neuromorphogenesis:

Borderline Personality Disorder

What is Borderline Personality Disorder?

Borderline Personality Disorder (BPD) is an often misunderstood, serious mental illness characterized by pervasive instability in moods, interpersonal relationships, self image and behavior. It is a disorder of emotional dysregulation. This instability often disrupts family and work, long-term planning and the individual’s sense of self-identity. While less well known than schizophrenia or bipolar disorder (manic-depressive illness), BPD is just as common, affecting between 1-2 percent of the general population.

The disorder, characterized by intense emotions, self-harming acts and stormy interpersonal relationships, was officially recognized in 1980 and given the name Borderline Personality Disorder. It was thought to occur on the border between psychotic and neurotic behavior. This is no longer considered a relevant analysis and the term itself, with its stigmatizing negative associations, has made diagnosing BPD problematic. The complex symptoms of the disorder often make patients difficult to treat and therefore may evoke feelings of anger and frustration in professionals trying to help, with the result that many professionals are often unwilling to make the diagnosis or treat persons with these symptoms. These problems have been aggravated by the lack of appropriate insurance coverage for the extended psychosocial treatments that BPD usually requires. Nevertheless, there has been much progress and success in the past 25 years in the understanding of and specialized treatment for BPD. It is, in fact, a diagnosis that has a lot of hope for recovery.

Causes:

Hippocampus

The hippocampus tends to be smaller in people with BPD, as it is in people with post-traumatic stress disorder (PTSD). However, in BPD, unlike PTSD, the amygdala also tends to be smaller.

Amygdala

The amygdala is smaller and more active in people with BPD. Decreased amygdala volume has also been found in people with obsessive-compulsive disorder. One study has found unusually strong activity in the left amygdalas of people with BPD when they experience and view displays of negative emotions. Since the amygdala is a major structure involved in generating negative emotions, this unusually strong activity may explain the unusual strength and longevity of fear, sadness, anger, and shame experienced by people with BPD, as well as their heightened sensitivity to displays of these emotions in others.

Prefrontal cortex

The prefrontal cortex tends to be less active in people with BPD, especially when recalling memories of abandonment. This relative inactivity occurs in the right anterior cingulate (areas 24 and 32). Given its role in regulating emotional arousal, the relative inactivity of the prefrontal cortex might explain the difficulties people with BPD experience in regulating their emotions and responses to stress.

Hypothalamic-pituitary-adrenal axis

The hypothalamic-pituitary-adrenal axis (HPA axis) regulates cortisol production, which is released in response to stress. Cortisol production tends to be elevated in people with BPD, indicating a hyperactive HPA axis in these individuals. This causes them to experience a greater biological stress response, which might explain their greater vulnerability to irritability. Since traumatic events can increase cortisol production and HPA axis activity, one possibility is that the prevalence of higher than average activity in the HPA axis of people with BPD may simply be a reflection of the higher than average prevalence of traumatic childhood and maturational events among people with BPD. Another possibility is that, by heightening their sensitivity to stressful events, increased cortisol production may predispose those with BPD to experience stressful childhood and maturational events as traumatic. Increased cortisol production is also associated with an increased risk of suicidal behavior.

On the one hand, a brain area called the insula—which helps determine how intensely we experience negative emotions—is hyperactive in people with BPD. On the other hand, regions in the frontal part of the brain—which are thought to help us control our emotional reactions—are underactive (Image 2). 

Neurobiological factors:

Estrogen

Individual differences in women’s estrogen cycles may be related to the expression of BPD symptoms in female patients. A 2003 study found that women’s BPD symptoms were predicted by changes in estrogen levels throughout their menstrual cycles, an effect that remained significant when the results were controlled for a general increase in negative affect.

