Borderline personality disorder, self-harm and suicide

People with borderline personality disorder (BPD) are said to be 'stable in their instability.' They have a terror of being alone with great efforts being made to avoid real or imagined abandonment. People's moods are extremely unstable and inappropriate anger and impulsive behaviour are common. People with BPD are much more likely to engage in self-harm and suicidal behaviour and researchers from the University of Bristol carried out an in-depth study interviewing four women with a history of self-injury and overdosing. They found that suicide and self-harm attempts could be triggered off by distressing events either a long time ago (such as child abuse) or more recently e.g. interpersonal conflict or negative thoughts about themselves. An overdose was seen as a last resort once self-injury had become insufficient as a means of self-help to manage feelings of desperation and isolation. The study found that the women felt ambivalence towards death with an overdose "appearing to depict an attempt to resolve unbearable feelings through an unarticulated 'cry for help.'"

Brooke, Stu and Horn, Nick - The meaning of self-injury and overdosing amongst women fulfilling the diagnostic criteria for 'borderline personality disorder.' Psychology and psychotherapy: theory, research and practice June 2010, 83(2), 113-128

Long road back to normality for borderline sufferers

Building a good social life and holding down a job can be tough for people with borderline personality disorder (BPD) even when their symptoms have disappeared. Mary Zanarini from McLean Hospital in Massachusetts followed 290 people with BPD over a decade to see how their condition changed; the participants in the study had all been inpatients at the hospital. 93% of the patients had had at least one 2-year break from BPD symptoms over the course of the study and 86% had had a four-year period without symptoms. However, only about half of the participants achieved 'full recovery' which was defined as a reprieve from symptoms lasting at least two years plus good social and vocational functioning. Of those who did recover about a third later redeveloped symptoms or once again struggled socially, or with their job.

http://uk.reuters.com/article/idUKTRE63L4RW20100422?feedType=RSS&feedName=healthNews

Borderline personality disorder and sleep problems in prison

Borderline personality disorder (BPD) is characterized by impulsiveness, unstable moods, relationship difficulties and low self-esteem. People with BPD are more likely to take drugs, behave antisocially and self-harm and are at much greater risk of getting into trouble with the law. Scientists think that only 1-2% of the population as a whole have BPD but this rises to 23-30% of people in prison. People with BPD who are in prison often have sleep problems but it is unclear whether it is the BPD itself of the depression that often goes with it that causes these. Researchers from George Mason University in Virginia studied 513 prisoners and found that symptoms of BPD were significantly associated with sleep problems even after allowing for the effects of depression. Drug use did not affect the link between BPD and depression. Depression was also associated with sleep disorders but again this link was independent of whether people were taking drugs or not.

Harty, Laura ... [et al] - Are inmates' subjective sleep problems associated with borderline personality, psychopathy, and antisocial personality independent of depression and substance dependence? Journal of Forensic Psychiatry and Psychology February 2010, 21(1), 23-38

Drug therapy for borderline personality disorder

Borderline personality disorder (BPD) is characterised by persistently unstable moods, inability to control one's impulses, problems getting on with other people and a poor self image. People with BPD have difficulty forming relationships, can be aggressive, harm themselves and have suicidal thoughts. It is thought that at any one time about 0.7% of the population have BPD with 5.9% of people getting it at some point in their lives. BPD often goes together with mood, anxiety disorders and substance-abuse problems and suicidal behaviour is reported to occur in up to 84% of people. In an article in the January 2010 edition of the British Journal of Psychiatry a team of researchers reviewed studies into the use of drugs to treat BPD. The team looked at 27 different studies and found that the most effective drugs were the mood stabilizers topiramate, lamotrigine and valproate semisodium and the antipsychotic drugs aripiprazole and olanzapine. However, most of the findings were based on single, small studies and there was little evidence that SSRI (serotonin specific reuptake inhibitors) antidepressants were effective. The review concluded that although some of the symptoms of BPD could be tackled on an individual basis by drugs there was little that could influence the overall severity of the condition.

