxiety attacks or generalized anxiety, types of other personality disorders like narcissistic personality disorder, dependent personality disorder or histrionic personality disorder, substance-abuse problems as well as problems being in touch with reality, like schizophrenia or delusional disorder. The professional will also likely try to ensure that the individual is not suffering from a medical problem that may cause emotional symptoms. The mental-health practitioner will therefore often inquire about when the person has most recently had a physical examination, comprehensive blood testing, and any other tests that a medical professional deems necessary to ensure that the individual is not suffering from a medical condition instead of or in addition to emotional symptoms. Due to the use of a mental-health interview in making the diagnosis and the fact that this disorder can be quite resistant to treatment, it is of great importance that the practitioner know to conduct a thorough assessment. This is to assure that the person is not incorrectly assessed as having BPD when he or she does not.
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What are borderline personality disorder complications?
The presence of BPD can often worsen the course of another mental condition with which it occurs. For example, it tends to change the symptoms of posttraumatic stress disorder and to worsen depression. Individuals with BPD are at risk for self-mutilation, as well as for attempting or completing suicide. While both self-mutilating and suicidal behaviors seem to be associated with alleviating negative feelings, it is thought that self-mutilating behaviors are more an expression of anger, punishing oneself, distracting oneself, and eliciting more normal feelings. In contrast, suicide attempts are thought to be more often associated with feeling survivors will be better off for their death. People who engage in self-mutilation are more likely to commit suicide compared to those who do not self-mutilate. Although most individuals with a mental disorder do not engage in violent behavior, those who suffer from BPD have a somewhat increased risk for such behaviors. That risk is also increased for individuals who suffer from antisocial personality disorder, have previous history of violent behavior, frequent use of sedative medications, or experience several changes in their psychiatric medications in general.
Complications of BPD also often involve families of the person with the disorder. For example, a parent with BPD is vulnerable to having depressive symptoms in their children.
What is the prognosis of people with borderline personality disorder?

