imnotdamagedgoods’ blog

I have two solid years worth of college credit, however, it has taken me much longer to earn those two years of credit than two years... College has been very difficult for me, perhaps more difficult than high school. I need that structure and checking of high school to make sure I am keeping up with my work and doing my studying. In college nobody checks up on you - not even your parents if you're away from home like I was. After I came home from "away" college, I took various classes at local community colleges. I would say at least half of my college courses were dropped, withdrawn, or I never bothered to withdrawl and because of that I received an 'F'.  This has been very difficult for me. I enjoy learning new things, but most college classes aren't structured in such a way that is conducive to my learning. It's very frustrating and expensive...

BPD, to my knowledge, isn't a learning disability, so I don't think there are any special acomodations they could make for me. I mean really, what could they do? Offer me a private class? I don't think so...

ugh....

-C

I am a good person with a big heart, and a lot to offer. Some of the positive things in my life include:

• Good general health
• I have loving, supportive parents
• A healthy 2 year relationship with a wonderful man
• A possible new job that will be a promotion for me (interview this week!)
• Working to help locate child sexual predators online (volunteer group)
• Working to help match unidentified bodies around the world with missing people (volunteer group)
• A daily prayer ritual
• Good friends who truly care about my well-being
• Looking to start a family, or adopt a child in the upcoming year\

Thanks for reading. -C

Pets have always been a source of therapy for me, even since childhood. I've always related to pets on a different level than most people I know. I feel like we understand each other, and are there for each other. Maybe this is because I was an only child growing up, I don't know... But the bottom line is that dogs & cats are a tremendous source of therapy for me.

I have one dog and one cat. When I cry my dog licks my face and sits with me. My cat sits with me at the computer when I write about my feelings and problems.

When I feel very upset or am having other problems, there is not much that can make me smile -- except my pets.

-C

Every night as I lay in bed I pray. I pray for the following:

• Forgiveness from my ex-boyfriend "Charles" and his family for what I've done to Charles
• Compassion & understanding from my ex-boyfriend "Charles" and his family for what I've done to Charles
• Blessings to my parents for their love, support & guidance during the situation with "Charles"
• Peace to my soul
• Strength to be proud of who I am and to move forward with my life
• Food to the mouths of those that are hungry
• Water to the mouths of those that are thirsty
• Education to those who do not have access to it
• Medicine & medical care to those who desperately need it
• Laughter to children who have never experienced joy
• Peace to places in the world who are experiencing war, violence, terrorism, extremism, political upheaval
• Freedom to those who do not have any, especially women
• Justice to those who have been wrongly accused or convincted of a crime
• Comfort to those who are in physical or emotional pain
• General prayers for missing children, adults & pets and the people who love them

If you pray, please pray for me. Please pray that I find peace in my soul and strength to move forward with my life.

Thank you!

-C

I figured I would put this right out in the open for anyone who reads my blog to see how destructive Borderline Personality Disorder (BPD) can be. It details how BPD can have serious affects on your impulsivity, decision making and other areas in life. This is a situation that has caused me an enormous amount of stress, agony, guilt, and worry. So much that I considered taking my own life because of my inner turmoil and fear of what would happen to me (jail, police involvement, legal troubles, etc - none of which happened fortunately).  I am still recovering from the intense emotions I experienced as a result of this situation. I am now in a much better place emotionally - partly because of the peace I find in prayer, and also from the love, support & guidance of my parents and my boyfriend of two years "Jason". My cat & my dog have also been a huge source of therapy for me. That is one of the amazing things about pets - they love you unconditionally.

What I Did -- While we were still together, I used my ex-boyfriend's credit to obtain credit cards to buy things for us that he wasn't willing to do on his own. He was unwilling to obtain credit cards, car loan, & mortgage on his own. I felt his reasons for this were not acceptable (ex. he didn't want "corporations" to know what he buys, doesn't believe in consumerism, etc) and for us to start a life & family together I felt it was necessary for him to build a credit history, especially since mine wasn't very good. Unfortunately, I never told him about it, charged approximately $8,000 and a few years later (after we had been broken up for 2 years) he discovered it. It has all since be paid off and there are no outstanding bills. It was a very embarasing & regretful situation. He has forgiven me, and the situation is now resolved (though my fear & embarasment live on).

