What is it
Borderline Personality Disorder is a relative newcomer to the psychiatric world—it was officially recognized by the American Psychiatric Association (APA) for the first time in 1980. Related areas of research, medication, treatment options and family support programs followed suit.
What makes a personality ‘disordered’?
Personality describes individual characteristic patterns of thinking, feeling and behaving. A personality disorder is a class of mental disorders that are diagnosed when these patterns are repeatedly and seriously inflexible and dysfunctional, over an extended period of time.
People with personality disorders behave and perceive themselves, and others, in a markedly different way to most in their culture. These ideas and behaviours tend to develop in adolescence or early adulthood and are enduring. This can cause significant distress and impairment in all facets of life.
Borderline Personality Disorder (BPD) is a pervasive disorder including difficulties with emotion regulation that can cause a lot of suffering, carries a risk of suicide and needs an accurate diagnosis along with targeted treatment.
Symptoms for people with this illness include emotional distress, self-harm, difficulty relating to themselves, others and the world around them. This can be very distressing for the person and for people close to them.
It is an often-misunderstood condition that has many challenging aspects, including intense and stormy relationships, low self-esteem, self-sabotaging acts, mood fluctuations and impulsivity.
A key feature of Borderline Personality Disorder is emotional dysregulation (severe difficulty regulating emotions). This can result in impulsive or self-destructive behaviours in an attempt to cope or re-regulate their emotional experience.
How common are personality disorders and Borderline Personality Disorder?
Personality disorders represent one of the most prevalent and severe mental health conditions. Up to 4% of Australians will have a personality disorder over their lifetime. Data samples of more than 21,000 people worldwide, including Europe, the Americas, Africa and Asia, show a similar prevalence of 6.1%.
In America about 40% to 60% of psychiatric patients have a personality disorder, with similar rates in drug and alcohol units and prisons.
In America personality disorders account for about one in four mental health emergency visits and inpatient hospitalisations.
Borderline Personality Disorder is estimated to affect about 1-2 percent of Australians. The symptoms of the disorder usually first appear in mid to late teens or in early adulthood, with women three times more likely to be diagnosed with BPD than men.
The causes of Borderline Personality Disorder are complex and not fully understood. They are likely to involve biological, social and/or environmental factors. Most experts agree there is not one single cause of borderline personality disorder. Historically BPD was seen as having abuse or neglect as central to the cause. However, we now know, as with most conditions, BPD appears to be the result of a combination of biological and environmental factors. Biological factors may include inheriting certain genes or personality traits, and there are a number of environmental factors that may play a role. The most severe may be various forms of abuse: emotional, physical and sexual. Loss, neglect and bullying may also be contributing factors.
However, some people with no history of abuse at all also develop BPD. The current theory is that some people may have a higher biological vulnerability to this condition, and adverse childhood experiences can increase the risk of eventually developing the disorder. The experiences of people living with BPD who have no history of abuse also indicate that there can be a very strong biological component to the condition. It is important to remember that due to biological differences, some children need much more support, emotional coaching and interpersonal validation than others. Therefore, there can be difficulties with ‘fit’ between the child and parents that may contribute to the development of BPD that is not abusive or neglectful in nature. The emphasis of many treatments is to focus on the present-day realities and strategies to cope while respecting the role of the past in the person’s life.
Contrary to common belief, people with BPD can recover! With early diagnosis, appropriate treatment and support the prognosis for people with BPD is positive.
With appropriate treatment many sufferers show improvement in one year. Over time, 80% of BPD sufferers reduce their symptoms.
Recent studies have suggested the majority of those with borderline personality disorder do well over time, with most experiencing sustained relief from symptoms, and around half being completely free of symptoms and able to function well in life. Evidence-based treatments include longer-term psychological therapies, which can be intensive in nature. However, pursuing treatment and learning about the condition and ways to manage it often pay off. In this way, BPD may be a high-risk condition but it has a good outlook.
Having BPD is not deliberate; it is an illness people do not choose to have. And, people can recover!
Current research shows that treatment can decrease the symptoms and suffering of people with BPD.
Talk therapy is usually the first choice of treatment (unlike some other illnesses where medication is often first.) Generally, treatment involves one to two sessions a week with a specialist mental health counselor. For therapy to be effective, people must feel comfortable with and trust their therapist.
There are several treatments that are most often used to manage BPD:
1. Dialectical behavior therapy (DBT) focuses on the concept of mindfulness, or paying attention to the present emotion. DBT teaches skills to control intense emotions, reduce self-destructive behavior, manage distress, and improve relationships. It seeks a balance between accepting and changing behaviors. This proactive, problem-solving approach was designed specifically to treat BPD. Treatment includes individual therapy sessions, skills training in a group setting, and phone coaching as needed. DBT is the most studied treatment for BPD and the one with the greatest research.
2. Schema-focused therapy
3. Cognitive analytic therapy (CAT)
4. Mentalization-based therapy (MBT) is a talk therapy that helps people identify and understand what others might be thinking and feeling.
5. Transference-focused therapy (TFP) is designed to help patients understand their emotions and interpersonal problems through the relationship between the patient and therapist. Patients then apply the insights they learn to other situations.
6. Good Psychiatric Management: GPM provides mental health professionals an easy-to-adopt “tool box” for patients with severe personality disorders.
7. Medications cannot cure BPD but can help treat other conditions that often accompany BPD such as depression, impulsivity, and anxiety. Often patients are treated with several medications, but there is little evidence that this approach is necessary or effective. People with BPD are encouraged to talk with their prescribing doctor about what to expect from each medication and its side effects. 1
8. Self-Care activities include: regular exercise, good sleep habits, a nutritious diet, taking medications as prescribed, and healthy stress management. Good self-care can help to reduce common symptoms of BPD such as mood changes, impulsive behavior, and irritability.
For the full DSM-5 diagnostic criteria for BPD go to Diagnostic Criteria for BPD
Clinical criteria as published by the American Psychiatric Association in the Diagnostic and Statistical Manual (DSM) 5 used to make a diagnosis of BPD are:
A pervasive pattern of instability of interpersonal relationships, self-image and affects and marked impulsivity beginning in early adulthood and presenting in a variety of contexts as indicated by five or more of the following:
1) frantic efforts to avoid real or imagined abandonment;
2) a pattern of unstable and intense interpersonal relationships;
3) identity disturbance;
4) impulsivity in at least two areas that are self–damaging;
5) recurrent suicidal behavior, suicidal gestures, threats or self-mutilating behavior;
6) affective [mood] instability;
7) chronic feelings of emptiness;
8) inappropriate, intense anger; and
9) transient stress-related paranoid ideation or severe dissociative symptoms.