Today we will continue our current theme of cluster B personality disorders as we discuss borderline personality disorder. Borderline PD is a topic of considerable clinical and research interest. In order to do this topic justice we will split the content into three separate days. Today’s post will cover an introduction, diagnostic criteria, epidemiology, pathogenesis, assessment, and clinical pearls. The next two posts will be dedicated exclusively to treatment considerations.
“Living with borderline personality disorder is like having emotional burns in a world where others only have paper cuts.” – Kiera Van Gelder
In this series on Borderline Personality Disorder (BPD), we explore the complex nature of this mental health condition, its symptoms, causes, and treatment options. Borderline Personality Disorder is characterized by emotional instability, intense and unstable relationships, impulsive behavior, and a distorted self-image.
Part 1 of this series will delve into the diagnostic criteria of BPD, providing an overview of the key symptoms and behavioral patterns associated with the disorder. We will explore the challenges faced by individuals living with BPD and the impact it has on their daily lives, relationships, and overall well-being.
Individuals with borderline personality disorder (BPD) have a lifelong pattern of unstablemoods (affects), behaviors and interpersonal functioning.
They are often impulsive, have a poorly formed self-identity, and fear abandonment in their relationships. They commonly have a pattern of dysfunctional/unstable relationships throughout their life.
The term “borderline” was first introduced in the early 1900s by psychiatrists to describe individuals with significantly unstable mood and behaviors and who were thought to be on the borderline of neurosis and psychosis. BPD is also sometimes called emotionally unstable personality disorder (EUPD).
Common traits/symptoms may include being -> impulsive, moody, unstable, “empty“, intense, labile, irritable, angry, vulnerable, and have a tendency to unravel when stressed (paranoia, dissociate, self-harm, or become suicidal).
The diagnosis of BPD requires a pervasive pattern of impulsivity and unstablerelationships, moods, behaviors, and self-image beginning by early adulthood and present in a variety of contexts.
≥5 of the following must also be present: Mnemonic “DESPAIRER“
Disturbance of identity– unstable self-image
Emotional– unstable mood/affect
Suicidal behavior– recurrent suicidal threats, suicidal attempts, or self-harm/mutilation
Paranoia or dissociative sx– transient when under stress
Abandonment (fear of)- frantic efforts to avoid real or imagined abandonment
Impulsive– in ≥ 2 potentially harmful ways (spending, sexual activity, substance use, binge eating, etc.)
Prevalence: Estimates vary in the general US population from 0.5-6% with a median of 1.5%. It is the most common personality disorder in clinical populations and are seen in all types of clinic settings. They account for ~10% of psychiatric outpatients, ~20% of psychiatric inpatients, and ~6% of patients presenting to family medicine, despite a community prevalence of ~1.5%.
Gender: ~2:1 female to male ratio.
As with all personality disorders, the dominant theory suggest BPD develops from a combination of genetic vulnerability and environmental stressors.
Genetics and Pathophysiology: BPD is more heritable than other personality disorders (65-75% per twin studies compared to 40-60%). Elevated risk if family history of borderline PD, antisocial PD, substance use disorders, and major depressive disorders. No specific genes have been demonstrated as causative, however a number of studies are examining polymorphisms in the serotonin promoter region, COMT allele, and MOA tandem repeats. Additionally, research has suggested increased cortisol and reactivity of the HPA axis (hypothalamic–pituitary–adrenal), low oxytocin (associated with increased social sensitivity and distrust), low opioids (associated with increased sensitivity to rejection and abandonment), and high vasopressin (associated with increased anger). Imaging studies have suggested prefrontal and frontolimbic dysfunction correlating with poor emotion control.
Trauma: Much higher rates of childhoodneglectand physical, emotional, and sexual abuse than the general population and to other personality disorders. This is believed to be one of the most important risk factors for BPD. Childhood trauma can disrupt the development of healthy/secure attachments, emotion regulation, identity formation, and interpersonal skills.
Course/Prognosis: High rates of social, functional, and occupational impairment and high use of treatment services. >75% of patients attempt suicide, often with frequent attempts and self-injurious behaviors. ~10% eventually die by suicide. It is commonly believed that patients with BPD are highly treatment-resistant, however a majority of patients will no longer meet criteria over time even without consistent long-term treatment. Some studies suggests that 10% remit after 6 months, 25% in 1 year, 45% in 2 years, and 85% in 10 years. Patients have a high incidence of major depressive episodes.