Lieb, Klaus ... [et al] - Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials British Journal of Psychiatry January 2010, 196(1), 4-12

ERT for BPD

STEPPS (Systems Training of Emotional Predictability and Problem Solving) has been shown to be effective in adults with borderline personality disorder (BPD). Emotion Regulation Training (ERT) is a simplified variation of the STEPPS programme which can be used in group therapy work with adolescents. It focuses on helping teenagers know themselves better, manage their emotions and improve their problem-solving skills. It involves 17 weekly sessions and two booster sessions 6 and 12 weeks after the main sessions have finished. A team of Ducth researchers studied the effectiveness of ERT, comparing 23 teenagers who had been given the treatment with 20 who had received treatment as usual. Both groups showed equal reductions in BPD symptoms over the course of the study but the ERT group had a significant increase in feeling that they were in control of their lives. The ERT participants also reported more sense of control over their mood swings.

Schuppert, H. Marieke ... [et al] - Effectiveness of an emotion regulation group training for adolescents: a randomized controlled pilot study Clinical Psychology and Psychotherapy November-December 2009, 16(6), 467-478

The borderline personality paradox - perception and performance in relationships

People with borderline personality disorder (BPD) can often have very unstable personal relationships. They have a great fear of abandonment and often perceive people in very black and white terms as either wholly good or wholly bad. However, past research has found that people with BPD can be very perceptive about working out other people's emotions. Researchers from Columbia University in New York, New York University and the City University of New York studied 55 people, 30 of them with BPD comparing their abilities on the Reading the Mind in the Eyes Test which asks people to judge emotions based solely on pictures of people's eyes. The group with BPD performed significantly better. The researchers thought that people with BPD go into situations expecting to be hurt, abandoned and rejected by others and that their extra sensitivity to emotions makes them pick up on signs that confirm these thoughts which other people might miss out on completely.

Fertuck, E. A. ... [et al] - Enhanced 'Reading the Mind in the Eyes' in borderline personality disorder compared to healthy controls Psychological Medicine December 2009, 39(12), 1979-1988

Borderline personality disorder and relationship problems

The changeable moods and unpredictable behaviour of people with borderline personality disorder (BPD) can lead to difficulties in relationships. However, there is little actual research to back this up. About 20-30% of people with borderline personality disorder are estimated to be in a relationship at any one time and researchers from the Institut Universitaire en Sante Mentale de Quebec looked into this issue more closely. They studied a sample of 35 couples where neither partner was affected. The partners filled out questionnaires about their personalities and how they thought their relationship was functioning. 68.7% of the couples in which the women suffered from BPD had frequent break-ups and reconciliations and nearly 30% of these couples dissolved their relationship. Nearly half of the men involved with a woman with BPD had at least one personality disorder. Couples with a partner with BPD had lower marital satisfaction, were less secure in their attachment to one another, had more communication problems and had higher levels of violence.

Bouchard, Sebastien ... [et al] - Relationship quality and stability in couples when one partner suffers from borderline personality disorder Journal of Marital and Family Therapy October 2009, 35(4), 446-455

Borderline personality disorder and invalidating childhoods

Borderline personality disorder (BPD) is marked by a chronic pattern of instability in personal relationships, impulse control, moods and self-image. Compared with other mental-health problems people with BPD are much more likely to attempt suicide (75%) and to actually succeed in killing themselves (10%). No-one is quite sure about the causes of BPD although it is often linked to child abuse and neglect. Some researchers think it can be linked to what is known as an invalidating childhood environment which is one in which there is a constant rejection of the child's feelings or behaviour, emotional display is punished but tantrums are sometimes rewarded and there is an over-simplification of the skills involved in problem-solving. As a result of this environment children learn not to trust their feelings, have difficulty recognising and regulating their emotions and tend to cope with distress in an unhelpful way. Because people who have been exposed to an invalidating childhood environment have a low tolerance for strong emotions or moods they often turn to impulsive behaviour - such as self-harm and drug-taking - to deal with them in a process known as avoidance of affect. Researchers from the Royal Melbourne Institute of Technology University looked into this theory in a sample of 141 people ranging in age from 18 to 71. They found that those people who said that they had had invalidating mothers were much more likely to display avoidance of affect and BPD features. The study found, in accordance with the theory, that maternal invalidation produced avoidance of affect, which in turn lead to BPD symptoms.

