Borderline Personality Disorder (BPD)

Stresses during early childhood may contribute to the development of borderline personality disorder. A childhood history of physical and sexual abuse, neglect, separation from caregivers, and/or loss of a parent is common among patients with borderline personality disorder.

Certain people may have a genetic tendency to have pathologic responses to environmental life stresses, and borderline personality disorder clearly appears to have a heritable component. First-degree relatives of patients with borderline personality disorder are 5 times more likely to have the disorder than the general population (1 Etiology references Borderline personality disorder is characterized by a pervasive pattern of instability and hypersensitivity in interpersonal relationships, instability in self-image, extreme mood fluctuations... read more ).

Disturbances in regulatory functions of the brain and neuropeptide systems may also contribute but are not present in all patients with borderline personality disorder (2 Etiology references Borderline personality disorder is characterized by a pervasive pattern of instability and hypersensitivity in interpersonal relationships, instability in self-image, extreme mood fluctuations... read more ).

When patients with borderline personality disorder feel that they are being abandoned or neglected, they feel intense fear or anger. For example, they may become panicky or furious when someone important to them is a few minutes late or cancels an engagement. They think that this abandonment means that they are bad. They fear abandonment partly because they do not want to be alone.

These patients tend to change their view of others abruptly and dramatically. They may idealize a potential caregiver or lover early in the relationship, demand to spend a lot of time together, and share everything. Suddenly, they may feel that the person does not care enough, and they become disillusioned; then they may belittle or become angry with the person. This shift from idealization to devaluation reflects black-and-white thinking (splitting, polarization of good and bad).

Patients with borderline personality disorder can empathize with and care for a person but only if they feel that another person will be there for them whenever needed.

Patients with this disorder have difficulty controlling their anger and often become inappropriate and intensely angry. They may express their anger with biting sarcasm, bitterness, or angry tirades, often directed at their caregiver or lover for neglect or abandonment. After the outburst, they often feel ashamed and guilty, reinforcing their feeling of being bad.

Patients with borderline personality disorder may also abruptly and dramatically change their self-image, shown by suddenly changing their goals, values, opinions, careers, or friends. They may be needy one minute and righteously angry about being mistreated the next. Although they usually see themselves as bad, they sometimes feel that they do not exist at all—eg, when they do not have someone who cares for them. They often feel empty inside.

The changes in mood (eg, intense dysphoria, irritability, anxiety) usually last only a few hours and rarely last more than a few days; they may reflect extreme sensitivity to interpersonal stresses.

Patients with borderline personality disorder often sabotage themselves when they are about to reach a goal. For example, they may drop out of school just before graduation, or they may ruin a promising relationship.

Impulsivity leading to self-harm is common. These patients may gamble, engage in unsafe sex, binge eat, drive recklessly, abuse substances, or overspend. Suicidal behaviors Suicidal Behavior Suicide is death caused by an act of self-harm that is intended to be lethal. Suicidal behavior encompasses a spectrum of behavior from suicide attempt and preparatory behaviors to completed... read more , gestures, and threats and self-mutilation Nonsuicidal Self-Injury (NSSI) Nonsuicidal self-injury is a self-inflicted act that causes pain or superficial damage but is not intended to cause death. Although the methods used sometimes overlap with those of suicide attempts... read more (eg, cutting, burning) are very common. Although many of these self-destructive acts are not intended to end life, risk of suicide in these patients is 40 times that of the general population. About 8 to 10% of these patients die by suicide (1 Symptoms and signs reference Borderline personality disorder is characterized by a pervasive pattern of instability and hypersensitivity in interpersonal relationships, instability in self-image, extreme mood fluctuations... read more ). These self-destructive acts are usually triggered by rejection by, possible abandonment by, or disappointment in a caregiver or lover. Patients may self-mutilate to compensate for their being bad, to reaffirm their ability to feel during a dissociative episode Overview of Dissociative Disorders Many people occasionally experience a failure in the normal automatic integration of memories, perceptions, identity, and consciousness. For example, people may drive somewhere and then realize... read more , or to distract from painful emotions.

Dissociative episodes, paranoid thoughts, and sometimes psychotic-like symptoms (eg, hallucinations, ideas of reference) may be triggered by extreme stress, usually fear of abandonment, whether real or imagined. These symptoms are temporary and usually not severe enough to be considered a separate disorder. In most patients, dissociative symptoms lessen over time, and the relapse rate is low. However, functional status does not usually improve as much as the symptoms.

For a diagnosis of borderline personality disorder (1 Diagnosis reference Borderline personality disorder is characterized by a pervasive pattern of instability and hypersensitivity in interpersonal relationships, instability in self-image, extreme mood fluctuations... read more ), patients must have

This persistent pattern is shown by ≥ 5 of the following:

Also, symptoms must have begun by early adulthood but can occur during adolescence.

General principles for treatment Treatment Personality disorders in general are pervasive, enduring patterns of thinking, perceiving, reacting, and relating that cause significant distress or functional impairment. Personality disorders... read more of borderline personality disorder are the same as those for all personality disorders.

Identifying and treating coexisting disorders is important for effective treatment of borderline personality disorder.