This paper will examine the mental illness that is commonly referred to as Borderline Personality Disorder. I will provide an outline, as well as examine this specific personality disorder's history, possible causes, symptoms, and available treatments, as well as its prognosis. This paper is an overview of the illness, which has gained significant prominence in the mass media. By no means is this paper a full representation of the clinical picture of Borderline Personality Disorder. In order to explain the diagnostic criteria, the standard manual for psychopathology will be employed, the Diagnostic and Statistical Manual of Psychological Disorders (DSM-V). This manual, along with relevant research, will shed much needed light on the disorder, a disorder that is more common than previously thought. In summary, this paper serves as an overview of the serious personality disorder called Borderline Personality Disorder -- an illness that can significantly impair normal, everyday functioning in its sufferers.
A. DSM-IV Criteria for Illness
B. Incidence of Borderline Personality Disorder (BPD)
1. How common is BPD in US?
2. How many adults are diagnosed with BPD?
a. How many children are diagnosed with BPD?
II. History of Illness
A. When was BPD first mentioned in literature?
B. Have BPD diagnoses become more common since its recognition?
III. Etiology of BPD
A. Genetic factors
1. What do fMRIs and PET Scans reveal in terms of structural abnormalities?
B. Environmental factors
1. What does family life reveal?
IV. BPD Treatments
A. Which treatments show the most promise, based on peer-reviewed research?
1. Cost-effectiveness of treaments
2. Modality of psychoanalysis. Does it work?
B. Medications for treatment
1. Co-morbidity with other treatable illnesses via medications
V. Prognosis for persons diagnosed with BPD
A. Case Studies
1. Successes and Failures
Borderline Personality Disorder (BPD) is a serious, but treatable mental illness that has become more diagnosed, as well as more understood during the past 40 years. It was first included in the Diagnostic and Statistical Manual for Mental Disorders, Third Edition (DSM-III) in 1980. Borderline Personality Disorder, or BPD, is characterized by unpredictable moods, unstable behavior, and rocky relationships (nimh.nih.gov, 2013, internet). BPD originally acquired its name because its occasional, atypical psychotic episodes bear a resemblance to extreme features of many different types of mental illnesses (nimh.nih.gov, 2013, internet). However, researchers do not believe this description is actually fitting, but the name has stuck, nonetheless. People with BPD commonly display impulsive and reckless behavior, have difficulties keeping their emotions regulated, and their relationships with other people are highly unstable (nimh.nih.gov, 2013, internet).
In order to be diagnosed with BPD, the DSM, Fourth Edition, Text Revision (DSM-IV-TR) requires that a person must demonstrate a lasting pattern of at least five of the following symptoms:
Extreme reactions—including depression, panic, rage, or rash actions—to feelings of abandonment, whether valid or not
An intense pattern of rocky relationships with family, friends, and loved ones, often wavering from extreme love and closeness (idealization) to extreme anger or dislike (devaluation)
Unstable and distorted sense of self or self-image, which may result in sudden changes in opinions, feelings, values, or plans and objectives for the future, such as school or job choices
Impulsive and often life-threatening behaviors, such as binge eating, spending sprees, unsafe sex, substance abuse, and/or reckless driving
Chronic suicidal ideation, threats, behaviors or self-harming behavior, such as cutting
Intense and highly mutable moods, with each episode lasting from only a few hours to several days
Chronic feelings of boredom and/or emptiness
Inappropriate rage or problems controlling anger
Having stress-associated paranoid thoughts or serious dissociative symptoms, such as feeling distant from oneself, perceiving oneself from outside the body, or not being in touch with reality (nih.nimh.gov, 2013, internet).
Currently, there is a healthy debate about the cause(s) of BPD. One avenue of research has focused on the role of childhood trauma in the incidence of BPD among adults. According to Herman et al. (1989), self-reported incidents of child abuse, including physical, emotional, and sexual abuse, were highly-correlated with the diagnosis of BPD among 21 subjects. Two other groups were interviewed -- subjects with borderline traits and those subjects with nonborderline, closely-related diagnoses such as bipolar II disorder or schizotypal personality disorder. The researchers found that 81% of subjects diagnosed with BPD reported a history that included childhood trauma, while 68% of BPD-diagnosed subjects reported sexual abuse, and 62% of the BPD subjects had witnessed domestic abuse during their childhood (Herman et al., 1989, p. 490). Furthermore, these numbers were significantly higher than the self-reports from the other two groups of subjects.
According to Nasrallah (2014), BPD is a heritable disorder, and MRIs reveal significant structural aberrations in the brains of those afflicted with BPD. For example, those persons diagnosed with BPD are more likely to exhibit hypoplasia of the causate, hippocampus, and dorsolateral prefrontal cortex, a smaller frontal lobe, an enlarged third cerebral ventricle, loss of gray matter in the parietal, frontal, and temporal cortices, as well as a host of other structural abnormalities of the brain (Nasrallah, 2014, internet). Nasrallah (2014) also asserts that a systematic review of nearly 60 research studies -- categorized into 12 family studies, 18 twin studies, 5 gene-environment interaction studies, and 24 association studies -- show genetic links to the illness (Nasrallah, 2014, internet). "Some studies have found evidence of hypermethylation in BPD, which can exert epigenetic effects. Childhood abuse might, therefore, disrupt certain neuroplasticity genes, culminating in morphological, neurochemical, metabolic, and white-matter aberrations—leading to pathological behavioral patterns identified as BPD" (Nasrallah, 2014, internet).