Sturrock, Bonnie A., Francis, Andrew and Carr, Steven - Avoidance of affect mediates the effect of invalidating childhood environments on borderline personality symptomatology in a non-clinical sample Clinical Psychologist July 2009, 13(2), 41-51

Dialectical Behaviour Therapy and Borderline Personality Disorder

Borderline personality disorder (BPD) usually involves unstable moods, "black and white" thinking (or splitting), unstable personal relationships and a disturbance in an individual's sense of self. One of the main ways of treating BPD is with dialectical behaviour therapy (DBT). This was first developed by Marsha Linehan from the University of Washington and draws its principles from cognitive behaviour therapy (CBT), dialectical philosophy and Zen Buddhism. The treatment aims to balance acceptance of things that cannot be changed with changing things that can and aims to help people not just survive but to build a worthwhile life. There are four stages of treatment with self-harm and other life-threatening behaviours being given priority. In the second stage patients are encouraged to experience the painful emotions they have been avoiding. Stage three addresses job and relationship problems while stage four focuses on helping people to feel complete and on reducing feelings of emptiness and boredom. Researchers from Brown University in the U.S. studied 47 women who had had a five-day, partial-hospitalization programme of DBT. They found that after three months the women's levels of depression, helplessness, anger, dissociation and mental-health problems had significantly decreased. Those who had felt emptiness, been impulsive and suffered from disturbed relationships showed improvement on a number of outcomes. However, those who had disturbed identities and a fear of abandonment showed less improvement.

Yen, Shirley ... [et al] - A 5-day dialectical behavior therapy partial hospital program for women with borderline personality disorder: predictors of outcome from a 3-month follow-up study Journal of Psychiatric Practice May 2009, 15(3), 173-182

Genetics of borderline personality disorder

Borderline personality disorder (BPD) is characterized by pervasive instability in moods, interpersonal relationships, self-image and behaviour and can lead to suicidal behaviour, substance abuse and failed relationships. It is more common than schizophrenia or bipolar disorder and is estimated to affect 2% of the population. A Dutch study of 711 pairs of twins and 561 parents looked into the genetic influences on BPD and found evidence for a link with chromosome 9. Another study by the same group of researchers looked at 5,496 twins in the Netherlands, Belgium and Australia and found that 42% of variation in BPD features was due to genetic factors and 58% due to environmental ones. There were no significant differences in the extent to which men and women inherited BPD and young adults displayed more BPD features than older ones.

You can find out more about this research by going to

http://psychcentral.com/news/2008/12/17/genetic-link-to-borderline-personality-disorder/3520.html

Service users or destructine whirlwinds?

Borderline personality disorder (BPD) is characterized by an unstable pattern of personal relationships, changeable moods (including intense anger), poor impulse control and self-mutilating behaviour. Psychiatric nurses often see service users with BPD in negative terms as manipulative, attention-seeking or troublemakers. A qualitative study of six psychiatric nurses in London and Hampshire used interviews to explore further nurses' perceptions of people with BPD. They found that nurses saw these people as a 'destructive whirlwind'; a powerful, dangerous, unrelenting force that leaves a trail of destruction in its wake. The major themes emerging from the study were: care giving; idealized and demonized; manipulation and threatening.

