Borderline+Personality+Disorder+(BPD)

Borderline Personality Disorder

toc =Introduction:=

Borderline Personality disorder is a persistent psychiatric condition characterised by severe emotional lability, impulsivity, self-harm, dissociative symptoms, low tolerance for rejection, as well as other symptoms.1 Though studies have sought to identify structural abnormalities and dysregulated neurotransmitter systems, no one neurobiological mechanism has emerged as the focal point of this disorder. Due to the presence of emotional lability, borderline personality disorder is categorized by the Diagnostical and Statistical Manual of Mental Disorders (DSM-IV) as a cluster B disorder along with Narcissistic, Histrionic and Antisocial Personality Disorders.2 Patients with BPD are often hospitalized for suicide attempts and other self-harming behaviour.1 Borderline personality disorder has a significant impact on the quality of life for the patients diagnosed with it. Historically, matters have been made worse by undue stigma from both laypeople and healthcare professionals, as well as a poor understanding of the condition. However, recent shifts toward intensified research and relief from stigma have improved the outlook for these patients.2 Though several risk factors have been identified for borderline personality disorder, no cause shows a direct one-to-one relationship with the disorder. Much like other mental illnesses, the interactions between different vulnerabilities and contributing factors appear to be complex for the genesis of borderline personality disorder in an individual patient. Comorbidities are also common in patients with borderline personality disorder. Though no treatment has yet shown exceptional results, BPD is not completely resistant to all intervention and novel treatments are being investigated – patients with borderline personality disorder are beginning to benefit from a paradigm shift happening both in the lab and the clinical setting.

=1.1 Symptoms and Diagnosis=

1.1a DSM


Chart taken from American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, DC: American Psychiatric Association.

1.1b Cognitive and Affective Symptoms
The affective symptoms of Borderline Personality Disorder include intense inner pain, identity diffusion3, disturbed sensitivity3, dissociative symptoms3, and emotional dysregulation resulting in emotional lability3. Emotional lability can present as alternation between low mood characterized by anhedonia, dysphoria and tediousness, and sudden, fleeting euphoria. These mood shifts can happen without any clear precipitating events.4 In addition to spontaneous mood disruption, there is also hypersensitivity which can lead to a higher risk of contagion from the affect of others. Disturbed cognition often centers around the patient’s perception of self which frequently exhibits “splitting” such that BPD patients may view themselves in black and white terms as “good” or “bad” at different times. More severely distorted cognition may feature psychotic qualities.5 media type="youtube" key="eOphgCJX1FY" height="315" width="420" align="right"

In the video (taken from Youtube) a patient with BPD describes some of the subjective experiences of BPD, focusing on cognitive and affective experiences. Subjects touched on include need for emotional attachment to regulate affect, self-harm, vigilance towards rejection, hypersensitivity to rejection, intense anger/labile mood, unstable self of self and unstable interpersonal relationships.

1.1.c Behavioural Symptoms
The most concerning behavioural symptoms found in Borderline Personality Disorder are suicide threats, attempts and self-harm behaviours such as slicing the wrists. The mortality rate of BPD patients from suicide at 8-10%6 is 50-fold that of the general population. Many classic impulsive behaviours such as drug addiction, risk seeking and promiscuity are associated with BPD4; most reliably this presents as earlier onset of sexual activity than the general population.7 An unusual feature of BPD patients is that they show altered pain perception in self-harm episodes, reporting relief and well-being rather than pain during the act.4

1.1d Neurobiological Symptoms
Borderline Personality Disorder has many subtle neurobiological differences but none are diagnostic or definitive. BPD patients show more densely concentrated grey matter in the amygdala and sparser gray matter in the subgenual anterior cingulate cortex as compared to healthy controls.8 Other structural abnormalities include smaller right parietal cortex volume or “leftward asymmetry” (associated with stronger psychotic symptoms) and reduced hippocampal volume (associated with trauma-related symptom) as compared to healthy controls.9 Functional imaging also shows hypometabolic activity in the frontal and prefrontal cortices (and hippocampi) of female BPD patients.10 When viewing faces displaying negative emotions, BPD patients show higher amygdala activity when compared with healthy controls, as well as higher activity in visual processing.11 This is reflective of the affective sensitivity noted earlier, BPD patients respond more strongly to the emotions of others in the case of negative emotions.

 In addition, there is evidence of neurotransmitter and neuroendocrine dysregulation. Samples of cerebrospinal fluid shows that BPD patients have lower concentrations of 5-hydroxyindoleacetic acid, a metabolite of serotonin.4 There is also unusually high beta-endorphin levels relative to ACTH (adrenocorticotropic hormone) in the blood of BPD patients12 suggesting dysregulation of the endogenous opioid system. This might explain the unusual pain perception of BPD patients such as higher pain threshold to mechanical (pin prick) and chemical (capsaicin) pain13. Pain perception is also altered with respect to migraines, with BPD patients experiencing more severe and pervasive headaches resulting in greater disability as compared to migraine patients without BPD.14 It is hypothesized that lower tonic endorphin levels contribute to the mild dyspohoria experienced by BPD patients. Low endorphin levels may then lead to sensitization of the receptors causing decreased pain perception during experiences that lead to endorphin release (cutting behaviour), but higher pain perception during painful experiences that do not lead to endorphin release (such as headaches). Finally, HPA dysregulation is also frequently found in BPD which may suggest that reduced gray matter volume in certain brain regions is caused by cortisol-induced apoptosis.15

1.1e Comorbidities and Misdiagnoses
 As with most psychiatric illnesses, comorbidity is common in Borderline Personality Disorder. The most common comorbid diagnoses are mood and anxiety disorders, bipolar disorder and, schizotypal and narcissistic personality disorders. 3 Eating disorders are also common among those diagnosed with BPD.16 Unfortunately, comorbid BPD negatively affects the treatment and course of other psychiatric illnesses such as depression.17 BPD is frequently misdiagnosed as bipolar disorder or a form of depression.

