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Primary Psychiatry. 2004;11(10):21-22
Diagnosis
Many psychiatrists are familiar with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,1 criteria for borderline personality disorder (BPD). The criteria include a pervasive (long-standing) pattern of instability of self-image, interpersonal relationships, and mood associated with self-damaging impulsivity manifested by five or more of the following: attempts to avoid feelings of abandonment, use of splitting (alternating idealization and devaluation), identity disturbance, self-injurious behavior, affective instability, feelings of emptiness, impulsivity, uncontrolled anger, and micropsychotic (transient) episodes. Still, it can be difficult to diagnose BPD because of the overlap of symptoms with mood disorders, eating disorders, substance abuse disorders, posttraumatic stress disorder (PTSD), and other personality disorders.
A history of physical or sexual abuse is not uncommon in BPD. The course of the illness is variable with functional impairment and risk of suicide greatest in early adulthood. The prevalence of BPD in the general population is approximately 2%, with a 5-fold greater prevalence among mental health outpatients. Approximately 75% of individuals with BPD are women, and individuals are five times as likely to be diagnosed with BPD if a first-degree biological relative has the disorder. Recurrent suicidal or self-destructive behaviors are frequently what brings these individuals to treatment. These behaviors are often in response to perceived rejection, abandonment, or separation, especially from idealized individuals. The resulting fear, anger, and devaluation may lead to impulsive, self-destructive behaviors, such as dramatic outbursts, self-mutilation, or suicide threats/attempts.
Neurobiology
A number of brain dysfunctions have been noted in individuals with BPD. Structural brain abnormalities have been found in hippocampal and amygdala volume (ie, smaller volumes) in women with childhood abuse and BPD using magnetic resonance imaging, although this may be more specific for the abuse than the diagnosis of BPD.2 Dysfunction of dorsolateral and medial prefrontal cortex, including the anterior cingulate, has been correlated with the recall of traumatic memories3 and memories of abandonment in women with BPD.4 Impulsive behaviors have been associated with functional abnormalities in serotonergic systems measured by the meta-chlorphenylpiperazine challenge test5 and using positron emission tomography.6 Serotonergic dysfunction is also implicated by a worsening of BPD symptoms associated with rising estrogen levels across the menstrual cycle, and use of oral contraceptives.7
Presentation
As discussed above, women with BPD frequently present with comorbid diagnoses that influence the approach to treatment and outcome. Symptoms of major depression or bipolar disorder may be obscured by angry outbursts, impulsivity, and interpersonal conflict, or the mood disorder may be misinterpreted as the affective instability of BPD. Assessment of duration of symptoms and evaluation of the severity of the identified stressor (ie, relationship break-up) can be important in recognizing comorbidity.
Women with both BPD and PTSD have significantly greater general dysfunction and likelihood of psychiatric hospitalization, despite a similar level of symptoms and psychiatric morbidity when compared with women with BPD without PTSD, and have increased suicidal behaviors and impulsivity compared to women with PTSD only.8
Women with BPD appear to experience emotions more intensely, and thus have greater difficulty in maintaining control of their responses.9 Further disinhibition through the abuse of alcohol or benzodiazepines may lead to increased impulsivity10 or self-injurious behaviors intended to relieve negative emotions. In one study,11 nonsuicidal self-injury, such as cutting, was reported as intended to express anger, as self-punishment, as a distraction, and to generate normal feelings, whereas suicide attempts were described as intended to make others better off.
In addition, women with BPD followed in a mental health setting were significantly more likely to overdose or hit themselves than women in a primary care subsample who were more likely to abuse laxatives, despite a similar level of symptomatology between the groups.12 This may be an artifact of referral, as primary care providers may be more likely to be aware of and concerned about overdose and striking behaviors than of laxative abuse, and thus less likely to refer patients with laxative abuse problems to a psychiatrist. In BPD patients 15–29 years of age, the mean time from first suicidal communication to completed suicide was 30 months, with more than two previous suicide attempts found in 56% of the women.13 This suggests that self-injurious behaviors may herald suicide, and should stimulate referral to a specialist.
Treatment
General issues in treatment include treating comorbid conditions, avoiding medications that may lower inhibitions on impulsive behaviors (eg, benzodiazepines, narcotics), and providing a holding environment with structure and limits. Psychotherapy should address symptoms, triggers, and harmful behaviors. Dialectical behavior therapy appears to be an effective treatment resulting in greater reductions in self-damaging impulsive behaviors than usual treatment, particularly in those with a significant history of self-mutilation.14 It also appears to enhance treatment retention,14,15 reduce associated dysfunctional behaviors, such as substance abuse and binge eating, and reduce psychiatric hospitalization.15
A primary concern in the use of medications in women with BPD is the avoidance of drugs that are potentially lethal in overdose, particularly in combination with alcohol. Medications that may be effective in the treatment of BPD include antipsychotics and antidepressants. In an 8-week trial,16 olanzapine and olanzapine plus fluoxetine were superior to fluoxetine alone in alleviating chronic dysphoria and impulsive aggression. Earlier research has also shown antipsychotic medications to be more efficacious than tricyclic antidepressants, and monoamine oxidase inhibitors to be superior to antipsychotics in effects on mood, anxiety, psychoticism, and function, while neuroleptics had greater effects on hostility and impulsivity. Serotonergic antidepressants may provide a benefit in mood and impulsivity over medications affecting other neurotransmitters, but direct comparisons have not been published. Systematic data for the use of mood stabilizers in BPD are not available, and the risk associated with overdose is considerable.
