Neurological patterns
Research into BPD has identified that the propensity for
experiencing intense negative emotions, a trait known as negative affectivity,
serves as a more potent predictor of BPD symptoms than the history of childhood
sexual abuse alone. This correlation, alongside observed variations in brain
structure and the presence of BPD in individuals without traumatic
histories,[96] delineates BPD from disorders such as PTSD that are frequently
co-morbid. Consequently, investigations into BPD encompass both developmental
and traumatic origins.
Research has shown changes in two brain circuits implicated
in the emotional dysregulation characteristic of BPD: firstly, an escalation in
activity within brain circuits associated with experiencing severe emotional
pain, and secondly, a decreased activation within circuits tasked with the
regulation or suppression of these intense emotions. These dysfunctional
activations predominantly occur within the limbic system, though individual
variances necessitate further neuroimaging research to explore these patterns
in detail.
Contrary to earlier findings, individuals with BPD exhibit
decreased amygdala activation in response to heightened negative emotional
stimuli compared to control groups. John Krystal, the editor of Biological
Psychiatry, commented on these findings, suggesting they contribute to
understanding the innate neurological predisposition of individuals with BPD to
lead emotionally turbulent lives, which are not inherently negative or
unproductive. This emotional volatility is consistently linked to disparities
in several brain regions, emphasizing the neurobiological underpinnings of BPD.
Mediating and
moderating factors
Executive function and
social rejection sensitivity
High sensitivity to social rejection is linked to more
severe symptoms of BPD, with executive function playing a mediating role.
Executive function—encompassing planning, working memory, attentional control,
and problem-solving—moderates how rejection sensitivity influences BPD
symptoms. Studies demonstrate that individuals with lower executive function
exhibit a stronger correlation between rejection sensitivity and BPD symptoms.
Conversely, higher executive function may mitigate the impact of rejection
sensitivity, potentially offering protection against BPD symptoms.
Additionally, deficiencies in working memory are associated with increased
impulsivity in individuals with BPD.
Family environment
The family environment significantly influences the
development of BPD, acting as a mediator for the effects of child sexual abuse.
An unstable family environment increases the risk of developing BPD, while a
stable environment can provide a protective buffer against the disorder. This
dynamic suggests the critical role of familial stability in mitigating or
exacerbating the risk of BPD.
Diagnosis
The clinical diagnosis of BPD can be made through a
psychiatric assessment conducted by a mental health professional, ideally a
psychiatrist or psychologist. This comprehensive assessment integrates various
sources of information to confirm the diagnosis, encompassing the patient's
self-reported clinical history, observations made by the clinician during
interviews, and corroborative details obtained from family members, friends,
and medical records. It is crucial to thoroughly assess patients for co-morbid
mental health conditions, substance use disorders, suicidal ideation, and any
self-harming behaviors.
An effective approach involves presenting the criteria of
the disorder to the individual and inquiring if they perceive these criteria as
reflective of their experiences. Involving individuals in the diagnostic
process may enhance their acceptance of the diagnosis. Despite the stigma
associated with BPD and previous notions of its untreatability, disclosing the
diagnosis to individuals is generally beneficial. It provides them with
validation and directs them to appropriate treatment options.
The psychological evaluation for BPD typically explores the
onset and intensity of symptoms and their impact on the individual's quality of
life. Critical areas of focus include suicidal thoughts, self-harm behaviors,
and any thoughts of harming others. The diagnosis relies on both the
individual's self-reported symptoms and the clinician's observations. To exclude
other potential causes of the symptoms, additional assessments may include a
physical examination and blood tests, to exclude thyroid disorders or substance
use disorders. The International Classification of Diseases (ICD-10)
categorizes the condition as emotionally unstable personality disorder, with
diagnostic criteria similar to those in the Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition (DSM-5), where the disorder's name remains
unchanged from previous editions.
