BORDERLINE PERSONALITY DISORDER
Running Head: BORDERLINE PERSONALITY DISORDER
Literature Review on Borderline Personality Disorder
Rachel Berry
Wake Forest University
1
BORDERLINE PERSONALITY DISORDER
2
Abstract
Borderline personality disorder is a stigmatizing and debilitating Axis II, cluster-b
personality disorder that affects approximately 1-2% of the general population and 10-20% of
the clinical population. Borderline is considered the most dysfunctional of the personality
disorders in terms of quality of life, interpersonal problems, and global functioning. The disorder
is characterized by unstable and intense interpersonal relationships, affect dysregulation, and
impulsivity. Little is understood about the neurobiology, genetics, and environmental factors that
contribute to borderline personality disorder. A lack of clear causation, inconsistent reaction to
pharmacological treatments, and variations in symptoms within and among individuals with
borderline personality disorder contribute to the complicated nature of the disorder. In addition,
borderline personality disorder is often comorbid with other Axis I and II disorders and can be
misdiagnosed as major depressive disorder or bipolar disorder. This review will provide an
overview of current research on diagnosis, including controversies and diagnostic tools, and
etiology of the disorder, including recent neurobiological research. It will provide an overview of
treatment options, focusing specifically on mentalization-based therapy. Finally, the manuscript
will identify gaps in the literature and important areas of further research.
BORDERLINE PERSONALITY DISORDER
3
Introduction
Background
Borderline personality disorder is an Axis II personality disorder characterized by “a
pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked
impulsivity” (American Psychiatric Association, 2000, p. 706). A personality disorder is defined
as “an enduring pattern of inner experience and behavior that deviates markedly from the
expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence
or early adulthood, is stable over time, and leads to distress or impairment” (American
Psychiatric Association, 2000, p. 686). Borderline personality disorder is grouped with
antisocial, histrionic, and narcissistic personality disorders in cluster b, the dramatic-emotionalerratic cluster of personality disorders. Cluster B disorders are the most common personality
disorders (American Psychiatric Association, 2000).
Borderline personality disorder is diagnosed by the presence of five or more of nine
criteria. These criteria are: (1) frantically avoiding abandonment, (2) unstable and intense
interpersonal relationships, (3) identity disturbance, (4) impulsivity, (5) self-injury and suicidal
ideation and behavior, (6) extreme reactivity of mood, (7) chronic emptiness, (8) difficulty
controlling anger, and (9) temporary episodes of paranoia and/or dissociation (American
Psychiatric Association, 2000).
Significance
Borderline personality disorder is a debilitating and stigmatizing disorder with a high
negative impact on quality of life for those who have the disorder and their loved ones.
Numerous studies have sought to estimate the prevalence of borderline personality disorder in
the general population and in clinical settings. Estimates in the general population range from
BORDERLINE PERSONALITY DISORDER
4
0%-6% (Lenzenweger, Lane, Loranger, & Kessler, 2007; Grant et al., 2008). A sound estimate
appears to be between 1-2% of the general population (American Psychiatric Association, 2000;
Skodol et al., 2011; Biskin & Paris, 2012). Among clinical populations, people with borderline
personality disorder account for 10% of mental health outpatients, 20% of psychiatric inpatients,
and 30-60% of people being treated for personality disorders (American Psychiatric Association,
2000). An estimated 70% of those diagnosed with borderline personality disorder are female
(Biskin & Paris, 2012).
Borderline personality disorder negatively impacts quality of life. Borderline is called
“generally the most severely dysfunctional disorder” (First, Frances, & Pincus, 2004, p. 1251).
People with borderline personality disorder experience extreme interpersonal difficulties and
trouble at work. Many engage in impulsive and self-harm behaviors ranging from gambling,
dangerous driving, and risky sexual behavior to cutting, burning, and suicide attempts. Among
people with borderline personality disorder, the lifetime completed suicide rate is approximately
8-10% (American Psychiatric Association, 2000). Borderline is often comorbid with other Axis I
and Axis II disorders. Common comorbid Axis I disorders are mood disorders, substance use
disorders, eating disorders (particularly bulimia nervosa), post-traumatic stress disorder, and
attention-deficit hyperactivity disorder (American Psychiatric Association, 2000). The most
common comorbid Axis II disorders are antisocial and dependent personality disorders
(McGlashan et al., 2000). In addition, dissociative symptoms occur more frequently with
borderline personality disorder than with any other group (Sar, Akyuz, Kugu, Ozturk & EtemVehid, 2006; Zanarini, Frankenburg, Jager-Hyman, Reich & Fitmaurice, 2008).
