Borderline personality disorder: Difference between revisions

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'''For patient information click [[Borderline personality disorder (patient information)|here]]'''
'''For patient information click [[Borderline personality disorder (patient information)|here]]'''


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{{SI}}
{{SI}}
{{CMG}}; {{AE}}; {{JH}}, {{I.D.}}
{{CMG}}; {{AE}} {{JH}}, {{I.D.}}


{{SK}} BPD; emotionally unstable personality disorder; unstable self-image; unstable relationships
{{SK}} BPD, unstable self-image, unstable relationships
   
   
==Overview==
==Overview==
Borderline personality disorder is defined as a [[personality disorder]] primarily characterized by [[emotional dysregulation]], extreme "black and white" thinking, or "[[Splitting#Borderline Personality Disorder|splitting]]", and chaotic relationships. The general profile of the disorder also typically includes a pervasive instability in [[Mood (psychology)|mood]], [[interpersonal relationship]]s,  self-image, [[Identity (social science)|identity]], and [[human behavior|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 (psychology)|dissociation]].<ref name="DSM-IV-TR">(2004). ''Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR'' (Text Revision). Washington, DC: American Psychiatric Association. ISBN [[Special:Booksources/0890420246|0890420246]]. [http://www.behavenet.com/capsules/disorders/borderlinepd.htm DSM-IV & DSM-IV-TR Borderline Personality Disorder criteria]. ''BehaveNet.com''. Retrieved on 2007-09-21.</ref> The disturbances suffered by those with borderline personality disorder have a wide-ranging and pervasive negative impact on many or all of the psychosocial facets of life, including ability to hold down a job and relationships in work, home, and social settings. [[Comorbidity]] is common; borderline personality disorder frequently occurring with substance use disorders and [[mood disorders]]. Attempted suicide and completed suicide are possible outcomes without proper care and effective therapy.
Borderline Personality Disorder (BPD) is defined as a [[personality disorder]] primarily characterized by [[emotional dysregulation]], extreme "black and white" thinking,"[[splitting#Borderline Personality Disorder|splitting]]", and chaotic relationships. The general profile of the [[disorder]] also typically includes a pervasive instability in [[Mood (psychology)|mood]], [[interpersonal relationship]]s,  [[self-image]], [[Identity (social science)|identity]], and [[human behavior|behavior]]. Moreover, there may be a disturbance in the individual's sense of self. In extreme cases, this disturbance in the sense of self may lead to periods of [[Dissociation (psychology)|dissociation]].<ref name="DSM-IV-TR">(2004). ''Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR'' (Text Revision). Washington, DC: American Psychiatric Association. ISBN [[Special:Booksources/0890420246|0890420246]]. [http://www.behavenet.com/capsules/disorders/borderlinepd.htm DSM-IV & DSM-IV-TR Borderline Personality Disorder criteria]. ''BehaveNet.com''. Retrieved on 2007-09-21.</ref> The disturbances suffered by those with borderline personality disorder have a wide-ranging and pervasive negative impact on many or all of the psychosocial facets of life, including the ability to hold down a job, maintain relationships at home, and interacting in social settings. [[Comorbidity]] is common; borderline personality disorder frequently occurs with [[substance use]] disorders and [[mood disorders]]. Attempted [[suicide]] and completed [[suicide]] are possible outcomes without proper care and effective [[therapy]]. '''The reference of "BPD" throughout this article refers to [[borderline personality disorder]] and not [[bipolar disorder]].'''
 
== Terminology ==
There is a debate as to whether BPD should be renamed. The term "borderline" started among clinical use within the late 1930s, originating from the idea (now out of favor) of some patients being on the "borderline" between [[neurosis]] and [[psychosis]]. As a deeper understanding of BPD began to emerge, the disorder could be classified and treated more efficiently once the disorder could be differentiated from neurotic behavior and psychotic behavior. BPD only became an official Axis II (personality) diagnosis in 1980 with the publication of DSM-III.<ref name="PToverview">Oldham, J. (July 2004). "[http://www.psychiatrictimes.com/p040743.html Borderline Personality Disorder: An Overview]" ''Psychiatric Times'' '''XXI''' (8). Retrieved on 2007-09-21.</ref>
 
Alternative suggestions for names include ''Emotional regulation disorder'' or ''Emotional dysregulation disorder''. According to TARA, (Treatment and Research Advancement Association for Personality Disorders) this terminology has "the most likely chance of being adopted by the American Psychiatric Association."<ref>Porr, Valerie MA (November 2001). [http://www.tara4bpd.org/ad.html How Advocacy is Bringing Borderline Personality Disorder Into the Light]. ''tara4bpd.org'' Axis II. Retrieved on 2007-09-21.</ref> An emotional regulation disorder is a term favored by Dr. Marsha Linehan, pioneer of one of the most popular types of BPD therapy. ''Impulse disorder'' and ''Interpersonal regulatory disorder'' are other valid alternatives, according to Dr. John Gunderson of [[McLean Hospital]] in the United States. [[Borderline personality disorder|Dyslimbia]] has been suggested by Dr. Leland Heller<ref name=heller>Heller, L. MD. "[http://www.biologicalunhappiness.com/21a.htm A Possible New Name For Borderline Personality Disorder]". ''Biological Unhappiness''. Retrieved on 2007-09-21.</ref> and ''Mercurial disorder'' has been proposed by McLean Hospital's Dr. Mary Zanarini.<ref>Hunter, Aina (2006-01-24). "[http://www.villagevoice.com/people/0604,hunter,71916,24.html Personality, Interrupted]". ''The Village Voice''. Retrieved on 2007-09-21.</ref>


Another term advanced (for example by psychiatrist Carolyn Quadrio) is ''Post Traumatic Personality Disorganisation'' (PTPD), reflecting the condition's status as (often) both a form of chronic [[Post Traumatic Stress Disorder]] (PTSD) and Personality Disorder, along with a common outcome of developmental or attachment trauma.<ref name="AxisOne/AxisTwo">Quadrio, C. (December 2005). "Axis One/Axis Two: A disordered borderline" (PDF). ''Psychology, Psychiatry, and Mental Health Monographs: The Journal of the NSW Institute of Psychiatry'' (2): 141-156. Retrieved on 2007-09-21.</ref>
== Historical Perspective ==
*In the 1930s, there was a debate as to whether BPD should be renamed. The term "borderline" started among clinical use and originated from the idea (now out of favor) of some patients being on the "borderline" between [[neurosis]] and [[psychosis]]. As a deeper understanding of BPD began to emerge, the disorder could be classified and treated more efficiently once the disorder could be differentiated from [[neurotic behavior]] and [[psychotic behavior]].
*In 1980, BPD only became an official Axis II (personality) diagnosis with the publication of [[DSM-III]].<ref name="PToverview">Oldham, J. (July 2004). "[http://www.psychiatrictimes.com/p040743.html Borderline Personality Disorder: An Overview]" ''Psychiatric Times'' '''XXI''' (8). Retrieved on 2007-09-21.</ref>
*Individuals who are [[labeling theory|labeled]] with "Borderline Personality Disorder" feel it is unhelpful and stigmatizing, as well as simply inaccurate, to support a name change.<ref>Bogod, E. "[http://www.mental-health-matters.com/articles/article.php?artID=338 Borderline Personality Disorder Label Creates Stigma]". ''mental-health-matters.com''. Retrieved on 2007-09-21.</ref> Criticisms have also come from a feminist perspective.<ref>Shaw and Proctor (2005). "[http://fap.sagepub.com/cgi/reprint/15/4/483 Women at the Margins: A Critique of the Diagnosis of Borderline Personality Disorder]" (PDF). ''Feminism Psychology'' (15): 483-90. Retrieved on 2007-09-21.</ref> It has also been claimed that, in some circles, "borderline" is used as a "garbage can" [[diagnosis]] for individuals who are hard to diagnose. This may be interpreted as meaning "nearly psychotic" despite a lack of empirical support for this conceptualization. It may also be used as a generic label for difficult clients or as an excuse for therapy going badly.<ref>Grohol, J. Psy.D. (June 22 2007). "[http://psychcentral.com/disorders/sx10.htm Symptoms of Borderline Personality Disorder]". ''PsychCentral.com''. Retrieved on 2007-09-21.</ref>


Significantly, the above proposals, if adopted, will likely result in the recognition of BPD as a trauma- and/or mood-related disorder, and should move BPD from Axis II to Axis I in the next [[DSM]] (''DSM-V'', due in 2012).
==Classification==
*Borderline personality disorder is characterized by three domains of [[dysfunction]]:
*Affect dysregulation
**[[Dysregulation]] results from abnormal [[top-down processes]].
*[[Behavioral dyscontrol]]
*Interpersonal [[hypersensitivity]]
**[[Interpersonal hypersensitivity]] is associated with a (pre)attentive bias toward negative social information and, on the level of the [[brain]], enhanced bottom-up [[emotion]] generation.


Individuals who are [[labeling theory|labeled]] with "Borderline Personality Disorder" feel it is unhelpful and stigmatizing, as well as simply inaccurate, to support a name change.<ref>Bogod, E. "[http://www.mental-health-matters.com/articles/article.php?artID=338 Borderline Personality Disorder Label Creates Stigma]". ''mental-health-matters.com''. Retrieved on 2007-09-21.</ref> Criticisms have also come from a feminist perspective.<ref>Shaw and Proctor (2005). "[http://fap.sagepub.com/cgi/reprint/15/4/483 Women at the Margins: A Critique of the Diagnosis of Borderline Personality Disorder]" (PDF). ''Feminism Psychology'' (15): 483-90. Retrieved on 2007-09-21.</ref> It has also been claimed that, in some circles, "borderline" is used as a "garbage can" diagnosis for individuals who are hard to diagnose. This may be interpreted as meaning "nearly psychotic" despite a lack of empirical support for this conceptualization. It may also be used as a generic label for difficult clients or as an excuse for therapy going badly.<ref>Grohol, J. Psy.D. (June 22 2007). "[http://psychcentral.com/disorders/sx10.htm Symptoms of Borderline Personality Disorder]". ''PsychCentral.com''. Retrieved on 2007-09-21.</ref>
=== Terminology ===
*Alternative suggestions for names include:
**''[[Emotional regulation disorder]]''
**''[[Emotional dysregulation disorder]]''
*According to TARA, (Treatment and Research Advancement Association for Personality Disorders) this terminology has "the most likely chance of being adopted by the American Psychiatric Association."<ref>Porr, Valerie MA (November 2001). [http://www.tara4bpd.org/ad.html How Advocacy is Bringing Borderline Personality Disorder Into the Light]. ''tara4bpd.org'' Axis II. Retrieved on 2007-09-21.</ref>  
*An emotional regulation disorder is a term favored by Dr. Marsha Linehan, pioneer of one of the most popular types of BPD therapy.
*''[[Impulse disorder]]'' and ''Interpersonal regulatory disorder'' are other valid alternatives, according to Dr. John Gunderson of [[McLean Hospital]] in the United States.
*[[Borderline personality disorder|Dyslimbia]] has been suggested by Dr. Leland Heller.<ref name="heller">Heller, L. MD. "[http://www.biologicalunhappiness.com/21a.htm A Possible New Name For Borderline Personality Disorder]". ''Biological Unhappiness''. Retrieved on 2007-09-21.</ref>
*''[[Mercurial disorder]]'' has been proposed by McLean Hospital's Dr. Mary Zanarini.<ref>Hunter, Aina (2006-01-24). "[http://www.villagevoice.com/people/0604,hunter,71916,24.html Personality, Interrupted]". ''The Village Voice''. Retrieved on 2007-09-21.</ref>


==Causes==
*Another term advanced (for example by psychiatrist Carolyn Quadrio) is ''[[Post Traumatic Personality Disorganisation]]'' (PTPD), reflecting the condition's status as (often) both a form of [[chronic]] [[Post Traumatic Stress Disorder]] (PTSD) and [[personality disorder]], along with a common outcome of developmental or attachment trauma.<ref name="AxisOne/AxisTwo">Quadrio, C. (December 2005). "Axis One/Axis Two: A disordered borderline" (PDF). ''Psychology, Psychiatry, and Mental Health Monographs: The Journal of the NSW Institute of Psychiatry'' (2): 141-156. Retrieved on 2007-09-21.</ref>


Researchers commonly believe that BPD results from a combination of a traumatic childhood, a vulnerable temperament, and stressful maturational events during [[adolescence]] or adulthood.<ref>Zanarini, M.C.; F.R. Frankenburg (1997). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9113824 Pathways to the development of borderline personality disorder]". ''Journal of Personality Disorder.'' '''11''' (1): 93-104. Retrieved on 2007-09-21.</ref> [[Otto Kernberg]] formulated the theory of [[Borderline Personality]] based on a premise of failure to develop in childhood. There are, according to Kernberg, three developmental tasks an individual must accomplish; when one fails to accomplish a certain developmental task, this often corresponds with an increased risk of developing certain psychopathologies. Failing the first developmental task,''psychic clarification of self and other'', may result in an increased risk to develop varieties of psychosis. Not accomplishing the second task, ''overcoming splitting'', may result in an increased risk to develop a borderline personality. <ref>Kernberg, O. (2000). ''Borderline Conditions and Pathological Narcissism''. New York: Aronson. [[Special:Booksources/0876687621|ISBN 0876687621]].</ref>
*Significantly, the above proposals, if adopted, will likely result in the recognition of BPD as a [[trauma]]- and/or [[mood-related disorder]], and should move BPD from Axis II to Axis I in the next [[DSM]] (''DSM-V'', due in 2012).
 
