Borderline Personality

What Are the Main Signs and Symptoms?

Borderline Personality Disorder encompasses symptoms in various domains, so it's important to be aware of the following signs:

1) Behavioral and Cognitive Domain

• Frantic efforts to avoid real or imagined abandonment;
• Recurrent suicidal behaviors, gestures, or threats or self-mutilation behaviors;
• Transient paranoid ideation (unjustified distrust of others) related to stress or dissociative symptoms (feeling detached from oneself and/or the world);
• Impulsivity in areas that are potentially self-damaging (e.g., risky sexual behaviors, reckless spending, substance abuse, reckless driving, binge eating);
• In severe cases, stress reactions can induce psychotic-like symptoms, including hallucinations and distortions of perceived reality (especially related to self-image).

2) Emotional Domain

• Affective instability due to marked reactivity of mood, e.g., intense episodes of euphoria, irritability, or anxiety, typically lasting a few hours or, rarely, a few days;
• Chronic feelings of emptiness;
• Inappropriate, intense anger that is difficult to control (e.g., frequent displays of irritation or recurrent verbal or physical aggression).

Relational Domain (Self and Others)

• A pattern of unstable and intense interpersonal relationships characterized by the alternating extremes of idealization and devaluation;
• Feeling safer in relationships with animals or inanimate objects than with people;
• Identity disturbance, including marked and persistent instability of self-image or sense of self.

What Are the Possible Causes and Risk Factors?

Biological Factors

Recent neurobiological data show a physiological inability to regulate emotions in Borderline Personality Disorder. Specifically, certain areas of the brain, such as the anterior cingulate cortex (which regulates the amygdala, the center of emotion) and the intraparietal sulcus, become inactive in highly emotional situations, resulting in extreme and unregulated emotional reactions. Heredity may also play a significant role, as this disorder is five times more common among first-degree relatives of individuals with the disorder.

Environmental Factors

Borderline Personality Disorder tends to manifest in individuals with absent parental bonding, who had neglectful, invalidating, absent, violent, or abusive parents. These parenting styles result in a lack or near-total absence of rules, boundaries, routines, and absent roles within the family, with absent self-care and self-regulation habits. Additionally, the condition tends to worsen when individuals have experienced traumatic events in childhood, and there is a high incidence in cases involving childhood abuse, with complex trauma development associated with sexual abuse. Regarding abuse, approximately 72% of individuals with this disorder report verbal abuse, 46% physical abuse, and 26% sexual abuse.

Can It Be Associated with Other Disorders?

Borderline Personality Disorder tends to occur concurrently with other mental health disorders. The most common comorbidities include Depressive, Bipolar, Substance Use Disorders, Anxiety Disorders (including Panic Disorder and Social Anxiety Disorder), Post-Traumatic Stress Disorder, and Attention-Deficit/Hyperactivity Disorder. It is also common to find comorbid Personality Disorders. Note that physical impairments or limitations may result from self-inflicted abuse behaviors or previous suicide attempts.

What Is the Prevalence and Mortality?

Borderline Personality Disorder is present in 2% of the general population. The onset of this disorder is in early adulthood and tends to stabilize between the ages of 30 and 40. Cultural context plays a significant role in diagnosing this disorder, as symptoms should be assessed in light of the individual's social norms.

There is a suicide rate of 3-9.5% in cases that have less than the 5 criteria required for an official diagnosis and a suicide rate of 40% in cases that meet 6 or more criteria. Suicide is mainly present in cases with impulsive and antisocial behaviors, Depressive Disorders, and Substance Use Disorders. However, deaths due to accidents or illness are also common in individuals with Borderline Personality Disorder.

How Can Psychotherapy Help?

The focus of psychotherapeutic intervention in Borderline Personality Disorder should be the client's relationship with themselves and with others, given that the relational area is the most sensitive. Therefore, the therapeutic relationship becomes an essential tool, along with a systemic, marital, and family perspective. This is crucial for understanding and managing the array of relational sources that underlie and maintain Borderline Personality Disorder.

One of the preferred approaches in treating this disorder is Dialectical Behavior Therapy (DBT). Studies have shown its effectiveness not only in Borderline Personality Disorder but also in areas related to impulse control, substance abuse, post-traumatic stress, eating and body image disorders, and depression. It values the ongoing dialectical work between validation and acceptance and is based on four pillars:

• Mindfulness
• Tolerance of distress
• Interpersonal effectiveness
• Emotion regulation

References

American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). American Psychiatric Association.

Koenigsberg, H. W., Fan, J., Ochsner, K. N., Liu, X., Guise, K. G., Pizzarello, S., et al. (2009). Neural correlates of the use of psychological distancing to regulate responses to negative social cues: a study of patients with Borderline Personality Disorder. Biological Psychiatry, 66(9), 854-863.

Linehan, M. M. (1993). Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford.

Linehan, M. M., Bohus, M., Lynch, T. R. (2007). Dialectical Behavior Therapy for Pervasive Emotion Dysregulation. In J. Gross (Ed.), Handbook of Emotion Regulation. New York: The Guilford Press.

Millon, Theodore (2004). Personality Disorders in Modern Life (2nd ed.). New York: John Wiley and Sons.

Safran, J. D., & Muran, J. C. (2000). Negotiating the Therapeutic Alliance: A Relational Treatment Guide. New York: Guilford.