Running head: BORDERLINE PERSONALITY DISORDER: A REVIEW

Borderline Personality Disorder: A Review

Lauren Moretti
James Madison University

BORDERLINE PERSONALITY DISORDER

Borderline Personality Disorder: A Review

Borderline Personality Disorder (BPD) is a serious psychiatric disorder characterized by

impulsivity and by instability in interpersonal relationships, affect, and self-image. There are a
great many clients with BPD in clinical settings. Clinicians acknowledge that the disorder
presented itself in the clients early adulthood and that presentation is seen in multiple contexts
(APA, 2013). The client must present five out of nine symptoms to meet full criteria for a
diagnosis of BPD (APA, 2013). Any five out of nine symptoms presented constitutes a diagnosis
of BPD. Therefore, there could be over 100 different combinations of symptoms in the
population. It is imperative, then, that clinicians are well informed of what BPD is, whom it
affects, and what can be done to address the disorder. This paper aims to continue the discussion
on BPD by providing a review of recent literature.
One of the main symptoms of BPD is a serious fear of abandonment. This fear is
responded to by making frantic efforts to avoid abandonment, whether it is real or imagined
(APA, 2013). Other clinicians, such as Gunderson, Singer, Adler, and Buie, explain this feature
of BPD as intolerance of aloneness (cited in Gunderson, 2008). Clients with BPD often have a
history of trauma (Keinanen, Johnson, Richards, & Courtney, 2012). It is possible that traumatic
experiences, such as separation, could be a reason for this fear of abandonment. Object relations
theorists could reason that fear of abandonment is due to the clients inability to have object
constancy, that is, to have available mental representations of absent figures (Gunderson, 2008).
The behaviors done to prevent abandonment may actually be successful in the short term, but
ultimately end in interpersonal instability (Bateman & Krawitz, 2013).
Clinicians can see such interpersonal instability through what is called splitting
(Gunderson, 2008). Splitting is when the client moves between extreme idealizing and devaluing

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(APA, 2013). This is a form of cognitive distortions through dichotomous thinking. In one

moment, the other person is seen as perfect, put on a pedestal. In the next moment, the same
person is hated. Clearly, this contributes to intense and unstable relationships.
BPD is also marked by an unstable self-image in what is called identity disturbance
(APA, 2013). This can be described more easily as feeling uncertain of what one wants out of
life. It has been suggested that avoiding feelings increases aspects of identity disturbance
(Bateman & Krawitz, 2013). Understandably, a client may choose to deal with intense emotions
by altogether avoiding them. However, emotions provide information about the self and without
such information, uncertainty may result (Bateman & Krawitz, 2013). Still, identity disturbance
may produce rapid shifts in a variety of areas of life, such as goals, relationships, and even sexual
orientation (Comer, 2014). It is important for clinicians to be able to distinguish, though, what
are developmentally appropriate questions of identity and what are identity disturbances seen in
BPD.
Often, clients with BPD have not yet learned how to cope with distress in effective,
adaptive ways. Impulsivity, one of the BPD criteria, can be a result. Impulsivity must be seen in
at least two areas and must be self-damaging for it to be included in the borderline diagnosis
(APA, 2013). The self-damaging aspect is important because that is used as a way to differentiate
from a hypomanic/manic episode or an antisocial characteristic (Gunderson, 2008). A number of
behaviors could be considered self-damaging and impulsive. Commonly described behaviors are
spending, sex, reckless driving, and binge eating (APA, 2013). More so, one study found that
about 50% of clients with BPD have a lifetime history of problems with substances (cited in
Bateman & Krawitz, 2013). There could be a variety of reasons for impulsivity in clients with
BPD. Perhaps feelings of emptiness (later discussed) are addressed and attempted to be filled

