Borderline Personality Disorder

Borderline Personality Disorder

Borderline personality disorder (BPD) is a psychiatric diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV Personality Disorders 301.83)[1] that describes a prolonged disturbance of personality function characterized by depth and variability of moods.[2] The disorder typically involves unusual levels of instability in mood; "black and white" thinking, or splitting; chaotic and unstable interpersonal relationships, self-image, identity, and behavior; as well as a disturbance in the individual's sense of self. In extreme cases, this disturbance in the sense of self can lead to periods of dissociation.[3] These disturbances can have a pervasive negative impact on many or all of the psychosocial facets of life. This includes difficulties maintaining relationships in work, home and social settings. Attempted suicide and completed suicide are possible outcomes, especially without proper care and effective therapy.[4]

Onset of Borderline Personality Disorder symptoms typically occurs during adolescence or young adulthood. Symptoms may persist for several years, but the majority of symptoms lessen in severity over time,[4] with some individuals fully recovering. The mainstay of treatment is various forms of psychotherapy, although medication and other approaches may also improve symptoms. While borderline personality disorder can manifest itself in children and teenagers, therapists are discouraged from diagnosing anyone before the age of 18, due to adolescence and a still-developing personality.

There are some instances when BPD can be evident and diagnosed before the age of 18. The DSM-IV states: "To diagnose a personality disorder in an individual under 18 years, the features must have been present for at least 1 year." In other words, it is possible to diagnose the disorder in children and adolescents, but a more conservative approach should be taken.

There is some evidence that BPD diagnosed in adolescence is predictive of the disease continuing into adulthood. It is possible that the diagnosis, if applicable, would be helpful in creating a more effective treatment plan for the child or teen.[5][6]

As with other mental disorders, the causes of BPD are complex and unknown.[7] One finding is a history of childhood trauma, abuse or neglect,[8] although researchers have suggested diverse possible causes, such as a genetic predisposition, neurobiological factors, environmental factors, or brain abnormalities.[7] The prevalence of BPD in the United States has been calculated as 1 percent to 3 percent of the adult population,[7] with approximately 75 percent of those diagnosed being female.[9] It has been found to account for 20 percent of psychiatric hospitalizations. Common comorbid (co-occurring) conditions are mental disorders such as substance abuse, depression and other mood, and personality disorders. BPD is one of four diagnoses classified as cluster B (dramatic-erratic) personality disorders typified by disturbances in impulse control and emotional dysregulation, the others being narcissistic, histrionic, and antisocial personality disorders.[10]

The term borderline, although it was used in this context as early as the 17th century, was employed by Adolph Stern in 1938 to describe a condition as being on the borderline between neurosis and psychosis. Because the term no longer reflects current thinking, there is an ongoing debate concerning whether this disorder should be renamed.[7] There is related concern that the diagnosis stigmatizes people, usually women, and supports pejorative and discriminatory practices.[11]

People suffering from borderline personality disorder and their families often feel the hardships are compounded by a lack of clear diagnoses, effective treatments, and accurate information. At their request, the U.S. House of Representatives unanimously declared the month of May as Borderline Personality Disorder Awareness Month (H. Res. 1005, 4/1/08), citing BPD's "prevalence, enormous public health costs, and ... devastating toll on individuals, families, and communities."

Diagnosis

Borderline Personality Disorder Diagnosis is based on a clinical assessment by a qualified mental health professional. The assessment incorporates the patient's self-reported experiences as well as the clinician's observations. The resulting profile may be supported or corroborated by long-term patterns of behavior as reported by family members, friends or co-workers. The list of criteria that must be met for diagnosis is outlined in the DSM-IV-TR.[3]

Borderline personality disorder was once classified as a subset of schizophrenia (describing patients with borderline schizophrenic tendencies). Today BPD is considered a relatively stable personality disorder and is used more generally to describe non-psychotic individuals who display emotional dysregulation, splitting and an unstable self-image.[citation needed] Individuals with BPD are at high risk of developing other psychological disorders such as anxiety and depression. Other symptoms of BPD, such as dissociation, are frequently linked to severely traumatic childhood experiences, which some put forth as one of the many root causes of the borderline personality. BPD has many similar characteristics to emotionally unstable personality disorder, subtype borderline; and complex post-traumatic stress disorder.[citation needed]

Diagnostic criteria (DSM-IV-TR = 301.83)

The Diagnostic and Statistical Manual of Mental Disorders fourth edition, DSM IV-TR, a widely used manual for diagnosing mental disorders, defines borderline personality disorder (in Axis II Cluster B) as:[37]

A pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:[24]

frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-injuring behavior covered in Criterion 5
a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
Identity disturbance: markedly and persistently unstable self-image or sense of self.
impulsivity in at least two areas that are potentially self-damaging (e.g., promiscuous sex, eating disorders, binge eating, substance abuse, reckless driving). Note: Do not include suicidal or self-injuring behavior covered in Criterion 5
recurrent suicidal behavior, gestures, threats or self-injuring behavior such as cutting, interfering with the healing of scars (excoriation) or picking at oneself.
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).
chronic feelings of emptiness
inappropriate anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
transient, stress-related paranoid ideation, delusions or severe dissociative symptoms

Diagnostic criteria (ICD-10)

The World Health Organization's ICD-10 has a comparable diagnosis called Emotionally unstable personality disorder - Borderline type (F60.31). This requires the following, in addition to the general criteria for personality disorder: disturbances in and uncertainty about self-image, aims and internal preferences (including sexual); liability to become involved in intense and unstable relationships, often leading to emotional crisis; excessive efforts to avoid abandonment; recurrent threats or acts of self-harm; and chronic feelings of emptiness.

Diagnostic criteria (CCMD)

The Chinese Society of Psychiatry's CCMD has a comparable diagnosis of Impulsive Personality Disorder (IPD). A patient diagnosed as having IPD must display "affective outbursts" and "marked impulsive behavior," plus at least three out of eight other symptoms. The construct has been described as a hybrid of the impulsive and borderline subtypes of the ICD-10's Emotionally Unstable Personality Disorder, and also incorporates six of the nine DSM BPD criteria.[38]

Differential diagnosis: associated and overlapping conditions

Borderline personality disorder and mood disorders often appear concurrently.[4] Some features of borderline personality disorder may overlap with those of mood disorders, complicating the differential diagnostic assessment.[40][41][42]

Both diagnoses involve symptoms commonly known as "mood swings." In borderline personality disorder, the term refers to the marked lability and reactivity of mood defined as emotional dysregulation.[citation needed] The behavior is typically in response to external psychosocial and intrapsychic stressors, and may arise or subside, or both, suddenly and dramatically and last for seconds, minutes, hours, days, weeks or months .[citation needed]

Bipolar depression is generally more pervasive with sleep and appetite disturbances, as well as a marked nonreactivity of mood, whereas mood with respect to borderline personality and co-occurring dysthymia remains markedly reactive and sleep disturbance not acute.[43]

The relationship between bipolar disorder and borderline personality disorder has been debated. Some hold that the latter represents a subthreshold form of affective disorder,[44][45] while others maintain the distinctness between the disorders, noting they often co-occur.[46][47]

Some findings suggest that BPD may lie on a bipolar spectrum, with a number of points of phenomenological and biological overlap between the affective lability criterion of borderline personality disorder and the extremely rapid cycling bipolar disorders.[48][49] Some findings suggest that the DSM-IV BPD diagnosis mixes up two sets of unrelated items—an affective instability dimension related to Bipolar-II, and an impulsivity dimension not related to Bipolar-II.[50]

Comorbid (co-occurring) conditions in BPD are common. When comparing individuals diagnosed with BPD to those diagnosed with other personality disorders, the former showed a higher rate of also meeting criteria for:[51]
anxiety disorders
mood disorders (including clinical depression and bipolar disorder)
eating disorders (including anorexia nervosa and bulimia)
and, to a lesser extent, somatoform or factitious disorders
dissociative disorders; if all DSM criteria are met, it is recommended that the person should also be tested to have Dissociative Identity Disorder.[citation needed]

Substance abuse is a common problem in BPD, whether due to impulsivity or as a coping mechanism, and 50 percent to 70 percent of psychiatric inpatients with BPD have been found to meet criteria for a substance use disorder, especially alcohol dependence or abuse which is often combined with the abuse of other drugs.[52]

Borderline Personality Disorder Treatment

The mainstay of treatment is various forms of psychotherapy, although medication and other approaches may also improve symptoms.

Psychotherapy

There has traditionally been skepticism about the psychological treatment of personality disorders, but several specific types of psychotherapy for BPD have developed in recent years. The limited studies to date do not allow confident claims of effectiveness but do suggest that people with BPD can benefit on at least some outcome measures.[75] Supportive therapy alone may enhance self-esteem and mobilize the existing strengths of individuals with BPD.[76] Specific psychotherapies may involve sessions over several months or, as is particularly common for personality disorders, several years. Psychotherapy can often be conducted either with individuals or with groups. Group therapy can aid the learning and practice of interpersonal skills and self-awareness by individuals with BPD,[77] though drop-out rates may be problematic.[78]

