What is Borderline Personality Disorder (BPD)?

What is Borderline Personality Disorder?

Borderline personality disorder (BPD) is a serious mental illness marked by unstable moods, behavior, and relationships. In 1980, the Diagnostic and Statistical Manual for Mental Disorders, Third Edition (DSM-III) listed BPD as a diagnosable illness for the first time. Most psychiatrists and other mental health professionals use the DSM to diagnose mental illnesses.
Because some people with severe BPD have brief psychotic episodes, experts originally thought of this illness as atypical, or borderline, versions of other mental disorders. While mental health experts now generally agree that the name "borderline personality disorder" is misleading, a more accurate term does not exist yet.
Most people who have BPD suffer from:

• Problems with regulating emotions and thoughts
• Impulsive and reckless behavior
• Unstable relationships with other people.

People with this disorder also have high rates of co-occurring disorders, such as depression, anxiety disorders, substance abuse, and eating disorders, along with self-harm, suicidal behaviors, and completed suicides.

Causes

Research on the possible causes and risk factors for BPD is still at a very early stage. However, scientists generally agree that genetic and environmental factors are likely to be involved.
Studies on twins with BPD suggest that the illness is strongly inherited. Another study shows that a person can inherit his or her temperament and specific personality traits, particularly impulsiveness and aggression. Scientists are studying genes that help regulate emotions and impulse control for possible links to the disorder.
Social or cultural factors may increase the risk for BPD. For example, being part of a community or culture in which unstable family relationships are common may increase a person's risk for the disorder. Impulsiveness, poor judgment in lifestyle choices, and other consequences of BPD may lead individuals to risky situations. Adults with borderline personality disorder are considerably more likely to be the victim of violence, including rape and other crimes.

Signs & Symptoms

According to the DSM, Fourth Edition, Text Revision (DSM-IV-TR), to be diagnosed with borderline personality disorder, a person must show an enduring pattern of behavior that includes at least five of the following symptoms:

• Extreme reactions—including panic, depression, rage, or frantic actions—to abandonment, whether real or perceived
• A pattern of intense and stormy relationships with family, friends, and loved ones, often veering from extreme closeness and love (idealization) to extreme dislike or anger (devaluation)
• Distorted and unstable self-image or sense of self, which can result in sudden changes in feelings, opinions, values, or plans and goals for the future (such as school or career choices)
• Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating
• Recurring suicidal behaviors or threats or self-harming behavior, such as cutting
• Intense and highly changeable moods, with each episode lasting from a few hours to a few days
• Chronic feelings of emptiness and/or boredom
• Inappropriate, intense anger or problems controlling anger
• Having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body, or losing touch with reality.

Seemingly mundane events may trigger symptoms. For example, people with BPD may feel angry and distressed over minor separations—such as vacations, business trips, or sudden changes of plans—from people to whom they feel close. Studies show that people with this disorder may see anger in an emotionally neutral face and have a stronger reaction to words with negative meanings than people who do not have the disorder.
Suicide and Self-harm
Self-injurious behavior includes suicide and suicide attempts, as well as self-harming behaviors, described below. As many as 80 percent of people with BPD have suicidal behaviors, and about 4 to 9 percent commit suicide.
Suicide is one of the most tragic outcomes of any mental illness. Some treatments can help reduce suicidal behaviors in people with BPD. For example, one study showed that dialectical behavior therapy (DBT) reduced suicide attempts in women by half compared with other types of psychotherapy, or talk therapy. DBT also reduced use of emergency room and inpatient services and retained more participants in therapy, compared to other approaches to treatment.
Unlike suicide attempts, self-harming behaviors do not stem from a desire to die. However, some self-harming behaviors may be life threatening. Self-harming behaviors linked with BPD include cutting, burning, hitting, head banging, hair pulling, and other harmful acts. People with BPD may self-harm to help regulate their emotions, to punish themselves, or to express their pain. They do not always see these behaviors as harmful.

Who Is At Risk?

According to data from a subsample of participants in a national survey on mental disorders, about 1.6 percent of adults in the United States have BPD in a given year.  BPD usually begins during adolescence or early adulthood. Some studies suggest that early symptoms of the illness may occur during childhood.

