Borderline Personality Disorder

Outline of the presentation

• Basics
• Clinical features
• Diagnostic guidelines
• Etiology
• Management
Basics about BPD
• Patients with borderline personality disorder stand on
the border between neurosis and psychosis
• They are characterized by extraordinarily unstable
affect, mood, behavior, object relations, and self-image.
• Other names:
– ambulatory schizophrenia
– as-if personality (a term coined by Helene Deutsch),
– pseudoneurotic schizophrenia (described by Paul Hoch and
Phillip Politan)
– psychotic character disorder (described by John Frosch).
FEATURES/CLINICAL PICTURE
OF BPD
Affective instability
• Frequent affect shifts that result from one’s reactivity to
environmental stimuli.
• Shifting between different types of negative affect (e.g.,
anger, depression, anxiety).
• Affect shifts occur in response to external stimuli in the
person’s environment.
• These stimuli might include interpersonal conflicts or
perceived rejection.
• This differentiates the disorder from other affective
disorders such as major depression, in which the shifts
in affect may result more from internal cues.
Impulsivity
• Engage in: potentially harmful behaviours to
themselves.
– substance abuse, promiscuity, excessive spending,
gambling, binge eating, reckless driving, criminal
activities etc.
• Reasons behind such behaviours:
– as a way to cope with the intense affective shifts
they experience;
– a lack of inhibition and impulse control
Unstable or poorly defined self-concepts
• Dramatically altering career goals, personal
ideals, opinions, attitudes, lifestyle, or ideas about
their sexual orientation, unrealistic body images.
• Basing identity on the idea that they are inherently
evil or worthless.
• These identity issues arise from the individual’s
inability to integrate positive and negative aspects
of the self.
• Lack of a cohesive self-image leads to intense
feelings of emptiness.
Difficulties in interpersonal relationships
• Nature of relationships: stormy and unstable.
• New relationships quickly reach a high level of
intimacy and intensity, often followed by the
person with BPD feeling that the other individual
is not equally committed, available, or attached.
• Shifting affective states, impulsive behaviors, and
identity disturbances add to the chaotic nature of
these relationships.
• They frequently vacillate between over idealizing
and devaluing friends, family, and romantic
partners.
Intense and inappropriate anger
• Difficulty controlling their anger or expressing
it in a productive way.
• Form of anger: verbal or physical aggression,
bitterness, or extreme sarcasm.
• Triggers for anger: interpersonal conflict, the
threat of abandonment
• Anger followed by: feelings of guilt/shame.
Fear of abandonment
• constant worrying that significant caregivers in
their life may leave, neglect, or reject them in
some way.
• A kind of separation anxiety
• Can often lead to frantic efforts on the part of
the individual with BPD to avoid this
abandonment. (responding to perceived signs
of abandonment with impulsive behaviors or
threats of suicide or self-mutilation)
Suicidal and self-mutilating behavior
• Recurrent suicidal attempts, threats, or gestures
are frequently displayed in these individuals and
often require or result in medical care.
• Cutting or burning the skin, swallowing objects,
or otherwise injuring oneself is common.
• Reasons:
– A way to express the pain that they are experiencing.
– To manipulate significant people in their lives, for
example, to avoid abandonment
– An attempt to distract themselves from the intense
negative affect they experience
 Transient dissociative
or paranoid symptoms
• Experiences such as abnormal bodily
sensations, feelings of being outside one’s own
body, or unusual auditory or visual
experiences.
• Experience of paranoid ideation, odd speech,
and disturbed thoughts.
Psychosocial impacts
• Constant emotional chaos can hinder one’s
ability to function effectively in work or
school.
• Impulsivity : leading to severe levels of
dysfunction due to its ever-lasting impacts
• Failed marriages or dysfunctional family
environment
• Experiencing abuse from the family members
(due to impulsive and other such behaviours)
DSM-V DIAGNOSTIC
CRITERIA
• 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, as indicated by five
(or more) of the following:
(1) frantic efforts to avoid real or imagined abandonment. Note: Do not
include suicidal or self-mutilating behavior covered in Criterion 5.
(2) a pattern of unstable and intense interpersonal relationships
characterized by alternating between extremes of idealization and
devaluation
(3) identity disturbance: markedly and persistently unstable self image
or sense of self
(4) impulsivity in at least two areas that are potentially self-damaging
(e.g., spending, sex, substance abuse, reckless driving, binge eating).
Note: Do not include suicidal or self-mutilating behavior covered in
Criterion 5.
(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 of 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.
ICD-10 DIAGNOSTIC
CRITERIA
F60.3 Emotionally unstable
personality disorder
• A personality disorder in which there is a marked
tendency to act
• impulsively without consideration of the consequences,
together with affective instability.
• The ability to plan ahead may be minimal, and
outbursts of intense anger may often lead to violence or
"behavioural explosions"; these are easily precipitated
when impulsive acts are criticized or thwarted by
others.
• Two variants of this personality disorder are specified,
and both share this general theme of impulsiveness and
lack of self-control.
F60.30 Impulsive type
• The predominant characteristics are emotional
instability and lack of impulse control.
• Outbursts of violence or threatening behaviour
are common, particularly in response to
criticism by others.
– Includes: explosive and aggressive personality
(disorder)
– Excludes: dissocial personality disorder (F60.2)
F60.31 Borderline type
• Several of the characteristics of emotional instability
are present; in addition, the patient's own self-image,
aims, and internal preferences (including sexual) are
often unclear or disturbed.
• There are usually chronic feelings of emptiness.
• A liability to become involved in intense and unstable
relationships may cause repeated emotional crises and
may be associated with excessive efforts to avoid
abandonment and a series of suicidal threats or acts of
self-harm (although these may occur without obvious
precipitants).
– Includes: borderline personality (disorder)
Comorbidity
• Mood disorders, substance use disorders,
eating disorders (particularly bulimia),
attention-deficit/hyperactivity disorder, and
anxiety disorders
• All these share impulsivity/ dis-inhibition and
negative affect/affective instability
DIFFERENTIAL DIAGNOSIS
Mood disorders and BPD
BPD Depression

Personality features impulsivity, unstable Anxiety, worry, and self-

interpersonal consciousness
relationships, and
devaluative attitudes

subjective experiences anger, loneliness, and hopelessness

emptiness and failure

Similarities dysphoric mood and suicidal thoughts or behaviors

BPD Bipolar-II

Personality features sensitivity to hostility and interpersonal insensitivity

separations , very and a grandiose self-
negative self-image image
Other differential diagnosis:
• Other personality disorders
• Personality changes due to another medical
condition
• Substance use disorder
• Identity related problems
ETIOLOGY
Factor Explanation
Genetic Depression: common in the family
backgrounds of patients with BPD
Overall mood disorders: prevalence more in patients having BPD

Neurotransmitters Low levels of 5-hydroxyindoleacetic acid (5- HIAA), a metabolite of

serotonin, in persons who attempt suicide and in
patients who are impulsive and aggressive

Childhood lack of trust, dissociative experiences, affective instability might result

trauma/abuse from the experience of physical or sexual abuse in childhood

attachment History of maladaptive attachment to caregivers or current maladaptive

attachment patterns in their intimate relationships.
MANAGEMENT
• DBT
 References
• Cognitive Therapy for Personality Disorders
(2nd ed. Beck et al.)
• Comprehensive Textbook of Psychiatry
(9th ed.)