BORDERLINE PERSONALITY DISORDER
5
Methods
I conducted preliminary research using the Diagnostic and Statistical Manual IV Text
Revision and Google for overview information as well as clues as to which key words would
prove fruitful in more advanced searches. The National Education Alliance Borderline
Personality Disorder (NEA.BPD) (2012) is a non-profit organization that aims to raise public
awareness, further research, and support those living with borderline personality disorder. The
organization’s website provides a brief introduction to the disorder, including DSM-IV-TR
diagnostic criteria and information on treatment options. The DSM-IV-TR provides information
on the diagnostic criteria, comorbid disorders, prevalence, course, familial pattern, and treatment
of borderline personality disorder (American Psychiatric Association, 2000).
After obtaining this preliminary information, I conducted keyword searches on
PsycINFO and PubMED databases for sources from 2000-present. PsycINFO produced the most
useful results. I initially used the keyword “borderline personality disorder” with the Boolean
operator “and” combined with terms such as “techniques”, “outcomes”, “psychopathology”,
“diagnosis”, “treatment effectiveness”, “psychodynamic”, “mentalization therapy”, and
“dialectical behavior therapy”. Based on citation lists from initial searches, the list of keywords
grew to include additional therapies such as “dynamic deconstructive psychotherapy”,
“mentalization-based treatment”, “schema therapy”, “supportive therapies”, and “transferencefocused psychotherapy”. I manually sorted articles based on date of publication and perceived
relevance. Many of the citation lists from these articles proved fruitful in leading me to
additional sources. Sources used include book chapters from the DSM-IV-TR and DSM-IV-TR
Guidebook, review articles, and original research from peer-reviewed journals. The most useful
BORDERLINE PERSONALITY DISORDER
6
journals proved to be the Journal of Personality Disorders and The American Journal of
Psychiatry.
Results
Diagnosis
A diagnosis of borderline personality disorder requires that symptoms developed in
adolescence and early adulthood and have remained relatively stable over time. To meet the
diagnosis, a person must match at least five of the nine diagnostic criteria. The first criterion is
desperate attempts to avoid abandonment, whether real or imagined (American Psychiatric
Association, 2000). Separation threatens self-image, which leads to extreme and sudden changes
in affect, cognition, and behavior. The second criterion is a history of volatile, intense
relationships. People with borderline personality disorder tend to become intimate very quickly
and idealize people. When someone does not live up to the imagined ideal, the person with
borderline personality disorder reaches a drastic level of anger quite suddenly. While people with
borderline do have an ability to care for people and form relationships, their expectations are
unrealistic, leading to negative responses that are much more extreme than those of a normal
person. Criterion three is identity disturbance, which manifests in a frequently changing selfimage and sense of self. People with borderline personality disorder report frequent feelings of
not knowing who they are and trying to conform to what they think others wish for them to be
(Lichtenstein & Peoples, 2006). A lack of identity leads them to abrupt changes in goals and
values such as career, sexual identity, friend group, and activities (American Psychiatric
Association, 2000). They often perceive themselves as evil, and many report feeling as though
they do not truly exist. The fourth criterion is detrimental impulsivity in areas such as spending,
sex, gambling, substance abuse, and binge eating. Impulsivity is considered distinct from the
BORDERLINE PERSONALITY DISORDER
7
fifth criterion, suicidal ideation and/or behavior and self-harm. Cutting and burning are common
among people with borderline personality disorder. They report using self-harm as an emotional
outlet to alleviate feeling states that they cannot stand and often cannot explain (Lichtenstein &
Peoples, 2006). Self-harm may occur during dissociative experiences or may be a response to a
threat of abandonment. Approximately 10% of people with borderline personality disorder
commit suicide by age 30, a rate over fifty times higher than the general population (Biskin &
Paris, 2012; Soler et al., 2009). People with borderline indicate a deep ambivalence about living
and a need for others to affirm their worth (Lichtenstein & Peoples, 2006). More than half of
people with borderline personality disorder abuse alcohol or drugs, which increases completed
suicides (Biskin & Paris, 2012). The sixth criterion is affect instability and intense reactivity of
mood (American Psychiatric Association, 2000). People with borderline personality disorder are
extremely sensitive to interpersonal stress and are likely to react with dysphoria, irritability, or
anxiety. These episodes normally last a few hours to a couple of days. Criterion seven is chronic
feelings of emptiness. Criterion eight is difficulty controlling anger. People with this disorder
often experience anger that is out of proportion to the stimulus and viewed by others as
inappropriate. It is often triggered by the perception that a loved one is neglecting, abandoning,
or withholding love. Eruptions of anger are characterized by bitterness, sarcasm, and verbal
outbursts and are often followed by feelings of guilt, shame, and a sense of being evil or bad.
The ninth criterion is paranoia or dissociation as a result of extreme stress. These episodes are
not so severe and long-lasting as to merit an additional diagnosis such as paranoid personality
disorder or dissociative identity disorder (American Psychiatric Association, 2000).
