Borderline personality disorder

Borderline personality disorder is characterized by intense affective instability & impulsivity together with unstable sense of self–identity.

They are often manifested by impulsive self–aggression & suicidal attempts, substance abuse, chronic feeling of emptiness & unstable interpersonal relationships.

Epidemiology:

1.5-5% of general population.
10-15% amongst psychiatric patient.
Female > Male
Commonly seen between 18-35years of age.

Aetiology:

1.Genetics:

Family history of patients with borderline personality disorder shows:
(a) Parents have a higher incidence of mood disorder(but not schizophrenia)
(b) High family incidence of antisocial personality disorder
(c) Positive family history of Alcoholism.

2. Biological:

(a) Reduced level of 5-HIAA in CSF
(b) Blunted prolactin response to serotonin agonists.
(c) Abnormal emotional reactivity in the limbic areas.
(d) Insufficient regulatory function at Cingulated & Prefrontal areas of brain.

3. Developmental:

Traumatic experiences (sexual abuse/neglect) are seen in childhood of patients with borderline personality disorder.

Onset of borderline personality disorder needs the interaction of predisposing factors and environmental precipitants.
They seem to be extremely sensitive to frustrations in the intimate relationships which are commonly detected at the onset of the disorder.

Clinical Features:

•The affect is chronically dysphoric & irritated.

•Mood is a mixture of depressed affect, anger, loneliness & emptiness.

•Impulsive – aggressive behaviour is a core feature.

•Easily suggestible & frequently change their decisions.

•Things & people are seen in black & White terms.

•”Transient & Brief Psychotic Episodes” are frequent associated with stressful situations.
Psychotic symptoms may have a typical dissociative-like nature or present as transient self-referential ideation.
Rejection sensitivity and suspiciousness usually colours the interpretations of behaviours of others.

•They are both “intensely dependent” & “hostile” towards significant others.

•Interpersonal relationships are unstable, intense, demanding, clinging & characterized by alternation between extremes of idealization & devaluation.

ICD-10 criteria: “Emotionally unstable personality disorder”(F60.3)

Marked tendency to act impulsivity without consideration of the consequences, together with affective instability.

Types:

1.Impulsive Type: F60.30

Outbursts of violence or threatening behaviour, particularly in response to criticism by others.

2. Borderline Type: F60.31

•Emotional instability
•Patient’s own self-image ,aims & internal preferences (including sexual) are often unclear and disturbed.
•Chronic feeling of emptiness.
•Intense & unstable relationships may cause repeated emotional crises.
•A Series of suicidal threats/ self harm.

Comorbidity:

•Depression
•Anxiety disorders
•Somatization disorder
•PTSD
•Alcohol abuse

Differential diagnosis

•Bipolar disorder
•Mild mental retardation
•Schizotypal personality disorder

Course & outcome:

•Often experience profound dysfunction in many important aspects of life like education, jobs & marriage.
•Alcohol & psychosexual problems
•Repeated suicide attempts(8-10% commit suicide).

* Diagnosis is rarely made in patient aged over 40. Neural structures & defence mechanisms mature with age. These changes together with social learning reduce symptomatology.

Treatment:

Pharmacotherapy:

For affective changes:
•SSRIS
•Mood stabilizers

For brief psychotic episodes :
•Antipsychotics

Psychotherapy :

1.Short term psychotherapy:
For managing crises
2.Supportive psychotherapy:
For more fragile borderline personality disorder patient
3.Dialectical behavioural therapy:
For emotional self regulations & behavioural self control.

Reference:

  • New Oxford Textbook of Psychiatry(2nd edition).
  • ICD-10 Classification of Mental and Behavioural Disorders.

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