Borderline personality disorder

From Wikipedia, the free encyclopedia

 Emotionally unstable personality disorder 
Classifications and external resources

ICD-10	F60.30 Impulsive type, F60.31 Borderline type
ICD-9	301.83

Borderline personality disorder (BPD) is defined within psychiatry and related fields as a disorder characterized primarily by emotional dysregulation, extreme "black and white" thinking (believing that something is one of only two possible things, and ignoring any possible "in-betweens"), and turbulent relationships.

Psychiatrists and some other mental health professionals describe borderline personality disorder as a serious mental illness characterized by pervasive instability in mood, interpersonal relationships, self-image, identity, and behavior. This instability often disrupts family and work life, long-term planning, and the individual's sense of self.

The majority of those diagnosed with this disorder appear to have been individuals abused or traumatized during childhood^[1][2]. According to Joel Paris^[3], "Some researchers, like Judith Herman, believe that BPD is a name given to a particular manifestation of post-traumatic stress disorder: in Trauma and Recovery, she theorizes that when PTSD takes a form that emphasizes heavily its elements of identity and relationship disturbance, it gets called BPD; when the somatic (body) elements are emphasized, it gets called hysteria, and when the dissociative/deformation of consciousness elements are the focus, it gets called DID/MPD."

Contents 1 Origin of the term 2 DSM-IV-TR diagnostic criteria 2.1 Mnemonic 3 Co-morbidity 3.1 Mood disorders 3.2 Anxiety disorders 3.3 Impulse disorders 3.4 Personality disorders 3.5 In contrast to other personality disorders 4 Signs and symptoms 4.1 Fear of abandonment 4.2 Emotional dysregulation 4.3 Lack of impulse control 4.4 Cutting and other self-harm 4.5 Suicidal ideation and mortality 5 Psychological roots 5.1 Progress in understanding the roots of BPD 5.1.1 Role of childhood abuse and PTSD 5.1.2 Combination of many factors 5.1.3 The bipolar / BPD debate 5.1.4 Neurology research 5.1.5 Future progress 6 Treatment 6.1 Psychotherapies 6.1.1 Precautions for therapists 6.1.2 New on the horizon: Schema therapy 6.1.3 Dialectical behavioral therapy 6.1.4 Cognitive behavioral therapy 6.1.5 EMDR 6.1.6 Case for BPDs who choose to avoid psychopharmacotherapy 6.2 Psychopharmacotherapy 6.2.1 Antidepressants 6.2.1.1 Lithium 6.2.2 Mood stablilizers 6.2.2.1 Lithium 6.2.2.2 Depakote / valproic acid 6.2.2.3 Antiseizure / antiepileptic medications 6.2.2.4 The neuroleptics / antipsychotics 6.2.3 Tranquilizers and sedatives 6.2.4 Psychotropic medication side-effects 6.2.4.1 Weight gain 6.2.4.2 Diminished sexual drive and arousal, impotency 6.3 Value of combining pharmacotherapy and psychotherapy 7 Theories of BPD in relationships 8 Footnotes 9 Bibliography 10 Further reading 11 See also 12 External links

[edit] Origin of the term

Originally thought to be at the "borderline" between psychosis and neurosis, people with BPD are now said to suffer from what has come to be called emotional dysregulation.

The name originated with the idea that individuals exhibiting this type of behavior were on the "borderline" between neurosis and psychosis. This idea has since fallen out of favor, but the name remains in use, as noted in the Diagnostic and Statistical Manual of Mental Disorders; the ICD-10 has an equivalent called emotionally unstable personality disorder, borderline type. There is currently some discussion by the American Psychiatric Association about changing their name for the disorder to emotional dysregulatory disorder, or emotional dysregulation disorder in the next version of the DSM.

While less well-known than schizophrenia or bipolar disorder (formerly known as manic-depressive illness), BPD is more common than either, affecting two percent of adults, mostly young women.^[4]

Borderline patients often need extensive mental health services, and they account for 20 percent of all psychiatric hospitalizations.^[5] It is widely recognized that they often receive poor service, however, in part due to lack of sympathy with or understanding of self-harm, impulsivity or so-called 'non-compliance' behavior. However, most individuals improve over time and are able to lead more stable and happy lives.