=== Childhood Abuse, Trauma or Neglect ===
Numerous studies have shown a strong correlation between childhood abuse and development of BPD.<ref>Zanarini, M.C.; J.G. Gunderson, et al. (January &ndash; February 1989). "[http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=2924564&dopt=AbstractPlus Childhood experiences of borderline patients]". ''Comprehensive psychiatry'' '''30''' (1): 18-25. Retrieved on 2007-09-21.</ref><ref>Brown G.R.; B. Anderson (1991). "[http://www.clogo.org/Archives/prd/lib/Brown1991.html Psychiatric morbidity in adult inpatients with childhood histories of sexual and physical abuse]". ''Am J Psychiatry'' '''148''' (1): 55-61. Retrieved on 2007-09-21.</ref><ref name = "Herman91">Herman, Judith (1997). ''Trauma and Recovery: The Aftermath of Violence--from Domestic Abuse to Political Terror''. Basic Books. [[Special:Booksources/0465087302|ISBN 0465087302]].</ref><ref name="AxisOne/AxisTwo"/> Many individuals with BPD report having had a history of abuse, neglect, or separation as young children.<ref>Zanarini M.C.; F.R. Frankenburg (1997). "Pathways to the development of borderline personality disorder". ''Journal of Personality Disorders'' '''11''' (1): 93-104.</ref> Patients with BPD have been found to be significantly more likely to report having been verbally, emotionally, physically, and sexually abused by caretakers of either gender. They were also much more likely to report having caretakers (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 caretaker and abuse by a male caretaker were consequently at significantly higher risk for being sexually abused by a noncaretaker (not a parent).<ref name=failchild>Zanarini, M.C.; F.R. Frankenburg (2000}. "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11019749 Biparental failure in the childhood experiences of borderline patients]". ''J Personal Disord'' '''14''' (3):264-73. Retrieved on 2007-09-21.</ref> These are also the same risk factors for [[reactive attachment disorder]] and it has been suggested that children who experience chronic early maltreatment and Reactive Attachment Disorder go on to develop a variety of personality disorders, including Borderline Personality Disorder.<ref name="Dozier-1999">Dozier, M.; K. C. Stovall, et al. (1999). "Attachment and psychopathology in adulthood" in Cassidy, J.; P. Shaver (Eds.), ''Handbook of attachment'' pp. 497–519. New York: Guilford Press.</ref> Many of these children are violent<ref>Robins, L.N. (1978). "Longitudinal studies: Sturdy childhood predictors of adult
antisocial behavior". ''Psychological Medicine'' (8): 611–22.</ref> and aggressive<ref>Prino, C.T., & M. Peyrot (1994). "The effect of child physical abuse and neglect on aggressive withdrawn, and prosocial behavior". ''Child Abuse and Neglect'' (18): 871–84.</ref> and as adults are at risk of developing a variety of psychological problems<ref>Schreiber, R.; W. J. Lyddon (1998). "Parental bonding and current psychological functioning among childhood sexual abuse survivors". ''Journal of Counseling Psychology'' (45): 358–362.</ref> such as borderline personality disorder.<ref name="Dozier-1999"/>


According to Joel Paris,<ref name ="Paris">Paris, Joel MD. "[http://www.jwoodphd.com/borderline_personality_disorder.htm Borderline Personality Disorder: What Is It, What Causes It? How Can We Treat It?]" ''jwoodphd.com''. Retrieved on 2007-09-21. </ref> "Some researchers, like Judith Herman, believe that BPD is a name given to a particular manifestation of [[post-traumatic stress disorder]] (PTSD): in ''Trauma and Recovery'', she theorizes that when PTSD takes a form that emphasizes heavily its elements of identity and relationship disturbance, it gets called BPD; when the somatic (body) elements are emphasized, it gets called hysteria, and when the dissociative/deformation of consciousness elements are the focus, it gets called DID/MPD" ([[dissociative identity disorder]] or multiple personality disorder).
==Pathophysiology==
*According to studies, a conceptual framework for future research in borderline personality disorder that is based on [[oxytocinergic modulation]] of the following [[biobehavioral mechanisms]]:<ref name="pmid26324303">{{cite journal| author=Herpertz SC, Bertsch K| title=A New Perspective on the Pathophysiology of Borderline Personality Disorder: A Model of the Role of Oxytocin. | journal=Am J Psychiatry | year= 2015 | volume= 172 | issue= 9 | pages= 840-51 | pmid=26324303 | doi=10.1176/appi.ajp.2015.15020216 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26324303  }} </ref>
**The [[brain's salience network]] favoring adaptive social approach [[behavior]]
**The affect regulation circuit normalizing [[top-down processes]]
**The [[mesolimbic circuit]] for improving social reward experiences
**Modulating [[brain regions]] involved in [[cognitive]] and [[emotional]] empathy


===Other Developmental Factors===
*In addition, preliminary data point to interactions between the [[oxytocin]] and [[cannabinoid system]], with implications for [[pain processing]].  
 
**These mechanisms, which the authors believe to be modulated by [[oxytocin]], may not be specific for borderline personality disorder but rather may be common to a host of [[psychiatric disorders]] in which disturbed parent-infant attachment is a major [[etiological factor]].
Some studies suggest that BPD may not necessarily be a trauma-spectrum disorder and that it is biologically distinct from the post traumatic stress disorder that could be a precursor. The personality symptom clusters seem to be related to specific abuses, but they may be related to more persistent aspects of interpersonal and family environments in childhood.<ref name=neurotrauma/>
 
There is evidence for the central role of family in the development of BPD, including interactions that are negative and critical rather than supportive and empathic, with parental and family behaviors transacting with the child's own behaviors and emotional vulnerabilities.<ref>Fruzzetti, A.E.; C. Shenk, P.D. Hoffman (2005). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=16613428 Family interaction and the development of borderline personality disorder: a transactional model]". ''Dev Psychopathol.'' '''17''' (4): 1007-30. Retrieved on 2007-09-21.</ref>
 
Some findings suggest that BPD may lie 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.<ref>Mackinnon, D.F.; R. Pies (February 2006). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=16411976 Affective instability as rapid cycling: theoretical and clinical implications for borderline personality and bipolar spectrum disorders]". ''Bipolar Disord.'' '''8''' (1): 1-14. Retrieved on 2007-09-21.</ref><ref>Goldberg, Ivan MD (February 2006). "[http://www.psycom.net/depression.central.bordbipol.html MMEDLINE Citations on The Borderline-Bipolar Connection]". ''Bipolar disord.'' '''8''' (1): 1-14. Retrieved on 2007-09-21.</ref> Some findings suggest that the DSM-IV BPD diagnosis mixes up two sets of unrelated items&mdash;an affective instability dimension related to Bipolar-II, and an impulsivity dimension not related to Bipolar-II.<ref>Benazzi, F. (January 2005). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=16019119 Borderline personality-bipolar spectrum relationship]". ''Prog Neuropsychopharmacol Biol Psychiatry'' '''30''' (1): 68-74. Retrieved on 2007-09-23.</ref>


===Genetics===
===Genetics===
 
A [[twin study]] found that if one identical twin met criteria for BPD, the other also met criteria in around a third (35%) of cases, whereas the concordance rate in dizygotic twin pairs was 7% in monozygotic, yielding an inheritance of 0.69.<ref name="pmid11086146">{{cite journal| author=Torgersen S, Lygren S, Oien PA, Skre I, Onstad S, Edvardsen J et al.| title=A twin study of personality disorders. | journal=Compr Psychiatry | year= 2000 Nov-Dec | volume= 41 | issue= 6 | pages= 416-25 | pmid=11086146 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&retmode=ref&cmd=prlinks&id=11086146 | doi=10.1053/comp.2000.16560 }} </ref>
An overview of the existing literature suggested that traits related to BPD are influenced by genes, and since personality is generally quite heritable then BPD should also be, but studies have had methodological problems and the links are not yet clear.<ref>Torgersen, S. (March 2000). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=10729927&query_hl=8&itool=pubmed_docsum Genetics of patients with borderline personality disorder]". ''Psychiatr Clin North Am'' '''23''' (1): 1-9. Retrieved on 2007-09-23.</ref> A major twin study found that if one identical twin met criteria for BPD, the other also met criteria in around a third (35%) of cases.<ref>Torgersen, S.; S. Lygren, P.A. Oien, et al. (November - December 2000). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11086146 A twin study of personality disorders]". ''Compr Psychiatry'' '''41''' (6): 416-25. Retrieved on 2007-09-23.</ref>
   
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.<ref name=neurotrauma/>
 
===Neurofunction===
 
[[Neurotransmitters]] implicated in BPD include [[serotonin]], [[norepinephrine]] and [[acetylcholine]] (related to various emotions and moods); [[GABA]], the brain's major inhibitory [[neurotransmitter]] (which can stabilize mood change); and [[glutamate]], an excitatory neurotransmitter.
 
Enhanced [[amygdala]] activation in BPD has been identified as reflecting the intense and slowly subsiding emotions commonly observed in BPD in response to even low-level stressors.<!-- The following ref has URL which does not correspond with given information. <ref>Herpertz, S.C.; T.M. Dietrich, B. Wenning, et al. (August 2001). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=Display&DB=pubmed Evidence of abnormal amygdala functioning in borderline personality disorder: a functional MRI study]". ''Biol Psychiatry'' '''15''';50(4):292-8.</ref> --> The activation of both the amygdala and prefrontal cortical areas can reflect attempts to control intensive emotions during the recall of unresolved life events.<ref>Beblo, T.; M. Driessen, M. Mertens, et al. (June 2006). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=16704749 Functional MRI correlates of the recall of unresolved life events in borderline personality disorder]". ''Psychol Med'' '''36''' (6): 845-56. Retrieved on 2007-09-23.</ref> Impulsivity or aggression, as sometimes seen in BPD, has been linked to alterations in serotonin function and specific brain regions in the cingulate and the medial and orbital [[prefrontal cortex]].<ref name=neurotrauma>Goodman M.; A. New, L. Siever (2004). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15677398&query_hl=7&itool=pubmed_docsum Trauma, genes, and the neurobiology of personality disorders]". ''Ann N Y Acad Sci'' (1032): 104-16. Retrieved on 2007-09-23.</ref>


==Differential Diagnosis==
==Differential Diagnosis==
*[[Depressive disorder]]
*Borderline personality disorder should be differentiated from other disorders including:<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
*[[Bipolar disorder]]
**[[Depressive disorder]]
*[[Paranoid personality disorder]]
**[[Bipolar disorder]]
*Medical conditions that affect the [[central nervous system]]
**[[Paranoid personality disorder]]
*Identity problems<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
**Medical conditions that affect the [[central nervous system]]
**Identity problems


==Epidemiology and Demographics==
==Epidemiology and Demographics==
===Prevalence===
===Prevalence===
The prevalence of borderline personality disorder is 1600 to 5900 per 100,000 (1.6% to 5.9%) of the overall population.<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
*The prevalence of borderline personality disorder is 1600 to 5900 per 100,000 (1.6% to 5.9%) of the overall population.<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref> <ref>{{cite web |url=https://www.nimh.nih.gov/health/statistics/personality-disorders.shtml |title=NIMH » Personality Disorders |format= |work= |accessdate=}}</ref>
*The prevalence of any personality disorder was 9.1%, with borderline personality disorder being 1.4%.<ref>===Gender===
*Sex and race were not found to be associated with the prevalence of borderline personality disorder.
 
==Risk Factors==
*First-degree biological relatives with borderline personality disorder<nowiki><ref name="DSMV"></nowiki>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
*Researchers commonly believe that BPD results from a combination of a traumatic childhood, a vulnerable temperament, and stressful maturational events during [[adolescence]] or adulthood.<ref>Zanarini, M.C.; F.R. Frankenburg (1997). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9113824 Pathways to the development of borderline personality disorder]". ''Journal of Personality Disorder.'' '''11''' (1): 93-104. Retrieved on 2007-09-21.</ref>
*[[Otto Kernberg]] formulated the theory of [[Borderline Personality]] based on a premise of failure to develop in childhood. There are, according to Kernberg, three developmental tasks an individual must accomplish:
**When one fails to accomplish a certain developmental task, this often corresponds with an increased risk of developing certain psychopathologies.
**Failing the first developmental task,''psychic clarification of self and other'', may result in an increased risk to develop varieties of psychosis.
**Not accomplishing the second task, ''overcoming splitting'', may result in an increased risk to develop a borderline personality. <ref>Kernberg, O. (2000). ''Borderline Conditions and Pathological Narcissism''. New York: Aronson. ISBN 0876687621.</ref>


==Risk Factors==
==Risk Factors==
*First-degree biological relatives with borderline personality disorder<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
 
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| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |Childhood abuse, Trauma, or Negelct
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*Numerous studies have shown a strong correlation between [[childhood abuse]] and the development of BPD.<ref>Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association (2013) '''12'''.</ref><ref>Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association (2013) '''13'''.</ref><ref>Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association (2013) '''14'''.</ref><ref>"Axis One/Axis Two: A disordered borderline" (PDF). Psychology, Psychiatry, and Mental Health Monographs: The Journal of the NSW Institute of Psychiatry (2): 141-156. Retrieved on 2007-09-21 '''6'''.</ref>
*Majority of individuals with BPD report having had a history of [[abuse]], [[neglect]], or separation as young children.<ref>'''15'''</ref>
*Patients with BPD have been found to be significantly more likely to report having been [[verbally]], [[emotionally]], [[physically]], and [[sexually abused]] by caretakers of either gender.
*Patients were also much more likely to report having caretakers (of both genders) deny the validity of their thoughts and feelings.
*They were also reported to have failed to been provided needed protection.
*Individuals with ignored child physical care during adolescence are more likely to have borderline personality disorder.
*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 caretaker and abuse by a male caretaker were consequently at significantly higher risk for being sexually abused by a non-caretaker (not a parent).<ref>Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013.'''16'''.</ref>
*It has been suggested that children who experience [[chronic early maltreatmen]]t and [[Reactive Attachment Disorder]] go on to develop a variety of personality disorders, including Borderline Personality Disorder.<ref>Stiglmayr, C.E.; T. Grathwol, M.M. Leneham, et al. (May 2005). "Aversive tension in patients with borderline personality disorder: a computer-based controlled field study." Acta Psychiatr Scand111 (5): 372-9. Retrieved on 2007-09-21 '''17'''.</ref>Many of these children are violent and aggressive.<ref>Koenigsberg H.W.; P.D. Harvey, V. Mitropoulou, et al. (May 2002). "Characterizing affective instability in borderline personality disorder". Am J Psychiatry 159 (5): 784-8. Retrieved on 2007-09-21. '''18'''</ref><ref>Meyer, B.; M. Ajchenbrenner, D.P. Bowles (December 2005). "Sensory sensitivity, attachment experiences, and rejection responses among adults with borderline and avoidant features". J Personal Disord 19 (6): 641-58. Retrieved on 2007-09-21. '''19'''</ref>
*As adults, these individuals are at risk of developing a variety of [[psychological]] problems such as borderline personality disorder.<ref>Zanarini, M.C.; F.R. Frankenburg, C.J. DeLuca, et al. (1998). "The pain of being borderline: dysphoric states specific to borderline personality disorder". Harvard Review of Psychiatry6 (4): 201-7. Retrieved on 2007-09-21. '''20'''</ref><ref>Stiglmayr, C.E.; T. Grathwol, M.M. Leneham, et al. (May 2005). "Aversive tension in patients with borderline personality disorder: a computer-based controlled field study." Acta Psychiatr Scand111 (5): 372-9. Retrieved on 2007-09-21 '''17'''.</ref>
**According to Joel Paris,"Some researchers, like Judith Herman, believe that BPD is a name given to a particular manifestation of [[post-traumatic stress disorder]] (PTSD): In Trauma and Recovery, she theorizes that when PTSD takes a form that emphasizes heavily on its elements of identity and relationship disturbance, the disorder is named BPD; when the [[somatic]] (body) elements are emphasized, the disorder is named hysteria; when the dissociative/deformation of consciousness elements are the focus, the disorder is named  DID/MPD" (dissociative identity disorder or multiple personality disorder).<ref>American Psychiatric Association (2001). "Psychiatric Services". Psychiatr Serv (52): 1569-70. Retrieved on 2007-09-21.'''21'''</ref>
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| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |[[Genetics]]
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*An overview of existing literature suggests that traits related to BPD are influenced by [[genes]]. [[Personality]] is generally quite [[heritable]]; therefore, BPD is likely to have a large [[genetical factor]] in that sense. However, studies have had methodological problems for the connection between genetical factors and BPD.<ref>Hoffman, P.D.; E. Buteau, J.M. Hooley, et al. (2003). "Family members' knowledge about borderline personality disorder: correspondence with their levels of depression, burden, distress, and expressed emotion". Family Process 42 (4): 469-78. Retrieved on 2007-09-21.'''27'''</ref>
*A major twin study found that if one identical twin met criteria for BPD, the other also met criteria in approximately a third (35%) of cases.<ref>Allen, D.M.; R.G. Farmer (January – February 1996). "Family relationships of adults with borderline personality disorder". Compr Psychiatry 37 (1): 43-51. Retrieved on 2007-09-21. '''28'''</ref>
*Twins, siblings, 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.<ref>'''22'''</ref>
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| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |[[Neurofunction]]
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*[[Neurotransmitters]] implicated in BPD include [[serotonin]], [[norepinephrine]], [[acetylcholine]] (related to various emotions and moods), [[GABA]] (the brain's major inhibitory neurotransmitter which can stabilize mood change), and [[glutamate]] (an excitatory neurotransmitter).
*Enhanced [[amygdala]] activation in BPD has been identified as reflecting the intense and slowly subsiding emotions commonly observed in BPD in response to low-level stressors.
**The activation of both the [[amygdala]] and prefrontal cortical areas can reflect attempts to control intensive emotions during the recall of unresolved life events.<ref>Daley, S.E.; D. Burge, C. Hammen (August 2000). "Borderline personality disorder symptoms as predictors of 4-year romantic relationship dysfunction in young women: addressing issues of specificity". J Abnorm Psychol 109 (3): 451-60. Retrieved on 2007-09-21.'''29'''</ref>
*[[Impulsivity]] or aggression, as sometimes seen in BPD, has been linked to alterations in [[serotonin]] function and specific brain regions in the [[cingulate]] and the medial and orbital prefrontal [[cortex]].<ref>'''22'''</ref>
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| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold; text-align:center;" |[[Other Developmental Factors]]
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*A few studies suggest that BPD may not necessarily be a [[trauma-spectrum disorder]] and that it is biologically distinct from the [[post-traumatic stress disorder]] that could be a precursor. The personality symptom clusters seem to be related to specific [[abuse]]s, but they may be related to more persistent aspects of interpersonal and family environments in childhood.<ref>'''22'''</ref>
*There is evidence for the central role of the family in the development of BPD, including interactions that are negative and critical rather than supportive and empathic, with parental and family behaviors transacting with the child's own behaviors and [[emotional]] vulnerabilities.<ref>Levy, K.N.; K.B. Meehan, M. Weber, et al. (March – April 2005). "Attachment and borderline personality disorder: implications for psychotherapy". [[Psychopathology]] 38 (2): 64-74. Retrieved on 2007-09-21. '''23'''</ref>
*A few findings suggest that BPD may lie 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.<ref>Allen, D.M.; R.G. Farmer (January – February 1996). "Family relationships of adults with BPD". Compr Psychiatry 37 (1): 43-51. Retrieved on 2007-09-21. '''24'''</ref><ref>'''25'''</ref>
*Moreover, a few findings suggest that the [[DSM]]-IV BPD diagnosis mixes up two sets of unrelated items: An effective instability dimension related to Bipolar-II and an [[impulsivity]] dimension not related to Bipolar-II.<ref>Linehan, M. (1993). [[Cognitive-behavioral treatment]] of borderline personality disorder. New York: Guilford. '''26'''</ref>
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==Natural History, Complications and Prognosis==
==Natural History, Complications and Prognosis==
===Natural History===
===Natural History===
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.<ref>Stiglmayr, C.E.; T. Grathwol, M.M. Leneham, et al. (May 2005). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=1581973 Aversive tension in patients with borderline personality disorder: a computer-based controlled field study.]" ''Acta Psychiatr Scand'' '''111''' (5): 372-9. Retrieved on 2007-09-21.</ref> Individuals with BPD may show [[lability]] (changeability) between anger and anxiety or between depression and anxiety<ref>Koenigsberg H.W.; P.D. Harvey, V. Mitropoulou, et al. (May 2002). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=11986132 Characterizing affective instability in borderline personality disorder]". ''Am J Psychiatry'' '''159''' (5): 784-8. Retrieved on 2007-09-21.</ref> and temperamental sensitivity to emotive stimuli.<ref>Meyer, B.; M. Ajchenbrenner, D.P. Bowles (December 2005). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16553560 Sensory sensitivity, attachment experiences, and rejection responses among adults with borderline and avoidant features]". ''J Personal Disord'' '''19''' (6): 641-58. Retrieved on 2007-09-21.</ref>
*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.<ref>Stiglmayr, C.E.; T. Grathwol, M.M. Leneham, et al. (May 2005). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=1581973 Aversive tension in patients with borderline personality disorder: a computer-based controlled field study.]" ''Acta Psychiatr Scand'' '''111''' (5): 372-9. Retrieved on 2007-09-21.</ref>  
 
