Personality disorder, borderline

A serious mental illness characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior. This instability often disrupts family and work life, long-term planning, and the individual’s sense of self-identity.

Originally thought to be at the “borderline” of psychosis, people with borderline personality disorder (BPD) suffer from a disorder of emotion regulation. While less well known than schizophrenia or bipolar disorder (manic-depressive illness), borderline personality disorder is more common, affecting 2% of adults, mostly young women. There is a high rate of self-injury without suicide intent, as well as a significant rate of suicide attempts and completed suicide in severe cases. Patients often need extensive mental health services and account for about 20% of psychiatric hospitalizations.

While a person with depression or bipolar disorder typically endures the same mood for weeks, a person with borderline personality disorder may experience intense bouts of anger, depression and anxiety that may last only hours, or at most a day. These may be associated with episodes of impulsive aggression, self-injury, and drug or alcohol abuse. Distortions in cognition and sense of self can lead to frequent changes in long-term goals, career plans, jobs, friendships, gender identity, and values. Sometimes people with borderline personality disorder view themselves as fundamentally bad, or unworthy. They may feel unfairly misunderstood or mistreated, bored, empty, and have little idea who they are. Such symptoms are most acute when people with borderline personality disorder feel isolated and lacking in social support, and may result in frantic efforts to avoid being alone.

People with borderline personality disorder often have highly unstable patterns of social relationships. While they can develop intense but stormy attachments, their attitudes towards family, friends, and loved ones may suddenly shift from idealization (great admiration and love) to devaluation (intense anger and dislike). Thus, they may form an immediate attachment and idealize the other person, but when a slight separation or conflict occurs, they switch unexpectedly to the other extreme and angrily accuse the other person of not caring for them at all. Even with family members, individuals with borderline personality disorder are highly sensitive to rejection, reacting with anger and distress to such mild separations as a vacation, a business trip, or a sudden change in plans. These fears of abandonment seem to be related to difficulties feeling emotionally connected to important persons when they are physically absent, leaving the individual with borderline personality disorder feeling lost and perhaps worthlessness. Suicide threats and attempts may occur along with anger at perceived abandonment and disappointments.

People with borderline personality disorder exhibit other impulsive behaviors, such as excessive spending, binge eating and risky sex. Borderline personality disorder often occurs together with other psychiatric problems, particularly bipolar disorder, depression, anxiety disorders, substance abuse, and other personality disorders.

Group and individual psychotherapy are at least partially effective for many patients with borderline personality disorder. A new psychosocial treatment termed dialectical behavior therapy (DBT) was developed by Marsha Linehan specifically to treat borderline personality disorder, and this technique appears promising. Pharmacological treatments are often prescribed based on specific target symptoms shown by the individual patient. Antidepressant drugs and mood stabilizers may be helpful for depressed and/or labile mood. Antipsychotic drugs may also be used when there are distortions in thinking.