[edit] DSM-IV-TR diagnostic criteria

The DSM-IV-TR, a widely-used reference book for diagnosing mental disorders, defines borderline personality disorder as 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. (not including suicidal or self-mutilating 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; [not including 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.

DSM-IV-TR, 301.83.

[edit] Mnemonic

A commonly used mnemonic to remember the features of the borderline personality disorder is PRAISE:

• P - Paranoid ideas
• R - Relationship instability
• A - Angry outbursts, affective instability, abandonment fears
• I - Impulsive behaviour, identity disturbance
• S - Suicidal behaviour
• E - Emptiness

[edit] Co-morbidity

BPD often occurs together with other psychiatric problems, particularly:

[edit] Mood disorders

• bipolar disorder
• depression

[edit] Anxiety disorders

[edit] Impulse disorders

• attention deficit disorder,
• any drug or alcohol substance abuse
• various other addictions
• eating disorders, anorexia, bulimia and compulsive overeating

[edit] Personality disorders

Borderline personality disorder is most commonly comorbid with other Cluster B personality disorders:

• Antisocial personality disorder
• Histrionic personality disorder
• Narcissistic personality disorder

It also tends to be comorbid with dependent personality disorder.

[edit] In contrast to other personality disorders

Study by Zanarini, Frankenburg, Dubo et. al (1998)^[6] showed that when comparing patients with other personality disorders (NON-BPD) to borderline personality disorder (BPD), borderline personality disorder patients had more axis-I diagnosis of the following diagnosis groups:

• anxiety disorders
• mood disorders
• eating disorders
• to the lesser extent somatoform disorders

No differences were found between psychotic disorders or substance use disorders.

Of particular diagnoses borderline personality disorder patients had at least 20% more:

• post traumatic stress disorder, PTSD (BPD 56% vs NON-BPD 22%)
• panic disorder (BPD 48% vs NON-BPD 20%)
• social phobia (BPD 46% vs NON-BPD 27%)

Finding that PTSD was quite common in BPD was interesting, because it supports the view that BPD is a kind of trauma disorder (particularly Complex post-traumatic stress disorder)

[edit] Signs and symptoms

While a patient with depression or bipolar disorder typically endures the same mood for weeks, a person with BPD may experience intense bouts of depression, anxiety, or anger that may last only minutes, hours, or at most a day.^[7] These may be associated with episodes of self-injury (including cutting), impulsive aggression, and drug or alcohol abuse. Difficulties in cognition and sense of self can lead to frequent changes in long-term goals, career plans, jobs, gender identity, sexual orientation, friendships, and values.

During episodes of high agitation associated with discordance with an ideation object, visual and aural hallucinations involving transposition of the non-present ideation with a present non-ideation object occur for short (no more than a few minutes) periods. Aggressive and potentially dangerous behaviors may evolve during these transferences, and are purportedly non-remembered.

[edit] Fear of abandonment

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. Ironically, it is the desperate clinging to other people that often serves as the very catalyst for conflict that drives others away.

[edit] Emotional dysregulation

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 trust for the other person, but when a separation or conflict occurs that others may see as slight, they can lose their sense of attachment and trust and may become withdrawn or angry.

Even with family members, individuals with BPD can be highly sensitive to rejection, for example reacting with distress or anger to separations. These fears of abandonment may be related to difficulties feeling emotionally connected to important persons when they are physically absent, leaving the individual with BPD feeling lost and perhaps worthless. Suicide attempts or self-injury may occur along with anger at perceived abandonment and disappointments.

As a consequence of difficulties with emotional regulation and maintaining some social boundaries, people with BPD can sometimes make rapid and seemingly deep connections with others, marked by unrealistically high levels of mutual admiration. When very open and in need of reassurance and love, they can sometimes overwhelm others with praise, attention and intimacy.

They can also feel overwhelmed by others or be taken advantage of. Due to the inherent instability of such relationships, and unresolved issues for the person with BPD, particularly in matters of trust and self-worth, they are prone to react strongly to apparent slights and reverse their over-positive view. This can be experienced by others as unexpected hostility or betrayal, and can also be confusing and painful for the person with BPD.

[edit] Lack of impulse control

People with BPD exhibit other impulsive behaviors, such as excessive spending, gambling binge eating and risky sex.

[edit] Cutting and other self-harm

THESE TWO AREAS need particularly thorough development since they are NOT simply different degrees of the same thing. They are totally different.