=1.2 Causes =

<span style="font-family: 'Times New Roman','serif';">1.2a Genetic
<span style="font-family: 'Times New Roman','serif';">In keeping with other psychiatric conditions, Borderline Personality Disorder does not appear to have a causative gene or collection of genes. However, the disorder is likely to have a genetic component, contributing 69% of the variance18 and there appear to be certain genes that increase an individual’s vulnerability to developing BPD under adverse conditions. The genes identified appear to center around serotonin transmission. Those with BPD are more likely to have “risk alleles” (A218C or G-6526A) for the tryptophan hydroxylase I gene.19 Tryptophan hydroxylase I is responsible for the rate limiting step (conversion of tryptophan to 5-hydroxytryptophan) in the serotonin synthesis pathway. A less efficient version of this enzyme could lead to lower levels of serotonin in BPD individuals. Other serotonin related polymorphisms more common in BPD are 5-HT2C and THP2.20 The promoter for the monoamine oxidase (MAO) gene has a greater frequency of polymorphisms in the variable number tandem repeat region in BPD cases.6

<span style="font-family: 'Times New Roman','serif';">1.2b Environmental
<span style="font-family: 'Times New Roman','serif';">There are many environmental risk factors for Borderline Personality Disorder, the most famously associated environmental event being childhood sexual abuse. Indeed, childhood sexual abuse (CSA) is a significant risk factor to borderline personality disorder, as is separation from parents and “unfavourable parental rearing styles”. 21 Other significant environmental events in the genesis of BPD such as other forms of childhood trauma or neglect, insecure attachment and family marital or psychiatric problems.17 Evidence also suggests that the traumatic life events patients with BPD experience are especially severe.21 Adverse childhood experiences appear to mediate neurological abnormalities even in individuals who do not have BPD or psychiatric diagnoses at all. Some of these abnormalities also associated with BPD include reduced hippocampal size2223 and reduced subgenual prefrontal cortex size.22 The heightened amygdala activation in response to negative facial expressions seen in BPD patients were also found in MDD patients, with a correlation between amygdala activation and abuse history, suggesting that the amygdala hyperactivation is mediated by life experience more than a specific disease state.24 The HPA-axis dysregulation found in BPD patients also correlates with childhood sexual abuse.25

=<span style="font-family: 'Times New Roman','serif';">1.3 Treatment = = =

<span style="font-family: 'Times New Roman','serif';"> 1.3a Medications
<span style="font-family: 'Times New Roman','serif';"> Medication given to BPD patients is often targeted towards comorbid Axis I disorders they may have (such as a mood disorder). Selective serotonin reuptake inhibitors (SSRIs) do not appear to alleviate the kind of dysphoria BPD patients suffer from but they do have a small effect on anxiety levels.26 Treatment with antipsychotics improve perceptual symptoms as well as reducing anger while treatment with mood stabilizers also reduces anger with the added benefits of reducing impulsivity, anxiety and dysphoria.26 Though mood stabilizers have the best effect on overall functioning,26 BPD is a heterogeneous disorder and no pharmacological treatment has emerged as a gold standard. There is growing support for the theory that opioid dysregulation plays a part in BPD and drugs that manipulate this system are beginning to be investigated as possible novel treatments.4 No large scale studies on the efficacy of opioid-blockers in BPD have been done, but case studies as well as small-group studies have been promising.2728

<span style="font-family: 'Times New Roman','serif';">1.3b Therapy
<span style="font-family: 'Times New Roman','serif';">Therapy is currently considered the most effective treatment for Borderline personality disorder29 and dialectical behaviour therapy is considered the current gold standard, though most patients do not remit to the point of no longer meeting diagnostic criteria for BPD. These patients may also be offered less specific forms of therapy such as cognitive behavioural therapy, group therapy or psychodynamic psychotherapy.6 Treatment of BPD appears to be most effective when it includes focus on certain principles including attention to affect (encouraging the patient to attend to, label, and contemplate his or her emotions), change-orientation (encouraging the patient to change maladaptive thoughts and behaviours that cause him or her distress), and attention to the relationship (investigating the relationship between patient and therapist).30 = =

<span style="font-family: 'Times New Roman','serif';"> 1.3c Stigma
<span style="font-family: 'Times New Roman','serif';"> The behaviours associated with Borderline Personality often elicit a great deal of stigma both from the public and health care practitioners who are meant to help them.313233 To some, the label is even considered a pejorative,333417 suggesting that the stigma attached to a diagnosis of borderline personality disorder is above and beyond that of mental illness in general. One classic study found that nurses responded with less empathy and had more “belittling” responses towards a hypothetical patient if they were diagnosed with BPD as opposed to schizophrenia.34 Because the BPD patient’s affective dysregulation (and resultant self-harm behaviour) is often mediated by the perception of interpersonal rejection, it is especially disturbing that they are more likely than the average psychiatric patient to receive care that is dismissive, lacking in empathy, or even contemptuous. Better education of health care professionals as well as improved public awareness is exceedingly important if these patients are to receive the same level of care afforded to all other patients.32

= = = = =References=

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