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What is Borderline
Personality Disorder?
Borderline personality disorder (BPD) is a
serious mental illness marked by unstable moods, behavior, and relationships.
In 1980, theDiagnostic and Statistical Manual for Mental Disorders, Third
Edition(DSM-III) listed BPD as a diagnosable illness for the first time.
Most psychiatrists and other mental health professionals use the DSM to
diagnose mental illnesses.
Because some people with severe BPD have brief
psychotic episodes, experts originally thought of this illness as atypical, or
borderline, versions of other mental disorders. While mental health experts now
generally agree that the name "borderline personality disorder" is
misleading, a more accurate term does not exist yet.
Most people who have BPD suffer from:
· Problems with regulating emotions and thoughts
· Impulsive and reckless behavior
· Unstable relationships with other people.
People with this disorder also have high rates
of co-occurring disorders, such as depression, anxiety disorders, substance
abuse, and eating disorders, along with self-harm, suicidal behaviors, and
completed suicides.
Causes
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Research
on the possible causes and risk factors for BPD is still at a very early stage.
However, scientists generally agree that genetic and environmental factors are
likely to be involved.
Studies
on twins with BPD suggest that the illness is strongly inherited. Another study
shows that a person can inherit his or her temperament and specific personality
traits, particularly impulsiveness and aggression. Scientists are studying
genes that help regulate emotions and impulse control for possible links to the
disorder.
Social
or cultural factors may increase the risk for BPD. For example, being part of a
community or culture in which unstable family relationships are common may
increase a person's risk for the disorder. Impulsiveness, poor judgment in
lifestyle choices, and other consequences of BPD may lead individuals to risky
situations. Adults with borderline personality disorder are considerably more
likely to be the victim of violence, including rape and other crimes.
Signs & Symptoms
According to the DSM, Fourth Edition, Text
Revision (DSM-IV-TR), to be diagnosed with borderline personality disorder, a
person must show an enduring pattern of behavior that includes at least five of
the following symptoms:
· Extreme reactions—including panic, depression,
rage, or frantic actions—to abandonment, whether real or perceived
· A pattern of intense and stormy relationships
with family, friends, and loved ones, often veering from extreme closeness and
love (idealization) to extreme dislike or anger (devaluation)
· Distorted and unstable self-image or sense of
self, which can result in sudden changes in feelings, opinions, values, or
plans and goals for the future (such as school or career choices)
· Impulsive and often dangerous behaviors, such as
spending sprees, unsafe sex, substance abuse, reckless driving, and binge
eating
· Recurring suicidal behaviors or threats or
self-harming behavior, such as cutting
· Intense and highly changeable moods, with each
episode lasting from a few hours to a few days
· Chronic feelings of emptiness and/or boredom
· Inappropriate, intense anger or problems
controlling anger
· Having stress-related paranoid thoughts or
severe dissociative symptoms, such as feeling cut off from oneself, observing
oneself from outside the body, or losing touch with reality.
Seemingly mundane events may trigger symptoms.
For example, people with BPD may feel
angry and distressed over minor
separations—such as vacations, business trips, or sudden changes of plans—from
people to whom they feel close. Studies show that people with this disorder may
see anger in an emotionally neutral face and have a stronger reaction to words
with negative meanings than people who do not have the disorder.
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Suicide and Self-harm
Self-injurious behavior includes suicide and
suicide attempts, as well as self-harming behaviors, described below. As many
as 80 percent of people with BPD have suicidal behaviors, and about 4 to 9 percent
commit suicide.
Suicide is one of the most tragic outcomes of
any mental illness. Some treatments can help reduce suicidal behaviors in
people with BPD. For example, one study showed that dialectical behavior
therapy (DBT) reduced suicide attempts in women by half compared with other
types of psychotherapy, or talk therapy. DBT also reduced use of emergency room
and inpatient services and retained more participants in therapy, compared to
other approaches to treatment.
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Unlike suicide attempts, self-harming behaviors
do not stem from a desire to die. However, some self-harming behaviors may be
life threatening. Self-harming behaviors linked with BPD include cutting,
burning, hitting, head banging, hair pulling, and other harmful acts. People
with BPD may self-harm to help regulate their emotions, to punish themselves,
or to express their pain. They do not always see these behaviors as harmful.
Who Is At Risk?
According
to data from a subsample of participants in a national survey on mental
disorders, about 1.6 percent of adults in the United States have BPD in a given
year. BPD usually begins during adolescence or early adulthood. Some
studies suggest that early symptoms of the illness may occur during childhood.
