Description

Beginning no later than adolescence or early adulthood, borderline personality disorder (BPD) is a consistent and pervasive pattern of labile affect and sense of self, impulsivity, and volatile interpersonal relationships (1):

• Common behaviors and variations:
  • Self-mutilation: Pinching, scratching, cutting
  • Suicide: Ideation, history of attempts, plans
  • Splitting: Idealizing then devaluing others
  • Presentation of helplessness or victimization
  • High utilization of emergency department and resultant inpatient hospitalizations for psychiatric treatment (2)
  • BPD patients are frequent users of primary care (3).
• High rate of associated mental disorders
• Typically display little insight into behavior

Geriatric Considerations
Illness (both acute and chronic) may exacerbate BPD and may lead to intense feelings of fear and helplessness.

Pediatric Considerations
Diagnosis is rarely made in children. Axis I disorders and general medical conditions are more probable.

Pregnancy Considerations
Physical, emotional, and social concerns may transiently mimic symptoms of BPD: Consider delay in diagnosis until pregnancy completed. Pregnancy may also induce stress or increased fears, resulting in escalation of borderline behaviors.

Epidemiology

Predominant age: Onset no later than adolescence or early adulthood (may go undiagnosed for years)

• General population: 0.5–5.9% of US population (3)
• Estimated lifetime prevalence: 10–13%
• 10% of all psychiatric outpatients and between 15% and 25% of patients in psychiatry inpatient settings have BPD (3).
• 20–30% of patients in primary care outpatient settings have a personality disorder.

Risk Factors

• Genetic factors contribute; however, no specific genes have yet been identified as causative (3).
• Childhood sexual and/or physical abuse and neglect
• Disrupted family life
• Physical illness and external social factors may exacerbate borderline personality behaviors.

Genetics
1st-degree relatives are at greater risk for this disorder (undetermined if due to genetic or psychosocial factors).

General Prevention

• Tends to be a multigenerational problem
• Children, caregivers, and significant others should have some time and activities away from the borderline individual, which may protect them.

Etiology

Undetermined, but generally accepted that psychiatric disorders are due to a combination of the following:

• Hereditary temperamental traits
• Environment (i.e., history of childhood sexual and/or physical abuse, history of childhood neglect, ongoing conflict in home)
• Stress is theorized to exert damaging effects on the brain, specifically the hippocampus (3,4).
• Neurobiological research of BPD continues to increase the understanding of the etiology:
  • Abnormalities of the frontolimbic circuitry in relation to poor emotional stability (3)
  • Potential alterations in the sensitivity of opioid receptors and/or deficiencies with endogenous opioids (5)
  • Deficient serotonergic functioning underlying mood dysregulation (6)

Commonly Associated Conditions

Other psychiatric disorders, including:

• Co-occurring personality disorders, frequent
• Mood disorders, common
• Anxiety disorders, common
• Substance-related disorders, common
• Eating disorders, common
• Posttraumatic stress disorder, common
• BPD does not appear to be independently associated with increased risk of violence.