Borderline Personality Disorder — The Dana Guide

by Larry J. Siever

March, 2007

[Editor's note: This article is from 2007.  Some newer treatments and prevalence statistics are not mentioned.]

sections include: clues to a biological causediagnosis and treatment 

Borderline personality disorder has two hallmark features. The first is the emotional instability that permeates the lives of people with this condition. People with this disorder are exquisitely sensitive to disappointments, frustration, and unmet expectations. Their responses to real or imagined adversity include such emotions as rage, despondency, sadness, or, when their emotional circuits are overloaded, even a bland feeling of numbness.

The second characteristic feature of people with borderline personality disorder is a marked tendency toward impulsive behavior and aggression directed against themselves or others. This can be apparent in angry tirades, verbal abuse, or self-destructive acts such as overdosing, cutting one’s wrist or arm, or suicide attempts. Someone with the disorder may also display a variety of other impulsive behaviors, such as reckless driving, alcohol or drug use, unsafe sex, binge eating, or gambling—though people without the condition do all these things as well. Often such behaviors are ways that people with borderline personality disorder vent their intense emotions and attempt to restore some sense of well-being. They perceive their actions as survival strategies for the hostile environment they experience.

The personal relationships of individuals with borderline personality disorder are characteristically quite stormy, frequently marked by the idealizing of another person in the early stages of the relationship, followed by an insecure attachment and fear of abandonment or, in other instances, devaluation. The intense fear of abandonment may result in exaggerated and manipulative behaviors, or cause individuals to cling to abusive relationships. Under periods of high stress, borderlines may become suspicious of others and even feel that people are acting in concert against them.

Because of their tumultuous emotions, people with borderline personality disorder have a hard time sustaining stable relationships and work commitments. They may not perceive how their behavior contributes to their problems, and may find themselves shunned by family members and colleagues. People with the disorder often have difficulties with their sense of identity or such “dissociative symptoms” as feeling unreal or as if the world around them were unreal. They are not frankly psychotic, however.

Individuals with borderline personality disorder often suffer from major depressive illness or bipolar (manic-depressive) disorder as well. In fact, at one point this condition was considered a variant of depression, but it is clear now that people with borderline personality disorder may not be depressed most of the time and that not all of them suffer from depression. Nonetheless, the sudden loss of a relationship, often with somebody they initially idealized, often causes them to be overwhelmed with such feelings of despair and abandonment that they seek treatment for depression.

Another disorder that has been associated with borderline personality disorder is post-traumatic stress disorder(PTSD). Some researchers have even proposed that borderline is a variant of PTSD. People with borderline personality disorder may indeed have experienced a history of trauma, often sexual abuse, which produces PTSD symptoms, but these seem to be only a minority of cases.

The symptoms of this condition may be very severe, with self-destructive behaviors leading to repeated hospitalizations. Ultimately there is a risk of lethal suicide attempts. Thus, borderline personality disorder can be among the most severe of the disorders affecting our brain and nervous system. On the other hand, many people with this condition can function adequately much of the time in work and relationships, even as they also experience a great deal of distress and cause the people close to them similar distress because of their recurring angry, irritable, and manipulative behaviors. 

Clues to a Biological Cause

We do not know the exact prevalence of borderline personality disorder, but one study suggests that slightly less than 2 percent of the general population suffers from it. Both men and women have the condition; the prevalence in women may be slightly greater. The symptoms often become apparent during adolescence or young adulthood. There is some suggestion that the prevalence of the disorder may decline or its intensity might decrease with advancing age.

Studies of identical and fraternal twins suggest that genes contribute significantly to the likelihood that a person will have borderline personality disorder, but those genes may be more closely related to impulsivity and emotional instability than to the disorder itself. There are some suggestions that genes related to certain brain chemical systems may contribute to an individual’s susceptibility, but definitive studies have yet to be completed. It may turn out that such genetic factors interact with childhood trauma, such as physical or sexual abuse, to contribute to borderline personality disorder. The condition is complex, and the possible explanations are still being explored.

Only a few studies have examined the brain structure and activity of people with borderline personality disorder. That research does suggest, however, that in those who have the disorder parts of the frontal cortex may be less active, while limbic regions may be very easily stimulated. The limbic structures of the brain regulate our emotional responses, and the cortex modulates the limbic region. (Phineas Gage, the railway worker described in chapter 1 of The Dana Guide to Brain Health, sustained damage to his left frontal cortex; he displayed unusually impulsive speech and behavior afterward.) If the limbic system is volatile and the cortex does not act to modulate it, the result might be like driving a runaway train of emotions. That combination might explain the impulsivity and emotional instability that people with borderline personality disorder display.

