Borderline Personality Disorder
Borderline personality disorder (BPD), (according to the ICD-10 World Health Organization disease classification, emotionally unstable personality disorder, borderline type), is a personality disorder marked by a prolonged disturbance of personality function, characterized by unusual variability and depth of moods. These moods may secondarily affect cognition and interpersonal relations.[n 1]
The disorder typically involves an unusual degree of instability in mood and black-and-white thinking, or splitting. BPD often manifests itself in idealization and devaluation episodes and chaotic and unstable interpersonal relationships, issues with self-image, identity, and behavior; as well as a disturbance in the individual's sense of self. In extreme cases, this disturbance in the sense of self can lead to periods of dissociation. It is only recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) in individuals over the age of 18; however, symptoms necessary to establish the disorder can also be found in adolescents.
Splitting in BPD includes a switch between idealizing and demonizing others (absolute good/love vs absolute evil/hate with no "grey area"). This, combined with mood disturbances, can undermine relationships with family, friends, and co-workers. BPD disturbances may also include harm to one self. Without treatment, symptoms may worsen, leading (in extreme cases) to suicide attempts.[n 2]
There is an ongoing debate among clinicians and patients worldwide about terminology and the use of the word borderline,[3] and some have suggested that this disorder should be renamed.[4] The ICD-10 manual has an alternative definition and terminology to this disorder, called Emotionally unstable personality disorder. There is related concern that the diagnosis of BPD stigmatizes people and supports discriminatory practices.
The disorder typically involves an unusual degree of instability in mood and black-and-white thinking, or splitting. BPD often manifests itself in idealization and devaluation episodes and chaotic and unstable interpersonal relationships, issues with self-image, identity, and behavior; as well as a disturbance in the individual's sense of self. In extreme cases, this disturbance in the sense of self can lead to periods of dissociation. It is only recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) in individuals over the age of 18; however, symptoms necessary to establish the disorder can also be found in adolescents.
Splitting in BPD includes a switch between idealizing and demonizing others (absolute good/love vs absolute evil/hate with no "grey area"). This, combined with mood disturbances, can undermine relationships with family, friends, and co-workers. BPD disturbances may also include harm to one self. Without treatment, symptoms may worsen, leading (in extreme cases) to suicide attempts.[n 2]
There is an ongoing debate among clinicians and patients worldwide about terminology and the use of the word borderline,[3] and some have suggested that this disorder should be renamed.[4] The ICD-10 manual has an alternative definition and terminology to this disorder, called Emotionally unstable personality disorder. There is related concern that the diagnosis of BPD stigmatizes people and supports discriminatory practices.
Signs and symptoms
The primary features of BPD are unstable interpersonal relationships, affective distress, marked impulsivity, and unstable self-image.
Individuals with BPD tend to experience frequent, strong and long-lasting states of aversive tension, often triggered by perceived rejection, being alone or perceived failure.[n 3] They may show lability (changeability) between anger and anxiety or between depression and anxiety[6] and temperamental sensitivity to emotive stimuli.
The negative emotional states specific to BPD fall into four categories: destructive or self-destructive feelings; extreme feelings in general; feelings of fragmentation or lack of identity; and feelings of victimization.
Individuals with BPD can be very sensitive to the way others treat them, reacting strongly to perceived criticism or hurtfulness. Their feelings about others often shift from positive to negative, generally after a disappointment or perceived threat of abandonment or of losing someone. Self-image can also change rapidly from extremely positive to extremely negative. Impulsive behaviors are common, including alcohol or drug abuse, promiscuous and intense sexuality, gambling and recklessness in general. Attachment studies have revealed a strong association between BPD and insecure attachment style, the most characteristic types being "unresolved", "preoccupied", and "fearful". Evidence suggests that individuals with BPD, while being high in intimacy- or novelty-seeking, can be hyper-alert to signs of rejection or devaluation and tend toward insecure, avoidant or ambivalent, or fearfully preoccupied patterns in relationships. They tend to view the world as generally dangerous and malevolent. BPD is linked to increased levels of chronic stress and conflict in romantic relationships, decreased satisfaction of romantic partners, abuse and unwanted pregnancy; these links may be general to personality disorder and subsyndromal problems.
Manipulation and deceit are viewed as common features of BPD by many of those who treat the disorder as well as by the DSM-IV. Some mental health professionals, however, caution that an overemphasis on these traits and an overly broad definition of "manipulation" can lead to prejudicial treatment of BPD sufferers, particularly within the health care system.
