Which personality disorder is characterized by an unstable or disorganized identity?

Nonpharmacologic Therapy

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Psychotherapy is the recommended primary treatment for BPD.

All psychotherapy modalities target the four psychopathological domains of BPD (emotional regulation, impulse control, behavioral and interpersonal skills).

Dialectical behavior therapy (DBT), mentalization-based therapy, variations of cognitive behavior therapy (CBT), and psychodynamic therapies (including transference-focused therapy) have the most empirical evidence.

The goal of DBT and most CBT variations is to help patients improve mindful awareness of emotions, control impulsive behaviors and angry outbursts, and develop social skills. In mindfulness treatment, the emphasis is on teaching patients to stand outside of their feelings and observe emotions in themselves and others. The focus of transference-focused psychotherapy is on examining the affect-laden themes that emerge in the relationship between patient and therapist. Preliminary evidence exists for effectiveness of more integrative treatment models, such as the unified protocol and mindfulness-based therapies generally.

The field is moving toward a “common factors” approach, with frameworks such as general (“good”) psychiatric management and structured clinical management. These combine principles from various therapies, emphasize psychoeducation and goal-setting, and focus on social adaptation.

Treatment may also include inpatient and partial hospitalization in more severe cases.

Introduction

Borderline personality disorder (BPD) is one of a set of ten discrete personality disorders – disorders affecting the characteristic and habitual ways the individual reacts to emotional stimuli, interpersonal situations, and impulses. At one time, the personality disorders were conceptualized as arising primarily from early life experience, whereas the acute, recurring, or chronic psychiatric syndromes, such as schizophrenia, depression, or bipolar disorder, were seen as having strong biological determinants. A body of work examining personality development and temperament, inheritance of personality traits, and the neurochemistry and regional brain activity in personality disorder patients has led to recognition of the role of neurobiological factors in the personality disorders.

BPD is a prevalent disorder, estimated to occur in 1% or 2% of the population. Patients with BPD are characterized by great emotional reactivity, high degrees of impulsivity, recurring self-destructive behaviors, inappropriate levels of anger, intense and unstable relationships with others, and a sense of emptiness and confusion about their own identities. As a result, their moods shift unpredictably, their relationships are stormy and tumultuous, they often alienate others, and they hurt themselves. They repeatedly threaten or attempt suicide. In the diagnostic classification system of the American Psychiatric Association, the diagnosis is made when five of nine observable features are present (Table 1).

Table 1. DSM-IV criteria for borderline personality disorder

From the American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Washington, DC: American Psychiatric Association.

The patterns of feeling and behaving which characterize BPD are likely to arise from the interaction between biological tendencies and developmental life experiences. Understanding the neurobiology of BPD provides a window onto one important determinant of the disorder. It may help in identifying factors that predispose to BPD, in clarifying the relationship between BPD and so-called near-neighbor disorders such as bipolar disorder, and in guiding the development of pharmacologic treatments. This article focuses on the neurobiological aspects of BPD.

Two distinct personality traits, impulsive aggression and affective instability, which appear to have strong biological correlates, co-occur in patients with BPD. Each of these traits has been shown to run separately in families of patients with BPD, and when they coincide in a relative, that individual is likely to meet criteria for a diagnosis of BPD. During the past decade, researchers have begun to tease out some key biological correlates of these personality traits.

BPD and BPD-DS

BPD and BPD-DS are only undertaken after extremely careful patient selection because they are associated with the highest rates of nutritional deficiencies.25 The most common nutrient deficiency in BPD and BPD-DS is protein malnutrition, represented by hypoalbuminemia, with an incidence that ranges from 3% to 11%.25 Iron deficiency anemia is also common, with an incidence of approximately 5% of cases, although the incidence could be as high as 12% to 47%.25 In long-term follow-up of these patients, deficiencies of other vitamins and minerals have been identified, particularly calcium and zinc.25 Moreover, this procedure reduces absorption of fat by 70% and is associated with high rates of fat-soluble vitamin deficiencies.25

3 A Psychostructural Nosology

Borderline personality organization is characterized by lack of integration of the concept of self and significant others, that is, identity diffusion, a predominance of primitive defensive operations centering around splitting, and maintenance of reality testing. The defensive operations of splitting and its derivatives (projective identification, denial, primitive idealization, omnipotence, omnipotent control, devaluation) have as a basic function to maintain separately the idealized and persecutory internalized object relations derived from the early developmental phases predating object constancy: that is, when aggressively determined internalizations strongly dominate the internal world of object relations, in order to prevent the overwhelming control or destruction of ideal object relations by aggressively infiltrated ones. This primitive constellation of defensive operations centering around splitting thus attempts to protect the capacity to depend on good objects and escape from terrifying aggression.

