AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Background

Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself. They are exhibited in a wide range of important social and personal contexts. When these traits are significantly maladaptive and cause serious functional impairment or subjective distress, they constitute a personality disorder. The manifestations of personality disorders are often recognized by adolescence and continue throughout most of adult life.

Personality disorders are not formally diagnosed in patients younger than 18 years because of the ongoing developmental changes. However, if the disturbance is pervasive and if the criteria are fully and persistently met and are not limited to a developmental stage, diagnosing borderline personality disorder (BPD) in children and adolescents is appropriate.

BPD has historically been considered to be on the border between psychosis and neurosis. It is characterized by marked instability in functioning, affect, mood, interpersonal relationships, and, at times, reality testing. In 1942, Deutsch described a group of patients who lacked a consistent sense of identity and source of inner direction.¹ She created the term "as-if personalities" because the patients completely identified with those upon whom they were dependent. In 1975, Kernberg conceptualized BPD to describe a group of patients with particular primitive defense mechanisms and pathologic internalized object relations (eg, splitting, projective identification).²

Borderline pathology in children refers to a syndrome characterized by a combination of externalizing symptoms (disruptive behavioral problems), internalizing symptoms (mood and anxiety symptoms), and cognitive symptoms. Follow-up studies of these children show that they have a tendency to develop a wide range of personality disorders, not specifically BPD. Further research in this area is imperative, not only to elucidate etiology, but also to allow for the earliest possible intervention.

Pathophysiology

Some studies have suggested that patients with BPD might have increased rates of soft neurologic signs,³ as well as learning disorders, attention deficit hyperactivity disorder, and abnormal EEG findings.⁴ Reports also indicate that adults with BPD have increased impulsivity, cognitive inflexibility, and poor self-monitoring and perseveration, which may be indicators of frontal lobe dysfunction.

As with most psychiatric disorders, the etiology of BPD is likely to include several factors, including an organic predisposition as well as psychosocial and environmental factors.

Some researchers postulate the presence of an underlying affective instability to which the individual responds with maladaptive behaviors.

Frequency

United States

To the authors' knowledge, no definitive prevalence studies have been performed; however, BPD is reported to be present in 1-2% of the general population. In a study performed by Clarkin et al in 1983, approximately 11% of psychiatric outpatients and 19% of inpatients met the criteria for BPD.⁵

Mortality/Morbidity

• Premature death among patients with BPD may be due to the increased risk of suicide in this population. Approximately 70-75% of patients with BPD have a history of at least one deliberate act of self-harm. According to Linehan et al, the mean estimated rate of completed suicides 9%.^{6, 7}
• BPD is associated with significant morbidity due to common comorbid conditions, including dysthymia, major depression, psychoactive substance abuse, and psychotic disorders. In a 1999 study of 409 patients, Zimmerman and Mattia demonstrated that patients with BPD were twice as likely to receive a diagnosis of 3 or more current axis-I disorders and that they were nearly 4 times as likely to have a diagnosis of 4 or more axis-I disorders than those without BPD.⁸ These included mood disorders, anxiety, substance abuse, eating disorders, and somatoform disorders.
• Morbidity in this population includes failure in social relationships, developmental delay, and occupational impairment. Health care costs in patients with borderline pathology are enormous, and treatment dropout rates are extraordinarily high.

Race

No evidence suggests a relationship between race and the diagnosis of BPD or borderline disorders of childhood.

Sex

Virtually every study of BPD has revealed that the diagnosis is more common in females than in males; the female-to-male ratios are as high as 4:1.

Age

Symptoms of BPD are usually present by late adolescence, but the diagnosis has been made in children. The initial diagnosis of this disorder is rarely made in patients older than 40 years.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

History

• In contrast to adult cases of borderline personality disorder (BPD), BPD in childhood has not been consistently and clearly categorized.
• • In the 1940s and 1950s, several researchers categorized this disorder in children in the realm of childhood psychoses or schizophrenia.^{9, 10} Clinical observations included fluctuations in ego states, primitive regressions, disturbed interpersonal relationships, and severe anxiety.
  • Anna Freud described children with deep levels of regression, massive developmental arrests, withdrawal of libido from the object world and displacement onto the body or self, an inability to receive comfort from others, and numerous specific ego deficits.¹¹
• In 1982, Pine developed a working nosology of borderline syndromes in children.¹² These clinical subgroupings remain highly relevant, although the Diagnostic and Statistical Manual, 4th Edition, (DSM-IV) nomenclature was not modified to establish the diagnosis in patients younger than 18 years.¹³
• • Patients may have failures in developmental lines associated with major ego functions or central aspects of object relationships.
  • Patients may have an inability to adequately soothe themselves, with demonstrations of overemotionality and maladaptive attempts at self-soothing.
  • Patients may have an unstable sense of self that manifests as maladaptive attempts to fulfill their needs by means of suicide threats, self-harm, and angry behavior.
• BPD is considered to have a condition on the border between psychosis and neurosis.
• • The disorder is characterized by marked instability in functioning, affect, mood, interpersonal relationships, and, at times, reality testing.
  • Patients with BPD may manifest overwhelming anger when in a state of crisis.
  • Psychotic symptoms, when present, are short lived, circumscribed, or accompanied by good reality testing.
  • Individuals with personality disorders are frequently dissatisfied with their marked and sustained impairment in social, occupational, or academic functioning.