Details of This Regretful Situation --  For almost 5 years I dated a guy (I will call him 'Charles'). We were friends for almost 10 years before we started dating. Charles had some issues of his own which added to making our relationship as a couple quite difficult (I will give some details later). There is nothing in life I wanted more than to get married and start a family. Today there is still nothing I want more than to get married and start a family. Charles, I discovered during the course of our lengthy relationship, was against marriage & children. Not because he didn't love me or didn't love kids (in fact he was amazing with his little nephews & nieces) - but for principle. He always felt the need to contradict the norm, to be extreme in every aspect of his life. He is the kind of person that always must have a 'cause' or 'mission' when he does something. For example, we couldn't go to the grocery store without causing a scene of some sort (i.e. putting up stickers for his band on light poles in the parking lot, rudely informing other customers about the awful corporations that make the products in their shopping cart, talking graphically about how meat is made while standing next to a crowded meat counter, etc). It was awful. It was stressful. It was completely inappropriate most of the time. He was also a complete workaholic (for lack of a better term) and many nights actually slept at work, only to wake up the next day to start working all over again. As a result, he developted personal hygiene issues, social interaction issues, and major anxiety/panic attacks. The majority of nights I would lay in bed waiting for him to call or email me, and when he didn't I would cry myself to sleep. Yet, I loved this man and wanted to have a life together. I was willing to compromise, to make changes in our lives so we would BOTH be happier. He was not as flexible with his beliefs as I had hoped of someone who supposedly cared so deeply for me. One day, during the last months of our relationship, a pre-approved credit card offer came in the mail with both of our names on it. I instantly decided I would get it. I didn't think about how I would pay the bill, I didn't think about how this would affect me or Charles. To me credit is a very difficult concept. I see it as free money. I mean, I do understand that credit cards are not actually 'free money' but if it is offered to me, I will not refuse it, and I will spend it. The same problems exisits with money from my paycheck - if I have it,  I must spend it. This is something I am trying to work on, and so far I've been doing very well. Anyway, this credit card was in both of our names and was used to take trips to London (something we did 3 times together), buy clothes, buy food, buy books, pay car insurance, buy gifts for his very large family at Christmas, etc etc etc. It quickly spiraled out of control and suddenly the balance was around $8,000. I had no idea how it happened, it just happened. I even wished they would increase the spending limit so I could buy more. To people who don't have or understand BPD this might not make any sense. With BPD, I have very little impulse control - shopping is where this usually manifests. Just a quick glance at my credit report will show you a history of late payments, or even lack of payments. I just don't care to pay bills. I don't like having bad credit because it prevents me from getting more credit cards, but I don't really "care" that I have bad credit. Do you see what I mean? Again, to someone who doesn't have or understand BPD this will just sound like an excuse. It's not.

About Him: I would just like to mention a few things about Charles so you can understand how his own issues made mine even worse. Charles was a closet crossdresser. I mean BIG TIME. His major "fetish" was pantyhose though. Sometimes he would put on three pairs of pantyhose and put a pair on each of his arms, sometimes even over his head. It was very disturbing, but at the time I played along because I didn't want him to abandon me for not accepting him. The only way sex could ever be initiated and completed was by including pantyhose and/or by him crossdressing (and by "sex" I mean him masturbating or me doing that to him - actual sex was a very rare occurence during our time together). My needs were very rarely addressed, even when I voiced my concerns and upsets. In fact, that usually made him very angry. When Charles crossdressed, he would wear everything from panties, bra (sometimes stuffed), pantyhose (usually multiple pairs at once), a dress (always made of spandex), high heels, full makeup, and a wig (the credit card was used to buy some of these items as well). He kept all of his crossdressing supplies at my house because he didn't want his family to find out about his secret (to my knowledge they still don't know, as it was always his biggest secret in life). During "sex" he would put certain clothes on me as well, such as "stripper heels", pantyhose, anything made of spandex, wigs, etc. This was very emotionally destructive to me as a BPD patient because I felt like I wasn't good enough "as is" and modifying me was the only way he could be satisfied with me. I even had expensive cosmetic surgery (liposuction to be exact) so that I would be more appealing to him (or so I thought). Charles' fetishes really had a huge impact on me (in a negative way). I believed with all of my heart that he found himself more sexually attractive (when crossdressed) than he ever found me. These thoughts were verified to me over & over again because he would often just stare at himself in the mirror (while crossdressed) and fondle himself, completely forgetting that I was even there. I was on birth control for several years yet he refused to have sex with me unless he wore 1-2 condoms, wore a pair of latex "form fitting" panties (like a pair of panties but with a big elephant trunk-like piece for a certain part of the male anatomy to fit into) and would never climax inside of me. I felt this was extremely excessive and insulting. It made me feel like I wasn't good enough to be the mother of his children (eventhough chances are I would not become pregnant since I was on the pill). After the credit card situation came out in the open, I told my parents about Charles' crossdressing & other habits. I was in so much emotional distress and considering suicide - I needed to get everything off my chest. They were not surprised at all hearing about Charles' habits. In fact, they have strong suspicions that he is gay (not that all crossdressers are gay, but he has other characteristics that we now realize). I don't care if he is gay, that is fine. I have nothing against homosexuals. I just hope he finds peace with himself, as I hope for me as well.