DSM-5 diagnostic
criteria
The Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5) has eliminated the multiaxial diagnostic system,
integrating all disorders, including personality disorders, into Section II of
the manual. For a diagnosis of BPD, an individual must meet five out of nine
specified diagnostic criteria. The DSM-5 characterizes BPD as a pervasive
pattern of instability in interpersonal relationships, self-image, affect, and
a significant propensity towards impulsive behavior. Moreover, the DSM-5
introduces alternative diagnostic criteria for BPD in Section III, titled "Alternative DSM-5 Model for
Personality Disorders". These criteria are rooted in trait research
and necessitate the identification of at least four out of seven maladaptive
traits. Marsha Linehan highlights the diagnostic challenges faced by mental
health professionals in using the DSM criteria due to the broad range of
behaviors they encompass. To mitigate these challenges, Linehan categorizes BPD
symptoms into five principal areas of dysregulation: emotions, behavior,
interpersonal relationships, sense of self, and cognition.
International
Classification of Disease (ICD) diagnostic criteria
ICD-11 diagnostic
criteria
The World Health Organization's ICD-11 completely restructured
its personality disorder section. It classifies BPD as Personality disorder,
(6D10) Borderline pattern, (6D11.5). The borderline pattern specifier is
defined as a personality disturbance marked by instability in interpersonal
relationships, self-image, and emotions, as well as impulsivity.
Diagnosis requires meeting five or more out of nine specific
criteria:
Frantic efforts to
avoid real or imagined abandonment.
A pattern of unstable
and intense interpersonal relationships, which may be characterized by
vacillations between idealization and devaluation, typically associated with
both strong desire for and fear of closeness and intimacy.
Identity disturbance,
manifested in markedly and persistently unstable self-image or sense of self.
A tendency to act
rashly in states of high negative affect, leading to potentially self-damaging
behaviors (e.g., risky sexual behavior, reckless driving, excessive alcohol or
substance use, binge eating).
Recurrent episodes of
self-harm (e.g., suicide attempts or gestures, self-mutilation).
Emotional instability
due to marked reactivity of mood. Fluctuations of mood may be triggered either
internally (e.g., by one's own thoughts) or by external events. As a
consequence, the individual experiences intense dysphoric mood states, which
typically last for a few hours but may last for up to several days.
Chronic feelings of
emptiness.
Inappropriate intense
anger or difficulty controlling anger manifested in frequent displays of temper
(e.g., yelling or screaming, throwing or breaking things, getting into physical
fights).
Transient dissociative
symptoms or psychotic-like features (e.g., brief hallucinations, paranoia) in
situations of high affective arousal.
Other manifestations of Borderline pattern, not all of which
may be present in a given individual at a given time, include the following:
A view of the self as
inadequate, bad, guilty, disgusting, and contemptible.
An experience of the
self as profoundly different and isolated from other people; a painful sense of
alienation and pervasive loneliness.
Proneness to rejection
hypersensitivity; problems in establishing and maintaining consistent and
appropriate levels of trust in interpersonal relationships; frequent
misinterpretation of social signals.
ICD-10 diagnostic criteria
The ICD-10 (version 2019) identified a condition akin to BPD
it termed emotionally unstable personality disorder (EUPD) (F60.3). This
classification described EUPD as a personality disorder with a marked
propensity for impulsive behavior without considering potential consequences.
Individual with EUPD had noticeably erratic and fluctuating moods and are prone
to sudden emotional outbursts, struggling to regulate these rapid shifts in
emotion. Conflict and confrontational behavior are common, especially in
situations where impulsive actions are criticized or hindered.
The ICD-10 recognizes two subtypes of this disorder: the
impulsive type, characterized mainly by emotional dysregulation and
impulsivity, and the borderline type, which additionally includes disturbances
in self-perception, goals, and personal preferences. Those with the borderline
subtype also experience a persistent feeling of emptiness, unstable and chaotic
interpersonal relationships, and a predisposition towards self-harming behaviors,
encompassing both suicidal ideations and suicide attempts.