*Individuals with BPD may show [[lability]] (changeability) between [[anger]] and [[anxiety]] or between [[depression]] and [[anxiety]] and [[temperamental sensitivity]] to [[emotional]] stimuli.<ref>Koenigsberg H.W.; P.D. Harvey, V. Mitropoulou, et al. (May 2002). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=11986132 Characterizing affective instability in borderline personality disorder]". ''Am J Psychiatry'' '''159''' (5): 784-8. Retrieved on 2007-09-21.</ref><ref>Meyer, B.; M. Ajchenbrenner, D.P. Bowles (December 2005). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16553560 Sensory sensitivity, attachment experiences, and rejection responses among adults with borderline and avoidant features]". ''J Personal Disord'' '''19''' (6): 641-58. Retrieved on 2007-09-21.</ref>
The negative emotional states particularly associated with BPD have been grouped into four categories: extreme feelings in general; feelings of destructiveness or self-destructiveness; feelings of fragmentation or lack of identity; and feelings of victimization.<ref>Zanarini, M.C.; F.R. Frankenburg, C.J. DeLuca, et al. (1998). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10370445 The pain of being borderline: dysphoric states specific to borderline personality disorder]". ''Harvard Review of Psychiatry'' '''6''' (4): 201-7. Retrieved on 2007-09-21.</ref>  


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.<ref>American Psychiatric Association (2001). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=11726742&dopt=Abstract Psychiatric Services]". ''Psychiatr Serv'' (52): 1569-70. Retrieved on 2007-09-21.</ref> Attachment studies suggest individuals with BPD, while being high in intimacy- or novelty-seeking, can be hyper-alert<ref name="cogemo"/> to signs of rejection or not being valued and tend towards insecure, ambivalent, preoccupied or fearful attitudes towards relationships.<ref>Levy, K.N.; K.B. Meehan, M. Weber, et al. (March &ndash; April 2005). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15802944 Attachment and borderline personality disorder: implications for psychotherapy]". ''Psychopathology'' '''38''' (2): 64-74. Retrieved on 2007-09-21.</ref> They tend to view the world generally as dangerous and malevolent, and themselves as powerless, vulnerable, unacceptable and unsure in self-identity.<ref name="cogemo"/>
*The negative emotional states particularly associated with BPD have been grouped into four categories:<ref>Zanarini, M.C.; F.R. Frankenburg, C.J. DeLuca, et al. (1998). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10370445 The pain of being borderline: dysphoric states specific to borderline personality disorder]". ''Harvard Review of Psychiatry'' '''6''' (4): 201-7. Retrieved on 2007-09-21.</ref>
**Extreme feelings in general
**Feelings of [[destructiveness]] or [[self-destructiveness]]
**Feelings of [[fragmentation]] or lack of identity
**Feelings of [[victimization]]


Individuals with BPD are often described, including by some mental health professionals (and in the DSM-IV), as deliberately manipulative or difficult, but analyses and findings generally trace behaviors to inner pain and turmoil, powerlessness and defensive reactions, or limited coping and communication skills.<ref name="manipulative">Potter, N. (April 2006). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16643118 What is manipulative behavior, anyway?]" ''J Personal Disord.'' '''20''' (2): 139-56; discussion 181-5. Retrieved on 2007-09-21.</ref><ref>McKay, D.; C.A. Gavigan, S. Kulchycky (2004). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=15224626 Social skills and sex-role functioning in borderline personality disorder: relationship to self-mutilating behavior]". ''Cogn Behav Ther'' '''33''' (1): 27-35. Retrieved on 2007-09-21.</ref><ref>Linehan, M. (1993). ''Cognitive-behavioral treatment of borderline personality disorder.'' New York: Guilford. [[Special:Booksources/0898621836|ISBN 0898621836]].</ref> 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.<ref>Hoffman, P.D.; E. Buteau, J.M. Hooley, et al. (2003). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=14979218 Family members' knowledge about borderline personality disorder: correspondence with their levels of depression, burden, distress, and expressed emotion]". ''Family Process'' '''42''' (4): 469-78. Retrieved on 2007-09-21.</ref> Parents of individuals with BPD have been reported to show co-existing extremes of over-involvement and under-involvement.<ref name="parents">Allen, D.M.; R.G. Farmer (January &ndash; February 1996). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=8770526 Family relationships of adults with borderline personality disorder]". ''Compr Psychiatry'' '''37''' (1): 43-51. Retrieved on 2007-09-21.</ref> BPD has been linked to somewhat increased levels of chronic stress and conflict in romantic relationships, decreased satisfaction of romantic partners, abuse, and unwanted pregnancy; these links may largely be general to personality disorder and subsyndromal problems,<ref>Daley, S.E.; D. Burge, C. Hammen (August 2000). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11016115 Borderline personality disorder symptoms as predictors of 4-year romantic relationship dysfunction in young women: addressing issues of specificity]". ''J Abnorm Psychol'' '''109''' (3): 451-60. Retrieved on 2007-09-21.</ref> but such issues are commonly raised in support groups and published literature for partners of individuals with BPD.
*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.<ref>American Psychiatric Association (2001). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=11726742&dopt=Abstract Psychiatric Services]". ''Psychiatr Serv'' (52): 1569-70. Retrieved on 2007-09-21.</ref>
**Attachment studies suggest individuals with BPD while being high in intimacy- or novelty-seeking can be hyper-alert to signs of rejection or not being valued and tend towards insecure, ambivalent, preoccupied or fearful attitudes towards relationships.<ref name="cogemo" /><ref>Levy, K.N.; K.B. Meehan, M. Weber, et al. (March &ndash; April 2005). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15802944 Attachment and borderline personality disorder: implications for psychotherapy]". ''Psychopathology'' '''38''' (2): 64-74. Retrieved on 2007-09-21.</ref>  
**They tend to view the world generally as dangerous and malevolent, and themselves as powerless, vulnerable, unacceptable and unsure in self-identity.<ref name="cogemo" />  


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.<ref>Hawton, K.; E. Townsend, E. Arensman, et al. (1999). "[http://www.cochrane.org/reviews/en/ab001764.html Cochrane Collaboration Psychosocial and pharmacological treatments for deliberate self harm]". ''Cochrane Database of Systematic Reviews'' (4). Art. No.: CD001764. DOI: 10.1002/14651858.CD001764. Retrieved on 2007-09-21.</ref> The [[suicide]] rate is approximately eight to ten percent.<ref name=bpdtoday>[http://www.borderlinepersonalitytoday.com/main/facts.htm Borderline Personality Disorder Facts]. ''BPD Today''. Retrieved on 2007-09-21.</ref> The most recognized form of self-injury is automutilation (cutting the self), usually of the arms, but often other areas such as the legs, chest, belly, and face. Self-injury attempts are highly common among patients and may or may not be carried out with suicidal intent.<ref>Soloff, P.H.; J.A. Lis, T. Kelly, et al. (1994). "Self-mutilation and suicidal behavior in borderline personality disorder". ''Journal of Personality Disorders'' '''8''' (4): 257-67.</ref><ref>Gardner, D.L.; R.W. Cowdry (1985). "Suicidal and parasuicidal behavior in borderline personality disorder". ''Psychiatric Clinics of North America'' '''8''' (2): 389-403.</ref> 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 major depression, with interpersonal stressors appearing to be particularly common triggers.<ref>Brodsky, B.S.; S.A. Groves, M.A. Oquendo, et al. (June 2006). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16805659&query_hl=15&itool=pubmed_docsum Interpersonal precipitants and suicide attempts in borderline personality disorder]". ''Suicide Life Threat Behav'' '''36''' (3): 313-22. Retrieved on 2007-09-21.</ref> Ongoing family interactions and associated vulnerabilities can lead to self-destructive behavior.<ref name="parents"/> Stressful life events related to sexual abuse have been found to be a particular trigger for suicide attempts by adolescents with a BPD diagnosis.<ref>Horesh, N.; J. Sever, A. Apter (July &ndash; August 2003). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=12923705 A comparison of life events between suicidal adolescents with major depression and borderline personality disorder]". ''Compr Psychiatry'' '''44''' (4): 277-83. Retrieved on 2007-09-21.</ref>
*Individuals with BPD are often described, including by some mental health professionals (and in the DSM-IV), as deliberately manipulative or difficult, but analyses and findings generally trace behaviors to inner pain and turmoil, powerlessness and defensive reactions, or limited coping and communication skills.<ref name="manipulative">Potter, N. (April 2006). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16643118 What is manipulative behavior, anyway?]" ''J Personal Disord.'' '''20''' (2): 139-56; discussion 181-5. Retrieved on 2007-09-21.</ref><ref>McKay, D.; C.A. Gavigan, S. Kulchycky (2004). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=15224626 Social skills and sex-role functioning in borderline personality disorder: relationship to self-mutilating behavior]". ''Cogn Behav Ther'' '''33''' (1): 27-35. Retrieved on 2007-09-21.</ref><ref>Linehan, M. (1993). ''Cognitive-behavioral treatment of borderline personality disorder.'' New York: Guilford. ISBN 0898621836.</ref>
*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.<ref>Hoffman, P.D.; E. Buteau, J.M. Hooley, et al. (2003). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=14979218 Family members' knowledge about borderline personality disorder: correspondence with their levels of depression, burden, distress, and expressed emotion]". ''Family Process'' '''42''' (4): 469-78. Retrieved on 2007-09-21.</ref> Parents of individuals with BPD have been reported to show co-existing extremes of over-involvement and under-involvement.<ref name="parents">Allen, D.M.; R.G. Farmer (January &ndash; February 1996). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=8770526 Family relationships of adults with borderline personality disorder]". ''Compr Psychiatry'' '''37''' (1): 43-51. Retrieved on 2007-09-21.</ref>
*BPD has been linked to somewhat increased levels of chronic stress and conflict in romantic relationships, decreased satisfaction of romantic partners, abuse, and unwanted pregnancy; these links may largely be general to personality disorder and subsyndromal problems,<ref>Daley, S.E.; D. Burge, C. Hammen (August 2000). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11016115 Borderline personality disorder symptoms as predictors of 4-year romantic relationship dysfunction in young women: addressing issues of specificity]". ''J Abnorm Psychol'' '''109''' (3): 451-60. Retrieved on 2007-09-21.</ref> but such issues are commonly raised in support groups and published literature for partners of individuals with BPD.