Reality testing, as mentioned before, is present in borderline personality organization. It refers to the capacity to differentiate self from nonself, intrapsychic from external stimuli and to maintain empathy with ordinary social criteria of reality, all of which are typically lost in the psychoses, and manifested particularly in hallucinations and delusions (Kernberg 1984). All patients with psychotic personality organization really represent atypical forms of psychosis. Therefore, strictly speaking, psychotic personality organization represents an exclusion criterion for the personality disorders in a clinical sense.

Borderline personality organization includes all the severe personality disorders in clinical practice. Typical personality disorders included here are the borderline personality disorder in the DSM IV sense, the schizoid and schizotypal personality disorders, the paranoid personality disorder, the hypomanic personality disorder, hypochondriasis (a syndrome which has many characteristics of a personality disorder proper), the narcissistic personality disorder (including the syndrome of malignant narcissism), and the antisocial personality disorder.

All these patients present identity diffusion, the manifestations of primitive defensive operations, and many evince varying degrees of superego deterioration (antisocial behavior). A particular group of patients typically suffer from significant disorganization of the superego, namely, the narcissistic personality disorder, the syndrome of malignant narcissism, and the antisocial personality disorder.

All the personality disorders within the borderline spectrum present, because of the identity diffusion, severe distortions in their interpersonal relations—particularly problems in intimate relations with others, lack of consistent goals in terms of commitment to work or profession, uncertainty and lack of direction in their lives in many areas, and varying degrees of pathology in their sexual life. They often present an incapacity to integrate tenderness and sexual feelings, and they may show a chaotic sexual life with multiple polymorphous perverse infantile tendencies. The most severe cases, however, may present with a generalized inhibition of all sexual responses. All these patients also evince nonspecific manifestations of ego weakness, that is, lack of anxiety tolerance, of impulse control, and of sublimatory functioning in terms of an incapacity for consistency, persistence, and creativity in work.

An additional group of personality disorders also presents the characteristics of borderline personality organization, but these patients are able to maintain more satisfactory social adaptation, and are usually more effective in obtaining some degree of intimacy in object relations and in integrating sexual and tender impulses. Thus, in spite of presenting identity diffusion, they also evince sufficient nonconflictual development of some ego functions, superego integration, and a benign cycle of intimate involvements, capacity for dependency gratification, and a better adaptation to work that make for significant quantitative significant differences. They constitute what might be called a ‘higher level’ of borderline personality organization or an intermediate level of personality disorder. This group includes the cyclothymic personality, the sadomasochistic personality, the infantile or histrionic personality, and the dependent personalities, as well as some better functioning narcissistic personality disorders.

The next level of personality disorder, namely, neurotic personality organization, is characterized by normal ego identity and the related capacity for object relations in depth, ego strength reflected in anxiety tolerance, impulse control, sublimatory functioning, effectiveness and creativity in work, and a capacity for sexual love and emotional intimacy disrupted only by unconscious guilt feelings reflected in specific pathological patterns of interaction in relation to sexual intimacy. This group includes the hysterical personality, the depressive-masochistic personality, the obsessive personality, and many so-called ‘avoidant personality disorders,’ in other words, the ‘phobic character’ of psychoanalytic literature (which remains a problematic entity).

Figure 1 summarizes the relationship among all the personality disorders mentioned, and represents their overall classification into neurotic and borderline personality organization.

What follows is a summary of the psychoanalytically based psychotherapy for borderline personality organization as developed and manualized by a team of psychoanalysts, psychoanalytic psychotherapists, and researchers at the Department of Psychiatry of the Cornell University Medical College (Clarkin et al. 1999).

Borderline personality

In 52 patients (43 women and 9 men) meeting the criteria for personality disorders who were randomly assigned to aripiprazole 15 mg/day (mean age 22 years; n = 26) or placebo (mean age 21 years; n = 26) for 8 weeks, there were significant changes in scores on currently used scales with the exception of somatization [37]. Detailed data on adverse effects were not given; it was merely stated that neither serious adverse effects, including weight gain, nor suicidal acts were observed during the study.

