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9. Siever LJ, Davis KL: A psychobiological perspective on the personality disorders. Am J Psychiatry 148: 1657-1658, 1991. 10. Turkat ID: The Personality Disorders: A Psychological Approach to Clinical Management. Elmsford, NY, Pergamon Press, 1990. 1 1. Tyrer P: Personality Disorders. Management and Course. London, Butterworth, 1988.

38. BORDERLINE PERSONALITY DISORDER

Robin A. McCann, P k D . , and Elissa M. Ball, M.D

1. What is borderline personality disorder? The key to recognizing borderline personality disorder (BPD) is instability-instability in affect, interpersonal relationships, and self-identity. The emotional instability of patients with BPD is characterized by vulnerability, intensity, and poor regulation. Emotions are quickly and easily aroused and more intense than those of others; patients often experience difficulty soothing themselves and returning to a stable emotional baseline. They are particularly vulnerable to perceived or actual abandonment and often react with rage, panic, and despair. As people with BPD have difficulty in soothing themselves, they may attempt to block the experience of pain by experiencing, if not inducing, changes in consciousness, including feelings of derealization, depersonalization, and brief psychotic reactions with delusions and hallucinations. Substance use, gambling, overspending, eating binges, and/or self-mutilation, including suicidal threats, gestures, and attempts, are often used to escape intensely painful affect. People with BPD frequently engage in self-injurious acts, ranging from minor scratches or self-inflicted cigarette bums to overdoses or other acts requiring ICU admissions; such nonfatal, intentionally self-harmful acts are referred to as parasuicidal behaviors. 2. What are the diagnostic criteria for BPD? The criteria for BPD were developed by consensus rather than empirical study and were first published in 1980 in DSM 111. Specific DSM IV diagnostic criteria' for BPD are as follows: A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or selfmutilating behavior covered in Criterion 5. 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. Identity disturbance: markedly and persistently unstable self image or sense of self. 4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5. 5 . Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. 6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days). 7. Chronic feelings of emptiness. 8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). 9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Copyright 1994 American Psychiatric Association.

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3. How is emotional lability evidenced in the BPD patient?

Emotional lability is often associated with a cognitive style characterized by all-or-nothing, either-or thinking. Patients vacillate suddenly between rigidly held, yet contradictory points of view and find it extremely difficult to formulate compromise positions. This cognitive style contributes to an unstable self-concept and unstable interpersonal relationships. For example, the belief that Dr. X is totally trustworthy leads to worship or idealization of Dr. X. When Dr. X inevitably disappoints the patient, perhaps by saying no to a particular request, the patient predictably decides that Dr. X is as totally untrustworthy individual who deserves punishment and denigration; Dr. Xs reasons for denying the request are not considered. Thus, relationships between patients with BPD and their significant others, including spouses, children, and treatment providers, often begin on a highly positive note (idealization), but deteriorate quickly into a chronically irritating and often emotionally and physically abusive interchange (devaluation). Unstable self-concept and emotional lability predict difficulty in maintaining commitment to long-term goals. Commitment to school, occupation, friends, mores, and treatment plans is erratic. Behavior is impulsive and unpredictable and further contributes to unstable relationships. People with BPD often frantically seek the company and attention of others to avoid feeling lonely, empty, and worthless. Examples of such characters in literature and film include Alex in Fatal Attraction and Natalya Fillipovna in Dostoyevskys The Idiot.

4. How common is BPD?

BPD is commonly diagnosed, particularly among women. Approximately 10% of psychiatric outpatients and 20% of psychiatric inpatients meet criteria for BPD. Approximately 75% of patients diagnosed with BPD are women.

5. Explain the origin of the term borderline.

The term borderline has both historical and colloquial uses extending beyond the DSM IV criteria. Historically, the term described individuals with both neurotic and psychotic symptoms who were believed to be on the borderline or continuum between psychosis and neurosis. Some patients diagnosed with schizophrenia before 1980 (when DSM I11 criteria for schizophrenia were constricted and refined) probably would be diagnosed with BPD today. Historically, the term also described a pathologic level of personality organization, subsuming some but not all of the characteristics of the current DSM IV criteria, including instability of self-concept and poor differentiation between self and others. Colloquially, the term sometimes has been used pejoratively to describe patients who evoke anger or hate in treatment providers.