Co-morbid (co-occurring) conditions in BPD are common. When comparing individuals diagnosed with BPD to those diagnosed with other kinds of personality disorders, the former showed a higher rate of also meeting criteria for:<ref>Zanarini, M.C.; F.R. Frankenburg, E.D. Dubo, et al. (1998). "[http://ajp.psychiatryonline.org/cgi/content/full/155/12/1733 Axis I Comorbidity of Borderline Personality Disorder]". ''Am J Psychiatry''. (155): 1733-9. Retrieved on 2007-09-23.</ref>  
*Suicidal or self-harming behavior is one of the core diagnostic criteria in [[DSM]] IV-TR. The management of and recovery from this can be complex and challenging.<ref>Hawton, K.; E. Townsend, E. Arensman, et al. (1999). "[http://www.cochrane.org/reviews/en/ab001764.html Cochrane Collaboration Psychosocial and pharmacological treatments for deliberate self-harm]". ''Cochrane Database of Systematic Reviews'' (4). Art. No.: CD001764. DOI: 10.1002/14651858.CD001764. Retrieved on 2007-09-21.</ref> The [[suicide]] rate is approximately 8%-10%.<ref name="bpdtoday">[http://www.borderlinepersonalitytoday.com/main/facts.htm Borderline Personality Disorder Facts]. ''BPD Today''. Retrieved on 2007-09-21.</ref>
*The most recognized form of self-injury is auto-mutilation (cutting the self), usually of the arms, but often other areas such as the legs, chest, belly, and face. Self-injury attempts are highly common among patients and may or may not be carried out with suicidal intent.<ref>Soloff, P.H.; J.A. Lis, T. Kelly, et al. (1994). "Self-mutilation and suicidal behavior in borderline personality disorder". ''Journal of Personality Disorders'' '''8''' (4): 257-67.</ref><ref>Gardner, D.L.; R.W. Cowdry (1985). "Suicidal and parasuicidal behavior in borderline personality disorder". ''Psychiatric Clinics of North America'' '''8''' (2): 389-403.</ref>
*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 major depression, with interpersonal stressors appearing to be particularly common triggers.<ref>Brodsky, B.S.; S.A. Groves, M.A. Oquendo, et al. (June 2006). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16805659&query_hl=15&itool=pubmed_docsum Interpersonal precipitants and suicide attempts in borderline personality disorder]". ''Suicide Life Threat Behav'' '''36''' (3): 313-22. Retrieved on 2007-09-21.</ref>
**Ongoing family interactions and associated vulnerabilities can lead to self-destructive behavior.<ref name="parents" />
**Stressful life events related to [[Sexual assault|sexual abuse]] have been found to be a particular trigger for [[suicide]] attempts by adolescents with a BPD diagnosis.<ref>Horesh, N.; J. Sever, A. Apter (July &ndash; August 2003). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=12923705 A comparison of life events between suicidal adolescents with major depression and borderline personality disorder]". ''Compr Psychiatry'' '''44''' (4): 277-83. Retrieved on 2007-09-21.</ref>
*[[Co-morbid]] (co-occurring) conditions in BPD are common.  
**When comparing individuals diagnosed with BPD to those diagnosed with other kinds of personality disorders, the former showed a higher rate of also meeting criteria for:<ref>Zanarini, M.C.; F.R. Frankenburg, E.D. Dubo, et al. (1998). "[http://ajp.psychiatryonline.org/cgi/content/full/155/12/1733 Axis I Comorbidity of Borderline Personality Disorder]". ''Am J Psychiatry''. (155): 1733-9. Retrieved on 2007-09-23.</ref>  


* [[Anxiety disorders]]
** [[Anxiety disorders]]
* [[Mood disorders]] (including [[clinical depression]] and [[bipolar disorder]])
** [[Mood disorders]] (including [[clinical depression]] and [[bipolar disorder]])
* [[Eating disorders]] (including [[anorexia nervosa]] and [[bulimia]])
** [[Eating disorders]] (including [[anorexia nervosa]] and [[bulimia]])
* and, to a lesser extent, [[somatoform disorders]]
** [[somatoform disorders]]


[[Substance abuse]] is a common problem in BPD, whether due to impulsivity or as a coping mechanism, and 50% to 70% of psychiatric inpatients with BPD have been found to meet criteria for a substance use disorder.<ref>Gregory, R. (2006). "[http://www.psychiatrictimes.com/showArticle.jhtml?articleID=194500290 Clinical Challenges in Co-occurring Borderline Personality and Substance Use Disorders]". ''Psychiatric Times'' '''XXIII''' (13). Retrieved on 2007-09-23.</ref>
*[[Substance abuse]] is a common problem in BPD, whether due to impulsivity or as a coping mechanism. 50%-70% of psychiatric inpatients with BPD have been found to meet criteria for a substance use disorder.<ref>Gregory, R. (2006). "[http://www.psychiatrictimes.com/showArticle.jhtml?articleID=194500290 Clinical Challenges in Co-occurring Borderline Personality and Substance Use Disorders]". ''Psychiatric Times'' '''XXIII''' (13). Retrieved on 2007-09-23.</ref>


===Prognosis===
===Prognosis===
Poor prognostic factors include:
*Poor prognostic factors include:<ref name="DSMV" />
*Female gender
**Female gender
*[[Adolescence]] and early adulthood
**[[Adolescence]] and early adulthood
*Identity problems
**Identity problems
*Relatives with the same disease<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
**Relatives with the same disease
 
== Diagnosis ==
Diagnosis is based on the self-reported experiences of the patient, as well as markers for the disorder observed by a [[psychiatrist]], [[clinical psychologist|psychologist]], or other qualified diagnostician through clinical assessment. This profile may be supported and/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 [[Diagnostic and Statistical Manual of Mental Disorders|DSM-IV-TR]].<ref name="DSM-IV-TR"/>


An initial assessment generally includes a comprehensive personal and family history, and may also include a physical examination by a physician. Although there are no physiological tests that confirm borderline personality disorder, medical tests may be employed to exclude any co-occurring medical conditions that may present with psychiatric symptoms. These include blood tests measuring [[Thyroid-stimulating hormone|TSH]] to exclude [[hypothyroidism|hypo-]] or [[hyperthyroidism]], [[Blood tests#Blood chemistry tests|basic electrolytes]] and serum [[calcium]] to rule out a metabolic disturbance, [[Complete blood count|full blood count]] including [[Erythrocyte sedimentation rate|ESR]] to rule out a systemic infection or chronic disease, and [[serology]] to exclude [[syphilis]] or [[HIV]] infection; two commonly ordered investigations are [[Electroencephalography|EEG]] to exclude [[epilepsy]], and a [[Computed tomography|CT scan]] of the head to exclude brain lesions.
==Diagnosis==
*A diagnosis is based on self-reported experiences of patients, as well as markers for the disorder observed by a [[psychiatrist]], [[clinical psychologist|psychologist]], or another qualified diagnostician through clinical assessment. This profile may be supported and/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 [[Diagnostic and Statistical Manual of Mental Disorders|DSM-IV-TR]].<ref name="DSM-IV-TR" />
*An initial assessment generally includes a comprehensive personal and family history. It may also include a [[physical examination]] by a physician. Although there are no physiological tests that confirm borderline personality disorder, medical tests may be employed to exclude any co-occurring medical conditions that may present with psychiatric symptoms. These include:
**[[Blood tests]] measuring [[Thyroid-stimulating hormone|TSH]] to exclude [[hypothyroidism|hypo-]] or [[hyperthyroidism]]  
**[[Blood tests#Blood chemistry tests|Basic electrolytes]] and serum [[calcium]] to rule out a metabolic disturbance
**[[Complete blood count]] including [[Erythrocyte sedimentation rate|ESR]] to rule out a systemic infection or chronic disease
**[[Serology]] to exclude [[syphilis]] or [[HIV]] infection
**Two commonly ordered investigations are:
***[[Electroencephalography|EEG]] to exclude [[epilepsy]]
***[[Computed tomography|CT scan]] of the head to exclude brain lesions


===Diagnosis Criteria===
===Diagnosis Criteria===
====DSM-V Diagnostic Criteria for Borderline Personality Disorder<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>====
====DSM-V Diagnostic Criteria for Borderline Personality Disorder<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>====
{{cquote|
{{cquote|
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked [[impulsivity]], beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
# Frantic efforts to avoid real or imagined abandonment. <SMALL>''Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.''</SMALL>
# Frantic efforts to avoid real or imagined abandonment. <SMALL>''Note: Do not include [[suicidal]] or [[self-mutilating behavior]] covered in Criterion 5.''</SMALL>
# A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
# A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
# Identity disturbance: markedly and persistently unstable self-image or sense of self.
# [[Identity disturbance]]: markedly and persistently unstable self-image or sense of self.
# Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). <SMALL>''Note: Do not include suicidal or selfmutilating behavior covered in Criterion 5.''</SMALL>
# [[Impulsivity]] in at least two areas that are potentially self-damaging (e.g., spending, sex, [[substance abuse]], reckless driving, [[binge eating]]). <SMALL>''Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.''</SMALL>
# Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
# Recurrent suicidal behavior, gestures, threats, or [[self-mutilating behavior]].
# 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).
# Affective instability due to a marked reactivity of [[mood]] (e.g., intense episodic [[dysphoria]], [[irritability]], or [[anxiety]] usually lasting a few hours (rarely more than a few days).
# Chronic feelings of emptiness.
# Chronic feelings of emptiness.
# Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
# Inappropriate behavior, intense or [[uncontrollable anger]] (e.g., frequent displays of [[temper]], constant anger, recurrent physical fights).
# Transient, stress-related paranoid ideation or severe dissociative symptoms.
# Transient, [[stress]]-related paranoid ideation or severe dissociative symptoms.
}}
}}


===Mnemonic===
===Mnemonic===
A commonly used [[mnemonic]] to remember some features of borderline personality disorder is '''''PRAISE''''':
*A commonly used [[mnemonic]] to remember some features of borderline personality disorder is '''''PRAISE''''':
*'''P''' - Paranoid ideas
**'''P''' - [[Paranoid]] ideas
*'''R''' - Relationship instability
**'''R''' - Relationship instability
*'''A''' - Angry outbursts, affective instability, abandonment fears
**'''A''' - Angry outbursts, [[affective instability]], abandonment fears
*'''I''' - Impulsive behavior, identity disturbance
**'''I''' - [[Impulsive behavior]] or identity disturbance
*'''S''' - Suicidal behavior
**'''S''' - [[Suicidal behavior]]
*'''E''' - Emptiness
**'''E''' - [[Emptiness]]


=== Emotionally Unstable Personality Disorder ===
=== Emotionally Unstable Personality Disorder ===


The World Health Organization's [[ICD-10]] has a comparable diagnosis called [[Emotionally Unstable Personality Disorder]] - Borderline type (F60.31). This requires, in addition to the general criteria for personality disorder: disturbances in and uncertainty about self-image, aims, and internal preferences (including sexual); liability to become involved in intense and unstable relationships, often leading to emotional crisis; excessive efforts to avoid abandonment; recurrent threats or acts of self-harm; and chronic feelings of emptiness.
*The World Health Organization's (WHO) [[ICD-10]] has a comparable diagnosis called [[Emotionally Unstable Personality Disorder]] - Borderline type (F60.31). This requires, in addition to the general criteria for personality disorder:
 
**Disturbances among and uncertainty about self-image, aims, and internal preferences (including sexual).
The Chinese Society of Psychiatry's CCMD has a comparable diagnosis of Impulsive Personality Disorder. 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's Emotionally Unstable Personality Disorder, and also incorporates six of the nine DSM BPD criteria.<ref>Zhong, J.; F. Leung (2007-01-05). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17254494 Should borderline personality disorder be included in the fourth edition of the Chinese classification of mental disorders?]" ''Chin Med J'' (English) '''120''' (1): 77-82. Retrieved on 2007-09-21.</ref>
**Liability to become involved in intense and unstable relationships, often leading to an emotional crisis.
 
**Excessive efforts to avoid abandonment; recurrent threats or acts of self-harm; and [[chronic]] feelings of [[emptiness]].
==Treatment==
A recent study found that any of three types of psychotherapy stimulate substantial improvements in people with this disorder.<ref name="Clarkin">Clarkin, J. (June 16 2007) "Science News". ''American Journal of Psychiatry'' '''171''' (24): 374.</ref>  The three approaches studies were Dialectical behavior therapy, transference-focused therapy, and schema-focused therapy.  "Psychotherapy that centers on emotional themes arising in the interaction between patient and therapist, known as transference-focused therapy, stimulates the most change in people with borderline personality disorder."<ref name="Clarkin"/>
 
===Psychotherapy===
There has traditionally been skepticism about the psychological treatment of [[personality disorders]], but several specific types of [[psychotherapy]] for BPD have developed in recent years. The limited studies to date do not allow confident claims of effectiveness but do suggest that people with a diagnosis of BPD can benefit on at least some outcome measures.<ref name ="Cochranepsychotherapy">Binks, C.A.; M. Fenton, L. McCarthy, et al. (2006). "[http://www.cochrane.org/reviews/en/ab005652.html Psychological therapies for people with borderline personality disorder]". ''Cochrane Database Systematic Reviews'' '''25''' (1): CD005652. Retrieved on 2007-09-23.</ref> Simple supportive therapy alone may enhance self-esteem and mobilize the existing strengths of individuals with BPD.<ref>Aviram, R.B.; D.J. Hellerstein, J. Gerson, et al. (May 2004). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15330220&dopt=Abstract Adapting supportive psychotherapy for individuals with Borderline personality disorder who self-injure or attempt suicide]". ''J Psychiatr Pract'' '''10''' (3): 145-55. Retrieved on 2007-09-23.</ref> Specific psychotherapies may involve sessions over several months or, as is particularly common for personality disorders, several years. Psychotherapy can often be conducted either with individuals or with groups. Group therapy can aid the learning and practice of interpersonal skills and self-awareness by individuals with BPD<ref name=AMN>Gunderson, J.G. MD (2006-04-10). "[http://www.health.am/psy/more/borderline_personality_disorder_psychotherapies "Borderline Personality Disorder - Psychotherapies]". ''American Medical Network''. Retrieved on 2007-09-23.</ref> although drop-out rates may be problematic.<ref>Hummelen, B.; T. Wilberg, S. Karterud (January 2007). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17266430 Interviews of female patients with borderline personality disorder who dropped out of group psychotherapy]". ''Int J Group Psychother'' '''57''' (1): 67-91. Retrieved on 2007-09-23.</ref>
   
====Dialectical behavioral therapy====
In the 1990s, a new psychosocial treatment termed dialectical behavioral therapy (DBT) became established in the treatment of BPD, having originally developed as an intervention for patients with suicidal behavior.<ref>Koerner, K.; M.M. Linehan (2000). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=10729937 Research on dialectical behavior therapy for patients with borderline personality disorder]". ''Psychiatric Clinics of North America'' '''23''' (1): 151-67. Retrieved on 2007-09-23.</ref>
 
Dialectical behavior therapy is derived from cognitive-behavioral techniques (and can be seen as a form of CBT) but emphasizes an exchange and negotiation between therapist and client, between the rational and the emotional, and between acceptance and change (hence dialectic). Treatment targets are agreed upon, with self-harm issues taking priority. The learning of new skills is a core component - including mindfulness, interpersonal effectiveness (e.g. assertiveness and social skills), coping adaptively with distress and crises; and identifying and regulating emotional reactions.
 
