Borderline Personality Disorder

Raising questions, finding answers

Borderline personality disorder (BPD) idea who they are. Such symptoms are
is a serious mental illness character­ most acute when people with BPD feel
ized by pervasive instability in mood, isolated and lacking in social support,
inter-personal relationships, self- and may result in frantic efforts to
image, and behavior. This instability avoid being alone.
often disrupts family and work life,
long-term planning, and the individ­ People with BPD often have highly
ual’s sense of self-identity. Originally unstable patterns of social relation-
thought to be at the “border-line” of ships. While they can develop intense
psychosis, people with BPD suffer from but stormy attachments, their atti­
a disorder of emotion regulation. While tudes towards family, friends, and
less well known than schizophrenia or loved ones may suddenly shift from
bipolar disorder (manic-depressive ill­ idealization (great admiration and
ness), BPD is more common, affecting love) to devaluation (intense anger
2 percent of adults, mostly young and dislike). Thus, they may form an
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women. There is a high rate of self- immediate attachment and idealize the
injury without suicide intent, as well other person, but when a slight sepa­
as a significant rate of suicide ration or conflict occurs, they switch
attempts and completed suicide in unexpectedly to the other extreme and
2,3
severe cases. Patients often need angrily accuse the other person of not
extensive mental health services, and caring for them at all. Even with fami­
account for 20 percent of psychiatric ly members, individuals with BPD are
4
hospitalizations. Yet, with help, many highly sensitive to rejection, reacting
improve over time and are eventually with anger and distress to such mild
able to lead productive lives. separations as a vacation, a business
trip, or a sudden change in plans.
Symptoms These fears of abandonment seem to
and drug or alcohol abuse. Distortions
While a person with depression or be related to difficulties feeling emo­
in cognition and sense of self can lead
bipolar disorder typically endures the tionally connected to important per-
to frequent changes in long-term goals,
same mood for weeks, a person with sons when they are physically absent,
career plans, jobs, friendships, gender
BPD may experience intense bouts of leaving the individual with BPD feel­
identity, and values. Sometimes people
anger, depression and anxiety that ing lost and perhaps worthless.
with BPD view themselves as funda­
may last only hours, or at most a day.
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Suicide threats and attempts may
mentally bad, or unworthy. They may
These may be associated with episodes occur along with anger at perceived
feel unfairly misunderstood or mis­
of impulsive aggression, self-injury, abandonment and disappointments.
treated, bored, empty, and have little
People with BPD exhibit other impul­ order as young adults. Adults with ter, may help people who experience
sive behaviors, such as excessive BPD are also considerably more likely BPD-like mood swings. Such brain-
spending, binge eating, risky sex, and to be the victim of violence, including based vulnerabilities can be managed
other self-harming behavior. BPD often rape and other crimes. This may result with help from behavioral interven­
occurs with other psychiatric problems, from both harmful environments as tions and medications, much as people
particularly bipolar disorder, depres­ well as impulsivity and poor judgment manage susceptibility to diabetes or
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sion, anxiety disorders, substance in choosing partners and lifestyles. high blood pressure.
abuse, and other personality disorders.
NIMH-funded neuroscience research is Future Progress
Treatment revealing brain mechanisms underly­ Studies that translate basic findings
Treatments for BPD have improved in ing the impulsivity, mood instability, about the neural basis of tempera­
recent years. Group and individual aggression, anger, and negative emo­ ment, mood regulation and cognition
psychotherapy are at least partially tion seen in BPD. Studies suggest that into clinically relevant insights—which
effective for many patients. Within the people predisposed to impulsive bear directly on BPD—represent a
past 15 years, a new psychosocial aggression have impaired regulation of growing area of NIMH-supported
treatment termed dialectical behavior the neural circuits that modulate emo- research. Research is also underway to
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therapy (DBT) was developed specifi­ tion. The amygdala, a small almond- test the efficacy of combining medica­
cally to treat BPD, and this technique shaped structure deep inside the brain, tions with behavioral treatments like
has looked promising in treatment is an important component of the cir­ DBT, and gauging the effect of child-
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studies. Pharmacological treatments cuit that regulates negative emotion. hood abuse and other stress in BPD on
are often prescribed based on specific In response to signals from other brain brain hormones. Data from the first
target symptoms shown by the individ­ centers indicating a perceived threat, it prospective, longitudinal study of BPD,
ual patient. Antidepressant drugs and marshals fear and arousal. This might which began in the early l990s, is
mood stabilizers may be helpful for be more pronounced under the influ­ expected to reveal how treatment
depressed and/or labile mood. ence of drugs like alcohol, or stress. affects the course of the illness. It will
Antipsychotic drugs may also be used Areas in the front of the brain (pre- also pinpoint specific environmental
when there are distortions in frontal area) act to dampen the activity factors and personality traits that pre­
thinking.
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of this circuit. Recent brain imaging dict a more favorable outcome. The
studies show that individual differ­ Institute is also collaborating with a
ences in the ability to activate regions
Recent Research Findings private foundation to help attract new
of the prefrontal cerebral cortex researchers to develop a better under-
Although the cause of BPD is thought to be involved in inhibitory standing and better treatment for BPD.
unknown, both environmental and activity predict the ability to suppress
genetic factors are thought to play a negative emotion.
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role in predisposing patients to BPD For More Information

symptoms and traits. Studies show National Institute of Mental Health
Serotonin, norepinephrine, and acetyl­
that many, but not all individuals with (NIMH)
choline are among the chemical mes­ Office of Communications and Public
BPD report a history of abuse, neglect,
8 sengers in these circuits that play a Liaison
or separation as young children. Forty
role in the regulation of emotions, Public Inquiries: (301) 443-4513
to 71 percent of BPD patients report
including sadness, anger, anxiety and Media Inquiries: (301) 443-4536
having been sexually abused, usually
9 irritability. Drugs that enhance brain E-mail: [email protected]
by a non-caregiver. Researchers
serotonin function may improve emo­ Web site: http://www.nimh.nih.gov
believe that BPD results from a combi­
tional symptoms in BPD. Likewise,
nation of individual vulnerability to
mood-stabilizing drugs that are known
environmental stress, neglect or abuse
to enhance the activity of GABA, the
as young children, and a series of
brain’s major inhibitory neurotransmit­
events that trigger the onset of the dis­
All material in this fact sheet is in the 8
Zanarini MC, Frankenburg FR.
public domain and may be copied or Pathways to the development of border-
reproduced without permission from line personality disorder. Journal of
the Institute. Citation of the source is Personality Disorders, 1997; 11(1):
appreciated. 93-104.

9
Zanarini MC. Childhood experiences
References associated with the development of
1
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Dysfunction in the neural circuitry of
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4
Zanarini MC, Frankenburg FR.
Treatment histories of borderline inpa­
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press.

5
Zanarini MC, Frankenburg FR, DeLuca
CJ, Hennen J, Khera GS, Gunderson JG.
The pain of being borderline: dysphoric
states specific to borderline personality
disorder. Harvard Review of Psychiatry,
1998; 6(4): 201-7.

6
Koerner K, Linehan MM. Research on
dialectical behavior therapy for
patients with borderline personality
disorder. Psychiatric Clinics of North
America, 2000; 23(1): 151-67.

7
Siever LJ, Koenigsberg HW. The frus­
trating no-mans-land of borderline per­
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NIH Publication No. 01-4928 January 2001

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