- Borderline syndrome;
- Borderline Personality Disorder;
- Emotionally Unstable Personality;
- Emotional Intensity Disorder.
The most commonly used nomenclatures in Brazil are Borderline or Borderline Personality Disorder.
Index – in this article you will find the following information:
- What is Borderline Personality Disorder?
- Types and Classifications
- Clinical groups
- Causes and Risk Factors
- Symptoms of Borderline Personality Disorder
- Can Borderline Personality Disorder be cured?
- What is the treatment?
- How to live together
Types and Classifications
In the scientific community, there is still no consensus on borderline personality types and none of the manuals used for diagnoses categorize different types. However, there are researchers and experts who suggest certain subdivisions that want a better description of the condition.
Although these classifications are known to many who study the disorder, researchers agree that they are not enough to categorize borderline patients. Research is still being done to investigate ways to classify them more precisely, since symptoms manifest differently in different individuals.
One of the best known is that of Randi Kreger, present in his book The Essential Family Guide to Borderline Personality Disorder , which classifies the disorder between the Conventional (low-functioning) and the Invisible (high-functioning).
Check below all the classifications that the TPB has:
Also classified as a Low Functioning Borderline, this type of borderline has more self-destructive symptoms, and can often be hospitalized for its attempts at self-mutilation and suicidal behavior. The author uses the term acting in to describe this type of borderline, which tries to relieve emotional pain through itself, making risky decisions that can have serious consequences for your health and future.
Due to frequent hospitalizations, this type can prevent the person from working or studying normally.
The person of the invisible type is even more difficult to be seen as having the disorder, because, on the outside, he seems to lead a normal life. He is able to work and study, he is not frequently hospitalized and his self-destructive behavior may not be as pronounced. For this reason, it is classified as a High Functioning Borderline.
However, the disorder manifests itself in interpersonal relationships, through verbal abuse, criticism and even physical violence. The anger intense is discounted on others instead of yourself. The author calls this acting out.
Another well-known classification is the subtypes proposed by Theodor Milon: Discouraged, Petulant, Impulsive and Self-destructive. His suggestion is that the TPB holder may exhibit none, one or more of the following characteristics:
It can include characteristics of the elusive personality (including isolation), it can be flexible, submissive, loyal. You tend to feel vulnerable and in constant danger.
Passive-aggressive behavior, can be negative, impatient, restless, stubborn, defiant, pessimistic and spiteful. He gets tired easily and is quickly disappointed.
It may have histrionic and antisocial characteristics. It tends to be capricious, superficial, distracted, indecisive, frantic and seductive. They shake when they fear loss, they become dark and irritable. Potentially suicidal.
It may have depressive or masochistic characteristics, it is more focused on you. Your anger is self-punishing. He tends to be conformist, tense and surly, he is not very respectful or insinuating. Possibly suicidal.
It is also possible to classify borderline individuals into 4 distinct clinical groups:
- Group A : Schizoid and / or paranoid characteristics predominate, approaching psychosis;
- Group B : Predominance of dysthymic and affective characteristics;
- Group C : Predominance of antisocial and perverse characteristics, they satisfy almost all the criteria of the DSM-5 (5th edition of the Diagnostic and Statistical Manual of Mental Disorders);
- Group D : Predominance of severe neurotic characteristics, such as obsessive-compulsive, hysterical and phobic.
Causes and Risk Factors
There is no consensus on the causes of Borderline Personality Disorder. There are, however, some factors that the researchers believe are related to the development of the disorder, being linked to genetics, social factors and even brain abnormalities.
It is important to note that BPD is a multifactorial condition, that is, it usually depends on the joint manifestation of risk factors. In this sense, the presence of an aspect does not determine the person’s involvement.
There is evidence that the development of BPD is linked to genetics, but it is not certain whether there is a gene responsible for it.
Twin studies show that if one of the twins suffers from the disorder, there is a high chance that the other sibling will also suffer. In addition, people who have a borderline parent (or both) are also more likely to develop the disorder.
Even so, it is necessary to be cautious with these results, as they may be more related to the family environment than to the genetics itself.
People can inherit some personality traits from their parents, and if they grew up with emotionally unstable and aggressive parents, it is possible that they inherited it from them, rather than having inherited TPB genetically.
