Borderline personality disorder
The borderline personality disorder ( BPD ) or emotionally unstable personality disorder of borderline type is a mental illness . Typical of them are impulsiveness , unstable but intense interpersonal relationships , rapid changes in mood and a fluctuating self-image due to impaired self-perception . In addition, there are often self-harming behavior, feelings of inner emptiness, experiences of dissociation and fear of being abandoned.
In this personality disorder , certain processes in the areas of feelings, thoughts and actions are impaired. This leads to problematic and sometimes paradoxical behaviors in social relationships and towards oneself. As a result, the borderline disorder often leads to considerable stress and can greatly reduce both the quality of life of those affected and their caregivers.
BPS is often accompanied by other mental disorders. Frequent additional disorders are z. B. Depression , attention deficit / hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), eating disorders , substance abuse and other personality disorders.
To the subject
The word borderline is derived from the English term borderland ("Grenzland"). The psychiatrist Charles H. Hughes was the first to describe an area of (land) diagnostic borderline cases between health and mental illness in 1884 . Adolph Stern then described most of the features of today's BPD in 1938 and called this group of symptoms the "border line group". In doing so, he coined the term used today and spread it in an era that was heavily influenced by psychoanalytic theory.
At that time, mental disorders were classified according to the principle of analyzability. Neurotic individuals were viewed as analysable and thus treatable. People with psychoses, on the other hand, were seen as not analyzable and thus not treatable. In this sense, the term “borderline” referred to a blurred and undefined borderline between neurosis and psychosis and was chosen because symptoms from both areas were identified in the affected patients.
Due to its proximity to psychosis, the borderline disorder was assigned to the schizophrenic group. Corresponding historical names for the borderline disorder are marginal psychosis , pseudoschizophrenia and pseudoneurotic schizophrenia . Today the assumption that borderline disorder is related to schizophrenia has been refuted.
Newer concepts after 2005 emphasize the disturbance of the self-image - and its modern social conditions - as the central core of the BPS.
Modern operationalized diagnostics has largely broken away from these theory-based concepts. Today it is limited entirely to describing the experience and behavior that characterize the disorder . This is also evident from the inclusion of the term borderline in the Diagnostic and Statistical Guide to Mental Disorders ( DSM ) and the International Statistical Classification of Diseases ( ICD ).
It is a profound pattern of instability in interpersonal relationships, self-image and affects, as well as marked impulsiveness . It starts in early adulthood and the pattern shows up in different situations.
At least five of the following criteria must be met:
- Frantic effort to avoid actual or suspected abandonment. ( Note: suicidal or self-harming acts that are included in criterion 5 are not considered here.)
- A pattern of unstable and intense interpersonal relationships that is characterized by an alternation between the extremes of idealization and devaluation .
- Identity disorder : pronounced and persistent instability of self-image or self-perception.
- Impulsiveness in at least two potentially self-harming areas, e.g. B. spending money, sexuality, substance abuse , reckless driving, " binge eating ". (Note: suicidal or self-harming acts that are included in criterion 5 are not considered here.)
- Repeated suicidal acts, suggestions or threats of suicide, or self-harm .
- Affective instability due to a pronounced reactivity of mood, e.g. B. severe episodic moodiness ( dysphoria ), irritability or anxiety, these moods usually lasting a few hours and rarely more than a few days.
- Chronic feelings of emptiness.
- Inappropriate, violent anger or difficulty controlling the anger, e.g. B. frequent outbursts of anger, persistent anger, repeated physical arguments.
- Temporary stress-induced paranoid or severe dissociative symptoms.
DSM-5 alternative model
The alternative model of the DSM-5 in Section III suggests the following diagnostic criteria:
A. Moderate or severe impairment in the functional level of the personality, which is manifested by typical difficulties in at least two of the following areas:
- Identity: Significantly impoverished, underdeveloped or unstable self-image, often with excessive self-criticism; chronic feelings of emptiness; dissociative symptoms caused by exercise.
- Self-control: instability in goals, preferences, values and career plans.
- Empathy: Impaired ability to recognize the feelings and needs of other people, combined with interpersonal sensitivity (e.g. a tendency to feel disliked or offended); the perception of others focuses on negative characteristics or vulnerabilities.
- Proximity: Intense, but unstable and conflict-ridden, close interpersonal relationships that are characterized by distrust, neediness and fearful preoccupation with actual or supposed abandonment; close relationships are often experienced in extremes of idealization and devaluation and alternate between over-involved and withdrawal.
