Borderline Personality Disorder: There Is Nothing Black and White About It

The exploration of borderline personality disorder has become increasingly important because borderline personality disorder is the most common personality disorder to be diagnosed. And it often has comorbidity with other psychiatric disorders. Borderline personality disorder is described as, “a severe personality disorder that causes significant social and functional impairments in youth and adults,” (Jovev, et al., 2014). It is important to explore borderline personality disorder, diagnosing, issues related to a diagnosis, prevalence in society, and possible treatment options. Often people with borderline personality disorder are described as black and white because small interpersonal disturbances can cause an extreme reaction. Often people say, “they love or hate you.” People with borderline personality disorder live in the extremes, but the more research learns about borderline personality disorder, the less black and white it becomes.

Borderline personality affects 1.6% of the adult population in the United States at any one time and has a life time prevalence of about 6% (Jabbar, Annsari, Czelusta, Sharoon, & Shah, 2018). There is one major misconception about borderline personality disorder, and that is that it affects the female population more than the male population. Studies have shown it is not more prevalent in any one gender, rather, both genders see an equal prevalence of this disorder. The misconception arose because women are more likely to seek treatment for this disorder (Jabbar, Annsari, Czelusta, Sharoon, & Shah, 2018). Although this may seem like a relatively low number of adults being affected by borderline personality disorder, this can be a highly disruptive disorder for those who are suffering from it.

According to the diagnostic and statistical manual for psychiatric disorders edition five (DSM-5) a diagnosis for borderline personality disorder can be made if the person in question meets the following:

“A. Significant impairments in personality functioning manifest by:

1. Impairments in self functioning (a or b): a. Identity or b. Self-direction


2. Impairments in interpersonal functioning (a or b): a. Empathy or b. Intimacy

B. Pathological personality traits in the following domains:

1. Negative Affectivity, characterized by: a. Emotional liability, b. Anxiousness, c. Separation insecurity, d. Depressivity

2. Disinhibition, characterized by: a. Impulsivity, b. Risk taking

3. Antagonism, characterized by: a. Hostility

C. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.

D. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment.

E. The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance or a general medical condition” (American Psyciatric Association, 2013).

The symptoms are rated from most significant to lease significant in the DSM-5 (Richetin, Preti, Costantini, & De Panfillis, 2017). Rather than putting an emphasis on the more significant symptoms, the DSM-5 requires a certain quantity of symptoms to be present. Specifically, five out of the nine possible symptoms. (American Psyciatric Association, 2013). Many of these requirements overlap heavily with Bipolar disorder. Impulsivity and risk taking are often linked to a bipolar manic episode. While symptoms like depressively, anxiousness, and hostility can easily be interpreted into a bipolar depressive episode. The DSM-5 gives more specific details to diagnosing bipolar disorder including length and prevalence of episodes. There are notable differences in the diagnosing of bipolar disorder and borderline personality disorder. But with the similarities in primary symptoms, it is easy to see why this may cause hesitation among providers to diagnose borderline personality disorder.

Another major overlapping issue is the high rate of hallucinations in individuals with borderline personality disorder. As reported by the Scientific Reports in 2017, the rate of hallucinations in patients with borderline personality disorder range from 25%-54% (Niemantsverdriet, et al., 2017). This percentage is significant because compared to other disorders the percentage is still high. Bipolar disorder has a rate of hallucinations ranging from 50%-70% depending on the episode type (Fast, 2018). Many other psychiatric disorders may accompany hallucinations.

Hallucinations are often thought to be limited to psychotic disorders or a mood disorder with psychosis. This element can make the diagnosis of borderline personality disorder even more difficult, especially if a patient states a hallucination as their primary symptom. Hallucinations in borderline personality disorder are more prevalent in patients that have experienced childhood adversities such as emotional abuse (Niemantsverdriet, et al., 2017), but a low correlation in patients that experienced solely emotional neglect (Niemantsverdriet, et al., 2017). There is a strong difference between borderline personality disorder hallucinations and hallucinations in patients with psychotic disorders like schizophrenia. Borderline personality disorder hallucinations were not accompanied by negative symptoms like avolition, alogia, asociality, or restricted affect. Borderline personality disorder hallucinations were more often found co-occurring with delusional thinking. This difference can help clinicians better distinguish between the two types of hallucinations, but a misdiagnosis may still be made.

