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Dissociation
About 1.6% of people have BPD in a given year.[3] Females are diagnosed about three times as often as males.
It appears to become less common among older people.
Up to half of people improve over a ten-year period. People aected typically use a high amount of healthcare
resources.[4] There is an ongoing debate about the naming of the disorder, especially the suitability of the word
borderline.[3]
1.2
Behavior
3
While strongly desiring intimacy, people with BPD
tend toward insecure, avoidant or ambivalent, or fearfully preoccupied attachment patterns in relationships,[28]
and they often view the world as dangerous and
malevolent.[25] BPD, like other personality disorders, is
linked to increased levels of chronic stress and conict in
romantic relationships, decreased satisfaction on the part
of romantic partners, abuse, and unwanted pregnancy.[29]
1.5
Sense of self
2 Causes
As is the case with other mental disorders, the causes
of BPD are complex and not fully agreed upon.[33] Evidence suggests that BPD and post-traumatic stress disorder (PTSD) may be related in some way.[34] Most researchers agree that a history of childhood trauma can be
a contributing factor,[35] but less attention has historically
been paid to investigating the causal roles played by congenital brain abnormalities, genetics, neurobiological factors, and environmental factors other than trauma.[33][36]
People with BPD tend to have trouble seeing a clear picture of their identity. In particular, they tend to have
diculty knowing what they value, believe, prefer, and
enjoy.[30] They are often unsure about their long-term
goals for relationships and jobs. This diculty with
knowing who they are and what they value can cause
people with BPD to experience feeling empty and
lost.[30]
1.6
2.1 Genetics
Cognitions
1.7
Disability
2.2
Brain abnormalities
CAUSES
A number of neuroimaging studies in BPD have reported ndings of reductions in regions of the brain involved in the regulation of stress responses and emotion, aecting the hippocampus, the orbitofrontal cortex, and the amygdala, amongst other areas.[43] A smaller
number of studies have used magnetic resonance spectroscopy to explore changes in the concentrations of
neurometabolites in certain brain regions of BPD patients, looking specically at neurometabolites such as Nacetylaspartate, creatine, glutamate-related compounds, Increased cortisol production is also associated with an
and choline-containing compounds.[43]
increased risk of suicidal behavior.[52]
2.2.1
Hippocampus
2.3.1 Estrogen
The hippocampus tends to be smaller in people with
BPD, as it is in people with post-traumatic stress disorder Individual dierences in womens estrogen cycles may
(PTSD). However, in BPD, unlike PTSD, the amygdala be related to the expression of BPD symptoms in fealso tends to be smaller.[45]
male patients.[53] A 2003 study found that womens BPD
symptoms were predicted by changes in estrogen levels
throughout their menstrual cycles, an eect that remained
signicant when the results were controlled for a general
2.2.2 Amygdala
increase in negative aect.[54]
The amygdalas are smaller and more active in people
with BPD.[45] Decreased amygdala volume has also been
found in people with obsessive-compulsive disorder.[46]
One study has found unusually strong activity in the left
amygdalas of people with BPD when they experience and
view displays of negative emotions.[47] Since the amygdala generates all emotions (including unpleasant ones),
this unusually strong activity may explain the unusual
strength and longevity of fear, sadness, anger, and shame
experienced by people with BPD, as well as their heightened sensitivity to displays of these emotions in others.[45]
2.2.3
Prefrontal cortex
The prefrontal cortex tends to be less active in people with BPD, especially when recalling memories of
abandonment.[48] This relative inactivity occurs in the
right anterior cingulate (areas 24 and 32).[48] Given its
role in regulating emotional arousal, the relative inactivity of the prefrontal cortex might explain the diculties
people with BPD experience in regulating their emotions
and responses to stress.[49]
2.6
giver were signicantly more likely to experience sexual executive function appears to mediate the relationship beabuse by a non-caregiver.[59]
tween rejection sensitivity and BPD symptoms.[62] That
It has been suggested that children who experience is, a group of cognitive processes that include planning,
chronic early maltreatment and attachment diculties working memory, attention, and problem-solving might
may go on to develop borderline personality disorder.[60] be the mechanism through which rejection sensitivity impacts BPD symptoms. A 2008 study found that the reWriting in the psychoanalytic tradition, Otto Kernberg ar- lationship between a persons rejection sensitivity and
gues that a childs failure to achieve the developmental BPD symptoms was stronger when executive function
task of psychic clarication of self and other and failure was lower and that the relationship was weaker when exto overcome splitting might increase the risk of develop- ecutive function was higher.[62] This suggests that high
ing a borderline personality.[61]
executive function might help protect people with high
[62]
A childs inability to tolerate delayed gratication at age rejection sensitivity against symptoms of BPD.