Physical

• No consistent physical findings are specific to BPD or borderline pathology in children.
• The diagnosis is based on clinical observations of behaviors and patient-reported symptoms.

Causes

• Most theories about the cause or pathogenesis of BPD include the notion of a biologic predisposition¹⁴ along with psychological and environmental factors.
• Several researchers have proposed the existence of a constitutional incapacity to tolerate stress.
• Kernberg has hypothesized that patients with borderline pathology have a constitutional inability to regulate their affect, which predisposes them to psychic disorganization or deterioration under early adverse environmental conditions.²
• Persons with BPD are at higher risk for axis-I syndromes, including depression, panic disorder, and agoraphobia. Studies commonly reveal that patients with BPD are anxious, dependent, and acutely sensitive to rejection and loss; these observations suggest that the condition might be specifically related to attachment bond regulation.
• • Mahler hypothesized that infants at risk are subjected to unpredictable and prolonged separation from their maternal figure during the separation-individuation process of development that occurs around age 18-36 months.⁹ The unavailability of the maternal figure might make the child forever vulnerable to disorganization brought on by separation experiences.
  • Kernberg suggested that patients with BPD internalize early pathologic object relations.² The use of primitive defense mechanisms (which individuals without BPD outgrow during normal development) maintains these early pathologic object relations. Kernberg hypothesized that, in the early stages of development, the infant experiences the maternal figure in 2 contradictory ways: The first is the good mother, who provides for, loves, and remains close. The second is the hateful, depriving mother, who unpredictably punishes and abandons the child. The result is intense anxiety, which leads to the borderline defense of splitting.
  • Several researchers have proposed a hypothesis for borderline personality by using a family systems perspective.¹⁵ In this view, the significant etiologic variables stem from the concepts of faulty family boundaries, the unpredictable proximity among family members, and the lack of an appropriate hierarchical structure.
• Although the borderline condition in childhood is not necessarily a precursor to BPD in adulthood, evidence suggests that both have strikingly similar risk factors, which might indicate a common etiology. These factors include family environments characterized by trauma, neglect, and/or separation; exposure to sexual and physical abuse; and serious parental psychopathology, such as substance abuse and antisocial personality disorder.
• The pathogenesis of borderline personality is complex and probably multifactorial, as in the theory of Linehan et al, which states that borderline pathology results from the interaction of a biologic emotional vulnerability and a pervasively invalidating environment.^{6, 7} More research involving developmental psychopathology, neurobiology, and family systems theory is necessary to explain how, when, and in what combination these various factors might pathologically affect development.

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Other Problems to be Considered

Numerous studies show that as many as one half of all patients with borderline personality disorder (BPD) may also meet the criteria for histrionic, antisocial, or schizotypal personality disorders. Chronic feelings of emptiness, impulsivity, self-mutilation, short-lived psychotic episodes, and manipulative suicide attempts help to discriminate BPD from other personality disorders. The Gunderson Diagnostic Interview for Borderlines¹⁶ and the Perry Borderline Personality Disorder Scale can be helpful structured tools in the diagnosis of BPD.

Andrulonis evaluated a population of 45 children (aged 5-12 y) who met the Diagnostic and Statistical Manuel, 3rd Edition, (DSM-III) and Gunderson criteria for BPD.¹⁷ The primary behaviors that differentiated these children from the control group were aggression and rage, attention deficit hyperactivity disorder, excessive use of fantasy, impulsivity, and poor relationships.

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Lab Studies

• No laboratory tests are useful in identifying this disorder.
• Some patients with borderline personality disorder (BPD) have abnormal results with dexamethasone suppression testing and with abnormal thyrotropin-releasing hormone testing; however, these findings are also present in many patients with depression.
• As with any thorough workup of a patient with a mood disorder, fasting glucose and thyroid function studies are usually indicated.
• Other laboratory tests are indicated depending on the clinical presentation.

Imaging Studies

• No diagnostic imaging studies are specific for borderline disorders in adults or children.

