The Oxford Handbook of Personality Disorder
Chapter 20 Borderline Personality Disorder
BPD is a severe form of psychopathology characterized by stable instability in cluster B.
Clinical aspects
Short history Borderline:
- Early 20th century: dominance of psychoanalytic thinking
o Neurosis – chronic distress but never delusions nor hallucinations
o Psychosis – loss of touch with reality
- Stern (1938): described patients on the border line between neurosis and psychosis. They were
hypersensitive and showed negative reactions in therapy & now called borderline patients.
- Knight: “Borderline” is a diagnostically uninformative state in which psychotic and neurotic
features were present in the same individual. Others called it ‘pseudo-neurotic schizophrenia’.
- Now, “borderline” is for patients who are problematic to deal with.
- More research in ‘60s and ‘70s. More attention. 3 developments:
1. New clinical and theoretical insights into borderline personality organization.
2. Preliminary and empirically based criterion set for the disorder. Important, because
the term was also used to described patients with some features of schizophrenia.
3. Review to help define it with 6 features:
Intense affect, impulsivity, relationship problems, brief psychotic experiences.
BPD as we know it now classified in DSM-3 and separated from schizophrenia.
- Highest prevalence in clinical practice
Problems with the name:
- No descriptive info about what it involves
- Confusing: what is the border?
- Term is associated with the psychoanalytic tradition (ego, id, etc.)
Borderline PD is termed ‘emotionally unstable’ PD in ICD-10. No psychoanalytic legacy.
Criteria BPD DSM-5:
1. Frantic efforts to avoid real or imagined abandonment
2. Pattern of instable and intense interpersonal relationships characterized by alternating between
extremes of idealization and devaluation (loving someone one day and hating them the other).
3. Identity disturbance; markedly and persistently unstable self-image or sense of self.
a. Hard to have long-term intrinsic goals or motivations.
4. Impulsivity in at least 2 areas that are potentially self-damaging (spending, sex, drugs)
5. Recurrent suicidal behavior, gestures, threats, or self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood (irritability, or anxiety usually lasting
a few hours/ few days).
a. Quickly changing; instable. Not for a long time.
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger (recurrent fights or constant anger)
9. Transient, stress-related paranoid ideation or severed dissociative symptoms.
a. Stress emotion-regulation dissociation/ out-of-body experience.
b. Different from the others.
4 domains of the instability:
6&8 focus on affective instability. Lots of emotions that can be very intense.
2 focuses on relationship with others. They sabotage them because of fear and the emotions make
relationships hard. 1 also about relationships with others, but this is a result of number 3. When you
have no intrinsic goals, you focus on others for guidance and that’s why they are anxious that their SO
will leave them, which in turn will again lead to 7. They need others to regulate them.
3&7 related to each other and they’re about self-concept. Emptiness follows instable self-image.
4&5 are behavioral symptoms. Impulsive behavior to distract from issues or to fit in.
For a diagnosis, you need at least 5 of these symptoms. 2 people with this disorder, might only have 1
symptom in common. Therefore, like all PDs, BPD can present itself very heterogenous.
, The Oxford Handbook of Personality Disorder
Comorbidity
Axis-1 comorbidity: the comorbidity with other mental disorders that were mentioned on Axis-1.
Axis-1 comorbidity is the rule:
- 70% BPD patients had 3 or more current Axis 1 disorders
- 31% non-BPD patients had 3 or more current Axis 1 disorders
BPD often co-occurs with:
- Mood disorders Underlying risks: many people with BPD experienced trauma in childhood.
o Major depression (61%).
BPD isn’t simply a form of this, since they respond differently to emotional stimuli.
o PTSD (36%).
BPD isn’t simply a form of this, since trauma isn’t necessary (often present).
o Bipolar (20%)
- Eating disorders (17%)
- Substance abuse & Other PDs
Co-morbidity is elevated especially in clinical BPD patients as compared to nonclinical (high-
functioning) BPD patients.