In Closing: So that is the majority of the story. I'd also like to mention that I've never done anything even remotely similar to this to anyone, ever. I have never been arrested, sued, or charged with any crimes. I have a perfect driving record, I perform well at work, and I love to help people. I am a good person who found herself in a relationship that was not compatible with my illness. This led to my destructive behaviors. With the support & love of my family and friends, I am able to be very productive at work, and at home, and live a quite normal life--something that was impossible during the relationship with Charles. My boyfriend "Jason" is aware of my needs and is very supportive of me and our future together. This is the worst situation I have ever been involved with as a result of BPD, but it has helped me as a patient to learn my limits and learn about consequences. I hope this story will help you as well....

Hi. This blog is to share my experiences in life with Borderline Personality Disorder (BPD). I am 30 (almost 31) years old, unmarried (in a comitted heterosexual relationship for the past 2 years), generally healthy, and generally normal. I hope this blog will provide you with helpful information about what it can be like to live with BPD. If you have any questions or comments, please post them here. Thanks! -C

 

 

Things that pertain to me / my illness have been highlighted in orange.

Borderline Personality Disorder (DSM-IV Personality Disorders 301.83) (BPD) is defined as a personality disorder primarily characterized by emotional dysregulation, extreme "black and white" thinking, or "splitting", and chaotic relationships. The general profile of the disorder also typically includes a pervasive instability in mood, interpersonal relationships, self-image, identity, and behavior, as well as a disturbance in the individual's sense of self. In extreme cases, this disturbance in the sense of self can lead to periods of dissociation.

The disturbances suffered by those with borderline personality disorder have a wide-ranging and pervasive negative impact on many or all of the psychosocial facets of life, including ability to hold down a job and relationships in work, home, and social settings. Comorbidity is common; borderline personality disorder frequently occurring with substance use disorders and mood disorders. Attempted suicide and completed suicide are possible outcomes without proper care and effective therapy.

Diagnosis

Diagnosis is based on the self-reported experiences of the patient, as well as markers for the disorder observed by a psychiatrist, psychologist, or other qualified diagnostician through clinical assessment. This profile may be supported and/or corroborated by long term patterns of behavior as reported by family members, friends or co-workers. The list of criteria that must be met for diagnosis is outlined in the DSM-IV-TR.

An initial assessment generally includes a comprehensive personal and family history, and may also include a physical examination by a physician. Although there are no physiological tests that confirm borderline personality disorder, medical tests may be employed to exclude any co-occurring medical conditions that may present with psychiatric symptoms. These include blood tests measuring TSH to exclude hypothyroidism or hyperthyroidism, basic electrolytes and serum calcium to rule out a metabolic disturbance, full blood count including ESR to rule out a systemic infection or chronic disease, and serology to exclude syphilis or HIV infection; two commonly ordered investigations are EEG to exclude epilepsy, and a CT scan of the head to exclude brain lesions.

DSM-IV-TR criteria

The latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), the widely-used American Psychiatric Association guide for clinicians seeking to diagnose mental illnesss, defines Borderline Personality Disorder (BPD) as: "a pervasive pattern of instability of interpersonal relationships, self image and affects, as well as marked impulsivity, beginning by early adulthood and present in a variety of contexts." BPD is classed on "Axis II", as an underlying pervasive or personality condition, rather than "Axis I" for more circumscribed mental disorders. A DSM diagnosis of BPD requires any five out of nine listed criteria to be present for a significant period of time. There are thus 256 different combinations of symptoms that could result in a diagnosis, of which 136 have been found in practice in one study. The criteria are:

1. Frantic efforts to avoid real or imagined abandonment such as lying, stealing, temper tantrums, etc.
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., promiscuous sex, eating disorders, binge eating, substance abuse, reckless driving, overspending, stealing).
5. Recurrent suicidal behavior, gestures, 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, worthlessness.
8. Inappropriate 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

Comparable diagnoses

The World Health Organization's ICD-10 has a comparable diagnosis called Emotionally Unstable Personality Disorder - Borderline type (F60.31). This requires, in addition to the general criteria for personality disorder: disturbances in and uncertainty about self-image, aims, and internal preferences (including sexual); liability to become involved in intense and unstable relationships, often leading to emotional crisis; excessive efforts to avoid abandonment; recurrent threats or acts of self-harm; and chronic feelings of emptiness.

