Borderline Personality Disorder (BPD) Part I

 Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD), is a personality disorder characterized by a pervasive, long-term pattern of significant interpersonal relationship instability, a distorted sense of self, and intense emotional responses. People diagnosed with BPD frequently exhibit self-harming behaviours and engage in risky activities, primarily due to challenges regulating emotional states to a healthy, stable baseline. Symptoms such as dissociation (a feeling of detachment from reality), a pervasive sense of emptiness, and an acute fear of abandonment are prevalent among those affected.

The onset of BPD symptoms can be triggered by events that others might perceive as normal, with the disorder typically manifesting in early adulthood and persisting across diverse contexts. BPD is often comorbid with substance use disorders, depressive disorders, and eating disorders. BPD is associated with a substantial risk of suicide; an estimated 8 to 10 percent of people with BPD die by suicide, with males affected at twice the rate of females. Despite its severity, BPD faces significant stigmatization in both media portrayals and the psychiatric field, potentially leading to its underdiagnosis.

The causes of BPD are unclear and complex, implicating genetic, neurological, and psychosocial conditions in its development. A genetic predisposition is evident, with the disorder significantly more common in people with a family history of BPD, particularly immediate relatives. Psychosocial factors, particularly adverse childhood experiences, have been proposed. Neurologically, the underlying mechanism appears to involve the frontolimbic neuronal network of the limbic system. The American Diagnostic and Statistical Manual of Mental Disorders (DSM) classify BPD as a cluster B personality disorder, alongside antisocial, histrionic, and narcissistic personality disorders. There is a small risk of misdiagnosis, with BPD most commonly confused with a mood disorder, substance use disorder, or other mental health disorders.

Therapeutic interventions for BPD predominantly involve psychotherapy, with cognitive behavioral therapy (CBT) or dialectical behavior therapy (DBT) the most effective modalities. This psychotherapy can occur one-on-one or in a group. Although pharmacotherapy cannot cure BPD, it may be employed to mitigate associated symptoms, with quetiapine and selective serotonin reuptake inhibitor (SSRI) antidepressants commonly prescribed even though their efficacy is unclear. A 2020 meta-analysis found the use of medications was still unsupported by evidence. In severe cases, hospitalization may be necessitated, even if for only short periods.

BPD has a point prevalence of 1.6% and a lifetime prevalence of 5.9% of the global population, with a higher incidence rate among women compared to men in the clinical setting of up to three times. Despite the high utilization of healthcare resources by people with BPD, up to half may show significant improvement over a ten-year period with appropriate treatment. The name of the disorder, particularly the suitability of the term borderline, is a subject of ongoing debate. Initially, the term reflected historical ideas of borderline insanity and later described patients on the border between neurosis and psychosis. These interpretations are now regarded as outdated and clinically imprecise.

Signs and symptoms

One of the symptoms of BPD is an intense fear of emotional abandonment.

Borderline personality disorder, as outlined in the DSM-5, manifests through nine distinct symptoms, with a diagnosis requiring at least five of the following criteria to be met:

Frantic efforts to avoid real or imagined emotional abandonment.

Unstable and chaotic interpersonal relationships, often characterized by a pattern of alternating between extremes of idealization and devaluation, also known as 'splitting'.

A markedly disturbed sense of identity and distorted self-image.

Impulsive or reckless behaviors, including uncontrollable spending, unsafe sexual practices, and substance use disorder, reckless driving, and binge eating.

Recurrent suicidal ideation or behaviors involving self-harm.

Rapidly shifting intense emotional dysregulation.

Chronic feelings of emptiness.

Inappropriate, intense anger that can be difficult to control.

Transient, stress-related paranoid ideation or severe dissociative symptoms.

The distinguishing characteristics of BPD include a pervasive pattern of instability in one's interpersonal relationships and in one's self-image, with frequent oscillation between extremes of idealization and devaluation of others, alongside fluctuating moods and difficulty regulating intense emotional reactions. Dangerous or impulsive behaviors are commonly associated with BPD.

Additional symptoms may encompass uncertainty about one's identity, values, morals, and beliefs; experiencing paranoid thoughts under stress; episodes of depersonalization; and, in moderate to severe cases, stress-induced breaks with reality or episodes of psychosis. It is also common for individuals with BPD to have comorbid conditions such as depressive or bipolar disorders, substance use disorders, eating disorders, post-traumatic stress disorder (PTSD), and attention-deficit hyperactivity disorder (ADHD).