Clinicians can diagnose borderline personality disorder using a number of structured and
semi-structured interview tools. As the biological pathways of borderline personality disorder are
BORDERLINE PERSONALITY DISORDER
8
poorly understood, there are no laboratory or imaging tests currently available for diagnosis
(Paris, 2008). At least five of the nine diagnostic criteria must have been present in the individual
since adolescence or early childhood and appear in multiple areas of the person’s life (American
Psychiatric Association, 2000). It is recommended that clinicians use a general personality
disorder diagnostic tool initially so as to make an accurate diagnosis of a personality disorder.
Borderline personality disorder can be comorbid with other personality disorders and Axis I
disorders (notably mood, PTSD and bulimia nervosa). Several tools exist such as the Diagnostic
Interview for Personality Disorders, the International Personality Disorder Examination, the
Personality Disorder Interview-IV, and the Structured Interview for DSM-IV-TR Personality
Disorders (American Psychiatric Association, 2000). The Diagnostic Interview for BorderlinesRevised (DIB-R) is a tool specifically designed to diagnose borderline personality disorder
(First, Frances, & Pincus, 2004). However, this assessment can take up to two hours and is
considered impractical by some clinicians.
Diagnostic Difficulties and Controversies
The current diagnostic criteria in the DSM-IV-TR allow for a possible 256 different
combinations of symptoms, making borderline personality disorder a challenge to diagnose
(Biskin & Paris, 2012). Individuals with borderline personality disorder show both stable and
unstable features over time, and sometimes the same person may be re-tested with different
results (Costa, Patriciu, & McCrae, 2005; Miller, Muehlenkamp, & Jacobson, 2008). Borderline
personality disorder can be difficult to diagnose because it may look like a mood disorder or
bipolar disorder (Biskin & Paris, 2012). In addition, high comorbidity with other Axis I and II
disorders complicated diagnosis. Borderline personality disorder is frequently comorbid with
major depressive disorder, anxiety disorders, bipolar disorder, bulimia nervosa, post-traumatic
BORDERLINE PERSONALITY DISORDER
9
stress disorder, and schizotypal, dependent, antisocial, and narcissistic personality disorders
(Grant et al, 2008; First, Frances, & Pincus, 2004).
The literature raises questions as to a possible relationship between borderline personality
disorder and bipolar disorder, a link that has been largely discredited. Paris, Gunderson, and
Weinberg (2007) conducted a review comparing the two disorders’ etiology, response to
medication, family prevalence, and course and found that the two disorders to be distinct. The
overall courses of the disorders are distinct, and there is no statistically significant indication that
one disorder evolves into the other over time. Additionally, family studies reveal that each
disorder is heritable, but families tend to show a prevalence of either borderline or bipolar but
not both. Finally, certain characteristics such as impulsivity, drastic changes in mood, and harm
avoidance are distinct between the disorders. People with borderline personality disorder seek to
avoid harm, a trait not present in bipolar disorder (Atre-Vaiydya & Hussain, 1999). Additionally,
bipolar II involves mood swings to euphoria, a state experienced briefly if at all by borderline
individuals (Koenigsberg et al., 2002). While individuals with both disorders show impulsive
behaviors, in bipolar disorder impulsivity is episodic compared to the recurring pattern of
impulsivity in borderline individuals (Swann, Pazzaglia, Nicholls, Dougherty, & Moeller, 2003;
Brown, Comtois, & Linehan, 2001).
New, Triebwasser, & Charney (2008) argue to shift borderline personality disorder to an
Axis I diagnosis. Borderline personality disorder has been classified as an Axis II diagnosis since
it was first included in the DSM-III in 1980 (Oldham, 2009). At that time, the field of mental
health believed that the personality disorders were caused by early trauma. More recent
evidence points to genetic origins of borderline personality disorder in which an individual’s
genetic predisposition towards certain traits is compounded by environmental stressors. In one
BORDERLINE PERSONALITY DISORDER
10
twin study by Torgersen (2000) showed that 69% of the variance in borderline personality
disorder is genetic. New, Triebwasser, & Charney (2008) argue that there is a lack of empirical
evidence to suggest distinguishing Axis I disorders from Axis II disorders. Additionally,
individuals with borderline personality disorder differ from those with other personality
disorders in that they frequently seek treatment, in large part because their thoughts and
behaviors are contrary to the needs of the ego (Paris, 2007). Although the authors make several
valid points, it appears that their primary motivation is to encourage more funding and research
into borderline personality disorder. While this is a worthwhile goal, reclassifying mental
disorders on this basis is a slippery slope.