The Chinese Society of Psychiatry's CCMD has a comparable diagnosis of Impulsive Personality Disorder. A patient diagnosed as having IPD must display "affective outbursts" and "marked impulsive behavior", plus at least three out of eight other symptoms. The construct has been described as a hybrid of the impulsive and borderline subtypes of the ICD's Emotionally Unstable Personality Disorder, and also incorporates six of the nine DSM BPD criteria.

Aspects of BPD

It has been noted that there is probably no other mental disorder about which so many articles and books have been written, yet about which so little is known based on empirical research.

Studies suggest that individuals with BPD tend to experience frequent, strong and long-lasting states of aversive tension, often triggered by perceived rejection, being alone, or perceived failure. Individuals with BPD may show lability (changeability) between anger and anxiety or between depression and anxiety and temperamental sensitivity to emotive stimuli.

The negative emotional states particularly associated with BPD have been grouped into four categories: extreme feelings in general; feelings of destructiveness or self-destructiveness; feelings of fragmentation or lack of identity; and feelings of victimization.

Individuals with BPD can be very sensitive to the way others treat them, reacting strongly to perceived criticism or hurtfulness. Their feelings about others often shift from positive to negative, generally after a disappointment or perceived threat of losing someone. Self-image can also change rapidly from extremely positive to extremely negative. Impulsive behaviors are common, including alcohol or drug abuse, unsafe sex, gambling, and recklessness in general. Attachment studies suggest individuals with BPD, while being high in intimacy- or novelty-seeking, can be hyper-alert to signs of rejection or not being valued and tend towards insecure, ambivalent, preoccupied or fearful attitudes towards relationships. They tend to view the world generally as dangerous and malevolent, and themselves as powerless, vulnerable, unacceptable and unsure in self-identity.

Individuals with BPD are often described, including by some mental health professionals (and in the DSM-IV), as deliberately manipulative or difficult, but analyses and findings generally trace behaviors to inner pain and turmoil, powerlessness and defensive reactions, or limited coping and communication skills. There has been limited research on family members' understanding of borderline personality disorder and the extent of burden or negative emotion experienced or expressed by family members.Parents of individuals with BPD have been reported to show co-existing extremes of over-involvement and under-involvement BPD has been linked to somewhat increased levels of chronic stress and conflict in romantic relationships, decreased satisfaction of romantic partners, abuse, and unwanted pregnancy; these links may largely be general to personality disorder and subsyndromal problems, but such issues are commonly raised in support groups and published literature for partners of individuals with BPD.

Suicidal or self-harming behavior is one of the core diagnostic criteria in DSM IV-TR, and management of and recovery from this can be complex and challenging. The suicide rate is approximately eight to ten percent. The most recognized form of self-injury is automutilation (cutting the self), usually of the arms, but often other areas such as the legs, chest, belly, and face. Self-injury attempts are highly common among patients and may or may not be carried out with suicidal intent. BPD is often characterized by multiple low lethality suicide attempts triggered by seemingly minor incidents, and less commonly by high lethality attempts that are attributed to impulsiveness or comorbid major depression, with interpersonal stressors appearing to be particularly common triggers. Ongoing family interactions and associated vulnerabilities can lead to self-destructive behavior. Stressful life events related to sexual abuse have been found to be a particular trigger for suicide attempts by adolescents with a BPD diagnosis.

Mnemonic

A commonly used mnemonic to remember some features of borderline personality disorder is PRAISE:

• P - Paranoid ideas
• R - Relationship instability
• A - Angry outbursts, affective instability, abandonment fears
• I - Impulsive behavior, identity disturbance
• S - Suicidal behavior
• E - Emptiness

Differential diagnosis

Borderline personality disorder often co-occurs with mood disorders. Some features of borderline personality disorder may overlap with those of mood disorders, complicating the differential diagnostic assessment.

Both diagnoses involve symptoms commonly known as "mood swings". In bipolar disorder, the term refers to the cyclic episodes of elevated and depressed mood generally lasting weeks or months. In the rapid cycling variant of bipolar disorder there are more than four episodes in a year, but even then the swings are more sustained than in borderline personality disorder.

The term in borderline personality refers to the marked lability and reactivity of mood defined as emotional dysregulation. The behavior is typically in response to external psychosocial and intrapsychic stressors, and may arise and/or subside suddenly and dramatically and last for seconds, minutes, hours or days.

Bipolar depression is generally more pervasive with sleep and appetite disturbances, as well as a marked nonreactivity of mood, whereas mood with respect to borderline personality and co-occurring dysthymia remains markedly reactive and sleep disturbance not acute.

The relationship between bipolar disorder and borderline personality disorder has been debated. Some hold that the latter represents a subthreshold form of affective disorder, while others maintain the distinctness between the disorders, noting they often co-occur.

