Borderline Personality Disorder (BPD)

Overview

Borderline personality disorder (BPD), sometimes known as emotionally unstable personality disorder (EUPD), is a personality disorder distinguished by a long-term pattern of unstable interpersonal relationships, a disordered sense of self, and intense psychological reactions. Those affected frequently engage in self-harm and other harmful behaviors, typically as a result of their inability to return to a healthy or normal emotional baseline.

They may also experience feelings of emptiness, abandonment, and separation from reality. BPD symptoms might be triggered by circumstances that appear normal to others. BPD often originates in early adulthood and manifests itself in a number of scenarios. BPD is frequently connected with substance use disorders, depression, and eating disorders. Suicide may be attempted by 8 to 10% of those suffering from the disorder. The condition is frequently vilified in the media and in the psychiatric community, and as a result, it is frequently underdiagnosed.

The causes of BPD are unknown, however genetic, neurological, environmental, and social variables appear to play a role. It occurs around five times more frequently in people who have a close family who is affected. Adverse life experiences appear to play a role as well. The underlying mechanism appears to involve a neuronal network in the frontolimbic region. The Diagnostic and Statistical Manual of Mental Diseases (DSM) classifies BPD as a personality disorder, along with nine other similar disorders. The illness must be distinguished from, for example, an identity disorder or substance use disorders.

BPD is often treated with psychotherapy, such as cognitive behavioral therapy (CBT) or dialectical behavior therapy (DBT). DBT may lower the risk of suicide in people with bipolar disorder. BPD therapy can take place one-on-one or in a group setting. While drugs cannot cure BPD, they can help with the symptoms. Despite no evidence of efficacy, SSRI antidepressants and quetiapine are nonetheless commonly recommended for the illness. Severe occurrences of the condition may necessitate hospitalization. 

Worldwide prevalence of Borderline Personality Disorder (BPD)

Large, nationwide epidemiologic studies published in 2007 and 2008 assessed the general population's point prevalence of borderline personality disorder at 1.6 %, with a lifetime prevalence of 5.9 %. In the general population, no significant difference in frequencies of borderline personality disorder was discovered between males and females. However, in the clinical setting, the female to male ratio has been observed to be 3:1. These investigations called into question prior findings that borderline personality disorder was more common in women. 

The prevalence of borderline personality disorder has been estimated to be 11% in the psychiatric outpatient community and up to 20% in the psychiatric inpatient population. Several research on the association between ethnicity and borderline personality disorder have yielded inconclusive results.

What causes Borderline Personality Disorder (BPD)?

The causes of BPD, like those of other mental diseases, are complicated and not entirely understood. Evidence suggests that bipolar disorder (BPD) and post-traumatic stress disorder (PTSD) are associated in some way. Most experts believe that a history of childhood trauma can be a factor, but less attention has been spent in the past to researching the causative roles played by congenital brain abnormalities, genetics, neurobiological factors, and environmental factors other than trauma.

Social factors include how people interact in their early development with their family, friends, and other children. Psychological factors include the individual's personality and temperament, shaped by their environment and learned coping skills that deal with stress.These different factors together suggest that there are multiple factors that may contribute to the disorder.

1. Genetics

The heritability of BPD is believed to range between 37% and 69%. That is, genetic differences account for 37 to 69 percent of the variability in liability underlying BPD in the community.

Because of the complicating factor of a common family environment, twin studies may overestimate the effect of genes on variability in personality disorders. Nonetheless, the study concluded that personality disorders "appear to be more substantially influenced by hereditary influences than practically any Axis I condition [e.g., depression, eating disorders], and more than most broad personality aspects."

Moreover, the study found that BPD was estimated to be the third most-heritable personality disorder out of the 10 personality disorders reviewed. Twin, sibling, and other family studies show that impulsive aggression is partially heritable, while studies of serotonin-related genes show very little contributions to behaviour.

2. Brain abnormalities:

A number of neuroimaging studies in BPD have found decreases in brain regions involved in the regulation of stress reactions and emotion, including the hippocampus, orbitofrontal cortex, and amygdala, among others. A lesser number of studies have used magnetic resonance spectroscopy to investigate changes in neurometabolite concentrations in specific brain regions of BPD patients, specifically N-acetylaspartate, creatine, glutamate-related chemicals, and choline-containing compounds.

Increased gray matter has been found in places such as the bilateral supplementary motor area, dentate gyrus, and bilateral precuneus, which extends to the bilateral posterior cingulate cortex, according to certain research. In patients with BPD, as in people with post-traumatic stress disorder, the hippocampus is smaller (PTSD). 