4 does not predict later development of BPD.[62]
A 2012 study found that problems in working memory
might contribute to greater impulsivity in people with
BPD.[67]
2.5
Neurological patterns
The intensity and reactivity of a persons negative affectivity, or tendency to feel negative emotions, predicts
BPD symptoms more strongly than does childhood sexual abuse.[63] This nding, dierences in brain structure
(see Brain abnormalities), and the fact that some patients
with BPD do not report a traumatic history,[64] suggest
that BPD is distinct from the post-traumatic stress disorder which frequently accompanies it. Thus, researchers
examine developmental causes in addition to childhood
trauma.
Research published in January 2013 by Dr. Anthony
Ruocco at the University of Toronto has highlighted two
patterns of brain activity that may underlie the dysregulation of emotion indicated in this disorder: (1) increased
activity in the brain circuits responsible for the experience of heightened emotional pain, coupled with (2) reduced activation of the brain circuits that normally regulate or suppress these generated painful emotions. These
two neural networks are seen to be dysfunctionally operative in the frontolimbic regions, but the specic regions
vary widely in individuals, which calls for the analysis of
more neuroimaging studies.[65]
Also (contrary to the results of earlier studies) suerers
of BPD showed less activation in the amygdala in situations of increased negative emotionality than the control
group. Dr. John Krystal, editor of the journal Biological Psychiatry, wrote that these results "[added] to the
impression that people with borderline personality disorder are 'set-up' by their brains to have stormy emotional
lives, although not necessarily unhappy or unproductive
lives.[65] Their emotional instability has been found to
correlate with dierences in several brain regions.[66]
2.6
A 2005 study found that thought suppression, or conscious attempts to avoid thinking certain thoughts, mediates the relationship between emotional vulnerability and
While high rejection sensitivity is associated with BPD symptoms.[63] A later study found that the relationstronger symptoms of borderline personality disorder, ship between emotional vulnerability and BPD symptoms
2.6.1
Executive function
3 DIAGNOSIS
is not necessarily mediated by thought suppression. However, this study did nd that thought suppression mediates
the relationship between an invalidating environment and
BPD symptoms.[70]
Diagnosis
According to Marsha Linehan, many mental health professionals nd it challenging to diagnose BPD using the
DSM criteria, since these criteria describe such a wide
variety of behaviors.[74] To address this issue, Linehan
has grouped the symptoms of BPD under ve main areas
of dysregulation: emotions, behavior, interpersonal relationships, sense of self, and cognition.[74]
3.7
3.3
Millons subtypes
3.4
Misdiagnosis
People with BPD are may be misdiagnosed for a variety of reasons. One reason for misdiagnosis is BPD has
symptoms that coexist with other disorders such as depression, PTSD, and bipolar disorder. The tests to narrow down what disorder a person has are also similar in
questions that if the patient doesn't respond with the answers that have the word usually, then the disorder will
go untreated due to improper diagnosis.[78][79]
3.5
Family members
8
with BPD met the criteria for a diagnosis of ADHD.[87]
In another study, 6 of 41 participants (15%) met the criteria for an autism spectrum disorder (a subgroup that had
signicantly more frequent suicide attempts).[90]
3 DIAGNOSIS
Third, when people with BPD experience euphoria, it is
usually without the racing thoughts and decreased need
for sleep that are typical of hypomania,[95] though a later
2013 study of data collected in 2004 found that borderline personality disorder diagnosis and symptoms were
associated with chronic sleep disturbances, including difculty initiating sleep, diculty maintaining sleep, and
waking earlier than desired, as well as with the consequences of poor sleep, and noted that "[f]ew studies have
examined the experience of chronic sleep disturbances in
those with borderline personality disorder.[98]
4.2
Medications
BPD.[88]
9
each of these treatments, and it is considered easier to
learn and less intensive.[6] Randomized controlled trials
have shown that DBT and MBT may be the most eective, and the two share many similarities.[111][112] However, a naturalistic study indicated that DDP may be
more eective than DBT.[113] Researchers are interested
in developing shorter versions of these therapies to increase accessibility, to relieve the nancial burden on patients, and to relieve the resource burden on treatment
providers.[109][112]
The second most common is another Cluster B disorder, which includes antisocial, histrionic, and narcissistic.
