Borderline Personality Disorder: Introduction

Borderline Personality Disorder (BPD) is a serious mental illness characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior. This instability often disrupts family and work life, long-term planning, and the individual's sense of self-identity.

Originally thought to be at the "borderline" of psychosis, people with BPD suffer from a disorder of emotion regulation. While less well known than schizophrenia or bipolar disorder (manic-depressive illness), BPD is more common, affecting 2 percent of adults, mostly young women.

There is a high rate of self-injury without suicide intent, as well as a significant rate of suicide attempts and completed suicide in severe cases.Patients often need extensive mental health services, and account for 20 percent of psychiatric hospitalizations.

Symptoms

While a person with depression or bipolar disorder typically endures the same mood for weeks, a person with BPD may experience intense bouts of anger, depression, and anxiety that may last only hours, or at most a day. These may be associated with episodes of impulsive aggression, self-injury, and drug or alcohol abuse. Distortions in cognition and sense of self can lead to frequent changes in long-term goals, career plans, jobs, friendships, gender identity, and values. Sometimes people with BPD view themselves as fundamentally bad, or unworthy. They may feel unfairly misunderstood or mistreated, bored, empty, and have little idea who they are. Such symptoms are most acute when people with BPD feel isolated and lacking in social support, and may result in frantic efforts to avoid being alone.

People with BPD often have highly unstable patterns of social relationships. While they can develop intense but stormy attachments, their attitudes towards family, friends, and loved ones may suddenly shift from idealization (great admiration and love) to devaluation (intense anger and dislike). Thus, they may form an immediate attachment and idealize the other person, but when a slight separation or conflict occurs, they switch unexpectedly to the other extreme and angrily accuse the other person of not caring for them at all. Even with family members, individuals with BPD are highly sensitive to rejection, reacting with anger and distress to such mild separations as a vacation, a business trip, or a sudden change in plans. These fears of abandonment seem to be related to difficulties feeling emotionally connected to important persons when they are physically absent, leaving the individual with BPD feeling lost and perhaps worthless. Suicide threats and attempts may occur along with anger at perceived abandonment and disappointments.

People with BPD exhibit other impulsive behaviors, such as excessive spending, binge eating and risky sex. BPD often occurs together with other psychiatric problems, particularly bipolar disorder, depression, anxiety disorders, substance abuse, and other personality disorders.

Treatments for BPD have improved in recent years. Group and individual psychotherapy are at least partially effective for many patients. Within the past 15 years, a new psychosocial treatment termed dialectical behavior therapy (DBT) was developed specifically to treat BPD, and this technique has looked promising in treatment studies. Pharmacological treatments are often prescribed based on specific target symptoms shown by the individual patient. Antidepressant drugs and mood stabilizers may be helpful for depressed and/or labile mood. Antipsychotic drugs may also be used when there are distortions in thinking.

Recent Research Findings

Although the cause of BPD is unknown, both environmental and genetic factors are thought to play a role in predisposing patients to BPD symptoms and traits. Studies show that many, but not all individuals with BPD report a history of abuse, neglect, or separation as young children.

Forty to 71 percent of BPD patients report having been sexually abused, usually by a non-caregiver. Researchers believe that BPD results from a combination of individual vulnerability to environmental stress, neglect or abuse as young children, and a series of events that trigger the onset of the disorder as young adults. Adults with BPD are also considerably more likely to be the victim of violence, including rape and other crimes. This may result from both harmful environments as well as impulsivity and poor judgement in choosing partners and lifestyles.

NIMH-funded neuroscience research is revealing brain mechanisms underlying the impulsivity, mood instability, aggression, anger, and negative emotion seen in BPD. Studies suggest that people predisposed to impulsive aggression have impaired regulation of the neural circuits that modulate emotion. The amygdala, a small almond-shaped structure deep inside the brain, is an important component of the circuit that regulates negative emotion. In response to signals from other brain centers indicating a perceived threat, it marshals fear and arousal. This might be more pronounced under the influence of drugs like alcohol, or stress. Areas in the front of the brain (pre-frontal area) act to dampen the activity of this circuit. Recent brain imaging studies show that individual differences in the ability to activate regions of the prefrontal cerebral cortex thought to be involved in inhibitory activity predict the ability to suppress negative emotion.