History: Borderline PD begins by early adulthood. The diagnosis is usually made before the age of 40 when patients are attempting to make occupational, marital, and other choices and are unable to deal with the normal stages of the life cycle. Individuals will have a pervasive pattern of instability in their mood, impulse control, and interpersonal functioning. Patients often self-present when triggered by an interpersonal conflict such as a fight or breakup with a partner.
Unstablemood: Pattern of intense, reactive, and quickly changing moods. Changes in mood typically last only a few hours or up to a few days and include irritability, anxiety, dysphoria, desperation, and anger. Patients may experience short-lived dissociative or psychotic episodes (“micro-psychotic episodes”) that occur in response to a stressor and are fleeting and more circumscribed than those seen true psychotic disorders.
Unstable self-image: Despite their flurry of changing affects, they often complain about chronic feelings of emptiness or boredom. They may say they feel detached and they do not know themself. They express a lack of a consistent sense of identity. When pressed, they often complain about how depressed they usually feel.
Unstablerelationships: Pattern of tumultuous relationships. Relationships may begin with intense attachments and end with the slightest conflicts. They may rapidly shift between idealizing or devaluing the other person. They may feel both dependent and hostile towards their relationships, and may express significant anger or aggression towards them. They often find it difficult being alone, often feel abandoned, and they prefer a frantic search for companionship, no matter how unsatisfactory.
Unstablebehaviors: They often have a history of self-injury, such as cutting, and chronic suicidal ideations. Contrast this with a major depressive disorder when suicidal ideations are more episodic. Episodes of self-harm may be a way to elicit help from others, to express anger, or to numb themselves to overwhelming affects. They may also engage in other impulsive behaviors such as reckless driving, excessive spending, bing-eating, substance use, or risky sexual behaviors. To assuage loneliness, if only for brief periods, they may accept a stranger as a friend or behave promiscuously.
Mental status exam: Patients frequently appear to be in a state of crisis and mood swings are common. Patients can be argumentative at one moment, depressed the next, and later complain of having no feelings. On the other hand they may have a mood-affect incongruence—they can look neutral or even cheerful when discussing morbid content. They commonly use the defense mechanism of splitting—they view others and themselves as all good or all bad. This may play out in your appointments in the way they view your or other providers as either nurturing attachment figures or as hateful figures who threaten them with abandonment whenever they feel dependent. Shifts of allegiance from one person or group to another are frequent. Another defense mechanism that may be seen is called projective identification. In this defense mechanism, intolerable aspects of the self are projected onto another; the other person is induced to play the projected role, and the two persons act in unison. Therapists must be aware of this process so they can act neutrally toward such patients.
Optional personality questionnaires: Several scales and structured interviews to assess BPD are available though rarely used within clinical practice. Examples include the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD), Minnesota Borderline Personality Disorder Scale (MBPD), Zanarini Rating Scale for Borderline Personality Disorder, Personality Assessment Inventory (PAI), and Minnesota Multiphasic Personality Inventory (MMPI). Of note, mood disorder questionnaires frequently misdiagnose BPD as bipolar disorder.
Differential diagnosis: Consider and rule out substance use disorders, bipolar disorder, majordepressive disorder, PTSD, and other personality disorders. Borderline PD often co-occurs with mood disorders and when criteria for both are met, both may be diagnosed. In contrast to the episodic nature of mania/hypomania, mood swings experienced in borderline PD are rapid, brief, moment-to-moment reactions to triggers. Borderline PD and PTSD also have an overlap of certain symptoms and, as stated previously, there is a strong correlation between childhood trauma and development of borderline PD. This is sometimes called “complex PTSD“. Also consider other personality disorders in the differential diagnosis, particularly other cluster B disorders (antisocial, histrionic, narcissistic).
Conclusion
Next lesson we will cover part 2 of borderline personality disorder as we focus exclusively on psychotherapy for BPD. If you want more learning resources then check out our recommended resources page.
Wellcare World specializes in providing the latest advancements in wellness technology, supplementation, and lifestyle changes that improve health and increase the quality of people's lives.To learn more, visit WellcareWorld.com and begin living a better life today.
