Medical Edge Newspaper Column

Borderline Personality Disorder: Managing an Inner Storm

Dec. 18, 2006
DEAR MAYO CLINIC:
What is borderline personality disorder and how is it treated? -- Moline, Ill.

ANSWER:
Borderline personality disorder (BPD) is characterized by a pattern of instability in personal relationships, poor self-image, mood fluctuations, and significant impulsivity. Individuals with this disorder may be excessively dependent on -- and therefore vulnerable to -- other people; but ironically, because BPD patients are also hypersensitive and easily excitable, they tend to drive others away. These patients lack skills that would enhance their independence and self-determination.

Borderline patients can have episodes of significant loss of control or have unpredictable emotional reactions. They can also be self-centered, manipulative, and emotionally ambivalent toward themselves and others. Because they tend to have significant difficulties in formulating a clear idea of their personal image, they change their self-representation often. Some clinicians think self-cutting and other self-inflicted injuries, including overt suicidal behaviors, are characteristic of these patients.

Given the stormy inner experience, BPD can be accompanied by anxiety, depression, violent outbursts, addiction problems, and psychotic symptoms. The name arose because of theories in the 1940s and '50s that the disorder was on the border between neurosis and psychosis. That view doesn't reflect current thinking. In fact, some advocacy groups have pressed for changing the name -- to "emotional dysregulation disorder," for example.

Borderline personality disorder is found in about 2 percent of the general population, 10 percent of psychiatric outpatients, and 20 percent of those admitted to psychiatric facilities. It appears to most often be diagnosed in young adults, predominantly women, who may also develop manifestations of an eating disorder.

The treatment of borderline personalities is primarily psychotherapeutic, but in many cases it also requires medications to deal with accompanying symptoms. The most successful therapeutic approach to BPD is so-called dialectic behavioral therapy (DBT), a comprehensive treatment that includes:

• increasing the patient's motivation to seek care
• stimulating his or her existing capacities and building new ones, while assuring that they can be applied to the patient's overall environment?;
• structuring that environment so that it will enhance the patient's abilities and relationship with a therapist? and
• enhancing motivation to deal with problems in an effective fashion?

DBT's primary goals are the emotional stabilization of patients and helping them acquire behavioral control. Once they are stabilized, treatment aims to improve patients' emotional response to traumatic events, ability to resolve problems of everyday life, and capacity to enjoy everyday life.

Other psychotherapeutic approaches include supportive therapy, group therapy and psychoeducational training, as well as techniques specifically oriented toward anger management, hypersensitivity, conflict resolution, self-image issues, and the avoidance of suicidal behavior and self-harming.

Medications can be an important complement, and may include antidepressants, anti-anxiety agents, mood stabilizers, and low doses of antipsychotics. Medications should be use judiciously, however, because of the risk of substance abuse or suicidal behaviors.

There is no single cause of borderline personality disorder -- it is thought to result from a combination of factors: genetics (some studies of twins and families suggest that personality disorders may be inherited); environment (many people with BPD have a history of childhood abuse, neglect, and separation from caregivers or loved ones); and brain abnormalities. Some research shows changes in BPD patients in certain areas of the brain involved in emotion regulation, impulsivity, and aggression. In addition, certain brain chemicals that help regulate mood, such as serotonin, may not function properly in BPD patients.

Because there is no definitive cure, management of the condition is long-term. Still, some of the "edgy" behaviors can be significantly reduced over time. Many people with the disorder find greater stability in their lives during their 30s and 40s and beyond. Their inner turmoil often lessens and they may go on to sustain loving relationships and enjoy meaningful careers.

-- Renato D. Alarcón, M.D., Medical Director of the Mood Disorders Unit of the Psychiatry and Psychology Treatment Center, Mayo Clinic, Rochester, Minn.