Serotonin, a brain chemical that regulates our appetite, mood, and temperature and suppresses aggressive behaviors, is an important regulator of frontal brain activity. You can think of serotonin as providing the fluid for our emotional brakes. Many studies have shown an association between the kind of impulsive aggression people with borderline personality disorder display and reduced signs of serotonin activity in the brain. For instance, in most people medications that increase the activity of serotonin activate the area of the frontal cortex directly over the eyes. For people with impulsive, aggressive personality disorders, brain imaging shows these medications to be less efficient. Other imaging studies suggest that the limbic regions of the brain in this disorder are hyperresponsive to drugs that might induce irritability in these brain areas.

These findings have set the stage for the development of medication to specifically treat borderline personality disorder. We suspect that agents that increase serotonin activity might play a role in normalizing frontal function, while agents that reduce limbic irritability, such as mood stabilizers, may dampen people’s emotional sensitivity.

Diagnosis and Treatment

Early recognition, diagnosis, and treatment of borderline personality disorder can be quite important. The behaviors characteristic of the disorder can cause serious harm to an individual’s occupational and personal development, not to mention his or her physical health and life. Psychiatrists are the most appropriate physicians to diagnose this disorder; they usually have more experience in recognizing its signs and symptoms, and are in the best position to evaluate people for possible treatment with medication. Clinical psychologists and social workers with specialized training in psychotherapy and personality disorders can evaluate an individual for possible psychotherapeutic treatment.

Physicians and mental health professionals diagnose borderline personality disorder primarily by hearing the history of the person’s symptoms and behaviors. It is often helpful for family members and others close to the individual to explain what they have witnessed, because people with the disorder may deny or minimize the extent of their problems. A person’s behavior during an evaluation interview or follow-up treatment also offers much useful information. There are no diagnostic tests for borderline personality disorder, but psychological testing can sometimes be helpful in identifying underlying problems.

Treatment for borderline personality disorder almost always makes use of some form of psychotherapy. People with this illness need to change their maladaptive patterns of behavior and develop new ways of coping with stress that involve delay and reflection rather than impulsive actions. There has been considerable research into effective treatments. One that has produced good results in a number of studies is called dialectical behavioral therapy. This is a form of cognitive behavioral therapy that seeks to change behavior and attitudes as well as to develop new skills for emotional regulation and social interaction. It includes a strong focus on reducing self-destructive behaviors. Other forms of cognitive behavioral therapy that employ anger management have also been successful. In addition to psychotherapy, training in managing interpersonal conflicts and frustration is an important part of treatment for people with borderline personality disorder.

Other types of psychotherapy include supportive psychotherapy, based on helping individuals cope with crises in their lives and become more comfortable with themselves while exploring new ways of handling their emotions. Psychodynamics psychotherapy relies on encouraging conscious decisions and shedding light on more unconscious patterns of behavior, usually in the context of a powerful relationship with the therapist. This provides an opportunity to understand the misconceptions and distortions individuals with the disorder carry with them from their childhood. This technique demands a certain capacity for insight and self-observation that may not be available to many people with the illness, however.

Treatment for borderline personality disorder may also include medications for certain accompanying problems. Antidepressants are usually effective in treating the major depression that an individual may also suffer from. The selective serotonin reuptake inhibitors (SSRIs), one type of antidepressant medication, have also been shown to be effective in treating the impulsive and aggressive behavior typical of the disorder, even in the absence of prominent depressive symptoms. Closely related medications, such as venlafaxine (Effexor) and nefazodone (Serzone), may also be useful in treating the impulsivity. These agents may help correct an underlying problem in the serotonin system. Unfortunately, people with borderline personality disorder can be very sensitive to medications’ side effects and often have difficulty taking high doses of the SSRIs or related compounds long enough to experience the beneficial effects.

Mood stabilizers such as lithium and the anticonvulsants valproate (Depakote) and carbamazepine (Tegretol) can be useful in dampening irritability, stabilizing the most rapidly changing emotions, and possibly even reducing the impulsivity. Clinical trials are evaluating these medicines’ therapeutic effects more rigorously. Antipsychotic medications, particularly such newer compounds as Clozaril, Risperdal, and Zyprexa, can be useful in reducing paranoid or psychotic-like symptoms, intense anxiety, and acting out, especially when a person is in acute crisis and needs to check into a hospital. Sometimes administering lower doses of these medications over a longer term can be helpful as well.

Finally, doctors may prescribe antianxiety medications such as buspirone or the benzodiazepines for some of the chronic anxious symptoms of this disorder. The benzodiazepines are potentially addictive, however, and they can have the effect of lowering a person’s inhibitions, thus working against the rest of the therapy.

Research into the causes of borderline personality disorder continues, including genetic, brain imaging, and biochemical studies. The more we know about what causes this disorder, the better we will be able to treat it and perhaps one day cure it.   

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