Borderline personality disorder (BPD) is a chronic, debilitating disorder affecting the limbic system, the area of the brain that controls emotions. Scientists have found inadequate regulation of serotonin, dopamine, and other neurotransmitters in those with BPD. Recently, BPD has been termed "emotion-impulse regulation disorder" (ERD) because people with BPD have great difficulty regulating their emotions and are very sensitive to environmental circumstances (BPD Today, 2006).

It is estimated that in the United States, 2% to 4% of all adults, 20% of all psychiatric inpatients, and 11% of outpatients have BPD (BPD Today, 2006). Approximately 75% of all diagnoses are among women. However, this may be the case because men with similar symptoms often are assigned a diagnosis of antisocial personality disorder (APD) or narcissistic personality disorder (NPD) (Dean, 2001). Among first-degree biologic relatives of those with the disorder, BPD is about five times more common than in the general population.

Environmental factors play a strong role in BPD. Physical and sexual abuse, neglect, hostile conflict, and early parental loss or separation (death, divorce) are common in the childhood histories of those with BPD. Researchers have linked early abuse to physiologic changes seen in BPD such as changes in the hippocampus and stress-response system. Other common disorders co-occurring with BPD include other personality disorders, mood disorders, substance-related disorders, eating disorders (notably bulimia), posttraumatic stress disorder, and attention-deficit/hyperactivity disorder (NIMH, 2001; Siever, 1997).

The Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 2000) defines BPD as "a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts" (p. 287). Five or more of the following diagnostic criteria must be present to confirm a diagnosis of BPD.

Criterion 1

Frantic efforts to avoid real or imagined abandonment. The perception of imminent separation, rejection, or loss of external structure can lead to profound changes in self-image, affect, cognition, and behavior. When faced with common separations or unavoidable changes in plans, persons with BPD experience intense abandonment fears and anger. They often manipulate others out of a need to be constantly nurtured.

Criterion 2

A pattern of unstable and intense interpersonal relationships. Individuals with BPD alternate between extremes of idealization and devaluation of caregivers or lovers early on in relationships, demanding a lot of time together and inappropriately sharing intimate information. However, they quickly switch to devaluing the same people, feeling the other person does not care enough.

Criterion 3

Identity disturbance: markedly and persistently unstable self-image or sense of self. Individuals with BPD may suddenly change their opinions and plans about career, sexual identity, values, and friends, or change from a needy person to a strong rescuer. Although typically they have a self-image based on being bad or evil, they may have feelings that they do not exist at all, usually when they feel a lack of meaningful nurturing and support.

Criterion 4

Impulsivity that is potentially self-damaging in at least two areas. Persons with BPD may gamble, spend money irresponsibly, binge eat, abuse substances, engage in unsafe sex, or drive recklessly.

Criterion 5

Recurrent suicidal or self-mutilating behavior, gestures, or threats. Suicide threats or attempts and self-mutilative acts (cutting, burning) are common, often resulting in physical handicaps. Successful suicide occurs for 8% to 10% of these individuals. Self-destructive acts usually are precipitated by threats of separation or rejection, or by expectations that they can assume increased responsibility. Self-mutilation brings relief by reaffirming their ability to feel or by atoning for "evil."

Criterion 6

Affective instability due to a marked reactivity of mood. Persons with BPD may have intense episodic dysphoria, irritability, or anxiety and despair that lasts a few hours and rarely more than a few days. Longer periods of well-being or satisfaction are rare.

Criterion 7

Chronic feelings of emptiness. Easily bored (related to extreme emotional reactivity), these individuals constantly seek something to do. Recurrent job losses, interrupted education, and broken marriages are common.

Criterion 8

Inappropriate, intense anger or difficulty controlling anger. Displays of temper, extreme sarcasm, enduring bitterness and anger, and physical fights are common, often elicited when a caregiver or lover is seen as neglectful or abandoning. Outbursts typically are followed by shame and contribute to the feeling of being evil.

Criterion 9

Transient, stress-related paranoid ideation or severe dissociative symptoms. These symptoms may occur during periods of extreme stress, but generally are of insufficient severity or duration to warrant an additional diagnosis. Episodes occur most frequently in response to real or imagined abandonment. Return of nurturance results in remission of symptoms.

There is considerable variability in the clinical course of BPD. Symptoms usually are most severe in young adulthood (ages 19-34 years) and gradually wane with advancing age. During their thirties and forties, the majority of individuals with BPD attain greater stability, with 75% of BPD individuals no longer meeting the criteria for BPD fifteen years after diagnosis. Because BPD has biological and environmental etiologies, treatment involves therapy and medication. Individual and/or group therapy is recommended, using approaches such as cognitive therapy, dialectical behavior therapy, or relapse prevention therapy. Psychopharmacologic intervention is based on symptom management (Dean, 2001; NIMH, 2001).-JCN