What Is Borderline Personality Disorder

Overview

As humans, we encounter and process a wide range of experiences daily  and these experiences influence  our thought patterns, mental makeup , and decision-making  process. These thoughts, emotions, and memories make up what is called the ‘personality’. If there is a problem in the way we think and feel and react to the environment to the extent that it disrupts our functioning in the world and others around us, it is called a personality disorder. 

Psychiatrists have found ten different types of personality disorders which are grouped into - ‘suspicious’, ‘emotional and impulsive’, and ‘anxious' types, of which the borderline personality disorder comes under the ‘emotional and impulsive’ group. 

People with borderline personality disorders have difficulties in four main areas:

1. Unstable emotions
2. Distorted ways of thinking
3. Impulsive behaviour
4. Relationships with others may be intense but unstable¹

Borderline personality disorder is a serious psychiatric disorder affecting about 4% of the population.² This disorder was poorly understood and difficult to treat but thanks to huge strides in the field of psychiatry, it has been studied more and more and a variety of treatments have been made available.²

Causes of borderline personality disorder

Borderline personality disorder has many causes. This condition has been found to run in families.³ Also, certain environmental factors have also been found to contribute to this problem. They include traumatic experiences in childhood like physical or sexual abuse and neglect, which were found in about 70% of people with this condition.³ In addition, difficulties in childhood faced because of separation from mother, lack of attachment to  mother, lack of well-defined boundaries, drug abuse by father, and serious mental conditions in parents.³

Many theories have evolved to explain the development of borderline personality disorder. Peter Fonagy and Antony Batman, have developed the ‘mentalising model’ where this condition is said to be due to a lack of resilience against psychological stressors or negative events.³ In the biosocial model proposed by Dr. Linehan, people who are vulnerable because of genetic factors when exposed to a negative environment develop the myriad of symptoms that characterise this disorder.³ Otto Kernberg hypothesized that when the infant experiences his mother in two contradicting circumstances- loving and punishing, and fails to integrate both concepts into one, they develop  intense anxiety and ‘splitting’. When splitting happens, the person cannot realistically perceive a person  as having both positive and negative attributes, and rather perceives people only as completely good or bad.³ Studies involving the structure and function of the brain have found that people suffering from borderline personality disorder may have unique structural and chemical differences attributable to this problem.³

Signs and symptoms of borderline personality disorder

According to the DSM-5 diagnostic criteria, having any 5 or more of  the following eight symptoms indicates  that the person could be suffering from borderline personality disorder.³

1. Trying hard to avoid a real or imaginary sense of abandonment
2. Unstable and intense in relationships swinging between idealising and devaluing
3. Having no stable self-image
4. Impulsive behaviour like reckless driving, abuse of drugs, sex,binge-eating spells, etc
5. Mood disturbances like intense fear, irritability, and sadness lasting a few hours to days
6. Feeling of emptiness lasting for a long time
7. Disproportionate anger, frequently ending in physical fights
8. Feeling obsessively mistrustful³

A person suspected to have this condition needs a complete physical and psychiatric assessment by a mental health professional. Patients who have been diagnosed with this disorder were found to have co-existing mental conditions like anxiety disorders, eating disorders, attention deficit hyperactivity disorder, and substance-abuse disorders.³

Treatment of borderline personality disorder

The main treatment of borderline personality disorder involves psychotherapy. Studies have proved three main types of psychotherapy available for this psychiatric condition. The first type is called ‘mentalising based therapy’ in which the patients are helped with managing their emotions by making them feel more understood, and encouraging  them to look at the intentions of the people around them in a different light.³

The second type of psychotherapy is called ‘dialectical behaviour therapy’ in which mindfulness training is given along with interpersonal and emotional management skills.³ In the third type called ‘transference-focused psychotherapy’, the interpersonal relationship between the psychotherapist and the patient is used to explore the problematic areas in the patient’s relationships.³

Both the first and the second types mentioned above are usually given as individual or group therapy over 12-18 months. When adolescents need treatment, sometimes family therapy involving other family members is advised.³

