We have little trouble understanding how a man with a tumor impinging on his frontal lobes may become irascible and display poor judgment, or how someone with an abnormal organization of her brain may hear voices and act out of touch with reality. Partly for these reasons, many people, among them many mental health professionals, think borderline personality disorder is far less common than it really is. Primarily manifested in irritating behaviors rather than signs more commonly associated with mental illness, the disorder frequently goes undiagnosed or misdiagnosed.
The prevalence of borderline personality disorder has not been established systematically, but estimates are on the order of 2 to 3 percent of the general population and more than 10 percent of psychiatric outpatients. One in ten people with the disorder commits suicide. People with borderline personality disorder are frequently treated for conditions—such as major depression, anorexia or bulimia, or substance abuse—that can coexist with it. Also, many people with the disorder are in nonclinical settings, such as prison.
The disorder is implicated in other public health problems, such as domestic abuse and compulsive gambling, in addition to suicide and substance abuse. One way to think about psychiatric disorders of this kind is as neurobiologic vulnerabilities. Just as each of us differs in hair color, height, or eye color, we differ in subtleties of brain structure and function. The end result is our own particular disposition, ways of behaving, and patterns of coping that are called our personality.
Then we begin to think of them as potential vulnerabilities. What in a milder form was a propensity for assertive action has become, in these extreme forms, a serious vulnerability. Two friends had to carry Melanie into the emergency room. She kept dozing off from the overdose of sleeping pills she had taken. The psychiatrist on call noticed bandages on her left arm that barely concealed dried blood. Her eyes were baggy, the lids droopy, her complexion pale.
They said Melanie had broken up with her boyfriend, a man often abusive to her, the previous night. She had called each of them in tears, feeling desperate and abandoned; they made plans to meet for coffee the next morning. Her friends became alarmed when she did not show up and went to her apartment. Melanie was admitted to the hospital for observation and a brief stay. The resident physician who admitted her heard her story the next day, when she was more alert.
She looked rested. She was fully made up and even cheerful. He elicited a long history of self-destructive behaviors that included drugs and alcohol, suicide attempts, cutting herself, and outbursts of temper, particularly with boyfriends. Her father was an alcoholic; her mother had been depressed. Growing up, Melanie had been sexually abused by an uncle and verbally abused by her father.
As an adult, she had had a series of relationships with men she initially idealized, but who inevitably abused her. She was often moody and had had several episodes of depression, but more prominent was her emotional volatility, rapidly shifting from feelings of abandonment to rage.
In her episodes of despair, usually after a relationship broke up, she would abuse sedatives and alcohol or behave promiscuously. She often ended up unconscious, sleeping off drug-induced somnolence until she had to get up the next day for work.
On some of these occasions, overwhelmed with rage and self-hatred, she cut her arms with a razor blade until she felt a sense of relief. Melanie had pursued many treatment options, but would inevitably become disillusioned and abruptly end treatment. She had seen several psychotherapists and, at one time, a psychiatrist who met with her twice a week. She explored her feelings about her parents and childhood experiences and examined her rage, which frequently was directed at her psychiatrist.
While at times she could see that anger at her psychiatrist was a distortion, based on her past experiences, rage ultimately overwhelmed her and she left treatment. She then sought the advice of a psychopharmacologist, who suggested she might have a rapid-cycling affective disorder because her intense emotions changed so frequently. He prescribed mood stabilizers, which she abandoned because of the weight gain they caused.
The next counselor felt that her problems arose from repressed memories of sexual abuse at the hands of her father, and spent sessions talking about her childhood traumas. During this odyssey of treatments sampled and abandoned, Melanie heard seemingly discrepant explanations of her condition. He suggested that much of her behavior was intended to make other people experience the rage that she found unbearable.
The psychopharmacologist explained that low serotonin levels might underlie her propensity to anger and aggression; he prescribed a selective serotonin reuptake inhibitor SSRI , an antidepressant that made more serotonin available in the brain.
He later prescribed a mood stabilizer that he explained might help with her irritability. The last counselor traced her problems to her early abuse and suggested that she talk through those experiences.
This catalog of explanations left her depressed and disillusioned. Does she have a brain disorder to be treated with medications? A disorder arising from faulty learning? Are its symptoms a direct consequence of the trauma or abuse many people with borderline personality disorder have experienced? Are these explanations mutually exclusive, or do they all contribute to a full understanding of her problem?
The development of these parts of the brain is affected by your early upbringing. These parts of your brain are also responsible for mood regulation, which may account for some of the problems people with BPD have in close relationships. A number of environmental factors seem to be common and widespread among people with BPD.
These include:. A person's relationship with their parents and family has a strong influence on how they come to see the world and what they believe about other people. Unresolved fear, anger and distress from childhood can lead to a variety of distorted adult thinking patterns, such as:. Despite the tremendous toll BPD takes on patients and society, its existence is frequently questioned and patients are stigmatized.
Research clearly demonstrates that BPD evolves from a complex interaction between environmental, anatomical, functional, genetic, and epigenetic factors.
There are many risk factors, and each one serves to strengthen the others. To treat BPD more effectively, it helps to conceptualize the major symptoms as neuropsychiatric. While functional imaging and genetic studies are beginning to gain momentum, these preliminary findings await replication with larger sample sizes, longitudinal capacities, and more refined methodologies.
The authors report no conflicts of interest concerning the subject matter of this article. Neural correlates of negative emotionality in borderline personality disorder: an activation-likelihood-estimation meta-analysis. Biol Psychiatry. The neurobiology of adolescent-onset borderline personality disorder. Neural correlates of disturbed emotion processing in borderline personality disorder: a multimodal meta-analysis. Amygdala-prefrontal disconnection in borderline personality disorder.
Dialectical behavior therapy alters emotion regulation and amygdala activity in patients with borderline personality disorder. J Psychiatr Res. The latest neuroimaging findings in borderline personality disorder. Curr Psychiatry Rep. Family study of borderline personality disorder and its sectors of psychopathology. Arch Gen Psychiatry. Borderline personality disorder traits and their relationship with dimensions of normative personality: a web-based cohort and twin study.
Acta Psychiatr Scand. Tryptophan-hydroxylase 2 haplotype association with borderline personality disorder and aggression in a sample of patients with personality disorders and healthy controls. Genetics of borderline personality disorder: systematic review and proposal of an integrative model.
Neurosci Biobehav Rev. Serotonin genes and gene-gene interactions in borderline personality disorder in a matched case-control study. Prog Neuropsychopharmacol Biol Psychiatry. Yet inappropriate anger, impulsiveness and frequent mood swings may push others away, even though you want to have loving and lasting relationships. Borderline personality disorder usually begins by early adulthood.
The condition seems to be worse in young adulthood and may gradually get better with age. If you have borderline personality disorder, don't get discouraged.
Many people with this disorder get better over time with treatment and can learn to live satisfying lives. Borderline personality disorder affects how you feel about yourself, how you relate to others and how you behave.
If you're aware that you have any of the signs or symptoms above, talk to your doctor or a mental health provider.
If you have fantasies or mental images about hurting yourself or have other suicidal thoughts, get help right away by taking one of these actions:. If you notice signs or symptoms in a family member or friend, talk to that person about seeing a doctor or mental health provider.
But you can't force someone to seek help. If the relationship causes you significant stress, you may find it helpful to see a therapist yourself. As with other mental health disorders, the causes of borderline personality disorder aren't fully understood.
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