Mood and affect

Individuals with BPD exhibit emotional dysregulation. Emotional dysregulation is characterized by an inability in flexibly responding to and managing emotional states, resulting in intense and prolonged emotional reactions that deviate from social norms, given the nature of the environmental stimuli encountered. Such reactions not only deviate from accepted social norms but also surpass what is informally deemed appropriate or proportional to the encountered stimuli.

A core characteristic of BPD is affective instability, which manifests as rapid and frequent shifts in mood of high affect intensity and rapid onset of emotions, triggered by environmental stimuli. The return to a stable emotional state is notably delayed, exacerbating the challenge of achieving emotional equilibrium. This instability is further intensified by an acute sensitivity to psychosocial cues, leading to significant challenges in managing emotions effectively.

As the first component of emotional dysregulation, individuals with BPD are shown to have increased emotional sensitivity, especially towards negative mood states such as fear, anger, sadness, rejection, criticism, isolation, and perceived failure. This increased sensitivity results in an intensified response to environmental cues, including the emotions of others. Studies have identified a negativity bias in those with BPD, showing a predisposition towards recognizing and reacting more strongly to negative emotions in others, along with an attentional bias towards processing negatively-valenced stimuli. Without effective coping mechanisms, individuals might resort to self-harm, or suicidal behaviors to manage or escape from these intense negative emotions. While conscious of the exaggerated nature of their emotional responses, individuals with BPD face challenges in regulating these emotions. To mitigate further distress, there may be an unconscious suppression of emotional awareness, which paradoxically hinders the recognition of situations requiring intervention.

A second component of emotional dysregulation in BPD is high levels of negative affectivity, stemming directly from the individual's emotional sensitivity to negative emotions. This negative affectivity causes emotional reactions that diverge from socially accepted norms, in ways that are disproportionate to the environmental stimuli presented. Those with BPD are relatively unable to tolerate the distress that is encountered in daily life, and they are prone to engage in maladaptive strategies to try to reduce the distress experienced. Maladaptive coping strategies include rumination, thought suppression, experiential avoidance, emotional isolation, as well as impulsive and self-injurious behaviors.

American psychologist Marsha Linehan highlights that while the sensitivity, intensity, and duration of emotional experiences in individuals with BPD can have positive outcomes, such as exceptional enthusiasm, idealism, and capacity for joy and love, it also predisposes them to be overwhelmed by negative emotions. This includes experiencing profound grief instead of mere sadness, intense shame instead of mild embarrassment, rage rather than annoyance, and panic over nervousness. Research indicates that individuals with BPD endure chronic and substantial emotional suffering.

Emotional dysregulation is a significant feature of BPD, yet Fitzpatrick et al. (2022) suggest that such dysregulation may also be observed in other disorders, like generalized anxiety disorder (GAD). Nonetheless, their findings imply that individuals with BPD particularly struggle with disengaging from negative emotions and achieving emotional equilibrium.

Euphoria, or transient intense joy, can occur in those with BPD, but they are more commonly afflicted by dysphoria (a profound state of unease or dissatisfaction), depression, and pervasive distress. Zanarini et al. identify four types of dysphoria characteristic of BPD: intense emotional states, destructiveness or self-destructiveness, feelings of fragmentation or identity loss, and perceptions of victimization. A diagnosis of BPD is closely linked with experiencing feelings of betrayal, lack of control, and self-harm.

Moreover, emotional lability, indicating variability or fluctuations in emotional states, is frequent among those with BPD. Although emotional lability may imply rapid alternations between depression and elation, mood swings in BPD are more commonly between anger and anxiety or depression and anxiety.

 

Interpersonal relationships

Interpersonal relationships are significantly impacted in individuals with BPD, characterized by a heightened sensitivity to the behavior and actions of others. Individuals with BPD can be very conscious of and susceptible to their perceived or real treatment by others. Individuals may experience profound happiness and gratitude for perceived kindness, yet feel intense sadness or anger towards perceived criticism or harm. A notable feature of BPD is the tendency to engage in idealization and devaluation of others – that is to idealize and subsequently devalue others – oscillating between extreme admiration and profound mistrust or dislike. This pattern, referred to as "splitting," can significantly influence the dynamics of interpersonal relationships. In addition to this external "splitting," patients with BPD typically have internal splitting, i.e. vacillation between considering oneself a good person who has been mistreated (in which case anger predominates) and a bad person whose life has no value (in which case self-destructive or even suicidal behavior may occur). This splitting is also evident in black-and-white or all-or-nothing dichotomous thinking.