As with any illness, an appropriate question about BPD is if it is curable. While improvement in any personality disorder is not synonymous with being cured, the symptoms of BPD do tend to diminish with time. How well or poorly people with BPD progress over time seems to be influenced by how severe the disorder is at the time that treatment starts, the state of the individual's current personal relationships, whether or not the sufferer has a history of being abused as a child, as well as whether or not the person receives appropriate treatment. Simultaneously suffering from depression, other emotional problems, or a low level of conscientiousness have been found to be associated with a greater likelihood of symptoms of BPD returning (relapse). Conversely, having steady employment or school status once symptoms of BPD subside (remit) tends to protect BPD sufferers from experiencing a future relapse.
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What are borderline personality disorder symptoms and signs?
As per the DSM (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Treatment Revision) definition , in order to qualify for the diagnosis of BPD, an individual must have at least five of the following symptoms: Unstable self-image, in that they may drastically and rapidly change in the way they perceive their own likes, dislikes, strengths, weaknesses, goals, and intrinsic value as a person
Unstable relationships, in that individuals with this disorder rapidly, drastically, and often frequently change from seeing another person as nearly perfect (idealizing) to seeing the other person as being virtually worthless (devaluing)
Unstable emotions (affects), in that the sufferer experiences marked, rapid changes in feelings (for example, severe anger, joy, euphoria, anxiety, including panic attacks and depression) that are stress related, even if the stresses may be seen as minor or negligible to others
Desperate efforts to avoid being abandoned, whether the abandonment is real or imagined
Significant impulsivity, in that the person with BPD tends to act before thinking to the point that it is self-damaging (for example, sexual behaviors, spending habits, eating habits, driving behaviors, or in the use of substances)
Recurring suicidal behaviors, threats, or attempts
Chronic feelings of emptiness
Inappropriate, intense anger or difficulty managing their anger when it occurs
Transient, stress-related paranoia or severe dissociation (lapses in memory)
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What is the treatment for borderline personality disorder?
Different forms of psychotherapy have been found to effectively treat BPD. Dialectical behavior therapy (DBT) is an approach to psychotherapy in which the therapist specifically addresses four areas that tend to be particularly problematic for individuals with BPD: self-image, impulsive behaviors, mood instability, and problems in relating to others. To address those areas, treatment with DBT tries to build four major behavioral skill areas: mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness. Talk therapy that focuses on helping the person understand how their thoughts and behaviors affect each other (cognitive behavioral therapy or CBT) has also been found to be effective treatment for BPD. Other psychotherapy approaches that have been used to address BPD include interpersonal psychotherapy (IPT) and psychoanalytic therapy. IPT is an approach that focuses on how the person's symptoms are related to the problems that person has in relating to others. Psychoanalytic therapy, which seeks to help the individual understand and better manage his or her ways of defending against negative emotions, has been found to be effective in addressing BPD, especially when the therapist is more active or vocal than in traditional psychoanalytic treatment and when this approach is used in the context of current rather than past relationships. The use of psychiatric treatment medications, like antidepressants (for example, fluoxetine [Prozac], sertraline [Zoloft], citalopram [Celexa], escitalopram [Lexapro], venlafaxine [Effexor], duloxetine [Cymbalta], or trazodone [Desyrel]), mood stabilizers (for example, divalproex sodium [Depakote], carbamazepine [Tegretol], or lamotrigine [Lamictal]), or antipsychotics (for example, olanzapine [Zyprexa], risperidone [Risperdal], aripiprazole [Abilify], paliperidone [Invega] or asenapine [Saphris]) may be useful in addressing some of the symptoms of BPD but do not manage the illness in its entirety. On the positive side, some women who suffer from both BPD and bipolar disorder may experience a decrease in how irritable and angry they feel, as well as a decrease in how often and severely they become aggressive when treated with a mood stabilizer like Depakote. On the other hand, the use of medications in the treatment of symptoms in individuals with BPD may sometimes cause more harm than good. For example, while people with BPD may experience suicidal behaviors no more often than other individuals with a severe mental illness, they often receive more medications and therefore suffer from more side effects. Also, given how frequently many sufferers of BPD experience suicidal feelings, great care is taken to avoid the medications that can be dangerous in overdose. Partial hospitalization is an intervention that involves the individual with mental illness being in a hospital-like treatment center during the day but returning home each evening. In addition to providing a safe environment and frequent monitoring by mental-health professionals, partial hospitalization programs allow for more frequent mental-health interventions like professional assessments, psychotherapy medication treatment, as well as development of a treatment plan for after discharge from the facility. While funding for a long-term stay in a partial hospitalization facility may be difficult, research shows that when it is provided using a psychoanalytic approach it may help the person with BPD enjoy a decrease in the severity of anxiety and depression, the frequency of suicide attempts and full hospitalizations, as well as developing improved relationships with others. Contrary to earlier beliefs, BPD has been found to significantly improve in response to treatment with appropriate inpatient hospitalization. Loved ones of individuals with BPD might
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Borderline Personality Disorder At A Glance
Borderline personality disorder is a personality disorder characterized by consistently problematic ways of thinking, feeling, and interacting. BPD is associated with unstable self-image, feelings, behaving, and relating to others. BPD affects 6% of adults, men as often as women in general, women more than men in treatment populations. Antisocial personality disorder in adults, substance-abuse problems in men, eating disorders in women, and anxious and odd personality disorders in adolescents tend to co-occur with BPD. There has been some controversy about whether or not BPD is its own disorder or a variation of bipolar disorder, but in many countries, there is more agreement on the existence of BPD. Like most other mental disorders, it is understood to be the result of a combination of biological vulnerabilities, ways of thinking, and social stressors (biopsychosocial model). BPD sufferers are more likely to have a learning problem or certain temperaments as children, or to come from families of origin where divorce, neglect, sexual abuse, substance abuse, or death occurred. In order to be diagnosed with BPD, the sufferer must experience at least five of the following symptoms: unstable self-image, relationships or emotions, severe impulsivity, repeated suicidal behaviors or threats, chronic feelings of emptiness, inappropriate anger, trouble managing anger, or transient paranoia or dissociation. As with other mental disorders, there is no specific definitive test, like a blood test, to diagnose BPD. Therefore, practitioners conduct a mentalhealth interview that looks for the presence of the symptoms previously described and usually explore the person's history for any medical problem or other emotional problem that may show symptoms of the disorder. Psychotherapy approaches that have been helpful in treating BPD include dialectical behavior therapy, cognitive behavioral therapy, interpersonal therapy, and psychoanalytic psychotherapy. The use of psychiatric medications like antidepressants, mood stabilizers, and antipsychotics may be useful in addressing some of the symptoms of BPD but do not manage the illness in its entirety. Partial hospitalization can help treat BPD by providing frequent supervision and assessment in a safe environment, while allowing the sufferer to go home each evening. The presence of BPD tends to worsen the symptoms of other mental illnesses and increase the risk for self-mutilation, as well as for attempting or completing suicide. People with BPD are at somewhat higher risk for engaging in violent behavior. That risk is further increased when the individual with BPD also is suffering from antisocial personality disorder, has a previous history of violent behavior, frequently uses sedative medications, or experiences several changes in their psychiatric medications. While they symptoms of BPD tends to diminish over years for many people, how well or poorly people with BPD progress over time seems to be influenced by the severity of the symptoms, the individual's current personal relationships, whether or not the sufferer has a history of being abused as a child, as well as whether or not the individual receives appropriate treatment. Steady employment or school status once symptoms of BPD subside (remit) tends to protect BPD sufferers from experiencing a future relapse.
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Borderline Personality Disorder Symptoms, Medication, Trea...