Co-morbidity

Co-morbid (co-occurring) conditions in BPD are common. When comparing individuals diagnosed with BPD to those diagnosed with other kinds of personality disorders, the former showed a higher rate of also meeting criteria for:

• anxiety disorders
• mood disorders (including clinical depression and bipolar disorder)
• eating disorders (including anorexia nervosa and bulimia)
• and, to a lesser extent, somatoform disorders

Substance abuse is a common problem in BPD, whether due to impulsivity or as a coping mechanism, and 50% to 70% of psychiatric inpatients with BPD have been found to meet criteria for a substance use disorder.

Prevalence

Figures from surveys of the prevalence of diagnosable BPD in the general population vary, ranging from approximately 1% to 2%. The diagnosis appears to be several times more common in (especially young) women than in men, by as much as 3:1 according to the DSM-IV-TR although the reasons for this are not clear.

BPDs are disproportionately represented in prison populations: 23 percent of incarcerated men and 20 percent of incarcerated women are diagnosed with BPD.

Terminology

There is a debate as to whether BPD should be renamed. The term "borderline" started in clinical use in the 1930s, originating in the idea (now out of favor) of some patients being on the "borderline" between neurosis and psychosis. BPD only became an official Axis II (personality) diagnosis in 1980 with the publication of DSM-III.

Alternative suggestions for names include Emotional regulation disorder or Emotional dysregulation disorder. According to TARA, (Treatment and Research Advancement Association for Personality Disorders) this terminology has "the most likely chance of being adopted by the American Psychiatric Association." Emotional regulation disorder is the term favored by Dr. Marsha Linehan, pioneer of one of the most popular types of BPD therapy. Impulse disorder and Interpersonal regulatory disorder are other valid alternatives, according to Dr. John Gunderson of McLean Hospital in the United States. Dyslimbia has been suggested by Dr. Leland Heller and Mercurial disorder has been proposed by McLean Hospital's Dr. Mary Zanarini.

Another term advanced (for example by psychiatrist Carolyn Quadrio) is Post Traumatic Personality Disorganisation (PTPD), reflecting the condition's status as (often) both a form of chronic Post Traumatic Stress Disorder (PTSD) and Personality Disorder and a common outcome of developmental or attachment trauma.

Significantly, the above proposals, if adopted, will probably result in the recognition of BPD as a trauma- and/or mood-related disorder, and should move BPD from Axis II to Axis I in the next DSM (DSM-V, due in 2012).

Some who are labeled with "Borderline Personality Disorder" feel it is unhelpful and stigmatizing as well as simply inaccurate, supporting and adding to calls for a name change. Criticisms have also come from a feminist perspective. It has also claimed that, in some circles, "borderline" is used as a "garbage can" diagnosis for individuals who are hard to diagnose, or is interpreted as meaning "nearly psychotic" despite a lack of empirical support for this conceptualization, or is used as a generic label for difficult clients or as an excuse for therapy going badly.

Etiology - causes and influences

Researchers commonly believe that BPD results from a combination that can involve a traumatic childhood, a vulnerable temperament, and stressful maturational events during adolescence or adulthood. Otto Kernberg formulated the theory of Borderline Personality based on a premise of failure to develop in childhood. There are, according to Kernberg, 3 developmental tasks an individual must accomplish, and, when one fails to accomplish a certain developmental task, this often corresponds with an increased risk in developing certain psychopathologies. Failing the first developmental task of psychic clarification of self and other, can result in an increased risk to develop varieties of psychosis. Not accomplishing the second task, overcoming splitting, results in an increased risk to develop a borderline personality.

Childhood abuse, trauma or neglect

Numerous studies have shown a strong correlation between childhood abuse and development of BPD. Many individuals with BPD report having had a history of abuse, neglect, or separation as young children. Patients with BPD have been found to be significantly more likely to report having been verbally, emotionally, physically, and sexually abused by caretakers of either gender. They were also much more likely to report having caretakers (of both genders) deny the validity of their thoughts and feelings. They were also reported to have failed to provide needed protection, and neglected their child's physical care. Parents (of both sexes) were typically reported to have withdrawn from the child emotionally, and to have treated the child inconsistently. Additionally, women with BPD who reported a previous history of neglect by a female caretaker and abuse by a male caretaker were consequently at significantly higher risk for being sexually abused by a noncaretaker (not a parent). These are also the same risk factors for reactive attachment disorder and it has been suggested that children who experience chronic early maltreatment and Reactive Attachment Disorder go on to develop a variety of personality disorders, including Borderline Personality Disorder.Many of these children are violent and aggressive and as adults are at risk of developing a variety of psychological problems such as borderline personality disorder.