DBT can be based on a biosocial theory of personality functioning in which BPD is seen as a biological disorder of emotional regulation in a social environment experienced as invalidating by the borderline patient.<ref name=promising>Murphy, E. T. PhD; J. Gunderson MD (January 1999). "[http://web.archive.org/web/19991014032825/http://www.mcleanhospital.org/psychupdate/psyupI-3.htm A Promising TreatmentBorderline Personality Disorder]". ''McLean Hospital Psychiatic Update''. Retrieved on 2007-09-23.</ref>
 
Dialectical behavioral therapy has been found to significantly reduce self-injury and suicidal behavior in individuals with BPD, beyond the effect of usual or expert treatment, and to be better accepted by clients.<ref>Verheul, R.; L.M. Van Den Bosch, M.W. Koeter, et al. (February 2003). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=12562741&query_hl=3&itool=pubmed_docsum Dialectical behavioural therapy for women with borderline personality disorder: 12-month, randomised clinical trial in The Netherlands]". ''British Journal of Psychiatry'' (182): 135-40. Retrieved on 2007-09-23.</ref><ref>Linehan, M.M.; K.A. Comtois, A.M. Murray, et al. (July 2006). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=16818865 Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder]". ''Archives of General Psychiatry'' '''63''' (7): 757-66. Retrieved on 2007-09-23.</ref> although whether it has additional efficacy in the overall treatment of BPD appears less clear.<ref name="Cochranepsychotherapy"/> Training nurses in the use of DBT has been found to replace a therapeutic pessimism with a more optimistic understanding and outlook.<ref>Hazelton, M.; R. Rossiter, J. Milner (February - March 2006). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16594889 Managing the 'unmanageable': training staff in the use of dialectical behaviour therapy for borderline personality disorder]". ''Contemporary Nurse'' '''21''' (1): 120-30. Retrieved on 2007-09-23.</ref>
 
====Schema Therapy====
 
Schema Therapy (also called Schema-Focused Therapy) is an integrative approach based on cognitive-behavioral or skills-based techniques along with [[Object relations theory|object relations]] and [[Gestalt therapy|gestalt approaches]].  It directly targets deeper aspects of emotion, personality and [[Schema (psychology)|schemas]] (fundamental ways of categorizing and reacting to the world). The treatment also focuses on the [[Transference|relationship with the therapist]] (including a process of "limited re-parenting"), daily life outside of therapy, and traumatic childhood experiences. It was developed by Jeffrey Young and became established in the 1990s.  Limited recent research suggests that it is significantly more effective than Transference Focused Psychotherapy, with half of individuals with borderline personality disorder assessed as having achieved full recovery after 4 years, with two thirds showing clinically significant improvement.<ref name="SFTvsTFT">Giesen-Bloo, J.; R. van Dyck, P. Spinhoven, et al. (June 2005). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16754838 Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy]". ''Archives of General Psychiatry'' '''63''' (6): 649-58. Retrieved on 2007-09-23.</ref><ref>Darden, M. (2006-10-10). "[http://www.eurekalert.org/pub_releases/2006-10/ppmr-nhf101006.php New hope for an 'untreatable' mental illness]". ''EurekAlert!'' Retrieved on 2007-09-23.</ref> Another very small trial has also suggested efficacy.<ref>Nordahl, H.M., T.E. Nysaeter (September 2005). "[http://cat.inist.fr/?aModele=afficheN&cpsidt=16983362 Schema therapy for patients with borderline personality disorder: a single case series]". ''J Behav Ther Exp Psychiatry'' '''36''' (3): 254-64. Retrieved on 2007-09-23.</ref>
 
====Cognitive behavioral therapy====
 
Cognitive Behavioral Therapy (CBT) is the most widely used and established psychological treatment for mental disorders, but has appeared less successful in BPD, due partly to difficulties in developing a therapeutic relationship and treatment adherence. Approaches such as DBT and Schema-focused therapy developed partly as an attempt to expand and add to traditional CBT, which uses a limited number of sessions to target specific maladaptive patterns of thought, perception and behavior. A recent study did find a number of sustained benefits of CBT, in addition to treatment as usual, after an average of 16 sessions over one year.<ref>Davidson, K.; J. Norrie, P. Tyrer, et al. (October 2006). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17032158 The effectiveness of cognitive behavior therapy for borderline personality disorder: results from the borderline personality disorder study of cognitive therapy (BOSCOT) trial]". ''Journal of Personality Disorders'' '''20''' (5): 450-65. Retrieved on 2007-09-23.</ref>
   
[[Eye Movement Desensitization and Reprocessing]] (EMDR) is a treatment for PTSD, a condition closely associated to BPD in many cases. It is similar to CBT, and seen by some as a type of CBT, but also includes unique techniques intended to facilitate full emotional processing and coming to terms with traumatic memories.
 
====Marital or Family Therapy ====
Marital Therapy can be helpful in stabilizing the marital relationship and in reducing marital conflict and stress that can worsen BPD symptoms. Family Therapy or Family Psychoeducation can help educate family members regarding BPD, improve family communication and problem solving, and provide support to family members in dealing with their loved one's illness.
 
Two patterns of family involvement can help clinicians plan family interventions: overinvolvement and neglect. Borderline patients who are from overinvolved families are often actively struggling with a dependency issue by denial or by anger at their parents.
 
Interest in the use of psychoeducation and skills training approaches for families with borderline members is growing.<ref name=AMN/>
 
====Psychoanalysis====
Traditional [[psychoanalysis]] has become less commonly used than in the past, both in general and in regard to BPD. This intervention has been linked to an exacerbation of BPD symptoms<ref name=no_to_psychoanalysis>"[http://www.medical-library.org/journals2a/borderline.htm Borderline Personality Disorder]". Retrieved on 2007-09-23.</ref> although there is also evidence of effectiveness of certain techniques in the context of partial hospitalization.<ref>Bateman, A.; P. Fonagy (January 2001). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11136631 Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up]". ''American Journal of Psychiatry'' '''158''' (1): 36-42. Retrieved on 2007-09-23.</ref>
 
====Transference Focused Psychotherapy====
 
{{see|Otto F. Kernberg#Transference-Focused Psychotherapy}}
 
Transference Focused Psychotherapy (TFP) is a form of psychoanalytic therapy dating to the 1960s, rooted in the conceptions of [[Otto Kernberg]] on BPD and its underlying structure (borderline personality organization). Unlike in the case of traditional psychoanalysis, the therapist plays a very active role in TFP.  In session the therapist works on the relationship between the patient and the therapist. The therapist will try to explore and clarify aspects of this relationship so the underlying [[object relations]] dyads become clear.  Some limited research on TFP suggests it may reduce some symptoms of BPD by affecting certain underlying processes,<ref>Levy, K.N.; J.F. Clarkin, L.N. Scott, et al. (2006). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16470612 The mechanisms of change in the treatment of borderline personality disorder with transference focused psychotherapy]". ''Journal of Clinical Psychology'' (62): 481-501. Retrieved on 2007-09-23.</ref> and that TFP in comparison to [[Dialectical behavioral therapy|Dialectical Behavior Therapy]] and supportive therapy results in increased reflective functioning (the ability to realistically think about how others think) and a more secure [[Attachment theory|attachment style]].<ref>Levy, K.N.; K.B. Meehan, K.M. Kelly, et al. (2006). "Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder". ''Journal of Consulting and Clinical Psychology'' (74): 1027-1040.</ref>  Furthermore, TFP has been shown to be as effective as DBT in improvement of suicidal behavior, and has been more effective than DBT in alleviating anger and in reducing verbal or direct assaultive behavior.<ref>Clarkin, J.F. PhD; K.N. Levy, PhD, M. F. Lenzenweger, PhD, et al. (June 2007). "[http://ajp.psychiatryonline.org/cgi/content/abstract/164/6/922 Evaluating Three Treatments for Borderline Personality Disorder: A Multiwave Study]". ''The American Journal of Psychiatry'' (164): 922-928. {{doi|10.1176/appi.ajp.164.6.922}}. Retrieved on 2007-09-23.</ref> Limited research suggests that TFP appears to be less effective than schema-focused therapy, while being more effective than no treatment.<ref name="SFTvsTFT"/>
 
====Cognitive Analytic Therapy====
 
Cognitive Analytic Therapy (CAT) combines cognitive and psychoanalytic approaches and has been adapted for use with individuals with BPD with mixed results.<ref>Ryle, A. (February 2004). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15061342&dopt=Abstract The contribution of cognitive analytic therapy to the treatment of borderline personality disorder]". ''J Personal Disord'' '''18''' (1): 3-35. Retrieved on 2007-09-23.</ref>
 
===Medication===
 
A number of medications are used in conjunction with BPD treatments, although the evidence base is limited.  As BPD has been traditionally considered a primarily psychosocial condition, medication is intended to treat co-morbid symptoms, such as anxiety and depression, rather than BPD itself.<ref name ="Cochranepharm">Binks, C.A.; M. Fenton, L. McCarthy, et al. (2006). "[http://www.cochrane.org/reviews/en/ab005653.html Pharmacological interventions for people with borderline personality disorder]". ''The Cochrane Database of Systematic Reviews'' (4). Retrieved on 2007-09-23.</ref>
 
====Antidepressants====
[[Selective serotonin reuptake inhibitor]] (SSRI) [[antidepressant]]s have been shown in [[randomized controlled trials]] to improve the attendant symptoms of anxiety and depression, such as anger and hostility, associated with BPD in some patients.<ref name ="Cochranepharm"/> According to ''[[Listening to Prozac]]'', it takes a higher dose of an SSRI to treat mood disorders associated with BPD than depression alone. It also takes about three months for benefit to appear, compared to the three to six weeks for depression.
 
====Antipsychotics====
The newer [[atypical antipsychotics]] are claimed to have an improved [[adverse effect]] profile than the [[typical antipsychotics]]. Antipsychotics are also sometimes used to treat distortions in thinking or false perceptions.<ref>Siever, L.J.; H.W. Koenigsberg (2000). "[http://www.dana.org/pdf/cerebrum/art_v2n4sieverkoenigsberg.pdf The frustrating no-man's-land of borderline personality disorder]" (PDF). ''Cerebrum, The Dana Forum on Brain Science'' '''2''' (4). Retrieved on 2007-09-23.</ref> Use of antipsychotics has varied, from intermittent, for a brief psychotic or dissociative episode, to more general, particularly atypical antipsychotics, for both those diagnosed with bipolar disorder (BiP), as well as those diagnosed with borderline personality disorder (BPD).
 
One [[meta-analysis]] of 14 prior studies has suggested that several atypical antipsychotics, including [[olanzapine]], [[clozapine]], [[quetiapine]] and [[risperidone]], may help BPD patients with psychotic-like, impulsive or suicidal symptoms.<ref>Grootens, K.P.; R.J. Verkes (January 2005). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15706462&query_hl=4&itool=pubmed_docsum Emerging evidence for the use of atypical antipsychotics in borderline personality disorder]". ''Pharmacopsychiatry'' '''38''' (1): 20-3. Retrieved on 2007-09-23.</ref> 
 
Long-term use of antipsychotics is particularly controversial. There are numerous adverse effects with the older medications, notably [[Tardive dyskinesia]] (TDK).<ref name=caseyde>Casey, D.E. (1985). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2860664&dopt=Abstract Tardive dyskinesia: reversible and irreversible]". ''Psychopharmacology Suppl'' (2): 88-97. Retrieved on 2007-09-23.</ref> Atypical [[antipsychotic]]s are also known for often causing considerable weight gain, with associated health complications.<ref>Ruetsch, O.; A. Viala, H. Bardou, et al. (July - August 2005). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16389718 Psychotropic drugs induced weight gain: a review of the literature concerning epidemiological data, mechanisms and management]". ''Encephale'' (4 Pt 1): 507-16. Retrieved on 2007-09-23.</ref>
 
===Mental Health Services and Recovery===
 
Individuals with BPD sometimes need extensive mental health services and have been found to account for around 20% of psychiatric hospitalizations.<ref>Zanarini, M.C.; Frankenburg, F.R. (March - April 2001). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=11244151 Treatment histories of borderline inpatients]". ''Comprehensive Psychiatry'' '''42'''(2): 144-50. Retrieved on 2007-09-23.</ref> 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.<ref>Zanarini, M.C.; F.R. Frankenburg, J. Hennen, et al. (January 2004). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=14744165 Mental health service utilization by borderline personality disorder patients and Axis II comparison subjects followed prospectively for 6 years]". ''J Clin Psychiatry'' '''65''' (1): 28-36. Retrieved 2007-09-23.</ref> Experience of services varies.<ref>Fallon, P. (August 2003). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12887630&dopt=Abstract Travelling through the system: the lived experience of people with borderline personality disorder in contact with psychiatric services]". ''J Psychiatr Ment Health Nurs'' '''10''' (4): 393-401. Retrieved on 2007-09-23.</ref> 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.<ref>Links, P.; Y. Bergmans, S. Warwar (July 1 2004). "[http://www.psychiatrictimes.com/Suicidal-Behavior/showArticle.jhtml?articleId=175802408 Assessing Suicide Risk in Patients With Borderline Personality Disorder]". ''Psychiatric Times'' '''XXI''' (8). Retrieved on 2007-09-23.</ref>
 
Particular difficulties have been observed in the relationship between care providers and individuals diagnosed with BPD. A majority of psychiatric staff report finding individuals with BPD moderately to extremely difficult to "deal" with, and more difficult than other client groups.<ref>Cleary, M.; N. Siegfried, G. Walter (September 2002). "[http://www.ingentaconnect.com/content/bsc/ano/2002/00000011/00000003/art00007 Experience, knowledge and attitudes of mental health staff regarding clients with a borderline personality disorder]". ''Australian and New Zealand Journal of Ophthalmology'' '''11''' (3): 186-191. Retrieved on 2007-09-23.</ref> On the other hand, those with the diagnosis of BPD have reported that the term "BPD" felt like a pejorative [[labeling theory|label]] rather than a helpful diagnosis, that self destructive behaviour was wrongly perceived as manipulative, and that they had limited access to care.<ref>Nehls, N. (August 1999). "[http://ebmh.bmj.com/cgi/content/full/3/1/32#R1 Borderline personality disorder: the voice of patients]". ''Res Nurs Health'' (22): 285–93. Retrieved on 2007-09-23.</ref> Attempts are made to improve public and staff attitudes.<ref>Deans, C.; E. Meocevic "[http://www.contemporarynurse.com/21.1/21.1.7.html Attitudes of registered psychiatric nurses towards patients diagnosed with borderline personality disorder]". ''Contemporary Nurse''. Retrieved on 2007-09-23.</ref><ref>Krawitz, R. (July 2004). "[http://www.blackwell-synergy.com/doi/abs/10.1111/j.1440-1614.2004.01409.x?journalCode=anp Borderline personality disorder: attitudinal change following training]". ''Australian and New Zealand Journal of Psychiatry'' '''38''' (7): 554. Retrieved on 2007-09-23.</ref>
 
====Combining Pharmacotherapy and Psychotherapy====
 
In practice, psychotherapy and medication may often be combined but there are limited data on clinical practice<ref name ="APAguide"></ref> Efficacy studies often assess the effectiveness of interventions when added to 'treatment as usual' (TAU), which may involve general psychiatric services, supportive counselling, medication and psychotherapy.
 