Clinical Description

The clinical description of borderline personality disorder (BPD) has remained stable since its original inclusion into the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders in 1980 (DSM-III; APA, 1980). Despite passionate debate and expectations for significant change in the conceptualization of the diagnosis, the current DSM-5 criteria (APA, 2013) for BPD remain unchanged from the DSM-IV-TR criteria (APA, 2000). They include frantic efforts to avoid abandonment, unstable interpersonal relationships alternating between idealization and devaluation, identity disturbance (including unstable self-image or sense of self), impulsivity, recurrent suicidal behavior or self-harm, affective instability, chronic feelings of emptiness, inappropriate anger, and transient paranoid ideation or dissociation related to stress.

No single symptom of BPD is required for diagnosis. Instead, an individual must exhibit at least five of these nine symptoms. One result of this is that there are as many as 126 possible ways that an individual can meet the five out of nine symptom requirement for the disorder. Although diagnostic labels are in part used to convey information about how individuals with that label are similar, the BPD diagnosis is inherently heterogeneous.

Despite this heterogeneity, BPD is well-characterized by ‘stable instability.’ What this means is that those with the disorder often show instability across domains of affect, interpersonal relationships, self-image, and behavior. DSM-5 describes the symptom profile of BPD as indicating “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity” (American Psychiatric Association, 2013, p. 663). Indeed, when BPD first appeared in the DSM-III, some suggested that it be named ‘unstable personality disorder’ to emphasize how integral instability is to this clinical condition (Spitzer et al., 1979).

People with BPD often show rapid changes in their emotions that are intense and unpredictable, leaving family members, friends or coworkers, feeling as though they have to ‘walk on eggshells’ to avoid triggering an emotional outburst. The affective instability that characterizes BPD can include intense episodic dysphoria (sad or negative mood), irritability, or anxiety that lasts for a relatively short period of time and rarely lasts more than a few days. Within a single day, an individual can fluctuate between a number of intense and difficult-to-control mood states including sadness, anger, happiness, and despair. Angry outbursts also represent affective instability and people with BPD may show frequent displays of anger.

Intense anger may also create some of the behavioral instability that characterizes BPD, as angry outbursts may be accompanied by recurrent physical fights or other displays of behavioral dyscontrol. Behavioral instability is also apparent in impulsive and self-damaging behavior including risky sexual behavior, eating binges, alcohol or drug abuse, and reckless driving. Perhaps the most concerning manifestation of behavioral instability, however, is suicidal behavior or recurrent non-suicidal self-injury, including skin cutting or burning.

The affective and behavioral dysfunction associated with BPD may be best conceptualized as the end product of interpersonal dysfunction. Psychological distress and negative affect in BPD are most commonly triggered by interpersonal stressors, especially those that induce feelings of abandonment or rejection (Stiglmayr et al., 2005). Stimuli evoking themes of interpersonal rejection and abandonment are highly arousing (emotionally and physiologically) to people who have BPD (Limberg et al., 2011; Schmahl et al., 2004). Moreover, real or imagined interpersonal conflict (Levy, 2005) or interpersonally difficult events (Brodsky et al., 2006) often trigger self-destructive behavior, including self-harm and suicidality. For these reasons, some have argued that interpersonal instability is the core feature of BPD (see Gunderson, 2010).

Interpersonal instability appears in how individuals with BPD view others: they often rapidly switch between idealizing others and devaluing them in a sharply contrasting, black-and-white manner. Individuals with BPD are also highly sensitive to rejection (Staebler et al., 2011) and are quick to perceive signs of rejection in the behaviors of others. Perhaps because of their fear of rejection from close others, individuals with BPD often ‘test’ relationships by making statements such as ‘If you really loved me, you would do this for me.’ Failure to follow through on the part of close others becomes evidence of rejection or abandonment, which may then trigger emotional instability, including rage, and behavioral instability, including suicidal behavior or self-harm.