Serotonin, norepinephrine and acetylcholine are among the chemical messengers in these circuits that play a role in the regulation of emotions, including sadness, anger, anxiety, and irritability. Drugs that enhance brain serotonin function may improve emotional symptoms in BPD. Likewise, mood-stabilizing drugs that are known to enhance the activity of GABA, the brain's major inhibitory neurotransmitter, may help people who experience BPD-like mood swings. Such brain-based vulnerabilities can be managed with help from behavioral interventions and medications, much like people manage susceptibility to diabetes or high blood pressure.

Studies that translate basic findings about the neural basis of temperament, mood regulation, and cognition into clinically relevant insights�which bear directly on BPD�represent a growing area of NIMH-supported research. Research is also underway to test the efficacy of combining medications with behavioral treatments like DBT, and gauging the effect of childhood abuse and other stress in BPD on brain hormones. Data from the first prospective, longitudinal study of BPD, which began in the early 1990s, is expected to reveal how treatment affects the course of the illness. It will also pinpoint specific environmental factors and personality traits that predict a more favorable outcome. The Institute is also collaborating with a private foundation to help attract new researchers to develop a better understanding and better treatment for BPD.

The Future of Nations Depends on Their Care of Children

Fortunate children and families in democratic, industrialized societies are healthier and intellectually better prepared than ever. Good prenatal care, immunizations, diet, treatment of diseases, schools with advanced courses, and stable family life is improving the health, life expectancy, and achievement of large groups of children and youth. At the same time, increasing numbers of children and families are facing grave and life-threatening risks that reduce potential and lead to emotional and intellectual dead-ends. Too often, the lucky children with access to health care, eduction and social supports are separated only by short geographical distances from those whose lives are burdened by multi-generational poverty, family dysfunction, and social trauma. More and more, in advanced nations, there are two societies living in close proximity—those who are educated and wealthy, and those who are increasingly alienated. This polarization is not only harmful to both groups of children, it threatens the security of society in their future.

IACAPAP is the international spokes-man for all children, from infants to young adults, and their families, as well as for the professions that serve them. Our special concern is with children who are vulnerable or already suffering from emotional, behavioral, and developmental disorders. Today, the theoretical orientation that guides our work emphasizes the multi-generational nature of developmental psychopathology—the transmission of biological and psychosocial vulnerability and protective factors from one generation to another, and the expression of strengths and impairments in specific communal contexts. For more than fifty years, IACAPAP has been engaged in disseminating advances in clinical and developmental knowledge, helping to supportprofessionalsand to train the next generation, encouraging the advancement of the scientific basis of child psychiatry and psychology, and promoting the welfare of children and families. The 14th International IACAPAP Congress in Stockholm in the summer of 1998 will continue this tradition. Focusing on the care of children by mental health clinicians, the Congress will describe new scientific knowledge and emerging mental health systems. The Congress will describe how the science and therapies of the future will draw upon the concepts and skills of many disciplines– including child psychiatry, psychology, pediatrics, epidemiology, public health, nursing, education and neuroscience. Working in collaboration with families and communities, the mental health clinician of the future will be armed with a broadening range of psychological and biological treatments and a widening scope of theory and concepts. The problems we face will remain very difficult, of course, but the work will become more intellectually challenging and hopefully more effective.

Left on their own, children and families mobilize their own modes of adaptation to stress and trauma; when they are successful, the child and parents can move ahead with new competence and with confidence. Failures in adaptation, however, set the stage for a child and parents to move further off the mainstream and along paths leading to increasing dysfunction.