- BPD (and other PD) patients in clinical practice often seek help for comorbid problems.
- More problems more chance they’ll seek help
- In community, mostly “high-functioning BPD”. 40% never needed help and less likely to have
had comorbid Axis 1 disorders. Maybe these other disorders cause functional impairments
Researchers wanted to switch to a dimensional model with DSM-5 (didn’t happen). Possible changes:
Categorical vs. dimensional model.
- Categorical: presence or absence of a disorder
You are either BPD or not. DSM is categorical.
Underlying assumption: disease represents a certain entity that we can ‘find’ (cancer)
- Dimensional: rank or continuous quantitative dimensions
How does someone score on several key symptoms of/ traits underlying BPD?
Big Five model used to describe personality:
- Extraversion (warmth, activity, excitement seeking)
- Neuroticism (anxiousness, hostility, depressiveness)
- Conscientiousness (competence, order, dutifulness, self-discipline)
- Agree-ableness (trust, straightforwardness, altruism)
- Openness (fantasy, aesthetics, actions, feelings)
Example: impulsivity dimensions
- Maladaptive low (overly restrained)
- Normal low (restrained)
- Normal high (self-indulgent)
- Maladaptive high (unable to resist impulses)
BPD: FFM factors and facets, maladaptively high or low.
- Traits: neuroticism (↑) and agreeableness (↓)
- Facets:
o ↑ neuroticism facets: anxiety, anger, depression, self-consciousness, immoderation
o ↓ several agreeableness facets: trust, compliance, morality
o Additionally: high on fantasy (O) and low on liberalism (O/C)
The dimensional concept might reflect the nature of BPD better.
Epidemiology
Epidemiology is the study of the distribution and determinants of health-related states or events,
including disease. Who has the disorder? Prevalence PDs in common population:
BPD prevalence:
- 1 – 2% in common population
- Men – women is 50/50, but not in psychiatric samples (1:3). Women look for help sooner?
- More in younger individuals (maybe because of completed suicide rates)
Treatment can also help and for some symptoms reduce with age.
, The Oxford Handbook of Personality Disorder
- Small associations to living currently in (un)fortunate social situation
Not strongly in comparison to some other PDs
- Highly related to poor functioning and quality of life (QoL)
- Highly related to attendance psychiatric facilities (10 – 15%)
Suicide and BPD:
- 1 in 3 attempt suicide. Average attempts in lifetime: 3 or 4
- 10% dies, often before age of 40
- Studies to understand risk factors present mixed results
(Affective instability, depressed mood, intensity negative affect, poor social adjustments)
Functions of self-harm and suicide attempts (attention, stop others from abandoning them
(focus on others), or because of stress and desperation).
difficult to predict suicidality in BPD patients
Treatment for these patients is hard because of the instability and the relationship difficulties.
Positive findings:
- Low dropout rate for those in inpatient treatment
- 93% showed significant reductions in their symptoms
- Happens quickly. Predictors for rapid remission:
o Younger age
o Absence of childhood sexual abuse & of family history of substance abuse disorders
o Good recent work history & Agreeable temperament
Some warnings;
- 4.4% still died after suicide
- Recurrences of symptoms weren’t uncommon
- Even if symptoms reduced, problems in psychosocial functioning could persist.
Important factor in family environment is expressed emotion (EE):
- Linked to relapse and poor clinical outcome
- Not predictive of a more unfavorable course of illness
- Patients did better if family member showed emotional overinvolvement (EOI).
- Hypothesis (supported): BPD patients see EOI has something positive.
Etiology
The many factors coming together to cause an illness.
Genes & BPD:
- Genetics are part of the explanation.
- Relatives of BPD patients: 4 – 20x more often, but they also share an environment.
- Monozygotic Twins: 35% concordance rates, 7% in Dizygotic Twins
- 45% heritable through multiple genes
- BPD as a disorder is not heritable, as BPD isn’t an existing entity somewhere. Only
susceptibility to central traits that underlie BPD as a specific set of symptoms is heritable.
