Over the past few decades, experts in the discipline of psychiatry have delved into developmental precursors for psychological disorders. Borderline personality disorder (BPD) is among the sensitive psychological conditions that have affected between 2% to 4% of the general population in all societies. BPD is a complex illness that inhibits healthy emotion regulation and is closely related to other psychotic disorders that are also comorbid. The reluctance in diagnosing the disorder due to its similarity in symptoms with other disorders has prompted extensive research to facilitate proper diagnosis and treatment. Therefore, the essence of this paper provides an in-depth epidemiological description of borderline personality disorder.
Over the years, scholars and researchers in the field of psychiatry have been involved in activities that seek the diagnosis, treatment, and mitigation of mental and psychological disorders. Personality ailments are linked to various behavioral, affective, perceptual, and cognitive abnormalities that interfere with the physical and psychosocial equilibrium of the individual. Borderline personality disorder (BPD) is among the personality disorders that have attracted attention from the field of psychiatry to prevent its prevalence by conducting studies that enhance the diagnosis and treatment of the condition (Beauchaine, Gatzke-Kopp, & Mead, 2007). BPD is a serious disorder that is characterized by emotional regulation difficulties. The symptoms of the condition include mood swings, poor self-image, wild personal relationships, and impulsivity, thus causing instability. Therefore, an analysis of BPD is essential for a comprehensive understanding of the disorder from a psychiatric approach. This paper seeks to describe borderline personality disorder, its etiology, risk factors, comorbidity, differential diagnosis, biopsychosocial approach, and the treatment approaches.
Description of the Disorder
Borderline personality disorder (BPD) was first considered as a diagnosable mental disorder in 1980 thereby necessitating extensive approaches to identify its symptoms, risk factors, diagnosis, and treatment. Originally, psychiatrists and other mental health experts perceived the disorder as atypical due to the brief psychotic occurrences that were portrayed by patients. Therefore, the atypical nature implied that the condition was due to the effects of other psychotic conditions, and thus referring to the condition as the borderline personality disorder is perceived as misleading.
The identification of the condition for diagnosis is based on various signs and symptoms. In this case, an individual portrays an enduring array of behaviors that includes the following symptoms. Extreme reactions characterized by panic, rage, and depression signify the presence of BPD. An array of stormy and intense relationships with family, friends, and significant others are other signs of BPD as depicted by the idealization and devaluation of the closeness. An individual suffering from BPD experiences an unstable and distorted self-image that leads to sudden changes in feelings, values, opinions, plans, and goals. Impulsive and threatening behaviors like substance abuse and unsafe sex are also signs of BDP (Laven, 2014).
Periodic suicidal threats coupled with self-harming behaviors as self-mutilation are common symptoms of the disorder due to psychological instability. Individuals affected by the disorder experience intensive and highly fluctuating moods that can last a couple of hours or even days. Chronic moods of boredom and emptiness are other signs of the condition as the affected individual exclude themselves socially. Besides, BPD is characterized by intense or inappropriate anger that affects the anger management capabilities of the individual negatively. Paranoid thoughts, which are stress-related, or extreme dissociative symptoms depicted by reflecting the image of oneself from outside the body, feeling cut-off from the individual, and disregarding reality are signs of BPD (Beauchaine et al., 2007).
Mundane experiences may trigger the escalation of the BPD symptoms as the individual experiences psychological imbalances. For instance, minor separations may induce anger and distress to the individual suffering from BPD, thus causing greater imbalances. Additionally, people with BPD perceive anger from an emotionally neutral perspective, and they strongly react to words with negative connotations.
Similar to other psychiatric disorders, BPD is also caused by genetic, neurochemical, neuroanatomical, psychological, and environmental factors (Brendel, Stern, & Silbersweig, 2005). The genetic aspect of the BPD’s etiology is substantial despite it being overlooked. BPD is not inherited, but the aspects of temperaments expose individuals to develop the disorder at an early age. The predisposing phenotypes of BPD are characterized by impulsivity, affective instability, and needy or fearful relationships. Affective instability during the nurturing process cultivates mood disorders while impulsivity exposes the individual to bulimia, substance abuse, and conduct disorder. Needy or fearful relationships between the individual and significant others facilitate the predisposition to dependent, histrionic, and avoidant personality illnesses (Laven, 2014). The inherited temperaments facilitate the explanation why BPD patients are usually comorbid with the other behavioral and psychotic disorders.