Despite a strong desire for intimacy, individuals with BPD may exhibit insecure, avoidant, ambivalent or fearfully preoccupied attachment styles in relationships, complicating their interactions and connections with others. Family members, including parents of adults with BPD, may find themselves in a cycle of being overly involved in the individual's life at times and, at other times, significantly detached, contributing to a sense of alienation within the family unit.

Personality disorders, including BPD, are associated with an increased incidence of chronic stress and conflict, reduced satisfaction in romantic partnerships, domestic abuse, and unintended pregnancies. Research indicates variability in relationship patterns among individuals with BPD. A portion of these individuals may transition rapidly between relationships, a pattern metaphorically described as "butterfly-like," characterized by fleeting and transient interactions and "fluttering" in and out of relationships. Conversely, a subgroup, referred to as "attached," tends to establish fewer but more intense and dependent relationships. These connections often form rapidly, evolving into deeply intertwined and tumultuous bonds, indicating a more pronounced dependence on these interpersonal ties compared to those without BPD.

Behavior

Behavioral patterns associated with BPD frequently involve impulsive actions, which may manifest as substance use disorders, binge eating, unprotected sexual encounters, self-injury among other self-harming practices. These behaviors are a response to the intense emotional distress experienced by individuals with BPD, serving as an immediate but temporary alleviation of their emotional pain. However, such actions typically result in feelings of shame and guilt, contributing to a recurrent cycle. This cycle typically begins with emotional discomfort, followed by impulsive behavior aimed at mitigating this discomfort, only to lead to shame and guilt, which in turn exacerbates the emotional pain. This escalation of emotional pain then intensifies the compulsion towards impulsive behavior as a form of relief, creating a vicious cycle. Over time, these impulsive responses can become an automatic mechanism for coping with emotional pain.

Self-harm and suicide

Self-harm and suicidal behaviors are core diagnostic criteria for BPD as outlined in the DSM-5. Between 50% and 80% of individuals diagnosed with BPD engage in self-harm, with cutting being the most common method. Other methods, such as bruising, burning, head banging, or biting, are also prevalent. It is hypothesized that individuals with BPD might experience a sense of emotional relief following acts of self-harm.

Estimates of the lifetime risk of death by suicide among individuals with BPD range between 3% and 10%, varying with the method of investigation. There is evidence that a significant proportion of males who die by suicide may have undiagnosed BPD.

The motivations behind self-harm and suicide attempts among individuals with BPD are reported to differ. Nearly 70% of individuals with BPD engage in self-harm without the intention of ending their lives. Motivations for self-harm include expressing anger, self-punishment, inducing normal feelings or feelings of normality in response to dissociative episodes, and distraction from emotional distress or challenging situations. Conversely, true suicide attempts by individuals with BPD frequently are motivated by the notion that others will be better off in their absence.

Sense of self and self-concept

Individuals diagnosed with BPD frequently experience significant difficulties in maintaining a stable self-concept. This instability manifests as uncertainty in personal values, beliefs, preferences, and interests. They may also express confusion regarding their aspirations and objectives in terms of relationships and career paths. Such indeterminacy leads to feelings of emptiness and a profound sense of disorientation regarding their own identity. Moreover, their self-perception can fluctuate dramatically over short periods, oscillating between positive and negative evaluations. Consequently, individuals with BPD might adopt their sense of self based on their surroundings or the people they interact with, resulting in a chameleon-like adaptation of identity.

Dissociation and cognitive challenges

The heightened emotional states experienced by individuals with BPD can impede their ability to concentrate and cognitively function. Additionally, individuals with BPD may frequently dissociate, which can be regarded as a mild to severe disconnection from physical and emotional experiences. Observers may notice signs of dissociation in individuals with BPD through diminished expressiveness in their face or voice, or through an apparent disconnection and insensitivity to emotional cues or stimuli.

Dissociation typically arises in response to distressing occurrences or reminders of past trauma, acting as a psychological defense mechanism by diverting attention from the current stressor or by blocking it out entirely. This process, believed to shield the individual from the anticipated overwhelming negative emotions and undesired impulses that the current emotional situation might provoke, is rooted in avoidance of intense emotional pain based on past experiences. While this mechanism may offer temporary emotional respite, it can foster unhealthy coping strategies and inadvertently dull positive emotions, thereby obstructing the individual's access to crucial emotional insights. These insights are essential for informed, healthy decision-making in everyday life.