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through impulsive behavior. It is also highly likely that impulsive behaviors are done to avoid or
deal with intense distress.
Clients with BPD also have affective instability as one of the defining characteristics. The
affective instability is due to marked reactivity in mood, such as intense anxiety, irritability,
and dysphoria (APA, 2013). Emotions are intense and out of control for clients with BPD. They
change rapidly and unpredictably (Bateman & Krawitz, 2013). One can differentiate between
BPD and other mood disorders because of time. Affective instability lasts usually a few hours
and rarely more than a few days in clients with BPD, unlike in many clients with mood disorders
(APA, 2013).
Chronic feelings of emptiness are also included in the DSM criteria (APA, 2013). This is
an important criterion because it helps clinicians differentiate between other types of depression
(Gunderson, 2008). Feelings of emptiness in this disorder are a result of avoidance and
disengagement in life. Not trying things or engaging in life avoids disappointment and distress.
However, it leaves someone without knowing what is meaningful and satisfying in life, thereby
resulting in feelings of emptiness (Bateman & Krawitz, 2013).
Anger is also often prominent in BPD. In fact, one characteristic is having inappropriate,
intense anger or difficulty controlling anger (APA, 2013). It should also be noted that such anger
does not have to be against another person; it can be directed toward the self. Inappropriate,
intense anger further causes issues in interpersonal relationships. Anger may result when others
do not meet the unrealistic expectations of perfection (Bateman & Krawitz, 2013). It can also be
seen when clients with BPD begin devaluing while splitting.
Transient, stress-related paranoid ideation or severe dissociative symptoms is also
defined by the DSM-5 as a feature of BPD (APA, 2013). This includes depersonalization,

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derealization, and hallucinations (Gunderson, 2008). Some clients may be very sensitive to

danger and hypervigilent (Bateman & Krawitz, 2013). Again, this feature may be a mechanism
by which to avoid feelings.
Finally, recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior is a
characteristic of BPD (APA, 2013). Suicidal or self-harm behavior can be a way of decreasing
intense distress. Suicidal or self-harm behavior can decrease distress either directly or indirectly.
Distress is decreased directly by feeling better, turning emotional pain to physical, distracting,
feeling in control, punishing oneself, feeling alive, feeling numb, not feeling, dissociating, or
feeling grounded. Distress is decreased indirectly by communicating, feeling heard, attracting
caring responses, getting access to mental health services, and controlling or punishing others
(Bateman & Krawitz, 2013). 75% of clients with BPD have a history of having self-harmed on at
least one occasion (Bateman & Krawitz, 2013). More so, suicide rates were 10% in older studies,
however, the rates are lower today thanks to better treatments (cited in Bateman & Krawitz,
2013). Regardless, clinicians should never assume that the sole purpose of self-harm is gaining
attention.
The prevalence rates for BPD differ depending on which population is being studied. It is
found that between 1-3% of the general community has BPD. In outpatient clinics, between 1115% of the population has BPD. Finally, in inpatient facilities, between 20-25% of all patients
are diagnosed with BPD (Bateman & Krawitz, 2013; Gunderson, 2008).
Some have questioned whether industrialization has influenced the development and
prevalence of BPD. Industrialization has caused many individuals to move to cities, increase
family movement, lose the culture of small villages, and lessen immediate family and extended
family connections (Bateman & Krawitz, 2013). This could result in feelings of abandonment,

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identity disturbance, and emptiness, to name a few, which are key characteristics in BPD. It is
plausible, then, that this could increase the likelihood that someone in a Westernized culture
would be diagnosed with BPD. More so, BPD is likely to result in rapidly changing cultures. A
cultures instability leaves its members with feelings of emptiness, high anxiety, fears of
abandonment, and identity problems, again, like those seen in BPD (Bateman & Krawitz, 2013).
As always, it is important to consider the differences in culture as it relates to mental
illness. Unfortunately, racial/ethnic differences in BPD have been inconsistent in the relevant
literature. One study found that there is a lower prevalence of BPD among black compared to
white populations (McGilloway, Hall, Lee, & Bhui, 2010). In another study, Hispanics were
more likely to be diagnosed with BPD (Chavira et al., 2003). However, the clinician has to be
aware of differences between cultures. For example, there is a syndrome in Hispanic culture
called ataque de nervios. This syndrome includes uncontrollable shouting, crying, trembling,
and verbal or physical aggression as a result of stressful events relating to the family (Chavira et
al., 2003). Clearly, ataque de nervios has many features that could be confused with BPD and
result in a misdiagnosis. More so, the clinician must also be aware of language barriers. The way
one communicates their symptoms may be miscommunicated or misinterpreted so that a
clinician may diagnosis BPD at an inappropriate time. In analyzing prevalence rates in different
racial/ethnic groups, there must also be a consideration that help seeking behavior differs across
cultures, as well.
There has been much controversy over the prevalence of BPD in women compared to
men. In one study, a large percentage (70-75%) of those diagnosed with BPD were female (cited
in Bateman & Krawitz, 2013). However, Grant and colleagues (2008) found no differences
between men and women (cited in Bateman & Krawitz, 2013). Clearly, there are discrepancies,