Diagnosis

Unfortunately, BPD is often underdiagnosed or misdiagnosed.
A mental health professional experienced in diagnosing and treating mental disorders—such as a psychiatrist, psychologist, clinical social worker, or psychiatric nurse—can detect BPD based on a thorough interview and a discussion about symptoms. A careful and thorough medical exam can help rule out other possible causes of symptoms.
The mental health professional may ask about symptoms and personal and family medical histories, including any history of mental illnesses. This information can help the mental health professional decide on the best treatment. In some cases, co-occurring mental illnesses may have symptoms that overlap with BPD, making it difficult to distinguish borderline personality disorder from other mental illnesses. For example, a person may describe feelings of depression but may not bring other symptoms to the mental health professional's attention.
Women with BPD are more likely to have co-occurring disorders such as major depression, anxiety disorders, or eating disorders. In men, BPD is more likely to co-occur with disorders such as substance abuse or antisocial personality disorder. According to the NIMH-funded National Comorbidity Survey Replication—the largest national study to date of mental disorders in U.S. adults—about 85 percent of people with BPD also meet the diagnostic criteria for another mental illness. Other illnesses that often occur with BPD include diabetes, high blood pressure, chronic back pain, arthritis, and fibromyalgia. These conditions are associated with obesity, which is a common side effect of the medications prescribed to treat BPD and other mental disorders.
No single test can diagnose BPD. Scientists funded by NIMH are looking for ways to improve diagnosis of this disorder. One study found that adults with BPD showed excessive emotional reactions when looking at words with unpleasant meanings, compared with healthy people. People with more severe BPD showed a more intense emotional response than people who had less severe BPD.

Treatments

BPD is often viewed as difficult to treat. However, recent research shows that BPD can be treated effectively, and that many people with this illness improve over time.
BPD can be treated with psychotherapy, or "talk" therapy. In some cases, a mental health professional may also recommend medications to treat specific symptoms. When a person is under more than one professional's care, it is essential for the professionals to coordinate with one another on the treatment plan.
The treatments described below are just some of the options that may be available to a person with BPD. However, the research on treatments is still in very early stages. More studies are needed to determine the effectiveness of these treatments, who may benefit the most, and how best to deliver treatments.
Psychotherapy
Psychotherapy is usually the first treatment for people with BPD. Current research suggests psychotherapy can relieve some symptoms, but further studies are needed to better understand how well psychotherapy works.
It is important that people in therapy get along with and trust their therapist. The very nature of BPD can make it difficult for people with this disorder to maintain this type of bond with their therapist.
Types of psychotherapy used to treat BPD include the following: Cognitive behavioral therapy (CBT). CBT can help people with BPD identify and change core beliefs and/or behaviors that underlie inaccurate perceptions of themselves and others and problems interacting with others. CBT may help reduce a range of mood and anxiety symptoms and reduce the number of suicidal or self-harming behaviors.

1. Dialectical behavior therapy (DBT). This type of therapy focuses on the concept of mindfulness, or being aware of and attentive to the current situation. DBT teaches skills to control intense emotions, reduces self-destructive behaviors, and improves relationships. This therapy differs from CBT in that it seeks a balance between changing and accepting beliefs and behaviors.
2. Schema-focused therapy. This type of therapy combines elements of CBT with other forms of psychotherapy that focus on reframing schemas, or the ways people view themselves. This approach is based on the idea that BPD stems from a dysfunctional self-image—possibly brought on by negative childhood experiences—that affects how people react to their environment, interact with others, and cope with problems or stress.

