Today we will continue our current theme of cluster B personality disorders as we discuss borderline personality disorder. Borderline PD is a topic of considerable clinical and research interest. In order to do this topic justice we will split the content into three separate days. Today's post will cover an introduction, diagnostic criteria, epidemiology, pathogenesis, assessment, and clinical pearls. The next two posts will be dedicated exclusively to treatment considerations.
Today's Content Level: All levels (Beginner, Intermediate, Advanced)
Individuals with borderline personality disorder (BPD) have a lifelong pattern of unstable moods (affects), behaviors and interpersonal functioning.
They are often impulsive, have a poorly formed self-identity, and fear abandonment in their relationships. They commonly have a pattern of dysfunctional/unstable relationships throughout their life.
The term "borderline" was first introduced in the early 1900s by psychiatrists to describe individuals with significantly unstable mood and behaviors and who were thought to be on the borderline of neurosis and psychosis. BPD is also sometimes called emotionally unstable personality disorder (EUPD).
Common traits/symptoms may include being -> impulsive, moody, unstable, "empty", intense, labile, irritable, angry, vulnerable, and have a tendency to unravel when stressed (paranoia, dissociate, self-harm, or become suicidal).
Diagnostic Criteria 2
The diagnosis of BPD requires a pervasive pattern of impulsivity and unstable relationships, moods, behaviors, and self-image beginning by early adulthood and present in a variety of contexts.
≥5 of the following must also be present: Mnemonic "DESPAIRER"
Disturbance of identity- unstable self-image
Emotional- unstable mood/affect
Suicidal behavior- recurrent suicidal threats, suicidal attempts, or self-harm/mutilation
Paranoia or dissociative sx- transient when under stress
Abandonment (fear of)- frantic efforts to avoid real or imagined abandonment
Impulsive- in ≥ 2 potentially harmful ways (spending, sexual activity, substance use, binge eating, etc.)
Relationships- unstable, intense interpersonal relationships (e.g., extreme love–hate relationships)
Emptiness - chronic feelings of emptiness
Rage (inappropriate) - dificulty controlling anger
Prevalence: Estimates vary in the general US population from 0.5-6% with a median of 1.5%. It is the most common personality disorder in clinical populations and are seen in all types of clinic settings. They account for ~10% of psychiatric outpatients, ~20% of psychiatric inpatients, and ~6% of patients presenting to family medicine, despite a community prevalence of ~1.5%.
Gender: ~2:1 female to male ratio.
As with all personality disorders, the dominant theory suggest BPD develops from a combination of genetic vulnerability and environmental stressors.
Genetics and Pathophysiology: BPD is more heritable than other personality disorders (65-75% per twin studies compared to 40-60%). Elevated risk if family history of borderline PD, antisocial PD, substance use disorders, and major depressive disorders. No specific genes have been demonstrated as causative, however a number of studies are examining polymorphisms in the serotonin promoter region, COMT allele, and MOA tandem repeats. Additionally, research has suggested increased cortisol and reactivity of the HPA axis (hypothalamic–pituitary–adrenal), low oxytocin (associated with increased social sensitivity and distrust), low opioids (associated with increased sensitivity to rejection and abandonment), and high vasopressin (associated with increased anger). Imaging studies have suggested prefrontal and frontolimbic dysfunction correlating with poor emotion control.
Trauma: Much higher rates of childhood neglect and physical, emotional, and sexual abuse than the general population and to other personality disorders. This is believed to be one of the most important risk factors for BPD. Childhood trauma can disrupt the development of healthy/secure attachments, emotion regulation, identity formation, and interpersonal skills.
Course/Prognosis: High rates of social, functional, and occupational impairment and high use of treatment services. >75% of patients attempt suicide, often with frequent attempts and self-injurious behaviors. ~10% eventually die by suicide. It is commonly believed that patients with BPD are highly treatment-resistant, however a majority of patients will no longer meet criteria over time even without consistent long-term treatment. Some studies suggests that 10% remit after 6 months, 25% in 1 year, 45% in 2 years, and 85% in 10 years. Patients have a high incidence of major depressive episodes.