Millon's subtypes
Psychologist Theodore Millon proposed four subtypes of BPD,
where individuals with BPD would exhibit none, one, or multiple subtypes. The
discouraged subtype is characterized by traits such as avoidance, dependency,
and internalized anger and emotions. Individuals belonging to this subtype tend
to exhibit impulsivity alongside compliance, loyalty, and humility. They often
feel vulnerable and perpetually at risk, experiencing emotions such as
hopelessness, depression, and a sense of helplessness and powerlessness. The
petulant type is characterized by negativism, impatience, restlessness,
stubbornness, defiance, angriness, pessimism, and resentment. Individuals of
this type tend to feel slighted and disillusioned with ease. The impulsive type
is characterized by being captivating, unstable, superficial, erratic,
distractible, frenetic, and seductive. When they fear loss, they become
agitated, gloomy, and irritable, potentially leading to suicidal thoughts or
actions. The self-destructive type is inward-turning, self-punishing, angry,
conforming, and displays deferential and ingratiating behaviors. Their behavior
tends to deteriorate over time, becoming increasingly high-strung and moody,
and they may also be at risk for suicide.
Misdiagnosis
Individuals with BPD are subject to misdiagnosis due to
various factors, notably the overlap (comorbidity) of BPD symptoms with those
of other disorders such as depression, PTSD, and bipolar disorder. Misdiagnosis
of BPD can lead to a range of adverse consequences. Diagnosis plays a crucial
role in informing healthcare professionals about the patient's mental health
status, guiding treatment strategies, and facilitating accurate reporting of
successful interventions. Consequently, misdiagnosis may deprive individuals of
access to suitable psychiatric medications or evidence-based psychological
interventions tailored to their specific disorders.
Critics of the BPD diagnosis contend that it is indistinguishable
from negative affectivity upon undergoing regression and factor analyses. They
maintain that the diagnosis of BPD does not provide additional insight beyond
what is captured by other diagnoses, positing that it may be redundant or
potentially misleading.
Adolescence and
prodrome
The onset of BPD symptoms typically occurs during
adolescence or early adulthood, with possible early signs in childhood.
Predictive symptoms in adolescents include body image issues, extreme
sensitivity to rejection, behavioral challenges, non-suicidal self-injury,
seeking exclusive relationships, and profound shame. Although many adolescents
exhibit these symptoms without developing BPD, those who do are significantly
more likely to develop the disorder and potentially face long-term social
challenges.
BPD is recognized as a stable and valid diagnosis during
adolescence, supported by the DSM-5 and ICD-11. Early detection and treatment
of BPD in young individuals are emphasized in national guidelines across
various countries, including the US, Australia, the UK, Spain, and Switzerland,
highlighting the importance of early intervention.
Historically, diagnosing BPD during adolescence was met with
caution, due to concerns about the accuracy of diagnosing young individuals, the
potential misinterpretation of normal adolescent behaviors, stigma, and the
stability of personality during this developmental stage. Despite these
challenges, research has confirmed the validity and clinical utility of the BPD
diagnosis in adolescents, though misconceptions persist among mental health care
professionals, contributing to clinical reluctance in diagnosing and a key
barrier to the provision of effective treatment BPD in this population.
A diagnosis of BPD in adolescence can indicate the persistence
of the disorder into adulthood, with outcomes varying among individuals. Some
maintain a stable diagnosis over time, while others may not consistently meet
the diagnostic criteria. Early diagnosis facilitates the development of effective
treatment plans, including family therapy, to support adolescents with BPD.
Differential
diagnosis and comorbidity
Lifetime co-occurring (comorbid) conditions are prevalent
among individuals diagnosed with BPD. Individuals with BPD exhibit higher rates
of comorbidity compared to those diagnosed with other personality disorders.