However, unlike in PTSD, the amygdala is smaller in BPD. This extremely intense activity may explain the exceptional depth and duration of fear, sadness, rage, and shame experienced by persons with BPD, as well as their heightened sensitivity to other people's manifestations of these emotions. Given its function in regulating emotional arousal, the prefrontal cortex's greater inactivity may explain the problems patients with BPD have in managing their emotions and responding to stress.

3. Neurobiology:

Previously, borderline personality disorder was significantly linked to the occurrence of childhood trauma. While many mental disorders are thought to be linked to traumatic experiences during critical times of childhood, distinct neurobiological variables have been discovered in BPD individuals.

Individuals who have had childhood traumas and have been clinically diagnosed with BPD have had their hypothalamic-pituitary-adrenal (HPA) axis and cortisol levels thoroughly investigated. When the body is exposed to stresses, the HPA axis acts to maintain homeostasis, but it has been discovered to be dysregulated in individuals with a history of childhood abuse.

When the body is exposed to stress, the hypothalamus, specifically the paraventricular nucleus (PVN) releases peptides arginine vasopressin (AVP) and corticotropin-releasing factor (CRF). When these peptides travel through the body, they stimulate corticotrophic cells, resulting in the release of adrenocorticotropic hormone (ACTH). ACTH binds to receptors in the adrenal cortex, which stimulates the release of cortisol.

 Intracellular glucocorticoid receptor subtypes of mineralocorticoid receptor (MR) and low-affinity type receptor (GR) have been found to mediate the effects of cortisol on different areas of the body. While MRs have high affinity for cortisol and are highly saturated in response to stress, GRs have low affinity for cortisol and bind cortisol at high concentrations when an individual is exposed to a stressor.

4. Hypothalamic-pituitary-adrenal axis:

The hypothalamic-pituitary-adrenal (HPA) axis regulates cortisol production in response to stress. Cortisol levels are typically increased in people with BPD, indicating a hyperactive HPA axis. This causes individuals to have a stronger physiologic stress response, which may explain why they are more prone to irritability. 

Because traumatic events can increase cortisol production and HPA axis activity, one possibility is that the higher than average prevalence of HPA axis activity in people with BPD is simply a reflection of the higher than average prevalence of traumatic childhood and maturational events in people with BPD.

5. Estrogen:

Individual differences in women's estrogen cycles may be related to the expression of BPD symptoms in female patients. A study found that women's BPD symptoms were predicted by changes in estrogen levels throughout their menstrual cycles, an effect that remained significant when the results were controlled for a general increase in negative affect.

6. Childhood trauma:

There is a strong link between child maltreatment, particularly sexual abuse, and the development of BPD. Many people with BPD report having been abused or neglected as children, however the link between the two is still being debated. Patients with BPD are substantially more likely to report being verbally, emotionally, physically, or sexually assaulted by caregivers of either sex.

They also report a high rate of incest and caregiver loss in early childhood. Individuals with BPD were also more likely to report having both male and female caregivers deny the validity of their thoughts and feelings. Caregivers were also accused of failing to offer necessary protection and neglecting their child's physical care. Parents of both sexes were commonly reported to have emotionally distanced themselves from their children and to have treated them inconsistently.

Furthermore, women with BPD who reported a history of neglect by a female caregiver or abuse by a male caregiver were considerably more likely to have been sexually abused by a non-caregiver.

Signs and symptoms of Borderline Personality Disorder (BPD)

Before doing a full psychiatric assessment, a thorough history and physical examination should be undertaken. Structured diagnostic screening instruments, such as the Zanarini Rating Scale for borderline personality disorder, are used to examine personality disorders and, in particular, borderline personality disorder.

A pervasive pattern of instability of interpersonal relationships, of 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. 
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, for example, spending, substance abuse, reckless driving, sex, binge eating, etc. 
5. Affective instability caused by a marked reactivity of mood, for example, intense episodic dysphoria, anxiety, or irritability, usually lasting a few hours and rarely more than a few days.
6. Chronic feelings of emptiness.
7. Inappropriate, intense anger, or difficulty controlling anger, for example, frequent displays of temper, constant anger, recurrent physical fights.
8. Transient paranoid ideation or severe dissociative symptoms.

Diagnosis of Borderline Personality Disorder (BPD)

Several diagnostic instruments are available to aid in diagnosis, such as:

• The McClean screening instrument for borderline personality disorder.
• Personality diagnostic questionnaire.
• Structured clinical interview for DSM-5 personality disorders.
• The Minnesota borderline personality disorder scale.
• The personality assessment inventory-borderline features scale.

Diagnostic tools may be separated into the general categories of the self-report and structured interview. Patients with borderline personality disorder have been shown to have high rates of comorbid disorders:

• Mood disorders 80% to 96%.
• Anxiety disorders 88%.
• Substance abuse disorders 64%.
• Eating disorders 53%.
• Attention deficit hyperactivity disorder (ADHD) 10%-30%.
• Bipolar disorder 15%.
• Somatoform disorders 10%.

