Borderline personality disorder (BPD) is a serious mental illness characterized by instability in functioning, affect, mood, interpersonal relationships, and reality testing. It affects the thinking and feeling about oneself and others, and thus causes problems while functioning in everyday life.
The incidence of the disorder tends to decrease after age 40 years, partly because personality disorders often decrease with age and partly because some who have the disorder commit suicide. The female-to-male ratios are as high as 4:1.
The studies suggest that 2% of the general population have BPD. The condition is diagnosed in up to 15% of psychiatric patients and 50% of inpatients with a diagnosis of personality disorder.
Risk Factors and Causes of Borderline Personality DisorderThe exact cause of borderline personality disorder is not yet known. Some of the proposed risk factors are:
- Environmental factors: such as a history of child abuse or neglect.
- Genetic factors: Some studies of twins and families suggest that personality disorders may be inherited in the family tree.
- Brain abnormalities: Some research has shown damage in certain areas of the brain can cause changes in emotion regulation, impulsivity, and aggression. Also, certain brain chemicals that help regulate mood, such as serotonin, may not function properly in patients with a personality disorder.
Signs and Symptoms of Borderline Personality DisorderSome of the common signs and symptoms are seen in patients with borderline personality disorder are:
- Patients have an intense fear of abandonment or separation from their loved ones. So, they even go to extreme measures to avoid real or imagined separation or rejection.
- Their history shows a pattern of unstable intense relationships, such as idealizing someone one moment and then suddenly believing the person is cruel.
- They show rapid changes in self-identity and self-image. There is a shifting of goals and values. They see themselves as bad or as if they don't exist at all.
- There are periods of stress-related paranoia and loss of contact with reality, for a few minutes to a few hours.
- These people have impulsive and risky behavior. They are involved in gambling, reckless driving, unsafe sex, binge eating or drug abuse, or sabotaging success by suddenly quitting a good job or ending a positive relationship.
- They often give suicidal threats or try to hurt themselves, in response to the fear of separation or rejection.
- Their mood swings last from a few hours to a few days, which can include intense happiness, irritability, shame, or anxiety.
- They suffer from feelings of emptiness and loneliness.
- They are often rude to people. There are anger outbursts as they frequently lose their temper or become sarcastic or bitter, or can even have many physical fights.
Complications of Borderline Personality DisorderOur personality is the image that we reflect about ourselves to others. Any personality change greatly affects our interpersonal relationships and this complicates every aspect of our lives.
People with such issues cannot manage their work-life properly and thus there are repeated job changes or losses. They cannot complete their education. They may suffer from legal issues due to conflicts in their daily life, marital stress, or divorce.
They are also prone to self-injury, such as cutting or burning, and frequent hospitalizations. They often seem to be involved in abusive relationships. There are mishaps of unplanned pregnancies, sexually transmitted infections, motor vehicle accidents, and physical fights. Many of these patients have attempted or completed suicide.
Moreover, they may have coexisting mental health disorders, such as depression, alcohol or other substance abuse, anxiety disorders, eating disorders, bipolar disorder, post-traumatic stress disorder (PTSD), attention-deficit/hyperactivity disorder (ADHD), and other personality disorders.
Diagnosing Borderline Personality DisorderBorderline personality disorders are diagnosed based on a detailed interview with a doctor or mental health provider that involves discussion of the symptoms and signs, psychological evaluation, along with medical history and examination.
Treatment for Borderline Personality DisorderFor personality disorders, the backbone of treatment is psychotherapy. Drug therapy aids to manage serious signs and symptoms and other comorbid psychiatric illnesses.
Psychotherapy is simply a talk therapy where the doctor helps the patient to cope up with the stress of the mental disease using different techniques. In the case of personality disorder we can use the following techniques:
- Dialectical behavior therapy (DBT): It is a modification of standard cognitive-behavioral techniques. It is currently the only data-supported treatment for BPD. DBT helps to manage emotions, tolerate distress and improve relationships.
- Schema-focused therapy: It can be done individually or in a group. Therapy focuses on helping to get unmet needs healthily to promote positive life patterns.
- Mentalization-based therapy (MBT): It helps to identify the thoughts and feelings at any given moment and create an alternate perspective on the situation. It helps the patient to think before reacting.
- Systems training for emotional predictability and problem-solving (STEPPS): It is a 20-week treatment. It involves working in groups with the family members, caregivers, friends, or significant others for treatment.
- Transference-focused psychotherapy (TFP): It is also called psychodynamic psychotherapy. It helps the patient to understand their emotions and interpersonal difficulties.