According to Joel Paris, "Some researchers, like Judith Herman, believe that BPD is a name given to a particular manifestation of post-traumatic stress disorder (PTSD): in Trauma and Recovery, she theorizes that when PTSD takes a form that emphasizes heavily its elements of identity and relationship disturbance, it gets called BPD; when the somatic (body) elements are emphasized, it gets called hysteria, and when the dissociative/deformation of consciousness elements are the focus, it gets called DID/MPD" (dissociative identity disorder or multiple personality disorder).

Other developmental factors

Some studies suggest that BPD may not necessarily be a trauma-spectrum disorder and that it is biologically distinct from the post traumatic stress disorder that could be a precursor. The personality symptom clusters seem to be related to specific abuses, but they may be related to more persistent aspects of interpersonal and family environments in childhood

There is evidence for the central role of family in the development of BPD, including interactions that are negative and critical rather than supportive and empathic, with parental and family behaviors transacting with the child's own behaviors and emotional vulnerabilities.^]

Some findings suggest that BPD may lie on a bipolar spectrum, with a number of points of phenomenological and biological overlap between the affective lability criterion of borderline personality disorder and the extremely rapid cycling bipolar disorders. Some findings suggest that the DSM-IV BPD diagnosis mixes up two sets of unrelated items—an affective instability dimension related to Bipolar-II, and an impulsivity dimension not related to Bipolar-II.

Genetics

An overview of the existing literature suggested that traits related to BPD are influenced by genes, and since personality is generally quite heritable then BPD should also be, but studies have had methodological problems and the links are not yet clear. A major twin study found that if one identical twin met criteria for BPD, the other also met criteria in around a third (35%) of cases.

Twin, sibling and other family studies indicate a partially heritable basis for impulsive aggression, but studies of serotonin-related genes to date have suggested only modest contributions to behavior.

Neurofunction

Neurotransmitters implicated in BPD include serotonin, norepinephrine and acetylcholine (related to various emotions and moods); GABA, the brain's major inhibitory neurotransmitter (which can stabilize mood change); and glutamate, an excitatory neurotransmitter.

Enhanced amygdala activation in BPD has been identified as reflecting the intense and slowly subsiding emotions commonly observed in BPD in response to even low-level stressors. The activation of both the amygdala and prefrontal cortical areas can reflect attempts to control intensive emotions during the recall of unresolved life events. Impulsivity or aggression, as sometimes seen in BPD, has been linked to alterations in serotonin function and specific brain regions in the cingulate and the medial and orbital prefrontal cortex.

Treatment

A recent study found that any of three types of psychotherapy stimulate substantial improvements in people with this disorder. The three approaches studies were Dialectical behavior therapy, transference-focused therapy, and schema-focused therapy. "Psychotherapy that centers on emotional themes arising in the interaction between patient and therapist, known as transference-focused therapy, stimulates the most change in people with borderline personality disorder."

Psychotherapy

There has traditionally been skepticism about the psychological treatment of personality disorders, but several specific types of psychotherapy for BPD have developed in recent years. The limited studies to date do not allow confident claims of effectiveness but do suggest that people with a diagnosis of BPD can benefit on at least some outcome measures. Simple supportive therapy alone may enhance self-esteem and mobilize the existing strengths of individuals with BPD. Specific psychotherapies may involve sessions over several months or, as is particularly common for personality disorders, several years. Psychotherapy can often be conducted either with individuals or with groups. Group therapy can aid the learning and practice of interpersonal skills and self-awareness by individuals with BPD although drop-out rates may be problematic.

Dialectical behavioral therapy

In the 1990s, a new psychosocial treatment termed dialectical behavioral therapy (DBT) became established in the treatment of BPD, having originally developed as an intervention for patients with suicidal behavior.

Dialectical behavior therapy is derived from cognitive-behavioral techniques (and can be seen as a form of CBT) but emphasizes an exchange and negotiation between therapist and client, between the rational and the emotional, and between acceptance and change (hence dialectic). Treatment targets are agreed upon, with self-harm issues taking priority. The learning of new skills is a core component - including mindfulness, interpersonal effectiveness (e.g. assertiveness and social skills), coping adaptively with distress and crises; and identifying and regulating emotional reactions.

DBT can be based on a biosocial theory of personality functioning in which BPD is seen as a biological disorder of emotional regulation in a social environment experienced as invalidating by the borderline patient.

Dialectical behavioral therapy has been found to significantly reduce self-injury and suicidal behavior in individuals with BPD, beyond the effect of usual or expert treatment, and to be better accepted by clients. although whether it has additional efficacy in the overall treatment of BPD appears less clear. Training nurses in the use of DBT has been found to replace a therapeutic pessimism with a more optimistic understanding and outlook.