The Personality and Personality Disorders Work Group for the DSM-V do not argue for
the reclassification of borderline personality disorder to Axis I (Skodol et al., 2011). The authors
propose five personality disorders including borderline for the DSM-V. Each of these disorders
is “identified by core impairments in personality functioning, pathological personality traits, and
common symptomatic behaviors”(Skodol et al., 2011, p. 136). The authors concede that DSMIV-TR personality diagnoses employ arbitrary thresholds and that diagnostic criteria are neither
empirically based nor specific enough. The DSM-IV-TR definition of personality disorder
indicates that symptoms are stable, but longitudinal studies show this not to be the case.
However, Skodol et al. (2011) argue that borderline personality disorder is “ a unidimensional
construct” and that borderline personality disorder represents “a distinct disorder, yet one with
dimensionally distributed temperamental characteristics” (p. 141). Based on data from the
Collaborative Longitudinal Personality Disorders Study (CLPS), the three main components of
borderline personality disorder are interpersonal problems, behavioral dysregulation, and affect
dysregulation (Skodol et al., 2002). As this research is more recent than the 2008 article by
BORDERLINE PERSONALITY DISORDER
11
New, Triebwasser, and Charney and conducted by the DSM-V workgroup, borderline
personality disorder will most likely continue to be classified as an Axis II personality disorder
for the foreseeable future.
Misconceptions about Borderline Personality Disorder
Borderline personality disorder is widely misunderstood due to its complex nature, lack
of knowledge of its causes, and resistance to treatment (both psychotherapy and medication).
The name borderline personality disorder was originally used by Adolf Stern in 1938 and was
expanded in the 1960s-1970s by Otto Kernberg (Stern, 1938; Kernberg, 1970). Borderline
personality disorder was originally conceptualized as being on the border between mental states,
but this is no longer considered to be the case (Paris, 2007). Specifically, people with borderline
personality disorder were originally conceived as lapsing into schizophrenic-like states
(Gunderson, 2009). However even before it was first included in the DSM-III, researchers
realized it was unrelated to schizophrenia.
Another area of confusion in borderline personality disorder is the relationship between
the disorder and childhood trauma or neglect. The DSM-IV-TR states, “Physical and sexual
abuse, neglect, hostile conflict, and early parental loss or separation are more common in the
childhood histories of those with borderline personality disorder” (American Psychiatric
Association, 2000, p. 708). However, family studies and neurobiological research cast doubt on a
purely causal relationship between early childhood stressors and borderline personality disorder.
A bidirectional relationship between genetic predisposition towards certain traits and the
presence of environmental stressors is more likely (Fonagy, Luyten, & Strathearn, 2011). 2045% of people with borderline personality disorder report no history of sexual abuse, and 80% of
people with a history of sexual abuse do not exhibit symptoms of personality pathology
BORDERLINE PERSONALITY DISORDER
12
(Goodman & Yehuda, 2002; Paris 1998). As borderline personality disorder has been shown to
run in families, it is possible that individuals with borderline were abused or neglected as
children by a caregiver who also shows traits of the disorder. Additionally, people with
borderline tend to conceptualize life events negatively, leading to possible negative self-report
bias among adults recalling childhood memories (New et al., 2008).
Genetics, Neurobiology, and the Environment
Although researchers have found that genetics play a significant role in borderline
personality disorder, there remain no unifying neurobiological theory and no biological markers
or imaging tests for the disorder (Gunderson, 2009; Biskin & Paris, 2012). Brain scans show
irregularity in the brains of individuals with borderline personality disorder. Donegan et al.
(2003) have found that people with borderline personality disorder have a hyperactive amygdala,
leading to oversensitive reactions to facial expressions. Indeed, individuals with borderline
personality disorder often perceive neutral faces as negative. Other studies have shown
abnormalities in parts of the brain that regulate emotions such as the anterior cingulate gyrus and
the orbital frontal cortex (New et al., 2008). Skodol et al. (2011) suggest that abnormal serotonin
functioning lead to a lack of impulse-control and aggression in people with borderline
personality disorder. Several studies have shown a link between brain reward circuits for
dopamine and oxytocin and attachment, the importance of which is noted by Fonagy et al. (2011;
Champagne et al., 2004; Ferris et al., 2005; Strathearn, Li, Fonagy, & Montague, 2008; Bartels
& Zeki, 2004; Champagne, Diorio, Sharma, & Meaney, 2001, Levine, Zagoory-Sharon,
Feldman, & Weller, 2007).
Of interest to clinicians and neuroscientists alike is borderline personality disorder’s
resistant to pharmacological treatment. If a mental disorder responds to a drug, one can learn
BORDERLINE PERSONALITY DISORDER
13
more about the neurological pathways of the disorder based on what is known about the way the
drug works in the brain. Individuals with borderline personality disorder respond differently to
different medications, and sometimes the response is only temporary (New et al., 2008).
Additionally, drugs from a wide variety of psychotropic classes have proven effective. A lack of
consistent and effective drug treatments for borderline personality disorder points to the lack of
knowledge of the brain biology. It is a compelling argument for further research into the
neurobiology of the disorder and effective psychotherapeutic treatments.
