This four-part series looks at a serious mental illness that is seriously neglected and heavily stigmatized.
In the previous article (part 1) I told the story of my friend’s recent suicide attempts following a history of self-harm and volatile mood swings, and our belief that he has borderline personality disorder (BPD).
In this article (part 2) and the subsequent articles (parts 3 and 4), I aim to improve your awareness and knowledge of BPD. This is important because, very disturbingly, people with BPD are heavily stigmatized not only by the public, but also by mental health practitioners1, and BPD research is being seriously neglected by governments in comparison to other mental illnesses. For example, in the United States2:
The lifetime prevalence rate of BPD in the population is twice that of both schizophrenia and bipolar disorder combined, and yet the National Institute of Mental Health (NIMH) devotes less than 2% of the monies apportioned to the studies of those illnesses to research on BPD.
This article (part 2) discusses the diagnosis, causes, and treatment of BPD. The next article (part 3) looks at how BPD is being seriously neglected and stigmatized in the community, including by mental health practitioners, and what can be done to address this, including by knowledge managers. The final article (part 4) provides information on how to effectively support a partner, family member, or friend with BPD.
Armed with your new awareness and knowledge, I encourage you to in turn help to improve the awareness and knowledge of others. People’s lives depend on it.
BPD has an horrifyingly high suicide rate. Around 10% of people with BPD will commit suicide at some point3, and people with BPD commit suicide more often4 than the general population. However, BPD is one of the least known mental illnesses, not only in the general community but also among therapists.
Thinking back, my friend is highly unlikely to be the first person I’ve encountered who has BPD. For example, there was the work colleague who had the sudden mood swings and anger outbursts that are among the criteria for a BPD diagnosis. I didn’t interact with this colleague enough to know if they satisfied other BPD criteria, but I’m deeply concerned to think that I’ve known people who were at very high risk of suicide and did nothing because of my lack of awareness and knowledge.
Borderline personality disorder (BPD) diagnosis, causes and treatment
What is BPD, and how is it diagnosed?
The US National Institute of Mental Health (NIMH) provides the following introduction to BPD:
Borderline personality disorder (BPD) is a serious mental disorder marked by a pattern of ongoing instability in moods, behavior, self-image, and functioning. These experiences often result in impulsive actions and unstable relationships. A person with BPD may experience intense episodes of anger, depression, and anxiety that may last from only a few hours to days.
The American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) has diagnostic criteria for BPD. DSM-IV, published in 2000, lists nine criteria, five (or more) of which a person must satisfy to be diagnosed with BPD. DSM-5, published in 2013, lists revised and more detailed criteria. The World Health Organization (WHO) International Classification of Diseases (ICD-10) also identifies the characteristics of a similarly described disorder.
As you read through these criteria, think about the behaviours of your family, friends and work colleagues.
DSM-IV Criteria (2000)
A. A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.
DSM-5 Criteria (2013)
The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose borderline personality disorder, the following criteria must be met:
A. Significant impairments in personality functioning manifest by:
1. Impairments in self functioning (a or b):
a. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.
b. Self-direction: Instability in goals, aspirations, values, or career plans.
2. Impairments in interpersonal functioning (a or b):
a. Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative
attributes or vulnerabilities.
b. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal.
B. Pathological personality traits in the following domains:
1. Negative Affectivity, characterized by:
a. Emotional liability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.
b. Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control.
c. Separation insecurity: Fears of rejection by – and/or separation from – significant others, associated with fears of excessive dependency and complete loss of autonomy.
d. Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feeling of inferior self-worth; thoughts of suicide and suicidal behavior.
2. Disinhibition, characterized by:
a. Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress.
b. Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one’s limitations and denial of the reality of personal danger.
3. Antagonism, characterized by:
a. Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.
C. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma.