The scientific study of children’s development, in the context of family and community, can help provide a rational, empiri- cally testable framework for effective intervention. Biological and behavioral methods already are becoming available to analyze the contributions of specific and general genetic and biological factors to the vulnerability for disorders, and the ways in which environmental adversity interacts with constitution in the emergence of specific conditions. This knowledge will increasingly help to pinpoint the sensitive moments for intervention– from gestation through each phase of development–and the precise blend of psychosocial, behavioral, and pharmacological treatments.

Clinicians need to know when to allow children to right themselves and how to provide well-timed, effective interventions when development becomes derailed. All our treatments must, of course, be humane and ethical; as we learn more, they must also be able to withstand rigorous, scientific examination for effectiveness, efficiency and replicability.

For children and families, strengths generally build upon strengths and risks are compounded by failures. Healthy babies in loving families acquire the preconditions for later achievement in school and community. Small, vulnerable, drug exposed infants who are raised in chaotic and dysfunctional families fail to thrive as infants and will be two or three years behind in language and social skills by the time they reach school, where they are likely to fail and drop out. Yet, not all vulnerable children in situations of danger become impaired. By studying children who move ahead, in spite of risk, we also can learn about inborn strengths, protective factors, and what helps children cope with adversity, as well as about luck.

Just as in other branches of public health, this knowledge of the normal tasks of development as well as the threats to individuals and groups provides a rational orientation for prevention and treatment. We already know that support at each phase of development and early detection of difficulties are far more caring and efficient–for the child, family, and broader society–than later attempts at remediation when things have gone badly for too long a time. However, no child or group should be written off. Even in situations of persistent and serious psychosocial adversity– such as the clinical situations that confront us when we deal with street children, abused children, children suffering from AIDS, and seriously delinquent children– communities and clinicians can offer opportunities and hope for self-righting and future achievement. Of course, as clinicians we have a special responsibility for the care and treatment of children and adults with the most severe developmental, emotional and behavioral disorders. For many of these children, our greatest contribution may be the advancement of knowledge that can fundamentally alter their prognoses.

There are good reasons for clinicians and researchers to emphasize the first years of life when behavioral and biological templates are being laid down. During the first years, children take in the care they are provided. They metabolize these experiences and make them a part of themselves. This process is both psychological and biological. Children’s experiences affect their feelings, thoughts, and the internal emotional portraits of their family. These experiences, we are now learning, also determine how the brain matures, the density of synaptic connections, and the relations among different parts of the brain. All future emotional and cognitive development is built upon these psychological and biological foundations.

The care of the children in loving families is ideally suited to fertilize and mold their emerging competencies. This care facilitates children’s intellectual and emotional development, their language and thinking, their sense of personal value and autonomy, and the depth of their inner lives. The cognitive and attentional abilities that emerge from the interactions between inborn endowment and experience prepare children to enter school and make use of what they are taught to acquire the formal academic skills that are necessary for success in technological societies. Yet, there is no single, magic phase of development. Children who have started well require continuing affection, stimulation, protection and education. Some children cope remarkably well with adversity and early strain to become productive, competent adults, especially if they are provided suitable care.

To an increasing degree, children’s opportunities for continuity of nurturance by parents and extended families are being eroded. Broad social changes are affecting families of all social classes. One century ago, in the U.S. and Europe, the average family had many children (seven in the U.S.), two parents, and a mother at home to care for the children; divorce was rare. Today, the situation is vastly different. In Europe and the U.S., the average family has two children, both parents work, and infants are placed in day care during the first year or two of life. With many children born out of wedlock and divorce rates of 50%, most children will live with only one parent sometime during childhood.

As families have become smaller and more mobile, many young families can no longer turn to their own parents for help and guidance. Increasingly, there must be social systems to support young families and intervene when there are problems. New models of intervention are available. They emphasize the importance of prevention, family support, and the availability of an integrated spectrum of community-based services for those with serious problems. These models draw upon collaborations among different disciplines and between professionals and parents. The future mental health professionals will require knowledge about these new systems and the skills to work with other professionals and with families and the community.

