Despite recent clinical and media attention to self-injurious behavior, not enough is understood regarding the actual experience of individuals who intentionally injure themselves without causing lethal harm. Even the terms and their definitions are unclear and conflicting. Several terms that have been used to discuss self-directed harm need to be clarified. Deliberate self-harm includes two forms of self-destructive behavior: one with an intent to die and one in which the self-inflicted damage does not connote this intent. Both forms involve self-inflicted physical harm
but do not include behaviors in which individuals provoke others into harming them, such as getting into fights. The two types of self-harm discussed here are defined as follows:
1. Suicide attempt: A suicide attempt is defined as an intentionally selfdestructive act performed with at least partial intent to die. Although this is an apparently straightforward definition, the assessment of an individual’s subjective intent is challenging for a number of reasons.
Intent may be difficult to determine through direct inquiry, because retrospective reports can be influenced by reinterpretation and by outcome and may no longer be accurate descriptions of the individual’s state of mind at the time of the self-injury. Clinically, suicidal intent is often deduced by external behaviors or factors (such as how medically lethal the self-injury is) or by the circumstances (such as the likelihood of being discovered during or immediately after the act surrounding the self-injury). These deductions can lead to erroneous assumptions, particularly for individuals with BPD who self-injure for many reasons and in whom the intent to die is often ambiguous. Perception of intent can also be distorted by the existence of previous nonlethal attempts (Stanley et al. 2001).
2. Self-injurious behavior: Nonsuicidal self-injury, sometimes called selfmutilation, is defined as intentional self-destructive behavior performed with no intent to die. Such self-injury with no suicidal intent is quite particular to the BPD diagnosis and can be understood within the context of BPD pathology as an effort to regulate emotions. Although suicidal intent is often ascribed to these behaviors by clinicians and family members, individuals with BPD are often quite clear that their intent is quite to the contrary and that these behaviors are often used in an attempt to feel better.
Two other terms are important to mention: self-mutilation and parasuicide. Although the term self-mutilation is commonly used to describe nonsuicidal self-harm, we believe that it is not inclusive enough. Some forms of self-injury, such as cutting and burning, involve mutilation; others, such as head banging and hitting oneself, do not. The term parasuicide is often used incorrectly. Although the term is mistakenly thought to include only behaviors without suicide intent, its actual definition is any self-injurious behavior, with or without suicidal intent, that does not result
in death. Thus all suicide attempts fall into the category of parasuicide, as do self-mutilation and nonsuicidal self-injury.
Suicidal and self injuries in BPD : a Background and Definitions
Outpatient Psychotherapies for personal disorder patient
Establishing an ongoing and productive working relationship with a therapist is a fundamental goal in any treatment, but it is of particular importance for individuals with BPD because it is often very difficult to facilitate with these patients. Consequently, therapists practicing a wide variety of therapy disciplines have recognized the importance of employing a supportive stance with their borderline patients. Winston and colleagues (2001) advocated the notion that “supportive therapy can be considered a ‘shell’ that fits over most theoretical orientations” (p. 346).
That is, whether the core orientation of the treatment is from a cognitivebehavioral or a psychodynamic tradition , a supportive demeanor is necessary to engage and keep the patient in treatment. Although it is important in establishing the alliance, this approach also allows the therapist to model an alternative way of interacting through such interventions as empathic responses and validation of feelings. The therapy relationship is used to teach the patient about his or her difficulties with other people, to enhance the patient’s self-esteem, and to assist in managing anxiety. A variety of psychotherapeutic approaches have incorporated supportive elements in treating patients with BPD, and many therapists now employ supportive psychotherapy as a distinct approach in and of itself.
The relevance of the attachment theory perspective
There have been many past attempts to illuminate the symptomatology of BPD using attachment theory. Implicitly or explicitly, Bowlby’s (1973) suggestion that early experience with the caregiver serves to organize later attachment relationships has been used in explanations of psychopathology in BPD.