Unfortunate environmental factors also cause the development of BPD. Early caretaking experiences are perceived to be very significant since the disease is induced by inconsistent parenting, neglect, or malevolence in most cases. The child significantly shapes the early nurturing experiences that are contrary to the notion that parental interactions facilitate personality development. Therefore, “the needy, fearful, hyperactive, and easily upset children would create special problems to their parents since they possess BPD’s predisposing temperaments” (Laven, 2014, p. 92). Unrealistic fears of abandonment from the hyperactive, needy, or fearful child may also crop up thereby causing BPD. The development of poor self-control due to impulsiveness that is caused by non-punitive limits and predictability also triggers the emergence of BPD at an early age. Additionally, traumatic experiences also prompt the BPD since the enduring consequences favor the development of the disorder’s temperaments.
The neurochemical vulnerability is also considered as an etiology of BPD considering the norepinephrine and serotonin transmitters. Decreased levels of norepinephrine and serotonin nervous system have been linked to increased aggressiveness and impulsivity. In this regard, neurological sections that handle controlling emotions, aggression, communication, and judgment may be hindered due to the inefficiency of the neurochemical transmitters (Beauchaine et al., 2007).
Neuroanatomical factors portray underlying differences in the levels of anatomical, physiological, and mental variations between healthy and BPD-infected individuals. The amygdala hyperactivity infringes the autonomic responses that are connected to fear, emotional responses, and arousal. The lowered capacity of affect control is common among BPD patients, thus implying that the functionality of the periorbital and prefrontal cortex has been altered. The findings explain an individual’s sensitivity to environmental stress inducers, which affects the interpersonal relationships between the BPD patient and his close ones.
Psychological factors are regarded as causes for BPD conditions. Most BPD patients report traumatic experiences in their early life. Childhood reports of sexual abuse, neglect, and physical abuse are more common among BPD patients as compared to mentally sound individuals or those diagnosed with other psychotic illnesses. Therefore, the regulation of emotional experiences among BPD patients is normally impaired due to the vicious effects of the inability to process their cognitive functionality adequately due to the traumatic events at an early age. Additionally, the inability to secure attachments at childhood evokes inconsistencies in the development of interpersonal relationships that extend to adulthood (Laven, 2014). The absence of affectionate bonds between the caregiver and the child infers that the caregivers are not regarded as sources of comfort and help, thus causing emotional disequilibrium. Metallization in the form of a child seeking physical proximity, but defensively creating a psychological distance due to painful childhood experiences is also attributed as a cause of BPD considering the perceptions that a patient has towards others.
Numerous factors increase the risks of an individual’s acquisition of BPD. The development of BPD is usually triggered by risk factors associated with personality development. A hereditary predisposition is a major risk factor for BPD transmission. In this case, individuals brought up from families that have members who have been diagnosed with BPD are at a greater risk of contracting the disease.
Stressful childhood experiences are also considered a primary risk factor for the development of BPD in an individual. Instances of childhood neglect, physical and sexual abuse are high among individuals diagnosed with the disorder since the unhealthy relationships with caregivers create negative emotions that favor the disorder. Further, the separation of the child and the parent or caregiver at an early age affects the psychological framework of the individuals negatively since their personality development process is altered. The risk factor causes poor attachment and inadequate nurturing from the parent or caregiver (Brendel et al., 2005).
Chaotic or unstable family relationships in childhood put the child at risk of developing BPD. Conflicts between the parents or other family members create feelings of distrust whereby the child is torn between who is more dependable. Additionally, exposure to the aggressiveness and emotional fluctuations depicted by disagreements creates an environment that favors the growth of the disorder to not only the child but also his or her close ones (Laven, 2014).
The personality development factors of an individual are potential risks for the disorder’s development. Personality traits that are characterized by aggression and impulsiveness subject the individual to a high risk of acquiring BPD since the traits are closely related to mood swings, dissociative feelings, and weak personal relationships (Chapman, 2008). Therefore, both biological and environmental risk factors characterized by heredity, abnormalities of brain functioning, poor parenting, and traumatic experiences are the major causes of BPD.