These have an overall prevalence of 49.2 percent in people with BPD, with narcissistic being the most common, at 38.9 percent; antisocial the second most common, at 13.7 percent; and histrionic the least common, at
10.3 percent.[88] The least common are Cluster C disorders, which include avoidant, dependent, and obsessivecompulsive, and have a prevalence of 29.9 percent in people with BPD.[88] The percentages for specic comorbid From a psychodynamic perspective, a special probAxis II disorders can be found in the adjacent table.
lem of psychotherapy with people with BPD is intense
projection. It requires the psychotherapist to be exible
in considering negative attributions by the patient rather
than quickly interpreting the projection.[114]
Management
10
EPIDEMIOLOGY
Because of weak evidence and the potential for serious side eects from some of these medications, the
UK National Institute for Health and Clinical Excellence (NICE) 2009 clinical guideline for the treatment
and management of BPD recommends, Drug treatment
should not be used specically for borderline personality disorder or for the individual symptoms or behavior
associated with the disorder. However, drug treatment
may be considered in the overall treatment of comorbid
conditions. They suggest a review of the treatment of
people with borderline personality disorder who do not
have a diagnosed comorbid mental or physical illness and
who are currently being prescribed drugs, with the aim of
reducing and stopping unnecessary drug treatment.[120]
4.3
Services
11
History
to a broad spectrum of issues, describing an intermediate level of personality organization[142] between neurosis
and psychosis.[144]
After standardized criteria were developed[145] to distinguish it from mood disorders and other Axis I disorders, BPD became a personality disorder diagnosis in
1980 with the publication of the DSM-III.[128] The diagnosis was distinguished from sub-syndromal schizophrenia, which was termed "Schizotypal personality disorder".[144] The DSM-IV Axis II Work Group of the American Psychiatric Association nally decided on the name
borderline personality disorder, which is still in use by
the DSM-5 today.[4] However, the term borderline has
been described as uniquely inadequate for describing the
symptoms characteristic of this disorder.[146]
8 Controversies
12
8.1
8 CONTROVERSIES
Dissociation
Lying as a feature
are more likely to develop the kind of symptoms that bring patients in for treatment. Twice
as many women as men in the community suffer from depression (Weissman & Klerman,
1985). In contrast, there is a preponderance
of men meeting criteria for substance abuse
and psychopathy (Robins & Regier, 1991), and
males with these disorders do not necessarily present in the mental health system. Men
and women with similar psychological problems may express distress dierently. Men
tend to drink more and carry out more crimes.
Women tend to turn their anger on themselves,
leading to depression as well as the cutting and
overdosing that characterize BPD. Thus, antisocial personality disorder (ASPD) and borderline personality disorders might derive from
similar underlying pathology but present with
symptoms strongly inuenced by gender (Paris,
1997a; Looper & Paris, 2000). We have even
more specic evidence that men with BPD may
not seek help. In a study of completed suicides
among people aged 18 to 35 years (Lesage et
al., 1994), 30% of the suicides involved individuals with BPD (as conrmed by psychological autopsy, in which symptoms were assessed
by interviews with family members). Most of
the suicide completers were men, and very few
were in treatment. Similar ndings emerged
from a later study conducted by our own research group (McGirr, Paris, Lesage, Renaud,
& Turecki, 2007).[20]
8.5
8.3
Terminology
Manipulative behavior
13
kind.[161] Their extreme aversion to violence can cause
many people with BPD to overcompensate and experience diculties being assertive and expressing their
needs.[161] This is one way in which people with BPD
choose to harm themselves over potentially causing harm
to others.[161] Another way in which people with BPD
avoid expressing their anger through violence is by causing physical damage to themselves, such as engaging in
non-suicidal self-injury.[13][160]
14
10 NOTES
Vader in the Star Wars lms meets six of the nine diagnostic criteria; Bui also found Anakin a useful example
to explain BPD to medical students. In particular, Bui
points to the characters abandonment issues, uncertainty
[180]
Alternative suggestions for names include emotional reg- over his identity, and dissociative episodes.
ulation disorder or emotional dysregulation disorder. Impulse disorder and interpersonal regulatory disorder are
other valid alternatives, according to John Gunderson of 9.2 Awareness
McLean Hospital in the United States.[172] Another term
suggested by psychiatrist Carolyn Quadrio is post trau- In early 2008, the United States House of Representatives
as Borderline Personality Dismatic personality disorganization (PTPD), reecting the declared the month of May
[181][182]
order
Awareness
Month.
conditions status as (often) both a form of chronic post
traumatic stress disorder (PTSD) as well as a personality
disorder.[57] However, although many with BPD do have
traumatic histories, some do not report any kind of trau- 10 Notes
matic event, which suggests that BPD is not necessarily a
trauma spectrum disorder.[64]
[1] Blom, Jan Dirk (2010). A dictionary of hallucinations (1
The Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigned unsuccessfully to change the name and designation of BPD in DSM-5, published in May 2013, in which
the name borderline personality disorder remains unchanged and it is not considered a trauma- and stressorrelated disorder.[173]
9
9.1
The lms Play Misty for Me[174] and Girl, Interrupted [9] Linehan 1993, p. 45
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rst case shows a person more aggressive to others than
to herself, which is not characteristic of the disorder.[175] [11] Linehan 1993, p. 44
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15
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21
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