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Mental Health

Borderline personality disorder (BPD)

Personality disorder characterized by unstable interpersonal relationships, fear of abandonment, difficulties in emotion regulation, feelings of emptiness, chronic dysphoria or depression, as well as impulsivity and heightened risk-taking behaviors.

Intrdouction

Personality disorder characterized by unstable interpersonal relationships, fear of abandonment, difficulties in emotion regulation, feelings of emptiness, chronic dysphoria or depression, as well as impulsivity and heightened risk-taking behaviors.

  • Cluster-B personality disorder (includes borderline, antisocial, narcissistic, and histrionic personality disorders)

History:

Milestones in BPD diagnosis, underlying mechanisms and treatment | Gunderson, J., Herpertz, S., Skodol, A. et al. Borderline personality disorder. Nat Rev Dis Primers 4, 18029 (2018). https://doi.org/10.1038/nrdp.2018.29

Aetiology

Borderline personality disorder is multifactorial in etiology.

Genetic predisposition: 50% heritability

Environmental factors :

  • Childhood maltreatment (physical, sexual, or neglect) (70% cases)
  • Maternal separation
  • Poor maternal attachment
  • Inappropriate family boundaries
  • Parental substance abuse
  • Serious parental psychopathology
A tentative logic model delineating the pathogenesis of Borderline Personality Disorder (BPD) from conception onwards | Winsper C. The aetiology of borderline personality disorder (BPD): contemporary theories and putative mechanisms. Curr Opin Psychol. 2018 Jun;21:105-110.

Clinical features

Symptom phenotypes of BPD | Gunderson, J., Herpertz, S., Skodol, A. et al. Borderline personality disorder. Nat Rev Dis Primers 4, 18029 (2018). https://doi.org/10.1038/nrdp.2018.29

DSM-5 diagnostic criteria for borderline personality disorder

A pervasive pattern of instability of interpersonal relationships, of self-image, and affects as well as marked impulsivity beginning by early adulthood and present in a variety of contexts as indicated by 5 or more of the following:
  1. Frantic efforts to avoid real/imagined abandonment (suicidal or self-mutilating behavior not covered in criterion)
  2. 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 2 areas that are potentially self-damaging, for example, spending, substance abuse, reckless driving, sex, binge eating, etc. (suicidal or self-mutilating behavior not covered in criterion)
  5. Affective instability caused by a marked reactivity of mood, for example, intense episodic dysphoria, anxiety, or irritability, usually lasting a few hours and rarely more than a few days.
  6. Chronic feelings of emptiness
  7. Inappropriate, intense anger, or difficulty controlling anger, for example, frequent displays of temper, constant anger, recurrent physical fights.
  8. Transient paranoid ideation or severe dissociative symptoms

Psychiatric comorbidities:

BPD is often a comorbid condition of other psychiatric disorders (formerly conceptualized as axis-I disorders according to DSM-IV), foremost depression, other personality disorders, and there seems to be syndromal overlap and/or comorbidity with bipolar disorder (BD), attention deficit/hyperactivity disorder (ADHD) and posttraumatic stress disorder (PTSD)
  • Mood disorders (80-96%)
  • Anxiety disorders (88%)
  • Substance abuse disorders (64%)
  • Eating disorders (53%)
  • Attention deficit hyperactivity disorder (ADHD) (10-30%)
  • Bipolar disorder (15%)
  • Somatoform disorders (10%)

Diagnosis

Clinical assessment:

Several diagnostic instruments are available to aid in diagnosis.
  • McClean Screening Instrument for BPD
  • Personality Diagnostic Questionnaire
  • Structured Clinical Interview for DSM-5 Personality Disorders
  • Minnesota Borderline Personality Disorder Scale
  • Personality Assessment Inventory-Borderline Features Scale

Management

Psychotherapies:

These therapies provide active and focused interventions that emphasize current functioning and relationships. These therapy modalities also provide; (a) a structured manual that supports the therapist and provides recommendations for common clinical problems; (b) they are structured so that they encourage increased activity, proactivity, and self-agency for the patients; (c) focus on emotional processing, particularly on creating robust connections between acts and feelings; (d) increased cognitive coherence in relation to subjective experience in the early phase of treatment by including a model of pathology that is carefully explained to the patient, and encouraging an active stance by the therapist, which invariably includes an explicit intent to validate and demonstrate empathy and generate strong attachment relationships to create a foundation of alliance.
  • Mentalizing-based therapy (MBT): Helps patients manage emotion dysregulation by feeling understood, allowing them to be more curious and make fewer assumptions about the intentions of the people around them.
  • Dialectical behavior therapy (DBT): Combines mindfulness practices with concrete interpersonal and emotion regulation skills.
    • MBT and DBT each incorporate individual and group treatment over 12 to 18 months
  • Transference-focused psychotherapy (TFP): Focuses on using patient-therapist relationship to develop the patient’s awareness of problematic interpersonal dynamics
  • Cognitive-behavioral therapy (CBT)
  • Schema-focused therapy
  • Family therapy (for adolescents): Appropriate substitute for group therapy, though not always.

Pharmacotherapy:

  • Antipsychotics
  • Anti-depressants: SSRIs, TCAs
  • Mood-stabilizing drugs

Summary:

Patients with borderline personality disorder face severe stigma owing to the type and severity of symptoms. These symptoms include interpersonal instability, behavioural dysregulation and emotional dysregulation | Borderline personality disorder. Nat Rev Dis Primers 4, 18030 (2018). https://doi.org/10.1038/nrdp.2018.30

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