Borderline

Personality
Disorder

 Patients stand on the border between neurosis and

psychosis
Characerized by extraordinarily unstable affect, mood,
behavior, object relations and self-image
Also
called
Ambulatory
Schizophrenia,
as-if
schizophrenia ( Helene Deutsch), pseudoneurotic
schizophrenia ( Paul Hoch and Phillip Politan) and
psychotic character (John Frosch)
In ICD-10: Emotionally unstable personality discorder

 No definitive prevalance but thouht to be prrsent in 1 or

2% of the population
2x as common in women as in men
An increased prevalance of major depressive disorder,
alcohol use disorders and substance abuse in first degree
relatives

Epidemiology

DSM-V

 Biological studies may aid in the diagnosis

Some show shortened REM, latency and sleep continuity
disturbances, abnormal dexamethasone suppression test
results and abnormal thyrotropin-releasing hormone test
results

 Almost always appear in a state of crisis

Mood swings are common
Patients may be argumentative at one moment and
depressed at the next and complain of having no feelings
at another time
May have short-lived psychotic episodes (micropsychotic
episodes) rather than full-blown psychotic breaks

Clinical Features

 Psychotic symptoms are almost always circumscribed,

fleeting or in doubt
Behavior highly unpredictable; consequently rarely
achieve up to the level of their abilities
Painful nature of their lives is reflected in repetitive selfdestructive acts:
Slash wrists and perform self-mutilations to elicit help from
others, to express hunger or to numb themselves to
overwhelming effect

 Can be dependent on those whom they are close and can

express enormous anger at their intimate friends when
frustrated
However, cannot tolerate being alone and prefer a frantic
search for companionship no matter how unsatisfactory,
to sitting by themselves
To assuage loneliness, if only for brief periods, they
accept a stranger as a friend or are promiscuous

Relationships

 Identity Diffusion
Often complain about chronic feelings of emptiness and
boredom and lack a consistent sense of identity
When pressed, often complain about how depressed they
feel most of the time in spite of the flurry of other affects

 Projectile Identification (Otto Kernberg)

Intolerable aspects of the self are projected into another
person
The other person is induced to play the role of what is
projected and the two persons act in unison

Defense Mechanism

 Functionally, distort their relationships by putting every

person into either an all-good or an all-bad category
See people as either nurturant and atachment figures or
hateful and sadistic persons who deprive themselves of
security needs ann threaten them with abandonement
whenever they feel dependent
As a result of the splitting, the good person is idealized
and the bad person is devalued
Shifts of allegiance from one person or group to another
are frequent

 Disorder is fairly stable in that patients change over time

Do not show a progression towards schizophrenia but
have a high incidence of major depressive disorder
episodes
Diagnosis usually made at the age of 40, when patients
are attempting to make occupational, marital and other
choices and are unable to deal with the normal stages of
life cycle

Differential Diagnosis

 Psychotherapy
Treatment of choice
Difficult for patents and therapist alike
Regression occurs easily, who act out their impulses and show
labile or fixed negative or positive transferences, which are
difficult to analyze
Projectile identification also cause countertransference problems
if the therapist is unaware that the patient is unconsciously trying
to coerce the therapist to act out a particular type of behavior
Splitting as a defense mechanism causes the patient to alternately
hate the therapist and others on the environment
A reality-oriented approach is more effective than in-depth
interpretations of the unconscious

Treatment

 Behavior therapy
Used in order to control impulses and angry outbursts and
to reduce sensitivity to criticisms and rejection
Social skills training
- especially with videotape playback is helpful to enable
patients to see how their actions affect others and to
improve interpersonal relationship

 Borderline personality patients often do well in a hospital

setting in which they receive intensive psychotherapy on both
individual basis and a group basis
Also interact with trained staff members and provided with
occupational, recreational and vocational therapy
Such programs are helpful if the home environment is
detrimental to the patients rehab because of intra-familial
conflict such as parental abuse
The borderline personality who is excessively impulsive, selfdestructive or self-mutilating can be provided with limits and
observation within the protected environment of hospital

In the Hospital

 Under ideal circumstances, patients remain in the hospital

until hey show marked improvement, which may take up
to one year at some cases
At that time, patients can be discharged to special support
systems, such as day hospitals, night hospitals and
halfway houses

Improvement

 Useful to deal with specific personality features that interfere with

the patient
Antipsychotics
- Have been used to control anger hostility and brief psychotic episodes

Antidepressants
-

Improve the depressed mood

MAOIs have been effective in modulating impulsive behavior
Benzodiazepines, particularly Alprazolam (Xanax) help anxiety
and depression but some patients show disinhibition with that
class of drugs
Anticonvulsant, such as Carbamazepine (Tegretol), may improve
global function in
Serotonergic agents, such as Fluoxetine, may be helpful in some
cases

Pharmacotherapy