For example, it has been suggested that the borderline person’s experiences of interpersonal attack, neglect, and threats of abandonment may account for their perception of current relationships as attacking and neglectful (Benjamin 1993). Others have suggested that individuals with BPD are specifically characterized by a fearful and pre-occupied attachment style reflecting ‘an emotional template of intimacy anxiety/anger’ (Dutton et al. 1994b). In studies of adult attachment interview (AAI) narratives of BPD patients, the classification of pre-occupied is most frequently assigned (Fonagy et al. 1996) and, within this, the confused, fearful, and overwhelmed sub-classification appears to be most common (Patrick et al. 1994). Past attempts at linking work on attachment with theories of borderline pathology have stressed the common characteristic shared by the ambivalently attached/pre-occupied and borderline groups ‘to check for proximity, signaling to establish contact by pleading or other calls for attention or help, and clinging behaviors’ (Gunderson 1996).
Borderline patients also tend to be unresolved with regard to their experience of trauma or abuse (Patrick et al. 1994; Fonagy et al. 1996). There is no doubt that borderline individuals are insecure in their attachment, but descriptions of insecure attachment from infancy or adulthood provide an inadequate clinical account for several reasons. (1) Anxious attachment is very common; in working class samples the majority of children are anxiously attached (Broussard 1995). (2) Anxious patterns of attachment in infancy correspond to relatively stable adult strategies (Main et al. 1985), yet the hallmark of the disordered attachments of borderline individuals is the absence of stability (Higgitt and Fonagy 1992). (3) In both delinquent and borderline individuals there are variations across situations or types of relationships. The delinquent adolescent is, for example, aware of the mental states of others in his gang and the borderline individual is at times hypersensitive to the emotional states of mental health professionals and family members. (4) The clinical presentation of borderline patients frequently includes a violent attack on the patient’s own body or that of another human being. It is likely that the propensity for such violence must include an additional component that predisposes such individuals to act upon bodies rather than upon minds. An adequate account of the relationship between the individual’s early attachment environment and their later manifestation of the symptoms of BPD requires that the way the individual experiences that environment be taken into account, and that the mere fact of experiencing it, which in Cartesian fashion has historically been viewed as an unproblematic given, be viewed as an achievement determined by developmental factors.
The developmental roots of borderline personality disorder (BPD)
Underpinning our approach is the assumption that understanding borderline personality disorder (BPD) depends on an understanding of normal human development. In thinking about self-development, rather than focusing on the content of the mental representation of self, which has been the focus of psychological investigation for much of the century (for a review see Harter 1999), we are instead concerned with the process that allows the representation of self to come into being: that is, the evolution of the ‘self as agent’. The development of the self as agent (for convenience often referred to here as the ‘agentive self’) has historically been a neglected topic, because of the dominance of the Cartesian assumption that the agentive self emerges automatically from the sensation of the mental activity of the self (‘I think therefore I am’).
The influence of Cartesian doctrine has encouraged the belief that the conscious apprehension of our mind states through introspection is a basic, direct, and probably pre-wired mental capacity, leading to the conviction that knowledge of the self as a mental agent (as a ‘doer’ of things and a ‘thinker’ of thoughts) is an innate-given rather than a developing or constructed capacity.
If we understand the acquisition of knowledge of the self as a mental agent to be the result of a developmental process, which can go wrong in certain circumstances, we can gain a new perspective on the origins of BPD. In order to gain this new perspective, we must first go back to consider our earliest days, reviewing self-development in the context of the individual’s early attachment relationships.
Is the Prognosis for BPD Hopeless?
Because of its associations with impairment in functioning, the need for hospitalization and intensive outpatient treatment, self-destructive behavior, and the potential for suicide, a diagnosis of BPD often provokes shock and despair in patients and families. However, follow-up studies of individuals who receive a diagnosis of BPD suggest that the prognosis is not as grave as is often presumed. A review of 13 studies of the stability of a BPD diagnosis made according to specified criteria and with the assistance of a standardized interview (Skodol et al. 2002b) revealed that only about half of the subjects retained the diagnosis. The lowest stability was found among patients who were diagnosed in adolescence, a time when
personality is often considered to be in flux. In general, the longer the follow-up period, the greater the chance for improvement (McDavid and Pilkonis 1996; Perry 1993). In the prospective follow-along CLPS study, 10% of those diagnosed with BPD showed dramatic improvement within the first 6 months of follow-up, and resolution of a co-occurring mental disorder or a psychosocial or interpersonal crisis played a major role in the improvement (Gunderson et al. 2003). Only 41% of BPD patients met full criteria every month for the first year (Shea et al. 2002). Poor prognostic factors include a history of childhood sexual abuse and incest; early age at first psychiatric contact; impulsivity, aggression, and substance abuse; and greater severity and chronicity of symptoms (Skodol et al. 2002b). Nonetheless, the prognosis of BPD is clearly not as poor as has generally been believed.