The development of BPD is not discriminative of culture since different societies have values, norms, and behavioral expectations that shape personalities. The condition is estimated to have affected between 2% to 4% of the general population cutting across several cultures. Studies show that BPD is more common in the cultures of developed countries as compared to developing countries. In this regard, the socioeconomic and cultural aspects of various environments trigger the variance of the psychiatric condition. Therefore, specific BPD symptoms can be subject to cultural issues across different settings (Beauchaine et al., 2007).
The communication aspect in the family setting is usually subject to cultural provisions, which are inherent in a particular society. Relatively, silent wives are usually submissive to their husbands implying that they are at great risk of developing mental illnesses. Families that are characterized by strict and conservative fathers cultivate anger within the mothers, thus resulting in conflicting situations that create environments that boost the development of the disorder. The trend is common among Korean families whereby male dominance is common.
Parents from different cultural backgrounds are perceived to induce different emotions based on the cultural expectations of the parties. In this case, one parent may consider labeling the children by directing what identity he or she expects from them. On the other hand, the other parent may consider fostering an environment that creates an individual approach towards personality development. The confusion that crops up due to divergent cultural expectations from parents creates emotional imbalances that trigger the development of BPD (Laven, 2014).
Comparing the rates of BPD rates among indigenous and immigrant populations portrays that there are variations in the prevalence concerning the cultural differences. Immigrant and minority subgroups in the general population depict lower cases of BDP as compared to the domestic population category. In this case, foreigners have better emotion management systems in the new environments due to the keenness to comply with cultural expectations. In the US, lower BDP diagnosis is regularly recorded among individuals from the sub-Saharan and Asian cultural subgroups as compared to the native, American, North American, and Western subgroups (Brendel et al., 2005).
Individuals that suffer from BDP have greater chances of being affected by other psychiatric disorders resulting in the development of comorbid or co-occurring conditions. The frequency of comorbidity among BPD patients is associated with the vulnerability of their specific genetic temperament. In most cases, psychiatrists treat the comorbid illnesses missing out on the BPD diagnosis thereby making the treatment of the other diseases ineffective. Treating both the comorbid disorders and the BPD is essential for enhanced recovery processes for equilibrium restoration. The comorbid disorders linked to BPD include major depressive disorder, posttraumatic stress disorder (PTSD), substance abuse, attention deficit hyperactivity, eating disorders, and anxiety disorders (Laven, 2014).
Major depressive disorder (MDD) is characterized by mood swings that are also attributed to BPD. Other symptoms of MDD include regular feelings of sadness and emptiness, suicide thoughts, apathy, decision-making problems, lack of sleep and appetite, and restlessness. The aspects of irritability, suicide thoughts, and agitation are also present in BPD patients implying that the two conditions are closely linked to psychiatric disorders (Chapman, 2008).
A significant proportion of individuals suffering from BPD also experience posttraumatic stress disorder (PTSD). Since many BPD patients have gone through experiences of physical and sexual abuse, the development of PTSD is highly triggered by traumatic events. The maladaptive coping mechanisms of BPD patients are mainly based on the chaotic and unpredictable environment in early childhood. The impulsivity, stormy relationships, and mood swings inherent among BPD individuals heighten the risks of causing traumatic events leading to the development of PTSD (Beauchaine et al., 2007).
Substance abuse is a common comorbid disorder that affects BPD individuals. The issue of substance abuse among BPD patients is linked to various factors that are associated with emotional weaknesses and poor self-control. The history of substance abuse in the family setting predisposes the individual to engage in the behavior. The tendency to engage in self-destructive activities due to impulsiveness also triggers substance abuse among BPD patients. Worsened judgment due to the stressful experiences brings about thoughts of engaging in substance abuse thereby developing the comorbid condition. Substance abuse among BPD patients is usually intended to justify self-mutilation and suicidal thoughts (Brendel et al., 2005).
Eating disorders are common among BPD-diagnosed individuals. Bulimia nervosa and anorexia nervosa are the typical eating disorders that are comorbid to BPD patients. Bulimia is the more occurring between the two eating disorders in BPD cases due to the vulnerability induced by impulsiveness and self-destructive tendencies.
