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Borderline Personality Disorder 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.1 There is a high rate of self-injury
without suicide intent, as well as a significant rate of suicide attempts and
completed suicide in severe cases.2,3 Patients often need extensive mental health
services, and account for 20 percent of psychiatric hospitalizations.4 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.5 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.6 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.7 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.8 Forty to 71 percent of BPD patients
report having been sexually abused, usually by a non-caregiver.9 Researchers believe that BPD results
from a combination of individual vulnerability to environmental stress,
neglect or abuse as young children, and 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 judgement 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.10 The amygdala, 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.11 Serotonin, norepinephrine 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.7 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. The National Institute of Mental Health (NIMH) is part
of the National Institutes of Health (NIH), a component of the U.S.
Department of Health and Human Services. http://www.nimh.nih.gov/health/publications/borderline-personality-disorder.shtml
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