Internet Mental Health
 
BORDERLINE (EMOTIONALLY UNSTABLE) PERSONALITY DISORDER
 


Prediction: Lasts For Decades

      Occupational-Economic:
  • Unemployment (interrupted education; sudden shifts in vocational aspirations; recurrent job losses)
      Wisdom vs Irrationality: N/A
      Courage vs Negative Emotion:
  • Separation anxiety, depressed mood, suicidal behavior
  • Separation or divorce are common; close relationships are unstable, intense
      Helping Others vs Detachment: N/A
      Self-Control vs Disinhibition:
  • Harmful impulsiveness, emotional instability, lacks meaningful life purpose & goals, unstable chaotic social life
      Justice vs Antagonism:
  • Physical violence
      Medical: N/A


SYNOPSIS

Emotionally Unstable [Borderline] Personality Disorder F60.3 - ICD10 Description, World Health Organization

Emotionally unstable [borderline] personality disorder is characterized by a definite tendency to act impulsively and without consideration of the consequences; the mood is unpredictable and capricious. There is a liability to outbursts of emotion and an incapacity to control the behavioural explosions. There is a tendency to quarrelsome behaviour and to conflicts with others, especially when impulsive acts are thwarted or censored. Two types may be distinguished: the impulsive type, characterized predominantly by emotional instability and lack of impulse control, and the borderline type, characterized in addition by disturbances in self-image, aims, and internal preferences, by chronic feelings of emptiness, by intense and unstable interpersonal relationships, and by a tendency to self-destructive behaviour, including suicide gestures and attempts.
Borderline Personality Disorder - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with borderline personality disorder needs to show at least 5 of the following criteria:

  • Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior here.)

  • A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

  • 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). (Note: Do not include suicidal or self-mutilating behavior here.)

  • Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

  • Affective instability due to a marked reactivity of mood (e.g., 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 (e.g., frequent displays of temper, constant anger, recurrent physical fights).

  • transient, stress-related paranoid ideation or severe dissociative symptoms.
Like all personality disorders, emotionally unstable [borderline] personality disorder is a deeply ingrained and enduring behaviour pattern, manifesting as an inflexible response to a broad range of personal and social situations. This behavior represents an extreme or significant deviation from the way in which the average individual in a given culture relates to others. This behaviour pattern tends to be stable. It causes subjective distress and problems in social performance.

Core Features

Individuals with borderline personality disorder grow up being emotionally unstable, hostile and impulsive. The core features of this disorder are: (1) negative emotions (emotional lability, anxiety, separation insecurity, depression, suicidal behavior), (2) antagonism (hostility), and (3) disinhibition (impulsivity, risk taking). This disorder is only diagnosed if: (1) it begins no later than early adulthood, (2) these behaviors occur at home, work, and in the community, and (3) these behaviors lead to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Lack Of Social Skills And Personality Disorders

There are social skills that are essential for healthy social functioning. Individuals with borderline personality disorder lack the essential social skills of emotional stability, stable self-image, and social stability. They lack chastity and caution (that are also lacking in individuals with histrionic personality disorder), and lack control of anger (that is also lacking in antisocial personality disorder).

    Social Skills That Are Lacking In Borderline Personality Disorder

    SOCIAL SKILL LOW LEVEL HIGH LEVEL
    Emotional Stability Emotional instability (emotions change rapidly and unpredictably) Having a predictable mood which does not quickly change
    Stable Self-Image Unstable self-image Being certain about “who-am-I” and “where-am-I-going-in-life”; having meaning & purpose to life
    Social Stability Social Instability (relationships are unstable, chaotic, and rapidly changing) Having a stable and peaceful social life
    Chastity Desire for casual or illicit sex Avoidance of casual sex (“one night stands”) AND absence of intense desire for illicit sex
    Caution Harmful impulsiveness (acting without forethought or concern for consequences) Thinking carefully before acting or speaking; being cautious
    Control of Anger Hostility (often angry or hostile) Absence of anger or irritability in response to minor slights; absence of mean or vengeful behavior

Antisocial personality disorder, narcissistic personality disorder, histrionic personality disorder, and borderline personality disorder are so closely related that they are referred to as the "antagonistic" cluster of personality disorders.

