Raising questions, finding answers
Borderline personality disorder (BPD) is a serious mental illness characterized by
pervasive instability in moods, interpersonal relationships, self-image, and behavior. This instability often disrupts family
and work life, long-term planning, and the individual's sense of self-identity. Originally
thought to be at the "borderline" of psychosis, people with BPD suffer from a disorder of emotion regulation.
While less well known than schizophrenia or bipolar disorder (manic-depressive illness),
BPD is more common, affecting 2 percent of adults, mostly young women.1 There is a high rate of self-injury without suicide intent, as well as a significant rate of suicide attempts and completed
suicide in severe cases.2,3
Patients often need extensive mental health services, and account for 20 percent
of psychiatric hospitalizations.4 Yet, with help, many improve over time and are eventually able to lead productive lives.
While a person with depression or bipolar disorder typically endures the same mood
for weeks, a person with BPD may experience intense bouts of anger, depression and anxiety that may last only hours, or at
most a day.5 These may be associated with episodes of impulsive aggression, self-injury, and drug or alcohol abuse.
Distortions in cognition and sense of self can lead to frequent changes in long-term
goals, career plans, jobs, friendships, gender identity, and values.
Sometimes people with BPD view themselves as fundamentally bad, or unworthy. They
may feel unfairly misunderstood or mistreated, bored, empty, and have little idea who they are. Such symptoms are most acute
when people with BPD feel isolated and lacking in social support, and may result in frantic efforts to avoid being alone.
People with BPD often have highly unstable patterns of social relationships. While
they can develop intense but stormy attachments, their attitudes towards family, friends, and loved ones may suddenly shift
from idealization (great admiration and love) to devaluation (intense anger and dislike). Thus, they may form an immediate
attachment and idealize the other person, but when a slight separation or conflict occurs, they switch unexpectedly to the
other extreme and angrily accuse the other person of not caring for them at all.
Even with family members, individuals with BPD are highly sensitive to rejection,
reacting with anger and distress to such mild separations as a vacation, a business trip, or a sudden change in plans.
These fears of abandonment seem to be related to difficulties feeling emotionally
connected to important persons when they are physically absent, leaving the individual with BPD feeling lost and perhaps worthlessness.
Suicide threats and attempts may occur along with anger at perceived abandonment and disappointments.
People with BPD exhibit other impulsive behaviors, such as excessive spending, binge
eating and risky sex. BPD often occurs together with other psychiatric problems, particularly bipolar disorder, depression,
anxiety disorders, substance abuse, and other personality disorders.
Treatments for BPD have improved in recent years. Group and individual psychotherapy
are at least partially effective for many patients. Within the past 15 years, a new psychosocial treatment termed dialectical
behavior therapy (DBT) was developed specifically to treat BPD, and this technique has looked promising in treatment studies.6
Pharmacological treatments are often prescribed based on specific target symptoms shown
by the individual patient. Antidepressant drugs and mood stabilizers may be helpful for depressed and/or labile mood. Antipsychotic
drugs may also be used when there are distortions in thinking.7
Recent Research Findings
Although the cause of BPD is unknown, both environmental and genetic factors are thought
to play a role in predisposing patients to BPD symptoms and traits. Studies show that many, but not all individuals with BPD
report a history of abuse, neglect, or separation as young children.8 Forty to 71 percent of BPD patients report having been sexually abused, usually by a non-caregiver.9 Researchers believe that BPD results from a combination of individual vulnerability to environmental stress, neglect
or abuse as young children, and a series of events that trigger the onset of the disorder as young adults. Adults with BPD
are also considerably more likely to be the victim of violence, including rape and other crimes. This may result from both
harmful environments as well as impulsivity and poor judgement in choosing partners and lifestyles.
NIMH-funded neuroscience research is revealing brain mechanisms underlying the impulsively,
mood instability, aggression, anger, and negative emotion seen in BPD.
Studies suggest that people predisposed to impulsive aggression have impaired regulation
of the neural circuits that modulate emotion.10
The amygdala, a small almond-shaped structure deep inside the brain, is an important component
of the circuit that regulates negative emotion. In response to signals from other brain centers indicating a perceived threat,
it marshals fear and arousal.
This might be more pronounced under the influence of drugs like alcohol, or stress. Areas
in the front of the brain (pre-frontal area) act to dampen the activity of this circuit. Recent brain imaging studies show
that individual differences in the ability to activate regions of the prefrontal cerebral cortex thought to be involved in
inhibitory activity predict the ability to suppress negative emotion.11
Serotonin, norepinephrine and acetylcholine are among the chemical messengers in these circuits
that play a role in the regulation of emotions, including sadness, anger, anxiety and irritability.
Drugs that enhance brain serotonin function may improve emotional symptoms in BPD. Likewise,
mood-stabilizing drugs that are known to enhance the activity of GABA, the brain's major inhibitory neurotransmitter, may
help people who experience BPD-like mood swings.
Such brain-based vulnerabilities can be managed with help from behavioral interventions
and medications, much like people manage susceptibility to diabetes or high blood pressure.7
Studies that translate basic findings about the neural basis of temperament, mood regulation
and cognition into clinically relevant insightswhich bear directly on BPDrepresent a growing area of NIMH-supported research.
Research is also underway to test the efficacy of combining medications with behavioral
treatments like DBT, and gauging the effect of childhood abuse and other stress in BPD on brain hormones.
Data from the first prospective, longitudinal study of BPD, which began in the early 1990s,
is expected to reveal how treatment affects the course of the illness. It will also pinpoint specific environmental factors
and personality traits that predict a more favorable outcome.
The Institute is also collaborating with a private foundation to help attract new researchers
to develop a better understanding and better treatment for BPD.