Fonagy et al. (2011) propose a bidirectional relationship between neurobiology and the
environment, manifested in unstable and hyper reactive attachment and a lack of mentalization.
The hormone oxytocin activates attachment, deactivates social avoidance, reduces responses to
stress, aids in mentalization, and enhances social memory and recognition of facial expressions
(Heinrichs & Domes, 2008; Fonagy, Gergely, & Target, 2007; Gergely, 2007; Heinrichs &
Gaab, 2008; Domes, Heinrichs, Michel, Berger, & Herpertz, 2007). Attachment is crucial for the
development of self-structure and the ability to manage stress. The authors characterize
individuals with borderline personality disorder as having “attachment hyper activating
strategies”, predisposing them to highly intense interpersonal relationships coupled with
panicked efforts to avoid abandonment (Fonagy et al., 2011, p. 55). In the absence of secure
attachment as children, the authors propose, borderline individuals do not establish a consistent
sense of self and often resort to splitting. Without healthy attachment, children do not achieve the
developmental milestone of basic trust (Oldham, 2009).
If an infant is predisposed to poor self-regulation, Fonagy et al. (2011) argue this will
cause difficulties developing self-control and mentalization. Mentalization is defined as
understanding the mental states of self and others. It is also possible that mentalization and
BORDERLINE PERSONALITY DISORDER
14
empathy were not taught to children with borderline personality disorder. Another theory is that
children who are abused and neglected avoid learning to mentalize in order to cope with abuse
and neglect. Understanding the mental states of abusive caretakers would be maladaptive and too
painful for a child, which could then lead to poor mentalization and splitting.
Psychotherapeutic Treatment
Although people with borderline personality disorder are often motivated to seek
treatment, working with people with this disorder is challenging for clinicians. In clinical trials,
six types of psychotherapy have shown efficacy for treating borderline personality disorder:
mentalization-based therapy, dialectical behavior therapy, transference-focused therapy, schemafocus therapy, supportive psychotherapy, and Systems Training for Emotional Predictability and
Problem Solving (Gabbard & Horowitz, 2009). Given the variety of symptomatic presentation
among individuals with borderline personality disorder, it is advisable to consider tailoring
therapeutic approaches to the individual (Higa & Gedo, 2012; Oldham, 2009).
A full discussion of the various treatments is beyond the scope of this review. As Fonagy
et al. (2011) and others argue that key components in borderline personality disorder are insecure
attachment and an inability to mentalize, this review focuses on mentalization-based therapy.
Higa and Gedo (2012) argue that learning to mentalize is an important first step toward improved
outcomes in individuals with borderline personality disorder. By focusing on the client’s current
mental state, clients can learn the skills of introspection and self-agency (Gabbard & Horowitz,
2009). Proponents of mentalization-based therapy believe that a client who cannot mentalize
cannot handle transference interpretations and may become destabilized (Gunderson, Bateman,
& Kernberg, 2007). As transference-focused therapy may cause overwhelming negative
emotions in borderline individuals, first using mentalization-based therapy can strengthen later
BORDERLINE PERSONALITY DISORDER
15
transference interpretations. In one case study, Higa and Gedo (2012) observed that clients
responded better to mentalization-based therapy early in treatment or when regressing and that
transference-focused therapy was more effective once the client learned to mentalize.
Mentalization can help individuals with borderline personality disorder better handle
interpersonal relationships, impulses, and affective dysregulation. A central tenet of
mentalization-based therapy is a focus on “mental resources that are available to deal with
recurrent patterns of behaviour [sic] and relationships rather than ideation of the patterns
themselves” (Bateman, Ryle, Fonagy, & Kerr, 2006, p. 59). The goal of mentalization-based
therapy is to help clients reflect on their cognitions and emotions before acting in order to gain
control over their automatic responses to situations (Gabbard & Horowitz, 2009). The clinician
teaches the client to mentalize, a process the client can then use in other experiences and
relationships. Rather than merely bestowing interpretations, the clinician helps the client develop
a capacity to think differently about his or her interactions. The capacity to mentalize is
considered a developmental milestone, and the failure to achieve this milestone is thought to be a
significant component in the development of borderline personality disorder. This can be helped
by learning to mentalize, which assists the individual in developing a stronger self-concept and
understanding the thoughts of self and others. Mentalization allows clients to accept the
therapist’s perspective, allowing the client to handle transference-interpretation and insight from
the clinician. Understanding mental states will transfer to the client’s outside relationships,
giving the client new ways to cope with intense emotional reactions and create healthier
attachment. As volatile interpersonal dynamics are a key symptom of borderline personality
disorder, mentalization appears to be a critical step towards amelioration of difficulties.