There is a high rate of self-injury without suicidal intent, as well as a significant rate of suicide attempts and, in severe cases, successful suicides.^[8][9]

[edit] Suicidal ideation and mortality

Suicidal or self-harming behaviour is one of the core diagnostic criteria in DSM IV-TR, and management of this can be a complex and challenging issue.^[10]

The suicide rate is approximately 8-10%. [1]

[edit] Psychological roots

• Shame Issues
  • Sometimes people with BPD view themselves as fundamentally bad or unworthy. Because of this, they often project onto others, feeling they are misunderstood, mistreated or treated unfairly, and they feel all these things to excess and great emotional distress.

• Boundary Issues
  • Children reared in abusive homes grow up with distortions concerning personal boundaries, or even totally unaware that such things exist.

• Inner self deficiencies - need more than this one
  • They may feel bored, empty, and have little idea who they are.

[edit] Progress in understanding the roots of BPD

[edit] Role of childhood abuse and PTSD

Numerous studies have shown a strong correlation between childhood abuse and development of BPD. ^[11][12]

Although the causes of BPD are uncertain, both environmental and genetic factors are thought to play a role in predisposing patients to BPD symptoms and traits, possibly through the final common pathway of reduced central serotonergic neurotransmission. Studies show that many (but not all) individuals with BPD report a history of abuse, neglect, or separation as young children.^[13] Self-reporting BPD patients of traumatic experiences, physical and/or sexual abuse in childhood demonstrate a larger percentage than in control group without BPD.

In addition, sexual identity disturbance and homosexual relations were associated with BPD. Early psychiatric hospitalization, suicide attempts and substance use disorders are all more frequently reported by BPD patients. ^[14]

Adults with BPD are also considerably more likely to be the victim of violence, including rape and other crimes. This may be the result of vulnerabilities resulting from BPD (e.g., willingness to tolerate unsafe environments to avoid abandonment, tendency to form intense relationships) as well as impulsivity and poor judgment in choosing partners and lifestyles. Anger, impulsivity, and poor judgment may also explain why people with BPD are more likely than average to be arrested for and convicted of crimes ranging from petty theft to murder.

Harvard Medical School did a study of adult BPD patients to statistically analyze how the incidence of biparental (both parents) abuse and neglect of the child who would go on to develop BPD.

It was found that borderline patients were significantly more likely to report having been verbally, emotionally, and physically abused, and sexually abused by caretakers of both sexes. They were also much more likely to report having caretakers (of both sexes) deny the validity (failure to mirror) of their thoughts and feelings. They also failed to provide needed protection, and neglected their child's physical care. Parents (of both sexes) were typically seen to withdraw from the child emotionally, and to treat child inconsistently. Additionally, female borderlines who reported a previous history of neglect by a female caretaker and abuse by a male caretaker were consequently at significantly higher risk for being sexually abused by a noncaretaker (not a parent). ^[15]

Taken together, the results of the study seemingly showed that biparental failure to properly parent to be a significant factor in the etiology of BPD. They also suggest that biparental failure significantly increases a preborderline girl's risk of being sexually abused by someone other than her parents. ^[15]

[edit] Combination of many factors

Researchers believe that BPD results from a combination of individual genetic vulnerability and environmental stress, neglect or abuse as young children, and maturational events that trigger the onset of the disorder during adolescence or adulthood. Scientists also believe that BPD is genetic. Approximately 35% of children whose parents have BPD will show signs of the disorder.^{[citation needed]}

Significant prolonged childhood trauma influenced by a genetic predisposition for serious mood disorder contributes to the neurobiology of the Cluster B personality disorders.^{[citation needed]}

A model for personality dysfunction strongly suggests a multifactoral interaction between inherited susceptibilities and aversive and traumatic environmental factors. The core biological vulnerabilities within the personality includes affective instability, impulsive aggression, and cognitive/perceptual difficulties. In impulsive aggression, often seen in BPD, the underlying neurobiology involves deficits in central serotonin function and alterations in specific brain regions in the cingulate and the medial and orbital prefrontal cortex. ^[16]