Symptoms experienced due to disturbed levels of estrogen are often misdiagnosed as BPD, like extreme mood swings and depression. As endometriosis is an estrogen responsive disease, severe PMS and PMDD symptoms are observed, that are both physical and psychological in nature. Hormone-responsive mood disorders also known as reproductive depression are seen to cease only after menopause or hysterectomy. Psychotic episodes treated with estrogen in women with BPD show considerable improvement but must not be prescribed to those with endometriosis as it worsens their endocrine condition. Mood stabilizing drugs used for bipolar disorder do not help patients with disturbed estrogen levels. A correct diagnosis between endocrine disorder and psychiatric disorder must be made.

Adverse childhood experiences

There is a strong correlation between child abuse, especially child sexual abuse, and development of BPD. Many individuals with BPD report a history of abuse and neglect as young children. Patients with BPD have been found to be significantly more likely to report having been verbally, emotionally, physically or sexually abused by caregivers of either gender. They also report a high incidence of incest and loss of caregivers in early childhood.

Individuals with BPD were also likely to report having caregivers of both sexes deny the validity of their thoughts and feelings. Caregivers were also reported to have failed to provide needed protection and to have neglected their child’s physical care. Parents of both sexes were typically reported to have withdrawn from the child emotionally, and to have treated the child inconsistently. 

However, none of these studies provide evidence that childhood trauma necessarily causes or contributes to causing BPD. Rather, both the trauma and the BPD could be caused by a third factor. For example, it could be that many caregivers who tend to expose children to traumatic experiences do so partly because of their own heritable personality disorders, the genetic predisposition for which they may pass on to their children, who develop BPD as a result of that predisposition and other factors, and not as a result of prior mistreatment.

Signs & Symptoms

According to the DSM, Fourth Edition, Text Revision (DSM-IV-TR), to be diagnosed with borderline personality disorder, a person must show an enduring pattern of behavior that includes at least five of the following symptoms:

• Extreme reactions—including panic, depression, rage, or frantic actions—to abandonment, whether real or perceived
• A pattern of intense and stormy relationships with family, friends, and loved ones, often veering from extreme closeness and love (idealization) to extreme dislike or anger (devaluation)
• Distorted and unstable self-image or sense of self, which can result in sudden changes in feelings, opinions, values, or plans and goals for the future (such as school or career choices)
• Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating
• Recurring suicidal behaviors or threats or self-harming behavior, such as cutting
• Intense and highly changeable moods, with each episode lasting from a few hours to a few days
• Chronic feelings of emptiness and/or boredom
• Inappropriate, intense anger or problems controlling anger
• Having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body, or losing touch with reality.

Seemingly mundane events may trigger symptoms. For example, people with BPD may feel angry and distressed over minor separations—such as vacations, business trips, or sudden changes of plans—from people to whom they feel close. Studies show that people with this disorder may see anger in an emotionally neutral face and have a stronger reaction to words with negative meanings than people who do not have the disorder.

Treatment:

Psychotherapy

Psychotherapy is the cornerstone of most treatments for Borderline Personality Disorder.  Although development of a secure attachment to the therapist is generally essential for the psychotherapy to have useful effects, this does not occur easily with the BPD diagnosed individual, given the intense needs and fears about relationships.  The standard recommendation for individual psychotherapy involves one to two visits a week with an experienced clinician.  The symptoms of the disorder can be as difficult for professionals to experience as those experienced by family members.  Some therapists are apprehensive about working with individuals with this diagnosis.

Medication

Of the typical antipsychotics studied in relation to BPD, haloperidol may reduce anger, and flupenthixol may reduce the likelihood of suicidal behavior. Among the atypical antipsychotics, aripiprazole may reduce interpersonal problems, impulsivity, anger, psychotic paranoid symptoms, depression, anxiety, and general psychiatric pathology. Antidepressant and anti-anxiety agents may be appropriate during particular times in the patient’s treatment

Mindfulness

In the past two decades, many psychiatrists, psychologists, and other mental health professionals have incorporated mindfulness meditation training into their psychotherapy practice. Mindfulness meditation has been used to help treat or ameliorate the symptoms of disorders such as major depressive disorder, chronic pain, generalized anxiety disorder, and borderline personality disorder, and research has found therapy based on mindfulness to be effective, particularly for reducing anxiety, depression, and stress.

Sources: 1 2 3 4 5