As my readers surely know, the nature-nurture debate in science continues unabated. Especially in psychiatry. When it comes to certain repetitive emotional reactions shown by a given individual, many in the field prefer to believe that the individual was just born that way. The truth, as described in Robert Sopolsky’s excellent book Behave, is that we have hundreds or even thousands of genes that make certain behaviors either a little more or a little less likely. No complex human behavior is determined entirely by a gene or group of genes. We are also strongly programmed to tend to react in certain ways to the behavior of our kin group, although we can still make the difficult choice not to once we reach a certain age.
Genetic and Environmental Factors in Emotional Reactions
There is without a doubt a strong genetic component to true brain diseases like Major Depressive Disorder or schizophrenia, but the situation for other emotional reaction patterns is that they, in my opinion, are far more affected by the family environment than by any specific genes.
Some studies sure do point in this direction. For example, in a recent study published in Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, Judith Morgan, Ph.D., recruited 49 children aged six to eight without a history of psychiatric illness. Half the kids’ mothers had a history of clinical depression, and half had no psychiatric history. To measure reward-related brain activity, children played a video game in which they guessed which of two doors contained a hidden token while they underwent functional magnetic resonance imaging (fMRI).
The Influence of Maternal Depression on Children’s Reward-Related Brain Activity
Depression may disrupt parents’ capacity for emotional socialization, a process by which kids learn from their parents’ reactions to their emotional responses. Positive socialization responses include acknowledgment, imitation, and elaboration, whereas negative or emotionally dampening parental responses may be dismissive, invalidating, or punitive.
“Nature and nurture are not enemies; they are partners in shaping human behavior.” – Robert Plomin
Mothers participating in the study completed an extensive questionnaire designed to measure parental emotional socialization by presenting a dozen situational vignettes of children’s displays of positive emotions and collecting parents’ reactions to them. Children with a maternal history of depression were more likely to have reduced reward-related activity in a part of their brains that handles this, but only if their mothers reported less enthusiastic and more dampening responses to their children’s positive emotions, the researchers found.
Note: The headings provided are based on the content provided. Adjustments can be made as per the specific context or requirements.
“In our study, mothers’ own history of depression by itself
was not related to altered brain responses to reward in early school-age
children,” said Dr. Morgan. “Instead, this history had an influence
on children’s brain responses only in combination with mothers’ parenting
behavior, such as the ability to acknowledge, imitate, or elaborate on their
child’s positive emotions.”
Wellcare World specializes in providing the latest advancements in wellness technology, supplementation, and lifestyle changes that improve health and increase the quality of people's lives.To learn more, visit WellcareWorld.com and begin living a better life today.
Although a person’s sexual or romantic orientation or gender identity may not be a source of distress, people who identify as lesbian, gay, bisexual, transgender, queer, questioning, asexual, experiencing gender fluidity, or any other orientation or gender identity may find that the social stigma of living as a minority is a source of stress or anxiety. Dr. Holland is LGBTQ+ affirming clinician who specializes in mental health issues associated with sexual, romantic, or gender identity. As a LGBTQ+ advocate she offers nonjudgmental therapy in a safe environment and has a great deal of experience with a wide range of LGBTQ+ issues.
Therapy for Gender and Sexual Identity Issues
Understanding and Acceptance: In therapy for gender and sexual identity issues, the primary focus is on helping individuals understand and accept their own sexual orientation or gender identity. The therapist provides a supportive and nonjudgmental space where clients can explore their feelings, thoughts, and experiences related to their identity. Through this process, individuals can gain a deeper understanding of themselves and develop self-acceptance.
Coping with Stigma and Discrimination: One significant aspect of therapy for gender and sexual identity issues is addressing the challenges and negative experiences associated with societal stigma and discrimination. Therapists work with clients to develop coping strategies to navigate these difficulties, build resilience, and enhance their overall well-being. This may involve exploring self-advocacy, building support networks, and finding ways to combat discrimination.
Identity Exploration and Expression: Therapy provides an opportunity for individuals to explore and express their gender identity or sexual orientation more fully. Clients may discuss their experiences of questioning, coming out, or transitioning, and work with the therapist to better understand their unique journey. Therapists can offer guidance and resources to support clients in their exploration and help them navigate any challenges they may encounter along the way.
Relationship and Intimacy Support: Therapy for gender and sexual identity issues also addresses the complexities of relationships and intimacy. Clients may explore topics such as dating, forming healthy relationships, managing relationship challenges, and building communication skills. Therapists can provide guidance on navigating intimate relationships while considering individual identities and preferences.
