Borderline personality disorder

Characterized by recurrent suicidality and self harm, excessive anger, sensitivity to rejection or abandonment.

It is characterized by alterations in self image, and interpersonal relationships, marked by sudden shifts between extremes of idealization, with extremely positive views, about the self, or others, and evaluation with extremely negative views about the self or others.

Accounts for 6% of primary care patients, and 15-20% of psychiatric patients (Gross R et al, Gunderson JG et al).

Patients with BPD typically have intense anxiety, irritability, or dysphoria, as well as impulsive behavior in regard to spending, sexual activity, substance, misuse, or binge eating.

it is a pervasive and persistent dysfunction, which can be distinguished from individuals with mood disorders, PTSD, anxiety disorders, substance related disorders, or bipolar disorders.

Symptoms of BPD include intense, anger, chronic feelings of emptiness, recurrent suicidal behavior, or self-mutilation, extreme efforts to avoid abandonment, and transient stress related paranoid ideation, or severe dissociative symptoms.

Disassociated symptoms meaning disintegration of usually integrated mental functions, such as consciousness, perception, memory, or identity, leading to amnesia or experiencing self or surroundings as unreal.

75% of persons with the disorder are female.

BPD affects approximately 0.7 to 2.7% of adults.

2.7% have been diagnosed with BPD in their lifetime.

Patients enter treatment facilities after suicide attempts, and have an average length of hospital stay of 6.3 days as a result.

More patients with BPD than patients with other personality disorders die by suicide.

Reported suicide rates of 2 to 5% over periods of follow up a 5 to 14 years occur among patients with BPD.

Patients have one emergency room visit every two years and that is a rate 6-12 times that of patients with major depressive disorder (Bender DS et al, Zanarini, MC et al).

Signs of the illness usually become evident in adolescence, with a diagnosis is usually made in young adulthood.

Diagnostic criteria: 5 or more of the follwing criteria.

Interpersonal hypersensivity-efforts to avoid real or imagined abandonment, a pattern of unstable and intense interpersonal relationships, alternating between extremes of idealization and devaluation

Affective dysregulation-Affective instability because of marked reactivity of mood-intense episodic dysphoria, irritability, or anxiety, usually lasting a few hours and rarely more than a few days, inappropiate intense anger or difficulty controlling anger with display of temper, constant anger, recurrent physical fights, chronic feelings of emptiness

Impulsitivity-Impulsive behavior in at least 2 areas potentially damaging such as spending money, sex, substance abuse, reckless driving, binge drinking, recurrent suicidal behavior, gestures, or self-mutilating behavior.

Borderline Personality Disorder can be understood as a combination of emotional lability, impulsivity  and hostility.

BPD associated with severe, social and vocational impairments, such as an inability to hold a job, high rates of comorbid mental disorders and somatic illnesses, more frequent use of outpatient and inpatient medical services, high rates of suicide, and a high, direct medical and indirect costs.

Identity disturbance with markedly and persistently unstable self-image or sense of self.

In a study comparing 100 healthy individuals to 100 borderline personality disorder patients, analysis showed that BPD patients were significantly more likely not to have been breastfed as a baby (42.4% in BPD vs. 9.2% in healthy controls).

Transient, stress related paranoid ideation or severe dissociative symptoms.

42-68% cases associated with genetic factors (Distal MA et al, Vallient GE et al).

Rates of BPD associated with genetic factors is similar to rates for hypertension.

All components of the disorder such as interpersonal hypersensitivity, affective dysregulation and impulsivity track in families.

Recurring suicidal threats or actions, when combined with fears of abandonment are strongly suggestive of the diagnosis.

Studies suggest that suicide attempts occur in more than 75% of patients with BPD.

Patients with BPD have a higher prevalence of endocrine, metabolic, respiratory, cardiovascular, and infectious disorders, and patients without BPD.

Patients with borderline personality have a higher incidence of other mental disorders: mood disorders, such as major depression, or bipolar disorder, 83%, anxiety disorders, 85%, substance-abuse disorders, 78%, post traumatic stress disorder, 30%, and other personality disorders, 53%.

Of patients with BPD, approximately 10% have bipolar 1 disorder and additional 10% have bipolar II disorder.

Among patients with attention deficit, hyperactivity disorder, the lifetime rate of BPD is almost 38%.

Mortality due to causes other than suicide is also higher with BPD.

Similar to patients with other mental disorders, patients with BPD die approximately 14 to 32 years earlier than individuals in the general population.