What is borderline personality disorder?
Borderline personality disorder (BPD) is a mental disorder that belongs to the group of mental illnesses called personality disorders. Therefore, like other personality disorders, it is characterized by a consistent pattern of thinking, feeling, and interacting with others and with the world that tends to cause significant problems for the sufferer. Specifically, BPD tends to be associated with a pattern of unstable ways of seeing oneself, feeling, behaving, and relating to others that markedly interferes with the individual's ability to function. Also, as with other personality disorders, the person is usually an adolescent or adult before they can be assessed as meeting full symptom criteria for BPD.
http://www.medicinenet.com/borderline_personality_disorder/a...
Historically, BPD has been thought to be a set of symptoms that include both mood problems (neuroses) and distortions of reality (psychosis), and therefore was thought to be on the borderline between mood problems and schizophrenia. However, it is now understood that while the symptoms of BPD may straddle those symptom complexes, this illness is more closely related to other personality disorders in terms of how it may develop and occur within families. Contrary to what the medical community thought in the past, BPD is now understood to occur equally in men and women in general, while primarily in women in groups of people who are receiving mental-health treatment (treatment populations). The frequency with which this disorder occurs is also thought to be considerably higher than previously thought, affecting nearly 6% of adults over the course of a lifetime.
What other disorders often occur with BPD?

While men with BPD are more likely to also have a substance-use disorder. BPD is more likely to be associated with eating disorders symptoms in women. In adolescents, BPD tends to co-occur with more anxious and odd personality disorders like schizotypal and passive aggressive personality disorder, respectively. Adults who have antisocial personality disorder, formerly also called sociopaths, may be more likely to also have BPD. Interestingly, even people who have some symptoms (traits) of BPD but do not meet full diagnostic criteria for the disorder can experience both traits of BPD and narcissistic personality disorder. Although there has been some controversy as to whether or not BPD is truly its own disorder or a variation of bipolar disorder, research supports the theory that BPD, like virtually every medical or other mental-health disorder can appear (present) in nearly as many unique and complex ways as there are people who have it. In other words, some individuals with BPD will have that disorder alone, while others will have it in combination with bipolar or another mental disorder. Still others will appear to have BPD but really qualify for the diagnosis of bipolar disorder and visa versa. BPD is not recognized worldwide. It is most closely diagnosed as emotionally unstable personality disorder in the International Classification of Disease, or ICD-10. Although countries like China and India recognize mental disorders that have some symptoms in common with BPD, its existence is not formally recognized.
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Borderline Personality Disorder Symptoms, Medication, Trea...

recognized.
http://www.medicinenet.com/borderline_personality_disorder/a...
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Borderline Personality Disorders
http://www.stanford.edu/~corelli/borderline.html
BORDERLINE PERSONALITY Diagnosis DISORDER

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
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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.
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Richard J. Corelli, M.D. corelli@leland.stanford.edu
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Borderline personality disorder - Wikipedia, the free encyclopedia