Written By Pranali Vora
Disorder Overview
Borderline Personality Disorder (BPD) was first coined by American psychoanalyst Adolf Stern in 1938 who used it to refer to patients whose symptoms deteriorated during therapy and showed signs of rigid psychological attitude (Biskin, 2012). 75% of those diagnosed with BPD are assigned female at birth, making it a female-predominant disorder. According to the DSM-V criteria, BPD in adolescents is a 12-month duration of immature personality development in at least five of the following nine domains: avoiding abandonment, unstable interpersonal relationships, identity disturbance, impulsivity, suicidality, self-mutilating behaviors, affective instability, chronic emptiness, intense anger, and stress-related paranoia (Guile, 2018).
Diagnostic Procedures and Criteria
BPD is now treated using the diagnostic measures relevant to the common symptoms of suicidality, aggression, and depressed mood. In the DSM-5, a “hybrid model” merges the two groups of psychometrics in BPD diagnosis: categorical and dimensional to account for personality traits (Biskin, 2012). However, there are limitations to accurate diagnosis due to the lack of a standardized biomarker to detect BPD and homogenous clinical correlates of symptoms in a population. To counteract this pushback, Jean Guile, an Adjunct Professor of Psychiatry at McGill University emphasizes early detection of BPD as it can appear in adolescents as young as 11 years of age. Currently, The Diagnostic Interview for Borderlines - Revised (DIB-R) is used, however, it is long and intensive, and therefore, self-report questionnaires such as the Mood Disorder Questionnaire have risen in popularity (Murray, 2023). It is important to note that additional self-report questionnaires addressing common symptoms of self-criticism, psychological distress, and social functioning are being assessed for diagnostic efficacy (Woodbridge, 2021). Although self-reporting is more feasible and does not require as many resources as for administering the DIB-R, it infamously misdiagnoses BPD as its common comorbid disorder, bipolar disorder. Due to the limited time that clinicians can spend with each patient, select “key factors” are used to decide whether further psychometric assessment is necessary. Therefore, clinicians touch upon the duration of symptoms (the longer, the more likely BPD is prevalent) and whether the patient is experiencing difficulties in multiple domains. Accurate diagnosis is extremely important as although BPD has a greater frequency of comorbidity, patients are more likely to be unresponsive to certain pharmacotherapy treatments if the diagnosis has been completed incorrectly (Jemal, 2022). Thus, once such accurate diagnoses are made, it is the clinician’s ethical duty as a provider to inform the patient of the diagnostic criteria and potential treatment plans to aid in seeing the “full picture”.
Symptoms
When patients are interviewed to assess for BPD prevalence, 4 categories are asked due to the relevance of their symptoms: affectivity, interpersonal functioning, impulse control, and cognition. The first category of affective symptoms relates to emotional dysregulation in which fluctuations between depression and anger (affective lability) are much shorter in length than when compared to bipolar disorder, are more likely to improve with time, and are caused by external, social events. Another common symptom is chronic emptiness which overlaps with hopelessness but for shorter periods of time than Major Depressive Disorder. The second category of impulsive symptoms is much easier to diagnose as it includes suicide attempts/threats, episodes of self-harm, and substance abuse as seen in more than 50% of BPD patients. Interpersonal symptoms are also considered when diagnosing BPD as attachment style is a key determinant as such patients often have unstable relationships, react to their fear of abandonment by isolating themselves from their loved ones and being dependent on their relationships to define their identity. The last category of symptoms is in the cognitive approach to psychological disorders as common BPD symptoms include dissociation, a disruption in consciousness and perception, paranoid thoughts, depersonalization, and misinterpretations of stimuli in their daily lives.
In contrast to BPD symptoms, BPD diagnosis can also be through a combination of the Five-Factor personality traits of neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. It is however, crucial to note that while BPD is a variety of personality traits to create a prototype score, the disorder is not merely a personality trait because the symptoms are volatile (Hopwood, 2011). Neuroticism, a tendency toward anxiety, depression, self-doubt, and other negative feelings in particular, have the strongest positive correlations with interpersonal characteristics of BPD. Extraversion and Agreeableness, on the other hand, tended to be negatively correlated with the likelihood of BPD diagnosis. Therefore, socially acceptable personality traits were more likely to be negatively correlated with BPD features.
In the long term, the Five-Factor model personality traits proved to be more effective than the already established BPD characteristics (four domains) as they accurately predict 10-year functioning. For short-term predictions, however, BPD characteristics are more likely to be used as they vary with great propensity and therefore, determine less stable pathological symptoms.
BPD Comorbidity
Bipolar Disorder (BD)
One out of five subjects show comorbidity between BPD and BD, and more likely, BPD characteristics often exacerbate the risk of BD with their symptoms of suicidality and worsened mood. Those with BPD and BD comorbid tend to have an increased chance of inpatient hospitalization due to suicide attempts and drug abuse which results in a longer inpatient stay and utilization of shock therapies such as electroconvulsive treatment to manage suicidal depression. The most overlapping feature between the two disorders, which also accounts for why one may be diagnosed as the other is mood instability as about 20% of bipolar II patients (less severe than bipolar I) have comorbid BPD, and most of whom belong to the demographics of female and young adult (Patel, 2019).
