Border Personality Disorder (BPD)

Overview

  • 2 times more prevalent in women than men

Notable Features:

High Yield:

  • Suicide is common, with about 10% of patients committing suicide before 30 years of age.

Other:

  • Increased risk for comorbid mood disorders, eating disorders, substance abuse, and PTSD

  • Many clinicians experience counter-transference towards BPD patients, so it is important for clinicians to be aware of their feelings.

Definition

A pervasive pattern of instability in interpersonal relationships, self-image, affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts. This pattern is inflexible and pervasive across a broad range of personal and social situations that leads to clinically significant distress or functional impairment. The onset of this pattern of behavior is stable and of long duration, and can usually be traced back to adolescence or early adulthood.

Criteria (5 or more):

  1. Frantic efforts to avoid real or imagined abandonment

  2. Unstable and intense interpersonal relationships, alternating between extremes of idealization and devaluation

  3. Identity disturbance with markedly and persistently unstable self-image

  4. Impulsivity in at least 2 areas that are potentially self-damaging

    1. Spending, sex, substance abuse, reckless driving, or binge eating

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

  6. Affective instability due to a marked reactivity of chronic feelings of emptiness

  7. Inappropriate, intense anger, or difficulty controlling anger

  8. Transient, stress-related paranoid ideation or severe dissociative symptoms

Diagnostics


Differential

  • Personality disorders

  • Bipolar disorders

  • Psychotic disorders

Assessment

The acute onset of depression and suicidal behavior in response to interpersonal stressors (e.g. feelings of rejection or abandonment) and feelings of emptiness are characteristic. Core disturbances in self-image and affect regulation result in these features.

Unlike primary mood disorders, the mood shifts in BPD occur in response to situational stressors and last on the order of minutes or hours instead of days or weeks.

Management

Treatment options:

  • Psychotherapy

    • Several types of therapy are effective, but the most proven is dialectical behavioral therapy (DBT), a form of CBT which focuses on opposing statements and views for almost every subject, highlighting different ways to think about each view (how to take in other POVs without feeling empty or unstable). DBT also integrates techniques of emotion regulation and principles of mindfulness and distress tolerance to combat mood reactivity, impulsivity, and suicidality.

  • Individual therapy

    • Aimed at increasing coping skills, distress tolerance, mindfulness, affect regulation, and crisis management

  • Medications can help target symptoms (e.g. impulsivity, emotional lability, intermittent psychosis, and mood symptoms)

    • Antidepressants

    • Low-dose antipsychotics

    • Mood stabilizers

Pharmacotherapy has been shown to be more useful in BPD than in any other personality disorder, but as it does not treat the core pathology of BPD, it is only used adjunctively.

Resources