These comorbidities include mood disorders (such as major depressive disorder
and bipolar disorder), anxiety disorders (including panic disorder, social
anxiety disorder, and post-traumatic stress disorder (PTSD)), other personality
disorders (notably schizotypal, antisocial, and dependent personality
disorder), substance use disorder, eating disorders (anorexia nervosa and
bulimia nervosa), attention deficit hyperactivity disorder (ADHD), somatic
symptom disorder, and the dissociative disorders. It is advised that a
personality disorder diagnosis should be made cautiously during untreated mood
episodes or disorders unless a comprehensive lifetime history supports the
existence of a personality disorder.
Comorbid Axis I
disorders
Gender variations in lifetime prevalence of comorbid Axis I
disorders among individuals diagnosed with BPD: A comparative study between
2008 and 1998
A 2008 study stated that 75% of individuals with BPD at some
point meet criteria for mood disorders, notably major depression and bipolar I,
with a similar percentage for anxiety disorders. The same study stated that 73%
of individuals with BPD meet criteria for substance use disorders, and about
40% for PTSD. This challenges the notion that BPD and PTSD are identical, as
less than half of those with BPD exhibit PTSD symptoms in their lifetime. The
study also noted significant gender differences in comorbidity among
individuals with BPD: a higher proportion of males meet criteria for substance
use disorders, whereas females are more likely to have PTSD and eating
disorders. Additionally, 38% of individuals with BPD were found to meet
criteria for ADHD, and 15% for autism spectrum disorder (ASD) in separate
studies, highlighting the risk of misdiagnosis due to "lower expressions" of BPD or a complex pattern of
comorbidity that might obscure the underlying personality disorder. This
complexity in diagnosis underscores the importance of comprehensive assessment
in identifying BPD.
Mood disorders
Seventy-five percent (75%) of individuals with BPD
concurrently experience mood disorders, notably major depressive disorder (MDD)
or bipolar disorder (BD), complicating diagnostic clarity due to overlapping
symptoms. Distinguishing BPD from BD is particularly challenging, as behaviors
part of diagnostic criteria for both BPD and BD may emerge during depressive or
manic episodes in BD. However, these behaviors are likely to subside as mood normalizes
in BD to euthymia, but typically are pervasive in BPD. Thus, diagnosis should
ideally be deferred until after the mood has stabilized.
Differences between BPD and BD mood swings include their
duration, with BD episodes typically lasting for at least two weeks at a time,
in contrast to the rapid and transient mood shifts seen in BPD. Additionally,
BD mood changes are generally unresponsive to environmental stimuli, whereas
BPD moods are. For example, a positive event might alleviate a depressive mood
in BPD, responsiveness not observed in BD. Furthermore, the euphoria in BPD
lacks the racing thoughts and reduced need for sleep characteristic of BD,
though sleep disturbances have been noted in BPD.
An exception would be individuals with rapid-cycling BD, who
can be a challenge to differentiate from the affective lability of individuals
with BPD.
Historically, BPD was considered a milder form of BD, or
part of the bipolar spectrum. However, distinctions in phenomenology, family
history, disease progression, and treatment responses refute a singular
underlying mechanism for both conditions. Research indicates only a modest
association between BPD and BD, challenging the notion of a close spectrum
relationship.
Premenstrual
dysphoric disorder
BPD is a psychiatric condition distinguishable from premenstrual
dysphoric disorder (PMDD), despite some symptom overlap. BPD affects
individuals persistently across all stages of the menstrual cycle, unlike PMDD,
which is confined to the luteal phase and ends with menstruation. While PMDD,
affecting 3–8% of women, includes mood swings, irritability, and anxiety tied
to the menstrual cycle, BPD presents a broader, constant emotional and
behavioral challenge irrespective of hormonal changes.