Dialectical behavioral therapy

University of Washington psychology professor Marsha Linehan is credited with developing the first empirically supported standard treatment for BPD, termed dialectical behavioral therapy (DBT). DBT grew dramatically in popularity among mental health professionals following the publication of Linehan’s treatment manuals for DBT in 1993. DBT was originally developed as an intervention for patients who meet criteria for BPD and particularly those who are highly suicidal.[79]

DBT draws its principles from behavioral science (including cognitive-behavioral techniques), dialectical philosophy and Zen practice. The treatment emphasizes balancing acceptance and change (hence dialectic), with the overall goal of helping patients not just survive but build a life worth living. Treatment is delivered in four stages, with self-harm and other life-threatening issues taking priority. In the second stage, patients are encouraged to experience the painful emotions that they have been avoiding. Stage three addresses problems of living such as career and marital problems. Finally, stage four focuses on helping clients feel complete and reducing feelings of emptiness and boredom.

DBT encompasses four modes of therapy, the first being traditional individual therapy between a single therapist and client. The second mode of therapy is skills training; a core component of DBT is learning new skills, including mindfulness, interpersonal effectiveness (e.g. assertiveness and social skills), coping adaptively with distress and crises, and identifying and regulating emotional reactions.[citation needed]

The third mode of therapy used is skills generalization, which focuses on helping clients integrate the skills taught in DBT into real-life situations. This usually involves coaching in the form of telephone contact outside of normal therapy hours. The calls are usually brief interactions focused on helping clients apply specific skills to circumstances they are experiencing. The fourth mode of therapy is the use of a consultation team designed to support the therapists. These teams have several important functions including reducing therapist burnout, providing therapy for the therapists, improving empathy for clients and providing ongoing consultations for client difficulties.

The goal of all DBT treatment approaches is to reduce the ineffective action tendencies linked to dysregulated emotions. DBT is based on a biosocial theory of personality functioning in which the core problem is seen as the breakdown of the patient’s cognitive, behavioral and emotional regulation systems when experiencing intense emotions. The etiology of BPD is seen as a biological predisposition toward emotional dysregulation combined with a perceived invalidating social environment.[80]

DBT can be based on a biosocial theory of personality functioning in which BPD is seen as a biological disorder of emotional regulation in a social environment experienced as invalidating by the borderline patient.[81]

Several random controlled trials (RCTs) comparing DBT to other forms of treatment have favored the use of DBT to treat borderline patients. Specifically, DBT has been found to significantly reduce self-injury, suicidal behavior, impulsivity, self-rated anger and the use of crisis services among borderline patients. These reductions have been found even when controlling for other treatment factors such as therapist experience, affordability of treatment, gender of therapist and the number of hours spent in individual therapy.[82][83] However, the additional efficacy in the overall treatment of BPD is less clear; future research is needed to isolate the specific components of DBT that are most effective in treating BPD.[75] Furthermore, little research has examined the efficacy of DBT in treating male and minority patients with BPD. Training nurses in the use of DBT has been found to replace a therapeutic pessimism with a more optimistic understanding and outlook.[84]

Schema therapy

Schema therapy (also called schema-focused therapy) is an integrative approach based on cognitive-behavioral or skills-based techniques along with object relations and gestalt approaches. It directly targets deeper aspects of emotion, personality and schemas (fundamental ways of categorizing and reacting to the world). The treatment also focuses on the relationship with the therapist (including a process of "limited re-parenting"), daily life outside of therapy and traumatic childhood experiences. It was developed by Jeffrey Young and became established in the 1990s. Limited recent research suggests it is significantly more effective than transference-focused psychotherapy, with half of individuals with borderline personality disorder assessed as having achieved full recovery after four years, with two-thirds showing clinically significant improvement.[85][86][unreliable source?] Another very small trial has also suggested efficacy.[87]

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is the most widely used and established psychological treatment for mental disorders, but has appeared less successful in BPD, due partly to difficulties in developing a therapeutic relationship and treatment adherence. Approaches such as DBT and Schema-focused therapy developed partly as an attempt to expand and add to traditional CBT, which uses a limited number of sessions to target specific maladaptive patterns of thought, perception and behavior. A recent study did find a number of sustained benefits of CBT, in addition to treatment as usual, after an average of 16 sessions over one year.[88]

Marital or family therapy

Marital therapy can be helpful in stabilizing the marital relationship and in reducing marital conflict and stress that can worsen BPD symptoms. Family therapy or family psychoeducation can help educate family members regarding BPD, improve family communication and problem solving, and provide support to family members in dealing with their loved one's illness.[citation needed]

Two patterns of family involvement can help clinicians plan family interventions: overinvolvement and neglect. Borderline patients who are from overinvolved families are often actively struggling with a dependency issue by denial or by anger at their parents.[citation needed]