Attention and self-control for BPD
The term self-control has been defined as ‘engaging in behaviours that result in delayed (but more) reward’ (Logue 1995, p. 3). The concept relates closely to those of delay of or deferral of gratification, self-regulation, self-discipline, and conscience. All such concepts imply being able to engage in something that provides less immediate pleasure in the expectation of greater long-term benefit or the satisfaction of an ethical imperative. As borderline pathology entails impulsivity, and yielding to immediate demands, the possibility of a deficit in self-control is obviously of relevance. Conditions co-morbid with BPD centrally involve issues of self-control, for example, addiction problems, eating disorders, ASPD, and associated childhood disorders such as ADHD and conduct disorder. Insufficiency of self-control has been observed to emerge early in life and to show impressive consistency over contexts and time across studies (see, e.g. Block 1996). Kochanska and colleagues (1997) designed a number of ingenious tests of self-control for young children.
Cortical localization of self-control invariably points to the pre-frontal cortex (Barkley 1997; Metcalfe and Mischel 1999). PET scan studies have shown that making choices between small likely rewards and large unlikely rewards entails activity in the right inferior and orbital pre-frontal cortex (Rogers et al. 1999). These pre-frontal regions are known to have rich interconnections with limbic structures likely to be involved in drives, rewards, and motivation. As these structures are also wellconnected to dorso-pre-frontal cortical areas that serve a broad range of cognitive processes independent of social or emotional salience, the orbital and
inferior pre-frontal cortex may be ideally suited to co-ordinate the probabilities
of outcomes with their emotional reward value. Further, and once again in line
with dysfunctions we have noted above, low serotonin activity is associated
with impulsiveness (Linnoila and Virkkunen 1992) while enhanced serotonergic
activity appears to enhance delayed gratification (Bizot et al. 1999).
There is considerable accumulating evidence that self-control and the capacity to direct attention are linked (Posner and Rothbart 1998, 2000). For example, in one study a laboratory measure of the ability to suppress attention to irrelevant stimuli was correlated with self-report of success in college students (Diefendorff et al. 1998). Attention may be just one component of self-control but it is likely to be an extremely important one (Cousens and Nunn 1997). Strong arguments have been advanced to suggest that self-control is a feature of temperament and therefore genetically determined. There is also good evidence that the quality of mother–child relationship is a further important predictor of the growth of self-control skills (Olson et al. 1990; Silverman and Ragusa 1990;Jacobsen et al. 1997; Mauro and Harris 2000; Strayhorn 2002). Stable relationships with individuals with whom a powerful affective bond is retained, outside of relationships with the primary caregiver, turn out to be important (Lewis 2000) because relationships serve as the context for the development of several aspects of emotion regulation (Bell and Calkins 2000).
Neurotransmitter abnormality
Studies have repeatedly demonstrated that the metabolites of serotonin are altered amongst those who have attempted suicide (Asberg et al. 1976) or manifest externally-directed aggression (Coccaro 1998). Those who display impulsive aggression consistently show blunted neuro-endocrinal responses to agents that enhance serotonergic activities (Coccaro et al. 1996). It seems that impulsiveness, autoaggression, and outwardly-directed aggression are all associated with dysfunctions of the serotonergic system indicated by low 5-hydroxyindoleaceticacid levels in lumbar cerebro-spinal fluid (CSF) (Linnoila and Virkkunen 1992) and blunted neuroendocrine responses to fenfluramine (O’Keane et al. 1992; Herpertz et al. 1995; Cleare et al. 1996).
There is some degree of cortical localization of these abnormalities to areas involved in inhibiting limbic aggression in the orbital-frontal cortex, ventralmedial
cortex and cingulate cortex which show decreased activation in response to serotonergic probes (Siever et al. 1999; New et al. 2002). Reduced serotonergic modulation of these inhibitory areas may result in the disinhibition of aggression. It is consistent with this assumption that selective serotonin re-uptake inhibitors (SSRIs) appear effective in reducing impulsive aggression independent of depression when used in higher doses and/or for longer durations ( Markovitz et al. 1991; Coccaro et al. 1997). The study of 5HT synthesis capacity using PET in medication-free BPD subjects (Leyton et al. 2001) provided evidence of reduced 5HT synthesis capacity in cortico-striatal sites, including the medio-frontal gyrus, anterior cingulated gyrus, superior temporal gyrus, and corpus striatum. Notably, the indication of 5HT synthesis capacity correlated with impulsivity scores.