6. What causes BPD? The many proposed etiologies reflect a variety of theoretical paradigms. From a psychodynamic paradigm, BPD is the result of poor mothering. Because the mother-child relationship serves as a template for later relationships, it is important that it is good enough. A good-enough mother adequately responds to her childs needs and fosters an adequate balance between dependence and independence. Without a mother who is adequately reflective and responding, the child who later develops BPD is unable to develop a sense of self that is strong, cohesive, and good. Without a strong sense of self, the child is unable to separate and differentiate self from mother. Thus, without a sufficiently cohesive sense of self, the child is unable to differentiate self from others. To an excessive degree, the child seeks self-definition and safety through others. A biologic paradigm suggests that BPD is the result of an innate inability to modulate or tolerate emotion. Regulation of emotion is complex and involves multiple areas of the brain. Research to date does not suggest any single neurologic or genetic factor common to all borderline patients. Abnormalities in limbic system reactivity have been suggested as causal factors of emotion dysregulation. Limbic abnormalities may result from genetic influences, intrauterine events, or negative effects on brain development of early childhood environments. Some researchers have suggested that chronic sexual abuse and other severe, recurrent traumas (more common in patients with BPD than in those without BPD or normative samples) may physiologically alter the limbic system and

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thereby cause permanent adverse effects on emotional arousal, sensitivity, and modulation. Some studies have suggested additional biologic vulnerability; first-degree relatives of borderline patients were found to have a higher prevalence of mood disorders than relatives of control groups. Biologic and psychodynamic paradigms have been incorporated into a variety of interactional, diathesis-stress, and transactional models. An example of a transactional model is the biosocial model described by Linehan, who attributes BPD to a transaction between biologic vulnerability to intense and unmodulated emotions (the diathesis) and an invalidating, unpredictably punishing environment. In invalidating environments, an individuals perception of personal experience is trivialized, punished, disregarded, or dismissed. An example is a sexually or physically abusive environment. Such an environment transacts with the child in that it causes the child to become even more emotionally vulnerable and unmodulated. Such an emotionally vulnerable and unmodulated child may then transact with the environment, in other words change his or her interpersonal milieu so that it becomes even more invalidating. For example, due to overwhelming emotions, a child may not consistently report her experience of sexual abuse to adults who could potentially help her, thus increasing the probability of disbelief, dismissal, disregard, or even punishment.

7. Why is BPD more frequently diagnosed among women? Some theorists argue that, at best, the paradigms described above miss the point, and at worst (particularly the psychodynamic paradigm) are women-blaming. Such theorists argue that the cause of BPD-a disorder so overwhelmingly diagnosed among women-is a society that disempowers and victimizes women. Extensive research has confirmed differences in the interpersonal relationship styles of men and women. Studies suggest that socialization, beginning in infancy, may render women generally more affectively connected and interpersonally perceptive than men. By age 6 , girls and boys already communicate and socialize in significantly different ways. Girls are more likely to play in intimate, confiding dyads; boys are more likely to play in rough-and-tumble, competitive groups. Studies have shown that rough-and-tumble play is aversive to some girls. Thus, when girls play with boys, they become relatively passive, allowing the boys to monopolize or control the game. This pattern may be reinforced by adults, who consciously or unconsciously encourage aggression in boys yet discourage identical behavior in girls. Perhaps as a result of such socialization, emotional health and sense of well-being among women is highly correlated with the degree of social support and intimacy. This socialization leaves women especially vulnerable to the needs, whims, and vicissitudes of others. Given a pathologic, invalidating environment, this vulnerability may lead to the instability of self, affect, and relationships of BPD. Such gender role socialization also may be related to the increased sexual victimization experienced by girls compared with boys. Although most theorists focus on the effects of early invalidating experiences, similar effects may result from later spouse abuse, especially if such experiences are cumulative. In addition, the high frequency of diagnosis among women may reflect clinician bias. It has been suggested that clinicians attribute specific symptoms to women to BPD yet attribute the same symptoms in men to antisocial or narcissistic personality disorder.
8. Is BPD caused by sexual andfor physical abuse? Possibly. Data suggest that the risk of sexual abuse is 2-3 times greater for girls than boys. Physical abuse rates are not significantly different for boys and girls, yet rates of physical abuse for patients with BPD are reported to be as high as 76% vs. 38% for patients with BPD. Eighty-six percent of inpatients with BPD report a history of sexual abuse compared with 34% of inpatients without BPD; 70% of outpatients with BPD compared with 26% of outpatients without BPD report such a history. Studies also have suggested a relationship between both sexual and physical abuse in childhood and adult suicidal behavior. Although childhood victimization appears to be tragically common, data suggest a unique relationship among female gender, sexual abuse, perhaps physical abuse, and BPD.

