borderline personality disorder

Etiology

• unknown
• psychodynamic theories
  • excessive aggression
    • unstable identity development
    • unstable development of affective tolerance
  • maternal withdrawal
    • incomplete differentiation of child from mother
    • dual & inconsistent image of mother
      • rewarding & gratifying in response to dependency
      • punitive & withdrawing in response to autonomy
    • child rejects attention to reality to maintain relationship to mother
  • introjective failure
    • child's failure to internalize sense of self
• biogenetic theories
  • affective dysregulation
    • inability to modulate emotional responses to environmental events
      • easy to enrage
      • quickly to sadness
    • secondary defect in brain catecholamine metabolism
  • neurological dysfunction
    • genetic predisposition or early organic insult
    • low threshold for activation of limbic structures

Epidemiology

• 6% of primary care patients

Pathology

• disconnection of cortical inhibition of amygdala may correlate with impulsive aggression & emotional lability

Clinical manifestations

• features must be present since young adulthood to meet criteria for personality disorder
• emotional dysregulation
  • frantic efforts to avoid real or imagined abandonment
• a pattern of unstable & intense interpersonal relationships characterized by alternations between extremes of idealization & devaluation
• identity disturbance: persistent & markedly disturbed, distorted or unstable image or sense of self
• impulsivity in at least 2 areas that are potentially self damaging; i.e financial affairs, sex, substance abuse, reckless driving, binge eating
• feelings of depression: recurrent suicidal behaviors, gestures of threats or self-mutilating behavior (episodes may be short)
• feelings of emptiness (episodes may be short)
• affective instability due to a marked reactivity of mood (i.e. intense episodic dysphoria, irritability, or anxiety usually lasting only a few hours, rarely more than a few days)
• inappropriate, intense anger or lack of control of anger; i.e. frequent displays of temper, constant anger, recurrent physical fights
• transient, stress-related paranoid ideation or severe dissociative symptoms
• no changes in sleep or appetite
• complaints about other health care providers, but you are different

Differential diagnosis

• may co-occur with mood disorder
  • distinguishing features of borderline personality disorder
    • volatile interpersonal relationships
    • episodes of intense anger
    • attributes problems to others
      • complains about healthcare providers
• histrionic personality disorder
  • histrionic patients exhibit more pure attention-seeking behavior & more superficial behavior
  • histrionic personality disorder not associated with difficulty in regulating anger
  • borderline patients exhibit
    • self-destructiveness
    • angry disruptions in close relationships
    • chronic feelings of deep emptiness & loneliness
• schizotypal personality disorder
  • common symptoms of paranoia & illusions are more transient, interpersonally reactive & responsive to external structuring in borderline personality disorder
• paranoid personality disorder
  • relative stability of self-image
  • lack of self destructiveness
  • lack of impulsivity
  • lack of abandonment concerns
• narcissistic personality disorder
  • relative stability of self-image
  • lack of self destructiveness
  • lack of impulsivity
  • lack of abandonment concerns
• antisocial personality disorder
  • common symptom of manipulative behavior
    • antisocial behavior
      • more likely for material gratification, power or profit
    • borderline personality disorder
      • more likely to gain nurturance
• episodic dyscontrol syndrome; intermittent explosive disorder
  • failure to control aggressive impulses

Management

• refer to psychiatrist
• psychodynamic psychotherapy
  • establish secure attachment & trusting alliance with patient to establish sense of safety
  • provide stable treatment framework with clear patient- physician boundaries, schedules, rules & fairness
  • therapist must actively identify, confront, & direct the patient's behaviors & establish connection between actions & feeling
  • set limits on behaviors that threaten safety of the patient or therapist or the continuation of therapy
  • make self-destructive behaviors ungratifying
• supportive psychotherapy
  • improve patient's adaptation to life circumstances
  • diminish self-destructive responses to interpersonal conflicts
• cognitive therapy
  • develop a collaborative relationship with specific goals
  • select initial goals or target areas
  • minimize non compliance through adherence to treatment framework
  • make patient aware of dichotomous thinking
    • review experience along a continuum rather than right or wrong behavior
    • work to decrease dichotomous thinking
  • increase control over emotions
  • improve impulse control
  • strengthen sense of identity
  • develop alternate nondestructive strategies to treat sense of emptiness & abandonment
• dialectical behavior therapy
  • group focuses on behavioral coping skills
  • individual focuses on 6 hierarchically set goals
    • suicidal behaviors
    • therapy-interfering behaviors
    • behaviors that interfere with quality of life
    • behavioral skill acquisition
    • post-traumatic stress behavior
    • self-respect behavior
• group therapy
  • peers confront maladaptive & impuse patterns without being perceived as controlling to the patient
  • dependent of maladaptive gratifications are more easily made undesirable
  • group demonstrates a number of different coping methods
  • network of support
• pharmacotherapy for mood & anxiety-related symptoms
  • selective serotonin re-uptake inhibitors (SSRI)
  • tricyclic antidepressants (TCA)
  • monoamine oxidase (MAO) inhibitors
  • lithium carbonate: control of angry impulses
  • anticonvulsants: control of angry impulses
  • neuroleptics (low dose)
    • effects in reducing depression, anxiety, hostility, psychotic-like symptoms (depersonalization, dereali- zation, illusions, ideas of reference)
  • anxiolytics
• follow-up
  • sustained long-term psychotherapy for 3-5 years
  • compliance
  • monitor effectiveness & judge side effects of pharmacotherapy

More general terms

• cluster B personality disorder

Patient information

borderline personality disorder patient information