B. At least four of the following seven problematic personality traits, at least one of which is (5) impulsiveness, (6) propensity for risky behavior, or (7) hostility.
- Emotional lability: unstable emotional experience and frequent changes in mood; Violent emotions or affects are easy to stimulate, highly intense and / or inappropriate with regard to situational triggers and circumstances.
- Anxiety: Intense feelings of nervousness, tension, or panic, often triggered by interpersonal tension; frequent concern about negative effects of past unpleasant experiences and about possible negative developments in the future; anxious feelings, apprehension, or feeling of threat when feeling unsafe; Fear of psychological breakdown or loss of control.
- Separation anxiety: Fear of rejection and / or separation from important caregivers, accompanied by fear of excessive dependence and complete loss of autonomy.
- Depression: Frequent feeling down, feeling miserable and / or hopeless; Difficulty in recovering from such moods; Pessimism about the future; profound feelings of shame; Feeling of inferiority; Thoughts of suicide and suicidal behavior.
- Impulsivity: Actions are headlong as an immediate reaction to a trigger; they are instantaneous, with no plan or consideration of the consequences; Difficulty developing and pursuing plans; Feeling of pressure and self-damaging behavior under emotional stress.
- Tendency to risky behavior: Carrying out dangerous, risky and potentially self-damaging acts without external necessity and without considering possible consequences; Lack of awareness of one's limits and denial of real personal danger.
- Hostility: Persistent and frequent feelings of anger; Anger or irritability even with minor insults or insults.
In the ICD-10 (the classification system of the World Health Organization ), borderline personality disorder (F60.31) is listed as one of two subtypes of emotionally unstable personality disorder (F60.3) :
- The impulsive type of this disorder is characterized by a lack of impulse control and unpredictable actions (F60.30).
- In the borderline type , self-image and relationship behavior are also impaired to a greater extent (F60.31). This type corresponds roughly to the definition of borderline disorder in DSM-5.
Borderline personality disorder is often difficult to recognize in practice, even for experienced specialists. It is therefore often only correctly diagnosed after several years of treatment for other predominant complaints (e.g. depression , anxiety , psychosomatic complaints, etc.). There is loud AWMF guideline increased comorbidity rate with other personality disorders (v. A. The narcissistic , histrionic , even insecure-avoidant , dependent , schizotypal , paranoid or antisocial personality disorder ), as well as with depression, anxiety, panic disorders and post-traumatic stress disorders and addictions .
Some of the symptoms can also occur with other disorders, such as: B. in depression, schizophrenia , schizoaffective psychosis , in Asperger's syndrome and other forms of autism , in attention deficit / hyperactivity disorder (ADHD), in bipolar disorders and various of the aforementioned personality disorders. The diagnosis therefore requires an extensive anamnesis (possibly with the involvement of relatives) and careful differential diagnostic differentiation from these other diseases.
A US study found a lifetime prevalence of 5.9% in a population sample from 2004 and 2005 in 34,653 adults (6.2% in women and 5.6% in men). The small gender difference was not statistically significant .
Data from 6,330 11 year old children in Bristol, England from 2002 to 2004 showed that 3.2% met the criteria of DSM-IV. Here, too, the gender difference was insignificant.
The US sample showed a steady decrease in prevalence with increasing age (20–29 years: 9.3%; 30–44 years: 7.0%; 45–64 years: 5.5%; 65+ years: 2nd , 0%). A noticeable decrease was also shown in a longitudinal study of 290 BPS patients over a period of six years at McLean Hospital ( Massachusetts / USA) in collaboration with Harvard Medical School .
Symptoms of BPD
A 2014 state of research report found that interpersonal behavior issues were the most visible and the most distinguishable features of BPD. Experimental data indicated unstable feelings, (self-) aggression, hypersensitivity to possible threats, little success in communicating after conflicts, frequent misunderstandings and a mixture of self-assessment and external assessment.
A 2013 overview highlighted the following three difficulties:
- Misjudgment of emotionally neutral situations,
- Feeling of rejection in situations of normal social involvement
- and problems recovering social intercourse after disappointment.
The difficulty emphasized in both overviews of repairing a disturbed cooperation was shown very clearly in behavioral experiments in which the associated strong deviations in certain brain functions were registered at the same time.
BPS also has a significant impact on couple relationships . However, a long-term study carried out over sixteen years showed that improvements in the course of the disease were accompanied by a clear tendency towards more stable couple and parent-child relationships.