Interest in the use of psychoeducation and skills training approaches for families with borderline members is growing.[77]

Psychoanalysis

The term dates back to 1884. It was C. Hugues who first spoke about subjects oscillating throughout their whole life between the limits of insanity and normality. A. Stern brings back the term in 1938 to describe a " hypersentimentality of the subjects, their defensive rigidity and their little self-respect." It is psychoanalysis that the term "borderline" was developed to define an "oedipian intermédaire organization." Edward Glover (psychoanalyst), for example, spoke about "transitional states" (1932). Addictions are real states borderline in the sense that they are one foot in the psychoses and the other one in the neurosis. (...). It have their root in the paranoid states and, occasionally in the dominant melancolic state.[citation needed] He had established a plan which placed very clearly the place of the borderline in touch with the other disorders.[89] Since, the works of Otto Kernberg, the French Jean Bergeret developed the concept which adapted itself to the modern psychoanalysis. It is in the apparition of the DSM 4 that the term took two orientations: psychiatric one behavioral and the other, included in a psychoanalytical psychopathology. According to this split, the diagnosis takes on, or a character objectivizing with ascendancy of symptoms to be eradicated or it indicates a particular type of patients of psychoanalysts to treat in modalities different from those typical cures.[90][91][92]

Transference-focused psychotherapy
Further information: Otto F. Kernberg#Transference-Focused Psychotherapy

Transference-focused psychotherapy (TFP) is a form of psychoanalytic therapy dating to the 1960s, rooted in the conceptions of Otto Kernberg on BPD and its underlying structure (borderline personality organization). Unlike in the case of traditional psychoanalysis, the therapist plays a very active role in TFP. In session the therapist works on the relationship between the patient and the therapist. The therapist will try to explore and clarify aspects of this relationship so the underlying object relations dyads become clear. Some limited research on TFP suggests it may reduce some symptoms of BPD by affecting certain underlying processes,[93] and that TFP in comparison to dialectical behavioral therapy and supportive therapy results in increased reflective functioning (the ability to realistically think about how others think) and a more secure attachment style.[94] Furthermore, TFP has been shown to be as effective as DBT in improvement of suicidal behavior, and has been more effective than DBT in alleviating anger and in reducing verbal or direct assaultive behavior.[95] Limited research suggests that TFP appears to be less effective than schema-focused therapy, while being more effective than no treatment.[85]

Cognitive analytic therapy

Cognitive analytic therapy (CAT) combines cognitive and psychoanalytic approaches and has been adapted for use with individuals with BPD with mixed results.[96]

Medication

A number of medications are used in conjunction with BPD treatments, although the evidence base is limited. As BPD has been traditionally considered a primarily psychosocial condition, medication is intended to treat comorbid symptoms, such as anxiety and depression, rather than BPD itself.[102] Indeed, UK's National Institute for Health and Clinical Excellence (NICE) has reiterated in their 2009 BPD treatment guidelines that medication is not appropriate for treating the condition itself, but for comorbid conditions only.[103]

Antidepressants

Selective serotonin reuptake inhibitor (SSRI) antidepressants have been shown in randomized controlled trials to improve the attendant symptoms of anxiety and depression, such as anger and hostility, associated with BPD in some patients.[102] According to Listening to Prozac, it takes a higher dose of an SSRI to treat mood disorders associated with BPD than depression alone. It also takes about three months for benefit to appear, compared to the three to six weeks for depression.

Antipsychotics

The newer atypical antipsychotics are claimed to have an improved adverse effect profile than the typical antipsychotics. Antipsychotics are also sometimes used to treat distortions in thinking or false perceptions.[dead link][104] Use of antipsychotics is generally short-term. One meta-analysis of two randomly controlled trials, four non-controlled open-label studies and eight case reports has suggested that several atypical antipsychotics, including olanzapine, clozapine, quetiapine and risperidone, may help BPD patients with psychotic-like, impulsive or suicidal symptoms.[105] However, there are numerous adverse effects of antipsychotics, notably Tardive dyskinesia (TD).[106] Atypical antipsychotics are known for often causing considerable weight gain, with associated health complications.[107]

Mood Stabilizers

Mood stabilizers (used primarily to treat Bipolar disorder) such as lithium or lamotrigine may be of some use to help depressed or labile periods, as well as rapid changes in mood.[108][109]