Among borderline patients, there are reports of childhood troubled by an unstable family environment. Parents and caregivers with hostile personalities, and environments where there were many conflicts and instability in relationships can be linked to the development of borderline traits.
Among the social factors, which are permeated by family and affective relationships, situations of emotional invalidation can occur, in which the person feels that his feelings and emotions are incoherent or undue at the moment.
Invalidation can occur through repression or criticism, which is often subtle. However, the construction that the feelings are wrong can be extremely harmful and become a conductive factor to TPB, as long as it is associated with other conditions.
In addition, living with people with other types of personality disorder can also have an influence.
Many patients report traumas such as emotional, verbal or even sexual abuse during childhood. There are reports of careless parents and caregivers who tended to invalidate the child’s thoughts and feelings, in addition to not providing the necessary physical care.
However, it is important to note that not all borderline patients experienced trauma during childhood, which is only a risk factor and not a direct cause.
Researchers found, through MRI scans, that some parts of the brains of people with BPD are smaller than normal or that their activity levels were unusual.
The cerebellar tonsils have been shown to be smaller and more active in people with BPD. This part of the brain is responsible for regulating emotions, including negative ones, which may explain the intensity of emotions in people with this disorder.
The hippocampus, which assists in behavior and self-control, also tends to be smaller in borderline individuals.
The prefrontal cortex assists in the regulation of negative emotions, curbing impulses and decreasing the intensity of those emotions. In borderline people, this part of the brain has been found to be less active, especially when patients experience the sensation of abandonment.
There are also abnormalities in the neurotransmitter serotonin . Such anomalies are linked to depression , aggressiveness and difficulty in controlling destructive impulses. Other neurotransmitters suspected of undergoing changes are dopamine and norepinephrine, related to emotional instability.
It is important to note that it has not yet been determined whether brain changes are caused by BPD or if they trigger the disorder. The researchers’ difficulty in determining this direction causes the anomalies to assume the role of cause or consequence.
In individuals with BPD, it has been found that the production of cortisol, a hormone directly related to stress , is increased.
In relation to women, the estrogen cycle revealed the possibility of predicting some symptoms according to the levels of the hormone.
Like brain changes, hormonal changes are still being researched and it is not known to determine whether BPD affects hormone production or whether it is affected by the disorder.
Symptoms of Borderline Personality Disorder
The symptoms of Borderline Personality Disorder are varied and can be grouped into 4 categories:
- Emotional instability (or affective deregulation);
- Cognitive and perception distortions;
- Impulsive behavior;
- Intense and unstable interpersonal relationships.
The emotions of borderline individuals are very unstable, and can change in a short period of time, in a matter of hours and with a maximum duration of a few days. It is common for these patients to feel despair along with suicidal thoughts and, a few hours later, to have positive emotions, as if nothing had happened.
The most frequent mood changes in borderline patients are between anger and anxiety , as well as depression and anxiety.
Borderline individuals feel emotions more intensely and more easily than other people. Emotions can also last longer, making the borderline take time to recover from some emotion. People with TPB have a tendency to feel euphoria instead of happiness, grief instead of sadness, intense hatred instead of anger.
Especially with anger, it is difficult to control the intensity and the actions themselves. These people tend to get very angry easily, without a plausible reason for outside observers. Dry and sarcastic responses can occur suddenly. Engaging in fights and physical violence is also common.
Sensitivity to rejection and criticism
Another striking symptom related to emotions is the high sensitivity to rejection and criticism. Borderline patients may feel that a criticism directed at their work is, in fact, a criticism of their person, or that the inability of a loved one to attend an appointment is a sign that that person does not want to see the patient.
Cognitive and perception distortions
Instability in self-image and self-identity
The bearer of TPB may report not being able to know who he is or what he likes. He has trouble identifying what is important to him, as well as describing himself. You can change plans and goals in no time. Sexuality and gender identity can also be affected.
Due to this instability, it is common for patients to have chronic feelings of emptiness. Some even think that life is meaningless.
Low self esteem
Another feeling that people with TPB experience is low self-esteem . They think that they are not good enough and even that they are bad people. Sometimes they may think that they do not exist.