According to a concept of emotional dysregulation in BPS from 2013, which was based on the biosocial development model of BPS by Marsha M. Linehan (1993 and 2009), four problem areas were distinguished: increased emotional sensitivity, strong and fluctuating negative moods, lack of appropriate clarification -Strategies and excess of poorly adapted clarification strategies.
In summary, a 2009 review of experimental studies on the perception of emotional expression on faces by BPD patients identified the following typical difficulties: registering basic feelings in others, a tendency to negative or angry reviews, and an increased sensitivity to discovering negative feelings other.
Fear of rejection
The fear of possible rejection is extremely pronounced in BPD patients. A 2011 study showed that it was - statistically speaking - even stronger in this group than in patients with social phobias .
An experimental study from 2014 found that the particular fear of rejection in BPD patients was linked to specific abnormalities and underfunctions in the brain.
According to two recent reviews from 2009 and 2014, up to two-thirds of BPD patients have symptoms of dissociation . These include depersonalization , derealization , distorted sense of time , unreal reliving ( flashbacks ) and deviations in self-perception .
A detailed analysis of these symptoms in 21 patients from 2009 revealed a wide range in the type of symptoms and the degree of impairment: 24% none, 29% mild, 24% non-specific and 24% dissociative identity disorder .
A comparative study from 2015 showed that in a group of 46 patients with self-harming behavior (SVV) associated with BPS, self-harm was more common and more severe than in a group of 54 patients who had SVV but no BPS. A similar study also showed this difference very clearly, although the lifetime course of SVV was the same in both groups: a sharp increase between the ages of 18 and 24 years and the continued frequency up to the age of 50 to 59 years.
According to a Chinese study, however, only a minority of SVV patients were also affected by BPD at the same time. Of the 160 people referred to the Prince of Wales Hospital in Hong Kong for SIA in the course of one year (2007–2008) , only 30 (18.8%) had BPD at the time.
Because of the frequent accompanying illnesses ( comorbidities ), the suicide rate can only be estimated very roughly. Often up to 10% is assumed. Since this high number contradicts the well-known tendency that the vast majority of patients improve in the course of the disease, a study from 2012 specifically examined whether there are certain subtypes of BPD with an increased risk of suicide. A more severe course of the disease, older age and more impaired psychosocial functions were identified as factors for an increased risk of suicide. In patients who are also dependent, suicidality is increased.
An analysis of patient records from 2011 found long-term physical and emotional impairments from psychotic symptoms that were hardly different from those of schizophrenia . The authors therefore suggested that the diagnostic category of BPD should be changed and that psychotic symptoms should also be included. The results are consistent with two other overview studies (2010 and 2013) on this question.
Some clinical pictures often occur together with BPD ( comorbidity ).
A systematic review and meta-analysis from 2015 came to the result that depression in BPD showed more hostility and a more negative self-image compared to other depressive disorders . The severity of the depression was the same in both groups.
According to a 2014 survey, about 20% of adults with BPD are also affected by attention deficit / hyperactivity disorder (ADHD). The prevalence is thus 4 to 10 times higher than in the adult population as a whole. Although BPD and ADHD overlap in several important symptoms, the results of the causal research require a strict separation of the two clinical pictures, even if they occur together in one person. For example, the lack of impulse control , which is common to both, showed different deviations in brain functions in ADHD than in BPS.
Long-term studies showed gender differences in several concomitant disorders. Post-traumatic stress disorder (PTSD) and eating disorders were more common in women with BPD, while substance abuse , narcissistic personality disorder, and antisocial personality disorder were more common in men with BPD. However, it was expressly emphasized that these gender differences are not typical BPS symptoms, but only reflect the known gender differences with regard to the frequency of these additional disorders.
There are various theories and models of how BPD develops, and there are various factors that are considered as possible causes or partial causes. Most scientists assume that several factors contribute to its development.
A systematic overview and meta-analysis from 2014 came to the conclusion that around 40% of BPS is hereditary. However, it was found that the search for certain genes and gene locations had so far been unsuccessful. The authors therefore suggested that the high heritability rate and the so far unsuccessful search for genes can be explained by deviations in the expression of genes ( modification ). Such deviations are environmental, and evidence of gene-environment interactions and correlations was another result of the study. The first molecular genetic results regarding BPS, also from 2014, have already supported this hypothesis.
A long-term study of 6,050 children born between April 1991 and December 1992 found that hostile parental behavior and arguments among parents increased the likelihood of BPD.
