Description

Borderline personality disorder (BPD) is a psychiatric disorder characterized by a consistent and pervasive pattern of emotional dysregulation including: distorted sense of self, rapidly labile mood, unstable sense of self, impulsivity, and volatile or chaotic interpersonal relationships. It is often manifested during adolescence but is typically diagnosed in early adulthood (1).

• Diagnostic criteria must include at least five of the following (1),(2):
  • Significant discordant sense of identity and values
  • Unstable interpersonal relationships including “splitting,” alternating between idealizing and devaluing
  • Impulsive behavior including excessive spending, substance abuse, unsafe sex, binge-eating, precipitous driving, or other reckless behaviors (need at least two domains, does not include self-mutilation as separate category below)
  • Recurrent suicidal actions or threats, including self-harm
  • Chronic feelings of emptiness
  • Extreme, out of proportion anger, or difficulty managing anger
  • Rapid and intense emotional shifts (usually hours)
  • Dissociative symptoms or paranoia, often transient and associated with stress
  • Frantic efforts to avoid perceived abandonment
• Patients may overuse of emergency department services due to nature of symptoms.
  • Overuse of emergency department services

Epidemiology

Onset during adolescence or early adulthood; however, may go undiagnosed for years

Prevalence

• 1.6% of general population (1),(2)
• 6% of primary care population
• 10% of outpatient psychiatric visits
• 20% of inpatient psychiatric milieu

Etiology and Pathophysiology

Undetermined but generally accepted that BPD is multifactorial in etiology including (1),(2),(3):

• Genetic transmission
• Environmental factors (i.e., history of childhood sexual and/or physical abuse, history of childhood neglect, ongoing conflict in home, maladaptive parenting styles)
• Neuroimaging studies have shown hyperactivity of the amygdala, decreased prefrontal cortex activation, and decreased brain volumes/white matter connectivity in frontal and limbic structures.
• Dysregulation of various neurotransmitter systems, including serotonin, oxytocin, and endogenous opiates, may also play a role.

Genetics
First-degree relatives are at greater risk for this disorder (1).

Risk Factors

• Childhood trauma, that is, sexual and/or physical abuse and neglect
• Lack of secure parental attachment beginning in early childhood
• External social stressors may exacerbate BPD.

General Prevention

Children, caregivers, and significant others should have some time and activities away from the borderline individual and set strict boundaries, which may protect their well-being.

Commonly Associated Conditions

High rate of associated comorbid psychiatric disorders such as depression, anxiety, panic disorder, and substance abuse (1),(2)