Borderline personality disorder co-occurs with attention deficit hyperactivity disorder (ADHD) whereby 25% of BPD patients are also diagnosed with the comorbid disorder. Impulsivity is common in the two disorders. ADHD treatments negatively affect the treatment for BPD since it worsens the symptoms leading to an escalation of the disorder (Distel et al., 2008).
Anxiety and panic disorders usually tag along with BPD due to traumatic childhood experiences, chaos, and conflict. Children nurtured in such environments experience anxiety and panic disorders. A considerable number of “BPD individuals are also diagnosed with Bipolar Disorder as characterized by erratic conduct and mood swings, and thus in some cases, inexperienced clinicians mistakenly diagnose BPD for Bipolar disorder, and vice versa” (Laven, 2014, p. 111).
The process of diagnosis for BPD requires gauging the probability of its presence versus other psychotic disorders. The diagnosis of BPD has received reluctance from clinicians due to the similarities of the symptoms with other disorders. In this case, symptoms overlap of a variety of Axis I disorders trigger keen differentiation diagnosis to treat the disorder. Reports indicate that BPD is usually underdiagnosed during the initial stages thereby prompting psychiatrists and mental health experts to improve the diagnosis process (Brendel et al., 2005). The considerable lag in the appropriate diagnosis of the BPD often results in polypharmacy with ineffective medications for the disorder. Theoretically, two individuals may possess a single overlapping symptom but qualify for the criteria for the diagnosis of the disorder.
The criteria for differentiation usually consider the presence of at least five of the following symptoms. The criteria aspects include abandonment avoidance, impulsivity, suicidality, unstable relationships, mood instability, identity disturbance, chronic emptiness, intense and inappropriate anger, and paranoid ideation and dissociation (Distel et al., 2008).
Therefore, the criteria mentioned above should be used to differentiate the diagnosis of other comorbid disorders. The disorders include mood disorders (major depression and bipolar disorder), anxiety disorders (panic disorder, PTSD, social anxiety disorder), substance abuse, dissociative disorders, eating disorders, and other personality disorders (Chapman, 2008). The complexity of identifying the BPD through diagnosis has evoked reluctance from the psychiatric clinicians who find it hard to differentiate the closely related and comorbid disorders. For instance, there has been debate over which symptoms represent bipolar disorder and BPD since they overlap (Crowell, Beauchaine, & Linehan, 2009). Additionally, stigmatization of the condition has proved to make the diagnosis of the treatment deviate to other psychiatric illnesses.
The biopsychosocial approach to the development of BPD focuses on the biological, psychological, and social attributes of the disorder. In this case, the etiological and predisposition temperaments for the development of the disorder based on the biological, psychological, and social aspects is essential for a comprehensive approach (Distel et al., 2008). Research has been conducted over the past few decades to explore the developmental precursors of BPD whereby the complexities of biological and psychosocial vulnerabilities are considered (Crowell et al., 2009).
The Biological Approach
The development of BPD is connected to heredity and biosocial aspects of personality development. The borderline pathology develops due to the emergence of poor impulse control resulting in overlap of biological vulnerabilities that arouse other comorbid disorders (Distel et al., 2008). The caregiving environment characterized by affection creates extreme emotional aspects of the BPD considering the emotional sensitivity element. The link between the biological factors and the psychosocial factors is depicted by the reciprocal reinforcement of the biological exposures and environmental predispositions that trigger emotional dysregulation (Brendel et al., 2005).
The aspects of structural, genetic, and neurochemical susceptibilities are the basis of BPD’s development. This approach has received empirical studies that seek to explore the mechanisms of neurological transmitters that include serotonin, vasopressin, dopamine, noradrenaline, and gamma-aminobutyric acid, and acetylcholine. The transmitters operate within several interrelated neurological frameworks that are believed to play central roles in BPD expressions. For this reason, neurological substrates are accountable for impulsive aggression and emotion dysregulation (Beauchaine et al., 2007). Therefore, the development of BPD is associated with peripheral nervous system dysfunctions from the biological point of view.