    Social Skills That Are Lacking In The "Antagonistic" Cluster Of Personality Disorders

    PERSONALITY DISORDER LACKING LACKING LACKING
    Antisocial Personality Respect (instead has disrespect) Responsibility (instead has irresponsibility) Honesty (instead has dishonesty)
    Narcissistic Personality Humility (instead has arrogance) Cooperation or Generosity (instead has being manipulative or greedy) Kindness (instead has callousness)
    Borderline Personality Emotional Stability (instead has emotional instability) Stable Self-Image (instead has unstable self-image) Social Stability (instead has social instability)
    Histrionic Personality Genuineness (instead has attention-seeking) Chastity (instead has desire for casual or illicit sex) Caution (instead has harmful impulsiveness)

Social Functioning

Individuals with borderline personality disorder have intense, unstable close relationships, which alternate between extremes of idealization and devaluation. They often make frantic efforts to avoid real or imagined abandonment.

Negative Emotion & Antagonism

Individuals with borderline personality disorder have marked negative emotions. They have frequent and intense experiences of high levels of a wide range of negative emotions (e.g., anxiety, depression, guilt/shame, worry). Antagonism: like many young teenagers, adults with this disorder have highly changeable moods and intense anger. Characteristically, these intense emotional episodes last only a few hours and only rarely more than a few days. The individual usually goes from one emotional crisis to another. Self harm and repeated, impulsive suicide attempts are seen in the more severely ill.

Borderline personality disorder is quite different from bipolar I disorder. The mood swings seen in borderline personality disorder seldom last more than one day. Mood swings in bipolar I disorder last much longer. Borderline personality disorder doesn't exhibit the prolonged episodes of decreased need for sleep, hyperactivity, pressured speech, reckless over-involvement, and grandiosity that are characteristic of bipolar I disorder.

    Negative Emotion
    • Emotions spiral out of control, leading to extremes of anxiety, sadness, rage, etc.
    • Has extreme reactions to perceived slights or criticism (e.g. may react with rage, humiliation, etc.).
    • Expresses emotion in exaggerated and theatrical ways.
    • Emotions change rapidly and unpredictably.
    • Feels unhappy, depressed, or despondent.

    Antagonism
    • Intense anger, out of proportion to the situation at hand (e.g. has rage episodes).
    • Often angry or hostile.

Borderline Traits

As well as having unstable emotional functioning and unstable interpersonal functioning; individuals with borderline personality disorder have a poorly developed, or unstable self-image, often associated with excessive self-criticism, chronic feelings of emptiness, and dissociative states under stress. Thus the main characteristic of this disorder is its instability. It has been argued that, rather than being a personality disorder, this disorder is just a delayed, unstable state of normal personality development. Individuals with this disorder appear to be having a developmental delay in passing through the emotionally turbulent phase of adolescence. Thus, in their twenties, they have the maturity of a young teenager.

    Borderline Traits
    • Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior.)
    • A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
    • 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). (Note: Do 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 (e.g., 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 (e.g., frequent displays of temper, constant anger, recurrent physical fights).
    • transient, stress-related paranoid ideation or severe dissociative symptoms.

    Borderline Coping Styles
    • Feels misunderstood, mistreated, or victimized.
    • Blames her own failures or shortcomings on other people or circumstances; attributes her difficulties to external factors rather than accepting responsibility for her own conduct or choices.
    • Gets into power struggles.
    • When upset, has trouble perceiving both positive and negative qualities in the same person at the same time (e.g. may see others in black or white terms, shift suddenly from seeing someone as an angel to seeing her as a devil).
    • Becomes irrational when strong emotions are stirred up; may show a significant decline from customary level of functioning.
    • Has little psychological insight into her own motives, behavior, etc.
    • Is unable to soothe or comfort herself without the help of another person (i.e. has difficulty regulating her own emotions).
    • Tends to “catastrophize”; is prone to see her problems as disastrous, unsolvable, etc.
    • Tends to hold grudges; may dwell on insults or slights for long periods.
    • When distressed, tends to revert to earlier, less mature ways of coping (e.g. clinging, whining, having tantrums).
    • Relationships tend to be unstable, chaotic, and rapidly changing.

    NOTE: These borderline traits and coping styles would be considered to be "normal" for many young adolescents. The majority of these young adolescents mature in their late teens and lose these borderline features. However, in normal development, it is not uncommon for these borderline features to persist into early adulthood; however it is less common for these borderline features to persist into middle adulthood. Thus the question is, for adults who still have borderline features, what factors prevented these individuals from maturing and losing these borderline features?

    It should be also noted that most of the coping styles seen in borderline personality disorder are also seen in antisocial, histrionic, and narcissistic personality disorders.