In an extensive twin and family study from 2009, the relationship between genetic and environmental influences in the occurrence of BPS was examined. Similarity of symptoms of BPS in biological relatives could be fully explained by assumption of genetic inheritance. Differences in symptoms were assigned 45% genetic and 55% environmental influences. There were no indications of a possible “cultural inheritance” of BPD from parents to children.
In an extensive meta-analysis from 2014, the evaluation of studies with brain scans showed that there is a general tendency towards underfunctions in the prefrontal cortex in BPS in various tests for impulse control . This particularly affects the orbitofrontal (OFC), dorsomedial and dorsolateral areas (DLPFC).
The hippocampus (memory functions) and amygdala (sensory reactions) tend to have a reduced volume, and malfunctions of the frontolimbic network (prefrontal cortex, hippocampus and amygdala) are believed to be the cause of most symptoms of BPD.
Forms of therapy
According to a meta-analysis of 33 studies with a total of 2,256 participants, psychodynamic methods and dialectical-behavioral therapy are slightly more effective than other methods in borderline personality disorder. It is not uncommon for BPD to be based on traumatic experiences, mostly in childhood, sometimes with superimposed (occasionally complex) post-traumatic stress symptoms, which is why in some cases the inclusion of a specific trauma therapy can prove to be useful.
A 2013 review that evaluated scientific studies on the response of treating professionals to patients diagnosed with BPS concluded that the majority of treating professionals were negatively biased towards patients with a diagnosis of BPS. Respondents indicated that BPD patients often caused less concern and instead caused negative feelings, including feelings of frustration, inadequacy and overwhelm, because they were manipulative and difficult and time-consuming to treat. They would react very sensitively to behavior interpreted as rejection and tend to behave in a crisis, would have difficulty maintaining stable social relationships and interacting appropriately socially with others.
Behavioral responses on the part of the practitioner included social and emotional distancing from patients with BPD, negative judgment, less empathic behavior, and expressing anger. The above-mentioned findings could either be interpreted to mean that treating professionals are more biased and judgmental, or that patients with BPD generally tend to elicit negative reactions from people around them, regardless of whether they are professionals or not.
The mentalisierungsbasierte Psychotherapy ( mentalization Based Treatment in short: MBT) is a psychoanalytic treatment method developed by Peter Fonagy and Anthony W. Bateman was developed. It is based on the concept of mentalization . The aim is to support the patient in improving their mentalization skills. For this, it is necessary that the practitioner is always aware of the patient's emotional states in order to get a better understanding of his current emotional state. In group and individual treatments, conversations and special conversation techniques are intended to create a better understanding of the mental basis of action and to enable a reflective assessment of one's own personality. The mentalization-based treatment concept showed good effects and a very low drop-out rate.
The transmission centered psychotherapy ( Transference-Focused-Psychotherapy , TFP) by John F. Clarkin, Frank E. Yeomans and Otto F. Berg core is a special form of the psychodynamic psychotherapy, mainly in patients with personality disorders is applied. The focus of the therapeutic work in the TFP is on working through the transference relationship between patient and psychotherapist in the “here and now” in order to achieve an improvement in the area of object relationships. A comparative study on TFP showed a lower dropout rate and better therapeutic success than conventional, non-specialized psychotherapy. However, another research group in the same journal accused the study of methodological errors and questioned the validity of the conclusions of this study.
The declaration oriented psychotherapy (KoP) by Rainer Sachse has specific therapeutic approaches, as well as trouble-free and therapy theoretical concepts for the treatment of difficult to treat personality disorders, such as the BPS developed. It is of fundamental importance for therapy that the therapist first perceives the client's central (relationship / interaction) motives and the strongest schemata and reacts to them correctly in order to establish a trusting and productive therapeutic relationship. Then the therapist can make the client's previously unconscious and uncontrollable schemas transparent and the disadvantages (“costs”) of his rigid, dysfunctional patterns of action (explication process), thus generating motivation for change. This allows these patterns to be worked on and changed therapeutically with the client, and more sensible alternative courses of action can be developed and stabilized.
The dialectical behavior therapy (DBT) was developed by Marsha M. Linehan developed. The aim is to strengthen the patient in various areas. The aim is to work out the advantages of certain behavioral strategies without declaring the previous attempts at solutions to be invalid. Dialectics in the sense of the DBT aims to dissolve apparent opposites in the patient's world and to integrate them step by step. In terms of effectiveness, this therapy is the most studied to date. Its effectiveness has been proven in several studies since 2000.