Borderline Personality Disorder
Norovirus Marfan syndrome Nasal Cancer Marburg Hemorrhagic Fever Malignant Hyperthermia Male Breast Cancer Lyme disease Lung cancer Legionellosis Latex Allergy Lassa Fever Jaundice / Kernicterus Hypothyroidism Kawasaki disease Genetic-Brain-Disorders Gallbladder-Diseases Fetal alcohol syndrome Diabetes Crimean-Congo Hemorrhagic Fever Dengue-and-Dengue-Hemorrhagic-Fever Chikungunya-Fever Cat Scratch Disease Cancer Larynx Cancer Among Children Borderline Personality Disorder Bladder cancer Baylisascaris Infection Benign tumor Skin Cancer African trypanosomiasis Coming Soon	Borderline Personality Disorder Borderline personality disorder (BPD) is a psychiatric diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV Personality Disorders 301.83)[1] that describes a prolonged disturbance of personality function characterized by depth and variability of moods.[2] The disorder typically involves unusual levels of instability in mood; "black and white" thinking, or splitting; chaotic and unstable interpersonal relationships, self-image, identity, and behavior; as well as a disturbance in the individual's sense of self. In extreme cases, this disturbance in the sense of self can lead to periods of dissociation.[3] These disturbances can have a pervasive negative impact on many or all of the psychosocial facets of life. This includes difficulties maintaining relationships in work, home and social settings. Attempted suicide and completed suicide are possible outcomes, especially without proper care and effective therapy.[4] Onset of Borderline Personality Disorder symptoms typically occurs during adolescence or young adulthood. Symptoms may persist for several years, but the majority of symptoms lessen in severity over time,[4] with some individuals fully recovering. The mainstay of treatment is various forms of psychotherapy, although medication and other approaches may also improve symptoms. While borderline personality disorder can manifest itself in children and teenagers, therapists are discouraged from diagnosing anyone before the age of 18, due to adolescence and a still-developing personality. There are some instances when BPD can be evident and diagnosed before the age of 18. The DSM-IV states: "To diagnose a personality disorder in an individual under 18 years, the features must have been present for at least 1 year." In other words, it is possible to diagnose the disorder in children and adolescents, but a more conservative approach should be taken. There is some evidence that BPD diagnosed in adolescence is predictive of the disease continuing into adulthood. It is possible that the diagnosis, if applicable, would be helpful in creating a more effective treatment plan for the child or teen.[5][6] As with other mental disorders, the causes of BPD are complex and unknown.[7] One finding is a history of childhood trauma, abuse or neglect,[8] although researchers have suggested diverse possible causes, such as a genetic predisposition, neurobiological factors, environmental factors, or brain abnormalities.[7] The prevalence of BPD in the United States has been calculated as 1 percent to 3 percent of the adult population,[7] with approximately 75 percent of those diagnosed being female.[9] It has been found to account for 20 percent of psychiatric hospitalizations. Common comorbid (co-occurring) conditions are mental disorders such as substance abuse, depression and other mood, and personality disorders. BPD is one of four diagnoses classified as cluster B (dramatic-erratic) personality disorders typified by disturbances in impulse control and emotional dysregulation, the others being narcissistic, histrionic, and antisocial personality disorders.[10] The term borderline, although it was used in this context as early as the 17th century, was employed by Adolph Stern in 1938 to describe a condition as being on the borderline between neurosis and psychosis. Because the term no longer reflects current thinking, there is an ongoing debate concerning whether this disorder should be renamed.[7] There is related concern that the diagnosis stigmatizes people, usually women, and supports pejorative and discriminatory practices.[11] People suffering from borderline personality disorder and their families often feel the hardships are compounded by a lack of clear diagnoses, effective treatments, and accurate information. At their request, the U.S. House of Representatives unanimously declared the month of May as Borderline Personality Disorder Awareness Month (H. Res. 1005, 4/1/08), citing BPD's "prevalence, enormous public health costs, and ... devastating toll on individuals, families, and communities." Diagnosis Borderline Personality Disorder Diagnosis is based on a clinical assessment by a qualified mental health professional. The assessment incorporates the patient's self-reported experiences as well as the clinician's observations. The resulting profile may be supported or corroborated by long-term patterns of behavior as reported by family members, friends or co-workers. The list of criteria that must be met for diagnosis is outlined in the DSM-IV-TR.[3] Borderline personality disorder was once classified as a subset of schizophrenia (describing patients with borderline schizophrenic tendencies). Today BPD is considered a relatively stable personality disorder and is used more generally to describe non-psychotic individuals who display emotional dysregulation, splitting and an unstable self-image.[citation needed] Individuals with BPD are at high risk of developing other psychological disorders such as anxiety and depression. Other symptoms of BPD, such as dissociation, are frequently linked to severely traumatic childhood experiences, which some put forth as one of the many root causes of the borderline personality. BPD has many similar characteristics to emotionally unstable personality disorder, subtype borderline; and complex post-traumatic stress disorder.