Borderline Personality Disorder (BPD)

Borderline Personality Disorder (BPD) is a personality disorder characterized by emotional dysregulation, a pattern of unstable interpersonal relationships and high impulsivity/recklessness. Patients can oscillate quickly between devaluing and idealizing relationships (commonly known as “splitting”). Other features include difficulty controlling anger, recurrent suicidal or self-harm behaviours, identity disturbance, and chronic feelings of emptiness.

• The population prevalence is estimated to be between 1.6 to 6%.
  • The prevalence in primary care settings is about 6%, and 10% in outpatient mental health clinics, and as high as 20% in psychiatric inpatients.^[1]
  • The prevalence of BPD decreases in older age groups.
• BPD is diagnosed predominantly in females (75%) and also present 3 times more commonly than men in treatment settings.^[2]

• The course of BPD is typically characterized by chronic instability in adolescence and early adulthood. Individuals can have serious affective instability, impulsivity (including self-harm and suicide attempts), and high levels of use of healthcare utilization.
• BPD has a significant impact on an individual's social and occupational functioning, including recurrent job losses, educational failure, and separation or divorce are common.
• Premature death from suicide can occur, especially in those with co-occurring depressive disorders or substance use disorders.
• Naturalistic studies have shown that patients with BPD can have progressive improvement and remission.^[3]
  • In one naturalistic study follow up after 10 years, 25% had full time employment and 40% were on disability benefits.^[4]
  • By the fourth decade of life, half of the individuals no longer have a pattern of behavior that meets full criteria for BPD.

• Depressive and bipolar disorders, eating disorders (in particular bulimia nervosa), posttraumatic stress disorder, attention-deficit/hyperactivity disorder, and substance use disorders are common.

• Physical and sexual abuse, neglect, hostile conflict, and early parental loss are risk factors
• BPD is five times more common among first-degree biological relatives of those with diagnosed BPD
  • There are certain genes that also predispose individuals to BPD.^[5]

BPD is associated with significant morbidity, mortality and healthcare costs (due to repetitive self harm and admissions to hospital). There is a significant suicide rate of about 10%.^[6] This is a source of significant distress for the patient, clinicians, and their community. Patients often have a chronic suicide risk that does not benefit from hospitalization. As a result, treating chronically suicidal patients requires balancing risks and require careful clinical judgment.^[7]

The term “borderline” originated with the concept that this disorder was on the border between neurosis and psychosis, essentially “bordering” on schizophrenia. The name continues as a historical term, but it is most certainly not a psychotic disorder. BPD is a diagnostic label that is used to group common features seen in this clinical population. There is ongoing debate about changing the name itself to something more accurate and less stigmatizing, such as emotion regulation disorder. There are also proposals to change the future diagnostic criteria beyond the DSM-5.

• Clinicians can be reluctant to make a diagnosis of BPD. One reason is that borderline personality is a complex syndrome with symptoms that resemble other primary psychiatric disorders such as depression, bipolar disorder, and psychosis.
  • Individuals with borderline personality disorder may be misdiagnosed as having one of these disorders, and have failed many medications over years, and not offered any evidence-based treatments for borderline personality such as dialectical behaviour therapy.
• However, making a borderline diagnosis does more justice to patients than avoiding it, because it guides clinicians and patients towards the most effective treatments.^[8]

• The term micropsychotic episodes is a historical term originating from the 1970s, when borderline personality was still being defined and thought of as being on the schizophrenia spectrum – the “borderline” between psychosis and neurosis.^[9]
  • At the time, patients with BPD were felt to have brief “psychotic” episodes that included paranoia, dissociation, and auditory hallucinations.
• Nowadays, this term continues to be used in a clinical context to describe these symptoms in a non-psychotic individual. Micropsychotic episodes may occur during periods of high stress for individuals with BPD.
• It is important to note that the term micropsychosis is not a formal terminology in the DSM, nor in the diagnostic criteria.^[10]

• Affective instability (i.e. - difficulty with emotional regulation) is most frequently occurring symptom in BPD. A single screening question, “Are you quick to react with anxiety/anger?” has a sensitivity of 94% and negative predictive value >95%.^[11]

• The exact etiology of BPD is currently unknown.
• The development of borderline personality is thought to be due an underlying sensitive temperament in the individual, plus an invalidating environment. Abuse and neglect is ubiquitous in the borderline population (>90%).
• A tripartite model of the development of BPD has been suggested by Zanarini (1997), which involves: (1) a traumatic childhood (i.e. - adverse childhood events), (2) a vulnerable (hyperbolic/sensitive) temperament, and (3) a triggering event(s).^[12]
  • This model suggests that borderline patients have a unique pathway to the development is a result of these three core elements.
• However, traumatic (physical/sexual/emotional) abuse alone does not cause BPD; there can be other factors that lead to the development of BPD.

• In neuroimaging findings, individuals with BPD have higher neural activity in the insular cortex (which correlates with individuals who experience who experience emotions more intensely) and the cingulate gyrus.^[13]
• Individuals with BPD also show less activation in prefrontal brain areas involved in cognitive control, which is impacted under conditions of negative emotions.^[14]

• Transference Focused Therapy (TFP)^[19]
• Mentalization Based Therapy (MBT)^[20]
• Schema Focused Therapy (SFT)^[21][22]
• Good Psychiatric Management^[23]

• While hospital admissions may provide temporary relief, there is no research evidence that shows hospitalizations actually increase safety or even reduce mortality in BPD.^[24][25]
• In fact, hospitalization can even be counterproductive or harmful. When there is chronic, unmodifiable suicidality, hospitalization can become recurrent and disruptive to the patient's life.^[26]
• However, this does not mean that individuals with BPD are never admitted to hospital. After a comprehensive safety and suicide risk assessment has been done, the clinician ultimately must make the decision on whether there are acute risk factors that would be modifiable with a hospital admission.

• Pharmacotherapy should never be (and is not) the first-line treatment for borderline personality disorder!
• Clinicians should always use medications for BPD with caution, and remind themselves it should be for short-term symptom relief.
• Current literature suggest that mood stabilizers and second-generation antipsychotics may be effective for treating a number of core symptoms. Pharmacotherapy should therefore be targeted at specific symptoms, with a review on whether or not medications are actually helping with the symptoms. ^[27]
• Unfortunately, there continues to be worldwide overuse of prescription medications for BPD.^[28] Medications (if prescribed at all) must be prescribed thoughtfully!