There is some evidence of enhanced dopaminergic activity in association with psychotic-like thinking in PD, particularly schizotypal PD. Increased dopamine concentrations have been found in the CSF of schizotypal patients (Siever et al. 1999) including BPD patients with co-morbid schizotypal presentations. Psychotic symptoms are induced by amphetamines (a dopamine agonist) in BPD patients (Schulz et al. 1988). These findings are consistent with clinical reports that amphetamines benefit BPD patients with psychotic symptoms. Noradrenergic abnormalities have been noted in BPD associated with risk taking and sensation seeking.
The course of BPD
There is surprisingly little information about the childhood precursors of adult PD. The Collaborative Longitudinal Personality Disorder Study suggests that a history of MDD with insidious onset in adolescence and recurrence, chronicity and progressive severity is particularly likely to be associated with adult PD (Skodol et al. 1999). A study of a random sample of 551 youths (Kasen et al. 2001) reported that the presence of MDD in adolescence increased the likelihood of the diagnosis of dependent PD, ASPD, passive-aggressive and histrionic PD, but not BPD. However, the odds ratios in this report were adjusted for childhood maltreatment and if MDD in BPD was principally a reaction to childhood abuse then MDD would not be observed to be associated with BPD in this analysis. A longitudinal study of 407 adolescents (208 boys and 199 girls) recruited from a community sample looked at the predictive significance of internalizing and externalizing symptoms for the development of Cluster B characteristics (Crawford et al. 2001b). The pattern for girls indicates that externalizing symptoms in adolescence (12–17) predict Cluster B symptoms
at 17–24, even when earlier Cluster B symptoms are controlled for. However,
early (10–14) internalizing symptoms (anxiety and depression) also predicted
Cluster B symptoms in adolescence. The pattern for girls at least appears from
this study to be that early internalizing symptoms predict adolescent Cluster B
symptoms but adolescent externalizing symptoms predict adult Cluster B
symptoms. The findings are intriguing because for boys there appears to be no
forward prediction of Cluster B symptoms from either internalizing or externalizing
symptoms.
This finding complements the retrospective observation that antisocial behaviour in female adolescents is associated with BPD symptoms in early adulthood (Goodman et al. 1999). There are those who recommend the establishment of the diagnosis of BPD in childhood. A review of the literature (e.g. Ad-Dab’bagh and Greenfield, 2001) supports the creation of a new diagnostic label to describe a population of children whose symptoms are currently subsumed under the labels ‘borderline’ or ‘multiple complex developmental disorder.’ A full characterization of the syndrome, including its evolution, would require prospective studies and may differ from the known
evolution for PD and/or pervasive developmental disorders.
There are a number of studies of the course of BPD although most have methodological problems. The studies tend to show reasonable stability for BPD, although less than one might expect for a PD (Paris 1998a; Grilo et al. 2000). The clinical course is somewhat heterogeneous even within samples. Borderline patients improve symptomatically over time. One exceptionally long (27-year) follow-up (Paris and Zweig-Frank 2001) showed that borderline patients continued to improve in late middle-age with only 8% of the BPD sample meriting diagnosis of BPD. Long-term outcome in this study was associated with severity of the disorder and the quality of adaptation (functioning) at the start of the study but not with parenting quality or child abuse or trauma (Zweig-Frank and Paris, 2002).