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and clinicians must consider if there is truly a greater prevalence in women or if other forces are
affecting the data. For example, though males are underdiagnosed in mental health settings, they
are more likely to be recognized in substance use centers and the justice system (Bateman &
Krawitz, 2013). Further, the clinician would also have to consider help seeking behavior in
different genders and how that affects prevalence. Gender stereotypes may be at play here, too,
where we assume that women are more emotional, defined by their relationships, and dependent
(Bjorklund, 2006). Finally, we must interpret our research findings cautiously for fear of
sampling bias, especially considering there are higher rates of women in clinical settings where
research is often done (Bjorklund, 2006).
There also has been some controversy on whether or not to diagnose a client with BPD at
certain ages. The DSM 5 defines BPD as a disorder that is presented in early adulthood (APA,
2013). It is less likely, then, that clinicians would diagnose children or adolescents with this
personality disorder. Still, some clinicians argue that it is possible to accurately diagnose BPD in
adolescence (Bateman & Krawitz, 2013; Gunderson, 2008). The clinician has to carefully
consider what is normal development in adolescence before making the BPD diagnosis. For
example, impulsivity is common in adolescent development and changes over time. Therefore,
the impulsivity criteria would have less weight than others when diagnosing in adolescents.
Research has found, though, that affect dysregulation, an important feature of BPD, continues
throughout life and therefore can be seen in adolescents and lead to a diagnosis (Eppel, 2005).
For years, treatment outcomes for those with BPD were very poor. Today, though, there
are a number of therapies that have proven to be effective in treating BPD. The primary
treatment of BPD is psychotherapy with medication to assist (Bateman & Krawitz, 2013). Both
Cognitive Behavioral and Psychodynamic theory have influenced the development of treatment.

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Three widely used treatments for BPD are Dialectical Behavior Therapy (DBT),

Mentalization Based Treatment (MBT), and Transference Focused Psychotherapy (TFP). The
DBT model conceptualizes BPD as the inability to integrate opposing views (Bliss & McCardle,
2014). Dialecticism is the concept that seemingly contradictory things can both be true, which
addresses the inability to integrate opposing views. DBT includes individual therapy, group skills
training, telephone coaching, and a consultation team for therapists (Bliss & McCardle, 2014).
Individual therapy seeks to eliminate life threatening behaviors, behaviors that interfere with
treatment, and behaviors that decrease the quality of life of the client (Lynch, Trost, Salsman, &
Linehan, 2007). The skills taught in skills training include mindfulness, distress tolerance,
emotional regulation, and interpersonal effectiveness (Lynch et al., 2007). Telephone coaching is
used to help clients apply the skills they learned to real life situations (Lynch et al., 2007).
Finally, a consultation team is used to support therapists working with this often challenging
population (Lynch et al., 2007). DBT shows improvements on self-harm behaviors and their
medical risk, total psychiatric inpatient hospital days, anger, global functioning, social
functioning, hopelessness, depression, anger expression, and impulsive behaviors (Lynch et al.,
2007; Zanarini, 2009).
MBT sees BPD as a disorder of attachment, separation intolerance, and mentalization.
Mentalization is the ability to think of oneself in relation to others and understand anothers state
of mind (Bliss & McCardle, 2014). In therapy, both the client and the therapist explore different
perspectives to the clients experience. In MBT, there is individual therapy, group therapy,
expressive therapy, community meetings, meetings with case administrators, and medication
reviews (Dixon-Gordon, Turner, & Chapman, 2011). MBT results in improvements in

