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Borderline Personality Disorder Researchers study causes and treatment of borderline personality disorder by Glen O. Gabbard, MD With a prevalence in the U.S. population of 1.8–4 percent, borderline personality disorder is one of the most common personality disorders. It is diagnosed three times more often in females than males, usually in young adulthood. Its somewhat awkward name derives from early observations of individuals with some features in common with neurotic conditions but others typical of psychotic disorders. Hence, they were thought to occupy a "border" between neurosis and psychosis. Certain characteristics typify borderline patients. Impulsivity in such areas as eating, sex, shoplifting, and thrill-seeking behavior is a core feature. Self-mutilation and suicide attempts are also common. In fact, 7–10 percent of these patients ultimately kill themselves. Intense emotional fluctuations are usually present and frequently involve extreme anger or depression. Affected persons develop a pattern of relationships that involves oscillating between closeness and distance, often with a fear of abandonment. They also tend to view other people in an "all-or-none" fashion—idealizing them or writing them off as worthless. Transient psychotic episodes may also lead to extreme suspicion. In the past decade, research has focused on the underlying causes of this disorder. Although no one cause has been identified, several factors appear to contribute. Researchers consistently find a higher rate of sexual abuse in borderline patients. About one third may be victims of incest, while 50–60 percent have suffered some form of sexual abuse. Prior physical and verbal abuse also appears linked to higher rates of occurrence. Certain patterns of overinvolvement between parent and child may be causative factors. Some studies have shown that parents may have difficulty allowing their child to grow up and become separate. Borderline patients may thus fear situations where they must be independent and autonomous. However, it would be incorrect to link this disorder to any one type of parent-child interaction. Some studies have found that neglect is at least as common. While some research has attributed the cause to parental failure, more recent studies suggest that blaming the parents is an oversimplification. Borderline -patients appear to have inborn difficulties that affect brain functioning. With sophisticated testing, they are consistently found to have higher rates of neuropsychological abnormalities. In addition, preliminary studies point to a problem with the neurotransmitter serotonin. Serotonin can be viewed as the "brakes" of the central nervous system. In other words, normal levels of this brain chemical inhibit impulsive aggression directed either at oneself or other people. Low levels of serotonin appear related to more impulsive and destructive behavior. Serotonin abnormalities may help explain recent findings that medications that increase serotonin levels improve many symptoms. Selective serotonin reuptake inhibitors like Prozac (fluoxetine) may result in less impulsivity, less anger, and more stable moods. These findings require corroboration, but the implications are promising. Medication by itself is rarely effective as the major treatment. Most experts agree that individual therapy is the cornerstone of treatment, with medication and group or family therapy as valuable adjuncts. Well-designed studies show that about a year of therapy is necessary for sustained improvement. In one study of dialectical behavior therapy, once-weekly individual and group sessions focused on coping strategies. Meanwhile, the individual process dealt with specific problems, beginning with suicidal and self-destructive behavior. After a year, the patients receiving behavior therapy showed less self-destructiveness, suicidality, and need for hospitalization. In an Australian study, patients were given twice-weekly psychodynamic psychotherapy for a year. They showed substantial improvement in the use of other medical services, reduced need for hospitalization, and improved ability to work. Long-term follow-up studies on outcome are encouraging. But they have not used control groups of people without the disorder, so the conclusions must be considered tentative. Nevertheless, about two thirds of borderline patients appear to function reasonably well 10–20 years after onset. Although problems appear entrenched and difficult to change early on in the disorder, there is much reason for optimism over time. About the author For more information, see: Paris, J. (1994). Borderline personality disorder: A multidimensional approach. Washington, DC: American Psychiatric Press. Stevenson, J., & Meares, R. (1992). An outcome study of psychotherapy for patients with borderline personality disorder. American Journal of Psychiatry, 149( 3), 358–362. Copyright
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