Diagnosis
Unfortunately,
BPD is often underdiagnosed or misdiagnosed.
A
mental health professional experienced in diagnosing and treating mental
disorders—such as a psychiatrist, psychologist, clinical social worker, or
psychiatric nurse—can detect BPD based on a thorough interview and a discussion
about symptoms. A careful and thorough medical exam can help rule out other
possible causes of symptoms.
The
mental health professional may ask about symptoms and personal and family
medical histories, including any history of mental illnesses. This information
can help the mental health professional decide on the best treatment. In some
cases, co-occurring mental illnesses may have symptoms that overlap with BPD,
making it difficult to distinguish borderline personality disorder from other
mental illnesses. For example, a person may describe feelings of depression but
may not bring other symptoms to the mental health professional's attention.
Women
with BPD are more likely to have co-occurring disorders such as major
depression, anxiety disorders, or eating disorders. In men, BPD is more likely
to co-occur with disorders such as substance abuse or antisocial personality
disorder. According to the NIMH-funded National Comorbidity Survey
Replication—the largest national study to date of mental disorders in U.S.
adults—about 85 percent of people with BPD also meet the diagnostic criteria
for another mental illness. Other illnesses that often occur with BPD include
diabetes, high blood pressure, chronic back pain, arthritis, and fibromyalgia.
These conditions are associated with obesity, which is a common side effect of
the medications prescribed to treat BPD and other mental disorders.
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No
single test can diagnose BPD. Scientists funded by NIMH are looking for ways to
improve diagnosis of this disorder. One study found that adults with BPD showed
excessive emotional reactions when looking at words with unpleasant meanings,
compared with healthy people. People with more severe BPD showed a more intense
emotional response than people who had less severe BPD.
Treatments
BPD is often viewed as difficult to treat.
However, recent research shows that BPD can be treated effectively, and that
many people with this illness improve over time.
BPD can be treated with psychotherapy, or
"talk" therapy. In some cases, a mental health professional may also
recommend medications to treat specific symptoms. When a person is under more
than one professional's care, it is essential for the professionals to
coordinate with one another on the treatment plan.
The treatments described below are just some of
the options that may be available to a person with BPD. However, the research
on treatments is still in very early stages. More studies are needed to
determine the effectiveness of these treatments, who may benefit the most, and how
best to deliver treatments.
Psychotherapy
Psychotherapy is usually the first treatment for
people with BPD. Current research suggests psychotherapy can relieve some
symptoms, but further studies are needed to better understand how well
psychotherapy works.
It is important that people in therapy get along
with and trust their therapist. The very nature of BPD can make it difficult
for people with this disorder to maintain this type of bond with their
therapist.
Types of psychotherapy used to treat BPD include
the following:Cognitive behavioral therapy (CBT). CBT can help
people with BPD identify and change core beliefs and/or behaviors that underlie
inaccurate perceptions of themselves and others and problems interacting with
others. CBT may help reduce a range of mood and anxiety symptoms and reduce the
number of suicidal or self-harming behaviors.
1.
Dialectical
behavior therapy (DBT). This
type of therapy focuses on the concept of mindfulness, or being aware of and
attentive to the current situation. DBT teaches skills to control intense
emotions, reduces self-destructive behaviors, and improves relationships. This
therapy differs from CBT in that it seeks a balance between changing and
accepting beliefs and behaviors.
2.
Schema-focused
therapy. This type of therapy
combines elements of CBT with other forms of psychotherapy that focus on
reframing schemas, or the ways people view themselves. This approach is based
on the idea that BPD stems from a dysfunctional self-image—possibly brought on
by negative childhood experiences—that affects how people react to their
environment, interact with others, and cope with problems or stress.
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Therapy can be provided one-on-one between the
therapist and the patient or in a group setting. Therapist-led group sessions
may help teach people with BPD how to interact with others and how to express
themselves effectively.
One type of group therapy, Systems Training for
Emotional Predictability and Problem Solving (STEPPS), is designed as a
relatively brief treatment consisting of 20 two-hour sessions led by an
experienced social worker. Scientists funded by NIMH reported that STEPPS, when
used with other types of treatment (medications or individual psychotherapy),
can help reduce symptoms and problem behaviors of BPD, relieve symptoms of
depression, and improve quality of life. The effectiveness of this type of
therapy has not been extensively studied.
Families of people with BPD may also benefit
from therapy. The challenges of dealing with an ill relative on a daily basis
can be very stressful, and family members may unknowingly act in ways that
worsen their relative's symptoms.