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9. List and discuss the differential diagnosis of BPD. What particular disorders are associated with BPD? Substance abuse or dependence Major depression Posttraumatic stress disorder Bipolar disorder Major depression and bipolar disorder are commonly considered in the differential diagnosis. Up to 50% of individuals diagnosed with BPD also may have concomitant diagnoses of either major depression or bipolar disorder. BPD can be described as marked instability of self, mood, interpersonal relationships, and symptoms. In contrast, a diagnosis of major depression requires stability of affective symptoms, notably a period of at least 2 weeks in which the patient experiences depression or anhedonia every day. The marked changes in mood in BPD generally occur within hours or days rather than within weeks or months as in bipolar disorder. Substance abuse frequently results in impulsive, emotionally labile behavior and unstable interpersonal relationships. The impulsivity associated with BPD often results in substance abuse or dependence. Studies suggest that 10-50% of hospitalized chemical abusers meet criteria for BPD. The high prevalence of physical and sexual trauma among patients with BPD suggests a differential diagnosis of posttraumatic stress disorder (PTSD). However, whereas rates of abuse and BPD in the general population are high, baseline rates for PTSD in the general population are low (1%). Whereas patients with either PTSD or BPD may have histories of abuse and experience intense emotional arousal, patients with PTSD avoid the feared stimuli and yet reexperience the trauma through dreams, flashbacks, or intrusive thoughts. For example, a rape victim with PTSD may avoid all men and experience nightmares of the rape. If a patient with BPD has a recent history of trauma but does not actively avoid similar stimuli or reexperience the trauma, a concomitant diagnosis of adjustment disorder may be more appropriate.