Mental Health and Emotional Well-being: Individuals who identify as LGBTQ+ may face higher rates of mental health concerns such as anxiety, depression, and substance abuse. Therapy aims to address these challenges and promote mental health and emotional well-being. Therapists work collaboratively with clients to develop strategies for managing stress, improving self-care, and fostering resilience.
Support for Families and Allies: Therapy for gender and sexual identity issues can also extend support to families, partners, and allies. Therapists can help loved ones better understand and support their LGBTQ+ family members or friends. This may involve education about sexual orientation and gender identity, addressing any concerns or misconceptions, and fostering healthy communication and acceptance within relationships.
It is important to note that therapy for gender and sexual identity issues should be conducted by trained professionals who have experience working with LGBTQ+ individuals. These therapists should be knowledgeable about LGBTQ+ issues, sensitive to the unique experiences faced by this community, and committed to providing affirming and inclusive care.
Wellcare World specializes in providing the latest advancements in wellness technology, supplementation, and lifestyle changes that improve health and increase the quality of people's lives.To learn more, visit WellcareWorld.com and begin living a better life today.
Last week, I attended the annual psyPAG conference in Cardiff, Wales. The opening Keynote by Dr Paul Hutchings has had a lasting impression on me and has inspired this blog post.
Misconceptions
To begin his presentation, a comical hypothetical experience was explained to the audience. When you tell people you study and research psychology, people react in one of two ways
1) “Wow, you can read my mind, I’ll stop talking now”
2) “I am crazy, you could write a book about me”
I looked around at this point and saw a lecture theatre of people nodding their heads in agreement, I think the majority of people involved in the field of psychology have heard one or both of these responses at some point. The general consensus is that Joe Public knows absolutely nothing about what we do. To put this in a more personal example, I have family members that think that I either:
1) Sit people on a couch and try to discuss their childhood and how that makes them feel.
2) Do nothing all day, because it isn’t a real “job” that I do
Why is this?
The whole point that, is that people think these stereotypes for many reasons such as the media, films etc. However, these false stereotypes exist is because ‘we’, the people involved in the field of psychology, do nothing to rectify these false ideas.
What do I do?
I am a research student. I research human behaviour using scientific methods to make a difference and improve things. Specifically, I am investigating how people identity can change following a diagnosis of multiple sclerosis.
What can ‘we’ do about this?
To rectify this problem we need to realise that we need to explain what we do a lot more clearly and actually talk about what we do. The more we get our research and what we do out in the public eye, the more the public can benefit from what we do.
Is it this easy?
In a nutshell, no. Research students usually do not have a lot of time to explain our research fully to people who are not involved in the field, this takes time and effort, something that we are usually lacking. The main goal of research in modern academia is to get your research published in academic journals or present at conferences. No member of the general public reads academic journals and they do not go to conferences so they are not going to hear about this research, secondly, most journals need an originality report, you can’t talk about your research elsewhere if you want to get it published. Finally, are people interested? Most people i know just really do not want to hear a bunch of complicated words that they will not understand and therefore don’t want to hear about what I do.
So, what next?
You might be asking what is the point of me telling you this? Am I doing anything to get my research out there? I do already try to do a couple of these things, however, i think there are some things that we can do to change this situation.
1) Disseminating Research
This blog was set up over a year ago for me to disseminate my research, using social media you can give an overview of your research, a bare-bones, lay language overview so that the general public can find out about and read your research and you can still get published in an academic journal.
2) Engage with your research audience
I have contact with a local MS support group. This group has been essential for my research, my main research direction has come from talks with members of this group and I try my best to keep them informed of my research. I also write yearly reports for the MS Society for them to further disseminate and get my research out there.
3) Impact
When you tell Joe Public about your research, the majority of people will look at you and ask why this needs to be done. All pieces of research have impact. This is the effect that your research can have. For example, my research hopes to improve therapy options for people with multiple sclerosis and low mood, for example when is group or individual psychotherapy more effective? This is my research’s real world impact, it has a potential impact on people’s wellbeing and health pathways and funding.