Other Tests

• In one small study of 20 patients with BPD, 40% of patients had abnormal, diffuse, slow activity on EEG findings.⁴
• Some patients with BPD have shortened rapid eye movement (REM) latency and sleep-continuity disturbances, but these findings are also found in a fair number of patients with depression.
• Although psychological testing reveals and highlights the clinical features, it does not increase diagnostic specificity.
• • Most authors agree that patients with BPD demonstrate ordinary reasoning abilities on structured tests with tools such as the Wechsler Adult Intelligence Scale (WAIS).
  • Abnormal processes are noted only on unstructured projective tests, such as the Rorschach test.
  • Projective testing highlights circumstantial reasoning and illogical and unrelated connections. In addition, responses of patients with BPD are often overwhelmingly negative.
• In 1999, Blais et al evaluated the DSM-IV criteria for BPD and indicated that the combination of the following criteria provides the best prediction of inclusion in the borderline or nonborderline group:¹⁸
• • Criterion 1 - Abandonment
  • Criterion 2 - Unstable relationships
  • Criterion 3 - Identity
  • Criterion 6 - Unstable affect

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical Care

• Psychotherapeutic treatment of patients with borderline personality disorder (BPD) is often difficult because of regression, overwhelming affect, and impulsive behavior.
• • Kernberg suggests that a modified psychoanalytic approach is most useful.² The goal of this type of therapy is the resolution of pathologic internalized representations of interpersonal relationships. The therapist requires adequate support systems, including access to prolonged hospitalization, which might be necessary.
  • Another view in the psychotherapeutic treatment of patients with BPD maintains that the regressive transference resulting from analytically oriented treatment is often detrimental to the patient. A supportive, reality-oriented approach in which the goal of therapy is a gradual social adjustment in the framework of a realistic therapeutic relationship is more beneficial.
  • A third viewpoint is that experience rather than explanations benefit the patient. In this approach, the therapist remains calm, without anxiety or anger, while remaining emotionally available. In this setting, the patient learns to tolerate the hateful and destructive feelings that arise because of transference and to eventually replace them with more constructive and positive reactions. The patient also internalizes a calm, soothing supportive object.
• Dialectic behavior therapy (DBT) is a modification of standard cognitive-behavioral techniques designed specifically for the treatment of BPD.¹⁹ Currently, DBT is the only data-supported treatment for BPD. Although DBT was developed as an outpatient program, it has been modified for use in hospital settings and among more diverse populations.
• • The focus of DBT is teaching patients 4 skills: mindfulness (attention to one's experience), interpersonal effectiveness (predominantly assertiveness), emotional regulation, and distress tolerance without impulsivity.
  • In randomized clinical trials, DBT was more effective than usual treatment in reducing suicidal and self-injurious behaviors, treatment dropout, hospitalizations, and self-reports of anger and anxious ruminations.^{6, 7} Increased rates of global adjustment were observed after one year of treatment, and these gains were maintained over the subsequent year.
• For the treatment of children with BPD traits, family-oriented interventions appear to be superior in benefiting the patient and in diminishing the risk of further undermining parental self-esteem. Many studies of these children highlight the importance of early acquisition of self-control for predicting a good developmental outcome. In 1982, Hanson et al demonstrated that most children and adolescents with traits of BPD appear to benefit from structured day programs with strong behavioral management components.²⁰
• Historically, the treatment of patients with BPD has been difficult. In any treatment approach, the therapist must combine elements of conflict resolution and social learning to minimize and limit aggression and impulsivity. Consultants must be readily available, and the therapist must have access to appropriate hospitalization for periods of severe regression and heightened suicidal risk. However, the therapist must also limit inpatient treatment whenever possible because of the costs and because of the inherent difficulties with inpatient treatment of this population. These difficulties include possible severe regression after admission and destructive countertransference enactments when staff training or supervision is less than ideal. Several authors report that offering a truly appropriate and adequate course of treatment is significantly less costly than the use of crisis interventions when required.

Consultations

• If BPD or borderline disorder of childhood is suspected, consult a child psychiatrist or other appropriately trained mental health professional.

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Patients with borderline personality disorder (BPD) tend to have strong placebo responses to medication; thus, impressive short-term improvement might occur and unexpectedly fade. Impulsivity, affective instability, and psychosis are the significant manifestations of borderline pathology that might require pharmacologic treatment.

Benzodiazepines are contraindicated in this population because they reduce inhibitions and are therefore likely to increase impulsivity. Furthermore, patients with BPD are prone to sedative addiction.

Drug Category: Selective serotonin reuptake inhibitors (SSRIs)

These antidepressant agents are chemically unrelated to the tricyclic, tetracyclic, and other available antidepressants. SSRIs inhibit CNS neuronal reuptake of serotonin (5HT). They may also have a weak effect on norepinephrine and dopamine neuronal reuptake. SSRIs are also used to treat anxiety, phobias, and obsessive-compulsive disorders (OCDs).

