Borderline Personality Disorder

Borderline personality disorder (BPD) is a serious and complex mental disorder marked by a pervasive, chronic pattern of instability and inability to regulate emotions, impulses, self-image, and interpersonal relationships. BPD is an extremely heterogeneous category, ranging from "antagonistic," "volatile" individuals to those who are actively violent and suicidal. BPD has been analyzed from several contrasting perspectives, including psychoanalysis, "traumatology," and biological psychiatry. Current thinking emphasizes that there are multiple causes involved, which vary from individual to individual. BPD is commonly comorbid with substance abuse disorders.

BPD is recognized as a diagnostic entity in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). The label "borderline" dates from an early concept of an area between "neurotic" and "psychotic." It is sometimes confused with the colloquial "borderline schizophrenic," but BPD has nothing to do with the brain disease schizophrenia. While a minority of BPDs may experience transient psychotic-like conditions, this is not a common or core feature of BPD. There have been proposals for a more descriptive label, such as "emotional regulation disorder" or "interpersonal regulatory disorder."

To diagnose a personality disorder, there must be an enduring, long-lasting pattern of thinking, feeling, interpersonal relations, and impulse control that is maladaptive and causes distress and impairment in functioning. In addition, a personality disorder cannot be accounted for by another major mental disorder, substance abuse, or transient reaction to trauma.

The DSM-IV-TR lists borderline personality disorder in its Cluster B (dramatic, emotional, erratic), along with antisocial, narcissistic, and histrionic personality disorders.

It is defined as a "pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts." Five or more of the following symptoms must be present to diagnose BPD:

• 1.
  Frantic attempts to avoid real or imagined abandonment
• 2.
  A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
• 3.
  Identity disturbance, that is, markedly and persistently unstable self-image or sense of self
• 4.
  Impulsivity in at least two areas that are potentially self-damaging (spending, sex, substance abuse, reckless driving, binge eating)
• 5.
  Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
• 6.
  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)
• 7.
  Chronic feelings or emptiness
• 8.
  Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
• 9.
  Transient stress-related paranoid ideation or severe dissociative symptoms

To extrapolate on criteria 1 and 2, persons with BPD typically go to extremes in their attachments, as seen in the book title / Hate You—Don't Leave Me. They may alternate between these extremes, inexplicably and unpredictably turning on an intimate, but have an "emotional amnesia" in which they will deny the previous emotional state or attitude (i.e., "I never liked you").

To extrapolate on criteria 6 and 9, persons with BPD show the following:

• An inability to modulate or damp down affects and emotional responses, what has been dubbed an "emotional hemophilia" or an "affective storm"
• An exquisite sensitivity to environmental shifts
• A lower threshold for frustrating stimuli
• Rage, fury, despair, humiliation at small or imagined slights or setbacks

To extrapolate on criteria 5, 6, and 9, in some individuals with BPD, overwhelming negative emotions [Page 133]and affective storms are turned against the self via self-mutilation (cutting) and suicide attempts. Through some as yet unknown mechanism, self-mutilation has the effect of relieving tension, anxiety, and other extreme affects. Other behavioral extremes listed under criterion 4 (i.e., shopping, shoplifting, sexual promiscuity, gambling) also allow them to feel calmer for a short time. BPD with self-destructive behavior is more often found among females than among males.

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