- Good psychiatric management: It focuses on understanding the emotionally difficult moments by considering the interpersonal context for feelings in the community for these people. This therapy integrates medications, groups, family education, and individual therapy to anchor treatment in a workplace or school.
For children and adolescents with BPD traits, family-oriented interventions appear to provide superior benefits. Most children and adolescents with traits of BPD appear to benefit from structured day programs with strong behavioral management components. Hospitalization may be necessary because of suicidal or other self-injurious behavior.
- Selective serotonin reuptake inhibitors (SSRIs): These are considered the first line of drug therapy. They help to reduce impulsivity and aggression. They have fewer side effects on overdose.
- Low-dose neuroleptics (eg, risperidone): They are effective in the short term for control of psychotic symptoms and can decrease general agitation.
- Opiate receptor antagonist naltrexone: They may reduce the duration and intensity of certain symptoms in BPD.
- Tricyclic antidepressants, lithium, and other mood stabilizers: They must be prescribed with great caution and as overuse of such drugs can be dangerous.
- Benzodiazepines: They are helpful with anxiety but create risks of increased impulsivity and dependency.
Ongoing Research and Clinical Trials for Borderline Personality DisorderThere have been studies showing the role of neuropeptide systems, such as opioids and vasopressin, and epigenetic modifications following early-life stressors. However, the evidence-based pharmacological treatment guidelines for BPD are still in their infancy. Some of the promising treatments include:
- Personality-Based Cognitive Behavioral Therapy (CBT): It requires many dedicated sessions of CBT. The first session will involve psychoeducation regarding BPD. The next two sessions will include exercises drawn from behavioral activation and motivational interviewing. Then, patients will receive 5 sessions of cognitive interventions to modify the way of thinking and 5 sessions of mindfulness skills. Finally, treatment will conclude with 2 sessions of relapse prevention strategies. All sessions will last for 60 minutes in duration.
- Brexpiprazole: It is an atypical antipsychotic. The efficacy and safety of brexpiprazole for the treatment of BPD are being studied.
- Oxytocin: Oxytocin is often known as a bonding hormone. In clinical trials, we study whether administration of intranasal oxytocin will improve trust and concomitant neural processing in the BPD group.
- Probiotics as oral Synbiotic 2000 Forte (SF): They are also used for clinical trials for the treatment of BPD. Participants will take the probiotic once daily in the form of a powder. It can be spread on top of cold foods such as muesli, salad, or yogurt. Placebo will be a non-digestible carbohydrate with a similar texture and flavor to the SF. Then the primary- and secondary outcomes will be collected and then monitored every five weeks and for 5 visits.
- NMDA antagonist: The trial conducted for NMDA receptor antagonists for the treatment of BPD has also been approved for Alzheimer's disease. NMDA is a receptor for glutamate, a signal-carrying molecule in the brain, that is thought to be involved in causing BPD.
- Ketamine: There are clinical trials going on regarding the impact of ketamine on suicidal thoughts in patients with BPD. It also tests the impact of ketamine on symptom intensity and cognition in people with BPD.
Widiger T.A., Weissman M.M. (1991) Epidemiology in borderline personality disorder. Hosp Community Psychiatry 42: 1015–1021
Moriya, N., Miyake, Y., Minakawa, K., Ikuta, N., & Nishizono-Maher, A. (1993). Diagnosis and clinical features of borderline personality disorder in the east and west: a preliminary report. Comprehensive Psychiatry, 34(6), 418–423. https://doi.org/10.1016/0010-440x(93)90069-g
Alafia, J., & Manjula, M. (2020). Emotion Dysregulation and Early Trauma in Borderline Personality Disorder: An Exploratory Study. Indian journal of psychological medicine, 42(3), 290–298. https://doi.org/10.4103/IJPSYM.IJPSYM_512_18
Harned MS, Korslund KE, Linehan MM: A pilot randomized controlled trial of Dialectical Behavior Therapy with and without the Dialectical Behavior Therapy Prolonged Exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behav Res Ther. 2014;55:7–17. 10.1016/j.brat.2014.01.008
Temes, C. M., & Zanarini, M. C. (2019). Recent developments in psychosocial interventions for borderline personality disorder. F1000Research, 8, F1000 Faculty Rev-561. https://doi.org/10.12688/f1000research.18561.1
Olabi, B., & Hall, J. (2010). Borderline personality disorder: current drug treatments and prospects. Therapeutic advances in chronic disease, 1(2), 59–66. https://doi.org/10.1177/2040622310368455