Bellevue Hospital Center / New York University

INTENSIVE PERSONALITY
DISORDER PROGRAM
(IPDP)

Borderline personality disorder (BPD) is a serious mental illness characterized by
pervasive instability in moods, interpersonal relationships, self-image, and behavior. This
instability often disrupts family and work life, long-term planning, and the individual's
sense of self-identity. Originally thought to be at the "borderline" of psychosis, people
with BPD suffer from a disorder of emotion regulation. While less well known than
schizophrenia or bipolar disorder (manic-depressive illness), BPD is more common,
affecting 2 percent of adults, mostly young women.1 There is a high rate of self-injury
without suicide intent, as well as a significant rate of suicide attempts and completed
suicide in severe cases.2,3 Patients often need extensive mental health services, and
account for 20 percent of psychiatric hospitalizations.4 Yet, with help, many improve
over time and are eventually able to lead productive lives.


SYMPTOMS
While a person with depression or bipolar disorder typically endures the same mood for
weeks, a person with BPD may experience intense bouts of anger, depression, and
anxiety that may last only hours, or at most a day.5 These may be associated with
episodes of impulsive aggression, self-injury, and drug or alcohol abuse. Distortions in
cognition and sense of self can lead to frequent changes in long-term goals, career
plans, jobs, friendships, gender identity, and values. Sometimes people with BPD view
themselves as fundamentally bad, or unworthy. They may feel unfairly misunderstood
or mistreated, bored, empty, and have little idea who they are. Such symptoms are most
acute when people with BPD feel isolated and lacking in social support, and may result
in frantic efforts to avoid being alone.

People with BPD often have highly unstable patterns of social relationships. While they
can develop intense but stormy attachments, their attitudes towards family, friends, and
loved ones may suddenly shift from idealization (great admiration and love) to
devaluation (intense anger and dislike). Thus, they may form an immediate attachment
and idealize the other person, but when a slight separation or conflict occurs, they
switch unexpectedly to the other extreme and angrily accuse the other person of not
caring for them at all. Even with family members, individuals with BPD are highly
sensitive to rejection, reacting with anger and distress to such mild separations as a
vacation, a business trip, or a sudden change in plans. These fears of abandonment
seem to be related to difficulties feeling emotionally connected to important persons
when they are physically absent, leaving the individual with BPD feeling lost and
perhaps worthless. Suicide threats and attempts may occur along with anger at
perceived abandonment and disappointments.
People with BPD exhibit other impulsive behaviors, such as excessive spending, binge
eating and risky sex. BPD often occurs together with other psychiatric problems,
particularly bipolar disorder, depression, anxiety disorders, substance abuse, and other
personality disorders.


TREATMENT
Treatments for BPD have improved in recent years. Group and individual
psychotherapy are at least partially effective for many patients. Within the past 15 years,
a new psychosocial treatment termed dialectical behavior therapy (DBT) was developed
specifically to treat BPD, and this technique has looked promising in treatment studies.6
Pharmacological treatments are often prescribed based on specific target symptoms
shown by the individual patient. Antidepressant drugs and mood stabilizers may be
helpful for depressed and/or labile mood. Antipsychotic drugs may also be used when
there are distortions in thinking.7


RESEARCH FINDINGS
Although the cause of BPD is unknown, both environmental and genetic factors are
thought to play a role in predisposing patients to BPD symptoms and traits. Studies
show that many, but not all individuals with BPD report a history of abuse, neglect, or
separation as young children.8 Forty to 71 percent of BPD patients report having been
sexually abused, usually by a non-caregiver.9 Researchers believe that BPD results from
a combination of individual vulnerability to environmental stress, neglect or abuse as
young children, and a series of events that trigger the onset of the disorder as young
adults. Adults with BPD are also considerably more likely to be the victim of violence,
including rape and other crimes. This may result from both harmful environments as
well as impulsivity and poor judgment in choosing partners and lifestyles.

NIMH-funded neuroscience research is revealing brain mechanisms underlying the
impulsivity, mood instability, aggression, anger, and negative emotion seen in BPD.
Studies suggest that people predisposed to impulsive aggression have impaired
regulation of the neural circuits that modulate emotion.10 The amygdala, a small almond-
shaped structure deep inside the brain, is an important component of the circuit that
regulates negative emotion. In response to signals from other brain centers indicating a
perceived threat, it marshals fear and arousal. This might be more pronounced under the
influence of drugs like alcohol, or stress. Areas in the front of the brain (pre-frontal
area) act to dampen the activity of this circuit. Recent brain imaging studies show that
individual differences in the ability to activate regions of the prefrontal cerebral cortex
thought to be involved in inhibitory activity predict the ability to suppress negative
emotion.11

Serotonin, norepinephrine and acetylcholine are among the chemical messengers in
these circuits that play a role in the regulation of emotions, including sadness, anger,
anxiety, and irritability. Drugs that enhance brain serotonin function may improve
emotional symptoms in BPD. Likewise, mood-stabilizing drugs that are known to
enhance the activity of GABA, the brain's major inhibitory neurotransmitter, may help
people who experience BPD-like mood swings. Such brain-based vulnerabilities can be
managed with help from behavioral interventions and medications, much like people
manage susceptibility to diabetes or high blood pressure.7


FUTURE PROGRESS
Studies that translate basic findings about the neural basis of temperament, mood
regulation, and cognition into clinically relevant insights—which bear directly on BPD—
represent a growing area of NIMH-supported research. Research is also underway to
test the efficacy of combining medications with behavioral treatments like DBT, and
gauging the effect of childhood abuse and other stress in BPD on brain hormones. Data
from the first prospective, longitudinal study of BPD, which began in the early 1990s, is
expected to reveal how treatment affects the course of the illness. It will also pinpoint
specific environmental factors and personality traits that predict a more favorable
outcome. The Institute is also collaborating with a private foundation to help attract new
researchers to develop a better understanding and better treatment for BPD.


REFERENCES
1 Swartz M, Blazer D, George L, Winfield I. Estimating the prevalence of borderline
personality disorder in the community. Journal of Personality Disorders, 1990; 4(3):
257-72.

2 Soloff PH, Lis JA, Kelly T, Cornelius J, Ulrich R. Self-mutilation and suicidal behavior
in borderline personality disorder. Journal of Personality Disorders, 1994; 8(4): 257-67.

3 Gardner DL, Cowdry RW. Suicidal and parasuicidal behavior in borderline personality
disorder. Psychiatric Clinics of North America, 1985; 8(2): 389-403.

4 Zanarini MC, Frankenburg FR. Treatment histories of borderline inpatients.
Comprehensive Psychiatry, in 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 frustrating no-mans-land of borderline personality
disorder. Cerebrum, The Dana Forum on Brain Science, 2000; 2(4).

8 Zanarini MC, Frankenburg. Pathways to the development of borderline personality
disorder. Journal of Personality Disorders, 1997; 11(1): 93-104.

9 Zanarini MC. Childhood experiences associated with the development of borderline
personality disorder. Psychiatric Clinics of North America, 2000; 23(1): 89-101.

10 Davidson RJ, Jackson DC, Kalin NH. Emotion, plasticity, context and regulation:
perspectives from affective neuroscience. Psychological Bulletin, 2000; 126(6): 873-89.

11 Davidson RJ, Putnam KM, Larson CL. Dysfunction in the neural circuitry of
emotion regulation - a possible prelude to violence. Science, 2000; 289(5479): 591-4.

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