A definitive study (Zanarini et al. 2003) followed the syndromal and sub-syndromal phenomenology of 362 adult in-patients with PD over 6 years of prospective follow-up. The cohort was assessed with the Revised Diagnostic Interview for Borderlines (DIB-R) and BPD module of the Revised Diagnostic Interview for DSM-III-R Personality Disorders. Of these patients, 290 met DIB-R and DSM-III-R criteria for BPD and 72 met DSM-III-R criteria for other axis II disorders (and neither criteria set for BPD). Over 94% of the total surviving subjects were reassessed at 2, 4, and 6 years by interviewers blind to previously collected information. Of the subjects with BPD over one-third met the criteria for remission at 2 years, half at 4 years, and over two-thirds at 6 years. When the entire follow-up period was considered almost three quarters could be considered to have recovered at some stage and only 6% of those with remissions experienced recurrences. Importantly, the comparison subjects with other axis II disorders did not develop BPD over the course of the follow-up. The patients with BPD had declining rates of symptoms but remained symptomatically distinct from the comparison subjects. Comparing the rate at which categories of symptoms decline, the study found impulsive symptoms to resolve most quickly and affective symptoms to be the most chronic. Cognitive and interpersonal symptoms were intermediate in the rate of decline. The results suggest that symptomatic improvement is both common and stable, even among the most disturbed borderline patients, and that the symptomatic prognosis for most, but not all, severely ill borderline patients is better than previously recognized.
This contrasts with the relative stability of the disorder in late adolescence and young adulthood. In a study of the stability of Cluster B symptoms between the ages of 12 and 20, Crawford and colleagues reported higher stability for PD symptoms than for Axis I symptoms (internalizing and externalizing) (Crawford et al. 2001a). The stability for Cluster B symptoms was 0.63 for boys and 0.69 for girls whereas the stability for internalizing symptoms was 0.24 and 0.39 and externalizing symptoms 0.32 and 0.38 for girls and boys respectively. These findings underscore the persistence of normal and abnormal personality constellations. The lower stability of Axis I symptoms may be disguised by some developmental heterotypy (i.e. different manifestations of the same underlying disorder at different developmental stages). Nevertheless, the stability of Cluster B disturbance is striking and many might interpret this as supporting the link of Cluster B with biologically predetermined personality dispositions such as novelty seeking where genetic loadings are high
(Livesley et al. 1998).
Borderline personality disorder patients who have been sexually abused in childhood (Paris et al. 1993; 1994a,b) or have been victims of incest (Stone, 1990) have a poor prognosis. If the patient’s first psychiatric contact takes place at an early age (Links et al. 1993) and his/her symptoms are chronic, spontaneous recovery is less likely (McGlashan 1992). Phenomenological factors that predict poor outcome include higher levels of affective instability, magical thinking, and aggression in relationships (McGlashan 1992), impulsivity and substance abuse (Links et al. 1993), and greater severity of disorder (Links et al. 1998). Further, if the patients have co-morbid schizotypal (McGlashan 1986), antisocial (Stone 1993), or paranoid features, then the prognosis is likely to be poor (Links et al. 1998). The evidence consistently suggests that even if the diagnosis of BPD ceases to be applicable, patients tend to remain functionally seriously impaired (Skodol et al. 2002c).
Dimensional models of BPD
Alternative to categorical descriptions of BPD are approaches that assume that PD is an amplification of normal personality traits (Paris 1998b). The best established is Cloninger et al.’s eight-factor model incorporated in the Temperament and Character Inventory (Cloninger et al. 1993). The dimensions suggested are: (1) novelty seeking, (2) harm avoidance, (3) reward dependence, (4) persistence, (5) self-directedness (autonomy), (6) co-operativeness, (7) compassion, and (8) self-transcendence (identity). More recently, Shedler and Westen proposed a clinician-oriented dimensional assessment procedure that asks the clinician to sort 200 personality characteristics into stacks of increasing applicability to an individual patient (Westen 1998; Westen and Shedler 1999a,b; Shedler 2002). The sort yields similarity scores to prototypes (profiles of characteristics) well-recognized by clinicians: (1) psychological health, (2) psychopathy, (3) hostility, (4) narcissism, (5) emotional dysregulation, (6) dysphoria, (7) schizoid orientation, (8) obsessionality, (9) thought disorder, (10) oedipal conflict, (11) dissociated, and (12) sexual conflict.
A range of studies reported BPD to be associated with temperament characterized by a high degree of neuroticism (i.e. emotional pain) and a low degree of agreeableness (i.e. strong individuality) (Clarkin et al. 1993a; Soldz et al. 1993; Trull 1993; Zweig-Frank and Paris 1995). BPD has also been shown to be associated with a high degree of harm avoidance (i.e. compulsivity) and novelty-seeking (i.e. impulsivity) (Svrakic et al. 1993). For BPD the key dimensions are likely to involve impulsive aggression and affective instability.