Instability manifests in one final area: self-concept. Much like the alternating (idealizing and devaluing) appraisals of others that are indicative of interpersonal instability, people with BPD also have fluctuating feelings about the self. They struggle with a highly negative self-concept and have difficulty forming a sense of who they really are. They also often have chronic feelings of emptiness, which is sometimes described as a ‘sense that there is nothing inside of me’ and they have difficulty tolerating being alone. Again, instability in self-concept is intimately connected to instability in interpersonal relationships. Because they find it so hard to be alone, people with BPD place great importance on interpersonal relationships. Anything that might threaten these relationships also presents a serious threat to their sense of emotional safety and well-being.

A final characteristic of BPD is transient, stress-related paranoia or dissociation. What this means is that, when they are under stress, people with BPD sometimes have difficulties thinking rationally or perceiving the world accurately. One study showed that patients with BPD were more stress reactive than people with other kinds of personality disorders (such as dependent personality disorder) and that their psychotic reactions to stress were even stronger than those of patients who were actively psychotic (Glaser et al., 2010). It is also worth noting that psychotic reactions in people with BPD go beyond simple paranoia, suggesting that the description of this symptom in DSM-5 may be too limited. Seventy-five percent of people with BPD experience paranoid ideas and/or dissociation (Lieb et al., 2004; Skodol et al., 2002).

BPD is currently conceptualized as a discrete diagnostic category in the DSM-5. However, not everyone supports this view. Although BPD remains a distinct clinical entity in DSM-5, evidence suggests that it would be better to conceptualize BPD as a dimensional concept (Rothschild et al., 2003). This idea was expected to be reflected in the DSM-5 criteria. However, the proposals made by the Personality Disorders Workgroup were not accepted. Instead, they now appear in a section of the DSM reserved for conditions in need of further study. Moreover, whereas some have argued for a dimensional (as opposed to a categorical) BPD diagnosis, others have argued that BPD is better conceptualized as a variant of mood disorder (Akiskal, 2002). However, this view is neither widely endorsed nor reflected in DSM-5.

Abstract

Borderline personality disorder (BPD) is comprised of a heterogeneous range of symptoms, including impairment in affect regulation and interpersonal relationships. Dimensional, as well as categorical, diagnostic approaches have been suggested to assess BPD. Twin and family studies indicate that genetic factors contribute to BPD and borderline personality features, and that these are partially shared with the factors influencing personality traits and other psychiatric disorders. The genome-wide association studies that have investigated borderline personality are in line with these observations. However, substantially larger studies are needed to identify the underlying molecular genetic mechanisms of borderline personality. Future genetic research integrating different levels of biological and clinical data has the potential to help guide and monitor personalized diagnosis and treatment. This chapter presents the current state of genetic research into BPD and explores the future contribution of genetic research to a personalized diagnosis and treatment process.

Borderline Personality Disorder

Borderline personality disorder as defined by the DSM-IV encompasses a number of symptoms of other psychiatric disorders, including major depression. In numerous studies of borderline personality disorder, it has been shown repeatedly that the sleep architecture changes are very similar to those observed in patients with major depression.175–178 Borderline personality disorder patients have less total sleep time, less sleep efficiency, reduced SWS, increased stage 2 sleep, reduced REM sleep latency, and increased REM density. Subjects with borderline personality disorder frequently have symptoms of depression and have been shown to have abnormalities of other biological markers associated with depression.179

Borderline Personality Disorder

Borderline personality disorder (BPD) probably affects between 1 in 50 and as many as 1 in 25 people, although it frequently co-occurs with other disorders. Similarly to ASPD, with which it can co-occur, BPD also is marked by powerful, poorly regulated emotionality, in addition to impulsive behavior. BPD patients are often in severe emotional distress. They form strong, but shifting and unstable emotional bonds. Often the emotional attachment is unreasonable and unreciprocated, leading to tragic disappointments. Our understanding of BPD and the advances in its treatment, limited though they may be, is due to the work of dedicated and brilliant psychiatrists. Don Klein, at Columbia University, was a pioneer in showing that pharmacotherapy was one way of helping the BPD patient gain at least some measure and sense of control. Larry Siever, working with Antonia New at Mt. Sinai Hospital, has used brain imaging to measure the differences in the brains of BPD patients. There are extraordinary obstacles in the way of such studies. BPD patients are not convenient to study and in the end, and despite the moderate heritability of BPD, it will probably be discovered that many of these patients suffer from emotional dysregulation because of early-life trauma, and not because of some innate difference or readily reversible neurochemistry. Here, I am reminded of multiple personality disorder, for which we really have no understanding of mechanism, are sympathetic to the suffering of people who have it and are thoughtful of the likelihood that many people who have it probably had some terrible early-life trauma. Yet, and perhaps unlike multiple personality disorder, BPD is amenable to systematic study. Larry and Antonia indeed appear to be making headway, finding that BPD patients have differences in regional brain metabolic activity correlating with their deficits in cognitive and emotional control. Again, the frontal lobe is implicated, but with BPD the ability of the frontal lobe to modulate emotion may also be coming into play.