When used at high doses, SSRIs appear to reduce impulsivity and aggression; however, the antidepressant effects are less impressive than those of other drugs. One important advantage of SSRIs is their relative safety because patients with BPD commonly take overdoses of their prescribed medication. Therefore, the use of tricyclic antidepressants, lithium, and other mood stabilizers is usually not indicated without specific relevant symptoms and a strong, ongoing therapeutic relationship.

SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder.

Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.

However, a recent study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declines, not rises, with the use of antidepressants. This is the largest study to date to address this issue.²¹

Currently, evidence does associate OCD and other anxiety disorders treated with SSRIs with an increased risk of suicide.

Drug Category: Antipsychotics

Low-dose neuroleptics are effective in the short term for control of transient psychotic symptoms. Antipsychotics have long been used to control impulsivity and aggression in patients with BPD, although SSRIs are preferred because of their more benign adverse effect profile. If an antipsychotic agent is necessary, avoid butyrophenones in favor of atypical agents such as risperidone.^{22, 23, 24}

Drug Category: Opiate receptor antagonist

In 1999, Bohus et al reported a significant reduction in the duration and intensity of dissociative symptoms in a small number of patients with BPD during treatment with naltrexone, an opiate receptor antagonist.²⁵ Evidence suggests that alterations of the endogenous opiate systems contribute to dissociative symptoms in patients with BPD. In a case report, naltrexone was reported decrease self-injurious behavior in a 3 year-old boy.²⁶ 

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Further Inpatient Care

• Inpatient care is generally not indicated, unless the goals of treatment are well defined (see Treatment).

Further Outpatient Care

• Patients usually require long-term treatment with an appropriate therapist in individual and/or group psychotherapy.

Deterrence/Prevention

• To the authors' knowledge, no specific information is available.

Complications

• Ongoing and serious psychosocial dysfunction occurs if borderline personality disorder (BPD) is left untreated.

Prognosis

• Short-term follow-up studies uniformly reveal that patients with BPD change little over time.
• • In a 1998 prospective follow-up study, Links et al reported that almost 50% of their former inpatients with BPD continued to meet diagnostic criteria at 7 years.²⁷
  • Furthermore, these patients have significantly more comorbid personality psychopathology; this finding supported the assertion that the level of pathology at the initial assessment primarily predicts the level of borderline psychopathology.
• The long-term outcome is generally unknown.
• • However, the initial diagnosis of BPD is rarely made in patients older than 40 years.
  • This observation might reflect the evolution of BPD into more stable personality disorders, or perhaps patients with BPD stop seeking help as they age.
• Children with borderline pathology tend to develop a wide range of personality disorders, not necessarily BPD. Andrulonis believes that BPD traits in girls are more likely to evolve toward affective disorders, whereas BPD traits in boys evolve toward episodic dyscontrol syndromes and substance abuse.¹⁷

Patient Education

• For excellent patient education resources, visit eMedicine's Mental Health and Behavior Center. Also, see eMedicine's patient education article Schizophrenia.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical/Legal Pitfalls

• Patients with BPD commonly take overdoses of their prescribed medication.
• • Therefore, the use of tricyclic antidepressants, lithium, and other mood stabilizers is usually not indicated without specific relevant symptoms and a strong, ongoing therapeutic relationship. Prescribing medication in the absence of ongoing individual or group psychotherapy is not appropriate.
  • SSRIs should be the first drug of choice for the treatment of most symptoms because of their relative safety.
• Antipsychotic medications might cause serious and permanent adverse effects, such as tardive dyskinesia or neuroleptic malignant syndrome.
• • This possibility is also true of atypical agents, such as risperidone, as well as typical neuroleptics.
  • Antipsychotics should be used (1) only for the treatment of transient psychotic symptoms (sometimes present in patients with BPD), (2) at the lowest doses, and (3) for the shortest duration possible.
• Although patients with BPD often use suicide threats in a manipulative manner, the primary care clinician must never ignore these threats or suicide attempts. In children and adolescents, any suicide attempt should be treated with a thorough psychiatric evaluation and with appropriate inpatient hospitalization to ensure the patient's safety.
• Because of the boundary issues in patients with BPD, primary care clinicians must be extremely careful not to become intimately involved with such patients.
• • No sexual activity between a clinician and a patient is ever appropriate, even if the person is no longer an active patient. The ethical standard for psychiatry is this: Once a patient, always a patient.
  • Furthermore, because of the instability and pervasive anger of many patients with BPD, false accusations might be made; therefore, the clinician might need to take extra care in avoiding even the appearance of impropriety.

ACKNOWLEDGMENTS

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Joseph A Davies, MD, to the development and writing of this article.

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

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Article Last Updated: Apr 1, 2008