10. Describe the main risks involved in the treatment of BPD. How significant is the risk of suicide in such patients? How are the risks assessed? Symptoms of BPD such as impulsivity, anxiety, anger, and concomitant affective and substance abuse disorders result in a high risk of suicide. Between 70-75% of patients with BPD have histories of at least one self-injurious act. Rates of completed suicides are about 9% for patients with BPD vs. 1% in the general population. In one longitudinal study in which psychiatric inpatients were followed for 10-23 years after discharge, patients who met all 8 of the DSM 111 criteria for BPD had a suicide rate of 36% vs. 7% for patients who met 5-7 of the criteria. Suicidal threats should be taken seriously and warrant psychiatric consultation. You cannot easily tell if a patient is really suicidal or just manipulating. Imminent risk factors include: Current suicidal ideation Current or recent suicide threats Current or completed suicide planning Suicide attempt in the last year Indirect references to own death Recent disruption or loss of a relationship Recent medical care Severe anxiety or panic Hopelessness Long-term risk factors include: Incarceration Family history of suicide Childhood sexual abuse history Diagnosis of borderline personality disorder Substance abuse diagnosis White male over age 45 Poor physical health Unemployment
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11. What feelings are commonly generated in professionals by patients with BPD? Patients with BPD often live in a state of chaos. Their moods shift rapidly and without apparent cause. They often appear to have normal cognitive abilities and yet demonstrate extremely poor judgment. They repeatedly present to emergency departments for treatment of self-inflicted injuries or overdoses. They overdramatize or give inconsistent reports of symptom history. One minute they appear to have a good relationship with their doctor and the next minute they are angry, hostile, and critical. They report an understanding of the risks and benefits of recommended treatment, but then are noncompliant. They miss scheduled follow-up appointments, yet demand immediate attention or call at all hours to discuss new symptoms. Such behaviors not surprisingly engender feelings of anger, irritation, confusion, helplessness, and hopelessness in providers. These feelings may lead providers to engage in treatment-destructive behaviors, including: Blaming the patient for lack of improvement Believing that the patient would be better off dead Failing to return phone calls Failure to carefully assess ongoing risk of prescribing medications Labeling the patients motivation as cause of treatment failure Overzealous use of potentially addictive medications Arguing with patient Arguing with other professional staff regarding the patient Borderline patients also may induce intensely positive feelings in treatment providers. Such feelings may lead providers to engage in other treatment-destructive behaviors, such as: Omnipotent beliefs and behaviors Rescue fantasies and behaviors: Only I can rescue this patient. Romantic and sexual fantasies or behaviors Keeping secrets Making housecalls Violations of usual boundaries: having coffee, talking about providers personal problems 12. When are providers especially vulnerable to experiencing these reactions? Can this experience be helpful? All of these reactions are especially likely to arise when care providers are particularly stressed (e.g., sleep deprivation during internship or in marital discord). Recognize that many such feelings are engendered simply by contact with the borderline patient. Borderline patients experience a broad range of emotions, which all humans are familiar with to some degree. Borderline patients simply experience emotions and defenses with less ability to modulate reactions and to maintain or regain a balanced perspective. When care providers become involved, they also may experience some loss of their normal ability to maintain balance. This emotional experience can be a highly useful tool to help professionals recognize what a patient suffers from BPD. The cognitive and behavioral techniques that the professional uses to reestablish balance also provide useful clues to treatment and management of the patient. Thus, a physicians acknowledgment of his or her own feelings, obtaining consultation or peer supervision, and possibly limiting clinical contact may be useful strategies.
13. What are some clues that the doctor-patient relationship is in trouble? Rescue fantasies (Only I can treat this patient) Defensive posture with colleagues, family, or other staff, concern expressed by clinic or hospital staff about the physicians involvement with the patient. Special behaviors or deviation from routine behaviors or procedures, including keeping secrets from supervisors, staff, or consultants; making house calls; giving out personal information; talking to the patient about personal stress in an intimate way; agreeing just to have coffee; feeling sexual tension when the patient is present; or feeling guilty about time spent with the patient, or thoughts or feelings about the patient.

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These become clues to problems within the doctor-patient relationship when they become the pattern rather than the unusual event. The common denominator for each is loss of equilibrium and objectivity in the professionals thinking, feelings, or behavior in regard to the specific patient. The key to reestablishing the necessary objectivity is recognition that something within the relationship is out of balance and must be rectified to provide competent treatment. Formal or informal consultation with a colleague often is helpful.