Some recent studies suggest that BPD is not a trauma-spectrum disorder and that it is biologically distinct from the posttraumatic stress disorder thought to be a precursor; however, high rates of childhood abuse and neglect do exist in persons with personality dysfunction. None of the personality symptom clusters seem to be unrelated to specific abuses, but they may relate to more persistent aspects of interpersonal and family environments in childhood.^[16] Twin, sibling and other family studies do indicate a partially heritable basis for impulsive aggression, but studies of serotonin-related genes to date have suggested only modest contributions to behavior. Recent gene-childhood environment studies have demonstrated the interrelationship of antisocial behaviors and aggression in rhesus monkeys. Ape studies like this one highlight the need for further research in this important area. ^[16]

[edit] The bipolar / BPD debate

[edit] Neurology research

Neuroscience research examines brain mechanisms possibly underlying the impulsivity, 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.^[17] 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 stress and/or drugs like alcohol. Areas in the front of the brain (pre-frontal area) act to damp 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.^[18]

[edit] Future progress

Studies that translate basic findings about the neural basis of temperament, mood regulation and cognition into clinically relevant insights which bear on BPD represent a growing area of 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. 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 hopefully pinpoint specific environmental factors and personality traits that predict a more favorable outcome.

[edit] Treatment

Treatments for BPD have improved in recent years. ^[19]

Many researchers have long focused on non-pharmacological treatments, such as dialectical behavior therapy because it was not recognized or believed that there were medication regimens that could be beneficial. Medications were more likely to be seen and experienced as routes to suicide attempts.

[edit] Psychotherapies

Sometimes called "the talking cures"

[edit] Precautions for therapists

There is a tendency for a person with borderline personality to fear abandonment and then act out their fear, often by attempting to reject a therapist before the therapist rejects them. This is a risk in all therapies and being mindful of it may be helpful when it occurs; those who exhibit turbulence in their relationships may also replicate them with their therapist too.

• Cognitive Behavioural Therapies such as Rational Emotive Therapy are, theoretically, the best of all theoretical epistemologies suited to curtail the behavioural manifestations of BPD symptomolgy. However, the degree to which this and other Cognitive Behavioural Therapies are effective in isolation is highly unsatisfactory, which is why perspectives from other orientations are also implicated by therapists
• Behaviourist Approaches - also not effective in isolation; one of the central arguments and key points that stands eclectic psychotherapists in good stead.
• Existential Psychotherapies such as Logotherapy are of notable efficacy and are usually coupled with one of the former, especially CBT, by an effective clinician seeking to ensure the cure of BPD, as opposed to its mere repression.
• Psychoanalysis
  • Traditional psychoanalysis is usually avoided, because it has been known to exacerbate BPD symptoms.^[20] Interestingly, there is also evidence of its effectiveness as well.^[21]

[edit] New on the horizon: Schema therapy

Google string for schema therapy

Recent research published in the American Medical Association's Archives of General Psychiatry suggests that half of all individuals with borderline personality disorder might achieve full recovery with schema focused therapy, with significant improvement in two thirds. [2]

[edit] Dialectical behavioral therapy

In 1991, a new psychosocial treatment termed dialectical behavioral therapy (DBT) was developed specifically to treat BPD, and this technique was the first to show any efficacy compared to a control group. Marsha Linehan, the developer of DBT, said in the early days that it took about a year to see substantial enduring improvement. Combining SSRIs and DBT (probably the standard treatment now) seems to give satisfying synergy and faster results.{fact}

Linehan's dialectical behavior therapy is based on negotiation between therapist and patient. The dialectic described in the treatment's name is of the therapists' acceptance and validation of patients as they are, combined with the insistence on the need for change. The idea is to give patients tools that they never acquired as children, typically to control and handle their emotions.

Some patients, when asked after several years of treatment, why they have stopped inflicting self-injury, give answers to the effect of "I picture myself sitting with my psychotherapist, and we talk about why I want to injure myself."^{[citation needed]}

Dialectical behavioral therapy results in more patients staying in therapy and greater reductions of self-mutilating and self-damaging impulsive behaviours compared with usual talking therapy treatements, especially among those with a history of frequent self-mutilation. ^[22]

[edit] Cognitive behavioral therapy

[edit] EMDR

Popular in treating PTSD

[edit] Case for BPDs who choose to avoid psychopharmacotherapy

[edit] Psychopharmacotherapy

People with BPD, who are often distressed by at least some of their symptoms, typically undertake a series of empirical trials of drugs to see whether anything helps them, and may end up taking no drugs at all.

