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Borderline personality disorder
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In psychiatry, borderline personality disorder (BPD) is a personality disorder characterised by extreme "black and white" thinking, mood swings, emotional reasoning, disrupted relationships and difficulty in functioning in a way society accepts as normal.
The name comes from the DSM-IV-TR; the ICD-10 has an equivalent called Emotionally Unstable Personality Disorder, borderline type. Psychiatrists describe borderline personality disorder as a serious disorder characterized by pervasive instability in mood, 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" between psychosis and neurosis, people with BPD actually suffer from what has come to be called emotional dysregulation. While less well-known than schizophrenia or bipolar disorder (manic-depression), BPD is more common, affecting two percent of adults, mostly young women. There is a high rate of self-injury without suicidal intent, as well as a significant rate of suicide attempts and completed suicide in severe cases. In some instances people with BPD kill themselves by accident in a case of self-injury that goes too far. Patients often need extensive mental health services, and they account for 20 percent of psychiatric hospitalizations. With help, however, many improve over time and are eventually able to lead productive lives.
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Diagnostic criteria
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DSM-IV-TR
The DSM-IV-TR, a widely used manual for diagnosing mental disorders, defines borderline personality disorder (see DSM cautionary statement) as 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. (not including suicidal or self-mutilating behavior covered in Criterion 5)
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
impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating; [not including] suicidal or self-mutilating behavior covered in Criterion 5)
recurrent suicidal behavior, gestures, or 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)
chronic feelings of emptiness
inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
transient, stress-related paranoid ideation or severe dissociative symptoms
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ICD-10
In the ICD-10 system, the equivalent disorder is Emotionally Unstable Personality Disorder (F60.3). The ICD-10 system has a slightly different categorization for personality disorders, as it does not use the DSM's 5-axis diagnosis system. Emotionally Unstable Personality Disorder has the following diagnostic criteria, which differs slightly from the DSM criteria above:
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F60.30 Impulsive type
The general criteria for personality disorder (F60) must be met. [see below]
At least three of the following must be present, one of which must be (2):
marked tendency to act unexpectedly and without consideration of the consequences;
marked tendency to quarrelsome behaviour and to conflicts with others, especially when impulsive acts are thwarted or criticized;
liability to outbursts of anger or violence, with inability to control the resulting behavioural explosions;
difficulty in maintaining any course of action that offers no immediate reward;
unstable and capricious mood.
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F60.31 Borderline type
The general criteria for personality disorder (F60) must be met. [see below]
At least three of the symptoms mentioned in criterion 2 for F60.30 must be present [see above], with at least two of the following in addition:
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 crises;
excessive efforts to avoid abandonment;
recurrent threats or acts of self-harm;
chronic feelings of emptiness.
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F60 Disorders of adult personality and behavior
There is evidence that the individual's characteristic and enduring patterns of inner experience and behavior as a whole deviate markedly from the culturally expected and accepted range (or "norm"). Such deviation must be manifest in more than one of the following areas:
cognition (i.e. ways of perceiving and interpreting things, people, and events; forming attitudes and images of self and others);
affectivity (range, intensity, and appropriateness of emotional arousal and response);
control over impulses and gratification of needs;
manner of relating to others and of handling interpersonal situations.
The deviation must manifest itself pervasively as behaviour that is inflexible, maladaptive, or otherwise dysfunctional across a broad range of personal and social situations (i.e. not being limited to one specific "triggering" stimulus or situation).
There is personal distress, or adverse impact on the social environment, or both, clearly attributable to the behavior referred to in criterion 2.
There must be evidence that the deviation is stable and of long duration, having its onset in late childhood or adolescence.
The deviation cannot be explained as a manifestation or consequence of other adult mental disorders, although episodic or chronic conditions from sections F00-F59 or F70-F79 of this classification may coexist with, or be superimposed upon, the deviation.
Organic brain disease, injury, or dysfunction must be excluded as the possible cause of the deviation. (If an organic causation is demonstrable, category F07.- should be used.)
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Symptoms
While a patient with depression or bipolar disorder typically endures the same mood for weeks, a person with BPD 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 including cutting, 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, and values. Sometimes people with BPD 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 BPD feel isolated and lacking in social support, and may result in frantic efforts to avoid being alone.
People with BPD 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 BPD 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 BPD feeling lost and perhaps worthless. Suicide threats and attempts may occur along with anger at perceived abandonment and disappointments.
People with BPD exhibit other impulsive behaviors, such as manipulativeness, excessive spending, binge eating and risky sex. BPD often occurs together with other psychiatric problems, particularly bipolar disorder, depression, anxiety disorders, substance abuse, and other personality disorders.
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Treatment
Treatments for BPD have improved in recent years. People with BPD, who are often distressed by at least some of their symptoms, typically undertake a series of empirical trials of drugs to see whether anything helps them, and may end up taking no drugs at all. Since about 1989, Prozac and other selective serotonin reuptake inhibitor antidepressants (SSRIs) have repeatedly been shown to improve the symptoms of BPD in some patients.
The book, Listening to Prozac describes some of these remarkable changes. In general, it takes a higher dose of an SSRI to treat BPD than depression. It also takes about three months to start seeing benefit, compared to two weeks for depression. The previous antidepressants, the tricyclics, were often unhelpful, and sometimes even worsened the symptoms. Increasing evidence implicates inadequate serotonergic neurotransmission as strongly related to impaired modulation of emotional and behavioral responses to everyday life, manifesting as "overreacting to everything." Even thinking is recruited by the intense (or underregulated) emotionality so that the world is perceived primitively in intense black-and-white terms.
Bassenco and Borderline Personality Disorder: it explains so much.
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