History: Borderline PD begins by early adulthood. The diagnosis is usually made before the age of 40 when patients are attempting to make occupational, marital, and other choices and are unable to deal with the normal stages of the life cycle. Individuals will have a pervasive pattern of instability in their mood, impulse control, and interpersonal functioning. Patients often self-present when triggered by an interpersonal conflict such as a fight or breakup with a partner.
Unstable mood: Pattern of intense, reactive, and quickly changing moods. Changes in mood typically last only a few hours or up to a few days and include irritability, anxiety, dysphoria, desperation, and anger. Patients may experience short-lived dissociative or psychotic episodes ("micro-psychotic episodes") that occur in response to a stressor and are fleeting and more circumscribed than those seen true psychotic disorders.
Unstable self-image: Despite their flurry of changing affects, they often complain about chronic feelings of emptiness or boredom. They may say they feel detached and they do not know themself. They express a lack of a consistent sense of identity. When pressed, they often complain about how depressed they usually feel.
Unstable relationships: Pattern of tumultuous relationships. Relationships may begin with intense attachments and end with the slightest conflicts. They may rapidly shift between idealizing or devaluing the other person. They may feel both dependent and hostile towards their relationships, and may express significant anger or aggression towards them. They often find it difficult being alone, often feel abandoned, and they prefer a frantic search for companionship, no matter how unsatisfactory.
Unstable behaviors: They often have a history of self-injury, such as cutting, and chronic suicidal ideations. Contrast this with a major depressive disorder when suicidal ideations are more episodic. Episodes of self-harm may be a way to elicit help from others, to express anger, or to numb themselves to overwhelming affects. They may also engage in other impulsive behaviors such as reckless driving, excessive spending, bing-eating, substance use, or risky sexual behaviors. To assuage loneliness, if only for brief periods, they may accept a stranger as a friend or behave promiscuously.
Mental status exam: Patients frequently appear to be in a state of crisis and mood swings are common. Patients can be argumentative at one moment, depressed the next, and later complain of having no feelings. On the other hand they may have a mood-affect incongruence---they can look neutral or even cheerful when discussing morbid content. They commonly use the defense mechanism of splitting---they view others and themselves as all good or all bad. This may play out in your appointments in the way they view your or other providers as either nurturing attachment figures or as hateful figures who threaten them with abandonment whenever they feel dependent. Shifts of allegiance from one person or group to another are frequent. Another defense mechanism that may be seen is called projective identification. In this defense mechanism, intolerable aspects of the self are projected onto another; the other person is induced to play the projected role, and the two persons act in unison. Therapists must be aware of this process so they can act neutrally toward such patients.
Optional personality questionnaires: Several scales and structured interviews to assess BPD are available though rarely used within clinical practice. Examples include the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD), Minnesota Borderline Personality Disorder Scale (MBPD), Zanarini Rating Scale for Borderline Personality Disorder, Personality Assessment Inventory (PAI), and Minnesota Multiphasic Personality Inventory (MMPI). Of note, mood disorder questionnaires frequently misdiagnose BPD as bipolar disorder.
Differential diagnosis: Consider and rule out substance use disorders, bipolar disorder, major depressive disorder, PTSD, and other personality disorders. Borderline PD often co-occurs with mood disorders and when criteria for both are met, both may be diagnosed. In contrast to the episodic nature of mania/hypomania, mood swings experienced in borderline PD are rapid, brief, moment-to-moment reactions to triggers. Borderline PD and PTSD also have an overlap of certain symptoms and, as stated previously, there is a strong correlation between childhood trauma and development of borderline PD. This is sometimes called "complex PTSD". Also consider other personality disorders in the differential diagnosis, particularly other cluster B disorders (antisocial, histrionic, narcissistic).
Next lesson we will cover part 2 of borderline personality disorder as we focus exclusively on psychotherapy for BPD. If you want more learning resources then check out our recommended resources page.