According to Nasrallah (2014), functional MRIs (fMRIs) have also yielded significant data regarding abnormalities in brain function in those who have been diagnosed with BPD. For example, fMRIs have revealed a greater excitability of the amygdala and a prolonged return to the baseline (Nasrallah, 2014, internet). The amygdala is a small, almond-shaped structure found in the midbrain that regulates strong emotions such as fear and anger. Along with these findings, fMRIs have revealed "marked frontal hypometabolism, hypermetabolism in the motor cortex, medial and anterior cingulate, and occipital and temporal poles" in subjects with diagnosed BPD (Nasrallah, 2014, internet). Moreover, fMRIs have shown "deactivation of the opioid system in the left nucleus accumbens, hypothalamus, and hippocampus, hyperactivation of the left medial prefrontal cortex during social exclusion, (and) more mistakes made in differentiating an emotional and a neutral facial expression" (Nasrallah, 2014, internet). Interestingly, the amygdala is one of the structures that is very important in "reading" facial expressions, in order to determine the likelihood of a threat stimulus -- a key neural structure involved in the so-called fight-or-flight response. These findings show that the brains of BPD sufferers show functional abnormalities when compared to control groups that are not diagnosed with the illness.
Taken into full consideration, both of these avenues of inquiry -- environmental etiology and neurological bases of BPD -- have yielded different treatment approaches in order to help its sufferers mitigate their symptoms, cope with their illness, and live fulfilling lives characterized by stable, satisfying relationships. No specific pharmacologic approach has proved to be beneficial in the treatment of BPD. Rather, clinicians treat the illness's varying, oft-nuanced symptoms. For example, a person diagnosed with BPD who exhibits depression may be treated with any one of a host of anti-depressants that target specific neurotransmitters in the brain. In addition, sufferers who show distortions of thought or a labile mood may benefit from traditional, as well as newer, anti-psychotics.
Interestingly, psychotherapy has proved to be highly-successful in treating patients who have been diagnosed with BPD. For instance, cognitive-behavioral therapy (CBT), dialectical behavioral therapy (DBT), and schema-focused therapy have all shown some success (nimh.nih.gov, 2103, internet). Cognitive-behavioral therapy helps patients change the way they think about and process their perceived behaviors, as well as stimuli from their environment. CBT, if exercised continually, can help a patient change his core beliefs, thus boosting self-esteem and promoting positive behavior and lessening negative behaviors such as suicidal acts. DBT, on the other hand, seeks to strike a balance between changing and accepting thoughts and behaviors, while approaching situations mindfully. DBT also teaches patients how to minimize negative, self-destructive emotions, eliminate dangerous behaviors, and improve relationships. Schema-focused therapy helps those with BPD reframe the way they view themselves, a process that improves a poor self-image that may have been damaged by childhood trauma.
Fortunately, the aforementioned treatments, and combinations thereof, have shown to lessen both the severity and persistence of BPD's symptoms. One type of promising treatment, called Systems Training for Emotional Predictability and Problem Solving (STEPPS), is a variant of group therapy. Coordinated by a social worker, the therapy entails 20 two-hour sessions over a brief period of time (nimh.nih.gov, 2013, internet). STEPPS therapy, when used in conjunction with psychotherapy and/or medication, has been pronounced as effective by the NIMH, but more extensive research has to be conducted about its long-term efficacy. Even so, when a person with BPD has symptoms that go into full remission, only 6% of these people will have a relapse. Thus, even without any type of therapy, persons with BPD have a low chance of relapse, such as violent and impulsive behaviors (nimh.nih.gov, 2013, internet).
The authenticity of Borderline Personality Disorder has been questioned for a long time. However, brain scans and family studies have demonstrated that BPD is a legitimate illness that afflicts nearly 2% of the American population. Although its symptoms are serious, BPD is an illness that is treatable, but not curable. Psychotherapy offers a great deal of promise for those with BPD, and combined with symptom-targeted medications as well as group therapy, the prognosis looks good for those who have been diagnosed with BPD.
Borderline personality disorder. (2013). (n.p.). Retrieved from http://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml
Herman, J.L., Perry, J.C., & van der Kolk, B.A. Childhood trauma in borderline personality disorder. American Journal of Psychiatry, 146:4, April 1989, pp. 490-495. Retrieved from http://www.researchgate.net/profile/Judith_Herman/publication/20226009_Childhoo d_trauma_in_borderline_personality_disorder/links/550a1b3a0cf20f127f90db77.pdf
Nasrallah, H.A. Borderline personality disorder is a heritable brain disease. Current Psychiatry 2014 April;13(4):19-20, 32. Retrieved from http://www.currentpsychiatry.com/the- publication/issue-single-view/borderline-personality-disorder-is-a-heritable-brain- disease/3bc96d9e33065b76fd114fcd15566bde.html