2er UNIT 3 - BORDERLINE PERSONALITY DISORDER

INTRODUCTION
Originally used to refer to patients who were thought to have a condition that was on the “border” between
neurosis and psychosis, Borderline Personality Disorder (termed as emotionally unstable disorder in ICD-
10) is characterised by great suffering on the part of the patients themselves. People with this personality
disorder are often intense, going from anger to deep depression in a short time. Dysfunction in the area of
emotion is sometimes considered one of the core features of borderline personality disorder (Linehan &
Dexter-Mazza, 2008) and is one of the best predictors of suicide in this group (McGirr et al., 2009). The
characteristic of instability (in emotion, interpersonal relationships, self-concept, and behavior) is seen as
a core feature with some describing this group as being “stably unstable” (Hooley et al., 2012).

------------------- CLINICAL PICTURE -------------------

DIAGNOSTIC CRITERIA (APA, 2013)

Proposed Criteria (Alternate Diagnosis): DSM 5 also lists an alternative model for the diagnosis of
personality disorders including a proposed criteria for BPD.

Associated features supporting diagnosis

- Individuals with borderline personality disorder may have a pattern of undermining themselves at
the moment a goal is about to be realized and their achievements are rarely at the level of their
abilities.
- The perception of impending separation or rejection, or the loss of external structure, can lead to
profound changes in self-image, affect, cognition, and behavior.
- These individuals are very sensitive to environmental circumstances. They experience intense
abandonment fears and inappropriate anger even when faced with a realistic time-limited
 separation or when there are unavoidable changes in plans. They may believe that this
“abandonment” implies they are “bad.”
- Because they feel both dependent and hostile, persons with this disorder have tumultuous
interpersonal relationships. They can be dependent on those with whom they are close and, when
frustrated, can express enormous anger toward their intimate friends.
- They may idealize potential caregivers or lovers at the first or second meeting, demand to spend a
lot of time together, and share the most intimate details early in a relationship. However, they may
switch quickly from idealizing other people to devaluing them, feeling that the other person does
not care enough, does not give enough, or is not “there” enough. These individuals can empathize
with and nurture other people, but only with the expectation that the other person will “be there” in
return to meet their own needs on demand. These individuals are prone to sudden and dramatic
shifts in their view of others, who may alternatively be seen as beneficent supporters or as cruelly
punitive. Such shifts often reflect disillusionment with a caregiver whose nurturing qualities had
been idealized or whose rejection or abandonment is expected.
- Projective identification is a defense mechanism that often occurs in patients with borderline
personality disorder. In this primitive defense mechanism, the patient projects intolerable aspects
of themselves onto another person, inducing them to play the projected role, and the two persons
act in unison (Sadock et al., 2017).
- Individuals with this disorder may feel more secure with transitional objects (i.e., a pet or inanimate
possession) than in interpersonal relationships.

AGE OF ONSET
BPD can be diagnosed as early as at 12 years if old symptoms persist for at least one year. Typically
individuals begin their first treatment around the age of 18, although symptoms are likely to start earlier. In
a study by Zanarini et al. (2001), it was found 30% of patients with BPD began self-harming when they were
12 years of age or less, with another 30% initiating self-harm between the ages of 13 and 17.

------------------- EPIDEMIOLOGY -------------------

PREVALENCE
Borderline personality disorder is one of the most common personality disorders observed in clinical
settings; it is observed in every culture and the median population prevalence of borderline personality
disorder is estimated to be 1.6% but may be as high as 5.9%. The prevalence of borderline personality
disorder is about 6% in primary care settings, about 10% among individuals seen in outpatient mental
health clinics, and about 20% among psychiatric inpatients. The prevalence of borderline personality
disorder may decrease in older age groups. Although early research found that approximately 75 percent
of individuals receiving this diagnosis in clinical settings are women, such findings likely arise from a
gender imbalance in treatment seeking rather than prevalence of the disorder. Consistent with this, more
recent epidemiological studies of community residents suggest an equal gender ratio (Coid et al., 2009;
Grant et al., 2008).

DEVELOPMENT AND COURSE

There is considerable variability in the course of borderline personality disorder. The most common
pattern is one of chronic instability in early adulthood, with episodes of serious affective and impulsive
dyscontrol and high levels of use of health and mental health resources. The impairment from the disorder
and the risk of suicide are greatest in the young-adult years and gradually wane with advancing age.
Although the tendency toward intense emotions, impulsivity, and intensity in relationships is often lifelong,
individuals who engage in therapeutic intervention often show improvement beginning sometime during
the first year. During their 30s and 40s, the majority of individuals with this disorder attain greater stability
in their relationships and vocational functioning. Impairment typically involves frequent job losses,
interrupted education, and broken marriages. Complications may include psychotic-like symptoms
(hallucinations, body image distortions, hypnagogic phenomena, ideas of reference) in response to stress,
as well as premature death or physical handicaps. Follow-up studies of individuals identified through
outpatient mental health clinics indicate that after about 10 years, as many as half of the individuals no
longer have a pattern of behavior that meets full criteria for borderline personality disorder.