Therapy can be provided one-on-one between the therapist and the patient or in a group setting. Therapist-led group sessions may help teach people with BPD how to interact with others and how to express themselves effectively.
One type of group therapy, Systems Training for Emotional Predictability and Problem Solving (STEPPS), is designed as a relatively brief treatment consisting of 20 two-hour sessions led by an experienced social worker. Scientists funded by NIMH reported that STEPPS, when used with other types of treatment (medications or individual psychotherapy), can help reduce symptoms and problem behaviors of BPD, relieve symptoms of depression, and improve quality of life. The effectiveness of this type of therapy has not been extensively studied.
Families of people with BPD may also benefit from therapy. The challenges of dealing with an ill relative on a daily basis can be very stressful, and family members may unknowingly act in ways that worsen their relative's symptoms.
Some therapies, such as DBT-family skills training (DBT-FST), include family members in treatment sessions. These types of programs help families develop skills to better understand and support a relative with BPD. Other therapies, such as Family Connections, focus on the needs of family members. More research is needed to determine the effectiveness of family therapy in BPD. Studies with other mental disorders suggest that including family members can help in a person's treatment.
Other types of therapy not listed in this booklet may be helpful for some people with BPD. Therapists often adapt psychotherapy to better meet a person's needs. Therapists may switch from one type of therapy to another, mix techniques from different therapies, or use a combination therapy.
Some symptoms of BPD may come and go, but the core symptoms of highly changeable moods, intense anger, and impulsiveness tend to be more persistent. People whose symptoms improve may continue to face issues related to co-occurring disorders, such as depression or post-traumatic stress disorder. However, encouraging research suggests that relapse, or the recurrence of full-blown symptoms after remission, is rare. In one study, 6 percent of people with BPD had a relapse after remission.
Medications
No medications have been approved by the U.S. Food and Drug Administration to treat BPD. Only a few studies show that medications are necessary or effective for people with this illness. However, many people with BPD are treated with medications in addition to psychotherapy. While medications do not cure BPD, some medications may be helpful in managing specific symptoms. For some people, medications can help reduce symptoms such as anxiety, depression, or aggression. Often, people are treated with several medications at the same time, but there is little evidence that this practice is necessary or effective.
Medications can cause different side effects in different people. People who have BPD should talk with their prescribing doctor about what to expect from a particular medication.
Other Treatments
Omega-3 fatty acids. One study done on 30 women with BPD showed that omega-3 fatty acids may help reduce symptoms of aggression and depression. The treatment seemed to be as well tolerated as commonly prescribed mood stabilizers and had few side effects. Fewer women who took omega-3 fatty acids dropped out of the study, compared to women who took a placebo (sugar pill).
With proper treatment, many people experience fewer or less severe symptoms. However, many factors affect the amount of time it takes for symptoms to improve, so it is important for people with BPD to be patient and to receive appropriate support during treatment.

Living With

Some people with BPD experience severe symptoms and require intensive, often inpatient, care. Others may use some outpatient treatments but never need hospitalization or emergency care. Some people who develop this disorder may improve without any treatment.
How can I help a friend or relative who has BPD?
If you know someone who has BPD, it affects you too. The first and most important thing you can do is help your friend or relative get the right diagnosis and treatment. You may need to make an appointment and go with your friend or relative to see the doctor. Encourage him or her to stay in treatment or to seek different treatment if symptoms do not appear to improve with the current treatment.
To help a friend or relative you can:
Offer emotional support, understanding, patience, and encouragement—change can be difficult and frightening to people with BPD, but it is possible for them to get better over time

• Learn about mental disorders, including BPD, so you can understand what your friend or relative is experiencing
• With permission from your friend or relative, talk with his or her therapist to learn about therapies that may involve family members, such as DBT-FST.

Never ignore comments about someone's intent or plan to harm himself or herself or someone else. Report such comments to the person's therapist or doctor. In urgent or potentially life-threatening situations, you may need to call the police.
How can I help myself if I have BPD?
Taking that first step to help yourself may be hard. It is important to realize that, although it may take some time, you can get better with treatment.
To help yourself:

• Talk to your doctor about treatment options and stick with treatment
• Try to maintain a stable schedule of meals and sleep times
• Engage in mild activity or exercise to help reduce stress
• Set realistic goals for yourself
• Break up large tasks into small ones, set some priorities, and do what you can, as you can
• Try to spend time with other people and confide in a trusted friend or family member
• Tell others about events or situations that may trigger symptoms
• Expect your symptoms to improve gradually, not immediately
• Identify and seek out comforting situations, places, and people
• Continue to educate yourself about this disorder.

What is Dissociative Idenity Disorder?

Dissociative Identity Disorder 

Dissociation is a common, naturally occurring defense against childhood trauma. When faced with overwhelming abuse, children can dissociate from full awareness of a traumatic experience. Dissociation may become a defensive pattern that persists into adulthood and can result in a full-fledged dissociative disorder.

Formerly known as Multiple Personality Disorder, Dissociative Identity Disorder (DID) is a condition in which a person has two or more distinct identity or personality states, which may alternate within the individual's conscious awareness. The different personality states usually have distinct names, identities, temperament, and self-image. At least two of these personalities repeatedly assert themselves to control the affected person's behavior and consciousness, causing long lapses in memory that far exceed typical episodes of forgetting. Additionally, physiological conditions, such as direct effects from substance use or general medical conditions such as seizures, must be ruled out.