The biological perspective also believes that heritable components induce BPD development. Almost 80% of the BDP disorder is inheritable implying that neuroanatomical correlates have a bearing on the predispositions associated with the condition through heredity factors (Chapman, 2008).
The Psychological Approach
The psychological model of analyzing the development of BPD is essential for comprehending the emotional regulatory aspects of the disorder. The family-based psychopathology aspects of BPD explore the psychopathology elements of some family members. Laven (2014) posits, “Initial studies investigated schizophrenic disorders, followed by mood disorders before impulse control disorders in the recent past” (p. 119). The results revealed that impulsiveness and mood disorders characterize psychopathological familial aggregation of individuals suffering from BPD.
Unsettled attachment relationships, child maltreatment, and invalidating environments have also been identified as core aspects of the psychological development of borderline pathology. Inconsistent attachment relationships have been hypnotized and validated through extensive research to prove that indeed, caregiving factors in early childhood have implications for personality development. In this case, maternal sensitivity is regarded as the key to the development of individual personalities. Enduring emotional connections are between infants and their caretakers characterized by soothing, touching, and proximity seeking is seen as vital to the cultivation of affectionate relationships. Research shows that the interactions between the gene and environment have an implication on character development as the DRD4 gene is perceived to be resilient to the formulation of early attachment challenges (Brendel et al., 2005).
The Socio-environmental Approach
The potential bearing of the broad environmental elements that include culture, ethnicity and race, socioeconomic status, and neighborhoods has been overlooked in BPD research endeavors in spite of its significance. This approach believes that all countries have cases of BPD diagnosis that are caused by diverse environmental factors as depicted by the cross-cultural heritability. There is a substantial prevalence difference of BPD rates across various cultural settings after a study was conducted among 34,653 individuals in the U.S. In this regard, the values of different racial-ethnic groups shape the personality development of culturally diverse individuals with variations in prevalence (Crowell et al., 2009). In the U.S, there Native American men account for 13.2% of BPD cases while Asian women make up 2.5%. Individuals in the lower social classes, which are characterized by low income, have high prevalence cases due to stress-induced economic instability (Porr, 2010).
The environmental factors can be associated with the biosocial approach to the development of BPD, the dynamic transactions among the attributes inherent in the child, caregiver, and the environmental aspects. In this case, early BPD susceptibilities are subject to impulsivity and emotional fluctuations.
Treatments for Borderline Personality Disorder
Recent studies have shown that the appropriate treatment can be used to lessen the symptoms of BPD. Psychotherapy is the highly recommended form of treatment that is also referred to as “talk” therapy. However, other forms of treatments can be applied to alleviate the escalation of the disorder. Besides psychotherapy, psychiatrists and mental health professionals also apply medications, hospitalization, and self-help procedures for the treatment of BPD. In treating the disorder, psychiatrists, and other related experts need to portray stability required to contrast the patient’s thinking and emotional ability (Crowell et al., 2009). A majority of mental health and behavioral development professionals have been disrupted by the reactions of people diagnosed with the disorder. The occurrence of this is depicted by the regular demands from the patients directed to the clinician, frequent suicidal threats, and the possibility of self-mutilating conduct (Porr, 2010). Therefore, these features create difficulties in the treatment process since they need greater understanding to make the process successful. The following are the currently and commonly applied forms of treatment for BPD.
Psychotherapy is the treatment of choice that is nearly always recommended for BPD. Since suicidality is a common attribute of BPD, the psychotherapist initially contracts with the client to rule out the possibility of committing the heinous act. Suicidality is closely monitored and evaluated throughout the treatment process but if its potentiality is high, medications and hospitalization are recommended.
The most current, effective, and successful psychotherapeutic approach is based on Marsha Linehan’s Dialectical Behavior Therapy. The effectiveness of the psychotherapeutic approach is attributed to the efficiency in instilling successful coping mechanisms as compared to other treatments. The motive of the approach is to instill better cognitive restructuring and emotion regulation techniques through self-knowledge procedures. The treatment is comprehensive and is usually administered in a group setting. Since the method of treatment is relatively new and involves complex procedures, the approach is not suitable for individuals who have challenges learning new conceptions (Distel et al., 2008).
