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Borderline Personality Disorder Centre for Addiction
and Mental Health

Borderline Personality Disorder

 
 

 What is BPD?

 

What is BPD?

 Borderline personality disorder can have degrees of severity and intensity, but at its most severe and intense the emotional vulnerability of a person with BPD has been described as akin to a burn victim without skin. The tiniest change in a person’s environment, such as a car horn, a perceived look, a light touch from another person, can set a person with BPD on fire emotionally. Some of the extreme feelings associated with BPD have been identified and include intense grief, terror, panic, abandonment, betrayal, agony, fury or humiliation.

Family members have feelings around BPD as well. They have described living with a person affected by BPD as constantly “walking on egg shells,” never knowing what will trigger an outpouring of emotion or anger (DBTSF, 2006).

Family members may often feel manipulated by their loved one, but any perceived manipulation is not deliberate. The person living with BPD is trying to manage and deal  with intense emotions that greatly affect his or her behaviour.

Borderline personality disorder (BPD) is a serious, long-lasting and complex mental health problem. Though it has received less attention than other serious mental health problems, such as bipolar disorder or schizophrenia, the number of people diagnosed with BPD is similar or higher than these disorders. People living with BPD have difficulty regulating or handling their emotions or controlling their impulses. They are highly sensitive to what is going on around them and can react with intense emotions to small changes in their environment. People with BPD have been described as living with constant emotional pain and the symptoms of BPD are a result of their efforts to cope with this pain. This difficulty with handling emotion is the core of BPD.

The types and severity of BPD symptoms experienced may differ from person to person because people have different predispositions and life histories, and symptoms can fluctuate over time.

The term borderline personality disorder was coined in 1938 by Adolph Stern, a psychoanalyst who viewed the symptoms of BPD as being on the borderline between psychosis and neurosis. However, some experts now feel the term does not accurately describe BPD symptoms and should be changed. Some also feel that the existing name can reinforce the stigma already attached to BPD.

The road to specialized treatment and recovery is often hard because the symptoms of BPD can make the affected person emotionally demanding and difficult to engage and retain in treatment. As a result, the disorder is often stigmatized and helping services may be reluctant to accept clients with a BPD diagnosis.

However, with appropriate treatment, people with BPD can make significant life changes, though not all symptoms of BPD will disappear. Remission is more common as people reach the middle years of life. Hope and recovery are important to both the person and family members. “The overarching message of ‘recovery’ is that hope and meaningful life are possible. Hope is recognized as one of the most important determinants of recovery” (O’Grady & Skinner, 2007).​


How common is BPD?

Studies in personality disorders are at an early stage of development. Community surveys of adults have indicated that the prevalence of BPD is close to one adult in 100, similar to that of schizophrenia (Paris, 2005). The most recent (and largest) community survey in the United States found a prevalence of BPD of six per cent. At this time, we don’t have accurate rates for Canada (Grant et al., 2008).

It is unclear whether BPD is more common among women than men and some reports state that about 70 to 80 per cent diagnosed are women. Other research suggests that although there are more women in a treatment setting, there is no significant difference between the incidence of BPD in women and men (Grant et al., 2008).


What causes BPD?

As with other mental health disorders, our current understanding of BPD is that a person’s genetic inheritance, biology and environmental experiences all contribute to the development of BPD. That is, a person is born with certain personality or temperamental characteristics because of the way their brain is “wired,” and these characteristics are further shaped by their environmental experiences as they grow up and possibly by their cultural experiences.

Researchers have found differences in certain areas of the brain that might explain impulsive behaviour, emotional instability and the way people perceive events. As well, twin and family history studies have shown a genetic influence, with higher rates of BPD and/or other related mental health disorders among close family members. Environmental factors that may contribute to the development of BPD in vulnerable individuals include separation, neglect, abuse or other traumatic childhood events. However, families that provide a nurturing and caring environment may still have children who develop BPD, while children who experience appalling childhoods do not develop BPD.