ICD-10 Criteria (2016)
F60.3 Emotionally unstable personality disorder
Personality disorder characterized by a definite tendency to act impulsively and without consideration of the consequences; the mood is unpredictable and capricious. There is a liability to outbursts of emotion and an incapacity to control the behavioural explosions. There is a tendency to quarrelsome behaviour and to conflicts with others, especially when impulsive acts are thwarted or censored. Two types may be distinguished: the impulsive type, characterized predominantly by emotional instability and lack of impulse control, and the borderline type, characterized in addition by disturbances in self-image, aims, and internal preferences, by chronic feelings of emptiness, by intense and unstable interpersonal relationships, and by a tendency to self-destructive behaviour, including suicide gestures and attempts.
Do you recognise any of these criteria in your family, friends, or work colleagues?
While my friend has been unable to receive a formal diagnosis, we have exhaustively reviewed the diagnostic criteria for all mental and personality disorders, and I am personally left in little doubt that he very likely has BPD. He satisfies eight of the nine DSM-IV criteria, and satisfies the criteria in DSM-5 and ICD-10. A feature article in the New England Journal of Medicine affirms our approach5, stating that “The diagnosis of BPD is most easily established by asking patients whether they believe that the criteria for the disorder characterize them.”
A formal diagnosis would still be highly desirable, especially as BPD can exist alongside or be confused with other disorders, but we don’t currently have that option. Here in China, the Chinese Classification of Mental Disorders (CCMD) does not currently identify BPD. A study6 has found that another personality disorder identified in CCMD-3, impulsive personality disorder (IPD), may have analogous diagnostic categories to BPD in the DSM, but ideally the CCMD should be updated to specifically identify BPD.
What causes BPD?
As with other mental illnesses, the evidence shows that there is no single specific cause of BPD, rather that it is the result of a combination of genetic, developmental, neurobiological, and social factors7.
A biosocial model has been proposed to explain the development of BPD8, where early vulnerabilities are heightened by environmental risk factors. The vulnerabilities are expressed initially as impulsivity, then increased emotional sensitivity, and later more extreme emotional, behavioral, and cognitive dysregulation.
An emotionally invalidating environment during childhood is believed to be a factor leading to the development of BPD in people with a biological predisposition to the disorder, and the environment does not necessarily need to take the form of abuse or neglect. However, it is difficult to find definitive evidence to support this view because most research into the causes of BDB can only be done retrospectively.
Can BPD be treated?
It was once thought that people with BPD had little chance of recovery. However, advances in treatment mean that the outlook is now much more positive9.
BPD is the only major mental illness where evidence-based studies indicate therapy rather than medication as the primary treatment. However, medications can be used in addition to therapy, for example to manage an associated condition such as severe depression. Two main schools of psychotherapy have emerged—cognitive-behavioural and psychodynamic—with a number of distinct approaches under each10.
Of these approaches, dialectical behavior therapy (DBT) has the most studies demonstrating its effectiveness, with systematic review by the Cochrane Collaboration finding that there is sufficient evidence for the efficacy of DBT in treating BPD.
DBT was created by Marsha M. Linehan, an inspiring United States psychologist who committed herself to trying to do something about the biggest cause of suicide. Linehan has founded the Linehan Institute and associated Behavioral Tech, which provide DBT training, certification, and other resources for therapists, and therapist directories and other resources for patients and their families.
For people unable to access DBT-trained therapists, there are also DBT-inspired online programs, for example DBT Path.
How effective is psychotherapy for BPD?
An article in Psychiatric News, the news service of the American Psychiatric Association (APA), reports the findings of a recent systematic review and meta-analysis of psychotherapies for BPD:
Psychodynamic psychotherapy and DBT demonstrated efficacy for treating self-harm, suicidal behavior, and general psychopathology as well as reducing health service use in patients with BPD. However, the treatment effects were only modestly superior to usual care, suggesting that the type of psychotherapy used to treat BPD, per se, may not be as important as certain underlying shared mechanisms of therapy that are conducive to improvement.