In a factor analysis of 18 personality traits assessed in the general population (n = 939), in patients with PD (n = 656), and in twins (n = 686 pairs) a four-factor solution was found (Livesley et al. 1992). The four factors were emotional dysregulation, dissocial behaviour, inhibitedness, and compulsivity.
There seems to be a general consensus that impulsivity and negative affectivity/ emotional dysregulation characterize BPD and possibly mediate the influence of psychosocial factors on BPD (Gurvits et al. 2000; Paris 2000; Silk 2000; Trull et al. 2000). It is the combination of impulsivity and negative affectivity that appears uniquely characteristic of BPD. Negative affectivity can be found in
Narcissistic personality disorder (NPD) while impulsivity is evidently marked in
ASPD.
Naturally, personality traits like affective instability or impulsive aggression are not unrelated to the putative intrapsychic disturbances such as identity disturbance or defense mechanisms such as passive aggression. In one study of 140 PD patients, degree of affective instability was found to be correlated with identity disturbance, chronic emptiness and boredom, defensive splitting, projection, acting out, and somatization (Koenigsberg et al. 2001). This kind of association is to be expected given that the phenomena upon which these apparently alternative modes of observation are made are the same.
However, the question of causality is moot. While dimensions such as affective instability and impulsiveness are known to be in part biologically-determined, the association with intrapsychic defenses may not be accounted for by the biological components of these traits. Nevertheless, the associations of trait and psychodynamic descriptions of BPD indicate the desirability of a multimodal approach to the aetiology of BPD.
Is Borderline Personality Disorder a Gender-Biased Diagnosis?
According to DSM-IV-TR, BPD is “diagnosed predominantly (about 75%) in females” (American Psychiatric Association 2000, p. 708). A female- to-male gender ratio of 3:1 is quite striking for a mental disorder and suggests the possibility of sampling or diagnostic bias or of biological or sociocultural differences between women and men that lead to the development of BPD.
A sampling bias can occur if the proportion of women with BPD is no greater than the proportion of women versus men seen in a clinical setting. If women were three times more likely to seek help for psychological problems, then it would be no surprise that the disorders found would appear on average to be three times more common in women.
Most studies in clinics that have used standardized interview assessments have found no greater proportion of women with BPD than of all women treated in the setting, suggesting that a sampling bias may account for at least some of the higher observed prevalence of BPD in women. There are as yet too few studies of BPD in the general population to know what the real gender ratio may be.
Diagnostic biases may exist if the construct of BPD or its criteria reflect a sexist characterization of female behavior as pathological, or if women exhibiting the same traits or behaviors as men would be more likely to be labeled as abnormal. Another diagnostic bias would exist if errors in making the diagnosis of BPD were more common for female patients than for male patients. A number of studies have shown that BPD criteria, except anger, may be considered slightly more characteristic of women than of men (Sprock et al. 1990) and more pathological in women (Sprock 1996). A study by Johnson et al. (2003) showed that women and men with BPD are more similar than different. Women may demonstrate their impulsivity differently than men do—for example, by engaging in binge eating rather than substance abuse. Also, female patients receive unwarranted diagnoses of BPD more often than do male patients, but, surprisingly perhaps to the gender-bias theorists, misdiagnosis occurs more often when the clinician is also a woman. Although there is modest support for diagnostic biases of various kinds, none of these are strong enough to account for the wide difference in prevalence reported. If the true prevalence rate of BPD in women is higher than that in men, it would have to be the result of biological or sociocultural factors.
Among the possible risk factors for BPD (Table 1–2), some have been found to be more common in women. For example, the personality trait of neuroticism (emotionality, impulsivity, vulnerability to stress), which is thought to underlie BPD and is under genetic influence, occurs more frequently in women. Childhood sexual abuse, which has been implicated in the genesis of BPD, is 10 times more common in women than
in men. Different rearing practices lead boys to develop more externalizing, action-oriented ways of dealing with problems and stress, whereas girls are often reared to be more internalizing and emotional. Future studies are needed to shed light on gender differences in biological and social processes that may foster the development of BPD.
Can Borderline Personality Disorder Be Diagnosed Reliably?