One small study, which excluded individuals with a comorbid Axis 1 disorder, has indicated that outpatients undergoing Dialectical Behavioral Therapy and taking the antipsychotic Olanzapine show significantly more improvement on some measures related to BPD, compared to those undergoing DBT and taking a placebo pill, although they also experienced weight gain and raised cholesterol. Another small study found that patients who had undergone DBT and then took fluoxetine (Prozac) showed no significant improvements, whereas those who underwent DBT and then took a placebo pill did show significant improvements.<ref name=dbtfluox>Simpson, E.B.; S. Yen, E. Costello, et al. (March 2004). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=15096078 Combined dialectical behavior therapy and fluoxetine]". ''Journal of Clinical Psychiatry'' '''65''' (3): 379-85. Retrieved on 2007-09-23.</ref>
 
====Difficulties in Therapy====
 
There can be unique challenges in the treatment of BPD, for example hospital care.<ref>Kaplan, C.A. (September 1986). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=3638699 The challenge of working with patients diagnosed as having a borderline personality disorder]". ''Nurs Clin North Am'' '''21''' (3): 429-38. Retrieved on 2007-09-23.</ref> In psychotherapy, a client may be unusually sensitive to rejection and abandonment and may react negatively (e.g., by harming themselves or withdrawing from treatment) if they sense this. In addition, clinicians may emotionally distance themselves from individuals with BPD for self-protection or due to the stigma associated with the diagnosis, leading to a self-fulfilling prophecy and a cycle of stigmatization to which both patient and therapist can contribute.<ref>Aviram, R.B.; B.S. Brodsky, B. Stanley (October 2006). "[http://taylorandfrancis.metapress.com/content/g886500785w755g6/ Borderline Personality Disorder, Stigma, and Treatment Implications]". ''Harvard Review of Psychiatry'' '''14''' (5). Retrieved on 2007-09-23.</ref>
 
Some psychotherapies, for example DBT, developed partly to overcome problems with interpersonal sensitivity and maintaining a therapeutic relationship. Adherence to medication regimes is also a problem, due in part to [[adverse effects]], with drop-out rates of between 50% and 88% in medication trials.<ref>American Psychiatric Association (October 2001). "Practice Guideline for the Treatment of Patients With Borderline Personality Disorder". ''Am J Psychiatry''.</ref> Comorbid disorders, particularly substance use disorders, can complicate attempts to achieve remission.<ref>Zanarini, M.C.; F.R. Frankenburg, J. Hennen, et al. (2004). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=15514413 Axis I comorbidity in patients with borderline personality disorder: 6-year follow-up and prediction of time to remission]". ''Am J Psychiatry'' '''161''' (11): 2108-14. Retrieved on 2007-09-23.</ref>
 
====Other Strategies====
Psychotherapies and medications form a part of the overall context of mental health services and psychosocial needs related to BPD. The evidence base is limited for both, and some individuals may forego them or not benefit (enough) from them. It has been argued that diagnostic categorisation can have limited utility in directing therapeutic work in this area, and that in some cases it is only with reference to past and current relationships that "borderline" behavior can be understood as partly adaptive and how people can best be helped.<ref>Warner, S.; T. Wilkins (2004). "[http://www.springerlink.com/content/l440244686765312/ Between Subjugation and Survival: Women, Borderline Personality Disorder and High Security Mental Hospitals]". ''Journal of Contemporary Psychotherapy'' '''34''' (3): 1573-3564. Retrieved on 2007-09-2].</ref>
 
Numerous other strategies may be used, including [[alternative medicine]] techniques (see [[List of branches of alternative medicine]]), exercise and physical fitness, including team sports; occupational therapy techniques, including creative arts; having structure and routine to the days, particularly through employment - helping feelings of competence (e.g. [[self-efficacy]]), having a social role and being valued by others, boosting [[self-esteem]].<ref>Flory, L. (2004). ''[http://www.mind.org.uk/Information/Booklets/Understanding/Understanding+borderline+personality+disorder.htm Understanding borderline personality disorder]''. London: Mind. Retrieved on 2007-09-23.</ref>


Group-based psychological services encourage clients to socialize and participate in both solitary and group activities. These may be in day centers. Therapeutic communities are an example of this, particularly in Europe, although their usage has declined many have specialised in the treatment of severe personality disorder.<ref>Campling, P. (2001). "[http://apt.rcpsych.org/cgi/content/full/7/5/365 Therapeutic communities]". ''Advances in Psychiatric Treatment'' (7): 365-372. Retrieved on 2007-09-23.</ref>
*The Chinese Society of Psychiatry's (CCMD) has a comparable diagnosis of impulsive personality disorder. 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's [[Emotionally Unstable Personality Disorder]], and also incorporates six of the nine DSM [[BPD]] criteria.<ref>Zhong, J.; F. Leung (2007-01-05). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17254494 Should borderline personality disorder be included in the fourth edition of the Chinese classification of mental disorders?]" ''Chin Med J'' (English) '''120''' (1): 77-82. Retrieved on 2007-09-21.</ref>


Psychiatric rehabilitation services aimed at helping people with mental health problems, to reduce psychosocial disability, engage in meaningful activities, and avoid stigma and social exclusion may be of value to people who suffer from BPD. There are also many mutual-support or co-counseling groups run by and for individuals with BPD. A goal may be full recovery rather than reliance on services.
===Treatment===


Data indicate that substantial percentages of people diagnosed with BPD can achieve remission even within a year or two.<ref name=PToverview/> A longitudinal study found that, six years after being diagnosed with BPD, 56% showed good psychosocial functioning, compared to 26% at baseline. Although vocational achievement was 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.<ref>Zanarini, M.C.; F.R. Frankenburg, J. Hennen, et al. (February 2005). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=15899718 Psychosocial functioning of borderline patients and axis II comparison subjects followed prospectively for six years]". ''J Personal Disord'' '''19''' (1): 19-29. Retrieved on 2007-09-23.</ref>
* '''1''' '''Therapies'''
** 1.1 '''Psychotherapy'''
*** Simple [[supportive therapy]] alone may enhance self-esteem and mobilize the existing strengths of individuals with BPD.<ref>Aviram, R.B.; D.J. Hellerstein, J. Gerson, et al. (May 2004). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15330220&dopt=Abstract Adapting supportive psychotherapy for individuals with borderline personality disorder who self-injure or attempt suicide]". ''J Psychiatr Pract'' '''10''' (3): 145-55. Retrieved on 2007-09-23.</ref> Specific psychotherapies may involve sessions over several months or, as is particularly common for personality disorders, several years.
*** [[Psychotherapy]] can often be conducted either with individuals or with groups. Group therapy can aid the learning and practice of interpersonal skills and self-awareness by individuals with BPD<ref name="AMN">Gunderson, J.G. MD (2006-04-10). "[http://www.health.am/psy/more/borderline_personality_disorder_psychotherapies "Borderline Personality Disorder - Psychotherapies]". ''American Medical Network''. Retrieved on 2007-09-23.</ref> although drop-out rates may be problematic.<ref>Hummelen, B.; T. Wilberg, S. Karterud (January 2007). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17266430 Interviews of female patients with borderline personality disorder who dropped out of group psychotherapy]". ''Int J Group Psychother'' '''57''' (1): 67-91. Retrieved on 2007-09-23.</ref>
** 1.2 '''Dialectical Behavioral Therapy'''
*** [[Dialectical behavior therapy]] is derived from [[cognitive-behavioral techniques]] (and can be seen as a form of CBT) but emphasizes an exchange and negotiation between therapist and client, between the rational and the emotional, and between acceptance and change (hence dialectic). Treatment targets are agreed upon, with self-harm issues taking priority.
*** The learning of new skills is a core component - including mindfulness, interpersonal effectiveness (e.g. assertiveness and social skills), coping adaptively with distress and crises; and identifying and regulating [[emotional]] reactions.
*** DBT can be based on a biosocial theory of personality functioning in which BPD is seen as a biological disorder of emotional regulation in a social environment experienced as invalidating by the borderline patient.<ref name="promising">Murphy, E. T. PhD; J. Gunderson MD (January 1999). "[http://web.archive.org/web/19991014032825/http://www.mcleanhospital.org/psychupdate/psyupI-3.htm A Promising TreatmentBorderline Personality Disorder]". ''McLean Hospital Psychiatric Update''. Retrieved on 2007-09-23.</ref>
*** [[Dialectical behavioral therapy]] has been found to significantly reduce self-injury and [[suicidal behavior]] in individuals with BPD, beyond the effect of usual or expert treatment, and to be better accepted by clients.<ref>Verheul, R.; L.M. Van Den Bosch, M.W. Koeter, et al. (February 2003). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=12562741&query_hl=3&itool=pubmed_docsum Dialectical behavioral therapy for women with borderline personality disorder: 12-month, randomized clinical trial in The Netherlands]". ''British Journal of Psychiatry'' (182): 135-40. Retrieved on 2007-09-23.</ref><ref>Linehan, M.M.; K.A. Comtois, A.M. Murray, et al. (July 2006). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=16818865 Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder]". ''Archives of General Psychiatry'' '''63''' (7): 757-66. Retrieved on 2007-09-23.</ref> Although, whether it has additional efficacy in the overall treatment of BPD appears less clear.<ref name="Cochranepsychotherapy" /> Training nurses in the use of DBT has been found to replace a therapeutic pessimism with a more optimistic understanding and outlook.<ref>Hazelton, M.; R. Rossiter, J. Milner (February - March 2006). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16594889 Managing the 'unmanageable': training staff in the use of dialectical behavior therapy for borderline personality disorder]". ''Contemporary Nurse'' '''21''' (1): 120-30. Retrieved on 2007-09-23.</ref>
** 1.3 '''Schema Therapy'''
*** [[Schema Therapy]] (also called Schema-Focused Therapy) is an integrative approach based on [[cognitive-behavioral]] or skills-based techniques along with [[Object relations theory|object relations]] and [[Gestalt therapy|gestalt approaches]].  It directly targets deeper aspects of emotion, personality and [[Schema (psychology)|schemas]] (fundamental ways of categorizing and reacting to the world). The treatment also focuses on the [[Transference|relationship with the therapist]] (including a process of "limited re-parenting"), daily life outside of [[therapy]], and traumatic childhood experiences.
*** It was developed by Jeffrey Young and became established in the 1990s.  Limited recent research suggests that it is significantly more effective than Transference-Focused [[Psychotherapy]], with half of the individuals with borderline personality disorder assessed as having achieved full recovery after 4 years, with two-thirds showing clinically significant improvement.<ref name="SFTvsTFT">Giesen-Bloo, J.; R. van Dyck, P. Spinhoven, et al. (June 2005). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16754838 Outpatient psychotherapy for borderline personality disorder: a randomized trial of schema-focused therapy vs transference-focused psychotherapy]". ''Archives of General Psychiatry'' '''63''' (6): 649-58. Retrieved on 2007-09-23.</ref><ref>Darden, M. (2006-10-10). "[http://www.eurekalert.org/pub_releases/2006-10/ppmr-nhf101006.php New hope for an 'untreatable' mental illness]". ''EurekAlert!'' Retrieved on 2007-09-23.</ref> Another very small trial has also suggested efficacy.<ref>Nordahl, H.M., T.E. Nysaeter (September 2005). "[http://cat.inist.fr/?aModele=afficheN&cpsidt=16983362 Schema therapy for patients with borderline personality disorder: a single case series]". ''J Behav Ther Exp Psychiatry'' '''36''' (3): 254-64. Retrieved on 2007-09-23.</ref>
** 1.4 '''Cognitive Behavioral Therapy'''
*** [[Cognitive Behavioral Therapy]] (CBT) is the most widely used and established [[psychological]] treatment for [[mental disorders]] but has appeared less successful in BPD, due partly to difficulties in developing a therapeutic relationship and treatment adherence. Approaches such as DBT and Schema-focused therapy developed partly as an attempt to expand and add to traditional CBT, which uses a limited number of sessions to target specific maladaptive patterns of thought, perception, and behavior. A recent study did find a number of sustained benefits of CBT, in addition to treatment as usual, after an average of 16 sessions over one year.<ref>Davidson, K.; J. Norrie, P. Tyrer, et al. (October 2006). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17032158 The effectiveness of cognitive behavior therapy for borderline personality disorder: results from the borderline personality disorder study of cognitive therapy (BOSCOT) trial]". ''Journal of Personality Disorders'' '''20''' (5): 450-65. Retrieved on 2007-09-23.</ref>
*** [[Eye Movement Desensitization and Reprocessing]] (EMDR) is a treatment for [[PTSD]], a condition closely associated to BPD in many cases. It is similar to [[CBT]] and seen by some as a type of [[CBT]], but also includes unique techniques intended to facilitate full [[emotional]] processing and coming to terms with traumatic memories.
** 1.5 '''Marital or Family Therapy'''
*** [[Marital Therapy]] can be helpful in stabilizing the marital relationship and in reducing marital conflict and stress that can worsen BPD symptoms. Family Therapy or Family Psychoeducation can help educate family members regarding BPD, improve family communication and problem-solving, and provide support to family members in dealing with their loved one's illness.
*** Two patterns of family involvement can help clinicians plan family interventions: overinvolvement and neglect. Borderline patients who are from over-involved families are often actively struggling with a dependency issue by denial or by anger towards their parents.
*** Interest in the use of psychoeducation and skills training approaches for families with borderline members is growing.<ref name="AMN" />
** 1.6 '''Psychoanalysis'''
*** Traditional [[psychoanalysis]] has become less commonly used than in the past, both in general and in regard to BPD. This intervention has been linked to an exacerbation of BPD symptoms<ref name="no_to_psychoanalysis">"[http://www.medical-library.org/journals2a/borderline.htm Borderline Personality Disorder]". Retrieved on 2007-09-23.</ref> although there is also evidence of the effectiveness of certain techniques in the context of partial hospitalization.<ref>Bateman, A.; P. Fonagy (January 2001). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11136631 Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up]". ''American Journal of Psychiatry'' '''158''' (1): 36-42. Retrieved on 2007-09-23.</ref>
** 1.7 '''Transference Focused Psychotherapy'''
*** [[Transference-Focused Psychotherapy]] (TFP) is a form of [[psychoanalytic therapy]] dating to the 1960s, rooted in the conceptions of [[Otto Kernberg]] on BPD and its underlying structure (borderline personality organization). Unlike in the case of traditional [[psychoanalysis]], the therapist plays a very active role in TFP.  In the session, the therapist works on the relationship between the patient and the therapist. The [[therapist]] will try to explore and clarify aspects of this relationship so the underlying [[object relations]] dyads become clear.
*** Some limited research on [[TFP]] suggests it may reduce some symptoms of BPD by affecting certain underlying processes,<ref>Levy, K.N.; J.F. Clarkin, L.N. Scott, et al. (2006). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16470612 The mechanisms of change in the treatment of borderline personality disorder with transference focused psychotherapy]". ''Journal of Clinical Psychology'' (62): 481-501. Retrieved on 2007-09-23.</ref> and that TFP in comparison to [[Dialectical behavioral therapy|Dialectical Behavior Therapy]] and [[supportive therapy]] results in increased reflective functioning (the ability to realistically think about how others think) and a more secure [[Attachment theory|attachment style]].<ref>Levy, K.N.; K.B. Meehan, K.M. Kelly, et al. (2006). "Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder". ''Journal of Consulting and Clinical Psychology'' (74): 1027-1040.</ref>  Furthermore, TFP has been shown to be as effective as DBT in the improvement of suicidal behavior, and has been more effective than DBT in alleviating anger and in reducing verbal or direct assaultive behavior.<ref>Clarkin, J.F. Ph.D.; K.N. Levy, Ph.D., M. F. Lenzenweger, Ph.D., et al. (June 2007). "[http://ajp.psychiatryonline.org/cgi/content/abstract/164/6/922 Evaluating Three Treatments for Borderline Personality Disorder: A Multiwave Study]". ''The American Journal of Psychiatry'' (164): 922-928. {{doi|10.1176/appi.ajp.164.6.922}}. Retrieved on 2007-09-23.</ref> Limited research suggests that TFP appears to be less effective than schema-focused therapy while being more effective than no treatment.<ref name="SFTvsTFT" />
** 1.8 '''Cognitive Analytic Therapy'''
*** [[Cognitive Analytic Therapy]] (CAT) combines cognitive and psychoanalytic approaches and has been adapted for use by individuals with BPD with mixed results.<ref>Ryle, A. (February 2004). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15061342&dopt=Abstract The contribution of cognitive analytic therapy to the treatment of borderline personality disorder]". ''J Personal Disord'' '''18''' (1): 3-35. Retrieved on 2007-09-23.</ref>
* 2 '''[[Medication]]'''
** 2.1 '''[[Antidepressants]]'''
*** [[Selective serotonin reuptake inhibitor]] (SSRI) [[antidepressant]]s have been shown in [[randomized controlled trials]] to improve the attendant symptoms of anxiety and depression, such as anger and hostility, associated with BPD in some patients.<ref name="Cochranepharm" />
*** '''Dosage''': According to ''[[Listening to Prozac]]'', it takes a higher dose of an SSRI to treat mood disorders associated with BPD than depression alone. It also takes about three months for benefit to appear, compared to the three to six weeks for depression.
** 2.2 '''[[Antipsychotics]]'''
*** The newer [[atypical antipsychotics]] are claimed to have an improved [[adverse effect]] profile than the [[typical antipsychotics]]. Antipsychotics are also sometimes used to treat distortions in thinking or false perceptions.<ref>Siever, L.J.; H.W. Koenigsberg (2000). "[http://www.dana.org/pdf/cerebrum/art_v2n4sieverkoenigsberg.pdf The frustrating no-man's-land of borderline personality disorder]" (PDF). ''Cerebrum, The Dana Forum on Brain Science'' '''2''' (4). Retrieved on 2007-09-23.</ref> Use of antipsychotics has varied, from intermittent, for a brief psychotic or dissociative episode, to more general, particularly atypical antipsychotics, for both those diagnosed with bipolar disorder (BiP), as well as those diagnosed with a borderline personality disorder (BPD).
*** Long-term use of antipsychotics is particularly controversial. There are numerous adverse effects with the older medications, notably [[Tardive dyskinesia]] (TDK).<ref name="caseyde">Casey, D.E. (1985). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2860664&dopt=Abstract Tardive dyskinesia: reversible and irreversible]". ''Psychopharmacology Suppl'' (2): 88-97. Retrieved on 2007-09-23.</ref> Atypical [[antipsychotic]]s are also known for often causing considerable weight gain, with associated health complications.<ref>Ruetsch, O.; A. Viola, H. Bardou, et al. (July - August 2005). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16389718][[Psychotropic drugs]] induced weight gain: a review of the literature concerning epidemiological data, mechanisms, and management". ''Encephale'' (4 Pt 1): 507-16. Retrieved on 2007-09-23.</ref>
*** '''Dosage''': One [[meta-analysis]] of 14 prior studies has suggested that several atypical antipsychotics, including [[olanzapine]], [[clozapine]], [[quetiapine]] and [[risperidone]], may help BPD patients with psychotic-like, impulsive or suicidal symptoms.<ref>Grootens, K.P.; R.J. Verkes (January 2005). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15706462&query_hl=4&itool=pubmed_docsum Emerging evidence for the use of atypical antipsychotics in borderline personality disorder]". ''Pharmacopsychiatry'' '''38''' (1): 20-3. Retrieved on 2007-09-23.</ref> 
* 3 '''Mental Health Services and Recovery'''
** 3.1 '''Combining [[Pharmacotherapy]] and [[Psychotherapy]]'''
*** In practice, [[psychotherapy]] and [[medication]] may often be combined but there is limited data on clinical practice.<ref name="APA guide" /> Efficacy studies often assess the effectiveness of interventions when added to 'treatment as usual' ([[TAU]]), which may involve [[general psychiatric services]], [[supportive counseling]], medication, and psychotherapy.
*** One small study, which excluded individuals with a comorbid Axis 1 disorder, has indicated that outpatients undergoing [[Dialectical Behavioral Therapy]] and taking the [[antipsychotic]], [[Olanzapine]], showed significantly more improvement on some measures related to BPD, compared to those undergoing DBT and taking a [[placebo pill]], although they also experienced weight gain and raised [[cholesterol]].
*** Another small study found that patients who had undergone DBT and then took [[fluoxetine]] (Prozac) showed no significant improvements, whereas those who underwent DBT and then took a placebo pill did show significant improvements.<ref name="dbtfluox">Simpson, E.B.; S. Yen, E. Costello, et al. (March 2004). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=15096078 Combined dialectical behavior therapy and fluoxetine]". ''Journal of Clinical Psychiatry'' '''65''' (3): 379-85. Retrieved on 2007-09-23.</ref>
** 3.2 '''Difficulties in Therapy'''
*** There can be unique challenges in the treatment of BPD, eg. hospital care.<ref>Kaplan, C.A. (September 1986). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=3638699 The challenge of working with patients diagnosed as having a borderline personality disorder]". ''Nurs Clin North Am'' '''21''' (3): 429-38. Retrieved on 2007-09-23.</ref> In [[psychotherapy]], a client may be unusually sensitive to rejection and abandonment and may react negatively (e.g., by harming themselves or withdrawing from treatment) if they sense this. In addition, clinicians may emotionally distance themselves from individuals with BPD for self-protection or due to the stigma associated with the diagnosis, leading to a self-fulfilling prophecy and a cycle of stigmatization to which both patient and therapist may contribute to.<ref>Aviram, R.B.; B.S. Brodsky, B. Stanley (October 2006). "[http://taylorandfrancis.metapress.com/content/g886500785w755g6/ Borderline Personality Disorder, Stigma, and Treatment Implications]". ''Harvard Review of Psychiatry'' '''14''' (5). Retrieved on 2007-09-23.</ref>
*** Some psychotherapies, for example, DBT, were developed partially to overcome problems with interpersonal sensitivity and maintaining a therapeutic relationship. Adherence to medication regimes is also a problem, due in part to [[adverse effects]], with drop-out rates of between 50% and 88% in medication trials.<ref>American Psychiatric Association (October 2001). "Practice Guideline for the Treatment of Patients With Borderline Personality Disorder". ''Am J Psychiatry''.</ref> Comorbid disorders, particularly substance use disorders, can complicate attempts to achieve remission.<ref>Zanarini, M.C.; F.R. Frankenburg, J. Hennen, et al. (2004). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=15514413 Axis I comorbidity in patients with borderline personality disorder: 6-year follow-up and prediction of time to remission]". ''Am J Psychiatry'' '''161''' (11): 2108-14. Retrieved on 2007-09-23.</ref>
** 3.3 '''Other Strategies'''
*** Psychotherapies and medications form a part of the overall context of mental health services and psychosocial needs related to BPD. The evidence base is limited for both. Some individuals may forego them or not benefit (enough) from them. It has been argued that diagnostic categorization can have limited utility in directing therapeutic work in this area and that, in some cases, it is only with reference to past and current relationships that "borderline" behavior can be understood as partly adaptive and how people can best be helped.<ref>Warner, S.; T. Wilkins (2004). "[http://www.springerlink.com/content/l440244686765312/ Between Subjugation and Survival: Women, Borderline Personality Disorder and High-Security Mental Hospitals]". ''Journal of Contemporary Psychotherapy'' '''34''' (3): 1573-3564. Retrieved on 2007-09-2].</ref>
*** Numerous other strategies may be used, including [[alternative medicine]] techniques (see [[List of branches of alternative medicine]]), exercise and physical fitness including team sports, occupational therapy techniques including creative arts, having structure and routine, employment - helping feelings of competence (e.g. [[self-efficacy]]), having a social role and being valued by others, boosting [[self-esteem]].<ref>Flory, L. (2004). ''[http://www.mind.org.uk/Information/Booklets/Understanding/Understanding+borderline+personality+disorder.htm Understanding borderline personality disorder]''. London: Mind. Retrieved on 2007-09-23.</ref>
*** Group-based psychological services encourage clients to socialize and participate in both solitary and group activities. These may be in day centers. Therapeutic communities are an example of this, particularly in Europe, although their usage has declined many have specialized in the treatment of severe personality disorder.<ref>Campling, P. (2001). "[http://apt.rcpsych.org/cgi/content/full/7/5/365 Therapeutic communities]". ''Advances in Psychiatric Treatment'' (7): 365-372. Retrieved on 2007-09-23.</ref>
*** [[Psychiatric rehabilitation]] services aimed at helping people with mental health problems to reduce psychosocial disability, engage in meaningful activities and avoid stigma and social exclusion of people who suffer from BPD. There are also many mutual-support or co-counseling groups run by and for individuals with BPD. A goal may be full recovery rather than reliance on services.
*** Data indicates that substantial percentages of people diagnosed with BPD can achieve remission even within a year or two.<ref name="PToverview" /> A longitudinal study found that six years after being diagnosed with BPD, 56% showed good psychosocial function compared to the 26% at baseline. Although vocational achievement was 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, at least one parent, good work/school performance, a sustained work/school history, good global functioning, and good psychosocial functioning.<ref>Zanarini, M.C.; F.R. Frankenburg, J. Hennen, et al. (February 2005). "[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=15899718 Psychosocial functioning of borderline patients and axis II comparison subjects followed prospectively for six years]". ''J Personal Disord'' '''19''' (1): 19-29. Retrieved on 2007-09-23.</ref>