14. Are there guidelines for successful management of BPD patient behavior when the physicians primary goal is medical stability and compliance with treatment? Management of emotional dyscontrol: Provide structure. Patients with BPD experience intense, poorly understood emotions, and their thinking becomes diffuse and disorganized. They have difficulty consistently providing order to internal experience. At times, self-destructive behaviors are their best, although primitive, attempt at grounding their emotional state. Borderline patients experience significantly less turmoil and engage in fewer negative behaviors if the environment around them is clearly structured. They need clear expectations and clear role definition. Be matter-of-fact. Patients with BPD become overwhelmed by emotions and are reassured by a professional who calmly addresses affect-laden issues. Avoid expression of extreme emotions. Help patients to validate their own experience by acknowledging their feelings while also clearly stating the expectation of behavior control. Many (perhaps most) patients with BPD were raised in traumatic and abusive environments. The childs feelings and needs were ignored. Such children grow into adults who, on the one hand, overvalue the importance of their emotions and, on the other hand, are profoundly confused and distrustful of their emotional experience. Consider frequent, brief, scheduled contacts for needy, demanding, or somaticizing patients with BPD. Gently encourage the patient to consider the relationship between psychological stressors and emotional stress and somatic symptoms. Be alert to the risk of suicide. Discuss this risk openly with the patient. Weigh potential overdose potential when deciding to prescribe medication, amount to be dispensed, and number of refills. Have a low threshold for seeking psychiatric or psychological consultation. Consider a referral for psychotherapy. Take care to make this referral in a nonrejecting manner, clearly defining the roles of medical and psychotherapy professionals. Management of interpersonal boundaries: Interact in a genuine manner, balancing appropriate warmth and concern with appropriate professional boundaries. Avoid interactions conveying either unresponsiveness or overinvolvement. Convey a demeanor of professional competence, yet also openly and matter-of-factly acknowledge minor errors. Presentation of oneself as infallible or omnipotent plays into the borderline patients idealization. Idealization invariably leads to devaluation and rage; no one can live up to the fantasy of perfection. Model comfort with nonperfection to decrease the intensity of expressed anger in response to expected disappointments. Perform physical examinations with a chaperone present, regardless of gender of doctor or patient. Patients with BPD have significant boundary problems and may misinterpret the meaning of physical exams or other procedures. When angry, patients also may consciously or unconsciously distort their recall of physical contact. Additional general guidelines: Be aware of the high risk of comorbid substance abuse and major depression. Avoid prescription of addictive medications. Consider providing treatment or referring the patient for treatment of these conditions. Confront noncompliance in a direct, calm, nonjudgmental manner; consider use of written contracts. Avoid global, black-white, all-or-none statements and thinking. Present the patient with choices. Think compromise. Set limits in a calm, nonhostile, nonjudgmental manner.

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Think balance. Continually ask, Am I over- or underreacting to the patients complaints? Aim for the middle ground.

15. Are patients with BPD competent to make medical decisions? Generally, yes. Patients with BPD are prone to brief psychotic episodes and to distortions in thinking, especially under stress; this at times may interfere with competency. Providing information about risks and benefits in a calm, structured manner often is sufficient to reestablish their capacity to participate in medical decisions. When in doubt, consult a mental health professional.

CONTROVERSY
16. Patients with BPD just need to try harder and be more motivated to act in a mature, adult manner. Psychotropic medications have no place in treatment. For 1. Although studies support biologic, genetic, and environmental contributions to the development of BPD, studies support no pharmacologic treatment of choice. Effects of all classes of medication studied are modest at best. 2. Patients with BPD have inadequate coping skills; medication does not replace the need to learn new coping skills. 3. Evidence suggests that the behavioral dyscontrol exhibited by patients with BPD is within their control. For example, when limits are set firmly, behavior improves. All medications have associated risks, which are not justified if control can be attained through behavioral interventions. 4. Patients with BPD cannot be trusted. They will use the medications in an attempt to kill themselves, will self-medicate their unstable moods and become addicted psychologically or physiologically, or will simply comply with prescribed medication in such an erratic manner that treatment trials are inadequate and inconclusive. Against 1. Having BPD does not provide protection from the typical medication-responsive axis I disorders. In fact, mood disorders, substance use disorders, anxiety disorders, gender identity disorders, eating disorders, and other personality disorders often coexist with BPD. BPD has the greatest overlap with other personality disorders; comorbidity with mood disorders (particularly dysthymia and major depression) and substance use disorders is extensive. At times, comorbidity may be due to overlap in diagnostic criteria, but studies suggest that, at least for some patients, borderline symptoms represent a characterologic variant within the affective spectrum. Clinicians must consider additional syndromes that may warrant separate treatment approaches. Withholding effective medications for coexisting psychiatric conditions cannot be justified. 2. Psychopharmacologic interventions reduce specific target symptoms (anxiety, behavioral dyscontrol, acute or chronic perceptual disturbances, and emotional lability). Symptom reduction may increase the patients ability to benefit from other psychosocial interventions. 3. Low-dose neuroleptics have been shown to decrease cognitive symptoms such as magical thinking, illusions, ideas of reference, tangentiality, and circumstantiality. Studies have shown superiority over placebo in measures of global functioning, hostility, anger, impulsivity, and subjective feelings of depression. Most patients, however, show only modest improvement and continue to meet criteria for BPD. Other patients show no improvement and/or cannot tolerate side effects. Because of the risk of tardive dyskinesia, antipsychotics are used more frequently during periods of acute stress or decompensation rather than for long-term maintenance. 4. Controlled pharmacologic trials and clinical experience suggest that some patients with BPD symptoms experience a decrease in emotional lability and impulsivity with use of carbamazepine, lithium, and monoamine oxidase inhibitors. 5. The minor tranquilizers generally should be avoided in patients with BPD because of their potential for abuse and disinhibition of impulses. Despite this relative contraindication, some patients benefit from cautious, controlled use.

