BORDERLINE PERSONALITY DISORDER (BPD) is a addition to mental disorder nosology, added to the Diagnostic and Statistical Manual (DSM)of the American Psychiatric Association in 1980. Many aspect of the disorder have been under a matter of controversy, discussion, and research. Perhaps most controversial was the decision to use "borderline" in the official designation of the disorder. It was first used by Adolf Stern in 1938 to describe a group of outpatients who did not profit from classical psychoanalysis and who did not seem to fit into the then standard neurotic or psychotic psychiatric catergories. Depending on the theorist, borderline patients have been viewed as on the borderline between neurosis and psychosis, schizophrenia and nonschizophrenia, the normal and the abnormal, and sanity and insanity.
The disorder is characterized by a pervasive instability in five functional domains: affect regulation, impulse control, self image and experiencing, interpersonal relationships, and reality testing. Dysregulation or emotions includes marked lability of mood, including intense, episodic dysphoria, anxiety, fear, anger and irritability. Impulsive behaviour is common, especially behaviours associated with intense emotions such as violence or "behavioral explosions" assocaited with anger and recurrent avoidance of tasks or precipitous quitting of jobs or school associated with fear and anxiety. A tendency to become involved in intense, chaotic, and unstable relationships may be associated with repeated interpersonal crises and with excessive efforts to avoid abandonment.
Self-image, goals, and preferences (including sexual) are often unclear, unstable, or disturbed, making pursuit of long-term goals difficult. Transient, stress-related severe paranoid ideation or dissociative experiences have been reported in 30 to 75% of BPD patients. Suicide attempts and other non-fatal self-injurious behaviors have said to be the hallmark of BPD. From 70 to 75% of BPD patients have a history of at least one self-injurious act.
Suicide rates are estimated at 8 to 10%. In a series of BPD inpatients followed from 10 to 23 years after hospital discharge, patients exhibiting eight of the BPD criteria when admitted had a suicide rate of 36% compared to a rate of 7% for individuals who meet five to seven criteria. (Stone, Hurt, & Stone, 1987).
The expert consensus is that BPD is best diagnosed using semistructured clinical interviews. Interrater reliability of the major interviews tend to be high and comparable to interviews for other major mental disorders. Comorbidity of BPD with other mental disorders (primarily depression and anxiety but also high rates of eating disorders and substance abuse disorders) and personality disorders (primarily aviodant, narcisstic, and schizotypal) is more the norm than the exception.
Major depression is diagnosed in 24 to 74% of BPD patients, while dysthymia is observed in approximately 3 to 14%. Bipolar Disorder is estimated to occur in 4 to 20% of this population. The most common comorbid anxiety disorder is panic disorder, found in 10 to 25% of BPD patients (Stein & Skodol, 1993). Posttraumatic stress disorder can also be high, especially in those BPD patients with histories of suicide attempts.
The high prevalence of BPD, especially among patients in mental health treatment, the high comorbidity of the disorder, and an association of BPD reports of severe childhood trauma (Paris, Zweig-Frank, & Guzder, 1994) have caused many to question the validity of the diagnoses. These individuals have suggested instead that BPD is best considered a marker of severity and comorbidity, a specific type of mood disorder, or a variation of posttraumatic stress disorder. Others have argued convincingly that the relationship between BPD and both mood and posttraumatic stress disorders is non specific at best (Gunderson & Phillips, 1991). Although association with childhood events suggests a possible etiological factor, it does not in itself negate the specific construct validity of the disorder. Biologically oriented theorists have conceptualized BPD as a set of clinical syndromes, each with its own etiology, course, and outcome based on respective types of biological trauma or disorder associated with the specific syndrome.
Follow-up studies consistently indicate that BPD is chronic. Two to three years after index assesssment, 60 to 70% of patients continued to meet the criteria. Other follow up studies found liitle change in level of functioning and consistently high rates of psychitric hospitalization over two to five years. Four to seven years after index assessment, 57 to 67% of patients continued to meet the criteria. An average of 15 years after index assessment, 25 to 44% continued to meet the criteria.
Last edited by Samara on 13 Dec 2008, 9:03 pm, edited 1 time in total.
13 Dec 2008, 7:35 pm