Though histories of physical and sexual abuse are reported to be high among those with BPD, many other experiences can play a role for a child who is already emotionally vulnerable.

Stigma and BPD

Some therapists are reluctant to treat people with BPD because they are seen as being resistant to treatment and because of their emotionally demanding behaviour. Their tumultuous relationships, mood swings and suicidal gestures can provoke anger and frustration in the therapist. Some programs have formal or informal policies that refuse treatment to people with BPD. Advocacy groups have also identified lack of funding for research on BPD, and exclusion of BPD from research studies.

Sadly, people living with BPD often experience more stigma than people living with other mental health disorders. More information about understanding stigma, experiencing stigma, surviving stigma and combating stigma can be found in A Family Guide to Concurrent Disorders.



From: Borderline personality disorder: An information guide for families. (© 2009 CAMH)

 

 Symptoms

 

 What feelings are associated with BPD?

Some common symptoms displayed by a person with BPD include:

  • intense but short-lived bouts of anger, depression or anxiety
  • emptiness associated with loneliness and neediness
  • paranoid thoughts and dissociative states in which the mind or psyche “shuts off” painful thoughts or feelings
  • self-image that can change depending on whom the person is with; this can make it difficult for the affected person to pursue his or her own long-term goals
  • impulsive and harmful behaviours such as substance abuse, overeating, gambling or high-risk sexual behaviours
  • non-suicidal self-injury such as cutting, burning with a cigarette or overdose that can bring relief from intense emotional pain (onset usually in early adolescence); up to 75 per cent of people with BPD self-injure one or more times
  • suicide (about 10 per cent of people with BPD take their own lives)
  • intense fear of being alone or of being abandoned, agitation with even brief separation from family, friends or therapist (because of difficulty to feel emotionally connected to someone who is not there)
  • impulsive and emotionally volatile behaviours that may lead to the very abandonment and alienation that the person fears
  • volatile and stormy interpersonal relationships with attitudes to others that can shift from idealization to anger and dislike (a result of black and white thinking that perceives people as all good or all bad).


 

Borderline personality disorder can have degrees of severity and intensity, but at its most severe and intense the emotional vulnerability of a person with BPD has been described as akin to a burn victim without skin. The tiniest change in a person’s environment, such as a car horn, a perceived look, a light touch from another person, can set a person with BPD on fire emotionally. Some of

the extreme feelings associated with BPD have been identified and include intense grief, terror, panic, abandonment, betrayal, agony, fury or humiliation.

Family members have feelings around BPD as well. They have described living with a person affected by BPD as constantly “walking on egg shells,” never knowing what will trigger an outpouring of emotion or anger (DBTSF, 2006).

Family members may often feel manipulated by their loved one, but any perceived manipulation is not deliberate. The person living with BPD is trying to manage and deal with intense emotions that greatly affect his or her behaviour.

How is BPD diagnosed?

In Ontario, a physician, a psychiatrist or a registered psychologist can make a formal diagnosis of BPD or any other mental health disorder. The first step toward diagnosis is often with a family physician or the emergency department of a hospital. If there is enough reason to be concerned about someone’s mental health, the family physician can make a referral for further assessment.

Whoever makes the diagnosis will use the DSM-IV-TR to ensure that the person fits the criteria for a diagnosis for BPD.

What other disorders co-occur with BPD?

It is very common for someone with borderline personality disorder to have other mental health problems that can complicate the diagnosis of BPD. Some disorders that commonly co-occur with BPD include major or moderate to mild depression, substance use disorders, eating disorders, problem gambling, posttraumatic stress disorder (PTSD), social phobia and bipolar (manic-depressive) disorder. Sometimes it can be difficult to diagnose BPD because the symptoms of the co-occurring disorder mimic or hide the symptoms of BPD. As well, relapse in one disorder may trigger a relapse in the other disorder.

When does BPD begin?