Unlike many other psychiatric disorders, medication has not been a mainstay of longterm treatment as there is little evidence for effectiveness for people who have BPD without a comorbid Axis I mental illness. ^[23]

• The Neurotransmitters Involved
  • 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 sometimes 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.

More recently, research has highlighted some abnormalities in serotonin metabolism^{[citation needed]} and at least some evidence for benefit with SSRIs.^[23] many other medicines, such as antipsychotics and benzodiazepines are beneficial for symptom relief from either hyperarousal or associated psychotic or dissociative symptoms. However, there are some associated risks, principally agitation and insomnia with SSRI and SNRI anti-depressants, and dependence and disinhibition with benzodiazepines. This mean that caution and care are required in an otherwise vulnerable population.

[edit] Antidepressants

Since about 1989, Prozac/fluoxetine and other selective serotonin reuptake inhibitor (SSRI) antidepressants have been shown in Randomized controlled trials to improve the symptoms of BPD in some patients, such as anger and hostility.^[23] This seems to be a separate effect to antidepressant as such, focusing more on affect regulation.

Psychiatrists often caution against use of SSRI and serotonin-norepinephrine reuptake inhibitors (SNRI) drugs due to the risk of triggering mania.^{[citation needed]} Wellbutrin is much less likely to trigger mania as it has a completely different mode of action. Bupropion is unique in that its major effect is on dopamine. According to the PDR, it inhibits reuptake of dopamine serotonin and norepinephrine, resulting higher bioavailability. In the final analysis, any antidepressant use must carefully monitored for antidepressant-triggered impulsiveness and mania, and monitored closely for suicide risk. Prescription drug mismanagement, whether by the BPD patient or the attending physician, can lead to a negative outcome.

The book Listening to Prozac describes some of these remarkable changes. In general, it takes a higher dose of an SSRI to treat BPD than depression. It also takes about three months for benefit to appear, compared to two weeks for depression. The previous antidepressants, the tricyclics, were often unhelpful; side-effects are generally difficult to tolerate and the drugs are often lethal in overdose. Increasing evidence implicates inadequate serotonergic neurotransmission as strongly related to impaired modulation of emotional and behavioral responses to everyday life, manifesting as "overreacting to everything". Even thinking is recruited by the intense (or underregulated) emotionality so that the world is perceived primitively in intense black-and-white terms.

Often, an SSRI or a SNRI drug is prescribed to a patient with BPD without proper supervision and involvement of family caregivers, or explanation or warning of side effects. The drugs often cause singificant agitation and insomnia initially and for some people these problems may persist. This can pose problems in someone who may have been having suicidal thoughts when they begin treatment. Many people can experience unpleasant withdrawal symptoms when stopping which can lead to the impression they are 'addicted ' to the medication.

The impulsivity, suicidality and possible lack of supports in borderline patients may render them much more vulnerable to self-harm than those without these vulnerablilies should these problems arise. It may be difficult for the treating physician to make the distinction between side effects that are worsened by increase of dose and the symptoms that a patient is experiencing from the disorder. Increasing the dose to address the worsening symptoms can be dangerous if the symptoms are in fact a side effect of the drug.

[edit] Lithium

Recent research has revealed the considerable action Lithium has in reducing suicide attempts and keeping depression at bay. All the antidepressants are capable of triggering excitability, impulsiveness, pressured speech and mania in many patients. Some can tolerate some of them, but many can't tolerate any of them. It is important to recognize that this old mainstay, the first mood stabiizer ever discovered, has such an important extra benefit. There is almost no current research nor much for many decades. This is because no one holds an exclusive marketing patent on Lithium. Lithium is very modestly priced and there is not enough profit to pay for new research.

[edit] Mood stablilizers

[edit] Lithium

[edit] Depakote / valproic acid

[edit] Antiseizure / antiepileptic medications

Other pharmacological treatments are often prescribed for certain other specific target symptoms shown by the individual patient, especially for people dually diagnosed with another psychiatric diagnosis. Mood stabilizers (such as lithium, effective in helping in controlling depression) and certain antiepileptic drugs (such as lamotrigine/Lamictal) are helpful in controlling explosive anger and lessening impulsivity. Mood stabilizers are also effective in treating "dysphoric mania," which is an admixture of simultaneous manic and depressive symptoms.^[24]

Some antipsychotics such as olanzapine and many of the anticonvulsants can be, broadly speaking, mood stabilisers, but traditionally, the term was meant to indicate lithium, Depakote/sodium valproate and Tegretol/carbamazepine.