BORDERLINE PERSONALITY DISORDER
16
Discussion
Based on the literature, borderline personality is a viable diagnostic construct with three
primary features of disturbed relatedness, difficulty regulating affect, and difficulty regulating
behavior. Based on the Global Assessment of Functioning Scale (GAFS), people with borderline
personality disorder have the greatest functional impairment, which stays relatively stable
(Skodol et al., 2011). Individuals with borderline personality disorder experience greater troubles
at work and in interpersonal relationships.
Borderline personality disorder is a prevalent and debilitating condition that merits
greater attention and funding. It occurs in as much as 6% of the population and in 30-60% of
clinical populations with personality disorders (American Psychiatric Association, 2000). In
addition to its prevalence, the disorder proves highly dangerous to individuals who suffer from it.
Self-harm behavior such as burning and cutting is found in over 90% of those with the disorder,
and more than 50% abuse drugs or alcohol. Impulsive and dangerous behaviors increase the risk
of successful suicide in borderline individuals, and the lifetime completed suicide rate is close to
10% (Biskin & Paris, 2012).
While researchers and clinicians generally agree on its continued utility and inclusion in
the DSM, much remains unclear about borderline personality disorder. The DSM-IV-TR
diagnostic criteria allow for a vast combination of symptoms, and symptoms are not necessarily
consistent over time. Borderline personality disorder responds inconsistently to a wide range of
psychotropic drugs and psychotherapeutic treatments. While a history of abuse or trauma is
common in individuals with borderline personality disorder, research casts doubt on the exact
relationship between negative early events and the disorder.
BORDERLINE PERSONALITY DISORDER
17
Unstable early attachment relationships and a lack of mentalization appear to be
important factors in the development of borderline personality disorder, as argued by Fonagy et
al. (2011). As such, mentalization-based therapy appears to be a successful intervention either
alone or in tandem with other treatment types. Researchers should conduct additional clinical
trials assessing the effectiveness of mentalization-based therapy by itself or with other types of
treatments. By combining aspects of various treatments with proven clinical efficacy, clinicians
can potentially improve outcomes for individuals with borderline personality disorder.
A major area for further research is the etiology of the disorder. Until more is known
about the genetic, neurobiological, and environmental influences on the development of the
disease, attempts at treatment are based on trial and error. When researchers learn more about the
causes of the disorder, clinicians can educate the public, diagnose earlier, and develop more
successful treatment. Individuals with borderline personality disorder frequently pursue
treatment due to the ego dystonic nature of the disease, and clinicians need to be ready with
effective interventions.
Researchers should also conduct studies to investigate the cognitive symptoms of
borderline personality disorder (Biskin & Paris, 2012). Observed cognitive features include
dissociation (occurring in as many as 50% of borderline individuals), depersonalization, and
derealization. These cognitive features may be related to an unstable self-image and maladaptive
coping strategies. Symptoms appear to result from stress, particularly interpersonal stress.
Research into the cognitions of individuals with borderline personality disorder may help mental
health professionals develop effective treatment interventions and understand the causes and
course of borderline personality disorder.
BORDERLINE PERSONALITY DISORDER
18
Another area for research in the near future is a continued exploration of effective
interventions in treatment. By comparing treatment modalities among individuals with different
symptom presentations and traits, researchers can guide clinicians towards effective treatment
planning for borderline clients. No one treatment is effective for every borderline client, and
research shows that often a combination of treatments is most effective. In clinical trials, results
are often based on mean values that fail to distinguish the ways individual patients responded
(Gabbard & Horowitz, 2009). Thus in addition to new clinical trials, re-examining past research
may prove fruitful in determining which therapies are most effective with which types of
borderline individuals.
Reference List
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders
(4th ed., Text Revision). Washington, DC: Author.
Atre-Vaiyda, N., & Hussain, S.M. (1999). Borderline personality disorder and bipolar mood
disorder: two distinct disorders or a continuum. Journal of Nervous and Mental Disease,
187(5), 313-357.
Bartels, A., & Zeki, S. (2004). The neural correlates of maternal and romantic love. Neuroimage,
21(3), 1155-1166.
Bateman, A.W., Ryle, A., Fonagy, P., & Kerr, I.B. Psychotherapy for borderline personality
disorder: Mentalization based therapy and cognitive analytic therapy compared.
International Review of Psychiatry, 19(1), 51-62. doi: 10.1080/09540260601109422
BORDERLINE PERSONALITY DISORDER
19
Biskin, R.S. & Paris, J. (2012). Diagnosing borderline personality disorder. Canadian Medical
Association Journal. Advanced online publication. doi: 10.1503/cmaj.090618
Brown, M.Z., Comtois, K.A., & Linehan, M.M. (2002). Reasons for suicide attempts and
nonsuicidal self-injury in women with borderline personality disorder. Journal of
Abnormal Psychology, 111(1), 198-202.
Champagne, F.A., Chretien, P., Stevenson, C.W., Zhang, T.Y., Gratton, A., & Meaney, M.J.