Impact

Having a loved one who has DID can be painful, confusing, and may evoke all kinds of emotional reactions. If you become aware of the abuse, you may feel angry, anxious, sad, or disgusted, along with empathy and worry. It may be hard keeping track of all the personalities (or "alters") if you have experienced them. Often, persons with DID cannot tell which of the alters is out at a given time and do not expect their loved ones to know either. A major adjustment for relatives and friends is the constant switching between personalities. Integration can bring about significant changes in a personality as the different alters grow and change dramatically. Although you may feel like the person you knew no longer exists, the part that you knew before integration still exists. Now you know more of him or her.

Causes

The main cause of DID is believed to be severe and prolonged trauma experienced during childhood, including emotional, physical or sexual abuse.

The development of dissociative identity disorder is understood to be a result of several factors:

• Recurrent episodes of severe physical, emotional or sexual abuse in childhood.
• Absence of safe and nurturing resources to overwhelming abuse or trauma.
• Ability to dissociate easily.
• Development of a coping style that helped during distress and the use of splitting as a survival skill.
• While abuse is frequently present, it cannot be assumed that family members were involved in the abuse.

Symptoms

Many symptoms of DID are similar to those of other physical and mental disorders, including substance abuse, seizure disorder and post-traumatic stress disorder.

The common symptoms of DID include:

• Inability to remember large parts of childhood.
• Unexplained events and inability to be aware of them (such as finding yourself somewhere without remembering how you got there or new clothes that you have no recollection of buying).
• Frequent bouts of memory loss or "lost time."
• Sudden return of memories, as in a flashback and/or flashback to traumatic events.
• Episodes of feeling disconnected or detached from one's body and thoughts.
• Hallucinations (sensory experiences that are not real, such as hearing voices talking to you or talking inside your head).
• "Out of body" experiences.
• Suicide attempts or self-injury.
• Differences in handwriting from time to time.
• Changing levels of functioning, from highly effective to nearly disabled.

Persons with DID may also have problems with:

• Depression or mood swings.
• Anxiety, nervousness, panic attacks and phobias (flashbacks, reactions to stimuli or "triggers").
• Eating disorders.
• Unexplained sleep problems (such as insomnia, night terrors, and sleep walking).
• Severe headaches or pain in other parts of the body.
• Sexual dysfunction, including sexual addiction and avoidance.

Seeking Help

The diagnosis of DID requires medical and psychiatric evaluation which can include specific questions about dissociation, prolonged interviews, and journals between visits. Specially designed questionnaires are used to screen and diagnose DID.

Seek professional medical help if you (or a loved one) have significant, unexplained memory loss, a chronic sense that your identity or the world around you is blurry or unreal, and you experience a major change in behavior when under stress. Immediate emergency care should be sought if there are serious thoughts of self-harm, suicide or homicide.

Early intervention and psychotherapy for experiences of abuse/trauma in both children and adults can help prevent the formation of dissociative symptoms and dissociative disorders.

Intervention and Treatment

Left untreated, DID can last a lifetime. While treatment for DID may take several years, it is effective. Persons with DID may find that they are better able to handle the symptoms in middle adulthood. Stress, substance abuse, and sometimes anger can cause a relapse of symptoms at any time. As a good standard of care, persons with DID should be treated by a mental health professional with specialized training and experience with dissociation. Since physical illness can sometimes mimic or contribute to a psychological disorder, a complete physical examination by a physician is warranted when there are concerns about physical conditions. For significant mood disorders and psychiatric conditions, a psychiatric consult is necessary.

1. Psychotherapy. Treatment for DID consists primarily of individual psychotherapy and can last for an average of five to seven years in adults. Individual psychotherapy is the most widely used modality as opposed to family, group or couples therapy. The main goal for treatment is the integration of the separate personality states into one cohesive, unified personality, unless the person with DID is not ready or motivated to work with trauma. Psychotherapy for dissociative disorders often involves techniques that help work through the trauma that triggers dissociative symptoms. Treatment may include the following stages: uncovering and "mapping" the alters or parts; treating the traumatic memories and "fusing" the alters; and consolidating the newly integrated personality. 
2. Family Therapy is recommended to help educate the family about DID and its causes, to understand the changes that can take place as the personality is being reintegrated, as well as help family members recognize symptoms of recurrence. Family therapy for a person with DID may produce significant negative and traumatic memories of other family members which can hinder clinical progress. 
3. Group therapy may be beneficial in addition to individual therapy, provided the group is exclusively for people with dissociative disorders. Persons with DID can sometimes have setbacks in mixed therapy groups because others may be bothered or disturbed by the personality switches. 
4. Medications. There is no medication to treat DID since it is not an organic disorder or a chemical imbalance. However, antidepressants and anxiolytics might help with mood disorders. 
5. Clinical Hypnosis. Despite controversy about therapists implanting false memories by suggestion, clinical hypnosis can be used in conjunction with psychotherapy when conducted safely by a trained therapist. Hypnosis can help clients access repressed memories, control problematic behaviors, such as self-mutilation and eating disorders, and help fuse the alters during the integration process.