[citation needed] Diagnostic criteria (DSM-IV-TR = 301.83) The Diagnostic and Statistical Manual of Mental Disorders fourth edition, DSM IV-TR, a widely used manual for diagnosing mental disorders, defines borderline personality disorder (in Axis II Cluster B) as:[37] A pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:[24] frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-injuring behavior covered in Criterion 5 a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. Identity disturbance: markedly and persistently unstable self-image or sense of self. impulsivity in at least two areas that are potentially self-damaging (e.g., promiscuous sex, eating disorders, binge eating, substance abuse, reckless driving). Note: Do not include suicidal or self-injuring behavior covered in Criterion 5 recurrent suicidal behavior, gestures, threats or self-injuring behavior such as cutting, interfering with the healing of scars (excoriation) or picking at oneself. 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). chronic feelings of emptiness inappropriate anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). transient, stress-related paranoid ideation, delusions or severe dissociative symptoms Diagnostic criteria (ICD-10) The World Health Organization's ICD-10 has a comparable diagnosis called Emotionally unstable personality disorder - Borderline type (F60.31). This requires the following, in addition to the general criteria for personality disorder: disturbances in and uncertainty about self-image, aims and internal preferences (including sexual); liability to become involved in intense and unstable relationships, often leading to emotional crisis; excessive efforts to avoid abandonment; recurrent threats or acts of self-harm; and chronic feelings of emptiness. Diagnostic criteria (CCMD) The Chinese Society of Psychiatry's CCMD has a comparable diagnosis of Impulsive Personality Disorder (IPD). A patient diagnosed as having IPD must display "affective outbursts" and "marked impulsive behavior," plus at least three out of eight other symptoms. The construct has been described as a hybrid of the impulsive and borderline subtypes of the ICD-10's Emotionally Unstable Personality Disorder, and also incorporates six of the nine DSM BPD criteria.[38] Differential diagnosis: associated and overlapping conditions Borderline personality disorder and mood disorders often appear concurrently.[4] Some features of borderline personality disorder may overlap with those of mood disorders, complicating the differential diagnostic assessment.[40][41][42] Both diagnoses involve symptoms commonly known as "mood swings." In borderline personality disorder, the term refers to the marked lability and reactivity of mood defined as emotional dysregulation.[citation needed] The behavior is typically in response to external psychosocial and intrapsychic stressors, and may arise or subside, or both, suddenly and dramatically and last for seconds, minutes, hours, days, weeks or months .[citation needed] Bipolar depression is generally more pervasive with sleep and appetite disturbances, as well as a marked nonreactivity of mood, whereas mood with respect to borderline personality and co-occurring dysthymia remains markedly reactive and sleep disturbance not acute.[43] The relationship between bipolar disorder and borderline personality disorder has been debated. Some hold that the latter represents a subthreshold form of affective disorder,[44][45] while others maintain the distinctness between the disorders, noting they often co-occur.[46][47] Some findings suggest that BPD may lie on a bipolar spectrum, with a number of points of phenomenological and biological overlap between the affective lability criterion of borderline personality disorder and the extremely rapid cycling bipolar disorders.[48][49] Some findings suggest that the DSM-IV BPD diagnosis mixes up two sets of unrelated items—an affective instability dimension related to Bipolar-II, and an impulsivity dimension not related to Bipolar-II.[50] Comorbid (co-occurring) conditions in BPD are common. When comparing individuals diagnosed with BPD to those diagnosed with other personality disorders, the former showed a higher rate of also meeting criteria for:[51] anxiety disorders mood disorders (including clinical depression and bipolar disorder) eating disorders (including anorexia nervosa and bulimia) and, to a lesser extent, somatoform or factitious disorders dissociative disorders; if all DSM criteria are met, it is recommended that the person should also be tested to have Dissociative Identity Disorder.[citation needed] Substance abuse is a common problem in BPD, whether due to impulsivity or as a coping mechanism, and 50 percent to 70 percent of psychiatric inpatients with BPD have been found to meet criteria for a substance use disorder, especially alcohol dependence or abuse which is often combined with the abuse of other drugs.[52] Borderline Personality Disorder Treatment The mainstay of treatment is various forms of psychotherapy, although medication and other approaches may also improve symptoms. Psychotherapy There has traditionally been skepticism about the psychological treatment of personality disorders, but several specific types of psychotherapy for BPD have developed in recent years. The limited studies to date do not allow confident claims of effectiveness but do suggest that people with BPD can benefit on at least some outcome measures.[75] Supportive therapy alone may enhance self-esteem and mobilize the existing strengths of individuals with BPD.