All About Personality Disorders: Borderline Personality Disorder #3

Borderline Personality disorder (BPD) is one of the personality disorders that we know a lot about, relative to the others. It is a cluster B personality disorder characterised by instability of mood, relationships and self-image, as well as impulsivity. People with BPD are said to have very black and white thinking, and often have co-morbid disorders or symptoms such as depression, anxiety or depersonalisation. The DSM-V criteria for this disorder is fairly complex, which reflects the complex nature of the disorder itself, and those who have the disorder. Those with a diagnosis of BPD firstly may have impairments in self-functioning, either through their identity or self-direction, this often means they have problems with who they are, and dissociative symptoms. Secondly, there may be impairments in relationships, either due to deficits in empathy or intimacy, they may intensely fear abandonment, and have pretty chaotic relationships. That is not to mean they cannot have functioning relationships however, they just may be more intense, and need more reassurance. Thirdly, there may be negative affect characterised by unstable emotional experiences, anxiousness, separation anxiety and/or depression, this leads to the depression, anxiety and mood swing symptoms that are seen. Fourthly, there may be deficits in disinhibition characterised by impulsivity or risk-taking, which can lead to rash decisions. These deficits need to be stable across time, not normal for the society or culture the person is in and not due to drugs or another medical condition. Due to the instability of emotions people with this disorder are often misdiagnosed as having Bipolar Disorder. It is important to note that symptoms will vary dramatically between people, and parts of the disorder are not always distressing or negative. It is important to remember that people with the disorder are people, and to listen to their experiences carefully, especial in regards to combating stigma.

As there is relatively a lot of research done on BPD, there is a fair amount known about potential causes. It seems about 65% of BPD is heritability, which means this much of the disorder is due to genetics. Several genetic materials are under investigation in the development of BPD (O’Neil & Thomas, 2012). There are also some striking brain abnormalities in those who have BPD. For example, the hippocampi tends to be smaller, and the amygdala small but overactive(Chapman & Gratz, 2007). As well as this, the prefrontal cortexes are less active (Schmahl et al., 2003) and this was particularly the case when those with BPD were recalling memories with themes of abandonment. Finally, those with BPD have been shown to have an elevated HPA axis (Grossman et al., 1997). The HPA axis is what controls our response to stress, and so this has major implications for coping skills of those with the disorder.

While these brain deficits are striking, it is important to remember it is unknown whether they are a cause or consequence of BPD. Also, biological factors are not the only ones that lead to the development of BPD. For example, BPD is very strongly linked to childhood abuse, particularly sexual abuse (Brown & Anderson, 1991). That is not to say that everyone with BPD was abused however, or that everyone who is abused will develop BPD, it is one of many risk factors that can lead to the development of this disorder. Another factor which can increase the likelihood of BPD developing is an infant’s caregiver ignoring the child’s needs and feelings (Zanarini et al., 2000), but again, this is not to say BPD always develops due to this. This shows clearly a number of environmental factors may increase the likelihood of a person developing BPD.

As with the research on the causes of BPD, there is considerable more research into treating the disorder than other personality disorders. Psychotherapy is generally the primary treatment used (Leichsenring et al., 2011). Generally medication will not treat the core problems, but will be used to treat related symptoms and illnesses such as depression or anxiety (Binks et al., 2006). This means generally antidepressants, anti-anxiety drugs and antipsychotics are the meds prescribed. In general, six types of long-term psychotherapy are used. These are dynamic deconstruction therapy, mentalising-based therapy (MBT), transference-focused therapy, dialect-behaviour therapy (DBT), general psychiatric management and schema-focused therapy (Gabbard, 2014). They are all thought to be effective, other than schema-focused therapy (Gunderson, 2005), and DBT and MBT are thought to be the best (Linehan et al., 2006). However, due to the complexity of humans, what works for one person may not for another, and so this finding may not hold true to everyone with the disorder.

In conclusion, BPD is a complex personality disorder with a number of different types of symptoms to it. It is often misdiagnosed due to this, and due to the fact other disorders are often co-morbid. A lot of the cause of BPD is linked to biological factors such as genetics and brain abnormalities, but environmental and developmental factors also seem to increase risk for the disorder. Finally, treatment is well documented, and long term psychotherapy is favoured over medication.

References

Binks, C., Fenton, M., McCarthy, L., Lee, T., Adams, C. E., & Duggan, C. (2006). Pharmacological interventions for people with borderline personality disorder. The Cochrane library.

Brown GR, Anderson B (1991). “Psychiatric morbidity in adult inpatients with childhood histories of sexual and physical abuse”. Am J Psychiatry 148 (1): 55–61.

Chapman, A. L., & Gratz, K. L. (2007). The borderline personality disorder survival guide: Everything you need to know about living with BPD. New Harbinger Publications.

Gabbard, G. O. (2014). Psychodynamic psychiatry in clinical practice. American Psychiatric Pub.

Grossman R, Yehuda R, Siever L; Yehuda; Siever (1997). “The dexamethasone suppression test and glucocorticoid receptors in borderline personality disorder”. Annals of the New York Academy of Sciences 821: 459–64

Gunderson, J. G., & Hoffman, P. D. (Eds.). (2007). Understanding and treating borderline personality disorder: A guide for professionals and families. American Psychiatric Pub.

Leichsenring F, Leibing E, Kruse J, New AS, Leweke F (2011). “Borderline personality disorder“. Lancet 377 (9759): 74–84.

Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., … & Lindenboim, N. (2006). 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), 757-766.

O’Neill, A., & Frodl, T. (2012). Brain structure and function in borderline personality disorder. Brain Structure and Function, 217(4), 767-782.

Schmahl CG, Elzinga BM, Vermetten E, Sanislow C, McGlashan TH, Bremner JD (2003). “Neural correlates of memories of abandonment in women with and without borderline personality disorder”. Biol. Psychiatry 54 (2): 142–51

Zanarini, M. C., Frankenburg, F. R., Reich, D. B., Marino, M. F., Lewis, R. E., Williams, A. A., & Khera, G. S. (2000). Biparental failure in the childhood experiences of borderline patients. Journal of personality disorders, 14(3), 264-273.