The text of this brochure written by Shobha Pais, PhD.

Suicide facts

Suicide does not discriminate. People of all genders, ages, and ethnicities can be at risk for suicide. But people most at risk tend to share certain characteristics. The main risk factors for suicide are:

• Depression, other mental disorders, or substance abuse disorder
• A prior suicide attempt
• Family history of a mental disorder or substance abuse
• Family history of suicide
• Family violence, including physical or sexual abuse
• Having guns or other firearms in the home
• Incarceration, being in prison or jail
• Being exposed to others’ suicidal behavior, such as that of family members, peers, or media figures.

The risk for suicidal behavior is complex. Research suggests that people who attempt suicide differ from others in many aspects of how they think, react to events, and make decisions. There are differences in aspects of memory, attention, planning, and emotion, for example. These differences often occur along with disorders like depression, substance use, anxiety, and psychosis. Sometimes suicidal behavior is triggered by events such as personal loss or violence. In order to be able to detect those at risk and prevent suicide, it is crucial that we understand the role of both long-term factors—such as experiences in childhood—and more immediate factors like mental health and recent life events. Researchers are also looking at how genes can either increase risk or make someone more resilient to loss and hardships.
Many people have some of these risk factors but do not attempt suicide. Suicide is not a normal response to stress. It is, however, a sign of extreme distress, not a harmless bid for attention.

What about gender?

Men are more likely to die by suicide than women, but women are more likely to attempt suicide. Men are more likely to use deadlier methods, such as firearms or suffocation.Women are more likely than men to attempt suicide by poisoning.

What about children?

Children and young people are at risk for suicide. Suicide is the second leading cause of death for young people ages 15 to 34.

What about older adults?

Older adults are at risk for suicide, too.While older adults were the demographic group with the highest suicide rates for decades, suicide rates for middle-aged adults has increased to comparable levels (ages 24–62). Among those age 65+, white males comprise over 80 percent of all late-life suicides.

What about different ethnic groups?

Among ethnicities, American Indians and Alaska Natives (AI/AN) tend to have the highest rate of suicides, followed by non-Hispanic Whites. Hispanics, African Americans, and Asian/Pacific Islanders each have suicide rates that are about half their White and AI/AN counterparts.

How can suicide be prevented?

Effective suicide prevention is based on sound research. Programs that work take into account people’s risk factors and promote interventions that are appropriate to specific groups of people. For example, research has shown that mental and substance abuse disorders are risk factors for suicide. Therefore, many programs focus on treating these disorders in addition to addressing suicide risk specifically.
Psychotherapy, or “talk therapy,” can effectively reduce suicide risk. One type is called cognitive behavioral therapy (CBT). CBT can help people learn new ways of dealing with stressful experiences by training them to consider alternative actions when thoughts of suicide arise.
Another type of psychotherapy called dialectical behavior therapy (DBT) has been shown to reduce the rate of suicide among people with borderline personality disorder, a serious mental illness characterized by unstable moods, relationships, self- image, and behavior. A therapist trained in DBT helps a person recognize when his or her feelings or actions are disruptive or unhealthy, and teaches the skills needed to deal better with upsetting situations.
Medications may also help; promising medications and psychosocial treatments for suicidal people are being tested.
Still other research has found that many older adults and women who die by suicide saw their primary care providers in the year before death. Training doctors to recognize signs that a person may be considering suicide may help prevent even more suicides.
 

How do I get help?

To get the help you need in your country you can visit HERE, where there are hotlines for different countries. Find the country you are in and access your countries hotline.

What should I do if someone I know is considering suicide?

If you know someone who is considering suicide, do not leave him or her alone. Try to get your loved one to seek immediate help from his or her doctor or the nearest hospital emergency room, or call 911. Remove any access he or she may have to firearms or other potential tools for suicide, including medications.