What makes diagnosing borderline personality disorder even more complicated, is the rate of co-morbid mental health disorders. The co-morbidity rate is very high. Statistically, of those diagnosed with borderline personality disorder, 85% are also diagnosed with another mental health disorder (Hall, DNP & Riedfored, PHD, 2017). The most common mental health disorders to exist comorbid with borderline personality disorder are substance abuse disorder in males and females (Hall, DNP & Riedfored, PHD, 2017). This is often because of the symptoms of borderline personality disorder is, “The feeling of chronic emptiness” (Hall, DNP & Riedfored, PHD, 2017). People with borderline personality disorder may to turn to substance abuse to deal with the emptiness. Thus, using alcohol or drugs as a maladaptive coping mechanism. The second most common comorbid disorder for females are eating disorders (Hall, DNP & Riedfored, PHD, 2017). Current statistics state that 42% of females with BPD also have and eating disorder (Hall, DNP & Riedfored, PHD, 2017). This may be linked both to the symptom of borderline personality disorder of chronic emptiness, but also to the symptom of impairment of identity (American Psyciatric Association, 2013). The emptiness feeling is most likely linked to binge eating disorder, while the poor self-image may be linked to anorexia nervosa or bulimia nervosa. The second most common comorbidity for males is an identity disturbance disorder. This is most likely linked to the symptoms in poor personality functions. There are many other comorbid disorders (see figure above) that may complicate the diagnosis or borderline personality disorder.

This symptom of chronic emptiness leads to one of the flag points for this disorder, non-suicidal self-injury (NSSI). NSSI can exhibit in my many ways, an eating disorder, intentional ingestion of foreign and harmful objects (Jabbar, Annsari, Czelusta, Sharoon, & Shah, 2018), and cutting - a more popular choice among adolescents (Brown, et al., 2018). Cutting has become a “cool” thing to do. A recent 2016 German study has found that the most popular hashtags associated with mental health and self-injury are “#cutting,” “#depression,” “#Ana” (a short hand for anorexia), “#scars,” and “#self-injury,” (Brown, et al., 2018). During four weeks in April 2016, a total number of 32,182 self-harm pictures were posted to German account holders (Brown, et al., 2018). Since this did not contain U.S. and other countries posts, and adding the number of private accounts, it is not hard to imagine how much exponentially higher that number would be. With the amount of exposure to self-harm images, it is desensitizing an important symptom and making it part of the accepted culture.

The direct causes of borderline personality disorder are still relatively unknow. It is suspected that the cause is genetic susceptibility, neurobiological dysfunction of the frontal lobe, altered neuropeptide function, neurotransmitter alterations, and childhood trauma (Hall, DNP & Riedfored, PHD, 2017). Unfortunately, at this time not many researchers have conducted specific studies on preceding symptoms or deformities. The research that has been done is not enough to classify empirical evidence that “x” causes borderline personality disorder. Currently there are many schools of thought on the exact cause.

One theory is based on the neurobiological theory of how someone reacts to four points of one’s personality (Jovev, et al., 2014). The four points are surgency (SUR) or commonly referred to as extroversion, negative affectivity (NA) or neuroticism, affiliation (AF) or openness, and effortful control (EC) or conscientiousness. People who experience these personality traits in the extreme are more likely to develop borderline personality disorder. People who experience very low AF are most strongly correlated to developing borderline personality disorder. Low AF presents itself as a strong lack of empathy or an inability to take interest in other people’s problems (Jovev, et al., 2014).

Another theory that has been presented is an asymmetrical balance in the hippocampus (Jovev, et al., 2014). The hippocampus is located deep in the brain, see figure below for exact location. Using positron emission technology (PET Scans), the levels of activity in the brain can be read and analyzed. People who were diagnosed with borderline personality disorder showed an elevation in right hemisphere hippocampal activity (R>L). As of 2013, no specific research study on borderline personality and asymmetrical activity had been done. The correlation between borderline personality disorder and the imbalance in activity in the hippocampus was found in a study looking at antisocial personality disorder (Jovev, et al., 2014).