Like the onset of other serious mental health problems such as schizophrenia, the symptoms of BPD appear in late adolescence or early adulthood. In some cases, parents may have no warning that something is wrong; their child who had appeared to be functioning well suddenly falls apart with the onset of behaviours such as emotional outbursts and suicidal gestures.​

 


From: Borderline personality disorder: An information guide for families. (© 2009 CAMH) 

 

 Therapies

 

What types of mental health services are available?

In the past, specialized treatment for BPD was hard to find, but the disorder is now being better recognized and diagnosed and more communities have established specialized treatment programs that significantly improve outcomes for people with BPD. However, the complexity and variety of BPD symptoms and their overlap with other psychiatric disorders continues to make accurate diagnosis difficult and time-consuming. For those affected and their families, there may be frustration before the right mix of help and resources can be found.

Services for people with mental health problems include hospital emergency departments, acute-stay hospital beds, extended residential care, as well as outpatient care provided by hospital outpatient services, community mental health clinics, assertive community treatment (ACT) programs or private practice psychiatrists, psychologists and other health professionals. There are also services that provide a variety of programs including housing and employment support, drop-in services and peer support. Some people may prefer to receive services from a health or social service agency, doctor or health practitioner providing language or culture-specific services. More information about specialized mental health services.

in your community can be found by contacting Mental Health Service Information Ontario or your local branch of the Canadian Mental Health Association. Further information on these and other resources is listed on p. 43. Health professionals such as your family physician, a nurse practitioner or social worker may be your first point of contact. They can determine whether they can assist you and your affected family member or whether you may need a referral to more specialized services. In smaller urban or rural communities, family physicians may provide the majority of mental health services and are often the primary support for people diagnosed with BPD.

Treatment for serious mental health problems such as BPD will usually involve:
  • education about BPD (psycho-education) with discussions on what is known about BPD and its causes, what kinds of treatments are available, how to self-manage BPD and how to prevent relapse
  • psychotherapy or counselling on an individual or group basis
  • prescribed medication for specific symptoms of BPD such as mood swings or anxiety.

In most cases, treatment will be on a community or outpatient basis, but some people may require a period of stabilization in hospital if they are experiencing severe symptoms such as suicide attempts, self-harming or psychotic behaviours. Being in the hospital can also give doctors the opportunity to review a person’s current medication regime, start new medications and monitor their impact.

Specialized and effective treatment for BPD requires a long-term commitment, often over a number of years. Families can benefit significantly by obtaining support to better understand BPD and developing their own self-care strategies.

What happens when BPD occurs with other mental health or addiction problems?

It is very common for someone with borderline personality disorder to have other mental health or substance use or gambling problems that can complicate the diagnosis and treatment of their BPD

What types of addiction services are available?

Many people with BPD also have a substance use problem that may require specialized substance abuse treatment either on a community outpatient or residential basis. Community-based outpatient or day programs are effective for most people with a substance use problem, though a person with few resources and supports may require the more intensive treatment and support provided in a residential program. In Ontario, specific admission criteria and standardized assessment tools have been developed to guide individualized treatment planning and referral to the most appropriate treatment program.

As well as assessment and referral, the continuum of specialized treatment resources includes withdrawal management services, community treatment (outpatient), day treatment, residential treatment, supportive residential treatment and continuing care. Some specialized programming based on gender, age, language or culture is also available across the province. You can get information on substance abuse services available in your community from your local addiction assessment and referral service or the Drug and Alcohol Registry of Treatment (DART). Specialized treatment definitions can be found on the dart website. Contact information for dart is given in Resources on p. 43.

In Ontario, treatment services for people with gambling problems are affiliated with substance abuse treatment services and available in many communities across Ontario. Information on gambling treatment is available through the Ontario Problem Gambling Helpline (see p. 43).

What types of concurrent disorder services are available?

Until recently, people with concurrent mental health and substance use disorders fell between the cracks because substance abuse and mental health services operated in isolation from each other. Staff members were often unwilling or felt unprepared to help someone with a concurrent disorder.