Side effects of mood stabilizers of the anti-epileptic type range from those that cause more or less mental slowing such as difficulties with word retrieval, while some cause little or no side effects, depending on the patient. Lamotrigine is potentially the most dangerous in that a very tiny percentage of patients can eventually die of a rash if it is ignored and medication continued. For this reason, titration on the drug is very gradual, inching up slowly with at least 5 days at each level. More likely, a somewhat sensitive patient will have some mouth sores which will resolve without danger to the patient. ^[25]

[edit] The neuroleptics / antipsychotics

Antipsychotic drugs, previously more commonly called neuroleptics, may also be used when there are distortions in thinking or perceptions.^[26] In general, these drugs are not a mainstay of treatment, but utilized intermittently in a brief psychotic or dissociative episode.

There is generally no indication for long term use unless there is an associated chronic psychosis as there are numerous side-effects and weak evidence for benefit from such use. ^{[citation needed]}

Tardive dyskinesia has generally been considered the most serious side effect of this type of medication. Tardive dyskinesia can become permanent and irreversible. The bizarre movements are highly diconcerting and off-putting to observers, and are usually greatly distressing to both patient and family. It quite often can be improved or completly alleviated if it is promptly recognized, then treated with lowering or ceasing the medication.^[27]

Atypical antipsychotics were widely promoted to doctors to be less likely to cause tardive dyskinesia, but this has proven to not be the case. The old neuroleptics still have definite benefits over the new ones. For the ones with a long half-life, it is now found, for instance, that dosages of some of these class of drugs can be trimmed to every other day.

The newer "atypical" antipsychotics have encouraged doctors to extend their use for the treatment of more patients, both children and adults. When other mood stabilizers do not effectively manage symptoms and signs, they are increasingly utilized for both those with bipolar disorder (BP) and with borderline personality disorder (BPD). A published study(2005) reviewed and discussed 14 earlier studies with widely varying methodologies. Every one yielded positive results from olanzapine, clozapine, quetiapine and risperidone.

The conclusion drawn was that a BPD patient with psychotic-like, impulsive or suicidal symptoms might benefit from atypical antipsychotics. ^[28]

[edit] Tranquilizers and sedatives

It once was the case that a prescription for tranquilizers was written for anyone complaining of nervousness and anxiety. However, research studies have indicated and psychiatric practice has demonstrated that most anxiety is best treated with antidepressants. Most anxiety is a actually a masking over of depression. Give an anxious jittery borderline a Valium, and they may very well be suicidal by the next day. This is because the anxiety is a barrier, shielding the person from awareness of their true emotional state. Take away the anxiety, and the person is suddenly up close and personal with the depths of their depression and they are overwhelmed. This type of depression is called an agitated depression.

There is limited information as to the usefulness of benzodiazepines in the treatment of borderline personality disorder. There is anecdotal evidence as to their effectiveness, especially with comorbidity of anxiety - they can be very effective in reducing hyperarousal, anxiety and dissociative states. However, they should be used with caution, as physiological and psychological addiction can occur from long term use and this is a population vulnerable to substance misuse and dependence.

[edit] Psychotropic medication side-effects

[edit] Weight gain

Atypical antipsychotics are notorious for often causing considerable weight gain and all the typical health complications associated with obesity. They also can cause the onset of diabetes, even in children who have not gained any appreciable weight. Atypical antipsychotics tend to cause more weight gain than conventional ones and weight gain, diabetes, dyslipidemia. While all are implicated, clozapine and olanzapine seem to be the worst. Conceming the underlying mechanisms of the weight gain, it is thought they interfere with central nervous functions regulating energy balance; patients report about: increase of appetite for sweet and fatty foods or "food craving" (for antidepressants, mood stabilizers, antipsychotic drugs). Additonally, atypical antipsychotics can cause and weight gain despite even reduced appetite and stable caloric intake which can be explained by an altered resting metabolic rate. ^[29] For these reasons, these drugs should not be considered first-line pharmacotherapy, but used only as backup if other mood stabilizers, lithium and benzodiazepines are not able to control problematic behavioral symptoms.