4) Talk about what you do
This is something I need to work on more. I think it is beneficial for all research students or people involved in the field to talk about their research and what they do, and learn to do so to a lay audience. We spend so much time talking to colleagues that we struggle to explain ourselves to other people. I think we can all benefit from this. If people have misconceptions about what you do, its because no ones ever corrected them, take time to tell them what you do and what thats like.
5) Express your opinion
It was pointed out that all of us in the lecture theatre were experts in our own research area, even if none of us wanted to admit it. Try and get your opinion out there as much as you can. If your research is relevant to something going on at the time talk to your university about getting involved and getting your opinion out there.
Ok, stop ranting now
Going forward, please try to take some of the things I’ve said on board. By working in this field you are doing fantastic things. Talk about your research, think of your impact and get it out in the public domain. This is something we all need to do if we’re going to change the stereotypes about the field we work in.
Wellcare World specializes in providing the latest advancements in wellness technology, supplementation, and lifestyle changes that improve health and increase the quality of people's lives.To learn more, visit WellcareWorld.com and begin living a better life today.
This article briefly discusses reasons why some mental health professionals are resistant to self-care. These reasons include the savior complex, avoidance, and lack of collegial assiduity. Several proposed solutions are offered.
Here is an excerpt:
Savior Complex
One hypothesis used to explain professionals’ resistance is what some refer to as a “savior complex.” Certain MHPs may be engaging in the cognitive distortion that it is their duty to save as many people from suffering and demise as they can and in turn need to sacrifice their own psychological welfare for those facing distress. MHPs may be skewed in their thinking that they are also invulnerable to psychological and other stressors. Inherent in this distortion is their fear of being viewed as weak or ineffective, and as a result, they overcompensate by attempting to be stronger than others. This type of thinking may also involve a defense mechanism that develops early in their professional lives and emerges during the course of their work in the field. This may stem from preexisting components of their personality dynamics.
Another reason may be that the extreme rewards that professionals experience from helping others in such a desperate state of need serve as a euphoric experience for them that can be addictive. In essence, the “high” that they obtain from helping others often spurs them on.
Avoidance
Another less complicated explanation for MHPs’ blindness to their own vulnerabilities may be their strong desire to avoid admitting to their own weaknesses and sense of vulnerability. The defense mechanism of rationalization that they are stronger and healthier than everyone else may embolden them to push on even when there are visible signs to others of the stress in their lives that is compromising their functioning.
Avoidance is also a way of sidestepping the obvious and putting it off until later. This may be coupled with the need that has increased, particularly with the recent pandemic that has intensified the demand for mental health services.
Denial
The dismissal of MHPs’ own needs or what some may term as, “denial” is a deeper aspect that goes hand-in-hand with cognitive distortions that develop with MHPs, but involve a more complex level of blindness to the obvious (Bearse et al., 2013). It may also serve as a way for professionals to devalue their own emotional and psychological challenges.
Denial may also stem from an underlying fear of being determined as incapacitated or not up to the challenge by their colleagues and thus prohibited from returning to their work or having to face limitations or restrictions. It can sometimes emanate from the fear of being reported as having engaged in unethical behavior by not seeking assistance sooner. This is particularly so with cases of MHPs who have become involved with illicit drug or alcohol abuse or addiction.
Most ethical principles mandate that MHPs strive to remain cognizant of the potential effects that their work has on their own physical and mental health status while they are in the process of treating others and to recognize when their ability to be effective has been compromised.
Last, in some cases, MHPs’ denial can even be a response to genuine and accurately perceived expectations in a variety of work contexts where they do not have control over their schedules. This may occur more commonly with facilities or institutions that do not support the disclosure of vulnerability and stress. It is for the aforementioned reasons that the American and Canadian Psychological Associations as well as other mental health organizations have mandated special education on this topic in graduate training programs (American Psychiatric Association, 2013; Maranzan et al., 2018).
Lack of Collegial Assiduity
A final reason may involve a lack of collegial assiduity, where fellow MHPs observe their colleagues enduring signs of stress but fail to confront the individual of concern and alert them to the obvious. It is often very awkward and uncomfortable for a colleague to address this issue and risk rebuke or a negative outcome. As a result, they simply avoid it altogether, thus leaving the issue of concern unaddressed.
Wellcare World specializes in providing the latest advancements in wellness technology, supplementation, and lifestyle changes that improve health and increase the quality of people's lives.To learn more, visit WellcareWorld.com and begin living a better life today.