(2004). Variations in nucleus accumbens dopamine associated with individual differences
in maternal behavior in the rat. Journal of Neuroscience, 24(17), 4113-4123.
Champagne, F., Diorio, J., Sharma, S., & Meaney, M.J. (2001). Naturally occurring variations in
maternal behavior in the rat are associated with differences in estrogen-inducible central
oxytocin receptors. Proceedings of the National Academy of Sciences, USA, 98, 1273612741.
Costa, P.T., Jr., Patriciu, N.S., & McCrae, R.R. (2005). Lessons from longitudinal studies for
new approaches to the DSM-V: The FFM and FFT. Journal of Personality Disorders,
19(5), 533-539.
Domes, G., Heinrichs, M., Michel, A., Berger, C., & Herpertz, S.C. (2008). Oxytocin improves
“mind-reading” in humans. Biological Psychiatry, 61(6), 731-733.
Donegan, N.H., Sanislow, C.A., Blumberg, H.P., Fulbright, R.K., Lacadie, C., Skudlarski, P., ….
Wesler, B.E. (2003). Amygdala hyperreactivity in borderline personality disorder:
Implications for emotional dysregulation. Biological Psychiatry, 54(11), 1284-1293. doi:
10.1016/S0006-3223(03)00636-X
Ferris, C.F., Kulkarnic, P., Sullivan, J.M., Harder, J.A., Messenger, T.L., & Febo, M. (2005).
Pup suckling is more rewarding than cocaine: Evidence from functional magnetic
BORDERLINE PERSONALITY DISORDER
20
resonance imaging and three dimensional computational analysis. Journal of
Neuroscience, 25, 149-156.
First, M.B., Frances, A., & Pincus, H.A. (2004). DSM-IV-TR guidebook. Washington, DC:
American Psychiatric Publication.
Fonagy, P., Gergely, G., & Target, M. (2007). The parent-infant dyad and the construction of the
subjective self. Journal of Child Psychology and Psychiatry, 48(3-4), 288-328.
Fonagy, P., Luyten, P., & Strathearn, L. (2011) Borderline personality disorder, mentalization,
and the neurobiology of attachment. Infant Mental Health Journal, 32(1), 47-69.
doi:10.1002/imjh.20283
Gabbard, G.O., & Horowitz, M.J. (2009). Insight, transference-interpretation, and therapeutic
change in the dynamic psychotherapy of borderline personality disorder. American
Journal of Psychiatry, 166(5), 517-521. doi: 10.1176/appi.ajp.2008.08050631
Gergely, G. (2007). The social construction of the subjective self: The role of affect-mirroring,
markedness, and ostensive communication in self development In L. Mayes, P. Fonagy,
& M. Target (Eds.), Developmental science and psychoanalysis (pp. 45-82). London:
Karnac.
Goodman, M., & Yehuda, R. (2002). The relationship between psychological trauma and
borderline personality disorder. Psychiatric Annals, 32(6), 337-346.
Grant, B.F., Chou, S.P., Goldstein, R.B., Hunag, B., Stinson, F.S., Saha, T.D., …. June, W.
(2008). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline
personality disorder: Results from the Wave 2 National Epidemiologic Survey on
Alcohol and Related Conditions. Journal of Clinical Psychiatry, 69(4), 533-545.
BORDERLINE PERSONALITY DISORDER
21
Gunderson, J.G. (2009). Borderline personality disorder: Ontogeny of a diagnosis. American
Journal of Psychiatry, 166(5), 530-539. doi: 10.1176/appi.ajp.2009.08121825
Gunderson, J.G., Bateman, A., & Kernberg, O. (2007). Alternative perspectives on
psychodynamic psychotherapy of borderline personality disorder: The case of “Ellen”.
American Journal of Psychiatry, 164(9), 1333-1339.
Heinrichs, M., & Domes, G. (2008). Neuropeptides and social behaviour: Effects of oxytocin
and vasopressin in humans. Progress in Brain Research, 170, 337-350.
Heinrichs, M., & Gaab, J. (2007). Neuroendocrine mechanisms of stress and social interaction:
Implications for mental disorders. Current Opinions in Psychiatry, 20(2), 158-162.
Higa, J.K., & Gedo, P.M. (2012). Transference interpretation in the treatment of borderline
personality disorder patients. Bulletin of the Menninger Clinic, 76(3), 195-210. doi:
10.1521/bumc.2012.76.3.195
Kernberg, O.F. (1970). A psychoanalytic classification of character pathology. Journal of the
American Psychoanalytic Association, 18(4), 800-822.
Koenigsberg, H.W., Harvey, P.D., Mitropolou, V., Schmeidler, J., New, A.S., Goodman, M., et
al. (2002). Characterizing affective instability in borderline personality disorder.