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6. Although the risk of suicide must be weighed in the decision to use any medication, overdose is commonly an interpersonal event and patients provide extensive opportunity for rescue. Many physicians find that when this issue is addressed i n a serious, matter-of-fact manner, patients with BPD consciously and consistently avoid overdose of physician-prescribed psychotropic medications.
17. Is BPD treatable? How is it treated? By definition, a personality disorder is a disorder with an enduring pattern. Hence, some theorists suggest that BPD is not treatable and that therapy, particularly analytic therapy, may have a worsening effect. More recent theorists (particularly brief dynamic and cognitive-behavioral theorists) have suggested that the symptoms of BPD can be significantly ameliorated and perhaps resolved. Linehanh successfully taught patients with BPD to monitor, recognize, and regulate painful affect; to inhibit inappropriate behaviors associated with affect; and to refocus attention on nondistressing stimuli. This technique ameliorates the negative effects of intense affect on interpersonal relationships. In clinical practice, to manage angry feelings, patients may be taught first to recognize the anger, to analyze its causes, to soothe themselves and then consciously to initiate a behavior that is the opposite of anger. For example, after recognizing anger related to her husbands interest in a friends art work, the patient may gently avoid discussion of the work and instead ask about her husbands work day, thereby resisting the impulse to attack. The success of this approach has been validated with controlled empirical data. Compared with controls, patients with BPD who were treated with DBT were less likely to engage in parasuicidal acts and to receive inpatient hospitalizations and more likely to remain in treatment and to rate themselves higher on measures of occupational and other role performance. A study of an adaptation of DBT for substance-using BPD patients found that patients assigned to DBT had greater reduction in illicit substance abuse (as measured by urinalysis) both during treatment and at followup, and greater improvements in global functioning and social adjustment at followup.
BIBLIOGRAPHY
I . American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 1994. 2. Beck AT, Freeman A: Cognitive Therapy of Personality Disorders. New York, Guilford Press, 1990. 3. Cowdry RW: Psychopharmacology of borderline personality disorder: A review. J Clin Psychiatry 48: 15-22, 1987. 4. Dimeff LA, McDavid J, Linehan MM: Pharmacotherapy for borderline personality disorder: A review of the literature and recommendations for treatment. Clin Psycho1 Med Sett, In Press. 5. Kreisman JJ, Straus H: I Hate You-Dont Leave Me: Understanding the Borderline Personality. New York, Avon, 1989. 6. Linehan MM, Schmidt H, Kanter JW, et al: Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. Arch Gen Psychiatry, Submitted. 7. Paris J: The treatment of borderline personality disorder in light of the research on its long term outcome. Can J Psychiatry 38:S28-S34, 1993. 8. Sansone RA, Sansone LA: Borderline personality disorder: Office diagnosis and management. Am Fam Physician 44:194-198, 1991. 9. Sedright HR: Borderline personality disorder: Diagnosis and management in primary care. J Fam Pract 34:605-612, 1992. 10. Tasman A, Hales RE, Frances AJ (eds): American Psychiatric Press Review of Psychiatry, vol. 8. Washington, DC, American Psychiatric Press, 1989.