The patient with BPD may have paranoid thoughts, such as thinking that a loved one is abandoning him when in fact that person is busy (with work, studies and the like), thinking that people are trying to harm him, among other similar thoughts to those.
Some patients report not being able to recall the existence of a feeling when it is not often demonstrated and, therefore, the absence of loved ones may lead you to think that he is no longer loved, that he has been abandoned and that people want him to suffer. .
Often induced by paranoid thoughts, the borderline individual may experience a phenomenon called dissociation. Dissociation is the feeling of being disconnected from what is around you, and you may even feel outside your own body.
The patient may feel as if he is dreaming, or as if he has a break with his personality. Your words and gestures can become mechanical and the person can feel that he is somewhere else, controlling the body as if he were a puppet.
It can also present dissociative amnesia, where important memories are repressed. The person can forget who he is, the last days, months or years.
To get rid of emotional pain, the borderline can impulsively engage in activities that can damage your health and even your future.
The patient may become involved in substance abuse, drinking, spending a lot of money on impulsive purchases or gambling, risky and promiscuous sex, including with strangers, among others.
Self-harm and suicide
Other impulses that the individual may not be able to control are self-destructive desires such as self-mutilation (cutting, burning, hitting, among others) and suicide.
In DSM-5, self-mutilation and suicidal behavior are one of the most important criteria for diagnosing BPD.
Patients report that self-mutilation does not always have suicidal intentions, being a way to relieve emotional pain or to return to reality during a dissociative episode. Some may also use self-mutilation as a way to punish themselves.
The lifetime risk of suicide in borderline patients varies between 3% and 10%. Men diagnosed with the disorder are more likely to commit suicide than women.
Intense and unstable interpersonal relationships
At the same time that they want intimacy, individuals with BPD have a hard time trusting people, creating insecurity in their relationships. They can often avoid people they love or have ambivalent feelings (like and dislike, for example) about them.
Intense fear of abandonment and frantic efforts to avoid it
Borderlines tend to be very attached to the people closest to them and can do anything to avoid being abandoned, even if this abandonment is imagined (due to paranoid thoughts).
If a loved one is going to travel for a weekend, the borderline can see it as abandonment by that person and fight with him for it. You can scream, curse and even become violent physically, and use threats like suicide to prevent the person from traveling.
Idealization and devaluation
People with BPD have dichotomous thinking regarding their interpersonal relationships. This type of thinking, also known as black-and-white, all or nothing, 8 or 80, leads them to idealize and devalue an important person in a short time.
When a person who is important to the person with borderline disorder does a good thing for him, the patient sees that person as entirely good, deserving of love and affection. However, when that same person does something that can hurt him, he begins to believe that this is a bad person and that he deserves to be punished.
Combined with paranoid thoughts and fear of abandonment, the person may often have done nothing for the patient and is still the target of attacks of anger and hatred. That’s because the patient thinks the person did something wrong, when in fact he didn’t.
There is no specific test or exam to diagnose BPD, and it is necessary to do it by other means. Only a mental health professional can make this diagnosis, and often you need to do a series of tests first to make sure that your symptoms are not being caused by any illness or disability (such as thyroid problems that can cause similar symptoms) .
In addition, the doctor can request the patient’s participation in the diagnosis, through questionnaires, asking how the patient has been feeling, among others. If necessary, there may be interviews with family and close friends.
For a person to be diagnosed with BPD, he must meet at least 5 of the 9 criteria present in the DSM-5:
- Marked affective instability due to intense reactivity of mood (for example: episodes of dysphoria, irritability, or anxiety, usually lasting at least a few hours and at most a few days).
- Inappropriate, intense, intense and difficult to control anger, hatred or anger (for example: frequent frequent displays of irritation, constant anger, feeling of revenge, recurrent body struggles)
- Chronic feelings of emptiness and boredom.
- Recurrent conduct of suicide attempts or threats and self-harm behaviors.
- A pattern of unstable and intense interpersonal relationships, characterized by extremes of idealization and devaluation, or love and hate, good or bad, etc.