Treatment of Borderline Personality Disorder (BPD)

Treatment of borderline personality disorder relies on psychotherapy. Three evidence-based therapies are effective for patients with borderline personality disorder. 

1. First, mentalizing-based therapy (MBT) assists patients in managing emotion dysregulation by making them feel understood, allowing them to be more inquiring and make fewer assumptions about the motives of those around them. 
2. Second, Dialectical behavior therapy (DBT) is a second therapy that integrates mindfulness practices with specific interpersonal and emotion regulation skills. 
3. Third, transference-focused psychotherapy (TFP) focuses on developing the patient's awareness of problematic interpersonal relationships through the patient-therapist connection. MBT and DBT both include individual and group therapy over the course of 12 to 18 months. Family therapy may be an appropriate option for group therapy for adolescents, though this is not always the case.

There are no FDA-approved medications for the treatment of borderline personality disorder. SSRIs, mood stabilizers, and antipsychotics have demonstrated minimal efficacy in trials aimed at controlling symptoms such as anxiety, sleep disturbance, depression, or psychotic symptoms. Anxiety can be difficult to treat because individuals may characterize their internal experiences as anxious, even if they are not actually fearful.

As a result, the term "anxiety" may need to be precisely re-labeled, with therapy recommendations based on the patient's distinct interior experience. Patients with borderline personality disorder, on the other hand, frequently experience a fear of being alone; in other words, they have attachment-related anxiety. Attachment-associated anxiety, on the other hand, is not always tied to known anxiety disorders in terms of genesis or therapy.

Borderline personality disorder patients face therapy obstacles due to self-injurious behavior, boundary concerns, and frequent suicidal threats. High prevalence of concomitant substance misuse may potentially complicate treatment of patients with borderline personality disorder. Patients with borderline personality disorder do not usually need to be hospitalized; nonetheless, inpatient care may be required in specific situations, such as:

• Imminent risk of high lethality behaviors due to overt suicidal ideation or impulsivity.
• Severe social stressors causing intense negative thoughts or transient psychosis.
• The rapid escalation in the severity of self-injurious behaviour.
• Decompensation of comorbid psychiatric diagnoses or severe substance abuse.

A recent study found that the traditional belief that prolonged (more than one week) inpatient hospitalization is unhelpful or perhaps harmful for people with borderline personality disorder was not validated. Over several weeks of hospitalization, both inpatients with and without borderline personality disorder improved equally.

Outcomes of Borderline Personality Disorder (BPD)

There is a good prognosis for patients with borderline personality disorder. A longitudinal study of 290 inpatients diagnosed with borderline personality disorder and reassessed at 2-year intervals over 16 years yielded the following rates of remission:

• 35% remission after 2 years
• 91% remission after 10 years
• 99% remission after 16 years

Unfortunately, this study found that remission was related with poor social relationships, prompting the researchers to speculate that individuals may appear to remit because they avoid interpersonal relationships rather than progressively learning improved interpersonal skills. Once obtained, remission was maintained in 75 percent of patients for more than eight years. A lack of co-morbid, axis-1 disorders, no history of childhood sexual abuse, no history of family substance addiction, excellent baseline functioning (demonstrated at school or in the job), and age less than 25 years were all associated with a speedier beginning of remission. Sustained remission from borderline personality disorder has also been shown in other investigations.

Complications of Borderline Personality Disorder 

The complications of borderline personality disorder include:

• Engaging in risky behavior (e.g., rash driving).
• Drug abuse.
• Not completing education.
• Job loss.
• Getting in trouble with the law.
• Problems with relationships.
• Suicide attempts.

Conclusion

Borderline personality disorder (BPD) is a severe mental disorder. It usually starts in your late teens or early twenties. It affects more women than men. There is no known cause, but it is thought to be a combination of the way your brain is developed and the experiences you have in life.

For example, you could be predisposed to it due to genes passed down via your family. However, anything can happen to set it off, such as being abused or neglected.

When you have BPD, you have a hard time controlling your emotions. This can cause you to:

• Take unnecessary risks
• Have intense mood swings
• Have bouts of anger, depression, or anxiety

You may find it difficult to:

• Manage daily tasks at home
• Perform at work
• Maintain relationships

This might result in divorce, separation from family and friends, and major financial problems. BPD is not an isolated problem. If you have it, you are more prone to suffer from other mental health issues. You may develop anxiety, depression, eating disorders, and suicidal ideation. Many people cope by using drugs and alcohol, which can lead to even more difficulties.

Though there is no cure, the severity of BPD may decrease with age and treatment.