Comorbid Axis II
disorders
Approximately 74% of individuals with BPD also fulfill
criteria for another Axis II personality disorder during their lifetime,
according to research conducted in 2008. The most prevalent co-occurring
disorders are from Cluster A (paranoid, schizoid, and schizotypal personality
disorders), affecting about half of those with BPD, with schizotypal
personality disorder alone impacting one-third of individuals. Being part of
Cluster B, BPD patients also commonly share characteristics with other Cluster
B disorders (antisocial, histrionic, and narcissistic personality disorders),
with nearly half of individuals with BPD showing signs of these conditions, and
narcissistic personality disorder affecting roughly one-third. Cluster C
disorders (avoidant, dependent, and obsessive-compulsive personality disorders)
have the least comorbidity with BPD, with just under a third of individuals
with BPD meeting the criteria for a Cluster C disorder.
Management
The main approach to managing BPD is through psychotherapy,
tailored to the individual's specific needs rather than applying a
one-size-fits-all model based on the diagnosis alone. While medications do not
directly treat BPD, they are beneficial in managing comorbid conditions like
depression and anxiety. Evidence states short-term hospitalization does not
offer advantages over community care in terms of enhancing outcomes or in the
long-term prevention of suicidal behavior among individuals with BPD.
Psychotherapy
The stages used in dialectical behavior therapy
Long-term, consistent psychotherapy stands as the preferred
method for treating BPD and engagement in any therapeutic approach tends to
surpass the absence of treatment, particularly in diminishing self-harm
impulses. Among the effective psychotherapeutic approaches, dialectical
behavior therapy (DBT) and psychodynamic therapies have shown efficacy,
although improvements may require extensive time, often years of dedicated effort.
Available treatments for BPD include dynamic deconstructive
psychotherapy (DDP), mentalization-based treatment (MBT), transference-focused
psychotherapy, dialectical behavior therapy (DBT), general psychiatric
management, and schema-focused therapy. The effectiveness of these therapies
does not significantly vary between more intensive and less intensive
approaches.
Transference-focused psychotherapy is designed to mitigate
absolutist thinking by encouraging individuals to express their interpretations
of social interactions and their emotions, thereby fostering more nuanced and
flexible categorizations. Dialectical behavior therapy (DBT), on the other
hand, focuses on developing skills in four main areas: interpersonal
communication, distress tolerance, emotional regulation, and mindfulness,
aiming to equip individuals with BPD with tools to manage intense emotions and
improve interpersonal relationships.
Cognitive behavioral therapy (CBT) targets the modification
of behaviors and beliefs through problem identification related to BPD, showing
efficacy in reducing anxiety, mood symptoms, suicidal ideation, and
self-harming actions
Mentalization-based therapy and transference-focused
psychotherapy draw from psychodynamic principles, while DBT is rooted in
cognitive-behavioral principles and mindfulness. General psychiatric management
integrates key aspects from these treatments and is seen as more accessible and
less resource-intensive. Studies suggest DBT and MBT may be particularly
effective, with ongoing research into developing abbreviated forms of these
therapies to enhance accessibility and reduce both financial and resource
burdens on patients and providers.
Schema-focused therapy considers early maladaptive schemas,
conceptualized as organized patterns that recur throughout life in response to
memories, emotions, bodily sensations, and cognitions associated with unmet
childhood needs. When activated by events in the patient's life, they manifest
as schema modes associated with responses such as feelings of abandonment,
anger, impulsivity, self-punitiveness, or avoidance and emptiness. Schema
therapy attempts to modify early maladaptive schemas and their modes with a
variety of cognitive, experiential, and behavioral techniques such as cognitive
restructuring, mental imagery, and behavioral experiments. It also seeks to
remove some of the stigma associated with BPD by explaining to clients that
most people have maladaptive schemas and modes, but that in BPD, the schemas
tend to be more extreme, while the modes shift more frequently. In schema
therapy, the therapeutic alliance is based on the concept of limited
reparenting: it does not only facilitate treatment, but is an integral part of
it as the therapist seeks to model a healthy relationship that counteracts some
of the instability, rejection, and deprivation often experienced early in life
by BPD patients while helping them develop similarly healthy relationships in
their broader personal lives.
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