- Impulsivity in at least two areas potentially harmful to the person himself (for example, exaggerations in: financial expenses, sex, drugs, alcohol, reckless driving, eating, kleptomania or other types of compulsions.) Note: do not include suicidal or self-injurious behavior established in the criterion 4.
- Frantic efforts to avoid real or imagined abandonment / rejection. Note: do not include suicidal or self-injurious behavior established in criterion 4.
- Identity instability: self-image, sexual preference, persistently unstable tastes and values.
- Transient paranoid ideation related to stress or severe dissociative symptoms.
The diagnosis of BPD is not usually made in children and adolescents because, at this stage, the personality is still in formation and some supposedly borderline traits may cease to exist over time, as a result of the person’s maturation. However, it is important that these traits are observed and, if necessary, treated, in order to prevent the development of the disorder.
It is also important to take into account that some comorbidities may be masking the disorder, leading to a wrong diagnosis, where it is necessary to treat the comorbidity in order to then be able to diagnose BPD.
Comorbidities are other diseases and disorders that can appear together with BPD. These diseases can make diagnosis more difficult, as some symptoms can mask the symptoms of borderline disorder.
- Mood disorders such as nervous depression, dysthymia and bipolar disorder;
- Anxiety disorder, panic, social phobia and post-traumatic stress disorder;
- Another personality disorder;
- Substance abuse;
- Eating disorders, such as anorexia and bulimia;
- Attention deficit hyperactivity disorder;
- Somatoform disorder;
- Dissociative disorder.
There are biological functions that end up being affected by borderline disorder. Some of them are:
- About 1/3 of the patients have reactive thyrotropin with limited releasing hormone, in addition to antibodies being found in the thyroid. Therefore, it is necessary to eliminate the suspicion of thyroid problems before diagnosing BPD.
- Some patients have mild neurological symptoms.
- They may have irregularities in sleep.
- Abnormal reactions to drugs.
- Abnormalities in the electroencephalogram, some of which are typical features of schizophrenia.
- Biochemical abnormalities.
- Abnormalities in the axial computed tomography of the head.
- Low levels of vitamin B12 can be found.
Abnormal drug reactions
Procaine and opioid anesthetics can cause increased irritability in BPD patients. In addition, some drugs may have a longer impregnation period, and larger doses may appear necessary.
Alprazolam can worsen patients’ lack of control, just as amitriptyline can increase aggressive tendencies and paranoid ideations, in addition to threats of suicide.
There may be difficulty in the transport of platelet serotonin and in the activity of monoaminoxidase. In addition, paroxetine may have a lower binding capacity than this enzyme, losing effectiveness.
Low levels of melatonin are found in borderline patients, as well as some have low levels of ion transport, especially lithium, which acts interacting with neurotransmitters and receptors.
Can Borderline Personality Disorder be cured?
Technically speaking, BPD has no cure , but its symptoms can be alleviated and even go into remission with treatment. In fact, it is rare for adults over 40 to continue with symptoms.
What is the treatment?
The treatment is mostly done through psychotherapy, and can be associated with mood stabilizing drugs, antidepressants and antipsychotics. Another method to treat is hospitalization in a psychiatric clinic when the patient is experiencing a lot of stress and his self-destructive and suicidal impulses are more pronounced.
There are several approaches that have satisfactory effects in borderline patients. Some are more recommended than others, while some psychologists prefer to use mixed approaches that best adapt to the patient’s needs. Below is a list of the approaches most commonly used to treat people with BPD:
Cognitive behavioral therapy
Cognitive Behavioral Therapy (CBT) helps borderline individuals to modify some beliefs and behaviors that support inaccurate perceptions of themselves and problems with other people. This type of therapy helps to deal with paranoid thoughts, to better understand emotions and to control them, as well as helps to reduce anxiety and self-destructive behaviors.
Dialectical Behavior Therapy
Based on the concept of full awareness, the aim of Dialectical Behavior Therapy is to promote interpersonal effectiveness, emotional regulation, stress tolerance and self-control.
Social behavior, that is, the way in which each person acts and reacts in the face of common situations (studies, work, social interaction) can be greatly affected by TPB. In this sense, Social Skills Training (HRT) can also be effective in therapy, as it consists in observing and understanding limiting factors in the patient’s life and working on them, so that the patient can adapt the behaviors.