According to an overview from 2013, schema therapy was rated as promising and inexpensive. However, there have only been a few studies on its effectiveness.
Cognitive restructuring and metacognitive training
One means of psychotherapeutic intervention in borderline patients is a form of so-called cognitive restructuring . This is a central element of cognitive behavior therapy . This involves therapeutic change processes in the patient's thinking, in particular the cognitive attributions are examined and, if necessary, processed. “Attributions” are properties or features that are projected onto people or things, ie something highly individual. The term comes from Latin and means, roughly translated, "attributions". In many areas of psychology, it refers both to a connection between two entities and to the resulting consequences for human experience and behavior. Borderline patients tend to project or attribute their fluctuating emotions directly onto other people without any internal control. In this way the patient's unstable inner emotional reality becomes an apparent external reality. A functionally intact distance between subjectivity and objectivity is missing here. The bottom line is that most of the social problems of borderline patients are caused by a misallocation of pathologically colored, unstable emotions to another person. This usually happens completely unintentionally, uncontrolled and uncontrolled. If, however, the borderline patient learns within the scope of an intensive cognitive restructuring to initially experience his feelings as something of his own and not to relate them to the outside world without reflection, then he can ideally free himself a little from the vicious circle of his social conflicts. Cognitive restructuring is not an independent therapeutic procedure, but an element of many cognitive-behavioral therapies.
The metacognitive training for borderline pursues a related approach , which, in addition to attributions (especially monocausal attributions), addresses other cognitive distortions that are more pronounced in people with borderline, such as B. the certainty of judgment for emotional judgments. Initial studies confirm that this approach leads to a reduction in symptoms compared to control conditions.
Psychoeducation plays a supporting role . This describes the education of people suffering from a mental disorder and the involvement of their relatives. Frequent areas of application are training courses for patients with BPD. The aim is for those affected and their relatives to understand the disease better and to be able to deal with it. For example, personal experiences regarding the disease are combined with current knowledge of the disorder, so that the current state of clinical knowledge is accessible to all those involved. They should also make use of their own opportunities to avoid possible relapses and to contribute to their own stability. In behavior therapy, informing the patient about the development and maintenance conditions of the disorder forms the basis for subsequent treatment steps. Since it is often difficult for patients and relatives to accept the diagnosis “borderline”, psychoeducation also has the function of helping to destigmatize mental disorders and to break down barriers to seeking treatment. Psychoeducation has its methodological origin in behavioral therapy, in which relearning one's own emotional and social skills is in the foreground. Psychoeducation is not a separate psychotherapy, but an element that is used in various therapies.
An overview study that evaluated research results up to August 2014 found that all drugs used in BPS up to that point were still “unsatisfactory”. As early as 2010, a meta-analysis came to the conclusion that no drug had a significant influence on the severity of the disease and that with drug treatment "no promising results with regard to the core symptoms of BPD - chronic feeling of emptiness, disruption of self-image and feeling of abandonment" - give. In 2009, the National Institute for Health and Care Excellence (NICE) in the UK recommended in a guideline for the treatment of BPD that drugs should not be used for BPD as a whole, or for individual symptoms or behavior. However, medication could be considered in treating comorbidities.
In an extensive longitudinal study of 290 BPS patients over a period of 16 years at McLean Hospital ( Massachusetts / USA) in collaboration with Harvard Medical School , information about the course of the disease and the prognosis of BPS was obtained. The study included patients who were initially inpatient and then outpatient at this clinic for BPS, who were 18–35 years old when they were recorded and who had not had any symptoms of schizophrenia, schizoid disorder, bipolar disorder (Bipolar I) or possible organic causes for had shown psychiatric symptoms. Your treatment was, depending on the case, primarily or even exclusively psychotherapeutic.
A decline in symptoms ( remission ) that lasted for years was very common. Within the sixteen year study period, 78% of patients experienced improvement that lasted at least eight years and 99% of patients experienced improvement that lasted at least two years. Relapses ( recurrences ) were relatively minor. They ranged from 36% after two years of improvement to only 10% after eight years of improvement.
A full recovery that lasted at least two years experienced 60% of the patients and a full recovery that lasted at least eight years experienced 40% of the patients. Relapses after two years of full recovery occurred in 44% of patients and after eight years of full recovery in 20%.
The study authors reviewed the figures for the relief of symptoms as "very good news" ( " very good news ") for patients and relatives, even if the figures for total relaxation "sobering" ( " more sobering ") are.
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