Reliability refers to the reproducibility of a measurement or assessment from one assessor or occasion to another. It has often been claimed that two clinicians cannot agree on whether a patient has BPD or not (i.e., that it cannot be diagnosed reliably). This impression may result from the different meanings of the term borderline, because the concept has evolved from its psychoanalytic origins to its DSM-IV-TR definition. The combination of a definition by specific diagnostic criteria, making explicit the signs and symptoms of the disorder, with the standardized interview schedules developed to collect relevant symptom information should ensure the reliability of the BPD diagnosis.
The Collaborative Longitudinal Personality Disorders Study (CLPS), funded by the National Institute of Mental Health, used a standardized interview to assess all DSM-IV (American Psychiatric Association 1994) personality disorders (Zanarini et al. 2000). In this study and in another using an interview designed exclusively to assess BPD symptoms (Zanarini et al. 2002), the reliability of the BPD diagnosis and most of its individual symptoms was very good to excellent. The high levels of reliability found in both of these studies are consistent with the results of other studies using standardized interviews and diagnosis by criteria; they are as high as or higher than those for many other mental disorders for which the reliability of diagnosis is seldom questioned. Of course, standardized interviews and specified criteria are not synonymous with excellent clinical judgment, and unless clinicians are well trained in the diagnosis of BPD, reliability of the diagnosis will be less than optimal.
Personality disorder :What Families Need to Know about the symtpoms
• Borderline personality disorder (BPD) is a serious and complex disorder affecting an estimated 1%–2% of the general population.
• The name borderline refers to the original notion that the disorder lies in between or on the border with the psychotic and neurotic mental disorders.
• The core symptoms common to most people with BPD are disturbed, unstable relationships with other people; emotional dysregulation (the inability to control mood or feelings); and impulsive behavior.
• Although BPD has some features in common with other personality disorders and with mood disorders (such as anxiety and depression), it is distinct from them.
• Women receive a diagnosis of BPD more frequently than men do, and this may be the result of biological and sociocultural factors. A partial explanation of this difference may be that women seek help more often than men for psychological problems.
• Although early reports suggested that those with BPD had a history of physical or sexual abuse, large-scale studies of child abuse in the general population show that 80% of adults with abuse histories do not develop any psychological problems.
• The current hypothesis (theory) suggests that individuals may be genetically prone to developing BPD and that certain stressful events may trigger the onset of BPD.
Diagnosis for borderline personality disorder
Borderline personality disorder, like other personality disorders (PDs), is most commonly diagnosed using a categorical approach (present vs absent) but personality in general is normally studied dimensionally assuming a more or less normally distributed set of underlying traits that best describe variation between individuals (Cloninger et al. 1993; Blais 1997; Wildgoose et al. 2001). There is no agreement that a categorical approach to the diagnosis of BPD is the most appropriate. Many favour a dimensional approach, which would do away with arbitrary thresholds, remove some of the heterogeneity that arises from categorical approaches, and limit the loss of information associated with categorical judgements of BPD (e.g. Clark et al. 1997).
Empirical support for diagnostic thresholds is problematic at best as it is impossible to distinguish clearly between ‘normal’ and ‘abnormal’ personalities. DSM-IV suggests that ‘when personality traits are inflexible and maladaptive and cause significant functional impairments or subjective distress do they constitute personality disorders’ (American Psychiatric Association 1994, p. 630). The problem with the categorical approach is not that the wrong individuals are being identified, since the individuals identified by criteria as having BPD are indeed normally different from comparison groups, but that this method of diagnosis is insufficiently sensitive. Many of those not meeting criteria, say amongst a group of depressed patients, will have three or more features of BPD, and this is likely to have an impact on the course and outcome of their treatment (e.g. McGlashan 1987).
Controversies About the Borderline Diagnosis
The term borderline originated from the psychoanalytic notion of a level of personality organization that was in between, or on the border of, the psychotic and the neurotic disorders. Although BPD has become of interest to mainstream psychiatry and psychology and is no longer solely a psychoanalytic construct, the name borderline has persisted; the search continues for other mental disorders that lie along the border with BPD.
An early hypothesis was that BPD represented patients with borderline schizophrenia. The Danish Adoption Study of Schizophrenia (Kety et al. 1968) identified a cohort of patients with a nonpsychotic form of schizophrenia who had a genetic relationship to schizophrenic parents.
Features describing these patients were included in Spitzer and colleagues’ (1979) empirical attempt to identify diagnostic criteria for BPD.
