Borderline Personality Disorder DSM-5 301.83 (F60.3)
DSM-5 Category: Personality Disorders
Borderline personality disorder is a complicated disorder that impacts interpersonal relationships and sense of self. The DSM-5 explains that a core feature of borderline personality disorder is an intense fear of abandonment (American Psychiatric Association, 2013). Although men can be diagnosed with borderline personality disorder, it primarily affects women. Individuals with borderline personality disorder may exhibit a variety of unsafe and unwise behaviors in an attempt to avoid abandonment. Patients with borderline personality disorder also struggle with emotional regulation. Suicidal threats, attempts and behaviors are common among the borderline population. Self-injury is another maladaptive coping mechanism common among those dealing with borderline personality disorder. Fortunately, borderline personality disorder is treatable. Dialectical behavioral therapy is the most successful form of treatment. Dialectical behavior therapy integrates individual therapy, group therapy and phone sessions to increase self-awareness, coping skills and emotional regulation.
Symptoms of Borderline Personality Disorder
The DSM-5 describes Borderline personality disorder as “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning in early adulthood and present in a variety of contexts.” (American Psychiatric Association, 2013). Patients with borderline personality disorder are typically terrified of abandonment, whether real or imagined. Frantic efforts to avoid such abandonment are a prominent feature. These intense fears of abandonment can occur even when the patient is expecting the separation. For example, a patient may panic or become angry when a therapist is out of town, even if the vacation was previously announced and alternate resources were provided. Another symptom of borderline personality disorder is frequent and intense changes in relationships. Often, the patient will strongly love than strongly hate partners, relatives, doctors, and others (American Psychiatric Association, 2013).
Borderline personality disorder is also characterized by identity problems, such as a weak or distorted sense of self. This can be manifested through dramatic changes in interests, goals or values. Similarly, individuals with borderline personality disorder undermine their efforts. They may destroy healthy relationships, or quit school right before graduation. Impulsivity is another common symptom of borderline personality disorder. The impulsivity is self-damaging and could relate to substance abuse, reckless driving, gambling, binge eating, unsafe sex, or unwise spending. Patients with borderline personality disorder frequently feel a strong sense of emptiness. Self harm behaviors, such as cutting, picking, or burning, as well as suicidal ideations, threats and behaviors are also common. Although self-harm and suicidal behaviors can be genuine and should be taken seriously, they can also be used as frantic efforts to avoid abandonment and can also be impulsive (American Psychiatric Association, 2013).
Individuals with borderline personality disorder have a difficult time controlling emotions. The DSM-5 explains that patients may express disproportionate or inappropriate anger. This can result in temper problems or physical fights. Finally, patients with borderline personality may experience dissociative symptoms or paranoia when under stress (American Psychiatric Association, 2013).
Prevalence of Borderline Personality Disorder
The prevalence of borderline is estimated to be around 2% of the general population and as high as 20% among the clinical population. The DSM-5 explains that although men can be diagnosed with borderline personality disorder, patients are predominantly female (American Psychiatric Association, 2013).
Morbidity and Mortality Related to Borderline Personality Disorder
The DSM-5 warns that 8-10% of individuals with borderline personality disorder complete a suicide. Many more attempt suicide or self-mutilate. Failed suicide attempts and self-mutilation can result in permanent injury or disability (American Psychiatric Association, 2013). Self-harm, or self-mutilation is defined as any deliberate destruction to one’s own body tissue without suicidal intent. Self-injury most often includes cutting, burning, skin picking, carving, and pinching, biting, hitting, banging, stabbing, poking, and inserting object under skin. Although any part of the body can be injured, injury to the arms, legs, and stomach are most common. Studies have reported a prevalence of 2.5-7% among teenage girls in a 12 month period and lifetime prevalence of 17% among American college students. 40-60% of teenagers already being treated for mental illness have reported or been treated for self-injury. Self-injury is more common among women and girls than men and boys and Caucasian than minority races, but occurs in all ethnic groups (Franklin, et al., 2010)
Treatment of Borderline Personality Disorder
Dialectical behavioral therapy (DBT) is the most effective intervention for treating borderline personality disorder. DBT asserts that all aspects of the patients are interrelated. Therefore, a whole systems approach is taken. DBT is a form of cognitive behavioral therapy that incorporates mindfulness and acceptance while reducing judgment. DBT views the negative behaviors associated with borderline personality disorder as learned behaviors. DBT accepts the painful feelings of the patient and teaches new coping skills from a position of empathy and understanding. Part of this includes the understanding that truth and reality are both subjective experiences (Van Dijk, 2013).
Emotional regulation is another important component of DBT. Part of this process includes helping the patient to recognize and label negative feelings. DBT also works to increase interpersonal skills, thereby reducing chaos in interpersonal relationships. Group therapy is one way of increasing interpersonal skills in a therapeutic setting. Another important component of DBT is that patients may call the therapist for brief coaching at any time (Van Dijk, 2013). This feature of treatment is extremely important because recurrent crises are a reality of borderline personality disorder. Helping a patient through a crisis offers the clinician important insight into the precipitating cause of the patient’s acute anxiety, panic or depression. Helping a patient through a crisis also teaches the patient crisis-management skills that can be implement in future crises (Borschmann and Moran, 2011).
The unsafe behaviors associated with borderline personality disorder are often the result of poor coping skills. Lack of coping skills has been associated with self-injury, both with and without diagnosis of borderline personality disorder. For example, very young teens often do not have access to adaptive or non-adaptive coping mechanisms. Leaving an unpleasant situation may be nearly impossible, and not all adolescents have access to alcohol and drugs. This is often a determining factor in whether an individual practices self-injury one time or habitually. As more coping skills are available, they tend to depend less on self-injury other unsafe behaviors (Nock, 2009)
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Borschmann, R. & Moran, P. (2011). Crisis management in borderline personality disorder. International Journal of Social Psychiatry, 57(1): 18-20
Franklin, J.C., Hessel, E.T., Aaron, R.V., Arthur, M.S., Heilbron, N. & Prinstein, M.J. (2010, Nov). The function of nonsuicidal self-injury: Support for cognitive-affect regulation and opponent processes from a novel psychophysiological paradigm. Journal of Abnormal Psychology. 119(4), 850-862.
Nock, M.K., Prinstein, M.J. (2009, Nov). Revealing the form and function of self-injurious thoughts and behaviors: A real-time ecological assessment study among adolescents and young adults. Journal of Abnormal Psychology, 118(4), 816-827
Van Dijk, S. (2013). DBT made simple : A step-by-step guide to dialectical behavior therapy. Oakland : New Harbinger Publications.
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