The authors of the systematic review and meta-analysis report suggest that those important mechanisms include coherence, consistence, and continuity, “because they provide cognitive structure for a patient group that lacks in metacognitive organization.”
The analysis suggests that the results of some studies may be inflated by “risk of bias (greater attention paid to patients in experimental arms) and publication bias (the likelihood that trials would be published when results were favorable to the experimental arm).”
However, an expert on BPD who is also a former APA president reviewed the report and has stated that “aside from the shortcomings and methodological problems in existing research, the news is generally good for the psychotherapeutic treatment of BPD.”
BPD: a seriously neglected and stigmatized mental illness
Despite encouraging advances in treatment, progress is being hampered by the gross underfunding of BPD research12. People with BPD are also being heavily stigmatized in the community, including by mental health practitioners, which negatively affects treatment13. The next article (part 3) will look at what can be done to address these obstacles to effective treatment, including actions that knowledge managers can consider.
The final article (part 4) provides information on how to effectively support a partner, family member, or friend with BPD.
Next article: The worst mental health killer you probably know nothing about (part 3). How BPD is a seriously neglected and heavily stigmatized mental illness, and what can be done to address this, including actions for knowledge managers to consider.
- Aviram, R. B., Brodsky, B. S., & Stanley, B. (2006). Borderline personality disorder, stigma, and treatment implications. Harvard review of psychiatry, 14(5), 249-256. ↩
- Kreisman, J. J., & Straus, H. (2010). I hate you—Don’t leave me: Understanding the borderline personality. Penguin. (Preface.); Gunderson, J. G. (2009). Borderline personality disorder: ontogeny of a diagnosis. American Journal of Psychiatry, 166(5), 530-539. ↩
- Paris, J. (2006). Managing suicidality in patients with borderline personality disorder. Psychiatric Times, 23(8), 34-34. ↩
- Pompili, M., Girardi, P., Ruberto, A., & Tatarelli, R. (2005). Suicide in borderline personality disorder: a meta-analysis. Nordic journal of psychiatry, 59(5), 319-324. ↩
- Gunderson , John G. (2011). Borderline Personality Disorder. New England Journal of Medicine, 364, 2037-2042. ↩
- Lai, C. M., Leung, F., You, J., & Cheung, F. (2012). Are DSM-IV-TR borderline personality disorder, ICD-10 emotionally unstable personality disorder, and CCMD-III impulsive personality disorder analogous diagnostic categories across psychiatric nomenclatures?. Journal of personality disorders, 26(4), 551-567. ↩
- Kreisman, J. J., & Straus, H. (2010). I hate you—Don’t leave me: Understanding the borderline personality. Penguin. (Chapter Three – Roots of the Borderline Syndrome.) ↩
- Crowell, S. E., Beauchaine, T. P., & Linehan, M. M. (2009). A biosocial developmental model of borderline personality: Elaborating and extending Linehan’s theory. Psychological bulletin, 135(3), 495. ↩
- Kreisman, J. J., & Straus, H. (2010). I hate you—Don’t leave me: Understanding the borderline personality. Penguin. (Preface.) ↩
- Kreisman, J. J., & Straus, H. (2010). I hate you—Don’t leave me: Understanding the borderline personality. Penguin. (Chapter Eight – Specific Psychotherapeutic Approaches.) ↩
- Blum, N., St. John, D., Pfohl, B., Stuart, S., McCormick, B., Allen, J., … & Black, D. W. (2008). Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: a randomized controlled trial and 1-year follow-up. American Journal of Psychiatry, 165(4), 468-478. ↩
- Gunderson, J. G. (2009). Borderline personality disorder: ontogeny of a diagnosis. American Journal of Psychiatry, 166(5), 530-539. ↩
- Aviram, R. B., Brodsky, B. S., & Stanley, B. (2006). Borderline personality disorder, stigma, and treatment implications. Harvard review of psychiatry, 14(5), 249-256. ↩