These traits of deficits in interpersonal relatedness and peculiarities of ideation, appearance, and behavior eventually came to describe the characteristics of schizotypal personality disorder, whereas BPD itself continues to be associated more with the borderline concept that grew from the psychoanalytic literature.
The next wave of research raised the issue of whether BPD was an atypical form of mood disorder. Because of the rapidly shifting mood states that characterize individuals with BPD, the latest version of this controversy is that BPD represents a treatment-refractory, rapid-cycling form of atypical bipolar II disorder (with only hypomanic or low-level mania experienced, not full-blown mania). Although this theory has led to the frequent prescription of mood-stabilizing medications, which can be
helpful for the affective instability in some cases, the bulk of the evidence fails to support the equivalence of BPD and any mood disorder (Gunderson and Phillips 1991). Although it is certain that mood disturbance and diagnosable mood disorder may coexist with BPD, mood disorder alone cannot account for the fears of abandonment, the particular types of interpersonal relatedness, and the impulsivity of BPD patients.
Most recently, the interest in childhood abuse as an etiological factor in BPD and the prevalence of posttraumatic stress disorder (PTSD) as a comorbid (or co-occurring) condition have led to studies investigating whether BPD was a variant of PTSD. Here too, research has shown that PTSD and BPD have certain features in common but that the psychopathology and functioning of BPD cannot be reduced to a variant of PTSD (Gunderson and Sabo 1993; Zlotnick et al. 2003).
A corollary to the search for a border disorder for BPD has been the search for a new name. If it is true that BPD is not really a variant of or on the border with any other major mental disorder but is a major disorder in its own right, perhaps the borderline concept has outlived its usefulness and ought to be replaced with a more descriptively accurate and potentially more useful term. The term borderline has also been used pejoratively to describe patients who “misbehave” or are difficult to treat because of their extremes of behavior and the fact that therapists often become entwined in their interpersonal problems. The most commonly suggested alternative names are emotional dysregulation disorder and emotional regulation disorder, which have been suggested by those who consider affective instability to be the core disturbance of BPD; the name emotional/impulse (dys)regulation disorder has been suggested by those who argue that at least two core disturbances exist: affective instability and impulse control. Because the fundamental basis of the disorder is not understood, there do not appear to be clear scientific grounds to resolve the controversy over a name change. Therefore, because the diagnosis of BPD has acquired widespread clinical usage and is recognized by clinicians who deal with patients with personality disorder as a clinically useful construct, its name will probably remain unchanged for the immediate future.
DSM-IV-TR diagnostic criteria for borderline personality disorder
A pervasive pattern of instability of interpersonal relationships, self-image, and
affects, and marked impulsivity beginning by early adulthood and present in a
variety of contexts, as indicated by five (or more) of the following:
(1) Frantic efforts to avoid real or imagined abandonment. Note: Do not
include suicidal or 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). Note: Do not
include suicidal or self-mutilating behavior covered in Criterion 5.
(5) Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
(6) Affective instability due to a marked reactivity of mood (e.g., intense
episodic dysphoria, irritability, or anxiety usually lasting a few hours and
only rarely more than a few days)
(7) Chronic feelings of emptiness
(8) Inappropriate, intense anger or difficulty controlling anger (e.g., frequent
displays of temper, constant anger, recurrent physical fights)
(9) Transient, stress-related paranoid ideation or severe dissociative symptoms
Source : Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual
of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric
Association, 2000. Copyright 2000, American Psychiatric Association. Used with permission.
Borderline personality disorder definition
Borderline personality disorder (BPD) is a complex and serious mental
disorder. It is estimated to occur in 1%–2% of the general population
(Torgersen et al. 2001) and is the most common personality disorder for
which people receive treatment. Ten percent of all psychiatric outpatients
and 15%–20% of inpatients are estimated to have BPD (Widiger
and Frances 1989). BPD is characterized by severe impairment in functioning
(Skodol et al. 2002a), extensive use of psychiatric treatments
(Bender et al. 2001), and a mortality rate by suicide of almost 10%—50
times higher than the rate in the general population (Work Group on
Borderline Personality Disorder 2001). Nevertheless, effective treatments
for BPD exist, and the prognosis—even over as short an interval as
1–2 years—may be better than expected (Gunderson et al. 2003; Shea et
al. 2002).
From the perspectives of both the public and the mental health professional,
BPD can also be a confusing and poorly understood disorder.