Suicidal or self-harming behavior is one of the core diagnostic criteria in DSM IV-TR, and management of and recovery from this can be complex and challenging. The suicide rate is approximately 8 to 10 percent. Self-injury attempts are highly common among patients and may or may not be carried out with suicidal intent. Ongoing family interactions and associated vulnerabilities can lead to self-destructive behavior. Stressful life events related to sexual abuse can be a particular trigger for suicide attempts by adolescents with BPD tendencies.
Individuals with BPD tend to experience frequent, strong and long-lasting states of aversive tension, often triggered by perceived rejection, being alone or perceived failure.[n 3] They may show lability (changeability) between anger and anxiety or between depression and anxiety[6] and temperamental sensitivity to emotive stimuli.
The negative emotional states specific to BPD fall into four categories: destructive or self-destructive feelings; extreme feelings in general; feelings of fragmentation or lack of identity; and feelings of victimization.
Individuals with BPD can be very sensitive to the way others treat them, reacting strongly to perceived criticism or hurtfulness. Their feelings about others often shift from positive to negative, generally after a disappointment or perceived threat of abandonment or of losing someone. Self-image can also change rapidly from extremely positive to extremely negative. Impulsive behaviors are common, including alcohol or drug abuse, promiscuous and intense sexuality, gambling and recklessness in general. Attachment studies have revealed a strong association between BPD and insecure attachment style, the most characteristic types being "unresolved", "preoccupied", and "fearful". Evidence suggests that individuals with BPD, while being high in intimacy- or novelty-seeking, can be hyper-alert to signs of rejection or devaluation and tend toward insecure, avoidant or ambivalent, or fearfully preoccupied patterns in relationships. They tend to view the world as generally dangerous and malevolent. BPD is linked to increased levels of chronic stress and conflict in romantic relationships, decreased satisfaction of romantic partners, abuse and unwanted pregnancy; these links may be general to personality disorder and subsyndromal problems.
Manipulation and deceit are viewed as common features of BPD by many of those who treat the disorder as well as by the DSM-IV. Some mental health professionals, however, caution that an overemphasis on these traits and an overly broad definition of "manipulation" can lead to prejudicial treatment of BPD sufferers, particularly within the health care system.
Suicidal or self-harming behavior is one of the core diagnostic criteria in DSM IV-TR, and management of and recovery from this can be complex and challenging. The suicide rate is approximately 8 to 10 percent. Self-injury attempts are highly common among patients and may or may not be carried out with suicidal intent. Ongoing family interactions and associated vulnerabilities can lead to self-destructive behavior. Stressful life events related to sexual abuse can be a particular trigger for suicide attempts by adolescents with BPD tendencies.
Diagnosis
Diagnosis is based on a clinical assessment by a qualified mental health professional. The assessment incorporates the patient's self-reported experiences as well as the clinician's observations. The resulting profile may be supported or corroborated by long-term patterns of behavior as reported by family members, friends, or co-workers. The list of criteria that must be met for diagnosis is outlined in the DSM-IV-TR.
Borderline personality disorder was once classified as a subset of schizophrenia (describing patients with borderline schizophrenic tendencies). Today BPD is used more generally to describe individuals who display emotional dysregulation and instability, with paranoid ideation or delusions being only one criterion (criterion #9) of a total of 9 criteria, of which 5 or more must be present for diagnosis.
Borderline personality disorder was once classified as a subset of schizophrenia (describing patients with borderline schizophrenic tendencies). Today BPD is used more generally to describe individuals who display emotional dysregulation and instability, with paranoid ideation or delusions being only one criterion (criterion #9) of a total of 9 criteria, of which 5 or more must be present for diagnosis.
Diagnostic and Statistical Manual
The Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV-TR), a widely used manual for diagnosing mental disorders, defines borderline personality disorder (in Axis II Cluster B)
A pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as 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. Note: Do not include suicidal or self-injuring 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., promiscuous sex, excessive spending, eating disorders, binge eating, substance abuse, reckless driving). Note: Do not include suicidal or self-injuring behavior covered in Criterion 5
Recurrent suicidal behavior, gestures, threats or self-injuring behavior such as cutting, interfering with the healing of scars or picking at oneself (excoriation).
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 anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
Transient, stress-related paranoid ideation, delusions or severe dissociative symptoms
It is a requirement of DSM-IV that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.
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