Psychotic symptoms

BPD is predominantly characterized as a disorder involving emotional dysregulation, yet psychotic symptoms frequently occur in individuals with BPD, with prevalence estimates ranging between 21% and 54%. These manifestations have historically been labeled as "pseudo-psychotic" or "psychotic-like", implying a differentiation from symptoms observed in primary psychotic disorders. Studies conducted in the 2010s suggest a closer similarity between psychotic symptoms in BPD and those in recognized psychotic disorders than previously understood. The distinction of pseudo-psychosis has faced criticism for its weak construct validity and the potential to diminish the perceived severity of these symptoms, potentially hindering accurate diagnosis and effective treatment. Consequently, there are suggestions from some in the research community to categorize these symptoms as genuine psychosis, advocating for the abolishment of the distinction between pseudo-psychosis and true psychosis.

The DSM-5 identifies transient paranoia, exacerbated by stress, as a symptom of BPD. Research has identified the presence of both hallucinations and delusions in individuals with BPD who do not possess an alternate diagnosis that would better explain these symptoms. Further, phenomenological analysis indicates that auditory verbal hallucinations in BPD patients are indistinguishable from those observed in schizophrenia.  This has led to suggestions of a potential shared etiological basis for hallucinations across BPD and other disorders, including psychotic and affective disorders.

Disability and employment

Individuals diagnosed with BPD often possess the capability to engage in employment, provided they secure positions that align with their skill sets and the severity of their condition remains manageable. In certain cases, BPD may be recognized as a disability within the workplace, particularly if the condition's severity results in behaviors that undermine relationships, involve engagement in risky activities, or manifest as intense anger, thereby inhibiting the individual's ability to perform their job role effectively. The United States Social Security Administration officially recognizes BPD as a form of disability, enabling those significantly affected to apply for disability benefits.

Causes

The etiology, or causes, of BPD is multifaceted, with no consensus on a singular cause. BPD may share a connection with post-traumatic stress disorder (PTSD). While childhood trauma is a recognized contributing factor, the roles of congenital brain abnormalities, genetics, neurobiology, and non-traumatic environmental factors remain subjects of ongoing investigation.

Genetics and heritability

Compared to other major psychiatric conditions, the exploration of genetic underpinnings in BPD remains novel. Estimates suggest the heritability of BPD ranges from 37% to 69%, indicating that human genetic variations account for a substantial portion of the risk for BPD within the population. Twin studies, which often form the basis of these estimates, may overestimate the perceived influence of genetics due to the shared environment of twins, potentially skewing results.

Despite these methodological considerations, certain studies propose that personality disorders are significantly shaped by genetics, more so than many Axis I disorders, such as depression and eating disorders, and even surpassing the genetic impact on broad personality traits. Notably, BPD ranks as the third most heritable among ten surveyed personality disorders.

Research involving twin and sibling studies has shown a genetic component to traits associated with BPD, such as impulsive aggression; with the genetic contribution to behavior from serotonin-related genes appearing to be modest.

A study conducted by Trull et al. in the Netherlands, which included 711 sibling pairs and 561 parents, aimed to identify genetic markers associated with BPD. This research identified a linkage to genetic markers on chromosome 9 as relevant to BPD characteristics, underscoring a significant genetic contribution to the variability observed in BPD features. Prior findings from this group indicated that 42% of BPD feature variability could be attributed to genetics, with the remaining 58% owing to environmental factors.

Among specific genetic variants under scrutiny as of 2012, the DRD4 7-repeat polymorphism (of the dopamine receptor D4) located on chromosome 11 has been linked to disorganized attachment, and in conjunction with the 10/10-repeat genotype of the dopamine transporter (DAT), it has been associated with issues with inhibitory control, both of which are characteristic of BPD. Additionally, potential links to chromosome 5 are being explored, further emphasizing the complex genetic landscape influencing BPD development and manifestation.

Psychosocial factors

Adverse childhood experiences

Studies based on empiricism have established a strong correlation between adverse childhood experiences such as child abuse, particularly child sexual abuse, and the onset of BPD later in life. Reports from individuals diagnosed with BPD frequently include narratives of extensive abuse and neglect during early childhood, though causality remains a subject of ongoing investigation.  These individuals are significantly more prone to recount experiences of verbal, emotional, physical, or sexual abuse by caregivers, alongside a notable frequency of incest and loss of caregivers in early childhood.