Recurrent crises and emotional volatility and self injurious behavior are willful and manipulative rather than signs of illness.

As individuals with BPD become older, emotional, dysregulation, unstable interpersonal relationships, anger, and attachment insecurity typically persist, whereas impulsivity and identity disturbances tend to decrease.

In older patients with BPD self harm may manifest, is non adherence to medications, or misuse of such.

Imaging studies reveal hyperesponsive amygdala and impared inhibition from the prefrontal cortex during tasks involving exposure to facial expressions, reactions to emotionally charged words, and interpersonal cooperation (Donegan NH et al, Silbersweig D et al, King-Casas B et al).

Neurohormones such as oxytocin, and opioids mediate exaggerated fears of rejection and abandonment seen in BPD.

Risk factors include childhood neglect, trauma, family problems, psychiatric problems, and insecure attachment.

BPD is more common in people with a family of BPD.

One study estimated heritability of BPD at 46%, with the remaining 54% of variance explained by non-shared environmental factors.

The hazard ratio is highest in identical twins at 11.5.

The risk of receiving a BPD diagnosis is increased by  4.7 fold for full siblings.

No single nucleotide variant has been identified.

Adverse childhood experiences, including physical, sexual, or emotional abuse, and neglect are more common in people with BPD, but not in all cases.

High remission rate of about 45% by two years and 85% by 10 years is achievable: Remission defined as no more than two diagnostic criteria being met for at least 12 months, and a low relapse rate of about 15% (Gunderson JG et al).

Suicide rate approximates 8-10%, and it is high for young women.

Despite remission rate only 25% can be fully employed and 40% receive disability payments at 10 years ( Gunderson JG et al).

Affects the course and management of comorbid medical conditions and other psychiatric diagnoses.

Increased association with reckless driving, domestic violence, incarceration and pathologic gambling.

Defining characteristics are hypersensitivity to rejection and preoccupation with abandonment.

Patients have little value of life unless connected to someone who cares for them, but they have unrealistic levels of availability and validation with such relationships.

When rejection is perceived rapid devaluation of the above relationship can occur.

Patients experience life in black or white, or all or nothing dichotomous thinking.

Patients vacillate between considering themselves as a good person being poorly treated and reacting with anger, or a bad person, without value, with suicide behavior.

Patients usually have poor body image, suffer from shame, search for exclusive relationships, have extreme sensitivity to rejection, experience behavioral problems including self harm.

The above factors indicate social disability and increase the risk of adult BPD by a factor of nine (Winograd G et al).

Frequently misdiagnosed as depression or bipolar disorder and are treated with antidepressants or mood stabilizers.

Depression in BPD associated with shame, and long-standing negative self-image.

Unlike bipolar disorder patients with BPD are extremely sensitive to rejection and do not have sustained periods of mania or elation.

On general personality disorders are characterized by two or more of the following: cognition, affectivity and impulse control.

Cognition includes perceiving in interpreting self, other people and events, affectivity includes intensity, lability, and appropriateness of emotional responses, and interpersonal functioning responses to interpersonal situation and impulse control.

BPD is characterized by perversive pattern of abrupt changes in self image, interpersonal relationships, and affects, including sudden shift between all good or all bad images of the self and others.

A borderline patient may describe a parent as abusive, then, several minutes later, described them as the best friend.

These extreme views of the self, and others, are unrelated to each other.

BPD is characterized by and marked impulsivity and shifting moods between intense anxiety, irritability and dysphoria, each lasting few hours to a few days.

Treatment involves setting, clear boundaries, avoiding response to provocation, avoiding polypharmacotherapy, and facilitating open communication.

Psychotherapy is the primary treatment, 4 types of therapy include: dialectical behavior therapy, metallization-based therapy, transference focused psychotherapy, and general psychiatric management.

Psychotherapy is first line treatment and is recommended to all patients with BPD.

Most patients experience remission of symptoms and treatments have been shown to be effective.

About half of the patients respond and treatment benefits are frequently not durable.

Medications are used for treating discrete, comorbid mental disorders, or in situation of crisis, such as suicidal behavior, extreme, anxiety, or psychotic episodes.

Observational studies report that over a ten-year period 50% of patients recover, defined as symptomatic, remission and good social and vocational functioning over a two-year period: of those that recover approximately a third have a recurrence of BPD symptoms and diagnosis after a 2 year long remission.

A meya analysis of 837 patients followed for at least five years reported remission rates between 50 and 70%.

Mean suicide rates range from 2 to 5%.

Some patients gain social functioning while others lose their gains.


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