Substance Abuse Disorders
Comorbid BPD and Substance Abuse Disorder patients are more likely to be Males with cluster type A and B personality disorders (Qian, 2022). Approximately 78% of BPD individuals develop a substance or addiction-related disorder during their adult years. As impulsivity is a symptom of BPD, it is therefore understandable that such individuals develop a degree of substance dependency as this is related to inhibited impulse control (Kienast, 2014). These patients often have an affinity for short-term rewards (dopamine spikes) rather than working for long-term rewards.
Due to this unique nature of symptoms, patients are more likely to be less mentally stable and drop out of treatment plans due to a lack of motivation to improve one’s self. Therefore, patients with comorbid BPD and addiction should be treated as soon as clinically possible to prevent recurrent addiction first, and then use forms of psychotherapy to manage BPD symptoms. Even though such a plan seems feasible, many clinicians are still uncertain about what actions to take when responding to self-harm behavior which leads to compromised patient-provider relationships. The previous outcomes can be reduced with pharmacological relapse prevention and psychotherapy which focus on the individual’s schema related to substance dependence.
Potential Causes
Genetics
Based on current findings, the genes that have been linked to BPD prevalence have been found in the serotonin system, especially because low levels of serotonin indicate impulsivity, aggression, and self-harm behaviors. When tested in monkeys, those with the short alleles of the serotonin 5-hydroxytryptamine (5-HT) had a greater risk of developing BPD symptoms (Lis, 2007). In humans, the same 5-HT short allele is associated with violent behaviors, however, less efficient short alleles in terms of polymorphism are associated with high rates of comorbid BPD. Therefore, selective serotonin reuptake inhibitors (SSRIs) are a viable treatment for mood shifts in BPD patients. In studying whether BPD runs in the family, Ali Amad and his research team found that an inherited predisposition to emotional dysregulation is due to a family heredity of 40% (Amad, 2014).
Neurobiological Theory
Based on Functional-MRI findings of BPD patients, Inga Niedtfeld at the Central Institue of Mental Health Mannheim in Germany discovered enhanced negative coupling amongst the limbic, paralimbic, and prefrontal regions responsible for impulsivity and rational thinking (Niedteld, 2012). Additionally, the amygdala, which is responsible for emotional regulation of the “extreme” emotions of rage, fear, and impulse is often disconnected from the prefrontal cortex, therefore explaining why BPD individuals have volatile shifts in mood.
One of the limitations of analyzing data about neuroanatomical changes is that the research studies concerning this topic are often contradictory. Therefore, it is almost impossible to come up with one outcome that is standardized across the entire BPD population (Lis, 2007). Therefore, understanding sleep disturbances has risen as a potential shift to neuroanatomical research as insomnia is particularly common in BPD, as is the case in the pathophysiology of similar psychiatric disorders. In a study assessing the extent to which circadian rhythm contributes to BPD onset, University of Oxford researchers Niall McGowan and Kate Saunders found that such disturbance is associated with longer onset sleep, reduced total sleep duration, and poor sleep quality (McGowan, 2021). As insomnia tends to occur comorbid with BPD, potential treatments related to sleep improvement such as consistent bedtimes are associated with BPD symptom improvement.
Psychosocial factors
BPD onset can also be due to traumatic experiences during childhood through emotional, physical, or sexual abuse, which may be the factor in causing drastic changes in brain anatomy. Traumatic experiences can lead to higher stress levels which explains why the hypothalamic-pituitary axis (HPA) is activated to release cortisol (stress hormone) in the amygdala, prefrontal cortex, and hippocampus (Mainali, 2020). As BPD is often associated with early life stressors, early diagnosis, and therefore intervention becomes necessary.
Treatments and Efficacy
Pharmacotherapy
Although no medication has yet been approved for BPD treatment, approximately 96% of patients receive at least one psychotropic medication to reduce the severity of their symptoms (Gartlehner, 2021). The common categories of pharmacotherapy intervention include anticonvulsive, antidepressant, antipsychotic, sedative, melatonin, or benzodiazepine medications. As in most psychiatric disorder treatments, medication alone does not solve the problem, and therefore, should be used with psychotherapy techniques.
Anticonvulsants are mostly effective in treating the BPD symptoms of temper outbursts, suicidal behavior, and impulse dyscontrol (aggression, anger, hostility, and self-destruction). Second-generation antipsychotics (which only partially block the dopamine pathway to control suicidal thoughts) are more effective than placebo (therefore, producing significant results) in cognition, however, the incidence of adverse events of dizziness and weight gain were higher in individuals receiving antipsychotic medication. Melatonin and sedatives are used in the case of circadian rhythm sleep disturbances while benzodiazepines and antidepressants control agitation and impulsive behavior.
Psychotherapy
Specific manualized psychotherapies such as dialectical behavior therapy along with pharmacotherapy provide the greatest improvement in BPD symptoms due to improved mood regulation (Jones, 2023). This type of therapy includes a cognitive approach for BPD patients who are either unresponsive to intervention or difficult to treat based on comorbid disorders. The goal of DBT is to promote mindfulness and the positive impact of interpersonal relationships by breaking the stigma behind them in BPD patients through skills training and consistent coaching/meetings. In addition to DBT, proposed BPD treatment using mentalization-based treatment, (MBT) as it promotes the individual learning about themselves to develop stable emotional regulation and impulse control, or mentalization (Bateman, 2010).
References
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