Borderline Personality Disorder - BPD & Me!
Raising questions, finding answers
Borderline personality disorder (BPD) is a serious mental
illness characterized by pervasive instability in moods,
interpersonal relationships, self-image, and behavior. This
instability often disrupts family and work life, long-term
planning, and the individual's sense of self-identity.
Originally thought to be at the "borderline" of psychosis,
people with BPD suffer from a disorder of emotion regulation.
While less well known than schizophrenia or bipolar disorder
(manic-depressive illness), BPD is more common, affecting 2
percent of adults, mostly young women.
There are a high rate of self-injury without suicide intent, as
well as a significant rate of suicide attempts and completed
suicide in severe cases. Patients often need extensive mental
health services, and account for 20 percent of psychiatric
hospitalizations.
Yet, with help, many improve over time and are eventually able
to lead productive lives. Symptoms While a person with
depression or bipolar disorder typically endures the same mood
for weeks. A person with BPD may experience intense bouts of
anger, depression, and anxiety that may last only hours, or at
most a day. These may be associated with episodes of impulsive
aggression, self-injury, and drug or alcohol abuse.
Distortions in cognition and sense of self can lead to frequent
changes in long-term goals, career plans, jobs, friendships,
gender identity, and values. Sometimes people with BPD view
themselves as fundamentally bad, or unworthy. They may feel
unfairly misunderstood or mistreated, bored, empty, and have
little idea who they are. Such symptoms are most acute when
people with BPD feel isolated and lacking in social support, and
may result in frantic efforts to avoid being alone.
People with BPD often have highly unstable patterns of social
relationships. While they can develop intense but stormy
attachments, their attitudes towards family, friends, and loved
ones may suddenly shift from idealization (great admiration and
love) to devaluation (intense anger and dislike).
Thus, they may form an immediate attachment and idealize the
other person, but when a slight separation or conflict occurs,
they switch unexpectedly to the other extreme and angrily accuse
the other person of not caring for them at all. Even with family
members, individuals with BPD are highly sensitive to rejection,
reacting with anger and distress to such mild separations as a
vacation, a business trip, or a sudden change in plans.
These fears of abandonment seem to be related to difficulties
feeling emotionally connected to important persons when they are
physically absent, leaving the individual with BPD feeling lost
and perhaps worthless. Suicide threats and attempts may occur
along with anger at perceived abandonment and disappointments.
People with BPD exhibit other impulsive behaviors, such as
excessive spending, binge eating and risky sex. BPD often occurs
together with other psychiatric problems, particularly bipolar
disorder, depression, anxiety disorders, substance abuse, and
other personality disorders.
Treatment
Treatments for BPD have improved in recent years. Group and
individual psychotherapy are at least partially effective for
many patients. Within the past 15 years, a new psychosocial
treatment termed dialectical behavior therapy (DBT) was
developed specifically to treat BPD, and this technique has
looked promising in treatment studies.
Pharmacological treatments are often prescribed based on
specific target symptoms shown by the individual patient.
Antidepressant drugs and mood stabilizers may be helpful for
depressed and/or labile mood. Antipsychotic drugs may also be
used when there are distortions in thinking.
Recent Research Findings
Although the cause of BPD is unknown, both environmental and
genetic factors are thought to play a role in predisposing
patients to BPD symptoms and traits. Studies show that many, but
not all individuals with BPD report a history of abuse, neglect,
or separation as young children Forty to 71 percent of BPD
patients report having been sexually abused, usually by a
non-caregiver.
Researchers believe that BPD results from a combination of
individual vulnerability to environmental stress, neglect or
abuse as young children. A series of events that trigger the
onset of the disorder as young adults.
Adults with BPD are also considerably more likely to be the
victim of violence, including rape and other crimes. This may
result from both harmful environments as well as impulsivity and
poor judgment in choosing partners and lifestyles.
NIMH-funded neuroscience research is revealing brain mechanisms
underlying the impulsivity, mood instability, aggression, anger,
and negative emotion seen in BPD. Studies suggest that people
predisposed to impulsive aggression have impaired regulation of
the neural circuits that modulate emotion. The amygdale, a small
almond-shaped structure deep inside the brain, is an important
component of the circuit that regulates negative emotion.
In response to signals from other brain centers indicating a
perceived threat, it marshals fear and arousal. This might be
more pronounced under the influence of drugs like alcohol, or
stress. Areas in the front of the brain (pre-frontal area) act
to dampen the activity of this circuit. Recent brain imaging
studies show that individual differences in the ability to
activate regions of the prefrontal cerebral cortex thought to be
involved in inhibitory activity predict the ability to suppress
negative emotion.
Serotonin, nor epinephrine and acetylcholine are among the
chemical messengers in these circuits that play a role in the
regulation of emotions, including sadness, anger, anxiety, and
irritability. Drugs that enhance brain serotonin function may
improve emotional symptoms in BPD.
Likewise, mood-stabilizing drugs that are known to enhance the
activity of GABA, the brain's major inhibitory neurotransmitter,
may help people who experience BPD-like mood swings. Such
brain-based vulnerabilities can be managed with help from
behavioral interventions and medications, much like people
manage susceptibility to diabetes or high blood pressure.
Future Progress Studies that translate basic findings about the
neural basis of temperament, mood regulation, and cognition into
clinically relevant insights which bear directly on BPD
represent a growing area of NIMH-supported research.
Research is also underway to test the efficacy of combining
medications with behavioral treatments like DBT, and gauging the
effect of childhood abuse and other stress in BPD on brain
hormones. Data from the first prospective, longitudinal study of
BPD, which began in the early 1990s, is expected to reveal how
treatment affects the course of the illness.
It will also pinpoint specific environmental factors and
personality traits that predict a more favorable outcome. The
Institute is also collaborating with a private foundation to
help attract new researchers to develop a better understanding
and better treatment for BPD.