Woollaston, K. and Hixenbaugh, P. - 'Destructive whirlwind': nurses' perceptions of patients diagnosed with borderline personality disorder Journal of Psychiatric and Mental Health Nursing November 2008, 15(9), 703-709

Borderline personality disorder - characteristics and causes

Borderline personality disorder is a severe personality disorder whose features include impulsivity, changeable moods, relationship problems and identity problems. It is associated with interpersonal and occupational impairment, an increased risk for suicide and higher rates of treatment in both medical and psychiatric settings. A study of 5,496 twins, between the ages of 18 and 86, from the Netherlands, Belgium and Australia looked into the characteristics of people with borderline personality disorder and attempted to see how much of the condition could be attributed to genetic factors and how much to environmental ones. The study found that women and young people were more likely to have the condition. 42% of the variations in the condition could be explained by genetic factors and 58% by environmental ones.

Distel, M.A. ... [et al] - Heritability of borderline personality disorder features is similar across three countries Psychological Medicine September 2008, 38(9), 1219-1229

Previous studies have shown that about 1% of the population have borderline personality disorder. It can improve over time but it affects the life and development of young adults over decades and about 10% of people with the condition kill themselves. Stress is thought to play an important role in producing the behaviour associated with borderline personality disorder and a study of 135 people in The Netherlands aimed to examine this link more closely. The study compared 44 people with borderline personality disorder, 42 people with psychosis (which is also known to be brought on by stress) and 49 unaffected controls. It found that the participants with borderline personality disorder reacted much more strongly to the stresses and strains of everyday life than people with psychosis and the control group; after stressful events their negative mood increased more and their positive mood decreased more than participants in the other two groups.

Glaser, J.-P. ... [et al] - A momentary assessment study of the reputed emotional phenotype associated with borderline personality disorder Psychological Medicine September 2008, 38(9), 1231-1239

STEPPS for Borderline Personality Disorder

The treatment of Borderline Personality Disorder is challenging. The use of medication has increased but while several drugs have proved useful their benefit has been modest. A range of psychotherapies has been developed and several have shown good results including dialectical behaviour therapy, mentalization-based therapy, cognitive-behavioural therapy (CBT), schema-focused therapy and transference-focused therapy. Systems Training for Emotional Predictability and Problem Solving (STEPPS) was developed in 1995 and combines CBT and skills training with a systems component for individuals with whom a patient regularly interacts. A U.S. study of 124 patients compared those taking part in the STEPPS programme with those receiving treatment as usual. Those taking part in STEPPS showed a greater overall improvement and became less impulsive, had less negative affectivity and mood, and functioned better. They also had less visits to emergency departments during treatment and follow-up. However, there were no differences between the groups in terms of sucide attempts or self-injury.

Blum, Nancee ... [et al] - Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: a randomized controlled trial and 1-year follow-up American Journal of Psychiatry April 2008, 165(4), 468-478

Quetiapine and borderline personality disorder

Quetiapine is a newer (atypical) anti-psychotic mainly used to treat schizophrenia and bipolar disorder. Some small studies have shown it to be effective in treating borderline personality disorder (BPD) but the research on this is limited. A Belgian study of 41 patients with BPD were given quetiapine over a period of 12 weeks and given a range of psychological tests. By the end of the study the participants' scores for impulsivity, hostility, affective lability (sudden changes of mood), depression, anxiety and anger had all decreased significantly.

Eynde, Frederique Van den ... [et al] - Efficacy of quetiapine for impulsivity and affective symptoms in borderline personality disorder Journal of Clinical Psychopharmacology April 2008, 28(2), 147-155

BPD and ADHD

Borderline personality disorder consists of pervasive affective (mood) instability, impulsivity, unstable relationships and self-image problems. It affects 1-2% of the population and is characterised by severe psychosocial impairment and a high suicide rate. According to some researchers 60% of adults with BPD meet the criteria for childhood Attention-Deficit Hyperactivity Disorder (ADHD) but no study has investigated the prevalence and impact of adult ADHD in people with BPD. A German study of 118 women seeking treatment for BPD found that 41.5% of them had suffered from ADHD in their childhood and 16.1% still suffered from it as adults. Childhood ADHD was associated with emotional abuse in childhood and greater severity of adult BPD symptoms while adult ADHD was associated with a greater risk for other mental-health problems.