==References==
==References==

Latest revision as of 00:15, 22 August 2022


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-in-Chief: Jesus Rosario Hernandez, M.D. [3], Irfan Dotani

Synonyms and keywords: BPD, unstable self-image, unstable relationships

Overview

Borderline Personality Disorder (BPD) is defined as a personality disorder primarily characterized by emotional dysregulation, extreme "black and white" thinking,"splitting", and chaotic relationships. The general profile of the disorder also typically includes a pervasive instability in mood, interpersonal relationships, self-image, identity, and behavior. Moreover, there may be a disturbance in the individual's sense of self. In extreme cases, this disturbance in the sense of self may lead to periods of dissociation.[1] The disturbances suffered by those with borderline personality disorder have a wide-ranging and pervasive negative impact on many or all of the psychosocial facets of life, including the ability to hold down a job, maintain relationships at home, and interacting in social settings. Comorbidity is common; borderline personality disorder frequently occurs with substance use disorders and mood disorders. Attempted suicide and completed suicide are possible outcomes without proper care and effective therapy. The reference of "BPD" throughout this article refers to borderline personality disorder and not bipolar disorder.

Historical Perspective

  • In the 1930s, there was a debate as to whether BPD should be renamed. The term "borderline" started among clinical use and originated from the idea (now out of favor) of some patients being on the "borderline" between neurosis and psychosis. As a deeper understanding of BPD began to emerge, the disorder could be classified and treated more efficiently once the disorder could be differentiated from neurotic behavior and psychotic behavior.
  • In 1980, BPD only became an official Axis II (personality) diagnosis with the publication of DSM-III.[2]
  • Individuals who are labeled with "Borderline Personality Disorder" feel it is unhelpful and stigmatizing, as well as simply inaccurate, to support a name change.[3] Criticisms have also come from a feminist perspective.[4] It has also been claimed that, in some circles, "borderline" is used as a "garbage can" diagnosis for individuals who are hard to diagnose. This may be interpreted as meaning "nearly psychotic" despite a lack of empirical support for this conceptualization. It may also be used as a generic label for difficult clients or as an excuse for therapy going badly.[5]

Classification

Terminology

  • Alternative suggestions for names include:
  • According to TARA, (Treatment and Research Advancement Association for Personality Disorders) this terminology has "the most likely chance of being adopted by the American Psychiatric Association."[6]
  • An emotional regulation disorder is a term favored by Dr. Marsha Linehan, pioneer of one of the most popular types of BPD therapy.
  • Impulse disorder and Interpersonal regulatory disorder are other valid alternatives, according to Dr. John Gunderson of McLean Hospital in the United States.
  • Dyslimbia has been suggested by Dr. Leland Heller.[7]
  • Mercurial disorder has been proposed by McLean Hospital's Dr. Mary Zanarini.[8]
  • Significantly, the above proposals, if adopted, will likely result in the recognition of BPD as a trauma- and/or mood-related disorder, and should move BPD from Axis II to Axis I in the next DSM (DSM-V, due in 2012).

Pathophysiology

Genetics

A twin study found that if one identical twin met criteria for BPD, the other also met criteria in around a third (35%) of cases, whereas the concordance rate in dizygotic twin pairs was 7% in monozygotic, yielding an inheritance of 0.69.[11]

Differential Diagnosis

Epidemiology and Demographics

Prevalence

  • The prevalence of borderline personality disorder is 1600 to 5900 per 100,000 (1.6% to 5.9%) of the overall population.[12] [13]
  • The prevalence of any personality disorder was 9.1%, with borderline personality disorder being 1.4%.[14]
  • Researchers commonly believe that BPD results from a combination of a traumatic childhood, a vulnerable temperament, and stressful maturational events during adolescence or adulthood.[15]
  • Otto Kernberg formulated the theory of Borderline Personality based on a premise of failure to develop in childhood. There are, according to Kernberg, three developmental tasks an individual must accomplish:
    • When one fails to accomplish a certain developmental task, this often corresponds with an increased risk of developing certain psychopathologies.
    • Failing the first developmental task,psychic clarification of self and other, may result in an increased risk to develop varieties of psychosis.
    • Not accomplishing the second task, overcoming splitting, may result in an increased risk to develop a borderline personality. [16]

Risk Factors

Etiology Description
Childhood abuse, Trauma, or Negelct
  • Numerous studies have shown a strong correlation between childhood abuse and the development of BPD.[17][18][19][20]
  • Majority of individuals with BPD report having had a history of abuse, neglect, or separation as young children.[21]
  • Patients with BPD have been found to be significantly more likely to report having been verbally, emotionally, physically, and sexually abused by caretakers of either gender.
  • Patients were also much more likely to report having caretakers (of both genders) deny the validity of their thoughts and feelings.
  • They were also reported to have failed to been provided needed protection.
  • Individuals with ignored child physical care during adolescence are more likely to have borderline personality disorder.
  • 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 caretaker and abuse by a male caretaker were consequently at significantly higher risk for being sexually abused by a non-caretaker (not a parent).[22]
  • It has been suggested that children who experience chronic early maltreatment and Reactive Attachment Disorder go on to develop a variety of personality disorders, including Borderline Personality Disorder.[23]Many of these children are violent and aggressive.[24][25]
  • As adults, these individuals are at risk of developing a variety of psychological problems such as borderline personality disorder.[26][27]
    • According to Joel Paris,"Some researchers, like Judith Herman, believe that BPD is a name given to a particular manifestation of post-traumatic stress disorder (PTSD): In Trauma and Recovery, she theorizes that when PTSD takes a form that emphasizes heavily on its elements of identity and relationship disturbance, the disorder is named BPD; when the somatic (body) elements are emphasized, the disorder is named hysteria; when the dissociative/deformation of consciousness elements are the focus, the disorder is named DID/MPD" (dissociative identity disorder or multiple personality disorder).[28]
Genetics
  • An overview of existing literature suggests that traits related to BPD are influenced by genes. Personality is generally quite heritable; therefore, BPD is likely to have a large genetical factor in that sense. However, studies have had methodological problems for the connection between genetical factors and BPD.[29]
  • A major twin study found that if one identical twin met criteria for BPD, the other also met criteria in approximately a third (35%) of cases.[30]
  • Twins, siblings, 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.[31]
Neurofunction
  • Neurotransmitters implicated in BPD include serotonin, norepinephrine, acetylcholine (related to various emotions and moods), GABA (the brain's major inhibitory neurotransmitter which can stabilize mood change), and glutamate (an excitatory neurotransmitter).
  • Enhanced amygdala activation in BPD has been identified as reflecting the intense and slowly subsiding emotions commonly observed in BPD in response to low-level stressors.
    • The activation of both the amygdala and prefrontal cortical areas can reflect attempts to control intensive emotions during the recall of unresolved life events.[32]
  • Impulsivity or aggression, as sometimes seen in BPD, has been linked to alterations in serotonin function and specific brain regions in the cingulate and the medial and orbital prefrontal cortex.[33]
Other Developmental Factors
  • A few studies suggest that BPD may not necessarily be a trauma-spectrum disorder and that it is biologically distinct from the post-traumatic stress disorder that could be a precursor. The personality symptom clusters seem to be related to specific abuses, but they may be related to more persistent aspects of interpersonal and family environments in childhood.[34]
  • There is evidence for the central role of the family in the development of BPD, including interactions that are negative and critical rather than supportive and empathic, with parental and family behaviors transacting with the child's own behaviors and emotional vulnerabilities.[35]
  • A few findings suggest that BPD may lie 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.[36][37]
  • Moreover, a few findings suggest that the DSM-IV BPD diagnosis mixes up two sets of unrelated items: An effective instability dimension related to Bipolar-II and an impulsivity dimension not related to Bipolar-II.[38]