[edit] Diminished sexual drive and arousal, impotency

Sexual issues can be significant in people with BPD. Sexual function is generally a fairly personal and private part of life; as such, sexual side effects may be perceived to be embarrassing to discuss, remaining undiagnosed and unaddressed. SSRIs are strongly linked with anorgasmia ^{[citation needed]}, while antipsychotics can impair sexual function via their effects on prolactin. ^{[citation needed]}

[edit] Value of combining pharmacotherapy and psychotherapy

In a representative study, 70% of BPD patients who took neuroleptics while participating in DBT showed statiscally significant improvements in depression, anxiety and impulsivity/aggressive behavior. Studies conclude that combining DBT with neuroleptics lower therapy dropout rates and constitutes an effective treatment for borderline personality disorder. ^[30]

[edit] Theories of BPD in relationships

NonBP is a non-clinical term originally coined by Kreger & Mason in the book Stop Walking on Eggshells (ISBN 1-57224-108-X) in the mid-1990's. It has since come into fairly widespread popular usage. The term describes individuals who are in a consistent, and sometimes significant, relationship with a person exhibiting a Borderline character, aspects of complex post traumatic stress disorder (C-PTSD), or a formally diagnosed borderline personality disorder. These people can be friends, spouses, lovers, offspring, co-workers, and extended family members, among others.

While "NonBP" is a colloquial expression, and not a clinically defined condition or syndrome, the idea parallels that of the "roles" that people often take on in alcoholic families, or abusive relationships. It is also consistent with the idea of "roles" described in co-dependent relationships, such as "enabler", "counter-dependent", and/or "agent". Part of the value of this type of informal terminology is that it helps describe the manner in which others potentially behave when in relationship to a person whose social skills are inadequate, in what ever way that presents itself.

When talking about the Borderline relationship, the "Non-reactive NonBP" is considered to be a person who interacts with the Borderline character, while not being drawn into, or engaging, the chaos of the disorder. The "Reactive NonBP", however, both interacts with the Borderline character, and engages the Borderline behavior. This often throws the person off-center, and promotes a kind of parallel emotional dysregulation within them. The "Reactive" relationship style breaks down into two distinct sub-styles; transpersonal, or the "trans-Borderline", and counterpersonal, or the "counter-Borderline".

The "trans-Borderline" is an individual who engages the Borderline character, and is drawn only to the chaos of the disorder itself. Rather than being directly affected, s/he is more apt to stay focused on "cleaning up" after the Borderline personality. This is something akin to the "caretaker/enabler" role found in alcoholic relationships. In both cases, this person is characteristically co-dependent, or set up to be co-dependent in that relationship. S/he acts as enabler, or agent, or both. ^{[citation needed]}

The "counter-Borderline", on the other hand, not only reacts to and integrates the Borderline style, but reflects it, as well. This individual is the most negatively affected by his/her relationship to the Borderline personality. Very often, this person will begin to behave in a manner very similar to a person with a Borderline personality. ^{[citation needed]}