Abnormalities in the hippocampus can disrupt hippocampus-prefrontal circuitry. The hippocampus-prefrontal circuitry is an important connection in the brain, essential to proper functioning. Changes or dysfunction of the hippocampus have been directly linked to disrupted social learning, in attention to environmental cues, impulsivity, inappropriate emotional responses, and a lack in inhibition (Jovev, et al., 2014). These abnormalities are believed to develop in utero and make an individual genetically predisposed to borderline personality disorder.

Positive and significant correlations have been found between borderline personality disorder and childhood abuse or trauma (Niemantsverdriet, et al., 2017). Current studies indicate that approximately 83% of those with borderline personality disorder have reported some interpersonal trauma during childhood (Westphal, Olfson, Bravova, Gameroff, & Gross, 2013). This kind of trauma includes sexual abuse, physical abuse, emotional abuse, or bullying. This can include perceived trauma including perceived unfair treatment by others. Most importantly is the feelings of being invalid against their peers. An example of this could be a child who was adopted, and had a loving family, but who heavily experienced a sense of abandonment by their birth parents. Another example would be a child that was bullied and lacked validation from their peers. Other childhood adversities have been linked to the development of borderline personality disorder. These adversity triggers are often found in individuals that come from a low socioeconomic background. This weighs heavily on the Hispanic and African American population (Westphal, Olfson, Bravova, Gameroff, & Gross, 2013). There is currently no genetic link between ethnicity and development of borderline personality disorder.

A common question is, “If I’ve experienced trauma, will I develop borderline personality disorder?” The answer to that is complicated as indicated above. However, the belief is that if someone is predisposed to borderline personality disorder (i.e. genetics, low hippocampal activity) exposure to childhood trauma could trigger borderline personality disorder to develop. At this time there is no direct formula of what will cause it to develop, just strong correlations between factors.

Currently there is no cure for borderline personality disorder. However, there are several forms of treatment that have been found effective at reducing or eliminating symptoms. Therapy has been found effective, particularly with dialectical behavioral therapy (DBT) (Jabbar, Annsari, Czelusta, Sharoon, & Shah, 2018). Dialectical behavioral therapy braces a mix of confrontation of emotions and validity or reassurance by the therapist. Dialectical behavioral therapy is a form of cognitive behavioral therapy that is ment to help the patient think and process emotions in a healthier manner (Elements Behavioral Health, 2013). Since DBT has been proven effective in borderline personality disorder and other mental illnesses, many worksheets and workbooks have been created. These workbooks and worksheets have become an important part in helping the therapy progress and preventing remission. Since these activities can be done in the comfort of one’s own home, patients can continue treatment between therapy sessions or after therapy has been discontinued.

Another common treatment for borderline personality disorder is the use of selective serotonin reuptake inhibitors (Jabbar, Annsari, Czelusta, Sharoon, & Shah, 2018). Selective serotonin reuptake inhibitors (SSRI) is a classification of select antidepressants. Depending on the presenting symptoms a mood stabilizer or antipsychotic may be prescribed alone or in conjunction with an SSRI. The goal of SSRI’s in borderline personality disorder is to “inhibit neuronal reuptake of serotonin in the central nervous system (CNS) and may have a weak effect on neuronal reuptake of norepinephrine and dopamine,” (Medscape, 2017). Serotonin, norepinephrine and dopamine balance is critical to elevating mood and helping individuals cope with life stressors. Mood stabilizers are believed to reduce impulsivity in those with borderline personality disorder. Antipsychotics may have a harsh sounding name, but they have been helpful in treating rage, depression, despair, and in some cases hallucinations (Niemantsverdriet, et al., 2017).

Borderline personality disorder is a complex psychiatric disorder. Diagnosing it should be taken with great care, considering any comorbid disorders. It effects much the population. With currently no direct cause of the disorder, the dream of preventative measures is still out of site. Thankfully there are some wonderful, effective treatments for borderline personality disorder. As much as many may think borderline personality disorder is cut and dry, it is much more complicated. It can truly be seen that borderline personality disorder is not black and white.

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