Disinhibition

In adulthood, individuals with borderline personality disorder are disinhibited. Like young teenagers, adults with this disorder often do impulsive, harmful activities (e.g., over-spending, reckless sex, substance abuse, reckless driving, binge eating). They want immediate gratification, and act without consideration of future consequences. In personality measurement, disinhibition is the opposite of conscientiousness. Research has shown that conscientiousness (or "grit") is even more important than intelligence in predicting scholastic and vocational success.

    Disinhibition
    • Tends to act impulsively (e.g. acts without forethought or concern for consequences).

Effective Therapies

A number of psychological treatments are partially effective for borderline personality disorder, but all lack robust evidence of their effectiveness. Dialectical behavior therapy (DBT) and general psychiatric management have been shown to be equally effective. Individuals with this disorder usually suffer from 2 or more psychiatric disorders. Thus, 2 years after therapy, even though two-thirds achieve diagnostic remission and significant increases in quality of life, 53% are neither employed nor in school, and 39% are still receiving psychiatric disability financial support. Pharmacotherapy can exert a modest beneficial effect on some core traits of borderline personality disorder.

These emotionally unstable individuals need a long-term mentor to establish a stable, supportive relationship in which clear and consistent boundaries are established. This mentor must have the patience and strength to withstand the patient's many crises and limit-testing episodes. Communication should always be clear, honest, optimistic and directed towards teaching more mature coping skills. This mentor could be a primary care physician, or some other qualified therapist.

Ineffective Therapies

Vitamin therapy, nutritional supplements, and special diets are all ineffective in the treatment of personality disorders.

Which Behavioral Dimensions Are Involved?

The ancient Greek civilization lasted for 1,300 years (8th century BC to 6th century AD). The ancient Greek philosophers taught that the 5 pillars of their civilization were: wisdom, courage, helping others, self-control, and justice. Psychiatry named the opposite of each of these 5 ancient themes as being a major dimension of psychopathology (i.e., irrationality, negative emotion, detachment, disinhibition, and antagonism). (Psychology named these same factors the "Big 5 dimensions of personality": "intellect", "neuroticism", "extraversion", "conscientiousness", and "agreeableness")

    Borderline Personality Disorder: Negative Emotions, Disinhibition and Antagonism
            Wisdom vs Irrationality: N/A
            Courage vs Negative Emotion:
      • Separation anxiety, depressed mood, suicidal behavior
      • Separation or divorce are common; close relationships are unstable, intense
            Helping Others vs Detachment: N/A
            Self-Control vs Disinhibition:
      • Harmful impulsiveness, emotional instability, lacks meaningful life purpose & goals, unstable chaotic social life
            Justice vs Antagonism:
      • Physical violence

Prevalence

The prevalence of borderline personality disorder is about 1.6% of the general population. It is seen in 20% of psychiatric inpatients. About 75% of these individuals are female.

Course

Borderline personality disorder is usually worse in the young-adult years and then it gradually decreases with age. In outpatient mental health clinics, after about 10 years, about half of individuals with this disorder no longer meet the full criteria for borderline personality disorder.

Familial Pattern

If individuals have borderline personality disorder; their first-degree biological relatives are 5 times more likely to have this disorder. These relatives also have an increased risk of having substance use disorders, antisocial personality disorder, and depressive or bipolar disorders.

Complications

Completed suicide occurs in 8%-10% of individuals with borderline personality disorder. Self-mutilation (e.g., cutting or burning), suicide threats and attempts are very common. Recurrent job losses, interrupted education, and broken marriages are common.

Comorbidity

Personality disorders are an overlooked and underappreciated source of psychiatric morbidity. Comorbid personality disorders may, in fact, account for much of the morbidity attributed to axis I disorders in research and clinical practice. "High percentages of patients with schizotypal (98.8%), borderline (98.3%), avoidant (96.2%), and obsessive-compulsive (87.6%) personality disorder and major depressive disorder (92.8%) exhibited moderate (or worse) impairment or poor (or worse) functioning in at least one area."
Some other disorders frequently occur with this disorder.