A latent construct is a variable that cannot be measured directly. The researcher must capture the
variable through questions representing the presence/ level of the variable in question. This is the case
with all PDs or mental disorders. It isn’t one gene or one symptom. Need to look at multiple ones.
Important neurotransmitters (chemical messengers in our body, influenced by genes):
- Serotonin (5-HT)
o Regulation of mood and appetitive behavior
o Inhibits activity of other neurotransmitter system
o Low 5-HT – impulsive (aggression)
- Dopamine – Reward pathways (substance abuse)
Environment and BPD
- Cultural transmission (shared learning with siblings, imitation and modeling) does NOT play a
significant role.
- Early traumatic experiences are much more common in BPD than any other disorder.
Both cross-sectional self-reports as more objective data.
Study from handbook by Johnson and colleagues about trauma and PDs:
, The Oxford Handbook of Personality Disorder
- Used objective data about trauma (reported trauma)
- Of those who experienced childhood maltreatment, 54% developed any PD vs. 11% that
developed PD following no childhood maltreatment.
They especially developed cluster B.
- For BPD: chances are 7-fold that you will develop BPD after childhood maltreatment to no
childhood maltreatment
Other findings about the link with childhood aversity – BPD:
- When there was abuse, there were probably other problems as well
- Traumatic early experiences are more commonly reported by people with BPD
- Stressful early environment problems with attachment ; less trusting.
However, other PDs are also characterized by relationship problems. No differentiation.
- Only 6 – 8% of BPD adult patients is securely attached
- 50 – 88% shows preoccupied attachment
o Secure attachment style: positive view about self and other
o Preoccupied: positive view about others, negative about self
o Fearful-avoidant: negative about others and self
o Dismissing-avoidant: positive about self and negative about others
Cluster A PDs (paranoid). Dismissing because you are negative about others.
The gene-environment interaction is most important:
- Genes determine the extent to which we are sensitive to environmental influences
- Environmental events regulate our gene transcription and playout
How does gene-environment interaction lead to BPD? There are several domains.
The first is altered neurochemistry (serotonin and dopamine), which is involved in heightened
impulsivity, emotional vulnerability, etc.
- Hard to find what is specific to BPD because of comorbidity.
- Genes involved in serotonin synthesis and metabolism are 5HTT, MAO-A and TPH. Studies
show BPD is related to more/less of these genes and/or a different built-up of these genes.
- Example: BPD patients who enhance short-term rewards on a gambling task have more of the
TPH-1 gene involved in serotonin production.
There are also changes in stress responsiveness.
- Also related to neurochemistry.
- HPA-axis: interactions between hypothalamus, anterior pituitary gland & adrenal cortex.
CRH in hypothalamus ACTH in anterior pituitary glucocorticoid hormone cortisol
- What is different again, is hard, because of different findings. Also, comorbidity.
- What is certain: HPA axis abnormalities. Cause is unclear (BPD, PTSD, etc.)
There are some brain abnormalities found:
- Limbic system: hippocampus and amygdala. Both are smaller. Related to PTSD?
- Frontal cortex
- The Frontolimbic system is involved in impulsivity, aggression, self-harming behavior and
fears of abandonment. Not BPD specific though.
There is evidence for problems in neurocognitive dysfunctioning.
- People with BPD perform worse on many tasks, such has go/no-go Task (behavioral
inhibition) but also cognitive inhibition. Possible errors with these tasks:
o Passive avoidance errors: number of times that a participant responded to a losing
number. So, press when you shouldn’t. Inhibition problems.
o Misses: the number of times that a participant failed to respond to a winning number.
Forgetting. This happened less.
- Related to specific brain abnormalities.
Problems were found with memory:
- Verbal memory: lists of words to remember or recall a story.
- Nonverbal memory: drawing a figure that was presented earlier.
BPD patients perform worse on both, but also on autobiographical memory.
And then there is emotion (dys)regulation:
