By Jaya Sowkyadha, Farooq Ali Khan, Abhishek Kumar, Raamesh Gowri Raghavan, and Sukant Khurana
Introduction
Borderline personality disorder (BPD) is a neuropsychiatric disorder characterized by severe emotional dysfunction, poor social skills, impulsivity, cognitive impairment and self-harming behavior. The term ‘Borderline personality’ was first proposed in 1838 by Adolph Stern to describe patients who were neither psychotic nor neurotic but bordered these two conditions. However, this is a misnomer since it’s a complex disorder. DSM-IV-Text Revision now categorizes BPD under “Personality disorders”.
Patients suffering from BPD tend to make drastic attempts in order to avoid real or perceived abandonments, including causing self-harm and/or suicide threats. As a result, they experience a lot of instability in their social relationships. The suicide rate among those suffering from BPD is also very high. Though it was earlier believed to be more common in females than in males, recent research suggests that it is equally common in both but often misdiagnosed or underdiagnosed in males.1
BPD is often accompanied by one or more psychiatric disorders such depression, anxiety disorders etc. Its treatment is usually based on psychotherapy and psychopharmacology. However, due to the emotional turmoil along with suicidal behaviors accompanying this disorder, it is one of the toughest challenges for psychiatrists today.
Epidemiology
Surveys estimate a prevalence of 1–6% in the American population, with self-harm behavior noted in more than 70% of them and 8–10% committing suicide eventually.2
Another community survey estimated 1% of cases among adults.1
Though 80% of those who receive treatment for BPD are women, there is no striking difference in the case of community samples (unlike samples from databases which includes those seeking clinical help alone). This implies that it is often underdiagnosed or misdiagnosed in males.1
Symptoms
The symptoms of BPD can be classified into three main dimensions, along with cognitive symptoms 3:
· Affective symptoms:
– Extreme mood swings, each episode lasting for few hours to few days
– Anger outbursts
–Chronic feeling of emptiness, anxiety, general discontent
· Impulsive symptoms:
– Unstable relationships with family and friends, often swinging from extreme idealization to extreme hate, anger or devaluation
– Impulsive and self-damaging behavior like binge drinking, substance abuse, reckless driving, going on spending sprees and other self-harm behaviors
–Alternations between extreme idealizations to devaluation/hate in interpersonal relationships
· Interpersonal symptoms:
–Frantic efforts to avoid perceived or real abandonments, including threats of self-harm, manipulative behavior
–Patient’s self-image is often distorted
· Cognitive symptoms: depressive symptoms, feelings of grandiosity and narcissism, dissociation
Diagnosis
Overall characteristics of the disease can be assessed by the clinician on the basis of DSM IV-TR, which requires 5 out of 9 criteria to be present. This often leads to heterogeneity in the cases of BPD patients. Therefore, more precise research definitions are being developed which takes into account a summation of all the dimensions mentioned in the above section. The patient’s history is examined thoroughly, and any maladaptive behavior since early age or family’s psychological history is noted. BPD has increased chances of occurring in patients with a history of similar personality disorders in their family.1
Since the symptoms seen in BPD patients is wide and variable in its intensity, it can often go undetected when present along with other disorders like mood and anxiety disorders, depressive disorder, substance abuse etc.. The rates of comorbidity are: mood (50.9%), anxiety (59.6%), substance use (50.7%), and other personality disorders (73.9%).The rate of co-occurring PTSD in individuals with BPD is estimated at 30% (in community samples).4,5,6
Due to the characteristic mood swings which are seen in BPD, it is often confused with bipolar disorder. However, the time period of mood swings is very low in BPD compared to those in Bipolar disorder, i.e., rapid shifts are observed in emotional states.
Another common misdiagnosis of BPD is with that of schizophrenia. Unlike in Schizophrenia, there are no long term psychotic episodes seen in BPD. However, one might experience episodes which are “micro-psychotic” (lasting few hours or days), and auditory hallucinations with normal insights (unlike in schizophrenia where they can’t separate real sounds from hallucinations).
Management, treatment, and prognosis
Managing patients with BPD comes as a challenge for clinicians since they may have to deal with repeated suicide threats/ attempts, and the patient is at a risk of becoming overly attached to a therapist, failing to respect their boundaries.
While pharmacotherapy is often used for symptom specific treatment, its scope is very limited. The trials published are very limited in their insights due to small sample sizes, short duration of administration of drugs and the follow-ups. 1
Due to the limitations of pharmacotherapy as well the risk of abuse it carries, most common and preferred treatment for BPD is psychotherapy. Dialectical behavior therapy (DBT) targets affective instability and impulsivity, with its sessions (which may be group or individual) aimed at helping the patient regulate their emotions. While they’re shown to be effective in reducing the suicidal behavior, their long term effectiveness is largely unknown. Counseling is also given in many cases to family members and close friend circle of BPD patients to help them understand the person’s condition. Another psychotherapy common in practice is called Cognitive Behavioral Therapy (CBT), which aims at changing the pattern of thinking or behavior of the patient which are the root causes problems which one might face in their daily life. Other treatment options include transference-focused psychotherapy (TFP), mentalization therapy (MBT) and schema-focused therapy.