However, many services now recognize the importance of providing integrated treatment for both problems, particularly for people with severe mental health and substance use problems. Integrated treatment is a way of making sure that treatment is smooth, co-ordinated and complete. It also helps to ensure that the client understands the treatment plan. The client receives help not only with the concurrent disorders but also in other life areas, such as housing and employment. In integrated treatment, one person, such as a case manager or therapist, is responsible for overseeing the client’s treatment, which is provided by a team of professionals. The team may include psychiatrists, social workers, psychiatric nurses, psychologists, vocational and occupational therapists, peer support workers and addiction therapists. This treatment may take place in a single setting, such as a residential facility, or through a mixture of different resources such as family doctors, hospital outpatient clinics and community outreach teams.

Integrated treatment is not always offered, but it is important that the primary therapist or treatment team co-ordinate their treatment with other services being used by your affected family member. More information about treatment for concurrent disorders can be found in A Family Guide to Concurrent Disorders listed in Publications on p. 44 at the end of this booklet.

Specialized psychosocial treatments for BPD

It’s still “work” to use most of the skills I learned. I’ve seen some small changes in my interpersonal relationships and in my ability to manage my emotions more effectively.
— a client

There are a number of approaches for treatment of BPD. Two major approaches are cognitive behavioural therapy (CBT), which focuses on the present and on changing negative thoughts and behaviours, and psychodynamic therapy, which focuses on early relationships and inner conflicts. Treatment may be offered either individually or in a group. Family treatment is another mode of treatment that engages the whole family and works on relationships and interactions between family members.

There tends to be a high drop-out rate from treatment for borderline personality disorder, and a key to successful treatment is a good match between the therapist and client. Therapy might focus on learning to understand and manage emotions, harmful behaviours and thoughts of suicide. Medication may be used to make concentrating on learning self-management skills easier. Specialized treatments, now being developed and evaluated for BPD, use either a cognitive behavioural or psychodynamic framework. They have been developed and evaluated to be delivered by trained therapists in a specific way outlined in a manual. Some of these treatments have been more extensively evaluated than others. Clincians may use a variety of treatment approaches depending on the goals of the client and the skills base of the clinician. These may include:
  • dialectical behaviour therapy
  • cognitive behavioural therapy
  • schema therapy
  • system training for emotional predictability and problem solving
  • transference-focused psychotherapy
  • mentalization-based therapy.

Definitions of each of these therapies are included in the Glossary, p. 52.

Medication for BPD

Medication has a role in the treatment of many serious mental health problems. Though there is no specific medication for BPD, medication may be prescribed to reduce the impact of specific symptoms of the disorder. For example, medication may be prescribed to reduce depression or psychotic-like symptoms such as paranoia.
Medication can also be helpful to the person with BPD by providing a period of time when their symptoms are reduced. This allows them to focus on learning new skills to manage their behaviours with the goal of discontinuing medication when they are able to self-manage.

Though medication can reduce the severity of symptoms, medication does not cure BPD and medication is not appropriate for everyone with this diagnosis. The medications can have side-effects, and people may experience many, some or almost none of them. Side- effects can usually be addressed by changing the medication dosage or switching to another medication. Because of the number of different symptoms of BPD, there is also a risk that a person may be prescribed too many medications at the same time. Taking a number of different medications together can increase the risk of medication-related problems when:
two or more medications, including prescribed, over-the-counter and herbal or other alternative medications, interact with each other to produce unwanted or unexpected effects, such as a greater or lesser effect than intended
an individual has difficulty managing his or her medications (forgetting to take a medication or inadvertently taking extra doses of the medication)
alcohol is taken at the same time as medication, which can make some medications less effective, or when it is combined with medications such as a benzodiazepine, which produces a greater than intended effect.

Most mental health medications are used to help restore chemical balance in the brain. They can help reduce the frequency and severity of symptoms. Medications are divided into four main groups based on the problems that they were developed to treat:
  • antidepressants
  • mood stabilizers
  • anti-anxiety drugs
  • antipsychotics.