Natural History, Complications and Prognosis

Natural History

  • 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.[43]
    • Attachment studies suggest individuals with BPD while being high in intimacy- or novelty-seeking can be hyper-alert to signs of rejection or not being valued and tend towards insecure, ambivalent, preoccupied or fearful attitudes towards relationships.[44][45]
    • They tend to view the world generally as dangerous and malevolent, and themselves as powerless, vulnerable, unacceptable and unsure in self-identity.[44]
  • Individuals with BPD are often described, including by some mental health professionals (and in the DSM-IV), as deliberately manipulative or difficult, but analyses and findings generally trace behaviors to inner pain and turmoil, powerlessness and defensive reactions, or limited coping and communication skills.[46][47][48]
  • 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.[49] Parents of individuals with BPD have been reported to show co-existing extremes of over-involvement and under-involvement.[50]
  • BPD has been linked to somewhat increased levels of chronic stress and conflict in romantic relationships, decreased satisfaction of romantic partners, abuse, and unwanted pregnancy; these links may largely be general to personality disorder and subsyndromal problems,[51] but such issues are commonly raised in support groups and published literature for partners of individuals with BPD.
  • Suicidal or self-harming behavior is one of the core diagnostic criteria in DSM IV-TR. The management of and recovery from this can be complex and challenging.[52] The suicide rate is approximately 8%-10%.[53]
  • The most recognized form of self-injury is auto-mutilation (cutting the self), usually of the arms, but often other areas such as the legs, chest, belly, and face. Self-injury attempts are highly common among patients and may or may not be carried out with suicidal intent.[54][55]
  • 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 major depression, with interpersonal stressors appearing to be particularly common triggers.[56]
    • Ongoing family interactions and associated vulnerabilities can lead to self-destructive behavior.[50]
    • Stressful life events related to sexual abuse have been found to be a particular trigger for suicide attempts by adolescents with a BPD diagnosis.[57]
  • Co-morbid (co-occurring) conditions in BPD are common.
    • When comparing individuals diagnosed with BPD to those diagnosed with other kinds of personality disorders, the former showed a higher rate of also meeting criteria for:[58]
  • Substance abuse is a common problem in BPD, whether due to impulsivity or as a coping mechanism. 50%-70% of psychiatric inpatients with BPD have been found to meet criteria for a substance use disorder.[59]

Prognosis

  • Poor prognostic factors include:[12]
    • Female gender
    • Adolescence and early adulthood
    • Identity problems
    • Relatives with the same disease

Diagnosis

  • A diagnosis is based on self-reported experiences of patients, as well as markers for the disorder observed by a psychiatrist, psychologist, or another qualified diagnostician through clinical assessment. This profile may be supported and/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]
  • An initial assessment generally includes a comprehensive personal and family history. It may also include a physical examination by a physician. Although there are no physiological tests that confirm borderline personality disorder, medical tests may be employed to exclude any co-occurring medical conditions that may present with psychiatric symptoms. These include:

Diagnosis Criteria

DSM-V Diagnostic Criteria for Borderline Personality Disorder[12]

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and 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-mutilating 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., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
  5. Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior.
  6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours (rarely more than a few days).
  7. Chronic feelings of emptiness.
  8. Inappropriate behavior, intense or uncontrollable anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
  9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Mnemonic

Emotionally Unstable Personality Disorder

  • The World Health Organization's (WHO) ICD-10 has a comparable diagnosis called Emotionally Unstable Personality Disorder - Borderline type (F60.31). This requires, in addition to the general criteria for personality disorder:
    • Disturbances among and uncertainty about self-image, aims, and internal preferences (including sexual).
    • Liability to become involved in intense and unstable relationships, often leading to an emotional crisis.
    • Excessive efforts to avoid abandonment; recurrent threats or acts of self-harm; and chronic feelings of emptiness.
  • The Chinese Society of Psychiatry's (CCMD) has a comparable diagnosis of impulsive personality disorder. 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's Emotionally Unstable Personality Disorder, and also incorporates six of the nine DSM BPD criteria.[60]

Treatment

  • 1 Therapies
    • 1.1 Psychotherapy
      • Simple supportive therapy alone may enhance self-esteem and mobilize the existing strengths of individuals with BPD.[61] Specific psychotherapies may involve sessions over several months or, as is particularly common for personality disorders, several years.
      • Psychotherapy can often be conducted either with individuals or with groups. Group therapy can aid the learning and practice of interpersonal skills and self-awareness by individuals with BPD[62] although drop-out rates may be problematic.[63]
    • 1.2 Dialectical Behavioral Therapy
      • Dialectical behavior therapy is derived from cognitive-behavioral techniques (and can be seen as a form of CBT) but emphasizes an exchange and negotiation between therapist and client, between the rational and the emotional, and between acceptance and change (hence dialectic). Treatment targets are agreed upon, with self-harm issues taking priority.
      • The learning of new skills is a core component - including mindfulness, interpersonal effectiveness (e.g. assertiveness and social skills), coping adaptively with distress and crises; and identifying and regulating emotional reactions.
      • DBT can be based on a biosocial theory of personality functioning in which BPD is seen as a biological disorder of emotional regulation in a social environment experienced as invalidating by the borderline patient.[64]
      • Dialectical behavioral therapy has been found to significantly reduce self-injury and suicidal behavior in individuals with BPD, beyond the effect of usual or expert treatment, and to be better accepted by clients.[65][66] Although, whether it has additional efficacy in the overall treatment of BPD appears less clear.[67] Training nurses in the use of DBT has been found to replace a therapeutic pessimism with a more optimistic understanding and outlook.[68]
    • 1.3 Schema Therapy
      • Schema Therapy (also called Schema-Focused Therapy) is an integrative approach based on cognitive-behavioral or skills-based techniques along with object relations and gestalt approaches. It directly targets deeper aspects of emotion, personality and schemas (fundamental ways of categorizing and reacting to the world). The treatment also focuses on the relationship with the therapist (including a process of "limited re-parenting"), daily life outside of therapy, and traumatic childhood experiences.
      • It was developed by Jeffrey Young and became established in the 1990s. Limited recent research suggests that it is significantly more effective than Transference-Focused Psychotherapy, with half of the individuals with borderline personality disorder assessed as having achieved full recovery after 4 years, with two-thirds showing clinically significant improvement.[69][70] Another very small trial has also suggested efficacy.[71]
    • 1.4 Cognitive Behavioral Therapy
      • Cognitive Behavioral Therapy (CBT) is the most widely used and established psychological treatment for mental disorders but has appeared less successful in BPD, due partly to difficulties in developing a therapeutic relationship and treatment adherence. Approaches such as DBT and Schema-focused therapy developed partly as an attempt to expand and add to traditional CBT, which uses a limited number of sessions to target specific maladaptive patterns of thought, perception, and behavior. A recent study did find a number of sustained benefits of CBT, in addition to treatment as usual, after an average of 16 sessions over one year.[72]
      • Eye Movement Desensitization and Reprocessing (EMDR) is a treatment for PTSD, a condition closely associated to BPD in many cases. It is similar to CBT and seen by some as a type of CBT, but also includes unique techniques intended to facilitate full emotional processing and coming to terms with traumatic memories.
    • 1.5 Marital or Family Therapy
      • Marital Therapy can be helpful in stabilizing the marital relationship and in reducing marital conflict and stress that can worsen BPD symptoms. Family Therapy or Family Psychoeducation can help educate family members regarding BPD, improve family communication and problem-solving, and provide support to family members in dealing with their loved one's illness.
      • Two patterns of family involvement can help clinicians plan family interventions: overinvolvement and neglect. Borderline patients who are from over-involved families are often actively struggling with a dependency issue by denial or by anger towards their parents.
      • Interest in the use of psychoeducation and skills training approaches for families with borderline members is growing.[62]
    • 1.6 Psychoanalysis
      • Traditional psychoanalysis has become less commonly used than in the past, both in general and in regard to BPD. This intervention has been linked to an exacerbation of BPD symptoms[73] although there is also evidence of the effectiveness of certain techniques in the context of partial hospitalization.[74]
    • 1.7 Transference Focused Psychotherapy
      • Transference-Focused Psychotherapy (TFP) is a form of psychoanalytic therapy dating to the 1960s, rooted in the conceptions of Otto Kernberg on BPD and its underlying structure (borderline personality organization). Unlike in the case of traditional psychoanalysis, the therapist plays a very active role in TFP. In the session, the therapist works on the relationship between the patient and the therapist. The therapist will try to explore and clarify aspects of this relationship so the underlying object relations dyads become clear.
      • Some limited research on TFP suggests it may reduce some symptoms of BPD by affecting certain underlying processes,[75] and that TFP in comparison to Dialectical Behavior Therapy and supportive therapy results in increased reflective functioning (the ability to realistically think about how others think) and a more secure attachment style.[76] Furthermore, TFP has been shown to be as effective as DBT in the improvement of suicidal behavior, and has been more effective than DBT in alleviating anger and in reducing verbal or direct assaultive behavior.[77] Limited research suggests that TFP appears to be less effective than schema-focused therapy while being more effective than no treatment.[69]
    • 1.8 Cognitive Analytic Therapy
      • Cognitive Analytic Therapy (CAT) combines cognitive and psychoanalytic approaches and has been adapted for use by individuals with BPD with mixed results.[78]
  • 2 Medication
    • 2.1 Antidepressants
    • 2.2 Antipsychotics
      • The newer atypical antipsychotics are claimed to have an improved adverse effect profile than the typical antipsychotics. Antipsychotics are also sometimes used to treat distortions in thinking or false perceptions.[80] Use of antipsychotics has varied, from intermittent, for a brief psychotic or dissociative episode, to more general, particularly atypical antipsychotics, for both those diagnosed with bipolar disorder (BiP), as well as those diagnosed with a borderline personality disorder (BPD).
      • Long-term use of antipsychotics is particularly controversial. There are numerous adverse effects with the older medications, notably Tardive dyskinesia (TDK).[81] Atypical antipsychotics are also known for often causing considerable weight gain, with associated health complications.[82]
      • Dosage: One meta-analysis of 14 prior studies has suggested that several atypical antipsychotics, including olanzapine, clozapine, quetiapine and risperidone, may help BPD patients with psychotic-like, impulsive or suicidal symptoms.[83]
  • 3 Mental Health Services and Recovery
    • 3.1 Combining Pharmacotherapy and Psychotherapy
      • In practice, psychotherapy and medication may often be combined but there is limited data on clinical practice.[84] Efficacy studies often assess the effectiveness of interventions when added to 'treatment as usual' (TAU), which may involve general psychiatric services, supportive counseling, medication, and psychotherapy.
      • One small study, which excluded individuals with a comorbid Axis 1 disorder, has indicated that outpatients undergoing Dialectical Behavioral Therapy and taking the antipsychotic, Olanzapine, showed significantly more improvement on some measures related to BPD, compared to those undergoing DBT and taking a placebo pill, although they also experienced weight gain and raised cholesterol.
      • Another small study found that patients who had undergone DBT and then took fluoxetine (Prozac) showed no significant improvements, whereas those who underwent DBT and then took a placebo pill did show significant improvements.[85]
    • 3.2 Difficulties in Therapy
      • There can be unique challenges in the treatment of BPD, eg. hospital care.[86] In psychotherapy, a client may be unusually sensitive to rejection and abandonment and may react negatively (e.g., by harming themselves or withdrawing from treatment) if they sense this. In addition, clinicians may emotionally distance themselves from individuals with BPD for self-protection or due to the stigma associated with the diagnosis, leading to a self-fulfilling prophecy and a cycle of stigmatization to which both patient and therapist may contribute to.[87]
      • Some psychotherapies, for example, DBT, were developed partially to overcome problems with interpersonal sensitivity and maintaining a therapeutic relationship. Adherence to medication regimes is also a problem, due in part to adverse effects, with drop-out rates of between 50% and 88% in medication trials.[88] Comorbid disorders, particularly substance use disorders, can complicate attempts to achieve remission.[89]
    • 3.3 Other Strategies
      • Psychotherapies and medications form a part of the overall context of mental health services and psychosocial needs related to BPD. The evidence base is limited for both. Some individuals may forego them or not benefit (enough) from them. It has been argued that diagnostic categorization can have limited utility in directing therapeutic work in this area and that, in some cases, it is only with reference to past and current relationships that "borderline" behavior can be understood as partly adaptive and how people can best be helped.[90]
      • Numerous other strategies may be used, including alternative medicine techniques (see List of branches of alternative medicine), exercise and physical fitness including team sports, occupational therapy techniques including creative arts, having structure and routine, employment - helping feelings of competence (e.g. self-efficacy), having a social role and being valued by others, boosting self-esteem.[91]
      • Group-based psychological services encourage clients to socialize and participate in both solitary and group activities. These may be in day centers. Therapeutic communities are an example of this, particularly in Europe, although their usage has declined many have specialized in the treatment of severe personality disorder.[92]
      • Psychiatric rehabilitation services aimed at helping people with mental health problems to reduce psychosocial disability, engage in meaningful activities and avoid stigma and social exclusion of people who suffer from BPD. There are also many mutual-support or co-counseling groups run by and for individuals with BPD. A goal may be full recovery rather than reliance on services.
      • Data indicates that substantial percentages of people diagnosed with BPD can achieve remission even within a year or two.[2] A longitudinal study found that six years after being diagnosed with BPD, 56% showed good psychosocial function compared to the 26% at baseline. Although vocational achievement was 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, at least one parent, good work/school performance, a sustained work/school history, good global functioning, and good psychosocial functioning.[93]

References

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  2. 2.0 2.1 Oldham, J. (July 2004). "Borderline Personality Disorder: An Overview" Psychiatric Times XXI (8). Retrieved on 2007-09-21.
  3. Bogod, E. "Borderline Personality Disorder Label Creates Stigma". mental-health-matters.com. Retrieved on 2007-09-21.
  4. Shaw and Proctor (2005). "Women at the Margins: A Critique of the Diagnosis of Borderline Personality Disorder" (PDF). Feminism Psychology (15): 483-90. Retrieved on 2007-09-21.
  5. Grohol, J. Psy.D. (June 22 2007). "Symptoms of Borderline Personality Disorder". PsychCentral.com. Retrieved on 2007-09-21.
  6. Porr, Valerie MA (November 2001). How Advocacy is Bringing Borderline Personality Disorder Into the Light. tara4bpd.org Axis II. Retrieved on 2007-09-21.
  7. Heller, L. MD. "A Possible New Name For Borderline Personality Disorder". Biological Unhappiness. Retrieved on 2007-09-21.
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    • Sex and race were not found to be associated with the prevalence of borderline personality disorder.

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See also

Template:DSM personality disorders


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