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psychosocial functioning, fewer suicide attempts, less psychotropic medication, and less service
use (Dixon-Gordon et al., 2011).
TFP understands BPD to be a problem with integrating positive and negative mental
representations of self and others (Bliss & McCardle, 2014). TFP uses transference as the
mechanism to change representations of self and others and, therefore, reduce symptomology
and self-destructive behavior (Zanarini, 2009). Treatment includes individual therapy twice a
week over three years (Dixon-Gordon, Turner, & Chapman, 2011). Clients in TFP show
improvement in suicidality, anger, impulsivity, irritability, attachment and the ability to reflect
(Zanarini, 2009).
Zanarini (2009) found evidence that no treatment is particularly better than another.
Rather, treatment may be beneficial if it is reasonable and provided by reasonable people in a
reasonable way (cited in Bliss & McCardle, 2014). There are a number of commonalities
between DBT, TFP, and MBT. All understand BPD as having deficits in integrating internal
representations of self and others. All treatment models, too, suggest increasing integration by
using dialectical thinking and searching for different explanations to the clients experience
(Bliss & McCardle, 2014). Therefore, it might be best to decide which treatment to use by
looking at the need of the individual client and the competencies of the therapist.
Many psychiatric disorders have been treated through psychopharmacology. Previously,
Selective Serotonin Reuptake Inhibitors (SSRIs) were used to treat BPD. However, recent
research has found that there is no use for SSRIs in the treatment of BPD unless there is a
concurrent depressive episode. Instead, there has been a move toward prescribing atypical
antipsychotics and anticonvulsants (Ripoll, 2012; Bateman & Krawitz, 2013). Still, many BPD
symptoms have not been proven to be affected by psychotropic medication: avoidance of

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abandonment, chronic feelings of emptiness, identity disturbance, and dissociation (Lieb, Vollm,
Rucker, Timmer, & Stoffers, 2010). In January 2009, the National Institute for Health and
Clinical Excellence (NICE) made a clinical guideline which stated, Drug treatment should not
be used specifically for borderline personality disorder or for individual symptoms or behavior
associated with the disorder (cited in Lieb et al., 2010). Therefore, psychotherapy is the primary
and only treatment if the clinician chooses to follow NICE guidelines.
Treatment outcomes are far more optimistic for clients with BPD than they were in the
past, likely due to the increase of evidence-based treatment approaches. That is both because of
the passage of time and developmental change (for example, regarding impulsivity, which
developmentally declines with age) and the learning of new skills (Bateman & Krawitz, 2013).
One study found that 78% of their sample were in remission by an 8-year follow up and 99% by
a 2-year follow up (cited in Zanarini, Frankenburg, Reich, & Fitzmaurice, 2012). Also, the
relapse rate (33%) is lower than other psychiatric disorders, like mood disorders and
schizophrenia (Bateman & Krawitz, 2013). Still, clients with BPD enter remission at a
significantly slower pace those clients with other personality disorders (PD) and recurrences
happen more rapidly (Zanarini et al., 2012). Recovery is defined by having symptom remission
and good social and vocational functioning. Clients with BPD achieve recovery less than clients
with other PDs, and recovery occurs more slowly (Zanarini et al., 2012). Clinicians now have a
sense of hope when working with clients with BPD because clients can and do improve thanks to
empirically supported treatments. Still, caution and patience is necessary to address the special
needs of clients with BPD who will take longer to meet achievements such as remission and
recovery.

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Again, BPD is a serious personality disorder marked by impulsivity and instability in
interpersonal relationships, affect, and self-image. Clients with BPD make up a significant part
of the clinical population and have needs specific to their disorder. Researchers and practitioners
have spent many years studying and working with these clients. Today, we have a number of
effective therapeutic treatments and optimism for prognosis. Still, it is important that we continue
the conversation on BPD and clients with the disorder so that we can further improve our
understanding and treatment of this special population.

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