The difficulty in treatment for the BPD due to its intrinsic nature similar to all personality disorders requires long-term coping mechanisms to alleviate the complexities. Therefore, the time ineffectiveness of the approach implies that it is costly since it can even last for a year. Other means of psychological treatments have been applied to lesser effectiveness. The following are some of the categories of psychological therapies that are applied in treating BPD (Distel et al., 2008).
Dialectical Behavior Therapy (DBT)
This type of therapy is keen on the mindfulness of the present emotional state of the individual suffering from BPD. DBT instills “skills to facilitate the control of intense emotions, distress management, curb self-destructive behavior, and improve relationships” (Porr, 2010, p. 86). The aim of this kind of psychotherapy seeks the formation of equilibrium between accepting and alternating behaviors. The treatments include “individual or group therapy sessions, phone coaching, and skills training” (Porr, 2010, p. 88). DBT is one of the most researched treatments, and it has emerged to be one of the most effective therapies for BPD.
Cognitive Behavior Therapy (CBT)
CBT facilitates the recognition and perceptions change that are coupled with behaviors that portray negative meanings of themselves and their close ones. The therapy enhances the clear vision of the difficult events and relationships so that they would identify better ways of coping and managing the situations (Porr, 2010). The effectiveness of CBT is evident in its ability to lessen the development of symptoms like self-harm, mood swings, and anxiety among BPD patients.
Metallization Based Therapies (MBT)
This kind of psychotherapy for BPD treatment applies the talk therapy approach to assist suffering individuals to comprehend other individuals’ thoughts and emotions. The aim is geared towards improving interpersonal relationships thereby curtailing impulsiveness.
This treatment approach employs the “combination of some elements of CBT with other types of psychotherapeutic aspects that focuses on the refraining schemas or the personal image reflection” (Porr, 2010, p. 106). The treatment considers the fact that BPD evokes a dysfunctional self-image that is usually due to traumatic childhood experiences (Distel et al., 2008). The personal client experiences are the basis for the treatment since they affect how they respond to the environment, cope with stress, and interact with others.
Treatment through hospitalization occurs when the BPD patients are admitted to hospital rooms and are often found in in-patient units due to severe depression experiences. During crises caused by adverse effects of BPD, patients are usually admitted to the local health facilities, at their therapist, or at emergency rooms. The disadvantage of this treatment approach is that it is costly thereby it should be avoided for alternative BPD therapy (Distel et al., 2008).
In most cases, “inpatient treatment is integrated with psychotherapy sessions individually or in groups” (Porr, 2010, p. 118). The hospitalization form of treatment is recommended if the individual with BPD is experiencing extremely challenging situations. The characteristic in-patient stay in U.S. hospitals usually ranges from 4-6 weeks that is dependent on the individual’s insurance policy. Day treatment or partial hospitalization is preferred for this form of treatment thereby allowing the patient to recover in a safe environment for a short period.
Medications are not the total remedy for curing BPD, but they are essential for the mitigation of comorbid disorders like impulsivity, depression, and anxiety. There is a range of medications for the treatment of BPD, but the effectiveness and necessity have not been validated. Omega -3 fatty acids are perceived to be effective for the reduction of depression and anxiety levels among BPD individuals.
Self-care treatment strategies for BPD include “regular exercises, healthy dieting, adequate sleep, following the prescribed medication, and effective stress management” (Porr, 2010, p. 85). The reduction of the common BPD symptoms can be enhanced by good self-help approaches thereby fostering the restoration of the psychological equilibrium.
Borderline personality (BPD) is a psychological disorder that is characterized by poor emotion regulation. Its symptoms include impulsivity, anxiety, depression, stormy, relationships, suicidality, and other behavior–related attributes. The etiological aspects of BPD include heredity, parental care, and environmental factors. The risk factors are based on the biological, environmental, and personality development elements of the individual. Comorbid disorders linked to BPD include PTSD, anxiety disorders, major depressive disorders (MDD), and attention deficit hyperactivity disorder (ADHD), among other personality disorders. The differential diagnosis aspect enhances its treatment due to the overlapping symptoms with its comorbid disorders. The biopsychosocial approaches facilitate the adoption of various treatment methods that include psychotherapy, medications, hospitalization, and self-care.
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