Borderline Personality Disorder

Borderline personality disorder (BPD) was a new addition to DSM-III (APA, 1980) and has since become the single most frequently diagnosed and studied PD. BPD is a pervasive pattern of impulsivity and instability in interpersonal relationships, affect, and self-image (APA, 2013). Its primary diagnostic criteria include frantic efforts to avoid abandonment, unstable and intense relationships, impulsivity (e.g., substance abuse, binge eating, or sexual promiscuity), recurrent suicidal thoughts and gestures, self-mutilation, and episodes of rage and anger. It is a disorder of extreme emotional instability, coupled with some secondary features of antagonism and disinhibition.

BPD is the most prevalent PD within clinical settings. Approximately 75% of persons with BPD are female (APA, 2013), consistent with the substantially higher levels of negative affectivity in women compared to men. Individuals with BPD are likely to have been emotionally unstable, impulsive, and perhaps oppositional as children but there is in fact little longitudinal research on the childhood antecedents of BPD (De Fruyt and De Clercq, 2012). As adolescents, their intense affectivity and impulsivity may contribute to involvement with rebellious groups, along with a variety of forms of psychopathology including eating, substance, and mood disorders. BPD is at times diagnosed in children and adolescents but considerable caution should be used when doing so, as some of the symptoms of BPD (e.g., identity disturbance, hostility, and unstable relationships) could be confused with normal adolescent turmoil. It is also true that, at times, the criteria may not be developmentally appropriate for children and adolescents (e.g., it may be difficult to demonstrate identity disturbance in a young person).

As adults, persons with BPD may be repeatedly hospitalized, due to their affective instability, impulse dyscontrol, psychotic-like and dissociative symptomatology, and suicidal gestures and attempts (Hooley et al., 2012). Intimate relationships tend to be very unstable, even explosive, and employment history can be quite poor. Persons with BPD are said to be manipulative with respect to their suicidal gestures, threats, and attempts, but the risk of death from suicide in people who suffer from BPD is quite high. Further, Linehan (1993) has cautioned against the use of the word ‘manipulative’ when referring to individuals suffering from BPD, arguing that individuals with BPD resort to these gestures when in extreme pain and do not do so with the intent to manipulate others. Managing severe suicidal ideation and suicidal behavior presents many challenges for mental health professionals who work with BPD patients. As the person reaches middle age, the most severe expressions of affective lability and impulsivity may begin to diminish.

There are studies supportive of BPD as a disorder with a distinct genetic disposition but many studies have also suggested a shared genetic association with mood and impulse control disorders as well as the general personality temperament of negative affectivity (Hooley et al., 2012). There is also a childhood history of physical and/or sexual abuse, parental conflict, loss, emotional abuse, and/or neglect (Silk et al., 2005). BPD is perhaps best understood as an interaction of an emotionally unstable temperament with a cumulative and evolving series of intensely stressful relationships.

The pathological mechanisms of BPD are addressed in numerous theories. Most concern issues of abandonment, separation, and/or exploitative abuse. Persons with BPD will often describe quite intense, disturbed, and/or abusive relationships with the significant persons in their life. A growing literature also suggests that BPD patients show differences relative to healthy controls in cortical structure and functioning (Hooley et al., 2012). A primary area of interest has been the limbic system. This includes reduction in the size of the hippocampus and amygdala. These brain areas are involved in the regulation of emotion and aggressive behavior.

Patients with BPD may form relationships with therapists that are similar to their other significant relationships; that is, the therapeutic relationship can often be tremendously unstable, intense, and volatile (APA, 2001). Ongoing consultation with colleagues is recommended. Treatment programs have been developed for BPD, along with empirical support for their effectiveness. The two most well validated are dialectical behavior therapy (Chapman and Linehan, 2005) and mentalization-based therapy (Bateman and Fonagy, 2012).