RISK AND PROGNOSIS FACTORS

Borderline personality disorder is about five times more common among first-degree biological relatives of
those with the disorder than in the general population. There is also an increased familial risk for
substance use disorders, antisocial personality disorder, and depressive or bipolar disorders. Physical
and sexual abuse, neglect, hostile conflict, and early parental loss are more common in the childhood
histories of those with borderline personality disorder.

COMORBIDITY
A significant proportion—about 6%—succeed at suicide (McGirr, Paris, Lesage, Renaud, & Turecki, 2009).
On the positive side, the long-term outcome for people with borderline personality disorder is
encouraging, with up to 88% achieving remission more than 10 years after initial treatment (Zanarini et al.,
2006). Premature death from suicide may occur in individuals with this disorder, especially in those with
co-occurring depressive disorders or substance use disorders. Physical handicaps may result from self-
inflicted abuse behaviors or failed suicide attempts.
Mood disorders are common among people with borderline personality disorder, with about 20% having
major depression and about 40% having bipolar disorder (Grant et al., 2008). Almost 25% of people with
bulimia also have borderline personality disorder (Zanarini et al., 2010). Up to 67% of the people with
borderline personality disorder are also diagnosed with at least one substance use disorder (Grant et al.,
2008). Other common co-occurring disorders include post traumatic stress disorder, and attention-
deficit/hyperactivity disorder. Borderline personality disorder also frequently co-occurs with other
personality disorders and comorbidity with schizotypal, narcissistic, and dependent disorder is
particularly high (Tomko et al., 2014).

------------------- CASE STUDY -------------------

19 year old Ms. R, had no formal history of psychiatric treatment. However, she reported a long history of
mood instability, suicidal gestures and skin cutting. She also has had many stormy relationships, including
a history of physical abuse, as well as three abortions. She was admitted to the hospital for the first time
after she threatened to kill herself following a physical fight with her boyfriend and crashing the family car.
The patient says that she recently moved out of her family home and went to live with her boyfriend. After a
fight with her boyfriend that left her with a bloody lip, she was feeling “depressed.” She returned home and
began to fight with her mother. She then stole the family car and crashed into a pole. When a neighbor
found her, she stated she was going to kill herself. Her mother subsequently brought her to the hospital. On
admission, Ms. R said she was “depressed” and suicidal. She was described as angry, entitled,
manipulative, and “regressed.” She was diagnosed with borderline personality disorder. The presence of
narcissistic traits was also noted. ( Avery et al., 2012).

------------------- DIFFERENTIAL DIAGNOSIS -------------------

Borderline personality disorder differs from schizophrenia on the basis that the patient with borderline
personality lacks prolonged psychotic episodes, thought disorder, and other classic schizophrenic signs.

Borderline personality disorder differs from major depressive disorder, bipolar disorder, dysthymic
disorder, and cyclothymia based on the presence of core borderline personality symptoms that are not
typically present in mood disorders.

Depressive and bipolar disorders : Borderline personality disorder often co-occurs with depressive or
bipolar disorders, and when criteria for both are met, both may be diagnosed. Because the cross-sectional
presentation of borderline personality disorder can be mimicked by an episode of depressive or bipolar
disorder, the clinician should avoid giving an additional diagnosis of borderline personality disorder
based only on cross-sectional presentation without having documented that the pattern of behavior had
an early onset and a longstanding course.

Other personality disorders: Other personality disorders may be confused with borderline personality
disorder because they have certain features in common. If an individual has personality features that
meet criteria for one or more personality disorders in addition to borderline personality disorder, all can
be diagnosed. Although histrionic personality disorder can also be characterized by attention seeking,
manipulative behavior, and rapidly shifting emotions, borderline personality disorder is distinguished by
self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness and
loneliness. Paranoid ideas or illusions may be present in both borderline personality disorder and
schizotypal personality disorder, but these symptoms are more transient, interpersonally reactive, and
responsive to external structuring in borderline personality disorder. Although paranoid personality
disorder and narcissistic personality disorder may also be characterized by an angry reaction to minor
stimuli, the relative stability of self-image, as well as the relative lack of self-destructiveness, impulsivity,
and abandonment concerns, distinguishes these disorders from borderline personality disorder. Although
antisocial personality disorder and borderline personality disorder are both characterized by
manipulative behavior, individuals with antisocial personality disorder are manipulative to gain profit,
power, or some other material gratification, whereas the goal in borderline personality disorder is directed
more toward gaining the concern of caretakers. Both dependent personality disorder and borderline
personality disorder are characterized by fear of abandonment; however, the individual with borderline
personality disorder reacts to abandonment with feelings of emotional emptiness, rage, and demands,
whereas the individual with dependent personality disorder reacts with increasing appeasement and
submissiveness and urgently seeks a replacement relationship to provide caregiving and support.
Borderline personality disorder can further be distinguished from dependent personality disorder by the
typical pattern of unstable and intense relationships.
Personality change due to another medical condition: Borderline personality disorder must be
distinguished from personality change due to another medical condition, in which the traits that emerge
are attributable to the effects of another medical condition on the central nervous system.

Substance use disorders: Borderline personality disorder must also be distinguished from symptoms that
may develop in association with persistent substance use.

Identity problems: Borderline personality disorder should be distinguished from an identity problem,
which is reserved for identity concerns related to a developmental phase (e.g., adolescence) and does not
qualify as a mental disorder.

(Sadock et al., 2017)