[76] Specific psychotherapies may involve sessions over several months or, as is particularly common for personality disorders, several years. Psychotherapy can often be conducted either with individuals or with groups. Group therapy can aid the learning and practice of interpersonal skills and self-awareness by individuals with BPD,[77] though drop-out rates may be problematic.[78] Dialectical behavioral therapy University of Washington psychology professor Marsha Linehan is credited with developing the first empirically supported standard treatment for BPD, termed dialectical behavioral therapy (DBT). DBT grew dramatically in popularity among mental health professionals following the publication of Linehan’s treatment manuals for DBT in 1993. DBT was originally developed as an intervention for patients who meet criteria for BPD and particularly those who are highly suicidal.[79] DBT draws its principles from behavioral science (including cognitive-behavioral techniques), dialectical philosophy and Zen practice. The treatment emphasizes balancing acceptance and change (hence dialectic), with the overall goal of helping patients not just survive but build a life worth living. Treatment is delivered in four stages, with self-harm and other life-threatening issues taking priority. In the second stage, patients are encouraged to experience the painful emotions that they have been avoiding. Stage three addresses problems of living such as career and marital problems. Finally, stage four focuses on helping clients feel complete and reducing feelings of emptiness and boredom. DBT encompasses four modes of therapy, the first being traditional individual therapy between a single therapist and client. The second mode of therapy is skills training; a core component of DBT is learning new skills, including mindfulness, interpersonal effectiveness (e.g. assertiveness and social skills), coping adaptively with distress and crises, and identifying and regulating emotional reactions.[citation needed] The third mode of therapy used is skills generalization, which focuses on helping clients integrate the skills taught in DBT into real-life situations. This usually involves coaching in the form of telephone contact outside of normal therapy hours. The calls are usually brief interactions focused on helping clients apply specific skills to circumstances they are experiencing. The fourth mode of therapy is the use of a consultation team designed to support the therapists. These teams have several important functions including reducing therapist burnout, providing therapy for the therapists, improving empathy for clients and providing ongoing consultations for client difficulties. The goal of all DBT treatment approaches is to reduce the ineffective action tendencies linked to dysregulated emotions. DBT is based on a biosocial theory of personality functioning in which the core problem is seen as the breakdown of the patient’s cognitive, behavioral and emotional regulation systems when experiencing intense emotions. The etiology of BPD is seen as a biological predisposition toward emotional dysregulation combined with a perceived invalidating social environment.[80] DBT can be based on a biosocial theory of personality functioning in which BPD is seen as a biological disorder of emotional regulation in a social environment experienced as invalidating by the borderline patient.[81] Several random controlled trials (RCTs) comparing DBT to other forms of treatment have favored the use of DBT to treat borderline patients. Specifically, DBT has been found to significantly reduce self-injury, suicidal behavior, impulsivity, self-rated anger and the use of crisis services among borderline patients. These reductions have been found even when controlling for other treatment factors such as therapist experience, affordability of treatment, gender of therapist and the number of hours spent in individual therapy.[82][83] However, the additional efficacy in the overall treatment of BPD is less clear; future research is needed to isolate the specific components of DBT that are most effective in treating BPD.[75] Furthermore, little research has examined the efficacy of DBT in treating male and minority patients with BPD. Training nurses in the use of DBT has been found to replace a therapeutic pessimism with a more optimistic understanding and outlook.[84] Schema therapy Schema therapy (also called schema-focused therapy) is an integrative approach based on cognitive-behavioral or skills-based techniques along with object relations and gestalt approaches. It directly targets deeper aspects of emotion, personality and schemas (fundamental ways of categorizing and reacting to the world). The treatment also focuses on the relationship with the therapist (including a process of "limited re-parenting"), daily life outside of therapy and traumatic childhood experiences. It was developed by Jeffrey Young and became established in the 1990s. Limited recent research suggests it is significantly more effective than transference-focused psychotherapy, with half of individuals with borderline personality disorder assessed as having achieved full recovery after four years, with two-thirds showing clinically significant improvement.[85][86][unreliable source?] Another very small trial has also suggested efficacy.[87] Cognitive behavioral therapy Cognitive behavioral therapy (CBT) is the most widely used and established psychological treatment for mental disorders, but has appeared less successful in BPD, due partly to difficulties in developing a therapeutic relationship and treatment adherence. Approaches such as DBT and Schema-focused therapy developed partly as an attempt to expand and add to traditional CBT, which uses a limited number of sessions to target specific maladaptive patterns of thought, perception and behavior. A recent study did find a number of sustained benefits of CBT, in addition to treatment as usual, after an average of 16 sessions over one year.