Philipsen, Alexandra ... [et al] - Attention-deficit hyperactivity disorder as a potentially aggravating factor in borderline personality disorder British Journal of Psychiatry February 2008, 192(2), 118-123

Parental bonding, anorexia nervosa and borderline personality disorder

It is generally agreed that the quality of parenting experienced in childhood affects personality development and is related to the development of mental-health problems in adulthood. Because specific problems might be linked to differences in the quality of maternal and paternal bonding between parent and child this aspect of the parent-child relationship is of particular interest. Researchers in Canada used a three-factor model of child-rearing to look into the links between parental bonding and borderline personality disorder (BPD) and parental bonding and anorexia nervosa. The first factor was care - the presence or absence of behaviours reflecting affection, warmth, empathy, understanding and closeness. The second was protectiveness or denial of psychological autonomy which ranged from overprotective, infantilising and intrusive child rearing at one extreme to over-permisiveness at the other and the third was authoritarianism or denial of behavioural freedom characterised by lack of parental encouragement of the child's independent behaviour at one end of the scale and permission for the child to exercise age-appropriate autonomous behaviour at the other. The researchers looked at the participants' ratings of their parents' behaviour on these three factors and compared 35 women with BPD, 34 with anorexia and 33 with no mental-health problems. Women with BPD reported very low levels of biparental care and significantly more paternal denial of behavioural freedom. Those with anorexia experienced more maternal denial of behavioural freedom. In terms of maternal bonding, lack of maternal care was the only factor to predict BPD ; for paternal bonding a combination of father's lack of care and denial of behavioural freedom predicted BPD.

Laporte, Lise and Guttman, Herta - Recollections of parental bonding among women with borderline personality disorder as compared with women with anorexia nervosa and a control group. Australian Journal of Psychology December 2007, 59(3), 132-139

Attachment, aggression and borderline personality disorder

There has been a lot of research recently into the causes, course and treatment of borderline personality disorder (BPD) which is typically, but not always, characterized by impulsive aggression, sucidality and self-harm, extreme dysphoria, abandonment sensitivity, identity disturbance and unstable, angry affect. People with BPD have a high risk of suicide and self-harm. Attachment theory (and you can find out more about this by clicking on the link below) provides a useful framework for understanding and predicting critical aspects of personality disorder and anxious and avoidant attachment styles have been linked with both aggression and BPD. A study of 92 people diagnosed with BPD looked into the links between the disorder, attachment styles and aggression. There was a significant association between the more fearful forms of attachment and the more reactive form of aggression involving expectation of hostility from others. Self-harm was significantly associated with relational avoidance while anger and irritability were associated with relational anxiety.

Critchfield, Kenneth L. ... [et al] - The relational context of aggression in borderline personality disorder: using adult attachment style to predict forms of hostility Journal of Clinical Psychology January 2008, 64(1), 67-82

More information about attachment style can be found at

http://en.wikipedia.org/wiki/Attachment_in_adults

Bulimia and borderline personality disorder

People with bulimia can range from only slightly disturbed individuals who recover with little help to people with severe personality disorders. In people with bulimia and a severe personality disorder other symptoms can include self-destructive behaviour, emotional instability, suicidal ideation and profound interpersonal and social problems. Those people with bulimia and borderline personality disorder (BPD) are regarded as the most difficult bulimia subgroup to treat and the one with the worst prognosis. A German study of 240 bulimia patients found that 13.8% of them had a diagnosis of BPD. There were no differences in binging and purging behaviour between those with and without BPD but BPD patients had significantly more feelings of ineffectiveness and less emotional self-awareness. Although the BPD group began treatment with more mental-health problems they improved as much as the other patients over the course of their treatment.

Zeeck, A. ... [et al] - Symptom severity and treatment course of bulimic patients with and without a borderline personality disorder European Eating Disorders Review November-December 2007, 15(6), 430-438