[edit] Footnotes

1. ^ Herman, Judith, "Trauma and Recovery: the aftermath of violence-- from domestic abuse to political terror", 1991.
2. ^ Quadrio, C. (2005). Axis One/Axis Two: A disordered borderline. Psychology, Psychiatry, and Mental Health Monographs, 141-156.(Proceedings of the NSW Institute of Psychiatry Conference (2004), Trauma: Responses Across the Life Span)
3. ^ Paris, Joel, Borderline Personality Disorder: What Is It, What Causes It? How Can We Treat It?
4. ^ Swartz M, Blazer D, George L, Winfield I. Estimating the prevalence of borderline personality disorder in the community. Journal of Personality Disorders, 1990; 4(3): 257-72.
5. ^ Zanarini MC, Frankenburg FR. Treatment histories of borderline inpatients. Comprehensive Psychiatry, in press.
6. ^ Zanarini MC, Frankenburg FR, Dubo ED, Sickel AE, Trikha A, Levin AB, Reynolds V. (1998). Axis I Comorbidity of Borderline Personality Disorder, Am J Psychiatry 155:1733-1739. http://ajp.psychiatryonline.org/cgi/content/full/155/12/1733
7. ^ Zanarini MC, Frankenburg FR, DeLuca CJ, Hennen J, Khera GS, Gunderson JG. The pain of being borderline: dysphoric states specific to borderline personality disorder. Harvard Review of Psychiatry, 1998; 6(4): 201-7.
8. ^ Soloff PH, Lis JA, Kelly T, Cornelius J, Ulrich R. Self-mutilation and suicidal behavior in borderline personality disorder. Journal of Personality Disorders, 1994; 8(4): 257-67.
9. ^ Gardner DL, Cowdry RW. Suicidal and parasuicidal behavior in borderline personality disorder. Psychiatric Clinics of North America, 1985; 8(2): 389-403.
10. ^ Cochrane Collaboration - Psychosocial and pharmacological treatments for deliberate self harm
11. ^ Zanarini, Gunderson, Marino, Schwartz, & Frankenburg. Childhood experiences of borderline patients. Comprehensive psychiatry, 1989; Jan-Feb;30(1):18-25.
12. ^ Brown GR, Anderson B. Psychiatric morbidity in adult inpatients with childhood histories of sexual and physical abuse. Am J Psychiatry, 1991; 148(1):55-61
13. ^ Zanarini MC, Frankenburg. Pathways to the development of borderline personality disorder. Journal of Personality Disorders, 1997; 11(1): 93-104.
14. ^ Factors associated to the diagnoses of borderline personality disorder in psychiatric out-patients -PubMed
15. ^ ^a b Biparental failure in the childhood experiences of borderline patients - PubMed
16. ^ ^a b c Trauma, genes, and the neurobiology of personality disorders - PubMed
17. ^ Davidson RJ, Jackson DC, Kalin NH. Emotion, plasticity, context and regulation: perspectives from affective neuroscience. Psychological Bulletin, 2000; 126(6): 873-89.
18. ^ Davidson RJ, Putnam KM, Larson CL. Dysfunction in the neural circuitry of emotion regulation - a possible prelude to violence. Science, 2000; 289(5479): 591-4.
19. ^ Koerner K, Linehan MM. Research on dialectical behavior therapy for patients with borderline personality disorder. Psychiatric Clinics of North America, 2000; 23(1): 151-67.
20. ^ BORDERLINE PERSONALITY DISORDER. Medical-library.org. Retrieved on September 25, 2006.
21. ^ Cochrane Review -Psychological therapies for people with borderline personality disorder
22. ^ Dialectical behavioural therapy for women with borderline personality disorder: 12-month, randomised clinical trial in The Netherlands - PubMed
23. ^ ^a b c [Cochrane Review -Pharmacological interventions for people with borderline personality disorder]
24. ^ Hollander E, et al. Impact of trait impulsivity and state aggression on divalproex versus placebo response in borderline personality disorder. Am J Psychiatry. 2005 Mar;162(3):621-4
25. ^ Physicians' Desk Reference
26. ^ Siever LJ, Koenigsberg HW. The frustrating no-man's-land of borderline personality disorder. Cerebrum, The Dana Forum on Brain Science, 2000; 2(4).
27. ^ Casey, D, E,Tardive dyskinesia: reversible and irreversible - PubMed
28. ^ Emerging evidence for the use of atypical antipsychotics in borderline personality disorder - PubMed
29. ^ Psychotropic drugs induced weight gain: a review of the literature concerning epidemiological data, mechanisms and management - PubMed
30. ^ Double-blind, placebo-controlled study of dialectical behavior therapy plus olanzapine for borderline personality disorder - PubMed

[edit] Bibliography

[edit] Further reading

List of further reading on Borderline personality disorder

[edit] See also

• Bipolar disorder
• PTSD
• Dialectical behavior therapy

[edit] External links

• DSM-IV Criteria for BPD from the BPD Resource Center
• Borderline Personality Disorder, Raising questions, finding answers (PDF) from the NIMH website
• BPD Information page at The Doctors Lounge
• TARA is devoted to teaching families effective ways to help their loved ones and to advancing treatment methods
• Mental Health Matters - Borderline Personality Disorder
• BPD synopsis - MentalHealth.com

v • d • e DSM-IV Personality Disorders
Cluster A (Odd): Schizotypal, Schizoid, Paranoid
Cluster B (Dramatic): Antisocial, Borderline, Histrionic, Narcissistic
Cluster C (Anxious): Dependent, Obsessive-Compulsive, Avoidant