Schema Therapy

Schema Therapy (also called Schema-Focused Therapy) is an integrative approach based on cognitive-behavioral or skills-based techniques along with object relations and gestalt approaches. It directly targets deeper aspects of emotion, personality and schemas (fundamental ways of categorizing and reacting to the world). The treatment also focuses on the relationship with the therapist (including a process of "limited re-parenting"), daily life outside of therapy, and traumatic childhood experiences. It was developed by Jeffrey Young and became established in the 1990s. Limited recent research suggests that it is significantly more effective than Transference Focused Psychotherapy, with half of individuals with borderline personality disorder assessed as having achieved full recovery after 4 years, with two thirds showing clinically significant improvement.Another very small trial has also suggested efficacy.

Cognitive behavioral therapy

Cognitive Behavioral Therapy (CBT) is the most widely used and established psychological treatment for mental disorders, but has appeared less successful in BPD, due partly to difficulties in developing a therapeutic relationship and treatment adherence. Approaches such as DBT and Schema-focused therapy developed partly as an attempt to expand and add to traditional CBT, which uses a limited number of sessions to target specific maladaptive patterns of thought, perception and behavior. A recent study did find a number of sustained benefits of CBT, in addition to treatment as usual, after an average of 16 sessions over one year.

Eye Movement Desensitization and Reprocessing (EMDR) is a treatment for PTSD, a condition closely associated to BPD in many cases. It is similar to CBT, and seen by some as a type of CBT, but also includes unique techniques intended to facilitate full emotional processing and coming to terms with traumatic memories.

Marital or Family Therapy

Marital Therapy can be helpful in stabilizing the marital relationship and in reducing marital conflict and stress that can worsen BPD symptoms. Family Therapy or Family Psychoeducation can help educate family members regarding BPD, improve family communication and problem solving, and provide support to family members in dealing with their loved one's illness.

Two patterns of family involvement can help clinicians plan family interventions: overinvolvement and neglect. Borderline patients who are from overinvolved families are often actively struggling with a dependency issue by denial or by anger at their parents.

Interest in the use of psychoeducation and skills training approaches for families with borderline members is growing.

Psychoanalysis

Traditional psychoanalysis has become less commonly used than in the past, both in general and in regard to BPD. This intervention has been linked to an exacerbation of BPD symptoms although there is also evidence of effectiveness of certain techniques in the context of partial hospitalization.

Transference Focused Psychotherapy

Transference Focused Psychotherapy (TFP) is a form of psychoanalytic therapy dating to the 1960s, rooted in the conceptions of Otto Kernberg on BPD and its underlying structure (borderline personality organization). Unlike in the case of traditional psychoanalysis, the therapist plays a very active role in TFP. In session the therapist works on the relationship between the patient and the therapist. The therapist will try to explore and clarify aspects of this relationship so the underlying object relations dyads become clear. Some limited research on TFP suggests it may reduce some symptoms of BPD by affecting certain underlying processes, and that TFP in comparison to Dialectical Behavior Therapy and supportive therapy results in increased reflective functioning (the ability to realistically think about how others think) and a more secure attachment style. Furthermore, TFP has been shown to be as effective as DBT in improvement of suicidal behavior, and has been more effective than DBT in alleviating anger and in reducing verbal or direct assaultive behavior.Limited research suggests that TFP appears to be less effective than schema-focused therapy, while being more effective than no treatment.

Cognitive Analytic Therapy

Cognitive Analytic Therapy (CAT) combines cognitive and psychoanalytic approaches and has been adapted for use with individuals with BPD with mixed results.

Medication

A number of medications are used in conjunction with BPD treatments, although the evidence base is limited. As BPD has been traditionally considered a primarily psychosocial condition, medication is intended to treat co-morbid symptoms, such as anxiety and depression, rather than BPD itself.

Antidepressants

Selective serotonin reuptake inhibitor (SSRI) antidepressants have been shown in randomized controlled trials to improve the attendant symptoms of anxiety and depression, such as anger and hostility, associated with BPD in some patients. According to Listening to Prozac, it takes a higher dose of an SSRI to treat mood disorders associated with BPD than depression alone. It also takes about three months for benefit to appear, compared to the three to six weeks for depression.

Antipsychotics

The newer atypical antipsychotics are claimed to have an improved adverse effect profile than the typical antipsychotics. Antipsychotics are also sometimes used to treat distortions in thinking or false perceptions. Use of antipsychotics has varied, from intermittent, for a brief psychotic or dissociative episode, to more general, particularly atypical antipsychotics, for both those diagnosed with bipolar disorder (BiP), as well as those diagnosed with borderline personality disorder (BPD).