No medication has been used to treat borderline personality disorder. In some cases, medicines prescribed for other mental disorders like anti-anxiety drugs or mood stabilisers are used but they were not found to be effective in this condition.³

It is particularly challenging to treat these patients as they are prone to self-harm and have boundary issues. Besides, their tendency to abuse narcotics makes  them particularly hard to manage.³

Borderline  personality disorder usually does   not require admission to  hospital. The exceptions are when they are at risk of suicide or  self-harm, socially stressful conditions resulting in uncontrollable negative thoughts, or when the co-existing mental condition or drug addiction  flares up beyond control.³

The good news for the patients and their carers is that when given continuous treatment for 2 years or more, remission of symptoms was  observed in 35% to 99% of people.

FAQs 

How is borderline personality disorder diagnosed?

A person suspected to have borderline personality disorder is advised to see a qualified health professional, usually a GP who can assess a person based on his symptoms. They will perform a thorough interview, go through the complete medical history dating back to early childhood, and do a psychological assessment before diagnosing a borderline personality disorder.

The presence  of at least 5 out of 8 symptoms mentioned above, makes it highly likely to be a borderline personality disorder.

Can borderline personality disorder be prevented?

Borderline personality disorder is a common mental disorder, a very disabling condition, that can be diagnosed early and responds well to therapy. These factors make it a suitable candidate for developing prevention and early intervention strategies. The prevention strategies for borderline personality disorder aim  to alter the course of the life path for these people by mitigating some of the adverse factors and supporting them towards more positive future outcomes . Since in many cases, traumatic experiences in early childhood have been seen to be a major contributor, preventing and treating the affected children early, engaging troubled family relationships in family therapy and child safeguarding  can be positive steps taken to reduce the chances of developing this disorder.

The ‘Australian Helping Young People Early’ and the ‘Dutch Emotion Regulation training’ are examples of interventions performed on  young people with this disorder.⁴

Working towards a positive and supportive family environment for the children to grow up, treating substance abuse and mental health conditions in parents, screening children under the care system for mental health conditions, and providing a safe environment for children to grow up are some measures that can be taken on an  individual and societal basis to prevent this disorder.

Who are at risk of borderline personality disorder? 

In several studies, the risk factors for developing borderline personality disorder  (BPD) have been identified. Among them are adverse childhood environmental conditions like low family socioeconomic  status, prolonged separations from mother, family adversities, low maternal care and mental disorders in parents, childhood neglect, sexual abuse in childhood, and victims of chronic bullying.⁵

In three studies by Stepp and colleagues, poverty requiring social support may predict the development of BPD in the teenage years.⁵ They also reviewed three studies where they found that BPD was associated with ‘maladaptive parenting’ like low display of affection between mother and offspring , rejection and high expression of negative emotions from the mother, inconsistent maternal behaviour, and over-involvement. 

How common is borderline personality disorder?

Borderline personality disorder has been found to be present in 1.6% of the general population according to surveys and 20% among people admitted for mental health conditions.³

Personality disorders are in general common in  the urban compared to rural areas. The health services are available on a self-help basis but early detection and treatment can be implemented by screening for children in care and under the criminal justice system.⁶ In a study done by the Cambridge University, personality disorders were more common in men when compared with women.⁶

When should you see a doctor

If you have doubts that you may have borderline personality disorder, it is  safe to see a GP. It can be difficult to diagnose it yourself as the symptoms may overlap with other mental conditions like depression or anxiety. The GP will make an assessment and if BPD is suspected, a referral will be made to the community mental health team. They will make an in-depth assessment and advise the right therapy.⁷

People with personality disorders are usually advised to involve their trusted friends and family members in their treatment. They can monitor the symptoms and support them with treatment. There are also local support groups for patients and their carers.⁷

Summary

To summarise,  borderline personality disorder is a common psychiatric condition yet highly distressing for the affected person and their carers. The good news is there have been great leaps in our knowledge and treatment methods available for this condition. However, such personality disorders largely have their roots at  a young age, when adverse conditions cause a lot of trauma to the developing mind. They can be detected and treated early to provide good outcomes for the future of the young person. An overall awareness of this condition will help us understand and support a family member or a friend who may be suffering from this mental health condition.