Medications have a generic (or chemical) name and a brand (or trade) name that is specific to the company that makes the medication. For example, the generic drug lorazepam is sold under the brand name Ativan. The brand name may change depending on the country in which the medication is marketed.


Antidepressants

Antidepressants are used to treat depression, as well as a number of other problems such as anxiety, chronic pain and bulimia. They work by increasing communication between nerve cells in the brain. A class of antidepressants called SSRIS (selective serotonin reuptake inhibitors) is most often prescribed for BPD. Some of the more common examples of SSRI medications are paroxetine (Paxil), fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa) and escitalopram (Cipralex).

Mood Stabilizers

Mood stabilizers are used to treat mood disorders, the most common of which is bipolar disorder (manic-depression). Mood stabilizers do not stabilize mood in BPD, but can help with outbursts of anger. Common examples are divalproex (Epival), carbamazepine (Tegretol), lamotrigine (Lamictal) and topiramate (Topamax).\

Anti-Anxiety Medications/ Sedatives

The main group of medications in this class are benzodiazepines, commonly used to treat sleep or anxiety problems or as a muscle relaxant. Examples are lorazepam (Ativan), clonazepam (Rivotril) and diazepam (Valium). They are effective for short-term treatment of sleep or anxiety problems, but can be addictive when used over the longer term.

Antipsychotics

These medications are used to treat schizophrenia and other psychotic disorders. The first generation of antipsychotic medications is called typical antipsychotics. Some examples include haloperidol (Haldol), perphenazine (Trilafon), loxapine (Loxapac or Loxitane) and chlorpromazine (Largactil). Atypical antipsychotics are a second generation of antipsychotic drugs that are categorized together because they work differently from typical antipsychotic drugs, by working primarily on the receptors of the neurotransmitters serotonin and dopamine. Common examples of atypical antipsychotics are olanzapine (Zyprexa), risperidone (Risperdal) and quetiapine (Seroquel). These second generation antipsychotics also have some mood stabilizing properties and are being used this way as well.

Family members can play an important role in supporting their affected family member to:
  • manage their medication by following prescribing instructions, and consult their physician or pharmacist if they have any concerns
  • determine whether their medication is helpful in reducing unpleasant symptoms
  • discuss their medication with their prescribing physician, its effects and side-effects and any difficulties they may be experiencing.

More information about different types of psychiatric medications can be found in A Family Guide to Concurrent Disorders, listed on p. 44 at the end of this booklet. 

Recovery from BPD

Despite its often devastating effects on the affected person and his or her family, treatment outcome research has found that for many people, treatment does work. Many people with BPD do learn to cope with their symptoms and do things differently, particularly as they reach middle age. Because of the serious and complex nature of their symptoms, people affected by BPD often require long-term treatment, often over several years.

Treatment accelerates the natural process of recovery. Studies have followed people affected by BPD for extended periods of time and found that most improve with time. About 75 per cent will regain close to normal functioning by age 35 to 40 and 90 per cent will recover by age 50 (Paris, 2005).

It may take a longer time for a person with BPD to have a remission of their symptoms compared to people with other mental health problems, but when symptoms do decline, remission seems stable with few relapses compared to other serious mental health problems.

However, studies have also found that some BPD symptoms endure longer than others in some people. Some of the more harmful behaviours such as self-harm and suicidal behaviour decline while other symptoms such as feelings of abandonment and difficulty being alone may last longer.

Hope and recovery are important to both the person with BPD and his or her family members. 





From: Borderline personality disorder: An information guide for families. (© 2009 CAMH) ​
 

 Finding Treatment

 

Treatment and Support:



Ontario Mental Health Helpline (open 24/7 for treatment anywhere in Ontario)​​​​)
 
 
 

 Resources

 
 

 Health Info A-Z

 
CAMH Switchboard 416-535-8501
CAMH General Information Toronto: 416-595-6111 Toll Free: 1-800-463-6273
Connex Ontario Help Lines
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