    Non-Personality Disorders

            Bipolar and Related Disorders:
      • Bipolar I or II disorder; cyclothymic disorder
            Depressive Disorders:
      • Major depressive disorder; persistent depressive disorder (dysthmia); substance/medication-induced depressive disorder
            Trauma- and Stressor-Related Disorders:
      • Posttraumatic stress disorder
            Feeding and Eating Disorders:
      • Bulimia nervosa
            Substance-Related and Addictive Disorders:
      • Substance use disorders
            Neurocognitive Disorders:
      • Attention-deficit/hyperactivity disorder

    Personality Disorders

            Antagonistic Cluster:
      • Histrionic, narcissistic, and antisocial personality disorders
        Note: Antisocial, narcissistic, borderline, and histrionic personality disorders are all closely related since they all share the same core feature of antagonism. This core feature is an exaggerated sense of self-importance, insensitivity towards the feelings and needs of others, and callous exploitation of others. These antagonistic behaviors put the individual at odds with other people. If an individual has one of these antagonistic personality disorders, they are very likely to have another.

Associated Laboratory Findings

No laboratory test has been found to be diagnostic of borderline personality disorder.

Primate Evolution

There appears to be three different ways in which primates have evolved socially:
  • The chimpanzees have evolved to be socially antagonistic, competitive, callous, and manipulative. Thus chimpanzee social behavior most closely mirrors the antagonistic behavior of the antisocial-narcissistic-borderline-histrionic cluster of personality disorders.

  • In contrast, the bonobos have evolved to be socially anxious, peaceful, cooperative, and loving. Thus bonobo social behavior most closely mirrors the negative emotion (anxious) behavior of the avoidant-dependent cluster of personality disorders.

  • Another separate evolutionary path was followed by the orangutans. They evolved to become solitary hermits. Thus orangutan social behavior most closely mirrors the detached behavior of the paranoid-schizoid-schizotypal cluster of personality disorders.

Core Behaviors Of The Antagonistic Cluster Of Personality Disorders

Cleopatra Seducing Caesar and Mark Antony


In this cluster of personality disorders, the males tend to be like Caesar and have antisocial and/or narcissistic personality disorders, and the females tend to be like Cleopatra and have borderline and/or histrionic personality disorders. The core feature of this cluster of personality disorders is antagonism. These individuals seem to be unconcerned about how their actions harm or upset others.

    Antagonism: The Core Feature Of The Antagonistic Cluster Of Personality Disorders

    • manipulativeness:
      In the past week, did you "con" or take advantage of someone?
    • callousness:
      In the past week, did you harm someone, but not care?
    • deceitfulness:
      In the past week, did you lie, steal, or cheat?
    • hostility:
      In the past week, were you actively hostile towards someone?
    • attention-seeking:
      In the past week, did you go out of your way to be the center of attention?
    • grandiosity:
      In the past week, did you treat others as if they were inferior to you?

Parental Behaviors Which Increase The Risk Of Developing A Personality Disorder

Research has shown that genetic, environmental, and prenatal factors all play important roles in the development of personality disorder. Recent research has also shown that low parental affection and harsh parenting increase the risk of a child later developing a personality disorder.

"Low affection" was defined as: low parental affection, low parental time spent with the child, poor parental communication with the child, poor home maintenance, low educational aspirations for the child, poor parental supervision, low paternal assistance to the child's mother, and poor paternal role fulfillment. "Harsh parenting" was defined as: harsh punishment, inconsistent maternal enforcement of rules, frequent loud arguments between the parents, difficulty controlling anger toward the child, possessiveness, use of guilt to control the child, and verbal abuse.

Setting Goals In Therapy

    Questions To Ask When Setting Goals

    In The Past Week:
    • WHO: was your problem?
    • EVENT: what did he/she do?
    • RESPONSE: how did you respond to that event?
    • OUTCOME: did your response help?
    • TRIGGER: what did you do that could have triggered this problem?
    • GOAL: what life skill(s) do you have to work on? (from checklist)

    Example Of Setting Goals In Interviewing A Person With Borderline Personality Disorder

    In The Past Week:
    • WHO: was your problem?
      "My husband."

    • EVENT: what did he/she do?
      "My husband is always angry at me, and is turning our children against me."

    • RESPONSE: how did you respond to that event?
      "I stand my ground and yell back at him."

    • OUTCOME: did your response help?
      "No, my kids can't take all this fighting. I think our marriage is nearly over."

    • TRIGGER: what did you do that could have triggered this problem?
      "Ever since my husband found out about my affair; he's been impossible to live with."

    • GOAL: what life skill(s) do you have to work on? (from checklist)
      "I want to work on: (1) Social Stability ("having a stable and peaceful social life"), and (2) Stable Self-Image ("being certain about “who-am-I” and “where-am-I-going-in-life”; having meaning & purpose to life")."

Description


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