Borderline Personality Disorder

Unstable Personality Disorder

What is it?

The key feature in the borderline personality disorder is its "instability in a variety of areas, including interpersonal behavior, mood, and self-image." Individuals with borderline personality disorder stand on the border between neurosis and psychosis and are characterized by an extraordinarily unstable affect, mood, behavior, and self-image. Borderlines often appear impulsive. They display abrupt, unexpected, and apparently spontaneous outbursts. This characteristic lends an unpredictability to their behavior. They may also exhibit irregular sleep-wake cycles that suggest some form of instability in regulated patterns of arousal. They frequently appear anxious to those who have contact with them. Borderline individuals tend to shift from experiencing a normal mood on one hand to inappropriately intense anger and rage, then to excitement or euphoria. These individuals, in addition to their vacillating and unstable mood, also seem to experience a chronic anxiety.

Borderlines may engage in self-damaging behaviors such as recurrent accidents, fights, self-mutilation, or suicidal gestures. Similarly, the borderline may engage in an excessive pattern of self-defeating behaviors such as overeating, gambling, spending sprees, shoplifting, or sexual behavior. These individuals almost always appear to be in a state of crisis. The painful nature of their existence is reflected in repetitive self-destructive acts as mentioned above. Their behavior is unpredictable and they may have short-lived psychotic episodes, rather than full-blown psychotic breaks. Separation anxiety is a prime motivator in the interpersonal behavior of borderline individuals. These individuals are exceedingly dependent on others. Identity disturbances are common in borderline individuals. They are uncertain about who they are and where they are headed in life. This disorder occurs in about one or two percent of the general population. It is twice as common in women as in men. First-degree relatives of borderlines have an increased prevalence of major depressive disorder, alcohol use disorders, and substance abuse.

How is it diagnosed?

History: Psychiatric interview and mental status exam are the primary methods of diagnosis. Borderline personality disorder is evident by a pervasive pattern of instability of interpersonal relationships, self-image, affects, and marked impulsivity. If individuals meet at least five of nine criteria as noted in the DSM-IV, a diagnosis can be made.

The borderline personality displays or expresses the following:

  • frantic efforts to avoid real or imagined abandonment (this does not include suicidal or self-mutilating behavior discussed below);
  • a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation;
  • evidence of identity disturbance (markedly and persistently unstable self-image or sense of self);
  • impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating) (does not include suicidal or self-mutilating behavior);
  • recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior;
  • affective instability due to a marked reactivity of mood (such as intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days);
  • chronic feelings of emptiness;
  • inappropriate, intense anger or difficulty controlling anger (such as frequent displays of temper, constant anger, recurrent physical fights);
  • or transient, stress-related paranoid ideation or severe dissociative symptoms.

Physical exam is generally not helpful in the diagnosis of borderline personality disorder. Observation of the individual's orientation, dress, mannerisms, behavior and content of speech provide essential signs to diagnose the illness.

Tests: Sleep studies have been suggested, as some individuals show shortened rapid eye movement (REM) latency and sleep continuity disturbances, abnormal dexamethasone-suppression test results, and abnormal thyrotropin-releasing hormone test results. These changes are also seen in some cases of depressive disorders.

How is it treated?

The treatment of choice for borderline personality disorder is psychotherapy. Individuals do well in a hospital setting with both intensive individual and group psychotherapy. A multidisciplinary approach is most successful, utilizing trained staff in recreational, occupational and vocational therapy. Ideally, individuals remain in the hospital until they show marked improvement, which could take as long as a year.

Behavior therapy and social skills training are utilized in an inpatient or outpatient setting. Outpatient settings utilized for these individuals include halfway houses, day treatment programs, night hospitals and other support groups.

Medications

Antipsychotics have been utilized to control anger, hostility, and brief psychotic episodes.

Mood stabilizing medications may help with mood swings.

Serotonergics and monoamine oxidase inhibitors (MAOIs) may help stabilize impulsive behavior and depressive symptoms.

Benzodiazepines (anti-panic or antianxiety drugs) can help anxiety and depression.

Information Brand Generic Label Rating
Buy Paxil Paxil Paroxetine Off-Label
Order Effexor Effexor Venlafaxine Off-Label
Sertraline Zoloft Sertraline Off-Label
Prozac Fluoxetine Off-Label
Seroquel Quetiapine Off-Label
Luvox Fluvoxamine Off-Label
Remeron Mirtazapine Off-Label
Zyprexa Olanzapine Off-Label
Trileptal Oxcarbazepine Off-Label

What might complicate it?

The borderline personality tends to be in a constant state of turmoil. There appears to be a constant and intense quest for support, security and love in their relationships. Complications occur when there is separation from, abandonment by, or disapproval from another person. Coexisting substance abuse, eating disorders, and promiscuity can all lead to complications in the course of the disorder. Other psychiatric disorders associated with the disorder and occurring along with the personality disorder will complicate the course, prognosis and outcome.

Predicted outcome

Borderline personality disorder has successful outcomes as long as treatment is initiated and maintained. In this scenario, psychotherapy and pharmacotherapy may allow the individual to maintain relationships. Without treatment, the course is usually chronic and the prognosis is poor.

Alternatives

Borderline personality disorder may be thought of as an extreme extension of less severe personality disorders (dependent, histrionic, passive-aggressive, or schizotypical). Associated Axis I disorders include generalized anxiety disorder, panic disorder, brief reactive psychosis, major depression and schizo-affective disorder.

Appropriate specialists

Psychiatrist or psychologist.

Last updated 18 November 2011


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