One meta-analysis of 14 prior studies has suggested that several atypical antipsychotics, including olanzapine, clozapine, quetiapine and risperidone, may help BPD patients with psychotic-like, impulsive or suicidal symptoms.

Long-term use of antipsychotics is particularly controversial. There are numerous adverse effects with the older medications, notably Tardive dyskinesia (TDK) Atypical antipsychotics are also known for often causing considerable weight gain, with associated health complications.

Mental health services and recovery

Individuals with BPD sometimes need extensive mental health services and have been found to account for around 20% of psychiatric hospitalizations. The majority of BPD patients continue to use outpatient treatment in a sustained manner for several years, but the number using the more restrictive and costly forms of treatment, such as inpatient admission, declines with time.Experience of services varies.Assessing suicide risk can be a challenge for mental health services (and patients themselves tend to underestimate the lethality of self-injurious behaviours) with typically a chronically elevated risk of suicide much above that of the general population and a history of multiple attempts when in crisis.

Particular difficulties have been observed in the relationship between care providers and individuals diagnosed with BPD. A majority of psychiatric staff report finding individuals with BPD moderately to extremely difficult to "deal" with, and more difficult than other client groups. On the other hand, those with the diagnosis of BPD have reported that the term "BPD" felt like a pejorative label rather than a helpful diagnosis, that self destructive behaviour was wrongly perceived as manipulative, and that they had limited access to care. Attempts are made to improve public and staff attitudes.

Combining pharmacotherapy and psychotherapy

In practice, psychotherapy and medication may often be combined but there are limited data on clinical practiceEfficacy studies often assess the effectiveness of interventions when added to 'treatment as usual' (TAU), which may involve general psychiatric services, supportive counselling, medication and psychotherapy.

One small study, which excluded individuals with a comorbid Axis 1 disorder, has indicated that outpatients undergoing Dialectical Behavioral Therapy and taking the antipsychotic Olanzapine show significantly more improvement on some measures related to BPD, compared to those undergoing DBT and taking a placebo pill,although they also experienced weight gain and raised cholesterol. Another small study found that patients who had undergone DBT and then took fluoxetine (Prozac) showed no significant improvements, whereas those who underwent DBT and then took a placebo pill did show significant improvements.

Difficulties in therapy

There can be unique challenges in the treatment of BPD, for example hospital care. In psychotherapy, a client may be unusually sensitive to rejection and abandonment and may react negatively (e.g., by harming themselves or withdrawing from treatment) if they sense this. In addition, clinicians may emotionally distance themselves from individuals with BPD for self-protection or due to the stigma associated with the diagnosis, leading to a self-fulfilling prophecy and a cycle of stigmatization to which both patient and therapist can contribute.

Some psychotherapies, for example DBT, developed partly to overcome problems with interpersonal sensitivity and maintaining a therapeutic relationship. Adherence to medication regimes is also a problem, due in part to adverse effects, with drop-out rates of between 50% and 88% in medication trials. Comorbid disorders, particularly substance use disorders, can complicate attempts to achieve remission.

Other strategies

Psychotherapies and medications form a part of the overall context of mental health services and psychosocial needs related to BPD. The evidence base is limited for both, and some individuals may forego them or not benefit (enough) from them. It has been argued that diagnostic categorisation can have limited utility in directing therapeutic work in this area, and that in some cases it is only with reference to past and current relationships that "borderline" behavior can be understood as partly adaptive and how people can best be helped.

Numerous other strategies may be used, including alternative medicine techniques, exercise and physical fitness, including team sports; occupational therapy techniques, including creative arts; having structure and routine to the days, particularly through employment - helping feelings of competence (e.g. self-efficacy), having a social role and being valued by others, boosting self-esteem.

Group-based psychological services encourage clients to socialize and participate in both solitary and group activities. These may be in day centers. Therapeutic communities are an example of this, particularly in Europe, although their usage has declined many have specialised in the treatment of severe personality disorder.

Psychiatric rehabilitation services aimed at helping people with mental health problems, to reduce psychosocial disability, engage in meaningful activities, and avoid stigma and social exclusion may be of value to people who suffer from BPD. There are also many mutual-support or co-counseling groups run by and for individuals with BPD. A goal may be full recovery rather than reliance on services.

Data indicate that substantial percentages of people diagnosed with BPD can achieve remission even within a year or two. A longitudinal study found that, six years after being diagnosed with BPD, 56% showed good psychosocial functioning, compared to 26% at baseline. Although vocational achievement was more limited even compared to those with other personality disorders, those whose symptoms had remitted were significantly more likely to have a good relationship with a spouse/partner and at least one parent, good work/school performance, a sustained work/school history, good global functioning and good psychosocial functioning.