Some therapies, such as DBT-family skills
training (DBT-FST), include family members in treatment sessions. These types
of programs help families develop skills to better understand and support a
relative with BPD. Other therapies, such as Family Connections, focus on the
needs of family members. More research is needed to determine the effectiveness
of family therapy in BPD. Studies with other mental disorders suggest that
including family members can help in a person's treatment.
Other types of therapy not listed in this
booklet may be helpful for some people with BPD. Therapists often adapt
psychotherapy to better meet a person's needs. Therapists may switch from one
type of therapy to another, mix techniques from different therapies, or use a
combination therapy. For more information see the NIMH website section on psychotherapy.
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Some symptoms of BPD may come and go, but the
core symptoms of highly changeable moods, intense anger, and impulsiveness tend
to be more persistent. People whose symptoms improve may continue to face
issues related to co-occurring disorders, such as depression or post-traumatic
stress disorder. However, encouraging research suggests that relapse, or the
recurrence of full-blown symptoms after remission, is rare. In one study, 6
percent of people with BPD had a relapse after remission.
Medications
No medications have been approved by the U.S.
Food and Drug Administration to treat BPD. Only a few studies show that
medications are necessary or effective for people with this illness. However,
many people with BPD are treated with medications in addition to psychotherapy.
While medications do not cure BPD, some medications may be helpful in managing
specific symptoms. For some people, medications can help reduce symptoms such
as anxiety, depression, or aggression. Often, people are treated with several
medications at the same time, but there is little evidence that this practice
is necessary or effective.
Medications can cause different side effects in
different people. People who have BPD should talk with their prescribing doctor
about what to expect from a particular medication.
Other Treatments
Omega-3 fatty acids. One study done on 30 women
with BPD showed that omega-3 fatty acids may help reduce symptoms of aggression
and depression. The treatment seemed to be as well tolerated as commonly
prescribed mood stabilizers and had few side effects. Fewer women who took
omega-3 fatty acids dropped out of the study, compared to women who took a
placebo (sugar pill).
With proper treatment, many people experience
fewer or less severe symptoms. However, many factors affect the amount of time
it takes for symptoms to improve, so it is important for people with BPD to be
patient and to receive appropriate support during treatment.
Living With
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Some people with BPD experience severe symptoms
and require intensive, often inpatient, care. Others may use some outpatient
treatments but never need hospitalization or emergency care. Some people who
develop this disorder may improve without any treatment.
How can I help a friend or relative who has BPD?
If you know someone who has BPD, it affects you
too. The first and most important thing you can do is help your friend or
relative get the right diagnosis and treatment. You may need to make an
appointment and go with your friend or relative to see the doctor. Encourage
him or her to stay in treatment or to seek different treatment if symptoms do
not appear to improve with the current treatment.
To help a friend or relative you can:
Offer emotional support, understanding,
patience, and encouragement—change can be difficult and frightening to people
with BPD, but it is possible for them to get better over time
·
Learn about mental
disorders, including BPD, so you can understand what your friend or relative is
experiencing
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With permission from
your friend or relative, talk with his or her therapist to learn about
therapies that may involve family members, such as DBT-FST.
Never ignore comments about someone's intent or
plan to harm himself or herself or someone else. Report such comments to the
person's therapist or doctor. In urgent or potentially life-threatening
situations, you may need to call the police.
How can I help myself if I have BPD?
Taking that first step to help yourself may be
hard. It is important to realize that, although it may take some time, you can
get better with treatment.
To help yourself:
· Talk to your doctor about treatment options and
stick with treatment
· Try to maintain a stable schedule of meals and
sleep times
· Engage in mild activity or exercise to help
reduce stress
· Set realistic goals for yourself
· Break up large tasks into small ones, set some
priorities, and do what you can, as you can
· Try to spend time with other people and confide
in a trusted friend or family member
· Tell others about events or situations that may
trigger symptoms
· Expect your symptoms to improve gradually, not
immediately
· Identify and seek out comforting situations,
places, and people
· Continue to educate yourself about this
disorder.
Clinical Trials
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NIMH
supports research studies on mental health and disorders. See also: A Participant's
Guide to Mental Health Clinical Research.
Participate,
refer a patient or learn about results of studies in ClinicalTrials.gov ,
the NIH/National Library of Medicine's registry of federally and privately
funded clinical trials for all disease.
Find
NIH-funded studies currently recruiting participants with BPD.
The above information is from
the National Institute of Mental Health (NIMH).
Learn more on the NIMH website at: http://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml
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Personality Disorder!
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