Crisis management of a personality disorder

People with BPD view themselves as victims and expect to be hurt and rejected by others.
People with BPD view themselves as victims and expect to be hurt and rejected by others.

At a glance

  • Borderline personality disorder (BPD) is the most common personality disorder seen in the primary-care setting.
  • The predominant traits associated with BPD are emotional lability, impulsiveness, and impaired relationships.
  • Symptoms of BPD may overlap with other mood, anxiety, and personality disorders, making diagnosis difficult.
  • Self-injurious behaviors and suicidal ideations are the main reasons people with BPD present for health-care services.

Borderline personality disorder (BPD) is a "pervasive pattern of instability of interpersonal relationships, self-image and affect as well as marked impulsivity beginning by early adulthood and present in a variety of contexts (personal, professional and social)."1 The term BPD was adopted in the early 1900s, when symptoms associated with mental disorders were considered as either psychosis or neurosis. Subsequently, symptoms that did not meet the criteria for psychotic or neurotic disorders were deemed borderline.

While the etiology remains unclear, there are multiple factors related to the development of BPD. Researchers have cited genetic predisposition, neurobiologic factors, and environmental factors as possible causes. Moreover, BPD in adults has been linked with early childhood trauma (i.e., sexual and physical abuse and neglect) in 60% to 90% of patients with the diagnosis.2

Prevalence

BPD is a condition that affects 1% to 4% of adults and is five times more common among first-degree relatives.3 According to recent data, 70% of persons diagnosed with BPD are women.4 Because BPD is generally diagnosed in psychiatric settings, the prevalence is higher in that setting. Studies utilizing structured surveys have estimated the prevalence of BPD in the primary-care setting at approximately 6% to 7%.5 BPD is the most common and one of the most severe types of personality disorder seen in the primary-care setting. The personal, social, and economic toll of this disorder makes it a significant public-health burden.

Characteristics of BPD

BPD is a heterogeneous type of disorder, meaning that it may cause a cluster of different symptoms in each person affected by it. In all cases, the predominant traits associated with this disorder are emotional lability, impulsiveness, and impaired relationships.

Emotional lability is a hallmark of BPD. Persons with the disorder are often overly dramatic in their expression of emotions. These emotions are related to their perception of acceptance or rejection by others, both personally and professionally. These patients report chronic dysphoria, despair, and feelings of nonexistence and hopelessness that are rarely relieved by a sense of well-being or satisfaction. This dysphoria is often disrupted by erratic mood changes. Patients with BPD may exhibit intense anger or heightened anxiety, or become verbally or physically aggressive. The source of this displaced and potentially volatile display of emotions and behaviors may not be apparent to the observer but is likely a reactive response to interpersonal stressors.

Persons with BPD are frenetic in their attempts to avoid separation, rejection, or abandonment. Because these individuals lack object constancy, their perception of others and their environment is without prior context, continuity, or consistency. Separation from significant others for even a short period of time may be perceived as abandonment and is likely to produce extreme fluctuations in thinking and impulsive behaviors. Impulsiveness may be demonstrated by such acts of self-defeating and high-risk behavior as sexual promiscuity, substance abuse, excessive spending, gambling, and binge eating. People with BPD may also engage in such repetitive and self-injurious behavior as hitting, cutting, or burning themselves. These patients commonly report that self-injury provides relief and a sense of emotional equilibrium. Self-injurious behaviors invariably attract attention and a rescue of some sort, which reinforces helplessness and dependency.

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