American Journal of Psychiatry, 159(5), 784-788.
Lenzenweger, M.F., Lane, M.C., Loranger, A.W., & Kessler, R.C. (2007). DSM-IV personality
disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 62(6),
553-564. doi: 10.1016/j.biopsych.2006.09.019
Levine, A., Zagoory-Sharon, O., Feldman, R., & Weller, A. (2007). Oxytocin during pregnancy
and early postpartum: Individual patterns and maternal-fetal attachment. Peptides, 28,
1162-1169.
BORDERLINE PERSONALITY DISORDER
22
Lichtenstein, B., & Peoples, J. (Producers). (2006). Back from the edge: Living with and
recovering from borderline personality disorder [motion picture]. United States: NewYork Presbyterian Hospital.
McGlashan, T.H., Grilo C.M., Skodol, A.E., Gunderson, J.G., Shea., M.T., Morey, L.C., et al.
(2000). The collaborative longitudinal personality disorders study: Baseline axis I/II and
II/II diagnostic co-occurrence. Acta Psychiatrica Scandinavica, 102, 356-264.
Miller, A.L., Muehlenkamp, J.J., & Jacobson, C.M. (2008). Fact or fiction: Diagnosing
borderline personality disorder in adolescents. Clinical Psychology Review, 28(6), 969981.
National Education Alliance Borderline Personality Disorder. (2012). National Education
Alliance Borderline Personality Disorder. Retrieved from
http://www.borderlinepersonalitydisorder.com/
New, A.S., Triebwasser, J., & Charney, D.S. (2008). The case for shifting borderline personality
disorder to axis I. Biological Psychiatry, 64(8), 653-659.
doi:10.1016/j.biopsych.2008.04.020
Oldham, J.M. (2009). Borderline personality disorder comes of age. The American Journal of
Psychiatry, 166(5), 509-511. doi: 10.1176/appi.ajp.2009.09020262
Paris, J. (2008). Treatment of borderline personality disorder: A guide to evidence-based
practice. New York, NY: Guilford Press.
Paris, J. (2007). The nature of borderline personality disorder: Multiple, dimensions, multiple
symptoms, but one category. Journal of Personality Disorders, 21(5), 457-473.
Paris, J. (1998). Does childhood trauma cause personality disorders in adults? Canadian Journal
of Psychiatry, 43(2), 148-153.
BORDERLINE PERSONALITY DISORDER
23
Paris, J., Gunderson, J., & Weinberg, I. (2007). The interface between borderline personality
disorder and bipolar spectrum disorders. Comprehensive Psychiatry, 48(2), 145-154. doi:
10.1016/j.comppsych.2006.10.001
Sar, V., Akyuz, G., Kugu, N., Ozturk, E., & Ertem-Vehid, H. (2006). Axis I dissociative disorder
comorbidity in borderline personality disorder and reports of childhood trauma. Journal
of Clinical Psychiatry, 67(10), 1583-1590.
Skodol, A.E., Bender, D.S., Morey, L.C., Clark, L.A., Oldham, J.M., Alarcon, R.D., …. Siever,
L.J. (2011). Personality disorder types proposed for DSM-5. Journal of Personality
Disorders, 25(2), 136-169. doi:10.1521/pedi.2011/25.2.136
Skodol, A.E., Gunderson, J.G., McGlashan, T.H., Dyck, I.R., Stout, R.L., Bender, D.S., ….
Oldham, J.M. (2002). Functional impairment in patients with schizotypal, borderline,
avoidant, or obsessive-compulsive personality disorder. American Journal of Psychiatry,
159(2), 276-283.
Soler, J., Pascual, J.C., Tiana, T., Cebria, A., Barrachina, J., Campins, M.J., …. Perez, V. (2009).
Dialectical behaviour therapy skills training compared to standard group therapy in
borderline personality disorder: a 3-month randomised controlled clinical trial. Behaviour
Research and Therapy, 47(5), 353-358.
Stern, A. (1938). Psychoanalytic investigation of and therapy in the border line group of
neuroses. Psychoanalytic Quarterly, 7, 467-489.
Swann, A.C., Dougherty, D.M., Pazzaglia, P.J., Pham, M., & Moeller, F.G. (2004). Impulsivity:
a link between bipolar disorder and substance abuse. Bipolar Disorder, 6(3), 204-212.
Torgersen, S. (2000). Genetics of patients with borderline personality disorder. Psychiatric
Clinics of North America, 23(1), 1-9.
BORDERLINE PERSONALITY DISORDER
24
Zanarini, M.C., Frankenburg, F.R., Jager-Hyman, S., Reich, D.B., & Fitzmaurice, G. (2008). The
course of dissociation for patients with borderline personality disorder and axis II
comparison subjects: A 10-year follow-up study. Acta Psychiatrica Scandanavica,
118(4), 291-296.