No drug is present currently which is designed specifically for the treatment of BPD, though drug based treatment is common in Psychiatry. These drugs mainly include those which are used to treat similar conditions such as depressive, anxiety disorders etc. Evidence from studies indicates that some second‐generation antipsychotics (aripiprazole, olanzapine, ziprasidone) and dietary supplementation by omega‐3 fatty acids, along with mood stabilizers (carbamazepine, lamotrigine, topiramate), are of significant benefit. 8
Successful management can be done by making an accurate diagnosis, maintaining a supportive relationship with the patient and establishing limited goals. Fortunately, almost 75% of times patients with BPD regain their normal states by the age of 35–40 years, and 90% by 50 years7.
Etiology
Many studies have concluded some of the major underlying causes of BPD to be childhood abuse (physical or sexual), childhood family environment, and familial aggregation of both internalizing and externalizing disorders. Since many of these factors tend to be to somewhat correlated, a study also examined all of these factors independently and concluded that: family environment, parental psychopathology, and history of abuse to be independently related to BPD (through multiple regression analysis). Sexual abuse was noted to contribute more to the prediction of BPD compared to family environment, although the latter’s contributed factors such as instability partially mediated the effect.9
Overall, etiological underpinnings of BPD can be seen as an emergent property of genes and environmental factors. The genetic basis is mainly said to be linked with the serotonin system (5-HTTLPR in specific), dopaminergic system, and genes which are involved in the production of monoamine oxidase-A (MAOA).10
Pathophysiology
Some of the insights which recent research on the neurobiology of BPD has provided include:
· Neuroanatomical and neuroimaging results:
o Volume analysis: Left amygdala and right hippocampus gray volume was noted to be decreased in people with BPD.11
o Functional analysis: Increased activation was noted while processing negative emotions in the left amygdala, left hippocampus, and posterior cingulate cortex along with diminished activation in prefrontal regions (mainly in dorsolateral prefrontal cortex). Another study reported heightened activity in the insula and diminished activation in the subgenual anterior cingulate cortex, but no significant difference in amygdala activity. The conflicting results can be attributed to the medications/ treatments which the patients might be taking.
Overall, we can say that BPD is marked by dysfunctional circuits in the hyperactive limbic regions and hypoactive pre-frontal modulation (which is most pronounced in dorsolateral prefrontal cortex). 11
· According to a study, patients with BPD, especially women, have a higher cortisol response upon awakening from sleep and throughout the day while awake, which may reflect a higher basal level of activity of the HPA axis in BPD. However, many of these endocrinological studies show inconsistent results, and its significance is not firm when measured independent of the social and pharmacological aspects.12
Drugs
As mentioned earlier, evidence from studies indicates that some second‐generation antipsychotics such as aripiprazole, olanzapine, ziprasidone, and dietary supplementation by omega‐3 fatty acids, along with mood stabilizers like carbamazepine, lamotrigine, topiramate, are of significant benefit. However, drugs specific to BPD are not yet available.
The prices of some of the above-mentioned drugs are as follows (according to MedIndia):
§ Aripiprazole (Arpizol) 15mg, Manufacture-Sun Pharmaceutical Industries Ltd.,
Cost for 10 tabs:
98.00
§ Olanzapine (Olan) 10mg, Manufacturer- Micro-labs (Synapse Division),
Cost for 10 tabs:
63.00
§ Ziprasidone (Zipsydon) 20mg, Manufacturer- Sun Rise International labs,
Cost for 50 tabs:
37.00
§ Carbamazepine (Carbacontin) Liquid, 50mg/mL: Manufacturer- Modi Mundi Pharma,
Cost for 10 mL:
18.95
Some of the common sources of omega-3 fatty acids are as follows:
1. Fish and seafood are some of the most common and rich sources of Omega-3 fatty acids. These mainly include Halibut, Herring, Mackerel, Oysters, Salmon, Sardines, Trout and fresh Tuna
2. Dairy and juice products fortified with Omega-3 fatty acids, i.e., eggs, milk, yogurt, soy milk etc.
3. Nuts and grains, such as cereal, flax seeds, chia seeds, walnuts, peanut butter, flour, bread and pasta which often have omega-3 supplements added to them
4. Leafy vegetables such as Kale, cauliflower, broccoli etc. are also rich in Omega-3 family content
Challenges
One should understand that mental health is of utmost importance to the overall health and well-being of an individual, and a challenge for the person suffering from it too in itself. Besides this general problem of people overlooking their mental health, some of the other challenges specific to the case of overcoming BPD from both social and clinical point of view are as follows:
§ In most of the clinical trials, there are very few follow-up studies which are done. This leads to a lack of insight in terms of the long term efficacy or side effects of the drugs.