Being aware of his feelings, thoughts and emotional difficulties, the TPB patient can reduce the negative impacts in several situations. This type of therapy is usually done in a group with individual therapy support.
Schema Therapy expands Cognitive Behavioral Therapy by integrating techniques derived from different schools of therapy and is focused on the way people see themselves. It is an approach that is based on the idea that BPD comes from a dysfunctional self-image possibly caused by negative situations during childhood.
Empirical research shows that Schema Therapy is not very effective in BPD individuals, but that it may be better than leaving you without any therapy.
Family or marriage therapy
Therapy can also be done in relationships that are shaken by TPB. Family therapy helps family members to better understand the patient’s condition, develop techniques to avoid conflicts and improve communication, in addition to providing support to family members.
There is no specific drug to treat BPD, but there are several drugs that are used to treat comorbidities that can affect the borderline patient.
Regarding the disorder itself, antidepressants are used to reduce the feeling of emptiness, antipsychotics to reduce impulsive conditions (including self-destructive) and dissociative symptoms, and mood stabilizers are used to decrease emotional oscillation in patients.
Some medications that can be indicated to borderline patients are:
- Fluoxetine ;
- Haloperidol ;
- Sertraline ;
- Risperidone ;
- Aripiprazole ;
- Olanzapine ;
- Valproate ;
- Lamotrigine ;
- Topiramate ;
- Amitriptyline .
It is important that the drugs used in borderline treatment are safe, as there are patients who tend to take more than the indicated dose due to suicidal behavior. It is also worth noting that only specialist doctors can recommend medications to control BPD, as they know the precise diagnosis and what is needed for treatment. The self-medication can cause adverse reactions and undesirable results.
NEVER self-medicate or stop using a medication without first consulting a doctor. Only he will be able to tell which medication, dosage and duration of treatment is the most suitable for his specific case. The information contained on this site is only intended to inform, not in any way intended to replace the guidance of a specialist or serve as a recommendation for any type of treatment. Always follow the instructions on the package insert and, if symptoms persist, seek medical or pharmaceutical advice.
How to live together
Because it directly affects interpersonal relationships, living with a borderline individual may not be easy. It is important that friends and family are aware of the disorder and that they know mechanisms to deal with the patient, avoiding conflicts and complications.
Family and friends can and should talk to the patient’s therapist about self-destructive behaviors and other situations that they may have overlooked in their sessions (out of shame, fear, etc.), as well as seeking family therapy.
It is common for patients not to seek help on their own, either out of pride or because they think they are well and do not need to, and this task often falls on relatives and friends during a crisis. The people closest to you should be prepared and have the phone number of the therapist in cases of urgency.
While the patient is undergoing treatment, the symptoms can be alleviated and with time the coexistence becomes easier. Over the years, it is common for symptoms to go into remission, even as a result of the patient’s emotional maturation.
It is important that those close to you do not stop living their lives as a function of the borderline person, but that they also take into account their feelings and thoughts while they are away. As the borderline tends to feel abandoned, a way to better deal with this is to demonstrate that it is there and that it cares, even if it is through electronic messages.
Due to problems with self-image and impulsivity, several areas of a borderline’s life can be affected. Complications can appear in careers, relationships, education, among others.
Some of the possible complications are:
- Frequent job changes or layoffs;
- Dropping out of college, never graduating;
- Problems with the law, including the possibility of imprisonment;
- Conflicting relationships, divorce;
- Self-mutilation and frequent hospitalizations;
- Involvement in abusive relationships;
- Unplanned pregnancy;
- Sexually transmitted infections and diseases;
- Automobile accidents;
- Physical struggles;
- Overdose of medications;
- Suicide attempts.
In addition, TPB increases the risk of developing other disorders (comorbidities), such as depression, anxiety, eating disorders, chemical dependency, among others.
There is no way to prevent Borderline Personality Disorder itself, but it is possible to prevent it from developing to a severe level if it is diagnosed early, including in adolescence.
Awareness campaigns can help mothers, fathers and caregivers to better understand the behavior of adolescent children who may be beginning to develop the disorder, which increases the possibility of previous treatment and, consequently, more effective.