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Borderline Personality Disorder: Signs and Treatment


Borderline Personality disorder (BPD) falls under the category of Cluster B personality disorders (PDs). These are defined by character traits such as dramatic, impulsive, and emotional. The core characteristics of BPD are extreme mood swings, difficulty controlling emotional responses, and unstable relationships. Individuals suffering from BPD are also at an increased risk of self-harm and suicide.

Onset and Prevalence

As with the majority of PDs, a diagnosis of BPD can only be made after an individual reaches 18 years of age, which is when the personality is fully developed. However, in the case of BPD, the onset of symptoms can be observed during the adolescent years. Some studies indicate that BPD can be reliably predicted in early adolescence as young as 11 years of age.

Prevalence in the general community is estimated to be up to 2% in individuals between 19 and 55 years of age. The rate is slightly higher among adolescents at around 3%. It is common for symptoms of BPD to ease with age and some reports suggest that they tend to mild in late adulthood between 30 and 40 years of age.

The prevalence of BPD is not equal between genders, as women have a higher risk of developing BPD. Clinical estimates suggest up to 75% of hospitalized individuals with BPD are female, but gender differences in the community are much smaller. During adolescence, the prevalence of BPD for both genders is reported to be around 2.6% for males and 3.9% for females. It’s important to note that these percentages vary based on age and country of residence.

Causes and Risk Factors

There is no single factor that causes BPD. The course of this disorder is less stable than the course of other personality disorders. Research indicates that environmental factors (especially adverse life events) and genetics both play a role in developing BPD.

Even though genetic markers have not been identified, BPD has a significant genetic component and is seen as a highly heritable disorder. Studies suggest that the key characteristics of BPD, namely hypersensitivity, emotion dysregulation, and impulsivity, tend to run in families and can be tracked across generations. BPD is more common in women than in men, which also supports the genetic component of this disorder.

Research has shown that childhood trauma is associated with a higher risk of developing BPD. Traumatic life experiences, especially early in childhood, are associated with BPD. Some examples include physical, sexual, or psychological abuse, neglect, and abandonment. In addition, maternal separation, parental substance use disorders, abnormal family relationships, and inappropriate boundaries can increase someone’s likelihood of developing BPD later in life.

Contemporary literature also suggests both functional and structural brain changes play a role in the development of BPD. The amygdala, which is a structure involved in emotion processing and memory, seems to be hyperresponsive in individuals with BPD. Structural brain imaging has indicated that, in comparison to healthy participants, the amygdala volumes were smaller in individuals diagnosed with BPD.

Symptoms

As with most personality disorders, BPD is commonly diagnosed in young adulthood. However, some markers can be seen during adolescence. These early symptoms are believed to be strong predictors of late-onset BPD:

  • Exaggerated sensitivity to rejection and fear of abandonment
  • A pronounced need and search for exclusive relationships
  • Body image problems such as eating disorders and body dysmorphia
  • Feelings of extreme shame
  • Deliberate self-harm behaviors

The central characteristic of BPD is a pattern of instability and notable impulsivity that greatly affects interpersonal relationships and self-image. An individual diagnosed with BPD will exhibit at least several of these essential features:

  • Exaggerated avoidance of abandonment, either real or imagined
  • Pervasive patterns of unstable interpersonal relationships (e.g., varying between extremes such as idolization and hatred)
  • Impulsivity resulting in destructive patterns, which must affect at least two of the following:
    • Financial wellness (e.g., spending too much, purchasing unaffordable items)
    • Romantic and sexual engagement
    • Substance use disorders
    • Feeding behaviors
    • Risk-taking activities (e.g., reckless driving)
  • Intense interpersonal relationships
  • An unstable sense of self and poor self-image
  • Recurrent threats or attempts at self-harm, self-mutilation, or suicide
  • A pervasive sense of emptiness
  • Periods of affective instability, which last from several hours to several days (e.g., intense episodes of dysphoria or anxiety)
  • Inappropriate anger (e.g., intense episodes of anger, irrational displays of temper, and recurrent physical fights)
  • Severe dissociative symptoms (e.g., feeling disconnected from oneself and the environment, forgetting about certain time periods, personal information, or events, and uncertainty about one's identity)

Treatment

The first line treatment for BPD is psychotherapy. If you think that you or your loved one is experiencing symptoms of BPD, seek out help by contacting your primary care physician who will refer you to a psychologist. There are a number of treatments available, such as cognitive behavioral therapy (CBT), psychotherapy, and dialectical behavior therapy (DBT). Your psychologist or psychiatrist will recommend the treatment that is most suitable for you. There is no specific medication for BPD, but medication can be used to treat some symptoms of BPD, such as depression. However, medication use is not a common treatment for BPD, especially for adolescents. For this reason, it is only prescribed in severe cases.

The prognosis for individuals with BPD is positive, especially in comparison with other PDs. The symptom severity of BPD often lessens with age. In some cases, symptoms may diminish completely around the age of 40. Most importantly, a commitment to therapy usually leads to successful symptom management with little to no impact on an individual’s quality-of-life.

It is important to note that the symptom severity of BPD is most intense during early adulthood and adolescence. Given the nature of this PD, individuals at that age are at an increased risk of self-harm, so seeking help as early as possible is crucial. If you have a loved one who is diagnosed with BPD, your support and encouragement are essential to assist them in seeking help or maintaining their course of treatment.

References

Guilé, J. M., Boissel, L., Alaux-Cantin, S., & de La Rivière, S. G. (2018). Borderline personality disorder in adolescents: prevalence, diagnosis, and treatment strategies. Adolescent health, medicine and therapeutics, 9, 199.

Leichsenring, F., Leibing, E., Kruse, J., New, A. S., & Leweke, F. (2011). Borderline personality disorder. The Lancet, 377(9759), 74-84.

Swartz, M., Blazer, D., George, L., & Winfield, I. (1990). Estimating the prevalence of borderline personality disorder in the community. Journal of personality disorders, 4(3), 257.

Tracie Shea, M., Edelen, M. O., Pinto, A., Yen, S., Gunderson, J. G., Skodol, A. E., ... & Morey, L. C. (2009). Improvement in borderline personality disorder in relationship to age. Acta Psychiatrica Scandinavica, 119(2), 143-148.

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