§ Borderline personality disorder is often misdiagnosed, due to its symptoms overlapping with many other psychiatric disorders. This leads to delay, and in some cases lack or even mistreatment of the condition.
§ There are very few psychiatrists and psychologists willing to treat, or trained to treat BPD patients since there are many challenges they have to face while treating them, along with frequent suicidal threats/ attempts/ behavior. This is very unfortunate since BPD patients often show significant improvement using DBT and CBT approaches, along with support from their friends, family and loved ones.
§ The negative stigma associated with this disease is so common that it goes beyond the actual disease, and often can have a devastating effect for the patient. This sort of stigmatization is seen both in media and among clinicians. While treating BPD does require a lot of patience, recovering from BPD is still possible with proper treatment along with supportive family and friends. Proper skill training among clinicians for both diagnosis and management of patients with BPD is a must, and remains a challenge currently
Popular culture and trivia
–The month of May has been declared as the BPD awareness month by the United States House of Representatives in the year 2008.
– “Girl, interrupted” written in 1993 is a memoir by an American author Susanna Kaysen, who was diagnosed with BPD at the age of 18. It was later adapted into a film of the same name, starring famous actresses like Angelina Jolie, Winona Ryder, and Brittany Murphy.
BPD-suspected characters have been portrayed in many films and books, though in most cases it’s not explicitly mentioned to be BPD.
-Famous celebrities who have been diagnosed with BPD at some point of their life include Doug Ferrari (comedian), Angelina Jolie (presumptive BPD) and Brandon Marshall (wide receiver for the New York Giants of the NFL).
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References
1. “Borderline personality disorder”, Joel Paris, CMAJ. 2005 Jun 7; 172(12): 1579–1583. doi: 10.1503/cmaj.045281
2. A Developmental Neuroscience of Borderline Pathology: Emotion Dysregulation and Social Baseline Theory; Amy E. Hughes, Sheila E. Crowell, Lauren Uyeji, and James A. Coan, J Abnorm Child Psychol. 2012 Jan; 40(1): 21–33. doi: 10.1007/s10802–011–9555-x, PMCID: PMC3269568
3. National Institute of Mental Health “Borderline Personality Disorder”, Last updated: August 2016
4. Lenzenweger MF, Lane MC, Loranger AW, et al: “DSM-IV personality disorders in the National Comorbidity Survey Replication.” Biol Psychiatry 2007; 62:553–564,
5. Grant BF, Chou SP, Goldstein RB, et al: “Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions”. J Clin Psychiatry 2008; 69:533–545
6. Pagura J, Stein MB, Bolton JM, et al: “Comorbidity of borderline personality disorder and posttraumatic stress disorder in the US population.” J Psychiatr Res 2010; 44:1190–1198
7. “A 27-year follow-up of patients with borderline personality disorder”. Paris J, Zweig-Frank H, Compr Psychiatry. 2001 Nov-Dec; 42(6):482–7, PMID: 11704940 DOI: 10.1053/comp.2001.26271
8. (Stoffers J, Völlm BA, Rücker G, Timmer A, Huband N, Lieb K. “Pharmacological interventions for borderline personality disorder. Cochrane Database of Systematic” Reviews 2010, Issue 6. Art. No.: CD005653. DOI: 10.1002/14651858.CD005653.pub2.)
9. “The neurobiology of borderline personality disorder: the synergy of “nature and nurture”” Journal of Psychiatric Practice. 8(3):133–42, MAY 2002
10. J Psychiatry Neurosci. 2007 May; 32(3): 162–173, PMCID: PMC1863557 “Neuroimaging and genetics of borderline personality disorder: a review” Eric Lis, Brian Greenfield, Melissa Henry, Jean-Marc Guilé, and Geoffrey Dougherty
11. “The Neurobiology of Borderline Personality Disorder” March 31, 2016, Psychiatric Times, Borderline Personality, Neuropsychiatry, Personality Disorders, By Katherine S. Pier, MD, Lea K. Marin, MD, MPH, Jaime Wilsnack, MA, and Marianne Goodman, MD
12. “A Neurobiological Model of Borderline Personality Disorder: Systematic and Integrative Review” Anthony C. Ruocco, Ph.D., and Dean Carcone, MA, DOI: 10.1097/HRP.0000000000000123