Moreover, there have been consistent accounts of caregivers invalidating the individuals' emotions and thoughts, neglecting physical care, failing to provide necessary protection, and exhibiting emotional withdrawal and inconsistency. Specifically, female individuals with BPD reporting past neglect or abuse by caregivers have a heightened likelihood of encountering sexual abuse from individuals outside their immediate family circle.

The enduring impact of chronic maltreatment and difficulties in forming secure attachments during childhood has been hypothesized to potentially contribute to the development of BPD. From a psychoanalytic perspective, Otto Kernberg has posited that the child's failure to navigate the developmental challenge of differentiating self from others, or as Kernberg terms it achieve the developmental task of psychic clarification of self and other, and failure to overcome the internal divisions caused by splitting may predispose that child to BPD.

Invalidating environment

Marsha Linehan's biosocial developmental theory posits that BPD arises from the interaction between a child's inherent emotional vulnerability and an invalidating environment. Emotional vulnerability is thought to be influenced by biological and genetic factors that shape the child's temperament. Traditional biomedical constructions of BPD often focus solely on biological factors. Though these factors certainly play a role in the development of borderline personality disorder, they do not provide a complete picture. A biosocial approach considers the interplay between genetic predispositions and environmental stressors, such as childhood trauma, invalidating environments, and social relationships, in shaping the course of the disorder.

Invalidating environments are characterized by the neglect, ridicule, dismissal, or discouragement of a child's emotions and needs, and may also encompass experiences of trauma and abuse. Invalidation from caregivers, peers, or authority figures can lead individuals with borderline personality disorder to doubt the legitimacy of their feelings and experiences. This can exacerbate their emotional dysregulation and contribute to a cycle of invalidation, distress, and maladaptive coping strategies. When emotions are consistently dismissed or criticized, individuals with BPD may resort to destructive behaviors such as self-harm, substance abuse, or impulsive actions to cope with their distress, further perpetuating the negative stigma attached to those who suffer from borderline personality disorder.

Clinical and cultural perspectives

Anthropologist Rebecca Lester raises two perspectives that BPD can be viewed: a clinical perspective where BPD is a “dysfunction of personality” and an academic perspective that views BPD as a “mechanism of social regulation”. Lester provides the perspective that BPD as a disorder of relationships and communication; that a person with BPD lacks the communication skills and knowledge to interact effectively with others within their society and culture given their life experience. Lester provides the metaphor of the particle-wave duality in quantum physics when dealing with the distinction between cultural and clinical perspectives of BPD. Like the particle-wave-duality, when asking particle-like questions you will get particle-like answers; and if you ask wave-like questions you will get wave-like answers. Lester argues the same applies to BPD; if you ask culturally based questions about the presence of BPD you will get culturally based answers, if you ask clinical personality-based questions it will reinforce personality-based perspectives. Lester advised both perspectives are valid and should work in tandem to provide a greater understanding of BPD culturally and for the individual.

In this light, Lester argues the high diagnosis of women than men with BPD goes towards arguing feminist claims. A higher diagnosis BPD in women would be expected in cultures where females are victimized. In this view BPD is seen as a cultural phenomenon. This is understandable when BPD behaviours are viewed as learnt behaviours as a consequence of their experience surviving environments that reinforce worthlessness and their rejection. To Lester these survival techniques evidence humans “resilience, adaptation, creativity”. Behaviors associated with BPD are therefore an inherently human response.

Brain and neurobiologic factors

Research employing structural neuroimaging techniques, such as voxel-based morphometry, has reported variations in individuals diagnosed with BPD in specific brain regions that have been associated with the psychopathology of BPD. Notably, reductions in volume enclosed have been observed in the hippocampus, orbitofrontal cortex, anterior cingulate cortex, and amygdala, among others, which are crucial for emotional self-regulation and stress management.

In addition to structural imaging, a subset of studies utilizing magnetic resonance spectroscopy has investigated the neurometabolic profile within these affected regions. These investigations have focused on the concentrations of various neurometabolites, including N-acetylaspartate, creatine, compounds related to glutamate, and compounds containing choline. These studies aim to show the biochemical alterations that may underlie the symptomatology observed in BPD, offering insights into BPD's neurobiological basis.