Child mental health professionals have been immersed in the lives of children in many contexts—in hospitals, clinics, schools, and in the consulting room. Each context calls upon expertise in the understanding of development, as well as new types of knowledge. To work in hospital settings and with severely disturbed children, mental health professionals will require knowledge of clinical neuroscience, genetics, pharmacology, and cognitive and behavioral strategies, while preserving their sense of the child’s inner experience and family relationships.

To work in the community will require greater understanding of systems and of the methods and goals of other professionals, such as teachers, probation officers, judges, police, and social service agencies. For those who work in the most high risk situations—the impact of urban violence and war, drugs and AIDS; abuse and neglect; child labor and sexual exploitation; and the impact of parental physical and psychiatric illness on children—a range of clinical, advocacy, and political skills are called upon, in addition to broad clinical knowledge.

IACAPAP has special commitments to the most threatened children, such as those who are caught in war and urban violence. Today, millions of children are refugees and live in camps or as undocumented aliens, often separated from their parents. Trauma-tized by war at home, they are then exposed to illness, danger, lack of schooling, and risks of exploitation. In this domain, IACAPAP has been an international spokesman for the rights of children as well as deeply immersed in supporting clinicians and organizations who are directly involved in providing care.

IACAPAP also has an important role in providing leaders in government and international organizations with authentic knowledge that comes from clinical work and from research. The daily, intimate engagement of clinicians with families and communities is a rich source of information about the state of children, of institutions that serve them, and of what is useful for treatment. We need specialists who can integrate all types of epidemiological, biological, and clinical knowledge and provide this information in ways that are useful for legislators who must make the final policy decisions about allocation of resources.

This domain has taken on increasing importance in relation to the future security of nations. Throughout the world, leaders are recognizing that a nation’s most critical natural resource are its children. In the United States, President and Mrs. Clinton convened a special working group in the White House to discuss brain and behavior in the first years of life; they, like other leaders, are increasingly concerned about the implications of new scientific knowledge for how society cares for and educates children. To succeed in the future, nations need to optimize the development of children—to launch them down paths that will lead to physical and emotional health and the capacity to deal with the tensions that are arising from the increased polarization within society between those who are prepared for modern society and those who are pushed further and further to the margins. This polarization will prove to be as great a threat to security as political dangers from without.

At the beginning of the twentieth century, child advocates and government leaders talked about this being the century of the child. At the end of the century, we can see that this has been a grim century indeed for children and nations. The work of IACAPAP is to help assure that mental health professions—child psychiatry, psychology, social work, nursing and the other allied professions—can contribute to knowledge and services that will offer more hope and optimism for the next decade and century.


Donald J. Cohen, M.D.President, IACAPAPDirector, Yale Child Study CenterNew Haven, CT USAemail: Donald.Cohen@Yale.Edu

What is Borderline Personality?

This paper includes an extensive literature review of the role of trauma in the development of BPD, along with a clinical case study of a girl with BPD, and a transcript of an actual conversation between therapist and patient. BPD is characterized by a combination of impulsive, emotional, and cognitive deficits in personality functioning. The disorder seems to develop as a result of early childhood trauma, especially traumatic experiences related to parental neglect and abuse. Children who are classified as being highly abused tend to have greater tendencies toward developing BPD than non-abused children. This paper explores the association between childhood trauma and the development of borderline personality disorder in adult females.

From the Paper:

"Borderline Personality Disorder is characterized by an array of symptoms that are most prevalent in females. According to the DSM-IV, BPD 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, 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 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).
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. (American Psychiatric Association, 1995) "
   

Keywords: abuse adolescent bpd case depession emotional females instability literature neglect review study therapy women

Setting My Sights

Life can be dificult or life can be a systematic, mechanized, and steralized immitation automation of programmed sensation executed with stunning consistancy, line after line, time after time in the hive-mind coded Empire Matrix Trance Reality. It all depends on , I figure, if you're alive or if you're dead. Take responsibility! Drop the charade! Wake up.