Conclusion
Treatment of BPD in women may include limit setting, ensuring safety, dialectical behavior therapy, and combination therapy with antipsychotic medications and serotonergic antidepressants. Symptom reduction and enhanced function are attainable goals that can improve long-term outcomes in women with BPD. PP
References
1. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.
2. Driessen M, Herrmann J, Stahl K, et al. Magnetic resonance imaging volumes of the hippocampus and the amygdala in women with borderline personality disorder and early traumatization. Arch Gen Psychiatry. 2000;57(12):1115-1122.
3. Schmahl CG, Vermetten E, Elzinga BM, Bremner JD. A positron emission tomography study of memories of childhood abuse in borderline personality disorder. Biol Psychiatry. 2004;55(7):759-765.
4. Schmahl CG, Elzinga BM, Vermetten E, Sanislow C, McGlashan TH, Bremner JD. Neural correlates of memories of abandonment in women with and without borderline personality disorder. Biol Psychiatry. 2003;54(2):142-151.
5. Paris J, Zweig-Frank H, Kin NM, Schwartz G, Steiger H, Nair NP. Neurobiological correlates of diagnosis and underlying traits in patients with borderline personality disorder compared with normal controls. Psychiatry Res. 2004;121(3):239-252.
6. Goyer PF, Andreason PJ, Semple WE, et al. Positron-emission tomography and personality disorders. Neuropsychopharmacology. 1994;10(1):21-28.
7. DeSoto MC, Geary DC, Hoard MK, Sheldon MS, Cooper L. Estrogen fluctuations, oral contraceptives and borderline personality. Psychoneuroendocrinology. 2003;28(6):751-766.
8. Zlotnick C, Johnson DM, Yen S, et al. Clinical features and impairment in women with borderline personality disorder (BPD) with posttraumatic stress disorder (PTSD), BPD without PTSD, and other personality disorders with PTSD. J Nerv Ment Dis. 2003;191(11):706-713.
9. Yen S, Zlotnick C, Costello E. Affect regulation in women with borderline personality disorder traits. J Nerv Ment Dis. 2002;190(10):693-696.
10. Hochhausen NM, Lorenz AR, Newman JP. Specifying the impulsivity of female inmates with borderline personality disorder. J Abnorm Psychol. 2002;111(3):495-501.
11. Brown MZ, Comtois KA, Linehan MM. Reasons for suicide attempts and nonsuicidal self-injury in women with borderline personality disorder. J Abnorm Psychol. 2002;111(1):198-202.
12. Sansone RA, Wiederman MW, Sansone LA, Monteith D. Patterns of self-harm behavior among women with borderline personality symptomatology: psychiatric versus primary care samples. Gen Hosp Psychiatry. 2000;22(3):174-178.
13. Runeson BS, Beskow J, Waern M. The suicidal process in suicides among young people. Acta Psychiatr Scand. 1996;93(1):35-42.
14. Verheul R, Van Den Bosch LM, Koeter MW, De Ridder MA, Stijnen T, Van Den Brink W. Dialectical behaviour therapy for women with borderline personality disorder: 12-month, randomised clinical trial in The Netherlands. Br J Psychiatry. 2003;182:135-140.
15. Koerner K, Linehan MM. Research on dialectical behavior therapy for patients with borderline personality disorder. Psychiatr Clin North Am. 2000;23(1):151-167.
16. Zanarini MC, Frankenburg FR, Parachini EA. A preliminary, randomized trial of fluoxetine, olanzapine, and the olanzapine-fluoxetine combination in women with borderline personality disorder. J Clin Psychiatry. 2004;65(7):903-907.
Dr. Clayton is professor of psychiatric medicine at the University of Virginia in Charlottesville.
Disclosure: Dr. Clayton is a consultant for Bayer, Boehringer-Ingelheim, Eli Lilly, GlaxoSmithKline, Organon, Pfizer, and Wyeth; is on the speaker’s bureaus of Eli Lilly, GlaxoSmithKline, Organon, Pfizer, and Wyeth; and receives grants from Bayer, Boehringer-Ingelheim, Eli Lilly, GlaxoSmithKline, Merck, Organon, Pfizer, and Pherin.
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