[88] Marital or family therapy Marital therapy can be helpful in stabilizing the marital relationship and in reducing marital conflict and stress that can worsen BPD symptoms. Family therapy or family psychoeducation can help educate family members regarding BPD, improve family communication and problem solving, and provide support to family members in dealing with their loved one's illness.[citation needed] Two patterns of family involvement can help clinicians plan family interventions: overinvolvement and neglect. Borderline patients who are from overinvolved families are often actively struggling with a dependency issue by denial or by anger at their parents.[citation needed] Interest in the use of psychoeducation and skills training approaches for families with borderline members is growing.[77] Psychoanalysis The term dates back to 1884. It was C. Hugues who first spoke about subjects oscillating throughout their whole life between the limits of insanity and normality. A. Stern brings back the term in 1938 to describe a " hypersentimentality of the subjects, their defensive rigidity and their little self-respect." It is psychoanalysis that the term "borderline" was developed to define an "oedipian intermédaire organization." Edward Glover (psychoanalyst), for example, spoke about "transitional states" (1932). Addictions are real states borderline in the sense that they are one foot in the psychoses and the other one in the neurosis. (...). It have their root in the paranoid states and, occasionally in the dominant melancolic state.[citation needed] He had established a plan which placed very clearly the place of the borderline in touch with the other disorders.[89] Since, the works of Otto Kernberg, the French Jean Bergeret developed the concept which adapted itself to the modern psychoanalysis. It is in the apparition of the DSM 4 that the term took two orientations: psychiatric one behavioral and the other, included in a psychoanalytical psychopathology. According to this split, the diagnosis takes on, or a character objectivizing with ascendancy of symptoms to be eradicated or it indicates a particular type of patients of psychoanalysts to treat in modalities different from those typical cures.[90][91][92] Transference-focused psychotherapy Further information: Otto F. Kernberg#Transference-Focused Psychotherapy Transference-focused psychotherapy (TFP) is a form of psychoanalytic therapy dating to the 1960s, rooted in the conceptions of Otto Kernberg on BPD and its underlying structure (borderline personality organization). Unlike in the case of traditional psychoanalysis, the therapist plays a very active role in TFP. In session the therapist works on the relationship between the patient and the therapist. The therapist will try to explore and clarify aspects of this relationship so the underlying object relations dyads become clear. Some limited research on TFP suggests it may reduce some symptoms of BPD by affecting certain underlying processes,[93] and that TFP in comparison to dialectical behavioral therapy and supportive therapy results in increased reflective functioning (the ability to realistically think about how others think) and a more secure attachment style.[94] Furthermore, TFP has been shown to be as effective as DBT in improvement of suicidal behavior, and has been more effective than DBT in alleviating anger and in reducing verbal or direct assaultive behavior.[95] Limited research suggests that TFP appears to be less effective than schema-focused therapy, while being more effective than no treatment.[85] Cognitive analytic therapy Cognitive analytic therapy (CAT) combines cognitive and psychoanalytic approaches and has been adapted for use with individuals with BPD with mixed results.[96] Medication A number of medications are used in conjunction with BPD treatments, although the evidence base is limited. As BPD has been traditionally considered a primarily psychosocial condition, medication is intended to treat comorbid symptoms, such as anxiety and depression, rather than BPD itself.[102] Indeed, UK's National Institute for Health and Clinical Excellence (NICE) has reiterated in their 2009 BPD treatment guidelines that medication is not appropriate for treating the condition itself, but for comorbid conditions only.[103] Antidepressants Selective serotonin reuptake inhibitor (SSRI) antidepressants have been shown in randomized controlled trials to improve the attendant symptoms of anxiety and depression, such as anger and hostility, associated with BPD in some patients.[102] According to Listening to Prozac, it takes a higher dose of an SSRI to treat mood disorders associated with BPD than depression alone. It also takes about three months for benefit to appear, compared to the three to six weeks for depression. Antipsychotics The newer atypical antipsychotics are claimed to have an improved adverse effect profile than the typical antipsychotics. Antipsychotics are also sometimes used to treat distortions in thinking or false perceptions.[dead link][104] Use of antipsychotics is generally short-term. One meta-analysis of two randomly controlled trials, four non-controlled open-label studies and eight case reports has suggested that several atypical antipsychotics, including olanzapine, clozapine, quetiapine and risperidone, may help BPD patients with psychotic-like, impulsive or suicidal symptoms.[105] However, there are numerous adverse effects of antipsychotics, notably Tardive dyskinesia (TD).[106] Atypical antipsychotics are known for often causing considerable weight gain, with associated health complications.[107] Mood Stabilizers Mood stabilizers (used primarily to treat Bipolar disorder) such as lithium or lamotrigine may be of some use to help depressed or labile periods, as well as rapid changes in mood.[108][109]
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